CHAPTER XLL.

CARCINOMA OF THE BODY OF THE UTERUS.

LITERATURE.

Schroeder-Op. cit., S. 295.

Breisky and Eppinger-Prager Med. Wochenschrift, 1877, S. 78. Gusserow-Neubildungen des Uterus: Stuttgart, 1878, S. 222. 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 develop 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

Carcinoma of the body of the uterus. The uterine cavity is increased in size but the cervix is undilated (Sir J. Y. Simpson).

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, hemorrhage, and fetid 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. Hemorrhage 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 fetid. 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 hemorrhage. 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,

Hemorrhagic endometritis.

These conditions have been already described. As to the first of these we note that carcinoma sometimes develops 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 menopause, the recurrence of hemorrhage 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 hemorrhage and discharge. The only hope of cure lies in extirpation of the uterus. These cases are more favorable 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. and Sarcoma of the Uterus, Lond. Obst. Journ., Vol. II., 1375, p. 437. Virchow-Die krankhaften Geschwulste: Bd. II., S. 350. For a full résumé of the literature, see Gusserow and A. R. Simpson.

566;

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 sub-epithelial 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 (Fig. 292) so that this form passes insensibly into the fibrous. The masses have a grayish-white brain-like appearance and soft pulpy consistence. The mucous membrane may be broken down but is not deeply excavated as in carcinoma. On microscopic examination the mucous membrane is seen

Sarcoma uteri with tumours in the vagina-from a specimen in the Pathological Institute at Strassburg

(Gusserow).

to be infiltrated with masses of closely-set round cells, more rarely spindle-cells. Epithelial cell proliferation often complicates this form of sarcoma and brings it into close relation to carcinoma. Klebs has proposed

to call such forms carcino-sarcomata.

The circumscribed fibro-sarcoma arises in the muscular coat; like the fibroid it may be submucous, interstitial or sub-peritoneal and is found