Part 87

After infective puerperal processes, it sometimes happens that there is far-reaching destruction of the uterine musculature, degeneration of the uterine mucosa, permanent and irreparable atrophy of the uterus, and suppuration and atrophy of the ovaries—conditions which result in an extinction of menstrual activity. A similar result may ensue upon the persistent and long-continued pressure upon the uterus and the ovaries of a large intrapelvic exudation; such exudation being commonly post-puerperal, but occasionally arising in the absence of pregnancy. Further, according to Freund, chronic atrophic parametritis may give rise to an incurable atrophy of the uterus, by interference with the circulation of the blood through the broad ligaments, and consequent impairment of the nutrition of the uterus. Gonorrhoeal inflammation may also lead to the termination of menstrual activity, when it gives rise to intramural inflammatory deposits in the uterus, and to chronic inflammatory processes in the ovaries. Tumours of the uterus and the uterine annexa may likewise induce a premature menopause.

We also meet with cases in which after a pregnancy, to all appearance normal in its course and termination, a premature menopause results. To this category belong the cases, according to Kleinwächter of no extreme rarity, in which perfectly healthy women are attacked by profuse uterine haemorrhage during the course of a normal, full-term labour, or during miscarriage; subsequently, though the lying-in period is passed without further misadventure or abnormality, and in the absence of lactation, the patient becomes permanently amenorrhoeic. The normal involution of the uterus passes on into hyperinvolution, and ultimately complete atrophy of uterus and ovaries results. In some cases, moreover, such hyperinvolution with consecutive atrophy follows normal labour or abortion without the occurrence of any excessive haemorrhage.

Much more frequently do we find that rapidly successive pregnancies, with long-continued exercise of the lacteal function, in badly nourished, anæmic women, give rise to a premature menopause, due to permanent atrophy of the uterus and ovaries, which are in such cases so poorly supplied with blood. This “lactationatrophy” is described by Frommel and Thorn as a concentric atrophy first of all affecting the corpus uteri, and to this, if the disease advances, there succeeds a general atrophy of the muscular, connective, and fatty tissues of the parametrium, the vagina, the pelvic floor, and ultimately of the ovaries, leading, when permanent, to a premature menopause.

Trauma of the genital organs may also lead to uterine atrophy and to premature menopause.

By many authors it is believed that too-early marriage, sexual excesses, and prostitution, may be the cause of cessatio praecox. In some cases, there is unquestionably a hereditary predisposition to a premature climacteric, since the mothers of the women in whom it occurs have themselves been similarly affected. In the remarkable case which came under my own observation, of a woman from Smyrna, there was hereditary predisposition. This woman began to menstruate when 12 years of age; menstruation was always scanty; she married when 15 years of age; and she ceased to menstruate for ever at the age of 19. In other cases we find there is a family tendency for menstruation to be delayed in its first appearance to a comparatively advanced age, and to cease at the usual time.

In cases of cessatio mensium praecox (unless the failure of menstruation has been quite a sudden one), and after the premature menopause is fully established, we find in the uterus and the ovaries anatomical changes similar to those met with after the natural climacteric—diminution in the size of the uterus with thinning of its walls, density and firmness of the tissues of the organ, smallness and a soft consistency of the ovaries; sometimes, also, the mammae are atrophic.

In cases of premature menopause, the troubles attending the change are commonly more severe and more enduring than those that occur at the natural menopause. Especially is this the case when the premature menopause is quite a sudden occurrence, but this phenomenon is rare. Most commonly the premature menopause is gradual in onset; the flow becomes more scanty month by month, until at last it fails altogether to appear. Irregularity in the menstrual rhythm is not often seen in such cases. Early senescence is exceptional in these women in whom a premature menopause occurs. Emaciation, greyness of the hair, wrinkling of the skin, the growth of hairs on the face, etc., are not usually associated with the atrophy of the reproductive organs; the physiognomy and figure of women with cessatio praecox being usually similar to those seen in women of corresponding age in whom menstruation still continues.

Tilt enquired regarding the cause of cessatio praecox in 27 instances, with the following results:

In 3 instances, parturition and lactation. In 1 instance, abortion. In 2 instances, a fall on the sacrum during menstruation. In 2 instances, suppression of menstruation from chill. In 1 instance, haemorrhage from the arm during menstruation. In 1 instance, celebration of nuptials during menstruation. In 2 instances, severe medicinal purgation. In 2 instances, cholera. In 2 instances, rheumatic fever. In 2 instances, febrile bronchitis. In 9 instances, intermittent fever.

In 1 case Tilt saw cessation of menstruation occur at the age of 29, in consequence of metritis. Atlee, in 15 cases of ovarian tumour, saw the menopause occur at ages of 30, 39, 40 and 42. Puech saw a premature menopause at the age of 30 in 3 cases, in each a sequel of cholera. Blondel reports a case of cessatio praecox after prolonged galactorrhoea, although the woman had not suckled her infant; Gottschalk and Rokitansky, cases following injury to the cervix uteri; Kiwisch, Simpson, and Kleinwächter, cases following full-time, normal deliveries, in which, however, severe losses of blood had taken place.

Courty and Brierre de Boismont report cases in which the menopause occurred as early as the age of 21; Mayer, 2 cases at the age of 22; Krieger, 1 case at 23; Brierre de Boismont, 1 case at 24; Mayer, 2 cases at 25; Brierre de Boismont, 1 case at 26, and 1 case at 27; Guy and Tilt, each 1 case at the age of 27; Brierre de Boismont, Courty, and Guy, each 1 case at the age of 28; Brierre de Boismont, Courty, and Mayer, each 1 case at the age of 29; Guy and Tilt, each 1 case at the age of 30; and Mayer, 5 cases at the age of 30.

An unusually late climacteric, the continuance of menstruation beyond the age of 50 years, is not an extremely rare occurrence, but is less often seen than cessatio praecox. There is, however, in these cases a difficulty which must not be underestimated, namely, to distinguish between a genuine menstrual bleeding and the other uterine haemorrhages which are common precisely at this age of life, due either to textural changes in the uterus, or to neoplasmata—more especially because in these non-menstrual haemorrhages also a certain periodicity may often be detected. When on careful examination no abnormality can be discovered in the reproductive organs, when the bleeding in question recurs at the intervals and in association with the general symptoms to which the woman thus affected has been accustomed during her previous menstruations, and when the amount of blood discharged is not abnormal, it is permissible to conclude that we have to do with a persistence of true menstruation, even though the woman has some time since completed the fifth decennium of her life. In some women, in fact, the reproductive system is so energetic, that ovulation continues to an age far beyond the average, and such women are to be regarded as sexually long-lived.

Although the instances of protracted menstruation contained in the older literature of the subject are open to suspicion, owing to the fact that at that time it was not possible to distinguish with certainty between menstrual and pathological uterine haemorrhage, quite recently numerous incontestable cases of enduring sexual vitality have been put on record.

I have myself seen no less than 106 cases in which the menopause did not occur until after the age of 50 years; among these there were 4 in which the age at the menopause was 56; 5 in which it was 57; 2 in which it was 58; 1 in which it was 59; and 1 in which it was 60. Tilt records 128 cases of menopause occurring after 50; among these there were 4 in which the woman was 56 when menstruation ceased; 2 who were 57; 4 who were 58; 1 who was 59; 1 who was 60; and 2 who were 61. Courty reports a case in which menstruation persisted after the age of 65; Mayer, 3 cases of menopause at 64; Beigel, 2 cases, 1 in which menstruation continued to the age of 65, the other, to the age of 72. Kleinwächter observed 33 cases in which menstruation continued to an age varying from 50 to 57 years. Emmet, in the year 1886, published the case of a woman who was then 70 years old, and who at this advanced age continued to menstruate regularly.

