In my opinion the cause in this case was a certain anfemia, although the hemorrhages during those years often ceased for a long time, and the patient usually presented an entirely satisfactory appearance.
The remarks previously made on vertigo also apply to the congestion (flushing) and localized hot feelings (`' flying heat ") and perspirations which appear in pretty nearly every woman at the climacteric period. These too were formerly attributed to the cessation of the flow, but I can not insist too strongly upon the fact that all these phenomena very often occur when menstruation is still quite regular, and the patient's age is merely correspondingly advanced, that the menses may disappear with marked rapidity without their being very much increased (when the nutrition of the individual continues to be good), that they are often well marked when the pt3riods cease very gradually, while they persist in case profuse intercurrent hemorrhages occur, and are rather increased than diminished by a certain degree of ancemia, and very frequently persist for many years after the menopause has taken place,' even to a time when a relative excess " of the amount of blood in the individual in question must long before have been poured out. Although in isolated cases we may have to do with so-called " plethoric congestions" (actual increase in the number of red blood-corpuscles), yet we are most often compelled to include the climacteric " flushings" among the passive congestions, in which nervous influences cause a relaxation of the muscular coat of the arteries.' The various momentary sensations of heat, which are mostly the expression of an increased irritability of the nervous system, we must class with paresthesia3 (heat, formication, etc.) observed in the cutaneous region in hysterical patient& Finally, we must in most of the cases as sociate with the altered irritability of the nervous system (in which the sweat-centre in the medulla, as well as the nervous apparatus presiding over sweating participates) the outbreaks of perspiration at the climacteric; this is especially so, since Luchsinger and Adamkiewicz have shown that the blood-pressure plays in general no active part in the secretion of sweat, but that it depends upon the activity of true secretory fibres, partly cerebro-spinal and partly sympathetic. In short the outbreaks of sweat ing at this time are somewhat comparable to that increased sc,.cretion of perspiration which we encounter under other circumstances in excitable and nervous individuals, only that in the first instance the instantaneous outbreak is characteristic.
Reference should be again made to a condition, the significance of which, as was already said, is so often undervalued a,t the climacteric— amemia. I believe that I hardly say too much when I affirm that the next most frequent cause of outbreaks of sweating is relative amemia in individuals. With regard to the frequency of amemic conditions at this time, I simply refer to what has been said before. An explanation of the occurrence of perspiration from amemia is furnished by Luchsinger's statement, that certain changes in the amount of gas in the blood act upon the system of sweat-ganglia, " so that the marked tendency to sweating in antemic subjects is to be ascribed in general to the diminu tion of the hlemoglobin and oxygen in their blood." The rapid appear
ance of perspiration in the ihdividuals in question is a phenomenon peculiar to the climacteric, which possibly presents a sort of combination of the causal factors, ana3mia and increased irritability. While at times certain regions of the body, corresponding to the size and number of the sweat-glands found at the places in question, appear as points of election for the sweating (the palms of the hands, soles of the feet, and axillte), at the climacteric the site of the outbreak varies, still it seems that the individual variations of this character in a certain case are usually very constant. In rare cases the perspiration extends over the entire surface of the body; it is usually limited t,o the upper half. There are different places in which the sweating occurs with special frequency, aS the breast, nape of the neck, hairy scalp, brows, etc. As was mentioned, the cir cumscribed region in question on which the sweat appears usually remains the same in the same individual. I saw a woman in whom the perspiration always appeared on the breast and back, another in whom it appeared only on the neck, and a third in whom it was confined to the brmst, nape of the neck, and brows, as well as upon the flexor surface of the forearm, ex-tending from the band upwards. Mrs. D., who at forty six had been irregular in her menses for some time, bad outbreaks of sweating for two years over a region extending in succession from the abdomen to the breast and head, and then the perspiration appeared on the bands and bends of the knees. The condition always lasted till eight dava before the next period. These outbreaks of sweating usually cease quite spontaneously. Diferely a slight movement of the body, or es pecially a mental emotion of any kind, will increase their. intensity and frequency; however, even repose at night usually makes no difference, and in some cases I was told that this was the worst time. In one patient, whom I remember, these outbreaks were even limited to the night time, without the patient presenting otherwise the least evidence suggestive of illness. Very often these attacks of sweating follow great fatigue and weariness, especially when they spread over the greater portion or entire surface of the body. As regards the duration of this condition, I have already remarked that it often begins a long time before the appearance of the first menstrual irregularities, and may persist for years after the establishment of the menopause. It is frequently noted that women are troubled in this way five or six years after the complete disappearance of menstruation- furthermore, I have often met with this phenomenon, and a short time oefore I referred to a Mrs. S., a widow aged sixty.seven, who had reached the menopause sixteen years before, but who neverthe less about once in one or two weeks was suddenly seized with sweating, which affected the upper part of her body, especially her face. This condition was always increased whenever she felt slightly indisposed.