Pain, or at least abnormal sensations of some kind, are almost invaria bly present. The important bearing which this symptom, under certain circumstances, exercises in the diagnosis of the variety and location of a uterine tumor, compels us to enter into a rather detailed analysis of its various features. In the first place pain in most cases manifests itself at first during menstruation, and is of a stretching or dragging character, depending upon the distension of the uterine walls, or upon a swollen condition of the tumor itself in consequence of menstrual congestion. This kind of pain is quite characteristic of the more interstitial tumors, and in cases of this description it frequently developes to an intense degree before the appearance of the menstrual flow; in fact it is often markedly relieved by the latter occurrence.
Even in cases of pediculated sub-serous myomata we not infrequently find patients complaining, at the time of menstruation, of similar pains, resulting from tumefaction of the tumor, and this seems mainly dependent upon the manner in which the tumor is connected through its pediele with the uterus. The more abundant the vascular supply of the tumor by way of the uterus, the more extensively will the former participate in the menstrual swelling. In such cases well-marked peritoneal irritation not infrequently affects the serous envelope of the tumor, and in this event there is acute pain on external pressure.
Peritoneal pain is not often observed, outside of the monthly periods, in patients with sub-serous fibroids, but when it does occur it is in many instances dependent upon true perinietritic processes, characterized by fever and other signs of peritonitis. These inflammations are probably often excited by the mechanical irritation incident to movern.nts of the tumor, but they may of course develop during menstrual congestion. They often lead in an astonishingly short space of time to adhesions of the tumor with the surrounding organs, so that a distinctly movable, pedicu lated fibroma may quickly become fixed. As we shall soon see, these tumors may cause peritonitis in other ways. The painful sensations which are felt during menstruation in cases of sub-mucous fibroids are of an entirely different nature They bear a closer resemblance to labor pains the more the tumors project into the cavity of the uterus, and are frequently so in tense that the neck of the uterus commences to dilate, thus permitting the tumor to become visible. As the uterine contractions induced by the menstrual hyperaemia abate, the tumor retracts and the os again closes.
This so-called birth' of a. sub-mucous fibroma often requires many menstrual periods for its completion. It depends to a certain extent upon the size of the downward growing tumor, but the chief factors are proba bly the thickness and breadth of the pedicle through which the growth is attached to the muscular tissue of the uterus. The greater the resistance of the former the more powerful are the uterine contractions, which come to a standstill only when the tumor actually protrudes beyond the os. It is self-evident that similar labor-simulating pains may also occur in cases of interstitial tumors, but this is observed much less frequently. I have 'often been struck with the great intensity of these pains (uterine colic), when the fibromata were soft, that is, when they consisted almost en tirely of muscular tissue. It would seem in these cases as if the tumors themselves participated in the contractions and thus aggravated the pains to an unbearable degree.
As soon as uterine fibroids have grown at all considerably, the above described paroxysmal pains connected with menstruation are associated with the most varied abnormal sensations in the lower part of the ab domen. A sense of fullness, of weight in the true pelvis, and of down ward pressure, persists after the uterine colic connected with menstrua tion has subsided. Painful sensations of a more chronic inflammatory character may also be present in these cases in consequence of perimetritis. There is rarely enough pressure on the nerves traversing the pelvic cavity to give rise to distinct neuralgia, still Kidd' describes a case of sciatica caused by a uterine fibroid and relieved by lifting the fibroid out of the pelvis by means of an air pessary.
Jude Hue' relates a similar case of long-standing sciatica, which was cured by the same method of treatment.
This kind of pain is produced by the pressure of the tumor, and is but one of the manifold and inconstant pressure-symptoms developed by fibromata. While no symptoms of this nature are caused by pediculated sub-serous myomata, a retro-vaginal, tightly wedged-in tumor may imperil the life of the bearer by pressure on the neighboring organs. The more closely the tumor is connected with the uterus, and the more sub-perito neal it at the same time is, the more readily will it occasion marked dis placements of the uterus, retroversion, retroflexion, or even complete dis location forwards, and these changes of position will modify the whole train of symptoms accordingly as the uterus itself is more or less enlarged by venous engorgement, etc.