One of them shows quite typically the insurmountable difficulties that may, in general, sometimes confront us in deciding the question before as. 3Irs. L., aged forty-five, always menstruated regularly from the age of seventeen, but had no children by two marriages. In her forty-second year, midway between two periods, she experienced extreme vexation; she felt at the same time a sudden pain in the middle of her abdomen, " as if her veins were being torn out of her," extending from the head into the true pelvis. Two days afterward she began to flow. The menses then ceased for six months, reappeared slightly, lasting for two days, then in t.he same manner after the lapse of another six months, and then they ceased entirely. She felt perfectly well, with the exception of slight attacks of cerebral congestion. A year after the original disturbance occurred, the patient observed a painless, immovable tumor, about as large as a nut, in the right hypogastric region; this gradually increased m size as years elapsed, and during the previous two months had grown rapidly. Violent pains along the course of the sciatic nerve, cedema of the lower limbs, obstinate constipation and difficulty in micturition led her to apply to me. I found that the symptoms were due to a universally hard and quite immovable tumor, having a smooth surface, which filled the pelvis and extended as high as the umbilicus. Nothing was dis covered on further palpation; through the vagina and rectum nothing could be felt but the lower segment of the tumor which filled the entire pelvic brim. In no position was it possible to move the tumor to the slightest extent The rectum was impassable; the bladder was elevated in such a way that the catheter could only be introduced with great diffi culty in a direction vertically upward. The urgent symptoms called for prompt treatment. A consultation was held at once, bnt it failed to cle,ar up the diagnosis. Two days later laparotomy was performed in our sur gical clinic. On account of the general firm adhesions, and fearful paren chymatous and venous hemorrhage at every attempt to separate them, our distinguished operator, Professor Rzehaczek, was obliged to close the abdominal wound at once, without accomplishing anything. Death occurred on the following day, with symptoms of extreme anomie and beginning peritonitis. An autopsy was refused.
Do we see here, from its final issue, how the premature and more or less sudden menopause was produced in this case ? The patient's former physicians asserted, without further thought, that the premature climac teric was caused by the great vexation referred to. At all events, this would have been the cause assigned if the e,ase had chanced to be published. But, in my opinion, there are three possible explanations. In the first place, the mental shock and the evident nervous disturbances connected with it, might have been the cause. Secondly, commencing degeneration of the ovaries (probably malignant), then in the early stage, might have destroyed the function of these organs; the marked decline in the patient's health, at the time when I saw her, as well as the appearances seen at the operation, speak in favor of this. Thirdly and lastly, it might have been simply an early normal establishment of the menopause, having no connection with the preceding,—perhaps a family peculiarity,—so that in this case all the above-mentioned abnormal conditions were unnecessary in order to explain it, although our entire attention is naturally directed to them at once. The last conclusion would seem to me to be most worthy of acceptance. The degeneration of the ovaries, if such there really was, is, as we shall see later, often a phenomenon noted after the climacteric. A year after the first disturbance of menstruation the patient first felt on one side a tumor, which at that time seemed to be not larger than a nut; hence it is hardly to be supposed that a year before the entire parenchyma of both ovaries had already undergone the de generative process. The irregular hemorrhage occurring at the time of
the nervous shock may have been the first beginning of the ordinary " irregularities," possibly having no connection with the shock; this is so much the more likely, since this hemorrhage recurred even after the lapse of six months; and a nervous disturbance exercising an importance here, would have tended much rather to iuterrupt permanently an exist ing hemorrhage, or, if it occurred in the interval, to have prevented future hemorrhages. Finally, I learned from the mother of the patient that she too had ceased to menstruate at the same age, so that this cir cumst,ance, as well as the late period at which menstruation began (in her seventeenth year), her sterility in two marriages, and the supposed spontaneous early menopause, combine to make us infer that in her case there was first of all merely " diminished sexual vitality," partly heredi tary, and that the accompanying condition should bo regardedp a serious complication which has no bearing upon the question at issue. This is, of course, only supposition; and this case illustrates clearly, as we have often observed in others, how in spite of all our endeavors to got at the facts, we are often compelled conscientiously to regard as extremely doubtful the value of our observations.
The following cases seem to me to be clearer: J. L., single, aged thirty, menstruated regularly since she was sixteen. At twenty-six she was delivered at term after a normal labor. Eight weeks after, she men struated regularly. On the third day after the menses appeared the second time the patient was wet through, when the flow stopped suddenly, but there was no pain. For over four years there has been no reappear ance of the flow, only a slight backache every four weeks. On the other hand, there are certain phenomena, which may be regarded partly as simple " congestions,'' partly as suggestive of climacteric phenomena, such as headache, vertigo, flushing, palpitation, neuralgia, depression, etc. On examination the external and internal genitals were found to be normal. Under the circumstances I felt justified in telling the patient that the periods would probably recur sooner or later.
The following is a genuine case of premature menopause of pathologi cal origin: Mrs. H., aged thirty-nine, menstruated regularly :since the age of twelve. Married at thirty-four, and aborted twice within two years. When she was thirty-six, her husband died suddenly, and she re • ceived such a shock that her menstruation ceased suddenly on the second day of the flow. She had slight traces of a flow twice, at intervals of four or five months, and for two years has seen nothing. There are no general symptoms except mental depression. On examination the vagina appears somewhat short and contracted; uterus small and thin- walled; ovaries quite small and freely movable. There could be no question here as to the diagnosis of premature menopause, since the secondary phe nomena, the atrophy of the uterus, etc., were characteristic. The cause seems to be somewhat doubtful. Shall we ascribe it simply to that mental shock ? After what has been said already, and from my experience in other cases, it would seem to me as if the previous abortions should not be disregarded. There is no proof that there was a general interstitial oophoritis with subsequent contraction, yet such a process can also not be excluded. However, the nervous disturbance may have been the causal factor, yet this must probably have acted upon organs which were already affected.