The effects of fibromata upon the lying-in period, and that of the latter condition upon the tumors, are various and important.
In the first place we must remind the reader of the frequent and for midable secondary hemorrhages, due to uterine atony induced by the development of fibromata in the parenchyma of the uterus, which occur within a few (lays after delivery. I will here append the history of a case observed by myself, and attended by hemorrhage from the neoplasm itself. • The case seems to be unique, as I have failed to find one of the same variety in the literature of the subject.
A woman twenty-seveu years• old presented herself at the Strasbourg gynecological clinic with a very large abdominal tumor, which presented fluctuation. The uterus was explored with a sound by the assistant phy sician. Soon afterward a macerated fa!tus, aged four months, was ex pelled. Pregnancy had been masked by the enormously developed tumor. On the following day, about forty hours after delivery, the patient died suddenly with symptoms of internal hemorrhage. At the autopsy the abdominal cavity was found filled with blood. A largo, soft, sub-serous myoma was attached to the posterior uterine wall. The surface of the tumor was covered with very numerous large and broad veins situated directly under or in the peritoneal coat. The vessels were almost all per forated by very numerous little apertures, the size of the largest among which was that of a pill's head. (Compare the drawing, which does not well represent the appearances). The hemorrhage had proceeded from these apertures. Isolated openings of the same kind were found in the uterine substance near the vessels where there were no veins. The mi croscope showed (v. Recklinghausen) that there were no special morbid changes, but merely patulous interspaces between the tissue elements of the uterus. These spaces had passed quite through the walls of the veins, owing to the intimate connection between the muscles of the veins and those of the uterus, and had thus produced the hemorrhage. Since there was no evidence of any special morbid process, in this case the sieve-like perforation of the vessels must have been due to the effect of the muscu lar contractions of the uterus in labor or during the puerperal state.
The peritonitis, which often presents itself in cases of uterine myomata during labor, but wincipally in the postpartum state, is perhaps, also partly due to the uterine contractions. This remark applies only to
those cases of peritonitis which occur without any change in the struc ture of the tumor, and are, therefore, not the result of softening or disin tegration of the latter. Cases of this simple peritonitis are not very often encountered. Empis,' Winkel,' Dkormeaux and Hecker report such cases.
Not only those cases are here cited in which the peritonitis seems to have been due to the tumor alone, without morbid changes in the same, but also those due to traumatism, but unattended by septicaemia. All cases are, therefore, excluded in which severe obstetrical operations, lia ble to produce peritonitis, were tundertaken. The infrequency of the cases is thus explained An interesting case observed by Spiegelberg,' shows how difficult it is, in any given case, to decide whether the tumor be the cause of the peri tonitis, or be only simultaaeously diseased. The case was one of purulent peritonitis, with ulcerative endocarditis and uterine lymphangitis. The fibroid was surrounded by a purulent fluid which infiltrated the hterus, and had in its interior numerous cavities filled with pus. Th%cavities - were not the result of abscesses, but were dilated lymph-spaces, which, in common with the remaining lymphatics of the uterus, were filled with pus. Spiegelberg is inclined, in view of the history, to regard the tumor as the point of departure for the peritonitis.
It can be readily proven by all the cases in which a primary change can be discovered in the tumor, that the latter is very often the cause of general peritonitis, or of puerperal septic processes. This is most plainly seen in gangrene of sub-mucous fibromata projecting into the cavity of the puerperal uterus. Sub-serous and interstitial tumors of that variety may, however, undergo peculiar softening processes which load to the above-mentioned general diseases. In sub-serous fibroids the process is most easily explained when, as in the case of Robinson, (Siisserott, hoc. cit., p. 8) a laceration of the peritoneal covering of the tumor, with hem orrhage into the peritoneum and consecutive peritonitis, is found.