A CONSIDERATION OF THE 
 
 PHENOMENA WHICH OCCUR TO WOMEN 
 
 AT THE CLOSE OF THE CHILD-BEARING PERIOD, 
 
 WITH INCIDENTAL ALLUSIONS TO THEIR RELATIONSHIP 
 
 TO MENSTRUATION. ALSO A PARTICULAR 
 
 CONSIDERATION OF THE PREMATURE 
 
 (ESPECIALLY THE ARTIFICIAL) 
 
 MENOPAUSE 
 
 BY 
 
 ANDREW F. CURRIER, A. B., M. D. 
 
 NEW YORK CITY 
 
 NEW YORK 
 
 D. APPLETON AND COMPANY 
 1897
 
 C <?7< 
 
 COPYRIGHT, 1897, 
 BY D. APPLETON AND COMPANY.
 
 J 
 
 TO i 
 
 THE MEMORY OP MY DEAR MOTHER, 
 
 LONG AT REST, 
 
 THIS BOOK IS AFFECTIONATELY 
 INSCRIBED.
 
 PREFACE. 
 
 IT is many years since an original work 
 on the menopause in the English language 
 has appeared before the public. Tilt's work 
 upon this subject was long the only one of 
 its kind, and was last seen in a reprint pub- 
 lished in this country some fifteen years ago. 
 That work may have been useful in its day, 
 but it contained a great deal of statistical 
 information from which, as it seems to the 
 writer of the present work, unwarrantable 
 deductions have been drawn. It also has 
 handed down the hoary tradition, which has 
 been current from time immemorial among 
 both the laity and the profession, that the 
 menopause is an experience fraught with 
 peril and difficulty. This and all similar 
 teaching the writer declares to be incorrect
 
 VI 
 
 PREFACE. 
 
 and unwarrantable in the light of his own 
 experience and observation. 
 
 Tilt's book is further defective because 
 the great fund of information which has 
 accumulated in connection with the artificial 
 menopause did not exist in his time. 
 
 A translation of a German work on the 
 menopause by. Borner was published in this 
 country about the same time as the reprint 
 of Tilt. This work, though very brief, is a 
 decided improvement, in the writer's opinion, 
 upon Tilt. It seems to have grasped the 
 subject in a more philosophical and scientific 
 manner than the work of Tilt, but is deficient, 
 nevertheless, upon certain important phases, a 
 comprehensive study of which has only been 
 possible within the past few years. 
 
 The writer would beg leave to say that he 
 has had the subject of this work under con- 
 sideration many years. He was never able to 
 see the sense nor the logic of the traditional 
 teaching, repeated generation after generation, 
 that the menopause was a serious yea, even 
 a most dangerous time and experience ; that
 
 PREFACE. vii 
 
 the matron and the maid alike should ap- 
 proach it with fear and awe ; that if this 
 dangerous Rubicon were once passed, joy and 
 felicity would wait upon the remaining years 
 of life. 
 
 If haemorrhage were exhausting the pa- 
 tient, she was told that if she could only pass 
 the menopause she would be secure, no mat- 
 ter whether the haemorrhage were due to 
 benign or malignant disease, and if the meno- 
 pause were suspected, too often the doctor 
 neglected to examine his patient and find out 
 with assistance, if unable alone whether 
 the disease were benign or malignant, and 
 whether there was good reason for thinking 
 that the menopause could produce a cure. 
 Now, in so far as this condition of opinion 
 exists at the present time, if it does exist, 
 either in the lay or the professional mind, to 
 that extent the writer wishes to lift up his 
 voice in earnest protest. The menopause is 
 not a dangerous time or experience for the 
 majority of women, any more than puberty 
 is. The majority of women pass through it
 
 viii PREFACE. 
 
 with as little incident or discomfort as they 
 experience at puberty. It is only the excep- 
 tional woman who has a hard time, and comes 
 to the doctor to tell him about it. Upon this 
 exceptional experience the doctrine of the 
 danger and serious character of the meno- 
 pause has been built up. 
 
 Another serious error which it is the 
 writer's desire to controvert is the very prev- 
 alent one that there is in some way the most 
 intimate relationship between cancer, espe- 
 cially cancer of the womb and the breast, and 
 the menopause. That many cases of malig- 
 nant disease do occur during the decade in 
 which the menopause usually takes place is 
 true. While this number is probably larger 
 than during any other decade, it by no means 
 includes the greater number of all cases, and 
 it is ridiculously small in its percentage when 
 compared with the total number of women 
 who undergo the experiences of the meno- 
 pause. Thus the principal props of this 
 threadbare theory of the dangerous character 
 of the menopause are seen to be composed of
 
 PREFACE. ix 
 
 the flimsiest material. Let us knock them 
 down and bury the rubbish out of sight and 
 memory. 
 
 So far as the writer is aware, little or no 
 attention has been given, in books similar to 
 this one, to the subject of the artificial meno- 
 pause. The great development of abdominal 
 and pelvic surgery within the past generation, 
 and the enormous number of women, tens of 
 thousands, who have been deprived of their 
 ovaries, for one reason or another, has opened 
 up a rich field for the investigation of the 
 phenomena which attend the removal of 
 those important organs. It is hoped that the 
 writer's contribution to that subject, imper- 
 fect as it is, may not be uninteresting to his 
 professional brethren, and may perhaps stimu- 
 late some one who may be better qualified to 
 pursue the study more exhaustively. 
 
 Concerning the question of the treatment 
 of the ills of the menopause, the writer earn- 
 estly hopes that his book may stimulate those 
 into whose hands it may fall, first, to a more 
 careful and systematic investigation of those
 
 x PREFACE. 
 
 ills than has been the usual custom, and, sec- 
 ond, to an early resort to surgical measures if 
 surgical measures are indicated. There are 
 many cases which can and should be relieved 
 by such measures, and it is hardly just or 
 scientific or humane to load them down with 
 drugs month after month, in the most em- 
 pirical fashion, if the condition is one which 
 can be effectually and permanently relieved 
 by the timely resort to surgery. 
 
 ANDREW F. CURKIEK, M. D. 
 
 NEW YORK, March, 1897.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAGES 
 
 HISTORICAL AND OTHER PRELIMINARY CONSIDERATIONS. . 1-40 
 
 On the choice of a term, 1. Relation to menstruation, 3. 
 Menstruation defined, 4. Literature of the subject, views of 
 ancient writers, etc., 5. Modern and recent writers and their 
 scope, 10. New significance to the subject through the de- 
 velopment of abdominal and pelvic surgery, 11. Various data 
 concerning the menopause, 13. The menopause should be a 
 normal function or experience ; previous teachings to the con- 
 trary are erroneous, 14. Amplified definition, 15. Exagger- 
 ated views concerning the menopause as a critical time for 
 good or evil, 16. Views of Kisch upon the subject, with analy- 
 sis of his table, 18. Analysis of Tilt's table, 21. Other statis- 
 tics, 22. Explanation of possible degenerative changes in the 
 tissues during the menopause, 25. Physical condition of wom- 
 an when the era of the menopause is reached, 27. Age, 28. 
 Experiences: 1, Normal, 28; 2, Moderately troublesome, 30 ; 
 3, Severe, 30; 4, Serious, 32. Table of cases of malignant 
 disease at the Skin and Cancer Hospital, 33. Classes or types 
 of women in conformity with the above classification, 35. 
 
 CHAPTER II. 
 
 CONSIDERATIONS CONCERNING THE ORGANS OF THE GENITAL 
 APPARATUS; ANATOMICAL CHANGES RELATED TO THE 
 
 MENOPAUSE 41-88 
 
 1. Anatomical changes which are the result of the meno- 
 pause, 42. 2. Anatomical changes which produce the meno- 
 pause, 42. 3. Anatomical changes which are coincidental with 
 the menopause, but not usually its cause or caused by it, 42. 
 xi
 
 xii CONTENTS. 
 
 PAGES 
 
 Study, in detail, of the changes in the reproductive organs 
 which result from the menopause, 42. 1, The ovaries, 42; 
 2, The uterus, 53 ; 3, The Fallopian tubes, vagina, and cli- 
 toris, 62 ; 4, The mammary glands, 64. Changes in other 
 structures of the body, 66. 
 
 Study of the changes in the reproductive organs which lead 
 to the menopause, 66. 1, The ovaries and Fallopian tubes, 66 ; 
 2, The peritonaeum, 70 ; 3, The uterus, 70 ; 4, The vagina, 75 ; 
 5, The mammary glands, 76. 
 
 Study of those changes which are merely coincidental with 
 the menopause, 78. Subin volution, 79. Malignant disease, etc., 
 80. Influence of destruction of the genital organs, 85. Besume 
 and conclusions, 86. 
 
 CHAPTER III. 
 
 SOME OF THE FACTORS WHICH INFLUENCE THE ADVENT AND 
 
 PROGRESS OF THE MENOPAUSE 89-186 
 
 Scheme of treatment of the subjects in this chapter, 90. 
 Unusual activity of the genital organs with increased vascu- 
 larity noticeable at the beginning of the menopause, 90. 
 Changes in habit and temperament as the menopause pro- 
 gresses, 91. Factors which influence the menopause vary for 
 different women and affect them with different degrees of 
 force, 92. Factors : 1, Age ; 2, Disease and traumatism ; 3, 
 Climate ; 4, Heredity ; 5, Temperament ; 6, Accidental influ- 
 ences, 92. 
 
 1. Age of the menopause as observed by the author, 93; 
 Kisch, 96 ; Leudet, 96 ; Tilt, 97 ; Faye, 97 ; Mayer, 97 ; Burner 
 and others, 97. Cases of early menopause, 99. Cases of late 
 menstruation by Battey, Felty, and others, 100. Conclusion as 
 to age limits for the cessation of menstruation, 102. 
 
 2 Disease and traumatism in their influence upon the 
 menopause, 102. 
 
 A. (a) Acute inflammatory processes, 'i 
 (6) Chronic " " 
 
 B. Degenerative processes. \ Classification, 103. 
 
 C. Neoplasms. 
 
 D. Trauma. 
 
 Subdivisions of (A) (a) acute, 103, and (J) chronic, 103, in- 
 flammatory processes. The acute are divided into (I) gen-
 
 CONTENTS. xiii 
 
 PAGES 
 
 cral and (II) local, the latter being subdivided into (x) puer- 
 peral, and (y) non-puerperal, ((c) infectious, (d) traumatic). 
 
 (b) Chronic inflammatory processes, 108. Wasting diseases 
 of the lungs and kidneys, 110. Diseases and disorders of the 
 nervous system, 112. Detailed statements concerning the in- 
 fluence of (B) degenerative processes, atrophy, obesity, de- 
 fective development, 115. 
 
 Influence of (C) neoplasms on the menopause, 120. Be- 
 nign and malignant, 121. The latter tend to increase the 
 menstrual flow and defer the menopause, the former may 
 hasten it, 122. 
 
 (D) Trauma as a factor in the development of the meno- 
 pause, 130. 
 
 3. Climate, including altitude and atmospheric conditions, 
 131. Observations of Leudet, 132, Kisch, 133, Bonier, 133, 
 Lieven, 134, Hannover, 134, and others concerning the in- 
 fluence of climate, 133. Influence of atmospheric pressure, 1 36. 
 
 4. Heredity, including family, national, or race pecul- 
 iarities, 139. The bearing of fertility and sterility upon the 
 menopause, 143. 
 
 5. Temperament, habits, occupation, and social surround- 
 ings, 150. Sexual excess and abstinence, 155. Concerning the 
 Oneida Community, 159. Prostitutes, 161. Influence of sexual 
 abstinence upon the menopause, 166. 
 
 6. Accidental influences, fear, emotion, grief, etc., 167. 
 Statistics with reference to conditions bearing upon the meno- 
 pause, 169. The influence or bearing of the menopause upon 
 ovulation and conception, 180. 
 
 CHAPTER IV. 
 
 THE PHENOMENA OF THE MENOPAUSE, NORMAL AND MORBID, 
 
 AND THEIR DURATION 187-229 
 
 The type of experience during the menopause should be 
 a condition of health ; it is not critical in the sense that it is 
 dangerous either to life or health, 187. Phenomena which are 
 common to the menopause and others which are less common 
 or infrequent, 190. Vasomotor phenomena and their types, 
 191. 1, Heat flash: 2, Sweating; 3, Sweating with chill or 
 shudder ; 4, Headache ; 5, Melancholia ; 6, Chilliness of ex- 
 tremities ; 7, Abundant discharge of urine ; 8, Diarrhoea and
 
 xiv CONTENTS. 
 
 PAGES 
 
 pelvic congestion, 194. Gastro-intestinal disturbances, es- 
 pecially 1, Constipation ; 2, Intestinal or gastric fermenta- 
 tion ; 3, Loss of appetite and indigestion, etc ; 4, Diarrhoea, 
 194. Pseudo-pregnancy, 195. Anaemia, 196. Haemorrhages, 
 197. Opinions of Scanzoni, 202; Kisch, 202; Frank, 203; 
 Hegar, 203. Lesions of the mind and nervous system in con- 
 nection with the menopause, 204. Observations of Merson, 
 204, and Hegar, 205. Hallucinations and sexual ardor, 206. 
 Climacteric insanity, investigations and investigators in this 
 field, 207. Lesions of the skin which accompany the meno- 
 pause, 218. Cases recorded by Grellety, 219, Martineau, 220, 
 Deligny, 221, and others. Lesions of other parts or organs, 
 221. Asthenopia, 222. Gastric troubles, 223. Cardiopathies, 
 223. Other lesions, especially those of a functional character, 
 224. 
 
 CHAPTER V. 
 
 THE PREMATURE MEXOPAUSE 230-266 
 
 Definition, 230. Relations to the natural menopause, 231. 
 Disease as a cause may be constitutional or local, 231. Other 
 causes climate, heredity, wasting diseases, 231. Excesses, 
 poverty, venereal disease, poisons, obesity, 233. Excessive 
 fertility, 235. Traumatism as a cause, 236. Artificial meno- 
 pause, 237. Respective claims of Battey and Hegar, 239. 
 Indications for the artificial production of the menopause, 
 240. 1, Inflammatory disease of the appendages, 241. 2, 
 Neoplasms of the appendages, 242. 3, Ovarian neuralgia or 
 dysmenorrhoea if severe and of considerable duration, 242. 
 4, Cases in which Caesarean section has been required, the 
 natural passages being entirely incompetent for the delivery 
 of a viable child, 243. 5, Osteomalacia, 243. 6, Severe dis- 
 ease of the uterus which can be relieved by no less severe 
 measures, 243. Insanity and epilepsy, per se, not indications, 
 243. The phenomena of the premature menopause, including 
 those which accompany operations for its production, 244. In 
 some cases the cessation of menstruation is the only symptom 
 of note, in others the symptoms are more or less like those 
 which come with the natural menopause, 244. Glaevecke's 
 investigations, 246. Battey's conclusions, 248. Observations 
 of Hegar, 250. Experience of the author in this field, 252. 
 Removal of one ovary and tube, even though seriously dis-
 
 CONTENTS. xv 
 
 PAGES 
 
 eased, does not bring the menopause, 253. Kemoval of both 
 ovaries and tubes has invariably brought the menopause, ex- 
 cepting in cases of uterine myomata with attachments to sur- 
 rounding structures, 254. Atrophy of the genital organs which 
 remain proceeds rapidly, 256. Influence upon the sexual appe- 
 tite, 257. The operation for producing the menopause does not 
 in all cases relieve the pain which may have been one of the 
 chief indications for its performance, but the pain will subside 
 eventually, 259. Effect of removing the ovaries prior to pu- 
 berty, 260. The analogous operation in young animals may 
 suggest the changes which might occur in the human female, 
 260. Arrested development of the genital organs, 261. Ap- 
 parent menopause occurring prematurely from disease, from 
 the influence of sea air, 262. Propriety and utility of attempts 
 to restore suspended menstruation, 264. Many cases entirel7 
 hopeless, 265. 
 
 CHAPTEE VI. 
 
 RETARDED MENOPAUSE 267-269 
 
 Definition : Cases of true menstruation beyond the fiftieth 
 year very infrequent, 267. Petrequin, 268. Scanzoni's limit, 
 268. (See also Chapter III, under Age, p. 101.) Mayer's cases, 
 also those of Kennedy, Eodsewitch, Sutherland, 268. 
 
 CHAPTEE VII. 
 
 TREATMENT 270-283 
 
 First requisite during the menopause is watchfulness on 
 the part of both patient and physician, 270. Treatment ia 
 that of symptoms, as they appear, 271. Diet should be sim- 
 ple, bowels kept freely open, sedatives given as indicated, skin 
 kept active, 273. Eemoval of blood when the genitals are con- 
 gested and cause erotism, 274. Particular attention should be 
 given to the haemorrhages of the menopause which are not 
 physiological, 274. Treatment is mainly surgical, 275. The 
 means which may be of use are the electro-cautery, curette, 
 tampon, etc., 276. Hysterectomy is indicated if the symptoms 
 are severe or threatening, 277. Astringent drugs sometimes 
 beneficial to check hiemorrhage, 277. Treatment of the neu-
 
 xvi CONTENTS. 
 
 roses of the menopause, especially the mental disorders, 278. 
 Depletive measures indicated, also hygienic and dietetic meas- 
 ures, 279. For treatment of neuralgias, etc., consult standard 
 works on diseases of the nervous system, 280. Cutaneous le- 
 sions treated locally, 280. For other lesions see works on 
 general medicine, 282.
 
 THE MENOPAUSE. 
 
 CHAPTER I. 
 
 IIISTOKICAL AND OTHER PRELIMINARY CON- 
 SIDERATIONS. 
 
 Definition. What do we mean by the 
 term menopause? Obviously the cessation 
 of the menstrual function. But is that all ? 
 By no means, for the arrest of the monthly 
 discharge of blood forms but a single inci- 
 dent in the concatenation of events which 
 occur in the experience of a great number 
 of women who reach and pass the limit of the- 
 childbeariug period. 
 
 Want of Comprehensiveness of tlie Term. 
 The definition which has been given is there- 
 fore lacking in comprehensiveness, and specifies 
 only one of the most noteworthy and impor- 
 tant facts which occur at an important epoch 
 
 in a woman's life. 
 
 2 l
 
 2 THE MENOPAUSE. 
 
 Substitutes for Term employed and their 
 Ambiguity. Should we then substitute for 
 menopause the term change of life, critical 
 time, climacteric, etc., as many writers have 
 done ? No, for these terms involve more of 
 ambiguity than does menopause. 
 
 The change of life is, with many individ- 
 uals, quite as definite an event at puberty as 
 at the end of the period which is inaugurated 
 by puberty nay, in many cases that change 
 is even more definite. 
 
 Critical times occur frequently in the lives 
 of some women,* and climacteric merely sub- 
 stitutes a synonym of Greek origin in the 
 place of critical time or period. 
 
 Obsolete Terms. Other terms such as 
 dodging time, climacteric disease, etc., have 
 become obsolete for various good reasons, 
 and need only be mentioned. 
 
 * Several periods in the lives of both men and women, 
 and not identical in the two sexes, have been determined by 
 different writers as critical or climacteric periods. See Hal- 
 ford, Medical Transactions, Royal College of Physicians, 
 London, 1813, iv, p. 316; Connolly, Dublin Journal of the 
 Medical Sciences, 1844, xxv, p. 245; O'Connor, ibid., 1875, 
 Ix, p. 78.
 
 PRELIMINARY CONSIDERATIONS. 3 
 
 The Term Menopause to he employed. 
 On the whole, while admitting the narrow- 
 ness of its etymological scope, the term meno- 
 pause is as little objectionable as any that is 
 now available, and will therefore be em- 
 ployed in this work to direct the mind of the 
 reader to the events which transpire during 
 those months and years in the life of a 
 woman when the childbearing function is 
 drawing to its close a period forming an 
 isthmus between growth and decay, a lull 
 between flowing and ebbing tides, a mile- 
 stone to mark the end of a definite period 
 of existence. 
 
 Relation to Menstruation. As the term 
 which has been thus chosen refers definitely 
 to the cessation of an important function, no 
 apology will be deemed necessary for such 
 reference to and consideration of that func- 
 tion as may have a bearing upon the sub- 
 ject in hand; at the same time no attempt 
 will be made to analyze exhaustively the 
 various interesting propositions in histol- 
 ogy and physiology with which it is in-
 
 4 THE MENOPAUSE. 
 
 timately related, in which both speculation 
 and fact are abundant, and concerning 
 which there still remains much to be 
 learned.* 
 
 Menstruation defined. As a working 
 definition of menstruation it may be said that 
 it is a function common to females of the 
 human species during that portion of life in 
 which fruitfulness is a characteristic. It 
 recurs with tolerable regularity each lunar 
 month and continues the greater portion of 
 a week. Its chief objective feature is a dis- 
 charge of blood from the uterine canal with 
 which epithelium and glandular secretion 
 from the uterus and vagina are mingled. 
 With the discharge are frequently associated 
 phenomena of considerable variety, appertain- 
 ing principally to the vascular and nervous 
 systems. From this definition the many ir- 
 
 * For the consideration of the subject of menstruation, es- 
 pecially in its histological aspect, the reader is directed to the 
 writings of Leopold, Wyder, Moricke, Kundrat and Engel- 
 mann, and John Williams, and for an exhaustive considera- 
 tion of the function to the brochure of Dr. Mary Putnam 
 Jacobi, American Journal of Obstetrics, 1885.
 
 PRELIMINAEY CONSIDERATIONS. 5 
 
 regularities of menstruation which are possi- 
 ble may be deduced.* 
 
 Importance of Menstruation has been ob- 
 served for Ages. From time immemorial 
 the importance of the menstrual function in 
 women has been a recognized fact among 
 critical observers. Its significance has, of 
 course, been differently interpreted by ob- 
 servers in different ages and in different con- 
 ditions of intellectual development. Among 
 the crude, the barbarous, and the super- 
 stitious the solution of such a problem 
 would not be one which would be univer- 
 sally satisfactory. Even among highly de- 
 veloped nations, like the Greeks, the inter- 
 
 * "The menstrual flow is due to the influence of the tubo- 
 ovarian (hypogastric) plexus which, in its turn, is controlled 
 by the solar plexus. The uterus, tubes, and ovaries are sup- 
 plied by the hypogastric plexus, and menstruation must con- 
 tinue as long as the influence of this plexus continues. With 
 the cessation of this influence the flow ceases and atrophy of 
 structure begins. The radiating currents of the ganglionic 
 centers with all their protean reflex actions are the sources of 
 the phenomena of the climacteric. When they are no longer 
 needed for reproductive purposes they expend their force in 
 every conceivable direction." Nowlin, The Climacteric, its 
 Phenomena and Dangers, Nashville Journal of Medicine and 
 Surgery, 1895, Ixxvii, p. 7.
 
 6 THE MENOPAUSE. 
 
 pretation could not be expected to conform 
 to the facts because of imperfect knowl- 
 edge in physiology and anatomy. And 
 among the observers of recent times, with 
 incorrect and imperfect views of pathology, 
 menstruation and its aberrations must neces- 
 sarily receive an entirely different interpre- 
 tation from that which is given them by us 
 who enjoy the accumulation of the knowl- 
 edge of all previous ages, but more especially 
 the results of the precise investigations of 
 the century which is now drawing to a 
 close.* 
 
 The Egyptians, who investigated so many 
 matters concerning the human body, realized 
 that menstruation was an important function. 
 This is shown in the books of Moses, much 
 of the information in which was derived 
 
 * For example, Paracelsus believed that the menstmal 
 blood was the greatest of poisons, and that with it the devil 
 produced spiders in the air; also that fleas, beetles, cater- 
 pillars, and other insects were generated by it. Democrates 
 in his Book of Antipathy declares that all those caterpillars 
 and other insects which destroy a garden fall off and die if a 
 woman with her menses upon her walk three times around 
 each quarter of the garden barefoot and with her hair loose.
 
 PRELIMINARY CONSIDERATIONS. 7 
 
 from Egyptian sources, and in which a men- 
 struating woman was declared ceremonially 
 unclean, coitus with her being forbidden, etc. 
 
 The Menopause not carefully observed by 
 most of the Ancient Writers. But while the 
 importance of menstruation was quite gener- 
 ally recognized among the more acute of 
 the ancient observers, it was not so with 
 the menopause. By some it was passed 
 over as a matter occult and inexplicable, 
 and, in general, it failed to receive that broad 
 and philosophic treatment with which so 
 many questions were discussed by the an- 
 cients. The following selections will show, 
 however, that with some of them the sub- 
 ject had not escaped their attention. 
 
 The Humoral Pathologists.^l&s humoral 
 pathologists believed that the humors or 
 juices ascended like gases, and that they 
 often settled in the brain and produced great 
 disorder, which required the abstraction of 
 blood from the head, arm, foot, or other part. 
 In the cessation of the menses, either tempo- 
 rarily or permanently, they saw the possibility
 
 8 THE MENOPAUSE. 
 
 of serious consequences, and they are prob- 
 ably responsible for much of the foreboding 
 of evil which is associated with the meno- 
 pause in the minds of so many of the 
 laity* 
 
 * Amid much that is curious in the writings of the hu- 
 moral pathologists we find it stated by Hoffmann, one of 
 their number, that if venesection is omitted when the menses 
 cease, violent cardialgias will result, accompanied with in- 
 tense heat and pain about the praecordia, the back, and scapu- 
 lae, especially in the nighttime. Others will suffer with in- 
 tolerable heat, pain in the joints, and erysipelatous fevers, 
 while still others will be affected with nephritic disorders 
 accompanied with pain in the loins, and terminating in cal- 
 culous concretions. Furthermore, some women, after their 
 sixtieth year, have discharges of bloody urine, or are seized 
 witli an immoderate discharge of their menses which at last 
 terminates in an hectic. Some women, especially those who 
 are wasted by prolonged grief, have been afflicted with pain 
 in the left hypochondrium accompanied with uneasiness and 
 heat of the praecordia, which afterward terminates in a vio- 
 lent vomiting of blood or the morbus niger of Hippocrates. 
 In such patients upon opening their bodies the spleen has 
 been found preternaturally large and putrid, the vasa brevia 
 of the stomach ruptured and gaping, and the blood discharg- 
 ing from these vessels into the ileum. 
 
 James, a writer of the early part of the eighteenth cen- 
 tury, states that unless women at the menopause are relieved 
 by seasonable venesection or by increasing the evacuations of 
 urine or transpiration, they generally become afflicted with 
 various "chronical" disorders. 
 
 Hippocrates, in his work on Diseases of Women, says: 
 "We learn from experience that exulcerations, violent and
 
 PEELIMINARY CONSIDERATIONS. 9 
 
 Modern Writers. The modern literature 
 of the subject is, of course, of a much less 
 sensational character than the ancient. Its 
 volume is not large when compared with the 
 literature of kindred subjects of a gynaeco- 
 logical character, the latter having increased 
 enormously in recent years. In the first half 
 of this century appeared a number of papers 
 and volumes treating of the menopause, prin- 
 cipally by French authors, only two of which 
 are particularly alluded to by Tilt in his 
 well-known work upon this subject. 
 
 Gardanne and Menville. One was by 
 Gardanne* and was published in 1861, and 
 the other by Menville,f published in 1840. 
 Tilt's opinion of these works, frankly ex- 
 
 even scirrhous tumors of the uterus, are sometimes produced 
 by cessation of the menses. Neither do the external parts of 
 the body escape the fatal consequences of such suppression, 
 since we know from experience that by this means they are 
 frequently affected with the itch, the elephantiasis, boils, 
 erysipelatous disorders, or scirrhous tumors." 
 
 In all this crude material there is the shadow of very im- 
 portant truths. 
 
 * Avis aux Femmes'entrant dans 1'Age critique. 
 
 t Du Temps critique chez les Femmes.
 
 10 THE MENOPAUSE. 
 
 pressed, is that they have little scientific 
 merit. A review of the remaining literature 
 
 O 
 
 of that period, so far as it was accessible to 
 the author, did not impress him with its 
 importance. 
 
 TiU.Tilfs work, entitled The Change 
 of Life, was for many years the only one 
 upon this subject available for readers of the 
 English language. It contains a vast amount 
 of information very laboriously prepared, but 
 aside from its wealth of statistics it is de- 
 fective in certain particulars, which are quite 
 essential to the comprehensive treatment of 
 the subject. This is partly for the reason 
 that important data relating to the meno- 
 pause, especially when artificially produced, 
 were not in existence when the book was 
 written. 
 
 Kisch and Borner. Kisch and Borner 
 have each written excellent works upon the 
 menopause in the German language, and an 
 English translation of Borner's work has 
 been published in this country. 
 
 The recent developments in pelvic and
 
 PRELIMINARY CONSIDERATIONS. 11 
 
 abdominal surgery have given new impor- 
 tance to the subject. The fact that the de- 
 velopment of pelvic and abdominal surgery 
 has resulted in an abrupt change of the cur- 
 rent of life in so many women gives to the 
 study of the menopause and to its phe- 
 nomena an importance which, previous to 
 this era, they did not have. 
 
 Conclusions, which are now possible as 
 the result of experience, could not be drawn 
 by Tilt and his predecessors, and hence the 
 subject is invested with a new interest and 
 is practically placed upon a new foundation. 
 
 VAKIOUS DATA CONCEROSTESTG THE MENOPAUSE. 
 
 Analogue of Menstruation in Animals. 
 The menstrual period has its analogue in 
 many of the animals, not that it recurs with 
 the same frequency or regularity as with 
 women, but it is manifested by a congestion 
 of the genital organs, a disturbance of the 
 nervous system, and an impulse which has 
 a very manifest relation to fruitbearing or 
 reproduction.
 
 12 THE MENOPAUSE. 
 
 If coitus and conception do not take 
 place, these conditions of disturbance disap- 
 pear, to return again after a longer or shorter 
 period. Every one is familiar with such 
 facts as these in the domestic animals.* 
 
 Menopause not regarded in Animals nor 
 in Women of Low Type or Great Physical 
 Development. The analogue of the meno- 
 pause, especially in its aberrations and dis- 
 turbing elements, is not seen, so far as the 
 author has been able to ascertain, among the 
 animals. 
 
 Among those human beings who are least 
 removed from the animals the savage and 
 the degraded, and among those, too, who are 
 subject to the vicissitudes of out-of-door life 
 and manual labor the menopause is least 
 likely to excite attention or create disturb- 
 ance. It is among the highly bred, tenderly 
 
 * Such facts have been repeatedly observed in the pri- 
 mates, apes and monkeys, in which the uterus resembles that 
 of women, and also in those animals in which the uterus is 
 hollow in asses, mares, ewes, sows, bitches, and cats. This 
 observation has been recorded by Buffon, Cuvier, Saint- 
 Hilaire, Ehrenberg, Raciborski, and others.
 
 PRELIMINARY CONSIDERATIONS. 13 
 
 reared women of civilized life, and among 
 those, 00, who have experienced an undue 
 share of the ills and stings of life, that the 
 menopause is a matter of great significance, 
 not infrequently being associated with a gen- 
 eral breaking up of the vital forces of the 
 individual. 
 
 Menopause should be a Normal Function 
 or Experience. In a healthy and perfectly 
 constructed individual the functions of the 
 body are performed painlessly. With such 
 an individual there is as little consciousness 
 of digestion, or of the very existence of the 
 stomach as a particular organ, as there is of 
 things in general during natural sleep. 
 
 The performance of menstruation should 
 be accomplished with equal ease, and the 
 period of its final cessation should be as un- 
 eventful as that of its beginning. That this 
 is not the case in many instances is simply 
 to say that there is not an organ or function 
 of the body that does not show derangement 
 and disturbance in one individual or another 
 indigestion, dysmenorrhoea, disturbed rueno-
 
 14 THE MENOPAUSE. 
 
 pause, and a thousand other ills arising, like 
 the miasm from the marshes, according as 
 the conditions favor. 
 
 The Abnormal arouses Attention. It is 
 the abnormal in Nature which most impresses 
 itself upon the average mind, not the normal, 
 and the serious disturbances which have hap- 
 pened to some women as they passed through 
 the menopause have led Tilt and others to 
 insist upon its essential seriousness and crit- 
 ical character. 
 
 Influenced by such authority, and perhaps 
 by personal observation to a very limited ex- 
 tent, the public at large has come to look 
 upon this experience with great apprehen- 
 sion, and women have been taught that they 
 must never consider themselves quite safe 
 until the menopause is entirely over and 
 passed. 
 
 Past Teaching concerning the Menopause 
 Erroneous in Many Respects. Such teaching 
 is mischievous and irrational in the light of 
 present knowledge, and the sooner it is done 
 away with, and the superstitions of the past
 
 PRELIMINARY CONSIDERATIONS. 15 
 
 respecting it forgotten, the better it will be 
 for humanity.* 
 
 Definition. We may define the meno- 
 pause, therefore, as the condition which exists 
 and the collective phenomena which appear 
 in connection with the cessation of menstrua- 
 tion. This cessation takes place gradually in 
 most cases, the intervals between the menses 
 lengthening, and the latter finally failing alto- 
 gether, after a period of from one to three or 
 four years. During this time the phenomena 
 are varied in character. With some women 
 there is scarcely any consciousness that any. 
 thins: unusual is occurring, aside from the 
 
 o "' 
 
 fact that the intermenstrual intervals are 
 
 longer than usual. With others the hsemor- 
 
 ~ 
 
 rhages, if less frequent, are much more pro- 
 
 * Larousse (Dictionnaire universelle, article Menopause) 
 notes the common belief among women that the menopause 
 is accompanied with grave clangers, but he considers this an 
 error, and that its only perturbations are slight disorders of 
 the stomach, blushings and sweatings, vertigo and headache. 
 Sometimes there are in addition pain and heaviness in the 
 uterus, lumbar region, and vulva, violent pulse, dyspnoea, 
 palpitations, haemorrhages, hemorrhoids, and occasionally 
 acne.
 
 16 THE MENOPAUSE. 
 
 fuse. The nervous system may be unaffected 
 or there may be disturbance of both cerebro- 
 spinal and sympathetic systems. Vasomotor 
 disturbances are extremely common, and 
 mental disturbances are by no means rare. 
 In cases in which there is predisposition to 
 the development of new growths, such 
 growths may develop at this time. 
 
 Atrophic changes take place in all the 
 genital organs as the menopause progresses. 
 
 Finally, the menopause may be as un- 
 eventful as any of the other necessary experi- 
 ences to which the female economy is sub- 
 jected, but it is also susceptible of varying 
 as far as possible in the opposite direction. 
 
 EXAGGERATED VIEWS CONCERNING THE MENO- 
 PAUSE AS A CRITICAL TIME FOR GOOD OR 
 EVIL. 
 
 We are all more or less in bondage to 
 
 O 
 
 tradition. 
 
 Statements which have been handed along 
 the ages as truth and fact are very often ac- 
 cepted without question until some one with
 
 PRELIMINARY CONSIDERATIONS. 17 
 
 a probing turn of mind comes along, sifts the 
 story, and perhaps succeeds in proving that 
 it has wandered far from the original per- 
 haps that there is no foundation truth in it 
 at all. 
 
 Tilt accepts the Ancient View of the Seri- 
 ous Character of the Menopause. The notion 
 that the menopause always signifies a serious 
 or critical experience is of respectable antiq- 
 uity, but we find the ancient statements re- 
 lating to it overlaid with so much humbug 
 and nonsense that we are compelled to doubt 
 the correctness of the original observations. 
 
 Perhaps a few who really suffered at the 
 menopause were observed and generalizations 
 were made from such data. At any rate, the 
 notion has come down to our time and finds 
 in Tilt a stanch supporter. 
 
 Suppose we compare the menopause with 
 any of the ordinary functions of the body 
 with digestion, for example. Errors of di- 
 gestion are certainly as common and as sig- 
 nificant as anything that can be associated 
 with the menopause, and yet we can not con-
 
 18 THE MENOPAUSE. 
 
 sider digestion as critical in any sense, nor its 
 aberrations as necessary adjuncts of the func- 
 tion. 
 
 Misleading Character of KiscKs Statis- 
 tics. How misleading are such statistics as 
 the following, which are taken from Kisch's 
 book,* and which, in many respects, is the 
 best book that has been written upon this 
 subject : 
 
 In an analysis of five hundred cases of 
 menopause which came under his observa- 
 tion, the following conditions were noted : 
 
 Polymenorrhcea or metrorrhagia 286 
 
 Chronic metritis 79 
 
 Leucorrhcea 327 
 
 Prolapsus uteri 65 
 
 Ante- or retroflexion 52 
 
 Pruritus vaginae or vulvse 46 
 
 Vaginismus 12 
 
 Carcinoma uteri 3 
 
 Fibroma uteri 5 
 
 Tumor mammae 8 
 
 Three out of every five in these five hun- 
 dred cases are said to have suffered with 
 uterine haemorrhage, but whether it was 
 
 * Das klimakterisches Alter der Frauen in physiologischer 
 und pathologischer Beziehung, Erlangen, 1874.
 
 PRELIMINARY CONSIDERATIONS. 19 
 
 sufficient to be significant or serious is not 
 apparent. 
 
 Contrast with tlie Author's Experience. 
 Ainono; those whom the author of these 
 
 O 
 
 pages has seen professionally in the course 
 of the menopause, in hospital, dispensary, 
 and private practice, who were not suffering 
 with pelvic or abdominal tumors or with 
 some other legitimate cause for haemorrhage, 
 the number who have suffered with this most 
 loudly heralded bugbear of the menopause 
 has been insignificant. This suggests that 
 the fact should not be overlooked that the 
 great majority of women who survive to old 
 age never consult a physician in regard to 
 the menopause, and that of these nothing is 
 said in tables of statistics, such tables includ- 
 ing only those who require the physician's 
 aid. 
 
 Chronic Metritis and Leucorrhwa. 
 Chronic metritis is a condition so indefinite 
 in character that the seventy-nine cases in 
 this table may have suffered much or little 
 with it. As a marked accompaniment of the
 
 20 THE MENOPAUSE. 
 
 menopause, the author has had little experi- 
 ence with it. If by this term the condition 
 of endoinetritis is meant, it would seem to 
 the author that its gravity and importance, 
 not only in relation to the menopause, but in 
 general, had been greatly overestimated in 
 recent years, the profoundly infectious vari- 
 ety being excepted. 
 
 Leucorrhoea is also a most indefinite term, 
 and, with the exception of the infectious va- 
 riety, would not seem to the author a serious 
 complication of the menopause. That three 
 hundred and twenty-seven of the five hun- 
 dred cases in the table should suffer with it 
 can be easily comprehended, for there are 
 few women, at any period of life, in whom it 
 may not be found, in greater or less degree, 
 if one wishes to find it. 
 
 Displacements of the Uterus. That sixty- 
 five should have suffered with prolapsus uteri 
 seems a large percentage much larger than 
 one would find in American women, espe- 
 cially if the prolapse were considerable. 
 
 Whether these figures apply only to mar-
 
 PRELIMINARY CONSIDERATIONS. 21 
 
 ried and parous women, and whether they 
 include those cases in which the vaginal walls 
 alone were prolapsed and in which the uterus 
 had not descended beyond the vulva, is not 
 apparent. Neither this nor the succeeding 
 three items ante- and retroflexion, pruritus 
 vaginae or vulvse, and vaginismus can fairly 
 be taken as the basis for any argument spe- 
 cifically directed against the menopause, since 
 they are quite as common, perhaps more so, 
 in the years which precede the menopause. 
 
 Neoplasms. With reference to carcinoma 
 uteri and fibroma uteri and tumor manimsB, 
 the number of cases in the table is very 
 small, and yet these are the very conditions 
 which the older writers have dreaded as the 
 particular concomitants of the menopause. 
 If, therefore, it is assumed upon the testi- 
 mony of this table that the menopause is a 
 dangerous and critical time, we are forced to 
 enter a plea of not proven. 
 
 Tilt 1 s Statistics. In Tilt's work on The 
 Change of Life we also find a table in which 
 there are statistics of five hundred cases,
 
 22 THE MENOPAUSE. 
 
 which, he says, were observed in the higher 
 classes, socially, in England in the course of 
 twenty-five years of practice. In addition to 
 such minor complaints as sick headache, bil- 
 iousness, diarrhoea, deafness, neuralgia, ery- 
 sipelas, etc., he has tabulated such conditions 
 as the following : 
 
 Insanity 16 
 
 Paraplegia 6 
 
 Apoplexy and hemiplegia 6 
 
 Fibroma uteri 4 
 
 Carcinoma uteri 5 
 
 Heart disease 1 
 
 Carcinoma mammae 1 
 
 That is, of malignant disease of the geni- 
 tal organs only a fraction over one per cent 
 was noted by this ardent advocate of the 
 serious character of the menopause, while of 
 mental disease there was only a fraction over 
 three per cent. The other complications 
 may be excluded, for it is improbable that 
 they were essentially related to the meno- 
 pause. 
 
 United States Census Statistics. In the 
 vital statistics of the United States census 
 for 1880 there were reported 48,950 deaths
 
 PRELIMINARY CONSIDERATIONS. 23 
 
 of women between the ages of forty and 
 fifty, out of a total of 4,558,226 women of 
 the respective ages. Of this number there 
 were 1,771 deaths from cancer, about one 
 quarter of them being cases of cancer of the 
 genital organs. That is, less than one per 
 cent of the women who died in the United 
 States from 1870 to 1880 between the ages 
 of forty and fifty, the usual period of the 
 menopause, died from cancer of the genital 
 organs. 
 
 Mortality from Malignant Disease of the 
 Genital Organs during the Menopause. Of 
 course, allowance must be made in statistics 
 of this character which can hardly be ex- 
 pected to have the merit of scientific accu- 
 racy for errors of diagnosis ; while, on the 
 other hand, it will also be admitted that no 
 inconsiderable number of cases of these varie- 
 ties are never reported. But, inasmuch as 
 the percentage of fatal cases is about the 
 same as is recorded in the statistics, it seems 
 fair to conclude that the mortality from ma- 
 lignant disease during the period of the men-
 
 24 THE MENOPAUSE. 
 
 opause does not greatly exceed one per cent. 
 This can not be said to make of the meno. 
 pause a period which should be especially 
 dreaded on this account. 
 
 Neuroses of the Menopause. Concerning 
 the neuroses of the menopause there is much 
 to be said, which will appear at a later period 
 in this discussion. It may be remarked, in 
 passing, that Krafft-Ebbing refers seven per 
 cent of cases of insanity in women to disturb- 
 ance which is associated with the menopause ; 
 in Meynert's clinic the climacteric was re- 
 garded as an getiological factor in sixteen out 
 of one hundred and twenty-six paralyzed 
 women. 
 
 Conclusions of Various Writers. Of the 
 many who have expressed an opinion at one 
 time or another concerning the various phe- 
 nomena of the menopause, Tissot, Dewees, 
 Meissner, Saucerotte, Landouzy, and a num- 
 ber of recent American writers deny that 
 they indicate especial gravity as to the con- 
 dition, while Fothergill, Clarke, Meigs, Bed- 
 ford, Lisfranc, Boivin, Dupuytren, Velpeau,
 
 PRELIMINARY CONSIDERATIONS. 25 
 
 and others support Tilt in his contention that 
 they do indicate such gravity. 
 
 Tilt modifies his statement, however, by 
 admitting that critical, with reference to the 
 menopause, does not necessarily mean fatal. 
 
 More Extensive Knowledge concerning 
 the Menopause than our Predecessors had 
 leads us to fear it less than they did. It 
 is possible that our increased knowledge 
 concerning the phenomena of the meno- 
 pause, together with our improved methods 
 of treating them, leads us to take the less 
 gloomy view of the situation compared with 
 many of those who have studied the sub- 
 ject in the past. 
 
 Possible Explanation of Degenerative 
 Changes during the Menopause. Exagger- 
 ated and incorrect as it is believed many of 
 the notions concerning the menopause have 
 been, it is admitted that serious conditions 
 may, and sometimes do, develop in the genital 
 organs at that time. This may be accounted 
 for as follows : When the period of fruit- 
 fulness is ended the activity of the tissues
 
 26 THE MENOPAUSE. 
 
 has reached its culmination, the secreting 
 power of the glandular organs begins to 
 diminish, the epithelium becomes less sensi- 
 tive and less susceptible to infectious influ- 
 ences, and atrophy and degeneration take the 
 place of the active up-building processes. 
 
 In the presence of an irritant, scar tissue 
 for example, or that vague condition of sus- 
 ceptibility which we call a diathesis or dys- 
 crasia, tissues which under ordinary con- 
 ditions of circulation and cell activity might 
 by virtue of abundant vitality be able to 
 resist an increase of irritation, now go down 
 before it, the result being heteroplasia or 
 malignant new growth. 
 
 If this explanation be unsatisfactory and 
 lacking in definiteness, it is at least as defi- 
 nite as anything which has thus far been sug- 
 gested. 
 
 TJie Menopause not Responsible for Degen- 
 erative Changes. The fact that malignant 
 disease develops at the time - of the meno- 
 pause does not prove that the menopause is 
 responsible for such development any more
 
 PRELIMINARY CONSIDERATIONS. 27 
 
 than that some other period of life is re- 
 sponsible when it occurs at some other 
 period. It merely shows that the tissues 
 are then favorable for such a development 
 in the individuals so affected or disposed. 
 Hence we should banish from all future con- 
 sideration the idea that the menopause is of 
 necessity the time for such unfavorable pro- 
 
 cesses.* 
 
 PHYSICAL CONDITION or WOMAN WHEN THE 
 EIIA OF THE MENOPAUSE is REACHED. 
 
 Of course there can be nothing like uni- 
 formity in the physical condition of woman 
 as a w r hole when the period of the menopause 
 is reached, since the conditions surrounding 
 them in the precedent portions of their lives 
 are so varied and different, and yet it has 
 been frequently observed that there are cer- 
 tain peculiar experiences which are common 
 
 * The great physiological activity of the uterus is assigned 
 by some writers, among them Braxton Hicks (Medical Times 
 and Gazette, 1877, i, 411), as a predisposing cause for malig- 
 nant disease. But why should not such a cause be equally 
 potent with other active organs ?
 
 28 THE MENOPAUSE. 
 
 to great numbers of them which account 
 fairly well for the similarities which prevail 
 during the menopause. 
 
 The age at which the phenomena of the 
 menopause occur will depend upon climate, 
 family or race peculiarities, temperament, so- 
 cial surroundings, previous state of health, 
 etc. 
 
 For the majority of women who live in 
 temperate climates like our own, they are 
 manifested in the decade between the forti- 
 eth and fiftieth years. 
 
 The experiences of the menopause may 
 be classified as 
 
 1. Normal. 
 
 2. Moderately troublesome. 
 
 3. Severe. 
 
 4. Serious. 
 
 1. Normal. The normal experiences af- 
 fect a larger number of women than any of 
 the others, for they pertain to the great mul- 
 titude who never consult a physician about 
 such matters, and who are scarcely conscious 
 that with the menopause an important func-
 
 PRELIMINARY CONSIDERATIONS. 29 
 
 tion of life has vanished, being reminded of 
 it chiefly by the fact that menstruation has 
 gradually or suddenly ceased. Their atten- 
 tion may also be drawn to the fact that the 
 outline of the body is undergoing a change, 
 straight lines yielding to curves, and moder- 
 ate curves to rotundity and obesity. 
 
 There are probably few women in this 
 class who do not occasionally experience the 
 vasomotor crises those commonest of all 
 concomitants of the menopause, which will 
 be referred to with the particular attention 
 which they deserve in the chapter devoted 
 especially to the phenomena of the meno- 
 pause. While they are frequently a source 
 of the greatest annoyance, they may give no 
 more trouble than a sudden gust of hot wind 
 which vanishes as quickly as it came leaving 
 no trace behind. In most other respects this 
 favored class experiences no particular dis- 
 tinction between the period of time which 
 includes the menopause and that which im- 
 mediately precedes or immediately follows it. 
 They are in good health, and that means, as
 
 30 THE MENOPAUSE. 
 
 already stated, unconsciousness as to the how 
 and when of the performance of the func- 
 tions of the body. 
 
 2. Moderately Troublesome. Of those 
 with whom the experiences of the meno- 
 pause are moderately troublesome, the gynae- 
 cologist sees many illustrations. The broad 
 distinction which may be made between 
 them and the women of the third class is 
 that their troubles are functional only, while 
 those of the third class are organic. They 
 sometimes remind one of the peculiar con- 
 ditions presented by women during their 
 first pregnancy. The symptoms pertaining 
 to the nervous system are most prominent 
 in fact, they probably dominate all others. 
 As the circulatory system is undergoing 
 profound changes we also find considerable 
 visceral disturbance. In general the distin- 
 guishing characteristics of this class are irri- 
 tability of disposition, hysteria, faults of diges- 
 tion and assimilation, and vasomotor crises. 
 
 3. Severe. In the third class of cases 
 there are actual lesions present, some of
 
 PRELIMINARY CONSIDERATIONS. 31 
 
 which are simply accentuated by the meno- 
 pause, while others are more or less directly 
 due to it. The digestive disorders, the vaso- 
 motor crises and other troubles which were 
 referred to as the sufferings of the second 
 class, may also be present, but they will be 
 overshadowed by the more serious troubles 
 of organic character. Chief among these 
 lesions are those which affect the womb it- 
 self, degeneration of the endometrium with 
 increase of the blood tension, resulting in pro- 
 fuse haemorrhages. Such accidents are es- 
 pecially common in those uteri which are the 
 seat of myomatous enlargement, and may be 
 prolonged through weary years, often wear- 
 ing the patients out with exhaustion and 
 anaemia. This class also includes those cases 
 in which nervous and mental troubles are 
 prone to culminate in insanity. Heart, kid- 
 ney, and other visceral diseases, if established 
 when the menopause appears, may take on a 
 serious aspect. Any serious disorder which 
 occurs during the period of the menopause 
 must be carefully investigated with reference
 
 32 THE MENOPAUSE. 
 
 to the bearing which the menopause may 
 have upon it, though this is by no means an 
 admission that serious diseases are peculiarly 
 prone to develop at this time unless the tend- 
 ency to them pre-existed. 
 
