The microscopical examination of isolated masses removed from the new growths (even when they belong to a sarcoma and are spontaneously expelled), does not furnish reliable evidence, since one often obtains pieces of healthy mucous membrane, in cases of sarcoma, and in endometritis polyposa, pieces looking like granulation tissue, or small-cell sarcoma.
We omit a consideration of the differential diagnosis between sarcoma, parametritis, cysto-fibromata, hrematocele, etc., because a careful ex amination will protect from such errors, and because in cysto-fibromata, a strict distinction between sarcomatous and other cysto-fibromata is im possible, infra +.'i/am. Our last reason for the omission is that, in specially complicated and difficult cases, no more can be stated than has been already done.
The prognosis in either form of uterine sarcoma must be characterized, after what has been stated, as unfavorable. These tumors are undoubtedly malignant. There is not a single well-authenticated case of sarcoma on record in which extirpation resulted in a permanent cure. Every tumor of this variety has led sooner or later to death. Nevertheless the prognosis, as contrasted with that of most uterine carcinomata, is a comparatively favorable one. The course of sarcomatous disease is much slower, at least in the beginning. Moreover the growths are more frequently diag nosticated at so early a period, that trivial operative measures, often re peated, may delay their progress and materially retard their development.
We have thus cited some cases above, in which the disease extended over a period of ten years, and the patients were not once so tormented by it as in cancer, but often enjoyed a very tolerable condition of health.
Timely operative treatment has, at all events, a favorable influence upon the course of the disease, since it remains a local one much longer than carcinoma does.
There is little to be said regarding the treatment of uterine sarcomata, especially since it must be considered in extenso, under the head of car cinoma.
Every sarcoma must be removed as speedily and thoroughly as possi ble. If removal of the tumors is impossible, the treatment must be symptomatic and analogous to that of fibromyomata and of cancer.
In all cases of sarcoma the question will have to be considered of total extirpation of the uterus, or if the neoplasm is confined to the body of the uterus, of supra-vaginal amputation. Operative interference is always called for, provided a positive diagnosis can be made. A more extended consideration of this subject will be found under the head of cancer. It
may be said in this connection that total extirpation of the uterus is all the more indicated, since the recurrence of the sarcoma is usually oonflned to that organ. • Supra-vaginal amputation of the uterus has been successfully performed for sarcoma by Schroder, by Gusserow and others. Total extirpation was done by Freund once (fatal result) and by Spiegelberg once (recovery). Total extirpation per vaginam was successfully performed by ZweifeL Fibro-sarcomata should, if possible, be thoroughly excised with cutting instruments. Care should be taken not to wound healthy tissues, since the possibility of their inoculation with sarcomatous material (Spiegelberg) cannot be entirely denied. The removal of the tumor must be as complete as possible, because a radical cure is not to be despaired of, and because the recurrence is delayed the longer the fewer the remnants of the tumor loft behind. It is, therefore, urgently recommended to excise the tumor as broadly and deeply as possible, and then to thoroughly cauterize the surface of the wound, if this be possible. If the tumor cannot be thus thoroughly extirpated, on account of its soft consistency or of its loca tion, the last resort is the method invariably employed in cases of diffuse sarcoma. It consists in shaving off the diseased tissues with likeamier's curette, or with Simon's sharp spoon, and in energetic cauterization of the surface of the wound. The cauterization may be most effectively accomplished with a fluid escharotic, viz., liq. ferri chloridi, acid. chromic, acid nitric. fort., etc. Under certain circumstances the actual cautery may, with advantage, be applied to the cavity of the uterus, either by means of the porcelain electrode of a galvano-cautery instrument, or with Pacquelin's apparatus.
The cautery must, naturally, be so applied as to avoid, so far as possible, the dangers of infection, hemorrhage, burning and gangrene. The necessary precautions will be considered in the article on carcinoma.
Although certain fibrous papillomata undoubtedly belong among the connective-tissue series of uterine new growths, it is as yet impossible to consider them separately from other papillomata. Allusion should, how ever, be made to Thiede's case,' in which abundant cartilaginous growths had so invaded a large fibrous papilloma of the portio vaginalis, that he designated the tumor a cartilaginous papillary fibroid. Since it recurred, however, after removal, and led to the patient's death by occasioning hemorrhage, we shall revert to the case under malignant papillomata.