“Very different is it with old maids of the second type. They are dissatisfied with life, irritable, quarrelsome, envious, and malicious. They are spiteful and revengeful, gossips and scandalmongers, boast of their own chaste and innocent lives, and never forgive any real or imaginary attempt upon their spotless virtue. At the same time they never lose hope for the future, and are full of imaginary love-affairs, in which they pass through scenes by no means chaste or innocent; they do not shrink from self-abuse and the abnormal gratification of the sexual needs, in which the lacking partner in the sexual act is supplied by the imagination. Under the influence of such abnormal conditions of life, these women frequently become affected by nervous disorders; migraine, neuralgia, cephalalgia, nervous depression, rachialgia, debility, anæmia, diseases of the reproductive organs, etc. Thus, when they enter the climacteric age, the soil is fully prepared for the development of mental disorder, which in such individuals is often characterized by hallucinations of sexual sensation and perception, erotic visual and auditory hallucinations, delusions of similar character, increased sexual irritability, a search for abnormal means of sexual gratification, a propensity to obscene speech and conduct, etc.
“Mental disorder is so common during the climacteric period, that the term ‘climacteric insanity’ has now become established in the literature of mental alienation. In almost all the textbooks of the subject we find an allusion to this form of mental disease, but there is no real ground for Maudsley’s assumption that there is a climacteric insanity sui generis. At the climacteric, very various forms of mental disorder may occur—paranoia, melancholia, and mania; the only common feature in the attacks, owing to which they are classed as ‘climacteric insanity’ being the fact that the final determining cause in each case is the onset of the change of life. In fact, this period is not without influence upon the manifestation of the disease—its stamp is imprinted upon the clinical picture, it endues the disease with certain characteristic features—but still, the peculiarities common to the cases of mental disorder occurring at this time of life in women are not so great as to justify us in describing them as a separate variety of psychosis.”
According to Kowalewski, this so-called climacteric insanity is met with in two principal forms: in many cases the mental disorder recurs in periodic paroxysms, associated either with the commencement of the menstrual flow, or having the periodicity of menstruation after the flow has already ceased to appear; in the other class of cases the psychosis has no direct connexion with menstruation, and is dependent upon the joint influence of all the manifestations of the climacteric period. Cases belonging to the former class have been distinguished by Bartel as “climacteric pseudomenstrual insanity.”
The psychoses dependent upon the climacteric influences may, according to Kowalewski, appear in almost all the known forms of mental disorder: precordial anxiety, melancholia, mania, amentia, paranoia, etc.; and although they exhibit no features which are absolutely characteristic, or which, as already said, enable us to distinguish a specific “climacteric insanity,” yet they all bear a common imprint by means of which we are enabled to detect in their causation the influence of this critical period of life. Thus, precordial anxiety occurs in paroxysms having a more or less regular periodicity, corresponding with that of the expected menstruation. The same feature is observable in the periodic exacerbations of hysterical and epileptic paroxysms. Often, also, there occur at this time sudden changes in the emotional disposition and in the character, in one direction or the other, without the development of actual melancholia or mania. The melancholia of the climacteric period occurs chiefly in married women, more especially in those whose circumstances are unhappy; and it is often manifested by attempts at suicide.
Mania is comparatively rare at the climacteric period; when it does occur, it commonly assumes a sexual form—sexual impulses, hallucinations, and delusions, and obscene conduct. Such manifestations are seen most often in widows, in “old maids” whose morals are not above reproach, and, speaking generally, in those whose sexual needs have remained partially or completely ungratified, and in those who have greatly erred in the conduct of this side of life. Amentia also occurs at this time of life; rarely in maniacal form, more frequently in association with menstruation as a periodic psychosis, or as a continuous disorder of mind with exacerbations corresponding to the menstrual periods; it is often characterized by pronounced eroticism.
Much more frequent during the climacteric period is the occurrence of paranoia, as Kowalewski rightly insists. It is most often met with in “old maids” with psychopathic predisposition. The imagination of such individuals is always concentrated upon men; they imagine that men in general, but more particularly certain individuals of the opposite sex, are continually regarding them, making eyes at them, making signs to them, in some way or other striving to attract their attention. The most ordinary and invariable forms of polite intercourse are regarded by these women, whose powers of observation are morbidly stimulated, as being indications of a special “attention” paid to themselves. They persecute these men with their own attentions, and imagine that it is the men who are persecuting them. Often this morbid mental state is associated with sexual malpractices, masturbation, etc. Not rarely, such degenerates are affected with lascivious dreams. Often they experience hallucinations of sexual perception in the form of supposed assaults on their virginity. All these states are apt speedily to develop into a condition of general suspiciousness and ideas of persecution. The ideas of persecution assume a peculiar form, one especially characteristic of the climacteric period. The patients believe that a man, often personally unknown to them, and perhaps living in another town, enters into spiritual and bodily intercourse with them. These relations are supposed to be effected in most cases by means of spiritualism, hypnotism, or electricity. The patient importunes the man in question with letters, supposes herself to be legally united with him, and not infrequently wishes to give him the pleasure of paying her bills and providing her with money. It is a very common occurrence for a Catholic priest to be worried by such a woman, her delusion being grounded upon the fact that the priest is supposed to assume an exceptionally intimate spiritual relationship with members of his flock. The patient with ideas of persecution often herself becomes an actual persecutor, not only pestering her victim with innumerable letters, but in her jealousy making “scenes” whenever she can encounter him, and sometimes giving rise to serious scandal. With such a mental state we often see associated sexual hallucinations and delusions; the patient believes herself to be pregnant, imagines herself to have been violated, or to be living in carnal intercourse with a man—some one, it may be, with whom she is not even acquainted. Medical men are especially apt to suffer from the accusations of such women, whom they may have examined in private in entire ignorance of the patient’s mental condition. Frequently, such ideas of sexual persecution are associated with paroxysms of violent nymphomania, and in this way also the unwary physician may find himself placed in an extremely unpleasant position. It occasionally happens in such patients that abnormalities of the sexual instinct arise, and they begin to feel desire towards individuals of their own sex.
Such delusions of persecution by means of hypnotism, spiritualism, the telephone, etc., in association with sexual delusions and nymphomania, are so frequent during the climacteric period, that they may be regarded as pre-eminently constituting climacteric insanity. Frequently some old hysterical state underlies this form of mental disorder.
Thus these peculiar manifestations of eroticism must be regarded as the distinctive characteristics of climacteric insanity and more particularly of climacteric paranoia. A second characteristic of climacteric insanity is, according to Garat, the marked development of jealous emotions and delusions.
In addition to these fully developed psychoses, there occur in degenerates at the climacteric age paroxysms of impulsive insanity in the form of dipsomania, kleptomania, pyromania; exhibitionism; irresistible impulse to suicide, homicide, infanticide, etc. Such paroxysmal impulsive manifestations are, according to Kowalewski, commonly associated with menstrual disturbances; they occur most frequently at the due dates of menstruation when the flow fails to appear.
One hundred and sixty-nine cases of climacteric psychosis were classified by Matusch as follows: