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 or 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 enucleated. 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 action. 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.
[Illustration: FIG. 131.--Interstitial fibroid tumor of the uterus. A
small submucous fibroid appears in the uterine cavity.]
[Illustration: FIG. 132.--Subperitoneal fibroid tumors of the uterus.]
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
substance.
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. 131). When they grow
outward, so that they project beneath the peritoneum, they are called
subperitoneal (Fig. 132). When they project into the uterine cavity
they are called submucous (see Fig. 131).
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. 133).
_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 character, or it may consist only of peritoneum, a little muscular
tissue, and blood-vessels.
[Illustration: FIG. 133.--Subperitoneal fibroids and an
intra-ligamentous fibroid of the uterus.]
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 blood-supply 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 omentum, intestine, or abdominal
wall. This is the origin of many so-called fibroid tumors of these
structures.
Detachment from the uterus may also occur, as the result of atrophy of
the pedicle or of violence, in the case of a pediculated subperitoneal
fibroid that has not contracted adhesions to other structures, and the
tumor will then be found free in the abdominal cavity.
The subperitoneal fibroid in its upward growth sometimes drags the body
of the uterus with it, and in this way may produce great elongation and
distortion of the cervix.
_The submucous fibroid_ grows toward the uterine cavity. It presses
the mucous membrane before it, and it may enter the cavity of the
uterus, being altogether extruded from the uterine wall. It then forms
a pediculated tumor lying in the uterus--an intra-uterine polyp. The
pedicle is composed of dense fibro-muscular tissue, and is invested by
a sheath of mucous membrane, unless this structure has been destroyed.
The pedicle may be but slightly vascular, or it may rarely contain
large arteries. As a general rule, the greater the degree of the
extrusion of the polyp and the longer the pedicle, the less is the
vascular supply. Rapid spontaneous hemostasis occurs after a fibroid
polyp is cut from its pedicle, as a result of the thickness of the
arterial walls and the contractility of the pedicle.
The intra-uterine polyp, from prolonged pressure, sometimes acquires
the shape of the uterine cavity.
Uterine contractions are excited by the presence of the polyp, and the
tumor may in time be expelled from the uterus, enter the vagina, and
protrude at the vulva.
Submucous fibroids form the most usual variety of uterine polypi. In
some cases the overlying mucous membrane becomes much stretched and
attenuated, and may finally rupture or slough. The fibroid tumor may
then escape through the opening in the mucous membrane, and, having
been extruded altogether from the uterine wall, may be expelled from
the body by uterine contractions.
The fibroid polyp, being exposed to septic influences from the vagina,
may become inflamed and suppurate; or sloughing and disintegration may
occur because of interference with the blood-supply in the pedicle.
_The intra-ligamentous fibroid_ grows from the side of the uterus or
from the supra-vaginal cervix. It pushes apart the peritoneal folds
of the broad ligament, and grows between them or beneath them. The
tumor is thus outside of the peritoneum. It may fill the whole pelvis
with a dense unyielding mass, pushing the uterus to the pelvic wall,
destroying anatomical relations, and exerting most disastrous pressure
upon blood-vessels, nerves, ureters, and other pelvic structures.
Sometimes, as these tumors enlarge in an upward direction, they carry
with them overlying pelvic organs; thus the ureter may be found passing
over the top of a tumor which, beginning as an intra-ligamentous pelvic
growth, has become abdominal.
In some cases the fibroid grows from the posterior aspect of the
supra-vaginal cervix, passes beneath the bottom of Douglas’s pouch,
pushes the peritoneum above it, and becomes a retro-peritoneal tumor.
Again, it may grow from the anterior aspect of the cervix in
the vesico-uterine space, and as it extends upward may push the
vesico-uterine fold of peritoneum above it and drag up the bladder, so
that this viscus is sometimes found spread out upon the anterior face
of the tumor and extending as high as the umbilicus.
As has already been said, fibroid tumors are usually multiple, and if
one of the terms designating the position of the tumor as subperitoneal
or intra-ligamentous is used to describe any case, we understand that
the chief tumor-mass is of this character.
The fibroid polyp is more likely to be single than any of the other
varieties. In fact, the fibroid polyp is usually single; that is, no
other fibroid tumor can be detected in the body of the uterus. This is
not always the case, however, and sometimes the repeated expulsion of
successive fibroid polypi from the same woman renders it probable that
several nodules were simultaneously present in the uterine wall.
As a rule, fibroid tumors of the uterus are of slow growth. In some
cases five, ten, or fifteen years may elapse before the tumor attains
the size of the fetal or the adult head. Sometimes the tumor appears
to be of limited growth, and early attains its maximum size, or it may
not increase at all in size after its first discovery by the woman;
in other cases the tumor slowly but steadily grows until, after a
lapse of ten or twenty years, it fills the whole of the abdominal
cavity and renders the woman helpless from weight and pressure; and,
finally, in some instances the tumor grows unlimitedly with the
rapidity characteristic of an ovarian cyst, and in one or two years
may crowd the woman out of existence. This rapid unlimited growth is
characteristic of tumors of the fibro-cystic variety.