 4. Serious. The serious lesions which ac- 
 company the menopause, and which tend al- 
 most inevitably to a fatal issue, are few hi 
 number, and the number of the cases is rela- 
 tively small. Cancer does not develop sim- 
 ply because menstruation has ceased, or be- 
 cause the period of childbearing is over, but 
 because the vitality of certain tissues is di- 
 minished and their ability to resist irritation 
 is greatly lessened. With many women this 
 point of vulnerability is not reached until the 
 menopause has long been passed, but with 
 some, especially with those who have borne 
 many children or have experienced much 
 trouble and privation, it is present during 
 the decade in which the menopause usually 
 occurs, and in such cases malignant degenera- 
 tion is the result. 
 
 The following table of cases from the
 
 PRELIMINAEY CONSIDERATIONS. 
 
 33 
 
 records of the New York Skin and Cancer 
 Hospital, the patients being taken from the 
 humbler and hard-working class of our com- 
 munity, shows a predominance for the decade 
 from forty to fifty. The number of cases is 
 of course too small for general deductions. 
 
 NATIVITY. 
 
 Age. 
 
 Organ. 
 
 Social con- 
 dition. 
 
 Children. 
 
 Miscar- 
 riages. 
 
 Ireland (49) 
 
 30-40= 9 
 
 Uter- 
 
 Married, 
 
 193 
 
 21 
 
 
 40-50=21 
 
 us. 
 
 44; sin- 
 
 Average 
 
 
 
 50-60=11 
 
 
 gle, 5. 
 
 (for mar- 
 
 
 
 60-70= 7 
 
 
 
 ried), 5. 
 
 
 
 80= 1 
 
 
 
 
 
 United States 
 
 20-30= 5 
 
 
 Married, 
 
 126 
 
 40 
 
 (36). 
 
 30-40= 9 
 
 
 34; sin- 
 
 Aver- 
 
 
 
 40-50=13 
 
 
 gle, 2. 
 
 age, 4. 
 
 
 
 50-60= 6 
 
 
 
 
 
 
 60-70= 3 
 
 
 
 
 
 Germany (32) . . . 
 
 20-30= 1 
 
 .... 
 
 Married, 
 
 97 
 
 15 
 
 
 30-40= 5 
 
 
 32. 
 
 Aver- 
 
 
 
 40-50=13 
 
 
 
 age, 3. 
 
 
 
 50-60= 9 
 
 
 
 
 
 
 60-70= 4 
 
 
 
 
 
 England (4) 
 
 20-30= 1 
 
 
 Married, 4. 
 
 10 
 
 
 
 
 30-40= 1 
 
 
 
 Aver- 
 
 
 
 40-50= 2 
 
 
 
 age, 2i. 
 
 
 Scotland (3) 
 
 30-40= 1 
 
 
 Married, 3. 
 
 4 
 
 
 
 
 40-50= 1 
 
 
 
 
 
 
 60-70= 1 
 
 
 
 
 
 France (2) 
 
 20-30= 1 
 
 
 Married, 2. 
 
 2 
 
 
 
 
 60-70= 1 
 
 
 
 
 
 Canada (1) 
 
 50-60= 1 
 
 
 Married, 1. 
 
 5 
 
 2 
 
 Wales (1) 
 
 50-60= 1 
 
 
 Married, 1. 
 
 6 
 
 
 
 Italy (1). . 
 
 50-(iO= 1 
 
 
 Married, 1. 
 
 3 
 
 
 
 Poland (1) 
 
 30-40= 1 
 
 
 Married, 1. 
 
 1 
 
 1 
 
 Sweden (1) 
 
 60-70= 1 
 
 
 Married, 1. 
 
 2 
 
 
 
 
 
 
 
 
 
 Total 
 
 131 
 
 
 
 
 
 
 
 
 

 
 THE MENOPAUSE. 
 
 Of these one hundred and thirty-one cases 
 cases the totals by decades are as follows : 
 
 DECADE. No. of cases. 
 
 20-30 8 
 
 30-40 26 
 
 40-50 50 
 
 50-60 29 
 
 60-70 17 
 
 80 1 
 
 131 
 
 According to this table, therefore, five 
 
 O ' ' 
 
 thirteenths of these cases developed cancer in 
 the decade during which the menopause usu- 
 ally occurs. Of other forms of cancer in 
 women the same records show the following : 
 
 AGE. 
 
 Organ. 
 
 Social con- 
 dition. 
 
 Chil- 
 dren. 
 
 Mis- 
 car- 
 
 
 
 
 Under 20, 1 
 
 Breast, 
 
 47 
 
 Married, 46 145 
 
 9 
 
 20-30, 2 
 
 Rectum, 
 
 8 
 
 Single, 10 
 
 Aver- 
 
 
 30-40, 8 
 
 Vulva, 
 
 5 
 
 Not 
 
 age, 3|. 
 
 
 40-50, 18 
 
 Clitoris, 
 
 1 
 
 known, 5 
 
 
 
 50-60, 12 
 
 Abdominal wall, 
 
 1 
 
 
 
 
 60-70, 15 
 
 Liver, 
 
 1 
 
 
 
 
 70-80, 5 
 
 General sarcoma, 
 
 1 
 
 
 
 
 
 Unclassified, 
 
 2 
 
 
 
 
 61 
 
 61 
 
 61 
 
 
 
 Of the entire number of cases of malig- 
 nant disease, one hundred and ninety-two, it 
 will be seen that sixty-eight occurred in the 
 decade forty to fifty that is, slightly more
 
 PRELIMINARY CONSIDERATIONS. 35 
 
 than one-third of all cases. Let us now con- 
 sider the distribution of the various classes or 
 types of women in accordance with the ex- 
 periences which they encounter during the 
 menopause, the classification being the same, 
 of course, which has already been followed. 
 
 1. Normal. All that tends to develop 
 and strengthen the physical part of woman 
 to render her insensitive to the ordinary ills 
 of life, to make her forgetful of self is fa- 
 vorable to a normal menopause. Races and 
 nations which are phlegmatic, cold, and apa- 
 thetic, women who are inured to out-of-door 
 life and severe manual labor, savage and bar- 
 barous women, peasants, Germans, Scandina- 
 vians, and Russians, are apt to complain little 
 of the experiences of the menopause ; while 
 the sensitive, passionate nations, like the 
 French, Spanish, and Irish, the highly organ- 
 ized, nervous, city-bred women, women of 
 fashion, women who fret and worry, are apt 
 to experience the disagreeable and annoying 
 features of the menopause. A study of the 
 sexual peculiarities of the American-Indian
 
 36 THE MENOPAUSE. 
 
 women failed to reveal any noteworthy ex- 
 perience during the menopause, and, accord- 
 ing to Dr. Frederic Cook, who has studied 
 the same peculiarities among the Eskimos, 
 the same may be said of them. 
 
 Among the French and Irish the troubles 
 which are now under consideration are ex- 
 ceedingly common, which proves the state- 
 ment that climate and race peculiarities have 
 a modifying influence upon the menopause. 
 
 2. Moderately Troublesome. The number 
 of women who belong to this class is very 
 large. It includes women who have had a 
 stormy menstrual life, who have suffered 
 much with dysmenorrhoea, who have suffered 
 much with anaemia, headnehe, and constipa- 
 tion. It also includes women who have been 
 addicted to venereal excesses, wno have had 
 frequent abortions, whose nervous systems 
 
 have suffered frequent shocks, who have had 
 
 r 
 
 great disappointments, whose lives have been 
 a constant worry and unrest ; also women 
 who have undergone privation, overwork, 
 and exposure of various kinds. Among
 
 PRELIMINARY CONSIDERATIONS. 37 
 
 them will be found many shopwomen, pros- 
 titutes, women of fashion, women who bring 
 up large families of children on very slender 
 incomes, women who are hysterical and with 
 whom the affairs of life are constantly going 
 wrong, wives of farmers and mechanics who 
 are frequently troubled to make ends meet. 
 
 3. Severe. This class is smaller than the 
 preceding one, but includes, nevertheless, 
 many well-marked cases. It includes many 
 highly wrought, nervous women, and has as 
 its t\vo chief types, as has already been re- 
 marked, those who suffer from profuse haem- 
 orrhages and those who develop profound 
 nervous and mental troubles. The haemor- 
 rhages may be due simply to a diseased and 
 degenerating endometrium, or to the presence 
 of fibroid tumors within the uterus. If from 
 the latter, the phenomena of the menopause, 
 including the haemorrhages, may be pro- 
 longed through many years, atrophy finally 
 taking place if the woman has sufficient vital- 
 ity to endure the prolonged drain -upon it. 
 With the women of the other type the con-
 
 38 THE MENOPAUSE. 
 
 stant irritation of the nervous system finally 
 culminates in insanity, melancholia or mania 
 appearing according to the temperament and 
 disposition of the individual. Insanity of 
 this form may be permanent, because it may 
 be dependent upon degenerative conditions 
 of the nerve substance. Of course there are 
 many cases in which ultimate recovery is 
 possible and does occur. Women who are 
 already the subjects of visceral disease of the 
 heart, liver, kidneys, lungs, stomach, etc., 
 when the menopause arrives may have their 
 symptoms intensified by the additional dis- 
 turbance which a troublesome menopause 
 brings. 
 
 4. Serious. -This class includes those 
 who are already foredoomed by an existing 
 or impending serious condition, to which the 
 processes which accompany the menopause 
 can add, or from which they can take away, 
 but little. The haemorrhage and destruction 
 of tissue and sepsis in such cases are not es- 
 sentially due to the menopause, for precisely 
 the same symptoms occur when the same dis-
 
 PRELIMINARY CONSIDERATIONS. 39 
 
 ease happens early in life, or long after the 
 menopause has ended. The cause must be 
 sought elsewhere, and, when it is found, it 
 will be found to be the same for all ages and 
 
 periods of life. 
 
 ADDENDA. 
 
 GUY. On the First and Last Appearance of the 
 Menses. Medical Times, London, 1845, xii, 363. 
 
 SMITH. The Climacteric Disease, a Paroxysmal 
 Affection occurring at the Decline of the Catamenia. 
 London Journal of Medicine, 1849, i, 601. 
 
 FELTY. The Menopause, its Relation to Disease. 
 Kansas Medical Journal, 1891, iii, 85. 
 
 THOMAS. The Menopause, or Change of Life. 
 Annals of Gynaecology and Paediatry, Philadelphia, 
 1890, iv, 449. 
 
 MILES. On the Climacteric Period, etc. Medical 
 Times and Hospital Gazette, 1894, xxii, 119. 
 
 JOHNSTONE. The Menopause. New York Jour- 
 nal of Gynaecology and Obstetrics, 1894, iv, 393. 
 
 MUXDE. The Menopause. International Clinics, 
 1894, 4s, i, 283. 
 
 KOBINSON. The Menopause. Journal of the 
 American Medical Association, 1894, xxiii, 345. 
 
 O'CONNOR. Observations on Climacteric Disease. 
 Dublin Journal of the Medical Sciences, 1875, Ix, 78. 
 
 WILLIAMS. Climacteric Disease. Boston Medical 
 and Surgical Journal, 1855, Iii, 69. 
 
 DE SERE. Sexual Activity and the Critical Period 
 in Man and Woman. Wood's Medical and Surgical 
 Monographs, iii.
 
 40 THE MENOPAUSE. 
 
 TARNOWSKI. Etude anthropometrique sur les 
 Prostituees et les Voleuses. Paris, Aux Bureaux des 
 Progres medicals, 1889 ; also Medical Record, August 
 9, 1890, p. 15.^ 
 
 BARIE. Etude sur la Menopause, Paris, 1877. 
 
 TILT. The Right Understanding of the Meno- 
 pause. British Medical Journal, 1870, ii, 435. 
 
 DE REDONDO. No edad critica. Fraternidad 
 medica, Valladolid, ii, 640. 
 
 BARON. De la Menopause, Paris, 1851. 
 
 NETTLER. The Menopause. Medical Register, 
 1887, ii, 323. 
 
 WYMAN. The Menopause. Michigan Medical 
 News, 1882, v, 313. 
 
 GOODELL. Transactions of the Pennsylvania Med- 
 ical Society, 1881, xiii, Part I, 638. 
 
 KENNEDY. Observations on Climacteric Disease. 
 Dublin Journal of the Medical Sciences, 1844, xxv, 
 245. 
 
 RACIBORSKI. De la Puberte et de 1'Age critique 
 chez la Femme et de la Ponte periodique chez la 
 Femme et les Mammiferes, Paris, 1844. 
 
 TILT. On Uterine and Ovarian Inflammation, and 
 on the Physiology and Diseases of Menstruation. Lon- 
 don, 1862. 
 
 STEPHENSON. On the Menstrual Wave. Ameri- 
 can Journal of Obstetrics, 1882, xv. 
 
 REINL. Die Wellenbewegung der Lebensprocesse 
 des Weibes. Volkmann's Vortrage, No. 243. 
 
 JENKS. Concerning Menstruation among the An- 
 cients. Transactions of the American Gynaecological 
 Society, vi, 373.
 
 CHAPTER II. 
 
 CONSIDERATIONS CONCERNING THE ORGANS OF 
 
 THE GENITAL APPARATUS ANATOMICAL 
 
 CHANGES EFFECTED BY THE MENOPAUSE. 
 
 Menopause indicates Completion of Fruit- 
 ful Period. The menopause is the signal 
 that fruition is ended. In the vegetable 
 world the period of fruition is followed by 
 decided and perceptible structural changes. 
 Foliage assumes its most brilliant colors, 
 then falls and withers. Analogous changes 
 occur in women with the period of the meno- 
 pause, and subsequently the hair whitens, 
 the figure becomes rotund, but in due course 
 of time withering and wrinkles follow. In 
 the reproductive organs the advent of the 
 menopause means the beginning of senility, 
 and that signifies atrophy and degeneration 
 of structure, and sometimes, though not ne- 
 cessarily, the institution of morbid processes. 
 
 41
 
 42 THE MENOPAUSE. 
 
 The subject will be studied from the follow- 
 ing standpoints : 
 
 Classification. 1. Anatomical changes 
 which are the result of the menopause. 
 
 2. Anatomical changes which produce the 
 menopause. 
 
 3. Anatomical changes which are coinci- 
 dental with the menopause, but which are 
 not usually its cause or caused by it. 
 
 Necessarily, the organs of the reproduc- 
 tive apparatus must be considered in detail. 
 
 ANATOMICAL CHANGES IN THE OVARIES. 
 The ovaries are, to a very decided degree, 
 the center of the reproductive apparatus in 
 women the sine qua non in the continua- 
 tion of species. Their function is ovulation 
 the development and extrusion of ova 
 and their intimate nervous relations with 
 other viscera doubtless explain the many 
 curious phenomena which are observable in 
 connection with menstruation and its discon- 
 tinuance. 
 
 Ovulation may continue after the menses
 
 ANATOMICAL CHANGES. 43 
 
 Lave ceased. The proof of this is that preg- 
 nancy sometimes takes place after the meno- 
 pause has occurred.* 
 
 After ovulation ceases the work of the 
 ovaries is accomplished, and unless some 
 morbid change takes place in them, they be- 
 come shriveled and atrophied. The anatom- 
 ical changes in the ovaries during and after 
 the menopause have been very clearly and 
 satisfactorily described in a paper published 
 by the late Prof. J. C. Dalton in the Trans- 
 actions of the American Gynaecological So- 
 ciety, vol. ii, 1877.f From that report the 
 following cases, in a condensed form, have 
 been taken : 
 
 * Puech, Renaudier, Kisch, Krieger, and Deshayes have 
 all reported cases of this character. A number of such cases 
 have been brought to the attention of the author. Among 
 them was one who was the mother of a medical colleague, 
 who gave birth to a son several years after she had passed 
 the menopause. Another was a case in which a child was 
 born fourteen years after the cessation of menstruation. 
 
 Piron (Lancet, ii, 1862, p. 27) observed a regular monthly 
 flow for six months in a woman seventy-two years of age. 
 She then became pregnant, but aborted at the second month, 
 the foetus being recovered. 
 
 t Report on the Corpus Luteum.
 
 44 THE MENOPAUSE. 
 
 I. Married woman, forty-eight years of 
 age, mother of seven children, died one day 
 after the end of a menstrual period. Men- 
 struation had always been regular and pain- 
 less. One of the ovaiies contained a super- 
 ficial Graafian follicle considerably enlarged 
 and filled with a fresh, dark-red blood clot. 
 Both ovaries exhibited alteration of structure 
 corresponding with the patient's age and the 
 near approach of the menopause. There 
 were few healthy, active, Graafian follicles ; 
 some were morbidly distended, others were 
 shriveled. Each ovary contained two unrup- 
 tured follicles which had undergone chronic 
 degeneration, the w r alls being thickened and 
 the contents absorbed, forming false corpora 
 lutea. 
 
 II. A widow, thirty-three years of age, 
 who died from phthisis pulmonalis. Last 
 pregnancy at twenty ; menstruation irregular 
 for a year; last period six months prior to 
 death. Ovaries small, surrounded with old 
 adhesions ; albuginea white and opaque. 
 Small rounded projection near one end of
 
 ANATOMICAL CHANGES. 46 
 
 right ovary, brownish in color. It contained 
 an ovoidal body three to four millimeters in 
 its long diameter, having the structure of a 
 retrograde corpus luteum of menstruation. 
 Its wall was convoluted half a millimeter in 
 thickness, its color white ; it contained 
 brownish gelatinous material. A similar 
 smaller body was at the opposite end of 
 the same ovary. The left ovary contained 
 a very thin, shriveled white-walled sac, con- 
 nected with a superficial cicatrix and contain- 
 ing black coloring matter. In both ovaries 
 there were collapsed, empty, degenerate 
 Graafian follicles, not connected with the 
 surface, but scattered through the tissue of 
 the organs. 
 
 III. Prostitute, thirty years of age, death 
 from waxy degeneration of the kidneys and 
 disease of the liver. Menstruation had ceased 
 eight months prior to death. Both ovaries 
 enveloped in old adhesions, their substance 
 being condensed and atrophied. In one 
 there were a few brownish or yellowish 
 streaks without definite structure. Neither
 
 4:6 THE MENOPAUSE. 
 
 contained healthy Graafian follicles or cor- 
 pora lutea. 
 
 IV. Prostitute, twenty-one years of age, 
 death from cardiac disease and pulmonary 
 oedema ; last menstruation ten months prior 
 to death. Ovaries small, but free from ad- 
 hesions, their tissue abnormally dense and 
 containing a few small Graafian follicles but 
 no corpora lutea. 
 
 V. Woman, forty-three years of age, who 
 had had one child twenty-one years previ- 
 ously. Death from cerebral meningitis. Last 
 menstruation a year prior to death. Ovaries 
 small and loose in texture, containing col- 
 lapsed, empty, degenerate Graafian follicles, 
 with slightly thickened walls, which had 
 long been inactive. In the ovarian tissue 
 were a few small blackish stains without 
 definite structure. No normal Graafian folli- 
 cles nor corpora lutea. 
 
 VI. Woman, fifty-five years of age, multi- 
 para, death from abscess of the liver and 
 pneumonia. Last menstruation six years 
 prior to death. One ovary weighed one
 
 ANATOMICAL CHANGES. 4? 
 
 gramme, the other less than one gramme and 
 a half. The external surface was opaque, yel- 
 lowish white, with numerous depressed curvi- 
 linear cicatrices. Internally the color was a 
 pale red, the consistency firm, and there were 
 neither Graafian follicles nor corpora lutea. 
 The entire substance consisted of a moder- 
 ately vascular connective tissue. 
 
 VII. Woman, forty-five years of age, the 
 mother of fourteen children. Death from 
 rupture of thoracic aneurism. Menstruated 
 once during last year of life. Ovaries under 
 the average size, white and opaque exter- 
 nally, with depressed, intercommunicating 
 cicatrices, beneath which were small colored 
 clots, with and without membranous walls, 
 flattened from within outward. The ovaries 
 contained four or five small Graafian follicles, 
 visible externally ; also two large ones be- 
 neath the albuginea, which had collapsed 
 after their contents had been reabsorbed. 
 Their walls were friable. Several other folli- 
 cles had thickened walls, and were collapsed 
 and empty. There were no corpora lutea.
 
 VIII. Woman, seventy years of age, mul- 
 tipara. Ovaries half the normal size. They 
 were lobular internally, and contained col- 
 lapsed Graafian follicles in the form of closed 
 empty sacs (saccular degeneration), with 
 firm, pale, thickened, and puckered walls. 
 The sacs were enucleated, and the interspaces 
 showed loose red connective tissue. No 
 healthy Graafian follicles nor other structural 
 formations. 
 
 Analysis of the Foregoing Cases. An 
 analysis of these most interesting cases gives 
 the following results, which may be consid- 
 ered an ensemble of the ovarian changes 
 which the menopause implies : In women 
 who reach the menopause prematurely from 
 wasting diseases, such as pulmonary phthisis 
 (case II), from amyloid disease (III), from 
 cardiac disease (IV), the ovaries may be re- 
 duced to half the size they usually reach 
 during functional activity. They may be 
 surrounded by evidences of previous inflam- 
 matory condition, or such evidences may be 
 wanting. They may be converted into
 
 ANATOMICAL CHANGES. 49 
 
 masses consisting chiefly of connective tissue, 
 or there may still be "more or less ovarian 
 stroma remaining, with more or fewer Graaf- 
 ian follicles and corpora lutea in varying 
 stages of degeneration, according to the near- 
 ness or remoteness of the time when func- 
 tional activity ceased, or the degree of malnu- 
 trition of the body in general, and the pelvic 
 organs in particular. It is not improbable 
 that similar changes would be found in the 
 ovaries of those who reach the menopause 
 prematurely from causes other than wasting 
 diseases, as from great obesity, frequent preg- 
 nancies in quick succession, and the trau- 
 matic conditions. 
 
 2. In women who reach the menopause 
 at the normal period the ovaries, if examined 
 while the change is in progress or soon after 
 it is completed, may show little reduction in 
 size. There may be evidences of pre-existent 
 disease in the form of bands and adhesions. 
 Some ovarian stroma may still be present, 
 but there will be an abundant formation of 
 connective tissue. The Graafian follicles and 
 
 5
 
 50 THE MENOPAUSE. 
 
 corpora lutea will, as a rule, be fewer and 
 less distinct than in ovaries which are in 
 active functional condition. 
 
 3. In women in whom the menopause has 
 long been passed, the ovaries may be shriv- 
 eled to a quarter or even a fifth of their 
 average size (Dalton). They will be com- 
 posed mostly of connective tissue, but the 
 scars of corpora lutea may usually be found 
 upon or within them, and there may be sac- 
 cular degeneration of Graafian follicles which 
 have long since become inactive, the latter 
 representing a peculiar phase of atrophy 
 which may or may not be of any pathological 
 significance. 
 
 Kisch, in the work to which reference has 
 been made, coincides with the statements 
 which were made by Dalton. He also ob- 
 served that the connective-tissue changes in 
 ovaries during and after the menopause were 
 from the periphery to the center, the epi- 
 thelial elements being thus gradually com- 
 pressed. In the Graafian follicles the first 
 retrograde change is fatty degeneration with
 
 ANATOMICAL CHANGES. 51 
 
 the formation of a granular detritus. While 
 the membrana propria of the follicle is still 
 unchanged, quantities of round fat drops may 
 be found in the granulation layer, together 
 with unchanged cells of that layer, and also 
 ovum cells. These constantly increase, so 
 that finally "none of the cell contents remain, 
 the follicle containing only granular matter 
 and fluid. The tunica propria then becomes 
 oval, long, or angular. In a subsequent 
 stage the Graafian follicle becomes a bladder- 
 like body, oblong, with many folds, continu- 
 ing to contract, and being filled with a trans- 
 parent fluid, round cells, and an intercellular 
 substance. It is finally converted into a 
 long, oval, fibroid mass, which is connected 
 with the surrounding stroma by thick fibrils, 
 and the cavity is reduced to a bare cleft 
 without appreciable contents. As the tunica 
 albuginea thickens, the opening of matured 
 follicles is prevented, and Kisch believes that 
 this causes the irregularity and difficulty of 
 menstruation at this period with pain, hys- 
 teria, etc.
 
 52 THE MENOPAUSE. 
 
 Among the other writers who may be 
 profitably consulted with reference to the 
 anatomical changes produced by the meno- 
 pause are Borner, Puech, Kiwisch, Waldeyer, 
 Hegar, and Strojnowski. 
 
 Puech found the ovaries nearly normal in 
 size in a woman who had passed the meno- 
 pause three years previous to the operation 
 in which he removed them, and Kiwisch and 
 Waldeyer also describe the atrophic process 
 as a very slow one. 
 
 Hegar and Krieger assert, in addition, 
 that atrophy of the ovaries precedes atrophy 
 of the uterus, owing to the arrest of the re- 
 productive power before complete cessation 
 of the menses. Of course this process is sub- 
 ject to exceptions. 
 
 Strojnowski reports eleven cases in which 
 atrophy of the ovaries was due to diabetes.* 
 
 We may therefore assert that the anatom- 
 ical changes in the ovaries at and after the 
 menopause are atrophic in character, and 
 usually take place slowly. The epithelial 
 
 * See Satellite, January, 1392, p. 93.
 
 ANATOMICAL CHANGES. 53 
 
 elements gradually give place to connective 
 tissue, the Graafian follicles and corpora lutea 
 are completely destroyed, or the only evi- 
 dence that they ever existed consists in a few 
 scars upon the tunica albuginea, which be- 
 comes thick and shriveled. 
 
 The nerve and vascular supply is dimin- 
 ished or cut off, and the same is true concern- 
 ing the lymphatic supply. With regard to 
 the latter, His and Slavjansky assert its 
 abundant distribution to the ovaries, while 
 Exner and Buckel deny it.* 
 
 Thus the imperious influence of these or- 
 gans upon the body at large is brought to an 
 end. 
 
 ANATOMICAL CHANGES .IN THE UTEEUS. 
 Changes in the uterus are also induced 
 
 o 
 
 by the menopause, and it will be convenient 
 again to invoke the work of Dalton already 
 impressed into service, for testimony upon 
 this portion of the subject. The numbers of 
 
 * Sec article Ovary in Reference Handbook of the Medical 
 Sciences.
 
 5 THE MENOPAUSE. 
 
 the cases are the same as were used in the 
 remarks concerning the ovaries. 
 
 II. Widow, thirty-three years of age, who 
 died of pulmonary phthisis. The uterus was 
 empty and normal in appearance. Its mu- 
 cous membrane was pale throughout. 
 
 III. Prostitute, thirty years of age, who 
 died of waxy degeneration of the kidneys and 
 disease of the liver. Uterus empty and of 
 small size, mucous membrane pale and 
 smooth. 
 
 IV. Prostitute, twenty-one years of age, 
 who died of cardiac disease and pulmonary 
 oedema. Uterus small and empty. Mucous 
 membrane of cervix pale; that of the body 
 very thin, but reddened with an uniform fine 
 vascularity. 
 
 V. Woman, forty-three years of age, who 
 died from cerebral meningitis. Uterus 
 empty, of medium size, and normal in ap- 
 pearance, with the exception of a constriction 
 at the os internum. The mucous membrane 
 was smooth and pale, marked only with a 
 slight arborization of fine vessels.
 
 ANATOMICAL CHANGES. 55 
 
 VI. Woman, fifty-five years of age, who 
 died from abscess of the liver and pneumonia. 
 Uterus small and empty, and mucous mem- 
 brane pale throughout. It contained a small 
 fibrous tumor in its posterior wall. 
 
 VII. Woman, forty-five years of age, who 
 died from thoracic aneurism. Uterus large, 
 but empty, and normal in appearance. Mu- 
 cous membrane pale except for a rosy tint 
 near the fundus. 
 
 VIII. Woman, seventy years of age. 
 Uterus healthy except for a small fibrous 
 tumor in one of its walls; also thickening 
 and reddening of the adjacent mucous mem- 
 brane. 
 
 The findings concerning the uterus in the 
 foregoing cases are meaner, but show suffi- 
 
 o o o / 
 
 ciently that with the menopause comes im- 
 paired nutrition and reduction in volume, ex- 
 cept in cases in which the uterus is the seat 
 of a neoplasm, when it may retain its large 
 size indefinitely. 
 
 The author is prepared to verify the state- 
 ments of Dalton upon the basis of numerous
 
 56 THE MENOPAUSE. 
 
 operations upon old women from whom, for 
 one cause and another, the uterus has been 
 removed. The fact that the endometrial mu- 
 cous membrane was not uniformly anaemic in 
 Dalton's cases, as well as the condition of the 
 ovaries in these cases, confirms Hegar's state- 
 ment that the ovaries atrophy prior to the 
 atrophy of the uterus. Indeed, many ob- 
 servers have noticed that in the early stages 
 of the menopause congestion of the uterine 
 mucous membrane and enlargement of the 
 organ are of common occurrence. 
 
 Thomas asserts * that the contraction and 
 atrophy of the cervix take place more rapidly 
 than do the similar processes in the corpus 
 uteri. Such a process may be followed by 
 atresia and stenosis of the cervical canal while 
 the glands of the endometrium are still pour- 
 ing out their secretion. This may result in 
 retention of secretions, in degeneration, in 
 haemorrhage, etc. Such an explanation will 
 fit a certain number of cases, but not all ; in- 
 deed the author believes that in many cases 
 
 * Annals of Gynaecology and Paediatry, 1891, iv, p. 449.
 
 ANATOMICAL CHANGES. 57 
 
 degeneration of the cervix and of the corpus 
 proceed pari passu. In married women 
 with whom sexual intercourse is of frequent 
 occurrence it is not unlikely that the corpus 
 atrophies more rapidly than the cervix. 
 
 Kisch * observed that the vaginal portion 
 of the cervix was usually soft during the 
 menopause, eroded, and easily provoked to 
 haemorrhage ; also that the entire organ was 
 rather soft and relaxed with evidences of 
 stasis in the vena cava ascendens, the pelvic 
 vessels, and those of the uterine walls and 
 mucous membrane. He had also not infre- 
 quently observed hydrometra as the result of 
 stenosis of the cervical canal and the reten- 
 tion of secretions ; also prolapsus and dis- 
 placements of the uterus, of which the latter 
 conditions may be less disturbing during the 
 menopause than during the childbearing 
 period. 
 
 With respect to the foregoing opinions of 
 Kisch, the author begs leave to say that in 
 his experience prolapsus uteri is not a result 
 
 * Op. cit.
 
 58 THE MENOPAUSE. 
 
 of the menopause ; in fact, so far as the uterus 
 itself is concerned, when it is not the seat of 
 an inflammatory or neoplastic process, the 
 atrophy which it undergoes, with diminution 
 in size and weight, would of course tend to 
 check rather than to exaggerate a condition 
 of prolapse. 
 
 Klob, whose work on the anatomy and 
 pathology of the uterus performed valuable 
 pioneer service, * regarded the changes in- 
 duced in the organ by the menopause as an- 
 alogous with those in the ovaries, the muscu- 
 lar fibers, especially those which are in the 
 fundus and corpus being finally reduced to 
 connective tissue. 
 
 Classification of Uteri. The author's in- 
 vestigation of a large number of cases in 
 which the uterus was undergoing the 
 changes of the menopause, would lead him 
 to divide such cases into the following 
 classes : 
 
 1. Those in which the menopause is pro- 
 gressing. 
 
 * See translation by Kammerer and Dawson, 1868, p. 222.
 
 ANATOMICAL CHANGES. 59 
 
 2. Those in which it has taken place at 
 the customary time as a natural process. 
 
 3. Those in which it has taken place pre- 
 maturely. 
 
 4. Those in which the interval of time 
 which has elapsed since it occurred has been 
 very long. 
 
 In the first class there is either no per- 
 ceptible anatomical change, or there is the 
 congestion, the hypertrophy, the granulations 
 of the endometrium, with enlargement of the 
 organ and the occasional profuse haemor- 
 rhages which are incidental. Frequently 
 there is also excessive discharge from the 
 overstimulated uterine glands, but seldom an 
 inflammatory process. 
 
 In the second class, two years or more 
 having intervened since the last menstruation, 
 atrophy of the tissues of the uterus is well 
 marked. The mucous membrane is pale and 
 less sensitive than formerly, except at the 
 fundus, and sometimes at the os internum, 
 where sensitiveness continues acute. The 
 entire organ is reduced in size, the reduction
 
 60 THE MENOPAUSE. 
 
 in the portio vaginalis being particularly 
 marked. Glandular discharge is usually in- 
 significant, the atrophic process having now 
 involved the glands as well as the other tis- 
 sues. 
 
 In the third class the changes are not ma- 
 terially different from those of the second. 
 It has seemed to the author that the entire 
 process of atrophy moved on more rapidly 
 when the menopause was induced abruptly 
 by the removal of the ovaries than under 
 natural conditions, more rapidly also than in 
 those cases in which obesity or excessive 
 childbearing had been the cause. 
 
 In the obesity cases there is more or less 
 deposit or infiltration of fat, or fatty degener- 
 ation of the muscular tissue of the uterus, so 
 that it may seem even larger than under nor- 
 mal conditions. 
 
 In the fourth class the uterus is, as a rule, 
 insignificant in size, the portio vaginalis may 
 be shriveled to a mere buttonlike projection 
 or may be reduced to a mere slit in the an- 
 terior vaginal wall. The corpus also may be
 
 ANATOMICAL CHANGES. 61 
 
 no larger than a pigeon's egg. In a few 
 cases the author has been unable to find any- 
 thing that could suggest the former existence 
 of a parous organ, so completely had atrophy 
 performed its work. On the other hand, even 
 in extreme age the organ has been found 
 several inches in length, its nutrition being 
 continued by the neoplasms within its struc- 
 ture. A condition of extension, and even 
 hypertrophy, may also accompany prolapsus 
 when the vagina and other natural supports 
 are no longer able to hold it in its proper 
 place. Posterior displacements of the uterus 
 do not retard the atrophic process unless 
 the circulatory disturbance is considerable. 
 Extensive venous stasis means increased 
 nutrition. In general, with virgins and 
 widows who are continent, uterine atrophy 
 is more complete and more prompt than 
 with married women. Of glandular dis- 
 charge from the uterus there is usually 
 none, the glands having become quite func- 
 tionless or perhaps having disappeared en- 
 tirely.
 
 62 THE MENOPAUSE. 
 
 Anatomical Changes in the Fallopian 
 Tubes, Vagina, and Clitoris. The uterus 
 and ovaries are not the only organs in which 
 the degenerative changes which have been 
 depicted occur. Such changes will also be 
 observed in the other members of the genital 
 apparatus nay more, in portions of the body 
 with which the genital apparatus has no im- 
 mediate association. 
 
 The Fallopian tubes shrink and shorten, 
 the fimbriated ends gradually disappear, and 
 the organs are reduced to mere hardened 
 strings of connective tissue, deficient in vascu- 
 larity, functionless. The preliminary changes 
 in the vagina may be hyperaemia, increased 
 glandular secretion and increased sensitive- 
 ness. The congestion may be an element in 
 that general congestion of the pelvic tissues 
 which no longer has expression and outlet in 
 the customary monthly flow. Hypersemia is 
 succeeded by contraction of the vessels and 
 anaemia ; the mucous membrane loses its rugae, 
 becomes smooth and pale ; the vaginal tube is 
 shortened, the vault contracted, and bands of
 
 ANATOMICAL CHANGES. 63 
 
 connective tissue may be stretched across the 
 latter or adhesions formed in other portions 
 of the vaginal tube. The introitus undergoes 
 narrowing, especially in virgins and nulli- 
 parse ; it is sometimes so narrow that it will 
 scarcely admit the examining finger, while the 
 tube is shortened to a length of not more than 
 an inch or two. The vaginal glands often se- 
 crete an acrid muco-purulent substance which 
 causes the most intense pruritus of the tissues 
 which may be soiled by it. Not infrequently 
 the relaxation of the vaginal tissues is fol- 
 lowed by prolapse of one or both vaginal 
 walls, and the uterus, bladder, or rectum, or 
 all together, may be included in the descent. 
 This happens especially with women in 
 whom the vagina is voluminous, who have 
 borne many children, and with whom the 
 structures which usually act as supports and 
 barriers for these organs have weakened or 
 given way. Atrophy of the clitoris and ex- 
 ternal genitals also occurs, the hair upon the 
 labia becomes thin and scraggy, the cushion 
 of fat in the labia majora and mons veneris
 
 64 THE MENOPAUSE. 
 
 shrinks, the vulva becomes wrinkled, the 
 labia minora contract, and in some cases dis- 
 appear entirely. The clitoris also ceases to 
 become sensitive or congested, and returns 
 to a rudimentary, permanently inactive con- 
 dition. 
 
 Coitus with those who have undergone 
 these senile changes is not only very painful 
 (to the women) in many cases, but may be 
 followed by certain neuroses and psychoses 
 to which women at this period of life are 
 very susceptible.* 
 
 Anatomical Changes in the Mammary 
 Glands. The mammary glands share in the 
 atrophic process of the remainder of the geni- 
 tal apparatus, they and the milk ducts shrink- 
 ing to rudimentary conditions. Hardening 
 of ducts and glands often leads to the sus- 
 picion of disease, and many breasts have 
 
 * In a case which occurred in the author's practice a 
 woman of forty-five, who passed the menopause at thirty- 
 nine, suffered with mental disturbance which was most 
 marked after the sexual approaches of a brutal husband. He 
 succeeded in having her committed to a lunatic asylum, where 
 she soon recovered, the cause of her trouble having been re- 
 moved.
 
 ANATOMICAL CHANGES. 65 
 
 fallen a sacrifice to the knife when the cause 
 of the trouble was purely a physiological one. 
 This being a matter of actual knowledge and 
 experience, the author would insist upon the 
 necessity of differentiating a physiological 
 from a diseased condition. The fat of the 
 breasts is, in most cases, gradually absorbed, 
 the nipple shrinks, and the breasts become 
 wrinkled, skinny, and no longer objects of 
 beauty and symmetry. Not a few women, 
 however, retain the beauty of outline of these 
 structures to extreme age, though the general 
 appearance is not and can not be that of the 
 breasts of the presenile period. Previous to 
 the occurrence of atrophy there may also be 
 a period of congestion and irritation in the 
 breasts. Tilt has observed such a condition 
 fourteen times in the five hundred cases of 
 menopause which he has tabulated and ana- 
 lyzed. In the cases in question the breasts 
 were swollen and painful, the nipples w r ere 
 sore, and occasionally they exuded a milky 
 or glutinous fluid. This condition of conges- 
 tion not infrequently gives rise to the sus-
 
 66 THE MENOPAUSE. 
 
 picion of pregnancy, at least in the mind of 
 the individual who suffers. It is always a 
 condition which calls for careful inspection 
 and treatment. 
 
 Changes in other Structures of the Body. 
 It may not be amiss to note that not in 
 the generative organs alone do degenerative 
 changes take place at the period of the meno- 
 pause. The hair changes its color, loses the 
 glossiness of youth, perhaps falls out ; the 
 teeth decay and loosen in their sockets, the 
 skin becomes wrinkled and flabby, the spleen, 
 the lymphatics, Peyer's patches, and probably 
 other structures, tell but too plainly that the 
 progressive period of life is over, that degen- 
 eration now controls. 
 
 (2.) ANATOMICAL CHANGES IN THE GENITAL 
 ORGANS WHICH LEAD TO THE MENOPAUSE. 
 
 The various organs and their morbid con- 
 ditions will be considered in the same man- 
 ner as in the preceding section. 
 
 The Ovaries and Fallopian Tubes. The 
 changes to which the ovaries are subject
 
 ANATOMICAL CHANGES. 67 
 
 which have an setiological bearing upon the 
 menopause are very numerous indeed. No 
 one who has paid even the most superficial 
 attention to the pathology of the pelvic or- 
 gans in women can have failed to note the 
 astonishing frequency and variety of diseases 
 which destroy the tissues of the ovaries, in- 
 terfere with their function, and maintain a 
 necessary and intimate connection with the 
 menopause. This does not mean that men- 
 struation stops or even is irregular in all cases 
 in which ovarian disease is present, for all 
 gynaecologists, indeed almost all physicians 
 who are carefully observant, are familiar with 
 cases in which that function is performed 
 with the utmost regularity in the presence of 
 most extensive disease of such a character. 
 
 Hence Hegar is not entirely correct in 
 asserting that menstruation depends on the 
 functional activity of the ovaries, and that 
 amenorrhcea is the usual result of patho- 
 logical conditions causing complete degenera- 
 tion of both ovaries. He is partly correct in 
 his statement that exceptions are due to per-
 
 68 THE MENOPAUSE. 
 
 sisting healthy parenchyma which may be in- 
 cluded in the pedicle of an ovarian tumor, 
 the tumor having been removed, and to col- 
 lateral fluxion and stasis. There is an addi- 
 tional element of nerve influence in such cases, 
 to which attention has been called by Arthur 
 Johnstone, and to which reference may be 
 made in the subsequent course of this discus- 
 sion.* 
 
 The chief forms of disease to which allu- 
 sion has been made in the foregoing portions 
 of this section consist of neoplasms, to which 
 the ovary is extremely susceptible. Such 
 growths include fibroma, sarcoma, carcinoma, 
 tubercle, and the large family of cystomata, 
 
 * Hoist reports a case, quoted by Borner (op. dt.), in 
 which pregnancy occurred, the patient dying before term, 
 and in which both ovaries had undergone complete degener- 
 ation, one of them being the seat of malignant disease. 
 
 Korn reports a case in which a woman fifty-three years of 
 age had always menstruated regularly, and when seen by 
 him both ovaries were the seat of malignant disease. 
 
 In J. Williams's case pregnancy occurred subsequent to 
 the removal of the left ovary. The case proceeded to term, 
 and during labor it became necessary to remove the remain- 
 ing ovary which had become the seat of cystic disease. 
 
 The author has operated in a number of instances in 
 which menstruation had been uninterrupted and in which
 
 ANATOMICAL CHANGES. 69 
 
 though, as already stated, numerous cases of 
 undisturbed menstruation are recorded in 
 which the ovaries have been found entirely 
 degenerated and disorganized by such dis- 
 ease. 
 
 Anatomical changes in the tubes interfer- 
 ing with menstruation are frequently associ- 
 ated with the changes which have been men- 
 tioned as affecting the ovaries. Changes of 
 an inflammatory character are more frequent 
 in these structures than are the neoplastic. 
 Degenerative or inflammatory processes, if 
 limited to the tubes, would rarely repress 
 menstruation or induce the menopause. 
 
 the ovarian stroma had entirely disappeared. Indeed such 
 cases could be multiplied. 
 
 Slavjansky's well-known investigations concerning paren- 
 chymatous and interstitial oophoritis are interesting and in- 
 structive in this connection. 
 
 At the last meeting (1896) of the American Gynaecological 
 Society cases were reported by Sutton, Gordon, and others in 
 which not only menstruation but pregnancy and labor at 
 term seemed to follow the removal of both ovaries. This 
 must mean either imperfect operations, supernumerary ova- 
 ries, or transmission of ova to the uterus in a way which is 
 not clearly explicable, and in addition independence of men- 
 struation in so far as the integrity of the ovaries is con- 
 cerned.
 
 70 THE MENOPAUSE. 
 
 Their integrity is not essential to the con- 
 tinuance of menstruation. 
 
 The Peritoneum. In the inflammatory 
 and neoplastic derangements of the peri- 
 toneum, the influence, with reference to the 
 menopause, is probably always or nearly al- 
 ways indirect that is, the pressure which a 
 tumor or a mass of contracting exudate, or a 
 collection of peritoneal fluid of whatever 
 nature, exerts upon the ovaries, tubes, or 
 uterus may interfere with the circulation of 
 these organs, and impair their nutrition to 
 such a degree as to induce the menopause, 
 and the same is true with regard to tumors 
 
 O 
 
 developing from any of the abdominal vis- 
 cera.* 
 
 The Uterus. Numerous are the ana- 
 tomical changes in the uterus which result 
 in the menopause. They may be of an in- 
 flammatory character, involving the periine- 
 trium or parametrium, though such disturb- 
 
 * This interjection, though somewhat wide of the subject 
 which is immediately under consideration, has a bearing 
 which, it is believed, will be readily appreciated.
 
 ANATOMICAL CHANGES. Yl 
 
 ances often end in resolution. Should they 
 terminate in abscess, not only is the effect 
 upon the vital forces in general severe and 
 exhausting on account of the sepsis and vari- 
 ous complications with the abdominal viscera 
 which are excited, but they are also quite 
 likely to terminate in cessation of the men- 
 strual function. 
 
 Anatomical changes in the uterine mu- 
 cous membrane of an inflammatory character 
 may be due to infection or traumatism, the 
 latter resulting from parturition, the use of 
 caustics, or other injuries unconnected with 
 pregnancy or parturition, the former arising 
 from the poison of various infectious diseases 
 which may attack the uterus, and including 
 syphilis, gonorrhoea, measles, diphtheria, ty- 
 phoid fever, or cholera. The inflammation in 
 such cases is followed by contraction and 
 atresia, the function of the uterine mucous 
 membrane being abolished, the ovaries par- 
 ticipating in the process, and the menopause 
 resulting. Amyloid disease affecting the 
 uterus may also interfere with menstruation
 
 72 THE MENOPAUSE. 
 
 and induce the menopause. This form of 
 disease is, however, a very rare one, only one 
 reported case having been found in literature. 
 This was reported long ago by Virchow.* 
 
 Fatty degeneration or infiltration of the 
 uterus apart from a general development of 
 fatty tissue may also occur, and have a detri- 
 mental action upon the menstrual function. 
 This subject has recently been studied by 
 Sanger f with reference to the puerperal 
 uterus, and in previous years by Andral, 
 Bureau, Heschl, Simpson, Kolliker, Rold- 
 tansky, and others. 
 
 Klob J regards fatty degeneration of the 
 uterus as of two varieties, (1) post-puerperal 
 and (2) that form which is due to a morbid 
 condition of the arteries of the uterus with 
 ischsemia, the arteries being first rigid, their 
 nutrition being impaired, and fatty degenera- 
 tion following;. 
 
 O 
 
 Fatty degeneration of the uterus may also 
 proceed from tuberculosis or from embolism. 
 
 * Klob, op. cit. % Op. cit., p. 255. 
 
 f Annals of Gynaecology, July, 1888.
 
 ANATOMICAL CHANGES. 73 
 
 It begins from within and works out\vard, 
 and as it progresses the ovaries and oviducts 
 shrivel. The menopause necessarily -follows. 
 As to the influence of the neoplasms of the 
 uterus upon the menopause, the myomata, if 
 subperitoneal, frequently seem to be unim- 
 portant in this particular, excepting in those 
 cases in which, owing to their size or their 
 peculiar situation, atrophy is caused by their 
 pressure. The nutrient elements in such 
 cases go to the tumor rather than to the 
 uterus, which accordingly may suffer reduc- 
 tion in its dimensions. Frequently in such 
 cases the menopause is long delayed. With 
 the intramural growths menstruation is usu- 
 ally profuse, especially in those cases in which 
 the tumors are implanted in the area of great- 
 est vascularity of the organ that is, near the 
 entrance into the uterus of the uterine ar- 
 teries. With the mucous and submucous 
 growths the conditions are also favorable to 
 great outpourings of blood. It is in uterine 
 disease of the varieties just mentioned that 
 women look with greatest longing and hope
 
 74 THE MENOPAUSE. 
 
 for relief with the menopause, a hope and 
 longing which are often delusive and just 
 ahead of one's grasp. Who has not seen 
 women with such disease broken down and 
 anaemic, prematurely old, dying with the 
 menopause still deferred ? Should the meno- 
 pause come prematurely, as it sometimes does 
 in such cases, it is usually for the reason 
 that the vital forces are exhausted, the flow 
 ceasing, as it does with other wasting pro- 
 cesses, simply because the vis nature has 
 given out. 
 
 With adenomata of the uterus, the in- 
 creased nutrition which their presence im- 
 plies necessitates an experience similar to 
 that which obtains with intramural myomata. 
 In cases in which they do not assume a 
 malignant character (though some writers in- 
 sist that they are invariably malignant) there 
 is no reason for supposing that they have any 
 tendency to favorably influence the meno- 
 pause. 
 
 In the very large majority of cases of 
 uterine disease it is the involvement of the
 
 ANATOMICAL CHANGES. 75 
 
 ovaries which checks the menstrual flow, if it 
 is checked. Even cases in which the uterus 
 has been removed, the ovaries being retained, 
 have in some instances continued their men- 
 strual history without interruption, the blood 
 escaping through the ruptured capillaries of 
 the vaginal scar, or by the mucous membrane 
 of the rectum, nose, or mouth, or appearing 
 as stigmata upon the surface of the body. 
 Atresia and stenosis of the uterine canal will, 
 of course, prevent the escape of fluid by that 
 channel, but if the ovaries continue to func- 
 tionate and the nexus in the pelvis, whatever 
 it may be, continues undivided and unde- 
 stroyed, menstruation or its substitute will 
 continue in one form or another. 
 
 The Vagina. The influence which in- 
 flammations and new growths of the vagina 
 and external genitals have upon the meno- 
 pause is necessarily indirect, the effect being 
 produced through the uterus and ovaries, if it 
 exists at all. The menopause sometimes oc- 
 curs after the infliction of severe injuries 
 upon the vagina during parturition, atresia
 
 76 THE MENOPAUSE. 
 
 and cicatrization seriously crippling all the 
 pelvic organs. Atresia of the vagina from 
 other causes, or obliteration of the vagina by 
 a neoplasm, may lead to retention of the men- 
 strual secretion with great attendant disturb- 
 ance ; but if the ovaries remain intact, the 
 menopause is unlikely to occur. In several 
 cases of this character which have been under 
 the author's care the unvarying rule has been 
 that the menopause did not result. 
 
 The Mammary Glands. The important 
 influence which is exerted by the mammary 
 glands upon the menstrual function, and con- 
 sequently upon the menopause, must not be 
 overlooked. 
 
 This subject has not received the atten- 
 tion at the hands of gynecologists which it 
 deserves. The mammary glands are a means 
 for the diversion of a considerable portion of 
 the vital energy of the uterus ; their irrita- 
 tion causes uterine contraction. During the 
 period of their highest functional activity the 
 pelvic circulation is at its minimum, men- 
 struation being diminished or discontinued.
 
