Part 94

“In considering the mental condition of women at the outset of the climacteric period, we must not forget those who are called ‘old maids.’ In their youth these maidens also have had their ideals, their hopes, their plans, and their sorrows. They also had a natural impulse to love and to be loved in return; they hoped to become wives and mothers. But life has failed to fulfil their hopes and their wishes, and their longings have remained unsatisfied. Some of them have taken up their cross without murmuring, and have devoted their talents, their intelligence, and their love to the service of those nearest to them. But others make an active protest against fate in the form of vindictive feelings towards their environment, of quarrelsomeness, scandal-mongering, etc. Here we see contrasted the two principal types of such women. On the one hand are those who devote their intellectual and spiritual powers to the service of society; these are unselfish sisters-of-mercy, untiring medical women, invaluable school-teachers and governesses, fanatical political agents, etc. Such as these have ceased to live for themselves. In the fullest sense of the words, they mortify the flesh, and guide their conduct by lofty moral principles. They have killed their sexual life, and they remain for ever virgins—both morally and physically. If, owing to a pathological inheritance, faulty conditions of life, exhausting illnesses, etc., a psychosis develops, the hallucinations and delusions from which they suffer very rarely assume a sexual character, nor are they of a degrading type. The sexual side of life seems, in fact, be they sane or insane, to have undergone complete atrophy. They suffer from simple melancholia with stupor, or their insanity takes a religious turn, but very rarely indeed has it an erotic character.

“Very different is it with old maids of the second type. They are dissatisfied with life, irritable, quarrelsome, envious, and malicious. They are spiteful and revengeful, gossips and scandalmongers, boast of their own chaste and innocent lives, and never forgive any real or imaginary attempt upon their spotless virtue. At the same time they never lose hope for the future, and are full of imaginary love-affairs, in which they pass through scenes by no means chaste or innocent; they do not shrink from self-abuse and the abnormal gratification of the sexual needs, in which the lacking partner in the sexual act is supplied by the imagination. Under the influence of such abnormal conditions of life, these women frequently become affected by nervous disorders; migraine, neuralgia, cephalalgia, nervous depression, rachialgia, debility, anæmia, diseases of the reproductive organs, etc. Thus, when they enter the climacteric age, the soil is fully prepared for the development of mental disorder, which in such individuals is often characterized by hallucinations of sexual sensation and perception, erotic visual and auditory hallucinations, delusions of similar character, increased sexual irritability, a search for abnormal means of sexual gratification, a propensity to obscene speech and conduct, etc.

“Mental disorder is so common during the climacteric period, that the term ‘climacteric insanity’ has now become established in the literature of mental alienation. In almost all the textbooks of the subject we find an allusion to this form of mental disease, but there is no real ground for Maudsley’s assumption that there is a climacteric insanity sui generis. At the climacteric, very various forms of mental disorder may occur—paranoia, melancholia, and mania; the only common feature in the attacks, owing to which they are classed as ‘climacteric insanity’ being the fact that the final determining cause in each case is the onset of the change of life. In fact, this period is not without influence upon the manifestation of the disease—its stamp is imprinted upon the clinical picture, it endues the disease with certain characteristic features—but still, the peculiarities common to the cases of mental disorder occurring at this time of life in women are not so great as to justify us in describing them as a separate variety of psychosis.”

According to Kowalewski, this so-called climacteric insanity is met with in two principal forms: in many cases the mental disorder recurs in periodic paroxysms, associated either with the commencement of the menstrual flow, or having the periodicity of menstruation after the flow has already ceased to appear; in the other class of cases the psychosis has no direct connexion with menstruation, and is dependent upon the joint influence of all the manifestations of the climacteric period. Cases belonging to the former class have been distinguished by Bartel as “climacteric pseudomenstrual insanity.”

The psychoses dependent upon the climacteric influences may, according to Kowalewski, appear in almost all the known forms of mental disorder: precordial anxiety, melancholia, mania, amentia, paranoia, etc.; and although they exhibit no features which are absolutely characteristic, or which, as already said, enable us to distinguish a specific “climacteric insanity,” yet they all bear a common imprint by means of which we are enabled to detect in their causation the influence of this critical period of life. Thus, precordial anxiety occurs in paroxysms having a more or less regular periodicity, corresponding with that of the expected menstruation. The same feature is observable in the periodic exacerbations of hysterical and epileptic paroxysms. Often, also, there occur at this time sudden changes in the emotional disposition and in the character, in one direction or the other, without the development of actual melancholia or mania. The melancholia of the climacteric period occurs chiefly in married women, more especially in those whose circumstances are unhappy; and it is often manifested by attempts at suicide.

Mania is comparatively rare at the climacteric period; when it does occur, it commonly assumes a sexual form—sexual impulses, hallucinations, and delusions, and obscene conduct. Such manifestations are seen most often in widows, in “old maids” whose morals are not above reproach, and, speaking generally, in those whose sexual needs have remained partially or completely ungratified, and in those who have greatly erred in the conduct of this side of life. Amentia also occurs at this time of life; rarely in maniacal form, more frequently in association with menstruation as a periodic psychosis, or as a continuous disorder of mind with exacerbations corresponding to the menstrual periods; it is often characterized by pronounced eroticism.

Much more frequent during the climacteric period is the occurrence of paranoia, as Kowalewski rightly insists. It is most often met with in “old maids” with psychopathic predisposition. The imagination of such individuals is always concentrated upon men; they imagine that men in general, but more particularly certain individuals of the opposite sex, are continually regarding them, making eyes at them, making signs to them, in some way or other striving to attract their attention. The most ordinary and invariable forms of polite intercourse are regarded by these women, whose powers of observation are morbidly stimulated, as being indications of a special “attention” paid to themselves. They persecute these men with their own attentions, and imagine that it is the men who are persecuting them. Often this morbid mental state is associated with sexual malpractices, masturbation, etc. Not rarely, such degenerates are affected with lascivious dreams. Often they experience hallucinations of sexual perception in the form of supposed assaults on their virginity. All these states are apt speedily to develop into a condition of general suspiciousness and ideas of persecution. The ideas of persecution assume a peculiar form, one especially characteristic of the climacteric period. The patients believe that a man, often personally unknown to them, and perhaps living in another town, enters into spiritual and bodily intercourse with them. These relations are supposed to be effected in most cases by means of spiritualism, hypnotism, or electricity. The patient importunes the man in question with letters, supposes herself to be legally united with him, and not infrequently wishes to give him the pleasure of paying her bills and providing her with money. It is a very common occurrence for a Catholic priest to be worried by such a woman, her delusion being grounded upon the fact that the priest is supposed to assume an exceptionally intimate spiritual relationship with members of his flock. The patient with ideas of persecution often herself becomes an actual persecutor, not only pestering her victim with innumerable letters, but in her jealousy making “scenes” whenever she can encounter him, and sometimes giving rise to serious scandal. With such a mental state we often see associated sexual hallucinations and delusions; the patient believes herself to be pregnant, imagines herself to have been violated, or to be living in carnal intercourse with a man—some one, it may be, with whom she is not even acquainted. Medical men are especially apt to suffer from the accusations of such women, whom they may have examined in private in entire ignorance of the patient’s mental condition. Frequently, such ideas of sexual persecution are associated with paroxysms of violent nymphomania, and in this way also the unwary physician may find himself placed in an extremely unpleasant position. It occasionally happens in such patients that abnormalities of the sexual instinct arise, and they begin to feel desire towards individuals of their own sex.

Such delusions of persecution by means of hypnotism, spiritualism, the telephone, etc., in association with sexual delusions and nymphomania, are so frequent during the climacteric period, that they may be regarded as pre-eminently constituting climacteric insanity. Frequently some old hysterical state underlies this form of mental disorder.

Thus these peculiar manifestations of eroticism must be regarded as the distinctive characteristics of climacteric insanity and more particularly of climacteric paranoia. A second characteristic of climacteric insanity is, according to Garat, the marked development of jealous emotions and delusions.

In addition to these fully developed psychoses, there occur in degenerates at the climacteric age paroxysms of impulsive insanity in the form of dipsomania, kleptomania, pyromania; exhibitionism; irresistible impulse to suicide, homicide, infanticide, etc. Such paroxysmal impulsive manifestations are, according to Kowalewski, commonly associated with menstrual disturbances; they occur most frequently at the due dates of menstruation when the flow fails to appear.

