The violent hemorrhages at the climacteric are of course much easier of explanation if some abnormality of the abdominal viscera is recognized on examination which, according to experience under other circumstances, also favors an increase of the normal hemorrhages from the genitals, or, moreover, may of itself give rise to bleeding. Every abnormality of this nature, of course, possesses increased significance in connection with the general tendency to more profuse loss of blood at the menopause, which loss is always referable in part to the before-mentioned condition. Among these we must mention: acute and chronic inflammatory processes in the pelvic organs, especially hyperplasia of the uterine muscle and connective tissue (Hegar), certain flexions (retroflexion), prolapsus uteri, polypi, fibroids, and carcinoma.
Likewise all those pathological conditions elsewhere in the pelvic cavity and thoracic viscera, should be considered, such as necessarily favor obstruction in the vena cava inferior and the resulting hemorrhages (tumors of the liver, cardiac lesions, etc.). Scanzoni lays stress on previ ous chronic enlargements of the uterus (as shown by the flabbiness, soft ness, and swelling of the uterine parenchyma) due to circulatory disturb ances in the abdominal viscera, as a common cause of profuse hemorrhages at the climacteric. We often meet with the most varied complications in this direction. Mrs. W., who hacl suffered from her youth with mitral insufficiency, began after the birth of her third child to suffer from ex tremely profuse menorrhagia, which was subsequently attended by metror rhagia. Finally, an examination revealed the presence of an interstitial fibroid. The case was then further complicated with psychical disturb ances (a delusion that she was being followed); she was then in the middle of her thirtieth year. A specialist in nervous diseases gave her to hope that the latter troubles would be relieved at the menopause; on the other hand, that period was to be feared on account of the condition within the abdomen. Before this time, however, under the administration of small doses of ergot, the fibroma was expelled piecemeal quite rapidly, and the uterus entirely recovered its normal condition. Now, at the beginning of the fortieth year, irregular hemorrhages are again noted. The psychi cal disturbances are disappearing. On account of the perfect normal state of the pelvic organs, I can attribute the present hemorrhages only to the premature climacteric bleeding favored by the heart trouble.
The following are two more cases belonging to the former class of hemorrhages, in connection with disease of the genital tract: Mrs. H. always menstruated profusely, but quite regularly, and had two normal labors. Now, in her thirty-ninth year, she has begun to have irregular hemorrhages. On examination a small interstitial fibroid, the size of a nut, is found in the anterior uterine wall. Considering some other phenomena (increase in fat, nervous disturbances, etc.), the present hemorrhages are to be ascribed rather to early climacteric bleed ing than to the small fibroma.
Mrs. M. menstruated regularly until her fortieth year. After forg one she flowed profusely, but regularly, for nine years. An interstitial fibroid was found on examination. The patient is now fifty-one, is very anwmic, and there is no diminution of the hemorrhage.
We emphasized at the outset the fact that the physician should, at the time of the menopause, consider most carefully every variation from the normal; this applies particularly to every case in which there are marked uterine hemorrhages. Even before we make an examination in cases in which hemorrhages depend upon some pathological condition of the ab dominal or thoracic viscera, we suspect three things. Either the menses are constantly becoming more profuse long before the usual menopause, or atypical hemorrhages are already beginning unusually early, or the hemorrhages at the ordinary time of the menopause (regular or inter rupted by irregular intervals) have become unusually profuse, or, finally, the regular or irregular losses of blood are unduly prolonged, often far beyond the fiftieth year of life. Whenever a patient gives a history point ing to these facts, we must at once make a thorough and accurate ex amination.
In the above-mentioned cases I have already cited some observations on the early appearance of abnormal hemorrhages in connection with sup posed diseases. Examples of unusually profuse bleeding of pathological origin at the normal period of the menopause occur very frequently during a year's practice. The most aggravated case of this nature that I ever saw occurred in a patient having a sub-mucous uterine fibroid as large as a child's head. The most dreadful hemorrhages set in towards tbe end of her fortieth year. All proposals to operate were declined. During her fiftieth, fifty-first and fifty-second years, after one or two attacks of flooding, she was each time literally near dissolution. She had advanced to general cedema, and on one occasion, bad a prolapse of the rectum as large as a man's fist. I was obliged to tampon. In another case a woman of fifty consulted three physicians in succession, on account of excessive hemor rhages and marked (edema. Without examining her, they all made a diagnosis of " bleeding due to the climacteric," and insisted that there was no danger. The real trouble was advanced carcinoma of the cervix. My own extremely unfavorable prognosis was, of course, received with some indignation by the attendants. Unfortunately it was confirmed, hardly two weeks after, by the death of the patient. Therefore I con sider it important always to insist upon the necessity of an immediate exatnination in all cases of rather marked bleeding at this period, as I have often observed the women themselves frequently fail to regard them as sufficiently serious, and may in consequence cause many a physician to err. Women are aware that irregularities and increased flowing are usual at the menopause; they generally console themselves with this explana tion, even when medical aid has been summoned.