The view that these tumors are usually developed from simple homolo gous fibromata and myomata, and that they are rarely primary. was even advanced by Hokitansky, Virchow and others. Kunert, and recently SchrOder, have advocated the theory that one always has to deal in these cases with a secondary metamorphosis of fibromyomata; that, therefore, fibro-sarcomata are always fibromata which have undergone sarcomatous degeneration.
The transformation of fibromyomata into sarcomata is certainly demon strated by a series of carefully investigated cases, while the evidence in favor of the development of primary fibroid sarcomata is less convincing.
Chroback describes a case in which "an ordinary pediculated uterine fibroid " and a smaller cervical one were simultaneously developed. Sarcomatous tissue appeared iu the older and larger tumor, and after the removal of the latter invaded the smaller, cervical tumor, probably by metastasis. When this latter tumor was after having grown rapidly for five months, a soft sarcoma, probably medullary, was found in the place of the original tumor. G. Muller's case was similar. He removed a portion of a large myoma which was producing symptoms of incarceration, and one year later excised from the same surface a cylin drical bloody excrescence, which was attached to the stump of the ampu tated fibroma, and proved to be sarcomatous. The large tumor, which had remained firm until that time, soon underwent sarcomatous degener ation, and produced metastases, which led to a fatal issue.
A. Simpson, Frankenhauser ' and Kurz' report similar cases.
The fact that no carefully observed case is extant in which a uterine sarcoma was provided with a " capsule," as is the case with most fibro mata,' has an important bearing on the question of the metamorphosis of fibromyomata into sarcomata. Winckel's case (loc. cit.), which was far ther observed by Schatz,' is the most noteworthy on record with reference to this point.
This case was at first one of a partially gangrenous myoma, in the pos terior uterine wall, which was removed by Winckel. Within forty weeks after the operation, a soft sarcoma was developed near the stump of the pedicle and was excised. The tumor recurred half a year later, in the form of a round-cell sarcoma, and was spontaneously expelled after the injection of a solution of the chloride of iron. After more than two years a new tumor as large as a hen's egg pressed into the os uteri, was removed by Schatz, and proved to be a pure myoma without any trace of sarcomatous degeneration. It cannot be decided whether there was an actual recurrence of the original tumor in this case, or whether, as Schatz believes, the masses removed at the second and third operation were portions of inflamed myomata. This case possibly dem
onstrates the manner in which fibromata undergo the sarcomatous degene ration.
We merely allude, in this place, to other changes occurring in fibro sarcoma, viz., transformation into myxosarcomata, cysto-sarcomata and other heterogeneous tumors.
A case of Rabl-Riickard deserves special mention, being adapted to show that uterine fibro-sarcomata may have certain intimate relations to carci nomata. A putrid tumor as large as a child's head was spontaneously expelled, during a coughing fit, from the uterus of a woman aged fifty one years, who had suffered from uterine hemorrhages and violent pains. The tumor was a round-cell sarcoma with isolated carcinomatous nodules. The latter were elongated and formed of closely packed, large-sized epi thelial cells, arranged at some points in concentric laminae. (Wegner.) The neoplasmata found in the deeper layers of the uterine walls were decidedly cancerous in character, and the sarcomatous elements in them were represented only by the poorly developed interstitial tissue.
In this case at least a fibro-sarcoma was combined with a carcinoma, unless we are to assume the transformation of the sarcoma into a cancer, lately insisted on by R. Maier.' According to his researches it seems not improbable that a fibroma may be transformed into a carcinoma, by pass ing through the process of sarcomatous degeneration. It remains un settled whether the above was a case of this kind or not.
A certain connection between cancerous degeneration and round-celled fibro-sarcomata cannot, after what has been stated, be positively denied. This connection is, however, so much more marked and constant in cases of so-called diffuse sarcomata, that it is almost doubtful whether they should be considered as a special variety of neoplasmata. The term diffuse sarcoma, sarcoma of the uterine mucous membrane, has been used since Virchow's time to designate a new growth proceeding from the connec tive tissue of the uterine mucous membrane, consisting mostly of small, closely-packed, round cells, though sometimes of spindle-cells, and con stituting an exceedingly soft, friable infiltration of the mucous membrane. This occurs in isolated clumps, or it may lead to a more decidedly sym metrical proliferation of the entire mucous membrane. It usually in volves the uterine muscles, infiltrates or penetrates the walls of the uterus, and oven leads to the development of the peculiar new growths upon the external uterine surface. ( Conf. the cases of West and two of the author's, one of which is published and is represented by Fig. No. 30.) The infiltration finally extends to the abdominal viscera and the ab dominal walls, involving the adjacent organs in the sarcomatous degenera tion.