The Early Diagnosis of 
Carcinoma of the Uterus. 
BY 
THOS. S. CULLEN, M.D. 
BALTIMORE, MD. 
Reprint from The Memphis Lancet, 
December, 1898 THE EARLY DIAGNOSIS OF CARCINOMA OF 
THE UTERUS * 
THOS. S. CULLEN, M.D. 
BALTIMORE, MD. 
Associate in Gynecology in the Johns Hopkins University. 
Dr. Cullen spoke first on the normal histological appearances 
of the uterine mucosa: 
[AUTHOR’S ABSTRACT.] 
(a) The squamous epithelium covering the vaginal portion of 
the cervix; usually ending at the external os, but not infrequently 
extending to a point midway up the canal, or even as far as the 
internal os. 
(b) The cervical epithelium which usually extends from the 
external to the internal os. This is very high and cylindrical; 
its nuclei are usually situated on the basement membrane, and are 
triangular, oval or elongate. The form appears to depend upon 
the amount of secretion contained in the cell. The cell protoplasm 
is very pale and tends to imbibe the hematoxylin stain instead of 
eosin. The racemose glands of the cervix may be looked upon as 
branching reduplications of the surface epithelium; their cylindrical 
epithelium is identical and continuous with that covering the sur- 
face of the canal. The stroma around the cervical glands is usually 
rather dense, but offers nothing very distinctive. 
(c) The uterine mucosa commences at the internal os and lines 
the entire uterine cavity. It is usually 2-4 mm. thick, is smooth, 
and has a surface covering of one layer of cylindrical epithelium. 
The cells are barely two-thirds as long as those of the cervix, have 
oval nuclei, which are situated some distance from the base of the 
cell or lie near the middle, and contain a protoplasm which takes 
the eosin stain; attached to their surfaces are cilia. Thus the cer- 
vical epithelium differs in almost every particular from that of the 
* Read before the Tri-State Medical Society of Tennessee, Georgia and Alabama, 
Birmingham, Ala., October, 1898. EARLY DIAGNOSIS OF CARCINOMA OF UTERUS. 
body. The uterine glands are tubular and may branch slightly 
near the muscle; they are lined by one layer of epithelium, con- 
tinuous with and similar to that covering the surface. This epi- 
thelium usually contains several nuclear figures. The tissue be- 
tween the glands we usually call the stroma of the mucosa. .The 
nuclei of this are oval and vesicular, the cells are usually spindle- 
shaped, and can be studied to best advantage where they are separ- 
ated from one another as in edema. A few small round cells 
are regularly found between the stroma cells. The blood supply 
of the stroma is rather interesting; the arteries are invariably in 
small bunches of from three to eight, and are surrounded by con- 
siderable connective tissue. The veins are large and merely have 
their endothelial lining separating them from the stroma. 
The classification of carcinoma has been rather complicated, 
and, to a great extent, indefinite. From a systematic examination 
of over ninety cases in the Johns Hopkins Hospital, and from a 
critical review of the literature, the author has made the following 
simple classification: 
(a) Epithelioma of the cervix. 
(6) Adeno-carcinoma of the cervix. 
(c) Adeno-carcinoma of the body of the uterus. 
(d) Epithelioma of the body of the uterus (rare). 
From this classification it is readily seen that varieties (a), (6) 
and (c) correspond to the three varieties of epithelium found in the 
uterus and which have already been described. 
The epithelioma of the cervix commences in the squamous 
epithelium, and starts as small papillary outgrowths and finger-like 
or branching ingrowths. It is just when the disease is in its earliest 
stage that we wish to recognize it. Given a patient over 36, com- 
plaining of a slight bloody or watery discharge between menstrual 
periods, insist on making or having an examination made. If the 
cervix show localized hardness, blue on slight manipulation, and 
have little masses springing from its surface, the diagnosis is fairly 
certain, but if one be in doubt, a small wedge-shaped piece should 
be cut out of the suspicious area and examined at once. 
