CHAPTER XXIX THE MENOPAUSE AND OLD AGE (Part 1)

CHAPTER XXIX THE MENOPAUSE AND OLD AGE The menopause, p. 587: General considerations, p. 588. Anatomical and physiological considerations, p. 592; Anatomy, p. 592. Atrophic changes in the uterine organs, p. 594; Physiology, p. 595. Age at which the menopause occurs, p. 597. Premature menopause, p. 598. Delayed menopause, p. 601. The dodging time, p. 611. Phenomena of the meno- pause in body and mind, p. 612; Cardio-vascular system, p. 612, Hot flashes, p. 612, Tachycardia and high arterial tension, p. 613; The nervous system, p. 613; Sexual feelings, p. 614; Mental diseases, p. 615; The alimentary canal, p. 615; The nutrition, p. 616; Rheumatism, p. 616; The skin, p. 617. Influence of uterine diseases on the menopause, p. 617; Hemorrhages, p. 617; (a) Fibroids, p. 617; (6) Subinvolution, p. 618; (c) Endometritis, p. 618; (d) Polypi, p. 618; (e) Cancer of the uterus, p. 619; Displacements of the uterus, p. 620; Cystocele and rectocele, p. 621; Vaginitis and injuries of the vagina from coitus, p. 621 ; Eczema or pruritus vulvae, p. 621; Vesical symptoms, p. 621. Old age, p. 622: General considerations, p. 622: Effects of old age on the ovaries, p. 623; On the Fallopian tubes, p. 623; On the uterus, p. 624; On the vagina, p. 625; On the vulva, p. 625. The menopause (vyves , menses, and Trader, cessation) sometimes called the change of life, or climacteric, the time when the cata- menia cease, marks not only the end of the reproductive period in the life of woman, but it means also a change in the psychical as well as in the bodily make-up of the individual. It occurs in tem- perate climates after a period of from thirty to thirty-two years of menstrual life, between the ages of forty-five and fifty years. Then ensues a period of rejuvenescence of ten or fifteen years in which the woman, freed from the annoyances and disturbing influences at- tendant on menstruation and childbearing, settles into a more staid and less emotional form of life, when she devotes herself to the duties and problems that confront her without the demands on her strength that reproduction or preparation for reproduction entail. As regards old age it becomes necessary at the outset to dis- tinguish between the general application of the term to the latter part of life and that portion of it in which there are present distinct evidences of degeneration of body or mind. Perhaps the latter time is more accurately defined by the term senility. That some individuals maintain vigor of both body and mind even to ad- vanced years, is common observation, so that placing a mark in 587 588 THE MENOPAUSE AND OLD AGE number of years for the beginning of senility is a manifestly difficult proceeding. The ancients said, — "iEtas non annis sed viribus Eestimatur." Nevertheless, Hippocrates placed the beginning of senility at fifty-six years; Daubenton, who lived in the eighteenth century, at sixty-three, and Flourens ("De la longevite," 1854), some hundred years later, at seventy. Most authors adopt a con- ventional age of sixty as the beginning of the retrogressive changes of old age, and we will follow their lead. THE MENOPAUSE General Considerations The term menopause, although signifying only the cessation of the menses, is, on the whole, the best we have to describe a com- plex condition. Whether the catamenia cease suddenly or by irregularly recurring periods scattered over a number of months or years, the stopping of the menses is only one symptom attend- ing changes not only in the reproductive organs, but also in many other organs and in the system at large, these changes having their origin in a cessation of the function of the ovaries. The symptoms consist roughly of the following: — On the part of the uterus, hemorrhages and leucorrhea; the heart, palpitation and irregular rhythm; the arteries, increased tension and hot flashes; the nervous system, neuralgias, insomnia, depression of spirits, and ner- vous instability; the alimentary tract, dyspepsia, gastro-enteritis, and constipation; the kidneys, renal insufficiency; the skin, derma- toses; and the general nutrition, obesity, rheumatism, and anemia. Among the savages, who lead an out-of-door life and are the least removed in their mode of existence from the animals, it would appear that the menopause occurs without any symptoms except the cessation of menstruation. (A. Currier, Amer. Gyn. Trans., Vol. 16, 1891.) Among the civilized races, however, the more artificial the life the more likely the occurrence of one or more of the symptoms enumerated. In fact, the absence of symptoms dining the change of life may be regarded as abnormal among women of all classes and conditions of life in civilized communities to-day. This should not be construed as meaning that the meno- pause is a critical time of life or that the gloomy views about this THE MENOPAUSE 589 period that obtained in ancient times, or even thirty or forty years ago, should be held true at the present time. For instance, Kisch ("Das klimakterische Alter der Frauen," 1874, p. 109), writing in 1874, gives the following table of gynecological affections he found in 440 women who complained of symptoms referable to the uterine organs, among five hundred women investigated, in many cases several diseases being found in one individual: — Cases Menorrhagia and metrorrhagia in 286 Chronic metritis 79 Leucorrhea 327 Prolapsus uteri 65 Ante- and retroflexion of uterus 52 Pruritus vaginae 46 Vaginismus 12 Carcinoma uteri 3 Uterine polyp 5 Tumor of the breast 8 Tilt ("The Change of Life/' E. J. Tilt, 1882, p. 143) has an even longer list of uterine diseases found in five hundred women, as follows: — Cases Floodings, in 138 Leucorrhcea 158 Remittent menstruation 33 Vaginitis 4 Follicular inflammation of the vulva 10 Inflammation of the labia 4 Ulceration of the neck of the womb 9 Hypertrophy and inflammation of the womb 2 Prolapsus of the womb 5 Uterine polypi 4 Uterine fibrous tumors 4 Uterine cancer 4 Ovarian tumors 3 Milky or glutinos secretion of the breasts 2 Irritation and swelling of the breasts 14 Tumor of the breast, non-malignant 2 Cancer of the breast 1 Habitual deposits in the urine 49 Pain and difficulty in passing urine 9 Incontinence of urine 4 Haematuria 1 Erectile tumor of the meatus urinarius 2 Perineal abscess 2 464 590 THE MENOPAUSE AND OLD AGE The earlier writers believed that many maladies of serious nature were necessarily due to the menopause and this view is still held by many, not only of the general public, but by members of the medical profession. The reason is to be found in the absence of accurate diagnosis in the past. For instance, take the uterine disease, fibroid tumor of the uterus. We know now that these tumors are the cause of a very large number of cases of flowing at the menopause, and further that, unless there is surgical interference, the cessation of the menses in these cases does not come for several years after the time observed in women who have no uterine disease. Fibroid cases were formerly included in the statistics of the meno- pause, whereas now they are treated surgically so often and are generally recognized as fit subjects for operative treatment, that no one thinks of leaving them to the kind offices of nature unassisted. The early recognition of uterine cancer was an unknown branch of diagnosis fifty years ago and instances of flowing caused by this dread disease were classed as natural concomitants of the climacteric. Now we know that cancer is found most frequently in both sexes between the ages of forty-five and fifty-five and there is reason to believe that the disease has some association with retrogressive changes in the tissues. At all events this holds true in the case of cancer of the breast where the atrophy of the tissues of the breast at the menopause is associated with the development of cancer in that organ. It is more than probable that the same may hold true of the uterus. Fibroids and cancer of the uterus are, therefore, truly diseases of the menopause, although the causative relations of the climacteric to these diseases is by no means proved, consequently they should be always in the mind of the practitioner while considering the case of a woman who is passing through this period of life. The point to keep in mind in this connection is that it is the uterine disease that causes the patient's ill health and not the time of life during which the disease manifests itself, in the same measure as regards the constitutional diseases. Tilt mentions in his table forty-nine cases of " habitual deposits in the urine." Now we look for faults in metabolism and a diminished ingestion of fluids to explain such deposits. In a study of the menopause for the purpose of gaining an in- sight into its true nature, one considers first the physiology of the THE MENOPAUSE 591 change of life in a normal woman and then the points of departure from the normal. If such a thing were possible we should utilize statistics of the symptoms manifested by women having normal uterine organs when they are passing through the period of the change. Most of the figures given by writers on this subject, such as Brierre de Boismont, Kisch, Kehrer, Tilt, and Borner, are made up largely of women suffering with uterine diseases. Normal women do not apply to physicians for advice, and whatever symp- toms they experience are not a matter of record, or are not sub- jected to expert analysis; therefore, most of our ideas must come from study of abnormal women and chiefly from those who are affected with uterine disease. The many variations in general health exhibited by women who are undergoing the menopause complicate an investigation into the phenomena and therefore hinder the sifting of cause and effect. During the last twenty years, since abdominal operations on the uterine organs have become so common, frequent opportunities have presented for more accurate study of the condition of these organs during and subsequent to the menopause. Moreover, our knowledge of the artificial menopause, induced by the removal of the ovaries, has become very minute of late years, because of the unfortunate practice which obtained in the eighties and nineties of removing the ovaries for the cure of a variety of diseases of the nervous system, and also, since the era of aseptic abdominal oper- ating began, the frequent sprayings made necessary by ovarian disease have furnished many examples. In this chapter I shall approach the subject of the menopause from the standpoint of the gynecologist, citing first the opinions of the most eminent authorities and then my own views formed by reading the literature and by an analysis of one hundred and fifteen cases taken from my private case records of women who were between the ages of forty-one and fifty-nine years, who had either passed by the menopause or were passing through it, all of the cases being women who consulted me for uterine disease. No cases of myoma or cancer are included except a few cases of small uterine polypi which may have been of myomatous origin, and a few cases of cancer of the uterus which were several years past the meno- pause. 