It is clear from what has been said that the duration of this so-called period of the climacteric varies greatly. It may be extremely short, or may extend over years. It usually occupies from one to three years. The much longer period noted by some authors (Tilt et alii) in different cases always awakens the suspicion that there was present some latent local or general disease.
As regards the physiology of the menopause we do well, in my opinion, to adhere to Hegar's view that the ut,erus and vagina form the duct of a gland, the ovary. Disappearance of this gland results, as in similar pro cesses in other glands, in disappearance of the duct also, just as at the formative period of the organism the development of the duct is related to that of the gland. When the ovaries are wanting, the uterus and tubes are absent or imperfectly developed. In case of absence or rudi mentary development of one ovary, the corresponding cornu of the uterus is wanting or rudimentary. At the time of the menopause this disap pearance of the gland, or atrophy of the ovary, takes place; it is accom panied by a more or less sudden cessation of menstruation, and a retro grade metamorphosis of the uterus, vagina, and external genitals. A trophy of the ovaries occurs very gradually. Puech found in one case that the ovaries were of normal size three years after the establishment of the menopause. Kiwisch describes the structural changes in this gland as consisting on the one haud in an increase of the connective-tissue stroma from the periphery towards the centre, the gradual hypertrophy of which results in destruction of the epithelial elements, and on the other hand, the Graafian vesicles themselves undergo retrograde change, fatty degeneration leading to complete atrophy of 'the granular epithelium and consequent cystic transformation of the vesicle with contraction of its cavity, and new formation of young connective tissue, which latter finally increases to such an extent that the entire ovisac is transformed into a fibrous mass. In consequence of these microscopical changes, which, as has been stated, take place very slowly, according to the same author, the entire organ becomes harder and smaller, decreases in length and breadth, and its exterior becomes nodular. In old age the ovary shrinks to a " flat, fibro-vascular induration." Waldeyer in one instance found no ovisacs present four years after the cessation of the menses.
Since, in order not to digress too far, I can not enter more minutely into the much-discussed question of the relation between o_vulation and menstruation, I must entirely omit a more extended consideration of the question as to whether the atrophy of the ovaries at the climacteric does or does not have an influence upon the cessation of menstruation. It should only be noted that at the menopause the before-mentioned disap pearance of the functional activity of the ovarian gland is attended with a more or less rapid cessation of tho periods, and that in view of this re• lation it is difficult for one to come to the conclusion that menstruation is independent of ovulation; this is especially true when we consider also the effect upon menstruation produced by entire extirpation, or general disease of the ovaries, or recall the fact that menstruation has never been observed in cases where the ovaries were originally absent or imperfectly developed. (Puech.) However, it might of course be quite different, and both the phenomena of ovarian atrophy and of cessation of the menses at the climacteric, might be the more or less simultaneous consequences of a third factor, to which we shall refer again. That the atrophy of the ovaries precedes that of the uterus, is probably due as llegar believes (supported by Krieger) to the cessation of the reproductive power in women before the occurrence of the menopause. The idea that the ovum
is no longer sufficiently developed to become fertilized, furnishes, in his opinion, a natural explanation of this relation. On the other hand, lIegar thinks also that a proof of the independence of the monthly flow and ovulation is furnished by those cases where pregnancy has occurred after menstruation has ceased for years, but where formerly the periods re curred normally for months.
As before stated, retrograde metamorphosis takes place also in the uterus, vagina, and external genitals. An increase in the size of the uterus (from increase in the amount of blood) is frequently noticed at the beginning of the menopause; later it becomes smaller in all its dimen sions. The wall of the organ becomes much thinner, the os internum smaller, and is often even obliterated. The cervix becomes shorter and thinner (Krieger), sometimes hard, sometimes as flabby as a membrane (Canstatt). Uterine catarrh occurs almost invariably, and only ceases in advanced years. Displacements of all kinds are frequent, but, on account of the now greatly-diminished weight of the uterus, these are without significance. The vagina, is at first almost always unifoi.mly hyperaemic. This disappears as the vessels successively atrophy, but it takes place much sooner in some spots than in others, hence that characteristic appearance of dark-red spots on a very pale ground. Whether or not it assumes the character of a true inflammatory process, gradually the vaginal canal becomes partly or entirely contracted, so that it is narrower, shorter, and often assumes quite a conical shape at its upper end. The nincous meinbrane gradually loses its rugw, and presents a pale, grayish, blanched hue (Krieger). The introitus is also narrowed and its mucosa shows the same changes. lIegar has properly called our attention to the fact that coitus in individuals with the " contractions and even strictures so often observed," representing the results of this atrophic change at the climacteric, may prove the source of nervous manifestations The changes in the mons veneris and labia consist in the gradual dis appearance of their adipose tissue. We must certainly agree with Kisch in attributing the final transformation of the labia into mere flaps of skin, the thinning out of the pubic hair, essentially to senile changes, and not directly to those of the climacteric. Still, it seems to me that it is diffi cult to make a precise distinction in this respect. Even these last mentioned tissue-changes, as well as most of those before described are observed sometimes earlier, sometimes later. IIegar adds with regard to the shrinking processes just mentioned, that we see them after the cli macteric, and " sometimes even in younger women." We must refer at least the beginning of all these changes to the thne of the menopause; the further development of the same, then, is included within the limits of this period, or extends more or less beyond them. Only in this way do we assign to these changes their proper sphere; the process which is im plied iu them all, retrograde metamorphosis, which affects the entire sexual system of the woman, has its definite beginning, at least, at the time of the menopause In this connection the folloWing case of Chad wick seems to me to be very instructive: A woman aged forty-eight had not menstruated for about ten years, and indulged in sexual inter course after having refrained from it for four montlts; in consequence she had violent pain and profuse hemorrhage. Chadwick discovered( in the upper third of the vagina a recent tear all inch long, extending to the depth of half an inch into the cellular tissue. The vagina, " on account of senile atrophy,'' was considerably shorter and narrower than it was origi 'tally.