the conditions described by Tilt as ganglionic shock, paralysis, hyperæsthesia, and dysæesthesia from abdominal neuralgias and many of the functional and organic diseases of the abdominal viscera. Finally, the connection of these various disorders, entirely irrespective of names, with the change of life has never been demonstrated, nor even rendered in a high degree probable.

Cerebral Hyperæmia.-The older authors dwell with especial emphasis upon hyperemia of the brain as an important functional disorder in connection with the change of life. The condition is supposed to be apt to occur, in the absence of perspirations, flushes, and the other so-called critical discharges, as the result of plethora. Headache, tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the face and neck, bounding pulse, are among the symptoms which have been referred to the lighter forms of cerebral hyperæmia. Few systematic writers, however, sustain Dusourd in his assertion that apoplexy and the severer forms of hyperemia of the brain are frequently caused by the cessation of men

struation.

Under the impression that plethora actually caused cerebral hyperæmia and the symptoms mentioned, and doubtless influenced by the teachings of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding in the treatment of climacteric neuroses. Fordyce Barker and Tilt may be mentioned among modern clinicians who retain the old opinion as to the nature and treatment of this condition.

Cohnheim,' representing the modern school of pathologists, says "that except as a transitory state polyæmia does not occur under any circumstances." In recent pathology the various appearances of plethora are regarded as caused chiefly by dilatations of the skin blood-vessels, and not by an increase in the total blood-mass. The changes in the character of the pulses are referred to alterations in the vessels or their innervation. Even admitting the existence of the so-called plethora universalis, it does not follow that headache, dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia. Andral has well said that these symptoms might with equal justice be ascribed to qualitative changes in the constitution of the blood.

Whatever view may be accepted as to the pathology of cerebral hyperæmia, and as to the necessary connection with the change of life, two important facts derived from experimental physiology deserve careful consideration before bleeding is performed for the relief of the symptoms mentioned: (1) A high blood-pressure does not imply an augmentation of the total blood-mass. A large quantity of blood may be injected into the vessels without any considerable elevation of pressure. (2) Bleeding does not directly lower blood-pressure unless the quantity of blood removed be dangerously large.

In the lighter cases the so-called derivative treatment fulfils all the indications. Hot, irritating foot-baths, purgatives, saline diuretics, are indicated for the relief of distressing symptoms. Diet, exercise, frequent bathing, and other hygienic resources exercise a most important prophylactic function.

Hysteria. The occurrence of hysteria during the menopause, as at other periods of life, is a well-established fact. Whether or no there is

1 Pepper, System of Medicine,, Vol. III. p. 886.

2 M. Foster, Physiology.

any direct pathological connection of cause and effect between the change of life and the disorder is a question which has been the subject of much controversy, and at the present time is unsettled. Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are of the opinion that the climacteric may stand in a causal relation. stand in a causal relation. Tilt's tabulated cases bearing upon this subject show nothing more than the coincidence of the two conditions, and contribute nothing to the solution of the problem. There are important considerations which favor the view that while the menopause may influence hysteria favorably or unfavorably, it is only in exceptional cases that the climacteric is the immediate cause of the affection. While hysteria may occur at any time of life, it is most frequently observed between the ages of fifteen and twenty years. It is in a high degree probable that a woman who has arrived at her forty-fifth year without hysterical mansfestations will not be molested during the change of life. It is not an uncommon observation to see hysterical woman rapidly regaining health during the pre-cessation period, and making complete recoveries before the permanent resettlement of health.

Hysteria during the menopause does not differ as to symptoms from the affection at other periods of life. It retains its protean character. Almost all the described forms of nervous disease may be accurately simulated. The severer forms of the disorder are paroxysms characterized by convulsions, coma more or less complete, or delirium. Coma enters to a greater or less degree into the paroxysms characterized by convulsions. Lypothæmia-a term used by the older writers to signify an hysterical semi-unconsciousness with feeble pulse and widely-dilated pupils -is frequently observed. This condition, as well as a state termed pseudo-narcotism by Tilt, may be regarded as a lighter form of coma. Functional paralyses and pareses of motion or sensation, or both, are occasionally observed. Paraplegia is of relatively frequent occurrence. Not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. Hemiplegia and general paralysis are observed less frequently.

