It is therefore of importance that at the time of the menopause women should continue to undertake appropriate active exercise, regular daily walks, which should include walking up a moderate incline. As a preparation for such exercise (in persons hitherto unaccustomed to walk much), or in bad weather, or, again, when there are special reasons against open air exercise, and finally as a supplementary exercise to walking, gymnastics and massage may be employed. Such gymnastic procedures are to be chosen as will serve to deplete the vessels of the head, will have a favourable influence upon the portal circulation, and will withdraw the blood-stream from the pelvic organs; such are, in addition to general gymnastic exercises, methodical deep breathing, methodical exercise of the abdominal muscles, exercises involving the extensors of the back and the abductors and external rotators of the thigh, and exercises of the extremities. Various gymnastic apparatus may be employed with advantage, and more especially those in which the various muscular movements are effected against a resistance. But in all cases extreme care must be taken to avoid over-fatigue and over-exertion. A graduated form of bodily exercise combined with passive gymnastics, suitable for climacteric women, is massage, in which by mechanical stimulation, by pressure and friction of the whole body or of certain parts, the nutrition of the muscles is favourably influenced, and the activity of the general circulation is increased. In the use of massage also, in climacteric women, all undue excitation of the nervous system is to be carefully avoided, a mild form of this powerful agent must alone be employed; gentle stretching and rubbing of the skin of the lower extremities, the back, and the abdomen, followed by gentle kneading of the muscles. Massage of the internal reproductive organs (the method of Thure Brandt), in view of the common tendency to sexual excitability in women at the climacteric, is mentioned only to be prohibited. For the same reason, and also on account of the frequency with which at the time of the menopause women suffer from tachycardia and from other disorders of the heart, bicycling is in most cases an unsuitable exercise at this time of life.

A matter of great importance is the regulation of the diet of women during this phase of life, the aim of such regulation being one which the older physicians sought to fulfil by means of venesection and wet cupping, namely, to overcome the abnormality in the constitution of the blood which arises from the cessation of the internal secretion of the ovaries, and further to relieve the symptom-complex of abdominal plethora and the various passive hyperaemias and collateral congestions; and in addition to subdue the great general nervous irritability, the sensibility to external stimuli, the inclination to excessive reflex manifestations, characteristic in women during the climacteric period.

The diet must be regulated in respect both of quality and quantity, and it is obvious that the regulation must be thoughtfully adapted to the needs of each individual case.

As regards quantity, the main general principle of dietetics for climacteric women is that over-nutrition is to be avoided, that the quantity of nutriment must be reduced to the absolute minimum necessary to supply the needs of the tissues. In view of the fact that we are concerned with women at a comparatively advanced period of life, whose physical labours are not as a rule exhausting, that quantity of food will usually be sufficient which is competent to furnish 35 to 40 calories per body-kilogram per diem. If we assume that the mean body-weight of a woman as the climacteric age is 60 kilograms, the heat-equivalent of the food required daily by such a woman may be estimated at 2,100 to 2,400 calories. This will be approximately supplied by a diet consisting of 100 grams albumen, 60 grams fat, and 350 grams carbohydrate. The customary preference for a large amount of nitrogenous food is, however, not dependent upon physiological requirements, and provided that the needful minimum of albumen is supplied (about 1.5 gram per body-kilogram per diem), the requisite number of calories may be furnished by very various combinations of the different nutritive elements.

The general principles of the qualitative regulation of the diet of climacteric women are: first that after the necessary minimum of albumen has been supplied, there shall be added an amount of carbohydrate and of fat varying in relative proportions and quantities according to the physiological requirements of the individual, but taken together sufficient to supply the necessary heat-equivalent; secondly, that there should be an abundant consumption of water; thirdly, that stimulating dietetic adjuvants should as far as possible be avoided.

The nitrogenous equilibrium of the body may be maintained either by animal or by vegetable proteids; in the case of the former (animal albumens), the climacteric woman should avoid those containing considerable quantities of nucleo-albumen or of deleterious products of tissue-change; in the case of the latter (vegetable albumens), she should avoid those likely to cause undue stimulation of the intestinal tract. Of flesh foods (mammals, birds, and fishes), those kinds are to be preferred which contain small quantities only of extractives (kreatin, xanthin, etc.) since these substances are supposed to have a stimulating influence upon the nerves and the heart. Hence, boiled meat is better than roasted, and the flesh of young animals (veal, for instance) and fish are to be preferred to game, and the last-mentioned is to be avoided especially for this reason, that the flavours for which it is valued by the gourmet are products of partial decomposition arising from prolonged hanging; for similar reasons, meat extracts, animal soups, sausages, smoked flesh and fish, and preserved (potted) meats, should all be avoided. From the intimate connexion between the ingestion of nuclein and the formation of uric acid, albumens rich in nuclein are to be forbidden; such are the various foods consisting chiefly of gland-cells—sweetbread, liver, brain, kidneys, etc. As well as from the appropriate flesh-foods, the requisite albumen may most suitably be obtained from eggs and milk (including buttermilk); on the other hand, caviare is unsuitable owing to its stimulant action on the genital organs, cheese because it contains large quantities of the products of decomposition of casein and milk-fat; the fermented milks, koumiss and kefir, are likewise unsuitable. Suitable vegetable foods for the supply of albumen (in addition to carbohydrates) are porridge, bread, and the leguminosae; nuts, on the other hand, cause too much irritation of the stomach and intestines.

For women during the climacteric period we recommend a mixed diet moderate in quantity; the amount of flesh and fat in the diet should not be large, whilst cereals, green vegetables, and fruit may be taken in greater abundance; irritant vegetable foods must be avoided, and especially those which tend to stimulate unduly intestinal muscular activity and intestinal secretion. It is important that an abundance of water should be taken, not less than two or three pints daily, and a pure, fresh, spring water is preferable to the aerated waters, natural or artificial. Alcoholic beverages are to be avoided, and more especially those which are rich in extractives as well as in alcohol. For this latter reason, beer and champagne are harmful, whilst spirits and liqueurs are to be condemned on account of the high percentage of alcohol they contain. The stimulating alkaloidal drinks, tea and coffee, are also to be avoided, or if taken at all, only in a very dilute form. With regard to the preparation of the food, the cardinal principle is that it should be as little irritant as possible; neither mechanically irritating the alimentary tract by an excess of indigestible or undigested residue, nor irritating it chemically by an excessive admixture of sugar, salt, vinegar, pepper and other spices; nor, finally, giving rise to thermal irritation by being excessively hot or extremely cold.

The individual meals are preferably small ones and they must therefore be taken at comparatively short intervals, five times daily, the principal meal being taken at one or two o’clock in the afternoon, and the supper (which should be small) comparatively early, at seven or eight o’clock.

Note.—In his discussion of the details of diet for women during the climacteric period, hours of meals, actual dishes, etc., the author refers exclusively to Austrian and German customs in these matters. The translator has not attempted to adapt the following pages to the needs of English readers, as he feels that the general principles already given will enable the English medical man to construct without serious difficulty suitable diet-tables for the cases with which he has to deal.

Suitable articles of food are the following:

Soups, Broths, and other Liquid Foods: Soups and broths made from the flesh or bones of beef, mutton, veal, chicken, or pigeon, without the addition of meat extract, or of meat juices, peptones, somatose or nutrose, but with the addition of barley, oatmeal, rice, wheatmeal, ryemeal, peas, beans, lentils, vermicelli, or macaroni; also broths or porridge made from any kind of ground cereal, or from potatoes, or from peas, beans, or lentils.

Flesh Foods: Lean beef, veal, mutton, roast or boiled, pigeon, chicken; certain fresh fish—pike, haddock, sole, perch, and trout. Unsuitable are: pork, goose, eels, salmon, herrings, oysters, caviare, lobster, crab, smoked meat, hare, venison, wild-duck, brain, liver, kidneys.

Vegetables, Sweets, and Savouries: Green peas, spinach, cauliflower, carrots, turnips, buttered eggs, omelette, boiled and baked puddings, rice boiled in milk, apples and rice, whipped cream, salads, wheaten bread, French rolls, biscuits, and rusks.

Fruits: Almost all fruits may be taken, raw, cooked, or preserved; also in the form of currant and other fruit cakes, and as fruit-ices.

Beverages: Milk, buttermilk, water, the same acidulated with various fruit-juices and essences (as lemonade, etc.), weak tea with plenty of milk, cocoa, chocolate. To be forbidden are: beer, strong and sweet wines, distilled spirits.

An example is subjoined of a simple diet-table compiled on the above principles:

In many cases, however, a mainly vegetarian diet may be more suitable, and more particularly a mainly fruit diet, in order to diminish persistent congestive symptoms. In such cases the following diet-table may be recommended for short periods:

First breakfast: An apple and an orange.

Second breakfast: 25 grams of white bread with butter and three baked apples.

Dinner (mid-day): 100 grams fish or meat, potatoes, green vegetables, 3 boiled or baked apples.

Afternoon: An orange, or an apple, or a pear, or some grapes.

Supper: Milk, apples and rice, oranges, grapes, figs.

Beverages: Water, with or without fruit juices or essences.

Changes in the above diet-table could very readily be effected, whereby the quantity of carbohydrate could be increased and the quantity of albumen lessened.

In women of sanguine temperament and full habit of body, who at the time of the menopause very rapidly become obese, important changes in the diet become necessary. The main principles of a fat-reducing diet are the following: Avoidance of all overfeeding, reduction of the quantity of food taken below the former average amount, with retention, however, of a sufficiency of nutrient material to maintain the metabolic equilibrium of the essential tissues; the maintenance of this metabolic equilibrium demands a sufficiency of nitrogenous foods, but the fats in the diet may be reduced to a minimum, and the carbohydrates may also be very greatly diminished. At the same time, there must be systematic bodily exercise, and the hours of sleep must not exceed a nightly average of seven.

For obese women at the climacteric period, a suitable average diet would contain 160 grams albumen, 12 grams fat, and 120 grams carbohydrate, yielding a daily heat-equivalent of 1,250 to 1,300 calories.

A sample diet-table constructed on these principles is appended:

In the selection of individual articles of diet, it is important to bear in mind the fact that in all climacteric women it must be our aim to stimulate intestinal muscular activity (peristalsis) and intestinal secretion to a moderate extent, for by more active intestinal secretion abdominal congestion is to some extent relieved, and by intestinal transudation and by diminution of the lateral pressure the circulation through the abdominal vessels is facilitated. By thus lowering the intra-abdominal blood-pressure, we shall assist in relieving a number of chronic hyperaemic states of the pelvic and various other organs, from which women are prone to suffer at the menopause. Hence all articles of diet must be forbidden which have a tendency to give rise to constipation. But we must also forbid all substances which leave extensive undigested residues, such as the rinds of fruits, large quantities of porridge, etc., hard meats, nuts, and the like. Most suitable are those articles of diet which contain large percentages of fluid constituents, such as milk, thin soups, weak tea (infused only a short time, so as to contain little tannic acid, which is very constipating), white meat—veal, breast of chicken, etc. Of vegetables, those are best which contain plenty of water and an abundance of the organic acids, young, fresh garden produce, lettuce, cauliflower, young green peas, young carrots, turnips, etc. Juicy fruits are good, apples, pears, cherries, and plums. Butter and honey are also excellent. In many persons suffering from constipation, all that is necessary for their relief is to give a tumblerful of cold water the first thing in the morning; with others, the use in addition of whole-meal bread with plenty of butter and honey and uncooked fruit, is required.

In women suffering from the various disturbances of the climacteric period in an aggravated form, either because the menopause occurs at an unusually early age, or because the suppression of menstruation has taken place suddenly instead of gradually—especially in cases of heart-trouble, severe vertigo, pronounced vasomotor disturbances, or mental excitement (also erotic excitement), I have sometimes found a methodical milk-cure carried on for several weeks most beneficial. By this I do not mean an exclusive diet of milk, but a diet consisting chiefly of milk and milk-foods; owing to the absence of all irritation of the nervous and vascular systems, this diet has a very definite sedative influence in such cases. The milk should be skimmed, and should be given four times daily in gradually increasing quantities, the total amount rising from ten ounces to fifty ounces daily. The only other meal should be a substantial mid-day dinner, consisting of soup, roasted white meat, young green vegetables, and a little fruit. In some instances, to prevent constipation, it is necessary to add ten grams of milk sugar to each glass of milk; in other cases it is necessary to dilute the milk with water. It is obvious that the quantity of milk given is not alone sufficient to maintain the metabolic equilibrium of the body; but the defect in this respect is made up by the substantial meal given at mid-day.

