I sketch briefly some striking cases that have come under my own ob servation. Mrs. K., aged forty-nine, has always menstruated regularly. During the past year she has had attacks of palpitation, beginning two or three days before her periods. These are repeated several times a day, and have increased to such an extent that the patient is now obliged to remain in bed during the whole period, on account of the constantly re corring attacks of syncope.
Mrs. B., aged forty-nine, has of late menstruated more profusely than before, and during the past two years she has suffered with depression, nervous irritability, vertigo, etc. She has always had a slight palpitation, but no organic trouble was ever found. During the last few months the palpitation has become unbearable; she has dyspntea, and can not take a step because of the increased cardiac disturbance thus produced.
Mrs. L., aged forty-five, has during the past six months menstruated regularly, but more profusely than normal. During this time she has had vertigo, headache, etc., and violent palpitation, especially at night, increased by the slight nervous excitement. She looks perfectly well and feels better at the time of menstruation, Such a case would be regarded by the hasty diagnostician as one of plethora, and a " reducing " regime would be advised. On more c,areful examination, we shall often find that the reverse is the case, just as here where the woman in question said that her red cheeks were at other times quite colorless, that her present state of nutrition was less than formerly, and that all her troubles, es pecially the distressing cardiac palpitation, were always worse just after her period, that is, after the actual loss of blood. The best evidence for the antemic condition, which was at the bottom of the trouble, WAS fur nished by the mucous membranes, which were strikingly pale, even at the times when the woman was looking at her best.
1 wish to refer here to another circumstance. Potain, in his " Diag nosia and Treatment of Chlorosis," describes three forms of the latter, a temporary one which is more or less connected with the period of devel opment, a second characterized by frequent recurrences, and a third which affects individuals previously very delicate, lasts during life, and although apparently cured, returns with the menopause. If the ciimacteric really exerts this unfavorable influence upon certain forms of chlorosis, the knowledge of this fact seems to me to be of importance in deciding upon many cases. Ilence we arrive at the simple conclusion, that in cases of long-standing chlorosis the climacteric is generally regarded with dis trust, and that again, when the menopause appeais with unfavorable phenomena, in cases in which there litu3 previously been obstinate chloro sis, there arises at once a suspicion that this trouble may be increased, and in this is sought the nearest explanation for the phenomena in ques tion. I believe that I can prove the v,ctual existence of the supposed evil influence of the climacteric upon chlorosis of long-standing by the fol lowing case, which at the same time furnishes another example of the phenomenon of palpitation of the heart before-mentioned. Mrs. R., aged forty-nine, the mother of five children, has for a year had vertigo, sweating and " congestions." Her periods are now quite irregular, and were absent during the last two months. The integument and mucous membranes are extremely pale. Her principal complaint now is of heari ness in the legs and unbearable palpitation, both of which conditions have increased to an unwonted degree during the past year. The heart
sounds are clear, the pulse 120 when the patient is in repose. No abnor mality can be found in the chest. Since the patient has lost no blood to speak of for a long time, and all other causes can be excluded, we must suppoee that this is an aggravation of her old chlorosis, due to the begin ning menopause. This patient's vertigo, etc., were relieved by a short aourse of iron, and her pulse soon sank to 96 beats.
If we turn now to the gastro-intestinal symptoms, we find that catar rhal conditions are most frequent during the climacteric. Busch is quite right in affirming " if digestive troubles were present before, they are increased at this time." Former catarrh of the stomach reappears, or becomes worse, and not infrequently catarrhal affections begin then. Now and then an improvement, or a complete cure of long-standing troubles of this nature, is noted. It is well known that there are obstruc tive congestions due to general plethora, which we are much inclined to regard as the cause of the conditions in question. From what has been mentioned in these lines, it is evident that in a large number of cases this view must be limited. Latent antemia is often at the bottom of it, and still more frequently perhaps it is merely a question of disturbance of innervation. The frequent occurrence of nervous dyspepsia at the climacteric proves how important a r6le may be played by the latter. It is highly interesting to consider other nervous phenomena of gastric ori gin which may he produced by the menopause. I have often encountered the unique parEesthesia of certain of the gastric nerves, known as heart burn. It was best marked in a Mrs. S., who since her thirtieth year had suffered with severe menorrhagia, and at the beginning of her fortieth year had become very anaemic. In her forty-fifth year the hemorrhages ceased for three months, and, although she had a good appetite and no other dyspeptic symptom, she had severe heart-burn, whjch had no con nection with eating and appeared during the day and night, lasting for two hours. This symptom lasted for five weeks and disappeared when the menses recurred, but reappeared in a less severe form during the sub sequent inter-menstrual periods. What I would call particular attention to in this case is the appearance of a single symptom which we are accus tomed to observe as one of a number of symptoms. In my opinion peculiar chamcteristic pictures are thus presented which are no more ob scured by others which we meet with. Take only the most familiar affection, nervous dyspepsia. With Leube we understand that it is an abnormal irritability of the nerves of the stomach, which arose sponta neously or in connection with a general neurosis (or chronic intoxication), and is recognized especially by dry retching and feelings of pressure in the region of the stomach, disturbance of appetite and heart-burn, head ache, disturbed sleep, and weariness. Although one or another of tile symptoms mentioned may be most prominent, it is the more or less marked combination of thesa conditions which constitutes the affection in question. The presence of a single one of these symptoms (although it may seem to have been directly withdrawn from this chain) does not justify us in diagnosticating this affection, still less one remot,ely to it; we are rather compelled to allow to the symptom in question a cer tain independence, and under some circumstances we may even speak of what we were otherwise accustomed to consider only as a symptom, 118 an affection in itself. This is often the case at the menopause.