An extremely distressing affection, and one which is especially apt to attack women during the change of life, is the previously mentioned pruritus genitalium. The itching is in some cases confined to the external genital organs, whilst in others it extends into the interior of the vagina; also it may pass backwards over the perineum, and on into the gluteal folds. In some cases, some local pathological condition will be found to account for the disorder: catarrh of the vagina or of the cervix uteri; displacements, inflammations, or new-growths of the uterus; anomalies of the ovary, the bladder, or the urethra. Cohnstein draws attention to a circular hyperplasia of the vaginal portion of the cervix, occurring during the menopause, and, “owing to the vascular dilation by which it is characterized, possessing close analogies with haemorrhoids;” the worst symptom of this affection is pruritus. That in these cases the pruritus is actually dependent upon the “haemorrhoidal hyperplasia” of the portio vaginalis, Cohnstein considers to be proved by the fact that, whilst local applications give no more than momentary relief to the itching, this symptom is completely relieved by the abstraction of blood from the cervix. But in addition to such cases as these, we have from time to time to deal with patients suffering from violent genital pruritus during the climacteric period, in whom we shall vainly seek for any local pathological changes, to the cure of which our therapeutic zeal may be directed. Analogy with some other disorders of the climacteric leads us to conclude that in these cases also we have to do with an idiopathic neurosis (Boerner).

The frequent recurrence of pruritus vulvae leads ultimately to the formation of nodules and papular eruptions.

Many authors state that they have observed the frequent occurrence of erysipelas during the climacteric period; others assert that furunculosis, prurigo, urticaria, and herpes zoster, are seen with especial frequency at this period of life.

Tilt, in his 500 cases of women at the climacteric age, made the following observations:

201, or 40.2%, suffered from heats and tendency to perspiration.

2, or 0.4%, suffered from monthly recurrence of periods of perspiration.

Krieger gives as an example of the “occurrence of new troubles” at the change of life, furunculosis; so also does Boerner. “The discolouration of the face, occurring usually in connexion with pregnancy or with diseases of the reproductive organs, and known as chloasma uterinum,” has been seen by Cohnstein, during the climacteric period, “chiefly in cases in which, owing to some degree of failure of general nutrition, the skin has been thrown into folds.” Wilson regarded prurigo and eczema as the commonest skin-diseases of the climacteric period; whilst Boerner draws attention to a connexion between climacteric conditions and the outbreak of herpes zoster.

Disorders of Metabolism.

Among the disorders of metabolism to which women are especially prone at the climacteric period, we must in the first place allude to obesity (lipomatosis universalis), and to gout (arthritis urica).

Numerous observations have shown us that the time of the change of life, the period between the ages of 40 and 50 years, is the one especially favourable in women to the extensive deposit of fat in the tissues.

In 200 cases of great obesity (lipomatosis universalis) in women, in which I instituted enquiries regarding the age at which an excessive deposit of fat in the tissues had first been noticed, I obtained the following results:

We learn from these figures that it is between the ages of 40 and 50 years that there is the greatest tendency in women for the accumulation of fat; but that as early as between the ages of 30 and 40 years this accumulation may in many instances begin. Speaking generally, there is in women an obvious connexion between the development of obesity and the state of the reproductive functions, inasmuch as at puberty, during the puerperium, and above all at the climacteric, there is a special tendency to the accumulation of fat in the subcutaneous tissues. At the commencement of the menopause, it is more especially in the abdominal wall, the breasts, and the buttocks, that we witness the deposit of fat. In the abdomen, owing to the thickening of the subcutaneous tissues and of the great peritoneal folds—especially of the great omentum—a marked protrusion occurs, whilst the umbilicus becomes more deeply hollowed, and ultimately funnel-shaped. In some instances, the deposit of fat around the navel favours the occurrence of umbilical hernia. After an artificial menopause, induced by oöphorectomy, it has also been noticed in from 42 to 52% of the cases that a marked general deposit of fat has occurred, affecting especially the breasts and the buttocks.

This obesity in climacteric women, not only impairs to a serious extent their good looks, but brings in its train a number of troubles, and gives rise to manifold morbid manifestations, and among these, changes in the heart, which may readily threaten the patient’s life. In consequence of extensive fatty deposits in the myocardium, associated with actual fatty degeneration of the muscular fibres, cardiac insufficiency ensues, with all its distressing and disastrous consequences. It is further necessary to insist upon the fact that obesity during the climacteric very definitely favours the occurrence of menorrhagia.

On examining 282 women, 5 years after the complete cessation of the menstrual flow, Tilt found that

Alike in the third class and in the first were a very large proportion of women in whom the change of life had entailed much illness and suffering; but in the first class, the women who had been thus affected had at that time lost weight, and only in the latter half of the climacteric period, when their troubles had become less severe, had the condition of embonpoint made its appearance.

Passing now to the consideration of arthritis urica in women at the climacteric, it is worthy of mention that Hippocrates was so much struck by the association that he went so far as to deny that gout occurred at all in women before the menopause. The fact of the matter is that whilst women are in general less disposed than men to the occurrence of gout, the tendency of women to this disease during the climacteric period is so marked, that at this epoch of life the disease is far more common in women than it is in men of corresponding age.

It is in obese women, with a soft, white, and lax integument, with a pallid, somewhat bloated countenance, a poorly developed muscular system, extensive varicosities of the veins of the legs, marked dyspeptic troubles, and habitual constipation, that during the preclimacteric and climacteric periods, gout is especially apt to make its appearance. It is then characterized by the following symptoms. From time to time the woman suffers from tearing or shooting pains in the joints, lasting at first a short time only, and returning after longer or shorter intervals. With the frequent return of the pains, the affected joints become swollen; and finally the patient suffers from the characteristic attacks of acute gouty arthritis, with the well-known consecutive symptoms of this affection.

According to the observations of Geist, during the climacteric period, 28 women suffer from gout as compared with 4 men of corresponding age. Tilt publishes the following figures showing the mortality of women from gout in England:

Regarding diabetes mellitus during the menopause, Lawson Tait, who maintained there was a distinct form of climacteric diabetes, asserted that this disorder of metabolism was less severe, and runs a longer course during the climacteric period than at other times of life.

