pathological basis of the majority of the disorders of the climacteric,
manifest themselves in the abdominal organs in the well-known form of
plethora abdominalis, chronic venous congestion of the gastric and
intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the
mucous membrane of the bladder, catarrh of the bladder, distension of
the haemorrhoidal veins, and the various symptoms dependent upon these
several forms of congestion.
Bleeding from the haemorrhoidal veins and chronic diarrhoea are two of
the troubles proceeding from the above mentioned congestion of the
intra-abdominal vessels, which occur so frequently during the
climacteric period that since the days of antiquity they have been
regarded as critical manifestations of the menopause, the object of
which is to afford a vicarious outlet for the menstrual flux, now become
irregular and intermittent. It can, indeed, be readily understood that a
discharge of blood and an increased secretion from the mucous membrane
of the lower part of the intestine may, if not too violent, exercise a
favourable influence upon the congestive states of the climacteric, by
relieving the distension of the abdominal vessels—by a local
blood-letting which regulates the disordered circulation. In this way,
even though we have ceased to regard it as a “critical” manifestation,
haemorrhoidal bleeding, accompanied by an increased secretion from the
intestinal mucous membrane, may at the climacteric period have a
distinctly favourable influence upon a woman’s general condition.
_Hippocrates_ already in his aphorisms pointed out the salutary effect
of epistaxis and of diarrhoea in women suffering from suppression of the
menses. Other authors have assigned a critical significance to
diarrhoeas occurring at the climacteric, and have warned against their
suppression. According to _Tilt_, diarrhoea occurred in 12% of all women
of this age coming under his observation; in 4% of the climacteric
women, this diarrhoea recurred at regular monthly intervals, whilst in
8%, the recurrence was irregular. In 500 women during the climacteric
age, _Tilt_ observed the following abdominal disorders:
Swollen haemorrhoids in 62 cases
Diarrhoea in 60 cases
Enduring disturbance of the biliary secretion in 56 cases
Bleeding haemorrhoids in 24 cases
Intestinal haemorrhages in 20 cases
Icterus in 6 cases
Hæmatemesis in 4 cases
Monthly intestinal haemorrhages in 2 cases
Monthly bleeding from haemorrhoids in 1 case
In my own observation, constipation is more frequent in climacteric
women than diarrhoea, the constipation being also a symptom of abdominal
congestion. Sometimes, when diarrhoea occurs, it is really secondary to
constipation. The accumulation of the faecal masses stimulates the
intestinal mucous membrane, and gives rise to a profuse aqueo-mucous
secretion; the firm faecal masses are then liquefied, the intestinal
wall is lubricated, and the constipation gives place to diarrhoea
lasting perhaps for several days. This is the explanation of many cases
in which there is a periodic recurrence of diarrhoea.
Dyspeptic disturbances are rarely absent during the climacteric period.
Most often we see disordered appetite, sluggish digestion, pyrosis,
eructation, at times nausea and retching, and actual vomiting of a
watery or bilious fluid. Occasionally, an abnormal sensation of hunger
follows each meal, associated, however, with a feeling of distension of
the stomach. A very distressing symptom is an excessive formation of gas
within the intestine. At times such meteorism is extreme, and it then
gives rise to very severe abdominal pain. The gas is evacuated slowly
and with difficulty, the patient is compelled to loosen all her
clothing; more especially after a meal she is compelled to take off her
stays and undo all the bands of her petticoats and skirt. At the same
time we see difficulty in breathing and tachycardia. Such an
accumulation of gas within the abdomen may give rise to serious errors
in diagnosis, the swelling being attributed to pregnancy or to abdominal
tumour.
Noteworthy also at the time of the menopause is the occurrence of
vomiting, either as an isolated symptom, or in association with some
other well-known climacteric disorder. When this vomiting is associated
with some unmistakable form of excessive secretory activity
(hyperhydrosis, etc.), we may readily suppose that the vomiting is due
to undue secretory activity on the part of the gastric mucous membrane.
An excessive production of gastric juice, perhaps altered in quality as
well as quantity, combined with some other disorder of gastric
innervation (hyperaesthesia, or hyperkinesia) will sufficiently explain
the occurrence of the sometimes excessive vomiting, even though in many
of the cases there may be no reason to suppose that there exists any
primary stimulation of the vomiting centre. In other cases, however, it
is probable that the trouble is really due to a primary disorder of that
centre; and a careful study of the clinical features of the case will be
needed to show how far there may be associated with this other disorders
of gastric innervation (_Boerner_).
