Under the name of senile irritation of the uterus, Maxwell has described a disease occurring at the climacteric, characterized by an enormously increased irritability of the uterus, with marked reflex manifestations; in these cases also we may perhaps have to do with a senile endometritis. The most pronounced symptom is a severe and constant uterine pain, to which in the course of the disease are superadded pains in the gastric and cardiac regions, the rectum, and the spinal column; these pains lasted a long time, and their severity was such that it became necessary in some cases to remove the uterus.

Hydrometra is a disease which makes its appearance principally late in the climacteric period, when menstruation has already completely ceased, and when the adhesions associated with the climacteric atrophy of the uterus have led to atresia of the cervical canal. Among 74 cases of hydrometra (from the material of the Pathologico-Anatomical Institute of Prague, in the years 1868 to 1871) not one of the women was less than 40 years of age; the age distribution of the cases was in fact the following:

In 40 of these cases, the occlusion was in the region of the os internum, in 23 it was in the region of the os externum, in 9 cases the whole length of the cervical canal was obliterated, and in 2 both the internal and the external os were occluded, the intervening portion of the cervical canal being still patent. In the two latter cases, there was hydrometra bicamerata, with retroflexion of the uterus.

Late in the climacteric period, haematometra also occurs, though less often than hydrometra. When, in cases in which the os uteri externum is occluded, in consequence of adhesion between the vaginal walls and the vaginal portion of the cervix, as a sequel of the vaginitis ulcerosa adhesiva of elderly women, there is haemorrhage from the atheromatous vessels of the uterus or the tubes, the blood necessarily distends the uterine cavity.

During the climacteric period, leucorrhoea is so extraordinarily frequent, as the figures previously given show, that the assumption is justified that with the diminution or cessation of the menstrual flow, this hypersecretion from the genital mucous membranes forms as it were a kind of vicarious flux. Sometimes, as in 12 cases recorded by Tilt, we actually have a periodic “menstrual leucorrhoea”; in one of these cases the discharge recurred at regular monthly intervals for 12 months, in another for 18 months, in several for 2 years, and in one for as long as 7 years. It is only by careful examination that the exact source of the discharge can be determined, for during the climacteric also, as well as earlier in life, leucorrhoea may be due either to endometritis or to colpitis. A muco-serous or sanguino-serous secretion may also be due to slight vulvitis.

A peculiar form of inflammation occurring after the completion of the menopause, and after the atrophic process in the vagina is considerably advanced, is known as colpitis senilis. In this disease, ulceration readily occurs, followed by cicatricial adhesion between the anterior and posterior walls of the vagina (vaginitis adhaesiva vetularum); in other cases herpetiform eruptions arise, with a tendency to pustule formation; occlusion of the vagina may lead to hydrometra and pyometra; sometimes the obliteration of the vagina is complete, so that there is neither outlet for blood from the uterus, nor inlet for the penis during coitus. This vaginitis adhaesiva vetularum is by no means rare in the climacteric period; as a rule it does not give rise to very serious trouble, the most prominent symptom being usually somewhat persistent haemorrhage, unaccompanied by any evil odour. On local examination, the characteristic strings of scar tissue are felt, passing from the portio vaginalis to the narrowed, senile vaginal fornix; from the cervical canal there exudes a usually somewhat vitreous mucus, mixed with blood. The cervix itself is thin and atrophied, the uterus also is greatly diminished in size.

The frequency at the time of the menopause of such catarrhal inflammatory processes in the vagina and vulva is said by Duprès to depend on the weakness or paresis of the bladder which is so common in women at this time of life. Owing to the incomplete evacuation of the urine, cystitis very readily ensues; the urine is evacuated involuntarily during sleep, and some of this fluid passes through the vaginal orifice, giving rise all the more readily to colpitis, because the secretion of the atrophic mucous membrane no longer possesses the normal acid bactericidal properties. According to Scott, vulvitis may also arise as a sequel of calculus-formation in the glands of Bartholin, a frequent occurrence in elderly life, followed by inflammation and abscess-formation in these glands. Among the diseases of the genital organs at the climacteric period, Fritsch also enumerates urethral caruncle and carcinoma of the clitoris.

