A Text-book of Diseases of Women

by Charles B. Penrose

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.

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 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.