Pathology of the Menopause.
Diseases of the Genital Organs.
Among the commonest of the symptoms of the sexual epoch of the menopause is menorrhagia. It occurs especially in plethoric women, in those who during the prime of their sexual life have been accustomed to menstruate abundantly, and in those who have given birth to many children or had many miscarriages; but it is seen also in weakly and delicate individuals, in whom the tissues of the genital organs have become extremely flaccid and loose in texture. A luxurious mode of life, more especially a free consumption of alcoholic beverages, and also frequent sexual intercourse during the climacteric period, appear to favour the occurrence of menorrhagia at this epoch.
Not infrequently, menorrhagia is the first sign of the commencement of the climacteric, menstruation having been hitherto regular, and not excessive in amount. Generally, when this climacteric menorrhagia begins, the intervals also become shorter, the menstrual period being reduced to three or even two weeks. At times, however, the more profuse menstruation recurs at longer intervals, six weeks, two months, or even longer. In any case, the occurrence at the climacteric age of a severe or atypical haemorrhage, renders it the imperative duty of the physician to undertake a local examination of the genital organs; for it is necessary to ascertain without delay whether such a haemorrhage is a true climacteric phenomenon, or whether it is due to some actual disease of the reproductive organs—a neoplasm, or the like.
If the haemorrhage is due solely to the change of life, the vaginal portion of the cervix will usually be found soft and flaccid, bleeding readily on slight injury, and sometimes eroded; there is generally associated leucorrhoea. This relaxation and loss of firmness in the uterine tissues at the time of the menopause is the cause of the predisposition to excessive haemorrhage. An additional cause exists in the circulatory disturbances in the pelvic organs. We presume that women affected with menorrhagia at this time of life suffer from some persistent disturbance in the region of the inferior vena cava, whereby the outflow of blood from the veins of the pelvis is hindered, and a chronic condition of stasis in the uterus is conditioned. Hence arises distension of the vessels of the uterine mucous membrane, and this rhexis is relieved by the excessive haemorrhages. In these considerations lies the explanation of the fact that women who have had many children or many miscarriages, are especially prone to suffer from climacteric menorrhagia; and also women who for any reason are predisposed to intra-abdominal stasis.
Another cause of climacteric menorrhagia is to be found in the frequent occurrence at this epoch of advanced arteriosclerotic changes in the uterine blood vessels, the disease being in some cases limited to the uterine arteries, and in others part of a general arterial degeneration. The blood may be derived from ruptured sclerotic capillaries of the mucous membrane; but in other cases it exudes in consequence of passive hyperaemia, without actual rupture of the bloodvessels. To such haemorrhages from atheromatous vessels we must refer many of the attacks of uterine haemorrhage that occur in elderly women, such as were formerly, before their true nature was understood, commonly regarded as instances of a very late return of menstruation. By careful examination the exact source of the blood can often be detected in such cases.
According to Theilhaber, one cause of the haemorrhages occurring at the climacteric is to be found in the atrophy of the uterine muscle which takes place at this period of life. Except during pregnancy and the puerperium, the uterus is usually in a state of moderate contraction; during the height of the menstrual flux, however, the uterus is relaxed. Then, as contraction of the muscle sets in, the menstrual hyperaemia and consequent haemorrhage are gradually brought to an end. When this contraction is insufficient, the hyperaemia and swelling of the uterus are more enduring. In association with the atrophy of the uterine muscle at the climacteric, there usually occurs a notable diminution in the size of the uterine vessels, so that, notwithstanding the diminished strength of the muscular contractions, any excessive loss of blood is prevented. But if this diminution in the calibre of the vessels fails to take place, the atony of the uterine muscle leads to hyperaemia, to haemorrhage, and often, in addition, to oedema of the organ, with elongation and thickening of its walls—hyperplasia uteri preclimacterica.
Among diseases of the uterus which during the climacteric may give rise to severe haemorrhage, and may lead to the mistaken opinion that menstruation still continues, we must in the first place mention carcinomatous disease of the cervix and of the body of the uterus; next in importance come myoma and fibrous polypi; less frequent causes of such haemorrhages are fungous endometritis, erosions, mucous polypi, prolapse of the uterus, and ovarian cystoma.
The climacteric age gives rise to a predisposition, not only to bleeding, but also to other pathological changes in the reproductive organs. We can by no means endorse the opinion of Currier—one long ago expressed also by Brierre de Boismont—that women during the sexual epoch of the menopause are less disposed to diseases of all kinds, and among them to diseases of the genital organs, than younger women, for the reason that their tissues are endowed with less vitality, and are, therefore, more resistent to all the causes of disease. On the contrary, the number of pathological disorders liable to affect the reproductive organs precisely at this period of life, is strikingly large. Among my 500 cases of women at the climacteric age, there were 440 who complained of such symptoms, the diseases from which they suffered being, in order of frequency:
| Profuse haemorrhages in | 286 cases |
| Chronic metritis in | 79 cases |
| Leucorrhoea in | 327 cases |
| Displacements of the uterus | 117 cases |
| viz., prolapsus in | 65 cases |
| anteflexion and retroflexion in | 52 cases |
| Genital pruritus in | 46 cases |
| Vaginismus in | 12 cases |
| Carcinoma uteri in | 3 cases |
| Myoma uteri in | 5 cases |
| Tumor mammae in | 8 cases |
I need hardly point out that in many individuals more than one of these diseases were present at the same time.
The most obvious feature of these statistics is the extraordinary frequency of uterine haemorrhage and of leucorrhoea in climacteric women. The former condition was present in more than half my cases; the latter actually in three-fourths.
The same two pathological states were also those most frequently recorded in Tilt’s statistics. This author, in 446 women at the climacteric, found the following diseases of the reproductive apparatus:
| Haemorrhages in | 138 cases |
| Leucorrhoea recurring at irregular intervals in | 146 cases |
| Leucorrhoea recurring monthly in | 12 cases |
| Remittent menstruation in | 33 cases |
| Vaginitis in | 4 cases |
| Follicular inflammation of the vulva in | 10 cases |
| Inflammation of the labia in | 4 cases |
| Ulceration of the cervix uteri in | 9 cases |
| Prolapsus uteri in | 5 cases |
| Uterine polypi in | 4 cases |
| Fibrous tumours of the uterus in | 4 cases |
| Cancer of the uterus in | 4 cases |
| Chronic ovarian tumours in | 3 cases |
| Irritation and swelling of the breasts in | 14 cases |
| Lacteal or gelatinous secretion in breasts in | 2 cases |
| Hard, non-malignant tumour of the breast in | 2 cases |
| Chancre of the breast in | 1 case |
| Frequent sedimentation in the urine in | 49 cases |
| Difficult and painful micturition in | 9 cases |
| Incontinence of urine in | 4 cases |
| Haematuria in | 2 cases |
| Perineal abscess in | 2 cases |
Chronic metritis and endometritis come under observation with considerable frequency during the climacteric age, but as a rule these diseases have originated during the period of sexual maturity, and in exceptional instances only does the cessation of the menses appear to be the etiological starting point of these disorders. In fact, this occurs only when the menopause is premature, or when it is quite sudden in onset, whether this be due to noxious influences or to constitutional disorder. For the menstrual process quite normally gives rise to a certain congestion of the genital organs; and should menstruation be suddenly suppressed, the blood-stasis in the uterus becomes so extreme that morbid tissue changes are very likely to ensue. And when chronic metritis has occurred before, the congestion and stasis in the uterus at the climacteric will usually suffice to light up the inflammatory process afresh. This is the explanation of the fact that symptoms of slight metritis make their appearance at the very beginning of the climax, manifested by thickening of the corpus uteri and of the portio vaginalis of the cervix, by swelling and softening of the mucous membrane, and by abundant secretion. In those who, either after full-term delivery or after abortion, have suffered formerly from chronic metritis or endometritis, but who have been quite free from any symptoms of these troubles for many years prior to the climacteric, it often happens that the change of life is ushered in by symptoms of congestion of the uterus with associated leucorrhoea. With the completion of the menopause, however, the resulting involution of the uterus exerts a favourable influence upon all such chronic inflammatory processes in the genital organs; as the atrophy progresses, the periodic attacks of congestion cease to recur. Thus it happens that women who for years have suffered from haemorrhages, from inflammatory disorders of the genital organs, and from various other troubles of a similar nature, will, once the menopause is fully over, feel quite well up to an advanced period of life—they seem as it were to begin life afresh.
According to Bennet, the characteristic signs of climacteric metritis are that the inflammatory symptoms are less pronounced, that the pains are less severe, that elongation of the cervix is less often seen, and that fungous changes are less marked, than is the case in the chronic metritis of younger women. On the contrary, the cervix appears smaller, often somewhat lobulated, it is harder, granulations are numerous, ulceration is rare, the enlargement of the uterine cavity is but slight. Bennet’s views are, however, opposed by Scanzoni, who maintains that there is no notable difference between the chronic metritis of younger women and the disease as it occurs in women at the climacteric.
In fact, the chronic metritis and endometritis of women during the climacteric age, differs in no important respect from these diseases as they are seen in women during their sexual prime. We merely note that the enlargement of the uterus is less marked; but the thickening and extreme hyperaemia of the mucous membrane are the same in both cases, the secretion is increased in quantity, the vaginal portion of the cervix is elongated, and usually displays erosions, excoriations, or ulcers. The subjective troubles appear less pronounced than in the case of the metritis of the menacme. The prognosis is as a rule a more favourable one than in the earlier years of sexual life, for as soon as the series of involuntary processes is completed, when the retrogressive changes in the genital organs are at an end, when senile atrophy of the uterus and the uterine annexa has set in, a cure of the troubles formerly so obstinate and so enduring speedily takes place.
Quite recently, much has been written upon the subject of a peculiar senile endometritis (Patru, Skene, Mundé, Rüder, Sheldon, Herman, and others), and it has been described as “a peculiar form of senile, haemorrhagic, leucocytal hyperplasia of the uterine mucous membrane” (Gottschalk). According to Maurange and Lorain it occurs in as many as 7.2% of elderly women. It is seen especially in women who earlier in life have suffered from diseases of the genital organs, more especially those who have previously suffered from endometritis; at times a senile vulvitis or vaginitis is the cause of the disease. Displacements of the uterus with kinking of its canal, whereby retention of the secretion and its decomposition are induced, has been assigned as an additional cause of the disorder, also prolapse of the uterus, and, in isolated instances, necrotic fibromata. According to the degree to which the atrophy of the tissues has proceeded, and according as the mucous membrane is still partly retained or entirely destroyed, and according to the extent to which the uterine vessels have been affected with the sclerotic processes of old age, does the pathologico-anatomical picture of senile endometritis vary. It may affect the body only of the uterus, it may extend also to the cervix, the vagina, and even the vulva; upwards it may pass to the uterine annexa and to the peritoneum. The first and most important symptom of this senile endometritis is the outflow, usually intermittent, rarely continuous, of a sero-purulent, and sometimes sanguineous discharge, with a powerful foetid smell; there are colicky pains, which pass off when the uterus has emptied itself; often, also, there are atypical bleedings, which are not profuse. The uterus is usually found to be larger than the atrophy general at the patient’s age would have led us to expect, it is often retroflexed, the cervix is thickened, the lips of the os uteri are usually everted and raw. When persistent, this senile endometritis causes profound constitutional disturbance, and is often difficult to differentiate from carcinoma of the uterus.
Under the name of senile irritation of the uterus, Maxwell has described a disease occurring at the climacteric, characterized by an enormously increased irritability of the uterus, with marked reflex manifestations; in these cases also we may perhaps have to do with a senile endometritis. The most pronounced symptom is a severe and constant uterine pain, to which in the course of the disease are superadded pains in the gastric and cardiac regions, the rectum, and the spinal column; these pains lasted a long time, and their severity was such that it became necessary in some cases to remove the uterus.
