Physicians unfortunately often show similar carelessness, and allow themselves to be more confirmed in this by the patients themselves. This is entirely wrong. The physician should from the outset be rather too mistrustful of such cases. He ought not to allow himself to be diverted from an examination which has once been decided upon. Finally, typi ml or atypical hemorrhages may, as before-stated, be unusually prolonged in the diseases in question.' In cases like those described above (heart lesions, interstitial fibroid) we shall scarcely go amiss if, taking into account the cause of the early onset of the atypical hemorrhages, we prophesy also their late cessation. In one of the eases cited (Mrs. M.). there is no diminution in the profuseness of the bleeding at the end of the fifty-first year, in spite of the fact that the increased flow has con tinued for ten years. In the case of sub-mucous fibroid, I noted the last and about the most violent flooding after the patient had passed her fifty-second year. A certain Mrs. T., now under my care, had at the close of the Spring, in the beginning of her fifty-second year, the most frightful hemorrhages from the uterus, which was enlarged by fibrous growths to fcrar times its normal size.
The following case is interesting: Mrs. D. has menstruated regularly since her thirteenth year, bore two children, and now at fifty-one there is not the slightest change in the character of her menses. In spit,e of various climacteric phenomena, the time of appearance, duration, and amount of the flow is the same each month as in former years. Since her mother was forty-eight when her last child was born, this may be simply a case of " increased vitality" in the organs involved. The con dition found on examination points to a different conclusion. In the right half of the corpus uteri is a sub-mucous fibroid as large as a man's fist, with a broad base. It seems to be legitimate to infer from this that the principal cause of the persistent hemorrhages lies in this abnormality of the uterus, and that these show no more marked irregularity, simply because the manner in which the tumor happens to be imbedded in the uterine wall is relatively favorable. The important fact to be derived from this case is this: The most perfect regularity in the monthly flow at this period does not justify us in deciding at once that the conditions are normal, and that there is simply a delayed menopause. If these regularly recurring hemorrhages are prolonged beyond the usual time for the menopause, we should at once consider the question of making a thor ough examination.
I come now in the following pages to speak of the hemorrhages that are observed at a still later period. I should like to emphasize the fa,ct that, so far as my own experience extends, fibroids in the uterine wall are the most frequent cause of profuse bleeding at the actual menopause. I have unfortunately not at hand a true summary of the experiences of others in this special direction. Inflammation of the pelvic organs, ac
cording to my own observations, were generally the cause of the disturb ances in question at an early period, while malignant growths (especially carcinoma uteri ') were the cause at an early period, or after the climacteric, although their commencement perhaps dates back to the menopause.
Although this may belong rather to the possibilities, nevertheless, it has always seemed to me to be worthy of note. In this connection I turn to another very important theme, that of hemorrhages after the climacteric. These, from the nature of the case, are observed less frequently, and perhaps many physicians must, therefore; be somewhat less conversant with them, but they deserve double the attention for this reason, since it is absolutely certain that they are due to some pathological condition. The women themselves, I must insist in the first place, are generally in clined to regard these hemorrhages as a recurrence, or, more exactly, as a prolongation of their menses, and in consequence mislead the physician, and frequently delay for a long time consulting him on the subject.. Now, it is important above all in the first place to positively insist upon the investigation of cases of hemorrhages at and after the menopause, and in the second, to observe with great caution every case, even of slight bleeding, -which, in our opinion, occurs after the menopause has. been established. It may, of course, happen that the causes of post-climacteric hemorrhages began at the actual menopause; the clinical picture may be obscured, so that it may be extremely difficult to exactly separate the bleeding at and after the change of life. Accurate observations, a review of all the phenomena, and a careful investigation of the most striking, will nevertheless settle the question. It will be established that the ap parently " protracted hemorrhages at the menopause " were only partly to be regarded as such, but that they really belonged to the post-climacteric period, arid were caused by one or another affection, the only striking points about them being that they occurred so soon after the establish ment of the menopause.
Usually, however, there is a rather long interval after the cessation of the true climacteric bleeding. The presence of certain links in the chain of the existing climacteric phenomena assures us that the menopause is already established. Fresh hemorrhages appear, but they are of shorter duration, slighter or more profuse, or more continuous than before, while they are atypical and irregular. If, however, they should ever show any regularity, this should be carefully noted, as I have always found them under such circumstances to be suspicious. This or that distnrbance in the health of the woman in question, or often the very manner in which the bleeding begins, points to certain affections; the examination, which ought at once to be undertaken in every case, soon throws light upon it as a rule.