Part 84

The numerous nervous disturbances of the climacteric epoch would appear also to depend upon the hyperplasia of the ovarian stroma which we have observed to be the characteristic anatomical change in the ovaries at this period of life.

FIG. 90. ]

Associated with the fibrous transformation of the graafian follicles there is, however, a failure of the so-called internal secretion of the ovaries, a matter to which much attention has recently been paid. Brown-Séquard has especially maintained that the ovaries secrete a substance which enters the blood, a substance which, notwithstanding the fact that its presence cannot be proved either by chemical or any other means known to us, yet is of considerable importance for the maintenance of the equilibrium of mental and physical well-being. It is supposed that the various profound disturbances of the general system occurring at the menopause are dependent upon the cessation of this internal secretion of the ovary—disturbances which rise to a maximum as the atrophy of the ovary proceeds, and which only gradually pass away after a considerable lapse of time.

After the menopause is completely over, in the ovaries, as in other parts of the female reproductive organs, the signs of senile degeneration make their appearance.

In old women, we find the ovaries either shrunken to the form of small fibrous cords, or else degenerated to form cysts of smaller or larger size, the stroma surrounding these cysts being extremely hard, dense, and tough.

FIG. 91. ]

FIG. 92.—Sagittal section through the Cervix of a woman 26 years of age. Dendriform branched Glands. ]

FIG. 93.—Sagittal section through the Cervix of a woman 65 years of age. Glands which have undergone Cystic Degeneration. ]

FIG. 94.—Cervix of a woman 70 years of age. The Cervical glands have undergone Cystic Degeneration. ]

Whereas at the commencement of the climacteric period, the uterus commonly exhibits a slight increase in size, owing to the condition of passive hyperaemia already described, subsequently a gradual diminution in the size of the organ may be observed. This atrophy begins with the portio vaginalis and proceeds upwards. Whilst the body still appears undiminished in size, the vaginal portion will be found already shorter, more slender, and more flaccid. Gradually, however, the entire organ is involved in the atrophic process. The uterus is then smaller than formerly, its walls are thinner, its cavity reduced in size. Its vascularity and its sensibility are alike diminished. The external os is smaller, and the internal os is sometimes entirely obliterated. There is a tendency at the climacteric period for the tubulo-racemose glands of the cervical mucous membrane (Fig. 92) to undergo a cystic degeneration (Fig. 93), and hence arise the cysts which are so commonly met with on the portio vaginalis of women at this time of life, cysts varying in size from that of a millet seed to that of a pea. In advanced life, the formation of such cysts may be regarded as normal, and sometimes in the form of grape-like clusters they almost completely occupy the lumen of the cervical canal. (Figs. 94, 95, 96, and 97).

Not infrequently, these cysts lead to the formation of polypi, by enlarging until the mucous membrane projects so far that a stalk is formed.

Examining the bodies of 47 women who died at ages varying from 42 to 80 years, I found in 28 ovula Nabothi in the cervical mucous membrane, for the most part at the os uteri externum, but in some cases also extending up to the os internum, sometimes between the plicae palmatae, sometimes isolated, sometimes grouped.

Sometimes in old women no trace of a vaginal portion remains, and the uterus is found to be transformed to a small, thin-walled, shrunken body, no more than one-fourth of its original size; in such cases the saying of Graaf appears to be justified, that after the menopause the uterus returns to the size it has in the young girl. In the majority of such cases, the cavity of the uterus is also contracted (concentric atrophy). It sometimes happens, however, that in old age the os externum and the os internum are the seat of atresia, whilst the intermediate portion of the cervical canal remains unaffected. In this way, especially when the cervical canal and the cavity of the body of the uterus are distended with mucus or with fungous growths, is produced what is known as the uterus bicameratus vetularum.

