Just as in the case before-mentioned, heart-burn was the only symp tom, so I have observed eructation, which was most marked in Mrs. D., in whom there seemed to be a cert,ain element of heredity, since her father and sister were said to have suffered greatly from "wind-colic." Since the birth of her last child, eighteen years before, she has had a sharp pain in the stomach on taking solid food, relieved by the passage of wind by the mouth and anus. She reached the menopause at forty-seven, and from this time until she was fifty-three the trouble increased so much that she was confined to her bed for a long time. When I saw her she seemed to be healthy, but was obliged to sit upright in bed for half of the night in order to empty her stomach of gas. Her appetite and nu trition were good. The eructation could be induced artificially by strok ing any part of the woman's body (except the front of the neck and the buttocks) with the fingers. Rudolfi reports a similar case.
I might in this case suppose that there was some more comprehensive disturbance in the alimentary tract (either catarrhal or peculiarly neuro tic), or I might explain it as a case of simple hysteria, as in an analogous case of Peter Frank's, but in this instance the isolated occurrence of the symptom described (no other hysterical complie,ations being present) was always striking, Vomiting is a symptom peculiar to the menopause, occurring either alone, or in connection with well-known climacteric phenomena. If there is at the same time increased secretory activity in other directions (hyperhidrosis, etc.), it is quite natural to regard the condition in the stomach as a hyperekrisia. The increased production of probable abnormal gastric juice, accompanied by further change in the innervation of the stomach (hyperiesthesia hyperkinesia) is regarded as a sufficient cause of the often excessive vomiting (Arndt's explanation of hysterical vomiting), although there is in this particular case no reason to suppose that there is a direct irritation of the vomiting-centre. However, the latter is sometimes probable, and then we have a peculiar picture dis played, whie,h we can refer to a combination of the conditions mentioned. Mrs. II., aged forty-four, ceased to menstruate six months ago. For two years she has had marked ausemia, attacks of vertigo, sweating, and finally vomiting. She has towards -morning, after site has had a good sleep, a genentl sensation of heat, restlessness, sweating and vertigo, and finally vomiting; she may vomit twenty times in between one and three hours. The patient then has a cold feeling over her body, but again falls asle.ep. The next forenoon she is very tired and is troubled by fr.equent retching; in the afternoon she feels perfectly well, especially if site has previously taken a nap. At first food is vomited, then mucus or bile, but never blood. When the attacks first began they recurred twice in a month, or more often twice a week; now they are often absent for months, and come on only at night. There is no clear connection between the attacks and the cessation of menstruation. The appetite is good, there
is no nausea or any pain in the stomach; the patient has increased in adipose during the past year.
A question which, I think, ought not to be omitted here is whether the menopause has any influence upon the development of round ulcer of the stomach, or not. Tilt,' under the head of diseases, reports four cases of hmmatemesis among 500 women during the menopause. Krieger observes that there is no proof that there is any connection between the trouble in question, and the cessation •of menstruation, " inematemesis, dependent on a round ulcer of the stomach, appears also in young per sons, so that it is not evident why these four case.s should have been caused by cessation of the tnenses." The matter cannot be dismissed so briefly. The fact that ulcer of the stomach may appear in women at other times also, and also in men, would not exclude the possibility of the climacteric playing a part among the predisposing causes. Only results of many observations can clear up this point. Let us study the question itself a little more carefully, and I ask permission to add something to the necessary material by communicating some observations made by myself. There are two points in our subject which are most prominent—first, whether from the observations on the average time of appearance of gas tric ulcer, it has any connection with the climacteric; secondly, whether the long recognized conditions under which the disease in question de velope.s, may now and then be again presented by the natural changes at the menopause. The substantiation of the latter point would justify us in speaking in connection with the cases observed at this point of a condition that is associated with the menopause. With reference to the first point, I find some infortnation, but only a little. Rokitansky ' observed the affection especially in the prime of life, " but often very early in the female, even in the fifteenth year." From this fact alone we can scarcely arrive at a conclusion, but it seems to me that this statement is important in connection with the following: Jaksch,' who, with others, has dis tinguished himself by his statistics on the frequency of round ulcer of the stomach, found that it occurs at every age, but in mature years more fre quently than in childhood, and that women are affected more frequently than men. Moreover, Niemeyer affirms (though with some reservation) that disturbances of menstruation are among the primary causes. Its frequent occurrence in females is e,ertainly established. It is probable that the prime e,ause of this lies in the sexual life of women. It seems possible (compare Rokitansky above) that puberty may cause a certain predisposition to the development of the disease. The idea that this possible predisposition at the time of puberty may recur at the climac teric, a relation which we have encountered quite frequently under other conditions, is at least not disproved by what has been mentioned.