Fibro-Myoma of the Uterus and Broad Ligament, 
of Forty-five Years Duration. 
BY 
THOMAS H. MANLEY, M. D., 
NEW YORK, 
Visiting' Surgeon to Harlem Hospital, Home and Hospital for the Aged, 
Yonkers, N. Y., and Hospital of Drumgoole Institution 
for Boys, Staten Island, New York. 
REPRINTED FROM 
The American Gynecological journal, Toledo, Ohio 
APRIL, 1893 1. Secondary Growth of Broad Ligament. 
2. Shell of Peritoneum over site of Atrophied Uterus. 
3. Fundus of Main Growth. 
4. Ex. Extremity of Main Growth or Tumor with Broad Ligament. 
5. Right Fallopian Tube over site < f Degenerated Ovum. 
6. Fimbriated Extremity of Left Fallopian Tube. 
7. Left Fallopian Tube. 
8. Elongated Cervix. 
9. Os Tincae. FIBRO-MYOMA OF THE UTERUS AND BROAD LIGAMENT, OF 
FORTY-FIVE YEARS DURATION. 
BY THOMAS II. MANLEY, M. D., NEW YORK, VISITING SURGEON TO HARLEM 
HOSPITAL, HOME AND HOSPITAL FOR THE AGED, YONKERS, N. Y., 
AND HOSPITAL OF DRUMGOOLE INSTITUTION FOR 
BOYS, STATEN ISLAND, NEW YORK. 
The history of the patient from whom the specimen here photo- 
graphed was removed, post-mortem, is remarkable, and the morbid 
anatomy with the pathological changes found on dissection are not only 
quite unique, but also teach a valuable lesson by the way of guiding us 
in the therapy of these cases. 
The patient was an old lady, in her 76th year. She had been 
under my observation for about five years. 
HISTORY OF THE CASE. 
The patient was of a healthy ancestry, her father and mother 
living into old age. There was no history in her family of neoplastic 
or malignant formations. She enjoyed good health until she first 
noticed the tumor. 
At the age of 29 years was married. Menstruation commenced 
early and continued regularly until five years after marriage, when she 
had some irregularities in this respect. Coincidentally with this, she 
noticed for the first time a fullness over the pubic symphysis. Her 
menstruation from this time on was irregular. She was never pregnant. 
For a long time she concealed the growth, but at the end of the fourth 
year it was so voluminous as to render further concealment impossible. 
She now consulted numerous physicians, few of whom agreed on diag- 
nosis. Finally, after suffering over several years, trying various 
applications locally, and taking freely of medicines internally, she went 
to Dr. Gunning Bedford. 
This was when she was 40 years old, and about the time that 
Kimball, of Lowell, and the elder Pancoast, of Philadelphia, were begin- 
ning the operations of the abdomen, which had brought down on their 
heads the fierce imprecations and smiting maledictions of the united 
medical profession of the world. But the news of the modern opera- 
tion had reached her ears, and she had her mind quite made up to risk 
her life and take her chances on surgical intervention. But, on the 2 
advice of friends, she first consulted one of the most noted authorities 
of his time, for Bedford was now at the zenith of his fame. 
He made a very thorough examination of her organs, the internal 
genital in particular. He informed her that she had an ovarian tumor. 
He strongly advised her against entertaining for a moment a thought of 
any sort of an abdominal operation. She abided by this decision, and 
hence, though in the latter years of her life these abdominal operations 
had attained to a marvellous degree of perfection, and she had been 
advised to place herself in the hands of the surgeon for operation, she 
declined, saying that as she had lived so long with it, she would not 
have anything done. 
She informed me that up to the menopause, which set in when she 
was 45 years old, the tumor was of great size, but that after this date 
it was reduced very considerably in volume, but was not reduced in 
weight. 
Independently of the weight of the mass, she suffered little incon- 
venience from it. She said, though, in earlier years it had caused 
bladder troubles, and constipation of late. The only discomfort it now 
gave her was when she stood or walked, it produced a dragging sensa- 
tion in the epigastrium and back. 
One of the most remarkable features in the ultimate history of her 
case was the " change of base," so to speak, in diagnosis. At the first 
time I saw her, five years ago, the case was regarded as one of hyper- 
trophic fibrosis of the right lobe of the liver, it being assumed that the 
supposed ovarian tumor had disappeared by resorption, and that this 
took its place. The case had been seen by Drs. Swift, Benedict and 
Harrington, 'of Yonkers, N. Y. Three years ago, in a consultation, it 
was examined by Drs. T. Waterman, George F. Shrady, of New York, 
and myself. At this time there was much diversity of opinion. Dr. 
