"Nature has caprices which art cannot imitate." - Macaulay.

Menstruatio precox is followed by climacterium retardum.
 

    The vagina has two sphincters, viz. : (a) one, the internal, ruled by the sympathetic; (b) the other, the external, dominated by the spinal nerves.
    The menopause ends slowly, as puberty begins.  It is frequently difficult to decide which produces the most profound impression on the general system.  The popular belief is that the period of menopause is a time of danger to woman.  It is claimed that she is more liable to malignant growths of the genital organs or the breasts, and the average woman expects disturbances to arise, either bodily or mentally.  Popular belief that woman is more liable to disease at the menopause is probably correct.
    The symptoms of the menopause are: (a) cessation of the monthly flow, (b) flashes of heat, (c) flashes of circulation, (d) irregular perspiration.  The cessation of the flow is a very irregular and indefinite matter, but generally occurs at about 45,years of age.  It requires an average of eighteen months for menstruation to become regularly established; besides, the genitals were being prepared for several years.  It requires two and one-half years for the monthly flow to cease, on an average.  The flow ceases very irregularly, even in normally physiologic cases.  The flow may be scant one month, not appear at all the next, and the third or fourth a flooding may occur.  Should the flow cease without pathologic manifestations?  I would answer "No." Many no doubt will oppose this view and say that it is a purely physiologic process, but it is frequently accompanied by ailments.  So is labor a physiologic process, but it is frequently accompanied by pain and other disturbances.  The cessation of menstruation means the death of a great function, the atrophy of a dominating organ which has the greatest nerve supply of all the viscera.
    The beginning of puberty shows vast changes in the entire vascular system and also much change in the whole sympathetic, besides the field of nutrition. The most manifest change at puberty is shown by a perturbed nervous system.
    The nervous apparatus of the visceral organs may well be compared to the equalizers on the horse-power of a threshing machine.  When the ten horses pull evenly the gearing works uniformly, but the neglect of one team puts the gearing awry, and though the machine may run, its working is not of such fine balance. The destruction of one function in a well-balanced nervous system is sure to destroy the well-established balance in the others, so that in my opinion pathologic disturbances may be looked for at the menopause.  In order to make my views clear and reasonable, let us construct a diagram of the sympathetic system.  The accompanying cut (Fig. 59) represents the sympathetic nerves.  It is drawn in the form of an elongated ellipse.  At the upper end of the ellipse begins the cerebral communicating artery at the so-called ganglion of Ribes.  The lower end of the ellipse ends
 

A SCHEMATIC DRAWING OF THE SYMPATHETIC NERVE       Fig. 59.  X, gangion of Ribes.  Y, coccygeal ganglion (impar).  L., liver.  K, kidney.  S, spleen.  Sp. P., (spermatic) ovarian plexus.  I., intestine.  A. B., abdominal brain (center  of reorganization).  S.p. N., splanchnic nerves.  C. N., cardiac nerves.  H. P., hypogastric (aortic) plexus (coming from three sources).  U., uterus, oviducts and ovaries. H., heart. C.G., the three cervical ganglion (secondary center of reorganization).       The three sides of the ellipse represent the lateral chain of the sympathetic.  One nerve strand goes from the abdominal brain (a. b.) to each viscus to represent its plexus. Observe that the spermatic plexus (sp. p.) arises from the abdominal brain, renal plexus and aortic plexus.  Any irritation starting in any viscus will pass to the abdominal brain, where reorganization occurs, and the forces are redistributed over the plexuses to every viscus.

at the coccyx or ganglion impar.  "rc" shows the connection of this ellipse with the cerebro-spinal axis.  The interior of this ellipse is of special interest, for here lies the vast and complicated network of this nervous ring.  "ab" indicates the abdominal brain, solar plexus or semilunar ganglia - the center or reorganizing locality of the sympathetic system.  From this abdominal brain, renal ganglia and the lateral sympathetic chain, passes off a large plexus of nerves, down the aorta to the uterus, oviducts and ovaries.  This is known as the hypogastric plexus.  The observation which I note in the dissection of quite a number of old women is, that after the menopause the genitals not only atrophy, but the hypogastric plexus also shrinks.
    However, the abdominal brain does not atrophy.  It retains its function and structure to the end of life.  Dr. Adolph Meyer, formerly of Chicago University, now in Worcester, Mass., writes me the following letter, which explains itself:

The Worcester Lunatic Asylum.
