_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.
_3. The Woman’s Sexual Activity._
An important influence upon the early or late onset of the menopause is
exerted by the degree to which a woman’s reproductive functions have
been exercised during the menarche. My personal observations have shown
me that in women who are in good health and of a powerful build, whose
menstrual flow has always been regular and sufficient in quantity, whose
reproductive organs have been adequately and properly exercised, who
have had a physiological amount of sexual intercourse, have given birth
to several children, and have suckled these children, the cessation of
the menstrual flow generally occurs much later than in women in whom the
conditions of the sexual life have been the opposite of those just
mentioned. The more regular menstruation has been, and the more normal
the deliveries, the later does the menopause ensue.
Especially striking is the influence of the number of deliveries upon
the time of occurrence of the menopause. In women who have given birth
to a number of children, menstruation as a rule continues for several
years later than in sterile women, or in those who have had one or two
children only. If a woman suckles her children, the date of the
menopause appears also to be postponed. Deliveries late in life seem
likewise to delay the onset of the menopause, whereas abortions
accelerate its occurrence. If, however, pregnancy succeeds pregnancy at
extremely short intervals, the menopause is likely to occur early; the
same result is brought about by sexual intercourse at too early an age.
The menopause occurs latest in women who have begun to menstruate early,
who have married, have given birth to more than three children, and have
been delivered of their last child at full term when 38 to 42 years of
age.
As regards the 500 women previously mentioned, in whom I made personal
observation as to the age at which the menopause occurred and the
circumstances by which its onset was influenced, the effect of marriage
and the number of children born is shown by the following details:
Of the 48 women in whom the menopause occurred between the ages of 35
and 40, 16 were unmarried, 6 married and childless, 18 married with one
or two children, 8 married with more than two children.
Of the 141 women in whom the menopause occurred between the ages of 40
and 45, 3 were unmarried, 4 married and childless, 46 married with one
or two children, 88 married with more than two children.
Of the 177 women in whom the menopause occurred between the ages of 45
and 50, 1 was unmarried, 2 were married and childless, 32 married with
one or two children, 142 married with more than two children.
Of the 89 in whom the menopause occurred between the ages of 50 and 55,
none were unmarried, none were childless, 19 were married with one or
two children, 70 were married with more than two children.
Of the 17 women in whom the menopause occurred at an age above 55 years,
there were two only who had not had more than two children, whilst there
were 10 who had had six to eight children.
The influence of lactation is shown by the fact that in the case of 40
women who had not suckled their children, the mean duration of menstrual
activity was four years less than the established mean duration of 27
years.
_4. The Social Circumstances of the Woman’s Life._
The conditions in which a woman passes her life are not without
influence upon the time of onset of the menopause. In general it may be
said that among the women of the labouring classes, whose livelihood is
so often precarious, and who are apt to suffer from habitual physical
overwork, menstruation ceases at an earlier age than among the women of
the well-to-do classes and those who lead an easier life. But though the
climacteric thus occurs earlier among the lower than among the upper
classes, the difference is not a considerable one.
According to _Mayer’s_ calculation, the mean age at which menstruation
ceases is, in upper class women, 47.13 years, in lower class women,
46.97 years. Small as this difference appears, amounting on the average
to no more than two months, it must not be forgotten that among the
upper classes, menstruation begins earlier than among the lower classes,
by an amount which averages 1.31 years. Thus the total duration of
sexual activity is almost one and a half years longer in the upper than
in the lower classes.
_5. General Constitutional and Pathological Conditions._
An important influence upon the time of occurrence of the menopause is
exerted by the individual and hereditary predisposition of the woman, by
her constitutional state, and by certain illnesses from which she has
suffered. Women who by inheritance are constitutionally weakly and
delicate, in whom the menstrual flow has always been pale and scanty, in
whom the intermenstrual intervals have been excessive, and who have a
slender habit of body, attain the climacteric age earlier than women
with vigorous bodily development and powerful muscles, with large
breasts, and in whom menstruation has always been regular and abundant.
