_Diseases of the Genital Organs._
Among the commonest of the symptoms of the sexual epoch of the menopause
is menorrhagia. It occurs especially in plethoric women, in those who
during the prime of their sexual life have been accustomed to menstruate
abundantly, and in those who have given birth to many children or had
many miscarriages; but it is seen also in weakly and delicate
individuals, in whom the tissues of the genital organs have become
extremely flaccid and loose in texture. A luxurious mode of life, more
especially a free consumption of alcoholic beverages, and also frequent
sexual intercourse during the climacteric period, appear to favour the
occurrence of menorrhagia at this epoch.
Not infrequently, menorrhagia is the first sign of the commencement of
the climacteric, menstruation having been hitherto regular, and not
excessive in amount. Generally, when this climacteric menorrhagia
begins, the intervals also become shorter, the menstrual period being
reduced to three or even two weeks. At times, however, the more profuse
menstruation recurs at longer intervals, six weeks, two months, or even
longer. In any case, the occurrence at the climacteric age of a severe
or atypical haemorrhage, renders it the imperative duty of the physician
to undertake a local examination of the genital organs; for it is
necessary to ascertain without delay whether such a haemorrhage is a
true climacteric phenomenon, or whether it is due to some actual disease
of the reproductive organs—a neoplasm, or the like.
If the haemorrhage is due solely to the change of life, the vaginal
portion of the cervix will usually be found soft and flaccid, bleeding
readily on slight injury, and sometimes eroded; there is generally
associated leucorrhoea. This relaxation and loss of firmness in the
uterine tissues at the time of the menopause is the cause of the
predisposition to excessive haemorrhage. An additional cause exists in
the circulatory disturbances in the pelvic organs. We presume that women
affected with menorrhagia at this time of life suffer from some
persistent disturbance in the region of the inferior vena cava, whereby
the outflow of blood from the veins of the pelvis is hindered, and a
chronic condition of stasis in the uterus is conditioned. Hence arises
distension of the vessels of the uterine mucous membrane, and this
rhexis is relieved by the excessive haemorrhages. In these
considerations lies the explanation of the fact that women who have had
many children or many miscarriages, are especially prone to suffer from
climacteric menorrhagia; and also women who for any reason are
predisposed to intra-abdominal stasis.
Another cause of climacteric menorrhagia is to be found in the frequent
occurrence at this epoch of advanced arteriosclerotic changes in the
uterine blood vessels, the disease being in some cases limited to the
uterine arteries, and in others part of a general arterial degeneration.
The blood may be derived from ruptured sclerotic capillaries of the
mucous membrane; but in other cases it exudes in consequence of passive
hyperaemia, without actual rupture of the bloodvessels. To such
haemorrhages from atheromatous vessels we must refer many of the attacks
of uterine haemorrhage that occur in elderly women, such as were
formerly, before their true nature was understood, commonly regarded as
instances of a very late return of menstruation. By careful examination
the exact source of the blood can often be detected in such cases.
According to _Theilhaber_, one cause of the haemorrhages occurring at
the climacteric is to be found in the atrophy of the uterine muscle
which takes place at this period of life. Except during pregnancy and
the puerperium, the uterus is usually in a state of moderate
contraction; during the height of the menstrual flux, however, the
uterus is relaxed. Then, as contraction of the muscle sets in, the
menstrual hyperaemia and consequent haemorrhage are gradually brought to
an end. When this contraction is insufficient, the hyperaemia and
swelling of the uterus are more enduring. In association with the
atrophy of the uterine muscle at the climacteric, there usually occurs a
notable diminution in the size of the uterine vessels, so that,
notwithstanding the diminished strength of the muscular contractions,
any excessive loss of blood is prevented. But if this diminution in the
calibre of the vessels fails to take place, the atony of the uterine
muscle leads to hyperaemia, to haemorrhage, and often, in addition, to
oedema of the organ, with elongation and thickening of its
walls—hyperplasia uteri preclimacterica.
Among diseases of the uterus which during the climacteric may give rise
to severe haemorrhage, and may lead to the mistaken opinion that
menstruation still continues, we must in the first place mention
carcinomatous disease of the cervix and of the body of the uterus; next
in importance come myoma and fibrous polypi; less frequent causes of
such haemorrhages are fungous endometritis, erosions, mucous polypi,
prolapse of the uterus, and ovarian cystoma.
The climacteric age gives rise to a predisposition, not only to
bleeding, but also to other pathological changes in the reproductive
organs. We can by no means endorse the opinion of _Currier_—one long ago
expressed also by _Brierre de Boismont_—that women during the sexual
epoch of the menopause are less disposed to diseases of all kinds, and
among them to diseases of the genital organs, than younger women, for
the reason that their tissues are endowed with less vitality, and are,
therefore, more resistent to all the causes of disease. On the contrary,
the number of pathological disorders liable to affect the reproductive
organs precisely at this period of life, is strikingly large. Among my
500 cases of women at the climacteric age, there were 440 who complained
of such symptoms, the diseases from which they suffered being, in order
of frequency:
Profuse haemorrhages in 286 cases
Chronic metritis in 79 cases
Leucorrhoea in 327 cases
Displacements of the uterus 117 cases
viz., prolapsus in 65 cases
anteflexion and retroflexion in 52 cases
Genital pruritus in 46 cases
Vaginismus in 12 cases
Carcinoma uteri in 3 cases
Myoma uteri in 5 cases
Tumor mammae in 8 cases
I need hardly point out that in many individuals more than one of these
diseases were present at the same time.
The most obvious feature of these statistics is the extraordinary
frequency of uterine haemorrhage and of leucorrhoea in climacteric
women. The former condition was present in more than half my cases; the
latter actually in three-fourths.
