The results of this operation are as follows. Schroeder has operated in eight cases (one of these was performed by his assistant), and in one only did the patient die; the death resulted from internal hæmorrhage caused by the rupture of a vessel in the broad ligament. The other seven made a good recovery. As regards the extirpation of the disease, sufficient time has not elapsed to ascertain whether or not it will return. The total results are (according to Hegar and Kaltenbach) that, of 29 completed operations, 21 recovered. The mortality has been therefore only 27.6 per cent., which contrasts favourably with that in Extirpation by Abdominal Incision (71 per cent).

CHAPTER XLI.

CARCINOMA OF THE BODY OF THE UTERUS.

LITERATURE.

Breisky and Eppinger-Prager med. Wochenschrift, 1877, S. 78. Gusserow-Neubildungen des Uterus: Stuttgart, 1878, S. 222. Schroeder-Op. cit., S. 295. Simpson, Sir J. Y.-Selected Obstetrical and Gynecological Memoirs, edited by Dr Watt Black, p. 769. Veit-Zeitschrift. für Geburts. und Gyn., Bd. I., S. 467.

PATHOLOGY AND ETIOLOGY.

CARCINOMA affects the body of the uterus much more rarely than the cervix; in only 13 out of 686 cases of uterine cancer, that is in rather less than 2 per cent, was the disease situated in the body of the uterus (Schroeder).

Its rarity is apparent from the fact that Gusserow, after a careful survey of the whole literature, has collected but 80 cases.

As in the cervix, the disease originates either in the substance of the walls of the uterus or in the mucous membrane. In the former case, it begins as localised nodules which grow rapidly and produce bulging of the mucous membrane or of the peritoneal coat but do not tend to ulcerate. When in the mucous membrane it causes a uniform swelling or, more usually, projects in polypoidal masses (fig. 291).

By Eppinger and Ruge the disease has been directly traced to the epithelium of the uterine glands; these first hypertrophy, and then their proliferating epithelium passes into carcinomatous epithelial cells. The new-formation ulcerates, so that the wall of the uterus becomes converted into an excavated surface with a hard base. Adhesions rapidly form with neighbouring organs, while secondary deposits may develope in the peritoneal cavity.

As to Etiology, what has been said of carcinoma of the cervix applies here with two additional facts. (1) The maximum number of cases is between 50 and 60 years, a decade later than in the cases of carcinoma

of the cervix (v. fig. 277). Out of 34 cases, 23 occurred during these years (Pichot). (2) A surprisingly large proportion of the cases are in nulliparæ (Schroeder).

SYMPTOMS AND DIAGNOSIS.

Again as in carcinoma of the cervix, the symptoms are pain, hæmorrhage, and fœtid discharge. 1. Pain, in contrast with carcinoma of the cervix, is always an early symptom. It occurs periodically; "slight and intermittent, perhaps, at first, but soon reaching a high pitch of intensity, at which it continues for an hour or two, and then gradually subsides" (Sir J. Y. Simpson). 2. Hæmorrhage is also present at an early stage; it takes the form of profuse menorrhagia, because the mucous membrane from which the menstrual flow takes place is diseased. 3. The Discharge is usually profuse and becomes after a time fœtid. Sometimes it is watery and not offensive; in rare cases is it altogether absent.

On vaginal examination, the cervix is found to be either normal or dilated. The uterus is enlarged, and may be freely movable or may be fixed by adhesions. The sound shows the cavity to be enlarged and may recognise irregularity of the mucous membrane; its introduction is followed by hæmorrhage. The condition of the mucous membrane is more precisely ascertained by examination with the finger after dilatation of

the cervix with a tent. In the majority of cases, certainty of diagnosis is possible only through microscopic examination of fragments removed by the curette. Should these show merely hypertrophied glands, we must remember that this is sometimes a transition stage to malignant disease. Typical carcinomatous cells are seen at fig. 279.

The Differential Diagnosis must be made from

Portions of retained placenta,

Sloughing submucous fibroid,

Hæmorrhagic endometritis.

As to the first of

These conditions have been already described. these we note that carcinoma sometimes developes during the puerperium. In three cases observed by Chiari, the development of carcinoma was directly connected with the puerperium and ran a rapid course to a fatal termination within six months after the birth of the child.

During the period of sexual activity, differential diagnosis is often extremely difficult; rapid growth and development of peritonitis fixing the uterus, point to malignant disease. After the meno-pause, the recurrence of hæmorrhage is an important diagnostic. The microscope is, when available, the most reliable guide.

TREATMENT.

As to the treatment of the symptoms, this is the same as in carcinoma of the cervix (v. chap. XL). As to the treatment of the disease, the scraping away of the polypoidal masses with the curette or sharp spoon gives temporary relief from the hæmorrhage and discharge. The only hope of cure lies in extirpation of the uterus. These cases are more favourable for extirpation than cases of carcinoma of the cervix, as there is a better prospect of excising the whole of the affected tissue.

CHAPTER XLII.

SARCOMA UTERI.

LITERATURE.

Clay, J.-On diffuse Sarcoma of the Uterus: Lancet, Jan. 1877. Galabin-Lond. Obst. Trans., Vol. XX. Gusserow-Die Neubildungen des Uterus: Stuttgart, 1878, S. 142. Jacubash-Vierfälle von Uterussarcom: Zeitschrift f. Geburts. u. Gyn., Bd. VII., Hft. I. Kunert -Ueber Sarcoma Uteri: Arch. f. Gyn., Bd. VI., S. 29. Rogivue-Du Sarcôme de l'utérus; Inaug. dissert., Zürich 1876. Schroeder-Op. cit., S. 301. Simpson, A. R.-Op. cit., p. 240. Thomas-Op. cit., p. 566; and Sarcoma of the Uterus, Lond. Obst. Journ., Vol. II., 1875, p. 437. Virchow-Die krankhaften Geschwulste: Bd. II., S. 350. For a full resumé of the literature, see Gusserow and A. R. Simpson.

By sarcoma we understand a connective tissue tumour of an embryonic type (Cohnheim). As we trace back carcinoma to the epithelium and true myoma to the muscular fibre, so we trace back sarcoma to the connective tissue.

For the recognition of sarcomata as of connective-tissue origin and the limitation of the term to malignant tumours of this type, we are indebted to Virchow. Formerly they were known in English literature as recurrent fibroids"; the existence of this form of tumour in the uterus was recognised and fully described by Hutchinson (1857).

PATHOLOGY.

Unlike carcinoma, sarcoma rarely occurs in the cervix; in the larger proportion of cases it is in the body of the uterus.

It occurs in two forms :

1. Diffuse sarcoma of the mucous membrane;

2. Circumscribed fibrous sarcoma.

The diffuse sarcoma of the mucous membrane arises from the subepithelial connective tissue. It appears as a general swelling of the mucous membrane which becomes soft and crumbly, or as irregular foldings or knobby projections into the uterine cavity; sometimes these projections have a polypoidal and apparently circumscribed character