Waterman, the senior medical officer of the institution, believed it to 
have its origin in the ovary. Dr. Shrady was more guarded, and said 
that as the mass presented so many confusing features, he would prefer 
delaying opinion " until a post-mortem could be held." 
PHYSICAL CONDITION. 4 
At this time, and up to the time she died, she was much emaciated. 
Her hair was gray, the skin dry, pale, wrinkled and atrophied. The 
teeth were all gone, and her body was so emaciated that the angular 
projections at the joints seemed all the more prominent. The same 
condition of bodily wasting caused the tumor in the abdomen to appear 
all the more conspicuous. It may be added here that while our 
patient was always ready to exhibit her deformity, under proper care 
to prevent exposure, her sense of modesty would not permit a vaginal 
examination. She walked with a stooped gait, her hands spread out 
over the tumor for its support, as it swung forward. 3 
Her temperature and pulse were normal. The appetite was feeble, 
but when she could secure a comfortable poeitiofi in bed she rested well, 
As the mass was very compact and weighty, it gave her much distress 
when she lay on the back, so that it was only on the lateral decubitus 
that rest was possible. Her urine was normal in quantity and quality. 
Now, on exposure of the entire abdomen, in the dorsal decubitus, 
its surface had a flattened outline, with a slight convexity in the right 
sacro-lumbar region. On this side, a large, hard mass could be felt to 
roll under the hand, from one side to the other. This, anteriorly, had 
a firm attachment to the umbilicus, which it had pushed forward, pro- 
ducing a nipple-shaped projection. The mass lay snugly up against 
the abdominal wall, so that on percussion it was clearly evident that 
the intestine was posterior to it. It was of a stone-like density, entirely 
insensitive to pressure. As she took the standing attitude, the charac- 
ter of the abdominal contour underwent a remarkable change. 
Now, the whole tumor tumbled forward over the pubic brim, 
through the abdominal centre. In fact, she had a ventral hernia. 
The tumor occupied a most singular position. It was covered only 
by the integument; hence, could be easily outlined quite distinctly 
with the fingers. 
On the right side, it was so lodged, coming down as it were from 
under the ribs, that it seemed continuous with the liver. With the 
fingers carried under its lower edge, it gave an impression of a wedge- 
shaped border, as the hepatic organ. It was freely movable in every 
direction for fl certain distance. 
My impression of the case was that it was a hernia composed of 
adenoid elements. I could not believe that the abdominal muscles 
would so atrophy as to entirely disappear by tumor pressure. My 
theory was that if the woman ever had an ovarian tumor it must have 
entirely disappeared; that she did have an omental, umbilical hernia, 
in which in time the lymph glands first underwent hypertrophic 
changes, and in its growth its borders gradually pressed their way in 
every direction, over the muscles and under the integument. 
There were many features in the history of the case which opposed 
this view, but, in considering the case from all its aspects, this seemed 
as natural as any other. 
Our patient in the end passed away from a slow, marasmic condi- 
tion, mal-assimilation and debility. 
POST-MORTEM EXAMINATION. 
Twenty-four hours after death an autopsy was made by me, in the 
presence of Drs. Waterman and Harrington. 
The abdominal cavity only was opened. 
It is unnecessary here to detail the different steps necessary to 
isolate and detach the growth. 4 
On opening the abdominal cavity, the fingers and then the hand 
were successively introduced, with a view of determining the relations of 
the uterus and ovaries. But no uterus could be found, and scarcely a 
remnant of either ovary. The anterior surface of the tumor was adhe- 
rent to the abdominal wall, from the ensiform cartilage to the symphysis 
pubis. Not a vestige of either rectus muscles could be found, as their 
parenchymatous substance had wholly disappeared, and nothing re- 
mained of the oblique or transverse muscles except a mere fringe, ex- 
tending about three inches from the spine. The constant, incessant 
pressure of the mass, for years in operation, had wholly annihilated the 
muscular wall, anteriorly and laterally. It was most remarkable that, 
while it had such extensive adhesions to the abdominal wall, the viscera, 
with the single exception of the base of the gall-bladder, had entirely 
escaped. 'And this adhesion was not extensive, so that it was easily 
detached. 
It would appear that the neoplasm Was originally submucous; 
that, as it mounted and distended the uterus, it wholly destroyed its 
muscular elements, the fibro-serous investment alone remaining; that 
as it rose in the abdomen it elongated the cervix, and was so forcibly 
crowded forward that it caused an adhesive inflammation, which bound 
it to the serous wall of the abdomen; so that, as the atrophic changes 
in it, caused by the menopause with senile shrinkage of the organs 
within the cavity of the peritoneum, and consequent diminution of 
intra-abdominal pressure, it swung pendulously from above downward; 
nature having in a most marvellous manner protected the organs vital 
to life from serious pressure. 
