THE
SEXUAL LIFE OF WOMAN
IN ITS
PHYSIOLOGICAL, PATHOLOGICAL AND HYGIENIC ASPECTS

BY

E. HEINRICH KISCH, M. D.

Professor of the German Medical Faculty of the University of Prague; Physician to the Hospital and Spa of Marienbad; Member of the Board of Health, Etc., Etc.

ONLY AUTHORIZED TRANSLATION INTO THE ENGLISH LANGUAGE FROM THE GERMAN BY

M. EDEN PAUL, M. D.

WITH 97 ILLUSTRATIONS IN THE TEXT

NEW YORK

REBMAN COMPANY

1123 BROADWAY

The sexual life of woman—the appearance of the first indications of sexual activity, the development of that activity and its culmination in sexual maturity, the decline of that activity and its ultimate extinction in sexual death—the entire process of the most perfect work of natural creation—has throughout all ages kindled the inspiration of poets, aroused the enthusiasm of artists, and supplied thinkers with inexhaustible material for reflection.

In the following pages, this sexual life of woman will be considered both in relation to the female genital organs, and in relation to the feminine organism as a whole; in relation both to the physical and to the mental development of the individual; and in relation alike to the state of health and to the processes of disease. Thus from the standpoint of clinical investigation and of practical experience, the book will be a contribution towards the solution of the sexual problem, nowadays recognized as one of supreme importance.

It is thirty years since I published a work on the histological changes that occur in the ovaries during the climacteric period (Archiv. für Gynecologie, Vol. xii, Section 3); and ever since that time, the influence exerted upon the general health of women by the physiological and pathological processes occurring in their reproductive organs, has been to me a favourite subject for observation and experiment. The result of these studies is incorporated in my monographs, “The Climacteric Period in Women” (Erlangen, 1874), “Sterility in Women” (2nd Ed., Vienna, 1895), “The Uterus and the Heart” (Leipzig, 1898), and in various contributions to medical periodicals. I now have a welcome opportunity of drawing a general picture of sexual activity in women, and of illuminating this picture both by the light of my own experience and by numerous references to the works of other authors. In passing, I have devoted considerable attention to questions of education and personal hygiene, both of which are greatly influenced by the processes of the sexual life. Thus, I hope, the work will be rendered more interesting to the physician, and the general picture it is intended to convey will be more fully characterized by contemporary actuality.

Natural divisions of the subject are, I consider, furnished by the three great landmarks of the sexual life of woman: the onset of menstruation—the menarche: the culmination of sexual activity—the vimenacme; and the cessation of menstruation—the menopause. These several sexual epochs are differentiated by characteristic anatomical states of the reproductive organs, by the external configuration of the feminine body, by functional effects throughout the entire organism, and, finally, by pathological disturbances of the normal vital processes.

Thus in separate chapters a description is given of sexual processes, a detailed exposition of which will be vainly sought in the textbooks of gynecology, yet which are none the less of far-reaching importance in relation to the physical, mental, and social well-being of women, and in relation also to the development of human society; such topics are, the sexual impulse, copulation, fertility, sterility, the employment of means for the prevention of conception, the determination of sex, sexual hygiene. To the topics of pregnancy, parturition, lying-in, and lactation, since these are adequately discussed in works on midwifery, but little space has here been allotted.

It is my earnest hope that physicians and biologists may derive benefit from the book equal in amount to the pleasure I have gained in the work of writing it.

By the sexual life of woman we understand the reciprocal action between the physiological functions and pathological states of the female genital organs on the one hand and the entire female organism in its physical and mental relations on the other; and the object of this book is to give a complete account of the influence exercised by the reproductive organs, during the time of their development, their maturity, and their involution, on the life history of woman.

From the earliest days of the medical art this sexual life of woman has aroused in the leaders of medical thought the highest interest, and for this reason great attention has been directed, not only to the anatomy of the genital organs and to the diseases of the reproductive system, but also to the individual manifestations of sexual activity and to the influence exercised by these on the female organism as a whole.

Several works by Hippocrates are extant on this subject, among which may be mentioned: περι Γυναικειης Φυσεος,^[1] a treatise on the physiology and pathology of woman; περι Αφορων,^[2] which discusses sterility in women; περι παρθενιων,^[3] a treatise on the pathological states of virgins. These writings of Hippocrates contain some very remarkable observations on the influence exercised by disorders of the reproductive organs on the general health of women.

Aristotle wrote at some length on the functions of the female genital organs. In the writings of Aretæus and Galen on the diseases of women we find striking observations, as for instance, in Galen’s De Locis Affectis,^[4] which contains a “Statement of the Similarity and Dissimilarity of Man and Woman.” Another notable work is that of Albertus Magnus, entitled De Secretis Mulierum.^[5]

The numerous works on the diseases of women published in the sixteenth century consisted for the most part of a repetition of the observations of ancient writers. The gynecological treatises of the 2eighteenth century, however, bore witness to an increased knowledge of the anatomy of the female reproductive organs, and were illumined by Haller’s researches on the functions of these organs.

The subject with which we are especially concerned is discussed in a work by Boireau-Laffecteur, Essai sur les Maladies Physiques et Morales des femmes,^[6] Paris, 1793; and also in Marie-Clement’s Considerations Physiologiques sur les Diverses Epoques de la Vie des Femmes,^[7] Paris, 1803. the same connection we must mention von Humboldt’s treatise, Ueber den Geschlechtsunterschied und dessen Einfluss auf die organische Natur.^[8] The first comprehensive work in which an exhaustive inquiry was made into the functional disorders of the female genital organs and the relation of these disorders to the female organism as a whole and to the physical and mental peculiarities of woman was Busch’s: Das Geschlechtsleben des Weibes,^[9] Leipzig, 1839.

In the second half of the nineteenth century a very large number of monographs were published, investigating and describing the reflex disturbances produced alike in the individual organs and in the nervous system as a whole by changes in the uterus and its annexa. Many of these works will be mentioned more particularly in the course of this treatise.

The sexual life, based upon the purpose, so important to every creature, of the propagation of the species, possesses in the female sex a vital significance enormously greater than sexual activity possesses in the male. From the very beginning of sexuality, when the idea of a bisexual differentiation dawns for the first time in the brain of the little girl, down to the sexual death of the withered matron, who laments the loss of her sexual potency, physical and mental activity, work and thought, function and sensation, arise for the most part, wittingly or unwittingly, from that germinal energy which is the manifestation of the unalterable law that the existing organism endeavors to reproduce its kind.

Every phase of the sexual life of woman, from the threshold of puberty to the extinction of sexual activity, the first appearance of menstruation, the complete development of the sexual organs, the act of copulation, conception, pregnancy, parturition, and the puerperium, finally the involutionary process which accompanies the cessation of menstruation at the climacteric period—every one of 3these sexual phases entails consecutive physiological processes and pathological changes alike in the individual organs and in the nutritive condition of the entire organism, in the functions of the cardio-vascular apparatus, of the brain and the nerves, of the skin and the sense-organs, in the processes of digestion and general metabolism. Herein we see a striking illustration of the old saying of von Helmont, propter solum uterum mulier est quod est;^[10] also of the similar aphorism of Hippocrates, uterus omnium causa morborum qui mulieres infestant;^[11] a conception summed up by Goethe in the words of Mephistopheles:

Just as in a tree the process of growth is made manifest to the superficial observer by the pleasure he feels at the sight of the buds and blossoms, by the refreshment he obtains from the fruit, and by the sadness which the withering of the leaves causes him, so in the sexual life of woman there are landmarks which no one can possibly overlook, by means of which three great epochs are distinguished. These are: puberty (the menarche), recognized by the first appearance of menstruation and the awakening of the sexual impulse; sexual maturity (the menacme), in the fully developed woman, characterized by the functions of copulation and reproduction; and sexual involution (the menopause), in which we see the gradual decline and ultimate extinction of sexual power and all its manifestations. In all these three epochs the sexual life of woman not only affects the hidden domain of the genital organs, but controls also all the vegetative, physical, and mental processes of the body, and is clearly and incontestably apparent in all vital manifestations. What Madame de Staël said of love is indeed true of the entire sexual life of woman: l’amour n’est qu’unc épisode de la vie de l’homme; c’est l’histoire tout entière de la femme.^[12].

The sexual life of woman is coextensive with the peculiar vital activity of the female sex, for it endures from the moment when 4individuality first begins to develop out of the indifferent stage of childhood until the decline into the dead-level of senility.

To illustrate this fact, I have drawn up a curve of the sexual life of woman, making use of the statistical data available in central Europe regarding the age at which menstruation first appears, the age at which maidens marry, the age at which the largest number of women give birth to a child, and the age at which menstruation ceases; and reducing the figures to averages. * denotes the fifteenth year of life, as the average age at the menarche; ** denotes the twenty-second year of life as the average age at marriage; *** denotes the thirty-second year of life, in which woman exhibits her maximum fecundity; **** denotes the forty-sixth year of life as the average age at the menopause. (Fig. 1.)

Fig. 1.—Curve of the sexual life of woman from the tenth to the sixtieth year of life.

Not in this respect alone, however, is the sexual life of woman of paramount importance; it is, in addition, the mainspring of the well-being and progress of the family, of the nation, of the entire human race. In the evolution of man from the primitive state in which he existed merely for the performance of vegetative functions up to the highest stage of contemporary culture, in the history of all races and of all times, the sexual life has been a most 5potent determining factor. With that life, religion, philosophy, ethics, natural science, and hygiene, have been most intimately related; for that life, they have furnished precepts and laws. The history of the sexual life is identical with the history of human culture.

In a primitive condition of society, among people living in a state of nature and among the lower races of mankind, the sexual life of woman possesses no great general interest, the female being merely a chattel; the ownership of this chattel, moreover, being often temporary and transient. The investigations of anthropologists have shown that among primitive people this form of property is neither highly esteemed nor carefully safeguarded. In such societies no restraint is imposed on the sexual impulse, which is gratified without shame and without formality. No hindrance is offered to the mutual intercourse of the two sexes. Chastity in the females is not prized by the males, nor do the latter compete for the favors of the former. Procreation is no more than a gregarious impulse of the masses among whom the common ownership of all booty is a matter of tribal custom. The woman has no disposing power over that which every one desires and which every one has the right to demand. Very gradually, however, a change takes place in this respect, so that in every period of social life since the very earliest, the modesty of young girls, the high valuation put upon the preservation of virginity, the ethical approbation of chastity in the wife, respect for the duties and rights of the mother, the reverence felt for the matron—all these, throughout the sexual life of woman, have had a civilizing, ennobling, and elevating effect. Thus, as family life has become developed, and as love and marriage have been more highly esteemed, woman has become the much-prized embodiment of all that is beautiful and good, of all that is summed up in the idea of the “housewife,” and her sexual life has been more completely, more ideally admired. The danger is not remote, however, that the leveling tendencies of the present day, and an inclination to despise the sexual life of woman, far from resulting in a further elevation of the social status of womanhood, will result rather in its abasement.

The Bible, as we may expect from the patriarchal relationships of the women of that time, bears witness to the worth of woman, and, whilst esteeming child-bearing, refers to yet higher duties. Precise religious and social precepts are furnished for all the phases of sexual life.

6In classical antiquity, also, we see that woman rose to some extent above the low position she had previously occupied in the family circle and in society at large. Both among the Greeks and among the Romans, there was open to women a more intimate place in social life and a more influential rôle in the life of the family, than would have been their portion regarded merely in relation to their child-bearing activity. Amongst the Germans in the very earliest times, chastity gave rise to purer and more moral sexual relations; whereas among the Slavonic peoples the conception of woman as the childbearer continued to dominate these relations.

In consequence of the diffusion of Christianity, woman became man’s companion and equal, and her life, the sexual life included, acquired a deeper significance, owing to the stress which that religion laid on chastity as a virtue, and as a result of the educational influence of woman in the family circle.

With the progress of civilization the sexual life of woman comes to exhibit its activities only within the bounds of morality and law, which in human society have replaced the crude rule of nature, and have supplied regulations adapted to the changing phases of sexual vital manifestations. The wise adaptation of these regulations requires, however, a full understanding of the mental and physical processes, an exact recognition of the bodily states and intellectual sensibilities, of woman regarded as a sexual being.

Modern culture and the social organization of the present day, in association with the resulting sexual neuropathy of women, have exercised on their sexual life an influence as powerful as it is unfavorable, manifesting itself in the overpowering frequency of the diseases of women. In one of the most thoughtful books ever written on the subject of woman, Michelet’s L’Amour,^[13] the author remarks that every century is characterized by the prevalence of certain diseases: thus, in the thirteenth century, leprosy was the dominant disease; the fourteenth century was devastated by bubonic plague, then known as the black death; the sixteenth century witnessed the appearance of syphilis; finally, as regards the nineteenth century, “se siècle sera nommé celui des maladies de la matrice”.^[14] It is certain that the education and mode of life of the modern woman belonging to the so-called upper classes are, as far as sexual matters are concerned, in direct opposition to those that are agreeable to nature and those that the laws of health demand.

7Even before sexual development begins, before the physical ripening of the reproductive organs to functional activity, the imagination of young girls is often prematurely occupied with sexual ideas in consequence of unsuitable literature, owing to visits to theatres and exhibitions, or on account of social intercourse with young men who are not overscrupulous in the selection of topics for conversation. From the time of puberty up to the time of marriage the growing woman is under the influence of the now awakened sexual impulse, which experiences ever-renewed stimulation. A sedentary mode of life, unsuitable nutriment, and the early enjoyment of alcoholic beverages, exhibit their inevitable result in the frequency with which, in this epoch of the sexual life, chlorotic blood-changes, neurasthenic conditions, and diverse symptoms of irritation of the genital organs, make their appearance. Thus, when marriage, so often unduly postponed in consequence of the condition of modern society, does at length take place, it is apt to find the woman not only fully enlightened as regards sexual matters, but often in a state of nervous weakness from sexual stimulation, one of the type whose characteristics have been happily summed up by the French writer Prévost in the expression demi-vierge.^[15] The conjunction of this state of affairs in the bride with the frequent partial impotence of the bridegroom, who has already dissipated the greater part of his virile power before entering upon marriage, leads often to the appearance of vaginismus and other sexual neuroses in young married women. Even more disastrous in its consequences as regards the future sexual life of the wife is the ever-increasing frequency of gonorrhœal infection in the first days of marital intercourse, with all the evil results of that infection. On the other hand, an ever-larger proportion of girls belonging to the “middle and upper classes,” abstaining alike from the good and the evil results of marriage, falls under the yoke of sexual impulses denied satisfaction or gratified by abnormal means, and suffers in consequence both physically and mentally. Further sources of injury arising from the conditions of modern social life are to be found in the neglect by women of the well-to-do classes of the duty of suckling their children, and in the ever-increasing frequency with which the women of these classes, after giving birth to one or two children, resort to the use of measures for the prevention of pregnancy, which result in serious consequences as regards both the nervous system and the genital organs of the women concerned. Thus there comes an accelerated ebb in the sexual life, leading to a premature appearance 8of the general phenomena of senility, with a cessation of the menstrual flow. The modern wife, who claims the right to lead the life that best pleases her, will be more rapidly overtaken by sexual death.

For the elucidation of the manifold reflex and other processes which are dependent upon or accompany the sexual phases of woman, we must in the first place consider the anatomical changes and physiological functions of the female reproductive organs characteristic of the several periods of sexual life which have already been distinguished. We must not fail also to take into consideration the mental states which accompany and characterize these respective phases.

The anatomical changes which occur in the female genital organs during these different phases of sexual life give rise to a number of manifold local stimuli, increasing and decreasing, varying greatly in intensity and area of distribution, upon which depend the reflex effects and remote manifestations in the sphere of the nervous and circulatory systems.

We must first consider the changes in the ovaries, which play an etiologically important part. At the onset of puberty, the follicular masses of the ovary exhibit a more active growth, the follicles increase in size, with their contained ova they approach the surface, and finally, by the bursting of the follicles, the ova are extruded. Then, in the life-phase in which conception occurs, and under the influence of the hyperæmia of all the pelvic viscera that accompanies this process, a notable development of the corpus luteum takes place, this latter body reaching its maximum size in the eleventh week of pregnancy, subsequently undergoing involution and leading to the formation of a considerable scar. Finally, in the critical period of life in which the menstrual flow ceases, a continually increasing growth and new formation of connective tissue-stroma takes place in the ovaries at the expense of their cellular constituents, and a regressive metamorphosis of the graafian follicles occurs.

In association with these sexual processes there ensues a series of striking changes in the shape and consistency of the ovaries, affecting both the surface and the parenchyma of these organs, and capable of stimulating the nervous ramifications in their tissue. In this connection it is worthy of note that the branches supplying the ovaries from the spermatic plexuses of the sympathetic contain a considerable proportion of sensory fibres.

Quite as significant, moreover, as the changes in the ovaries, are those which, in the course of the sexual life, the uterus undergoes, in shape and size, in its muscular substance and mucous lining, and in its vascular and nervous supply.

9

Fig. 2.—Portion of the pelvic viscera in the female, and their relation to the muscles of the pelvic outlet (or perineal muscles), shown in the left half of the pelvis, seen from the right side.—The parametrium. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

10At the time of puberty the infantile uterus undergoes changes affecting both its external form and the shape of its interior cavity. The body of the uterus enlarges to the size characteristic of sexual maturity, and its mucous membrane becomes the seat of periodic changes. This waxing and waning growth and transformation of the uterine mucous membrane continues throughout the period of menstrual activity, the most superficial layers of the membrane being shed during menstruation, a process followed by regeneration, which is itself succeeded by the premenstrual thickening. When conception occurs, still more extensive changes ensue, the fertilized ovum becoming imbedded in the uterine mucous membrane, and the pregnant uterus, in shape and structure and in the respective relations of the body and neck of the organ, in the increasing distension of its veins and the increasing size of its nerves, becoming adapted to the important functions it has now to fulfil. When these have been fulfilled, and, parturition having taken place, the uterus is empty once more, the organ again adapts itself to altered circumstances by the process of involution. Later, in the climacteric period, a slow regressive process occurs, the outward manifestation of which is the cessation of the menstrual flow, characterized anatomically by atrophy of the muscular tissue of the uterus and of its vascular apparatus, by the dessication of its mucous membrane, by obliteration of the lumen of the uterine cavity, and ultimately by senile degeneration and atrophy of the now entirely functionless organ, so that it becomes an insignificant, cicatrized, solid body.

Next to the ovaries and the uterus, it is the pelvic fascia which in its entire architectonic structure as well as in its individual parts undergoes the most notable changes in consequence of the processes of generation.

A short account of the nerves and blood vessels of the female genital organs appears indispensable, to facilitate the comprehension of the manner in which sexual processes are influenced by the nervous system, and to demonstrate the intimate connection between the blood-supply of the genital apparatus and the general circulation.

The complex nervous network of the female sexual organs is supplied by spinal as well as by sympathetic fibres, the fibres from the two systems anastomosing in a very intimate manner.

11

Fig. 3.—The distribution of the pudic nerve, n. pudendus, in the female perineal and pubic regions. The trunk of the pubic nerve, n. pudendus, is covered by the gluteus maximus muscle. On the right side of the body the branches of the inferior pudendal nerve, rami perineales, nervi cutanei fermoris posterioris have been dissected out; but the branches of this nerve to the labium majus have been cut short. The formation of the anococcygeal or subcaudal nerves, nn. anococcygei, out of the posterior primary division of the coccygeal nerve and out of the perforating branches which arise from the anterior primary divisions of the fourth and fifth sacral nerves and the coccygeal nerve. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

12The greater number of the spinal nerves distributed to the genital organs arise from the lumbar portion of the spinal cord, pass as rami communicantes to the first four lumbar ganglia of the great sympathetic cord, whence they proceed to the series of symmetrical (paired) and asymmetrical (azygos) sympathetic plexuses in front of, and adjacent to the abdominal aorta, which already contain afferent and efferent spinal fibres derived from the pneumogastric, phrenic, and splanchnic nerves. A small number only of coarse nerve-filaments, a larger number of fine nerve-filaments, derived from the sacral nerves, proceed direct to the internal genital organs; many of these fibres enter the lower extremity of the pelvic or inferior hypogastric pleans, some pass to the cervical ganglia of the uterus. Below the bifurcation of the aorta and in front of the sacral promontory, a large number of the uterine nerves, both of spinal and of sympathetic origin, unite to form an azygos plexus which has been shown by experiment to possess great functional importance. Anatomically this constitutes the upper undivided portion of the hypogastric plexus, which is the downward continuation of the abdominal aortic sympathetic plexus; but inasmuch as it is the principal channel of nervous impulses to the uterus it is often known at the present day as the great uterine plexus (plexus uterinus magnus). The nerves to the ovary and Fallopian tube (ovarian nerves) are derived from the spermatic (ovarian) plexus, an offshoot of the renal plexus; as the spermatic plexus descends, it is reinforced by branches from the abdominal aortic plexus, these branches often arising from a small ganglion (spermatic ganglion). The hypogastric or great uterine plexus, single and median above, divides below into the paired pelvic or inferior hypogastric plexuses, which pass downward and forward on either side of the rectum; these plexuses are reinforced by spinal elements derived from the sacral nerves. Before the terminal expansions of the pelvic or inferior hypogastric plexus enter the tissues of the internal genital organs, the bladder, and the rectum, small masses of ganglionic matter are interspersed among the nerve fibres.

To the above general sketch, which has been based on the synoptical description of Chrobak von Rosthorn, must be added a more detailed account of the innervation of the ovaries, this branch of the subject being of especial importance. The nerves of the ovary are derived from the sympathetic system, in part from the spermatic ganglion, in part from the second renal ganglion, and in part from the superior mesenteric plexus. The nerves of 13the ovary are for the most part vascular nerves, which unite before entering the ovary to form the ovarian plexus, and then pass into the hilum with the vessels, envelop the vessels of the medullary layer, and thence pass to the follicular region; exceedingly numerous, they form a close-meshed network, surrounding all the vessels up to the finest capillary ramifications; those fibres which terminate in the capillary walls and those also which reach the follicles are regarded by Riese as sensory. The great trunks of the uterine nerves are transversely disposed in relation to the great lateral vessels of the uterus, and passing inward toward the mucous membrane they break up into pencils of filaments; the uterine nerves proper are distributed for the most part to the muscular substance. In the Fallopian tubes, the nerves form arches around the lumen of the tube; some fibres also pass to the longitudinal folds of the mucous membrane.

This expansion of the nerves of the cerebrospinal and sympathetic systems in the female reproductive organs manifests the multiple interconnection of the two systems in this region, and proves beyond doubt that the sensory nerves of the genital organs have manifold connections with the motor tracts of the whole organism on the one hand and with the sensory ganglia of the central nervous system on the other, and in addition with the vasomotor centres and with efferent motor and secretory fibres.

As regards the vascular system of the female genital organs, the latter are supplied by the internal iliac artery. One of the two terminal branches of the common iliac, the internal iliac artery, descends into the pelvis over the sacro-iliac synchondrosis. Its branches may be arranged in four groups: anterior group, the hypogastric, iliolumbar, and obturator arteries; posterior group, the lateral sacral, gluteal, and sciatic arteries; internal group, the inferior vesical, uterine, and middle haemorrhoidal arteries; inferior group, comprising a single artery only, the internal pudic; the uterine artery supplies the uterus and the vaginal fornices; the ovarian artery supplies the ovary, the Fallopian tube, and the broad ligament of the uterus; the vaginal, cervicovaginal, or vesico-vaginal artery supplies the vagina; the internal pudic artery supplies the vestibule and the clitoris; the superior and inferior external pudic arteries (branches of the femoral artery) supply the labia majora. The veins of the female genital organs correspond in general to the arteries in their course and nomenclature, and empty their blood into the internal iliac vein.

14

Fig. 4.—The distribution of the lateral sacral arteries, the superior haemorrhoidal or superior rectal artery, the uterine artery, the ovarian artery and the distal portion of the internal pudic artery. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

15Attention must also be paid to the extremely rich lymphatic vascular system of the female genital apparatus. The body of the uterus and the annexa of that organ, the neck of the uterus and the vaginal fornices, the middle segment of the vagina, the lower segment of the vagina, the vestibule and the external genital organs—each of these possesses an independent set of lymphatic vessels, leading moreover to independent groups of lymphatic glands. It may be said that the lymph from the vulva passes to the inguinal glands, that from the vagina and the neck of the uterus to the internal and the external iliac lympathic glands, that from the upper part of the uterus and also that from the ovaries and Fallopian tubes to the median group of lumbar lymphatic glands (also known, from their position in front of the aorta and the vena cava, as the aortic lymphatic glands) (Chrobak von Rosthorn).

The important influence which the genital processes exercise on the female organism as a whole is established not only by the anatomical relations just described but also by a number of physiological investigations and experiments and by the result of operations on the female genital organs.

Thermic and mechanical stimulation of the female genitals has, as my own experiments have shown, a notable influence on the heart and the general circulation. In these experiments, when uterine douches were given at temperatures of 4° C. (39° F.) and 45° C. (113° F.), the reflex nervous impulse which resulted from these manipulations had a two-fold influence on the circulation, manifesting itself first by an immediate and considerable augmentation in the functional activity of the heart, the frequency of which was increased in a degree proportional to the nervous sensibility of the individual, and secondly by a notable rise in blood pressure.

With a view to determining the influence of stimulation of the ovary on blood-pressure, Röhrig carried out some experiments on bitches, from which it appeared that electrical stimulation of the ovary invariably produced a remarkable increase in the general blood-pressure, an increase ranging from twelve to twenty-four millimeters of mercury. It further appeared in the course of these experiments that toward the end of the period of stimulation the rise in blood-pressure was always followed by a decline; to which, however, a renewed rise of blood-pressure succeeded after the stimulation was discontinued, provided the duration of this had not been excessive. Only after this second rise was the normal mean blood-pressure regained. Finally it was established that the pronounced 16phenomena of vagus-irritation exhibited by the curve during and immediately after the stimulation of the ovary were invariable concomitants of the rise of blood-pressure produced by such stimulation.

According to the observations of Federns, the blood-pressure undergoes a rhythmical change between one menstrual period and the next, the pressure curve being normally at its lowest at the time of the commencement of the flow, and at its highest at some time during the two days immediately preceding the flow. This rhythmical change of blood-pressure manifests itself also some time before the first onset of menstruation, when the approach of puberty is indicated only by the menstrual molimina.

Observations made by Kretschy in a patient with a gastric fistula have proved the influence exercised on gastric digestion by the physiological processes occurring in the female reproductive organs. In this patient, his attention was especially directed to determining at what period of digestion the secretion of acid by the stomach attains its maximum, and how that secretion increases and diminishes. He observed that the digestion of breakfast was completed in four and one-half hours, the acid-maximum occurring in the fourth hour, and the reaction of the gastric contents becoming neutral one and one-half hours later. This apparently constant acid-curve began, however, to become irregular as soon as the first symptoms of the approach of menstruation became apparent. When the flow had actually begun, he found that the reaction of the gastric contents remained acid throughout the entire day. As soon as the flow was over, the normal acid-curve was immediately reëstablished.

These observations have been confirmed by Fleischer. This investigator carried out his researches in menstruating women with normal stomachs, and found that with the appearance of the catamenia the process of digestion was almost always notably retarded, but that with the diminution and cessation of the flow digestion returned to the normal.

By stimulation of the central segment of the divided hypogastric or great uterine plexus, Cyon was able to provoke vomiting, a confirmation of the well-known physiological fact that irritative disturbances of the female reproductive organs have a reflex influence on the vomiting centre.

It is also clearly established that diverse stimulation of peripheral nerves, those for instance of the mammary gland, of the internal genitals, or of the epigastrium, is capable of affecting the motor centre of the uterus.

Worthy of note also are Strassmann’s experiments, showing that 17rise of pressure in the ovary causes swelling and structural changes in the uterine mucous membrane.

Striking also are Neusser’s discoveries that during menstruation there is an increase in the eosinophil cells of the blood, and that by the intermediation of the sympathetic nervous system the ovaries exercise an influence on the hæmatopoietic function of the red marrow of the bones. Most noteworthy is the connection between the functional activity of the ovaries and osteomalacia. In this disease of metabolism we have to do, according to Fehling’s now generally accepted assumption, with a trophoneurosis of the bones, a stimulation of the vasodilator nerves of the osteal vessels, dependent on a reflex impulse from the ovaries. The connecting path between the ovaries and the bones Neusser finds in this case also in the sympathetic nervous system.

The reflex influence exercised on the heart and the general circulation has been shown also by the results of operations on the female genital organs. In cases in which the ovaries have been removed, or in which these organs have been roughly handled, Hegar has noticed a great diminution in the frequency of the pulse, sometimes even cessation of the heart’s action. In similar circumstances Champonière also observed as a rule diminished frequency of the pulse, but in some cases increased frequency. Mariagalli and Negri have described tachycardia following laparotomy and the extirpation of double pyosalpinx. Bonvalot has published cases in which, in consequence of vaginal or intra-uterine injections, in consequence of simple examination, and in consequence of the performance of version, sudden death has resulted from cardiac syncope.

The psychical influences which proceed from the female genital organs in the different periods of sexual life have also great significance for the organism as a whole. Manifold impulses both stimulating and depressing arising in the reproductive organs affect the workings of the mind. The maiden at puberty is affected by the knowledge of sexuality; the sexually mature woman, by the desire for sexual satisfaction, and by the yearning for motherhood; the wife, by the processes of pregnancy, parturition, and suckling, or, on the other hand by the distressing consciousness of sterility; the woman at the climacteric period, by the knowledge of the disappearance of her sexual potency. The mind is further sympathetically influenced by the stimulation of the terminals of the sensory nerves in the genital organs. Through the increase of such stimulation, through its spread to adjacent nerves and nerve tracts and to the entire nervous system, the mind is affected, 18directly by irradiation, or indirectly by vasomotor processes and spinal hyperæsthesia.

Psychical manifestations and the nervous states associated with these are somewhat frequently, and even actual psychoses occasionally, encountered in the various phases of the sexual life of woman, sometimes taking the form of violent sexual storms, which may indeed, as ordinary menstrual reflexes, accompany every catamenial period.

Of great interest are the facts which have, in recent times especially, been scientifically established, pointing to a certain periodicity, to an undulatory movement of the general bodily functions of the female organism, dependent upon the sexual life. The observations of Goodman, Jacobi, von Ott, Rabuteau, Reinl and Schichareff, have shown that in woman the principal vital processes pursue a cycle made up of stages of increased and diminished intensity, and that this periodicity of the chief general processes of vital activity finds expression also in the functions of the reproductive organs. Goodman has compared this play of general vital functions to an undulatory movement. According to this writer, a woman’s life is passed in stages, each of which corresponds in duration with a single menstrual cycle. Each of these stages exhibits two distinct halves, in which the vital processes are respectively ebbing and flowing: in the latter we see an increase of all vital processes, a larger heat production, a rise in blood-pressure, and an increased excretion of urea; in the former we see, on the contrary, that all these vital processes display a diminished intensity. The moment when the period of increased vital activity is at an end, the moment when the ebb begins, corresponds, according to Goodman, to the commencement of the catamenial discharge.

Goodman sought for verification of this undulatory theory of the sexual life of woman in certain data regarding the bodily temperature and the blood-pressure. A more extensive research was undertaken by Jacobi, who, as the result of her observations, came to the following conclusions. In eight cases she noticed in the premenstrual epoch a rise of temperature ranging from 0.05° C. to 0.44° C. (0.09° F.–0.79° F.); and during the catamenial discharge a gradual fall of 0.039° C.–0.25° C. (0.072° F.–0.45° F.), never less, that is to say, than a quarter of a degree Centigrade; but in the majority of cases the temperature did not, while the catamenia lasted, regain the normal mean. She further observed in the generality of cases an increased excretion of urea during the premenstrual epoch; and a notable fall in blood-pressure during menstruation.

Reinl’s observations on healthy women, in whom menstruation ran a normal course, showed that in the great majority of cases in 19the premenstrual epoch the temperature was elevated as compared with that of the interval, that in eleven out of twelve cases the temperature gradually declined during menstruation, to fall in three-fourths of the cases below the mean temperature of the entire interval, and exhibiting in the post-menstrual epoch a still further depression, giving place, however, to a somewhat higher mean temperature during the first half of the interval. In the second half of the interval a higher mean temperature was observed than in the first half.

If we make a graphic representation of the mean differences in temperature commonly observed throughout the various stages of an entire menstrual cycle, we see that the curve does in fact take the form of a wave. That drawn by Reinl is shown in the following figure: (Fig. 5.)

Fig. 5.

The rising portion of the wave, the beginning of the tidal flow, corresponds to the second half of the interval; the height of the tidal flow, the crest of the wave, corresponds to the premenstrual epoch. As the flow gives place to the ebb, as the wave begins to decline, we come to the actual period of the catamenial discharge; later in the ebb is the post-menstrual epoch, and the lowest portion of the declining wave corresponds to the first half of the interval. Rhythmic changes corresponding to those observed in the temperature have been recorded—at least in isolated stages of the menstrual cycle—affecting the blood-pressure by Jacobi and by von Ott, affecting the excretion of urea by Jacobi and by Rabuteau, and affecting the pulse by Hennig. It is evident that the vital activity of the organism attains its maximum shortly before menstruation; and that with or immediately before the appearance of the catamenial discharge, a decline of that activity commences.

Schrader, through his researches on metabolism during menstruation in relation to the condition of the bodily functions during this process, has established that immediately before menstruation the elimination of nitrogen in the fæces and the urine is at its lowest, a fact which indicates that at this period of the menstrual cycle the disintegration of albumen in the body is notably diminished.

20Von Ott found in thirteen cases out of fourteen that at the beginning of the catamenial discharge or just before a considerable fall in blood-pressure occurred, and that throughout the flow the pressure almost always remained below the mean, no rise taking place till menstruation was finished; this fall in blood-pressure during menstruation was more considerable than could be accounted for by the moderate hæmorrhage. The same author, in conjunction with Schichareff, examined fifty-seven healthy women in respect of heat-radiation, muscular power, respiratory capacity, expiratory and inspiratory power, and tendon-reflexes. He found that the energy of the functions of the female body increased before the beginning of menstruation, but declined with or immediately before the appearance of the catamenial discharge. He exhibited this rhythmical variation in the vital processes by means of the following curve, in which the line A B represents these physiological variations, whilst on the abscissa line c e, the days of observation are recorded, and the interval m n represents the menstrual period. The degree of intensity of the united functions is indicated by the numbers 0–100 on the ordinate.

Fig. 6.

Still another point of view from which the influences affecting the female organism as a whole may be regarded has very recently become apparent in consequence of the doctrine of Brown-Séquard relating to the internal secretions of ductless glands. As regards the female reproductive glands, which in consequence of their structure must be referred to the group of ductless glands, and yet owing to 21their secretory function must be classed among secreting glands (so that the nature of the ovary is that of a secreting gland without an excretory duct), it would appear that these glands are not concerned only with the specific female reproductive functions of menstruation and ovulation, but that they also exercise a powerful influence on the nutritive processes, on metabolism and hæmatopoiesis, and on growth and development in their mental as well as their physical relations.

