and which sometimes extends up to the navel in peritoneal hæmatocele,
but in the subperitoneal variety no tumor whatever may be discoverable
by these explorations, unless conjoined manipulation be added to it for
the sake of deeper and more thorough search.
DIFFERENTIATION.--Hæmatocele may be confounded with pelvic cellulitis
or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and
dislocated ovarian cyst.
The tumor of cellulitis develops slowly, with great pain; is hard at
first, and then softens; is tender from the first; does not elevate the
uterus or press it forward; and is not often accompanied by
metrorrhagia.
Retroversion will readily be detected by the uterine sound, conjoined
manipulation, and the absence of anæmic symptoms.
The development of extra-uterine pregnancy is slow and gives the signs
of gestation.
Fibrous tumors grow slowly, are painless, and move with the uterus, and
they are hard, irregular, and do not lift the uterus against the
symphysis.
Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia,
and yield fluctuation readily to palpation.
COMPLICATIONS.--The complications to be feared in this disease are
septicæmia, suppuration and abscess, and peritonitis.
COURSE, DURATION, AND TERMINATION.--The hemorrhage may be so severe as
to destroy life immediately. Five such instances have been recorded by
Voisin; I have met with one; and Ollivier d'Angers mentions two in
which death occurred in half an hour from a varicose utero-ovarian
vein. Such a termination is, however, very rare.
As a rule, absorption takes place unaided by art; in some cases
suppuration occurs, and the mass is discharged as if it were a large
abscess by the vagina, rectum, bladder, or abdominal walls; and at
other times septic absorption, accompanied by septic peritonitis,
destroys the life of the patient.
PROGNOSIS.--The prognosis will depend in great degree upon the severity
of the constitutional symptoms. As a rule, it is decidedly favorable
unless the surgical tendencies of the attending practitioner alter its
natural inclination. The prognosis of the peritoneal form is graver
than that of the subperitoneal, and when the tumor is very large the
danger is greater than when it is small. A large tumor argues great
loss of vital fluid, which may in itself destroy life, and the
necessity for the absorption of a large amount of coagulated material
which may poison the blood.
The usual causes of death are loss of blood, shock from sudden invasion
of the peritoneum, peritonitis, secondary discharge of the encapsulated
mass into the peritoneum, or septicæmia.
TREATMENT.--Should the physician be called in the inception of the
attack, the patient should at once be placed in the recumbent posture,
all excitement around her be quelled, the head be kept low, warmth be
applied to the soles of the feet, and perfect quiet enjoined. An effort
should be made to check the flow by applying bladders of ice or cloths
wrung out of hot water over the hypogastrium, pain and tendency to
{244} shock met by the use of morphia hypodermically, and ammonia and
brandy freely administered by the mouth. This is all that promises
benefit, and further efforts should be avoided as calculated to do
absolute harm.
After reaction has occurred let it be borne in mind that the factors
which tend to the production of death are--1st, peritonitis; 2d,
septicæmia; 3d, suppuration and discharge through some dangerous
outlet; and let all efforts be directed toward the prevention of these
events.
All pain should be quieted by opium or one of its salts, hypodermically
or by mouth or rectum; the patient should be thoroughly nourished by
milk and strong animal broths, given as often as every two hours;
febrile action should be controlled by the coil of running ice-water
and quinine; and strict quietude observed, all unnecessary examinations
being avoided, as belonging to the most pernicious class of perturbing
influences.
Should the case progress favorably, no surgical procedure looking
toward the artificial evacuation of the accumulated blood either by
bistoury or by the aspirator should be thought of, however large the
accumulation be; for experience has proved that cases left to nature,
as a rule, do better than those interfered with.