With the exception of the generative, all the other abdominal 
viscera were devoid of gross pathological changes. 
When the growth was removed, it was found to consist of two 
independent tumors: one, the larger, intra-uterine, and the other intra- 
ligamentous, had developed in the left broad ligament, close to the left 
horn of the uterus. Both weighed five and one-half pounds. 
On section, the stroma of both were found to have undergone ad- 
vanced degenerative changes ?f a fatty fibroid, gelatinoid and calcareous 
character. 
The cervical canal was nearly six inches in length, of the same 
diameter in the uterine terminus as at its outlet. 
COMMENTS. 
This case demonstrates that under certain circumstances the 
presence of a uterine fibroid is not incompatible with longevity, to say 
the least. 
When, as with the case cited, our patient has little else to do but ' 
nurse herself and is not obliged to work for a living, and there are no 
extensive adhesions with the intestines, digestion is not seriously 
disturbed. 5 
Yet, after all, when nature had come to her relief to her fullest 
measure, what do we find? A poor, suffering, helpless cripple for many 
of the best years of her life; an object of pity and commiseration. This 
burdensome load the abdominal muscles for years supported; but in 
time, as no succor came, they wasted away, let go their grip and per- 
mitted the mass to practically roll out of the cavity of the abdomen. 
In the end, though greatly reduced in volume, yet it persisted as 
a foreign substance, was an inconvenience while she was on her feet, and 
was a constant menace to her comfort while in bed. 
It was an ideal case in surgical operation; exclusive of the gall- 
bladder, having no important visceral adhesions; the cervix being so 
elongated, the entire mass could be rolled out of the abdominal wound 
by a high hysterectomy and the cervix clamped in the wound. With 
moderate precaution, neither hemorrhage nor sepsis should follow; 
convalescence should be rapid and a permanent cure assured. 
It will be noted in the cut that no trace of the uterus remains, nor 
anything like the normal ovary. The complete assimilation of the 
uterus in the case was an interesting feature and one important for the 
operator to bear in mind when measures are being considered of a sur- 
gical description. Displacement, total or partial absorption of one or 
more of the organs of generation, in the course of gynecological opera- 
tions, is a common event. Hence, unless one is familiar with the phase 
of the morbid anatomy which may present itself, he must needs be 
greatly embarrassed when the critical moment has arrived that the 
abdominal cavity is opened. 
We often hear of the removal of the ovaries spoken of as a means 
of arresting the growth of a fibroid, as though it were a simple opera- 
tion and effective in its results. 
Well, it is not always, either. One of the largest and most dis- 
tressing cases of fibroid I ever saw was spayed on both sides, without 
the slightest impression being made on the growth, which went on in- 
creasing in size after as before operation. This case was fully reported 
in "Annals of Gynecology " for May, 1888. 
Within a week I have seen a death in a young, hearty colored 
woman who had been operated on by one of the most expert in this 
line of surgery in this city. 
It required more than three full hours anaesthesia, and the ovaries 
were so matted down and adherent to adjacent parts by a previous in- 
flammation that they were discovered and gouged out only with the 
greatest difficulty. The shock was too much for the patient. 
A woman came under my care some years ago for operation on a 
large uterine fibroid. The dome of the mass was above the umbilicus. 
When the peritoneal cavity was opened, it was found that the tumor- 
which was an intra-uterine fibroid-had turned over partly on its axis, 
so that the tube, now larger in diameter than the finger, extended 6 
across the upper, horizontal surface, and higher than this was the ovary 
on the left side. After excision of the tumor, tube and ovary, which 
brought us down to the cervix, we sought in vain for the ovary on the 
right side. It was deemed necessary to remove this ovary to secure 
the menopause, as the woman was but 34 years old. She recovered 
and as a proof that there is an ovary or ovarian tissue somewhere in 
the pelvis, she menstruates still. Had we undertaken in this case to 
simply remove the ovaries and leave the tumor undisturbed, it would 
have been a total failure. Besides, though we did find the right one, 
which had been carried so far up by the growth, it would have availed 
nothing, for pathological changes had already so effectually destroyed 
it that the thickened capsule alone remained, its parenchyma having 
been entirely resorbed, and nothing remained of the gland but a hollow 
shell. 
Another case of ectopia came under my care, in the case of a 
woman who had an enormous intra-ligamentous cyst on the right side. 
Here, on the most careful bi-manual examination, no trace of the uterus 
could be found. But, under ether, when the abdominal walls were re- 
laxed, a nodular lump was easily made out, close to the umbilicus. It 
was supposed to be an outgrowth of the tumor. On operation, which 
was fatal in its consequences, this proved to be the uterus, which had a 
cervix of most unusual length. 