It is supposed that these glands under normal conditions enrich the blood with certain substances, which in part assist in hæmatopoiesis, and in part by regulating the vascular tone in the various organs are concerned in the normal processes of assimilation and general metabolism. According to Etienne and Demange, ovariin possesses an oxidising power similar to that possessed by spermin. Thus it becomes easy to understand how disturbances in the functions of the ovaries give rise to disturbances in the processes of general metabolism and of assimilation. Some go even further, though in doing so they leave the ground of assured fact, suggesting that the ovary in certain circumstances produces toxins, or that the normal ovary possesses an antitoxic function, and speaking of an occasional ovarian auto-intoxication of the body or of a menstrual intoxication. Thus, chlorosis is by some regarded as a disturbance of hæmatopoiesis, dependent on an abnormal condition of the female reproductive organs during the period of development, and referable to a disturbance of the internal secretion of the ovaries (Charrin, von Noorden, Salmon, Etienne, and Demange). And it is now generally assumed, the assumption being based on the observations recently made concerning the organo-therapeutic employment of the chemical constituents of the ovary, that many of the disorders, and especially those connected with the vasomotor system, common during the climacteric period, are dependent on the deficiency of the products of the internal secretion of the ovary that accompanies the cessation of the menses.

Recent experimental investigations on this subject have shown that the interconnection between the female genital organs and the organism as a whole, between the functions of the reproductive organs and the functions of other organs, does not depend on nervous influences only, but that in this interconnection the blood vascular system and the lymphatic vascular system also play their parts. Goltz has proved by actual experiment that the nervous influence on menstruation and ovulation is not the only determinant. In a bitch, he divided the spinal cord at the level of the first lumbar vertebra, and observed, as soon as the animal had recovered from the operation, the appearance of the usual signs of heat; the bitch was 22impregnated, and gave birth to one living and two dead puppies; lactation and sucking took place as in a normal animal. When the bitch was killed and the body examined it was found that no reunion had taken place in the severed spinal cord. The experiments of Halban gave similar results. He found that in apes, if the ovaries are removed from their normal situation and successfully transplanted to some region remote from the genital organs, the animals remain capable of menstruating. But if the ovaries, which have been transplanted beneath the skin or beneath the peritoneum, are subsequently entirely removed, menstruation, which has continued regularly after the first operation, ceases altogether after the second. It follows from these experiments that the cessation of the menstrual process may be considered to be brought about through the intermediation of the lymphatic or blood-vascular system, by the absence of a kind of internal secretion.

Loewy and Richter have further proved by experiment that in spayed bitches the consumption of nitrogen is less by about 20 per cent. and the entire gaseous interchange less by about 9 per cent., as compared with what takes place in normal animals, and that this change in respiratory metabolism lasts for a long time after the oöphorectomy, for as much as nine to twelve months. If dried ovaries are given to such animals in their food, the gaseous interchange rises to the former level and even higher.

The undulatory movement of the vital processes in woman is apparently in some way dependent on ovulation, though the nature of the connection has not hitherto been fully elucidated. This view is confirmed by the fact that no such rhythmic variation in the bodily functions can be detected either in girls under thirteen years of age, or in women from fifty-eight to eighty years of age in whom menstrual activity has entirely disappeared. The menstrual rhythm begins at puberty and ends when ovulation ceases.

A further contribution to the doctrine of the undulatory movement of the vital processes in woman is to be found in my own observations that pathological symptoms which have become manifest before and at the time of the first onset of menstruation, and have given but little trouble throughout the period of developed and regular sexual activity, are apt when menstruation ceases to recrudesce, and to become as prominent as they were at the commencement of the sexual life. Women who at the time of puberty suffered from cardiac troubles, from digestive disturbances, or from various forms of nervous irritation, and in whom as they grew up these disorders passed more or less into abeyance, are apt at the climacteric period to exhibit, as I have frequently been able to observe, a violent return of these symptoms, in the form, as the 23case may be, of tachycardia, of dyspeptic troubles, or of psychoneuroses. In this connection we may mention an observation of Potain’s, who distinguishes a peculiar form of chlorosis, occurring in individuals of delicate constitution, which, though apparently cured, reappears at the menopause.

Related to the sexual life of woman is another attribute, one intimately connected with the idea of the female sex, and one which since the primeval days of humanity has filled men with delight and poets with inspiration—the attribute of beauty.

The beauty of woman, a prominent secondary sexual character, makes its first appearance at puberty, when the girl’s form, hitherto undifferentiated in its external bodily configuration, begins to assume a soft and rounded appearance, when the features become regular, the breasts enlarge, and the pubic hair begins to grow—when, in short, to the primary sexual characters already existing, the secondary sexual characters are superadded.

Feminine beauty continues to increase until the attainment of sexual maturity. In her third decade woman arrives at the acme of her sexual life and at the same time attains the perfection of her beauty.

The ensuing sexual phases, pregnancy, parturition, and lactation, entail a decline in beauty, not rapid indeed, but advancing gradually, with the slow yet sure-footed pace of time. The organic revolutions accompanying these processes leave traces recorded upon the surface of the body in conspicuous and indelible characters. The illnesses, also, which so often accompany the fulfilment of sexual functions, in injuring health impair also beauty.

A woman who has given birth to and nursed an infant begins to lay on fat, and this tendency to obesity becomes more pronounced as the climacteric period approaches. The breasts become inelastic and pendent, the abdomen becomes ungracefully prominent; the tonicity of the entire organism gradually declines, and, in consequence of the loss of elasticity in the subcutaneous cellular tissue, the dreaded wrinkles make their appearance and the features become wizened. Beauty is a thing of the past. With the cessation of the sexual life the external secondary sexual characters disappear, and the old woman is even farther removed than the old man from our conception of beauty.

As Mantegazza insists, the beauties peculiar to women are one and all sexual; they depend, that is to say, upon the peculiar functions that nature has allotted to woman in the great mystery of procreation. One of the most vivid and poetical descriptions in ancient or modern literature of these secondary sexual characters on which feminine beauty depends is to be found in the Song of Solomon.

24In the following figure (Fig. 7) the curve of beauty of woman is given as drawn up by Stratz. In one case it may rise very quickly, to decline with equal quickness—the so-called beauté du diable;^[16] in other cases, again, the curve rises very slowly, and declines also very slowly, the culmination of the curve being in this case attained later, and when attained being absolutely higher, than in the case of the steeper curve.

Fig. 7.

The age at which the maximum of beauty is attained is a very variable one. In the southern races this often occurs as early as the fourteenth or fifteenth year of life; but in the peoples of the Teutonic stock, Germans, Dutch, Scandinavians, and English, not as a rule before the twentieth year, and it may be even later. Stratz has known cases in which women did not attain the prime of their beauty until the thirtieth and even the thirty-third year. The same author, a most competent authority as regards the subject of feminine beauty, affirms that a beautiful woman is most beautiful when the period of maximum beauty coincides in her case with the first month of her first pregnancy. With the commencement of pregnancy the processes of nutrition are accelerated, all the tissues are tensely filled, the skin is more delicately and at the same time more brightly tinted owing to the greater activity of the circulation, the breasts become firmer and more elastic. Thus the attractive characteristics of beauty at its fullest maturity become 25enhanced, but for a short time only, since the enlargement of the abdomen in the further course of pregnancy impairs the harmony of the figure. Finally we must point out, before dismissing this subject, that women of the so-called better classes arrive as a rule at maturity later, and remain beautiful for a longer period, than women of the working classes.

The degree to which the female organism as a whole is influenced by the processes of the sexual life that occur in the genital organ depends upon many of the characteristics that combine to make up the individuality. Inherited characteristics, temperament, and race, play a great part in this connection; and not less important than these are the social conditions, the environment, in which the women under consideration pass their life. Thus, among women belonging to the poorer, labouring classes, the reflex manifestations in other organs dependent upon the processes of the genital organs are less frequent and less intense than among women belonging to the well-to-do strata of society and to the cultured classes; less also in the country than in large towns. In phlegmatic individuals, such manifestations exhibit less intensity than in those of an active, ardent temperament; they are less frequent in persons with a powerful constitution than in those endowed by inheritance with an unstable nervous system. Finally, they are less often encountered among families whose upbringing has aimed at hardening the constitution and at inculcating the control of instinctive impulses, than among those in whom from early childhood sensibility and impulsiveness have been given a loose rein.

Extremely variable also are the sympathetic disturbances and morbid states which depend on the processes of the sexual life of woman. “Le cri de l’organe souffrant ne vient pas de l’utérus, mais de tout l’organisme,”^[17] says Courty. And a large number of isolated observations has shown how complex are the relations between the healthy and unhealthy female genital organs and the other organs of the body as well as the organism as a whole. Precise and incontestable proofs exist of such relations between the female genital organs and morbid changes in the eye and ear, the skin, the respiratory organs, and the vascular and nervous systems.

The influence exercised by the reproductive system on the general vital processes of woman is indicated also by the general statistics of mortality and the incidence of disease. Mortality in women, the earliest years of childhood being left out of consideration, 26is at its highest precisely during the great sexual epochs, namely at the time of puberty, during pregnancy, during the puerperium, and at the climacteric period. The complete performance of the reproductive functions entails a higher proportion of illnesses and death; and statistical records show that the mortality of married women between twenty and forty years of age, during the period, that is to say, in which in consequence of marriage they fulfil the duties of sexual intercourse and procreation, and are exposed to the dangers connected with these sexual acts, is much higher than the mortality of unmarried women of corresponding ages. Infection with the gonococcus and with the virus of syphilis, chronic salpingitis, metritis, and parametritis, the manifold diseases of pregnancy, the diseases of the puerperium, the various displacements of the uterus, osteomalacia—all these are pathological states the dependence of which upon the sexual life of the married or at any rate sexually active woman is indisputable. But the complete renunciation of sexual activity appears also to exercise an injurious influence on the health, and to give rise or at least predispose to morbid manifestations. Hysteria, for instance, chlorosis, uterine myomata, and various neuroses, have long been supposed to depend in part upon such renunciation, though the causal connection cannot be regarded as yet fully established.

Especially true as regards woman, indeed, is that which Ribbing says concerning the sexual life in general: “Since all human life and being has its origin in sexual relations, these sexual relations may be regarded as the heart of humanity. We may work day and night for the good of humanity, we may sacrifice for that good our time and our blood, but all this work and all this sacrifice appear to me to remain useless if we neglect and despise the sexual life, the eternally self-renewing elementary school of true altruism.”

From the vital phase in which, marked by the visible manifestations of puberty and by the first appearance of menstruation, ovulation is assumed to begin, the sexual life of woman continues to the period of life in which, marked by the climacteric cessation of menstruation, ovulation also ceases. The total duration of this sexual period in woman’s life is usually about thirty years; but it is subject to great variations, from six to forty-six years according to the available statistics, these variations depending upon climate, race, constitution, and the sexual activity of the person under consideration.

The duration and the intensity of the sexual life of woman depends upon a series of external conditions affecting the individual, but especially upon the inherited predispositions, upon the constitutional conditions, upon the varying vital power of the individual. 27My own observations have led me to formulate, as a general law, that the earlier a woman (climatic and social conditions being similar in the cases under comparison) arrives at puberty, the earlier, that is to say, that menstruation first makes its appearance, the greater will be the intensity and the longer the duration of sexual activity, the more will the woman in question be predisposed to bear many children, the more powerfully will the sexual impulse manifest itself in her, and the later will the menopause appear. It seems that in such women a more intense vitality animates the reproductive system, bringing about an earlier ripening of ova, a more favorable predisposition on the part of these ova to fertilization by the spermatozoa, a livelier manifestation of sexual sensibility, and a longer duration of ovarian functional activity.

My general views on this subject are embodied in the following propositions:

1. The duration of sexual activity is less in the women belonging to the countries of southern Europe than in those belonging to the countries of northern Europe. It would appear that in those climates in which ovulation begins sooner and menstruation first appears at an earlier age, the menopause also appears earlier; but that, on the contrary, in those climates in which puberty is late in its appearance, the decline of sexual activity is similarly postponed.

2. Women in our mid-European climates, in whom puberty appears at an early age, the first menstruation occurring between the ages of thirteen and sixteen, exhibit a more prolonged duration of the sexual life, of menstrual functional activity, than women in whom menstruation begins late, between the ages of seventeen and twenty. Extremely early appearance of the first menstruation—so early as to be altogether abnormal—has, however, the same significance as abnormally late onset of menstruation; both indicate that the sexual life will be of short duration.

3. Women whose reproductive organs have been the seat of a sufficient amount of functional activity, who have had frequent sexual intercourse, have given birth to several children, and have themselves suckled their children, have a sexual life of longer duration, as manifested by the continuance of menstruation, than women whose circumstances have been just the opposite of these, unmarried women, for instance, women early widowed, and barren women. Sexual intercourse at a very early age, however, accelerates the onset of the climacteric period and the termination of the sexual life. The same result follows severe or too frequent confinements.

4. The sexual life has a shorter duration in the women of the laboring classes and belonging to the lower strata of social life, as 28compared with upper class and well-to-do women. Bodily hardships, grief, and anxiety also hasten the onset of sexual death.

5. Women who are weakly and always ailing have a shorter sexual life than women who are powerfully built and always in good health. When irregularities and disorders have appeared in the various sexual phases, the decline of sexual activity occurs earlier than in women whose functions have in this respect been normal. Certain constitutional conditions, such as extreme obesity, certain acute diseases, such as typhoid fever, malaria, and cholera, and certain diseases of the uterus and its annexa, chronic inflammatory conditions for instance, bring about a notable shortening of the duration of the sexual life.

In 500 cases that have come under my own observation, the women concerned belonging to very various nationalities, the duration of the sexual life, as witnessed by the continuance of menstruation, was as follows:

Menstruation continued for:

Thus we see that the duration of the sexual life varies from 6 to 46 years. The most frequent duration is one of 32 years, next to this one of 29, next again, 31, 33, and 37 years, respectively. In 6 women only did the duration of the sexual life exceed 40 years, and in 4 only was it less than 11 years. In half of all my cases the duration of the sexual life was between 27 and 34 years, and from these figures we obtain an average duration of about 30 years.

For North Germany, Krieger gives data from which it appears that in this region the average duration of the sexual life is 30.49 years. In more than half of the 722 cases recorded by this writer the duration was between 31 and 37 years. In isolated cases the duration was very short, not exceeding 8, 9, or 10 years, or, on the other hand, as long as 47 years; whilst the number of cases increased fairly regularly up to the duration of 34 years, and thereafter again diminished.

As regards Austria, Szukits has collected information in the case of 269 women, and found, in these, that the duration of the sexual life varied from 12 to 45 years. The average duration was 2929.16 years; in more than half of the women, the period of sexual activity lasted from 21 to 30 years; the shortest period observed was 12 years, the longest 45 years.

The period of sexual activity lasted:

In Poland, according to Raciborski, the duration of sexual activity is in Jewesses 23 years, but in women of Slavonic blood 31 years.

In France, according to Courty and Puech, the usual duration of the sexual life is from 28 to 30 years.

According to Puech, among 10 women menstrual activity lasted:

Brierre de Boismont gives the following particulars of the duration of menstrual activity in 178 Frenchwomen:

For England, Tilt gives the mean duration of menstrual activity, as observed in 500 women, as 31.21 years; it varies between 11 and 47 years; there are more cases with a period of 34 years than with any other integral number of years. Tilt found the duration to be:

30For London the average figure is 34 years; for Paris, 30 years; for Vienna, 29 years; and for Berlin, 34 years.

From the data of various observers obtained from diverse nationalities, the following table has been compiled, exhibiting the mean duration of the sexual life:

In the temperate zone the sexual life of woman lasts longer than in the colder and subarctic regions. Still more favorable is the contrast between the temperate zone and the countries of the tropics, in which the duration of the period of menstrual activity is limited to eighteen or twenty years. According to some isolated observations the duration of sexual activity in Arabian women in Africa was as little as nine years.

A certain influence on the duration of the sexual life is exercised by the commencement of menstruation at an earlier or later age than the average. The total duration of menstrual activity is more variable in women who begin to menstruate early than in women who begin to menstruate late, in whom the duration of the sexual life is a more regular one. In those women who begin to menstruate early the mean duration of the sexual life is about thirty-three years, in those who begin to menstruate late it is about twenty-seven years.

The following data, based on the observation of 250 cases, are published by W. Guy, regarding the duration of the sexual life, that is to say of menstrual activity, in women beginning to menstruate early and those beginning to menstruate late, respectively:

31A further analysis of these 250 cases is given by Guy in the following table:

Hannover also gives data respecting the relation between the duration of menstrual activity and the early or late appearance of menstruation. These data are tabulated as follows:

Totals: In 412 cases the average age at the menopause was 44.82, and the average duration of menstrual activity was 27.973 years.

From the tables of L. Mayer, Krieger has instituted a comparison between the duration of menstrual activity in 101 women who began to menstruate early and 180 women who began to menstruate late, finding in the case of the former a mean duration of 33.673 years, and in the case of the latter a mean duration of 27.344 years, showing therefore a sexual life longer on an average by 6.429 years in those in whom puberty was early as compared with those in whom puberty was late.

From the tables of Tilt, based on the observation of 164 cases, 76 women in whom menstruation appeared early and 88 in whom 32it appeared late, we learn that among the former the shortest duration of menstrual activity was 18 years, among the latter 12 years; among the former the longest duration was 37 years, among the latter only 33. The majority of those who began to menstruate early continued to menstruate for 28, 31, 32, 33, 34, 35, 36, 38, or 39 years; those who began to menstruate late, for 23, 27, 28, 30, or 31 years. The mean duration of the sexual life in those who began to menstruate early was 33.66 years; in those who began to menstruate late it was 28.28 years. Since the average duration of the menstrual function is given by Tilt as 31.33 years, those who began to menstruate early exceeded this average by 2.33 years, while those who began to menstruate late exhibited a duration of menstrual activity of at least three years less than the average.

In addition to climate, nationality, and the age at which menstruation begins, the sexual activity of women also exercises an influence on the duration of their sexual life, and of especial importance in this connection are the number of children born, and exercise or neglect of the function of lactation. From my own observations on this matter it appears, that in women who are healthy and of powerful constitution, whose reproductive organs have been sufficiently exercised, who have given birth to several children and have suckled these children themselves, the duration of menstrual activity is in general notably longer than in women whose circumstances have been just the opposite in these respects. Among the women in my own series of cases in whom menstrual activity lasted longest, of the 177 women in whom menstruation ceased between the forty-fifth and the fiftieth year of life, 1 only was unmarried, 2 were married but childless, 32 married with 1 or 2 children only, and 142 married and with more than 2 children; of the 89 women in whom menstruation ceased between the fiftieth and the fifty-fifth year of life, none were either unmarried or childless, 19 were married with 1 or 2 children, 17 married and with more than 2 children; of the 17 women in whom menstruation ceased later than the fifty-fifth year of life, there were 2 only with less than 2 children, but 10 who had each given birth to from 6 to 8 children. A similar influence is exercised by the function of lactation. Among 40 women who had not suckled their children, the average duration of menstrual activity was 4 years less than the general mean.

As regards the conditions of life, L. Mayer affirms that the duration of sexual activity among well-to-do women is on the average a year and a half longer than among women of the working classes.

Metschnikoff has drawn attention to the remarkable disharmony in the development of three of the phases of the sexual life of 33woman, inasmuch as the sexual impulse, the union of the sexes, and the capacity for procreation, which, considering their nature and purpose, might have been expected to be attuned so as to act in harmony, exhibit as a matter of fact no such relation; the different factors of the sexual function develop independently and unharmoniously. In a child not yet fitted to fulfil the function of procreation, the sexual impulse will none the less make its appearance, and be liable to misuse. In the girl the pelvis does not attain that complete development which fits it for the process of parturition until toward the age of twenty, whilst puberty occurs at the age of sixteen. “A girl of ten is capable of aspiring to play the part of a woman, but not before the age of sixteen is she fitted to play that part, nor indeed fitted to become a mother before the age of twenty.”

In general, we may say, regarding the women of our own part of the world, that in those who are healthy, who lead a regular life, are well fed, free from the pressure of anxieties, with their sexual functions sufficiently exercised, the duration of the sexual life is longer than in women whose circumstances are the reverse of those just enumerated. It is a sign of decadence when women of the well-to-do classes, leading a life of ease, manifest a diminished duration of the sexual life. The greatest physical power and the highest ethical development are associated with a lengthening of life in general, and associated also with a lengthening alike in the sexual life of woman and the sexual potency of man. A decline in morals and culture entails a diminution of sexual vital capacity, this being true alike of individuals, of families, and of nations. Woman is venerated and valued the more, the longer the duration of her sexual life; a woman in whom the sexual life is short quickly loses value and significance, both in domestic and in social circles.

The social significance of the sexual life of woman is disproportionately greater and farther reaching than the sexuality of the male, as the former is concerned with the fundamental principles of human social life, influencing the constitution of the family, and controlling the good of the coming race. Sexual purity, which to the youth is a romantic dream, is to the maiden a vital condition of existence; adultery, in the husband a pardonable transgression, is in the wife an overwhelming sin committed against family life. To the freedom of the male in affairs of love is opposed the strict restraint of the female, based on monogamic marriage. The sexual needs and desires of the female are transformed in an ideal manner by means of the feeling of duty of the wife and mother; the violent pressure of the sexual impulse is restrained by the opposition of ethical forces. When this restraint fails, the running off the rails that ensues has a far profounder influence in the case of the female than 34of the male, an influence not limited to her own personality, but dragging down the whole family into the abyss of consequences, into the depths of moral and physical destruction.

Though in nature everywhere the same, the sexual life of woman exhibits in the various gradations of social life different outward manifestations, from the brutal sexual congress that does not greatly shun publicity, to the modern would-be philosophical free love. And throughout all variations the two darkest points remain, the illegitimate child and venereal infection, both of which entail upon the woman the most unspeakable anxieties and the greatest possible misery, whilst the man who is in either case to blame passes comparatively unscathed.

The social sexual position of woman suffers most at the present day from the mature age at which under existing social conditions men are alone able to marry and from the ever-increasing number of cases of venereal infection. In both these directions social science and medical skill must work hand in hand for the amelioration of the sexual life of woman.

On the twentieth century falls the duty of furnishing a solution for these problems. Contesting voices are heard on all sides. Tolstoi’s rigid demand for complete sexual abstinence, the exhortation of the professors of the German universities to their students in favor of moral purity, the associations for the official prevention of venereal diseases, the agitation among young men in favor of abstinence from sexual intercourse before marriage, finally, the clamorous voices of the supporters of women’s rights—all these are influences within the sphere of sexual morality, which must lead slowly but surely to extensive social changes in the sexual life of women.

The discussion of the sexual life of woman, which for many centuries was concealed by a thick veil from the eyes of the profane, or was viewed only through the frosted glass of poetical metaphor, has in recent times assumed a quite revolting character. Not only have the acquired liberties and the social aims of the present day a tendency to give to women in general a freer and higher position, to emancipate them from the bonds in which owing to the conditions of family life they have so long been shackled, but some members of the women’s rights party go even farther, and demand for women greater freedom in the sphere of sexual activity.

With this end in view the sexual life of woman is used as the fulcrum of the lever, and is withdrawn from the twilight into the open light of day, or indeed too often into a dazzling and altogether false illumination. Women writers especially, who have hitherto been accustomed to delude themselves and the world with sensational 35representations of the feminine soul, of feminine modesty, and the fineness of feminine sensibility in matters sexual, now find their greatest joy in unveiling themselves and their sisters before the face of all the world, and in discussing in the plainest language the most intimate processes of the genital organs. In writings exhibiting but little good taste, though all the more temperament, they emphasize again and again one side only of the sexual life, to wit, the sexual impulse, the force of which is intentionally exaggerated to a high degree, so that it is described as a mighty current of passion, which may with great pains be held in check for a season, but must ultimately break loose, and with devastating rage must overwhelm everything which has hitherto been regarded as discipline and good morals. Young girls, even, step down into the arena to take part in the contest concerning the reform that is to take place in the relations between men and women. Especially sensational in this connection was Eine für Viele. Aus dem Tagebuche eines Mädchens von Vera,^[18] a book which, totally ignoring the biological differentiation of the sexes and their diverse sociological course of development, goes so far as to insist that from the man entering upon marriage, as from the woman, sexual purity and virginity are to be demanded. (The heroine of the book commits suicide because her lover has in earlier years had experience of sexual intercourse.)

From a mistaken standpoint other supporters of women’s rights oppose the ideal method in sex-relations, life-long monogamy, and the ideal of sexual sensibility, motherhood, and they put forward quite new sexual pretensions on behalf of women, as belonging to them by natural right. Upon these pretensions it is the duty of physicians, who truly know and truly prize womanhood, to pass their judgment, and that judgment, which will find ample justification in the ensuing descriptions of the individual phases of the sexual life of woman, is that the modern movement on behalf of the emancipation of women goes much too far. We do not, however, mean to imply that this movement is totally unjustified.

The growing girl must not, as has hitherto been the case, be kept in a state of ignorance (which is indeed in most cases apparent merely) regarding the sexual processes of her own body, she must no longer, when she asks to be informed concerning these matters, be put off with conventional lies and prevarication. But her enlightenment must not be effected in such a manner as to lead to excitement and excessive stimulation, to the awakening of slumbering feelings, and to the conversion of fantasy into a devouring flame. Sexual enlightenment must not be made an excuse for the 36unchaining of sensibility. When about to be married, a woman should certainly be instructed regarding her sexual duties and rights, and enter as one well informed into the act in which she is to play a leading part. But she ought not, with the excessive valuation of herself attained in recent times, to regard the man as her enemy, as one whom she is always justified in fighting and always ready to fight with the equal weapons of sexual transgression. It cannot be doubted that the ideal of “pure marriage” at an early age is one greatly to be prized as the foundation of a powerful future generation; but the real nature of the male must not be overlooked, nor must his sexual honor be put to too difficult a test. We regard as reasonable the modern demand of woman that in marriage her individuality should not be buried, and that space should be given for the development of her personality; but every sober-minded person will reject the “moral demand” for “ideal passion” in accordance with “entire mutual freedom” in the sexual relation between man and wife, and will regard such free love as social insanity and as a barbaric retrogression toward the rude sexual habits of savage peoples. Further, in view of the continually increasing intensity of the struggle for existence and in view of the difficulties of the task of rearing children, we cannot fail to recognize that it is not right for women to be overburdened with the task of reproduction, and that she does not live simply and solely for the bearing of children—but those rush to the other extreme who undervalue motherhood and the duties of maternity, who speak scornfully of the woman who is “a mother, and a mother only,” who despise women whom they regard merely as “means for the production of children,” and who employ all possible methods to free women from the pressing claims of nature and of society.

In all social circumstances, and in all times the great principle of sexual morality must dominate the sexual life of woman. As the ethical characteristics of the three great epochs in that sexual life we recognize the purity of the maiden, the faithfulness of the wife, and the love of the mother. But within the limits imposed by these demands it is still possible to satisfy the modern claim for a free development of the personality, and to accommodate the circumstances of the sexual life to the individual vital needs and vital claims of the present day.

The term menarche (μήν, a month, ἀρχή, the beginning) was introduced by me into medical literature to denote the period of life in which, as a sign of puberty, menstruation first makes its appearance.

The age at which this occurs is subject to variations depending upon race, occupation, hereditary tendencies, and climate; but in Germany and Austria the average age at puberty is 14 or 15, the extreme limits being 12 to 19.

Until about the age of 13, the physical differentiation of the sexes, except for the anatomical peculiarities of the genital organs, is in our climates a trifling one. But at puberty the important changes occur by which the sexes are so strikingly differentiated. Whereas in the growing boy all physical change takes the form of increasing strength and energy, in the development of the girl, we note the appearances of the rounded outlines so characteristic of womanhood. At the same time the voice alters, becoming less sharp, with a softer quality, and yet a fuller tone; and we may observe that young brunettes have commonly a contralto voice, young blondes, more often a soprano. The intellectual changes undergone by the girl at puberty are no less extensive and characteristic than the physical changes. In brief, the undifferentiated, neuter girl is transformed into a young woman, endowed with all the attributes, mental and bodily, characteristic of femininity.

As regards the age at which the menarche usually occurs, and the manner in which its occurrence is anticipated or retarded by the various influences already mentioned, the following propositions may be put forward, based on the available statistics and observations:

1. Climate is an important factor. In the torrid zone, menstruation appears at a very early age, on the average from 11 to 14; in the temperate zone, it appears later, on the average from the age of 13 to 16; in the frigid zone, later still, on the average from the age of 15 to 18. The mean temperature of the atmosphere appears to have a direct influence on the age at which menstruation begins, the hotter the climate, the earlier being the menarche. The height of the place of residence above the sea level and its distance from the coast also have a certain influence.

382. Race and constitution have a distinct influence upon the age at which menstruation makes its appearance. In women of the Semitic races the menarche occurs earlier than in women of the Aryan races. The average age at which menstruation begins is in Jewish girls, from 14 to 15; in Magyar girls from 15 to 16; in German girls from 16 to 16½; and in Slavonic girls from 16 to 17.

In general the menarche is earlier in girls of a sanguine, lively temperament and a powerful constitution than in girls of a phlegmatic temperament and a weakly constitution; further, other things being equal, menstruation appears earlier in brunettes, girls with black hair, thick skin, dark eyes, and a dark complexion, than it appears in blondes, girls with light hair, thin skin, blue eyes, and a fair complexion.

3. The age at which menstruation begins is also affected by the conditions of life and the social circumstances. In the higher circles of society, in the upper, well-to-do classes, menstruation appears earlier than among women of the laboring classes, who are compelled to strive for their daily bread. Amongst upper-class girls the menarche occurs at the age of 14 in one-fourth of their number, whereas among lower-class girls barely one-sixth begin to menstruate at the age of 14.

In large towns, again, menstruation appears earlier than in small towns, whilst in the open country the menarche is still further delayed. In the women of Paris the average age at the menarche is 14 years and 6 months, in the women of smaller French towns it is 14 years and 9 months, in French countrywomen it is 14 years and 10 months.

How far the mode of nutrition is concerned in the production of these results is not yet determined.

4. The time of the menarche appears to be influenced by inheritance to this extent, that the daughters of women who began to menstruate early begin themselves to menstruate at an early age, whereas in other families we observe that both mothers and daughters began to menstruate late. But this relation is by no means a constant one.

Ploss has collected observations made in various countries and towns regarding the age at which menstruation begins, and the mean results of these observations are given below.

The average age at which menstruation began was:

The collective results of the investigations of French authors regarding the average age at which menstruation first appears are given in the following table:

from these observations we obtain an average of 15 years.

from these observations we obtain an average of 16 years and 3 months.

from these observations we obtain an average of 12 years and 7 months.

40In 6,550 cases collected by Krieger menstruation first appeared:

From these figures it appears that in the 6,550 cases under consideration, the age 15 was that at which the first appearance of menstruation was most frequently observed, namely in 1,240 instances, or 18.9 per cent. The age 14 comes next, with 1,193 instances, or 18.2 per cent. The case in this series in which menstruation appeared earliest, namely in the ninth year, was observed by Mayer, the girl being a blonde of average height, good family, and German descent; the case in which menstruation appeared latest, namely in the twenty-ninth year, was that of a woman living in Berlin, who was sickly and chlorotic up to the time of her marriage, and in whom menstruation did not appear until some years after that event.

As regards climatic influences, all the data at our disposal prove that the hotter the climate the earlier the menarche. According to Marc d’Espine the age at puberty varies in an almost geometrical ratio with the mean annual temperature.

The dependence of the menarche upon climatic influences is clearly shown by the statistical data collected from various regions of the world. We append the general compilation of Gebhard dealing with this question.

A. Europe.

For Europe the data furnished by Ploss are grouped by Gebhard in the following manner.

1. Northern Europe.

The average age at which menstruation first appears, according to the older statistics, is in Swedish Lapland 18, in Norway, 16.12. In Copenhagen it is 16.75, in St. Petersburg 14.5.

More recent statistics for Finland are furnished by Engström. 41Among 3,500 women of pure Finnish descent, he found that menstruation began:

Thus, in nearly half of all Finnish women, menstruation begins with the completion of the fourteenth and fifteenth years. The statistics include women of all classes of society.

At the Pirogoff Congress Grusdeff furnished particulars of the first onset of menstruation in Russia among 10,000 women. Menstruation began:

In women of German race living in Russia puberty was earliest, occurring at the average age of 15.16 years; in Finnish women it was latest, occurring at the average age of 16.17 years.

2. Middle Europe.

In Germany, according to the tables of Krieger and L. Mayer, who have recorded 11,500 cases in all, menstruation begins most commonly (in 18.931 per cent. of the cases) at the age of 15; the next most frequent age is 14 (18.213 per cent. of the cases).

For Berlin, in a number of cases collected from the lower classes of society, we find the average age for the first appearance of menstruation to be 16.18 years.

Notwithstanding the more northerly situation of Berlin, the average age at puberty is somewhat less than in Munich, situated 4½ degrees to the southward, for the reason that the retardation dependent upon altitude makes itself manifest in the latter town, which is situate about 500 metres (1,640 feet) higher above the sea level. Whereas in Berlin 18 per cent. of all cases begin to menstruate at the age of 14, and 19 per cent. at the age of 15, in Munich the two 42leading years are 15 with a percentage of 17½, and 16 with a percentage of 18¾.

In Great Britain, according to Krieger, the average age at which menstruation begins is 15 years, 1 month, and 5 days. For Manchester the age given is 15 years, 6 months, and 23 days. In France, according to the calculation of Brierre de Boismont, the most frequent age for the first onset of menstruation is 16. In Paris the average age is 14 years, 6 months, and 14 days. Bohemia, Upper and Lower Austria, and Moravia have an average age of 16 years and 2 to 3 months.

3. Southern Europe.

In Southern Europe the influence of the higher mean temperature manifests itself. The average age at which Spanish girls begin to menstruate is 12. In Northern and Middle Italy the most frequent age is 14; in Southern Italy, 13. In Lyons the average age at which menstruation begins is 14 years, 5 months, and 29 days; in Marseilles and Toulon it is 13 years and 10 months. For Hungary, Doktor gives the statistics of 9,600 cases. In 22⅓ per cent. menstruation began at the age of 15; in 20½ per cent. at the age of 16, and in 10 per cent. at the age of 17. The earliest age among these cases was 8 years; the latest, 33 years. (The latter must no doubt be regarded as pathological.)

B. Asia.

In Palestine puberty most commonly occurs at the age of 13; in Turkey even as early as 10. Rouvier calculated the average of 742 cases observed in Syria to be the age of 12. As regards Persian women, the data vary between the age of 14 for the northern part of the country and the age of 9 or 10 for the southern. According to Joubert’s data in 46.4 per cent. of the indigens of India, menstruation begins at the age of 12 or 13. Similar figures are given for Ceylon and for Siam. In Japan menstruation most frequently begins at the age of 14, sometimes as early as 13; mothers of 15 are by no means rarities in this country, but for menstruation to begin before the age of 12 is considered a very exceptional occurrence. According to a table dealing with 584 women of Tokio menstruation began:

The data available regarding China are so exceedingly variable that little importance can be attached to them.

The average age at which menstruation begins in the negro women of Africa is from 10 to 13. In Algeria puberty occurs at 9 or 10 years. Among the Australian indigens, menstruation commonly begins as early as 8 years, and at the very latest at the age of 12 years. The data available concerning the indigens of the Oceanic Archipelago are extremely variable and inexact, but we cannot go far astray in stating the age of puberty among these to be from 10 to 13. In tropical South America girls begin to menstruate from the age of 9 to 14 years. The Indian women of North America begin to menstruate at the ages of 12, 13, 14, or even as late as 18 or 20. In the Arctic zone of North America and in Greenland the onset of menstruation is delayed till 17 and even till 23 years.

