signs. These symptoms are--sensations of cold, shivering, chills,
sinking or faintness referred to the pit of the stomach. Usually,
however, they are not attended by any premonitory phenomena. They are
frequently accompanied by dilatations of the skin blood-vessels,
corresponding to definite areas of distribution of the vaso-motor
nerves, which are popularly known as flushes. When the perspirations
following the dilatations of the skin blood-vessels are insensible,
women are in the habit of terming the symptoms dry flushes. The number
and duration, as well as the time of occurrence, of these sweats and
flushes are various in different women. Tilt has observed them to occur
as often as five or six times in an hour, and last from two to fifteen
minutes. They are usually noticed during the daytime. The regions
involved are, in the order of frequency, face, chest, lower portions of
the trunk, upper and lower extremities. Very seldom the entire skin
surface is affected. In point of intensity the heightened activity of
the sudoriparous glands varies from a gentle perspiration to a
drenching sweat.
The function of these perspirations and flushes cannot be regarded as
definitely settled. The popular opinion is that they constitute an
important outlet for the actual energy liberated by the cessation of
ovulation and menstruation. Tilt, adopting the popular view, thinks
that the relief obtained by increased perspiration is the most
important and habitual safety-valve of the system during the change of
life. There are certain a priori considerations which render this
hypothesis in some degree probable.
The quantity of matter which leaves the human body by the skin, per
hour, is considerable. Seguin[15] has estimated it at eleven grains,
while the quantity excreted by the lungs is seven grains. It is
possible to isolate three factors which directly influence the
secretion of sweat: (1) The skin, apart from its glandular apparatus,
is a simple animal membrane, and permits a relatively small quantity of
water to transude through the portions intervening between the mouths
of the glands. As pointed out by Erismann,[16] this function of the
skin is a subordinate one. The simple transudation of water is greater
through those portions of the skin abundantly supplied with glands than
through those in which they are sparsely distributed. (2) Vascular
dilatation accompanies, and at least aids, the secreting activity of
the cutaneous surface. Bernard's experiments on the division of the
cervical sympathetic and clinical observation abundantly demonstrate
the operation of this etiological factor. (3) Independently of vascular
supply, it is in a high degree probable that there are special nerves
directly controlling the activity of the sudoriparous glands.
Stimulation of the sciatic nerve causes an increase in perspiration in
the toes of the dog, without any concomitant hyperæmia, as shown by the
experiments of Kendal and Luchsinger.[17] In a word, the skin is
adequate to the regulation of aberrations in nerve-force and
blood-supply and to the restoration of equilibrium. If superfluous
actual energy is liberated by the cessation of the monthly ovarian
stimulus and determination of blood to the uterus, it is not improbable
that the perspirations and flushes of the menopause may constitute an
efficient means of discharge.
[Footnote 15: _Ann. de Chim._, xc. pp. 52, 403.]
[Footnote 16: _Zeitschrift f. Biol._, xi. p. 1.]
[Footnote 17: _Pflüger's Archiv_, xiii., 1876, p. 212.]
{437} ALTERATIONS IN THE SECRETION BY THE KIDNEYS.--In many cases of
the menopause important changes occur in the urine. The secretion
becomes turbid and the quantity of sediments is large. These sediments
usually consist of the inorganic salts. The phosphates, carbonates, and
sulphates are increased, while no change is observed in the quantity of
sodium chloride. The quantity of nitrogenous crystalline bodies is
apparently not influenced in the great majority of cases. Occasionally
the quantity of uric acid is increased,[18] and gives origin to many
distressing symptoms. In the absence of accurate data respecting the
changes in the constitution of the urine it is useless to speculate
about the significance of the occasional increase in the quantity of
inorganic salts and uric acid. Doubtless the functional activity of the
skin and lungs, diseases of the genito-urinary tract, and diet play an
important part in the production of the alterations in the chemical
constituents of the excretion. It cannot, however, be denied that the
menstrual flow performs some office as an emunctory, and it is not at
all improbable that its cessation throws additional work on the
kidneys.
