Krieger and others refer to varicose vessels in the cervical canal, as the seat of post-climacteric bleeding.
Furthermore sub-mucous polypi of the uterus should be mentioned here, since they are apparently quite often the cause of the disturbance in question.' Scanzoni mentions the case of a woman aged sixty-one, with hemorrhages .ecurring pretty regularly. She died of pneumonia, and at the autopsy th ovaries were found t,o be completely atrophied, while in the cervical canal were two small polypi. Krieger reports a similar case in a woman of eighty. I had a patient, aged sixty, in whom the bleeding was found to be due to two polypi in the cervix.
Post-climacteric hemorrhages in a fibroma of the uterus of long stand ing form one of the principal grounds for the suspicion of sarcoma. (For a more extended discussion of the process of degeneration, see further on.) Carcinoma uteri is unfortunately a very frequent cause of hemor rhages after the menopause. From the merely " suspicious " cervix to the already extensive destructive processes, there may be every stage of the affection, at which the patient afflicted with e,arcinoma first comes under our observation. The reasons why at this period of life the disease is submitted t,o the physician, sometimes at its very ine,eption, and again st such a late stage, are both the varying symptoms of the affection and certain mental factors, a tenacious adherence to the idea that the hemor rhages are simply recurring periods for Nature's necessary relief of ex cessive " fullness of blood," while in one case the pains are attributed to phenomena attending the change of life, and in another there is a fear of death, through some suspicion of an incurable disease, and through a constant belief that the menopause or the period succeeding it must be attended by some evil. I have very often observed at this time cases of Larcinoma of the body and fundus of the uterus.' It is in the incipient stages of this disease, especially, that we must pay particular attention to certain pathological phenomena (an occasional slight reddish discharge, moderate tenderness of the abdomen, with increased general irritability, slight enlargement of the corpus uteri, etc.), even when these are slightly marked, since with these the local conditions often remain so long un changed as to lull us into a certain security. (The portio remaining intact and the os closed, the uterus being freely movable, the parametrium not involved, the general condition good, etc.) As a rule, after considering all the details of such a case, we shall bo very early placed in a position to decide rightly concerning it, even with out resorting to the microscope, for which there is naturally often no opportunity. It is by especially adopting the method of exclusion that
we arrive at a conclusion here. If we are accurate in our clinical observa tion, we shall always find in these cases one point or another that allows us to exclude almost with certainty any other affection. In the case of a Mrs. M., depending almost entirely upon the hemorrhages, I gave an unfavorable prognosis to her relatives four years before ler death, which occurred at sixty-one. For a long time my opinion was censured bocause of her persistent good condition. The rapidly-advancing cachexia, that finally appeared, unfortunately convinced all beyond a doubt. Another time the symptom was slight pain of a characteristic kind in the region of the uterus, occurring some years after the extirpation of a nodule in the breast and a gland in the axilla (after the menopause). My diagnosis of a smondary deposit in the corpu3 uteri, on account of the absolutely negative result of the examination, was doubted by the attending physi cian, even after the atypical hemorrhage began. Here too the confirma tion of my diagnosis was not wanting. Mrs. T. was supposed by two physicians to have carcinoma of the liver, because of advanced cachexia and some peculiar symptoms which were misinterpreted. I found abso lutely no change in the liver, while the corpus uteri was enlarged and hard, so that, in spite of the absence of any additional symptoms, I arrived at the conclusion (based especially on the existing cachexia) that the condition of the genitals was alone responsible for the entire trouble. As matter of fact, the characteristic discharge soon appeared, and hem orrhages which hastened the fatal termination. Careful probing of the uterine cavity furnishes an extremely valuable aid in the early recogni tion of such cases. Not only does the expert generally recognize promptly in this way spots which are the seats of pathological changes, but he can usually draw some approximate conclusions as to the character of the change. When the affected spot is still quite small, curetting (to be mentioned presently) is a valuable means of ascertaining the exact seat of the disease. The removal with the curette or sharp spoon of piee,es of the growth of sufficient size, on their examination with the microscope, of course, gives us certain information concerning the affection in que,stion. This expedient should be employed wherever it is practicable.