The same two pathological states were also those most frequently
recorded in _Tilt’s_ statistics. This author, in 446 women at the
climacteric, found the following diseases of the reproductive apparatus:
Haemorrhages in 138 cases
Leucorrhoea recurring at irregular intervals in 146 cases
Leucorrhoea recurring monthly in 12 cases
Remittent menstruation in 33 cases
Vaginitis in 4 cases
Follicular inflammation of the vulva in 10 cases
Inflammation of the labia in 4 cases
Ulceration of the cervix uteri in 9 cases
Prolapsus uteri in 5 cases
Uterine polypi in 4 cases
Fibrous tumours of the uterus in 4 cases
Cancer of the uterus in 4 cases
Chronic ovarian tumours in 3 cases
Irritation and swelling of the breasts in 14 cases
Lacteal or gelatinous secretion in breasts in 2 cases
Hard, non-malignant tumour of the breast in 2 cases
Chancre of the breast in 1 case
Frequent sedimentation in the urine in 49 cases
Difficult and painful micturition in 9 cases
Incontinence of urine in 4 cases
Haematuria in 2 cases
Perineal abscess in 2 cases
Chronic metritis and endometritis come under observation with
considerable frequency during the climacteric age, but as a rule these
diseases have originated during the period of sexual maturity, and in
exceptional instances only does the cessation of the menses appear to be
the etiological starting point of these disorders. In fact, this occurs
only when the menopause is premature, or when it is quite sudden in
onset, whether this be due to noxious influences or to constitutional
disorder. For the menstrual process quite normally gives rise to a
certain congestion of the genital organs; and should menstruation be
suddenly suppressed, the blood-stasis in the uterus becomes so extreme
that morbid tissue changes are very likely to ensue. And when chronic
metritis has occurred before, the congestion and stasis in the uterus at
the climacteric will usually suffice to light up the inflammatory
process afresh. This is the explanation of the fact that symptoms of
slight metritis make their appearance at the very beginning of the
climax, manifested by thickening of the corpus uteri and of the portio
vaginalis of the cervix, by swelling and softening of the mucous
membrane, and by abundant secretion. In those who, either after
full-term delivery or after abortion, have suffered formerly from
chronic metritis or endometritis, but who have been quite free from any
symptoms of these troubles for many years prior to the climacteric, it
often happens that the change of life is ushered in by symptoms of
congestion of the uterus with associated leucorrhoea. With the
completion of the menopause, however, the resulting involution of the
uterus exerts a favourable influence upon all such chronic inflammatory
processes in the genital organs; as the atrophy progresses, the periodic
attacks of congestion cease to recur. Thus it happens that women who for
years have suffered from haemorrhages, from inflammatory disorders of
the genital organs, and from various other troubles of a similar nature,
will, once the menopause is fully over, feel quite well up to an
advanced period of life—they seem as it were to begin life afresh.
According to _Bennet_, the characteristic signs of climacteric metritis
are that the inflammatory symptoms are less pronounced, that the pains
are less severe, that elongation of the cervix is less often seen, and
that fungous changes are less marked, than is the case in the chronic
metritis of younger women. On the contrary, the cervix appears smaller,
often somewhat lobulated, it is harder, granulations are numerous,
ulceration is rare, the enlargement of the uterine cavity is but slight.
_Bennet’s_ views are, however, opposed by _Scanzoni_, who maintains that
there is no notable difference between the chronic metritis of younger
women and the disease as it occurs in women at the climacteric.
In fact, the chronic metritis and endometritis of women during the
climacteric age, differs in no important respect from these diseases as
they are seen in women during their sexual prime. We merely note that
the enlargement of the uterus is less marked; but the thickening and
extreme hyperaemia of the mucous membrane are the same in both cases,
the secretion is increased in quantity, the vaginal portion of the
cervix is elongated, and usually displays erosions, excoriations, or
ulcers. The subjective troubles appear less pronounced than in the case
of the metritis of the menacme. The prognosis is as a rule a more
favourable one than in the earlier years of sexual life, for as soon as
the series of involuntary processes is completed, when the retrogressive
changes in the genital organs are at an end, when senile atrophy of the
uterus and the uterine annexa has set in, a cure of the troubles
formerly so obstinate and so enduring speedily takes place.
Quite recently, much has been written upon the subject of a peculiar
senile endometritis (_Patru_, _Skene_, _Mundé_, _Rüder_, _Sheldon_,
_Herman_, and others), and it has been described as “a peculiar form of
senile, haemorrhagic, leucocytal hyperplasia of the uterine mucous
membrane” (_Gottschalk_). According to _Maurange_ and _Lorain_ it occurs
in as many as 7.2% of elderly women. It is seen especially in women who
earlier in life have suffered from diseases of the genital organs, more
especially those who have previously suffered from endometritis; at
times a senile vulvitis or vaginitis is the cause of the disease.
Displacements of the uterus with kinking of its canal, whereby retention
of the secretion and its decomposition are induced, has been assigned as
an additional cause of the disorder, also prolapse of the uterus, and,
in isolated instances, necrotic fibromata. According to the degree to
which the atrophy of the tissues has proceeded, and according as the
mucous membrane is still partly retained or entirely destroyed, and
according to the extent to which the uterine vessels have been affected
with the sclerotic processes of old age, does the pathologico-anatomical
picture of senile endometritis vary. It may affect the body only of the
uterus, it may extend also to the cervix, the vagina, and even the
vulva; upwards it may pass to the uterine annexa and to the peritoneum.
The first and most important symptom of this senile endometritis is the
outflow, usually intermittent, rarely continuous, of a sero-purulent,
and sometimes sanguineous discharge, with a powerful foetid smell; there
are colicky pains, which pass off when the uterus has emptied itself;
often, also, there are atypical bleedings, which are not profuse. The
uterus is usually found to be larger than the atrophy general at the
patient’s age would have led us to expect, it is often retroflexed, the
cervix is thickened, the lips of the os uteri are usually everted and
raw. When persistent, this senile endometritis causes profound
constitutional disturbance, and is often difficult to differentiate from
carcinoma of the uterus.
Under the name of senile irritation of the uterus, _Maxwell_ has
described a disease occurring at the climacteric, characterized by an
enormously increased irritability of the uterus, with marked reflex
manifestations; in these cases also we may perhaps have to do with a
senile endometritis. The most pronounced symptom is a severe and
constant uterine pain, to which in the course of the disease are
superadded pains in the gastric and cardiac regions, the rectum, and the
spinal column; these pains lasted a long time, and their severity was
such that it became necessary in some cases to remove the uterus.
Hydrometra is a disease which makes its appearance principally late in
the climacteric period, when menstruation has already completely ceased,
and when the adhesions associated with the climacteric atrophy of the
uterus have led to atresia of the cervical canal. Among 74 cases of
hydrometra (from the material of the Pathologico-Anatomical Institute of
Prague, in the years 1868 to 1871) not one of the women was less than 40
years of age; the age distribution of the cases was in fact the
following:
Quinquennium 40 to 45 3 cases
Quinquennium 45 to 50 2 cases
Quinquennium 50 to 55 2 cases
Quinquennium 55 to 60 8 cases
Quinquennium 60 to 65 18 cases
Quinquennium 65 to 70 12 cases
Quinquennium 70 to 75 11 cases
Quinquennium 75 to 80 8 cases
Quinquennium 80 to 85 4 cases
Quinquennium 85 to 90 6 cases
In 40 of these cases, the occlusion was in the region of the os
internum, in 23 it was in the region of the os externum, in 9 cases the
whole length of the cervical canal was obliterated, and in 2 both the
internal and the external os were occluded, the intervening portion of
the cervical canal being still patent. In the two latter cases, there
was hydrometra bicamerata, with retroflexion of the uterus.