[Footnote 18: Barnes, _Diseases of Women_, 1878, p. 285.]
ALTERATIONS OF NUTRITION.--Of the various alterations of nutrition
consequent upon the change of life, obesity is of greatest clinical
interest. It is a matter of common observation that women frequently
grow fat coincidently with the cessation of menstruation. Out of 383
cases collected by Tilt, 121 women grew stouter within five years after
cessation; 3 women became suddenly fat when the menstrual flow ceased
to recur. Barnes, Baillie, Fothergill, and numerous other clinicians
abundantly confirm this observation. Adipose tissue is usually
deposited in the omentum, abdominal walls, breasts, face, and limbs.
The nature of the relation between the formation of fat and the change
of life is obscure. In the attempt to ascribe due influence to the
menopause in the production of adipose tissue it must not be forgotten
that in males the maximum of weight is attained, according to Quetelet,
about the fortieth year. But the accumulation of fat in many of the
lower animals after the extirpation of the ovaries, and the frequent
occurrence of obesity in women after normal ovariotomy and the
Porro-Müller operation of Cæsarean section (Braun, Spaeth), indicate
that in some cases, at least, there is a necessary relation between the
two phenomena. The generally received view is that the formation of
adipose tissue is an outlet for the more or less sudden aberrations in
nerve-force and blood-supply following cessation. The weight of
probable evidence is very decidedly in favor of this opinion.
Physiology teaches that fat fluctuates in bulk more than any other
tissue in the body. As remarked by Foster,[19] a large amount of
adipose tissue may disappear within a very short space of time, or the
quantity in a body may be multiplied many times within an equally short
time. Although the direct influence of trophic nerves on metabolic
activity has not been demonstrated, there is still evidence of a high
order in favor of such a view.
[Footnote 19: M. Foster, _Physiology_.]
The Mammary Glands.--Apart from the enlargement of the mammary gland
from the deposition of adipose tissue, the organ may be the seat of
active secretory changes. Tilt observed this phenomenon in 15 out of
his 500 cases. The breasts increase in size and become tender. Blue
veins are visible through the skin, and changes resembling in kind
{438} those of pregnancy may be observed about the nipples and areolæ.
A milky fluid is sometimes secreted. Semple has described a case in
which a monthly discharge of blood continued for five years after
cessation. Tilt has published a case in which a painless exudation of
red serum, lasting for several days, recurred every three weeks.
In view of the intimate connection between the ovaries and uterus and
mammary glands at other periods of life, it is in a high degree
probable that many cases of active nutritive disturbances in the
mammary glands, occurring about the forty-fifth year, are directly due
to cessation. The exact nervous mechanism has not been fully worked
out. These nutritive disturbances are probably physiological, and
partake of the nature of the so-called critical discharges.
HEMORRHAGES AND MUCOUS AND SEROUS DISCHARGES.--Vicarious hemorrhages
are occasionally though rarely observed in connection with the change
of life. These more or less regular discharges of blood occur from a
great variety of sites. The region is usually so located that the
external escape of blood can easily be effected. The more usual forms
of vicarious hemorrhage are hæmatemesis, epistaxis, hæmoptysis, and
bleeding from hemorrhoids. General hæmatidrosis, bleeding from the
nipples, intestinal hemorrhage, bleeding from the alveoli of the teeth,
and subcutaneous ecchymoses are more uncommon types. Every case of
suspected vicarious hemorrhage deserves most rigid scrutiny. The
condition is such a rare one, and so many local causes sufficient to
explain the phenomena frequently exist, that a certain amount of
scepticism in the concrete case is perfectly justifiable.
The nervous mechanism of these hemorrhages, so far as it has been
worked out, may be stated in a very few words. The cessation of
menstruation causes an increase in vascular tension, and consequent
irritation of the vaso-motor centres. Various local hæmostases result,
which cause the symptoms of suffusion of the face, tinnitus, headache,
giddiness, etc. In a limited number of cases these local congestions
are relieved by the escape of blood. Vicarious hemorrhages seldom lose
their physiological character.
