SARCOMA OF THE UTERUS.
BY W. H. BYFORD, M.D.
This disease is as much entitled to the clinical definition given to cancer as any of the varieties of that malignant affection. Miller, as quoted by West, says: "Those growths may be termed cancerous which destroy the natural structure of all the tissues; which are constitutional from their very commencement or become so in the natural process of their development; and which, when once they have infected the constitution, if extirpated, invariably return and conduct the person who is affected by them to inevitable destruction." If we substitute the word malignant for cancerous in the above quotation, the definition would include sarcoma as well as carcinoma. It will be found upon comparing sarcoma with fibrous and cancerous tumors that it possesses clinical and histological features common to both. If it is not indeed the result of a transition of fibrous tumors into a malignant form of disease, it is a connecting link between fibromatous and carcinomatous affections, and illustrates in a remarkable manner a relationship of these two forms of growths—viz. the morbid proliferation of the tissue resembling those of the structure in which they originate. Sarcoma has its origin in the fibrous portion of the connective tissue, as do many of the fibrous tumors. It consists of a redundant proliferation of the cells of that tissue, while the fibrous tumor is constituted of a morbid proliferation of the fibrous element of the connective and muscular tissues. Cancer now is admitted to be an excessive production of the cells of the epithelium; this excessive growth of the cells inhabiting these structures, sarcomatous and epithelial, seems to give to them respectively the feature of malignancy. The fibrous tumor is contained in a capsule; both forms of these malignant growths invade the tissues without any such limitation. In this respect the two latter resemble each other and differ from the former. In sarcoma the cells are mingled intimately with the fibres, and are not generally contained in alveoli, or nests, as they are sometimes called. Cancerous cells are always surrounded by alveoli. Sarcoma in many instances resembles very closely the fibrous tumor. In malignancy it is very much like the cancerous tumor.
CLINICAL HISTORY.—The early symptoms of sarcoma are leucorrhoea, hemorrhage, and tumefaction. The discharge from the genital organs resembles that of fibrous tumors. This does not generally possess an offensive odor, but as the disease advances necrosis of the tumor occurs to a greater or less extent, and then the smell of the discharge comes to resemble that of cancer. The necrosis does not take place at the expense of the uterine tissues, but is a process of disintegration going on in the growth. The ulcer resulting does not corrode the uterus, but it eats away the tumor. It in this respect resembles epithelial fungus. The tumor formed by the sarcomatous deposit is sometimes polypoid, and presents the appearance of the fibrous polypus. In other instances it resembles to the touch a submucous fibrous tumor, and again in others it is diffusely disseminated into the whole structure of the uterus. When thus diffused, like cancer it invades the neighboring organs. When the tumor projects from the inner surface of the womb, and has attained a considerable growth, limited necrosis occurs, and sloughs of varying size take place, and offensive sanious discharges occur very similar to the flow observed in cancer.
The general symptoms at first are slight, consisting of obscure pelvic pains and pressure and increased discharge. Gradually septicæmia is developed, and this is the condition in which the patient usually dies.
DIAGNOSIS.—There is nothing in the symptoms by which we can arrive at a correct diagnosis, as in the early periods they resemble those of fibrous tumors so closely as to be undistinguishable from them, and in the latter cancer neither manual nor ocular examination will give us any more definite information. Their qualities in this respect also are in the early stages of development those of fibrous tumors, and in the latter of some forms of cancer. We are therefore reduced to the evidence afforded by microscopical examination.
When the tumor is in such a position and of such a consistence that we can remove a fragment from it, we can study its histology. There are two varieties, as distinguished by the shape and size of the cells. One variety is called the small-celled sarcoma, from the size of the cells; they are round, or nearly so, in shape. The other is called the spindle-celled sarcoma. In some specimens of this variety the cells are much larger than others; and hence there is the large and small spindle-celled sarcoma. The cells are different among the fibres of the tissues affected, and in rare instances some of the cells are contained in imperfectly-formed alveoli, in this respect showing a further analogy to the growth in cancer.
PROGNOSIS.—The malignancy of sarcoma is now universally recognized in the known facts of its persistency in returning when removed, and its simultaneous existence in many organs of the body. This acquired or innate constitutional dissemination is not constant—no more than in cancer, perhaps less so. Hence when the size of the tumor is small and apparently isolated there is some encouragement to attempt a cure.
The comparative prognosis is also probably better than cancer, as it pursues a less rapid course of development, and hence the patient may survive for a longer time.
The local dissemination of the cells cannot always be measured, and that their dissemination into the surrounding tissues may reach much beyond the boundaries of the apparent tumor must be regarded as an important element in considering the subject of prognosis in connection with treatment by ablation or cauterization. The widespread local dissemination of the cells of this growth is doubtless an explanation of the term at first applied to it—viz. recurrent fibroid.
TREATMENT.—It will not be necessary to consume the time of the reader by giving the treatment of sarcoma in detail, as most of it is identical with that of Cancer, and may be found under that head. I will only call attention to the excellent palliative effects of ergot: this drug will often arrest, and generally modify, the hemorrhage so often one of the most annoying symptoms. When the tumor is in a state of progressive necrosis, protrudes like a submucous fibrous tumor, or is pendulous, resembling the fibrous polypus, it may, by inducing contraction of the uterus, be expelled, partially if not completely, and thus for the time being do away with the source of sepsis. I have in several instances been highly gratified with its effects in this way. In one case, when the patient was so overwhelmed with symptoms of septic fever as to cause apprehension of immediate dissolution, the administration of ergot expelled large masses of sloughing tissue, and so cleansed the uterus that the symptoms subsided, the patient rallied, and lived several months in comfort. Not less than four times this process of expulsion was successful in relieving the same patient for long intervals: each time the medicine was administered relief was so marked that both she and her friends anticipated recovery.