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.
It is therefore of importance that at the time of the menopause women
should continue to undertake appropriate active exercise, regular daily
walks, which should include walking up a moderate incline. As a
preparation for such exercise (in persons hitherto unaccustomed to walk
much), or in bad weather, or, again, when there are special reasons
against open air exercise, and finally as a supplementary exercise to
walking, gymnastics and massage may be employed. Such gymnastic
procedures are to be chosen as will serve to deplete the vessels of the
head, will have a favourable influence upon the portal circulation, and
will withdraw the blood-stream from the pelvic organs; such are, in
addition to general gymnastic exercises, methodical deep breathing,
methodical exercise of the abdominal muscles, exercises involving the
extensors of the back and the abductors and external rotators of the
thigh, and exercises of the extremities. Various gymnastic apparatus may
be employed with advantage, and more especially those in which the
various muscular movements are effected against a resistance. But in all
cases extreme care must be taken to avoid over-fatigue and
over-exertion. A graduated form of bodily exercise combined with passive
gymnastics, suitable for climacteric women, is massage, in which by
mechanical stimulation, by pressure and friction of the whole body or of
certain parts, the nutrition of the muscles is favourably influenced,
and the activity of the general circulation is increased. In the use of
massage also, in climacteric women, all undue excitation of the nervous
system is to be carefully avoided, a mild form of this powerful agent
must alone be employed; gentle stretching and rubbing of the skin of the
lower extremities, the back, and the abdomen, followed by gentle
kneading of the muscles. Massage of the internal reproductive organs
(the method of Thure Brandt), in view of the common tendency to sexual
excitability in women at the climacteric, is mentioned only to be
prohibited. For the same reason, and also on account of the frequency
with which at the time of the menopause women suffer from tachycardia
and from other disorders of the heart, bicycling is in most cases an
unsuitable exercise at this time of life.
A matter of great importance is the regulation of the diet of women
during this phase of life, the aim of such regulation being one which
the older physicians sought to fulfil by means of venesection and wet
cupping, namely, to overcome the abnormality in the constitution of the
blood which arises from the cessation of the internal secretion of the
ovaries, and further to relieve the symptom-complex of abdominal
plethora and the various passive hyperaemias and collateral congestions;
and in addition to subdue the great general nervous irritability, the
sensibility to external stimuli, the inclination to excessive reflex
manifestations, characteristic in women during the climacteric period.
The diet must be regulated in respect both of quality and quantity, and
it is obvious that the regulation must be thoughtfully adapted to the
needs of each individual case.
As regards quantity, the main general principle of dietetics for
climacteric women is that over-nutrition is to be avoided, that the
quantity of nutriment must be reduced to the absolute minimum necessary
to supply the needs of the tissues. In view of the fact that we are
concerned with women at a comparatively advanced period of life, whose
physical labours are not as a rule exhausting, that quantity of food
will usually be sufficient which is competent to furnish 35 to 40
calories per body-kilogram per diem. If we assume that the mean
body-weight of a woman as the climacteric age is 60 kilograms, the
heat-equivalent of the food required daily by such a woman may be
estimated at 2,100 to 2,400 calories. This will be approximately
supplied by a diet consisting of 100 grams albumen, 60 grams fat, and
350 grams carbohydrate. The customary preference for a large amount of
nitrogenous food is, however, not dependent upon physiological
requirements, and provided that the needful minimum of albumen is
supplied (about 1.5 gram per body-kilogram per diem), the requisite
number of calories may be furnished by very various combinations of the
different nutritive elements.
The general principles of the qualitative regulation of the diet of
climacteric women are: first that after the necessary minimum of albumen
has been supplied, there shall be added an amount of carbohydrate and of
fat varying in relative proportions and quantities according to the
physiological requirements of the individual, but taken together
sufficient to supply the necessary heat-equivalent; secondly, that there
should be an abundant consumption of water; thirdly, that stimulating
dietetic adjuvants should as far as possible be avoided.