As regards the position in life and the upbringing years it has been shown by numerous observers that among the well-to-do classes, whose mode of living is luxurious, and whose social circumstances allow free play to the imagination, menstruation begins at an earlier age than among the working classes, whose life is one of want and privation. According to the statistical data of Mayer’s regarding 6,000 women, menstruation began:

From this table we learn that in nearly one-fourth of the girls of the upper classes puberty occurs at the age of 14, whilst in girls of the lower classes barely one-sixth begin to menstruate at this age. The average age at the first menstruation in girls belonging to the upper classes is seen to be 14.69 years, but in girls belonging to the lower classes, 16.00 years. According to other observers the average age at the first menstruation is:

Comparative observations on women living in towns and women 44living in the country show also that in the former, menstruation begins on the average at an earlier age. According to Brierre de Boismont, the average age at the first menstruation is:

Similarly it was found by Ravn that menstruation first occurred:

Mayer states that the average age at which the first menstruation occurs is:

In Italy, according to Calderini, in a thousand instances, menstruation begins at the age of 14 in 280, at the age of 15 in 219, at the age of 13 in 205, at the age of 12 in 116, at the age of 16 in 89, at the age of 17 in 55, at the age of 18 in 14, at the age of 11 in 7, at the age of 10 in 6, and at the age of 20 in 6 instances. In girls attending town schools, the first menstruation most commonly occurs in the months of June and August; but in girls attending country schools most commonly in the spring months.

A certain hereditary predisposition is so far determinant in the matter of the early or late onset of the first menstruation, that from a knowledge of the age at which menstruation began in the mother, we are able with great probability to predict the age at which it will begin in the daughter. Among fifty cases which I investigated with this point in view, I found forty-one in which the daughters of mothers who had begun to menstruate early began themselves to menstruate early, usually indeed in about the same year of life; or conversely that when the mother had begun to menstruate late, late onset of menstruation was usually to be observed in the daughter also. Tilt relates a case in which a woman began to menstruate at the age of fourteen, and her daughter and granddaughter both began to menstruate at the same age. Courty observed a mother who began to menstruate at the age of eleven, and whose eight daughters all began to menstruate at the same age.

Gynecologists agree in stating that girls of sanguine temperament and powerful constitution begin to menstruate earlier than weakly and phlegmatic individuals. Tilt describes a peculiar ovarian temperament, in which menstruation begins early; such women have as a rule striking nervous sensibilities, with a dark complexion and glistening, longing eyes, always surrounded by dark rings.

45The opinion is general that in girls with black hair, dark eyes, thick skin, and dark complexion, menstruation begins earlier than in blondes with blue eyes and delicate white skin. Brierre de Boismont states in this connection that not fair hair only, but also chestnut-tinted locks, indicate a late onset of menstruation. L. Mayer found that:

According to the same author, the average age at which menstruation begins is:

As regards race, it is well known that in Jewesses menstruation begins at an early age. According to Joachim the age of puberty varies very greatly among the different races inhabiting Hungary. The first menstruation appears:

First Appearance of Menstruation.

The first appearance of menstruation is commonly preceded by various symptoms dependent on the increased flow of blood to the genital organs. Such symptoms are: Sacrache; dragging sensation in the loins; an indefinite feeling of pressure in the lower part of the belly, especially in the region of the uterus and the ovaries, which region is sometimes also tender on pressure; a slight feeling of weariness in the lower extremities; sudden flushings or pallors; alternating sensations of heat and chilliness, sometimes accompanied by actual though slight change of temperature. In many cases also there are disturbances in the intestinal evacuations and urinary secretion, in the process of cutaneous transpiration, and in the functional activity of the gastro-intestinal canal. A frequently observed symptom is an increased irritability of the entire nervous system, with an inclination to melancholy and indefinite amorous desires—symptoms which Tilt denotes by the term “ovarianismus,” Emmet by the term “erection,” Lecal by the term “phlogose amoureuse,” and the older writers by the term “molimina menstrualia.”

The nervous irritability manifests itself already before the appearance of the menstrual flow by headache and moodiness, weariness, 46nervous irritability, and low spirits; further, by slight changes in the facial aspect, dark rings round the eyes, spontaneous blushing, uneasy sensations, epigastric pain, loss of appetite, a sensation of pressure in the abdomen, palpitation, vertigo, dragging sensations passing from the loins to the thighs, feeling of weakness and numbness in the lower extremities—symptoms which often endure for several months and in such cases tend to lower the resisting powers of the organism.

Courty enumerates as prodromal symptoms which are observed in the majority of girls before the first appearance of menstruation: swelling and tenderness of the breasts, sensation of fulness and weight in the hypogastric region, moderate intestinal meteorism, sacrache, aqueo-mucous vaginal discharge, finally, an itching sensation in the genital organs. These manifestations may also assume a morbid character, taking the form of violent abdominal and lumbo-sacral pain, general fatigue and weakness, dyspepsia and diarrhœa, cephalalgia, various kinds of neuralgia, some degree of moral aberration. After the first menstruation, two or three months may elapse before the girl menstruates again, but after the lapse of a year the flow usually recurs at quite regular periods. Sometimes the early periods are very violent and recur very frequently, every twenty days, for instance.

The greatest increase in size and weight occurs in the female sex at the time of the menarche. Amongst the poorer classes the greatest development in size and strength occurs between the ages of 13 and 15 years, whereas in the upper classes of society, those who ultimately attain the same weight exhibit their greatest growth at the ages of 12, 13, and 14 years. According to Pagliani the greatest growth in the female sex always precedes puberty, so that for example a girl who begins to menstruate at the age of 12 will grow most rapidly in the year preceding this, whereas a girl who begins to menstruate at a more advanced age will not undergo her most rapid phase of growth so early as the age of 11. According to the observations of Bowditch, A. Hey, Lombroso, Pagliani, and Ploss, up to the age of 11 or 12 years the growth of girls exceeds that of boys, but whereas in girls growth ceases suddenly at the age of 14, in boys growth proceeds regularly up to the age of 16 years. At birth boys are on the average 1 cm. (⅖″) longer than girls; but during puberty the female sex catches up the male in height, or even surpasses it. According to Ploss, a girl of 16 or 17 years is as tall as a young man of 18 or 19 years.

The earlier development of the female as compared with the male at the time of puberty is a constant phenomenon, to be observed in all races, in every climate, and in all strata of society. 47According to the statistical data published by the authors just quoted, the age of greatest development in the respective sexes is:

Puberty occurs in the female on the average about two years earlier than in the male, and upon this difference the observed differences in growth also depend.

The menarche in the wider signification of the term includes the development which occurs at the time of puberty, and continues through a period of several months, and even years, before complete sexual maturity is attained; and includes also the time, which may be considerable, following the first appearance of the menses and before the regular rhythm of the menstrual function is established and the full development of the female genital organs is attained. This time, which forms a notable phase of the sexual life of woman, is characterized by great changes in the genital organs and in the vital processes connected therewith, by a strong tendency to suffer from a series of very various pathological changes and disorders of function in the principal organs, and a lessened general resisting power to disease—a change which finds its most definite expression in the well-established fact that in this period of life the mortality among females is much greater than among males of corresponding age. According to the statistical data of Quetelet and Smits, from the age of 14 to the age of 18 (the period of the menarche) there are 128 deaths of females for every 100 deaths of males; and even in the four succeeding years, from the age of 18 to the age of 22, the unfavorable conditions peculiar to sex are witnessed by 105 deaths of females to every 100 deaths of males.

Many authors draw a distinction between the age of puberty (from the Latin pubes, puberis), when the growth of the pubic hair occurs as an external sign of sexual development, and the age of nubility (from the Latin nubere), when the individual becomes fitted for marriage. The distinction is a partial one only, inasmuch as capacity for copulation is attained already at puberty. The law, however, maintains such a distinction, the Austrian Penal Code, for example, regarding intercourse with a female less than fourteen years old as rape, and the German Code likewise punishing carnal knowledge of a girl under fourteen.

The signs of puberty in girls were noticed and explained in very early times. From the anthropological studies of Ploss and Bartels we take the following data regarding this matter. In the Bible we read (Ezekiel, xvi, 7): “Thy breasts are fashioned and thine hair 48is grown, whereas thou wast naked and bare.” The early Indian physician, Susruta, refers only to the regular recurrence of menstruation as a sign of puberty. That a woman is menstruating may be known by the fact that her face is swollen and bright. In the Roman Empire Justinian ordained that all young women should be examined as to the growth or absence of the pubic hair in order to ascertain if they were ripe for marriage. The early Chinese physicians recorded that in every woman at the age of fourteen or fifteen years a monthly flow of blood from the genital organs began, the period of recurrence being thirty days. The physicians of the Talmud express themselves variously regarding puberty in women. In one place they advance as a sign of puberty the growth of the hair on the genital organs; in another they speak of the notable enlargement of the breasts, and mention as a sign of more complete sexual development that the nipples become elastic. Other Talmudists refer to the appearance of a dark brown coloration in the areola and to the enlargement of the mons Veneris as signs of puberty. Savage races regard the first appearance of the menstrual flow as the only certain sign of puberty, and among many such races this is the occasion of peculiar ceremonial rites. The attainment of puberty in savage tribes is often solemnized by the seclusion of the girls from the time of the first menstruation; they fast during the period of seclusion, which sometimes terminates in an elaborate ritual of purification.

For two reasons in particular, the period of the menarche is a time of storm and stress to women, first on account of the developmental processes in the genital organs, and secondly on account of the intellectual changes that occur at this period.

The local cause is to be found in the extensive transformation of the ovaries and the uterus, by means of which a peculiar and powerful stimulus, the menstrual stimulus, is elaborated, which has a reflex influence upon heart and brain, vascular and nervous systems, and secretory and nutritive processes. Since we know that in every premenstrual period by the growth of the follicles hyperæmia is excited in the ovary, by means of which the liquor folliculi is increased in amount, we can well understand that at the time of the menarche the ripening of the graafian follicles is accompanied by a considerable degree of hyperæmia of the ovaries and of the whole of the genital organs, now undergoing their fullest development, and we can easily see how this hyperæmia may result in manifold reflex disturbances. But in addition to these reflex disturbances, we have once more to take into consideration the as yet imperfectly known chemical processes which are associated with the ripening and development of the graafian follicles, and an abnormal course of 49which may give rise to a disordered constitution of the blood, manifesting itself as chlorosis or in other ways. In connection with the growth and ripening of the ova, extensive and novel demands are made on the organism, and these may well endanger metabolic processes which are not established on a very secure foundation.

The other cause is to be found in the intellectual processes which occur at this time in the youthfully receptive, highly sensitive organ of mind, the brain. The girl growing into womanhood, who with astonishment and stress has witnessed the visible changes in her body, the outward signs of puberty, as they gradually make their appearance, receives powerful psychical stimulation which cannot fail to exercise an influence upon the entire nervous system and its complex interlacements, alike in the sensory and in the motor sphere.

The degree to which these influences radiating from the genital organs make themselves manifest is chiefly dependent upon the resisting power of the nervous system as a whole, upon the temperament, the inherited constitution, and the mode of education of the young girl. In children belonging to families noted for sensibility and irritability, in dwellers in large cities who have attended high schools for girls and have at an early age lifted the veil that covers the sexual processes, the reflex disturbances of the menarche will be more manifold and will manifest themselves with greater intensity than in children brought up in country districts, whose sensibilities are chiefly physical and whose mind is less susceptible to the influence of external stimuli.

A further important consideration is the time at which the menarche occurs, and whether on the one hand it is at or near the average age, or whether on the other, as precocious menstruation, it is unusually early, anticipating the general bodily development, or again as retarded menstruation it is unduly delayed. In some cases of retarded menstruation, the external genital organs are thoroughly well developed, and it is menstruation only that remains in abeyance; but in other cases the external genitals are also backward in development, the pubes and mons Veneris being but sparsely supplied with hair, and the breasts remaining very small.

In addition to these abnormal temporal relations of the menarche, certain other irregularities at the commencement of menstruation are worthy of note. Thus, the first menstruation may be normal, but thereafter amenorrhœa may persist for several months, or if the flow occurs it may be exceedingly scanty, or very pale in color; on the other hand, menstruation may be very profuse, lasting many days.

50The environment in which the young girl is placed during the period of her sexual development has a great influence on the processes of the sexual life and on the pathological disturbances that affect these processes.

In working-class families the immoderate physical strain often thrown upon girls, in many cases continuous movements of the upper extremities whilst the lower extremities and the pelvis are absolutely quiescent, or conversely, an excessive employment of the muscles of the lower extremities—these circumstances in conjunction with insufficient nutriment, night-work, association when at work with persons of the opposite sex, and the frequent premature sexual stimulation, will combine to have a most deleterious effect.

Amongst country-folk, indeed, the girl has the enjoyment of fresh air, and as a rule nutritive food, moreover, there are not so many occasions of nervous stimulation; puberty therefore arrives more slowly and gives rise to less disturbance; but the ignorance of the girls very frequently leads to an early experience of coition, the natural and unnatural consequences of which have then to be taken into account.

Amongst the better classes of townspeople such hygienic regulations and educational measures are in common employment that young girls during the years of development usually receive reasonable care and attention—but very frequently, intercourse with older girls, association with young men, visits to theatres, evening-parties, and balls, and the perusal of stimulating literature, form unfavorable features of urban life which exercise their inevitable effects in the sexual sphere. In some cases, fortunately sufficiently rare, the stimulation of the sexual impulse and the longing for its satisfaction are so intense, that a kind of demi-vierge is brought into being, a young woman who is concerned only to preserve the physical token of virginity, but whose thoughts and fancies are anything but maidenly. It is to be feared that in consequence of the excessive freedom in education and the emancipated independence of feminine youth, these “half-virgins” are increasing both in number and in intensity, a fact which cannot fail to increase also the number of sexual maladies and perversions.

Anatomical Changes in the Female Genital Organs in the Period of the Menarche.

The female reproductive organs, which in childhood were in a comparatively quiescent state, now become powerfully active, as is witnessed by the changes that occur in the external genitals.

51The soft, hairless vulva of the child becomes enlarged at the time of the menarche by the deposit of fat, and its substance becomes tough and elastic. Some time before puberty, fine, pale hairs make their appearance here and there, but not until puberty does the hairy covering of the pubic region become more or less thick. The growth of the denser pubic hair begins with the appearance of hairs along the middle of the mons Veneris and at the margins of the labia majora. Early sexual development is commonly indicated by an early and thick growth of the pubic hair. In the virgin this hair is smoother and less curly than in the later course of the sexual life. In certain tribes of negroes it is the custom for the young unmarried girls to shave off the pubic hair, which is not allowed to grow freely until after marriage. In some of the tribes of South Sea Islanders it is customary at puberty to tattoo the external genitals and the surrounding skin.

Fig. 8.—Internal genital organs of a new-born, powerfully developed female infant. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

In young virgins the rima urogenitalis or vulval cleft is closed by the accurate opposition of the labia majora; the labia minora or nymphæ are delicate in texture, rose-red in color, hairless, free from fat, and completely covered by the labia majora; whilst the clitoris is likewise concealed. The sebaceous glands of the labia minora secrete a smegma which collects especially around the glans clitoridis, and as it undergoes decomposition diffuses a peculiar odor, resembling that of old cheese. A wing-like elongation of the labia minora in young girls, with free secretion and a generally moist appearance, leads to a suspicion of the practice of 52masturbation. In the virgin the orifice of the vagina is covered by the hymen.

Fig. 9.—Reproductive organs of a new-born, powerfully developed female infant in median sagittal section. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

Fig. 10.—Internal genital organs of a girl aged eight years. Seen from behind. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

The entrance to the vagina in the virgin is rounded, the posterior border of the aperture being deeply concave, whilst the anterior border is often slightly convex backwards. Where this feature is 53strongly marked, the orifice has a semilunar shape. The posterior concave border projects forward in the form of a fold, continuous above with the posterior vaginal wall; this fold is the hymen.

Fig. 11.—Reproductive organs of a girl aged ten years in median sagittal section. Left half. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

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Fig. 12.—Female external genital organs of a virgin, attached to the vagina which has been isolated and opened, and a portion of the cervix uteri, Hymen, etc. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

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Fig. 13.—The external genital organs of a virgin, drawn apart transversely (after von Preuschen). c. Clitoris. f. c. Frænum of the clitoris. n. Nymphæ. l. Labia majora. o. u. Urethral orifice. h. Hymen. f. n. Fossa navicularis.

56The infantile uterus is so proportioned that its neck (collum vel cervix uteri) constitutes the larger part of the organ, as much indeed as two-thirds. Owing to the small size of the body (corpus uteri), the whole uterus is very flat, and its borders ascend in a direction almost parallel to each other, diverging somewhat abruptly into the Fallopian tubes, recalling in some degree the two-horned embryonic form of the organ (uterus bicornis). The plicæ palmatæ on the surface of the cervical canal, which make up the arbor vitæ uterina, are strongly developed; the median longitudinal ridge bifurcates, and its divisions can be traced on either side into the uterine orifice of the Fallopian tube (ostium uterinum tubæ). The lips of the vaginal portion of the cervix are comparatively speaking very large and terminate in sharp angles. The vaginal mucous membrane is everywhere beset with long papillæ. The development of the uterus shortly before puberty consists chiefly in the enlargement of the body of the uterus, and the growth of its walls in thickness.

Fig. 14.—Sagittal section of the female pelvis (after Breiolei).

At the time of puberty, according to Toldt, the body of the uterus in the virgin has already increased till its length is half that of the entire organ; and at the first appearance of menstruation the body and neck of the virgin uterus are nearly equal, with perhaps a slight preponderance in size of the cervix, and the walls of the uterus have become convex. In consequence of this change the organ becomes pear-shaped, and the uterine cavity (cavum uteri) assumes the form of a triangle with moderately incurved sides. The cervical canal becomes wider in the middle; the margin of the os uteri becomes smooth and rounded. The walls of the virgin vagina 57are marked with numerous dentate transverse ridges (rugæ), especially near the lower end and on the anterior walls, the columns of the vagina (columnæ rugarum), from which the transverse ridges run to either side at right angles, extend half way up the vagina, and are of a hard consistence.

The characteristic changes in the ovary at the time of the menarche originate in the changes undergone by the ovarian follicles. A large number of small separate follicles is to be found already in the ovary of the new-born infant. These structures, known as primitive follicles, are formed by detachment from the egg-tubes that grow down into the stroma from the superficial germinal epithelium; they are spheroidal vesicles, enveloped by a single layer of cubical cells, and their interior is entirely filled by the primitive ovum or egg-cell. This latter consists of very finely granulated protoplasm with spherical nucleus and distinct nucleolus, but no trace of an investing membrane can as yet be discerned. The further development of the ovarian follicles takes according to Toldt the following course: A rapid multiplication of the cubical cells that form the wall of the follicle occurs, so that the ovum is surrounded by two, three, or several layers of cubical or rounded cells, and the whole follicle gradually increases in size. At the same time the ovum assumes an eccentric position in the interior of the follicle. At or near the middle of the follicle a slit-shaped space now appears, filled with a clear colorless fluid. As this space gradually enlarges, the follicle^[19] becomes converted into a vesicle filled with fluid, the wall of which is composed of small cubical cells. Simultaneously with the growth of the follicle a lamination of the elements of the surrounding stroma takes place, so that a somewhat sharply defined capsule is formed. In this condition these glandular structures of the ovary are known as graafian follicles.^[19]

Before puberty, these graafian follicles are small vesicles of a diameter of one to two millimetres, containing the large unicellular ova. Each of these consists of an envelope, the zona pellucida (also known as the zona radiata, or striated membrane of the ovum); an external granular mass of protoplasm, the vitellus or yolk; a vesicular, spherical nucleus, the germinal vesicle; and a nucleolus, which if single is large and prominent, the macula germinativa or germinal spot. As early as the second year of infancy every imaginable intermediate stage between the primitive follicle and the fully-developed vesicular graafian follicle can be observed.

58At the time of puberty certain larger follicles are always to be distinguished, which have moved inward toward the interior layers of the ovary, whereas the smaller follicles have a more peripheral situation; thus, according to Waldeyer, we observe at this time in a section of the ovary, proceeding from without inward, first the epithelium, next the fibrous tunic, next the zone of younger follicles, and finally the zone of older follicles. According to Henle and Waldeyer, at the commencement of puberty, there are in each ovary about 36,000 ova, giving a total for the two of 72,000.

Fig. 15.—Primitive follicles.

In the further course of development of the graafian follicles at this period, the most advanced now reapproach the surface of the ovary, so that a fully-matured follicle comes to occupy almost the entire thickness of the cortical substance, and may even give rise to a localized bulging of the surface of the organ. In such a mature follicle, which has attained nearly the size of a pea, we recognize an outermost connective-tissue investment (theca folliculi), consisting 59of condensed ovarian stroma, in which two layers are distinguished, sometimes called simply outer tunic and inner tunic, sometimes known by the names of tunica fibrosa (outer) and tunica propria (inner), respectively; within this is the cellular layer known as the membrana granulosa (or stratum granulosum), the portion of which, now greatly enlarged, immediately surrounding the ovum is known as the discus proligerus (or cumulus oöphorus); the interspace between the discus proligerus and the membrana granulosa is filled with a clear fluid, the liquor folliculi. In consequence of the continued increase in its fluid contents, the graafian follicle ultimately bursts along the most prominent portion of the superficial wall, and the ovum passes out through the rupture, finding its way under normal conditions into the Fallopian tube and through this into the uterus. The follicle itself then undergoes a regressive metamorphosis, forming the corpus luteum, the rent in the envelope of which, after the absorption of the yellowish semi-fluid contents, undergoes cicatrization. Contemporaneously with this development at puberty of the process of ovulation, menstruation also for the first time makes its appearance, recurring thenceforward at four-weekly intervals as the regular catamenial discharge.

We append the account given by Pfannenstiel regarding the ovarian follicles. He writes: “In correspondence with the especial function of the female reproductive gland, which is to bring to maturity and to evacuate only after the lapse of a considerable period and at successive intervals, the ova which it has contained from the very outset, we find that primitive follicles continue to exist in the ovary up to the very end of the period of sexual activity, though naturally in diminishing numbers; and the size and shape of these primitive follicles remain nearly identical throughout the various periods of life. As the follicle ripens, the epithelium grows, the cells becoming cubical with a rounded nucleus, and increasing in number by cell-division, so that several layers are formed. As soon as these layers are three or four in number, a space, at first slit-shaped, forms in the epithelium on the peripheral surface of the ovum; this space is filled with fluid, known as the liquor folliculi; the peripheral layer of cells, the membrana granulosa, is thus separated from the mass of epithelial cells immediately enveloping the ovum, the discus proligerus, which is situate in the side of the follicle adjacent to the hilum of the ovary. By the increase of the liquor folliculi the graafian follicle is formed, a vesicle the envelope of which is formed by the multilaminar membrana granulosa, whilst in the pole of the vesicle directed toward the hilum ovarii is the ovum imbedded in the mass of cells forming the discus proligerus, a mass which has the form of a truncated cone. The liquor folliculi is formed by 60the epithelium, the nuclei of which disappear by chromatolysis or by simple atrophy whilst the cell-bodies liquefy in consequence of albuminous, not fatty, degeneration (Schottländer). Within the epithelium of the follicle we find the faintly glistening epithelial vacuoles of Fleming, likewise cells which liquefy and assist in increasing the bulk of the liquor folliculi. This liquor is a thin, serous fluid, and contains albumin. * * * Every graafian follicle has a bilaminar investing membrane, which is formed by the ovarian stroma. * * * The ovum of the growing follicle increases in size very slowly indeed, attaining on the average, according to Nagel, a diameter of 165 to 170 µ, it retains its zona pellucida, the greater part of the protoplasm of the cell is transformed into deutoplasm (food-yolk, or yolk-granules), the nucleus assumes an eccentric position. Between the zona pellucida and the cell-body a narrow perivitelline space appears. The ovum is then full-grown, but not yet fully prepared for fertilization; for this, maturation is required, certain changes in the germinal vesicle, which occur after the bursting of the follicle. * * * As a rule each follicle contains a single ovum. But two and even three ova have beyond doubt been observed in one follicle.”

According to Waldeyer, the bursting of the follicle is not to be regarded as dependent upon a sudden rise of pressure in its interior, but as the result of a gradual ripening process. At the deepest pole of the follicle, which in the course of its development has now approached the surface of the ovary, an exuberant growth takes place in the internal layer (tunica propria) of the theca folliculi, with a profuse formation of new vessels. Here numerous “epithelioid” cells, the “lutein-cells,” make their appearance. In consequence of this proliferation of the lutein-cells, the contents of the follicle are gradually pressed toward the “stigma,” the superficial pole of the follicle, and the follicle itself is pushed toward the surface until it finally comes into contact with the germinal epithelium. Meanwhile the follicular epithelium undergoes fatty degeneration, alike in the membrana granulosa and in the discus proligerus. In consequence of the proliferation of the lutein-cells, on the one hand, and the fatty degeneration of the epithelium, on the other, the follicle opens at its weakest point, the stigma, and the ovum is extruded, with the liquor folliculi, and a number of cells belonging to the follicular epithelium. (To illustrate these changes we have borrowed Figs. 15, 16, and 17 from the monograph, by Pfannenstiel on Diseases of the Ovary, in J. Veits’ Handbook of Gynecology.)

The ovaries, which in the new-born female infant are flattened, ribbon-like bodies one-half to one centimeter (0.2 to 0.4″) in length, and in childhood are cylindrical, with a perfectly smooth surface, 61assume at the time of puberty a more or less flattened form. During the menarche they have an elongated oval shape, flattened from side to side, their average length being 2.5 to 5.0 centimetres (1 to 2″), width 1.5 to 3.0 centimetres (0.59 to 1.18″), thickness 0.6 to 1.4 centimetres (0.24 to 0.55″), weight 5 to 8 grammes (77 to 123 grains). After the repeated occurrence of ovulation, the surface of the ovary becomes more and more uneven, being thickly covered with fossæ or scar-like fissures.

Fig. 16.—Ripening follicles.

The vagina during virgin girlhood is narrow, and its mucous surface is beset with numerous rugæ, which may be plainly felt as well as seen. The calibre of the vagina is proportionately less the younger the girl. The examining finger is gripped by the vaginal wall as by an india-rubber tube (Maschka). The vaginal portion of the cervix is felt in the form of a truncated cone, with a smooth surface, rather dense in consistence; the external os opens at the bottom of a small depression on its surface, in the form of a short oval, the long axis of which is transversely directed. Shortly before the menarche, Bartholin’s glands become noticeable on either side of the lower end of the vagina between the sphincter muscles.

The clitoris in many cases attains a very large size, and this is apt to lead to sexual malpractices. According to Hyrtl, in southern countries the clitoris is larger than in temperate and cold climates. In the women of Abyssinia and among the Mandingoes and the Ibboes, the size is portentous, and amongst the first-named, circumcision of females is a customary operation. It is said that female slaves belonging to these races are greatly esteemed by the 62ladies of the harem, and are eagerly sought for. In the anatomicopathological museum at Prague there is a preparation of the female genital organs with a clitoris as large as the penis of a full-grown man.

Fig. 17.—Graafian follicles.

Sonini describes “as peculiar to women of Egyptian or Koptic descent, the presence of a thick, fleshy, but soft and pendent outgrowth in the pubic region, completely covered with hair,” which he compares to the hanging caruncle on the bill of the male turkey. This appendage becomes thicker and longer with advancing years. Sonini found such an appendage one-half inch in length in a girl of eight years, one of more than four inches in a woman of twenty to twenty-five years. Circumcision in girls consists in the removal of this outgrowth, which hinders copulation; in that part of the world the operation is usually effected in the seventh or eighth year, just before puberty.

The circumcision of girls as practiced by Mahommedan peoples in Africa is said by Ploss and Bartels to consist in abscission of the labia minora, the clitoris, and the præputium clitoridis. Brehm is of opinion that the object of the operation is to diminish the intensity of the sexual impulse, so overpowering among these races; but others believe that the great enlargement of the clitoris and the 63labia minora usual in those countries is regarded as a serious defect in beauty, a defect removed by the operation; whilst others again hold that the circumcision is required for the removal of the hindrance to copulation presented by the abnormally large clitoris. Closely related to the operation of circumcision in females, according to Ploss and Bartels, is the custom peculiar to Africa of infibulation, wherein, after a preliminary cutting operation like that for circumcision, the fresh wound surfaces are brought into accurate opposition, either by sutures or by appropriate bandages, so that when cicatrization occurs the vulval cleft is closed except for a very small aperture. The object of infibulation is to enforce on girls complete abstinence from sexual intercourse. (Before marriage, the vulval cleft is reopened to an extent corresponding with the size of the genital organs of the future husband; and when pregnancy occurs, the opening is still further enlarged before parturition; but after that event, the wound surfaces are refreshed, and the whole opening is once more closed). On the other hand, in many savage tribes, elongation of the labia minora and the clitoris is artificially undertaken from the earliest years of girlhood, this elongation being regarded as a beauty.

The parts of the external reproductive organs of the female concerned in sexual sensation, first described as such by Kobelt, are already fully developed at the time of the menarche. Of these parts a small portion only, the glans clitoridis, is visible externally, surrounded by the præputium clitoridis, a prolongation of the labia minora, which passes round the front of the clitoris, and sends from each side a fine process behind the glans to become attached to its under surface, forming the frænum of the clitoris. The erectile apparatus of the external genitals is formed by the corpora cavernosa clitoridis. As two delicately constructed trabecular masses of erectile tissue, the crura of the clitoris, these are attached on either side to the inferior or descending rami of the pubic bones; at first passing upwards parallel to the bones, they subsequently curve downward as they converge and unite to form the body of the clitoris; these masses of erectile tissue embrace the sides and the front of the lower extremity of the vagina. This erectile apparatus, when the supply of arterial blood is greatly accelerated and at the same time the outflow of venous blood is diminished, becomes distended with blood, enlarged and stiffened; the process of erection plays an important part, as we shall explain more fully later, in the production of sexual excitement and sexual pleasure during the act of copulation.

In the virgin and in the earlier phases of the sexual life, the hymen is so characteristic an organ that its more minute description would seem desirable.

64The hymen, a fold of mucous membrane, springing from the periphery of the vaginal orifice, separates as a perforated diaphragm the vagina from the vulva. Between the two epithelial layers of which, as a fold of mucous membrane, the hymen consists, is a supporting layer of connective tissue of variable strength; in other respects the mucous membrane of the hymen has the same structure as the mucous membrane of the vagina. On its inner surface the rugæ and folds of the vaginal mucous membrane are prolonged. The shape of the hymen is very variable; most commonly its aperture is more or less central, so that the hymen has a ringed or semilunar shape.

Fig. 18.—Annular Hymen.

Fig. 19.—Annular Hymen.

In the new-born female infant, the hymen has the appearance of a tubular stopper closing the lower end of the vagina; according to Dohrn it exhibits as a rule one of three typical forms: Hymen annularis, denticulatus, et linguiformis; the annular, the denticulate, and the linguiform (or linguliform) hymen. The transverse ridges on the inner surface of the hymen, prolongations of the rugose columns of the vagina, are strongly developed. During the girl’s further growth, in association with the enlargement of the vagina, the hymen undergoes important changes in form and structure. Its border becomes thinner and more tense; and in the virgin at the time of the menarche, the annular hymen is the fundamental type, subject, however, to extensive variations. In most cases, at any rate, the aperture in the hymen is more or less centrally situated; very commonly, however, this opening is crescentic, when we have a 65semilunar hymen, the height of the border posteriorly being much greater than anteriorly. The consistency of the hymen, its extensibility, and its thickness, are as variable as its shape.

Fig. 20.—Semilunar Hymen.

Fig. 21.—Annular Hymen with congenital Symmetrical Indentations.

Fig. 22.—Fimbriate Hymen.

Fig. 23.—Deflorated Fimbriate Hymen.

In the normal position of the reproductive organs the hymen has very rarely the appearance of a tense membrane; as a rule it 66is folded up, and becomes plainly manifest only when the genital organs are stretched. The margin of the hymeneal aperture, as a close examination shows, is sometimes sharp and regular, sometimes lobulated, with small congenital notches. These congenital notches are to be distinguished from the lacerations resulting from defloration by the fact that the former have a smooth border, which is of the same consistency as the general substance of the hymen. In some instances the border of the aperture in the hymen is beset with small, fine villi (villous hymen).

The common varieties of the hymen are thus classified by Maschka:

1. The annular hymen, in which the membrane when stretched is seen to have a rounded aperture, which may be central or eccentric; very often, indeed, the aperture is more toward the upper half of the hymen, in which case it is not always circular, but frequently rather ovoid in shape.

2. The semilunar or crescentic hymen, in which the aperture is eccentrically placed in the upper half of the membrane, in such a manner that the hymen exhibits a wide surface below the aperture, which surface narrows at either side as it passes upwards until it disappears, the two sides failing to reunite above the aperture.

3. The heart-shaped or cordiform hymen, the general shape of which may be circular, ovoid, or even semilunar, but in which from the middle of the upper or lower margin a three-cornered tongue projects across the aperture, which is thus given the form of the conventional heart of a pack of cards.

4. The infundibuliform hymen has the form of a small projecting funnel resembling in appearance the invaginated end of the finger of a glove.

Maschka refers also to the rare condition in which the hymen is sometimes said to be absent. As a matter of fact, however, in such cases, it is represented by a very narrow annular eminence, the genitals being in other respects normal. The smooth character of the eminence will serve to differentiate it from the remains of a destroyed hymen. Other rare forms are:

1. The imperforate hymen, an occlusive membrane, entirely blocking the vaginal orifice. In some cases, however, the hymen is not absolutely imperforate, a very small, punctiform aperture being present.

2. The cribriform hymen, a hymen which is “imperforate” in the sense that there is no opening of a size approaching the normal, but in which several minute apertures are present.

3. The septate, bridged or divided hymen (hymen bifenestratus, etc.), exhibits a strip of mucous membrane, most commonly running 67directly from before backward, occasionally, however, somewhat obliquely, across the aperture in the membrane, which is thus divided into two equal or unequal parts. In some instances the process that bridges the aperture of the hymen is expanded in the vertical plane to form a septum which projects for some distance into the vagina.

Fig. 24.—Septate Annular Hymen.

Fig. 25.—Septate Semilunar Hymen.

Fig. 26.—Extremely tough Annular Hymen, with an obliquely disposed Septum.

Fig. 27.—Septate Hymen with Apertures of unequal size.

684. The lobate, lobulated, or labiate hymen, which consists of several (two to four) lobes on either side, each overlapping the next like the tiles in a roof, whilst the aperture between the two sides has the form of an antero-posterior slit (Fig. 37); in some cases the lobes of a lobulated hymen are so disposed that the membrane has the appearance of a fold of mucous membrane with a central furrow.

Fig. 28.—Septate Hymen with Apertures of unequal size.

Fig. 29.—Hymen with rudimentary Septum.

Fig. 30.—Hymen with posterior rudimentary Septum.

Fig. 31.—Labiate Hymen with posterior rudimentary Septum.

69It is obvious that an imperforate or cribriform hymen, by the hindrance it offers to the passage of the menstrual discharge, is liable at the time of the menarche, and as soon as menstruation begins, to give rise to serious disorder and to pathological states.

Fig. 32.—Hymen with anterior rudimentary Septum.

Fig. 33.—Hymen with anterior rudimentary Septum projecting in a opiniform Manner.

