[Reprinted from the American Gynaecological and Obstetrical Journal 
for May, 1895.] 
A CONTRIBUTION TO THE CLINICAL STUDY 
OF UTERINE FIBROIDS.* 
By Anna M. Fullerton, M. D., 
Physician in Charge, Woman's Hospital of Philadelphia. 
There is, perhaps, no subject in the domain of gynaecology which 
has of recent years excited so much interest and discussion as that of 
the management of uterine fibroids. 
The theory of Gottschalk that the occurrence of these growths is 
favored by every form of local irritation which tends to produce cir- 
culatory disturbance explains, I think, a fact well borne out by clin- 
ical experience ; viz., that uterine fibroids are on the increase. This 
view of the possible origin of fibroids invests the management of all 
conditions of uterine disease with new importance and extends its 
significance to the progress of involution during the puerperium when 
all such measures should be employed as are essential to the overcom- 
ing of any tendency to subinvolution, or to the prevention of inflam- 
matory or septic complications. 
The systematic examination of the puerperal woman two weeks after 
her delivery, with a view to the employment of such gynaecological 
treatment as may be indicated for the restoration of the pelvic organs 
to their normal state, will often serve to avert the dangers attendant 
upon subinvolution ; for, it is early in the lying-in that this condition 
can best be combated, the pelvic absorbents then being sufficiently 
active to aid materially in the work. Recent lacerations should be 
repaired immediately after delivery. 
The cases I desire to report to the Society to-night have been se- 
lected from among a number that have come under my personal care 
in the wards of the Woman's Hospital, and are of interest as serving 
to emphasize the character of the complications which may arise in 
the history of uterine fibroids. 
The first four of these cases involve the perplexing question of the 
* Read before the Philadelphia Obstetrical Society, April 4, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. 2 
Anna M. Fullerton, M. D. 
management of pregnancy complicated by the presence of these tu- 
mors. Suturgin, in the Annual of the Universal Medical Sciences for 
1891, claims that scarcely one fifth of the cases complicated by such 
tumors terminate without surgical interference, and that about one 
third of the mothers and one half of the children die during or soon 
after labor. It has been claimed that pedunculated tumors may be 
freed by careful manipulations from any obstructing position they may 
occupy and not materially affect a labor ; also, that an interstitial my- 
oma of the upper zone of the uterus, even of considerable size, usually 
offers no mechanical obstruction to labor and should not be touched 
unless untoward symptoms arise which render an operation imperative. 
The utter uncertainty as to prognosis, even in tumors thus favorably 
placed, is shown in the cases I shall narrate. 
Case I.-M. B. was a colored woman aged twenty-nine years, and 
a primigravida. She came to the hospital February 28, 1889, with the 
following history : A small tumor had been .observed by herself in 
the lower part of her abdomen during the preceding June. This had 
rapidly increased in size during the winter, and was the cause of fre- 
quent severe colicky pains, for which she sought relief. An examina- 
tion demonstrated the existence of a tumor about the size of a large 
orange which was inseparable from the uterus, being attached to the 
posterior portion of the fundus to the right. The uterus itself was 
enlarged to the size of a four months gestation and its consistence 
was suggestive of pregnancy. Colostrum was found in the breasts. 
The patient was kept under observation for the next five months, dur- 
ing which time the tumor increased with remarkable rapidity. The 
entire period of gestation was one of such intense suffering as to ne- 
cessitate the almost continuous use of opiates for the relief of pain, 
particularly during the latter month or two of pregnancy when pres- 
sure upon the liver and diaphragm produced most distressing pain 
and dyspnoea. There was no pelvic contraction so that the foetal 
head engaged without difficulty. On the 27th and 28th of July the 
patient suffered with irregular and very severe uterine contractions, but 
there was little impression made upon the os uteri. At 12.30 p. m. cn 
the 29th the membranes ruptured and the amniotic liquid came away 
colored with meconium. Douches of warm bichloride solution and 
manual dilatation were resorted to, to hasten the labor in the interests 
of the child. When the os was sufficiently dilated for the application 
of forceps, the child, a girl weighing 3010 grammes, was extracted 
without much difficulty at 9.40 p. m. Though asphyxiated it was re- 
suscitated and lived to be discharged in good condition from the hos- A Contribution to the Clinical Study of Uterine Fibroias. 
