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

by Unknown

When situated near the mucous membrane, nature sometimes turns these organic changes into a means of cure by destroying the portions of the capsule near the uterine cavity and permitting the pus or gangrenous material to escape. They are also subject to pressure from the development of other tumors, and either disappear, become inflamed and adherent, or cause great trouble to adjacent organs. Their clinical history is sometimes modified by complication with pregnancy.

This complication is rare, because the uterus in most cases, on account of the effects produced upon its circulation, nerve-supply, and mucous membrane especially, will not retain the ovum, and conception does not take place. The uterus being more vascular, and subject to congestions that affect the placental attachment injuriously, miscarriages are likely to occur. It is also morbidly sensitive to the pressure of the ovum, while the mucous membrane is rendered incapable of decidual changes. The retentive power of the uterus is further interfered with from the irregularity of its growth: the fibres where the tumor exists, being under a morbid influence, cannot partake of the regular hypertrophy necessary to normal gestation. There is something of uniformity in the circumstances under which the coexistence of pregnancy and fibrous tumor is observed. The nearer the tumor is situated to the mucous membrane, the less likelihood of pregnancy—the more remote, the greater the tolerance of pregnancy. Tumors that occupy the wall of the corporal portion are conducive of sterility. Those in the cervical portion of the corporal and the cervical zone are more likely to be accompanied with pregnancy than those situated in other parts of the organ. While the reader will find these statements borne out by his experience as general facts, he will also discover that pregnancy is occasionally compatible with almost any form, variety, or position of tumor. When this complication occurs, it does not generally influence the process of gestation or the condition of the tumor. The main symptoms depending on it are those caused by pressure. When small this is not very considerable.

Complication with labor generally gives rise to more apprehension than difficulty. Most of the cases of labor terminate spontaneously and happily, and the others are generally within reach of the less destructive modes of delivery. Labor more frequently decidedly affects the growth of the tumor, in the majority of cases causing its disappearance during the process of involution. The cervical polypi affect labor less, and are less affected by labor, than any other variety of the tumor. If small, they are sometimes merely pressed to one side or into the hollow of the sacrum, and the head passes by them; if a polypus is large, the head of the foetus carries it before it beyond the vulva, where it remains until the child is expelled, when it may recede into the vagina.

DIAGNOSIS.—The history usually includes hypersecretion, hemorrhage, pressure, and enlargement. These, while suggestive, are not conclusive, hence physical examination becomes indispensable to accuracy. The methods of examination vary with the size of the tumor. It is generally near the truth to say that the uterus is enlarged, and may be shown to be so by the introduction of the sound; yet the cavity is not always enlarged, and it is often so tortuous that the ordinary sound may be arrested before reaching the fundus. The sound, therefore, should in such condition be flexible. The fine whalebone or the sound of Jenks will generally pass obstructions caused by tortuosities. The most skilled and dexterous use of the inflexible sound is often delusive. We may generally determine the size by bimanual examination—one finger in the vagina or rectum while the hand is passed down into the pelvis from above. The uterus of normal size cannot be felt with any distinctness from above in this way, while an enlargement of 50 per cent. may be thus determined. The finger below will sometimes recognize the pressure from above when the upper hand will not feel the fundus distinctly. Small tumors of the uterus may be mistaken for many other conditions, and the converse. If one is situated in the posterior wall, it may be mistaken for retroflexion. We may make the distinction by means of the inflexible sound and the finger in the rectum. If the case is one of retroversion, the finger in the rectum will pass behind it and overlap it above. If a retro-uterine tumor is in the cul-de-sac, the finger will not reach above the uterus. If the case is one of retroflexion, a strongly bent sound may be made to enter it, especially if the fundus is slightly raised by the finger in the rectum. If there is a tumor in the posterior wall, the sound with slight flexion will pass above it; which is clearly ascertained by the finger in the rectum. When the sound is introduced in the case of retroflexion, the fundus may be elevated to its proper position by turning the sound upon its axis. In making these examinations with the sound the finger should be made to co-operate with it by being kept in the rectum. A small tumor in the anterior wall may be distinguished from anteflexion by the sound passing upward instead of forward, or into the part lying on the bladder. When a small tumor is intra-uterine, the uterus will occupy its natural position, with the mouth directed slightly backward; and if the polypus is large, the cervix can be moved forward with considerable difficulty. A flexible sound, especially the thin whalebone, may sometimes be made to partially or wholly surround it, and its size or connections be determined. But the diagnosis may be more definitely made out by dilating the cervical cavity and introducing the finger. The difference between a polypus and an intramural submucous tumor may be determined in this way. In the case of a polypus the finger will pass around it, while if the tumor is intramural or submucous the finger will be arrested at the point of attachment. A polypus or intramural submucous tumor presenting at the os externum may sometimes be mistaken for a partial inversion. Such a mistake may be prevented by using the sound. In the case of a tumor the flexible sound will pass to more than the normal depth. In one of inversion the sound will pass very much less or not at all. When a polypus has escaped from the mouth of the uterus and occupies the vagina, the sound will pass beyond it into the enlarged uterus, whereas in complete inversion it cannot be passed into the uterus in any direction. We cannot rely upon consistence or shape as marks of distinction in these two conditions. When the tumor rises above the pelvic brim and is not very large it generally displaces the os from its normal position. If in the front wall, the os will be too far back; if in the posterior, it will be displaced forward. In the former, when a sound is introduced, it will pass backward and upward; in the latter, the sound will pass forward and upward. In both cases the bimanual examination will enable us to determine that the tumor above the pelvis is continuous with or attached to the uterus. With the hands in this position, if we move the uterus the tumor will move with it, and vice versâ. Tumors of this size are usually more or less uneven in their outline, and of greater consistence than the uterus when enlarged from other causes. Tumors of this size may be generally distinguished from the pregnant uterus by the history of pregnancy, by the consistence, and by the size of the cervix. When pregnancy and a tumor are associated, this may be determined by a part of the enlargement being very hard and other parts quite elastic, and by auscultation. I need not caution the reader against the use of the sound where there is any suspicion of pregnancy. When a doubt exists, we should await the progress of the case until pregnancy becomes obvious. We may generally determine whether a tumor is uninuclear by the fact that a single tumor is nearly round, when if there are several points of origin it will be irregular and nodular.

