PATHOLOGICAL HEMORRHAGES.
We rn— en tioned at the beginning that irregular and rather profuse bleeding was of quite common occurrence at this period. Sometimes, however, these attain considerable importance, and the patient may by single or re peated hemorrhages, be brought to a condition of dangerous anfemia. This tendency to hemorrhages, in the absence of any gross changes in the pelvic organs, it is, of course, difficult to explain. The true causes are probably different in different cases. Scanzoni thinks that in many in stances they are due to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure that is brought to bear on their walls. According to Kisch, the menorrhagite at the climacteric are due to the softening and relaxation of the uterine tissue. Additional causes are found in circula tory disturbances in the pelvic organs, and obstruction of the vena cava inferior, whereby the outflow of blood from the pelvic vessels is hindered, and a chronic stasis in the uterine walls is produced. The same author in another place quotes from Peter Frank, who attributes it to early and profuse menstruation, frequent and difficult labors, frequent abortion, and also to excess in drinking. IIegar affirms that in certain cases there is only simply an absence of any etiological factor. After numerous ob servations I am convinced that these climacteric menorrhagim, for which no cause can be assigned, may be explained from a different standpoint. I have sometimes observed such profuse bleeding in individuals who pre sented absolutely no ground for the supposition that structural changes in the vessel-walls have already occurred, and in whose cases the causes above-mentioned (frequent labors, etc.) do not exist, but whom I was obliged to regard before and after the menopause as intact, so to speak. The only explanation of such cases seemed to me to be this, that the single or repeated floodings in question were only the expression of vaso-motor disturbances,' such as those in other regions, which frequently characterize the menopause. These hemorrhages might, as regards their etiology, be
compared with those irregular, sometimes very profuse uterine hemor rhages, which we frequently observe in certain women, having no connec tion with the menopause, due simply to different disturbances of the nerve-centres (fear, anguish, etc.); they are also analogous to certain other vicarious phenomena, epistaxis, intestinal hemorrhages, " conges tive symptoms," which, as we shall see later, are almost always to be re garded more properly as a vaso-motor disturbance than as the result of " excess of blood." Afid they should finally (which seems to me of the most importance) be generally considered as nothing more than a special form of." sexual disturbance," a view which always leads us again to seek for their origin within the abdomen, but they are to be classed exclusively with the so-called general phenomena of the climacteric, the foundation of which is in certain profound changes of the organism outside the sexual sphere.
Although I am convinced that some of the above-mentioned etiologi cal factors (friability of the vessels, obstruction within the abdomen) fre quently play an important Hie, I believe, on the other hand, that in many of these cases the explanation given is the only one necessary, and that to disregard it would be to leave an hiatus in our explanations.
The following case shows how severe such hemorrhages may be: Mrs. R., aged sixty, was always regular, only she menstruated rather profusely. She married at twenty.three, and had three normal labors within seven years. She was always healthy, but her nervous system was highly irritable. Although perfectly well, she had a sudden and profuse flooding at forty-nine, and this was repeated at intervals until she became so anmmic that she was obliged to pass two entire winters in bed. The hemorrhages ceased at fifty-one, and she became strong and well as before. The most careful physie,a1 examination failed to explain the loss of blood.