Part 89

From Gusserow’s collection of 526 cases, observed by Lebert, Kiwisch, Chiari, Scanzoni, and Saexinger, the following table has been drawn up, and it shows very clearly the great preponderance of the disease in the fifth decennium of a woman’s life:

At ages of from 20 to 30 there were 12 cases At ages of from 30 to 40 there were 161 cases At ages of from 40 to 50 there were 217 castes At ages of from 50 to 60 there were 102 cases At ages of from 60 to 70 there were 38 cases At ages of from 70 and upwards there were 5 cases

From the mortality statistics we obtain a similar result as regards the age incidence of carcinoma of the uterus. Thus, in England there died of this disease in one year:

Women at ages of from 15 to 25 44 Women at ages of from 25 to 35 184 Women at ages of from 35 to 45 717 Women at ages of from 45 to 55 1110 Women at ages of from 55 to 65 1116 Women at ages of from 65 to 75 876

Coming now to the consideration of fibromyomata of the uterus, we cannot share the opinion that at the climacteric age there is a special predisposition to the origination of such tumours, or that the climax favours the growth of already existing fibromyomata. It appears to us that in the preclimacteric epoch and the commencement of the climacteric, the symptoms of existing fibromyomata become more troublesome, the haemorrhages are more severe, the pains more violent; but that as the menopause is established, these troublesome symptoms decline progressively in intensity, and not only is there an arrest in the growth of the tumours, but often an actual diminution in their size.

I have myself repeatedly observed such cases, in which I had the opportunity of watching the growth of the myomata during a period of ten years or more. Other cases, indeed, show that myomata may increase in size after the menopause, at times with remarkable rapidity, and further that at this period of life a malignant degeneration may occur in such tumours. Carcinomatous, sarcomatous, and myxomatous degeneration have been observed, and also the transformation of a myoma into a soft fibrocystic tumour.

Atrophy of fibromyomatous tumours at the menopause, associated with the atrophy of the uterus that then occurs, has been observed by Playfair and by Doran. The tumour shrinks, its muscle-cells become smaller, and undergo fatty degeneration, there is an increase in the interstitial connective tissue, so that ultimately the fibromyoma is transformed into a firm and dense fibroid swelling. Cases in the older literature and also a recent observation of Yamagiron have shown that calcification of uterine fibromyomata sometimes occurs, leading to the formation of the so-called “uterine calculi.” In the case of pure myomata, the diminution in size occurring at the climacteric is generally due to resorption and fatty degeneration, whereas in the case of fibromyoma it depends on induration and atrophy. It remains uncertain whether the growth of purely fibrous tumours is also affected by the climacteric.

Whilst the influence of the climacteric on the growth of fibromyomata is thus usually advantageous to the patient, exceptions occur, as is shown by cases recorded by Lawson Tait, Schorler, and Boerner; the last-named author points out that at the climacteric there is a tendency for the transformation of fibromyomata into sarcomata.

Kleinwächter had under observation 78 cases of fibromyomata of the uterus in women who were older than 45 years; in only 8 of these was a diminution in the size of the tumour observed at the menopause; in 11 cases at this time, the tumour increased in size more or less rapidly; in 3 cases, a carcinomatous change occurred in the tumour; in 3 cases, the tumour was first observed at the time of the menopause; in 13 cases, the haemorrhages appeared to undergo a complete arrest at the menopause, but the size of the tumour was not affected; in the remaining 48 cases, no influence, either favourable or unfavourable, appeared to be exercised by the menopause on the fibromyoma of the uterus.

Cases reported by Rogival, Simpson, and Gusserow indicate the existence of a certain predisposition to the growth of sarcomata of the uterus at the climacteric period. Gusserow more particularly insists on the fact that we must bear in mind the likelihood of the origination of a fibrosarcoma or of the sarcomatous transformation of a fibromyoma, in all cases in which a fibrous tumour of the uterus first attracts attention at the climacteric period; or in which a tumour hitherto small and inconspicuous and giving little or no trouble, begins at this time to increase in size or to give rise to troublesome symptoms.

Neuroses of the Reproductive Organs.—One of the commonest neuroses of the reproductive organs at the climacteric period is pruritus vaginae et vulvae, and it is one of the most distressing symptoms of which women of this age complain. The disorder depends upon a hyperaesthesia of the sensory nerves of the vagina and the external organs of generation. It is characterized by enduring sensations of itching and burning, which may be either periodic (and then usually nocturnal) or continuous; at times it becomes so severe that the women thus affected have an unceasing desire to scratch, avoid all society, and ultimately find life quite unbearable. In the slighter degrees of pruritus, no objective changes are to be observed in the genital organs, or at most some slight hyperaemia of the vaginal orifice. In the more severe forms, however, there are local nutritive changes: the labia are swollen, their surface has an erythematous blush, a number of the hair-follicles are enlarged and prominent; the vaginal orifice is abnormally sensitive, it is scarlet or livid-red in colour and here and there denuded of epithelium, and there are scattered mucous follicles distended with a serous or purulent fluid; these small vessels are to be seen chiefly on the inner surfaces of the labia minora and around the clitoris. At the same time, the vulva secretes an acid, burning fluid, which greatly increases the patent’s sufferings, and at times impels her irresistibly to the practice of masturbation. In cases of long standing, we find hypertrophy, elongation, and deformity of the nymphæ, and pigmentation of these organs, with the formation of varices.

According to Fritsch, in exceptional cases pollutions are the originating cause of the pruritus, and this may be the case in women who are not sexually passionate. It occurs, indeed, especially in matrons who have not had sexual intercourse for years, and who have quite ceased to think about sexual matters; during the night, such a woman will begin to have voluptuous dreams, associated with a degree of sexual stimulation which is described as being actually painful. The woman often suffers greatly from these lascivious sensations. She complains that she cannot understand how it is that she has become affected with such utterly undesired feelings. She becomes profoundly depressed. Coitus often gives no relief whatever; but many women thus affected declare, as Fritsch points out, that by powerful, almost involuntary scratching, the stimulus is speedily subdued, and that for this reason they are absolutely compelled to scratch. It will readily be understood, that in this way persistent pruritus will arise, with local effects of scratching, and vulval eczema. According to the same author, in some instances pruritus is due to great insufficiency of secretion, such as occurs in the endometritis atrophicans which he was the first to describe. This scanty secretion, as it passes over the external genital organs, gives rise to irritation and itching. Haemorrhoids also play a part in the etiology of pruritus.

Diseases of the Mammae.—The sympathy which in the earlier phases of the sexual life—during the menarche, during pregnancy, and during the puerperium—so obviously exists between the breasts and the uterus, is seen also during the climacteric period. It now finds expression chiefly in the marked tendency to new growths in the mammae, a matter to which attention was already drawn by Galen. The commonest of these neoplasmata is carcinoma mammae, a disease which occurs chiefly during the climacteric epoch. In the great majority of cases, cancer of the breast is a primary disorder; in exceptional cases, however, the carcinoma of the breast arises by metastasis from a cancer of the uterus or the ovary. Sometimes the breast tumour is preceded by Paget’s disease of the nipple. For several years the patient suffers from what appears to be a chronic dermatitis of the nipple, the areola mammae, and the surrounding skin; but ultimately, and hardly ever before the commencement of the menopause, carcinoma of the breast ensues.

The older statistical enquiries of Birkett, Lebert, Scanzoni, and Velpeau, showed that carcinoma mammae most commonly occurred between the ages of 40 and 50 years, and next to that in frequency between the ages of 50 and 60 years.

A general hypertrophy of the mammary gland, affecting not only the enveloping and intra-lobular adipose and connective tissue, but also the proper glandular substance, is very rarely observed during the climacteric period; but in the preclimacteric epoch and in the early part of the climacteric, we not uncommonly see a hyperplasia of the adipose tissue of the breast, either as a local manifestation of a developing general obesity, lipomatosis universalis, or as a purely local excessive deposit of fat. In such circumstances, the mammae may at times be transformed into monstrous tumours.

Diseases of the Organs of Circulation.

Among the cardiac disorders of the menopause, the earliest and the commonest is, in my own experience, the following. At the time of the menopause, exceptionally not till after the complete cessation of menstruation, but usually at the commencement of this period of life, some time, that is to say, between the age of 40 and 50, either when menstruation has become irregular, the intermenstrual interval having become longer or shorter than has hitherto been the case, or when the discharge has become abnormal in character, a woman who has not before suffered from any kind of cardiac disorder, will begin to complain of paroxysms of palpitation.

In some cases the attacks of palpitation occur in the absence of any discoverable exciting cause; in others, some trifling stimulus gives rise to them. They may arise when the patient is in any position, walking, standing, sitting, or recumbent; sometimes even during sleep. The subjective sensation aroused by the increased force and frequency of the cardiac action is described as extremely distressing; it is associated with a feeling of anxiety (Angst), with a sense of pressure in the chest, with forcible pulsation of the carotids and of the abdominal aorta; frequently also with a feeling of a rush of blood to the head, with fugitive heats, and severe headache; sometimes towards the end of the attack there is a sense of flickering before the eyes (as of muscae volitantes), tinnitus aurium, dizziness, and in rare cases actual syncope.