Displacements of the Uterus.—Among the commonest of the displacements of the uterus occurring during and after the menopause, is prolapse of the organ. Previously existing descent of the uterus is apt to be greatly aggravated at the climacteric, a partial prolapse, for instance, becoming complete; or prolapse of the uterus may first set in at this period of life.

There are several contributory causes of the liability to prolapse at this particular epoch, especially in women who have had a great many children, and in those with either enlargement of the uterus or with lacerated perineum; the most powerful of these causes being the weakening of the uterine supports in consequence of the general relaxation of the pelvic tissues. At the menopause, the connective tissue by means of which the uterus is attached to surrounding structures, withers; simultaneously the vagina atrophies, and this source of support is weakened; the whole pelvic floor loses its firmness and power of support. For these reasons, a uterus which has hitherto been in correct position readily becomes retroverted and to some extent prolapsed; whilst one that was already thus far displaced prior to the menopause, will now be apt to descend still further till it rests upon the perineum. With the disappearance from the vulva and the perineum of the adipose tissue on which their firmness so largely depends, complete prolapse of the uterus is now likely to ensue. Prolapse of the urethra may also result from senile involution of the pelvic contents.

Among my 500 cases of women at the climacteric, there were 65 instances of more or less severe prolapse of the uterus. The frequency of prolapse in women at the climacteric and in those at a more advanced age, is shown by the following figures, which are compiled from the post mortem statistics of the Pathologico-Anatomical Institute of Prague (years 1868 to 1871). Prolapse of the uterus was found:

Flexions and versions of the uterus, common as they are at the time of the menopause, have no longer the same importance that they possessed during the prime of the sexual life. For on the one part the size of the uterus is greatly diminished, in consequence of the lessened blood-supply and of senile involution of the organ; and on the other, after the cessation of menstruation, the profuse haemorrhages and severe colicky pains which for the most part occurred during menstruation in these cases of kinking of the uterine canal, and which gave rise to such severe general disturbance, now no longer occur. Herein lies the explanation of the fact, well known to all experienced practitioners, that women who have for many years suffered from retroflexion or retroversion of the uterus associated with severe and painful symptoms, cease to suffer after the menopause is established, and regain excellent health, although the local condition of the uterus remains unrelieved.

Neoplasmata of the Uterus and of the Uterine Annexa.—The most serious danger to the life of a woman during the climacteric period is to be found in the strong tendency to the occurrence of carcinomatous disease of the uterus—a predisposition so marked that not less than one-half of all illnesses affecting the reproductive organs of women at this age are cases of carcinoma of the uterus. The disease occurs especially at the beginning of the climacteric, between the ages of 45 and 50 years, most often in the form of carcinoma of the portio vaginalis, whereas after the completion of the menopause, carcinoma of the body of the uterus is the preponderant form. The true reason for the frequency of the occurrence of carcinoma at this period of life will only become clear to us when we are more fully acquainted with the nature and origin of this form of malignant disease. Meanwhile, it would seem that the predisposition to cancer during and shortly after the menopause depends upon the anatomical changes in the reproductive organs at the time of involution, which render these organs a more suitable soil for the proliferation of malignant growths; and further it is probable that the loss of the acid, bactericidal quality of the vaginal secretion, opens the door for the entrance of pathogenic micro-organisms. Noteworthy is the observation of Baer and Leopold, that very frequently a preclimacteric or climacteric fungous endometritis forms the stage of transition to the development of carcinoma of the body of the uterus. At the time of the menopause there is also an increased liability to the occurrence of cancer of the ovaries. Numerous statistical data have been published regarding the frequency with which carcinoma of the uterus occurs at various periods in women’s lives, and, notwithstanding all variations, one fact stands out clearly, namely, that this disease occurs most frequently in the fourth and fifth decennia, and above all during the climacteric period.

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:

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:

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:

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.

But in addition to the causes of climacteric tachycardia already enumerated, we have to take into consideration the results of recent investigations concerning the organo-therapeutic employment of the chemical constituents of the ovarian tissue; it would seem that when at the menopause the ovaries undergo atrophy, so that their internal secretion is no longer poured into the blood, the resulting alteration in the chemical constitution of that fluid gives rise to a disturbance of the vasomotor centre in the medulla oblongata.

In some cases, the tachycardiac paroxysms appear to be connected with the erotic excitement to which women are sometimes subject at the climacteric, voluptuous crises and ejaculation occurring; it is possible that in some of these cases masturbation plays a part.