 ANATOMICAL CHANGES. 77 
 
 The effect of continuous or nearly con- 
 tinuous lactation for a prolonged period, chil- 
 dren being suckled almost without inter- 
 ruption for several years, can not fail in 
 women who lack a superabundance of vi- 
 tality to produce such a degree of contraction 
 of the uterus that atrophy and the meno- 
 pause will result. 
 
 The somewhat rare condition of superin- 
 volution of the uterus may have such a cause. 
 The author has seen it result in the meno- 
 pause in the person of a vigorous young 
 woman of twenty-six who had borne six chil- 
 dren in rapid succession. 
 
 In the neoplasms of the mammary glands, 
 however, the author has not observed that 
 the influence upon the menstrual function 
 was marked. Though this is one of the com- 
 monest seats of disease in women at all ages, 
 such disease does not appear to have any par- 
 ticular bearing upon menstruation or the 
 menopause. It is only when the glands in 
 their genetic influence or relation, as some 
 writers call it, are affected or concerned that
 
 78 THE MENOPAUSE. 
 
 we see the diminution or cessation of men- 
 struation. 
 
 That malignant disease of the breast oc- 
 curs most frequently in the decade between 
 forty and fifty, or the decade in which the 
 menopause is of most frequent occurrence, is 
 well known and has been the occasion of 
 investigation by Birkett, Lebert, Scanzoni, 
 Velpeau, Gross, and Winiwarter, but that it 
 produces the menopause, except perhaps 
 indirectly, as the nutrition becomes greatly 
 impaired, the facts do not seem to indicate. 
 
 3. ANATOMICAL CHANGES WHICH ARE COINCI- 
 DENTAL WITH THE MENOPAUSE, BUT WHICH 
 AKE NOT USUALLY ITS CAUSE NOR CAUSED 
 
 BY IT. 
 
 Accidental or Incidental Occurrences as- 
 sociated with the Menopause. The third sub- 
 ject for consideration in this connection con- 
 cerns anatomical changes in the genital organs 
 which are incidental to or collateral with the 
 menopause, but which have no setiological re- 
 lation to it. The field which is covered by
 
 ANATOMICAL CHANGES. 79 
 
 this subject is a large and important one, for 
 it will be apparent that there are many dis- 
 eased conditions occurring during the prog- 
 ress of the menopause, sometimes of a severe 
 or even fatal character, but not essential to 
 it. The mistake has too often been made in 
 the past of confusing these accidental occur- 
 rences with that which was customary and 
 usual in the history of the menopause. 
 
 Subinvolution. One of the very common 
 morbid conditions which is incidental to the 
 menopause is subinvolution of the uterus, a 
 term which seems to the author more expres- 
 sive and apt than areolar hyperplasia, or 
 chronic parenchymatous metritis. It im- 
 plies, of course, that one or more pregnancies 
 have been experienced in a given case. With 
 women who have borne many children, es- 
 pecially if child bearing has been begun rather 
 late in life, such a condition may be easily 
 explained. 
 
 Haemorrhages explained by Exuberant 
 Nutrition. The superabundance of tissue in 
 the uterus and the exuberant nutrition of the
 
 80 THE MENOPAUSE. 
 
 endometrial mucous membrane explain the 
 profuse haemorrhages which often accompany 
 this condition, prolong the menopause, and 
 contribute greatly to the discomfort and in- 
 convenience of the patient. In other cases 
 the exhaustion produced by the haemorrhages, 
 or in part by them, causes premature appear- 
 ance of the menopause, while in yet others, 
 and perhaps the greater number of cases, the 
 effect upon the menopause is insignificant. 
 
 Relation of Malignant Diseases of the 
 Pelvis to the Menopause. The entire series 
 of malignant diseases of the pelvic organs, 
 whether internal or external, has long been 
 regarded as bearing a peculiar relation to the 
 menopause. It is true that many cases of 
 such disease take place between the fortieth 
 and fiftieth years, when the menopause most 
 frequently occurs. We have already alluded 
 to this coincidence in previous pages and to 
 other facts which had a bearing in the mat- 
 
 O 
 
 ter. We shall also find it necessary to allude 
 to it aimin. 
 
 O 
 
 Galen and others of the early writers
 
 ANATOMICAL CHANGES. 81 
 
 originated the idea that there was a neces- 
 sary connection between malignant disease of 
 the breast and uterus and the menopause. 
 From observations which were made by Boi- 
 vin, Chiari, and others, the following table 
 was constructed, representing the ages at 
 which uterine cancer had developed. 
 
 Cases. 
 
 Under 20 years 12 
 
 From 20 to 30 years 193 
 
 " 30 " 40 " 519 
 
 " 40 " 50 " 959 
 
 " 50 " 60 " 481 
 
 " 60 " 70 " 279 
 
 Beyond 70 years 210 
 
 The opinion of many writers also is that 
 cancer of the breast occurs most frequently 
 in the decade from forty to fifty. This has 
 already been alluded to. (See also table on 
 page 33.) 
 
 Menopause is Conservative; Malignant 
 Disease is Destructive. The theory of the 
 menopause, however, is hostile to the plan 
 and progress of malignant disease. The 
 former is conservative, and consists essentially 
 in utilizing to the utmost impaired and worn- 
 out tissues and processes. With malignant
 
 82 THE MENOPAUSE. 
 
 disease, on the contrary, a tissue is built up or 
 infiltrated only to break down and be de- 
 stroyed, the destructive process continuing 
 and spreading until it annihilates. 
 
 Total Number of Cases of Malignant 
 Disease greatest before and after tlie Decade 
 which includes the Menopause. It must also 
 be remembered that the larger percentage of 
 cases of malignant disease of the genital or- 
 gans occur before and after the menopause. 
 When such disease follows the menopause 
 the mistake has not infrequently been made 
 of attributing the coincident haemorrhage to 
 an incomplete menopause or to recurrent 
 menstruation. Such mistakes are less ex- 
 cusable than they once were. 
 
 Warning should be sounded before Ma- 
 lignant Disease becomes too Extensive. In 
 any event it would be unreasonable for an 
 intelligent physician, whether with or with- 
 out special knowledge concerning the pelvic 
 organs, to allow malignant disease of those 
 organs, accompanied with repeated haemor- 
 rhages, to reach the irremediable stage that
 
 ANATOMICAL CHANGES. 83 
 
 is, the stage when radical surgical measures 
 would be unavailing or impossible before he 
 called to his assistance the expert gynaecol- 
 ogist. 
 
 Fibroid Tumors of the Uterus may sim- 
 ulate Malignant Disease. The anatomical 
 changes which accompany fibroid tumors .of 
 the uterus during the menopause, especially 
 the degeneration of the uterine mucous mem- 
 brane with the sometimes attendant profuse 
 haemorrhage, simulate malignant disease, and 
 require most careful attention in order that 
 the differential diagnosis may be correctly de- 
 termined. Benign growths of different varie- 
 ties may develop in the genital organs coinci- 
 dently with the menopause. Especially is 
 this true of cystic tumors of the ovary, the 
 active developmental period of which may 
 continue even to the most advanced age. 
 
 Changes in Neoplasms during and after 
 Menopause. Atrophic changes in the solid 
 and fibrocystic tumors of the genital organs 
 are not as marked nor as frequent during the 
 menopause as was formerly taught. We now
 
 84 THE MENOPAUSE. 
 
 know that tlieir development may continue 
 uninterruptedly in spite of the menopause, 
 that they may enlarge after the menopause 
 has terminated, and that they may even un- 
 dergo malignant degeneration after that pe- 
 riod has passed.* 
 
 Anatomical Changes due to Inflamma- 
 tion. The anatomical changes which may be 
 produced by purely inflammatory processes 
 of the genital organs during the menopause 
 are the same as might occur if the menopause 
 w r ere not present. They are either of trau- 
 matic or infectious origin, and are not of fre- 
 quent occurrence. The tissues at this period 
 of life are far less susceptible to inflammatory 
 influences than during the earlier part of life. 
 The increased vascularity which such pro- 
 cesses imply, certainly during their early 
 stages, may possibly be accompanied with in- 
 creased haemorrhage at the returning men- 
 strual epochs, and it would even be possible 
 that the menopause might be retarded by 
 
 * See in this connection the writings of Muller, Gusserow, 
 and others upon this subject.
 
 ANATOMICAL CHANGES. 85 
 
 such a process. The infrequency of such pro- 
 cesses at such a time has resulted in the ab- 
 sence of investigations for the ascertainment 
 of their particular significance. 
 
 Destruction of the Generative Organs may 
 hasten the Menopause. Complete destruction 
 of the generative organs while the menopause 
 is in progress, from whatever cause, will have 
 decided influence in accelerating the termina- 
 tion of the menopause, especially if the uterus 
 and the adnexa as well are destroyed or re- 
 moved. If the mammary glands alone are 
 removed or destroyed there is no evidence, so 
 far as the author is aware, that the meno- 
 pause will be influenced.* 
 
 * Gross and Winiwarter, in their analysis of six hundred 
 and forty-two cases of mammary cancer, found four hundred 
 and ninety-six in which it occurred subsequent to the age of 
 forty. There is nothing in their writings, nor in those of 
 Birkett, Lebert, Scanzoni, Velpeau, and Virchow upon this 
 subject, to indicate that disease or destruction of these glands 
 influences the menopause.
 
 86 THE MENOPAUSE. 
 
 RESUME OF THE FOREGOING OBSERVATIONS 
 CONCERNING ANATOMICAL CHANGES, WITH 
 CONCLUSIONS. 
 
 The Changes of the Menopause are 
 Atrophic / The Time Required Varies. 
 The menopause is attended invariably by 
 anatomical changes in the genital organs 
 which are normally atrophic in character, 
 but the period of time which elapses be- 
 fore such changes take place is a variable one. 
 
 Atrophic Changes are the more Uniform 
 in the Natural Menopause. When it occurs 
 as a natural process the atrophic changes in 
 the different organs are more uniform and 
 more steadily progressive than when it is pre- 
 mature or complicated by diseased conditions 
 of these organs. 
 
 Diseased Organs may cause Irregulari- 
 ties. In cases in which there is disease of the 
 genital organs or of any of the tissues which 
 compose them the course of the menopause is 
 irregular, and there is also irregularity as to 
 the anatomical changes. 
 
 O
 
 ANATOMICAL CHANGES. 87 
 
 In some cases the menopause is retarded, 
 the vascular supply to the genital organs be- 
 ing abundant, or if the disease is limited to 
 one of the organs while the vascular supply 
 is withdrawn from the others, atrophic 
 changes may take place in the latter and 
 not in the former. 
 
 In other cases, in consequence of disease, 
 traumatism, or excessive function, the meno- 
 pause may come prematurely, atrophy of the 
 genital organs being also premature. 
 
 In yet other cases in which pathological 
 anatomical changes in the genital organs have 
 taken place, the menopause is indefinitely de- 
 ferred, the organs do not atrophy, the dis- 
 charge of blood continues, the tissue changes 
 become destructive, and unless relieved by 
 art the termination will eventually be a fatal 
 one. 
 
 ADDENDA. 
 
 FARRE. Anatomy and Pathology of the Uterus. 
 
 HENSEN. Physiologic der Zeugung. Hermann's 
 Handbuch der Physiologie, Leipzig, 1881. 
 
 PFLUGER. Die teleologische Mechanik der leben- 
 digen Natur. Archiv f iir Physiologie, xv. ^
 
 88 THE MENOPAUSE. 
 
 KOBELT. Die Mannlichen und Weiblichen "Wol- 
 lustorgane des Menschen, Freiburg, 1844. 
 
 VEIT. Physiologic der weiblichen Geschlechtsor- 
 gaue. Miiller's Handbuch der Geburtshiilfe. 
 
 PUECH. Des ovaires et de leurs anomalies. Paris, 
 1873. 
 
 GROSS. Tumors of the Mammary Glaiid. D. Ap- 
 pleton, & Co., New York, 1880.
 
 CHAPTER III. 
 
 SOME OF THE FACTORS WHICH INFLUENCE THE 
 ADVENT AND PROGRESS OF THE MENOPAUSE. 
 
 THE scope of this chapter has included 
 more or less which has been stated in the 
 foregoing pages (anatomical changes, etc.), 
 and it will also comprehend, to a certain 
 extent, the material which will be found in 
 the chapter immediately following this one, 
 which will deal specifically with the phe- 
 nomena peculiar to the menopause. The 
 indulgence of the reader is besought if 
 
 O O 
 
 his patience is tried with apparent repeti- 
 tions. 
 
 The following scheme represents the 
 treatment of the subjects which are to be 
 considered in this chapter. 
 
 89
 
 90 THE MENOPAUSE. 
 
 FACTORS CONSIDERED. 
 
 1. Age. 2. Disease and traumatisiu. 3. Climate. 4. He- 
 redity. 5. Temperament. 6. Accidental influences. 
 
 1. Age. 
 
 The testimony of various observers in different nations and 
 countries. 
 
 2. Disease and Traumatism. 
 f [I. General. 
 
 A. Acute 
 
 a. Acute. J ( x - Puerperal. 
 
 ! c. Infec- 
 and chronic J (_ II. Local. -{ 
 
 inflammato- 1 \V- Nonpuer- j 
 
 npral I TrU- 
 ry processes. 
 
 L matic. 
 
 . b. Chronic wasting diseases of various organs. 
 
 B. Degenerative processes. 
 
 C. Neoplasms. 
 
 D. Trauma. 
 
 3. Climate. 
 
 Including altitude and various atmospheric conditions. 
 
 4. Heredity. 
 
 Family, national, or race peculiarities. Fertility and ster- 
 ility. 
 
 5. Temperament. 
 
 Habits, occupation, social surroundings. Sexual excess and 
 abstinence. 
 
 6. Accidental Influences. 
 Fear, emotion, grief, etc. 
 
 The Menopause means Tissue Changes. 
 We have seen that the menopause signified 
 tissue changes, changes in structure in the 
 genital organs, and also that at the begin-
 
 ADVENT AND PROGRESS. 91 
 
 ning of the process those organs sometimes 
 seem stimulated to unusual activity, the 
 mammary glands swelling and perhaps se- 
 creting milk, or a fluid which resembles it, 
 the uterus increasing in size and vascu- 
 larity, and the entire genital apparatus un- 
 dergoing a quite unusual degree of func- 
 tional activity. 
 
 Early Phenomena of tlie Menopause may 
 indicate General Congestion. The discharges 
 of blood from the uterus though less fre- 
 quent are more copious, the sexual appetite 
 may become intense, and this is the more 
 noteworthy since it sometimes occurs in 
 women who have previously been insensitive 
 and unresponsive in this respect. The change 
 in the individual, in her disposition, tem- 
 perament, habits, as this process advances, 
 is sometimes radical, marking quite as dis- 
 tinct an era in the life of the person as did 
 the advent of puberty. The waves advance 
 from puberty to the menopause ; from this 
 time onward they recede. 
 
 It was observed in a previous chapter
 
 92 THE MENOPAUSE. 
 
 (see pages 27-38) in a general way that the 
 individuals who constituted the different 
 types of women experiencing the meno- 
 pause varied in their peculiarities, and the 
 experiences to which they were subjected 
 were more or less significant. Let us now 
 look at the matter rather more specifically 
 and consider the factors which influence the 
 advent and progress of the menopause. 
 
 Factors of Influence 'vary for Different 
 Women. These are not the same for all 
 women nor do they influence all women 
 with the same degree of effect. In the 
 course of an experience of ten or more years 
 of practice one will find the application of 
 each factor in more or fewer cases. These 
 factors may be classified as in the scheme 
 at the beginning of this chapter, as follows : 
 
 2. Disease and traumatism, including the 
 
 ' O 
 
 influence of undeveloped and badly nour- 
 ished organs. 
 
 3. Climate, including altitude and all at- 
 mospheric conditions.
 
 ADVENT AND PROGRESS. 93 
 
 4. Heredity, including family, national, or 
 race peculiarities. 
 
 5. Temperament, habits, occupations, and 
 social surroundings. 
 
 6. Accidental influences, fear, misfortune, 
 grief, etc. 
 
 1. AGE. 
 
 The age at which the menopause occurs 
 is modified, as stated on page 28, by many 
 conditions, and the period of its duration is 
 equally a variable quantity. 
 
 In the United States, at the latitude 
 of New York and under the influence 
 of a moist atmosphere, the menopause 
 takes place in the large majority of in- 
 stances between the fortieth and fiftieth 
 years. 
 
 The menopause was observed in 150 
 cases taken at random from the histories of 
 many thousand women who were seen at the 
 class for gynaecology at the Outdoor Poor 
 Department of Belle vue Hospital, in New 
 York city, during a period lasting between
 
 94 THE MENOPAUSE. 
 
 four and five years. The age limits in these 
 cases were 30 and 53. 
 
 In 96 of these cases menstruation had 
 ended, in 54 it still recurred, though in- 
 frequently. Of the first of these groups 
 the terminations of menstruation were as fol- 
 lows : 
 
 Age. 
 30 
 
 No. of 
 cases. 
 
 2 
 
 Age. 
 42 
 
 No. 
 case 
 2 
 
 31 ... 
 
 
 
 43 . 
 
 9 
 
 32 
 
 1 
 
 44 
 
 10 
 
 33 
 
 2 
 
 45 
 
 6 
 
 34 . . . . 
 
 .. . .2 
 
 46 
 
 5 
 
 35 
 
 
 
 47 
 
 5 
 
 36 
 
 1 
 
 48 
 
 10 
 
 37 
 
 6 
 
 49 
 
 4 
 
 38 
 
 5 
 
 50 
 
 2 
 
 39 
 
 8 
 
 51 
 
 1 
 
 40 
 
 4 
 
 52 
 
 . ... 2 
 
 41.. 
 
 6 
 
 53.. 
 
 3 
 
 The average age of this group was 39f, 
 but it is quite important to note that 63 
 were between the ages of 40 and 50. 
 
 Of the second group, viz., the 54 cases 
 in which the interval of irregularity varied 
 from a few weeks to ten months, the age 
 limits were 38 and 52, the average being
 
 ADVENT AND PROGRESS. 95 
 
 For the entire series of 150 the average 
 age was 41^.* 
 
 As to the nationality of the women in 
 this series, Irish and American predominated, 
 but all the others had lived here long enough 
 to be thoroughly influenced by such climatic 
 and other surroundings as would have a 
 bearing upon the appearance and progress 
 of the menopause. 
 
 All these women, be it observed, be- 
 longed to the class of hard workers. 
 
 The duration from the beginning to the 
 end of the menopause was not determinable 
 in the greater number of these cases, unless 
 we should consider the termination of men- 
 struation as identical with the termination 
 of the menopause. With the great majority 
 of women, certainly with those who come to 
 the notice of the physician, there is no such 
 
 * The much lower average age in this series than in the 
 statistics which follow may be in part due to the smaller 
 number of cases involved, and in part to the incident, not 
 easily explainable, that so large a number as 39 of the cases 
 which were investigated happened to be 40 years of age or 
 less.
 
 96 THE MENOPAUSE. 
 
 identity, and with many the common phe- 
 nomena of the menopause, especially the heat 
 flashes or vasomotor crises, are continued to 
 the end of life, no matter how prolonged 
 life may be. 
 
 More as a matter of curiosity or in- 
 formation than because any fundamental 
 principles are to be deduced from them, 
 the following statistical data, gathered from 
 various sources, have been introduced : 
 
 Germany. Kisch analyzes 500 cases from 
 among German and Austrian women, in 
 which the menopause had been passed, the 
 termination of menstruation being probably 
 alluded to.* 
 
 His figures are as follows: 
 
 Age. No. of cases. 
 
 35-40 48 
 
 40-45 141 
 
 45-50 177 
 
 50-55 89 
 
 France. Leudet f investigated the his- 
 tories of 170 women at Rouen who had 
 
 * See article Climakterisches Alter in Real Encyclopadie. 
 t Comptes Rendus, Paris International Medical Congress, 
 1867.
 
 ADVENT AND PKOGRESS. 97 
 
 passed the menopause, and found the aver- 
 age age for those who were in easy circum- 
 stances 47*4; for those who lived amid the 
 surroundings of country life, 47*9; for those 
 who were compelled to get their living by 
 hard work, 48'7. 
 
 England and France. Tilt analyzed the 
 histories of 1,082 women in England and 
 France, and found the average age for the 
 menopause 45 '7. * 
 
 Norway. Faye found the average age 
 in Norway, 391 cases being examined, to 
 be 49.f 
 
 Germany. In Berlin, Mayer investigated 
 1,546 cases with the result that the average 
 was 47-034 
 
 Borne^s Statistics. Borner * found that 
 the average for the women of northern Eu- 
 rope was higher than for those in the south- 
 ern countries, the following data from ap- 
 proved authorities being given by him: 
 
 * Comptes Rendus, Paris International Medical Congress, 
 1867. 
 
 t Ibid. f Ibid. * The Menopause.
 
 98 THE MENOPAUSE. 
 
 Queirel and Rouvier give 46 years 
 months as the average for Marseilles women. 
 Goth gave the limits of 39 and 51 years for 
 the women of seven tribes in Transylvania. 
 
 Hussia. R-odsewitch gave the average at 
 St. Petersburg as 48 years 8J months, while 
 Binsenger, at Moscow, found it only 40 to 43. 
 
 Furthermore, Lieven, at St. Petersburg, 
 analyzed 100 cases in which the age limits 
 were 40 and 53. In the same series 54 
 were between 47 and 50. 
 
 Denmark. In Denmark 312 cases were 
 analyzed by Hannover, the average being 44'82. 
 
 The following data were obtained by 
 the author in the course of an investigation 
 concerning the functions of the reproduc- 
 tive apparatus in our native American In- 
 dian women : * 
 
 Ape at cessation 
 Names of tribes. of menstruation. 
 
 Sac and Fox 48 
 
 Crow and Assiniboine 49-50 
 
 Cmtah 40-50 
 
 Apache 42-53 
 
 Cheyenne and Arapahoe 46-73 
 
 Sioux 38-58 
 
 * See Transactions, American Gynaecological Society, 1891.
 
 ADVENT AND PROGRESS. 99 
 
 Early Menopause. As illustrations of 
 very early age for the occurrence of the 
 menopause the Arab women of the desert 
 are cited, with whom it is frequently said 
 to occur between the ages of 20 and 30. 
 
 Kisch tells of a Hungarian Jewess, fat 
 from her youth, who menstruated at 9, mar- 
 ried at 15-J-, was sterile, and ceased men- 
 struating at IT. In another of his cases 
 menstruation began at 13, marriage occurred 
 at 16, sterility followed, and the menopause 
 came at 20. 
 
 Mayer * saw two cases in Berlin in which 
 menstruation ceased at 22. In one of these 
 cases three children were born after the men- 
 ses had ceased. In two others the phenom- 
 ena of the menopause were present at 25. 
 One of these women menstruated once in her 
 twenty-fifth year after her second labor ; she 
 subsequently became epileptic and idiotic 
 after having experienced severe fright. In 
 another of Mayer's cases the menopause came 
 
 * Comptes Rendus, Paris International Medical Congress, 
 1867.
 
 100 THE MENOPAUSE. 
 
 at 29 in a very fat woman who had borne six 
 children at term and had had one miscar- 
 riage. 
 
 Brierre de Boismont and Courty (quoted 
 by Borner, op. cit.) saw two cases of meno- 
 pause at 21. 
 
 Schlichting observed that the menopause 
 came at an early age in his experience with 
 Jews and Roumanians, but no figures were 
 quoted.* 
 
 Late Menopause. Illustrations of pro- 
 longed menstrual life that is, to the age of 
 60 are not very rare ; but beyond 60 they 
 are very unusual. Statements purporting to 
 narrate such prolonged menstruation should 
 be examined very cautiously before being ac- 
 cepted as facts. 
 
 The following cases are to be found in lit- 
 erature : 
 
 Battey. One by Battey in which it is 
 said that a woman of 93 menstruated.f 
 
 * Zeitschrift fur Geburtshulfe und Gynakolqgie, 1880, p. 
 203. 
 
 t Borner, I. c.
 
 ADVENT AND PROGEESS. 101 
 
 Pirou. One by Pirou in which a woman 
 menstruated six months during her seventy- 
 second year, then became pregnant, and 
 aborted at the second month. The foetus 
 was recovered.* 
 
 Sumpter. Four by Sumpter in women of 
 60, TO, 77, and 80, in which menstruation had 
 been continuous at regular intervals, f 
 
 Norton. One by Norton in which there 
 had been regular menstruation without cessa- 
 tion in a woman of 74.^ 
 
 Two by Royle, one in the sixty-seventh 
 and one in the ninety-third year.* 
 
 Neumann. Neumann has collected re- 
 ports from various authors who have re- 
 ported cases to him between the sixtieth 
 and one hundred and fourth years. | 
 
 Kisch. The oldest case reported by 
 Kisch was 60. 
 
 The author has known families in which 
 it seemed to be customary to continue to 
 
 * Lancet, 1866, i, p. 387. J Lancet, ii, 1862, p. 27. 
 
 t Lancet, ii, 1887, p. 284. * Lancet, ii, 1860, p. 527. 
 
 \ Monatschrift fur Geburtshulfe und Gynakologie, Berlin, 
 1895, i, p. 238.
 
 102 THE MENOPAUSE. 
 
 menstruate regularly until the fifty-fifth or 
 fifty-sixth year. 
 
 Conclusion as to Age Limit. It would 
 therefore appear that the age limit is not one 
 which can be defined with any approach to 
 accuracy. 
 
 It is within the truth to say that the very 
 large majority of women in temperate cli- 
 mates reach the menopause, or at any rate 
 cease menstruating, between the fortieth and 
 fiftieth years. It is probable that the greater 
 number arrive at this condition between the 
 forty-fifth and fiftieth years, while in the 
 tropical climates the decade between 30 and 
 40 is the decade of the menopause, the ma- 
 jority of the women reaching it between 35 
 and 40. 
 
 2. DISEASE AND TRAUMATISM, INCLUDING THE 
 INFLUENCE OF BADLY NOURISHED AND UN- 
 DEVELOPED ORGANS AS FACTORS WHICH 
 BEAR UPON THE MENOPAUSE. 
 
 Result of Sensitiveness of Menstrual Func- 
 tion. The menstrual function being one of
 
 ADVENT AND PROGRESS. 103 
 
 such extreme sensitiveness with many women 
 it is not strange that perturbations of the 
 general physical condition should lead in some 
 instances to exaggeration of its phenomena, in 
 others to diminished accentuation of the same, 
 and in others to their complete suppression 
 or disappearance. 
 
 Either of these experiences may be inci- 
 dental to the menopause when induced by 
 such physical perturbations, the menopause, 
 as already remarked, applying not merely to 
 the menstrual flow or the absence of it, but 
 to the phenomena associated with it.* 
 
 CLASSIFICATION. 
 
 The conditions which are alluded to in this 
 connection may be classified as follows : 
 
 1. Acute and chronic inflammatory pro- 
 cesses. 
 
 2. Degenerative processes (atrophy, obes- 
 ity, defective development). 
 
 * The reader will please bear in mind that we are now 
 discussing the accidental, not the regular, conditions which 
 have a bearing upon the menopause. The regular or usual 
 concomitants will be considered in a subsequent chapter.
 
 104 THE MENOPAUSE. 
 
 3. Neoplasms. 
 
 4. Trauma. 
 
 A. Acute Inflammatory Processes. The 
 acute inflammatory processes which have a 
 tendency to precipitate the menopause are 
 not numerous nor are they of very frequent 
 occurrence. They are either (I) general or 
 (II) local. 
 
 Among the former (I) may be mentioned 
 measles, typhoid and typhus fevers, cholera, 
 acute tuberculosis, the acute infectious dis- 
 eases in general, and the toxaemia induced by 
 various vegetable and mineral poisons e. g., 
 that of acute malaria and that which attacks 
 workers in copper, lead, phosphorus, and ar- 
 senic. The rationale of their action consists 
 in the diversion of the blood current from its 
 pelvic channels and the development of a 
 general acute anaemia in connection with or 
 as a sequel of the inflammatory process. The 
 menopause is especially liable to occur if the 
 individual attacked is already in an enfeebled 
 condition at the time of the attack or has 
 such weak recuperative powers that the ef-
 
 ADVENT AND PROGRESS. 105 
 
 fects of the disease can not readily be 
 thrown off. The defective nutrition of the 
 pelvic organs in such cases results in im- 
 pairment of their function and atrophy 
 which may prove permanent, the menopause 
 being established with or without other, phe- 
 nomena. 
 
 (II) The local acute inflammatory pro- 
 cesses which lead to the menopause are rather 
 more noteworthy than those of a general 
 or systemic character, because attention is 
 called to the condition and functions of the 
 pelvic organs from the beginning. In a gen- 
 eral way they may be divided into (x) those 
 which are associated with the puerperal con- 
 dition and (y) those which are not so asso- 
 ciated. 
 
 (x) Of the former the processes which 
 result in the menopause are extremely de- 
 structive, the ovaries being either disinte- 
 grated directly or destroyed by the pressure 
 of the inflammatory material effused about 
 them. Life itself is often sacrificed in such 
 cases, or the patient may recover after a long
 
 106 THE MENOPAUSE. 
 
 convalescence to find that the function of 
 menstruation has departed. 
 
 The destruction of other tissues and or- 
 gans, in addition to the ovaries, is incidental, 
 and is always more or less extensive. 
 
 (?/) The inflammatory processes unasso- 
 ciated with the puerperal condition and re- 
 sulting in the menopause are of (c) infectious 
 or (d) traumatic origin. 
 
 (<?) Of the infectious processes gonorrhoea 
 is one of the most common and noteworthy. 
 It is true that it is usually a chronic process, 
 and only develops its severer consequences 
 with the lapse of months or years. There 
 are frequently cases, however, in which its 
 virulent effects upon the uterus and adnexa 
 are almost immediate upon the reception of 
 the poisonous elements. The menstrual func- 
 tion is immediately disturbed, the flow being in 
 most cases greatly increased, and the result in 
 a short time is the destruction of the ovaries 
 and the abolition of menstruation. 
 
 Such a course of events is frequently to 
 be observed when young and active men of
 
 ADVENT AND PROGRESS. 107 
 
 vicious habits, and with manifest or latent gon- 
 orrhoea at the time of marriage, marry young 
 and vigorous girls with tissues which are in the 
 highest possible condition of functional activ- 
 ity. The author has repeatedly seen such cases, 
 the infection taking place almost immediately 
 after marriage, and the woman becoming an in- 
 valid from that time onward unless relieved 
 by surgical procedures. Infectious disease re- 
 sulting in destruction of the ovaries and aboli- 
 tion of the menstrual function is also of occa- 
 sional occurrence from the carelessness of 
 physicians who may have introduced the 
 specific germs by means of soiled fingers or 
 instruments. Fortunately, with increasing in- 
 telligence and cleanliness on the part of those 
 who practice gynaecology, such cases are be- 
 coming rare. 
 
 (d) Trauinatism as the cause of abolition 
 of the menstrual function, by local acute in- 
 flammatory process, may be accidental or 
 intentional. In accidental cases, as, for in- 
 stance, those in which the peritoneal cavity 
 is penetrated, either through the vagina or the
 
 108 THE MENOPAUSE. 
 
 abdomen by violent means, and the genital 
 organs seriously injured, a condition of acute 
 inflammation resulting, it may be questioned 
 whether destructive consequences would fol- 
 low without the abolition of the element of 
 infection. As a matter of fact, it would be 
 almost impossible to eliminate the element of 
 infection from such cases. 
 
 This class of cases and also that other 
 great class in which the trauma is inflicted 
 deliberately by the surgeon, with the inten- 
 tion of producing the menopause, will come 
 under consideration again and in a more 
 specific manner. 
 
 CHRONIC INFLAMMATORY PROCESSES LEADING 
 TO THE MENOPAUSE. 
 
 Greater Frequency of the Menopause from 
 Chronic Inflammatory Processes. The meno- 
 pause is induced by chronic inflammatory 
 conditions and processes much more fre- 
 quently than by acute. 
 
 They are simply the continuation of the 
 acute processes, the element of time being
 
 ADVENT AND PROGRESS. 109 
 
 added, and the fact that the tissues in some 
 individuals have greater powers of resistance 
 than in others ; also that an established func- 
 tion holds much more stubbornly with some 
 women than with others. Like the acute 
 processes, therefore, the chronic ones may be 
 puerperal and nonpuerperal, infectious and 
 traumatic ; they may abolish menstruation by 
 the anasmia which they induce, by the diver- 
 sion of the blood current away from the pel- 
 vis, by direct destruction of the ovaries by 
 pressure, or by the removal of the sources of 
 nutrition of the organs by other means. 
 
 Of the systemic chronic conditions which 
 are sufficiently well recognized as leading to 
 the menopause, those which are associated with 
 disease of the lungs, kidneys, and nervous sys- 
 tem are to be mentioned, while as incidental 
 processes, which will be a matter for subse- 
 quent consideration, may be mentioned cer- 
 tain lesions of the heart, liver, skin, digestive 
 apparatus, eyes, etc.
 
 110 THE MENOPAUSE. 
 
 WASTING DISEASES OF THE LUNGS AND 
 KIDNEYS. 
 
 The chronic wasting diseases of the lungs 
 and pleura, whether in the form of tubercu- 
 losis, abscess, congestion, or empyeina, are 
 very frequently attended with abolition or 
 suspension of the menstrual function. This 
 is a conservative act on the part of Nature, 
 for individuals suffering with such diseases 
 have no blood to spare. It is sometimes 
 considered a bad omen by the uninformed, 
 especially when it occurs in young women. 
 It is a bad omen in the sense that women 
 with such diseases frequently die as a con- 
 sequence. If amelioration should occur 
 and the patient should not have reached 
 middle life, if, moreover, the genital or- 
 gans have not been seriously damaged by 
 disease in their own structure or in the 
 tissues contiguous to them, the restoration of 
 the menstrual function would be possible. 
 The author has never seen it restored, 
 when it has once been suspended, in one
 
 ADVENT AND PROGRESS. HI 
 
 who was suffering with, fatal disease of the 
 lungs.* 
 
 The exhausting effect of certain chronic 
 diseases of the kidneys is sometimes mani- 
 fested, as we have seen was the case with 
 disease of the lungs, in the disappearance 
 of the menses. This is true of the chronic 
 forms of Bright 's disease and of diabetes. 
 The latter seems to have an especial pre- 
 dilection for disturbing the sexual appetite 
 and apparatus in females as well as in 
 males. 
 
 Lecorche f has observed cessation of the 
 menses in seventy out of a hundred and four- 
 teen diabetic women who came under his 
 care. This observation was made not only in 
 women who had reached the forty-fourth and 
 forty-fifth years, but in those who had reached 
 
 * The evidence from autopsies in matters like these which 
 are under consideration is always interesting and instruc- 
 tive. Simpson observed a case in which the menopause fol- 
 lowed a first confinement in a tuberculous woman. She died 
 soon afterward and her ovaries were found to be small, hard, 
 and without Graafian follicles. See also Cases II, III, and 
 IV (pp. 44-46) in Dalton's series. 
 
 t Annales de Gynecologic, October, 1885.
 
 112 THE MENOPAUSE. 
 
 only the thirtieth to the thirty-fifth. Tait * 
 has also observed that this disease frequently 
 leads to the menopause at the time when ar- 
 rest of the menses is about to take place. 
 Strojnowski f observed that atrophy of the 
 uterus and ovaries attended diabetes in women, 
 one case in a women thirty years of age re- 
 sulting in atrophy of the uterus, and eleven 
 others resulting in atrophy of the ovaries. 
 Premature occurrence of the menopause was 
 also observed in such cases. It would seem, 
 therefore, that the diseases of the kidney 
 to which reference has been made might 
 be causative of as well as incidental to the 
 menopause. 
 
 DISEASES AND DISOKDERS OF THE NEKVOUS 
 SYSTEM. 
 
 Influence of Nervous Diseases on the Meno- 
 pause. The diseases and disorders of the nerv- 
 ous system play so prominent a part in the 
 
 * Climacteric Diabetes in Women. Practitioner, June, 
 1886, p. 401. 
 
 t Diabetes with the Menopause. Satellite, January, 1892, 
 vol. i, p. 93.
 
 ADVENT AND PEOGEESS. 113 
 
 history of the menopause that the question 
 very naturally suggests itself whether they 
 may not sometimes be cause as well as so fre- 
 quently consequence or concomitant. 
 
 Abundant observations concerning the 
 latter of these two situations are at hand and 
 will be referred to in a subsequent chapter, 
 while no correspondingly precise information 
 is available with regard to the former. 
 
 It is safe to say in general, however, that 
 those diseases of the nervous system which 
 are attended with marked anaemia will be fol- 
 lowed by diminution of the menstrual flow, 
 and in some instances by its permanent arrest. 
 
 General Paralysis in Relation to the 
 Menopause. Petit,* in an interesting paper 
 relating to this subject, remarks that Ger- 
 mans and Italians believe that cessation of 
 the menses is a frequent cause of general 
 paralysis, the latter being thus constituted 
 one of the diseases of the menopause. 
 
 * The Relations of General Paralysis in Women to Certain 
 Disorders of Menstruation. Gazette Medicale, February 23, 
 1889. 
 
 9
 
 THE MENOPAUSE. 
 
 Menstrual Troubles the Consequence of 
 Paralysis. It is the opinion of Petit, how- 
 ever, that the menstrual troubles of paralytic 
 women may be the direct or sympathetic con- 
 sequence instead of the cause of cerebral dis- 
 ease. 
 
 In fifty-nine cases of paralysis in women 
 which came under his observation there was 
 disturbance of menstruation in fifty-two, and 
 in every case the menstrual disturbance fol- 
 lowed the paralysis. His conclusions are : 
 
 1. The development of general paralysis 
 in women often leads to disorders of men- 
 struation. 
 
 2. These disorders may be characterized 
 by sudden and definite arrest of the menses, 
 or by irregularity, though the menses may 
 previously have been regular. 
 
 3. If there is remission of the general 
 paralysis, the menses are usually restored. 
 
 4. If in a person who is attacked with 
 diffuse meningo-encephalitis there is no exist- 
 ing menstrual disorder, such a person will re- 
 sist menstrual disorder longer than one who
 
 ADVENT AND PROGRESS. 115 
 
 has had suppression or irregularity of the 
 menstrual function. 
 
 B. INFLUENCE OF DEGENERATIVE PROCESSES, 
 ATROPHY, OBESITY, DEFECTIVE DEVELOP- 
 MENT, UPON THE ADVENT AND PROGRESS 
 OF THE MENOPAUSE. 
 
 Atrophy producing the Menopause may be 
 Primary or Secondary. Atrophic processes, 
 as a cause of the menopause, may be pri- 
 mary or secondary. The latter may result 
 from inflammatory conditions of an acute or 
 chronic character, the nutrition of the essen- 
 tial genital organs being arrested or diverted 
 or it may be directly shut off by persistent 
 and destructive pressure upon the organs. 
 The nutrition is sometimes sustained in a re- 
 markable manner through the medium of the 
 adhesions and new tissue in which the ovaries 
 may be embedded, though the normal vessels 
 of supply may be quite obliterated. 
 
 Atrophy may be due to Excess of Func- 
 tion. When the atrophy takes place without 
 the intervention of inflammation or neoplasm
 
 116 THE MENOPAUSE. 
 
 it may be due to individual or racial pecul- 
 iarity, to overstiinulation or overactivity, as 
 from excessive sexual indulgence or excessive 
 childbearing, or to the anemia which results 
 from prolonged continuance of excessive men- 
 struation in women of imperfect general con- 
 dition. 
 
 Supei'involution may induce the Meno- 
 pause. That condition of the uterus which 
 is known as superin volution, and which some- 
 times follows a series of childbirths which 
 rapidly succeed each other, lactation also being 
 continuous, is usually an indication of exhaus- 
 tion of the reproductive forces and a fore- 
 lunner of the menopause. The atrophic con- 
 dition of the uterus in such cases is mani- 
 fest enough and the lessening or absent men- 
 strual flow intimates the analogous condition 
 of the ovaries. 
 
 Obesity may induce the Menopause. 
 Obesity has a decided influence both as to 
 the advent and the progress of the meno- 
 pause. The circulation in a very fat person 
 is usually impaired.
 
 ADVENT AND PROGEESS. 117 
 
 The nutrition of the muscles and viscera 
 must suffer when the tendency to undue ac- 
 cumulation of fat is present. In the viscera 
 such a tendency takes the form of fatty de- 
 generation, which is in every way an un- 
 favorable condition. 
 
 With obese individuals it is readily de- 
 termined that the pelvic organs suffer in 
 common with the others, their functions 
 likewise being involved, the menstrual func- 
 tion included^ 
 
 Very fat women menstruate scantily 
 (oligomenorrhcea) and suffer pain with each 
 returning period. They are usually sterile 
 or bear at most one or two children. This 
 fact was observed long since, and was re- 
 corded by the ancient writers Hippocrates, 
 Avicenna, Laurans, and Hoeflerus. 
 
 Formula concerning Obesity. The law 
 which governs this matter may be formulated 
 as follows : * 
 
 1. A woman under thirty years of age, 
 
 * See also author's paper on Obesity, Transactions, New 
 York State Medical Society, 1888, p. 98.
 
 118 THE MENOPAUSE. 
 
 who bears four, five, six, or more children in 
 rapid succession and suckles them, prema- 
 turely reaches the limit of her reproductive 
 capacity, the phenomena of the climacteric 
 supervening. This applies to the average 
 woman under existing conditions of civiliza- 
 tion, and in a marked degree to those who 
 become obese after such frequent pregnan- 
 cies. 
 
 2. A woman under thirty years of age who 
 becomes obese, from whatever cause, will usu- 
 ally suffer with amenorrhoea or oligonienor- 
 rhoea, the menstrual flow, if present at all, 
 being accompanied with pain, though prior 
 to the accumulation of fat it may have been 
 painless. If such women marry, they are 
 usually sterile. 
 
 The Menopause from Defective Develop- 
 ment. The menopause w^hich results from 
 defective development is easily comprehended 
 and accounted for. Individuals with in- 
 herited deficiency of vital force, with syphi- 
 litic or tuberculous taint, whose lives are one 
 long struggle with disease, do not, as a rule,
 
 ADVENT AND PROGRESS. 119 
 
 possess great reproductive force. If the 
 menses are established at all, they are imper- 
 fectly performed, almost always with attend- 
 ant pain, and terminate after a few abortive 
 attempts. 
 
 The defective development may be limited 
 to the pelvic organs, the remainder of the 
 body being sufficiently vigorous. A defective 
 uterus does not necessarily imply inability to 
 menstruate, for menstruation and even preg- 
 nancy continuing to term may take place in 
 a unicornate uterus or one which is otherwise 
 defective. As a rule, however, menstruation 
 will be imperfect and the menopause will 
 arrive early in those women with whom the 
 uterus is small, hard, badly nourished, and 
 composed largely of connective tissue, the 
 ovaries small and poorly nourished, and the 
 Fallopian tubes mere strings of connective 
 tissue, with a few muscular fibers. Defective 
 development of the genital organs in other 
 particulars may be present, and the function 
 of menstruation be unimpaired, at least for a 
 time. The vagina may be defective or even
 
 120 THE MENOPAUSE. 
 
 absent, the hymen may be preternaturally 
 firm, the os uteri may be nearly or quite oc- 
 cluded, and yet menstruation go on regularly, 
 a part of the menstrual flux being reabsorbed 
 and the residue remaining to distend the 
 organ which contains it. The consequences 
 may be serious if the retained material is not 
 liberated and the passages made pervious for 
 the future ; but if that is done, the function 
 of menstruation may continue uninterrupted 
 by this incident. 
 
 C. NEOPLASMS, THEIK INFLUENCE UPON THE 
 MENOPAUSE. 
 
 The Influence of Neoplasms on the Meno- 
 pause is very Great. The influence of neo- 
 plasms as a factor which has a bearing in 
 hastening or retarding the menopause is very 
 great, in fact, there is no factor which bears 
 upon the subject which is of greater impor- 
 tance. The conditions of the question vary 
 according as the neoplasm is intrinsic, devel- 
 oped within the structure of the pelvic 
 organs, or extrinsic, developed without and
 
 ADVENT AND PEOGRESS. 121 
 
 bearing only an accidental relation to 
 them. 
 
 Neoplasms which are External to the Or- 
 gans essential to Menstruation. When the 
 neoplasm is external to the organs which are 
 essential to menstruation the field for consid- 
 eration becomes a rather restricted one. Those 
 cases are excluded in which the process is 
 simple and entirely an inflammatory one, 
 though the resulting exudate may cement the 
 extra pelvic organs into a mass which pre- 
 sents the gross appearance of a neoplasm and 
 exerts unfavorable influence upon the men- 
 strual function. Such cases have already 
 been considered. 
 
 Malignant Growths predominate. The 
 neoplasms which are now to be discussed 
 may be benign or malignant, but the latter 
 predominate. They include the morbid 
 growths which are sometimes associated with 
 tuberculosis of the abdominal viscera, ascitic 
 accumulations which are associated with va- 
 rious diseases of those viscera, the rare cystic 
 neoplasms of the pancreas, kidneys, mesen-
 
 122 THE MENOPAUSE. 
 
 tery, etc., usually of a benign character, and 
 the entire series of malignant growths of the 
 liver, mesentery, omentum, kidneys in fact, 
 all the abdominal viscera. These diseased 
 conditions attack women at all periods of life, 
 certain forms being encountered more fre- 
 quently at one period than another, and influ- 
 ence the menstrual function, both through 
 
 ' O 
 
 their immediate contact with the genital or- 
 gans and their influence upon the general 
 nutrition. 
 
 Pressure may cause Atrophy of tlw Or- 
 gans of Generation. The pressure influence 
 may be sufficient to occasion atrophy of the es- 
 sential organs of menstruation, as has been 
 observed with respect to other conditions, in 
 which case the menstrual function might be 
 suspended or an intimate bond of union 
 might be established between neoplasm and 
 pelvic organs, with the result of greatly 
 increasing the vascular supply of those organs 
 and greatly increasing the menstrual flow. 
 
 Malignant Growths may increase the 
 Menstrual Flow. Increase of the menstrual
 
 ADVENT AND PROGRESS. 123 
 
 flow is the usual course of events with the 
 malignant neoplasms. They are of rapid 
 growth, often cause great distress by their 
 
 o / 
 
 pressure influence, and quickly induce, by 
 means of the exhausting discharges which 
 accompany them, an ansemia which is only a 
 forerunner of the fatal issue soon to occur. 
 When the neoplasm is developed from the 
 pelvic organs themselves, its influence upon 
 the menstrual function is often a matter of 
 vital importance. The current opinions upon 
 certain aspects of the subject are undergoing 
 change which will be referred to at a later 
 stao-e of the discussion. 
 
 O 
 
 Here also neoplasms are to be considered, 
 \vith reference to their effect upon the meno- 
 pause, as benign or maJignant, the distin- 
 guishing feature of the latter being that they 
 always provoke an increase in the discharge 
 from the uterus, while with the former the 
 menopause is in some cases hastened, in others 
 retarded, while in others no effect is apparent. 
 
 Tfie -Evil Effects of Malignant Neoplasms 
 are manifold. The evil effects of the ma-
 
 124 THE MENOPAUSE. 
 
 lignant neoplasms, whether of the uterus, 
 ovaries, or tubes, and whether solid or cystic, 
 are manifold. The constitutional effects, anae- 
 mia and debility, do not in this case tend to 
 lessen the flow of blood from the uterus, 
 neither does the pressure of even large tumors 
 produce the atrophy of the genital organs and 
 subsequent cessation of uterine haemorrhage 
 which sometimes occurs with benign tumors. 
 On the contrary, the malignant disease almost 
 always signifies greatly increased vascularity, 
 and not only increased loss of blood at the 
 menstrual epoch, but at irregular periods as 
 well. Great loss of blood from the uterus 
 is so common a symptom of malignant disease 
 of that organ or its adnexa that the possibil- 
 ity of such disease must always be considered 
 when such haemorrhage occurs. 
 
 Hemorrhages during the Menopause call 
 for Careful A Mention. Especially should one 
 be very watchful if the profuse haemorrhage 
 occurs during the period of the menopause, 
 while if it occurs years after the disappear- 
 ance of the menses it furnishes one of the
 
 ADVENT AND PROGRESS. 125 
 
 strongest possible evidences that malignant 
 disease is present. 
 
 Neoplasms, apart from the Genital Ap- 
 paratus, not under discussion. Neoplasms 
 of the pelvic organs, apart from the organs of 
 the genital apparatus, are not especially under 
 discussion. They would include tumors of 
 the bladder, rectum, peritoneum, and bony 
 structure of the pelvis, and the same remarks 
 would apply to them that were made concern- 
 ing neoplasms of the abdominal cavity. 
 
 Pressure Influence of Solid Tumors usu- 
 ally greater than that of Cystic. The benign 
 neoplasms of the pelvic genital organs, in 
 their influence upon menstruation and the 
 menopause, may be considered as solid and 
 cystic, as acting by simple contact and pres- 
 sure, and as having additional action by means 
 of the organic union which results when a 
 neoplasm becomes attached to an organ by 
 adhesive inflammation. The pressure influ- 
 ence of solid neoplasms upon the structure 
 which is essential to menstruation that is, 
 the influence which causes atrophy when
 
 126 THE MENOPAUSE. 
 
 the structures fill the pelvis is usually 
 greater than that of the cystic. We would 
 therefore expect that the abolition of men- 
 struation by destructive pressure upon the 
 ovaries would take place more quickly with a 
 solid than with a cystic tumor. 
 
 Ovarian Tumors may be very Large and 
 Menstruation remain undisturbed. A tumor 
 of the ovary may reach a great size, or both 
 ovaries may be involved in extensive cyst 
 formation, menstruation continuing uninter- 
 ruptedly meanwhile and without especial dis- 
 turbance. But when the tumors are removed 
 menstruation either stops at once or within a 
 very short time, which shows either that 
 menstruation was continued by virtue of a 
 portion of ovarian tissue which remained in- 
 tact, or by the vital connection with the re- 
 maining pelvic organs which continues unim- 
 paired. Whether this means the presence of 
 an essential nerve structure or a glandular 
 structure which has been found by anatomists 
 who were unable to find the nerve described 
 by Johnstone, is at this moment undecided.
 
 ADVENT AND PROGRESS. 127 
 
 The benign tumors, involving more or less 
 of the structure of the uterus, are either solid 
 or nbro-cystic, the latter being infrequent 
 compared with the former. 
 
 Influence of Uterine Tumors upon Men- 
 struation. When the relation of the tumor 
 to the uterus is not very intimate that is, 
 when the bond of union is a stalk or pedicle 
 the influence of the tumor upon menstrua- 
 tion and the menopause may be slight or 
 nil. When the tumor is within the wall of 
 the uterus or has protruded into its cavity, 
 its influence upon menstruation is consider- 
 able ; the blood stream which nurtures the 
 tumor must nurture the uterus as well, and 
 the action and reaction of uterus and tumor 
 upon each other, in this particular, become 
 the more marked as the site of the tumor ap- 
 proaches the area of greatest vascularity of the 
 uterus that is, the area contiguous to the 
 entry of the uterine artery into and the exit 
 of the uterine vein from the uterus. In such 
 cases menstruation is almost certain to be 
 profuse, and in many cases there are effusions
 
 128 THE MENOPAUSE. 
 
 of blood, aside from the menstrual flow, at 
 frequent intervals ; in not a few cases the 
 leakage of blood is almost continuous. 
 
 The Opinion that the Menopause will see 
 the end of Uterine Haemorrhages is frequently 
 erroneous. It was formerly supposed that 
 all these cases would get well if they could 
 only pass the trying ordeal of the menopause, 
 and they were encouraged to hold out until 
 that event should occur. 
 
 But the hopes which were aroused were 
 often delusive 
 
 "The baseless fabric of a dream." 
 
 The menopause constantly eluded these suf- 
 ferers like an aggravating Will-o'-the-wisp, and 
 many of them died from sheer exhaustion and 
 loss of blood, without the least amelioration 
 in the conditions relating to the uterine tu- 
 
 O 
 
 rnor. All this was the result of an imperfect 
 pathology and of imperfect observation. It 
 is true that some uterine tumors ameliorate 
 with the menopause. Some were never the 
 source of any particular trouble, especially 
 those with w^hich the pedicle is a long one.
 
 ADVENT AND PROGRESS. 129 
 
 Others may have given much discomfort, and 
 if they occur in women who have never been 
 pregnant and who never have sexual inter- 
 course in other words, if the only congestion 
 to which they are subject is the congestion of 
 menstruation they sometimes improve with 
 the menopause. 
 
 In many Cases of fibroid of the Uterus 
 the Menopause does not come unless it is in- 
 duced. In many other cases, perhaps the ma- 
 jority, the menopause brings no relief, or 
 rather the menopause does not take place, 
 and the sufferers continue to lose blood and 
 vitality indefinitely unless radical measures 
 are adopted for their relief. Fortunately, 
 such measures of relief are now entirely 
 available in any portion of the world where 
 the science and art of gynaecology are suc- 
 cessfully cultivated, and the old argument 
 that the menopause will bring a cure be- 
 comes true, but under conditions which are 
 entirely different from those which once pre- 
 vailed. 
 
 10
 
 130 THE MENOPAUSE. 
 
 D. TKAUMA AS A FACTOR IN THE DEVELOP- 
 MENT or THE MENOPAUSE. 
 
 Destruction of the Genital Organs by Ac- 
 cidental Traamatism very Rare. If we con- 
 sider the element trauma or traumatism 
 merely as an accidental condition resulting 
 in the menopause, it would not require very 
 extended notice. One of the rarest occur- 
 rences in the world is an accident which de- 
 stroys the genital organs and, as a conse- 
 quence, abolishes the menstrual function. It 
 is possible for a woman to fall astride a 
 picket fence, or to have the leg of a chair or 
 a poker or some other brutal instrument 
 thrust into her vagina, or to be ripped open 
 by the horn of an angry animal, and, if she 
 survives the accident, to do so with her 
 sexual organs destroyed or so mutilated that 
 menstruation would not recur. An accident 
 of such a character would excite interest 
 quite as much on account of its peculiarity 
 as from the seriousness of its nature and im- 
 port.
 
 ADVENT AND PROGRESS. 131 
 
 The Artificial or Surgically Induced Meno- 
 pause. There is, however, a form of trauma- 
 tism which results almost uniformly in the 
 menopause which occurs with great frequency 
 at the present time, and is inflicted delib- 
 erately by the surgeon with the knowledge 
 and intention that the menopause shall re- 
 sult. Such a result thus produced is known 
 as the artificial menopause, and has intro- 
 duced a new era into surgical practice, scat- 
 tering blessings broadcast, producing good 
 results in some cases and bad results in 
 others. 
 
 It will be considered at greater length in 
 another chapter. 
 
 3. CLIMATE, INCLUDING ALTITUDE AND ALL 
 ATMOSPHERIC CONDITIONS. 
 
 Atmospheric Influence varies with Differ- 
 ent Conditions. The influence of atmospheric 
 conditions upon the menstrual function is of 
 course much more marked in some individ- 
 uals and families than in others. 
 
 The statements which are to be made
 
 132 THE MENOPAUSE: 
 
 upon this subject must be received with a 
 certain amount of latitude, though it is be- 
 lieved that the observations have in most 
 cases been sufficiently extensive and the con- 
 clusions sufficiently accurate to warrant their 
 acceptance. 
 
 The question of the establishment and 
 the continuance of menstruation naturally 
 calls for a certain degree of consideration in 
 this connection. 
 
 An Out-of-door Life may favor the pro- 
 longation of the Menstrual J^ra. Bearing 
 upon this subject is the observation which 
 has been frequently made that country 
 women retain the menstrual function longer 
 than city women, and workingwomen that 
 is, those who work out of doors and in the 
 fields providing that their labor is not of 
 too severe a character, retain it still longer. 
 Thus Leudet * found the average age at the 
 menopause of the first of these three classes 
 in question 47*4 years, of the second 47*9, of 
 the third 48'7. 
 
 * Comptes Rendus, Paris, 1867.
 
 ADVENT AND PROGRESS. 133 
 
 Observations as to the Age of the Meno- 
 pause by Various Writers. The same rela- 
 tive differences obtained in Leudet's experi- 
 ence in the establishment of the menstrual 
 function. 
 
 Somewhat similar facts were observed by 
 Kisch, whose book on the menopause has 
 been frequently alluded to. Kisch and Bor- 
 ner observed also that in the northern coun- 
 tries of Europe the menopause came later 
 than in the southern. 
 
 On the other hand, it does not always 
 follow that early puberty, which is sufficiently 
 frequent to become almost the rule in warm 
 countries, means necessarily an early meno- 
 pause. Upon this latter point Tilt has ob- 
 served * that while the average age of puberty 
 among the Hindus is twelve years, the meno- 
 pause is frequently delayed until the age of 
 fifty. The same author states that the aver 
 age for the menopause in Norway was 49, 
 puberty averaging 16*375, while in England 
 and France the average was 45'7. 
 
 * Comptes Rendus, Paris, 1867, p. 187.
 
 134 THE MENOPAUSE. 
 
 In the latitude and climate of St. Peters- 
 burg 100 cases were analyzed by Lieven, the 
 limits of puberty being 11 and 22, while 
 those of the menopause were 40 and 53 ; but 
 in 54 of these cases the limits were 47 
 and 50. 
 
 In Denmark Hannover found the average 
 age for the menopause 44*82, which seems a 
 low estimate for that latitude and climate. 
 Another writer placed the average of pu- 
 berty for nearly 4,000 cases at 16 years 10 
 months 5 days. For the north and center 
 of Germany Mayer* found the average of 
 puberty for the upper classes 15*19, for the 
 lower classes 16*50, for country girls 15*20, 
 for city girls 15*98. He satisfied himself that 
 the age of puberty varied directly with the 
 altitude. The average for the menopause at 
 Berlin in 1,546 cases which he analyzed was 
 
 * Comptes Rendus, Paris, 1867. 
 
 f The foregoing data have been already quoted, see pages 
 99 and 100, but in the former instance they were adduced to 
 show the influence of age with reference to the menopause ; 
 now they are invoked in respect to climate.
 
 ADVENT AND PROGRESS. 135 
 
 Cortajarena is on record as believing that 
 climate, race, and differing conditions of life 
 have no direct and immediate effect on men- 
 struation, but that their effect is subordinate 
 to nutrition. 
 
 Different Effects of Tropical and Tem- 
 perate Climates. It would seem to be both 
 reasonable and logical that the same forces 
 which in the tropics result in rank vegetation 
 and early maturity should have a like effect 
 in the physical development of human beings, 
 unless means were taken to prevent or neu- 
 tralize such results. The forces in question 
 are mainly high temperature, abundance of 
 food, and vis inertice, and they may and in- 
 deed do prove deleterious when considered 
 from certain points of view ; thus India can 
 not be colonized by the English as they have 
 colonized Australia and America, for the 
 simple reason that the intense and prolonged 
 heat of the climate is too exhausting to their 
 vitality, and their reproductive force is said 
 to be spent with the second generation. 
 
 In the temperate climates growth and ma-
 
 136 THE MENOPAUSE. 
 
 turity are slowly acquired, vitality is longer 
 retained than in the tropics, and we should 
 consequently be led to expect a somewhat 
 later occurrence of the menopause. In very 
 cold climates the forces which dwarf vegeta- 
 tion and limit its fecundity have an analogous 
 effect upon the vital functions of man. For 
 example, the Eskimos are small in stature, 
 the women do not menstruate until the 
 twentieth year or later, and the number of 
 children in a family seldom exceeds three; 
 oftener it is less than that number. Both 
 the menstrual function and vital force itself 
 are exhausted at an early age. 
 
 Varying Effect of Atmospheric Pressure. 
 The effect of atmospheric pressure upon 
 menstruation and indirectly upon the meno- 
 pause deserves a word in passing. Of course, 
 when the atmospheric pressure is great, as at 
 the sea level and by the seashore or on the 
 sea, the internal pressure that is within the 
 cavities and canals of the body is exposed to 
 its greatest resistance ; while as one advances 
 
 into the interior and ascends to higher and 
 
 ~
 
 ADVENT AND PROGRESS. 137 
 
 higher elevations the pressure relations are 
 reversed, the external diminishing v/ith the 
 rarefication of the atmosphere and the ten- 
 sion within the vessels and the cavities in- 
 creasing;. 
 
 O 
 
 Suspension of Menstrual function with 
 Change of Residence. A woman who passes 
 from the interior of a country to the seashore 
 or who takes a sea voyage will in most cases 
 observe that her menstrual function is for 
 the time suspended, or the flow is diminished, 
 or she suffers pain to which she may have 
 been a stranger at previous menstrual epochs. 
 In certain cases it is possible that the meno- 
 pause may result from a sea voyage or the 
 transfer of one's residence to the seashore, ad- 
 justment to surrounding conditions in refer- 
 ence to the menstrual function not being 
 effected. This fact is too often overlooked 
 in the treatment of women who are ap- 
 proaching the menopause, and it should be 
 carefully considered in the hygienic regula- 
 tions which are formulated for such indi- 
 viduals.
 
 138 THE MENOPAUSE. 
 
 In prescribing Change of Residence the 
 Effect of Atmospheric Pressure may be a 
 
 Matter for Serious Consideration. The ac- 
 *. J . 
 tion of physical laws upon the surface and 
 
 the interior of the body should also be taken 
 into consideration when a woman removes 
 her residence to a locality in which the at- 
 mospheric pressure is low. Haemorrhage is 
 favored by such physical conditions, and the 
 menopause may be indefinitely prolonged or 
 deferred by them. Especially is this the case 
 with those who are suffering with uterine dis- 
 ease in which haemorrhage is a noteworthy 
 feature. The same physical conditions which 
 favor nosebleed, haemoptysis, purpura, etc., 
 in those who are susceptible to such acci- 
 dents will favor haemorrhage from the uterus, 
 and, to a greater or less degree, delay the 
 menopause with individuals who suffer with 
 uterine disease in which haemorrhage is a 
 characteristic symptom. The fact that ad- 
 justment to climatic surroundings is possible 
 is of course admitted, but the risk in acquir- 
 ing such adjustment and acclimation is some-
 
 ADVENT AND PROGRESS. 139 
 
 times as great with uterine disease as with 
 pulmonary disease. 
 
 The Risk in acquiring Acclimation at 
 great Altitudes is sometimes Considerable. 
 The subject of climatology in its relation 
 to the diseases peculiar to women is one 
 which has been almost universally ignored 
 by those who teach as well as by those who 
 practice gynaBcology. It offers a promising 
 field for future investigation in a limited 
 range of conditions. 
 
 4. HEBEDITY, INCLUDING FAMILY, NATIONAL, 
 OE RACE PECULIAEITIES. 
 
 Reproduction of Family Peculiarities. 
 One of the most plausible propositions in 
 Darwin's theory of evolution is that the 
 habits and tendencies of parents are prone to 
 produce certain peculiarities which are re- 
 peated, sometimes with more or less modifica- 
 tion or accentuation in their offspring, lead- 
 ing in process of time to a change of type. 
 
 While this may not hold as a universal 
 law and thus enables many a keen observer
 
 140 THE MENOPAUSE. 
 
 to deny that it holds as a law at all, any phy- 
 sician who has practiced within a limited area 
 of territory and has observed the characteris- 
 tics of the families in his clientele for a long 
 period of years can recall plenty of instances 
 in which parental peculiarities have been re- 
 produced from one generation to another. 
 
 The menstrual function is no exception to 
 the somatic conditions which are influenced 
 by heredity. 
 
 Lateness of the Menopause as a Family 
 Characteristic. Lateness in the appearance 
 of the menopause is a characteristic in some 
 families. The author is acquainted with such 
 family histories in which the fifty-fifth or 
 fifty-sixth year is looked upon as the time 
 when the menopause may be expected, this 
 having been the rule for two or more genera- 
 tions. In some families the menopause comes 
 abruptly, menstruation suddenly ceasing for- 
 ever; in others irregular periods of menstrua- 
 tion drag along through one or more years. 
 The bleedings are insignificant in some fami- 
 lies ; in others they are always profuse
 
 ADVENT AND PROGRESS. 141 
 
 though the result may not be malignant dis- 
 ease. 
 
 family Taint. Family taint probably 
 has something to do with the fact that both 
 the men and the women in certain families 
 develop malignant disease as age advances. 
 There seems to be no more inherent improba- 
 bility as to such a tendency, which doubtless 
 is outlived or overcome in some cases, than 
 there is as to the manifest tendency in other 
 families to the development of tuberculosis, 
 scrofula, etc. Certain family or race traits in 
 respect to the menopause become intensified 
 as time progresses, while others become modi- 
 fied and gradually lost. Especially is there a 
 modification of these traits when the family 
 or the race migrates to a locality in which 
 the climatic conditions are radically different 
 from those to which they have been accus- 
 tomed. 
 
 Peculiarities of Jewesses and Indians. 
 Jewish women, as a race, suffer less during 
 the menopause than other races, whether on 
 account of their ceremonial laws and customs
 
 142 THE MENOPAUSE. 
 
 or for some other reason, the writer is unable 
 to state. 
 
 The American Indian women are very 
 rarely conscious of anything unusual during 
 the menopause, and they may be taken as the 
 type, in regard to this matter, of savages and 
 barbarians in general whose surroundings are 
 of the average degree of comfort and en- 
 lightenment. The phenomena connected with 
 the nervous system are very prominent and 
 decided during the menopause, and the in- 
 fluence of family traits and tendencies is most 
 pronounced in this direction. Melancholia, 
 cerebral congestion, hysteria, etc., are the an- 
 ticipated accompaniments of the menopause 
 in certain households. Perhaps if they were 
 not expected, in a sort of historical succes- 
 sion, they would not appear. 
 
 The Menopause is Insignificant with tlie 
 Majority of Women. After all, we must re- 
 member that the greater number of women 
 who reach old age never consult a physician 
 concerning the experiences of the menopause. 
 They are as ignorant of the significance of the
 
 ADVENT AND PROGRESS. 143 
 
 cessation of the menses as they are of its es- 
 tablishment. It is fair to assume that with 
 such women the menopause is not an experi- 
 ence of serious moment or one in which ex- 
 tensive information would be of any particu- 
 lar value. 
 
 " When ignorance is bliss, 'tis folly to be wise." 
 
 
 
 THE BEARING or FERTILITY AND STERILITY 
 UPON THE MENOPAUSE. 
 
 This is a subject of no little importance, 
 and the one or the other of these conditions 
 is often the characteristic of certain families 
 or tribes. 
 
 Fertility and Sterility are Relative Terms. 
 It must be remembered that these terms 
 have a relative as well as an absolute mean- 
 ing, fertility in individuals of one class or 
 type not being applicable to those of another. 
 There is also a sterility which is relative 
 and one which is absolute. 
 
 In the case of a rather feeble, poorly de- 
 veloped, physically, inferior woman, the bear- 
 ing of three or four children at brief intervals
 
 144 THE MENOPAUSE. 
 
 may be a great tax on her vitality, indeed it 
 may be a strain greater than her vital re- 
 sources will bear. Another woman with 
 robust physique and great vitality may bear 
 a dozen children in as many years without 
 serious detriment. If we take the average of 
 women, however, it is very much the same as 
 it is with the fruit trees a period of bearing 
 should be succeeded by a period of rest. If 
 the boughs are heavily laden with fruit year 
 after year the vitality of the tree will soon be 
 exhausted. Such a result is prevented by 
 the off years in which little or no fruit is 
 borne. 
 
 Excessive Fertility may hasten the Meno- 
 pause. With many women the bearing of six 
 or seven children in rapid succession, lacta- 
 tion being almost uninterrupted, means the 
 exhaustion of the reproductive force, and 
 women who are thus excessively fertile prior 
 to the thirtieth year usually reach the meno- 
 pause very early. 
 
 Excessive fertility in women of weak or 
 depraved constitution, if it does not exhaust
 
 ADVENT AND PROGRESS. 145 
 
 their vitality completely, is apt to lead to a 
 premature menopause, even though there 
 may be an interval of two or three years be- 
 tween pregnancies. 
 
 Examples of this are women with phthis- 
 ical tendency, and women with slender phy- 
 sique and frail constitution, though without 
 deep-seated disease. Such women abound in 
 our modern society, especially in the cities, 
 the visible evidence of false ideas in the 
 training and development of children. Ill 
 prepared are they to bear the strain of re- 
 peated pregnancies, especially when they have 
 in addition the cares of a household, the dis- 
 sipations or the exactions of society life, and 
 it may be an unreasonable, selfish husband. 
 The children in such cases are too often puny 
 and short-lived, and a premature menopause 
 to the mother may be regarded in the light 
 of a blessing and a relief. 
 
 Prevention of Pregnancy Warranted in 
 some Cases. It would seem to follow from 
 the foregoing that with some women preg- 
 nancy under any circumstances would be 
 11
 
 146 THE MENOPAUSE. 
 
 injudicious and undesirable. This is un- 
 hesitatingly admitted, not that the interrup- 
 tion of pregnancy by forcible means is ad- 
 vocated far from it. A pregnancy having 
 begun must not be interfered with, except 
 when it becomes an actual menace to the life 
 of the mother. But when the conditions in- 
 volved are a delicate, diseased, badly devel- 
 oped woman, with not enough vitality for 
 her own use, and a feeble, puny, imperfect 
 child, with little hope or prospect of being 
 anything but a burden to others as long 
 as it may live, it would seem logical and 
 reasonable that so much mischief and misery 
 should be forestalled either by the avoidance 
 of marriage on the part of the woman or the 
 avoidance of conception if marriage is in- 
 sisted upon. Fertility in such individuals is 
 excessive, under any circumstances, and is to 
 be deprecated. 
 
 Cliildbearing no Burden to many Well- 
 developed Women. With the woman of 
 grand physique, to whom childbeariug is no 
 burden, but merely the accomplishment of a
 
 ADVENT AND PROGRESS. 147 
 
 physiological act, the response to one of the 
 highest impulses of their nature, the meno- 
 pause is not hastened nor in any way un- 
 favorably influenced by pregnancies as fre- 
 quent as Nature will permit.* 
 
 Such women are often the mothers of 
 heroes. They glide into pregnancy and labor 
 and out again with little discomfort, taking 
 up the thread of ordinary life again with lit- 
 tle disposition to get it tangled, menstruating 
 perhaps until the fiftieth year or its vicinity, 
 and experiencing little trouble with its pass- 
 ing away. 
 
 Bearing Children a Normal Function of 
 Women. With regard to the influence of 
 sterility upon the menopause, a writer has 
 recently said that from a physiological stand- 
 point the great object for which woman was 
 created was to reproduce her kind. This 
 seems the more reasonable when we realize 
 
 * The author reserves as exceptional those cases already 
 alluded to, in which repeated pregnancies and lactation in 
 almost uninterrupted succession, especially in young women, 
 exhaust the reproductive force and hasten the menopause.
 
 148 THE MENOPAUSE. 
 
 that a decidua or nest for a foatus is provided 
 each month, only to be shed and cast off in 
 case it is not utilized by a fertilized ovum. 
 From a physiological standpoint, therefore, a 
 sterile woman is a failure. 
 
 Virgins and Married Nulliparce. There 
 are two classes of such women, virgins and 
 married nulliparae. According to the exist- 
 ing status of civilized society the former are 
 debarred from becoming pregnant, and prop- 
 erly so, unfortunate though it may often seem. 
 to be from the before-mentioned physiological 
 standpoint. The latter are in some cases in- 
 tentionally and willfully sterile, and in others 
 the sterility is due to deformity or defect on 
 the part of the woman or her husband, or 
 both. 
 
 It would seem as if such a contravention 
 of physical laws * must be followed by bad 
 results which would manifest themselves, par- 
 ticularly in connection with the menstrual 
 
 * Of course, reference is made exclusively to those who 
 are physically competent to conceive and carry offspring to 
 term.
 
 ADVENT AND PROGRESS. 149 
 
 function. Such a result does occur, and 
 would probably occur more frequently if 
 women led merely an animal life ; fortu- 
 nately, however, the cares and occupations 
 which come to most of them, whether single 
 or married, divert them from undue attention 
 to such subjects, and in a measure compen- 
 sate for the incomplete accomplishment of 
 natural functions. 
 
 Course of Menstruation and the Meno- 
 pause in the Sterile. With the sterile a pro- 
 cess goes on which is analogous to the 
 atrophy of structure when that structure 
 goes long unused ; the recurring congestions 
 of the menstrual epoch fail to excite those 
 impulses to reproduction which are excited 
 in those with whom such impulses take 
 their natural course, and the menopause is 
 approached and experienced without any un- 
 usual phenomena resulting from the sterilty. 
 With those who have preserved their vitality 
 the menses may suddenly stop, and the indi- 
 viduals will be conscious of no particular 
 change except that they no longer have
 
 150 THE MENOPAUSE. 
 
 monthly molimina and bleeding and that 
 they are increasing in weight. 
 
 In occasional instances the development 
 of a serious disease settles upon them like a 
 pall, all trace of the monthly sickness disap- 
 pearing in the general breaking up of Nature. 
 In others, again, there are the same pains and 
 aches, with infrequent recurrences of the flow, 
 perhaps an occasional metrorrhagia, vasomo- 
 tor disturbances, so noteworthy at this pe- 
 riod, and final subsidence in the quiet of 
 mature life. 
 
 5. TEMPERAMENT, HABITS, OCCUPATION, AND 
 SOCIAL SURROUNDINGS. 
 
 Inherent Tendencies in Individuals. 
 There is much to be said concerning the des- 
 tiny or fate of human beings on the side of 
 the influences which are fastened to them 
 when they come into the world. Some indi- 
 viduals may appear to shape and fashion a 
 portion, at least, of their experiences as a 
 helmsman guides a ship. But this may be 
 only the outward appearance, and it is cer-
 
 ADVENT AND PROGRESS. 151 
 
 tain that even these individuals, heroes, be- 
 ings of exceptional strength, are at times 
 driven irresistibly by forces over which they 
 have no control, though they sometimes 
 gain control, after years of struggling have 
 elapsed, by that process of adaptation which 
 so often adjusts means to ends. 
 
 There are also Inherent Tendencies with 
 Reference to Menstruation and the Meno- 
 pause. It is the same with the functions of 
 the body, and menstruation with the meno- 
 pause is not an exception. There are the 
 unconscious influences those with which 
 women are born, the family and race pecul- 
 iarities the intrinsic, and there are the ex- 
 trinsic, the outward, also great modifiers of 
 experience which may be useful or harmful, 
 according to circumstances. 
 
 Disposition as to the Individual has 
 much to do with the Course of the Meno- 
 pause. A woman who is endowed with a 
 quiet placid temperament, who takes the 
 experiences of life philosophically and with- 
 out fret, is more than likely to pass through
 
 152 THE MENOPAUSE. 
 
 the menopause peacefully, provided, of 
 course, that there is no intercurrent develop- 
 ment of disease. 
 
 It is the nervous and hysterical woman, 
 the one whose thoughts and sympathies are 
 centered upon herself, who has a hard time 
 at the menopause, or at any rate she thinks 
 she has. 
 
 These are the influences of inheritance 
 (though sometimes, of course, they are due 
 to faulty education, to want of restriction 
 and training during childhood and young 
 womanhood), the conditions to which we 
 are chained when being begins, and they 
 can not easily be shaken off. 
 
 Unfavorable Experience during the Men- 
 strual Life often implies a Similar Experi- 
 ence during the Menopause. As to outward 
 influences, those who have had a stormy 
 experience in general, and especially those 
 who have always suffered with their men- 
 strual periods, whether from pain, excessive 
 flowing, or irregularity, are prone to be suf- 
 ferers during the menopause. We should
 
 ADVENT AND PROGRESS. 153 
 
 hardly expect anything else when we realize 
 the vascular and nervous conditions which 
 attend it. 
 
 Irregular and Unwomanly Occupation 
 may bring an Early and an Uncomfortable 
 menopause. Those whose lives have been 
 marked by excesses of various kinds, by in- 
 temperate use of alcohol, by sexual vice, by 
 exhausting labor, by bad hygienic surround- 
 ings, are very apt to cease menstruating 
 early, and with more or less associated pain 
 and other trouble. 
 
 Women with occupations in which there 
 is exposure to great atmospheric changes, 
 who have an insufficiency of pure air, food, 
 and clothing, often reach the menopause 
 early in life and with no little discomfort. 
 Such are workers in various metals, copper, 
 phosphorus, lead, etc., fishwives, women 
 who work in mines, and as day laborers in 
 the streets and fields. Surely this is not 
 woman's work or we would not see such 
 pitiful spectacles of decrepit and wrinkled 
 and worn-out creatures at a period when the
 
 THE MENOPAUSE. 
 
 blusli should still be on the cheeks. The 
 great hospitals in the European cities are 
 crowded with such as these. 
 
 Effects of Occupation upon Cooks, Laun- 
 dress '38, and Others. There are also other oc- 
 cupations for which women seem to have 
 more or less of fitness, but which, neverthe- 
 less, produce rather striking results upon the 
 physical condition, and results which are not 
 always favorable. Types of this class are 
 furnished by cooks and laundresses women 
 who work many hours a day in a very ele- 
 vated temperature, and, in the case of cooks 
 at least, are constantly inhaling the volatile 
 portions of cooking food. Such women in 
 many instances not only become very fat, 
 but suffer greatly with menstrual disorders 
 (dysmenorrhcea, oligomenorrhoea, polynienor- 
 rhcea) ; they are usually sterile, and reach the 
 menopause at a comparatively early period. 
 
 One's Trade or Occupation may be the 
 most Potent Factor in Determining the Meno- 
 pause. It will thus be seen that the influ- 
 ence of one's trade or occupation, the purely
 
 ADVENT AND PROGRESS. 155 
 
 external and extrinsic media, may be a most 
 potent factor, perhaps the most potent factor, 
 in determining the time and the mode of the 
 menopause. 
 
 SEXUAL EXCESS AND ABSTINENCE. 
 
 Very Important Subject. This is a sub- 
 ject in which the relation to the menopause 
 would seem to be so intimate, and in which 
 there is so much material for thought and 
 consideration, that though it is but a subdi- 
 vision of the section which is now under con- 
 sideration, it is of sufficient importance for 
 particular attention. The sexual apparatus 
 is an essential portion of the structure of the 
 body that is, the body is incomplete if the 
 sexual apparatus is wanting. 
 
 Imperious Character of the Sexual Appe- 
 tite. The sexual appetite is as appropriate to 
 an individual as the appetite for food. In 
 many cases it is quite as imperious as the 
 appetite for food, and in individuals with 
 whom the animal part of their nature pre- 
 dominates it is practically uncontrollable.
 
 156 THE MENOPAUSE. 
 
 This fact explains many of the horrible 
 crimes which have been perpetrated upon 
 helpless women and defenseless children. 
 Excessive indulgence of this appetite is fol- 
 lowed by results which are sometimes dis- 
 astrous. Complete abstinence is probably 
 followed by bad results in some cases, but 
 the proportion of cases in which injury fol- 
 lows denial of the natural inclinations is very 
 much smaller than that in which those in- 
 clinations are uncontrolled and unregulated. 
 The submission of the material side of an 
 individual to the spiritual is seldom followed 
 by any but desirable consequences. 
 
 Sexual Excess and the Functions of the 
 Genital Apparatus are Relative to the Indi- 
 vidual Concerned. To fix a standard as to 
 sexual indulgence or to define sexual excess 
 is extremely difficult and will not be at- 
 tempted. It must always be relative to cer- 
 tain conditions inherent in the individual 
 concerned. 
 
 The same is true concerning the func- 
 tions, in general, of the uterus, and therefore
 
 ADVENT AND PROGRESS. 157 
 
 in one case menstruation must be encouraged, 
 in another repressed. Childbearing will be 
 a blessing; in one case, in another a bane. 
 
 O / 
 
 Coitus may be practically unrestrained, so 
 far as tolerance is concerned, with one wom- 
 an, while with another it must be abstained 
 from. 
 
 If we were to consider that the normal 
 type of operation as to the sexual functions 
 exists among savages who are living in the 
 so-called " state of Nature," and look among 
 them for the best, that is, the most natural 
 results, we should be disappointed. Those 
 who live in accordance with natural appe- 
 tites that is, but a short remove from the 
 animals do not present the best results from 
 a physical standpoint. 
 
 The Best Types of the Sexual Life are not 
 to be found among Savages. The women, 
 among savages, must do the work ; they must 
 yield to the caprice of their husbands' appe- 
 tites, whatever be their own physical condi- 
 tion ; they must bear and look after the chil- 
 dren, and, as a consequence, they are worn
 
 158 THE MENOPAUSE. 
 
 out relatively early ; their sexual organs and 
 proclivities suffer from abuse and excess, and 
 they become old and wrinkled when those 
 who are less hardy and robust, but who have 
 been more rational in their sexual life, are 
 still menstruating and capable of procreating 
 healthy offspring. 
 
 We should learn from the experience 
 with the domestic animals that when women 
 are well and intelligently treated and cared 
 for the physical results will be better in all 
 respects. 
 
 Attempts have been made from time to 
 time to reduce the question of sexual indul- 
 gence and childbearing to scientific limits. 
 
 The Experience of Stock Breeders sug- 
 gests the application of Similar Principles 
 among Human Beings. In view of the ex- 
 cellent results which are attained by stock 
 raisers by judicious mating and crossing, it 
 would seem as if great results might be pos- 
 sible in the begetting of children by the ap- 
 plication of analogous methods. The obsta- 
 cles in the way of such an end have thus far,
 
 ADVENT AND PROGKESS. 159 
 
 however, proved insuperable, individuals in 
 general appearing to act as if the laws which 
 govern and control reproduction in man were 
 different from those which affect other ani- 
 mals. 
 
 Concerning the Oneida Community. In- 
 teresting in this connection are the experi- 
 ments which have been made by different 
 communities of socialists, and especially in- 
 teresting is the study of the Oneida Commu- 
 nity of socialists which was made a few years 
 ago by Dr. Ely Van de Warker.* 
 
 The conditions in this case were extreme- 
 ly favorable for scientific investigation, for 
 the individuals concerned were, for the most 
 part, occupied with healthful duties ; they 
 had good hygienic surroundings, plenty of 
 food and clothing, relief from the ordinary 
 worry of life, and freedom from the dissipa- 
 tion which ordinarily goes hand in hand with 
 lives of sexual indulgence. 
 
 The total number of the cases which were 
 studied is small, but if we take these cases as 
 
 * See American Journal of Obstetrics, 1884, p. 785.
 
 160 THE MENOPAUSE. 
 
 fair examples of that which might usually 
 occur under similar conditions, we can see 
 that abundant sexual indulgence is not nec- 
 essarily followed by unusual experiences at 
 the menopause. The theory of the Oneida 
 communists was that sexual intercourse being 
 the response to a natural appetite might be 
 indulged in until the appetite was satisfied, 
 but that inasmuch as good specimens could 
 be reproduced only by certain types of indi- 
 viduals, conception was to be prevented ex- 
 cepting in selected cases. 
 
 Van de Warker's table contains histories 
 of forty-two women, many of whom were 
 born in the Community or were placed there 
 in early life. Sexual intercourse was begun 
 as early as the tenth year, and was followed 
 by the early appearance of the menses. In 
 the table which was given one of the cases 
 menstruated at ten years, eleven at twelve 
 years, and twelve at thirteen years. 
 
 Among thirty of the childbearing women 
 only eighteen children were born during the 
 communistic life, and there were four miscar-
 
 ADVENT AND PROGRESS. 161 
 
 riages which were not artificially produced. 
 In many cases sexual intercourse was in- 
 dulged in seven or more times per week, some- 
 times to the discomfort and displeasure of 
 the women. The diet of the women was 
 principally a vegetable one. They com- 
 plained little of the pains and aches from 
 which so many women suffer, and there were 
 few nervous phenomena in fact, the health 
 of the women was good. 
 
 No menstrual derangements were com- 
 plained of, notwithstanding the excessive 
 copulation. The average age for those who 
 had completed the menopause was 48*7 years, 
 the number who had passed through the meno- 
 pause while living in the Community being 
 eight. It was unattended by any unusual 
 incident. 
 
 The Menopause in Prostitutes The sex- 
 ual excesses of professional prostitutes and 
 women of loose character in general might be 
 supposed to offer a profitable field for re- 
 search with regard to the consequences of 
 
 such excesses during the menopause. The 
 12
 
 1G2 THE MENOPAUSE. 
 
 results, nevertheless, are disappointing, how- 
 ever true the general statement may be that 
 irregular living and the practice of vice find 
 their appropriate physical penalty. 
 
 A large number of such women have been 
 under the professional care of the author 
 from time to time, including women of all 
 ages, all degrees of prosperity and success, as 
 such things go, and all grades of depravity. 
 It has been a matter of constant surprise, in 
 not a few of these cases (certainly not in all 
 of them), in view of the abuse to which most 
 of them subject their genital organs, as well 
 as the irregularity of their lives in general, 
 that their menstrual history differed so little 
 from that of women who live virtuously and 
 respectably. 
 
 Prostitutes very Susceptible to Disease. 
 This does not mean that such women do not 
 acquire disease ; far from it, for sooner or 
 later the majority of them do acquire syphilis, 
 gonorrhoea, or both. They also suffer almost 
 invariably with endometritis, sometimes with 
 only a simple catarrhal discharge, and some-
 
 ADVENT AND PROGRESS. 163 
 
 times with uterine hemorrhage. Pelvic peri- 
 tonitis is very common among them, especially 
 among the more degraded, who are less care- 
 ful and particular about personal cleanli- 
 ness than others, and by whom also their de- 
 grading occupation is constantly practiced, 
 regardless of the presence of menstruation, 
 gonorrhoea, syphilis, or anything else. 
 
 Certain Diseases very Common among 
 Prostitutes. The fact that such women suf- 
 fer extensively from venereal disease has, of 
 course, been recognized from time imme- 
 morial. The particular disease of the tubes 
 and ovaries which results from the infectious 
 element of gonorrhoea was first described by 
 Mercier in 1849, who made many autopsies 
 upon prostitutes in Paris and discovered this 
 fact in the course of such labors. The fact 
 has since then been verified many times upon 
 the living and may be regarded as one of the 
 most common consequences of a life of prostitu- 
 tion. This disease often runs a very prolonged 
 course, and in some instances has been known 
 to wear itself out or be recovered from spon-
 
 164: THE MENOPAUSE. 
 
 taneously. Such cases have been seen by the 
 writer, and the pathological phenomena are 
 analogous in some respects to those which are 
 often seen in cases of tuberculosis in which 
 the disease is circumscribed and in which 
 the products undergo degenerative changes. 
 These cases are believed to be rare, however ; 
 certainly they have been infrequent in the 
 experience of the writer. 
 
 Serious Disease of the Genital Organs 
 may result, also an Early Menopause. The 
 irregularities of a prostitute's life are such as 
 would naturally result in serious disease of 
 one organ or another, the general resisting 
 power of the individual being also weak- 
 ened, and these conditions doubtless combine 
 in at least a certain portion of these unfor- 
 tunate individuals in abbreviating the men- 
 strual life and bringing on an early meno- 
 pause. In spite of the irregularities and ex- 
 cesses of such a life, however, there are some 
 who tolerate such conditions with no ap- 
 parent evil consequence from the physical 
 standpoint. The shrewder and more careful
 
 ADVENT AND PROGRESS. 165 
 
 prostitutes frequently continue their business 
 many years, and some of them save consider- 
 able amounts of money. Some of them marry 
 and have children, though this is rare for 
 women who have been prostitutes very long, 
 and they eventually go through the meno- 
 pause with an experience very similar to that 
 of other women who are in a similar physical 
 condition. They sometimes have fewer of 
 the uncomfortable phenomena of the meno- 
 pause than women who have always taken 
 the best of care of themselves. 
 
 The Experience of Prostitutes sometimes 
 contradicts the Results which would ordi- 
 narily be expected. To predict a trouble- 
 some menopause for a woman who has been 
 guilty of such sexual excesses as would rea- 
 sonably warrant such a prediction is not in 
 all cases in accord with the facts of experi- 
 ence.* 
 
 * A case may be mentioned of a woman who had kept a 
 house of prostitution thirty years, marrying and bearing 
 children in the meantime, suffering with syphilis and vari- 
 cose ulcers, and with excessive obesity, but otherwise appear- 
 ing to lead a very comfortable life physically. Another
 
 166 THE MENOPAUSE. 
 
 Sexual Abstinence and its Relation to the 
 Menopause. The opposite view of this sub- 
 ject that is, the influence of complete absti- 
 nence from sexual intercourse upon menstru- 
 ation and the menopause could best be 
 furnished from the experience of such a com- 
 munity as that of the Shakers, with whom 
 the custom prevails which is the very oppo- 
 site of that which is characteristic of the 
 Oneida Community. By the Shakers sexual 
 intercourse is regarded as wrong and to be 
 abstained from absolutely. 
 
 Experience of ike Shakers. The utmost 
 pains was taken to procure information upon 
 this subject ; the Shaker communities through- 
 out the country were corresponded with, but 
 all requests for definite information were de- 
 clined. 
 
 woman, forty years of age, has kept a house of prostitution 
 or has been associated with one twenty-five years. She had 
 a miscarriage at sixteen, has had syphilis, and has been ad- 
 dicted to the excessive use of morphine and alcohol. She 
 appears to be well preserved, says she has no trouble with 
 her menstruation, and would not know that she had a womb. 
 Such cases might be multiplied in the experience of the 
 writer.
 
 ADVENT AND PROGRESS. 167 
 
 Shakers Noncommittal concerning the 
 Sexual Organs. One correspondent stated 
 that subjects relating to the genital ap- 
 paratus were not to be thought of, still less 
 to be talked about, among them. The only 
 positive information that could be obtained 
 was from the presiding officer of one of the 
 principal communities, who stated that he 
 knew that the women in such communities 
 suffered with disorders as to their genital ap- 
 paratus and as to their menstruation, but to 
 what extent he was unable to say. He re- 
 ferred the writer to the superintendent or 
 principal one among the women in his com- 
 munity, but she declined to discuss the sub- 
 ject. 
 
 6. ACCIDENTAL INFLUENCES, FEAE, EMOTION, 
 GRIEF, ETC. 
 
 Women more Sensitive to Impressions 
 than Men. The average woman is at all 
 times more sensitive to impressions than the 
 average man, and there are certain periods in 
 her career when this sensitiveness is intensi-
 
 168 THE MENOPAUSE. 
 
 fied ; for example, when she is menstruating 
 and when she is pregnant. 
 
 Sudden Intense Impressions may bring 
 the Menopause. A sharp, sudden impression 
 would, with many women, check menstrua- 
 tion at once, and with not a few women, the 
 pregnant state being premised, it would bring 
 on an abortion. Since the poise in such mat- 
 ters is so delicate it is easy to understand 
 that an impression may be intense enough not 
 only to check an existing menstrual flow, or 
 cause the uterus to throw off the foetus which 
 it contains, but to produce permanent cessa- 
 tion of the menstrual flow and prevent any 
 subsequent conception. 
 
 These Intense Impressions may occur at 
 any Time. Such a result may be accom- 
 plished by sudden news of a great calamity, 
 intense fear, apprehension of impending ca- 
 tastrophe, grief, disappointment in love, in- 
 deed, the entire current of a woman's life 
 may be changed by such an experience. 
 Such an experience may occur at any age, 
 and we may therefore see the menopause pro-
 
 ADVENT AND PROGRESS. 169 
 
 duced by sudden impressions in early life, at 
 maturity, or at a time when in the natural 
 course of events the menstrual habit would 
 be near its limit. The study as to the cause 
 of such far-reaching results is curious and in- 
 teresting, but it belongs especially to the neu- 
 rologist. It is strange that the nervous sys- 
 tem should so dominate the body as to control, 
 by an influence of a moment's duration, the 
 entire subsequent channel of events of life. 
 
 STATISTICS WITH REFERENCE TO CONDITIONS 
 BEARING UPON THE MENOPAUSE. 
 
 Statistical Data bearing upon the Meno- 
 pause. While realizing that statistics are of 
 uncertain value, since they can be twisted to 
 prove almost anything or to prop up any 
 statement, no matter how improbable, it has 
 nevertheless seemed fitting that a work of 
 this character should not be entirely void of 
 such matter. Such statistics as are presented 
 are offered, therefore, rather with the idea 
 that the reader may draw such inferences 
 and conclusions as may seem to him warrant-
 
 170 
 
 THE MENOPAUSE. 
 
 able, than to support any theory which the 
 writer may have. It is also believed that 
 they will serve as a fair illustration of the 
 conditions which attend the menopause in 
 our heterogeneous New York population. 
 They were taken from the records of the 
 class in gynaecology, for the past few years, 
 at the Out-Patient Department of Bellevue 
 Hospital in New York. In so far as these 
 data have a bearing upon the age question 
 of the menopause they have already been in- 
 troduced (see pages 93-102). They are here 
 repeated with additional specific references 
 upon which comment will be appropriate. 
 
 NATIVITY. 
 
 Age. 
 
 Children. 
 
 Miscar- 
 riages. 
 
 Age when 
 menses be- 
 came irregu- 
 lar or ceased. 
 
 Ireland 
 
 52 
 
 10 
 
 o 
 
 49 
 
 
 54 
 
 4 
 
 2 
 
 52 
 
 
 50 
 
 7 
 
 3 
 
 48 
 
 
 51 
 
 4 
 
 
 
 51 
 
 
 50 
 
 o 
 
 1 
 
 47 
 
 
 50 
 
 3 
 
 1 
 
 48 
 
 
 50 
 
 5 
 
 1 
 
 43 
 
 
 47 
 
 11 
 
 5 
 
 41 
 
 
 45 
 
 7 
 
 
 
 44 
 
 
 44 
 
 15 
 
 1 
 
 44 
 
 
 37 
 
 8 
 
 1 
 
 37 
 
 
 43 
 
 9 
 
 
 
 43 
 
 
 46 
 
 7 
 
 o 
 
 M 
 
 46
 
 ADVENT AND PROGRESS. 
 
 171 
 
 NATIVITY. 
 
 Age. 
 
 Children. 
 
 Miscar- 
 riages. 
 
 Age when 
 menses be- 
 came irregu- 
 lar or ceased. 
 
 Ireland 
 
 48 
 
 10 
 
 
 
 48 
 
 < 
 
 47 
 
 8 
 
 2 
 
 46 
 
 
 48 
 
 8 
 
 1 
 
 47 
 
 
 45 
 
 6 
 
 4 
 
 45 
 
 
 40 
 
 6 
 
 2 
 
 39 
 
 
 49 
 
 11 
 
 4 
 
 49 
 
 
 40 
 
 7 
 
 1 
 
 40 
 
 
 48 
 
 8 
 
 
 
 47 
 
 
 40 
 
 8 
 
 2 
 
 38 
 
 
 40 
 
 8 
 
 2 
 
 40 
 
 
 40 
 
 8 
 
 4 
 
 38 
 
 
 42 
 
 9 
 
 
 
 38 
 
 
 56 
 
 3 
 
 
 
 43 
 
 
 51 
 
 8 
 
 3 
 
 46 
 
 
 47 
 
 2 
 
 
 
 45 
 
 
 44 
 
 
 
 
 
 43 
 
 
 46 
 
 1 
 
 6 
 
 43 
 
 
 60 
 
 
 
 
 
 42 
 
 
 28 
 
 o 
 
 1 
 
 26 
 
 
 48 
 
 1 
 
 
 
 38 
 
 
 43 
 
 2 
 
 1 
 
 40 
 
 
 39 
 
 
 
 
 
 37 
 
 
 38 
 
 
 
 
 
 38 
 
 
 38 
 
 
 
 
 
 38 
 
 
 40 
 
 
 
 
 
 39 
 
 
 50 
 
 
 
 
 
 50 
 
 
 42 
 
 
 
 
 
 41 
 
 
 50 
 
 
 
 1 
 
 50 
 
 
 44 
 
 
 
 
 
 44 
 
 
 50 
 
 
 
 
 
 45 
 
 
 41 
 
 
 
 
 
 41 
 
 
 45 
 
 
 
 
 
 40 
 
 
 45 
 
 
 
 
 
 43 
 
 
 48 
 
 
 
 
 
 45 
 
 
 58 
 
 
 
 
 
 53 
 
 
 50 
 
 
 
 
 
 40 
 
 
 40 
 
 
 
 
 
 38 
 
 
 52 
 
 
 
 
 
 48 
 
 United States. ... 
 
 52 
 
 3 
 
 2 
 
 50 
 
 
 54 
 
 5 
 
 
 
 46 
 
 H 
 
 52 
 
 10 
 
 1 
 
 52 
 
 (1 
 
 55 
 
 7 
 
 8 
 
 53 
 
 II 
 
 42 
 
 6 
 
 1 
 
 41
 
 172 
 
 THE MENOPAUSE. 
 
 NATIVITY. 
 
 Age. 
 
 Children. 
 
 Miscar- 
 riages. 
 
 Age when 
 menses be- 
 came irregu- 
 lar or ceased. 
 
 United Stutes 
 
 46 
 
 13 
 
 
 
 46 
 
 
 45 
 
 17 
 
 
 
 45 
 
 
 49 
 
 10 
 
 1 
 
 48 
 
 
 43 
 
 6 
 
 2 
 
 42 
 
 
 48 
 
 6 
 
 
 
 48 
 
 
 30 
 
 7 
 
 
 
 30 
 
 
 39 
 
 8 
 
 4 
 
 37 
 
 
 40 
 
 7 
 
 
 
 40 
 
 
 45 
 
 
 
 
 
 44 
 
 
 44 
 
 
 
 
 
 44 
 
 
 50 
 
 
 
 
 
 48 
 
 
 49 
 
 
 
 
 
 48 
 
 
 54 
 
 
 
 
 
 48 
 
 
 40 
 
 
 
 
 
 40 
 
 
 46 
 
 
 
 
 
 46 
 
 
 40 
 
 
 
 
 
 40 
 
 Polanrl 
 
 43 
 
 6 
 
 4 
 
 43 
 
 Germany 
 
 48 
 54 
 
 10 
 10 
 
 2 
 
 
 48 
 46 
 
 
 47 
 
 8 
 
 3 
 
 47 
 
 
 47 
 
 9 
 
 2 
 
 45 
 
 
 44 
 
 8 
 
 3 
 
 44 
 
 
 43 
 
 
 
 
 
 42 
 
 Italy. ... 
 
 46 
 
 9 
 
 1 
 
 45 
 
 
 45 
 
 9 
 
 1 
 
 43 
 
 Belgium 
 
 52 
 
 2 
 
 3 
 
 51 
 
 England 
 
 55 
 
 15 
 
 3 
 
 48 
 
 
 41 
 
 
 
 
 
 39 
 
 Denmark 
 
 45 
 
 
 
 2 
 
 45 
 
 Total, 85. 
 
 
 
 
 
 Excessive Fertility does not, of Necessity, 
 Precipitate the Menopause. These data show 
 that excessive fertility does not necessarily 
 precipitate the menopause, one woman who 
 had borne 17 children still menstruating 
 irregularly at the age of 45, another who
 
 ADVENT AND PROGRESS. 173 
 
 had given birth to 15 menstruating at in- 
 tervals of six months at the age of 44, and 
 another who had given birth to 13 menstru- 
 ating at intervals of seven weeks at 46. 
 
 Of these 85 cases menstruation ceased or 
 became very irregular with 21 at the age of 
 40 or less. 
 
 Such cases as the one in which the meno- 
 pause came at 30, after the birth of seven 
 children, are instructive and illustrative of 
 the exhaustion of the reproductive force to 
 which allusion has been made. 
 
 In the case in which the menopause oc- 
 curred at 26 the cause of this early appear- 
 ance could not be ascertained. The fore- 
 going data were taken from the records 
 consecutively, without any attempt at selec- 
 tion. In only two cases was there any ob- 
 servation which called attention to serious 
 disease, one of them being a case of malig- 
 nant disease of the uterus. 
 
 Of the 85 women there were 31, nearly 
 all of whom were married, who carried no 
 children to term, and only three of whom
 
 1T4 THE MENOPAUSE. 
 
 had ever been pregnant. This large per- 
 centage of sterile women is to be regarded 
 only as an incident, for the percentage in 
 our population at large, whether native 
 or foreign born, can not be nearly so great as 
 this. 
 
