in the vagina (fig. 244); the accompanying distortion of the os externum leads to difficulty in diagnosis. Cases in which a large tumour bulges through the ostium vagina have been mistaken for inversion and prolapsus. Sometimes, prolapsus is due to the weight of the tumour and disappears after its removal. The interstitial form is easily mistaken for inversion when the os is converted into a transverse cleft which escapes observation and the unaffected lip is thinned out to a mere band.

ETIOLOGY.

Gusserow, to whose exhaustive article-Die Neubildungen des Uterus-in Billroth's Handbuch we are greatly indebted in this chapter, says in regard to etiology, "Ueber die Ursachen der Uterusmyome wissen wir so wenig, wie über die Ursachen der meisten pathologischen Neubildungen, nämlich nichts" (of the causes of fibroid tumours we know as little as of the causes of most pathological newformations, that is nothing). Virchow and Winckel have both made elaborate attempts to assign a cause to the development of fibroid tumours. The number and variety of causes adduced by these observers only show how far we are from the knowledge of the real cause; with such a variety of causes, the difficulty would not be to explain why they are present in some but why they are not present in every case. They are without doubt the most frequent new formation in the Klob says that they are present in 50 p.c. of women who die over fifty years of age; and Bayle, in 20 p.c. of those who die over thirty-five years; both of these estimates are probably beyond the mark.

uterus.

Their development is in some way related to the development of the sexual apparatus. Thus, there are no well-authenticated cases of their arising before puberty or after the menopause. The majority of patients are between the ages of thirty and forty when they first seek medical advice, as is evident from the accompanying table based on statistics collected by Gusserow (fig. 245). Schroder says that of 196 patients, who during three years of his private practice consulted him for fibroid tumours, 104 were between forty and fifty and 62 between thirty and forty.

Sexual activity predisposes to their development as they are almost twice as frequent in married as in unmarried women; of 959 cases collected by Gusserow, 672 were married women. It is important to note this as it was formerly supposed that single life favoured their development. As the presence of a fibroid tumour interferes with conception, we often find sterility present.

* Barnes-Obst. Trans., III., p. 211.

Below 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 Above 70

CHAPTER XXXIV.

FIBROID TUMOURS OF THE UTERUS: SYMPTOMS;
DIAGNOSIS; PROGNOSIS.

LITERATURE.-See Literature of Chaps. XXXIII. and XXXV.

LIKE other pathological conditions of the uterus, fibroid tumours sometimes produce no symptoms and their presence is discovered accidentally or on post-mortem examination. This absence of symptoms is more likely to occur should the tumour be small, or should there be no sexual activity as in unmarried women. In the latter case, although symptoms appear only when the patient enters married life, the tumour may have been already a long time present. Subperitoneal tumours, even when large, may only produce discomfort from undue abdominal distention.

The symptoms usually present may be tabulated as follows:

1. Menorrhagia, irregular hæmorrhages;

2. Painful menstruation;

3. Pelvic sensations due to size and weight of tumour, peri

tonitic pain ;

4. Symptoms of pressure on bladder and rectum,

5. Sterility and abortion.

blood vessels and nerves,
ureters;

1. Hæmorrhage is the most characteristic symptom in submucous fibroids, and appears first as a gradual increase of the normal menstrual flow; it never begins with a sudden flooding, as in carcinoma uteri. In menorrhagia, the hæmorrhage comes from the hypertrophied mucous membrane of the uterine cavity generally; it does not come from the mucous membrane covering the surface of the tumour which is frequently thinned and atrophied, nor from the substance of the tumour itself which as we have seen is sparingly vascular. When, however, the submucous fibroid projects as a polypus, passive congestion and

hæmorrhage from the mucous membrane covering it may be occasioned by the constriction of its pedicle. Irregular hæmorrhages arise from ulceration of the mucous membrane covering the tumour, or rupture of the dilated veins in its capsule. Fig. 246 shows a case* in which,

Uterus containing Fibroid Tumour, from a case which terminated fatally through hæmorrhage. Note the large venous sinuses in the capsule, one of which ruptured at the point a (Matthews Duncan).

through the rupture of a uterine sinus in the lower part of the tumour, a sudden and fatal hæmorrhage occurred. In subperitoneal fibroids menstruation is not increased, and in certain rare cases is diminished. 2. Pain accompanies menstruation. In the submucous variety

*

Reported by Matthews Duncan-Edin. Med. Jour., 1867, p. 634. He also refers to a case of Cruveilhier's in which death was occasioned in the same way.

there is often characteristic uterine dysmenorrhea, in which the pain resembles labour pains. The congestion causes the polypus to swell, and this produces uterine contractions (v. Uterine Polypi). In interstitial and even in subserous fibroids, there is often pain at the menstrual period which cannot be thus explained. In subserous fibroids with a pedicle containing large vessels, as well as in interstitial, Gusserow ascribes the pain to the distention of the tumour with blood. This pain is of a stretching or dragging nature, and is quite different from the pain of uterine contractions.

3. Increased weight of the uterus occasions sensations of discomfort, which are described as fulness or weight in the pelvis," "a sensation of dragging," "bearing down pain." When the tumour is so large that it fills the pelvis and becomes wedged in it, intense pain is produced; this is either always present, or recurs only at the menstrual periods when the tumour is distended by blood. As in carcinoma uteri, peritonitic pains-indicated by local tenderness and reflex contraction of abdominal muscles may arise at any time from secondary chronic peritonitis. Neuralgic pain is sometimes present locally (see below), but may be also through the whole body.

*

4. Frequency of micturition, due to pressure on the bladder, is the most common pressure symptom. Pressure on the urethra produces difficulty of micturition and even retention; with some patients, this recurs regularly at the menstrual period. Even very small fibroids, when they are situated in the anterior uterine wall, may press on the neck of the bladder and produce symptoms of cystitis. Pressure on the rectum by fibroids in the posterior wall, occasions constipation or, more rarely, mucous diarrhoea. Incarcerated fibroids have produced complete obstruction, and led to a fatal result or furnished an indication for colotomy. Intestinal obstruction has also resulted from adhesions between the tumour and the small intestine.t Pressure on the veins produces hæmorrhoids and varicose veins in the legs. Interesting cases of neuralgia due to pressure on pelvic nerves have been recorded. In these cases the neuralgia entirely disappeared as soon as the tumour was lifted up and supported by a pessary. Compression of the ureters, with consequent dilatation and hydronephrosis, occurs less frequently in fibroid tumours than in carcinoma. The reason for this is evident; in carcinoma the compression is due to infiltration of the tissue round the ureter, which from the anatomical relation of the ureters to the *Holdhouse-Lond. Path. Soc. Trans., III., 371.

+ Eade-Lancet, Dec. 21, 1872.

‡ Kidd-Dub. Quart. Journ., 1872. Jude Hue-Annales de Gyn., IV., p. 239