Reprint from the St. Lotus Courier of Medicine, December, 1881. 
Primary Cancer of tlie Corpus Uteri. 
DIAGNOSIS AND TREATMENT 
Freund’s Operatiori, and the Scoop 
Geo. J. Engelmann, M. 1)., St. Louis. 
[Bead before the St. Louis Obstetrical and Gynecological Society, Oct., ISSI.] 
Primary cancer of tlie body of the womb lias but once 
come under my observation, and I am inclined to concur 
with the statement made by those careful observers, Drs. 
Huge and Yeit, in their recent exhaustive treatment of the 
subject (C.Ruge nnd J. Yeit. Der Krebs der Gebmrmutter. 
Zeitschrift f. Gebnrtsh. nnd Gynsekologie VI. 2,1881, p. 261), 
that “ until of late there have been but few privileged 
gynecologists who have seen more than one or two cases of 
this kind in their practice. It has been necessary, in 
describing the symptoms by which this treacherous and 
deeply-disguised form of cancer maybe recognized, to com- 
pare the isolated and scattered cases of many authorities, 
as the observations of no one individual would suffice.” 
Even if we accept the opinion of Thomas, that “ the cancer 
of the body is much more common than is generally 
thought,” the careful study of each individual case appears 2 
Cancer of the Corpus Uteri. 
no less important, as lie says that “ the most marked feature 
of this affection is the obscurity attending diagnosisand 
correctly continues : “ For a long time, and perhaps through- 
out the case, uterine hemorrhage and fetid discharges will 
be the symptoms which will excite suspicion. These lead- 
ing to further and fuller exploration, a portion of the mor- 
bid tissue will be removed by the curette, examined by the 
microscope, and thus the diagnosis will be established.” 
As symptoms which mark this condition, he enumerates : 
hemorrhage, especially if occurring after the menopause ; 
depreciation of vital forces ; cachectic appearance; fetid 
discharge, and pains of severe and lancinating character. 
Whilst the physical signs he gives are: enlargement and 
hardening of the uterine body ; increased capacity of 
uterus ; profuse hemorrhage upon probing; uterine tenes- 
mus, with dilatation of os ; recognition of peculiar in- 
tra-uterine growth by introduction of the finger; micro- 
scopic evidence of cancer. We will see that the symptoms 
in our case are not quite the same, and such as to make a 
diagnosis even more difficult. 
I am satisfied that many cases are improperly designated 
as cancer of the uterine body, from the fact that it is the 
locality most deeply affected ; it is often the case that, when 
malignant disease has spread from bladder or rectum, 
vagina or cervix, to the fundus, the ravages of the disease are 
so much more rapid and so much more marked in the part 
last affected, that appearances favor the belief that this 
was the original seat; and the part from which it actually 
sprung is looked upon as secondarily attacked. 
During the spring of this year I had been repeatedly 
consulted by Dr. Staudinger, of Marthasville, Mo., in refer- 
ence to a case which was giving him a great deal of annoy- 
ance ; he had successfully battled against the persistent 
hemorrhages, but still the patient did not improve but tem- 
porarily ; the constitutional symptoms, as well a£ the phy- 
sical signs, left room for doubt; it was a question whether 
it was a decaying polypoid or a malignant disease of the Cancer of the Corpus Uteri. 
3 
uterine body ; and I was unable to come to a definite con- 
clusion until I bad been enabled to make a microscopic 
examination of a recently removed piece of tlie morbid 
growth; and then the unfortunate sufferer did not consent 
to come to the city for operative treatment until she began 
to fail signally. 
May 28, 1881, she came under my care; and I give the 
following history, as obtained partially from the patient 
herself, and partially from the notes of her carefully ob- 
serving attendant; 
Mrs. P. Q., aged 47, had always been in good health, and 
had borne several children, the last 18 years ago. During 
this childbed she suffered from pelvic cellulitis, and has not 
conceived since ; the menstrual flow has always been rather 
frequent and profuse; so much so during the past eight 
years that she was frequently weakened thereby, although 
she always rapidly rallied; several years ago she was in 
bed for days at a time, enfeebled by loss of blood. Mrs. 