Late in the climacteric period, haematometra also occurs, though less
often than hydrometra. When, in cases in which the os uteri externum is
occluded, in consequence of adhesion between the vaginal walls and the
vaginal portion of the cervix, as a sequel of the vaginitis ulcerosa
adhesiva of elderly women, there is haemorrhage from the atheromatous
vessels of the uterus or the tubes, the blood necessarily distends the
uterine cavity.
During the climacteric period, leucorrhoea is so extraordinarily
frequent, as the figures previously given show, that the assumption is
justified that with the diminution or cessation of the menstrual flow,
this hypersecretion from the genital mucous membranes forms as it were a
kind of vicarious flux. Sometimes, as in 12 cases recorded by _Tilt_, we
actually have a periodic “menstrual leucorrhoea”; in one of these cases
the discharge recurred at regular monthly intervals for 12 months, in
another for 18 months, in several for 2 years, and in one for as long as
7 years. It is only by careful examination that the exact source of the
discharge can be determined, for during the climacteric also, as well as
earlier in life, leucorrhoea may be due either to endometritis or to
colpitis. A muco-serous or sanguino-serous secretion may also be due to
slight vulvitis.
A peculiar form of inflammation occurring after the completion of the
menopause, and after the atrophic process in the vagina is considerably
advanced, is known as colpitis senilis. In this disease, ulceration
readily occurs, followed by cicatricial adhesion between the anterior
and posterior walls of the vagina (vaginitis adhaesiva vetularum); in
other cases herpetiform eruptions arise, with a tendency to pustule
formation; occlusion of the vagina may lead to hydrometra and pyometra;
sometimes the obliteration of the vagina is complete, so that there is
neither outlet for blood from the uterus, nor inlet for the penis during
coitus. This vaginitis adhaesiva vetularum is by no means rare in the
climacteric period; as a rule it does not give rise to very serious
trouble, the most prominent symptom being usually somewhat persistent
haemorrhage, unaccompanied by any evil odour. On local examination, the
characteristic strings of scar tissue are felt, passing from the portio
vaginalis to the narrowed, senile vaginal fornix; from the cervical
canal there exudes a usually somewhat vitreous mucus, mixed with blood.
The cervix itself is thin and atrophied, the uterus also is greatly
diminished in size.
The frequency at the time of the menopause of such catarrhal
inflammatory processes in the vagina and vulva is said by _Duprès_ to
depend on the weakness or paresis of the bladder which is so common in
women at this time of life. Owing to the incomplete evacuation of the
urine, cystitis very readily ensues; the urine is evacuated
involuntarily during sleep, and some of this fluid passes through the
vaginal orifice, giving rise all the more readily to colpitis, because
the secretion of the atrophic mucous membrane no longer possesses the
normal acid bactericidal properties. According to _Scott_, vulvitis may
also arise as a sequel of calculus-formation in the glands of Bartholin,
a frequent occurrence in elderly life, followed by inflammation and
abscess-formation in these glands. Among the diseases of the genital
organs at the climacteric period, _Fritsch_ also enumerates urethral
caruncle and carcinoma of the clitoris.
_Displacements of the Uterus._—Among the commonest of the displacements
of the uterus occurring during and after the menopause, is prolapse of
the organ. Previously existing descent of the uterus is apt to be
greatly aggravated at the climacteric, a partial prolapse, for instance,
becoming complete; or prolapse of the uterus may first set in at this
period of life.
There are several contributory causes of the liability to prolapse at
this particular epoch, especially in women who have had a great many
children, and in those with either enlargement of the uterus or with
lacerated perineum; the most powerful of these causes being the
weakening of the uterine supports in consequence of the general
relaxation of the pelvic tissues. At the menopause, the connective
tissue by means of which the uterus is attached to surrounding
structures, withers; simultaneously the vagina atrophies, and this
source of support is weakened; the whole pelvic floor loses its firmness
and power of support. For these reasons, a uterus which has hitherto
been in correct position readily becomes retroverted and to some extent
prolapsed; whilst one that was already thus far displaced prior to the
menopause, will now be apt to descend still further till it rests upon
the perineum. With the disappearance from the vulva and the perineum of
the adipose tissue on which their firmness so largely depends, complete
prolapse of the uterus is now likely to ensue. Prolapse of the urethra
may also result from senile involution of the pelvic contents.
Among my 500 cases of women at the climacteric, there were 65 instances
of more or less severe prolapse of the uterus. The frequency of prolapse
in women at the climacteric and in those at a more advanced age, is
shown by the following figures, which are compiled from the post mortem
statistics of the Pathologico-Anatomical Institute of Prague (years 1868
to 1871). Prolapse of the uterus was found:
In the quinquennium 30 to 35 in 2 women
In the quinquennium 35 to 40 in 2 women
In the quinquennium 40 to 45 in 6 women
In the quinquennium 45 to 50 in 3 women
In the quinquennium 50 to 55 in 6 women
In the quinquennium 55 to 60 in 8 women
In the quinquennium 60 to 65 in 6 women
In the quinquennium 65 to 70 in 4 women
In the quinquennium 70 to 75 in 4 women
In the quinquennium 75 to 80 in 4 women
In the quinquennium 80 to 85 in 2 women
Flexions and versions of the uterus, common as they are at the time of
the menopause, have no longer the same importance that they possessed
during the prime of the sexual life. For on the one part the size of the
uterus is greatly diminished, in consequence of the lessened
blood-supply and of senile involution of the organ; and on the other,
after the cessation of menstruation, the profuse haemorrhages and severe
colicky pains which for the most part occurred during menstruation in
these cases of kinking of the uterine canal, and which gave rise to such
severe general disturbance, now no longer occur. Herein lies the
explanation of the fact, well known to all experienced practitioners,
that women who have for many years suffered from retroflexion or
retroversion of the uterus associated with severe and painful symptoms,
cease to suffer after the menopause is established, and regain excellent
health, although the local condition of the uterus remains unrelieved.
