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- 5. Chapter 7 • Challenge Exercise Find the 10 errors in the following article. WELCOMETO ALASKA!! Before traveling to Alaska, you will want to be sure you study the following interesting facts about this state: • Alaska become a state on January 3, 1959. • The Alaska state flower is the Forget-me-not, adopted in 1917. • The Alaska state bird is the Ptarmigan, adopted in 1955. • The Alaska state tree is the Sitka Spruce, adopted in 1962. • The Alaska state fish are the King Salmon, adopted in 1962. • The Alaska state sport is dog mushing, adopted in 1972. The Alaska state flag were selected through a contest held for seventh grade students in 1926. The winning design consist of eight gold stars on a blue field. The stars represented the Big Dipper and the North Star. The Alaska state seal was design in 1910 while Alaska were still a territory and not a state. Alaska was purchase from Russia in 1867 for $7.2 million by Secretary of State William H. Seward. Alaska is well know for having the tallest mountain in North America (Mount McKinley), the most glaciers in the nation (29,000⫹), and the largest state in the union (586,412 square miles). Anchorage is Alaska’s largest city and is locate on Cook Inlet. Thanks to long daylight hours during their summer, the nearby Matanuska Valley raise giant vegetables, such as cabbages the size of basketballs! You will be glad you know something about Alaska before traveling there. Welcome to this important but vital state! Solution a is was was ed ed d d n s
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- 7. Fig. 130.—Diffuse sarcoma of the mucous membrane of the uterus. In the later stages ulceration and disintegration of tissue occur. The cervix is not involved by the disease. The symptoms of this form of sarcoma resemble those of cancer of the fundus. There are hemorrhage, discharge, and pain. The discharge is serous, and is less fetid than in cancer, as ulceration takes place later in the course of the disease. The cervical canal is patulous, and in the polypoid form the tumor may be felt projecting into the cavity of the uterus or protruding from the external os.
- 8. The fundus uteri is enlarged and is tender upon pressure. A positive diagnosis can be made only by microscopic examination of curetted or excised tissue. Sarcoma of the uterine parenchyma, or fibro-sarcoma, or recurrent fibroid, begins in the muscular coat of the uterus. It appears as nodules of various size, which may be interstitial or confined to the muscular coat, submucous or projecting beneath the mucous membrane, or subperitoneal, projecting beneath the peritoneal coat. On section these nodules are pale in appearance and soft in consistency. They are rarely found in the cervix. The submucous form of nodule may become polypoid, project into the cavity of the uterus, and with comparative frequency produce inversion of the uterus. The nodules of sarcoma differ from those of benign fibroid tumors in the fact that they have no capsule. They cannot be enucleated, but are intimately connected with the surrounding uterine tissue. Metastatic nodules occur in the vagina, the peritoneum, and in other parts of the body. In the later stages of the disease the nodules disintegrate and break down. It is probable that fibro-sarcoma usually, if not always, originates in a benign fibroid tumor. In the early stage of the disease the microscopic appearances of fibroid tumor are present, and the transition from the benign to the malignant growth may be studied. Symptoms.—The symptoms of this form of sarcoma resemble at first those of fibroid tumor; they are—hemorrhage in the form of menorrhagia; a serous, non-odorous discharge; and a moderate degree of pain. Later, when ulceration and disintegration take place, the hemorrhage becomes more profuse and continuous. The discharge becomes fetid, and contains broken-down sarcomatous tissue. The pain
- 9. becomes more severe. The uterus is enlarged, and the nodular outline may be determined by palpation. Before metastasis has taken place the differential diagnosis between sarcoma and benign fibroid tumor can be made only by microscopic examination of the discharge or of curetted or excised portions of tissue. The duration of sarcoma of the uterus is about three years. Sarcoma may occur at almost any age. Hysterectomy has been performed for this disease in a girl of thirteen. Several cases have been reported under twenty years of age. The most usual period is about the time of the menopause, in the decade from forty to fifty. The treatment of sarcoma of the uterus is immediate complete hysterectomy. If in the early stage a positive diagnosis cannot be made between benign fibroid and sarcoma, the woman should not be exposed to the dangers of waiting, but the uterus should be immediately removed. Chorio-epithelioma or syncytioma malignum is a rare and peculiar malignant growth of the uterus which occurs after pregnancy. It originates at the placental site from the epithelial cells covering the chorionic villi. It occurs during the course or after the termination of a uterine or tubal pregnancy. In typical cases the disease immediately follows labor at term, abortion, or a destroyed extra-uterine pregnancy. It may, however, remain latent for weeks or months. The tumor may be a nodular or pedunculated outgrowth attached to the uterine wall; a fungoid growth from the endometrium; or an intramural growth covered with endometrium. The tumor varies in size from that of a cherry-stone to a mass several inches in diameter. It is composed of soft fragile spongy tissue, light or dark red in color, infiltrated with blood, and containing circumscribed hemorrhages. Histologically the tumor consists of many types of cells irregularly placed; syncytial tissue, cells derived from Langhans’ layer, and
- 10. sometimes chorionic connective tissue. There are numerous cavities containing blood and connective tissue. Metastatic growths have a similar structure. Metastasis takes place through the vascular system and may reach distant organs—the lungs, liver, and spleen. Symptoms.—There is no characteristic symptom of chorio- epithelioma. The chief symptom is irregular or continuous hemorrhage from the uterus following a labor, an abortion, or an extra-uterine pregnancy. The body of the uterus is enlarged, and the cervical canal dilated as in cancer and sarcoma. A positive diagnosis can be made only by microscopic examination of tissue removed by the curet. Treatment.—As the disease is exceedingly malignant and of rapid growth, immediate hysterectomy is indicated.
- 11. CHAPTER XX. 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
- 12. 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.
- 13. Fig. 131.—Interstitial fibroid tumor of the uterus. A small submucous fibroid appears in the uterine cavity. Fig. 132.—Subperitoneal fibroid tumors of the uterus.
- 14. 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
- 15. 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. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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.
- 20. 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.
- 21. 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
- 22. 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.
- 23. 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
- 24. 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
- 25. 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.
- 26. 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.
- 27. 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
- 28. 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
- 29. 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
- 30. 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.
- 31. 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
- 32. 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
- 33. 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.
- 34. 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.
- 35. 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
- 36. 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.
- 37. 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
- 38. 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.
- 39. 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
- 40. 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.
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