THE COURSE, SYMPTOMS AND COMPLICATIONS OF UTERINE FIBROIDS.
The morbid manifestations naturally vary according to the size and location of the fibroids. In the first place it is a noteworthy fact that a not inconsiderable number of these tumors develop no symptoms at all during the life of their bearer& This is shown by their being frequently detected by pure accident in the living, but still more often in the dead subject. As a rule, the tumors give less trouble the smaller they are and the less active the sexual functions are. Thus, we find that, in individuals who have reached the climacteric period, they often, indeed usually, exist for years without creating any disturbance. This is also often the case in individuals who rarely or never have sexual intercourse, while, per contra, symptoms often manifest themselves with great intensity and astonishing rapidity, as soon as a patient affected with one of these tumors enters into wedded life or passes through a con finement.
The symptoms of uterine fibromata develop chiefly after puberty and probably depend, in the main, upon the location of the growth. Neverthe less the individual phenomena are neither so characteristic nor so constant as to enable us to determine from them alone the location of the tumors, namely whether they are sub-sorous, sub-mueous, or chiefly interstitial. This is the more readily understood when we remember that even the anatomical limits between these three varieties cannot always be accurately defined. In the following paragraphs each symptom will be discussed _ singly, but their bearing upon the question of the location of the tumors will be considered under the heading of diagnosis.
Among the various symptoms of fibroids of the uterus, there are two which for constancy of occurrence and importance are pre-eminent; these are hemorrhage and pain.
Hemorrhage is usually the first, at any rate certainly the most frequent symptom, and in the majority of cases it occurs chiefly under the guise of a profuse menstrual flow, i.e., menorrhagia. The amount of the flow is often very considerable within a few moments, so much so that patients justly speak of a gush of blood when they have their courses. In other in
stances the great amount of blood lost during a period is due to the latter being prolonged over many days, so many, in fact, that there is often an interval of only a few days between successive menstrual epochs. While the menstrual type of hemorrhage is in this manner finally obliterated, irregular hemorrhages (metrorrhagias) also not infrequently occur, espe cially after insignificant exciting causes, such as lifting a weight, and so forth.
Hemorrhages are usually entirely absent in cases of well-marked sub serous uterine myomata, especially when these are provided with a pedi cle. Still, sub-serous tumors, even when pediculated, may be associated with such pathological conditions of the uterine mucous membrane as will give rise to hemorrhages; this will happen when the tumors are so situated as to interfere with the circulation within the uterus. Hemor rhages are, however, observed more constantly and are of greater severity in all examples of sub-mucous, and in most instances of interstitial myomata. Sub-mucous pediculated tumors usually occasion the most profuse hemor rhages while they remain enclosed in the cavity of the uterus. The bleed ing very often ceases as soon as they protrude beyond the os uteri, but it is not seldom aggravated by this occurrence, as in case the contraction of the os is sufficiently powerful to induce venous stasis in the tumor and its enveloping mucous membrane.
It is only in very exceptional instances that the hemorrhage proceeds from the tumor itself, as most of the ordinary forms of uterine myomata are but poorly supplied with blood-vessels, and are, moreover, always cov ered by the uterine mucous membrane. Blood can escape from the tumor itself only when the latter is provided with vessels of large calibre, or with distended sinuses which have been laid open by ulceration or some other injury. Klob observed hemorrhage from the tortuous vessels en veloping a uterine myoma, after fracture of the pelvis. Matthews Dun ' observed fatal hemorrhage from the rupture of a venous sinus in a case of interstitial myoma.