seemed to exercise a favorable influence on the course of the disease.
Upon this ground the induction of abortion or premature labor has been
seriously proposed. The operation, after an extended trial, has fallen
into deserved disrepute.
SYPHILIS.
Syphilis is a frequent complication of pregnancy. Sigmund[38] has
observed and described the characters of syphilis contracted at the
beginning or during the course of gestation. The duration of the stage
of incubation is abbreviated. Two weeks is the rule, six weeks the
exception. The initial lesions are characterized by an unusual degree
of intensity, occasionally involving the vulva, vagina, cervix, nates,
and inner surfaces of the thighs. The intensity of the initial lesions
is due to the anatomical relations of the genitalia in the pregnant
woman and the increased nutritive activity of the parts. The symptoms
are marked local reaction, reddening and excoriation of the skin and
mucous membrane, swelling, oedema, eczema, follicular abscesses, and
necrosis of the connective tissue. Induration is not a characteristic
of chancre situated about the genitalia of the pregnant woman.
Phagedenic ulceration sometimes attacks the chancre, and then the case
may be mistaken for one of phagedenic chancroid. The secondary symptoms
are unusually mild. Condylomata appear about the genitalia, and
psoriasis is noticeable on the palms of the hands and soles of the
feet. Glandular infiltration follows slowly, and alopecia, iritis,
laryngitis, and the skin manifestations are observed with comparative
infrequency.
[Footnote 38: _Wien. Med. Presse_, 1873, No. 1, xiv.]
{429} Constitutional Syphilis.--The influence of constitutional
syphilis upon the foetus is marked, and always unfavorable. The foetus
may be infected through the medium of the spermatic fluid, the ovum,
and by the mother after conception. From an enormous number of
carefully-recorded observations it is possible to deduce the following
conclusions with reference to the modes of infection and the effect
upon the product of conception:
1. When the mother is perfectly healthy, but the father is affected
with constitutional syphilis, the foetus is infected by the diseased
spermatozoids. The intensity of the foetal disease will depend upon the
degree of latency and age of the paternal affection. This mode of
infection is observed in the severer forms of hereditary syphilis.
Usually the mother is not infected. Occasionally the disease is
communicated to her by the foetus in the mode termed by the French
syphilographers choc en rétour.
2. When the mother has had constitutional symptoms prior to conception
the ovum is infected before its fertilization. The child usually dies
in utero, and is expelled in a state of maceration.
3. When the mother is infected during the act of coitus it was formerly
believed that the foetus could only be syphilized during its passage
through the parturient canal. Sigmund and Vajda have shown that even
under these circumstances the infection may be communicated by the
mother to the foetus in the course of pregnancy. If the father is
affected with constitutional syphilis when the mother acquires the
initial lesion, the result sketched in the first proposition follows.
4. Infection of the foetus may occur during its passage through the
parturient canal. Weil[39] records a case of this nature.
[Footnote 39: _Deutsch. Zeitsch. f. prakt. Med._, 1877, No. 42.]
5. When both parents are affected with constitutional syphilis the
disease will be communicated to the foetus. The intensity of the foetal
syphilis will depend upon the degree of latency and age of the parental
affection. When both parents have passed through the tertiary forms an
apparently healthy child may be born. Evidences of hereditary syphilis,
however, are usually developed before puberty.
According to the intensity of the poison the foetus dies in utero,
causing the interruption of pregnancy; is born alive, with
manifestations of hereditary syphilis, seldom acquired; or may give
evidence of the inheritance of the disease after a variable interval of
from weeks to months.
TREATMENT.--Fortunately, syphilis as a complication of pregnancy is a
very tractable affection. The interruption of pregnancy may be
prevented and the effect of the syphilitic poison upon the foetus
favorably modified in the large majority of cases by appropriate
specific treatment. Mercurial inunctions are preferable to the
exhibition of the remedy by the mouth. Iodide of potassium must be used
with care, on account of its tendency to provoke uterine contractions.
Attention must be paid to local primary or secondary lesions, since the
child may be infected during its passage through the parturient canal.
Cardiac Diseases.
The mutually unfavorable relations between acute and chronic cardiac
diseases and pregnancy depend largely upon the seat and character of
the affection.
