The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

In 1 case Tilt saw cessation of menstruation occur at the age of 29, in consequence of metritis. Atlee, in 15 cases of ovarian tumour, saw the menopause occur at ages of 30, 39, 40 and 42. Puech saw a premature menopause at the age of 30 in 3 cases, in each a sequel of cholera. Blondel reports a case of cessatio praecox after prolonged galactorrhoea, although the woman had not suckled her infant; Gottschalk and Rokitansky, cases following injury to the cervix uteri; Kiwisch, Simpson, and Kleinwächter, cases following full-time, normal deliveries, in which, however, severe losses of blood had taken place.

Courty and Brierre de Boismont report cases in which the menopause occurred as early as the age of 21; Mayer, 2 cases at the age of 22; Krieger, 1 case at 23; Brierre de Boismont, 1 case at 24; Mayer, 2 cases at 25; Brierre de Boismont, 1 case at 26, and 1 case at 27; Guy and Tilt, each 1 case at the age of 27; Brierre de Boismont, Courty, and Guy, each 1 case at the age of 28; Brierre de Boismont, Courty, and Mayer, each 1 case at the age of 29; Guy and Tilt, each 1 case at the age of 30; and Mayer, 5 cases at the age of 30.

An unusually late climacteric, the continuance of menstruation beyond the age of 50 years, is not an extremely rare occurrence, but is less often seen than cessatio praecox. There is, however, in these cases a difficulty which must not be underestimated, namely, to distinguish between a genuine menstrual bleeding and the other uterine haemorrhages which are common precisely at this age of life, due either to textural changes in the uterus, or to neoplasmata—more especially because in these non-menstrual haemorrhages also a certain periodicity may often be detected. When on careful examination no abnormality can be discovered in the reproductive organs, when the bleeding in question recurs at the intervals and in association with the general symptoms to which the woman thus affected has been accustomed during her previous menstruations, and when the amount of blood discharged is not abnormal, it is permissible to conclude that we have to do with a persistence of true menstruation, even though the woman has some time since completed the fifth decennium of her life. In some women, in fact, the reproductive system is so energetic, that ovulation continues to an age far beyond the average, and such women are to be regarded as sexually long-lived.

Although the instances of protracted menstruation contained in the older literature of the subject are open to suspicion, owing to the fact that at that time it was not possible to distinguish with certainty between menstrual and pathological uterine haemorrhage, quite recently numerous incontestable cases of enduring sexual vitality have been put on record.

I have myself seen no less than 106 cases in which the menopause did not occur until after the age of 50 years; among these there were 4 in which the age at the menopause was 56; 5 in which it was 57; 2 in which it was 58; 1 in which it was 59; and 1 in which it was 60. Tilt records 128 cases of menopause occurring after 50; among these there were 4 in which the woman was 56 when menstruation ceased; 2 who were 57; 4 who were 58; 1 who was 59; 1 who was 60; and 2 who were 61. Courty reports a case in which menstruation persisted after the age of 65; Mayer, 3 cases of menopause at 64; Beigel, 2 cases, 1 in which menstruation continued to the age of 65, the other, to the age of 72. Kleinwächter observed 33 cases in which menstruation continued to an age varying from 50 to 57 years. Emmet, in the year 1886, published the case of a woman who was then 70 years old, and who at this advanced age continued to menstruate regularly.

That not every case in which after the age of 50 years there is recurrent, more or less periodic, haemorrhage from the genital organs, is to be regarded as an instance of delayed menopause, we are taught by the records of post mortem examination in several cases of the kind. Scanzoni reports the case of a woman who at the age of 60 was affected with a fairly regular periodic discharge of blood from the vagina. During one of these haemorrhages, she died of pneumonia, and the autopsy showed that the ovaries were completely atrophied and transformed into dense scar tissue, and contained no trace of corpus luteum or of fresh extravasation of blood, whilst in the upper part of the cervical canal there were two mucous polypi each of about the size of a bean. In another case, that of a woman 64 years of age, periodic losses of blood, at intervals of from three to four weeks, continued to the time of her death. This woman suffered from mitral valvular insufficiency, and it was clear that the haemorrhages had been due to the venous engorgement consequent upon imperfect compensation. The ovaries were completely atrophied, and showed no trace of any recent maturation of ova; the uterus was enlarged, the mucous membrane hyperaemic, and the cavity contained a recent clot.

Not infrequently, the haemorrhages attributed to the persistence of menstruation are really due to senile arteriosclerosis—to rigidity and brittleness of the uterine arteries; in other cases they arise from varicosity of the veins of the cervical canal. A common cause of such bleedings from the genital passage in comparatively advanced life, is to be found in the growth of uterine myomata.

To myoma uteri we must attribute a part, though by no means all, of the cases in which menstruation seems to recur some years after the menopause has, to all appearance, been fully established. In most of these cases, indeed, we have to do with pathological haemorrhages, the cause of which is, however, but too often obscure. Still, cases certainly occur in which, two or three years or even longer after the menopause, some unknown stimulus leads to the regular recurrence of menstruation. The possibility of such an occurrence is, in my opinion, fully proved by post mortem examinations of the bodies of elderly women in whom the menopause has been fully established and yet the ovaries are found to contain follicles of various degrees of ripeness, and also fresh corpora lutea—signs that ovulation may persist for a considerable time after the complete cessation of menstruation. Another proof of the last fact is the well known experience that women who have some time ago ceased to menstruate, may nevertheless become pregnant. Waldeyer, indeed, asserts that when four years have elapsed since the menopause, follicles are never to be found in the ovaries, but this negative experience is not decisive, especially as regards the cases in which regular menstruation is resumed some time after the occurrence of a premature menopause.

I have myself seen several cases in which the menopause occurred at 35, 38, 39, and 42 years, respectively; 3, 4, or 5 years later, as a result of hydropathic treatment, regular menstruation recurred. In one case, a woman who had ceased to menstruate ten years before, gave birth to a child at the age of 45.

Numerous indisputable cases of this kind are reported in the recent literature of the subject. Krieger had under his personal observation a woman of a robust habit of body, in whom menstruation ceased at the age of 48 years, her eighth child having been born fifteen years before. Two years later irregular menstruation recurred, and on the cessation of these haemorrhages, it appeared that the woman was once more gravid; she was delivered at full term of a girl. Mayer observed the following case: A strong working-class woman 33 years of age had begun to menstruate regularly when 13 years old; between the ages of 17 and 28 she gave birth to five children, and in addition had one miscarriage when 19 years old. Widowed at the age of 29, she fell ill, and on examination the uterus was found to be small and relaxed, whilst the vaginal portion of the cervix was reduced to a mere rudiment. Since she had been 22 years of age she had had persistent leucorrhoea, but no trace of menstrual haemorrhage; yet since that age she had had three children. Renaudin delivered a woman 61 years of age, who had ceased to menstruate 12 years earlier. Meissner reports a case in which a woman first began to menstruate at the age of 20, had her first child when 47 years old, and gave birth to the last of her eight children when 60 years of age.