The Importance of a Systematic Microscopical 
Examination of Uterine Scrapings 
and of Excised Pieces as an 
Aid to Diagnosis. 
Based upon the Analysis of One Hundred Cases. 
BY 
HUNTER ROBB, M.D., 
PROFESSOR OF GYNAECOLOGY, WESTERN RESERVE UNIVERSITY, 
CLEVELAND, OHIO. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1897. Extracted from The American Journal of the Medical Sciences, January, 1897. 
THE IMPORTANCE OF A SYSTEMATIC MICROSCOPICAL EXAM- 
INATION OF UTERINE SCRAPINGS AND OF EXCISED 
PIECES AS AN AID TO DIAGNOSIS, BASED UPON 
THE ANALYSIS OF ONE HUNDRED CASES. 
By Hunter Robb, M.D., 
PROFESSOR OF GYNAECOLOGY, WESTERN RESERVE UNIVERSITY, CLEVELAND, OHIO. 
The object of the present paper is to call attention once more to the 
advantages to be derived from a systematic microscopical examination of 
tissues removed from patients at gynaecological operations. It has for 
some time been a matter of routine with me to preserve for microscopical 
examination all structures so removed, the findings in each case being 
recorded regularly in a systematic way. The results thus obtained have 
been by no means without interest. While it is true that in perhaps a 
majority of instances the microscopical examination simply verified more 
or less completely the diagnosis which had been previously arrived at 
from a careful clinical study of the case, it has not infrequently brought 
to light evidences of the presence of a malignant tumor whose existence 
had by no means been suspected. On the other hand, in several instances 
the microscope has proved a suspicion of malignancy to be unfounded, 
and in ordinary benign cases has thrown much light upon the exact 
nature of the existing process. And, lastly, in a small number of cases 
the microscopical examination has proved of the utmost importance in 
that it has placed us in a position to recognize a malignant process in its 
very earliest stages, and while it was still possible to remove the growth 
completely by operation, before it had given rise to metastases, or had 
spread by contiguity or continuity to such a degree that all attempts at 
complete removal would have been useless. 
The importance of a microscopical examination of scrapings from the 
uterine or cervical cavity, and in distinctly suspicious cases of deeper 
portions of the cervix, or, indeed, of the uterus itself, excised for pur- 
poses of diagnosis, does not, in this country, seem to have been as yet 
sufficiently appreciated. The difficulties in the way of a general appli- 
cation of the method, it is true, are somewhat formidable. Thus, in 
addition to the technique and experience necessary to make the results 
of the examination of value, the question of time has to be considered, 
so that the majority of busy surgeons will be compelled to delegate the 
work to a well-trained assistant or to a pathological colleague. In 
Europe, and especially in Germany and Austria, attached to the best 2 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
clinics are a number of competent men whose duties as assistants include 
the making of such examinations, and gynaecologists in this country 
have long been in the habit, in doubtful cases, of submitting specimens 
for microscopical examination to pathologists in whom they have confi- 
dence. The tendency to make these examinations, as a matter of rou- 
tine is gradually growing, and the aid to be derived from the microscope 
in apparently simple as well as in doubtful cases is becoming more and 
more appreciated. 
There has existed in the past an idea, now, fortunately, becoming less 
prevalent, that the result of the pathological examination in a clinically 
doubtful case is never certain. This, I think, grew out of the unreason- 
able demand of the clinician that, when his own methods failed in estab- 
lishing a diagnosis, the pathological appearances should always be path- 
ognomonic. While, however, the most enthusiastic supporters of the 
microscope as an aid to diagnosis are the most ready to admit their 
inability to give a positive statement as to the malignancy or non- 
malignancy in every case, this much at any rate can be asserted : in 
cases which are doubtful clinically the microscope will sometimes clear 
up the diagnosis absolutely, and were such instances met with only once 
in a dozen, or even in a hundred patients, the results obtained would 
more than repay us for the time and trouble spent in the systematic 
microscopical examination of every case. The technical procedures em- 
ployed in this branch of work are simple and can be easily carried out 
by anyone who has been trained in the ordinary histological and path- 
ological technique. The experience necessary to form a satisfactory 
judgment as to the evidence concerning the presence or absence of a 
malignant growth in a given case, or as to the nature of inflammations, 
hyperplasias, and other changes, is indeed considerable; but we may 
safely assume that modern gymecologists will not grudge time spent 
in preparing themselves for this work. The field for original studies in 
this direction, in which all modern histological and micro-chemical 
methods are applicable, is very wide and attractive; but, leaving out all 
such considerations here, it is my aim in this paper rather to lay stress 
upon the importance of the more simple work and that which is done foi' 
purposes of diagnosis alone. For the sake of clearness it may be well 
to outline briefly the routine followed in my own work, in which I have 
the help of a pathological assistant. 
The Obtaining of the Material; its Preservation and Preparation for the 
Microscope. In the majority of cases the material which is to be exam- 
ined is that which is brought away by curetting the uterus. For pur- 
poses of examination this material possesses decided disadvantages as 
well as advantages. 
The two main advantages are (1) the ease with which such material 
can be obtained, even from regions, such, for example, as the fundus ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
3 
of the uterus, from which a portion of tissue can be excised only with 
difficulty ; and (2) because it gives an opportunity to study portions 
of the mucous membrane from many different areas. The chief disad- 
vantages that may be mentioned are: 1. In only a few of the cases does 
one obtain any of the muscular tissue from the body of the uterus, and 
scarcely any of the tissue, whether mucous membrane or muscular tissue, 
from the cervix. 2. The sections are necessarily made up of very small 
pieces, thus rendering it possible to miss just the tissue for which we 
are searching. 3. Examination of the material removed by curetting 
from the cavity of the uterus is frequently less satisfactory than the 
examination of tissues excised directly from the wall. This objection, 
as will be mentioned presently, applies even more strongly to scrapings 
from the cervical canal. 4. In curetted particles one necessarily loses 
almost all idea of the topographical relations of the tissue under exam- 
ination. 
