I might mention, as closely related to these post-climacteric hemor rhages, those which seem t,o depend purely upon vaso-motor disturbances, a typical example of which I have already mentioned in the case of Mrs. R. " Five years after the establishment of the menopause, a violent hemor rhage took place, limiting for ten days, which never recurred. The ex amination in such cases, as in the one here referred to. gives an entirely negative result with the single exception of the highly irritable condition of the nervous system, which is general or limited to certain regions. That this irritability is increased in the most varied ways about the time of the climacteric, and for some time after, is not surprising after what we shall learn subsequently regarding the changes in the rest of the body at the menopause. A second variety allied to post-climacteric hemor rhages are those due to circulatory disturbances (obstruction of the vena cava inferior) the result of certain affections of the thoracic or abdominal viscera, excluding those of the pelvi& This form is completely obscured except for the difference in time by those mentioned above, under the pathological hemorrhages referable to the time of the menopause. We are indebted to Scanzoni for an instructive example of this character. A woman, aged sixty-four, ceased to menstruate at forty-eight, but from her fifty-second year until the time of her death hemorrhages recurred at intervals of three or four weeks. She had stenosis and insufficiency of the mitral valve of the heart. " The obstruction to the circulation in the system of the vena cava inferior could not be recognized in the cadaver.'' The ovaries atrophied, and there was no trace of ovulation at the former period. The uterus was enlarged and softened, the mucous membrane was congested, and within the cavity was a blood-clot that was quite recent.
The *third and last variety includes those cases in which the post climacteric hemorrhage is to be referred to some diseased condition of the pelvic organs themselves, especially of the uterua I mention here first the much-described apoplexy of the uterus, due to rigidity and cal cification of the vessels (increased friability), which is one of the most frequent evidences of senile atrophy. According to Klob there is au extravasation of blood especially in the fundus of the organ, less often in the posterior wall, and the foci in question vary in size from a pea to a pigeon's egg. Although such a fresh extravasation is observed in the uterine wall, an effusion of blood is often found within the cavity. The external hemorrhages due to this cause are frequently several (Klob), and apoplexy of the uterus in advanced life is the origin of many attacks of menorrhagia that are regarded as recurring menstruation. But sinc,e, according to the latter author, this condition " often gives rise .to no marked symptoms except a more or less extensive infiltration of blood into the substance of the uterus, which becomes degenerat,ed so as to form a sanious, dark red pultaceous material, subsequently changing to rusty brown and saffron yellow, we are justified in the opinion that, as regards external bleeding, every possible variation may appear from actual metror rhagia to occasional slight traces." But the fact that this condition recurs now and then (so that it may even show a certain periodicity again) may serve to clear up many hitherto obscure cases of slight repeated hemor rhages.
Thus, I sometimes see a Mrs. M., who menstruated regularly from her seventeenth year, bore two children, and at forty-three presented every evidence of having passed the menopause. Now the woman is well on in the fifties, and for some time at intervals of from four to eight weeks, she has lost slight traces of dark-red blood, which escaped in drops, without pain and without any known cause, perhaps from occasional rather violent bodily movements. The most careful examination of the
other organs gives a negative result, while the genitals merely show evi dences of retrograde metamorphosis. There is no evidence of increased nervous irritability, warranting the inference that there is in this case a reflex vaso-motor hypera3inia of the uterine mucous membrane, although this may possibly play a part. The most probable explanation, I think, is that there is in this instance a certain friability of the vessel-walls (even when the woman uses her handkerchief rather vigorously, she observes at the conclusion of the act traces of blood coming from the nose), which, aside from the evident external hemorrhage, possibly c,auses changes also in the substance of the uterine wall, analogous to those referred to. Erosions of the portio vaginalis constitute an additional causal factor in this series of post-climacteric hemorrhages. These are often to be re ferred merely to profuse leucorrhcea (which, as is well known, is of quite common appearance after the establishment of the menopause), and then become the source of slighter or more marked hemorrhages, if any trau matic influence (strain, pessary, or coitus) is added.
Displacements of the uterus can be of significance at this time only in a restricted sense. Certain positions of the portio will, by reason of constant friction of the mucous membrane lead to the formation of erosions, and under favorable conditions to occasional hemorrhages. Enlargement and flabbiness of the organ will play a special rOle here (causing descent and prolapse). The following observation seems to me to be worthy of note in this respect: Mrs. P., who is otherwise perfectly healthy, pi.ssed the menopause thirteen years ago. On account of prolapse of the uterus, she has long worn a T-bandage. She recently informed me in great alarm that she had had traces of blood, which she was disposed to regard as the beginning of a serious affection, since nothing like this had ever happened before in all the past years. An examination revealed simply and solely that the source of the bleeding was some slight excoriation at the os. Even these were merely due to the fact that she had dispensed with her bandage for some time, and thus the cervix protruding from the vulva bad been much irritated. Matthews Duncan describes as " bleed ing lupus" of the female genitals an affection " which from its histologi cal character, should not receive this name, but from its external appear mice may be classified under it." The peculiarity of the affection consists in its tendency to hemorrhages of varying duration and intensity; the trouble must also bear a certain relation to the vaginitis that often developes after the menopause. In the first of the accompanying cas4s the patient was fifty-seven, in whom the author discovered a small urethral caruncle, and beside it a small red spot. The former had at the time of writing grown to the size of a pea, while the latter had become a flat ulcer of somewhat larger size, from which, as the highly-intelligent patient had herself positively declared, a very copious hemorrhage had recently 0'2 curred. Further experience must teach to what extent the condition here described is to be classed with post-climacteric hemorrhages. In the other cases, occurring in younger individuals, the ulcer, which was " half visible," was situated upon the cervical mucous membrane, in one case on the vaginal mucosa, while in a fourth the entire posterior wall of the urethra was wanting, and on the inner side of the left labium majus was a pale irregular ulcer, with sharp indurated edges, which extended into the vagina; subsequently bleeding took place from two arteries in its floor. Finally, there was on the right vaginal wall a smaller ulcer, like an incision, which was folded upon itself.