| FIG. 25. |
| Diagram showing Muscular Strata of Uterus, as divided for clinical purposes. |
If we run one line between the serous and another between the mucous membrane and the central line, as in the diagram, other strata with intervening spaces will be indicated. a would represent the centre stratum of the wall; b, the space immediately outside of that; c, a stratum still farther out; e, the subserous; and d, a deeper one. When we look at the inner layers of fibres, we find f situated immediately beneath the mucous membrane; g, farther out; and h, next the median line. The nucleus of a tumor may be first manifested in any of the strata or spaces marked by these lines, and its position with reference to the central line will, to a great extent, govern the direction it takes during development. A tumor the nucleus of which is situated in line a will, as it develops, press the muscular fibres equally in every direction, and when large, the prominence caused by pressure of the tumor would be equal in the uterine cavity and on the peritoneal surface. In marked contrast to this, when the nucleus is at f the growing tumor presses the mucous membrane before it until it becomes pendulous, and then the name of polypus is given to it; or if the origin is at e, the serous membrane is pressed before it, and the tumor is called subserous. When the nucleus is at d, the tumor elevates the serous membrane and becomes a prominent hemispherical protuberance. It is also called a subserous tumor, although situated some distance from the membrane. When a tumor takes its origin at g the mucous membrane is crowded before it, and a marked prominence into the cavity of the uterus is observed. This is the submucous tumor. These illustrations are intended to call the attention of the student to the fact that practically these tumors spring from any one or all the fibrous strata of the uterus instead of only the central, submucous, and subserous layers, and that it is profitable, on account of the difference in their effects upon the shape and functions of the uterus, to study them in this aspect of their growth.
ETIOLOGY.—While we know many of the conditions under which fibrous tumors exist, we have really very little, if any, definite and reliable information as to their causes, either remote or proximate. We know that they occur much more frequently near the time when the uterus begins to undergo senile degeneration, although they do originate in earlier years. They very seldom, if ever, are observed in the foetus or child, nor is it common for them to commence growing after the menopause. Women belonging to the African race are the most frequent subjects of these tumors.
The married or single status does not seem to have any effect in predisposing to these tumors. We do not know what physiological or pathological states of the uterus or other organs predispose to them. There is probably no tumor in the body strictly analogous in structure, mode of origin, supply, or development to the fibroid tumor of the uterus. There is no other organ in the body that undergoes analogous normal trophic changes. The vast multiplication of tissue that takes place in the uterus during gestation, and the more rapid but equally great changes toward degeneration or atrophy, would naturally suggest pathological possibilities of a peculiar nature. The rhythmical changes of menstruation are like no other functional condition. They too involve the processes of hypertrophy and atrophy. When the menstrual and generative changes are normal every part of the body of the uterus is simultaneously and proportionately hypertrophied and atrophied. Local derangements of these processes of hypertrophy and degeneration must sometimes occur, probably from defective or excessive innervation of loculi in the fibrous structure. Congestion or hyperæmia may thus result, and consequently very great influence be exerted upon the nutrition of the parts concerned after the deposit has begun; its presence increases the hyperæmia and thus perpetuates its growth indefinitely.
CLINICAL HISTORY.—Probably the earliest, most frequent, and constant symptoms connected with fibrous tumors of the uterus are hemorrhage and leucorrhoea. They are both the result of active or arterial hyperæmia, and doubtless come from the endometrium. Polypi, submucous, and intramural tumors are more likely to give rise to these two symptoms. The nearer the mucous membrane, and the greater that membrane is expanded, the greater the amount of hemorrhage and leucorrhoea, and, as a counter-fact, the nearer the serous membrane, the less the amount of these two discharges. While this statement in reference to the effects of the proximity of the tumor to the two membranes is usually true, it is not always so.
Hemorrhage is sometimes not very great, but at others it is appalling, and constitutes an imperative reason for the employment of desperate remedies. The hemorrhage is usually first noticed in connection with the menstrual flow, and it may even be confined to the periods: sometimes it extends over the whole of the interval. The leucorrhoea is generally constant, and sometimes thin and watery, especially after the hemorrhagic paroxysm has subsided, and at others it is constituted mainly of mucus with the débris of the mucous membrane and blood-corpuscles.
Other symptoms are pelvic pressure, vesical and rectal, with tenesmus, distension, and dysmenorrhoea. The pelvic pressure and tenesmus are observed early in the development of the growth, and may be relieved as the tumor becomes large enough to rise out of the pelvic cavity. The abdominal distension of course comes later. Solid tumors do not often attain to such a size as to cause great abdominal distension. The fibro-cystic generally are inconvenient, if not fatal, from this cause.
The above are the more direct and common symptoms. A less frequent yet important effect and symptom is oedema of the lower extremities from pressure upon the venous trunk passing through the pelvis. In rare cases this symptom is aggravated to a degree constituting phlegmasia alba dolens. As the tumor rises and enlarges the pressure may embarrass or interrupt the function of any or all the abdominal viscera.
In many cases none of these symptoms present themselves to an inconvenient degree, and the tumor is discovered by accident. Again, we meet with cases in which the symptoms are formidable for a time, and then entirely subside, leaving the patient free from suffering the balance of her lifetime. While this subsidence may take place at any time during the growth of the tumor, it is very apt to take place at the menopause.
The clinical history of the fibrous tumor may be very much modified by the intervention of various circumstances. As organized bodies they are subject to those affecting the organs of the body. We must regard them as adventitious growths acted upon by organs in a state of disease and reacting in turn upon them. They may become inflamed, undergo suppuration and gangrene, and produce symptomatic fever, hectic fever, prostration, gastric, hepatic, and nervous derangement in a degree sufficient to prove fatal.