Disturbances of the biliary secretion, icterus of greater or less
severity, are by no means rare manifestations of the abdominal
congestion of climacteric women, and such disorders have also been
regarded as vicarious processes originated by the cessation of the
menstrual flux (_Aran_, _Bennet_, _Henoch_, and others.) _Frerichs_ also
has pointed out that with the cessation of menstruation at the
climacteric we not infrequently observe swelling of the liver, which
disappears when, after a considerable period, the menstrual flow
recurs—a sequence of symptoms which may be repeated again and again for
a considerable time.
_Diseases of the Skin._
The most characteristic symptom of disorder of the skin met with at the
climacteric period—one which, indeed, may be said to be never absent—is
ardor fugax, fugitive heat; and scarcely less common is hyperhydrosis,
an excessive secretion of sweat. Almost invariably, at the commencement
of the menopause, women complain of a feeling of burning heat, rising up
from the breast to the face; and if they are kept under observation we
see from time to time a sudden redness of the face, and sometimes also
of the neck and chest, associated with the outbreak of a thin
perspiration. Moreover, in nearly all climacteric women, we notice an
increased secretion of sweat over the whole surface of the body, and at
times this secretion is extremely profuse.
In association with these symptoms we often see the hyperaemic processes
in the skin known by the names of erythema and roseola, taking the form
of larger or smaller bright red patches, which are most frequently seen
on the sides of the neck, the front of the chest, and the face.
In many women, at the menstrual periods, when the flow has become scanty
or has already entirely ceased, we observe the occurrence of eczematous
eruptions, which have for this reason received the distinctive name of
climacteric eczema. In the majority of these cases, the eczema does not
make its appearance until the regular menstrual flux has completely
ceased to occur; and in the less common cases in which the flow persists
after the climacteric eczema has begun, menstruation is rarely regular,
but has begun to exhibit the variability and disorder characteristic of
the time of the menopause. If the eczema comes on after the menopause is
completely established, it usually appears in from six to twelve months
after the cessation of the flow; but in some cases, the eruption appears
very soon after the menopause, whilst in others, its onset may be
delayed for as long as four or five years. Climacteric eczema is
obstinate, and shows no tendency to spontaneous cure. With regard to the
localization of the eruption, _Bohn_ found that in three-fourths of the
cases it affected the hairy scalp and the ears; _Rayer_ and _Hebra_ also
state that the eczema of the menopause is most frequently seen in these
two situations, whilst the next commonest site for the eruption is the
face. As regards other parts of the skin, it is only that of the
extremities that is ever affected by this disease, especially the hands
and the fingers, less often the forearms or the backs of the feet; it
never appears on the trunk. With regard to the types of eczema occurring
in connexion with the menopause, we see almost exclusively the squamous
and the weeping forms of the disease.
In general, at the climacteric period, the skin is extremely sensitive,
and devoid of powers of resistance to outward noxious influences.
Alternations of dampness and dryness or of heat and cold readily give
rise to redness, infiltration, and the formation of scales and fissures
of the skin; sometimes this occurs merely after cold ablutions. These
acute stages of swelling, redness, and vesiculation of the skin, readily
pass on into chronic and obstinate dermatitis.
Not infrequently, during the climacteric, as during the menarche,
inflammation of the sebaceous glands occurs, acne, at times accompanied
by seborrhœic manifestations. In other cases, we see disfigurations of
the face in consequence of vascular dilatations, especially on the nose
and on the adjoining portions of the cheeks, rosacea, in which disease
also there is associated inflammation of the sebaceous glands. Another
disorder of the skin of the face which is greatly dreaded by women at
this time of life, owing to the unsightly appearance it produces, is the
development of sinuous dilatations of some of the superficial vessels,
at times associated with connective tissue proliferation in the form of
red or violet-coloured painless nodules.