In the differential diagnosis it is necessary to exclude epilepsy and eclampsia, although it is well to bear in mind the fact that both these conditions may coexist.

The treatment of climacteric hysteria differs in no essential particular from that of the same disorder at other periods of life. The practitioner, however, has the comfortable knowledge that with the resettlement of health all symptoms, in the absence of local disease, will probably disappear.

It may not be amiss, in passing, to notice the value as a palliative measure of that old and well-tried remedy, the hot-water enema containing asafoetida. One to two ounces of the tincture of asafoetida in one quart of hot water, carried well up into the colon, is usually productive of excellent results, moral and physical.

Climacteric Pseudocyesis.-False or spurious pregnancy is a neurosis of not infrequent occurrence at or about cessation. It may justly be regarded as one of the mimetic forms of hysteria. The symptoms which give origin to the illusion may be observed in young, unmarried women or long after the cessation of ovulation and menstruation. Iu

the large proportion of cases, however, the phenomenon is noticed at or about the climacteric. The subjective and objective signs of this curious condition may simulate pregnancy very closely. The breasts are swollen and tender, and a milky fluid may exude from the nipple. Nausea and vomiting in the morning and the various sympathetic disorders of pregnancy may be feigned. The abdomen may become enormously distended from the deposition of adipose tissue in the abdominal walls and omentum and the flatulent distension of the intestines. Foetal movements are simulated by intestinal peristalsis and irregular contractions of the abdominal muscles. The ensemble of symptoms may be very deceptive, as shown by the famous case of Joanna Southcott. Crichton Browne1 relates the history of an illustrative case which came under his observation in the West Riding Asylum. A woman long past the menopause claimed to be two months advanced in pregnancy. At the end of seven

months she informed her friends that she was about to be confined. Accordingly she went to bed, and the process of simulated parturition lasted four days, terminating with a bloody discharge from the vagina. The differential diagnosis is easy. The mammary changes, upon close examination, will be found to differ from those of pregnancy. Inspection, palpation, percussion, and auscultation will disclose the fact that the woman is only big with fat and wind, as Barnes puts it. Anæsthesia will facilitate the examination. Bimanual examination usually reveals the characteristic senile changes in the uterus or a pathological enlargement differing essentially from the gravid organ.

The so-called phantom tumors sometimes observed during the menopause are closely analogous to spurious pregnancies.

Epilepsy.-Epilepsy is a relatively uncommon disorder during the menopause. The present state of our knowledge indicates that the climacteric cannot be regarded as a distinct cause of the disease in the absence of previous epileptic seizures or inherited predisposition. Out of 200 cases of epilepsy occurring during the climacteric, observed by Jewell of Chicago, not a single case could be traced by the most rigid analysis to the change of life. Considering the rôle the sympathetic nerve plays in the etiology of epilepsy, it would not seem improbable, on a priori grounds, that the disease should be aggravated at the menopause. Evidence derived from clinical observation, however, is entirely inadequate to settle this question.

Insanity. Various opinions are held as to the relation between the menopause and insanity. Mania, monomania, dementia, and even idiocy, are among the forms of mental alienation which have been attributed to climacteric influences.

Monomania. There is much probable evidence in support of the view that the change of life may stand in a direct causal relation to monomania. On the other hand, no proof exists sufficient to establish a necessary pathological connection between cessation and mania, dementia, or idiocy.

Gardanne, Dubois d'Amiens, and Chambon have called attention to the occurrence of melancholia and hypochondriasis at this period. This opinion is confirmed by the results of Battey's operation in the hands of Lawson Tait, Bantock, Thornton, and other operators of large experi

1 British Medical Journal, 1841.

ence.

