A. Cysts

Cysts are very rarely formed in the uterus; we have not met with a single example in Vienna, and I myself have only inspected one case of uterine acephalocysts. It is necessary to distinguish the very much hypertrophied follicles that may occur in the uterine cervix, from newly-formed cysts.

B. Fibroid Tumors

Anomalous fibrous tissue is the most frequent of all new formations occurring in the uterus, in the shape of fibroid or fibrous tumors (tumor fibrosus, desmoides, formerly called sarcoma; when ossified, osteosteatoma of the uterus; scirrhus; W. Hunter's carneous tubercles, etc.) These fibroid growths of the uterus not only present all the essential characters peculiar to them elsewhere in a remarkable degree, but they also offer numerous important and accidental modifications, some of which exert a considerable influence upon the uterus; it therefore becomes necessary to devote a more extended consideration to them, in addition to the general outline which we have already given. The uterus, as well as the adjoining tissues, are particularly liable to be the seat of fibroid growths. They not only present all the varieties and degrees as regards size and volume, shape, number, and metamorphosis, in so characteristic a form, that we have thought it right to take them as the specimen and groundwork of general disquisitions on the subject, but they also offer the most various modifications in reference to their seat, and consequent reflex influence upon the womb.

We also find that the changes in position of the uterus, the deviations of its shape, and of the direction and form of its cavity, of its size in reference to the coexistent hypertrophy and atrophy of the organ, and the relations of the uterine mucous membrane, etc, are very remarkable.

The three varieties distinguishable in the fibroid tumor, according to its internal structure, are all found in the uterus. The variety in which a concentric disposition of the fibres is displayed, is here also distinguished by its density, hardness, poverty of vessels, smallness, and spherical shape.

The second variety, in which the fibres appear irregularly disposed, and issue from numerous centres or nuclei, present a rounded form, and an uneven, nodulated surface, which indicates the aggregation of the fibrous centres in reference to density and consistency, vascularity and volume, they offer the extensive modifications already spoken of; they may, on the one hand, be very dense and hard, and unvascular; on the other, in consequence of an accumulation of cellular tissue in the interstices of the fibrous layers, they may be more or less vascular and succulent, or soft and elastic, soft and doughy, flabby, etc, sometimes resembling a soft mammary gland, sometimes a coarse-grained salivary gland. Those fibroid tumors, the interstices of which are dilated into cells or cavities, containing a serous fluid from excessive exhalation of the intervening cellular tissue, are of extreme importance. They present fluctuation, and may, on account of the deceptive appearances accompanying fibroid tumors, be easily mistaken for ovarian dropsy, hydrometra, acephalocyst of the uterus, or pregnancy.

The fibrous polypus of the uterus, the third variety of fibroid tumors, takes it origin by a single or divided trunk in the interstitial cellular tissue of the uterine parenchyma; the former expands into striated fasciculi, which are bound together by softer vascular and cellular interstitial substance, and the entire mass presents a distinctly lobulated structure, which is more or less visible externally. The' polypus grows into the cavity of the uterus, with which it is in the closest anatomical connection, and upon the functions of which it exerts a considerable influence. It enlarges chiefly in one direction, and has a cylindrical, fusiform, clubbed, pyriform shape, and is more or less flattened; it is provided with numerous and very large vessels, is apt to swell, and in consequence of excessive congestion and rupture of the vessels, we often meet with extravasation within its tissues.

The anatomical relation of fibroid tumors to the uterine parenchyma is very intimate in the third variety, less so in the second, and least of all in the first, in which the tumors adhere to the uterine parietes by a thin layer of whitish or reddish, more or less vascular, cellular tissue, so that they may be detached without difficulty.

The form of the fibroid tumors of the first and second variety, we have already described as being generally round; in the second variety some alterations may occur, though the globular form still predominates. The peculiarities of shape of the fibrous polypus, or third variety have already been stated. The greatest variety occurs in reference to size. Fibroid tumors are found from the size of a hemp-seed to that of a man's head.

The fibroid tumors belonging to the second variety attain the largest size, especially when of loose texture, and rich in interstitial cellular tissue; the fibrous polypi also reach a considerable magnitude, but the fibroid tumors of the first variety are the smallest. They are all generally developed slowly, though the second and third variety are occasionally developed with extraordinary rapidity; they are also liable to a temporary increase of size or tumefaction proportionate to their vascularity.

As to their number, we sometimes only find a single, sometimes several or many fibroid tumors in the same uterus. We then observe tumors of the most different sizes coexisting. This applies chiefly to the first two varieties; the fibrous polypus is often solitary, but it also occurs in company with the others.

The uterine parietes are the seat of the fibroid tumors, but not only do they occur much more frequently in the body than in the cervix, but in the former they chiefly affect the upper portion or fundus. They very rarely occur at the inner orifice, and if possible, still less frequently in the vaginal portion. This is the case with all fibroid tumors, a fact that forms an interesting contradistinction to the relation which cancerous disease bears to the inferior segment of the uterus. Fibrous polypus, more especially, is apt to commence at the fundus, and at the orifices of the Fallopian tubes. The fibroid tumor is inserted into, and takes its origin from, the middle layers of the uterine substance, or it appears to be more connected with the external layer, or even to lie under the peritoneum, or again, it lies nearer the inner surface, or immediately under the mucous membrane. The first two varieties are developed in the most various layers, though generally in the external ones; the third forms upon the internal layer exclusively. The former also very frequently present other curious relations, whether they have been developed in the vicinity of the peritoneum, or of the mucous membrane of the uterus. In the first instance the tumor, as it enlarges, gradually becomes detached from the uterus, dragging the peritoneum after it, and thus at last becomes pediculated or pendulous, by a peritoneal cord of various length. In the second instance it pushes the mucous membrane before it, as it enlarges, and at last hangs into the uterus by a mucous pedicle, thus resembling the true fibrous polypus, from which it may be distinguished by its relation to the uterine parenchyma, and by its internal structure.

We must here advert to a circumstance that is not of very rare occurrence, viz. we sometimes find a fibroid tumor in the pelvic cavity, and generally in Douglas's space, without any further connection with the uterus, except by means of cellular cords, or laminae of new formation (false membranes), which pass from the tumor to the uterus and its appendages, to the pelvic walls, the rectum, etc. The question presents itself, which is the original point of development of such fibroid tumors. They are generally tumors which have originally been developed under the uterine peritoneum, and, after having become entangled in a network of pseudo-membranous formations, resulting from the peritonitis they have excited, are gradually detached from the uterus. Occasionally, however, they may have been developed within the false membranes themselves, which is the more probable, if we consider that the new tissue as it proceeds from the uterine peritoneum, participates in the character of the subserous uterine cellular tissue. Hence it is extremely likely that we really see very small fibroid tumors occasionally developed in this new tissue.

To these fibroid tumors, the loose fibrous concretions which are sometimes found in the pelvic cavity are allied; they must be considered as fibroid tumors of the uterus, which have become detached in consequence of atrophy of the peduncle.