An extremely distressing affection, and one which is especially apt to
attack women during the change of life, is the previously mentioned
pruritus genitalium. The itching is in some cases confined to the
external genital organs, whilst in others it extends into the interior
of the vagina; also it may pass backwards over the perineum, and on into
the gluteal folds. In some cases, some local pathological condition will
be found to account for the disorder: catarrh of the vagina or of the
cervix uteri; displacements, inflammations, or new-growths of the
uterus; anomalies of the ovary, the bladder, or the urethra. _Cohnstein_
draws attention to a circular hyperplasia of the vaginal portion of the
cervix, occurring during the menopause, and, “owing to the vascular
dilation by which it is characterized, possessing close analogies with
haemorrhoids;” the worst symptom of this affection is pruritus. That in
these cases the pruritus is actually dependent upon the “haemorrhoidal
hyperplasia” of the portio vaginalis, _Cohnstein_ considers to be proved
by the fact that, whilst local applications give no more than momentary
relief to the itching, this symptom is completely relieved by the
abstraction of blood from the cervix. But in addition to such cases as
these, we have from time to time to deal with patients suffering from
violent genital pruritus during the climacteric period, in whom we shall
vainly seek for any local pathological changes, to the cure of which our
therapeutic zeal may be directed. Analogy with some other disorders of
the climacteric leads us to conclude that in these cases also we have to
do with an idiopathic neurosis (_Boerner_).
The frequent recurrence of pruritus vulvae leads ultimately to the
formation of nodules and papular eruptions.
Many authors state that they have observed the frequent occurrence of
erysipelas during the climacteric period; others assert that
furunculosis, prurigo, urticaria, and herpes zoster, are seen with
especial frequency at this period of life.
_Tilt_, in his 500 cases of women at the climacteric age, made the
following observations:
201, or 40.2%, suffered from heats and tendency to perspiration.
2, or 0.4%, suffered from monthly recurrence of periods of perspiration.
84, or 16.8%, suffered from profuse perspirations.
13, or 2.6%, suffered from cold sweats.
14, or 2.8%, suffered from dry heats (dry flushes).
186, or 37.2%, remained free from such attacks of heat or perspiration.
_Krieger_ gives as an example of the “occurrence of new troubles” at the
change of life, furunculosis; so also does _Boerner_. “The
discolouration of the face, occurring usually in connexion with
pregnancy or with diseases of the reproductive organs, and known as
chloasma uterinum,” has been seen by _Cohnstein_, during the climacteric
period, “chiefly in cases in which, owing to some degree of failure of
general nutrition, the skin has been thrown into folds.” _Wilson_
regarded prurigo and eczema as the commonest skin-diseases of the
climacteric period; whilst _Boerner_ draws attention to a connexion
between climacteric conditions and the outbreak of herpes zoster.
_Disorders of Metabolism._
Among the disorders of metabolism to which women are especially prone at
the climacteric period, we must in the first place allude to obesity
(lipomatosis universalis), and to gout (arthritis urica).
Numerous observations have shown us that the time of the change of life,
the period between the ages of 40 and 50 years, is the one especially
favourable in women to the extensive deposit of fat in the tissues.
In 200 cases of great obesity (lipomatosis universalis) in women, in
which I instituted enquiries regarding the age at which an excessive
deposit of fat in the tissues had first been noticed, I obtained the
following results:
In early childhood in 19 cases
At the age between 15 and 20 years in 30 cases
At the age between 20 and 30 years in 45 cases
At the age between 30 and 40 years in 52 cases
At the age between 40 and 50 years in 54 cases
At ages over 50 years 0 cases
We learn from these figures that it is between the ages of 40 and 50
years that there is the greatest tendency in women for the accumulation
of fat; but that as early as between the ages of 30 and 40 years this
accumulation may in many instances begin. Speaking generally, there is
in women an obvious connexion between the development of obesity and the
state of the reproductive functions, inasmuch as at puberty, during the
puerperium, and above all at the climacteric, there is a special
tendency to the accumulation of fat in the subcutaneous tissues. At the
commencement of the menopause, it is more especially in the abdominal
wall, the breasts, and the buttocks, that we witness the deposit of fat.
In the abdomen, owing to the thickening of the subcutaneous tissues and
of the great peritoneal folds—especially of the great omentum—a marked
protrusion occurs, whilst the umbilicus becomes more deeply hollowed,
and ultimately funnel-shaped. In some instances, the deposit of fat
around the navel favours the occurrence of umbilical hernia. After an
artificial menopause, induced by oöphorectomy, it has also been noticed
in from 42 to 52% of the cases that a marked general deposit of fat has
occurred, affecting especially the breasts and the buttocks.
This obesity in climacteric women, not only impairs to a serious extent
their good looks, but brings in its train a number of troubles, and
gives rise to manifold morbid manifestations, and among these, changes
in the heart, which may readily threaten the patient’s life. In
consequence of extensive fatty deposits in the myocardium, associated
with actual fatty degeneration of the muscular fibres, cardiac
insufficiency ensues, with all its distressing and disastrous
consequences. It is further necessary to insist upon the fact that
obesity during the climacteric very definitely favours the occurrence of
menorrhagia.
