I might take occasion in this connection to call attention to what, in my opinion, is a necessary modification of our view of the menopause. I hold that we should, above all, regard the climacteric changes as resting upon a broader basis than is generally received. Excluding things such as those last mentioned (influence of the patient's own reflections, etc.), it will be especially important not to refer too many of the climacteric phenomena to changes in the sexual organs, no matter how tempting this always is, for obvious reason& The latter are also frequently the only evidence of the climacteric,' and are nearly always the most striking one. It is certainly much more correct to suppose an extensive general change in the organism which simply results in sexual changes as well as every other single phenomenon.
To return to our real theme, I would call attention in connection with psychical alienation to another phenomenon, which is sometimes observed at the time of the menopause, 1.e., the occurrence of actual compulsory ideas. According to Krafft-Ebing ' this " formal disturbance of ideas " is characterized by this peculiarity, " that some concrete, quite significant, and by no means ridiculous, idea remains fixed in the mind with an ab normal intensity and permanence, but so that the patient, in contrast to the insane delusion, is aware of the existence of the diseased condition, especially as regards the character of the idea." There is certainly a close relation between the disturbance in question and the sad thoughts already described. But while in the former case there is rather a general, vague feeling of ill-humor, in the latter the object is held more decidedly and tenaciously. We must remember, indeed, that in both instances we have to do with phenomena in individuals at the climacteric, and that in the second case we have also to do with a certain change in the dis position (inclination to melancholia). In patients with forced ideas there is, according to Krafft-Ebing,' a simple elementary disturbance of the unclouded consciousness. while in the mentally diseased woman (with melancholia) with forced ideas of a quite similar character are associated complicated functional disturbances, and a diseased and altered con sciousnes& In neither sense have we to do here with pure forced ideas The intellect is unimpaired, as has been said, and there is not yet an actual mental disease. We have to do also with a kind of transitional form of forced ideas; at least, I think that such obsemtions as the fol lowing. must be included under this head. Miss C., aged forty-seven, with a neurotic history, ceased to menstruate at forty-five. Now she is worried with a growing fear of apoplexy, which at first was confined to the times when she was attacked with dizziness, but is now constant. She is afraid to go out in public, and feels like falling when she is in the street. Mrs. G., aged fifty-six, was, during the climacteric, so troubled with the idea that she was going to lose her reason, that she consulted me repeatedly for this reason alone, and on each occasion she was in such despair that it was only after a long explanation that I succeeded in re assuring her. Mrs. K., aged forty-nine, has been irregular in her periods for four years, and during this time has been so distressed by fear of malignant disease of the abdomen, that it was necessary to consult a gynecologist. When I first saw her, she seethed to be really very ill, but the most careful examination revealed nothing. Every physician en counters occurrences of this kind. There is no doubt that the meno pause with its different phenomena, some of which have been partly de scribed and partly referred to, is an extremely active factor in producing certain constraining ideas. These are generally " not really irrational,'' since they are founded partly on actual anomalies of feeling (as the climacteric symptoms), and partly upon the correct observation of the actual misfortune that has occurred to others under similar circum stances. Fortunately these notions are not usually deeply-seated, they
are quickly exchanged for others, and are often entirely absent for a long time. True forced ideas, like those above-mentioned, are much more rare. Individuals with an hereditary taint certainly form the majority of these cases. The following is a case in which the peculiar forced idea bore no direct relation to any particular climacteric phenomenon: Mrs. F. has completed her fortieth year. Her menses, hitherto quite regular, disappeared for a month. She was always extremely nervous, and suf fered with severe headaches, but now feels better in this respect Al though she has no bladder trouble at present, on every occasion before she goes into company she is overcome with the fear that she may be obliged to pass her water, and will have no opportunity of doing so. Unless she is exactly acquainted with the situation, therefore, she no longer goes to any strange place. She attended a large concert, and although she had herself engaged a seat near the door of exit, she never theless gave it up bee,ause the door might possibly be blocked with people. Although, as I have said, the direct influence of a climacteric change is not evident in this instance, yet another forced idea, i.e., fear of attract ing notice, may have led to the development of the feeling described The latter, however, might have its origin quite as well in some other noticeable climacteric phenomena (restlessness, change of color, etc.), and would not awaken our surprise, especially in the case of a woman who had always been thus irritable. A very frequent trouble with women at the time of the menopause is the occurrence of slighter or more severe attacks of dizziness. Throughout the opinions on this point there runs generally a certain view like a red thread. Just as on occasions this or that condition of the genitals is held responsible for a series of climacteric phenomena, so the dizziness, and many other symptoms, are regarded as an. effect of the arrested blood-flow, in consequence of which all the vessels are immoderately congested (plethora). Now, it may certainly be true that sometimes hypertemia lies at the bottom of the attacks of dizziness at the menopause, but this by no means explains all cases. Landois defines vertigo as a disturbance of the commoh sensation of motion. This occurs if, by a perverse activity of those sensory nerves which convey sensations of motion, wrong impressions regarding the movements of the body or portions of it are transmitted to the central organ. These are the sensory nerves of the skin, muscles, joints, the ampullary branches of the acoustic nerve in the head, and the visual sense. Without enter ing into a detailed explanation, wd can at once accept the one fact that in true vertigo, which alone we are discussing here, there is first of all a changed activity in definite nerve-tracts. Now the question arises how far this perverted nervous activity at the menopause is due to hypenemia; the process itself might be regarded as due to vaso-motor influences ex erted upon the labyrinth, analogous to the common explanation of other forms of vertigo. In my opinion this question is to be decided principally by the clinical observation of several individual cases. I have myself been long studying this point, and have made the following deductions: In an entirely healthy individual, who has hitherto menstruated regularly (as regards quality and quantity), the periods may disappear at once and for ever, and nevertheless the woman may show no variation as regards con sumption of food, digestion and general well-being (although the most favorable conditions for the occurrence of a relative plethora may e:cist); in her case attacks of vertigo may not necessarily appear.