surface is grayish-white and the consistence soft and homogeneous, quite unlike the dark, fibrous, dense fibroids.

Microscopically they are composed of spindle-cells, the spindles usually being large and long. Round-cell forms have occasionally been seen. From a microscopic examination alone the diagnosis of this tumor presents many difficulties, for the cells closely resemble those of rapidly growing muscle tissue. In both tissues the cells are large spindles with oval or spindle-shaped nuclei of distinctly vesicular form. The nuclei usually stain similarly with the ordinary stains. The ends of the cells often present

FIG. 317.-Sarcoma of the body of the uterus, secondary to that in the right ovary. The uterus is considerably enlarged. Occupying the posterior wall is a new growth which projects into the uterine cavity, forming two large and numerous smaller, sharply defined, smooth, and faceted nodules. Their shapes and relations to one another rernind one somewhat of calculi. On histologic examination it is found that the surfaces of several are still covered by the mucosa, which is, of course, much atrophied (natural size) (H. A. Kelly).

markings suggestive of cross-striations.

substance.

There is no visible intercellular

Both tumors are quite avascular and are prone to undergo myxomatous degeneration. The sarcoma develops more rapidly; both tumors develop in middle life. The sarcoma, like the fibroid, may remain interstitial, or may grow in one or the other direction, becoming subperitoneal and pedunculated or submucous. The pedunculated tumors are usually nodular in appearance and sometimes distinctly lobulated. They may grow into the broad ligament. A subperitoneal sarcoma may become as large as a gravid

uterus.

The theory that sarcoma of the body of the uterus occurs in consequence of sarcomatous "degeneration" of fibroids is scarcely acceptable. They

usually do not give metastasis, though some cases of pulmonary secondary growths are recorded.

Sarcoma of the endometrium springs from the subepithelial tissue of the endometrium. The differentiation of this tumor from the sarcoma of the myometrium is not always possible, but the classification is useful where applicable.

Endometrial sarcomata may occur as circumscribed, sessile, or pedunculated nodes, or as diffuse infiltrations. They are likely to occur in the neighborhood of the cervical canal, and not infrequently project from the external os as good-sized, nodular, pale-colored, spongy, soft, more or less vascular, pedunculated growths. The surface is usually smooth, and may be covered with a mucopurulent layer. Sometimes the tumor is devoid of vessels and prone to extensive degeneration; sometimes it is telangiectatic. Angiosarcoma is rare.

The diffuse form fills up the cavity of the uterus with a whitish, spongy, seminecrotic mass, accompanied by a fetid discharge.

The endometrial sarcomata may be composed of spindle- or round-cells,

FIG. 318.-Condyloma acuminatum: a, Greatly thickened epithelial layer; 0, papilla with arborescent branching (Ziegler).

and not infrequently contain giant-cells. and contain, both round- and spindle-cells.

Some of the tumors are mixed

In the growth of the endometrial sarcomata, endometrial glands are sometimes caught and seem to proliferate, suggesting the combination of sarcoma and adenoma. The addition of the epithelial elements is probably purely accidental, and has no special significance.

Spiegelberg's grape-like sarcoma, or sarcoma uteri hydropicum papillare, is a peculiar tumor observed in youth and childhood, which probably has its origin in embryonal remnants of Wolff's bodies. The tumor makes its appearance at the cervix and upper part of the vagina as a collection of rounded, grape-like or berry-like, soft, grayish bodies, which, upon microscopic examination, show round- and spindle-cells in a more or less advanced state of myxomatous degeneration. Sometimes epithelial tubules are present, sometimes islets of cartilage, sometimes smooth or striated muscular elements, so that the tumor is greatly mixed in character. It is malignant.

Papilloma of the cervix uteri is rather frequent. It appears as a pedunculated, more or less cauliflower-like growth, consisting of numerous papillæ

covered with stratified pavement epithelium. It occurs chiefly in middle life, and may be multiple. It may gather the uterine discharges in its sulci, their putrefaction causing some fetor.

