FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.
BY W. W. JAGGARD, A.M., M.D.
DEFINITION AND TERMINOLOGY.—The time of life in a woman when the natural cessation of ovulation and menstruation occurs has received a variety of appellations more or less descriptive of the phenomena which are supposed to precede, attend, and follow that event. Change of life, Turn of life, Critical time, Climacteric, in English; Das klimacterium, Das aufhören menstrualer Ausscheidung, Das aufhören der Weiblichen Reinigung, in German; Ménopause, Âge de retour, Âge critique, Temps critique, in French; Cessatio mensium, Climacterium, in Latin; Menolipsis, in Greek,—are terms used to mark out a certain period of time commencing with the functional and organic disorders connected with the cessation of ovulation and menstruation in a causal relation, and terminating with the permanent resettlement of health.
DATE OF CESSATION OF MENSTRUATION, AND DURATION OF THE CHANGE OF LIFE.—The function of ovulation, as far as we know, ceases with the discontinuance of menstruation, although immature ova still exist in the ovaries. The date of natural cessation of menstruation and ovulation is variable in different women. It is difficult to determine an average date, because the menopause may be gradually ushered in, and then women are apt to interpret any genital hemorrhage as menstruation. In certain cases the menstrual flow may cease between the ages of thirty and forty years, or even at an earlier period. On the other hand, the function has been noted by competent observers1 to continue up to and beyond the sixtieth year. According to tradition, Cornelia, the mother of the Gracchi, was confined in her seventieth year. Parvin2 has recently called attention to another historical instance of alleged late menstruation, recorded in a note to the fifty-sixth chapter of the Decline and Fall of the Roman Empire. On the authority of D'Herbelot's great work, Bibliothèque orientale, 1777, Gibbon mentions the case of Asima, the mother of Abdallah. When the tidings of the death of her son were borne to Asima her menses reappeared at the age of ninety as the physical effect of her grief. The historian informs us that the flow proved fatal in five days. These anomalous cases of so-called protracted menstruation are frequently examples of pathological hemorrhages dependent upon structural changes, sometimes of a malignant character. Even admitting the possibility of the condition of extremely protracted menstruation, such cases, as remarked by Playfair, like examples of unusually precocious menstruation, cannot be regarded as having any bearing on the general rule.
1 Tilt, The Change of Life, 4th ed., 1882, p. 24.
2 The Medical News 26th Sept., 1885, p. 352.
The periodic discharge of blood from the uterus usually ceases between the ages of forty and fifty years. Raciborski3 concludes, from the observation of a large number of cases, that the average date of cessation is the forty-sixth year. This estimate is confirmed by the observations of Brierre de Boismont, Guy, and Tilt. The average date of cessation in 1082 cases,4 collected by these three observers, was forty-five years and nine months.
3 Traité de la Menstruation, Paris, 1868.
4 Tilt, The Change of Life, 4th ed., 1882, p. 22.
Climate, race, and the various accidental circumstances which exercise such potent influence upon the establishment of the functions of ovulation and menstruation have measurably less effect upon their cessation. Mayer5 attaches some importance to social condition as determining the date of cessation. From the observation of a large number of cases belonging to the higher classes he determines the average age to be 47.138 years. It is a popular belief that the period of menstrual life is a constant number of years, usually from thirty to thirty-five; that is to say, if a woman commences to menstruate when very young, cessation will occur at an earlier age than in a woman who begins to menstruate later in life. Cazeaux, Raciborski, Frank, Dusourd, and Tilt, supported by Guy's6 analysis of 1500 cases, are of the opinion, on the contrary, that the duration of menstruation is longest in women who have menstruated earliest. In the words of Négrier,7 "It seems well proved that the ovarian function, creative of germs, is prolonged in life in direct ratio of the volume of the ovaries and of the precocity of ovulation; thus the girl nubile at twelve will continue menstruating until fifty or even fifty-five; whilst the girl who did not menstruate until eighteen or twenty—a fact which reveals feeble development and small energy of the organs—will cease to menstruate at forty, an early age."8 Cessation occurs later in women who have passed through repeated normal pregnancies than in virgins or sterile females. Cohnstein9 observed the longest duration of menstruation in women who had menstruated early, married, and borne more than three children, suckled their offspring, and were normally confined for the last time between the ages of thirty-eight and forty-two years. An interesting opinion with reference to the relation between longevity and the date of cessation was expressed by Robert Cowie at the Paris Medical Congress in 1867. According to Cowie, there is a direct and constant relation between longevity and protracted menstruation. A woman who menstruates up to an advanced period of life has more chances of attaining extreme old age than one whose menstrual function has ceased earlier. Cowie derives this opinion from the observation of numerous cases of longevity and coincident protracted menstruation which occurred in the Shetland Islands.