The nitrogenous equilibrium of the body may be maintained either by
animal or by vegetable proteids; in the case of the former (animal
albumens), the climacteric woman should avoid those containing
considerable quantities of nucleo-albumen or of deleterious products of
tissue-change; in the case of the latter (vegetable albumens), she
should avoid those likely to cause undue stimulation of the intestinal
tract. Of flesh foods (mammals, birds, and fishes), those kinds are to
be preferred which contain small quantities only of extractives
(kreatin, xanthin, etc.) since these substances are supposed to have a
stimulating influence upon the nerves and the heart. Hence, boiled meat
is better than roasted, and the flesh of young animals (veal, for
instance) and fish are to be preferred to game, and the last-mentioned
is to be avoided especially for this reason, that the flavours for which
it is valued by the gourmet are products of partial decomposition
arising from prolonged hanging; for similar reasons, meat extracts,
animal soups, sausages, smoked flesh and fish, and preserved (potted)
meats, should all be avoided. From the intimate connexion between the
ingestion of nuclein and the formation of uric acid, albumens rich in
nuclein are to be forbidden; such are the various foods consisting
chiefly of gland-cells—sweetbread, liver, brain, kidneys, etc. As well
as from the appropriate flesh-foods, the requisite albumen may most
suitably be obtained from eggs and milk (including buttermilk); on the
other hand, caviare is unsuitable owing to its stimulant action on the
genital organs, cheese because it contains large quantities of the
products of decomposition of casein and milk-fat; the fermented milks,
koumiss and kefir, are likewise unsuitable. Suitable vegetable foods for
the supply of albumen (in addition to carbohydrates) are porridge,
bread, and the leguminosae; nuts, on the other hand, cause too much
irritation of the stomach and intestines.
For women during the climacteric period we recommend a mixed diet
moderate in quantity; the amount of flesh and fat in the diet should not
be large, whilst cereals, green vegetables, and fruit may be taken in
greater abundance; irritant vegetable foods must be avoided, and
especially those which tend to stimulate unduly intestinal muscular
activity and intestinal secretion. It is important that an abundance of
water should be taken, not less than two or three pints daily, and a
pure, fresh, spring water is preferable to the aerated waters, natural
or artificial. Alcoholic beverages are to be avoided, and more
especially those which are rich in extractives as well as in alcohol.
For this latter reason, beer and champagne are harmful, whilst spirits
and liqueurs are to be condemned on account of the high percentage of
alcohol they contain. The stimulating alkaloidal drinks, tea and coffee,
are also to be avoided, or if taken at all, only in a very dilute form.
With regard to the preparation of the food, the cardinal principle is
that it should be as little irritant as possible; neither mechanically
irritating the alimentary tract by an excess of indigestible or
undigested residue, nor irritating it chemically by an excessive
admixture of sugar, salt, vinegar, pepper and other spices; nor,
finally, giving rise to thermal irritation by being excessively hot or
extremely cold.
The individual meals are preferably small ones and they must therefore
be taken at comparatively short intervals, five times daily, the
principal meal being taken at one or two o’clock in the afternoon, and
the supper (which should be small) comparatively early, at seven or
eight o’clock.
NOTE.—In his discussion of the _details_ of diet for women during
the climacteric period, hours of meals, actual dishes, etc., the
author refers exclusively to Austrian and German customs in these
matters. The translator has not attempted to adapt the following
pages to the needs of English readers, as he feels that the general
principles already given will enable the English medical man to
construct without serious difficulty suitable diet-tables for the
cases with which he has to deal.
Suitable articles of food are the following:
Soups, Broths, and other Liquid Foods: Soups and broths made from the
flesh or bones of beef, mutton, veal, chicken, or pigeon, _without_ the
addition of meat extract, or of meat juices, peptones, somatose or
nutrose, but _with_ _t_he addition of barley, oatmeal, rice, wheatmeal,
ryemeal, peas, beans, lentils, vermicelli, or macaroni; also broths or
porridge made from any kind of ground cereal, or from potatoes, or from
peas, beans, or lentils.
