If we were obliged to speak with the greatest reserve with reference to the transformation of fibromata into fibro-cysts, and to point to the influence of the climacteric in this direction simply as a possibility, its influence upon another process--the transformation of fibromata into sarcomata—must be described quite positively as a fact. It must be this process to which G. E. Sussdorff ' refers, when he says: "Although most of the functional and organic affections of the female genital organs de crease in severity after the menopause, in a considerable number of cases exactly the opposite occurs, so that a benignant degeneration may even become malignant." This process appears as a frequent occurrence in the practice of every busy physician, if only attention was more generally directed to it. Its slow course, the fact that the symptoms are often not urgent, the appearance of intercurrent conditions, which in one way or another divert the attention, the lack of opportunity for extended ob servation, or, finally, the absence of autopsy (which can indeed seldom be obtained), all unite in bringing it to pass that many a ease escapes notice. I myself, at least, after what I have observed, have no longer any doubt that the given cluinges in the character of those growths during or after the establishment of the climacteric, are of far more frequent occurrence than is commonly supposed. In deciding upon the cases ob served. I was of course confronted with the difficulties just mentioned. The patients were on a journey, or came from different parts of the coun try, and could, therefore, not be seen again. Others were placed under the care of other physicians for intercurrent affections, etc. I often had an opportunity to make a positive diagnosis in individual cases, yet I could not confirm this; at other times I learned that my opinion had been correct, but in the place where they were, there was not such interest taken in the matters that the value of the details or of the case itself were properly estimated. As I am aware, much was in this way lost to the general sum of knowledge. But by diligent questioning afterward, I could always supply data, and could, to my own satisfaction at least, supply the proof of the relative frequency of the occurrence in question. My fellow-specialists, by reason of similar experiences, have personally arrived at the same conclusion. It is due to the difficulty of following individual cases throughout their entire course that the statistics are still comparatively so small. I would mention the frequency of the process in question, simply because it seems to me as if sufficient stress had not been laid upon it hitherto.
It has long been proven that the process stands in general in close relation to the menopause. A collection of sixty-two eases of sarcoma (fifty-six by Rogivue from the literature, four observed by Simpson, and two by Gusserow), of which fourteen were referred to the period between thirty and thirty-nine, twenty-six between forty and forty-nine, and four teen between fifty and sixty, leads Gusserow to make this reserved ex pression of opinion: " If any conclusion is permissible, it would certainly appear from this that the climacteric period of life, just as in the case of other malignant uterine growths, shows a certain predisposition to sar coma of the uterus." In another place, however, this excellent observer expresses himself thus positively: " We must suspect the development of a fibro-sarcoma, or the transformation of a fibroma into the former, when ever a fibroma appears just at the climacteric, or whenever a growth of this character, that has hitherto been small, and has given rise to slight symptoms, or to none at all, at or after this period increases in size, or produces marked symptoms." Finally, he says: "Another characteristic
sign of sarcoma may be presented by the abnormally rapid growth of the doubtful tumor, especially, again, if this takes place during the climac teric period." It is well-known that Rokitansky and Virchow hold that the given process of transformation in fibromata (the more or less extensive com piession of the fibrous or myomatous structure, by a rich growth of round, less often spindle-cells) is the most common way in which the sarcoma is formed; far less frequently it developes primarily, and others (Sunert and Schroder) go so far as to assert that all fibro-sarcomata are fibromata that have undergone sarcomatous degeneration. Why it is, however, that the menopause should constitute the favorable period for the transition of homoOplestic to heteroplastic growths is entirely beyond our present knowledge. We had occasion in former pages t,o refer to the frequent development of carcinoma at the climacteric and post-climacteric periods. We have in this closely-allied process merely another link in this fatal chain before us, and this transformation that takes place in fibrous growths represents perhaps the most exaggerated nutritive changes, in which the change of innervation during and after the cli macteric finds expression.
I have recently observed the following cases: Mrs. W. suffered for several years with a sub-mucous fibroid and declined an operation, in spite of repeated hemorrhages. Since her fiftieth year the tumor has increased enormously, also the hemorrhages, while there is pain, emacia tion, and a watery discharge. When I examined the woman at the be ginning of her fifty-third year, the tumor extended to the navel, and protruded from the os, filling the vagina; the portion that could be felt was very soft, but not broken down. An operation was declined, and the woman returned home. Mrs. H. had for some years a uterine fibroid as large as the head, but so few symptoms that she married (?). Last year (when she was in her forty-ninth year) I saw her ag,ain, when she presented a cachectic appearance, and the tumor was much larger, softer, and very painful. Her physician tells me that her case is now hopeless; she, is extremely amemic, suffers greatly, and has hemorrhages and a fcetid discharge. Mrs. G. was examined by a gynecologist twenty years ago, and was said to have an interstitial fibroid. Towards the end of her fortieth year, the growth increased in size, and the pressure-symptoms were aggravated. I saw the patient when she was about fifty, when she complained of severe pains, hemorrhages and a constant watery dis charge; on examination, I found that the abdomen was filled with a solid tumor. The os was dilated, and on introducing the finger I felt a soft tumor. At the autopsy the growth was found to be cancerous. I have ilo doubt that in these three cases of complication of the menopause there was sarcomatous degeneration of pre-existing fibro-myomata.