Hydrometra is a disease which makes its appearance principally late in the climacteric period, when menstruation has already completely ceased, and when the adhesions associated with the climacteric atrophy of the uterus have led to atresia of the cervical canal. Among 74 cases of hydrometra (from the material of the Pathologico-Anatomical Institute of Prague, in the years 1868 to 1871) not one of the women was less than 40 years of age; the age distribution of the cases was in fact the following:
| Quinquennium 40 to 45 | 3 cases |
| Quinquennium 45 to 50 | 2 cases |
| Quinquennium 50 to 55 | 2 cases |
| Quinquennium 55 to 60 | 8 cases |
| Quinquennium 60 to 65 | 18 cases |
| Quinquennium 65 to 70 | 12 cases |
| Quinquennium 70 to 75 | 11 cases |
| Quinquennium 75 to 80 | 8 cases |
| Quinquennium 80 to 85 | 4 cases |
| Quinquennium 85 to 90 | 6 cases |
In 40 of these cases, the occlusion was in the region of the os internum, in 23 it was in the region of the os externum, in 9 cases the whole length of the cervical canal was obliterated, and in 2 both the internal and the external os were occluded, the intervening portion of the cervical canal being still patent. In the two latter cases, there was hydrometra bicamerata, with retroflexion of the uterus.
Late in the climacteric period, haematometra also occurs, though less often than hydrometra. When, in cases in which the os uteri externum is occluded, in consequence of adhesion between the vaginal walls and the vaginal portion of the cervix, as a sequel of the vaginitis ulcerosa adhesiva of elderly women, there is haemorrhage from the atheromatous vessels of the uterus or the tubes, the blood necessarily distends the uterine cavity.
During the climacteric period, leucorrhoea is so extraordinarily frequent, as the figures previously given show, that the assumption is justified that with the diminution or cessation of the menstrual flow, this hypersecretion from the genital mucous membranes forms as it were a kind of vicarious flux. Sometimes, as in 12 cases recorded by Tilt, we actually have a periodic “menstrual leucorrhoea”; in one of these cases the discharge recurred at regular monthly intervals for 12 months, in another for 18 months, in several for 2 years, and in one for as long as 7 years. It is only by careful examination that the exact source of the discharge can be determined, for during the climacteric also, as well as earlier in life, leucorrhoea may be due either to endometritis or to colpitis. A muco-serous or sanguino-serous secretion may also be due to slight vulvitis.
A peculiar form of inflammation occurring after the completion of the menopause, and after the atrophic process in the vagina is considerably advanced, is known as colpitis senilis. In this disease, ulceration readily occurs, followed by cicatricial adhesion between the anterior and posterior walls of the vagina (vaginitis adhaesiva vetularum); in other cases herpetiform eruptions arise, with a tendency to pustule formation; occlusion of the vagina may lead to hydrometra and pyometra; sometimes the obliteration of the vagina is complete, so that there is neither outlet for blood from the uterus, nor inlet for the penis during coitus. This vaginitis adhaesiva vetularum is by no means rare in the climacteric period; as a rule it does not give rise to very serious trouble, the most prominent symptom being usually somewhat persistent haemorrhage, unaccompanied by any evil odour. On local examination, the characteristic strings of scar tissue are felt, passing from the portio vaginalis to the narrowed, senile vaginal fornix; from the cervical canal there exudes a usually somewhat vitreous mucus, mixed with blood. The cervix itself is thin and atrophied, the uterus also is greatly diminished in size.
The frequency at the time of the menopause of such catarrhal inflammatory processes in the vagina and vulva is said by Duprès to depend on the weakness or paresis of the bladder which is so common in women at this time of life. Owing to the incomplete evacuation of the urine, cystitis very readily ensues; the urine is evacuated involuntarily during sleep, and some of this fluid passes through the vaginal orifice, giving rise all the more readily to colpitis, because the secretion of the atrophic mucous membrane no longer possesses the normal acid bactericidal properties. According to Scott, vulvitis may also arise as a sequel of calculus-formation in the glands of Bartholin, a frequent occurrence in elderly life, followed by inflammation and abscess-formation in these glands. Among the diseases of the genital organs at the climacteric period, Fritsch also enumerates urethral caruncle and carcinoma of the clitoris.
Displacements of the Uterus.—Among the commonest of the displacements of the uterus occurring during and after the menopause, is prolapse of the organ. Previously existing descent of the uterus is apt to be greatly aggravated at the climacteric, a partial prolapse, for instance, becoming complete; or prolapse of the uterus may first set in at this period of life.
There are several contributory causes of the liability to prolapse at this particular epoch, especially in women who have had a great many children, and in those with either enlargement of the uterus or with lacerated perineum; the most powerful of these causes being the weakening of the uterine supports in consequence of the general relaxation of the pelvic tissues. At the menopause, the connective tissue by means of which the uterus is attached to surrounding structures, withers; simultaneously the vagina atrophies, and this source of support is weakened; the whole pelvic floor loses its firmness and power of support. For these reasons, a uterus which has hitherto been in correct position readily becomes retroverted and to some extent prolapsed; whilst one that was already thus far displaced prior to the menopause, will now be apt to descend still further till it rests upon the perineum. With the disappearance from the vulva and the perineum of the adipose tissue on which their firmness so largely depends, complete prolapse of the uterus is now likely to ensue. Prolapse of the urethra may also result from senile involution of the pelvic contents.
Among my 500 cases of women at the climacteric, there were 65 instances of more or less severe prolapse of the uterus. The frequency of prolapse in women at the climacteric and in those at a more advanced age, is shown by the following figures, which are compiled from the post mortem statistics of the Pathologico-Anatomical Institute of Prague (years 1868 to 1871). Prolapse of the uterus was found:
| In the quinquennium 30 to 35 in | 2 women |
| In the quinquennium 35 to 40 in | 2 women |
| In the quinquennium 40 to 45 in | 6 women |
| In the quinquennium 45 to 50 in | 3 women |
| In the quinquennium 50 to 55 in | 6 women |
| In the quinquennium 55 to 60 in | 8 women |
| In the quinquennium 60 to 65 in | 6 women |
| In the quinquennium 65 to 70 in | 4 women |
| In the quinquennium 70 to 75 in | 4 women |
| In the quinquennium 75 to 80 in | 4 women |
| In the quinquennium 80 to 85 in | 2 women |
Flexions and versions of the uterus, common as they are at the time of the menopause, have no longer the same importance that they possessed during the prime of the sexual life. For on the one part the size of the uterus is greatly diminished, in consequence of the lessened blood-supply and of senile involution of the organ; and on the other, after the cessation of menstruation, the profuse haemorrhages and severe colicky pains which for the most part occurred during menstruation in these cases of kinking of the uterine canal, and which gave rise to such severe general disturbance, now no longer occur. Herein lies the explanation of the fact, well known to all experienced practitioners, that women who have for many years suffered from retroflexion or retroversion of the uterus associated with severe and painful symptoms, cease to suffer after the menopause is established, and regain excellent health, although the local condition of the uterus remains unrelieved.
Neoplasmata of the Uterus and of the Uterine Annexa.—The most serious danger to the life of a woman during the climacteric period is to be found in the strong tendency to the occurrence of carcinomatous disease of the uterus—a predisposition so marked that not less than one-half of all illnesses affecting the reproductive organs of women at this age are cases of carcinoma of the uterus. The disease occurs especially at the beginning of the climacteric, between the ages of 45 and 50 years, most often in the form of carcinoma of the portio vaginalis, whereas after the completion of the menopause, carcinoma of the body of the uterus is the preponderant form. The true reason for the frequency of the occurrence of carcinoma at this period of life will only become clear to us when we are more fully acquainted with the nature and origin of this form of malignant disease. Meanwhile, it would seem that the predisposition to cancer during and shortly after the menopause depends upon the anatomical changes in the reproductive organs at the time of involution, which render these organs a more suitable soil for the proliferation of malignant growths; and further it is probable that the loss of the acid, bactericidal quality of the vaginal secretion, opens the door for the entrance of pathogenic micro-organisms. Noteworthy is the observation of Baer and Leopold, that very frequently a preclimacteric or climacteric fungous endometritis forms the stage of transition to the development of carcinoma of the body of the uterus. At the time of the menopause there is also an increased liability to the occurrence of cancer of the ovaries. Numerous statistical data have been published regarding the frequency with which carcinoma of the uterus occurs at various periods in women’s lives, and, notwithstanding all variations, one fact stands out clearly, namely, that this disease occurs most frequently in the fourth and fifth decennia, and above all during the climacteric period.
From Gusserow’s collection of 526 cases, observed by Lebert, Kiwisch, Chiari, Scanzoni, and Saexinger, the following table has been drawn up, and it shows very clearly the great preponderance of the disease in the fifth decennium of a woman’s life:
| At ages of from 20 to 30 there were | 12 cases |
| At ages of from 30 to 40 there were | 161 cases |
| At ages of from 40 to 50 there were | 217 castes |
| At ages of from 50 to 60 there were | 102 cases |
| At ages of from 60 to 70 there were | 38 cases |
| At ages of from 70 and upwards there were | 5 cases |
From the mortality statistics we obtain a similar result as regards the age incidence of carcinoma of the uterus. Thus, in England there died of this disease in one year:
| Women at ages of from 15 to 25 | 44 |
| Women at ages of from 25 to 35 | 184 |
| Women at ages of from 35 to 45 | 717 |
| Women at ages of from 45 to 55 | 1110 |
| Women at ages of from 55 to 65 | 1116 |
| Women at ages of from 65 to 75 | 876 |
Coming now to the consideration of fibromyomata of the uterus, we cannot share the opinion that at the climacteric age there is a special predisposition to the origination of such tumours, or that the climax favours the growth of already existing fibromyomata. It appears to us that in the preclimacteric epoch and the commencement of the climacteric, the symptoms of existing fibromyomata become more troublesome, the haemorrhages are more severe, the pains more violent; but that as the menopause is established, these troublesome symptoms decline progressively in intensity, and not only is there an arrest in the growth of the tumours, but often an actual diminution in their size.
I have myself repeatedly observed such cases, in which I had the opportunity of watching the growth of the myomata during a period of ten years or more. Other cases, indeed, show that myomata may increase in size after the menopause, at times with remarkable rapidity, and further that at this period of life a malignant degeneration may occur in such tumours. Carcinomatous, sarcomatous, and myxomatous degeneration have been observed, and also the transformation of a myoma into a soft fibrocystic tumour.
Atrophy of fibromyomatous tumours at the menopause, associated with the atrophy of the uterus that then occurs, has been observed by Playfair and by Doran. The tumour shrinks, its muscle-cells become smaller, and undergo fatty degeneration, there is an increase in the interstitial connective tissue, so that ultimately the fibromyoma is transformed into a firm and dense fibroid swelling. Cases in the older literature and also a recent observation of Yamagiron have shown that calcification of uterine fibromyomata sometimes occurs, leading to the formation of the so-called “uterine calculi.” In the case of pure myomata, the diminution in size occurring at the climacteric is generally due to resorption and fatty degeneration, whereas in the case of fibromyoma it depends on induration and atrophy. It remains uncertain whether the growth of purely fibrous tumours is also affected by the climacteric.
Whilst the influence of the climacteric on the growth of fibromyomata is thus usually advantageous to the patient, exceptions occur, as is shown by cases recorded by Lawson Tait, Schorler, and Boerner; the last-named author points out that at the climacteric there is a tendency for the transformation of fibromyomata into sarcomata.
Kleinwächter had under observation 78 cases of fibromyomata of the uterus in women who were older than 45 years; in only 8 of these was a diminution in the size of the tumour observed at the menopause; in 11 cases at this time, the tumour increased in size more or less rapidly; in 3 cases, a carcinomatous change occurred in the tumour; in 3 cases, the tumour was first observed at the time of the menopause; in 13 cases, the haemorrhages appeared to undergo a complete arrest at the menopause, but the size of the tumour was not affected; in the remaining 48 cases, no influence, either favourable or unfavourable, appeared to be exercised by the menopause on the fibromyoma of the uterus.
Cases reported by Rogival, Simpson, and Gusserow indicate the existence of a certain predisposition to the growth of sarcomata of the uterus at the climacteric period. Gusserow more particularly insists on the fact that we must bear in mind the likelihood of the origination of a fibrosarcoma or of the sarcomatous transformation of a fibromyoma, in all cases in which a fibrous tumour of the uterus first attracts attention at the climacteric period; or in which a tumour hitherto small and inconspicuous and giving little or no trouble, begins at this time to increase in size or to give rise to troublesome symptoms.
