It may also be stated here that according to Cruveilhier this process may be excited by thrombosis of the surrounding veins. Whenever I have found venous thrombi in the vicinity of sloughing tumors it has always seemed to me as if the former were rather the result than the cause of the latter.
When gangrene starts from the mucous membrane and commences as an ulceration, hemorrhages are usually observed from the outset, and are followed almost immediately by a fetid and putrid discharge. When sloughing occurs from other causes, in an uninjured tumor, it is very often preceded by the symptoms of softening or of the so-called inflamma tion of the tumor. The growth becomes larger, more tense, and fre quently yields a feeling of fluctuation. It is painful to the touch, and spontaneously excites either painful contractions of the uterus, or painful sensations in the peritoneum. As far as my experience goes, these occur rences take place spontaneously more often when the fibromata are soft —that is, when we have to do with myomata or myoma—than when the tumors are dense, although mortification is relatively frequent in cases of calcified fibromata. But in these instances it usually results from dissect ing suppuration. The patients suffer from fever, rapidly emaciate and lose their appetite. Violent uterine contractions cause the mouth of the womb to dilate, and then the gangrenous tissue is expelled, usually in rather large pieces mixed with an exceedingly fetid discharge of blood and pus.
In other cases there is merely a discharge of a very penetrating odor. At the same time very high fever is almost always present, together with all the signs of putrid infection. The further progress of the case de pends upon whether the sloughy masses have a free exit or not, and also upon the size of the tumor. In any event recovery is very rare ly observed. In cases that have terminated favorably errors of diag nosis have often been committed, in so far as the condition has probably been one of loosening and expulsion of the tumor en masse, after se questration by sloughing. Still, there have been occasional recoveries after sloughing of the tumor in its entirety. Thus recovery occurred in a case of uterine myoma extending an inch above the umbilicus, reported by Ziemssen.' This writer emphasizes the fact that the expelled manes consisted chiefly of muscular tissue, a fact to which attention has often been directed, and which suggests the question—are pure myomata pv titularly susceptible to mortification, or does the intervening connective tissue slough away more rapidly and thus set free the muscular bundles? Baker Brown' observed sloughing in a tumor of this nature, the proce€ lasting two years before the patient recovered. Braun, Chiari and Spith'
report two favorable cases, in which the mortified tissue was expelled through the patent os uteri by violent contractions.
In 3I'Clintock's ' paper, on the spontaneous elimination of uterine tumors, several instances are described of tumors which were first driven by uterine contractions outside of the vulva, and then became gangrenous. Similar cases have been reported by Field,' Saxinger,' Kristeller,' Heiberg, Playfair,' Chassagnac, and Demarquay.
Calcification, as has been already stated, appears to facilitate the de velopment of spontaneous gangrene, and under these circumstances re covery not infrequently takes place (Lumpe '). Under the heading of treatment, attention will be again directed to the fact that operative inter ference in cases of uterine tumors is liable to lead/to gangrene, either as an accidental sequel, or as an intentional therapeutic measure.
The course of spontaneous gangrene differs widely from that induced by artificial means. In the former event recovery may take place, as hai been shown above. In the latter, as we shall see, almost, all the patients perish. Even when symptoms of septicemia manifest themselves during the course of spontaneous gangrene, the final result of the affection may be favorable, as is seen in a case reported by Hardie.' In the whole literature of the subject I have succeeded in discovering but one case of fatal pyeemia following the spontaneous mortification of a myoma. This was reported by Spiegelberg,' and even in this one instance there is con siderable doubt as to the spontaniety of the process. Compare also Braun, Chiari and Spath, 1. c. Spontaneous gangrene, followed by ex pulsion and ending in the death of the patients, are also described by Labat ' and Jackson.' Although it may be true that numerous cases of spontaneous gan grene have not been made public, as not having been sufficiently striking,. there is yet a well-marked difference in the course and final result of these cases, as contrasted with those of artificially induced gangrene. The why and wherefore of this difference will be best explained by the recollection of the fact that, spontaneous gangrene occurs, as a rule, only after the tumors have been cut off from their nutrient source, that is, from their connections with the rest of the body, while in every instance of op erative interference, not only are fresh wounds inflicted, which facilitate the entrance of septic agents into the system, but the entire tumor still remains intimately connected with the uterus.