This method seems to be a decided improvement upon the others, since it enables us to operate more quickly and therefore with less shock and less danger to the patient, and also with less danger of hemorrhage. Hemorrhage and shock are the chief immediate dangers, sepsis and inflammation the principal remote ones. Occasionally it may be better to use both ligatures and the hemostatic forceps; the former for the cut vaginal edges and small bleeding surfaces, the latter for the main parts of the broad ligaments and such extensive bleeding surfaces as can be gathered into the jaws of one pair.

Should we desire to amputate the body from the cervix this method. of bringing the uterus out of the peritoneal cavity would give us an excellent opportunity with the minimum risk.

Redner explains how the favorable results in ovariotomy led also to the removal of myoma and carcinoma of the uterus by laparotomy, and then how more recently the unfavorable results of the method of operating advocated by Freund led to a neglect of laparotomy. This change was favored also by the fact that the large number of cancers springing from the cervix uteri could only be removed imperfectly and with difficulty by this method, hence we have drifted back to the older practice of attacking the organ through the vagina. Redner himself operated several years ago in twenty-eight cases of carcinoma. uteri through the vaginal wall, with almost invariable success (only three deaths, two by infection, one by hemorrhage), by supravaginal excision of the cervix. And once having gone so far it was but a step to remove the whole uterus through the vagina.

The prognosis is not only considered good by Schroeder* because the mortality figure is so small, but also because the convalescence is so rapid and easy, for in the cases cited only two showed slight fever, and two others mild symptoms of collapse.

As to the indications for such operative measures, Schroder advises against interference when the cellular tissue of the pelvis is already invaded by cancer, which must be determined by careful palpation. He further calls attention to the fact that the larger the diseased. uterus the greater will be the difficulties by this method, and the more appropriate will Freund's procedure become, and, at the same time, that in cases of cancer of the cervix situated low down we should be more conservative in either enucleation or supravaginal incision; yet after all, notwithstanding all of the advantages of the new procedure, the former methods would still retain their merits, according as they might be selected in particular cases.

* Paper read by Schroder (Berlin) on "Total Extirpation of the Uterus per Vaginam" in the gynecological section of the fifty-third Versammlung der deutsche Naturforscher und Aertze in Danzig, in September, 1880. Reported in the Archives für Gynäcologie Sechszehnter Band, Drittes Heft.

In Martin's three cases he found such difficulty that in only one case was the operation complete. 2d case: Impossible to sever all adhesions; portion of diseased tissue remained behind. 3d case: Same kind of difficulty; conclusion that firm adhesions and brittleness or friability of the uterus contraindicate the operation.

Interrogated by Meyerbeer, Schroeder says he closes the vaginal opening with curved needle and silk, but recommends ligation of ligaments by wire.

Baum (of Danzig) says he formerly operated successfully by supravaginal incision seven times, without resulting fever, that in only two cases had he failed to find a return, but in the last few months had operated per vaginam four times, two of the cases resulting in death from shock and septic peritonitis. He operated after Billroth's manner, and in one case removed the ovarian tubes, but applied no sutures in order to allow better drainage of the secretions. A drainage-tube was introduced, through which, in case of fever, the parts were washed out.

Schroder favors sutures which do not render septicemia more liable, and insure against protrusion of intestines.

Baum prefers his method, and thinks protrusion of intestine can be prevented by position.

CHAPTER XXX VII.

SARCOMA.

It

ANOTHER variety of malignant disease of the uterus is sarcoma. generally shows itself in the form of a tumor, developed at the expense of the fibrous structure of the uterus, an apparently isolated portion of which is infiltrated by an abundance of peculiar cells.

While not encapsulated, like the fibrous tumors, these growths displace the surrounding tissue, and protrude in a submucous or subserous direction until they become, to a greater or less degree, pediculated. When first discovered and described these tumors were denominated recurrent fibroids, because ablation did not destroy them. Their recurrence is, doubtless, due to the fact that, while apparently isolated, the neighboring tissues are permeated by the sarcomatous cells. Instances of diffuse sarcoma are also sometimes met with when all the tissues of the entire uterus are infiltrated.

The cases of diffuse sarcoma with which I have met have all belonged to the small-celled variety, and the process of degeneration has spread from the uterus to the surrounding tissues, invading especially the connective tissue of the broad ligament. Sarcoma is a less frequent disease than carcinoma or epithelioma.

