University of Virginia Library

PART IV.--THE MENOPAUSE.

CHAPTER XIII.
THE MENOPAUSE.

Average Duration of the Menstrual Function; Duration of Menopause; the Menopause; General Phenomena of the Menopause; Prominent Symptoms of Menopause; Pathologic Conditions of the Menopause; Hemorrhage at the Menopause a Significant Symptom of Cancer; Causes of Suffering at Menopause.

Average Duration of Menstrual Function.--The average duration of the menstrual function is from thirty to thirty-two years. Raciborski estimated the duration of menstrual life at about thirty-one years and nine months. According to him, the mean age of puberty at Paris was fourteen years and seven months; therefore, the average age of the menopause was forty-six and one-half years. Tilt gives the average age of the cessation of menstruation in 1082 cases as forty-five

years and nine months. The average age is between forty-five and fifty years. It has been shown by Krieger, Kisch, and others, that the earlier the menses appear, the later they cease, and vice versa. However, when the first period is unusually early or late, the menopause comes very early. Also that the sexual function is usually abolished earlier in the laboring classes, who are compelled to work hard and who have many cares, than in the well-to-do and rich.

Race does unquestionably influence the duration, but given a sound healthy race, which is not too much enervated with civilization, and the menstrual process will, equally with the total physical vigor and the vitality, be increased. At the present day there is an increased sexual vitality, which shows itself in the fact that the duration of menstrual life has been increased three to four years during the past generation. The inference can be fairly deduced that vigorous vitality causes prolongation of the menstrual process and the actual age.

Duration of Menopause.--By the menopause or climacteric is understood the whole period from the beginning irregularities in the time of appearance of the menstrual flow until its actual cessation. The average duration of the menopause is from two and a half to three years.

The Menopause.--The menopause is a physiologic and conservative process. It occurs at a time of life when all the tissues are most stable and the nutrition of

the body is at its best. Other physiologic changes which occur at the same time are decrease in the size of the spleen and lymphatic glands, the muscular coats of the intestine atrophy, and lessened peristalsis ensues; hence the increased tendency to constipation. These are not the degenerations of age, but the blood-supplying, blood-making, and blood-elaborating organs of the body have completed the growth of the organism, done their work, and are striking a balance with the needs of the economy.

The object of each metamorphic or developmental epoch is a critical readjustment of the organism, in order to insure the greatest possible amount of health for each subsequent period of life. In the vast majority of cases this object is quietly effected, but sometimes the constitution only rallies after having been severely shaken for a varying period.

General Phenomena of the Menopause.--Borner states that while many women pass this period without noting any change in their former condition, and are conscious of the occurrence of the change of life only by reason of the absence of the menstrual flow, others suffer for years with a host of troubles.

One of the most essential changes is that of the woman s psychic condition--from slight vagaries, loss of interest in the daily affairs of life, to melancholia and insanity.

"Two factors are generally taken into account: first, the sudden cessation of the menses; second, the reflections

of the patient caused by her condition, meditations on the loss of youth and sexual power, and anxiety in view of the dangers of the climacteric. It cannot be denied that there is some truth in the supposed sad thoughts about the beginning of old age, and the depression caused by them can scarcely be considered abnormal" (Borner).

Napier believes that it is extremely rare for the cessation to occur without some physical discomfort or some disturbance of the nervous system, but adds that: "Some women, however, cease menstruating with very slight inconvenience." As a rule, the woman misses one, two, or more periods, then a menstruation of almost normal quantity and duration; and this is again repeated at gradually longer intervals, and with a diminished flow, until actual cessation occurs.

The periods cease owing to the degeneration and disappearance of the glandular tissues of the uterus, and secondarily to similar changes in the ovaries and other glands. This is followed by an atrophy of all the structures of the genitalia.

An increase in the size of the uterus, from increase in the amount of blood, is frequently noticed at the beginning of the menopause; later it becomes smaller in all its dimensions. The wall becomes thinner; the cervix becomes shorter and thinner, sometimes hard, sometimes flabby as a membrane. But the distinguishing feature of the menopastic uterus is atrophy of its lining membrane.

The changes in the uterus and Fallopian tubes are earlier than those in the ovaries, so that ovulation, though lessened in activity, may persist for a considerable time after menstruation has ceased. Ovarian atrophy has been referred to senile rather than menopastic changes.

Atrophy of the ovaries occurs very gradually. Peuch found that in one case the ovaries were of normal size three years after the establishment of the menopause. Kiwisch describes the structural change in this gland as consisting, on the one hand, of an increase of the connective-tissue stroma; and, on the other hand, the Graafian vesicles themselves undergo retrograde change. In consequence of these microscopic changes, which take place very slowly, the entire organ becomes harder and smaller.

Napier believes that the ovaries secrete specialized substances which aid in determining menstruation; and that in a less degree the utricular glands and the glands of the Fallopian tubes share in this action. He considers that this is probably secondary to the chain of peripheral irritation from the uterine glands, but that this secretion is none the less an essential feature of the menstrual process.

In support of this view he calls attention to the pigmentation of the skin which occurs during pregnancy and chlorosis, showing that the absence of the catamenia results in the retention in the blood of some substance which would normally be excreted at this time.

Other atrophic changes in the genitalia are shriveling of the vulva, with prolapse of the vagina or uterus from relaxation of the ligaments and loss of the natural support afforded by the changed perineal body.

