FIBROID TUMORS OF THE UTERUS. 
BY 
JOHN HOMANS, M.D., 
OF BOSTON, MASS. 
FROM 
THE MEDICAL NEWS, 
June ii, 1892. [Reprinted from THE MEDICAL News, June 11, 1892.] 
FIBROID TUMORS OF THE UTERUS.1 
By JOHN HOMANS, M.D., 
OF BOSTON, MASS. 
This paper is not, in any sense of the word, a 
treatise or an essay on fibroid tumors, but simply an 
account of their natural history as I have watched 
them, their effect on the women that have had them, 
the means that may be employed when necessary to 
remove them, and the condition in which patients 
are left after operation. Nor have I thought it 
necessary to enumerate and tabulate all my own 
cases, although this might be interesting to the Asso- 
ciation and instructive to me, but I have simply 
illustrated my remarks by citing a few descriptions 
applicable to the subject mentioned. 
I suppose it is unnecessary for me to define a 
fibroid tumor of the uterus. We all know them to 
be aggregations of normal uterine tissues in abnormal 
situations and masses. They may cause symmetrical 
enlargement of the uterus, or more or less one-sided 
enlargement; they may be in the walls of the uterus, 
or protruding toward its outside, or toward its inner 
cavity; they may be incorporated with the uterus, 
or connected with it by a broad attachment, or by 
3 Read at the meeting of the American Surgical Association, 
held in Boston, May 31, June 1 and 2, 1892. 2 
HOMANS, 
a pedicle; or they may be entirely separated from 
it, and get their nourishment from the vessels of the 
omentum or mesentery, to which they are adherent; 
they may grow under the broad ligament, or they 
may grow directly out into the general cavity of the 
peritoneum. Certain of them that grow near the 
cornu of the uterus are sometimes gradually ex- 
truded until they are merely connected with the 
uterus by the Fallopian tube and broad ligament, 
and have a pedicle as distinct as that of an ovarian 
pedicle. I have seen this state of things three 
times, and always on the right side. 
Uterine fibroids may be dense or edematous, or 
filled with lymph-spaces, or they may, in very rare 
instances, be fibro-cystic, having true cysts as distinct 
as those in an ovarian tumor, not the dilatations 
in the substance of the tumor—already mentioned, 
which are filled with clear yellow or bloody fluid and 
are simply dilated lymph-spaces, but fibroid tumors, 
having true cysts on their outer surfaces, with thin 
walls, and filled with fluid of different densities. I 
am of the opinion that a certain number of tumors 
that have been described as fibro-cystic belong to 
the class I have mentioned as fibroids with dilated 
lymph-spaces. True fibro-cysts are very rare, and 
I should say that a frequent operator would not 
meet with more than one or two in many hundred 
cases of uterine tumors. 
In size these tumors vary from that of a mere dot 
to masses weighing fifty or more pounds. Their 
rate of growth is generally slow, by which I mean 
that several years’ growth will be required to produce 
a tumor the size of one’s fist. They are very com- FIBROID TUMORS OF THE UTERUS. 
3 
mon. In order to settle this question for myself, I 
have gone over my records of office-patients. I 
find that I have seen in my office during the past 
fifteen years 370 cases of fibroid tumors of the 
uterus, and, as I have seen many at the hospitals and 
in consultation, I think I may fairly add 150 more, 
making in all 520 cases. When one surgeon has 
seen that number in fifteen years, I think they may 
be called common. These tumors are said to occur 
more frequently in the black than in the white 
race, while ovarian tumors are said to be more 
common in the whites than in the blacks. 
Operations to relieve women of fibroid tumors 
are rarely necessary, judging from my own experi- 
ence. Of these 520 cases, I have operated only on 
sixty, or about 11 per cent. The conditions that 
should guide us in recommending the removal of 
the tumors are : when they threaten life by hemor- 
rhage; when they are unbearable from their weight, 
or from the inconvenience they cause, particularly 
in the act of stooping or bending, or from their 
position when they prevent a woman from sitting 
down ; when in a young woman they cause distress, 
chagrin, and shame, from the alteration they have 
made in her figure; when they cause so much pain 
as to make life a burden ; when by their presence 
they so obstruct the circulation as to cause swelling 
and edema of the limbs, or interfere so much with 
the action of the digestive and eliminative organs 
as to cause emaciation and weakness; when they 
block up the pelvis so as to cause obstruction of the 
bowels; or when they have caused strangulation 
of the bowel; or when their pedicles have become 
twisted—and sometimes the whole uterus becomes 4 
HOMANS, 
twisted on its axis exactly as the pedicle of an ova- 
rian tumor does, and presents the same symptoms, 
and requires immediate operation. 