FIG. 319.-Squamous-cell carcinoma of the cervix; finger-like processes arising from a common stem. Traversing the center of the specimen is a delicate stem of connective tissue, in the center of which is a blood vessel. This stem gives off lateral branches, which likewise contain blood vessels. The main stem is covered in some places by only one layer, in others by many layers of squamous epithelium. The epithelial cells next to the stroma tend to be cuboidal. The epithelial nuclei throughout are fairly uniform in size. Near the left lower corner are several cross-sections of the terminal branches or fingers. These present a typical appearance (X 80) (Cullen).

It is not infrequent to find the tumor growing upon the wall of the vagina as well as upon the uterine neck. As long as it is a pure excrescence it is a benign growth, but it seems to be commonly accompanied by epitheliomatous infiltration of the cervix.

Venereal warts or condyloma acuminata also occur upon the neck of the uterus and vagina, but are benign in nature.

Squamous epithelioma of the cervix is the most frequent malignant tumor of the uterus. It usually appears between the thirty-fifth and fiftieth years of life, upon the vaginal surface of the cervix, not infrequently causing cauliflower-like papillary excrescences that cannot be distinguished in all cases from the simple papilloma, either by macroscopic or microscopic examination. Clark's cauliflower growth or destructive papilloma is one of the most typical forms, the excrescence from the cervix being accompanied by a more or less wide-spread epithelial infiltration of the tissues of the cervix. The excrescence may be as large as the fist, and the

FIG. 320.-Adenocarcinoma of the body of the uterus. The cervix is greatly enlarged, but its vaginal portion is intact. Occupying almost the entire cervix and the greater part of the uterine cavity is a new growth presenting a coarsely lobulated appearance, with numerous clefts between the elevations. Springing from the surface at a few points are delicate fingerlike outgrowths. Laterally, the growth has extended almost to the broad ligament attachments, and its advancing margin is sharply defined. The uterine mucosa over the area indicated by a is apparently still intact, but the surface is somewhat uneven. The uterine walls in the upper part of the body present the usual appearance. Laterally, the uterine arteries are seen. The body of the uterus is free from adhesions, and the tubes are apparently normal. The marked involvement of the cervix naturally suggests a cervical origin for the growth, but histologic examination proved that the majority of the cervical glands were normal, and that the type of the growth corresponded to that usually found in the body (Cullen).

infiltration of the cervix slight, but after the removal of the former the latter remains and continues to infiltrate, producing a new excrescence and sometimes rapidly invading the neighboring tissues. Sooner or later the squamous epithelioma leads to the formation of ulcers which slowly and persistently increase, at the same time often developing papillary outgrowths. The tumor tissue is pinkish in color and very hard and dense. In tendency the squamous epithelioma is more locally destructive than metastatic. infiltrates the vagina, bladder, and rectum, and occasions hemorrhage, perforation, and peritonitis.

It

Histologically, the tumor is typical. Epithelial pearls are usually absent, cases in which they occur showing unusual keratin production.

A more usual form of squamous epithelioma of the uterus arises from the portio vaginalis of the cervix, and is without the papillary growths described.

FIG. 321.-Adenocarcinoma of the body of the uterus: o, May be likened to a main stem from which arise numerous secondary stems, which in turn give off delicate terminals, consisting entirely of epithelial cells. The glands may be divided into groups a, b, c, d, and e, by the stems of stroma f. g, and h. The stems are covered by several layers of cylindric epithelium, while projecting into the gland cavities are long slender ingrowths of epithelium, devoid of stroma, as seen in i. Very delicate ingrowths consisting merely of two layers of epithelium are seen at k and k. At the epithelium is several layers in thickness, and at m many layers with leukocytes. The arborescent character of the growth and peculiar gland grouping are characteristic of adenocarcinoma (Cullen).

It begins as a dense infiltration of the tissue, in the cervical canal, just within the external os, where the squamous and columnar transformation occurs, and in the beginning may be sharply circumscribed. The cells in