Uterine catarrh occurs almost invariably, and only ceases in advanced years. Displacements of all kinds are frequent, but on account of the now greatly diminished weight of the uterus, these are insignificant.

The vagina is at first almost always hyperemic, but this disappears as the vessels successively atrophy. The vagina gradually becomes narrower and shorter. The mucous membrane loses its rugae and presents a pale, grayish, blanched hue.

The researches of Byron Robinson, made by the dissection of a number of old women, show that after the menopause not only is there an atrophy of the genital organs, but that the hypogastric plexus of the great sympathetic nervous system also shrinks away. "It becomes smaller and firmer, and no doubt some strands disappear. On this fact must he based the pathologic symptoms accompanying the cessation of the menstrual function."

The importance of the genital organs is shown by the vast nerve-supply sent to them. When this great nerve-tract becomes atrophic, so that it can no longer transmit the higher physiologic orders, all parts of the sympathetic system must be unbalanced, until a new line, the next line of least resistance is established. And Robinson believes that this is the explanation of

the many pathologic manifestations of every viscus at the menopause; that is, "the irritation which arises 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 unable to detect it."

Chemical changes in the blood and tissues are constant vital phenomena; increased oxidation causes increased activity of the circulation, increase of temperature, increase of urea and carbonic acid in the economy from retrograde changes, and, finally, during menstrual life the flow of blood from the uterus carried off the effete materials from the highly charged system.

The elimination of albuminoids, as shown by the altered condition of the blood after menstruation, is greater than can be accounted for by the blood discharged. When the menopause is attained suddenly, the retention of such albuminoid substances must act toxically. Hence the resulting clinical fact that sudden cessation of the menses is, in the majority of cases, attended with pronounced symptoms of discomfort, and it is in these cases that untoward results are most likely.

James Oliver believes that the catamenial flow eliminates from the body substances whose presence in the blood would exert a deleterious influence on the animal economy.

The Prominent Symptoms of the Menopause.--Christopher Martin holds that the symptoms of the change of life are produced largely by a condition of

instability and increased excitability of certain other cerebrospinal centers directly brought about by failure of the menstrual center, and adds: "It is probable that the ovaries, like the liver and thyroid gland, modify the blood circulating through them, and add to the blood some peculiar product of their metabolism. It may be that some of the climacteric symptoms are due to the loss of this substance from the system."

Arthur Johnstone's theory of the symptoms of the menopause is that the lining membrane of the uterus atrophies and becomes old cicatricial tissue, and sinks into quiet decay. The nervous system begins to readjust itself; but no longer having free outlet through the soft, lymphoid tissues of the uterus, the wave pressure meets with resistance and a choppy sea results. Vertigos, bilious attacks, and so forth are nothing more than reflex waves. The weakest organ of the individual is the one that generally suffers. And that the kidneys, which all along have borne the brunt of life, should now show positive signs of disease is natural.

The etiology and pathology of the menopause lie in the sympathetic nervous system. And it is by the breaking up of the harmony of previous processes that nervous disturbances are produced.

After the cessation of the flow, over 8% of women suffer from "flashes"; this symptom is caused by irritation of the heart and vasomotor centers. The blood-vessels of the head and neck seem to be most affected, yet the skin of the whole body shares in the disturbance.

Besides the vasomotor and heat center being disturbed, the sweat center is irritated. The flushes and flashes are followed by various degrees of sweating, which varies from a slight moisture to great drops.

Nervous irritability is a prominent symptom in 8% of women at the time of the menopause. Most of the pain arises around the stomach; that is, the solar plexus. Digestive disturbances are very common at this time; they may be in the shape of fermentation, diarrhea, or constipation, accompanied by congestion of the liver.

Tilt holds the very plausible view that the too strong reaction of the sexual organs on the central ganglia of the sympathetic nervous system is their principal cause of disease. Puberty, menstruation, pregnancy, lactation, or the menopause almost always entail some derangement of this system which is sometimes sufficiently severe to lead to insanity and suicide. Debility underlies all affections of the sympathetic nervous system, in the same way as nervous irritability underlies all cerebral diseases. Sometimes there is an overpowering sense of exhaustion pervading the whole system.

Forms of climacteric insanity are delirium, mania, hypochondriasis, melancholia, irresponsible impulses, and the perversion of moral instincts.

"If the reproductive apparatus does not act on the brain by the instrumentality of the circulating organs of the blood, it must do so by means of the nerves. The genital apparatus is richly endowed with nerves from

the sympathetic system, and I have shown how frequently evident signs of disturbance in these centers coincided or alternated with headaches, nervousness, hysteria, and epilepsy. What wonder, then, if the same powerful influence of the sexual organs, through the instrumentality of the sympathetic system, should at times produce a permanent derangement of the mental and moral faculties. I am thus led to look on the sympathetic nervous center as a source of vital power producing reflex morbid phenomena, in accordance with variable cerebral predisposition" (Tilt).