Death by hemorrhage is very rare. I have knowl- 
edge of only three instances. Many women are 
blanched, and anemic, and feeble, but they live, 
and most of them are relieved by curetting, or at 
times by electrolysis a la Apostoli, or by the removal 
of a pedunculated fibroid from the interior of the 
uterus, or by enucleating a half-extruded one. 
The feeling of weight and inconvenience caused 
by these tumors is sufficient in some cases to call 
for their removal, and the sufferer has a right to 
demand operation, even if life is not threatened, for 
surgery is not only to save life, but to contribute to 
its comfort; and there is no class of cases in which 
the decision of the patient has more weight than in 
these cases of fibroid tumors. “Ido not want to 
carry this thing any longer; it annoys me. I can- 
not stoop to button my boots, and I want it re- 
moved,” said a woman to me. I had put her off 
several months, and she had abundant time to think 
the matter over. I thought she had a right to 
decide the question of operation. I removed the 
tumor, and she got well. 
A growing tumor in a young woman of from 
fifteen to thirty years old, which has distended the 
abdomen and is prominent and unsightly, and 
causes remark, may with propriety be removed, if 
the sufferer cannot bear to know how she looks, 
even if the tumor gives rise to no symptoms. It is 
her tumor and her life, and her body and appear- FIBROID TUMORS OF THE UTERUS. 
5 
ance, and she has a right to look like other women 
if she wants to. 
Some large tumors interfere very little with res- 
piration and nutrition, and cause but little edema 
and emaciation; while others, not so large, cause 
great debility. Those tumors that have become 
entirely separated from the uterus are dangerous 
from the opportunities they afford for strangulation 
of the intestine, and should be removed. I have 
seen a case of death caused by some loops of the 
bowel becoming strangulated by slipping in between 
points of adhesion formed between a fibroid that 
had became wholly separated from the uterus and 
other loops in a tumor nourished solely by its adven- 
titious adhesions. Such loose-lying fibroids should 
be removed. 
Again, a fibroid may threaten to render delivery 
impossible by the natural passages. At the same 
time, Nature will generally get these fibroids out of 
the way if you will give her a chance. I remember 
a case of this kind in the practice of Dr. John 
Benson, of Chatham, New Brunswick. It was a 
first labor; the tumor was so obstructive that 
Caesarean section was seriously considered, but at 
length the tumor receded and allowed the head to 
pass. A few weeks after delivery, Dr. Benson sent 
the lady to me. I opened the abdomen, turned 
the body of the uterus and both ovaries forward 
upon the pubes, split the capsule of the tumor and 
enucleated it from its bed, sewing up the rent in the 
uterus where its pedicle had arisen from the poste- 
rior part of the body near its junction with the 
neck. Recovery was uneventful. The tumor was 6 
HOMANS, 
about six inches in diameter and weighed two and 
a half pounds; it was growing, and if it had been 
allowed to remain would undoubtedly have ren- 
dered the next delivery impossible. 
At the same time, as I have said, Nature will 
generally lift these tumors out of the way when the 
attending accoucheur would think natural delivery 
impossible. I remember a case in which a large 
fibroid tumor filled the vagina at the beginning or 
just before the beginning of labor. I could not 
move it by pressing on it with my hand, even with 
a purchase against the wall of the room with my 
feet, and yet in twenty-four hours Nature had 
pulled that tumor up and had pushed the cervix, 
through the orifice of which one could feel the 
child’s head, down into the vagina. 
I remember another case of pregnancy at five 
months in which I advised non-interference, but 
another gentleman said that the tumor must be 
removed, as delivery at term would be impossible. 
This was done and the woman died in two hours. 
In another case that I remember, a practitioner 
induced labor somewhat prematurely and ruptured 
the uterus, and the woman died. Both of these 
cases could not have done worse if they had been 
let alone, and they might have done better. 
Sometimes these tumors, when quite small, by 
their position make it impossible for a woman to sit 
down with comfort. One of my patients said she 
felt as if she was sitting on a spool, and that she 
had to stand or lie down to have any comfort. She 
was sent to me by Dr. W. G. Kimball, of Worth- 
ington, Mass. A fibroid about the size of a horse- FIBROID TUMORS OF THE UTERUS. 
7 
chestnut, on the posterior and left side of the 
fundus, was tied and burnt off. Another near it, 
the size of a boy’s marble, was torn off There 
was no drainage. Rapid recovery and complete 
relief followed. 
