As an example, I shall again refer briefly to a case alrea,dy noted. When the lady came under my care she was well up in the forties, probably very near her climacteric, and, by reason of the fact that the fibroma had ex isted for many years, was actually accustomed to severe hemorrhages, as it were. However, I felt it my duty, considering the amemic condition in which she then was, and in expectation of the impending menopause, t,o advise strongly the removal of the tumor by an operation. Since I was not allowed to interfere surgically at that time, when the patient was later really at the height of the menopause (when the semi-annual intervals between her hemorrhages really awakened the hope that at each time tho end had been reached) I could, notwithstanding, not refrain from representing the necessity of an operation in still more urgent terms. I was again unsuccessful; the patient passed her critical period, literally grazing the edge of the grave, and now, as we have seen, she is not only perfectly healthy, but is also free from her tumor. However, if I had the same case to-day, I would only decide with redoubled earnestness for operative interference. The recollection of what I experienced in em ploying with the greatest activity every possible agent in order to control to some extent the fearful hemorrha,ges, and still entered the roorn each day dreading lest I should find the patient a corpse,—this recollection would make me regard any other advice as criminal sporting with a life that had been entrusted to me. The advances in operative technique are, I believe, too great not to make us reflect upon them when such op portunities are presented to us. Under somewhat favorable circumstances we shall be able to decide almost with certainty whether the spontaneous hemorrhages in question surpass in quantity the amount of blood that it is necessary to lose, or whether it ought not in all probability to be much less. On account of the strength of the patient we should sometimes, after the cessation of the last spontaneous hemorrhage, not feel too great anxiety; subsequent hemorrhages in such cases teach quite well how much the constitution can tolerate at times. Such cases as the one which has been mentioned here, in which the slightest additional attack would cer tainly have been sufficient to destroy the life which was already in jeop ardy, will serve as a proof. We will, therefore, be quite frequently obliged to weigh thoroughly and conscientiously both sides of the ques tion under consideration; this will be more especially the case according as our special knowledge becomes more extended, and we accordingly become more capable of estimating the true significance of every possible variation of these two sides.
I have not yet been able to convince myself that the menopause influ ences in another way the cure of fibrous disease, viz., by causing spon taneous expulsion of the tumor. As is known, this process is mostly observed in connection with delivery or the puerperal state, but it may occur quite well also at a later period. This is reported in articles that I have recently seen,' in the case of a woman forty-five years of age (who had had thirteen children, and for three years had observed a turnor as large as a child's head), and in that of E. Labat," where the patient was forty-seven, and had for six years noted a gradual increase in the size of her abdomen. In the first instance, after bleeding had continued for several months (the flow finally becoming watery and extremely fcetid), for five weeks gangrenous raasses of the interstitial uterine fibroid, half as large as the hand, were discharged. In the case of the second patient, who had latterly been greatl:a reduced by pain and hemorrhage, there came away at first a decomposing, very offensive mass, which was attached to the uterus, and was cut away,—then for ten days small fragments of a similar character were discharged. The patient succumbed to general purulent peritonitis, and the pieces found within the uterus, as well as those that had been previously discharged, showed under the microscope a fibromatous structure (the tumor being sessile). In Zeiss's report ' of Berthod's interesting case, in which a patient, after showing for almost two years most varied, and to some extent inflamntatory symptoms, con tinued to discharge one fibroid polypus after the other, partly entire and partly in pieces and fragments; there is no mention of her age, but I myself have made some similar observations at the time of the climac teric. We certainly cannot prove clearly that (excluding delivery and the puerperium) the menopause may also exert a favorable influence upon the expulsion of fibrous tumors, which, like the shrinking process before referred to, may lead to spontaneous cure. Of course further ob servations on this point are necessary, or, at least, the material already collected mtist be specially examined with regard to this question. It seems to me that there is a possibility that this may occur when we con sider, as regards pedunculated tumors, that the retrograde metamorphosis which affects the uterus can hardly occur without affecting the strength of the pedicle, hence the greater liability to tearing or stretching of the pedicle until the tumor is " delivered "; moreover, that (as I have con vinced myself) deep sub-mticous, or more interstitially situated tumors, may at the climacteric readily (and repeatedly) become pedunculated, which forms a prelude, if I may so express it, to expulsion; finally, that by reason of the commencing friability of the vessel-walls there is a dis position to hemorrhages, which may also take place within the tumor itself, so that the climacteric shrinking of these growths is frequently as sociated with calcification of the same. Now, hemorrhages and cedema
tons softening dispose to spontaneous gangrene, and partial calcification in its turn leads to dissecting 6uppuration, and in the majority of cases indeed to necrosis also (Gusserow). Thus expulsion of the tumor may take place in this way also, in case, of course, the very dangerous charac ter of one of them does not previously lead to a fatal termination (peri tonitis or septictemia).