Fig. 34.—Hymen with anterior and posterior rudimentary Septa.

Fig. 35.—Hymen with filiform process projecting from the anterior margin.

Fig. 36.—Hymen in which there are two symmetrically disposed thinned areas. The left of these is perforated.

The illustrations we append, showing the various forms of the hymen, are taken from von Hoffmann’s Handbook of Medical Jurisprudence. (Figs. 18–45.)

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Fig. 37.—Very unusual form of Hymen.

Fig. 38.—Semilunar Hymen with cicatrized Lacerations in its Border.

Fig. 39.—Deflorated Semilunar Hymen with laterally disposed Symmetrical Lacerations.

Fig. 40.—Deflorated Annular Hymen with several cicatrized Lacerations.

Fig. 41.—A. Septate Hymen in which Defloration has been effected through one of the Apertures. U. Urethra. Cl. Clitoris. H. Cicatrized margin. C. Septum. B. Lateral View of Septum.

In some cases the hymen is exceedingly thin and delicate, so that it is liable to be torn if handled at all roughly; in other cases, on the contrary, it may be very firm, thick, and fleshy, interlaced with strands of connective tissue and muscle, so that it forms a veritable cuirass for the protection of physical virginity.

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Fig. 42.—Deflorated Septate Hymen.

Fig. 43.—Hymen with larger anterior and smaller posterior Apertures.

Fig. 44.—Carunculæ Myrtiformes in a Primipara.

Fig. 45.—Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes. Slight Prolapse of anterior and posterior Vaginal Walls.

As signs of virginity in the female, a knowledge of which is required, not only for the purposes of medical jurisprudence, but 72for various other reasons, we may enumerate the following anatomical characteristics of the genital organs. The labia majora are elastic in consistence and are in close apposition with one another; the labia minora or nymphæ are covered by the labia majora and are but little pigmented; the vestibule and the vaginal orifice are narrow, and the vagina itself is narrow, tense, and markedly rugose; the hymen is normal and uninjured (this, of course, is the most trustworthy of all the signs of virginity); the breasts have the virgin conformation. In opposition to the plea that the hymen can be destroyed by other causes than defloration, as by a fall, especially a fall which brings the external genitals in contact with some hard body, or by diphtheritic, variolous, or syphilitic ulceration, Maschka maintains that such occurrences are among the greatest rarities.

On the other hand it is sufficiently well known that the presence of an uninjured hymen affords no certain assurance of actual virginity. Cases enough are recorded, both in older and more recent medical literature, in which even pregnancy occurred in women in whom the hymen had remained intact, the explanation being that during copulation penetration of the penis had failed to occur, the semen being ejaculated on the vulva. Scanzoni and Zweifel have recorded cases in which the intact hymen offered a hindrance to parturition. The first-named author explains these occurrences by the assumption that the hymen was so stout that the penis was unable to rupture it. Veit remarks that both male and female youth, in these days of the continued advance of knowledge, are well acquainted with coitus sine immissione penis, and that very frequently a woman who is informed that she is pregnant makes answer that this is impossible, her paramour having assured her that pregnancy could not occur. On the other hand, cases are met with in which the aperture in the hymen is a very large one, so large that the penis can penetrate to the vagina without lacerating the membrane.

Broudardel reports a case of rape in which the lacerated hymen healed so completely that an expert maintained the integrity of the membrane, until another pointed out the fine scar.

In general, that we may be assured of the existence of virginity, we must find the hymen uninjured; and, on the other hand, we must regard the laceration of the membrane, unless known to be the result of gynecological examination or other manipulation, as a proof of defloration.

In ancient times among savage races the integrity of the hymen was prized as a proof of virginity, and in the Bible also great stress is laid on this sign in connection with defloration, and its absence was even regarded as a ground for the death punishment (Deut. 73xxii, 21). But amongst other races the hymen was held in no particular esteem as a token of virginity.

Fig. 46.—Mamma, the breast of a virgin aged eighteen years. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

In ancient times, and even at the present day in the Philippine Islands, the Ladrone Islands, and certain other islands of the Polynesian Archipelago, also among many African tribes, the right of defloration belonged, not to the bridegroom, but to every man belonging to the same tribe; sometimes on the bridal night all the men of the tribe had access to the bride, the bridegroom coming last, but thenceforward having undisputed possession of his wife. Amongst certain other tribes a similar custom prevails, differing however in this respect, that the rite of defloration is performed by a priest or by one of the chiefs of the tribe. In mediæval Europe, again, the great landed proprietors exercised the well-known jus primae noctis or droit du seigneur.

In girls at the time of the menarche who have long practiced masturbation, some of the following indications of the habit will 74be found: Elongation, redness, and general enlargement of the clitoris; elongation and thickening of the nymphæ, which are also of a tough consistency and deeply pigmented; flaccidity of the labia majora; redness of the vaginal orifice; flaccidity of the hymen, which also may exhibit lacerations, caused by the forcible introduction of the finger or of some hard foreign body.

Not until the time of the menarche do the breasts attain the hemispherical form which constitutes one of the graces of young womanhood, and at the same time these organs assume a firm, elastic consistency; their size of course varies in different individuals. The nipple now has a rose-red color, darker in brunettes than in blondes; it is usually small, sometimes quite inconspicuous, being withdrawn into a cutaneous furrow. The two breasts when regarded from the front are seen to diverge from the longitudinal axis of the body. In some cases even in childhood, before the time of the menarche, the breasts are powerfully developed, being as large as an apple or larger. This depends on climate, race, and sexual excitement; as regards the last of these, early sexual stimulation promotes premature mammary development.

Although it is unusual for any secretion to appear in the mammary gland before the occurrence of pregnancy, cases have certainly been observed in which the breasts of virgins secreted a milk-like fluid, especially in consequence of sexual excitement or during menstruation. Thus Maschka observed in a girl the condition of whose genital organs showed her to be a virgo intacta that pressure on the breast caused a few drops of an opalescent fluid having the appearance of milk to exude from the nipple. She acknowledged that amatory relations had long subsisted between her and a lover who was in the habit of handling her breasts, and that this always produced strong sexual excitement. Hofmann also reported that in two virgins who died during menstruation he was able to express a drop of milk from the breast.

The most important indication of the general changes occurring in the external and internal genital organs, the proof that the young woman has become fitted for the fulfilment of her reproductive vocation, is the appearance of menstruation, a sanguineous discharge from the genital organs recurring every four weeks as the external manifestation of the internal process of ovulation.

The anatomical changes that have already been described as occurring in the genital organs at the time of the menarche will serve to elucidate the numerous reflex processes that manifest themselves at this period of life in so many departments of vital activity.

It is especially the extensive developmental processes in the ovary, influencing the nerves of that organ, which give rise to centripetal 75stimuli and evoke reflex manifestations. In the working of the circulatory system, such influences are apparent; and during the menarche, some time already before the first onset of menstruation, variations occur in the blood-pressure, and these during menstruation take the form of a typical undulatory curve.

Fig. 47.—Horizontal section through the female breast. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

Thus it becomes comprehensible that even in healthy girls, the first appearance of the catamenia and likewise the expectation of the flow induce a certain modification and alteration in the whole nature and disposition. Girls often lose their previous cheerful and lively character, becoming quiet, self-absorbed, sometimes even melancholy; they are disinclined for study, have a repugnance to all sustained physical or mental activity, become annoyed and snappish on slight occasion, are restless at night, consider themselves to be ailing, and so on. During the first menstruation girls commonly appear pale and anxious, they have blue lines beneath the eyes, the face has a tired aspect, the movements lack energy, and a general want of tone combined with an abnormal irritability may be noticed. Some days before the first menstruation, the vulva, the labia majora 76and minora, and the vaginal mucous membrane, are swollen, the clitoris becomes conspicuous in consequence of erectile processes, a slight secretion appears in the genital passage, and the breasts become sensitive and slightly turgid. The urine deposits a thick sediment, and occasionally severe strangury is observed. In many cases, also, digestive disturbances occur, loss of appetite, constipation, or a tendency to diarrhœa.

The first menstruation usually lasts four or five days. On the first day the discharge is blood-stained mucus, thereafter becoming sanguineous. In some cases, the bleeding at the first menstruation is profuse and of long duration.

It is not always after the first menstruation that the subsequent discharges follow at the regular intervals of four weeks. In delicate, anæmic girls the second menstruation may not occur till several months have elapsed after the first; less often the second menstruation ensues a fortnight after the first, or even earlier.

At the time of the menarche the sexual impulse, which has hitherto been dormant, becomes strongly developed. It is evoked at this time of life by the anatomico-physiological changes undergone by the reproductive glands; the stimulus aroused by these processes in the ovary, being conducted to the brain, awakens passion. At the same time the observation of the growth of the hairy covering on the genital organs, the development of the breasts, and the appearance of menstruation, tend to arouse erotic presentiments. The reading of romances, conversations with female friends, and observation of the conduct of full-grown persons, convert these presentiments into clear ideas, and excite the impulse to the production of passionate sexual sensations, the sexual impulse. How far these stimuli arising from the reproductive apparatus are encouraged and accentuated, on the one hand, or repressed and diminished, on the other, depends on external impressions of various kinds. The environment is the determinant for the further transformation of the as yet undifferentiated sexual impulse into the fully-developed copulative and reproductive impulses.

In his work on the Physiology of Love, Mantegazza describes the yearning and stress of the awakening sexual life, arising out of the presentiments, hazy sensations, and impulses, which are felt in the very earliest period of the developmental phase known as puberty.

In general, in a young girl during the menarche, the sexual impulse manifests itself rather in the form of semi-conscious reverie, of platonic love. The adolescent girl exercises her imagination with the circumstances of her chaste love, her mind turns to this subject when in solitude, her mood is apt to become melancholy, and it is the perusal of equivocal novels, or the educational assistance of 77sexually experienced female friends, that transforms the sexual impulse to a vivid flame.

Some authors believe that a sign of the awakening of the sexual impulse when directed toward some particular man is a change of color on the part of the girl when she sees this individual or hears him spoken of. Palpitation of the heart comes on, the pulse is increased in frequency, the respiration also, and the voice fails. In this manner, it is asserted, Galen discovered the love of a Roman lady, Justa, for the dancer, Pylades.

The psychological reaction of the sexual impulse at the time of puberty manifests itself, as von Krafft-Ebing points out, in manifold ways, common to all of which, however, is the emotional state of the mind, and the need that the strange and new feelings now experienced should find some objective centre of interest. Such objective and emotional interests lie ready to hand in religion and poetry, both of which, after the period of sexual development is at an end, and the originally incomprehensible desires and impulses have received an explanation, continue to have intimate relations with the world of sexual experience. Any one who doubts this must be reminded of the frequency with which religious fanaticism makes its appearance at the time of puberty. No less influential is the sexual factor in the awakening of æsthetic feelings. This world of the ideal opens itself at the time when the development of the sexual processes begins. * * * The love of early youth, continues von Krafft-Ebing, has a romantic, idealizing tendency. In its first manifestations it is platonic, and willingly exercises itself in poetry and history. But as the sensibility awakens, the danger arises that this passion, with its idealizing power, will be transferred to persons of the opposite sex who in intellectual, physical, and social relations are by no means all that could be wished. Hence proceed misalliances, elopements, and seductions, with the entire tragedy of impassioned love, which conflicts with the dictates of morality and convention, and sometimes finds its bitter end in suicide or a double self-destruction. Love in which the senses play too prominent a part can never be a true and lasting love. For this reason, first love is as a rule very transitory, since it is in most cases no more than the first flare of passion. * * * Platonic love is a thing without existence, a self-deception, a false description of sexual sensations.

Bebel remarks that the number of suicides among women of the ages of sixteen to twenty-one years is an exceptionally large one, and he refers this chiefly to unsatisfied sexual impulse, unfortunate love, secret pregnancy, and to betrayal by men.

(Precocious and Retarded Menstrual Activity.)

By the term precocious menarche we understand the pathological state in which a typical, four-weekly, sanguineous discharge from the female genital organs sets in at an abnormally early age, and is to be regarded as a symptom of a premature sexual development. Very commonly such children with precocious menstruation and premature sexual development, exhibit a comparatively high body-weight, great development of fat, early dentition; they look older than their years; and they have genital organs that also develop very early, with hair on the pubes and in the axillæ; the labia majora and the breasts resemble those of full-grown women, and the pelvis also has the adult form. Commonly also the sexual impulse develops early, whilst, in other respects, the intellectual development lags behind the physical. It is most probably a primary hyperplasia of the ovaries that gives rise to precocious menstruation, the ovarian follicles ripening earlier than usual. Frequently other pathological processes are associated with this early sexual development, such as general lipomatosis, rachitis, and new growths of the ovaries. In several cases of this nature, early conception has also been observed. According to oriental tradition, Khadijah was married at the age of five years to the prophet Mohammed, who cohabited with her three years later.

Even if we except those cases in which in earliest infancy there is a sanguineous discharge from the vagina which remains, however, an isolated occurrence, or if repeated is repeated a few times only and at quite unequal intervals (cases in which the bleeding cannot be regarded as menstrual—such, for instance as were reported by Eröss of six new-born female infants in whom a sanguineous discharge from the vagina appeared three or four days after birth and lasted two to five days, the infants not remaining subsequently under observation),—numerous well-authenticated cases yet remain in which menstrual hæmorrhage was observed before the end of the first year of life. One case, even, is recorded by Bernard in which from the time of birth to the twelfth year menstruation with molimina occurred every month, lasting two days; from the twelfth to the fourteenth year menstruation ceased, recurring subsequently at irregular intervals.

In the recorded cases of such precocious menstruation the menstruation recurred as a rule at regular intervals of four weeks; only in quite exceptional cases were the intervals three to five months.

Some of the most striking and well-authenticated cases of precocious menstruation recorded in the recent literature of the subject are appended.

79Observed by Combys: A girl aged 6 years and 2 months had the appearance of a girl aged 14 or 15; she was a brunette, 3′ 10½″ in height, with full, firm, rounded breasts, girth of chest 28⅓″, mons Veneris covered with hair, uterus normal on rectal examination, hymen intact; menstruation had occurred regularly since the second year of life. Mother and five sisters began to menstruate between the ages of twelve and fourteen. General condition good.

Case recorded by Diamant: A girl aged 6 years, weight 75 pounds, thighs, buttocks, and breasts developed like those of a sexually mature woman, axillæ and mons Veneris covered with hair. Menstruation began at the age of 2 and recurred regularly, the flow lasting 4 days.

Case recorded by Plyette: A girl with precocious physical development began to menstruate in the fourth year of life; menstruation continued regularly with the exception of two monthly periods, when vicarious epistaxis occurred.

From the collection made by Gebhard of the records of fifty-four cases of precocious menstruation, giving the first appearance and the type of menstruation, the development of the breasts, the other signs of premature sexual development, and any complications that may have been observed, we extract the age at which the first menstruation occurred. This was:

80From this collection of Gebhard’s we learn that in one case menstruation already existed at birth, and that in a large number of cases it occurred before the expiration of the first year. In many cases the development of the breasts preceded the appearance of menstruation, and was noticed from the time of birth. The vulva also early exhibited the characteristics seen in the sexually mature woman. Further, a high body-weight, great development of fat, and early dentition, were usually seen in these cases, in which, however, the intellectual development was not in correspondence with that of the body.

In several of these cases of premature puberty, moreover, sexual intercourse and even parturition occurred at a very early age. A girl in whom menstruation began at the age of one year, gave birth to a child when she was ten years old (Montgomery). A girl who began to menstruate at the age of nine years, became pregnant very shortly afterward (d’Outreport). The well-known case recorded by Haller, in which at birth the pubic hair was already grown, and in which menstruation began at the age of two years, was also one of very early pregnancy, the girl giving birth to a child when nine years old. Another girl in whom at birth the pubes were already covered with hair began to menstruate when four years old, copulated regularly from the age of eight, and at nine years became pregnant, and was delivered of a vesicular mole with an embryo (Molitor). A girl began to menstruate at the age of two, had a growth of hair on the pubes and developed mammæ at the age of three, and became pregnant at the age of eight (Carus). With these cases must be classed that observed by Martin in America of a woman who was a grandmother at the age of twenty-six. Lantier, in his Travels in Greece, speaks of a mother of twenty-five with a daughter of thirteen.

Observations made by Kussmaul and by Hofmeier prove that in many cases changes in the ovaries form the probable cause of precocious menstruation and the other phenomena of premature puberty. In one case of Hofmeier’s, for instance, of a girl of five with precocious menstruation, the removal of a rapidly growing ovarian tumor was followed by the cessation of menstruation, and the pubic hair, which had been shaved off, did not grow again.

Abnormally early puberty related to the early practice of sexual intercourse is seen in many prostitutes. This is shown by the following figures relating to 150 prostitutes in Russia. Sexual intercourse began:

Thus, among the 150 prostitutes, 65 were less than 16 years of age.

Parent-Duchatelet found among 3,517 prostitutes under official observation, 5.6 per cent. under 17 years of age. There were:

Martineau’s observations also showed that in nearly all prostitutes the first coitus took place in very early youth. Of 607 prostitutes there were 489 in whom defloration had occurred between the ages of 5 and 20 years. According to Grimmaldi and Gurrieri defloration usually takes place in prostitutes before they attain the age of 10 years.

Sometimes we find increased sexuality in early life as a pathological manifestation—psychopathia sexualis. Thus, Esquirol records the case of a little girl aged four years who undertook improper manipulations in association with little boys. A female prisoner, Lombroso writes, had at the age of six years practiced mutual masturbation with her brother aged seven, and at the age of eight years underwent defloration; another murderess, while still a schoolgirl, had conducted herself after the manner of an experienced prostitute. Laurent reports the case of a girl who from the age of ten was engaged in sexual malpractices with her brothers and sisters, and finally underwent defloration at the age of fifteen.

In many cases premature sexual development is manifested by enlargement of the breasts and growth of the axillary and pubic hair, and yet menstruation fails to appear. Thus, Kussmaul has observed girls who while yet children exhibited all the external characteristics of sexually mature women, but who had not yet begun to menstruate. Ploss has published a photograph showing in a girl five years of age the mons Veneris and the labia majora developed like those of a full-grown young woman, and covered with long thick hair; in this case, however, not only had menstruation not yet begun, but the breasts were still in the infantile condition.

The opposite state to menarche praecox is that in which the first appearance of menstruation is unduly delayed; it may be even till after the age of twenty. Such a postponement of the menarche sometimes occurs in girls who exhibit at this period of life an extraordinarily great general fatty development of the body, or a notably severe chlorotic state of the blood, or in whom during the years of 82development some sudden and extensive change in the mode of life has occurred, as for instance when the girl’s place of residence has been removed from the country to the town, or when she has had to undertake some completely new kind of physical or mental work. Raciborski attributes the late appearance of menstruation, at the ages of 20, 22, 24, or 26, in otherwise healthy girls, to an “apathy of the sexual sense,” a phrase which does not convey much meaning.

According to Marc d’Espine, puberty occurs early in girls with dark hair, grey eyes, a delicate white skin, and of a powerful build; late, on the other hand, in girls with chestnut hair, greenish eyes, a coarse darkly-pigmented skin, and of a delicate weakly build.

The genitals of girls in whom the first appearance of menstruation is delayed, frequently exhibit distinct signs of the backwardness of the reproductive organs in their development. The external genitals, in such cases, have little if any covering of hair, and are flabby and relaxed; the body and the fundus of the uterus are shorter and more slender than usual, the uterus as a whole is small and flaccid, sometimes anteflexed; the vaginal portion of the cervix is small, often almost undeveloped, its anterior lip barely projecting above the surface of the vaginal fornix; the vagina is usually short and narrow. The ovaries also are flaccid and inelastic, and occasionally are remarkably small. The breasts are small, the nipples and areolæ undeveloped.

In other cases, notwithstanding the delay in the appearance of the menarche, the genital apparatus is developed to a degree quite in correspondence with the age, but some pathological condition is present, for instance, the mucous membrane secretes excessively, exhibits a catarrhal tendency, there are erosions at the os uteri, etc.

Pathology of the Menarche.

A series of disturbances of function and pathological changes in the organs may occur at the time of the menarche, either directly connected with the genital organs, or etiologically dependent upon the changes occurring in these organs.

The commencement of menstruation, as we have already mentioned, may itself be abnormal in character, being either precocious (menarche precox), or retarded (menarche tardiva). But even where menstruation begins in a normal manner, the period of the menarche may be disturbed by a great number of pathological phenomena, of which the developmental processes occurring in the genital organs of the young girl must be regarded as the cause. First of all, the menstrual hæmorrhage itself may be abnormal in amount and duration. Then, again, functional disturbances of the most various character may occur: especially prominent are, disturbances 83of hæmatopoiesis, of the cardiac functions, and of the nervous system, and constitutional anomalies, which deserve attentive consideration; in addition we have to mention disorders of digestion and disorders of the sense-organs, among which latter certain changes in the skin especially deserve attention.

The diseases of the female genital organs at the time of the menarche are very various in nature. Whereas during infancy and early childhood the uterus and its annexa are in a state of complete quiescence, so that nothing occurs in them to attract attention, at the approach of puberty these organs emerge from obscurity, and the percentage of diseases of the reproductive organs suddenly rises to a great height. In very young girls, among diseases of these organs, we observe only malformations, malignant tumors, and gonorrhœal infections, and these pathological states, even, are quite rare; but at puberty all this is altered, and we have to do with disturbances of the menstrual function and their consequences, and with various inflammatory processes, and the period of sexual maturity offers us an overplus of diseases connected with the reproductive system, justifying the epigram of the French gynecologist who defined a sexually mature woman as “un uterus servi par des organes.”^[20]

Anomalies of Menstruation.

Not infrequently, though the catamenial flow has appeared at the usual age and has for a time been regular, pathological disturbances of this function ensue.

Amenorrhœa at the time of the menarche may depend on complete aplasia of the ovaries, associated with a rudimentary and imperfect development of the uterus. In such girls, the development of whose reproductive system is thus imperfect, the continually expected menstrual flow fails to appear, in spite of the fact that a recurrent menstrual discomfort, evoked by the congestion of the genital organs, recurs at intervals of four weeks; as, for instance, colicky pains in the abdomen, irritable, nervous states, and mental disturbances. Further, amenorrhœa may be due to one of the various forms of atresia of the genital organs, as for instance to vaginal or hymeneal atresia. In such individuals the first period passes by without anything to attract attention. But at the second period, distress will usually be manifested; and from this time forward, painful contractions of the uterus will continue to occur at four-weekly intervals, and to become more violent as period succeeds period, whilst the menstrual discharge is wanting, or, to speak strictly, fails to find an outlet. The blood collects behind the seat of atresia, and the accumulation gives rise to pressure symptoms 84affecting the bladder and the rectum, and ultimately also the sacral nerves.

Menstruation, after its first appearance in normal fashion, may be suppressed in young girls in consequence of mental impressions, such as sudden fright; such cases are observed after an escape from a fire, or after a railway accident. Mental stimuli of less intensity but longer duration have a similar effect; sometimes these take the form of auto-suggestion. A well-known instance of the latter phenomenon is furnished by the case of a girl who, in consequence either of actual intercourse or it may be merely of too intimate an embrace with a man, fears she has become pregnant, and actually suffers from amenorrhœa though pregnancy does not really exist. I saw a case in which amenorrhœa was thus produced in a girl seventeen years of age, whose ideas on the process of sexual intercourse were still far from clear. She had permitted a young man to kiss her repeatedly and fervently, and to clasp her in a close embrace. She was then afraid that she had become pregnant; the catamenial flow, which had been regular since she was fifteen years old, ceased to appear; and it was not until at length I was consulted, was able to assure myself that the girl was essentially virgin, and was, therefore, in a position to reassure her as to her own condition, that menstruation again became regular.

Functional amenorrhœa may also occur in young girls in consequence of a sudden change in the conditions of life, a removal from town to country, for instance, or the reverse, travel in regions where the climatic conditions differ widely from those hitherto experienced, or a change from an active to a sedentary kind of occupation. Of this nature is the following case observed by Winter: Miss Q., aged 20; menstruation began at the age of 13 and was regular thereafter; on three successive occasions amenorrhœa occurred during a visit to Berlin, in one case lasting 3 months, another 2 months, and a third 6 weeks, whereas when at home menstruation was regular though somewhat scanty. There were no molimina. Examination showed the wall of the uterus to be thin, length of this organ 7 centimetres (2¾″), both ovaries distinctly palpable. Such a form of amenorrhœa as this, commonly disappears when the girl removes from the conditions unfavorable to the fulfilment of her sexual functions to the conditions favorable to that function.

Not infrequently a chill is in young girls the cause of suppression of the menstrual flow that has hitherto been quite regular, especially effective in this respect being, standing in cold water, getting the feet wet, the influence of rain and wind at the menstrual period on the insufficiently clothed lower extremities, and vaginal injections with water at too low a temperature. Such cases are common 85among the working classes, especially in washerwomen; but they are also observed among the well-to-do. An example is given by Winter: Miss H., aged 19; menstruation began at the age of 13, regular, at intervals of 4 weeks, the flow lasting 2 to 3 days, and being normal in amount. Several years ago the patient caught a severe cold through paddling in cold water during the period. Suppression of the menses resulted, amenorrhœa being complete for a year and a half. Then menstruation recommenced, but was irregular, sometimes anticipating, sometimes postponing the proper period, the interval being occasionally as long as four months; when it occurred, the flow was represented by a drop or two of blood only, and dysmenorrhœa was severe. At each proper period, if the flow failed to appear, severe molimina occurred in the form of abdominal cramps and headache. Examination showed the uterus to be normal in shape, 4½ centimetres (1¾″) in length, with a very thin wall; both ovaries were palpable, but smaller than normal.

The commonest form of amenorrhœa at this period of life is, however, the constitutional amenorrhœa associated with chlorosis. In chlorotic subjects we have to do, not with a symptomatic absence of the menstrual discharge, but with a failure of the ovarian function, the graafian follicles failing to ripen. We generally find, according to Gebhard, that chlorotic girls begin to menstruate at the usual age, or even earlier. Menstruation recurs once or twice at irregular intervals, and then gives place to complete amenorrhœa, it may be suddenly, it may be gradually, the flow on each occasion being scantier than before. In chlorotic patients, the menstrual discharge, when present, is very thin and watery, and often contains a large admixture of mucus derived from the cervical canal and the cavity of the uterus. The amenorrhœa may be of short duration; or it may last for a long time; so that it is not until after the lapse of months or years, and as a rule in consequence of suitable treatment, that menstruation recurs, being henceforward either normal in frequency and strength, or on the other hand permanently scanty and of the postponing type. The associated disorders from which the patients suffer take the form of headache, dizziness, syncope, feelings of oppression, disinclination for mental and physical exertion, and so on. Since in such cases the ripening of the ovarian follicles also fails to occur, when the amenorrhœa is complete the menstrual molimina are generally wanting (Gebhard).

Stephenson also states that in girls who have been chlorotic for a longer or a shorter time, menstruation frequently begins very early, in any case earlier than in healthy girls.

Usually in these cases various other disorders are associated with the amenorrhœa, such as colicky pains in the abdomen, sensitiveness 86of the abdominal wall to contact or pressure, headaches, attacks of hemicrania, general mental depression, and hysterical manifestations.

In chlorotic girls, at the times when menstruation is due, a watery discharge often occurs, sometimes slightly tinged with blood. Dysmenorrhœa may also occur at such times.

Attacks of menorrhagia in young girls are usually dependent on disturbances of the nervous system. Sometimes such an attack occurs at the very first menstrual period. Occasionally also menorrhagia may occur in association with chlorosis, to be distinguished according to Virchow from a rare condition named by him “menorrhagic chlorosis,” characterized by excessive menstruation of an anticipating type. The bleeding is in such cases seldom very profuse, however, but the periods are very long, and the intervals exceedingly short. Castan regards such profuse menorrhagia and metrorrhagia occurring in young chlorotic girls, especially at the commencement of puberty, as of an endoïnfective nature dependent upon auto-intoxication. The toxins lead to inflammatory and degenerative changes in the muscular substance of the uterus. According to Frænkel in these cases the ovaries are usually enlarged, seldom smaller than normal.

Frœlich has discussed this subject exhaustively in his monograph on Menorrhagia of Young Girls and Hypertrophy of the Cervix Uteri.^[21] He states that the cases of menorrhagia in young girls at the time of the menarche may be arranged in two groups. In one of these the patients are chlorotic, and menstruation is normal neither in amount nor in duration, but it is the long continuance of the flow rather than its profuseness that gives rise to danger; in the cases belonging to the other group the patients are in excellent health at the commencement of puberty, but menstruation soon takes the form of long-continued and profuse menorrhagia. Cases of the latter kind are due to hypertrophy of the cervix uteri and fungous metritis. Such attacks of menorrhagia in young girls are seen also in cases of infectious disorders, as in smallpox, measles, scarlatina, and above all, influenza. The hæmorrhage often begins in the first days of the infection, and even during the period of incubation, one or two days before the appearance of the general symptoms. If the patient is attacked by influenza while menstruating, the menstrual flow may assume the character of a true menorrhagia. More often, however, in such cases, we have to do with an extra-menstrual hæmorrhage, such as may indeed be observed in girls who have not yet begun to menstruate.

Chronic metro-endometritis, both corporal and cervical, occurs occasionally in young girls during the years of development. It is especially common in chlorotic subjects; and next to these in girls who are careless about the observance of hygienic precautionary measures during the menstruation. Thus it may result from physical exertion among the working classes; and from dancing, skating, riding, or mountaineering, among girls belonging to the well-to-do classes, during menstruation. Again, we meet with it in girls who work very hard at the sewing-machine; and, finally, in those who have long practiced masturbation. Through uncleanliness at the time of menstruation, the blood with which chemise and drawers are stained and the pubic hair soiled, undergoes decomposition, and this may lead to catarrhal inflammation of the vulva and vagina and of the endometrium. The most striking symptom in persons thus affected is the discharge of mucus, which in cervical metro-endometritis leads to a very moist condition of the external genitals, and leaves greenish-yellow spots on the under-linen; in corporal metro-endometritis the discharge is of a thinner consistence, milky in appearance, and not very abundant. As a result of the endometritis, the patient suffers from various pains in the body, a feeling of fulness, sacrache, general sense of fatigue, and diverse nervous manifestations; sometimes also from dysmenorrhœa, strangury, or obstinate constipation. In consequence of the great thickening of the mucous membrane that often occurs, menstruation becomes very profuse and long-continued, lasting from one to two weeks.

A form of chronic vulvitis, sometimes, though indeed quite rarely, met with in girls at this time of life, is inflammation of the external genitals dependent on masturbation. As characteristic signs of this we may observe an elongation of the nymphæ, the clitoris, or the præputium clitoridis, and at the same time on the inner surface of the greatly stretched labiæ we may notice a great increase in the sebaceous glands, so that the yellowish spots formed by these structures may be seen beneath the mucous membrane with the unassisted eye—the mucous surface, indeed, may be slightly uneven in consequence of their enlargement, so that they resemble small retention-cysts. The mucous membrane of the vulva between the margin of the hymen and the nymphæ is moreover, according to Veit’s description of masturbatory vulvitis, often beset with small pointed excrescences, the soft furrow between the clitoris and the external orifice of the urethra being very commonly marked by swelling of the mucous membrane and the presence of these little outgrowths; but sometimes also the parts lying to either side of the urethral orifice may exhibit similar changes. These small structures differ 88entirely from pointed condylomata—they do not branch, they occur only upon the vulval surface proper, not upon the parts exhibiting the characters of true skin, and they are non-infecting. More particularly, it must be remembered, we find these changes principally in virgins in whom on account of obscure symptoms an examination of the genital organs has been undertaken, and who suffer in addition from nervous and hysterical manifestations. The hymen, when intact, as it usually is in these cases, furnishes objective evidence that sexual intercourse is not the cause of the patient’s trouble, and indeed a distinctly ascertainable cause is hard to find. The patient usually exhibits abnormal sensitiveness and excessive prudery. Veit is of opinion that the association of all these symptoms justifies the diagnosis of masturbation as the exciting cause of the chronic vulvitis; in such cases we may at one time find the mucous membrane pale, but at a later examination fiery red, and we often see a clear, transparent secretion exuding from the ducts of Bartholin’s glands.

In consequence of long-continued masturbation, other pathological changes may take place in the female genital organs, such as hypertrophy of the nymphæ, proliferation or glandular hypertrophy of the uterine mucous membrane, ovarian irritation, pains in the ovarian region which, in severe attacks, may radiate to the thighs. These pains become more severe at the menstrual period, especially at the beginning of that period; and are sometimes also especially troublesome in the middle of the intermenstrual interval, in this case usually as a result of great bodily exertion.

These morbid processes in the genital organs of young girls have long attracted the attention of physicians, and it is more than sixty years since Bennet described the “virginal metritis” observed by him in twenty-three virgins. Bonton published in 1887 a monograph on this condition. Gallard assigns masturbation as its principal cause.

Retroflexion of the uterus is also sometimes observed in virgins, induced by the bad habits which are so common in young girls of retaining the urine for excessively long periods and of neglecting constipation. The prolonged distension of the bladder leads to a daily, long-continued stretching of the ligamentous apparatus of the uterus; the full bladder presses the uterus backwards, and after the viscus has been emptied, the flaccid ligaments are no longer able to restore the uterus to its normal position of anteflexion. The organ is left with its fundus directed backwards, and the intra-abdominal pressure keeps it permanently in this position; at the same time, an accumulation of fæces in the rectum, by pressing the cervix forward, favors this displacement of the uterus. Moreover, when the uterine tissues are flaccid through malnutrition in 89chlorotic or anæmic subjects, the organ yields more readily to mechanical influences than it would if its muscular tone was healthy.

Disorders of Hæmatopoiesis.

Chlorosis is in general rightly regarded as a disease of the period of puberty etiologically dependent on the processes that at this time of life occur in the genital organs. Its appearance generally coincides with the menarche, occurring at the age of 14 to 16, or even later, at the age of 19 to 21. As regards the composition of the blood in chlorosis, investigations have shown that its hæmoglobin-richness is always diminished; its specific gravity is proportionately lessened, but the specific gravity of the serum is normal. The erythrocytes are normal in number, or only slightly diminished; their shape is sometimes normal, sometimes, however, poikilocytosis is present. The leucocytes are generally normal both as regards number and form; myelocytes (Markzellen) are also described as present in the blood of chlorotic patients (Neusser, Hammerschlag, Gilbert, Weil); the blood-plates are normal in number, the alkalinity of the blood also normal, the isotonicity of the erythrocytes rather low.

The relation of chlorosis to the menarche is variously explained. Kahane, in his elaborate monograph on chlorosis, regards it as an independent disease belonging to the group of “disorders of vegetation” (Kundrat), one which “according to its essential nature is an expression of the disharmony that obtains between the congenitally inefficient hæmatopoietic apparatus and the demands made upon the feminine organism by the processes of puberty.”

An insufficiency of the hæmatopoietic organs as regards their functional capacity is believed by Kahane to be in the case of women so far physiological inasmuch as their blood is inferior to that of men in hæmoglobin-richness and corpuscular richness to the extent of about 10 per cent. In this way the predisposition of the female sex to chlorosis may perhaps be explained. A further fact which must be taken into consideration is the difference between the development undergone by the respective sexes at puberty. In the female sex, this development is quickly completed, and has the characteristics of a revolution; but in the male, the development is a more gradual one, and has the characteristics of an evolution.