In many of the cases of artificial induction of the menopause melancholia has been observed as a most distressing sequela. However, in connection with Battey's operation there are numerous and important considerations which must be carefully weighed in order to distinguish between a relation of cause and effect and mere coincidence. The number of women operated upon is now large, and some of the cases of melancholia following ovarian extirpation are probably examples of the return of a disease of earlier life or of the influence of heredity. Then, the fact of disqualification for maternal duties supplies in many cases an adequate psychological cause for more or less complete mental alienation. The important effects of chronic hepatic hyperemia and the coexisting gastro-intestinal catarrh-conditions so frequently present at cessation-must not be forgotten when disorders of the intellect are referred to the cessation of the ovarian stimulus.

The positive diagnosis of climacteric melancholia and hypochondriasis is always difficult, frequently impossible. After the careful exclusion of all other possible causes, it may be assumed with a certain degree of probability that the intellectual disorder is due to the change of life.

The prognosis of climacteric melancholia and hypochondriasis is not necessarily unfavorable. In a large proportion of cases sanity returns with the re-establishment of health. The treatment, in the absence of a positive diagnosis, must be expectant. Effort must be addressed to the removal of any possible cause. Hygienic measures fulfil all the indications for treatment in the disorder when it is caused by the change of life. Opium and alcohol must be employed with extreme care in view of the great danger of the formation of obstinate habits.

Uncontrollable impulses and perversions of moral instincts are frequently observed during the climacterium, as at other periods of life. There is no reliable statistical evidence sufficient to establish a necessary pathological connection between cessation and uncontrollable peevishness, impulse to deceive, suicidal impulse, nymphomania, dipsomania, kleptomania, and the like. Nor is it possible to assert that these various disorders are of more frequent occurrence during the menopause than at other periods of life.

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.

By W. W. JAGGARD, A. M., M. D.

Acute Metritis.

THE Occurrence of an acute inflammation of the parenchyma of the non-gravid uterus has been denied by many systematic writers. Wenzel1 says the condition is a figment of the imagination; Duparcque is sceptical; Klob2 up to 1864 had never seen a case in which a positive diagnosis was possible. Emmet writes in the last edition of his valuable book, "Inflammation of the uterine body never occurs except after par

turition."

Comparatively recent investigations, however, have established the fact of occurrence beyond doubt or question. While a relatively uncommon condition, many facts with reference to its causation, pathological anatomy, and clinical course are definitely known.

ETIOLOGY.-Disturbances in connection with menstruation play a rôle of great importance in the production of acute inflammation of the uterine parenchyma. The rapid cooling off of extensive areas of the skin surface, as in wetting the feet in cold water, severe exertion, or the cold-water vaginal douche, may transform the normal menstrual congestion into an acute inflammation. The retention of menstrual blood within the uterine cavity, the result of organic stenoses, flexions, or tumors, occasionally gives origin to acute septic metritis. The inflammatory process frequently extends from the endometrium to the muscular substance. Gonorrhoeal endometritis is of chief clinical significance in this connection. Duparcque's observations, confirmed in 1872 by Noeggerath, have recently attracted a great deal of attention. Säuger's statement at Magdeburg, that one-ninth of all gynecological cases are of gonorrhoeal origin, created some surprise at the time. In the light of the recent investigations of Schroeder, Bumm,* Lomer, Oppenheimer, and others, it is not considered an exaggeration, although it is still unsettled whether or no the gonococcus of Neisser is the agent of infection.

5

6

Under the heading of traumatism a great number and variety of etiological factors are included. Operations on the cervix, curetting the uterine cavity, and other minor gynæcological procedures, in the absence 2 Pathol. Anatomie der Weibl. Sexualorgane.

1 Krankheiten des Uterus, p. 42.

3

Gynaecology, 1884, p. 31.

5 Deutsch. Med. Wochenschrift, 22d Oct., 1885.

4

Arch. f. Gyn., xxiii. 3.

6

Arch. f. Gyn., xxv. 1.