_Intramural multiple myomas produce a characteristic irregular enlargement and hardening of the uterus, with long, irregular cavity that is difficult to sound. Adherent ovarian tumor or inflamed ap pendages simulate fibroid enlargement, but are connected with a history of in flammation, with a congested or hyper plastic cervix, tenderness, and a sulcus between the uterus and the projecting mass. The uterine cavity may be but slightly enlarged. A myoma of the vag inal portion gives the as a crescentic shape, with flattening of the opposite lip. Carcinoma does not thus alter the shape of the os, is harder, and, if ulcerated, is !. excavated and fissured, instead of being merely eroded. The tenaculum holds firmly in the fibroid, while it tears out of cancerous tissue easily and causes free bleeding.
Very large soft myomas or eysto myomas of the corpus cannot always be satisfactorily diagnosed. The myoma usually draws up and immobilizes the cervix, and the uterine cavity admits the sound farther than normal. The uterine body can be palpated, and vascular mur murs can be heard over the sides of the tumor. Slow growth is characteristic of uterine myomas and ovarian dermoids.
Etiology. — They are supposed to de velop from the walls of the blood-vessels. Vascularity in connection with micro parasitic development would seem to be in line with the tendency of recent dis coveries in bacteriology.
Pathology.—The young tumor is com posed of fibrous and muscular tissue irregularly interlaced, which develops in different proportions in different growths. It presents a whitish or yellowish-white, glistening surface, unless an unusual amount of muscular tissue is present, when it will be pinkish. The submu eons and polypoid tumors retain some of the glandular structure of the mucosa, while a variety called adenomyoma is partly composed of glandular structure, and when cut presents the appearance of a coarse net-work of fibres, instead of the ordinary smooth sheen.
As they develop they usually deviate somewhat from the type. Those which are surrounded by amemic tissue, as the multiple and subserous, grow slowly and become hard and fibrous and sometimes ' calcareous. Those which are surrounded by vascular tissue, as in the single in tramural and submucous, grow compara tively fast, hut, being poorly supplied with blood-vessels in their interior sub stance, are apt to undergo oedematous, myxomatosis, cystic, and fatty changes. Sarcomatous and carcinomatous trans formation may also take place. The hard tumors seldom grow very large, the soft ones often do, while the cystic may even destroy life by their great size.
All eases of so-called carcinomatous degeneration of fibromyomata uteri are, in reality, simply secondary carcinoma tous infiltration of the tumor from primarily diseased endometrium. Rode maeher (Centralb. f. Cyn., No. 41, '97).
In studying the vascular supply of the uterine muscle by means of injections, small bloodless foci (lots) were found, which seemed to increase in size at the expense of the surrounding muscular fibres. Around the minute myomata were zones of vascular tissue, which evidently served to nourish them. In the centre of the nodule could often be seen what appeared to be the lumen of a blood-vessel which had not been reached by the injecting fluid. These myomata grow first centripetally, then horizontally.
It is probable that uterine fibromyo mata represent a localized hypertrophy of the tissue in the neighborhood of cer tain vessels, or the isolation of vasculn• areas due to thrombosis, prolonged pressure. or other circulatory disturb ance. Reiffer (Soc. Beige d'Anat. Path.; La Gynee., Feb. 15, 119).
Seven eases of combined carcinoma and fibromyoma of the uterus. The cap sule of the fibroid seems to oppose a cer tain barrier to the advance of the can cer. As soon as the capsule has been destroyed the malignant disease spreads rapidly through the fibro-mnscular tis sue. Only two cases have been recorded in which epithelial ingrowths developed in the centre of a fibroid, nor were they clearly demonstrated as evidence of actual malignant degeneration of the benign tumor. Begat. (Centralb. f. Cyniik., No. 27, 1901).
Prognosis.—On account of their slow growth and a tendency to stop growing after the menopause, they may run a comparatively benign course; yet in young people the persistence of the haemorrhages and gradual growth may seriously impair the health before the advent of the delayed menopause.
Treatment. — The best treatment for growing myomas in women under thirty five years of age is removal (enueleation) of the tumor, with preservation of the uterus, if possible, otherwise by hys terectomy with preservation of the cervix and ovaries. Removal of the ovaries for fibroids is now almost an obsolete prac tice, and has given way to myomectomy or myomotomy. In older patients per sistent limmorrhage, pressure pains, or rapid growth may call for radical treat ment unless palliative measures prove rapidly beneficial. Slowly-growing tu mors near the menopause without symp toms require only palliative treatment, and often none at all.