predisposing to these tumors. We do not know what physiological or
pathological states of the uterus or other organs predispose to them.
There is probably no tumor in the body strictly analogous in structure,
mode of origin, supply, or development to the fibroid tumor of the
uterus. There is no other organ in the body that undergoes analogous
normal trophic changes. The vast multiplication of tissue that takes
place in the uterus during gestation, and the more rapid but equally
great changes toward degeneration or atrophy, would naturally suggest
pathological possibilities of a peculiar nature. The rhythmical changes
of menstruation are like no other functional condition. They too
involve the processes of hypertrophy and atrophy. When the menstrual
and generative changes are normal every part of the body of the uterus
is simultaneously and proportionately hypertrophied and atrophied.
Local derangements of these processes of hypertrophy and degeneration
must sometimes occur, probably from defective or excessive innervation
of loculi in the fibrous structure. Congestion or hyperæmia may thus
result, and consequently very great influence be exerted upon the
nutrition of the parts concerned after the deposit has begun; its
presence increases the hyperæmia and thus perpetuates its growth
indefinitely.
CLINICAL HISTORY.--Probably the earliest, most frequent, and constant
symptoms connected with fibrous tumors of the uterus are hemorrhage and
leucorrhoea. They are both the result of active or arterial hyperæmia,
and doubtless come from the endometrium. Polypi, submucous, and
intramural tumors are more likely to give rise to these two symptoms.
The nearer the mucous membrane, and the greater that membrane is
expanded, the greater the amount of hemorrhage and leucorrhoea, and, as
a counter-fact, the nearer the serous membrane, the less the amount of
these two discharges. While this statement in reference to the effects
of the proximity of the tumor to the two membranes is usually true, it
is not always so.
Hemorrhage is sometimes not very great, but at others it is appalling,
and constitutes an imperative reason for the employment of desperate
remedies. The hemorrhage is usually first noticed in connection with
the menstrual flow, and it may even be confined to the periods:
sometimes it extends over the whole of the interval. The leucorrhoea is
generally constant, and sometimes thin and watery, especially after the
hemorrhagic paroxysm has subsided, and at others it is constituted
{251} mainly of mucus with the débris of the mucous membrane and
blood-corpuscles.
Other symptoms are pelvic pressure, vesical and rectal, with tenesmus,
distension, and dysmenorrhoea. The pelvic pressure and tenesmus are
observed early in the development of the growth, and may be relieved as
the tumor becomes large enough to rise out of the pelvic cavity. The
abdominal distension of course comes later. Solid tumors do not often
attain to such a size as to cause great abdominal distension. The
fibro-cystic generally are inconvenient, if not fatal, from this cause.
The above are the more direct and common symptoms. A less frequent yet
important effect and symptom is oedema of the lower extremities from
pressure upon the venous trunk passing through the pelvis. In rare
cases this symptom is aggravated to a degree constituting phlegmasia
alba dolens. As the tumor rises and enlarges the pressure may embarrass
or interrupt the function of any or all the abdominal viscera.
In many cases none of these symptoms present themselves to an
inconvenient degree, and the tumor is discovered by accident. Again, we
meet with cases in which the symptoms are formidable for a time, and
then entirely subside, leaving the patient free from suffering the
balance of her lifetime. While this subsidence may take place at any
time during the growth of the tumor, it is very apt to take place at
the menopause.
The clinical history of the fibrous tumor may be very much modified by
the intervention of various circumstances. As organized bodies they are
subject to those affecting the organs of the body. We must regard them
as adventitious growths acted upon by organs in a state of disease and
reacting in turn upon them. They may become inflamed, undergo
suppuration and gangrene, and produce symptomatic fever, hectic fever,
prostration, gastric, hepatic, and nervous derangement in a degree
sufficient to prove fatal.
When situated near the mucous membrane, nature sometimes turns these
organic changes into a means of cure by destroying the portions of the
capsule near the uterine cavity and permitting the pus or gangrenous
material to escape. They are also subject to pressure from the
development of other tumors, and either disappear, become inflamed and
adherent, or cause great trouble to adjacent organs. Their clinical
history is sometimes modified by complication with pregnancy.
