Forms of climacteric insanity are delirium, mania, hypochondriasis, melancholia, irresponsible impulses, and the perversion of moral instincts.

“If the reproductive apparatus does not act on the brain by the instrumentality of the circulating organs of the blood, it must do so by means of the nerves.  The genital apparatus is richly endowed with nerves from the sympathetic system, and I have shown how frequently evident signs of disturbance in these centers coincided or alternated with headaches, nervousness, hysteria, and epilepsy.  What wonder, then, if the same powerful influence of the sexual organs, through the instrumentality of the sympathetic system, should at times produce a permanent derangement of the mental and moral faculties.  I am thus led to look on the sympathetic nervous center as a source of vital power producing reflex morbid phenomena, in accordance with variable cerebral predisposition” (Tilt).

Another very frequent symptom of the menopause is distress in the region of the heart, with palpitation and shortness of breath.  It may be caused by the condition of the blood, whether it be impoverished—­ anemia—­ or too rich in red globules; by reflex irritation of the pneumogastric or sympathetic nerves; by overexertion; or by alcoholism.  It may also be due to general debility; the woman resists fatigue less easily, and she experiences a general malaise.  To the palpitations are rapidly added faintness and shortness of breath.  The sleep is troubled with distress in the region of the heart.  It is said that women in whom the menopause occurs early are more liable to tachycardia than those who menstruate later in life; and that it occurs with especial frequency when the menopause has been prematurely induced by surgical operation or by disease.  It is believed that this functional heart trouble is caused by the increased connective-tissue fibers of the sexual organs acting in some unknown way on the terminal fibers of the sympathetic; and it is not infrequently due to the formation of scar tissue at the seat of a cervical laceration, and has often been promptly and permanently relieved by removing the cicatricial tissue and suturing the wound.  The cause acts by producing a transitory paralysis of the inhibitory fibers of the pneumogastric nerve.

Pathologic Conditions of the Menopause.—­ Perhaps the most alarming symptom of the menopause is hemorrhage.  It may be due to general or local causes.  Among the general causes are diseases of the heart, lungs, spleen, and kidneys.  Local causes of hemorrhage are:  inflammation of the lining membrane of the uterus, chronic pelvic inflammations, faulty uterine positions, erosions and ulcerations of the mouth of the uterus, fibroid tumors, and cancer.  All competent observers agree that cancer in women is much commoner from forty to fifty years than at any other age.