The solid fibroid tumors rarely have any adhe- 
sions, and are removed without much difficulty 
after a little practice. The true fibro-cystic tumors 
are very rare. In the 520 cases mentioned I am 
only sure that 8 were fibro-cystic—only about 1.3 
per cent. Of these, I did not remove any success- 
fully. In all the operations I was unable to sepa- 
rate the cysts from the bowel and other peritoneal 
structures. One woman recovered from an incom- 
plete operation. The others all died. Of course, 
there may have been a carcinomatous element in 
some of these tumors, as very few of them were 
followed by autopsies. Most of these operations 
were attempted many years ago, when my manual 
dexterity was not as much developed as it is to-day; 
but I still regard true fibro-cysts of the uterus as 
very rare, and, as a rule, very dangerous of removal. 
An extraordinary case of twisting of the uterus as 
the pedicle of a large fibroid tumor of many years’ 
existence was reported by me in the American Jour- 
nal of Obstetrics, 1892, vol. xxv, No. 3.' The uterus 
was twisted one and one-half times on its axis, and 
the blood-supply was cut off from the tumor and 
from the ovaries and tubes. The case was fatal, no 
operation having been done. There was general 
peritonitis and lobular pneumonia. How this twist- 
ing of a great solid tumor and of the uterus could 
have happened is incomprehensible to me. Here 8 
HOMANS, 
was a solid fibroid tumor, weighing at least six 
pounds, and this, with the body of the uterus, and 
with both ovaries, tubes, and broad ligaments, was 
twisted around one and a half times. 
The natural history of 90 per cent, of fibroid 
tumors is to grow to a size to reach the umbilicus, 
or to reach higher or lower than this point, and then 
to remain stationary, and after the menopause to 
become cretaceous and atrophied. Some of them, 
I think, shrivel up almost entirely, while others 
remain as large as a cocoanut without giving rise to 
great inconvenience. About 10 per cent, of them 
require removal for one of the various reasons I have 
mentioned in the earlier part of this paper; others 
atrophy of themselves, without any treatment being 
employed. A large number of them are discovered 
by the attending physician, the women being totally 
unaware of their presence, though they may have 
been in the womb for many years. 
Patients with fibroid tumors present themselves 
between the ages of twenty and sixty years, rarely 
before or after these periods of life. The average 
age of those on whom I have found it necessary 
to operate is thirty-nine years. One-quarter of them 
were about thirty-four years old. The youngest 
patient on whom I have done abdominal hysterec- 
tomy for a fibroid was eighteen, and the oldest sixty- 
five years of age. Of 60 cases, i was sixty-five, i 
sixty-three, to were between fifty and fifty-two, i 
was eighteen; only 3 were between twenty and 
thirty, while 44 were between thirty and fifty years 
of age. 
The treatment of these cases may be by drugs or FIBROID TUMORS OF THE UTERUS. 
9 
by surgery, or by both, or by letting alone. The 
most common drug used is ergot. Alone, as a rule, 
it is ineffectual; combined with curetting, it helps 
to stop hemorrhage. The treatment by high doses 
of electricity sent through the uterus and tumor d la 
Apostoli, I have written upon at length elsewhere.1 
Suffice it to say that it sometimes arrests hemor- 
rhage, almost always relieves pain and gives strength, 
but rarely diminishes the size of the tumor. 
Removal of the ovaries for the cure of fibroids, 
particularly bleeding ones, was at one time exten- 
sively practised. I have practised it but four times. 
In one woman, forty-four years old, the tumor dis- 
appeared in a few weeks, and menstruation ceased 
at once. In another, thirty-three years old, the cata- 
menia gradually ceased after three years, and the 
tumor remained about the same when I last heard, in 
1887. In another woman, thirty-four years old, the 
operation was done on August 5, 1885. By May, 
1886, she had gained twenty-four pounds in weight, 
and was well and strong. From the time of the 
operation until November 10, 1885, a period of 
three months, she flowed incessantly, but slightly, 
nothing in amount to what she had done before the 
removal of the ovaries and tubes. From November 
10, 1885, until February 24, 1886, the flow wholly 
ceased. Since the latter date until May 13, 1886, 
she flowed continually, but not one-tenth as much 
as she used to. The tumor was somewhat dimin- 
ished. I have not seen her for six years. Another, 
thirty-six years old, was not at all relieved by the 
1 Boston Medical and Surgical Journal, vol. cxxiv, March 5, 
1891. IO 
HOMANS, 
operation. The tumor reached to the umbilicus, 
and the flooding was severe. I removed the ovaries 
and the tubes on January 21, 1886. Two years 
later the tumor had descended into the cavity of 
the uterus, and was removed per vaginam. Of 
course, after this the hemorrhage ceased. In another 
case, not my own, I have seen the tumor grow enor- 
mously after removal of the appendages, and I am 
inclined to regard the method as unreliable. 