Neuroses of the Reproductive Organs.—One of the commonest neuroses of the reproductive organs at the climacteric period is pruritus vaginae et vulvae, and it is one of the most distressing symptoms of which women of this age complain. The disorder depends upon a hyperaesthesia of the sensory nerves of the vagina and the external organs of generation. It is characterized by enduring sensations of itching and burning, which may be either periodic (and then usually nocturnal) or continuous; at times it becomes so severe that the women thus affected have an unceasing desire to scratch, avoid all society, and ultimately find life quite unbearable. In the slighter degrees of pruritus, no objective changes are to be observed in the genital organs, or at most some slight hyperaemia of the vaginal orifice. In the more severe forms, however, there are local nutritive changes: the labia are swollen, their surface has an erythematous blush, a number of the hair-follicles are enlarged and prominent; the vaginal orifice is abnormally sensitive, it is scarlet or livid-red in colour and here and there denuded of epithelium, and there are scattered mucous follicles distended with a serous or purulent fluid; these small vessels are to be seen chiefly on the inner surfaces of the labia minora and around the clitoris. At the same time, the vulva secretes an acid, burning fluid, which greatly increases the patent’s sufferings, and at times impels her irresistibly to the practice of masturbation. In cases of long standing, we find hypertrophy, elongation, and deformity of the nymphæ, and pigmentation of these organs, with the formation of varices.
According to Fritsch, in exceptional cases pollutions are the originating cause of the pruritus, and this may be the case in women who are not sexually passionate. It occurs, indeed, especially in matrons who have not had sexual intercourse for years, and who have quite ceased to think about sexual matters; during the night, such a woman will begin to have voluptuous dreams, associated with a degree of sexual stimulation which is described as being actually painful. The woman often suffers greatly from these lascivious sensations. She complains that she cannot understand how it is that she has become affected with such utterly undesired feelings. She becomes profoundly depressed. Coitus often gives no relief whatever; but many women thus affected declare, as Fritsch points out, that by powerful, almost involuntary scratching, the stimulus is speedily subdued, and that for this reason they are absolutely compelled to scratch. It will readily be understood, that in this way persistent pruritus will arise, with local effects of scratching, and vulval eczema. According to the same author, in some instances pruritus is due to great insufficiency of secretion, such as occurs in the endometritis atrophicans which he was the first to describe. This scanty secretion, as it passes over the external genital organs, gives rise to irritation and itching. Haemorrhoids also play a part in the etiology of pruritus.
Diseases of the Mammae.—The sympathy which in the earlier phases of the sexual life—during the menarche, during pregnancy, and during the puerperium—so obviously exists between the breasts and the uterus, is seen also during the climacteric period. It now finds expression chiefly in the marked tendency to new growths in the mammae, a matter to which attention was already drawn by Galen. The commonest of these neoplasmata is carcinoma mammae, a disease which occurs chiefly during the climacteric epoch. In the great majority of cases, cancer of the breast is a primary disorder; in exceptional cases, however, the carcinoma of the breast arises by metastasis from a cancer of the uterus or the ovary. Sometimes the breast tumour is preceded by Paget’s disease of the nipple. For several years the patient suffers from what appears to be a chronic dermatitis of the nipple, the areola mammae, and the surrounding skin; but ultimately, and hardly ever before the commencement of the menopause, carcinoma of the breast ensues.
The older statistical enquiries of Birkett, Lebert, Scanzoni, and Velpeau, showed that carcinoma mammae most commonly occurred between the ages of 40 and 50 years, and next to that in frequency between the ages of 50 and 60 years.
A general hypertrophy of the mammary gland, affecting not only the enveloping and intra-lobular adipose and connective tissue, but also the proper glandular substance, is very rarely observed during the climacteric period; but in the preclimacteric epoch and in the early part of the climacteric, we not uncommonly see a hyperplasia of the adipose tissue of the breast, either as a local manifestation of a developing general obesity, lipomatosis universalis, or as a purely local excessive deposit of fat. In such circumstances, the mammae may at times be transformed into monstrous tumours.
Diseases of the Organs of Circulation.
Among the cardiac disorders of the menopause, the earliest and the commonest is, in my own experience, the following. At the time of the menopause, exceptionally not till after the complete cessation of menstruation, but usually at the commencement of this period of life, some time, that is to say, between the age of 40 and 50, either when menstruation has become irregular, the intermenstrual interval having become longer or shorter than has hitherto been the case, or when the discharge has become abnormal in character, a woman who has not before suffered from any kind of cardiac disorder, will begin to complain of paroxysms of palpitation.
In some cases the attacks of palpitation occur in the absence of any discoverable exciting cause; in others, some trifling stimulus gives rise to them. They may arise when the patient is in any position, walking, standing, sitting, or recumbent; sometimes even during sleep. The subjective sensation aroused by the increased force and frequency of the cardiac action is described as extremely distressing; it is associated with a feeling of anxiety (Angst), with a sense of pressure in the chest, with forcible pulsation of the carotids and of the abdominal aorta; frequently also with a feeling of a rush of blood to the head, with fugitive heats, and severe headache; sometimes towards the end of the attack there is a sense of flickering before the eyes (as of muscae volitantes), tinnitus aurium, dizziness, and in rare cases actual syncope.
Objectively, during the paroxysm, a notable increase in the frequency of the heart’s action can be detected, the pulse-rate rising to 120 or even 150 per minute. In most of my cases, the pulse throughout the attack remained strong, well-filled, and regular. Sphygmographic tracings taken during the seizures showed a remarkably high pulse-wave, the ascending limb of the curve rose rapidly and suddenly, the descending limb fell with corresponding steepness and rapidity, and it reached an unusually low level before the commencement of the dicrotic elevation, which latter was exceptionally large; the predicrotic elevations, on the other hand, were but slightly developed. On auscultation, the tones of the heart were pure, but were louder than normal.
Sometimes during a paroxysm a sudden reddening of the face was noticeable, extending often to the neck and the thorax. In the areas mentioned, vivid red patches would suddenly make their appearance, disappearing more gradually after lasting a few minutes—this appearance was associated with a burning sensation of the affected areas. In some cases during the paroxysm there was an outbreak of perspiration on the head and the back.
Associated with these cardiac troubles of women at the climacteric we usually find a state of physical and mental disquiet; less common associations are, an incapacity for regular work, sleep uneasy and much disturbed by dreams, great general nervous irritability, or signs of passive congestion in various organs; occasionally there is oedema of the lower extremities; the urine remains free from albumen.
In most of the cases of this nature which came under my own observation, a certain plethora was noticeable; among women at the menopause, it was especially the well-nourished, powerful, sanguine individuals, that were liable to palpitation of the heart. Direct examination of the blood sometimes showed a very high haemoglobin richness—110, 115, or even 120, as compared with a haemoglobin-richness of 93 in normal woman. Several of my patients presented the clinical picture of the plethoric form of lipomatosis universalis.
In all, during ten years, I observed 67 cases of paroxysmal tachycardia in climacteric women. The age distribution was the following:
| 36 years of age | 1 woman |
| 38 years of age | 1 woman |
| 39 years of age | 2 women |
| 40 to 45 years of age | 37 women |
| 45 to 50 years of age | 28 women |
| Over 50 years of age | 8 women |
Five of the patients were unmarried, three were married but childless, the remaining 59 were parous women.
As a general rule, women live in great dread of all manifestations of bodily disorder during the menopause; those who become affected with paroxysmal tachycardia are exceptionally anxious, and regard themselves as threatened by a “stroke.” This pessimistic view is however, by no means justified. These cardiac disorders may make their appearance some time before the menopause, they may persist throughout the period during which menstruation is irregular, they may even endure for some time after the total cessation of the flow—but serious consequences of this climacteric tachycardia have never come under my observation. As regards treatment of the disorder, I have seen very favourable results from the following measures: The systematic employment of mild purgatives, combined with suitable dietetic and hygienic regulations (bland diet, regular and strenuous exercise, cold ablutions, and wet compresses surrounding the abdomen).
When we enquire regarding the cause of the tachycardiac paroxysms occurring at the menopause, we must first of all bear in mind that in the cases which have come under my own observation, the cardiac impulse was powerful, the pulse strong and well-filled, that signs of general vasomotor disturbance (ardor fugax, etc.) accompanied the tachycardiac seizures,—hence we are led to infer that we have to do with a stimulation of the excito-motor nerve fibres, which would appear to be due to the climacteric changes previously described as occurring in the female reproductive organs. This view receives support from the fact that after oöphorectomy, when, as in the normal climacteric, atrophic processes occur in the internal reproductive organs, paroxysms of nervous palpitation are frequently observed. The same explanation applies to the fact that in women at the climacteric affected with these tachycardiac troubles, we frequently see in association therewith the symptoms of uterine dyspepsia.
But in addition to these local anatomical changes in the reproductive organs, to which an etiological role must be assigned in the production of climacteric tachycardia, the irritable state of the accelerator nerves must also depend in part upon that general nervous hyperexcitability which is so often a characteristic feature of the climacteric period in women, manifesting itself in manifold hyperaesthesias, hyperkinesias, neuralgias, and, in extreme cases, mental aberration. The sensory nerves are more irritable than in their normal state, so that every stimulus acting upon them evokes a greater central effect than heretofore, and upon this ensues an exaggeration of various reflex manifestations, which appear altogether disproportionate to the strength of the exciting cause; among these disproportionate reflex effects, is to be numbered the tachycardia just described.
But in addition to the causes of climacteric tachycardia already enumerated, we have to take into consideration the results of recent investigations concerning the organo-therapeutic employment of the chemical constituents of the ovarian tissue; it would seem that when at the menopause the ovaries undergo atrophy, so that their internal secretion is no longer poured into the blood, the resulting alteration in the chemical constitution of that fluid gives rise to a disturbance of the vasomotor centre in the medulla oblongata.
In some cases, the tachycardiac paroxysms appear to be connected with the erotic excitement to which women are sometimes subject at the climacteric, voluptuous crises and ejaculation occurring; it is possible that in some of these cases masturbation plays a part.
A second group of cardiac troubles occurring in climacteric women consists of cases which are very common, but not often very severe. The cases in question depend upon the liability to an increased deposit of adipose tissue in the body at the time of the menopause, and in this connexion the plethoric form of lipomatosis universalis almost invariably predominates. It is a well-known fact that between the ages of 40 and 50 years women have an excessive tendency to obesity, and that even those women who have hitherto been extremely lean are apt to become quite plump at the climacteric period. Chiefly in consequence of this increasing obesity, there occurs in climacteric women a series of cardiac troubles of very variable intensity. If the deposit of fat is effected very gradually, and if the obesity does not become extreme, it is only after vigorous bodily exercise, such as fast walking or going upstairs, and after meals, that the patient is troubled with a little shortness of breath and moderate palpitation; appetite, digestion, and sleep remain usually unaffected in cases of this degree of severity. Definite attacks of cardiac asthma, and well-marked signs of cardiac insufficiency affecting the entire circulatory system, will very rarely occur in such persons.
It is an interesting fact, that the troubles which arise from fatty deposits around the heart are in general far less severe in climacteric women than they are in obese men of corresponding age. This may be due to the circumstance discovered by W. Müller, in the course of his investigations on the proportions of the human heart, that in the development of general obesity, the pericardial fat increases proportionately to a greater extent in the male than in female. But in my opinion the true explanation is to be found in the fact that variations in the amount of fat in the body are normally far more extensive in women than in men; at puberty, during pregnancy, and during lactation, extensive though gradually effected changes in the amount of adipose tissue in various parts of the body occur, so that experience has rendered the organism ready to adapt itself to the further changes that take place at the climacteric—above all, the heart has become competent to meet very various demands upon its powers.
Only in women who from youth onwards have exhibited a marked tendency to obesity, and in whom at the climacteric age such obesity has become extreme, do the cardiac troubles attendant on the menopause become very severe. In such persons, palpitation and shortness of breath occur on slight exertion, and attacks of cardiac asthma are frequent. In consequence of the diminished propulsive power of the heart, circulatory difficulties make their appearance in the most widely divergent venous areas; the forms most commonly met with are, varices in the veins of the lower extremities, permanent dilatation of certain of the small superficial veins of the skin, phlebectases of the rectal veins (i. e. “piles”), and ultimately we see the well-known series of symptoms of venous engorgement—oedema of the feet, passive congestion of the lungs, albumen in the urine, etc.
When such cardiac troubles are present, the objective examination of the heart shows in the early stage no gross abnormality; at most the heart-tones seem somewhat weakened, with a moderate enlargement of the area of percussion-dulness, whilst the impulse is displaced a little outwards, and is weaker than normal. In some cases, however, a marked dulness on percussion over the sternum indicates an extensive deposit of fat in the mediastinal tissues. In the second stage of the fatty heart, when the symptoms have become more severe, we find a considerable enlargement of the area of cardiac dulness both in the vertical and the horizontal extent; the cardiac impulse is diffused as well as feeble. The sounds of the heart are usually pure but faint—in some cases they remain loud and clear. Exceptionally, a short blowing murmur is heard with the first sound; and sometimes this sound is reduplicated.