On examining 282 women, 5 years after the complete cessation of the
menstrual flow, _Tilt_ found that
121 had become stouter than before,
71 were unchanged in this respect, and that
90 were thinner than formerly.
Alike in the third class and in the first were a very large proportion
of women in whom the change of life had entailed much illness and
suffering; but in the first class, the women who had been thus affected
had at that time lost weight, and only in the latter half of the
climacteric period, when their troubles had become less severe, had the
condition of embonpoint made its appearance.
Passing now to the consideration of arthritis urica in women at the
climacteric, it is worthy of mention that _Hippocrates_ was so much
struck by the association that he went so far as to deny that gout
occurred at all in women before the menopause. The fact of the matter is
that whilst women are in general less disposed than men to the
occurrence of gout, the tendency of women to this disease during the
climacteric period is so marked, that at this epoch of life the disease
is far more common in women than it is in men of corresponding age.
It is in obese women, with a soft, white, and lax integument, with a
pallid, somewhat bloated countenance, a poorly developed muscular
system, extensive varicosities of the veins of the legs, marked
dyspeptic troubles, and habitual constipation, that during the
preclimacteric and climacteric periods, gout is especially apt to make
its appearance. It is then characterized by the following symptoms. From
time to time the woman suffers from tearing or shooting pains in the
joints, lasting at first a short time only, and returning after longer
or shorter intervals. With the frequent return of the pains, the
affected joints become swollen; and finally the patient suffers from the
characteristic attacks of acute gouty arthritis, with the well-known
consecutive symptoms of this affection.
According to the observations of _Geist_, during the climacteric period,
28 women suffer from gout as compared with 4 men of corresponding age.
_Tilt_ publishes the following figures showing the mortality of women
from gout in England:
At ages from 20 to 30 years 56 women
At ages from 30 to 40 years 121 women
At ages from 40 to 50 years 291 women
At ages from 50 to 60 years 152 women
At ages from 60 to 70 years 104 women
Regarding diabetes mellitus during the menopause, _Lawson Tait_, who
maintained there was a distinct form of climacteric diabetes, asserted
that this disorder of metabolism was less severe, and runs a longer
course during the climacteric period than at other times of life.
_Diseases of the Nervous System._
The disturbances of the nervous system that occur during the climacteric
period, manifest themselves chiefly in the form of hyperaesthesia and
hyperkinesia. The sensory nerves appear to me for the most part to be
more irritable than normal, inasmuch as every stimulus by which they are
affected arouses a comparatively greater sensation, and gives rise to an
excessive reaction in the sphere of consciousness. The cutaneous
hyperaesthesia of climacteric women is shown in very various ways, the
commonest being the anomaly of sensation which gives rise to the symptom
known as pruritus, characterized by paroxysms of itching in more or less
extensive areas of skin, with consecutive nutritive changes in the
affected portions of the integument. The commonest and the most
distressing form of this disorder during the menopause is pruritus
vulvae.
In addition to such manifestations of cutaneous hyperaesthesia,
vasomotor disturbances of the skin are of frequent occurrence,
characterized by redness, rise of temperature, and sometimes the
formation of nodules in the affected areas. Almost without exception, at
the outset of the climacteric period, and sometimes also in the
preclimacteric epoch, women complain of a very distressing feeling of
fugitive heat in various portions of the surface of the body, manifested
objectively by the rapid appearance and no less rapid subsidence of a
red colouration of the skin of the face, the neck, and the chest. Such
fugitive heats are due to disturbances of vasomotor innervation giving
rise to sudden variations in the amount of blood passing through the
vessels of the affected areas of skin.
Hardly less frequent during the climacteric are the sensations of
imaginary movement which give rise to the subjective symptom known as
vertigo. Often in women at this time of life it occurs quite without
apparent cause, but in other cases on the performance of some unusual
movement or the adoption of some unusual posture; there is a sudden
perception of rotatory movement, either of the patient’s own body or
else of her visible and palpable environment. With this feeling of
disturbed equilibrium, there is often associated optical and auditory
hyperaesthesia, flickering before the eyes (muscae volitantes), tinnitus
aurium, painful sensations in the head and more especially in the
occipital region, nausea, vomiting, sense of anxiety, cold sweats,
muscular twitchings, alternating redness and pallor of the face, and
coldness of the feet. The vertigo occurs in paroxysms, usually of short
duration, varying from one to fifteen minutes. It is especially in
plethoric and obese women that climacteric vertigo occurs.
