The Four Epochs of Woman's Life - Chapters XIV-XVI



PART IV. -- THE MENOPAUSE.

CHAPTER XIV.
THE MENOPAUSE.
Average Duration of the Menstrual Function; Duration of Menopause; the 
Menopause; General Phenomena of the Menopause; Prominent Symptoms of 
Menopause; Pathologic Conditions of the Menopause; Hemorrhage at the 
Menopause a Significant Symptom of Cancer; Causes of Suffering at 
Menopause.

"Yet I doubt not through the ages one increasing purpose runs, 
 And the thoughts of men are widened with the process of the suns. 
 Knowledge comes, but wisdom lingers, and I linger on the shore, 
 And the individual withers, and the world is more and more. 
 Knowledge comes, but wisdom lingers, and he bears a laden breast, 
 Full of sad experience, moving toward the stillness of his rest." 
-- "Locksley Hall."

Average Duration of Menstrual Function.-- The average duration of the 
menstrual function is from thirty to thirty-two years. Raciborski 
estimated the duration of menstrual life at about thirty-one years and 
nine months. According to him, the mean age of puberty at Paris was 
fourteen years and seven months; therefore, the average age of the 
menopause was forty-six and one-half years. Tilt gives the average age of 
the cessation of menstruation in 1082 cases as forty-five years and nine 
months. The average age is between forty-five and fifty years. It has been 
shown by Krieger, Kisch, and others, that the earlier the menses appear, 
the later they cease, and vice versa. However, when the first period is 
unusually early or late, the menopause comes very early. Also that the 
sexual function is usually abolished earlier in the laboring classes, who 
are compelled to work hard and who have many cares, than in the well-to-do 
and rich. 

Race does unquestionably influence the duration, but given a sound healthy 
race, which is not too much enervated with civilization, and the menstrual 
process will, equally with the total physical vigor and the vitality, be 
increased. At the present day there is an increased sexual vitality, which 
shows itself in the fact that the duration of menstrual life has been 
increased three to four years during the past generation. The inference 
can be fairly deduced that vigorous vitality causes prolongation of the 
menstrual process and the actual age. 

Duration of Menopause.-- By the menopause or climacteric is understood the 
whole period from the beginning irregularities in the time of appearance 
of the menstrual flow until its actual cessation. The average duration of 
the menopause is from two and a half to three years. 

The Menopause.-- The menopause is a physiologic and conservative process. 
It occurs at a time of life when all the tissues are most stable and the 
nutrition of the body is at its best. Other physiologic changes which 
occur at the same time are decrease in the size of the spleen and 
lymphatic glands, the muscular coats of the intestine atrophy, and 
lessened peristalsis ensues; hence the increased tendency to constipation. 
These are not the degenerations of age, but the blood-supplying, blood-
making, and blood-elaborating organs of the body have completed the growth 
of the organism, done their work, and are striking a balance with the 
needs of the economy. 

The object of each metamorphic or developmental epoch is a critical 
readjustment of the organism, in order to insure the greatest possible 
amount of health for each subsequent period of life. In the vast majority 
of cases this object is quietly effected, but sometimes the constitution 
only rallies after having been severely shaken for a varying period. 

General Phenomena of the Menopause.-- Borner states that while many women 
pass this period without noting any change in their former condition, and 
are conscious of the occurrence of the change of life only by reason of 
the absence of the menstrual flow, others suffer for years with a host of 
troubles. 

One of the most essential changes is that of the woman s psychic 
condition-- from slight vagaries, loss of interest in the daily affairs of 
life, to melancholia and insanity. 

"Two factors are generally taken into account: first, the sudden cessation 
of the menses; second, the reflections of the patient caused by her 
condition, meditations on the loss of youth and sexual power, and anxiety 
in view of the dangers of the climacteric. It cannot be denied that there 
is some truth in the supposed sad thoughts about the beginning of old age, 
and the depression caused by them can scarcely be considered abnormal" 
(Borner). 

Napier believes that it is extremely rare for the cessation to occur 
without some physical discomfort or some disturbance of the nervous 
system, but adds that: "Some women, however, cease menstruating with very 
slight inconvenience." As a rule, the woman misses one, two, or more 
periods, then a menstruation of almost normal quantity and duration; and 
this is again repeated at gradually longer intervals, and with a 
diminished flow, until actual cessation occurs. 

The periods cease owing to the degeneration and disappearance of the 
glandular tissues of the uterus, and secondarily to similar changes in the 
ovaries and other glands. This is followed by an atrophy of all the 
structures of the genitalia. 

An increase in the size of the uterus, from increase in the amount of 
blood, is frequently noticed at the beginning of the menopause; later it 
becomes smaller in all its dimensions. The wall becomes thinner; the 
cervix becomes shorter and thinner, sometimes hard, sometimes flabby as a 
membrane. But the distinguishing feature of the menopastic uterus is 
atrophy of its lining membrane. 

The changes in the uterus and Fallopian tubes are earlier than those in 
the ovaries, so that ovulation, though lessened in activity, may persist 
for a considerable time after menstruation has ceased. Ovarian atrophy has 
been referred to senile rather than menopastic changes. 

Atrophy of the ovaries occurs very gradually. Peuch found that in one case 
the ovaries were of normal size three years after the establishment of the 
menopause. Kiwisch describes the structural change in this gland as 
consisting, on the one hand, of an increase of the connective-tissue 
stroma; and, on the other hand, the Graafian vesicles themselves undergo 
retrograde change. In consequence of these microscopic changes, which take 
place very slowly, the entire organ becomes harder and smaller. 

Napier believes that the ovaries secrete specialized substances which aid 
in determining menstruation; and that in a less degree the utricular 
glands and the glands of the Fallopian tubes share in this action. He 
considers that this is probably secondary to the chain of peripheral 
irritation from the uterine glands, but that this secretion is none the 
less an essential feature of the menstrual process. 

In support of this view he calls attention to the pigmentation of the skin 
which occurs during pregnancy and chlorosis, showing that the absence of 
the catamenia results in the retention in the blood of some substance 
which would normally be excreted at this time. 

Other atrophic changes in the genitalia are shriveling of the vulva, with 
prolapse of the vagina or uterus from relaxation of the ligaments and loss 
of the natural support afforded by the changed perineal body. 

Uterine catarrh occurs almost invariably, and only ceases in advanced 
years. Displacements of all kinds are frequent, but on account of the now 
greatly diminished weight of the uterus, these are insignificant. 

The vagina is at first almost always hyperemic, but this disappears as the 
vessels successively atrophy. The vagina gradually becomes narrower and 
shorter. The mucous membrane loses its rugae and presents a pale, grayish, 
blanched hue. 