In adeno-carcinoma of the cervix the process is much more in- 
sidious, the patient perhaps complaining of a slight bloody or 
watery discharge. On vaginal examination frequently nothing 
can be detected. The only accurate means of diagnosis is by the aid THOS. S. CULLEN. 
of the microscope. In adeno-carcinoma of the cervix the growth 
may commence from the epithelium lining the canal, as beautifully 
shown in one of Cullen’s drawings; here the surface epithelium 
had rapidly proliferated and formed large masses of cells which 
were, to a great extent, arranged as new glands, but as yet there 
was no connective tissue between the glands, a condition that 
speaks conclusively against Ribbert’s recently advanced view, that 
the carcinoma is primarily due to a ripping oft' of epithelium by 
the underlying stroma. 
Adeno-carcinoma of the body of the uterus is much more fre- 
quent than was formerly supposed. In its early stages the symp- 
toms are usually only a slight bloody or watery discharge, and on 
bimanual examination one finds the uterus little, if any, enlarged, 
hence without further aids in diagnosis the true condition could 
not be accurately determined. Before curetting such a uterus it 
is well to bear in mind that while at times the mucous membrane 
of the entire cavity is involved in the new growth, frequently the 
process is limited to one wall or even to a small portion of one 
wall, hence if the operator curette at random and not in a system- 
atic way, the diseased area may not be disturbed at all, only nor- 
mal tissue from the surrounding jDortions being removed; it is, 
therefore, always wise to thoroughly curette the walls anteriorly, 
posteriorly and laterally. If carcinoma be present the curettings 
are usually abundant, the surface of the mucosa has a branching 
or tree-like appearance instead of the normally smooth and velvety 
covering, and the tissue is very friable. Histologically the car- 
cinoma is very readily diagnosed from even the smallest amount 
of tissue, and then from the characteristic gland formation. The 
widespread idea that the glands must be seen penetrating the 
muscle is erroneous, as not in one case out of ten do we find 
uterine muscle in the scrapings, and yet the diagnosis is clear. 
Epithelioma of the body of the uterus is exceedingly rare, 
probably not more than six or seven cases having been reported. 
This variety is identical with epithelioma of the cervix and it is 
most likely due to the squamous epithelium having extended ab- 
normally far upward. 
The clinical phenomena of carcinoma of the uterus are not 
satisfactory, so many of those present being common to other 
diseases. The presence of a bloody or watery discharge should EARLY DIAGNOSIS OF CARCINOMA OF UTERUS. 
always arouse one’s suspicion and stimulate him to make an 
immediate diagnosis. 
Prognosis. Adeno-carcinoma of the cervix is undoubtedly the 
most malignant. Epithelioma of the cervix is next in the cate- 
gory, while adeno-carcinoma of the body is the most amenable to 
treatment. 
The treatment in the early cases is of course complete enuclea- 
tion. It is interesting to note the advance in this line. First we 
had the amputation of the cervix as practiced by Schroder and 
others, then hysterectomy as recommended by Freund in 1878; 
later a distinct advance was made when Pawlik, in 1889, recom- 
mended catheterization of the ureter preparatory to removing the 
uterus. This was not, however, adopted by the profession at large, 
and it remained for Kelly, who conceived the idea independently, 
to establish it as a routine procedure. Recently a further step has 
been taken. This was independently advocated by Reis, Clark 
and Rumpf. The operation as performed by Clark and Reis leaves 
little to be added in this direction, and yet where the disease has 
advanced far, none of these operations are of permanent benefit. 
Our only hope lies in the early diagnosis. THE 
MEMPHIS LANCET 
EDITED BY 
R. B. MAURY, M.D. 
M. B. HERMAN, M.D. 
W. W. TAYLOR, M.D. 
WM. KRAUSS, M.D. 
M. GOLTMAN, M.D. 
E. C. ELLETT, M.D. 
S. E. RICE, M.D. 
J. M. MAURY, M.D. 
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