In the first place and most frequently this pressure manifests itself by pain or other abnormal sensations (tingling, etc.) in the lower extremi ties, as has already been alluded to. I have neither myself observed any instance of true paralysis from this cause, nor have I been able to find any references thereto in literature. Indeed, very little mention is made of the remaining pressure symptoms, although the lighter degrees occur very frequently, and the severer forms, such as often enough lead to the death of the sufferer, are by no means rare.
Let us first consider the symptoms of pressure upon the urinary apparatus, particularly the bladder and ureters. Both movable and stationary tumors do not, as a rule, exercise any severe pressure upon the bladder; they simply prevent full distension of this viscus, and thus occasion frequent micturition or only a desire to pass water frequently. On the other hand they sometimes cause retention of urine, and in this way favor the development of vesical catarrh. With reference to this point, Hardie' calls particular attention to those fibromata which are situated in the anterior wall of the uterus, and which, although so small as not to excite any symptoms of incarceration, yet exert pressure upon the neck of the bladder and urethra, especially if they become more or less swollen during menstruation.
Kidd' describes the occurrence of similar conditions in cases of small tumors when these have given rise to retroversion of the uterus. Close adhesions between tumor and bladder may also so obstruct the evacua tion of urine as to render even catheterization difficult. Fouresti6 des cribes a case of this kind, where the bladder, although empty, was spread out like a fan in front of the uterus, and extended as high as the um bilicus.
These conditions derive, of course, much greater importance in case the pressure upon the bladder and ureters is continuous or, worse still, is increasing, as happens in cases of incarcerated fibromata, which have either become firmly attached to the walls of the pelvis and to the neighboring viscera by perimetritic adhesions, or which, as is certainly much oftener the case, are firmly retained within the pelvis, being " in carcerated " in the true sense of the word.
Instances in which urwmic symptoms terminating fatally have been due to pressure exercised by the tumor upon the bladder and ureters, have been enumerated by Judo ' and Murphy.' Minot ' records a case of double hydronephrosis and consequent fatal uraemia, induced by a turner having a diameter of twelve centimetres, and adherent to the walls of the pelvis. Hubert' observed albuminuria, and diagnosticated " Morbus
Brightii " in consequence of compression of the ureters.
Budin's ' case is of importance from a diagnostic point of view. The patient was affected with a small, interstitial myoma in the inferior portion of the anterior wall of the uterus, completely occluding the outlet of the bladder, with great distension of the viscus. The swelling was diagnosed as an ovarian cyst, and was punctured with a fatal result, the cause of death being " Phlebitis uteri." Caternault ' and others mention similar errors in diagnosis. Dolbeau's patient died of uraemia from a purely incarcer ated tumor without adhesions. Fouresti6 and others report the formation of abscesses of the kidneys from pressure on the ureters (?).
Slight ursemic symptoms, such as persistent vomiting associated with scanty urination, are not infrequently observed.° Incarcerated tumors very often, of course, exercise pressure on the rec tum. Mato& reports such cases, among others, one in which total occlu sion of the rectum having been produced by a small uterine fibroid, he performed enterotomy, with a fatal result. A similar case, in which Broca' performed enterotomy, also terminated disastrously. In this case the oc clusion of the intestine was produced by adhesions, not by the direct pres sure of the tumor. Ducheussoy ° observed a case which terminated in death, with the symptoms of intestinal obstruction from pressure upon the rectum. Similar cases have been observed by Hold house," Dolbeau " and P. Rade," intestinal occlusion having been produced by cord-like adhesions between small tumors and intestine Ringland's " and Jude Hue's" cases pursued a more favorable course, albuminuria and the symptoms of intestinal occlusion passing off after elevation of the tumor out of the pelvis. Let me also call attention to the fact that such tumors, although firmly adherent within the pelvis, and giving rise to symptoms of pressure, may yet manifest a certain de gree of mobility on vaginal exploration, in so far as the vagina moves along with them.' Further information concerning incarcerated uterine fibro mata may be gained by consulting the papers of Spiegelberg and P. Mai ler.' Mild symptoms of pressure upon the rectum, such as obstinate constipation and hemorrhoidal conditions, are very frequently caused by even small fibroids.