Contributions to the Histology 
and Histogenesis of Sarcoma 
of the Uterus 
BY 
J. WHITRIDGE WILLIAMS, M.D. 
Associate in Obstetrics, 
Johns Hopkins University, Baltimore 
R1PRINTBD FROM 
The American Journal of Obstetrics 
Vol. XXIX., No. 6, 1894. 
NEW YORK 
WILLIAM WOOD & COMPANY, PUBLISHERS 
1894 CONTRIBUTIONS TO THE 
HISTOLOGY AND HISTOGENESIS OF SARCOMA 
OF THE UTERUS.1 
I. MYOMA. SARCOMATODES UTERI. 
II. SARCOMA MUCOSAS UTERI ET MYOMA INTERSTITIALS UTERI. 
III. MELANO-SARCOMA CORPORIS ET CERVICIS UTERI. 
It is only comparatively recently that sarcoma of the uterus 
has been recognized as a distinct affection, the first caseshaving 
been described little more than thirty years ago. But the very 
abundant literature upon the subject bears evidence of the 
interest which it has aroused among gynecologists as well as 
pathologists. Unfortunately the great majority of the articles 
upon uterine sarcoma have been written almost exclusively 
from a clinical point of view, and have devoted very little 
attention to the pathological aspect of the affection ; in maDy 
instances the diagnosis being made from the clinical history 
alone, without microscopical examination. The pathological 
articles, on the other hand, have usually had only a limited scope, 
and have generally been characterized by a lack of knowledge 
of the work done by others, the result being that many authors 
claim to have made discoveries for the first time which in real- 
ity had been described years before. 
Before entering upon the main object of this article—the 
consideration of the transformation of myomata into sarcomata, 
and the description of several specimens from the museum of 
1 From Prof. H. Chiari’s Pathological-Anatomical Institute in Prague. 
Translated by the author from his article appearing simultaneously in the 
Zeitschrift fur Heilkunde, Bd. xv., Hefte 2 und 3. 2 
williams: contributions to the histology and 
tlie Pathological Institute in Prague—we shall endeavor to give 
a brief review of the present status of sarcoma of the uterus 
and bring together some of the scattered statements concern- 
ing its pathology. It is more than probable that some of the 
growths described by Lebert as fibroplastic tumors of the uterus 
were in reality sarcomata. There is absolutely no doubt that 
the tumors described by Hutchinson,52 Callender,11 "West,102 and 
Paget62 as “recurrent fibroids ” were sarcomata; and the careful 
microscopical examination in Callender’s11 case shows clearly 
that he had to deal with a spindle-cell sarcoma of the uterus 
with metastases in various parts of the body. The first case to 
be described as sarcoma of the uterus was a polypus, the size of 
a fist, which C. Mayer55 exhibited before the Berlin Obstetrical 
Society in 1860, and upon which Yircliow97 made the pathologi- 
cal report. He was soon followed by Langenbeck,51 who reported 
a case of inversion of a sarcomatous uterus. The affection, how- 
ever, did not assume a definite position in pathology until the 
appearance of Virchow’s98 “ Krankhafte Gescliwiilste” in 1865, 
in which he accurately described sarcoma of the endometrium 
and pointed out the possibility of the transformation of fibro- 
mata and myomata into sarcomata. In 1867 G. Veit96 devoted 
a portion of a chapter in his work upon the diseases of women 
to the affection, and described three cases of his own, including 
one involving the cervix, the first on record. Beginning with 
the first volume of the Arcliiv fur Gyndkologie, 1870, cases of 
sarcoma of the uterus were frequently described, and within 
the next five years nearly all the prominent gynecologists of 
Germany published cases of their own, among whom we may 
mention Gusserow,26 Hegar,50 Chrobak,18 Spiegelberg,90 Winck- 
el,104 Leopold,52 Scanzoni,81 Alilfeld,3 and Fehling.18 Hegar’s 30 
article appeared in 1871 and was based upon nine cases. In it 
he distinguished between sarcoma of the endometrium and the 
uterine wall, and gave so good a description of their histology 
that the abundant literature of the past twenty years has added 
comparatively little to his excellent work. We shall not attempt 
to further review the literature of the subject, and would refer 
those interested to the recent article of Von Kahlden,37 in which 
he refers to a considerable number of the reported cases. 
Generally speaking, sarcoma of the uterus may be divided 
into two great groups : those affecting (1) its mucosa and (2) its 3 
HISTOGENESIS OF SARCOMA OF THE UTERUS. 
parenchyma. Under these two main divisions there are, of 
course, numerous subdivisions, upon which we shall only briefly 
touch. 
Sarcoma of the Endometrium.—Sarcoma of the endometrium 
is the most frequent of all forms of uterine sarcoma, and is usu- 
ally limited to the body of the uterus. When affecting the mu- 
cous lining of the cervical canal it assumes a characteristic form, 
which we shall consider separately further on. Of one hundred 
and forty-four fairly accurately described cases which we have 
collected from the literature, at least forty-four, or about one- 
cthird, were limited to the mucous membrane lining the corpus 
uteri; and no doubt a considerable number, which we could 
not include among them on account of uncertainty as to their 
-origin, also belonged in this category. 
Sarcoma of the endometrium occurs either as a diffuse infil- 
fration of the mucosa or as circumscribed growths which tend 
to assume a polypoid form. The former variety is the more 
frequent and may involve varying areas of the interior of the 
uterus, and is usually situated at or near the fundus. It leads 
to marked thickening of the mucosa, which often assumes a 
villous or jagged appearance, bleeds readily, and often presents 
large, necrotic areas. In most cases the process remains limited 
to the mucosa and does not invade the muscularis to any great 
extent, while in other instances it rapidly invades the uterine 
wall and leads to its destruction. According to the amount of 
fibrous connective tissue which they contain, the growths present 
on section a perfectly homogeneous or a more or less striated 
appearance, and may vary in color from grayish-white to light 
pinkish. These growths are frequently so rich in blood vessels 
that they may be designated as hemorrhagic or telangiectatic 
sarcomata. Of course when there is marked necrosis the typi- 
cal appearance disappears and gives place to a very soft, dark 
tissue which readily breaks down. When the growth assumes 
a polypoid form it not infrequently presents a markedly fibrous 
structure, and on casual examination may readily be mistaken 
for an ordinary “ fibroid polypus.” 
Sarcoma of the Parenchyma of the Uterus.—Sarcoma of the 
parenchyma of the uterus likewise appears in two forms, diffuse 
and circumscribed, the latter being of far more frequent occur- 
rence. Indeed, the former occurs so rarely that many authors 4 
WILLIAMS : CONTKIBUTIONS TO THE HISTOLOGY AND 
do not mention it at all. It is due to the growth of the cells 
about the blood vessels or to the proliferation of the connective- 
tissue cells between the muscle bundles. 
The circumscribed form, generally speaking, bears a marked 
resemblance to the myomata and gives rise to roundish tumor 
masses of various size and consistence, sometimes quite hard 
and again very soft. They are usually quite well marked off 
from the surrounding uterine parenchyma, except when they 
have attained a very large size, but are not usually surround- 
ed by a capsule. Like the myomata, they occur either singly 
or multiple, and may be situated in any part of the uterine 
wall and so be either subserous, interstitial, or submucous. 
The interstitial and submucous sarcomata have a marked ten- 
dency to make their way toward the uterine cavity and there 
assume a polypoid form, so that it is frequently impossible to 
decide whether a given polypoid sarcoma arises primarily from 
the parenchyma or mucosa. This is even more difficult dur- 
ing life than at the autopsy table, for in some cases a small 
portion of an interstitial sarcoma may perforate into the ute- 
rine cavity and hang down into it as a polypus, as in the cases 
of Orthmann,62 Schultze,86 and Wyder,107 so that during life 
they would in all probability be diagnosed as arising from the 
mucosa. 
It accordingly becomes evident that a very considerable num- 
ber of cases cannot be definitely classified as arising either 
from the mucosa or the parenchyma of the uterus, and can only 
be said to arise from the corpus uteri. And consequently the 
statistical statements as to the frequency of the various forms 
of uterine sarcoma are open to serious doubt. Of course there 
can be no doubt in the cases in which the growth is surrounded 
on all sides by uterine tissue or arises from the external surface 
of the uterus. 
This form of uterine sarcoma, on section, presents a varying 
appearance, and may be either entirely homogeneous or contain 
large fibrous areas; the latter being of such frequent occurrence 
that these growths are generally spoken of as fibro- or myo- 
sarcomata, and are generally considered to be derived from 
the fibromyomata. Owing to necrotic changes they frequently 
present various colors and not infrequently cystic formations. 
Like the myomata, they may contain many dilated vessels and HISTOGENESIS OF SARCOMA OF THE UTERUS. 
5 
so assume a telangiectatic form, as in the cases reported by 
Johannovsky,34 Jacubusch,33 and others; or may contain cysts 
of various sizes, the result of dilatation of the lymphatics, and 
thus give rise to lymphangiectatic sarcomata, which have been 
described by Fehling and Leopold18 and Fenger.19 And in 
some instances sarcomatous nodules may be found in the wall 
of a uterus whose endometrium is also sarcomatous, thus pre- 
senting a combination of the two forms. 
Microscojrically the uterine sarcomata do not differ greatly 
from sarcomata in other parts of the body, and may consist of 
round, spindle, or giant cells, or a mixture of the various forms. 
It is generally stated that the round-cell sarcoma occurs most 
frequently; next in frequency is a mixture of round and spindle 
cells, while the pure spindle-cell sarcoma occurs comparatively 
rarely; and, as will be seen later, very little is said about giant- 
cell sarcomata. 
It is interesting to note that several observers claim to have 
been the first to describe a pure spindle-cell sarcoma of the 
uterus. Thus, in 1874, both Leopold 32 and Grenser26 stated that 
they were the first to observe such a case, and as late as 1890 
Beissheim 7 made a similar claim, when in reality the case of 
Callender,11 reported in 1857, was apparently the first of the 
kind to be recorded. Personally we have not been impressed 
with the great rarity of spindle-cell sarcoma of the uterus, and 
an analysis of the literature afforded us eighty-eight cases in 
which the form of the cells composing the growths was definitely 
described ; of these, thirty-one were spindle-, twenty-seven round-, 
and thirty mixed-cell sarcomata. We do not wish to claim that 
these figures represent the relative frequency of the various 
forms of sarcoma of the uterus, and we only adduce them to 
demonstrate that the spindle-cell variety occurs more frequently 
than many writers suppose. We believe, however, that the 
round-cell variety is found most usually in sarcoma of the endo- 
metrium. We find here, as in sarcomata in other parts of the 
body, variations in the quantity of cells composing the growth, 
and in the arrangement of the intercellular tissue, which give 
rise to varying forms, which we designate as medullary, fibro-, 
and alveolar sarcoma. 
Sarcoma of the Cervix.—It is generally stated that sarcoma of 
the cervix occurs but rarely, and we have met with only one 6 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
case in Baltimore, which we are unfortunately unable to report 
in this connection, as our records are not accessible at present. 
But we have been able to collect thirty-four cases from the 
literature in which the process was limited to the cervix, and 
several other cases in which both the cervix and body of the 
uterus were involved when the case was first seen. The cases of 
cervical sarcoma are readily divided into two groups, one of 
which appears to be very distinct, while the other, no doubt, 
includes several varieties of growths. 
“ Grape-like ” Sarcoma of the Cervix.—From the mucous 
membrane of the cervical canal and the vaginal portion a growth 
may arise which closely resembles in appearance an hydatiform 
mole or myxomatous degeneration of the chorion. 
Spiegelberg91 was the first to direct attention to this class of 
growths, under the title, “ Sarcoma colli uteri hydropicum papil- 
lare,” when he described a case occurring in a 17-year-old girl, 
in whom he found the anterior lip of the cervix thickened and 
enlarged, and covered on its margin as well as its surface by a 
group of oval, yellowish-brown outgrowths, one to two centi- 
metres long, which looked like transparent cysts, which were 
readily crushed when touched and contained a thick, sticky fluid. 
The anterior lip of the cervix was removed with scissors. Nine 
months later the girl returned with the entire vagina filled by a 
growth which resembled an hydatiform mole in appearance, which 
also arose from the anterior lip by numerous strong, thread-like 
pedicles. The mass was again removed and rapidly recurred ; 
eventually the entire uterus was removed, and the patient died 
later from recurrence. 