A fibroid tumor causes very marked changes in the body of the
uterus--the muscular coat and the endometrium. The whole uterus becomes
enlarged. The cavity is increased in length, and the muscular wall
becomes often very much hypertrophied. This hypertrophy resembles that
occurring in pregnancy. Even small fibroid tumors may produce this
condition, which seems to depend more upon the position than upon the
size of the growth. The interstitial and the submucous tumors are
accompanied by a greater degree of uterine hypertrophy than accompanies
the subperitoneal growths. In some cases the uterus may be of normal
size if the subperitoneal growth has become pedunculated. The uterus
may appear to be uniformly enlarged to the size of the fourth or fifth
month of pregnancy, and when incised it will be found to contain
one or more interstitial or subperitoneal tumors that have become
encapsulated by it. When such a case is subjected to celiotomy the
resemblance of the uterus to pregnancy is very striking. Between such
a smooth, uniformly enlarged uterus on the one hand, and the irregular,
distorted mass of subperitoneal fibroids on the other, there are an
infinite number of varieties. A great increase in the vascular supply
accompanies the hypertrophy of the uterus. The ovarian and uterine
arteries and their branches become very much hypertrophied, while the
veins in the broad ligaments and the sinuses in the capsule of the
tumor become enormous.
The endometrium shares in the changes that take place in the uterus.
It is, of course, increased in area with the increase of the uterine
cavity. There may be atrophic changes from pressure upon or tension
of this membrane, or various forms of endometritis may be present,
most usually the interstitial and the glandular. The glandular form
of the disease is said to occur most frequently when the tumor is
remote from the cavity of the uterus, as in the subperitoneal variety;
while interstitial endometritis occurs with the submucous and the
interstitial tumors.
In the Fallopian tubes and the ovaries pathological changes occur as
the result of uterine fibroids. The tubes may present any of the forms
of cystic change--hydrosalpinx, pyosalpinx, or hematosalpinx--that are
caused by salpingitis. It is probable that these diseases are often
caused by extension of endometritis. The tubes and ovaries may be much
distorted and displaced from the normal position. In some cases the
ovary is drawn out into a long cord five inches in length; in other
cases it is spread out upon the face of the tumor.
Fibroid tumors are liable to several forms of degeneration--calcareous,
fatty, myxomatous, edematous, cystic, telangiectatic, gangrenous or
suppurative, necrobiotic, and malignant.
_Calcareous change_, from the deposit of lime-salts in the fibroid
nodules, is an unusual occurrence. It appears most often in women
beyond the menopause, and is part of the atrophic changes that take
place at this time. (It has occurred in a woman who had been subjected
to oöphorectomy for the relief of a fibroid tumor.)
I have seen a fibroid tumor the size of the adult head--a solid
calcareous mass which could be divided only by means of a saw.
The calcareous nodules are surrounded by uterine tissue to which they
are but loosely attached. They may be forced out of the uterus and
escape at the vulva. They have been called “womb-stones.”
_Fatty degeneration_ is a very unusual condition. It has been assumed
to take place, as a step preliminary to absorption, in those cases in
which a fibroid tumor disappears after labor or from other cause.
_Myxomatous degeneration_ is also rare. In it an effusion of mucous
fluid takes place between the bundles of fibrous tissue. Sometimes
large cavities are formed in this way.
In the _edematous fibroid_ the whole tumor is permeated by a serous
fluid. This condition is not unusual. It resembles edema in any other
part of the body. It is often found in young women before the thirtieth
year.
_Cystic degeneration_ of fibroid tumors may result from any of the
forms of degeneration with softening in which cystic cavities are
formed.
In some cases _fibro-cystic tumors_ are caused by dilatation of the
lymphatics. They have been called “lymphangiectatic fibroids.” An
endothelial lining has occasionally been found in the cystic cavities
of these tumors. The fluid removed from the cyst-cavities coagulates
spontaneously. Such fibroids have frequently been mistaken for ovarian
cysts.
In the _telangiectatic_ or the _cavernous_ form of fibroid tumor there
is an enormous dilatation of the vessels in the new growth. The venous
spaces are sometimes as large as a walnut, and are filled with clotted
or fluid blood. This change usually affects one part, and not all, of
the tumor, which presents the gross appearance of a sponge soaked with
blood.
_Gangrene_ is most liable to occur in the fibroid polyp. During the
process of expulsion from the uterus the vascular supply through the
pedicle becomes impeded, so that there is not sufficient blood for
nutrition. The tumor is exposed to septic infection through the vagina
and the cervix, and sloughing and suppuration occur. As a result of
such disintegration the tumor may be discharged piecemeal.