F. A. Hoffmann also regards chlorosis as associated with the development of the uterus and the establishment of menstruation. It is possible that these processes exercise some reflex influence; but we must also remember that the chemical processes involved in the growth and maturation of the ovarian follicles are still insufficiently understood, and that it is quite possible that these too 90may have powerful and unaccustomed effects on the organism such as may well disturb metabolic processes of a somewhat unstable character.

Grawitz, who regards chlorosis as a vasomotor neurosis in which disturbances arise in the interchange of fluids between the tissues and the vessels, refers the appearance of chlorosis at puberty to the general disposition to disorder exhibited at this age by the vasomotor system.

Other authors consider chlorosis to be an ovarian auto-intoxication, believing that under certain conditions the ovaries give off into the organism certain poisons; or, on the other hand, supposing that a certain antitoxic function, normally possessed by the ovary, fails. Von Noorden, for instance, regards chlorosis as a disorder of blood formation referable to a disturbance of the internal secretion of the ovary during the developmental period.

Blondel, who also regards ovarian auto-intoxication as causal, is of opinion that chlorosis is induced by products of decomposition formed in the organism during the process of growth. As in childhood the thymus gland, so later in life the ovary, renders these products innocuous. When this peculiar functional activity of the ovary is retarded in its appearance, the intoxication effected by the products of decomposition formed during the process of growth gives rise to chlorosis.

Meinert, in an interesting manner, brings the harmfulness of wearing a corset during the years of development into etiological relations with chlorosis. In the transitional period between childhood and the age of puberty the wearing of the corset usually begins. Now Meinert discovered that in chlorosis, as a result of wearing a corset, a vertical or subvertical position of the stomach ensues as a partial manifestation of enteroptosis, leading to tension on the abdominal plexus of the sympathetic, which in turn results in changes in the blood, and other nervous symptoms. According to this view, chlorosis is a peculiar general neurosis dependent upon an artificially induced gastroptosis; this form of enteroptosis being due, not to relaxation of the suspensory ligaments of the abdominal viscera, but to pressure exercised by adjacent organs in consequence of a change in the form of the thorax, which has been permanently constricted by tight-lacing (fixierter Schnurthorax).

Of importance is the fact that in girls suffering from chlorosis a condition of hypoplasia of the genital organs is not infrequently met with. It would seem, not only that imperfect development of the female genital organs may be a cause of chlorotic changes in the blood, as appears possible in view of the relations between the ovaries and the hæmatopoietic organs through the intermediation 91of the sympathetic system; but also that genuine chlorosis and the anomalies of the genital organs met with in this disease, may perhaps be common manifestations of some more general disturbance.

According to Virchow, two distinct forms of chlorosis are to be recognized, one form in which no great abnormalities of the reproductive apparatus exist, and another form in which imperfections in the development of the central portion of the vascular system are associated with similar imperfections in the reproductive apparatus. In many cases of chlorosis, he found the ovaries small and imperfectly developed, in an infantile condition; in other cases, however, they were three times the normal size; the development of the uterus in such cases usually corresponds with that of the reproductive glands. With regard to the etiological connection between chlorosis and developmental disturbances, Virchow inclines to the view, that in chlorosis a predisposition, either congenital or else acquired in early youth, must be assumed to exist, but that this does not manifest itself by the production of actual disorder until the arrival of puberty; and he considers it likely that primary deficiencies of the blood and the vascular apparatus hinder the development of the reproductive apparatus.

Stieda found that in chlorotics displacements of the uterus were common, with abnormal narrowness of the vagina, absence of the pubic hair, imperfect development of the pelvis, and the growth of the breasts interfered with to this extent, that the nipples and areolæ were abnormally small. He classifies these manifestations as disturbances of development in the sense that they are among the so-called stigmata of degeneration. If in chlorotics the breasts in certain cases have a normally full and rounded appearance, this appearance is sometimes deceptive, the fulness being due, not to a proper growth of the parenchymatous mammary tissue, but to an excessive deposit of fat. Genuine chlorosis, therefore, not referable to some other primary disorder, is a developmental disorder, in the sense in which various other stigmata of degeneration met with in the human body are developmental disorders, and is indeed frequently associated with other stigmata of degeneration, or with malformations due to arrest of development, as for instance, an infantile type of pelvis or of genital organs, abnormalities of the cranial bones, vaulted palate, the root of the nose broad and depressed, extreme prognathism.

Hegar also maintains the view that chlorosis is in most cases a developmental disturbance, the origin of which is not limited to the so-called years of puberty; it often arises from noxious influences which are either strictly inherited or began to operate when the infant was still in her mother’s womb. Frænkel is inclined to 92regard a primary developmental disorder of the genital organs as the cause of many cases of chlorosis.

Recently, Breuer and Seiler have undertaken experiments on bitches, which they spayed at the outset of puberty, and from the results of these experiments it seems probable that a disordered influence exercised by the ovaries on the blood plays a part, at least, in the pathological mechanism by which chlorosis is induced.

The intimate relationship believed to exist between chlorosis and the sexual life of woman finds expression in the opinion, which dates back to the days of antiquity, and has been widely held even by physicians, that the disease (hence designated morbus virgineus or febris amatoria) is due to sexual abstinence in individuals with powerful sexual impulse, and that for this reason chlorosis is often cured by marriage. This result of marriage, which, though apparent merely, may indeed often be witnessed, is explained by Kahane on the ground, that in very many cases, the symptoms of chlorosis become less severe after the first five years have elapsed since the commencement of puberty, the improvement occurring quite independently of the marriage or continued celibacy of the sufferer. The influence of marriage in curing chlorosis is thus apparent merely to this extent, that a very common age for marriage in women is precisely in the twentieth, twenty-first, or twenty-second year, when five years have passed since menstruation began. By this time the organism will to a large extent have become accommodated to the demands made upon it by the processes of puberty. Experience also shows that chlorotic girls sometimes continue to suffer from the various symptoms of chlorosis even after they have become wives, and that chlorosis is not infrequently rendered more severe by the puerperium—but in a wife it is no longer customary to describe such symptoms by the name of chlorosis, they are called anæmia, hysteria, nervousness, etc. Further, in order to give the doctrine of morbus virgineus its death-stroke, Kahane directs attention to the fact that numerous cases of chlorosis are met with in young girls who are far from practicing sexual abstinence, especially, for instance, amongst the lower classes, amongst whom it is hardly customary to wait for marriage before beginning sexual intercourse. The connection between masturbation and chlorosis, which has also been widely alleged from the etiological standpoint, is moreover one that cannot be admitted. On the other hand it is easy to understand that the erotic reveries which are so often seen in chlorotic girls are very likely to induce the habit of masturbation.

In young girls at the time of the menarche, especially in those who suffer from amenorrhœa or from irregular menstruation, the anæmic form of obesity not infrequently develops. Such patients 93at the time of puberty exhibit signs of marked anæmia in association with a notable increase in fat. The skin in such cases is always strikingly pale and of a whitish-yellow color; in bodies which are in other respects beautiful the bust may have the appearance of a marble statue. Such girls are strikingly stout, but the fatty tissue is flaccid, soft, and spongy, and dependent parts readily become œdematous; the muscular system is generally feeble.

What especially characterises this anæmic form of lipomatosis in young girls is, that, even in mild forms of the affection, cardiac symptoms are apt to become prominent. Frequent and violent palpitation will occur even in the absence of any severe exertion or especial excitement, often also we see shortness of breath, precordial pain, anxiety, respiratory distress, and sensations of chilliness and fatigue.

The principal cause of the obesity in these cases is to be found in the anæmia, inasmuch as the diminution in the number of the erythrocytes is a diminution in the number of the oxygen-carriers, and this entails defective and insufficient oxidation. The deficiency in the albuminous constituents of the body also gives rise to a rapid and extensive deposit of fat, the power for the combustion of the fats absorbed from the food being insufficient. An auxiliary factor in producing obesity in such anæmic girls is their disinclination to physical exercise, dependent on the speedy onset of sensations of fatigue. The long-continued repose of the muscles, and the remaining almost continuously in close rooms insufficiently supplied with oxygen, also result in the withdrawal from the blood of the circulating fat and its deposit as adipose tissue.

Albuminuria at the time of the menarche is a disease of development which is not infrequently met with in chlorotic girls, as in adolescent boys. On examination of the urine in such young girls we detect the presence of a variable quantity of albumin, which is present especially after severe physical exertion, mental application, or emotional excitement, whilst the urine secreted at night is usually free from albumin. The skin is pale, the accessible mucous surfaces are comparatively colorless, the face is puffy, the eyelids are œdematous; the patients suffer from various nervous troubles, especially headache and dizziness, and they are also liable to dyspeptic disorders.

The cause of this albuminuria of puberty is according to von Leube in part disordered hæmatopoiesis, in part a slight degree of cardiac insufficiency with a tendency to stasis. At the time when the processes of development and the growth of the body in height are most active, there is not a corresponding increase in the energy of hæmatopoiesis, and the heart also fails to keep pace with the growth 94of the body and to meet the demands thus made upon it by vigorous growth and increased energy. In general the capacity of the heart in such individuals is indeed sufficient to maintain the circulation through the kidneys; but as soon as the functional activity of the heart is more strongly taxed and the energy of the circulation consequently declines, albuminuria occurs—and occurs all the more readily in consequence of the fact that, the hæmoglobin-richness of the blood having been lowered by the customary anæmia, the epithelium of the renal glomeruli is badly nourished and functionally inadequate.

When the period of the menarche is safely passed, when the menses recur with regularity, and the chlorotic manifestations disappear, when the process of hæmatopoiesis has improved in quality, and the growth of the body is completed—when, in short, the functional equilibrium of all the vital processes becomes re-established, the albuminuria of puberty ceases. It seems, however, that those who have suffered in this way are predisposed to a return of the albuminuria at the climacteric period, when the metabolic balance is once more disturbed.

Cardiac Disorders.

The commonest cardiac disorder at this period of life is nervous palpitation, occurring in young girls who are in other respects in good health, being free from anæmia and from any discoverable disease of the heart or vessels. That this disorder is dependent on the sexual processes is indicated by the fact that it first manifests itself in a stormy manner some time, weeks it may be or months, before the first appearance of menstruation; recurring at irregular intervals, the attacks continue till after the first menstruation, and cease soon after the regular return of the period. Objectively, the palpitation of the heart manifests itself by an increase in the frequency and strength of the cardiac impulse, and increased frequency and tension of the pulse; in a few cases, however, it is perceived subjectively only by the patient, as a distressing sensation of excessively frequent and powerful cardiac action. In the former group of cases, the enhanced activity of the heart is perceptible, not only by auscultation, by which we usually find the heart-sounds quite pure, but also by inspection, which shows us the violent agitation of the thoracic wall and increased pulsation of the carotids. On percussion, no change is found in the area of cardiac dulness. The frequency of the pulse is increased, usually reaching 120 to 140 beats per minute; it is full, and may be intermittent or irregular. In those cases in which the palpitation of the heart is a purely subjective sensation, we find no increase either in the frequency or 95in the strength of the pulse, which may indeed be less frequent than normal. With the palpitation is associated a sensation of strong pulsation in the great vessels of the neck, and often there is pain on the left side of the lower part of the chest, with a sensation of shortness of breath, respiratory distress, precordial pain, and a feeling of pressure upon the chest. Respiration is shallow, and abnormally frequent. The attacks of palpitation recur daily in some patients, in others at intervals of several days; they may occur entirely without exciting cause, or with a cause so trifling that it would not in a normal subject have produced any nervous excitement; the duration of the attacks varies from a few minutes to several hours, and they may occur either by day or by night; in the intervals between the attacks the functions of the heart and the arteries are conducted in a normal manner. The pulse-curves I have obtained during the attacks of palpitation, in those cases in which the manifestations were objective as well as subjective, exhibit a high pulse-wave, the upstroke being rapid and steep, the downstroke also sudden and steep, the predicrotic elevation but little marked, the dicrotic elevation often very distinct.

Less frequent than such attacks of palpitation recurring at irregular intervals are paroxysmal attacks of tachycardia, in which the frequency of the heart and pulse is increased to an enormous extent. This disorder manifests itself a little time before the first appearance of menstruation, thenceforward recurring regularly every three or four weeks, accompanying menstruation, or occurring at the proper menstrual period if menstruation is in abeyance; the attacks last several days. This trouble also disappears a few months after the establishment of menstruation.

Associated with these cardiac troubles are, not constantly indeed, but in the majority of cases, disturbances of the digestive organs.

From the heart-troubles already described, another group of cases must be distinguished, which are also observed at the time of the menarche. They occur in girls in whom the first appearance of menstruation is strikingly delayed, not having yet begun at the ages of 18, 19, or 20 years, or in whom considerable irregularities have occurred in connection with the commencement of menstruation. In such girls, in whom menstruation has appeared late and been irregular, or who are perhaps entirely amenorrhoeic, cardiac troubles may be so pronounced that the physician may be led to suspect the presence of organic disease of the heart. The most prominent symptom is frequent and violent palpitation, with strong pulsation in the carotids, respiratory distress, and feeling of anxiety, on continued exertion or even on very slight occasion. On percussion, the heart is not found to be enlarged; on auscultation, the heart-sounds 96are found to be very loud, often with a systolic murmur in the mitral region, whilst over the lower end of the internal jugular vein, the humming-top murmur (bruit de diable) is audible. The pulse is increased in frequency, at times arhythmical, and easily compressible. The sphygmographic tracing usually shows a subdicrotic or dicrotic character. The upstroke is not high; the downstroke descends low, almost to the lowest level of the curve, before the enlarged dicrotic elevation begins. The skin is always strikingly pale, pale also are the visible mucous surfaces, the hæmoglobin-richness and the corpuscular richness of the blood are considerably diminished, a feeling of fatigue and various other nervous manifestations are constantly present—in short, in all cases we have to do with the well-known chlorotic disposition, sometimes in association with the manifestations of the anæmic form of lipomatosis universalis. In several such cases, skin affections were also present. Some suffered from acne vulgaris of the face with the usual comedones; others perspired profusely from the palms of the hands and the soles of the feet; others exhibited a bluish coloration of the nose and the ears.

There is yet a third form of heart trouble, much rarer indeed than the forms already described, from which young girls sometimes suffer at the time of the menarche. It occurs in girls who just before the first appearance of menstruation have grown very rapidly, “shooting up to a great height.” They are not anæmic, nor do they appear “nervous;” but they are extremely thin, and they have grown enormously in height during the previous year. These individuals also, who in the previous course of their life have been free from heart trouble, now complain of cardiac distress. As in the cases previously described, they complain of severe palpitation, a feeling of fulness in the chest, shortness of breath on exertion, etc.; but the results of the objective examination are very different. The cardiac dulness is increased in area, especially in vertical extent, the apex-beat may be normal in position or displaced outwards, the impulse is always heaving, abnormally powerful and resistant, the heart-sounds, especially those of the left ventricle, are louder than usual, the aortic second sound accentuated, sometimes ringing, the carotids pulsate visibly. The radial pulse, the tension of which is abnormally high, can be compressed by the finger only with difficulty; sometimes it is jerky in character. The sphygmographic tracing shows a rapid and steep upstroke; in the downstroke, the predicrotic elevation is much larger than normal and also nearer the summit of the curve. Thus we see that all the signs of cardiac hypertrophy are present, hypertrophy, that is to say, of the left ventricle.

97The cases of this nature that have come under my observation have not been in girls of the working classes, but among the well-to-do. We cannot therefore regard them as due to overstrain of the heart in consequence of excessive bodily exertions, comparable to the cases met with in young recruits after long marches and violent exercise. We must rather assume that the development of the female genital organs has evoked a storm in the cardio-vascular system, more especially that in some way an increased resistance has been offered to the work of the heart, and that thus the hypertrophy has been brought about; though we may suppose that other unfavorable influences have also been in operation. Such an influence, in these cases, is the rapid growth of the body, which makes enhanced demands on the work of the heart; another is furnished by the almost universally worn unhygienic article of clothing, the cuirass-like corset, which offers a rigid hindrance to the rapid growth of the female body, to the development of the breasts, the thorax, and the upper abdominal organs, and which fails to accommodate itself to the changing conditions of growth, so that much extra work is thrown upon the heart. In such young girls we have very frequently found tight stays, which were worn unchanged without regard to the growth of the body in length, and which, by pressure on the epigastric region, elevation of the diaphragm, and limitation of the respiratory movements of the thorax, actually offered such considerable resistances to the driving power of the heart, as ultimately to lead to hypertrophy of the cardiac muscle.

Summing up our observations, we find that at the time of the menarche cardiac disorders occur in young girls which may be arranged in three groups of cases:

1. Nervous palpitation and paroxysmal tachycardia in persons in other respects in good health, the affection appearing shortly before the commencement of menstruation, and disappearing soon after the flow is regularly established.

2. Cardiac disorders occurring in young girls suffering from chlorosis, which itself results from the processes of the menarche.

3. Cardiac hypertrophy developing at the time of the menarche, and dependent on the circulatory disturbances associated with that process, its appearance being favored also by rapid growth of the girl and by unsuitable clothing (tight lacing).

With respect to the activity of the heart and the circulation of the blood at the time of the menarche, the little-known observations made by Beneke, on the growth of the heart and arteries in the various stages of development, deserve especial attention. According to this writer, the growth of the heart is slow until the age of fifteen years is attained, but becomes accelerated at the commencement 98of puberty. During this time of puberty, the blood-pressure attains its highest level, being comparatively low in childhood and later in life. The development at puberty of the female heart is less extensive than that of the male heart, and for this reason throughout adult life the capacity of a woman’s heart is on the average 25 to 30 cubic centimeters (1.5 to 1.8 cubic inches) less than that of a man. In women, also, the great arteries are on the average somewhat smaller than in men. The various arteries do not develop with equal rapidity throughout the period of growth; after puberty the common carotid grows very much more slowly than the common iliac artery, the former vessel being the only large trunk which has already nearly reached its maximum size at puberty.

The comparatively great development which the heart undergoes at the time of puberty is a phenomenon so important alike in its physiological and its pathological relations that it deserves the special designation of the puberal development of the heart; the commencement and the completion of puberty appear beyond question to be to a large extent dependent upon this development of the heart and upon the simultaneous rise in the blood-pressure of the systemic circulation due to the comparative diminution in the calibre of the arteries.

In the literature of this subject of cardiac disorders during the menarche, we find only short annotations on palpitation of the heart in young adolescent girls, and on cardiac manifestations in chlorotic subjects. Further, the statistical fact that valvular lesions of the heart are commoner in women than in men is by many authors explained on the ground that the disturbances of the time of puberty, which certainly occur more frequently and are more severe in the female sex than in the male, play an important part in their causation. Changes also in the vessel, such as cirsoid aneurysm (angioma arteriale racemosum), are supposed to be connected with the sexual processes of this period of life. C. Heine maintains that in consequence of puberty and of the sexual functions that become established at this period, a telangiectases will not infrequently undergo transformation into a cirsoid aneurysm; especially in cases in which menstruation is scanty and irregular, angiectatic tumors may exhibit a vicarious periodic increase.

Krieger describes nervous palpitation and also “cramps of the heart”^[22] as occurring in girls who have not yet begun to menstruate, in the form of prodromal manifestations; similar attacks may occur also at every menstrual period in girls in whom menstruation is 99fully established. In most of these cases the pulse is increased in the patients who complain of a sensation of anxiety, and speak of feeling the heart roll, tremble, or flutter, to which is sometimes superadded a sensation of sudden cessation in its activity. Not infrequently there is a blowing adventitious sound, masking or accompanying the heart-sounds; there are also venous murmurs, especially when the heart-trouble is associated with anæmia or chlorosis. Of the cases of pseudo-angina pectoris^[22] observed by Krieger, the attacks occurred as prodromal manifestations before the first appearance of menstruation in 22 per cent. of the cases, after menstruation was fully established in 78 per cent. of the cases; as regards the relation of the attacks, in cases of the latter group, to the menstrual period, they occurred before the flow in 33 per cent., during the flow in 67 per cent.; menstruation was irregular in 10 per cent. of the cases under observation, in most of the other cases menstruation had been irregular, but was now regular.

Hennig records a case in which he observed as a prodromal symptom before the establishment of menstruation the regular recurrence of congestion of the pelvic organs associated with cardiac disorder.

Diseases of the Nervous System.

The extensive transformatory processes occurring in the genital organs of young girls at the time of the menarche, and the powerful impression which the new thoughts, hopes, and fears excited at this period of life cannot fail to exercise on the nervous and emotional life, will enable us to understand how it is that the appearance of the first menstruation may give rise, especially in neurasthenic or psychopathic subjects, to manifold nervous disturbances and also to disorders of the mind.

Amongst the severe neuroses and psychoses liable to occur at the menarche in those suffering from congenital nervous weakness, in those the conditions of whose life are very unfavorable, and in those affected by some sudden disagreeable and powerful influences, we may enumerate: Hemicrania, precordial pain, hysteria, and epilepsy; impulsive manifestations, such as bulimia, longings for various unsuitable things, kleptomania, and pyromania; severe feelings of anxiety; various forms of psychoses.

On the other hand, the first appearance of menstruation has sometimes a favorable influence in girls suffering from nervous or mental disorder. This is seen, for example, in cases of chorea in 100fully developed, rapidly growing girls who have not yet begun to menstruate; in such subjects the chorea sometimes disappears as soon as menstruation is regularly established.

Quite frequently, the first appearance of hemicrania in young girls coincides with the menarche. According to Warner, hemicrania made its first appearance:

Toothache, according to Holländer, in the early days of puberty sometimes exhibits the twenty-eight-day type of menstruation. The same periodicity has been recorded in cases of vicarious bleeding from the gums in girls suffering from disturbance of the menstrual function.

In the period of the menarche and before this period, chorea minor occurs, as a functional disturbance of the motor region of the nervous system, and especially in girls is it associated with the processes of the period of physical development. The statistical data supplied by a number of authors, Hughes, Pye-Smith, Russ, Sée, and Steiner, show that the proportion of boys to girls affected with chorea minor is 1 to 2.8, and that of all ages 49 per cent. of the cases occurred at the ages of 6 to 11 years, 29.8 per cent. at the ages of 11 to 13 years. In several cases, in quite young girls suffering from chorea, pathological changes were found in the genital organs. Thus, in 24 out of 27 girls from the age of 9 to 15 years affected with chorea, Marie found the symptom-complex designated by Charcot as ovarie. Ovarian tenderness was manifested on palpation, and always on that side on which the chorea had first manifested itself. Leonard found in a girl aged eleven suffering from chorea, adhesion of the præputium clitoridis; after the separation of the prepuce, the chorea disappeared.

As in respect of various nervous affections, so also in respect of various mental abnormalities, we witness at the time of the menarche numerous manifestations confirming the statement that, “no spinal reflex has such widely-opened and easily accessible paths of conduction toward the organ of mind, as the sexual reflex.” “The menstrual process,” continues Friedmann, “is the only bodily process in relation to which the organ of mind somewhat readily loses the remarkable stability of its equilibrium.”

In the experience of all alienists, it is, speaking generally, the inherited psychopathic tendency that especially manifests itself at the time of puberty; and it appears that this predisposition, the manifestations of which the resisting powers of childhood have 101hitherto been competent to suppress, undergoes a sudden and stormy development in consequence of the action of the menstrual stimulus, leading to the unexpected appearance of mental disorders. The commonest of these are mania and melancholia of the ordinary type, the prognosis in first attacks being favorable; next in frequency to these are the psychoses characterized by fixed ideas, which usually terminate favorably after a short time; finally, we meet with the moral psychoses of puberty, and the form of melancholia distinguished by Kahlbaum as Hebephrenie,^[23] the prognosis of which is very unfavorable, for it speedily terminates in dementia, similarly to the dementia of puberty described by Svetlin, dependent upon or associated with premature synostosis of the cranial bones. Very often we witness at puberty the beginning of the periodic varieties of mental disorder, which develop into periodic menstrual psychoses, manifesting themselves regularly at the recurrence of every menstrual period.

The fact that hysteria often first manifests itself at the time of the first appearance of menstruation was noticed already by Hippocrates, who indeed believed that the association was sufficiently explained by the well-known manifold relations between this nervous disease and disturbances in the female genital organs. The first hysterical attack often coincides with the first menstruation; or the first menstruation may lead to the recrudescence of hysteria which had manifested itself previously, but had passed into abeyance. We have to deal chiefly with the minor forms, such as uncontrollable and unconditioned attacks of laughing and crying, globus hystericus, clavus hystericus, etc.; hysteria major, on the other hand, is very seldom observed at the time of the menarche. As regards the frequency of hysteria at the time of puberty, we append certain statistical data.

Landouzy found:

After the age of twenty-five is attained, the frequency of hysteria declines very rapidly.

According to Bernutz, all the statistical data prove that hysteria in more than half the cases first manifests itself either just before or simultaneously with the commencement of menstruation. It seems also that at the time of puberty amenorrhoeic and dysmenorrhœic 102manifestations may give rise to the development of hysteria. In girls at this time of life, hysteria seldom takes the form of the great hystero-epileptic crisis, manifesting itself rather as nervous and moody states of mind, moral changes, weakness of will, in association with various forms of anæsthesia, spasm, and paralysis.

On the threshold of puberty the girl with a hereditarily neuropathic disposition may exhibit a tendency to epilepsy. In such cases, as Kowalewski writes, the patient has sudden attacks of loss of consciousness, commonly ushered in by a wild scream; during the attacks, tonic and clonic muscular spasms occur, the patient is completely insensible, the pupils are dilated and do not react to light, the pulse-frequency is increased—in short, the typical phenomena of an epileptic fit are exhibited. The loss of consciousness lasts from two to three minutes; and when the girl recovers, she remembers nothing of what has occurred during the fit. Though consciousness has returned, the mind is still at first somewhat disordered; but this disorder soon passes off, the girl becomes calm, and forgets what has happened. The physician is summoned, but in ninety-nine cases out of a hundred, he assures the relatives that “the attack is nothing of any consequence—a simple fainting-fit, the result of menstruation—a transient trouble merely.” A second “fainting-fit” disturbs the calm of the parents, but the reiterated authoritative assurance of the physician that “the trouble will soon pass away” restores their confidence; and they gradually become accustomed to the “fainting-fits” from which their daughter suffers at each successive menstrual period. The daughter marries, and gives birth to neuropathic and psychopathic children, and every one wonders what can be the cause of this misfortune. Hence it is necessary to pay careful attention to these “fainting-fits during menstruation.” In the great majority of cases they are in fact epileptic seizures, and as such they must be treated. Binswanger points out that in such cases, in which epilepsy first appears at the commencement of menstruation, the attacks may continue to accompany menstruation for several years thenceforward. Already established epilepsy is said by some authors, Lawson Tait, Tissot, and Marotte, for instance, to undergo at puberty in young girls an increase both in the severity and in the frequency of the attack; Esquirol, on the contrary, attributes to puberty a favorable influence on the course of epilepsy, a view held already by Hippocrates.

Not infrequently, attacks of precordial pain associated with tachycardia occur during the first menstruation. These attacks are usually of short duration.

Acromegaly, a disease regarded as a trophoneurosis, also requires mention here, this disturbance of growth being considered by several 103authors, and especially by W. Freund, to be in some way connected with the development of puberty; the tendency to acromegaly, it is suggested, is produced by the remarkable transmigration that occurs at puberty of the energy of growth from its accustomed paths into new channels. The relations which Neusser has shown to exist between the ovaries on the one hand and the vegetative nervous system and the process of hæmatopoiesis on the other, give a certain amount of support to this hypothesis, even though we have no intimate knowledge of disturbances occurring in the reproductive system during the period of development, which might have an influence in the causation of acromegaly.

Of old and of recent observations on the psychoses connected with the menarche, there is no lack. From the time of Hippocrates down to the present day, the authorities have continued to report cases in which the commencement of menstruation proved the exciting cause of the appearance of psychoses. Rousseau writes of a girl at the time of the menarche, who before the first appearance of menstruation suffered from attacks of melancholia and a tendency to pyromania, and under the influence of the latter tendency she twice committed acts of incendiarism.

According to Kirn, the psychoses that manifest themselves in the first period of the commencement of menstruation, sometimes melancholia, sometimes amentia in the form of slight and transitory maniacal derangement, more rarely a katatonic^[24] condition, may precede the menarche, or may accompany or follow it.

A special form of psychosis is associated with the menarche (von Krafft-Ebing, Griesinger, Friedmann, Schönthal). The influence exercised by puberty in this direction manifests itself in various ways, and is the more powerful for the reason that several factors are in operation, each of which exercises an individual influence upon the type of the psychical affection; these factors are, childhood, the development of puberty, and the periodicity of the disturbance exercised by the menstrual reflex. The last named of these influences is the most potent. It manifests itself in the following manner: Certain psychoses which develop before the commencement of menstruation or during the suppression of the flow, undergo modification when menstruation appears; further, in the typical menstrual psychoses of psychopathically predisposed girls, the attacks recur either at the beginning of each period, or, when the flow is in abeyance, at the dates when it should appear—the menstrual stimulus thus being the exciting cause of the successive attacks in an organ of mind whose resisting powers are deficient; and, finally 104a disturbance in the development of menstruation may be, not merely the exciting cause, but the efficient cause of the psychosis.

In cases of the last kind, which have been observed by Schönthal and also by Friedmann, who has described them very fully under the name of primordial menstrual psychosis, we have to do with young girls in whom the appearance of menstruation is retarded, or in whom the flow has been suppressed very soon after its commencement. The girls were as a rule hereditarily well endowed, and the psychosis thus appeared without warning, like a storm from a clear sky. Exactly periodical in form and character, the period of recurrence being three or four weeks, this psychosis clearly showed its dependence upon menstruation; the individual attacks usually lasted a few days only, and were characterized by distinct mental disorder, in the form either of maniacal restlessness, or of dominant depression; vasomotor disturbances were very prominent, with disordered pulse, as for instance, a rapid rise in the pulse-wave just before the onset of the attack, succeeded during the attack by a correspondingly rapid decline.

Friedmann enumerates a number of the peculiarities that characterize these attacks. The general course of the malady is an exceptionally stormy one. The ultimate cure may coincide with the definite regularization of menstruation; or, in cases in which menstruation is restored but remains inadequate, the course of the disorder may become a gentle undulatory one, the violent stimulus of total suppression being replaced by a more moderate stimulus—here also, however, a cure ultimately follows when menstruation at length becomes free as well as regular. But during the height of the malady a proper development of menstruation is always wanting. The total duration of the malady may vary from as little as two to as long as nine months, or even longer. The cure is, however, ultimately a complete one. The combination of a disturbed and delayed development of menstruation with a stormy periodic cycle of attacks of mental disorder, and the ultimately favorable termination, constitute according to Friedmann the peculiar characteristics of this form of puberal psychosis.

Masturbation.

Masturbation is sometimes practised in very early childhood, being then commonly due to local irritation of some kind, as for instance when threadworms find their way into the vagina. Itching results, leading the child to rub the genital organs. This rubbing produces a pleasurable sensation, and gives rise to repeated masturbation. But in adolescent girls at the time of the menarche, a vague impulse arises to handle the genital organs, depending upon cerebral 105processes which are themselves the result of sexual sentiments, of reading, or of conversations with sexually instructed female friends. This vague impulse may lead to masturbation, and will do so earlier and more surely if the girl is a neuropsychopath by inheritance. The local influence of menstrual congestion, however, also plays a part in provoking the impulse toward masturbation, since at every period a hyperæsthetic state recurs in the genital organs.

Girls thus addicted have sometimes a very striking general appearance. They are pale, with a weary expression of countenance, their eyes are dull-looking and darkly ringed, their movements are sluggish, they like to spend a long time in bed—signs, however, which I by no means wish to adduce as characteristic of onanists.

Temperament and mode of life are decisive in determining the greater or less frequency of the habit of masturbation in young girls. Girls of a passionate temperament, those also who from early childhood have been accustomed to mix much with young persons of the opposite sex, and those, finally, in whom from conversation on the subject with female friends or from the perusal of erotic literature, sexual enlightenment has occurred at an early age, experience the awakening of the sexual impulse earlier and with greater force, than phlegmatic girls, than those who have grown up apart from boys, and than those who have been strictly and carefully brought up. Masturbation may arise either instinctively or from instruction.

In young girls masturbation is usually effected by friction of the clitoris; less often by intra-vaginal manipulation, since this is liable to lead to injury to the hymen. For the former purpose the finger may be used; or some other article, such as a knot tied in the nightgown, or a rounded projection on some article of furniture; in one case the friction was effected by the naked heel. If two female onanists come together, they practice tribadism, presently to be described. Opportunity for this practice occurs especially in institutions in which young girls occupy a common dormitory, and sleep together without adult supervision.

An experienced physician, Gutceit, is of opinion that in young girls of 10 to 16 years of age masturbation is on the whole less common than in boys of the same age, but that on the other hand from the ages of 18, 19, and 20 onward, “sexual self-gratification is almost universally practiced by women, even if it be not always practiced to excess,” an opinion which cannot, however, be regarded as conclusive. As consequences of masturbation in the female sex, this author has observed: Fluor albus, menorrhagia, enlargement and prolapse of the uterus, pains in one or other ovary, hysterical paroxysms, great pallor.

106L. Löwenfeld remarks that the manifestations of the sexual impulse are not normally present in the days of childhood. In consequence of pathological conditions, especially of such as effect the genital organs, in consequence of chance impressions, or in consequence of a bad example, sexual passion may indeed be awakened in children in its fullest intensity. Normally, however, the distinct manifestation of the sexual impulse is associated with a certain degree of development, of ripeness, of the reproductive organs. Physiologically, sexual passion is entirely wanting in young girls before the age of puberty.

As regards the act of sexual self-gratification, this author distinguishes two forms of masturbation: (a) Peripheral-mechanical; (b) mental (psychical onanism). In the former class of cases, the sexual orgasm is produced solely or chiefly by mechanical stimulation of the skin or mucous membrane of the genital organs. In the female sex, in addition to manual stimulation, an extraordinary variety of hard and soft articles are introduced into the vagina for this purpose. Many females effect sexual self-gratification by rubbing and pressing movements of the thighs one against the other, in which the clitoris is implicated. In psychical onanism, on the contrary, as Löwenfeld points out, the orgasm is produced solely by central stimulatory representations, without the assistance of any manipulation of the genital organs. The ideas that have this effect are for the most part lascivious trains of thought or the recollection of previous sexual experiences, on which the attention is concentrated. If we wish to estimate the harmfulness of the different forms of masturbation as regards the mind and the nervous system, psychical onanism must incontestably be regarded as the most deleterious.

In the female sex onanism is, in Löwenfeld’s opinion, less widely practiced than in the male; none the less, it is in the former sex far commoner than is generally believed, a fact on which Eulenburg likewise insists. Frequently, also, in females, a congenital neuropathic tendency plays a part in the causation of masturbation, in so far as this tendency takes the form of premature sexual excitement or of excessive intensity of the sexual impulse. In the absence of this tendency, masturbation rarely leads to the production of well-marked nervous disturbances, and does so only when practiced to very great excess. Beard reports that in the powerful and full-blooded working-class girls of the Irish race, masturbation, even when practiced for many years, did not result in any notable disorder to health.