The researches of Byron Robinson, made by the dissection of a number of 
old women, show that after the menopause not only is there an atrophy of 
the genital organs, but that the hypogastric plexus of the great 
sympathetic nervous system also shrinks away. "It becomes smaller and 
firmer, and no doubt some strands disappear. On this fact must he based 
the pathologic symptoms accompanying the cessation of the menstrual 
function." 

The importance of the genital organs is shown by the vast nerve-supply 
sent to them. When this great nerve-tract becomes atrophic, so that it can 
no longer transmit the higher physiologic orders, all parts of the 
sympathetic system must be unbalanced, until a new line, the next line of 
least resistance is established. And Robinson believes that this is the 
explanation of the many pathologic manifestations of every viscus at the 
menopause; that is, "the irritation which arises by trying to pass more 
nervous impulses over plexuses than normal gives origin to what is 
unfortunately known as functional disease. It is just as organic as any 
disease, only we are unable to detect it." 

Chemical changes in the blood and tissues are constant vital phenomena; 
increased oxidation causes increased activity of the circulation, increase 
of temperature, increase of urea and carbonic acid in the economy from 
retrograde changes, and, finally, during menstrual life the flow of blood 
from the uterus carried off the effete materials from the highly charged 
system. 

The elimination of albuminoids, as shown by the altered condition of the 
blood after menstruation, is greater than can be accounted for by the 
blood discharged. When the menopause is attained suddenly, the retention 
of such albuminoid substances must act toxically. Hence the resulting 
clinical fact that sudden cessation of the menses is, in the majority of 
cases, attended with pronounced symptoms of discomfort, and it is in these 
cases that untoward results are most likely. 

James Oliver believes that the catamenial flow eliminates from the body 
substances whose presence in the blood would exert a deleterious influence 
on the animal economy. 

The Prominent Symptoms of the Menopause.-- Christopher Martin holds that 
the symptoms of the change of life are produced largely by a condition of 
instability and increased excitability of certain other cerebrospinal 
centers directly brought about by failure of the menstrual center, and 
adds: "It is probable that the ovaries, like the liver and thyroid gland, 
modify the blood circulating through them, and add to the blood some 
peculiar product of their metabolism. It may be that some of the 
climacteric symptoms are due to the loss of this substance from the 
system." 

Arthur Johnstone's theory of the symptoms of the menopause is that the 
lining membrane of the uterus atrophies and becomes old cicatricial 
tissue, and sinks into quiet decay. The nervous system begins to readjust 
itself; but no longer having free outlet through the soft, lymphoid 
tissues of the uterus, the wave pressure meets with resistance and a 
choppy sea results. Vertigos, bilious attacks, and so forth are nothing 
more than reflex waves. The weakest organ of the individual is the one 
that generally suffers. And that the kidneys, which all along have borne 
the brunt of life, should now show positive signs of disease is natural. 

The etiology and pathology of the menopause lie in the sympathetic nervous 
system. And it is by the breaking up of the harmony of previous processes 
that nervous disturbances are produced. 

After the cessation of the flow, over 8% of women suffer from "flashes"; 
this symptom is caused by irritation of the heart and vasomotor centers. 
The blood-vessels of the head and neck seem to be most affected, yet the 
skin of the whole body shares in the disturbance. Besides the vasomotor 
and heat center being disturbed, the sweat center is irritated. The 
flushes and flashes are followed by various degrees of sweating, which 
varies from a slight moisture to great drops. 

Nervous irritability is a prominent symptom in 8% of women at the time of 
the menopause. Most of the pain arises around the stomach; that is, the 
solar plexus. Digestive disturbances are very common at this time; they 
may be in the shape of fermentation, diarrhea, or constipation, 
accompanied by congestion of the liver. 

Tilt holds the very plausible view that the too strong reaction of the 
sexual organs on the central ganglia of the sympathetic nervous system is 
their principal cause of disease. Puberty, menstruation, pregnancy, 
lactation, or the menopause almost always entail some derangement of this 
system which is sometimes sufficiently severe to lead to insanity and 
suicide. Debility underlies all affections of the sympathetic nervous 
system, in the same way as nervous irritability underlies all cerebral 
diseases. Sometimes there is an overpowering sense of exhaustion pervading 
the whole system. 

Forms of climacteric insanity are delirium, mania, hypochondriasis, 
melancholia, irresponsible impulses, and the perversion of moral 
instincts. 

"If the reproductive apparatus does not act on the brain by the 
instrumentality of the circulating organs of the blood, it must do so by 
means of the nerves. The genital apparatus is richly endowed with nerves 
from the sympathetic system, and I have shown how frequently evident signs 
of disturbance in these centers coincided or alternated with headaches, 
nervousness, hysteria, and epilepsy. What wonder, then, if the same 
powerful influence of the sexual organs, through the instrumentality of 
the sympathetic system, should at times produce a permanent derangement of 
the mental and moral faculties. I am thus led to look on the sympathetic 
nervous center as a source of vital power producing reflex morbid 
phenomena, in accordance with variable cerebral predisposition" (Tilt). 

Another very frequent symptom of the menopause is distress in the region 
of the heart, with palpitation and shortness of breath. It may be caused 
by the condition of the blood, whether it be impoverished-- anemia-- or 
too rich in red globules; by reflex irritation of the pneumogastric or 
sympathetic nerves; by overexertion; or by alcoholism. It may also be due 
to general debility; the woman resists fatigue less easily, and she 
experiences a general malaise. To the palpitations are rapidly added 
faintness and shortness of breath. The sleep is troubled with distress in 
the region of the heart. It is said that women in whom the menopause 
occurs early are more liable to tachycardia than those who menstruate 
later in life; and that it occurs with especial frequency when the 
menopause has been prematurely induced by surgical operation or by 
disease. It is believed that this functional heart trouble is caused by 
the increased connective-tissue fibers of the sexual organs acting in some 
unknown way on the terminal fibers of the sympathetic; and it is not 
infrequently due to the formation of scar tissue at the seat of a cervical 
laceration, and has often been promptly and permanently relieved by 
removing the cicatricial tissue and suturing the wound. The cause acts by 
producing a transitory paralysis of the inhibitory fibers of the 
pneumogastric nerve. 

Pathologic Conditions of the Menopause.-- Perhaps the most alarming 
symptom of the menopause is hemorrhage. It may be due to general or local 
causes. Among the general causes are diseases of the heart, lungs, spleen, 
and kidneys. Local causes of hemorrhage are: inflammation of the lining 
membrane of the uterus, chronic pelvic inflammations, faulty uterine 
positions, erosions and ulcerations of the mouth of the uterus, fibroid 
tumors, and cancer. All competent observers agree that cancer in women is 
much commoner from forty to fifty years than at any other age. 

