A post-puerperal condition which gives rise to menorrhagia is chronic inversion of the uterus, most likely to be confounded with a fibroid polypus, but distinguished from it by the fact that per rectum the fundus of the uterus is felt to be absent, and a dimple is made out in the abdominal aspect of the cervix. For the appropriate treatment, see Uterine Dis placements: Inversion.
A fairly common cause of haemorrhage is the condition known as sub involution of the uterus. The organ is enlarged and firm. If the con dition is recognised within a few months of the labour, Ergotin in doses three times a day may be given, or Ext. Hydrastis Canadensis, 3o mins. in water three times a day, or a pill Aloin.
Ext. Nnc. Vont.
Pulv. Ipecac. Oa gr. 3. illisce.
Ft. pit. c pt. i.
may be given. If these measures fail to produce involution, the most satisfactory treatment is to curette and pack with iodoform gauze, to be followed by daily warm douches, and the administration of ergotin or hydrastis canadensis.
We have, finally, the condition known as " fibroid metritis " or " arterio sclerosis of the uterus," which causes a most intractable form menor rhagia. The uterus is enlarged, very firm and feels gritty to the curette, A good deal of evidence has recently been accumulated tending to prove that this condition is syphilitic in origin, at least in a large number of cases, and cures have been reported after the use of iodide in large doses. Curetting and packing with gauze should first be tried, but in established cases of this disease the only treatment which affords relief is the removal of the uterus.
(3) Menorrhagia due to Tumours.—The form of tumour which is the most common cause of menorrhagia in the middle decades of sexual life is uterine fibroid and the allied tumour adeno-fibroma, which is responsible for some of the most inveterate cases of mcnorrhagia. It should be remembered that the amount of bleeding bears no relation to the size of the tumour, and that quite a small submucous or polypoid fibroid, causing an inconsiderable amount of increase in the size of the uterus on himanual examination, may give rise to profuse and even dangerous haemorrhage.
With a patient aged over thirty the practitioner should be on his guard against the possibility of malignant disease either of the cervix or body of the uterus, and it is as well to have a microscopic examination of the scrapings made by a competent pathologist in every case in which curettinE has been done for the relief of mcnorrhagia. Sometimes the symptom is caused by ovarian or tubal tumours, dermoid cysts almost invariably giving rise to increased loss, probably through their proneness to inflam. mation with consequent pelvic congestion. The treatment of this grout of cases of menorrhagia resolves itself into the treatment appropriate tE the form of tumour present (see under Cancer, Uterine, Ovarian Tumour Uterine Fibroid).
4. Menorrhagia at the Menopause.—As it is from the fortieth yea onwards that cancer of the uterus is most commonly found, and as the disease is a very common one amongst women, who are doomed by it to a certain, a painful and a distressing death, from which their only hope of escape lies in early hysterectomy, I should like to impress on every practitioner the folly and even the criminality of prophesying smooth things in regard to hwmorrhage at the time of the menopause without making a thorough examination of the patient. Only too often a patient is deluded into the belief that the loss is a normal occurrence at her time of life; only too often she wastes months drinking ergot while a cancer of the cervix is growing, until operative removal is futile and hopeless. When a woman over forty complains of hemorrhage, the wise practitioner assumes that the hemorrhage comes from a cancer until he has proved that it does not. To prove the point, he will make an immediate vaginal examination, and will curette and have the scrapings microscopically examined. The curetting will cure a senile endometritis, which may be the cause of the hwmorrhage. Other causes, such as a cervical polypus or a fibroid, may be present about the time of the menopause, and will be discovered in the course of a routine examination. The treatment of these several conditions will be found under the appropriate headings.