Whilst in the first stage the pulse is hardly abnormal, in the second stage, very various changes occur; often it is subdicrotic or dicrotic in character.
In the great majority of instances, in these cases of cardiac disorder at the menopause, provided a suitable dietetic regimen is early adopted and perseveringly carried out, we may give a hopeful prognosis.
A third, less common but far more serious form of cardiac disorder occurring at the menopause, displays the well-known symptoms of cardiac failure. Those thus affected are usually slightly built, delicate women, who during the years of development suffered from chlorosis, who in adult life were troubled with anæmic symptoms, and in whom the menopause was ushered in by very severe losses of blood; sometimes, again, they are women who throughout their sexual prime have been accustomed to menstruate very abundantly, who have had numerous and severe deliveries, or who have had frequent miscarriages—it is in those who have thus been weakened by frequent and profuse haemorrhages, that the symptoms of cardiac failure ensue at the climacteric period. The women thus affected also frequently suffer from palpitation of the heart; the pulse is abnormally frequent, small, low, and easily compressible, and sometimes intermittent or arrhythmical. The heart’s action is weak and devoid of energy. The heart-sounds are usually obscure, and sometimes a systolic murmur is audible. The patients are short of breath and are subject to attacks of cardiac asthma, not infrequently associated with angina pectoris. In conjunction with these symptoms, we see signs of venous congestion: sudden attacks of coldness in the hands and feet, often also oedema of the feet; the urine at times contains albumen. The haemoglobin-richness of the blood is always notably diminished. I need not discuss in further detail the well-known symptoms of cardiac insufficiency, and I need only insist that when these symptoms are met with in women at the climacteric, it is of the greatest importance, alike from the prognostic and from the therapeutic standpoint, to make a careful examination of the reproductive organs, so as to determine the exact source of the recurrent bleedings which usually constitute the primary cause of the patient’s sufferings.
In several cases of this kind, I found that the haemorrhages were due to a relaxation of the uterine tissues, and that this relaxation was itself referable to intrapelvic circulatory disturbances, dependent upon obstruction in the vena cava inferior, whereby the venous return from the pelvis was rendered difficult, and an engorgement of the uterine vessels was brought about.
In some instances of cardiac failure at the menopause, chronic inflammation within the pelvis is to blame for the menorrhagia upon which the cardiac failure depends. Often, again, the haemorrhages are referable to vasomotor influences, such as are liable during the menopause to affect various vascular areas. In other cases, the recurrent bleeding is due to retroflexion of the uterus, to prolapse of that organ, or to tumour, it may be myoma, polypus, or carcinoma.
Finally, during the menopause, more especially in women in whom menstruation has continued up to or beyond the fiftieth year, or in those who have given birth to a large number of children or have lived lives of severe bodily exertion, cardiac troubles may arise dependent upon arteriosclerosis of the great vessels. The signs of such changes in the walls of the bloodvessels are clearly marked: the cardiac impulse is heaving, the second sound of the heart is accentuated; the pulse is full and large, usually giving a very powerful blow to the examining finger, whilst its sphygmographic tracing exhibits characteristic signs in the exceptional height and great distinctness of the first predicrotic elevation. The subjective troubles are in these cases very severe; dyspnoea and attacks of asthma or of vertigo are common, and sometimes albumen may be found in the urine.
We may thus summarize the cardiac disorders met with at the menopause, and more or less directly dependent upon the changes undergone by the feminine organism at that period of life:
1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric changes in the ovaries.
2. Nervous palpitation in women who were similarly affected at the time of the menarche, and in whom the trouble is merely the expression of a very unstable nervous system, and one influenced with especial readiness by impressions proceeding from the reproductive organs.
3. Cardiac disorder due to the obesity so commonly occurring as a part of the general metabolic changes of the menopause, but more particularly dependent upon a deposit of fat in the neighbourhood of the heart itself.
4. Symptoms of cardiac failure, due to excessive losses of blood at the menopause, either as an exaggeration at this time of menstrual processes, or as a result of some actual disease within the pelvis.
5. Cardiac disorder in women in whom the menopause occurs at an unusually advanced age, and dependent upon arteriosclerosis.
Particular consideration must be given to a symptom not infrequently occurring in association with the cardiac troubles of climacteric women, and referable to the circulatory disturbances characteristic of this period of life, namely, vertigo. The attack in some cases comes on without apparent cause, in others it occurs on the performance of some unusual movement or the adoption of some peculiar posture (stooping, or the like); the patient is suddenly seized with a sense of rotation, either of his own body, or else of his visible and palpable environment; with this is associated a sensation of disturbance of equilibrium, flickering before the eyes (muscae volitantes), tinnitus aurium, palpitation of the heart, increased frequency of the pulse, which may be either full or small, redness or pallor of the face, coldness of the hands and feet, muscular twitchings, a sense of great anxiety, and the outbreak of a cold perspiration. The vertigo occurs in paroxysms, usually of short duration—a few minutes to a quarter of an hour. It is especially plethoric and obese women who are liable at the climacteric to suffer from this disorder.
A somewhat similar condition is described by Tilt under the name of “pseudo-narcotism,” as frequently occurring in climacteric women. Tilt indeed states that in 500 such women, he noted its presence in no less than 277.
Many hypotheses have been promulgated to account for the vertigo that so frequently occurs at the menopause. Both anæmia and hyperaemia of the brain have been assumed as causes, alike dependent upon the irregularity of menstruation, which is supposed to have a reflex influence upon the cerebral circulation. Others regard the vertigo as a climacteric neurosis, since it occasionally occurs before the menstrual irregularities begin, and in such cases a reflex disturbance of the cerebral circulation cannot be supposed to have arisen. According to Matusch, climacteric vertigo is a manifestation of epilepsy—an explanation which has been often extended to include all the menstrual psychoses. Windscheid believes that in many of the cases the vertigo is to be explained by the existence of arteriosclerotic changes in the blood vessels, such as are already by no means rare at the age at which the menopause usually occurs; whilst in other cases, he believes, the vertigo is to be regarded as one of the symptoms of a nervous disorder. That in any case the vertigo is dependent in some way upon the changes that occur in the reproductive organs at the climacteric period, is shown by the fact that after the final cessation of menstrual activity the patient as a rule ceases to suffer from this symptom.
To the circulatory disturbances consequent upon the menopause we must also refer ardor fugax, fugitive heat, the sudden rushes of blood to which women are prone at this period of life.
The cardiac troubles of the menopause are seen especially in women in whom the cessation of menstruation occurs quite suddenly, and in those in whom menstrual activity ceases at an exceptionally early age. It would seem that in such cases, owing to the continuance of periodic maturation of the graafian follicles associated with congestion of the intrapelvic organs, in the absence of the periodic relief to that congestion afforded by the menstrual flux, there results a summation of stimuli, whereby the accelerator nerves of the heart are very powerfully affected.
Thus, I had under my care a lady from Smyrna 36 years of age. She had begun to menstruate when 12 years of age and menstruation was always scanty; she married when 15 years old, and finally ceased to menstruate when 19 years of age; she was sterile, and no abnormality could be detected on physical examination of her reproductive organs. Every month she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of blood to the head, perspiration of the face, etc.
In another case, that of a woman 45 years of age, menstruation, hitherto regular, was suddenly suppressed, during the flow, in consequence of a severe fright. The next month the flow failed to appear at the usual time, but instead the patient was affected with severe cardiac distress, accompanied by sudden sensations of heat in the face, palpitation of the heart, and vertigo; these symptoms lasted for several days, and since then have recurred at intervals of three or four weeks.
The cardiac troubles of the menopause are seen with especial frequency in women who were affected with similar disturbances at the time of the menarche. Experience clearly shows that a certain connexion exists between the manifestations that accompany the commencement of sexual activity, and those that accompany the decline and extinction of that activity; and a physician will rarely be mistaken if he bases on the fact that the general health was or was not seriously affected at the age of puberty, a prognosis that the course of the climacteric will be an unfavourable or a favourable one, respectively. In other words, in women whose nervous system is an unstable one, and in those with hereditary predisposition to the occurrence of cardiac disorder, the changes that take place in the reproductive organs both during the menarche and during the menopause, are likely during these vital phases to arouse reflex disturbances of the cardiac functions. The facts thus noted are analogous to those observed by Potain, who distinguishes a peculiar form of chlorosis, occurring in delicate individuals at the age of puberty, and, though apparently cured during the menacme, recurring in its primitive severity at the time of the menopause.
Again, women with a sanguine and erethistic temperament are more inclined to suffer from cardiac troubles at the menopause than women of a tranquil temperament and those endowed with an unimpressionable nervous system.
Finally, elderly virgins, women who have for many years lived in chaste widowhood, sterile women, women who have married shortly before the menopause, or who at this time have recently been delivered, are all more inclined to the cardiac troubles of the climacteric period than women whose sexual life has been of a less abnormal character.
In the literature of the subject, we find numerous references to the fact that among the disorders of the climacteric, circulatory disturbances play a part. But a full and accurate account of these disorders is lacking alike in the literature of gynecology and in that relating to diseases of the heart—and this is true even of the most recent publications.
Among striking individual cases, one recorded by Moon may be mentioned here, a case of tachycardia consequent upon a sudden menopause: “In a woman 35 years of age the menses were suppressed owing to chill; the pulse-frequency increased from 80 to 200, without any apparent change in the heart or its valves; the symptom lasted for several days, when menstruation became once more established, and the pulse-frequency fell again to the normal.”
Tilt expresses the opinion that the heart is but little involved in the disturbances of the climacteric, his experience coinciding with that of Quain. Boerner and Glaevecke, on the contrary, describe the heart troubles of the climacteric in terms very similar to those employed by myself.
A. Clément describes a peculiar form of disturbance of the functions of the heart at the climacteric period, to which he gives the name of Cardiopathie de la Ménopause, and of which he has seen four cases. The age of his patients varied from 46 to 50 years. They were all vigorous women, free from hysterical symptoms, and they had never suffered from rheumatism or from any functional disturbance of the heart. In all these cases the cardiac disorder occurred at a time of life when menstruation still continued, but had already become somewhat irregular. Usually the trouble in question makes its first appearance during the flow, or, if occurring independently of menstruation, becomes more severe at that time. Prior to the development of the actual heart symptoms, we observe for a time, two or three months it may be, signs of general exhaustion and weakness. Then occurs an attack of palpitation of the heart, rapidly succeeded by faintness, sense of precordial anxiety, and dyspnoea. During repose the patient does not usually suffer from any difficulty in breathing, but sleep is apt to be disturbed by paroxysms of palpitation and severe precordial anxiety. As the disease advances, dyspnoea is observed on the slightest exertion. Ultimately, the symptoms mentioned, palpitation, precordial anxiety and dyspnoea, become permanent, but are less severe when the patient is at rest. Constant now is also the feeling of weakness and faintness, which from time to time increases to actual syncope with complete loss of consciousness, and coldness of the entire surface of the body. Examination of the heart gives negative results. The cardiac impulse is a little stronger than normal; the cardiac rhythm may be either regular or irregular, but actual intermission of the beats does not occur. The heart-sounds are pure, there is no murmur; the first sound, if altered at all, will be stronger, not weaker than normal. Neither swelling of the jugular veins nor venous pulsation is to be observed. The most striking symptom of heart affection, indeed the only positive physical sign, is the great increase in the frequency of the heart’s action, the pulse rate often being as much as 150 or 160 per minute, and in addition weak and somewhat variable in strength. At the outset of the disease, no oedema of the lower extremities is to be observed, and it only appears after three or four attacks. In all the patients the extreme pallor of the face is a striking feature. An increased quantity of urine is eliminated. The course of the disease is characterized by a series of successive paroxysms, separated by periods of almost complete remission. At first, these remissions last for a month or two, but they gradually become shorter and shorter, whereas the duration of the attacks continually increases, until it is as much as seven or eight days. At this stage, disturbance of digestion ensues, the appetite is lost, and the general vigour declines. Recovery ultimately occurs, but very gradually. Clément refers the disease to a profound disturbance of the cardiac innervation through the sympathetic nerves, but believes that anæmia constitutes a contributory cause of the cardiac disorder.
