Ramsbotham, Pajot, Ashwell, and Grimsdale ' cite cases of abortion, accompanied by profuse bleeding, produced by fibroids. Lloyd Roberts ' saw a sub-mucous, pediculated fibroma extruded with violent hemorrhage from the os uteri during the sixth month of pregnancy. Premature delivery did not occur in this case until a month later. Grimedale was obliged to enucleate a fibro-myoma from the posterior uterine wall during pregnancy, on account of dangerous hemorrhage. On the second day after the operation a foetus, four months old, was expelled. The mother recovered.
Tarnier° and mention violent pains, unaccompanied by inflam matory phenomena, among the symptoms of fibromata complicating preg nancy. Worship' saw death result in the sixth month of pregnancy from peritonitis. The foetus was not expelled. In this case a cystic myoma of the fundus was discovered to be the cause of the peritonitis. An attack of peritonitis, produced in the fifth month of pregnancy by inflammation in a pediculated sub-serous myoma, terminated in a similar manner. At the height of the disease artificial abortion had been induced. (R. Lee.') I have been unable to find any case of rupture of the pregnant uterus resulting from the growth of tumors.
It would not be surprising if these tumors often gave rise to extra uterine pregnancy. I have, however, been unable to find more than two such cases. Stolz ° observed tubal pregnancy in a case where a sub mucous fibroma filled the entire uterine cavity, and George Harley de scribes a tubal pregnancy which ended in fatal rupture of the uterus the fifth month. The uterus contained several sub-serous fibromata. One of these, situated at the junction of the left Fallopian tube with the uterus, was of specially large size. The ovum had been developed in the left Fallopian tube.' Nauss found the placenta abnormally located in only 16 out of 241 cases of myomata. Placenta prmvia occurred twice.' The placenta was situated very deeply in three cases. In eight cases the placenta was situated entirely or in great part upon the tumor, and, in three instances, a small portion of it was located upon the neoplasm. In eight of the last-men tioned cases sub-mucous tumors were present. It is at least probable that threatening hemorrhages, and perhaps gangrene of the tumor, in the puerperal state, may occur, with special frequency, after the expulsion of a placenta thus abnormally situated.
Michauk ' describes a deficiency in the membranes as large as a saucer, produced by their adhesion to a sub-mucous fibroid and the consequent retention, in utero, of a part of their tissues.
Morbid changes in the foetus, referable to these tumors, are rarely dis coverable during pregnancy. Gussmann' saw death of the foetus result. from premature separation of the placenta produced by a fibroid.
So long as the amniotic cavity is intact and the fmtns is alive, or even with a dead foetus, so long as the liquor amnii has not materially dimin ished in quantity, a fibroid can have but little influence on the shape of the child, which is protected by the fluid from the pressure of the tumor. Flattening of the foetus, fissures of the skull, etc., occur only when labor is rendered very difficult by oue of these tumors, and we shall revert to the consideration of these tumors in another place. The hrtus is only compressed when it has died during utero-gestation, and been reabsorbed. Depaul' and Lachapelle describe cases of this kind. Lever' saw a premature child born alive, but with its lower extremities bent, as if from close contact with a round body, in a case of fibroma which was large and hard.
Pregnancy complicated by uterine tumors often renders a diagnosis exceedingly difficult. It is very common for either th% pregnancy or the tumor to be overlooked. All the diagnostic symptoms of tumors cited above, as well as all the signs of pregnancy, must be carefully sought for. The most numerous and fatal diagnostic errors have been made because the possibility of co-existing pregnancy has not been considered.
The fact that many of the tumors produce no symptoms during preg nancy, accounts for the fact that they often escape observation. In other ,cases the symptoms due to the tumors become so prominent as to over shadow those of pregnancy. Whenever a tumor, occurring in a patient at puberty, grows rapidly or induces violent symptoms with relative rapidity, one must always consider the possibility of co-existent pregnancy. The oedematous infiltration of myomata, during pregnancy, has often caused these tumors to be regarded as of ovarian origin and to he punctured. The latter operation usually leads to abortion, and even to gangrene of the tumor. James Henry' undertook the operation of ovariotomy in a case which proved to be a softened sub-serous myoma. The patient died two and one-half hours after the operation, and the autopsy dis closed a foetus four months old in the uterus.