The structure of these growths is the same as that of the other fibromyo mata, except that most of them seem to be more purely myomata, present ing a localized hypertrophy of the uterine substance. The cells of which they are composed are frequently larger, and provided with larger nuclei, than those of the normal muscular tissue of the uterus. They resemble more the muscular tissue of the gravid uterus (Klebs). These tumors may attain a very considerable size, and are not infrequently multiple or mixed with other varieties of fibromata. (Schulze' counted over fifty tumors of this kind in one uterus.) Commonly if there is a single tumor, (though often also when there are several together), its point of origin lies in the posterior wall near the fundus; more rarely is it in the anterior wall, and exceptionally only is it found on the side.
The influence which they exert upon the uterus is manifested first by a considerable hypertrophy of the entire organ which undergoes changes very like those occurring in pregnancy. Tillaux found in one case post mortem that a few small fibroids, situated in the lower segment of the uterus, had caused an hypertrophy of the entire organ, so that it was of the size of a large child's head. The tissues surrounding these tumors are very vascular, while the tumors themselves often have but a scanty blood supply; not infrequently one sees large vessels, usually veins, passing into the growth.
While hypertrophy of the uterine wall is the rule in this variety, we nevertheless not infrequently find atrophy to such a degree that the mus cular tissue seems to have almost entirely disappeared and the tumor appears to be covered only by the peritoneum. This condition of the uterus is not by any means always dependent upon the size of the til 1 mor, but rather upon the age and general condition of the patient. The cavity of the uterus is almost without exception markedly increased in depth, but has usually lost its normal straightness, and seems to be flexed or even bent at a sharp angle.
The shape of the uterus, except where there are multiple tumors, is usually rounded. But it may be so changed and the adnexa may be in so many ways displaced, as to give great trouble, on an anatomical ex• amination, in making out clearly the exact condition.
The position of the uterus varies according to the situation of the tumor. There is seldom much elevation of the organ, nor is pro lapse or even a very low position of the uterus frequently met with. A much more common condition is the complete dislocation of the womb toward the anterior or posterior wall of the pelvis; or there may be flexions of the organ. When the tumors have developed on the side, and especially when they extend between the layers of the broad lig ament, the lateral deviation of the womb is marked. The most constant displacements are those which occur when the tumors are wedged into the pelvis, growing backwards and downwards from the uterus, and when they can in no way be dislodged. This is what often happens in the
case of subserous tumors which have sunk down into Douglas's sac. In such a case an intra-parietal myoma may seem to be situated not only behind the uterus but even posterior to the vagina. The tumor may also develop downwards into the uterine cavity, and passing through the internal os, may reach into the vagina, the cervical canal having dis appeared. In these cases one finds upon examination the same condition of things as in the birth or expulsion of a pediculated submucous fibroma, although the tumor is situated entirely within the wall of the uterus.
There is a specimen of a very peculiar development of an intra-parietal myoma in the pathological collection of Strasburg (for permission to de scribe which I am indebted to the kindness of Dr. von Recklinghausen). It consists of a myoma of nearly the size of a child's head, origina ting within the anterior wall of the uterus, which has grown downwards into the anterior lip. The posterior lip has entirely disappeared, while the anterior ono, the size of a man's fist, reaches down into the vagina. At the lowest point there is a perforation of the capsule, as also of the mus cular layer of the portio vaginalis, and the tumor projects through a lacer ation of the anterior lip into the vagina. The case is described in the thesis of v. Duchemin.` The patient was an unmarried woman, thirty years of age. The upper border of the tumor could be felt at the navel, while the lower part entirely filled the vagina. The tumor was dragged outwards and a ligature passed around it in order to strangulate it. Gangrene of the tumor set in and the patient died of tetanus. This case shows how a fibroma of the body may become one of the cervix.
Although fibroids of the cervix in all three forms are developed ex actly like those of the body, yet, not only on account of their rarity, but also because they occupy a peculiar position as regards diagnosis, symp toms and treatment, it seems proper to devote a separate paragraph to them. Those which have the greatest practical interest, and whose re moval seems impossible, are the subserous fibroids of the neck of the womb. These usually grow outwards and posteriorly from the cervix, seldom laterally; they are developed either toward the abdominal cavity between the layers of the broad ligament, or pressing up the pelvic peri toneum, or else they grow downwards, behind the uterus or at its side, into the connective tissue of the pelvis alongside of the vagina. In the latter case they may be taken for tumors of the vagina. In every case, when they have attained a certain size, they must fill the pelvis more or less, and occasion thereby grave symptoms, especially, as we shall see later on, during child-birth. Since the attachment to the uterus is close, the mobility of these tumors is greatly restricted, especially as they cannot be pushed into the abdominal cavity on account of their extra-peritoneal situation.