Kostkewitsch has made observations regarding the influence of the climacteric upon previously existing heart-disease, and has thereby been led to conclude that the influence is unfavourable. The functional disturbances of the cardio-vascular apparatus which commonly accompany the menopause, readily lead, should organic heart-disease exist, to the onset of severe cardiac weakness, which may have a rapidly fatal termination. In 55.5% of the women who enter the climacteric period with organic disease of the heart, the menopause gives rise to a failure of compensation. Such failure of compensation is especially likely to occur in women suffering from valvular insufficiency; it is least probable in cases of arteriosclerosis without valvular defect. The symptoms of defective compensation—dilatation of the heart, increased frequency of the pulse, arrhythmia cordis, etc.—are manifested especially during the menstrual flow.
Diseases of the Digestive Organs.
The congestions which, as we have already pointed out, constitute the pathological basis of the majority of the disorders of the climacteric, manifest themselves in the abdominal organs in the well-known form of plethora abdominalis, chronic venous congestion of the gastric and intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the mucous membrane of the bladder, catarrh of the bladder, distension of the haemorrhoidal veins, and the various symptoms dependent upon these several forms of congestion.
Bleeding from the haemorrhoidal veins and chronic diarrhoea are two of the troubles proceeding from the above mentioned congestion of the intra-abdominal vessels, which occur so frequently during the climacteric period that since the days of antiquity they have been regarded as critical manifestations of the menopause, the object of which is to afford a vicarious outlet for the menstrual flux, now become irregular and intermittent. It can, indeed, be readily understood that a discharge of blood and an increased secretion from the mucous membrane of the lower part of the intestine may, if not too violent, exercise a favourable influence upon the congestive states of the climacteric, by relieving the distension of the abdominal vessels—by a local blood-letting which regulates the disordered circulation. In this way, even though we have ceased to regard it as a “critical” manifestation, haemorrhoidal bleeding, accompanied by an increased secretion from the intestinal mucous membrane, may at the climacteric period have a distinctly favourable influence upon a woman’s general condition.
Hippocrates already in his aphorisms pointed out the salutary effect of epistaxis and of diarrhoea in women suffering from suppression of the menses. Other authors have assigned a critical significance to diarrhoeas occurring at the climacteric, and have warned against their suppression. According to Tilt, diarrhoea occurred in 12% of all women of this age coming under his observation; in 4% of the climacteric women, this diarrhoea recurred at regular monthly intervals, whilst in 8%, the recurrence was irregular. In 500 women during the climacteric age, Tilt observed the following abdominal disorders:
In my own observation, constipation is more frequent in climacteric women than diarrhoea, the constipation being also a symptom of abdominal congestion. Sometimes, when diarrhoea occurs, it is really secondary to constipation. The accumulation of the faecal masses stimulates the intestinal mucous membrane, and gives rise to a profuse aqueo-mucous secretion; the firm faecal masses are then liquefied, the intestinal wall is lubricated, and the constipation gives place to diarrhoea lasting perhaps for several days. This is the explanation of many cases in which there is a periodic recurrence of diarrhoea.
Dyspeptic disturbances are rarely absent during the climacteric period. Most often we see disordered appetite, sluggish digestion, pyrosis, eructation, at times nausea and retching, and actual vomiting of a watery or bilious fluid. Occasionally, an abnormal sensation of hunger follows each meal, associated, however, with a feeling of distension of the stomach. A very distressing symptom is an excessive formation of gas within the intestine. At times such meteorism is extreme, and it then gives rise to very severe abdominal pain. The gas is evacuated slowly and with difficulty, the patient is compelled to loosen all her clothing; more especially after a meal she is compelled to take off her stays and undo all the bands of her petticoats and skirt. At the same time we see difficulty in breathing and tachycardia. Such an accumulation of gas within the abdomen may give rise to serious errors in diagnosis, the swelling being attributed to pregnancy or to abdominal tumour.
Noteworthy also at the time of the menopause is the occurrence of vomiting, either as an isolated symptom, or in association with some other well-known climacteric disorder. When this vomiting is associated with some unmistakable form of excessive secretory activity (hyperhydrosis, etc.), we may readily suppose that the vomiting is due to undue secretory activity on the part of the gastric mucous membrane. An excessive production of gastric juice, perhaps altered in quality as well as quantity, combined with some other disorder of gastric innervation (hyperaesthesia, or hyperkinesia) will sufficiently explain the occurrence of the sometimes excessive vomiting, even though in many of the cases there may be no reason to suppose that there exists any primary stimulation of the vomiting centre. In other cases, however, it is probable that the trouble is really due to a primary disorder of that centre; and a careful study of the clinical features of the case will be needed to show how far there may be associated with this other disorders of gastric innervation (Boerner).
Disturbances of the biliary secretion, icterus of greater or less severity, are by no means rare manifestations of the abdominal congestion of climacteric women, and such disorders have also been regarded as vicarious processes originated by the cessation of the menstrual flux (Aran, Bennet, Henoch, and others.) Frerichs also has pointed out that with the cessation of menstruation at the climacteric we not infrequently observe swelling of the liver, which disappears when, after a considerable period, the menstrual flow recurs—a sequence of symptoms which may be repeated again and again for a considerable time.
Diseases of the Skin.
The most characteristic symptom of disorder of the skin met with at the climacteric period—one which, indeed, may be said to be never absent—is ardor fugax, fugitive heat; and scarcely less common is hyperhydrosis, an excessive secretion of sweat. Almost invariably, at the commencement of the menopause, women complain of a feeling of burning heat, rising up from the breast to the face; and if they are kept under observation we see from time to time a sudden redness of the face, and sometimes also of the neck and chest, associated with the outbreak of a thin perspiration. Moreover, in nearly all climacteric women, we notice an increased secretion of sweat over the whole surface of the body, and at times this secretion is extremely profuse.
In association with these symptoms we often see the hyperaemic processes in the skin known by the names of erythema and roseola, taking the form of larger or smaller bright red patches, which are most frequently seen on the sides of the neck, the front of the chest, and the face.
In many women, at the menstrual periods, when the flow has become scanty or has already entirely ceased, we observe the occurrence of eczematous eruptions, which have for this reason received the distinctive name of climacteric eczema. In the majority of these cases, the eczema does not make its appearance until the regular menstrual flux has completely ceased to occur; and in the less common cases in which the flow persists after the climacteric eczema has begun, menstruation is rarely regular, but has begun to exhibit the variability and disorder characteristic of the time of the menopause. If the eczema comes on after the menopause is completely established, it usually appears in from six to twelve months after the cessation of the flow; but in some cases, the eruption appears very soon after the menopause, whilst in others, its onset may be delayed for as long as four or five years. Climacteric eczema is obstinate, and shows no tendency to spontaneous cure. With regard to the localization of the eruption, Bohn found that in three-fourths of the cases it affected the hairy scalp and the ears; Rayer and Hebra also state that the eczema of the menopause is most frequently seen in these two situations, whilst the next commonest site for the eruption is the face. As regards other parts of the skin, it is only that of the extremities that is ever affected by this disease, especially the hands and the fingers, less often the forearms or the backs of the feet; it never appears on the trunk. With regard to the types of eczema occurring in connexion with the menopause, we see almost exclusively the squamous and the weeping forms of the disease.
In general, at the climacteric period, the skin is extremely sensitive, and devoid of powers of resistance to outward noxious influences. Alternations of dampness and dryness or of heat and cold readily give rise to redness, infiltration, and the formation of scales and fissures of the skin; sometimes this occurs merely after cold ablutions. These acute stages of swelling, redness, and vesiculation of the skin, readily pass on into chronic and obstinate dermatitis.
Not infrequently, during the climacteric, as during the menarche, inflammation of the sebaceous glands occurs, acne, at times accompanied by seborrhœic manifestations. In other cases, we see disfigurations of the face in consequence of vascular dilatations, especially on the nose and on the adjoining portions of the cheeks, rosacea, in which disease also there is associated inflammation of the sebaceous glands. Another disorder of the skin of the face which is greatly dreaded by women at this time of life, owing to the unsightly appearance it produces, is the development of sinuous dilatations of some of the superficial vessels, at times associated with connective tissue proliferation in the form of red or violet-coloured painless nodules.
An extremely distressing affection, and one which is especially apt to attack women during the change of life, is the previously mentioned pruritus genitalium. The itching is in some cases confined to the external genital organs, whilst in others it extends into the interior of the vagina; also it may pass backwards over the perineum, and on into the gluteal folds. In some cases, some local pathological condition will be found to account for the disorder: catarrh of the vagina or of the cervix uteri; displacements, inflammations, or new-growths of the uterus; anomalies of the ovary, the bladder, or the urethra. Cohnstein draws attention to a circular hyperplasia of the vaginal portion of the cervix, occurring during the menopause, and, “owing to the vascular dilation by which it is characterized, possessing close analogies with haemorrhoids;” the worst symptom of this affection is pruritus. That in these cases the pruritus is actually dependent upon the “haemorrhoidal hyperplasia” of the portio vaginalis, Cohnstein considers to be proved by the fact that, whilst local applications give no more than momentary relief to the itching, this symptom is completely relieved by the abstraction of blood from the cervix. But in addition to such cases as these, we have from time to time to deal with patients suffering from violent genital pruritus during the climacteric period, in whom we shall vainly seek for any local pathological changes, to the cure of which our therapeutic zeal may be directed. Analogy with some other disorders of the climacteric leads us to conclude that in these cases also we have to do with an idiopathic neurosis (Boerner).
The frequent recurrence of pruritus vulvae leads ultimately to the formation of nodules and papular eruptions.
Many authors state that they have observed the frequent occurrence of erysipelas during the climacteric period; others assert that furunculosis, prurigo, urticaria, and herpes zoster, are seen with especial frequency at this period of life.
Tilt, in his 500 cases of women at the climacteric age, made the following observations:
201, or 40.2%, suffered from heats and tendency to perspiration.
2, or 0.4%, suffered from monthly recurrence of periods of perspiration.
84, or 16.8%, suffered from profuse perspirations.
13, or 2.6%, suffered from cold sweats.
14, or 2.8%, suffered from dry heats (dry flushes).
186, or 37.2%, remained free from such attacks of heat or perspiration.
Krieger gives as an example of the “occurrence of new troubles” at the change of life, furunculosis; so also does Boerner. “The discolouration of the face, occurring usually in connexion with pregnancy or with diseases of the reproductive organs, and known as chloasma uterinum,” has been seen by Cohnstein, during the climacteric period, “chiefly in cases in which, owing to some degree of failure of general nutrition, the skin has been thrown into folds.” Wilson regarded prurigo and eczema as the commonest skin-diseases of the climacteric period; whilst Boerner draws attention to a connexion between climacteric conditions and the outbreak of herpes zoster.
Disorders of Metabolism.
Among the disorders of metabolism to which women are especially prone at the climacteric period, we must in the first place allude to obesity (lipomatosis universalis), and to gout (arthritis urica).
Numerous observations have shown us that the time of the change of life, the period between the ages of 40 and 50 years, is the one especially favourable in women to the extensive deposit of fat in the tissues.
In 200 cases of great obesity (lipomatosis universalis) in women, in which I instituted enquiries regarding the age at which an excessive deposit of fat in the tissues had first been noticed, I obtained the following results:
| In early childhood in | 19 cases |
| At the age between 15 and 20 years in | 30 cases |
| At the age between 20 and 30 years in | 45 cases |
| At the age between 30 and 40 years in | 52 cases |
| At the age between 40 and 50 years in | 54 cases |
| At ages over 50 years | 0 cases |
We learn from these figures that it is between the ages of 40 and 50 years that there is the greatest tendency in women for the accumulation of fat; but that as early as between the ages of 30 and 40 years this accumulation may in many instances begin. Speaking generally, there is in women an obvious connexion between the development of obesity and the state of the reproductive functions, inasmuch as at puberty, during the puerperium, and above all at the climacteric, there is a special tendency to the accumulation of fat in the subcutaneous tissues. At the commencement of the menopause, it is more especially in the abdominal wall, the breasts, and the buttocks, that we witness the deposit of fat. In the abdomen, owing to the thickening of the subcutaneous tissues and of the great peritoneal folds—especially of the great omentum—a marked protrusion occurs, whilst the umbilicus becomes more deeply hollowed, and ultimately funnel-shaped. In some instances, the deposit of fat around the navel favours the occurrence of umbilical hernia. After an artificial menopause, induced by oöphorectomy, it has also been noticed in from 42 to 52% of the cases that a marked general deposit of fat has occurred, affecting especially the breasts and the buttocks.
