pathological changes in the nervous system connected with the
menopause. In comparison with these alterations the other phenomena of
the menopause are insignificant. In the absence of precise knowledge,
however, it is useless to devote time and attention to empty
speculation.
In no part of the subject of climacteric neuroses are notions more
obscure or information less precise than in connection with the
diseases of the sympathetic or ganglionic nervous system. Under the
term gangliapathy Tilt[27] has grouped a number of symptoms frequently
observed during the menopause, which have their origin in a condition
of "more or less debility associated with paralysis, hyperæsthesia, or
dysæsthesia of the central ganglia of the sympathetic system."
Gangliapathy includes the functional disorders described by other
observers under the terms cardialgia, gastralgia, gastrodynia, and the
like.
[Footnote 27: _The Change of Life_, 4th ed., p. 109, 1882.]
But it is impossible to view affections of the sympathetic apart from
disorders of the general nervous system. It is impossible to
distinguish {443} the conditions described by Tilt as ganglionic shock,
paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and
many of the functional and organic diseases of the abdominal viscera.
Finally, the connection of these various disorders, entirely
irrespective of names, with the change of life has never been
demonstrated, nor even rendered in a high degree probable.
Cerebral Hyperæmia.--The older authors dwell with especial emphasis
upon hyperæmia of the brain as an important functional disorder in
connection with the change of life. The condition is supposed to be apt
to occur, in the absence of perspirations, flushes, and the other
so-called critical discharges, as the result of plethora. Headache,
tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the
face and neck, bounding pulse, are among the symptoms which have been
referred to the lighter forms of cerebral hyperæmia. Few systematic
writers, however, sustain Dusourd in his assertion that apoplexy and
the severer forms of hyperæmia of the brain are frequently caused by
the cessation of menstruation.
Under the impression that plethora actually caused cerebral hyperæmia
and the symptoms mentioned, and doubtless influenced by the teachings
of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding
in the treatment of climacteric neuroses. Fordyce Barker and Tilt may
be mentioned among modern clinicians who retain the old opinion as to
the nature and treatment of this condition.
Cohnheim,[28] representing the modern school of pathologists, says
"that except as a transitory state polyæmia does not occur under any
circumstances." In recent pathology the various appearances of plethora
are regarded as caused chiefly by dilatations of the skin
blood-vessels, and not by an increase in the total blood-mass. The
changes in the character of the pulses are referred to alterations in
the vessels or their innervation. Even admitting the existence of the
so-called plethora universalis, it does not follow that headache,
dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia.
Andral has well said that these symptoms might with equal justice be
ascribed to qualitative changes in the constitution of the blood.
[Footnote 28: Pepper, _System of Medicine_, Vol. III. p. 886.]
Whatever view may be accepted as to the pathology of cerebral
hyperæmia, and as to the necessary connection with the change of life,
two important facts derived from experimental physiology deserve
careful consideration before bleeding is performed for the relief of
the symptoms mentioned:[29] (1) A high blood-pressure does not imply an
augmentation of the total blood-mass. A large quantity of blood may be
injected into the vessels without any considerable elevation of
pressure. (2) Bleeding does not directly lower blood-pressure unless
the quantity of blood removed be dangerously large.
[Footnote 29: M. Foster, _Physiology_.]
In the lighter cases the so-called derivative treatment fulfils all the
indications. Hot, irritating foot-baths, purgatives, saline diuretics,
are indicated for the relief of distressing symptoms. Diet, exercise,
frequent bathing, and other hygienic resources exercise a most
important prophylactic function.
Hysteria.--The occurrence of hysteria during the menopause, as at other
periods of life, is a well-established fact. Whether or no there is
{444} any direct pathological connection of cause and effect between
the change of life and the disorder is a question which has been the
subject of much controversy, and at the present time is unsettled.
Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation
one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are
of the opinion that the climacteric may stand in a causal relation.