Women with a great tendency to obesity cease to menstruate earlier than
women of more normal proportions; blondes earlier than brunettes; women
of phlegmatic temperament earlier than women of a sanguine and ardent
temperament.
In general it may be said, that all influences which have a weakening
effect upon the feminine organism, tend also to accelerate the onset of
the menopause: such are, severe labour, great sorrow, wearisome
occupations, severe menstrual losses, rapidly succeeding pregnancies,
and abortions; also a number of pathological general states shortly to
be discussed, as well as local diseases of the reproductive organs.
_Fritsch_ points out that menstruation continues to a later age in
proportion as the woman’s state of general nutrition is a good one. He
also asserts that women with a very large uterus, who have always had an
abundant menstrual flow, those with retroflexion, with hypertrophy of
the portio vaginalis, or chronic endocervicitis and endometritis, and
those with small myomata which have given rise to no marked symptoms,
often continue to menstruate far beyond the usual age.
The mean duration of the climacteric phenomena, from the commencement of
these until the final cessation of menstruation, is about two years.
This mean is made up of extremely wide individual variations; in a small
proportion of the cases the climacteric manifestations may last no more
than a month or two, whilst at the other end of the scale we meet with
cases in which the duration extends to 4, 6, 8, and even 18 years.
In considerably more than half of all the cases, however, the duration
of the climacteric manifestations varies between six months and three
years. Thus, in _Tilt’s_ series of cases, the duration of the “change of
life” was
6 months in 12.07 of all cases
1 year in 22.64 of all cases
2 years in 18.62 of all cases
3 years in 9.43 of all cases
_6. Premature, Delayed and Sudden Onset of the Menopause._
In exceptional cases, the menopause, instead of taking place between the
fortieth and the fiftieth year of life, occurs at an abnormally early or
an abnormally late age.
Premature cessation of menstrual activity, in the third or the fourth
decennium of life—very rarely indeed before the third decade—depends in
part upon disturbances of metabolism and of haematopoiesis, and in part
upon diseases of the female reproductive organs; in some cases, however,
it may be due to some hereditary constitutional peculiarity; or it may
occur suddenly, in consequence of some violent shock to the nervous
system.
Among the disorders of metabolism which may lead to a premature
menopause, excessive adiposity, lipomatosis universalis, occupies the
first place. Next in order of importance come a chloro-anæmic condition
of the blood, pernicious anæmia, splenic leukaemia, certain of the acute
infectious disorders—typhoid, cholera, scarlatina, acute articular
rheumatism,—further pulmonary tuberculosis, diabetes mellitus, Graves’
disease, Addison’s disease, and myxoedema. These various conditions may
give rise, in part by infective processes, and in part in consequence of
the general cachectic condition, to atrophy of the ovaries with
destruction of the graafian follicles, and to atrophic processes in the
uterus, and these changes lead to the premature cessation of menstrual
activity.
Excessive obesity has a restrictive influence upon ovarian activity,
manifested in part, as already mentioned, by the occurrence of
sterility, but in part also, in very obese women, by the onset of a
premature menopause. Among 215 cases of extreme obesity in women, I
found 49 in which the menopause occurred at a remarkably early age. In
these cases the menopause occurred at the following age:
In 1 woman at the age of 17 years
In 14 women at the age of 20 to 25 years
In 11 women at the age of 25 to 30 years
In 9 women at the age of 30 to 35 years
In 14 women at the age of 35 to 40 years
In none of these cases did the local examination of the reproductive
organs disclose the existence of any noteworthy disease.
Of the diseases of the genital organs which are competent to give rise
to a premature cessation of menstrual activity, the most important are
the puerperal infective processes and other inflammatory states of the
reproductive organs, with their results—chronic metritis, perimetritic
and parametritic exudations, chronic oophoritis, atrophy of the uterus
and the ovaries.