A second group of cardiac troubles occurring in climacteric women consists of cases which are very common, but not often very severe. The cases in question depend upon the liability to an increased deposit of adipose tissue in the body at the time of the menopause, and in this connexion the plethoric form of lipomatosis universalis almost invariably predominates. It is a well-known fact that between the ages of 40 and 50 years women have an excessive tendency to obesity, and that even those women who have hitherto been extremely lean are apt to become quite plump at the climacteric period. Chiefly in consequence of this increasing obesity, there occurs in climacteric women a series of cardiac troubles of very variable intensity. If the deposit of fat is effected very gradually, and if the obesity does not become extreme, it is only after vigorous bodily exercise, such as fast walking or going upstairs, and after meals, that the patient is troubled with a little shortness of breath and moderate palpitation; appetite, digestion, and sleep remain usually unaffected in cases of this degree of severity. Definite attacks of cardiac asthma, and well-marked signs of cardiac insufficiency affecting the entire circulatory system, will very rarely occur in such persons.

It is an interesting fact, that the troubles which arise from fatty deposits around the heart are in general far less severe in climacteric women than they are in obese men of corresponding age. This may be due to the circumstance discovered by W. Müller, in the course of his investigations on the proportions of the human heart, that in the development of general obesity, the pericardial fat increases proportionately to a greater extent in the male than in female. But in my opinion the true explanation is to be found in the fact that variations in the amount of fat in the body are normally far more extensive in women than in men; at puberty, during pregnancy, and during lactation, extensive though gradually effected changes in the amount of adipose tissue in various parts of the body occur, so that experience has rendered the organism ready to adapt itself to the further changes that take place at the climacteric—above all, the heart has become competent to meet very various demands upon its powers.

Only in women who from youth onwards have exhibited a marked tendency to obesity, and in whom at the climacteric age such obesity has become extreme, do the cardiac troubles attendant on the menopause become very severe. In such persons, palpitation and shortness of breath occur on slight exertion, and attacks of cardiac asthma are frequent. In consequence of the diminished propulsive power of the heart, circulatory difficulties make their appearance in the most widely divergent venous areas; the forms most commonly met with are, varices in the veins of the lower extremities, permanent dilatation of certain of the small superficial veins of the skin, phlebectases of the rectal veins (i. e. “piles”), and ultimately we see the well-known series of symptoms of venous engorgement—oedema of the feet, passive congestion of the lungs, albumen in the urine, etc.

When such cardiac troubles are present, the objective examination of the heart shows in the early stage no gross abnormality; at most the heart-tones seem somewhat weakened, with a moderate enlargement of the area of percussion-dulness, whilst the impulse is displaced a little outwards, and is weaker than normal. In some cases, however, a marked dulness on percussion over the sternum indicates an extensive deposit of fat in the mediastinal tissues. In the second stage of the fatty heart, when the symptoms have become more severe, we find a considerable enlargement of the area of cardiac dulness both in the vertical and the horizontal extent; the cardiac impulse is diffused as well as feeble. The sounds of the heart are usually pure but faint—in some cases they remain loud and clear. Exceptionally, a short blowing murmur is heard with the first sound; and sometimes this sound is reduplicated.

Whilst in the first stage the pulse is hardly abnormal, in the second stage, very various changes occur; often it is subdicrotic or dicrotic in character.

In the great majority of instances, in these cases of cardiac disorder at the menopause, provided a suitable dietetic regimen is early adopted and perseveringly carried out, we may give a hopeful prognosis.

A third, less common but far more serious form of cardiac disorder occurring at the menopause, displays the well-known symptoms of cardiac failure. Those thus affected are usually slightly built, delicate women, who during the years of development suffered from chlorosis, who in adult life were troubled with anæmic symptoms, and in whom the menopause was ushered in by very severe losses of blood; sometimes, again, they are women who throughout their sexual prime have been accustomed to menstruate very abundantly, who have had numerous and severe deliveries, or who have had frequent miscarriages—it is in those who have thus been weakened by frequent and profuse haemorrhages, that the symptoms of cardiac failure ensue at the climacteric period. The women thus affected also frequently suffer from palpitation of the heart; the pulse is abnormally frequent, small, low, and easily compressible, and sometimes intermittent or arrhythmical. The heart’s action is weak and devoid of energy. The heart-sounds are usually obscure, and sometimes a systolic murmur is audible. The patients are short of breath and are subject to attacks of cardiac asthma, not infrequently associated with angina pectoris. In conjunction with these symptoms, we see signs of venous congestion: sudden attacks of coldness in the hands and feet, often also oedema of the feet; the urine at times contains albumen. The haemoglobin-richness of the blood is always notably diminished. I need not discuss in further detail the well-known symptoms of cardiac insufficiency, and I need only insist that when these symptoms are met with in women at the climacteric, it is of the greatest importance, alike from the prognostic and from the therapeutic standpoint, to make a careful examination of the reproductive organs, so as to determine the exact source of the recurrent bleedings which usually constitute the primary cause of the patient’s sufferings.

