Simultaneously with the latter, the discharge becomes either ichorous or purulent, and gives off a fetid odor, which is, however, seldom as in tense as in cancer of the cervix, probably because the atmospheric air has not such free access to the ulcerating parts.
These two symptoms, pain and hemorrhage, are the only distinctive symptoms of the disease. All further symptoms and signs depend upon how extensively or how soon the peritoneum participates in the morbid process, whether the cancerous infiltration spreads to the neighboring organs, and whether or where metastatic deposits occur. As neither of these events is quite common, death rarely takes place very quickly. Playfair mentions an instance, however, in which the tumor perforated into the abdominal cavity, with a rapidly fatal result. As ichorous dis integration usually sets in late in the course of the disease, and with but moderate intensity, cachexia develops very slowly. - All these facts help to explain why it is that cancerous affections of the body of the uterus run a much slower course than cancer of the cervix. Pichot found that only in four out of twenty-five cases was the duration of the disease less than a year, while in four it was more than four years. The average duration according to the same author, is thirty one months.
The differential diagnosis from cancer of the vaginal portion is very readily made, for the simple reason that in isolated cancer of the corpus uteri the cervix is perfectly healthy, both to the touch and on examina tion with the speculum. It usually possesses the same shape and consis tency that is found in healthy uteri; more rarely it is shortened, the os being fully dilated. The latter is usually the case when cancerous poly poid tumors project into the cavity of the uterus, and dilate its lower segment either mechanically or by exciting pains like those of labor. A similar condition, or at least a partial pateney of the os may result when the diffuse affection of the mucous membrane extends far downwards and transforms the uterine walls into unyielding, dense, infiltrated masses. As for the rest, the uterus is generally symmetrically enlarged and hard; but isolated, sensitive and exceedingly soft tumors can sometimes be detected as projections on its external surface. The enlarged and heavy uterus is as a rule freely movable, because there is usually no infiltration of the surrounding cellular tissue. Immobility of the organ when pres ent, is generally caused by perimetritic adhesions.
Another important diagnostic point is the discharge from the cervical canal, although sloughing fibromata occasion a similar discharge; but neither the microscopical examination of this fluid, nor the introduction of a sound into the uterus will suffice to establish the diagnosis with cer tainty. Yet the diminution in depth of the cavity of the uterus, and the infiltrated condition of its walls, are very striking when contrasted with the symmetrical enlargement of the organ as ascertained by external palpa tion.
In order to arrive at a certain diagnosis it is first necessary to dilate the canal of the cervix and the internal os sufficiently to permit of the intro duction of the finger into the uterus, when the infiltration of its walls, the hypertrophy of the mucous membrane, and the protuberant tumor masses can be distinctly felt. If a portion of the tumor be then removed and submitted to microscopical examination, we shall be able to determine whether it is a carcinoma, a sarcoma, or a softened myoma with which we have to deal. The smaller the particle of the tumor the more diffi culty and uncertainty will there be in establishing an exact anatomical diagnosis.
In the treatment of these conditions, it is clear, after what has been already said in connection with malignant disease of the cervix, that re moval of the affected organ is alone to be thought of. Of course this applies only to those cases where surgical interference is still feasible, owing to the fact that the neoplasm is confined to the uterus.
Now, although quite a large number of operations have been reported, it is difficult, at present, to decide which method should be employed. Amputation of the body of the uterus after laparotomy has been repeatedly practiced. But it is not always easy to decide how far the disease may have encroached upon the cervix. In several cases recurrence from the cervix, which was allowed to remain, has been observed. Hence total ex tirpation of the uterus is after all the safest procedure. From what has been already said concerning this operation, it appears that the vaginal method of total extirpation is to be preferred. When this is impracticable the operation of Freund is called for. I have collected the following in stances of operations of this kind: Fifteen cases of amputation of the uterus following laparotomy (thirteen of these cases belong to Schroder). with four deaths, i.e., 26 per cent. Three total extirpations after the method of Freund, with two deaths. Ten total extirpations per vagi nam, with one death.
As regards recurrence of the cancer after these operations, we learn from Schroder (Hofmeier, L c.) that three of his patients died therefrom within one year. Four of his patients remained well more than two years, and one over five years.
If a radical operation can not be done, the diseased masses are to be removed by the curette or scoop as thoroughly as possible. Care must be taken not to perforate with the instrument the infiltrated walls of the uterus (case of Spiegelberg, 1. c.).
In addition to these measures we must employ the various caustics, in order to limit growth as far as possible, and to moderate hemorrhage and discharge. A detailed account of these measures has already been given in discussing sarcoma of the uterus.