It is claimed by some writers that suppuration is sometimes preceded by cedema of the loose cellular tissue of the capsule. Fenerly and Empis' have each reported a case of these "bourses sereuses." Fenerly's1 case, however, is the only one having any value in this connection. That of Empis' relates to a woman who died of puerperal peritonitis, in which disease cedema of the pelvic connective tissue and uterus is quite preva lent. However that may be, the above described " dissecting " suppu ration and relaxation of the connective tissue of the capsule are most com monly observed in cases of calcified fibromata, which are thus placed in a condition favorable for expulsion. In this category belong cases such as that of Tysow,' who describes a fibroid, which, originating from the posterior wall of the uterus, and situated entirely within the true pelvis, underwent suppuration on its posterior aspect, thence pus made its way into the abdominal cavity, and gave rise to fatal peritonitis.
Maisonneuve ' reports an instance of purulent infiltration of the capsule of a myoma growing from the posterior wall of the uterus; here the pus penetrated through an opening in the wall of the uterus into the subper itoneal pelvic cellular tissue. Similar cases have been observed by Huguier and others.
Now, while inflammation of fibroid tumors of the uterus is seldom en• countered alone, it is frequently the cause of, and participate in, the breaking down and sloughing of these tumors. Many assume a condition of softening as a sort of transition stage from inflammation to mortifim tion, but there are no grounds for regarding this condition as one peculiar to uterine fibromata. The softening is either simple cedema, such as occurs quite often in disturbances of circulation within these tumors, in which event it is frequently enough a forerunner of gangrene, or it is a true breaking down of the tumor, in which, for some reason or other, the or dinary signs of decomposition, such as fcetor, discharge and so forth, are not well marked. The particular varieties of softening, such as the mxyomatous form and that which occurs in the puerperal state will be discussed later on. (Compare Hecker, Klinik II. 130 ) Necrosis of fibromata may be occasioned by insufficient supply of nu trient material. It is observed most frequently in cases of interstitial and submucous growths, when the overlying mucous membrane or the capsule is in any way affected. I am inclined to doubt whether simple catar rhal inflammation of the mucous membrane is capable of producing such an effect. When, however, a tumor of this variety is pressed into the os, the blood-supply of that portion of the enveloping mucous membrane which lies in the latter situation is often interfered with and leads to ulceration at that point. For a time this may be of no particular conse quence, but, finally, perhaps by infection from without, the ulceration presents a putrid aspect and then decomposition, starting from this point as a focus, attacks the entire substance of the tumor.
More frequently gangrene starts from an injury to the enveloping mu cous membrane, inflicted, either intentionally or accidentally, by the intro duction of sponge tents or a uterine sound, from the employment of intra uterine injections, or from attempts at instrumental removal of the tumor. Every gynecologist knors of one or more cases of this description. Putre faction will also occur whenever the capsule, which is the carrier of the nutrient vessels, is loosened from its attachments to the surrounding tissues by dissecting suppuration, and the tumor is thereby more or less cut off from its sources of nutrition. For the same reason decomposition so often affects calcified uterine fibromata, inasmuch as either large portions of the tumor are directly starved, or because the greater extent of the capsule participates in the calcareous change.
Pediculated submucous tumors also most frequently undergo decompo sition as a result of injuries inflicted on their enclosing mucous membrane —not infrequently, however, also, as a result of obstructed circulation. When a tumor of this class protrudes from the mouth of the womb, that aperture commonly contracts so firmly around the pedicle as to prevent the return flow of blood from the tumor, giving rise first to cedema, then to extravasations of blood, and finally to necrosis of the prolapsed portion. Subsorous tumors undergo putrefaction much more rarely, and in these cases, the process when not dependent upon an immediately preceding childbirth, is usually associated with partial calcareous degeneration. Of course, in this class of tumors hemorrhages may be occasioned by falls, blows and axial torsion' of the pedicle, and then decomposition of the extravasted fluid leads to putrefaction in the entire mass.
I could quote numerous examples of all of the above-mentioned contin gencies from my own experience and from the literature of the subject. I have personally investigated the cases reported by Pinault,' Barth,' Willaume • and Seyfert-Sixinger.• Neugebauer reports the following remarkable case. The putrefying contents of a calcified, subserous fibro ma broke externally through the anterior abdominal wall, the calcified shell remaining behind for a long period of time, presenting as a large cavity with rough, rigid and encrusted walls. Dumesnil ' describes an analogous instance of the spontaneous putrefaction of a subserous myoma. The case of Ziemssen t and Braxton Hicks' are remarkable as regards the size of the putrescent tumors. In the first case the summit of the swelling rose one inch above the umbilicus, while in that reported by Hicks the tumor dilated the uterus to the size attained in the seventh month of pregnancy.