In several cases of this kind, I found that the haemorrhages were due to a relaxation of the uterine tissues, and that this relaxation was itself referable to intrapelvic circulatory disturbances, dependent upon obstruction in the vena cava inferior, whereby the venous return from the pelvis was rendered difficult, and an engorgement of the uterine vessels was brought about.

In some instances of cardiac failure at the menopause, chronic inflammation within the pelvis is to blame for the menorrhagia upon which the cardiac failure depends. Often, again, the haemorrhages are referable to vasomotor influences, such as are liable during the menopause to affect various vascular areas. In other cases, the recurrent bleeding is due to retroflexion of the uterus, to prolapse of that organ, or to tumour, it may be myoma, polypus, or carcinoma.

Finally, during the menopause, more especially in women in whom menstruation has continued up to or beyond the fiftieth year, or in those who have given birth to a large number of children or have lived lives of severe bodily exertion, cardiac troubles may arise dependent upon arteriosclerosis of the great vessels. The signs of such changes in the walls of the bloodvessels are clearly marked: the cardiac impulse is heaving, the second sound of the heart is accentuated; the pulse is full and large, usually giving a very powerful blow to the examining finger, whilst its sphygmographic tracing exhibits characteristic signs in the exceptional height and great distinctness of the first predicrotic elevation. The subjective troubles are in these cases very severe; dyspnoea and attacks of asthma or of vertigo are common, and sometimes albumen may be found in the urine.

We may thus summarize the cardiac disorders met with at the menopause, and more or less directly dependent upon the changes undergone by the feminine organism at that period of life:

1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric changes in the ovaries.

2. Nervous palpitation in women who were similarly affected at the time of the menarche, and in whom the trouble is merely the expression of a very unstable nervous system, and one influenced with especial readiness by impressions proceeding from the reproductive organs.

3. Cardiac disorder due to the obesity so commonly occurring as a part of the general metabolic changes of the menopause, but more particularly dependent upon a deposit of fat in the neighbourhood of the heart itself.

4. Symptoms of cardiac failure, due to excessive losses of blood at the menopause, either as an exaggeration at this time of menstrual processes, or as a result of some actual disease within the pelvis.

5. Cardiac disorder in women in whom the menopause occurs at an unusually advanced age, and dependent upon arteriosclerosis.

Particular consideration must be given to a symptom not infrequently occurring in association with the cardiac troubles of climacteric women, and referable to the circulatory disturbances characteristic of this period of life, namely, vertigo. The attack in some cases comes on without apparent cause, in others it occurs on the performance of some unusual movement or the adoption of some peculiar posture (stooping, or the like); the patient is suddenly seized with a sense of rotation, either of his own body, or else of his visible and palpable environment; with this is associated a sensation of disturbance of equilibrium, flickering before the eyes (muscae volitantes), tinnitus aurium, palpitation of the heart, increased frequency of the pulse, which may be either full or small, redness or pallor of the face, coldness of the hands and feet, muscular twitchings, a sense of great anxiety, and the outbreak of a cold perspiration. The vertigo occurs in paroxysms, usually of short duration—a few minutes to a quarter of an hour. It is especially plethoric and obese women who are liable at the climacteric to suffer from this disorder.

A somewhat similar condition is described by Tilt under the name of “pseudo-narcotism,” as frequently occurring in climacteric women. Tilt indeed states that in 500 such women, he noted its presence in no less than 277.