Tilt's tabulated cases bearing upon this subject show nothing more than
the coincidence of the two conditions, and contribute nothing to the
solution of the problem. There are important considerations which favor
the view that while the menopause may influence hysteria favorably or
unfavorably, it is only in exceptional cases that the climacteric is
the immediate cause of the affection. While hysteria may occur at any
time of life, it is most frequently observed between the ages of
fifteen and twenty years. It is in a high degree probable that a woman
who has arrived at her forty-fifth year without hysterical
manifestations will not be molested during the change of life. It is
not an uncommon observation to see hysterical woman rapidly regaining
health during the pre-cessation period, and making complete recoveries
before the permanent resettlement of health.
Hysteria during the menopause does not differ as to symptoms from the
affection at other periods of life. It retains its protean character.
Almost all the described forms of nervous disease may be accurately
simulated. The severer forms of the disorder are paroxysms
characterized by convulsions, coma more or less complete, or delirium.
Coma enters to a greater or less degree into the paroxysms
characterized by convulsions. Lypothæmia--a term used by the older
writers to signify an hysterical semi-unconsciousness with feeble pulse
and widely-dilated pupils--is frequently observed. This condition, as
well as a state termed pseudo-narcotism by Tilt, may be regarded as a
lighter form of coma.
Functional paralyses and pareses of motion or sensation, or both, are
occasionally observed. Paraplegia is of relatively frequent occurrence.
Not infrequently this condition is of reflex origin, the eccentric
irritant residing in the uterus and adnexa or the gastro-intestinal
canal. Hemiplegia and general paralysis are observed less frequently.
In the differential diagnosis it is necessary to exclude epilepsy and
eclampsia, although it is well to bear in mind the fact that both these
conditions may coexist.
The treatment of climacteric hysteria differs in no essential
particular from that of the same disorder at other periods of life. The
practitioner, however, has the comfortable knowledge that with the
resettlement of health all symptoms, in the absence of local disease,
will probably disappear.
It may not be amiss, in passing, to notice the value as a palliative
measure of that old and well-tried remedy, the hot-water enema
containing asafoetida. One to two ounces of the tincture of asafoetida
in one quart of hot water, carried well up into the colon, is usually
productive of excellent results, moral and physical.
Climacteric Pseudocyesis.--False or spurious pregnancy is a neurosis of
not infrequent occurrence at or about cessation. It may justly be
regarded as one of the mimetic forms of hysteria. The symptoms which
give origin to the illusion may be observed in young, unmarried women
or long after the cessation of ovulation and menstruation. In {445} the
large proportion of cases, however, the phenomenon is noticed at or
about the climacteric. The subjective and objective signs of this
curious condition may simulate pregnancy very closely. The breasts are
swollen and tender, and a milky fluid may exude from the nipple. Nausea
and vomiting in the morning and the various sympathetic disorders of
pregnancy may be feigned. The abdomen may become enormously distended
from the deposition of adipose tissue in the abdominal walls and
omentum and the flatulent distension of the intestines. Foetal
movements are simulated by intestinal peristalsis and irregular
contractions of the abdominal muscles. The ensemble of symptoms may be
very deceptive, as shown by the famous case of Joanna Southcott.
Crichton Browne[30] relates the history of an illustrative case which
came under his observation in the West Riding Asylum. A woman long past
the menopause claimed to be two months advanced in pregnancy. At the
end of seven months she informed her friends that she was about to be
confined. Accordingly she went to bed, and the process of simulated
parturition lasted four days, terminating with a bloody discharge from
the vagina.
[Footnote 30: _British Medical Journal_, 1841.]
The differential diagnosis is easy. The mammary changes, upon close
examination, will be found to differ from those of pregnancy.
Inspection, palpation, percussion, and auscultation will disclose the
fact that the woman is only big with fat and wind, as Barnes puts it.
Anæsthesia will facilitate the examination. Bimanual examination
usually reveals the characteristic senile changes in the uterus or a
pathological enlargement differing essentially from the gravid organ.
The so-called phantom tumors sometimes observed during the menopause
are closely analogous to spurious pregnancies.
Epilepsy.--Epilepsy is a relatively uncommon disorder during the
menopause. The present state of our knowledge indicates that the
climacteric cannot be regarded as a distinct cause of the disease in
the absence of previous epileptic seizures or inherited predisposition.