I desire here to mention more particularly my experience (before re ferred to) regarding the pedunculation of interstitial tumors which occurs at the climacteric. This, I may say, is derived from only a few cases, but one of these was extremely valuable by reason of the opportu nity that I had for making careful observations. I have no doubt that similar observations already exist, but I do not happen to have access to them. I referred briefly to this case before in speaking of protracted climacteric hemorrhages due t,o fibromata, etc. But the fibrous gmwths in this particular instance presented the following peculiarity: When I examined the patient on account of her first profuse climacteric hemor rhage, I found, as mentioned above, that the uterus was enlarged to four times its normal size, while the walls were thickened and nodular, the uterine cavity, as measured by the sound, was increased in depth and empty, the cervix was normal, and the os closed. When the bleeding re curred I examined her again. The enlargement and nodular condition of the uterus were the same as before, but the portio vaginalis was soft ened and somewhat shorter, the os gaped somewhat, and the uterine cavity was filled with a fibroid polypus. Then I thought at once that I was mistaken in my first diagnosis of interstitial fibroid, and that I had to do from the outset with a fibroid polypus, which not only simulated nodular thickening of the uterine wall, but also, by allowing the sound to glide past it, gave a false impression concerning the emptiness of the uterine cavity. Yet, after the removal of the small polypus (as large as an egg), the nodular condition of the uterine wall persisted, and there was no diminution in the depth of the cavity. I could then adhere to my first diagnosis, only it was now changed to extrusion and complete pedunculation of one of those intra-mural nodules. Again, as I was able to convince myself after completing the operation, by careful palpation with the finger, the uterine cavity was entirely empty, and I could (con sidering the advanced age of the patient) certainly hope, in spite of the small nodules that still remained within the wall, that no further incident would occur. As a matter of fact, for six months after that there was a decided improvement. The hemorrlutges became much less and appeared but seldom. During this period I was not obliged to make a further examination. The-patient's strength continued to increase, and tbe long expected retrograde process with its beneficial results appeared to have begun. Then at the end of the supposed menopause we were again sur prised by a violent hemorrhage. It seemed at first as if this was only a climacteric hemorrhage favored by the (already-recognized) presence of the interstitial nodules, as it were, since I was able to convince myself in the most satisfactory manner at the time of the operation that the uterine cavity was empty. However, I at once made an examination, and found, quite contrary to my expectation, that there was another fibrous polypus of the same size as the first. This time I was obliged to dilate the cervix by the bloodless method; then I succeeded in removing it completely, as in the first instance, by means of the wire icraseur. The pedicles were in both cases about the thickness of a goose-quill. Of course I was now doubly interested in again making a most careful examination of the inner wall of the uterus. This time I was able to introduce the finger with un usual ease, since it was necessary on account of the operation to dilate thoroughly. Again was the cavity free from any further smaller polypi. The seat of insertion of the one that had just been removed, was exactly at the fundus, while that of the first one was lower down on the wall of the body. As contrasted with the condition found at the first examina tion, the following circumstance was very striking: while immediately after the removal of the polypus, aside from the breadth of the uterine cavity, I could detect nothing except the normal inner wall, while by the bi-manual or vaginal touch only the remaining intra-mural fibrous nodules could be felt, this time the index finger, while exploring the cavity, at once detected three or four quit,e hard, hemispherical masses projecting above the normal mucosa, the significance of which, after the observations already made in this case, must at once be evident. All of these intra.mural nodules, which I long ago recognized, undoubtedly tended to grow towards the cavity, and to become pedunculated, in short, to form a series of fibrous polypi like the two already removed.