With reference to the cervix, I am of the belief that it is almost 
an impossibility to obtain with the curette suitable material for micro- 
scopical examination. The mucous membrane adheres so closely to the 
underlying fibromuscular layer that it is almost impossible to sepa- 
rate it satisfactorily with any of the ordinary curettes. In order to 
examine the mucous membrane of the cervix it is always much better 
to excise a small wedge-shaped piece of tissue, which should include an 
appreciable portion of the suspicious growth, and, whenever possible, 
together with it a small portion of what is apparently healthy tissue. 
The piece excised should be of sufficient size to enable us to handle 
it readily and to recognize macroscopically its former relations. The 
incisions should be made sufficiently deep into the tissues of the cervix 
to include the bottoms of the glands, and should be carried some distance 
up the cervical canal. After the required portion has been removed 
the edges of the wound can be brought together by means of inter- 
rupted silk or catgut sutures. 
If an immediate microscopical examination of the tissue is not de- 
manded, the scrapings may be satisfactorily prepared as follows : 1. They 
are washed quickly in salt-solution or in cold water to free them from 
blood as thoroughly as possible. We have found that the addition of a 
small amount of sodium bicarbonate to lukewarm water facilitates this 
procedure very much. The tissues should not be permitted to lie in 
water or in salt-solution, however, as they will soon become macerated 
and unfit for examination. 2. The specimens are then placed in 50 per 
cent, alcohol for several hours 3. They are transferred to 97 per cent, 
or to absolute alcohol. The former, as a rule, is sufficiently strong, and, 
although absolute alcohol is perhaps better, it has the disadvantage of 
being much more expensive.1 
The more solid excised portions should be allowed to remain for from 4 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
twenty-four to forty-eight hours in the stronger alcohol until they are 
perfectly free from water. If, however, they are comparatively large, 
Jt will be necessary to pass them previously through a number of alcohols 
graded from 50 pei' cent, to absolute alcohol, since it has been found that 
the transferrence of too large pieces directly from the 50 per cent, alcohol 
solution to absolute alcohol will cause them to shrink extensively, so that 
the various relations may be distorted. Thus, for example, we have found 
that the epithelial cells often become detached from their base of sup- 
port. 4. The specimens are then usually placed in a mixture consisting 
of equal parts of commercial ether and alcohol, in which they are allowed 
to remain for twenty-four hours. They may then be placed in ether for 
twenty four hours. This step, however, in our experience has proved to 
be unnecessary and may be omitted. 5. They are next transferred to a 
thin solution of celloidin (of about the consistency of milk), in which they 
are allowed to remain for twenty-four to thirty-six hours. 6. They are 
then placed in thick celloidin (of the consistency of treacle) for from 
twenty-four to forty eight hours or even longer. By employing a solution 
of a consistency about midway between that of the thin and that of the 
thick solution we have often succeeded in preparing sections ofjendome- 
trial scrapings with a single solution ; but with portions excised from the 
cervix, or with pieces of relatively large size-over one centimetre square, 
for instance-it is advisable that they should be thoroughly saturated in 
both solutions. Instead of the ordinary celloidin, an excellent home-made 
substitute can readily be prepared by making ether-alcoholic solutions 
of photographers' fibre-cotton, which costs from about fifty cents to one 
dollar an ounce. 7. The specimens are next to be placed on small blocks 
made from wood, cork, paper, or glass. When dealing with uterine 
scrapings we usually place ten or twelve pieces on one block. 8. The 
" blocked " specimens are then allowed to remain for about fifteen minutes 
exposed to the influence of the air, until some setting and contraction of 
the superficial part of the celloidin have taken place. The blocks are 
then placed in 50 or 75 per cent, alcohol, and after several hours are 
ready to be cut with the microtome. When on the blocks and kept in 
the alcohol the specimens remain comparatively good for an indefinite 
length of time, although after some months, as a rule, sections which 
are taken from them do not stain so well as when they are cut shortly 
after the specimens have been prepared. 
This " celloidin-imbedding method" is in general use in the prepara- 
tion of pathological specimens, and is for ordinary work preferable to 
all others. For " ribbon-sections," or serial sections in continuous bands, 
the " paraflin-method " must be employed. It may besides be objected 
1 The ordinary 97 per cent, alcohol may be converted into nearly absolute alcohol by the 
addition of sulphate of copper from which the water has been dried off by heat, the alcohol 
being afterward decanted off as required. ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
5 
that the celloidin-sections are also somewhat thicker; but certainly the 
after-handling of them is much easier and the method itself is simpler. 
Serial sections, though not in continuous bands, of course, can be made 
by the celloidin-method. 
Some of the European gynecologists prefer to employ paraffin in pre- 
paring tissues for microscopical examination. The method is somewhat 
as follows : 1. The specimens are first hardened in absolute alcohol. 2. 
They are then placed for twenty-four hours in some solution in which 
paraffin is soluble. Chloroform, xylol, or an ethereal oil may be used for 
this purpose. 3. They are then saturated with paraffin, either directly 
by placing them in paraffin melting at 50° C. for twenty-four hours, or 
indirectly by permitting them to remain in an open vessel in a solution 
of paraffin in xylol at a temperature of 50' to 55° C., the xylol being 
gradually volatilized. 4. A small paper cell is prepared of sufficient size 
to hold the preparation and at the same time to allow considerable 
free space, which is first filled with melted paraffin of a slightly higher 
melting-point. The specimens are then taken from the paraffin and 
placed in the cell in the desired position, hot needles being used for this 
purpose. The cell is then cooled either by exposing it to the air or by 
pouring cold water around it, after which the paraffin, which has now 
become a solid block, and which holds the preparation firmly imbedded 
in it, is removed from the cell and the sections can be cut with the 
microtome. 