One hundred and sixty-nine cases of climacteric psychosis were classified by Matusch as follows:

Melancholia 36 cases Mania 2 cases Melancholia passing on into paranoia 28 cases Melancholia passing on into secondary dementia 17 cases Paranoia 43 cases Neurasthenia during the climacteric period followed by mental disorder 19 cases Neurasthenia prior to the climacteric period, followed by mental disorder during the climacteric period 10 cases Apoplexy, cerebral abscess, dementia 6 cases Epilepsy 2 cases Alternating insanity 3 cases Paralytic dementia 5 cases

Von Krafft-Ebing classified 60 cases of climacteric psychosis as follows:

Melancholia 4 cases Alternating insanity 1 case Acute delirium 1 case Primary insanity: a. With primordial delirium 36 cases b. Paralytic dementia 12 cases

The prognosis in cases of climacteric psychosis is regarded by Kowalewski as unfavourable; unfavourable vital conditions are associated with retrogressive metamorphosis of the tissues, hence mental disorder arising at this time of life is hardly less serious than that due to actual degeneration of cerebral tissues. Indeed, according to Schüle there is during the climacteric period an especial danger of the development of atrophic cerebral processes (Encephalitis atheromatosa) with apoplectic and epileptic seizures. Schlager also regards the prognosis of climacteric insanity as unfavourable; but Merson, on the other hand, observed among women suffering from climacteric psychoses a recovery rate of over 50%. On previously existent psychoses in women, the onset of the climacteric exercises in most cases an unfavourable influence, and very exceptionally only at this time do we observe the cure or remission of a chronic mental disorder to occur. Kowalewski has seen cases of chronic mania in which a cure was obtained at the climacteric period; a somewhat excessive excitability and inclination to violence remained, however, as vestiges of the former insanity. Matusch, keeping under observation 60 women affected with chronic mental disorder as they attained the climacteric period, noticed that in 14 instances the mental condition changed for the worse at this period, whilst in 13 the character of the mental disease underwent a change, excitement giving place to apathy and dementia. Griesinger had earlier pointed out that at the time of the cessation of menstruation there would occasionally occur amelioration, and even cure, of a previously existing chronic mental disorder; more often, however, the influence of the menopause was an unfavourable one, a hitherto changeable and irritative form of mental disease becoming transformed into chronic insanity with inalterable delusions, or into dementia. The course of mental disorder, such as melancholia, first making its appearance at the climacteric epoch, was also regarded by Griesinger as likely to be unfavourable.

HYGIENE DURING THE MENOPAUSE.

During the critical years of a woman’s life it is the aim of hygiene to employ all the means available to counteract the changes in the circulation of the blood, the disturbances in the working of the nervous system, and the nutritive disorders, which are in various ways dependent upon the changes occurring in the reproductive organs during the climacteric period; its endeavour should be so to regulate the conduct of life in this epoch that the important episode of the gradual decline and ultimate extinction of sexual productivity shall be effected with as few local troubles as possible, and as slight variations in the general condition.

By means of baths of various temperature, duration, mode of application, and composition, and by other selected hydrotherapeutic procedures, we are enabled during the disturbances of the menopause to exert upon the skin a powerful derivative influence, and in this way to diminish the passive hyperaemia of the uterus and the uterine annexa; by the same means we can exercise a sedative influence on the peripheral nerves and thus further upon the entire nervous system, whenever such measures are called for by the manifold indications of increased irritability; further, by the use of baths we can influence the circulation of the blood, we can increase the sudatory activity of the skin, and in various additional ways we can affect heat production and metabolism, thus modifying the processes occurring in the reproductive organs, making the conditions favourable for the absorption of exudations, and promoting a healthy tissue-change in the mucous membrane of the genital passages.

In climacteric women, the most usual indications are for the employment of water-baths at an indifferent temperature. 35 to 37° C. (95 to 98° F.), of moderate duration, 15 to 20 minutes, the bath being one of simple immersion, not of douche or affusion, and the temperature being kept constant by continuous inflow of a sufficient quantity of hot water. Such baths as these promote in a mild but continuously efficient manner the functions of the skin—so important during the climacteric epoch; and they lessen the almost constant tendency to perspirations and to the development of diseases of the skin (the commonest of which is climacteric eczema). The moderate degree of thermic stimulus exercised by baths at such an indifferent temperature leads them to have an equable sedative effect upon the nervous system, which is probably dependent upon an influence exerted through the intermediation of the sensory nerve-terminals in the skin; and this is most beneficial in lessening the increased general irritability, both spontaneous and reflex, so commonly manifested by the nervous system at the climacteric period. In women at this time of life, such baths are most useful in allaying the common cutaneous hyperaesthesias and neuralgias, and have a reflex influence also upon the visceral neuralgias and psychical hyperaesthesias.

In climacteric women suffering from abnormal sensitiveness to sensory impressions, to strong light and loud noises, or from painful sensations in the most diverse nerve areas; in those subject to palpitation of the heart after some trivial exciting cause; in those affected with cramp-like seizures in the pharynx, the œsophagus, the stomach, and the intestinal tract; in women with distressing sensations of itching and burning in the reproductive organs, or in those in whom there is a great increase in the intensity of the sexual impulse—in all these common disturbances of the menopause, by the daily use of such immersion baths of water at an indifferent temperature, best taken immediately before retiring to rest, we shall often succeed in inducing both local and general repose, in diminishing the spontaneous and reflex irritability of the nervous system, and in inducing quiet and restorative sleep.