 Among those who had borne children 1 
 had given birth to 17, 2 to 15, 1 to 13, 2 to 
 11, 6 to 10, 5 to 9, 11 to 8, 7 to 7, 5 to 6. 
 This gives the large average of 9 to 40 
 women. Thus, with nearly 50 per cent, of 
 the cases in this collection in which there is 
 an average of nine children, and nearly 40 
 per cent, in which there is an average of nil, 
 what could be satisfactorily proved or de- 
 duced ? 
 
 These Statistics are admitted to be of no 
 Great Value for General Deduction. Even 
 though the number of cases considered might 
 be very much larger, it is doubtful whether 
 the conclusions one might draw from them 
 would be altogether safe for guidance, and 
 hence such a method of arriving at the an- 
 swer of questions which we are discussing
 
 ADVENT AND PROGRESS. 
 
 175 
 
 must not be accepted with too great a de- 
 gree of reliance. 
 
 Of the cases in which menstruation was 
 still an occasional occurrence at intervals of 
 less than a year the intervals noted were 1, 
 2, 3, 4, 5, 6, 8, and 10 months. If there had 
 been no recurrence of the menstrual flow for 
 a year or more it was assumed that the men- 
 strual function had terminated. 
 
 A series of 134 cases (including, how- 
 ever, many which are in the foregoing series) 
 was studied with reference to the ailments 
 which caused the patients to seek medical 
 advice. Those conditions which were most 
 noteworthy were as follows : 
 
 AILMENT. 
 
 No. of 
 cases. 
 
 Age. 
 
 No. of 
 chil- 
 dren. 
 
 No. of 
 miscar- 
 riages. 
 
 Urethral irritation 
 
 1 
 
 55 
 
 15 
 
 3 
 
 Endometritis 
 
 1 
 
 48 
 
 4 
 
 1 
 
 Cardiac lesion 
 
 1 
 
 50 
 
 3 
 
 1 
 
 Rheumatism 
 
 1 
 
 50 
 
 o 
 
 3 
 
 Perimetritis and cystitis 
 
 1 
 
 49 
 
 3 
 
 2 
 
 Bronchitis 
 
 1 
 
 45 
 
 o 
 
 o 
 
 Umbilical hernia 
 
 2 
 
 (47 
 
 11 
 
 5 
 
 Cystitis 
 
 1 
 
 ( 78 
 43 
 
 
 6 
 
 
 
 
 Leucorrhoea. . 
 
 1 
 
 40 
 
 2 
 

 
 176 
 
 THE MENOPAUSE. 
 
 AILMENT. 
 
 No. of 
 cases. 
 
 Age. 
 
 No. of 
 chil- 
 dren. 
 
 No. of 
 miscar- 
 riages. 
 
 Lumbar neuralgia 
 
 5 
 
 (48 
 
 46 
 1 50 
 
 2 
 
 2 
 
 
 
 1 
 
 Occipital neuralgia 
 
 1 
 
 145 
 [30 
 38 
 
 2 
 
 7 
 
 
 1 
 
 
 
 Salpingitis (Fallopian tubes re- 
 moved, immediate menopause). 
 Gastric catarrh 
 
 1 
 1 
 
 45 
 42 
 
 4 
 3 
 
 1 
 
 
 
 Dyspepsia . . , 
 
 1 
 
 54 
 
 
 
 
 
 Anaemia and constipation. . . . 
 
 1 
 
 38 
 
 1 
 
 
 
 Nausea and tympanites 
 
 1 
 
 53 
 
 
 
 
 
 Tvmpanites 
 
 1 
 
 40 
 
 8 
 
 2 
 
 Dizziness 
 
 1 
 
 48 
 
 3 
 
 
 
 Heat flashes 
 
 1 
 
 37 
 
 
 
 
 
 Heat flashes, dizziness, and dysuria 
 Heat flashes, dizziness, tympanites 
 
 Intense pain in head and abdomen 
 Headache and palpitation 
 
 1 
 2 
 
 1 
 
 1 
 
 44 
 J43 
 42 
 43 
 44 
 
 3 
 
 9 
 6 
 
 
 
 
 
 4 
 
 
 Dysentery 
 
 1 
 
 (single) 
 54 
 
 5 
 
 
 
 Iliac pain and purulent vaginal 
 discharge 
 
 1 
 
 45 
 
 4 
 
 1 
 
 Lumbar and iliac pain and leucor- 
 rhoea . 
 
 1 
 
 45 
 
 
 
 
 
 Iliac pain, flatulence 
 
 1 
 
 51 
 
 4 
 
 
 
 Varicose veins 
 
 1 
 
 40 
 
 8 
 
 2 
 
 Metrorrhagia (possibly of malig- 
 nant origin, menopause at 45). . 
 
 1 
 
 47 
 
 9 
 
 2 
 
 In this table are 35 cases out of the en- 
 tire series of 134 in which the menopause 
 had been completed or was in process of ex- 
 perience in which the ailment complained of 
 was of sufficient defmiteness to elicit atten- 
 tion in the clinical histories which had been
 
 ADVENT AND PROGRESS. 177 
 
 taken. In only one of them was there a sus- 
 picion of malignant disease, and in the great 
 majority of them the ailment was, in all 
 probability, quite distinct in its origin from 
 the menopause. 
 
 Percentage of Malignant Disease very 
 Small. It is interesting that the percentage 
 of malignant disease was so small, and if it 
 bears any particular relation to the subject 
 which is under discussion, it would seem to 
 indicate the infrequency rather than the fre- 
 quency of malignant disease in connection 
 with the menopause. As a matter of fact, 
 statistics aside, we know that malignant dis- 
 ease is not so very infrequent in the decade 
 from 40 to 50. The menopause, however, as 
 has been already remarked on several occa- 
 sions, has little, if anything, to do with its 
 causation.* 
 
 The Percentage of Cases of Disease of tlie 
 Alimentary Canal is Large. In about 25 
 
 * In contrast with the table on pages 175-176 the follow- 
 ing group of twenty-two cases, from the author's private 
 records, shows the great variability of statistics, especially 
 13
 
 178 
 
 THE MENOPAUSE. 
 
 per cent, of the 35 cases analyzed the alimen- 
 tary canal was more or less implicated, and 
 in more than 40 per cent, the nervous system 
 was involved, the preponderating phenomena 
 being pain located most frequently in the 
 
 when the numbers of cases studied are small, and also the 
 futility of making general deductions from them. The per- 
 centage of serious cases in this group is very large. 
 
 NATIVITY. 
 
 Age. 
 
 Age of 
 meno- 
 pause. 
 
 cha- 
 
 dren. 
 
 Mis- 
 car- 
 ri'ges. 
 
 Disease. 
 
 United States.. . 
 Ireland 
 
 46 
 53 
 
 40 
 43 
 
 2 
 
 
 2 
 
 
 
 Carcinoma uteri. 
 Myoma uteri. 
 
 United States. . . 
 German v 
 
 50 
 42 
 53 
 
 45 
 41 
 45 
 
 5 
 
 3 
 
 1 
 
 
 1 
 
 Cystoma ovarii. 
 Myoma uteri. 
 Carcinoma uteri. 
 
 United States.. . 
 
 H 
 
 
 
 M 
 
 Germany 
 
 54 
 49 
 53 
 54 
 
 48 
 
 51 
 46 
 52 
 51 
 
 47 
 
 3 
 
 1 
 ? 
 
 7 
 5 
 
 2 
 
 
 ? 
 
 
 
 Gall-stones. 
 Kolpokleisis. 
 Nephritis. 
 Retroversio uteri. 
 Myoma uteri. 
 
 United States.. . 
 Ireland 
 
 52 
 45 
 60 
 54 
 
 51 
 43 
 52 
 
 48 
 
 2 
 
 
 2 
 
 7 
 
 
 
 
 1 
 o 
 
 Osteosarcoma sterni. 
 Haematoma lig. br. 
 Carcinoma uteri. 
 Tumor abdominis. 
 
 H 
 
 50 
 
 43 
 
 2 
 
 o 
 
 Mvoma uteri. 
 
 M 
 
 48 
 
 47 
 
 8 
 
 
 
 Menopause. 
 
 M 
 
 41 
 
 40 
 
 1 
 
 o 
 
 Carcinoma uteri. 
 
 
 
 50 
 
 48 
 
 5 
 
 
 
 Carcinoma uteri. 
 
 United States. . . 
 Germany 
 
 44 
 50 
 55 
 
 38 
 49 
 53 
 
 2 
 6 
 2 
 
 
 3 
 
 o 
 
 Salpingitis. 
 Menopause. 
 Cystoma ovarii. 
 
 Ireland 
 
 50 
 
 37 
 
 2 
 
 1 
 
 Haemorrhoids et 
 
 
 
 
 
 
 
 
 
 1,010 
 
 
 
 
 Average age at the menopause, 46 years.
 
 ADVENT AND PROGRESS. 170 
 
 lumbar region and vasomotor crises that is, 
 the heat flashes to which multitudes of wom- 
 en are subject at some time or other during 
 the progress of the menopause with varying 
 degrees of discomfort. Ten of the 35 wom- 
 en, nearly one third, had been sterile, and 
 only one had never been married. 
 
 Such Statistics not Suited for formulat- 
 ing a Definite Disease of the Menopause. 
 From these statistics and they have been 
 taken without any attempt at selection a 
 fair picture may be made of the phenomena 
 which may accompany the menopause. It 
 would evidently be impossible to build up 
 a reasonable theory as to a definite disease of 
 the menopause from such or similar data. 
 Not a few writers have referred to "climac- 
 teric disease " as if the experience of the 
 menopause might include a distinct patho- 
 logical process. It is hardly necessary to 
 say, after what has already been said, that 
 in the opinion of the author no such patho- 
 logical process exists.
 
 180 THE MENOPAUSE. 
 
 THE INFLUENCE OR BEAKING OF THE MENO- 
 PAUSE UPON OVULATION AND CONCEPTION. 
 
 The End of Menstruation does not neces- 
 sarily signify the End of Ovulation. It does 
 not follow because a woman has ceased to 
 menstruate that ovulation and the possibility 
 of conception are at an end, not even though 
 she may have passed through many of the 
 experiences which are the common accom- 
 paniments of the menopause, and which are 
 so frequently an indication that fruitfulness 
 no longer exists. 
 
 Some one has said that the enormous 
 number of ovules in an ovary was an argu- 
 ment that ovulation continued from birth to 
 extreme old age. Such an argument without 
 anatomical basis would hardly require con- 
 sideration. 
 
 Ovulation means Exuberance as in JVa- 
 ture in General. Prodigal as Nature is in 
 the supply of germs of this character, there is 
 apparently the same allowance for waste that 
 is seen in the reproductive elements of ani-
 
 ADVENT AND PROGEESS. 181 
 
 mal and plant life in general. The ultimate 
 secret or reason for this no human being has 
 found out. The researches of Dalton, which 
 have already been drawn upon for an earlier 
 chapter, throw some light upon the subject, 
 and by references to cases quoted in Chapter 
 II we see that the condition of the ovaries as 
 to the power or function of ovulation varied 
 much. 
 
 The absence of corpora lutea may be 
 considered an evidence that ovulation has 
 ceased. 
 
 Details from Dalton's Series of Cases in 
 Chapter II. In case II of the series referred 
 to a patient who had died of phthisis pul- 
 monalis at the age of thirty-three, after an 
 arnenorrhoea lasting six months, there was 
 contraction and cirrhosis of the ovaries, with 
 few remnants of Graanan follicles and cor- 
 pora lutea, ovulation and the reproductive 
 force being nearly obliterated. 
 
 In case III, in which death came at the 
 age of thirty from waxy degeneration of the 
 kidneys and disease of the liver, no men-
 
 182 THE MENOPAUSE. 
 
 struation having occurred for eight months 
 prior to death, the ovaries were condensed 
 and atrophied and enveloped in old adhe- 
 sions. In neither ovary were there healthy 
 Graafian follicles nor corpora lutea. 
 
 In case IV, in which death occurred at 
 twenty-one from cardiac disease and pulmo- 
 nary oedema after amenorrhoea which had 
 lasted ten months, there was atrophy of the 
 ovaries, no corpora lutea, and only a few 
 small Graafian follicles. Ovulation had ter- 
 minated. 
 
 In case V, in which death occurred from 
 meningitis at forty-three, one year after the 
 last menstruation, there were no normal 
 Graafian follicles nor corpora lutea. A few 
 degenerate Graafian follicles had evidently 
 been long inactive. The meaopause had oc- 
 curred at the proper time and the function of 
 ovulation had ceased normally. 
 
 In case VI, in which death came at fifty- 
 five from abscess of the liver and pneumonia, 
 six years after the last menstruation, the 
 ovaries had been reduced to connective tissue,
 
 ADVENT AND PROGRESS. 183 
 
 with nothing to indicate that ovulation was 
 possible. 
 
 In case VII, in which death caine at forty- 
 five from rupture of an aneurism, there had 
 been only one menstrual period during the 
 last year of life. The woman had borne four- 
 teen children. The ovaries were small and 
 contained a number of Graaiian follicles, but 
 no corpora lutea. The follicles showed a 
 tendency to collapse before maturity. Ovu- 
 lation had probably terminated. 
 
 In case VIII, in which death occurred at 
 seventy, the ovaries contained a few collapsed 
 Graafian follicles, but no other evidence of 
 ovulation. 
 
 In a case which was attended by the au- 
 thor in 1890 the patient was thirty-nine, had 
 borne one child at twenty-five, and otherwise 
 had never been pregnant. She was operated 
 upon July 3, 1890, for pelvic abscess and 
 peritonitis. The adhesions in the pelvis were 
 dense and abundant, the right ovary had dis- 
 appeared, the right tube was a mere cord of 
 fibrous tissue, the uterus was small and atro-
 
 184 THE MENOPAUSE. 
 
 phied, the left tube and ovary firmly united, 
 surrounded by adhesions and converted into 
 pus sacs. The ovary contained neither Graa- 
 fian follicles nor corpora lutea, and there had 
 been no menstruation for three months. There 
 was no tissue in which ovulation would have 
 been possible. 
 
 There are not a few well authenticated 
 cases in which conception has taken place 
 long after the menopause has transpired, and 
 in some of them the pregnancy has continued 
 uninterrupted until term and delivery. In 
 others an abortion at an early month showed 
 that the reproductive force was defective.* 
 
 * The mother of an esteemed colleague became pregnant 
 and was delivered at term of a child who has proved in his 
 twenty years of life to have been sufficiently endowed with 
 vital force. Pregnancy occurred subsequent to the fiftieth 
 year, several years after the menstrual flow had ceased. 
 
 A case is recorded in a recent French journal (1892), the 
 particulars of which, unfortunately, can not be given, in 
 which pregnancy occurred at fifty-nine. Another case was 
 narrated to the author by a colleague, which had come under 
 his personal observation and attention, in which there was 
 pregnancy at the age of sixty, which continued to term, and 
 which began fourteen years after the menses had ceased. Such 
 instances as the foregoing are not isolated, but have occurred 
 to many observers who have given attention to such matters.
 
 ADVENT AND PROGRESS. 185 
 
 Ovulation may continue after Menstrua- 
 tion has ceased. From what has been stated 
 in the foregoing pages it would appear prob- 
 able that in the great majority of cases the 
 cessation of menstruation signifies the termi- 
 nation of ovulation, the functional power of 
 the ovaries having reached its natural limit. 
 But it is also apparent that in exceptional 
 cases ovulation may continue after menstrua- 
 tion has ceased, perhaps without noticeable 
 or noteworthy phenomena, and in such cases 
 pregnancy is not an impossibility. Should 
 pregnancy occur the evidence would be prima 
 facie that senile degenerative changes in the 
 uterine mucous membrane had not taken 
 place, for if the formation of a decidua were 
 impossible the development of a fecundated 
 ovum would be equally impossible. 
 
 ADDENDA. 
 
 OLIVE. Menstruaciones suplementarias ; una forma 
 rara, etiologia, tratamiento. Eevista homeopatica. 
 Barcelona, 1895, vi, 329. 
 
 STOCQUART. Gas de cessation tardive des regies. 
 Archives de medecine et chirurgie pratique. Bruxelles, 
 1890, iv, 132.
 
 186 THE MENOPAUSE. 
 
 DRENTEL. On the Climacteric Age of Woman. 
 Akuscherka Briansk, 1892, iii, 109. 
 
 MULLER. Influence of the Climacteric upon Fibro- 
 myomata. Archiv fiir Gynakologie, xl, 2. 
 
 TAIT. Myomata of the Uterus. Transactions, 
 London Obstetrical Society, xxv.
 
 CHAPTER IV. 
 
 THE PHENOMENA OF THE MENOPAUSE, NORMAL 
 AND MOBBED, AND THEIR DURATION. 
 
 The Typical Menopause a Colorless, Un- 
 eventful Experience. It is a presumption 
 which would seem perfectly reasonable and 
 warrantable that there are myriads of women, 
 away from the influence of doctors, perhaps 
 where doctors are infrequent or inaccessible, 
 who, having plenty of healthful occupation 
 and little time or inclination for musing and 
 brooding over physical ills and ailments, glide 
 away from the menstrual function and men- 
 strual life with as little disturbance and dis- 
 comfort as they had when entering it that 
 is, they are conscious of nothing amiss in re- 
 spect to this portion of their functional ex- 
 istence and such women constitute the type 
 
 187
 
 188 THE MENOPAUSE. 
 
 of that which the menopause ought normally 
 to afford. 
 
 Facility in obtaining Medical Advice may 
 exaggerate the Evils of the Menopause. 
 How large the number of such women may 
 be, who can tell, for it is not the well who 
 consult the physician, but the sick or those 
 who think themselves sick. On the other 
 hand, the majority of women who attain old 
 age under the eye of the physician have more 
 or fewer disturbances and annoyances during 
 the years which mark the menopause, such 
 annoyances varying from the flashes of heat, 
 followed by perspiration, which come and go 
 without warning and sometimes without ap- 
 parent exciting cause, to the most profound 
 vascular and nervous derangements. 
 
 The Normal Menopause not a Dangerous 
 Experience to Life or Healtli. The position 
 is therefore maintained that there is a nor- 
 mal that is, an uneventful menopause, and 
 that if there is no pre-existing foundation of 
 disease, the menopause should not be consid- 
 ered critical in the sense that it is dangerous
 
 PHENOMENA OF THE MENOPAUSE. 189 
 
 to life or health. The savage and the aver- 
 age woman in civilized life who has lived out 
 of doors or who is of an insensitive tempera- 
 ment, knows nothing, as a rule, from expe- 
 rience of the trials of the menopause. Does 
 this prove the superiority of the savage state 
 or the state of Nature from the physical 
 standpoint ? 
 
 The Civilized preferable to the Savage 
 State. It would perhaps be so considered if 
 we adopt the reasoning and admit the argu- 
 ments of writers like Rousseau ; but there are 
 compensations in civilized life for the ills 
 which may accompany the menopause, and 
 this compensatory factor, which makes civi- 
 lized life preferable to the life of the savage 
 or to the state of Nature, does not seem to 
 have been appreciated by Rousseau in his 
 writings which tended in this direction, nota- 
 bly in his celebrated essay (Eniile) on edu- 
 cation.* 
 
 * One is reminded, in this connection, of the remark 
 which has been attributed to the late Henry Ward Beecher, 
 that he would rather be an unhappy man than a happy flea.
 
 190 THE MENOPAUSE. 
 
 The situation has been admirably covered 
 by Braxton Hicks in the Croonian lectures 
 for 1877, and with his usual felicity of ex- 
 pression:"* "After the change is completed 
 the system improves, the many irritations 
 connected with menstruation and pregnancy 
 are gone, and the changes in the individual 
 show that many of the earlier troubles were 
 functional without permanent lesion. The 
 local irritations, engorgements, and fluxes, all 
 the reflex symptoms neuroses, vomiting, 
 neuralgias, headaches gradually pass off." 
 
 Phenomena which are Common, others 
 which are Infrequent. Perhaps it is not 
 strictly correct to say that there are phe- 
 nomena which are normal to the menopause. 
 There are, however, phenomena which are 
 common and others which are less common or 
 infrequent. In the former the nervous and the 
 vascular systems have a predominating influ- 
 ence. The vasomotor phenomena are pre-emi- 
 nently conspicuous, and they are most notice- 
 able in women of nervous temperament. 
 
 * Medical Times and Gazette, 1877, i, p. 411.
 
 PHENOMENA OF THE MENOPAUSE. 191 
 
 The Individual's Disposition, whether Sen- 
 sitive or Phlegmatic, determines in a measure 
 the Phenomena of the Menopause. It is but 
 a logical consequence that women who dur- 
 ing their menstrual lives blush furiously at 
 the slightest stimulus of one character and 
 pale at an equally slight stimulus of another, 
 should have the same vasomotor disturbances 
 during the period of the menopause when the 
 equilibrium of the forces of the body is un- 
 stable in so many cases. With phlegmatic 
 women such disturbances are less common, 
 and even should they occur their significance 
 would be far less than with the supersensi- 
 tive women at the opposite pole of tem- 
 perament. 
 
 Vasomotor Phenomena easily excited. 
 The origin of these disturbances may be 
 either central or peripheral that is, there 
 may be an exciting cause in the vasomotor 
 centers within the cerebral cortex, the me- 
 dulla, or the spinal cord, or the stimulus may 
 come from without, the peripheral ends of 
 the cutaneous nerves suffering irritation.
 
 192 THE MENOPAUSE. 
 
 Works on neural anatomy and neuro-pathol- 
 ogy should be consulted for the special pa- 
 thology of the subject.* 
 
 Vasomotor Phenomena due to an Explo- 
 sion of Nervous Force. A mental sugges- 
 tion, a draught of wind, a sudden emotion, 
 violence of any character, or possibly a cause 
 of which the patient has no clew, may excite 
 the phenomena in question, the patient being 
 suddenly conscious of an explosion of nerve 
 force, a flash of heat about the face and head, 
 and a minute or two later a profuse perspira- 
 tion. In some cases, at least, this condition of 
 affairs seems kindred to the aura of epilepsy, 
 and like that phenomenon is not entirely ex- 
 plicable. It frequently leaves the patient 
 rather weak, like any other discharge of 
 nervous force, and like attacks of hysteria 
 may be followed by a copious discharge of 
 limpid urine. 
 
 Manifestly, both cerebro-spinal and sym- 
 
 * A very good consideration of the subject may be found 
 in Ross's Diseases of the Nervous System. Wood, 1883, vol. 
 i, pp. 214-220.
 
 PHENOMENA OF THE MENOPAUSE. 193 
 
 pathetic nerve elements are involved, and in 
 the absence of any satisfactory explanation 
 thus far, based upon exact investigation, it 
 would seem possible to attribute it to dis- 
 turbance in the molecular arrangement of 
 nerve cells, which, it must be admitted, 
 is but a meager and unsatisfactory state- 
 ment. As the menopause progresses this 
 condition may recur at longer and yet longer 
 intervals, gradually fading away from the 
 experience, or it may continue as an occa- 
 sional visitor to the very end of life, even 
 when life is prolonged to an unusual 
 limit. 
 
 A number of distinct varieties or types of 
 this condition have been observed. 
 
 1. That which is simplest of all, manifest- 
 ing the heat flash which comes suddenly and 
 seldom lasts more than a moment. Its modi- 
 fications are the following : 
 
 2. Sweating. 
 
 3. Sweating and more or less pronounced 
 chill or shudder, like a mild paroxysm of ma- 
 larial fever. 
 
 u
 
 THE MENOPAUSE. 
 
 4. Headache, which may continue long 
 after the disappearance of the heat flash. 
 
 5. Melancholia and depression or mania. 
 
 6. Chilliness of the extremities. 
 
 7. Abundant discharge of urine. 
 
 8. Diarrhoea and congestion of the pelvic 
 organs, with the addition, in some instances, 
 of intense sexual ardor. 
 
 These Types may be Distinct or they may 
 interllend. These several types may be clear 
 and distinct or they may interblend. More- 
 over, they do not cover the entire range of 
 phenomena which are included in this com- 
 plex condition. 
 
 GASTKO-INTESTINAL DISTURBANCES. 
 
 Less frequent than the vasomotor disturb- 
 ances, but sufficiently common, and the source 
 of considerable annoyance, though seldom of 
 any real danger, are the gastro-intestinal dis- 
 turbances. As they have been observed by 
 the author they may be mentioned in the fol- 
 lowing order of frequency : 
 
 1. Constipation.
 
 PHENOMENA OF THE MENOPAUSE. 195 
 
 2. Intestinal or gastric fermentation with 
 tympanites, gurgling, gulping, etc. 
 
 3. Loss of appetite with indigestion and 
 the usual accompaniments of so-called bilious- 
 ness viz., furred tongue, offensive breath, 
 muddy skin, scanty and light-colored stools. 
 
 4. Diarrhoea. 
 
 Troublesome Phenomena of the Meno- 
 pause may be the .Result of Previous Bad 
 Habits. These conditions are very often the 
 result of the bad habits or indiscretions of 
 the patients, and are usually quite amenable 
 to treatment. 
 
 It would be strange, indeed, if women 
 who have all their lives neglected or abused 
 their stomachs and bowels should go through 
 the change of life without disturbance, and 
 troubles of this character will sometimes 
 serve as a prelude to other and more seri- 
 ous ones which are entailed by neglect or 
 improper treatment.* 
 
 * The disturbed condition of the alimentary canal with 
 tympanites, flatulence, and constipation has in very many 
 instances given rise to a suspicion of the existence of preg-
 
 196 THE MENOPAUSE. 
 
 Ancemia signifies Poverty of tlie Blood. 
 Closely associated with the vasomotor and 
 gastro-intestinal disturbances is the condition 
 of anaemia. Anaemia during the menopause 
 does not necessarily imply great losses of 
 blood any more than it does in young wom- 
 en who have just reached or just passed 
 puberty, and with whom it is of common 
 occurrence. "What" it really implies is pov- 
 erty of the blood in red corpuscles, and con- 
 sequently in haemoglobin, iron, and oxygen. 
 Of course, it sometimes signifies profuse 
 haemorrhages, as it likewise does occasion- 
 
 nancy, and this has sometimes been insisted upon by the 
 individual who was the subject of it, until such insistence, 
 unduly prolonged, became ludicrous, the wish being father 
 to the thought. 
 
 Mary, Queen of England, wife of Phillip II of Spain, is 
 said to have been deluded by such a misunderstanding and 
 miscalculation as the foregoing. 
 
 Unless the physician is entirely on his guard he is liable 
 to make awkward mistakes, and perhaps be held heavily re- 
 sponsible in cases like these. Indeed, ignorance or error of 
 diagnosis in times like the present, when the helps and means 
 of information are so abundant, is not creditable and often is 
 inexcusable.
 
 PHENOMENA OF THE MENOPAUSE. 197 
 
 ally in young women, and it may also be 
 one of the chain of symptoms pointing to 
 the presence of malignant disease in the 
 uterus or elsewhere; but in the experience 
 of the author this has been a somewhat rare 
 coincidence. 
 
 The Menopause is not especially Favor- 
 able to the development of Malignant Dis- 
 ease except in those who are predisposed to 
 it. The object of this work, to a degree that 
 is earnestly desired, is to dispel, if possible, 
 from both the lay and the professional mind, 
 the idea that there is any especial danger of 
 the development of malignant disease during 
 the menopause, excepting in those who have 
 a predisposition to such disease, either by 
 heredity or by virtue of a depraved condi- 
 tion of their tissues from other causes. 
 
 HAEMORRHAGES OF THE MENOPAUSE. 
 
 Hcemorrhages at the Menopause formerly 
 regarded as an Essential Accompaniment. 
 There is no feature of this subject which has 
 given rise to so much of alarm and uncer-
 
 198 THE MENOPAUSE. 
 
 tainty and to such erroneous conclusions as 
 this. 
 
 It has already been stated that prior to 
 the era when gynaecology began to be prac- 
 ticed in an intelligent and reasonable manner 
 it was the almost universal custom to con- 
 sider haemorrhages which occurred after the 
 childbearing period had passed as necessary 
 and unavoidable, and this false notion, it is 
 surprising to say, still prevails, to a certain 
 extent, especially with the older generation 
 of practitioners. This haemorrhage marked 
 the critical time and would cease when that 
 time had passed, or it might result in cancer 
 and death. What its cause might be was 
 usually unknown, and very little was done 
 to find out the cause or to overcome it. It 
 was in this way that the ideas concerning 
 cancer became associated with those which 
 concerned the menopause. 
 
 Such Practice counted many Victims. 
 The relative harmlessness of great losses of 
 blood during the menopause was an article 
 of faith which was a suitable accompani-
 
 PHENOMENA OF THE MENOPAUSE. 199 
 
 ment to that doctrine which made venesec- 
 tion a cardinal principle in its therapeutic 
 system. Such erroneous views have led to 
 the sacrifice of untold victims. 
 
 We in these later days can appreciate 
 heartily the pungent wit and satire of 
 Moliere in E amour medecin and Le malade 
 imaginaire as we think of the bleeders, pukers, 
 and purgers of his time, their solemn consul- 
 tations, their bombastic rhetoric, their infinite 
 complacency, and their self-satisfying conclu- 
 sions. 
 
 Of course, we are to understand by the 
 term haemorrhage in this connection a loss 
 of blood far in excess of that which is ordi- 
 narily lost at the menstrual period, for only 
 such a loss would excite unusual attention or 
 alarm. 
 
 Haemorrhages may recur at Long or 
 Short Intervals. This haemorrhage some- 
 times recurs at intervals of a week or two, 
 or there may be an interval of one or sev- 
 eral months. If the intervals are long there 
 is an increased formation of the decidual en-
 
 200 THE MENOPAUSE. 
 
 dometrium that is, the portion which the 
 uterus is accustomed to shed and necessarily 
 increased vascularity. The breaking down 
 of this tissue opens up an unusual number 
 of vessels, and favors an increased outpour- 
 ing of blood. If the intervals are short the 
 haemorrhage may be due to increased fria- 
 bility of the endometrial tissue, as Scanzoni 
 has suggested, and also to a decided increase 
 in that impulse by which, during the child- 
 bearing period, the blood current is diverted 
 to the pelvic tissues. 
 
 Conditions Different from those wliich at- 
 tend Ordinary Menstruation. The condi- 
 tions regulating the coagulability of the 
 blood are also different from those which 
 obtain with the ordinary product of the 
 menstrual period. The latter, as is well 
 known, does not, under the usual condi- 
 tions, become clotted, being influenced by 
 its admixture with epithelial detritus and 
 acid glandular secretion, while the blood 
 which pours from the uterine vessels in the 
 condition under discussion is often coagu-
 
 PHENOMENA OF THE MENOPAUSE. 201 
 
 lated like blood from any other part of the 
 body. It is true, however, that when one 
 has been weakened by frequent haemor- 
 rhages, and the blood has become thin and 
 watery in consequence, its coagulating ele- 
 ments are defective, as in anaemia under any 
 other conditions. 
 
 Such Haemorrhages demand the Relief 
 which Intelligent Treatment can afford. 
 The foregoing remarks apply to great num- 
 bers of cases in which, with the exception of 
 the local lesions of the endometrium, nothing 
 of a morbid character can be detected. It is 
 believed that it is eminently unsafe and un- 
 scientific to leave such cases to Nature's un- 
 aided efforts at relief. 
 
 The necessity for the thorough investi- 
 gation of all cases is seen in the fact that 
 haemorrhages may be due to disease of the 
 endometrium differing from that which has 
 been mentioned, arising from myomata of 
 the uterus or from benign or malignant dis- 
 ease of the adnexa or other structures con- 
 tiguous to the uterus.
 
 202 THE MENOPAUSE. 
 
 Scanzoni's Theory and Objections thereto. 
 Scanzoni's theory concerning the haemor- 
 rhages of the menopause is that they are 
 due to senile rigidity or friability of the en- 
 dometrial vessels which are unable to stand 
 the blood pressure. Such an hypothesis 
 might be sufficient, as has already been ad- 
 mitted in some cases, but would not be of 
 general application. A morbid process of 
 such a character affecting the endometrial 
 vessels would be likely to affect small ves- 
 sels elsewhere for example, in the mucous 
 membrane of the nose and any unusual ex- 
 ertion would be followed by their rupture 
 and by free haemorrhage. As a matter of 
 fact, such haemorrhages have not been ob- 
 served to be of especial frequency during 
 the menopause. 
 
 KiscKs Theory. Kisch attributes the 
 haemorrhage to softening and relaxation of the 
 uterine tissue with circulatory disturbance in 
 the pelvic organs and obstruction of the vena 
 cava ascendens, stasis in the vessels of the uter- 
 ine walls and haemorrhage being the result.
 
 PHENOMENA OF THE MENOPAUSE. 203 
 
 Franks Theory. Frank ventures the 
 opinion that the haemorrhages are associated 
 with early and profuse menstruation, fre- 
 quent and difficult labors, frequent abor- 
 tions, and excesses in drinking. 
 
 Hegar^s Theory. Hegar very aptly says 
 there is an absence of aetiological factors in 
 some of these cases. Perhaps it would be 
 more to the point to say, in such cases, that 
 we do not know the cause of the trouble. 
 
 Another hypothesis of Hegars is that the 
 haemorrhage is due to diminished pressure 
 on the uterus in consequence of relaxed and 
 flabby abdominal walls and uterine supports. 
 But in how small a number of cases, relative- 
 ly, does this exist ! Furthermore, the fatty 
 degeneration of old age appears usually only 
 after the menopause is concluded and the 
 haemorrhages have ceased.* 
 
 * Borner in his work The Menopause, frequently referred 
 to in this book, has quoted the foregoing opinions, and the 
 substance of them has been borrowed from him.
 
 204 THE MENOPAUSE. 
 
 LESIONS OF THE MIND AND NEEVOUS SYSTEM 
 IN CONNECTION WITH THE MENOPAUSE. 
 
 Not a little has been written concerning 
 the influence of the menopause upon the 
 mind and nervous system. Cerebral conges- 
 tion is, indeed, not an uncommon occurrence 
 at this period, and may be due to the diver- 
 sion of the blood current and to the fact 
 that pelvic congestion and uterine discharge 
 no longer take place with their accustomed 
 regularity. But cerebral anaemia is also of 
 frequent occurrence at this period, and there 
 may be present a great variety of phenomena 
 resulting from these opposite conditions. 
 
 From West Riding Asylum Report. 
 Merson has observed* that epilepsy, general 
 paralysis, or atrophy may be modified dur- 
 ing the climacteric. He believed that the 
 condition of nervous irritability in connec- 
 tion with ovarian changes must depend on 
 changes in the blood supply, or must be 
 due to a change of nutrition in the nervous 
 
 * West Riding Lunatic Asylum Report, 1876.
 
 PHENOMENA OF THE MENOPAUSE. 205 
 
 centers which arises spontaneously, or else 
 is induced by influences emanating from the 
 reproductive organs. The blood supply to 
 the brain may be increased, diminished, or 
 changed by retention products during the 
 climacteric. Or, if the cause of disturbance 
 at this time be not in the blood, it may be in 
 the ganglionic centers, influences being reflect- 
 ed from the abdominal ganglia to the brain. 
 
 Segals Comments on the Nervous Phe- 
 nomena of the Menopause. Hegar* refers 
 to one hundred and twenty-six paralyzed 
 women in Meynert's clinic, in nine of whom 
 there were menstrual derangements, while in 
 sixteen there was progressive paralysis which 
 was apparently due to influences connected 
 with the menopause. Hegar likewise thinks 
 that diseases of the nervous system are next 
 in frequency to those of the sexual organs 
 during and after the menopause, the more 
 prominent symptoms being hyperaesthesia?, 
 hyperkinesiaB, prickling and burning of the 
 
 * Handbook of General and Operative Gynaecology, p. 291.
 
 206 THE MENOPAUSE. 
 
 skin, dizziness, pseudo-narcotism, uncertainty 
 in walking, muscular weakness, sleeplessness, 
 hemicrania, hallucinations, etc. The halluci- 
 nations may be of hearing, sight, smell, taste, 
 or feeling, and may develop into progressive 
 paralysis. 
 
 Sexual Ardor of the Menopause. In 
 women who are passing through the meno- 
 pause the author has, in some instances, ob- 
 served sexual ardor in connection with hallu- 
 cinations and other nervous phenomena. 
 
 This observation is probably kindred to 
 that which has been made by Thomas,* and 
 in which attention is called to the hysterical 
 symptoms (senile hysteria) accompanied with 
 tympanites, which symptoms are sometimes 
 seen in those with whom the climacteric 
 comes unusually late in life. 
 
 Kischf also has observed and commented 
 upon the congestive conditions of the meno- 
 pause which are associated with irritability 
 
 * Medical Record, December 6, 1879. 
 f Die nervosen Leiden in climakterischen Alter. Wiener 
 Medicinischer Presse, 1876, xvii, 600, 644.
 
 PHENOMENA OF THE MENOPAUSE. 207 
 
 of the peripheral nerves and with sensitive- 
 ness of the sexual organs. He attributes the 
 somewhat unnatural marriages which occa- 
 sionally occur between elderly women and 
 young men to such causes. 
 
 CLIMACTEEIC INSANITY. 
 
 Not a Definite Type of Mental Disease. 
 The very great importance which attaches to 
 the subject of lesions of the mind during the 
 period of the menopause has suggested a par- 
 ticular consideration of the subject. It has 
 even been proposed by a number of writers 
 to dignify this condition by the term climac- 
 teric insanity, though it does not appear that 
 the psychical condition is such as to establish 
 a distinct type of mental disease. 
 
 Among those who have investigated the 
 subject from the standpoint of the alienist 
 may be mentioned Griesinger, Esquirol, 
 Krafft-Ebbing, Guislain, Schlager, Skae, 
 Merson, Morel, and L. Mayer. 
 
 Griesinger thinks that the Melancholia of 
 the Menopause has an Unfavorable Progno-
 
 208 THE MENOPAUSE. 
 
 sis. Griesinger was of the opinion that psy- 
 chical disease was, in some instances, bene- 
 fited by the experiences of the menopause, 
 but that in a greater number of cases it was 
 made worse. If melancholia developed dur- 
 ing the menopause he was accustomed to 
 give an unfavorable prognosis. 
 
 Tilt has recorded 430 cases of psychical 
 disease among 1,320 cases in which the phe- 
 nomena of the menopause were analyzed. 
 This number seems quite incredible in the 
 light of ordinary experience with the phe- 
 nomena of the menopause, but it is possible 
 that in many of the cases the psychical dis- 
 ease was of so mild a type as to be over- 
 looked by any except an unusually keen 
 observer. 
 
 In most of Skae's Cases the Type was 
 Melancholia. Skae's opinion is that climac- 
 teric insanity includes an important natural 
 group of conditions.* An analysis was made 
 by this writer of 200 cases which were ob- 
 
 * Edinburgh Medical Journal, 1865, x, p. 703.
 
 PHENOMENA OF THE MENOPAUSE. 209 
 
 served in the Royal Asylum, at Edinburgh, 
 and in which the age of the greater number 
 of the patients was between 44 and 51. In 
 almost all the cases the form of insanity was 
 melancholia, and in 107 of them it was very 
 pronounced. Depression, insomnia, listless- 
 ness, delusions, suicidal and homicidal im- 
 pulse, though the latter was a rare occur- 
 rence, were noteworthy symptoms, and most 
 of the patients were asthenic, anaemic, and 
 constipated. Demonomania was a common 
 delusion, also fear of losing the soul. The 
 duration of the disease was about four 
 months in most of the cases, the recoveries 
 amounted to 53'5 per cent, the deaths to 10 
 per cent, and there was one case with cancer 
 of the uterus. 
 
 Skae's Conclusions. The conclusions" 
 which were reached by Skae were as fol- 
 lows : 
 
 1. Climacteric insanity has peculiar fea- 
 tures which are easily recognized. 
 
 2. It is one of the most curable forms of 
 insanity in which melancholia is present. 
 
 15
 
 210 THE MENOPAUSE. 
 
 3. It rarely continues longer than from 
 three to six months. 
 
 4. It is rarely fatal except from suicide or 
 when associated with organic disease. 
 
 5. The patient should be separated from 
 her friends, carefully watched, and should re- 
 ceive suitable diet and narcotics. 
 
 Scene's Opinion concerning Insanity at 
 the Menopause. Skene, who has investigated 
 the question of climacteric insanity from the 
 standpoint of the gynaecologist,* is of the 
 opinion that among the poor, at least, this 
 form of insanity is associated with bad nutri- 
 tion, which has also been accompanied with 
 frequent childbearing and lactation. His 
 opinion is, furthermore, that this form of 
 insanity may be caused by organic disease 
 of the uterus, or that the presence of the 
 latter may retard recovery from the insanity. 
 
 Analysis of Conklin's Cases. Conklinf 
 has made an interesting analysis of 57 cases 
 
 * Archives of Medicine, 1880, iii, p. 1 
 t American Journal of the Medical Sciences, 1871, Ixii, p. 
 365.
 
 PHENOMENA OF THE MENOPAUSE. 211 
 
 which were under his care at the Southern 
 Ohio Lunatic Asylum. In 25 of the cases 
 there was hereditary tendency to insanity, 
 the disease progressing gradually, and in 
 some cases being somewhat badly defined 
 until the menses had entirely disappeared. 
 There was mania in 5 of the cases, there 
 was melancholia in 41 ; almost all the cases 
 showed general debility ; there was suicidal 
 tendency in 26, this symptom usually ap- 
 pearing early in the morning and during 
 the period of convalescence. There were 
 25 recoveries, 3 remained in the asylum in 
 a condition of dementia, 4 died, and the 
 termination in 15 remained unknown. With 
 those who recovered the duration of the dis- 
 ease was not less than two months nor more 
 than two years. 
 
 Sutherland^ Conclusions. Sutherland 
 has summarized the relations of the meno- 
 pause to insanity clearly and tersely as fol- 
 lows : * 
 
 * British and Foreign Medico-Chirurgical Review, i, 1874, 
 p. 505.
 
 212 THE MENOPAUSE. 
 
 1. Insanity occurring at the change of 
 life is not usually caused by that condition 
 per se, but is most frequently due to some 
 other moral or physical cause coincident with 
 that period. 
 
 2. It occurs most frequently at the age of 
 forty -five years and two months. 
 
 3. Its onset is usually a year after the 
 cessation of menstruation. 
 
 4. The married state does not predispose 
 to it. 
 
 5. Neither does the number of labors 
 which a woman may have had. 
 
 6. It takes the form of melancholia oft- 
 ener than mania. 
 
 7. Climacteric insanity has certain symp- 
 toms which are characteristic. 
 
 8. The prognosis is favorable, more than 
 40 per cent of the cases result in recov- 
 ery. 
 
 9. Its duration is usually more than three 
 months and less than three years. Complete 
 recovery seldom takes place in less than 
 twelve months.
 
 PHENOMENA OF THE MENOPAUSE. 213 
 
 10. The treatment should consist of seda- 
 tives, aperients, and watchfulness. 
 
 Mer son's Conclusions. Merson has al- 
 ready been alluded to in connection with 
 this subject, and his excellent contribution 
 may be found in the report of the West 
 Eiding Lunatic Asylum for 1876.* The 
 following data were taken from the report 
 in question : 
 
 During a given period of four years 392 
 insane women between the ages of 25 and 
 40 were admitted to the West E-iding Asy- 
 lum, and 333 additional ones between the 
 ages of 40 and 55. In 69 of the latter in- 
 sanity had developed prior to the cessation 
 of menstruation, while in 147 it developed 
 during the progress of the menopause. 
 
 The menopause was not alone responsi- 
 ble for the insanity in these cases, addi- 
 tional causes being present as follows : 
 
 Cases. 
 
 Bereavement in 15 
 
 Cruelty on the part of the husband 18 
 
 Financial trouble 5 
 
 * The Climacteric Period in Relation to Insanity.
 
 214 THE MENOPAUSE. 
 
 Cases. 
 
 Fright 6 
 
 Disappointment in love 2 
 
 Remorse 3 
 
 111 health and want 4 
 
 Uterine haemorrhage 4 
 
 Fall and injury of the head 3 
 
 Fever and inflammation 4 
 
 Intemperance 5 
 
 Disease of the heart 3 
 
 Pulmonary phthisis 4 
 
 Organic disease of the brain, not related to the 
 
 menopause 31 
 
 In the 147 cases last mentioned 90 were 
 married, 33 single, 24 widows. 
 
 With 43 a tendency to insanity was 
 hereditary, with 49 there had been previous 
 attacks, with 13 there had been recovery 
 from such attacks during the puerperal 
 period. 
 
 Excluding cases of organic brain disease, 
 Merson divides the instances of climacteric 
 insanity which he has analyzed into three 
 groups, as follows : 
 
 1. Those in which there is simple depres- 
 sion without hallucination of the senses or 
 intellectual derangement, and in which nerv- 
 ous irritability and hyperaBsthesia are also 
 present.
 
 PHENOMENA OF THE MENOPAUSE. 215 
 
 2. Those in which there is depression 
 with emotional and intellectual disturbance, 
 also hallucinations and delusions of a depress- 
 ing character. 
 
 3. Those in which there are delusions of 
 suspicion and persecution, hallucinations of 
 the senses, and outbursts of excitement. 
 
 Merson differs with Bucknill and Tuke 
 and also with Vanderkolk in their belief that 
 the prognosis of this condition is a gloomy 
 one. In his 147 cases there were 69 re- 
 coveries. 
 
 Rohe * has observed that mental disor- 
 ders, especially melancholia, were very fre- 
 quent between the ages of forty and fifty. 
 With the degenerative changes in the sexual 
 organs which are to be found in such cases 
 there may also be associated hallucinations of 
 hearing and smell, religious delusions, also 
 delusions as to the digestive organs, delusions 
 of grandeur, and pseudo-cyesis. He has not 
 been able to satisfy himself that there is any 
 
 * Climacteric Psychoses. Medical Standard, Chicago, 
 1896, xviii, p. 69.
 
 216 THE MENOPAUSE. 
 
 period -in the life of men which corresponds 
 with the menopause. The insanity which 
 sometimes follows removal of the ovaries is, 
 in his opinion, identical with climacteric in- 
 sanity, and he has found that the prognosis 
 for this condition was favorable in 40 to 
 60 per cent of all cases. 
 
 Matusch * has found that the two critical 
 phases of life in women were appropriate for 
 the development of psychoses and hereditary 
 and degenerative neuroses. In the asylum at 
 Sachsenburg there were 551 insane peasant 
 women who came under his observation, and 
 of this number there were 60 who were pass- 
 ing through the menopause. 
 
 Braxton Hicks f calls attention to the 
 power of the reflexes from the uterus and 
 ovaries, and to the increased sensitiveness of 
 woman compared with man. He concludes 
 from this that woman should be expected to 
 show the greater tendency to mental derange- 
 ments and disorders. He refers also to the 
 
 * Allgemeine Zeitschrift fur Psychiatric, xlvi, S. 4. 
 t Medical Times and Gazette, 1877, i, p. 411.
 
 PHENOMENA OF THE MENOPAUSE. 
 
 statement of Mayer that among six thousand 
 insane women and girls who had been seen 
 by him in Berlin there was a percentage of 
 81 '03 in which menstrual disorder of one 
 character or another was complained of. 
 
 The Mind is in Unstable Equilibrium at 
 the time of the Menopause. The foregoing 
 evidence shows at least that mental and nerv- 
 ous troubles play an important part in the 
 history of the menopause. This relation is in 
 many cases a merely accidental one, and it 
 does not appear that any one has demon- 
 strated or even tried to demonstrate that 
 there were specific lesions peculiar to the in- 
 sanity which occurs at this period. Without 
 doubt the mind and nervous system are at 
 this time in a state of unstable equilibrium, 
 as was observed in one of the preceding para- 
 graphs, especially in the case of nervous 
 and supersensitive women, and it is easy to 
 understand that an existing lesion might at 
 such time be intensified or a weak mind be 
 thrown entirely off its balance. 
 
 The relations of the ovaries to the mental
 
 218 THE MENOPAUSE. 
 
 condition were at one time supposed to be 
 so intimate that Goodell,* Battey, and others 
 anticipated that they would be able to cure 
 insanity in general by the removal of those 
 organs irrespective of their apparently healthy 
 or diseased condition. 
 
 Such theories were soon found to be futile 
 in practice, and the theory and practice were 
 both quickly abandoned. 
 
 Rohe has shown, however, by a not in- 
 considerable experience, that if mental disease 
 coexists with decided lesions of the ovaries 
 the removal of the latter may be of service in 
 relieving the former.f 
 
 LESIONS OF THE SKIN WHICH MAY ACCOMPANY 
 THE MENOPAUSE. 
 
 Common Lesions of the Skin during the 
 Menopause. There are certain well-marked 
 lesions of the skin which are of common oc- 
 
 * Transactions of the Pennsylvania Medical Society, 1881, 
 xiii, Part II, p. 638. 
 
 f For further testimony upon this interesting question 
 one may refer to Braxton Hicks, Medical Times and Gazette, 
 1877, i, p. 411; Barnes, Lancet, 1, 1873, p. 585.
 
 PHENOMENA OF THE MENOPAUSE. 219 
 
 currence in the history of the menopause. 
 The blushing or erythema which comes and 
 goes so frequently and mysteriously, and 
 which has already been referred to with suffi- 
 cient definiteness, may be considered the most 
 striking member of this group, while less 
 noteworthy is the pronounced pallor which is 
 observable in the anaemic cases. 
 
 Rohe's * observations upon this subject 
 are of great interest and demonstrate the 
 great variety of skin affections which may oc- 
 cur while the menopause is in progress. 
 
 Pigmentation, etc. Grelletyf reports a 
 peculiar case in which dark pigment discol- 
 ored the entire cutaneous surface of a woman 
 of fifty-seven whose menses ceased at fifty- 
 five, the exudation into the skin apparently 
 taking the place of the customary menstrual 
 flow. The same author has observed pseudo- 
 lipomata, chronic oedema, and numerous erup- 
 tions indicating disturbance of the circulation. 
 
 * American Journal of Obstetrics, 1888, p. 1094. 
 t Wood's Medical and Surgical Monographs, vol. Hi, July, 
 1889, p. 1.
 
 220 THE MENOPAUSE. 
 
 Martineau * lias also observed deposits of 
 pigment and glandular disorders, chloasma, 
 etc. 
 