3 
pital, three weeks after its birth. Immediately after the extraction 
there was quite a free flow from the uterus, which was, however, read- 
ily controlled. A few perineal stitches were introduced to repair a 
slight laceration. The patient soon aroused from the anaesthetic and 
asked intelligent questions about herself. About two hours later, at 
11.25 p-m., she went into a sudden state of collapse from which the 
most vigorous measures faded to resuscitate her. The autopsy re- 
vealed no internal haemorrhage, and, beyond a slight congestion of the 
kidneys, no lesion of any organ of the body existed. A large fibro- 
Fig. i.-Fibro-cystic tumor of uterus attached over placental site. 
cystic tumor was found, connected with the uterine fundus. A few 
recent adhesions existed between the tumor and the anterior abdom- 
inal wall. The caecum was found lying across the pedicle. The pla- 
cental site was over the uterine attachment of the pedicle, which ac- 
counted no doubt for the rapid growth of the tumor. Upon opening 
the cavities of the heart, numerous bubbles of air escaped. This air 
it was supposed had entered the uterine sinuses, which, owing to the 
peculiar situation of the placenta, could not be properly closed. A 
sudden movement on the part of the patient had probably produced 4 
Anna M. Fullerton, M. D. 
sufficient suction in these sinuses to draw in the air-emboli, thus caus- 
ing death from paralysis of the heart. 
Case II.-B. H., aged thirty-one years, also a colored woman and 
a primigravida, came to the hospital Apiil i, 1889, complaining of diffi- 
cult micturition and severe abdominal pain. Patient had always suf- 
fered from menorrhagia and dysmenorrhoea until within the four 
months preceding her coming to the hospital, when the flow had been 
scant. She had noticed at the same time a swelling in her left side, 
which was excessively tender. The uterus was found enlarged, the 
fundus reaching the umbilicus and inclined to the right side. A tu- 
mor about the size of a foetal head occupied the left side, its upper 
border being somewhat higher than the uterine fundus. A pedun- 
culated fibroid complicating pregnancy was diagnosticated and the 
patient kept under observation until the close of gestation. Her 
symptoms of pain, nausea, dyspnoea, etc., were identical with those 
in the case just reported, and required the same palliative treatment. 
Labor began with premature rupture of the membranes, dilatation 
was slow and had to be aided manually. The irregular character of 
the uterine contractions with indications of threatened foetal asphyxia, 
necessitated a high-forceps application. The child, a boy of over 
normal weight at term, was asphyxiated when born and could not be 
resuscitated. A primary trachelorrhaphy and perinaeorrhaphy were 
done for the patient whose puerperium was without event. She left 
the hospital three weeks after delivery promising to return for the 
removal of her tumor. 
Case III.-J. V., a farmer's wife, white, aged forty-two and a 
primigravida, had been seen early in her pregnancy by the late Dr. 
William Goodell and advised to see him some months later regarding 
the possibility of her requiring operative treatment for the delivery of 
her child. The patient was led by her sufferings to come to the city 
to see Dr. Goodell on July 6, 1890. As the doctor was not in town, 
she came to the Woman's Hospital and was examined by myself. She 
then appeared to be in the eighth month of her pregnancy. She had 
been married one year. About six months previous to her marriage 
she had noticed a small lump in the right inguinal region which she 
said increased markedly in size before each menstrual epoch. It gave 
her no especial discomfort. Upon examination after admission, the 
uterus was found to be studded with multiple fibroids. A peduncu- 
lated tumor about the size of a large orange was attached to the right 
side of the uterus low enough down to be distinctly appreciated at the 
inlet by examination per vaginam. One a little smaller was attached A Contribution to the Clinical Study of Uterine Fibroids. 