The tumors were examined by Weigert, who found that the 
cyst-like masses were covered by a single layer of cylindrical 
epithelium, and their interior composed of large round, spindle, 
and branching cells, which were separated from one another by 
clear spaces which were traversed by fine threads. In these 
spaces lymph corpuscles were found, and between the cells thin- 
walled blood vessels. In the more compact portions of the 
growth, and in the pedicles of the “cysts,” large cells without 
the clear ground substance were seen. The growth at first sug- 
gested a myxomatous sarcoma, but fresh specimens failed to give 
the characteristic mucin reaction with acetic acid. Spiegelberg 
accordingly concluded that the appearance was due to edema HISTOGENESIS OF SAECOMA OF THE UTERUS. 
7 
the result of stasis in the numerous lymph sinuses of the cervix 
and suggested for it the above-mentioned name. 
The next year he reported a similar case,9'2 and stated that one 
of his cases, which had been reported by Kunert,49 was also 
of this variety. Similar cases were soon reported by several 
observers under various names. For example, Rein 70 described 
a case as “myxoma enchondromatodes arborescens colli uteri” ; 
Pernice,64 as “ traubiges Myosarcoma striocellulare uteri” ; and 
Munde,57 as “ a rare case of adeno-myxo-sarcoma of the cer- 
vix.” 
Pfannenstiel66 in 1892 reported a new case, and in his excel- 
lent monograph collected the previous cases and suggested for 
the group the neutral name of “grape-like” sarcoma (“das 
trailbige Sarcom ”) of the cervix, under which the various cases 
could be classified and note taken of their peculiarities. He 
agrees with the majority of observers that the growths in ques- 
tion are not myxomata or myxo-sarcomata, and believes with 
Spiegelberg91,93 and Weigert that they are sarcomata infiltrated 
with lymph and could be designated with propriety as “ sarcoma 
lymphangiectaticum et hydropicum.” He showed conclusively 
that the growth in his case arose from the superficial portions 
of the cervical mucous membrane, to whose papillary structure 
it owed its peculiar form ; and in all probability that it was 
connected in its origin with proliferative changes, which he 
observed about the lymphatics and blood vessels. 
Exclusive of his own case he found eleven other cases in 
the literature—namely, those described by Weber,101 Kunert,49 
Kunitz,60 two by Spiegelberg,91’93 Rein,70 Thomas,95 Winckler106 
(Sanger), Pernice,64 Munde,57 and Kleinschmidt.44 We do not 
believe that the case of Kleinschmidt44 should be reckoned 
among the “grape-like” sarcomata (traubige Sarcomata), for in 
its description he failed to mention that it had the appearance 
which is so characteristic of this form of growths, and he classed 
it himself among the angio-sarcomata. It is also doubtful whether 
the case described by Winckel105 as an “adeno-myxo-sarcoma 
cervicis” belongs in this category. 
On the other hand, it is quite certain that a specimen which 
Byford10 obtained by vaginal hysterectomy in a woman aged 57 
should be classed among the “ grajDe-like ” sarcomata of the 
cervix, and more than probable that the cases described by 8 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
Ahlfeld a and Smith89 in girls, respectively, 15 and 3 years of 
age also belong in the same group. 
It is interesting to note that glandular structures were found 
in the cases of Munde," Winckel,105 and Byford,10 and that hya- 
line cartilage was found in the cases of Hein,™ Bernice,'4 Ivlein- 
schmidt,44 and Pfannenstiel,66 and striated muscle in those of 
Weber,101 Kunert,49 and Pernice.*1 The presence of cartilage 
and striated muscle in these growths is of great interest in 
connection with their histogenesis ; and, unless we accept the 
theories of Weber and Pfannenstiel, who regard them as the 
result of metaplasia of the sarcoma cells, they would appear to 
us to indicate a vitium primce formationis ('Keimverlagerung) in 
Colinheim’s sense. 
It is also interesting to note that the great majority of these 
cases occurred in persons under 20 years of age or past the 
menopause, and only three in the intermediate period; and 
also that they all died from regionary metastases, with the ex- 
ception of Byford’s 10 patient, of whom it is only stated that she 
recovered from the operation; and that true metastases occurred 
only in the cases of Kunert49 and Kunitz.60 
Other Forms of Sarcoma of the Cervix.—Besides this well- 
defined group of “ grape-like” sarcomata, we have found eight- 
een other cases in the literature in which there is no doubt that 
the affection arose primarily from some portion of the cervix, 
either from its parenchyma, or from the mucosa lining its canal, 
or from the submucosa of the vaginal portion. From the de- 
scription of the cases it is not always evident from which 
structure they originated, but it is apparent that they do not 
constitute so definite a group of tumors as those just men- 
tioned. Thus, for example, we find fire cases in which it was 
said that the growth arose from the cervical canal with a broad 
basis, and usually from its mucosa—namely, those of Leopold,62 
Hunter,31 Dressier,18 and two of Kaltenbacli.S8 The cases of 
Veit,96 Hackeling,29 Beermann,6 Johnston,36 and Bommer8 had a 
polypoid form, were attached by a pedicle to some part of the 
cervical canal, and usually protruded into the vagina with the 
pedicle passing through the os externum. In Scanzoni's81 case 
the sarcoma arose from the anterior lip of the cervix, those 
of Kleinschmidt44 and Rosthorn76 from the posterior lip, and 
the two cases reported by Bommer9 arose from both lips. HISTOGENESIS OF SARCOMA OF THE UTERUS. 
9 
The cases of Grenser26 and Zweifel109 presumably arose from 
the exterior of the cervix, and we are unable to give any par- 
ticulars as to the case mentioned by Rogivue 74 on account of 
its meagre description. The microscopical examination of the 
various tumors makes their diversity even more apparent than 
their macroscopical appearance. Thus the specimens of Hack- 
eling29 and Johnston35 contained glandular elements, and the 
latter was also said to be a melano-sarcoma. Leopold stated 62 
that his tumor was originally a fibroma which had become sarco- 
matous. Kleinschmidt’s44 specimen was a spindle-cell angio- 
sarcoma, while those of Grenser25 and Zweifel109 were spindle- 
and round-cell sarcomata respectively; and in Rosthorn’s case 
it was clearly shown that the primary growth arose from the 
submucosa of the vaginal portion. 
Besides the varieties of sarcoma to which we have already 
referred, there are a considerable number of cases on record 
which are described as combinations of sarcoma with other tu- 
mor formations—as adeno-, carcino-, chondro-, and osteo-sareoina. 
Acleno-sarcoma.—When considering the u grape-like ” sarco- 
mata of the cervix we mentioned that several of the cases had 
been described as adeno-sarcomata; but it is evident that the 
presence of glandular structures in them is due only to the per- 
sistence of some of the original glands of the cervical mucous 
membrane, and therefore is of no great importance and does not 
entitle them to a separate classification. 
On the other hand, Schmitt83 and Kay 40 have described cases 
of adeno-sarcoma of the body of the uterus in which glandular 
structures were observed in the sarcomatous endometrium. 
From the description of their specimens it appears that they had 
only to deal with, more or less normal uterine glands which had 
not yet been destroyed by the sarcomatous new growth; and 
Schmitt83 said of his two cases that “ the glands were scarcely 
increased in number,” which appears to us to be sufficient evi- 
dence that he did not have to deal with true adenomatous 
growth. 
Carcinosarcoma.—We cannot dispose of the carcino-sarco- 
mata with the same ease, for their existence is vouched for by 
Yirchow,98 Gusserow,27 Klebs,4'2 and others. 
In his “Geschwiilste” Yirchow98 stated, without giving any 
particulars, that he had seen several cases, and that they were 10 
williams: contkibutions to the histology and 
far more malignant than the ordinary varieties of uterine sar- 
coma ; and lately, in the discussion upon the work of Abel 
and Landau,1 he reaffirmed his belief in the existence of this 
class of tumors. Ivlebs42 also stated that they were of frequent 
occurrence, and Gusserow27 said : “ If the existence of a certain 
relationship between the round fibrosarcoma of the uterus and 
cancerous formations (.Krebsentivickelung) cannot be denied, it 
is so much more frequent and marked in the second form of 
sarcoma of the uterus (sarcoma of the endometrium) that it has 
become doubtful whether one is justified in regarding it as a 
particular variety of tumor formation.” 
Cases of so-called carcino-sarcoma have also been described 
by Rabl-Riickhardt,68 Rosenstein,76 and Keller,41 but it is not at 
all evident from the descriptions of Rabl-Riickhardt68 and Ro- 
senstein 75 that they had to deal with sarcomata; Rabl-Riick- 
hardt’s case, upon which Gusserow appears to base his belief in 
this class of tumors, being apparently a carcinoma of the corpus 
uteri which had grown down into a submucous myoma. In 
Keller’s41 case a tumor the size of a walnut arose from the pos- 
terior wall of the uterus, near the mouth of the right tube, 
which he stated presented a combination of a round- and spindle- 
cell sarcoma with a carcinoma. This he regarded as a “secon- 
dary metaplasia” of a mixed submucous polypus, in which the 
carcinoma arose from the glands and the sarcoma from the 
interglandular tissue. We should hesitate to regard this case 
as a carcino-sarcoma; and it is evident that the term is as inap- 
plicable to Rabl-Riickhardt’s68 case, admitting that it was a sar- 
coma, as the term carcino-fibroma or myoma would be to the 
not very infrequent cases in which carcinomata of the corpus 
invade fibromyomata which are situated in its walls. It is not 
improbable that some of the so-called carcino-sarcomata of Xir- 
chow,97 Klebs,42 and others were decidual-cell sarcomata (deci- 
duoma malignum); and Keller41 states that in three instances 
he has mistaken diffuse carcinoma of the endometrium for sar- 
coma, and Orth69 says that endotheliomata of the uterus may 
assume an adenomatous form and readily be mistaken for 
carcinomata. 
None of us who believe in the purely epithelial origin of 
carcinoma can admit the existence of transition forms between 
sarcoma and carcinoma, or vice versa. Nor do we believe that HISTOGENESIS OF SARCOMA OF THE UTERUS. 
11 
the so-called “ sarcomatous degeneration ” of the endometrium 
of Abel and Landau 1 represents the initial stage in the develop- 
ment of carcinoma of the body of the uterus, or that it results 
from the same cause which produces the carcinoma of the 
cervix. 
Chondrosarcoma.—Chondro- and osteo-sarcomata may be the 
result of further changes on the part of the connective-tissue 
elements of the sarcoma (metaplasia), as well as accidental 
complications (vitium primer formations). 
A case described by E. 'Wagner99 as an enchondroma of the 
uterus in all probability was a chondro-sarcoma. It occurred 
in a woman, aged 55, whose uterus measured 5, 3.5, 3.5 inches 
in its several diameters. When cut open it resembled a thin- 
walled cyst, from whose inner surface many villous structures 
and nodular ridges arose. These portions creaked on section, 
and under the microscope “ consisted of fibres and homogeneous 
bundles, which in many places went over into areas of hyaline 
cartilage. Between the fibrous bundles were many connective- 
tissue elements, spindle- and star-shaped,” many of them being 
very fatty. The growth contained very few vessels. In each 
lung there were about fifteen nodules, which varied from a pea 
to a walnut in size and presented the same structure as the 
uterine tumor. 
Geissler22 also observed areas of hyaline cartilage in a spindle- 
arid round-cell sarcoma of the endometrium which arose from 
the posterior and lateral wall of the uterus in a woman 50 years 
old, and which gave rise to a tumor about 2.5 centimetres in 
diameter; and when considering the “grape-like” sarcomata 
of the cervix we stated that areas of hyaline cartilage had been 
found in the cases of Rein,70 Pernice,64 Kleinschmidt,44 and 
Pfannenstiel.66 
As far as we can learn, no one has as yet reported an un- 
doubted case of osteosarcoma of the uterus, the case reported 
by Newton58 under that name being merely a calcified subperi- 
toneal fibromyoma which arose from the fundus of the uterus, 
weighed twenty-two pounds, and had existed for twenty-five 
years. 
Up to the present it appears uncertain whether a case of true 
melanosarcoma of the uterus has ever been reported, and for 12 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
the scanty references in the literature to this form of sarcoma 
we would refer to the remarks which follow our Case 3. 
Sarcoma deciduo-cellulare.—During the past few years an- 
other variety of sarcoma has been added to the various forms 
which may affect the uterus, under the name of deciduoma 
malignum, or sarcoma deciduo-cellulare. This, which is the 
most malignant of all forms of uterine sarcoma, was brought to 
the attention of the profession by Sanger78 and Pfeifer,67 a pupil 
of Chiari, each describing a case. The cases were published 
within a short time of each other, but totally independently, 
Sanger’s article appearing first. Both described similar cases, 
and both proposed to call them deciduoma malignum. 