This obesity in climacteric women, not only impairs to a serious extent their good looks, but brings in its train a number of troubles, and gives rise to manifold morbid manifestations, and among these, changes in the heart, which may readily threaten the patient’s life. In consequence of extensive fatty deposits in the myocardium, associated with actual fatty degeneration of the muscular fibres, cardiac insufficiency ensues, with all its distressing and disastrous consequences. It is further necessary to insist upon the fact that obesity during the climacteric very definitely favours the occurrence of menorrhagia.
On examining 282 women, 5 years after the complete cessation of the menstrual flow, Tilt found that
| 121 | had become stouter than before, |
| 71 | were unchanged in this respect, and that |
| 90 | were thinner than formerly. |
Alike in the third class and in the first were a very large proportion of women in whom the change of life had entailed much illness and suffering; but in the first class, the women who had been thus affected had at that time lost weight, and only in the latter half of the climacteric period, when their troubles had become less severe, had the condition of embonpoint made its appearance.
Passing now to the consideration of arthritis urica in women at the climacteric, it is worthy of mention that Hippocrates was so much struck by the association that he went so far as to deny that gout occurred at all in women before the menopause. The fact of the matter is that whilst women are in general less disposed than men to the occurrence of gout, the tendency of women to this disease during the climacteric period is so marked, that at this epoch of life the disease is far more common in women than it is in men of corresponding age.
It is in obese women, with a soft, white, and lax integument, with a pallid, somewhat bloated countenance, a poorly developed muscular system, extensive varicosities of the veins of the legs, marked dyspeptic troubles, and habitual constipation, that during the preclimacteric and climacteric periods, gout is especially apt to make its appearance. It is then characterized by the following symptoms. From time to time the woman suffers from tearing or shooting pains in the joints, lasting at first a short time only, and returning after longer or shorter intervals. With the frequent return of the pains, the affected joints become swollen; and finally the patient suffers from the characteristic attacks of acute gouty arthritis, with the well-known consecutive symptoms of this affection.
According to the observations of Geist, during the climacteric period, 28 women suffer from gout as compared with 4 men of corresponding age. Tilt publishes the following figures showing the mortality of women from gout in England:
| At ages from 20 to 30 years | 56 women |
| At ages from 30 to 40 years | 121 women |
| At ages from 40 to 50 years | 291 women |
| At ages from 50 to 60 years | 152 women |
| At ages from 60 to 70 years | 104 women |
Regarding diabetes mellitus during the menopause, Lawson Tait, who maintained there was a distinct form of climacteric diabetes, asserted that this disorder of metabolism was less severe, and runs a longer course during the climacteric period than at other times of life.
Diseases of the Nervous System.
The disturbances of the nervous system that occur during the climacteric period, manifest themselves chiefly in the form of hyperaesthesia and hyperkinesia. The sensory nerves appear to me for the most part to be more irritable than normal, inasmuch as every stimulus by which they are affected arouses a comparatively greater sensation, and gives rise to an excessive reaction in the sphere of consciousness. The cutaneous hyperaesthesia of climacteric women is shown in very various ways, the commonest being the anomaly of sensation which gives rise to the symptom known as pruritus, characterized by paroxysms of itching in more or less extensive areas of skin, with consecutive nutritive changes in the affected portions of the integument. The commonest and the most distressing form of this disorder during the menopause is pruritus vulvae.
In addition to such manifestations of cutaneous hyperaesthesia, vasomotor disturbances of the skin are of frequent occurrence, characterized by redness, rise of temperature, and sometimes the formation of nodules in the affected areas. Almost without exception, at the outset of the climacteric period, and sometimes also in the preclimacteric epoch, women complain of a very distressing feeling of fugitive heat in various portions of the surface of the body, manifested objectively by the rapid appearance and no less rapid subsidence of a red colouration of the skin of the face, the neck, and the chest. Such fugitive heats are due to disturbances of vasomotor innervation giving rise to sudden variations in the amount of blood passing through the vessels of the affected areas of skin.
Hardly less frequent during the climacteric are the sensations of imaginary movement which give rise to the subjective symptom known as vertigo. Often in women at this time of life it occurs quite without apparent cause, but in other cases on the performance of some unusual movement or the adoption of some unusual posture; there is a sudden perception of rotatory movement, either of the patient’s own body or else of her visible and palpable environment. With this feeling of disturbed equilibrium, there is often associated optical and auditory hyperaesthesia, flickering before the eyes (muscae volitantes), tinnitus aurium, painful sensations in the head and more especially in the occipital region, nausea, vomiting, sense of anxiety, cold sweats, muscular twitchings, alternating redness and pallor of the face, and coldness of the feet. The vertigo occurs in paroxysms, usually of short duration, varying from one to fifteen minutes. It is especially in plethoric and obese women that climacteric vertigo occurs.
A peculiar form of this climacteric vertigo is that described by Tilt under the name of “Pseudo-Narcotism” of climacteric women, characterized by a sense of swimming movements, uncertainty in the gait, vacancy of expression, a confused look in the eyes like those of a drunken person, and a kind of mental stupor which the patient cannot shake off without considerable effort. The women thus affected state that they feel as if they had had too much to drink, as if something had gone to their heads; indeed their great fear is that they will be supposed to be intoxicated by those who see them walking in the streets; they feel even that they must refuse to receive the visits of their acquaintances if they wish to preserve their reputation for sobriety. They suffer also from great drowsiness, from a disagreeable sense of weight or pressure in the head, from a feeling “as if the brain was clouded, or needed to have some cobwebs swept away.” They feel a disinclination to both mental and physical exertion, and their memory and all other intellectual powers are impaired.
Boerner maintains that the attacks of vertigo so frequently occurring at the menopause are in a minority of cases only dependent upon hyperaemic states (arising from the cessation of the menstrual flow); on the contrary, he believes that the cause more often lies in hysteria, in chronic disorder of the digestive tract, or, finally, in anæmia. In his opinion, vertiginous attacks dependent upon cerebral anæmia are very common indeed during the climacteric period, and even for a long time afterwards; and he believes that their nature is often completely misinterpreted.
Another very unpleasant indication of disordered nervous function during the climacteric period is the sleeplessness that is so common at this time of life. Women who during the day time feel comparatively well, suffer at night, sometimes periodically at exactly the same hour night after night, from a state of general restlessness, and for this reason are unable to obtain the sleep for which they long. They throw themselves uneasily from side to side of the bed, or wander restlessly about the room, and before long, owing to this want of sufficient repose, become greatly depressed.
Among the neuroses of the sensory apparatus, the various kinds of cutaneous neuralgia are less common than during the menarche and the menacme; but on the other hand, in my personal experience at any rate, the visceral neuralgias are commoner, more especially cardialgia and hypogastric neuralgia. Of the superficial neuralgias, hemicrania and intercostal neuralgia are those which occur most often during the climacteric period.
During the change of life, hemicrania most commonly occurs in typical association with menstruation; or, if the flow has already ceased, the attacks of hemicrania recur at what should be the menstrual periods. This affection is characterized by the paroxysmal occurrence of a severe boring pain in the side of the head, more often the left side than the right, affecting the temporal, the parietal, or the occipital region, or the entire side of the calvaria at once, usually accompanied with redness and local rise of temperature of the painful part; the duration of the paroxysms varies in different cases from one or two to many hours; with the pain are associated chilliness, nausea, exhaustion, and a severe feeling of general malaise.
Of the intercostal neuralgias, one form deserves especial mention in this connexion: I refer to mastodynia, which is both physically and mentally one of the most distressing affections to which women are subject during the climacteric period. For a middle-aged woman suffering from mastodynia—the “irritable breast” of Cooper—almost invariably feels assured that these pains localized in the breast and its immediate vicinity are indications of a commencing cancer of the breast; and it is an exceedingly difficult matter, in most cases, to convince her that her fears are without foundation. In this manner, partly in consequence of the directly depressing effect of the pains, which are commonly intensely severe, and partly owing to the disturbance of mind produced by the belief that an incurably fatal disorder has begun, I have in several instances seen cases of profound melancholia originate.
According to Windscheid, among the enduring painful sensations of the climacteric period, pains in the lower extremities are of somewhat frequent occurrence. Day after day the patient suffers from distressing tearing or lancinating sensations in the legs; the trouble is insusceptible of more exact description, but is none the less a very severe one. In addition to the lower extremities, the back, the spinal column, and more particularly the lumbo-sacral region, are often the seats of incessant pain. In the thoracic region of the back, the pain is usually diffuse; when confined to the spinal column, however, it is commonly limited to individual vertebrae, the spinous processes of those affected being also sensitive to pressure. The sacral pains may in some cases predominate to such an extent, that it is on this ground alone that the patient comes to seek medical advice. The sacrache is equally severe when the patient is standing, sitting, or recumbent; it often radiates into the lower extremities. Boerner draws attention to the fact that in many cases the pains in the sacrum or higher up in the back may be due to excessive tension of the abdominal parietes in consequence of the great accumulation of fat. Among motor manifestations, Windscheid draws especial attention to a certain degree of weakening of the muscles of the lower extremities. Although on examination no abnormality can be detected, fatigue and functional incapacity, more especially in the lower extremities, ensue in a manner altogether disproportionate to the exertion, so that the patient is most unwilling to take even a short walk, to go upstairs, etc. In pronounced cases, the patient will never go out walking without carrying a campstool, so that she can sit down to rest directly she begins to feel fatigued. In association with these disorders of motility we most commonly see the above-mentioned painful sensations in the legs, and by these latter the functional incapacity of the lower limbs is of course increased. Weakness of the arms is far less frequently observed; but occasionally we hear complaints that on the performance of domestic duties, needlework, etc., which previously could be carried out quite easily, the arms and hands are now speedily fatigued, and rendered functionally incapable.
Of the visceral neuralgias, cardialgia is by no means rare during the climacteric period; the pain is concentrated in the epigastric region, but not infrequently radiates to the back and to the chest. Hypogastric neuralgia is also not uncommon, pain in the lower part of the abdomen, associated with a sense of pressure in the bladder, the uterus, and the rectum, and sometimes radiating to the thighs and to the region of the haemorrhoidal nerves.
The opinion expressed by several authorities, that the menopause favours the occurrence of cerebral apoplexy, must, according to Windscheid, be received with caution; we have to remember that with advancing years atheromatous changes are apt to occur in the cerebral arteries, and it is to these changes, altogether independently of the climacteric, that cerebral haemorrhage is due. It appears, however, to be a fact that the menopause favours the onset of progressive paralysis. According to Jung, 60%, and according to von Krafft-Ebing, 27%, of women affected with paralysis were first affected in this way during the climacteric period. Von Krafft-Ebing explains this occurrence by the fact that during the menopause fluxions of vasomotor origin are common, and these serve as the starting point of transudative processes.
Among the neuropathic manifestations of the climacteric period we must reckon the at times excessive increase of the sexual impulse. We have already insisted upon the fact that the sexual impulse is not normally extinguished in women at the time of the cessation of menstruation; on the contrary, sexual desire commonly persists long after the menopause, and on this fact is largely dependent the frequency with which elderly women espouse quite young men. But in some cases, the sexual impulse is enormously enhanced during the climacteric period, and the patient experiences paroxysms of intense voluptuous sensation, associated with manifestations of abnormal reflex and psychical reaction, with increased frequency of the pulse and the respiration, emotional excitement, it may be loss of consciousness, and even general convulsions. Some of these cases of disordered sexuality occur in those previously affected with pruritus vulvae et vaginae.
More particularly Guenceau de Mussy and Boerner have described cases of such excessive libido sexualis during the climacteric period, voluptuous crises with pollutions, occurring independently of any external cause; the women thus affected have a continued succession of erotic ideas, they experience an itching and burning sensation in the genital organs, and from time to time this culminates in a paroxysm of sexual feeling, with orgasm, and increased secretion from the glands of the vulva.
