THE GROWTH AND MORBID CHANGES OF UTERINE FIBROIDS.
a rule, fibromyomata of the uterus grow very slowly, their devel opment being inversely proportional to the contained amount of connective tissue, or, in other words, the more they approximate to the character of pure fibromata. Tumors rich in muscular elements, pure myo mata, grow more rapidly. They may, indeed, at times, undergo an exceed ingly rapid increase in size, especially when, as has been often noted, they are complicated with pregnancy. This condition being excluded, a sud den augmentation of volume of the tumors under consideration is due not, as many assert, to sudden growth, that is to proliferation and hyper trophy of their histological elements, but rather to circulatory changes taking place in them, such as oedema, inflammation or other pathological processes. Thus, very vascular fibromata undergo changes in volume before and after menstruation; in fact, the subsidence in size after the cessation of the menstrual flow has been so marked as to have been mistaken for actual atrophy of the tumor. This plienomedtni will be further des cribed later on, when we roach the consideration of the different forms of so-called cystofibromata. Similar changes may often be observed in cases of pediculated fibromata, when these are extruded beyond the external os, and the latter encircles the pedicle so tightly as to partially strangulate it, giving rise thereby to passive congestion and consequent oedema of the parts beyond the seat of constriction. When this occurs it should also not be mistaken for a sudden growth. On the other hand, a transient diminution of volume has been observed during the course of various de bilitating diseases, followed, after convalescence, by comparatively rapid in crease in size. Braun, Chiari and Spath ' state that this is particularly liable to happen in cases of Asiatic cholera. These changes also our chiefly in the various kinds of cystofibromata, and can scarcely be regarded as examples of growth. The numerous instances of uterine myomata met with in the practice of every physician, and which, during periods of close observation lasting many years, are found to manifest no perceptible increase in size, all prove how gradual the growth of most of these tumors really is. Their development is, however, entirely arrested only after they have undergone calcification.
In order to obtain a better idea of the growth of these tumors, I have endeavored, in the last fourteen of these cases which have been under my care, to determine how long they had already existed. This
method is, it is true, quite unreliable, for in Most instances we can designate the commencement of the new formation only by the date when it first gave rise to any symptoms. How uncertain such designa tion is does not require demonstration. In each concrete case it is uncertain what disturbances are to be regarded as the initial symptoms; moreover the statements of patients are usually unreliable; and finally, the first subjective phenomena of disease depend very closely upon the size of the tumor. A submucous myoma will at an early stage of its ex istence engender symptoms, while a subserons myoma may attain a large size before it manifests its presence by any morbid phenomena whatsoever. The following data will yield, therefore, only approximative figures in es timating the rapidity of growth of myomata. Counting from the date of the manifestation of the first symptoms, in one case the tumor attained the size of a fist in six months, in another it grew to the size of an apple in a year; in still another it became as large as a fist in the same space of time. After a duration of one and a half years, post-mortem examination revealed in one case the presence of two fibromata, one of them 55 milli, metres, the other 40 millimetres in diameter. In three cases the tumors had existed about two years: in the first the growth was as large as a fist, in the second the abdomen was distended by the tumor to a circumference of 76 centimetres, in the third the swelling was as large as a child's head, but had apparently not grown for the last two years. After having been no ticed for three years, in one case, the circumference of the abdomen had reached 88 centimetres, the distance from the ensiform process to the pubic symphysis being 38 centimetres; in a second case the tumor was about the size of the palm of the hand, in a third case the patient had noticed the swelling three years before, when it was as large as a hen's egg, while, when examined by me, it extended from the true pelvis up to the umbilicus. In two cases the tumor had existed five years, in one it was as large as a fist, in the other it projected three fingers' breadth above the symphysis. One tumor had existed for eight years, and was only as large as a fist, although it had not undergone calcification; and, finally, one had been noticed for at least nine and a half years, and had attained the size of a man's head. Judging from the above list, small though it be, it must be acknowledged that uterine myomata do not exhibit a par ticularly rapid rate of growth.