5 Schroeder, Handbuch der Krankheiten der Weiblichen Geschlechtsorgane, 1881, p. 321.
6 Medical Times and Gazette, 1845.
7 Barnes, Diseases of Women, 1878, p. 194.
8 T. Gallard, Pathologie des Ovaires, Paris, 1885, p. 114.
9 Deutsche Klinik, 1873, No. 5.
Among the pathological factors which determine the early occurrence of cessation, puerperal atrophy of the uterus, syphilis—especially the graver forms—and chronic alcoholism deserve particular attention (Lancereaux).
The average date of cessation of menstruation may be regarded as the fixed time from which to estimate the duration of the pre-cessation and post-cessation periods of the menopause. The duration of the pre-cessation period—or the dodging-time, as it is popularly termed—is subject to many and extreme variations. Tilt10 places the limits of normal variation between a few months and six or seven years. The average length of the dodging-time in 275 cases Tilt estimates at two years and three months. The same observer claims to have seen cases of morbid prolongation of the pre-cessation period through ten and even twelve years. Equally variable and indefinite, in point of duration, is the post-cessation period. From the study of his 500 cases, Tilt concludes that cessation of menstruation divides involution into two periods of nearly equal length when no disease of the uterus or adnexa is present. In 383 cases, three or four years after cessation all functional disorders due to the menopause disappeared. But the length of the post-cessation period, as in the case of the dodging-time, is liable to abnormal protraction. Tilt is very positive in the assertion that disturbances directly traceable to the menopause may continue ten or twelve years after cessation of menstruation. The statistical evidence adduced by Tilt in support of his peculiar views as to the possible protraction of the pre-cessation and post-cessation periods (twenty to twenty-four years) may well be questioned. His analysis of cases does not indicate rigid scrutiny. The line between merely coincident phenomena and disorders which are directly traceable to the menopause is nowhere clearly and distinctly drawn. Robert Barnes11 is of the opinion that the average duration of the change of life, comprehending the pre-cessation and post-cessation periods, is from two to three years—an estimate more in accord with the experience of the majority of clinicians.
10 The Change of Life, 4th ed., p. 46 et seq.
11 Diseases of Women, 1878, p. 287.
THE NATURAL HISTORY OF THE CHANGE OF LIFE.—In order to gain an adequate conception of the dynamic disorders in connection with the menopause, it is necessary to bear clearly and distinctly in mind the alterations in functional activity of a purely physiological character which attend that event. Many of the so-called functional disorders of the change of life are merely physiological processes consequent upon the transition from active ovario-uterine life to sexual decrepitude. There is nothing remarkable in the fact that the cessation of menstruation and ovulation, after functional activity of an average period of time varying from thirty to thirty-five years, is sometimes attended by a series of disturbances of a local and constitutional character. The changes of functional activity under these conditions are in analogy to the course and constitution of nature as observed in connection with dentition, puberty, and other epochs in human life.
The physiology of the menopause is a subject extremely difficult of investigation. The reasons are obvious. Our knowledge of the nature and significance of the function of ovulation and menstruation is very defective. The phenomena in connection with the change of life are numerous and complex. All interpretations of the appearances are peculiarly liable to fallacies and unavoidable sources of error. Correction and confirmation by anatomical research are usually impossible. Then the number of recorded cases in which the phenomena have been rigidly analyzed is very limited. But, despite the difficult nature of the subject and the poverty of the literature, a solid nucleus of acquired truth exists. Familiarity with these definitely established facts will clear up many obscure points in the pathology of the menopause.
RESPIRATORY CHANGES. The researches of Andral and Gavarret12 indicate that the quantity of carbonic acid exhaled by the lungs during the second infancy (eight years to puberty) is increased in man and woman. With the establishment of menstruation the quantity of carbonic acid exhaled by the female becomes constant, and persists in this state throughout her menstrual life. During the pre-cessation period the quantity of carbonic acid exhaled by the lungs is rapidly augmented, attaining its maximum about the time of cessation. During the post-cessation period the quantity gradually diminishes until the resettlement of health is effected. After this period it remains relatively constant. In the male, on the other hand, the quantity of carbonic acid exhaled increases up to the thirtieth year, and then progressively diminishes until the end of life.
12 "Recherches sur la quantité d'Acide carbonique exhalé par les Poumons dans l'Éspèce humaine," Annales de Chimie et de Physique, 3e Série, t. viii.
During pregnancy the amount of carbonic acid exhaled is approximately the same as at the time of cessation.
Aran13 recognizes in this augmented excretion of carbonic acid during the change of life a critical or compensating discharge—a waste-gate or outlet, to use the figurative expressions of Tilt and Barnes, for the energy set free in the system by the more or less suddenly suppressed functions of ovulation and menstruation. Gallard,14 on the other hand, has pointedly called attention to the fact that the menstrual blood carries out of the system a quantity of carbonic acid which during pregnancy and change of life is excreted by the lungs—that, accordingly, the increased exhalation of carbonic acid during the climacterium cannot be regarded in the light of a critical discharge.
13 Leçons cliniques sur les Maladies de l'Utérus et de ses Annexes, Paris, 1858-60, p. 284.
14 T. Gallard, Pathologie des Ovaires, p. 87, Paris, 1885.
ALTERATIONS IN THE FUNCTIONS OF THE SKIN.—It is a matter of common observation that the functions of the skin are profoundly influenced in many cases by the changes consequent upon the menopause. Tilt records 300 cases of more or less profuse perspiration, occurring in 500 women, due in some degree at least to the change of life. This estimate is probably exaggerated. A variety of agents influences the total amount of perspiration, as well as the relation between sensible and insensible perspiration, at all periods of life. The dryness, temperature, and amount of movement of the surrounding atmosphere, nature and quantity of food taken and liquid drank, exercise, mental condition, medicines, poisons, diseases, and the relative activity of the other excreting organs (e.g. the kidneys), are factors which deserve due consideration before attributing all increased activity of the sudoriparous glands about the forty-fifth year to the effects of the change of life. In the tables mentioned no distinction is drawn between mere coincidence and causal relation.
The perspirations due to the change of life may have prodromal signs. These symptoms are—sensations of cold, shivering, chills, sinking or faintness referred to the pit of the stomach. Usually, however, they are not attended by any premonitory phenomena. They are frequently accompanied by dilatations of the skin blood-vessels, corresponding to definite areas of distribution of the vaso-motor nerves, which are popularly known as flushes. When the perspirations following the dilatations of the skin blood-vessels are insensible, women are in the habit of terming the symptoms dry flushes. The number and duration, as well as the time of occurrence, of these sweats and flushes are various in different women. Tilt has observed them to occur as often as five or six times in an hour, and last from two to fifteen minutes. They are usually noticed during the daytime. The regions involved are, in the order of frequency, face, chest, lower portions of the trunk, upper and lower extremities. Very seldom the entire skin surface is affected. In point of intensity the heightened activity of the sudoriparous glands varies from a gentle perspiration to a drenching sweat.
The function of these perspirations and flushes cannot be regarded as definitely settled. The popular opinion is that they constitute an important outlet for the actual energy liberated by the cessation of ovulation and menstruation. Tilt, adopting the popular view, thinks that the relief obtained by increased perspiration is the most important and habitual safety-valve of the system during the change of life. There are certain a priori considerations which render this hypothesis in some degree probable.
The quantity of matter which leaves the human body by the skin, per hour, is considerable. Seguin15 has estimated it at eleven grains, while the quantity excreted by the lungs is seven grains. It is possible to isolate three factors which directly influence the secretion of sweat: (1) The skin, apart from its glandular apparatus, is a simple animal membrane, and permits a relatively small quantity of water to transude through the portions intervening between the mouths of the glands. As pointed out by Erismann,16 this function of the skin is a subordinate one. The simple transudation of water is greater through those portions of the skin abundantly supplied with glands than through those in which they are sparsely distributed. (2) Vascular dilatation accompanies, and at least aids, the secreting activity of the cutaneous surface. Bernard's experiments on the division of the cervical sympathetic and clinical observation abundantly demonstrate the operation of this etiological factor. (3) Independently of vascular supply, it is in a high degree probable that there are special nerves directly controlling the activity of the sudoriparous glands. Stimulation of the sciatic nerve causes an increase in perspiration in the toes of the dog, without any concomitant hyperæmia, as shown by the experiments of Kendal and Luchsinger.17 In a word, the skin is adequate to the regulation of aberrations in nerve-force and blood-supply and to the restoration of equilibrium. If superfluous actual energy is liberated by the cessation of the monthly ovarian stimulus and determination of blood to the uterus, it is not improbable that the perspirations and flushes of the menopause may constitute an efficient means of discharge.
15 Ann. de Chim., xc. pp. 52, 403.
16 Zeitschrift f. Biol., xi. p. 1.
17 Pflüger's Archiv, xiii., 1876, p. 212.
ALTERATIONS IN THE SECRETION BY THE KIDNEYS.—In many cases of the menopause important changes occur in the urine. The secretion becomes turbid and the quantity of sediments is large. These sediments usually consist of the inorganic salts. The phosphates, carbonates, and sulphates are increased, while no change is observed in the quantity of sodium chloride. The quantity of nitrogenous crystalline bodies is apparently not influenced in the great majority of cases. Occasionally the quantity of uric acid is increased,18 and gives origin to many distressing symptoms. In the absence of accurate data respecting the changes in the constitution of the urine it is useless to speculate about the significance of the occasional increase in the quantity of inorganic salts and uric acid. Doubtless the functional activity of the skin and lungs, diseases of the genito-urinary tract, and diet play an important part in the production of the alterations in the chemical constituents of the excretion. It cannot, however, be denied that the menstrual flow performs some office as an emunctory, and it is not at all improbable that its cessation throws additional work on the kidneys.
18 Barnes, Diseases of Women, 1878, p. 285.
ALTERATIONS OF NUTRITION.—Of the various alterations of nutrition consequent upon the change of life, obesity is of greatest clinical interest. It is a matter of common observation that women frequently grow fat coincidently with the cessation of menstruation. Out of 383 cases collected by Tilt, 121 women grew stouter within five years after cessation; 3 women became suddenly fat when the menstrual flow ceased to recur. Barnes, Baillie, Fothergill, and numerous other clinicians abundantly confirm this observation. Adipose tissue is usually deposited in the omentum, abdominal walls, breasts, face, and limbs.
The nature of the relation between the formation of fat and the change of life is obscure. In the attempt to ascribe due influence to the menopause in the production of adipose tissue it must not be forgotten that in males the maximum of weight is attained, according to Quetelet, about the fortieth year. But the accumulation of fat in many of the lower animals after the extirpation of the ovaries, and the frequent occurrence of obesity in women after normal ovariotomy and the Porro-Müller operation of Cæsarean section (Braun, Spaeth), indicate that in some cases, at least, there is a necessary relation between the two phenomena. The generally received view is that the formation of adipose tissue is an outlet for the more or less sudden aberrations in nerve-force and blood-supply following cessation. The weight of probable evidence is very decidedly in favor of this opinion. Physiology teaches that fat fluctuates in bulk more than any other tissue in the body. As remarked by Foster,19 a large amount of adipose tissue may disappear within a very short space of time, or the quantity in a body may be multiplied many times within an equally short time. Although the direct influence of trophic nerves on metabolic activity has not been demonstrated, there is still evidence of a high order in favor of such a view.
19 M. Foster, Physiology.
The Mammary Glands.—Apart from the enlargement of the mammary gland from the deposition of adipose tissue, the organ may be the seat of active secretory changes. Tilt observed this phenomenon in 15 out of his 500 cases. The breasts increase in size and become tender. Blue veins are visible through the skin, and changes resembling in kind those of pregnancy may be observed about the nipples and areolæ. A milky fluid is sometimes secreted. Semple has described a case in which a monthly discharge of blood continued for five years after cessation. Tilt has published a case in which a painless exudation of red serum, lasting for several days, recurred every three weeks.
In view of the intimate connection between the ovaries and uterus and mammary glands at other periods of life, it is in a high degree probable that many cases of active nutritive disturbances in the mammary glands, occurring about the forty-fifth year, are directly due to cessation. The exact nervous mechanism has not been fully worked out. These nutritive disturbances are probably physiological, and partake of the nature of the so-called critical discharges.
HEMORRHAGES AND MUCOUS AND SEROUS DISCHARGES.—Vicarious hemorrhages are occasionally though rarely observed in connection with the change of life. These more or less regular discharges of blood occur from a great variety of sites. The region is usually so located that the external escape of blood can easily be effected. The more usual forms of vicarious hemorrhage are hæmatemesis, epistaxis, hæmoptysis, and bleeding from hemorrhoids. General hæmatidrosis, bleeding from the nipples, intestinal hemorrhage, bleeding from the alveoli of the teeth, and subcutaneous ecchymoses are more uncommon types. Every case of suspected vicarious hemorrhage deserves most rigid scrutiny. The condition is such a rare one, and so many local causes sufficient to explain the phenomena frequently exist, that a certain amount of scepticism in the concrete case is perfectly justifiable.
The nervous mechanism of these hemorrhages, so far as it has been worked out, may be stated in a very few words. The cessation of menstruation causes an increase in vascular tension, and consequent irritation of the vaso-motor centres. Various local hæmostases result, which cause the symptoms of suffusion of the face, tinnitus, headache, giddiness, etc. In a limited number of cases these local congestions are relieved by the escape of blood. Vicarious hemorrhages seldom lose their physiological character.
Metrorrhagia is a less uncommon event than vicarious hemorrhage during the climacteric. Uterine hemorrhage is regarded as a critical discharge due to the changes brought about by the menopause, when it occurs, in the absence of local disease or constitutional vice, in connection with the perspirations, flushes, obesity, nervous phenomena, and other signs of cessation. In point of time these uterine hemorrhages, or floodings, usually occur after cessation. The causes of the floodings of the menopause are not at all evident. Barnes20 is of the opinion that they are ultimately referable to imperfect functional activity of the liver and kidneys. Local congestions occur, vascular tension is increased, the heart and blood-vessels are engorged, and a disposition to uterine hemorrhage is created. In many cases flooding seems to exert a salutary influence upon the health of the individual. J. Frank says he has observed cases of critical floodings after cessation in which checking the bleeding caused apoplexy. Tilt21 confirms this opinion by the citation of two cases. Not infrequently, however, metrorrhagia during the change of life exceeds physiological limits and endangers the life of the individual. In the large majority of cases flooding after cessation is always a cause for anxiety, and constitutes an urgent indication for a physical examination. By careful indagation it is usually possible to eliminate cases of metrorrhagia due to carcinoma, fibroids, and diseases of the endometrium.