On the other hand, the great value of surgical interference in those
cases in which suppurative action occurs, or in which septicæmia
develops itself either in acute or chronic form, must not for a moment
be lost sight of. Should the case not progress toward recovery, should
the symptoms of septicæmia develop as a sharp attack or as the
insidious hectic fever, the accumulated blood or pus and blood should
at once be evacuated, and the nidus from which it is discharged be
thoroughly washed out with a 2½ per cent. solution of carbolic acid or
a solution of the bichloride of mercury, 1 to 2000 of water. Should the
accumulation be attainable, tuto, cito, et jucunde, by the vagina, an
exploring-needle should be carried into it, and as soon as the fluid is
seen to flow a sharp-pointed bistoury should be slid along this and a
free opening be made, all the contents of the sac evacuated, and
antiseptic washing be at once practised by means of Davidson's syringe
and a glass tube.
Should the accumulation point toward the abdominal walls, the opening
may with perfect safety be accomplished there. I have operated thus
upon 3 cases, with recovery in all, but the accumulation had at the
time of operation assumed the character rather of an abscess than of an
hæmatocele. A. Martin of Berlin has operated by abdominal section upon
8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden
has done so upon 1 case, with recovery. Zweifel has collected 30 cases
operated upon by free vaginal incision, with a result of 3 deaths,
giving a mortality of 10 per cent. Mere puncture through the vagina he
found followed by a mortality of 15 per cent.
The question of surgical interference in pelvic hæmatocele is still sub
judice. In my judgment, the rule of practice may, with the present
light which we have to guide us, be safely formulated thus: So long as
the symptoms are good and the case progresses toward recovery, avoid
surgical interference of all sorts, however great be the sanguineous
effusion. So soon as symptoms of decided septicæmia or septic
peritonitis develop themselves, evacuate the accumulation by a free
opening practised by the safest outlet which presents itself, and use
antiseptic washings thoroughly.
{245}
FIBROUS TUMORS OF THE UTERUS.
BY WILLIAM H. BYFORD, M.D.
RELATIONS AND STRUCTURE.--These tumors grow from the muscular and
connective tissues of the uterus, and consequently partake of the
character of these tissues. Sometimes the substance of the tumor
consists principally of connective, at others of muscular, tissue. The
variations in the relative proportion of these two fibrous substances
constitute the main differences in the characters and appearances of
the tumors, and lead to the different terms applied to them, as
myomata, fibromata, myo-fibromata, etc. The firmer the tumor the more
connective tissue it contains. When we inspect, either ante- or
post-mortem, a uterus with a fibrous tumor attached or contained within
its wall, it will be found to present a much darker hue than natural.
Instead of the normal light rose-color, it is generally dark, sometimes
almost of a purplish tint. The time of menstruation makes some
difference; just before it is darker than soon after the menstrual
flow. The color also varies with the character and size of the tumor.
In large solid tumors the color is darker than in the large
fibro-cystic variety; indeed, in some of the latter the pearly color
strongly reminds one of an ovarian cyst. We cannot therefore depend on
the color or shape of surface for a diagnosis. Even after the abdominal
cavity is opened the contour of the uterus is usually not regular. If
we make an incision into the tumor, we find that it is surrounded by a
distinct capsule, which limits and defines its boundaries and separates
it from the adjacent substance. This envelope is not a cyst or other
form of membrane: it is continuous with, and inseparable from, the
muscular structure of the uterine walls. It, in fact, is a condensed
layer of the fibrous substance of the uterus. In cases of true encysted
tumors the cyst-wall is the generating portion of the growth. In
fibrous tumors of the uterus the growth produces the capsule by
displacing the surrounding substance in every direction, pressing it
strongly against the unaffected fibrous tissue and condensing it into
the smooth capsule. It is thus engendered in, and enveloped by, the
muscular walls of the uterus. These latter of course grow to dimensions
sufficient to keep pace with the increasing tumor. The growth may, as a
consequence of such a connection, be hulled out or enucleated, and will
not be reproduced. Inflammation or other degenerating processes may
occasionally cause adhesion of the capsule and tumor, but this is an
accident of uncommon occurrence. To understand this mode of
encapsulation we must remember that the uterine muscles are irregularly
stratified, {246} and that the tumors are developed between the strata
as between the leaves of a book, separating them sufficiently to gain
lodgment and room.
