CHAPTER XXIX THE MENOPAUSE AND OLD AGE (Part 4)

youngest 10 yrs. 49 8 mos. Sense of prolapse, lacer- ated cervix and perine- um, procidentia. 104. M. D. 48 Sing. No ch. Noab. 47 1 yr. Flowing for one year, polyp. 105. A.C. 49 Mar. 8ch. 48 Sense of prolapse, lac- erated cervix and peri- neum, prolapse. 106. M. D. 54 Mar. 3ch. 48 Can't control bowels, lac- erated cervix and peri- neum through sphincter. 107. J. M. 52 Mar. 10 ch. youngest 7 yrs. 50i Prolapse, lacerated cervix and perineum. THE MENOPAUSE THE MENOPAUSE. — {Continued.) 611 6 6 B to ■35 d d) CO • cj CO 1 M • 1H O hfl pd.5 o> Leading symptoms and fe c3 < OT3 O o d-g • go 8s o) ^ S^ O) % ^ Jl diagnosis. 108. L. D. 46 Sing. 1 ch. 12 yrs. 44 Prolapse, lacerated cer- vix and perineum, uter- us and ovaries atrophic. 109. B.B. 54 Mar. 2ch. 44 Leucorrhea and sense of prolapse, cystocele and rectocele. 110. M. D. 52 Mar. No ch. lab. 48 Flowing two and a half years, uterus large, spin- dle-celled sarcoma of ovary. 111. C.N. 54 Mar. 7ch. 47 None Painful and bloody mictu- rition two months, can- cer of bladder. 112. A.H. 48 Sing. No ch. No ab. 45 ... Flowing for six months, cancer of body of uterus. 113. M.E.T. 56 Mar. 2ch. youngest 32 yrs. 50 No complaint except pro- lapse, lacerated peri- neum. 114. M. M. 57 Sing. No ch. No ab. 51 Acute obstruction of bow- els, cancer of sigmoid. 115. B.D. 54 Mar. 44 Pain in abdomen, cysto- ma of left ovary, right ovary atrophic at oper- ation. The Dodging Time Tilt and others have called the time from the beginning of ir- regularity of the menses to their cessation, the dodging time. In his 500 tabulated cases there was no dodging time in 137 women, menstruation stopping suddenly in these. The average length of the dodging time in 265 cases was 2.2 years. In my own list, data as to the length of the dodging time were obtained in 62 cases. Of these 8 had no dodging time and of the 54 remaining the average time was 2.2 years. However, of these the dodging time was surely completed in only 23 and in these the average was 2.8 years, the longest 10 years, and the shortest 3 months. I think we should agree with Tilt that very little can be deduced as to the normal dodging time from these figures. Sudden cessation of the menses is of comparatively infrequent occurrence. In many of the women there was noted an alteration in either or both the quantity and the quality of the menstrual blood, also certain 612 THE MENOPAUSE AND OLD AGE phenomena such as hot flashes and nervous instability, previous to the beginning of irregularity of rhythm, so that the inference is justified that ovarian influence begins to fail before menstruation becomes irregular. Two years and nine and a half months (2.8 years) represents the average duration of the dodging time as influenced by uterine or ovarian disease in my series of cases; hardly enough cases to warrant any weighty conclusions, however. We know nothing about the factors that govern a sudden or a prolonged menopause, and we have no means of knowing in any given case what the issue is likely to be. We speak of the menopause being over, or passed, when the genital hemorrhages have ceased. Of course, this is not necessarily the case, for the changes in both the body (the uterine organs and the system at large) and in the psychical state of the individual that are peculiar to the menopause may be only begun when the menses cease. On the other hand, these general phenomena may precede the disappearance of the menses; therefore we might, perhaps, mark the beginning and the end of the climacteric by the appearance and the cessation of these phenomena, rather than by the stopping of menstruation. Phenomena of the Menopause in Body and Mind Leaving for consideration in the succeeding section the influence of diseased uterine organs on the menopause, let us examine here the manifestations of the change of life in the other portions of the body. Cardio- vascular System. — Hot Flashes.— -Hot flashes, or flushes, are probably the most frequent and the most annoying of the symptoms of the menopause. In a well-developed hot flash the patient at first feels hot, some portion of the skin of the body, generally the face and hands, being suddenly filled with blood; a sort of exaggerated blush. Immediately afterward sweating occurs and finally the patient feels cold, the chilly sensation coming on either while the sweating is in progress or after it has ceased. The vigor with which these flashes seize the individual vary greatly in different patients and in the same patient at different times. Also the frequency of their recurrence varies from as many as ten THE MENOPAUSE 613 an hour in one case of artificial menopause, reported by Bland- Sutton ("Surgical Diseases of the Ovaries and Fallopian Tubes/' p. 486) to an occasional irregular flash. No two cases are alike and there seems to be no definite relation between the sudden occurrence of the menopause and the severity or frequency of the flashes, except that in the case of the artificial menopause the flashes are generally more severe. Ordinarily the flashes are most severe in the beginning when the menses first become irregular and gradually, as the months go by, are less and less pronounced. Tachycardia and High Arterial Tension. — Paroxysmal increase in the rapidity of the heart's action and a general high arterial tension have been observed in women at the menopause. These disturbances are, as in the case of the hot flashes, due to derange- ment of the vaso-motor nervous mechanism. They may be due to preexisting heart disease, but occur in women who have no dis- coverable heart lesion. Stokes first called attention to them and they have been studied more recently by Kisch (Berlin, klin. Woch., 1889), Fiessinger (Journ. des Praticiens, 1902, p. 802), Pawinski ("Tension arterielle dans la menopause," Acad. Med., 1904), and L. Williams (Clin. Journ., March. 