20 Diseases of Women, p. 283.
21 Change of Life, p. 197.
Leucorrhoea.—Closely allied in function to the floodings of the menopause is the profuse flow of mucus, unmixed with pus, from the cervix and vagina. This phenomenon is of frequent occurrence in connection with the other signs of the change of life. In the absence of local disease and constitutional vice it may be regarded as a critical discharge, an effort of nature to relieve pelvic congestion.22
22 Emmet, Gynæcology, 1884, p. 184.
Diarrhoea.—The recurrence of a profuse serous diarrhoea at more or less regular intervals during the change of life is common. Gendrin, Brierre de Boismont, and Chambon regard diarrhoea as habitual at this time. It acquires particular prominence as a symptom in the absence of the other critical discharges already mentioned. Indeed, it may constitute the only sign of the menopause apart from cessation of the menstrual flow. Care must be exercised, however, to differentiate in the concrete case between the purely functional serous diarrhoea of the change of life and those forms of the affection which depend upon local or general causes.
The explanation of the serous diarrhoea of the menopause, viewed as a critical discharge, is simple when the intimate connection between the pelvic circulation and that of the mesentery is considered.23
23 Ibid.
FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.—Vague, indefinite, and speculative as our conception of the physiology of the climacterium is, the deficiency of precise knowledge becomes more apparent when we come to consider the functional disorders of cessation. Many women pass through the change of life without the slightest disturbance of normal functional activity. In such women menstruation has usually been established at an early age and without local or general disorders. Moreover, all traces of disease of the uterus and adnexa are usually absent. Again, it is not an uncommon observation to see hysterical women, afflicted for years with uterine disease, begin to improve in health at an early stage of the pre-cessation period. These facts indicate that the change of life does not necessarily involve morbid phenomena.
In the large majority of cases, however, various functional and organic disorders are observed during this period of life. Under these circumstances it becomes a matter of extreme difficulty to distinguish between accidental complications, dependent upon collateral disease and pathological conditions of the pelvic viscera, and those disorders which stand in some causal nexus with the change of life. The scanty literature of the subject is to a great extent a mass of confused generalizations, in which the distinction between the relation of cause and effect and mere coincidence in point of time is seldom adequately drawn. Tilt's meritorious treatise is not free from this defect. In Table xxi., among the morbid liabilities at the change of life in five hundred women, heart disease, rheumatism, erysipelas, hysteria, epilepsy, cancer of the womb, ovarian tumors, and more than one hundred and fifty other pathological states are mentioned! Any paper on the subject at the present time, to perform a serviceable office, must direct attention to the obscure, confused, inadequate state of knowledge rather than aid in the perpetuation of error by the description of purely hypothetical forms of disease. The comparatively few functional disorders which stand in direct pathological connection with the change of life are, in the large majority of cases, examples of pathological exaggerations of physiological processes. Under these conditions it requires an unusual degree of diagnostic skill and penetration to draw the boundary-line between health and disease. Then in the matter of treatment, as remarked by Spiegelberg, it requires tact to determine how long a purely expectant attitude should be maintained and the time when active interference should be instituted.
The woman passing through the change of life possesses no immunity from accidental diseases. But some of these accidental diseases may be modified in symptoms and course by the changes consequent upon the climacterium.
DISORDERS OF THE ALIMENTARY CANAL.—Salivation.—Ptyalism has been observed by Bouchut and other observers to occur in connection with the other symptoms of the change of life. It is a phenomenon of infrequent occurrence. In the absence of any other adequate explanation it may be regarded as an example of sympathetic irritation strictly analogous to the salivation sometimes observed in pregnancy.
The milder degrees of this affection deserve slight attention. When, however, the flow of saliva is so great as to incommode the individual or seriously endanger her health, active treatment must be instituted. Chalybeate tonics, quinine, hypodermatic injections of atropia over the glands—especially the submaxillary—and iodide of potassium, are among the more reliable remedies. Astringent mouth-washes are grateful and relieve the congestion of the mucous membrane.
Constipation.—The habit of constipation, although not induced, may be aggravated, during the change of life. Interference with the action of the voluntary muscles and intestinal peristalsis by the deposition of adipose tissue in the abdominal walls and omentum, diminution of the intestinal secretions as the result of profuse perspirations and critical discharges, are etiological factors frequently referable to the menopause. Alterations in the innervation of the intestinal walls are probably productive of conditions which tend to constipation. The nature of the changes in the functions of the abdominal sympathetic nervous system during the menopause is a matter of pure speculation. There are many a priori considerations, however, which render probable the view that the constipation in connection with the menopause is, in some degree at least, a visceral neurosis. The prominence of the symptoms, enteralgia and flatulence, lends additional probability to this opinion. The treatment of constipation in connection with the menopause is a subject of the greatest practical importance. Many of the obscure nervous symptoms, distressing perspirations, and critical discharges may be relieved, if not prevented, by attention to the regular daily evacuation of the bowels. The specific hygienic and medical means to be used to secure this end are fully discussed in other portions of this work.