_Inflammation_, and occasionally _suppuration_, of fibroid tumors
remote from the cavity of the uterus may occur from infection through
the intestinal tract or other channel.
_Necrobiosis_ occurs if the nutrition of the fibroid is cut off
and there is no infection of the dead tissue. The tumor becomes
soft, undergoes fatty degeneration, and liquefies. The necrobiotic
degeneration may involve only part or all of the tumor. There is always
danger of septic infection occurring in this form of degeneration.
_Sarcoma_ may develop in a fibroid tumor of the uterus. As has already
been stated, the “circumscribed fibroid sarcoma,” or sarcoma of the
uterine parenchyma, is thought by some authorities always to originate
from degeneration of a benign fibroid tumor. It seems probable that the
fibroid tumor predisposes the woman to the development of sarcoma of
the uterus.
Cancer may also occur in the endometrium of a fibroid uterus. This
occurrence is by no means an unusual one. We cannot yet say positively
that the fibroid favors the development of cancer, but it seems
probable that the diseased endometrium that accompanies fibroids
furnishes a place of diminished resistance for the development of
malignant disease.
Martin has made an interesting analysis of 205 cases of fibroid tumor
of the uterus that had been submitted to operation. From this analysis
we may form some estimation of the frequency of the various forms of
degeneration that have been described.
Fatty degeneration existed in 7 cases. Calcification was present in 3
cases. In 10 cases there was suppuration, and this process was found
in the submucous, interstitial, and subperitoneal tumors. In 11 cases
there was extensive edema of the fibroid. In 8 cases the tumors had
become cystic.
The telangiectatic change was found to a marked degree in 3 cases.
Sarcomatous degeneration had occurred in 6 cases.
In 7 cases the fibroid was complicated with cancer of the fundus uteri,
and in 2 cases with cancer of the neck of the womb.
The fatty and calcareous changes are not to be considered dangerous
forms of degeneration.
The other changes, however, are often attended with great danger to
life. The dangers of suppuration and of sarcomatous degeneration are
obvious. The edematous fibroid is often of rapid and unlimited growth,
and is usually accompanied by profuse hemorrhages from the uterus. The
cystic fibroid may grow as rapidly and as large as an ovarian cyst.
The telangiectatic tumors grow to large size and are attended by the
dangers of thrombosis and embolism.
Cancer of the fundus with fibroid tumor may only be a coincidence,
and we will not assume that predisposition to cancer is caused by the
fibroid.
The statistics that have been given, however, show that in at least 38
cases out of 205, or in about 18 per cent. of the cases, changes took
place in the fibroid that seriously endangered the life of the woman.
Sterility, abortion, and difficult or impossible labor are caused by
uterine fibroids. Conception is impeded on account of the displaced,
distorted uterus and the hemorrhage and discharge. Abortion is likely
to occur, on account of the endometritis and the unequal expansibility
and the irritability of the uterus.
Labor is sometimes rendered impossible by the presence of a uterine
fibroid that obstructs the pelvis, and Cesarean section has been
performed for this cause.
The cause of fibroid tumor of the uterus is unknown. Some authorities
consider the condition, or at least the predisposition to the
condition, to be congenital. Uterine fibroids have been observed in
girls near the age of puberty, and hysterectomy for fibroid has been
performed at the age of eighteen.
Usually the disease begins to cause symptoms, and first comes under
the observation of the physician, after the thirtieth year. It is very
probable that small interstitial or subperitoneal fibroids exist in
many women before this period, but, on account of the small size and
the position of the growths, they produce no marked symptoms, and if
the woman bears children, the tumors are very likely absorbed during
the process of uterine involution.
Fibroid tumors occur in both the white and the black races--with
somewhat greater frequency in the latter than in the former. Tait says
that fibroid tumors of the uterus are unknown among the black women of
Africa. The disease is certainly very common among their descendants in
this country.
The frequency of uterine fibroids is difficult to determine, for there
are many cases in which the disease is unrecognized on account of the
small size of the tumor and the absence of symptoms. It is, however,
one of the commonest diseases with which women suffer. In a series of
504 celiotomies performed for diseases of women at the University and
Gynecean Hospitals, uterine fibroids were found in 85, or in about 17
per cent. of the cases.
Fibroid tumors are found both in multiparous and in nulliparous
women--much more frequently in the latter than in the former. Single
women and sterile married women are especially predisposed to this
disease. There are two probable causes for this difference. The
unceasing congestions of menstruation favor the development of the
neoplasm; and, when once started, its further growth is not checked by
the retrograde changes that accompany involution of the uterus, and
that sometimes cause the disappearance of even large fibroids.
Fibroid tumors are essentially growths of the menstrual life of the
woman. They usually first appear after the thirtieth year, and they
continue to grow until the menopause. The size of the tumor and the
severity of all the symptoms progressively increase during the active
sexual period of life. It is very unusual for favorable retrograde
changes or permanent amelioration of symptoms to occur during this
period. In a woman with fibroid tumor of the uterus the menopause is
delayed for five to fifteen years beyond the normal time. This is an
important fact to be remembered in connection with the prognosis and
the treatment of any case.
At the menopause, in the majority of cases, the growth of the tumor
is arrested, and the retrograde changes that affect the genital
apparatus involve also the fibroid tumor, and atrophy of the neoplasm,
with marked diminution in size, and in some cases its complete
disappearance, may take place. The tumor becomes quiescent, and the
woman may finish her life in comparative comfort. This, however, is by
no means always the case. The fibroid sometimes continues to grow after
the menopause, and the suffering is sometimes so unbearable that the
woman is finally driven to operation.
In some cases the tumor has developed entirely after the menopause has
been reached.
At each menstrual period there is usually a decided increase in the
size of the tumor and in the severity of the symptoms. And at these
periods, in the case of a submucous or an interstitial fibroid, the
cervical canal becomes more patulous.
=Symptoms.=--The chief symptom of fibroid tumor of the uterus is
_hemorrhage_. This symptom is present in the great majority of fibroids
of all kinds. It is not, however, universally present. I have removed
tumors the size of the adult head, composed of interstitial and
subperitoneal fibroids, from women who had never suffered with even
slight menorrhagia. The hemorrhage appears in the form of menorrhagia
or metrorrhagia. It may be an increase in the regular menstrual
bleeding. It may appear as a periodical bleeding occurring every two
weeks--a phenomenon that occurs in other diseases of the uterus and the
endometrium. It may appear as a show of blood or a slight hemorrhage,
after unwonted effort, between the regular menstrual periods. This may
occur after straining at stool, coitus, or even emotional disturbance.
And, finally, it may appear as a continuous bleeding from the uterus.
The cause of these hemorrhages is to be found in the increased area
of the endometrium accompanying the uterine enlargement, and in the
diseased condition of the endometrium.
The hemorrhage is not usually alarming in amount, and it may be
somewhat controlled by rest in bed and the administration of ergot or
other drugs. In some cases, however, it produces the most profound
anemia, and in others, especially in the uterine polyp, the woman may
literally bleed to death.
The symptom of hemorrhage is independent of the size of the tumor, but
depends upon the position of the fibroid. As a rule, the hemorrhage
is most severe with the uterine polyp, less severe with the submucous
and the interstitial tumors, and least with the subperitoneal variety.
In some cases, when the mucous membrane overlying a submucous tumor
ruptures, the hemorrhage may come directly from venous sinuses in the
capsule.
The hemorrhage also depends upon the variety of the growth. The
edematous fibroid and the soft myoma appear always to be accompanied by
profuse bleeding. In some cases the hemorrhage may occur periodically
or continuously in old women who have passed the menopause, and in
whom there had been no bleeding for several years. This has been
observed in the small submucous fibroids which, after a period of
quiescence, have gradually become polypoid, or which have undergone
suppuration and disintegration. The hemorrhage, the offensive odor of
the discharge, and the age and the history of the patient are very
likely to lead to the diagnosis of cancer.
The blood that escapes from the fibroid uterus may be fluid or clotted,
or it may be partly decomposed from the retention of clots.
_A profuse secretion_ from the utricular glands often occurs between
the uterine hemorrhages. This secretion is usually thin and watery in
character, and may be so profuse as to require the continuous wearing
of a napkin. In some unusual cases there is no marked hemorrhage, but a
continuous abundant watery discharge.
_Pain_ is a more or less constant accompaniment of fibroid tumors. It
varies a great deal in character and position. It is often referred
to the sacrum and to the top of the head or the occiput. Pain of this
character is due to the accompanying metritis and endometritis. That it
is uterine in origin is shown by the fact of its complete and permanent
disappearance from the day that hysterectomy is performed.
The pain is always increased at the menstrual periods, and may at first
be present only at these times. It afterwards becomes continuous.
In the case of a submucous or a polypoid fibroid there may be present
the pain of uterine contractions, referred to the center of the lower
abdomen, and resembling labor-pains.
The pain from pressure is sometimes intense. It occurs in large tumors
and in those of pelvic growth, like the intra-ligamentous fibroids.
Sciatic or crural neuralgia may be thus developed.
In all these cases there is a feeling of weight and dragging in the
pelvis which is most marked in the erect position, and which is caused
by the weight of the tumor and of the enlarged uterus.
The symptoms of pressure are very marked in the case of
intra-ligamentous tumors. The capacity of the bladder may be so
diminished that there may be continuous incontinence of urine; or
the bladder and the urethra may be so distorted, from traction and
pressure, that urine is voided with great difficulty, and it is
sometimes impossible to introduce the catheter. I have seen a woman
with a fibroid the size of the adult head who could urinate only when
upon her hands and knees.