As regards the nature of the nervous manifestations met with in women as a result of masturbation, there develops, according to 107Löwenfeld, in one group of the cases, the sexual form of myelasthenia, characterized principally by sacrache and lumbago, hyperæsthesia and paræsthesia in the domain of the genital organs (ovarie,^[25] pruritus vulvæ et vaginæ, etc.), irritable bladder, coccygodynia, weakness and paræsthesia of the legs (feelings of fatigue and chilliness), finally, the onset of erotic dreams. In many cases, in the course of time, to these symptoms are superadded the manifestations of cerebral and visceral neurasthenia (headache, insomnia, nervous dyspepsia, palpitation), so that the clinical picture comes to be one of general neurasthenia. In addition to the neurasthenic troubles, manifold hysterical manifestations may occur.

Disorders of Digestion.

Disorders of the digestive apparatus are quite common in girls during the period of puberty, and usually take the form of nervous dyspepsia. Disturbances of sensibility predominate, with a sensation of pressure after meals, sometimes increasing to nausea, retching, and vomiting, as manifestations of general hyperæsthesia of the gastric mucous membrane, loss of appetite, a pasty or acid disagreeable taste, sometimes bulimia, perverse sensations of taste, and pyrosis. Especially in chlorotic girls, periodic attacks of pain occur, localized in the epigastrium and its neighbourhood, and exhibiting no relation to the ingestion of food. The free hydrochloric acid varies in amount, being now normal, now diminished, sometimes also increased. In chlorotic cases, the symptoms of round ulcer of the stomach are sometimes observed. Intestinal activity is usually depressed, peristalsis is diminished, so that more or less obstinate constipation is one of the most frequent symptoms.

Hypertrophy of the tonsils at the time of puberty is in some way related to the menstrual processes, whether by the intermediation of the nervous system or by that of the blood. Eisenhart quotes observations made by Chassaignac, of girls eighteen or nineteen years of age with hypertrophy of the tonsils, associated with retarded puberty, menstruation having begun late and being scanty, and the breasts being underdeveloped; in one young girl with tonsillar hypertrophy, one of the breasts had failed to develop properly, but after the removal of the tonsils it speedily grew to the normal size.

Diseases of the Respiratory Organs.^[26]

Not uncommonly at this period of life the growth of a goitre is observed. The influence of puberty on the growth of the thyroid 108body has indeed been asserted by several authors; and Neudörfer maintains that precisely during the period of puberty to this body must be assigned an important regulatory trophic significance for the nourishment and growth of the reproductive organs. Steinberger and Sloan record the observation of cases occurring in young girls in whom, menstruation having first been regular, but having been suddenly suppressed in consequence of external noxious influences, a rapidly growing goitre suddenly appeared.

P. Müller states that in many regions, as for instance in Canton Berne in Switzerland, where the school children exhibit with extraordinary frequency a hereditary tendency to the formation of goitre, during the years of childhood these growths are much less frequent in girls than in boys. At the time of puberty, however, this relation is entirely changed. Whereas in boys from this time onward no further growth of the thyroid body is observed, in girls at puberty the hypertrophy greatly increases, so that very large goitres are formed. The same author recurs to the earlier observations of Heidenreich and Schönlein, as well as to those of Friedreich, by which this influence of puberty is strikingly manifested, and he believes it to be established by experience that sexual excitement can produce a transient swelling of the thyroid body. He alludes also to the remarkable fact that a swelling of the thyroid body, to which a number of animals show a tendency, occurs chiefly at the time of heat or rut; this is especially well known to occur in the case of stags. Similarly, during menstruation, a transient swelling of the thyroid body can sometimes be detected; the swelling is greater if the menstrual discharge fails to occur.

Diseases of the Organs of the Senses.

At the time of the menarche in cases in which there is retardation or some other disturbance in the regular appearance of menstruation, affections of the eye are observed, which are in part functional, dependent on reflex influences proceeding directly from the genital organs without organic changes, and in part are due to circulatory disturbances. Mooren, S. Cohn, and Power have discussed the relations between the uterus and the eyes in general, and also in this especial connection. Of ocular troubles during the menarche, iridochoroiditis, hæmorrhages into the vitreous body, long-continued blindness, and pannous keratitis, are mentioned, which may either disappear with the reestablishment of menstruation (spontaneous or artificially effected), or may exhibit in such circumstances a notable alleviation. Chronic inflammatory states of the conjunctiva, usually of an eczematous nature, which frequently occur at the time of puberty, often exhibit a relation to the menstrual process, a monthly exacerbation of the ocular trouble 109coinciding with disordered menstruation, and cure taking place only when menstruation has become perfectly regular. Vicarious hæmorrhages into the vitreous body also occur, associated with disturbances of menstruation, the relapses ceasing as soon as menstruation becomes regular; such a case was observed by Courserants in a girl of fourteen years.

Disturbances of hearing have been observed at the time of puberty in young girls addicted to masturbation; the patients complain of subjective noises, rising in intensity till actual hallucinations may be experienced. Lichtenberg reports the case of a strong girl eighteen years of age, in whom the congestion associated with puberty was followed by atrophy of the auditory nerve. The same author, also Ashwell, Law, Puech, Rossi, Stepanow, and Gilles de la Tourette, have published cases of vicarious menstrual hæmorrhage from the external auditory meatus, occurring in girls of ages varying from 14 to 16, 17, 20, and 22 years. Amongst these cases, in some the auditory organ was in a healthy condition, but in others there was associated purulent discharge; the bleeding took place from the ears at the menstrual periods, the proper menstrual discharge being absent or scanty; after the ear trouble was cured, menstruation was normal. Of 200 cases of vicarious menstruation, there were, according to Puech, six in which the vicarious bleeding was from the ears.

Disturbances of the olfactory sense, taking the form, sometimes of diminished acuteness of this sense, sometimes of increased acuteness, and sometimes of perversion, also anomalies in the secretion of the nasal mucous membrane, either abnormal dryness, or greatly increased secretion of mucus, come under observation at this period of life, either as reflex manifestations through the intermediation of vasomotor nerves at the time of the first appearance of menstruation, or in consequence of chronic nasal catarrh, which may be connected with masturbation. In cases in which the menarche is retarded, vicarious epistaxis may also occur, the bleeding sometimes being very profuse, in one case, indeed, reported by Fricke, in a girl seventeen years of age, having a fatal termination. According to Mackenzie, sexual excitement leads to swelling of the nasal mucous membrane, and habitual masturbation to chronic nasal catarrh; the same author asserts that during menstruation, swelling of the turbinate bodies may always be observed, and that in this lies the explanation of the fact that many women complain of a monthly cold in the head as an accompaniment of menstruation.

Diseases of the skin are not uncommon in young girls at the time of the menarche, and later as an accompaniment of each successive menstruation. It is a well-known fact that at puberty girls sometimes lose a hitherto beautiful complexion, and suffer from various 110disfigurements of the skin of the face. These are produced especially by the profuse secretion of sweat, and by the excessive secretion of the sebaceous glands, which so often results in acne, an inflammation of these glands. Ecchymoses also, effusions of blood into the skin, are observed, especially, as a form of vicarious menstruation, in cases in which menstruation is irregular. When actual bleeding occurs from the intact skin, the blood finds its way out through the sudoriferous ducts—hæmatidrosis occurs; in some cases, however, the hæmorrhage takes place from areas of skin altered and injured by disease, from wounds or other injuries, from ulcers, or from excrescences. Hæmorrhage into the skin occurs also in the so-called stigmatization, in which condition also an etiological role has been assigned to menstruation.

In the skin, remark Spietschka and Grünfeld, a new life begins at the time of the development of puberty, and it is this which first gives to human beings the external characteristics of sexual maturity. In certain regions which have hitherto been covered only by fine downy hairs,^[27] thick, strong hairs develop, and at the same time the general growth of hair becomes more active. These regions are, the genital region, and the axillæ. This increased growth of hair is accompanied by a stronger secretion of the sebaceous glands, which very often is in excess of actual requirements, and may thus lead to cosmetic disturbances and to various diseases of the skin. Thus arise the various forms of seborrhœa.^[28] The commonest of these is the formation of comedones, which, at the time of puberty, may make their appearance especially on the nose, the forehead, and below the corners of the mouth, but also on other parts of the face or on the back and the breast; in those regions, that is to say, in which the sebaceous glands attain a considerable size. The retention of the sebum may give rise to inflammation, which the access of micro-organisms converts into suppuration. Thus arises acne vulgaris. In another form of seborrhœa,^[28] the secretion is more fluid in consistence, and collects on the surface of the skin, furnishing this with an oily covering—seborrhœa oleosa.^[28] This most 111commonly occurs on the face; if the fatty layer is removed, the skin remains dry for a brief period only, and soon becomes greasy and shiny once more. Dust readily adheres to the greasy surface, and this gives the face a dirty appearance. Seborrhœa faciei is readily converted into eczema.

With the puberal development of the external genital organs is associated an increase in the sebaceous secretion of these regions. On the clitoris and its prepuce, and on the folds and in the furrows of the vulva, in consequence of insufficient cleanliness, an accumulation of sebum and cast-off epidermic scales readily occurs; such an accumulation may become rancid, may irritate the skin, and may thus give rise to erosions and to purulent secretion.

In chlorotic girls at the time of puberty, on account of the anæmic condition of the blood, eczema is not uncommon, especially on the hands and the face. On the face, or on the forehead, red papules appear on circumscribed areas, and become vesicular; raw, weeping spots are thus formed, and have a very disfiguring appearance. Such eczema may occur also in connection with disturbances of menstruation, when the menses are scanty and pale, or when dysmenorrhœa is present.

At the time when menstruation ought to appear, but fails to do so, sometimes also, when menstruation is regular, with each successive period, an eruption of urticaria takes place; it usually disappears quickly, but in some cases is more persistent; owing to the intense itching it is always an extremely distressing complaint. Sometimes it takes the form of urticaria factitia, in which the skin reacts to every kind of mechanical stimulation, such as rubbing, scratching, or pressure, all of which alike lead to the formation of weals, which may be diffused all over the body. Less often in association with disturbances of menstruation, acute œdema or erythema are observed.

Finally, we must mention herpes progenitalis, a rather uncommon acute condition in which, with violent itching and burning sensation, intense redness and œdematous swelling of the skin, vesicles form on the præputium clitoridis, the nymphæ, and the inner surface of the labia majora.

Hygiene During the Menarche.

It is the object of rational hygiene to increase the resisting power of the organism, which has been depressed by the processes of the menarche, in order that the increased demands made by the awakened sexual life may be adequately met.

The principal means for this purpose are, suitable diet, a suitable mode of life, and the employment of physical therapeutic measures, 112among which strengthening and hardening measures are to be preferred.

The diet should be at once as richly albuminous as possible and readily digestible, there should be several, four or five, meals every day; in chlorotic patients food should be taken at regular intervals of two to three hours. Meat should be a predominant article in the diet, but fresh vegetables should also be eaten in abundance for the sake of the nutritive salts they contain; the vegetables rich in compounds of iron, such as spinach, oats, beans, and lentils, are to be recommended; fruit, raw or cooked, should also be taken in considerable quantities. The evening meal^[29] should not be too succulent or too plentiful; it may best consist of soft-boiled eggs, an omelette, or milk. Alcoholic beverages should be avoided or taken in minimal quantities; only as a stomachic may a glass of beer or of light wine be recommended.

Chlorotic patients should even at their first breakfast^[29] have a meal rich in albumin, such as a considerable helping of meat, or a beefsteak, with rolls, butter, and tea or coffee. Milk should be taken in small quantities only, not more than a pint to a pint and a half daily; only when solid food cannot be tolerated should milk be given freely. Beer and wine are often of value in chlorotic girls from their stimulant action on digestion and circulation. Half an hour’s rest before and after meals is useful.

For the bill of fare of these patients I recommend especially: Roast beef and veal, underdone beefsteak à l’Anglaise, ham; roasted venison, hare, partridge, grouse, fieldfare, hazel-hen, ptarmigan, pheasant, chicken, pigeon, turkey, oysters; asparagus, cauliflower, and spinach. For variety, fish or shellfish may occasionally be taken. Sweetbread in soup or with sauce forms a very delicious and easily digestible dish.

Kahane recommends for chlorotic patients the systematic use of Bavarian beer, to the amount of about two pints daily; it should, he says, be a beer rather dark in tint, full-brewed, rich in malt, but containing a comparatively small proportion of hops, alcohol, and carbonic acid. Jaworski has recommended a dietetic iron-beer, containing 4.7 per cent. of alcohol and from 0.0317 to 0.0644 per cent. of iron.

When girls are at the same time anæmic and very thin, fat-containing foods must be taken in abundance, such as milk, butter, and 113cream; also large quantities of carbohydrates. Farinaceous foods, rice, potatoes, arrowroot, sago, tapioca, oatmeal, barley meal, carrots, turnips, sweet fruits, grapes, dates, pippins, plums, pears, and preserved fruits—all these must appear at table more frequently than usual; beverages, in addition to milk, that are suitable are chocolate and cocoa, Bavarian beer, and sweet, heavy wines.

The diet-table of such thin chlorotic patients should be as follows:

First breakfast, 7.30 to 8 A. M.: Coffee or cocoa with milk, or a pint of milk, white bread and butter, honey. Second breakfast, 10 A. M.: Half a pint to a pint of milk, egg and bread and butter, or sandwiches of sausage, ham, or roast meat. Mid-day dinner, 1 P. M.: Soup, roast meat with vegetables and potatoes, or fish may take the place of the soup, sweets to follow. Afternoon, 4 P. M.: Coffee with milk, or a pint of milk, with bread and butter. Supper, 7.30 P. M.: A plate of meat with accessories. Evening, 9 P. M.: A glass of milk.

In the treatment of the anæmic form of obesity, to which chlorotic patients of the better classes are subject, in consequence of sedentary habits and overfeeding, the diet must be so arranged that albumins predominate, whilst carbohydrates should be given sparingly, and as little fat as possible. As the average quantities of the food elements required in such cases, I suggest, 200 grammes of albumin, 12 grammes of fat, and 100 grammes of carbohydrate.

The quantity of fluid taken must be as small as possible, since the deprivation of water may result in a proportionate increase in the solid constituents of the blood, and thus increase its hæmoglobin-richness.

The amount of physical exercise taken by young girls at this period of life must vary according to the circumstances of each individual case. In general, we may recommend for them much active movement, especially in the open air, in order to counteract the effects of sedentary habits and confinement in close rooms. Chlorotic patients must, however, be careful to avoid overdoing their exercise, and in some cases it will be necessary to limit the amount of this very strictly. In severe cases of chlorosis, Nothnagel, Hayem, and other authorities recommend complete rest in bed for from four to six weeks. This rest-cure can be carried out as far as possible in the open air, and can be combined with systematic massage and the use of passive movements.

114I have drawn up the following diet-table for obese chlorotic patients:

For young girls at this period of life systematic gymnastic exercises are usually valuable, not only for strengthening the muscular system and improving the physique during these years of growth, but also for assisting the functions of respiration, circulation, and digestion. Beginning with the simplest and easiest exercises of chamber gymnastics, the girl gradually proceeds to more difficult and elaborate exercises and to the use of medico-mechanical apparatus.

The clothing of young girls at the time of the menarche must receive attention to this extent, that all articles of clothing should be rejected which increase the tendency already existing to hyperæmia of the genital organs or offer any hindrance to the circulation in general. Above all, the physician must take his part in the contest so long and so vainly urged against the corset. But further, all tight clothing, such as restricts the freedom of movement of the thorax and the abdomen, tight collars, and tight garters—all these must be forbidden; moreover excessively warm underclothing, of the lower extremities especially, which may stimulate the genital organs, must also be prohibited.

115As regards the night hours, a thick feather bed is unsuitable. The young girl should sleep on a hair mattress, and the bed clothing should be light. Eight to nine hours sleep is sufficient; in the words of the English proverb, “early to bed and early to rise, is the way to be healthy, and wealthy, and wise.”

To live by rule, with regular hours of work and suitable pauses for rest, is of great importance. Among the well-to-do classes also care should be taken that the adolescent girl takes moderate physical exercise for several hours daily; she should go for a good walk, and not spend hour after hour recumbent upon a sofa in idle reverie. Sitting for too long a time, whether engaged in sewing or at the piano, is harmful; working at the sewing-machine is permissible for short periods only, and is indeed at this period of life better altogether avoided. Bicycling is also an unsuitable exercise at this age and readily leads to masturbation. Lawn tennis and croquet, on the other hand, are very suitable active open-air games; in winter, skating may be indulged in if proper precautions are taken against chill; in summer, swimming and rowing. The reading of light literature should be kept under supervision; equivocal novels, such as may give rise to erotic reverie and sensual excitement, must be strictly forbidden. A watch should be kept for any indications of the habit of masturbation; and if the habit exists, appropriate measures should be taken.

Hydrotherapeutic procedures and baths are of great hygienic and therapeutic importance for girls at the menarche. In healthy girls at this period of life, a cold sponge-bath lasting one or two minutes, the temperature of the water ranging from 10° to 20° C. (50° to 63° F.), taken either on rising in the morning or immediately before going to bed, is a valuable means for hardening the whole body; equally useful are cold shower-baths, lasting from a few seconds up to half a minute. If the girl is somewhat anæmic, it will be well for her to take a glass of warm milk or a cup of tea half an hour before the bath, in order to guard against too great an abstraction of heat. Cold bathing in rivers, when available, may also be recommended. In cases in which a considerable degree of anæmia or chlorosis is present, cold baths and every form of strong mechanical stimulation by the use of water, douches and the like, are to be avoided, since we have to fear both excessive abstraction of heat and overstimulation of the nerves. In such anæmic and chlorotic patients, either partial washing with lukewarm water or general lukewarm baths, the temperature of which may be gradually and cautiously lowered, either on rising or at bedtime, have a refreshing and stimulating effect.

In girls who are in other respects healthy, but in whom the menarche 116is delayed, and in whom menstruation, when begun, has been scanty and irregular, cold sitz-baths of short duration, the abdomen being simultaneously douched from a considerable height, or cold shower-baths in combination with powerful abdominal douches, are often of value.

Recently, hot air and vapor baths have been especially recommended for girls suffering from chlorosis, at first, by Scholz and Schubert, in association with phlebotomy, but also without this. Kühne, for example, has seen the most satisfactory results follow the simple use of sudatory baths in cases of chlorosis; improvement was manifested by an increase in the corpuscular richness of the blood, an increase in the hæmoglobin-richness, and an increase in the body-weight. In cases of chlorosis, Traugott also has seen favorable results follow the use of hot air baths and the consequent diaphoresis.

Still more recently Dehio and especially Rosin have recommended hot baths for girls suffering from chlorosis. In fifty cases of chlorosis, in which other methods of treatment had given negative results, Rosin gave three times a week baths at a temperature of 40° C. (104° F.), lasting at first a quarter of an hour, but later half an hour. After the bath, in those strong enough to bear it, a very short cold douche or cold sponging followed; then the patient had to lie down for an hour. The treatment was carried out for from four to six weeks. Each bath by itself had a notable refreshing effect in these patients, and at the end of the course most of the cases exhibited an improvement in all their symptoms, such as other methods of treatment had failed to produce.

The favorable influence exercised by these hot baths, as by steam bath-cabinets, light baths, sun baths, wet packing, and similar sudorific measures, may in part be explained by the dehydration of the system that is thus effected; whilst those who maintain the auto-intoxication theory of chlorosis may regard the diaphoresis as a means for the elimination of noxious substances from the body.

Bathing in water aerated with carbonic acid may be recommended for patients suffering from anæmia and chlorosis at this period of life, for the reason that such baths can be tolerated at a lower temperature than baths of ordinary water. The natural mineral waters containing free carbonic acid, and chalybeate waters rich in carbonic acid, when used as baths, are effective principally in virtue of the carbonic acid they contain, which stimulates the skin; this stimulus being conducted by the nervous system from the periphery to the nerve-centres, is reflected thence, and by irradiation exercises a quickening effect on all the processes of nutrition. These baths are usually taken at a temperature progressively reduced from 32° C. 117to 25° C. (90° F. to 77° F.), and each bath lasts from ten to twenty minutes; they are in most cases taken every other day only. For young girls in whom the menarche is delayed, also for chlorotic patients with amenorrhœa and neuralgic manifestations, chalybeate peat baths are indicated, which influence the peripheral nerves by the exercise of a gentle yet considerable thermic stimulus. These chalybeate peat baths have further been shown to increase the hæmoglobin-richness, the corpuscular richness, and the specific gravity of the blood, transitorily after each bath, but to some extent permanently also, a certain increase enduring after the course is over.

Young girls suffering from disturbances of their general health dependent upon a scrofulous or rachitic habit of body may with advantage be sent to brine baths, especially to such as are situated in the Alps or other mountainous regions. These weakly, lymphatic, scrofulous girls, suffering from scanty or irregular menstruation, may also practice sea-bathing with advantage, especially at watering places on the sea coast, where the waves are powerful. In such cases, however, it is advisable in the first instance to take artificially warmed sea-water baths, before proceeding to actual sea-bathing.

If the sensibility of a chlorotic patient is so great that she can endure neither peat baths nor carbonic acid containing mineral water baths, we must add to the latter, in order to make their action milder, decoctions of chamomile, wheat bran, malt, and the like.

In cases in which nervous symptoms predominate, with an apathetic, melancholic frame of mind, aromatic herb baths are sometimes useful. For this purpose such herbs should be employed as contain a notable quantity of ethereal oils, such as sage (salvia officinalis), wild thyme (thymus serpyllum), hyssop (hyssopus officinalis), wild marjoram (origanum vulgare), rue (ruta graveolens), archangel (archangelica officinalis), levisticum (levisticum officinale). Equally useful are the balsamic pine needle baths, for which the fluid obtained by the distillation of pine needles (pinus sylvestris), freshly collected day by day, is employed.

As regards the climatic conditions suitable for adolescent girls suffering from the disorders of the menarche, from the nervous conditions associated therewith, and from chlorosis, residence either in the mountains or at the seaside is especially to be recommended. An altitude of about 1,200 metres (4,000 feet) is the most suitable, being that at which the peculiar characteristics of mountain climates are most fully developed. The influence of such a climate on hæmatopoiesis has to be taken into consideration, as well as its special influence on the menstrual function.

Even though it cannot yet be regarded as fully determined whether the increase observed by Viault, Egger, and Mercier, in the 118corpuscular richness and hæmoglobin-richness of the blood in consequence of residence in a mountain climate, is lasting or merely transitory, yet it is certain that the hæmatopoietic organs are favorably influenced by such residence, and that the good results are augmented by the stimulating effect mountain air exercises on the appetite and the digestion. Lombard has moreover observed, that at a high altitude the menstrual flow is more abundant and dysmenorrhœa is less common. For young girls, therefore, suffering from irritable conditions of the heart, increased frequency of the pulse, or increased arterial tension, and for those also in whom the resisting power of the organism appears deficient, a visit to a mountain health resort situated amid forests may be recommended. For scrofulous girls a visit to the coast of the North Sea is especially suitable. For the slighter forms of anæmia, a sea voyage, in which the benefits of sea air can be obtained more fully, and for a longer period, may be advised; but such a voyage is quite unsuitable for those suffering from severe anæmia or chlorosis.

Such very weakly, intensely anæmic and chlorotic patients should spend the winter in some southern health resort.

The skin, in which disturbances so readily occur at the time of the menarche, requires careful attention, all the more because it is precisely at this age that young girls have the greatest need of their personal charms. The skin of the face, which is often disfigured by comedones and acne, must be carefully guarded against the accumulation of sebum in the sebaceous glands by sedulous washing with warm water and a good soap. If the seborrhœic^[30] process in these glands becomes at all severe, ordinary soaps are unsuitable, and a potash soap must be used, such as sapo viridis, or spiritus saponatus kalinus, which have great power of dissolving fats.

The best way of dealing with seborrhœa is according to Spietschka and Grünfeld the following: The washing is best effected in the evenings, when the skin will not again for many hours be exposed to the fresh air, to wind, or to dust. Pour into a basin about a pint of warm water and add from one to two teaspoonfuls of spirit of soap (equivalent to the linimentum saponis of the British Pharmacopœia) or as much soft soap as can be taken up on the end of a table-knife. The water is then stirred vigorously till a good lather is formed, and with the water and the lather the face is thoroughly washed. The skin must then be carefully dried, and thereafter it is well to smear it with some greasy material, such as boric vaseline, in order to prevent the plugging of the pores with 119dust, and to protect the sebum subsequently exuded from dessication. On the next day the washing should be repeated only if the face has become covered with sebum within an hour or two after the first washing. If the exudation is less free, the eyes only should be washed with fresh water, whilst the rest of the face should not be wetted, but merely be wiped with a dry face towel lightly dusted with toilet powder, in order to remove any accumulation of sebum.

The skin of the genital regions must be carefully cleansed, especially in cases in which there is a tendency to hypersecretion of the sebaceous glands, to eczema, or to herpes progenitalis; subsequently it should be powdered, and pads of absorbent cotton-wool dusted with toilet powder should be placed in the labial furrows.

It is of great importance that in girls at this time of life gynecological examination should be undertaken only in cases of the utmost need, and this restriction should be especially inflexible in the case of girls with a neuropathic predisposition. Instances have been observed in which a vaginal examination, the introduction of a vaginal speculum, or the use of the uterine sound, has determined the onset of a psychosis. Still more does what has been said hold true of local treatment in gynecological cases. Repeated passage of the uterine sound, cauterization of the cervix, and the manipulations of gynecological massage, make a very deep impression upon the mind of a girl, and give rise to morbid ideas and erotic storms, so that even in those with a powerful constitution, various neuroses, neurasthenic states, and even mental disorders may result. If in such cases, especially in girls of a neuropathic temperament, gynecological treatment is quite indispensable, a single, though energetic, operative procedure is to be preferred to a number of successive, though taken singly less extensive, manipulations of and in the female genital organs. The importance of this proposition has been repeatedly established. Saenger, for instance, points out as a fact to be regretted that uterine cauterization with mild caustics is far too frequently undertaken; and Odebrecht from the same standpoint proclaims the advantage of a single curetting as compared with milder intra-uterine impressions repeated during a course of treatment lasting many months. On the other hand, the physician must bear in mind the fact, established by the record of a very large number of cases, that in women predisposed to psychoses severe gynecological operations are apt to lead to the actual appearance of mental disorders, or to the exacerbation of mental disorders which have previously been very mild or have merely threatened to appear. Careful consideration is needed, on the one hand as regards the severity of the disease of the genital organs, and on the other as regards the resisting power, temperament, and constitution of the 120girl concerned, and in many cases a consultation between the gynecologist and the neurologist is expedient.

A very powerful influence on the physical and moral well-being of the girl at puberty is exercised by her domestic upbringing. The general truth of Gœthe’s saying, that the circumstances into which we are born exercise a determining influence on the whole life, being admitted, we have to remember that this applies with especial force in the case of girls.

The educational views which obtain at the present day among the upper ten thousand, are by no means calculated for the production of a woman healthy in body and sound in mind. From the time when the young girl becomes sexually developed, the claims which society makes upon her become pressing. Every day, by a number of stimuli, her curiosity and her desires are directed toward sexual matters. Visits to museums, picture galleries, and theatres, the perusal of modern romances, the free mingling of the sexes in all places of amusement—all these combine to awaken prematurely an instinct to which the “old fashioned” methods of education allowed a much more prolonged slumber. In other cases, the mother’s supervision of the developing girl is hindered and rendered insufficient because the mother herself is claimed by her society duties and taken much away from her home. In addition, the young brain is overburdened with mental work, the modern idea of the equality of the sexes in matters of love is instilled, and a desire is artificially evoked, and is matured by a certain idle vanity, to indulge the “natural” instincts—to manifest sexual passion and to indulge it to excess—and thus the modesty so natural and so becoming to young girls is completely lost. Nourished in such a soil, neurasthenic and hysterical states, disorders of menstruation, and masturbation, cannot fail to flourish.

In these respects also a change is requisite, and a mode of upbringing must be inculcated from which everything likely to inflame the sexual impulse is removed. For the adolescent girl a systematic alternation of work and recreation must be arranged. From great entertainments where she will mix with young men, from theatres, evening parties, and balls, the young girl at the time of the menarche, at the period when menstruation commences, must as far as possible be kept away, and such pleasures must be reserved for a more advanced stage of this period of development. Intellectual overstrain, the overtaxing of the young head, must be avoided; the acquirement of knowledge must take place gradually and slowly, and in a manner adapted to individual peculiarities. Intercourse with female friends also requires supervision in respect of the moral characteristics of these latter. Religious reverie must be 121avoided, but also to be avoided is the modern nihilism in respect of religion and good morals. Books must be carefully chosen in order that the imagination may remain pure and in order that girlish illusions may not be prematurely destroyed. Domestic recreations in the way of games, music, singing, painting, and other forms of artistic culture, are of importance for the development of a strenuous faculty for learning. Travel in regions where the scenery is beautiful, forms a most valuable means for the ennoblement of the intellect and the emotions.

Additional matters demanding attention are, as already mentioned, the suitability of the diet, and proper physical exercise. All stimulating articles of food are to be avoided, the excessive use of meat is to be forbidden, and a sufficient mixed diet, containing both animal and vegetable substances, is to be prescribed. Tea and coffee should be taken as sparingly as possible, and alcoholic beverages must be absolutely prohibited. The regulation of the bowels is of great importance. Young girls should accustom themselves to evacuate the bowels every day at a fixed hour, the best time to adopt being either immediately on rising or just after breakfast. Constipation is very apt to lead to the production of irritable conditions of the genital organs.

We can point out as a happy instance of modern progress that the practice of certain physical exercises has actually become the fashion for young girls. Gymnastics, with or without apparatus, swimming, skating, and lawn tennis, involve a number of bodily movements advantageous for the health; and in connection with most of these the enjoyment of fresh air offers an additional favorable influence. Bicycling, however, at this period of life is open to many objections, not only on account of the likelihood of direct injury to the genital organs now in course of development, but also on account of the impulse it produces toward onanistic manipulations.

Especial attention must be paid to the clothing, regarding which the requirements of fashion so often conflict with those of hygiene, the victory, unfortunately, in most cases falling to the former. The period of the menarche is indeed usually regarded as the proper time for the young girl to begin wearing a corset, if it has not been worn before. In this connection M. Runge makes the significant remark: “As long as bodice and skirt form the two principal articles of woman’s clothing, the corset or some similar article cannot be dispensed with. The vicious features in the corset are its constriction of the thorax, with the object of giving the woman a ‘figure,’ and the introduction into its substance of strips of whalebone or steel in order to give firmness to the figure. The harm done by the 122former feature, the compression of the abdominal viscera, the corset liver (lacing liver, constricted liver, Ger. Schnürleber), the movable kidney, etc.—all are so well known that they need not be particularly described. But the strong pressure from above has a deleterious effect upon the internal genital organs also, leading to passive hyperæmia and to displacements. The ‘bones’ of the corset take part in the compression, and they replace the functions of the muscles of the back. If a woman who has long worn a corset lays it aside later in life, she complains that she is no longer able to hold herself upright. In consequence of insufficient work the muscles of the back have become incapable of keeping the back straight. The corset, then, must neither constrict the body, nor must it contain ‘bones.’ An article of clothing analogous to the corset is, however, required for the support of the skirt and the petticoats that clothe the lower limbs. These latter are usually fastened by means of bands which encircle the body above the crest of the ilium. In order to give these bands a sufficient hold, this region of the body is compressed by the corset. The burden of skirt and petticoats is thus borne by a furrow, above the pelvis and below or in the region of the asternal or false ribs, which is in great part artificially produced. All this is bad. In order to avoid the necessity for any constriction, the petticoats should be fastened to the corset, and this latter should be supported from the shoulders by means of shoulder-straps or braces crossing one another behind. No constriction of the thorax then occurs, and if the corset has suitable supporting pouches for the breasts, and the wearer is accustomed to hold herself erect, the figure of a well-formed woman thus attired is far from unpleasing, and is, above all, natural. If the weight of skirt and petticoats is too great to be borne by the shoulders, the burden can be divided, some being fastened to the corset, others tied round the waist. This method is less to be commended, but may be regarded as a permissible middle course. If chemise and drawers are woven in one piece, as in the ‘combination’ under garment, there is one article the less to be attached to the corset. Recently a number of corsets and articles of clothing have been made in accordance with these principles.

“The growing girl, then, may wear a soft corset with shoulder-straps, made to measure, to which all the garments clothing the parts below the waist should be made to fasten. It must unfortunately be admitted that this rational mode of arranging the clothing cannot be adapted to the ‘low dress’ which etiquette demands on so many occasions for evening wear, since with the latter the shoulder-straps cannot be worn.

“It is most unhygienic for women to wear, as they so often do, 123drawers that are widely open. Both cleanliness and the need for an equable warmth demand that these garments should be closed between the thighs, not to speak of other reasons.”

In order to diminish the sexual impulse in girls at the menarche, where this impulse has developed prematurely or is abnormally intense, and even in later years with the same end in view, it is necessary, not merely that the diet should be suitable and non-stimulating and that the educational environment should be satisfactory, but above all that there should be regular occupation and regular physical activity. Ribbing rightly calls attention to his experience in dealing with animals, that equally in the case of the stallion and of the mare, the whole of life may without difficulty be passed in complete abstinence from sexual gratification, provided that the diet is suitable, being neither too rich nor too meagre, and that the animal has regular occupation of a nature and degree adapted to its powers. In these animals a certain amount of disquiet, of restlessness, of sulky irritability, etc., may indeed be noticed at times, but these manifestations are to be overcome by mingled gentleness and firmness, aided now and again also by mild chastisement, but altogether without any severity. “Chastity,” says Oesterlen, “is possible only when the mode of life is simple and regular, and is characterized by appropriate self-command and frugality. For this reason it is rarely encountered in palaces and similar places, in which from youth onwards every one can do what he pleases; but just as little is it really practicable amid conditions of lack of culture, rudeness, and poverty.”

From the point of view of education, what Moreau wrote a hundred years ago is of importance: “In the ordinary course of nature the young woman at the time of the first appearance of menstruation is still in full possession of those amiable qualities of blamelessness and chastity which we are accustomed to denote by the term moral virginity. To an honorable and pure-minded man this beautiful attribute of budding womanhood is much dearer and more estimable than physical virginity. By libertines only is the latter regarded as a most valuable possession, since it furnishes a powerful stimulus to their jaded imaginations. But moral virginity and physical virginity are not always and necessarily associated, for either can be present in the absence of the other. Physical virginity may be destroyed by diverse forms of violence, and yet moral virginity may remain pure and uninjured amidst its ruins. Thus the two are widely different one from the other, widely different also are they in value and significance.”

What Eulenburg says regarding the prophylaxis of sexual neurasthenia in general is true regarding the sexual life of the girl at this 124period of life. “What is needed,” he writes, “is the control of educational influences with these ends in view, that, on the one hand, the sexual excitability of developing youth shall be diminished and kept within bounds, and that nevertheless, on the other, the urgently needed enlightenment shall be afforded to the young people at the proper time and in a suitable form. How these aims are to be effected cannot be explained in generally applicable propositions. It is a matter which must be left to the tact of the parents and of other members of the family, who will be guided by the insight they have acquired into the mental life of those concerned. * * *. Children inclined to onanism must be carefully supervised by day and by night; they must be protected from all stimulating things and from bad company; in boarding-schools it is the common dormitories that require the most strict, most careful, and most continuous control. In the case of auto-onanists, female as well as male, we must enquire into the possible existence of local stimulating influences, among which, in both sexes, oxyuris must be mentioned—but in truth it is rare for such local conditions to be the exciting cause of masturbation. A healthy mode of life in respect of clothing, sleep, and diet, and the systematic practice of bodily exercises to the point of considerable fatigue, are the most effectual means of counteracting the noxious propensity to onanism.”

