We have already stated that any genuine softening, aside from the (edematous infiltration above described, does not occur in these tumors during pregnancy. This is confirmed by the statement of Nauss" that he discovered, on post-mortem examination of nineteen such cases, that only (edematous infiltration was present in thirteen of them. In the re maining literature of this subject I am unable to find any well-authenti cated cases of softening due to other causes.
Cases said to present softening of another kind have usually owed their necrotic disintegration to uterine contractions or to puerperal processes.
It cannot, however, be denied that this change may occur in such tumors Besides these changes in the growth of myomata during pregnancy, alterations in their forms are sometimes observed, and produce an ap parent disappearance of the tumors. Myomata located in the lower seg ment of the uterus may be so distorted and flattened by uterine contrac tions, particularly if they be interstitial, that they can be no longer discov ered by palpation. After the evacuation of the uterus the tumors re appear, owing to the diminution in the size of the uterine parietes.
The flattening of the fibroids may be produced by the pressure of the growing ovum, but is usually referable to the above-mentioned changes in form of the pregnant uterus. The flattening has always been most marked in the case of pure myomata lying free in the muscular walls. Such cases have been observed by Depaul, Gueniot,' Spiegelberg,' and Olshausen.' Gueniot describes a similar case of a large, pediculated sub mucous fibroma, which had been so imbedded in the uterine tissues during pregnancy, that it was considered an interstitial tumor. It ob structed labor to such an extent that it was necessary to perforate the child. The mother died, five days later, from peritonitis, and it was then discovered, for the first time, that the tumor was pediculated and might possibly have been removed before the death of the child.
Mention should be made of the displacement of fibroids from their original sites during pregnancy. Charrier saw a firm fibroma extruded from the uterus into the vagina of a woman in the seventh month of pregnancy without the occurrence of uterine contractions. It then began
to mortify, and spontaneous abortion, which occurred twenty-four days later, was followed by recovety. When the tumor finally appeared at the vulva it was gradually excised. It is doubtful whether it be wise to leave a gangrenous tumor so long connected with the uterus during preg nancy, parturition and the puerperal state as Charrier recommends. While this is the only case of the kind, so far as I know, which has been observed during pregnancy, similar ones are far more frequently encoun tered during labor. It is easy to understand how the uterine pains may force downward movable tumors occupying the lower segments of the uterus.
These changes in the seat of fibro-myomata are rare, but subserous tumors, situated in the body of the uterus, frequently wander from the pelvis into the abdominal cavity as the pregnant uterus enlarges. Nu merous cases have been reported in which such a tumor, which originally completely filled the pelvis, gradually escaped from it into the abdominal cavity.
However various the results of pregnancy may be upon the course of fibro-myomata, the influences of these tumors upon utero-gestation are still more manifold and of far greater importance to the patient. Cases are by no means rare in which pregnancy, labor and the puerperal state are not disturbed by the presence of such tumors.
It is oftentimes surprising that these functions should be faultlessly performed in spite of great distortion of the uterus by numerous fibroids. Ganiot ' mentions the case of a woman whose pregnancy and confine ment were normal, but whose uterus was filled with twenty fibromata of various sizes. Hecker' and others report similar cases.
On the other hand, abortion and preniature delivery are often induced by comparatively diminutive tumors. Toloczinow' found 21 cases of abortion among 119 pregnancies complicated with fibroids. West found 28 abortions among 36 similar cases, and Winckel 16 abortions out of 46 cases. Nauss found 47 of abortion among 241 pregnancies, and SAileau° 15 abortions among 47 cases. Lefour' observed 39 abortions in 307 cases. The mothers died 14 times. He also saw 23 premature confinements, with 3 deaths of the mothers.