Atrophy of the ovaries occurs very gradually. Peuch found that in one case the ovaries were of normal size three years after the establishment of the menopause. Kiwisch describes the structural change in this gland as consisting, on the one hand, of an increase of the connective-tissue stroma; and, on the other hand, the Graafian vesicles themselves undergo retrograde change. In consequence of these microscopic changes, which take place very slowly, the entire organ becomes harder and smaller.

Napier believes that the ovaries secrete specialized substances which aid in determining menstruation; and that in a less degree the utricular glands and the glands of the Fallopian tubes share in this action. He considers that this is probably secondary to the chain of peripheral irritation from the uterine glands, but that this secretion is none the less an essential feature of the menstrual process.

In support of this view he calls attention to the pigmentation of the skin which occurs during pregnancy and chlorosis, showing that the absence of the catamenia results in the retention in the blood of some substance which would normally be excreted at this time.

Other atrophic changes in the genitalia are shriveling of the v.u.l.v.a, with prolapse of the v.a.g.i.n.a or uterus from relaxation of the ligaments and loss of the natural support afforded by the changed perineal body.

Uterine catarrh occurs almost invariably, and only ceases in advanced years. Displacements of all kinds are frequent, but on account of the now greatly diminished weight of the uterus, these are insignificant.

The v.a.g.i.n.a is at first almost always hyperemic, but this disappears as the vessels successively atrophy. The v.a.g.i.n.a gradually becomes narrower and shorter. The mucous membrane loses its rugae and presents a pale, grayish, blanched hue.

The researches of Byron Robinson, made by the dissection of a number of old women, show that after the menopause not only is there an atrophy of the genital organs, but that the hypogastric plexus of the great sympathetic nervous system also shrinks away. "It becomes smaller and firmer, and no doubt some strands disappear. On this fact must he based the pathologic symptoms accompanying the cessation of the menstrual function."

The importance of the genital organs is shown by the vast nerve-supply sent to them. When this great nerve-tract becomes atrophic, so that it can no longer transmit the higher physiologic orders, all parts of the sympathetic system must be unbalanced, until a new line, the next line of least resistance is established. And Robinson believes that this is the explanation of the many pathologic manifestations of every viscus at the menopause; that is, "the irritation which arises by trying to pa.s.s more nervous impulses over plexuses than normal gives origin to what is unfortunately known as functional disease. It is just as organic as any disease, only we are unable to detect it."

Chemical changes in the blood and tissues are constant vital phenomena; increased oxidation causes increased activity of the circulation, increase of temperature, increase of urea and carbonic acid in the economy from retrograde changes, and, finally, during menstrual life the flow of blood from the uterus carried off the effete materials from the highly charged system.

The elimination of alb.u.minoids, as shown by the altered condition of the blood after menstruation, is greater than can be accounted for by the blood discharged. When the menopause is attained suddenly, the retention of such alb.u.minoid substances must act toxically. Hence the resulting clinical fact that sudden cessation of the menses is, in the majority of cases, attended with p.r.o.nounced symptoms of discomfort, and it is in these cases that untoward results are most likely.

James Oliver believes that the catamenial flow eliminates from the body substances whose presence in the blood would exert a deleterious influence on the animal economy.

The Prominent Symptoms of the Menopause.-- Christopher Martin holds that the symptoms of the change of life are produced largely by a condition of instability and increased excitability of certain other cerebrospinal centers directly brought about by failure of the menstrual center, and adds: "It is probable that the ovaries, like the liver and thyroid gland, modify the blood circulating through them, and add to the blood some peculiar product of their metabolism. It may be that some of the climacteric symptoms are due to the loss of this substance from the system."

Arthur Johnstone's theory of the symptoms of the menopause is that the lining membrane of the uterus atrophies and becomes old cicatricial tissue, and sinks into quiet decay. The nervous system begins to readjust itself; but no longer having free outlet through the soft, lymphoid tissues of the uterus, the wave pressure meets with resistance and a choppy sea results. Vertigos, bilious attacks, and so forth are nothing more than reflex waves. The weakest organ of the individual is the one that generally suffers. And that the kidneys, which all along have borne the brunt of life, should now show positive signs of disease is natural.

The etiology and pathology of the menopause lie in the sympathetic nervous system. And it is by the breaking up of the harmony of previous processes that nervous disturbances are produced.

After the cessation of the flow, over 8% of women suffer from "flashes"; this symptom is caused by irritation of the heart and vasomotor centers. The blood-vessels of the head and neck seem to be most affected, yet the skin of the whole body shares in the disturbance. Besides the vasomotor and heat center being disturbed, the sweat center is irritated. The flushes and flashes are followed by various degrees of sweating, which varies from a slight moisture to great drops.

Nervous irritability is a prominent symptom in 8% of women at the time of the menopause. Most of the pain arises around the stomach; that is, the solar plexus. Digestive disturbances are very common at this time; they may be in the shape of fermentation, diarrhea, or constipation, accompanied by congestion of the liver.

Tilt holds the very plausible view that the too strong reaction of the s.e.xual organs on the central ganglia of the sympathetic nervous system is their princ.i.p.al cause of disease. p.u.b.erty, menstruation, pregnancy, lactation, or the menopause almost always entail some derangement of this system which is sometimes sufficiently severe to lead to insanity and suicide. Debility underlies all affections of the sympathetic nervous system, in the same way as nervous irritability underlies all cerebral diseases. Sometimes there is an overpowering sense of exhaustion pervading the whole system.

Forms of climacteric insanity are delirium, mania, hypochondriasis, melancholia, irresponsible impulses, and the perversion of moral instincts.

"If the reproductive apparatus does not act on the brain by the instrumentality of the circulating organs of the blood, it must do so by means of the nerves. The genital apparatus is richly endowed with nerves from the sympathetic system, and I have shown how frequently evident signs of disturbance in these centers coincided or alternated with headaches, nervousness, hysteria, and epilepsy. What wonder, then, if the same powerful influence of the s.e.xual organs, through the instrumentality of the sympathetic system, should at times produce a permanent derangement of the mental and moral faculties. I am thus led to look on the sympathetic nervous center as a source of vital power producing reflex morbid phenomena, in accordance with variable cerebral predisposition" (Tilt).

Another very frequent symptom of the menopause is distress in the region of the heart, with palpitation and shortness of breath. It may be caused by the condition of the blood, whether it be impoverished-- anemia-- or too rich in red globules; by reflex irritation of the pneumogastric or sympathetic nerves; by overexertion; or by alcoholism. It may also be due to general debility; the woman resists fatigue less easily, and she experiences a general malaise. To the palpitations are rapidly added faintness and shortness of breath. The sleep is troubled with distress in the region of the heart. It is said that women in whom the menopause occurs early are more liable to tachycardia than those who menstruate later in life; and that it occurs with especial frequency when the menopause has been prematurely induced by surgical operation or by disease. It is believed that this functional heart trouble is caused by the increased connective-tissue fibers of the s.e.xual organs acting in some unknown way on the terminal fibers of the sympathetic; and it is not infrequently due to the formation of scar tissue at the seat of a cervical laceration, and has often been promptly and permanently relieved by removing the cicatricial tissue and suturing the wound. The cause acts by producing a transitory paralysis of the inhibitory fibers of the pneumogastric nerve.

Pathologic Conditions of the Menopause.-- Perhaps the most alarming symptom of the menopause is hemorrhage. It may be due to general or local causes. Among the general causes are diseases of the heart, lungs, spleen, and kidneys. Local causes of hemorrhage are: inflammation of the lining membrane of the uterus, chronic pelvic inflammations, faulty uterine positions, erosions and ulcerations of the mouth of the uterus, fibroid tumors, and cancer. All competent observers agree that cancer in women is much commoner from forty to fifty years than at any other age.

Hemorrhages occupy the foremost place among the pathologic phenomena of the genital tract during the menopause. Hemorrhage has been attributed in many instances to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure which is brought to bear on their walls; there is also softening and relaxation of the uterine tissue.

Additional causes are found in the circulatory disturbances in the pelvic organs, whereby the outflow of blood from the pelvic vessels is hindered a chronic congestion in the uterine vessels is produced. It has also been attributed to early and profuse menstruation, frequent and difficult labors, frequent abortions, and excess in drinking.

The third and last variety includes those cases which may be referred to some disease of the pelvic organs themselves. Anatomic changes may lead up to pathologic conditions. A chief feature characteristic of uterine disease is malnutrition from atrophy-- a sudden curtailing of the blood-supply from the degeneration of the genital-nerve apparatus and consequent impaired vitality of tissue from defective nourishment.