592 THE MENOPAUSE AND OLD AGE Anatomical and Physiological Considerations Anatomy. — The ovaries are developed in the embryo from epi- blast and mesoblast on the inner surface of the Wolffian bodies in close relationship with Miiller's ducts, which eventually form the Fallopian tubes, uterus, and vagina. Most of the ovary is composed of cortex, which is made up of primary ova enclosed in primary follicles which lie in a delicate connective-tissue framework. At birth there are some one hundred thousand of these primary ova present in an ovary, over half of them disappearing before puberty is reached, and the rest developing into ripened ova in their Graafian follicles to be constantly diminished in number during the thirty or thirty-two years of sexual maturity by the repeated discharge of ova through the surface of the ovary, leaving it, as the years go by, with an ever-increasingly corrugated appearance. After the ovum has escaped from the Graafian follicle there is formed, on the inner surface of the walls of the follicle, the corpus luteum, a wrinkled yellow membrane made up of polygonal epithe- lioid lutein cells, the yellow color being due to the lutein. If preg- nancy supervenes the corpus luteum persists for a long time; if it does not, connective tissue takes the place of the lutein cells, the yellow color disappears, and the corpus is gradually absorbed. When the menopause has been established the cortical zone of the ovary is diminished in thickness, the ova and their follicles disappear, and the ovary becomes progressively smaller in size and more shrunken in appearance as the connective tissue, of which it is now mainly composed, atrophies with the advancing years. The office of the ovary is to furnish ova, and in addition it has an important influence on various functions of the body, chiefly the circulation of the blood, the nervous system, and the nutrition. The theory has been suggested by various observers that the ovaries are ductless glands like the thyroid and suprarenal glands and that they furnish an internal secretion. More recently the view has gained ground that this internal secretion is produced by the corpus luteum. This is not the place to discuss the various theories and the facts advanced to substantiate them. Suffice it to say that as yet we know nothing more than probabilities and these seem to me to be that the ovaries exercise their influence on the THE MENOPAUSE 593 system chiefly through the circulation, an argument in favor of the theory of an internal secretion. The function of the thyroid gland seems to have some relation to that of the ovary, both being in sympathy as essential to the develop- ment and preservation of the genital organs, and yet opposed in certain respects, as shown by the enlargement of the thyroid at the menopause. Thyroid feeding produces excellent results in cretinism and in infantilism, and ovarian extract ameliorates the symptoms of exophthalmic goitre. Vinay ("La menopause," 1908, p. 60) points out that in parts of Switzerland where goiters are common, many women develop these tumors for the first time at the menopause, but not before or after. The suprarenal glands have been found hypertrophied, or the seat of tumor formation, in cases of sexual precocity; and atrophy has been found associated with insufficient development of the genital organs, so we are led to be- lieve that these organs have an intimate relationship with the ovaries. Hegar likened the tubes, uterus, and vagina to the duct of a gland, the ovary. Disappearance of this gland results, as in similar processes in other glands, in disappearance of the duct also. So in the developmental stage of the organism the growth of the duct is related to that of the gland, and when in anomalies the ovaries are found absent, the tubes and uterus or the vagina are generally either defective or wanting. At the time of the menopause the atrophy of the ovary is accompanied not only by a cessation of menstruation, but by a shrinking of the tubes, uterus, vagina, and external genitals, all a slow process requiring a variable amount of time in different individuals, but always, in all probability, a series of months or years. In the following case reported by J. C. Dalton {Trans. Amer. Gyn. Soc, 1878, Vol. 2, p. 134), the ovaries one year after the menopause showed Graafian follicles in a state of degeneration, and no corpora lutea: — UA woman, forty-three years of age, of average bodily development, who had had one child twenty-one years before, died at the Charity Hospital, New York, February 7, 1877, of cerebral meningitis. Menstruation had ceased within a few days of one year before death. "The uterus was empty, of medium size, and normal in appearance except for a constriction of the os internum, which was reduced to 38 594 THE MENOPAUSE AND OLD AGE an orifice two millimeters in diameter.. The uterine mucous mem- brane was generally smooth and pale, marked only with a slight arborization of fine blood-vessels. The ovaries were somewhat undersized, and loose in texture. They contained a number of collapsed, empty, degenerate Graafian follicles with slightly thick- ened walls, presenting the appearance of having been long in an inactive condition. One ovary contained ten or fifteen such bodies, the other from fifteen to twenty. In the ovarian tissue there were also a few small, blackish stains, without definite structure. There were no normal Graafian follicles anywhere, and no corpora lutea in either organ." In contrast to this case Puech (cited by E. Borner, "Die Wech- seljahre der Frau," 1886, p. 8) found the ovaries of normal size in a woman three years after the menopause. In my own list of cases (Case No. 17, see table on page 605) I removed atrophic ovaries from a single woman forty-one years of age before the menopause had become established, although the patient had been in the dodging time for two years; whereas in Case 60, that of a married woman of forty-six, the ovaries were normal in size and appear- ance at operation one year after the beginning of irregularity of the menses. As a rule I have found the ovaries atrophied at opera- tions performed on patients who have passed the menopause (as in Case 108) except in cases where the ovaries with their tubes were the seat of a chronic inflammatory process. Atrophic Changes in the Uterine Organs. — During and following the cessation of menstruation retrograde metamorphosis takes place in the ovaries, the Fallopian tubes, the uterus, the vagina, and the external genitals, the process of atrophy of these organs requiring a variable amount of time in different