Boerner has observed that characteristic variations in the libido sexualis commonly occur at the climacteric period. Not infrequently at this time the sexual desire becomes greatly diminished in intensity, or even entirely disappears; more often, however, the desire persists throughout this epoch; finally, in many instances, the desire undergoes an increase, at times to a degree amounting to positive torment. The first of these changes, the decline in the intensity of the sexual desire, harmonising as it does with the general extinction of the sexual functions at the change of life, might have been expected to be the normal occurrence. And it is a fact that in many cases characterized by an increase of libido sexualis at the climacteric epoch, Boerner found that there existed anatomical abnormalities in the reproductive organs (fibromata, flexions, etc.). Be this as it may, an increase in the intensity of sexual desire, as long as that increase is not altogether excessive, may be regarded as one manifestation of the visceral hyperaesthesias so general at this time of life. In the excessive degrees of this affection, however, those in which at times the sexual crisis is associated with general convulsions, we must, with Romberg, recognize the existence of a direct neuralgic state of the spermatic plexus. It is especially before the commencement of an actual menstrual period, or before a due period which fails to occur, that during the critical years complaint is made of this state of excessive sexual desire and sensibility; and in many instances the trouble begins at the very first appearance of the menstrual irregularities which foreshadow the menopause.
Windscheid draws attention to the fact that occasionally the nervous manifestations may make their appearance prior to the occurrence of any menstrual irregularity, so that it is by the nervous disturbance that the woman or her physician is warned of the approach of the menopause. “When the menstrual anomalies begin,” continues Windscheid, “that is to say, at the commencement of the climacteric, the nervous troubles may have already attained their maximum and have begun to decline in intensity. As a general rule, however, the appearance of the nervous disturbances coincides with the commencement of the menstrual irregularities. It may happen that these disturbances are intensified with each recurring period, but this is not the rule. Sometimes, however, we may observe that when menstruation occurs with excessive frequency—a by no means rare phenomenon at the outset of the climacteric—the nervous disturbances become more severe; and especially is this the case when the unduly frequent flow is also abnormally profuse, as indeed often happens.” The manifestations of climacteric neurosis occur, as Windscheid rightly insists, most frequently in the sphere of the psyche. “We observe a change in the disposition, which usually becomes more excitable. A woman previously calm and composed becomes irritable, inclined to emotional disturbance and to fits of temper, and unable to bear with equanimity the pinpricks so frequent in daily life, and especially in the daily life of a housewife. In other cases, however, the disturbance of the psyche is rather in the direction of depression: we observe a kind of spiritual inhibition, a deficiency of vital energy, an indifference to things which formerly gave pleasure. Almost always, also, complaints of loss of memory are among the indications of such depression. To these intellectual anomalies are superadded disturbances of sensibility. There is excessive sensitiveness to bright lights, loud noises, and strong odours. Frequently, also, in such cases, we see great intolerance to alcohol, quite small doses giving rise to extremely disagreeable sensations in the head.”
Climacteric Psychoses.
The powerful influence which the changes occurring at the climacteric period has in the origination of psychoses, has long been recognized, the menopause, in fact, being a favourable soil for the cultivation of mental disease. The fact is embodied in medical terminology, since many authors speak of “climacteric insanity,” assuming that the psychoses of this period of life present a definite and characteristic clinical picture.
In an earlier part of this work it was shown that the process of menstruation has generally a marked effect upon the psyche, and that disturbances of menstrual activity are competent to exercise a pathogenic influence upon the mental condition of the woman who suffers from them; still greater and more intense is the influence of the cessation of menstrual activity, with its powerful and widespread disturbance of the entire organism, with its destructive oscillations of equilibrium in the spheres of sensation, perception, ideation, and volition. It is easy to understand how the rarer recurrence of menstruation, the occasional profuse losses of blood, the complete suppression of menstruation, the conditions peculiar to the climacteric period of stasis and congestive hyperaemia of the brain, are competent, more especially in hereditarily predisposed persons, to give rise to the development of psychoses; whilst in those already suffering from mental disorder, the menopause will be likely to bring about an aggravation in their symptoms. At this time of life, also, we have to take into account the effect of certain ideational influences to which allusion has already been made, the thought that womanhood and its joys are passing away for ever, and the fear of the dangers attendant upon this critical period of the change of life. A French proverb alludes to “le diable de quarante ans, si habille à tourmenter les femmes.”
Mental disorder will be more likely to ensue at the climacteric period in those women whose nervous systems have always been unduly irritable, and in those affected with hereditary predisposition to insanity. Further, it is more likely to occur in those in whom the menopause takes place quite suddenly, in a catastrophic manner, than in those in whom the climacteric proceeds gradually, and unaccompanied by any stormy manifestations in the organism at large.
It is not in my opinion possible to recognize any specific form of mental disorder peculiar to the climacteric period, but nevertheless the psychoses occurring at this time of life do exhibit certain striking and characteristic features, more especially in this respect, that states of mental depression with melancholia predominate, whilst erotic influences are manifest in their etiology. In the slighter forms, volition and ideation are unaffected, and the trouble manifests itself in the form of hypochondriacal moods, associated with bodily troubles. In more severe cases we see emotional depression, states of anxiety, limitation of the powers of conception and judgment, indecisiveness, low-spiritedness, and apathy; or on the other hand, restlessness, an inclination to continued moving about, the eager pursuit of continually varying occupations, loquacity, etc.; finally, if the mental disorder becomes still more severe, hallucinations, delirium, paroxysms of intense excitement, and in exceptional instances, fully developed mania.
As with regard to the other disorders attending the climacteric, so also in respect of the climacteric psychoses, women who have been or are married, who have had a reasonable number of children, and have been accustomed to a sufficiency of sexual activity, are more favourably situated, are far more immune, than women whose sexual circumstances have been the opposite of those mentioned, who have had one or two children only, who have indulged in intercourse only when protected from pregnancy by the use of preventive measures, or have remained sexually unsatisfied, and, finally, women who have never married, and those who for many years prior to the commencement of the menopause have lived in chaste widowhood. In “old maids,” to the somatic effects of sexual abstinence (or in some cases of abnormal sexual gratification), are superadded the effects of the intellectual and emotional recognition of a wasted life. Again, it by no means rarely comes under our observation that women who in youth, at the time of the menarche, suffered from psychical disturbances, are apt once again to be affected with transitory mental disorder at the change of life. Once, however, the menopause is completely at an end, a condition of mental quiescence is as a rule established, and then it may happen that previously existent mental disorders undergo amelioration; but on the other hand we have in all cases to reckon with the possibility that they may take an unfavourable turn in the direction of the development of senile psychoses.
Of considerable interest is the fact, first pointed out by Glaevecke, and subsequently confirmed by other observers, that in cases of artificial menopause, melancholic mental disturbances not infrequently follow the operation, in some instances so severe as to lead to weariness of life and actual suicide; and in general, after the artificial induction of the menopause, psychical disturbances are by no means rare, and are sometimes very severe. Such disturbance of the mental balance is seen after oöphorectomy especially in women who are still comparatively young, and whose sexual powers are still in a ripe state; whereas when the operation is performed in women of a more advanced age, whose ovaries were already nearly or completely functionless, no psychopathic changes are likely to ensue. In women belonging to the former category, the same etiological influences come into operation as in the physiological menopause, the patient, that is, is affected by the psychical influences of the removal of the ovaries—not only by the cessation of menstruation and the disappearance of the internal secretion of the reproductive glands, leading to a disturbance of the physical equilibrium, but also by the intellectual recognition of the loss of sexual potency, and a consequent disturbance of the mental balance.
In Schlager’s opinion the climacteric has a potent influence in promoting the development of psychical disturbances in women, even when the involution occurs at the normal age. The course of these disturbances is as follows: soon after the commencement of the process of involution, when for a few months already the menstrual periodicity has been irregular, or the flow has been unduly profuse, a change of disposition makes its appearance, at first hardly noticeable, but after a little time manifesting itself clearly in the form of an increase in irritability. The woman finds fault with everything and everybody, becomes mistrustful, suspicious, full of complaints, imagines that the most insignificant annoyances are due to intentional slights; at the same time she complains of continued sleeplessness, palpitation, various indescribable sensations, and of headache. Occasionally, congestions of the head occur, with alarming dreams, and the moodiness may increase greatly; in this condition three such patients of Schlager’s were impelled to attempts at suicide. Schlager further draws attention to the fact that in 22 cases known to him in which suicide was performed or unsuccessfully attempted by women, in eleven of these the patient was at the climacteric age. He believes that the most important etiological influence in the production of climacteric mental disorder in such cases is the sudden suppression of menstruation. In the majority of these instances, the mental disorder takes the form of mania; exceptionally, however, the form of chorea or of catalepsy.
By Tilt the following forms of “climacteric insanity” are distinguished: delirium, mania, hypochondriasis, melancholia, impulsive insanity, and perversion of the moral instincts. The same author publishes the following table showing the age incidence in 1,320 cases of mental disorder in women, from which it appears that during the age of the menopause, a very considerable number of the cases originate, but that after the change of life comparatively few cases occur.
In these 1,320 cases the women were:
| Under 15 years of age in | 9 instances |
| Over 15 and under 20 years in | 61 instances |
| Over 20 and under 25 years in | 216 instances |
| Over 25 and under 30 years in | 223 instances |
| Over 30 and under 35 years in | 217 instances |
| Over 35 and under 40 years in | 218 instances |
| Over 40 and under 45 years in | 162 instances |
| Over 45 and under 50 years in | 153 instances |
| Over 50 and under 55 years in | 122 instances |
| Over 55 and under 60 years in | 57 instances |
| Over 60 and under 65 years in | 55 instances |
| Over 65 and under 70 years in | 27 instances |
Fuchs tabulated the ages of 26.300 insane persons. Reducing his results to the ratios per 10,000, he obtained the following results:
| Women. | Men. | |
|---|---|---|
| At ages under 20 | 563 | 649 |
| At ages over 20 and under 30 | 1,895 | 2,132 |
| At ages over 30 and under 40 | 2,557 | 2,614 |
| At ages over 40 and under 50 | 2,180 | 2,080 |
| At ages over 50 and under 60 | 1,362 | 1,247 |
| At ages over 60 | 1,443 | 1,278 |
According to Esquirol, among 198 women who committed suicide, there were 77 between the ages of 40 and 50 years—a number considerably larger than those in any other age-decade. Among 235 women suffering from dementia, a moiety had first come under treatment during the climacteric age. The same author published the following data regarding the age-incidence of insanity in the case of 6.713 female patients:
| At ages under 20 years | 348 cases |
| Between the ages of 20 and 25 | 563 cases |
| Between the ages of 25 and 30 | 727 cases |
| Between the ages of 30 and 40 | 1,607 cases |
| Between the ages of 40 and 50 | 1,479 cases |
| Between the ages of 50 and 60 | 954 cases |
| At ages above 60 years | 1,035 cases |
Matusch found that among 551 women suffering from mental disorder, there were:
| At ages 0 to 10 years | 9 cases |
| At ages 10 to 20 years | 73 cases |
| At ages 20 to 30 years | 140 cases |
| At ages 30 to 40 years | 114 cases |
| At ages 40 to 50 years | 107 cases |
| At ages over 50 years | 38 cases |
According to von Krafft-Ebing, among 858 insane women, there were about 60 in whom the disorder of the mind appeared to depend upon the influence of the climacteric, and in 25 of these there was hereditary predisposition to mental disease.
From Kowalewski’s interesting work on the psychoses of the climacteric, we quote the following:
“In women, the climacteric has a distinct influence upon the mental life, and that influence is strongly manifested more especially in cases in which during the age of puberty mental disturbance had previously been noticed. The mental condition in which women approach the change of life is a very variable one, and it is one largely dependent upon the circumstances in which the active years of the sexual life have been passed. In some cases, a woman has been so fortunate as to marry early and from affection, and her whole married life has been passed without disturbance; her labours have not been exhausting, and her children have enjoyed good health; all have passed through the years of childhood without untoward incident, and their development has been a happy and successful one; in a word—everything has gone well with her and hers. Such a woman will give thanks to God for the rare felicity she has enjoyed; and quietly, patiently, and with understanding will endure the inevitable end of her sexual life. For such a woman, more especially if she comes of a healthy stock, the changes which occur in her reproductive organs at the epoch of the climacteric, need not entail any serious shock to her nervous system, nor need they form the culture ground for morbid manifestations in her nervous system or in her mind. Even if any anomalies in nervous working should occur, it will be such only as are aroused by the disturbance of the normal menstrual rhythm; in such cases, they will rarely prove of a serious or enduring character.