3, 1909, Vol. XXXIII., p. 329). If we assume that a manometric reading of the pulse just before a normal menstrual period of 130 to 150 millimeters of mercury represents the highest average during sexual life (the lowest being about 110 millimeters just after a menstrual period) the manometer may show a blood pressure of 180 millimeters in the pulse of a woman who is passing through the menopause. The pulse feels bounding and full. The patient complains of palpita- tion, which is often especially annoying at night and is accompanied by smothering sensations. Sometimes in marked cases there is active dyspnea, the respiration becoming embarrassed at the least effort. The pulse rate may be as high as 150 or 160 a minute and sometimes it is also irregular, even in cases where organic heart disease can be absolutely excluded. The Nervous System. — The phenomena of derangement of function of the vascular system that have been described already are un- doubtedly caused by some unknown impairment of the nervous mechanism. Other indications of functional nervous disease are intercostal neuralgia, insomnia, ringing in the ears, loss of memory, suspicions, and change in character, especially by developing irri- 614 THE MENOPAUSE AND OLD AGE tability of temper. The small every-day annoyances assume ex- aggerated importance and become insupportable. Many women from being of a ■ cheerful disposition become habitually sad and depressed. The thought is forced upon us that this state of mind is in part due to the gloomy views about the change of life that have been held by both laity and the profession in the past. To some women we can imagine that the knowledge that the child- bearing function is going, that she is becoming unsexed, is a dispirit- ing thought. If in addition sexual pleasures have been an important feature of her life the disappearance of these may be an added source of melancholy. Vinay (loc. cit., p. 107) thinks that such a thought caused Mme. du Deffant to remark with regret, " Formerly, when I was a woman." Neurasthenia is a common accompaniment of the menopause but, more often than not, does not originate at that time. Many nervous stigmata long existent, perhaps inherited but not noticed by either the patient or her physician, come to the fore at the change of life. Hysteria is developed sometimes at the menopause, but here in a majority of cases a careful sifting of the history will detect stigmata as having been present in the past. Sexual Feeling at the Menopause. — This subject has been studied by Brierre cle Boismont, Gueneau de Mussy, and other French writers. It would appear that there exists in many women an excess of sexual passion at the close of the menstrual life in not only the married but in widows and the unmarried. This is shown by platonic affections, by a morbid attraction for the opposite sex, young boys even being selected as the objects of lavish attentions, or by mas- turbation, nymphomania, or excessive lustfulness. Venereal desires become a positive obsession in some women and they may affect those who have not experienced them previously during their lives. Sexual feelings are apt to be manifest at the times when menstruation should occur and the seizures, which are of short duration, but perhaps often repeated, seem to replace the periods. They are accompanied often by hypochondria and melan- choly. At the conclusion of the menopause sexual feeling gen- erally disappears, though it may not. R. G. Hann (Journ. Obstet. and Gyn. of British Empire, 1902, Vol. II., p. 290) reports the unusual case of a woman, the mother of twelve children, who ceased to menstruate at forty-six years. Then all sexual feeling THE MENOPAUSE 615 was lost. Three years later she gave birth to her thirteenth child and sexual feeling returned with the first menstrual period. Mental Diseases. — Many diseases of the nervous system are separated by such a delicate line from the diseases of the mind that their differentiation is often a matter of great difficulty. In the first place it may be best to state that there is no such thing as climacteric insanity in the opinion of such an authority on insanity as M. Craig, of the West Riding Asylum in England. Of the two hundred and twenty-two cases of insanity during the menopause occurring in the West Riding and Bethlehem asylums in ten years, (Journ. of Mental Science, 1894, Vol. XL., p. 236) between 63.3 and 68.6 per cent, respectively, were cases of melancholia. H. Berger, of Jena (Monatss. filr Psychiatrie u. Neurol, 1907, Bd. XXII., Erganz. Heft 13), reports a similar conclusion from a series of fourteen cases which he has studied and a review of the literature, and this corresponds with the experience of most writers on mental disease that melancholia is most often observed at this time of life. The other diseases with their respective percentages observed by Craig were as follows: — Mania, 15-18 ; Weak-mindedness, 2-1 ; Delusional insanity, 9-14; General paralysis, 2-1. He attributes an important influence to