This complication is rare, because the uterus in most cases, on account
of the effects produced upon its circulation, nerve-supply, and mucous
membrane especially, will not retain the ovum, and conception does not
take place. The uterus being more vascular, and subject to congestions
that affect the placental attachment injuriously, miscarriages are
likely to occur. It is also morbidly sensitive to the pressure of the
ovum, while the mucous membrane is rendered incapable of decidual
changes. The retentive power of the uterus is further interfered with
from the irregularity of its growth: the fibres where the tumor exists,
being under a morbid influence, cannot partake of the regular
hypertrophy necessary to normal gestation. There is something of
uniformity in the circumstances under which the coexistence of
pregnancy and fibrous tumor is observed. The nearer the tumor is
situated to the mucous membrane, the less likelihood of pregnancy--the
more remote, the greater the tolerance of pregnancy. Tumors that occupy
the wall of the corporal portion {252} are conducive of sterility.
Those in the cervical portion of the corporal and the cervical zone are
more likely to be accompanied with pregnancy than those situated in
other parts of the organ. While the reader will find these statements
borne out by his experience as general facts, he will also discover
that pregnancy is occasionally compatible with almost any form,
variety, or position of tumor. When this complication occurs, it does
not generally influence the process of gestation or the condition of
the tumor. The main symptoms depending on it are those caused by
pressure. When small this is not very considerable.
Complication with labor generally gives rise to more apprehension than
difficulty. Most of the cases of labor terminate spontaneously and
happily, and the others are generally within reach of the less
destructive modes of delivery. Labor more frequently decidedly affects
the growth of the tumor, in the majority of cases causing its
disappearance during the process of involution. The cervical polypi
affect labor less, and are less affected by labor, than any other
variety of the tumor. If small, they are sometimes merely pressed to
one side or into the hollow of the sacrum, and the head passes by them;
if a polypus is large, the head of the foetus carries it before it
beyond the vulva, where it remains until the child is expelled, when it
may recede into the vagina.
DIAGNOSIS.--The history usually includes hypersecretion, hemorrhage,
pressure, and enlargement. These, while suggestive, are not conclusive,
hence physical examination becomes indispensable to accuracy. The
methods of examination vary with the size of the tumor. It is generally
near the truth to say that the uterus is enlarged, and may be shown to
be so by the introduction of the sound; yet the cavity is not always
enlarged, and it is often so tortuous that the ordinary sound may be
arrested before reaching the fundus. The sound, therefore, should in
such condition be flexible. The fine whalebone or the sound of Jenks
will generally pass obstructions caused by tortuosities. The most
skilled and dexterous use of the inflexible sound is often delusive. We
may generally determine the size by bimanual examination--one finger in
the vagina or rectum while the hand is passed down into the pelvis from
above. The uterus of normal size cannot be felt with any distinctness
from above in this way, while an enlargement of 50 per cent. may be
thus determined. The finger below will sometimes recognize the pressure
from above when the upper hand will not feel the fundus distinctly.
Small tumors of the uterus may be mistaken for many other conditions,
and the converse. If one is situated in the posterior wall, it may be
mistaken for retroflexion. We may make the distinction by means of the
inflexible sound and the finger in the rectum. If the case is one of
retroversion, the finger in the rectum will pass behind it and overlap
it above. If a retro-uterine tumor is in the cul-de-sac, the finger
will not reach above the uterus. If the case is one of retroflexion, a
strongly bent sound may be made to enter it, especially if the fundus
is slightly raised by the finger in the rectum. If there is a tumor in
the posterior wall, the sound with slight flexion will pass above it;
which is clearly ascertained by the finger in the rectum. When the
sound is introduced in the case of retroflexion, the fundus may be
elevated to its proper position by turning the sound upon its axis. In
making these examinations with the sound the finger should be made to
co-operate with it by being kept in {253} the rectum. A small tumor in
the anterior wall may be distinguished from anteflexion by the sound
passing upward instead of forward, or into the part lying on the
bladder. When a small tumor is intra-uterine, the uterus will occupy
its natural position, with the mouth directed slightly backward; and if
the polypus is large, the cervix can be moved forward with considerable
difficulty. A flexible sound, especially the thin whalebone, may
sometimes be made to partially or wholly surround it, and its size or
connections be determined. But the diagnosis may be more definitely
made out by dilating the cervical cavity and introducing the finger.
