Part 93

The opinion expressed by several authorities, that the menopause favours the occurrence of cerebral apoplexy, must, according to Windscheid, be received with caution; we have to remember that with advancing years atheromatous changes are apt to occur in the cerebral arteries, and it is to these changes, altogether independently of the climacteric, that cerebral haemorrhage is due. It appears, however, to be a fact that the menopause favours the onset of progressive paralysis. According to Jung, 60%, and according to von Krafft-Ebing, 27%, of women affected with paralysis were first affected in this way during the climacteric period. Von Krafft-Ebing explains this occurrence by the fact that during the menopause fluxions of vasomotor origin are common, and these serve as the starting point of transudative processes.

Among the neuropathic manifestations of the climacteric period we must reckon the at times excessive increase of the sexual impulse. We have already insisted upon the fact that the sexual impulse is not normally extinguished in women at the time of the cessation of menstruation; on the contrary, sexual desire commonly persists long after the menopause, and on this fact is largely dependent the frequency with which elderly women espouse quite young men. But in some cases, the sexual impulse is enormously enhanced during the climacteric period, and the patient experiences paroxysms of intense voluptuous sensation, associated with manifestations of abnormal reflex and psychical reaction, with increased frequency of the pulse and the respiration, emotional excitement, it may be loss of consciousness, and even general convulsions. Some of these cases of disordered sexuality occur in those previously affected with pruritus vulvae et vaginae.

More particularly Guenceau de Mussy and Boerner have described cases of such excessive libido sexualis during the climacteric period, voluptuous crises with pollutions, occurring independently of any external cause; the women thus affected have a continued succession of erotic ideas, they experience an itching and burning sensation in the genital organs, and from time to time this culminates in a paroxysm of sexual feeling, with orgasm, and increased secretion from the glands of the vulva.

Boerner has observed that characteristic variations in the libido sexualis commonly occur at the climacteric period. Not infrequently at this time the sexual desire becomes greatly diminished in intensity, or even entirely disappears; more often, however, the desire persists throughout this epoch; finally, in many instances, the desire undergoes an increase, at times to a degree amounting to positive torment. The first of these changes, the decline in the intensity of the sexual desire, harmonising as it does with the general extinction of the sexual functions at the change of life, might have been expected to be the normal occurrence. And it is a fact that in many cases characterized by an increase of libido sexualis at the climacteric epoch, Boerner found that there existed anatomical abnormalities in the reproductive organs (fibromata, flexions, etc.). Be this as it may, an increase in the intensity of sexual desire, as long as that increase is not altogether excessive, may be regarded as one manifestation of the visceral hyperaesthesias so general at this time of life. In the excessive degrees of this affection, however, those in which at times the sexual crisis is associated with general convulsions, we must, with Romberg, recognize the existence of a direct neuralgic state of the spermatic plexus. It is especially before the commencement of an actual menstrual period, or before a due period which fails to occur, that during the critical years complaint is made of this state of excessive sexual desire and sensibility; and in many instances the trouble begins at the very first appearance of the menstrual irregularities which foreshadow the menopause.

Windscheid draws attention to the fact that occasionally the nervous manifestations may make their appearance prior to the occurrence of any menstrual irregularity, so that it is by the nervous disturbance that the woman or her physician is warned of the approach of the menopause. “When the menstrual anomalies begin,” continues Windscheid, “that is to say, at the commencement of the climacteric, the nervous troubles may have already attained their maximum and have begun to decline in intensity. As a general rule, however, the appearance of the nervous disturbances coincides with the commencement of the menstrual irregularities. It may happen that these disturbances are intensified with each recurring period, but this is not the rule. Sometimes, however, we may observe that when menstruation occurs with excessive frequency—a by no means rare phenomenon at the outset of the climacteric—the nervous disturbances become more severe; and especially is this the case when the unduly frequent flow is also abnormally profuse, as indeed often happens.” The manifestations of climacteric neurosis occur, as Windscheid rightly insists, most frequently in the sphere of the psyche. “We observe a change in the disposition, which usually becomes more excitable. A woman previously calm and composed becomes irritable, inclined to emotional disturbance and to fits of temper, and unable to bear with equanimity the pinpricks so frequent in daily life, and especially in the daily life of a housewife. In other cases, however, the disturbance of the psyche is rather in the direction of depression: we observe a kind of spiritual inhibition, a deficiency of vital energy, an indifference to things which formerly gave pleasure. Almost always, also, complaints of loss of memory are among the indications of such depression. To these intellectual anomalies are superadded disturbances of sensibility. There is excessive sensitiveness to bright lights, loud noises, and strong odours. Frequently, also, in such cases, we see great intolerance to alcohol, quite small doses giving rise to extremely disagreeable sensations in the head.”