TREATMENT OF UTERINE FIBROIDS. 
A word on the treatment of uterine myomata, and these notes 
will be brought to a close. 
There are a few simple cardinal principles which should govern the 
treatment of this type of abdominal neoplasms, and applies equally to all. 
First.-Nothing in the way of direct surgical treatment should be 
recommended until we have first given constitutional and local 
measures a faithful trial. 
Let no one deceive himself about the general safety and simplicity 
of abdominal operations, for they are all perilous procedures which 
call for the highest degree of judgment and skill in their performance, 
and in the hands of the most expert may be followed by unpleasant 
consequences. Hence, internal medication properly directed, with cli- 
mating, dieting, travel, etc., combined with local treatment. 
Second.- Topical treatment, pressure, massage, electricity, etc. 
Rest in bed is an important adjunct. If the patient be suffering 
from organic disease which, in all probability, will soon cut off life or 
render an operation extra hazardous, then particularly we should 
confine our efforts to local treatment. 
Electricity has come prominently to the front lately in the treat- 
ment of fibroids. That it possesses useful properties in many, few 
unprejudiced can deny. That it will dissolve and scatter away a 7 
calloused old fibroid is too absurd to for a moment admit. But it will 
amuse the patient, and if she be highly hysterical, through its psycho- 
logical effects, it will make its impress on the growth, perhaps reduce 
or banish pain, induce retrogressive changes, and in that way render 
life more tolerable, But the electro-puncture should be interdicted, as 
there is no proof that it in the slighest manner affects those decompos- 
ing atrophic changes claimed for it by its most ardent partisans; but, 
on the contrary, by the extensive adhesions which it excites, it no 
doubt often renders a simple, safely operable tumor quite impossible of 
removal. 
Third.-Direct surgical intervention. 
There is but one thing in connection with the surgical therapy of 
these cases which will be here considered, and which it seems to me is 
of prime importance, viz., to keep out of the peritoneal cavity as much 
as possible. The majority of all large single fibroids are primarily sub- 
mucous or intra-uterine, and make their way through the uterine wall 
to reach the inferior surface of the peritoneal investment, only by a slow 
process. 
In their earlier stages they are low down in the pelvis, therefore, at 
this time, the uterine neck is short, as the mass from above crowds it 
downward. The histological elements are slowly disorganized and 
break down rapidly under inflammatory changes. 
Accordingly, when the cervical canal is short, it may be readily 
dilated and those masses easily reached and torn away, piece-meal or en 
masse. At any rate we can perforate it through the vagina, stuff the 
opening with iodoform gauze; in the meantime observing strict antisep- 
tic precautions. We must keep the track clear, administer a little 
ergot and aid nature in the work of evicting her useless tenant in such 
manner as subsequent indications point. 
The text-books generally set it down that intra-uterine fibroids 
always bleed, and that metrorrhagia is never absent. This is a mistake. 
One of the worst cases I ever saw had none at all. In her case, which 
was wrongly diagnosed and declared incurable, in two weeks the entire 
mass was delivered in segments, through the vagina. 
In another case of a colored woman sent to me by her physician to 
be spayed or hysterectomized, after two days dilation and preparation, 
two tumors were removed by forceps delivery. The larger one, even 
when turned on its long axis, would not come through until it was 
split in two. 
A lawyer's wife was sent to me for examination. She had made 
arrangements for a hysterectomy the next week, and was sent to me for 
my opinion, as her husband, when he learned that the operation meant 
the sacrifice of the uterus, was reluctent to have the operation per- 
formed. She was a young woman of 30, of a fine physique. Exami- 
nation revealed a large fibroid, filling the uterine cavity. She was ad- 8 
vised not to have the uterus amputated. The following week, after 
proper preparation, the mass was removed by myself without any diffi- 
culty. In none of these cases has there been any relapse. 
Pean's operation of clamping off the broad ligaments through the 
vagina, splitting the uterus and tumor in pieces and removing it 
through this outlet, strikes me as a very destructive expedient. It en- 
dangers the bladder and rectum and unsexes the woman. It may suf- 
fice in small growths low down; in large ones high up it is a measure 
full of peril. 
Hysterectomies for uterine fibroids are justifiable when they have 
destroyed the uterus, particularly with those advanced in years. Ab- 
dominal hysterectomy is a highly valuable operation in skilled hands 
and under proper surroundings. 
In the first case here narrated, had it been performed years ago, the 
patient would have been spared much torturing pain in early life, and 
in her declining years would have had that mental quiet which the 
successful ablation of the neoplasms always secures.