The follovring much more aggravated case may also be cited here, since it shows the influence of the climacteric: L., aged forty-four, widow, of a neurotic family, has suffered for twelve years with strong sexual de sire on the slightest irritation. At the time of puberty, whenever she had the slightest relation with a man, she was affected with vertigo, headache and sleeplessness. At twenty-one the least sexual excitement was always followed by vertigo, clonic spasms, and syncope lasting for an hour or two. At the beginning of her thirtieth year the attacks assumed more of a tonic character, and at thirty-five the slightest sexual excitement caused such an attack, attended by complete loss of consciousness. At forty-four her menstruation became more profuse, and her sexual irritability increased. The spasms became less marked, and the patient now began to indulge in fancies, until she reached a condition of complete unconsciousness, from which she awoke as from a profound, unrestful slumber, weary and de pressed, with head and backache, so that she could do no work for hours. Moreover, since the beginning of the climacteric, things which stand in no direct relation to sexual processes also act as irritants, producing the same effect, such as domestic occupation, the least mental exertion, etc., and now the whole trouble is of a mental character, while the patient occasionally has suicidal impulses. There is here at least a transition to an actual psychical disturbance. We must not overlook the fact that in consequence of the increased sexual desire at the climacteric, there is very often a sufficient excuse for satisfying it in au unnatural way. Thus arise a series of physie,al, and especially psychical, abnormalities, on ac count of which the physician is sooner or later consulted. In this connec tion I have often observed a deep dejection, bordering on despair, which at first is always attended with certain rational reflections (such as the an tagonism between their own action and certain firmly implanted early precepts), which is twice as glaring, considering thoir advanced age; or, they may think of the possible injury to their health, etc., but which ex presses itself in an indefinite stupor, which on the one hand makes them heedless of advice, and on the other leads to the loss of all will-power, such as might prevent the further continuance of the causal condition. 'There is no doubt that just here is to be sought a cause of psychoses, which in many cases can not be under-estimated.
A frequent affection of an extremely painful character, which is most common in women at the menopause, is itching of the genitals. The itching is usually confined to the external genitals, or extends upward to the vagina, as well as over the perineum to the crural folds. Sometimes a local condition can be found to account for it. Catarrh of the vagina or cervix, displacements, inflammation, morbid growths within the utenis, abnormalities of the ovaries, bladder and urethra, may now and then be properly held responsible for this trouble. Cohnstein calls attention to a condition of circular hyperplasia of the portio vaginalis, " which, on account of the ectaske of the vessels, bears the closest resemblance to hemorrhoids," (in fact Virchow has observed it sometimes alone, and sometimes associated with hemorrhoids,) the most annoying symptom of which is pruritus. That the latter is only a reflex irritation, due to the " hemorrhoidal hyperplasia " of the portio, Cohnstein thinks is confirmed by the fact that external applications give only temporary relief, while the evacuation of blood from the cervix cures the itching at once. Aside from all these forms, we occasionally meet with cases of severe pruritus during the climacteric, in which we seek with the greatest zeal for some cause which is accessible to local treatment, but in vain. As in the case of other climacteric phenomena, such an external cause is often entirely wanting, there being only an idiopathic neurosis (if I may so term it), like those of which we have seen so many examples of other sorts at this epoch.
The patient often complains of itching confined to the anus. Ecta site of the hemorrhoidal veins are usually found in such cases, while at other times all the relations are perfectly normal. Although the condition
often defies all treattnent, it usually disappears quickly after existing for a shorter or longer period.
Among the trophic changes certain hypertrophies generally appear during the climacteric period. A general deposit of fat occurs, or there is frequently an increased amount of adipose in the abdominal wall and the breasts, while here and there coarse hair appears, with a fresh depo sition of pigment, etc. As is known, the increase in adipose has been connected with the retention of blood within the body, which is now diverted to a different use, or, on the other hand, the chief cause of the fat-formation is found in the cessation of ovarian activity, as proved by the greater ease with which female animals are fattened after extirpation of the ovaries. The former idea at once appears doubtful if we only re call the numerous cases in which a marked increase of adipose has taken place before the periods ceased, and when the regular monthly flow was even increased, or where there were occasional climacteric hemorrhages, which were so profuse as to render the patient actually amemic. The second view, that the increase of fat is due to the cessation of ovarian activity, seems to be much more plausible. Aside from the experience in the case of animals, to which reference was made, this is supported by other observations; castration in the human female is frequently followed by an increased development of fat, while younger women, in whom there is a tendency to the accumulation of adipose, often conceive no longer, etc. But, there are some weighty arguments opposed to this view also. If the increase in fat at the climacteric is a result of the cessation of the ovarian function, then we should expect that, since every individual is affected by this change, a more or less marked increase in adipose would be a constant climacteric phenomenon, or at least that it must appear in every normal, healthy woman. But this is not the case, as Krieger ' has rightly sffirmed with emphasis. " We cannot assert," says this author, 4` that embonpoint in women belong-s necessarily among the transforma tions which take place in the body at this period of life. Out of 282 women whom Tilt examined five years after the complete cessation of the menstrual flow, he found that 121 had become stouter than before, 71 had not increased in circumference, and 90 were thinner than they were for merly. The 90 last mentioned did not include all those women in whom the menopause had been associated with many sufferings and diseases, but these were found in about the same proportion as in the 121 who had become stouter; only those women who had had troubles had become thinner during the first half of the climacteric, but during the latter half they had acquired the embonpoint which they showed subsequently." I have also frequently had the opportunity of seeing women, whose size did not change at all during the climacteric, or others who became smaller from this very time, although no pathological process had been present in any of these cases. Furthermore, it is a striking fact that a marked increase of fat may take place in women who were slender some years before their periods began to be irregular, as well as at a time when, to all appeamnce, the ovaries must still be normally active. Thus, I have before me reports of several cases in which tho climacteric was supposed to be approaching, by reason neither of advanced age, nor of any marked. change in the menstruation, but on account of the commencing increase in adipose; and the same was also true of cases in which the menopause had actually become established, where it is expressly stated that the be ginning of the present increased accumulation of fat was to be referred to a time from two or three years before the first menstrual disturbances. On the other hand, it often happens that the menses have ceased entirely and permanently, and in all probability also. there is complete cessation of ovarian activity, and yet some years elapse before an increase of fat begins to be noted.