Part 26

As regards the forms of neuralgia most apt to accompany menstruation, Windscheid mentions trigeminal neuralgia as the commonest, especially affecting the first division of the nerve, and producing localized pains which are to be distinguished from the headaches already mentioned. They are characterized by their intensity and their persistence in spite of anti-neuralgic treatment, and by their spontaneous disappearance as soon as menstruation is over. According to the same author, the relations between hemicrania and the process of menstruation are indisputable; at the very least it must be admitted that menstruation predisposes to an attack of hemicrania.

Cases also occur in which convulsions almost invariably accompany menstruation, convulsions which are to be regarded as symptoms of hysteria.

The extraordinarily powerful influence which the menstrual stimulus exercises on the mind is shown by the frequency with which the slighter psychopathic states occur as an accompaniment even of normal menstruation, these manifestations being sometimes melancholic in type, sometimes maniacal or erotic, and, when of long duration, leading ultimately to pronounced mental disorder. This influence of the menstrual stimulus is yet more potent in cases in which important changes in the course of menstruation have occurred, in cases, for instance, of suppressed, painful, or irregular menstruation. In this connection, however, in order to avoid a confusion of cause and effect, we must carefully bear in mind, that it is a much commoner causal sequence for psychical disorders to disturb the normal course of menstruation, than for disorders of menstruation to evoke psychical disorders. This view has only quite recently become established, and for this reason it is necessary to regard such data when obtained from the writings of the older gynecologists in a somewhat critical spirit.

By the modern alienist, the influence of the menstrual reflex on mental affections is recognized only in cases in which a proper valuation of the predisposing causes has been made, in such cases as the following: First, we have to recognize the modifying influence exercised by the menstrual stimulus on established psychoses, inasmuch as these latter not infrequently undergo cure when previously irregular menstruation has become regular, and, moreover, the recurrence or the first appearance of menstruation has often a powerful influence on the course of some established mental disorder. In some cases this influence is a strikingly favorable one on psychoses that have developed before the commencement of menstruation, or during the suppression of that function; it may be, however, and, indeed, more frequently is, an unfavorable influence, inasmuch as such a psychosis, on the first appearance or on the reappearance of menstruation, may assume a menstrual type, the attacks becoming more frequent or more violent with the successive recurrence of each menstrual or premenstrual period. This is the history of the typical menstrual psychosis.

Again, certain processes of the sexual life, disorders of menstruation, diseases of the genital organs, operations on these organs, and the processes of the climacteric, influence the origin and the character of mental disorder, generally giving rise to chronic affective insanity (insanity of the emotions and feelings) or to paranoia (chronic delusional insanity, insanity of the intellect). The menstrual stimulus must in these cases be regarded as a psychopathically exciting physical cause.

Further, physical disturbances may equally affect the menstrual function and the functions of the mind, rendering the exact causal sequence in such cases a difficult one to determine; and, conversely, the circumstances that restore the normal working of the mind may also regulate the menstrual function.

Finally, we may have to do with isolated sporadic occurrences in which the exciting influence of menstrual processes may be traced. Thus, for the outbreak of a periodical menstrual psychosis, an especial temporal predisposition must exist, connected with the great developmental epoch of the sexual life.

There is, for instance, a group of transitory states occurring during menstruation, and taking the form of disorders of the intelligence or of explosive emotional states; such may be witnessed, not in those suffering from psychopathic predisposition, but in quite healthy individuals.

The successive menstruations as they recur regularly throughout the course of the sexual life may, just like the first menstruation, though with diminished intensity, give rise to manifestations of nervous and mental disorders. In many women who are in other respects healthy, we see during menstruation, hemicrania, nervous irritability, ill-temper, low-spiritedness, and even hysterical and epileptic attacks; these occur chiefly on the first and second days of the flow, and disappear altogether toward the end of the period. These manifestations are more severe in individuals weakened by profuse losses of blood or by chronic disorder in various organs, more severe also in those predisposed to such disturbances in consequence of neuropathic inheritance, more severe in women suffering from menorrhagia and dysmenorrhœa, and from any kind of mental stress.

