Symptoms.-The symptoms of this form of sarcoma resemble at first those of fibroid tumor; they are-hemorrhage in the form of menorrhagia; a serous, non-odorous discharge; and a moderate degree of pain.

Later, when ulceration and disintegration take place, the hemorrhage becomes more profuse and continuous. The discharge becomes fetid, and contains broken-down sarcomatous tissue. The pain becomes more severe. The uterus is enlarged, and the nodular outline may be determined by palpation.

Before metastasis has taken place the differential diagnosis between sarcoma and benign fibroid tumor can be made only by microscopic examination of the discharge or of curetted or excised portions of tissue. The duration of sarcoma of the uterus is about three years.

Sarcoma may occur at almost any age. Hysterectomy has been performed for this disease in a girl of thirteen. Several cases have been reported under twenty years of age. The most usual period is about the time of the menopause, in the decade from forty to fifty.

The treatment of sarcoma of the uterus is immediate complete hysterectomy. If in the early stage a positive diagnosis cannot be made between benign fibroid and sarcoma, the woman should not be exposed to the dangers of waiting, but the uterus should be immediately

removed.

CHAPTER XX.

FIBROID TUMORS OF THE UTERUS.

FIBROID TUMORS originate in the muscular wall of the uterus. They are composed of elements resembling, to a greater or less extent, those that compose the middle uterine wall. They consist of connective tissue and of unstriped muscular tissue in varying proportions. Uterine tumors composed exclusively of muscular fibres-true. myomata-very rarely occur.

A number of names, based upon the proportion of the component elements, have been used by writers to designate these tumors. They have been called fibroma, myoma, myo-fibroma, and fibro-myoma. The natural history of all the varieties is about the same, and varies but little with the proportion of the elements. I shall therefore consider them under the general name of fibroid tumors of the uterus.

Fibroid tumors of the uterus are benign, in the sense that they do not, like cancer, infiltrate contiguous structures of infect the general system.

Fibroid tumors are loosely attached to the surrounding uterine wall. They are usually invested by loose cellular tissue, forming a capsule from which they may easily be enneleated. Blood-vessels, usually of small size, connect the tumor with its capsule. Dense adhesion between the tumor and its capsule is the result of inflammatory The loose connection of the fibroid tumor with the surrounding structures explains the ease with which these tumors travel and are squeezed out of the uterine

wall. It will be remembered that in this respect the fibroid differs from the nodule of cancer and of sarcoma.

To the naked eye fibroid tumors present a white or rosy appearance. The intensity of the red color is, as a rule, proportional to the amount of muscular tissue. On section the bundles of fibrous tissue, arranged more or less concentrically about many axes, may be apparent. The vessels in the tumor itself are usually small and few in number. The large arteries and venous sinuses are found in the capsule.

Fibroid tumors vary in hardness from the soft myoma to dense stony nodules composed almost entirely of fibroid tissue.

Fibroid tumors vary in size from the smallest nodule in the uterine wall to a solid mass weighing one hundred and forty pounds. The tumors that usually come under observation weigh from one to ten pounds.

Fibroid tumors occur most frequently in the body of the uterus. As has already been mentioned, however, they are sometimes found in the infra-vaginal portion of the cervix, and a peculiarly dangerous form of fibroid grows from the supra-vaginal cervix.

Fibroid tumors are multiple in the great majority of cases. It is unusual to find a single fibroid nodule or tumor in the uterus. Sometimes one tumor far outgrows the rest, but if the uterine wall is carefully examined. other small nodules will usually be found in its sub

stance.

Fibroid tumors originate in the muscular wall of the uterus, and extend thence in various directions. When they are situated in the muscular wall they are said to be interstitial (Fig. 130). When they grow outward, so that they project beneath the peritoneum, they are called subperitoneal (Fig. 131). When they project into the uterine cavity they are called submucous (see Fig. 130).

When they grow from the side of the uterus, and especially from the supra-vaginal portion of the cervix, and extend outward into the cellular tissue between the folds.

of the broad ligaments, they are said to be intra-ligamentous (Fig. 132).

The subperitoneal fibroid may continue to grow, pushing the peritoneum ahead of it, until the tumor becomes altogether extruded from the body of the uterus. It is then attached to the uterus only by a pedicle of varying thickness. The pedicle may be fibro-muscular in cha

racter, or it may consist only of peritoneum, a little muscular tissue, and blood-vessels.

Such a hard, freely movable tumor often causes a great deal of peritoneal irritation. A serous fluid may be thrown out by the peritoneum, and a moderate degree of ascites may occur. Adhesions may be formed between the fibroid tumor and contiguous structures-the abdominal parietes, the omentum, or intestines. These adhesions are often exceedingly extensive, firm, and vascular, so that in some cases the tumor derives its chief bloodsupply and mechanical support from such adventitious attachments. The uterine pedicle may, as a result of progressive atrophy, traction, or violence from a fall, become detached, and the tumor, having then lost all uterine connection, appears to be a fibroid growth of the