Flesh Foods: Lean beef, veal, mutton, roast or boiled, pigeon, chicken;
certain fresh fish—pike, haddock, sole, perch, and trout. _Unsuitable_
are: pork, goose, eels, salmon, herrings, oysters, caviare, lobster,
crab, smoked meat, hare, venison, wild-duck, brain, liver, kidneys.
Vegetables, Sweets, and Savouries: Green peas, spinach, cauliflower,
carrots, turnips, buttered eggs, omelette, boiled and baked puddings,
rice boiled in milk, apples and rice, whipped cream, salads, wheaten
bread, French rolls, biscuits, and rusks.
Fruits: Almost all fruits may be taken, raw, cooked, or preserved; also
in the form of currant and other fruit cakes, and as fruit-ices.
Beverages: Milk, buttermilk, water, the same acidulated with various
fruit-juices and essences (as lemonade, etc.), weak tea with plenty of
milk, cocoa, chocolate. To be _forbidden_ are: beer, strong and sweet
wines, distilled spirits.
An example is subjoined of a simple diet-table compiled on the above
principles:
_Quantity _Albumen._ _Fat._ _Carbohydrate._
in grams._
AFTERNOON:
A cup of milk 150 5.4 5.4 7.5
Roll and butter 70 4.9 0.4 39.2
MIDDLE OF MORNING:
Soup 100 1.1 1.5 5.7
Roll 70 4.9 0.4 39.2
MID-DAY MEAL:
Soup 100 1.1 1.5 5.7
Roast meat 100 38.2 1.7
Green vegetables 100 1.6 0.4 8.4
Pudding 200 17.4 30.0 57.8
Fruit 100 3.0 15.0
Bread 35 2.4 0.2 19.0
BREAKFAST:
A cup of milk 150 5.4 5.4 7.5
Roll 70 4.9 0.4 39.2
SUPPER:
Soup 100 1.1 1.5 5.7
Two soft eggs 90 11.2 10.8 0.4
Bread 70 4.9 0.4 39.2
Fruit 100 3.0 15.0
————— ————— ———— —————
Total 1,617 110.5 69.9 304.5
===== ===== ==== =====
In addition, water, _ad libitum_, and perhaps a little light wine.
In many cases, however, a mainly vegetarian diet may be more suitable,
and more particularly a mainly fruit diet, in order to diminish
persistent congestive symptoms. In such cases the following diet-table
may be recommended for _short_ periods:
First breakfast: An apple and an orange.
Second breakfast: 25 grams of white bread with butter and three baked
apples.
Dinner (mid-day): 100 grams fish or meat, potatoes, green vegetables, 3
boiled or baked apples.
Afternoon: An orange, or an apple, or a pear, or some grapes.
Supper: Milk, apples and rice, oranges, grapes, figs.
Beverages: Water, with or without fruit juices or essences.
Changes in the above diet-table could very readily be effected, whereby
the quantity of carbohydrate could be increased and the quantity of
albumen lessened.
In women of sanguine temperament and full habit of body, who at the time
of the menopause very rapidly become obese, important changes in the
diet become necessary. The main principles of a fat-reducing diet are
the following: Avoidance of all overfeeding, reduction of the quantity
of food taken below the former average amount, with retention, however,
of a sufficiency of nutrient material to maintain the metabolic
equilibrium of the essential tissues; the maintenance of this metabolic
equilibrium demands a sufficiency of nitrogenous foods, but the fats in
the diet may be reduced to a minimum, and the carbohydrates may also be
very greatly diminished. At the same time, there must be systematic
bodily exercise, and the hours of sleep must not exceed a nightly
average of seven.
For obese women at the climacteric period, a suitable average diet would
contain 160 grams albumen, 12 grams fat, and 120 grams carbohydrate,
yielding a daily heat-equivalent of 1,250 to 1,300 calories.