Pressure upon the pelvic nerves may, as has already been mentioned,
produce great pain, and in some cases paralysis. Women are sometimes
affected with sudden complete paralysis of one or both legs from the
pressure of a fibroid. I have performed hysterectomy upon a woman who
had on several occasions fallen helpless in the street from paralysis
of the left leg caused by the pressure of a small intra-ligamentous
fibroid tumor. All the pressure-symptoms are exaggerated at the
menstrual period, on account of the swelling of the tumor that occurs
at this time.
Pressure upon the rectum is often very marked, and may cause
constipation and hemorrhoids. Pressure upon the ureters causes
dilatation, hydronephrosis, and uremia. This is a not infrequent cause
of death, both in the untreated case and after operation for the relief
of fibroids.
The effect of fibroid tumors of large size upon the heart and
blood-vessels has been remarked by several writers. Fatty degeneration
and brown atrophy have been found associated with uterine fibroids in a
number of instances. This is undoubtedly the explanation of some cases
of death after operation.
Martin has called attention to the disposition to thrombosis and
embolism which seems to be especially marked in the telangiectatic
form of tumor. This also explains some of the cases of sudden death
that occur after operation. Operators have observed cases of sudden
death, probably from embolism, occurring sometimes several weeks after
hysterectomy for fibroid tumor.
The =diagnosis= of uterine fibroids is made from a study of the
symptoms already described and from the physical examination.
If the tumor is large enough to be palpated through the abdominal
wall, the hard consistency and the irregular bossed outline of the
multinodular form of fibroid may be detected.
By bimanual examination we determine the general enlargement, and
perhaps the irregular outline, of the uterus. Sometimes, when the
fibroid is small and interstitial, a slight elevation, or perhaps
merely a local induration, may be felt. By grasping the cervix with
a tenaculum and drawing it down while the palpating finger is in the
rectum the whole of the posterior face of the uterus may be explored
and small fibroid nodules discovered.
The tumors are found to be continuous with the uterus and movable with
it. If the tumor is sufficiently large to be grasped by an assistant,
who draws it up or to either side, it will be found that the motion
is communicated to the vaginal cervix. The cervix is often very hard,
and may have been dragged upward to such an extent that it cannot be
reached by the vaginal finger; or it may project from the rounded
surface of the tumor like the nipple on the breast.
The hard, non-fluctuating character of the tumor may usually be
determined by bimanual examination. A sensation resembling that
of fluctuation may be elicited in the edematous fibroid, and true
fluctuation is, of course, present in the cystic variety.
The uterine sound shows the increased length and the irregularity of
the uterine cavity. The sound is not often necessary for diagnosis.
It is useful, however, in the case of small interstitial fibroids. It
will be remembered that uterine enlargement is one of the most usual
symptoms of fibroid tumor.
The presence in the wall of the uterus of a hard nodule or of an area
of induration, with a decided increase in the length of the uterine
cavity (three to four inches), is strong evidence of fibroid tumor.
Those fibroid tumors which cause symmetrical uterine hypertrophy
without any irregularity of surface are sometimes difficult of
diagnosis. They have been mistaken for the pregnant uterus. The
reverse mistake has also very frequently been made, and the woman has
been subjected to celiotomy for fibroid tumor when a normal pregnancy
alone was present. The differential diagnosis between fibroid and
pregnancy is usually not difficult. In making such a differential
diagnosis it must be remembered that in some cases of pregnancy the
menstrual periods continue during the early months or throughout the
course of pregnancy, and that irregular bleeding may occur during
pregnancy; also, on the other hand, that the symptoms of menorrhagia
and metrorrhagia may be absent in the case of fibroid tumors. Mammary
changes, nausea, and pigmentation of the skin may occur with fibroid
tumors as with other diseases of the uterus or the ovaries, and
resemble the similar phenomena of pregnancy. The bluish discoloration
of the ostium vaginæ, the soft cervix, the pulsation of the vaginal
vessels, the movements of the child, and the fetal heart-sounds are
absent in fibroid tumors. The recent history of the tumor and its
typical increase in size are observed in pregnancy.
In the event of doubt the case should be watched for a few months until
the diagnosis becomes clear. Fibroid tumors are of slow growth, and
such delay is usually not dangerous.
If the fibroid tumor is complicated with pregnancy, the diagnosis
becomes more difficult. This complication is not an unusual one, and
should always be borne in mind.
The differential diagnosis between uterine fibroid and ovarian cyst is
easy except in the case of the fibro-cystic tumor. Such tumors have
very often been mistaken for ovarian cysts. The mistake is not at
all serious, as celiotomy is indicated in either case. The operator,
however, should always determine the nature of the tumor before
proceeding with the operation after the abdomen has been opened, as
puncture of a fibro-cystic tumor may be attended by alarming hemorrhage.