After infective puerperal processes, it sometimes happens that there is
far-reaching destruction of the uterine musculature, degeneration of the
uterine mucosa, permanent and irreparable atrophy of the uterus, and
suppuration and atrophy of the ovaries—conditions which result in an
extinction of menstrual activity. A similar result may ensue upon the
persistent and long-continued pressure upon the uterus and the ovaries
of a large intrapelvic exudation; such exudation being commonly
post-puerperal, but occasionally arising in the absence of pregnancy.
Further, according to _Freund_, chronic atrophic parametritis may give
rise to an incurable atrophy of the uterus, by interference with the
circulation of the blood through the broad ligaments, and consequent
impairment of the nutrition of the uterus. Gonorrhoeal inflammation may
also lead to the termination of menstrual activity, when it gives rise
to intramural inflammatory deposits in the uterus, and to chronic
inflammatory processes in the ovaries. Tumours of the uterus and the
uterine annexa may likewise induce a premature menopause.
We also meet with cases in which after a pregnancy, to all appearance
normal in its course and termination, a premature menopause results. To
this category belong the cases, according to _Kleinwächter_ of no
extreme rarity, in which perfectly healthy women are attacked by profuse
uterine haemorrhage during the course of a normal, full-term labour, or
during miscarriage; subsequently, though the lying-in period is passed
without further misadventure or abnormality, and in the absence of
lactation, the patient becomes permanently amenorrhoeic. The normal
involution of the uterus passes on into hyperinvolution, and ultimately
complete atrophy of uterus and ovaries results. In some cases, moreover,
such hyperinvolution with consecutive atrophy follows normal labour or
abortion without the occurrence of any excessive haemorrhage.
Much more frequently do we find that rapidly successive pregnancies,
with long-continued exercise of the lacteal function, in badly
nourished, anæmic women, give rise to a premature menopause, due to
permanent atrophy of the uterus and ovaries, which are in such cases so
poorly supplied with blood. This “lactationatrophy” is described by
_Frommel_ and _Thorn_ as a concentric atrophy first of all affecting the
corpus uteri, and to this, if the disease advances, there succeeds a
general atrophy of the muscular, connective, and fatty tissues of the
parametrium, the vagina, the pelvic floor, and ultimately of the
ovaries, leading, when permanent, to a premature menopause.
Trauma of the genital organs may also lead to uterine atrophy and to
premature menopause.
By many authors it is believed that too-early marriage, sexual excesses,
and prostitution, may be the cause of cessatio praecox. In some cases,
there is unquestionably a hereditary predisposition to a premature
climacteric, since the mothers of the women in whom it occurs have
themselves been similarly affected. In the remarkable case which came
under my own observation, of a woman from Smyrna, there was hereditary
predisposition. This woman began to menstruate when 12 years of age;
menstruation was always scanty; she married when 15 years of age; and
she ceased to menstruate for ever at the age of 19. In other cases we
find there is a family tendency for menstruation to be delayed in its
first appearance to a comparatively advanced age, and to cease at the
usual time.
In cases of cessatio mensium praecox (unless the failure of menstruation
has been quite a sudden one), and after the premature menopause is fully
established, we find in the uterus and the ovaries anatomical changes
similar to those met with after the natural climacteric—diminution in
the size of the uterus with thinning of its walls, density and firmness
of the tissues of the organ, smallness and a soft consistency of the
ovaries; sometimes, also, the mammae are atrophic.
In cases of premature menopause, the troubles attending the change are
commonly more severe and more enduring than those that occur at the
natural menopause. Especially is this the case when the premature
menopause is quite a sudden occurrence, but this phenomenon is rare.
Most commonly the premature menopause is gradual in onset; the flow
becomes more scanty month by month, until at last it fails altogether to
appear. Irregularity in the menstrual rhythm is not often seen in such
cases. Early senescence is exceptional in these women in whom a
premature menopause occurs. Emaciation, greyness of the hair, wrinkling
of the skin, the growth of hairs on the face, etc., are not usually
associated with the atrophy of the reproductive organs; the physiognomy
and figure of women with cessatio praecox being usually similar to those
seen in women of corresponding age in whom menstruation still continues.
