Degeneration of the parenchyma of the ovary by benigu or malignant neoplasms, on the other band, always plays one of the most important roles in our question. As regards its bearing upon the early occurrence of the menopause, it seems to me that this cause is best classed with in flammation of the ovaries or peri-oophoritis. In this case, as in the latter, both ovaries may be affected, and yet their function may be preserved; if the process in question becomes more extended, complete and permanent loss of their activity results. Hoist reports the case of a multipara, aged forty-seven, who died at the eighteenth or twentieth week of pregnancy. The left ovary was transformed into three cysts as large as apples, while at the site of the right was a medullary carcinotna; on both sides there were no traces of the normal parenchyma. Yet pregnancy occurred, so that a short time before the requirements for the fulfillment of the physio logical function were fully satisfied. Born reported at the Gynecological Society in Dresden a laparotomy on account of cancer of both ovaries, in a woman aged fifty-eight, who had up to that time menstruated regularly. It, of course, does not belong to our task to investigate the question how far menstruation may persist in cases of benign or malignant degenera tion of one or both ovaries,' how small a residuum of normal ovarian tissue may suffice for ovulation, in what portions of the tumor the latter is still to be found (at the insertion of the pedicle, according to Waldeyer), what kind of a flow, in such conditions, is to be regarded as true menstruation, and what as a pathological hemorrhage, etc.,—topies which we find described in a particularly ingenious manner in Gusserow's work on menstruation and dysmenorrhcea. It hardly concerns us to decide, with regard to the opposite question, whether when the early (sudden) menopause has actually occurred, it should be attributed to the presene,e of degeneration of the ovaries or not. There e,an, of course, be no doubt on that point, especially if no other causes can be found, and the morbid process seems to have assumed sufficient importance. If other possible causes, such as recent inflammation, etc., exist simultane ously, these must naturally be taken into account.
4. With reference to the tio.called exhausting influences we must be allowed to speak rather more generally; only at the outset it should be emphasized that from this list all those cases are to be omitted in which inflammatory processes play a part. However, it is difficult to prove positively that in many of the observations reported up to the present time there must have been latent inflammation, the significance of which was not suspected. Such an explanation is, in my opinion, to be offered of certain cases of premature menopause after the too rapid recurrence of parturition, after too violent coitus, and perhaps also instead of the causal factor " purgation during the menstrual period," etc. IIowever, aside from these, there remain some important factors (usually described under the terms " exhaustion," " wasting sickness," " weakening of the bodily powers," or, to use the most comprehensive expression, " sudden anmmia ") which we must take into account. In addition to these there are " clear " cases of too rapidly recurring parturition, persistent diar rhcoa, etc., as well as profuse hemorrhages after abortion, cases of bleed ing hemorrhoids, venesection during menstruation, etc. Among all these anEetnia certainly plays the principal part, not only where it results sud denly from actual loss of blood, but also in cases in which it has developed gradually in consequence of impaired nourishment, due to some other disease, etc. The ovaries are rendered functionally incapable, sometimes suddenly, in other cases in consequence of successive deprivations of their blood supply. In certain instances (and these are the ones with which we are concerned here) this disturbance is permanent. We are ig-norant of one fact which might explain this matter, and that is, why the acute loss of blood, which is certainly soon made good in most cases, should lead to such permanent bad results. Here again we can hardly infer tile presence of rapidly-developing, but irreparable disturbance of the in nervation. Their true character is still obscure, although analogies are not wanting in other cases.
When we can exclude successive attacks of arnemia, the only explana tion that is left to us is this before-mentioned disturbance of innervation.
Although tho true nature of the latter, as has been stated, has not yet been discovered, the manner in which it acts in the various isolated cases of premature menopause, must soon be understood. Thus, we know that after numerous labors, for example, a moderate degree of cirrhosis of the ovaries (to which reference was made) occurs in the women in question as a physiological consequence. Klebs classes this with the hyperplasia of tho ovarian stroma, that takes place in every pregnancy, and which may then, like a pathological hyperplasia, lead to contraction. Early occurrence of the menopause may result in some increase of this process. Although the real cause will perhaps remain unknown, we already under stand clearly how this effect is produced.
If now we review these collected explanations concerning the various commonly-received causes of sudden (premature) menopause, it is evident that we ought not to be satisfied with many of these factors, at least as they have hitherto been described. Cases in which a shock or fright are briefly mentioned as the cause of the sudden cessation of menstruation, we ought not to reg,ard as resting on a scientific foundation. Moreover, we cannot be content with the report of serious general affection, of an inflammatory process within the abdomen, or of an abdominal tumor, associated with amenorrhcea, urged in support of the supposed diagnosis; the same applies to the cessation of menstruation observed after rapidly repeated confine ments, excessive loss of blood, etc. In all these cases there might be a tem porary amenorrhcea, occurring after a short or protracted convalescence, in which after a moderate disturbance of the innervation the balance is again restored, an intercurrent lowering of the vitality is succeeded by restoration of the same, loss of blood is made good, etc. We cannot be sure even after long observation, for it is self-evident that in any instance the func tion of the ovaries (or of such remains of the ovarian parenchyma as might be present in tumors) might remain perfect, even where the men strual flow was permanently absent; a fresh conception may surprise in cases where we hastily inferred the premature appearance of the meno pause, just as well as in later years the advanced age of the patient seems t,o afford a double guarantee to the contrary. Our diagnosis of sudden (premature) menopause must rest upon a surer foundation. For this reason it certainly becomes infinitely more difficult, so difficult, that it is scarcely possible clinically to make a perfectly correct one. It in volves proving that in the case in question there is actually a sufficient disturbance of the follicles, the environs of the ovary, etc., to completely and permanently destroy their functions. It is evident that this bare fact can only be fully established by a examination, unless possibly the ovaries should be removed by the surgeon. Still there is a method which even in the living subject will enable us satisfactorily (when we consider the great difficulties) to discover this state of affairs. We have in the preceding pages considered briefly the causes which usually endanger the activity of the ovaries. Let us see how far the history of a given case renders it probable that such a disturbance existed. If we discover that the patient had an acute infectious disease, we must at once think of parenchymatous oi5phoritis and its consequences; the same applies to certain toxic conditions. A similar suspicion will be awakened if there has been a general or localized peritonitis. Puerperal affections point to interstitial oophoritis; again, after a moderate inter stitial miphoritis, secondary peri-i5phoritis may assume importance. Gon orrhoeal infection and acute catarrhal inflammation may cause primary peri-oophoritis. Atrophy of the ovaries may accompany paraplegia. Innocent or malignant neoplasms of the ovaries may finally invade the entire normal parenchyma. The hyperplasia of the ovarian stroma ac companying numerous pregnancies may lead to threatening contraction. It will always be logical to assign a prominent role to nervous disturb ances; however, we should never cease t,o be dissatisfied with this vague explanation, and should always endeavor to arrive at the true nature of such processes, varied as they are.