Q., however, considered herself in good health until the 
spring of 1880, one year ago, when she began to ail and to 
suffer from a constant hemorrhagic discharge, more to be 
likened to a bloody serum, slight at times, off and on devel- 
oping into severe flooding; this, however, was not regular, 
nor in any way connected with the menstrual period. Fluor 
albus made its first appearance some nine months ago; 
then only slight and after each period, becoming more per- 
manent since January, and varying occasionally with a 
reddish mucoid discharge, even in the inter-menstrual 
period ; during this time the menses had also become more 
profuse, and continued for twelve or fifteen days. The dis- 
charges had always been perfectly sweet; and not until the 
end of April, one month previous to her coming here, did 
they become at all fetid. 
Dr. Staudinger was first consulted in January on account 
of debilitating hemorrhage ; the patient was then confined 
to her bed for a time, and complained of some pain in the 
left leg, off and on ; and when severe it was also felt across 4 
Cancer of the Corpus Uteri. 
the abdomen and in the right leg, the back always remaining 
free. These pains, which the patient considered rheumatic, 
did not continue long, and left so slight an impression that 
I heard nothing of them until she was very carefully ques- 
tioned. 
Dr. S. temporarily overcame the metrorrhagia by the in- 
ternal use of ergot, gallic acid and opium ; rest in bed, in- 
tra-uterine injections of iodine, and tampons of tannin and 
glycerine, quinine and tonics were used; but although a 
certain improvement was manifest, the patient did not seem 
to rally. The uterus was enlarged, ante verted, movable, 
and through the slightly dilated os quite a large piece of a 
polypoid growth was removed; after this the leucorrheal 
discharge seemed to increase and the fetid odor to appear. 
This was merely a coincidence, however. Pulse varied from 
100 to 103, and the temperature was from I£° to 2° F. above 
the normal. When consulted toward the end of March, I 
felt unable to make a positive diagnosis; the absence of a 
decided cachexia and of the characteristic pains as well as 
the fetid discharge, led me to hope that the doctor’s patient 
might be suffering from a disintegrating polypoid growth 
within the uterine cavity. I advised large doses of 
quinine, with injections of ergotine into the uterine tissue, 
and dilatation and removal of some of the morbid mass 
for the purpose of diagnosis. 
On examination, the section sent me showed an areolar 
tissue, a fibrous network containing round and epithelioid 
cells, no distinct nests as in typical cancer; and although 
the specimen was insufficient, I felt satisfied that the growth 
was malignant; moreover, the patient seemed to decline, 
notwithstanding Dr. Staudinger’s energetic and judicious 
treatment. 
Mrs. Q. now consented to come to the city, and when I 
first saw her, May 23d, she appeared in fair condition, by no 
means emaciated, weighing perhaps 150 pounds; her com- 
plexion showing but little pallor beneath her bronzed, rather 
peculiar hued, skin; the pulse was somewhat accelerated,. Cancer of the Corpus Uteri. 
5 
and the temperature a little above normal. The examination 
revealed vulva and vagina normal, thedatter containing hut 
little secretion, which possessed a slightly fetid odor ; the 
uterus was well up in the pelvis, slightly anteverted, some- 
what enlarged, S-- centimeters (8| inches) in length, the 
sound being freely movable in the enlarged cavity. The 
uterus was movable in every direction; the body was en- 
larged, hard and nodular, the enlargement being more 
marked toward the left. 
All other parts were normal; there was no infiltration, 
no thickening or tenderness in any of the surrounding 
parts ; the broad ligaments were most carefully examined; 
the right one was free, whilst a question arose as to the 
possibility of a slight thickening of the left; the thicken- 
ing, however, if any, was most trifling. 
The cervix was normal in feel and appearance, soft, 
slightly congested, not nodular ; the os and cervical canal 
were enlarged so as to admit the finger, and through the 
widened canal the polypoid, broad-based neoplasm could 
be reached with the dressing forceps. There was no pain 
upon pressure any where. In comparing the results of my 
examinations, physical and microscopic, with the symp- 
toms of the case, I could come to no other conclusion than 
that this was a primary cancer of the uterine body, with a 
nodular enlarged uterus and polypoid mucous growth 
within the cavity, the disease being still strictly confined to 
the uterus itself. 