Many hypotheses have been promulgated to account for the vertigo that so frequently occurs at the menopause. Both anæmia and hyperaemia of the brain have been assumed as causes, alike dependent upon the irregularity of menstruation, which is supposed to have a reflex influence upon the cerebral circulation. Others regard the vertigo as a climacteric neurosis, since it occasionally occurs before the menstrual irregularities begin, and in such cases a reflex disturbance of the cerebral circulation cannot be supposed to have arisen. According to Matusch, climacteric vertigo is a manifestation of epilepsy—an explanation which has been often extended to include all the menstrual psychoses. Windscheid believes that in many of the cases the vertigo is to be explained by the existence of arteriosclerotic changes in the blood vessels, such as are already by no means rare at the age at which the menopause usually occurs; whilst in other cases, he believes, the vertigo is to be regarded as one of the symptoms of a nervous disorder. That in any case the vertigo is dependent in some way upon the changes that occur in the reproductive organs at the climacteric period, is shown by the fact that after the final cessation of menstrual activity the patient as a rule ceases to suffer from this symptom.

To the circulatory disturbances consequent upon the menopause we must also refer ardor fugax, fugitive heat, the sudden rushes of blood to which women are prone at this period of life.

The cardiac troubles of the menopause are seen especially in women in whom the cessation of menstruation occurs quite suddenly, and in those in whom menstrual activity ceases at an exceptionally early age. It would seem that in such cases, owing to the continuance of periodic maturation of the graafian follicles associated with congestion of the intrapelvic organs, in the absence of the periodic relief to that congestion afforded by the menstrual flux, there results a summation of stimuli, whereby the accelerator nerves of the heart are very powerfully affected.

Thus, I had under my care a lady from Smyrna 36 years of age. She had begun to menstruate when 12 years of age and menstruation was always scanty; she married when 15 years old, and finally ceased to menstruate when 19 years of age; she was sterile, and no abnormality could be detected on physical examination of her reproductive organs. Every month she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of blood to the head, perspiration of the face, etc.

In another case, that of a woman 45 years of age, menstruation, hitherto regular, was suddenly suppressed, during the flow, in consequence of a severe fright. The next month the flow failed to appear at the usual time, but instead the patient was affected with severe cardiac distress, accompanied by sudden sensations of heat in the face, palpitation of the heart, and vertigo; these symptoms lasted for several days, and since then have recurred at intervals of three or four weeks.

The cardiac troubles of the menopause are seen with especial frequency in women who were affected with similar disturbances at the time of the menarche. Experience clearly shows that a certain connexion exists between the manifestations that accompany the commencement of sexual activity, and those that accompany the decline and extinction of that activity; and a physician will rarely be mistaken if he bases on the fact that the general health was or was not seriously affected at the age of puberty, a prognosis that the course of the climacteric will be an unfavourable or a favourable one, respectively. In other words, in women whose nervous system is an unstable one, and in those with hereditary predisposition to the occurrence of cardiac disorder, the changes that take place in the reproductive organs both during the menarche and during the menopause, are likely during these vital phases to arouse reflex disturbances of the cardiac functions. The facts thus noted are analogous to those observed by Potain, who distinguishes a peculiar form of chlorosis, occurring in delicate individuals at the age of puberty, and, though apparently cured during the menacme, recurring in its primitive severity at the time of the menopause.

Again, women with a sanguine and erethistic temperament are more inclined to suffer from cardiac troubles at the menopause than women of a tranquil temperament and those endowed with an unimpressionable nervous system.

Finally, elderly virgins, women who have for many years lived in chaste widowhood, sterile women, women who have married shortly before the menopause, or who at this time have recently been delivered, are all more inclined to the cardiac troubles of the climacteric period than women whose sexual life has been of a less abnormal character.

In the literature of the subject, we find numerous references to the fact that among the disorders of the climacteric, circulatory disturbances play a part. But a full and accurate account of these disorders is lacking alike in the literature of gynecology and in that relating to diseases of the heart—and this is true even of the most recent publications.

Among striking individual cases, one recorded by Moon may be mentioned here, a case of tachycardia consequent upon a sudden menopause: “In a woman 35 years of age the menses were suppressed owing to chill; the pulse-frequency increased from 80 to 200, without any apparent change in the heart or its valves; the symptom lasted for several days, when menstruation became once more established, and the pulse-frequency fell again to the normal.”

Tilt expresses the opinion that the heart is but little involved in the disturbances of the climacteric, his experience coinciding with that of Quain. Boerner and Glaevecke, on the contrary, describe the heart troubles of the climacteric in terms very similar to those employed by myself.

A. Clément describes a peculiar form of disturbance of the functions of the heart at the climacteric period, to which he gives the name of Cardiopathie de la Ménopause, and of which he has seen four cases. The age of his patients varied from 46 to 50 years. They were all vigorous women, free from hysterical symptoms, and they had never suffered from rheumatism or from any functional disturbance of the heart. In all these cases the cardiac disorder occurred at a time of life when menstruation still continued, but had already become somewhat irregular. Usually the trouble in question makes its first appearance during the flow, or, if occurring independently of menstruation, becomes more severe at that time. Prior to the development of the actual heart symptoms, we observe for a time, two or three months it may be, signs of general exhaustion and weakness. Then occurs an attack of palpitation of the heart, rapidly succeeded by faintness, sense of precordial anxiety, and dyspnoea. During repose the patient does not usually suffer from any difficulty in breathing, but sleep is apt to be disturbed by paroxysms of palpitation and severe precordial anxiety. As the disease advances, dyspnoea is observed on the slightest exertion. Ultimately, the symptoms mentioned, palpitation, precordial anxiety and dyspnoea, become permanent, but are less severe when the patient is at rest. Constant now is also the feeling of weakness and faintness, which from time to time increases to actual syncope with complete loss of consciousness, and coldness of the entire surface of the body. Examination of the heart gives negative results. The cardiac impulse is a little stronger than normal; the cardiac rhythm may be either regular or irregular, but actual intermission of the beats does not occur. The heart-sounds are pure, there is no murmur; the first sound, if altered at all, will be stronger, not weaker than normal. Neither swelling of the jugular veins nor venous pulsation is to be observed. The most striking symptom of heart affection, indeed the only positive physical sign, is the great increase in the frequency of the heart’s action, the pulse rate often being as much as 150 or 160 per minute, and in addition weak and somewhat variable in strength. At the outset of the disease, no oedema of the lower extremities is to be observed, and it only appears after three or four attacks. In all the patients the extreme pallor of the face is a striking feature. An increased quantity of urine is eliminated. The course of the disease is characterized by a series of successive paroxysms, separated by periods of almost complete remission. At first, these remissions last for a month or two, but they gradually become shorter and shorter, whereas the duration of the attacks continually increases, until it is as much as seven or eight days. At this stage, disturbance of digestion ensues, the appetite is lost, and the general vigour declines. Recovery ultimately occurs, but very gradually. Clément refers the disease to a profound disturbance of the cardiac innervation through the sympathetic nerves, but believes that anæmia constitutes a contributory cause of the cardiac disorder.

Kostkewitsch has made observations regarding the influence of the climacteric upon previously existing heart-disease, and has thereby been led to conclude that the influence is unfavourable. The functional disturbances of the cardio-vascular apparatus which commonly accompany the menopause, readily lead, should organic heart-disease exist, to the onset of severe cardiac weakness, which may have a rapidly fatal termination. In 55.5% of the women who enter the climacteric period with organic disease of the heart, the menopause gives rise to a failure of compensation. Such failure of compensation is especially likely to occur in women suffering from valvular insufficiency; it is least probable in cases of arteriosclerosis without valvular defect. The symptoms of defective compensation—dilatation of the heart, increased frequency of the pulse, arrhythmia cordis, etc.—are manifested especially during the menstrual flow.

Diseases of the Digestive Organs.

The congestions which, as we have already pointed out, constitute the pathological basis of the majority of the disorders of the climacteric, manifest themselves in the abdominal organs in the well-known form of plethora abdominalis, chronic venous congestion of the gastric and intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the mucous membrane of the bladder, catarrh of the bladder, distension of the haemorrhoidal veins, and the various symptoms dependent upon these several forms of congestion.