In other cases of disturbances of health during the climacteric period, however, more benefit may be derived from hot immersion baths, taken at a temperature well above blood heat, (37° C.—98.4° F.) and lasting longer than the warm baths just described. These are indicated when we wish to increase the activity of the circulation through the skin, to give rise to hyperaemia of the superficial structures of the body, to stimulate powerfully the cutaneous nerves, to promote cutaneous perspiration—in short, to exercise a powerful derivative effect, to promote resorption, and to accelerate the general processes of tissue-change. This method of treatment is suitable for cases in which at the commencement of the menopause there are already pathological conditions of the reproductive organs, the morbid states being now aggravated by the processes of the climacteric—such conditions are metritis and endometritis, chronic inflammations of the intrapelvic connective tissue and of the pelvic peritoneum; and one of the first aims of treatment must be to promote the softening and subsequent absorption of these inflammatory products. Again, in cases in which the climacteric troubles, dependent in part on increased general arterial blood-pressure, manifest themselves chiefly in the form of active congestions, fugitive heats, vertigo, etc., the employment of hot baths is likely to be most useful by leading to a notable enlargement of the cutaneous capillary bloodvessels and consequent lowering of arterial blood-pressure. Further, in cases of compensatory fluxes, periodic diarrhoeas, periodic leucorrhoea, following the suppression of the menstrual flow, in cases of vicarious haemorrhage (especially periodic epistaxis and periodical haemorrhoidal bleedings), the use of hot baths is often competent to restore the functional activity of the ovaries when this has undergone premature cessation. In addition, their use assists us in our endeavours to counteract excessive obesity and gouty disorders, diseases which tend especially to make their appearance in women at the epoch of the menopause, disorders of metabolism intimately associated with the disturbances of the uterine and ovarian functions characteristic of the change of life.

In all the conditions just enumerated, if we desire a still more powerful influence than that exerted by ordinary hot baths, it is in our power to employ hot mineral water baths, by means of which a chemical, and perhaps also an electrical, stimulation of the cutaneous nerves is superadded to the simple thermic stimulus conveyed by the hot water. The different effects of the various mineral baths depends upon both the saline and the gaseous constituents of the different springs, and upon the peculiar physical properties of the mineral waters.

Sudorific baths are of various kinds. Some, Russian baths, consist of hot air saturated with moisture; others, Roman-Irish baths, consist of dry hot air; the most recent of all are the electric light baths, in which the radiant heat of electric lamps is utilized. But owing to the great increase in the body temperature which they cause, with consequent increased frequency of pulse and breathing, and still more on account of the rapid and extensive increase in blood-pressure to which they give rise, these powerful sudorific baths are rarely suitable for climacteric women, and if used at all in such cases the greatest caution must be employed. Their use is indicated only in women in whom at the time of the menopause the rapid onset of obesity has given rise to serious troubles, but in whom the heart is perfectly sound and in whom the blood vessels show no trace of sclerosis.

