CLINICAL HISTORY, COURSE, AND SYMPTOMS.
Our knowledge of the symptomatology of uterine sarcoma would not be essentially improved by a separate consideration of the two distinct forms of these tumors above described. The two forms have so much in common, have been so little studied and so poorly differentiated in the reported cases, that their clinical pictures cannot be sharply distinguished from each other. It may be stated as a general rule, that fibro•sarcomata present, at first, the symptoms of fibromata, and only demonstrate their sarcomatous nature by their later course. These tumors were, therefore, known in earlier literature, especially in England, as recurrent fibroids.
There can be no doubt, alter what nas preceded, that the tumors in such cases were originally fibromyomata.
The symptoms are due to pressure, and vary according to the location and size of the tumors. The chief one is pain due to growth of the neo plasm, or to its propulsion downwards by uterine contractions. Hemor rhages at first occur particularly in the form of menorrhagia, exactly as they do with ordinary fibroids, and often change their character at a later period, or are followed by a discharge resembling bloody water.
A number of these tumors have been removed, as examples of fibromy omata, by operative means, and their malignant character only detected by subsequent microscopical examination. In other cases their recur rence and their farther course showed that they were not fibromyomata.
There is often, however, even from the beginning, a peculiar differ ence observed between these tumors and fibromyomata. It consists in softness of the tumor, from which, although it be not gangrenous, pieces may be broken off. These pieces may be penetrated by the finger. The absence of a capsule, in cases of fibro-sarcomata, is frequently striking, particularly during extirpation. Their growth is, moreover, rapid, the pains attendant upon their development unusually violent, and they occasion a discharge resembling the bloody water without becoming gangrenous. They also produce a cachexia, rapid emaciation and a loss of strength incompatible with their apparently benign character.
However variable these symptoms may be, and however little charac teristic of sarcomatous growths, the farther course, in all cases of sarcoma, is the same. If they are removed, they soon recur (after an interval varying from four to six weeks, to one or two years.) The tumor usually grows more rapidly after its recurrence, and occa sions more violent hemorrhages, a more abundant discharge, more in tense pain and more rapid and marked asthenia.
Repeated extirpations may arrest the course of the disease, even for six and a quarter years (West). Death, however, always occurs, being pre ceded by intense anaemia, and often with symptoms of fatty degeneration of the heart. In other instances the fatal issue may be referable to intes tinal obstruction, peritonitis, or to pymemia following gangrene of the tumor. (L. Mayer.) Metastases are rare, but are found more frequently than in cases of diffuse sarcoma. They have been observed in the vertebrae (West, Hutch inson), the lymphatic glands, the lungs, the pleura, the liver, and in the pelvic connective tissue. In the last position the secondary tumors had not been developed on account of more contiguity of tissue. (P. Muller.) The symptoms of diffuse sarcoma are very similar to those described. In cases of this variety there is no distinct tumor perceptible by surface examination, the uterus is enlarged and moved with difficulty. (NW. a few cases of West, Gusserow and others, in which these conditions did not obtain.) The proliferating tissues often protrude, however, from the os uteri, and thus simulate a circumscribed tumor.
The fact that the sarcomatous growths have spontaneously protruded from the os, in these cases, is proven by the absence of genuine uterine pains. Small portions of the tumors are, moreover, easily separated from the latter, and are expelled with the discharge. This does not occur with any other uterine neoplasm. Very violent hemorrhages are hardly ever wanting. They usually soon lose the menstrual type, and are more copious when they begin at or Subsequently to the menopause.