 Similar phenomena have been observed 
 and recorded by Kaposi, Brett, Cazenave, 
 Hardy, Guibout, Rayer, Leroy de Meri- 
 court, Grisolle, and Brierre de Boismont. 
 
 Eczema Genitalium. Deligny is quoted 
 by Grellety f as responsible for the opinion 
 that eczema genitalium was almost peculiar 
 to the menopause. 
 
 Such an opinion does not correspond, 
 however, with the experience of the author, 
 this disease having been observed by him at 
 nearly every period of life, as well when the 
 menses were present as when they were sup- 
 pressed or had been superseded. It has been 
 observed by him many times in a very aggra- 
 vated and troublesome form in old women 
 many years after the cessation of the men- 
 strual now. 
 
 Skin Lesions upon the Breasts. The skin 
 
 * Diseases of the Uterus, p. 104. 
 f Concours Medical, April 14, 1888.
 
 PHENOMENA OF THE MENOPAUSE. 221 
 
 upon the breasts is occasionally the seat of 
 most annoying pruritus during the progress 
 of the menopause, and neuralgia or mastodyn- 
 ia may be associated with it. Paget's dis- 
 ease of the nipple may begin at this period of 
 life, but in most cases it comes at a more ad- 
 vanced age. 
 
 In addition to the foregoing there is quite 
 a mass of other literature which is devoted 
 to this subject, which has been contributed by 
 Alibert, Danlos, Jacquemier, Courty, and 
 Potain. 
 
 Lesions of the skin may therefore be re- 
 garded as among the essential phenomena of 
 the menopause, though it is important to 
 differentiate those which are closely asso- 
 ciated from those which are merely acci- 
 dental. 
 
 LESIONS OF OTHER PARTS OR ORGANS. 
 
 Incidental Relationships to the Meno- 
 pause. It will be evident from the foregoing 
 remarks that the relation between the meno- 
 pause and diseases of the nervous system and
 
 222 THE MENOPAUSE. 
 
 the skin is often very intimate, and the rela- 
 tionship must be closely studied in order to 
 conduct the menopause to the most favorable 
 issue possible. 
 
 There are other lesions in which the rela- 
 tionship to the menopause is not so intimate, 
 in which, moreover, it is apparently acci- 
 dental or incidental, but in which it is also 
 sufficiently prominent to excite attention and 
 call for consideration in connection with this 
 discussion. 
 
 In a previous chapter this matter has 
 been alluded to in some of its bearings. 
 Asthenopia has been occasionally observed in 
 women who were passing through the meno- 
 pause, these women having been free from 
 this trouble prior to the menopause, and ex- 
 periencing relief from the same when the 
 menopause was terminated. 
 
 Higgins * has reported nine such cases in 
 women between the ages of forty-four and 
 fifty. 
 
 * British Medical Journal, 1878, ii, p. 557.
 
 PHENOMENA OF THE MENOPAUSE. 223 
 
 Stolz * has recorded his observation of 
 the peculiar tendency of women passing 
 through the menopause to vomiting, dyspep- 
 sia, jaundice, constipation, haemorrhoids, rheu- 
 matism, asthma, and bronchitis. 
 
 Cardiopathies. Cardiopathies are of fre- 
 quent occurrence during this period, as might 
 be expected in view of the vascular lesions 
 which are so common, and which have been 
 referred to heretofore. 
 
 While there is no particular reason for 
 supposing that lesions de novo are excited by 
 the processes which are in course of develop- 
 ment, there is ground for the belief that pre- 
 existing lesions are sometimes intensified, 
 somewhat as is the case during pregnancy, 
 though not from the same causes and condi- 
 tions, of course. 
 
 Clement f divides the Cardiopathies of the 
 menopause into two groups : 
 
 1. Those which exhibit all the symptoms 
 
 * Nouveau Dictionnaire de Medecine et de Chirurgie 
 Pratique, sub Menstruation, 
 t Lyon Medical, 1884, p. 433.
 
 224 THE MENOPAUSE. 
 
 of profund perturbation of the cardiac func- 
 tion with no physical signs of valvular le- 
 sions. 
 
 2. Those in which there are signs of val- 
 vular trouble, which is first seen during the 
 menopause and, as Clement believed, under 
 its influence. 
 
 In none of the cases which has been seen 
 by the author was there previous history 
 of heart disease or rheumatism. The promi- 
 nent symptoms in these cases were palpita- 
 tion, dyspnoea, syncope, and weak pulse, the 
 latter running from 150 to 160 beats per 
 minute. 
 
 These symptoms recurred in paroxysms. 
 Similar phenomena have been observed by 
 Kisch, Groedel, Moon, and Stokes.* 
 
 Tachycardia has been observed by Bald- 
 win^ and he believes this symptom is espe- 
 cially liable to occur when the menopause is 
 artificially induced. 
 
 Other Lesions which are probably attribu- 
 
 * Diseases of the Heart and Aorta. 
 
 t Brooklyn Medical Journal, 1895, ix, p. 698.
 
 PHENOMENA OF THE MENOPAUSE. 225 
 
 table to Old Age. In addition to the lesions 
 referable to the heart there have been ob- 
 served in the cases which are under con- 
 sideration an increase in the excretion of 
 carbonic acid, deposits in the urine of phos- 
 phates, carbonates, sulphates, and uric acid, 
 ptyalisin, diarrhoea, an engorged portal circu- 
 lation, and jaundice. If this series of symp- 
 toms may seem somewhat incoherent, it is 
 vouched for, nevertheless, by some of the 
 most distinguished observers of the last gen- 
 eration. 
 
 Other lesions which have been attributed 
 to the influences of the menopause, but which 
 would seem to the author to be due rather 
 to the degenerative changes which accom- 
 pany the onset of old age, are atrophy of 
 the spleen, the lymphatics, Peyer's patches, 
 thickening of the boundaries of the lymph 
 spaces, etc. 
 
 Changes in glandular activity in general 
 may be expected at this period of physical 
 development, increased activity being soon 
 followed by a diminution of the same. 
 
 16
 
 226 THE MENOPAUSE. 
 
 From the kidneys more uric acid and 
 phosphates are eliminated, and albuminuria 
 may be present without necessarily imply- 
 ing serious lesion of the kidneys. 
 
 Increased Susceptibility to Disease at the 
 Menopause calls for Increased Watchfulness 
 on the part of the Physician. The function 
 of the lungs may also be deranged. In a 
 word, while it is quite possible that a woman 
 may pass out of the childbearing period with 
 no symptoms which could disturb her or give 
 her serious inconvenience, it is equally pos- 
 sible that during the same period she might 
 be the subject of a great variety of troubles. 
 These troubles are not necessities, inevitables, 
 but they are seen with sufficient frequency 
 among civilized and highly bred women to 
 make it incumbent upon the careful physician 
 to keep a watchful eye upon his patients who 
 are approaching the menopause, and to re- 
 member the increased susceptibility to dis- 
 ease which accompanies that period.
 
 PHENOMENA OF THE MENOPAUSE. 227 
 
 ADDENDA. 
 
 GROS. Rheumatism at the Menopause and cure 
 with the Waters of Lamalou 1'Ancien. Nice Medical, 
 1883-'84, viii, 17-22. 
 
 GUENAU DE MUSSY. Erotism of the Menopause. 
 Clinique Medical, Paris, 1875, ii, 343-352. 
 
 IVANOFF. On the Great Number of Cases of 
 Dropsy and Jaundice during the Period of the Change 
 of Life. Voyenno-med. Journal of St. Petersburg, 
 1883, cxlvii, pp. 3, 62, 92. 
 
 JAGGARD. Functional Disorders in connection 
 with the Menopause. Pepper's System of Practical 
 Medicine. Philadelphia, 1886, iv, 432-446. 
 
 BAX. Cessation des regies et sueur de sang chez 
 une hysterique. Gazette des hopitaux de Toulouse, 
 1895, ix, 274. 
 
 MANTOST. Note on Menopausal Polysarcia Ab- 
 dominalis. Medical Age, Detroit, 1895, xiii, 420. 
 
 OLLIVE. The Menopause, its Complications and 
 Treatment. Texas Medical Journal, Austin, 1895-'96, 
 xi, 9. 
 
 BLOOM. Physiological and Surgical Menopause 
 compared. University Medical Magazine, Philadel- 
 phia, 1895, viii, 342. . 
 
 ROHE. The Mental Disturbances of the Climac- 
 teric Period. Maryland Medical Journal, 1895, xxxiv, 
 258. 
 
 KISCH. Die Herzbeschwerden klimakterischen 
 Frauen. Berliner Klinischer Wochenschrift, 1889, 
 xxvi, 1087. 
 
 CONKLIN". Some Neuroses of the Menopause. 
 Transactions of the American Association of Gynas-
 
 228 THE MENOPAUSE. 
 
 cologists and Obstetricians, Philadelphia, 1889, ii, 
 301. 
 
 NELSON. The Beginning of the Menopause. 
 Medical and Surgical Reporter, Philadelphia, 1890, 
 Ixii, 507. 
 
 JOAL. Sur certains Phenomenes de la Meno- 
 pause d'Origine genito-nasale. Congres International 
 d'Otologie et de Laryngologie, Paris, 1889, 347. 
 
 KRISHABEK. Hemorrhagie Linguale a 1'Epoque 
 de la Menopause. Annales des Maladies de 1'Oreille, 
 du Larynx et des org. com., Paris, iii, 38. 
 
 KISCH. Ueber Tachycardie zur Zeit der Meno- 
 pause. Internationale Klinische Rundschau, Wien, 
 1891, xvi, 337. 
 
 COE. Pelvic Suppuration after the Menopause. 
 American Journal of Obstetrics, 1893, xxvii, 421. 
 
 GARAT. Influence de la Menopause sur la De- 
 veloppement de la Folie. Paris, 1892, G-. Steinheil, 
 pp. 103. 
 
 ELIOT. Disorders of the Nervous System Asso- 
 ciated with the Change of Life. American Journal 
 of the Medical Sciences, 1893, cvi, 292. 
 
 SAVAGE. Some Mental Disorders associated with 
 the Menopause. Lancet, 1893, ii, 1128. 
 
 CAMPBELL. Flushing and Morbid Blushing. Lon- 
 don, Lewis. 
 
 GEBER. Anomalien der Schweissdriisen und ihrer 
 Function. Ziemssen's Handbuch der speciellen Pa- 
 thologic und Therapie., xiv, Heft 2. 
 
 RICORD. Etude sur les Troubles de la Sensibilite 
 genesique a 1'Epoque de la Menopause. Paris, pp. 45, 
 1879. 
 
 UNITED STATES CENSUS, 1890. Statistics of
 
 Women who became Insane during the Decade from 
 Forty to Fifty. 
 
 PAGES. De la Menopause et de son Influence dans 
 la Production de 1'Alienation Mentale. Paris, 1872. 
 
 WERTH. Entstehung von Psychosen im Gefolge 
 von Operationen am weiblichen Genital apparate. Ver- 
 handlungen des Deutschen Gesellschaft fiir Gynakolo- 
 gie. Zweiter Congress, 1888. 
 
 BRUANT. De la Melancolie survenant a la Meno- 
 pause. Gazette Medicale, February 14, 1891, p. 81. 
 
 WILLETTE. Etude sur les Accidents Nerveux de 
 la Menopause. Paris, 1877. 
 
 EXGELMANN. The Hystero-neuroses. Transac- 
 tions of the American Gynaecological Society, ii, 483, 
 and xiii, 332. 
 
 HEGAR. Der Zusammenhang der Geschlechts- 
 krankheiten mit Nervosen Leiden und die Castration 
 bei Neurosen. Stuttgart, 1885. 
 
 KISCH. Die Nervosen Leiden der Frauen im Kli- 
 makterischen Alter. Wiener Medicinische Presse, 1876, 
 xvii, 600. 
 
 PETIT. The Relations of General Paralysis in 
 Women to certain Disorders of Menstruation. Gazette 
 Medicale, February 23, 1889.
 
 CHAPTER V. 
 
 THE PEEMATUEE MENOPAUSE. 
 
 Definition. By this term is meant that 
 variety or form of the menopause which takes 
 place more or fewer years in advance of the 
 time when it would be expected to occur as a 
 natural and looked for experience. It is im- 
 material to our present purpose whether this 
 end is accomplished with or without the in- 
 tervention of art. 
 
 Great Importance of ih# Subject resulting 
 from the Development of Q-ync&cology. The 
 development of the science of gynsecology has 
 given this feature of our subject an impor- 
 tance and interest which it never had before. 
 It has opened entirely new fields for observa- 
 tion and discussion, and while it is true that 
 the menopause often occurred prematurely 
 before it came to be produced artificially and 
 
 230
 
 THE PREMATURE MENOPAUSE. 231 
 
 intentionally, it seems to have excited little 
 attention, and its relations to the normal pro- 
 cess were seldom if ever made a matter for 
 thoughtful consideration and comment. 
 
 Premature Menopause Unnatural. The 
 premature occurrence of the menopause is 
 unnatural, and is therefore the evidence or the 
 result of disease or fault. 
 
 Like the Natural Process its Phenomena 
 vary. It may resemble the natural process 
 in that no noteworthy incident may accom- 
 pany it ; again it may show all the vagaries 
 which are encountered when the menopause 
 comes at the time of life when it is usually 
 looked for. Temperament and surroundings 
 have much to do with it, just as they have 
 with the mature process. 
 
 Involvement. The disease which will in- 
 duce the early occurrence of the menopause 
 may be constitutional or local ; it may involve 
 primarily the nervous system, the vascular 
 system, the lungs, the kidneys, the glands, 
 the genital apparatus collectively, or only a 
 portion of the latter. Climate has a potent
 
 232 THE MENOPAUSE. 
 
 influence in the matter, so have heredity, 
 habit, and function. 
 
 Effective Causes. Those who live in the 
 tropics and mature early reach the menopause 
 early also, though this rule has many excep- 
 tions. The same causes are not always similarly 
 effective in producing the end in question 
 in other words, the individual factor in the 
 case is an important one. 
 
 Menstruation often Independent of In- 
 tegrity of the Ovaries. It is often a matter 
 of astonishment that the sexual organs in 
 women can be so thoroughly diseased with- 
 out producing the termination of the men- 
 strual function, and sometimes without even 
 disturbing its regularity. It is certainly an 
 evidence that menstruation is not necessarily 
 dependent upon integrity of the ovarian 
 stroma, perhaps not upon the stroma at all, 
 for its continuance or termination, the nexus 
 being in all probability in the vascular and 
 nerve relationships. 
 
 Influence of Wasting Diseases. Pre-emi- 
 nent among the constitutional disorders and
 
 THE PREMATURE MENOPAUSE. 233 
 
 derangements which cause an early meno- 
 pause may be mentioned the wasting diseases, 
 and of these tuberculosis is first in impor- 
 tance. There are some tuberculous women 
 who have never menstruated at all ; there are 
 others who are regular at the beginning of 
 their menstrual history, and when the disease 
 gets well under way either stop menstruating 
 abruptly or after a series of irregular recur- 
 rences. 
 
 Amenorrlicea may be Conservative. It is 
 useless to try and restore the menstrual func- 
 tion in such cases. It is often attempted, es- 
 pecially because the patients are wont to be- 
 lieve that with its restoration will come an 
 improvement in their general condition. This 
 idea is entirely erroneous, the cessation of 
 bleeding being an attempt on the part of Na- 
 ture to ameliorate the condition of those who 
 have no blood to spare. 
 
 Various factors which induce Prema- 
 ture Menopause. An early menopause is also 
 not infrequent with those whose lives have 
 been irregular and characterized by excesses
 
 234 THE MENOPAUSE. 
 
 of various kinds, like prostitutes, with those 
 who have suffered from poverty, or whose 
 lives have been embittered by grief, sorrow, 
 or disappointment. Other causes are syphilis, 
 the amyloid disease (Klob), various poison- 
 ous substances, phosphorus, alcohol, arsenic, 
 opium, mercury, and ergot, acute diseases in- 
 cluding typhus, typhoid, intermittent, remit- 
 tent, and yellow fevers, septicaemia, and the 
 acute exanthemata. 
 
 Excessive sexual indulgence will likewise 
 hasten it. 
 
 The foregoing are conditions in which a 
 relation of time, at least, coexists with the 
 menopause ; the relation of cause, evident in 
 some cases, is not clearly demonstrable in all. 
 
 It may be affirmed, however, that in so 
 far as these conditions impair nutrition they 
 tend to produce the result in question, the 
 blood current in the pelvic region being 
 feeble in volume and tension. 
 
 Obesity induces the Menopause. Another 
 class of women with whom the menopause 
 comes early includes those who are very fat.
 
 THE PREMATURE MENOPAUSE. 235 
 
 This has not been generally recognized in 
 medical writings, but has been observed by 
 the author many times.* Fat women are 
 physically inferior in many respects : they 
 suffer with scanty and painful menstruation, 
 and they are very often sterile. 
 
 Premature Menopause in tlie Excessively 
 Fertile. Women who begin to bear children 
 early, and have five, six, or more in rapid suc- 
 cession, often have an early menopause. The 
 reproductive force in such cases is exhausted. 
 This is especially noteworthy in women 
 whose lives are monotonous with continued 
 and severe labor. Kisch, Kriiger, and Mayer 
 have made the same observation. (See also 
 Chapter III, page 136.) 
 
 Venereal Diseases causing the Meno- 
 pause. Diseases which involve the integrity 
 of the genital organs may hasten the meno- 
 pause. Mention has already been made of 
 syphilis and excessive sexual indulgence ; 
 
 * See author's paper on The Influence of Obesity on Men- 
 struation and Reproduction in Young Women. Medical 
 News, 1888, p. 172.
 
 23G THE MENOPAUSE. 
 
 to these should be added gonorrhoea, which 
 is responsible for a very large portion of the 
 severe inflammatory disease of the entire 
 genito-urinary apparatus. 
 
 General Condition of the Nutrition one of 
 the Principal Factors in Menstruation. It is 
 the depraved nutrition of the body in general 
 rather than the local disease itself, be it of 
 the uterus, tubes, or ovaries, which hastens 
 the menopause, for, as has already been re- 
 marked, the ovaries may be entirely disor- 
 ganized, as far as their normal structure and 
 relations are concerned, the tubes may be 
 mere sacs of pus or dense masses of connec- 
 tive tissue, and the uterus may be entirely 
 transformed as to the structure of its endome- 
 trium, so that the formation of a decidua 
 would be impossible, and yet menstruation 
 may continue without interruption. 
 
 PREMATURE MENOPAUSE RESULTING FROM 
 TRAUMATISM. 
 
 Menopause from Injuries. Of course it 
 is possible that injuries may be received in
 
 THE PREMATURE MENOPAUSE. 237 
 
 various parts of the body wounds, bruises, 
 etc. the influence of which may be reflected 
 to the pelvic organs and determine the cessa- 
 tion of the menstrual function. Especially 
 would this be possible if such injury were 
 followed by prolonged illness, prolonged sup 
 puration, or wasting and emaciation. 
 
 Menopause from Sequelce of Parturition. 
 There are also not a few cases in which 
 the menopause results in consequence of 
 severe injuries attending parturition ; for in- 
 stance, cases in which labor has been pro- 
 longed, and sloughing and loss of tissue have 
 resulted, or in which the same results have 
 followed severe obstetrical operations. Those 
 cases are less frequent than they used to be, 
 thanks to the benign influence of modern 
 gynaecology, for the development of that sci- 
 ence has necessitated development, pari passu, 
 in the science and art of obstetrics. 
 
 Menopause surgically induced. The trau- 
 matisms to which especial attention is in- 
 vited are those which are intentionally pro- 
 duced by the surgeon upon the uterus, tubes,
 
 238 THE MENOPAUSE. 
 
 or ovaries, or all of them, with the knowledge 
 and often with the desire that the menopause 
 should result. 
 
 This aspect of our subject was not con- 
 sidered by Tilt and others who have written 
 upon it, for the very good reason that such a 
 short cut to the menopause was never heard 
 of by them. 
 
 Jfegar, Battey, and Tail. It is a chapter 
 in the history of surgery which reflects the 
 greatest credit upon three names Hegar, 
 Battey, and Tait and has been the means 
 of conferring health and happiness upon 
 thousands of suffering women. These three 
 names are referred to in particular, because 
 these men saw the inestimable advantages 
 which were to be obtained by certain suf- 
 fering women if the menopause were in- 
 duced, while the handful of ovariotomists, 
 including McDowell, Clay, Keith, Wells, 
 Peaslee, Baker Brown, Sims, and a few 
 others, did their noble work solely or main- 
 ly with the idea of saving life. All honor 
 to them for their genius, their skill, their
 
 THE PREMATURE MENOPAUSE. 239 
 
 humanity, which often produced their grand 
 results in defiance of persecution and oblo- 
 quy, and finally disarmed their opponents 
 through the unimpeachable testimony of a 
 great cloud of witnesses rescued from dis- 
 ease and death ! 
 
 CLAIMS OF BATTEY AND HEGAK AS TO PEIOK- 
 ITY IN SUGGESTING THE ARTIFICIAL PttO- 
 DUCTION OF THE MENOPAUSE. 
 
 The idea of the inestimable value of the 
 induced menopause occurred to Battey in this 
 country and Hegar in Germany independent- 
 ly of each other and at about the same time. 
 
 Hegar states* that he performed his first 
 castration f July 27, 1872, for the relief of 
 intolerable dysmenorrhoea and ovarian neu- 
 
 * Handbook of General and Operative Gynaecology. Cy- 
 clopaedia of Obstetrics and Gynaecology, vol. vi, p. 294. 
 
 t The Germans use this ungainly term to signify the opera- 
 tion for removal of the ovaries. Etymologically it may be 
 correct enough, for it means cutting or pruning. Pliny was 
 the first to use the term, so far as can be ascertained, and it 
 does not appear that Pliny's use of it when applied to animals 
 differs from that to which we are accustomed, namely, the re- 
 moval of the testicles.
 
 240 THE MENOPAUSE. 
 
 ralgia, his patient dying of septic peritoni- 
 tis. Battey's first operation was performed 
 August 17, 1872, his express purpose being 
 the induction of the menopause. 
 
 Influence of the different Genital Organs 
 in the Induction of the Menopause. In the 
 majority of cases the removal of the ovaries 
 is sufficient to produce the menopause. Tait 
 laid great stress upon the importance of the 
 simultaneous removal of the tubes ; but Bat- 
 tey, who carefully followed for many years 
 the clinical history of the women upon whom 
 he operated, found no advantage in such re- 
 moval as far as its influence in producing the 
 menopause w T as concerned. In some cases, es- 
 pecially those in which troublesome tumors 
 of the uterus were present, the menopause has 
 not resulted until the uterus was removed. 
 
 INDICATIONS FOR THE ARTIFICIAL PRODUCTION 
 OF THE MENOPAUSE. 
 
 Cases for Induction of the Menopause 
 should he selected with Great Care. Battey 
 has well said that there is need of the great-
 
 THE PEEMATUEE MENOPAUSE. 241 
 
 est care in the selection of cases for the pro- 
 duction of the menopause if the existence of 
 extensive lesions in the uterus or its append- 
 ages is wanting. Doubtless very many mis- 
 takes have been made in this particular by 
 men of good intentions, and the lines are not 
 yet so clearly drawn as to enable one to say 
 precisely what cases require or will be bene- 
 fited by operation and what ones will not. 
 The table of indications which is given is 
 therefore provisional and may require modi- 
 fication. 
 
 1. All cases in which there is extensive 
 inflammatory disease of the ovaries or tubes, 
 or both. If the tubes are removed the ova- 
 ries should be removed also, for, the tubes 
 having been removed, the functional power 
 of the ovaries is practically destroyed. If a 
 portion of ovarian tissue seems intact, it will 
 be better practice in the majority of cases, 
 notwithstanding, to remove the entire organ. 
 Resection ,has been advocated and practiced 
 by numerous gynaecologists, but disease is 
 
 prone to recur in the fragment which was 
 
 17
 
 24-2 THE MENOPAUSE. 
 
 retained and a secondary operation is fre- 
 quently required. 
 
 2. All cases in which the ovaries or tubes 
 are the seat of new growths, whether benign 
 or malignant. A tumor in the pelvis, of 
 whatever size, is always a menace to life 
 and health. 
 
 3. Cases in which ovarian neuralgia and 
 dysmenorrhoea have become intolerable, es- 
 pecially if occurring in women who depend 
 upon their own exertions for their living. 
 The author has had no cases which have 
 given him more pleasing and satisfactory re- 
 sults than these, but it is just this class of 
 cases about which opinions are most likely 
 to differ. Withholding an operation from 
 a woman who suffers intensely on the plea 
 that she will be unable to bear children is 
 unworthy of serious consideration. In the 
 majority of cases, if such women were able 
 to bear children, the children would be feeble 
 specimens with the poorest possible chances 
 of receiving the care and attention they re- 
 quired.
 
 THE PREMATURE MENOPAUSE. 243 
 
 4. Cases in which Csesarean section has 
 been required and in which it is absolutely 
 impossible for the women to bear children 
 through the natural channels. This will not 
 be deemed good practice by all, especially by 
 those who are fond of doing Csesarean sec- 
 tion. The wishes of the woman in regard to 
 bearing children should have some weight, 
 but the author, for one, can not conscien- 
 tiously urge a woman to run a more or less 
 decided risk of losing her life even to gratify 
 the natural desire for offspring. 
 
 5. Cases of osteomalacia. The results of 
 the operation for this rare disease have been 
 very gratifying. 
 
 6. Cases in which the uterus is the seat 
 of inflammatory trouble or new growth which 
 is the cause of obstinate pain, haemorrhage, 
 or pressure symptoms which can be relieved 
 in no other way. It is not infrequently neces- 
 sary to remove the uterus with the append- 
 ages in such cases. 
 
 Insanity, epilepsy, etc., have been consid- 
 ered an indication by some writers, but the
 
 244 THE MENOPAUSE. 
 
 propriety of such operations is doubtful if 
 the insanity is the result of a brain lesion. 
 Battey had cured but one such case out of 
 five which were reported by him in 1887.* 
 
 THE PHENOMENA OF THE PREMATURE MENO- 
 PAUSE, INCLUDING THOSE WHICH ACCOMPANY 
 OPERATIONS FOR ITS PRODUCTION. 
 
 Menopause may be established Suddenly 
 or Gradually. As already stated (p. 204) 
 the premature menopause may be estab- 
 lished abruptly, without any of the symp- 
 toms which so often indicate the progress 
 of this condition, or it may be characterized 
 by some or all of those symptoms. When it 
 comes as an accompaniment of serious dis- 
 ease tuberculosis, anaemia, chronic visceral 
 diseases the absence of menstruation alone 
 indicates that it has occurred. It is as if 
 the vital forces were all occupied in oppos- 
 ing the march of a deadly enemy. Explo- 
 sions of energy and force which are so com- 
 
 * Transactions of the American Gynaecological Society, 
 1887, p. 253.
 
 THE PEEMATURE MENOPAUSE. 245 
 
 mon when the menopause comes at the usual 
 time are wanting because there is no surplus 
 of energy and force to explode. 
 
 The Phenomena are usually the same as 
 in the Natural Process. There are other 
 cases which are equally without symptoms 
 marked, like those which have just been 
 mentioned, by an abrupt cessation of the 
 menstrual flow and nothing more. Such 
 may be the history of those who have sud- 
 denly become obese, and of some of those 
 from whom the appendages have been re- 
 moved whether the degeneration of the ova- 
 ries be complete or incomplete. With by far 
 the greater number of women, however, the 
 history is that of women who are going 
 through the menopause at the ordinary 
 period of life. But if the appendages have 
 been removed the bleeding, if it recurs at all, 
 usually lasts but a short time, other symp- 
 toms such as flashes of heat and various nerv- 
 ous and vascular phenomena continuing for 
 varying periods of time. 
 
 The removal of the Uterus may be re-
 
 246 THE MENOPAUSE. 
 
 quired to induce the Menopause. There are 
 some cases of bleeding fibroid of the uterus 
 in which removal of the ovaries does not 
 cause cessation of the haemorrhage, and for 
 such the removal of the uterus may become 
 an ultimate necessity. 
 
 The changes which occur after the ova- 
 ries have been removed have been systemat- 
 ically investigated by Glaevecke,* also the 
 changes in the organism after the removal 
 of the uterus. After the ovaries were re- 
 moved Glaevecke found that menstruation 
 ceased in 88 per cent of cases either at 
 once or after an interval, in the remaining 
 12 per cent the flow became scanty and 
 irregular. Substitutional haemorrhages (ato- 
 pomenorrhoea) in other parts of the body 
 were of rare occurrence. In 50 per cent of 
 the cases menstrual molimina continued after 
 the cessation of the flow. Flushing, vertigo, 
 irregular sweating, leucorrlicea, etc., were of 
 common occurrence, also atrophy of the gen- 
 
 * Archiv ftir Gynakologie, xxxv, 1.
 
 THE PREMATURE MENOPAUSE. 247 
 
 ital organs. Even in cases in which the 
 uterus was enlarged by chronic endometritis 
 or fibroids it returned to its original size or 
 atrophied in most of the cases. The general 
 condition improved in most of the cases, 
 and in 42 per cent the women became 
 obese. Sexual desire was usually diminished 
 and in some cases it was extinguished. Psy- 
 chical disturbances, including melancholia, 
 were sometimes very prominent. It was be- 
 lieved that the artificial menopause was exactly 
 similar to the natural one. In cases in which 
 the uterus was extirpated the menstrual flow 
 ceased, but in some cases the molimina con- 
 tinued a few months, probably as the result 
 of recurring pelvic congestion. If the ova- 
 ries were not removed with the uterus they 
 atrophied, though it was believed that ovula- 
 tion continued until the menopause was con- 
 cluded. The effect upon the body in general 
 of removal of the uterus alone was not so 
 profound as from the removal of the ovaries, 
 and sexual feeling was rarely changed. In 
 half the cases there was no psychical dis-
 
 248 THE MENOPAUSE. 
 
 turbance, but in a third of them there was 
 depression tending to melancholia. 
 
 To these opinions, which evidently re- 
 sulted from careful and sufficiently extensive 
 investigations and with which the author's 
 experience has not brought him entirely into 
 harmony, may be added the conclusions of 
 Battey after fifteen years' careful observation 
 of his own cases.* 
 
 Of the 54 cases operated upon by him, 
 33 were cured, 8 much improved, 5 little 
 improved, 8 not improved. In 50 cases the 
 menopause resulted, in 4 it did not.f 
 
 In almost all cases he believed that pa- 
 tients must pass through the varying experi- 
 ence of the menopause before the full benefit 
 of the operation would be obtained, and this 
 might require as long a time as three or even 
 
 * See Transactions of the American Gynaecological So- 
 ciety, 1887, p. 253. 
 
 f It is to be remembered that the express object which 
 Battey has in view in all the cases upon which he has operated 
 is the production of the menopause. It is this which he be- 
 lieves will work the cure in cases which are curable by such 
 an operation.
 
 THE PREMATURE MENOPAUSE. 249 
 
 five years. Much would also depend upon a 
 judicious selection of cases ; of course, some 
 patients would be incurable by any opera- 
 tion, and this would include some who had 
 long been subject to vicious habits, to the use 
 of alcohol, chloral, opium, etc. 
 
 He observed that in some cases there was 
 an intractable pelvic neuralgia following the 
 operation, which he thought was caused by 
 pressure of the unabsorbed ligature upon the 
 stump. This phenomenon has been observed 
 by others, the author included, but the au- 
 thor thinks that this condition is by no means 
 universally attributable to such a cause. 
 Many such cases were formerly treated by 
 him with electricity, with relief to the pain, 
 at least for the time. The discouraging part 
 of such treatment is the length of time dur- 
 ing which it must be employed. Both pa- 
 tient and physician become weaiy of its use. 
 
 Battey did not believe that the removal 
 of the Fallopian tubes had any influence 
 upon the final result, either with reference to 
 the establishment of the menopause or in the
 
 250 THE MENOPAUSE. 
 
 final cure of the disease, except in so far as 
 the tubes themselves were the seat of disease. 
 In this respect he took issue with Tait, who 
 regarded the tubes as the essential organs of 
 menstruation aside and apart from their func- 
 tion as oviducts. 
 
 Important observations upon this subject 
 of the changes which follow the removal of 
 the ovaries have also been made by Hegar.* 
 He called attention to the fact that the gen- 
 eral structure of the body, pelvis, breasts, ex- 
 ternal genitals, sexual desire, and the mode 
 of feeling are independent of the ovaries or 
 only relatively dependent on them. 
 
 In young female animals spaying is fol- 
 lowed by a more quiet temperament than 
 ordinarily exists, a tendency to the deposit of 
 fat, and cessation in the growth of all parts 
 of the genital apparatus. He also made the 
 very reasonable suggestion that one must not 
 be disappointed if the menopause did not re- 
 sult at once in women with whom the habit 
 
 * Operative Gynaecology. Cyclopaedia of Obstetrics and 
 Gynaecology, vol. vi, p. 291.
 
 THE PREMATURE MENOPAUSE. 251 
 
 of menstruation had existed many years with 
 the recurrent molimina and turgescence of 
 organs and tissues. He also admitted the 
 possibility of the blending of the sexual 
 types, with growth of hair upon the face, 
 deeper voice, change of ideas, and of the men- 
 tal and emotional life. This, just as in cer- 
 tain animals there were analogous changes, 
 the peahen assuming the feathers and ap- 
 pearance of the male after ovulation had 
 ceased, and the antlers of the doe becoming 
 better developed. But Hegar avowed that 
 he had never seen the assumption of this 
 masculine type in those whose ovaries had 
 been removed. With this experience of He- 
 gar's the author concurs, and it would seem 
 to him that if the condition in question were 
 ever to occur it would be in the case of 
 women whose ovaries were removed at a 
 time remote from that in which the meno- 
 pause would under ordinary conditions take" 
 place. 
 
 It is an agreeable thought that with many 
 women beauty becomes more pronounced
 
 252 THE MENOPAUSE. 
 
 with advancing age ; coarseness of features is 
 an event far from common in its occurrence 
 with those whom we have known and loved, 
 and we readily admit that the type of beauty 
 is not that of youth. 
 
 The Menopause is Premature when occur- 
 ring Prior to the Fortieth Year. The au- 
 thor's experience with those who have reached 
 the menopause prematurely has not been in- 
 considerable, either in public or in private prac- 
 tice, and it extends over a period of more 
 than sixteen years. In the class of cases 
 which has come under his observation in the 
 city of New York and its surroundings he 
 has been accustomed to regard the meno- 
 pause as premature if it occurred prior to the 
 fortieth year. 
 
 Of those who have reached it as the re- 
 sult of wasting disease the rule has been, as 
 already stated, that the only prominent symp- 
 tom was the cessation of menstruation. 
 
 Tlie Obese suffer considerably, as a Rule. 
 The obese who have suffered with dys- 
 menorrhcea and sterility, and the obese who
 
 THE PREMATUKE MENOPAUSE. 253 
 
 have become so after bearing a large family 
 of children, almost invariably suffer with the 
 vasomotor troubles, to which attention has so 
 frequently been called. Several cases have 
 been observed in which an early menopause 
 was reached, the patients being unconscious 
 that it had taken place ; the fact was casually 
 determined while investigating the condition 
 of the patient for other troubles. 
 
 Removal of the Appendages of One Side 
 does not induce the Menopause. A great 
 number of cases has been seen in which 
 the menopause has followed removal of the 
 uterine appendages, and the observation of 
 these cases has been continued during months 
 and years. They have included not only the 
 author's cases, but those of numerous other 
 surgeons. The following phenomena have 
 been observed : If the appendages from only 
 one side have been removed the menopause 
 has never been observed to occur, and symp- 
 toms which have been attributable to the 
 functional activity of the ovaries (e. g., uter- 
 ine haemorrhage) have not been alleviated by
 
 254 THE MENOPAUSE. 
 
 the removal of one ovary, even though that 
 might be seriously diseased. 
 
 The Menopause may be deferred even 
 though both Ovaries be Removed. If the 
 appendages of both sides have been thor- 
 oughly removed the menopause has invari- 
 ably occurred, excepting in cases of uterine 
 myoma adherent to surrounding structures 
 in which activity and vascularity were con- 
 tinued through this adventitious relation.* 
 
 Concerning Supernumerary Ovaries. 
 Much has been said at various times about 
 the existence of supernumerary ovaries. The 
 author has been skeptical as to their exist- 
 ence, or rather as to their functional power. 
 
 * An exception has recently occurred in the author's prac- 
 tice. A woman twenty-six years of age was operated upon 
 by the author in June, 1890, for ruptured tubal pregnancy. 
 Both ovaries and tubes were removed as thoroughly as pos- 
 sible. The patient has menstruated ever since with perfect 
 regularity until four months ago, when menstruation failed 
 to appear and has remained in abeyance. She also has most 
 marked vasomotor phenomena, and is apparently experi- 
 encing the menopause. She returned to the author on ac- 
 count of an enormous ventral hernia, which was operated 
 upon, and nothing found in the pelvis to indicate that the 
 previous operation had been defective.
 
 THE PREMATURE MENOPAUSE. 255 
 
 At the last meeting (1896) of the American 
 Gynaecological Society cases were narrated in 
 which total extirpation of the appendages was 
 supposed to have been performed, and the 
 operations were followed by pregnancy and 
 delivery at term. This is rather staggering 
 to one's cherished convictions. The dilemma 
 which is offered is that a supernumerary 
 ovary existed, with, of course, some commu- 
 nication with the stump of the tube, or that 
 the operations in question were defective and 
 incomplete. In any event, it is difficult to 
 see how an opening could be made in the 
 stump of the tube, and at the proper place, 
 for the ingress of an escaped ovum. 
 
 Arthur Johnstone offers a solution to the 
 riddle in the statement that the Fallopian 
 tubes have accessory ostia, and that one or 
 more of them may reopen in the stump, espe- 
 cially if the tube were ligated with catgut. 
 
 Of the two cases reported by Gordon at 
 the meeting in question the first can be 
 readily dismissed, the evidence being entire- 
 ly inconclusive that both ovaries had been
 
 256 THE MENOPAUSE. 
 
 removed. In the second, in which the ap- 
 pendages were removed by Gordon, the ex- 
 planation of the pregnancy is not easy. 
 
 In the great majority of cases the month- 
 ly bleeding has ceased at once ; in some cases 
 it has continued a few months ; in none, with 
 the exception of myomatous cases, has it per- 
 sisted as long as a year after the opera- 
 tion.* 
 
 Atrophy of the uterus is considerable in 
 most cases within a year from the operation. 
 This is especially noticeable in middle-aged 
 women. In young women, especially in the 
 married and in prostitutes, atrophic changes 
 are much less marked. 
 
 The author has never seen but one case 
 in which any domestic unhappiness had been 
 caused by the so-called sterilizing operation ; 
 this was in a young and wretchedly poor 
 Russian Jewess who said, with tears in her 
 eyes, some months after her operation, that 
 her husband told her she was " no good " any 
 
 * See also in this connection the statements of Glaevecke, 
 p. 246; also Diihrssen Archiv fur Gynakologie, 1889.
 
 THE PREMATURE MENOPAUSE. 257 
 
 longer, being unable to bear children, men- 
 struate, or respond to his sexual ardor. But 
 the author has often listened to a similar 
 story from women who have not been de- 
 prived of their ovaries. 
 
 Concerning Sexual Desire in its Rela- 
 tions with the Menopause. Much has been 
 said against this operation which is under 
 consideration because of its supposed effect 
 in abolishing the sexual appetite. It is pos- 
 sible that the operation has very little to do 
 with the sexual appetite. A woman who is 
 without sexual ardor prior to an operation 
 will not be likely to acquire it afterward ; 
 the operation does not create the desire. 
 Those who are of ardent disposition will 
 not be likely to lose it by the removal of 
 the ovaries, at least not for months and 
 years. In other words, young women will 
 not be much affected as to their sexual de- 
 sire, middle-aged and old women may lose 
 it, and it is quite proper at such periods of 
 life that they should. 
 
 The author has repeatedly interrogated 
 
 18
 
 258 THE MENOPAUSE. 
 
 prostitutes who had been operated upon, and 
 has never seen one who admitted that the 
 operation had affected her in this respect. 
 He has seen women with whom sexual in- 
 tercourse was the cause of intense pain and 
 dread who were entirely relieved by the op- 
 eration, and were enabled to endure sexual 
 intercourse without pain or dread. He has, 
 on the other hand, seen middle-aged women 
 who said their husbands had ceased to have 
 intercourse with them long before they were 
 operated upon, and had made no attempt to 
 renew the sexual relation after the operation. 
 He would therefore submit that the day has 
 passed for any rational man or woman to 
 urge the sterilizing or unsexing effect of the 
 removal of the ovaries as a valid excuse in 
 cases in which the operation is indicated. 
 This is said with full consciousness of the 
 power of human passion, and of the fact 
 that it is a perfectly natural thing for wom- 
 en to bear children ; but it is also urged that 
 the sole function of a woman is neither the 
 bearing of children, especially if she is unfit
 
 THE PREMATURE MENOPAUSE. 259 
 
 to bear healthy children, nor the gratification 
 of the sexual appetite, and it is a sad com- 
 mentary on human nature and the quality 
 of the love which men have for their wives 
 when the present or prospective inability of 
 the latter to gratify the sexual appetite of 
 the former is held up as an excuse for with- 
 holding from them the advantages of a be- 
 neficent operation. 
 
 Pain and Neuralgia not always Cured 
 by removal of Appendages. In a number of 
 cases a continuance of the pain and neuralgia, 
 which formed an indication for operation, 
 have been observed for a more or less pro- 
 longed period after its performance.* 
 
 This pain has always yielded to the in- 
 fluence of electricity (see page 249), though 
 months of treatment might be required be- 
 fore it was permanently relieved. In most 
 of the author's cases the vasomotor disturb- 
 ances so common with the menopause at the 
 usual period of life were present, but in some 
 
 * See also Battey's remarks upon this subject, p. 248.
 
 260 THE MENOPAUSE. 
 
 of them, especially in very young women, 
 nothing of the kind was complained of. 
 
 Only one case has been observed in which 
 melancholia developed, and this was relieved 
 after treatment which was continued about a 
 year. 
 
 In the great majority of the cases in 
 which the appendages have been removed by 
 the author for salpingitis and ovaritis the re- 
 lief has been prompt, complete, and permanent. 
 
 The Effect of removing the Ovaries prior 
 to Puberty has not been thoroughly investi- 
 gated. The effect of removing the ovaries 
 prior to puberty can not be stated with 
 the definiteness which could be desired, for 
 there is little testimony upon this subject 
 which is available. The indications for such 
 operations are fortunately very few and 
 limited. If we were to reason from the effect 
 of the corresponding operations upon animals 
 we might expect such changes in the struc- 
 ture and bearing of the individuals as would 
 
 O 
 
 render them disagreeably conspicuous among 
 their fellow-beings.
 
 THE PREMATURE MENOPAUSE. 261 
 
 The Changes which occur in Eunuchs are 
 Suggestive. The changes which take place in 
 eunuchs are sufficiently well known, and there 
 is no reason to suppose there would not be 
 analogous changes in females if the ovaries 
 were removed before physical development 
 had been completed. So pelvic congestion 
 having never been established, it would not 
 be within the range of the probable that the 
 changes which accompany its arrest, whether 
 abruptly or gradually, would be observed. 
 Nondevelopinent of the genital structures, 
 the breasts, and the external genitals would 
 be expected, because there would be no func- 
 tional use for such structures.* 
 
 * A case which bears somewhat upon the foregoing oc- 
 curred in the author's practice, and is as follows : The patient 
 was a small, illy-developed girl of fifteen when first seen by 
 the author in 1892. The vagina was absent, but menstrua- 
 tion had been established, causing the development of an 
 abdominal tumor extending nearly to the umbilicus. This 
 tumor was evacuated by an incision through the rectum. 
 Subsequently an opening was torn through the tissue be- 
 tween the rectum and the bladder and drainage effected. 
 After a time the drainage tube was removed, and this was 
 followed by closure of the artificial canal and a reaccumula- 
 tion of menstrual fluid. An abdominal section was then
 
 262 THE MENOPAUSE. 
 
 APPARENT MENOPAUSE OCCURRING 
 PREMATURELY. 
 
 Cases in which Menstruation is Sus- 
 pended, but may Return. In not a few cases 
 in which the menstrual flow is suspended this 
 suspension is only temporary. Attention has 
 already been called to cases in which this was 
 the permanent result of sickness or disease of 
 varying character, in an earlier portion of this 
 chapter. 
 
 In a certain percentage of cases in which 
 no menstruation appears for a number of 
 months Nature will provide for the return of 
 
 performed, the ovaries removed, and in the course of the 
 following two or three months, by a process of dilating and 
 tearing, a substitute for a vagina was constructed about 
 two inches long. After an interval of three years the fol- 
 lowing information was obtained : The patient has had ex- 
 aggerated vasomotor phenomena, flashes of heat and cold, 
 and sensations of perspiration upon her limbs. She has not 
 gained in weight, her breasts are undeveloped, her voice has 
 not changed, there is no hair on her face, and only a slight 
 growth upon the pubes. She has pleasure and satisfaction 
 such as is usual and proper in the society of young men. 
 The vaginal passage is one inch and a half long and tapers to 
 a point. General health excellent.
 
 THE PREMATURE MENOPAUSE. 263 
 
 the flow at the proper time, but in other 
 cases some assistance must be rendered. It 
 would be easy to anticipate a further elucida- 
 tion of this subject by recalling the condition 
 in which the function was only in abeyance 
 for the time, and for the benefit of the stu- 
 dent it may be said that these cases must be 
 carefully distinguished from those in which 
 the cessation is permanent though premature. 
 No unerring rules can be given for determin- 
 ing the one from the other ; each case is sui 
 generis, and must be studied on its own 
 merits. Therefore a strict classification of 
 such cases would be out of the question, and 
 one must be content to mention conditions in 
 which groups of such cases may appear. 
 
 Menstruation may be Suspended a few 
 Months and then return. Allusion has been 
 made (page 137) to the influence which a 
 heavy atmosphere (e. g., during a sea voyage) 
 may have in suspending menstruation, many 
 examples of which are to be seen in New 
 York among our young immigrant women. 
 It has been particularly noticeable among the
 
 264: THE MENOPAUSE. 
 
 Irish and Swedes, usually among the unmar- 
 ried, and especially among those who are 
 anaemic and deficient in vitality. This sus- 
 pension may last several months, perhaps as 
 long as a year, and with the recurrence of 
 vigorous health is almost invariably followed 
 by the return of the flow. In anaemic women 
 in general the temporary cessation of the 
 menses is a desirable incident. It is Nature's 
 call for the accumulation rather than the dis- 
 tribution of blood and blood-making ele- 
 ments. If the call is heeded the result \vill 
 usually be returning health and re-established 
 menstrual function. In these and all other 
 cases of suspended menstruation one must 
 never lose sight of the possibility of the pres- 
 ence of the pregnant state, and must not be 
 beguiled by external appearances or the state- 
 ments of patients. 
 
 In any case of suspended menstruation in 
 which the condition causing it does not lead 
 to a fatal result, whether the cause be any of 
 those which have been mentioned, acute or 
 chronic disease, or traumatism, we must ever
 
 THE PREMATURE MENOPAUSE. 265 
 
 consider the possibility of restoration of the 
 disturbed function. 
 
 Attempts at Restoration may be Futile. 
 In some cases all efforts in this direction will 
 prove futile, in others they will be crowned 
 with success, and the satisfaction in such 
 cases is usually considerable to all who have 
 been concerned with them. It is well enough 
 to state that some cases are quite hopeless, 
 and offer no prospect of any advantage from 
 treatment of any character. Such are cases 
 of great obesity, exhaustion from excessive 
 childbearing or hard work, or excesses in al- 
 cohol and venery, and usually superinvolu- 
 tion ; also the occasional cases in which there 
 is defective development of the genital or- 
 gans, and in which menstruation has never 
 reached the condition of a mature function. 
 
 ADDENDA. 
 
 MONTGOMERY. The Premature Menopause. Med- 
 ical News, 1894, Ixv, p. 461. 
 
 KLEINWACHTER. Ein Beitrag zur Battey-Hegar- 
 'schen Operation. Archiv fur Gynakologie, xvi. 
 
 ODEBRECHT. Ein Beitrag zur Castration des 
 Weibes. Berliner Klinische Wochenschrift, 1881.
 
 266 THE MENOPAUSE. 
 
 HEGAR. Die Castration der Frauen. Leipzig, 
 1878. 
 
 ORMIERE. Sur la menstruation apres 1'Ovariotomie 
 et 1'Hysterectomie. These de Paris, 1880. 
 
 TISSIER. De la Castration de la Femme. These 
 de Paris, 1885. 
 
 TAUFFER. Beitriige zur Lehre der Castration der 
 Frauen. Zeitschrift fiir Geburtshiilfe und Gyniikolo- 
 gie, ix, 1883. 
 
 PROCHOWNIK. Beitriige zur Castrationsfrage. 
 Archiv fiir Gyniikologie, xxix. 
 
 PEAN. De 1'Ablation des Tumeurs du Ventre con- 
 sideree dans ses Eapports avec Menstruation, etc. 
 Gazette Medicale de Paris, 1880. 
 
 KEHRER. Versuche uber Castration und Erzen- 
 gung von Hydrosalpinx. Beitriige zur Klinischen 
 und experimentellen Geburtskunde und Gyniikologie, 
 Band, ii, Heft 3, Giessen, 1887. 
 
 BRUXTZEL. Vier Castrationen. Archiv fiir 
 Gyniikologie, xvi.
 
 CHAPTER VI. 
 
 RETARDED MENOPAUSE. 
 
 THIS term does not refer to those cases in 
 which bleeding at irregular intervals takes 
 place years after the customary flow has 
 ceased. Such cases are not instances of re- 
 tarded menopause, but of disease of the uter- 
 ine structure, and may occur at advanced 
 periods of life, perhaps many years after the 
 regular menopause has occurred. 
 