_Neoplasmata of the Uterus and of the Uterine Annexa._—The most serious
danger to the life of a woman during the climacteric period is to be
found in the strong tendency to the occurrence of carcinomatous disease
of the uterus—a predisposition so marked that not less than one-half of
all illnesses affecting the reproductive organs of women at this age are
cases of carcinoma of the uterus. The disease occurs especially at the
beginning of the climacteric, between the ages of 45 and 50 years, most
often in the form of carcinoma of the portio vaginalis, whereas after
the completion of the menopause, carcinoma of the body of the uterus is
the preponderant form. The true reason for the frequency of the
occurrence of carcinoma at this period of life will only become clear to
us when we are more fully acquainted with the nature and origin of this
form of malignant disease. Meanwhile, it would seem that the
predisposition to cancer during and shortly after the menopause depends
upon the anatomical changes in the reproductive organs at the time of
involution, which render these organs a more suitable soil for the
proliferation of malignant growths; and further it is probable that the
loss of the acid, bactericidal quality of the vaginal secretion, opens
the door for the entrance of pathogenic micro-organisms. Noteworthy is
the observation of _Baer_ and _Leopold_, that very frequently a
preclimacteric or climacteric fungous endometritis forms the stage of
transition to the development of carcinoma of the body of the uterus. At
the time of the menopause there is also an increased liability to the
occurrence of cancer of the ovaries. Numerous statistical data have been
published regarding the frequency with which carcinoma of the uterus
occurs at various periods in women’s lives, and, notwithstanding all
variations, one fact stands out clearly, namely, that this disease
occurs most frequently in the fourth and fifth decennia, and above all
during the climacteric period.
From _Gusserow’s_ collection of 526 cases, observed by _Lebert_,
_Kiwisch_, _Chiari_, _Scanzoni_, and _Saexinger_, the following table
has been drawn up, and it shows very clearly the great preponderance of
the disease in the fifth decennium of a woman’s life:
At ages of from 20 to 30 there were 12 cases
At ages of from 30 to 40 there were 161 cases
At ages of from 40 to 50 there were 217 castes
At ages of from 50 to 60 there were 102 cases
At ages of from 60 to 70 there were 38 cases
At ages of from 70 and upwards there were 5 cases
From the mortality statistics we obtain a similar result as regards the
age incidence of carcinoma of the uterus. Thus, in England there died of
this disease in one year:
Women at ages of from 15 to 25 44
Women at ages of from 25 to 35 184
Women at ages of from 35 to 45 717
Women at ages of from 45 to 55 1110
Women at ages of from 55 to 65 1116
Women at ages of from 65 to 75 876
Coming now to the consideration of fibromyomata of the uterus, we cannot
share the opinion that at the climacteric age there is a special
predisposition to the origination of such tumours, or that the climax
favours the growth of already existing fibromyomata. It appears to us
that in the preclimacteric epoch and the commencement of the
climacteric, the symptoms of existing fibromyomata become more
troublesome, the haemorrhages are more severe, the pains more violent;
but that as the menopause is established, these troublesome symptoms
decline progressively in intensity, and not only is there an arrest in
the growth of the tumours, but often an actual diminution in their size.
I have myself repeatedly observed such cases, in which I had the
opportunity of watching the growth of the myomata during a period of ten
years or more. Other cases, indeed, show that myomata may increase in
size after the menopause, at times with remarkable rapidity, and further
that at this period of life a malignant degeneration may occur in such
tumours. Carcinomatous, sarcomatous, and myxomatous degeneration have
been observed, and also the transformation of a myoma into a soft
fibrocystic tumour.
Atrophy of fibromyomatous tumours at the menopause, associated with the
atrophy of the uterus that then occurs, has been observed by _Playfair_
and by _Doran_. The tumour shrinks, its muscle-cells become smaller, and
undergo fatty degeneration, there is an increase in the interstitial
connective tissue, so that ultimately the fibromyoma is transformed into
a firm and dense fibroid swelling. Cases in the older literature and
also a recent observation of _Yamagiron_ have shown that calcification
of uterine fibromyomata sometimes occurs, leading to the formation of
the so-called “uterine calculi.” In the case of pure myomata, the
diminution in size occurring at the climacteric is generally due to
resorption and fatty degeneration, whereas in the case of fibromyoma it
depends on induration and atrophy. It remains uncertain whether the
growth of purely fibrous tumours is also affected by the climacteric.
Whilst the influence of the climacteric on the growth of fibromyomata is
thus usually advantageous to the patient, exceptions occur, as is shown
by cases recorded by _Lawson Tait_, _Schorler_, and _Boerner_; the
last-named author points out that at the climacteric there is a tendency
for the transformation of fibromyomata into sarcomata.
_Kleinwächter_ had under observation 78 cases of fibromyomata of the
uterus in women who were older than 45 years; in only 8 of these was a
diminution in the size of the tumour observed at the menopause; in 11
cases at this time, the tumour increased in size more or less rapidly;
in 3 cases, a carcinomatous change occurred in the tumour; in 3 cases,
the tumour was first observed at the time of the menopause; in 13 cases,
the haemorrhages appeared to undergo a complete arrest at the menopause,
but the size of the tumour was not affected; in the remaining 48 cases,
no influence, either favourable or unfavourable, appeared to be
exercised by the menopause on the fibromyoma of the uterus.
Cases reported by _Rogival_, _Simpson_, and _Gusserow_ indicate the
existence of a certain predisposition to the growth of sarcomata of the
uterus at the climacteric period. _Gusserow_ more particularly insists
on the fact that we must bear in mind the likelihood of the origination
of a fibrosarcoma or of the sarcomatous transformation of a fibromyoma,
in all cases in which a fibrous tumour of the uterus first attracts
attention at the climacteric period; or in which a tumour hitherto small
and inconspicuous and giving little or no trouble, begins at this time
to increase in size or to give rise to troublesome symptoms.
_Neuroses of the Reproductive Organs._—One of the commonest neuroses of
the reproductive organs at the climacteric period is pruritus vaginae et
vulvae, and it is one of the most distressing symptoms of which women of
this age complain. The disorder depends upon a hyperaesthesia of the
sensory nerves of the vagina and the external organs of generation. It
is characterized by enduring sensations of itching and burning, which
may be either periodic (and then usually nocturnal) or continuous; at
times it becomes so severe that the women thus affected have an
unceasing desire to scratch, avoid all society, and ultimately find life
quite unbearable. In the slighter degrees of pruritus, no objective
changes are to be observed in the genital organs, or at most some slight
hyperaemia of the vaginal orifice. In the more severe forms, however,
there are local nutritive changes: the labia are swollen, their surface
has an erythematous blush, a number of the hair-follicles are enlarged
and prominent; the vaginal orifice is abnormally sensitive, it is
scarlet or livid-red in colour and here and there denuded of epithelium,
and there are scattered mucous follicles distended with a serous or
purulent fluid; these small vessels are to be seen chiefly on the inner
surfaces of the labia minora and around the clitoris. At the same time,
the vulva secretes an acid, burning fluid, which greatly increases the
patent’s sufferings, and at times impels her irresistibly to the
practice of masturbation. In cases of long standing, we find
hypertrophy, elongation, and deformity of the nymphæ, and pigmentation
of these organs, with the formation of varices.