In Sanger’s 78 case a healthy young woman, 23 years old, had 
an incomplete abortion in the eighth week. She bled for four 
weeks after it, and when Sanger saw her she presented the 
symptoms of resorptive fever. The uterus was cleaned out and 
the hemorrhage ceased, but she did not regain her health. The 
uterus gradually increased in size, and soon a tumor appeared in 
the right iliac fossa. She developed cough, shortness of breath, 
became greatly emaciated, and died seven months after the 
abortion. At autopsy the uterus was found to be as large as if 
three to four months pregnant, and its walls occupied by four 
tumor masses of dark-red color and hemorrhagic consistence, the 
largest being five to six centimetres in diameter. The endo- 
metrium did not appear to be involved. There were metastases, 
of the same character as the original tumor, in the lungs, 
diaphragm, iliac fossa, and the tenth rib on the right side. 
The microscopical examination showed that the metastases, 
as well as the original uterine tumors, were made up of areas 
of large epithelioid cells, which closely resembled decidual cells, 
and which were separated from similar areas by areas of hemor- 
rhage. The cells themselves were separated by a fine reticulum. 
Throughout the specimen there were a large number of open 
spaces and many giant cells, so that it corresponded very closely 
in structure to the stratum spongiosum of the decidua. In 
some places these cells could be seen along the sides of the 
vessels and apparently taking the place of their endothelium, 
though it was impossible to decide whether they were derived 
from it or not. This relation of the growth to the vessels 
readily explained its hemorrhagic appearance as well as the HISTOGENESIS OF SAKCOMA OF THE UTERUS. 
13 
rapid formation of metastases. From the study of his case 
Sanger had no hesitation in considering it due to an abnormal 
proliferation of the decidual cells. 
Pfeifer’s07 case was almost exactly similar, the woman dying 
five months after the first hemorrhage, with cough, emaciation, 
etc. From the posterior wall of the uterus a growth the size of 
a fist arose, which had the same appearance and microscopical 
structure as in Sanger’s case. There were also metastases of a 
similar character in the lungs and vagina. Pfeifer at first be- 
lieved that he had to deal with a carcinoma, but the discovery 
of a reticulum between the cells, and its general resemblance to 
the decidua, soon led him to recognize its true character and 
propose to call it a deciduoma malignum. Upon examining the 
specimen in Pfeifer’s case Chiari immediately stated that three 
cases which he had described in 1877 13 as primary carcinoma of 
the uterus developing after the puerperium, with regionary and 
pulmonary metastases, were exactly similar, and that he had no 
hesitation in grouping the four cases together as malignant deci- 
duomata. 
At the Breslau meeting of the German Gynecological Society 
(1891) Sanger70 read a paper upon this subject, and very 
properly showed that the term deciduoma malignum had not 
been happily chosen, and proposed instead to designate this 
form of growth as sarcoma deciduo-cellulare and thus give it its 
proper place among the sarcomata. In the discussion which 
followed P. Muller56 reported another case without autopsy; 
and within the past year a number of cases have been reported 
by Gottschalk,24 Kottnitz,46 two by Schmorl,84 and one by 
Lohlein.63 In the cases of Kottnitz,46 Gottschalk,24 and Lbhlein 63 
the diagnosis of deciduoma malignum was made intra vitam, 
and the uterus removed in the last two cases. Gottschalk’s34 
patient, however, died seven months later with hemorrhagic 
metastases in various parts of the body, and up to the present 
Lohlein’s53 patient appears to be the only one who has not 
died from the affection. 
In the cases of Gottschalk,24 Kottnitz,46 and one of Schmorl,84 
besides the typical decidual character of the growths, there also 
appears to be a sarcomatous change in the chorionic villi, which 
they consider the initial change, and from which they suppose 
the rest of the uterus is infected. Gottschalk 24 proposed to call 
his case a sarcoma chorion-deciduo-cellulare ; while Schmorl84 14 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
considers that they are closely related to the “ destruirende Pla- 
centarpolypen ” of Yon Kalnden,36 Zalin. and others, and is doubt- 
ful whether they can be properly designated as sarcomata, and 
consequently proposes to designate the entire group as “ blastoma 
cliorion-deeiduo cellulare.” It would lead us too far, however, 
to attempt to discuss the many aspects of this variety of uterine 
sarcoma, and for their consideration we would refer those 
interested to Sanger’s80 recent monograph upon the subject. 
There is no doubt that many cases of so-called hemorrhagic 
sarcoma belong in this category, and we have no hesitation in 
saying that Jacubusch’s fourth case, and one described by Gut- 
tenplan as sarcoma hemorrhagicum, should also undoubtedly be 
classed among them. There is also but little doubt that some of 
the other cases of carcinoma of the body of the uterus, as well 
as those of Chiari,12 belong in this group ; and, as we have already 
hinted, it is more than probable that some of the so-called car- 
cino-sarcomata also belong in this category. When we consider 
the marked uniformity of the clinical history as well as the 
anatomical conditions in these cases, we must feel that we have 
to deal with the most interesting as well as the most malignant 
of the uterine sarcomata. 
Metastases.—It is generally stated that metastases occur but 
rarely in the course of sarcoma of the uterus; and we may say 
that their occurrence is not general, death usually resulting from 
exhaustion rather than from the formation of metastases. 
With one exception, as stated above, every case of decidual- 
cell sarcoma has proved rapidly fatal, and in every instance 
hemorrhagic metastases were found in the lungs and frequently 
in the vagina and other organs. In addition to the eleven cases 
of decidual-cell sarcoma we have found twenty-three other cases 
in the literature, including two cases of our own, in which true 
metastases were found at the autopsy ; in nearly every case 
they were situated in the lungs and frequently in other organs, 
and in only two or three instances in the lymphatic glands. 
The occurrence of metastases in organs far distant from the 
uterus, without involvement of the lymphatic glands, can only 
be explained by infection through the blood. Ample proof for 
this mode of origin is afforded by the cases of decidual-cell sar- 
coma of Sanger78 and Pfeifer,67 the cases which Pestalozza66 
calls infectious hemorrhagic sarcoma, and the angio-sarcomata 
described by Kleinschmidt44 and Yon Kahlden,87 for in all of HISTOGENESIS OF SARCOMA OF THE UTERUS. 
15 
them sarcoma cells and tumor masses were observed within ves- 
sels which were apparently venous ; and also by the cases of 
Katz 39 and Geissler,22 in which the pelvic veins were found 
iilled by sarcomatous thrombi. In Katz’s 39 case definite sarco- 
matous thrombi were found in the pulmonary arteries, which 
gave rise to pulmonary metastases ; while in Geissler’s22 case 
the process was still limited to the pelvic veins and had not yet 
led to their formation. These observations serve to demonstrate 
that Zenker’s108 statement, that most sarcoma metastases are 
due to infection by the blood, applies as well to the uterus as to 
the other organs. The vaginal metastases which occur so fre- 
quently in the cases of decidual-cell sarcoma are far more diffi- 
cult of explanation, and their mode of origin is still an open 
question. 
Other Complications of Sarcoma of the Uterus.—Besides the 
formation of metastases, sarcoma of the uterus may give rise to 
several other complications, several of which are of interest and 
deserve a brief mention. 
In several instances the sarcomatous new growths have per- 
forated the uterine wall, thus allowing its necrotic contents to 
escape into the peritoneal cavity. This was noted in cases of 
Weber101 and Dressier,16 in which death resulted from acute 
peritonitis; and in the case of Jacubusch,33 which wre have 
included among the decidual-cell sarcomata, death was due to 
hemorrhage from the rupture of a nodule on the posterior wrall 
of the uterus. In the cases of Finlay 20 and Reunert,71 the ute- 
rine growth perforated into the intestines ; and in the cases of 
Gusserow28 and Ritter 73 abscesses followed the perforation into 
the peritoneal cavity, which in turn ruptured through the abdo- 
minal wall. In several cases of sarcoma of the endometrium 
the internal os has become clogged up, thus preventing the 
escape of the contents of the uterus and so leading to the for- 
mation of a pyometra; this was noted in cases of Freund,21 
Terillon,93 and Kay;40 and in our Case 3. In Terillon’s93 case 
the uterus contained seven litres of thick, dark fluid, and he 
mentioned a case of Pean in which the uterus contained fifteen 
litres of fluid. In several cases of sarcoma of the endometrium 
inversion of the uterus has been observed ; this was noted in 
cases of Wilks,103 Langenbeck,61 Spiegelberg,90 Simpson,88 and 
Beissheim,7 and in most instances was mistaken for a sarcoma- 
tous polypus, whose removal was attempted with fatal result. 16 
"WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
It is interesting to note that the cases of Spiegelberg90 and Simp- 
son 88 occurred in nalliparous women, among whom inversion of 
the uterus is practically unknown ; and Simpson88 attributed it 
to loss of tone of the uterine musculature, resulting from its 
invasion by the sarcomatous new growth ; and, lastly, in the 
cases of sarcoma of the endometrium described by Simpson88 and 
Coleman 14 the process had extended directly into the tubes, 
the submucous tissue being the first to become affected. 
Histogenesis.~The consideration of the histogenesis of sar- 
coma of the uterus will be simplitied if we consider separately 
the forms occurring in its endometrium and parenchyma. 
The comparatively simple structure of the mucous membrane 
of the uterus renders it evident that sarcoma of the endometrium 
can have only two sources of origin—namely, from the inter- 
glandular tissue and the vessel walls. There is no doubt that 
the great majority of sarcomata of the endometrium are devel- 
oped directly from its connective-tissue cells; and it is only 
necessary to recall the histological appearance of some forms of 
interstitial endometritis to understand what a slight histological 
difference exists between the malignant and benign forms of 
proliferation of the connective tissue of the endometrium. 
In a certain number of cases, however, the growth may ori- 
ginate bv proliferative processes about the vessels. Indeed, 
Waldeyer 100 considers it the usual mode of origin for sarcoma in 
general, and it likewise undoubtedly applies to a certain propor- 
tion of cases of sarcoma of the endometrium. Pfannenstiel66 
is as yet the only observer to demonstrate this, though Amann 4 
has recorded a case of endothelioma of the vaginal portion of the 
cervix which arose from the lymph channels in the lower layers 
of its mucous membrane. 
As shown by Keller 41 and Yon Kahlden,37 sarcomata may origi- 
nate in the lower layers of the endometrium and for a long time 
leave its superficial layers more or less intact, so that the entire 
surface of the growth may be covered by tissue containing glands. 
The decidual-cell sarcomata likewise originate in the mucosa, 
but the consideration of their histogenesis would necessitate the 
discussion of the origin of the decidual cells themselves; and 
as those who have busied themselves with the study of the pla- 
centa have not yet decided whether they arise entirely from the 
connective-tissue cells or also in part from the vessel walls, we 
must leave their consideration to others. HISTOGENESIS OF SARCOMA OF THE UTERUS. 
17 
As we have already stated, a large number of authors sup- 
pose that sarcoma of the parenchyma of the uterus is always the 
result of secondary changes in uterine myomata. Most writers 
upon sarcoma of the uterus have accepted this doctrine with- 
out hesitation, and consequently have entirely overlooked other 
modes of origin ; and even those who have not accepted it in 
its entirety believe that it is the most frequent mode of origin, 
while the development of sarcoma from the normal constituents 
of the uterine wall is the exception. There is, however, no 
doubt that sarcomata may arise from the interstitial connective 
tissue and the blood vessels of the uterine wall, in which there 
is no sign of tibromyomatous formations. 
As far as we can learn, Eppinger17 is the only observer who 
has described sarcomata arising from the interstitial connective 
tissue of the uterine wall. In his case there were sarcomatous 
nodules of considerable size in the walls of the uterus, which he 
demonstrated were due to the proliferation of the interstitial 
connective tissue and the adventitia of the vessels. 
Beermann 5 and Klebs42 both state that sarcomata of the ute- 
rine wall may also arise from the blood vessels, but fail to give 
any histological details. The first actual proof for this mode of 
origin was adduced by Kleinschmidt,44 who described an angio- 
sarcoma of the cervix, to which we have already referred. A 
soft, nodular tumor, the size of an orange, arose from the pos- 
terior lip of the cervix, which was removed and cauterized ; 
recurrence two months later. It soon attained the same size 
and was once more removed. The microscopical examination 
showed that both tumors presented the same structure and were 
made up of large spindle cells arranged parallel to the vessels. 
He then says: “ The sarcoma appears to arise from the blood 
and lymph vessels, which are very abundant in both tumors. 
Generally it appears to originate from the adventitia of the 
vessels, but in many places a distinct proliferation of the intima 
can also be observed, generally forming an opaque, tolerably 
broad, almost homogeneous layer about the vessel. In many 
places nothing more can be seen of the real vessel wall, as it is 
completely transformed into sarcomatous tissue.” 