Diseases of the Nervous System.

The disturbances of the nervous system that occur during the climacteric period, manifest themselves chiefly in the form of hyperaesthesia and hyperkinesia. The sensory nerves appear to me for the most part to be more irritable than normal, inasmuch as every stimulus by which they are affected arouses a comparatively greater sensation, and gives rise to an excessive reaction in the sphere of consciousness. The cutaneous hyperaesthesia of climacteric women is shown in very various ways, the commonest being the anomaly of sensation which gives rise to the symptom known as pruritus, characterized by paroxysms of itching in more or less extensive areas of skin, with consecutive nutritive changes in the affected portions of the integument. The commonest and the most distressing form of this disorder during the menopause is pruritus vulvae.

In addition to such manifestations of cutaneous hyperaesthesia, vasomotor disturbances of the skin are of frequent occurrence, characterized by redness, rise of temperature, and sometimes the formation of nodules in the affected areas. Almost without exception, at the outset of the climacteric period, and sometimes also in the preclimacteric epoch, women complain of a very distressing feeling of fugitive heat in various portions of the surface of the body, manifested objectively by the rapid appearance and no less rapid subsidence of a red colouration of the skin of the face, the neck, and the chest. Such fugitive heats are due to disturbances of vasomotor innervation giving rise to sudden variations in the amount of blood passing through the vessels of the affected areas of skin.

Hardly less frequent during the climacteric are the sensations of imaginary movement which give rise to the subjective symptom known as vertigo. Often in women at this time of life it occurs quite without apparent cause, but in other cases on the performance of some unusual movement or the adoption of some unusual posture; there is a sudden perception of rotatory movement, either of the patient’s own body or else of her visible and palpable environment. With this feeling of disturbed equilibrium, there is often associated optical and auditory hyperaesthesia, flickering before the eyes (muscae volitantes), tinnitus aurium, painful sensations in the head and more especially in the occipital region, nausea, vomiting, sense of anxiety, cold sweats, muscular twitchings, alternating redness and pallor of the face, and coldness of the feet. The vertigo occurs in paroxysms, usually of short duration, varying from one to fifteen minutes. It is especially in plethoric and obese women that climacteric vertigo occurs.

A peculiar form of this climacteric vertigo is that described by Tilt under the name of “Pseudo-Narcotism” of climacteric women, characterized by a sense of swimming movements, uncertainty in the gait, vacancy of expression, a confused look in the eyes like those of a drunken person, and a kind of mental stupor which the patient cannot shake off without considerable effort. The women thus affected state that they feel as if they had had too much to drink, as if something had gone to their heads; indeed their great fear is that they will be supposed to be intoxicated by those who see them walking in the streets; they feel even that they must refuse to receive the visits of their acquaintances if they wish to preserve their reputation for sobriety. They suffer also from great drowsiness, from a disagreeable sense of weight or pressure in the head, from a feeling “as if the brain was clouded, or needed to have some cobwebs swept away.” They feel a disinclination to both mental and physical exertion, and their memory and all other intellectual powers are impaired.

Boerner maintains that the attacks of vertigo so frequently occurring at the menopause are in a minority of cases only dependent upon hyperaemic states (arising from the cessation of the menstrual flow); on the contrary, he believes that the cause more often lies in hysteria, in chronic disorder of the digestive tract, or, finally, in anæmia. In his opinion, vertiginous attacks dependent upon cerebral anæmia are very common indeed during the climacteric period, and even for a long time afterwards; and he believes that their nature is often completely misinterpreted.

Another very unpleasant indication of disordered nervous function during the climacteric period is the sleeplessness that is so common at this time of life. Women who during the day time feel comparatively well, suffer at night, sometimes periodically at exactly the same hour night after night, from a state of general restlessness, and for this reason are unable to obtain the sleep for which they long. They throw themselves uneasily from side to side of the bed, or wander restlessly about the room, and before long, owing to this want of sufficient repose, become greatly depressed.

Among the neuroses of the sensory apparatus, the various kinds of cutaneous neuralgia are less common than during the menarche and the menacme; but on the other hand, in my personal experience at any rate, the visceral neuralgias are commoner, more especially cardialgia and hypogastric neuralgia. Of the superficial neuralgias, hemicrania and intercostal neuralgia are those which occur most often during the climacteric period.

During the change of life, hemicrania most commonly occurs in typical association with menstruation; or, if the flow has already ceased, the attacks of hemicrania recur at what should be the menstrual periods. This affection is characterized by the paroxysmal occurrence of a severe boring pain in the side of the head, more often the left side than the right, affecting the temporal, the parietal, or the occipital region, or the entire side of the calvaria at once, usually accompanied with redness and local rise of temperature of the painful part; the duration of the paroxysms varies in different cases from one or two to many hours; with the pain are associated chilliness, nausea, exhaustion, and a severe feeling of general malaise.

Of the intercostal neuralgias, one form deserves especial mention in this connexion: I refer to mastodynia, which is both physically and mentally one of the most distressing affections to which women are subject during the climacteric period. For a middle-aged woman suffering from mastodynia—the “irritable breast” of Cooper—almost invariably feels assured that these pains localized in the breast and its immediate vicinity are indications of a commencing cancer of the breast; and it is an exceedingly difficult matter, in most cases, to convince her that her fears are without foundation. In this manner, partly in consequence of the directly depressing effect of the pains, which are commonly intensely severe, and partly owing to the disturbance of mind produced by the belief that an incurably fatal disorder has begun, I have in several instances seen cases of profound melancholia originate.

