The intrauterine tumor discharged, on simple manipulation, large quantities of fluid spontaneously coagulable when exposed to air, which contained no mucin, but large quantities of serum, albumin and fibrino genous material. At the autopsy (von Recklinghausen) the tumor was found imbedded in the posterior uterine wall, and covered to the depth of 2 to 10 mm., by uterine parenchyma, the mucous membrane covering which was still intact. The tissue of the neoplasm is reddish. Below it is paler; at the fundus quite gelatinous and only slightly trabeculated. Between the individual bands of fibres there are no large cavities, but only small spaces or chinks, of the size of a pea. The walls of these spaces are formed by the tissue itself. The microscope showed the tissue to be very rich in cells. Most of the cells are purely fusiform, or being rounded at one end are pointed at the other. On both sides of the spindle cells one sees fine, pale prolongations which terminate in part by free extremities, and in part are connected with other spindle cells. The cells themselves have rod-like nuclei, and are slightly granular. Large collections of connective tissue are rarely found, except in the superficial parts which are in close apposition to the uterine parenchyma. In those places where the fibres above-described are present in large numbers, and where only a few spindle cells are imbedded between them, one also finds large round cells of the size of mucous corpuscles, and larger, granular and not dis tinctly nucleated. Similar cells are found disseminated through the whole mass, either isolated and at long intervals, or closely packed together between the fibrous processes of the spindle cells. In some places are seen small masses of granular detritus, and also masses penetrated by bright fibres similar to the processes of the cells, and filled with little granules.
If this process of softening becomes widely disseminated, large cavities, often containing several quarts of fluid, may form in the uterine sub stance. These cavities have no special walls, but are surrounded by torn muscular fibres, undergoing degeneration, and so separated as to form trabeculie. Dupuytren compared the inner wall of those spaces with that of the cardiac cavities.
The tumor consists of a metamorphosed solid fibromyoma, as Virchow (loc. cit.,p. 200) definitely stated. This must be emphasized, because faulty interpretations of the pathological conditions are often found in foreign literature. The larger the cavities the more are their contents composed of detritus of the tissues, mixed with more or less blood, since numerous blood-vessels, large and small, are involved in the destruction of the muscular tissue. In accordance with the period at which the blood became mingled with the contents of the " cysts," their color is changed from bright red to dark brown or yellowish brown. The fluid mass usually does not coagulate It may partially coagulate, if it contains large quantities of comparatively fresh blood.
The cavities vary from the size of a small nut to that of the adult male head. Although the terms myoma cystic= and eystofibroma are applied to this tumor, it is not a genuine cyst, since an independent wall, which is the chief characteristic of a cyst, is wanting.
A case observed by Spiegelberg and kindly placed at my disposal for publication, best illustrates the close connection of this kind of fibrocysts with that just described, and shows them to be nothing more than a more fully developed form of the same. I again openly return thanks to
Spiegelberg for his permission to utilize this case.
The tumor was a large abdominal one, which presented all the physical properties of a multilocular ovarian tumor. Since, however, at the ex ploratory puncture, 800 gm. of a thin sero-sanguinolent, spontaneously coagulable fluid was obtained, ovarian tumor was excluded. No direct connection between the tumor and the uterus could be discovered. The sound entered the uterine cavity to the depth of 9 etm. The patient died suddenly of peritonitis, complicated with septicemia, in consequence, as was subsequently ascertained, of gangrene in the tumor. The gan grene was the result of the use of the uterine sound, which had been twice introduced to the depth of 17 ctm. by an assistant. The autopsy revealed the fact that the sound had perforated the uterine wall, and penetrated the tumor.
The autopsy (Dr. Weigert) also revealed a large tumor, attached to the uterine wall, and permeated by innumerable small and large cavities varying from a hardly perceptible size to that of a child's head. The largest one, near the fundus uteri, was connected with the uterine cavity, by means of the artificial opening. The contents of these apparent cysts consists partially of sanguinolent and partly of yellowish fluid material. The walls of the cysts have, in some parts, a smooth glittering appearance. but no genuine membranous lining. The microscopical examination of the fluid showed red and white blood corpuscles. No epithelium can be found in the cyst wall, whether the specimen be fresh or hardened. The entire tumor consisted, for the rest, of smooth muscular fibres.
This case is well adapted to show the genetic relation between the two forms of cysto-fibromata already described. The majority of the eases encountered in literature belong to the latter variety.
It seems as though the processes of pregnancy and of the puerperal state had some influence upon the production of this metamorphosis in fibromyomata. This view is rendered more probable by the case of Hecker' than by any other of the recorded cases. These peculiar pro cesses of infiltration have probably not been always distinguished from gangrene.
The following cases undoubtedly belong to the class now under dis cussion, and have been studied by myself in the original reports. Ki wisch,' Braun, Chiari and Spencer Wells,' C. Mayer,' Groethuy sell.* Tanner's ease seems to have been possibly a cyst of the ligarnen tun' Tatum. linker,' Schuh, Atlee, Peaslee.' Compare farther, the histories of 0. Schroder,' of 0. Ileer," and of Plan, Urdy and Pozzi. Also compare Robert," Bryant, Bixby,'" Demarquay," and Isaac Brown." Koeberh'.. " expressed the opinion, as early as 1869, that a number of these cysto-fibromata, owed their origin to dilatation. of the lymphatics. Klebs also called attention to the fact that in uterine fibromyomata, the lymph spaces are dilated into " smooth-walled cysts, devoid of a special membrane, and filled with a clear fluid." Leopold and Fehling," however, made the first determined effort to separate one particular form of cysto-fibromata from the others, and to designate it by the term flbromyoma lymphangiectodes.