According to _Fritsch_, in exceptional cases pollutions are the
originating cause of the pruritus, and this may be the case in women who
are not sexually passionate. It occurs, indeed, especially in matrons
who have not had sexual intercourse for years, and who have quite ceased
to think about sexual matters; during the night, such a woman will begin
to have voluptuous dreams, associated with a degree of sexual
stimulation which is described as being actually painful. The woman
often suffers greatly from these lascivious sensations. She complains
that she cannot understand how it is that she has become affected with
such utterly undesired feelings. She becomes profoundly depressed.
Coitus often gives no relief whatever; but many women thus affected
declare, as _Fritsch_ points out, that by powerful, almost involuntary
scratching, the stimulus is speedily subdued, and that for this reason
they are absolutely compelled to scratch. It will readily be understood,
that in this way persistent pruritus will arise, with local effects of
scratching, and vulval eczema. According to the same author, in some
instances pruritus is due to great insufficiency of secretion, such as
occurs in the endometritis atrophicans which he was the first to
describe. This scanty secretion, as it passes over the external genital
organs, gives rise to irritation and itching. Haemorrhoids also play a
part in the etiology of pruritus.
_Diseases of the Mammae._—The sympathy which in the earlier phases of
the sexual life—during the menarche, during pregnancy, and during the
puerperium—so obviously exists between the breasts and the uterus, is
seen also during the climacteric period. It now finds expression chiefly
in the marked tendency to new growths in the mammae, a matter to which
attention was already drawn by _Galen_. The commonest of these
neoplasmata is carcinoma mammae, a disease which occurs chiefly during
the climacteric epoch. In the great majority of cases, cancer of the
breast is a primary disorder; in exceptional cases, however, the
carcinoma of the breast arises by metastasis from a cancer of the uterus
or the ovary. Sometimes the breast tumour is preceded by Paget’s disease
of the nipple. For several years the patient suffers from what appears
to be a chronic dermatitis of the nipple, the areola mammae, and the
surrounding skin; but ultimately, and hardly ever before the
commencement of the menopause, carcinoma of the breast ensues.
The older statistical enquiries of _Birkett_, _Lebert_, _Scanzoni_, and
_Velpeau_, showed that carcinoma mammae most commonly occurred between
the ages of 40 and 50 years, and next to that in frequency between the
ages of 50 and 60 years.
A general hypertrophy of the mammary gland, affecting not only the
enveloping and intra-lobular adipose and connective tissue, but also the
proper glandular substance, is very rarely observed during the
climacteric period; but in the preclimacteric epoch and in the early
part of the climacteric, we not uncommonly see a hyperplasia of the
adipose tissue of the breast, either as a local manifestation of a
developing general obesity, lipomatosis universalis, or as a purely
local excessive deposit of fat. In such circumstances, the mammae may at
times be transformed into monstrous tumours.
_Diseases of the Organs of Circulation._
Among the cardiac disorders of the menopause, the earliest and the
commonest is, in my own experience, the following. At the time of the
menopause, exceptionally not till after the complete cessation of
menstruation, but usually at the commencement of this period of life,
some time, that is to say, between the age of 40 and 50, either when
menstruation has become irregular, the intermenstrual interval having
become longer or shorter than has hitherto been the case, or when the
discharge has become abnormal in character, a woman who has not before
suffered from any kind of cardiac disorder, will begin to complain of
paroxysms of palpitation.
In some cases the attacks of palpitation occur in the absence of any
discoverable exciting cause; in others, some trifling stimulus gives
rise to them. They may arise when the patient is in any position,
walking, standing, sitting, or recumbent; sometimes even during sleep.
The subjective sensation aroused by the increased force and frequency of
the cardiac action is described as extremely distressing; it is
associated with a feeling of anxiety (Angst), with a sense of pressure
in the chest, with forcible pulsation of the carotids and of the
abdominal aorta; frequently also with a feeling of a rush of blood to
the head, with fugitive heats, and severe headache; sometimes towards
the end of the attack there is a sense of flickering before the eyes (as
of muscae volitantes), tinnitus aurium, dizziness, and in rare cases
actual syncope.
Objectively, during the paroxysm, a notable increase in the frequency of
the heart’s action can be detected, the pulse-rate rising to 120 or even
150 per minute. In most of my cases, the pulse throughout the attack
remained strong, well-filled, and regular. Sphygmographic tracings taken
during the seizures showed a remarkably high pulse-wave, the ascending
limb of the curve rose rapidly and suddenly, the descending limb fell
with corresponding steepness and rapidity, and it reached an unusually
low level before the commencement of the dicrotic elevation, which
latter was exceptionally large; the predicrotic elevations, on the other
hand, were but slightly developed. On auscultation, the tones of the
heart were pure, but were louder than normal.
Sometimes during a paroxysm a sudden reddening of the face was
noticeable, extending often to the neck and the thorax. In the areas
mentioned, vivid red patches would suddenly make their appearance,
disappearing more gradually after lasting a few minutes—this appearance
was associated with a burning sensation of the affected areas. In some
cases during the paroxysm there was an outbreak of perspiration on the
head and the back.
Associated with these cardiac troubles of women at the climacteric we
usually find a state of physical and mental disquiet; less common
associations are, an incapacity for regular work, sleep uneasy and much
disturbed by dreams, great general nervous irritability, or signs of
passive congestion in various organs; occasionally there is oedema of
the lower extremities; the urine remains free from albumen.
In most of the cases of this nature which came under my own observation,
a certain plethora was noticeable; among women at the menopause, it was
especially the well-nourished, powerful, sanguine individuals, that were
liable to palpitation of the heart. Direct examination of the blood
sometimes showed a very high haemoglobin richness—110, 115, or even 120,
as compared with a haemoglobin-richness of 93 in normal woman. Several
of my patients presented the clinical picture of the plethoric form of
lipomatosis universalis.
In all, during ten years, I observed 67 cases of paroxysmal tachycardia
in climacteric women. The age distribution was the following:
36 years of age 1 woman
38 years of age 1 woman
39 years of age 2 women
40 to 45 years of age 37 women
45 to 50 years of age 28 women
Over 50 years of age 8 women
Five of the patients were unmarried, three were married but childless,
the remaining 59 were parous women.