The anatomic changes in the glands and substance of the uterus also favor the irritation, and the development of new growths, which may be malignant or benign-- as cancers, fibroid growths, and so forth.

Hemorrhage at the Menopause a Significant Symptom of Cancer.-- Not only should any excessive and prolonged bleeding at the time of the menopause be a source of great anxiety to the woman, but even the irregular appearance of a slight show of blood just sufficient to keep the clothing stained, or a slight bleeding following coition; since all of these are symptoms of very great gravity, and demand an immediate local examination and appropriate treatment.

The widespread belief among the laity that hemorrhage at the time of the menopause is a normal condition, and that if left alone it will stop in the course of a few years, is most erroneous and fatal. On this altar of ignorance thousands of women sacrifice their lives every year. The case-book of any gynecologist will testify to the truth of this statement. The following three cases will serve to ill.u.s.trate different types of hemorrhage in cancer patients, in no one of which did the patient even suspect that she was suffering from anything more serious than the "vagaries of the menopause."

Case I.-- Woman aged seventy years; came on account of incontinence of urine, which had been troublesome for two years. The menopause occurred at fifty. She stated that three or four years previous to her visit, she had had a return of the flow of blood, perhaps twice in the first year, and that during the past year there had been a flow every month-- about the same that there used to be. This she took to be a return of the menstrual period. She said, further, that there was a constant bleeding-- enough to necessitate the wearing of a napkin-- and an occasional severe hemorrhage; that she could not take long walks or drives because of the excessive flow which followed.

The case was one of cancer of the uterus which had spread to all the pelvic viscera; and in addition to this, the patient's general condition was such that any operation was out of the question. Yet the patient had never thought of the possibility of any uterine trouble sufficiently serious to make a local examination necessary. It was only the loss of control over the bladder that drove her to seek a physician's advice.

Case II.-- Woman aged fifty-three years came to consult me because of pain, hemorrhage, and loss of weight. There had never been any cessation of the menstrual period. She said that she began to have irregular hemorrhages three years previously, and that they were constantly becoming more frequent and more alarming, and that, in addition to this, there was a constant discharge of blood, which necessitated her wearing a napkin all the time. She also stated that for the preceding six months the pain had been so severe that she had not had one solid night's sleep, and that in that time she had lost forty pounds in weight.

This patient was in the very last stages of cancer of the uterus, and all that could be done for her was to make her comfortable. She had given birth to one child which caused a deep tear of the neck of the womb; and it is probable that this neglected tear was the primary cause of the cancer, which began in the neck of the womb.

Case III.-- Woman aged forty-five years; married, but had never had any children. She said that the periods were normal as to duration and amount, but that for the past two years they had two days ahead of time, and that for the past four months she had been having just enough irregular bleeding between the periods to keep her clothing stained.

On examination a diagnosis of cancer of the uterus was made. The pathological examination proved this to be a most malignant type of cancer of the neck of the womb. The entire uterus and appendages were at once removed. And although the patient made an excellent recovery from the operation, she succ.u.mbed to the disease one year after the operation was performed.

These cases have been cited at length because they are all typical and because of the variety of symptoms and the great difference of age.

Only in one of the cases was there any very severe pain, and it was really the pain, which had become unendurable, which caused the patient to seek relief.

It is the concensus of opinion of the medical profession that cancer of the uterus is one of the common causes of death among women; that the cancer rate of mortality has increased during the last four decades; that it is most common near the time of the menopause; and that there is a direct causal relation between cancer of the neck of the womb and the traumatisms which occur during childbirth.

The symptoms of cancer of the uterus are hemorrhage, a more or less offensive discharge, and pain. The quant.i.ty of blood may vary from a slight amount which occasionally stains the clothing to a profuse hemorrhage. In the married, bleeding following coition is always a suggestive symptom. During the menopause any irregular or profuse bleeding should excite suspicion. After the cessation of the menopause any bleeding whatsoever, whether slight or profuse, should always be regarded as a danger signal which demands an immediate and thorough local examination. The same is true of any offensive v.a.g.i.n.al discharge. Pain is frequently so late a symptom that to wait for its appearance means that the favorable time to perform an operation has pa.s.sed by. Emaciation is also a symptom of advanced disease.

Cancer is chiefly a disease of the climacteric; when there is a diminished power on the part of the tissues to resist adverse influence. It affects the debilitated and overworked, but it is also found in the well nourished and in the comparatively young.

