Part 83

When the congestion is long-lasting, various further morbid changes may arise, pulmonary hyperaemia may eventuate in bronchitis, hyperaemia of the cerebral meninges may cause very severe headache, there may be syncopal attacks, tinnitus aurium, choroidal congestion, impaired vision, etc.

Congestion of a more active nature arises from an increased and usually accelerated flow of blood through the vessels of a part in which the resistance to the blood stream has been lowered proportionately to its propulsive force. In this way arises that characteristic symptom of the menopause known as ardor fugax—fugitive heat—one link in the long chain of vasomotor manifestations occurring at this period of life. Fugitive heats are commonly most clearly marked in the face, head, and neck, in which region there suddenly occurs a reddening of the skin, with diffuse and increasing subjective sensation of heat. At the same time there is often a sense of tension, as if the part were about to burst. Actual slight swelling may be noticed, the eyes sparkle and are somewhat prominent, the head feels heavy, stupid, and dizzy. Sometimes these symptoms last for a considerable time; at other times they terminate speedily and suddenly with a local perspiration or with an attack of epistaxis. Not infrequently, after lasting a short time in one region, they pass away as rapidly as they came, but are immediately succeeded by a similar attack in some other part of the body, or by vasomotor phenomena of a slightly different kind. Thus, such a flushing and heat of the face may be replaced by a sudden sense of heat in the small of the back or in the sacral region, by pruritus of the extremities, by palpitation of heart, or by an attack of pseud-angina.

A further consequence of active hyperaemia is the onset of those confused states, so common in the climacteric age, of mental and bodily disquiet, which find expression, now in states of excitement, and now in states of depression. So we often observe change of disposition, associated with incapacity for regular work, whilst sleep is restless, and much disturbed by dreams; and again states of dizziness, a sense of mental uneasiness and confusion, and even actual delirium.

In the skin, in addition to the fugitive heats, we often have a peculiar pricking, itching, or stabbing sensation, and various kinds of hyperaesthesia, frequently associated with disturbances of tactile sensation. We observe also muscular twitchings, and general weakness of the organs of locomotion.

In association with the passive and active hyperaemias of the menopause, we frequently see increase or some qualitative change in the various secretions. Above all, these changes affect the various secretions of the different reproductive organs, but we have also increased intestinal secretion, leading to diarrhoea, increased excretion of urinary deposits, and increased secretion by the skin. Symptoms which are common at the menarche, and frequently recurs at the menopause, are: headache, migraine, a state of pseudo-narcotism, slight hysterical attacks, indications of moral insanity, lumbo-abdominal neuralgias, neuralgia of the breasts, leucorrhoea, and various skin eruptions.

According to Tilt, the changes occurring in the organism at the climacteric period may be summarized under the following heads:

1. Increased elimination of carbonic acid by the lungs,

2. Increased elimination of uric acid in the urine,

3. Increased perspiration,

4. Increased mucous flux,

5. Haemorrhages from various organs.

As regards the first point, the extensive researches of Andral and Gavaret have shown that in the female sex the quantity of carbonic acid eliminated by the lungs diminishes when menstruation first appears at puberty, but increases again at the climacteric age, when menstruation ceases—whereas in the male a gradual diminution in the elimination of carbonic acid begins already in the 36th year of life; in old age the quantity eliminated is greatly reduced in both sexes alike.

CHANGES IN THE FEMALE REPRODUCTIVE ORGANS AT THE MENOPAUSE.

FIG. 84.—Sagittal section through the ovary of a girl aged 16. ]

In considering the changes that take place in the female reproductive organs at this period of life, we must distinguish between the proper period of the climacteric, with its various manifestations antecedent to and associated with the irregularity and ultimate cessation of menstruation, from the condition of old age in which menstruation has actually and completely ceased, in which the menopause has been fully accomplished, and in which the changes of senescence have set in at once in the organs of the reproductive system and in the organism as a whole.

The most important and most significant changes of this sexual epoch are unquestionably the anatomical alterations in the ovaries. A good many years ago I undertook an investigation whose purpose was to follow the natural involution of the graafian follicles from the time of the climax on into old age, and for this purpose I examined a very large number of ovaries of women at ages varying from 42 to 75 years (Archiv. für Gynecologie, Bd, XII., Heft 3).

