Another very favorable, but equally rare event, is the spontaneous expulsion of fibroids. This may happen, on the one hand, in cases of pediculated tumors as the result of simple tearing of the pedicle, or the tumor may actually be born, so to speak, through the medium of violent uterine contractions, and may then break off. But even in the case of the more interstitial tumors, those deeply seated beneath the mucous membrane, the capsule may be ruptured by the pains, and the entire mass may then be cast off. Both occurrences, although rare, terminate favorably with scarcely any exceptions. At most the act of expulsion is momentarily accompanied, or preceded, by a short period of profuse hemorrhage. Cases in which fibromata have torn away purely in conse quence of their own weight have been described by Routh and R. Lee (1. c.). Mansfield Clarke mentions vomiting as contributing to the same result, Marchand the association of straining during defecation, with violent hemorrhage.
Barnes' observed the expulsion of a fibroma as large as a walnut after rupture of the thin capsule, or avulsion of the pedicle from uterine con tractions resembling labor pains, Whiteford' after intense pains lasting several days, Dorsch" a similar event. Berdinel ° describes a case in which expulsion was preceded by pains resembling those of labor and by hemor rhage during a period of two months. During a violent paroxysm of coughing, associated with very profuse hemorrhage, the tumor suddenly sank until it lay just within the external genitals. No pedicle was de tected. The patient died. Hybre ' reports a similar case of a myoma weighing 2420 grammes, which was driven down as far as the vulva. It will be shown later that such accidents are very prone to occur during or after parturition.
The expulsion of uterine tumors after the occurrence of dissecting suppuration or disintegration takes place much more frequently than the above-described varieties of spontaneous extrusion. The processes of dis integration do not affect the body of the tumor, or if so, only to a slight extent, but are confined to the capsule or to the lax connective tissue surrounding the growth. The inflammation either starts, as is usually the case, from the enveloping mucous membrane, or the latter only becomes secondarily affected. The tumor is in every instance expelled en maw, except that scattered patches of the growth are here and there encountered in a sloughing condition. This mode of expulsion is sometimes associated with febrile manifestations, but generally terminates without danger to the patient. Calcified fibromata—so called uterine calculi—are most frequently cast off in this manner. These cases also are often intimately connected with the processes incident to parturition and childbed. In
stances of this description are numerous. Field' and Barnes' each oh served a case several weeks after childbed, Kiichenmeister ' saw one forty five days after confinement, and Schneider ° one five weeks after confine ment. It would take up too much space to mention all the cases reported in the literature of the subject : let it suffice to call attention to those of Kauffman, Ruge,• and Wardie.' Although the process of expulsion after dissecting suppuration is in many respects analogous to that of purulent liquefaction of the entire mass of the tumor, yet there is a broad line of demarcation between the two, both the course and the final termination being essentially different. Thus, while dissecting suppuration usually leads in a short time to the expulsion of the tumor, purulent liquefaction generally requires a much longer time for its completion, according as the tumor is large or small. Moreover, the process of purulent liquefaction necessarily carries with it the greater dangers of pyasmic infection, and consequently often leads to a fatal termination.
Uterine fibromata very frequently slough in consequence of the em ployment of various operative procedures, either for purposes of diagnosis (sponge tents, incision of the mouth of the womb), or in order to check hemorrhage (intrauterine injections), or finally after attempted extirpa tion of the neoplasms. The injury inflicted in these cases upon the en closing mucous membrane, often interferes with the nutrition of the tumor to such an extent as to induce mortification of the latter. The more extensive and severe the traumatism, and the more intimate the con nections of the tumor with the uterus, the greater is the liability to septi cemia and pyaemia. At any rate there is no doubt that a much larger num ber of those patients die in whom operative interference has been followed by sloughing of the tumor, than of those in whom the tumor has undergone gangrene spontaneously. It is self-evident that the duration of the gangrenous process as well as the size of the tumor involved are of prime importance in this respect.
Spontaneous gangrene develops most frequently from ulceration of the mucous membrane covering the tumor. Ulceration occurs quite rarely as long as the tumor is still entirely within the cavity of the uterus, and so long as no operative measures of any kind have been attempted. Under these circumstances it is most prone to develop during childbed, as will be shown hereafter. But these injuries occur very readily when the tu mor has forsaken the uterus, and rests either wholly or partly in the vagina. On the other hand it has previously been explained how hemorrhages into and cedetnatous softening of a tumor may lead to spontaneous gangrene of the latter.