The case which I have described certainly gave me a fine opportunity to observe this entire process climacterically. Whether we observe the development of two or ten polypi does not affect the value of the ob servation. The number in my case would certainly increase if the limit is not placed to the process by the attending circumstances. While '1'. had already suffered for many years with profuse menstruation, so that the opinion was certainly justified that the fibromata were of long stand ing, this extrusion of the fibrous polypi, as we have seen, began originally at the commencement of the climacteric. Since the process in question, as we saw above, was accomplished, and I removed the second polypus, four months have elapsed, during which the bleeding has been entirely absent, which was never before the case with her. If I add to this that the patient has already entered upon her fifty-third.year, both of these facts lead us to infer that her critical period is near its end, and that with it also the process in question must be concluded, since the remaining nodules simply undergo shrinking. Whether this will take place without further phenomena,, or whether the above-described occurrence (new polypus-formation and hemorrhage) will again be repeated, the essential character of the matter, that is, the relation of the entire process to the climacteric, is not altered.
I recapitulate briefly the principal facts, which I think may be deduced from this observation.' At the time of the menopause there seems to be a tendency for fibrous nodules, that were previously interstitial, to become polypoid. These polypi (more often perhaps than has hitherto been noted) are probably the cause of profuse hemorrhage at the climacteric. After the removal of these fibrous polypi, the subsequent climacteric hemorrhages diminish in a marked degree, even when many interstitial nodules are still present. Since the said polypus-formation may continue _ to be repeated, after removing thoroughly such a tumor, we must remain watchful, especially if we have been able to convince ourselves of the ex istence of other interstitial nodules. The newly-formed polypus (often when quite recent) will cause increased hemorrhage; in every case fresh profuse hemorrhages should at least lead us to make another thorough examination of the uterine cavity. After the close of the critical period, this disposition to pedunculation of the interstitial nodules must cease; those which still remain, become shrunken, unless they undergo other changes.
It would be of especial interest now, to inquire the reason why the climacteric period exercises this peculiar influence that results in the formation of polypi. I should like to avoid an explanation; but if I may
give my own unqualified opinion, I would say that it must depend upon two factors, and indeed in the first place upon the fact that the growth of many fibromata is undoubtedly related at times to the climacteric, (to which I shall refer later), and secondly upon the changes in the ut,erine wall itself, which take place normally at the climacteric. In this way both conspire t,o assist; the interstitial nodule, that has perhaps remained the same for years, begins to increase in size at the commencement of the menopause, causes protrusion of the inner wall of the uterus in one direction (as I had a chance to feel in the above-mentioned case), and at once acquires a tendency to extend entirely into the uterine cavity, as soon as it meets with the least opposition in this direction. The latter will be the case when that portion of the wall-stratum to the inner side of the nodule is thinner than that to the outer, but especially when the stratum, which is perhaps already very thin, has also undergone tissue changes by reason of which its original capacity for resistance is diminished. Now, I stated in the introduction that although existing senile changes in the generative organs doubtless scarcely belong to the post-climacteric period, still their early beginning must be referred to the menopause. If this is so, then the first insignificant changes in the uterine muscle will affect favorably the locomotion of the fibrous nodule under consideration, while they allow the necessary use of pressure in the given wall-strata to occur more easily than when these are in an entirely normal condition. I might here add another observation, which really belongs to another department, but which I could not properly omit, before I leave the last described case of T., since it stands in a certain relation to our subject, and was well observed in that case. It has to do with the question of the " recurrence " of uterine fibromata. It would be quite probable that a case like the one described would, if observed rather superficially, be re garded as an example of such a supposed recurrence. We investigate what is apparently a violent climacteric hemorrhage, find a fibrous polypus the size of an egg, and remove it. The examining finger subsequently proves that the uterine cavity is completely empty and the matter seems to be ended for good. Six months later, another severe hemorrhage takes place, and another fibrous polypus of the same size is discovered; what prevents this occurrence from being called an undoubted " recurrence ?" As opposed to this view my c,ase actually forms a new proof against it.