A sample diet-table constructed on these principles is appended:
_Quantity _Albumen._ _Fat._ _Carbohydrate._
in grams._
BREAKFAST:
A cup of weak 150 0.45 0.9
tea
With milk, but 30 1.29 0.9 1.2
no sugar
White bread 50 4.8 0.4 30.0
Lean cold meat 50 19.1 0.9
DINNER (Mid-Day):
Small cup of 100 1.1 1.5 5.7
clear soup
Lean beef 200 76.4 3.4
Green 100 1.6 0.4 8.4
vegetables,
salad, etc.
Fruit 100 3.0 15.0
Roll 35 2.4 0.2 19.6
AFTERNOON:
A cup of weak 150 0.45 0.9
tea
With milk, but 30 1.29 0.9 1.2
no sugar
SUPPER:
Soup 100 1.1 1.5 5.7
Lean roast meat 100 38.2 1.7
Roll 50 4.8 0.4 30.0
————— ————— ———— —————
Total 1,245 155.9 13.2 118.6
===== ===== ==== =====
In the selection of individual articles of diet, it is important to bear
in mind the fact that in all climacteric women it must be our aim to
stimulate intestinal muscular activity (peristalsis) and intestinal
secretion to a moderate extent, for by more active intestinal secretion
abdominal congestion is to some extent relieved, and by intestinal
transudation and by diminution of the lateral pressure the circulation
through the abdominal vessels is facilitated. By thus lowering the
intra-abdominal blood-pressure, we shall assist in relieving a number of
chronic hyperaemic states of the pelvic and various other organs, from
which women are prone to suffer at the menopause. Hence all articles of
diet must be forbidden which have a tendency to give rise to
constipation. But we must also forbid all substances which leave
extensive undigested residues, such as the rinds of fruits, large
quantities of porridge, etc., hard meats, nuts, and the like. Most
suitable are those articles of diet which contain large percentages of
fluid constituents, such as milk, thin soups, weak tea (infused only a
short time, so as to contain little tannic acid, which is very
constipating), white meat—veal, breast of chicken, etc. Of vegetables,
those are best which contain plenty of water and an abundance of the
organic acids, young, fresh garden produce, lettuce, cauliflower, young
green peas, young carrots, turnips, etc. Juicy fruits are good, apples,
pears, cherries, and plums. Butter and honey are also excellent. In many
persons suffering from constipation, all that is necessary for their
relief is to give a tumblerful of cold water the first thing in the
morning; with others, the use in addition of whole-meal bread with
plenty of butter and honey and uncooked fruit, is required.
In women suffering from the various disturbances of the climacteric
period in an aggravated form, either because the menopause occurs at an
unusually early age, or because the suppression of menstruation has
taken place suddenly instead of gradually—especially in cases of
heart-trouble, severe vertigo, pronounced vasomotor disturbances, or
mental excitement (also erotic excitement), I have sometimes found a
methodical milk-cure carried on for several weeks most beneficial. By
this I do not mean an exclusive diet of milk, but a diet consisting
chiefly of milk and milk-foods; owing to the absence of all irritation
of the nervous and vascular systems, this diet has a very definite
sedative influence in such cases. The milk should be skimmed, and should
be given four times daily in gradually increasing quantities, the total
amount rising from ten ounces to fifty ounces daily. The only other meal
should be a substantial mid-day dinner, consisting of soup, roasted
white meat, young green vegetables, and a little fruit. In some
instances, to prevent constipation, it is necessary to add ten grams of
milk sugar to each glass of milk; in other cases it is necessary to
dilute the milk with water. It is obvious that the quantity of milk
given is not alone sufficient to maintain the metabolic equilibrium of
the body; but the defect in this respect is made up by the substantial
meal given at mid-day.