Among the stimulating influences which during the sexual epoch of the menopause are as far as possible to be avoided we must unhesitatingly include the practice of coitus, inasmuch as at this time of life there already exists a strong tendency towards the occurrence of hyperaemia of the reproductive organs; and sexual intercourse, increasing as it inevitably must this tendency to hyperaemia, should be indulged in as little as possible. And yet precisely in women of the climacteric age, in “la femme demi-vieille” there often exists a strong desire to drain the cup of sexual pleasure to its dregs. Not infrequently, therefore, the physician is asked to advise regarding the proposed marriage of a woman in whom the menopause is drawing near, the desired husband being young, or at least still fully virile. If the advice is given in all sincerity with a sole eye to the woman’s health, the medical man will definitely forbid the marriage.

When, however, the changes of the menopause are fully completed, when the woman’s reproductive organs have undergone complete senile atrophy, there is no medical reason why a couple who wish to give a tenderer name to an intimate friendship between man and woman, should refrain from marriage—provided that both have attained a like stage of sexual decline. “But,” writes Tilt, “a union between frosty January and blooming May is likely to be as dangerous to the health as it is to the happiness of both.”

Whilst attending to the regulation of the physical diet of his climacteric patient, the physician should not overlook her psychical regimen. A woman’s mind is very powerfully affected by the processes of the menopause. On the one hand, her fears are stimulated by the thought that she is entering upon the “critical age,” of whose dangers she has often been warned; and, on the other hand, she is mentally depressed by the knowledge that she is about to lose the charms of womanhood, and to decline in sexual esteem. It is well, therefore, for women during the years of change, to have some kind of employment, which fills their hours, occupies their thoughts, and—leaves a certain scope for the exercise of feminine vanity. Works of benevolence or of general utility, and literary occupations, are thus of great advantage to climacteric women. Plato, indeed, pointed out that women at this time of their lives should occupy themselves with literature and intellectual culture.

Just as it is the duty of the physician, more especially of the family physician, to enlighten the maiden on the threshold of her sexual development regarding the processes of the awakening sexual life, and to give her the necessary instruction concerning the hygienic measures which it is proper for her to adopt—so also is it his duty to convey medical information to the woman who stands on the threshold of sexual decadence. A woman’s ignorance is often equally profound at both these epochs of the sexual life. A woman in the early forties often does not suspect, or at least refuses to acknowledge, that she is gradually drawing near to the end of her sexual life; and she is still farther from the knowledge that definite rules of general and sexual hygiene must be observed by her if she wishes to minimize the dangers of the critical period.

The medical friend, in an earnest though far from gloomy manner, will expound to her the nature of the physiological processes of the menopause, and will instruct her regarding the corresponding preventive measures—diet, exercise, clothing, care of the skin, and the regulation of sexual intercourse. Moreover, the physician, by means of skilfully directed enquiries regarding certain symptoms, will be enabled to gain early information about the occurrence of abnormal processes at this period of life, and will in this way detect the first beginnings of many diseases which are amenable to treatment only at the very outset of their course. For example, Brierre do Boismont, an early and accurate observer of this sexual epoch in the life of woman, points out that in cases in which, during the change of life, a woman experiences an increased inclination for sexual intercourse, nineteen times out of twenty, a local examination will disclose the existence of some disease of the reproductive apparatus. Similarly, every gynecologist is now familiar with the fact that unusually free, atypical haemorrhages during the climacteric period, are commonly indications of the existence of a uterine neoplasm.

Much evil may be avoided, and much suffering can be diminished if the physician, in accordance with the advice of Hippocrates, does not limit his activities strictly to the exercise of the healing art, but stands by a woman’s side as her mentor and confidant during the troublesome years of her sexual decline. And he will best fulfil these functions, if he succeeds in convincing the climacteric woman of the profound truth embodied in the saying of the great French philosopher: