I have just referred to the value of the sound. Before introducing a curette it is always wiser to dilate the cervical canal slightly, for the os internum offers a certain amount of opposition to the passage of even the smallest instruments used for diagnostic purposes. I would state here that a series of ordinary English bougies always do me good service enough in accomplishing this dilatation; one who may not possess the dilators of IIegar or Fritsch may readily aid himself in this way. As I have already said, it seems to me to be important that the size of the curette that is selected should correspond to the diameter of the dilator that was last introduced. When Fritsch, after ascertaining the width of the cervical canal, introduces the " corresponding" curette, I agree with him in this respect as well as in his investigations on the necessity of digital examina tion of the uterine cavity, which on the one hand involves previous dila tation up to the breadth of the finger, and on the other may be very dangerous, by reason of the manner of forcing in the finger. It is self-evident that after the curette has once been introduced, it is also used to touch and investigate the endometrium. I add here two recent strik ing observations: B., widow, aged sixty-ono. Menses stopped suddenly at fifty-four. Since then no bleeding, only constipation, frequent slight pains around the navel, general nervous irritability, and during the last two years severe intercostal neuralgia. During the past six months has begun to have a slight discharge of watery blood every two to three days. Moderate pain in the hip on locomotion and increase of the pains around the navel. Sleeps poorly and is losing flesh. First examination negative. At the second a sound was introduced and encountered a projection of rather firm consistence. Some fragments were removed and examined micro seopically. The growth was found to be a typical adenoma, such as was described by Breisky. The mass was removed thoroughly, but recurred as an adenoma-carcinoma.
It should never be forgotten that the microscopical examination may be negative (if the scraping instrument fails to reach the site of the neo plasm), and nevertheless the diagnosis of carcinoma of the corpus uteri may be made clinically.
Mrs. K., aged sixty-eight, reached the menopause fifteen years ago. Well until four months ago, when she began to have hemorrhages. During the past eight weeks she has had pains in the abdomen, and for about a week there has been a fcetid discharge from the genitals. On examination I found her general condition good. Nothing was discovered by the bi-manual. On introducing the sound the uterine cavity was deeper than normal, and there seemed to be a projection near the fundus. Fragments were removed by the curette, and examined microscopically, the appearances being those characteristic of atrophy of the uterus with hemorrhagic infiltration of the mucosa. In spite of the favorable micro scopical examination, the patient died a few months later with symptoms referable solely to carcinoma of the corpus uteri. From this case we see how important it is to search for the true cause of the post-climacteric hemorrhages, even if certain facts (in this case the microscopical examina tion) already seem to justify us in forming a definite conclusion. The tenderness of the abdomen, the quite irregular and finally constant hemorrhages, the foul discharge, the enlargement of the corpus uteri determined by the sound, and finally the growths which were certainly detected on its inner wall, necessarily aroused the suspicion of carcinoma of the body, especially when the age of the patient was taken into con sideration, which, as we have seen above, pointed strongly to this form of disease. Although this could not be confirmed by the microscopical ex amination, the serious clinical symptoms must be considered, and it was absolutely impossible to take a more favorable view of the case, in spite of the microscopical appearances. The subsequent course of the disease removed every doubt. The case seems to me to be instructive, on the other hand, by reason of the microscopical appearances, which seem to show that the malignant degeneration was a final step in the process of senile involution.
Before I leave the subject of post-climacteric hemorrhages dependent upon some anomaly in the uterus itself, I would like to call attention to a circumstance which may possibly have connection with the same.
Ilegar calls attention in one place to certain consequences of extreme re laxation of the abdominal wall of the pelvis, to which too little attention has been paid. The anatomical change extends not only to the muscles and aponeuroaes, but also the peritoneum and its folds, and nearly always involves the pelvic floor, the pelvic diaphragm, levator aui and fascia, as well as the peritoneal covering of the pelvis and its folds, the sacro uterine and broad ligaments. The relaxation of the ligaments often leads to permanent displacement and abnormal mobility of the pelvic viscera, while the diminution of the intra-abdominal pressure causes increased congestion of the veins of the abdomen. The lowering of the intra abdominal and intra-vaginal pressure affects the position of the uterus, and (in case the organ is fixed) also its circulation, so that after removal of the ovaries, for example, hemorrhages occur. Hegar observed in several instances that women whose ovaries had been removed continued to be quite well for some time, and then, in spite of every warning, they discarded their abdominal bandages and made violent exertions; hernia soon resulted, and all their nervous symptoms appeared together with hemorrhage& I myself have not observed whether relaxation of the ab dominal walls may also play a similar part during the period that succeeds the normal menopause. At the outset it seems to me as if this matter could not easily be proved, and, therefore, I would like to direct my reader's attention to this point. On the one hand the conditions after the natural and artificial menopause are in many respects quite similar, but on the other (if we reckon senile conditions particularly among the former) it would be of significance not only if the relaxation of the ab dominal walls could in itself cause post-climacteric bleeding, but also if this relaxation favored or kept up a post-climacteric hemorrhage due to other causes. That the latter might occur I should regard as probable. Special attention is also to be called to the fact that at the time of the climacteric there is almost invariably a marked tendency to enlargement of the abdomen, in consequence of an accumulation of fat in the abdominal wall, or meteorismus. If now these conditions, after having existed for some time, again disappear, there may often in such cases remain quite a marked relaxation of the wall, although in the beginning this was not present at all, so that, if the idea above advanced is correct, sometimes the direct exciting cause of these hemorrhages (i.e., the relaxation and venous congestion) has its origin in the post-climacteric conditions them selves, and accordingly we must think of the existence of a sepamte class of genital hemorrhages which are perhaps characteristic of the post climacteric epoch in the same way as are the hemorrhages that result from senile change in the vessel-walls.
Finally, I desire to state positively that, in my opinion, delayed re current menses can never be classed with post-climacteric hemorrhages. As was explained before, m the cases that apparently belong under this head (if the hemorrhages in question are really menstrual) it must be that, by the patient or her physician who based the opinion on certain phe nomena, the climacteric was erroneously supposed to have appeared too early, when it really occurs later, often a good deal later, that is, with the termination of those late-recurring periods which were erroneously regarded as post-climacteric. But if this has really occurred, then the post-climacteric hemorrhages are, as I remarked at the beginning of this chapter, really the expression of some pathological condition—an important point which must not be forgotten even if these hemorrhages appear with typical regularity, so as perhaps to simulate in every particular the men strual flow. The appearance of such regular losses of blood in connec tion with different pathological conditions at this time of life, is frequently noted. Here is an example from Battey (" Normal Ovariotomy," p. 16) who mentions the case of a woman who ceased to menstruate at fifty-five, and the flow reappeared at sixty, apparently in a perfectly normal manner. The uterus was hard, somewhat nodular, and immovable, but there was no ulceration. A year later she died of carcinoma.