lymphatics and veins, a fatal termination soon resulting from sarcoma of the glands, abdominal walls, lungs, etc.

Sarcoma of the uterine muscle originates directly from the interstices, in the form of scattered nodules which displace the tissues, penetrate the vessels, become subperitoneal, extend to adjacent organs, and are carried by the veins to the lungs, spleen, liver, kidneys and brain, causing in these organs hemorrhagic infiltration and fatal inflammation. One of the most interesting cases of this kind which I have ever observed, and where metastasis into all the above-named organs occurred, is shown in figs. 64 and 65.

Sarcoma of the exterior of the uterus begins either in the subserous tissue or in the peritoneum itself. There are plexiform angio-sarcomata, and the one represented in the preceding illustration belongs to this class.

Symptoms. The more rapidly a mucous sarcoma grows, the sooner a profuse mucous secretion, often mixed with blood,

Interstitial Primary Sarcoma of the Body of the Uterus. a, anterior wall laid open; b and c, multiple, pedunculated ovarian cysts; d and e, tubes; f, posterior wall of bladder.

appears. Severe hemorrhages are rare.

tions of the tumor pressing through the

Pain is caused by por

internal os; otherwise,

the pain is slight. The menses are more profuse and protracted.

Hydrorrhoea of the uterus may cause slight hydrometra by retention when portions of the tumor occlude the internal os.

The discharge becomes brownish and has an offensive odor when the papillary masses begin to degenerate. If the tumors are relatively firm and enclosed in a muscular capsule, they may become submucous, form a pedicle, and be expelled like a polypus, or, as the pedicle is usually very firm, they may even cause inversion of the uterus, as has been reported by Langenbeck,

Interstitial Sarcoma of the Body of the Uterus.

Cav. ut., uterine cavity; Sarcoma lab. post., sarcoma of the posterior lips.

1

Spiegelberg, Nyrop and others. Sarcoma of the uterus may be secondary, arising from a primary sarcoma of the ovary, the latter being the more common; indeed, it is often impossible to say, in the dead subject, which of the two tumors was primary.

Patients with uterine sarcoma are, as a rule, very pale; dema is frequently an early symptom; when there are no hemorrhages, symptoms of anemia may be almost or entirely wanting, indeed, the cheeks, lips and hands may be cyanotic, particularly if there

are metastases in the lungs, and then the great frequency of respiration stands in marked contrast with the temperature which is normal, and at once directs attention to these organs.

Diagnosis.—A positive diagnosis of uterine sarcoma cannot be made without a microscopical examination, even though the rational signs render its existence probable. Sarcomatous tumors are very easily confounded with adenoma and adeno-carcinoma. They can be differentiated only after excising the growth or a part of it, or by scraping the prominences on the uterine mucous membrane, and demonstrating the presence of large cells, everywhere separated by intercellular tissue. Suspicion will be excited that a hard, round, isolated nodule in the uterine wall is a sarcoma, whenever it grows rapidly and becomes sensitive, when other nodules appear and profuse discharges occur, and when the patient becomes very pale and begins to lose strength rapidly. Granular endometritis occurring, for example, after the extirpation of a sessile myoma, may show cells, etc., in the masses, scraped out of the uterus, which are very similar to those of sarcoma, and really are closely related to it, though they represent simple granulation tissue.

Etiology. We know but little concerning the causes of sarcoma. The disease may be congenital, and it may occur at any age, though less common in the old than carcinoma. Sarcoma of the uterus is very rare; for about eight years I sought diligently for a case of the disease in order to obtain an illustration for my Atlas, and was unable to find one. None occurred in the Dresden Hospital, in my clinic, nor in my private practice. Since I have been in Munich, I have seen four cases in two years. Sixty-two cases reported in the literature of the subject, would indicate that the climacteric period shows a certain predisposition to the affection. Among sixty-three patients twenty-five were sterile, which is a very large number when compared with the sterility observed in women having carcinomatous affections.

