We have already spoken of ossification, congestion, inflammation, suppuration, and solution of fibroid tumors generally; and those remarks apply with the more force to uterine fibroid tumors, as we assumed the latter as the foundation upon which we based our observations. Ossification occurs very frequently, congestion less so, and inflammation and its terminations rarely. A spontaneous cure, under which head we must also class ossification, on account of the destruction of vitality in the tumor, occurs in a few rare cases, by a detachment of the fibroid tumor as it projects into the uterus, or is suspended in it by a mucous pedicle. It is effected in the following manner: the mucous membrane of the uterus covering the apex of the tumor is in a condition of permanent irritation and congestion; this is at last converted into inflammation, and terminates in suppuration and gangrene. The tumor is thus partially exposed towards the uterine cavity, and the destructive process gradually involving its entire cellular investment, it becomes detached, and passes through the opening in the uterine mucous membrane into the uterine cavity. Ancient and modern cases are on record, in which fibroid tumors of various sizes and ossified tumors were thus discharged. The powers of nature rarely suffice if the tumors are of considerable size, as the extensive suppuration necessary for that purpose is likely to prove fatal, both by exhaustion and by the extension of inflammation to neighboring organs. It would appear that the fibrous polypus is occasionally, though very rarely, discharged in a similar manner, in consequence of suppuration occurring at its roots and in the surrounding tissues.

The changes in the uterus, consequent upon the presence of one or of several large fibroid tumors, are numerous and important, by reason of the diagnostic characters they afford.

In the first instance, the volume of the uterus increases in proportion to the number and size of the tumors; the fibrous polypus causes an enlargement of the uterine cavity, corresponding to the size of the polypus. The increase in the substance, the hypertrophy of the uterus, which the fibroid growths generally induce, and, on the other hand, the atrophy of the organ, are of greater interest. The hypertrophy appears as a development of the uterine tissue, resembling that occurring in pregnancy; it varies in degree. In reference to the latter subject, the question presents itself by what means the different degrees of hypertrophy are determined, and on account of the occasional passive condition and the occasional atrophy of the uterus, it is necessary still further to generalize, and to ask how it happens that under some circumstances the uterus becomes hypertrophied, in others remains unchanged, and in others again becomes atrophic? In answer, we offer the following remarks: a. The nearer the fibroid growths approach to the uterine mucous membrane, and project into the cavity of the uterus, and thus maintain the mucous membrane in a state of irritation and inflammation, the more palpable is the hypertrophy of the uterus. It is most fully developed, so as to resemble pregnancy, in the case of the fibrous polypus.

/3. Hypertrophy of the uterus appears to be encouraged by a vascular state of the tumor, by the latter being less dense and capable of rapid growth.

y. As also by the development of the tumor, during or shortly after the period of conceptivity.

d. The size of the tumor exerts no direct influence upon the origin of hypertrophy or atrophy.

s. Atrophy undoubtedly results very rarely from fibroid tumors, nor must we forget that they are not unfrequently developed in the uterus during the period of decrepitude, and that they increase very slowly on account of the universal state of marasmus. In this case the atrophy of the uterus is entirely independent of and antecedent to the fibroid tumors.

The atrophy of the cervix accompanying large fibroid growths is, as we shall have occasion to explain more fully, the result of mechanical traction.

An important change takes place in the position of the uterus, which may be discovered by external examination. Not only does a large fibroid tumor that occupies the external layer of the uterine tissue, push the organ to the opposite side of the pelvis, but we also notice a remarkable ascent of the organ. The more numerous and the larger the tumors are, and the more they consequently rise out of the pelvis, as it interferes with their growth, the more they drag the uterus after them; its vertical position being also changed in proportion as the fibroid tumors preponderate on one side or the other. This traction necessarily causes an elevation and elongation of the cervix.

