Finally, another point: I certainly do not know as regards the before mentioned experience in the case of animals, whether the result there ob tained (more rapid fattening) is one to be counted OIL in all cases; its concerns the extirpation of the ovaries in women, I could show from my own experience, that an increase of adipose does not necessarily take place, even at a much later period. However, if this were so, and if the removal of the ovaries in animals, as well as in man, was certain to cause soon in all cases an increase of fat, it would still be an open question. whether the spontaneous retrograde change in the ovaries at the climac teric, and the removal of these organs by the knife, are such equivalents that the inferences to be drawn with regard to the results of the opera tion may, with perfect propriety, be compared with the conditions at the normal 'climacteric. We can best overcome these difficulties, in my opin ion, if here again we cease to m.ake one phenomenon dependent upon others, and keep firmly in mind more the concomitant symptoms and the equivalence of single phenomena than their mutual dependence. At all events, we can at least meet all the opinions above expressed by classing the accumulation of fat at the climacteric with the various other climacteric phenomena also described in this book. All sorts of distur bances of innervation, psychical abnormalities, etc., which are observed in one case and are absent in another, may appear early in this case (long before the first menstrual irregularities), and late in that one (long after the cessation of the menses), while one accompanying phenomenon may appear of this sort, in another of that. The retrograde process in the ovaries should be regarded as merely the same as the other phenomena described. A8 regards cause and effect, it is " equivalent," and is simply a constant occurrence in every case. It is not a causal factor in the in creased formation of fat, but it itself, as well as the latter, is merely a result of the expressions of that deeply hidden transformation in the vital action of the female organism which testifies to the true nature of the. change.
In concluding this chapter, I should like to call attention in eonnec tion with the climacteric, to certain eruptions on the skin. There seems to be no doubt that such a connection in general exists, and tnat certain affections of the skin are directly influenced by the menopause, and may also form a part of the " climacteric phenomena.' Of course it is rather difficult in individual cases to draw the line between affections that are due to the climacteric and those which may be entirely accidental com plications. The forms in question have no distinguishing characteristic, and they may all appear in a precisely similar manner at another time, and may again perhaps complicate the menopause also. Still, we have certain diagnostic points. If we have certain skin-affections which have never appeared in the individual in question during her entire previous life, but which are observed only during the climacteric irregularities or soon after the establishment of the menopause, and in which every other etiological factor is wanting; or if we have to do with affections which previously appeared but once at the time of puberty, and are observed again only now at the critical time; or if the same affections which now appear were formerly produced by disturbances of menstruation, but by no other cause; finally, if such affections, which, by reason of the con nection of the circumstances, in many cases (perhaps also noted by dif ferent observers), must be directly regarded as a climacteric phenomenon, then we may generally be allowed to express a positive opinion regarding the significance of the affection under consideration. We have still much to do in elucidating the last point, the repeated confirmation of the fact that a certain skin-affection is a climacteric phenomenon. As far as I
have been able to inform myself in this matter, this special significance has been attached to only a few forms of skin-disease. It is therefore certainly fitting that other cases, which, according to their character, may belong to this category, should be carefully reported Many varieties have hitherto been mentioned by this or that author, only as important in this connection. It is highly necessary that additional proof of such state ments should be forthcoming.
Perhaps the most common of the affections noted in this connection, is acne of the face, which in many cases is observed at the time of pu berty, and then again at the climacteric. Hebra calls attention to the frequency of. comedones and acne (so-called " impure complexion "), es pecially with irregular menstruation, which every physician frequently has an opportunity to confirm, and he describes the special form_ acne rosacea—as characteristic of puberty and the cha,nge of life. Nie meyer, Cohnstein, et alii, refer to the frequency of the latter form, espe cially during the climacteric years.
I observed a case of so-called milium after the menopause in a woman of fifty.six. Although this woman had not observed them before, of late years the sebaceous glands over the entire right shoulder were enlarged so as to form white globular bodies, and the skin in consequence felt quite coarse and greasy, while elsewhere it presented the normal smoothness. To the characteristic " ardor fugax " before referred to, which is especially characteristic of the climacteric, should be added Kisch's ' erythema and roseola, simple hyperwmile of the skin which appear " in the form of larger or smaller vivid red patches, most frequent at the sides of the neck, on the breast, and face, especially under the influence of some violent psychical irritation." " They appear suddenly, come flying over the skin, as it were, and usually disappear after the lapse of a few minutes.'' The form of hyperxmia here described is doubtless one of the most common phenomena at the menopause. When consulting the physician especially, these usually quite large, sharply marked, transient red patches (due to the momentary excitement) are often observed. I have regarded these as among the most transient forms of erythema. The conditions that determine their locality, appearance and manner of appearing and disap pearing, justify us in assigning the special affection to some extent to a category of its own; still it seems to me to be important to mention that it is extremely probable that more serious forms of erythema should also be connected with the climacteric, such as show more or less the diameter of dermatitis, and therefore, as is known, are so regarded by some authors, by others, however, as erythema. The following case is interesting: Mrs. S., aged forty-eight, had long suffered with migraine and gastric catarrh, both of which improved at the menopause. She began to be irregular at forty:five; early in the Spring, two days after a period, she had a slight reddening of the skin on the inner side of the right knee, which persisted for four days. On the fifth day it extended over half of the thigh and leg, and appeared on the left knee, gradually over the thigh. There was slight cedema, burning and itching, but no fever. After fourteen days the redness disappeared in the same order in which it appeared, and there was marked peeling. The history showed that this woman had bad a similar affection on one occasion only, just at the time of puberty. Krieger ' mentions furunculosis as an example of " the appearance of new troubles" at the menopause. Mrs. E., aged fifty two, who had for a year been troubled with the first menstrual irregularities, told me that during this year, now and then, a pustule had appeared on the ala of the nose, or even on the inside of the nostril, a thing that had never occurred before in her whole life.