COMPLIMENTS OE TUE WRITERS. 
MALIGNANT DEGENERATION OF A FIBROID 
TUMOR OF THE UTERUS. 
LARGE FALSE ANEURISM IN THE SUBSTANCE OF THE GROWTH. 
Drs. ALBERT N. BLODGETT , and CLIFTON E. WING, 
BOSTON. MALIGNANT DEGENERATION OF A FIBROID TUMOR OF 
THE UTERUS* 
Large False Aneurism in the Substance of the Growth. s' 
Drs. ALBERT N. BLODGETT and CLIFTON E. WING, 
BOSTON, MASSACHUSETTS. 
The following case presented some features which are so uncom- 
mon that it is considered worthy of being recorded :— 
Mrs. , a native of Massachusetts, was, at the time of her death, 
in November, 1878, fifty-three years of age. She was married when 
twenty-four. Had been a widow a number of years. Never was pregnant. 
Menstruation began at about the age of fourteen, and during all her mens- 
trual life was remarkably regular, recurring each twenty-eighth day Avith but 
one exception, when after exposure to cold its appearance was delayed two 
weeks, and then, for the only time in her life, was accompanied with some 
pain. The flow usually lasted ten or eleven days; was always profuse, but 
never enough to cause much prostration or give rise to alarm, and never 
required treatment. She never had much leucorrhcea. Menstruation ap- 
parently ceased the January before her death, but reappeared in small 
amount in July, and again, for the last time, in August. 
At the age of twenty-five (one year after marriage), on attempting to 
move a heavy piece of furniture, she “ felt something give way,” as she 
expressed it, and feeling of her abdomen at the seat of the sensation, she for 
the first time detected the presence of a hard mass of considerable size. 
This grew gradually larger up to the time of her death. Naturally 
enough, the lady, when she discovered the enlargement, regarded the strain 
which she had given herself as its cause, but doubtless the tumor had then 
existed for a considerable time, and in all probability her muscular effort 
caused the uterine mass to move, and this gave her the sensation which 
she experienced. 
The tumor did not at this time cause much inconvenience. It was neither 
painful nor tender, but as it did not disappear, the lady, after a while, took 
medical advice regarding it, and was told that she had an ovarian tumor. 
This view of her case she held until a few months before her death, although 
her family attendant, Dr. Brick, of Worcester, who attended her in her 
last sickness, has informed me that he regarded the tumor as a uterine 
fibroid, and supposed that she understood his opinion. She made several 
changes of residence during her married life, and thus had occasion to em- 
ploy a number of physicians at different times, but the idea of ovarian 
tumor seems to have been held by them all, with this one exception. She 
was a woman of much firmness of character, and when first told that she 
had an ovarian tumor, took the question of an operation for its removal 
under consideration (ovariotomy was not then as favorably regarded as now), 
and, after due deliberation, made up her mind, once and for all, that she 
would not undergo any operation. This partially explains why, although 
possessed of ample means, she never consulted a specialist nor any physician 
expert in such cases. Had she done so, the true nature of her trouble 
would, on proper examination, have been at once apparent. As it was, the 
* Published in the New York Medical Record, Jan. 3, 18S0, 2 
wrong diagnosis caused the case to excite much attention in social circles, 
for she had a wide acquaintance and many friends, and after it was reported 
that she had an ovarian tumor, and had decided to have nothing done, it 
was generally supposed that she would die in a comparatively short time. 
When, contrary to all expectation, she continued to live, it created much 
comment, and her case was often cited as proving that the idea held by 
physicians that ovarian tumors were so fatal, if left to themselves, was er- 
roneous. On several occasions, women with ovarian tumors, wrho had been 
advised to submit to ovariotomy, hearing of her case, came from'a distance 
to talk with her before making up their minds. How much harm may 
have been in this way caused by the mistaken diagnosis cannot, of course, 
be determined. 
In 1861 the lady had a severe attack of peritonitis following a journey 
by rail to New York, being confined to her room some months, and at 
several other times, after long drives or active exercise, she had attacks of 
abdominal tenderness, enough to confine her to the house for a few days, 
but nothing more serious up to the time of her fatal illness. In the last 
years of her life she had several attacks of renal colic, passing at various 
times a considerable amount of gravel from the bladder. With these ex- 
ceptions, her sufferings were mainly those arising from the weight and size 
of the abdominal tumor, which for years made her larger than a woman at 
the full term of pregnancy; but, notwithstanding the burden which she 
carried, she led a much more active life than most women, taking into her 
own hands the charge of her.large country place, and always herself driving 
her pair of ponies. Some time before her last illness she told me, in talk- 
ing about herself, that she thought she had had quite as little real suffering 
as the average of women. She was accustomed to eat but little, as “ there 
did not seem to be room for much.” She passed water rather frequently, 
but, strange to say, her bowels were always remarkably regular. 
In the spring before her death her friends noticed that she was not seem- 
ing as strong as usual, and during the early heated tern# of that year she 
was much prostrated, but on the advent of cooler weather felt better. 
Still, she did not regain her usual strength. During a friendly visit at her 
house in the summer, she asked my advice about what she had considered 
an umbilical hernia. On examination I found at the navel a large mass of 
varicose veins, evidently caused by the pressure of the tumor. She also 
had a bulging at the right inguinal ring, which did not seem to be either 
intestine or omentum, but simply peritoneum. The tumor at this time pre- 
sented the hard, rounded surface, and characteristic feel of a uterine fibroid, 
and appeared to fill the whole lower abdomen, extending above the navel. 
In the course of the conversation she remarked to me how curious it was 
that she should have lived so long with such a tumor. I explained to her 
that there was a great difference in abdominal tumors; that some were of 
rapid growth, and therefore quickly fatal if left to themselves, citing ovarian 
tumors as examples, while others were of very slow growth, and but rarely 
fatal, instancing fibroid tumors of the uterus, such as hers was. She asked 
if I thought it was a solid tumor of the womb itself, and not connected 
with the ovaries. I replied, that there could be no reasonable doubt that 
such was the case. She gave no evidence of being surprised, and I did not 
then know that she had ever been told that she had an ovarian tumor. I 
learned afterward, that when I left she went to a friend and expressed the 
greatest astonishment at what I had told her. 
Her fatal attack of illness, lasting about three months, came on after she 
had spent most of a day at a fair, where she was upon her feet much of the 
time—afterward riding a number of miles to her home. She felt, at the 3 
time, that she had done too much. She was soon after taken with abdo- 
minal pain and tenderness, and symptoms such as might accompany peri- 
tonitis. After a while a large effusion took place into the abdominal cavity. 
The increased distention gave her much distress, and interfered with res- 
piration, and her physician, Dr. Brick, used an aspirator, and drew off a 
large quantity of fluid with considerable relief, but she gradually failed, and 
finally died very quietly, having previously made the request that I should 
make an examination of her body, in order that if anything should be 
learned from it, other sufferers might in the future have the benefit of the 
knowledge thus obtained. 
Feeling that the post-mortem examination should be in the hands of a 
competent pathologist, I requested Dr. Blodgett to make it, and he has 
written out the following account of what he found. 
Autopsy, twenty-one hoars post-mortem.—The body is that of a tall, well- 
nourished person. Rigor mortis not well pronounced. The general ap- 
pearances give no evidence of prolonged suffering. Limbs generally well 
developed; face somewhat emaciated. Lower extremities moderately 
oedematous, particularly below the knees; upper extremities free from 
oedema. Upon surface of body generally more or less extensive livores, 
most marked upon dependent surfaces. Two centimetres (f inch) to right 
of umbilicus is a surface of cicatricial skin which extends 7.5 cm. in.) 
toward the pubes, and has a breadth varying from 4 cm. (1| in.) to 8 cm. 