5 
to the left side somewhat higher up, while numerous nodules of vary- 
ing sizes were discovered over the anterior surface of the uterus. 
An eminent gynaecologist who kindly examined the case with me 
upon the occasion of a visit to the hospital, expressed it as his opin- 
ion that a uterus so full of fibroid growths would probably contract 
very irregularly and be subject to rupture ; therefore, that a Porro 
operation would offer the best chances to mother and child. The pa- 
tient anticipated any operative procedure by a premature rupture of the 
membranes at 4.30 p. m., July 8, 1890. The pediculated tumors were 
kept pushed up by manipulations per vaginam during the labor and 
the head allowed to descend-which it did sufficiently to be within 
the grasp of the obstetric forceps. Extraction was effected by 5 a. m. 
the next day. The pains throughout the labor were irregular and 
severe. The child, a girl baby weighing 2710 grammes, was in good 
condition and still continues to live and thrive. 
The mother's convalescence was uneventful, the tumors rapidly 
decreasing in size. About three weeks after her delivery she left the 
hospital, determined to return for a hysterectomy. On August 25, 
1891 (thirteen months after her first delivery), she returned to the 
hospital, again pregnant eight months. The history of the preceding 
pregnancy as to pain and discomfort was repeated. 
The uterine tumors, particularly the one to the right, were larger 
than in the preceding year, and thus offered more of an obstruction 
to the descent of the presenting part-the head. After waiting long 
enough to find that the head would not mold sufficiently to engage in 
the superior strait, I performed version. , Some difficulty was ex- 
perienced in the extraction of the after-coming head which became 
extended, hence the child, a boy, made some premature efforts at 
respiration before extraction was completed. The child was larger 
than the former child, the head firmer. It lived twenty-four hours 
and then died of secondary asphyxia. The mother's convalescence 
was uneventful. On April 30, 1893, about a year and a half from the 
time of her last discharge from the hospital, the patient returned, 
pregnant for the third time. The head of the foetus descended with 
less difficulty as the pedicles of the tumors seemed somewhat elonga- 
ted, hence they could be more readily pushed up from their encroach- 
ment upon the inlet. The child, a girl baby, weighing 3100 grammes, 
was extracted by forceps-in good condition. It still continues to live 
and thrive. The mother again made a good convalescence. Since 
her return to her home she has written me that the tumors have 
greatly decreased in size. 6 
Anna M. Fullerton, M. D. 
Case IV.-A. B., a colored woman, aged twenty-nine years, a 
primigravida, was sent to the hospital on November 20, 1893, for the 
removal of a uterine fibroid which caused her much bladder irritation 
and pelvic pain, with aggravated nervous symptoms of a reflex char- 
acter. The patient had suffered with menorrhagia up to October, 
1893, after which the discharge had entirely ceased, and the abdomen 
increased rapidly in size. Upon examination the fundus of the 
uterus was found to be one finger's breadth from the costal margin 
anteriorly on the left side and within three fingers' breadth on the right. 
There was more decided resistance on the left side of the uterus than 
on the right. Some colostrum was found in the breasts, the uterine 
cervix was softened, nausea and vomiting existed. A possible preg- 
nancy complicating the fibroid tumor was diagnosticated. The foetal 
heart sounds could not be heard before December nth, when they 
were appreciated near the right lumbar region. Hospital care re- 
lieved the patient of some of her most distressing symptoms, and, 
after consultation with some of the other members of the hospital 
staff, she was allowed to go home, until nearer the close of her gesta- 
tion, when she was advised to return for a possible Porro operation. 