Diarrhoea.—Diarrhoea referable to the menopause and regarded simply as a critical discharge, sometimes, though rarely, passes beyond physiological limits and demands active remedial treatment. This statement holds true especially in cases of chronic diarrhoea aggravated by cessation. It is frequently a matter of extreme difficulty to draw the boundary-line between the physiological process and its pathological exaggeration. Careful attention to the symptoms, however, will usually disclose the fact whether or no the frequent alvine dejections conduce to the patient's well-being. Sometimes the stools are very profuse, and threaten life from the loss of large quantities of serum. Entorrhagia and colic are frequently observed under these circumstances. Rest, restricted diet, opium, the vegetable and mineral astringents, usually suffice to fulfil all the indications.
DISORDERS OF THE LIVER.—Many eminent clinicians unite in the opinion that functional derangements of the liver are peculiarly liable to occur during the change of life. Sir J. Y. Simpson, Robert Barnes, Tilt, Gardanne, Gendrin, Meissner, and Otterburg may be mentioned among the observers who hold that there is some direct relation between certain dynamic disorders of the liver and the menopause. There are also many a priori considerations in favor of this view. Habitual or long-continued constipation—a condition frequently observed in connection with the change of life—interferes materially with the secretion and excretion of bile. Barnes ascribes to the menstrual flow an excretory function. In the absence of this emunctory an increased amount of work is thrown on the liver and other secretory organs. The portal venous system is engorged. Under these circumstances disorders are apt to arise as the result of increased functional activity in an organ which may be undergoing organic change.
Well-pronounced jaundice, however, is of infrequent occurrence during this period in the absence of more potent factors than those just mentioned. It is not more justifiable to speak of the icterus of the menopause than of the icterus of menstruation. Flint24 has justly said that the occurrence of jaundice at the menstrual periods is too infrequent to suppose that there is any direct pathological connection, as implied in the term icterus menstrualis proposed by Senator.
24 Practice of Medicine, 1881, p. 637.
On the other hand, that condition vaguely described as biliousness, implying the constitutional effects of chronic hepatic hyperæmia, has been noted by many clinical observers. The derangement referred to is aptly described in the words of B. Lane and quoted by Tilt:25 "Nothing can be more common than to find severe biliary derangement occurring at or about the period of menstrual cessation; and, looking at the great physiological change which then takes place in connection with hepatic development, it is naturally to be expected. A woman will complain of being bilious; there may be a bitter taste in the mouth, a burning in the throat, frontal headache, nausea, and even vomiting, the urine high-colored, the bile abounding in the alvine dejections, and perhaps causing heat and a stinging sensation in the rectum; the tongue furred, a biliary tinge pervading the cutaneous surface." The propriety of ascribing the symptoms so graphically described in these words to excess, deficiency, or vitiation of the biliary secretion, in the entire absence of precise knowledge, may well be questioned. Tilt is of the opinion that the gastro-intestinal disorders produced by functional disturbances of the liver during the menopause are peculiarly obstinate in their resistance to treatment. Many other clinicians bear testimony to the truth of this statement. This fact increases the importance of the subject of treatment. As this matter is very fully discussed in other parts of this work, it is only necessary to call attention at this time to the importance of directing the therapy to the gastro-intestinal disorders, such as the accompanying subacute gastro-duodenitis and constipation, rather than to the hepatic viscus itself.
25 The Change of Life, 4th ed., p. 227, 1882.
Incidentally, it may be remarked that gall-stones are apt to give origin to distressing symptoms during the menopause. The causes in operation are substantially the same as those already mentioned in connection with the functional disorders of the liver.
CLIMACTERIC NEUROSES.—Incidental mention has been made, in the discussion of the physiology of the menopause, of functional changes in the nervous system, as involved in the perspirations, flushes, hemorrhages, and other so-called critical discharges. Knowledge at the present time of the physiological changes undergone by the nervous system during the menopause is limited to these few general statements, all of which are not yet definitely established facts. The field has always been a fascinating one to the medical writer, probably because, in the utter absence of precise information, the widest play is given to the most vivid and fertile imagination. The literature of the subject abounds in vague terms, figurative expressions, and rhetorical forms. Numerous ingenious and interesting speculations may be found in the writings of systematic authors from Gardanne26 to Barnes and Tilt.
26 Aris aux Femmes entrant dans l'Âqe critique, 1816.
Tilt, following in the wake of the French writers, asserts that the nervous system is in a state of irritability or nervocism. This assertion conveys no information, as irritability may be the expression of weakness as well as of strength. The system is said to be in a condition of nervous plethora. We have seen that the rôle of plethora in recent pathology is insignificant. Cohnheim denies its existence altogether, except as a transitory state. Even admitting the existence of that state, what evidence is there that nerve-force accumulates in the body under the same conditions as the blood?
We have no desire to minify the importance of the physiological and pathological changes in the nervous system connected with the menopause. In comparison with these alterations the other phenomena of the menopause are insignificant. In the absence of precise knowledge, however, it is useless to devote time and attention to empty speculation.
