Part 85

3. The sexual activity of the woman during the period of the menacme, the number of her pregnancies, the exercise or neglect of the function of lactation.

4. The social circumstances of the woman’s life.

5. General constitutional and pathological conditions.

1. Race.

From the statistical data regarding the age at which the menopause occurs among the women of the various nations of Northern Europe, it appears that the latest average age for the cessation of menstruation is met with in Lapland, namely 49.4 years; next comes Norway, where the average age is 48.9; next Germany, where the average age is 47; next England, 46.1; next Russia, 44; and finally Austria, 42.2. In the four principal capital cities, the average age is: in London, 45.5; in Paris, 43.65; in Vienna, 43, and in Berlin, 47. Generally speaking, in southern countries the cessation of menstruation occurs at an earlier age than in northern countries, as the following comparison shows: northern countries: England (Tilt), 48 to 50; France (Courty), 50; North Germany (Mayer), 50; Austria (Szukits), 42; southern counties: Persia (Chardin), 27; Java, 30; various Asiatic races, 30 to 40.

In the case of 500 women of various nationalities in whom I was able to ascertain by personal observation the age at which menstruation ceased, I found that the menopause occurred:

In the quinquennium 35 to 40 in 48 women In the quinquennium 40 to 45 in 141 women In the quinquennium 45 to 50 in 177 women In the quinquennium 50 to 55 in 89 women ——— 455

Thus we see that in about one tenth of my cases, menstruation ceased between the ages of 35 and 40; in more than one-fourth, between the ages of 40 and 45; in more than one-third between the ages of 45 and 50; and in about one-sixth between the ages of 50 and 55. In 267, that is, in more than one-half of the 500, menstruation ceased between the ages of 42 and 51. In 28 women, menstruation ceased before the age of 35; and in 17, after the age of 55. In a very large majority of my 500 cases the women were of German or Austro-Hungarian nationality; next, in order of frequency, came Poles, Russians, women of various southern countries, Swedish women. In women of Slavonic nationality, menstruation ceased remarkably late as compared with women of German nationality.

Brierre de Boismont, Tilt, Courty, and various other observers, have published statistical data regarding the age at which menstruation ceases in women of different nationalities. Krieger, compiling from several authors, statistics relating to 2291 women (European) gives the following average results: menstruation ceased

Between the ages of 35 and 40 in 272 women 11.87 per cent. Between the ages of 40 and 45 in 595 women 25.97 per cent. Between the ages of 45 and 50 in 940 women 41.03 per cent. Between the ages of 50 and 55 in 334 women 14.58 per cent. Before 35 and after 55 in 150 women 6.54 per cent. ———— ————— 2291 99.99

We append a statistical table showing the average age at which menstruation ceases in women of different European nationalities:

══════════════╤════════╤════════════════╤════════╤═════════ │Germany.│Austria-Hungary.│ France │ England │ │ │(Paris).│(London). ──────────────┼────────┼────────────────┼────────┼───────── Number of │ 824│ 256│ 178│ 500 cases │ │ │ │ Average age at│ │ │ │ the │ 47.0│ 42.2│ 44.0│ 46.1 cessation of│ │ │ │ menstruation│ │ │ │ │ │ │Brierre │ Observer │ Magar │ Szukits │ de │ Tilt │ │ │Boismont│ ══════════════╧════════╧════════════════╧════════╧═════════

══════════════╤═══════╤════════╤═══════╤════════ │Russia.│Denmark.│Norway.│Lapland. │ │ │ │ ──────────────┼───────┼────────┼───────┼──────── Number of │ 100│ 312│ 391│ 34 cases │ │ │ │ Average age at│ │ │ │ the │ 45.9│ 44.8│ 48.9│ 49.4 cessation of│ │ │ │ menstruation│ │ │ │ │ │ │ Faye │ Observer │Lieven │Hannover│ and │ Vogt │ │ │ Vogt │ ══════════════╧═══════╧════════╧═══════╧════════

2. The Age at Which the Menarche Occurred.

Until recently, it was generally believed that the earlier the age at which menstruation first made its appearance, the earlier also would the menopause occur; and that, on the other hand, the later the age at which the flow began, the later also would it cease. Virey summarized this opinion in the saying: prius pubescentes prius senescunt. This view of the matter is, however, true only in respect of the influence of climate upon sexual development. In a cold climate, a woman begins to menstruate late and ceases to menstruate late; in a hot climate the opposite conditions prevail. But if we make our comparison between women living in similar conditions as regards latitude and climate, we find that Virey’s saying is far from accurately describing the facts.

In general, and climatic influences apart, it may be said that the earlier in any woman the age at which menstruation first occurs, the later will be the age at which menstruation ceases.

In order to ascertain the influence of the age at the menarche upon the disappearance of menstrual activity, I placed in comparison first the cases of 50 women in whom menstruation had first appeared between the ages of 12 and 16—i. e., cases of early menarche; and secondly the cases of 50 women in whom menstruation had begun between the ages of 16 and 20—i. e., cases of late menarche. The result was the following:

In the 50 women in whom the menarche had been early, the menopause occurred

At ages 35 to 40 in 5 instances At ages 40 to 45 in 12 instances At ages 45 to 50 in 25 instances At ages 50 to 55 in 8 instances

On the other hand, in the 50 women in whom the menarche had been late, the menopause occurred

At ages 35 to 40 in 9 instances At ages 40 to 45 in 28 instances At ages 45 to 50 in 10 instances At ages 50 to 55 in 3 instances

Thus whilst among the women in whom the menarche had been late, there were thirteen only who continued to menstruate until they were at least 45 years of age; among those in whom the menarche had been early, the number in whom menstruation thus continued up to the age of 45 or beyond was 33, nearly three times as great.

On the other hand, in those cases in which the menarche occurred at an abnormally early age, i. e., before the age of 12 years, the menopause was also a remarkably early one. The menopause also came on very early in women in whom the menarche had been extremely retarded, until the age of 20 and upwards. An extremely early and an extremely late menarche alike tend to be followed by a premature menopause.

To this rule there are, however, exceptions, and we occasionally meet with women whose reproductive energies are so powerful, that the menarche occurs at an unusually early age, and the menopause is postponed to an age considerably beyond the average. Thus, among 100 women in the Salpetrière, Raciborski observed 29 in whom menstruation had begun at the exceptionally early age of 12 years, and who, notwithstanding this, all experienced a very late menopause. Three of them were still menstruating at the age of 57, 1 at 56, 2 at 52, 2 at 50, 3 at 48, 3 at 45, and 13 at an age less than 45.

Brierre de Boismont reports the case of a woman who began to menstruate in her 12th year; she married, had several children, and continued to menstruate regularly until she was 60 years of age.

The results obtained by W. Guy, who examined a series of 250 cases, confirm the proposition stated above, that the earlier menstruation begins (the extremely early cases being excluded), the later it ceases.

According to Cohnstein, who bases his conclusions upon the observation of 400 cases, in women who begin to menstruate early, the menopause occurs on an average three years later, than in women who begin to menstruate late. Puech also states that menstruation lasts longer in women who begin to menstruate early, than in those who begin to menstruate late. According to Scanzoni, in women who begin to menstruate in very early youth, the climacteric age is commonly reached earlier, than in those in whom puberty occurs at the normal age—commonly between the ages of 40 and 42 years.

The homology between the pathological states which, in any particular individual, occur at the respective periods of the menarche and the menopause, is sometimes extremely remarkable; the very same symptoms by which the first appearance of menstruation was preceded, recur as antecedents of the menopause. This is seen in the case of certain eczematous conditions of the skin, of dyspeptic manifestations, epistaxis, nervous disturbances, hysterical and epileptic seizures, vasomotor symptoms, congestions, cardiac troubles, albuminuria, etc. Alibert pointed out that certain skin-diseases may appear twice only during life, once shortly before the commencement of menstruation, and the second time shortly before the cessation of menstrual activity. Brierre de Boismont alludes to the occurrence of hysteria and epilepsy before both these important epochs in a woman’s life, whilst in the intervening period the patient had remained entirely free from such troubles. H. Marsh records the observation that women who just before puberty have suffered from repeated attacks of epistaxis, have suffered from the same trouble as a predominant symptom of the climacteric period. Tilt has seen in several cases the outbreak of numerous furuncles with subsequent diarrhoea, and still more frequently peculiar attacks of severe vertigo, occurring in women just before the two critical epochs in her life, whilst in the intervening period there has been no trace of such troubles, either in connexion with menstruation, with the puerperium, or with lactation.