CHAPTER XV THE DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS (Part 1)

CHAPTER XV THE DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS Definition, p. 244. Pathology, p. 244. Classification, p. 245. Situation, p. 248. Frequency, p. 248. Etiology, p. 250. Course and Develop- ment, p. 251. Degenerations, p. 252. Complications, p. 255. Effect on neighboring organs, p. 257. Effect on distant organs, and on the system, p. 258. Relation of fibroid tumors to heart disease, p. 259. Dangerous to life, p. 260. Symptoms, p. 260. Symptoms of adenomyoma, p. 262. Diagnosis and differential diagnosis, p. 262. Subserous fibroids, p. 262. Intraligamentous fibroids, p. 263. Interstitial fibroids, p. 263. Submucous fibroids, p. 264. DEFINITION Fibroid tumor, also called myoma, fibromyoma or fibroma of the uterus, is a nodular growth developing from some portion of the uterus, usually, but not always, above the cervix, varying in size from a minute speck to a mass or masses filling the pelvic and abdominal cavities. PATHOLOGY The largest fibroid which I have found recorded was one re- moved at autopsy from a single woman fifty-three years of age by S. H. Hunt of Long Branch, N. J. (Amer. Jour. Obstet., 1888, XXL, p. 62.) It weighed one hundred and forty pounds and the cadaver after the removal of the tumor weighed ninety- five pounds. The tumors are generally round in shape, with smooth surface, but may be pear-shaped, kidney-shaped, mulberry-shaped; may be molds of the pelvic cavity, or, very rarely, may resemble a fetus. They are single or multiple, as many as one hundred and fifty tumors having been found in the uterus by Bland-Sutton. (Brit. Med. Jour., April 6, 1901.) They are of a hard consistence, though a predominance of muscular tissue in their structure, or degenerative changes, may render them softer. They are classed 244 CLASSIFICATION 245 as benign tumors because they do not "eat up" the surrounding tissues by extending into their substance, and they do not cause destruction by metastases. They are composed of the same tissues as the uterus, namely, unstriped muscle fibers and connective tissue. On section a fibroid tumor is of a glistening white, or whitish-yellow color and is seen to be made up of a disorderly intertwining of muscular and connective-tissue fibers. In the Larger masses, however, these are grouped in more or less well-defined whorls (see Fig. 106) which somewhat resemble knots in a piece of wood. Between the groups of fibers run arteries, veins, and lymph channels derived from the normal vessels of the uterus, ramifying at first beneath the capsule of the tumor and then plunging directly into its interior. As a rule these tumors are poorly nourished because they derive their blood from the sur- rounding constricted uterine tissue. Occasionally they are sup- plied by large vessels through adhesions to surrounding organs. CLASSIFICATION Fibroid tumors may be classified according to their situation with reference to the uterus. They are — 1. Subserous, (a) Intraligamentous. (b) Tumors of the cervix. 2. Interstitial. 3. Submucous. They are described further by defining their number and size, and by noting any special kind, as adenomyoma. For instance, in Fig. 102 we see a specimen of a multiple fibroid uterus: an interstitial fibroid of the anterior uterine wall, a subserous fibroid springing from the fundus uteri, and an interstitial tumor of the posterior wall. All fibroids originate in the uterine muscle, there- fore all are interstitial in the beginning. It' the tumor develops in the outer wall of the uterus and grows from the uterus under the peritoneum, it is called an adenomyoma. Adenomyoma is a special variety of myoma characterized by the presence of glands similar to those found in the uterine mucosa. Thomas S. Cullen ("Adenomyoma of the Uterus" L908) found 246 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 73 cases of adenomyoma among 1283 cases of myoma examined microscopically in the Johns Hopkins Hospital Surgical-Patho- logical Laboratory during thirteen years, or 5.7 per cent of all fibroids. These tumors are diffuse and may or may not be definitely encapsulated. 1. Subserous Fibroid Tumor. — Such tumors have the greater part of their periphery outside the uterine wall and have no considerable covering of uterine tissue. (See Fig. 102, upper tumor.) The Fig. 102.— Multiple Fibroids, One Subserous and Two Interstitial. (Winter.) greater the size of the subserous tumor the more it is separated from the uterus, as a rule. It may be relatively small or large. If, instead of developing under the serosa, the tumor separates the folds of the broad ligament and distorts the viscera to a greater or less degree, it is called an (a) Intraligamentous Fibroid Tumor. (See Fig. 105.)— These tumors have the greater part of their circumference outside the uterus and are not covered by uterine tissue. Noble (" Gynecology and Abdominal Surgery/' II. A. Kelly and 0. P. Noble, 1907, p. 669) CLASSIFICATION 247 found this form of tumor in 3.5 per cent of the 2,274 cases of fibroid tumor he studied. The same characteristics belong to (b) Tumors which originate in the lower posterior segment of the uterus and grow into the cervix and then into the posterior pelvis, or those rare tumors which originate in the cervix itself and de- velop away from the uterus. (See Fig. 108.) The cervix, to be sure, has no covering of peritoneum. As the tumor incn in size and rises in the pelvis it pushes the peritoneum before it. Therefore, this class of tumors may be included among the sub- Fig. 103. — Large Multinodular Subperitoneal Fibroid with Thin Abdominal Walls. Seen in Profile. (Kelly.) serous. In subserous fibroids the uterine cavity is altered little if at all in length or shape. 2. Interstitial (intramural, intraparietal) fibroid tumors are those which arc situated in the wall of the uterus and are surrounded by a covering of uterine musculature. (See Figs. L02 and 101. > They may or they may not alter the contour of the uterus. The uterine cavity is almost always lengthened, and it may be broad- ened and made asymmetrical in shape by this form of tumor. 3. Submucous Fibroid Tumors. These are the tumors which velop into the uterine cavity and are covered with mucous mem- brane and with little, if any, of the uterine musculature. Figs. 104 and 100.) Of all the three varieties these cause the greatest changes in the form of the uterine cavity. Tin-' are 248 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS the bleeding fibroids. The pressure exerted by the tumor on the nervous mechanism of the uterus sets up reflex uterine con- tractions producing a gradual delivery of the tumor. At first the tumor becomes pedunculated; then the pedicle is elongated until the inter- nal os has been dilated. Finally, in favorable cases, the tumor is delivered. More often necrosis of the tumor sets in before the delivery is accomplished, and we have a Sloughing Fibroid. A pedunculated submucous fibroid, if of small size, is called a fibroid polyp (see Fig. 107), and is to be dis- tinguished from a mucous polyp, one of the manifestations of glandular endo- metritis. In all forms of fibroids, more especially in the submucous and the in- terstitial, the mucous membrane of the corpus uteri may show evidences of glandular and interstitial endometritis. Kelly and Cullen ("Myomata of the Uterus") state that the mucous membrane of the uterine cavity is generally normal, but that cervical endometritis is relatively frequent when a sloughing submucous myoma exists, otherwise it is rare even if there be present evidences of an old inflamma- tory process in the ovaries and tubes. Therefore they point out that the surgeon may open the uterine cavity with impunity in the absence of vaginal discharge and signs of tubal disease. Fig. 104. — Interstitial and Submucous Fibroids. SITUATION Fibroid tumors always originate in the substance of the uterine wall. They almost always develop in the body rather than in the neck of the uterus, and they are more commonly found in the posterior than in the anterior or lateral walls. FREQUENCY Fibroid tumors are the most prevalent of all neoplasms affecting the uterus. As regards their frequency among women, most FREQUENCY 249 authors quote Bayle (S. H. Bayle, "Diet." on 60 vol., Paris, 1813, t. VII., p. 73) who stated as long ago as 1813 that 20 per cent of all women over thirty-five years of age have fibroids; but as other authors have arrived at different results (Klob, for instance, assert- ing that 40 per cent of the uteri of women who die after the fiftieth year contain fibroid tumors), and as Bayle' s opinion has not been confirmed, we may state that the exact frequency of the tumors is yet to be determined. They are met with mostly during the period of sexual maturity, between the ages of thirty and fifty years, being rare before twenty and after fifty-five. Gusserow, out of 919 cases of fibroids, found only 15 under twenty years of age and only 17 over Le/f tube. Left ovary ~Righlfoyarij Fig. 105. — Diagram Showing an Intraligamentous Fibroid. sixty years of age. The highest percentage, 38. 8, was between the ages of thirty and forty, and the next highest, 36.7, was between forty and fifty. Fibroids are undoubtedly very frequenl in the negro race. The autopsy statistics of the Johns Hopkins Hospital show, according to Kelly and Cullen ("Myomata of the Uterus," 1909), that out of 742 autopsies on white and black women, over twenty years of age, 20 per cent bad fibroids in their uteri, and oi these, 33.7 per cent of the black women had uterine myomata, and 10 per cent of the white women were affected in this way. I' « not yet determined whether fibroids are more common among the 250 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS single than the married. Bayle and other authors thought that they were, while Gusserow, Dupuytren, West, and others, hold that they are not. ETIOLOGY The causation of these tumors is even now unknown, although the problem has been studied assiduously by many noted investi- Fig. 106. — Large Submucous Fibroid showing Distortion of the Uterine Cavity. (Kelly.) gators during the last fifty years, and many hypotheses have been advanced, but so far none has been proved correct. An ingenious theory is that advanced by A. Claisse (These de Paris, 1900). He thinks they are due to infection of the uterine mucosa; subacute inflammatory lesions of the mucosa, especially about the little blood-vessels of the muscular wall, causing proliferation of round cells, which are transformed into fibrous tissue. Heredity has been supposed to play a part in the causation of fibroids; Hofmeier, Veit, Klein waehter, and others considering it a predisposing cause. It is doubtful whether this assumption is well founded, however, and we must regard the occurrence of fibroid tumors in members COURSE AND DEVELOPMENT 251 of the same family — a not uncommon happening — as coincidences rather than examples of heredity. Sexual irritation, such as masturbation or abnormal sexual practices, has been assigned as a cause of myoma by Veit. While the chronic congestion which is due to undue irritation of the genital organs may assist the growth of a fibroid, it is difficult to see how it could originate one. It is probable that man}' fibroids are of congenital origin, perhaps due to a fetal misplacement of tissue according to Colmheim's theory, but, as already stated, this has not been proved. The tumors do not attain any con- siderable size until the late child-bearing period* therefore age must be considered a factor in the etiology. COURSE AND DEVELOPMENT The development of a fibroid is a slow affair, generally a matter of years. H. A. Kelly has cited a case which was under medical observation for twenty-five years before operation and two years after. (" Operative Gynecology," 1907, Vol. II, p. 347.) A large interstitial tumor, with a uterine cavity measuring eight or nine inches, became larger and subperitoneal and pedunculated so that at operation it was found attached to a small uterus by a pedicle 1 centimeter long and 3 centimeters broad. It weighed 59 pounds. I have spoken of the direction of the growth in describing the different kinds of tumors. Upon the course taken by the tumor in its growth depends often its subsequent fate. For instance. if it grows subserous it may become pedunculated and in lime may be separated entirely from the uterus, receiving its nourish- ment through adhesions to surrounding structures. Such cases are rare, but are met with occasionally. If, on the other hand, the tumor grows toward the uterine cavity, it is apt to be extruded through the external os. In either case the blood supply to the tumor is interfered with and there 18 a tendency to necrosis and degenerative changes. If the tumor remains in the substance oi the uterus, as in the ease of an interstitial fibroid, its nourishment is established on a surer footing. It is possible for all tumors and for small tumors especially, to remain in a quiescenl state for an indefinite period. Bland-Sutton ("Tumours Ennocenl and Malig- nant," 4th Edition, 1900, p. 1ST: calls attention to the latent seedling 252 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS fibroids, in regard to which he says: "If a number of uteri be ex- amined from women between the twenty-fifth and fiftieth years by the simple means of sectioning them with a knife, in a large propor- tion of these uteri a number of small rounded fibroids, resembling