Dertnoids, which begin in fcetal life, as is known, generally give rise to no symptoms for a long time, and first come under observation in consequence of the changes that take place in them at certain periods. Puberty favors their growth, and the lesions produced by parturition lead to suppuration and necrosis, but the menopause does not seem to exert any special influence upon their growth. They have been accidentally discovered at the autopsy in quite old women, in whom they had given rise to no symptoms throughout their entire lives, not even at the climacteric.
Of the solid ovarian growths the comparatively rare fibromata gener ally occur in early life. According to Leopold, of thirteen patients, five were under thirty. They tend to grow slowly during the climacteric as well; yet Klob found an ovarian fibroma as large as a child's head in a woman of fifty-eight. The opposite retrograde change, such as was de scribed in uterine fibromata after the menopause, is generally absent in them, by reason of the small number of muscle-elements; Spiegelberg and Leopold affirm that it never occurs. The frequent calcification of the exterior of these tumors must be regarded in many cae.es as a post climacteric change.
Olshausen ' gives a table of 17 cases of sarcoma of the ovary (Leopold's, Winckel's, and four of his own cases), of which 3 developed before twenty, 4 before thirty, 8 between thirty and forty, and 2 in the sixty-second and sixty-sixth years. Small as these statistics are, they show the even dis tribution of the disease among different periods of life, and they at least show that there is no tendency to appearance at the time of the meno pause. Reference has repeatedly been made to the particular predisposi tion to this affection in early life, a tendency which, as regards carcinoma, Virchow considers as even of diagnostic value. Finally, as regards car cinoma of the ovary, we are also indebted to Olshausen 2 for a valuable collection of his own and others' cases. In this it is noted that 4 patients were under twenty. 12 between twenty and thirty, 7 between thirty and forty, 12 between forty and fifty, and 13 were fifty or older. A pretty positive conclusion can be drawn from this series of 48 cases. On the one hand, it supports the view entertained by Olshansen himself, that there is a certain predisposition to this affection in early life; he shows that of the patients who were over twenty, the majority had not passed forty, " unquestionably at and just after the age of puberty." On the
other hand, this table proves decidedly that the time of the menopause also disposes towards this disease, which agrees with Virchow's view before-mentioned, tlutt the tendency in question also belongs to later years. It follows naturally from Olshausen's assertion, that the diagnos tic value of this fact is limited to sarcoma; the youth of an individual by no means excludes the possibility of ovarian carcinoma in a given ease, since it has even been observed in children. But we are especially in terested in the second period of life, in which a disposition to this trouble is especially noticeable; this is without doubt the period during and after the establishment of the menopause. If now we remember the relative frequency of this affection as compared with all the other solid ovarian growths, we have here another important link iu the chain of noxious conditions, which may result from the menopause. Since we also saw before, that carcinoma of the corpus uteri generally occurs at a somewhat late period, and that carcinoma of the cervix has a preference for the time of the menopause itself, and that as regards carcinoma of the ovaries, too many cases show the first tntces of the disease after the establishment of the change, there appears to be a certain definite relation between all these affections and the period of life which we are studying. We shall see later how various other still more common " climacteric conditions '' persist for years after the normal cessation of the menses, and we shall be justified in assigning the term " menopause " to a more extended period than that which it hitherto has been the custom to allot to it. When thus considered, a whole series of abnormal changes will be in cluded rather under this head (especially most of the troubles mentioned, whether they appear a few years sooner or later), and we may formulate so much the more positively the law that the tendency to malignant dis ease of the pelvic organs is increased at the climacteric. Finally, I would call attention in this place to a fact that is explained by the intimate re lation between the organs in question, i.e., the frequency of malignant disease of the breast, at this time of life. According to Cohnstein ' the direct influence of the climacteric upon the development of carcinoma =mime can be shown more clearly than in case of cancer of the uterus.