A high degree of freedom permitted to girls from a very early age is, as Rousseau already maintained, by no means favorable to the preservation of virginity.

A wise mother or a wise instructress can do much towards the preservation of physical and moral virginity, by enlightening her daughter or pupil at the right time and in a proper manner as to the nature of the sexual processes, and their significance for the whole life of woman. Ignorance in this respect, equally with pseudo-knowledge, entails many dangers. I regard it as indispensable that the adolescent girl should in good time learn from her mother the nature of menstruation, lest she should first receive enlightenment in an unfitting manner from some more experienced female friend. The mother should explain that the impending flow of blood is a natural process, unattended by danger, but indispensable to the sexual life, and a characteristic part of the process of “growing up.”

The knotty and important topic of how the young girl may best receive sexual enlightenment from her mother, is discussed by E. Stiehl in her notable work “A Maternal Duty.”^[31] The authoress points out that this enlightenment must not take place suddenly and without apparent motive, but that the mother must in a gentle 125and gradual manner introduce to her child the secrets of nature. A beginning may be made by teaching the child to observe the nature and growth of plants; then she may be led to interest herself in the family life of animals; and thus an easy way is found to answer the questions connected with reproduction—to answer them in a manner at once true and befitting.

Let the mother indicate to her child the methods employed by nature for the preservation of the life of the young plant; let her demonstrate in a flower the stamens and the pistil as male and female organs respectively; and let her explain how when the pollen-grain reaches and fertilizes the tiny ovule in the ovary, this ovule becomes capable of development into a large seed containing an active rudimentary plant, which latter itself enlarges to become a new full-grown specimen of its kind. The opportunity may then be seized to draw attention to the resemblance between the little ovules in the ovary of the flower and the minute ova by means of which all animal life reproduces its kind. Proceeding further, an earnest and thorough introduction to the sanctity and responsibility, the perils and duties, of the sexual life, is urgently required by the young girl before she proceeds either to marriage or to an economically independent mode of life.

Not only in America and England, but now also in Germany, there exist excellent books which may actually be put into the growing girl’s own hands, by means of which she will be introduced in an intelligent manner to a knowledge of the method of reproduction in the human species.

Often enough, when the mother is lacking in intelligence or sympathy, it will be the duty of the physician to give this enlightenment to the young girl. The interpreter of such tidings at the time of love’s dawning will be the family doctor, to whom the girl and her family have been confidently accustomed to turn for information regarding the bodily state and well-being. He is accustomed to remove many a veil without any offense to maidenly modesty. Many sexual disorders and much sexual aberration may thus be prevented.

Certain definite hygienic rules must now be prescribed. First of all, the strictest cleanliness must be observed, not only in the intervals, but also during menstruation. The prejudice against changing the under linen during the flow must be overcome, and care must be taken that at this time the external genitals are washed twice daily with water at a temperature of 26° C. to 28° C. (about 80° F.), and a wad of absorbent cotton-wool or a piece of clean linen (sponges are not to be used for this purpose); any article of underclothing 126that becomes soiled with blood must be changed. Most useful are the so-called “sanitary towels,” made of sterilized absorbent cotton-wool, fastened to a linen band which surrounds the waist, or simple pads of absorbent material may be used, kept in place by means of a bandage. During menstruation, full baths, warm or cold, are to be avoided, likewise long walks, riding, long journeys by rail, gymnastics, with or without apparatus, skating, lawn tennis, and bicycling; dancing, above all, must be prohibited, since it involves a combination of several noxious influences—the very active movement, which produces hyperæmia of the genital organs, sexual excitement, loss of sleep, long hours spent in close rooms, prolonged voluntary retention of urine, and the risk of a chill. Singing, also, must be discontinued during menstruation, since otherwise an injury to the voice is very likely to result. A certain limitation in respect of physical and mental activity is indicated as a general precautionary measure during menstruation, but this measure must not be pushed to excess, so that the habit is acquired of resting completely during the period, passing the days on a sofa. The favorite practice, in cases of scanty menstruation, of taking hot foot-baths is to be rejected. At the conclusion of each menstrual period, however, a tepid bath should be taken. The knowledge we have now acquired of the rhythmical “menstrual wave” process (see p. 19 et seq.) points to the practical conclusion that the physician should not direct his attention to the actual menstrual period only, but also, and more than has hitherto been customary, to the premenstrual period, in which temperature, blood-pressure, and excretion of urea attain their acme; especially should this be done, with the aim of prescribing suitable hygienic precautions, in cases in which the menstrual discharge is very profuse or in which nervous manifestations accompany menstruation.

Important is it also for the physician to take precautions against the practice by young girls of unduly prolonged voluntary retention of the urine, resulting in over-distension of the bladder; also against the performance of very active movements and against powerful muscular efforts when the bladder is in a distended state. All of these are liable to result in displacements of the uterus.

During menstruation the diet should be sufficient, but free from stimulating elements. When the menstrual flow is greatly in excess, strong tea and coffee, wine, and beer should be forbidden; conversely, when menstruation is scanty, an invigorating diet is especially indicated, and the use of strong wines. According to the investigations of T. Schrader, in order to maintain the nitrogenous balance 127during menstruation, it is necessary to give the following daily diet, representing a heat value of 2,013 to 2,076 calories:

For chlorotic girls the following diet may be recommended during menstruation. Before rising a pint of milk should be taken slowly, in sips, during a period not exceeding half an hour; for the first breakfast (see note to p. 112), tea or coffee with an abundance of milk, a considerable portion of meat (roast beef, cold fowl, cutlets, or beefsteak); for the second breakfast, a tumbler of milk, bread, butter, and a couple of eggs; for mid-day dinner, a good helping of fresh meat so cooked as to be easily digested, green vegetables, potatoes, farinaceous pudding, stewed fruit, and a glass of burgundy or claret; at 4 P. M., coffee and bread and butter, or a tumbler of milk; at 7 P. M., a similar meal to the mid-day dinner, but lighter; no supper. In this diet-table, which represents a heat-value of about 2,200 calories, albumin and fat are present in abundance (182.8 grammes albumin and 763 grammes fat), but carbohydrates in small quantity only (176.9 grammes).

For those chlorotic patients who find it difficult to digest much butcher’s meat, the necessary quantum of albumin must be supplied by increasing the amount of milk, soup, and the white varieties of flesh (chicken and the like), giving also a considerable amount of the more easily digested vegetables, with fruit, beer, and a little claret. For such cases Desqué has drawn up the following diet-table, representing 3,290 calories and containing 150 grammes of albumin, 110.7 grammes of fat, and 449.6 grammes of carbohydrate; meat is given once a day only:

7.30 A. M.—

Half a pint of milk, 50 grammes roll, 10 grammes butter.

10 A. M.—

300 grammes apples, strawberries, or cranberries, 50 grammes roll, 10 grammes butter.

12.30 P. M.—

200 grammes of beefsteak, 100 grammes of macaroni, 300 grammes of bread, 400 grammes of spinach, 200 grammes of stewed apples or gooseberries.

4 P. M.—

200 grammes vegetable-peptone-cocoa, 50 grammes roll, 10 grammes butter.

7.30 P. M.—

200 grammes rice-broth, 500 grammes buttermilk, 100 grammes bread, 10 grammes butter, 200 grammes salad, 300 grammes uncooked pears, 40 grammes curds.

128In cases of profuse metrorrhagia in girls, von Winckel recommends in addition to rest in the recumbent posture, a diet containing large quantities of fluid, and much easily assimilable albuminous nutrient material, all stimulating articles and those likely to cause nausea and vomiting being avoided. He gives the following diet-table:

7 A. M.—

250 grammes of milk.

9 A. M.—

250 grammes of bouillon, 1 egg, 20 grammes of brandy.

11 A. M.—

250 grammes of milk.

1 P. M.—

100 grammes of roast meat, 250 grammes of rice-broth with 5 grammes of somatose, and 150 grammes of claret.

3 P. M.—

250 grammes of milk.

5 P. M.—

1 egg, 20 grammes of brandy.

7 P. M.—

250 grammes of bouillon or white soup with 5 grammes of somatose.

As a beverage in the intervals, weak cold tea is allowed. When the hæmorrhage has ceased, the following beverages are suitable: oatmeal, cocoa, Pilsener beer (one pint daily), milk (2 to 3 pints daily), claret (a half bottle daily). For food, the lighter varieties of meat, 200 to 300 grammes daily, sweetbread, pigeon, ham, nutrient and easily digestible vegetables, spinach, carrots, and pea-soup, may be recommended.

In cases of amenorrhœa or scanty menstruation, especially when due to anæmia or to underfeeding, mental excitement, or over-exertion, warm baths at a temperature of 28° to 29° R. (90° to 92° F.), rubbing the body with wet towels, and warm sitz-baths, are of good service.

[Note: Although in this translation the English equivalents of the measures used on the Continent have as a rule been appended in parenthesis, this has not been thought necessary in the case of the diet-tables, since even in English works these are commonly stated in terms of the metric system. It may here be mentioned that, as regards fluid measures, 250 grammes (a quarter of a litre) is roughly equivalent to half a pint, an ordinary tumblerful or breakfast-cupful; and that, as regards solid measures, 30 grammes are equivalent to a very little more than an avoirdupois ounce.]

Menstruation.

Menstruation is the name given to the process which manifests itself in the human female after the age of puberty by the discharge from the genital organs at regular four-weekly intervals of a mucosanguineous secretion. This discharge is not merely the result of a local hyperaemic condition, but is the expression of a periodic excitation of the entire nervous system and blood vascular system, intimately related with the whole sexual life of woman; this excitation is itself dependent upon the process of ovulation, an incident in the series of manifestations that arise from the periodic undulatory movement in the vital processes of woman.

129The Mosaic law regarded the process of menstruation as unclean in nature; the menstruating woman was unclean, and must be purified in a prescribed manner. In the fifteenth chapter of Leviticus, vv. 19–29, we read: “And if a woman have an issue, and her issue in her flesh be blood, she shall be put apart seven days: and whosoever toucheth her shall be unclean until the even. * * * Every bed whereon she lieth all the days of her issue shall be unto her as the bed of her separation. * * * But if she be cleansed of her issue, then she shall number to herself seven days, and after that she shall be clean. And on the eighth day she shall take unto her two turtles, or two young pigeons, and bring them unto the priest, to the door of the tabernacle of the congregation.”

In a similar manner the adherents of the faith of Islam regard a menstruating woman as unclean.

This view is found also in the earliest medical writings, alike in the early Indian book of Susruta and in the later writings of Hippocrates, and it persists to the present day in the use of the expression “monthly purification.” Susruta teaches that in India menstruation begins at the age of twelve, and recurs monthly, the flow lasting three days. In the Jewish Talmud it is asserted (see “La Médécine du Talmud,” by Dr. Rabbinowicz) that menstruation begins as soon as the girl has two hairs on the pubic region, or at the age of twelve, even in the absence of any growth of the pubic hair. The menstrual blood is quite peculiar in its characters. Thus, Raschi relates, the mother of the King of Persia exhibited sixty varieties of blood, and among them Rabba was able to detect which was the menstrual blood. According to a rabbinical authority, a woman can become pregnant as soon as she has completed her twelfth year. As signs of puberty, Rabbi Jossé mentions the appearance of a fold beneath the nipple, Rabbi Akiba, the erection of the nipples, Rabbi d’Azai, the appearance of a dark areola around the nipples, Rabbi Jossé, the recession of the nipple under pressure followed by its gradual protrusion when the pressure is removed, also the softening of the mons Veneris (in consequence of the deposit of fat in its substance). As prodromal signs of the first appearance of menstruation, the Talmud mentions, pain in the region of the umbilicus and in the uterus, flatulence, shivering, white flux, heaviness in the head and the limbs, and nausea.

The blood discharged during menstruation has certain peculiar properties. It is always fluid, and rarely contains fibrinous clots, it is always mixed with a larger or smaller quantity of mucus, which gives it a sticky character; the reaction is alkaline, the smell characteristic. Only when the bleeding is very profuse are coagulated masses evacuated. On microscopical examination of menstrual 130blood, we detect erythrocytes and leucocytes, the proportional number of the latter being greater than in pure blood; there is an admixture also of epithelium from the genital mucous membranes, cylindrical cells from the uterus, flattened cells from the superficial layers of the stratified scaly epithelium of the vagina, also various micro-organisms and granular detritus. At the beginning of each menstruation, the admixture of mucus is greatest, so that the discharge sometimes has the appearance of blood-stained mucus; but during the height of the discharge the consistency is almost that of pure blood. The quantity of blood lost at each period is said to vary from 90 to 240 grammes (about 3 to 8 fluid ounces); but in tropical climates the average is said to be 600 grammes (20 ounces). According to the accurate analysis of Denis, menstrual fluid contains in a thousand parts:

Both the quality and the quantity of the blood are subject to great variations. Thus, for instance, Bouchardat estimates the solid constituents at 99.20 per mille, Vogel at 161 per mille, and Simon at 215 per mille. The amount of blood discharged during menstruation depends upon the temperament, the constitution, and the occupation, of the woman concerned. It is greater in vivacious brunettes than in phlegmatic blondes, greater in southern women than in those dwelling in the north, greater in town dwellers than in women living in the open plains, greater in those whose mode of life is sedentary than in those engaged in some active occupation.

Similar considerations apply with regard to the duration of each period. The mean duration is in the great majority of cases from four to five days, being generally the same in successive periods in the same individual; in exceptional cases the flow may last a week or more. Menstruation lasting more than eight days must be regarded as abnormal.

Krieger has collected data relating to the duration of the individual periods. He found the duration constant in the great majority of cases, i. e., 93.285 per cent.; but variable in a small minority, i. e., 6.715 per cent.

131The periods in which the duration was regular did not always last precisely the same number of days, the duration in many cases being 3 to 4 days, 5 to 6 days, etc.; but the same duration recurred regularly at each successive period, so that all these instances must be reckoned among the periods of regular duration. The duration must be regarded as irregular or variable in those cases in which the variation was from 2 to 4 days, 3 to 8 days, etc. Sometimes a regular three-day or five-day period becomes transformed into an eight-day period; or conversely an eight-day period into a four-day period.

Among the cases in which the duration was regular, it amounted

L. Mayer has also drawn a distinction between constant and variable duration of the menstrual periods. Among 4,927 women, he found 4,542 (92.185%) in whom the duration was constant, and 385 (7.815%) in whom it was variable. Of the constant periods, the duration was:

An extremely short duration, less than 24 hours, was found in 70 women, an extremely long duration, 7 to 14 days, was found in 175 women, and finally a duration exceeding 14 days was found in 19 women.

The mean duration in these cases was 5.387 days.

The results obtained by Szukits, who investigated the duration of the periods in 1,013 women, are somewhat divergent from the above. He found:

The mean duration in these cases was 3.87 days.

The mean duration of the menstrual flow is:

132The interval between one menstruation and the next (the period that elapses, that is to say, between the commencement of one period and the commencement of the next) is in the great majority of cases twenty-eight days. The recurrence in many women is extraordinarily exact, not merely as regards the day, but even as regards the hour of the day. The twenty-eight-day type of menstruation is found in about 70 per cent. of the cases; in the remainder, the thirty-day type is most frequent, and next to that the twenty-one-day type. The periodicity of menstruation in any individual may however be very irregular.

The quantity of blood lost during menstruation varies within wide limits; according to approximate estimates the usual loss at a single period is from 90 to 240 grammes (about 3 to 8 fluid ounces). The following summary statement is made by Krieger regarding the quantity lost in different social circumstances and in various nationalities:

The amount of blood lost and the duration of the flow are less in strong, healthy women, leading an occupied, active, and regular life, especially in countrywomen and in women who are poor and chaste, than it is in delicate, weakly women, leading a sedentary life, whose diet is abundant and stimulating, and who are accustomed to an ultra-luxurious and enervating existence. In nuns, for example, the quantity of the menstrual discharge gradually declines; shortly after their entrance into the cloister, various irregularities are apt to occur, but ultimately the flow becomes exceedingly scanty and lasts for a single day only. Climate also has a great influence, for in hot countries women usually menstruate very abundantly, whilst in cold countries the flow is scanty, and often appears only in the warmer months of the year. Of the Lapp and Samoyede women this was already reported by Linnæus and Virey. Tilt further relates that Eskimo women menstruate only during the summer months, and even then scantily. In southern France, according to Courty, the quantity varies from 120 to 240 grammes (about 4 to 8 ounces); but it may rise to 300, 350, and even to 500 grammes (about 10, 12, and 16½ fluid ounces). In the tropics, severe menorrhagia is said to be common; and the fact was already known to Blumbenbach, that women of European descent born in the tropics not infrequently succumb to hæmorrhage during childbirth.

L. Mayer has endeavored to determine the relations between the quantity and the quality of the discharge, and distinguishes the regular composition, when a considerable quantity of dark-tinted, fluid blood is passed, from the irregular composition, when a small quantity of blood, usually pale in color, is passed, or an excessive quantity of dark blood, often coagulated, or a discharge of varying composition.

133Of 4,542 women questioned by Mayer in regard to this matter, there were:

and among the latter the discharge was

Investigation regarding the individual variations that occur in this respect among women, showed that blondes usually menstruate more profusely than brunettes, and that in the former also the duration of the individual periods is longer.

The loss of blood must be considered less in respect of its absolute quantity than in respect of the effect which continued observation shows its loss to have upon the organism. If the loss of blood continues to have an effect after the flow has ceased, if a woman recovers but slowly, or even fails to recover fully from one loss before another begins, if symptoms of increasing anæmia become apparent, the bleeding must be regarded as a pathological perversion of normal menstruation. Pathological is it also if the menstrual flow does not exhibit the normal slowly rising and slowly declining curve, but sets in profusely, ceases or almost ceases for a time, and then again suddenly recurs. In some cases the flow is not profuse, but lasts for a long time, and owing to this long duration it has a debilitating effect, especially in anæmic and chlorotic individuals.

As a rule, in normal menstruation, the admixture of the alkaline cervical mucus suffices to keep the menstrual discharge fluid and to prevent the formation of fibrin. On the other hand, the discharge of coagulated masses of blood will alone suffice to indicate an abnormally free and rapid flow of blood.

The commonest type of menstruation is the more or less regular recurrence of the flow at intervals of twenty-eight days. Variations in this respect are, however, very frequent, and are dependent upon constitution, position in life, and race. In general it may be said that in persons of strong constitution, the type of menstruation is much more regular, than in persons of a weakly, delicate constitution; that in vivacious, ardent natures the menses more readily anticipate the expected period of their return, whereas in those of a flaccid, lymphatic temperament a retardation is more likely to occur; and that amongst women of the upper classes of society the type of menstruation is far more frequently irregular than amongst women of the working classes and amongst countrywomen. Whereas in many women the regularity of the menstrual rhythm 134is so precise that the flow recurs, not merely at regular intervals of twenty-eight days, but even time after time at exactly the same hour of the day—in other cases the interval between two periods may vary from twenty-one to thirty days.

L. Mayer, who made observations on the type of menstruation in 5,671 women, and tabulated his results, distinguishes between constant and inconstant intervals. Among the constant intervals he enumerates those forms, both regular and irregular, which do not during the whole life of the individual undergo transformation into another form, but remain always of the same type. If, for instance, in any individual the interval is always either two or eight weeks, in that woman menstruation is indeed irregular, but constant in type. If, however, for some years she menstruates at intervals either of two or of eight weeks, and then proceeds to menstruate at intervals of four weeks, her menstruation is of the inconstant type. Mayer found among his 5,671 cases

Of the cases in which the type was constant there were 69.68 per cent. in which the regular period of four weeks obtained, and 20.31 per cent. in which it was irregular in the sense above defined. Among these latter, the commonest periods were 15 to 21 days and 22 to 27 days. The same author observed the irregular type of menstruation in nearly one-fourth of the women belonging to the well-to-do classes.

According to the observations of Krieger on 481 cases in which the periods were regular, that is, in which the intervals in each case were equal in duration, the time from the commencement of one period to the commencement of the next was:

As regards the season in which menstruation first appears, Krieger states that in one-half of the women examined by him menstruation had begun in the autumn season, in the month of September, October, or November.

Szukits, as a result of an investigation into the menstrual functions of Austrian women, determined that among 1,013 women menstruation occurred:

135In 500 Jewish women, Hirsch found that menstruation occurred:

and in the remaining cases at other intervals than those stated. He is, therefore, of opinion that in the majority of Jewish women the type of menstruation is shorter then twenty-nine days.

According to Brierre de Boismont, among 100 women menstruation recurred:

Tilt found among 100 women that menstruation recurred:

Foster instituted inquiries regarding this matter in 56 healthy women. In 380 periods, 45 recurred after an interval of 28 days, 225 after a shorter interval than this, 110 after a longer interval. The duration of the flow varied from 1 to 14 days; most commonly it lasted from 3 to 5 days.

A peculiar change in the type of menstruation sometimes manifests itself in this way, that in women in whom the regular four-weekly type of menstruation has prevailed, exactly in the middle of this four-weekly period the menstrual molimina, with or without menstrual discharge, make their appearance; the patient suffers from pain in the lower belly, sacrache, sensation of weight, and bearing-down pains. Courty, Dubois, and Pajot Négrier have described such cases of molimen utérin intermenstruel, which Tilt denotes by the term remittent menstruation.

From the earliest times the process of menstruation has attracted the attention of natural philosophers, and has led them to formulate hypotheses and to institute investigations, especially in order to ascertain whether the connection between ovulation and menstruation is one of temporal succession merely, or whether the relation is a causal one.

From Hippocrates and Galen downwards until well beyond the middle ages, the view of the father of medicine was generally accepted, 136that menstruation is a purificatory process by means of which materials harmful to the organism are eliminated from the body—a view which finds expression also in the religious and legal ordinances of all times.

A new epoch of scientific research into the nature of menstruation began with de Graaf’s discovery of the ovarian follicles (1672). This discovery did not, indeed, bring ovulation and menstruation into immediate relationship, but it certainly paved the way for the opinion expressed by Sintemma, a countryman of de Graaf, that the ova, even in virgins, leave the ovary spontaneously, and by their contact with the capillary terminations of the bloodvessels give rise to the menstrual bleeding (1728).

As a result of anatomical investigations, Négrier, in 1840, was the first to establish the thesis that in women suffering from congenital absence of the ovaries, menstruation never occurs; that after the loss of the ovaries, menstruation always ceases; that during pregnancy and lactation and during the climacteric period, ovulation ceases; and that a relation of temporal succession obtains between ovulation and menstruation. This close relation between the two processes was maintained also by Gendrin at about the same date. Later, Girdwood, by post mortem research, proved that the number of scars in the ovary coincides with the number of previous menstruations.

Brierre de Boismont, in his exhaustive work on Menstruation, lays stress on the view that the periodically recurring ovulation furnishes the impulse for the menstrual flow. First among German investigators, Bischoff upheld the opinion that maturation and discharge of ova are spontaneous processes occurring independently of sexual intercourse, and compared heat or rut in other animals to menstruation in women—a view shared by Pouchet and Coste. Ovulation occurs simultaneously with the menstrual flow, and the follicles burst toward the end of menstruation.

Pflüger, in his important work on the significance and cause of menstruation, has demonstrated the causal connection between menstruation and ovulation. The bleeding and the discharge of the ova are according to him joint effects of a common cause. It is not the bursting of the follicle, but the ripening of the follicle, that gives rise to the menstrual congestion. The pressure of the growing follicle on the surrounding ovarian tissue gives rise to a continued stimulation of the ovarian nerves; the summation of these stimuli, which after the lapse of a certain time attain always a certain degree of intensity, results in a reflex from the spinal cord taking the form of great congestion of the genital organs; this congestion leads, on the one hand, to hæmorrhage from the uterine mucous membrane, 137and, on the other hand, and as a rule simultaneously, to the bursting of the ovarian follicle. The swelling and granulation of the uterine mucous membrane at every menstrual period signifies nothing else than the commencement of the formation of the decidua.

Nägele already mentioned the view, that inasmuch as immediately after the first appearance of menstruation a woman has become capable of reproducing the species, each process of menstruation must be regarded as a renewal of the exhausted faculty for conception.

Pflüger’s teaching has been opposed by Sigismund, who, whilst admitting the periodicity of ovulation and menstruation, yet regards the two processes, in the uterus the formation of the menstrual decidua, in the ovary the rupture of the graafian follicle, as independent of one another, even though they occur simultaneously. Should fertilization occur, the ovum implants itself in the prepared soil; should fertilization fail to occur, the menstrual hæmorrhage ensues. Thus, the occurrence of menstruation indicates that fertilization of the ovum has failed to occur. On this theory, then, the ovum that is fertilized belongs to the first period missed, whereas Pflüger assumes that when pregnancy occurs, it is always the ovum belonging to the time of the previous menstruation—the last actual menstrual discharge—that is fertilized.

Löwenhardt, in his work on the Diagnosis and Duration of Pregnancy, advances the same views as Sigismund. The fertilized ovum, in his opinion also, is that of the first period missed; and since at the time at which he believes fertilization to occur the ovum is certainly still in the ovary, fertilization, on this theory, must always take place in the ovary itself, and the fertilized ovum cannot begin its intra-uterine life till a month has elapsed after fertilization. Reichert, Kundrat, Engelmann, and Williams, basing their views on anatomical data, are of opinion that ovulation recurs periodically, and that the extrusion of the ovum occurs not before but after the commencement of menstruation.

According to Hensen, the observed facts support the view that the follicles burst as a rule toward the end of menstruation; anticipation or postponement of the opening of the follicle (conception before or after menstruation) would, however, appear not to be impossible.

Leopold, who assumes that menstruation may occur without ovulation and ovulation without menstruation, maintains on anatomical grounds that the rupture of the graafian follicle occurs chiefly during menstruation, under the influence of the swelling due to menstrual congestion. Menstruation with ovulation he believes to be a common occurrence, menstruation without ovulation, an unusual 138occurrence. Further, it is certain that, at the time when the periodic bleeding is due, ovulation may occur, even though the menstrual discharge fails to make its appearance (ovulation without menstruation).

Chazan and Gläveke also adhere to the generally accepted view that ovulation is a periodic process, usually but not necessarily synchronous with menstruation.

Strassmann bases on clinical facts and on experiments the following view of the connection between ovulation and menstruation. The principal processes in the organism of the sexually mature woman run their course in a periodic rhythm resembling an undulatory movement, the acme of which occurs in the antemenstrual period with the aim of preparing for the development of an infantile organism. Whilst an ovum is maturing in the ovary, in the uterus, in dependence upon this maturation, the antemenstrual mucous membrane, fitted for the reception and nutrition of the fertilized ovum, is also undergoing development. At the acme of the undulatory movement, the graafian follicle ruptures and the ovum is liberated, to undergo fertilization in the infundibulum of the Fallopian tube. If fertilization fails to occur, or if for any reason the graafian follicle fails to rupture, then, in consequence of and at the time of the highest intra-ovarian tension, at the time, when the rupture of the follicle usually occurs, the extrusion of blood from the capillaries of the uterine mucous membrane begins. The intermediation between the ovary and the uterus is probably effected by means of the sympathetic ganglion in the ovary discovered by Elizabeth Winterhalter, and effected in this manner, that the stimulus proceeding from the ripening follicle passes along the nerve-fibrils surrounding the follicle to the processes of the nerve cells of this sympathetic ganglion, accumulating in these cells till a certain degree of intensity has been reached, and then, by means of other processes and of the vasomotor nerves, influencing the vessels of the uterus.

Gebhard likewise believes menstruation to be dependent on the ovarian function, and thinks that it is probably brought about in a reflex manner by the gradual growth of the ovarian follicles. It appears that most commonly at the time of menstruation a graafian follicle ripe to bursting is to be found in the ovary, but to this rule there are many exceptions. We cannot exclude the possibility, that the ovum from a follicle that burst after the commencement of the menstrual flow may be fertilized; but more commonly the ovum that is fertilized is that of the first period missed. The sudden decline in vital energy that occurs just before menstruation is explained by Gebhard as a kind of atavism, dependent on the fact 139that many of the lower animals, butterflies, for instance, succumb as soon as they have fulfilled their duty of reproducing the species.

A number of modern investigators, however, deny that any relation, temporal or causal, exists between ovulation and menstruation, and affirm that the latter process is quite independent of the former.

Thus, Christopher Martin maintains that a special menstrual centre exists in the lumbar portion of the spinal cord, the impulses from which proceed to the uterus by way of the splanchnic plexus, the ovarian plexus, or perhaps by both. Similar views are held by Lawson Tait, Collins, and Johnstone, who severally maintain that the ovaries are no more concerned in the production of menstruation than any other organ of the body—the liver, for instance. They direct attention to the periodicity that occurs in the functional activity of various other organs, in respiratory and cardiac activity, for instance, both of which undergo rhythmical changes as a result of nervous influences. The cessation of menstruation after oöphorectomy they attribute, not to the cessation of ovulation, but to the division of the nerves which run across the broad ligaments of the uterus and upon which menstruation depends. Heat and rut in animals have a different significance from menstruation. The latter process is induced by civilization and by the adoption of the upright posture.

But, taking all this into consideration, we must hold fast to the fundamental principles, that ovulation occurs at that period of life, and only at that period, during which menstruation proceeds regularly; that ovulation begins when externally and in the whole development of the girl the signs of sexual maturity manifest themselves; and that ovulation ceases at the climacteric, when menstruation also ceases. We must regard as rare exceptions to this rule cases in which ovulation begins before the menarche and persists after the menopause.

A physiological interruption of menstruation occurs during pregnancy and lactation; it seems improbable, however, that during this interval ovulation also is in abeyance. It is established by anatomical investigations that ovulation and menstruation commonly occur in association; but that menstruation sometimes, though rarely, occurs in the absence of ovulation; and, finally, that intermenstrual ovulation is also a rare occurrence. In the majority of cases, either just before or just after the commencement of the menstrual flow, rupture of a graafian follicle occurs. After complete oöphorectomy, menstruation ceases; it is only when functionally active portions of ovarian tissue have been left behind, that menstruation continues to occur. In the absence of the ovaries, the menstrual function is 140in abeyance; hence, for the performance of that function, the presence of ripening ovarian follicles and of other follicles capable of ripening later, is an indispensable requisite.

A certain analogy between heat and rut in animals and menstruation in women may, according to the investigations of Bischoff, Hegar, Strassmann, and others, certainly be maintained. Heat or rut is a process occurring in mammals, dependent on the reproductive glands, characterized by an increase in sexual and general excitability, with congestion of the pudendum and the vagina, swelling of the sebaceous glands of the external genitals, and increased secretion; from the vulval cleft there flows a peculiar, strong-smelling mucus, often tinted red from admixture with blood; there is frequent micturition, the uterine glands are swollen, the Fallopian tubes are also swollen, and are soft and erected. A well-developed menstrual bleeding, analogous to that which occurs in the human species, occurs, among the lower animals, only in apes. Maturation of ova precedes the period of heat, and rupture of the graafian follicle occurs during that period.

Heat or rut occurs in animals at certain seasons of the year, which may, according to the species and the mode of life of the animal concerned, be in spring, summer, autumn, or winter. The season of heat or rut has further several periods of heat, each lasting several days, and among domesticated animals, mares, cows, and bitches, succeeding one another at intervals of three or four weeks; in wild animals, rut occurs once only in the year. In animals, sexual intercourse takes place during the time of the menstrual discharge, and during this time also the capacity for conception is increased; in the absence of heat, the genital organs are in a more quiescent condition. In this connection, the experiments on animals made by Strassmann, with a view to determining the influence upon the uterus of rise of pressure in the ovary, are of great interest; these experiments showed that a rise of intra-ovarian pressure, produced by the injection of fluid into the parenchyma of the ovary, led to changes in the endometrium and the external genital organs corresponding to those occurring in an animal on heat.

In the human species, however, in contradistinction to what occurs in the lower animals, there is a certain disinclination, on the part of the male at any rate, to sexual intercourse during menstruation. The human female moreover, notwithstanding the periodicity of her sexual life, is at all times capable of conception; this capability is not confined to any particular part of the intermenstrual period, for conception may occur at any time during that period, and has even been known to result from intercourse during menstruation. 141This peculiar characteristic of the human reproductive capacity has been regarded as compensatory, furnished by nature in her continual endeavour for the perpetuation of the species, to counteract the restricting influences imposed by civilization on the normal process of reproduction.

Credible observations even exist, indicating that among many primitive peoples, in whom at the time of puberty no social laws hinder the limitless exercise of the reproductive functions, this capacity on the part of woman to conceive at any time has no existence, and that the reproductive capacity of such human beings is, like that of the lower animals, confined to a certain season of the year. Thus, G. Schlesinger reports of the Ainus of the island of Yezo, “A friend of mine in Sapporo believes himself to have observed that the Ainus have a certain definite rutting period, and that in them, as in many of the lower animals, the process of reproducing the species occurs only at a certain season of the year.” An identical statement is current concerning the Indians of Western America.

The mucous membrane of the uterus undergoes during menstruation important changes, and a question much disputed is, whether in the course of menstruation the whole of the uterine mucous membrane is removed, or a part only, whether it is shed in its entire thickness, or is at least deprived of its epithelium. According to the observations made by Leopold on dead bodies, the mucous membrane of the uterus becomes swollen shortly before the commencement of the menstrual discharge, until, partly in consequence of cellular proliferation, partly in consequence of œdematous infiltration, and partly in consequence of enlargement of the lymph-spaces, it attains a thickness of 6 to 7 millimetres (¼ of an inch). The superficial capillaries are notably enlarged, and an effusion of blood-elements continues for several days, without the occurrence of any fatty degeneration in the tissues. The epithelium and the most superficial cell-layers of the mucous membrane are, however, undermined and shed. No complete destruction of the mucous membrane occurs, however, and fatty degeneration forms no part of the menstrual process as such.

Möricke, who examined portions of the uterine mucous membrane removed with the curette during menstruation from living women, found the superficial layers of the mucous membrane to be intact, and he regards the shedding of the epithelium described by other authorities as cadaveric phenomenon. Sinéty, who also found the uterine mucous membrane intact during menstruation, adheres to the same view.

Von Kahlden concludes, as a result of investigations made post 142mortem, that during menstruation the greater part of the mucous membrane, not the superficial epithelium only, but the stroma itself down to its deepest layers, is shed. According to von Tassenbroek and Mendes le Leon, however, the most superficial layers only are shed during menstruation.

According to Westphalen, whose investigations were made, partly on masses removed by the curette, and partly on freshly extirpated uteri, a sanguineo-serous infiltration of the mucous membrane begins about ten days before menstruation. Great vascular dilatation occurs only just before menstruation. The uterine glands undergo enlargement, and during and immediately after the flow, numerous shed epithelium cells occupy the lumen of the glands. For the rest, however, in the interior of the uterus shortly after menstruation, we find an almost continuous epithelial covering. Some days after menstruation, the proper regeneration of the mucous membrane occurs.

Mandl, who examined totally extirpated uteri, asserts that during menstruation the epithelial covering of the mucous membrane is never completely lost, but that just as little does it remain completely intact. The regeneration of the lost areas of epithelium proceeds even during menstruation.