(3 in.). The skin is smooth and tense at this part. The cicatrix is not of 
recent date. Below is a small red spot covered with plasters, where, it is 
said, paracentesis was performed twenty-four hours before death. Abdomen 
is enormously distended, presenting almost the figure of a hemisphere, the 
axis of which would be a line drawn from the ensiform appendix to the 
symphysis pubis. Through the abdominal parietes a large solid mass can 
be felt, which occupies the whole of the lower part of the cavity of the ab- 
domen and extends upward to a point half way between the umbilicus and 
ensiform cartilage, where there is an interval of distinct fluctuation, which 
is most perceptible in a line across the upper part of the abdomen. Nearer 
the ensiform appendix, fluctuation is no longer detected, the feeling being 
as if a soft solid were yielding before the pressure of the fingers. The 
liver cannot be felt, and percussion is unsatisfactory. The following are 
the measurements around the body: At the waist, 92.5 cm. (36 in.); at 
level of umbilicus, 121.5 cm. (47f in.); between umbilicus and pubis, 122 
cm. (47J in.); from umbilicus to ensiform cartilage, 28 cm. (11 in.); from 
umbilicus to pubis, 30.5 cm. (Ilf in.); from umbilicus to anterior superior 
spinous process of right ilium, 33.5 cm. (13 in.) ; from umbilicus to anterior 
superior spinous process of left ilium, 28.5 cm. in.). 
adiposus thick, and the tissues generally quite moist. Mus- 
cular portion of abdominal wall very much attenuated and seemingly atro- 
phied. Parietal peritoneum thickened almost to the density of fascia, 
feels brawny, and offers considerable resistance to the knife. Upon opening 
the abdomen a quantity, estimated at 3.5 litres (3£ qts.), of bloody serum 
escaped from its cavity. Diaphragm is very much thickened and quite 
dense and firm in all parts, the muscular portions greatly hypertrophied, 
the concavity very much exaggerated, reaching on the right side to the third 
rib, on the left side to the third intercostal space. The internal surface of 
the peritoneum is covered with numerous hard, firm, rounded prominences,- 
which are either attached by a flat surface to the peritoneum, or are, to a 
greater or less extent, pediculated and projected into the peritoneal cavity. 4 
They are generally of a rosy color and of an uniform consistency. A por- 
tion of peritoneum, about 10 cm. in.)in diameter, situated midway be- 
tween the umbilicus and the anterior superior spinous process of the right 
ilium, is covered with recent shaggy lymph, and at one point upon its sur- 
face is an adherent blood coagulum 2 cm. (f in.) in diameter and 1 cm. ($■ 
in.) in thickness, which apparently followed the operation of paracentesis, 
and is at present in a state of partial disintegration. Upon the left side is 
a tuft of about thirty separate filiform processes, which are attached separ- 
ately to the peritoneum at a point half way between the umbilicus and the 
axillary line, and extend to the surface of the pelvic growth to be presently 
described. The seat of attachment of these filamentous adhesions is a sur- 
face of about 8 square cm. (3-J- in.). The stomach is not visible, but is 
found in a position downward and backward from its normal situation in 
the immediate neighborhood of the spleen. The small bowel occupies a 
space of about 15 cm. (5£ in.) by 25 cm. (9£ in.) surface just below the 
ensiform appendix, and is much compressed. The surface of the bowel is 
dotted here and there with small nodular growths, similar to those observed 
upon the peritoneum. The liver is thickened and elongated, extending far 
into the left epigastric region, is of somewhat doughy consistency and of 
grayish, reddish-brown color. Upon being incised, tracings of fatty degen- 
eration of the portal sections of the acini are observable, together with 
hypera?mia and pigmentation of those portions of the acini surrounding the 
ultimate branchings of the hepatic vein. The capsule of the liver is at 
some points thickened, and presents nodules varying in size from a pin’s 
point to that of half a pea, scattered irregularly over its surface, more 
generally upon the lower aspect of the organ. The spleen presents nothing 
peculiar. 
