So far as we have yet studied the subject, the climacteric generally exercises a favorable influence upon fibrous tumors. However, the number of observations is increasing, in which the changes referred to which often produce a cure are waited for in vain; and in which, at the climacteric, or after it, fibrous growths assume a more unfavorable char acter than before. In my opinion, this too is a chapter in pathology which ought to receive zealous attention. Of what profound importance it would be if our knowledge in its bearing upon prognosis could be some what extended, and in this way the above-mentioned doubts of the physi cian regarding such patients would, to some extent at least, be dispelled.
The most important point of all is the circumstance to which atten tion has already been called in the former pages, increase in size of fibro mata during and after the climacteric.
As Lawson Tait,' for example, observed " that the growth of the fibrous tumor does not cease in every case with the cessation of the menses," and he operated upon four women who had passed the meno pause, and suffered with rapidly-growing myomata, and Schorler has re ported four histories which show the exceptional growth of fibro-myomata after the menopause, — I have myself on some occasions been able to demonstrate such a condition. I have under observation at the present time a Mrs. P., aged about fifty-six, who was childless, ceased to men struate at forty-five, and came to me for the first time fifteen months ago, on account of an abdominal tumor which she had herself noticed two years before. I found at that time a sub-serous uterine fibroid, which extended upward to within two finger-breadths of the umbilicus, rested on the left side within the iliac fossa, and on the right extended to a point midway between the spine of the ilium and the linea alba, while below it caused quite a prominent protrusion of the posterior vaginal fornix. The tumor then caused absolutely no symptoms. A little more than nine months later the tumor extended a finger-breadth above the navel, its other dimensions remaining nearly the same as before, and caused various symptoms by pressing against the diaphragm. Three months later it allowed a marked enlargement in all directions, while the subjective troubles (dyspneea, nausea, etc.) increased still more, and to these were added further pressure-symptoms in the shape of extremely severe pains in the legs. There was an entire absence of any factor which would lead one to infer a change in the tumor itself (such as localized softening or fluctuation, sensitiveness on pressure, increased temperature, disturbance of the general nutrition, etc.), other than a simple increase in the size. The tumor always presented the same firmness and insensitiveness at every point, and the patient's troubles, although they were unpleasant and painful, nevertheless were only confined within the limits of pressure symptoms. Now the lady, by reason of the further increase in all her symptoms, has for some time entertained the idea of risking a radical operation. I have seen two or three other women with large interstitial tumors which continued to grow in spite of the establishment of the menopause, but the time during which I was able to observe them was too short to make the cases of value in this connection. In the case of H., which I described before, I was able to recognize in the clearest manner the growth of the fibrous masses during the climacteric period; and in the case of T., also, in which I had such an excellent opportunity to trace the transformation of the interstitial nodules into fibrous polypi, the first ones may indeed have produced those evident projections on the inner wall of the uterus, during the climacteric, simply by increasing in size.
This growth of fibro-myomata during, or after, the climacteric, which, as we have here recognized it, takes place without any change in the original character of the tumor, of course is rather opposed to the other retrograde processes which take place in the entire genital tract at this period, but especially to the shrinking processes observed in tumors of an entirely similar character in other cases. In the present state of our knowledge, it is impossible to recognize the true cause of the occasional occurrence of such an exception. We may perhaps throw light upon this subject subsequently, by observing next some parallel processes that take place in other parts of the body at this time. It may at least become clear how we can classify, so to speak, the occurrence in question. The closest comparison that can be instituted, in my opinion, is that with the increase in size of the uterus, which, as I mentioned in the introduc tion, precedes in many instances the retrograde metamorphosis of this organ. This increase in size depends, in all probability, merely upon a temporary congestion, and hence stands in a certain relation to the various localized congestions in other organs that are characteristic of the meno pause. If, now, we suppose that there is such a local increase in the sup ply of nutritive material, which is furnished to a fibroma that has existed for a year, but has hitherto remained of the same size, then this supply must be sufficient to cause further development of the tumor, that is, to form cell-elements similar to pre-existing ones, just as at other times the simple withdrawal of nourishing material (as in treatment by ergotin, cutting off of the blood-supply by operative interference, etc.) produc ing diminution in the size of the growth. At least it seems to me not improbable that, in most of the cases in which an increase in the size of a fibrous growth is recognized before each menstrual period, a true enlargement of the same c,ertainly results, if equalization is effected each time, by the influx of menstrual blood; and that accordingly the mere absence of this equalization at or after the climacteric, may always induce a further development of the tumor, when in any way increased congestion is produced. As we shall see later, these localized conges
