Chapter XV., page 244. It is enough here to counsel a thorough (Part 1)

Chapter XV., page 244. It is enough here to counsel a thorough local examination in the case of every woman who has excessive flowing at or about the menopause. We know that, although some fibroid tumors diminish in size and cause no symptoms after the 618 THE MENOPAUSE AND OLD AGE menopause has been established, the majority do not atrophy, and even if they do they are subject to a variety of degenerative changes that jeopardize the health or even the life of the patient. Not only that, but the change of life is delayed in the possessors of fibroid uteri and the loss of strength from prolonged and repeated hemor- rhage, with its consequent anemia, constitutes a handicap from which many untreated women never recover. Others, hardier, the more rapid blood-makers, survive the drain on their vitality and are able to get back into good condition after a series of years of invalidism, and still others, the very tough sort who can stand anything, are not seriously incommoded. (b) Subinvolution. — The next most frequent cause of hemorrhages at the climacteric is the condition known variously as subinvolution or chronic metritis, with or without lacerated cervix. In looking over my list of cases of women who were either passing through or had passed the menopause (see pages 604—611) I find the diagnosis of subinvolution or badly lacerated cervix noted in thirty-five of the ninety parous women in the list. Not all of these suffered with flowing, but it is plain that if the uterine muscle has been replaced by connective tissue or elastic tissue and has acquired an increased bulk because of these changes in its tissues brought about by chronic engorgement, the retrograde alterations in its structure which normally take place at the menopause are hindered, so that the organ can not shrink to the diminutive size found in old age under non-pathological conditions, except after a longer time and at the expense of disquieting local symptoms in the form of hemor- rhages and leucorrhea, and general symptoms as described in the last section. (c) Endometritis.— Endometritis occurring under the varieties of fungous, polypoid, and glandular, is a cause of both flowing and leucorrhea at the menopause in a considerable number of cases. (d) Polypi were found in ten of the cases in my list and other observers have found these frequently during the menopause, some authors in the past alleging that they were due to the change of life. Endometritis so often accompanies subinvolution that in an analysis one can not separate the two. We must regard the disease as originating in some infection long before the menopause, but as becoming the cause of hemorrhage and leucorrhea at that time because of the altered rhythm of the pelvic circulation. On account THE MENOPAUSE 619 of the decreased vitality of the uterine organs at the menopause the opportunities for the entrance of infection into the tissues are enhanced ; therefore, it may well be the case that infections origi- nate at this time in the uterine endometrium as they do in the vagina. My observation leads me to think that in most instances of endometritis at the menopause the disease is an exaggerated stage of a preexisting endometritis. (e) Cancer of the Uterus. — In looking up my cases of women who were passing through the menopause I found in addition to those in the list four who had flowing because of cancer, — two each of cancer of the cervix and of cancer of the body. There is no evidence to prove that the occurrence of cancer, except in the late stages of the disease, has any more effect on the menopause than subin- volution. As previously stated, cancer is a disease of the atrophic tissues. In my list of one hundred and fifteen cases there are seven cases of cancer of the cervix and three of cancer of the body of the uterus, all ten presenting no symptoms until the menopause had been well established for ten months in the short- est time, and eight years in the longest. Thus we have ten cases of cancer of the uterus first manifesting its presence after the menopause was over, as contrasted with four cases diagnosed in women of the same ages, — forty-one to fifty-nine, — during the menopause. Before leaving the subject of hemorrhage at the menopause it may be proper to state that there are cases, although they are rare, in which no adequate explanation of flowing at the climacteric can be found either in the uterine organs or in the system at large. There is a probability, as suggested by Scanzoni long ago, that arteriosclerosis at this time of life, by rendering the blood-vessels of the uterus more rigid and friable so that they can not withstand increased blood pressure, predisposes to hemorrhage. Borner (loc. cit., p. 42) reports the following case of unexplained climac- teric flowing: "Mrs. R., aged sixty, had always menstruated regularly but profusely. She married at twenty-three and had three normal labors within seven years. She had always enjoyed good health except that she had a highly irritable nervous system. At forty-nine she suffered with a sudden and profuse flowing. Repeated local examinations failed to find any abnormality of the uterine organs and a general physical examination detected nothing 620 THE MENOPAUSE AND OLD AGE wrong with the circulatory system. Repeated hemorrhages at longer or shorter intervals produced such profound anemia that she was obliged to pass two entire winters in bed. Then, at fifty-one, the hemorrhages ceased and she became strong and well as before. Another examination of the uterine organs at this time failed to reveal any abnormality." Displacements of the Uterus at the Menopause. — Displacements of the uterus at the menopause except prolapse are of minor impor- tance. Retroversion is a condition of the uterus that may be regarded as normal after the climacteric atrophy has taken place. Prolapse : A uterus made heavy by subinvolution is more apt to sag down and to become prolapsed at the menopause than before because of the weakening of the uterine ligaments and the disappearance of the muscular wall of the vagina, coupled with a shortening and change in shape of the vagina at this time. The cervix becoming smaller and the upper vagina assuming a narrowed caliber and a conical shape, the cervix no longer enters the latter organ with its long axis at a right angle to the long axis of the vagina, but is a button at the upper end of the shortened, flabby- walled vagina. Although only twelve of my one hundred and fifteen cases were affected with prolapse, the affection is common arnong the uterine diseases of the menopause. It occurs even in the virgin. Of this I remember having seen two cases. Borner (loc. tit., p. 64) cites the following case: "Miss G. had passed the menopause about ten years before. She had been free from any sort of abdominal dis- turbances during her entire life. She was in good health, although incommoded recently by getting fat. Shortly before, she happened to be assisting in moving a chest, something she had done many times previously, when she felt suddenly a pain in the abdomen, and at once noticed a foreign body between her thighs. Soon after she consulted me and I found a total prolapse of the uterus and vagina while in every other respect the genitals were intact. The patient was a nullipara and had accordingly an uninjured, firm perineum; the vagina, already somewhat narrowed by senile shrinking, was absolutely free from those changes (hypertrophy, a dry leathery feel of some portions, etc.) which would have pointed to a procidentia of long standing; the uterus was already atrophied and was small, light and thin-walled, and the cervix was absolutely intact." Such a case must be explained by increased intra-abdominal THE MENOPAUSE 621 pressure coupled with the atrophic conditions of the uterine organs just described that favor prolapse. Cystocele and rectocele are frequently found at the menopause because of the weakening of the vagina by atrophic changes in its walls; therefore the walls are more apt to become pouched during the climacteric than they are previously when the muscular and tendinous tissues of the perineum and vaginal walls are in a tonic condition. Vaginitis and Injuries of the Vagina from Coitus. — A discussion of senile vaginitis will be found in Chapter XX., p. 365. Infection and inflammation of the atrophic vagina are not infrequently met during the menopause. The disease is more common, however, as a so- called post-climacteric phenomenon and will be considered under the diseases of old age. As previously stated, the non-elastic atro- phic vagina may be excoriated or even torn as a result of coitus. Chadwick reported a case of this sort in which a woman forty-eight years old, who had not menstruated for about ten years, indulged in sexual intercourse after having refrained from it for four months, with a result that she had violent pain and profuse hemorrhage. Examination showed a recent tear an inch long in the upper third of the vagina, extending into the cellular tissues to a depth of half an inch. The vagina, on account of senile atrophy, was consider- ably shorter and narrower than in the childbearing period. Eczema or pruritus vulvae was noted eight times in my list of cases and I remember having found these affections rather fre- quently during the menopause in dispensary practice. They may occur at other times and they are more frequently met in the post- climacteric period, — in old age, — than during the menopause. Pruritus may be independent of any known pathological lesion of the skin of the vulva, and is thought often to be a local manifes- tation of a lesion of the general nervous system. Vesical Symptoms. — Urinary symptoms were noted in twenty- three of my cases. The symptoms included frequent micturition, painful micturition, and incontinence of urine. A detailed analysis of the different diseases present is hardly worth while in such a small number of cases. The following were noted, however: urethritis, cystitis, dislocation of the urethra downward, and four cases of urethral caruncle. The menopause might act as a causative agent indirectly in producing urinary difficulties by the exaggera- 622 THE MENOPAUSE AND OLD AGE tion of preexisting malpositions and traumatisms clue to child- bearing, or through the atrophy of the labia pudendi and the labia urethrse offering more easy access of pathogenic bacteria to the canal of the urethra. In addition to the local causative agents the unstable equilibrium of the nervous system at the menopause is to be reckoned with when considering the function of urination. How much the derangement of function is caused by actual disease of the urinary organs, and how much by disorder of the general nervous system, we find most difficult to state in many actual cases in practice. My observation leads me to the view that the situation is the same with the urinary apparatus as with the uterine organs; that preexisting disease, or impairment of function, causes a stormy change of life ; that unsound organs which, while nourished by a well-equalized blood supply, cause only minor symptoms, under changed conditions cry out loudly. Therefore, let it be our aim to discover the abnormalities of the genital organs during the period of sexual maturity in the life of our patients and, by treating the diseases, help the patients to avoid many of the discomforts of the menopause. OLD AGE Bichat, writing in 1800, said: "The man who has reached the end of a long career dies in detail; his visible functions end one after the other. " Woman apparently grows old faster than man and the exact reason can not be found. Women of tropical climes reach senility sooner than those of northern latitudes, just as