When the sarcomatous and fibroid degenerations are associated, the re sult may be tumors of incredible size. This actually occurs, although the individual cases have not been very carefully conducted. In rare instances uterine cysto-fibromata and ovarian cysts have existed simulta neously, rendering the diagnosis exceedingly difficult. Supported by a few such cases, and by some actual diagnostic errors, Boinet rmade an absurd effort to disprove the existence of uterine cysto-fibromata. Ile regarded all these tumors as ovarian cysts closely connected with the uterus. This view does not claim any farther refutation than is afforded by pathological facts.
Sub-serous collections of fluid found sometimes in the uterus and in the pelvic connective tissue, and which have probably been reckoned among uterine " cysts," have nothing in common with the variety now being discussed.
After Koeberli. and others had called attention to the fact that the fluid from fibro-cysts coagulated spontaneously and immediately on contact with the air, Atlee, who found that this rule obtained in all of his cases, laid great stress upon its diagnostic value. Although the spontaneous coagulability of the cyst fluid is a very characteristic and constant condi tion in a large number of the cases, it is by no means constant. 0 Meer only found this phenomenon mentioned in fourteen of his seventy cases.
The cystic fluid is more or less bloody, dark black, or consists of a vis cid pulp containing shreds of tissue. The variable nature of the fluid is easily explained by the differences in the genesis of the neoplasmata Only the lymphangiectatic tumors, or those connected with them, will contain a thin, spontaneously coagulable and usually clear fluid. Since studies into the etiology of fibromata have not resulted in enlightenment on this subject, we are obliged to admit that future investigations of the same question promise but little information. In regard to the age of patients, Heer found among fifty-one cases, It would be of interest, as Leopold suggested, to inquire if it be possible to obtain an anatomical investigation whether any obstacles have existed in the circulation which could have produced ectasia of the lymph or blood-vessels of the tumor, and what the nature of the obstacle was, if any such existed. We have already stated that injuries may produce hemorrhage within a myoma. In the majority of these cases the bleeding is followed by gangrene, which is not always carefully distinguished from tumors, which are, properly speaking, cysto-fibromata.
We shall inquire farther on, to what extent the existence of the puer• peral state may favor the development of cysto-fibromata.
The symptoms of these tumors are almost identical with those of myomata in general. Routh' calls attention to the infrequency of hemorrhages due to them. This is accounted for by the fact that most of the fibromyomata are sub-serous, and hence have but little influence upon the mucous membrane of the uterus. In the case of sub-mucous fibro-cysts, observed by me, the hemorrhages were profuse, and a large quantity of watery fluid, similar in its character to the fluid in the tissue, was discharged in the intervals between the hemorrhages.
The only symptom which can be regarded as somewhat characteristic of these tumors is their rapid growth, which results in an equally rapid aggravation of the disturbances referable to their pressure. We shall consider their physical signs in our discussion of the diagnosis. The fact that the varying arterial tension during and after menstruation produces great changes in the size and consistency of the myoma te]angiectodos or cavernosum, may assist in the diagnosis of this class of fibromata, although the same phenomena are also encountered in other varieties.
Weber (loc. cit.) also noticed the immense distension of the dilated vessels in the case of a sub-mucous myoma cavernosum, which was ex pelled under his observation.
The diagnosis of these tumors has only been made in the most excep tional cases, and even then has been the result of accident rather than of correct appreciation of the symptoms. Fibro-cysts so closely resemble multilocular ovarian cysts, particularly in their location and in their fluctuation,' that the frequency with which they have been mistaken for ovarian tumors is not astonishing.
The slow growth of the fibre-cysts, as contrasted with the rapid de velopment of ovarian tumors, has been suggested as a diagnostic distinc tion between these tumors, but the exceptions to the rule are so numerous as to render it uncertain. The same remark applies to the differerces said to be discovered by palpation. Nan and Urdy emphasize the re markable hardness, and others the usually smooth and uniform surface of fibro-cysts. Beatty' states that they impart the sensation of soft flesh, being less tense than ovarian tumors. All the other diagnostic criteria, based upon palpation, have no practical value, although they may be useful in isolated cases.