In his work on the influence of the so-called menstrual wave on the course of mental disorders, Schüle remarks that the mental equilibrium even of a perfectly healthy woman is not a stable one, but is subject to a series of oscillations. “The menstrual period,” he continues, “has a distinct influence on woman’s mental equilibrium. Even in those whose nervous system is a healthy one, menstruation evokes a state, now of depression, now of excitement; in neurotic women, on the other hand, menstruation may give rise to nervous diseases which may equally exhibit the characteristics of depression or the characteristics of excitement. In nervously predisposed women, the influence of regularly established menstruation, even when the circumstances are favorable, is pretty much the same as the influence of menstruation when it first makes its appearance; the influence is merely somewhat weaker in so far as the woman has learned to endure and to be patient. The menstrual state, in nervously predisposed women, evokes the particular neurosis to which the individual happens to be liable. The disorders most commonly met with in this association are, hysteria, hemicrania, swimming in the head, epileptic paroxysms, toothache, and neurasthenia.”

Especially frequent during menstruation is hemicrania. Sometimes hemicrania may begin a day or two before menstruation, as a prodromal sign, and may accompany its whole course, becoming, however, less severe toward the end of the flow. Hysteria most commonly manifests itself in association with menstruation by a depressed emotional state, by tearfulness, by complaints made without sufficient grounds, by globus hystericus or clavus hystericus; sometimes also by paroxysms of muscular spasm; very rarely by hystero-epileptic seizures. Epilepsy may occur either by day or by night. Nocturnal seizures usually occur without any apparent external cause, as a result of the central stimulus; diurnal attacks, on the other hand, have usually some external exciting cause. Often, however, years may elapse without any attack of major epilepsy occurring, the disease manifesting itself in one or more of the many varieties of the minor form (petit mal), as transient absences of mind, attacks of vertigo, etc.

The nervous disturbance in a menstruating woman may be so great as to lead to the production of psychoses. The question of the existence of a menstrual insanity sui generis has been answered by many alienists in the affirmative; by others, however, who see in the alleged cases nothing specific, it has been answered in the negative. The relation of menstruation to the mental disorder may be a double one: 1, menstruation may occur repeatedly in the course of an already established mental disorder; 2, menstruation and its morbid variations may favor the occurrence of psychoses that exist already in a latent form, and may lead to the origination of psychoses to which the organism is predisposed.

In the former connection, Brierre de Boismont undertook an investigation which showed that in women suffering from mental disorder, an exacerbation of that disorder was to be observed during menstruation. Schlager, who regards the menstrual process as possessing when anomalous a high significance for the development and course of mental disturbances, observed that in 33 per cent. of women suffering from mental disorder, the menstrual state had an unfavorable influence upon the course of that disorder, inasmuch as it led to an increased irritability; in the rest of the cases, however, menstruation was without influence upon the course of the ordinary chronic psychoses. In the cases that were unfavorably influenced, epileptic attacks usually became more frequent, and chronic melancholia became much more profound. Schröder observed in chronic forms of melancholia that during menstruation the sadness became intolerable and was associated with a suicidal tendency; in chronic maniacal forms of mental disorder, the excitement underwent an increase during menstruation. Von Krafft-Ebing, as a result of his investigations into insanity during menstruation, came to similar conclusions with regard to the unfavorable influence of the menstrual process. Algeri likewise states that menstruation notably aggravates the cerebral symptoms in the course of mental disorders.

Other authors, Marcé and Kowalewski for instance, whilst emphasizing the powerful influence exerted by menstruation on any existing psychosis, point out that in some instances, as in states of mental and physical depression, this influence is for the worse; but in other instances, especially in states of maniacal excitement, the condition of the patient undergoes notable amelioration during menstruation. Schäfer also, in his researches into the relations between the processes of menstruation and psychoses, discovered that anomalies in the course of menstruation ran almost parallel with anomalies in the course of mental activity.

In psychopathically predisposed women, disorders of menstruation, such as amenorrhœa, delayed menstruation, and dysmenorrhœa, are more effective than the normal process of menstruation in evoking manifestations of psychical abnormalities previously latent, and in leading to attacks of precordial anxiety, pathological emotional states, melancholic seizures, epilepsy in all its varieties, and impulsive manifestations, such as pyromania, kleptomania, infanticide, homicide, etc. As results of a special predisposition may appear in this connection, congenital imbecility, idiocy, melancholia, and chronic weak-mindedness.