Throughout these years a slow but continuously progressive atrophy proceeds in the ovaries; they become smaller and denser, diminishing especially in height and width; their surface becomes extremely uneven; and in extreme old age they wither away until no more is left in the region formerly occupied by the ovaries than a flattened fibro-vascular thickening (Figs. 84–88). The histological characteristic of the changes in the ovary which proceed gradually from the commencement of the menopause to extreme old age, may be summed up as consisting in a continual increase and new formation of the connective tissue stroma at the expense of the cellular layer, accompanied by retrogressive metamorphosis of the graafian follicles.

FIG. 85.—Sagittal section through the ovary of a woman aged 72 years. ]

The connective tissue ground substance of the ovary increases from the periphery towards the centre, and progressively compresses the epithelial structures of the organ. In the outermost layer of the ovarian stroma, the so-called tunica albuginea, the strata of short, dense connective tissue fibres increase notably in number, so that whereas at first three layers at most could be distinguished, the tunic ultimately comes to consist of from six to eight layers; at the same time also the interior ovarian stroma becomes exceedingly dense, so that numerous well-defined interlacing bundles of fibres can be made out in its substance.

The first retrogressive metamorphosis which can be observed in the graafian follicles is fatty degeneration, the formation of granule spheres. Whilst the membrana propria (the theca folliculi) of the follicle remains quite unaltered, we observe in the membrana granulosa, in addition to the ovum, and the ordinary cells of this layer, spherical aggregates of fat droplets, the granule spheres, which continually increase in size, until ultimately of the cellular contents of the follicle nothing whatever remains, and it now appears full of granule spheres and fluid. The theca folliculi has now lost its spherical shape, and assumes an ovid form (Fig. 89).

In a later stage of the degeneration of the graafian follicle, it appears as a vesicular body with a relaxed wall, thrown into numerous folds, this folded wall being formed by the theca folliculi. The cavity of the follicle is reduced to a mere cleft, filled with a transparent substance, and the space between this cleft and the inner surface of the theca folliculi is occupied by round cells and a fibrous intercellular substance, and is traversed by a vascular network. This second stage of the retrogression of the follicle may therefore be designated the stage of vesicular degeneration (Fig. 90).

FIG. 86.—Diagrammatic representation of the Graafian Follicle. ]

FIG. 87.—Ovary of a girl aged 19 years. (Normal size.) ]

FIG. 88.—Ovary of a woman 72 years of age. (Normal size.) ]

In the last stage of this retrogressive metamorphosis, we find the follicle completely transformed to a fibrous mass. It appears as an elongated oval body, much lobulated, connected with the surrounding stroma by thick strands of fibres; a trace of the original cavity can still be distinguished in the form of a narrow cleft, without distinguishable contents. The tissue of this body consists of connective tissue fibres, with interspersed nuclei and nuclear fibres (Fig. 91).

The three stages I have observed in the retrogression of the follicle, of which I have given a summary account above, may, I think, be explained in the following manner: When the woman’s reproductive activity ceases, the graafian follicles become subject to a retrogressive metamorphosis, a fatty degeneration setting in in the cells of the membrana granulosa and in the ovum, until ultimately the whole of the granular epithelium has undergone atrophy. The follicle now undergoes a vesicular transformation with shrinkage of its cavity, and with the formation of a new tissue which appears to be young connective tissue. As time goes on, this new connective tissue is formed in increasing quantities, until finally the entire follicle is transformed into a firm fibrous mass.

FIG. 89. ]

Thus we are led to infer that the gradual but extensive thickening of the tunica albuginea (i. e., the outer, condensed layer of the ovarian stroma), which, as we have seen, always occurs at the climacteric period, offers a hindrance to the bursting of the follicles as they mature, and in this we find the explanation of the irregularity of menstruation and of the various troubles which attend the performance of that function at the time of the menopause. It is reasonable to assume that the resistance of this thickened tunica albuginea is responsible for the fact that the interval between the bursting of the successive follicles is now greater than normal, as much as six or eight weeks—this retardation of menstruation being one of the commonest ways in which the onset of the menopause is first manifested. Another phenomenon connected with the onset of the menopause also finds a plausible explanation in the anatomical grounds just mentioned. As already pointed out, in parous women the menopause sets in later than in nulliparae. At every pregnancy, the ovaries share in the more abundant nutrition of all the reproductive organs, due to the general dilatation of the intrapelvic vessels which accompanies this process; hence the ovaries become larger, richer in lymph, and therefore softer, the cellular elements increase in size, and perhaps also in number, and it is readily conceivable that in such ovaries the cellular elements are able for a longer time to resist the induration and the new formation of connective tissue which occur at the climacteric.