That not every case in which after the age of 50 years there is recurrent, more or less periodic, haemorrhage from the genital organs, is to be regarded as an instance of delayed menopause, we are taught by the records of post mortem examination in several cases of the kind. Scanzoni reports the case of a woman who at the age of 60 was affected with a fairly regular periodic discharge of blood from the vagina. During one of these haemorrhages, she died of pneumonia, and the autopsy showed that the ovaries were completely atrophied and transformed into dense scar tissue, and contained no trace of corpus luteum or of fresh extravasation of blood, whilst in the upper part of the cervical canal there were two mucous polypi each of about the size of a bean. In another case, that of a woman 64 years of age, periodic losses of blood, at intervals of from three to four weeks, continued to the time of her death. This woman suffered from mitral valvular insufficiency, and it was clear that the haemorrhages had been due to the venous engorgement consequent upon imperfect compensation. The ovaries were completely atrophied, and showed no trace of any recent maturation of ova; the uterus was enlarged, the mucous membrane hyperaemic, and the cavity contained a recent clot.

Not infrequently, the haemorrhages attributed to the persistence of menstruation are really due to senile arteriosclerosis—to rigidity and brittleness of the uterine arteries; in other cases they arise from varicosity of the veins of the cervical canal. A common cause of such bleedings from the genital passage in comparatively advanced life, is to be found in the growth of uterine myomata.

To myoma uteri we must attribute a part, though by no means all, of the cases in which menstruation seems to recur some years after the menopause has, to all appearance, been fully established. In most of these cases, indeed, we have to do with pathological haemorrhages, the cause of which is, however, but too often obscure. Still, cases certainly occur in which, two or three years or even longer after the menopause, some unknown stimulus leads to the regular recurrence of menstruation. The possibility of such an occurrence is, in my opinion, fully proved by post mortem examinations of the bodies of elderly women in whom the menopause has been fully established and yet the ovaries are found to contain follicles of various degrees of ripeness, and also fresh corpora lutea—signs that ovulation may persist for a considerable time after the complete cessation of menstruation. Another proof of the last fact is the well known experience that women who have some time ago ceased to menstruate, may nevertheless become pregnant. Waldeyer, indeed, asserts that when four years have elapsed since the menopause, follicles are never to be found in the ovaries, but this negative experience is not decisive, especially as regards the cases in which regular menstruation is resumed some time after the occurrence of a premature menopause.

I have myself seen several cases in which the menopause occurred at 35, 38, 39, and 42 years, respectively; 3, 4, or 5 years later, as a result of hydropathic treatment, regular menstruation recurred. In one case, a woman who had ceased to menstruate ten years before, gave birth to a child at the age of 45.

Numerous indisputable cases of this kind are reported in the recent literature of the subject. Krieger had under his personal observation a woman of a robust habit of body, in whom menstruation ceased at the age of 48 years, her eighth child having been born fifteen years before. Two years later irregular menstruation recurred, and on the cessation of these haemorrhages, it appeared that the woman was once more gravid; she was delivered at full term of a girl. Mayer observed the following case: A strong working-class woman 33 years of age had begun to menstruate regularly when 13 years old; between the ages of 17 and 28 she gave birth to five children, and in addition had one miscarriage when 19 years old. Widowed at the age of 29, she fell ill, and on examination the uterus was found to be small and relaxed, whilst the vaginal portion of the cervix was reduced to a mere rudiment. Since she had been 22 years of age she had had persistent leucorrhoea, but no trace of menstrual haemorrhage; yet since that age she had had three children. Renaudin delivered a woman 61 years of age, who had ceased to menstruate 12 years earlier. Meissner reports a case in which a woman first began to menstruate at the age of 20, had her first child when 47 years old, and gave birth to the last of her eight children when 60 years of age.

The sudden and permanent cessation of menstruation, whether at the normal climacteric age, or earlier in life, is always a pathological occurrence. As compared with the normal, gradual disappearance of menstruation, associated with the usual climacteric symptoms, such a sudden extinction of menstrual activity is, moreover, quite rare. When it does occur, the cause is to be found in one of various pathological general states, such as one of the acute infectious disorders, or some other exhausting disease, or sometimes in some local disease of the reproductive organs; occasionally, however, it may occur in perfect health, in consequence of some powerful physical or mental stimulus, such as a severe blow or intense fright.