The whole of the remaining abdominal space is occupied by an enormous 
growth consisting of a large central mass surrounded by a number of 
smaller growths attached to its periphery and projecting in various direc- 
tions from it. The mass in the centre is of roughly ellipsoidal form, pre- 
senting a depression in its posterior aspect, in which a portion of the small 
intestine is accommodated and entirely concealed from view (until the upper 
portion of the tumor is raised with the hands), and has a transverse 
diameter of about 20 cm. (7£ in.), an antero-posterior diameter of about 17 
cm. (Gf in.), and a height of about 25 cm. (9|- in.). Upon the right and 
left sides are excrescences in great number from 5 cm. (2 in.) to 15 cm. (5| 
in.) in diameter. These are most abundant behind and upon the left side, 
where they completely fill up the left iliac fossa. No trace of bladder, 
uterus, or rectum can be seen. The inguinal glands of both sides are en- 
larged and indurated, and the femoral vessels are accompanied in their way 
to the thigh by a dense funicular mass of tissue with bulbous enlargements 
scattered along its course. 
Owing to extensive adhesions between the tumor and the pelvic organs, 
particularly on the posterior surface, the whole of the mass was now 
removed from the body, together with the abdominal blood-vessels, 
glands, kidneys, spleen, rectum, vagina, bladder, and ovaries, and was 
placed upon a table where the relations of the parts could be more care- 
fully studied. The bladder was first laid open by an incision extending 
from the urethra to the fundus. The organ was of moderate size and 
contained no urine. No sacculations or other signs of vesical disease were 
observed, excepting a moderate injection of the smaller blood-vessels about 
the neck. The orifices of both ureters were found at the proper points in 
the bladder, and a flexible probe passed readily throughout the whole 
length of each. The vagina is. about 13 cm. (5 in.) deep, quite narrow 5 
and tense. The finger inserted in it can detect nothing resembling cervix 
or os, but is arrested by a firm hard wall. Upon laying the vagina open, a 
linear fissure is discovered in its deepest portion, into which a probe can be 
passed in a sinuous direction, a distance of about 7 cm. in.). The 
main direction of the canal is forward and toward the left side. Upon 
cutting the growth so as to expose the canal, this is seen to be the cavity of 
the uterus, and can be followed to a depth of 15 cm. (5£ in.). In its 
course lay an elongated mass of thicji gelatinous mucus of greenish-yellow 
color and tenacious character, and at the deepest portion of the canal are 
found two or three soft jelly-like mucous polypi which nearly fill its cavity, 
and are attached by small pedicles to its lining membrane. To the right and 
left of the uterine cavity the mass swells to a large tumor, upon the surface 
of which are numerous protuberances of various sizes, from that of a mar- 
ble to that of an infant’s head. The cut surface also shows numerous 
hard nodules of globular form, which are included in the mass arid can be 
easily separated from the body of the growth. Upon its posterior aspect 
the tumor gives off many accessory growths, one of which extended deep- 
ly into the cul-de-sac of Douglas and pressed firmly upon the perineum be- 
tween the rectum and vagina. Between the last mentioned portion and the 
main body of the growth are found, on each side, the ureters, each ureter 
lying much higher in the pelvis than the new growth, and closely applied 
to it, but not included in it. After long search the ovaries were found in a 
position upward, outward, and forward from this region. The left ovary 
is much encroached upon by a cystic formation of the size of a hen’s egg 
in the broad ligament. The ovary itself seems to be in fairly normal con- 
dition. The left Fallopian tube is found and traced for a distance of 12 
cm. (4|in.), at which point it is lost in the tissues about the tumor. It is 
pervious until it reaches this point, where no further canal can be discov- 
ered. The right ovary is the seat of numerous small cysts containing a 
clear, glairy fluid. One well-marked relic of menstruation was discovered. 