Worcester, Mass., Feb. 20, 1896.

My Dear Dr. Robinson:        I

    Nearly two years ago you asked me to give you some specimens of a sympathetic ganglion, to ascertain that it is not a degenerate organ, but a living organ with numerous ganglion cells.  Those of your opponents who would not believe this may see this specimen from a woman of 74, who had been insane thirty years, and died of heart rupture.  The ganglion cells of the semilunar ganglion are large, numerous, moderately pigmented (not more than the spinal ganglia and other nerve cells).

Adolph Meyer.

    The hypogastric plexus becomes smaller, finer and no doubt some strands disappear at the beginning of the menopause.  On this fact must be based the pathologic symptoms accompanying the cessation of the menstrual function.  In dissecting infants which have lain in alcohol for some six weeks, the very opposite condition of the hypogastric plexus may be observed, for in the young child the hypogastric (sympathetic) plexus is disproportionately large and can be very plainly dissected out.  The explanations of the disturbances of the menopause may be shown as follows: For thirty years monthly rhythmic impulses have passed over the hypogastric plexus to the uterus and oviducts.  A fixed habit has been established and the genital organs lie in ,the sensory and motor grasp of the hypogastric plexus.  The importance of the genital organs is shown by the vast nerve supply sent to them and also because the hypogastric originates in great central sources.  It arises plainly from the abdominal brain, the renal plexus and sympathetic lateral chain.  It is intimately and closely associated with the whole sympathetic ellipse.  Now when this great nerve tract, known as the hypogastric plexus, will not transmit the higher physiologic orders, it will unbalance all other parts of the ellipse.  If the nervous forces cannot go over an old-established line they will go over the next line of least resistance.  The hypogastric plexus cannot carry the orders as it is atrophied and destroyed for the old work.  Monthly rhythm of thirty years established in the abdominal brain is not to die without a struggle.  This explanation will enable us to understand the many pathologic manifestations of every viscus at the menopause.  The irritation which arose by trying to pass more nervous impulses over plexuses than normal, gives origin to what is unfortunately known as "functional disease." It is just as organic as any disease, only we are not able to detect it. Acute atrophy is a pathologic condition and no doubt this is the condition of the hypogastric plexus at the menopause.  The sudden assumption of function of the hypogastric plexus at puberty produces similar disturbances, only they do not assume such definite symptoms as at the menopause.  The young woman has more depression than the woman in menopause, unless her ovaries be diseased.  The advent of menstruation is an important feature in the life of woman.
    After the cessation of the flow the most prominent symptom is what is called flushes.  Over eighty per cent. of women will experience this peculiar phenomenon at the menopause.  Two distinct propositions will explain this subject: Flushes result from a disturbance of the vaso-motor centers, and flashes from irritation of the heat centers. Heat and circulative disturbances are so intimate and go together so frequently that I shall not attempt to describe them separately.  The heart and vaso-motor centers are unbalanced by irritation at the menopause.  The hot flashes may come on rapidly and irregularly for a short period, and then remain away for days.  The patient indicates that the disturbances are first manifest near the stomach, and then rapidly spread over the head and chest.  It would seem from carefully watching these manifestations at the menopause that wave after wave succeeds each other.  I have watched them under attacks and they seem to be under a desperate struggle to control themselves.  The blood-vessels of the head and neck appear most aff ected, yet the skin of the whole body shares in the disturbance.  The nerve impulse, which should be emitted along the hypogastric plexus, is abnormally forced over other plexuses and the vaso-motor becomes irritated, resulting in dilatation and contraction of the peripheral vessels.  All molecular action generates heat, and it may be that much of the heat experienced is due to the rapid dilatation of the vast number of vessels and the rapid flow of fresh blood in them.  As the cheeks glow the patient experiences sudden heat, the skin grows red with flushing blood.  Besides the disturbance of the vaso-motor and the heat center, the sweat center is also irritated, the flushes and flashes followed by various degrees of sweating. This is just as irregular and uncertain.  The quantities of sweat vary from a fine moisture to great drops.  It is apparent to any ordinary observer that profound disturbances arise at both puberty and menopause and it is not strange that tradition attributes some diseases to the advent of puberty and many grave conditions to the menopause.