{430} ACUTE ENDOCARDITIS,
occurring in the course of gestation, evinces a distinct tendency to
the malignant, ulcerative form. This disposition is much more marked
during the puerperium. The dangers of the detachment of particles of
valvular vegetations, giving origin to the processes of thrombosis and
embolism, are obvious.
The PROGNOSIS of acute endocarditis during pregnancy and the puerperium
is much more unfavorable than in the non-gravid state.
CHRONIC HEART DISEASES.
The mode in which pregnancy, parturition, and puerperium exert an
unfavorable influence on chronic heart diseases is still the subject of
controversy. Spiegelberg accounts for the disastrous results attending
aortic insufficiency observed in the second half of pregnancy on the
ground of the inadequacy of the compensatory hypertrophy of the left
ventricle. The intercalation of the placental circulation, the increase
of the total blood-mass, the increase in arterial tension, throw an
extra amount of work upon the left heart, which it is not able to
perform. Irregular heart-action and dyspnoea, sometimes leading to the
interruption of pregnancy, are the results.
After labor the placental circulation is eliminated, arterial
blood-pressure is lowered, venous blood-pressure is elevated, and the
right heart is threatened. In case of mitral insufficiency and
dilatation of the left ventricle, without compensatory hypertrophy of
the right heart, the effect of these sudden variations in vascular
tension is obviously serious. Dyspnoea, pulmonary catarrh, general
oedema, albuminuria, ascites, pleural effusions, occur. Fritsch[40] is
of the opinion that these phenomena, sometimes observed in the course
of mitral disease after labor, are due to the sinking of
intra-abdominal pressure, the accumulation of blood in the great
abdominal vessels, and cardiac paralysis from insufficient
blood-supply.
[Footnote 40: _Arch. f. Gyn._, viii. p. 373; x. p. 270.]
During parturition Spiegelberg[41] thinks the chief danger in all forms
of valvular defects consists in pulmonary oedema as the result of
circulatory disturbances.
[Footnote 41: _Lehrbuch d. Geburtshülfe_, 1882, p. 248.]
Löhlein and Kleinwächter[42] believe that the chief danger of chronic
valvular disease occurs during the puerperium, and lies in the tendency
to the recurrence of endocarditis.
[Footnote 42: _Kleinwächter's Grundriss d. Geburtshülfe_, 1881, p.
190.]
TREATMENT.--The treatment of acute and chronic heart disease is not
materially modified by the coexistence of pregnancy.[43] In threatened
asphyxia the induction of premature labor is indicated in the interest
of the child. During labor the timely performance of version or
application of the forceps lessens the bearing-down efforts, and may
prevent alarming complications.
[Footnote 43: Carl Braun, _Lehrb. d. g. Gynaek._, 1881, p. 708.]
Diseases of the Lungs.
ACUTE LOBAR PNEUMONIA.
This is a rare affection in women at all times, and is a very
infrequent complication of pregnancy. Occurring with greatest relative
frequency {431} in the early months of pregnancy, the unfavorable
character of the prognosis grows with the duration of pregnancy.
Interruption of pregnancy may occur as the result of a variety of
causative agencies. The elevation of maternal temperature, insufficient
oxygenation of the maternal blood, placental anæmia from inadequate
supply of blood to the left heart, are of chief etiological moment.
The PROGNOSIS with reference to mother and child is always grave.
The TREATMENT is that of pneumonitis in the non-gravid state.
Parturition exerts a prejudicial influence by overtaxing the failing
heart-power and increasing the hydræmia. The induction of premature
labor is therefore strongly contraindicated. In the event of labor
every effort must be made by operative procedure to save the mother's
strength.
ACUTE PLEURITIS
is nearly as fatal a complication of pregnancy as pneumonitis, and for
the same reason. The danger is especially great during labor.
CHRONIC PLEURISY, EMPHYSEMA, AND EMPYEMA
are dangerous complications of pregnancy, limiting respiratory space
and producing cardiac complications. The induction of premature labor
may be indicated by these conditions in the interest of mother and
child.
PULMONARY TUBERCULOSIS.