heredity in the causation of mental disease at this time, and points out that the menopause has a deleterious effect on preexisting psychoses; therefore, from this point of view, we are justified in classing the menopause as a critical time of life. We must remember, however, that the patients who happen to be in the insane asylums during the climacteric years, are only a small proportion of all women of that age in the community, and that the causative agency of the menopause in producing mental disease is still most indefinite. The Alimentary Canal. — Eisner found in the stomachs of men- struating women hyperchlorhydria that he attributed to hyperemia of the gastric mucous membrane coincident with the hyperemia of the uterine mucosa. At the menopause there is often found an atonic gastritis with hyperchlorhydria. Dyspepsia of one kind or another is frequently observed at the menopause, especially among American women where dyspepsia is such a common disease at all ages. Patients suffer with epigastric pain and heartburn two or 616 THE MENOPAUSE AND OLD AGE three hours after eating. There are acid eructations and some- times vomiting and constipation. Gallard, according to Vinay, called attention to the penchant that many women have during the menopause for strong liquors and assigned part of the dyspepsia to an alcoholic habit. Chronic gastro-enteritis may be the cause of obstinate constipation which is common at the menopause. Puech found hematemesis as a vicarious menstruation in some of his women, but other authors do not mention it. The Nutrition. — Obesity appears in certain young girls of a lymphatic type as they reach puberty. It is also often observed in women after prolonged lactation, and it is a very frequent con- comitant of the menopause, either normal or artificial. The same increase in fat is seen in capons, oxen, and other castrated animals. Most of the fat is deposited in the panniculus adiposus of the anterior abdominal wall, over the breasts, the buttocks and the hips, and less in the limbs and face. The abdomen gets larger at the menopause both because of the excessive accumulation of adipose tissue in the anterior abdominal wall, and also because of the deposit of fat in the mesentery of the intestine and in the omentum, perhaps accompanying gastro-intestinal disturbances with chronic flatus. The increase in body size due to obesity at the menopause is seldom excessive. Where loss of flesh accompanies the menopause, as it occasionally does, we look for some definite fault of nutrition. Anemia occurs at the climacteric especially in those women who have lost much blood as a result of uterine hemorrhages. There are pallor of the face and lips, shortness of breath on the slightest effort, indigestion, hemic murmurs over the precordia, and headaches and nervous irritability. Rheumatism.— F. Neumann (Med. Klin., Berlin, 1908, Vol. IV., p. 407), physician to the baths of Baden-Baden where 3,158 women with joint disease (acute and chronic rheumatism of the joints, arthritis deformans, and gout) were treated in the seven years from 1901 to 1907, inclusive, notes the frequency of the association of chronic joint disease with the menopause. He has found that many women with chronic joint disease date the beginning of their ailment from the climacteric or the time just after it. He had seen forty- seven cases of this relation in the previous two years and a case where joint affections had been associated with the menopause artificially induced by castration. Whether the occurrence of THE MENOPAUSE 617 rheumatism at this time has to do with deficient elimination of waste products because of changes in the excretory glands of the body at the menopause, as assumed by many writers, is still sub judice. The urinary function seems to be impaired and deficient elimination with lithiasis occurs in some cases. The Skin. — Pruritus and eczema are most common at the meno- pause and are frequently localized in the region of the vulva or anus. Urticaria and acne rosacea are not infrequently seen. Growth of hair, especially on the chin, the upper lip, and about the breasts, is sometimes observed at this time. The diseases of the breasts have been considered in Chapter XXVII, page 531. Influence of Uterine Diseases on the Menopause A certain relatively few uterine diseases originate at the meno- pause, such as injuries to an atrophic vagina from coitus, pruritus vulvae, and prolapse. A large majority, however, have their origin long before the menses begin to be irregular, even though they may have previously excited little attention from either the patient or the physician. Hemorrhages. — Let us consider first the pathological conditions which give rise to hemorrhages at the menopause. (a) Fibroids. — The most frequent of these are fibroids of the uterus in situation either submucous or interstitial. The bleeding in such cases is apt to begin as menorrhagia occurring after the thirty-fifth year, gradually becoming greater in amount, and finally resulting in metrorrhagia as the patient enters the forties. Ab- dominal or pelvic pain may accompany the flow; it may be in- dependent of it or it may be absent. Expulsive, labor-like pains are present sometimes when a submucous nodule is being driven out of the uterus. More often the uterus becomes atonic from the prolonged presence of the foreign body and the patient experiences no pain. The subject of fibroid tumors is described at length in