The right Fallopian tube cannot be found. 
Upon incising the tumor more freely, so as to follow the course of the 
uterine canal to its extremity, the median orifices of both Fallopian tubes 
are found, and both are pervious as far as the point where they emerge from 
the tumor, at which place there is atresia of both tubes for the space of 0.5 
cm. ; beyond this point both tubes are again pervious. The left tube 
measures 20 cm. (71 in.), the right 28 cm. (11 in.) from the surface of the 
tumor to the fimbriated extremity. Several large calcareous masses are 
found in various parts of the tumor, some of which seem to have resulted 
from extensive central calcification of certain nodules of the new growth, while 
in other parts the hard masses are made up of numerous small distinct nuclei 
of separate calcification. In many parts of the tumor, the true uterine 
muscular tissue is still found, while in other parts it cannot be detected. A 
large soft nodule, 15 cm. (5£ in.) in diameter, springs from the right side 
of the tumor at its posterior part, and upon being incised proved to be a 
false aneurism of 13 cm. (5£ in.) diameter, the wall of which is composed 
of uterine muscular tissue, and which is filled with blood. That portion of 
the clot which is in apposition with the wall of the sac, presents the appear- 
ance of having been effused at some considerable period previous to the 
death of the patient, and is partially organized and quite adherent to the 
wall of the sac. The central portion of the mass is occupied by a large 
soft clot of recent blood. Large vessels can be traced in the wall of the sac, 
but no communication can be discovered with the mass in the centre. Upon 
carefully turning out the clot from the median half of the sac, a large 
calcareous mass is found at its base, which protrudes to a moderate extent 6 
into the cavity of the sac. Upon one side of this mass is a true aneurism 
of one of the larger vessels, of flattened shape, 3 cm. ()■$• in.) long. 1 cm. 
(| in.) broad, and 0.5 cm. (| in.) deep. From the aneurism, blood-vessels 
pass in various directions, and two are discovered which open by torn and 
ragged extremities into the large sac before mentioned. A probe passed 
into either of these vessels emerges in the central clot of the large sac. This 
was afterward shown to the late Dr. Jackson, who pronounced it a remark- 
ably exceptional occurrence, and said that in his large experience he hud 
never observed a similar instance in connection with a fibroid tumor. 
The rectum is flattened and closely applied to the pathological growth, to 
which it is firmly bound by connective-tissue adhesions. At the situation 
of the sigmoid flexure it is forced into the shape of the letter U; its calibre 
is much diminished, and in some parts almost obliterated. Above this por- 
tion the bowel is moderately distended with fieces, and seems to be in 
normal condition. The lumbar glands are bound firmly together about the 
coeliac axis, and are adherent to the posterior aspect of the tumor. The 
blood-vessels are not noticeably affected, and are pervious. The blood-sup- 
ply to the pathological growth is mainly from branches of the internal iliac 
arteries, though other sources of nutrition may have existed. The kidneys 
were found in their normal relations to the aorta, and were carefully separ- 
ated, leaving only the ureters attached. These were followed downward and 
outward around the sides of the morbid growth, where they lay in intimate 
relations with it, but are not included in its structure. Both ureters are 
pervious, and show no signs of disturbance of function from the proximity 
of the diseased growth. 