Besides alcohol for hardening and preserving tissues may be mentioned 
formalin, corrosive sublimate, and Muller's fluid. Formalin acts very 
quickly indeed in solutions even as dilute as 2 per cent., except in the 
case of mucous membranes, where even very strong solutions do not 
seem to harden tissues nearly so well as alcohol. It is especially good 
in dealing with gross specimens, and preserves the blood-cells in the sec- 
tions. Formalin-tissues do not, however, stain satisfactorily in haema- 
toxylin and eosin. The fumes are irritating and may produce an 
unpleasant and persistent coryza. With some individuals even in 
weak solutions it produces a peculiar dryness of the skin if allowed to 
come in contact with it for any length of time. The sensation which 
is thus caused is somewhat comparable with that following expo- 
sure to strong solutions of carbolic acid, but the effects are probably 
much more decided. Dr. Cullen, of the Johns Hopkins Hospital, advo- 
cates a formalin-method for rapidly preparing permanent sections.1 
His method in brief is as follows : 1. The tissues are cut by means 
of the freezing-microtome. 2. The cut sections are placed in a 5 per cent, 
aqueous solution of formalin for from three to five minutes. 3. They are 
then placed in 50 per cent, alcohol for three minutes. 4. Then in abso- 
1 The full description ot this method, which is one of the most valuable recently introduced 
is to be found in the Johns Hopkins Hospital Bulletin, No. 49, April, 1895. 6 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
lute alcohol for only one minute. 5. Further treatment is carried out 
as with the ordinary celloidin-sections. Cullen advises that when possible 
the tissue should be hardened in a 10 per cent, formalin-solution for two 
hours before it is frozen and cut. He believes that this is of special 
value in preparing scrapings from the uterine cavity. The first method 
occupies about fifteen minutes, while the second consumes an additional 
two hours. Cullen says that by the latter method the blood in the tissues 
is partially retained and will stain to some extent, but not wholly satis- 
factorily. Personally we have not had any experience with this second 
method, but we propose to employ it in the near future. As was said 
before, the rapidity with which it penetrates and hardens the tissues 
makes formalin of special value in the preparation of gross specimens. 
Corrosive Sublimate. A saturated solution in normal salt-solution fixes 
tissues well, if minute particles only are used. After being fixed the 
tissues are further hardened in alcohol. The metallic deposits may be 
removed from the sections with tincture of iodine, and this in turn with 
80 per cent, alcohol. 
Muller's Fluid. The action of this fluid upon tissues is so slow that 
in the preparation of small tissues it is advisable to use other agents for 
fixing and hardening. It requires several weeks to harden small objects 
in Muller's fluid, and the fluid must be frequently changed. 
When it is necessary to make an immediate examination of tissues it 
is best to cut the tissues into sections by means of the freezing-microtome, 
or better still, perhaps, to follow out Cullen's suggestion. It is to be 
remembered that only thin fragments are suitable for the freezing-micro- 
tome.1 It is hardly necessary to mention that alcoholic specimens will 
not freeze unless the alcohol is first removed from them. 
Although in normal histological work it is especially desirable to 
make thin sections, moderately thick ones can, as a rule, be utilized 
for pathological examinations. We have been able to obtain at 
times very thin celloidin-sections by properly diluting or strengthen- 
ing the alcohol which is employed in keeping the knife and specimen 
moist. We find, however, that absolute alcohol is not to be recom- 
mended, as it will render the celloidin sticky, and may even dissolve it. 
About 85 to 90 per cent, is the limit of strength which should be 
employed for this purpose. The sections which are cut away may be 
removed from the knife-blade either with the flat of the finger, or, better 
sill, by means of a moderate-sized camel's-hair brush, which may also 
be employed to keep the knife and specimens wet. These sections 
when cut are put into the 75 percent, alcohol, and are now ready for 
staining. 
Staining of Sections. A great variety of staining-methods are in use, 
1 An excellent description of the technique of the freezing-microtome will be found in Fried- 
lander's Microscopische Technik or Kahlden's Histologische Untersuchung. ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
7 
but for ordinary pathological work in gynaecology a few simple stains 
suffice. Much can be learned as to " form-relations " from the study 
of unstained specimens ; but for finer histological changes staining with 
one or more dyes is highly desirable. Delafield's haematoxylin alone 
or in conjunction with eosin as a counter-stain yields excellent results, 
especially if acid alcohol be used as a differentiating fluid. Carmine, 
picro-carmine, and Van Giesen's mixture are valuable general stains. 
For demonstrating bacteria in specimens the four following methods1 are 
the most common in use for purposes of diagnosis : 1. Gram's method, 
either simple, or Gram's method with previous staining with picro-lithium 
carmine. 2. Weigert's fibrin-stain, which stains many forms of bac- 
teria, fibrin, hyaline, and sometimes elastic tissue. 3. Carbol-fuchsin. 
4. Methylene-blue. 
The Clinical Records of the Cases. 
In order to enhance the value of the microscopical examinations I have 
made it a rule to keep parallel clinical protocols of the cases, paying 
particular attention to the following points : 
Name, age, social condition, residence, color, occupation. 
Number of labors, whether instrumental or not. Age of oldest and 
youngest child ; character of puerperia. 
