G. Richter' observed the evolution of a tumor of this kind in a girl 23 years old. The growth was so rapid that in two and a half years the cir cumference of the abdomen reached 1.62 metre. Schorler records the following observations, based on eighteen cases occurring at the clinic of Schroder. The first signs permitting a positive diagnosis were observed in three months. After a year there was still no very marked enlarge ment. In five years the tumors were about as large as a fist, and in thir teen had reached the size of a man's head. Eight months to one year ap peared to elapse before the abdominal circumference had increased 10 ctm., 2-1 years for 18 ctm. Twice the circumference increased 20 ctm. in about three years, and once in a year and a half.
That fibroids cease to grow after the menopause, or even diminish in volume has been repeatedly observed. But according to Schorler (L c.) women having fibroids reach the climacteric period later than others. The average age at the menopause may be placed at 47.13 years and at 50 the menopause is sure to have occurred. But Schorler found the change of life to occur on the average at 49.14 years in 29 cases observed in private practice, and in 23 dispensary patients at the age of 48. At 50 years of age (and over) 5.4 per cent, of all his private cases and 7.7 per cent. of all his dispensary cases of uterine fibroids still had regularly recur ring menstrual periods.
It appears probable that in all those cases where fibroids grow consider ably after the menopause, the tumors have vascular connections outside of the genital apparatus.' The pathological alterations to which fibromyomata are liable are of great interest in this respect, that they may each and every one lead to spontaneous cure, that is, either to an arrest of development, or to the extrusion, or finally, to the complete disappearance of the tumors by ab sorption.
Quite often one reads of inflammations affecting a fibroid tumor, with out being able to gain a clear idea of the change from a perusal of the re ports. Inflammatory processes are no doubt met with in fibromata when necrotic disintegration of the growth happens to take place, as we shall take occasion to describe later on. In such cases we often find on the bound ary line of the necrosed tissue a zone of reactive inflammation, which fre quently exhibits marked purulent infiltration, giving the adjoining tissue a streaked appearance. I have never been able to discover any other form _ of inflammation, provided the uterine tumors were intact. That which has been described as such in literature, usually from a clinical point of view, is either an active hypermmia or an (edematous swelling, occur ring as a rule at the time of menstruation, and giving rise to pain without fever. There can be no question but that inflammatory pains, now and
then associated with fever, do sometimes occur in cases of subserous fibro mata, but in these instances we undoubtedly have to do with a local ized affection of the peritoneum, and not with inflammation of the growth itself.
G. Braun ' describes an instance of " suppuration " of a fibroma, where by the uterus was distended to a length of seventeen centimetres. The pas escaped partly through the os uteri, partly through an opening in the right inguinal region.
Hecker' passed a trocar into a supposed ovarian cyst and let out many pints of pure pus. examination, a short time afterwards, showed not a cyst, but a large subperitoneal uterine fibroid.
Ch. Carter' 'demonstrated in the Obstetrical Society of London a speci men of fibroma of the uterus, eight inches long and six inches wide, at tached to the anterior wall of the uterus of a woman of sixty-nine years. The patient had first become aware of the existence of the tumor forty years before. The anterior wall of the tumor presented an opening as large as a sixpence, through which three pints of pus were evacuated. The internal surface of the cavity was rough and ragged, the enveloping shell being calcified, and varying in thickness from three quarters of an inch to two inches. Routh very properly inquired whether, taking into consideration the extreme rarity of suppuration in these cases, the sup posed pus had been examined microscopically, and further, whether any history of traumatism could be elicited. No answer, it seems, was given.
A similar, but very imperfectly reported case is that of Chambers.' He states that he found, on making an autopsy, a large, pediculated sub serous fibroid, which yielded on incision from ten to twelve pints of pus.
There can be no doubt that inflammatory processes, eventuating in sup puration, and which have occurred around fibroids, in the connective tis sue of their capsule, have been confounded with inflammation of the tumors themselves. Leaving out of consideration the cases that occur during the puerperal state, the former, although not by any means fre quent are nevertheless more often met with than suppuration of the tumors themselves. Suppuration of this character in the capsule of a tumor either leads to gangrene of the latter with ichorous disintegration, or the tumor is thereby so thoroughly loosened from its connection with the uterus, that it is often expelled whole and uninjured. It is an open question whether such inflammations develop spontaneously or depend upon traumatic influences.