Metrorrhagia is a less uncommon event than vicarious hemorrhage during
the climacteric. Uterine hemorrhage is regarded as a critical discharge
due to the changes brought about by the menopause, when it occurs, in
the absence of local disease or constitutional vice, in connection with
the perspirations, flushes, obesity, nervous phenomena, and other signs
of cessation. In point of time these uterine hemorrhages, or floodings,
usually occur after cessation. The causes of the floodings of the
menopause are not at all evident. Barnes[20] is of the opinion that
they are ultimately referable to imperfect functional activity of the
liver and kidneys. Local congestions occur, vascular tension is
increased, the heart and blood-vessels are engorged, and a disposition
to uterine hemorrhage is created. In many cases flooding seems to exert
a salutary influence upon the health of the individual. J. Frank says
he has observed cases of critical floodings after cessation in which
checking the bleeding caused apoplexy. Tilt[21] confirms this opinion
by the citation of two cases. Not infrequently, however, metrorrhagia
during the change of life exceeds physiological limits and endangers
the life of the individual. In the {439} large majority of cases
flooding after cessation is always a cause for anxiety, and constitutes
an urgent indication for a physical examination. By careful indagation
it is usually possible to eliminate cases of metrorrhagia due to
carcinoma, fibroids, and diseases of the endometrium.
[Footnote 20: _Diseases of Women_, p. 283.]
[Footnote 21: _Change of Life_, p. 197.]
Leucorrhoea.--Closely allied in function to the floodings of the
menopause is the profuse flow of mucus, unmixed with pus, from the
cervix and vagina. This phenomenon is of frequent occurrence in
connection with the other signs of the change of life. In the absence
of local disease and constitutional vice it may be regarded as a
critical discharge, an effort of nature to relieve pelvic
congestion.[22]
[Footnote 22: Emmet, _Gynæcology_, 1884, p. 184.]
Diarrhoea.--The recurrence of a profuse serous diarrhoea at more or
less regular intervals during the change of life is common. Gendrin,
Brierre de Boismont, and Chambon regard diarrhoea as habitual at this
time. It acquires particular prominence as a symptom in the absence of
the other critical discharges already mentioned. Indeed, it may
constitute the only sign of the menopause apart from cessation of the
menstrual flow. Care must be exercised, however, to differentiate in
the concrete case between the purely functional serous diarrhoea of the
change of life and those forms of the affection which depend upon local
or general causes.
The explanation of the serous diarrhoea of the menopause, viewed as a
critical discharge, is simple when the intimate connection between the
pelvic circulation and that of the mesentery is considered.[23]
[Footnote 23: _Ibid._]
FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.--Vague,
indefinite, and speculative as our conception of the physiology of the
climacterium is, the deficiency of precise knowledge becomes more
apparent when we come to consider the functional disorders of
cessation. Many women pass through the change of life without the
slightest disturbance of normal functional activity. In such women
menstruation has usually been established at an early age and without
local or general disorders. Moreover, all traces of disease of the
uterus and adnexa are usually absent. Again, it is not an uncommon
observation to see hysterical women, afflicted for years with uterine
disease, begin to improve in health at an early stage of the
pre-cessation period. These facts indicate that the change of life does
not necessarily involve morbid phenomena.