The appearances of the substance of the tumor are not uniform. In many
cases the color of the interior of the tumor is dark gray; in some it
is dull red; again, sometimes almost livid. The surface of the tumor
after the capsule has been removed is often marked by sulci denoting a
division into lobules. In other cases the tumor is smooth and
symmetrical in shape, and the fibres distinctly visible to the naked
eye. The smooth tumor is apt to be very dense and comparatively
difficult to destroy, while the lobulated variety is less dense and
sometimes easily broken to pieces. But the difference of density does
not correspond altogether with the color or shape of surface.
We seldom find large tumors of uniform structure. In some places they
are of solid fibrous structure; in others there are cavities of greater
or less size, containing a tenacious red serum. These cavities, which
seem to be made by localized disintegration of the fibrous tissue, are
sometimes of great size, containing several pounds of serum (Atlee).
Much more frequently they are small and hold a small amount of fluid. I
have met with several where the substance of the tumor seemed to be
made up of alveoli filled with a tenacious fluid the color of milk.
Besides this effect upon the density of the tumor resulting from what
might be called its usual course, there are numerous modifications in
it and in the other properties of the tumors arising from spontaneous
degeneration.
It may be said, I think, that without adventitious or supplementary
vascular supply the life of a fibrous tumor is self-limited, and it
ceases to grow after it has attained to a certain size, and that then
it either remains stationary or undergoes degeneration. As I shall have
occasion to say farther on, the original supply of blood-vessels cannot
be increased to an indefinite degree, and the tumor that grows
indefinitely derives a supplementary supply of blood by contracting
adhesions to the viscera or abdominal walls. Such adhesions are common
and mischievous.
After a tumor has attained its growth, degeneration into the more
elementary forms of tissue sets in, as the cartilaginous degeneration,
and there is often a deposition of earthy material found in it which
reduces it to a hard, dense, stationary, and indestructible body. In
such cases there is almost a complete loss of vitality in the tumor,
and it becomes a calcified mass.
We may easily demonstrate that the structure of these tumors is
essentially fibrous. By maceration and careful dissection the fibres
are traceable to a greater or less degree in all of them, the
proportion and characters of which, as before said, differ greatly. In
the smooth, symmetrically-developed tumor the fibres are usually long
and distinctly traceable, while in the lobulated light-gray tumor the
fibres are more rudimentary and not so easily followed up by
dissection.
MODE OF DEVELOPMENT.--It has already been stated that the fibrous tumor
of the uterus grows in or on its wall and originates in the fibrous
structure of the organ. The point of beginning is in one or more
fasciculi of the muscular system or the connective tissue of the
uterus. If in one fasciculus, the point of origin is very minute, as
indeed it is generally at first.
The development consists in an hypertrophy of the bundle of fibres
{247} affected and a deposit of material similar in structure to that
first involved. Sometimes there are numerous nuclei, and nearly all the
fibrous structure of the uterus is involved in fibrous degeneration. In
the case where the deposit is defined and occupies a small space, it
should be borne in mind that the future tumor, however large it
becomes, must occupy the same nidus in which it first originated. The
nidus becomes enlarged sufficiently to accommodate the growing tumor.
The nucleus of development is enlarged by the accretion of substance
similar, if not identical, in character to its own proper material. The
nature of the tumor is determined by this fact, and its fibres are
rudimentary in organization, instead of being hypertrophied and highly
developed, as those of the uterine wall by which it is surrounded. As
the tumor grows the fibrous structure surrounding it is pressed aside
in every direction in such a way as to completely embrace the growth
and encapsulate it. The tumor does not incorporate the adjacent fibres
and grow by inducing degeneration in them, but, as before said, it
presses them aside. As it thus moulds and shapes a bed in the solid
substance of the interior wall, it impresses upon the embracing
muscular fibres an increased vitality, and they grow by hypertrophy of
a character similar to that of pregnancy. The fibres become longer, and
apparently, if not really, more numerous. This hypertrophy of the
uterine fibres surrounding the tumor is equal to the capacity demanded
by the increasing size of the growing tumor. In this description of the
method of development and the embracing capacity of the hypertrophied
fibres surrounding it the reader will trace the formation of the
capsule in which the tumor is contained. The inner surface of the
capsule is smooth, and there are many feeble fibres of connective
tissue seen to connect it with the surface of the tumor. There is no
adhesion proper between the surface of the tumor and its capsule.