Hemorrhages occupy the foremost place among the pathologic phenomena of 
the genital tract during the menopause. Hemorrhage has been attributed in 
many instances to the senile rigidity and friability of the uterine 
vessels, which are not in a condition to offer sufficient resistance to 
the blood-pressure which is brought to bear on their walls; there is also 
softening and relaxation of the uterine tissue. Additional causes are 
found in the circulatory disturbances in the pelvic organs, whereby the 
outflow of blood from the pelvic vessels is hindered a chronic congestion 
in the uterine vessels is produced. It has also been attributed to early 
and profuse menstruation, frequent and difficult labors, frequent 
abortions, and excess in drinking. 

The third and last variety includes those cases which may be referred to 
some disease of the pelvic organs themselves. Anatomic changes may lead up 
to pathologic conditions. A chief feature characteristic of uterine 
disease is malnutrition from atrophy-- a sudden curtailing of the blood-
supply from the degeneration of the genital-nerve apparatus and consequent 
impaired vitality of tissue from defective nourishment. The anatomic 
changes in the glands and substance of the uterus also favor the 
irritation, and the development of new growths, which may be malignant or 
benign-- as cancers, fibroid growths, and so forth. 

Hemorrhage at the Menopause a Significant Symptom of Cancer. -- Not only 
should any excessive and prolonged bleeding at the time of the menopause 
be a source of great anxiety to the woman, but even the irregular 
appearance of a slight show of blood just sufficient to keep the clothing 
stained, or a slight bleeding following coition; since all of these are 
symptoms of very great gravity, and demand an immediate local examination 
and appropriate treatment. 

The widespread belief among the laity that hemorrhage at the time of the 
menopause is a normal condition, and that if left alone it will stop in 
the course of a few years, is most erroneous and fatal. On this altar of 
ignorance thousands of women sacrifice their lives every year. The case-
book of any gynecologist will testify to the truth of this statement. The 
following three cases will serve to illustrate different types of 
hemorrhage in cancer patients, in no one of which did the patient even 
suspect that she was suffering from anything more serious than the 
"vagaries of the menopause." 

Case I.-- Woman aged seventy years; came on account of incontinence of 
urine, which had been troublesome for two years. The menopause occurred at 
fifty. She stated that three or four years previous to her visit, she had 
had a return of the flow of blood, perhaps twice in the first year, and 
that during the past year there had been a flow every month-- about the 
same that there used to be. This she took to be a return of the menstrual 
period. She said, further, that there was a constant bleeding-- enough to 
necessitate the wearing of a napkin-- and an occasional severe hemorrhage; 
that she could not take long walks or drives because of the excessive flow 
which followed. 

The case was one of cancer of the uterus which had spread to all the 
pelvic viscera; and in addition to this, the patient's general condition 
was such that any operation was out of the question. Yet the patient had 
never thought of the possibility of any uterine trouble sufficiently 
serious to make a local examination necessary. It was only the loss of 
control over the bladder that drove her to seek a physician's advice. 

Case II.-- Woman aged fifty-three years came to consult me because of 
pain, hemorrhage, and loss of weight. There had never been any cessation 
of the menstrual period. She said that she began to have irregular 
hemorrhages three years previously, and that they were constantly becoming 
more frequent and more alarming, and that, in addition to this, there was 
a constant discharge of blood, which necessitated her wearing a napkin all 
the time. She also stated that for the preceding six months the pain had 
been so severe that she had not had one solid night's sleep, and that in 
that time she had lost forty pounds in weight. 

This patient was in the very last stages of cancer of the uterus, and all 
that could be done for her was to make her comfortable. She had given 
birth to one child which caused a deep tear of the neck of the womb; and 
it is probable that this neglected tear was the primary cause of the 
cancer, which began in the neck of the womb. 

Case III.-- Woman aged forty-five years; married, but had never had any 
children. She said that the periods were normal as to duration and amount, 
but that for the past two years they had two days ahead of time, and that 
for the past four months she had been having just enough irregular 
bleeding between the periods to keep her clothing stained. 

On examination a diagnosis of cancer of the uterus was made. The 
pathological examination proved this to be a most malignant type of cancer 
of the neck of the womb. The entire uterus and appendages were at once 
removed. And although the patient made an excellent recovery from the 
operation, she succumbed to the disease one year after the operation was 
performed. 

These cases have been cited at length because they are all typical and 
because of the variety of symptoms and the great difference of age. Only 
in one of the cases was there any very severe pain, and it was really the 
pain, which had become unendurable, which caused the patient to seek 
relief. 

It is the concensus of opinion of the medical profession that cancer of 
the uterus is one of the common causes of death among women; that the 
cancer rate of mortality has increased during the last four decades; that 
it is most common near the time of the menopause; and that there is a 
direct causal relation between cancer of the neck of the womb and the 
traumatisms which occur during childbirth. 

The symptoms of cancer of the uterus are hemorrhage, a more or less 
offensive discharge, and pain. The quantity of blood may vary from a 
slight amount which occasionally stains the clothing to a profuse 
hemorrhage. In the married, bleeding following coition is always a 
suggestive symptom. During the menopause any irregular or profuse bleeding 
should excite suspicion. After the cessation of the menopause any bleeding 
whatsoever, whether slight or profuse, should always be regarded as a 
danger signal which demands an immediate and thorough local examination. 
The same is true of any offensive vaginal discharge. Pain is frequently so 
late a symptom that to wait for its appearance means that the favorable 
time to perform an operation has passed by. Emaciation is also a symptom 
of advanced disease. 

Cancer is chiefly a disease of the climacteric; when there is a diminished 
power on the part of the tissues to resist adverse influence. It affects 
the debilitated and overworked, but it is also found in the well nourished 
and in the comparatively young. 

Cancer always begins as a local disease, and when it occurs in the uterus, 
it is easily accessible and eradicable in its earliest stages; that is, if 
the disease is discovered in its incipiency, an operation will remove all 
the diseased tissue. If, on the contrary, the disease is left to nature, 
the growth spreads out into the surrounding viscera like the roots of a 
tree in the earth, and the cancer may be literally said to eat into the 
tissues which it invades. At the same time the germs of the disease begin 
to be carried all through the body, and the entire constitution is 
affected. 

Prophylaxis, or the Prevention of Cancer.-- All pelvic inflammations 
should be promptly treated, and not allowed to become chronic. Leucorrhea 
is a symptom of inflammation, the true cause of which can be determined 
only by local examination. Women who have given birth to children-- and 
this is more especially necessary as they near the age of forty years-- 
should be carefully examined for tears of the neck of the womb. If these 
tears are extensive they should be repaired, as it is certain that 
malignant growths frequently do follow local injuries and traumatisms. 

Any irregular or profuse bleeding demands an immediate investigation by 
means of a local examination. 

A stormy, irregular, or delayed menopause should excite in the woman a 
suspicion of some abnormal condition. 