tions at the time of the menopause are much less dependent upon an absolute plethora of the organism,—as has been quite generally admitted hitherto,—as upon a change in the activity of the vaso-motor nerves. This is of great importance in its bearing upon the question at issue, inasmuch as in this way it becomes further evident how it is that at the climacteric, at one time atrophy and at another increased development may take place in fibrous tumors that are quite similar in their structure. If the local increase in the blood-supply were due only to the influence of a general congestion, caused by the cessation of the menses, then this mu.st certainly take place in v.11 normally nourished women after the meno pause, and an existing fibroma would always begin to grow. But if the nervous system plays the principal 'part, whatever the general state of the circulation may be (compare the congestions in ana3mic women), then the actual individual differences in this respect at once seem to be con ceivable. After what has been said, then, the growth of fibrous tumors at or after the menopause, in isolated cases, should be attributed to local congestion, produced by individual changes in the innervation, and would then belong among the consequences of the vaso-motor disturbances due to the climacteric. As regards the still rather obscure subject of the transformation of fibrous into fibro-cystic tumors, it is often difficult to decide whether the menopause has any influence in this direction. The idea that the varying changes in the circulation occurring at this time may be directly connected with the occurrence of ectasite of the lymph or blood-vessels, is certainly worth entertaining. It is also not entirely without significance that llegar found in a series of fifty-one cases of fibro-cyst, that they were of most frequent occurrence between the ages of forty and fifty (in twenty-three cases); seventeen occurred between thirty and forty, the other eleven at an earlier or later period. I myself recall a case in this connection, in which the principal changes also oc curred at the time of the climacteric. Mrs. L. suffered for about thirty years with an interstitial fibromyoma, which apparently dated from the time of her second (and last) pregnancy. During the e,arly years a Vienna physician affirmed that it was about as large as a man's fist. Throughout the entire intervening period it is said to have undergone no marked changes; only the menses, which were profuse, since she began to suffer, continued to increase in amount as time went on, and eventually there was essentially a condition of atimmia, in consequence of which the patieitt felt very badly. Towards the end of her fortieth year the tumor underwent a striking enlargement, the entire set of severe pressure symptoms developed, and the climacteric hemorrhages (which were then very profuse, but now appear at intervals) gave her different physicians considerable to do. When I first saw the lady she was in the middle of her fiftieth year. The question which was presented to me then related to the great pain on the right side, which had awakened the suspicion of local peritonitis. I found the abdomen much enlarged, the tumor occu pying the entire pelvic cavity, and extending above the navel, while it was partly of firm consistence, but partly fluctuating. Besides, in the right hypogastrium, there projected prominently such a cystic portion with a smooth surface, and gave rise in that region to that severe localized pain, perhaps by reason of the excessive distension of the peritoneum. This condition, in connection with results of the examination, which I have described most accurately, left no doubt as to the diagnosis,—cysto fibroma,—but it can readily be imagined that I only established this with difficulty, since, as in most cases, here also the evident fluctuation con stantly led my colleagues to infer the presence of an ovarian cyst. The proposal of a radical operation was not accepted, and we were accordingly compelled, on account of the pains, which became unendurable as the tumor grew larger, to resort to puncture at that spot, in spite of the slight results which were to be expected, and the well-known danger of this procedure under such circumstances. On the first occasion we obtained scarcely a liter of clear, yellowish fluid, and no evil consequences followed; more than that, a decided amelioration of the local pain was noted, but unfortunately, as it appeared this lasted only a few days. A second puncture, undertaken some days later, at the urgent request of the patient, furnished a still smaller quantity of bloody fluid, containing fragments of tissue, and this time there was absolutely no relief from the pain. Whether wisely or not, finally laparotomy was permitted, and was performed by Professor R. The removal of the growth was rendered ex tremely difficult by the most extensive adhesions, as well as by the great friability of its walls, yet he succeeded in detaching the entire tumor, which consisted of large and minute spaces, and was mostly sub-serous, and in closing the large uterine wound carefully. In spite of the favora ble course of the case at first, the patient succumbed on the fifth day with evidences of peritonitis.