Microscopical examinations of different portions of the foreign growth 
reveal a varying structure. The original tumor, in which the tissues of the 
uterus are found imbedded, is formed of dense connective tissue. Bundles 
of this tissue, with spindle-shaped cells, run in different directions, inter- 
lacing so as to form a close, firm structure, presenting the well-known 
appearances of an ordinary fibroid of the uterus. Some of the newer por- 
tions situated upon the periphery of the original growth possess the same 
structure, but others are composed of connective-tissue cells of varying 
shape and of large size, with large nuclei, provided with only a scanty inter- 
cellular substance, from which they easily separate, and float about in the 
field of the microscope, thus presenting a character not belonging to the 
structure of fibroid, but peculiar to sarcomatous growths. In many of the 
nodules projecting from all parts of the original fibroid the histological 
structure is so decidedly sarcomatous, that, judging from these portions 
alone, no one would suspect fibroma. The lymphatic glands of the lumbar 
plexus are enlarged and present the appearances of sarcomatous growth 
above described. The bronchial glands are affected in a peculiar manner: 
certain of them present only the ordinary structure and size of these glands, 
and are pigmented in the usual manner. Others are found in the immediate 
vicinity which are much enlarged, some being double the size of their 
neighbors, and these upon section show the original pigmented gland in the 
centre, surrounded by a layer of varying thickness of a white color, which 
presents, under the microscope, the same general appearances as the 
sarcomatous growths in the pelvis, and are evidently of metastatic origin. 
Scattered through the pulmonary structure, more generally in the lower 
lobes, are numerous nodules of a similar structure. These are firm, white 
or whitish-yellow, and vary in size from that of a pin’s head to that of half 
a pea. Throughout the whole abdomen are countless pendulous masses 
attached to the viscera, to the omentum, to the ligaments of the liver, to the 
surface of the bowel in its course, and to the whole upper part of the parietal 7 
peritoneum. These growths vary in size from that of a pea to that of a 
grape, are of somewhat irregular shape, of whitish-gray color, and prove to 
be of still another histological structure. They are made up of round cells, 
and surrounded by a capsular layer of varying density, and are good ex- 
amples of granulation tissue, such as is found in the indurated base of 
chronic ulcers, and is also the medium of new formation in the healing of 
wounds. These excrescences seem to have resulted, not from any infection 
from the tumor, hut from the long-continued irritation caused by its pres- 
ence, and resemble the papillary growths sometimes seen in other parts of 
the body as the result of chronic inflammatory action. The kidneys were 
apparently normal, as were the remaining abdominal organs. The heart 
was not noticeably diseased. A considerable amount of fat was deposited 
on and about it, but not more than the amount corresponding to the corpu- 
lency of the individual. The valves are all in a healthy condition. The 
head was not examined. 
In these days of operative interference the full history of such a case, 
left to run its natural course, is interesting, particularly so in this instance, 
on account of the rare conditions revealed by the autopsy. 
In former times, uterine fibroids were pretty generally looked upon as of 
a malignant nature and confounded with “ cancer,” especially when they 
grew to very large size. More lately, since their benign character has 
been understood, many distinguished authorities have held to the opinion 
that they were never the seat of primary malignant degeneration, and there 
has been considerable discussion upon this point. At present, although the 
possibility of such degeneration is generally accepted, its rareness is denied 
by no one. There are but few well-authenticated cases on record. From the 
post-mortem appearances in this case there seemed no doubt that the 
primary change began in the uterine mass, the changes found elsewhere 
being secondary in character. 
The finding of the false aneurism in such a growth was entirely unex- 
pected. That it should have attained such a size when its walls were 
formed of firm, dense, uterine tissue, is remarkable, and only to be explained 
by remembering that the principle of hydraulics utilized in the hydraulic 
press must have come into’play here up to the time of the coagulation of 
the effused blood. 
On abdominal palpation after death, I was surprised to feel the large 
mass formed by the aneurism, supposing at the time that it was an irreg- 
ularity of the fibroid, and wondering why, in feeling of the tumor in my 
examination some months before, I had not at once detected it, as then there 
was apparently no water in the abdominal cavity, and the surface of the 
growth could be plainly felt. On explaining to an intimate friend of the 
deceased, who was with her constantly during her sickness, what was found 
at the autopsy, she at once asked if the aneurism would not account for the 
fact that the pain was always worse on the right side, and told me that the 
patient, during her sickness, often spoke of a strange “swashing” sensation 
at that point, saying that that was the only word which seemed to at all ex- 
press the feeling. It therefore seems likely that the aneurism formed, and 
became filled with the clots found in it. during her last illness. 