Two years later (1893) Yon Ivahlden37 also described a case of 
angio-sarcoma affecting the body of the uterus as well as the 
cervix, in which this mode of origin was also clearly demon- 
strated. The growths were composed of oval cells, which were 18 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
arranged concentrically about the vessels, thus forming small 
nodules, which by their coalescence gave rise to larger ones. 
He claims that he is the first to have observed such a case, 
and completely ignores the claims of Kleinschmidt’s44 case in 
this regard, of which he says: “ The microscopical examination 
revealed a sarcoma, very rich in blood vessels, which was com- 
posed of spindle cells thickly crowded together.” Orth69 also 
states “ that there are also sarcomatous tumors which resemble 
the carcinomata very closely, particularly certain adenomatous 
forms, but which must be classed among the sarcomata, as they 
are new growths which are due to a proliferation of the endo- 
thelium of the blood vessels, and accordingly must be desig- 
nated as endotheliomata.” There is also no doubt that sarcoma- 
like growths may be derived from the muscle cells themselves, 
as was stated by Beissheim 7 and Pestalozza.05 We shall, how- 
ever, defer the consideration of this mode of origin until after 
the consideration of our Case 1. 
The transformation of fibromata and fibromyomata into sar- 
comata, or their “ sarcomatous degeneration,” as most authors 
insist upon calling it, has long been a favorite theme with those 
who have busied themselves with the consideration of uterine 
sarcomata; and a very large number of authors do not hesi- 
tate to state that it occurs very frequently, and indeed is the 
most usual, if not the only, mode of origin for sarcoma of the 
parenchyma of the uterus. But, unfortunately, most of the 
arguments in favor of this mode of origin are based entirely 
upon clinical grounds or upon the mere macroscopical appear- 
ance of the tumors. It is generally believed, if a “fibroid 
growth ” be removed from the uterus and be soon followed 
by another, that the second is necessarily a recurrence of the 
first, and such cases are generally regarded, without an attempt 
at microscopical examination, as conclusively demonstrating the 
malignant character of the growth and the transformation of a 
fibromyoma into a sarcoma; while the more natural explanation 
is that they are frequently totally independent of each other 
and the apparent recurrence is only a coincidence. In this con- 
nection it must be remembered that cases have been recorded by 
Klebs,43 Krische,41 and Orth80 which tend to show that fibro- 
myomata may recur in very rare instances, and even give rise 
to metastases, and still present absolutely no sign of being sar- 
comatous. Such observations, though extremely rare, show the HISTOGENESIS OF SARCOMA OF THE UTERUS. 
19 
great need of caution in drawing conclusions in these cases, and 
■demonstrate the absolute necessity of the microscopical demon- 
stration of the sarcomatous nature of the growths before basing 
any arguments upon them. In some instances even the micro- 
scopical examination does not render an infallible verdict, as 
was demonstrated by a case in which Winckel104 removed, in 
the course of a little more than two years, three tumors from 
the interior of the uterus, the first of which he regarded as a 
fibroma and the other two as round-cell sarcomata which were 
due to the “ sarcomatous degeneration” of the base of the first. 
Two years later Scliatz82 removed a fourth tumor from the 
same patient, which he demonstrated was only an inflamed myo- 
ma, and clearly showed that 'Winckel104 had regarded similar 
tumors as sarcomata. The subsequent history of the case de- 
monstrated the correctness of Schatz’s 82 verdict, for the woman 
was perfectly well three years after the removal of the third 
recurrence.” 
Most of the authors who attempt to demonstrate this trans- 
formation by means of the microscope fail to show anything 
more than sarcomatous tissue adjoining myomatous. But, in 
our judgment, no one has as yet conclusively demonstrated the 
histological stages in this transition (Uebergang). It cannot be 
denied, however, that there is a great deal to be said in favor of 
its occurrence, and we do not care to be understood as attempt- 
ing to throw doubt upon it, and in the remarks which follow 
we shall endeavor to prove that it does occur ; but, in view of 
what has already been said, it is evident that it does not consti- 
tute the universal mode of origin for sarcoma of the parenchyma 
of the uterus. 
The macroscopical resemblance of many uterine sarcomata to 
the ordinary “ fibroid polypi ” early suggested to the English 
observers that they were closely related to one another, and in 
designating them as “ recurrent fibroids ” they gave evidence of 
this belief ; but since the demonstration of their sarcomatous 
nature the term has gradually fallen into disuse. 
Virchow,98 in his “ Geschwiilste,” stated the possibility of the 
transformation of fibromata and myomata into sarcomata, and 
most of the earlier writers readily accepted his statement. Ile- 
gar,93 Leopold,52 and Chrobak13 soon published cases which they 
considered exemplified this transformation. To Hegar’s 30 cases 
we shall have occasion to refer later. Chrobak13 reported a poly- 20 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
pus which he had removed from the fundus of the uterus, which 
upon microscopical examination presented for the most part the 
typical structure of a fibroma, with here and there proliferative 
processes between its connective-tissue fibres. The cells were 
generally round and a few spindle shaped, and several showed 
signs of cell division. But from his description they could just 
as readily have been areas of inflammation ; and if they were sar- 
comatous, no clue was given as to their origin. And Leopold 62 
contented himself with stating that there was no doubt that the 
specimen in his case was a young sarcoma which was due to the 
“degeneration” of a fibroma. Kuuert,49 in 1875, reported six 
cases from Spiegelberg’s clinic, one of which was a “ fibrosar- 
coma ” of the uterine wall, upon the strength of which he stated 
that it and all similar growths were due to the “ degeneration ” 
of fibromata, though he did not attempt to adduce proof in 
support of his statements. Schroder/6 in his text book upon 
the “Diseases of Women,” also took a similar position, and 
in nearly all the subsequent articles both he and Kunert are re- 
ferred to as having proved that all sarcomata of the uterine wall 
originate in this way, while in reality they simply expressed 
their opinion without attempting to prove its correctness. 
Rogivue,” in his dissertation, stated that all parenchymatous 
sarcomata did not originate in this manner ; and Raymond stated 
that the presence of sarcomatous and myomatous nodules in the 
same uterus, as in his case, did not necessarily indicate that the 
former were the result of secondary changes in the latter. 
In 1880 A. R. Simpson88 reported a large sarcomatous 
growth which he had removed from the interior of the uterus. 
On section it was perfectly homogeneous and of a light-pinkish 
color, except for a very few circumscribed myomatous nodules. 
The homogeneous portion consisted of spindle- and round-cell 
sarcoma, while the myomatous nodules presented the usual 
appearance. The growth recurred several times, but in none 
of the later specimens could any trace of myomatous tissue 
be found, so he had no hesitation in declaring that the entire 
growth represented a metamorphosis of a fibromyoma. Jacu- 
buscli33 and Kundrat48 also described a number of specimens 
which they considered proved the point in question ; but none 
of them were carefully examined microscopically, and they based 
their opinions purely upon the macroscopical appearance of 
the specimens, some portions of which presented the usual IIISTOGEXESIS OF SARCOMA OF THE UTERUS. 
21 
appearance of fibromyomata, while other portions appeared to 
be sarcomatous. Gusserow,21 in his article upon sarcoma of 
the uterus in Billroth-Liicke’s “ Handbuch der Frauenkrank- 
heiten,” stated that sarcomata of the wall of the uterus are usu- 
ally the result of the “sarcomatous degeneration” of fibromata 
or myomata, but in a few cases they may be due to a primary 
sarcomatous infiltration of its parenchyma. The statements of 
Reunert,71 who reported three cases from Winckel’s clinic in a 
very careful dissertation, are not much more satisfactory, for, 
in speaking of the “sarcomatous degeneration” of myomata, 
he said (page 35): “ Perhaps one could also suppose, if one finds 
at the same time a fibroma and a sarcoma, that the latter tumor 
was not primarily malignant, but that it represented a degene- 
rated fibroma. In any event this would explain the coexistence 
of a benign and a malignant new growth in the same organ.” 
Rothweiler77 also reported a case in which Schroder per- 
formed vaginal hysterectomy. The uterus was as large as an 
ostrich egg, and from its fundus four polypoid growths, as large 
as a walnut, protruded into the uterine cavity. One of them 
was pedunculated and the others sessile; their surface, as well 
as the endometrium in the upper portion of the uterus, was sar- 
comatous. Microscopical examination showed that the bases 
of the polypi were composed of unchanged myomatous tissue, 
which was continuous with the parenchyma of the uterine wall, 
but that the portion which projected into the uterine cavity was 
the seat of a spindle- and round-cell sarcoma. He believed that 
he had to do with the “ sarcomatous degeneration ” of myo- 
matous polypi, and considered that he was able to trace the 
transition from one tissue to the other. Ilis description, how- 
ever, is not very clear, and, in view of the fact that the rest of 
the endometrium was likewise sarcomatous, we are inclined to 
believe that he had to deal with a primary sarcoma of the endo- 
metrium which had invaded the surfaces of the submucous 
polypi, rather than with their “ sarcomatous degeneration,” 
somewhat as in our second case. He, however, regarded it as 
a striking verification of Schroder’s view—“ ein sprechendes 
Beispiel fiir die Schroder’sche Ansicht.” 
In 1887 Orthmann 61 exhibited before the Berlin Obstetrical 
Society a sarcomatous uterus which had been removed by 
Martin, and which was afterward described by Ritter7S in a 
dissertation “ Heber das Myosarkom des Uterus.” The patient 22 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
had noticed the growth for about ten years, when it rapidl}7 
became larger and necessitated the supravaginal amputation of 
the uterus. Recovery from operation ; rapid recurrence in the 
peritoneal cavity ; perforation of the abdominal walls by the 
growth ; death six weeks after the operation. In the anterior 
wall of the uterus was a tumor, twenty centimetres in diameter, 
which wras generally surrounded by a capsule. Upon its ante- 
rior surface were two smaller subperitoneal tumors; one, 
enclosed in a capsule, was a typical fibromyoma, while the 
other, which was in communication with the large tumor, was 
a round-cell sarcoma. Portions of the large tumor were dis- 
tinctly sarcomatous, and other portions presented a typical 
myomatous structure. Ritter73 considered the sarcoma the re- 
sult of “ degeneration of the myoma,” and stated : In some 
portions, “ between the connective tissue and muscle fibres one 
finds at first a few small round cells or small collections of 
cells. They become more and more numerous. Definite cell 
division may be observed. With the various methods of stain- 
ing one can trace all its stages up to the formation of double 
nuclei. Finally we see the fibres pressed apart by masses of 
cells which occupy nearly the entire field ” (page 3d). In this 
case he clearly demonstrated proliferative changes in the in- 
terstitial portions of a fibromyoma, and so is in accord with 
Birch-Hirschfeld,8 who states that sarcomata are always derived 
from myomata in this way. 
The lymphangiectatic forms of sarcoma which were described 
by Fehling and Leopold 18 and Fenger 10 were believed by them 
to have been originally lymphangiectatic fibromyomata which 
later became converted into sarcomata; but they adduced no 
histological proof in support of their statements. Bommer,9 
Doran,15 Dressier,16 and Behnke 6 have also reported cases which 
they considered were due to the transformation of fibromyomata 
into sarcomata ; but the microscopical examination showed only 
the coexistence of myomatous and sarcomatous tissue, without 
giving any definite information as to the transformation from 
one to the other. 
The latest work upon this subject is that of Yon Ivalilden,37 
who, in the third case of his recent article, believes that he 
reports the first case in which the transformation of a fibro- 
myoma into a sarcoma has been definitely proven. 
In his case the uterus was 15.5 centimetres in length, with HISTOGENESIS OF SARCOMA OF THE UTERUS. 
23 
walls from 2.5 to 3 centimetres in thickness. Its cavity was 
dilated, and three large, nodular, sessile to mors, which were 
apparently covered by endometrium, projected into it. The 
uterine walls were crowded with large numbers of round or 
oval tumors, up to a hazelnut in size, which are surrounded by 
capsules. Each tumor is composed of smaller nodules, which 
generally present a fibrous appearance. In the midst of the 
fibrous structure of many of the nodules are homogeneous areas. 
This formation extends from just beneath the mucosa to the 
outer part of the uterine wall, where it ceases and gives place to 
a layer of normal uterine musculature. 
The microscopical examination showed that the glandular 
structure of the endometrium was preserved. In the portions 
of the growth nearest the muscularis he found microscopical 
nodules, which were surrounded by a thin connective-tissue 
capsule and sharply marked off from the surrounding tissue. 
