A Text-book of Diseases of Women

by Charles B. Penrose

The effect of fibroid tumors of large size upon the heart and blood-vessels has been remarked by several writers. Fatty degeneration and brown atrophy have been found associated with uterine fibroids in a number of instances. This is undoubtedly the explanation of some cases of death after operation.

Martin has called attention to the disposition to thrombosis and embolism which seems to be especially marked in the telangiectatic form of tumor. This also explains some of the cases of sudden death that occur after operation. Operators have observed cases of sudden death, probably from embolism, occurring sometimes several weeks after hysterectomy for fibroid tumor.

The diagnosis of uterine fibroids is made from a study of the symptoms already described and from the physical examination.

If the tumor is large enough to be palpated through the abdominal wall, the hard consistency and the irregular bossed outline of the multinodular form of fibroid may be detected.

By bimanual examination we determine the general enlargement, and perhaps the irregular outline, of the uterus. Sometimes, when the fibroid is small and interstitial, a slight elevation, or perhaps merely a local induration, may be felt. By grasping the cervix with a tenaculum and drawing it down while the palpating finger is in the rectum the whole of the posterior face of the uterus may be explored and small fibroid nodules discovered.

The tumors are found to be continuous with the uterus and movable with it. If the tumor is sufficiently large to be grasped by an assistant, who draws it up or to either side, it will be found that the motion is communicated to the vaginal cervix. The cervix is often very hard, and may have been dragged upward to such an extent that it cannot be reached by the vaginal finger; or it may project from the rounded surface of the tumor like the nipple on the breast.

The hard, non-fluctuating character of the tumor may usually be determined by bimanual examination. A sensation resembling that of fluctuation may be elicited in the edematous fibroid, and true fluctuation is, of course, present in the cystic variety.

The uterine sound shows the increased length and the irregularity of the uterine cavity. The sound is not often necessary for diagnosis. It is useful, however, in the case of small interstitial fibroids. It will be remembered that uterine enlargement is one of the most usual symptoms of fibroid tumor.

The presence in the wall of the uterus of a hard nodule or of an area of induration, with a decided increase in the length of the uterine cavity (three to four inches), is strong evidence of fibroid tumor.

Those fibroid tumors which cause symmetrical uterine hypertrophy without any irregularity of surface are sometimes difficult of diagnosis. They have been mistaken for the pregnant uterus. The reverse mistake has also very frequently been made, and the woman has been subjected to celiotomy for fibroid tumor when a normal pregnancy alone was present. The differential diagnosis between fibroid and pregnancy is usually not difficult. In making such a differential diagnosis it must be remembered that in some cases of pregnancy the menstrual periods continue during the early months or throughout the course of pregnancy, and that irregular bleeding may occur during pregnancy; also, on the other hand, that the symptoms of menorrhagia and metrorrhagia may be absent in the case of fibroid tumors. Mammary changes, nausea, and pigmentation of the skin may occur with fibroid tumors as with other diseases of the uterus or the ovaries, and resemble the similar phenomena of pregnancy. The bluish discoloration of the ostium vaginæ, the soft cervix, the pulsation of the vaginal vessels, the movements of the child, and the fetal heart-sounds are absent in fibroid tumors. The recent history of the tumor and its typical increase in size are observed in pregnancy.