Miscarriages or abortions ; at what period of pregnancy. Any pos- 
sible sequelae. 
Menses. Age at first appearance. Regularity; amount; duration ; 
whether painful or not. Date of last menstrual period. 
Leucorrhcea; whether present or not. Character of discharge, whether 
irritating or not; color and amount. 
Micturition ; any disturbance noticed by patient. 
Bowels. Usual condition ; general effects of laxatives and purgatives. 
Family history. 
Personal history. 
Patient's chief complaints ; i. e., those subjective symptoms which led 
the patient to present herself for treatment or diagnosis. 
Present condition, embracing a thorough physical examination. 
Examination of urine, chemical and microscopical. 
Results of the examination : (1) without amesthesia, (2) under anaes- 
thesia. 
Ill studying the sections particular attention is paid to the following 
points, and the results are recorded : 
1. The superficial epithelium; i. e., the layer of epithelium lining the 
cavity of the uterus. 
The Histological Protocols. 
1 These methods are fully described in the books on microscopical technique. 8 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
Character of cells : 
Ciliated or not. 
Single layer or multiple layers, etc. 
2. Utricular glands: 
Course. 
Length. 
Size. 
Lumina. 
Shape. 
Glandular epithelium. Character of cells : 
Ciliated or not. 
Single layer or multiple layers. 
3. Stroma. Size of cells. Physical characteristics. 
Different sorts of cells : 
Lymphoid. 
Ovoid or round. 
Fusiform or spindle. 
Peculiarities in arrangement of cells. 
4. Vessels. Those near the superficial mucous membrane, and those 
further away from the surface. 
5. Muscular tissue. If present or not; and if any peculiarities noted. 
6. Cervical tissues. If present or not; and if any peculiarities noted. 
7. Histological Diagnosis. 
8. Notes or Remarks. 
In this way it will be seen that the careful clinical history which is 
taken of the cases and the histological findings are made to supplement 
one another. A discussion of the many different points to be considered 
in the diagnosis of the specimens is impossible in the present paper. 
Fortunately, however, we now have at our disposal a rich literature upon 
the subject, and especially worthy of mention in this connection are the 
work of Ruge and Veit on Uterine Carcinoma, Abel's Technik und Diag- 
nostic in der Gyndkologischen Praxis, and the section of Orth's Pathol- 
ogy, entitled " Weibliche Geschlechtsorgane." 
Conclusions. A study of the appended tables, in which the results 
of the parallel examinations of 100 cases have been systematically 
arranged, reveals a number of interesting points. 
Thus, in Table I., it will be seen that of 100 cases the question of 
malignancy or benignancy could be settled in 95. In 2 cases which clin- 
ically appeared to be benignant, positive and timely evidence was given 
of malignancy by the microscopical examination. In 2 cases in which 
the clinical symptoms pointed to malignant disease the microscope en- 
abled us to confirm the clinical diagnosis beyond all doubt. In 1 case 
in which there was clinically at least a warrantable suspicion of malig- 
nancy the microscope changed the condition of suspicion to one of 9 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
certainty. In 26 cases in which the clinical symptoms rendered the sus- 
picion of malignancy at least warrantable the microscopical examination 
proved the absence of malignant disease. In 63 cases in which the 
clinical symptoms pointed to a benign disease the microscopical examin- 
ation confirmed the clinical diagnosis or showed a normal endometrium. 
In Table I.(a) the clinical symptoms met with in different conditions 
of the endometrium and in some few malignant conditions have been 
tabulated. 
Pain. In 22 cases in which the microscope showed normal or approxi- 
mately normal endometrium pain was absent in but 3 cases. This is a 
point we think worthy of some emphasis, inasmuch as it proves the pos- 
sibility of the existence of painful affections referable to the uterus, in 
cases in which histological changes, at least by the methods ordinarily 
employed, are not demonstrable. In 31 cases of endometritis glandu- 
laris pain was absent in but 1 case. ' In 24 cases of endometritis inter- 
stitialis pain was absent in only 2 cases. In 5 cases of endometritis 
glandularis et interstitialis pain was absent in but 1 case. In 8 cases of 
endometritis post abortum sive partum pain was absent in but 2 cases. 
In the 5 malignant cases it was not absent in a single instance, and was 
generally continuous. In 30 cases of endometritis glandularis dull pain 
occurred in 21 and sharp pain in 9. In 19 cases of endometritis inter- 
stitialis dull pain occurred in 9 ; sharp pain in 10. In endometritis 
Table I. 
Normal endometrium. 
Endometritis glandu- 
laris. 
Endometritis inter- 
stitialis. 
Endometritis glandu- 
laris et interstitialis. 
Endometritis post par- 
turn sive post abortuni 
Adenocarcinoma. 
Squamous carcinoma. 
Sarcoma. 
Material insufficient, or 
diagnosis doubtful, oi 
malignancy doubtful. 
Total cases 
100 
22 
31 
24 
5 
8 
2 
3 
0 
5 
a. Cases in which clinical symptoms pointed 
to benign disease. Microscope showed 
absence of malignant disease .... 
67 
17 
20 
15 
4 
7 
• 
4 
6. Cases in which clinical symptoms pointed 
to benign disease. Microscope showed 
presence of malignant disease .... 
2 
2 
c. Cases in which clinical symptoms pointed 
to malignant disease. Confirmed by 
microscope 
2 
1 
1 
d. Cases clinically suspicious as to malig- 
nancy ; microscope showed undoubted 
malignant disease 
1 
1 
e. Cases clinically suspicious as to malig- 
nancy ; microscope showed absence of 
malignant disease 
28 
5 
11 
9 
1 
* 
1 10 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
Table I.(a)- Clinical Sheet. 
