These remarks do not, it is true, apply to the application of a ligature to the neck of a pediculated myoma, as the result of which sloughing almost inevitably occurs. The dangers of this procedure will be made apparent later. But in these cases the connection of the tumor with the rest of the body becomes very insignificant. When death results in cases of spontaneous gangrene it is more often caused by peritonitis, which is not necessarily due to the escape of mortifying tissue into the abdominal cavity. Cases have been reported by Braxton Hicks,' Maisonneuve and Maslieurat-Lagamar.° Cockle' reports a case of fatal peritonitis due to the passage of sloughy masses of the decomposed tumor through the dilated right Fallopian tube into the abdominal cavity.
Finally rupture may occur in any direction in cases of central mor tification, or when the os uteri does not dilate sufficiently to permit of the exit of the discharge, or when the tumor does not project into the cavity of the uterus. The perforation may occupy the abdominal wall in case this has previously become adherent to the surface of the tumor.
In addition to those instances of this accident which have been spoken of on page 220, let me mention one reported by Neugebauer.' The patient was affected with a subserous pediculated fibroma, partly calcified, winch became adherent to the abdominal parietes after parturition, and some time afterwards underwent spontaneous mortification, with the forma tion of an opening on the external surface of the abdomen. From this fragments of necrosed tumor tissue were removed, and there remained for a long time a cavity bounded by a calcareous shell. The patient final:• recovered.
Loir's2 case of gangrenous interstitial myoma, which worked its way through the walls of the uterus and abdomen, terminated unfavorably. Similar cases have been narrated by Dumesnil (compare page 220), Pinault' and Huguier.' Viardin ' observed perforation of gangrenous masses into the abdominal cavity, followed by fatal peritonitis.
I should like to mention in this connection a very peculiar and inter esting communication by W. A. Freund.' This gentleman observed in two cases of uterine fibroma, which were attacked by spontaneous soften ing or inflammation, the complete elimination of the tumors in the shape of a very profuse fluid discharge, mixed with solid fragments. No other signs of decomposition were present. The discharge was never fetid, there was no fever, there were no pains like those of labor, in short there were none of the symptoms which usually accompany the occurrence of true gangrene. The expelled masses consisted simply of softened fibroid tissue, with "einyesprenkelten gelben, sehr lockeren Parthien, ohne jedrn Geruch tend von blassgelber Farbe." They also contained con cretions of lime. Microscopical examination showed mainly fatty de. generation of the elements of the tumor. Both patients recovered com pletely. It must of course remain undecided whether, as asserted by Freund, the softening and expulsion of these tumors was due to the use of the mineral waters of Jastrzemb.
A second case, of the same nature probably, is reported by Botureau,' who found a fibroma converted into a faintly yellow, purulent, and but slightly foetid fluid.
Nothing need be added to what has been said above as to the final results of the calcification of uterine fibromata. These tumors either remain stationary and then give rise to no disturbance, or. they are es pulled in tho form of so-called uterine calculi,' after isolation by dissect ing suppuration.
Partial calcification, however, leads much more frequently to gangrene with all its attendant dangers. Perforation into the peritoneum, followed by fatal peritonitis, and perforation of the bladder by a calcified tumor, have also been observed (M'Clintock, 1.c.). Compare also Simpson' and Aran.' The freely discussed question—Do uterine fibroids recur after removal ? —may be answered in the negative. Tumors, which possess a structure in all respects similar to that of the tissues upon which and from which they have originated, manifest the peculiarity of developing at several points at the same time. But after removal they do not recur in the same situation. This definition of benignity also holds good clinically in the case of uterine fibroids. All observations which appear to show the contrary are susceptible of different explanations. Not a single one is calculated to prove beyond doubt the recurrence of these tumors. When we come to the consideration of sarcomata of the uterus it will be shown that the so-called " recurrent fibroids" of the English are probably nothing else than sarcomata. This is clearly demonstrated by a recent observation of M. Milner,' who found a sarcoma occupying the situation from which fibro-myomata had previously been removed.
In other cases there seems to have been only the later growth of an incompletely extirpated fibroma. Thus Valenta' records an instance of fibroma which was cut away as far as possible after the vagina had become invaded, but which grew so rapidly that within a few months it again reached as far as the vulva, requiring the removal of additional masses weighing If pounds. L. Mayer offers the same explanation for the reappearance of a peculiarly lobulated fibroid in a situation from which a similar tumor, as large as a child's head, had been removed two years previously.
Another explanation of seeming recurrence is that after the extirpa tion of a large tumor, other previously existing but small, and therefore undetected, tumors continued to grow until they attained a size sufficient to cause disturbance. Multiple occurrence is very characteristic of uterine fibroids. This affords the simplest explanation of cases like that of Kidd,' who removed from the uterus of a young woman twenty-nine different fibrous polypi in the course of a few years.
Finally it has happened to me (G. Braun describes a similar case) to have removed only the lower half of an hour-glass-shaped fibroma, under the impression that it was the entire tumor, the remaining upper half not being detected until Some time afterwards. When such an oversight is committed one is very liable to regard the subsequently appearing tumor as a recurrence.