PHENOMENA OF THE MENOPAUSE IN THE BODY IN GENERAL.
The most varied forms are pre sented in this field, such as repeatedly perplex the most careful observer by their novelty. However, they may be entirely absent; in fact, hardly any two cases are alike. 1Vhile many women pass this period without noticing any change in their former condition, and are conscious of the occurrence of their change of life only by reason of the absence of the menstrual flow, others suffer for years with one affection or another, or there are a whole host of lesser or greater troubles, by which they are per sistently or alternately affected. It is to be noted that commonly few complaints are made about certain conditions that are often quite annoy ing; these are the most frequent disturbances which are known to the women themselves, partly from hearsay, and partly from the observation of others, and are, therefore, quietly accepted as self-evident and necessary. We are consulted regarding such conditions only when they exceed the ordinary bounds. In order to obtain a correct view, it will, therefore, be necessary for the physician to question each patient very thoroughly.
One of the most essential changes at the climacteric period, which will hardly escape the attentive observer, is that of the woman's psychic-al condition. Vagaries in this direction are generally observed by associates, and by the physician if they become marked. The slightest forms usually escape the notice of all; the women themselves, on being questioned on this point, give the first information regarding the change in their char acters, which had for some time completely escaped them. The question to be asked in this connection naturally does not relate to this or that positive change of disposition, hut may be a very vague inquiry regarding the quality of dispositions. It is quite striking what a marked similarity usually exists between the individual answers obtained. These nearly always give evidence of a certain lowering of the vital energy, if I may so express it. The daily duties lose their interest, and there is a certain indifference towards everything, or everything seems to the patients to be more difficult and wearisome than it used to be; they are often sur prised at finding themselves plunged in a certain stupor or dejection, while they are troubled more than before with the consciousness of their own imperfections, and the transient character of every pleasure, and with forebodings of sickness and death, etc. Some think that they have become forgetful, while others fear that they are no longer able to per form this or that bodily exertion; others, again, are disquieted on account of the possible loss of their property, while nearly every one experiences, consciously or unconsciously, a certain amount of ennui, more or less of a dtsposition to peevish melancholy. These changes in the disposition are usually confined to certain times in the day; they are often absent for days and weeks. If the menses have not yet entirely ceased, but still recur now and then, there is sometimes manifested a certain connection between the change of disposition and the periods (the peevishness gen erally appears during the days preceding the beginning of the flow), yet this relation is often entirely absent. The psychical vagaries in question frequently begin a long time before the first irregularity in menstruation is noticed, often appear at and after the time of the irregularities, with out any relation to the menses, and continue for years after the cessation of the flow. This is true of another form of psychical disturbance, which in my experience is more rare, which produces in women a certain in creased irritability, impatience, restlessness, tendency to outbursts of anger, etc.
The importance of the climacteric as an etiological factor in the de velopment of actual mental maladies has been clearly affirmed by dis tinguished authorities. According to the deductions of Tilt, Brafft-Ebing and Meynert, the connection between mental disease and the menopause is extremely common. It is sufficient for the framework of our argu ment to have alluded to this latter fact. But I should like to discuss another point also. According to Brierre de Boismont, Esquirol and Griesinger, the climacteric generally exerts an aggravating influence, but sometimes improvement, or even perfect cure, occurs at this time. I
saw an example of the latter result in a case which was complicated by delusions of persecution. The woman is now just at the commencement of her menopause, but mentally she is perfectly sound again. If we see actual mental affections develop in consequence of the menopause in women who were healthy, or at the most nervous and excqable, and then again existing psychical disturbances become worse at this time, or change for the better until they are completely cured, we must from this draw the conclusion that the climacteric may lead to marked changes in the psychical condition of the patient in question. This applies to actual mental affections, but it applies in the same way at least to the vagaries of the slighter and more insignificant kind which interest us here, and are almost invariably observed. As we have remarked, there is usually a sort of outspoken depression, often expressing itself by a tendency to weeping, but even at the climacteric a healthy, contented, even gay dis position may be present, even where this was not hitherto the case. What I would call attention to here is quite different from this quality of dis position, especially the transformation of the psychical condition of the individual by the menopause, which is apparent even in these slight variations. I claim that this often merely slight change in the character is quite a characteristic symptom of the menopause. Without wishing to bring forward a new explanation of this phenomenon, I should like to be allowed to say a few words regarding the point in gnostic), We find that in works which discuss this subject, two factors are gen erally taken into account, first the processes in the sexual sphere that result at this time (much importance is attached especially to the sudden cessation of the menses), as well as certain simultane9us pathological changes that occur in these organs, such as flexion, catarrh, erosions, etc.; secondly, the reflexions of the patient caused by her condition, medita tions on the loss of youth and sexual power, anxiety in view of the dangers of the climacteric, etc. Without doubt some importance is to be attached to this factor, and one or the other is often quite striking. In my opinion, it is necessary to remember the following facts: (1). In two different women the phenomena depending upon sexual causes (irregularity of the menses, etc.) may be identical, and both may be nervous, yet in one there may be a very slight, in the other an ex tremely serious change psychically. Because of the sudden cessation of the menses, on which so much emphasis was laid, I have had several cases in which the psychical alienation was really not so marked as before; sometimes under such circumstances, it was hardly noticeable. Abnor malities of the genitals frequently occur at other times without affecting the mind; if they are found at the climacteric, we can not be sufficiently cautious in estimating their etiological value. Successful treatment of the sexual trouble, even if it is accompanied by relief of the psychical disturbance, need not be directly capable of explanation; the latter may be transient, and it frequently terminates withou.t any local treatment. The affection of the genitals is often cured, and the psychical disturbance nevertheless does not appear. It can not be denied that there is some truth in the supposed sad thoughts about the beginning of old age, the possibility of bodily suffering, etc., and accordingly the depression caused by them can scarcely be regarded as abnormal. But the woman's sensi tive nature is often subjected to infinitely more of a shock, without any such change in her psychical individuality resulting, and on the other hand, it does not often happen that such reflections precede the supposed alienation. It is not the reflection on the epoch in question which causes the existing ill-temper (as I have frequently convinced myself), but this peevishness is often the first thing that points to the menopause; it comes upon the woman in an entirely involuntary way, and she asks herself, her associates and the physician, what may be the cause of the change. This ill-temper also takes possession of those women who, for whatever reason, wish that the menopause was already passed, and have no reason to lament that it has finally begun.