A rich literature exists of cases in which mental abnormalities occurred in psychopathically predisposed individuals as a result of menstruation. Thus, von Krafft-Ebing reports a case in which, during menstruation, a mentally undeveloped woman murdered her husband; and another case in which to chronic weak-mindedness and chronic delusional insanity were superadded during menstruation peculiar attacks having the character of psychical storms. Tuke reports a case in which a mother, in a state of alcoholic excess during menstruation, murdered her daughter. Pelmann records acts of pyromania committed during menstruation by a girl seventeen years of age. Mabille records a case in which a woman suffering from severe mental disorder was affected during menstruation by impulsive kleptomania, whilst after the periods the memory of what had happened passed away. Philo-Indicus records the case of a woman suffering from severe neuropathy who at the menstrual periods exhibited great irritability, experienced marked sexual excitement, and had suicidal impulses, and who on one occasion attempted to murder a female friend who had refused to assist her in the practice of sexual aberrations. Giraud describes a woman suffering from passive melancholia, in whom during menstruation horrible fantastic ideas occurred. Ball records the case of a woman who suffered always from acute mental disorder during menstruation, and who, in one of these attacks, murdered her son. Kowalewski reports a case of chronic imbecility, in which during menstruation attacks of precordial anxiety developed, and in the course of one of these attacks the patient set fire to her own house. “In such cases,” remarks Kowalewski, “menstruation represents the last drop that makes the full goblet overflow.”

In addition, we meet with cases in which the influence of menstruation is so powerful that it must be regarded as the principal cause of the psychosis. We must then speak of a true menstrual psychosis, the impulse to which is supplied by the normal or abnormal changes occurring in the process of menstruation, and characterized by the menstrual periodicity and the brief duration of the attacks. These are the characteristics of the menstrual psychoses of the menarche and of the climacteric period; and such cases occur also during the period of full menstrual activity.

The menstrual psychosis most commonly makes its appearance shortly before the flow, becomes less severe with the establishment of the flow, and disappears when the flow ceases; in other cases, the psychosis appears toward the end of menstruation, and speedily passes away; or, again, in amenorrhoeic cases, the attacks of mental disorder replace the proper menstrual flow, and become less severe or disappear entirely as soon as the flow is regularly re-established. The commonest forms of these menstrual psychoses are, melancholia, mania, irresistible impulses, acute amentia, in rare cases alternating insanity (folie circulaire) in which the periods of alternation assume the menstrual rhythm. The duration of these psychoses is usually short, from a few days up to a fortnight; there may be only a single attack, or there may be a number of attacks presenting precisely similar characters.

The consciousness may be more or less disturbed. Von Krafft-Ebing points out, as a very dangerous peculiarity of the menstrual psychoses, that the fact that the morbid process has once occurred in connection with menstruation furnishes in itself a sufficient reason for the recurrence of such attacks, which are dependent on constantly repeated functional changes in the brain closely analogous to those that occur in epilepsy. When the menstrual insanity recurs frequently, it gradually becomes less acute in its characters and more protracted in its course; the lucid intervals are less clearly indicated and shorter in duration; and thus in course of time the mental disorder may be transformed into chronic imbecility—a transformation liable to occur in all forms of periodic psychosis. In such cases we must always assume the existence of a certain lack of resisting power on the part of the organism, especially of the nervous system, which amounts to a congenital predisposition. During the period of full menstrual activity, the favorable soil for the cultivation of such disorders is usually furnished by anomalies of menstruation, by difficult labor and its consequences, severe losses of blood, prolonged lactation, physical over-exertion, and mental shock and stress.

In the development under the influence of menstruation of such periodic acute mental disorders, we may observe various gradations, as for instance short, syncope-like cataleptic seizures, states of hallucinatory confusion lasting several hours or several days, disordered consciousness, and even severe mania.