The prognosis was self-evident; the treatment equally 
so ; and this I distinctly enunciated to the patient; that, 
1. A curative treatment was possible, by Freund’s oper- 
ation, the extirpation of the entire diseased organ, but 
this itself endangering life. 
2. A palliative treatment, the removal of the diseased 
masses by the scoop was without danger, and within the 
limits of ordinary surgical interference. 
Mrs. Q., a brave, sensible woman, knowing the final re- 
sults of an even temporarily successful palliative treatment, 6 
Cancer of the Corpus Uteri. 
unhesitatingly chose to risk every thing for the sake of per- 
manent cure; and I had thoroughly satisfied myself that, 
if ever Freund’s operation were justifiable, it was so in 
this case. The patient was still strong and in fairly good 
health; pulse and temperature were but slightly raised, 
and as far as our present methods of examination were to 
be relied upon, the disease was confined to the uterus, 
which was non-adherent and freely movable, whilst the 
neighboring organs were intact. 
The very thorough first examination, in which I had re- 
moved a piece of the neoplasm for examination, was fol- 
lowed by some hemorrhage and fever, so that I was obliged 
to undertake a careful preparatory treatment—rest, warm 
baths, frequent disinfectant hot water injections, quinine, 
tonics and opiates. Patient rallied rapidly ; and June sth 
I undertook the operation for removal of the cancerous 
uterus, attempted for the first time in this city, in the pres- 
ence and with the assistance of Drs. Prewitt, Hodgen, 
Schenck, Papin, Nelson, Fischel, D’Oench, Henske, and 
her attendant, Dr. Staudinger. 
The following notes were kindly made by Dr. D’Oench: 
10 a. m., chloroform administered. 10:25, incision into the 
abdominal walls from the umbilicus to within three-fourths 
of an inch of the pubis ; adipose tissue well-developed ; mus- 
cular layer equally so, and of good color. 10:30, opened the 
peritoneum, after slight oozing and small bleeding vessels 
had been completely checked. A desperate condition of 
affairs was now disclosed; the omentum was found adhe- 
rent to the anterior abdominal wall; to the left, it was 
firmly attached as high as the highest point of incision, 
and above; to the right the line of attachment could be 
traced from the umbilicus toward the right anterior supe- 
rior spine; practically, the enlarged omentum was firmly 
adherent to the anterior parietes at. all points below the 
navel, also to the elongated bladder, which was at the same 
time attached to the abdominal walls, and drawn far up- 
ward by the omentum ; the enlarged, nodular and hard Cancer of the Corpus Uteri. 
7 
uterus was in four or five places closely bound to coils of 
intestines by old, unyielding adhesions ; these, although 
serious obstacles to the operation, left the womb freely 
movable ; neither broad ligaments nor any other of the sur- 
rounding tissues appeared abnormally thickened. 
The operation, in itself one of the most difficult, I believe 
the most dangerous and difficult in abdominal surgery, ap- 
peared an impossibility in the face of these complications, 
and I reluctantly yielded to, the unanimous opinion of Drs. 
Hodgen, Prewitt and Schenck, to desist and close the 
wound ; this was done with the thickest silver wire obtain- 
able, fastened with flattened shot almost the size of a gold 
dollar, the sutures being three-fourths of an inch apart; 
very fine silk serving for the comparatively few superficial 
sutures needed for a perfect adaptation of the surfaces, upon 
which I always insist. I might here add that I know of no 
other method which permits so careful an adaptation of the 
parts as thick silver wire clamped by this peculiar “ flat- 
tened and stemmed” shot. 
The wound was closed at 11:30 a. m., and my usual dress- 
ing applied, which differs essentially from the Lister regu- 
lation only in the substitution of the yielding carbolized or 
salicylated cotton in place of the hard gauze. Over the 
dressing proper I place sufficient cotton to furnish an 
even and nicely-rounded surface for the better application 
of the binder and the even distribution of the pressure 
thereby. 