 Cases of Menstruation prolonged beyond 
 the Fiftieth Year. There are exceptional 
 cases in which menstruation seems to be pro- 
 longed beyond a reasonable limit that is, 
 beyond the fiftieth year for it is clear, as 
 has been already stated, that in temperate 
 climates we may consider the decade between 
 the fortieth and fiftieth years as the period in 
 which the menopause occurs with the great 
 
 267
 
 208 THE MENOPAUSE. 
 
 majority of women. In some families it 
 seems to be usual for the menopause to be 
 deferred beyond the fiftieth year without ap- 
 preciable disturbance to the individual.* 
 
 * An instance of this kind has already been noted in 
 Chapter III, p. 101. 
 
 Petrequin, in an analysis of 60 cases of women who had 
 passed the menopause, found 7 in whom it came between the 
 fiftieth and fifty-fifth years. 
 
 Scanzoni believed that no women menstruate naturally 
 beyond the fifty-third year. 
 
 Mayer (Expose Statistique de la Menstruation dans 1'Alle- 
 magne Septentrionale et Centrale) reports the delayed meno- 
 pause in one women at 60, in 3 at 59, and in 6 at 58. In his 
 analysis of 6,000 cases, most of the women being residents of 
 Berlin, there were 115 who reached the menopause between 
 the ages of 50 and 64. 
 
 J. Kennedy (quoted by Borner, op. cit.) knew of a woman 
 who had a child in her sixty-second year, She began to 
 menstruate at 13, bore her first child at 20, and between that 
 age and 62 had 20 additional children. 
 
 Rodsewitsch (from Borner) collected from Russian litera- 
 ture, between the years 1872 and 1881, 11 cases in which 
 children were born between the ages of 50 and 55. 
 
 Sutherland reports a case (British Medical Journal, ii, 
 1879, p. 774) in which a condition which he supposed to be 
 a renewal of menstruation, after 8 years' cessation, began at 
 the age of 59. 
 
 Orfila is said to have reported the case of a woman who 
 had her first child at 47 and her seventh and last at 60, men- 
 struation continuing until she was 99. 
 
 Mayer has correctly observed that uterine tumors may 
 grow after the menopause has apparently occurred and cause
 
 RETARDED MENOPAUSE. 269 
 
 The author has recently seen and oper- 
 ated upon a woman of sixty-nine who sus- 
 pected a renewal of menstruation on account 
 of profuse haemorrhages. The case was one 
 of carcinoma of the uterus. He has seen 
 other similar cases. 
 
 All cases of haemorrhage from the uterus 
 which occur late in life that is, after the 
 fiftieth year should therefore excite suspi- 
 cion of the existence of malignant disease, 
 and should not be looked upon as a necessary 
 accompaniment of the menopause or as a re- 
 newal of the menstrual function. If this 
 fact is borne in mind many cases may be re- 
 lieved which it has heretofore been the fash- 
 ion to allow to remain untreated. 
 
 uterine bleedings which may be mistaken for a renewal of men- 
 struation. Such tumors may become fibro-cystic or sarcoma- 
 tous and cause irregular bleedings, and this fact has been 
 observed by Tait, Schorler, Borner, Gusserow, and others.
 
 CHAPTER VII. 
 
 TREATMENT. 
 
 Carefulness and Watchfulness requisite. 
 What treatment is indicated for women 
 who are passing through the menopause ? 
 Certainly the old method was radically 
 wrong, which consisted in ignorant inactivity. 
 To this extent it may be admitted that the 
 period of the change of life is a critical time 
 namely, that it is a time to be watchful 
 and active. That eternal vigilance which is 
 the price of liberty may also serve a very 
 good purpose in making one always prepared 
 for any mishap which may occur during the 
 menopause. 
 
 Glasses of Women with whom the Meno- 
 pause should be Uneventful. The author be- 
 lieves, as he has already asserted, that the 
 majority of women will not require to have 
 
 270
 
 TREATMENT. 271 
 
 anything done by a physician during this pe- 
 riod, reaffirming a proposition already enun- 
 ciated, that a process through which every 
 mature woman has to pass can not be ex- 
 pected to have abnormalities in all or even in 
 the majority of cases. Among savage and 
 barbarous women, among women who live 
 out of doors and are inured to manual labor 
 or exercise, the occasions will be rare indeed 
 in which any aid from a physician will be re- 
 quired in order to meet the exigencies of the 
 menopause. 
 
 Classes of Women wlio suffer. Tlie treat- 
 ment is tliat of Symptoms. Among the nerv- 
 ous, highly organized, sensitive women who 
 spend the most of their lives in the house, 
 among those who are harassed with cares do- 
 mestic and social, the fashionable and dissi- 
 pated, among those who have suffered with 
 pelvic troubles more or less of their lives, 
 among many who have suffered from poverty 
 or disappointment, the menopause will call 
 for more or less constant attention, and it 
 will be well to remember that we have no
 
 272 THE MENOPAUSE. 
 
 definite disease, as a rule, to treat, but a 
 series of symptoms. 
 
 Vasomotor PJienomena tlie most Fre- 
 quent. Let us first consider the treatment of 
 those who are affected with nervous and vas- 
 cular troubles, for this includes by far the 
 greater number of sufferers at the meno- 
 pause.* 
 
 The vasomotor troubles, blushes, flashes 
 of heat with possible subsequent profuse 
 perspiration or discharge of urine, which 
 sometimes persist until advanced life, form 
 the commonest of all symptoms and fre- 
 quently appear with women who are in other 
 respects in the most perfect health.f 
 
 Many of these women would scorn the 
 idea of medical treatment or even advice for 
 such a condition, but there are many others 
 
 * See remarks on climacteric insanity, Chapter IV; see 
 also Geber, Anomalien der Schweissdriisen und ihrer Func- 
 tion, in Ziemssen Handbuch der speciellen Pathologic und 
 Therapie, xiv, Heft 2. 
 
 t C. Liegeois recommends the use of atropia sulphate 
 for the sweating of the menopause, which is sometimes very 
 annoying. Revue medicale de 1'Est, Nancy, xi, p. 460.
 
 TEEATMENT. 273 
 
 who are so annoyed by it that they seek re- 
 lief. Such women should always pay close 
 attention to the condition of the gastro-intes- 
 tinal canal, their diet should be simple and 
 wholesome ; alcohol, spices, highly seasoned 
 food should be abstained from ; the bowels 
 should be kept freely open, and, as such peo- 
 ple are in very many instances constipated, a 
 gentle purge, especially with salines, should 
 occasionally that is, according to the urgency 
 of the condition be given. 
 
 Salines and Nervines. The so-called nerv- 
 ines, valerian, asafoetida, scutellarium, hyo- 
 scyamus, etc., will all be found serviceable occa- 
 sionally. Another most important matter con- 
 sists in encouraging free elimination through 
 the skin by exercise, friction, and frequent 
 bathing in water at a temperature of 60 to 70 
 F. Salt-water baths will be found a particu- 
 larly grateful and efficient mode of treatment. 
 
 Abstraction of Blood for Congestions of 
 the Pelvic Organs. The author has alluded 
 to the congestions of the genital organs, 
 which are sometimes particularly distress- 
 
 19
 
 274 THE MENOPAUSE. 
 
 ing in causing sexual excitement. He has 
 known cases in which this was a source of 
 great mortification to very worthy women. 
 Such congestions are a valid cause for pro- 
 fessional assistance. Relief may often be 
 obtained by the abstraction of blood from 
 the os uteri either with leeches or by means 
 of punctures with a tenaculum or scalpel, 
 an ounce or more of blood being removed. 
 Vaginal douches with water at a tempera- 
 ture not exceeding 70 or 75 F. would also 
 be found efficient, and the intelligence of 
 such patients should be appealed to by a 
 candid statement of the condition and the 
 means required for its relief.* 
 
 Profuse Haemorrhages during the Meno- 
 pause are an Evidence of Disease. The con- 
 gestions of the genital organs which cause 
 free haemorrhage at the time when the 
 menopause is supposed to be present should 
 always receive investigation and explana- 
 
 * See in reference to this feature of the subject H. Ricord, 
 Etudes sur les Troubles de la Sensibilite" G6n6sique a 1'Epoque 
 de la Menopause, Paris, 1879.
 
 TEEATMENT. 275 
 
 tion. It is insisted, as has been insisted 
 repeatedly, that they are not physiological, 
 they are not normal, but are the evidence 
 of disease. Excluded are those congestions 
 and haemorrhages which occur years after 
 the menopause has occurred, which have 
 heretofore been explained by many physi- 
 cians as a renewal of menstruation, a second 
 experience of the menopause, which ex- 
 planation is absurd, for they always indi- 
 cate disease, and, with those who are ad- 
 vanced in life, usually or often malignant 
 disease. 
 
 Vasomotor Paralysis may be a Factor in 
 ike HcemorrJiages of the Menopause. It is 
 probable that there is in these menopause- 
 uterine haemorrhages the same element of 
 vasomotor paralysis which occurs in other 
 parts of the body, and that the uterine 
 capillaries and their supporting connective 
 tissue have less resisting power on account 
 of atrophy and fatty degeneration processes 
 which are going on than they have had in 
 previous years. Hence whenever the vaso-
 
 276 THE MENOPAUSE. 
 
 motor paralysis occurs the resulting haemor- 
 rhage is much more likely to be profuse 
 than when the tissues have the vitality of 
 earlier years. The haemorrhage is more pro- 
 fuse and more persistent if there is also a 
 diseased endometrium or a neoplasm in the 
 parenchyma of the uterus. 
 
 Carettage. - - The treatment should be 
 mainly surgical ; the uterus should be di- 
 lated, the endometrium examined, a wire 
 curette being carefully passed over its en- 
 tire surface, first for diagnosis and then 
 with sufficient force to break down and re- 
 move all diseased tissue if any there be, 
 and this operation should be repeated if 
 the occasion warrants. This is a more log- 
 ical and rational procedure than tampon- 
 ing the vagina, or even the uterus, previ- 
 ous exploration of the uterine cavity not 
 having been made. 
 
 If an uterine tumor causes severe bleed- 
 ing one may practice galvano-cauterization 
 of the endometrium with the positive pole, 
 and if this fails to be effective and there is
 
 TREATMENT. 277 
 
 prospect of a troublesome future, hysterec- 
 tomy should be performed. 
 
 Radical Measures indicated for Cancer. 
 Should cancer of the uterus develop at this 
 time and this is possible, for it may de- 
 velop at any period of life hysterectomy, 
 usually per vaginam, is indicated at the 
 earliest possible moment. Baker, Byrne, and 
 others have had excellent results from the 
 high amputation of the cervix for cancer, 
 Baker using the scissors and cautery in his 
 operations (several of which were followed 
 by cures, the patients being alive and well 
 from three to eleven years after the opera- 
 tions. See Transactions American Gynaeco- 
 logical Society, 1891), and Byrne using only 
 the cautery. The author feels entirely con- 
 vinced, however, that the radical operation, 
 and performed as radically as possible, is the 
 best for all cases in which the deadly dis- 
 ease is not too far advanced to make an 
 extensive operation practicable. 
 
 Drug Treatment for Haemorrhage. The 
 tampon will be available and useful in some
 
 278 THE MENOPAUSE. 
 
 cases, and so will the astringent drugs er- 
 got, hydrastis, antipyrine, iron, iodine, alum, 
 etc. The first two of these are to be given 
 in sufficient quantities by mouth, and the 
 author has frequently given them in com- 
 bination. The othei's are to be used local- 
 ly in the vagina or uterus, or both. If 
 they are introduced into the uterine canal, 
 it is better to moderately dilate it first as 
 the drug will thereby be absorbed in greater 
 quantity and with correspondingly greater 
 efficacy. 
 
 Nerve Lesions of the Menopause are main- 
 ly of the Sympathetic System. The mental 
 disease which has been considered in a 
 previous chapter as an accompaniment of 
 the menopause is in many cases but an- 
 other manifestation (or perhaps a deriva- 
 tive) of vasomotor disturbance. In fact 
 the purely cerebro-spinal lesions of the 
 menopause are rare compared with those of 
 the sympathetic system. The insanity of 
 the menopause then is frequently due to 
 cerebral congestion, and hence the greatest
 
 TREATMENT. 279 
 
 benefit may sometimes be derived in such. 
 cases from depletive measures. 
 
 Depletive Measures in Nerve Complica- 
 tions. They may be used in the following 
 order : First, salines, until purging has been 
 sufficiently free ; second, vaginal tampon 
 soaked in glycerin ; third, abstraction of 
 blood from the uterus or from the veins of 
 the arm or leg. It is astonishing how 
 quickly relief will come in some cases from 
 such treatment. Other treatment for the 
 insane will readily suggest itself in the form 
 of careful diet and hygiene, avoidance of 
 care and worry, if possible, cheerful sur- 
 roundings, occupation which shall be divert- 
 ing but not fatiguing. We have the testi- 
 mony of Merson and other alienists who 
 have been quoted that the prognosis of the 
 mental disease of the menopause is often 
 very good. 
 
 No Special Treatment is Indicated for 
 the Nerve Lesions of the Menopause. The 
 author has no particular treatment to rec- 
 ommend as especially efficacious for the
 
 280 THE MENOPAUSE. 
 
 neuralgias, paralyses, hysterias, and epilep- 
 sies of the menopause. They are merely 
 incidents in its course and require the same 
 treatment which would be indicated were 
 the menopause not present. Therefore the 
 reader is referred to the special treatises 
 upon nervous diseases, or to those upon gen- 
 eral medicine, to Ross, Hammond, Gowers, 
 Striimpell or other reliable authorities for 
 information upon this subject. 
 
 Treatment of Cutaneous Complications 
 External and Internal. The cutaneous le- 
 sions which are so often met with during the 
 menopause are wont to have a very direct 
 relation to it. Some of them have already 
 been referred to in connection with the treat- 
 ment of vasoniotor disturbances. The acne, 
 urticaria, erythema, and other morbid con- 
 ditions of the skin are almost always sus- 
 ceptible of relief, and the treatment should 
 consist of both external and internal meas- 
 ures. Itching surfaces may be bathed with 
 a solution of bicarbonate of soda or lime 
 water. If caused by a discharge from the
 
 TEEATMENT. 281 
 
 vagina the latter must be stopped before 
 the itching will disappear. The indication 
 is for astringents, and the author is in the 
 habit of using a vaginal tampon moistened 
 with glycerite of tannin 
 
 $ Acidi tannici 3j 
 
 Glycerinae j 
 
 or with a solution of silver nitrate, thirty 
 or even sixty grains to the ounce, or with 
 a two-per-cent solution of icthyol in glyc- 
 erin. The condition of the stomach and 
 bowels must also be interrogated and pur- 
 gatives given if required. The abstraction 
 of blood in the manner referred to will 
 also be helpful with some of the cases in 
 which the skin furnishes elements of com- 
 plication. 
 
 Nothing new is offered for the compli- 
 cations which affect the kidneys, eyes, liver, 
 spleen, alimentary canal, etc. Since they 
 are usually incidental and not characteristic, 
 they should be treated in accordance with 
 the principles which would govern their 
 treatment apart from the menopause. The
 
 282 THE MENOPAUSE. 
 
 works on general medicine are, of course, to 
 be consulted with reference to their treat- 
 ment. 
 
 There is little additional which can be 
 said in regard to the general treatment of 
 those who are passing through the meno- 
 pause. Those who are not sick, but think 
 they are, must be disillusioned with gentle- 
 ness but firmness. They must be assured 
 that the process is a physiological one 
 through which the great majority of 
 women pass unharmed ; and yet the un- 
 usual sensitiveness of both body and mind 
 at this juncture must be fully recognized 
 and proper caution enforced against all 
 means which could destroy the sensitive 
 equilibrium. Those who are sick must be 
 treated upon rational principles, not by 
 superstition or tradition; surgical conditions 
 should be recognized promptly and prompt- 
 ly treated; and those which are susceptible 
 of relief by drugs should receive remedies 
 which are tried and reliable, not the nos- 
 trums and cure-alls of the quacks.
 
 TEEATMENT. 283 
 
 ADDENDA. 
 
 CIIERON. Traitemeut des Ecoulements nevral- 
 giques de I'Uterus apres la Menopause. Revue medico- 
 chirurgique des Maladies des Femmes, Paris, 1890, xii, 
 383. 
 
 LIEGEOIS. Les Sueurs de 1'Age critique, leur 
 Traitemeut par le Sulfate d'Atropine. Revue medi- 
 cale de 1'Est, Nancy, xi, p. 4GO. 
 
 SUSSDORFF. On Radical Treatment of Local Dis- 
 ease at the Menopause. New York Medical Record, 
 *iv, p. 486 
 
 HOUZEL. Influence of Sea Baths on Menstrua- 
 tion. Congres d'hydrotherapie marine, 1894.
 
 INDEX OF AUTHOKS. 
 
 Alibert, 221. 
 Andral, 72. 
 Avicenna, 117. 
 
 Baker, 277. 
 
 Baker Brown, 238. 
 
 Baldwin, 224. 
 
 Bar! 6, 40. 
 
 Barnes, 218. 
 
 Baron, 40. 
 
 Battey, 100, 218, 238, 239, 240, 
 
 248, 249, 259. 
 Bax, 227. 
 Bedford, 24. 
 Beech er, 189. 
 Binsenger, 98. 
 Birkett, 78, 85. 
 Bloom, 227. 
 Boivin, 24, 81. 
 Borner, 10, 52, 68, 97, 100, 133, 
 
 268, 269. 
 Brett, 220. 
 
 Braxton-Hicks, 190, 216, 218. 
 Brierre de Boismont, 100, 220. 
 Bruant, 229. 
 Bruntzel, 266. 
 Buckel, 53. 
 Bucknill, 215. 
 Buffon, 12. 
 Bureau, 72. 
 Byrne, 277. 
 
 Campbell, 228. 
 Cazenave, 220. 
 Cheron, 283. 
 Chiari, 81. 
 Clarke, 24. 
 Clay, 238. 
 Clement, 223, 224. 
 Coe, 228. 
 
 Conklin, 210, 227. 
 Cortajarena, 135. 
 244. Courty, 100, 221. 
 Cuvier, 12. 
 
 Ballon, 43, 50, 55, 56, 111, 181. 
 
 Danlos, 221. 
 
 Bawson, 58. 
 
 Beligny, 220. 
 
 Bemocrates, 6. 
 
 Be Eedondo, 40. 
 
 Be Se"re, 39. 
 
 Beshayes, 43. 
 
 Bewees, 24. 
 
 Biihrssen, 256. 
 
 Bupuytren, 24. 
 
 Ehrenberg, 12. 
 Eliot, 228. 
 Engelmann, 4, 229. 
 Esquirol, 207. 
 Exner, 53. 
 285 
 
 203.
 
 286 
 
 INDEX OF AUTHORS. 
 
 Farrc, 87. 
 
 Jacobi, M. P , 4. 
 
 Faye, 97. 
 
 Jacquemier, 221. 
 
 Felty, 39. 
 
 Jaggard, 227. 
 
 Fothergill, 24. 
 
 James, 8. 
 
 Frank, 203. 
 
 Jenks, 40. 
 
 
 Joal, 228. 
 
 Galen, 80. 
 
 Johustone, 39, 68, 126, 255. 
 
 Garat, 228. 
 
 
 Gardanne, 9. 
 
 Kammerer, 58. 
 
 Geber, 228, 272. 
 
 Kaposi, 220. 
 
 Glacvecke, 246, 256. 
 
 Kehrer, 266. 
 
 Goodell, 40, 218. 
 
 Keith, 238. 
 
 Gordon, 69, 255, 256 
 
 Kennedy, 40, 268. 
 
 Goth, 98. 
 
 Kisch, 10, 18, 43, 50, 51, 57, 96, 99, 
 
 Gowers, 280. 
 
 101, 133, 202, 200, 224, 227, 228, 
 
 Grellcty, 219, 220. ' 
 
 229, 235. 
 
 Griesinger, 207, 208. 
 
 Kiwisch, 52. 
 
 Grisolle, 220. 
 
 Kleinwachter, 265. 
 
 Groedel, 224. 
 
 Klob, 58, 72, 234. 
 
 Gros, 227. 
 
 Kobelt, 88. 
 
 Gross, 78, 85, 88. 
 
 Kolliker, 72. 
 
 Guenau do Mussy, 227. 
 
 Kora, 68. 
 
 Guibout, 220. 
 
 Krafft-Ebbing, 24. 
 
 Guislain, 207. 
 
 Krieger, 43, 52. 
 
 Gusserow, 84, 269. 
 
 Krishaber, 238. 
 
 Guy, 39. 
 
 Kriiger, 235. 
 
 
 Kundrat, 4. 
 
 Hammond, 280. 
 
 
 Hannover, 98, 134. 
 
 Landouzy, 24. 
 
 Hardy, 220. 
 
 Larousse, 15. 
 
 Hegar, 52, 56, 67, 203, 205, 229, 
 
 Laurans, 117. 
 
 238, 239, 250, 251, 266. 
 
 Lebert, 78, 85. 
 
 Hensen, 87. 
 
 Lecorche, 111. 
 
 Heschl, 72. 
 
 Leopold, 4. 
 
 Higgins, 222. 
 
 Leroy de Mericourt, 220. 
 
 Hippocrates, 8, 117. 
 
 Leudet, 96, 132, 133. 
 
 His, 53. 
 
 Lever, 281. 
 
 Hoeflerus, 117. 
 
 Lidgeois, 272, 283. 
 
 Hoffman, 8. 
 
 Lieven, 98, 134. 
 
 Hoist, 68. 
 
 Lisfranc, 24. 
 
 Houzel, 283. 
 
 
 
 Manton, 227. 
 
 Ivanotf, 227. 
 
 Martiueau, 220.
 
 INDEX OF AtJTHORS. 
 
 287 
 
 Mary, 196. 
 
 Piron, 43, 101. 
 
 Matusch, 216. 
 
 Pliny, 239. 
 
 Mayer, 97, 99, 134, 217, 235, 268. 
 
 Potain, 221. 
 
 Mayer, L., 207. 
 
 Prochownik, 266. 
 
 McDowell, 238. 
 
 Puech, 43, 52, 88. 
 
 Meigs, 24. 
 
 
 Meissner, 24. 
 
 Queirel, 98. 
 
 Menville, 9. 
 
 
 Mercier, 163. 
 
 Kaciborski, 12, 40. 
 
 Merson, 204, 207, 213, 214, 215, 
 
 Eayer, 220. 
 
 279. 
 
 Eeinl, 40. 
 
 Meynert, 24, 205. 
 
 Eenaudier, 43. 
 
 Miles, 39. 
 
 Eicord, 228, 274. 
 
 Montgomery, 265. 
 
 Eobinson, 39. 
 
 Moliere, 199. 
 
 Eodsewitch, 98, 268. 
 
 Moon, 224. 
 
 Rohe, 215, 218, 219, 227. 
 
 Morel, 207. 
 
 Kokitansky, 72. 
 
 Moricke, 4. 
 
 Ross, 192, 280. 
 
 Moses, 6. 
 
 Eousseau, 189. 
 
 M filler, 84, 186. 
 
 Rouvier, 98. 
 
 Munde, 39. 
 
 Royle, 101. 
 
 Nelson, 228. 
 
 Saint-Hilaire, 12. 
 
 Nettler, 40. 
 
 Stinger, 72. 
 
 Neumann, 101. 
 
 Saucerotte, 24. 
 
 Norton, 101. 
 
 Savage, 228. 
 
 Nowlin, 5. 
 
 Scanzoni, 78, 85, 200, 202, 268. 
 
 
 Schlager, 207. 
 
 O'Connor, 39. 
 
 Schlichting, 100. 
 
 Odebrecht, 265. 
 
 Schorler, 269. 
 
 Olive, 185. 
 
 Simpson, 72, 111. 
 
 Ollive, 227. 
 
 Sims, 238. 
 
 Orfila, 268. 
 
 Skae, 207, 208, 209. 
 
 Ormiere, 266. 
 
 Skene, 210. 
 
 
 Slavjansky, 53, 69. 
 
 Pages, 229. 
 
 Smith, 39. 
 
 Paracelsus, 6. 
 
 Stephenson, 40. 
 
 Pean, 266. 
 
 Stocquart, 186. 
 
 Peaslee, 238. 
 
 Stokes, 224. 
 
 Petit, 113, 114, 229. 
 
 Stolz, 223. 
 
 Petrequin, 268. 
 
 Strojnowski, 52, 112. 
 
 I'll Tiger, 87. 
 
 Strum pell, 280. 
 
 Phillip, 196. 
 
 Sampler. 101.
 
 288 
 
 INDEX OF AUTHORS. 
 
 Sussdorff, 283. 
 Sutherland, 211, 268. 
 Sutton, 69. 
 
 Tait, 112, 186, 238, 240, 250, 269. 
 
 Tarnowski, 40. 
 
 Taufter, 266. 
 
 Thomas, 39, 56, 206. 
 
 Tilt, 9, 10, 14, 17, 21, 40, 65, 97, 133, 
 
 208, 238. 
 Tissier, 266. 
 Tissot,'24. 
 Tuke, 215. 
 
 Vanderkolk, 215. 
 
 Van de Warker. 159, 160. 
 Veit, 88. 
 
 Yelpeau, 24, 78, 85. 
 Virchow, 72, 85. 
 
 Waldeyer, 52. 
 Wells, 238. 
 Werth, 229. 
 Willette, 229. 
 Williams, 4, 39, 68. 
 Winiwartcr, 78, 85. 
 Wyder, 4. 
 Wyman, 40. 
 
 Ziemssen, 272.
 
 INDEX. 
 
 Abdominal section, 261. 
 
 Abnormal, attention aroused by 
 the, 14. 
 
 Abortion, consequences of, 36. 
 from sudden impressions, 168. 
 
 Abscess resulting from disease of 
 . the uterus, 171. 
 
 Absence of corpora lutea, 181. 
 
 Abstinence, 155, 156. 
 sexual, 166. 
 
 Abstraction of blood for conges- 
 tion of the pelvic organs, 273, 
 274. 
 
 of blood from the uterus, 279, 
 281. ' 
 
 Abundant discharge of urine, 194. 
 
 Accessory ostia of the Fallopian 
 tubes, 255. 
 
 Accidental influences of the men- 
 opause, 93, 167. 
 
 Acne, 280. 
 
 Acute diseases which may induce 
 the menopause, 234. 
 
 Adenomata of the uterus, 74. 
 
 Adhesions as a means of sustain- 
 ing nutrition, 115. 
 
 Age as an influence of the meno- 
 pause, 92, 93, 102. 
 limit, conclusion as to, 102. 
 of the menopause, table show- 
 ing the, 94, 96-98. 
 
 Age when the phenomena of th e 
 
 menopause occur, 28. 
 Alienists, 279. 
 Alimentary canal, 281. 
 diseases of the, 177. 
 Alum, 278. 
 
 Ambiguity in various terms, 2. 
 Amenorrhoea, 118. 
 
 conservatism of, 233. 
 Amyloid disease, 234. 
 
 of the uterus, 71. 
 Anaemia, 244. 
 cerebral, 204. 
 
 during the menopause, 196, 201. 
 significance of, 196. 
 sufferers from, 36. 
 Analogue of menstruation in ani- 
 mals, 11, 12. 
 of the menopause wanting in 
 
 animals, 12. 
 
 Anatomical changes due to inflam- 
 mation, 84. 
 changes in the Fallopian tubes, 
 
 vagina, and clitoris, 62. 
 changes in the genital organs 
 leading to the menopause, 66. 
 changes in the ovaries, 42, 52. 
 changes in the ovaries, accord- 
 ing to Dalton, 43. 
 changes in the uterine mucous 
 membrane, 7. 
 
 20 
 
 289
 
 290 
 
 INDEX. 
 
 Anatomical changes in the uterus, 
 
 53, 55. 
 
 changes incidental to the meno- 
 pause, 78. 
 
 changes of traumatic or infec- 
 tious origin, 84. 
 
 changes resulting from the men- 
 opause, 42. 
 
 changes which produce the 
 menopause, 42. 
 
 Ancient writers on menstruation 
 and the menopause, 7. 
 
 Anteflexkm of the uterus, 21. 
 
 Antipyrine, 278. 
 
 Aperients, 213. 
 
 Apoplexy, 22. 
 
 Apparent menopause occurring 
 prematurely, 262. 
 
 Appendages, removal of the, does 
 not always cure pain and neu- 
 ralgia, 259. 
 
 Appetite, loss of, 195. 
 
 Areolar hyperplasia, 79. 
 
 Arrest of the monthly discharge, 1. 
 
 Artificial menopause, 247. 
 production of the menopause, 
 indications for the, 240. 
 
 Ascitic accumulations, 121. 
 
 Assimilation, faults of, 30. 
 
 Asthenopia, 222. 
 
 Asthma, 223. 
 
 Astringent drugs, 278, 281. 
 
 Atmospheric influence on the 
 menstrual function varies, 
 131. 
 
 pressure, varying effects of, 136, 
 138. 
 
 Atopomenorrhcea, 246. 
 
 Atresia of the cervical canal, 56. 
 of the uterine canal, 75. 
 of the vagina, 75, 76. 
 
 Atrophic changes are uniform in 
 the natural menopause, 86. 
 
 Atrophic, changes of the meno- 
 pause are, 16, 86. 
 Atrophy, 204, 275. 
 due to excess of function, 115, 
 
 116. 
 
 of structure, 5, 41. 
 of the cervix, 56. 
 of the clitoris, 63. 
 of the external genitals, 63. 
 of the genital organs, 246. 
 of the mammary glands, 64. 
 of the organs of generation from 
 
 pressure, 122. 
 of the ovaries, 247. 
 of the ovaries due to diabetes. 52. 
 of the ovaries precedes atrophy 
 
 of the uterus, 52, 56. 
 of the uterus, 59-61, 256. 
 of the uterus and ovaries from 
 
 diabetes, 112. 
 producing the menopause may 
 
 be primary or secondary, 115. 
 Atropia sulphate for the sweating 
 
 of the menopause, 272. 
 Aura of epilepsy, 192. 
 Author's experience concerning 
 
 the menopause, 19. 
 
 Bathing, 273. 
 
 Baths, salt water, 273. 
 
 Bereavement, 213. 
 
 Bicarbonate of soda, 280. 
 
 Biliousness, 195. 
 
 Blending of sexual types, 251. 
 
 Blood, abstraction of, 273, 274, 279. 
 
 coagulability of the, 200, 201. 
 
 discharge of, 4. 
 
 increase in the tension of the, 31- 
 
 poverty of the, 196. 
 Brain lesion, 244. 
 
 organic disease of the, 214. 
 Breast, malignant disease of the, 
 78.
 
 INDEX. 
 
 291 
 
 Breast, skin lesions of the, 220. 
 Bronchitis, 223. 
 
 Caesarean section, 243. 
 
 Canal, uterine, 4. 
 
 Cancer, association of, with the 
 
 menopause, 198. 
 high amputation of the cervix 
 
 for, 277. 
 
 of the uterus, 209, 277. 
 radical measures indicated for, 
 
 277. 
 statistics from the United States 
 
 census of 1880, 23. 
 Carcinoma mammae, 22. 
 
 uteri, 21, 22, 269. 
 Cardiopathies. 223. 
 Castration, 239. 
 
 Caustics, injury to the uterine 
 mucous membrane from, 71. 
 Cautery, 277. 
 Cerebral anaemia, 204. 
 
 congestion, 142, 204, 278. 
 Cerebro-spinal lesions, 278. 
 Cervix, degeneration of the, 57. 
 during the menopause, 57. 
 high amputation of the, for 
 
 cancer, 277. 
 
 Cessation of the flow, 246. 
 Change of life, 2, 10. 
 Changes in animals after the ces- 
 sation of ovulation, 251. 
 in eunuchs, 261. 
 
 structural, in the body in gen- 
 eral, 66. 
 
 Childbearing, 157. 
 frequent, 210. 
 function, 3. 
 
 no burden to certain women, 146. 
 normal function of, 147. 
 Chilliness of the extremities, 194, 
 Chloasma, '220. 
 Chronic endometritis, 247. 
 
 Chronic inflammatory processes 
 leading to the menopause, 108. 
 inflammatory processes, varie- 
 ties of, 109. 
 oedema, 219. 
 
 parenchymatous metritis, 79. 
 visceral diseases, 244. 
 Civilized life preferable to savage 
 
 189. 
 
 Climacteric, 2, 204-206. 
 diabetes, 112. 
 disease, 2, 179. 
 insanity, 207-209, 210, 212-214, 
 
 216, 272. 
 
 phenomena of the, 5, 24. 
 psychoses, 215. 
 Climate as an influence of the 
 
 menopause, 28, 92, 131. 
 effect of, in producing the meno- 
 pause prematurely, 231. 
 effect of, upon the menstrua- 
 tion, 135. 
 
 Climatic surroundings, adjust- 
 ment to, 138. 
 
 Climatology, relation of, to gynae- 
 cology, 139. 
 Clitoris, anatomical changes ill 
 
 the, 62, 64. 
 atrophy of the, 63. 
 Coagulability of the blood, 200, 
 
 201. 
 
 Coitus, 157. 
 effects of, when senile changes 
 
 have occurred, 64. 
 with menstruating women for- 
 bidden, etc., 7. 
 Compensations in civilized life, 
 
 189. 
 
 Conception, influence of the men- 
 opause upon, 180. 
 prevention of, 160. 
 Concomitants of the menopause, 
 29.
 
 292 
 
 INDEX. 
 
 Congestion, 274. 
 cerebral, 204, 278. 
 of the genital organs in men- 
 struation, 11. 
 
 of the pelvic, organs, 194, 273. 
 of the uterus in the early stages 
 
 of the menopause, 56. 
 Consequences of arrest of the 
 
 menses, 71. 
 
 Considerations concerning the or- 
 gans of the genital apparatus, 
 41. 
 Constipation, sufferers from, 36, 
 
 194, 195, 223. 
 Convalescence, 211. 
 Cooks, 154. 
 
 Corpora lutea, absence of, 181. 
 Corpus luteum, report on the, 43. 
 
 uteri, degeneration of the, 57. 
 Crises, vasomotor, 29. 
 Critical time, 2, 198, 270. 
 Cruelty, 213. 
 Cure-alls, 282. 
 Currents, radiating, of ganglion- 
 
 ic centers, 5. 
 Curettage, 276. 
 
 Cutaneous complications, treat- 
 ment of, 280. 
 lesions, 280. 
 
 Data concerning the menopause, 
 
 11. 
 Decidua provided each month, 
 
 148. 
 
 Decidual endometrium, 199. 
 Defective development, meno- 
 pause from, 118, 119. 
 development of the genital or- 
 gans, 265. 
 
 Definition of the menopause, 1. 
 of menstruation, 4. 
 of menstruation, deduction from 
 the, 4. 
 
 Degeneration, fatty, 275. 
 
 of structure, 41, 62. 
 
 of the cervix and corpus uteri, 57. 
 
 of the endometrium, 31. 
 Degenerative changes due to old 
 age, 225. 
 
 changes in thesexual organs,215. 
 Delusions, 209, 215. 
 Dementia, 211. 
 Demonomania, 209. 
 Depletive measures, 279. 
 
 measures in nerve complica- 
 tions, 279. 
 
 Deposits of pigment, 220. 
 Depression, 194, 209, 214, 215. 
 Derangement of the function of 
 
 the lungs, 226. 
 
 Destruction of the genital organs, 
 85, 130, 
 
 of the mammary glands, 85. 
 Diabetes, cessation of the menses 
 in, 111. 
 
 climacteric, 112. 
 Diarrhoea, 194, 195, 225. 
 Diathesis, 26. 
 Diet, 210. 
 
 Different effects of climate, 135. 
 Digestion compared with the men- 
 opause, 17. 
 
 consciousness of, 13. 
 
 faults of, 30. 
 Disappearance of the menses from 
 
 kidney lesions. 111. 
 Disappointment in love, 214. 
 
 sufferers from, 36. 
 Discharge from the vagina, 280. 
 Disease, acute inflammatory, 104. 
 
 and traumatism, 93, 102, 103. 
 
 of the heart, 214, 224. 
 
 organic, 210. 
 
 psychical, 208. 
 
 variety of, involving the ovaries, 
 67.
 
 INDEX. 
 
 293 
 
 Disillusioned, 282. 
 
 Disorders, chronical, 8. 
 digestive, 31. 
 
 Disposition determines the phe- 
 nomena of the menopause, 191. 
 influence of the, upon the men- 
 opause, 151. 
 
 Disturbance, emotional and intel- 
 lectual, 215. 
 
 Dizziness, 205. 
 
 Dodging time, 2. 
 
 Domestic unhappiness from ster- 
 ilization, 256. 
 
 Douches, vaginal, 274. 
 
 Drug treatment for haemorrhage, 
 277. 
 
 Duration of climacteric insanity, 
 
 212. 
 of the menopause, 95. 
 
 Dyscrasia, 26. 
 
 Dysmenorrhoea, 239, 242, 252. 
 suiferers from, 36, 154. 
 
 Dyspepsia, 223. 
 
 Dyspnoea, 224. 
 
 Eczema genitalium, 220. 
 Edinburgh Royal Asylum, 209. 
 Egyptians, interpretation of men- 
 struation by the, 6. 
 Electricity for the relief of pai^ 
 
 259. 
 
 treatment with, 249. 
 Embolism, 72. 
 Emile, 189. 
 
 Emotional and intellectual dis- 
 turbance, 215. 
 Endometrial tissue, friability of 
 
 the, 200. 
 
 Endometrium, 276. 
 decidual, 199. 
 degeneration of the, 31. 
 granulations of the, 59. 
 haemorrhage from the, 37. 
 
 Endometritis, chronic, 247. 
 
 in prostitutes, 162. 
 Enlargement, myomatous, of the 
 
 uterus, 31. 
 Epilepsy, 204, 243, 280. 
 
 aura of, 192. 
 
 Equilibrium, sensitive, 282. 
 Ergot, 278. 
 Erythema, 219, 280. 
 Eskimos, 136. 
 Eunuchs, physical changes which 
 
 occur in, 261. 
 
 Evils of the menopause exagger- 
 ated, 188. 
 Evolution, Darwin's theory of 
 
 139. 
 Exaggerated views concerning the 
 
 menopause, 16. 
 Exanthemata, 234. 
 Excess, sexual, 155, 156. 
 Excesses, venereal, 36. 
 Excessive sexual indulgence, 234., 
 
 235. 
 Excessively fertile, premature 
 
 menopause in the, 235. 
 Experience of stock breeders, 158. 
 Exposure, results of, 36. 
 External genitals, atrophy of the, 
 
 63. 
 Eyes, 281. 
 
 Factors influencing the advent 
 and progress of the meno- 
 pause, 89, 92. 
 
 Fall and injury of the head, 214. 
 Fallopian tube, accessory ostia of 
 
 the, 255. 
 tubes, anatomical changes in 
 
 the, 62, 66. 
 Family peculiarities, 140. 
 
 taint, 141. 
 
 Fatty degeneration, 275. 
 degeneration of the uterus, 72.
 
 294 
 
 INDEX. 
 
 Fatty degeneration of the uterus, 
 
 varieties of, 72. 
 Fear of losing the soul, 209. 
 Fermentation, intestinal or gas- 
 tric, 195. 
 Fertility and sterility are relative 
 
 terms, 143. 
 and sterility, bearing of, upon 
 
 the menopause, 143. 
 excessive, 146, 172. 
 may hasten the menopause, 
 
 144. 
 
 Fever and inflammation, 214. 
 Fevers which may induce the 
 
 menopause, 234. 
 Fibro-cystic, 269. 
 Fibroids, 247. 
 
 uterine, may defer the meno- 
 pause indefinitely, 129. 
 Fibroma uteri, 21, 22. 
 Financial trouble, 213. 
 Flashes of heat, 245, 272. 
 Flatulence, 195. 
 Flow, cessation of the, 246. 
 
 menstrual, 5. 
 Flushing, 246. 
 
 Friability of the endometrial tis- 
 sue, 200. 
 Fright, 214. 
 Fruition in the vegetable world, 
 
 41. 
 
 Function, childbearing, 3. 
 menstrual, cessation of the, 1, 3. 
 of menstruation, 4. 
 Functional activity at the begin- 
 ning of the menopause, 91. 
 troubles of the menopause, 30. 
 Functions painless under normal 
 conditions, 13. 
 
 Galvano-cauterization, 276. 
 Gastro-intestinal canal, 273. 
 intestinal disturbances, 194. 
 
 General changes in the early 
 
 stages of the menopause, 91. 
 congestion in the early stages of 
 
 the menopause, 91. 
 paralysis, 113, 204. 
 Genital organs, congestion of the, 
 
 273, 274. 
 organs, defective development 
 
 of the, 265. 
 
 Glands, congestion of the, 65. 
 mammary, changes in the, 64, 
 
 65. 
 
 Glandular discharge from the ute- 
 rus, 59, 61. 
 disorders, 220. 
 secretion, 4. 
 Glycerin, 281. 
 Glycerite of tannin, 281. 
 Gonorrhoea, effect of latent, upon 
 
 newly wedded women, 107. 
 influence of, in inducing the 
 
 menopause, 236. 
 in prostitutes, 163. 
 Granulations of the endometrium, 
 
 59. 
 
 Greeks, interpretation of men- 
 struation by the, 5. 
 Gulping, 195. 
 Gurgling, 195. 
 Gynaecologist, 210. 
 Gynaecology has given importance 
 to the premature menopause, 
 230. 
 
 Habits, 50. 
 Haemoptysis, 138. 
 Haemorrhage as influenced by at- 
 mospheric conditions, 138. 
 drug treatment for, 277. 
 during the menopause, 124. 
 from exuberant nutrition of the 
 
 endometrium, 79. 
 from the endometrium, 37, 59.
 
 INDEX. 
 
 295 
 
 Haemorrhages from the uterus, 269. 
 menopause-uterine, 275. 
 of the menopause, 197, 198. 
 of the menopause at long or 
 
 short intervals, 198, 199. 
 of the menopause, conditions of 
 
 the blood iu, 200. 
 of the menopause demand ac- 
 tive treatment, 201. 
 of the menopause, different con- 
 ditions of, from those of ordi- 
 nary menstruation, 200. 
 of the menopause from vaso- 
 
 motor paralysis, 275. 
 of the menopause, theories of 
 Frank, Hegar, Kisch, and 
 Scanzoni, 202, 203. 
 profuse, 2(59, 274. 
 substitutional, 246. 
 uterine, 214, 253. 
 uterine, not always checked by 
 
 the menopause, 128. 
 Haemorrhoids, 223. 
 Hallucinations, 206, 214, 215. 
 Headache, 194. 
 
 sufferers from, 36. 
 Health, state of the, as a factor in 
 
 inducing the menopause, 28. 
 Heart disease, 22, 214 
 Heat flashes, 96, 139, 193, 194. 
 Hemicrania, 206. 
 Hemiplegia, '22. 
 
 Hereditary and degenerative neu- 
 roses, 216. 
 Heredity as an influence of the 
 
 menopause, 93. 
 
 habit, and function, effect of, 
 in producing the menopause 
 prematurely, 232. 
 Hernia, ventral, 254. 
 Heteroplasia, 26. 
 
 High amputation of the cervix for 
 cancer, 277. 
 
 Hindus, 133. 
 Histology, 3. 
 Homicidal and suicidal impulse, 
 
 209. 
 Humoral pathologists, belief of 
 
 the,?. 
 
 Hydrastis, 278. 
 
 Hydrometra from stenosis, 57. 
 Hymen, 120. 
 
 Hyperaeniia of the vagina, 62. 
 Hyperaesthesiae, 205, 214. 
 Hyperkinesiae, 205. 
 Hyperplasia, areolar, 79. 
 Hypogastric plexus, 5. 
 Hysterectomy, 277. 
 
 without interruption of the men- 
 strual history, 75. 
 Hysteria, 142, 192. 
 
 during the menopause, 30. 
 
 Icthyol, 281. 
 
 Ignorant inactivity, 270. 
 
 Ill health and want, 214. 
 
 Importance of the menopause in 
 the light of recent develop- 
 ments, 11. 
 
 Impulse, suicidal and homicidal, 
 
 209. 
 to reproduction, 11. 
 
 Increase of the blood tension, 31. 
 
 Incurability of subjects with vi- 
 cious habits, 249. 
 
 Indians, peculiarities of. 141. 
 
 Indications for the artificial pro- 
 duction of the menopause. 240. 
 
 Indigestion, 195. 
 
 Induction of the menopause, care 
 in selecting cases for the, 240. 
 
 Infection as a cause of changes in 
 the uterine mucous mem- 
 brane, 71. 
 
 in connection with latent gonor- 
 rhoea, 107.
 
 296 
 
 INDEX. 
 
 Infectious inflammatory processes, 
 
 106. 
 
 Inflammatory processes unasso- 
 ciated with the puerperal con- 
 dition, 106. 
 
 Influence of the different genital 
 organs in the induction of the 
 menopause, 240. 
 
 Influence of wasting diseases, 232. 
 Inheritance, influence of, 152. 
 Insanity, 22, 24, 38, 211, 212, 243, 
 
 244. 
 
 at the change of life, 212. 
 climacteric, 207-210, 212-214, 
 
 216, 272. 
 
 of the menopause, 38, 210, 278. 
 relation of the menopause to, 
 
 211. 
 resulting from nervous and 
 
 mental trouble, 31. 
 Insomnia, 209. 
 
 Intellectual derangement, 214. 
 Intemperance, 214. 
 Intense impressions may bring the 
 
 menopause, 168, 169. 
 Intermenstrual intervals, 15. 
 Intermittent fever, 234. 
 Intestinal or gastric fermentation, 
 
 195. 
 
 Intramural myomata, 74. 
 Iodine, 278. 
 Iron, 278. 
 
 Irregular and unwomanly occupa- 
 tion, 153. 
 bleeding, 269. 
 sweating, 246. 
 Irregularities in the menopause 
 
 from diseased organs, 86. 
 Irritability, nervous, 204. 
 of disposition during the meno- 
 pause, 30. 
 Ischa-rnia, 72. 
 Itching, 280, 281. 
 
 Jaundice, 223, 225. 
 Jewesses, peculiarities of, 141. 
 
 Kidneys, 281. 
 
 disease of the, causing disap- 
 pearance of the menses, 111. 
 
 Labia minora, 64. 
 Lactation, 210. 
 
 effect of prolonged, 77. 
 Laundresses, 154. 
 Lesion, brain, 244. 
 
 cerebro-spinal, 278. 
 Lesions attributable to old age, 
 224, 225. 
 
 of the mind and nervous sys- 
 tem, 204. 
 Leucorrhcea, 246. 
 
 of the menopause, 19. 
 Life, change of, 2, 10. 
 Lime water, 280. 
 Listlessness, 209. 
 Loss of appetite, 1 95. 
 Lungs and kidneys, wasting dis- 
 eases of the, 110. 
 
 derangement of the, 226. 
 
 Malignant disease, 269. 
 
 disease, destructive character 
 of, 81. 
 
 disease following the meno- 
 pause and attributed to it, 82. 
 
 disease, increased vascularity 
 with, 124. 
 
 disease, the menopause does not 
 necessarily favor, 197. 
 
 disease of the breast, 78. 
 
 disease should not be allowed 
 to reach the irremediable 
 stage, 82. 
 
 disease simulated by fibroid tu- 
 mors of the uterus, 83. 
 
 disease, small percentage of 
 cases of at the menopause, 197.
 
 INDEX. 
 
 297 
 
 Malignant disease, total number of 
 cases of, 82. 
 
 growths, 121, 122. 
 Mammary glands, changes in 
 the, 64. 
 
 glands, destruction of the, 85. 
 
 glands, influence of the, upon 
 the menstrual function, 76. 
 
 glands, neoplasms of the, 77. 
 Mania, 38, 194, 211, 212. 
 Mastodynia, 221. 
 
 Melancholia, 38, 142, 211, 212, 215, 
 247, 248, 260. 
 
 of the menopause, 207-209. 
 Meningo-encephalitis, 114. 
 Menopause, 2, 3. 
 
 abrupt occurrence of the, 140. 
 
 accidental influences of the, 
 93. 
 
 accompaniments of the, 142. 
 
 according to modern writers, 9. 
 
 age for the, at the Oneida Com- 
 munity, 161. 
 
 age of American Indian women 
 at the, 98. 
 
 age among Hindus, and in Nor- 
 way, Kussia, Denmark, -Ger- 
 many, England, and France, 
 133, 134. 
 
 age among Danish, English, 
 French, German, Austrian, 
 Norwegian, and Russian wom- 
 en, 96-98. 
 
 age dependent upon climate, 
 etc., 28. 
 
 among the Shakers, 166. 
 
 anaemia during the, 196. 
 
 analogue of the, absent in ani- 
 mals, 12, 
 
 anatomical changes coincidental 
 with the, 42. 
 
 anatomical changes effected by 
 the, 41. 
 
 Menopause, anatomical changes 
 
 incidental to the, 78. 
 anatomical changes resulting 
 
 from the, 42. 
 
 anatomical changes which pro- 
 duce the, 42, 66. 
 ancient opinions of the, not well 
 
 founded, 17. 
 
 apparent, occurring premature- 
 ly, 262. 
 
 artificial, 131, 247. 
 artificial production of the, 239. 
 as a complication of visceral 
 
 diseases, 31. 
 association of the, with cancer, 
 
 198. 
 atrophic changes more uniform 
 
 in the natural, 86. 
 bearing of cancer during the, 32. 
 bearing of coincidental diseases 
 
 upon the, 31. 
 bearing of fertility and sterility 
 
 upon the, 143. 
 benign neoplasms developing 
 
 simultaneously with the, 83. 
 by Borner, 10. 
 by Kisch, 10. 
 careful selection of cases for the 
 
 induction of the, 240. 
 changes during the, 16. 
 changes in neoplasms during 
 
 and after the, 83. 
 changes in the outline of the 
 
 body during the, 29. 
 changes in the uterus during 
 
 the, 58. 
 changes in the uterus which 
 
 produce the, 70. 
 changes in women induced by 
 
 the, 41. 
 
 changes of the, are atrophic, 86 
 classification of experience of 
 
 the, 28.
 
 298 
 
 INDEX. 
 