Far less often than warm or hot baths, or mineral water baths, are cold baths employed during the climacteric period, for baths at a temperature considerably below the indifferent point, and other hydrotherapeutic procedures in which cold water is used, stimulate the nervous system so powerfully and give rise to so great an increase in blood-pressure, that their use is generally to be avoided in climacteric women, since indeed it is apt to entail serious dangers both physical and mental. Immersion baths, plunge baths, or sponge baths, in which the water employed is at a temperature of 18° C. (64° F.) or less, are contra-indicated, for they act too energetically, abstract heat too powerfully, to be safely employed at this epoch of life. If we seek by means of hydrotherapeutic measures to counteract states of congestion at the time of the menopause, and at the same time to bring about a general invigoration of the patient’s nervous system, immersion baths the water of which is not below 20° C. (68° F.), and lasting from five to fifteen minutes, would appear to be indicated. In the majority of such cases, however, a somewhat higher temperature is preferable, from 26 to 28° C. (79 to 82° F.), the patient lying at full length in the bath, immersed to above the shoulders, and the water not being agitated except by a moderate rubbing of the surface of the body whilst the patient is in the bath. When, however, the patient sits in the bath, the water covering only the lower half of the body as high as the navel, a somewhat lower temperature is permissible, 20 to 25° C. (68 to 77° F.); but the duration should not exceed five minutes, moderate mechanical manipulations being carried out meanwhile; such baths appear to reduce nervous irritability and to have a sedative effect in the manifold nervous disturbances of the climacteric period. Sitz-baths, again, of a longer duration, twenty to sixty minutes, the water reaching only to the navel, and being at a temperature varying from 16 to 25° C. (60 to 77° F.), are useful in relieving chronic inflammatory states of the reproductive organs and the associated erotic states and abdominal pain and irritability. Colder sitz-baths, even of brief duration, should, on the other hand, be avoided. Similarly, a shower-bath of water at a temperature of 18 to 24° C. (64 to 75° F.), lasting one to two minutes, and the water falling only from a very slight elevation above the head, have a valuable sedative action; but, on the other hand, a colder shower-bath, of water falling from a greater height, has an exciting action, and is to be avoided at this time of life. When there are severe congestive symptoms, friction of the hands and feet for a short time with water at a temperature from 12 to 17° C. (54 to 63° F.), followed by a quarter of an hour’s rest in bed, may be recommended; also immersion of the feet for a minute in water at a temperature of 10° C. (50° F.), the feet being vigorously rubbed the while, followed by a walk in the open for five or ten minutes. In cases of sleeplessness at the menopause due to congestion, a useful method is to dip the feet for twenty or thirty seconds in water at a temperature of 8 to 10° C. (46 to 50° F.), the feet being briskly rubbed whilst in the water, or moved rapidly up and down with treading movements; after withdrawal, they are quickly dried, and the patient immediately goes to bed. Another useful mild soporific measure is to apply before going to bed bandages wrung out of cold water; these reach from the foot to the knee, and are left on for the whole night. In cases of climacteric menorrhagia, my vaginal refrigerator should be used for the direct application of cold to the reproductive organs; this is a cylindrical apparatus introduced into the vagina, cold water flows through the interior of the apparatus without wetting the vaginal mucous membrane. This cooling apparatus is useful also in troublesome cases of genital pruritus; cold douches to the vulva for one or two minutes at a time are likewise valuable in the relief of this affection.

For climacteric women, cold sea-bathing is as little to be recommended as other cold hydrotherapeutic measures, owing to its powerful refrigerative effect, and the great mechanical influence of the moving water in the waves. But in certain cases, in which sea-air is likely to be beneficial, lukewarm sea-baths may also be recommended; their effect is similar to that of weak brine-baths at a similar temperature.

During the climacteric period, especial attention must be paid to the care of the skin. Owing to the extreme sensitiveness of the skin at this time of life to outward noxious influences, it is necessary to exercise great care to dry the skin very thoroughly after ordinary ablutions of the face and hands; irritating soaps should be avoided, and a bland powder should be applied after drying. During the earlier part of the climacteric period, when menstruation has already ceased, and senile changes in the skin with atrophy of the subcutaneous tissues have commenced, the extreme dryness of the skin may be relieved by lukewarm baths with wet packs to follow; after the bath, the woman is enveloped in moist linen cloths and then covered over all with a blanket. When the skin chaps readily, inunction of lanolin ointment will be found useful.

Cleanliness of the genital organs, at all times of importance, is doubly so during the climacteric period, for the reason that neglect in this respect is apt to lead to the onset of genital pruritus. Not only after defæcation, but after each act of urination as well, the external genital organs and the anus should be carefully washed over with a pad of clean absorbent wool moistened with lukewarm water. After the washing, either powder or ointment should be applied, the former in cases in which the skin of the parts is usually damp from a natural tendency to excessive secretion, the latter in cases in which the skin is dry and tends to crack.

Bodily exercise, carefully selected and regulated to suit the individuality of each patient, is a powerful means of relieving the disturbances of the menopause. Regular and methodical bodily exercise—to which it must be remembered, women at the climacteric period commonly feel considerable aversion—manifests its good effects in the form of improvement in the nutritive conditions and functional activity of all the organs, and increased activity of all metabolic changes, which are commonly sluggish in women at the change of life. Moreover, muscular exercise, by increasing the volume of blood passing through the muscles, has a beneficial derivative influence in diminishing the congestion of the brain and the other troublesome congestive symptoms which are liable to occur in women during the menopause. Again, in cases of excessive obesity such as so commonly occur in women at the change of life, the increased combustion of fat promoted by regular muscular exercise, cannot fail to have a beneficial effect. Finally, suitably selected muscular exercise has a favourable influence also upon the nervous system, the functional activity of which it facilitates, while at the same time it strengthens the powers of the will.