    The theory of disease at the menopause must rest on the unbalancing of the nervous system by changing the old established nerve channel through which they have carried impulses for a generation.  It must rest on actually diseased genitals, or atrophy of the organs on the plexuses which transmit controlling forces to them.  Disease at the menopause must rest on some irritating center, which is chiefly the genitals and their nerves.  Like many old gynecologists, we need not look for the sole cause in the ovaries, but the trouble is due to reflex irritation.  Eighty per cent of such women suffer in general from nervous irritability.  Fifty per cent. have disturbance in the heat and circulatory centers.  Probably fifty per cent. suffer deranged sensations, hyperesthesia and anesthesia.  Perhaps forty per cent. of women at the menopause suffer from the headache, abdominal pain and perspiration.  About twenty-five per cent. of women at the menopause suffer from leucorrhea, sudden flooding and sweats.  This means that all the secretary apparatus of the skin, mucous membrane and centers are deranged.  The first thing to suspect in such patients is deceased genitals.  Endometritis is an arch fiend at this period in a woman's menstrual life.
    Inflammation of some kind may be found in the uterus, oviducts and ovaries.  Acute atrophy - a form of degeneration or malnutrition - must be recorded among the diseases.  If no pelvic trouble be found, the whole abdomen and chest must be examined for some disorder.  I have found that the glycerin tampon twice weekly, and the hot douche gradually increased to ten quarts twice daily, often cures such patients, at least symptomatically.  Curetting may be required in a limited few, however it is not so dangerous in the menopautic as in the young woman on account of atrophy and consequent inability to receive infection.  Radical disturbances in the menopause mean disease, and generally it is located in the pelvis.  Women are expected to suffer from neuralgia at this time, nerve irritation, but their intellect is also often disturbed, especially in the will power.  General treatment especially visceral drainage is right and reasonable, with baths and attention to food and evacuations.  The patients fret and worry and do not rest or sleep well.  The bromides act well, especially given at night.  I make over half the dose sodium bromide, as that does not irritate the skin so much as potassium bromide.  The bowels are best regulated by a glass of water each night at bed-time, in which there is from one-half to one dram of epsom salt; with the additional advice to go to stool every morning immediately after breakfast, i. e., after the hot coffee has stimulated peristalsis of the bowel.
    It is traditional that women become like men after the menopause and it is common for women to argue against removal of the ovaries, fearing that hair will grow on the face and that they will become mannish.  Flesh may increase because of disappearing disturbances.  It is common for women to take on fat at the menopause.  This is a form of low-grade nutrition.  I have examined at least half a dozen patients of this nature who were considered subjects of tumors or pregnancy.  But a little experience and patience will prove to the physician that the tumor consists simply in abnormally thick and fleshy belly walls.
    No one can number the many and varied pains that attack women in the menopause.  Most of the pains arise around the stomach, i. e., in the abdominal brain - the solar plexus.  The pains which originate in the epigastric region are innumerable, indefinable and baffle all systematic description.  We must, however, have charity sufficient to allow that these numberless disturbances are real to the sufferer.  The "something moving in the stomach" may be abnormal peristalsis, induced by a diseased focus, as in the globus hystericus.  Whatever opinion is held by the physician, a reasonable treatment should be introduced.  Such patients have so little confidences in themselves, their physician and their friends, that they have not the will power to persist a systematic course of treatment.  Hence they go around from one physician to another.  The duty of the physician is to locate the disease and attempt to restore order in a disordered sympathetic nervous system, which becomes unbalanced by reason of some irritation arising from atrophy, senility and inflammation.  A thorough automatic and physiologic knowledge of the sympathetic nervous system is required for intelligent practice in gynecology.  The pathologic condition must be found in order to show skill in removing it.  It must be remembered that a stormy puberty generally means a stormy menopause.  If a girl begins menstruation with pain and disturbance it generally means diseased genitals - oviducts or uterus probably - and the sympathetic system will suffer.
    The intimate and wide connection of the nervous system and genitals is phenomenal.  The nervous connection of the genitals is profound and any genital trouble deeply impresses the whole system.  It would not be strange, also, if one uterus were found with vastly more nervous connections than another, or that is, at least, much more sensitive than others.  My experience in the dead-house, as well as observation in the living, is that viscera vary much in size.  In some the uterus is small, in others large, without regard to the individual stature.