Out of 200 cases of epilepsy occurring during the climacteric, observed
by Jewell of Chicago, not a single case could be traced by the most
rigid analysis to the change of life. Considering the rôle the
sympathetic nerve plays in the etiology of epilepsy, it would not seem
improbable, on a priori grounds, that the disease should be aggravated
at the menopause. Evidence derived from clinical observation, however,
is entirely inadequate to settle this question.
Insanity.--Various opinions are held as to the relation between the
menopause and insanity. Mania, monomania, dementia, and even idiocy,
are among the forms of mental alienation which have been attributed to
climacteric influences.
Monomania.--There is much probable evidence in support of the view that
the change of life may stand in a direct causal relation to monomania.
On the other hand, no proof exists sufficient to establish a necessary
pathological connection between cessation and mania, dementia, or
idiocy.
Gardanne, Dubois d'Amiens, and Chambon have called attention to the
occurrence of melancholia and hypochondriasis at this period. This
opinion is confirmed by the results of Battey's operation in the hands
of Lawson Tait, Bantock, Thornton, and other operators of large {446}
experience. In many of the cases of artificial induction of the
menopause melancholia has been observed as a most distressing sequela.
However, in connection with Battey's operation there are numerous and
important considerations which must be carefully weighed in order to
distinguish between a relation of cause and effect and mere
coincidence. The number of women operated upon is now large, and some
of the cases of melancholia following ovarian extirpation are probably
examples of the return of a disease of earlier life or of the influence
of heredity. Then, the fact of disqualification for maternal duties
supplies in many cases an adequate psychological cause for more or less
complete mental alienation. The important effects of chronic hepatic
hyperæmia and the coexisting gastro-intestinal catarrh--conditions so
frequently present at cessation--must not be forgotten when disorders
of the intellect are referred to the cessation of the ovarian stimulus.
The positive diagnosis of climacteric melancholia and hypochondriasis
is always difficult, frequently impossible. After the careful exclusion
of all other possible causes, it may be assumed with a certain degree
of probability that the intellectual disorder is due to the change of
life.
The prognosis of climacteric melancholia and hypochondriasis is not
necessarily unfavorable. In a large proportion of cases sanity returns
with the re-establishment of health. The treatment, in the absence of a
positive diagnosis, must be expectant. Effort must be addressed to the
removal of any possible cause. Hygienic measures fulfil all the
indications for treatment in the disorder when it is caused by the
change of life. Opium and alcohol must be employed with extreme care in
view of the great danger of the formation of obstinate habits.
Uncontrollable impulses and perversions of moral instincts are
frequently observed during the climacterium, as at other periods of
life. There is no reliable statistical evidence sufficient to establish
a necessary pathological connection between cessation and
uncontrollable peevishness, impulse to deceive, suicidal impulse,
nymphomania, dipsomania, kleptomania, and the like. Nor is it possible
to assert that these various disorders are of more frequent occurrence
during the menopause than at other periods of life.
{447}
DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.
BY W. W. JAGGARD, A.M., M.D.
Acute Metritis.
The occurrence of an acute inflammation of the parenchyma of the
non-gravid uterus has been denied by many systematic writers. Wenzel[1]
says the condition is a figment of the imagination; Duparcque is
sceptical; Klob[2] up to 1864 had never seen a case in which a positive
diagnosis was possible. Emmet[3] writes in the last edition of his
valuable book, "Inflammation of the uterine body never occurs except
after parturition."
[Footnote 1: _Krankheiten des Uterus_, p. 42.]
[Footnote 2: _Pathol. Anatomie der Weibl. Sexualorgane_.]
[Footnote 3: _Gynæcology_, 1884, p. 31.]
Comparatively recent investigations, however, have established the fact
of occurrence beyond doubt or question. While a relatively uncommon
condition, many facts with reference to its causation, pathological
anatomy, and clinical course are definitely known.
