CHAPTER XXIX THE MENOPAUSE AND OLD AGE (Part 2)

individuals and proceeding with the same rate of speed in the different organs in no two patients alike. In the absence of definite demonstrable patho- logical conditions the atrophic changes should proceed from the ovaries downward, involving in progressive sequence tubes, uterus, vagina, and external genitals, and this, I think, is the rule. The tubes lose their lining epithelium and finally their lumen is closed and they become mere cords; the uterus becomes smaller in all its dimensions, its walls grow thinner, and the internal os is contracted and is often obliterated. The cervix generally atrophies before the body of the uterus, becoming shorter and thinner, but in women THE MENOPAUSE 595 who have regular sexual intercourse this may not be the case, and of course, if the cervix is the seat of old lacerations and chronic metritis, it may be the last portion of the organ to show atrophic changes. When the menopause is well established the vagina, which during the change is apt to be hyperemic, becomes pale, — perhaps only in patches, while the rest is dark red; it is narrower and shorter and assumes a conical shape because the contraction is greatest in the upper portion. It loses its elasticity and the mucous membrane gradually is deprived of its rugse, so that the walls become more friable and the surface smoother. Sometimes coitus in the case of an atrophic vagina causes excoriation, pain, and bleeding, and may be the source of impairment of the nervous balance of the patient. Laxity of the tissues of the vagina with atrophy of the muscular walls at the menopause favors. prolapse. The changes in the external genitals consist in loss of subcutaneous fat and in a gradual shrinking, but these transformations are so closely bound up with the nutrition of the system as a whole, that, although having their origin at the menopause, they are generally not marked until old age. Therefore, we seldom note absence of fat under the mons veneris and the labia pudendi until old age sets in, even in the cases of premature and artificially induced menopause. The condition here is not dissimilar to that in the mammas which atrophy at the menopause, the gland tissue being replaced by fatty tissue, which is deposited in abundance throughout the entire body, especially in its upper portions, at this time. Physiology. — To obtain an understanding of the physiology of menstruation it seems to me that the menstrual-wave theory developed by Mary Putnam Jacobi ("On the Question of Rest for Women during Menstruation," 1878) and by William Stephenson (Amer. Journ. Obstet., 1882, Vol. XV, p. 287) offers the best explanation. It is that menstrual life is associated with a well- marked wave of vital energy manifested by variations in the body temperature, in the daily amount of excretion of urea, and in the arterial tension, as demonstrated by the investigations of these authors. The highest body temperature, the greatest daily ex- cretion of urea, and the highest arterial tension as registered by the sphygmograph occur at a period of five or six days before menstruation, and the lowest point of all three of these indices of 596 THE MENOPAUSE AND OLD AGE the vital processes is just after the cessation of menstruation. In other words, the woman's system is prepared by a gradual rhythmic process for menstruation and reproduction. We know that at the menstrual period the uterus, ovaries, tubes, and vagina pass through a phase of increased functional activity and engorgement that necessitates an increased blood supply to these organs. Accordingly the tributary arteries dilate and the arteries of the rest of the body, in obedience to the law of compensation, undergo a vaso-constriction, whence the slight drop in arterial tension noted by Stephenson in the radial pulse just before and during menstruation. The blood in the pelvic circulation is forced at increased pressure through the capillaries of the uterus, with a result that there is hemorrhage from the endometrium. It is plain that anything that profoundly upsets the balance of blood-pressure upon which menstruation depends may cause either an increase in the flow or a diminution, or even cessation. This upsetting may come through the nervous system, as in the case of nervous worry or shock, or it may come directly through the circulation. Dr. Francis Hare (Clinical J own. , Aug. 29, 1906) has reported a case where the inhalation of amyl nitrite immediately checked a normal menstrual flow, and in the olden days when our forefathers employed venesection as a universal therapeutic measure it is reported that blood-letting, in the case of a menstruating woman, was followed by the same result. In one case the blood was re- moved from the pelvis by vaso-dilation of the systemic arteries, and in the other by abstraction from the general circulation. The tonicity of the blood-vessels, of the portal system, that great reser- voir of the body, must have an important influence on menstruation, and in the future we may look to see results of investigations on the circulation conducted to determine the causes of greater or less congestion of the uterine organs at the catamenia. We may regard the time between menstrual periods not as a period of rest from preparation for reproduction, but as a marshal- ing of the forces which reach their acme just before the molimen, then, after a brief period of slack water, to rise again to high tide, with ever-recurring regularity of rhythm until the stimulus ceases to emanate from the ovary and menstruation and the capacity for reproduction are no more. THE MENOPAUSE 597 Age at which the Menopause Occurs All the statistics found in the literature as to the age of the beginning of the menopause are unsatisfactory because they in- clude chiefly women having all sorts of uterine diseases as well as those afflicted with various other bodily ailments. Many of the statistics include the cases of premature menopause. For these reasons the available statistics do not represent fairly the average age of the occurrence of the menopause, at least among women who are not the subjects of uterine disease, for it is my belief that uterine disease is the principal cause of prolongation of the men- strual function. As long ago as 1869 E. Krieger ("Die Menstru- ation," p. 171) gathered the statistics of six authors, of which the following is a summary: — Two thousand two hundred and ninety-one cases reported by Mayer, Tilt, Guy, Brierre de Boismont, Courty, and Puech. Between the No. of Percentage years cases of all 36-40 '. 