Normal endometrium. 
Endometritis glandu- 
laris. 
Endometritis inter- 
stitialis. 
Endometritis glandu- 
laris et interstitialis. 
Endometritis post par- 
turn sive post abortum. 
Adenocarcinoma. 
Squamous carcinoma. 
Sarcoma. 
Material insufficient, or 
diagnosis doubtful, or 
malignancy doubtful. 
Pain absent ....... 
3 
1 
2 
1 
2 
continuous 
3 
2 
4 
2 
2 
intermittent ...... 
15 
27 
15 
4 
4 
1 
5 
worse at periods or on exertion 
11 
19 
11 
3 
5 
i 
1 
5 
lancinating or sharp .... 
4 
9 
10 
2 
1 
1 
2 
4 
dull or boring 
10 
21 
9 
3 
3 
1 
1 
1 
limited to pelvis 
17 
29 
19 
4 
4 
1 
2 
5 
headache 
3 
6 
2 
1 
backache 
12 
21 
11 
5 
5 
i 
f 
5 
Discharge, moderate 
7 
13 
11 
4 
5 
i 
2 
absent 
2 
8 
5 
2 
2 
profuse ....... 
13 
10 
8 
1 
3 
i 
1 
1 
Menses, amenorrhcea 
2 
1 
1 
i 
1 
too frequent ...... 
3 
6 
6 
2 
i 
i 
too infrequent 
2 
3 
4 
1 
i 
2 
1 
regular 
15 
22 
13 
2 
6 
3 
scanty 
5 
6 
6 
1 
1 
2 
1 
profuse 
9 
17 
8 
3 
3 
i 
1 
2 
normal in amount 
6 
8 
9 
1 
3 
1 
normal in duration 
10 
18 
12 
1 
2 
1 
2 
too long in duration .... 
6 
10 
6 
3 
5 
i 
1 
1 
too short in duration .... 
4 
3 
5 
1 
1 
1 
painless ....... 
10 
13 
7 
1 
2 
2 
2 
painful 
10 
18 
16 
4 
5 
i 
1 
2 
with clots of blood 
3 
5 
3 
2 
3 
i 
1 
Metrorrhagia 
2 
3 
1 
5 
2 
1 
1 
O-parous women 
10 
16 
12 
4 
3 
1 
3 
Parous women ...... 
12 
15 
12 
1 
5 
1 
3 
2 
Abortion diagnosed clinically 
2 
Results of treatment: 
cured ....... 
1 
1 
benefited permanently .... 
14 
20 
18 
1 
8 
1 
2 
temporarily 
7 
10 
6 
3 
2 
1 
3 
unimproved ...... 
1 
1 
died 
glandularis et interstitialis, 5 cases, dull pain occurred in 3 and sharp 
pain in 2. This would seem to show that in cases of glandular endome- 
tritis dull or boring pain is more frequently met with than sharp or lan- 
cinating pain, while to a somewhat less extent the reverse is true in 
cases of interstitial endometritis. The pain complained of is in the 
great majority of instances limited to the pelvis or to the lower portion of 
the abdomen. We found this to be true in about 80 per cent, of cases. 
Headache is a rather infrequent symptom, being met with but 12 times. 
Backache is much more frequently met with, being recorded 61 times. 
Discharge. In 22 cases in which the microscope showed normal endome- 
trium discharge was absent in but 2 cases, and in 20 cases it was consid- 
erable in amount. In these cases the discharge probably originated from 
the cervix, and not from the body of the uterus ; that is to say, the cases, 
or the majority of them, must have been instances of " cervical " endo- 
metritis. In 31 cases of definite glandular endometritis discharge was ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
11 
Table I.(i)-Histological Sheet. 
Normal endometrium. 
Endometritis glandu- 
laris. 
Endometritis inter- 
stitialis. 
Endometritis glandu- 
laris et interstitialis. 
Endometritis post par- 
turn sive postabortum. 
Adenocarcinoma. 
Squamous carcinoma. 
Sarcoma. 
Material insufficient, or 
diagnosis doubtful, or 
malignancy doubtful. 
Superficial epithelium: 
wanting, or insufficient for diagnosis . 
2 
3 
1 
1 
2 
2 
2 
single layer 
20 
2G 
24 
'1 
7 
... 
1 
3 
multiple layers 
... 
2 
2 
high columnar 
1G 
19 
15 
2 
3 
medium columnar 
3 
8 
6 
1 
3 
1 
low columnar or cuboidal 
1 
1 
4 
... 
4 
ciliated 
17 
24 
15 
3 
2 
1 
3 
cilia not demonstrable .... 
3 
4 
9 
5 
character of epithelium undetermined 
(not sufficient to judge from) 
1 
1 
Utricular glands : 
wanting or material insufficient 
1 
1 
1 
course, tortuous or zig-zag 
1 
si 
9 
4 
6 
straight or nearly so . . . 
21 
15 
1 
1 
1 
2 
number, increased 
is 
4 
1 
2 
2 
normal ...... 
22 
6 
6 
1 
• 2 
... 
1 
1 
diminished 
1 
10 
2 
3 
... 
1 
size of lumina, regular .... 
17 
4 
1 
1 
irregular 
5 
81 
20 
5 
6 
2 
3 
shape of lumina regular 
20 
21 
1 
1 
2 
irregular . 
2 
31 
3 
4 
7 
2 
2 
invaginated glands 
8 
21 
13 
2 
Glandular epithelium: 
wanting or insufficient to judge from . 
1 
1 
single layer 
22 
28 
24 
5 
6 
i 
1 
5 
multiple layers 
... 
7 
3 
2 
3 
2 
high columnar ..... 