_Tilt_ enquired regarding the cause of cessatio praecox in 27 instances,
with the following results:
In 3 instances, parturition and lactation. In 1 instance, abortion.
In 2 instances, a fall on the sacrum during menstruation. In 2
instances, suppression of menstruation from chill. In 1 instance,
haemorrhage from the arm during menstruation. In 1 instance,
celebration of nuptials during menstruation. In 2 instances,
severe medicinal purgation. In 2 instances, cholera. In 2
instances, rheumatic fever. In 2 instances, febrile bronchitis.
In 9 instances, intermittent fever.
In 1 case _Tilt_ saw cessation of menstruation occur at the age of 29,
in consequence of metritis. _Atlee_, in 15 cases of ovarian tumour, saw
the menopause occur at ages of 30, 39, 40 and 42. _Puech_ saw a
premature menopause at the age of 30 in 3 cases, in each a sequel of
cholera. _Blondel_ reports a case of cessatio praecox after prolonged
galactorrhoea, although the woman had not suckled her infant;
_Gottschalk_ and _Rokitansky_, cases following injury to the cervix
uteri; _Kiwisch_, _Simpson_, and _Kleinwächter_, cases following
full-time, normal deliveries, in which, however, severe losses of blood
had taken place.
_Courty_ and _Brierre de Boismont_ report cases in which the menopause
occurred as early as the age of 21; _Mayer_, 2 cases at the age of 22;
_Krieger_, 1 case at 23; _Brierre de Boismont_, 1 case at 24; _Mayer_, 2
cases at 25; _Brierre de Boismont_, 1 case at 26, and 1 case at 27;
_Guy_ and _Tilt_, each 1 case at the age of 27; _Brierre de Boismont_,
_Courty_, and _Guy_, each 1 case at the age of 28; _Brierre de
Boismont_, _Courty_, and _Mayer_, each 1 case at the age of 29; _Guy_
and _Tilt_, each 1 case at the age of 30; and _Mayer_, 5 cases at the
age of 30.
An unusually late climacteric, the continuance of menstruation beyond
the age of 50 years, is not an extremely rare occurrence, but is less
often seen than cessatio praecox. There is, however, in these cases a
difficulty which must not be underestimated, namely, to distinguish
between a genuine menstrual bleeding and the other uterine haemorrhages
which are common precisely at this age of life, due either to textural
changes in the uterus, or to neoplasmata—more especially because in
these non-menstrual haemorrhages also a certain periodicity may often be
detected. When on careful examination no abnormality can be discovered
in the reproductive organs, when the bleeding in question recurs at the
intervals and in association with the general symptoms to which the
woman thus affected has been accustomed during her previous
menstruations, and when the amount of blood discharged is not abnormal,
it is permissible to conclude that we have to do with a persistence of
true menstruation, even though the woman has some time since completed
the fifth decennium of her life. In some women, in fact, the
reproductive system is so energetic, that ovulation continues to an age
far beyond the average, and such women are to be regarded as sexually
long-lived.
Although the instances of protracted menstruation contained in the older
literature of the subject are open to suspicion, owing to the fact that
at that time it was not possible to distinguish with certainty between
menstrual and pathological uterine haemorrhage, quite recently numerous
incontestable cases of enduring sexual vitality have been put on record.
I have myself seen no less than 106 cases in which the menopause did not
occur until after the age of 50 years; among these there were 4 in which
the age at the menopause was 56; 5 in which it was 57; 2 in which it was
58; 1 in which it was 59; and 1 in which it was 60. _Tilt_ records 128
cases of menopause occurring after 50; among these there were 4 in which
the woman was 56 when menstruation ceased; 2 who were 57; 4 who were 58;
1 who was 59; 1 who was 60; and 2 who were 61. _Courty_ reports a case
in which menstruation persisted after the age of 65; _Mayer_, 3 cases of
menopause at 64; _Beigel_, 2 cases, 1 in which menstruation continued to
the age of 65, the other, to the age of 72. _Kleinwächter_ observed 33
cases in which menstruation continued to an age varying from 50 to 57
years. _Emmet_, in the year 1886, published the case of a woman who was
then 70 years old, and who at this advanced age continued to menstruate
regularly.