 Menopause, compared with diges- 
 tion, 17. 
 
 concomitants of the, 29. 
 
 conservative character of the, 81. 
 
 considered as a cause of dan- 
 ger, 14. 
 
 course of menstruation and the, 
 in the sterile, 149. 
 
 deferred, 254. 
 
 definition of, 1, 15, 
 
 degeneration of neoplasms after 
 the, 84. 
 
 development of neoplasms after 
 the, 84. 
 
 diabetes with the, 112. 
 
 due to the pressure of neoplasms 
 of the uterus, 73. 
 
 due to traumatism, 108. 
 
 duration of the, 95. 
 
 early, 99, 253. 
 
 from disease of the genital or- 
 gans, 164. 
 
 not necessarily the result of 
 early puberty, 133. 
 
 occurrence of the, in the trop- 
 ics, 233. 
 
 erroneous views of the relation 
 of the, to haemorrhage, 128. 
 
 establishment of the, 249. 
 
 evils of the, exaggerated, 188. 
 
 exaggerated views concerning 
 the, lt>. 
 
 experience of the author con- 
 cerning the, 19. 
 
 explanation of degenerative 
 changes during the, 25. 
 
 factors which influence the ad- 
 vent and progress of the, 
 89, 92. 
 
 fails to come with many cases 
 of fibroid disease, 129. 
 
 faults of assimilation with the, 
 30. 
 
 Menopause, faults of digestion 
 with the, 30. 
 
 following injuries to the va- 
 gina, 75. 
 
 from chronic inflammatory pro- 
 cesses, 108. 
 
 from defective development, 
 118. 
 
 from excesses in alcohol or 
 venery, 265. 
 
 from excessive childbearing, 
 265. 
 
 from hard work, 265. 
 
 from injuries, 236. 
 
 from obesity, 116, 265. 
 
 from removal of the appendages, 
 253. 
 
 from superinvolution, 77, 116. 
 
 from the fortieth to the fiftieth 
 year, 28. 
 
 from the sequela? of parturition, 
 237. 
 
 from traumatism, 2S6. 
 
 functional activity at the begin- 
 ning of the, 91. 
 
 functional troubles of the, 30. 
 
 general congestion in the early 
 stages of the, 91. 
 
 general paralysis in relation to 
 the, 113. 
 
 haemorrhages of the, 37, 124, 
 197, 202, 203. 
 
 haemorrhages of the, due to vaso- 
 motor paralysis, 275. 
 
 hastened by destruction of the 
 genital organs, 85. 
 
 hope and longing for the, 73. 
 
 hysteria of the, 30. 
 
 if troublesome may intensify 
 pre-existing visceral disease, 
 38. 
 
 incomplete erroneous ideas con- 
 cerning, 82.
 
 INDEX. 
 
 299 
 
 Menopause indefinitely deferred, 
 87. 
 
 indicates completion of fruitful 
 period, 41. 
 
 indications for the artificial pro- 
 duction of the, 246. 
 
 induced by obesity, 234. 
 
 influence of age upon the, 92. 
 
 influence of climate upon the, 92. 
 
 influence of degenerative pro- 
 cesses upon the, 115. 
 
 influence of disease and trauma- 
 tism upon the, 92. 
 
 influence of the peritonaeum 
 upon the, 70. 
 
 influence of the vagina upon 
 the, 75. 
 
 influence of disposition as to 
 the, 151. 
 
 influence of heredity upon the, 
 93. 
 
 influence of menstrual life 
 upon the, 152. 
 
 influence of neoplasms upon 
 the, 120. 
 
 influence of nervous diseases 
 upon the, 112. 
 
 influence of occupation on the, 
 154. 
 
 influence of race upon the, 35. 
 
 influence of temperament, hab- 
 its, occupations, and social 
 surroundings upon the, 93. 
 
 influence of the genital organs 
 in the induction of the, 240. 
 
 influence of the, upon ovulation 
 and conception, 180. 
 
 influence of tumors of the ab- 
 dominal viscera upon the, 7. 
 
 influences of the, vary for differ- 
 ent women, 92. 
 
 inherent tendencies in individ- 
 uals as to the, 151. 
 
 Menopause in prostitutes, 161, 164, 
 165. 
 
 insanity of the, 38,210, 213, 278. 
 
 insignificance of the, with many 
 women, 142. 
 
 irregularities of the, from dis- 
 eased organs, 86. 
 
 irritability of disposition dur- 
 ing the, 30. 
 
 is premature prior to the fortieth 
 year, 252. 
 
 Kisch's analysis of 500 cases of 
 the, 18. 
 
 late, 100. 
 
 lateness of the. as a family char- 
 acteristic, 140, 
 
 is least troublesome in women 
 who are highly developed 
 physically rather than men- 
 tally, 12. 
 
 lesions of the mind and nerv- 
 ous system in connection 
 with the, 204. 
 
 lesions of the skin which may 
 accompany the. 218. 
 
 less to be feared as knowledge 
 concerning it increases, 25. 
 
 malignant degeneration result- 
 ing with the, 32. 
 
 malignant disease of the, 22. 
 
 may be established suddenly or 
 gradually, 244. 
 
 may be hastened by excessive 
 fertility, 144. 
 
 may be uneventful, 16. 
 
 melancholia of the, 207, 208. 
 
 mental disease of the, 22. 
 
 moderately troublesome, 30, 36. 
 
 modified by race peculiarities, 36. 
 
 mortality during the, from ma- 
 lignant disease, 23. 
 
 most significant among highly 
 bred women, 13.
 
 300 
 
 INDEX. 
 
 Menopause, neoplasms of the, 21. 
 
 nerve lesions of the, 278, 279. 
 
 nervous symptoms of the, 30, 205. 
 
 neuroses of the, 24. 
 
 new foundation for the, 11. 
 
 no distinct disease of the, 179- 
 
 normal, 28, 35. 
 
 not carefully observed by the 
 ancient writers, 7. 
 
 not induced by removal of the 
 appendages of one side, 253. 
 
 not necessarily followed by ma- 
 lignant disease, 197. 
 
 not responsible for degenerative 
 changes, 26. 
 
 observations as to the age of the, 
 133. 
 
 opinion of Larousse concerning 
 the, 15. 
 
 organic troubles of the, 30. 
 
 ovarian changes of the, 48. 
 
 past teaching about the, erro- 
 neous, 14. 
 
 phenomena of the, may be due 
 to bad habits, 195. 
 
 phenomena of the, normal and 
 morbid, 187, 208. 
 
 phenomena of the, prolonged, 
 37. 
 
 phenomena of the, varied, 15. 
 
 physical condition of women at 
 the time of the, 27. 
 
 premature. 112, 145, 230. 
 
 premature, caused by constitu- 
 tional or local lesions, 231. 
 
 premature, effective causes of 
 the, 232. 
 
 premature, factors which induce 
 the, 233. 
 
 premature, from exhaustion of 
 *the vital forces, 74. 
 
 premature, individual factor in 
 the, 232. 
 
 Menopause, premature, in the ex- 
 cessively fertile, 235. 
 premature, phenomena of the, 
 
 244, 245. 
 premature, substances which 
 
 may induce the, 234. 
 premature, surgically induced, 
 
 237. 
 premature, venereal disease 
 
 causing the, 235. 
 produced by removal of the 
 
 ovaries, 240. 
 production of the, 248. 
 profuse haemorrhage during the, 
 
 274. 
 prognosis of the mental disease 
 
 of the, 279. 
 prolonged, 140, 267- 
 regular, 267. 
 relation of excessive fertility to 
 
 the, 172. 
 relation of malignant disease of 
 
 the pelvis to the, 80. 
 relation of sexual excess and 
 
 abstinence to the, 155. 
 relation of the, to insanity, 
 
 211. 
 removal of the uterus to induce 
 
 the, 245. 
 resulting from amyloid disease, 
 
 71. 
 
 resulting from sudden impres- 
 sions, 108, 169. 
 retarded, 267. 
 retarded by neoplasms, 73. 
 second experience of the, 275. 
 seldom induced by disease of 
 
 the tubes, 69. 
 
 serious lesions of the, 32, 38. 
 severe types of the, 37. 
 sexual abstinence in its relation 
 
 to the, 166. 
 sexual ardor of the, 206.
 
 INDEX. 
 
 301 
 
 Menopause, sexual desire in its 
 relations with the, 257. 
 
 should be a normal function, 13. 
 
 signifies tissue changes, 90. 
 
 sometimes results in ameliora- 
 tion of uterine tumors, 128. 
 
 statistics concerning the, 169- 
 179. 
 
 substitute for the term, 2. 
 
 surgically induced, 131. 
 
 sweating of the, 272. 
 
 table showing the age of the, 94. 
 
 the normal, not a dangerous ex- 
 perience, 188. 
 
 the typical, an uneventful ex- 
 perience, 187. 
 
 Tilt's view concerning the, 17. 
 
 time required for the changes of 
 the, varies, 86. 
 
 trauma in the development of 
 the, 130. 
 
 treatment of the, 271. 
 
 uncomfortable, caused by occu- 
 pation, 153. 
 
 uneventful, 271. 
 
 unstable equilibrium of the 
 mind at the, 217. 
 
 uterine haemorrhages, 275. 
 
 various data concerning the, 11. 
 
 venesection for the, 8. 
 
 visceral disturbances of the, 30. 
 
 women who suffer from the, 271. 
 Menses, consequences of the arrest 
 
 of the, 8. 
 Menstrual derangements, 205. 
 
 disorder, 217. 
 
 era, prolongation of the, favored 
 l>y outdoor life, 132. 
 
 flow, 5. 
 
 flow, abrupt cessation of the, 245, 
 247. 
 
 flow diminished with anaemia 
 and nervous disease, 113. 
 
 Menstrual flow, increase of, from 
 malignant growths, 122. 
 
 fluid, 261. 
 
 function, 264, 269. 
 
 function, abolition of the, from 
 disease of the lungs and pleu- 
 ra, 110. 
 
 function, abolition of the, from 
 traumatism, 107, 108. 
 
 function, abolition of the, in va- 
 rious ways, 109. 
 
 function, brochure on the, 4. 
 
 function, cessation of the, 1. 
 
 function disturbed by infectious 
 inflammatory processes, 106. 
 
 function, early exhaustion of the, 
 136. 
 
 function, influence of fatty de- 
 generation of the uterus upon 
 the, 72. 
 
 function, influence of sea air 
 upon the, 137. 
 
 function, influence of the mam- 
 mary glands upon the, 76. 
 
 function, influence of neoplasms 
 of the mammary glands upon 
 the, 77. 
 
 function, restoration of the, 
 sometimes possible, 110. 
 
 function, result of sensitiveness 
 of the, 102. 
 
 history uninterrupted in certain 
 cases of hysterectomy, 75. 
 
 life, prolonged, 100. 
 
 life, stormy, 36. 
 
 life, unfavorable influences dur- 
 ing the, 152. 
 
 molimina, 246. 
 
 period, analogue of the, in ani- 
 mals, 11. 
 
 Menstruating women are ceremo- 
 nially unclean, 7. 
 Menstruation, abolition of, 106.
 
 302 
 
 INDEX. 
 
 Menstruation, abolition of, from 
 diabetes, 111. 
 
 abolition of, from disease of the 
 kidneys, 111. 
 
 absence of, 244. 
 
 after removal of the ovaries, 69. 
 
 among the Shakers, 166. 
 
 analogue of, in animals, 11, 12. 
 
 and reproduction, influence of 
 obesity upon, 235. 
 
 and the menopause, course of, in 
 the sterile. 149. 
 
 cessation of, 246, 252. 
 
 cessation of, ite relation to the 
 menopause, 15. 
 
 condition of the nutrition in, 236. 
 
 congestion of the genital organs 
 in, 11. 
 
 defined, 4. 
 
 different interpretation of, in 
 different ages, 6. 
 
 disappearance of the disturb- 
 ances of, 12. 
 
 disturbance of the nervous sys- 
 tem in, 11. 
 
 early appearance of, 160. 
 
 effect of climate, race, etc., upon, 
 135. 
 
 end of, not always the end of 
 ovulation. 180, 185. 
 
 Hegar's view concerning, 67. 
 
 histological consideration of, 4. 
 
 importance of, 5, 7, 11. 
 
 impulse to reproduction in, 11. 
 
 independent of integrity of the 
 ovaries, 232. 
 
 influenceof uterine tumors upon, 
 127. 
 
 inherent tendencies in individ- 
 uals concerning, 151. 
 
 in the tuberculous, 233. 
 
 may continue with disorganized 
 appendages, 236. 
 
 Menstruation may not be affected 
 
 by ovarian tumors, 126. 
 nerve influence in, 68. 
 painless under normal condi- 
 tions, 13. 
 
 profuse in the presence of uter- 
 ine tumors, 127. 
 
 recurrent, erroneous ideas con- 
 cerning, 82. 
 renewal of, 269, 275. 
 restoration of suspended, may be 
 
 impossible, 265. 
 scanty and painful in the obese, 
 
 235. 
 
 scanty and irregular, 246. 
 seldom repressed by disease of 
 
 the tubes, 69. 
 
 significance of, differently inter- 
 preted, 5. 
 
 sudden checking of, 168. 
 suspension of, 262-264. 
 with disease of the ovaries, 69. 
 with disease of the tubes, 69. 
 Mental condition, relation of the 
 
 ovaries to the, 217. 
 Mental disease, 278. 
 disease of the menopause, prog- 
 nosis of the, 279. 
 disorders, 215, 216. 
 disturbances of the menopause, 
 
 16. 
 Metritis, chronic parenchymatous, 
 
 79. 
 
 of the menopause, 19. 
 Metrorrhagia, 150. 
 Mind and nervous system, lesions 
 
 of the, 204. 
 unstable equilibrium of the, 
 
 217. 
 Modern writers on the menopause, 
 
 9. 
 
 Molimina, 150. 
 menstrual, 246, 247, 251.
 
 INDEX. 
 
 303 
 
 Monthly bleeding, cessation of the, 
 
 256. 
 
 Morbus niger, 8. 
 Mortality from malignant disease 
 
 of the genital organs, 23. 
 Muscular weakness, 206. 
 Myoma, uterine, 254. 
 Myomata, intramural, 74. 
 Myomatous enlargement of the 
 
 uterus, 31. 
 
 Narcotics, 210. 
 
 Natural menopause, atrophic 
 
 changes in the, 86. 
 Nature, state of, 157. 
 Neoplasms, 21, 120, 123, 125, 276. 
 changes in, during and after the 
 
 menopause, 83. 
 cystic, 121. 
 
 degeneration of, after the meno- 
 pause. 84. 
 development of, may continue 
 
 after the menopause, 84. 
 external to the organs of men- 
 struation, 121. 
 influence of, upon the uterus, 
 
 61. 
 
 malignant, evil effects of, 123. 
 of the mammary glands, 77. 
 of the ovaries, 68, 
 of the uterus, 73. 
 Nerve complications, depletive 
 
 measures in, 279. 
 lesions of the menopause, 278. 
 Nervines, 273. 
 
 Nervous and mental trouble re- 
 sulting in insanity, 31. 
 irritability, 204, 214. 
 phenomena of the menopause, 
 
 205. 
 
 symptoms of the menopause, 30. 
 system, disturbance of the, in 
 menstruation, 11. 
 
 Neuralgia, 221, 280. 
 ovarian, 239, 242. 
 pelvic, 249. 
 Neuroses, 24, 216. 
 
 following coitus, 64. 
 Nexus between the uterus and 
 
 ovaries, 75. 
 of menstruation and the ovaries, 
 
 232. 
 
 Nitrate of silver, 281. 
 Nondevelopment of the genital 
 
 structures, 261. 
 Normal menopause, 28. 
 Nosebleed, 138. 
 Nostrums, 282. 
 N ulliparae, married, 148. 
 Nutrition, condition of the, one of 
 the principal factors in men- 
 struation, 236. 
 sustained by adhesions, 115. 
 
 Obese, sufferings of the, 252. 
 Obesity as an inducer of the 
 
 menopause, 234, 265. 
 causing the menopause. 116. 
 favors scanty and painful men- 
 struation, 235. 
 favors sterility, 235. 
 formula concerning, 117. 
 from the artificial menopause, 
 
 247. 
 in those who have borne many 
 
 children, 252. 
 influence of, on menstruation 
 
 and reproduction, etc., 235. 
 influence of, upon the uterus, 
 
 60. 
 
 of the menopause, 29. 
 sudden occurrence of, 245. 
 Observations as to the age of the 
 
 menopause, 133. 
 Obsolete terms, 2. 
 Occupation, 150, 154.
 
 304 
 
 INDEX. 
 
 Occupation, effects of, upon cooks, 
 
 laundresses, and others, 154. 
 (Edema, chronic, 219. 
 Oligomenorrhcea, 117, 118, 154. 
 Oneida Community, 159, 160. 
 Oophoritis, 69. 
 Organic disease, 210. 
 disease of the brain, 214. 
 disease of the uterus, 210. 
 troubles of the menopause, 30. 
 Osteomalacia, 243. 
 Outbursts of excitement, 215. 
 Outline of the body is changed 
 
 during the menopause, 29. 
 Ova, the development and extru- 
 sion of the, 42. 
 
 Ovarian changes of the meno- 
 pause, 48, 66. 
 neuralgia, 239, 242. 
 tumors may not atfect menstrua- 
 tion, 126. 
 Ovaries, anatomical changes in 
 
 the, 42. 
 atrophy prior to atrophy of the 
 
 uterus, 52, 56. 
 changes occurring after removal 
 
 of the, 246. 
 condition of the, when ovulation 
 
 has ceased, 181-184. 
 cystic disease of the, 68. 
 degeneration of the, 68. 
 destruction of the, 106, 107. 
 independence of menstruation 
 as to the integrity of the, 232. 
 involvement of the, in uterine 
 
 disease, 74. 
 
 malignant disease of the, 68. 
 menstruation, pregnancy, and 
 labor after the removal of 
 the, 69. 
 
 neoplasms of the, 68. 
 regularity of function in the, 
 when diseased, 67. 
 
 Ovaries, reflexes from the uterus 
 
 and, 216. 
 relation of the, to the mental 
 
 condition, 217. 
 removal of the, 246, 247. 
 removal of the, prior to puberty, 
 
 200. 
 
 supernumerary, 254, 255. 
 the center of the reproductive 
 
 apparatus, 42. 
 variety of disease involving the 
 
 67. 
 
 Ovaritis, 260. 
 Ovary, 53, 250. 
 Overwork, results of, 36. 
 Oviducts, 250. 
 Ovulation, 247. 
 absence of corpora lutea marks 
 
 the end of, 181. 
 cessation of, marks the end of 
 
 the work of the ovary, 43. 
 changes in animals after the 
 
 cessation of, 251. 
 influence of the menopause 
 
 upon, 180. 
 
 means exuberance, 180. 
 not necessarily ended when 
 
 menstruation ends, 180, 185. 
 the function of the ovaries, 42. 
 continuance of, after menstrua- 
 tion has ceased, 42. 
 
 Paget's disease, 221. 
 Pain and neuralgia not always 
 cured by removal of the ap- 
 pendages, 259. 
 Palpitation, 224. 
 Paralysis, 280. 
 general, 113, 114 
 menstrual troubles the conse- 
 quence of, 114. 
 progressive, 205. 
 Paraplegia, 22.
 
 INDEX. 
 
 305 
 
 Parenchyma of the uterus, 276. 
 Parturition as a cause of injury 
 to the uterine mucous mem- 
 brane, 71. 
 injuries from, 237. 
 Pathologists, belief of humoral, 7. 
 Peculiarities of family or race as 
 a factor of the menopause, 28. 
 of Jewesses and Indians, 141. 
 reproduction of, in families, 140. 
 Pelvic congestion, 204, 247, 261. 
 neuralgia, 249. 
 organs, congestion of, 273. 
 peritonitis in prostitutes, 163. 
 troubles, sufferers from, 271. 
 Period, analogue of menstrual, in 
 
 animals, 11. 
 Peritonaeum, influence of disease 
 
 of the, 70. 
 Peritonitis, pelvic, in prostitutes, 
 
 163. 
 
 septic, 240. 
 
 Phenomena, nervous and vascu- 
 lar, 245. 
 of the menopause, common and 
 
 infrequent, 190. 
 of the menopause determined 
 
 by the disposition, 191. 
 of the menopause, distinct or 
 
 intcrblending, 194. 
 of the menopause may be due 
 
 to bad habits, 195. 
 of the menopause, nervous, 205. 
 of the menopause, normal and 
 
 morbid, 187. 
 
 of the menopause, varied, 15. 
 of the menopause, vasomotor, 
 
 191, 192. 
 of the premature menopause 
 
 vary, 231. 
 
 Pigment, deposits of, 220. 
 Pigmentation, 219. 
 Plexus, hypogastric, 5. 
 21 
 
 Plexus, solar, 5, 
 
 tubo-ovarian, 5. 
 Polymenorrhoea, 154. 
 Poverty of the blood, 196. 
 Pregnancy after the removal of 
 
 the ovaries, 69. 
 
 following extirpation of the ap- 
 pendages, 255. 
 occurrence of, after the cessation 
 
 of menstruation, 43. 
 prevention of, sometimes war- 
 ranted, 145. 
 
 Premature menopause, 230, 252. 
 menopause caused by constitu- 
 tional or local disease, 231. 
 menopause from traumatism, 
 
 236. 
 
 menopause is unnatural, 231. 
 menopause, phenomena of the, 
 
 231, 244, 245. 
 
 Pressure influence of solid tu- 
 mors, 125. 
 
 of unabsorbed ligatures, 249. 
 Privation, results of, 36. 
 Profuse perspiration, 272. 
 Prognosis of climacteric insanity, 
 
 212, 215, 216. 
 of melancholia, 207, 208. 
 of mental disease, 279. 
 Progressive paralysis, 26, 205. 
 Prolapsus uteri, 20, 61. 
 uteri, relief to, from atrophy, 58. 
 vaginae, 63. 
 
 Prolongation of menstrual era, 132. 
 Prostitutes, menopause in, 161, 
 
 165. 
 very susceptible to disease, 162, 
 
 163. 
 
 Pruritus, 221. 
 vaginae, 21. 
 vulvse, 21, 63. 
 Pseudo-cyesis, 215. 
 lipomata, 219.
 
 306 
 
 INDEX. 
 
 Pseudo-narcotism, 206. 
 
 pregnancy, 195, 196. 
 Psychical disease, 208. 
 
 disturbances, 247. 
 Psychoses, 216. 
 
 climacteric, 215. 
 
 following coitus, 64. 
 Ptyalism, 225. 
 Puberty, 2, 133, 134. 
 
 early, significance of, 133. 
 Pulmonary phthisis, 214. 
 Purging, 279. 
 Purpura, 138. 
 
 Race, influences of, 35. 
 modifying peculiarities of, 36. 
 
 Radical measures indicated for 
 cancer, 277. 
 
 Reflexes from the uterus and ova- 
 ries, 216. 
 
 Remittent fever, 234. 
 
 Remorse, 214. 
 
 Removal of the ovaries, 246, 247. 
 of the ovaries prior to puberty, 
 
 260. 
 
 of the uterus may be necessary, 
 245-247. 
 
 Renewal of menstruation, 275. 
 
 Reproduction of family peculiari- 
 ties, 139. 
 
 Restoration of the suspended men- 
 strual function may be im- 
 possible, 265. 
 
 Resume concerning anatomical 
 changes, 86. 
 
 Retroflexion of the uterus, 21. 
 
 Rheumatism, 223, 224. 
 
 Risk of acclimation at great alti- 
 tudes, 139. 
 
 Rotundity, 29. 
 
 Sachsenburg, asylum of, 216. 
 Salines, 273, 279. 
 
 Salpingitis, 260. 
 
 Salt-water baths, 273. 
 
 Savages do not show the best types 
 
 of sexual life, 157. 
 Scar tissue, 26. 
 
 Scheme of factors in the advent 
 and progress of the meno- 
 pause, 90. 
 
 Secretion, glandular, 4. 
 Sedatives, 213. 
 Senile hysteria, 206. 
 Senility, beginning of, 4. 
 Sensitiveness of women to impres- 
 sions, 167. 
 Septicaemia. 234. 
 Septic peritonitis, 240. 
 Sequela? of parturition, 237. 
 Sexual appetite, 257, 259. 
 appetite, condition of the, 91. 
 appetite, disturbance of the, 
 
 from kidney disease, 111. 
 appetite, imperious character of 
 
 the, 155. 
 ardor, 194, 257. 
 desire, 247. 
 
 desire, relations of the, 257. 
 excess, 155, 156. 
 excitement, 274. 
 feeling, 247. 
 intercourse, 258. 
 intercourse, early, 16. 
 intercourse, frequent, 161. 
 intercourse, ideas among the 
 
 Shakers concerning, 166. 
 life among savages, 157. 
 organs, degenerative changes in 
 
 the, 215. 
 relation, 258. 
 
 Shakers, menstruation and the 
 menopause among the,166, 167. 
 Shocks, results of nervous, 36. 
 Skin and Cancer Hospital, table 
 of cases from the, 33, 34.
 
 INDEX. 
 
 307 
 
 Skin, lesions of the, 218, 219. 
 
 lesions of the, upon the breasts, 
 220. 
 
 prickling of the, 206. 
 Sleeplessness, 206. 
 Social surroundings, 28, 150. 
 Solar plexus, 5. 
 Soul, fear of losing the, 209. 
 Southern Ohio Lunatic Asylum, 
 
 211. 
 
 Spaying, 250. 
 Spleen, 281. 
 
 Stasis, influence of venous, 61. 
 State of nature, 157. 
 Statistics concerning the meno- 
 pause, 169-179. 
 
 United States census, 22. 
 Stenosis causing hydrometra, 57. 
 
 of the cervical canal, 56. 
 
 of the uterine canal, 75. 
 Sterile, course of menstruation and 
 
 the menopause in the, 149. 
 Sterility common with obese wo- 
 men, 235. . 
 
 in the obese, 252. 
 Stock breeders, experience of, 
 
 158. 
 
 Structure of the body, etc., inde- 
 pendent of the ovaries, 250. 
 Structural changes follow fruition, 
 
 41. 
 
 Subinvolution of the uterus, 79. 
 Substitutes for the term meno- 
 pause, 2. 
 
 Substitutional haemorrhage, 246. 
 Sufferers at the menopause, 37. 
 Suicidal and homicidal impulse, 
 209. 
 
 tendency, 211. 
 Suicide, 210. 
 
 Superinvolution, 77, 116, 265. 
 Supernumerary ovaries, 254, 255. 
 Superstition, 282. 
 
 Suspension of menstruation, 262-^ 
 
 264. 
 Sweating, 113, 272. 
 
 and other phenomena, 193. 
 
 irregular, 246. 
 Sympathetic nerve lesions, 278. 
 
 system, 278. 
 Syncope, 224. 
 Syphilis, 234, 235. 
 
 Table of cases from the Skin and 
 
 Cancer Hospital, 33, 34. 
 Tachycardia, 224. 
 Tampon, 277. 
 
 vaginal, 279, 281. 
 Temperament, 28, 93, 150. 
 Tendencies inherent in individu- 
 als, 150, 151. 
 
 Tension, increase of the blood, 31. 
 Time, critical, 2. 
 dodging, 2. 
 
 required for changes varies, 86. 
 Tradition, 282. 
 Trauma, 130. 
 
 Traumatic inflammatory pro- 
 cesses, 106, 107. 
 Traumatic or infectious origin of 
 
 anatomical changes, 84. 
 Traumatism as a cause of change 
 in the uterine mucous mem- 
 brane, 71. 
 
 causing the premature meno- 
 pause, 236. 
 destruction of the genital organs 
 
 by, 130. 
 Treatment of climacteric insanity, 
 
 213* 
 
 of cutaneous complications, 280. 
 Tuberculosis, 72, 233, 244. 
 Tubes, importance of removal of 
 
 the, 240. 
 
 Tubo-ovarian plexus, 5. 
 Tumor mammae, 21.
 
 308 
 
 INDEX. 
 
 Tumors, benign, 127. 
 influence upon menstruation of 
 
 uterine, 127. 
 Turgescence, 251. 
 Tympanites, 195, 206. 
 Typhoid fever, 234 
 Typhus fever, 234. 
 
 Uncertainty in walking, 206. 
 Unfavorable experience during 
 
 menstrual life, 152. 
 Uniformity in the physical con- 
 dition of women, 27. 
 United States census, 22, 228. 
 Unrest, results of, 36. 
 Urine, abundant discharge of, 
 
 194 
 
 Urticaria, 280. 
 Uterine canal, 4. 
 canal, atresia and stenosis of the, 
 
 75. 
 
 fibroid may defer the meno- 
 pause, 129. 
 
 haemorrhage, 128, 214. 
 myoma, 254. 
 
 tumors, influence of, upon men- 
 struation, 127. 
 
 tumors, influence of the meno- 
 pause upon, 128. 
 Uterus, abstraction of blood from 
 
 the, 279. 
 
 adenomata of the, 74. 
 anatomical changes in the, 53, 
 
 55, 58. 
 
 anatomical changes in the mu- 
 cous membrane of the, 71, 
 atrophy of the, 59, 61. 
 bleeding fibroid of the, 246. 
 cancer of the, 209, 277. 
 classification of the anatomical 
 
 changes in the, 58, 70. 
 congestion of the, 59. 
 discharges from the, 91, 204. 
 
 Uterus, disease of the, resulting in 
 
 abscess, 71. 
 
 displacements of the, 20, 62. 
 effect upon the, of poisons, 71. 
 extension of the, 61. 
 extirpation of the, 247. 
 fatty degeneration of the, 72. 
 glandular discharge from the, 
 
 59, 61. 
 haemorrhage from fibroids of 
 
 the, 37. 
 
 haemorrhage from the, 59, 269. 
 hypertrophy of the, 59, 61. 
 influence of obesity upon the, 
 
 60. 
 
 malignant disease of the, 27. 
 myomatous enlargement of the, 
 
 31. 
 
 neoplasms of the, 73. 
 organic disease of the, 210. 
 parenchyma of the, 276. 
 prolapse of the, 61. 
 reflexes from the, and ovaries, 
 
 316Q 
 
 removal of the, 240, 245-247. 
 subinyolution of the, 79. 
 superin volution of the, 77. 
 tamponade of the, 276. 
 unicornate, 119. 
 
 Vagina, anatomical changes in 
 the, 62, 63. 
 
 atresia of the, 75, 76. 
 
 congestion of the, 62. 
 
 defective, 119. 
 
 discharges from the, 280. 
 
 influence of disease of the, 75. 
 
 injuries of the, 75. 
 
 preliminary changes in the, 62. 
 
 prolapse of the, 63. 
 
 tampon of the, 276. 
 Vaginal douches, 274. 
 
 tampon, 279, 281.
 
 INDEX. 
 
 309 
 
 Varieties of vasomotor disturb- 
 ances, 193. 
 Variety of diseases involving the 
 
 ovaries, 67. 
 
 Various classes of sufferers, 37. 
 Vasa brevia of the stomach, 8. 
 Vasomotor crises, 29-31, 96. 
 
 disturbances, 16, 150, 191-193, 
 253, 259. 
 
 paralyses, 272, 275, 278, 280. 
 
 phenomena, 254, 262, 272. 
 Venereal disease, 235. 
 
 disease in prostitutes, 163. 
 
 excesses, 36. 
 Venesection, 8,199. 
 Venous stasis, influence of, 61. 
 Ventral hernia, 254. 
 Vertigo, 246. 
 
 Victims of erroneous views, 198. 
 Views, exaggerated, 16. 
 Virgins, 148. 
 Visceral disease, chronic, 244. 
 
 disease, intensified, 38. 
 
 disturbance, 30. 
 Vomiting, 223. 
 Vulva, 64. 
 
 Wasting diseases, influence of the, 
 
 232. 
 
 Watchfulness, 213. 
 Weak pulse, 224. 
 West Riding Asylum report, 204, 
 
 213. 
 Worry, results of, 36. 
 
 Yellow fever, 234. 
 
 THE END.
 
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 of obstetric science, and safe guide to student and practitioner." London 
 Lancet. 
 
 "It is but a short time since we had occasion to review this work, of 
 which we were enabled to speak in the highest terms of praise. The rapid 
 advance of many departments of obstetrics has meantime called for a few 
 additions. These having been made, it can be confidently said that Lusk's 
 Midwifery holds a high place among American authors, and deserves to be 
 extensively employed for reference, and recommended to students as a re- 
 liable and unusually readable text-book." Canada Medical and Surgical 
 Journal. 
 
 New York: D. APPLETON & CO., Publishers, 72 Fifth Avenue.
 
 MONTHLY NURSING 
 
 By A. WORCESTER, A. M., M. D., 
 
 Fellow of the Massachusetts Medical Society , Physician to the 
 Walthain Hospital. 
 
 SECOND EDITION. 
 
 12mo, 250 pages. Cloth, $1.25. 
 
 " This little work, intended as a text-book for nurses, is a mottel 
 of its kind, and it is a pity that its scope is limited, as its name 
 implies, to obstetric nursing. . . . The book is issued in a neat and 
 attractive style, and contains many practical hints which would not 
 come amiss to the physician, which he would not otherwise learn, 
 except through experience." Weekly Medical Review. 
 
 " This is one of the most practical little books we have seen. 
 Not only does it reveal the duties of the nurse, but it contains an 
 amount of useful details that will be invaluable to the young prac- 
 titioner." Practice. 
 
 "... We regard this book as of great importance, and doctors 
 should insist upon their monthly nurses adopting it as a text-book 
 for constant bedside use." Virginia Medical Monthly. 
 
 " This little volume is one of the most complete treatises of the 
 kind we have seen. Mothers and nurses will find it invaluable." 
 New York Medical Times. 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 A MANUAL OF INSTRUCTION 
 
 IN THE PRINCIPLES OF 
 
 Prompt Aid to the Injured. 
 
 INCLUDING A CHAPTER ON HYGIENE, AND THE DRILL 
 
 REGULATIONS FOR THE HOSPITAL CORPS, U. S. A. 
 
 DESIGNED FOR MILITARY AND CIVIL USE. 
 
 By ALVAH H. DOTY, M.D., 
 
 Major and Surgeon, Ninth Regiment, N. G. S. N. Y. ; Attending Surgeon to 
 Bellevue Hospital Dispensary, New York. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 12mo. 3O4 pages, with 124 Illustrations. Cloth, 81. 5O. 
 
 This book is intended to impart the knowledge necessary for the prompt 
 and intelligent care of persons suffering from hemorrhage, fractures, dislo- 
 cations, wounds, contusions, burns, shocks, sprains, poisoning, the effects 
 of heat or cold, apoplexy, epilepsy, those rescued from the water, and other 
 accidents which are liable to occur at any time, the results of which may be 
 materially influenced by the care and attention which the sufferer receives at 
 the outset. 
 
 The book is of a size convenient for the pocket, and embraces a greater 
 range of subjects than is found in any work of the kind heretofore pub- 
 lished ; and its completeness and simplicity commend it to the general public 
 as well as to that portion which forms the militia of the States of the Union. 
 
 "... This is the most satisfactory little monograph on this subject with which 
 we are familiar. It is enriched by numerous illustrations, taken, with due credit, 
 largely from the works of Esmarch, Flint, and others. In addition to the usual 
 matter contained in such little works, a chapter on Hygiene has been introduced, 
 and also one containing the recently adopted drill regulations of the ambulance 
 corps of the United States Army." Columbus Medical Journal. 
 
 ". . .This book should be in every physician's office. This edition will sus- 
 tain the reputation acquired by its predecessor in every respect, and the work is 
 likely to have a wide field of usefulness." Charlotte Medical Journal. 
 
 "... It is a manual written in plain, clear style. It would be of value in the 
 hands of the police of large cities. The instructions are good, and particularly 
 those of the chapter on Haemorrhage. The chapter on Hygiene is a desirable addi- 
 tion." Medical Standard. 
 
 " . . . It is the best book that the layman, hospital assistant, or nurse can get, 
 and it is a most excellent work for the medical man also. To be pointed in our 
 opinion, we say unhesitatingly it is the best book of its kind we have ever seen." 
 Southern Clinic. 
 
 "... To the ambulance corps connected with the different military organiza- 
 tions it will be especially valuaole ; and not less so to all those who may at any 
 time be benefited by the knowledge or application of its excellent precepts and 
 practical suggestions." College and Clinical Record. 
 
 "... The author seems to have succeeded remarkably well in the difficult task 
 of giving to nonmedical persons information which will properly instruct them 
 to cope with emergencies without encouraging them to usurp the functions of the 
 physician or surgeon." Charleston Sunday News. 
 
 New York : D. APPLETON & CO., 72 Fifth Avenue.
 
 A TEXT-BOOK ON 
 THE DISEASES OF WOMEN. 
 
 By ALEXANDER J. C. SKENE, M. D., 
 
 Professor of Gynaecology in the Lone Island College Hospital, Brooklyn, N. Y., 
 
 formerly Professor of Gynaecology in the New York Post-Graduate 
 
 Medical School and Hospital, etc. 
 
 With Two Hundred and Fifty-four Illustrations, of which One Hundred and 
 Sixty-five are Original and Nine Chromolithographs. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 SOLD BY SUBSCRIPTION ONLY. 
 
 THIS treatise is the outcome and represents the experience of a long 
 and active professional life, the greater part of which has been spent in 
 the treatment of the diseases of women. It is especially adapted to meet 
 the wants of the general practitioner in recognizing this class of diseases 
 as he meets them in every-day practice and in treating them successfully. 
 
 The arrangement of subjects is such that they are discussed in their 
 natural order, and thus more easily comprehended and remembered by 
 the student. 
 
 Methods of operation have been much simplified by the author in his 
 practice, and it has been his endeavor to so describe the operative pro- 
 cedures adopted by him, even to their minutest details, as to make his 
 treatise a practical guide to the gynaecologist. 
 
 Although all the subjects which are discussed in the various text- 
 books on gynaecology have been treated by the author, it has been a 
 prominent feature in his plan to consider also those which are but inci- 
 dentally, or not at all, mentioned in the text-books hitherto published, 
 and yet which are constantly presenting themselves to the practitioner 
 for diagnosis and treatment. 
 
 The illustrations are mostly entirely new, and have been specially 
 made for this work. The drawings are from nature, or from wax and 
 clay models from nature, and have been reproduced by processes best 
 adapted to represent in the most truthful and permanent forms the exact 
 appearances of the diseased organs, methods of operation, or instrument? 
 which they are designed to illustrate. 
 
 Wherever it has been possible to make clearer the author's methods 
 of treatment by histories of cases which have actually occurred in his 
 practice, this has been done. A simple, typical case, such as is ordi- 
 narily met with, is first described, and then difficult and obscure cases, 
 with the various complications which occur. 
 
 New York : D. APPLETON & CO., 72 Fifth Avenue.
 
 Appletons 
 
 Popular Science Monthly. 
 
 Edited by WILLIAM JAY YOU MANS. 
 
 The Popular Science Monthly is without a competitor. 
 
 It is not a technical magazine. 
 
 It stands alone as an educator, and is the best periodical 
 for people who think. 
 
 All its articles are by writers of long practical ac- 
 quaintance with their subjects, and are written in 
 such a manner as to be readily understood. 
 
 It deals particularly with those general and practical 
 subjects which are of the greatest interest and im- 
 portance to the people at large. 
 
 It keeps its readers fully informed of all that is being 
 done in the broad field of science. 
 
 Illustrations, from drawings or photographs, are freely 
 used in all cases in which the text may be thereby 
 elucidated. 
 
 Examination of any recent number will more than con- 
 firm the foregoing. 
 
 $5.00 per annum; single copy, 50 cents. 
 New York: D. A PPL ETON & CO., 72 Fifth Avenue.
 
 i// New, Thoroughly Revised, and Enlarged Edition of 
 
 Quain's Dictionary of Medicine. 
 
 BY VARIOUS WRITERS. 
 
 EDITED BY 
 
 Sir RICHARD QUAIN, Bart, M. D., LL. D., etc., 
 
 Physician Extraordinary to Her Majesty the Queen ; Consulting Physician to the 
 Hospital for Diseases of the Chest, Brompton, etc. 
 
 Assisted by FREDERICK THOMAS ROBERTS, M. D., B. Sc., 
 
 Fellow of the Royal College of Physicians, etc. ; 
 
 And J. MITCHELL BRUCE, M.A., M. D., 
 Fellow of the Royal College of Physicians, etc. 
 
 WITH AN AMERICAN APPENDIX 
 
 By SAMUEL TREAT ARMSTRONG, Ph. D., M. D., 
 
 Visiting Physician to the Harlem, Willard Parker, and Riverside Hospitals, New York. 
 
 IN TWO VOLUMES. Sold only by subscription. 
 
 This work is primarily a Dictionary of Medicine, in which the several diseases are 
 fully discussed in alphabetical order. The description of each includes an account of 
 its etiology and anatomical characters ; its symptoms, course, duration, and termi- 
 nation ; its diagnosis, prognosis, and, lastly, its treatment. General Pathology com- 
 prehends articles on the origin, characters, and nature of disease. 
 
 General Therapeutics includes articles on the several c'asses of remedies, their 
 modes of action, and on the methods of their use. The articles devoted to the sulject 
 of Hygiene treat of the causes and prevention of disease, of the agencies and laws 
 affecting public health, of the means of preserving the health of the individual, of the 
 construction and management of hospitals, and of the nursing of the sick. 
 
 Lastly, the diseases peculiar to women and children are discussed under their re- 
 spective headings, both in aggregate and in detail. 
 
 The American Appendix gives more definite information regarding American 
 Mineral Springs, and adds one or two articles on particularly American topics, besides 
 introducing some recent medical terms and a few cross-references. 
 
 The British Medical Journal says of the new edition : 
 
 "The original purpose which actuated the preparation of the original edition was, 
 to quote the words of the preface which the editor has written for the new edition, 'a 
 desire to plac ; in the hands of the practitioner, the teacher, and the student a means 
 of ready reference to the accumulated knowledge which we possessed of scientific and 
 practical medicine, rapid as was its progress and difficult of access as were its scat- 
 tered records ' The scheme of the work was so comprehensive, the selection of writers 
 so judicious, that this end was attained more completely than the most sanguine ex- 
 pectations of the able editor and his assistants could have anticipated. ... In pre- 
 paring a new edition the fact had to be faced that never in the history cf medicine had 
 progress been so rapid as in the last twelve years. New facts have been ascertained, 
 and new ways of looking at old facts have come to be recognized as true. ._ . . The 
 revision which the work has undergone has been of the most thorough and judicious 
 character. . . . The list of new writers numbers fifty, and among them are to be found 
 the names of those who are leading authorities upon the subjects which have been com- 
 mitted to their care." 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 A TREATISE ON INSANITY, 
 
 IN ITS MEDICAL RELATIONS. 
 
 By WILLIAM A. HAMMOND, M.D., 
 
 Burgeon-General U. 8. Array (retired list) ; Professor of Diseases of the Mind and 
 
 Nervous System in the New York Post-Graduate Medical School ; 
 
 President of the American Neurological Association, etc. 
 
 8vo, 767 pages. Clotb, $5.00 ; sheep, $6.00. 
 
 In this work the author has not only considered the subject of Insanity, 
 but has prefaced that division of his work with a general view of the mind 
 and the several categories of mental faculties, and a full account of the vari- 
 ous causes that exercise an influence over mental derangement, such as 
 habit, age, sex, hereditary tendency, constitution, temperament, instinct, 
 sleep, dreams, and many other factors. 
 
 Insanity, it is believed, is in this volume brought before the reader in an 
 original manner, and with a degree of thoroughness which can not but lead 
 to important results in the study of psychological medicine. Those florins 
 which have only been incidentally alluded to or entirely disregarded in the 
 text-books hitherto published are here shown to be of the greatest interest 
 to the general practitioner and student of mental science, both from a 
 normal and abnormal stand-point. To a great extent the work relates to 
 those species of mental derangement which are not seen within asylum 
 walls, and which, therefore, are of special importance to the non-asylum 
 physician. Moreover, it points out the symptoms of Insanity in its first 
 stages, during which there is most hope of successful medical treatment, 
 and before the idea of an asylum has occurred to the patient's friends. It is 
 believed that the issue of this work will constitute an era in the progress of 
 the study of Insanity. 
 
 New York : D. APPLETON & CO., 72 Fifth Avenue.
 
 A TEXT-BOOK OF 
 HUMAN PHYSIOLOGY. 
 
 By AUSTIN FLINT, M. D., LL. D., 
 
 Professor of Physiology and Physiological Anatomy in the Bellevue Hospital Medical 
 College, New York; Visiting Physician to Bellevue Hospital, etc. 
 
 Illustrated with Three Hundred and Sixteen Woodcuts ar.d Two Plates. 
 FOURTH EDITION, REWRITTEN. 
 
 8vo, 890 pages. - - Cloth, $6.00; sheep, $j.oo. 
 
 "Dr. Flint has long been recognized as a teacher of distinction upon the subject of 
 physiology. A new wc-rk which this practically is from his pen is of importance to 
 the student of medicine. . . . The form and typography of the book have been changed 
 and very much improved. . . ." Buffalo Medical and Surgical Journal. 
 
 "As a teacher and experimenter in physiology the author of this work is well 
 known, and we hail with delight this new edition of his book. . . . The mechanical 
 part of the publication does great credit to the publishers, for the type is open and clear- 
 the paper fine, the illustrations well executed, and the whole strongly bound together, 
 Physicians who wish to be acquainted with all the latest facts of physiology will do well 
 to possess themselves of this volume." Medical Register. 
 
 " This is the fourth edition of one of the most popular American text-books. A com- 
 parison with former editions shows that while the general arrangement of subjects has 
 been retained, bul little remains of the original text; it has, indeed, been entirely re- 
 written in order to keep pace with the rapid advances in physiological research. The 
 author has adopted the new chemical nomenclature, and he has very wisely retained 
 the English weights and measures and the Fahrenheit scale of the thermometer, placing 
 their metric equivalents in parentheses. If one thing more than another has contributed 
 to make this the Text-Book of Human Physiology, it is that established facts have been 
 allowed to take precedence over peculiar views and pet theories, whether of the author 
 or of others." Practice. 
 
 THK 
 
 SOURCE OF MUSCULAR POWER. 
 
 Arguments and Conclusions drawn from Observations upon the 
 Human Subject under Conditions of Rest and Muscular Exercise. 
 
 By AUSTIN FLINT, Jr., M. D., 
 
 Professor of Physiology in the Bellevue Hospital Medical College, New York, etc. 
 8vo, 10} pages. Cloth, $1.00. 
 
 ON THE PHYSIOLOGICAL EFFECTS 
 
 OF SEVERE AND PROTRACTED MUSCULAR EXERCISE. 
 With Special Reference to its Influence upon the Excretion of Nitrogen. 
 
 By AUSTIN FLINT, Jr., M. D., 
 
 Professor of Physiology in the Bellevue Hospital Medical College, New York, etc. 
 8vo, 91 pages. Cloth, $1.00. 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 Functional Nervous Diseases: 
 
 THEIR CAUSES AND THEIR TREATMENT. 
 
 Memoir for the Concourse of 1881-1883, Academie Royale de Medecine d? Belgique. 
 With, a SuppleTient, on the Anomalies of Refraction and Accommoda- 
 tion of the Eye, and of (fie Ocular Muscles. 
 
 By GEORGE T. STEVENS, M.D., Ph. D., 
 
 MEMBER OF THB AMERICAN MEDICAL ASSOO1 iTION, OF THE AMERICAN OPHTHALMO- 
 
 LOG1CAL SOCIETY, ETC.; FOEMEELY PROFESSOR OK OPHTHALMOLOGY AND 
 
 PHYSIOLOGY IN THE ALBANY MKDICAL COLLEGE. 
 
 Small 8vo, 217 pages. With Six Photographic Plates and Twelve Illustrations. 
 Cloth, $2.5O. 
 
 The main portion of this work is one of the several memoirs which were pre- 
 sented to the Royal Academy of Medicine in 1883, some of which were contributed 
 by Europeans of pre-eminent rank in the department of Nervous Diseases. To the 
 present memoir the highest honors were awarded. 
 
 Dr. Stevens does not, in this work, present a treatise upon all the known facts 
 relating to the etiology and therapeutics of the disorders considered. He has, to a 
 great extent confined the work to a discussion of the relation of ocular defects to the 
 class of complaints known as -'functional nervous diseases. 1 ' 
 
 The relations of the accommodating and rotating muscles of the eyes, and of the 
 perplexities arising from a want of harmony in the performance of the function of 
 accommodation and of adjustments, are forcibly stated, and- the author declare? that. 
 in the absence of harmnnio is action, "continual compromising adjustments must be 
 made and great nervous perplexity must occur : for no sooner is one part of the ad- 
 justment corrected than the other is wrong." He illustrates this principle by several 
 interesting but well-known facts. 
 
 The work takes up in order various forms of functional diseases, such as Cepha- 
 lal'.-ia. Migraine, Neuralgia, Chorea, Epilepsy, etc.. and after a concise description of 
 the main characteristics of each, brings each to the test of his hypothesis. A number 
 of illustrative cases are introduced under each beading. Photographs from typical 
 cases of neuroses are introduced, in which the striking changes of physiognomy 
 resulting from relief of the tension of the eye-muscles in such cases is shown. Some 
 of these contrasts are very remarkable, and fully confirm the statements trade in the 
 text. 
 
 In the general summary of treatment the author dwells emphatically upon the 
 necessity of givinsr mimite'attention to the ocular conditions. He does' not ignore 
 other therapeutic measures, such as tonics, rest, change of air and scene, electrici'y, 
 and other agencies known to exert favorable influences, but these measures, familiar 
 to all students of nervous diseases, are too well known to require discussion in this 
 work, and the author refers the reader to treatises of a more general character :or 
 the consideration of those agencies. 
 
 In the supplemental portion of the work the subject of refractive and muscular 
 anomalies of the eyes is tersely presented. These subjects are treated in so lucid and 
 practical a manner as to enable the general practitioner, who would like to make ex- 
 aminations of the eyes of his nervous patients, to accomplish it in a satisfactory man- 
 ner. In the chapters on muscular anomalies very much that is new is presented. 
 This work introdueas the reader to ano nalies of the; eye-muscles in all directions, and 
 it is claimed by the author that insufficiency of the interni" is not only not the sole 
 important anomaly of its class, but that it is not the one of the greatest importance. 
 He has tiioro'ighly systi-matizt-d the study of this class of anomalies, in which respect 
 he has certainly made a great advance. 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 DATE DUE 
 
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