Objectively, during the paroxysm, a notable increase in the frequency of the heart’s action can be detected, the pulse-rate rising to 120 or even 150 per minute. In most of my cases, the pulse throughout the attack remained strong, well-filled, and regular. Sphygmographic tracings taken during the seizures showed a remarkably high pulse-wave, the ascending limb of the curve rose rapidly and suddenly, the descending limb fell with corresponding steepness and rapidity, and it reached an unusually low level before the commencement of the dicrotic elevation, which latter was exceptionally large; the predicrotic elevations, on the other hand, were but slightly developed. On auscultation, the tones of the heart were pure, but were louder than normal.

Sometimes during a paroxysm a sudden reddening of the face was noticeable, extending often to the neck and the thorax. In the areas mentioned, vivid red patches would suddenly make their appearance, disappearing more gradually after lasting a few minutes—this appearance was associated with a burning sensation of the affected areas. In some cases during the paroxysm there was an outbreak of perspiration on the head and the back.

Associated with these cardiac troubles of women at the climacteric we usually find a state of physical and mental disquiet; less common associations are, an incapacity for regular work, sleep uneasy and much disturbed by dreams, great general nervous irritability, or signs of passive congestion in various organs; occasionally there is oedema of the lower extremities; the urine remains free from albumen.

In most of the cases of this nature which came under my own observation, a certain plethora was noticeable; among women at the menopause, it was especially the well-nourished, powerful, sanguine individuals, that were liable to palpitation of the heart. Direct examination of the blood sometimes showed a very high haemoglobin richness—110, 115, or even 120, as compared with a haemoglobin-richness of 93 in normal woman. Several of my patients presented the clinical picture of the plethoric form of lipomatosis universalis.

In all, during ten years, I observed 67 cases of paroxysmal tachycardia in climacteric women. The age distribution was the following:

36 years of age 1 woman 38 years of age 1 woman 39 years of age 2 women 40 to 45 years of age 37 women 45 to 50 years of age 28 women Over 50 years of age 8 women

Five of the patients were unmarried, three were married but childless, the remaining 59 were parous women.

As a general rule, women live in great dread of all manifestations of bodily disorder during the menopause; those who become affected with paroxysmal tachycardia are exceptionally anxious, and regard themselves as threatened by a “stroke.” This pessimistic view is however, by no means justified. These cardiac disorders may make their appearance some time before the menopause, they may persist throughout the period during which menstruation is irregular, they may even endure for some time after the total cessation of the flow—but serious consequences of this climacteric tachycardia have never come under my observation. As regards treatment of the disorder, I have seen very favourable results from the following measures: The systematic employment of mild purgatives, combined with suitable dietetic and hygienic regulations (bland diet, regular and strenuous exercise, cold ablutions, and wet compresses surrounding the abdomen).

When we enquire regarding the cause of the tachycardiac paroxysms occurring at the menopause, we must first of all bear in mind that in the cases which have come under my own observation, the cardiac impulse was powerful, the pulse strong and well-filled, that signs of general vasomotor disturbance (ardor fugax, etc.) accompanied the tachycardiac seizures,—hence we are led to infer that we have to do with a stimulation of the excito-motor nerve fibres, which would appear to be due to the climacteric changes previously described as occurring in the female reproductive organs. This view receives support from the fact that after oöphorectomy, when, as in the normal climacteric, atrophic processes occur in the internal reproductive organs, paroxysms of nervous palpitation are frequently observed. The same explanation applies to the fact that in women at the climacteric affected with these tachycardiac troubles, we frequently see in association therewith the symptoms of uterine dyspepsia.

But in addition to these local anatomical changes in the reproductive organs, to which an etiological role must be assigned in the production of climacteric tachycardia, the irritable state of the accelerator nerves must also depend in part upon that general nervous hyperexcitability which is so often a characteristic feature of the climacteric period in women, manifesting itself in manifold hyperaesthesias, hyperkinesias, neuralgias, and, in extreme cases, mental aberration. The sensory nerves are more irritable than in their normal state, so that every stimulus acting upon them evokes a greater central effect than heretofore, and upon this ensues an exaggeration of various reflex manifestations, which appear altogether disproportionate to the strength of the exciting cause; among these disproportionate reflex effects, is to be numbered the tachycardia just described.