A peculiar form of this climacteric vertigo is that described by _Tilt_
under the name of “Pseudo-Narcotism” of climacteric women, characterized
by a sense of swimming movements, uncertainty in the gait, vacancy of
expression, a confused look in the eyes like those of a drunken person,
and a kind of mental stupor which the patient cannot shake off without
considerable effort. The women thus affected state that they feel as if
they had had too much to drink, as if something had gone to their heads;
indeed their great fear is that they will be supposed to be intoxicated
by those who see them walking in the streets; they feel even that they
must refuse to receive the visits of their acquaintances if they wish to
preserve their reputation for sobriety. They suffer also from great
drowsiness, from a disagreeable sense of weight or pressure in the head,
from a feeling “as if the brain was clouded, or needed to have some
cobwebs swept away.” They feel a disinclination to both mental and
physical exertion, and their memory and all other intellectual powers
are impaired.
_Boerner_ maintains that the attacks of vertigo so frequently occurring
at the menopause are in a minority of cases only dependent upon
hyperaemic states (arising from the cessation of the menstrual flow); on
the contrary, he believes that the cause more often lies in hysteria, in
chronic disorder of the digestive tract, or, finally, in anæmia. In his
opinion, vertiginous attacks dependent upon cerebral anæmia are very
common indeed during the climacteric period, and even for a long time
afterwards; and he believes that their nature is often completely
misinterpreted.
Another very unpleasant indication of disordered nervous function during
the climacteric period is the sleeplessness that is so common at this
time of life. Women who during the day time feel comparatively well,
suffer at night, sometimes periodically at exactly the same hour night
after night, from a state of general restlessness, and for this reason
are unable to obtain the sleep for which they long. They throw
themselves uneasily from side to side of the bed, or wander restlessly
about the room, and before long, owing to this want of sufficient
repose, become greatly depressed.
Among the neuroses of the sensory apparatus, the various kinds of
cutaneous neuralgia are less common than during the menarche and the
menacme; but on the other hand, in my personal experience at any rate,
the visceral neuralgias are commoner, more especially cardialgia and
hypogastric neuralgia. Of the superficial neuralgias, hemicrania and
intercostal neuralgia are those which occur most often during the
climacteric period.
During the change of life, hemicrania most commonly occurs in typical
association with menstruation; or, if the flow has already ceased, the
attacks of hemicrania recur at what should be the menstrual periods.
This affection is characterized by the paroxysmal occurrence of a severe
boring pain in the side of the head, more often the left side than the
right, affecting the temporal, the parietal, or the occipital region, or
the entire side of the calvaria at once, usually accompanied with
redness and local rise of temperature of the painful part; the duration
of the paroxysms varies in different cases from one or two to many
hours; with the pain are associated chilliness, nausea, exhaustion, and
a severe feeling of general malaise.
Of the intercostal neuralgias, one form deserves especial mention in
this connexion: I refer to mastodynia, which is both physically and
mentally one of the most distressing affections to which women are
subject during the climacteric period. For a middle-aged woman suffering
from mastodynia—the “irritable breast” of _Cooper_—almost invariably
feels assured that these pains localized in the breast and its immediate
vicinity are indications of a commencing cancer of the breast; and it is
an exceedingly difficult matter, in most cases, to convince her that her
fears are without foundation. In this manner, partly in consequence of
the directly depressing effect of the pains, which are commonly
intensely severe, and partly owing to the disturbance of mind produced
by the belief that an incurably fatal disorder has begun, I have in
several instances seen cases of profound melancholia originate.