272 11.87 41-45 595 25.97 46-50 940 41.03 51-55 334 14.58 Before 35 or after 55 150 6.54 In this list the greatest number of cases were the women who ceased to menstruate between the ages of forty-six and fifty. Tilt (loc. cit., p. 26) gives an average age of 45.7 among 1,082 women observed in London and Paris, including the cases of premature menopause. As regards the influence of race or locality on the time of the menopause we know so little from what sort of women the statistics were gathered, and the figures of different observers are so much at variance, that the only conclusion we are justified in drawing is that the age is somewhat more advanced in the women of the higher latitudes than is the case in those living nearer the equator; and in the Jewish race the menopause occurs relatively early in whatever part of the world the women happen to live. As an ex- ample of the variability of statistics concerning neighboring races leading a similar mode of life, we may cite the following: — In a study of the menopause among the American Indians 598 THE MENOPAUSE AND OLD AGE Andrew F. Currier (Trans. Amer. Gyn. Soc, 1891, Vol. 16, p. 274) found an average age of 47.2 among twenty-five Sioux Indians, and 53.4 among ten of the Cheyenne and Arapahoe tribes. He states (loc. cit., p. 277) that among the Quapaws the child-bearing period ends at thirty-five to forty, whereas among the Crows and Assini- boines (loc. cit, p. 278) the child-bearing period frequently con- tinues until the forty-fifth year. Tilt gives a table of the compara- tive dates of the cessation of menstruation in different countries as follows: — France, Paris, 44, Rouen, 48.7; England, 46.1 and 47.5; Central Germany, 47; Denmark, 44.8; Norway, 48.9; Lap- land, 49.4; Russia, 45.9. Something must be assigned to the influence of heredity in the matter of the age at which the menopause is established. It has been my observation that the climacteric appears at about the same age in mother and daughter; that a late or an early menopause is a common characteristic in the women of certain families. My personal experience as to the average age has to do with an analysis of the records of eighty-eight cases of women between the ages of forty-one and fifty-nine who consulted me in Boston or New England, for uterine disease. (See tables, pp. 604-611). All cases of myoma, cancer of the uterus which manifested itself previous to several years after the cessation of the menses, and, of course, artificially induced menopause, are excluded. The average age of the menopause in these cases was 46.78 years. This may be considered as a fair average for women with uterine disease ex- clusive of fibroids and cancer, who live in New England, although a larger number of cases, both of those afflicted with gynecological troubles and of more nearly normal women, should be gathered and analyzed before arriving at definite conclusions. Premature Menopause The cessation of the menses previous to the normal average time is known as premature menopause, but as variations from the normal an4 so frequently seen it will be convenient to consider as cases of this abnormality those which occur before the fortieth year. The important point to bear in mind in establishing the diagnosis is to be sure that a reasonable time has elapsed since the last menstrual period to make its recurrence in the future THE MENOPAUSE 599 seem improbable. Apprehensive patients often think the change of life is at hand upon the occurrence of a transitory irregularity in the menses. A direct cause for the cessation of the menses early is to be found sometimes in (a) a sudden blow or fall, extreme fright, anxiety, or grief acting through the nervous system; (6) serious constitutional diseases, such as cholera, septicemia, the acute exanthemata, or poisoning by alcohol, phosphorus, mercury, arsenic, or lead; (c) diseases affecting the uterine organs directly, such as excessive lactation-atrophy of the uterus, steaming of the uterine cavity after the method of Pincus (see p. 286), or inflammations and tumors of the ovaries. Other factors which seem to stand in a causal relationship to an early menopause are rapidly succeeding pregnancies beginning early in life, and excessive venery. Some authors consider that the southern races who mature relatively young have the menopause correspondingly early; but others do not agree to this view and consider that there is no relationship between the age at which menstruation begins and the time of its cessation. Obesity, especially that form which is rapidly acquired, is a cause of an early menopause both in the opinion of A. Currier (Medical News, 1888, p. 173) and myself. Although any of these causes may result in a permanent disap- pearance of the menstrual flow, we are by no means sure, as pointed out by Borner (loc. cit.), that ovulation is also abolished and that true cessation of the reproductive function has been established, and we may agree with him in the statement that many of the reported cases of premature menopause are to be regarded with suspicion because the absence of the menses for a sufficiently long period of time has not been observed