In each of these he found two varieties of cells—one which 
stains lightly, and another which stains deeply ; the former 
representing muscle, and the latter sarcoma cells. As the 
cavity of the uterus is approached the nodules become larger 
and visible to the eye, when they are found to be made up 
of a number of smaller ones, those nearest to the uterine cav- 
ity being frequently composed entirely of sarcoma cells. The 
tumors which project into the cavity of the uterus are made up 
of the larger nodules, and in places represent a diffuse sarcoma 
which has extended into the lower layers of the mucosa. 
Yon Kahlden37 considers that this specimen illustrates the very 
earliest stages in the formation of myoma of the uterus, and 
that in the very smallest nodules the first stages in the devel- 
opment of sarcoma may be observed. “ This occurred in the 
smallest fibromyoma nodules,by the direct transformation of the 
muscle cells into roundish and then into short-oval cells which 
are rounded off at their poles.” Nowhere were the muscle 
and sarcoma cells indiscriminately mixed together, but in each 
nodule there were definite areas of well-marked sarcoma as 
well as muscle. And finally he says : “ The direct histological 
proof of the transformation of myoma into sarcoma is here pre- 
sented for the first time.” 
After carefully considering Yon Kahldeirs 37 cases wTe feel 
compelled to state that we do not consider that he has really 
demonstrated that the sarcoma cells were derived from the 24 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
muscle cells of the tibromyomata, as he believes. And we are 
unable to understand from the description of the specimen how 
he excluded the possibility of the connective tissue which exists 
between the muscle bundles having given rise to them, or at 
least having taken part in their formation. Certainlj his Fig. 6 
does not exclude this possibility, any more than it demonstrates 
that the sarcoma cells were derived from the muscle cells. 
In view of these facts we do not believe that the proof 
adduced by Yon Kahlden in support of the transformation of 
fibromyomata into sarcomata is at all convincing. 
Fig. 1.—Lateral aspect of the tumor from Case 1, one-fourth natural size. 
From the preceding review of the work upon this subject it 
is evident that fibromyomata may be transformed into sarcomata, 
but the demonstration of the initial histogenetie changes which 
occur in the process has yet to be adduced. 
We shall now pass to the description of our new cases. 
Case I. Sarcoma-like Myoma of the Uterus (Myoma sarcoma- 
todes Uteri').—Museum specimen .No. 4729. From the clinical 
history, for which we are indebted to the courtesy of Prof. 
Pibram, we extract the following : Augusta S., admitted to hos- 
pital February 4tli, 1891; age 47 ; no children or miscarriages. 
Menses appeared in the sixteenth year, always regular; menopause 
four years ago; no loss of blood since. She was perfectly well HISTOGENESIS OF SARCOMA OF THE UTERUS. 
25 
up to June, 1890, when she first noticed a gradual enlargement 
of her abdomen, which increased with great rapidity for the five 
weeks previous to her admission to the hospital. She did not 
complain of pain, and was able to go about her work until one 
week previous to entering the hospital. For the past few weeks 
there had been marked emaciation and edema of the abdominal 
walls, legs, and feet. The physical examination revealed no 
abnormality of the heart, lungs, or kidneys, and showed the 
abdomen filled by large tumor masses, which were diagnosed as 
malignant growths arising from the generative tract. Death 
seven weeks after admission. 
Autopsy March 26th, 1S91. Anatomical diagnosis: “ sarcoma 
Fig. 2.—Sagittal section of the same. 
fuso cellulare uteri (e myomate); morbus Brightii cliron.; hy- 
drops et marasmus universalis.” Except for the abdominal tumor 
the autopsy offers little of interest, there being only some old 
chronic nephritis and old pericardial adhesions. In the abdomi- 
nal cavity there were over three litres of clear fluid. The intes- 
tines were forced into the upper and left portion of the abdomi- 
nal cavity by a large tumor which entirely filled the j3elvis and 
extended up into the right side of the abdominal cavity, and 
was adherent to the anterior abdominal wall, the omentum, and 
surrounding intestines. 
The tumor (Fig. 1) measures thirty-six centimetres in its 
antero-posterior diameter, and is readily divisible into three 
parts : a central portion, about twelve centimetres in diameter, 26 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
which corresponds to the enlarged uterus, from whose anterior 
and posterior surfaces a large tumor arises, each the size of a 
man’s head. As is seen from Fig. 2, which represents a sagittal 
section through the entire mass, the anterior tumor arises from 
the central portion by a thick pedicle, and thus presents a some- 
what mushroom-like appearance. The posterior tumor is some- 
what larger than the anterior, and is attached by a broad base to 
the posterior surface of the central portion. Extending from 
either side of the central portion are the apparently normal tubes 
and ovaries. 
The surface of the central tumor is perfectly smooth, while 
the others are covered with thin adhesions and are studded with 
thin-walled cysts of various sizes, with clear or bloody contents, 
which are more abundant and of larger size in the posterior 
tumor. 
The vagina is greatly increased in length, and from it a sound 
may be introduced for sixteen centimetres into the uterine 
cavity, which occupies 'the left side of the central part of the 
tumor, thus showing that its greater part was developed in the 
right wall of the uterus. The uterine cavity is lengthened, but 
not otherwise increased in size. 
A sagittal section through the entire tumor mass (Fig. 2) 
shows that the anterior portion generally presents a firm, 
homogeneous appearance, with here and there, particularly 
toward its anterior border, areas of hbrons structure and small 
cysts with clear contents ; while the other portions present many 
cysts of varying size, separated by dense grayish-white tissue 
and alternating with necrotic areas. As is seen from Fig. 2, 
the upper part of the central tumor mass is surrounded by 
a layer of unchanged uterine musculature, forming a capsule 
which in places is over one centimetre in thickness and is readily 
separated from the underlying tumor. The portions adjoining 
the capsule are dense and of a firm consistence, while the lower 
portion is composed of the necrotic areas and cystic formations 
which characterize the greater part of the growth. 
Microscopical Examination.—Small portions were removed 
from various parts of the tumor and submitted to microscopical 
examination. Sections through the uterine cavity show that 
its mucous membrane is atrophic, with comparatively few 
glands and a slight increase of connective tissue, and presents 
the typical appearance of the endometrium after the meno- ERRATUM. 
Thb- description under figure 3, page 27, should go under 
figure 4 on page 28, and vice versa. HISTOGENESIS OF SARCOMA OF THE UTERUS. 
27 
pause. It is surrounded on all sides by unchanged muscularis, 
and it is only at a distance of a centimetre or more from its 
right margin that the sarcomatous growth makes its appearance. 
A casual examination of sections from various parts of the 
growth shows that we have to deal with a spindle-cell tumor 
with many necrotic areas; but a more careful examination 
shows that it presents many points of interest and gives us im- 
portant information as to its mode of origin. 
Sections through the upper part of the central tumor mass 
Fig. 3 —Sarcomatous portion from the anterior portion of the same tumor, showing 
giant cells and reticulum. Zeiss Oc. 2, Ob]'. E. 
show that the capsule is composed of perfectly normal uterine 
musculature, and the superficial portions of the tumor beneath 
it present for the most part the appearance of a myoma, with 
here and there sarcomatous areas scattered through it. The 
sarcomatous structure becomes more evident as we approach the 
central part of the tumor, where we find the large, necrotic 
areas and cystic formations. The sarcomatous tissue is com- 
posed of large spindle cells, which are thickly crowded together, 
with here and there large giant cells with from two to six or 
eight central nuclei. Where the cells are not too closely crowded 28 
williams: contkiihjtions to the histology and 
together we see that they are separated by a small amount of 
connective tissue (Fig. 3). The growth contains many vessels, 
the walls of many of the arteries presenting marked hyaline 
degeneration. 
As the capsule is approached the cells become less crowded 
together, and gradually myomatous tissue appears. In places 
it appears quite probable that the sarcoma cells are derived 
from those of the myoma. For in some portions of the growth 
we see apparently perfectly normal muscle cells; then their 
nuclei become larger, some attaining two or three times their 
normal size, while in others karyokinetic figures are observed. 
Then the cells become greatly increased in number and much 
more closely crowded together, and the tissue assumes a dis- 
Fig. 4.— Showing the transformation of muscle into sarcoma cells, from the median por- 
tion of the tumor. Zeiss Oc. 2, Obj. E 
tinctly sarcomatous appearance. The connective tissue which 
is between the muscle cells is seen to be continuous with that 
between the sarcoma cells. Fig. 3 gives a fair idea of this 
change. In its lower right-hand corner we see perfectly typical 
spindle-cell sarcoma with many vessels and marked intercellular 
substance, while in the upper right-hand portion of the figure 
we see apparently normal muscle cells with long (stdbchen- 
formig) spindle-shaped nuclei; then the nuclei become larger 
and more oval, and the cells gradually increase in number, so 
that at last at one end of the field we see a typical spindle-cell 
sarcoma, while at the other we have apparently normal muscle. 
While the examination of portions from the central tumor 
renders it probable that the sarcoma cells are derived from the 
muscle cells, this mode of origin is rendered absolutely certain HISTOGENESIS OF SARCOMA OF THE UTERUS. 
29 
upon the study of sections from the anterior tumor. A short dis- 
tance from the surface the growth presents the typical structure 
of a spindle- and giant-cell sarcoma (Fig. 4). Here we see 
large spindle and giant cells separated bv a large amount of 
intercellular substance with many vessels. Immediately ad- 
joining this, however, are areas in which the sarcomatous struc- 
ture is not so well marked, and adjoining them areas in which 
we find only typical myomatous tissue. But in many places the 
transition is so gradual that it is absolutely impossible to say 
where the muscular tissue ends and the sarcomatous begins, and 
we only feel sure of ourselves when we are at one or other end 
of the process; and even in the otherwise normal myomatous 
Fig. 5.—Myomatous tissue with enlarged cells and nuclei scattered through it, from the 
anterior portion of the same tumor. Zeiss Oc. 4, Obj. AA. 
tissue we find some of the cells increased in size, and here and 
there a giant cell or a karyokinetic figure. 
Fig. 5 represents a section from near the surface of the 
anterior tumor under a low power; and it is evident that here 
we have to deal with myomatous tissue, the only regard in 
which it differs from perfectly normal myomatous tissue being 
the presence of very large, deeply staining bodies, of various 
size and frequently of bizarre form, which are scattered through 
it. Fig. 6 represents an area from the above Fig. 5, more 
highly magnified. In its centre we see a large space lined 
by endothelial cells, from whose upper end extends a small 
capillary which contains several leucocytes. The surrounding 
tissue is composed of typical long, spindle-shaped muscle cells 30 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
which are separated by a considerable amount of connective tis- 
sue. Scattered through the section are large cells with nuclei 
of various sizes and shapes, some being hardly larger than the 
muscle cells, while others are five or six times as large. Sev- 
eral of them contain large vacuoles; in others the large nucleus 
appears to be going to break down into several smaller ones ; 
and in others (not represented in the drawing) we find several 
smaller nuclei in a single cell body—in other words, t}7pical 
giant cells. In some of the smaller cells karyokinetic figures are 
also observed. Accordingly there can be no doubt that the 
great part of the growth, spindle as well as giant cells, is 
derived from the muscle cells of a primary fibromyoma, while 
its connective-tissue elements do not appear to be involved in 
the process. 
Fig. 6.—A portion of Fig. 2 more highly magnified. Zeiss Oc. 2, Obj. E. 
Our specimen, judging from the history and microscopical 
appearance, was apparently originally a fibromyoma of the ute- 
rus, composed of a single interstitial and two larger subperito- 
neal nodules, which at a later period underwent the changes 
which we have just described. It accordingly represents the 
transformation of a primary fibromyoma into a sarcoma-like 
growth by the proliferation of its muscle cells, and presents a 
marked contrast to the case in which Yon Kalilden *7 attempted 
to demonstrate a similar inode of origin, for in it he found 
only sarcoma cells adjoining muscle cells, but failed to demon- 
strate the transition of one to the other; and the fact that the 
sarcoma cells are not scattered through the smallest myoma 
nodules, but are grouped together and sharply marked off from HISTOGENESIS OF SARCOMA OF THE UTERUS. 
31 
the adjacent muscle cells, speaks against such a mode of origin, 
instead of for it as he believes. And it is the converse of 
Ritter’s 73 case, in which the sarcoma was in all probability the 
result of the proliferation of the connective-tissue elements of 
the myoma. 
As the new growth in our case was derived from a prolifera- 
tion of the muscle cells and not from the connective tissue, 
the question naturall}T arises, Are we entitled to class it among 
the sarcomata ? 
