From a large series of observations on vertigo during the climacteric, I cite only a few examples. Miss C. dates her first attacks of dizziness from the time of her first irregular periods at forty-four; they increased in severity, and are now, at forty-seven, worse than ever. The attack is complicated by various hysterical manifestations. A certain feeling of anxiety frequently precedes them; then she feels as if ants were crawling from her finger-tips over the backs of her hands to her elbows, and from the tips of her toes over the extensor surfaces of her legs to ber knees. Palpitation sometimes follows. The attacks themselves appear at no definite time; they begin by a buzzing or rumbling in the right ear, the patient thinks that she must fall and quickly supports herself. She usually has a feeling of weight in the stomach or slight nausea, and then the affair is over.
Mrs. H., aged fifty, has not menstruated for three years. One after noon she was seized with a dizzy feeling, w'hich lasted all night, and in the morning on rising it increased so much that the patient, without losing consciouimess, sank to the floor. She could not leave her bed for several days thereafter, without feeling dizzy. For several weeks she had slight returns; sometimes there were frequent momentary attacks of congestion with general perspiration.
Mrs. G. C., aged sixty-seven, reached the menopause at fifty-three. The vertigo which she then had is now worse than ever. The patient herself naturally attributes it to her " full habit," but during the entire latter part of the time, she has had less appetite, sleeps poorly, and feels very nervous.
I need not cite any special examples of vertigo depending on actual anaemia. If we pay only moderate attention to this question, we shall find almost as many examples as those of loss of blood at the menopause. I only desire to emphasize in general the importance of this etiological factor. In the marked antemia,--a direct consequence of profuse clitnac• teric hemorrhages,—simultaneous attacks of vertigo are ascribed by every one to the antemia, just as other attacks after all profuse bleeding. Antemia is only readily overlooked when this connection is somewhat ob scure, and at the climacteric we are especially inclined to the one-sided idea of a " sufficient " or " excessive " amount of blood. That it is highly important to differentiate the attaeks of vertigo at the climacteric, ac cording to their different causes, is best seen when we consider the ques tion of the regime to be adopted in any ca,se. Without desiring to enter upon the question of therapeutics here, I can not avoid calling attention to the frequent uselessness of the precepts (which are generally quite artificial) with regard to women at the menopause. Considerable exer cise, bland nourishment, the avoidance of liquors, and aperient mineral waters, should be prescribed; the occasional use of leeches may be useful in many cases, but in others they are positively contra-indicated. Indi vidual peculiarities must unquestionably be carefully considered, and we must not allow ourselves to be influenced by certain prevalent ideas as to the necessity of dealing with this entire period in quite a summau manner.
I should like to add here a description of a peculiar phenomenon, which I have seen at the climacteric, sometimes slightly marked, and once quite plainly--the appearance of a sort of compulsory movement It is well-known that this term has been applied to those characteristic dis turbances of motion which are noted after the experimental injury of certain portions of the brain in animals, and which Henle refers to " dizzy feelings in the wounded animals." The injury, according to Landois,1
causes in the animal in question, by irritating or paralyzing the apparatus that 'transmits sensations of locomotion, the delusion that the body or its environment is moving in a certain direction. The compulsory move ments are executed involuntarily in consequence of this supposed motion. their purpose being to compensate for the abnormal fictitious movements by passive movements in a contrary direction. If now we observe a similar phenomenon in man (all injuries being excluded) it is most natural to infer that there is a cause of the direct " wound " correspond ing to the injurious effect, and to make the external symptom, or dis turbance of motion, identic,a1 with the above-mentioned forced move ments. It can certainly not be clearly proved that the menopause, with its multiform disturbances of innervation (probably due to localized hyperemia or aruemia), may give rise to conditions of irritation or paraly sis of a nerve-centre, which, even if it only be transient (purely func tional) in its action, may yet in its action closely simulate the cerebral lesions in question. The following is a case in which I found this phe nomenon well marked: Mrs. G. is of a neurotic family, but has healthy sisters, and had herself no trouble of this nature until the beginning of the menopause. She married at twenty, and bore five children, the last at the age of thirty-one. After previous irregularities, the menopause appeared at fifty. The patient is now fifty-six. From the age of forty three until fifty, the patient suffered from a complex variety of disturb ances. Severe attacks of vertigo alternated with a sensation of extreme constriction of the breast, neck, etc.; vague anxious feelings, and for a long time a positive fear of becoming insane, crying out at night, frequent buzzing in the ears, etc., disturbed her to an unusual extent. What I wish to call particular attention to is this: while in bed, when her head was low and she was perfectly quiet, she felt quite well, but the slightest movement made her feel as if she was about to fall towards the right side; once she actually fell out of bed on the right side. On standing and walking, often everything went well, until suddenly the seine feeling came over her and she was obliged to grasp at a support; if she could not reach it, she fell towards the right, even when the ground was smooth. Moreover, in walking it was impossible for her to move in a straight line, for, if not supported, after taking a few steps, she deviated somewhat to the right, in spite of the most determined resolution to the contrary. If she began to descend the stairs on the left side, after going down ten or twelve steps, she found herself on the right-hand wall. On the street she always preferred to hug the right-hand wall for support; if it chanced to be on the left-hand side, she invariably reached toward it, so as not to leave it. She passed on the right persons whom she met. This peculiar condition persisted at intervals until after her fiftieth year, when other vagaries appeared. Now she is quite well.