knots in wood, will appear, their whiteness being in strong contrast with the redness of the surrounding muscle tissue. These discrete bodies, in many instances no larger than mustard seeds, are in histologic structure identical with the fully grown tumours." Fig. 107. — Pedunculated Fibroid Originating in the Cervix that has been Expelled into the Vagina. (After Auvad.) When removing fibroids by operation one can never be sure that all tumors have been removed; therefore, a patient can not be assured that the fibroids will not grow. On the other hand, tumors may increase rapidly in size. Soft tumors grow faster than hard ones, as a rule. Fibroid tumors grow during pregnancy and diminish in size markedly after delivery. They increase in size just before each menstrual period and diminish after the flow has ceased. In many instances they lessen in size after the meno- pause, but not always. All these facts must be kept in mind when examining a patient at different times to determine the relative bulk of a tumor. DEGENERATIONS There are certain alterations of structure occurring in fibroids, the causes of which we do not know, except that sometimes they can be explained by the presence of arteriosclerosis and a diminished blood supply. Degenerations in fibroids are observed frequently following pregnancy. An increased formation of fibrous and hya- DEGENERATIONS 253 line tissue occurs in practically all myomata and, when the pn is extensive, necrosis of the center occurs, with a resulting cyst cavity with walls of irregular outline. Softening of a fibroid tumor may be due to several causes. Among them we may enumerate hyaline, colloid, and fatty de- generation. Hyaline degeneration was noted in 3.1 per cent of 2,274 cases of fibroid tumors collected by Noble from the literature ("Gynecol- ogy and Abdominal Surgery," H. A. Kelly and C. P. Noble, 1907, p. 669). Often these tumors become progressively indurated, especially after the menopause. Colloid or Myxomatous Degeneration. — This is characterized by the effusion of mucous material between the muscle bundles, the mucin and proliferation of round cells in the interstitial tissue distinguishing it from edema. Noble found myxomatous degen- eration in 3.4 per cent of his 2,274 cases. Small, hard tumors are found at autopsies on old women, their presence not having been detected during life. Fibro-cystic Tumors. — These tumors result from the breaking down and liquefaction of areas of degeneration in fibroids and the fusion of different foci by the absorption of the dividing partitions. The degenerated areas are separated, not by distinct walls, but by portions of the fibrous structure of the tumor. These tumors are not, as formerly thought, a separate class of tumors. Doleris (Archiv. de tocologie, janv. et fev., 1883, pp. 1 and 364 . noted a proliferation of connective tissue becoming colloid in a fibroid tumor during pregnancy. After delivery it is supposed that the diminution in the size of a fibroid is due to fatty degen- eration. Calcification. — This is rather a rare transformation which Noble (loc. cit.) found in 1.7 per cent of his cases. Deposits of phos- phate and carbonate of lime are found near the periphery of the center of the tumor and make either a- bony framework net true bone, however— or a shell. Rarely is the tumor solidified to make the so-called "uterine stone." Small areas of calcification are not uncommon. Fatty Degeneration. Gusserow ("Die Neubildungen d rus," 1886) has called attention to the fact thai fatty degeneration of a fibroid tumor has been determined microscopically in only three 254 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS cases — those of Freuncl, A. Martin, and Brunings — where there has not been resulting diminution in the size of the tumor as well. There is a form of fibroid tumor called lipomyoma in which a por- tion of the tumor is composed of fatty tissue. Edema. — Edema is often present in fibroids and may be con- sidered a beginning stage of necrosis. It most often affects the subserous tumors. Amyloid Degeneration. — A single case of amyloid degeneration Fig. 108. — Fibroid of the Cervix Distending the Vagina. (After Dartigues.) of a fibroid polypus has been observed by Stratz. (Zeit. f. Geburts. u. Gyn., 1889, Bd. XVII., H. 1, p. 80.) Suppuration. — This is the result of the infection of the tumor with bacteria derived from the intestinal canal, the genital tract, or the blood. Prolonged pressure of a tumor on the bowel, or an appendix