19 
18 
20 
3 
2 
1 
4 
medium columnar 
3 
10 
4 
1 
1 
i 
low columnar or cuboidal 
... 
3 
1 
5 
2 
1 
ciliated 
20 
22 
23 
5 
3 
i 
4 
cilia not demonstrable .... 
1 
9 
1 
4 
2 
1 
undetermined 
1 
1 
Stroma: 
small round and ovoid cells with fusi- 
form cells around gland lumina . 
20 
27 
13 
3 
5 
1 
i 
4 
round or oval cells, varying in size, 
some large, some small 
1 
4 
7 
2 
2 
1 
bands of spindle-cells running through 
stroma 
18 
2 
1 
spindle-cell element in excess 
3 
1 
23 
3 
2 
1 
cells crowded closely together 
4 
11 
6 
1 
1 
i 
cells not closely packed together . 
1 
4 
4 
1 
1 
lymphoid cells 
12 
13 
12 
1 
6 
i 
2 
2 
polynuclear leucocytes . 
13 
14 
10 
6 
2 
3 
regularly distributed 
3 
6 
3 
... 
2 
grouped in spots 
2 
... 
2 
free red blood-cells numerous 
14 
18 
i'2 
3 
3 
1 
few .... 
4 
5 
4 
1 
2 
decidual cells 
8 
1 
Vessels, numerous 
14 
20 
15 
3 
8 
2 
1 
scanty or none found .... 
8 
11 
9 
2 
4 
dilated 
10 
16 
13 
3 
8 
i 
2 
collapsed . 
6 
8 
4 
1 
4 
Muscle-tissue, present . 
4 
4 
5 
1 
i 
1 
3 
absent 
18 
27 
19 
5 
7 
i 
2 
2 
Cervical tissue, present . 
1 
2 
1 
... 
2 
- 
2 
2 
absent .... 
21 
29 
23 
5 
6 
2 
1 
3 
Placental villi, chorionic or amniotic rem- 
nants 
5 
22 
31 
24 
5 
8 
2 
3 
0 
5 12 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
absent in 8 cases, or in nearly 25 per cent. This shows that leucorrhoea 
is by no means always present in such cases. In 24 cases of interstitial 
endometritis leucorrhoeal discharge was absent in 5 cases, or in about 20 
per cent. This is also interesting when considered together with the 
immediately preceding statement. In 8 cases of endometritis following 
abortion or labor a leucorrhoeal discharge is noted in every case. In 2 
cases of adenocarcinoma, one of the cervix, the other of the fundus of 
the uterus, a leucorrhoeal discharge was present in both cases. In 3 
cases of squamous carcinoma leucorrhoeal discharge was absent in 2 
cases, and was profuse in 1 case. In the two cases the disease being 
incipient, there were, in fact, no well-marked clinical symptoms such as 
would have rendered one even suspicious of a malignant condition. It 
was only in the course of the routine examination of all tissues that the 
presence of a malignant growth was demonstrated. In the third case 
carcinoma could be diagnosed clinically, but the condition unfortunately 
had progressed too far to admit of a removal of the uterus. 
Menses. Regularity: in the majority of cases the menses are noted 
as being regular. It is interesting to note that in 8 cases of endometritis 
after abortion, or after labor, the menses are noted as being regular in 6. 
Amount: in 31 cases of glandular endometritis the amount was scanty 
in 6 ; profuse in 17 ; normal in 8. In 24 cases of interstitial endome- 
tritis it was scanty in 6 ; profuse in 8 ; normal in 9. We shall watch 
with interest the results in such cases in the future in order to see 
if the relations here presented be characteristic in these diseases. The 
table shows that in over 50 per cent, of cases of glandular endometritis 
profuse menstruation was met with, but in only 33 per cent, of cases of 
interstitial endometritis was the same condition found. In 8 cases of 
endometritis post abortum sive partum menstruation is recorded as pro- 
fuse in but 3. In only one of the eight cases is amenorrhcea noted. 
Five of these eight patients are recorded as having the menstrual period 
of too long duration. Of the 2 cases of adenocarcinoma, one patient 
was past the menopause, being about sixty or sixty-five years of age. 
She had had a very trifling hemorrhage from the uterus previous to her 
admission into the hospital. This was the only symptom that the patient 
complained of ; but she had been further told by her attending physician 
that there was no malignant disease of the uterus, and on physical ex- 
amination alone nothing could be made out suggesting such a condition. 
As regards painfulness or painlessness of menses, pain seems to be more 
constantly present in the interstitial form of endometritis than in that 
of the glandular type ; in endometritis interstitialis, 23 cases, the menses 
were painful in 16, painless in 7, with clots of blood noted altogether 
18 times. Out of 8 cases of endometritis post abortum sive partum pain 
was present in 3 cases. 
Metrorrhagia was noted twice in 22 cases in which the endometrium ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
13 
appeared to be normal on microscopical examination ; three times in 
31 cases of endometritis glandularis ; in no instance in 24 cases of endo- 
metritis interstitialis ; five times in 8 cases of endometritis post abortum, 
sive partum ; twice in 2 cases of adenocarcinoma ; once in 3 cases of 
squamous carcinoma. It is interesting to observe that in 8 cases of endo- 
metritis post abortum sive partum abortion had been diagnosed in but 
2 cases. Exactly what proportion of these 8 cases were post abortum 
and what post partum I was unable to say, but three of the 8 cases are 
recorded as occurring in nulliparous women. In 1 case placental villi 
were found in a fairly well preserved condition nine months after the 
abortion was said to have taken place. 
Results of Treatment. No deaths are recorded. 2 cases are classed 
as unimproved. In the majority of cases, 64, treatment effected a per- 
manent benefit; temporary benefit was experienced in 32 cases. 