A small fibroid in the posterior wall of the uterus has often been
mistaken for retroflexion, and the woman has been treated with a
pessary. This mistake may be avoided by feeling, with the abdominal
hand, the fundus uteri in its normal forward position, or by
determining the true direction of the uterus with the uterine sound.
The =prognosis= of uterine fibroids may be determined from a
consideration of the natural history, the degenerations, and the
complications of these neoplasms, which have already been described.
Fibroid tumors are benign growths, in contradistinction to cancer and
sarcoma. They do not infiltrate contiguous structures or invade the
general system; but they are not benign in the sense that they are not
dangerous to life.
As has been said, the disease may terminate as a uterine polyp, which
may be discharged from the body. But during this process the woman
may die from hemorrhage or from septic absorption from the sloughing,
disintegrating tumor.
Some unusual fibroids give no trouble whatever, never attain a large
size, and are discovered only accidentally during the life of the woman
or at the autopsy.
In very exceptional cases--so rare that they are to be looked upon as
medical curiosities--the fibroid disappears spontaneously even after
it has reached a large size. This has occurred as the result of an
accident, exploratory celiotomy, and pregnancy.
We have no right in any case, however, to look for such favorable
termination.
The accidents that may happen to the tumor itself, and which imperil
the life of the woman, are various and occur frequently. The dangerous
forms of degeneration--the edematous, the cystic, the telangiectatic,
and the sarcomatous--occur with sufficient frequency always to be
dreaded; and, even though these dangers be avoided, the anemia from
the continual hemorrhage exposes the woman to fatal results from the
diseases and accidents of daily life. The most favorable course that we
have a right to expect, in any case of fibroid tumor of the uterus that
is not discharged as a uterine polyp, is that it will grow slowly, that
it will produce symptoms not unendurable, and that at the menopause it
will cease to grow and will atrophy or disappear.
This comparatively favorable course condemns the woman to a life of
invalidism, more or less marked, during the years that should be the
most useful and active of her existence. The menopause may be delayed
for five, ten, or fifteen years, or it may be indefinitely postponed;
and even after the menopause has occurred, in a certain number of cases
the fibroid, contrary to the usual rule, continues to grow, and may
ultimately cause death.
=Treatment of Fibroid Tumors of the Uterus.=--Operative treatment
is usually demanded in the case of fibroid tumors. A few years ago
the treatment usually advised was palliative and expectant. The
imperfect technique rendered operations for this disease so fatal
that it was considered safest for the woman to allow the tumor to
pursue its natural course, hoping that, if small and single, it would
be discharged as a polyp, or that it would grow slowly and would
atrophy at the menopause, the physician meanwhile relieving as much as
possible, by palliative treatment, the symptoms that presented before
this favorable termination.
Many women, following this advice, have suffered through the years of
active life, and have finally found relief and cure when the menopause
was reached; others have started upon this dreary course, and have
died from some of the accidents incident to these tumors; still others
have passed through these years of suffering, and then have found the
hoped-for goal vanished, the menopause indefinitely postponed, or the
tumor continuing to grow after this period had been reached.
Many of these women are driven to the operating-table to-day, after
lives that have been wasted by this expectant plan of treatment.
The great majority of fibroid tumors of the uterus demand immediate
operation. The operative technique has been so perfected that the
mortality after operation is very small. The danger of operation is
much less than the dangers to which the woman is exposed from the
various accidents that are liable in this disease.
There are some cases, however, in which immediate operation is not
demanded. In a young woman with a fibroid tumor of small size that is
not causing serious symptoms operation may be deferred and the case may
be watched. This plan is especially desirable if the woman is anxious
to have children. She should be told, however, that conception is less
likely to occur than in the well woman, that she is liable to abort,
and that the tumor will grow more rapidly during her pregnancy. On the
other hand, there is the possibility of its disappearance after labor.
If the tumor, even though small, is intra-ligamentous and of pelvic
growth, the expectant plan of treatment is not justifiable. Dangerous
pressure-symptoms are too imminent, and if pregnancy occurs labor will
be obstructed. If the woman has reached the menopause, if menstruation
has ceased, and the tumor is causing no serious symptoms from its size
and position, the case may be watched with the hope that the disease
will shortly become quiescent. Such cases are exceptional. Usually
the tumor produces symptoms that render the woman more or less of an
invalid, and she should not be condemned to this suffering and to the
dangers of waiting. In these cases we must not rely altogether upon the
statement of the woman in regard to the suffering caused by the tumor.
A woman, dreading operation, will often underrate her suffering, or she
will consider as normal the disturbances to which she has, through a
long period of years, gradually become accustomed.
No drug has been discovered that has any influence upon the growth of
the fibroid tumor.
The most serious symptom, hemorrhage, may be alleviated in a variety
of ways. Rest in the recumbent posture, to relieve congestion, is
most important. Such rest is especially demanded at the menstrual
period. Pressure-symptoms and pain are likewise relieved by rest.