Sarcomatous degeneration of a uterine myoma is likewise rare. I have operated upon and reported one case of the kind.* Prognosis.-Sarcomata are undoubtedly malignant tumors;

* Berichte und Studien, Bd. iii., 1878.

they grow rapidly and soon destroy the tissues affected. It seemed to me very remarkable that, in all the cases of sarcoma of the uterine mucous membrane which I have observed, their extension outward was so slow. The rigidity of the submucous tissue, and the firm muscular fasciculi may be unfavorable to their rapid growth.

When they are completely extirpated in their early stages, it appears that there is less danger of a recurrence than after total extirpation of a carcinoma.

If this operation is impossible, the prognosis is bad, and they are generally more rapidly fatal than carcinomata.

Treatment. The first and only indication after sarcoma is diagnosticated, is its early removal. Those affecting the mucous membrane must be scraped out or, if pedunculated, they must be cut off and the base of the pedicle cauterized. When the uterus is very much enlarged and the cervix is free, total vaginal extirpation of the organ is indicated; in one case I performed this operation with a fortunate result. When complete removal is not possible, we are confined to symptomatic treatment, which is essentially the same as in carcinoma under the like conditions.

III. MUSCULAR TUMORS OF THE UTERUS.

The most frequently occurring neoplasms of the female sexual organs are myomata, muscular tumors of the uterus. They were formerly called scleroma, steatoma, sarcoma, scirrhus, fibroma and fibroids; the polypoid forms were designated as moles, fungi, and excrescences. Though these tumors were known for a thousand years, their liability to become polypoid was first pointed out by Bayle in 1813. The term myoma or leiomyoma has been applied to them only since 1843, when they were carefully examined in regard to their histological nature by Julius Vogel. The names formerly used may be understood when we remember that the relations of the several constituents of these tumors to each other are extremely variable. If the muscular fibres, which are usually larger in the myoma than in the non-gravid uterus and have large nuclei, predominate, the tumor is soft and elastic; if the tumor is chiefly composed of connective tissue it is firmer;

and in the first case we speak of myoma, in the latter of fibromyoma.

Ordinarily these tumors are not very vascular, but in exceptional cases, not only the adjoining tissues, but the tumor itself contains a great number of large vessels, so that upon section it appears like cavernous tissue, the myoma teleangiectodes seu cavernosum of Bastard, Blodgett, Grammatikati, Rubio and Soller.

When there is ectasis of the lymphatics lying between the muscular fasciculi and near the sheaths of the vessels, we speak of myoma lymphangiectodes. The muscular and connective tissue fasciculi are often arranged concentrically around wide capillary vessels.

Nerves have hitherto been seldom demonstrated in myomata, but Astruc asserted that he found them in the parenchyma of a polypus. Bidder once found a nerve-fibre having a double contour in a large fibroid; but most observers have been unable to discover them.

The great majority of myomata originate in the walls of the body of the uterus; they are very rarely developed in those of the cervix, which has less muscular and more fibrous tissueonly about 5 per cent. of all cases. Most of these tumors are at first intraparietal, either central, as in figs. 67 a and 67 b, nearer the peritoneum, as in fig. 66, or nearer the uterine mucous membrane, as shown in fig. 68. They evidently grow in the direction of the least resistance.

a. When they grow externally they become subserous (fig. 66). As they leave the muscular walls, they push the peritoneum before them, and are therefore apt to form a pedicle, thus becoming peritoneal polypi (fig. 68). Sessile tumors of this kind grow for a longer time, and may reach great dimensions; I have seen in a parturient woman a movable tumor of the left wall as large as a man's head; it seemed very much like an ovarian tumor, for it had undergone central fatty degeneration, and showed indistinct fluctuation. When the tumor itself elongates the pedicle, the muscles diminish in size, the vessels are obliterated, and the serous membrane and connective tissue form the chief attachment to the uterine wall. Such peritoneal polypi are usually multiple; solitary external myoma of the