According to _Windscheid_, among the enduring painful sensations of the
climacteric period, pains in the lower extremities are of somewhat
frequent occurrence. Day after day the patient suffers from distressing
tearing or lancinating sensations in the legs; the trouble is
insusceptible of more exact description, but is none the less a very
severe one. In addition to the lower extremities, the back, the spinal
column, and more particularly the lumbo-sacral region, are often the
seats of incessant pain. In the thoracic region of the back, the pain is
usually diffuse; when confined to the spinal column, however, it is
commonly limited to individual vertebrae, the spinous processes of those
affected being also sensitive to pressure. The sacral pains may in some
cases predominate to such an extent, that it is on this ground alone
that the patient comes to seek medical advice. The sacrache is equally
severe when the patient is standing, sitting, or recumbent; it often
radiates into the lower extremities. _Boerner_ draws attention to the
fact that in many cases the pains in the sacrum or higher up in the back
may be due to excessive tension of the abdominal parietes in consequence
of the great accumulation of fat. Among motor manifestations,
_Windscheid_ draws especial attention to a certain degree of weakening
of the muscles of the lower extremities. Although on examination no
abnormality can be detected, fatigue and functional incapacity, more
especially in the lower extremities, ensue in a manner altogether
disproportionate to the exertion, so that the patient is most unwilling
to take even a short walk, to go upstairs, etc. In pronounced cases, the
patient will never go out walking without carrying a campstool, so that
she can sit down to rest directly she begins to feel fatigued. In
association with these disorders of motility we most commonly see the
above-mentioned painful sensations in the legs, and by these latter the
functional incapacity of the lower limbs is of course increased.
Weakness of the arms is far less frequently observed; but occasionally
we hear complaints that on the performance of domestic duties,
needlework, etc., which previously could be carried out quite easily,
the arms and hands are now speedily fatigued, and rendered functionally
incapable.
Of the visceral neuralgias, cardialgia is by no means rare during the
climacteric period; the pain is concentrated in the epigastric region,
but not infrequently radiates to the back and to the chest. Hypogastric
neuralgia is also not uncommon, pain in the lower part of the abdomen,
associated with a sense of pressure in the bladder, the uterus, and the
rectum, and sometimes radiating to the thighs and to the region of the
haemorrhoidal nerves.
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.
“In considering the mental condition of women at the outset of the
climacteric period, we must not forget those who are called ‘old maids.’
In their youth these maidens also have had their ideals, their hopes,
their plans, and their sorrows. They also had a natural impulse to love
and to be loved in return; they hoped to become wives and mothers. But
life has failed to fulfil their hopes and their wishes, and their
longings have remained unsatisfied. Some of them have taken up their
cross without murmuring, and have devoted their talents, their
intelligence, and their love to the service of those nearest to them.
But others make an active protest against fate in the form of vindictive
feelings towards their environment, of quarrelsomeness,
scandal-mongering, etc. Here we see contrasted the two principal types
of such women. On the one hand are those who devote their intellectual
and spiritual powers to the service of society; these are unselfish
sisters-of-mercy, untiring medical women, invaluable school-teachers and
governesses, fanatical political agents, etc. Such as these have ceased
to live for themselves. In the fullest sense of the words, they mortify
the flesh, and guide their conduct by lofty moral principles. They have
killed their sexual life, and they remain for ever virgins—both morally
and physically. If, owing to a pathological inheritance, faulty
conditions of life, exhausting illnesses, etc., a psychosis develops,
the hallucinations and delusions from which they suffer very rarely
assume a sexual character, nor are they of a degrading type. The sexual
side of life seems, in fact, be they sane or insane, to have undergone
complete atrophy. They suffer from simple melancholia with stupor, or
their insanity takes a religious turn, but very rarely indeed has it an
erotic character.
“Very different is it with old maids of the second type. They are
dissatisfied with life, irritable, quarrelsome, envious, and malicious.
They are spiteful and revengeful, gossips and scandalmongers, boast of
their own chaste and innocent lives, and never forgive any real or
imaginary attempt upon their spotless virtue. At the same time they
never lose hope for the future, and are full of imaginary love-affairs,
in which they pass through scenes by no means chaste or innocent; they
do not shrink from self-abuse and the abnormal gratification of the
sexual needs, in which the lacking partner in the sexual act is supplied
by the imagination. Under the influence of such abnormal conditions of
life, these women frequently become affected by nervous disorders;
migraine, neuralgia, cephalalgia, nervous depression, rachialgia,
debility, anæmia, diseases of the reproductive organs, etc. Thus, when
they enter the climacteric age, the soil is fully prepared for the
development of mental disorder, which in such individuals is often
characterized by hallucinations of sexual sensation and perception,
erotic visual and auditory hallucinations, delusions of similar
character, increased sexual irritability, a search for abnormal means of
sexual gratification, a propensity to obscene speech and conduct, etc.