The importance of women being carefully watched by gynecologists at this 
period of their lives cannot be too emphatically stated, for upon the 
early recognition of cancer depends the only hope of radical cure of the 
disease. It is estimated that at the present time not less than 95 per 
cent. of all cases of cancer of the uterus come under the observation of 
the profession at a stage of the disease when all prospect of permanent 
relief is out of the question. 

It is a deplorable state of affairs that women, not knowing what a normal 
climacteric is, attribute all hemorrhages, no matter how severe, to the 
change of life. Therefore, regarding the hemorrhage as a necessary evil, 
they fail to consult a specialist until the favorable time for eradicating 
the disease by means of an operation has passed. And whatever knowledge 
science may bring in the future as to the cure of cancer, at present it is 
a fact universally agreed upon that early operation, while the cancer is 
still local, is the only radical cure for the disease. 

Pruritus Vulvae. Perhaps one of the most annoying and obstinate symptoms 
of the menopause is pruritus vulvae. This is sometimes caused by sugar in 
the urine; there is a congestion of the liver which results in sugar being 
thrown into the system and this is eliminated by the kidneys. It is quite 
possible that this is due to the altered circulatory conditions of the 
menopause. 

Kidney Disease.-- The last pathologic condition which we will mention is 
kidney disease. Le Gendre believes that the menopause exerts a deleterious 
effect on the kidneys, whether this be a congestion, followed by a 
diminution in the quantity of urine, or a sort of auto-intoxication due to 
the retention of a poison in the system that has been prevented from 
leaving by the ordinary path. 

Armstrong says that in almost all cases at the time of the menopause the 
amount of urine passed is below normal, the specific gravity is increased, 
and that the urine contains urates and almost always uric acid in excess. 
Further, that the functions of digestion and assimilation and the various 
metabolic changes are so largely under the control of the nerve-centers 
that nothing seems more likely than that so great a disturbance of that 
system as takes place at the menopause should cause secondary derangements 
of these most important functions. That being so, the blood becomes loaded 
with waste products, and the usual symptoms follow-- gout and so forth. 

It has been a grave question in the mind of the medical profession whether 
the dangers that certainly do attend the menopause are natural or 
acquired; that is, could these dangers be averted by any precautions or 
hygienic measures on the part of women, or are these dangers a necessary 
accompaniment of this period of life? 

Tilt has reached the conclusion that: "The best way to avoid the dangers 
of this critical time is to meet its approach with a healthy constitution. 
A marked want of strength prevents the regular succession of the vital 
phenomena by which all critical periods are carried on. And as the change 
of life is marked by debility, when this is grafted on constitutional 
weakness, loss of power will be of long duration. All complaints remain 
chronic because there is not stamina enough to carry them through their 
stages." 

Causes of Suffering at Menopause.-- Dusourd, whose practice lay in an 
agricultural district in the south of France, as well as Tilt, believes 
that peasant women suffer little at this time. Their health is generally 
good when the menopause comes on and they are little liable to nervous 
disorders. The poor of large towns suffer much at this epoch-- the 
necessity of working hard, the anxieties of poverty and their unhygienic 
surroundings. But by a fortunate compensation the necessity for working 
hard prevents or cures the nervous affections which so often assail the 
rich at this period. 

Tilt's cases showed that women who suffered much at the menopause had 
previously suffered at puberty and at the menstrual periods. And among 
thirty-nine cases where there was no suffering at the menopause, there was 
the same immunity from suffering at puberty and at the menstrual epochs. 

Tilt's statistics were, or course, taken from English women. In forty-four 
cases of my own, all women past the menopause, the average age of the 
first menstruation was fourteen years and four months; and the average age 
of the actual cessation of the menstrual flow was forty-eight years and 
five and two-thirds months. Subtracting from this the average age of the 
first menstruation, we have as the mean age of menstrual life thirty-four 
years one and two-thirds months; that is, the average duration of the 
menstrual function was from two to four years longer than that usually 
given. 

A further investigation in order to ascertain any possible relation 
between the age of marriage and the number of pregnancies and the 
sufferings of the menopause elicited the following statistics. The average 
age of marriage was twenty-five years and ten months. Of the four women 
who were married after thirty-eight years, all were sterile; among the 
remaining there was an average of slightly above three children each. 
Forty per cent. of all these cases had one or more miscarriages. Nine had 
habitually suffered from severe dysmenorrhea, eleven had slight 
dysmenorrhea, and twenty-two had never felt the slightest inconvenience. 

In a list of fifty-two cases, eight were added to the list already given, 
all of whom had passed the menopause. Five were perfectly healthy and had 
never suffered the slightest inconvenience. Of these, one was single and 
only one had one miscarriage. Ten had suffered at the time of the 
menopause from slight malaise, but not sufficiently to call in a medical 
attendant. Thirty-seven were more or less seriously ill; thirty of these 
needed local as well as constitutional treatment, and seven constitutional 
treatment only. 

The prominent symptoms of the climacteric were as follows: Marked 
debility, 24; intense nervousness, 31; nervous prostration, 9; 
melancholia, 10; headache, 14; neuralgia, 6; hysteria, 7; irritable heart, 
11; tachycardia, 8; insomnia, 19; indigestion, 32; constipation, 28; 
diarrhea, 3; leucorrhea, 38; rheumatism, 21; gout, 1; Bright's disease, 
12; hemorrhage, 6; alcoholism, 2; corpulency, 2. 

As a result of the study of these cases, the most striking feature was the 
relation of miscarriages to the sufferings and ill health at the time of 
the menopause. Of the nineteen women who had miscarriages, only one did 
not suffer in some way at the time of the menopause. Four suffered only 
slightly, and fourteen suffered extremely, not only during the menopause, 
but in the post-climacteric period as well. And the next most striking 
feature was that the prominent symptoms of the menopause are preeminently 
reflex or the functional diseases of the nervous system. 

Tilt believes that single women suffer less than other women at the time 
of the menopause. He further writes: "As at puberty, from the ignorance in 
which it is still thought right to leave young women, so at the change of 
life, women often suffer from ignorance of what may occur, or from 
exaggerated notions of the perils which await them. It would be well if 
they were made to understand that if in tolerable health, provided that 
they will conform to judicious rules, they have only blessings to expect 
from the change of life. Most unfortunately, the individual not cognizant 
of the invisible changes going on in the economy does not adapt the mode 
of life to the new conditions of the organism, and the weakened and 
lessened amount of the digestive fluids is unable to master the large 
quantities of food. The absorbents refuse to take more than is needed to 
repair the tissues. The atrophying muscles of the digestive tube, unable 
to hurry on the mixed products of indigestion; fermentation; and micro-
organisms inciting fermentations and elaborating toxic alkaloids, poison 
and disorder the functions of life. Man's outdoor life enables him to 
escape many of these evils. 

"Woman's enervating mode of life, the continued introspection, coupled 
with the peculiar changes in the nutrition of the body at this time, 
render the nervous system peculiarly impressionable and liable to the 
manifold forms of diseases. 'The woman is told that she must be calm and 
patient, and in time the tomb-builder will alleviate all her sufferings.' 
This critical period may be dangerous to those who are always ailing, for 
habitiual sufferers at the menstrual periods, and for those affected with 
uterine diseases. If, on the first indication of the change of life, women 
who are in fair health carefully followed a regimen and pursued a line of 
life in harmony with the physiologic processes on which this change 
depends, disease would be prevented. But as the change concerns a natural 
function, it is left to nature; no additional precautions are taken, and 
advice is sought only when the mischief is done." 

It is not wise to marry during this period. On the first appearance of the 
irregularities of the menopause the amount of food and stimulants to which 
women have been accustomed should be curtailed rather than augmented. The 
system requires supporting by medicine and regimen-- as, baths, mental and 
moral hygiene, and occupation-- rather than stimulating by spirits. 

We have seen that, in accordance with the plethric theory, which prevailed 
until 1835, and with the nerve theory, which is based on the latest 
anatomic and physiologic researches, menstruation is a physiologic process 
to get rid of effete material, and is therefore an excretion. 

At the end of perhaps thirty years, by a conservative process of nature, 
the child-bearing period ceases and the organism is readjusted to the end 
that the woman's vitality may all be conserved for her own individual 
life. 

Each metamorphic or developmental period of life-- dentition, puberty, and 
the menopause-- throws a special strain on the nervous system, and the 
recent studies of the sympathetic nervous system at the time of the 
menopause show that very extensive anatomic changes occur at this time. 
That being the case, the woman must lead such a life as will insure her 
having on hand a large reserve force necessary to meet these heavy 
demands. Tilt's observations show that women who have experienced no 
suffering at puberty or, at the menstrual periods do not suffer at the 
menopause. It is therefore evident that the time to begin this preparation 
is in childhood. 

That single women suffer less than married women would suggest that 
excessive coitus and the occurrence of abortions, frequent child-bearing, 
and lesions as the result of pregnancies, many of which lesions could have 
been prevented or cured by the timely aid of the physician, are the 
combined sources of much of the suffering at the time of the menopause. 

That the most frequent and serious disturbances are those of the nervous 
system, and that from their mode of life and habits of introspection the 
rich suffer more from these ailments than the poor, must cause serious 
consideration of the physiologic necessity for a definite occupation for 
the daughters as well as for the sons of the rich. 

The frequency with which Bright's disease is found at the time of the 
menopause is dependent not so much on the local physiologic changes which 
are taking place as on the time of life. Loomis says that it was not until 
life-insurance examinations became so common that the frequency with which 
kidney disease existed in persons who believed themselves well was even 
imagined. And as a result of his observations in these cases, and of a 
large number of autopsies conducted at the Bellevue, he stated that it was 
his belief that 90% of men and women over forty years of age suffer from 
some form of Bright's disease. That being the case, it would seem that 
after this period of life at least as much attention should be directed to 
the kidneys as to the teeth, and that a semi-annual examination of the 
urine should be made. 

Although the menopause is a physiologic occurrence, yet, owing to the many 
pathologic changes which are liable to take place at this time, the woman 
should be as carefully watched during the menopause by the gynecologist as 
the pregnant woman now is by the obstetrician. If the same care were 
taken, in the majority of cases, the dangers attending the menopause would 
be avoided, and the woman would be prepared to enjoy a healthy and useful 
post-climacteric period of life. 



CHAPTER XV.
HYGIENE OF THE MENOPAUSE.
Diet; Constipation; Stimulants; the Kidneys; the Skin; Turkish Baths; 
Massage; Exercise; Profuse Menstruation; Hemorrhage; Mental Therapeutics.

"'Tis the breathing time of day." 
-- "Hamlet."

Hygiene of the Menopause.-- The changes which occur in all the organs of 
the body at the time of the menopause are retrograde, and therefore just 
the opposite of those which occur at the time of puberty. This fact should 
be borne in mind in the matter of alimentation. All that is now needed is 
to make the repair equal to the waste. 

Diet.-- Unless the woman is taking a great deal of active exercise, it is 
better to diminish the amount of meat eaten, and to increase the vegetable 
food and take more fluids. Unless the effect of the meat eaten is 
counterbalanced by active outdoor exercise, it produces an excess of waste 
matter, which accumulates and causes biliousness, and sometimes rheumatism 
and gout. A vegetable diet is less taxing to the excretory organs than an 
animal diet. 

Indigestion is at this time of life apt to appear in the form of 
fermentation, which may assume the gastric or intestinal type. The chief 
causes of the formation of gases are the lessened peristaltic action of 
the intestines, the increased tendency to congestion of the liver and to 
obstinate constipation. 

All dishes rich in sugar, as cake, candy, preserves, and jelly, should be 
indulged in with moderation; or where there is a tendency to fermentative 
indigestion, they should be wholly avoided. 

All dishes known to be difficult of digestion, as hot breads, pastry, 
cheese, fried dishes, and rich salads, should be cut off the menu, since 
these readily overtax an already weakened digestive system. 

If there is a hereditary tendency to rheumatism or gout, the disease is 
most apt to take on an active form at this time. In either case the 
manifestation of the disease indicates an excess of uric acid in the 
system, and a diet becomes a necessity. Pickles, all highly spiced 
articles of food, and vinegar must be omitted from the bill of fare. The 
vinegar may be replaced in salad-dressings by lemon juice. Tomatoes, 
rhubarb, strawberries and grapefruit are contra-indicated; also all 
articles of food rich in sugar. 

In chronic cases animal food cannot, as a rule, be excluded from the 
dietary, but must be limited in quantity. Fish, eggs, and fowl may be 
eaten, also a moderate amount of lean meat in the form of beef, lamb, and 
mutton. Milk may be indulged in freely. The diet should consist 
principally of easily digested fresh green vegetables. The amount of tea 
and coffee should be limited. All malt liquors, sweet wines, and champagne 
must be absolutely prohibited. 

Constipation.-- A daily free evacuation of the bowels is essential to good 
health. Where constipation exists, and the woman is full-blooded, with a 
tendency to a rush of blood to the head, saline laxatives are indicated. 
But if the woman is constipated and anemic, cascara sagrada is a better 
laxative; while cod-liver oil acts as a laxative and at the same time 
improves the quality of the blood. 

Stimulants.-- Women resort to alcoholic stimulants as an analgesic to 
relieve pain, whether physical or mental; as a narcotic to produce sleep; 
and as a spur to a failing appetite or bodily powers. 

The majority of women patients say that they first used alcohol in the 
shape of whisky, brandy or gin to relieve pain at the time of the 
menstrual period. The pain that is caused at this time by a chilling of 
the body would be as effectually relieved by drinking a cup of hot tea; 
while if the pain is intense and constant, recurring every month, it is 
doubtless caused by some local inflammation, and the use of alcohol only 
veils the real trouble, and the woman loses valuable time by not 
consulting a physician at once. 

As to the use of alcohol to blunt the nervous sensibility due to mental 
suffering, it is the testimony of the entire medical profession that this 
is the greatest cause of inebriety or drunkenness among women of all 
classes of society. 

Sleeplessness generally arises from some well-defined physical cause-- 
very frequently from inaction of the liver-- and the proper remedial 
agents should be used to remove the cause. 

While at first the use of alcoholic beverages increases the appetite, as 
the amount taken is increased, distaste for food is created, the system 
languishes under an insufficient food-supply, and the original aim of 
increasing the appetite is defeated. 

As to taking stimulants to do more work than one could otherwise 
accomplish, it is by means of stimulants that woman can accomplish her 
physiological ruin more quickly than is possible in any other way. And the 
early symptoms of chronic alcoholism show themselves in the form of 
neuralgia, insomnia, palpitation of the heart, and muscular tremors. 

The Kidneys.-- On account of the prevalence of some form of Bright's 
disease after forty years of life, the kidneys should be carefully watched 
at this time. And in order to keep them in good condition they must be 
well flushed with water every day. Three pints of urine should be excreted 
daily, and three pints of water as such must be taken into the system 
daily. The urine should be examined by the physician every six months. In 
this way kidney disease is often discovered in its incipiency, which 
otherwise might run into a serious form of Bright's disease. 

The Skin.-- It must be remembered that the skin is one of the excretory 
organs of the body, and the pores should be kept well open by the various 
forms of baths. 

The Turkish bath or some modification of it will often be found to be 
particularly useful. Massage with alcohol after the bath lessens the 
tendency to take cold. For a woman who is anemic or run down, it is well 
to follow the Turkish with the Roman bath, which is an inunction with 
almond oil or cocoa-butter. A much more thorough massage is given with the 
Roman bath than with the "alcohol rub." It is often necessary to modify 
the Turkish bath by omitting the steam-room and shortening the time spent 
in the hot dry air. In ordinary cases the time spent in the hot dry-room 
should be only that necessary for producing a free perspiration. This time 
varies in different individuals from ten to twenty minutes. No woman 
should go to a Turkish bath without first consulting her physician, since 
if the woman has a weak heart, the bath may be the source of positive 
danger. Comparatively few women are strong enough to take the cold plunge. 

Massage.-- Massage, well given by a skilful masseuse twice a week, will 
greatly tone up the nervous and circulatory systems. Women who are very 
stout and who have sluggish livers with obstinate constipation will find 
massage particularly beneficial. 

Exercise.-- Daily exercise in the open air is absolutely essential to 
every woman's good health. The minimum amount of outdoor exercise 
compatible with health is an hour's walk, at the rate of three miles an 
hour. If the woman has never taken any exercise, she must begin with a 
very short walk and stop on the first sign of fatigue. Gradually increase 
the distance and the speed until the three miles is reached. 

Profuse Menstruation.-- If the menstrual flow is unusually profuse or 
lasts beyond the regular time, the woman should stay quietly in bed until 
the flow ceases. All exercise increases the flow. 

The flow now becomes less in quantity, and the periods more infrequent 
than formerly. Hemorrhage must always be regarded as a danger-signal the 
significance of which can scarcely be overestimated. To immediately 
consult a specialist on the appearance of any irregularities of the flow 
would, in the opinion of the most eminent gynecologists of the day, be the 
means of saving thousands of women's lives every year. 

Mental Therapeutics.-- It is particularly necessary at this time of life 
that the mind should be pleasantly occupied. Her children have passed the 
age when they need her constant supervision, and the mother must take some 
relaxation from her home cares, in the form of social diversions, 
amusements, outdoor life, and change of scene. Any mental occupation that 
will take the woman out of herself is the best possible safeguard against 
a state of introspection which conjures up a host of evil fantasies, and 
which is the first step in the downward road to a fixed and permanent 
melancholia. 

"Hang sorrow, care will kill a cat; 
And therefore let 's be merry." 



CHAPTER XVI.
HINTS FOR HOME TREATMENT
Indigestion; Constipation; Diarrhea; Enemas; Vaginal Douche; Baths; 
Headache; Fainting; Hemorrhage.

"Woman is woman's natural ally." 
-- EURIPIDES. 

Indigestion.-- The chief causes of indigestion are: eating rapidly, eating 
at irregular hours, eating indigestible foods, constipation, and lack of 
exercise. No one who values her good health will allow herself to be 
hurried through a meal, nor will she allow the perplexities of life to be 
thrust upon her at the table for solution. The first requisite for the 
digestion of foods is that they should be well masticated, so that the 
digestive fluids may act on the finely divided particles to the greatest 
possible advantage. And while digestion is going on all mental labor 
should be held in abeyance, in order to avoid drawing the blood away from 
the stomach to the brain. Furthermore, it is a well-known fact that 
digestion is best performed when the meals are served at regular hours. 

Constipation leads to the formation of gases in the intestines, to 
fermentation, and to the absorption of toxic materials by the blood. 

Through lack of exercise, the appetite fails, the liver becomes torpid, 
and the muscular and nervous systems lose their tone. 

The exercise which the housekeeper gets in going around her house is not 
sufficient. Daily exercise in the open air is essential to health; as this 
is to supplement the indoor exercise, the amount taken will vary in 
proportion to the former. For teachers or those who have a sedentary 
occupation an hour's active exercise in the open air-- a three-mile walk-- 
should be supplemented by active gymnastic exercise. 

For people in good health, a mixed diet-- that is to say, a diet 
consisting of meat, vegetables, and fruit-- is the best. If the individual 
is not well, then the diet must be adapted to meet the needs of that 
particular case. 

Hot breads, all articles of food fried in fats, salads, and pastry are 
difficult to digest. Tea is very constipating, and when taken in excessive 
quantities renders the individual nervous. An excess of coffee leads to 
congestion of the liver. 

Where indigestion exists, the simplest and most sensible remedies are to 
regulate the diet, and avoid eating between meals. By drinking a glass of 
water as hot as it can be sipped one hour before each meal, the mucus is 
washed out of the stomach, the stomach is empty on coming to the table, 
and in the best possible condition for the gastric juice to act on the 
food-stuffs. 

Constipation.-- Constipation is the rule with the average American woman; 
the causes are their corsets, the tight bands of their clothing, lack of 
exercise, and the fact that they drink too little water and too much tea. 
The most rational means to overcome it is to drink more water; at least 
three pints a day should be taken, in addition to soups, tea and coffee, 
and so forth; the water must be taken into the system as such. Then 
attention must be given to the diet; plenty of fruit should be eaten, 
vegetables, and coarse bread. 

Regularity in this, as in all other habits of life, is most essential, and 
the individual should go to the toilet at the same hour every day, even if 
there is no inclination to have a bowel movement, and thus the habit will 
be established; the most convenient time is directly after breakfast. 

Medical Treatment.-- But if all these means have failed, medicines must be 
resorted to. Cold water is a better laxative than hot; to a glassful of 
cold water add from one teaspoonful to one tablespoonful of the 
effervescing granules of the phosphate of soda, and take this the first 
thing on rising in the morning. This preparation of soda is particularly 
useful because it acts slightly on the liver. Other laxatives are: a 
seidlitz powder dissolved in a glass of cold water on rising; a wineglass 
or more of Hunyadi Janos, also taken on rising. Any of these may be taken 
with safety by pregnant women. For children the simplest laxative is one 
teaspoonful of Husband's milk of magnesia, to be taken in one glass of 
water on rising. 

Enemas.-- Perhaps one of the most common methods used by the laity for the 
relief of constipation is the rectal injection, or enema. Enemas 
habitually given to unload the bowels are productive of much harm by 
overdistending the rectum, so that in time the rectum fails to react to 
the normal stimulus-- namely, the presence of the feces-- as it otherwise 
would. But by some means or other the bowels must be well moved once every 
twenty-four hours. And it is much better to use an enema than to go to bed 
without a bowel movement. If the woman is going around, so that she can 
give the enema to herself, the most effective way to take it is in the 
knee-chest position or an approximation to this. Either a fountain or bulb 
syringe may be used for this purpose; a quart of water at a temperature of 
110 degrees F. should be prepared by making it into a suds with castile 
soap, or one tablespoonful of glycerin may be added to one pint of water. 
The nozle to be used is the smallest one that comes with the syringe, the 
so-called infant's nozle; this is quite large enough, and its insertion is 
not nearly so painful as the larger ones; the nozle must be well greased 
with vaselin. When everything is ready, the patient gets down on her knees 
with the shoulders near the floor, having first loosened all of her bands 
and taken off her corsets; the nozle is introduced as far as it will go 
into the rectum, and if a bulb syringe is used the water must be very 
gradually squeezed into the rectum, otherwise it will not retain so much; 
or if the fountain syringe is used, it must not be hung too high. So soon 
as the patient feels that she has taken all that she can retain, she 
should lie down on the left side, and retain the water as long as 
possible, as it is thus rendered more effective. An enema so taken will be 
very much more effective than one taken in the ordinary manner of sitting 
on the toilet. In the method just described more water can be used and it 
will be longer retained; it can be felt to go up along the course of the 
large bowel, and it will often be found very effective when the ordinary 
enema fails. This enema will often be found to be a very valuable aid in 
curing an obstinate chronic diarrhea, which is kept up by particles of 
feces remaining in the folds of the large intestine. If the patient is 
confined to bed, she should lie on the left side, with a heavy towel 
folded under her to prevent the bed from becoming wet; when the nurse 
withdraws the nozle she should make pressure on the anus with the towel, 
to help the patient to retain the water as long as possible. But should 
the patient have gone so long without a bowel movement that all these 
means fail, it will be necessary to precede the water enema with one of 
oil; or still more effective is the following combination: take one 
teaspoonful of the spirits of turpentine, the yolk of one egg, and two 
tablespoonfuls of olive oil, and beat well together, and add to these one 
pint of water at a temperature of 110 degrees F. Constipation, however, of 
so obstinate a character as this demands a physician's attention. 

Diarrhea.-- A diarrhea may be acute or chronic; the treatment is 
essentially different. For an acute attack accompanied by frequent stools 
and severe abdominal pain the first thing to do is to go to bed. If there 
is nausea, drink a glass of water as hot as can be taken, at once; for the 
diet, a glass of scalded milk, not boiled but just allowed to come to the 
boiling-point, every two hours; and nothing else should be taken until the 
diarrhea is well in check. If the pain is severe, a spice plaster over the 
abdomen will be found to be very comforting. It is made as follows: take 
of powdered allspice, cinnamon, cloves, and ginger each two 
tablespoonfuls, and two teaspoonfuls of cayenne pepper; mix well together 
in a bowl; then quilt in a piece of flannel large enough to cover the 
abdomen; when ready for use, dip in hot whisky and apply as hot as the 
patient can bear; cover over with a large napkin, as the plaster produces 
a deep stain which does not wash out; keep on as long as necessary. If the 
rest in bed and the milk diet kept up for twenty-four hours do not suffice 
to cure the diarrhea, it is not wise to take any risks, but send for your 
doctor at once. Or if there should be any blood in the stools, do not wait 
for anything, but send for the doctor without delay. 

For a chronic diarrhea an enema given in the knee-chest position, as 
already described, will often be found a most efficient remedy. In 
diarrheas the use of fruits and vegetables should be avoided; the best 
diet after the milk is bread well toasted through, toast-water, soft-
boiled eggs, beefsteak, oyster stew, and clam broth. 

Vaginal Douche.-- To be of service except for mere cleansing purposes the 
douche must be taken in the horizontal position, either on a couch or, if 
it is not cold, on the floor. Of course, this position necessitates the 
use of a douche-pan. The douche-pan is best of agate-ware, oblong in 
shape, and with a broad strip which comes under the nates. On lying down 
to take the douche the nates must come down well over the pan and the 
clothing must be pushed well up to prevent the water from seeping up the 
back. To make the woman more comfortable there should be a pillow under 
the head, and she must have a shawl or some light woolen material to throw 
over her while taking the douche to prevent chilling; thus doing more harm 
than good. 

There are two forms of syringes on the market: the bag or fountain 
syringe, which is hung up sufficiently high-- about three feet above the 
patient-- to cause the water to flow; and the bulb syringe, in which the 
bulb has to be constantly squeezed by the hand, which is tiresome to many 
women, but this is a much more convenient form to have in traveling. 
During pregnancy the fountain syringe only should be used, and it should 
be hung as low as will enable the water to flow. For a woman who has never 
taken douches it is well to begin with a temperature of 110 degrees F., 
gradually increasing the temperature to 118 degrees or 120 degrees; this 
is as high as the woman should attempt to go, for a higher temperature 
would burn her, leaving the vulva so sensitive that she would only be able 
to take cool douches for a long time after this; a bath thermometer should 
be used in all cases to test the temperature, so that the woman knows 
exactly what she is doing. 