Of the malignant cases, in 2 cases of adenocarcinoma temporary ben- 
efit was recorded. In one of these cases radical treatment was impossi- 
ble on account of the local extent of the disease and the occurrence of 
metastases. In one case the age of the patient and her general condition 
compelled the writer to advise against any operation, although the disease 
was not advanced. One of the cases of squamous carcinoma reported 
as temporarily benefited has had a third operation for curetting and 
cauterization since, and is in a very precarious condition, the disease now 
involving the bladder and rectum. In the other two cases vaginal hys- 
terectomy was performed over two years ago and the patients have been 
up to the present time free from any return, and are apparently in ex- 
cellent health. 
Table 1.(6).' Superficial epithelium. In the majority of instances 
a single layer was demonstrated. Multiple layers are noted in 2 
cases each of endometritis glandularis and endometritis interstitialis. 
We should say here in passing that the determination of the question 
whether a single layer or multiple layers are present is attended with a 
great deal of difficulty. One has constantly to keep in mind the readi- 
ness with which the appearance of multiple layers is produced by oblique 
section and by thick sections, so that considerable experience in inter- 
preting the microscopical image is demanded. We cannot agree with 
some authors that a multiple layer of epithelium, either of the superficial 
or glandular type, is of itself a sign of malignancy. The appearance 
may be accounted for in several ways ; it may be due, for example, to 
shrinkage and distortion of the specimen during preparation, to oblique 
and thick sections, and possibly to other causes. We believe also that, 
in the majority of instances where these external causes may be excluded, 
multiple layers denote merely a hyperplasia of the cells. 
1 From the Pathological Laboratory of the Western Reserve University. 14 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
With regard to the height of the cell, Abel has pointed out that low or 
medium columnar cells are suspicious of pregnancy. Now, in eight of 
our cases of endometritis post abortum sive partum low or cuboidal epi" 
thelium is noted in four cases and medium columnar in three. This 
effect of flattening out the cells, which may indeed go so far that the 
superficial epithelium becomes changed into a sort of endothelial mem- 
brane with cells having more breadth than depth, and resembling endo- 
thelial cells very closely, is probably, though not entirely, the result of 
pressure. We have noticed similar flattening of cells in cases of ectatic 
glands and in cases of hydrosalpinx, where the pressure of the contents 
must have been greater than the usual pressure which is exerted upon 
the cells. 
Fig.1. 
Fig. 2. 
Fig. 3. 
Fig. 4. 
Fig. 5. 
Section a-a in Fig. 1. 
Section e-e in Fig. 2. 
The presence or absence of cilia. In the majority of cases cilia were 
found, their absence being recorded only 21 times. In 8 cases of endo- 
metritis post partum or post abortum they were demonstrated in but 2 
cases and not demonstrated in 5 cases. 
Utricular glands. A tortuosity of the glands, probably in the lower 
layer of the mucous membrane, seems to be an almost constant finding 
in cases of endometritis post abortum sive partum. There is also some 
irregularity in the size and more especially in the shape of the glands in 
these cases. Invaginated glands were found 8 times in 22 cases, where 
the endometrium had to be designated as normal; 21 times in 31 cases ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
15 
of endometritis glandularis ; 13 times in 24 cases of endometritis inter- 
stitialis ; twice in 5 cases of endometritis glandularis et interstitialis. 
Invaginated glands or sections of lumina within lumina, or rather the 
appearance of such things in the microscopical section, may be produced 
in a variety of ways. A pictorial representation will illustrate this to 
better advantage than can be done in other ways. Fig. 1 represents a 
true intussusception or invagination of a utricular gland. Fig. 2 shows 
Fig. 6. 
a 
c 
Adenocarcinoma of the cervix uteri. 
a. Gland-ducts, but little changed, b. Alveolus filled with flat cells, c. Atypical gland-duct. 
a uterine gland dividing dichotomously. Fig. 3 shows a papillary pro- 
jection into the lumen of gland. The lines aa to ee represent sections. 
If these be made perpendicular to the plane of the paper, we should have 
somewhat the result pictured in Figs. 4 and 5. The papillary projec- 
tions in Fig. 3 may appear somewhat diagrammatic, but we have seen 
just such a condition under the microscope. 
Glandular epithelium. What has been said of the superficial epithe- 
lium holds true also for that of the glandular type. Multiple layers, 
however, are more frequently met with in the glands. 
Stroma. The typical normal stroma may be said to consist of small 16 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
round or oval cells, almost, but not quite, as small as lymphoid cells, all 
of about one size, with a single layer of fusiform cells round the gland 
lumina. These fusiform cells make the membrana propria for the gland- 
ular epithelium. They show the fusiform shape under the microscope, 
but they are probably flat endothelial-like cells. We can readily under- 
stand this when represented pictorially. These cells which appear to be 
fusiform are in all probability only endothelial like cells, through which 
perpendicular sections have been made. In 20 of the 22 cases of nor- 
Fig. 7. 
- a 
' b 
Decidual remnants and placental villi. 
a. Placental villus, b. Large piece of decidua showing large decidual cells. 
mal endometrium and in 27 of the 31 cases of endometritis glandularis 
this condition was found. In 13 of the 24 cases of endometritis inter- 
stitialis, in 3 of the 5 cases of endometritis interstitialis et glandularis, 
and in 5 of the 8 cases of endometritis post abortum sive partum these 
structures could easily be made out. In all of these last 8 cases, however, 
decidual cells were also found. It is interesting to note in this connec- 
tion the behavior of the stroma-cells to staining with the different dyes. 
