Part 17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_Von Krafft-Ebing_ puts forward the following propositions with regard to the forensic significance of offences committed by women during menstruation: 1. The mental integrity of a menstruating woman is questionable from the forensic standpoint. 2. In the case of women on trial for any offence, the point should be determined whether that offence was committed at a menstrual period. 3. An inquiry into the mental condition is expedient in cases in which such a coincidence is established; light is thrown on the matter when investigation shows the existence of hereditary predisposition, when we learn that psychopathic manifestations have occurred at previous menstrual periods, or when the very nature of the offence is one suggesting the presence of mental disorder. 4. A recognition of the powerful influence which the menstrual process exercises upon the mental life should lead, even in cases in which no menstrual psychosis has been proved to exist, to the admission of extenuating circumstances in apportioning the punishment for the offence. 5. In the case of the commission of a punishable act during menstruation by a weak-minded individual, we must as a rule admit the plea of irresponsibility—at any rate in the case of an offence committed under the influence of strong emotion. 6. Persons who have been discharged without punishment on the plea of mental disorder accompanying menstruation must be regarded as dangerous to the community, and should always be under careful supervision during the menstrual periods.

_Amenorrhœa, Menorrhagia, and Dysmenorrhœa._

Amenorrhœa, permanent or transient abnormal lack of the menstrual flow, may depend upon anatomical changes in the genital organs, upon incomplete development or absence of the uterus and the ovaries, upon enduring or transient defective nutrition or upon atrophy of these organs, or upon parenchymatous disease of the ovaries; or it may be due to functional disturbances of ovarian activity, itself dependent upon changes in the nervous system, upon constitutional diseases, or upon general nutritive disturbances in the body. Among the latter conditions must be especially mentioned chlorosis, obesity, diabetes, chronic alcoholism, and morphinism, myxoedema, exophthalmic goitre, etc.

The amenorrhœa that occurs at the time of the menarche has already been described in connection with the symptomatology of that period.

If in cases of amenorrhœa the ovaries continue to perform their functions, we frequently witness severe and painful menstrual molimina, occurring periodically at the times when the flow might be expected, but fails to appear. In cases of atrophy of the uterus and the ovaries, we see complete and permanent amenorrhœa without any discomfort. As a kind of vicarious menstruation, in certain cases of amenorrhœa, we see hæmorrhages into the vitreous body or conjunctival hæmorrhages; also, as more extensive disturbances of the visual organs, interstitial keratitis, disseminated choroiditis, intermittent amaurosis, acute retrobulbar neuritis, amblyopia, and limitation of the field of vision.

_Mooren_ publishes the following cases, showing the influence of amaurosis on the eye. A girl aged fourteen, with severe bilateral pannous keratitis, was amenorrhoeic notwithstanding the existence of well-marked menstrual molimina. Every four weeks, at the times when the menstrual flow should have appeared, the corneal inflammation became more severe; it became amenable to treatment for the first time a year later, when the menstrual flow had become established. A peasant woman, twenty-eight years of age, had never menstruated; the uterus was badly developed; every month an intolerable heat and swelling of the face recurred. Since the age of fifteen she had suffered from bilateral interstitial keratitis, which had resisted all treatment, and had been subject every four weeks to a recurrent exacerbation of this trouble, lasting several days. The exhibition of powerful emmenagogues and the use of Friedrichshall water brought about on a few occasions a scanty discharge of blood. The comfort to the patient, relieved as if by miracle from her pain and photophobia, was most remarkable. Unfortunately, however, this state of comparative happiness lasted from twelve to fourteen weeks only, after which, in spite of everything that was tried, there was no further recurrence of menstruation, and the condition of the eyes relapsed to what had existed for thirteen years. In other cases described by _Mooren_ the amenorrhœa was complicated with disseminated choroiditis and with posterior sclero-choroiditis.