Climacteric Psychoses.

The powerful influence which the changes occurring at the climacteric period has in the origination of psychoses, has long been recognized, the menopause, in fact, being a favourable soil for the cultivation of mental disease. The fact is embodied in medical terminology, since many authors speak of “climacteric insanity,” assuming that the psychoses of this period of life present a definite and characteristic clinical picture.

In an earlier part of this work it was shown that the process of menstruation has generally a marked effect upon the psyche, and that disturbances of menstrual activity are competent to exercise a pathogenic influence upon the mental condition of the woman who suffers from them; still greater and more intense is the influence of the cessation of menstrual activity, with its powerful and widespread disturbance of the entire organism, with its destructive oscillations of equilibrium in the spheres of sensation, perception, ideation, and volition. It is easy to understand how the rarer recurrence of menstruation, the occasional profuse losses of blood, the complete suppression of menstruation, the conditions peculiar to the climacteric period of stasis and congestive hyperaemia of the brain, are competent, more especially in hereditarily predisposed persons, to give rise to the development of psychoses; whilst in those already suffering from mental disorder, the menopause will be likely to bring about an aggravation in their symptoms. At this time of life, also, we have to take into account the effect of certain ideational influences to which allusion has already been made, the thought that womanhood and its joys are passing away for ever, and the fear of the dangers attendant upon this critical period of the change of life. A French proverb alludes to “le diable de quarante ans, si habille à tourmenter les femmes.”

Mental disorder will be more likely to ensue at the climacteric period in those women whose nervous systems have always been unduly irritable, and in those affected with hereditary predisposition to insanity. Further, it is more likely to occur in those in whom the menopause takes place quite suddenly, in a catastrophic manner, than in those in whom the climacteric proceeds gradually, and unaccompanied by any stormy manifestations in the organism at large.

It is not in my opinion possible to recognize any specific form of mental disorder peculiar to the climacteric period, but nevertheless the psychoses occurring at this time of life do exhibit certain striking and characteristic features, more especially in this respect, that states of mental depression with melancholia predominate, whilst erotic influences are manifest in their etiology. In the slighter forms, volition and ideation are unaffected, and the trouble manifests itself in the form of hypochondriacal moods, associated with bodily troubles. In more severe cases we see emotional depression, states of anxiety, limitation of the powers of conception and judgment, indecisiveness, low-spiritedness, and apathy; or on the other hand, restlessness, an inclination to continued moving about, the eager pursuit of continually varying occupations, loquacity, etc.; finally, if the mental disorder becomes still more severe, hallucinations, delirium, paroxysms of intense excitement, and in exceptional instances, fully developed mania.

As with regard to the other disorders attending the climacteric, so also in respect of the climacteric psychoses, women who have been or are married, who have had a reasonable number of children, and have been accustomed to a sufficiency of sexual activity, are more favourably situated, are far more immune, than women whose sexual circumstances have been the opposite of those mentioned, who have had one or two children only, who have indulged in intercourse only when protected from pregnancy by the use of preventive measures, or have remained sexually unsatisfied, and, finally, women who have never married, and those who for many years prior to the commencement of the menopause have lived in chaste widowhood. In “old maids,” to the somatic effects of sexual abstinence (or in some cases of abnormal sexual gratification), are superadded the effects of the intellectual and emotional recognition of a wasted life. Again, it by no means rarely comes under our observation that women who in youth, at the time of the menarche, suffered from psychical disturbances, are apt once again to be affected with transitory mental disorder at the change of life. Once, however, the menopause is completely at an end, a condition of mental quiescence is as a rule established, and then it may happen that previously existent mental disorders undergo amelioration; but on the other hand we have in all cases to reckon with the possibility that they may take an unfavourable turn in the direction of the development of senile psychoses.

