Other instances of the same kind will be found under the heading of gangrene of fibromata. While the bursting through of the tumors is due in these cases to their decomposition, the contrary occurred in the cases described by Schroder.' In the latter the abdominal walls were greatly thinned, and were pushed out, so as to resemble hernial protrusions, by the pressure of large interstitial and submucous fibromata. In one case the abdominal wall was distended until it was as thin as a sheet of paper and finally underwent mortification, fully exposing the otherwise intact tumor. Neuschler's' case is almost identical.
peritonitis very seldom results in consequence of perforation from the pressure of fibroids, it develops more frequently as the result of mere tension of the peritoneal investment of these tumors, in case they begin to grow very rapidly or have become tightly wedged in the pelvis. Still, most of the cases of peritonitis which are observed in patients affected with myomata, are due to changes which have taken place in the tumors themselves, such as calcification and purulent liquefaction. Indeed, in cases of incarcerated fibromata the incipient stage of sloughing, the oedematous softening which is so frequently observed as the result of pressure, often leads to fatal general peritonitis, or to circumscribed perimetritis.
As frequently as perimetritic and parametritic processes occur in these and other cases of fibromata, as seldom do they, as a rule, end in the formation of abscesses. 1I'Clintock ' describes five cases of this descrip tion, death resulting in four from general peritonitis. One of these cases should perhaps be excluded, as the disease occurred in connection with the operative removal of the tumor—a not infrequent sequel. Kiiberle ' reports a case of fibroma in which a peritoneal abscess broke externally, leaving a fecal fistula.
Ascites is a not very frequent accompaniment of uterine fibromata, although, on the other hand, it does occur if the tumors have un dergone softening, or if great anemia has been caused by hemorrhage. Even when present it need not excite any symptoms. Cases of very abundant ascites persistently recurring after tapping have been described by KOberle and Pean.' We need make but passing mention of some other symptoms of uterine fibroma, edema, petechial extravasations on the lower extremities during the menstrual period (Winckel, e. p. 25), thromboses in the encircling veins, more rarely persistent vomiting and enlargement of the breasts. They are so seldom observed in these cases, besides being occasionally met with in all sorts of uterine diseases, that a characteristic relation to fibro mata cannot be assigned to them.
We see then, that fibromata, even when they are stationary, give rise to very varied symptoms; moreover, that their course is usually one of un interrupted growth up to the time of the menopause. This reached, a number of the more important symptoms, prominent among which is profuse menstruation, usually pass away, although this is not invariably the case. The tumor stops growing and the patent is relatively cured.
While this is a not infrequent occurrence, it certainly happens much more rarely that patients perish in consequence of the tumor, provided the latter have undergone no morbid alteration. In these cases death may be
due to severe hemorrhages, to acute peritonitis, or to uraemia from press ure on the pelvic viscera, as has previously been described. Mention should also be made, in this connection, of fatty degeneration of the heart. It has been observed by others as well as myself in cases of uterine fibroids, and is presumably due to chronic anaemia of the patients. This condition is doubtless frequently responsible for the fatal issue of the cases under consideration. Indeed, Ridirig (l.c.) observed "heart dis ease" in 8.4 per cent. of his cases. (Cr also the article of Rose.)' The course of the tumors under consideration is influenced chiefly by the anatomical changes to which they are liable. Among these the most favorable, and consequently the most important one is their complete disappearance, either by absorption (an undoubted but uncommon event), or more often by spontaneous exfoliation. Both processes are, indeed, ex ceedingly rare. While it is doubtful, to say the least, whether the former is often caused by parturition and childbed, the latter appears to he chiefly dependent on these states, as will be shown in another chapter.
Many refuse to accept the possibility of the perfect regressive metamor phosis of these tumors, and many of the reported instances of this occur rence are undoubtedly illusory. Diagnostic errors of this kind have been made in numerous cases of parametritic exudation, of the presence and course of which we formerly possessed but imperfect knowledge. Hard, indolent, often spherical pelvic exudations attached to the uterus are, even at the present time, often diagnosed as fibromata, and nothing is more common than the disappearance of such infiltrations after a longer or shorter interval. Prieger's' cases may probably be included in this cate gory. On the other hand, fibromata often undergo atrophic shrinkage after the menopause, and it is at least questionable whether these cases belong here. Moreover, fibroids not infrequently enlarge during pregnancy, in consequence of swelling, and return to their original size daring childbed. One cannot in these cases speak of an absorption of the tumor, in the proper sense of the word.' Notwithstanding all these objections, there remain a number of au thentic instances, in which absorption has certainly been observed. But these cases are by no means as numerous as many have asserted. Thus, while Schroder' collected thirty-six eases of this character from the litera ture of the subject, careful sifting of the original reports demonstrates that a large number of these will have to be excluded. Among these there is one reported by Clarke (quoted by Ashwell), who states that the tumor was "as big as a child's head," and was provided with two excres cences which became smaller after two years of observation,the uterus being as large as this organ is iu the fifth month of pregnancy. Of Ashwell's' cases at least one must be regarded as an exudation.