“Mental disorder is so common during the climacteric period, that the
term ‘climacteric insanity’ has now become established in the literature
of mental alienation. In almost all the textbooks of the subject we find
an allusion to this form of mental disease, but there is no real ground
for _Maudsley’s_ assumption that there is a climacteric insanity sui
generis. At the climacteric, very various forms of mental disorder may
occur—paranoia, melancholia, and mania; the only common feature in the
attacks, owing to which they are classed as ‘climacteric insanity’ being
the fact that the final determining cause in each case is the onset of
the change of life. In fact, this period is not without influence upon
the manifestation of the disease—its stamp is imprinted upon the
clinical picture, it endues the disease with certain characteristic
features—but still, the peculiarities common to the cases of mental
disorder occurring at this time of life in women are not so great as to
justify us in describing them as a separate variety of psychosis.”
According to _Kowalewski_, this so-called climacteric insanity is met
with in two principal forms: in many cases the mental disorder recurs in
periodic paroxysms, associated either with the commencement of the
menstrual flow, or having the periodicity of menstruation after the flow
has already ceased to appear; in the other class of cases the psychosis
has no direct connexion with menstruation, and is dependent upon the
joint influence of all the manifestations of the climacteric period.
Cases belonging to the former class have been distinguished by _Bartel_
as “climacteric pseudomenstrual insanity.”
The psychoses dependent upon the climacteric influences may, according
to _Kowalewski_, appear in almost all the known forms of mental
disorder: precordial anxiety, melancholia, mania, amentia, paranoia,
etc.; and although they exhibit no features which are absolutely
characteristic, or which, as already said, enable us to distinguish a
specific “climacteric insanity,” yet they all bear a common imprint by
means of which we are enabled to detect in their causation the influence
of this critical period of life. Thus, precordial anxiety occurs in
paroxysms having a more or less regular periodicity, corresponding with
that of the expected menstruation. The same feature is observable in the
periodic exacerbations of hysterical and epileptic paroxysms. Often,
also, there occur at this time sudden changes in the emotional
disposition and in the character, in one direction or the other, without
the development of actual melancholia or mania. The melancholia of the
climacteric period occurs chiefly in married women, more especially in
those whose circumstances are unhappy; and it is often manifested by
attempts at suicide.
Mania is comparatively rare at the climacteric period; when it does
occur, it commonly assumes a sexual form—sexual impulses,
hallucinations, and delusions, and obscene conduct. Such manifestations
are seen most often in widows, in “old maids” whose morals are not above
reproach, and, speaking generally, in those whose sexual needs have
remained partially or completely ungratified, and in those who have
greatly erred in the conduct of this side of life. Amentia also occurs
at this time of life; rarely in maniacal form, more frequently in
association with menstruation as a periodic psychosis, or as a
continuous disorder of mind with exacerbations corresponding to the
menstrual periods; it is often characterized by pronounced eroticism.
Much more frequent during the climacteric period is the occurrence of
paranoia, as _Kowalewski_ rightly insists. It is most often met with in
“old maids” with psychopathic predisposition. The imagination of such
individuals is always concentrated upon men; they imagine that men in
general, but more particularly certain individuals of the opposite sex,
are continually regarding them, making eyes at them, making signs to
them, in some way or other striving to attract their attention. The most
ordinary and invariable forms of polite intercourse are regarded by
these women, whose powers of observation are morbidly stimulated, as
being indications of a special “attention” paid to themselves. They
persecute these men with their own attentions, and imagine that it is
the men who are persecuting them. Often this morbid mental state is
associated with sexual malpractices, masturbation, etc. Not rarely, such
degenerates are affected with lascivious dreams. Often they experience
hallucinations of sexual perception in the form of supposed assaults on
their virginity. All these states are apt speedily to develop into a
condition of general suspiciousness and ideas of persecution. The ideas
of persecution assume a peculiar form, one especially characteristic of
the climacteric period. The patients believe that a man, often
personally unknown to them, and perhaps living in another town, enters
into spiritual and bodily intercourse with them. These relations are
supposed to be effected in most cases by means of spiritualism,
hypnotism, or electricity. The patient importunes the man in question
with letters, supposes herself to be legally united with him, and not
infrequently wishes to give him the pleasure of paying her bills and
providing her with money. It is a very common occurrence for a Catholic
priest to be worried by such a woman, her delusion being grounded upon
the fact that the priest is supposed to assume an exceptionally intimate
spiritual relationship with members of his flock. The patient with ideas
of persecution often herself becomes an actual persecutor, not only
pestering her victim with innumerable letters, but in her jealousy
making “scenes” whenever she can encounter him, and sometimes giving
rise to serious scandal. With such a mental state we often see
associated sexual hallucinations and delusions; the patient believes
herself to be pregnant, imagines herself to have been violated, or to be
living in carnal intercourse with a man—some one, it may be, with whom
she is not even acquainted. Medical men are especially apt to suffer
from the accusations of such women, whom they may have examined in
private in entire ignorance of the patient’s mental condition.