In cases of inflammation of the uterus or its adnexa four quarts of water 
should be used, and the douche should be taken in the horizontal position. 
The water thus acts as a hot poultice about the uterus, and the woman will 
find on rising that some water flows out from the vagina. Ordinarily plain 
hot water is all that is necessary to use, but where the discharge is 
acrid and scalding, the plain hot-water douche should be followed by a 
warm douche containing one teaspoonful of borax to a pint of water. The 
best time for taking a douche is at night just before retiring; there is 
also less danger of taking cold when the douche is taken at this time. 

The scalding sensations at the vulva may be due to the acidity of the 
urine, in which case it will be increased just after urination; or it may 
be due to an acrid discharge from the vagina. A little observation on the 
part of the patient will enable her to distinguish which is the real 
cause. If there is any trouble with the urine, it should be carefully 
examined at once, as some congestion or inflammation of the kidneys is not 
infrequently present, which if attended to might be cured, and which if 
allowed to run on unattended to, may develop into a serious form of 
Bright's disease. 

The genitals should be washed with soap and water night and morning. Women 
who do not suffer from leuchorrhea need not take a vaginal douche more 
than once a week; after the menstrual flow the vaginal injection is 
advised to remove the detritus of the flow. 

Baths.-- The most ordinary forms of baths used may be classified under 
sponge-, shower-, sitz-, and tub-baths. The sponge-bath as ordinarily 
taken is of service for cleansing purposes, and if the water be cold it 
tones up the system to some extent, and is so a preventive against taking 
cold. The effect of this bath will be found to be vastly more beneficial 
if salt is added to the bath in the proportion of a pint of salt to a 
gallon of water; either sea-salt may be used or the ordinary coarse salt. 
It is most advantageously taken sitting in a bath or hat-tub, so that the 
entire surface of the body will be wet at the same time, and the water can 
be allowed to run down the back and over the chest. It is well to begin 
these baths at a temperature of 80 degrees F. and to gradually decrease 
this until the bath is taken at 70 degrees, which is about the temperature 
of running water, and the bath should be kept up at this. For most people 
the best time to take the bath is just before retiring; this bath is not 
only very strengthening, but also is excellent in cases of insomnia and 
nervousness. 

Shower-baths.-- These may be taken after a hot bath, or taken alone after 
violent muscular exercise. The body should be quickly scrubbed off and the 
shower should be warm at the beginning and gradually allowed to become 
cold, stooping over so as to get the full force of the shower on the spine 
and over the region of the stomach and heart. They will be found to be 
most refreshing after great muscular fatigue, and, when taken after the 
hot tub-bath, greatly lessen the susceptibility of the individual to 
taking cold. 

Sitz-baths.-- These are given for their local effect in cases of 
inflammation; whether this inflammation be of the kidneys, bladder, or of 
the uterus and its adnexa. A sitz-tub is necessary to properly take this 
form of bath. The water should be used as hot as is comfortable to the 
patient, from 105 degrees to 110 degrees F., hot water being added as the 
first cools off; a pint of salt should be added to the gallon of water, 
and the patient should remain in this from five to eight minutes. A 
blanket should be wrapped about the patient so that she will be thrown 
into a perspiration; it is almost needless to say that the only time for 
taking this bath is just before retiring, and that this bath does make the 
woman more susceptible to taking cold, so that it is necessary to wear an 
abdominal woolen bandage day and night. 

Tub-baths.-- The tub-bath ought not, as a rule, be taken more than twice a 
week, unless the cold plunge is used, which may be taken every day. If the 
tub-bath is taken hot, the woman should remain in it not much longer than 
is necessary to scrub off with a flesh-brush; this bath should be followed 
either with a cold shower-bath, or the water in the tub be gradually 
allowed to cool off until it is down to 70 degrees F. 

Headaches.-- Headaches, aside from those of acute illness, may be roughly 
divided into three classes: first, those which are due to indigestion; 
second, neuralgic headaches; and, third, those due to pelvic 
inflammations. The headaches due to indigestion are usually located over 
the eyes and all over the forehead; they are more or less constant and are 
accompanied by other symptoms of indigestion, and very often by 
constipation. The feces are allowed to remain in the bowels overlong, the 
toxic matters are taken up by the blood, and headaches and vertigo result. 

Neuralgic headaches are of an entirely different character; the pains are 
here of a lancinating character, and are not confined to any one region of 
the head. As a rule, they are accompanied by neuralgic pains in other 
parts of the body. Neuralgia generally means a rundown state of the system 
from overwork, worry, or malaria, and tonics and cod-deliver oil are 
indicated. 

A constant dull pain on the top of the head or in the back of the neck 
generally indicates some uterine inflammation, and can only be cured by 
removing the cause. In any case it is very evident that taking the various 
"headache powders" with which the market is flooded will never cure the 
woman of her headaches; and many of these powders are very dangerous, 
especially where the heart is weak, as most of them are heart-depressants. 

Fainting.-- Fainting may be due to a weak heart, to heart disease, or to 
sudden shock, as on receiving a bad piece of news; during pregnancy the 
close air of a room may cause a woman to faint. The first thing to be done 
is to lay the woman down on the floor or bed with nothing under her head; 
loosen all her clothes about the neck and waist, and throw the windows 
open so that she will get plenty of fresh air. If she is able to drink, 
give her one teaspoonful of aromatic spirits of ammonia in four 
tablespoonfuls of cold water. If the feet are cold, place hot-water 
bottles to them to improve the circulation. And if at the end of fifteen 
minutes she does not show signs of decided improvement, give her two 
tablespoonfuls of whisky in an equal quantity of hot water. In the 
meantime the physician will have been summoned. These attacks of fainting 
often occur in a crowded ball-room, and are due to tight lacing and the 
poor ventilation of the room. 

Hemorrhage.-- A profuse hemorrhage is the most alarming as well as the 
most dangerous thing which can befall a woman, and the very nearest doctor 
should be summoned until the family physician can be gotten there. The 
woman should be made to lie down wherever she may happen to be, her 
clothes loosened, the windows thrown open, so that she will not only have 
plenty of fresh air, but that the air shall be cool. If the blood is 
coming from the mouth, give her pieces of ice to hold in it; if she coughs 
up the blood, it would be well to put a bag of ice-cold water or cloths 
wrung out of ice-water on the chest. If the woman is suffering from a 
uterine hemorrhage, have her take at once a hot vaginal douche, from 118 
degrees to 120 degrees F., and have the foot of the bed raised. The head 
should always be kept low. 

Women hold their health in their own hands to a far greater extent than 
they have ever dreamed of; and if the majority of women suffer, it is very 
often their own fault, either because they have disregarded nearly every 
law of health, or have allowed trivial ailments to go on until they were 
almost incurable. 

"The broad mountain-top, with its sunlight and free air, is possible to 
all of us, if we choose to struggle on and reach it." 
-- Phillips Brooks.