On February 24 and 25, 1894, the patient suffered with severe uterine 
contractions and came to the hospital at 2 a. m. February 26th. There 
was no decided shortening of the uterine cervix, hence an effort was 
made to quiet the contractions by the use of opium suppositories, 
with rest in bed. At 7 a. m. on the 28th the pains returned with re- 
newed vigor and could not be thus controlled. Dilatation went on 
rapidly and the foetus was spontaneously expelled. The placenta 
being retained, an anaesthetic was given and the hand carried into 
the uterine cavity. The placenta was found to be adherent to the 
right side of the anterior wall of the uterus opposite the site of the 
tumor. It was carefully separated and removed. During the ma- 
nipulation it was found that the tumor was a large submucous fibroid, 
which entirely filled the uterine cavity when its walls contracted down 
upon it. In looking at the specimens from this case it would seem 
almost incredible that gestation for so advanced a period of preg- 
nancy could have existed with so large an intra-uterine growth. The 
portions of the uterine wall not occupied by the tumor were so 
thinned by the distention to which they were subjected, that it was a 
marvel no rupture occurred. After delivery the uterus and vagina 
were thoroughly irrigated with a bichloride solution. An iodoform 
suppository was introduced into the vagina, and the usual antiseptic 
occlusion dressings applied. A Contribution to the Clinical Study of Uterine Fibroids. 
7 
The child was alive when born and lived about half an hour. It 
opened its eyes and used its limbs. The length was forty centime- 
tres, weight five hundred and twenty grammes. The face, limbs, and 
back were covered with lanugo. There was no vernix caseosa. No 
toe-nails. Beginning development of one or two finger-nails. The 
aural and nasal cartilages were undeveloped. The fontanelles were 
large and separation of nearly one centimetre existed in the sagittal 
suture. The skin was very thin and transparent. The placenta was 
largely covered with areas of thickened decidua, and there were some 
spots of fatty degeneration. Until the second week, following the 
Fig. 2.-Submucous fibroid of uterus complicating pregnancy 
Six months' gestation. 
delivery, the puerperium was without event, except for the persist- 
ence of pain, localized in the inguinal regions and supposed to be 
induced by uterine contractions excited by the presence of the tumor. 
There was no rise of temperature, the pulse ranged between 75 and 
80. On the thirteenth day following her delivery there was a sudden 
rise of temperature to 102.6° and the pulse to 104. A slight odor was 
noticed to the lochia. The uterus was irrigated with a bichloride 
solution and the patient's temperature fell to ioo°. Vomiting of a 
greenish mucus set in and continued so persistently that the patient 8 
Anna M. Fullerton, M. D. 
had to be nourished entirely by bowel. Uterine irrigation was em- 
ployed daily and the patient and her friends urged to give their con- 
sent to an operation for removal of the pelvic organs. This was not 
gained until six days after the manifestation of the first septic symp- 
toms. During this time the tumor increased markedly in size, gen- 
eral peritonitis set in and prostration was extreme. After the friends 
gave their consent to operative interference a consultation was held 
immediately, but it was deemed unadvisable to proceed as the patient 
was then moribund. She died within six hours after the consent of 
her friends had been obtained. An autopsy made three hours after 
death proved that operative interference at that late date would have 
done nothing for her, and afforded a most striking illustration of the 
rapidity of the action of sepsis during the puerperium. The abdo- 
men was distended and tense, filled with about a quart of a dirty-gray 
fluid, emitting a foul odor which, upon microscopical examination, was 
found to be full of pus. The entire parietal peritonaeum was covered 
with fibrinous lymph. The intestines were matted together and in- 
jected in patches, and their mucous coat considerably thickened. 
The great omentum was thickened, injected, and adherent to the in- 
testines. The spleen was flabby, necrotic, and highly congested ; its 
parietal surface was a light-green color with small foci of pus. The 
liver, soft and necrotic, showed fatty degeneration, as also did the 
kidneys. The uterus was greatly enlarged, its fundus three fingers 
breadth above the umbilicus. The whole organ was glued to the sur- 
rounding tissues. Adhesions on left side were apparently of older 
formation than on the right. Both left tube and ovary were tightly 
adherent to the parietal peritonaeum and rectum by their outer and to 
the uterus by their inner surface. The right tube and ovary were 
adherent to a less extent. Considerable purulent fluid welled up 
from the left broad ligament and ovary as the pelvic cavity was en- 
tered. Section of the uterus showed the cavity to be occupied by a 
single submucous myoma in a state of degeneration. The endome- 
trium was in a condition of gangrenous endometritis. Death, it was 
decided, was- due to sepsis from gangrenous endometritis resulting 
from the breaking down of the tumor which infected the endome- 
trium. 