In no part of the subject of climacteric neuroses are notions more obscure or information less precise than in connection with the diseases of the sympathetic or ganglionic nervous system. Under the term gangliapathy Tilt27 has grouped a number of symptoms frequently observed during the menopause, which have their origin in a condition of "more or less debility associated with paralysis, hyperæsthesia, or dysæsthesia of the central ganglia of the sympathetic system." Gangliapathy includes the functional disorders described by other observers under the terms cardialgia, gastralgia, gastrodynia, and the like.
27 The Change of Life, 4th ed., p. 109, 1882.
But it is impossible to view affections of the sympathetic apart from disorders of the general nervous system. It is impossible to distinguish the conditions described by Tilt as ganglionic shock, paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and many of the functional and organic diseases of the abdominal viscera. Finally, the connection of these various disorders, entirely irrespective of names, with the change of life has never been demonstrated, nor even rendered in a high degree probable.
Cerebral Hyperæmia.—The older authors dwell with especial emphasis upon hyperæmia of the brain as an important functional disorder in connection with the change of life. The condition is supposed to be apt to occur, in the absence of perspirations, flushes, and the other so-called critical discharges, as the result of plethora. Headache, tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the face and neck, bounding pulse, are among the symptoms which have been referred to the lighter forms of cerebral hyperæmia. Few systematic writers, however, sustain Dusourd in his assertion that apoplexy and the severer forms of hyperæmia of the brain are frequently caused by the cessation of menstruation.
Under the impression that plethora actually caused cerebral hyperæmia and the symptoms mentioned, and doubtless influenced by the teachings of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding in the treatment of climacteric neuroses. Fordyce Barker and Tilt may be mentioned among modern clinicians who retain the old opinion as to the nature and treatment of this condition.
Cohnheim,28 representing the modern school of pathologists, says "that except as a transitory state polyæmia does not occur under any circumstances." In recent pathology the various appearances of plethora are regarded as caused chiefly by dilatations of the skin blood-vessels, and not by an increase in the total blood-mass. The changes in the character of the pulses are referred to alterations in the vessels or their innervation. Even admitting the existence of the so-called plethora universalis, it does not follow that headache, dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia. Andral has well said that these symptoms might with equal justice be ascribed to qualitative changes in the constitution of the blood.
28 Pepper, System of Medicine, Vol. III. p. 886.
Whatever view may be accepted as to the pathology of cerebral hyperæmia, and as to the necessary connection with the change of life, two important facts derived from experimental physiology deserve careful consideration before bleeding is performed for the relief of the symptoms mentioned:29 (1) A high blood-pressure does not imply an augmentation of the total blood-mass. A large quantity of blood may be injected into the vessels without any considerable elevation of pressure. (2) Bleeding does not directly lower blood-pressure unless the quantity of blood removed be dangerously large.
29 M. Foster, Physiology.
In the lighter cases the so-called derivative treatment fulfils all the indications. Hot, irritating foot-baths, purgatives, saline diuretics, are indicated for the relief of distressing symptoms. Diet, exercise, frequent bathing, and other hygienic resources exercise a most important prophylactic function.
Hysteria.—The occurrence of hysteria during the menopause, as at other periods of life, is a well-established fact. Whether or no there is any direct pathological connection of cause and effect between the change of life and the disorder is a question which has been the subject of much controversy, and at the present time is unsettled. Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are of the opinion that the climacteric may stand in a causal relation. Tilt's tabulated cases bearing upon this subject show nothing more than the coincidence of the two conditions, and contribute nothing to the solution of the problem. There are important considerations which favor the view that while the menopause may influence hysteria favorably or unfavorably, it is only in exceptional cases that the climacteric is the immediate cause of the affection. While hysteria may occur at any time of life, it is most frequently observed between the ages of fifteen and twenty years. It is in a high degree probable that a woman who has arrived at her forty-fifth year without hysterical manifestations will not be molested during the change of life. It is not an uncommon observation to see hysterical woman rapidly regaining health during the pre-cessation period, and making complete recoveries before the permanent resettlement of health.
Hysteria during the menopause does not differ as to symptoms from the affection at other periods of life. It retains its protean character. Almost all the described forms of nervous disease may be accurately simulated. The severer forms of the disorder are paroxysms characterized by convulsions, coma more or less complete, or delirium. Coma enters to a greater or less degree into the paroxysms characterized by convulsions. Lypothæmia—a term used by the older writers to signify an hysterical semi-unconsciousness with feeble pulse and widely-dilated pupils—is frequently observed. This condition, as well as a state termed pseudo-narcotism by Tilt, may be regarded as a lighter form of coma.
Functional paralyses and pareses of motion or sensation, or both, are occasionally observed. Paraplegia is of relatively frequent occurrence. Not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. Hemiplegia and general paralysis are observed less frequently.
In the differential diagnosis it is necessary to exclude epilepsy and eclampsia, although it is well to bear in mind the fact that both these conditions may coexist.
The treatment of climacteric hysteria differs in no essential particular from that of the same disorder at other periods of life. The practitioner, however, has the comfortable knowledge that with the resettlement of health all symptoms, in the absence of local disease, will probably disappear.