Another very frequent symptom of the menopause is distress in the region of the heart, with palpitation and shortness of breath. It may be caused by the condition of the blood, whether it be impoverished--anemia--or too rich in red globules; by reflex irritation of the pneumogastric or sympathetic nerves; by overexertion; or by alcoholism. It may also be due to general debility; the woman resists fatigue less easily, and she experiences a general malaise. To the palpitations are rapidly added faintness and shortness of breath. The sleep is troubled with distress in the region of the heart. It is said that women in whom the menopause occurs early are more liable to tachycardia than those who menstruate later in life; and that it occurs with especial frequency when the menopause has been prematurely induced by surgical operation or by disease. It is believed that this functional heart trouble is caused by the increased connective-tissue fibers of the

sexual organs acting in some unknown way on the terminal fibers of the sympathetic; and it is not infrequently due to the formation of scar tissue at the seat of a cervical laceration, and has often been promptly and permanently relieved by removing the cicatricial tissue and suturing the wound. The cause acts by producing a transitory paralysis of the inhibitory fibers of the pneumogastric nerve.

Pathologic Conditions of the Menopause.--Perhaps the most alarming symptom of the menopause is hemorrhage. It may be due to general or local causes. Among the general causes are diseases of the heart, lungs, spleen, and kidneys. Local causes of hemorrhage are: inflammation of the lining membrane of the uterus, chronic pelvic inflammations, faulty uterine positions, erosions and ulcerations of the mouth of the uterus, fibroid tumors, and cancer. All competent observers agree that cancer in women is much commoner from forty to fifty years than at any other age.

Hemorrhages occupy the foremost place among the pathologic phenomena of the genital tract during the menopause. Hemorrhage has been attributed in many instances to the senile rigidity and friability of the uterine vessels, which are not in a condition to offer sufficient resistance to the blood-pressure which is brought to bear on their walls; there is also softening and relaxation of the uterine tissue. Additional causes are found in the circulatory disturbances in the pelvic organs, whereby the outflow of blood from the pelvic

vessels is hindered and a chronic congestion in the uterine vessels is produced. It has also been attributed to early and profuse menstruation, frequent and difficult labors, frequent abortions, and excess in drinking.

The third and last variety includes those cases which may be referred to some disease of the pelvic organs themselves. Anatomic changes may lead up to pathologic conditions. A chief feature characteristic of uterine disease is malnutrition from atrophy--a sudden curtailing of the blood-supply from the degeneration of the genital-nerve apparatus and consequent impaired vitality of tissue from defective nourishment. The anatomic changes in the glands and substance of the uterus also favor the irritation, and the development of new growths, which may be malignant or benign--as cancers, fibroid growths, and so forth.

Hemorrhage at the Menopause a Significant Symptom of Cancer.--Not only should any excessive and prolonged bleeding at the time of the menopause be a source of great anxiety to the woman, but even the irregular appearance of a slight show of blood just sufficient to keep the clothing stained, or a slight bleeding following coition; since all of these are symptoms of very great gravity, and demand an immediate local examination and appropriate treatment.

The widespread belief among the laity that hemorrhage at the time of the menopause is a normal condition, and that if left alone it will stop in the course of a few years, is most erroneous and fatal. On this altar of ignorance thousands of women sacrifice their lives every year. The case-book of any gynecologist will testify to the truth of this statement. The following three cases will serve to illustrate different types of hemorrhage in cancer patients, in no one of which did the patient even suspect that she was suffering from anything more serious than the "vagaries of the menopause."

Case I.--Woman aged seventy years; came on account of incontinence of urine, which had been troublesome for two years. The menopause occurred at fifty. She stated that three or four years previous to her visit, she had had a return of the flow of blood, perhaps twice in the first year, and that during the past year there had been a flow every month--about the same that there used to be. This she took to be a return of the menstrual period. She said, further, that there was a constant bleeding--enough to necessitate the wearing of a napkin--and an occasional severe hemorrhage; that she could not take long walks or drives because of the excessive flow which followed.

The case was one of cancer of the uterus which had spread to all the pelvic viscera; and in addition to this, the patient's general condition was such that any operation was out of the question. Yet the patient had never thought of the possibility of any uterine trouble sufficiently serious to make a local examination necessary. It was only the loss of control over the bladder that drove her to seek a physician's advice.

Case II.--Woman aged fifty-three years came to consult me because of pain, hemorrhage, and loss of weight. There had never been any cessation of the menstrual period. She said that she began to have irregular hemorrhages three years previously, and that they were constantly becoming more frequent and more alarming, and that, in addition to this, there was a constant discharge of blood, which necessitated her wearing a napkin all the time. She also stated that for the preceding six months the pain had been so severe that she had not had one solid night's sleep, and that in that time she had lost forty pounds in weight.

This patient was in the very last stages of cancer of the uterus, and all that could be done for her was to make her comfortable. She had given birth to one child which caused a deep tear of the neck of the womb; and it is probable that this neglected tear was the primary cause of the cancer, which began in the neck of the womb.

Case III.--Woman aged forty-five years; married, but had never had any children. She said that the periods were normal as to duration and amount, but that for the past two years they had two days ahead of time, and that for the past four months she had been having just enough irregular bleeding between the periods to keep her clothing stained.

On examination a diagnosis of cancer of the uterus was made. The pathological examination proved this to be a most malignant type of cancer of the neck of the womb. The entire uterus and appendages were at once removed. And although the patient made an excellent recovery from the operation, she succumbed to the disease one year after the operation was performed.