While there is no doubt that connective tissue and muscle 
cells are both of mesoblastic origin and consequently more or 
less closely related, there is equally no doubt that they repre- 
sent essentially distinct tissues ; and a priori we should hardly 
be justified in classing non-striated muscle among the connec- 
tive-tissue elements, as we should be obliged to do were we to 
designate the growth before us as a sarcoma. 
For these reasons, when we first became acquainted with the 
nature of our tumor, we sought to designate it by some term 
which would indicate its muscular origin and at the same time 
keep it distinct from the sarcomata, and we thought of calling 
it a malignant myoma, “myoma malignum,” thereby briefly 
stating its origin and its malignant, proliferative properties; but 
upon further consideration we concluded to designate it as a 
“ sarcoma-like myoma,” or “myoma sarcomatodes,” thereby ex- 
pressing its relationship to both the myomata and sarcomata. 
We do not consider this term as at all synonymous with the 
term myo-sarcoma. The former, we believe, indicates a sar- 
eoma-like tumor derived from the muscle cells of a myoma ; 
while the latter, according to the somewhat loose terminology 
in vogue among the sarcomata, only indicates a mixture of sar- 
comatous and muscular tissue and has no reference to its origin. 
In connection with our specimen of “ myoma sarcomatodes,” 
two cases described by Pestalozza65 as infectious hemorrhagic 
sarcoma of the uterus are of great interest, for in them he be- 
lieved that he observed changes in the muscle cells more or less 
similar to those in our specimen. He described small hemor- 
rhagic growths arising from the fundus of the uterus in two 
women, aged respectively 25 and 33 years, which rapidly led to 
death—in one case within six months—with hemorrhagic me- 
tastases in the lungs and vagina. The uterine tumor in each 
ease was a round-cell sarcoma, which contained large numbers of 32 
WILLIAMS : CONTKIBUTIONS TO THE HISTOLOGY AND 
giant cells with usually not more than two nuclei. He believed 
that the giant cells were derived from the muscle cells of the 
parenchyma of the uterus, and in his Fig. 7 gave a draw- 
ing, illustrating the process, which is quite similar to our Fig. 4. 
He also found giant cells in the muscularis some distance from 
the sarcomatous growth, just as in our case ; and in several 
instances they could be found making their way into the vessels 
or already within them, which readily explains the formation 
of metastases. 
It is not clear from his description to what the round cells, 
which make up the greater part of the growth, owe their origin. 
He was inclined to believe that they were connected in some 
way with the decidua and were probably closely related to the 
decidual-cell sarcomata. After carefully considering his cases 
we believe that they are decidual-cell sarcomata, and the muscle 
changes, if they really occur, play only an insignificant part in 
the production of the growths. 
Beissheim,7 a pupil of Rindfleisch, has also attempted to show 
that sarcomata may arise from the muscle cells. But his state- 
ments are based mostly upon theoretical considerations as to the 
relation between muscle and connective tissue, and the speci- 
men which he adduces in their support does not appear con- 
vincing; but after our own experience we do not wish to deny 
that he observed such changes. 
It is quite probable that Hegar80 observed structures similar 
to those described by Pestalozza65 and ourselves, for in his 
article upon sarcoma of the uterus he reported a case (Case 8) in 
which he had removed a tumor weighing two pounds from the 
uterus of a woman aged 44 years. Fifteen months later there 
was a recurrence, the second growth exceeding the first in size. 
The first growth he considered a fibromyoma, and the examina- 
tion of the second by R. Maier showed that it was a fibromyoma 
which differed in only one particular from the normal: “ Als 
auffallig und nicht gewohnlich ist nur ein Yerhalten zu bemer- 
ken. Es linden sich an einzelnen IStellen und an diesen dann 
gewohnlich zahlreich mitten in dem Zuge der Fasermassen und 
parallel mit diesen spindelfbrmige grosse Figuren, wie ungeheuer 
vergrosserte Spindelzellen. Sie batten die grosste Aehnlichkeit 
mit den oft zu formlichen Brutschlauchen umgewandelten Zellen 
des Bindegewebes bei lebhaften Proliferations proceesen oder 
bei Umwandlung von Bindegewebe in Knorpelgewebe. Die HISTOGENESIS OF SARCOMA OF THE UTERUS. 
33 
Riiuine sind gefiillt mit einer Masse von Kernen, Kornern, 
Fettmolekiilen. Sie sind oft ziemlicli lang, 0.04 millimetre, und 
breit 0.0047.” 1 
From the consideration of our case and the work of our pre- 
decessors, it is evident that fibroinyomata may be transformed 
into sarcomata either by the proliferation of the connective-tissue 
cells between the muscle bundles (Ritter), or by the proliferation 
of the muscle cells themselves, or possibly by a combination 
of both processes, the first giving rise to ordinary sarcomata 
and the second to muscle-cell sarcomata. 
In connection with the consideration of the “sarcomatous 
degeneration ” of fibromyomata, our second case is of consider- 
able interest—namely, a sarcoma of the endometrium which has 
invaded the surface of several interstitial'myomata. Similar 
cases have been regarded by Rothweiler77 and others as dem- 
onstrating the transformation of myoma into sarcoma. We, 
however, regard the two processes as absolutely distinct, and 
consider the involvement of the myoma as purely accidental, 
it being entirely due to its situation just beneath the endome- 
trium. Similar cases have been described by Martin,54 Dress- 
ier,16 and others. 
The case of Raymond69 and the first case of Yon Kahlden, in 
which there was sarcoma of the endometrium with myomatous 
nodules in the uterine wall, and the case of Gottschalk,23 in 
which a subperitoneal myoma was associated with sarcoma of 
the endometrium, all serve to demonstrate that the involvement 
of the myoma in such cases is absolutely dependent upon its 
situation, and not upon any connection between the two pro- 
cesses. 
Case II. Sarcoma Mucosas, Uteri et Myomata Uteri.—Mu- 
seum specimen No. 3381. Marie Z., age 52 years; no clinical 
history. Anatomical diagnosis: “ Sarcoma uteri gangrenosum ; 
ulcera necrotica in vagina; urocystitis catarrhalis; pyelonephri- 
1 As remarkable and uncommon only one peculiarity is to be noted. There 
are found in a few places, in the centre of the fibrous stroma and parallel with 
it, numerous large spindle-shaped bodies resembling immensely magnified 
spindle cells. These had a marked resemblance to those connective-tissue 
cells which sometimes change into regular breeding places (Brutschlauchen) 
at the time of active proliferation or during the transformation stage of 
connective tissue into cartilage. The interstices are filled with nuclei, 
granular masses, and fat molecules. They are sometimes quite long, 0.04 
millimetre ; their width is 0.004?. 34 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
tis lateris utriusque; pneumonia lateris dextri; septicemia; ma- 
rasmus.” 
The vagina was 9.5 centimetres long. Its upper portion was 
smooth and of a dark color mottled with whitish spots, while its 
lower half was of a bluish-violet color. At the posterior com- 
missure was an ulcer, 2.5 centimetres in diameter, with sharp 
margins and a shallow, yellowish base. Around it were several 
smaller ulcers, and at one side a prominence 5 by 3 millimetres 
arose. 
The uterus measured 14.5 centimetres from the external os to 
the fundus, its greatest breadth being 11 centimetres. Undei 
its serosa, near the attachment of the left tube, was a small nod- 
ule the size of a bean. At the fundus the uterine wall was 1 
centimetre thick, its lower portion being of various thickness; 
for a nodular fibroid (?) tumor, 4 centimetres in diameter, oc- 
cupied its anterior wall and extended down as far as the os 
internum. The surface of the tumor projected into the uterine 
cavity and presented a jagged, irregular, ulcerated appearance. 
The rest of the uterine cavity showed no trace of its normal 
mucous membrane, but presented an irregular, villous, necrotic 
surface, which wras composed of a soft tissue rich in vessels, and 
which apparently extended down into the muscularis. In the 
centre of the posterior wall wras another nodule, the size of a 
hazelnut, which appeared to be a fibroid. The cervix was intact, 
3.5 centimetres long, and its walls 0.8 centimetre in thickness. 
The tubes and ovaries were normal. 
Microscopical Examination.—Sections from various parts of 
the specimen clearly show that the sarcomatous new growth is 
limited to the inner surface of the uterus and extends only a 
short distance into its walls. It is probable that it originated in 
the mucosa, but, as no trace of the endometrium remains, posi- 
tive proof for this mode of origin cannot be adduced. 
Sections through the upper part of the large myomatous 
nodule and the adjacent portions of the uterine wall and cavity 
show clearly that the growth did not originate in the myoma, 
but only involved the portions of it which were adjacent to the 
uterine cavity, just as it did the other portions of the uterine 
wall. 
The growth is a spindle- and round-cell sarcoma, which con- 
tains some giant cells and very few vessels, and is entirely 
limited to the inner surface of the uterus. In general its most HISTOGENESIS OF SARCOMA OF THE UTERUS. 
35 
internal portions are necrotic and present nothing but cellular 
debris and the remains of nuclei. A little further removed 
from the interior of the uterus the tissue is well preserved and 
consists of spindle and round cells, closely packed together, with 
a very small amount of intercellular substance. The smallest 
cells are hardly larger than leucocytes. In many portions small 
bands of non-striated muscle may be seen scattered through it, 
which increase in number and size as the exterior of the uterus 
is approached, until at last we come to well-marked muscular 
tissue with only a few sarcoma cells scattered between its fibres, 
beyond which the uterine wall presents its normal appearance. 
From the study of the specimen it is readily seen that the 
growth is invading the uterine walls from within outward, and 
in its course affects the myomata which happen to be in the 
uterine wall, as well as the perfectly normal uterine tissue. 
The various myomatous nodules, where they are not invaded 
by the sarcoma, present the typical microscopical appearance and 
contain many areas of myxomatous degeneration. 
And, finally, we desire to describe the following unique case 
of melano-sarcoma of the uterus: 
Case III. Melano-sarcoma Corporis et Cervicis TJteri.—Mu- 
seum specimen No. 2717. R., aged 60 years; no clinical his- 
tory. Anatomical diagnosis: “ Melano-sarcoma uteri; sarcomata 
metastatica cerebri ; marasmus; edema pulmonum.” From the 
autopsy records we extract the following: “Dura mater pale; 
pia mater contains a considerable amount of serous effusion. 
Brain substance soft, doughy ; cortex pale brown; medullary 
substance yellowish-white in color, with many blood points 
scattered through it. Scattered through both the superficial and 
deep portions of the cortex are numerous blackish nodules 
which are composed of a soft tissue.” 
The lungs normal except for edema. Heart normal except 
for a small excrescence upon one of the semilunar valves. Other 
organs normal. 
The uterus is converted into a tumor the size of a head. The 
cervical region was preserved and markedly dilated, and the 
cavity which resulted was filled by a collection of thick fluid. 
The anterior lip of the cervix was converted into a tumor the 
size of an orange. The tubes and ovaries were normal, and 
the lymphatic glands of the neighborhood were enlarged. 
We shall now describe the specimen, which had been preserved 36 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
for some years in alcohol. The uterus has been cut open from 
its anterior surface, and, generally speaking, has an hour-glass 
shape, which is due to the presence of tumor masses in its 
fundus and cervix, while the intervening portion of its body 
remains intact. From the fundus to the lower margin of the 
cervical new growth the uterus measures seventeen centimetres, 
its greatest antero-posterior thickness being seven centimetres. 
The fundus is occupied by an irregularly-shaped tumor mass 
which completely fills the upper part of the uterus and extends 
downward for a distance of eight centimetres. It is generally 
of a dark color, in some portions being almost black and in 
others lighter in color. It is dense on section and presents a 
striated appearance. The tumor is very intimately connected 
with the uterine walls, but the distinction between it and the 
uninvolved musculature is very marked. The muscularis is most 
invaded at the fundus, where it does not exceed one millimetre 
in thickness; it then gradually increases in thickness, until at the 
lower margin of the new growth it measures one centimetre. 
The entire cervical region is transformed into an irregular, 
globular mass, about seven centimetres in diameter, which has 
the same general appearance as the tumor in the fundus, but is 
of a lighter color. It protrudes into the vagina, but does not 
involve its walls; no trace of the cervical canal can be found 
within it; and as with the tumor in the fundus, so here, the 
distinction between the new growth and the muscularis is very 
marked. The fundal and cervical tumors are separated from 
one another by an area of perfectly intact uterine wall, which 
in its narrowest part has a vertical diameter of three centi- 
metres. Upon the inner surface of this area there are numerous 
small depressions, the largest not exceeding one millimetre in 
diameter, which represent the openings of the- uterine glands. 
From this a portion of the endometrium may be traced upward 
and be found to cover a considerable portion of the lower surface 
of the fundal new growth. The intact portions of the uterine 
wall vary from four to ten millimetres in thickness. The vagina 
is wide and smooth, and appears to be perfectly normal. The 
tubes are normal, and the ovaries small and atrophic. 
Microscopical Examination.—Sections through the fundal 
tumor and the underlying portions of the uterine wall show that 
the tumor is sharply marked off from the uninvolved portions 
of the muscularis by a slight line of small-cell infiltration. The HISTOGENESIS OF SARCOMA OF THE UTERUS. 
37 
most superficial portions of the tumor are necrotic, and nothing 
can be distinguished in it save fragmented nuclei and granular 
debris. In its deeper portions the structure is well preserved, 
and it is seen that it is composed for the most part of large 
spindle cells with very deeply staining nuclei. These cells vary 
considerably in size, but the smallest are at least twice the size 
of polynuclear leucocytes. In some portions of the tumor large 
numbers of giant cells are observed, which are of varying size 
and possess from one to eight or ten central nuclei. Occasion- 
ally they are so abundant that fifteen or twenty may be counted 
in a single field under the high power, while in other places it 
is necessary to search through several fields before finding one. 
Many of the cells, spindle as well as giant cells, are filled with 
yellowish-brown pigment grannies, to which the growth owes its 
dark color. In some of the cells karyokinetic figures may be 
observed. As the muscularis is approached, bands of nnchanged 
muscular tissue may be seen extending up into the tumor, and 
throughout its greater part very small bands of muscle may be 
found, indicating its invasion by the new growth. The tumor 
from the cervical region presents identically the same structure 
as that from the fundus. In no part of the tumor are there 
large quantities of blood vessels. 
Sections through the uninvolved portions of the uterine wall 
show that its muscularis is perfectly normal and that very little 
is left of the endometrium. There is no trace of its superficial 
epithelium ; there is some small-cell infiltration, and here and 
there small cavities which are lined by a single layer of cuboidal 
epithelium, and which represent all that is left of the glandular 
structure of the endometrium. The tissue is not well enough 
preserved to permit us to make any definite statements as to the 
probable histogenesis of the tumor. 
As far as we can learn, this is the only well-authenticated case 
of melano-sarcotna of the uterus which has been recorded; for, 
while several cases may be found in the literature which may 
possibly belong among them, this is the only one which has pre- 
sented the typical macroscopical appearance of a melano-sarcoma, 
and, after careful microscopical examination, been described as 
such. 
We have been able to find in the literature only three refe- 
rences to this class of growths, and, as will be seen, none of them 
present the characteristics of the melano-sarcomata to the same 38 
WILLIAMS : CONTKIBUTIONS TO THE HISTOLOGY AND 
degree as our case, even admitting tliat they were melano-sarco- 
mata, which appears more than doubtful. 
It is probable that some of the cases referred to by Ivlob45 as 
carcinoma melanodes, or “ Pigmentkrebs,” may belong in this 
category; but he stated that, as far as he knew, a primary case 
of melano-carcinoma of the uterus had never been described, and 
that “ I know also of a case, observed in Rokitansky’s Anatomical 
Institute in Vienna, of diffuse carcinoma melanodes in a mark- 
edly enlarged uterus, with a similar growth in both ovaries.” 
It is quite probable that this case was similar to our own, but 
in view of its scanty description we are not justified in stating 
that it was a melano-sarcoma. 
The next reference in this connection is a case which G. W. 
Johnston35 reported as a melano-sarcoma of the cervix uteri. 
He removed from a negress, aged 40 years, a pear-shaped poly- 
pus, three-quarters of an inch in its greatest diameter, which 
arose from the cervical canal just above the os externum by a 
pedicle 1.5 inches long and as thick as a lead pencil. “ The tumor 
was pear-shaped, with a smooth, glistening outer surface; it was 
hollow and contained about half a drachm of greenish-yellow 
fluid.” 
The tumor was examined by Dr. Gray, of the Army Medical 
Museum in Washington, who made the following report: “The 
outer surface is covered by a squamous epithelial mucous mem- 
brane, the central cavity being lined by a ciliated, columnar 
epithelium. The mass of the tumor is composed of large spindle 
cells and very delicate connective-tissue fibres, which in places 
form alveoli containing small round cells whose protoplasm is 
entirely obscured by pigment. In the neighborhood of the 
alveolar structures the blood vessels are in an embryonic state, 
in other places better developed, but nowhere are seen perfectly 
formed blood vessels. The tumor also exhibits a tendency to 
cystic degeneration ; several of the cysts are lined by columnar 
epithelium, and the cavities filled by a finely granular mass con- 
taining a few epithelial cells. I would designate the specimen 
as one of melanotic alveolar sarcoma or of endothelial cancer 
undergoing cystic degeneration.” 
From the above description it is evident that the polypus in 
question cannot be compared with ours, and that even its sarco- 
matous nature is open to doubt. 
The only other reference in this connection is to be found in HISTOGENESIS OF SAECOMA OF THE TJTEEUS. 
39 
a dissertation by Seeger87 (1891), in which he reports five cases 
of sarcoma of the uterus from Gusserow’s clinic. It is probable 
that his fourth case may belong in this category, though he 
does not describe it as a melano-sarcoma. Gusserow performed 
supravaginal amputation of the uterus in a woman aged 50 years. 
“The microscopical examination of the tumor show's areas rich 
m cells, wTith little intercellular substance alongside of fibrous por- 
tions, the cells exhibiting all possible gradations, from smaller 
and larger spindle cells to distinct giant cells writh many nuclei 
and occasionally of a branching shape. Many cells contain a 
finely granular pigment, here and there fatty degeneration, but 
not marked enough to lead to softening.” 
The consideration of the references just adduced renders evi- 
dent our statement that our Case 3 is the only well-described 
case of melano-sarcoma of the uterus which has as yet been 
recorded. 
A point of considerable interest, in connection wTith the three 
cases which wTe have just described, is that they all contained 
considerable numbers of giant cells with from two or three to 
eight or ten central nuclei. Occasionally as many as fifteen or 
twenty giant cells might be counted under a single field of the 
microscope, under others only a few*, and sometimes it was 
necessary to search through several fields to find a single one. 
In view of their comparative abundance, however, in our 
cases, it is surprising to find that Rheinstein,72 in describing his 
case of “ giant-cell sarcoma of the endometrium,” stated that he 
was the first to have observed giant cells in sarcoma of the ute- 
rus, and that Yon Kalilden 37 stated that they had been noted 
very rarely, and, wTith the exception of his case, had only been 
observed by Ahlfeld2 and Rheinstein.72 
On the other hand, exclusive of our cases have found at 
least eleven other cases of sarcoma of the uterus2 in w'hich giant 
cells had been described previous to the appearance of Yon 
Kahlden’s37 article, and several others since then. Besides the 
two cases of Pestalozza65 and the cases of Hegar30 and Seeger,67 
to which we have already referred, giant cells were found in 
four cases of Terillon 94 and in one of Katz,39 not to mention the 
cases of Ahlfeld 2 and Rheinstein,72 to which Yon Kahlden37 
referred. Giant cells were also described recently by Cole- 
man 14 in a case of sarcoma of the endometrium. 
Strange to say, Sanger80 is the only observer who mentions 40 
williams : contributions to the histology and 
their presence in the decidual-cell sarcomata, where one would 
naturally expect to find them. They were likewise observed 
in a case recently operated upon by Dr. Menge in the Leipzig 
Frauenklinik, the specimens from which he kindly allotted us 
to examine. We suppose that they occurred likewise in most 
of the other cases, but failed to be mentioned by the various 
observers. 
It is evident, however, from our experience and from the 
facts which we have gleaned from the literature, that they occur 
much more frequently than is generally supposed ; and now 
that we have directed attention to their more frequent occur- 
rence, they should no longer be regarded as rarities and will be 
mentioned more frequently. 
In conclusion, we desire to express our thanks to Prof. Chiari 
for the material upon which this article is based, and especially 
for his kindness in supervising our work. We also desire to 
express our indebtedness to Prof. Sanger, of Leipzig, for the 
use of his library, which he very kindly placed at our disposal. 
Leipzig, March 15th, 1894. 
1. (a) Abel: Ueber das Verhalten der Schleimhaut des Uterus bei Carcinom 
der Portio. Arch. f. Gyn., xxxii., 271, 1888. 
(b) Abel und L \ndau : Beitrage zur path. Anat. des Endometriums. 
Arch. f. Gyn., xxxiv., 165-190, 1889. 
(c) Abel und Landau : Ueber das Verhalten der Schleimhaut des. 
Uterus-Kbrpers bei Carcinom der Portio vaginalis. Arch. f. Gyn., xxxv., 
214-238, 1889. 
(d) Abel und Landau: “ Eigenartige ” interstitielle Endometritis oder 
sarcomatose Degeneration der Uterusschleimhaut. Centralbl. f. Gyn., xiv., 
673, 1890. 
(e) Abel und Landau : Sarcoma endometrii und Stiickchendiagnose. 
Centralbl. f. Gyn., xiv., 845, 1890. 
2. Ahlfeld : Diffuse sarcomatose Entartung des Uterus und der Vagina. 
Wagner’s Arch. f. Heilkuude, viii., 560, 1867. 
3. Ahlfeld : Ein Beitrag zur Casuistik der Uterussarcome. Arch. f. Gyn., 
vii., 1875. 
4. Amann : Ueber Neubildungen des Cervix, p. 31, 1892. 
5. Beermann : Ueber Sarcoma uteri. D. i., Gottingen, 1876. 
6. Behnke : Zur Radicaloperation des Sarcoma uteri. D. i., Jena, 1891. 
7. Beissheim : Reines Spindelzellensarcom des Uterus mit Uebergreifen auf 
Portio und Scheide nebst Histogenese. D. i., Wurzburg, 1890. 
8. Birch-Hirschfeld : Randbuch der path. Anat., ii. Auf., Bd. ii., 804, 
1886. 
1 Does not include the purely clinical articles, and also several references to 
American journals which we were unable to obtain in Leipzig. 
LITERATURE.' HISTOGENESIS OF SARCOMA OF THE UTERUS. 
41 
9. Bommeb : Ueber das Uterussarcom. D. i., Zurich, 1890. 
10. Byford: A case of vaginal hysterectomy. Am. Journ. Obst., xxi., 
1203, 1888. 
11. Callender : Recurrent fibroid tumor of the uterus, with growths of a 
similar character in the pericardium, the lungs, and the body of the sixth 
ervical vertebra. Trans. London Path. Soc., ix., 327, 1858. 
12. Chiari : Ueber drei Fiille von primitren Carcinom im Fundus und 
Corpus uteri. Med. Jahrbucher der K. K. Gesell. der Aerzte in Wien, 1877, 
363-368. 
13. Chrobak : Beitrag zur Kenntniss des Uterussarcoms. Arch. f. Gyn., 
iv., 549, 1872. 
14. Coleman : A case of diffuse sarcoma of the mucous membrane of the 
uterus. Am. Jour. Obst., xxviii., 811, 1893. 
15. Doran : Myoma of the uterus becoming sarcomatous. Trans. London 
Path. Soc., xli., 206, 1890. 
16. Dressler : Ueber Uterussarcome. D. i., Halle, 1890. 
17. Eppinger : Mittheilungen aus dem path.-anat. Institut zu Prag. 
Prager Vierteljahrsschr. f. d. pract. Heilkunde, cxxvi., 9, 1875. 
18. Fehling und Leopold : Ein Beitrag zur Lehre von den kystischen 
Myomen des Uterus (Myo-sarcoma lymphangiectodes uteri). Arch. f. Gyn., 
vii. 531, 1875. 
19. Fexger : Fibro-cysto-sarcoma of uterus. Am. Jour. Obst., xxi., 
1200, 1888. 
20. Finlay : Fibromyoma of the uterus becoming sarcomatous, with 
secondary growths in pleura, heart, and kidneys. Trans. London Path. Soc., 
xxxiv., 177, 1883. 
21. Freund: Beitriige zur Pathologie des doppelten Genitalcanals. 
Zeitschr. f. Geb. u. Gyn., i., 231, 1877, Case 1. 
22. Geissler : Ueber Sarcoma uteri. D. i., Breslau, 1891. 
23. Gottschalk : Centralbl. f. Gyn., xi., 242, 1887. 
24. Gottsciialk : Ueber das Sarcoma chorion-deciduo-cellulare (Deciduoma 
malignum). Berliner klin. Woclienschr., 1893, No. 4, 26. 
25. Grenser : Spindelzellensarcom der Portio vaginalis ; Galvano-caustische 
Operation ; Heilung ; kein Recidiv in zwei und ein lialb Jakren. Arch. f. 