In the large majority of cases, however, various functional and organic
disorders are observed during this period of life. Under these
circumstances it becomes a matter of extreme difficulty to distinguish
between accidental complications, dependent upon collateral disease and
pathological conditions of the pelvic viscera, and those disorders
which stand in some causal nexus with the change of life. The scanty
literature of the subject is to a great extent a mass of confused
generalizations, in which the distinction between the relation of cause
and effect and mere coincidence in point of time is seldom adequately
drawn. Tilt's meritorious treatise is not free from this defect. In
Table xxi., among the morbid liabilities at the change of life in five
hundred women, heart disease, rheumatism, erysipelas, hysteria,
epilepsy, cancer of the womb, ovarian tumors, and more than one hundred
and fifty other pathological states are mentioned! Any paper on the
subject at the present time, to perform a {440} serviceable office,
must direct attention to the obscure, confused, inadequate state of
knowledge rather than aid in the perpetuation of error by the
description of purely hypothetical forms of disease. The comparatively
few functional disorders which stand in direct pathological connection
with the change of life are, in the large majority of cases, examples
of pathological exaggerations of physiological processes. Under these
conditions it requires an unusual degree of diagnostic skill and
penetration to draw the boundary-line between health and disease. Then
in the matter of treatment, as remarked by Spiegelberg, it requires
tact to determine how long a purely expectant attitude should be
maintained and the time when active interference should be instituted.
The woman passing through the change of life possesses no immunity from
accidental diseases. But some of these accidental diseases may be
modified in symptoms and course by the changes consequent upon the
climacterium.
DISORDERS OF THE ALIMENTARY CANAL.--Salivation.--Ptyalism has been
observed by Bouchut and other observers to occur in connection with the
other symptoms of the change of life. It is a phenomenon of infrequent
occurrence. In the absence of any other adequate explanation it may be
regarded as an example of sympathetic irritation strictly analogous to
the salivation sometimes observed in pregnancy.
The milder degrees of this affection deserve slight attention. When,
however, the flow of saliva is so great as to incommode the individual
or seriously endanger her health, active treatment must be instituted.
Chalybeate tonics, quinine, hypodermatic injections of atropia over the
glands--especially the submaxillary--and iodide of potassium, are among
the more reliable remedies. Astringent mouth-washes are grateful and
relieve the congestion of the mucous membrane.
Constipation.--The habit of constipation, although not induced, may be
aggravated, during the change of life. Interference with the action of
the voluntary muscles and intestinal peristalsis by the deposition of
adipose tissue in the abdominal walls and omentum, diminution of the
intestinal secretions as the result of profuse perspirations and
critical discharges, are etiological factors frequently referable to
the menopause. Alterations in the innervation of the intestinal walls
are probably productive of conditions which tend to constipation. The
nature of the changes in the functions of the abdominal sympathetic
nervous system during the menopause is a matter of pure speculation.
There are many a priori considerations, however, which render probable
the view that the constipation in connection with the menopause is, in
some degree at least, a visceral neurosis. The prominence of the
symptoms, enteralgia and flatulence, lends additional probability to
this opinion. The treatment of constipation in connection with the
menopause is a subject of the greatest practical importance. Many of
the obscure nervous symptoms, distressing perspirations, and critical
discharges may be relieved, if not prevented, by attention to the
regular daily evacuation of the bowels. The specific hygienic and
medical means to be used to secure this end are fully discussed in
other portions of this work.
Diarrhoea.--Diarrhoea referable to the menopause and regarded simply as
a critical discharge, sometimes, though rarely, passes beyond
physiological limits and demands active remedial treatment. This
statement {441} holds true especially in cases of chronic diarrhoea
aggravated by cessation. It is frequently a matter of extreme
difficulty to draw the boundary-line between the physiological process
and its pathological exaggeration. Careful attention to the symptoms,
however, will usually disclose the fact whether or no the frequent
alvine dejections conduce to the patient's well-being. Sometimes the
stools are very profuse, and threaten life from the loss of large
quantities of serum. Entorrhagia and colic are frequently observed
under these circumstances. Rest, restricted diet, opium, the vegetable
and mineral astringents, usually suffice to fulfil all the indications.