    Menstruation must be looked upon as arising and subsiding in the nervous system, especially in the sympathetic system.  I would like to make a plea for more study of the nervous system, and particularly the visceral nervous system.  From the lack of this knowledge physicians are constantly mistaking nervous diseases for uterine disease.  A great evil is going on today in regard to the misunderstanding, that a little nervousness does not always belong to the ovaries or uterus.  The nervous system is a vast, finely ordered, nicely-balanced machine, which can be easily disordered without the least need of removing the ovary, uterus or oviduct.  Some general or local treatment may be amply sufficient.  Too many laparotomies are being done today by unskilled men without proper facilities.  Sweeping removal of organs is a backward step in surgery, and the general disapprobation of the leading gynecologic surgeons must cry it down.  It must be insisted that he who would work in the peritoneal cavity must be trained.  Training and skill, coupled with a decent sense of right, will alone stand the test of time in any branch of surgery.  The colleges must begin with chairs of anatomy and abdominal experiments for small classes.  A large plea should be entered for an attempt to understand the pathology of the sympathetic nervous system, i. e., visceral nervous system.
    A pathologic state is one manifesting abnormal conditions, whether they are recognizable changes in structure, or simple deranged functions without perceptible disordered structure.  There are reflex neuroses, by which I mean disturbances in distant parts produced by irritation of some sensory or motor-peripheral area.  It is easy to note that a woman is irritable or nervous, without in the least being able to locate the pathology from which the disturbance originated.  One of the most marked features of the menopause is this kind of nervous irritability.  It may be easily observed that women in the menopause do not suffer from tumors and malignant diseases so much as they do from disturbance in the sympathetic system and cerebrospinal axis.  Nervous irritability characterizes four women out of five during the menopause.  How does this come about?  Two ideas explain the complicated but slow course of the disease, viz., Reflex irritation and malnutrition.  It can be easily seen that the nervous system is out of balance in the menopause.  The beginning and end of menstruation is in the sympathetic nerves.  Puberty is heralded by ganglionic rhythm and the menopause comes in at the cessation of the rhythm.  The entrance and disappearance of menstruation are nervous phenomena. The genitals then become a point of new irritation as puberty begins, and the genitals are again the focus of irritation as the rhythm departs forever.  Menstrual starting chafes the system profoundly, but its cessation irritates the system notably with its dying struggles.  By the figure it is plain that any genital irritation can be easily carried to the abdominal brain where the reorganization occurs.  The newly organized force will go to every viscus in the sympathetic ellipse and damage the rhythm.  Now the visceral rhythm is for the purpose of nutrition, and pursues its even tenor in a kind of orderly manner.  But irritation from a focus never comes or goes by rule.  It goes at all times and any time, while the viscera are performing their nutritive rhythm.  The irritation from the diseased focus forces itself up the hypogastric plexus to the organizing center and is emitted to all viscera, in addition to the abdominal nutrition and rhythm and disorders natural to visceral rhythm.  Few but the special clinical gynecologist fully recognize that uterine disease is often such a slow process and that it can start a train of evils.
    A few weeks or months of pelvic irritation gradually produce deranged visceral rhythm and consequent indigestion.  The addition of indigestion to a diseased visceral focus makes a double burden on the whole system.  The nerves become more irritable. Indigestion persists and soon brings on distinct malnutrition - another burden to the ganglionic system of nerves.  All this continues until anemia arises, the result of waste-laden blood.  Now it is apparent to all, when waste-laden blood bathes all the thousands of ganglia and nerve strands in the body, that the patient becomes nervous or irritable.  The sympathetic ellipse is unbalanced and its centers are disordered.  It is a slow process for a woman to pass from a single focus of visceral disease to a neurotic condition.  The whole disturbance becomes intelligible by comprehension of the nervous system and a knowledge of the condition of the diseased genitals.  The intelligent practitioner always examines the genitals in a disordered menopause.  A stormy menopause means diseased genitals.  It means a focus of pathology which is nearly always situated in the pelvis.  The effects on the individual may be described by noting how the irritation can pass up the hypo-gastric plexus to the abdominal brain and being reorganized be emitted to the digestive tract. The irritation goes on day and night; when it reaches the digestive canal by way of the gastric, superior and inferior mesenteric plexus, it first affects Auerbach's ganglionic plexus of nerves which lie between the muscular layers of the intestinal wall.  This simply disturbs peristalsis and induces perhaps some colic.  But as the irritation passes to Meisner's plexus it disorders secretion.