Frequently, such ideas of sexual persecution are associated with
paroxysms of violent nymphomania, and in this way also the unwary
physician may find himself placed in an extremely unpleasant position.
It occasionally happens in such patients that abnormalities of the
sexual instinct arise, and they begin to feel desire towards individuals
of their own sex.
Such delusions of persecution by means of hypnotism, spiritualism, the
telephone, etc., in association with sexual delusions and nymphomania,
are so frequent during the climacteric period, that they may be regarded
as pre-eminently constituting climacteric insanity. Frequently some old
hysterical state underlies this form of mental disorder.
Thus these peculiar manifestations of eroticism must be regarded as the
distinctive characteristics of climacteric insanity and more
particularly of climacteric paranoia. A second characteristic of
climacteric insanity is, according to _Garat_, the marked development of
jealous emotions and delusions.
In addition to these fully developed psychoses, there occur in
degenerates at the climacteric age paroxysms of impulsive insanity in
the form of dipsomania, kleptomania, pyromania; exhibitionism;
irresistible impulse to suicide, homicide, infanticide, etc. Such
paroxysmal impulsive manifestations are, according to _Kowalewski_,
commonly associated with menstrual disturbances; they occur most
frequently at the due dates of menstruation when the flow fails to
appear.
One hundred and sixty-nine cases of climacteric psychosis were
classified by _Matusch_ as follows:
Melancholia 36 cases
Mania 2 cases
Melancholia passing on into paranoia 28 cases
Melancholia passing on into secondary dementia 17 cases
Paranoia 43 cases
Neurasthenia during the climacteric period followed by mental
disorder 19 cases
Neurasthenia prior to the climacteric period, followed by
mental disorder during the climacteric period 10 cases
Apoplexy, cerebral abscess, dementia 6 cases
Epilepsy 2 cases
Alternating insanity 3 cases
Paralytic dementia 5 cases
_Von Krafft-Ebing_ classified 60 cases of climacteric psychosis as
follows:
Melancholia 4 cases
Alternating insanity 1 case
Acute delirium 1 case
Primary insanity:
_a._ With primordial delirium 36 cases
_b._ Paralytic dementia 12 cases
The prognosis in cases of climacteric psychosis is regarded by
_Kowalewski_ as unfavourable; unfavourable vital conditions are
associated with retrogressive metamorphosis of the tissues, hence mental
disorder arising at this time of life is hardly less serious than that
due to actual degeneration of cerebral tissues. Indeed, according to
_Schüle_ there is during the climacteric period an especial danger of
the development of atrophic cerebral processes (Encephalitis
atheromatosa) with apoplectic and epileptic seizures. _Schlager_ also
regards the prognosis of climacteric insanity as unfavourable; but
_Merson_, on the other hand, observed among women suffering from
climacteric psychoses a recovery rate of over 50%. On previously
existent psychoses in women, the onset of the climacteric exercises in
most cases an unfavourable influence, and very exceptionally only at
this time do we observe the cure or remission of a chronic mental
disorder to occur. _Kowalewski_ has seen cases of chronic mania in which
a cure was obtained at the climacteric period; a somewhat excessive
excitability and inclination to violence remained, however, as vestiges
of the former insanity. _Matusch_, keeping under observation 60 women
affected with chronic mental disorder as they attained the climacteric
period, noticed that in 14 instances the mental condition changed for
the worse at this period, whilst in 13 the character of the mental
disease underwent a change, excitement giving place to apathy and
dementia. _Griesinger_ had earlier pointed out that at the time of the
cessation of menstruation there would occasionally occur amelioration,
and even cure, of a previously existing chronic mental disorder; more
often, however, the influence of the menopause was an unfavourable one,
a hitherto changeable and irritative form of mental disease becoming
transformed into chronic insanity with inalterable delusions, or into
dementia. The course of mental disorder, such as melancholia, first
making its appearance at the climacteric epoch, was also regarded by
_Griesinger_ as likely to be unfavourable.