THE MENOPAUSE.
The phenomena of this period are so various and change able, that he must certainly have had a wide experience who has ob served and learned to estimate them all. So ill-defined are the bound aries between the physiological and the pathological in this field of study, that it is highly desirable in the interests of our patients of the other sex, that the greatest possible light should be thrown upon this question.
In undertaking in the following pages to investigate anew this impor tant subject, and to report a series of striking clinie,al observations (with an occasional reference to some view regarding the nature of this period which has particularly impressed me), I hope that I shall contribute in some degree to the advancement of our knowledge in this direction, and that I may possibly incite others to continue the work in this field.
By the " change of life " we understand that phase in the life of a woman in which her sexual activity ceases. In determining the time at which this period begins and ends we usually rely upon the most striking sign, the sudden or more gradual cessation of menstruation; we say in a given case that a woman has entered upon the climacteric when, after reaching a comparatively advanced age, her previously regular periods begin to be irregular, and we say that she has reached the climacteric as long as these irregularities continue, and we infer that she has passed the change of life when menstruation ceases permanently.
With reference to the particular age at which the change usually oc curs, I have numerous statistics that have been elaborated with commend able industry, but it is not my purpose to dilate upon these. Without doubt the change occurs later in Northern people than in those of the South. In our regions the average age is between forty-five and fifty.
What this variation is in certain zones I shall shortly demonstrate on the authority of some recent publications, which have not been utilized by former writers on this subject. A. Queirel and J. Bouvier found that in the vicinity of Marseilles the average age at which menstruation ceases is forty-six yew% and eleven and one half months. Goth states that among the seven different tribes of Transylvania the time at which the menopause occurs varies from thirty-nine to fifty-one years; on the other hand, Rodsewitsch reports that at St. Petersburg the aventge time is
forty-eight years and eight and three-quarter months, while in Moscow (on the authority of Bensenger) it falls between forty-three and forty eight. Of course isolated cases occur everywhere in which the meno pause is delayed until much later than the average time in the given region. In looking through the literature we observe every possible va • riation. For example, in order to select an extreme instance from those now before me, Bri(Tre de Boismont observed two e,ases and Courty one, in which menstruation ceased at twenty-one, while Hegar recalls a case (mentioned in Battey's " Normal Ovariotomy ") in which the periods con tinued to recur until the extreme age of ninety-three, the woman enjoy ing good health. Blancard and Langgland even report cases of persistent menstruation in women one hundred and six years of age. But, aside from such remarkably exceptional cases, in my opinion we cannot insist too strongly upon the necessity of the attending physician ascertaining the cause of the slightest deviations from the normal in this direction.
Still, hereditary peculiarities, or perhaps unknown disturbing influ ences, are sometimes to be held responsible for the premature or delayed appearance of the menopause, but we can sometimes find no possible ex planation, and must be content with accepting it as a so-called " freak of Nature;" but the accurate observer will generally reduce such cases to a minimum, and the variations hitherto recorded will be shown to be com paratively few in number. In by far the larger number of abnormal cases it will be found that some pathological process was the cause, and I make it a rule from the outset to search for such a process in every ease of this kind. To digress slightly, Scanzoni, whose opportunities for clinical observation were so great, mentions a woman aged fifty-three, as the oldest whose hemorrhages he was " inclined '' to reg,ard as really of a menstrual character; in every instance above this limit he was able to find, either in the living subject or after death, some pathological fa, tor to account for the hemorrhage. I myself, who have recently given some attention to the subject, can add only one case in which the menses persisted after fifty-four without some discoverable cause.