According to Windscheid, among the enduring painful sensations of the climacteric period, pains in the lower extremities are of somewhat frequent occurrence. Day after day the patient suffers from distressing tearing or lancinating sensations in the legs; the trouble is insusceptible of more exact description, but is none the less a very severe one. In addition to the lower extremities, the back, the spinal column, and more particularly the lumbo-sacral region, are often the seats of incessant pain. In the thoracic region of the back, the pain is usually diffuse; when confined to the spinal column, however, it is commonly limited to individual vertebrae, the spinous processes of those affected being also sensitive to pressure. The sacral pains may in some cases predominate to such an extent, that it is on this ground alone that the patient comes to seek medical advice. The sacrache is equally severe when the patient is standing, sitting, or recumbent; it often radiates into the lower extremities. Boerner draws attention to the fact that in many cases the pains in the sacrum or higher up in the back may be due to excessive tension of the abdominal parietes in consequence of the great accumulation of fat. Among motor manifestations, Windscheid draws especial attention to a certain degree of weakening of the muscles of the lower extremities. Although on examination no abnormality can be detected, fatigue and functional incapacity, more especially in the lower extremities, ensue in a manner altogether disproportionate to the exertion, so that the patient is most unwilling to take even a short walk, to go upstairs, etc. In pronounced cases, the patient will never go out walking without carrying a campstool, so that she can sit down to rest directly she begins to feel fatigued. In association with these disorders of motility we most commonly see the above-mentioned painful sensations in the legs, and by these latter the functional incapacity of the lower limbs is of course increased. Weakness of the arms is far less frequently observed; but occasionally we hear complaints that on the performance of domestic duties, needlework, etc., which previously could be carried out quite easily, the arms and hands are now speedily fatigued, and rendered functionally incapable.

Of the visceral neuralgias, cardialgia is by no means rare during the climacteric period; the pain is concentrated in the epigastric region, but not infrequently radiates to the back and to the chest. Hypogastric neuralgia is also not uncommon, pain in the lower part of the abdomen, associated with a sense of pressure in the bladder, the uterus, and the rectum, and sometimes radiating to the thighs and to the region of the haemorrhoidal nerves.

The opinion expressed by several authorities, that the menopause favours the occurrence of cerebral apoplexy, must, according to Windscheid, be received with caution; we have to remember that with advancing years atheromatous changes are apt to occur in the cerebral arteries, and it is to these changes, altogether independently of the climacteric, that cerebral haemorrhage is due. It appears, however, to be a fact that the menopause favours the onset of progressive paralysis. According to Jung, 60%, and according to von Krafft-Ebing, 27%, of women affected with paralysis were first affected in this way during the climacteric period. Von Krafft-Ebing explains this occurrence by the fact that during the menopause fluxions of vasomotor origin are common, and these serve as the starting point of transudative processes.

Among the neuropathic manifestations of the climacteric period we must reckon the at times excessive increase of the sexual impulse. We have already insisted upon the fact that the sexual impulse is not normally extinguished in women at the time of the cessation of menstruation; on the contrary, sexual desire commonly persists long after the menopause, and on this fact is largely dependent the frequency with which elderly women espouse quite young men. But in some cases, the sexual impulse is enormously enhanced during the climacteric period, and the patient experiences paroxysms of intense voluptuous sensation, associated with manifestations of abnormal reflex and psychical reaction, with increased frequency of the pulse and the respiration, emotional excitement, it may be loss of consciousness, and even general convulsions. Some of these cases of disordered sexuality occur in those previously affected with pruritus vulvae et vaginae.

More particularly Guenceau de Mussy and Boerner have described cases of such excessive libido sexualis during the climacteric period, voluptuous crises with pollutions, occurring independently of any external cause; the women thus affected have a continued succession of erotic ideas, they experience an itching and burning sensation in the genital organs, and from time to time this culminates in a paroxysm of sexual feeling, with orgasm, and increased secretion from the glands of the vulva.

Boerner has observed that characteristic variations in the libido sexualis commonly occur at the climacteric period. Not infrequently at this time the sexual desire becomes greatly diminished in intensity, or even entirely disappears; more often, however, the desire persists throughout this epoch; finally, in many instances, the desire undergoes an increase, at times to a degree amounting to positive torment. The first of these changes, the decline in the intensity of the sexual desire, harmonising as it does with the general extinction of the sexual functions at the change of life, might have been expected to be the normal occurrence. And it is a fact that in many cases characterized by an increase of libido sexualis at the climacteric epoch, Boerner found that there existed anatomical abnormalities in the reproductive organs (fibromata, flexions, etc.). Be this as it may, an increase in the intensity of sexual desire, as long as that increase is not altogether excessive, may be regarded as one manifestation of the visceral hyperaesthesias so general at this time of life. In the excessive degrees of this affection, however, those in which at times the sexual crisis is associated with general convulsions, we must, with Romberg, recognize the existence of a direct neuralgic state of the spermatic plexus. It is especially before the commencement of an actual menstrual period, or before a due period which fails to occur, that during the critical years complaint is made of this state of excessive sexual desire and sensibility; and in many instances the trouble begins at the very first appearance of the menstrual irregularities which foreshadow the menopause.

Windscheid draws attention to the fact that occasionally the nervous manifestations may make their appearance prior to the occurrence of any menstrual irregularity, so that it is by the nervous disturbance that the woman or her physician is warned of the approach of the menopause. “When the menstrual anomalies begin,” continues Windscheid, “that is to say, at the commencement of the climacteric, the nervous troubles may have already attained their maximum and have begun to decline in intensity. As a general rule, however, the appearance of the nervous disturbances coincides with the commencement of the menstrual irregularities. It may happen that these disturbances are intensified with each recurring period, but this is not the rule. Sometimes, however, we may observe that when menstruation occurs with excessive frequency—a by no means rare phenomenon at the outset of the climacteric—the nervous disturbances become more severe; and especially is this the case when the unduly frequent flow is also abnormally profuse, as indeed often happens.” The manifestations of climacteric neurosis occur, as Windscheid rightly insists, most frequently in the sphere of the psyche. “We observe a change in the disposition, which usually becomes more excitable. A woman previously calm and composed becomes irritable, inclined to emotional disturbance and to fits of temper, and unable to bear with equanimity the pinpricks so frequent in daily life, and especially in the daily life of a housewife. In other cases, however, the disturbance of the psyche is rather in the direction of depression: we observe a kind of spiritual inhibition, a deficiency of vital energy, an indifference to things which formerly gave pleasure. Almost always, also, complaints of loss of memory are among the indications of such depression. To these intellectual anomalies are superadded disturbances of sensibility. There is excessive sensitiveness to bright lights, loud noises, and strong odours. Frequently, also, in such cases, we see great intolerance to alcohol, quite small doses giving rise to extremely disagreeable sensations in the head.”

Climacteric Psychoses.

The powerful influence which the changes occurring at the climacteric period has in the origination of psychoses, has long been recognized, the menopause, in fact, being a favourable soil for the cultivation of mental disease. The fact is embodied in medical terminology, since many authors speak of “climacteric insanity,” assuming that the psychoses of this period of life present a definite and characteristic clinical picture.

In an earlier part of this work it was shown that the process of menstruation has generally a marked effect upon the psyche, and that disturbances of menstrual activity are competent to exercise a pathogenic influence upon the mental condition of the woman who suffers from them; still greater and more intense is the influence of the cessation of menstrual activity, with its powerful and widespread disturbance of the entire organism, with its destructive oscillations of equilibrium in the spheres of sensation, perception, ideation, and volition. It is easy to understand how the rarer recurrence of menstruation, the occasional profuse losses of blood, the complete suppression of menstruation, the conditions peculiar to the climacteric period of stasis and congestive hyperaemia of the brain, are competent, more especially in hereditarily predisposed persons, to give rise to the development of psychoses; whilst in those already suffering from mental disorder, the menopause will be likely to bring about an aggravation in their symptoms. At this time of life, also, we have to take into account the effect of certain ideational influences to which allusion has already been made, the thought that womanhood and its joys are passing away for ever, and the fear of the dangers attendant upon this critical period of the change of life. A French proverb alludes to “le diable de quarante ans, si habille à tourmenter les femmes.”

Mental disorder will be more likely to ensue at the climacteric period in those women whose nervous systems have always been unduly irritable, and in those affected with hereditary predisposition to insanity. Further, it is more likely to occur in those in whom the menopause takes place quite suddenly, in a catastrophic manner, than in those in whom the climacteric proceeds gradually, and unaccompanied by any stormy manifestations in the organism at large.

It is not in my opinion possible to recognize any specific form of mental disorder peculiar to the climacteric period, but nevertheless the psychoses occurring at this time of life do exhibit certain striking and characteristic features, more especially in this respect, that states of mental depression with melancholia predominate, whilst erotic influences are manifest in their etiology. In the slighter forms, volition and ideation are unaffected, and the trouble manifests itself in the form of hypochondriacal moods, associated with bodily troubles. In more severe cases we see emotional depression, states of anxiety, limitation of the powers of conception and judgment, indecisiveness, low-spiritedness, and apathy; or on the other hand, restlessness, an inclination to continued moving about, the eager pursuit of continually varying occupations, loquacity, etc.; finally, if the mental disorder becomes still more severe, hallucinations, delirium, paroxysms of intense excitement, and in exceptional instances, fully developed mania.

As with regard to the other disorders attending the climacteric, so also in respect of the climacteric psychoses, women who have been or are married, who have had a reasonable number of children, and have been accustomed to a sufficiency of sexual activity, are more favourably situated, are far more immune, than women whose sexual circumstances have been the opposite of those mentioned, who have had one or two children only, who have indulged in intercourse only when protected from pregnancy by the use of preventive measures, or have remained sexually unsatisfied, and, finally, women who have never married, and those who for many years prior to the commencement of the menopause have lived in chaste widowhood. In “old maids,” to the somatic effects of sexual abstinence (or in some cases of abnormal sexual gratification), are superadded the effects of the intellectual and emotional recognition of a wasted life. Again, it by no means rarely comes under our observation that women who in youth, at the time of the menarche, suffered from psychical disturbances, are apt once again to be affected with transitory mental disorder at the change of life. Once, however, the menopause is completely at an end, a condition of mental quiescence is as a rule established, and then it may happen that previously existent mental disorders undergo amelioration; but on the other hand we have in all cases to reckon with the possibility that they may take an unfavourable turn in the direction of the development of senile psychoses.

Of considerable interest is the fact, first pointed out by Glaevecke, and subsequently confirmed by other observers, that in cases of artificial menopause, melancholic mental disturbances not infrequently follow the operation, in some instances so severe as to lead to weariness of life and actual suicide; and in general, after the artificial induction of the menopause, psychical disturbances are by no means rare, and are sometimes very severe. Such disturbance of the mental balance is seen after oöphorectomy especially in women who are still comparatively young, and whose sexual powers are still in a ripe state; whereas when the operation is performed in women of a more advanced age, whose ovaries were already nearly or completely functionless, no psychopathic changes are likely to ensue. In women belonging to the former category, the same etiological influences come into operation as in the physiological menopause, the patient, that is, is affected by the psychical influences of the removal of the ovaries—not only by the cessation of menstruation and the disappearance of the internal secretion of the reproductive glands, leading to a disturbance of the physical equilibrium, but also by the intellectual recognition of the loss of sexual potency, and a consequent disturbance of the mental balance.

In Schlager’s opinion the climacteric has a potent influence in promoting the development of psychical disturbances in women, even when the involution occurs at the normal age. The course of these disturbances is as follows: soon after the commencement of the process of involution, when for a few months already the menstrual periodicity has been irregular, or the flow has been unduly profuse, a change of disposition makes its appearance, at first hardly noticeable, but after a little time manifesting itself clearly in the form of an increase in irritability. The woman finds fault with everything and everybody, becomes mistrustful, suspicious, full of complaints, imagines that the most insignificant annoyances are due to intentional slights; at the same time she complains of continued sleeplessness, palpitation, various indescribable sensations, and of headache. Occasionally, congestions of the head occur, with alarming dreams, and the moodiness may increase greatly; in this condition three such patients of Schlager’s were impelled to attempts at suicide. Schlager further draws attention to the fact that in 22 cases known to him in which suicide was performed or unsuccessfully attempted by women, in eleven of these the patient was at the climacteric age. He believes that the most important etiological influence in the production of climacteric mental disorder in such cases is the sudden suppression of menstruation. In the majority of these instances, the mental disorder takes the form of mania; exceptionally, however, the form of chorea or of catalepsy.

By Tilt the following forms of “climacteric insanity” are distinguished: delirium, mania, hypochondriasis, melancholia, impulsive insanity, and perversion of the moral instincts. The same author publishes the following table showing the age incidence in 1,320 cases of mental disorder in women, from which it appears that during the age of the menopause, a very considerable number of the cases originate, but that after the change of life comparatively few cases occur.

In these 1,320 cases the women were:

Fuchs tabulated the ages of 26.300 insane persons. Reducing his results to the ratios per 10,000, he obtained the following results:

According to Esquirol, among 198 women who committed suicide, there were 77 between the ages of 40 and 50 years—a number considerably larger than those in any other age-decade. Among 235 women suffering from dementia, a moiety had first come under treatment during the climacteric age. The same author published the following data regarding the age-incidence of insanity in the case of 6.713 female patients:

Matusch found that among 551 women suffering from mental disorder, there were:

According to von Krafft-Ebing, among 858 insane women, there were about 60 in whom the disorder of the mind appeared to depend upon the influence of the climacteric, and in 25 of these there was hereditary predisposition to mental disease.

From Kowalewski’s interesting work on the psychoses of the climacteric, we quote the following:

“In women, the climacteric has a distinct influence upon the mental life, and that influence is strongly manifested more especially in cases in which during the age of puberty mental disturbance had previously been noticed. The mental condition in which women approach the change of life is a very variable one, and it is one largely dependent upon the circumstances in which the active years of the sexual life have been passed. In some cases, a woman has been so fortunate as to marry early and from affection, and her whole married life has been passed without disturbance; her labours have not been exhausting, and her children have enjoyed good health; all have passed through the years of childhood without untoward incident, and their development has been a happy and successful one; in a word—everything has gone well with her and hers. Such a woman will give thanks to God for the rare felicity she has enjoyed; and quietly, patiently, and with understanding will endure the inevitable end of her sexual life. For such a woman, more especially if she comes of a healthy stock, the changes which occur in her reproductive organs at the epoch of the climacteric, need not entail any serious shock to her nervous system, nor need they form the culture ground for morbid manifestations in her nervous system or in her mind. Even if any anomalies in nervous working should occur, it will be such only as are aroused by the disturbance of the normal menstrual rhythm; in such cases, they will rarely prove of a serious or enduring character.

“But look, on the other hand, upon this picture. A woman has married without affection and from pure necessity. Her husband has been a drunkard, and rough and unfaithful. She has had a great many children, her labours have been tedious and difficult and accompanied with severe losses of blood. Some of the children fell sick and died; those that survived proved idle, good-fornothing, and a burthen. The family life is dominated by quarrelsomeness, disorder, and insufficiency of means. The mother is affected with some chronic disorder of the reproductive organs, and is hardly ever out of the doctor’s hands. After 25 or 30 years of a life of this kind, the woman enters upon the change of life. Physically exhausted, weary of life, never having known happiness, after an existence full of trouble and wretchedness, with nothing joyful either in her memories of the past or in her prospect of the future—the chief hope of such a woman is that her troubles may soon end with her life. Where the soil is thus physically and mentally exhausted, the development of a neurosis or a psychosis is only too probable on the most trifling exciting cause. Her life seems of so little worth, that thoughts of suicide are likely to be very near at hand. Thus, when the climacteric alterations in the reproductive organs are superadded, melancholia is very likely to supervene. When, however, the case is complicated by hereditary predisposition to insanity, and by the occurrence of actual degenerative changes in the central nervous system, instead of the passive depression of melancholia, we shall rather see the ideas of persecution of paranoia. As an actual fact, these two psychoses, melancholia and paranoia, are the commonest forms of mental disorder at this period of a woman’s life.

“These are the two extremes in woman’s mental state at the time when the physical changes of the climacteric period begin in her reproductive organs. It will, of course, be readily understood that between these two extremes lies a series of combinations any one of which may in individual cases occur.

“In considering the mental condition of women at the outset of the climacteric period, we must not forget those who are called ‘old maids.’ In their youth these maidens also have had their ideals, their hopes, their plans, and their sorrows. They also had a natural impulse to love and to be loved in return; they hoped to become wives and mothers. But life has failed to fulfil their hopes and their wishes, and their longings have remained unsatisfied. Some of them have taken up their cross without murmuring, and have devoted their talents, their intelligence, and their love to the service of those nearest to them. But others make an active protest against fate in the form of vindictive feelings towards their environment, of quarrelsomeness, scandal-mongering, etc. Here we see contrasted the two principal types of such women. On the one hand are those who devote their intellectual and spiritual powers to the service of society; these are unselfish sisters-of-mercy, untiring medical women, invaluable school-teachers and governesses, fanatical political agents, etc. Such as these have ceased to live for themselves. In the fullest sense of the words, they mortify the flesh, and guide their conduct by lofty moral principles. They have killed their sexual life, and they remain for ever virgins—both morally and physically. If, owing to a pathological inheritance, faulty conditions of life, exhausting illnesses, etc., a psychosis develops, the hallucinations and delusions from which they suffer very rarely assume a sexual character, nor are they of a degrading type. The sexual side of life seems, in fact, be they sane or insane, to have undergone complete atrophy. They suffer from simple melancholia with stupor, or their insanity takes a religious turn, but very rarely indeed has it an erotic character.

“Very different is it with old maids of the second type. They are dissatisfied with life, irritable, quarrelsome, envious, and malicious. They are spiteful and revengeful, gossips and scandalmongers, boast of their own chaste and innocent lives, and never forgive any real or imaginary attempt upon their spotless virtue. At the same time they never lose hope for the future, and are full of imaginary love-affairs, in which they pass through scenes by no means chaste or innocent; they do not shrink from self-abuse and the abnormal gratification of the sexual needs, in which the lacking partner in the sexual act is supplied by the imagination. Under the influence of such abnormal conditions of life, these women frequently become affected by nervous disorders; migraine, neuralgia, cephalalgia, nervous depression, rachialgia, debility, anæmia, diseases of the reproductive organs, etc. Thus, when they enter the climacteric age, the soil is fully prepared for the development of mental disorder, which in such individuals is often characterized by hallucinations of sexual sensation and perception, erotic visual and auditory hallucinations, delusions of similar character, increased sexual irritability, a search for abnormal means of sexual gratification, a propensity to obscene speech and conduct, etc.

“Mental disorder is so common during the climacteric period, that the term ‘climacteric insanity’ has now become established in the literature of mental alienation. In almost all the textbooks of the subject we find an allusion to this form of mental disease, but there is no real ground for Maudsley’s assumption that there is a climacteric insanity sui generis. At the climacteric, very various forms of mental disorder may occur—paranoia, melancholia, and mania; the only common feature in the attacks, owing to which they are classed as ‘climacteric insanity’ being the fact that the final determining cause in each case is the onset of the change of life. In fact, this period is not without influence upon the manifestation of the disease—its stamp is imprinted upon the clinical picture, it endues the disease with certain characteristic features—but still, the peculiarities common to the cases of mental disorder occurring at this time of life in women are not so great as to justify us in describing them as a separate variety of psychosis.”

According to Kowalewski, this so-called climacteric insanity is met with in two principal forms: in many cases the mental disorder recurs in periodic paroxysms, associated either with the commencement of the menstrual flow, or having the periodicity of menstruation after the flow has already ceased to appear; in the other class of cases the psychosis has no direct connexion with menstruation, and is dependent upon the joint influence of all the manifestations of the climacteric period. Cases belonging to the former class have been distinguished by Bartel as “climacteric pseudomenstrual insanity.”

Mania is comparatively rare at the climacteric period; when it does occur, it commonly assumes a sexual form—sexual impulses, hallucinations, and delusions, and obscene conduct. Such manifestations are seen most often in widows, in “old maids” whose morals are not above reproach, and, speaking generally, in those whose sexual needs have remained partially or completely ungratified, and in those who have greatly erred in the conduct of this side of life. Amentia also occurs at this time of life; rarely in maniacal form, more frequently in association with menstruation as a periodic psychosis, or as a continuous disorder of mind with exacerbations corresponding to the menstrual periods; it is often characterized by pronounced eroticism.

Much more frequent during the climacteric period is the occurrence of paranoia, as Kowalewski rightly insists. It is most often met with in “old maids” with psychopathic predisposition. The imagination of such individuals is always concentrated upon men; they imagine that men in general, but more particularly certain individuals of the opposite sex, are continually regarding them, making eyes at them, making signs to them, in some way or other striving to attract their attention. The most ordinary and invariable forms of polite intercourse are regarded by these women, whose powers of observation are morbidly stimulated, as being indications of a special “attention” paid to themselves. They persecute these men with their own attentions, and imagine that it is the men who are persecuting them. Often this morbid mental state is associated with sexual malpractices, masturbation, etc. Not rarely, such degenerates are affected with lascivious dreams. Often they experience hallucinations of sexual perception in the form of supposed assaults on their virginity. All these states are apt speedily to develop into a condition of general suspiciousness and ideas of persecution. The ideas of persecution assume a peculiar form, one especially characteristic of the climacteric period. The patients believe that a man, often personally unknown to them, and perhaps living in another town, enters into spiritual and bodily intercourse with them. These relations are supposed to be effected in most cases by means of spiritualism, hypnotism, or electricity. The patient importunes the man in question with letters, supposes herself to be legally united with him, and not infrequently wishes to give him the pleasure of paying her bills and providing her with money. It is a very common occurrence for a Catholic priest to be worried by such a woman, her delusion being grounded upon the fact that the priest is supposed to assume an exceptionally intimate spiritual relationship with members of his flock. The patient with ideas of persecution often herself becomes an actual persecutor, not only pestering her victim with innumerable letters, but in her jealousy making “scenes” whenever she can encounter him, and sometimes giving rise to serious scandal. With such a mental state we often see associated sexual hallucinations and delusions; the patient believes herself to be pregnant, imagines herself to have been violated, or to be living in carnal intercourse with a man—some one, it may be, with whom she is not even acquainted. Medical men are especially apt to suffer from the accusations of such women, whom they may have examined in private in entire ignorance of the patient’s mental condition. Frequently, such ideas of sexual persecution are associated with paroxysms of violent nymphomania, and in this way also the unwary physician may find himself placed in an extremely unpleasant position. It occasionally happens in such patients that abnormalities of the sexual instinct arise, and they begin to feel desire towards individuals of their own sex.

Such delusions of persecution by means of hypnotism, spiritualism, the telephone, etc., in association with sexual delusions and nymphomania, are so frequent during the climacteric period, that they may be regarded as pre-eminently constituting climacteric insanity. Frequently some old hysterical state underlies this form of mental disorder.

Thus these peculiar manifestations of eroticism must be regarded as the distinctive characteristics of climacteric insanity and more particularly of climacteric paranoia. A second characteristic of climacteric insanity is, according to Garat, the marked development of jealous emotions and delusions.

In addition to these fully developed psychoses, there occur in degenerates at the climacteric age paroxysms of impulsive insanity in the form of dipsomania, kleptomania, pyromania; exhibitionism; irresistible impulse to suicide, homicide, infanticide, etc. Such paroxysmal impulsive manifestations are, according to Kowalewski, commonly associated with menstrual disturbances; they occur most frequently at the due dates of menstruation when the flow fails to appear.