Among the stimulating influences which during the sexual epoch of the
menopause are as far as possible to be avoided we must unhesitatingly
include the practice of coitus, inasmuch as at this time of life there
already exists a strong tendency towards the occurrence of hyperaemia of
the reproductive organs; and sexual intercourse, increasing as it
inevitably must this tendency to hyperaemia, should be indulged in as
little as possible. And yet precisely in women of the climacteric age,
in “la femme demi-vieille” there often exists a strong desire to drain
the cup of sexual pleasure to its dregs. Not infrequently, therefore,
the physician is asked to advise regarding the proposed marriage of a
woman in whom the menopause is drawing near, the desired husband being
young, or at least still fully virile. If the advice is given in all
sincerity with a sole eye to the woman’s health, the medical man will
definitely forbid the marriage.
When, however, the changes of the menopause are fully completed, when
the woman’s reproductive organs have undergone complete senile atrophy,
there is no medical reason why a couple who wish to give a tenderer name
to an intimate friendship between man and woman, should refrain from
marriage—provided that both have attained a like stage of sexual
decline. “But,” writes _Tilt_, “a union between frosty January and
blooming May is likely to be as dangerous to the health as it is to the
happiness of both.”
Whilst attending to the regulation of the physical diet of his
climacteric patient, the physician should not overlook her psychical
regimen. A woman’s mind is very powerfully affected by the processes of
the menopause. On the one hand, her fears are stimulated by the thought
that she is entering upon the “critical age,” of whose dangers she has
often been warned; and, on the other hand, she is mentally depressed by
the knowledge that she is about to lose the charms of womanhood, and to
decline in sexual esteem. It is well, therefore, for women during the
years of change, to have some kind of employment, which fills their
hours, occupies their thoughts, and—leaves a certain scope for the
exercise of feminine vanity. Works of benevolence or of general utility,
and literary occupations, are thus of great advantage to climacteric
women. _Plato_, indeed, pointed out that women at this time of their
lives should occupy themselves with literature and intellectual culture.
Just as it is the duty of the physician, more especially of the family
physician, to enlighten the maiden on the threshold of her sexual
development regarding the processes of the awakening sexual life, and to
give her the necessary instruction concerning the hygienic measures
which it is proper for her to adopt—so also is it his duty to convey
medical information to the woman who stands on the threshold of sexual
decadence. A woman’s ignorance is often equally profound at both these
epochs of the sexual life. A woman in the early forties often does not
suspect, or at least refuses to acknowledge, that she is gradually
drawing near to the end of her sexual life; and she is still farther
from the knowledge that definite rules of general and sexual hygiene
must be observed by her if she wishes to minimize the dangers of the
critical period.
The medical friend, in an earnest though far from gloomy manner, will
expound to her the nature of the physiological processes of the
menopause, and will instruct her regarding the corresponding preventive
measures—diet, exercise, clothing, care of the skin, and the regulation
of sexual intercourse. Moreover, the physician, by means of skilfully
directed enquiries regarding certain symptoms, will be enabled to gain
early information about the occurrence of abnormal processes at this
period of life, and will in this way detect the first beginnings of many
diseases which are amenable to treatment only at the very outset of
their course. For example, _Brierre do Boismont_, an early and accurate
observer of this sexual epoch in the life of woman, points out that in
cases in which, during the change of life, a woman experiences an
increased inclination for sexual intercourse, nineteen times out of
twenty, a local examination will disclose the existence of some disease
of the reproductive apparatus. Similarly, every gynecologist is now
familiar with the fact that unusually free, atypical haemorrhages during
the climacteric period, are commonly indications of the existence of a
uterine neoplasm.
Much evil may be avoided, and much suffering can be diminished if the
physician, in accordance with the advice of Hippocrates, does not limit
his activities strictly to the exercise of the healing art, but stands
by a woman’s side as her mentor and confidant during the troublesome
years of her sexual decline. And he will best fulfil these functions, if
he succeeds in convincing the climacteric woman of the profound truth
embodied in the saying of the great French philosopher:
Qui n’a pas l’esprit de son âge,
De son âge a tout le malheur.