Of considerable interest is the fact, first pointed out by Glaevecke, and subsequently confirmed by other observers, that in cases of artificial menopause, melancholic mental disturbances not infrequently follow the operation, in some instances so severe as to lead to weariness of life and actual suicide; and in general, after the artificial induction of the menopause, psychical disturbances are by no means rare, and are sometimes very severe. Such disturbance of the mental balance is seen after oöphorectomy especially in women who are still comparatively young, and whose sexual powers are still in a ripe state; whereas when the operation is performed in women of a more advanced age, whose ovaries were already nearly or completely functionless, no psychopathic changes are likely to ensue. In women belonging to the former category, the same etiological influences come into operation as in the physiological menopause, the patient, that is, is affected by the psychical influences of the removal of the ovaries—not only by the cessation of menstruation and the disappearance of the internal secretion of the reproductive glands, leading to a disturbance of the physical equilibrium, but also by the intellectual recognition of the loss of sexual potency, and a consequent disturbance of the mental balance.

In Schlager’s opinion the climacteric has a potent influence in promoting the development of psychical disturbances in women, even when the involution occurs at the normal age. The course of these disturbances is as follows: soon after the commencement of the process of involution, when for a few months already the menstrual periodicity has been irregular, or the flow has been unduly profuse, a change of disposition makes its appearance, at first hardly noticeable, but after a little time manifesting itself clearly in the form of an increase in irritability. The woman finds fault with everything and everybody, becomes mistrustful, suspicious, full of complaints, imagines that the most insignificant annoyances are due to intentional slights; at the same time she complains of continued sleeplessness, palpitation, various indescribable sensations, and of headache. Occasionally, congestions of the head occur, with alarming dreams, and the moodiness may increase greatly; in this condition three such patients of Schlager’s were impelled to attempts at suicide. Schlager further draws attention to the fact that in 22 cases known to him in which suicide was performed or unsuccessfully attempted by women, in eleven of these the patient was at the climacteric age. He believes that the most important etiological influence in the production of climacteric mental disorder in such cases is the sudden suppression of menstruation. In the majority of these instances, the mental disorder takes the form of mania; exceptionally, however, the form of chorea or of catalepsy.

By Tilt the following forms of “climacteric insanity” are distinguished: delirium, mania, hypochondriasis, melancholia, impulsive insanity, and perversion of the moral instincts. The same author publishes the following table showing the age incidence in 1,320 cases of mental disorder in women, from which it appears that during the age of the menopause, a very considerable number of the cases originate, but that after the change of life comparatively few cases occur.

In these 1,320 cases the women were:

Under 15 years of age in 9 instances Over 15 and under 20 years in 61 instances Over 20 and under 25 years in 216 instances Over 25 and under 30 years in 223 instances Over 30 and under 35 years in 217 instances Over 35 and under 40 years in 218 instances Over 40 and under 45 years in 162 instances Over 45 and under 50 years in 153 instances Over 50 and under 55 years in 122 instances Over 55 and under 60 years in 57 instances Over 60 and under 65 years in 55 instances Over 65 and under 70 years in 27 instances

Fuchs tabulated the ages of 26.300 insane persons. Reducing his results to the ratios per 10,000, he obtained the following results:

Women. Men. At ages under 20 563 649 At ages over 20 and under 30 1,895 2,132 At ages over 30 and under 40 2,557 2,614 At ages over 40 and under 50 2,180 2,080 At ages over 50 and under 60 1,362 1,247 At ages over 60 1,443 1,278

According to Esquirol, among 198 women who committed suicide, there were 77 between the ages of 40 and 50 years—a number considerably larger than those in any other age-decade. Among 235 women suffering from dementia, a moiety had first come under treatment during the climacteric age. The same author published the following data regarding the age-incidence of insanity in the case of 6.713 female patients:

At ages under 20 years 348 cases Between the ages of 20 and 25 563 cases Between the ages of 25 and 30 727 cases Between the ages of 30 and 40 1,607 cases Between the ages of 40 and 50 1,479 cases Between the ages of 50 and 60 954 cases At ages above 60 years 1,035 cases

Matusch found that among 551 women suffering from mental disorder, there were:

At ages 0 to 10 years 9 cases At ages 10 to 20 years 73 cases At ages 20 to 30 years 140 cases At ages 30 to 40 years 114 cases At ages 40 to 50 years 107 cases At ages over 50 years 38 cases

According to von Krafft-Ebing, among 858 insane women, there were about 60 in whom the disorder of the mind appeared to depend upon the influence of the climacteric, and in 25 of these there was hereditary predisposition to mental disease.

From Kowalewski’s interesting work on the psychoses of the climacteric, we quote the following:

“In women, the climacteric has a distinct influence upon the mental life, and that influence is strongly manifested more especially in cases in which during the age of puberty mental disturbance had previously been noticed. The mental condition in which women approach the change of life is a very variable one, and it is one largely dependent upon the circumstances in which the active years of the sexual life have been passed. In some cases, a woman has been so fortunate as to marry early and from affection, and her whole married life has been passed without disturbance; her labours have not been exhausting, and her children have enjoyed good health; all have passed through the years of childhood without untoward incident, and their development has been a happy and successful one; in a word—everything has gone well with her and hers. Such a woman will give thanks to God for the rare felicity she has enjoyed; and quietly, patiently, and with understanding will endure the inevitable end of her sexual life. For such a woman, more especially if she comes of a healthy stock, the changes which occur in her reproductive organs at the epoch of the climacteric, need not entail any serious shock to her nervous system, nor need they form the culture ground for morbid manifestations in her nervous system or in her mind. Even if any anomalies in nervous working should occur, it will be such only as are aroused by the disturbance of the normal menstrual rhythm; in such cases, they will rarely prove of a serious or enduring character.

“But look, on the other hand, upon this picture. A woman has married without affection and from pure necessity. Her husband has been a drunkard, and rough and unfaithful. She has had a great many children, her labours have been tedious and difficult and accompanied with severe losses of blood. Some of the children fell sick and died; those that survived proved idle, good-fornothing, and a burthen. The family life is dominated by quarrelsomeness, disorder, and insufficiency of means. The mother is affected with some chronic disorder of the reproductive organs, and is hardly ever out of the doctor’s hands. After 25 or 30 years of a life of this kind, the woman enters upon the change of life. Physically exhausted, weary of life, never having known happiness, after an existence full of trouble and wretchedness, with nothing joyful either in her memories of the past or in her prospect of the future—the chief hope of such a woman is that her troubles may soon end with her life. Where the soil is thus physically and mentally exhausted, the development of a neurosis or a psychosis is only too probable on the most trifling exciting cause. Her life seems of so little worth, that thoughts of suicide are likely to be very near at hand. Thus, when the climacteric alterations in the reproductive organs are superadded, melancholia is very likely to supervene. When, however, the case is complicated by hereditary predisposition to insanity, and by the occurrence of actual degenerative changes in the central nervous system, instead of the passive depression of melancholia, we shall rather see the ideas of persecution of paranoia. As an actual fact, these two psychoses, melancholia and paranoia, are the commonest forms of mental disorder at this period of a woman’s life.

“These are the two extremes in woman’s mental state at the time when the physical changes of the climacteric period begin in her reproductive organs. It will, of course, be readily understood that between these two extremes lies a series of combinations any one of which may in individual cases occur.

“The conditions of life during earlier years have thus a strong determinative influence in the production of mental disorder; and not infrequently in these conditions alone shall we find the efficient cause of the mental degeneration. At times, the memories of her own life have in a woman at the climacteric age so serious an effect, that these memories alone constitute the causal agent of the development of a psychosis, or at least so influence the soil as to make it a suitable culture-ground for the development of mental disorder, the actual exciting cause of the pathological state being a disturbance of the ordinary menstrual rhythm.