I must call attention to another point that governs the extent and
limits of the growth of the tumor--viz. the number and distribution of
its vessels. The vessels entering the tumor represent the minute twigs
that supplied the fasciculus in which it originated. They arrive at the
point of morbid deposit from the parts constituting the capsule, and
there are always several of them. The number of these vessels always
remains the same, and their calibre is increased with the hypertrophy
of the surrounding tissues. They cannot grow at the demand of the
trophic energies of the tumor to an unlimited degree, but their size is
limited by the growth of the surrounding parts. As the tumor grows and
its capsule expands, the vessels are separated farther from each other,
until after a while the area becomes so large that the supply of blood
will not admit of further growth and the tumor comes to a standstill.
Thus their growth, from the nature of their supply, is limited; hence
the usual history of the tumor is one of self-limitation. It is
all-important in forming an opinion in reference to the greater or less
vitality of the fibrous tumor, therefore, to remember that it is not
supplied by one large arterial trunk entering at one place and
spreading over its capsule, but that the supply is by a number of small
vessels penetrating the tumor at different points; that their number
cannot be increased and their growth is limited; that as the tumor
grows their capacity to supply it grows gradually less until entirely
exhausted: then the growth stops.
{248} There is another and adventitious source of nutritious supply,
and I think it is essential to very large growths: at least, so far as
I know, it is always present. I mean the adhesion of the uterus or
tumor to the wall of the abdomen, the pelvic or abdominal viscera, or,
what is more common, the omentum. When adhesions occur from whatever
cause, the vessels of the tumor increase in size and supply it with a
vast increase in the amount of blood. All the large tumors I have had
an opportunity of examining were to a greater or less extent covered by
a network of large vessels contained in the omentum. These vessels
penetrate the uterus, carrying a deluge of blood into its substance.
These large vascular adhesions are a source of embarrassment in
operations for their removal. Operators allude to them and give
instructions how to overcome the difficulty presented by them. The
uterine vessels alone would never be sufficient to supply the forty- or
fifty-pound tumors so often mistaken for ovarian tumors.
EFFECTS UPON THE UTERUS.--I have already said that the fibres
immediately surrounding the growth undergo a true hypertrophy,
acquiring dimension, susceptibility, and capacity similar to the
hypertrophy of gestation. All the fibres of the uterus undergo a
similar change, only less in degree; the more remote from the tumor,
the less marked the hypertrophy. This remark must be modified somewhat
by the consideration of the locality of the tumor. A polypoid tumor
growing from the fundus causes universal hypertrophy of the uterine
fibres. A submucous tumor will usually cause a general hypertrophy of
the uterine fibres, but greater on the side of the tumor. A subserous
tumor is attended by a slight hypertrophy, and in a centrally-located
intramural tumor the hypertrophy would be much like that in the
submucous variety, only less in degree. But this augmentation of tissue
is not confined to the fibrous structure: it extends to the vascular
and nervous apparatus and to the serous and mucous membranes. With this
growth of the tissues comes change in the properties and functions of
the uterus itself. It is more sensitive, the secretions are increased,
and almost parturient contractility is acquired.
But probably as remarkable and uniform a symptom as any arising from
the general hypertrophy is hemorrhage. The mucous membrane of the
uterus is hypertrophied in all its constituents and proportions. The
membrane acquires larger superfices and greater thickness, its glands
are enlarged, and its blood-vessels augmented. Its functions, as a
consequence of these changes, are exaggerated. The glands secrete
greater quantities of mucus, and the vessels when ruptured in the
processes of menstruation pour out a superabundance of blood. Indeed, I
know of no other way to account for the hemorrhages so generally
present in cases of fibrous tumors of the uterus, except upon the
ground that the endometrium, a natural hemorrhagic surface, has its
properties and functions enhanced by a general hypertrophy.