When the tumor is large enough to nearly or quite fill up the abdominal cavity, the flexible sound may be made to pass a great distance into it. It is not often that a solid tumor grows large enough to fill the abdominal cavity. Before it grows to such dimensions it generally undergoes cystic degeneration. When the tumor is solid, generally its very great hardness, and often its irregular shape, will distinguish it from other abdominal tumors. The condition with which I have seen these tumors most frequently confounded is enlargement of the liver or spleen. In the South and West an enormously enlarged spleen is not infrequently met with. It sometimes spreads over the whole anterior part of the abdomen, completely covering the intestines. Less frequently the liver is found similarly enlarged. In this condition the organ becomes greatly indurated, and sometimes nodular. The distinguishing features of these enlargements are—first, that the abdomen does not present the prominent rotundity it does when filled by a growth; second, that somewhere in the extent of abdominal surface by careful manipulation the edge may be discovered and the fingers be made to sink beneath and grasp it; third, percussion will elicit general deep resonance, in some parts quite obvious, and in others less so. In the case of tumor none of these signs will be present. Again, the enlarged liver or spleen, while it may reach to the brim of the pelvis, does not reach into that cavity far enough to be recognized by the finger in the vagina, while the tumor does.

Sometimes inflammatory effusions form indurated masses in the abdomen that are mistaken for fibrous tumors. These of course have the history of inflammation, are generally if not always tender, and yield obvious intestinal resonance upon percussion. The large fibro-cystic tumor may be mistaken for pregnancy, ovarian tumor, cystic degeneration of the kidney, and omental tumors. Pregnancy can generally be established by absence of the menses, by the shape, size, consistency, and position of the cervix, together with auscultation. It may be said that in case of fibro-cystic tumor the cervix is greatly displaced in some direction, indurated, and not enlarged. In pregnancy none of these conditions prevail.

The fluctuation of the fibro-cystic tumor is more obscure than that of the ovarian tumor, and, although sometimes noticeable over a large space, it is usually more constricted in extent. There is also usually less regularity in the shape of it. In large ovarian tumors the uterine cervix is not changed in shape and size. The whole organ generally lies beneath the tumor, and the elastic sound will not pass very deeply into the cavity. If the uterus is attached to the anterior part of the tumor, which sometimes happens, the elastic sound will pass into it and the depth will not be very great. The fibro-cystic tumor may be distinguished from the enlarged encysted kidney by the facts that the kidney is traceable to one side more than the other, and it cannot be reached by the finger through the vagina or rectum. Still, if we cannot make the differentiation clear in any other way, we can generally do so by aspiration. In most cases we cannot draw the fluid from the fibro-cystic uterine tumor; in almost all cases the quantity removable in that way is small. When fluid is drawn, it usually coagulates, contains hæmatin, and none of the cells so generally found in ovarian tumors.

The fluid drawn from the kidneys presents epithelial cells, is not coagulable, certainly does not coagulate spontaneously. The abdominal cavity is sometimes more or less filled with peritoneal serum. After this is withdrawn from the peritoneal cavity the uterine attachment of the tumor may be made out by bimanual examination, as above directed, if undertaken immediately after the evacuation.

PROGNOSIS.—Less than twenty years ago the general prognosis to be made upon the discovery of a tumor of the uterus was very grave. The profession knew so little about the clinical history and diagnosis of these tumors that they were invested with many of the bad qualities of other tumors, with which they were so often confounded; and we had so little knowledge of their nature and the measures which would influence their growth that we felt an entire helplessness in the treatment of them. Fortunately, there have been many favorable changes in these respects. We understand their clinical history better, and can make a pretty clear diagnosis. We know that relatively few of them prove fatal even when left wholly to nature. Compared to all other uterine and ovarian growths, they are innocuous. Most of them are self-limited in consequence of the mode of blood-supply. A goodly number not only stop growing, but disappear without the application of any remedial measures. Then, as I shall have occasion to show, they may be often cured by the judicious administration of medicines, and the surgery for their extirpation has become a reliable resort in extreme cases. These considerations render the general prognosis of the true fibrous tumor quite hopeful. The menopause generally starves them out, and thus removes all the bad qualities they may possess.

When they lead to fatal results, they generally do so through three different conditions—viz. hemorrhage, pressure, and complicating inflammations—and probably in the order mentioned. Hemorrhage is by far the most fatal symptom. The kind of fibrous tumor accompanied with severe hemorrhage is usually the submucous variety. The submucous tumor with a broad base is the most mischievous, because it induces great hypertrophy in the vascular system of the mucous membrane especially, and also the vessels of the whole organ. A sessile submucous tumor arising from one nucleus is worse than one in the same situation with several nuclei of origin. The intracorporal polypus or pendulous tumor is almost as bad in this respect as the sessile submucous, especially if it originates at or near the fundus. Fortunately, these forms of the tumor are more amenable to the effects of medicine and more accessible to surgical treatment. The tumors located in the central stratum of fibres are next to these in mischievous qualities. The more remote the tumor is located from the mucous membrane, the less hemorrhage will attend its development.