One hundred and sixty-nine cases of climacteric psychosis were classified by Matusch as follows:

Von Krafft-Ebing classified 60 cases of climacteric psychosis as follows:

The prognosis in cases of climacteric psychosis is regarded by Kowalewski as unfavourable; unfavourable vital conditions are associated with retrogressive metamorphosis of the tissues, hence mental disorder arising at this time of life is hardly less serious than that due to actual degeneration of cerebral tissues. Indeed, according to Schüle there is during the climacteric period an especial danger of the development of atrophic cerebral processes (Encephalitis atheromatosa) with apoplectic and epileptic seizures. Schlager also regards the prognosis of climacteric insanity as unfavourable; but Merson, on the other hand, observed among women suffering from climacteric psychoses a recovery rate of over 50%. On previously existent psychoses in women, the onset of the climacteric exercises in most cases an unfavourable influence, and very exceptionally only at this time do we observe the cure or remission of a chronic mental disorder to occur. Kowalewski has seen cases of chronic mania in which a cure was obtained at the climacteric period; a somewhat excessive excitability and inclination to violence remained, however, as vestiges of the former insanity. Matusch, keeping under observation 60 women affected with chronic mental disorder as they attained the climacteric period, noticed that in 14 instances the mental condition changed for the worse at this period, whilst in 13 the character of the mental disease underwent a change, excitement giving place to apathy and dementia. Griesinger had earlier pointed out that at the time of the cessation of menstruation there would occasionally occur amelioration, and even cure, of a previously existing chronic mental disorder; more often, however, the influence of the menopause was an unfavourable one, a hitherto changeable and irritative form of mental disease becoming transformed into chronic insanity with inalterable delusions, or into dementia. The course of mental disorder, such as melancholia, first making its appearance at the climacteric epoch, was also regarded by Griesinger as likely to be unfavourable.

Hygiene During the Menopause.

During the critical years of a woman’s life it is the aim of hygiene to employ all the means available to counteract the changes in the circulation of the blood, the disturbances in the working of the nervous system, and the nutritive disorders, which are in various ways dependent upon the changes occurring in the reproductive organs during the climacteric period; its endeavour should be so to regulate the conduct of life in this epoch that the important episode of the gradual decline and ultimate extinction of sexual productivity shall be effected with as few local troubles as possible, and as slight variations in the general condition.

By means of baths of various temperature, duration, mode of application, and composition, and by other selected hydrotherapeutic procedures, we are enabled during the disturbances of the menopause to exert upon the skin a powerful derivative influence, and in this way to diminish the passive hyperaemia of the uterus and the uterine annexa; by the same means we can exercise a sedative influence on the peripheral nerves and thus further upon the entire nervous system, whenever such measures are called for by the manifold indications of increased irritability; further, by the use of baths we can influence the circulation of the blood, we can increase the sudatory activity of the skin, and in various additional ways we can affect heat production and metabolism, thus modifying the processes occurring in the reproductive organs, making the conditions favourable for the absorption of exudations, and promoting a healthy tissue-change in the mucous membrane of the genital passages.

In climacteric women, the most usual indications are for the employment of water-baths at an indifferent temperature. 35 to 37° C. (95 to 98° F.), of moderate duration, 15 to 20 minutes, the bath being one of simple immersion, not of douche or affusion, and the temperature being kept constant by continuous inflow of a sufficient quantity of hot water. Such baths as these promote in a mild but continuously efficient manner the functions of the skin—so important during the climacteric epoch; and they lessen the almost constant tendency to perspirations and to the development of diseases of the skin (the commonest of which is climacteric eczema). The moderate degree of thermic stimulus exercised by baths at such an indifferent temperature leads them to have an equable sedative effect upon the nervous system, which is probably dependent upon an influence exerted through the intermediation of the sensory nerve-terminals in the skin; and this is most beneficial in lessening the increased general irritability, both spontaneous and reflex, so commonly manifested by the nervous system at the climacteric period. In women at this time of life, such baths are most useful in allaying the common cutaneous hyperaesthesias and neuralgias, and have a reflex influence also upon the visceral neuralgias and psychical hyperaesthesias.

In other cases of disturbances of health during the climacteric period, however, more benefit may be derived from hot immersion baths, taken at a temperature well above blood heat, (37° C.—98.4° F.) and lasting longer than the warm baths just described. These are indicated when we wish to increase the activity of the circulation through the skin, to give rise to hyperaemia of the superficial structures of the body, to stimulate powerfully the cutaneous nerves, to promote cutaneous perspiration—in short, to exercise a powerful derivative effect, to promote resorption, and to accelerate the general processes of tissue-change. This method of treatment is suitable for cases in which at the commencement of the menopause there are already pathological conditions of the reproductive organs, the morbid states being now aggravated by the processes of the climacteric—such conditions are metritis and endometritis, chronic inflammations of the intrapelvic connective tissue and of the pelvic peritoneum; and one of the first aims of treatment must be to promote the softening and subsequent absorption of these inflammatory products. Again, in cases in which the climacteric troubles, dependent in part on increased general arterial blood-pressure, manifest themselves chiefly in the form of active congestions, fugitive heats, vertigo, etc., the employment of hot baths is likely to be most useful by leading to a notable enlargement of the cutaneous capillary bloodvessels and consequent lowering of arterial blood-pressure. Further, in cases of compensatory fluxes, periodic diarrhoeas, periodic leucorrhoea, following the suppression of the menstrual flow, in cases of vicarious haemorrhage (especially periodic epistaxis and periodical haemorrhoidal bleedings), the use of hot baths is often competent to restore the functional activity of the ovaries when this has undergone premature cessation. In addition, their use assists us in our endeavours to counteract excessive obesity and gouty disorders, diseases which tend especially to make their appearance in women at the epoch of the menopause, disorders of metabolism intimately associated with the disturbances of the uterine and ovarian functions characteristic of the change of life.

In all the conditions just enumerated, if we desire a still more powerful influence than that exerted by ordinary hot baths, it is in our power to employ hot mineral water baths, by means of which a chemical, and perhaps also an electrical, stimulation of the cutaneous nerves is superadded to the simple thermic stimulus conveyed by the hot water. The different effects of the various mineral baths depends upon both the saline and the gaseous constituents of the different springs, and upon the peculiar physical properties of the mineral waters.

