The successive menstruations as they recur regularly throughout the course of the sexual life may, just like the first menstruation, though with diminished intensity, give rise to manifestations of nervous and mental disorders. In many women who are in other respects healthy, we see during menstruation, hemicrania, nervous irritability, ill-temper, low-spiritedness, and even hysterical and epileptic attacks; these occur chiefly on the first and second days of the flow, and disappear altogether toward the end of the period. These manifestations are more severe in individuals weakened by profuse losses of blood or by chronic disorder in various organs, more severe also in those predisposed to such disturbances in consequence of neuropathic inheritance, more severe in women suffering from menorrhagia and dysmenorrhœa, and from any kind of mental stress.
In his work on the influence of the so-called menstrual wave on the course of mental disorders, Schüle remarks that the mental equilibrium even of a perfectly healthy woman is not a stable one, but is subject to a series of oscillations. “The menstrual period,” he continues, “has a distinct influence on woman’s mental equilibrium. Even in those whose nervous system is a healthy one, menstruation evokes a state, now of depression, now of excitement; in neurotic women, on the other hand, menstruation may give rise to nervous diseases which may equally exhibit the characteristics of depression or the characteristics of excitement. In nervously predisposed women, the influence of regularly established menstruation, even when the circumstances are favorable, is pretty much the same as the influence of menstruation when it first makes its appearance; the influence is merely somewhat weaker in so far as the woman has learned to endure and to be patient. The menstrual state, in nervously predisposed women, evokes the particular neurosis to which the individual happens to be liable. The disorders most commonly met with in this association are, hysteria, hemicrania, swimming in the head, epileptic paroxysms, toothache, and neurasthenia.”
Especially frequent during menstruation is hemicrania. Sometimes hemicrania may begin a day or two before menstruation, as a prodromal sign, and may accompany its whole course, becoming, however, less severe toward the end of the flow. Hysteria most commonly manifests itself in association with menstruation by a depressed emotional state, by tearfulness, by complaints made without sufficient grounds, by globus hystericus or clavus hystericus; sometimes also by paroxysms of muscular spasm; very rarely by hystero-epileptic seizures. Epilepsy may occur either by day or by night. Nocturnal seizures usually occur without any apparent external cause, as a result of the central stimulus; diurnal attacks, on the other hand, have usually some external exciting cause. Often, however, years may elapse without any attack of major epilepsy occurring, the disease manifesting itself in one or more of the many varieties of the minor form (petit mal), as transient absences of mind, attacks of vertigo, etc.
The nervous disturbance in a menstruating woman may be so great as to lead to the production of psychoses. The question of the existence of a menstrual insanity sui generis has been answered by many alienists in the affirmative; by others, however, who see in the alleged cases nothing specific, it has been answered in the negative. The relation of menstruation to the mental disorder may be a double one: 1, menstruation may occur repeatedly in the course of an already established mental disorder; 2, menstruation and its morbid variations may favor the occurrence of psychoses that exist already in a latent form, and may lead to the origination of psychoses to which the organism is predisposed.
In the former connection, Brierre de Boismont undertook an investigation which showed that in women suffering from mental disorder, an exacerbation of that disorder was to be observed during menstruation. Schlager, who regards the menstrual process as possessing when anomalous a high significance for the development and course of mental disturbances, observed that in 33 per cent. of women suffering from mental disorder, the menstrual state had an unfavorable influence upon the course of that disorder, inasmuch as it led to an increased irritability; in the rest of the cases, however, menstruation was without influence upon the course of the ordinary chronic psychoses. In the cases that were unfavorably influenced, epileptic attacks usually became more frequent, and chronic melancholia became much more profound. Schröder observed in chronic forms of melancholia that during menstruation the sadness became intolerable and was associated with a suicidal tendency; in chronic maniacal forms of mental disorder, the excitement underwent an increase during menstruation. Von Krafft-Ebing, as a result of his investigations into insanity during menstruation, came to similar conclusions with regard to the unfavorable influence of the menstrual process. Algeri likewise states that menstruation notably aggravates the cerebral symptoms in the course of mental disorders.
Other authors, Marcé and Kowalewski for instance, whilst emphasizing the powerful influence exerted by menstruation on any existing psychosis, point out that in some instances, as in states of mental and physical depression, this influence is for the worse; but in other instances, especially in states of maniacal excitement, the condition of the patient undergoes notable amelioration during menstruation. Schäfer also, in his researches into the relations between the processes of menstruation and psychoses, discovered that anomalies in the course of menstruation ran almost parallel with anomalies in the course of mental activity.
In psychopathically predisposed women, disorders of menstruation, such as amenorrhœa, delayed menstruation, and dysmenorrhœa, are more effective than the normal process of menstruation in evoking manifestations of psychical abnormalities previously latent, and in leading to attacks of precordial anxiety, pathological emotional states, melancholic seizures, epilepsy in all its varieties, and impulsive manifestations, such as pyromania, kleptomania, infanticide, homicide, etc. As results of a special predisposition may appear in this connection, congenital imbecility, idiocy, melancholia, and chronic weak-mindedness.
A rich literature exists of cases in which mental abnormalities occurred in psychopathically predisposed individuals as a result of menstruation. Thus, von Krafft-Ebing reports a case in which, during menstruation, a mentally undeveloped woman murdered her husband; and another case in which to chronic weak-mindedness and chronic delusional insanity were superadded during menstruation peculiar attacks having the character of psychical storms. Tuke reports a case in which a mother, in a state of alcoholic excess during menstruation, murdered her daughter. Pelmann records acts of pyromania committed during menstruation by a girl seventeen years of age. Mabille records a case in which a woman suffering from severe mental disorder was affected during menstruation by impulsive kleptomania, whilst after the periods the memory of what had happened passed away. Philo-Indicus records the case of a woman suffering from severe neuropathy who at the menstrual periods exhibited great irritability, experienced marked sexual excitement, and had suicidal impulses, and who on one occasion attempted to murder a female friend who had refused to assist her in the practice of sexual aberrations. Giraud describes a woman suffering from passive melancholia, in whom during menstruation horrible fantastic ideas occurred. Ball records the case of a woman who suffered always from acute mental disorder during menstruation, and who, in one of these attacks, murdered her son. Kowalewski reports a case of chronic imbecility, in which during menstruation attacks of precordial anxiety developed, and in the course of one of these attacks the patient set fire to her own house. “In such cases,” remarks Kowalewski, “menstruation represents the last drop that makes the full goblet overflow.”
In addition, we meet with cases in which the influence of menstruation is so powerful that it must be regarded as the principal cause of the psychosis. We must then speak of a true menstrual psychosis, the impulse to which is supplied by the normal or abnormal changes occurring in the process of menstruation, and characterized by the menstrual periodicity and the brief duration of the attacks. These are the characteristics of the menstrual psychoses of the menarche and of the climacteric period; and such cases occur also during the period of full menstrual activity.
The menstrual psychosis most commonly makes its appearance shortly before the flow, becomes less severe with the establishment of the flow, and disappears when the flow ceases; in other cases, the psychosis appears toward the end of menstruation, and speedily passes away; or, again, in amenorrhoeic cases, the attacks of mental disorder replace the proper menstrual flow, and become less severe or disappear entirely as soon as the flow is regularly re-established. The commonest forms of these menstrual psychoses are, melancholia, mania, irresistible impulses, acute amentia, in rare cases alternating insanity (folie circulaire) in which the periods of alternation assume the menstrual rhythm. The duration of these psychoses is usually short, from a few days up to a fortnight; there may be only a single attack, or there may be a number of attacks presenting precisely similar characters.