 

LUMBAR AND SACRAL PORTIONS OF THE SYMPATHETIC (SAPPEY)       Fig. 60. 1, cut edge of diaphragm; 2. lower end of oesophagus; 3, left half of stomach; 4, small intestine; 5, sigmoid flexure of the colon; 6, rectum; 7, bladder; 8, prostate; 9. lower end of left vagus; 10, lower end of right vagus; 11, solar plexus; 12, lower end of great splanchnic nerve; 13, lower end of lesser splanchnic nerve; 14, 14, two last thoracic ganglia; 15, 15, the four lumbar ganglia; 16, 16, 17, 17, branches from the lumbar ganglia; 18, superior mesenteric plexus; 19, 21, 22, 23, aortic lumbar plexus; 20, inferior mesenteric plexus; 24, 24, sacral portion of the sympathetic; 25, 25, 26, 26, 27, 27, hypogastric plexus; 28, 29, 30, tenth, eleventh and twelfth dorsal nerves: 31, 32, 33, 34, 35, 36, 37, 38, 39, lumbar and sacral nerves.

    Thus the great assimilating laboratory of life is deranged.  Digestive disorders are common in the menopause.  Liver disturbances are common.  The irritation passes through the abdominal brain to the liver, inducing excessive, deficient or disproportionate bile, glycogen, and urea.  The rhythm of the liver is deranged.  Its rhythmical activity and quiet repose are continually disturbed by reflex irritation.  It is easy to observe disease of the liver from the condition of the patient in menopause  - skin and bowel abnormalities.  The route from the genitals to the heart is made plain by the diagram.  The irritation from the diseased genitals passes to the abdominal brain, thence up the splanchnics to the three cervical ganglia, whence the reorganized irritation passes to the heart over the three cardiac nerves.  The result is that the heart goes rapidly, irregularly - it palpitates.
    After nervous irritability the woman in menopause probably suffers most frequently from flushes and flashes, i. e., irritation of the vaso-motor and heat centers.  Her skin glows with fresh red blood or burns with prickling heat.  This seems to me to be merely an unbalanced condition of the nervous system due to a disordered focus.  The transmission goes in a tumultuous manner, over roads which are not accustomed to so much vigorous commerce and the centers are not able to orderly reorganize it.  The circulation floods or depletes the vaso-motor centers.
    One may observe that some women enter puberty with many indescribable pains and they continue to complain of peculiar abdominal pains during the reproductive period, and at menopause they simply become chronic grumblers and complain more and more bitterly.  What must be said of such women?  We must not consider them as fabricating untruths for a whole generation we must attempt to study the ganglionic system of the sympathetic in order to unravel the apparent mystery.  We may say that women with these abdominal pains are in a poor state of nourishment.  Debility characterizes the ganglionic disease while irritability is the feature of cerebrospinal axis pathology.      Women with ganglionic diseases are weak, illnourished creatures, often unable to do a little housework.  Can we not consider that such patients have hyperesthesia or anesthesia of the visceral ganglia?  The ganglia are little brains, for they all have the elements of the cranial cerebrum, - nerve cells and processes.  In short every nerve cell is a unit in itself.  It is an isolated anatomic unit, a neuron, a brain and a reorganizing center.  The essential of the cell is the nucleus because it has the power of nutrition, hence reproduction.  Hence each ganglion is a little brain, a reorganizing center.
Now, a brain or ganglion cell receives sensation, emits motion and controls nutrition.  It reproduces itself, it controls secretion and lives in balanced relations with its environment.  Can we not think that such patients have over-sensitive or irritable abdominal brains?  Their visceral nerve apparatus is abnormal, it is out of order.  But this center holds in abeyance nerve energy and nerve force.  It holds all the assimilating and circulatory laboratory in living tension.  Such patients have not a perfect machine with which to work.  They are generally congenitally defective, or are made so by the acquisition of some profound function, such as menstruation.  The female visceral nerves seem to be peculiarly liable to rapid derangement.  Women faint easily and slight occurrences disorder their viscera.  The flying of a bird will make the heart palpitate.  A sudden noise deranges respiration or circulation.  A change of locality either corrects or disorders the nervous system.  The female nervous system is much more unstable than the male, and no doubt that is the reason that so many physicians mistake nervous disease for uterine disease.  Such physicians are either ignorant of the delicate nerve mechanism or are over-zealous operators.