That not every case in which after the age of 50 years there is
recurrent, more or less periodic, haemorrhage from the genital organs,
is to be regarded as an instance of delayed menopause, we are taught by
the records of post mortem examination in several cases of the kind.
_Scanzoni_ reports the case of a woman who at the age of 60 was affected
with a fairly regular periodic discharge of blood from the vagina.
During one of these haemorrhages, she died of pneumonia, and the autopsy
showed that the ovaries were completely atrophied and transformed into
dense scar tissue, and contained no trace of corpus luteum or of fresh
extravasation of blood, whilst in the upper part of the cervical canal
there were two mucous polypi each of about the size of a bean. In
another case, that of a woman 64 years of age, periodic losses of blood,
at intervals of from three to four weeks, continued to the time of her
death. This woman suffered from mitral valvular insufficiency, and it
was clear that the haemorrhages had been due to the venous engorgement
consequent upon imperfect compensation. The ovaries were completely
atrophied, and showed no trace of any recent maturation of ova; the
uterus was enlarged, the mucous membrane hyperaemic, and the cavity
contained a recent clot.
Not infrequently, the haemorrhages attributed to the persistence of
menstruation are really due to senile arteriosclerosis—to rigidity and
brittleness of the uterine arteries; in other cases they arise from
varicosity of the veins of the cervical canal. A common cause of such
bleedings from the genital passage in comparatively advanced life, is to
be found in the growth of uterine myomata.
To myoma uteri we must attribute a part, though by no means all, of the
cases in which menstruation seems to recur some years after the
menopause has, to all appearance, been fully established. In most of
these cases, indeed, we have to do with pathological haemorrhages, the
cause of which is, however, but too often obscure. Still, cases
certainly occur in which, two or three years or even longer after the
menopause, some unknown stimulus leads to the regular recurrence of
menstruation. The possibility of such an occurrence is, in my opinion,
fully proved by post mortem examinations of the bodies of elderly women
in whom the menopause has been fully established and yet the ovaries are
found to contain follicles of various degrees of ripeness, and also
fresh corpora lutea—signs that ovulation may persist for a considerable
time after the complete cessation of menstruation. Another proof of the
last fact is the well known experience that women who have some time ago
ceased to menstruate, may nevertheless become pregnant. _Waldeyer_,
indeed, asserts that when four years have elapsed since the menopause,
follicles are never to be found in the ovaries, but this negative
experience is not decisive, especially as regards the cases in which
regular menstruation is resumed some time after the occurrence of a
premature menopause.
I have myself seen several cases in which the menopause occurred at 35,
38, 39, and 42 years, respectively; 3, 4, or 5 years later, as a result
of hydropathic treatment, regular menstruation recurred. In one case, a
woman who had ceased to menstruate ten years before, gave birth to a
child at the age of 45.
Numerous indisputable cases of this kind are reported in the recent
literature of the subject. _Krieger_ had under his personal observation
a woman of a robust habit of body, in whom menstruation ceased at the
age of 48 years, her eighth child having been born fifteen years before.
Two years later irregular menstruation recurred, and on the cessation of
these haemorrhages, it appeared that the woman was once more gravid; she
was delivered at full term of a girl. _Mayer_ observed the following
case: A strong working-class woman 33 years of age had begun to
menstruate regularly when 13 years old; between the ages of 17 and 28
she gave birth to five children, and in addition had one miscarriage
when 19 years old. Widowed at the age of 29, she fell ill, and on
examination the uterus was found to be small and relaxed, whilst the
vaginal portion of the cervix was reduced to a mere rudiment. Since she
had been 22 years of age she had had persistent leucorrhoea, but no
trace of menstrual haemorrhage; yet since that age she had had three
children. _Renaudin_ delivered a woman 61 years of age, who had ceased
to menstruate 12 years earlier. _Meissner_ reports a case in which a
woman first began to menstruate at the age of 20, had her first child
when 47 years old, and gave birth to the last of her eight children when
60 years of age.
