The Abdominal and Pelvic Brain
Byron Robinson, M. D.
"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
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 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
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).
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
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
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
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
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)
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
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
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
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.
1. The average menopause lasts two and one-half
2. It comes on slowly as does puberty.
3. A stormy puberty means a stormy menopause
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
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
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
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
23. A reflex neurosis is a disturbance in
distant organs caused by the irritation of a peripheral sensory or motor
24. The chief manifestations of disturbances during
menopause are those of pathologic physiology rather than pathologic anatomy.