These cases have been cited at length because they are all typical and because of the variety of symptoms and the great difference of age. Only in one of the cases was there any very severe pain, and it was really the pain, which had become unendurable, which caused the patient to seek relief.

It is the concensus of opinion of the medical profession that cancer of the uterus is one of the common causes of death among women; that the cancer rate of mortality has increased during the last four decades; that it is most common near the time of the menopause; and that there is a direct causal relation between cancer of the neck of the womb and the traumatisms which occur during childbirth.

The symptoms of cancer of the uterus are hemorrhage, a more or less offensive discharge, and pain. The quantity of blood may vary from a slight amount which occasionally stains the clothing to a profuse hemorrhage. In the married, bleeding following coition is always a suggestive symptom. During the menopause any irregular or profuse bleeding should excite suspicion. After the cessation of the menopause any bleeding whatsoever, whether slight or profuse, should always be regarded as a danger signal which demands an immediate and thorough local examination. The same is true of any offensive vaginal discharge. Pain is frequently so late a symptom that to wait for its appearance means that the favorable time to perform an operation has passed by. Emaciation is also a symptom of advanced disease.

Cancer is chiefly a disease of the climacteric; when there is a diminished power on the part of the tissues to resist adverse influence. It affects the debilitated and overworked, but it is also found in the well nourished and in the comparatively young.

Cancer always begins as a local disease, and when it occurs in the uterus, it is easily accessible and eradicable in its earliest stages; that is, if the disease is discovered in its incipiency, an operation will remove all the diseased tissue. If, on the contrary, the disease is left to nature, the growth spreads out into the surrounding viscera like the roots of a tree in the earth, and the cancer may be literally said to eat into the tissues which it invades. At the same time the germs of the disease begin to be carried all through the body, and the entire constitution is affected.

Prophylaxis, or the Prevention of Cancer.--All pelvic inflammations should be promptly treated, and not allowed to become chronic. Leucorrhea is a symptom of inflammation, the true cause of which can be determined only by local examination. Women who have given birth to children--and this is more especially necessary as they near the age of forty years--should be carefully examined for tears of the neck of the womb. If these tears are extensive they should be repaired, as it is certain that malignant growths frequently do follow local injuries and traumatisms.

Any irregular or profuse bleeding demands an immediate investigation by means of a local examination.

A stormy, irregular, or delayed menopause should excite in the woman a suspicion of some abnormal condition.

The importance of women being carefully watched by gynecologists at this period of their lives cannot be too emphatically stated, for upon the early recognition of cancer depends the only hope of radical cure of the disease. It is estimated that at the present time not less than 95 per cent. of all cases of cancer of the uterus come under the observation of the profession at a stage of the disease when all prospect of permanent relief is out of the question.

It is a deplorable state of affairs that women, not knowing what a normal climacteric is, attribute all hemorrhages, no matter how severe, to the change of life. Therefore, regarding the hemorrhage as a necessary evil, they fail to consult a specialist until the favorable time for eradicating the disease by means of an operation has passed. And whatever knowledge science may bring in the future as to the cure of cancer, at present it is a fact universally agreed upon that early operation, while the cancer is still local, is the only radical cure for the disease.

Pruritus Vulvae. Perhaps one of the most annoying and obstinate symptoms of the menopause is pruritus vulvae. This is sometimes caused by sugar in the urine; there is a congestion of the liver which results in sugar being thrown into the system and this is eliminated by the kidneys. It is quite possible that this is due to the altered circulatory conditions of the menopause.

Kidney Disease.--The last pathologic condition which we will mention is kidney disease. Le Gendre believes that the menopause exerts a deleterious effect on the kidneys, whether this be a congestion, followed by a diminution in the quantity of urine, or a sort of auto-intoxication

due to the retention of a poison in the system that has been prevented from leaving by the ordinary path.

Armstrong says that in almost all cases at the time of the menopause the amount of urine passed is below normal, the specific gravity is increased, and that the urine contains urates and almost always uric acid in excess. Further, that the functions of digestion and assimilation and the various metabolic changes are so largely under the control of the nerve-centers that nothing seems more likely than that so great a disturbance of that system as takes place at the menopause should cause secondary derangements of these most important functions. That being so, the blood becomes loaded with waste products, and the usual symptoms follow--gout and so forth.

It has been a grave question in the mind of the medical profession whether the dangers that certainly do attend the menopause are natural or acquired; that is, could these dangers be averted by any precautions or hygienic measures on the part of women, or are these dangers a necessary accompaniment of this period of life?

Tilt has reached the conclusion that: "The best way to avoid the dangers of this critical time is to meet its approach with a healthy constitution. A marked want of strength prevents the regular succession of the vital phenomena by which all critical periods are carried on. And as the change of life is marked by debility, when this is grafted on constitutional weakness,

loss of power will be of long duration. All complaints remain chronic because there is not stamina enough to carry them through their stages."

Causes of Suffering at Menopause.--Dusourd, whose practice lay in an agricultural district in the south of France, as well as Tilt, believes that peasant women suffer little at this time. Their health is generally good when the menopause comes on and they are little liable to nervous disorders. The poor of large towns suffer much at this epoch--the necessity of working hard, the anxieties of poverty and their unhygienic surroundings. But by a fortunate compensation the necessity for working hard prevents or cures the nervous affections which so often assail the rich at this period.

Tilt's cases showed that women who suffered much at the menopause had previously suffered at puberty and at the menstrual periods. And among thirty-nine cases where there was no suffering at the menopause, there was the same immunity from suffering at puberty and at the menstrual epochs.

Tilt's statistics were, or course, taken from English women. In forty-four cases of my own, all women past the menopause, the average age of the first menstruation was fourteen years and four months; and the average age of the actual cessation of the menstrual flow was forty-eight years and five and two-thirds months. Subtracting from this the average age of the first menstruation, we have as the mean age of menstrual life thirty-four years one and two-thirds months;

that is, the average duration of the menstrual function was from two to four years longer than that usually given.

A further investigation in order to ascertain any possible relation between the age of marriage and the number of pregnancies and the sufferings of the menopause elicited the following statistics. The average age of marriage was twenty-five years and ten months. Of the four women who were married after thirty-eight years, all were sterile; among the remaining there was an average of slightly above three children each. Forty per cent. of all these cases had one or more miscarriages. Nine had habitually suffered from severe dysmenorrhea, eleven had slight dysmenorrhea, and twenty-two had never felt the slightest inconvenience.

In a list of fifty-two cases, eight were added to the list already given, all of whom had passed the menopause. Five were perfectly healthy and had never suffered the slightest inconvenience. Of these, one was single and only one had one miscarriage. Ten had suffered at the time of the menopause from slight malaise, but not sufficiently to call in a medical attendant. Thirty-seven were more or less seriously ill; thirty of these needed local as well as constitutional treatment, and seven constitutional treatment only.

The prominent symptoms of the climacteric were as follows: Marked debility, 24; intense nervousness, 31; nervous prostration, 9; melancholia, 10; headache, 14;

neuralgia, 6; hysteria, 7; irritable heart, 11; tachycardia, 8; insomnia, 19; indigestion, 32; constipation, 28; diarrhea, 3; leucorrhea, 38; rheumatism, 21; gout, 1; Bright's disease, 12; hemorrhage, 6; alcoholism, 2; corpulency, 2.

As a result of the study of these cases, the most striking feature was the relation of miscarriages to the sufferings and ill health at the time of the menopause. Of the nineteen women who had miscarriages, only one did not suffer in some way at the time of the menopause. Four suffered only slightly, and fourteen suffered extremely, not only during the menopause, but in the post-climacteric period as well. And the next most striking feature was that the prominent symptoms of the menopause are preeminently reflex or the functional diseases of the nervous system.

Tilt believes that single women suffer less than other women at the time of the menopause. He further writes: "As at puberty, from the ignorance in which it is still thought right to leave young women, so at the change of life, women often suffer from ignorance of what may occur, or from exaggerated notions of the perils which await them. It would be well if they were made to understand that if in tolerable health, provided that they will conform to judicious rules, they have only blessings to expect from the change of life. Most unfortunately, the individual not cognizant of the invisible changes going on in the economy does not adapt the mode of life to the new conditions of the organism,

and the weakened and lessened amount of the digestive fluids is unable to master the large quantities of food. The absorbents refuse to take more than is needed to repair the tissues. The atrophying muscles of the digestive tube, unable to hurry on the mixed products of indigestion; fermentation; and micro-organisms inciting fermentations and elaborating toxic alkaloids, poison and disorder the functions of life. Man's outdoor life enables him to escape many of these evils.

"Woman's enervating mode of life, the continued introspection, coupled with the peculiar changes in the nutrition of the body at this time, render the nervous system peculiarly impressionable and liable to the manifold forms of diseases. 'The woman is told that she must be calm and patient, and in time the tomb-builder will alleviate all her sufferings.' This critical period may be dangerous to those who are always ailing, for habitiual sufferers at the menstrual periods, and for those affected with uterine diseases. If, on the first indication of the change of life, women who are in fair health carefully followed a regimen and pursued a line of life in harmony with the physiologic processes on which this change depends, disease would be prevented. But as the change concerns a natural function, it is left to nature; no additional precautions are taken, and advice is sought only when the mischief is done."

It is not wise to marry during this period. On the first appearance of the irregularities of the menopause

the amount of food and stimulants to which women have been accustomed should be curtailed rather than augmented. The system requires supporting by medicine and regimen--as, baths, mental and moral hygiene, and occupation--rather than stimulating by spirits.

We have seen that, in accordance with the plethric theory, which prevailed until 1835, and with the nerve theory, which is based on the latest anatomic and physiologic researches, menstruation is a physiologic process to get rid of effete material, and is therefore an excretion.

At the end of perhaps thirty years, by a conservative process of nature, the child-bearing period ceases and the organism is readjusted to the end that the woman's vitality may all be conserved for her own individual life.

Each metamorphic or developmental period of life--dentition, puberty, and the menopause--throws a special strain on the nervous system, and the recent studies of the sympathetic nervous system at the time of the menopause show that very extensive anatomic changes occur at this time. That being the case, the woman must lead such a life as will insure her having on hand a large reserve force necessary to meet these heavy demands. Tilt's observations show that women who have experienced no suffering at puberty or, at the menstrual periods do not suffer at the menopause. It is therefore evident that the time to begin this preparation is in childhood.

That single women suffer less than married women would suggest that excessive coitus and the occurrence of abortions, frequent child-bearing, and lesions as the result of pregnancies, many of which lesions could have been prevented or cured by the timely aid of the physician, are the combined sources of much of the suffering at the time of the menopause.