Sudorific baths are of various kinds. Some, Russian baths, consist of hot air saturated with moisture; others, Roman-Irish baths, consist of dry hot air; the most recent of all are the electric light baths, in which the radiant heat of electric lamps is utilized. But owing to the great increase in the body temperature which they cause, with consequent increased frequency of pulse and breathing, and still more on account of the rapid and extensive increase in blood-pressure to which they give rise, these powerful sudorific baths are rarely suitable for climacteric women, and if used at all in such cases the greatest caution must be employed. Their use is indicated only in women in whom at the time of the menopause the rapid onset of obesity has given rise to serious troubles, but in whom the heart is perfectly sound and in whom the blood vessels show no trace of sclerosis.

Far less often than warm or hot baths, or mineral water baths, are cold baths employed during the climacteric period, for baths at a temperature considerably below the indifferent point, and other hydrotherapeutic procedures in which cold water is used, stimulate the nervous system so powerfully and give rise to so great an increase in blood-pressure, that their use is generally to be avoided in climacteric women, since indeed it is apt to entail serious dangers both physical and mental. Immersion baths, plunge baths, or sponge baths, in which the water employed is at a temperature of 18° C. (64° F.) or less, are contra-indicated, for they act too energetically, abstract heat too powerfully, to be safely employed at this epoch of life. If we seek by means of hydrotherapeutic measures to counteract states of congestion at the time of the menopause, and at the same time to bring about a general invigoration of the patient’s nervous system, immersion baths the water of which is not below 20° C. (68° F.), and lasting from five to fifteen minutes, would appear to be indicated. In the majority of such cases, however, a somewhat higher temperature is preferable, from 26 to 28° C. (79 to 82° F.), the patient lying at full length in the bath, immersed to above the shoulders, and the water not being agitated except by a moderate rubbing of the surface of the body whilst the patient is in the bath. When, however, the patient sits in the bath, the water covering only the lower half of the body as high as the navel, a somewhat lower temperature is permissible, 20 to 25° C. (68 to 77° F.); but the duration should not exceed five minutes, moderate mechanical manipulations being carried out meanwhile; such baths appear to reduce nervous irritability and to have a sedative effect in the manifold nervous disturbances of the climacteric period. Sitz-baths, again, of a longer duration, twenty to sixty minutes, the water reaching only to the navel, and being at a temperature varying from 16 to 25° C. (60 to 77° F.), are useful in relieving chronic inflammatory states of the reproductive organs and the associated erotic states and abdominal pain and irritability. Colder sitz-baths, even of brief duration, should, on the other hand, be avoided. Similarly, a shower-bath of water at a temperature of 18 to 24° C. (64 to 75° F.), lasting one to two minutes, and the water falling only from a very slight elevation above the head, have a valuable sedative action; but, on the other hand, a colder shower-bath, of water falling from a greater height, has an exciting action, and is to be avoided at this time of life. When there are severe congestive symptoms, friction of the hands and feet for a short time with water at a temperature from 12 to 17° C. (54 to 63° F.), followed by a quarter of an hour’s rest in bed, may be recommended; also immersion of the feet for a minute in water at a temperature of 10° C. (50° F.), the feet being vigorously rubbed the while, followed by a walk in the open for five or ten minutes. In cases of sleeplessness at the menopause due to congestion, a useful method is to dip the feet for twenty or thirty seconds in water at a temperature of 8 to 10° C. (46 to 50° F.), the feet being briskly rubbed whilst in the water, or moved rapidly up and down with treading movements; after withdrawal, they are quickly dried, and the patient immediately goes to bed. Another useful mild soporific measure is to apply before going to bed bandages wrung out of cold water; these reach from the foot to the knee, and are left on for the whole night. In cases of climacteric menorrhagia, my vaginal refrigerator should be used for the direct application of cold to the reproductive organs; this is a cylindrical apparatus introduced into the vagina, cold water flows through the interior of the apparatus without wetting the vaginal mucous membrane. This cooling apparatus is useful also in troublesome cases of genital pruritus; cold douches to the vulva for one or two minutes at a time are likewise valuable in the relief of this affection.

For climacteric women, cold sea-bathing is as little to be recommended as other cold hydrotherapeutic measures, owing to its powerful refrigerative effect, and the great mechanical influence of the moving water in the waves. But in certain cases, in which sea-air is likely to be beneficial, lukewarm sea-baths may also be recommended; their effect is similar to that of weak brine-baths at a similar temperature.

During the climacteric period, especial attention must be paid to the care of the skin. Owing to the extreme sensitiveness of the skin at this time of life to outward noxious influences, it is necessary to exercise great care to dry the skin very thoroughly after ordinary ablutions of the face and hands; irritating soaps should be avoided, and a bland powder should be applied after drying. During the earlier part of the climacteric period, when menstruation has already ceased, and senile changes in the skin with atrophy of the subcutaneous tissues have commenced, the extreme dryness of the skin may be relieved by lukewarm baths with wet packs to follow; after the bath, the woman is enveloped in moist linen cloths and then covered over all with a blanket. When the skin chaps readily, inunction of lanolin ointment will be found useful.

Bodily exercise, carefully selected and regulated to suit the individuality of each patient, is a powerful means of relieving the disturbances of the menopause. Regular and methodical bodily exercise—to which it must be remembered, women at the climacteric period commonly feel considerable aversion—manifests its good effects in the form of improvement in the nutritive conditions and functional activity of all the organs, and increased activity of all metabolic changes, which are commonly sluggish in women at the change of life. Moreover, muscular exercise, by increasing the volume of blood passing through the muscles, has a beneficial derivative influence in diminishing the congestion of the brain and the other troublesome congestive symptoms which are liable to occur in women during the menopause. Again, in cases of excessive obesity such as so commonly occur in women at the change of life, the increased combustion of fat promoted by regular muscular exercise, cannot fail to have a beneficial effect. Finally, suitably selected muscular exercise has a favourable influence also upon the nervous system, the functional activity of which it facilitates, while at the same time it strengthens the powers of the will.