Another point, of no less importance than the one just touched upon, is the influence of the menopause upon existing displacements of the uterus. This applies particularly to those cases in which the menopause exercises a favorable influence upon pathological conditions of the pelvio organs. Not that the principal result is an improvement in the malposi tion, although that might very well occur, where, for example, the uterus was flexed or bent in consequence of somc enlargement, which now dis appears, but the favorable influence is shown by tho fact that the often distressing symptoms are allayed. As the periods cease, the former dys menorrhcea is eliminated, and with the diminution in the weight and size of the uterus consequent upon involution of the organ, the numerous disturbances, which formerly year after year formed a subject of com plaint, are felt slightly or no more. This improvement in the sufferings caused by displacements after the climacteric is so common, that we may properly consider this as the rule, and confidently reckon upon it. The exceptions are so few that I believe it would be an interesting task to direct attention to them. I have no case in which the 'disturbances due to a flexion or version of the uterus have continued to any marked degree after the normal climacteric, although after the artificial menopause I once noted this phenomenon of such a peculiar character, that, although the case does not strictly belong here, I shall mention it briefly.
Castration was performed on account of most dreadful dysmenorrhcea, the patient being nervous and hysterical and a confirmed morphine-taker. After the operation she suffered from severe backache, which could not be relieved, but as the uterus diminished in size, the pain grew less, and has now (six years after the operation) reached a minimum, being most marked when she is under nervous excitement. In writing to Hegar recently concerning this case, I expressed my doubt as to whether this could be regarded a8 simply a periodical hyperzesthesia occurring in nervous persons (having no connection with the malposition), or as the expreoion of increased sensibility which, nevertheless, has no perceptible relation to the permanent and otherwise insignificant deviation of the uterus, that has evidently diminished in size. I was unable to make use of the shortest way of arriving at an explanation, that is by undertaking to replace the organ, since now, as before, the slightest attempt at mechanical treat ment is absolutely intolerable. Hegar himself, in hie kind reply to my letter, was inclined to refer the phenomenon in question to certain re collections, impressions which often remain for a long time even aft,er the cause that has actually produced the latter is eliminated.
I have already referred to a certain connection between the climacteric and foreign growths of the uterus. Observations on this point seem to correspond in the main to show that carcinoma of the cervix is especially frequent at about the time of the menopause, carcinoma of the body most common after the establishment of the same. This period of life also seems to exert a decided influence upon the development of the diseases in question, aside from all the other factors which have been shown to be active in this respect. This influence seems to consist in increasing the affection—how, is still unknown.
The menopause exerts an almost exactly opposite influence upon fibrous tumors of the uterus. These frequently undergo marked contrac tion. Remarkable observations are recorded in this connection. For example, in the case mentioned above, as an example of dreadful hemor rhages, which gave me so much trouble in the patient's fiftieth year, after the bleeding had flintily ceased thero occurred at once a rapid diminu tion of a fibroma, which, as was mentioned, was found to be quite as large as a child's head. In watching her advanced an,semia (from which
she also fortunately made a speedy recovery) I often saw the woman after that critical period, and at each visit it was only necessary to make very superficial palpation through the abdominal wall iu order to make known the c,onstant variations in the size of the growth.' Even in the course of a year, I think, the tumor, that formerly extended as high as the navel, could no longer be felt above the symphysis.
With the exception of the puerperium the period in question is the most favorable time for the spontaneous cure of fibroids. The process that takes place consists in fatty degeneration and absorption; it occurs especially in pure interstitial myomata, that are non-capsulated,, in a manner quite similar to the change in the rest of the uterine muscle, in consequence of the puerperal or climacteric retrogmde metamorphosis (Spiegelberg). The same process occurs to some extent in encapsulated fibromata, but in this case the principal change consists in a diminution of size in consequence of induration and atrophy, and " evident, or at least anatomic,ally-demonstrable remains " of the neoplasm often persist (Gnsserow). This induration is frequently associated with calcification.
It is of course extremely important for the physician to bear in mind this mode of termination of the fibrous disease. Ile is not only thus able to console the patient by holding out to her the possibility or probability of such a spontaneous cure, after the establishment of the menopause, bnt far more important is the significance of this possible atrophy of the growth in connection with the physician's treatment. We know that a uterine fibroma can delay the menopause and protract it; that further more it often gives ris9 to profuse hemorrhages at this time, and finally, moreover, that it may undergo a retrograde process, so as to completely disappear. This is one side of the picture. It imposes upon the physi cian a certain passiveness in his treatment, since a delay in the menopause is not usually important in itself, because it is a matter of experience that often patients bear profuse loss of blood surprisingly well, and true pallia tive treatment consists in opposing the hemorrhage& The opinion that a patient who is near the climacteric should not be exposed to a radical operation, but that matters should be allowed to take their own course in the hope of spontaneous cure, is deeply rooted. This view of the sul}.. ject is generally the convincing one, and it is doubtless right that it is so. However, sometimes another view of not les,s importance may be opposed to it. The delay of the menopause from one cause or another may be of decided harm to the patient, since anEernia either before or at the begin ning of the menopause may reach such a degree that further loss of blood is to be extremely feared; and finally the local condition, as regards the tumor itself, may awaken the supposition that its further progress must by some means tend with certainty to its easy spontaneous cure. Then it is the physician's duty to consider the question of operative interference; this may arise even when the patient stands upon the very threshold of the climacteric, or it may be when the menopause has actually begun.