ETIOLOGY.--Disturbances in connection with menstruation play a rôle of
great importance in the production of acute inflammation of the uterine
parenchyma. The rapid cooling off of extensive areas of the skin
surface, as in wetting the feet in cold water, severe exertion, or the
cold-water vaginal douche, may transform the normal menstrual
congestion into an acute inflammation. The retention of menstrual blood
within the uterine cavity, the result of organic stenoses, flexions, or
tumors, occasionally gives origin to acute septic metritis. The
inflammatory process frequently extends from the endometrium to the
muscular substance. Gonorrhoeal endometritis is of chief clinical
significance in this connection. Duparcque's observations, confirmed in
1872 by Noeggerath, have recently attracted a great deal of attention.
Säuger's statement at Magdeburg, that one-ninth of all gynæcological
cases are of gonorrhoeal origin, created some surprise at the time. In
the light of the recent investigations of Schroeder, Bumm,[4] Lomer,[5]
Oppenheimer,[6] and others, it is not considered an exaggeration,
although it is still unsettled whether or no the gonococcus of Neisser
is the agent of infection.
[Footnote 4: _Arch. f. Gyn._, xxiii. 3.]
[Footnote 5: _Deutsch. Med. Wochenschrift_, 22d Oct., 1885.]
[Footnote 6: _Arch. f. Gyn._, xxv. 1.]
Under the heading of traumatism a great number and variety of
etiological factors are included. Operations on the cervix, curetting
the uterine cavity, and other minor gynæcological procedures, in the
absence {448} of careful antisepsis, may cause traumatic inflammation
in the vicinity of the wound, which may involve the entire organ. An
ill-fitting pessary, especially the intra-uterine stem, cauterization
of the cervix or endometrium with the solid stick of nitrate of silver,
intra-uterine injections, the careless passage of the sound, inordinate
sexual indulgence,--are all potential causes. Bloeschke[7] relates the
history of a case in which a piece of straw penetrated the cervix of a
peasant-woman working in the fields. An acute metritis was the result.
[Footnote 7: Säxinger, _Prager Vierteljahrschrift_, 1866, i. p. 130.]
Finally, acute inflammations of the muscularis may be lighted up in the
vicinity of new growths, as in the case of carcinoma of the cervix or
mural fibroids. Such inflammations, however, as remarked by Schroeder,
possess only a secondary significance.
PATHOLOGICAL ANATOMY.--The uterus, of a bluish-red color, is enlarged,
especially in its upper two-thirds, to the size of a goose's egg, and
is thickened in its antero-posterior diameter. Its walls, filled with
venous and arterial blood, are soft and succulent from the transudation
of serum. The bundles of muscular fibres are swollen, and the
inter-muscular tissue is infiltrated with white blood-corpuscles and a
few pus-corpuscles. Extravasations of blood, sometimes larger,
sometimes smaller, are usually observed in the connective tissue. These
changes are most marked in the innermost layers, where there is a
greater abundance of connective tissue, and the inflammatory process is
propagated toward the periphery. The endometrium, pelvic peritoneum,
and connective tissue are usually involved. The tubes and ovaries are
less frequently affected except in the case of gonorrhoeal infection.
SYMPTOMS.--The attack is usually ushered in by a chill, followed by
elevation of bodily temperature--a symptom which is apt to persist
throughout the course of the disorder. Pain, referred to the lower
portion of the abdomen and sacral region, is constant. The sensation
may be dull, gnawing, or boring, like the pains in the first stage of
labor or abortion, or sharp and lancinating. Tenderness on pressure,
indicating involvement of the perimetrium, is marked. The pain is
increased in intensity by standing, walking, coughing, straining at
stool, or any act which causes an elevation of intra-abdominal
pressure. Distressing symptoms arise in connection with the bladder and
rectum. Urination is frequent and painful, while the secretion may
contain blood. Griping pains are felt along the colon and rectum; the
sensation of fulness or the presence of a foreign body excites a
frequent or constant desire to defecate, and the act is accompanied
with straining.
When acute metritis is caused by wetting the feet in cold water during
the period, the menstrual flow may be suddenly arrested, to return
after a variable interval. In very rare cases menstruation is
permanently suppressed, and even atrophy of the uterus may result. In
other cases profuse menorrhagia may occur. Not infrequently this
copious hemorrhage is physiological, relieving as it does the
congestion of the organ.
Various sympathetic disturbances, as nausea and even vomiting, are
occasionally observed.
Acute metritis is frequently complicated by inflammation of the
endometrium, pelvic peritoneum, and connective tissue. Under these
circumstances the symptoms peculiar to inflammation of the muscular
substance {449} are masked. Acute metritis may terminate (1) in
resolution, with gradual resorption of the exudation and return of the
organ to its normal relations. (2) New connective tissue may be formed,
giving origin to induration of tissue and permanent increase in
size--the chronic uterine infarct of Kiwisch. The acute inflammation
has become chronic. While admitting the possibility of this mode of
termination, A. Martin[8] is of the opinion that a causal nexus is only
demonstrable in isolated cases. (3) A very rare mode of termination is
suppuration and the formation of abscesses in the muscular tissue. In
these cases it is necessary, as pointed out by A. Martin,[9] to exclude
myomata, which have undergone suppuration in the process of retrograde
metamorphosis.
[Footnote 8: _Pathologie und Therapie der Frauenkrankheiten_, 1885, p.
181.]
[Footnote 9: _Ibid._]
DIAGNOSIS.--The more or less sudden occurrence of a chill, fever, and
localized pain and tenderness urgently indicates a careful examination
of the pelvic viscera by bimanual palpation. The uterus is exquisitely
painful upon the slightest touch, even in the absence of any exudate.
The organ is enlarged, especially in its upper two-thirds, and
thickened in its antero-posterior diameter. The uterus is softened,
resembling in its consistence the organ in the early months of
pregnancy. During the stage of active hyperæmia the secretions are
diminished in amount; at a later period profuse leucorrhoea, especially
in the absence of menorrhagia, is a prominent symptom. The diagnosis of
abscess in the uterine walls is difficult, if not impossible, when the
collection of pus is small. The gradual enlargement of the uterus, the
presence of fluctuation, the indications of pointing, and the
constitutional symptoms are usually sufficient to establish the
diagnosis when the pus-cavity has attained a considerable size.
PROGNOSIS.--Under appropriate treatment the prognosis of acute metritis
is not unfavorable. It must, however, always be guarded, as it will be
governed to a great degree by the causation, clinical course, and
complications. Acute metritis from wetting the feet in cold water
during the period and the like usually terminates in resolution. It is
necessary to bear in mind the fact that in rare cases the function of
menstruation may be permanently arrested, and even atrophy of the
uterus induced. In acute metritis from traumatism the danger of general
sepsis constitutes the unfavorable prognostic element. In gonorrhoeal
infection the tendency to involvement of the tubes and peritoneum is
great; moreover, the condition is apt to recur. In all forms of the
disorder the relation to chronic uterine infarct deserves
consideration. Finally, death may result from the rupture of an
abscess, located in the uterine walls, into the abdominal cavity.[10]
Fortunately, these abscesses usually open into the uterine cavity,
rectum, or through the abdominal parietes.
[Footnote 10: Scanzoni, _Krankh. d. Weibl. Sexualorg._, iv. Aufl. Bd.
i., p. 203; Lados, _Gaz. médic. de Paris_, 1839, p. 605.]
TREATMENT.--In general terms, the treatment may be described as
vigorously antiphlogistic.
Chrobak[11] has pointed out in a detailed manner the absolute necessity
of the most rigid attention to antisepsis in all the minor as well as
the major operative procedures in gynæcology. The prophylaxis, a
subject {450} of vital importance, is limited, so far as the general
practitioner is concerned, to the enforcement of absolute cleanliness
in all manipulations of the female genito-urinary tract.
[Footnote 11: "Untersuchung. der Weibl. Genitalia und Allgem. gyn.
Therapie," _Deutsche Chirurgie_, Lief. 54.]
Absolute rest in bed in the dorsal decubitus, with the pelvis elevated
or depressed according to the patient's sensations, is a matter of
primary importance. Pain demands for its relief the free use of
morphine hypodermatically or opium per rectum. Chloral is a valuable
adjuvant.