We must always bear in mind certain general facts regarding the causes that influence the appearance of the climacteric, but these should never lull us into a feeling of security, und lead us to forget to make a rigid ex amination in any given case. Such causes, as we have already hinted, are climate, nature of the soil, elevation of place of habitation, race, mode of life, social relations, and the early or late establishment of the menses in the individual case; thus Schlichting says that nienstruation begins earlier in the women of Berlin than in those of Munich, which is about 1600 feet lower than the former city-, and Goth finds menstruation begins among the Germans inhabiting Transylvania at the same time as it does among the former dwellers in that country who now live on the Rhine. The latter also says that in all countries the Jews show the same tendency to early establishment of the menses, while among both Jews and Rouma.nians the early appearance of the menopause was striking.
Excessive sexual activity, especially numerous and rapidly succeeding pregnancies, leading to " premature marasmus of the woman " (Scanzoni), favor early appearance of the menopause. According to Kisch the sexual function is generally abolished earlier " in the laboring class, who are compelled to work hard and have many cares." Krieger decides, from observations of Mayer's, with regard to social status. that in women of the lower ranks the menopause occurs earlier than in the well-to-do and rich. As regards the time at which menstruation begins, it has been shown by Krieger, Kisch and others, that the earlier the menses appear, the later they cease and vice versa; however, when the first period is unusually early or late, the change of life comes very early. Some (as Tilt) think differently, while others (as Queirel and Rouvier) affirm that the time of appearance of the menses has no marked influence on the time of the menopause.
Mv own experience is that it is often difficult to establish the above mentioned causal relation between the time of establishment and the cessation of the menses, because the exceptions are so numerous, and the causes of the variation in this or that direction in individual eases play such an important part. But we can depend upon a certain law, riz., that there is a certain limit to the sexual activity of the normal female. Other things being equal, it is self-evident that in the perfectly healthy woman this " normal time " for the beginning of menstruation corre sponds with the " normal time " for the cessation of sexual activity. If we describe the former as " early " which we are justified in doing, con sidering the relatively late beginning of menstruation in many abnormal cases, and the latter as " late " (in comparison with the premature devel opment of the menopause in many abnormal cases), it certainly follows that there is some connection between the early appearance and the late disappearance of the periods. Since this law depends more or less ex clusively upon the normal condition of the organism, deviations from the same must be related to abnormalities of the organism, and here as in all other cases, the rules can hardly be established by the exceptions. Too early or too late establishment of the menstrual function can, in conse quence of the abnormal condition that causes it, also be associated with premature menopause; but, as I and many others have had an opportunity of observing, in both instances the change is just as likely to occur at the proper time, or too late. In this sense I would understand Kisch's very
interesting explanation of the " greater sexual vitality " which prevails in certain women, which in his opinion lies at the bottom of the relation above-mentioned, especially when abnormal conditious exist. This . " increased vitality " may consist to some extent in an increase of the usual normal condition, and may really approach the abnormal. The author himself gives us some reason to think thus by confining this peculiarly to certain women." It seems to me that the first principle is properly applied as a rule to the healthy female, every case of " in creased vitality " being regarded as abnormal, or at least as a transition to the abnormal. We could certainly speak of greater vitality, as shown not only in premature menstruation and very late menopause, but also merely when the first period appears very early (the menopause being normal or premature), or in cases of very late climacteric alone. As regards the manner in which menstruation ceases, every possible variation is observed. The time of its appearance is delayed; the intervals become longer (six weeks to several months) or shorter (fourteen days). The flow continues longer, often during the entire intermenstrual period; there is seldom a diminution in the amount. Continuous and slight losses of blood often alternate. The quantity is often much larger than usual, and may amount to a perfect out-gush. Between the periods we again observe for some time insignificant hemorrhages. The amount of blood lost during the entire time of the climacteric is rarely leas than during the early normal periods. The blood itself is often watery, or darker than usual, and is frequently mixed with a quantity of mucus. The condition described is the one commonly observed. Less often the periods cease suddenly, the patient suffering more or less, or (as I re cently noted in some cases) the menstrual flow may gradually decrease, becoming less and less, until it finally ceases entirely. For example. a woman began to be irregular at forty-three, and continued so till she was forty-five, the menses at first recurring every three weeks, then every four, five, six weeks, then every three months, then every six, and finally they disappeared. The hemorrhage each time was less than it was at the preceding period. After the cessation there was moderate leucorrhwa and sweating, which continued for some tirne longer. Another peculiar form which has interested me, and which I have certainly encountered but rarely, is as follows: At about the age of forty, as far as I could estimate it, in perfectly normal women, the menses fail to appear on one or two occasions, and then recur quite regularly for several years, eventu ally ceasing at the usual time for the menopause, and in the usual man ner. Finally, I may mention here that the sudden cessation of menstrua tion, of which we shall speak more at length, subsequently takes place, as before-mentioned, with more or less disturbance, although this is by no means absolutely necessary. 3rloreover, I have observed some women in whom the last period appeared at the usual time, and followed the normal course, and neither before nor after it was any disturbance of the geneml health noted. It by no means necessarily follows that some pathological process is always at the bottom of sudden cessation of men struation.