It may not be amiss, in passing, to notice the value as a palliative measure of that old and well-tried remedy, the hot-water enema containing asafoetida. One to two ounces of the tincture of asafoetida in one quart of hot water, carried well up into the colon, is usually productive of excellent results, moral and physical.
Climacteric Pseudocyesis.—False or spurious pregnancy is a neurosis of not infrequent occurrence at or about cessation. It may justly be regarded as one of the mimetic forms of hysteria. The symptoms which give origin to the illusion may be observed in young, unmarried women or long after the cessation of ovulation and menstruation. In the large proportion of cases, however, the phenomenon is noticed at or about the climacteric. The subjective and objective signs of this curious condition may simulate pregnancy very closely. The breasts are swollen and tender, and a milky fluid may exude from the nipple. Nausea and vomiting in the morning and the various sympathetic disorders of pregnancy may be feigned. The abdomen may become enormously distended from the deposition of adipose tissue in the abdominal walls and omentum and the flatulent distension of the intestines. Foetal movements are simulated by intestinal peristalsis and irregular contractions of the abdominal muscles. The ensemble of symptoms may be very deceptive, as shown by the famous case of Joanna Southcott. Crichton Browne30 relates the history of an illustrative case which came under his observation in the West Riding Asylum. A woman long past the menopause claimed to be two months advanced in pregnancy. At the end of seven months she informed her friends that she was about to be confined. Accordingly she went to bed, and the process of simulated parturition lasted four days, terminating with a bloody discharge from the vagina.
30 British Medical Journal, 1841.
The differential diagnosis is easy. The mammary changes, upon close examination, will be found to differ from those of pregnancy. Inspection, palpation, percussion, and auscultation will disclose the fact that the woman is only big with fat and wind, as Barnes puts it. Anæsthesia will facilitate the examination. Bimanual examination usually reveals the characteristic senile changes in the uterus or a pathological enlargement differing essentially from the gravid organ.
The so-called phantom tumors sometimes observed during the menopause are closely analogous to spurious pregnancies.
Epilepsy.—Epilepsy is a relatively uncommon disorder during the menopause. The present state of our knowledge indicates that the climacteric cannot be regarded as a distinct cause of the disease in the absence of previous epileptic seizures or inherited predisposition. Out of 200 cases of epilepsy occurring during the climacteric, observed by Jewell of Chicago, not a single case could be traced by the most rigid analysis to the change of life. Considering the rôle the sympathetic nerve plays in the etiology of epilepsy, it would not seem improbable, on a priori grounds, that the disease should be aggravated at the menopause. Evidence derived from clinical observation, however, is entirely inadequate to settle this question.
Insanity.—Various opinions are held as to the relation between the menopause and insanity. Mania, monomania, dementia, and even idiocy, are among the forms of mental alienation which have been attributed to climacteric influences.
Monomania.—There is much probable evidence in support of the view that the change of life may stand in a direct causal relation to monomania. On the other hand, no proof exists sufficient to establish a necessary pathological connection between cessation and mania, dementia, or idiocy.
Gardanne, Dubois d'Amiens, and Chambon have called attention to the occurrence of melancholia and hypochondriasis at this period. This opinion is confirmed by the results of Battey's operation in the hands of Lawson Tait, Bantock, Thornton, and other operators of large experience. In many of the cases of artificial induction of the menopause melancholia has been observed as a most distressing sequela. However, in connection with Battey's operation there are numerous and important considerations which must be carefully weighed in order to distinguish between a relation of cause and effect and mere coincidence. The number of women operated upon is now large, and some of the cases of melancholia following ovarian extirpation are probably examples of the return of a disease of earlier life or of the influence of heredity. Then, the fact of disqualification for maternal duties supplies in many cases an adequate psychological cause for more or less complete mental alienation. The important effects of chronic hepatic hyperæmia and the coexisting gastro-intestinal catarrh—conditions so frequently present at cessation—must not be forgotten when disorders of the intellect are referred to the cessation of the ovarian stimulus.
The positive diagnosis of climacteric melancholia and hypochondriasis is always difficult, frequently impossible. After the careful exclusion of all other possible causes, it may be assumed with a certain degree of probability that the intellectual disorder is due to the change of life.
The prognosis of climacteric melancholia and hypochondriasis is not necessarily unfavorable. In a large proportion of cases sanity returns with the re-establishment of health. The treatment, in the absence of a positive diagnosis, must be expectant. Effort must be addressed to the removal of any possible cause. Hygienic measures fulfil all the indications for treatment in the disorder when it is caused by the change of life. Opium and alcohol must be employed with extreme care in view of the great danger of the formation of obstinate habits.
Uncontrollable impulses and perversions of moral instincts are frequently observed during the climacterium, as at other periods of life. There is no reliable statistical evidence sufficient to establish a necessary pathological connection between cessation and uncontrollable peevishness, impulse to deceive, suicidal impulse, nymphomania, dipsomania, kleptomania, and the like. Nor is it possible to assert that these various disorders are of more frequent occurrence during the menopause than at other periods of life.