Bleeding from the haemorrhoidal veins and chronic diarrhoea are two of the troubles proceeding from the above mentioned congestion of the intra-abdominal vessels, which occur so frequently during the climacteric period that since the days of antiquity they have been regarded as critical manifestations of the menopause, the object of which is to afford a vicarious outlet for the menstrual flux, now become irregular and intermittent. It can, indeed, be readily understood that a discharge of blood and an increased secretion from the mucous membrane of the lower part of the intestine may, if not too violent, exercise a favourable influence upon the congestive states of the climacteric, by relieving the distension of the abdominal vessels—by a local blood-letting which regulates the disordered circulation. In this way, even though we have ceased to regard it as a “critical” manifestation, haemorrhoidal bleeding, accompanied by an increased secretion from the intestinal mucous membrane, may at the climacteric period have a distinctly favourable influence upon a woman’s general condition.

Hippocrates already in his aphorisms pointed out the salutary effect of epistaxis and of diarrhoea in women suffering from suppression of the menses. Other authors have assigned a critical significance to diarrhoeas occurring at the climacteric, and have warned against their suppression. According to Tilt, diarrhoea occurred in 12% of all women of this age coming under his observation; in 4% of the climacteric women, this diarrhoea recurred at regular monthly intervals, whilst in 8%, the recurrence was irregular. In 500 women during the climacteric age, Tilt observed the following abdominal disorders:

In my own observation, constipation is more frequent in climacteric women than diarrhoea, the constipation being also a symptom of abdominal congestion. Sometimes, when diarrhoea occurs, it is really secondary to constipation. The accumulation of the faecal masses stimulates the intestinal mucous membrane, and gives rise to a profuse aqueo-mucous secretion; the firm faecal masses are then liquefied, the intestinal wall is lubricated, and the constipation gives place to diarrhoea lasting perhaps for several days. This is the explanation of many cases in which there is a periodic recurrence of diarrhoea.

Dyspeptic disturbances are rarely absent during the climacteric period. Most often we see disordered appetite, sluggish digestion, pyrosis, eructation, at times nausea and retching, and actual vomiting of a watery or bilious fluid. Occasionally, an abnormal sensation of hunger follows each meal, associated, however, with a feeling of distension of the stomach. A very distressing symptom is an excessive formation of gas within the intestine. At times such meteorism is extreme, and it then gives rise to very severe abdominal pain. The gas is evacuated slowly and with difficulty, the patient is compelled to loosen all her clothing; more especially after a meal she is compelled to take off her stays and undo all the bands of her petticoats and skirt. At the same time we see difficulty in breathing and tachycardia. Such an accumulation of gas within the abdomen may give rise to serious errors in diagnosis, the swelling being attributed to pregnancy or to abdominal tumour.

Noteworthy also at the time of the menopause is the occurrence of vomiting, either as an isolated symptom, or in association with some other well-known climacteric disorder. When this vomiting is associated with some unmistakable form of excessive secretory activity (hyperhydrosis, etc.), we may readily suppose that the vomiting is due to undue secretory activity on the part of the gastric mucous membrane. An excessive production of gastric juice, perhaps altered in quality as well as quantity, combined with some other disorder of gastric innervation (hyperaesthesia, or hyperkinesia) will sufficiently explain the occurrence of the sometimes excessive vomiting, even though in many of the cases there may be no reason to suppose that there exists any primary stimulation of the vomiting centre. In other cases, however, it is probable that the trouble is really due to a primary disorder of that centre; and a careful study of the clinical features of the case will be needed to show how far there may be associated with this other disorders of gastric innervation (Boerner).

Disturbances of the biliary secretion, icterus of greater or less severity, are by no means rare manifestations of the abdominal congestion of climacteric women, and such disorders have also been regarded as vicarious processes originated by the cessation of the menstrual flux (Aran, Bennet, Henoch, and others.) Frerichs also has pointed out that with the cessation of menstruation at the climacteric we not infrequently observe swelling of the liver, which disappears when, after a considerable period, the menstrual flow recurs—a sequence of symptoms which may be repeated again and again for a considerable time.

Diseases of the Skin.

The most characteristic symptom of disorder of the skin met with at the climacteric period—one which, indeed, may be said to be never absent—is ardor fugax, fugitive heat; and scarcely less common is hyperhydrosis, an excessive secretion of sweat. Almost invariably, at the commencement of the menopause, women complain of a feeling of burning heat, rising up from the breast to the face; and if they are kept under observation we see from time to time a sudden redness of the face, and sometimes also of the neck and chest, associated with the outbreak of a thin perspiration. Moreover, in nearly all climacteric women, we notice an increased secretion of sweat over the whole surface of the body, and at times this secretion is extremely profuse.