THE MENOPAUSE-PATHOLOGICALLY CONSIDERED AND ILLUSTRATED BY RECENT CASES. BY C. MCKANE, Ph. D., M. D., Savannah, Ga. [Written for the MEDICAL BRIEF.] Our modern civilization, with its artificial requirements, imposes unnecessary burdens upon our women. Conditions perfectly natural in their course, physiological in their function, are perverted into serious, if not dangerous pathological phenomena. Why should the commencement of menstrual life, or its ending, be attended with so much complication and misery? It is a remarkable fact, well known to many physiologists, that women in Eastern countries suffer less from complications at puberty, and during the process known as the "change of life." Unlike our women, they live the natural life, hindered neither by dress nor fashion; they breathe easily, freely and naturally an abundance of uncontaminated air, and enjoy the sun and its rays. In their supposed semi-civilized condition, they recognize, unconsciously, certain physiological limitations of their sex, and remain always women. The swinging of the physiological pendulum to either extreme is fraught with much danger. A woman is neither a butterfly nor a doll. Within certain limitations, bearing in mind the difference in anatomical structure and physiological functions between the sexes, a woman's life should be free from the artificial restraints that modern society forces upon her. Nor should she be compelled to bear burdens and exposures that, in the nature of things, men should bear. Many valuable lives are lost during this epoch in the woman's career, when the nation needs her counsel to her sons and daughters. Ripe in experience, sounder in judgment, conservative, resting from her labors, we need her now, and she should be saved. We are told that in a climate like ours, between the fourteenth and fifteenth years, the majority of girls pass from that stage of playful innocence into a development in which dignity is recognized, and grace assumed, and the reproductive organs, external and internal, have undergone certain changes preparatory to reproduction. Ovulation and menstruation begin, and puberty is attained. Whether the woman has engaged in sexual life, and, in consequence, bore fruit and multiplied the earth, in obedience to the great command, or not, somewhere between forty-five and fifty years, she can no longer be fruitful; the end is at hand, concurrently, both ovulation and menstruation cease. This we call the menopause, or "the end of menstrual life." Of course, there are exceptions to this rule. There can be no fast and ironclad rules in medicine until we know more about physiology. As we shall soon see, every woman.is a law to herself. In a normal case, a woman who had been menstruating regularly, observes her "flow" becoming irregular, slight congestion of the abdominal organs, enlargement of the abdomen, with accumulation of gas. THE PSEUDO-CYESIS OF THE MENOPAUSE. It is then she is likely to consult us, and seek advice as to the probable date of her approaching delivery. In most instances, she is proud, vain, and insistent, feels life; the breast enlarges, in some instances, and gives prominence to the deception. The careful examiner is seldom led astray. The usual methods of examination will always reveal an empty uterus, congested or well advanced towards atrophy. It will not do to turn these women away carelessly. Unfortunately, there seems to be in the minds of most women that to woman belongs the inherent right to the spring of perpetual youth, and no evidence can be placed on their statement as to age. An experienced observer can, usually, approximate the age, in spite of massage, paint, or powder. Having satisfied ourselves on the age, we proceed carefully to interrogate the internal organs, obtaining all the information possible from that source. Fact and good judgment must be exercised, and by adroit and sympathetic questioning we receive much valuable information that might otherwise escape us. In dealing with women of all classes, the more gentle and considerate we are, the more successful will we become in treating their diseases. There are times when positiveness and decision are essential, but vulgar brutality and harshness are never necessary. In this connection it might be well to warn practitioners, with large female practice, whether in populated districts or small communities, that it pays to have an assistant within hailing distance. Physicians are not free from envy, intrigue and jealousy, within or without their own profession. This is no new fact to the old medical man, but the ambitious, successful, rising young man, is likely to be brought speedily to grief unless he heeds the hint here incidentally thrown out. For a number of years, both in hospital and private practice, it has been my good fortune to treat many women passing through their climacteric period. Selection has been made from