Such a case was observed by Wille. Under the influence of menstruation and of a trifling source of mental disturbance (having soldiers billeted on them in a quiet country village), a young woman aged twenty-one, whose mental health had previously been good, had a sudden attack of anxiety, succeeded by a violent but transitory mania, lasting five or six hours; after a short free interval came another attack, this time lasting several days. Similar cases were recorded by Friedmann. A blooming and healthy maid-servant eighteen years of age (some mental unsoundness was recorded in both grandfather and aunt on the maternal side) fell asleep in a chair a few days before menstruation, awakened with a start, was subsequently disordered in mind, though tranquil, with many hallucinations, listening to voices which repeated monotonously “they come,” was drowsy, and slow to answer when spoken to. On the third day she was recovered, her mind being clear and normal; she was not fully aware of what had happened. Since this attack, her mind has been free from disorder, during menstruation as well as at other times. She is said to have had a similar attack about four years ago, that is, at the commencement of puberty.—A girl aged thirteen, quite healthy, not nervous, physically rather powerful, with quite healthy family history. Complaints of having suffered for two days from general sense of depression with pains in the abdomen; during the afternoon was lying on a sofa, but suddenly sprang up, looked extremely anxious and confused, ran about the room, begged to be protected from the black man, etc., her speech was disconnected, gabbling, and difficult to understand. After two hours she became quiet, and fell into a sound sleep, from which she awoke calm and quite forgetful of what had passed. On the following day menstruation appeared for the first time, with abdominal pains, but without any mental abnormality. During the subsequent six years she has remained quite well.

Since the days of antiquity an extremely important part has been assigned to suppression of the menses in the production of mental disorders; but in the opinion of modern alienists, who are opposed to the old humoral pathology, no more is to be recognized in this connection than the ordinary menstrual stimulus, which, indeed, when the soil is already prepared, may furnish a causal determinant for an increase in the intensity of an already existing anomalous mental condition. Quite recently numerous cases have been published in which such an influence has been recognized as powerful. Von Krafft-Ebing writes: “In isolated cases, as a sequel of sudden cessation of the menstrual flow, generally, due to a fright or to a chill, the development of insanity (usually acute mania) has been observed, and the suppression of menstruation has been regarded as the causal determinant. It is indeed conceivable that the connection between the two events is supplied by a collateral vicarious congestion of the brain. As a rule, however, the psychosis and the suppression of menstruation are the coeffects of the same cause, and are both of vasomotor origin.”

Mairet reports a case of violent mental disorder of a maniacal type, associated with chorea, occurring at puberty, the exciting cause of which, in a constitution hereditarily predisposed to insanity, he believed to be suppression of the menses. Diamant had under observation a girl in whom, at the age of six years, menstruation ceased, having previously been regular since the age of two years; after the suppression of menstruation, violent epileptiform seizures set in, occurring at what should have been the menstrual periods. Westphal described a case of infanticide committed in a state of melancholia at the proper menstrual period, the menses being suppressed.

Menstrual psychoses are observed for the most part in comparatively young women; after the age of thirty-five they are uncommon. Among von Krafft-Ebing’s cases there were:

4 patients between the ages of 15 and 20 years. 6 patients between the ages of 20 and 25 years. 2 patients between the ages of 25 and 30 years. 6 patients between the ages of 30 and 35 years. 2 patients above the age of 35 years.

The same author insists that for the development of a menstrual psychosis a predisposition on the part of the brain must exist, either in the form of an inherited predisposition, or in the form of a primary mental disorder, or, finally, as the result of some special exciting cause, such as emotional disturbance, the abuse of alcohol, or bodily illness. Among 19 cases observed by von Krafft-Ebing

12 were hereditarily predisposed. 4 had previously exhibited great nervousness during menstruation. 7 suffered from primary mental weakness.

Very remarkable is the influence, demonstrated especially by Lombroso, exercised by menstruation on the commission of certain crimes. Of eighty women taken into custody for resisting the police, there were nine only who were not menstruating at the time. Four notorious murderesses and one woman convicted of arson were all menstruating at the times when their crimes were committed. Krugenstein found evidence of menstruation in the bodies of 107 women who committed suicide. Thefts committed by ladies in the great shops of Paris are most commonly effected during menstruation, as was found by Legrand du Saulle to be the case in thirty five instances out of fifty-six investigated by him in respect to this matter. According to the same author, hysterical girls who steal articles of clothing, bottles of scent, and the like, from the counters of shops, are almost always menstruating at the time.