LOCATION OF THE TUMOR.--For the purpose of considering the relation of
these tumors to the different regions of the uterus we may call that
part situated above the entrance of the Fallopian tubes the fundal
zone, and that above the internal os uteri the corporal zone; all below
this the cervical zone. Fibrous tumors may and do originate in all of
these zones or regions, but they spring more frequently from the
corporal {249} than either of the others, and less frequently from the
fundal zone. The part of the corporal zone in which these tumors more
frequently grow is the lower or cervical portion. There is another
important view of the relation of the tumors to the uterus. The
muscular fibres of that organ run in every direction with reference to
the latitude and longitude of the uterine circumference--transversely,
longitudinally, obliquely, spirally, etc. There is probably not much
more definiteness in the layers constituting the walls of the uterus.
If they cannot be completely separated into regular strata, there is
sufficient distinctness in the layers to justify us in employing the
term strata in connection with their arrangement, and this term will
enable us to get a more exact understanding of the language used in the
description of tumors. Authorities differ as to the exact number of
strata to be found in the body of the uterus, but for clinical purposes
it is convenient to describe them as follows: By drawing a line through
the middle of the uterine wall longitudinally we will indicate a
central stratum of fibres. A tumor originating in that line or stratum
is what is usually called an intramural tumor. The number of tumors
growing in this stratum is not very great as compared with those
situated nearer the two surfaces.
[Illustration: FIG. 25. Diagram showing Muscular Strata of Uterus, as
divided for clinical purposes.]
If we run one line between the serous and another between the mucous
membrane and the central line, as in the diagram, other strata with
intervening spaces will be indicated. _a_ would represent the centre
stratum of the wall; _b_, the space immediately outside of that; _c_, a
stratum still farther out; _e_, the subserous; and _d_, a deeper one.
When we look at the inner layers of fibres, we find _f_ situated
immediately beneath the mucous membrane; _g_, farther out; and _h_,
next the median line. The nucleus of a tumor may be first manifested in
any of the strata or spaces marked by these lines, and its position
with reference to the central line will, to a great extent, govern the
direction it takes during development. A tumor the nucleus of which is
situated in line _a_ will, as it develops, press the muscular fibres
equally in every direction, and when large, the prominence caused by
pressure of the tumor would be equal in the uterine cavity and on the
peritoneal surface. In marked contrast to this, when the nucleus is at
_f_ the growing tumor presses the mucous membrane before it until it
becomes pendulous, and then the name of polypus is given to it; or if
the origin is at _e_, the serous membrane is pressed before it, and the
tumor is called subserous. When the nucleus is at _d_, the tumor
elevates the serous membrane and becomes a prominent hemispherical
protuberance. It is also called a subserous tumor, although situated
some distance from the membrane. When a tumor takes its origin at _g_
the mucous membrane is crowded before it, and a marked prominence into
the cavity of the uterus is observed. This is the submucous tumor.
These illustrations are intended to call the attention of the student
to the fact that practically these tumors spring {250} from any one or
all the fibrous strata of the uterus instead of only the central,
submucous, and subserous layers, and that it is profitable, on account
of the difference in their effects upon the shape and functions of the
uterus, to study them in this aspect of their growth.
ETIOLOGY.--While we know many of the conditions under which fibrous
tumors exist, we have really very little, if any, definite and reliable
information as to their causes, either remote or proximate. We know
that they occur much more frequently near the time when the uterus
begins to undergo senile degeneration, although they do originate in
earlier years. They very seldom, if ever, are observed in the foetus or
child, nor is it common for them to commence growing after the
menopause. Women belonging to the African race are the most frequent
subjects of these tumors.