the more pronounced and complicated cases for your study, consideration and reflection. Case 1-Lizzie K., gave her age at this consultation as thirty-eight years-seven years were added, forty-five years being more nearly the correct age. I had, in former years, treated this lady for minor ailments. She was fairly well educated, a good conversationalist, and well up on the free medical literature sent out by the advertising medical bureaus, with the usual pictures, instruments, etc., for domestic use. Her menses were playing "hide and seek," as she herself expressed it, and she was confident, from the literature read on the subject, that pregnancy existed. Never having been pregnant, she was advised by her husband to consult some woman's doctor, and the lot fell on the writer. General inspection revealed a marked tendency towards corpulency. The facial expression was that of expectancy and anxiety. Percussion elicited no abnormal condition of the lungs, but in the region of the abdomen tympanites were in evidence in every direction, save in the naturally dull areas. Auscultation demonstrated feeble heart sounds, more pronounced with the second sound; unmistakable evidences of accumulation of excessive fluid in the abdominal cavity were abundant. The pulse was not strong, with wiry inclination, examination of the pudendum showed swelling and edema. The vagina was hot, sensitive, and rather hyperesthetic; still, the woman was voluptuous, sexual appetite unusually exaggerated and unsatisfied. The husband was unable to meet her demands and rebelled. The midwives had explained that this was one of the demands of the foetus; however, the husband, who was near at hand during most of the examination, could not understand. "Something must be done," for he was bordering on desperation. The speculum was introduced, and the os and cervix uteri brought into view, disclosing a virgin os, with a long, narrow cervix. Bimanual examination had already informed us of an empty, insignificant uterus, well on its way to retirement. Our opinion was withheld. We sought by tonics to build up, by saline cathartics to rid the abdominal cavity of its fluids, and by bromides to control the unusual sexual appetite until we could honestly and conscientiously make a diagnosis. We grew solemn, but politely remained silent. In the course of a few weeks our patient disappeared. During the interval many of the local practitioners, including some well-advertised specialists and "cure-alls," had their day. Dr. A. W. McKane and myself were conducting a small sanitarium in the west of the city, about four miles from the City Hall, for the treatment of the diseases of women. April 10, 1904, my former patient applied for admission to our sanitarium, after an absence of several years. Her condition now was much more intense and aggravated, dejected in spirit, moral responsibility lost, with partial paralysis of the muscles of the forearm. The facial expression was that of one who had lost hope in all things, worldly or heavenly. The attendants notified us that she was practicing masturbation. Investigation proved that our informants were correct. Menstruation was absent for three or four months at a time, and when it appeared it was metrorrhagic in character. The uterus was considerably reduced in size. The corpulency was greatly augmented. The mental faculties were very much impaired. From a cultured, refined, ambitious being that we knew in former times, we now had a gross, immoral woman, apparently of the very lowest type of degeneracy. There was no doubt now, to our minds, that we had on our hands a case of a woman undergoing the change of life, with unhappy complications. Our treatment at the sanitarium was as follows: The diet was nonstimulating, no condiments of any kind, consisting chiefly of fish, fruits, chicken and vegetables, plenty of fresh air, no alcoholic beverages of any kind, pure water and milk, out-door exericse in abundance, when the weather permitted, under the care of an attendant. We pushed the bromides to the limit. We used ergot and viburnum in combination, the former to check the excessive hemorrhages and to aid along the natural contraction taking place, and the latter as a uterine sedative and tonic. Iron, nux vomica and the hypophosphites were used as general or systemic tonics. Under this plan of treatment, there was physical, moral and intellectual improvement. Our treatment and observation extended for many weeks, the patient returning to her home. We were again called to see her about the 20th of September, 1907. Menstruation had ceased for about eighteen months or more. She had recovered her former self, and was rational, sane and hopeful; but for a slight irritability of the bladder, brought about by exposure, she was in excellent health. Case 2-Anna E. B., a native of Macon, Ga., candidly gave her age as forty-eight years. Her apperance