    The pathologic condition of the genital organs in the natural menopause is generally atrophy, absorption of fat and consequent shrinkage, lessened vascular supply and consequent smaller organs.  It is a pure senile atrophy.  The organs assumed action, served their purpose and subsided forever.  Even in a natural menopause the distinct dying struggle may be expected in the hypogastric plexus.  Puberty increases the volume of the organs, while menopause lessens it.  Puberty is the real birth while menopause is the real death of the female genitals.  The appearance of the individual organs at the menopause is peculiar.  The pudendum wrinkles and shrivels through the absorption of fat and other tissues.  In dissecting senile genitals the pudendal sac of Bichat and Savage become more apparent than ever.  One can push the index finger into it and the greater labia will appear and feel very thin, while the sac seems disproportionately large.  The fat, rounded form of youth obscures this peculiar pudendal sac, even in dissecting.  In old women the sac flattens out and exposes the clitoris and nymphae.  The clitoris becomes smaller and blends with the surrounding parts so much that it is occasionally difficult to find.  The vagina becomes smoother in its folds.  It contracts in every direction and frequently it may seem to thicken, but that is probably a delusion from blending with other tissue.  The cervix gets smaller and may appear entirely absent, from the excessive shrinkage and contracting of the vagina.  The uterus becomes smaller and harder.  It has a peculiar tough, elastic feeling from the atrophy of muscular tissue.  It assumes to some extent the form it had before puberty, except that the neck is more prominent before puberty.  It straightens out.  Its nerves and vessels shrink.  The oviducts are notably thinner and shorter.  The circular muscular layers seem to suffer most.
    The ovaries atrophy very much and resemble a peach-stone on the surface.  In quite a number of old female cadavers I found them the size of beans and in some it required considerable searching to find and recognize them.  Then we found in the contracted and atrophic broad ligament the sheaths and nerves themselves atrophied.
    In women with a stormy menopause it is not unusual to find subinvolution.  While a pupil of Lawson Tait, fifteen years ago, I gained some knowledge in regard to a disease of the pudendum which may not infrequently be seen in women from forty to fifty, or about the menopause.  It is a trouble that one would easily pronounce on a glance, eczema of the pudendum.  Mr. Tait remarked that it was due to a kind of climacteric diabetes; that is a kind of eczema at the menopause.  Dr. Martin, Mr. Tait's assistant, was very kind in displaying to me these unfortunate cases.  The labia were swollen and edematous and the red flaming eczema extended far and wide beyond the pudendum.  The disease made the patient's life almost intolerable.  Mr. Tait's treatment for such cases was a solution of hypophosphate of soda (an ounce to a pint of water). The solution should be applied every two to five hours as required, to destroy the germ which induced the itching.  He then gave heavy doses of opium.  Mr. Tait claims that there is a kind of diabetes mellitis during the menopause; a limited diabetes, as they all finally recover.  The distress of the patient with this climacteric diabetes is due to the sugary urine causing irritation of the pudendum.  Peculiar crusts form, due to the multiplication of the vegetable germ known as Torula cerevisiae,.  The eczema due to this cause will spread over the buttocks, over the abdomen and even to the thighs.  In one case I saw the eczema extend so far that the patient could walk only with difficulty.  The hyposulphite of sodium arrests the formation of this germ.  Mr. Tait would sometimes give as high as one grain of opium three times daily and then two grains at night.  After a few months of such treatment the opium was lessened, and in from Ave to ten months such patients fairly recovered.  They are liable to mild relapses.
    M. Lecorche, of Paris, has also made researches independently of Mr. Tait and curiously enough they agree in many ways.  Mr. Tait carries his views into more definite plans of treatment.  This climacteric form of diabetes is then a disease which begins at the menstrual cessation and lasts a few years. Menstruation seems to give immunity from it.  Nature appears to finally overcome it.  If the hyposulphite of sodium is inefficient to arrest the trouble, on account of the fluid quickly running off the parts, an ointment of sulphur will remain on the pudendum for hours.  Any substance which will arrest the fermentation changes in sugar is an effective remedy.  I have noted no special form of climacteric vaginitis, but one form is liable to arise which is due to laying bare some peripheral nerves in the vaginal wall.  The, spots are red and most exquisitely tender; they occur mainly at the pudendal orifice and are very persistent.  The treatment consists in applying cocaine and sufficient caustic or Paquelin to entirely destroy the exposed nerves.  These neuromatic patches are apt to arise in women at other times also.  In severe cases it is best to anesthetize the patient and destroy the exposed nerves widely with the Paquelin.
