A system of practical medicine. By American authors. Vol. 4

by Unknown

MODE OF DEVELOPMENT.—It has already been stated that the fibrous tumor of the uterus grows in or on its wall and originates in the fibrous structure of the organ. The point of beginning is in one or more fasciculi of the muscular system or the connective tissue of the uterus. If in one fasciculus, the point of origin is very minute, as indeed it is generally at first.

The development consists in an hypertrophy of the bundle of fibres affected and a deposit of material similar in structure to that first involved. Sometimes there are numerous nuclei, and nearly all the fibrous structure of the uterus is involved in fibrous degeneration. In the case where the deposit is defined and occupies a small space, it should be borne in mind that the future tumor, however large it becomes, must occupy the same nidus in which it first originated. The nidus becomes enlarged sufficiently to accommodate the growing tumor.

The nucleus of development is enlarged by the accretion of substance similar, if not identical, in character to its own proper material. The nature of the tumor is determined by this fact, and its fibres are rudimentary in organization, instead of being hypertrophied and highly developed, as those of the uterine wall by which it is surrounded. As the tumor grows the fibrous structure surrounding it is pressed aside in every direction in such a way as to completely embrace the growth and encapsulate it. The tumor does not incorporate the adjacent fibres and grow by inducing degeneration in them, but, as before said, it presses them aside. As it thus moulds and shapes a bed in the solid substance of the interior wall, it impresses upon the embracing muscular fibres an increased vitality, and they grow by hypertrophy of a character similar to that of pregnancy. The fibres become longer, and apparently, if not really, more numerous. This hypertrophy of the uterine fibres surrounding the tumor is equal to the capacity demanded by the increasing size of the growing tumor. In this description of the method of development and the embracing capacity of the hypertrophied fibres surrounding it the reader will trace the formation of the capsule in which the tumor is contained. The inner surface of the capsule is smooth, and there are many feeble fibres of connective tissue seen to connect it with the surface of the tumor. There is no adhesion proper between the surface of the tumor and its capsule.

I must call attention to another point that governs the extent and limits of the growth of the tumor—viz. the number and distribution of its vessels. The vessels entering the tumor represent the minute twigs that supplied the fasciculus in which it originated. They arrive at the point of morbid deposit from the parts constituting the capsule, and there are always several of them. The number of these vessels always remains the same, and their calibre is increased with the hypertrophy of the surrounding tissues. They cannot grow at the demand of the trophic energies of the tumor to an unlimited degree, but their size is limited by the growth of the surrounding parts. As the tumor grows and its capsule expands, the vessels are separated farther from each other, until after a while the area becomes so large that the supply of blood will not admit of further growth and the tumor comes to a standstill. Thus their growth, from the nature of their supply, is limited; hence the usual history of the tumor is one of self-limitation. It is all-important in forming an opinion in reference to the greater or less vitality of the fibrous tumor, therefore, to remember that it is not supplied by one large arterial trunk entering at one place and spreading over its capsule, but that the supply is by a number of small vessels penetrating the tumor at different points; that their number cannot be increased and their growth is limited; that as the tumor grows their capacity to supply it grows gradually less until entirely exhausted: then the growth stops.

There is another and adventitious source of nutritious supply, and I think it is essential to very large growths: at least, so far as I know, it is always present. I mean the adhesion of the uterus or tumor to the wall of the abdomen, the pelvic or abdominal viscera, or, what is more common, the omentum. When adhesions occur from whatever cause, the vessels of the tumor increase in size and supply it with a vast increase in the amount of blood. All the large tumors I have had an opportunity of examining were to a greater or less extent covered by a network of large vessels contained in the omentum. These vessels penetrate the uterus, carrying a deluge of blood into its substance. These large vascular adhesions are a source of embarrassment in operations for their removal. Operators allude to them and give instructions how to overcome the difficulty presented by them. The uterine vessels alone would never be sufficient to supply the forty- or fifty-pound tumors so often mistaken for ovarian tumors.

EFFECTS UPON THE UTERUS.—I have already said that the fibres immediately surrounding the growth undergo a true hypertrophy, acquiring dimension, susceptibility, and capacity similar to the hypertrophy of gestation. All the fibres of the uterus undergo a similar change, only less in degree; the more remote from the tumor, the less marked the hypertrophy. This remark must be modified somewhat by the consideration of the locality of the tumor. A polypoid tumor growing from the fundus causes universal hypertrophy of the uterine fibres. A submucous tumor will usually cause a general hypertrophy of the uterine fibres, but greater on the side of the tumor. A subserous tumor is attended by a slight hypertrophy, and in a centrally-located intramural tumor the hypertrophy would be much like that in the submucous variety, only less in degree. But this augmentation of tissue is not confined to the fibrous structure: it extends to the vascular and nervous apparatus and to the serous and mucous membranes. With this growth of the tissues comes change in the properties and functions of the uterus itself. It is more sensitive, the secretions are increased, and almost parturient contractility is acquired.

But probably as remarkable and uniform a symptom as any arising from the general hypertrophy is hemorrhage. The mucous membrane of the uterus is hypertrophied in all its constituents and proportions. The membrane acquires larger superfices and greater thickness, its glands are enlarged, and its blood-vessels augmented. Its functions, as a consequence of these changes, are exaggerated. The glands secrete greater quantities of mucus, and the vessels when ruptured in the processes of menstruation pour out a superabundance of blood. Indeed, I know of no other way to account for the hemorrhages so generally present in cases of fibrous tumors of the uterus, except upon the ground that the endometrium, a natural hemorrhagic surface, has its properties and functions enhanced by a general hypertrophy.

LOCATION OF THE TUMOR.—For the purpose of considering the relation of these tumors to the different regions of the uterus we may call that part situated above the entrance of the Fallopian tubes the fundal zone, and that above the internal os uteri the corporal zone; all below this the cervical zone. Fibrous tumors may and do originate in all of these zones or regions, but they spring more frequently from the corporal than either of the others, and less frequently from the fundal zone. The part of the corporal zone in which these tumors more frequently grow is the lower or cervical portion. There is another important view of the relation of the tumors to the uterus. The muscular fibres of that organ run in every direction with reference to the latitude and longitude of the uterine circumference—transversely, longitudinally, obliquely, spirally, etc. There is probably not much more definiteness in the layers constituting the walls of the uterus. If they cannot be completely separated into regular strata, there is sufficient distinctness in the layers to justify us in employing the term strata in connection with their arrangement, and this term will enable us to get a more exact understanding of the language used in the description of tumors. Authorities differ as to the exact number of strata to be found in the body of the uterus, but for clinical purposes it is convenient to describe them as follows: By drawing a line through the middle of the uterine wall longitudinally we will indicate a central stratum of fibres. A tumor originating in that line or stratum is what is usually called an intramural tumor. The number of tumors growing in this stratum is not very great as compared with those situated nearer the two surfaces.