Patient suffered from nausea and other unpleasant effects 
of chloroform for so long a time, and so severely, that I 
feayed more serious troubles, and felt some alarm, when on 
the second day all unfavorable symptoms passed off; and 
from that time on not an incident occurred to mar the un- 
usually rapid progress of her recovery, and the perfect 
freedom from pain which accompanied it. 
Not more than three or four doses of morphia were given; 
no opium, no oil, the bowels soon beginning to move natur- Cancer of the Corpus Uteri. 
8 
ally. At first the catheter was resorted to every six hours, 
but was soon dispensed with. 
Union by first intention occurring, not a drop of pus was 
seen, and I was enabled to remove some of the stitches on 
the seventh, and the remainder on the ninth day. As I had 
repeatedly noticed that in cases of such rapid recovery in 
which I have removed stitches at so early a day, the tender 
cicatricial tissue in the line of the wound was likely to 
yield a little and leave a broad line instead of a narrow 
cicatrix, I applied a few long strips of adhesive plaster to 
rest and fix the abdominal walls, and for the same purpose 
ordered a binder. 
Before the end of the month, three weeks after the oper- 
ation, Mrs. Q. returned to her home, none the worse for the 
trip, but none the better for the attempted operation. By 
the use of disinfectant injections, of tonics and good food, 
as well as a nursing of her strength, she kept up very fairly; 
but anxious for some help, a stay of her sufferings and pro- 
longation of her days, and mindful of the relief I had prom- 
ised her from a much less serious, in short, a trifling, but 
only palliative operation, she determined upon having this 
performed, and insisted on it, regardless of the intense 
heat. 
Before leaving on my summer vacation, July 15th, I oper- 
ated at the patient’s home, with the assistance of Drs. 
Staudinger and Eimbeck: a cupful of the diseased tissue 
was removed with the scoop, putrid in part, but not any of 
it grangrenous in appearance. The largest of Simon’s 
scoops, which for this purpose I use in preference to any 
other, entered readily the enlarged cervical canal, and rap- 
idly cut away the softer and more superficial portions, the 
broad-based polypoid masses, and then, as the tissue be- 
came more resistant, I removed pieces of the size of a small 
hickory-nut at each cut of the scoop. The great advantage 
of this instrument over the slightly modified form of Sims’, 
which alone is known and used in this country, is, that by 
reason of its more elliptoid shape, pieces can be cut Cancer of the Corpus Uteri. 
9 
out, and it serves a greater variety of purpose. The appa- 
rent thinness, apparent absence, of the uterine wall, which 
allowed the feeling of the inserted instrument through the 
rectum, and also through the abdominal walls, as if little 
else intervened, caused me to cease; the cavity was washed 
out with hot water, sponged with perchloride of iron, and a 
tampon of cotton steeped in equal parts of perchloride of 
iron and water was next introduced into the rapidly con- 
tracting shell. 
The vagina was plugged with cotton tampons, the first of 
which were well oiled in order to facilitate their removal 
from the vagina contracted, and corrugated by a little of 
the iron, which necessarily escapes. 
Patient suffered, as before, exceptionally from the use of 
chloroform; the tampons were gradually removed, the cav- 
ity cleansed regularly, applications made, as well as copious 
hot and disinfectant injections used, yet there was no im- 
provement ; neither the operation carried to its utmost ex- 
tent, nor the close and unswerving attention with which the 
after treatment was conducted, in any way affected the pro- 
gress of this fearful malady; quinine and tonics were given ; 
beef-tea, milk and whisky; injections and local applica- 
tions were used, acids and astringents, until the patient re- 
fused to be annoyed any longer by any attempts at treat- 
ment, whatever they be, as Dr. Staudinger writes me under 
date of August 18th, 1881. 
November sth, he writes that, after not seeing her for 
a month or more, he was called to ease her, and began the 
use of morphine injections, which he is now obliged to give 
three times a day, and over a grain each time; she suffers 
no pains, but demands morphine for the sake of rest and 
peace of mind; for the past fourteen days she has taken 
almost no nourishment at all, gags constantly if not under 
the influence of the anesthetics, and will hardly linger many 
more days.* 
* Died November 15th. 10 
Cancer of the Corpus Uteri. 
