Instances of gangrene attacking pediculated tumors after partial or complete extrusion through the os uteri have been reported by Braun, Chiari and Spaeth (p. 402), McClintock,' Freuitd," Mannel,' and many others. Baker-Brown,' Retzius,' and Jager' have intentionally lacerated the surface of such a tumor and induced decomposition as a curative measure. In another chapter we shall return to the consideration of these cases, as well as of those accidents of the same nature which occur during the puerperal state.
The microscopical examination of such necrosed tumors does not' dis close any peculiar features. We find all of the cellular elements in a state of fatty or finely-granular cloudy degeneration. The connective tissue fibrils have become liquified into cloudy granular masses, contain ing fatty corpuscles. The coloring matter of the contained blood is con verted into crystalline and granular particles. Fat crystals are also pres ent (Virchow), as well as spherules of leucin (Waldeyer).
While uterine myomata, when affected by sloughing, almost always at the same time undergo fatty degeneration, that process occurring alone and independent of other changes is certainly an exceedingly rare event. One is accustomed to speak of the fatty metamorphosis of these tumors as a very likely occurrence, particularly after childbirth, being led to this as sumption by the recollection of the process of involution which the muscu lar tissues of the uterus usually undergo after confinement. As a matter of fact, this occurrence has never been demonstrated. Virchow, Spiegel berg and others very properly call attention to the fact that the process of fatty metamorphosis attacks essentially only the muscular elements of the tumor, so that, at all events, the connective tissue stroma remains be hind. Now since some tumors, the pure myomata, consist solely of mus cular tissue, it is conceivable that these may undergo fatty metamorphosis throughout their whole extent, and there are cases in which the complete disappearance of such tumors can be explained on this assumption alone. But it would clearly be reasoning in a circle to attempt to demonstrate the frequency of such fatty degenerative changes, or even indeed their mere occurrence, simply from the fact of the disappearance, often more apparent than real, of uterine myomata. The literature of the subject
abounds in instances of the so-called fatty metamorphosis of fibromyo mata, but the only cases that are based on microscopical examination are those of Freund,' who clearly demonstrated the presence of fatty degener ation, although the tumors themselves had not undergone any diminution in volume, and A. Martin,' who records the case of a lying-in woman who had a broken-down fibroid filled with fatty detritus. Whether the obser vations of Hecker (Blinik. II. p. 130) concerning the occurrence of pulpy softening in the interior of fibromata during the puerperal state have any bearing on this point, will be investigated later.
There is another kind of regressive metamorphosis to which fibromata seem to be quite often subject. At any rate it cannot infrequently be de monstrated anatomically, namely induration or atrophy. The most preg nant examples of this change are met with in uterine tumors of a firm consistence, and rich in connective tissue, especially after the menopause. The muscular elements seem to be destroyed by fatty disintegration, while the connective tissue masses shrink and become atrophic and thus lead to a sort of cirrhosis of the growth. While such a condition is often ob served in the bodies of people of advanced age, it may also be met with iu rather young individuals. We may also include in this category all those cases in which a conspicuous and permanent decrease in the size of the uterine tumor has been observed during the life of the patient. Prieger,' Simpson,' and Kidd ° have each reported a case of this kind. In Kidd's case, a tumor, which at one time reached midway between the . symphysis and the umbilicus shrank, until only a small remnant could be detected. Meadows° and many others have recorded similar cases. It must be acknowledged, however, that many of these observations are of questionable value. Pelvic exudations have been confounded with tumors, and the transient enlargement of a tumor during the catemenial epoch, with a subsequent decrease in size, has been mistaken for induration. The latter error has certainly been committed by Bartels,' whose observa tion was disputed by C. Mayer as soon as it was promulgated.