Hemorrhages occupy the foremost place among the pathologic phenomena of the genital tract during the menopause.  Hemorrhage has been attributed in many instances to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure which is brought to bear on their walls; there is also softening and relaxation of the uterine tissue.  Additional causes are found in the circulatory disturbances in the pelvic organs, whereby the outflow of blood from the pelvic vessels is hindered a chronic congestion in the uterine vessels is produced.  It has also been attributed to early and profuse menstruation, frequent and difficult labors, frequent abortions, and excess in drinking.

The third and last variety includes those cases which may be referred to some disease of the pelvic organs themselves.  Anatomic changes may lead up to pathologic conditions.  A chief feature characteristic of uterine disease is malnutrition from atrophy—­ a sudden curtailing of the blood-supply from the degeneration of the genital-nerve apparatus and consequent impaired vitality of tissue from defective nourishment.  The anatomic changes in the glands and substance of the uterus also favor the irritation, and the development of new growths, which may be malignant or benign—­ as cancers, fibroid growths, and so forth.

Hemorrhage at the Menopause a Significant Symptom of Cancer.—­ Not only should any excessive and prolonged bleeding at the time of the menopause be a source of great anxiety to the woman, but even the irregular appearance of a slight show of blood just sufficient to keep the clothing stained, or a slight bleeding following coition; since all of these are symptoms of very great gravity, and demand an immediate local examination and appropriate treatment.

The widespread belief among the laity that hemorrhage at the time of the menopause is a normal condition, and that if left alone it will stop in the course of a few years, is most erroneous and fatal.  On this altar of ignorance thousands of women sacrifice their lives every year.  The case-book of any gynecologist will testify to the truth of this statement.  The following three cases will serve to illustrate different types of hemorrhage in cancer patients, in no one of which did the patient even suspect that she was suffering from anything more serious than the “vagaries of the menopause.”

Case I.—­ Woman aged seventy years; came on account of incontinence of urine, which had been troublesome for two years.  The menopause occurred at fifty.  She stated that three or four years previous to her visit, she had had a return of the flow of blood, perhaps twice in the first year, and that during the past year there had been a flow every month—­ about the same that there used to be.  This she took to be a return of the menstrual period.  She said, further, that there was a constant bleeding—­ enough to necessitate the wearing of a napkin—­ and an occasional severe hemorrhage; that she could not take long walks or drives because of the excessive flow which followed.