Pregnancy exerts a prejudicial influence on hereditary or acquired
tuberculosis as a rule. Latent tendencies to the disease are developed,
and the progress of the existing affection is hastened. These effects
upon the course of phthisis, Lusk says, are most frequently observed
between the ages of twenty and thirty years, although of not infrequent
occurrence between the ages of thirty and forty years. To these general
propositions there are occasional rare exceptions. The disease is
sometimes--very rarely--observed to make no progress during gestation
and the patient may decidedly improve during the lying-in period. The
puerperal phases, says Spiegelberg, exercise such varied influences
upon the development and course of tuberculosis that it is an
imperative necessity to individualize in every case.
When the disease progresses during pregnancy, abortion or premature
labor may take place, or the woman may die undelivered. Infants born of
tuberculous mothers are usually weak and sickly, and perish during the
first months of life.
For these reasons it is an established rule in practice to inform women
of the tuberculous diathesis of the dangers entailed by the marital
relation. A woman affected with tuberculosis ought never to nurse her
own child. As a rule, however, there is seldom any necessity for such a
warning, as the function of lactation is rarely established under these
conditions.
{432}
FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.
BY W. W. JAGGARD, A.M., M.D.
DEFINITION AND TERMINOLOGY.--The time of life in a woman when the
natural cessation of ovulation and menstruation occurs has received a
variety of appellations more or less descriptive of the phenomena which
are supposed to precede, attend, and follow that event. Change of life,
Turn of life, Critical time, Climacteric, in English; Das klimacterium,
Das aufhören menstrualer Ausscheidung, Das aufhören der Weiblichen
Reinigung, in German; Ménopause, Âge de retour, Âge critique, Temps
critique, in French; Cessatio mensium, Climacterium, in Latin;
Menolipsis, in Greek,--are terms used to mark out a certain period of
time commencing with the functional and organic disorders connected
with the cessation of ovulation and menstruation in a causal relation,
and terminating with the permanent resettlement of health.
DATE OF CESSATION OF MENSTRUATION, AND DURATION OF THE CHANGE OF
LIFE.--The function of ovulation, as far as we know, ceases with the
discontinuance of menstruation, although immature ova still exist in
the ovaries. The date of natural cessation of menstruation and
ovulation is variable in different women. It is difficult to determine
an average date, because the menopause may be gradually ushered in, and
then women are apt to interpret any genital hemorrhage as menstruation.
In certain cases the menstrual flow may cease between the ages of
thirty and forty years, or even at an earlier period. On the other
hand, the function has been noted by competent observers[1] to continue
up to and beyond the sixtieth year. According to tradition, Cornelia,
the mother of the Gracchi, was confined in her seventieth year.
Parvin[2] has recently called attention to another historical instance
of alleged late menstruation, recorded in a note to the fifty-sixth
chapter of the _Decline and Fall of the Roman Empire_. On the authority
of D'Herbelot's great work, _Bibliothèque orientale_, 1777, Gibbon
mentions the case of Asima, the mother of Abdallah. When the tidings of
the death of her son were borne to Asima her menses reappeared at the
age of ninety as the physical effect of her grief. The historian
informs us that the flow proved fatal in five days. These anomalous
cases of so-called protracted menstruation are frequently examples of
pathological hemorrhages dependent upon structural changes, sometimes
of a malignant character. Even admitting the {433} possibility of the
condition of extremely protracted menstruation, such cases, as remarked
by Playfair, like examples of unusually precocious menstruation, cannot
be regarded as having any bearing on the general rule.
[Footnote 1: Tilt, _The Change of Life_, 4th ed., 1882, p. 24.]
[Footnote 2: _The Medical News_ 26th Sept., 1885, p. 352.]
The periodic discharge of blood from the uterus usually ceases between
the ages of forty and fifty years. Raciborski[3] concludes, from the
observation of a large number of cases, that the average date of
cessation is the forty-sixth year. This estimate is confirmed by the
observations of Brierre de Boismont, Guy, and Tilt. The average date of
cessation in 1082 cases,[4] collected by these three observers, was
forty-five years and nine months.
[Footnote 3: _Traité de la Menstruation_, Paris, 1868.]
[Footnote 4: Tilt, _The Change of Life_, 4th ed., 1882, p. 22.]
Climate, race, and the various accidental circumstances which exercise
such potent influence upon the establishment of the functions of
ovulation and menstruation have measurably less effect upon their
cessation. Mayer[5] attaches some importance to social condition as
determining the date of cessation. From the observation of a large
number of cases belonging to the higher classes he determines the
average age to be 47.138 years. It is a popular belief that the period
of menstrual life is a constant number of years, usually from thirty to
thirty-five; that is to say, if a woman commences to menstruate when
very young, cessation will occur at an earlier age than in a woman who
begins to menstruate later in life. Cazeaux, Raciborski, Frank,
Dusourd, and Tilt, supported by Guy's[6] analysis of 1500 cases, are of
the opinion, on the contrary, that the duration of menstruation is
longest in women who have menstruated earliest. In the words of
Négrier,[7] "It seems well proved that the ovarian function, creative
of germs, is prolonged in life in direct ratio of the volume of the
ovaries and of the precocity of ovulation; thus the girl nubile at
twelve will continue menstruating until fifty or even fifty-five;
whilst the girl who did not menstruate until eighteen or twenty--a fact
which reveals feeble development and small energy of the organs--will
cease to menstruate at forty, an early age."[8] Cessation occurs later
in women who have passed through repeated normal pregnancies than in
virgins or sterile females. Cohnstein[9] observed the longest duration
of menstruation in women who had menstruated early, married, and borne
more than three children, suckled their offspring, and were normally
confined for the last time between the ages of thirty-eight and
forty-two years. An interesting opinion with reference to the relation
between longevity and the date of cessation was expressed by Robert
Cowie at the Paris Medical Congress in 1867. According to Cowie, there
is a direct and constant relation between longevity and protracted
menstruation. A woman who menstruates up to an advanced period of life
has more chances of attaining extreme old age than one whose menstrual
function has ceased earlier. Cowie derives this opinion from the
observation of numerous cases of longevity and coincident protracted
menstruation which occurred in the Shetland Islands.
[Footnote 5: Schroeder, _Handbuch der Krankheiten der Weiblichen
Geschlechtsorgane_, 1881, p. 321.]
[Footnote 6: _Medical Times and Gazette_, 1845.]
[Footnote 7: Barnes, _Diseases of Women_, 1878, p. 194.]
[Footnote 8: T. Gallard, _Pathologie des Ovaires_, Paris, 1885, p.
114.]
[Footnote 9: _Deutsche Klinik_, 1873, No. 5.]
Among the pathological factors which determine the early occurrence
{434} of cessation, puerperal atrophy of the uterus,
syphilis--especially the graver forms--and chronic alcoholism deserve
particular attention (Lancereaux).
The average date of cessation of menstruation may be regarded as the
fixed time from which to estimate the duration of the pre-cessation and
post-cessation periods of the menopause. The duration of the
pre-cessation period--or the dodging-time, as it is popularly
termed--is subject to many and extreme variations. Tilt[10] places the
limits of normal variation between a few months and six or seven years.
The average length of the dodging-time in 275 cases Tilt estimates at
two years and three months. The same observer claims to have seen cases
of morbid prolongation of the pre-cessation period through ten and even
twelve years. Equally variable and indefinite, in point of duration, is
the post-cessation period. From the study of his 500 cases, Tilt
concludes that cessation of menstruation divides involution into two
periods of nearly equal length when no disease of the uterus or adnexa
is present. In 383 cases, three or four years after cessation all
functional disorders due to the menopause disappeared. But the length
of the post-cessation period, as in the case of the dodging-time, is
liable to abnormal protraction. Tilt is very positive in the assertion
that disturbances directly traceable to the menopause may continue ten
or twelve years after cessation of menstruation. The statistical
evidence adduced by Tilt in support of his peculiar views as to the
possible protraction of the pre-cessation and post-cessation periods
(twenty to twenty-four years) may well be questioned. His analysis of
cases does not indicate rigid scrutiny. The line between merely
coincident phenomena and disorders which are directly traceable to the
menopause is nowhere clearly and distinctly drawn. Robert Barnes[11] is
of the opinion that the average duration of the change of life,
comprehending the pre-cessation and post-cessation periods, is from two
to three years--an estimate more in accord with the experience of the
majority of clinicians.
[Footnote 10: _The Change of Life_, 4th ed., p. 46 _et seq._]
[Footnote 11: _Diseases of Women_, 1878, p. 287.]