_Beer_ reports a case of retrobulbar neuritis occurring with amenorrhœa, consequent on infantile aplasia of the uterus. An interesting case was recorded by _Dunn_ of a girl fifteen years of age, who had not yet begun to menstruate, and who suffered from interstitial keratitis, with severe photophobia. The ocular symptoms vanished with extreme rapidity as soon as menstruation first appeared. _Napier_ observed complete blindness, without discernible anatomical cause, associated with amenorrhœa of sudden onset; the amaurosis disappeared as soon as menstruation was re-established.

Striking and manifold are the disturbances of the nervous system which may be caused by amenorrhœa, ranging from increased irritability, hyperæsthesia of various nerve tracts, neuralgia, and the like, to severe psychoses.

_Barnes_ reports a case of mental disturbance consequent upon amenorrhœa in a woman twenty-seven years of age, who had begun to menstruate when sixteen years old, and in whom the menses had been suppressed a year earlier when she was informed of the sudden death of her father. From that time a progressively increasing weakness of the mind was observed. In a case recorded by _Macnaughton Jones_ the mental depression consequent on amenorrhœa was so great that it led to an attempt at suicide.

_Lawrence_ observed in young girls who from any cause suffered from amenorrhœa, that an increased pigmentation of the skin sometimes occurred, analogous to that met with in _Addison’s_ disease. This amenorrhoeic pigmentation he compares to the chloasma that is seen in pregnant women.

By menorrhagia we understand the occurrence of typical discharges of blood from the uterus, occurring at more or less regular intervals and differing from normal menstruation in respect either of the greater intensity or of the longer duration of the hæmorrhage; whereas by metrorrhagia we understand the occurrence of atypical discharge of blood from the uterus, which is related to menstruation neither in respect to its causation nor in respect to the time of its appearance.

Menorrhagia may be due to local changes in the genital organs, to organic diseases of other organs, and to general diseases.

Local changes which may give rise to menorrhagia are, active hyperæmia and passive hyperæmia (hyperæmia from engorgement) of the genital organs, such hyperæmia being itself due to sexual excitement, especially when ungratified, to violent physical exercise, or to chill during menstruation; menorrhagia is also liable to occur when the abdominal circulation is disturbed by extreme obesity or by the presence of tumors, also in connection with endometritis, uterine myomata, erosions of the cervix, etc. Diseases of organs other than those belonging to the reproductive system which are especially likely to give rise to severe bleeding are, disease of the heart, such as valvular incompetence, lung disease, and nephritis. General diseases in which menorrhagia may occur are, anæmia, chlorosis, hæmophilia, scurvy, scarlatina, cholera, smallpox, influenza, and obesity.

Through severe loss of blood in menorrhagia, whether the bleeding be sudden and profuse or more moderate but long continued, a condition of chronic anæmia results, with all its threatening consequences to the health and the life of the woman affected. She becomes pale and weak, unfitted for any great physical or mental exertion, and is liable to attacks of cardiac enfeeblement and to fainting fits; in some cases degenerative changes ensue in the cardiac muscle.

Dysmenorrhœa is characterized by severe pain occurring before, during, and after menstruation. The pain is caused either by abnormally powerful contractions of the uterus or else by abnormal sensitiveness of that organ. Abnormally powerful contractions are caused by various mechanical hindrances to the normal processes of menstruation; abnormal sensitiveness is due to inflammatory and congestive states of the uterus and its annexa or to a general increase of nervous sensibility.

_Schauta_, therefore, distinguishes a mechanical, an inflammatory, and a nervous form of dysmenorrhœa. Mechanical dysmenorrhœa is most frequently due to stenosis or flexion of the canal of the cervix in some part of its course from the internal to the external os, dependent upon malformation or flexion of the uterus, hyperplasia of the mucous membrane, chronic metritis, scarring resulting from operative procedures, uterine polypi, etc. In inflammatory dysmenorrhœa we have to do “either with an inflammatory process or with excessive tension of the intrapelvic organs, dependent upon abnormal distension of their blood vessels.” To the same category belong ovarian dysmenorrhœa, and dysmenorrhœa due to inflammatory changes in the Fallopian tubes and to pelvic peritonitis. In nervous dysmenorrhœa, no anatomical cause is apparent, but the uterine contractions normally occurring during menstruation, and the normal congestive distension of the intrapelvic organs at that period, become extremely painful, in consequence of a morbid increase in the sensibility of the nervous system.

