Not to speak of the different places of insertion, which in this instance happened to be demonstrable, I could trace exquisitely by the various ex aminations, the successive transformation of the long-existing (and long recognized) intra-mural nodules into polypi.
According to Gusserow, the so-called recurrence of fibrous tumors is more often explained by the fact " that after removal of a large tumor, others after a certain time attain such a size that they again give rise to trouble, rather than that smaller ones already present develop further in another way (sarcomatous degeneration, subsequent growth of a fibroma that had been only partially removed, etc.) In this way he explains in the simples'. way Kidd's case ' of a young woman, from whom in the course of a few years twenty-nine different fibrous polypi were removed. In many such cases the transformation of the intra-mural nodules into fibrous polypi, which was directly proved in one instance, would render still more readily conceivable the real existence of this supposed recur rence.
As regards my own additional observations in this direction, up to this time I have had no other opportunity of following out a case so thor oughly, but I have repeatedly met with a confirmation of one or the other point in our previous analyses. The spinster A., by reason of profuse hemorrhages at the beginning of the menopause, had already arrived at a state of profound aniemia. I removed from her at one operation three fi brous polypi the size of nuts, and found afterward that, although the uter ine cavity was empty, there were several nodular protuberances in the wall of the body, representing other intra-mural fibromata, which seemed to me, by reason of their projection outwards being more especially marked, to tend principally to a sub-serous development. When I saw the patient again about a year later, I found that the hemorrhages had returned only at inter vals, and were much less profuse, but that they were succeeded by extremely serious disturbances of another sort, a feeling of weight and fullness in the abdomen, backache, vesical tenesmus, etc. As I supposed, I found now that the isolated fibrous nodules had actually grown to a remarkable size, but that they all seemed to have a tendency to extend outward. They could be felt with especial ease through the anterior and posterior fornices, and were, by reason of their decided extension downward, to be regarded as the direct cause of the above-mentioned troubles. Notwithstanding, vio lent hemorrhages again occurred, and a year later I was obliged to remove a fibrous polypus as large as an orange (being obliged to incise the cervix in several places) and a second the size of a nut. The uterine cavity was
subsequently again found to be entirely empty, aiid the nodules were found extending outward in about the same way as before. The hemor rhages subsequently became less profuse, and have remained so until the present time, that is, for six months more. It is impossible to say what will finally, be the condition of this patient, who is now in her forty-eighth year, and still menstruates.
IIere again there seems to have been a formation of polypi at the menopause (at least the profuse hemorrhages were certainly of earlier date than the patient reported the first time), and the consequence of re moving the polypi, as regarded the hemorrhages, was again extremely favorable, in spite of the remaining intra-mural nodules. On the other hand, the case proves what I stated above with regard to the " recur rence" of polypi under such circumstances. There was only a partial tendency among the single interstitial nodules, as I learned by experi ence, to grow outward. Finally, I would again call attention here to the marked increase in size, which was noticed in the fibromata in this case, also, at the time of the climacteric, and which manifested itself by the series of subjective disturbances referred to, and could be demonstrated on examination.
Mrs. H., about fifty years of age, was at her home, pronounced to be incurably affected with cancer. She suffered for many months with hemorrhage and fcetid discharge, her mucous membranes were perfectly blanched, and there was extensive cedema. An internal examination re vealed a disintegrating tumor larger than a man's fist, which filled the entire vagina. By careful palpation, however, the intact edge of the os could be felt, as well as the pedicle of the tumor, reaching up into the uterine cavity. I removed the tumor, and found that it was purely fibrous in structure. A subsequent careful examination of the uterus revealed no further abnormality, and the woman recovered from that time. The hemorrhages, too, were at the same time permanently cured. Here, too, the climacteric was complicated by the formation of polypi. The polypus was in this case the sole cause of the continued bleeding; when it was removed the former was simultaneously and forever cured. As regards the above-mentioned subject of " recurrence," the return of a similar formation could be excluded at the outset, as well on account of the com plete removal of the first one, as in consequence of any other sub-mucous or interstitial fibroma, which could be shown with sufficient certainty. The subsequent history of the patient proved the correctness of the diagnosis.