THE NATURAL HISTORY OF THE CHANGE OF LIFE.--In order to gain an
adequate conception of the dynamic disorders in connection with the
menopause, it is necessary to bear clearly and distinctly in mind the
alterations in functional activity of a purely physiological character
which attend that event. Many of the so-called functional disorders of
the change of life are merely physiological processes consequent upon
the transition from active ovario-uterine life to sexual decrepitude.
There is nothing remarkable in the fact that the cessation of
menstruation and ovulation, after functional activity of an average
period of time varying from thirty to thirty-five years, is sometimes
attended by a series of disturbances of a local and constitutional
character. The changes of functional activity under these conditions
are in analogy to the course and constitution of nature as observed in
connection with dentition, puberty, and other epochs in human life.
The physiology of the menopause is a subject extremely difficult of
investigation. The reasons are obvious. Our knowledge of the nature and
significance of the function of ovulation and menstruation is very
defective. The phenomena in connection with the change of life are
numerous and complex. All interpretations of the appearances are
peculiarly liable to fallacies and unavoidable sources of error.
Correction {435} and confirmation by anatomical research are usually
impossible. Then the number of recorded cases in which the phenomena
have been rigidly analyzed is very limited. But, despite the difficult
nature of the subject and the poverty of the literature, a solid
nucleus of acquired truth exists. Familiarity with these definitely
established facts will clear up many obscure points in the pathology of
the menopause.
RESPIRATORY CHANGES. The researches of Andral and Gavarret[12] indicate
that the quantity of carbonic acid exhaled by the lungs during the
second infancy (eight years to puberty) is increased in man and woman.
With the establishment of menstruation the quantity of carbonic acid
exhaled by the female becomes constant, and persists in this state
throughout her menstrual life. During the pre-cessation period the
quantity of carbonic acid exhaled by the lungs is rapidly augmented,
attaining its maximum about the time of cessation. During the
post-cessation period the quantity gradually diminishes until the
resettlement of health is effected. After this period it remains
relatively constant. In the male, on the other hand, the quantity of
carbonic acid exhaled increases up to the thirtieth year, and then
progressively diminishes until the end of life.
[Footnote 12: "Recherches sur la quantité d'Acide carbonique exhalé par
les Poumons dans l'Éspèce humaine," _Annales de Chimie et de Physique_,
3^e Série, t. viii.]
During pregnancy the amount of carbonic acid exhaled is approximately
the same as at the time of cessation.
Aran[13] recognizes in this augmented excretion of carbonic acid during
the change of life a critical or compensating discharge--a waste-gate
or outlet, to use the figurative expressions of Tilt and Barnes, for
the energy set free in the system by the more or less suddenly
suppressed functions of ovulation and menstruation. Gallard,[14] on the
other hand, has pointedly called attention to the fact that the
menstrual blood carries out of the system a quantity of carbonic acid
which during pregnancy and change of life is excreted by the
lungs--that, accordingly, the increased exhalation of carbonic acid
during the climacterium cannot be regarded in the light of a critical
discharge.
[Footnote 13: _Leçons cliniques sur les Maladies de l'Utérus et de ses
Annexes_, Paris, 1858-60, p. 284.]
[Footnote 14: T. Gallard, _Pathologie des Ovaires_, p. 87, Paris,
1885.]
ALTERATIONS IN THE FUNCTIONS OF THE SKIN.--It is a matter of common
observation that the functions of the skin are profoundly influenced in
many cases by the changes consequent upon the menopause. Tilt records
300 cases of more or less profuse perspiration, occurring in 500 women,
due in some degree at least to the change of life. This estimate is
probably exaggerated. A variety of agents influences the total amount
of perspiration, as well as the relation between sensible and
insensible perspiration, at all periods of life. The dryness,
temperature, and amount of movement of the surrounding atmosphere,
nature and quantity of food taken and liquid drank, exercise, mental
condition, medicines, poisons, diseases, and the relative activity of
the other excreting organs (_e.g._ the kidneys), are factors which
deserve due consideration before attributing all increased activity of
the sudoriparous glands about the forty-fifth year to the effects of
the change of life. In the tables mentioned no distinction is drawn
between mere coincidence and causal relation.