This sudden menopause has been observed after severe labour or abortion with profuse haemorrhage, or after cholera or typhoid; we must assume that in such cases the anæmia of the genital organs has disturbed the function of ovulation; whilst in cases due to mental shock, the interference with ovulation must be through the intermediation of the nervous system. Frequently, of course, in these cases, the sudden menopause is also a premature one.

Tilt reports a case in which a sudden menopause ensued upon phlebotomy during menstruation; several cases also in which women at ages varying from 30 to 34, or 39 years, ceased to menstruate suddenly and permanently in consequence of grief at the unexpected death of the husband; and another case of sudden menopause due to a fall down stairs. Courty reports three cases of sudden menopause at the age of 30, consequent upon an attack of cholera. Dusourd has seen three cases in which, in women aged 40 to 43 years, severe haemorrhoidal bleeding was followed by sudden and permanent cessation of menstruation. Mayer reports the case of a delicate middle-class woman 34 years of age, who had begun to menstruate at the age of 14, had married at the age of 20, and at the age of 21 after a normal delivery, ceased for ever to menstruate; and another case of a working-class woman 34 years of age who first menstruated at the age of 13 years, married at the age of 20, had two children in rapid succession, and finally ceased to menstruate, in consequence of a fright, at the age of 30 years. Krieger reports the case of a very nervous woman who first menstruated at the age of thirteen, and in whom at the age of 23 a sudden menopause ensued upon a nervous attack; in another case reported by the same observer, a sudden menopause occurred in a delicate woman 41 years of age owing to her husband’s death—this woman had previously experienced six months amenorrhœa in consequence of sorrow at the death of one of her children. The following remarkable case is reported by Brierre de Boismont: A sempstress began to menstruate at the age of 13 years; she married very soon after this, and gave birth to four children, the last when 21 years of age. In the course of the following year there was a fire in the house, and owing to this fright a sudden menopause occurred. Similar cases have been reported quite recently by Bossi and Walter.

The harmful influence which the occurrence of a sudden menopause exercises upon the general condition of the woman who experiences it, is manifested chiefly by violent circulatory disturbances, hyperaemia and congestion of the brain, lungs, and abdominal organs, and by states of excitement and depression of the nervous system. Of the vicarious haemorrhages which are apt to ensue upon such a sudden menopause, we have already spoken.

Generally speaking, women in middle life, in whom the whole organism is accustomed to the onset and decline of the menstrual hyperaemia, endure the functional disturbances induced by a sudden and complete cessation of menstruation much more easily than women who have already entered upon the climacteric age, or have nearly attained that age. The climacteric age is one in which women are already predisposed to circulatory disturbances in the pelvic organs, and it will readily be understood that in them the sudden interruption of the menstrual haemorrhages will have more serious consequences than in women in the prime of their sexual life, and therefore endowed with a greater power of resisting disturbances of the normal functions.

PATHOLOGY OF THE MENOPAUSE.

Diseases of the Genital Organs.

Among the commonest of the symptoms of the sexual epoch of the menopause is menorrhagia. It occurs especially in plethoric women, in those who during the prime of their sexual life have been accustomed to menstruate abundantly, and in those who have given birth to many children or had many miscarriages; but it is seen also in weakly and delicate individuals, in whom the tissues of the genital organs have become extremely flaccid and loose in texture. A luxurious mode of life, more especially a free consumption of alcoholic beverages, and also frequent sexual intercourse during the climacteric period, appear to favour the occurrence of menorrhagia at this epoch.

Not infrequently, menorrhagia is the first sign of the commencement of the climacteric, menstruation having been hitherto regular, and not excessive in amount. Generally, when this climacteric menorrhagia begins, the intervals also become shorter, the menstrual period being reduced to three or even two weeks. At times, however, the more profuse menstruation recurs at longer intervals, six weeks, two months, or even longer. In any case, the occurrence at the climacteric age of a severe or atypical haemorrhage, renders it the imperative duty of the physician to undertake a local examination of the genital organs; for it is necessary to ascertain without delay whether such a haemorrhage is a true climacteric phenomenon, or whether it is due to some actual disease of the reproductive organs—a neoplasm, or the like.