the exuberance of vegetation in the torrid zones, after a season of forcing, comes to a climax and dies earlier than in the slower growth of the temperate regions. Hereditary predisposition of the individual to prolonged life, or to the longevity of certain functions of body or mind, must be considered in making a diagnosis and a prognosis in the case of any disease of advanced life. The menopause represents a phase of life which is introductory to old age. It is not, however, a part of old age, and, as has been said already in treating that period of life, is not to be credited with all the atrophic changes in the organs of the body which occur with advancing years. A good deal is said in the literature of the "post- climacteric phenomena." At the beginning of this chapter we OLD AGE 623 adopted the age of sixty years as an arbitrary point for the be- ginning of old age, and although some of the post-climacteric changes in the organs of the body must in single instances antedate this age, still this mark is as good as any other for our purpose. This is not the place for a discussion of the alterations which take place, as a result of age, in the tissues and in the function of the heart and blood-vessels, the spleen, the thyroid and the supra- renal capsules, the nervous system, the digestive canal, the kidneys, the liver, the lungs, the skin, and the general nutrition. For an able exposition of these important considerations the reader is referred to Professor G. Rauzier's "Traite des Maladies des Vieillards," (Paris, 1909). Here it will be sufficient to call attention briefly to alterations in the structure and function of the genito-urinary system in old age. The senile changes in the breasts have been referred to in Chapter XXVII, page 531. The Ovaries. — The ovaries are withered and have a cicatricial aspect, and finally shrivel to little knobs of connective tissue containing a few cysts in the outer portions where formerly was the cortical zone. Ovarian tumors not infrequently develop in old age and cases have been reported by many observers where cystomata developed after the age of sixty, notably those re- ported by Johnson x who operated on a woman sixty-four years old, Davis 2 at the age of sixty-five, Spencer Wells 3 and J. Boeckel 4 at seventy-three, Josephson 5 at seventy-six, F. Terrier 6 at sev- enty-seven, E. M. Owen 7 at eighty, and John Homans 8 at eighty- two years, four months. The last author (Three hundred and eighty-four laparotomies, 1887) in the course of two hundred and eighty-two ovariotomies, removed ovarian tumors from one woman aged seventy-two and three aged seventy-three years. The Fallopian Tubes. — The Fallopian tubes are deprived of their lining epithelium, they shrink in all their dimensions, finally the lumen is obliterated, and they become mere cords of connective 1 Virginia Med. Monthly, 1888, Vol. XV., p. 644. ■ 2Brit. Med. Journ., 1887, Vol. II., p. 1050. 3 "Tumours of the Ovary," 1888. 4Gaz. Med. de Strasbourg, 1896, p. 26. 5 Centralblatt fur Gyn., 1889, No. 47, p. 824. 6Progres Med., 1888, No. 24, p. 466. 7 Brit. Med. Journ., 1888, Vol. IX., p. 38. 8 N. Y. Med. Rec, May 5, 1888, p. 496. 624 THE MENOPAUSE AND OLD AGE tissue. Diseases of the tubes are extremely rare in old age. Chron- ically inflamed tubes necessarily can not undergo the retrograde changes as readily as healthy tubes. But, as a matter of clinical observation, diseased tubes generally cause symptoms during the childbearing period of life, exceptionally during the menopause, and almost never in old age. The Uterus. — The uterus becomes lessened both in volume and in weight as a result of retrograde changes in its structure and only when chronic metritis during menstrual life has converted the muscular structure of the organ into connective tissue and elastic tissue is its volume greater than normal. Aran found that after seventy years the uterus diminished in length from 2| inches (68 millimeters) to 2 J- inches (57 millimeters) and in thickness from 1-J--J- inches (43 millimeters) to 1t9-q inches (40 millimeters). According to his observation the weight of the organ diminished in the case of the virgin uterus from 45 grammes to 35 grammes, and in the case of the parous uterus from 70 grammes to 60 grammes. Ordinarily this amount of diminution' both in dimensions and in weight is rather below the normal, and other observers, notably Arnal (Weinberg and Arnal, Mem. Soc. Anatom., May, 1905), who found a senile uterus which weighed 11.5 grammes, have reported finding a smaller organ after atrophic changes are well advanced. The walls of the uterus are diminished in thickness and the cavity is reduced in all its dimensions. The cervix generally, unless hin- dered by lacerations and thickenings, withers more than the body of the uterus. The internal os of the senile uterus is commonly found closed, probably because of the disproportionate atrophy of the cervix, the os being stenosed either by a thin diaphragm or by the formation of a ring of sclerotic tissue formed in this situation. Guy on (Thesis, Paris, 1858) found the os closed in thirteen out of twenty cases he observed, and Arnal (loc. cit.) found obliteration in sixteen cases and a partial stricture in five out of forty-one cases. Occasionally the external os is found closed also. If the cervical canal is closed the uterus generally contains a variable quantity of mucus. I have known of two cases, neither of them due to cancer, in which the uterine cavity was converted into an abscess cavity. As a rule the atrophic uterine mucosa of the senile uterus is covered with a thick, yellowish-white mucus. The mucous membrane is thinned and contains in its structure, often, hemorrhagic areas or OLD AGE 625 small cysts, and its surface is wrinkled so that the appearance of hypertrophy is given to it. Senile endometritis, which is sometimes present, has been de- scribed