    The special diseases of the uterus which I have observed in menopause are endometritis and myometritis accompanied with leucorrhea.  Chronic endometritis with an excoriating discharge is frequently found.  The uterus is generally slightly large.  The mouth is red, bleeds easily and out of it runs a muco-purulent substance of varied color. The hot douche (15 quarts) twice daily and the additional use of glycerin tampons cure most cases.  Occasionally a curetting is required, followed by the thorough application of 95 percent carbolic acid.  I apply the 95 percent carbolic acid to the endometrium three times, so that it will destroy the old inflamed endometrium, and drain with a little rubber tube or pack in gauze, and remove it in twenty-four to thirty-six hours. Fortunately the senile endometritis is generally cured with one curetting, unlike the stubborn endometritis of youth.  Mild forms of endometritis in the menopause I have frequently noted.  The subinvolution or suspended involution is a much graver matter.  It has had a more evil and wide effect on health and especially on the nervous system.  It consists essentially of a myometritis, and so far as I can observe rests on an old endometritis.  It is not clear whether Klob or Rokitansky is correct, in regard to the theories of the conditions producing a hypertrophic uterus.
    Whether the hypertrophic uterus is due to excess of connective tissue or muscle, or whether it is due to a natural proportionate increase of both is still undecided.  In such cases a lax pelvic floor is often observed.  So far as my experience goes, the tampons and douche are insufficient and are too slow for satisfactory results.  Thorough curetting is the best means at command, with the application of 95 percent carbolic acid to the whole endoinetrium.  The cure is slow at best but finally quite satisfactory.  The pathology of the climacteric or senile endometritis must not be lost sight of.  At first the leucorrhea is more abundant.  It may be mucous, muco-purulent and finally purulent.  The explanation of the changes of the fluid secreted from the endometrium rests on the endometric glands.  At first the glands are able to be increased in their function; with time they atrophy, but the inflammation proceeds and finally only sero-purulent substance or chiefly pus results from the glandular destruction; only now and then a glandular endometritis.  The remnants only of the endometrium remain and these are involved in a state of low vitality.  Low and mild forms of granulation are visible at the neck and can be scraped out of the uterus.  Slow necrosis, local death, gradually proceeds until raw ulcerative surfaces are exposed and only pus will be secreted, The glands have disappeared practically.
    We must observe that cervical laceration frequently exists with this trouble.  The reason such conditions do not heal well is because the blood supply and nerve supply to the uterus are now being cut off, are imperfect, so that nutrition is very deficient in the uterus.  For thirty years the uterus has had high feeding from fresh blood and the fine control of a complicated nerve apparatus, but suddenly the high feeding is curtailed and the delicately balanced nerve apparatus is impaired by the atrophy of the menopause.  Hence low granulations, imperfect reproductions of cells, ulcerative surfaces, may be expected.  It must be remembered that there are other troubles than cancer in the uterus at the menopause.  The essential feature of the climacteric uterine trouble is imperfect nutrition.  This will not astonish one so much after he has carefully examined and dissected or post-mortemed a dozen female cadavers above 50 years of age.  In them he will note atrophy, shrinkage, contraction and pale white tissue.
    The differential diagnosis between cancer and benign uterine disease (endometritis) may be looked for in the case of cancer by infiltration, thickening and peculiar watery, sanious discharges.  As regards ovarian tumors at the menopause they grow more rapidly.  The vital power of the patient is at a lower ebb, and besides the nutrition of the ovary is degraded by diminished blood supply and atrophy of its nerve supply.
    It would appear that the branches of the hypogastric plexus, which are sent to the bladder and rectum, are not atrophied to the same degree as the branches sent to the genitals (uterus, oviducts and ovaries).  Yet in my postmortems and dissections it appears to me that the vesical and rectal branches do atrophy.  The present idea of medicine is that there is an automatic structure disordered somewhere to account for disease.  A portion only of a man is diseased and pathologic anatomy would always indicate the origin, had we sufficient acumen.
