CHAPTER XXXVI.

FIBROCYSTIC TUMOUR OF THE UTERUS.

LITERATURE.

Atlee-Ovarian Tumours: Philadelphia, 1873. De Sinéty-Op. cit., p. 413. Gusserow -Neubildungen, etc., S. 102. Heer-Ueber Fibrocysten des Uterus: Zurich, 1874. Leopold and Fehling-Archiv. für Gyn., Bd. VII., S. 531. Peaslee—Ovarian Tumours: London, 1873. Rein-Archiv. f. Gyn., IX., S. 414. Schroeder—Op. cit., S. 213. Spencer Wells-Diseases of the Ovaries: London, 1872. Spiegelberg -Archiv. f. Gyn., VI., S. 348. Thomas-Op. cit., p. 551.

SYNONYM.-Cysto-fibroma.

ATTENTION has been directed only of recent years to this, the rarest form of uterine tumour. Its pathology is now being worked out, and at present we group under this head tumours which may afterwards be shown to be anatomically separable. Since ovariotomy has come to be extensively practised, they have derived their clinical importance from a close resemblance to ovarian tumours.

PATHOLOGY.

The majority of fibrocystic tumours are simply fibroid tumours which have become softened. The spaces between the bundles of fibrous tissue open out and contain serum; the trabeculae between adjoining spaces give way, which allows these to run together to form larger cavities. Fig. 260 shows this in a subserous fibroid, which form most frequently undergoes this change.

The term "cystic" is, it is evident, misleading as applied to this form of tumour. The cavities are not " cysts," that is, they do not possess a special wall.

Koeberlé was the first to suggest that some forms of fibrocystic tumour might be due to dilated lymphatics. Leopold and Fehling have carefully described a case in which the cavities were lined with endothelium. The fluid from these cavities was of a clear yellow colour, and coagulated as

soon as it was exposed to the air; fibrin was present in it. To this form the name of Fibromyoma lymphangiektodes has been given. Atlee says. that this coagulation of the fluid-formation of colourless blood-clot-is diagnostic of the fluid from all fibrocystic tumours, and may be relied on

Large three-lobed fibroid springing from the fundus by a somewhat thin pedicle, of which C F is cystic, while S s F and the dark-shaded mass behind the uterus are subserous. This, along with two smaller fibroids growing from the posterior surface of the uterus, was removed by laparotomy (Schroeder).

to distinguish them from ovarian. Spiegelberg records a case in which this spontaneous coagulation of the fluid was observed, but the most careful microscopic examinations could detect no epithelial lining of the cavities. A transition case has been described by Rein, in which the cavities were not themselves lined with endothelium but communicated directly with the lymphatic spaces.

Mucoid degeneration of a fibroid tumour has been described by Vir

chow as Myxomyoma. In this case the interstitial tissue contained fluid rich in mucin and with numerous nucleated round cells.

SYMPTOMS.

These are the same as those of fibroid tumours, except that their increase in size is rapid. As they are usually subserous, menorrhagia is not often present.

DIAGNOSIS; DIFFERENTIAL DIAGNOSIS.

Their diagnosis is often difficult, as the difference in consistence between the more solid and the fluid parts may escape detection. The most important point to make out is the relation to the uterus, and the displacement of the latter which is produced. To ascertain its connection with the uterus, we make the examination per rectum : to do this thoroughly, it may be necessary to anesthetise the patient and to introduce two fingers; the uterus is at the same time drawn down with the volsella. As to the displacement of the uterus, it is elevated towards the abdomen; with an ovarian tumour, it is depressed to the front or to the back. The sound is now passed; if the uterine cavity is increased in size, and more especially if the movement of the tumour by an assistant is immediately communicated to the sound, the tumour is probably uterine.

Differential Diagnosis.-Their diagnosis from ovarian tumours is the most important and, at the same time, the most difficult. As in the majority of cases they are merely altered fibroid tumours, their differentiation from a simple fibroid is merely a matter of degree of softness. Their diagnosis from ovarian tumours is of importance as regards ovariotomy, though with greater experience in the extirpation of fibroids and a lower mortality, this may come to be of less importance.

TREATMENT.

The treatment consists in removal through the abdominal walls, according to the method described for fibroid tumours (v. p. 401).

CHAPTER XXXVII.

POLYPI OF THE UTERUS.

LITERATURE.

Barnes-Op. cit., p. 195. De Sinéty-Op. cit., p. 419. Gusserow-Op. cit., S. 160. Hegar und Kaltenbach-Die operative Gynäkologie: Stuttgart, 1881, S. 493. Hicks, Braxton-Three Cases of very large Polypi of the Uterus, etc.: Obstet. Journ. of Great Brit., Jan., 1879. Mathews, Duncan-Edin. Med. Journal, July, 1871; and Obstet. Journ., 1873, p. 497. Simpson, Sir J. Y.-Op. cit., p. 704. Thomas-Op. cit., p. 558. Underhill-On the Structure of Three Cervical Polypi, and The Structure of a True Mucous Polypus of the Cervix: Edin. Obst. Soc. Trans., vol. iv., pp. 231 and 241.

By the term "Polypus" is understood a pediculated tumour attached to the mucous membrane of the uterus. It includes the following tumours, which are anatomically distinct :

(1) Submucous fibroids, which have become pediculated and are in process of extrusion;

(2.) Mucous polypi;

(3.) Pediculated cystic follicles;

(4.) Placental polypi.

For clinical reasons, it is convenient to use the term polypus in its general sense as implying an external form alone; the symptoms produced by these tumours resemble one another, and their exact nature is sometimes not made out till they are removed. Pathologically, the term should be limited to mucous polypi. It is confusing to speak of a fibroid tumour which has a broad base of attachment as a submucous fibroid, and of one which has a pedicle as a fibrous polypus. The polypoidal projections formed by pediculated ovula Nabothii are only pediculated retention-cysts. Placental polypi are not true new-formations.

1. Pediculated submucous fibroid tumours form the so-called "fibrous polypi." They spring from the muscular wall of the uterus, usually from the body, which, as we have seen, is more commonly the seat of fibroid tu

mours than the cervix. They are of firm consistence, of a size varying from a goose's egg and upwards, and are of a rounded or pyriform shape (Fig. 261), sometimes elongated and constricted through the pressure of the uterine walls (Fig. 243); the surface is smooth or marked with furrows corresponding to the fasciculi of fibrous tissue.

Sometimes they are of such a size that, although lying in the vagina, they fill the pelvis and press on the bladder and rectum; the uterus is then raised above the pelvic brim (just as it is elevated when the vagina is

Fibrous polypus laid open to show its identity in structure with a fibroid tumour (Sir J. Y. Simpson).

distended with fluid), and is felt as a smaller body riding on the top of the tumour. Adhesions may form between the surface of the fibroid and the vagina, producing the impression that the tumour springs from the vaginal mucous membrane.'

The pedicle consists of a narrowing of the calibre of the tumour towards its base of attachment, or of a distinct stalk, which may be long enough to allow the fibroid to lie at the vulva. As fibroid tumours are