showed she was telling the truththe snowflakes of time were scattered here and there, the telltale wrinkles were not obliterated by the skillful hands of the professional artist. She was a poor woman, the mother of three sturdy young men, and four daughters, who were married and rearing sons and daughters. She began to menstruate at the early age of thirteen and one-half years, and at eighteen years was already married, and had given birth to a son. Hale and hearty all her life, never a pain did she experience throughout her menstrual life, as regular as a clock, unless something was up. "For six months things were acting funny," she explained it. There were pains in her back and head, dizziness, loss of memory, malaise, and a general disposition to shirk the usual household duties. She was no longer interested in sexual life; her husband, who was five years her senior, had lapsed into indifference, so it did not matter much anyway, but the pain annoyed her, and, instead of the flow of four days, with its bright color and regular recurrence, it was a dirty black discharge, that occurred about once in three months, accompanied by a disagreeable pruritus, both anal and pudendal. From a delicate individual she was spreading out in all directions, assuming such proportions that she was alarmed at her own immensity. This lady was a stranger to me. I had to rely on her statements, making my own deductions, here and there, hoping that the physical examination would clear up all doubts, but when we arrived at this stage of the procedure she bluntly informed me that no man had ever examined her, and I should not. I assumed an air of indifference, told her nothing could be done without an examination, and turned my attention to other patients, who were awaiting their turn, and politely bowed her out of the consulting room. Later, I found she was still waiting, earnestly pleading for a prescription, that her description of the case was sufficiently illustrative, that any physician could successfully treat it. Digressing, for a moment, may I be permitted to state that the most dangerous position a medical man can assume is to treat patients in absentia, or relying only upon unsupported statements. The most careful and experienced men, under favorable circumstances, with the patient before them, fail in making a diagnosis at times, therefore it is essentially proper that at all times, and under all circumstances, we carefully examine our patients, regardless of their statements. Again we listened with patience while our patient insisted on rehearsing the old story. After some delay, we succeeded in examining her, with the following results: The uterus was large and retroflexed, the cervix almost obliterated, the os star-shaped, the remains of a former laceration; projecting from the cs was an elongated mass, which, we afterwards discovered, was a polypoid growth; the discharge was offensive and irritating, and was the cause of the pruritus already referred to. This patient was inclined to make trouble, and we were compelled to resort to medical treatment entirely. Relying almost solely on the fluid extract of ergot to expel the mass, by giving a teaspoonful in simple, syrup every four hours, during the day; two grains of permanganate of potash, dissolved in a quart of water, was given as a vaginal wash, to be injected, using the ordinary rubber fountain syringe. Tonics were given. In the course of a few weeks the mass was expelled, the uterus contracted, the abdomen reduced in size, and the woman gradually regained her former strength, her corpulency becoming less potent. Menstruation has ceased now for nearly a year. My original intention was to have presented several cases, but I have already exhausted your time, space, and patience. I hope, however, that I have succeeded in calling your attenttion to a class of patients that need more attention than they receive from the average practitioner. THE TREATMENT OF RINGWORM OF THE SCALP BY THE APPLICATION OF X-RAYS. BY M. DRUMMOND SALE-BARKER, M. R. C. S., L. R. C. P., Medical Officer in Charge of the Electrical Department Westminster Hospital; Mcdical Officer in [Written for the MEDICAL BRief.] The great difficulty which has presented itself in the treatment of ringworm of the scalp has lain in the fact that the actual root of the hair, owing to its depth beneath the surface, is inaccessible to outward applications in the shape of ointments, and it is the root of the hair which is the seat of the fungus. Attempts at curing the disease by the application of inflammatory substances have not proved very satisfactory, and epilation by needling with croton oil is a long and tedious process. To a child suffering from tinea tonsurans the enforced absence from school is a very serious mater, considering that the disease may run a course passing into years. This disadvantage, at least so far as children |