Primary Carcinoma of Bartholin’s Gland*

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find out what it is that kills thesP bahieg. I have Sl.'\'l.'r:;l easvs wlwre 1 tried twiee to carry out a pregnancy in an establishPd diu betic beforp pr<:gnaney; and each resulted in intrauterine death ,just before term. I am inrlin(•d to think there is some justification in offering cesarean section two weeks before tnm in the int{•rest of the baby to these partieular patients if tlwy insist on further pregnaney. I han• no fL•ar of surgery in a diabetic patient provided I havr the ease under th!' <'are of a !'Ompetent internist who controls the diabetes as he s!'es fit. DR. H. J. STANDER.-! do not think one ean make a definite statemt>nt about a patient with diabetes at the beginning of pregnancy. The effeets of pregnancy or the effects perhaps of tbe fetal pancreas on diabetes are questions of great interest and I am quite eonvineed from six eas0s that I studied throughout pregnancy that there is a good effrct on many of the diabetic patients as a result of the ])regnancy itself. We have seen four patients who had a blood sugar around 150-200; the sugar tolcranep test was way up, at the fourth hour it was still in the neighborhood of 200 mg. There was not any question about the diagnosis of diabeh•s. About the seventh month of pregnancy the patients showed improvement, at the ninth month of pTegnaney they had gonp without using insulin, and approximah•ly a month after their babies were born they reverted to their prepregnancy state of diabetes. So I am convinced tllat in the milder forms of diabetes pn•gnaney, either through the fetal hormone or through the fact that the carbohydrate is used up mainly hy tlH• drild, as is (wideneed hy the large ehild, exerts a good effect on the diabetes. I cannot agree with the speaker and regard diabetes as always a very serious complication of pn•g11ancy. Judging by the very seven• eases of diabetes that I have had and thos!' that we haw studied, I believe if you get them early in pregnancy, the second month, and carry them through their pregnanq on a diabetic regimen in the hospital, having them come in for two or three days ('H'l'Y second month and study them eurcfully, you ean earry them through. I cannot agree with the doctor on the desirability of eesar!'tm s!'etion in diabetPH because I feel that while> insulin has don(' a great deal, the diah<>tie patient is not quite the risk fOl' cesarean section, and with the results that we all know ahout in these children. I would not subject a patit•nt with diab!'tes to ~ection, t:Wn at the seventh or !'ighth month, to get a live child.

PRIMA_RY

CARCI~OMA

OF BARTHOLIN'S GLAND*

-vv. BENsoN HARER, l\LD., F.A.c.s., PHILADELPHIA, PA. (From the Gynecological Depa·rtrnent of St. Agnes Hospital)

ARCINOMA of Bartholin's gland as a primary tumor is very rare. Rabinovitch, in the most recent contribution to the subject states that there are not over forty cases in the literature but unfortunately he does not append a complete bibliography. My own review of the literature reveals only thirty eases of which several are doubtfuL Probably the earliest ease reported was that of Klob, who in 1864 described a tumor of Bartholin's gland which had the appearance of a eystosarcoma of the nipple. In 1880, Sinn while making an autopsy, fonnd a tumor of undoubted malignaney originating in Bartholin's gland in a woman twentyeight years of age. August Martin, in his book cites a rase of carcinoma of Bartholin's gland which recurred four years after removal of the orig. inal tumor. Geist in 1887 reported a case described as part tubular car-

C

•Read at a meeting of the Obstetrical Society of Philadelphia, November 3, 1932.

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715

cinoma and part scirrhus. Schweizer and 1\fackenrodt both reported eases in 1893, but omitted such important details as the type of tumor, metastases, and final result. In fact, many of the reported cases are quite incomplete so that we are unable to draw definite conclusions as to many interesting and important points. During the past forty years occasional contributions have been made to the subject, the most valuable of which are articles by 0. V. Frisch in 1904, Sitzenfrey in 1906, Spencer in 1913, and Falls in 1923. Only seven cases of primary carcinoma of Bartholin's gland have been reported in American literature and of these, Lynch's case is not fully described and Taussig's case is somewhat doubtful. There has been much speculation as to the etiology of carcinoma of Bartholin's gland. Of course, nothing definite is known, but the same theories have been advanced as for carcinoma arising in other structures. Chronic inflammation is generally believed to be a predisposing factor in the development of carcinoma and has been present in many of the reported cases. A definite history of neisserian infection was present in only one case. The role played by heredity is not well established. Only two of the reported cases mention a history of cancer in the patient's antecedents. There was no history of direct trauma in any reported case. As in other cancers, carcinoma of Bartholin's gland is generally seen after the age of forty. In fact, more than half of the reported cases oecurred in women of fifty or more years of age. The youngest was twenty-eight and the oldest ninety -one. It has been found in unmarried women but not in virgins. Because of the fragmentary character of many of the reports, the incidence of other possible etiologic factors cannot be determined. Two types of carcinoma are possible in the previously normal Bartholin's gland: ( 1) squamous cell tumors arising in the ducts near the surface of the gland and (2) columnar cell carcinoma or adenocarcinoma arising in the acini or in the epithelium of the deeper portions of the ducts. Furthermore, it has been pointed out by Sitzenfrey, G. Noble and others that in cases of chronic gonorrheal infections of Bartholin's gland a metaplasia of the normal columnar epithelial cells of the deeper portions of the ducts, occurs with their conversion into squamous cells so that the entire excretory duct may be lined with squamous cells. Hence in sueh a gland, a carcinoma arising even in the deeper portions of the ducts would be of the scirrhus type. It is also possible that a carcinoma arising from the columnar cells of the deeper portion of the gland may, as the tumor develops and approaches the surface, come to resemble a squamous cell carcinoma, a phenomenon comparable to that seen in certain adenocarcinoma of the cervix uteri. In fact, it seems quite likely that this is the explanation of both Geist's and Speneer 's cases. Because of the extreme rarity of the condition the correct diagnosis is rarely made although actually the diagnosis is easy when the possibility of cancer is kept in mind. The presence of a hard lump in the posterior part of the labium majus, painless at first, later becoming painful and accompanied by edema of the vulva and skin over Bartholin's gland and hard,

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shotty enlargement of the inguinal lymph glands in a woman beyond the age of forty, should make one suspect carcinoma of Bartholin's gland. The chronicity of the disease, its failure to respond to ordinary therapeutie measures, the tendency to degenerative processes in the tumor, and biopsy in doubtful cases, establish the diagnosis.

Fig. 1.-Low-power microscopic view of primary adenocarcinoma of Bartholin's gland showing duct. Magnified eighty diameters.

Fig. 2.-High-powered microscopic picture of primary adenocarcinoma of Bartholin'" gland. Portion of duet is seen at upper right-hand corner. ( 280x.)

Case History.-Mrs. H. H., white, aged thirty-three, married, para 0, no miscarriages, admitted with a complaint of ''Swelling at entrance to vagina. and profuse irritating vaginal discharge. '' About eight or nine months ago the patient first noticed a small, hard, painless lump in the posterior part of the left labium. It caused no discomfort so she paid no further attention to it until about April 1, 1932, when, during the course of a general physical

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717

examination, she called the internist's attl'ntion to the mass. At that time she was told it was simply a small glandular cyst of no importance whatsoever but was advised to have it removed simply because it was growing larger. About this time she noticed a very irritating vaginal discharge which became more and more profuse and could not be relieved by ordinary douches. This continued untH April 18, 1932, at which time she presented herself to me for treatment. Patient's previous history uneventful and there was no malignancy in the family. Menstruation normal. Last period March 25, 1932. No pregnancies. No operations. Physical Examination.-White adult female of good bony and muscular develop· ment, with a moderate enlargement of the thyroid gland, chiefly of the left lobe. The heart shows an extrasystolic arrhythmia but is otherwise negative. Pelvic examination reveals a hard lump about the size of a walnut in the left labium majus in the position of Bartholin's gland. It is freely movable and not tender. There is a slightly irregu· Jar or lobulated outline to the mass on careful palpation. The skin over the tumor is freely movable, slightly inflamed but otherwise normal. No enlargement of any of the regional lymphatics could be detected. The skin of the inner surface of the thighs and of the labia is moderately inflamed. The vaginal mucosa is inflamed and bathed in a thin watery secretion. The cervix is inflamed but otherwise presents the normal appearance of a nulliparous cervix. The uterus and adnexa are normal. Vaginal smean were negative for gonococci but showed B. coli and Trichomonas vaginalis in large numbers. Blood count normal. A diagnosis of tumor of Bartholin's gland was made and operation advised. Because it was nearly time for her menses, the patient would not submit to operation until May 2, 1932. At that time the tumor was excised under nitrous-oxide-oxygen anesthesia. It was encapsulated and shelled out with the greatest ease. The incision was closed with interrupted catgut sutures and healed by primary union. The patient was discharged from the hospital on the fourth day and told to report to my office for further treatment of her leucorrhea. The malignant character of the tumor was not discovered until sections were cut and studied. An attempt was then made to communicate with the patient but it was discovered that she had gone out of town on a vacation. Her husband was accordingly acquainted with the facts of the case, and upon return of the patient, she was again taken to St. Agnes' Hospital where on July 18, 1932, she was given 1200 mg. hr. of radium over the affected area, and a careful search again was made for possible evidence of lymphatic involvement. At that time the left labium was perfectly healed and free of all induration. No evidence of metastasis or recurrence was found. Her vaginal discharge cleared up promptly with the use of tincture of green soap followed by the application of 5 per cent solution of mereurochrome and the liberal use of kaolin and soda bicarbonate. Pathologic Report.-Gross examination: The specimen is an irregular lobate tumor 3 by 2 by 1.5 em. which apparently has been well encapsulated and this capsule with underlying parenchyma has been incised at one place. When sectioned the substance is firm, pale, and quite homogeneous in texture. Sections cut from both ends. Microscopic examination: Sections show the mass to consist, ahnost entirely, of epithelial cells massed together in an irregular fashion or sometimes arranged in incomplete alveoli. Many of the nuclei of these cells are large and granular. In an occasional nucleus are seen mitotic figures. Along the edge of one section there is seen a duct which closely resembles the ducts usually seen in Bartholin's gland. Diagnosis.- Adenocarcinoma of Bartholin's gland. REFERENCES

Klob, J. M.: Pathologische Anatomie der weiblichen Sexualorgane Wien, W. Braumuller, 1864. Martin, A.: Diseases of Women. Klein: Stricker Handbuch der Lehre von den Geweben, Leipz. 72: 648, 1871. Langerhans: Vir chows Arch. f. path. Anat. 61: 208, 187 4. Geist: Inaugural Dissertation, Mar burg, 1880. Thomas,

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J.: Inaugural Dissertation, Mar burg, 1880. Sinn, W.: Inaugural Dissertation, Marburg, 1880. deSinety: Com pt. rend. Soc. de biol. 7: 280, 1880. Maclcenrodt: Ztschr. f. Gynak. 26: 186, 1893. Schweizer: Arch. f. Gynak. 44: 322, 1893. Honan, J. H.: Inaugural Dissertation, Berlin, 1897. Oodart: Bull. Soc. Belge de Gynec. 9: 109, 1899. Trotta: Arch. di Ost. e Ginec~. 193, 1900. Schaffer, R.: Ztschr. f. Geburtsh. u. Gynak. 1: 193, 1903. Burghele, W. N.: Ztschr. f. Geburtsh. u. Gynak. 1: 1102, 1903. Frisoh, 0. V.: Monatschr. f. Geburtsh. u. Gynak. 19: 60, 1904. 8itzenfrey, A.: Zentralbl. f. Geburtsh. u. Gynak. 58: 363, 1906. J ambon and Chaboux: Lyon Med. 112: 3, 1906. Kelly, H.: Operative Gynecology, 257, 1907. Pape: Deutsche med. Wchnschr. 33: 1620, 1907. Spencer, H.: Proc. Royal Soc. 7: 102, 1913-14. Eden: Proc. Royal Soc. 7: 102, 1913-14. Taussig, F. J.: Am . •T. Obst. 76: 794,1917. Oomez, L.A.: Thesis, Montpellier, 1914. Lynch, F. W.: Pelvic Neoplasms, 32, 1922. Falls, F. H.: AM. J. OBST. & GYNE:O. 6: 673-680, 1923. N euw·irth, K.: Monatschr. f. Geburtsh. u. Gynak. 70: 93-99, 1925. Hunt, V. C., and Powell, L. D.: S. Clin. N. Am. 6: 1325-1328, 1926. Schneider, P.: Zentralbl. f. Gynii.k. 32: 1986, 1930. Rabinovitch, J.: AM . .T. 0BST. & GYNEC. 23: 268-274, 1932. ABSTRACT OF DISCUSSION DR. JOHN A. McGLIN.K .-I have never seen a ease nor can I recall a similar case having been presented. There is no gland, with the possible exception of the salivary, which works more intensively and more frequently to fulfill its physiologic function in the body, and none as subject to great and more frequent traumatism, or to more widespread infection. And yet in spite of all this, carcinoma occurs but rarely, so rarely that in all the literature of the world only forty cases appear.

DbDERLEIN'S BACILI~us IN THE TREATMENT OF VAGINITIS• RoY

W.

MoHLER, M.D., F.A.C.S., AND CLAUDE P. BRoWN, M.D., PHILADEI.PHIA, PA.

(From the Gynecological Departrnent of Jefferson Medical College)

a preliminary report on the treatment of vaginitis WEwithAREpurepresenting viable cultures of Doderlein 's bacillus. So far as we know this form of treatment has not been reported in American literature. A statement of the favorable results secured and an explanation of the physiologic principles upon which the treatment is based are the purposes of this report. In contemplating any treatment for vaginitis which may be the cause of leucorrhea we must first exclude the possibility of a latent infection of the cervix and Skene's tubules. The cervix is excluded as the source of the vaginitis when there is no eversion or erosion present and when its secretion is moderate in amount and contains none or only a few pus cells. The Skene's tubules are regarded as normal when there is no granulation about them and when no pus cells and only a few epithelial cells can be recovered from them. Past Treatment.-In most of the published reports in the English language with which we are familiar, mechanical cleansing of the vagina and the application o£ antiseptics have been the basis of treatment for vaginitis, particularly the so-called Trichomonas vaginalis vaginitis. *Read at a meeting of the Philadelphia Obstetrical Society, November 3, 19:12.