Symptoms.

Its early clinical history is very similar to that of the fibrous tumor, and is more generally mistaken for it than any other growth. Serous leucorrhoea, metrorrhagia, and enlargement are the main ones. Its course is usually rapid, less so, perhaps, than cancer, and more so than fibrous growths. In some cases it attains to a large size before any peculiar phenomena appear. After a time, especially if submucous or polypoid, it begins to break down, the discharge becomes offensive and copious, and the disease proves fatal in much the same way as cancer.

The general symptoms in the early periods of development are not marked, and they only become so after the tumor has grown large enough to interfere by pressure with the fecal and urinary excretions, or in breaking up furnish septic material in such quantities as to induce septicemia, when all the disastrous symptoms of that formidable fever are established. Thus diarrhoea, copious perspiration, elevated temperature, rapid pulse, failure of the assimilative functions, and great nervous prostration tend to a fatal issue with as much certainty as any other of the malignant affections.

Diagnosis.

In the commencement it is always difficult to arrive at a correct diagnosis. The symptoms are not characteristic, and until the commencing dissolution of the tumor are as much like those of fibrous tumor as they are like carcinoma, and when disintegration begins they thoroughly simulate cancer or epithelioma. The only sure diagnostic sign of sarcoma is afforded by the microscope. A portion of the tumor

Structure of Sarcoma.-From Cornil and Ranvier.

should be submitted to microscopic examination, when the characteristic cell may at once be discovered (Fig. 284).

Mr. Butlin* makes the following histologic distinction between sarcoma and carcinoma.

He says:

"I should then define carcinoma to be a tumor of epithelial origin, having generally an alveolar structure, and sarcoma a tumor of connective-tissue origin, formed generally of embryonic tissues, and without alveolar structure. And, for the minor differences, the cells of carcinoma generally resemble those of the epithelium from which it grows; there is little intercellular tissue; the vessels run in the fibrous tissues, not among the cells; and multiplications of cells is by endogenous formation. On the other hand, sarcoma is composed of round or fusiform or giant cells, and these are packed, in a more or less abundant basis; the vessels are often mere fissures between the cells, and the cells increase in number by division. These minor characters are common, but they are not constant. One or other of them may be absent in a tumor of either class; or, worse, may be present in a tumor of the other class. More com. monly it is sarcoma, which simulates the appearance of carcinoma; but, fortunately, this feigning takes place most often in textures where there can be no question of the origin, and therefore of the nature, of the tumor. The alveolar structure, found in some sarcomas, is rarely so perfect as that of most epithelial tumors; indeed, careful study, discovers that the tissue which surrounds the alveoli is generally formed of spindle cells. There is, in most cases, no real difficulty in assigning each tumor to its class."

* Lectures on the Relation of Sarcoma to Carcinoma, by Henry Trentham Butlin, F.R.C.S. American reprint. London Lancet, February, 1881.

Prognosis.

The prognosis is no more favorable than that of cancer. While in many instances the tumor caused by the morbid growth seems to be quite isolated, the cells penetrate the surrounding tissue to such an extent as not to be eradicable.

The contamination of the surrounding tissue does not seem to take place by absorption and transmission of the cells, or débris of the sarcomatous cells, but to be due to the insinuation of the cells into the contiguous substance surrounding the growth. It is, probably, always local in its origin and progress. This consideration, if true, would encourage us to hope that, by ablation of all the morbid substance, we might arrive at a cure.

Treatment.

To be radical the treatment should consist of the entire removal of the growth. When the disease is confined to the uterus, I think the most rational treatment would be the removal of that organ. Hysterectomy would seem to me to be more promising in sarcoma than in carcinoma.

In addition to the general palliative treatment, detailed under the head of cancer, the removal of sloughing masses by the curette and scoop, we will often derive great benefit from the free administration of ergot. The contraction of the uterus, under the influence of ergot, will do more to clear out the softening mass from its cavity than any instrumental interference. I have in several instances removed the sarcomatous growth by ergot so thoroughly that the improvement of the patient's health led them to hope for ultimate recovery. When the growth is submucous, and of the most friable variety, I would fully expect it to be expelled by ergot. It does not, however, affect the spread of the growth, and ultimate fatal result.