Cruveilhier describes a similar case, the bleeding proceeding from an opening in a uterine sinus in the lower part of the tumor. (Matthews Duncan, I. c.) It is often stated that the investing uterine mucous mem brane is the source of the hemorrhages ordinarily encountered in patients affected with these tumors, but this can only be true of a small number of cases. The investing mucous membrane of sub-mucous, pediculated tumors will bleed, only in case it is in a state of venous stasis, as the result of compression, or when it is ulcerated. In either of these events uterine contractions give rise to profuse or even fatal hemorrhage from the torn and dilated veins.
But this accident scarcely ever happens when the tumors are sub mucous and attached by a broad base, or when they are interstitial. In these cases the mucous membrane enclosing the tumor is more or less thinned, atrophied and stretched, according to the size of the growth, and is only here and there permeated by thin-walled, ectatic veins of larger calibre. There is neither sufficient evidence, nor are there known anal ogous conditions to warrant the acceptance of the assertions of Atlee ' and others, who claim that such veins may tear at any menstrual epoch, and may thus occasion hemorrhage. At the same time I will not assert that such an occurrence is impossible. In fact I shall take occasion to describe later on a case, which belongs, perhaps, in this category.
The stretching and atrophy of the investing mucous membrane always induce marked collateral venous stasis in the remainder of the mucous membrane, which condition in itself leads to swelling and increased suc culence, and thereby to profuse hemorrhage at the menstrual period, just as always occurs under similar conditions, such as chronic metritis. To what an extent collateral congestion may develop, in cases of large•sized uterine fibromata, is well described by Cruveilliier: " Les veines utero-ovariennes et les veines ut•rines qui viennent de l'hypogastrique ont un volume enorme, dans un cas de ce genre, oil les veines superficielles avaient sillonne In surface do l'uterus, plusieurs avaient le volume d'une tres grosse plume a ecrire et memo d'avantage. Les arteres n'avaient aug ment& de volume que dans une bien moindre proportion." The changes in the uterine mucous membrane are not always produced in a purely mechanical way by congestive hyperiemia. Tumefaction of the mucous membrane of a more inflammatory nature may also occur, arising from irritant action of the tumor. Thus hemorrhages sometimes, although rarely, occur in cases of pure sub-serous fibromata associated with a diseased condition of various parts of the uterine tissue, which may best be designated as chronic metritis, and is more often associated with the presence of interstitial growths. How greatly developed and
extensive the collateral congestion may be, is well shown by an observa tion of Rokitansky, who reports a case of fatal hemorrhage from rupture 'of a greatly dilated varicose vein of the mucous membrane of the bladder, in a patient affected with a uterine fibroid. The menstrual flow has .always been unusually profuse in the few cases of uterine tumors, which have been both observed by me during the lifetime of the individuals. and recognized as pure myomata on post-mortem examination. In these cases the myomata had usually grown rapidly, especially in consequence of preg nancy, conformably to which the uterine mucous membrane was exceed ingly hypertrophic and was permeated by large venous sinuses.
In 1878 Wyder ' showed that the presence of fibroids of the interstitial and sub-serous varieties, leads to certain definite changes in the mucous membrane of the uterus. lie describes this condition in the following way: " The mucous membrane appeared much thickened. The microscope always showed considerable proliferation of the uterine glands. specimens they were closely crowded and appeared like cork-screws placed perpendicularly to the surface. In other cases the mucous membrane presented a more areolar appearance. Dilated, but not cystic gland tubules were found in these. The tubules were separated 5110600 other by broad trabecles of interglandular connective tissue." Wyder further emphasizes the fact that these changes resemble the condition known as adenoma diffusum. The observations of Wyder have since been confirmed by von Campe.' In spite of the fact that in most cases of fibromyomats, there is a con stantly present swelling of the mucous membrane, the secretion from the latter, outside of the menstrual epoch, is by no means always uniformly profuse. Just before and after the periods there is usually a rather free mucous discharge which in many instances soon ceases entirely, or at any rate diminishes to such an extent that patients do not pay any attention to it. In case a purulent discharge, the so-called fluor albus, makes its appearance later, we will almost always be able to detect an ulcerated con dition of the os uteri, with changes in the mucous membrane of the cervix. On the whole, it may be safely stated that a muco-purulent secre tion is by no means a prominent feature in the life-history of uterine fibroids.