Even fatty degeneration plays only a subordinate role in this morbid process. The above-mentioned case of A. Martin is the oirly accurately reported one of fatty degeneration extant.
Beginning fatty degeneration of myomata has been more frequently observed to affect these tumors in the postpartum state, but it does not lead to the above-described degeneration. The causes of this peculiar morbid process are not definitely known. It is unsatisfactory to refer it to circulatory derangements occurring during pregnancy and parturition. Nor can it be explained by the retrogressive changes in the uterine mus cles taking place in the post-partum state, because it should if referable to this cause, consist essentially in fatty degeneration. A review of the cases bearing on this question plainly shows that this form of degenera tion has been observed with special frequency after difficult and pro tractad labors. This fact suggests the thought that injuries of the tumors attendant upon parturition, and produced by compression of the fibroids between the child's head or the forceps, may act as a predisposing cause of fatty degeneration, by causing laceration of vessels with extravasation and consequent disturbances of nutrition.
0. Lehnerdt's ' case is very instructive with reference to the question under discussion. In that case the pelvis was considerably obstructed by a fibroma, which was extracted with the forceps. One half of the tumor had been transformed into a reddish, pulpy mass " not like pus," and " of the consistency of apple sauce." In the solid parts of the fibroid there were numerous extravasations of blood, which were probably the result of the injuries inflicted during labor. Hecker' had a similar case. The question whether the tumor may be absorbed, and thus entirely disap pear, must remain sub judice.
In some cases of this nature the softening of the tumor is said to have resulted from peritonitis or the cases of Hlwiz, loc. cit.). This is doubtless the case when the tumors contain genuine abscesses, which are usually situated, as Spiegelberg's careful investigations prove, in the lymph spaces of the tumor. Besides the cases of this kind already referred to, those of Banetche and Hecker (loc. cit.) deserve mention. Both cases were terminated by fatal peritonitis, which was, it is true, very probably caused by the morbid changes in the tumors. In C. Mayer's case' the tumor was punctured during labor, and changes in its tissues, which led to a fatal peritonitis, thus induced. This case, therefore, does not perhaps belong in this category. We must finally allude to Ashwell's case (Siisserott, loc. cit., p. 48) as belonging to this class.
Our knowledge concerning these changes in fibromyomata, during the puerperal state is therefore not exact, and the same remark applies to the post-parlum disappearance of these tumors. We have already alluded to the absorption of fibromata, and cited a number of cases in which it occurred. The number of well-attested cases in which these tumors grew smaller, in the puerperal state, is quite small, but their complete disap pearance has been proven to occur in still rarer instances. Besides the
cases above quoted, in which evident diminution of the tumors was dem onstrated, we farther cite those of Cazin, (Zoe. Braer,' Playfair,' Madge' and finally the interesting cases of Lohlein.' It has already been stated that complete disappearance of uterine inyo mata is not easily imaginable, since the connective-tissue elements of these tumors can not be readily absorbed. It is, however, doubtless true that such a tumor, if rich in muscular tissue, may become so much reduced in size that it produces no symptoms, and can not be certainly demon strated even by means of its anatomical characters. There is no doubt that such tumors do actually become decidedly smaller in the lying-in period.
The majority of the reported cases of this kind possess, however, very little significance, because they were probably cases in which a fibrosis had become hypertrophied or only oedematous, in the manner described during pregnancy, and having undergone atrophic changes in the puer peral state, had been restored to its original size by uterine contrac tions. If, therefore, in such a case the tumor had not been detected before, but was discovered during labor and was observed to diminish postpartum, it seemed, to the observer, to actually disappear. In real ity, however, it only returned to its original volume. Those cases in which this process could be studied in several pregnancies of the same patient are very instructive. The tumors which were not perceptible, or were discovered with difficulty before, grew considerably during each pregnancy, and returned in each instance to their former size during the puerperal state. Lorain,' Playfair (/oc. cit.) and others report such cases. There are, however, a few carefully observed cases in which the size of the tumor before conception was known, and in which the neoplasm be came decidedly smaller or almost entirely disappeared post-parturn.
Lohlein's case belongs here, in which a large fibromyoma, which had been observed a long time before the beginning of pregnancy, diminished materially in size during the puerperal state, and did not even attain to its original dimensions in a subsequent pregnancy.
Kauffman' saw a large fibroma disappear after abortion. Pregnancy ensued, but the tumor did not reappear. We wish to again call attention to the fact that fatty degeneration of the neoplasms, although often as sumed, has not been so often proven to exist.
In some cases it has been found possible to remove sub-mucous fibro mata, according to various methods, either immediately after confine ment simultaneously with the placenta, or during the earlier stages of the puerperal state.
This procedure is of course only really indicated when the tumor is easily accessible, and the injury inflicted trivial, since the prognosis of more serious operations might be sadly impaired by those conditions in cident to the puerperal state. Henry Yeld, Senderling, Ramsay, Kiwisch, Wynn-Williams,' Matthews Duncan,' Weber,' and Dfintzer' report cases of this kind.