THE INFLUENCE OF THE CLIMACTERIC ON CERTAIN PATIIOLOGICAL CONDITIONS OF THE PELVIC ORGANS.
Certain anomalies are directly caused by the menopause. Others, which already exist, are aggravated; others again retrograde and may be entirely cured, as soon as the menopause is estab lished. Here and there I have already had occasion to refer to these cir cumstances. We saw that at the climacteric a e,atarrhal condition of the uterine mucosa may develop, which often lasts for a long time. This may frequently attain quite a marked intensity, even when the mucous membrane was previously perfectly normal. Enlargement of the entire uterus, sometimes merely in consequence of an increased supply of blood to this organ, sometimes directly due to inflammatory swelling at the menopause, frequently proceeds to subsequent atrophy.' We have several times alluded to the displacements of the uterus of all kinds, which may be referred to this period. Desceusus and prolapsus uteri are especially frequent. The occurrence of these conditions is, however, often already fiwored at an earlier time (through violent bodily exertion, frequent labors, uterine infarcts, etc.), yet they may also appear in the case of organs that were previously intact. Without doubt there are many causes which, during the climacteric, and especially during the post-climacteric period, concur to bring this about. The retrograde metamorphosis of the uterine muscle, the frequent relaxation of the vagina (aside from partial or general contraction of the e,anal), the disappearance of the fat cushion around the vulva, finally the relaxation of the ligaments and the diminished intra-abdominal and intra-vaginal pressure, are conditions that altogether have much to do with it. On the other hand, increase in the original size and weight of the uterus,—which must be of especial signitleattee when, on account of the constipation that is almost invariably present at this time, the pressure of the abdominal walls is greatly in creased,—and other influences must all be considered.
The most peculiar and instructive observation of this kind that I ever made was the following: Miss G. had passed the menopause about ten years before. During her whole life she had been free from all abdominal disturbances, and up to the time in question had felt perfectly well, so much so that of late years she was somewhat incommoded by a rather considerable development of fat. Shortly before she happened to be assisting in the moving of a chest, when she suddenly felt a pain in the abdomen, and at once felt some foreign body between her legs. She came to me soon after and I found a total prolapse of the uterus and vagina, while in every other respect the genitals were intact. The patient was a nullipara and had accordingly a perfectly firm perineum; the vagina, which was already somewhat narrowed through senile contraction, was absolutely free from those changes (hypertrophy, a dry leathery feel of some portions, etc.) which would have pointed to a procidentia of long
standing; the uterus was already atrophied, was small, light, and thin walled, and the portio was absolutely intact; in short, before the accident (with the exception of those changes that were due to advanced age) the pelvic organs were normal in every respect. It is proper to add also that the above-mentioned bodily exertion was not excessive, since the patient had previously undertaken it on several occasions (and probably to a much great,er extent) without injury, so that this case cannot be regarded as simply one of those frequent cases of more or less marked displacement of the uterus, resulting from great increase of the abdominal pressure under conditions that are otherwise more or less normal. The only explanation in my opinion lies in this case in the post-climacteric changes which, as above stated, especially favor the occurrence of descensus or prolapse, and here bad such a striking influence that in spite of the insignificant causal factor, and the oth, ,Ivise unimpaired condition of the entire genital tract (there being no increase in the weight of the uterus, previous prolapse of the vagina, loss of tone of the perineum, etc.), there could occur in an instant a complete prolapse of the vagina and uterus. More exactly, then, we adopt this view, in the absence of other explanations, that in our case probably senile changes in the ligaments of the uterus were the cause of the sudden displacement, and in this connection I again call attention to the possible consequences of relaxation of the abdominal walls, previously referred to. The great adipose development in my case might, it is evident, have contributed to cause that relaxation of the liganients leading frequently " to permanent displacement and abnormal mobility of the pelvic organs." If this is so, then this is a so.ealled pure case of post-climacteric prolapsus, without the existence of any accom panying predisposition of long standing, due solely to the changes peculiar to the degenerative period of life, of course aided by some causal factor. It is self-evident that the more advanced these changes 'Ire, the more insignifie,ant need the latter be; hence, an apparently " spontaneous" prolapse occurring at this time of life will not surprise us, but will at once lead us to infer that the changes in question are extensive, and that the causal factors are so insignificant that they may readily have .been overlooked, especially by the laity.