The difference between a polypus and an intramural submucous tumor may
be determined in this way. In the case of a polypus the finger will
pass around it, while if the tumor is intramural or submucous the
finger will be arrested at the point of attachment. A polypus or
intramural submucous tumor presenting at the os externum may sometimes
be mistaken for a partial inversion. Such a mistake may be prevented by
using the sound. In the case of a tumor the flexible sound will pass to
more than the normal depth. In one of inversion the sound will pass
very much less or not at all. When a polypus has escaped from the mouth
of the uterus and occupies the vagina, the sound will pass beyond it
into the enlarged uterus, whereas in complete inversion it cannot be
passed into the uterus in any direction. We cannot rely upon
consistence or shape as marks of distinction in these two conditions.
When the tumor rises above the pelvic brim and is not very large it
generally displaces the os from its normal position. If in the front
wall, the os will be too far back; if in the posterior, it will be
displaced forward. In the former, when a sound is introduced, it will
pass backward and upward; in the latter, the sound will pass forward
and upward. In both cases the bimanual examination will enable us to
determine that the tumor above the pelvis is continuous with or
attached to the uterus. With the hands in this position, if we move the
uterus the tumor will move with it, and vice versâ. Tumors of this size
are usually more or less uneven in their outline, and of greater
consistence than the uterus when enlarged from other causes. Tumors of
this size may be generally distinguished from the pregnant uterus by
the history of pregnancy, by the consistence, and by the size of the
cervix. When pregnancy and a tumor are associated, this may be
determined by a part of the enlargement being very hard and other parts
quite elastic, and by auscultation. I need not caution the reader
against the use of the sound where there is any suspicion of pregnancy.
When a doubt exists, we should await the progress of the case until
pregnancy becomes obvious. We may generally determine whether a tumor
is uninuclear by the fact that a single tumor is nearly round, when if
there are several points of origin it will be irregular and nodular.
When the tumor is large enough to nearly or quite fill up the abdominal
cavity, the flexible sound may be made to pass a great distance into
it. It is not often that a solid tumor grows large enough to fill the
abdominal cavity. Before it grows to such dimensions it generally
undergoes cystic degeneration. When the tumor is solid, generally its
very great hardness, and often its irregular shape, will distinguish it
from other abdominal tumors. The condition with which I have seen these
tumors most frequently confounded is enlargement of the liver or
spleen. {254} In the South and West an enormously enlarged spleen is
not infrequently met with. It sometimes spreads over the whole anterior
part of the abdomen, completely covering the intestines. Less
frequently the liver is found similarly enlarged. In this condition the
organ becomes greatly indurated, and sometimes nodular. The
distinguishing features of these enlargements are--first, that the
abdomen does not present the prominent rotundity it does when filled by
a growth; second, that somewhere in the extent of abdominal surface by
careful manipulation the edge may be discovered and the fingers be made
to sink beneath and grasp it; third, percussion will elicit general
deep resonance, in some parts quite obvious, and in others less so. In
the case of tumor none of these signs will be present. Again, the
enlarged liver or spleen, while it may reach to the brim of the pelvis,
does not reach into that cavity far enough to be recognized by the
finger in the vagina, while the tumor does.
Sometimes inflammatory effusions form indurated masses in the abdomen
that are mistaken for fibrous tumors. These of course have the history
of inflammation, are generally if not always tender, and yield obvious
intestinal resonance upon percussion. The large fibro-cystic tumor may
be mistaken for pregnancy, ovarian tumor, cystic degeneration of the
kidney, and omental tumors. Pregnancy can generally be established by
absence of the menses, by the shape, size, consistency, and position of
the cervix, together with auscultation. It may be said that in case of
fibro-cystic tumor the cervix is greatly displaced in some direction,
indurated, and not enlarged. In pregnancy none of these conditions
prevail.
