Thus it may perhaps happen that, in order to avoid the latter re proach, we speak of precursors and after-pains of the climacteric (these are those further climacteric phenomena referred to above), as well as of a true climacteric, which as regards its duration, corresponds with that of those menstrual irregularities which continue until the final cessation of the menses; still that too can certainly not be done without doing vio lence to the fa,cts. To speak of all the processes that occur in the genital organs as simply an expression of the real climacteric, and, in spite of their great significance, and their constant occurrence (which distinguishes it from all other climacteric phenomena) to give to every one of these phenomena the same significance, and not to consider them specially in connection with the determination of the limits of the climacteric, this is certainly the first step which must be ramie towards the proper concep tion of this important period.
We saw before that certain peculiar psychical abnormalities and well known characteristic phenomena, such as vertigo, flushing, outbreaks of perspiration, an increased accumulation of fat, etc., appear some time before the appearance of the first menstrual irregularities, and may like wise persist for some time after the final cessation of the flow. We always agree in considering these phenomena as evidences of the meno pause, so far as they fall within the limit of menstrual irregularities; before and after we refer to them in a different manner, or regard them, as was said, as phenomena of the change of life, yet we describe them (since the periods still recur regularly, or have already been entirely absent for a long time) as premonitory signs, or as the final knell of the climacteric. This is entirely incorrect logically. The early (in regular menstruation) or late (after the cessation of the genital hemorrhages) psychical abnormalities, which occur with the same intensity as during the menstrual irregularities, the early or late attacks of vertigo and out breaks of perspiration, etc., which are just as marked as they are during the menstrual irregularities. always show that the changes within the body, which lie at the bottom of them, exist to the same degree. If we designate the ensemble of these changes by the term " climacteric," we have accordingly to speak not only apparently of a definite group of phenomena, which owe their existence to these changes, but of every such phenomenon of the climacteric; or, in other words, we must regard the limits of the extension of the climacteric as determined by the first and last undoubted climacteric phenomenon, without disturbing ourselves as to what these phenomena may be, and what other ones may intervene.
I must also add a word regarding those so-called critical hemorrhages. These are made use of as criteria in deciding as to the deeper-seated processes in the genital organs, and the so-called change of life, Le., time of cessation of sexual activity, is defined by the appearance of these hemorrhages, as well as by the cessation of the same. No one will deny what I said above, that this influence must be only a very vague one, since the connection between these two facts (hemorrhages and deeply seated metamorphosis) is hardly a very close one. There is without doubt a casual relation, and on this is based our conception of the meno pause, certainly not the less on this account, that the clinical symptom, hemorrhage, is one very easily observed. If, however, the critical hemor rhages and the supposed changes in the internal sexual organs do not correspond in the usual manner, then the beginning of the cessation of menstrual activity must very often be inferred long before the time of the first menstrual irregularities (compare the commonly observed. cessa tion of child-bearing towards the menopause), and the " end " of this cessation of sexual activity will probably be generally looked for some time after the disappearance of the flow. Puech found the ovaries still of normal size three years after the establishment of the menopause. It is quite possible that the beginning -and end of cessation of the sexual activity may, in point of time, be nearer to the first and last of the other climacteric phenomena than to the first and last critical hemorrhage, and it is accordingly from this standpoint also probable (since the atten tion is directed chiefly to the cessation of the sexual activity) that it is much more correct to enlarge the idea•of the extension of the climacteric to the degree mentioned, and instead of the readily-observed, but quite unreliable, symptom of hemorrhage, to recognize as the limits the begin ning and concluding phenomena, which at all events deinand more exact observation, but are more reliable clinically.
On the other hand, we must also remember the not infrequent cases in which, without the action of any injurious cause, the periods, hitherto perfectly regular, at once disappear permanently. In such cases the before-mentioned critical hemorrhages are entirely absent, and the period which is limited by these hemorrhages is completely wanting; still even in these the cessation of sexual activity must occur within a certain definite period, and in these too a climacteric must take place, from whatever standpoint we may consider it. Here also the criterion furnished by the critical hemorrhages is absent; we speak, as we were obliged to do in the previous pages, of a sudden climacteric, yet every one is perhaps aware that this term " sudden " in such clearly-marked cases (where no in jurious factor lies at the bottom of them) merely refers to. the one symp tom, hemorrhage from the genital organs, which is permanently absent. If, however, we bear in mind that which I said before in regard to the necessary manner of determining the time of the climacteric, we shall understand such cases also; every other climacteric phenomenon can under some circumstances be made use of, in order to attain the result in question. At all events, I observed before that occasionally such a " sudden climacteric " may occur, without any sort of disturbance of the constitution having arisen before or after; still I referred in this only to the question whether such a rapid disappearance of the menses must lead to an actual injury to the health. The attentive observer, even in the cases of this kind which run the most favorable course, will not lose sight of the slight changes in this or that region which he is justified in calling climacteric phenomena.' Now I must still, in order to prevent all mis understanding. refer to two points, riz., so-called post-climacteric phenom ena and those isolated phenomena of the menopause which persist for a long series of years, after the flow has normally ceased. With regard to the former, it might be urged that in adhering to the idea of the extension of the menopause in the sense above signified, we must very often speak of a climacteric phenomenon at a time at which we are accustomed to regard certain notable occurrences as post-climacteric phenomena, which must necessarily now and then lead to errors. I must unquestionably admit this, unless hereafter we are not allowed some variations with regard to the use of the term " post-climacteric." But these are absolutely necessary. In tbe same sense the previous custom of speaking of a post climacteric period (which I also adopted in the former pages, in order to make myself clear) as soon as only the one symptom—irregular hemor rhagea—positively disappears, is not justifiable. Just as we should in general think that the clitnacteric period is at an end only after the phenomena have disappeared, so tbe expression post-climacteric should be used when the phenomena, of whatsoever sort they may be, have been' absent for a shorter or longer time. It will follow from this that a large number of the occurrences, described bere and there as post-climacteric conditions, and related to well-known climacteric conditions, are to be regarded as standing really in direct relation to the menopause. How ever, we shall see later (and here I hold is the true practical application of the matter) that by adhering to this point of view, we shall be com pelled in the future to keep more clearly before us various late phe nomena, which we at present regard as accidental, intercurrent, and due to entirely different causes, and thus perhaps be able to show their con nection with the climacteric—in short, to widen our knowledge of the climacteric phenomena in general.