FIG. 95.—Ovula Nabothi in the Portio Vaginalis. ]

In many cases, when the cervical canal has been obliterated, we find the uterine cavity distended with mucous secretion (excentric atrophy). The substance of the uterine wall is in old age commonly dense and tough, but occasionally, in extreme old age, less firm than formerly, withered and friable, and traversed by degenerated arteries, and in this state it is predisposed to haemorrhages (apoplexia uteri). Such intramural haemorrhages usually occur in the fundus; the friable uterine substance has then a blackish-red appearance, infarcted with extravasated blood; sometimes the uterine cavity is also filled with blood. In general it may be said that when the menopause is completely over, when uterine activity has entirely ceased, the uterus returns to the state in which it was before the menarche—it is physiologically dead.

The tubes become flaccid, thinner, shorter, and are at times obliterated. In the mucous membrane of the tubes in old women we no longer find any trace of the glands described by Hennig; the epithelial cells have also lost their cilia.

During the climacteric period, the vagina is usually relaxed and roomy, the mucous membrane is smooth, injected and secretes freely; subsequently, in old age, it becomes firm, tough and dry.

FIG. 96.—Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane. ]

Wendeler found that the initial change of the climacteric in the ovary is a chronic and progressive endarteritis obliterans; the result of this process is, in addition to the obliteration of the follicles, a continually increasing hyaline degeneration of the smallest arteries and the arterioles, especially along the line of transition between the cortical and the medullary substance of the organ; this degeneration extends to the surrounding connective tissue, and thus leads to the formation of peculiar, vitreous, translucent foci of sclerotic connective tissue, containing few cells or none; these are the so-called corpora fibrosa or corpora albicantia. Only subsequently to the formation of these bodies does the characteristic wrinkling of the surface of the ovary occur, with general shrinkage of the organ, these changes being due to the contraction that sets in in the numerous scattered foci of connective tissue, which, as already mentioned, are situated in close proximity to the cortex.

FIG. 97.—Mucous glands undergoing Cystic Degeneration. ]

The gradual atrophy of the uterus after the extinction of its sexual activity leads to a diminution in all the diameters of the organ, so that in old women it becomes flattened as in childhood, all its curves having disappeared; the muscular substance is replaced by connective tissue; and the portio vaginalis dwindles and even entirely disappears.

As regards the bacterial flora of the genital organs of elderly women, Menge and Koenig find that the vagina for the most part contains bacteria which do not thrive when cultivated aërobically on alkaline agar plates. In exceptional cases, however, such bacteria are found, and may even be sufficiently vigorous to produce pyogenic infection. According to Strogamoff, the vagina in all circumstances contains a great variety of micro-organisms—cocci, diplococci and rod-forms. Rod-forms are the prevailing types found in normal conditions in elderly women, but they are much smaller than in women who are still in the period of reproductive activity. Organisms liquefying gelatine were found in one instance only, a case of vaginal prolapse. In one half of the cases examined, there was no development of culture media inoculated from the cervix uteri, whether on agar or gelatine.

THE TIME OF THE MENOPAUSE.

The age at which the menopause begins is one which varies owing to manifold conditions, congenital and acquired, owing to the local influences which have been brought to bear on the reproductive organs during the menacme, and to the general circumstances of life during this period. In Northern Europe it commonly begins some time between the ages of 40 and 50 years. According to the most trustworthy statistical data, the commonest age for the onset of the menopause is between the ages of 45 and 50 years. Next to these in frequency we find the menopause commencing between the ages of 40 and 45 years. If, however, the menopause does not begin during the fifth decennium, it is more apt to occur during the quinquennium after 50 than during the quinquennium preceding 40 years of age; that is to say, an abnormally late menopause is more often met with than an abnormally early menopause. In a very small proportion of women does the menopause begin either after the age of 55 or before the age of 35.

THE AGE AT WHICH THE MENOPAUSE OCCURS.

My own observations show that the age at which the menopause begins is affected by the following circumstances:

1. The race (nationality) of the woman.

2. The age at which the menarche occurred.