    Now in the menopause the cerebrospinal axis is disturbed through the means of the vaso-motor nerves, and the circulation by some form of reflex neurosis.  A woman's mind is often disturbed.  She has lost her old will-power; her memory is impaired; she cannot concentrate effort.  She is liable to do damage from inability to control her own action.  The law recognizes any deviation from rectitude during the menopause with leniency.  The treatment of women during the menopause must be local, general and moral.  The cog in the wheel which disturbs even physical existence must be remedied.  General debility and irritability must be allayed by anodynes with both tonics and good nourishment, while the unhinged moral views must be removed by changing the life from the old ruts which caused them.  One feature must not be lost sight of.  When pelvic disease has started a train of evils and continued for years, we cannot expect very much from mere treatment, but radical removal of diseased organs often alone gives relief.

CONCLUSIONS.

    1.  The average menopause lasts two and one-half years.
    2.  It comes on slowly as does puberty.
    3.  A stormy puberty means a stormy menopause generally.
    4.  The general rule is that an early puberty means a late menopause.  In my opinion it simply means that early puberty and late menopause rest on largely developed abdominal and pelvic brains and hypogastric plexus.  Precocious puberty means well developed genitals and ganglionic nerves.
    5.  The disturbance at the beginning of puberty is profound, but since it is an active (depletive) physiologic process it quickly fits the growing and adaptive nervous system.  But the menopause is a destructive process.  It breaks up the harmony of the previous processes and unbalances the even distribution of nervous energy and circulation.
    6.  It is probable that every viscus receives an equal or greater shock at menopause than at puberty.
    7.  The changes at menopause consist in menstrual cessation, atrophy of the genitals, the hypogastric plexus and pelvic brain.
    8.  Women do not suffer at the menopause so much from malignant diseases as they do from nervous troubles, neuralgias, mental deviations, disturbed visceral rhythm, disordered circulation, indigestion and above all neuroses.
    9.  The heat center (flashes), the vaso-motor center (flushes) and the sweat center (perspiration), are the especial centers disturbed.  Excessive, deficient or disproportionate blood-supply characterizes the disturbed phenomena of these centers.
    10.  The etiology and pathology of the menopause lies in the sympathetic or ganglionic nervous system.
    11.  The sympathetic pathologic stages in menopause are: (a) a focus of disease, or irritation (the genitals), (b) indigestion, (c) malnutrition, (d) anaemia, (e) neurosis.  It is a slowly progressive process.
    12.  Atrophy is a disease just as much as hypertrophy or inflammation.  Atrophy traumatises nerves by cicatritial compression.
    13.  Chief among the actual disease in the menopause is endometritis.  This is due to infection from desquation of epithelia.  The peculiar floodings doubtless depend on this inflammation.
    14.  The menopause is characterized by various discharges (mucous membrane), leucorrhea, bronchitis, hemorrhages from the bowels, epistaxis (skin) perspiration.
    15.  Circulatory, perspiratory and caloric changes are the common heritages of the menopause.
    16.  A characteristic phenomenon of the menopause is an unbalanced, unstable nervous system; cerebrospinal (irritation), or sympathetic (debility).
    17.  Debility characterizes the trouble in the ganglionic system, while irritability characterizes the cerebrospinal axis.
    18.  The explanation of the various phenomena lies in the nervous and circulatory systems.
    19.  Excessive sexual desire at the menopause is indicative of disease.
    20.  In the menopause the nutrition is impaired, as is shown by the occurrence of malignant disease in the sexual organs which are in a state of retrogression.
    21.  A chief characteristic of uterine disease is malnutrition from atrophy, which suddenly limits blood supply.  This arises from the sudden ,degeneration of the genital nerve apparatus, pelvic brain and hypogastric plexus, and consequent impaired control of tissue by defective nourishment.  Ulcerative processes, local death and purulent secretions arise from low granular cell-formations.
    22.  In the menopause a disturbed point has arisen in the harmony of visceral rhythm.  This pathologic focus must be looked on as the cause of the innumerable reflex neuroses at this time of life.
    23.  A reflex neurosis is a disturbance in distant organs caused by the irritation of a peripheral sensory or motor area.
    24.  The chief manifestations of disturbances during menopause are those of pathologic physiology rather than pathologic anatomy.