The influence of dysmenorrhœa on the general condition of the woman suffering from it is often a very potent one.

The normal undulatory course of the bodily temperature—which as _Reinl_ has shown, undergoes a gradual rise until shortly before the appearance of the menstrual flow, gradually falls during menstruation, and continues to fall for a time after menstruation is over—undergoes a change in cases of dysmenorrhœa due to anteflexion of the uterus, parametritis, or salpingitis, inasmuch as in these cases the acme of the temperature curve is reached actually during menstruation and the decline of temperature comes, not at the commencement of the menstrual flow, but often only after the flow has ceased. The curve of blood pressure and the curve indicating the excretion of urea are similarly affected in these cases.

As symptoms in other organs occurring in cases of dysmenorrhœa _Schauta_ mentions “sensations of heat, coldness of the feet, retching and vomiting, cramps of the stomach and of the voluntary muscles, general disorders of nutrition, loss of appetite, strangury, constipation, dyspepsia, headache, and finally hysteria. As symptoms of the latter affection we may notice, anæsthesia, hyperæthesia of certain parts of the abdomen, attacks of cramp, paralysis, uterine cough, hiccough, spasm of the glottis, epileptiform seizures. The repeated severe attacks of pain may seriously disturb the nervous system, leading to the appearance of general neuroses and psychoses. Frequently we observe, as a peculiar accompaniment of dysmenorrhœa, changes in the fulness of the blood vessels of the face and also in other regions of the skin, in consequence of vascular paralysis. In other cases, actual effusion of blood occurs, and, as a sequel of this, deposits of pigment; and the semicircles beneath the eyes may become so dark as to look as if they had been artificially tinted (_Macnaughton Jones_). In one case, during menstruation periodic swelling of the gums was observed (_Regnier_). Finally, in association with dysmenorrhœa, various forms of neuralgia, changes in refraction, and slight attacks of neuritis and retinitis may occur.”

One of the commonest symptoms and sequelæ is headache, sometimes in the form of hemicrania, which may be associated with dyspeptic manifestations, sometimes diffused over the whole surface of the skull.

Dyspepsia is a very frequent associate of dysmenorrhœa. Thus we meet with pain and tenderness in the gastric region, nausea, vomiting, and also cardialgia. Sometimes the liver becomes enlarged and tender on pressure; in many cases also jaundice is witnessed.

_Gebhard_ refers to another phenomenon which may be classed under the head of dysmenorrhœa, from the character of the pain that is experienced, even though this pain is not felt at the menstrual periods, but in the intermenstrual epoch. This is the so-called intermediate dysmenorrhœa (intermenstrual pain, Ger. _Mittelschmerz_). In the character of the localized pain, intermediate dysmenorrhœa closely resembles ordinary dysmenorrhœa; it recurs often with precise regularity on certain days during the intermenstrual interval. _Croom_ distinguishes three forms of intermediate dysmenorrhœa; that in which there is no discharge at all from the uterus, that in which there is a sanguineous discharge, and that in which there is a clear watery discharge. The first form he attributes to asynchronism in the processes of ovulation and menstruation; the second form, to endometritis with disintegration of the mucous membrane; the third, to a kind of hydrops tubæ profluens (profluent dropsy of the Fallopian tubes—hydrosalpinx in which the fluid accumulates in the tube, and at a certain stage of its accumulation flows into the uterus). Cases of intermediate dysmenorrhœa are somewhat rare, if we eliminate the cases in which pains occur in the intermenstrual epoch in consequence of disease of the uterine annexa. Inflammatory manifestations may be discovered in nearly all typical cases of intermediate dysmenorrhœa.

Long-continued dysmenorrhœa may give rise to numerous hysterical troubles, general convulsive seizures, local muscular spasm and paralysis, hiccough, spasm of the glottis, uterine cough, twitching and spasm of various groups of voluntary muscles. In some cases we see fully developed epileptic convulsions, with complete loss of consciousness and immobility of the pupils. Finally, psychoses may arise in association with dysmenorrhœa.