The sudden and permanent cessation of menstruation, whether at the
normal climacteric age, or earlier in life, is always a pathological
occurrence. As compared with the normal, gradual disappearance of
menstruation, associated with the usual climacteric symptoms, such a
sudden extinction of menstrual activity is, moreover, quite rare. When
it does occur, the cause is to be found in one of various pathological
general states, such as one of the acute infectious disorders, or some
other exhausting disease, or sometimes in some local disease of the
reproductive organs; occasionally, however, it may occur in perfect
health, in consequence of some powerful physical or mental stimulus,
such as a severe blow or intense fright.
This sudden menopause has been observed after severe labour or abortion
with profuse haemorrhage, or after cholera or typhoid; we must assume
that in such cases the anæmia of the genital organs has disturbed the
function of ovulation; whilst in cases due to mental shock, the
interference with ovulation must be through the intermediation of the
nervous system. Frequently, of course, in these cases, the sudden
menopause is also a premature one.
_Tilt_ reports a case in which a sudden menopause ensued upon phlebotomy
during menstruation; several cases also in which women at ages varying
from 30 to 34, or 39 years, ceased to menstruate suddenly and
permanently in consequence of grief at the unexpected death of the
husband; and another case of sudden menopause due to a fall down stairs.
_Courty_ reports three cases of sudden menopause at the age of 30,
consequent upon an attack of cholera. _Dusourd_ has seen three cases in
which, in women aged 40 to 43 years, severe haemorrhoidal bleeding was
followed by sudden and permanent cessation of menstruation. _Mayer_
reports the case of a delicate middle-class woman 34 years of age, who
had begun to menstruate at the age of 14, had married at the age of 20,
and at the age of 21 after a normal delivery, ceased for ever to
menstruate; and another case of a working-class woman 34 years of age
who first menstruated at the age of 13 years, married at the age of 20,
had two children in rapid succession, and finally ceased to menstruate,
in consequence of a fright, at the age of 30 years. _Krieger_ reports
the case of a very nervous woman who first menstruated at the age of
thirteen, and in whom at the age of 23 a sudden menopause ensued upon a
nervous attack; in another case reported by the same observer, a sudden
menopause occurred in a delicate woman 41 years of age owing to her
husband’s death—this woman had previously experienced six months
amenorrhœa in consequence of sorrow at the death of one of her children.
The following remarkable case is reported by _Brierre de Boismont_: A
sempstress began to menstruate at the age of 13 years; she married very
soon after this, and gave birth to four children, the last when 21 years
of age. In the course of the following year there was a fire in the
house, and owing to this fright a sudden menopause occurred. Similar
cases have been reported quite recently by _Bossi_ and _Walter_.
The harmful influence which the occurrence of a sudden menopause
exercises upon the general condition of the woman who experiences it, is
manifested chiefly by violent circulatory disturbances, hyperaemia and
congestion of the brain, lungs, and abdominal organs, and by states of
excitement and depression of the nervous system. Of the vicarious
haemorrhages which are apt to ensue upon such a sudden menopause, we
have already spoken.
Generally speaking, women in middle life, in whom the whole organism is
accustomed to the onset and decline of the menstrual hyperaemia, endure
the functional disturbances induced by a sudden and complete cessation
of menstruation much more easily than women who have already entered
upon the climacteric age, or have nearly attained that age. The
climacteric age is one in which women are already predisposed to
circulatory disturbances in the pelvic organs, and it will readily be
understood that in them the sudden interruption of the menstrual
haemorrhages will have more serious consequences than in women in the
prime of their sexual life, and therefore endowed with a greater power
of resisting disturbances of the normal functions.