Curetting the interior of the uterus often cures 
hemorrhage completely, and this curetting I follow 
by wiping the interior of the uterus with tincture of 
iodine. At the present time the surgical treatment 
is almost wholly by removal of the tumor, with or 
without the uterus. The kind of operation to be 
adopted has varied, and will vary with the particular 
case and the particular operator. In general, the 
two varieties of the operation are described as intra- 
peritoneal and extra-peritoneal treatment of the 
pedicle. 
Of course, if the tumor has been gradually ex- 
truded more or less into the cavity of the uterus, it 
should be enucleated and removed under the most 
careful antisepsis. Such protrusion will invariably 
be preceded by great hemorrhage, and will give 
abundant warning of the necessity of interference. 
Quite large tumors are extruded in this way. 
Tumors that have carried the fundus of the uterus 
to the umbilicus may occasionally, in the course of 
two or three years, descend into the cavity of the 
uterus, and be removed per vaginam. But tumors 
requiring removal, which do not thus become ex- 
truded, must be removed by abdominal section. FIBROID TUMORS OF THE UTERUS. 
II 
There are several ways of finishing this operation. 
Sometimes one can close the wound in the uterus 
by stitches and leave no pedicle, but simply a 
sutured wound, and then close the abdominal 
wound. Sometimes the base of the tumor and the 
body or neck of the uterus are compressed by a small 
ecraseur or serre-noeud, and a long pin, passed 
through the stump, holds it outside the skin of the 
abdomen ; this is called the extra-peritoneal treat- 
ment of the pedicle by Koeberle’s serre-noeud, or 
some modification of that instrument. Sometimes 
the stump is simply tied around as the pedicle of an 
ovarian tumor is, and is dropped back. Sometimes 
the stump is turned into the vagina after being 
ligated ; this is called the intra-vaginal treatment of 
the stump, and is, of course, extra-peritoneal. 
An the different modes of treatment depend for 
their fundamental success on asepsis, and on securing 
the vessels of the broad ligament, no matter in what 
way the pedicle or body or neck of the uterus is ulti- 
mately disposed of. I will not enumerate the differ- 
ent methods. The members of the Association are 
referred to the ingenious methods of operation 
described in the American Journal of Obstetrics, 
particularly in the contributions from Chicago 
during the past few years, and to the foreign jour- 
nals, particularly the German ones. 
The condition of most of those from whom fibroid 
tumors have been successfully removed by lapar- 
otomy is very comfortable. Some of them—I do not 
know exactly what proportion—suffer from what 
they call “hot flashes,” by which they mean a sen- 
sation of heat rushing to their heads. This is ex- 12 
HOMANS, 
tremely uncomfortable. In some cases it takes 
place every few minutes, in others at longer inter- 
vals. I do not know any way of relieving this 
distressing symptom. Others get extremely fat. A 
certain proportion, particularly those in whom the 
pedicle has been treated extra-peritoneally, suffer 
from ventral hernia. In all cases, however, in which 
the operation was really necessary the state of health 
is much improved, and the individual is very com- 
fortable. 
Sometimes the bladder is cut off by the wire 
ecraseur, owing to its not having been sufficiently 
dissected off from the tumor ; but in the only case 
of the kind occurring to me, the injury healed in a 
few weeks by keeping the bladder drained by means 
of a Sims’s catheter, and the accident has caused no 
subsequent trouble, the bladder having remained 
perfectly normal since the operation, some ten years 
ago. 
The length of an incision does not complicate an 
operation, provided there are no adhesions. I re- 
member one extending from the sternum to the 
pubes, in which a tumor weighing fifty-three pounds 
was removed. The scar remained sound, and there 
is no hernia. 
Very rarely, insanity follows the operation of re- 
moving a fibroid by laparotomy, as it sometimes 
does other surgical operations. Attacks of insanity 
that I have seen after surgical operations—such as 
ovariotomy, for instance—come on with normal 
temperature when recovery is taking place, and the 
insanity becomes more fixed and established as con- 
valescence merges into health. One of my patients FIBROID TUMORS OF THE UTERUS. 
13 
was an elderly person, sixty-eight years old, who 
recovered rapidly from ovariotomy; another was 
much younger, being only twenty-five years old. I 
have never seen insanity after hysterectomy. 
I have seen tetanus twice in cases of other opera- 
tors, but have never myself had an instance of it after 
hysterectomy. I have, however, had one case after 
an ovariotomy. 
I invariably see that my patients that have re- 
covered from abdominal hysterectomy are fitted 
with a firm abdominal supporter, and impress upon 
them the necessity of being careful about carrying 
heavy loads or straining themselves. The Medical News. 
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