1. In the first category, physical or mental shock, there are numerous observations regarding suddenly-occurring amenorrhcea. The results of examination of the external genitals are negative. There is, moreover, no doubt that we are generally predisposed to include such cases among those of simple menostasis, no matter how evident it is from the first that, in such cases here and there, there may actually occur changes so pro found as to correspond to those of the true menopause.
2. Linder the second head severe general diseases, we have already a considerable amount of positive information. As regards the conditions in tuberculosis, a case of Simpson's is extremely instructive. After her first confinement a tuberculous patient had amenorrhcea; at the autopsy the uterus was found to be greatly diminished in size, and the ovaries were small, hard, and without follicles. In this case also the presence of more or less normal conditions was established a priori, as shown by the pregnancy, and the appearance of the genitals resulted from secondary processes, which, from all the indications, pointed to a prema ture climacteric in consequence of the general affection. The follicular apoplexy' in intermittent yellow fever, etc., described by authors, Slav jansky attributes to a parenchymatous oophoritis, which usually _occurs among other affections of the sexual organs in acute infectious diseases. The same writer always found after typhus, recurrent fever, cholera, septicsemia, and the like, parenchymatous inflammation of the ovary in rapid forms of disease, near the periphery in the cortical zone, and con fined almost exclusively to the primordial follicles, but in chronic forms limited to the more (or quite) mature Graafian vesicles. The inflammation of the interstitial tissue immediately adjacent to the ovisac in these most marked forms of the affection, is then recognized microscopically as so called follicular apoplexy. We are especially interested in the appended observations on its course and termination. When an inflammation has once begun in the parenchyma of the follicle, the latter is destroyed; the primordial follicles, which are most frequently affected, beconae linear cicatrices. If the inflammation was not too intense, the normal ovisacs may be preserved. As regards our subject, wo find here an explanation
for those cases in which, in spite of a febrile affection (and in spite of the possible fear that the ovaries are already seriously involved), the function of the genital organs continues undisturbed. In a subsequent chance autopsy " the ovary offered few microscopical changes," corresponding to the negative results obtained by examining the ovaries in the subject when alive, but iu harmony with the history, " the above-mentioned inflam matory processes were invariably found on examining carefully the corti• cal zone." Moreover, after a severe attack of typhus, or other affection, in which all, or nearly all, the follicles have undergone advanced paren chymatous inflammation, a post-mortem examination during the period of convalescence shows " the different phases of the destructive procesk in the large follicles," but in a section made at a later period, if the stellate cicatrices already occupy nearly the entire ovary, the latter " tesembles closely the ovaries of women at the time of the climacteric; it appears smaller, its surface is corrugated, the tissue is hardened by reason of the development of the rbovementioned cicatrices, and frequently not a single follicle is to be seen on the put surface." The condition thus pic tured we can regard as essentially a sort of anatoniical diagram applicable to all those cases in which, after recovery from typhus and similar dis eases, a sudden change takes place in the sexual life. Under these cir cumstances we can properly refer the sudden amenorrlicea to a true rapid development (premature) of the menopause, because this, when compared with parallel cases, at once recalls the anatomical scheme; because, if the patient was sufficiently long under observation, the fact that the func tions of the ovaries have ceased is proved by the sterility (women, whose ovaries are thus changed, must inevitably remain sterile, according to Slavjansky), and because, finally. the shrinking-process in the ovary, which causes alterations in tneir form and consistence, will hardly be overlooked during the bi-manual examination as made by a practiced hand.