It is also worthy of notice that, with such a large, irregular fibroid, the 
woman never suffered with dysmenorrhoea; the menses were regular; 
metrorrhagia never occurred. Notwithstanding the encroachment upon the 
calibre of the rectum, there was never constipation, and in spite of their 
position between masses of the growth, the ureters were not obstructed and 
the kidneys remained healthy. 8 
It is interesting to consider what might have been the result if, previous 
to her last sickness, an attempt had been made to remove the uterine mass 
by the operation of hysterotomy, made popular of late years by the pub- 
lication of the treatise of M. Pean, of Paris. The fact that with the exception 
of the tuft noted by Dr. Blodgett in his autopsy record, and which might 
have been easily separated, there were no adhesions above the pelvis, would 
very likely have induced the operator to go so far in attempting to separate 
those found in the pelvis, that before he was convinced the operation was 
not feasible, he would, perhaps, have inflicted an amount of damage in- 
compatible with the recovery of the patient. 
Again, supposing that the operator had succeeded in separating the pelvic 
adhesions, that portion of the growth which intruded upon Douglas’ cul-de- 
sac lay so much lower in the pelvis than did the ureters, and the latter 
were in such intimate relation with the mass, that one or both of them 
might easily have been injured in the removal of the tumor. 
This latter danger is not an imaginary one. I have myself seen the ac- 
cident happen at the hands of a well-known operator. The case is reported 
in the American Journal of Obstetrics for August, 1876, but no mention is 
made of the autopsy or this fact disclosed by it. In this case the tumor 
weighed fifty pounds, and was of such rapid growth that it was at first 
thought to be ovarian. As in the case we report, there had been little or 
no leucorrhoea, no dysmenorrhoea, and, up to its cessation, one year before, 
perfect regularity of the menstrual function. The flow, however, had 
usually lasted but three days, and been scanty during that time. The pa- 
tient’s sufferings arose simply from the weight of the tumor. She was 
able to walk about, had a good appetite, and good digestion. 
At the operation there were found pretty general adhesions at the upper 
part of the growth, which were easily separated. Luckily, there were no 
firm adhesions in the pelvis. Finally, the mass having been raised by as- 
sistants, the pedicle, consisting of the vagina and adjacent tissues, was 
ligated and cut, and the tumor removed. The patient, after rallying 
from the operation, soon began to show symptoms of internal hemorrage, 
and next day the abdomen was again opened, cleansed of much effused 
blood, and a vessel, which had been torn in separating adhesions, was 
found bleeding and tied. The patient being very low, transfusion was at- 
tempted without result. The next day transfusion was again done, but 
with no perceptible effect, and the patient died. 
At the autopsy considerable effused blood was found in the abdominal 
cavity, probably having come from other vessels torn in separating ad- 
hesions. A loop of the left ureter was found included ip the ligature which 
had been tied about the upper part of the vagina. The ureter above the 
part was very much distended, and the corresponding kidney in a state of 
acute disintegration. 
The operator, Dr. Thomas, in the last edition of his well-known text- 
book, mentions the case twice in the chapter on uterine fibroids. At one 
place, in speaking of the size to which such tumors grow, he simply states, 
without further particulars, the fact that he has “ removed one with uterus 
and both ovaries” weighing fifty pounds. Twenty pages further along, a 
foot-note to a table of statistics in which the case is tabulated as fatal, gives 
the same information. There is no reference to the injury to the ureter, 
nor is the liability to this accident included in his mention of the dangers 
of removal of fibroid uteri by gastrotomy. Thus the only particularly in- 
structive point about his case is not brought out. Curiously enough, the 
chapter closes with the sound remark, “ gastrotomy should be performed 
only when life is in jeopardy.”