The fluctuation of the fibro-cystic tumor is more obscure than that of
the ovarian tumor, and, although sometimes noticeable over a large
space, it is usually more constricted in extent. There is also usually
less regularity in the shape of it. In large ovarian tumors the uterine
cervix is not changed in shape and size. The whole organ generally lies
beneath the tumor, and the elastic sound will not pass very deeply into
the cavity. If the uterus is attached to the anterior part of the
tumor, which sometimes happens, the elastic sound will pass into it and
the depth will not be very great. The fibro-cystic tumor may be
distinguished from the enlarged encysted kidney by the facts that the
kidney is traceable to one side more than the other, and it cannot be
reached by the finger through the vagina or rectum. Still, if we cannot
make the differentiation clear in any other way, we can generally do so
by aspiration. In most cases we cannot draw the fluid from the
fibro-cystic uterine tumor; in almost all cases the quantity removable
in that way is small. When fluid is drawn, it usually coagulates,
contains hæmatin, and none of the cells so generally found in ovarian
tumors.
The fluid drawn from the kidneys presents epithelial cells, is not
coagulable, certainly does not coagulate spontaneously. The abdominal
cavity is sometimes more or less filled with peritoneal serum. After
this is withdrawn from the peritoneal cavity the uterine attachment of
the tumor may be made out by bimanual examination, as above directed,
if undertaken immediately after the evacuation.
PROGNOSIS.--Less than twenty years ago the general prognosis to be made
upon the discovery of a tumor of the uterus was very grave. The
profession knew so little about the clinical history and diagnosis of
these {255} tumors that they were invested with many of the bad
qualities of other tumors, with which they were so often confounded;
and we had so little knowledge of their nature and the measures which
would influence their growth that we felt an entire helplessness in the
treatment of them. Fortunately, there have been many favorable changes
in these respects. We understand their clinical history better, and can
make a pretty clear diagnosis. We know that relatively few of them
prove fatal even when left wholly to nature. Compared to all other
uterine and ovarian growths, they are innocuous. Most of them are
self-limited in consequence of the mode of blood-supply. A goodly
number not only stop growing, but disappear without the application of
any remedial measures. Then, as I shall have occasion to show, they may
be often cured by the judicious administration of medicines, and the
surgery for their extirpation has become a reliable resort in extreme
cases. These considerations render the general prognosis of the true
fibrous tumor quite hopeful. The menopause generally starves them out,
and thus removes all the bad qualities they may possess.
When they lead to fatal results, they generally do so through three
different conditions--viz. hemorrhage, pressure, and complicating
inflammations--and probably in the order mentioned. Hemorrhage is by
far the most fatal symptom. The kind of fibrous tumor accompanied with
severe hemorrhage is usually the submucous variety. The submucous tumor
with a broad base is the most mischievous, because it induces great
hypertrophy in the vascular system of the mucous membrane especially,
and also the vessels of the whole organ. A sessile submucous tumor
arising from one nucleus is worse than one in the same situation with
several nuclei of origin. The intracorporal polypus or pendulous tumor
is almost as bad in this respect as the sessile submucous, especially
if it originates at or near the fundus. Fortunately, these forms of the
tumor are more amenable to the effects of medicine and more accessible
to surgical treatment. The tumors located in the central stratum of
fibres are next to these in mischievous qualities. The more remote the
tumor is located from the mucous membrane, the less hemorrhage will
attend its development.
When the tumor becomes cystic the danger from pressure is very much
greater; yet the solid form becomes sometimes so large as to do much
mischief from pressure upon the abdominal organs; and any of these,
except perhaps the polypoid variety, may be so situated as to cause
mischievous if not fatal pressure upon the pelvic organs.