That the most frequent and serious disturbances are those of the nervous system, and that from their mode of life and habits of introspection the rich suffer more from these ailments than the poor, must cause serious consideration of the physiologic necessity for a definite occupation for the daughters as well as for the sons of the rich.

The frequency with which Bright's disease is found at the time of the menopause is dependent not so much on the local physiologic changes which are taking place as on the time of life. Loomis says that it was not until life-insurance examinations became so common that the frequency with which kidney disease existed in persons who believed themselves well was even imagined. And as a result of his observations in these cases, and of a large number of autopsies conducted at the Bellevue, he stated that it was his belief that 90% of men and women over forty years of age suffer from some form of Bright's disease. That being the case, it would seem that after this period of life at least as much attention should be directed to the kidneys as to the

teeth, and that a semi-annual examination of the urine should be made.

Although the menopause is a physiologic occurrence, yet, owing to the many pathologic changes which are liable to take place at this time, the woman should be as carefully watched during the menopause by the gynecologist as the pregnant woman now is by the obstetrician. If the same care were taken, in the majority of cases, the dangers attending the menopause would be avoided, and the woman would be prepared to enjoy a healthy and useful post-climacteric period of life.

CHAPTER XIV.
HINTS FOR HOME TREATMENT

Indigestion; Constipation; Diarrhea; Enemas; Vaginal Douche; Baths; Headache; Fainting; Hemorrhage.

Indigestion.--The chief causes of indigestion are: eating rapidly, eating at irregular hours, eating indigestible foods, constipation, and lack of exercise. No one who values her good health will allow herself to be hurried through a meal, nor will she allow the perplexities of life to be thrust upon her at the table for solution. The first requisite for the digestion of foods is that they should be well masticated, so that the digestive fluids may act on the finely divided particles to the greatest possible advantage. And while digestion is going on all mental labor should be held in abeyance, in order to avoid drawing the blood away from the stomach to the brain. Furthermore, it is a well-known fact that digestion is best performed when the meals are served at regular hours.

Constipation leads to the formation of gases in the intestines, to fermentation, and to the absorption of toxic materials by the blood.

Through lack of exercise, the appetite fails, the liver becomes torpid, and the muscular and nervous systems lose their tone.

The exercise which the housekeeper gets in going around her house is not sufficient. Daily exercise in the open air is essential to health; as this is to supplement the indoor exercise, the amount taken will vary in proportion to the former. For teachers or those who have a sedentary occupation an hour's active exercise in the open air--a three-mile walk--should be supplemented by active gymnastic exercise.

For people in good health, a mixed diet--that is to say, a diet consisting of meat, vegetables, and fruit--is the best. If the individual is not well, then the diet must be adapted to meet the needs of that particular case.

Hot breads, all articles of food fried in fats, salads, and pastry are difficult to digest. Tea is very constipating, and when taken in excessive quantities renders the individual nervous. An excess of coffee leads to congestion of the liver.

Where indigestion exists, the simplest and most sensible remedies are to regulate the diet, and avoid eating between meals. By drinking a glass of water as hot as it can be sipped one hour before each meal, the mucus is washed out of the stomach, the stomach is empty on coming to the table, and in the best possible condition for the gastric juice to act on the food-stuffs.

Constipation.--Constipation is the rule with the

average American woman; the causes are their corsets, the tight bands of their clothing, lack of exercise, and the fact that they drink too little water and too much tea. The most rational means to overcome it is to drink more water; at least three pints a day should be taken, in addition to soups, tea and coffee, and so forth; the water must be taken into the system as such. Then attention must be given to the diet; plenty of fruit should be eaten, vegetables, and coarse bread.

Regularity in this, as in all other habits of life, is most essential, and the individual should go to the toilet at the same hour every day, even if there is no inclination to have a bowel movement, and thus the habit will be established; the most convenient time is directly after breakfast.

Medical Treatment.--But if all these means have failed, medicines must be resorted to. Cold water is a better laxative than hot; to a glassful of cold water add from one teaspoonful to one tablespoonful of the effervescing granules of the phosphate of soda, and take this the first thing on rising in the morning. This preparation of soda is particularly useful because it acts slightly on the liver. Other laxatives are: a seidlitz powder dissolved in a glass of cold water on rising; a wineglass or more of Hunyadi Janos, also taken on rising. Any of these may be taken with safety by pregnant women. For children the simplest laxative is one teaspoonful of Husband's milk of magnesia, to be taken in one glass of water on rising.

Enemas.--Perhaps one of the most common methods used by the laity for the relief of constipation is the rectal injection, or enema. Enemas habitually given to unload the bowels are productive of much harm by overdistending the rectum, so that in time the rectum fails to react to the normal stimulus--namely, the presence of the feces--as it otherwise would. But by some means or other the bowels must be well moved once every twenty-four hours. And it is much better to use an enema than to go to bed without a bowel movement. If the woman is going around, so that she can give the enema to herself, the most effective way to take it is in the knee-chest position or an approximation to this. Either a fountain or bulb syringe may be used for this purpose; a quart of water at a temperature of 110 degrees F. should be prepared by making it into a suds with castile soap, or one tablespoonful of glycerin may be added to one pint of water. The nozle to be used is the smallest one that comes with the syringe, the so-called infant's nozle; this is quite large enough, and its insertion is not nearly so painful as the larger ones; the nozle must be well greased with vaselin. When everything is ready, the patient gets down on her knees with the shoulders near the floor, having first loosened all of her bands and taken off her corsets; the nozle is introduced as far as it will go into the rectum, and if a bulb syringe is used the water must be very gradually squeezed into the rectum, otherwise it will not retain so much; or if the fountain syringe is used, it must not

be hung too high. So soon as the patient feels that she has taken all that she can retain, she should lie down on the left side, and retain the water as long as possible, as it is thus rendered more effective. An enema so taken will be very much more effective than one taken in the ordinary manner of sitting on the toilet. In the method just described more water can be used and it will be longer retained; it can be felt to go up along the course of the large bowel, and it will often be found very effective when the ordinary enema fails. This enema will often be found to be a very valuable aid in curing an obstinate chronic diarrhea, which is kept up by particles of feces remaining in the folds of the large intestine. If the patient is confined to bed, she should lie on the left side, with a heavy towel folded under her to prevent the bed from becoming wet; when the nurse withdraws the nozle she should make pressure on the anus with the towel, to help the patient to retain the water as long as possible. But should the patient have gone so long without a bowel movement that all these means fail, it will be necessary to precede the water enema with one of oil; or still more effective is the following combination: take one teaspoonful of the spirits of turpentine, the yolk of one egg, and two tablespoonfuls of olive oil, and beat well together, and add to these one pint of water at a temperature of 110 degrees F. Constipation, however, of so obstinate a character as this demands a physician's attention.

Diarrhea.--A diarrhea may be acute or chronic; the treatment is essentially different. For an acute attack accompanied by frequent stools and severe abdominal pain the first thing to do is to go to bed. If there is nausea, drink a glass of water as hot as can be taken, at once; for the diet, a glass of scalded milk, not boiled but just allowed to come to the boiling-point, every two hours; and nothing else should be taken until the diarrhea is well in check. If the pain is severe, a spice plaster over the abdomen will be found to be very comforting. It is made as follows: take of powdered allspice, cinnamon, cloves, and ginger each two tablespoonfuls, and two teaspoonfuls of cayenne pepper; mix well together in a bowl; then quilt in a piece of flannel large enough to cover the abdomen; when ready for use, dip in hot whisky and apply as hot as the patient can bear; cover over with a large napkin, as the plaster produces a deep stain which does not wash out; keep on as long as necessary. If the rest in bed and the milk diet kept up for twenty-four hours do not suffice to cure the diarrhea, it is not wise to take any risks, but send for your doctor at once. Or if there should be any blood in the stools, do not wait for anything, but send for the doctor without delay.

For a chronic diarrhea an enema given in the knee-chest position, as already described, will often be found a most efficient remedy. In diarrheas the use of fruits and vegetables should be avoided; the best diet after

the milk is bread well toasted through, toast-water, soft-boiled eggs, beefsteak, oyster stew, and clam broth.

Vaginal Douche.--To be of service except for mere cleansing purposes the douche must be taken in the horizontal position, either on a couch or, if it is not cold, on the floor. Of course, this position necessitates the use of a douche-pan. The douche-pan is best of agate-ware, oblong in shape, and with a broad strip which comes under the nates. On lying down to take the douche the nates must come down well over the pan and the clothing must be pushed well up to prevent the water from seeping up the back. To make the woman more comfortable there should be a pillow under the head, and she must have a shawl or some light woolen material to throw over her while taking the douche to prevent chilling; thus doing more harm than good.

There are two forms of syringes on the market: the bag or fountain syringe, which is hung up sufficiently high--about three feet above the patient--to cause the water to flow; and the bulb syringe, in which the bulb has to be constantly squeezed by the hand, which is tiresome to many women, but this is a much more convenient form to have in traveling. During pregnancy the fountain syringe only should be used, and it should be hung as low as will enable the water to flow. For a woman who has never taken douches it is well to begin with a temperature of 110 degrees F., gradually increasing the temperature to 118 degrees or 120 degrees; this is as high as the woman should attempt to go, for a higher temperature

would burn her, leaving the vulva so sensitive that she would only be able to take cool douches for a long time after this; a bath thermometer should be used in all cases to test the temperature, so that the woman knows exactly what she is doing.

In cases of inflammation of the uterus or its adnexa four quarts of water should be used, and the douche should be taken in the horizontal position. The water thus acts as a hot poultice about the uterus, and the woman will find on rising that some water flows out from the vagina. Ordinarily plain hot water is all that is necessary to use, but where the discharge is acrid and scalding, the plain hot-water douche should be followed by a warm douche containing one teaspoonful of borax to a pint of water. The best time for taking a douche is at night just before retiring; there is also less danger of taking cold when the douche is taken at this time.

The scalding sensations at the vulva may be due to the acidity of the urine, in which case it will be increased just after urination; or it may be due to an acrid discharge from the vagina. A little observation on the part of the patient will enable her to distinguish which is the real cause. If there is any trouble with the urine, it should be carefully examined at once, as some congestion or inflammation of the kidneys is not infrequently present, which if attended to might be cured, and which if allowed to run on unattended to, may develop into a serious form of Bright's disease.

The genitals should be washed with soap and water

night and morning. Women who do not suffer from leuchorrhea need not take a vaginal douche more than once a week; after the menstrual flow the vaginal injection is advised to remove the detritus of the flow.

Baths.--The most ordinary forms of baths used may be classified under sponge-, shower-, sitz-, and tub-baths. The sponge-bath as ordinarily taken is of service for cleansing purposes, and if the water be cold it tones up the system to some extent, and is so a preventive against taking cold. The effect of this bath will be found to be vastly more beneficial if salt is added to the bath in the proportion of a pint of salt to a gallon of water; either sea-salt may be used or the ordinary coarse salt. It is most advantageously taken sitting in a bath or hat-tub, so that the entire surface of the body will be wet at the same time, and the water can be allowed to run down the back and over the chest. It is well to begin these baths at a temperature of 80 degrees F. and to gradually decrease this until the bath is taken at 70 degrees, which is about the temperature of running water, and the bath should be kept up at this. For most people the best time to take the bath is just before retiring; this bath is not only very strengthening, but also is excellent in cases of insomnia and nervousness.

Shower-baths.--These may be taken after a hot bath, or taken alone after violent muscular exercise. The body should be quickly scrubbed off and the shower should be warm at the beginning and gradually allowed

to become cold, stooping over so as to get the full force of the shower on the spine and over the region of the stomach and heart. They will be found to be most refreshing after great muscular fatigue, and, when taken after the hot tub-bath, greatly lessen the susceptibility of the individual to taking cold.

Sitz-baths.--These are given for their local effect in cases of inflammation; whether this inflammation be of the kidneys, bladder, or of the uterus and its adnexa. A sitz-tub is necessary to properly take this form of bath. The water should be used as hot as is comfortable to the patient, from 105 degrees to 110 degrees F., hot water being added as the first cools off; a pint of salt should be added to the gallon of water, and the patient should remain in this from five to eight minutes. A blanket should be wrapped about the patient so that she will be thrown into a perspiration; it is almost needless to say that the only time for taking this bath is just before retiring, and that this bath does make the woman more susceptible to taking cold, so that it is necessary to wear an abdominal woolen bandage day and night.

Tub-baths.--The tub-bath ought not, as a rule, be taken more than twice a week, unless the cold plunge is used, which may be taken every day. If the tub-bath is taken hot, the woman should remain in it not much longer than is necessary to scrub off with a flesh-brush; this bath should be followed either with a cold shower-bath, or the water in the tub be gradually allowed to cool off until it is down to 70 degrees F.

Headaches.--Headaches, aside from those of acute illness, may be roughly divided into three classes: first, those which are due to indigestion; second, neuralgic headaches; and, third, those due to pelvic inflammations. The headaches due to indigestion are usually located over the eyes and all over the forehead; they are more or less constant and are accompanied by other symptoms of indigestion, and very often by constipation. The feces are allowed to remain in the bowels overlong, the toxic matters are taken up by the blood, and headaches and vertigo result.

Neuralgic headaches are of an entirely different character; the pains are here of a lancinating character, and are not confined to any one region of the head. As a rule, they are accompanied by neuralgic pains in other parts of the body. Neuralgia generally means a rundown state of the system from overwork, worry, or malaria, and tonics and cod-deliver oil are indicated.

A constant dull pain on the top of the head or in the back of the neck generally indicates some uterine inflammation, and can only be cured by removing the cause. In any case it is very evident that taking the various "headache powders" with which the market is flooded will never cure the woman of her headaches; and many of these powders are very dangerous, especially where the heart is weak, as most of them are heart-depressants.

Fainting.--Fainting may be due to a weak heart, to heart disease, or to sudden shock, as on receiving a bad

piece of news; during pregnancy the close air of a room may cause a woman to faint. The first thing to be done is to lay the woman down on the floor or bed with nothing under her head; loosen all her clothes about the neck and waist, and throw the windows open so that she will get plenty of fresh air. If she is able to drink, give her one teaspoonful of aromatic spirits of ammonia in four tablespoonfuls of cold water. If the feet are cold, place hot-water bottles to them to improve the circulation. And if at the end of fifteen minutes she does not show signs of decided improvement, give her two tablespoonfuls of whisky in an equal quantity of hot water. In the meantime the physician will have been summoned. These attacks of fainting often occur in a crowded ball-room, and are due to tight lacing and the poor ventilation of the room.

Hemorrhage.--A profuse hemorrhage is the most alarming as well as the most dangerous thing which can befall a woman, and the very nearest doctor should be summoned until the family physician can be gotten there. The woman should be made to lie down wherever she may happen to be, her clothes loosened, the windows thrown open, so that she will not only have plenty of fresh air, but that the air shall be cool. If the blood is coming from the mouth, give her pieces of ice to hold in it; if she coughs up the blood, it would be well to put a bag of ice-cold water or cloths wrung out of ice-water on the chest. If the woman is suffering from a uterine hemorrhage, have her take at once a hot

vaginal douche, from 118 degrees to 120 degrees F., and have the foot of the bed raised. The head should always be kept low.

Women hold their health in their own hands to a far greater extent than they have ever dreamed of; and if the majority of women suffer, it is very often their own fault, either because they have disregarded nearly every law of health, or have allowed trivial ailments to go on until they were almost incurable.