PREMATURE MENOPAUSK Let us first turn to one of the most striking phenomena, the so-called sudden establishment of the menopause. I have already touched briefly on this phenomenon in the earlier part of this work, when I referred to the different ways in which the periods may cease, and alluded in that place to the fact that the sudden cessation of menstruation may certainly occur under entirely normal conditions, so that it may present at all events the form (although rather an unusual oner of the normal meno pause. Under this head are included those cases in which at about the proper age of the given subject, the periods, which had hitherto recurred regularly and in a normal or slightly abnormal manner, cease for good, without being affected by any injurious external influence, and without the occurrence of any previous or subsequent disturbance of the economy, or without the objective demonstration of any organic disease. I myself have observed such cases, and every physician will be able to establish the fact of their occasional occurrence, as soon as he gives some attention to this matter.
In the great majority of the cases, however we can not doubt that the sudden cessation of the menses is pathological. As is known, this usually occurs in consequence of the influence of some physical or mental shock, or a serious general disease, an affection of the genital organs, a so-called " exhausting" factor that affects too severely the general strength. We find the following causes noted: Mechanical violence by a violent blow, push, or fall, a severe cold or wetting, a sudden fright, extreme anxiety, sudden grief, etc.; serious general diseases, such as tuberculosis, inter mittent fever, typhus, cholera, recurrent feve_ septicsemia, the acute exanthemata, poisoning (by phosphorus, arsenic, mercury, alcohol and ()plum); affections of the genital organs, inflammation of the ovaries, the uterus or its surroundings, atrophy of the uterus after difficult labors, benign or malignant neoplasms of the ovary. Among the so-called ex hausting influences are the too rapid succession of confinements, abortion with profuse hemorrhage, violent coitus, continued diarrhcea, drastic purgatives, when taken during the menstrual flow, bleeding from hemor rhoids, venesection during menstruation, etc. It is evident that the causal factors of the sudden menopause ordinarily described are extremely varied. Since it is self-evident that the same causes may produce the same effect (cessation of the menses) at a relatively earlier period of life— some naturally always affect younger women—these factors are obscured by those which were mentioned as causes of the premature climacteric, that occurs in consequence of unhealthy influences. I can also omit special mention of these latter. I have already referred to the sudden and
premature occurrence of the change in consequence of disturbing influ ences, social relations, etc. But the important question in this matter is this, to decide in certain c,ases whether the above-mentioned sudden and often premature cessation of the periods really signifies the true establish ment of the inenopause, or only consists in a disappearance of the men strual flow, while ovulation continues undisturbed; and how then, this or that injurious influence in cases where it actually muses a sudden and sometimes premature abolition of all sexual activity, and consequently the true change of life, produced this effect.' This is certainly a difficult question to solve, and if we keep it clearly in view, it can generally be answered only in part. We can dismiss from our consideration all those cases in which simple absence of the men strual flow is at first inferred, and is subsequently demonstrated. All physicians have long been familiar with most of the forms of intercurrent, and even more prolonged absence of the menses, but we can not regard too skeptically the cases included under the head of sudden (premature) occurrence of the climacteric, not those which have been handed down to us, but also those of whick'we hear at the present day. Formerly the disappearance of the menstrual flow alone was always regarded as the in dication. As long as the accompanying conditions did not point to one of the recognized forms of simple menostasis, the diagnosis of early meno pause was soon made. By reason of the period of observation being too brief, it is probable that the observer also frequently overlooked the com plete restoration of all the sexual functions, or the occurrence of a fresh conception with or without a previous recurrence of the menstrual flow. Accidental attendant phenomena of an external character seemed to establish the diagnosis. An accurate examination of the internal organs was either omitted, or was in part (as the examination of the ovaries) not yet sufficiently understood, as a rule. Post-mortem evidences sought for with sufficient zeal or those which were observed, were not properly com pared with parallel cases. In fact, if we examine the literature critically, we find that in by far the great majority of the cases there is all absence of convincing evidence to support the diagnosis of sudden (premature) occurrence of the menopause. We are indebted to Hegar for a more thorough sifting of the typical cases. Depending mostly on his classifica tion, I shall btiefly estimate at their true value our previous list of the causes of the sudden (premature) climacteric. It will 800T1 be evident from this how rich a field for still more extended work lies open in this direction.