Careful attention to the regularity of the bowels is desirable. The
administration of saline purgatives to the extent of mild purgation
depletes the pelvic circulation, and is especially useful immediately
before a menstrual period. Coitus should be avoided immediately before
and during the menstrual period.
Ergot, gallic acid, hydrastis, bromide of potash, and erigeron are
useful to control the bleeding. They should be administered in
frequently repeated doses for a long period.
Thorough curetting of the cavity of the uterus is the most certain
method of controlling the hemorrhage. By this procedure the diseased
endometrium is removed, and the bleeding is usually very decidedly
diminished for several months afterwards.
The treatment by electricity, once popular with some physicians, has
not stood the test of time and experience. It does not stop the growth
of the tumor. It has caused many deaths. It may produce peritoneal
adhesions, which render subsequent operation most difficult.
Ligature of the arteries supplying the uterus has been performed with
the object of arresting the growth of a uterine fibroid. The results of
this operation, however, have not been satisfactory.
_Salpingo-oöphorectomy_ has been practised for a number of years,
and a large number of fibroid tumors have been cured by it. Before
the present perfected technique of hysterectomy had been developed
salpingo-oöphorectomy was much the safer operation, and was always
practised whenever possible.
The object of the operation is to cause arrest of growth and atrophy of
the tumor by stopping menstruation and producing a premature menopause.
According to the statistics of Tait, the operation results in cure of
the fibroid in 95 per cent. of the cases.
In some cases the bleeding stops immediately and never recurs; in other
cases the bleeding continues, in steadily diminishing amount, for
several weeks or a few months after the operation; and finally, in a
small proportion of the cases, the bleeding is not arrested at all.
The atrophy of the tumor after this operation is also variable.
Sometimes the atrophy begins immediately, and in a few weeks after the
operation has proceeded to a very marked degree, the tumor disappearing
or being so small as to give no trouble; in other cases the atrophy is
much slower; sometimes there is no arrest of growth whatever.
The operation seems to produce most benefit in cases of the hard
fibroid. The edematous fibroid is often unaffected by it; and it is
not applicable in the case of fibro-cystic tumors, which continue in
unabated growth.
In performing the operation it is important that every portion of
ovarian tissue should be removed, and that the Fallopian tube should be
amputated as closely as possible to the uterine cornu. Many cases of
failure of this operation are due to neglect of these precautions.
A very small portion of ovarian tissue may be sufficient to continue
menstruation.
A good many women who had derived no benefit from the first operation
have been subjected to a second operation, a small remaining portion
of the ovary being removed or the stump of the Fallopian tube being
excised, complete cure resulting.
The nature of the influence of the Fallopian tube in this matter is
not understood. Tait lays especial stress upon the necessity of its
complete removal.
The importance of the removal of the tubes may be realized from Tait’s
statement that “removal of the ovaries alone is followed by immediate
and complete arrest of menstruation in about 50 per cent. of the cases.
Removal of both tubes, with or without the ovaries, is followed by the
same arrest in about 90 per cent. of the cases.” From this statement it
appears that if one wishes to stop menstruation, removal of the tubes
is of even more importance than removal of the ovaries.
The operation of salpingo-oöphorectomy is not advisable in some cases,
and in some others it is impossible to perform it.
As has already been said, the operation is likely to fail in the soft
edematous fibroids. It should not be advised in the fibro-cystic
tumors. It is not advisable in the case of large fibroid tumors of
abdominal growth, because, even though atrophy occur, it will be slow,
and the symptoms referable to the large hard tumor in the abdomen will
be but slowly relieved.
The operation is not applicable to the intra-ligamentous fibroid of
pelvic growth, producing urgent pressure-symptoms that demand certain
and immediate relief. In the case of profuse exhausting hemorrhage,
when the anemia is so great that immediate and certain arrest of
bleeding is required, salpingo-oöphorectomy should not be practised.
If the woman has reached the menopause, and, notwithstanding
the cessation of menstruation, the tumor continues to grow,
salpingo-oöphorectomy will do no good.
In some cases the tubes and ovaries cannot be removed. They often
occupy a position behind or under the tumor, so that they cannot be
removed without first taking the tumor away. The tube and ovary may
be so distorted that only partial excision is possible, and this will
result in no benefit; or the tube and ovary may be spread out upon
the face of the tumor, incorporated with its capsule, so that removal
is impossible, and any attempt at removal may result in rupture or
penetration of large venous sinuses--a most dangerous accident.
The operator should therefore never undertake the operation of
salpingo-oöphorectomy for uterine fibroid unless he is prepared to
perform hysterectomy if this operation is found necessary.
_Hysterectomy_ is deservedly the favorite operation for uterine
fibroids at the present day.
The danger of the operation is small, being but little, if any, greater
than that attending salpingo-oöphorectomy for fibroids, if we compare
only those cases in which either operation may be performed.
The operation is applicable to every kind of fibroid tumor. The relief
of symptoms is immediate and certain.