It was found when using the picro-carmine method that the nuclei of 
the small round and oval cells stained intensely with the carmine, while 
the cell-bodies, though taking on faintly the same stain, did not stain 
at all with the picric acid. In other words, unless they are undergoing ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
17 
some degenerative process, no yellow tint could be seen in them. Blood- 
cells, on the other hand, whether free in the stroma or inside the vessels, 
stained intensely with the picric acid. The cell-bodies stained with 
eosin, however, but faintly. Decidual cells took on the eosin-stain 
deeply, and one could recognize them even with low powers by the 
peculiar pinkish tinge of the section whenever they were present in 
sufficient numbers. In 7 cases of endometritis interstitialis out of a 
Fig. 8. 
a 
b 
c 
d 
Papillary growth encroaching upon lumina of glands. 
a. Pedicle. &. Foreign body. c. Complicated papillary growth, d. Bloodvessels, 
total of 24, and in 4 cases of endometritis glandularis out of 31 cases 
the stroma-cells are noted as varying much in size, some being larger, 
some smaller than normal. Giant cells with many nuclei were seen in 
quite a number of the cases of endometritis post abortum sive partuni. 
The exact'record of the number of times of their occurrence, unfortu- 
nately, has not been noted, but I can recall three instances in which 
they were found. In one case they were so numerous as to give rise to 
a suspicion of giant-celled sarcoma, there being at the time no clinical 
history of abortion or miscarriage, and the foetal structures not being 
positively demonstrable. The answers of the patient, however, upon 
being closely questioned as to the occurrence of an abortion, previous 18 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
to her applying at the clinic, went to show that she had miscarried. 
Histologically the picture presented by the section under the microscope 
resembled closely that of a myosarcoma. 
Bands of spindle-cells in the stroma were observed 18 times in 24 cases 
of endometritis interstitialis, while the spindle-cell elements were found 
in excess 23 times. Very characteristic pictures in endometritis inter- 
stitialis are the concentric whorls of spindle-cells which form around the 
gland lumina. Instead of the normal single layer of spindle or fusi- 
Fig. 9. 
Muscularis. 
Endometritis glandularis hyperplastica. 
The cleft in the middle of the section is part of the cavity of the uterus. 
form cells, sometimes as many as ten layers may be seen. In many 
places these cells are seen to be compressing the gland, and the gland- 
epithelium is undergoing degenerative changes, sometimes of the nature 
of simple atrophy, while sometimes active degenerative changes-e. g., 
cloudy swelling or necrosis-have taken place. 
Polynuclear leucocytes were found free in the stroma as follows : in 22 
cases of normal endometrium, 13 times ; in 31 cases of endometritis 
glandularis, 14 times ; in 24 cases of endometritis interstitialis, 10 times ; 
in 8 cases of endometritis post abortum sive partum, 6 times. Just what 
their presence signifies it is hard to say. In most of the cases they were 
found sparsely, but more or less regularly distributed, not being present BOBB: EXAMINATION OF UTERINE SCRAPINGS. 
19 
in great numbers and evidently not representing inflammatory infiltra- 
tion. Their almost constant presence (in six out of eight cases) in cases 
of endometritis post abortum sive partum would seem to indicate that 
they are perhaps playing some role in the involution of the mucosa. 
It is evident, however, that their presence in the uterine mucosa (when 
sparsely and regularly distributed) is of no great pathological signifi- 
cance. 
Fig 10 
Endometritis glandularis hypertrophica. Specimen obtained by curetting. 
Free blood-cells were also frequently met with ; in 22 cases in which 
the endometrium has been classed as normal, 18 times; in 31 cases of 
endometritis glandularis, 23 times ; in 24 cases of endometritis intersti- 
tialis, 16 times ; in 5 cases of endometritis glandularis et interstitialis, 
3 times ; in 8 cases of endometritis post abortum sive partum, 4 times. 
The explanation of their presence in such a number of cases with nor- 
mal endometrium does not seem clear. What their role is, apart from 
the phenomena of menstruation, we do not understand. 
Decidual cells were found in all the 8 cases of endometritis post aboi- 
tum sive partum. True decidual cells were not found in any of the 
other conditions, though cells approaching them closely in size were often 
found in cases of interstitial endometritis. 
Vessels. No true arteries or veins are found in the superficial layers of 
the mucosa. Here the bloodvessels are all venous or arterial capillaries, 20 
ROBB: EXAMINATION OF UTERINE SCRAPINGS. 
the latter far outnumbering the former. In all 8 cases of endometritis 
post abortum sive partum the vessels were found dilated. 
Muscular Tissue and Cervical Tissue. We desire to call attention espe- 
cially to the infrequency with which muscular tissue and cervical tissue 
were met with. Muscular tissue is recorded as being present in but 19 
cases. Cervical tissue is recorded as being present in but 11 cases. 
The above table includes several cases in which sections were made 
from the cervix, so that cervical tissue really was obtained by curetting 
even fewer times than would at first appear from the table. 
Fig. 11 
Endometritis interstitialis. Specimen obtained by curetting, 
Placental villi, chorionic or amniotic remnants, were found in 5 cases of 
endometritis post abortum sive partum. We are inclined to the opinion 
that, lacking a clinical history of abortion or pregnancy, it is impossible 
in many instances to make an absolute diagnosis of a foregoing preg- 
nancy unless such foetal remnants be demonstrated. Their presence, 
however, must be considered, of course, as proof positive of a preceding 
pregnancy. 
In conclusion, I wish to thank my assistant, Dr. Walter R. Lincoln, 
for valuable aid in the preparation of the tissues and in the laborious 
analysis of the cases. 
The several micro-photographs illustrate typical microscopic findings 
in some of the cases to which we have referred. Tl?e JoUrpal 
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