The second point concerns the unusual prolongation of certain cli macteric conditions (of which I gave some examplei in the former pages) and the possible objection based upon it, that it is difficult to regard this entire length of titne as the climacteric period, while we were formerly accustomed (even from the observation of irregular hemorrhages) to assign about two years to this same epoch, in exceptional cases somewhat longer. In reply I might repeat what I said before, that we must un questionably allow in the majority of the cases a certain extension of the term " climacteric" considered as a period of time. To one who has given some attention to this question, it seems to be entirely inadmissible to speak again and again of the " menopause being passed " in cases where the women are still afflicted with a number of climacteric troubles, simply because of the fact that they have not had a trace of genital hemorrhage for a long time. On the other hand, however, if we adhere in future actually to the principle laid down above, and reckon the commencement of the climactetic period in a given case, from the first marked climacteric phenomenon, and the termination of the same from the disappearance of the last real phenomenon, according•to my experience the difference in comparison with the former will not be proportionally excessive, and will hardly interfere with our general division of the periods of life; more over, in this way we shall always satisfy better our need of a logical classi fication of the facts observed than was formerly the case with the methods hitherto adopted in the direction mentioned. We must always accept with a certain amount of skepticism very late climacteric phenomena; such an one will only pass as a climacteric phenomenon with us in the sense above-mentioned, az.: if, after at first existing more or less con tinuously, it is shown that it is absent for some time, and reappears at a much later period, when all the other phenomena have ceased (or, more over, if the phenomenon which at first can be referred only to climacteric processes, is perhaps at a later period unquestionably prolonged by an other recent etiological factor), or, if the phenomenon in question, al though it corresponds perfectly with climacteric symptoms commonly observed, was perhaps at first entirely absent in the case under considera tion (while all the other phenomena were present), and appears quite late, long after the other climacteric phenomena have disappeared, etc. In connection with this question we must also take into account the fact that there may be certain nervous states which may be produced by some conditions which exist for some time, and according to experience may readily become permanent, and which may persist for many years after their real cause has ceased to act.
If we sift the matter down in this way, we shall, in the sense which we mean, establish the limits of the climacteric pretty strictly, and we need not fear that the field included by these limits will be too wide. Further practical observation will determine this. So far as I can judge, it will be found that there will generally be a series of well-recognized climacteric phenomena for some years (or less) before the beginning of the menstrual irregularities, and that the final cessation of the menses occurs some years later. These symptoms are of course different in in dividual cases. We shall perhaps agree in our opinions, if we make our idea of the beginning and end of the climacteric period dependent upon the more or less simultaneous appearance or disappearance of several of these phenomena, as these aro ordinarily presented in the individual case. We shall adhere to this division, even when one or another isolated phe monenon is present, and sluill in every instance describe such a phenome non (when no other cause is to be found) as " dependent upon the cli macteric," but should not allow ourselves to go further than this and fall into error. We shall, finally, describe as climacteric phenomena, in a given case, certain transient ones (such as I have before described) as are now known t,o be possibly connected with the menopause, or in which in the future such a relation may perhaps be established—that is, if they occur within the period described, or, on the other hand, if they in some striking manner precede or follow this period.
While in the former chapters I endeavored to lay particular stress upon the great importance of certain individual questions connected with the climacteric, the consideration of the frequent occurrence of anfemia in contrast t,o the commonly-described " plethora," the investigation of the relation of the menopause to certain pre-existing processes, the ques tion as to whether these or those processes were t,o be included among the true climacteric phenomena, etc., I desire in these concluding lines t,o call attention to the necessity of modifying certain general notions which are inseparaEy connected with the above questions, but which possess great significance in many other ways.
Whether we consider that the long and short of the climacteric lies in the cessation of the sexual activity of woman, and also believe that all the numerous phenomena of this period stand in a certain relation with the changes in the sexual organs; or, whether (as I remarked incidentally) we regard. the climacteric as simply a deeply-seated general change in the organism, and assign to the collective processes that occur in the sexual system, as well as to every other climacteric phenomenon, simply the role of a symptom of this deeper change; moreover, whether we consider that the limits of the climacteric are constituted by the beginning and end of the irregular genital hemorrhages that correspond to this period of life, or whether we consider, contrary to the usual custom (which, as I have already said, is extremely necessary), that the first and last pronounced climacteric phenomenon, of whatsoever sort, or the first and last collec tion of climacteric phenomena, indicate the beginning and termination of the menopause, all this must unquestionably influence us in our de cision in every individual case, I might almost say with regard to every phenomenon, and thus, moreover, determine our whole conduct as medi cal advisers in the case in question. The important bearing of these things, I think, might be proved by any example that lies nearest at hand. How much well-meant, but useless labor may be devoted to the carrying out of this or that method of gynecological treatment, in order to remove some distressing climacteric phenomenon, which was through out erroneously believed to depend upon processes situated within the genital tract ! How many accidents, quite harmless in themselves, are innocently suspected as the causes of one or the other disturbance, merely because the regular recurrence of the menses gave rise to the idea that the disturbance in question might be a simple climacteric phenomenon, however this may have corresponded to the true condition ! How often may one or another somewhat striking anomaly be erroneously regarded as the symptom of a more serious affection, merely because the fact that the genital hemorrhages have been absent for a long time, did not lead to the correct supposition that the observer had to do with a transient climacteric phenomenon ! I ought, perhaps, to have introduced these observations on the charac ter and duration of the climacteric at the beginning of my work, and ought to have made them the basis upon which all the subsequent dis cussions should rest. I did not do this, since I was obliged to follow out more thoroughly the facts which were presented for discussion, from the same standpoint from which they ha,d already in great part been viewed briefly, or in extenso from other directions. I also did not do this, because it seemed to me profitable for my readers to be able to know the result of my conclusions from the outset, and that they might, per haps, in- common with myself, be led, simply from the facts of the case, to adopt the views here espoused.