Cohnstein ' frequently had an opportunity of observing the chloasma of the face, that appears in connection with pregnancy and sexual disease, at the menopause, " especially when the skin, in consequence of poor nutrition, had assumed a rugose condition." The same author calls at tention, as above stated, to a special cause for the itching of the vulva and vagina, which is especially frequent at the climacteric. In conse quence of the continual scratching with this affection, other skin diseases are known to occur, such as excoriations, etc. I have already mentioned other demonstrable causes of pruritus, which may possibly also stand in relation to the menopause. Wilson considers prnrigo and eczema as the most frequent skin affections of the climacteric period.' As regards the latter affection, I, in common with others, observed a Mrs. D., aged fifty six, who after the establishment of the menopause bad varicose veins and patches of eczema around them, covering both thighs, legs and the sac rum. Mrs. H., forty-four years of age, has not menstruated for six months. During the last two years, while the rest of her skin remains perfectly pure, she has had in the supm-clavicular fossa a patch of eczema, which disappeared and returned several times a year. Mrs. D., aged forty-five, who has been irregular during the past two years, has had for four weeks itching, eczematous patches on the flexor surfaces of both knees.
Urticaria is also an interesting affection to remember in this connec tion, I think. Hebra distinguishes a variety that is closely connected with uterine irritation (disease of the uterus, menstruation, pregnancy). Kaposi affirms quite positively that there is a chronic and symptomatic urticaria resulting from dysmenorrhcea, amenorrhcea, chronic hypertrophy and sterility. It would doubtless be useful to ascertain whether the climacteric changes of the female sexual system do not also cause a pre disposition to this peculiar skin affection. If we take into consideration the other factors which are known to cause urticaria, we must admit that some of these, as chronic gastric and intestinal catarrh, and persistent psychical irritation, occur very frequently at the time of the menopause. And if we exclude this (symptomatic) urticaria, due to reflex irritation from the internal organs, many an idiopathic urticaria (produced by di rect irritation of the skin) may also perhaps be shown to be connected with the climacteric. Since, indeed, it is possible for a patient to possess the peculiarity " that itching at one point on the skin causes such an irri tation that, being transmitted by the sensory nerves, urticaria-wheals appear in a reflex way on other entirely different parts of the body, and on many such parts, and we, therefore, " meet with urticaria in all the affections in which itching is generally present,'" the intense itching of the skin, which is so often present at the climacteric, may doubtless lead occasionally to urticaria. In all cases of this kind the skin affection
in question results from a local change, due to the climacteric. Now it is still a question whether the matter is settled, or whether there is not possibly still another form of urticaria, which is the direct consequence of general ehanges in the organism, peculiar to the menopause. Kaposi mentions among the etiological factors of chronic and symptomatic urti caria, in addition to " demonstrable disease of some internal organ,'' also indefinite general conditions (somatic and psychical),and cites them as illus trative of the latter form, and also of those cases in which the urticaria must be regarded as only the expression of a general senile marasmus. It is not unlikely that a corresponding form of urticaria may be produced by the climacteric as such. This applies especially to chronic urticaria.. It must be much more difficult to prove that occasionally a case of acute urticaria (usually, as is known, caused by epizoa, by nutritive ingesta, or by drugs) can be directly connected with some climacteric proe,ess. There must in such cases be a causal factor, which depends upon some climacteric change, but is only of short duration. We fluty possibly ob tain such support by excluding every other tausal factor, or in the circum stance that the individual in question had had the eruption before, and had had it only once or twice during this period, or finally, that (again excluding all other causal factors) the acute urticaria in an individual was observed only at the time of puberty, and then again at the menopause. Without wishing to draw any conclusion from one case or another, I should like in this place to report the following caaes: Mrs. A., aged forty-five, the mother of four children, has been irreg ular in her menstruation for two years. Suddenly on one ocasion, without any known cause, her entire body was covered for half a day with urticaria wheals. She was sure that this had occurred only once before, just before puberty.
Mrs. D. O., aged forty-seven, has been irregular for two years. Re cently, just at the time when her period, if present, would have been over, she had a severe urticaria on the forefinger and thumb, which lasted for about an hour, and returned in the same place during the succeeding tluve or four days, lasting the same length of time. It was absolutely impossible to discover any cause; the patient had never before had this eruption.