As a general rule, women live in great dread of all manifestations of
bodily disorder during the menopause; those who become affected with
paroxysmal tachycardia are exceptionally anxious, and regard themselves
as threatened by a “stroke.” This pessimistic view is however, by no
means justified. These cardiac disorders may make their appearance some
time before the menopause, they may persist throughout the period during
which menstruation is irregular, they may even endure for some time
after the total cessation of the flow—but serious consequences of this
climacteric tachycardia have never come under my observation. As regards
treatment of the disorder, I have seen very favourable results from the
following measures: The systematic employment of mild purgatives,
combined with suitable dietetic and hygienic regulations (bland diet,
regular and strenuous exercise, cold ablutions, and wet compresses
surrounding the abdomen).
When we enquire regarding the cause of the tachycardiac paroxysms
occurring at the menopause, we must first of all bear in mind that in
the cases which have come under my own observation, the cardiac impulse
was powerful, the pulse strong and well-filled, that signs of general
vasomotor disturbance (ardor fugax, etc.) accompanied the tachycardiac
seizures,—hence we are led to infer that we have to do with a
stimulation of the excito-motor nerve fibres, which would appear to be
due to the climacteric changes previously described as occurring in the
female reproductive organs. This view receives support from the fact
that after oöphorectomy, when, as in the normal climacteric, atrophic
processes occur in the internal reproductive organs, paroxysms of
nervous palpitation are frequently observed. The same explanation
applies to the fact that in women at the climacteric affected with these
tachycardiac troubles, we frequently see in association therewith the
symptoms of uterine dyspepsia.
But in addition to these local anatomical changes in the reproductive
organs, to which an etiological role must be assigned in the production
of climacteric tachycardia, the irritable state of the accelerator
nerves must also depend in part upon that general nervous
hyperexcitability which is so often a characteristic feature of the
climacteric period in women, manifesting itself in manifold
hyperaesthesias, hyperkinesias, neuralgias, and, in extreme cases,
mental aberration. The sensory nerves are more irritable than in their
normal state, so that every stimulus acting upon them evokes a greater
central effect than heretofore, and upon this ensues an exaggeration of
various reflex manifestations, which appear altogether disproportionate
to the strength of the exciting cause; among these disproportionate
reflex effects, is to be numbered the tachycardia just described.
But in addition to the causes of climacteric tachycardia already
enumerated, we have to take into consideration the results of recent
investigations concerning the organo-therapeutic employment of the
chemical constituents of the ovarian tissue; it would seem that when at
the menopause the ovaries undergo atrophy, so that their internal
secretion is no longer poured into the blood, the resulting alteration
in the chemical constitution of that fluid gives rise to a disturbance
of the vasomotor centre in the medulla oblongata.
In some cases, the tachycardiac paroxysms appear to be connected with
the erotic excitement to which women are sometimes subject at the
climacteric, voluptuous crises and ejaculation occurring; it is possible
that in some of these cases masturbation plays a part.
A second group of cardiac troubles occurring in climacteric women
consists of cases which are very common, but not often very severe. The
cases in question depend upon the liability to an increased deposit of
adipose tissue in the body at the time of the menopause, and in this
connexion the plethoric form of lipomatosis universalis almost
invariably predominates. It is a well-known fact that between the ages
of 40 and 50 years women have an excessive tendency to obesity, and that
even those women who have hitherto been extremely lean are apt to become
quite plump at the climacteric period. Chiefly in consequence of this
increasing obesity, there occurs in climacteric women a series of
cardiac troubles of very variable intensity. If the deposit of fat is
effected very gradually, and if the obesity does not become extreme, it
is only after vigorous bodily exercise, such as fast walking or going
upstairs, and after meals, that the patient is troubled with a little
shortness of breath and moderate palpitation; appetite, digestion, and
sleep remain usually unaffected in cases of this degree of severity.
Definite attacks of cardiac asthma, and well-marked signs of cardiac
insufficiency affecting the entire circulatory system, will very rarely
occur in such persons.
It is an interesting fact, that the troubles which arise from fatty
deposits around the heart are in general far less severe in climacteric
women than they are in obese men of corresponding age. This may be due
to the circumstance discovered by _W. Müller_, in the course of his
investigations on the proportions of the human heart, that in the
development of general obesity, the pericardial fat increases
proportionately to a greater extent in the male than in female. But in
my opinion the true explanation is to be found in the fact that
variations in the amount of fat in the body are normally far more
extensive in women than in men; at puberty, during pregnancy, and during
lactation, extensive though gradually effected changes in the amount of
adipose tissue in various parts of the body occur, so that experience
has rendered the organism ready to adapt itself to the further changes
that take place at the climacteric—above all, the heart has become
competent to meet very various demands upon its powers.
Only in women who from youth onwards have exhibited a marked tendency to
obesity, and in whom at the climacteric age such obesity has become
extreme, do the cardiac troubles attendant on the menopause become very
severe. In such persons, palpitation and shortness of breath occur on
slight exertion, and attacks of cardiac asthma are frequent. In
consequence of the diminished propulsive power of the heart, circulatory
difficulties make their appearance in the most widely divergent venous
areas; the forms most commonly met with are, varices in the veins of the
lower extremities, permanent dilatation of certain of the small
superficial veins of the skin, phlebectases of the rectal veins (i. e.
“piles”), and ultimately we see the well-known series of symptoms of
venous engorgement—oedema of the feet, passive congestion of the lungs,
albumen in the urine, etc.
When such cardiac troubles are present, the objective examination of the
heart shows in the early stage no gross abnormality; at most the
heart-tones seem somewhat weakened, with a moderate enlargement of the
area of percussion-dulness, whilst the impulse is displaced a little
outwards, and is weaker than normal. In some cases, however, a marked
dulness on percussion over the sternum indicates an extensive deposit of
fat in the mediastinal tissues. In the second stage of the fatty heart,
when the symptoms have become more severe, we find a considerable
enlargement of the area of cardiac dulness both in the vertical and the
horizontal extent; the cardiac impulse is diffused as well as feeble.
The sounds of the heart are usually pure but faint—in some cases they
remain loud and clear. Exceptionally, a short blowing murmur is heard
with the first sound; and sometimes this sound is reduplicated.
Whilst in the first stage the pulse is hardly abnormal, in the second
stage, very various changes occur; often it is subdicrotic or dicrotic
in character.
In the great majority of instances, in these cases of cardiac disorder
at the menopause, provided a suitable dietetic regimen is early adopted
and perseveringly carried out, we may give a hopeful prognosis.
A third, less common but far more serious form of cardiac disorder
occurring at the menopause, displays the well-known symptoms of cardiac
failure. Those thus affected are usually slightly built, delicate women,
who during the years of development suffered from chlorosis, who in
adult life were troubled with anæmic symptoms, and in whom the menopause
was ushered in by very severe losses of blood; sometimes, again, they
are women who throughout their sexual prime have been accustomed to
menstruate very abundantly, who have had numerous and severe deliveries,
or who have had frequent miscarriages—it is in those who have thus been
weakened by frequent and profuse haemorrhages, that the symptoms of
cardiac failure ensue at the climacteric period. The women thus affected
also frequently suffer from palpitation of the heart; the pulse is
abnormally frequent, small, low, and easily compressible, and sometimes
intermittent or arrhythmical. The heart’s action is weak and devoid of
energy. The heart-sounds are usually obscure, and sometimes a systolic
murmur is audible. The patients are short of breath and are subject to
attacks of cardiac asthma, not infrequently associated with angina
pectoris. In conjunction with these symptoms, we see signs of venous
congestion: sudden attacks of coldness in the hands and feet, often also
oedema of the feet; the urine at times contains albumen. The
haemoglobin-richness of the blood is always notably diminished. I need
not discuss in further detail the well-known symptoms of cardiac
insufficiency, and I need only insist that when these symptoms are met
with in women at the climacteric, it is of the greatest importance,
alike from the prognostic and from the therapeutic standpoint, to make a
careful examination of the reproductive organs, so as to determine the
exact source of the recurrent bleedings which usually constitute the
primary cause of the patient’s sufferings.
In several cases of this kind, I found that the haemorrhages were due to
a relaxation of the uterine tissues, and that this relaxation was itself
referable to intrapelvic circulatory disturbances, dependent upon
obstruction in the vena cava inferior, whereby the venous return from
the pelvis was rendered difficult, and an engorgement of the uterine
vessels was brought about.
In some instances of cardiac failure at the menopause, chronic
inflammation within the pelvis is to blame for the menorrhagia upon
which the cardiac failure depends. Often, again, the haemorrhages are
referable to vasomotor influences, such as are liable during the
menopause to affect various vascular areas. In other cases, the
recurrent bleeding is due to retroflexion of the uterus, to prolapse of
that organ, or to tumour, it may be myoma, polypus, or carcinoma.
Finally, during the menopause, more especially in women in whom
menstruation has continued up to or beyond the fiftieth year, or in
those who have given birth to a large number of children or have lived
lives of severe bodily exertion, cardiac troubles may arise dependent
upon arteriosclerosis of the great vessels. The signs of such changes in
the walls of the bloodvessels are clearly marked: the cardiac impulse is
heaving, the second sound of the heart is accentuated; the pulse is full
and large, usually giving a very powerful blow to the examining finger,
whilst its sphygmographic tracing exhibits characteristic signs in the
exceptional height and great distinctness of the first predicrotic
elevation. The subjective troubles are in these cases very severe;
dyspnoea and attacks of asthma or of vertigo are common, and sometimes
albumen may be found in the urine.
We may thus summarize the cardiac disorders met with at the menopause,
and more or less directly dependent upon the changes undergone by the
feminine organism at that period of life:
1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric
changes in the ovaries.
2. Nervous palpitation in women who were similarly affected at the time
of the menarche, and in whom the trouble is merely the expression of a
very unstable nervous system, and one influenced with especial readiness
by impressions proceeding from the reproductive organs.
3. Cardiac disorder due to the obesity so commonly occurring as a part
of the general metabolic changes of the menopause, but more particularly
dependent upon a deposit of fat in the neighbourhood of the heart
itself.
4. Symptoms of cardiac failure, due to excessive losses of blood at the
menopause, either as an exaggeration at this time of menstrual
processes, or as a result of some actual disease within the pelvis.
5. Cardiac disorder in women in whom the menopause occurs at an
unusually advanced age, and dependent upon arteriosclerosis.
Particular consideration must be given to a symptom not infrequently
occurring in association with the cardiac troubles of climacteric women,
and referable to the circulatory disturbances characteristic of this
period of life, namely, vertigo. The attack in some cases comes on
without apparent cause, in others it occurs on the performance of some
unusual movement or the adoption of some peculiar posture (stooping, or
the like); the patient is suddenly seized with a sense of rotation,
either of his own body, or else of his visible and palpable environment;
with this is associated a sensation of disturbance of equilibrium,
flickering before the eyes (muscae volitantes), tinnitus aurium,
palpitation of the heart, increased frequency of the pulse, which may be
either full or small, redness or pallor of the face, coldness of the
hands and feet, muscular twitchings, a sense of great anxiety, and the
outbreak of a cold perspiration. The vertigo occurs in paroxysms,
usually of short duration—a few minutes to a quarter of an hour. It is
especially plethoric and obese women who are liable at the climacteric
to suffer from this disorder.
A somewhat similar condition is described by _Tilt_ under the name of
“pseudo-narcotism,” as frequently occurring in climacteric women. _Tilt_
indeed states that in 500 such women, he noted its presence in no less
than 277.
Many hypotheses have been promulgated to account for the vertigo that so
frequently occurs at the menopause. Both anæmia and hyperaemia of the
brain have been assumed as causes, alike dependent upon the irregularity
of menstruation, which is supposed to have a reflex influence upon the
cerebral circulation. Others regard the vertigo as a climacteric
neurosis, since it occasionally occurs before the menstrual
irregularities begin, and in such cases a reflex disturbance of the
cerebral circulation cannot be supposed to have arisen. According to
_Matusch_, climacteric vertigo is a manifestation of epilepsy—an
explanation which has been often extended to include all the menstrual
psychoses. _Windscheid_ believes that in many of the cases the vertigo
is to be explained by the existence of arteriosclerotic changes in the
blood vessels, such as are already by no means rare at the age at which
the menopause usually occurs; whilst in other cases, he believes, the
vertigo is to be regarded as one of the symptoms of a nervous disorder.
That in any case the vertigo is dependent in some way upon the changes
that occur in the reproductive organs at the climacteric period, is
shown by the fact that after the final cessation of menstrual activity
the patient as a rule ceases to suffer from this symptom.
To the circulatory disturbances consequent upon the menopause we must
also refer ardor fugax, fugitive heat, the sudden rushes of blood to
which women are prone at this period of life.
The cardiac troubles of the menopause are seen especially in women in
whom the cessation of menstruation occurs quite suddenly, and in those
in whom menstrual activity ceases at an exceptionally early age. It
would seem that in such cases, owing to the continuance of periodic
maturation of the graafian follicles associated with congestion of the
intrapelvic organs, in the absence of the periodic relief to that
congestion afforded by the menstrual flux, there results a summation of
stimuli, whereby the accelerator nerves of the heart are very powerfully
affected.
Thus, I had under my care a lady from Smyrna 36 years of age. She had
begun to menstruate when 12 years of age and menstruation was always
scanty; she married when 15 years old, and finally ceased to menstruate
when 19 years of age; she was sterile, and no abnormality could be
detected on physical examination of her reproductive organs. Every month
she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of
blood to the head, perspiration of the face, etc.
In another case, that of a woman 45 years of age, menstruation, hitherto
regular, was suddenly suppressed, during the flow, in consequence of a
severe fright. The next month the flow failed to appear at the usual
time, but instead the patient was affected with severe cardiac distress,
accompanied by sudden sensations of heat in the face, palpitation of the
heart, and vertigo; these symptoms lasted for several days, and since
then have recurred at intervals of three or four weeks.
The cardiac troubles of the menopause are seen with especial frequency
in women who were affected with similar disturbances at the time of the
menarche. Experience clearly shows that a certain connexion exists
between the manifestations that accompany the commencement of sexual
activity, and those that accompany the decline and extinction of that
activity; and a physician will rarely be mistaken if he bases on the
fact that the general health was or was not seriously affected at the
age of puberty, a prognosis that the course of the climacteric will be
an unfavourable or a favourable one, respectively. In other words, in
women whose nervous system is an unstable one, and in those with
hereditary predisposition to the occurrence of cardiac disorder, the
changes that take place in the reproductive organs both during the
menarche and during the menopause, are likely during these vital phases
to arouse reflex disturbances of the cardiac functions. The facts thus
noted are analogous to those observed by _Potain_, who distinguishes a
peculiar form of chlorosis, occurring in delicate individuals at the age
of puberty, and, though apparently cured during the menacme, recurring
in its primitive severity at the time of the menopause.
Again, women with a sanguine and erethistic temperament are more
inclined to suffer from cardiac troubles at the menopause than women of
a tranquil temperament and those endowed with an unimpressionable
nervous system.
Finally, elderly virgins, women who have for many years lived in chaste
widowhood, sterile women, women who have married shortly before the
menopause, or who at this time have recently been delivered, are all
more inclined to the cardiac troubles of the climacteric period than
women whose sexual life has been of a less abnormal character.
In the literature of the subject, we find numerous references to the
fact that among the disorders of the climacteric, circulatory
disturbances play a part. But a full and accurate account of these
disorders is lacking alike in the literature of gynecology and in that
relating to diseases of the heart—and this is true even of the most
recent publications.
Among striking individual cases, one recorded by _Moon_ may be mentioned
here, a case of tachycardia consequent upon a sudden menopause: “In a
woman 35 years of age the menses were suppressed owing to chill; the
pulse-frequency increased from 80 to 200, without any apparent change in
the heart or its valves; the symptom lasted for several days, when
menstruation became once more established, and the pulse-frequency fell
again to the normal.”
_Tilt_ expresses the opinion that the heart is but little involved in
the disturbances of the climacteric, his experience coinciding with that
of _Quain_. _Boerner_ and _Glaevecke_, on the contrary, describe the
heart troubles of the climacteric in terms very similar to those
employed by myself.
_A. Clément_ describes a peculiar form of disturbance of the functions
of the heart at the climacteric period, to which he gives the name of
Cardiopathie de la Ménopause, and of which he has seen four cases. The
age of his patients varied from 46 to 50 years. They were all vigorous
women, free from hysterical symptoms, and they had never suffered from
rheumatism or from any functional disturbance of the heart. In all these
cases the cardiac disorder occurred at a time of life when menstruation
still continued, but had already become somewhat irregular. Usually the
trouble in question makes its first appearance during the flow, or, if
occurring independently of menstruation, becomes more severe at that
time. Prior to the development of the actual heart symptoms, we observe
for a time, two or three months it may be, signs of general exhaustion
and weakness. Then occurs an attack of palpitation of the heart, rapidly
succeeded by faintness, sense of precordial anxiety, and dyspnoea.
During repose the patient does not usually suffer from any difficulty in
breathing, but sleep is apt to be disturbed by paroxysms of palpitation
and severe precordial anxiety. As the disease advances, dyspnoea is
observed on the slightest exertion. Ultimately, the symptoms mentioned,
palpitation, precordial anxiety and dyspnoea, become permanent, but are
less severe when the patient is at rest. Constant now is also the
feeling of weakness and faintness, which from time to time increases to
actual syncope with complete loss of consciousness, and coldness of the
entire surface of the body. Examination of the heart gives negative
results. The cardiac impulse is a little stronger than normal; the
cardiac rhythm may be either regular or irregular, but actual
intermission of the beats does not occur. The heart-sounds are pure,
there is no murmur; the first sound, if altered at all, will be
stronger, not weaker than normal. Neither swelling of the jugular veins
nor venous pulsation is to be observed. The most striking symptom of
heart affection, indeed the only positive physical sign, is the great
increase in the frequency of the heart’s action, the pulse rate often
being as much as 150 or 160 per minute, and in addition weak and
somewhat variable in strength. At the outset of the disease, no oedema
of the lower extremities is to be observed, and it only appears after
three or four attacks. In all the patients the extreme pallor of the
face is a striking feature. An increased quantity of urine is
eliminated. The course of the disease is characterized by a series of
successive paroxysms, separated by periods of almost complete remission.
At first, these remissions last for a month or two, but they gradually
become shorter and shorter, whereas the duration of the attacks
continually increases, until it is as much as seven or eight days. At
this stage, disturbance of digestion ensues, the appetite is lost, and
the general vigour declines. Recovery ultimately occurs, but very
gradually. _Clément_ refers the disease to a profound disturbance of the
cardiac innervation through the sympathetic nerves, but believes that
anæmia constitutes a contributory cause of the cardiac disorder.
_Kostkewitsch_ has made observations regarding the influence of the
climacteric upon previously existing heart-disease, and has thereby been
led to conclude that the influence is unfavourable. The functional
disturbances of the cardio-vascular apparatus which commonly accompany
the menopause, readily lead, should organic heart-disease exist, to the
onset of severe cardiac weakness, which may have a rapidly fatal
termination. In 55.5% of the women who enter the climacteric period with
organic disease of the heart, the menopause gives rise to a failure of
compensation. Such failure of compensation is especially likely to occur
in women suffering from valvular insufficiency; it is least probable in
cases of arteriosclerosis without valvular defect. The symptoms of
defective compensation—dilatation of the heart, increased frequency of
the pulse, arrhythmia cordis, etc.—are manifested especially during the
menstrual flow.
_Diseases of the Digestive Organs._