and because an accurate gynecological examination eliminating the common causes of amenorrhea has not been made. How causes in class (a) act to produce amenorrhea we do not know. It is probable that the general constitutional diseases act directly on the ovaries. We know that the exanthemata cause changes in the ovaries, as shown by Lebedinsky's examinations of the ovaries from cases of scarlet fever. (See Chapter XVII., p. 285.) C. Vinay ("La menopause," 1908) has called attention to the frequency with which sclerosis of the ovaries is found in tuberculous individuals, and Slavjansky, according to Borner, found paren- 600 THE MENOPAUSE AND OLD AGE chymatous inflammation of the ovary in cholera, recurrent fever, and septicemia. The destructive diseases of the ovaries originating either in those organs or in the neighboring organs of the pelvis, may well cause the menopause. The surprising fact is that they so seldom do cause it, for in cases of large cystomata of both ovaries where at operation no sound ovarian tissue can be discovered by macro- scopic examination, the patients generally report that menstruation has taken place with more or less regularity during the growth of the tumors. We must assume in such cases that some function- ating ovarian tissue has been preserved, even though it can not be easily discovered. We know that in ovarian transplantation from one individual to another, menstruation and ovulation continue as long as ovarian tissue is present, even though this tissue is not in its usual situation with reference to the uterus, and it seldom happens that destructive inflammatory processes completely eliminate all of both ovaries. A recent writer (M. M. Stark, Surg., Gynecol., and Obstet., Jan., 1910, Vol. X., p. 40) has collected from the literature the following fifty-nine cases of premature menopause, occurring between the ages of seventeen and thirty, all reported by reliable authorities. Menopause at Reporter No. of Cases 17 Iiisch 1 18 Stark 1 19 Frazer, Stark, 1 each 1 20 Dalton, Kisch, Stark, 1 each 3 21 Schalit 1, Boismont 2, Courty 1, Stark 1 5 22 Mayer 2, Stark 1 3 23 Krieger, Walter, Stark, 1 each 3 24 Boismont, Stark, 1 each 2 25 Mayer 2 26 Montgomery 1, Munde 1, Boismont 1, Stark 2 5 27 Tilt, Guy, Boismont, 1 each 3 28 Foster, Currier, Guy, Boismont, Stark, Courty, 1 each . 6 29 Mayer, Boismont, Courty, Napier, 1 each 4 30 Mayer 5, Tilt 10, Guy 1, Felty 1, Napier 1, Stark 1. . . 19 The number of cases occurring between thirty and forty years of age is, of course, the largest. Bonier (loc. tit., p. 39) gives the following as a genuine case of premature menopause of unknown causal ion: "Mrs. H., now thirty-nine years old, menstruated THE MENOPAUSE 601 regularly after twelve years of age. Married at thirty-four and aborted twice in the course of two years. When she was thirty-six her husband, who had been seriously ill and for whom she had cared constantly, died suddenly. Her menses ceased on the second day of her period and although she saw slight traces of a flow twice subsequently at intervals of four or five months, there had been absolutely no flow for the past two years. The only symptom was mental depression. On local examination the vagina was somewhat shortened and contracted; the cervix thin- walled, soft and small, with a tear (one of the abortions was a rapid one at six months), and the uterus as a whole very thin- walled and almost membranous. The ovaries, of practically normal consistency, were freely movable but small in size." Delayed Menopause The menopause may be said to be delayed when menstruation is continued beyond the fiftieth year. An important point in diagnosing this condition is to distinguish between irregular hemorrhages and menstruation. In many cases careful questioning of the patient is necessary to bring out the difference clearly. Are ovulation and fertility- prolonged with menstruation? There are many cases on record of both menstruation and childbearing late in life, some of them most sensational and far too large a pro- portion founded on hearsay evidence rather than on the personal observation of the reporters. One of the earliest cases is that recorded by Pliny the Elder, of Cornelia, of the family of Scipio, who at the age of sixty bore a son who was named Volusius Satur- ninus. Fordyce Barker ("The Age of Women When the Capacity for Childbearing Ceases," Phila. Med. Times, 1874) pointed out that the eldest child of Cornelia was born in the year 163 B.C. and that Pliny was born in the year 23 a.d. and his " Historia Natur- alis" was published about the year 77; therefore, at least two hundred years must have elapsed from the time of this extraor- dinary birth to the time when Pliny wrote. Pliny gave no docu- mentary evidence and, as he was something of a romancer at best, we may class the case as a tradition and not as an observed fact. In the same way, if the cases in the literature are examined carefully 602 THE MENOPAUSE AND OLD AGE and the sources of information sifted, the facts generally rest on hearsay evidence. Take the case of Ann Woods who is said by Dr. Benjamin Rush "to have given birth to a child after she was sixty years old." In this case the evidence of the truth of the story rests entirely upon the assertion of the old woman herself who claimed to be ninety-six years of age when she called at Dr. Rush's home "to beg for cold victuals." Dr. Fordyce Barker (loc. cit.) reports the following authentic case of late childbearing: "May 6, 1852, I attended a case of labor in St. Mark's Place, New York City, in consultation with the late Dr. Robson, of this city. The labor was normal but tedious and our patient was delivered of a daughter by the aid of forceps. This lady had been married twenty-seven years and this was her first pregnancy. After the birth of the child, the husband showed to Dr. Robson and myself a family Bible,