Cancer always begins as a local disease, and when it occurs in the uterus, it is easily accessible and eradicable in its earliest stages; that is, if the disease is discovered in its incipiency, an operation will remove all the diseased tissue. If, on the contrary, the disease is left to nature, the growth spreads out into the surrounding viscera like the roots of a tree in the earth, and the cancer may be literally said to eat into the tissues which it invades. At the same time the germs of the disease begin to be carried all through the body, and the entire const.i.tution is affected.

Prophylaxis, or the Prevention of Cancer.-- All pelvic inflammations should be promptly treated, and not allowed to become chronic.

Leucorrhea is a symptom of inflammation, the true cause of which can be determined only by local examination. Women who have given birth to children-- and this is more especially necessary as they near the age of forty years-- should be carefully examined for tears of the neck of the womb. If these tears are extensive they should be repaired, as it is certain that malignant growths frequently do follow local injuries and traumatisms.

Any irregular or profuse bleeding demands an immediate investigation by means of a local examination.

A stormy, irregular, or delayed menopause should excite in the woman a suspicion of some abnormal condition.

The importance of women being carefully watched by gynecologists at this period of their lives cannot be too emphatically stated, for upon the early recognition of cancer depends the only hope of radical cure of the disease. It is estimated that at the present time not less than 95 per cent. of all cases of cancer of the uterus come under the observation of the profession at a stage of the disease when all prospect of permanent relief is out of the question.

It is a deplorable state of affairs that women, not knowing what a normal climacteric is, attribute all hemorrhages, no matter how severe, to the change of life. Therefore, regarding the hemorrhage as a necessary evil, they fail to consult a specialist until the favorable time for eradicating the disease by means of an operation has pa.s.sed. And whatever knowledge science may bring in the future as to the cure of cancer, at present it is a fact universally agreed upon that early operation, while the cancer is still local, is the only radical cure for the disease.

Pruritus v.u.l.v.ae. Perhaps one of the most annoying and obstinate symptoms of the menopause is pruritus v.u.l.v.ae. This is sometimes caused by sugar in the urine; there is a congestion of the liver which results in sugar being thrown into the system and this is eliminated by the kidneys. It is quite possible that this is due to the altered circulatory conditions of the menopause.

Kidney Disease.-- The last pathologic condition which we will mention is kidney disease. Le Gendre believes that the menopause exerts a deleterious effect on the kidneys, whether this be a congestion, followed by a diminution in the quant.i.ty of urine, or a sort of auto-intoxication due to the retention of a poison in the system that has been prevented from leaving by the ordinary path.

Armstrong says that in almost all cases at the time of the menopause the amount of urine pa.s.sed is below normal, the specific gravity is increased, and that the urine contains urates and almost always uric acid in excess. Further, that the functions of digestion and a.s.similation and the various metabolic changes are so largely under the control of the nerve-centers that nothing seems more likely than that so great a disturbance of that system as takes place at the menopause should cause secondary derangements of these most important functions. That being so, the blood becomes loaded with waste products, and the usual symptoms follow-- gout and so forth.

It has been a grave question in the mind of the medical profession whether the dangers that certainly do attend the menopause are natural or acquired; that is, could these dangers be averted by any precautions or hygienic measures on the part of women, or are these dangers a necessary accompaniment of this period of life?

Tilt has reached the conclusion that: "The best way to avoid the dangers of this critical time is to meet its approach with a healthy const.i.tution. A marked want of strength prevents the regular succession of the vital phenomena by which all critical periods are carried on. And as the change of life is marked by debility, when this is grafted on const.i.tutional weakness, loss of power will be of long duration. All complaints remain chronic because there is not stamina enough to carry them through their stages."

Causes of Suffering at Menopause.-- Dusourd, whose practice lay in an agricultural district in the south of France, as well as Tilt, believes that peasant women suffer little at this time. Their health is generally good when the menopause comes on and they are little liable to nervous disorders. The poor of large towns suffer much at this epoch-- the necessity of working hard, the anxieties of poverty and their unhygienic surroundings. But by a fortunate compensation the necessity for working hard prevents or cures the nervous affections which so often a.s.sail the rich at this period.

Tilt's cases showed that women who suffered much at the menopause had previously suffered at p.u.b.erty and at the menstrual periods. And among thirty-nine cases where there was no suffering at the menopause, there was the same immunity from suffering at p.u.b.erty and at the menstrual epochs.