It is impossible to decide, by reference to the data at our disposal, whether the tendency of fibromata to induce abortion be directly propor tionate to the extent of their projection into the uterine cavity. It would rather seem that interruption of pregnancy is the more frequently pro duced by these neoplasmata the lower their seat in the uterus, and the closer their approximation to the cervix.
According to Forget, Stbileau, and Toloczinow, those tumors which are attached to the fundus rather produce abortion, while those located at a lower point induce premature deliveries. This theory has not been universally accepted.
Abortion, when produced by these tumors, is caused by changes in the position of the uterus, by incarceration of that organ in the pelvis, and by hemorrhages referable to the presence of the tumors. But these exciting causes may be wanting, and the expulsion of the ovum be directly due to the tumor, or, rather, to its influence upon the uterine walls. Such eases of course occur more frequently than one would suppose from an examina tion of the literature of the subject, since only few of them are interesting for publication. Hall Davis ° describes such a case which produced the mother's death by pyremia. Beatty' reported a case of abortion at the third month, after which the tumor led to the development of uterine in version.
Fibromata very often produce backward displacements of the uterus in the first months of pregnancy. These retroflexions of the pregnant uterus are produced by the pressure of a very large fibro-myorna situated either at the fundus or on the anterior uterine wall. Still more fre quently the displacement is due to pediculated or non-pediculated sub serous tumors on the posterior wall.
In some cases the uterus, together with the tumor, spontaneously re turns to its normal position. In other instances symptoms of incucera tion manifest themselves, and manual reposition or artificial abortion be come necessary. Sometimes spontaneous abortion results from the in carceration or from attempts at reposition. Such cases of retrofiexion of the gravid uterus, induced by tumors at the fundus, in which, after suc cessful reposition spontaneous abortion occurred, are described by Simp son;' Lorimer,' who reported a case in which a fibroma as large as an orange and in the posterior wall, produced retroflexion and incarceration of the uterus, which rendered artificial abortion necessary. The patient
nevertheless died of gangrene of the bladder. Other cases are cited by Depaul and Ziegler (Conf. Nauss, loc. cit.) More frequently, for the rest, it happens that a myoma of the posterior uterine wall, which of itself produces incarceration of the uterus in the true pelvis and consequently induces threatening symptoms, is mistaken for retroflexion of the gravid uterus. Hall Davis' describes such a case as retroflexio uteri.
Exceedingly severe symptoms of incarceration, produced by a tumor on the posterior wall, or, more probably, in the cervix, occurred in a woman during the third or fourth month of pregnancy. Reposition seemed impos sible. When the sound was introduced it showed that there was no re troflexion. As a result of the exploration a putrescent foetus of about four months was expelled, after which the tumor was easily displaced from the pelvic into the abdominal cavity. The patient died of pyelone phritis.
Depaul' reported a similar case, in which so marked an incarceration of the tumor and the uterus occurred, in the fourth month of pregnancy, that the patient could neither defecate nor urinate, and the diagnosis of incarcerated hernia had been made. Artificial abortion resulted in the expulsion of an entirely flattened foetus. The patient recovered, and, after five months, the tumor was no larger than a small apple.
Sedgwick's ' case proves that incarceration may be by the upward displacement of the tumor beyond the superior strait. This case, however, terminated in spontaneous abortion. At a later stage of pregnancy the symptoms of incarceration may become so violent that all possibility of inducing artificial abortion disappears.
In such a case Cazin ' successfully performed Caesarean section in the seventh month of pregnancy. We shall revert to this subject later.
Hemorrhage must be cited as another threatening symptom liable to result during pregnancy from fibro-myomata. It is not often men tioned, because pregnancy rarely exists together with sub-mucous fibroids. Among nineteen cases of hemorrhage during pregnancy, collected by Nauss, there were sub-mucous myomata in eleven, interstitial in six and sub-peritoneal in two cases. These hemorrhages usually induce abortion. Nauss found only eight cases in which pregnancy reached a normal ter mination in spite of repeated hemorrhages.