THE LIMITS OF THE MENOPAUSE.
Of course I was not able from my own ex perience to treat this important subject in a perfectly exhaustive manner. This requires the continued labor of many observers; still, I think that in what I have said here, I have contributed in some degree to the clearing up of questions in this special department which still remain unsettled, and perhaps also have opened up new ideas in one direction or another. Wherever this seemed important to me, I have also pointed out the way in which more exact work was originally hindered, or, by reference to what had already been accomplished, what further observations were de sirable.
Before I conclude this work, I have still a task to perform. I have called attention with some emphasis, earlier in the volume, how, in my ()pinion, the true character of the menopause could be properly interpreted only in one way. I hold, however, and I have already called attention to this several times before, that it is necessary to settle definitely the question of the extension of the climacteric. As I said in the beginning, it has always been the traditional custom to date the commencement of the menopause (according to the age of the individual) from the first ir regularities in the menstrual flow, and to make the duration of the meno pause correspond with the duration of these irregularities; finally, to consider the entire cessation of the genital hemorrhages as the termination of the menopause. Whatever notable occurrence takes place subsequent to this time, is described as a post-climacteric phenomenon. In general, the notion of the " climacteric period " is fully identified with the pro long,ation of the menstrual irregularities that are present at this time of life. In the same sense also the expressions "climacteric" and "menopause" are usually employed as synonymous terms. If now we consider the cur rent definition of the climacteric period (which we combated at the be ginning of this work), and which implies that by the term climacteric is understood that phase in the life of woman at which her sexual activity ceases, then it follows from these two points, that our idea of the climac teric rests upon a sound hypothesis, and that the disappearance of sexual activity in woman may be accurately inferred from the condition of the flow at a given time. After all that has been said in the foregoing, and after what we know regarding the probably very loose connection between ovarian activity and menstrual hemorrhage, this is always a somewhat hazardous undertaking. But let us leave this side of the question for the time being; it is necessary for many reasons to describe accurately those periods which intervene between the first menstrual irregularity, and the final cessation of the menses, and it is proper on the other hand, as I have also already remarked in the beginning, that these irregular hemorrhages should usually be regarded as the most striking evidence of the changes in the genital tract referred to. There is another point that seems to me to be far more important, and that is, whether we can ac cordingly employ the term climacteric period in all cases, which as every one will admit, is a rather important question. This, as we may daily prove to ourselves, does not follow. Physicians are already so familiar with most of the climacteric phenomena (and to some extent the laity also), that these should not genemlly be at once termed such wherever they are observed. These phenomena occur with extreme frequency, as I have repeatedly insisted in the foregoing pages, long before the first menstrual irregularities, and they very often persist for years after the cessation of the flow; still, where no further doubts exist, no one hesitates to describe these well-known phenomena as climacteric, no matter how early they begin or how late they persist. If now the individual enters
upon the Menopause in the manner already described, as soon as the first menstrual disturbances are observed, and the menopause has been " passed," aa soon as the genital hemorrhage is positively at an end, it is perhaps not well to speak of climacteric phenomena so long before this first, and so long after this final, termination. However, the latter course is doubtless the correct one. The inconsistency noted occurs because the true relation of affairs makes it unavoidable. The error lies in this, not that we speak of climacteric phenomena before the commencement of the menstrual irregularities, and after the definite conclusion of these in a given case, but in that in our customary definitions of the term " menopause," we always adhere too strictly to phenomena specially re ferable to the genital tract, among which the kind of hemorrhages are of course particularly included. Just here, in my opinion, it is most im portant to apply the lever. The conception of the menopause nmst the oretically be understood in a wider sense than it has hitherto been, as broad as more earnest observation teaches us it should be. I was careful to explain in the foregoing how one and another recognized climacteric phenomenon often begins very early, or continues long after the menopause has been established. This must be still further proved, in order to establish more definitely the limits of the climacteric, with regard to both the early and late appearance. At all events theoretically, in a given case, the menopause begins with the first positive climacteric phenomenon, and ends with the last actual climacteric phenomenon which is still demon strable. In practice, as is well known, this law controls our decision (partly, at least) as soon as we recognize somewhat intimately the isolated. climacteric phenomena. I said before that it was necessary, for many reasons, t,o describe accurately those periods also which intervene between the first menstrual irregularity, and the final disappearance of the menses. We must at all events hold fast to this. Describe this period as the period of climacteric irregularities, as the period of menstrual irregularities at the climacteric; give any scientific name to it, only do not call it positively a climacteric, or the change of life, for that does not harmonize with that conception of the true change of life, which is partly traditional with us, and which continued observations will certainly always establish more firmly. The real change of life, as we may demonstrate one hundred times with careful observation, commonly stretches over a much longer period than that occupied by the above-mentioned menstrual irregularities at the climacteric. In this sense, also we ought, I think, no longer to be satisfied with the special definition of the climacteric as that period of life in which the sexual activity is extinguished. By this definition the true nature of the climacteric is not embraced in its entirety; in it is in cluded only one of the phenomena, though perhaps the most important. But this introduces an error, and usually leads us, by concentrating our attention upon the one phenomenon, to overlook or to under-estimate the others. This leads us again to recognize in the condition of the flow (beginning irregularities, etc.), this criterion which is at all events con venient, but is nevertheless very unreliable as an indication of the more deeply-seated processes in the genital organs, the root of the matter, and from them to infer the presence of the supposed retrograde metamor phosis within the uterus, and, that which is most important, through their very particular consideration of the processes within the abdomen, to lose sight of and interest in the revolutions that take place in the entire organism.