DISORDERS OF THE LIVER.--Many eminent clinicians unite in the opinion
that functional derangements of the liver are peculiarly liable to
occur during the change of life. Sir J. Y. Simpson, Robert Barnes,
Tilt, Gardanne, Gendrin, Meissner, and Otterburg may be mentioned among
the observers who hold that there is some direct relation between
certain dynamic disorders of the liver and the menopause. There are
also many a priori considerations in favor of this view. Habitual or
long-continued constipation--a condition frequently observed in
connection with the change of life--interferes materially with the
secretion and excretion of bile. Barnes ascribes to the menstrual flow
an excretory function. In the absence of this emunctory an increased
amount of work is thrown on the liver and other secretory organs. The
portal venous system is engorged. Under these circumstances disorders
are apt to arise as the result of increased functional activity in an
organ which may be undergoing organic change.
Well-pronounced jaundice, however, is of infrequent occurrence during
this period in the absence of more potent factors than those just
mentioned. It is not more justifiable to speak of the icterus of the
menopause than of the icterus of menstruation. Flint[24] has justly
said that the occurrence of jaundice at the menstrual periods is too
infrequent to suppose that there is any direct pathological connection,
as implied in the term icterus menstrualis proposed by Senator.
[Footnote 24: _Practice of Medicine_, 1881, p. 637.]
On the other hand, that condition vaguely described as biliousness,
implying the constitutional effects of chronic hepatic hyperæmia, has
been noted by many clinical observers. The derangement referred to is
aptly described in the words of B. Lane and quoted by Tilt:[25]
"Nothing can be more common than to find severe biliary derangement
occurring at or about the period of menstrual cessation; and, looking
at the great physiological change which then takes place in connection
with hepatic development, it is naturally to be expected. A woman will
complain of being bilious; there may be a bitter taste in the mouth, a
burning in the throat, frontal headache, nausea, and even vomiting, the
urine high-colored, the bile abounding in the alvine dejections, and
perhaps causing heat and a stinging sensation in the rectum; the tongue
furred, a biliary tinge pervading the cutaneous surface." The propriety
of ascribing the symptoms so graphically described in these words to
excess, deficiency, or vitiation of the biliary secretion, in the
entire absence of precise knowledge, may well be questioned. Tilt is of
the opinion that the gastro-intestinal disorders produced by functional
disturbances of the liver during the menopause are peculiarly obstinate
in their resistance to {442} treatment. Many other clinicians bear
testimony to the truth of this statement. This fact increases the
importance of the subject of treatment. As this matter is very fully
discussed in other parts of this work, it is only necessary to call
attention at this time to the importance of directing the therapy to
the gastro-intestinal disorders, such as the accompanying subacute
gastro-duodenitis and constipation, rather than to the hepatic viscus
itself.
[Footnote 25: _The Change of Life_, 4th ed., p. 227, 1882.]
Incidentally, it may be remarked that gall-stones are apt to give
origin to distressing symptoms during the menopause. The causes in
operation are substantially the same as those already mentioned in
connection with the functional disorders of the liver.
CLIMACTERIC NEUROSES.--Incidental mention has been made, in the
discussion of the physiology of the menopause, of functional changes in
the nervous system, as involved in the perspirations, flushes,
hemorrhages, and other so-called critical discharges. Knowledge at the
present time of the physiological changes undergone by the nervous
system during the menopause is limited to these few general statements,
all of which are not yet definitely established facts. The field has
always been a fascinating one to the medical writer, probably because,
in the utter absence of precise information, the widest play is given
to the most vivid and fertile imagination. The literature of the
subject abounds in vague terms, figurative expressions, and rhetorical
forms. Numerous ingenious and interesting speculations may be found in
the writings of systematic authors from Gardanne[26] to Barnes and
Tilt.
[Footnote 26: _Aris aux Femmes entrant dans l'Âqe critique_, 1816.]
Tilt, following in the wake of the French writers, asserts that the
nervous system is in a state of irritability or nervocism. This
assertion conveys no information, as irritability may be the expression
of weakness as well as of strength. The system is said to be in a
condition of nervous plethora. We have seen that the rôle of plethora
in recent pathology is insignificant. Cohnheim denies its existence
altogether, except as a transitory state. Even admitting the existence
of that state, what evidence is there that nerve-force accumulates in
the body under the same conditions as the blood?