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.