The external surface of the uterus is, as may be easily understood, variously disfigured by the projecting tumors. In the same manner the cavity of the uterus, in addition to a corresponding elongation, undergoes various alterations in form and direction, proportionate to the number and size of the tumors which project internally. In reference to the displacement, we sometimes find the entire cavity forced out of the mesial line, at others it presents more or less angular deflections. The most important disfiguration is effected by the upward traction exerted by numerous and large fibroids. The uterus, and particularly the cervix, is elongated to a degree proportioned to the degree of traction, it becomes thinner, and the attenuation may, in rare cases, even cause a gradual solution of continuity, one portion remaining attached to the vagina, another following the upward direction of the uterus, and the connection being maintained by a mere band of cellulo-fibrous tissue. The channel of the cervix at the same time contracts, and may even become entirely obliterated. The vaginal portion gradually disappears, the vagina itself becomes smooth and narrower in consequence of the elongation, and its arch is converted into a funnel, the apex of which terminates in the os uteri.

If one or more fibroid growths occupy a lateral portion of the uterine parietes, and especially if they be seated in the vicinity of the Fallopian tubes, the external form of the uterus may be rendered oblique; if under these circumstances the tumors enlarge, and consequently exert lateral traction, this may be recognized by the elevation of the corresponding side of the os tincae, and the increased distension of the vagina.

Fibrous polypus gives rise to a dilatation of the uterine cavity, and of the cervix, corresponding to the size of the morbid growth; if the enlargement proceeds to a greater extent, the external orifice becomes dilated, and the tumor projects through it into the vagina. Large and heavy morbid masses of this description frequently cause a slight descent of that portion of the uterus into which they are inserted, by the traction they exert, and sometimes even induce complete inversion of the womb.

The mucous membrane of the uterus is the more liable to catarrh and blennorrhcea, the nearer the fibroid tumor approaches to it; sometimes it becomes hyperaemic, and blood is effused upon it. This is particularly the case with the fibrous polypus, which is not only accompanied by the ordinary hemorrhage from the capillaries of the mucous membrane, but also from larger vessels of the uterus, or sinuses of the morbid growth that have given way to excessive traction.

Fibroid tumors of the uterus scarcely ever occur before the twentieth year; a fact which is established by the numerous observations made by ourselves and other anatomists. They are even unusual up to the thirtieth, and present themselves most frequently shortly after the fortieth year. Without entering into an analysis of the almost innumerable cases that we have ourselves met with, we may mention the results of Bayle's calculations as to the frequency of their occurrence; he states that of one hundred females that die after the thirty-fifth year of life, twenty at least are affected with fibroid tumors.

They are found in complication with the most various morbid growths of the uterus and its appendages; but especially with cancer of the cervix, with the corroding ulcer of the os tincae, with ovarian dropsy, etc, still on the whole the complication with cancer is not frequent.

The powers of conception are commonly not impaired by the presence of fibroid tumors, and if these are small, and do not occupy an unusual position, they have not necessarily an injurious influence upon pregnancy and parturition, though they frequently cause abortion and hemorrhage after birth. Parturition may be very much impeded if they occupy the cervix uteri. It is important to know that these tumors become more vascular, succulent, and softened during pregnancy, and assume a bluishred color, so that their original appearance is entirely changed. As the uterus returns to its original shape, the morbid growth also resumes its ordinary characters. Pregnancy is even said to give rise to hemorrhage and inflammation in the tissue of the fibroid tumor.

An unusual though very important occurrence, brought on by the excessive expansion and traction exerted by large fibroid tumors, is the laceration of the vessels, and especially of the veins. We have once observed the rupture of a vesical vein (with that of the mucous membrane) followed by hemorrhage into the bladder, and in another case the rupture of the subperitoneal vein of a fibroid tumor, with hemorrhage into the abdominal cavity, as described by other writers.

Ligature of the fibrous polypus is sometimes followed by uterine phlebitis.

5. Osteoid Growths

We have not met with osseous formations in the uterus, except in the shape of ossification of the fibroid tumors.