The reflex symptoms, such as backache and headache, which are
directly due to the pathological condition of the uterus, often
disappear immediately and permanently. This cannot be said of
salpingo-oöphorectomy, after which operation these symptoms often
continue for an indefinite period.
The treatment of uterine fibroids has followed in development the
growth of abdominal and pelvic surgery. In the days when celiotomy was
a dangerous operation the palliative treatment was advisable. When
salpingo-oöphorectomy could be safely performed this treatment was
practised; and now that hysterectomy is equally safe, it has become the
operation of election.
The details of the operation of hysterectomy for uterine fibroids will
be considered in a subsequent chapter.
_Myomectomy (Abdominal)._--In some cases of uterine fibroid it is
possible to remove the tumor without taking away the uterus. This
operation, when performed through an abdominal incision, is called
abdominal myomectomy. From a surgical standpoint it is the ideal plan
of treatment, as the woman is cured of the disease without suffering
mutilation.
Myomectomy is especially adapted to the treatment of single fibroid
tumors which may be excised or shelled out of the body of the uterus.
It is indicated in the case of young women who are anxious for children.
The field of myomectomy is at present a limited one. Single
subperitoneal and interstitial fibroid tumors are rare. Even though the
secondary nodules may be small at the time of operation, they will grow
after the removal of the chief mass. Hysterectomy has been required
at a second operation in a woman on whom myomectomy had been first
performed.
The operation is still on trial: its limitations and remote results
have not yet been determined. It should be performed only by the
experienced abdominal surgeon. Many fatal cases of post-operative
hemorrhage and of sepsis have occurred. Though successful cases have
been reported by men of unusual skill and experience, in which large
numbers of uterine fibroids have been removed from the uterus at
one operation, yet these cases must be looked upon as rare surgical
triumphs which it is to be hoped will become more frequent in the
future.
On the ground of safety, hysterectomy is to be preferred to myomectomy.
The details of the operation of myomectomy are described in a
subsequent chapter.
When the fibroid tumor is complicated by pregnancy it may be necessary
to perform Cesarean section, followed by hysterectomy. This is not
justifiable, however, unless the fibroid is so situated that the
passage of the child by the natural way is impossible. The fibroid
usually increases more rapidly in size during pregnancy, but may
diminish a good deal with the involution of the uterus.
[Illustration: FIG. 134.--Fibroid polyp producing partial inversion of
the uterus.]
_Treatment of the Fibroid Polyp._--When the fibroid tumor is polypoid,
and projects into the uterine cavity, or the cervix, or beyond the
external os, none of the operations that have just been described are
required. The tumor should then be attacked by way of the vagina. If
the fibroid polyp projects from the external os, the pedicle may very
easily be divided with curved scissors. If the tumor is still within
the cavity of the uterus, it will be necessary to dilate the cervix,
or to enlarge the canal by lateral incisions, so that the pedicle may
be reached. It should always be remembered that the polyp may, by
traction, produce partial or complete inversion of the uterus (Fig.
134), and in dividing the pedicle, therefore, the operator should cut
close to the tumor, leaving, if necessary, a portion of the surface
of the tumor. In case the polyp is so large that the vagina is filled
to such an extent that the pedicle is not accessible, it is advisable
to remove the tumor piecemeal, grasping portions with a tenaculum and
cutting away with scissors until the pedicle is reached. The fibroid
polyp is not vascular, and hemorrhage is not alarming. The pedicle
usually contains no large vessel. It retracts after the tumor has been
cut away, and spontaneous hemostasis is secured. It was formerly the
custom to ligate the pedicle or to remove the polyp with the écraseur,
but these methods are unnecessary. If any hemorrhage should follow the
operation, the cavity of the uterus should be packed with sterile gauze.
=Adenomyoma= is a rare form of myoma of the uterus, which contains
epithelial canals of the glandular type. Unlike the common fibromyoma,
this tumor has no connective-tissue capsule and its structure cannot be
well differentiated from the tissue of the surrounding uterine wall.
Adenomyomata are of two varieties: in one variety the epithelial canals
seem to be derived from the utricular glands; in the other from the
embryonal remains of the Wolffian body.
In the first variety the tumor is situated in the posterior, anterior,
or lateral uterine wall, and has the usual characteristics of a
fibromyoma, except for the presence of glandular structures and the
absence of a capsule.
Adenomyomata, which are derived from the Wolffian body, develop in the
posterior portion of a uterine horn, or less often in the tube, and
when small, in the peripheral layers of the muscular wall. The tumor
may afterward become interstitial or submucous.
These tumors are of various degrees of hardness. They may be dense in
consistence, in case the muscular tissue is in excess of the glandular,
or they may be soft cystic tumors containing numerous distinct
macroscopic cavities. Telangiectatic adenomyomata also occur.
The _treatment_ of adenomyoma of the uterus is hysterectomy.