Gyn., vi., 501, 1874. 
26. Gusserow : Ueber Sarcome des Uterus. Arch. f. Gyn., i., 240, 1870. 
27. Gusserow : Sarcome des Uterus. Billroth-Lucke, Handb. d. Frauen- 
kranklieiten, Bd. ii., 158, 1886. 
28. Guttenplan : Ein Fall von kiimorrhagisckem Sarcom des Uterus und 
der Vagina mit Metastasen in den Lungen. D. i., Strassburg. 1883. 
29. Hackeling : Das Fibrosarcom canalis cervicalis uteri. D. i., Gottin- 
gen, 1873. 
30. Hegar : Das Sarcom des Uterus. Arch. f. Gyn., ii., 29, 1871. 
31. Hunter : Sarcoma of cervix uteri. Am. Jour. Obst., xvii., 522, 1884. 
32. Hutchinson : Recurrent fibroid tumor of the uterus assuming a 
polypoid shape ; three times partially removed. Trans. London Path. Soc., 
viii. 287, 1857. 
33. Jacubusch : Vier Falle von Uterussarcom. Zeitschr. f. Geb. u. Gyn., 
vii., 53, 1882. 
34. Johannovsky : Sarcoma telangiectaticum uteri. Prager med. Wocli- 
enschr., 1878, iii., 421. 42 
WILLIAMS : CONTRIBUTIONS TO THE HISTOLOGY AND 
35. Joiinston, G. W. : Abnormalities and diseases of the genito-urinary 
system in negro women. 4—Melanotic sarcoma of the cervix uteri. Mary- 
land Med. Journ., xx., 428, 1889. 
36. Von Kahlden : Ueber destruirende Placentarpolypen. Centralbl. f. 
allg. Path. u. path. Anat., ii., 1 u. 54, 1891. 
37. Yon Kaiilden : Das Sarcom des Uterus. Ziegler’s Beitritge zur path. 
Anat. u. allg. Path., xiv., 134-224, 1893. 
38. Kaltenbach : Erfahrungen uber Uterussarcom. Yerh. X. internat. 
med. Congress, Bd. iii., Abth. viii., 71, 1890. 
89. Katz : Ein Fall von Sarcom des Uterus. D.vi., Kiel, 1887. 
40. Kay : Uterine adeno-sarcoma with pyometra. New York Med. Record, 
xxxv., No. 13, 346, 1889. 
41. Keller: Zur Diagnose des Schleimhautsarcoms des Uterus. Zeitschr. 
f. Geb. u. Gyn., xx., 116, 1890. 
42. Klebs: Handbuch der path. Anat., Bd. i., Abth. ii., 889, 1876. 
43. Klebs: Metastasen von Myomen. Allg. Path., ii., 704, 1889. 
44. Kleinschmidt : Ueber primiires Sarcom des Cervix uteri. Arch. f. 
Gyn., xxxix., 1-16, 1891. 
45. Klob: Das Carcinom des Uterus. Path. Anat. d. weibl. Sexualorgane, 
Wien, 1864, 191. 
46. Kottnitz : Ueber chorio-deciduale Tumoren malignen Characters. 
Deutsche med. Wochensclir., No. 21, 1893. 
47. Krische • Ein Fall von Fibromyom des Uterus mit multiplen Metasta- 
sen bei einer Geisteskranken. D. i., Gottingen, 1889. 
48. Ivundrat : Zwei Fade von Fibroiden des Uterus, die in Sarcome ilber- 
gegangen sind. Wiener med. Bl., iv., 449, 1883 ; also Wiener med. Presse, 
xiv., 475, 1883. 
49. Kunert : Ueber Sarcoma uteri. Arch. f. Gyn., vi., Ill, 1874. 
50. Kunitz : Ueber Papillome der Portio vaginalis. D. i., Berlin, 1885. 
51. Langenbeck : Praparat einer vollstiiudig invertirten (sarcomatosen) 
Gebarmutter. Monatschr. f. Geburtskunde,’xv., 173, 1860. 
52. Leopold : Ueber Sarcoma uteri. Arch. f. Gyn., vi., 493, 1874. 
53. Lohlein : Sarcoma deciduo-cellulare, nach vorausgegangenen Myxoma 
chorii. Centralbl. f. Gyn., No. 13, 1893. 
54. Martin: Centralbl. f. Gyn., viii., 401, 1884. 
55. Mayer, C. : Ein Fall von Extirpation eines Medullarsarcoms aus der 
Gebarmutterhohle. Verb. d. Berliner Gesell. f. Geb., xii., 19. 1860. 
56. Muller, P. : Ueber das Deciduoma malignum. Yerh. der deutschen 
Gesell. f. Gyn., iv., 1892, 341. 
57. Munde : A rare case of adeno-myxo-sarcoma of the cervix. Am. Jour. 
Obst., xxii., 1889. 
58. Newton : Osteo-sarcoma of the uterus. Proceedings of the Connecticut 
Med. Soc., N. S. iii.. No. 1, 31. 
59. Orth : Uterussarcom. Lehrbuch der spec. path. Anat., Bd. ii., Lief, iii., 
485, 1893. 
60. ORTn : Ditto, 496. 
61. Orthmann : Myo-sarcoma uteri intraparietale. Centralbl. f. Gyn., x., 
815, 1886. 
62. Orthmann : Zwei Fade von Uterussarcom. Centralbl. f. Gyn., xi., 
780, 1887. HISTOGENESIS OF SARCOMA OF THE UTERUS. 
43 
63. Paget : Recurrent fibroid tumors. Lectures on Surgical Pathology, 
London, 1863, 575-585. 
64. Pernice : Ueber ein traubiges Myo-sarcoma striocellulare uteri. Vir- 
chow’s Arch., cxiii., 46, 1888. 
65. Pestalozza : Contributo alio studio dei sarcomi dell’ utero. Morgagni, 
xxxiii., September, 1891, 517. 
66. Pfannenstiel : Das traubige Sarcom des Cervix uteri. Virchow’s 
Arch., cxxvii., 305, 1892. 
67. Pfeifer : Ueber eine eigenartige Geschwulstform des Uterus-Fundus 
(Deciduoma malignum). Prager med. Wochenschr., No. 26, 1890. 
68. Rabl-Ruckhardt : Sarcoma uteri carcinomatodes mit spontaner Aus- 
stossung. Berliner Beitritge zur Geb. u. Gyn., i., 76, 1872. 
69. Raymond : Sarcome du corps de l’uterus, generalises. Sarcome de la 
dure-mere siegeant au niveau de la partie superieure de la circonvolution 
parietale ascendante, etc. Progrtis Medical, ix., 741, 1881. 
70. Rein : Myxoma enchondromatodes arborescens colli uteri. Arch. f. 
Gyn., xv., 187, 1880. 
71. Reunert : Ueber Uterussarcome unter Mittheilung drei neuer Fiille. 
D. i., Munehen, 1886. 
72. Riieinstein : Riesenzellensarcom des Endometrium. Virchow’s Arch., 
cxxiv., 507, 1891. 
73. Ritter : Ueber das Myosarcom des Uterus. D. i., Berlin, 1887. 
74. Rogivue : Du sarcome de l’uterus. D. i., Zurich, 1876. 
75. Rosenstein : Carcino-sarcoma uteri bei einem Kind von zwei Jahren. 
Virchow’s Arch., xcii., 191, 1883. 
76. Rosthorn : Zur Kenntniss des primiiren Scheidensarcoms, der Portio 
vaginalis und der Vagina. Wiener klin. Wochenschr., ii., 729-732, 1889. 
77. Rothweiler : Ueber das Sarcom des Uterus. D. i., Berlin, 1886. 
78. Sanger : Ueber Deciduoma malignum. CeDtralbl. f. Gyn., 132, 1889. 
79. Sanger : Ueber Deciduome. Verb. d. deutschen Gesell. f. Gyn., iv., 
333, 1892. 
80. Sanger : Ueber Sarcoma uteri deciduo-cellulare und andere deciduale 
Geschwiilste. Arch. f. Gyn., xliv., 89, 1893. 
81. Scanzoni : Lehrbuch der Krankheiten der weiblichen Sexualorgane. 
V. Auf., 366-378, 1875. 
82. Schatz : Entzltndetes Myom des Uterus tiiuscht ein Myosarcom vor. 
Arch. f. Gyn., ix., 145, 1876. 
83. Schmitt : A contribution to the pathology of the mucous membrane of 
the uterus. Am. Jour. Obst., xvii., 1, 1884. 
84. Schmorl, : Ueber malignes Deciduom. Centralbl. f. Gyn., No. 8, 169, 
1893. ' 
85. Schroder : Das Sarcom des Uterus. Handbuch der Krankheiten der 
weiblichen Geschlechtsorgane, ix. Auf., 340, 1889. 
86. Schultze : Ueber Sarcoma uteri. D. i., Berlin, 1887. 
87. Seeger : Ueber Sarcoma uteri. D. i., Berlin, 1891. 
88. Simpson, A. R. : Sarcoma uteri. Contributions to Obstetrics and Gyne- 
cology, Edinburgh, 240-261, 1880. 
89. Smith, Thos. C. : Sarcoma and multiple mucous polypi of the uterus in 
a child. Am. Jour. Obst., xvi., 555, 1883. 
90. Spiegelberg : Casuistische Mittheilungeu zu den Sarcomen des Uterus 
und der Scheide. Arch. f. Gyn., iv., 344, 1872. 44 
WILLIAMS : HISTOLOGY AND HISTOGENESIS OF SARCOMA OF UTERUS. 
91. Spiegelberg : Sarcoma colli uteri kydropicum papillare. Arch. f. 
Gyn., xiv., 178, 1879. 
92. Spiegelberg : Ein weiterer Fall von papillaren kydropiscken Cervix- 
sarcom und von Extirpation nacli Freund. Arcli. f. Gyn., xv., 436, 1880. 
Nachtrag zu dem im Bd. xv. mitgetkeilten Fall, Arch. f. Gyn., xvi., 124, 
1880. 
93. Terillon : Sarcome de la muqueuse uterine et hematometre. Bull, et 
mem. de la Soc. de Ckir. de Paris, xii., 157-168, 1886. 
94. Terillon : Bull, et mem. de la Soc. de Ckir. de Paris, 746, 1890. 
95 Thomas : Uterine polypi. Practical Treatise on the Diseases of Women, 
5tk ed., Philadelphia, 559-560, 1880. 
96. Veit, G. : Medullarsarcom der Gebilrmutter. Kranklieiten der weib- 
lichen Geschleclitsorgane, ii. Auf., 413, 1867. 
97. Virchow : Medullarsarcom des Uterus. Verb. d. Berliner Gesell. f. 
Geb., xii., 22, 1860. 
98. Virchow : Die krankliaften Gesckwiilste. Bd. ii., 350, 1864-1865. 
99. Wagner, E.: Verjaucliende Enchondrome des Uterus, Lungenenchon- 
drome, frisclie Peritonitis, der Gebarmutterkrebs. Leipzig, 129, 1854. 
100. Waldeyer : Ueber den Krebs. Volkmann’s Samml. kliu. Vortrage, 
No. 33, 190, 1872. 
101. Weber : Ueber die Neubildung quergestreifter Muskelfasern, insbe- 
sondere die regenerative Neubildung derselben, nach Verletzungen. Virchow’s 
Arch., xxxix., 216, 1867. 
102. West : Recurrent fibroid. Lehrbuch der Frauenkranklieiten Got- 
tingen, 387, 1860. Langenbeck’s translation. 
103. Wilks: Recurrent fibroid disease. Lectures on Path. Anat., 404, 
1859. 
101. Winckel : Zwei Falle von Uterussarcom. Arch. f. Gyn., iii , 297, 
1872. 
105. Winckel: Adeno-myxosarcoma cervicis. Lehrbuch der Frauen- 
krankheiten, 432, 1886. 
106. Winckler : Ein weiterer Fall von Sarcoma papillare kydropicum 
cervicis et vaginae. Arch. f. Gyn., xxi., 309, 1883. 
107. Wyder : Die Mucosa uteri bei Myomen. Fall 18—Fibrosarcoma uteri 
mit Perforation nach der Uterushokle hin. Arch. f. Gyn., xxix., 1, 1887. 
108. Zenker : Zur Lehre von der Metastasenbildung der Sarcome. Vir- 
chow’s Arch., cxx., 68, 1890. 
109. Zweifel : Drei Falle von vaginalen Totalexstirpation des Uterus, mit 
zwei Heilungen, darunter eine Operation bei einem 13-jakrigen Madcken 
wegen Sarcom. Centralbl. f. Gyn., viii., 401, 1884. MEDICAL JOURNALS 
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