I have so carefully detailed this case— 
1. On account of its rarity, 
2. The discrepancy of the symptoms observed with those 
usually accepted. 
8. As showing some of the difficulties of a correct diagnosis 
of cases suitable for Freund’s operation. 
4. As cautioning us not to rely too firmly upon the sup- 
posed palliative operation by the scoop. 
This is the first distinct case of primary cancer of the- 
body of the uterus which I have seen, so that I am not in a 
position to make any statement as to the relative frequency 
of the affection in relation to the cancer of the neck, which 
is variously mentioned as about 1 in 420, 1 in 50, and even 
lin every 16. The most thorough and modern of German 
pathologists look upon this as a most rare disease, whilst 
equally able men of clinical experience think that it occurs 
more frequently. Are they not confounding cancer of the 
body secondary with the 'primary affection ? 
Waldeyer, in Virchow’s Archives, Vol. LV., p. 111, says 
that he has never seen a primary cancer of the body of the 
womb, while Barnes and Thomas do not consider the dis 
ease by any means a very rare one. 
The symptoms usually accepted as indicative of primary 
cancer of the body I have already enumerated, and it will 
be seen that in the case before us the intense periodical 
pains were wanting; in the earlier stage, and for a short 
time only, was some slight pain complained of, but thi& 
passed away entirely; the hydrorrhea was wanting, 
cachexia appeared late; the discharge did not have that 
intensely putrid odor which is common, and the hemor- 
rhage, though severe at first, ceased after having been 
once checked. Patient was also younger than common, as 
this malady usually appears after the climacteric, between 
the fiftieth and sixtieth year. 
As far as the most careful examination could reveal, the 
disease was confined to the uterus, which was movable and. Cancer of the Corpus Uteri. 
11 
free from adhesions, the condition accordingly being one 
justifying Freund’s operation; we have seen how unfortu- 
nate a state of affairs was revealed as soon as the abdomi- 
nal cavity had been opened, adhesions to movable parts 
not to be diagnosed beforehand, yet sufficient to prevent a 
-completion of the operation. 
Remarkable, also, was the complete failure of that sup- 
posedly palliative operation by the scoop. Curetting is one 
of those few operations which I have found, I may say, uni- 
versally successful; it had never before failed me, and 
always gave relief from pain, from hemorrhage and putrid 
discharge, and usually a season of apparently good health to 
the unfortunate sufferer. In one other case only has it failed 
me, and that was one operated on about the time of Mrs. 
Q.’s first operation—cancer of neck and body. In this case 
a bold use of the curette, the removal of a cupful of dis- 
eased tissue, gave no relief whatsoever; there was not even 
a momentary improvement, no amelioration of the dis- 
charge. As may be supposed, it was excessively mortify- 
ing to me that this brave woman, who had so firmly deter- 
mined to risk everything, to undergo every danger, bear all 
suffering for the sake first of health, and then of only a few 
months’ respite, that this woman should have dared all in 
vain ; a usually successful operation failed completely. 
Cancer of the fundus uteri appears, according to investi- 
gations of Ruge and Veit, either as a diffuse infiltration or 
in a circumscribed, nodular form, and it is this latter which 
we see distinctly characterized in the case in hand, polypoid 
growths of the mucous membrane protruding into the en- 
larged cavity, and nodular tumors throughout the muscular 
tissues, seen and felt after the abdominal cavity had been 
opened. The diagnosis is positively established by the 
microscope only, but with considerable certainty by the 
hemorrhage and fetid discharge; less so by pains and 
cachexia. 
The treatment, not to speak of the self-evident attention 
to hemorrhage, discharge, etc., is palliative and curative: 12 
Cancer of the Corpus Uteri. 
palliative, by the sharp curette of Simon or Sims ; curative, 
by Freund’s operation, which I deem feasible, but only to 
be attempted in the earliest stage of the disease, at a time 
when the affection is strictly confined to the body of the 
womb, but when the condition of the patient, unfortunately, 
is still such that she will hardly consent to so dangerous 
an operation.