It is rare, however, that the pressure in either of these cavities
proves fatal, especially when the case is under intelligent management.
The supervention of inflammation in the tumor, even to a moderate
degree, is very apt to lead to gangrene and death from peritonitis,
shock, or septicæmia. Sometimes subacute inflammation of the peritoneal
surface of the tumor gives rise to serous effusion or dropsy in the
abdominal cavity that proves fatal; and, as before stated, peritonitis
sometimes causes adhesions which result in augmented vascularity and
consequent increase of blood-supply. This condition, I believe, often
changes a solid to a fibro-cystic growth, a more highly vitalized
tumor, and consequently a more mischievous one.
Do these tumors ever become sarcomatous or malignant? I do not {256}
believe they have any innate tendency of that kind. Where they are
found complicated with malignant growths I believe the malignancy is an
independent quality, and is an invasion resulting from some cause
extraneous to its organization, and in that respect is analogous to an
attack on the cervix or other portions of the uterus.
The prognosis when complicated with pregnancy is of course more grave,
but experience has demonstrated the practicability of complete and
normal gestation. Conception will not often occur where these growths
have attained any great size, but may sometimes. Of the nine cases
which I have met and had an opportunity to follow, not one has been
attended with abortion or premature labor. In one the pregnancy seems
to have been protracted at least four weeks. The foetus was in a state
of decomposition, and had probably been dead four or five weeks before
labor began. What is not less remarkable also is that labor did not
seem to be seriously affected in but one case, and in that the
difficulty was easily overcome by turning.
Until lately there were several supposititious sources of danger at the
time of confinement--viz. inefficient uterine contractions, and
consequent tedious or impracticable labor, and after expulsion or
artificial removal of the foetus dangerous hemorrhages from the same
cause; also, the possibility of the placental connection being made at
the site of the tumor, with the imperfect closure of the sinuses that
was supposed to follow.
Reports of cases occurring within the last few years, while they have
not completely swept away the grounds for such apprehensions, prove
that the accidents so greatly feared do not in fact occur. Chadwick
reports a case where the placenta was attached to the mucous membrane
over the tumor, yet the placenta was spontaneously expelled and there
was no considerable hemorrhage. The efficiency of the expulsive efforts
were not materially affected in any of the cases I have attended. And
this is what we might expect, because conception and gestation would
not be perfect where there is not a sufficiency of healthy mucous
membrane, upon which a normal decidua could be formed, and of fibrous
structure to permit the hypertrophy of gestation.
The apprehension of obstruction from the tumor lying in such a position
as to intercept the expulsion of the foetus is not often realized; for
those in the cervix, either pendulous or otherwise, are pressed out of
the external parts in advance of the head, while those in the body and
fundus are lifted up into the abdominal cavity, where there is plenty
of room. It must indeed be rare that the tumor becomes impacted in the
pelvis so as to interfere with the passage of the foetus.
Neither does the puerperal condition seem to be rendered materially
more dangerous in consequence of the presence of these tumors.
What effect does pregnancy have upon the growth of these tumors? It
might be supposed, from the plentiful supply of blood afforded them by
the growth of the vascular system of the uterus, and from the fact of
their being situated in and surrounded by tissues in a state of active
hypertrophy, that the tumors would grow in a corresponding degree with
the uterus itself; but this is not generally, if it is ever, the case.
I have not witnessed a decided increase in the size of the tumor in any
of my cases. Pregnancy usually produces the opposite effect; and this
can be easily understood when we remember that the tumor is subjected
to great {257} and uniform pressure, which prevents its own circulation
from becoming as great as it otherwise would be; and I think this
pressure often inaugurates a retromorphosis that results in the final
disappearance of the tumor. Whether degeneration begins during
pregnancy or not, the tumor is very apt to disappear after pregnancy
and labor. In six of my own cases the tumor disappeared by a slow
process of some kind after labor. Speculating as to what might be,
another apprehension of danger arises out of the tumultuous excitement
and terrible pressure to which it is subjected during the throes of
parturition. But this apprehension is rarely if ever realized.