“But look, on the other hand, upon this picture. A woman has married without affection and from pure necessity. Her husband has been a drunkard, and rough and unfaithful. She has had a great many children, her labours have been tedious and difficult and accompanied with severe losses of blood. Some of the children fell sick and died; those that survived proved idle, good-fornothing, and a burthen. The family life is dominated by quarrelsomeness, disorder, and insufficiency of means. The mother is affected with some chronic disorder of the reproductive organs, and is hardly ever out of the doctor’s hands. After 25 or 30 years of a life of this kind, the woman enters upon the change of life. Physically exhausted, weary of life, never having known happiness, after an existence full of trouble and wretchedness, with nothing joyful either in her memories of the past or in her prospect of the future—the chief hope of such a woman is that her troubles may soon end with her life. Where the soil is thus physically and mentally exhausted, the development of a neurosis or a psychosis is only too probable on the most trifling exciting cause. Her life seems of so little worth, that thoughts of suicide are likely to be very near at hand. Thus, when the climacteric alterations in the reproductive organs are superadded, melancholia is very likely to supervene. When, however, the case is complicated by hereditary predisposition to insanity, and by the occurrence of actual degenerative changes in the central nervous system, instead of the passive depression of melancholia, we shall rather see the ideas of persecution of paranoia. As an actual fact, these two psychoses, melancholia and paranoia, are the commonest forms of mental disorder at this period of a woman’s life.
“These are the two extremes in woman’s mental state at the time when the physical changes of the climacteric period begin in her reproductive organs. It will, of course, be readily understood that between these two extremes lies a series of combinations any one of which may in individual cases occur.
“The conditions of life during earlier years have thus a strong determinative influence in the production of mental disorder; and not infrequently in these conditions alone shall we find the efficient cause of the mental degeneration. At times, the memories of her own life have in a woman at the climacteric age so serious an effect, that these memories alone constitute the causal agent of the development of a psychosis, or at least so influence the soil as to make it a suitable culture-ground for the development of mental disorder, the actual exciting cause of the pathological state being a disturbance of the ordinary menstrual rhythm.
“In considering the mental condition of women at the outset of the climacteric period, we must not forget those who are called ‘old maids.’ In their youth these maidens also have had their ideals, their hopes, their plans, and their sorrows. They also had a natural impulse to love and to be loved in return; they hoped to become wives and mothers. But life has failed to fulfil their hopes and their wishes, and their longings have remained unsatisfied. Some of them have taken up their cross without murmuring, and have devoted their talents, their intelligence, and their love to the service of those nearest to them. But others make an active protest against fate in the form of vindictive feelings towards their environment, of quarrelsomeness, scandal-mongering, etc. Here we see contrasted the two principal types of such women. On the one hand are those who devote their intellectual and spiritual powers to the service of society; these are unselfish sisters-of-mercy, untiring medical women, invaluable school-teachers and governesses, fanatical political agents, etc. Such as these have ceased to live for themselves. In the fullest sense of the words, they mortify the flesh, and guide their conduct by lofty moral principles. They have killed their sexual life, and they remain for ever virgins—both morally and physically. If, owing to a pathological inheritance, faulty conditions of life, exhausting illnesses, etc., a psychosis develops, the hallucinations and delusions from which they suffer very rarely assume a sexual character, nor are they of a degrading type. The sexual side of life seems, in fact, be they sane or insane, to have undergone complete atrophy. They suffer from simple melancholia with stupor, or their insanity takes a religious turn, but very rarely indeed has it an erotic character.
“Very different is it with old maids of the second type. They are dissatisfied with life, irritable, quarrelsome, envious, and malicious. They are spiteful and revengeful, gossips and scandalmongers, boast of their own chaste and innocent lives, and never forgive any real or imaginary attempt upon their spotless virtue. At the same time they never lose hope for the future, and are full of imaginary love-affairs, in which they pass through scenes by no means chaste or innocent; they do not shrink from self-abuse and the abnormal gratification of the sexual needs, in which the lacking partner in the sexual act is supplied by the imagination. Under the influence of such abnormal conditions of life, these women frequently become affected by nervous disorders; migraine, neuralgia, cephalalgia, nervous depression, rachialgia, debility, anæmia, diseases of the reproductive organs, etc. Thus, when they enter the climacteric age, the soil is fully prepared for the development of mental disorder, which in such individuals is often characterized by hallucinations of sexual sensation and perception, erotic visual and auditory hallucinations, delusions of similar character, increased sexual irritability, a search for abnormal means of sexual gratification, a propensity to obscene speech and conduct, etc.
“Mental disorder is so common during the climacteric period, that the term ‘climacteric insanity’ has now become established in the literature of mental alienation. In almost all the textbooks of the subject we find an allusion to this form of mental disease, but there is no real ground for Maudsley’s assumption that there is a climacteric insanity sui generis. At the climacteric, very various forms of mental disorder may occur—paranoia, melancholia, and mania; the only common feature in the attacks, owing to which they are classed as ‘climacteric insanity’ being the fact that the final determining cause in each case is the onset of the change of life. In fact, this period is not without influence upon the manifestation of the disease—its stamp is imprinted upon the clinical picture, it endues the disease with certain characteristic features—but still, the peculiarities common to the cases of mental disorder occurring at this time of life in women are not so great as to justify us in describing them as a separate variety of psychosis.”
According to Kowalewski, this so-called climacteric insanity is met with in two principal forms: in many cases the mental disorder recurs in periodic paroxysms, associated either with the commencement of the menstrual flow, or having the periodicity of menstruation after the flow has already ceased to appear; in the other class of cases the psychosis has no direct connexion with menstruation, and is dependent upon the joint influence of all the manifestations of the climacteric period. Cases belonging to the former class have been distinguished by Bartel as “climacteric pseudomenstrual insanity.”
The psychoses dependent upon the climacteric influences may, according to Kowalewski, appear in almost all the known forms of mental disorder: precordial anxiety, melancholia, mania, amentia, paranoia, etc.; and although they exhibit no features which are absolutely characteristic, or which, as already said, enable us to distinguish a specific “climacteric insanity,” yet they all bear a common imprint by means of which we are enabled to detect in their causation the influence of this critical period of life. Thus, precordial anxiety occurs in paroxysms having a more or less regular periodicity, corresponding with that of the expected menstruation. The same feature is observable in the periodic exacerbations of hysterical and epileptic paroxysms. Often, also, there occur at this time sudden changes in the emotional disposition and in the character, in one direction or the other, without the development of actual melancholia or mania. The melancholia of the climacteric period occurs chiefly in married women, more especially in those whose circumstances are unhappy; and it is often manifested by attempts at suicide.
Mania is comparatively rare at the climacteric period; when it does occur, it commonly assumes a sexual form—sexual impulses, hallucinations, and delusions, and obscene conduct. Such manifestations are seen most often in widows, in “old maids” whose morals are not above reproach, and, speaking generally, in those whose sexual needs have remained partially or completely ungratified, and in those who have greatly erred in the conduct of this side of life. Amentia also occurs at this time of life; rarely in maniacal form, more frequently in association with menstruation as a periodic psychosis, or as a continuous disorder of mind with exacerbations corresponding to the menstrual periods; it is often characterized by pronounced eroticism.
Much more frequent during the climacteric period is the occurrence of paranoia, as Kowalewski rightly insists. It is most often met with in “old maids” with psychopathic predisposition. The imagination of such individuals is always concentrated upon men; they imagine that men in general, but more particularly certain individuals of the opposite sex, are continually regarding them, making eyes at them, making signs to them, in some way or other striving to attract their attention. The most ordinary and invariable forms of polite intercourse are regarded by these women, whose powers of observation are morbidly stimulated, as being indications of a special “attention” paid to themselves. They persecute these men with their own attentions, and imagine that it is the men who are persecuting them. Often this morbid mental state is associated with sexual malpractices, masturbation, etc. Not rarely, such degenerates are affected with lascivious dreams. Often they experience hallucinations of sexual perception in the form of supposed assaults on their virginity. All these states are apt speedily to develop into a condition of general suspiciousness and ideas of persecution. The ideas of persecution assume a peculiar form, one especially characteristic of the climacteric period. The patients believe that a man, often personally unknown to them, and perhaps living in another town, enters into spiritual and bodily intercourse with them. These relations are supposed to be effected in most cases by means of spiritualism, hypnotism, or electricity. The patient importunes the man in question with letters, supposes herself to be legally united with him, and not infrequently wishes to give him the pleasure of paying her bills and providing her with money. It is a very common occurrence for a Catholic priest to be worried by such a woman, her delusion being grounded upon the fact that the priest is supposed to assume an exceptionally intimate spiritual relationship with members of his flock. The patient with ideas of persecution often herself becomes an actual persecutor, not only pestering her victim with innumerable letters, but in her jealousy making “scenes” whenever she can encounter him, and sometimes giving rise to serious scandal. With such a mental state we often see associated sexual hallucinations and delusions; the patient believes herself to be pregnant, imagines herself to have been violated, or to be living in carnal intercourse with a man—some one, it may be, with whom she is not even acquainted. Medical men are especially apt to suffer from the accusations of such women, whom they may have examined in private in entire ignorance of the patient’s mental condition. Frequently, such ideas of sexual persecution are associated with paroxysms of violent nymphomania, and in this way also the unwary physician may find himself placed in an extremely unpleasant position. It occasionally happens in such patients that abnormalities of the sexual instinct arise, and they begin to feel desire towards individuals of their own sex.
Such delusions of persecution by means of hypnotism, spiritualism, the telephone, etc., in association with sexual delusions and nymphomania, are so frequent during the climacteric period, that they may be regarded as pre-eminently constituting climacteric insanity. Frequently some old hysterical state underlies this form of mental disorder.
Thus these peculiar manifestations of eroticism must be regarded as the distinctive characteristics of climacteric insanity and more particularly of climacteric paranoia. A second characteristic of climacteric insanity is, according to Garat, the marked development of jealous emotions and delusions.
In addition to these fully developed psychoses, there occur in degenerates at the climacteric age paroxysms of impulsive insanity in the form of dipsomania, kleptomania, pyromania; exhibitionism; irresistible impulse to suicide, homicide, infanticide, etc. Such paroxysmal impulsive manifestations are, according to Kowalewski, commonly associated with menstrual disturbances; they occur most frequently at the due dates of menstruation when the flow fails to appear.
One hundred and sixty-nine cases of climacteric psychosis were classified by Matusch as follows:
| Melancholia | 36 cases |
| Mania | 2 cases |
| Melancholia passing on into paranoia | 28 cases |
| Melancholia passing on into secondary dementia | 17 cases |
| Paranoia | 43 cases |
| Neurasthenia during the climacteric period followed by mental disorder | 19 cases |
| Neurasthenia prior to the climacteric period, followed by mental disorder during the climacteric period | 10 cases |
| Apoplexy, cerebral abscess, dementia | 6 cases |
| Epilepsy | 2 cases |
| Alternating insanity | 3 cases |
| Paralytic dementia | 5 cases |
Von Krafft-Ebing classified 60 cases of climacteric psychosis as follows:
| Melancholia | 4 cases |
| Alternating insanity | 1 case |
| Acute delirium | 1 case |
| Primary insanity: | |
| a. With primordial delirium | 36 cases |
| b. Paralytic dementia | 12 cases |
The prognosis in cases of climacteric psychosis is regarded by Kowalewski as unfavourable; unfavourable vital conditions are associated with retrogressive metamorphosis of the tissues, hence mental disorder arising at this time of life is hardly less serious than that due to actual degeneration of cerebral tissues. Indeed, according to Schüle there is during the climacteric period an especial danger of the development of atrophic cerebral processes (Encephalitis atheromatosa) with apoplectic and epileptic seizures. Schlager also regards the prognosis of climacteric insanity as unfavourable; but Merson, on the other hand, observed among women suffering from climacteric psychoses a recovery rate of over 50%. On previously existent psychoses in women, the onset of the climacteric exercises in most cases an unfavourable influence, and very exceptionally only at this time do we observe the cure or remission of a chronic mental disorder to occur. Kowalewski has seen cases of chronic mania in which a cure was obtained at the climacteric period; a somewhat excessive excitability and inclination to violence remained, however, as vestiges of the former insanity. Matusch, keeping under observation 60 women affected with chronic mental disorder as they attained the climacteric period, noticed that in 14 instances the mental condition changed for the worse at this period, whilst in 13 the character of the mental disease underwent a change, excitement giving place to apathy and dementia. Griesinger had earlier pointed out that at the time of the cessation of menstruation there would occasionally occur amelioration, and even cure, of a previously existing chronic mental disorder; more often, however, the influence of the menopause was an unfavourable one, a hitherto changeable and irritative form of mental disease becoming transformed into chronic insanity with inalterable delusions, or into dementia. The course of mental disorder, such as melancholia, first making its appearance at the climacteric epoch, was also regarded by Griesinger as likely to be unfavourable.