A patient is at present under my care, having fibroids complicat- 
ing a pregnancy. She is colored, aged twenty-six, and pregnant for 
the second time. She miscarried at five months last July. The mis- 
carriage she states was followed by childbed fever. The present 
pregnancy has been prolonged to the end of the seventh month, A Contribution to the Clinical Study of Uterine Fibroids. 
9 
simply by continuous rest in bed, the foot of the bed being elevated 
to relieve pelvic pressure, and opiates almost constantly employed to 
quiet uterine contractions. The sum of human suffering and calamity 
represented by the history of the cases just cited, incline me to the 
belief that should we be able to prolong this pregnancy to term, a 
Porro operation would be the most satisfactory method in the manage- 
ment of the case ; or, should the patient at any time be delivered per 
via naturales, we should be prepared to do hysterectomy at the earliest 
manifestation of septic complication. 
As time is limited, I shall refer but briefly to the other specimens 
presented to the Society to-night. 
One of these-a large, oedematous myoma-was removed by me 
four weeks ago, from a patient who had been so exsanguinated by 
successive haemorrhages, as to be reduced to a condition bordering 
upon pernicious anaemia. She is a white woman, forty years of age, 
married and childless. The growth had been noticed nine years. 
Her blood was examined upon admission to the hospital, with the fol- 
lowing result : Red cells, irregular in shape, agglutinated, and num- 
bering about 2,400,000. Haemoglobin twenty five per cent. Upon the 
recommendation of Professor Frederick P. Henry, who saw her with 
me, she was placed upon treatment for anaemia prior to any operative 
procedure. Rest in bed, with the foot of the bed elevated to relieve 
pelvic pressure, ferruginous tonics, bone-marrow, and forced feeding 
were employed. The vagina was kept continuously tamponed with 
iodoform gauze. The blood was examined every two or three weeks. 
The patient was thus kept under treatment from the middle of Octo- 
ber, 1894, until March 6, 1895, when the operation was done. On 
the 26th of February the examination made of the blood showed the 
increase of red blood-corpuscles to 5,300,000, their shape regular, 
while the haemoglobin was increased to fifty-five per cent. The opera- 
tion was therefore decided upon. The entire uterus was removed by 
amputation at the vaginal junction, the peritonaeum being drawn over 
the stump. 
A separate nodule-subperitoneal-was an outgrowth from the 
supravaginal portion of the ceivix and occupied Douglas' cul-de-sac. 
The peritonaeum was stripped from this and it was peeled out, after 
the remainder of the uterus was cut away. The ovaries were greatly 
enlarged, and the ovarian plexus of vessels on both sides greatly en- 
gorged. The patient received a pint of normal salt solution by cellu- 
lar transfusion after operation. Her recovery has been very satis- 
factory. 10 
Anna M. Fullerton, M. D. 
Another specimen removed by me on January 12, 1895, is of in- 
terest as showing the condition of calcareous degeneration in a uterine 
fibroid-the largest tumor I have ever seen which has undergone this 
change. The patient is fifty-nine years of age, married and childless. 
The tumor lay in the hollow of the sacrum and caused great distress 
from pressure. The uterus was amputated at the vaginal junction. 
The patient made a good recovery. 
The other two specimens were deep-seated fibroids removed by the 
same process by myself, during the preceding year. They had caused 
much haemorrhage and pain. I have brought them here to-night 
simply in illustration of a class of cases in which I think management 
of the stump according to the old method would have been exceed- 
ingly difficult, if not impossible. The patients made an excellent re- 
covery.