The researches of Kundrat and Engelmann on uteri obtained post mortem led these authors to describe as follows the anatomical changes that occur in the uterine mucous membrane at the time of the catamenial hæmorrhage. In the premenstrual epoch a round-cell infiltration occurs in the interglandular tissue, the lumina of the uterine glands become enlarged, and the bloodvessels dilated; subsequently, fatty degeneration of the superficial epithelium and the epithelium of the glands occurs, leading to laceration of the vessels and destruction of the affected area of tissue; after the cessation of the bleeding, regeneration of the mucous membrane occurs.

According to Gebhard, three stages may be distinguished. The first stage is that of premenstrual congestion, or stage of engorgement: the capillary vessels of the mucous membrane become distended with blood, the membrane itself becomes softened, the meshes of the stroma become enlarged and are filled with the morphological constituents of the blood, subepithelial hæmatomata are formed. The second stage is that in which the blood finds its way to the exterior: owing to the turgescence of the mucous membrane the blood is able to exude between the cells of the intact epithelium; further, the epithelium becomes lacerated in various places where hæmatomata have formed beneath it, allowing the blood to exude through the apertures thus formed; shreds of epithelium may be washed 143away by the blood-stream. The third stage is that of post-menstrual regeneration: the swelling of the mucous membrane disappears, the detached areas of epithelium readhere, the blood effused into the interstices of the tissue is reabsorbed, or is in part transformed into yellowish-brown flakes of pigment. According to Gebhard’s view, during menstruation destruction of the uterine mucous membrane does not occur. At no time is the membrane denuded of large areas of epithelium; a very active process of regeneration occurs, however, in the superficial epithelium and the epithelium of the glands, which fits the uterine mucosa for the reception of the fertilized ovum by keeping it in an ever-young and renovated condition. The mucous membrane of the cervix takes part in menstruation at most by an increased secretion of mucus.

According to Landau and Rheinstein, the mucous membrane of the Fallopian tubes contributes to the menstrual hæmorrhage; Fritsch and Strassmann, however, are opposed to the view that there is a regular tubal menstruation.

Pathology of Menstruation.

Only a small proportion of girls and women are entirely free, at the time of menstruation, from all change both in their bodily and in their mental state. A very great majority complain of feeling more or less unwell, of sensations of weight and pressure in the hypogastric region, of a general feeling of languor, loss of appetite, headache, irritability, sometimes of an inclination to weep; in women, a change in the intensity of the sexual impulse manifests itself, an increase in some, a decrease in others.

Not infrequently during menstruation, the cardiac activity is notably affected, so that, regularly at the commencement of each period, disagreeable sensations occur in the cardiac region, with increased frequency of the heart’s action; or complaint is made of coldness and dampness of the hands, of icy coldness of the feet, which feel as if “dead” to half way up the calves, and cannot be warmed—phenomena which, in the cases under consideration, occur only at the time of menstruation, and are to be regarded as manifestations of the menstrual reflex.

I examined 140 women in whom the heart and the vascular system were normal, during a number of successive menstrual periods, and in 12 of these women, either at the commencement or during the course of the flow, I observed an increase in the frequency of the heart to the extent of from 12 to 28 beats per minute; in young girls, a systolic murmur was sometimes audible during menstruation, but was inaudible in the intermenstrual intervals. In all these persons, menstruation was regular; there was no abnormality in respect 144either of the duration or of the quantity of the flow. The heart in these cases was, therefore, affected by the normal menstrual process.

A remarkable illustration of the alleged influence of menstrual disturbances on the pulse is reported by de Villeneuve, who states that Chinese physicians, being accustomed to feel the pulse in many different arteries, are able, by a comparison of the characters of the pulse in the two arms, to determine whether a woman menstruates regularly or irregularly.

Many women and girls show well-marked menstrual molimina, uneasy or actually painful local sensations in the genital organs, sacrache, painful uterine contractions, and disturbances of the general constitutional state, which are dependent upon menstrual congestion of the pelvic organs, upon local engorgement; sometimes such symptoms are the result of uterine contractions caused by hyperæmia of the uterus, and these cases often take a paroxysmal form.

Important disturbances of the general constitutional state result from sudden suppression of the normal menstrual flow, such as may be the effect of a severe chill, of sudden mental impressions, even of errors in diet or the use of certain drugs, and may sometimes follow artificial withdrawal of blood.

In many women, a few days or it may be a few hours only before every menstruation, changing manifestations of manifold disorders may recur. Among these may be mentioned, general excitement of the nervous system, notable alteration in the voice, strong inclination to sadness, tearfulness, erotic longings, great irritability and sensitiveness of the sensory system, drowsiness, flushings of the face, giddiness, swooning. The appetite is impaired, the breath has a disagreeable smell, the digestion is disturbed, there is a tendency to diarrhœa; the facial aspect may be altered, there are blue rings round the eyes, eruptions on the skin, tendency to sweating, palpitation and feeling of anxiety, and a sensation in the extremities as if they had been beaten. Local symptoms also occur: disturbances of the function of micturition, swelling of the breasts, pains and colics in the renal region, feeling of warmth in the genital organs, pruritus vulvæ, sensation of weight in the uterus, and a strong impulse toward coition. The secretions may be pathological, sometimes there are profuse sweats, sometimes profuse mucous or bilious diarrhœa, whilst the urine may either be very abundant, almost colorless, and nearly free from saline matter, or thick and overladen with phosphates and urates.

Schauta writes regarding the complex of menstrual phenomena which occur in normal menstruation: “In the process of menstruation, 145blood and sanguineous mucus find their way through a mucous canal, the normal calibre of which is merely a capillary fissure. If the flow is slow, without the formation of coagula, and if the passage through the cervix is free, very gentle contractions of the uterine muscle suffice on the whole, as the blood exudes into the cavity of the uterus, to expel it into the vagina. Without such contractions, menstruation is hardly conceivable. Physiologically, they are characterized by a bearing-down sensation, passing down toward the thighs, and by pains in the back. It is rarely, that no pain at all is experienced; there are some women, however, who affirm that in their case menstruation begins quite unexpectedly, and without the slightest warning; but it does not follow that contractions of the uterus do not occur in these women also during menstruation. * * * The local disturbances which occur as an accompaniment even of physiological menstruation are, a sensation of fulness and weight in the pelvis, and pains in the lower part of the back, and these probably all result from the uterine contractions. The general disturbances of a reflex nature consist of tenderness on pressure in the epigastrium, headaches, general sense of languor, irritability, and an inclination to shed tears. Among changes in the functions of remote organs may be mentioned, swelling of the breasts, of the vocal cords, and of the thyroid body, increased respiratory capacity shortly before menstruation followed by rapid decrease during the flow, tendency to diarrhœa, nausea, vomiting, flatulence, salivation, profuse secretion of the sebaceous glands of the vulva, increased secretion of sweat, tendency to the formation of acne pustules. The mental condition also exhibits as a rule a considerable change during menstruation, even in cases which cannot in any sense be regarded as pathological. In many instances, an apparently normal woman may during menstruation exhibit a mental state so abnormal that we are led to speak of it as a menstrual psychosis. Apart from this, however, it appears that during menstruation the mental life of woman never remains entirely unaffected. Finally, we must mention certain changes in the sense-organs which not infrequently accompany menstruation, such as herpes conjunctivæ, exophthalmos, limitation of the visual field, and swelling of the nasal turbinate bodies.”

In the digestive organs, during the menstrual process, changes in the secretions of the glands, nausea, vomiting, and flatulence are not infrequently observed. In one-half of the women concerning whose state during menstruation Krieger made inquiries, he found, especially just before and during the discharge, a tendency to diarrhœa, or at least to more copious and more frequent evacuations of the bowels than occurred at other times. On the surface of the tongue, 146at the premenstrual epoch, a pronounced exfoliation of the epithelium may occur, so that in some instances the papillæ are entirely exposed.

Not infrequently hyperæmia of the liver appears to be connected with the menstrual process; and by many observers, among whom Senator and Fleischmann may be mentioned, jaundice, slight or intense, has been seen to occur during menstruation. In a case of long-standing amenorrhœa, Duncan noted the appearance of a transient vicarious jaundice, apparently reflex in its origin. In some cases, jaundice precedes menstruation, and disappears as the flow becomes established.

In the respiratory organs also, menstrual changes frequently occur. According to von Ott, respiratory capacity attains a maximum shortly before menstruation, and diminishes rather rapidly during the flow; the expiratory power is similarly affected. In the larynx, according to Bottermund, great swelling of the posterior wall occurs during menstruation, whereby the closure of the glottis is hindered, and a rapid onset of fatigue ensues in the muscles that perform this action when the woman sings or speaks; the fulness of the voice is also diminished. More or less extensive swelling of the thyroid body^[32] occurs during the menstrual period. According to Fliess, in most women, the inferior, sometimes the middle and the inferior nasal turbinate bodies are greatly swollen; sometimes also the tubercula septi are swollen. It is said that the right half of the nose is more frequently and more intensely swollen than the left half. Epistaxis is sometimes observed at the menstrual periods.

In the urinary organs, the influence of the menstrual period is manifested by a change in the urine. According to Schrader, the elimination of urea is diminished shortly before menstruation; according to Laval, the elimination of uric acid undergoes a sudden diminution on the second day of the flow, followed by an increase on the third day, subsequently rising above the normal level. This change is to be attributed, not to any excitation of the genital organs, but to the loss of blood.

Hebra already drew attention to the connection between diseases of the skin and the physiological and pathological processes occurring in the female genital organs; and emphasized the fact that for the cure of certain eruptions, local treatment of the disorder of the reproductive organs was requisite. He gave four examples of such eruptions: 1, an acute attack of eczema, which disappeared only after the removal of a badly fitting pessary; 2, in a chlorotic girl, two large red spots on the cheeks disappeared when menstruation was established; 3, improvement of a skin-affection when a coexisting 147disorder of the genital organs received appropriate treatment, followed by recrudescence of the skin trouble when the genital disorder became more severe; 4, a case of obstinate seborrhœa, lasting for many years, which disappeared only when the patient became pregnant, for the first time, seven years after her marriage.

Similar cases have been recorded by subsequent observers, and numerous monographs have been published on menstrual skin-eruptions. Schramm, for instance, reports the case of a woman in whom at each menstrual period tubercles and papules appeared on the backs of the hands and on the neck; and the same author mentions another case in which during menstruation red papules arranged in rows appeared on the back. Wilhelm observed dark blue macules, the size of hazelnuts, which appeared on the thighs shortly before menstruation and disappeared when the flow was over. Of two cases of menstrual disorder of the skin reported by Stiller, in one, an itching eruption appeared on the upper and the lower extremities; in the other, small red papules appeared on the dorsum of the hands and feet. Other cases of menstrual skin-eruptions were published by Joseph, Pauli, Janovsky, and Schwing. Sometimes at the menstrual periods severe pruritus vulvæ occurs, due, no doubt, to the temporary increase in the secretion of the menstrual passages, and to the more active influence exercised by this secretion on the vulva.

In two cases in which the menstrual flow was in abeyance, Heitzmann observed affections of the skin. In one of these, a young woman aged twenty who had not yet begun to menstruate, there appeared every four weeks isolated papules surrounded by a bright red areola, itching so violently that scratching resulted. In the other, macules the size of a lentil, of a light red or dark red color, appeared, and lasted two or three days; when menstruation became regular, fresh crops no longer formed.

Schauta, in a case of chronic oöphoritis, observed the regular recurrence of urticaria at each successive menstrual period. The suffering being very great, the rest at night being greatly disturbed during the periods of eruption, and the patient’s general health declining more and more in consequence, extirpation of the ovaries was undertaken, and the operation resulted in a complete cure. Schauta further observed that in cases of obstinate skin-affections of unknown causation occurring in persons of the female sex, some disorder of the genital organs was nearly always present; moreover, in many of these cases, as soon as the genital disorder was cured by appropriate measures, the skin-affection disappeared spontaneously and without any further treatment. He had been able to collect twenty-six cases of this nature, in which an indubitable 148connection obtained between disease of the skin and disease of the reproductive system. The forms of affection of the genital organs chiefly noticed in this association were, retroflexion and retroversion of the uterus, erosion and ectropium or eversion of the cervix (chronic cervical catarrh), chronic endometritis, oöphoritis, and salpingitis, and finally with especial frequency uterine myomata; the skin-diseases observed were, acne, eczema, disorders of pigmentation, psoriasis, lichen, and urticaria.

During menstruation we observe not infrequently a number of changes in the skin, such as hyperidrosis, acne, seborrhœa, erythema, and the form of dermatitis known as erysipelas of menstruation; sometimes also effusion of blood into the skin as a form of vicarious menstruation, and peculiar forms of cutaneous œdema. In many women during menstruation the secretion of sweat is markedly increased every month; in exceptional cases, menstruation is vicariously replaced by profuse sweating. In association with menstruation we frequently observe excessive secretion of the sebaceous glands, especially of those of the hairy scalp. Often urticaria manifests itself as a recurrent menstrual eruption. In cases of scanty menstruation and of amenorrhœa, discoloration and excessive pigmentation of the skin may occur, sometimes taking the form (as also in pregnancy) of chloasma uterinum. Sometimes also in these cases the formation of dark rings round the eyes, already seen in slighter degree as an accompaniment of normal menstruation, is excessive.

In the organ of vision, changes associated with menstruation have been recorded by various observers. Hordeolum menstruale (menstrual stye) may recur month after month at the menstrual periods as an exacerbation of a chronic conjunctivitis. Herpes of the ocular or palpebral conjunctive and eczematous affections may be connected with menstruation; also exophthalmos may occur during menstruation in association with swelling of the thyroid body and palpitation of the heart (H. Cohn); again, as an accompaniment of normal menstruation, severe papillitis with retinal hæmorrhages may occur (Heber). According to the investigations of Finkelstein, a limitation of the field of vision may be noticed during menstruation, beginning on the first, second, or third day of the flow, attaining its greatest intensity on the third or fourth day of the flow, and gradually disappearing during the three or four days next ensuing.

The organ of hearing is stated by Haug to be affected during menstruation, inasmuch as congestive redness and swelling of the external ear, of the external auditory meatus, and of the skin over the mastoid process, sometimes occurs; occasionally also, periodic neuralgia manifests itself at the menstrual periods.

149In the circulatory organs, as already mentioned, normal menstruation quite frequently manifests its influence by the production of disorders of greater or less severity, referable to the stimulus of ovulation. In 8.5 per cent. of the women of whom I have made inquiries with regard to this matter, palpitation of the heart of variable severity occurred during menstruation, and was most frequent and most severe on the first and second days of the flow. Associated with the palpitation in some cases were, vasomotor disturbances, transient feelings of heat, a sense of congestion in the head, and profuse perspiration without apparent cause. The day before the commencement of the flow, the blood-pressure rises considerably, but falls rapidly during the flow. This menstrual rise in blood-pressure is accompanied by a rise in temperature and an increase in metabolic activity. The influence of menstruation on the heart is most powerfully displayed in cases in which for some reason a disturbance occurs of the normal appearance or normal course of menstruation.

Disorders of menstruation likely to give rise to cardiac disorders are, amenorrhœa, menorrhagia, and dysmenorrhœa.

Amenorrhœa is especially apt to induce cardiac disorder in cases in which, in consequence of some sudden impression, such as a fright or a severe chill, menstruation, which began at puberty in normal fashion and subsequently recurred with perfect regularity, has undergone sudden and complete suppression; also in cases in which severe anæmia or obesity has rapidly led to the onset of amenorrhœa. In such cases, attacks of tachycardia sometimes occur, it may be at irregular intervals, or it may be exhibiting a menstrual rhythm, the cardiac affection manifesting itself always a few days before the date at which menstruation ought to begin. In these cases, also, systolic murmurs are not infrequently audible.

In cases in which menstruation is very painful, the dysmenorrhœa may give rise to attacks of colic or to convulsive seizures, whether the dysmenorrhœa is itself due to inadequacy or to complete suppression of the flow, to metritis, to anteflexion, to new growths in the uterus, or, finally, to diseases of the ovaries or to pathological disorders of ovulation. Among the various disorders associated with dysmenorrhœa, heart troubles are not infrequent, most often taking the form of reflex neuroses, evoked by the stimulus of the pain in the genital organs; but it has also been asserted that an acute dilatation of the heart occurs in these attacks.

Very threatening cardiac symptoms as an accompaniment of severe dysmenorrhœa have been seen by me especially in the case of two women, one of whom was in the thirties and the other in the forties. The attacks took the form of increased frequency of 150the heart’s action, with severe cardiac dyspnœa on trifling exertion, sense of suffocation, and intense anxiety. This severe cardiac and respiratory distress was a sequel to the appearance of severe dysmenorrhœa, and was relieved as soon as the course of menstruation became regular and painless; but the cardiac trouble recurred in association with each successive attack of dysmenorrhœa. In one of these two women, the dysmenorrhœa was the result of extreme anteflexion of the uterus; in the other woman, the cause of the dysmenorrhœa was not apparent. I was unable to decide with certainty whether in these cases an acute dilatation of the heart occurred. French authorities, who describe similar cardiac trouble resulting from diseases of the liver and the stomach by the name of asystolic gastrohépatique (Potain), give the following explanation of its mode of occurrence. The intra-abdominal plexus of the sympathetic is stimulated, this stimulus is reflected to the lungs, in which organs it gives rise to vaso-constriction, resulting in increased tension in the lesser circulation; in consequence of this the right heart has difficulty in emptying itself, when weak it undergoes dilatation, and a moderate or extreme tricuspid insufficiency ensues. We have to do, then, in these cases, with reflex symptoms, with a reflex arc, the starting point of which is the sensory nerve-terminals in the abdomen, the afferent tract of which is formed by the sympathetic and pneumogastric nerves, and the efferent tract of which passes along the pulmonary sympathetic nerves.

In other cases of dysmenorrhœa we observed signs of cardiac weakness; the pulse was small, very frequent, and barely perceptible, the face became suddenly pale, the hands and feet were cold; complete syncope sometimes occurred.

Menorrhagia sometimes leads to cardiac symptoms, owing to the severity of the anæmia which follows extensive and long-continued loss of blood; sometimes, however, the heart troubles associated with menorrhagia are reflex manifestations, dependent on the disease which has also caused the menorrhagia, endometritis, it may be, new growths, lukæmia, or scurvy. Sometimes here also we observe transient attacks of acute dilatation of the heart.

Nervous disturbances during menstruation, which are so frequent that Emmet regards it as abnormal for a menstruating woman to be entirely free from pain and from uneasy sensations, are divided by Windscheid into two classes, general nervous disorders, and local nervous manifestations. Among general disorders, the commonest is a general bodily incapacity; in women, who in other respects are quite healthy, during menstruation everything will be too great an exertion, and fatigue speedily ensues on the performance of occupations which at other times are undertaken 151without the slightest difficulty. Another common nervous disorder is an uneasy sensation in the head, it may be a feeling of weight or pressure, sometimes described as a feeling as if an iron band were compressing the forehead. Slight mental irritation is commonly present also, the woman is capricious, her mental equilibrium is disturbed. Very common also are vasomotor disturbances, transient feelings of heat, a sense of congestion in the head, or an outbreak of perspiration. Among local nervous disturbances, Windscheid enumerates, pains in the back (occasionally and erroneously described as spinal irritation), sacrache, pains in the lower extremities, which by preference generally take the course of the great sciatic nerves. Pains in the abdomen also frequently accompany menstruation; these may be diffused over the whole abdomen, or may predominate in the two hypochondriac regions. Disorders of the sense-organs sometimes occurring during menstruation are, the flickering of objects before the eyes, photophobia, and tinnitus aurium. The heart may also be affected with palpitation in association with these nervous disturbances; the stomach may exhibit associated disorder in the form of cardialgia, or more frequently in the form of vomiting, this latter being very frequent at the outset of the flow. Less common is profuse diarrhœa, pain in the anus, or spasm of the sphincter ani.

The intensity of such nervous manifestations during menstruation is dependent upon the woman’s general state of nutrition, upon the degree of instability of her nervous system, and upon her occupation. Robust and powerful women, regularly employed in the open air, such as the wives and daughters of farmers and agricultural laborers, are much less affected by the nerve-weakening influences of menstruation than the sedentary and anæmic town-dwelling women, whether these latter belong to the higher classes of society and are addicted to nerve-straining enjoyments, or to the class of shop-girls, seamstresses, and factory-women, whose employment is apt to lead to nervous exhaustion.

As regards the forms of neuralgia most apt to accompany menstruation, Windscheid mentions trigeminal neuralgia as the commonest, especially affecting the first division of the nerve, and producing localized pains which are to be distinguished from the headaches already mentioned. They are characterized by their intensity and their persistence in spite of anti-neuralgic treatment, and by their spontaneous disappearance as soon as menstruation is over. According to the same author, the relations between hemicrania and the process of menstruation are indisputable; at the very least it must be admitted that menstruation predisposes to an attack of hemicrania.

152Cases also occur in which convulsions almost invariably accompany menstruation, convulsions which are to be regarded as symptoms of hysteria.

The extraordinarily powerful influence which the menstrual stimulus exercises on the mind is shown by the frequency with which the slighter psychopathic states occur as an accompaniment even of normal menstruation, these manifestations being sometimes melancholic in type, sometimes maniacal or erotic, and, when of long duration, leading ultimately to pronounced mental disorder. This influence of the menstrual stimulus is yet more potent in cases in which important changes in the course of menstruation have occurred, in cases, for instance, of suppressed, painful, or irregular menstruation. In this connection, however, in order to avoid a confusion of cause and effect, we must carefully bear in mind, that it is a much commoner causal sequence for psychical disorders to disturb the normal course of menstruation, than for disorders of menstruation to evoke psychical disorders. This view has only quite recently become established, and for this reason it is necessary to regard such data when obtained from the writings of the older gynecologists in a somewhat critical spirit.

By the modern alienist, the influence of the menstrual reflex on mental affections is recognized only in cases in which a proper valuation of the predisposing causes has been made, in such cases as the following: First, we have to recognize the modifying influence exercised by the menstrual stimulus on established psychoses, inasmuch as these latter not infrequently undergo cure when previously irregular menstruation has become regular, and, moreover, the recurrence or the first appearance of menstruation has often a powerful influence on the course of some established mental disorder. In some cases this influence is a strikingly favorable one on psychoses that have developed before the commencement of menstruation, or during the suppression of that function; it may be, however, and, indeed, more frequently is, an unfavorable influence, inasmuch as such a psychosis, on the first appearance or on the reappearance of menstruation, may assume a menstrual type, the attacks becoming more frequent or more violent with the successive recurrence of each menstrual or premenstrual period. This is the history of the typical menstrual psychosis.

Again, certain processes of the sexual life, disorders of menstruation, diseases of the genital organs, operations on these organs, and the processes of the climacteric, influence the origin and the character of mental disorder, generally giving rise to chronic affective insanity (insanity of the emotions and feelings) or to paranoia (chronic delusional insanity, insanity of the intellect). The menstrual 153stimulus must in these cases be regarded as a psychopathically exciting physical cause.

Further, physical disturbances may equally affect the menstrual function and the functions of the mind, rendering the exact causal sequence in such cases a difficult one to determine; and, conversely, the circumstances that restore the normal working of the mind may also regulate the menstrual function.

Finally, we may have to do with isolated sporadic occurrences in which the exciting influence of menstrual processes may be traced. Thus, for the outbreak of a periodical menstrual psychosis, an especial temporal predisposition must exist, connected with the great developmental epoch of the sexual life.

There is, for instance, a group of transitory states occurring during menstruation, and taking the form of disorders of the intelligence or of explosive emotional states; such may be witnessed, not in those suffering from psychopathic predisposition, but in quite healthy individuals.

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; 154the 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 155of 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 156impulsive 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.

The consciousness may be more or less disturbed. Von Krafft-Ebing points out, as a very dangerous peculiarity of the menstrual psychoses, that the fact that the morbid process has once occurred in connection with menstruation furnishes in itself a sufficient reason for the recurrence of such attacks, which are dependent on 157constantly repeated functional changes in the brain closely analogous to those that occur in epilepsy. When the menstrual insanity recurs frequently, it gradually becomes less acute in its characters and more protracted in its course; the lucid intervals are less clearly indicated and shorter in duration; and thus in course of time the mental disorder may be transformed into chronic imbecility—a transformation liable to occur in all forms of periodic psychosis. In such cases we must always assume the existence of a certain lack of resisting power on the part of the organism, especially of the nervous system, which amounts to a congenital predisposition. During the period of full menstrual activity, the favorable soil for the cultivation of such disorders is usually furnished by anomalies of menstruation, by difficult labor and its consequences, severe losses of blood, prolonged lactation, physical over-exertion, and mental shock and stress.

In the development under the influence of menstruation of such periodic acute mental disorders, we may observe various gradations, as for instance short, syncope-like cataleptic seizures, states of hallucinatory confusion lasting several hours or several days, disordered consciousness, and even severe mania.

Such a case was observed by Wille. Under the influence of menstruation and of a trifling source of mental disturbance (having soldiers billeted on them in a quiet country village), a young woman aged twenty-one, whose mental health had previously been good, had a sudden attack of anxiety, succeeded by a violent but transitory mania, lasting five or six hours; after a short free interval came another attack, this time lasting several days. Similar cases were recorded by Friedmann. A blooming and healthy maid-servant eighteen years of age (some mental unsoundness was recorded in both grandfather and aunt on the maternal side) fell asleep in a chair a few days before menstruation, awakened with a start, was subsequently disordered in mind, though tranquil, with many hallucinations, listening to voices which repeated monotonously “they come,” was drowsy, and slow to answer when spoken to. On the third day she was recovered, her mind being clear and normal; she was not fully aware of what had happened. Since this attack, her mind has been free from disorder, during menstruation as well as at other times. She is said to have had a similar attack about four years ago, that is, at the commencement of puberty.—A girl aged thirteen, quite healthy, not nervous, physically rather powerful, with quite healthy family history. Complaints of having suffered for two days from general sense of depression with pains in the abdomen; during the afternoon was lying on a sofa, but suddenly sprang up, looked extremely anxious and confused, ran 158about the room, begged to be protected from the black man, etc., her speech was disconnected, gabbling, and difficult to understand. After two hours she became quiet, and fell into a sound sleep, from which she awoke calm and quite forgetful of what had passed. On the following day menstruation appeared for the first time, with abdominal pains, but without any mental abnormality. During the subsequent six years she has remained quite well.

Since the days of antiquity an extremely important part has been assigned to suppression of the menses in the production of mental disorders; but in the opinion of modern alienists, who are opposed to the old humoral pathology, no more is to be recognized in this connection than the ordinary menstrual stimulus, which, indeed, when the soil is already prepared, may furnish a causal determinant for an increase in the intensity of an already existing anomalous mental condition. Quite recently numerous cases have been published in which such an influence has been recognized as powerful. Von Krafft-Ebing writes: “In isolated cases, as a sequel of sudden cessation of the menstrual flow, generally, due to a fright or to a chill, the development of insanity (usually acute mania) has been observed, and the suppression of menstruation has been regarded as the causal determinant. It is indeed conceivable that the connection between the two events is supplied by a collateral vicarious congestion of the brain. As a rule, however, the psychosis and the suppression of menstruation are the coeffects of the same cause, and are both of vasomotor origin.”

Mairet reports a case of violent mental disorder of a maniacal type, associated with chorea, occurring at puberty, the exciting cause of which, in a constitution hereditarily predisposed to insanity, he believed to be suppression of the menses. Diamant had under observation a girl in whom, at the age of six years, menstruation ceased, having previously been regular since the age of two years; after the suppression of menstruation, violent epileptiform seizures set in, occurring at what should have been the menstrual periods. Westphal described a case of infanticide committed in a state of melancholia at the proper menstrual period, the menses being suppressed.

Menstrual psychoses are observed for the most part in comparatively young women; after the age of thirty-five they are uncommon. Among von Krafft-Ebing’s cases there were:

The same author insists that for the development of a menstrual psychosis a predisposition on the part of the brain must exist, either 159in the form of an inherited predisposition, or in the form of a primary mental disorder, or, finally, as the result of some special exciting cause, such as emotional disturbance, the abuse of alcohol, or bodily illness. Among 19 cases observed by von Krafft-Ebing

Very remarkable is the influence, demonstrated especially by Lombroso, exercised by menstruation on the commission of certain crimes. Of eighty women taken into custody for resisting the police, there were nine only who were not menstruating at the time. Four notorious murderesses and one woman convicted of arson were all menstruating at the times when their crimes were committed. Krugenstein found evidence of menstruation in the bodies of 107 women who committed suicide. Thefts committed by ladies in the great shops of Paris are most commonly effected during menstruation, as was found by Legrand du Saulle to be the case in thirty five instances out of fifty-six investigated by him in respect to this matter. According to the same author, hysterical girls who steal articles of clothing, bottles of scent, and the like, from the counters of shops, are almost always menstruating at the time.

Von Krafft-Ebing puts forward the following propositions with regard to the forensic significance of offences committed by women during menstruation: 1. The mental integrity of a menstruating woman is questionable from the forensic standpoint. 2. In the case of women on trial for any offence, the point should be determined whether that offence was committed at a menstrual period. 3. An inquiry into the mental condition is expedient in cases in which such a coincidence is established; light is thrown on the matter when investigation shows the existence of hereditary predisposition, when we learn that psychopathic manifestations have occurred at previous menstrual periods, or when the very nature of the offence is one suggesting the presence of mental disorder. 4. A recognition of the powerful influence which the menstrual process exercises upon the mental life should lead, even in cases in which no menstrual psychosis has been proved to exist, to the admission of extenuating circumstances in apportioning the punishment for the offence. 5. In the case of the commission of a punishable act during menstruation by a weak-minded individual, we must as a rule admit the plea of irresponsibility—at any rate in the case of an offence committed under the influence of strong emotion. 6. Persons who have been discharged without punishment on the plea of mental disorder accompanying menstruation must be regarded as dangerous to the community, and should always be under careful supervision during the menstrual periods.

Amenorrhœa, permanent or transient abnormal lack of the menstrual flow, may depend upon anatomical changes in the genital organs, upon incomplete development or absence of the uterus and the ovaries, upon enduring or transient defective nutrition or upon atrophy of these organs, or upon parenchymatous disease of the ovaries; or it may be due to functional disturbances of ovarian activity, itself dependent upon changes in the nervous system, upon constitutional diseases, or upon general nutritive disturbances in the body. Among the latter conditions must be especially mentioned chlorosis, obesity, diabetes, chronic alcoholism, and morphinism, myxoedema, exophthalmic goitre, etc.

The amenorrhœa that occurs at the time of the menarche has already been described in connection with the symptomatology of that period.

If in cases of amenorrhœa the ovaries continue to perform their functions, we frequently witness severe and painful menstrual molimina, occurring periodically at the times when the flow might be expected, but fails to appear. In cases of atrophy of the uterus and the ovaries, we see complete and permanent amenorrhœa without any discomfort. As a kind of vicarious menstruation, in certain cases of amenorrhœa, we see hæmorrhages into the vitreous body or conjunctival hæmorrhages; also, as more extensive disturbances of the visual organs, interstitial keratitis, disseminated choroiditis, intermittent amaurosis, acute retrobulbar neuritis, amblyopia, and limitation of the field of vision.

Mooren publishes the following cases, showing the influence of amaurosis on the eye. A girl aged fourteen, with severe bilateral pannous keratitis, was amenorrhoeic notwithstanding the existence of well-marked menstrual molimina. Every four weeks, at the times when the menstrual flow should have appeared, the corneal inflammation became more severe; it became amenable to treatment for the first time a year later, when the menstrual flow had become established. A peasant woman, twenty-eight years of age, had never menstruated; the uterus was badly developed; every month an intolerable heat and swelling of the face recurred. Since the age of fifteen she had suffered from bilateral interstitial keratitis, which had resisted all treatment, and had been subject every four weeks to a recurrent exacerbation of this trouble, lasting several days. The exhibition of powerful emmenagogues and the use of Friedrichshall water brought about on a few occasions a scanty discharge of blood. The comfort to the patient, relieved as if by miracle from her pain and photophobia, was most remarkable. Unfortunately, however, this state of comparative happiness lasted from twelve to fourteen 161weeks only, after which, in spite of everything that was tried, there was no further recurrence of menstruation, and the condition of the eyes relapsed to what had existed for thirteen years. In other cases described by Mooren the amenorrhœa was complicated with disseminated choroiditis and with posterior sclero-choroiditis.

Beer reports a case of retrobulbar neuritis occurring with amenorrhœa, consequent on infantile aplasia of the uterus. An interesting case was recorded by Dunn of a girl fifteen years of age, who had not yet begun to menstruate, and who suffered from interstitial keratitis, with severe photophobia. The ocular symptoms vanished with extreme rapidity as soon as menstruation first appeared. Napier observed complete blindness, without discernible anatomical cause, associated with amenorrhœa of sudden onset; the amaurosis disappeared as soon as menstruation was re-established.

Striking and manifold are the disturbances of the nervous system which may be caused by amenorrhœa, ranging from increased irritability, hyperæsthesia of various nerve tracts, neuralgia, and the like, to severe psychoses.

Barnes reports a case of mental disturbance consequent upon amenorrhœa in a woman twenty-seven years of age, who had begun to menstruate when sixteen years old, and in whom the menses had been suppressed a year earlier when she was informed of the sudden death of her father. From that time a progressively increasing weakness of the mind was observed. In a case recorded by Macnaughton Jones the mental depression consequent on amenorrhœa was so great that it led to an attempt at suicide.

Lawrence observed in young girls who from any cause suffered from amenorrhœa, that an increased pigmentation of the skin sometimes occurred, analogous to that met with in Addison’s disease. This amenorrhoeic pigmentation he compares to the chloasma that is seen in pregnant women.

By menorrhagia we understand the occurrence of typical discharges of blood from the uterus, occurring at more or less regular intervals and differing from normal menstruation in respect either of the greater intensity or of the longer duration of the hæmorrhage; whereas by metrorrhagia we understand the occurrence of atypical discharge of blood from the uterus, which is related to menstruation neither in respect to its causation nor in respect to the time of its appearance.

Menorrhagia may be due to local changes in the genital organs, to organic diseases of other organs, and to general diseases.

Local changes which may give rise to menorrhagia are, active hyperæmia and passive hyperæmia (hyperæmia from engorgement) of the genital organs, such hyperæmia being itself due to sexual excitement, 162especially when ungratified, to violent physical exercise, or to chill during menstruation; menorrhagia is also liable to occur when the abdominal circulation is disturbed by extreme obesity or by the presence of tumors, also in connection with endometritis, uterine myomata, erosions of the cervix, etc. Diseases of organs other than those belonging to the reproductive system which are especially likely to give rise to severe bleeding are, disease of the heart, such as valvular incompetence, lung disease, and nephritis. General diseases in which menorrhagia may occur are, anæmia, chlorosis, hæmophilia, scurvy, scarlatina, cholera, smallpox, influenza, and obesity.

Through severe loss of blood in menorrhagia, whether the bleeding be sudden and profuse or more moderate but long continued, a condition of chronic anæmia results, with all its threatening consequences to the health and the life of the woman affected. She becomes pale and weak, unfitted for any great physical or mental exertion, and is liable to attacks of cardiac enfeeblement and to fainting fits; in some cases degenerative changes ensue in the cardiac muscle.

Dysmenorrhœa is characterized by severe pain occurring before, during, and after menstruation. The pain is caused either by abnormally powerful contractions of the uterus or else by abnormal sensitiveness of that organ. Abnormally powerful contractions are caused by various mechanical hindrances to the normal processes of menstruation; abnormal sensitiveness is due to inflammatory and congestive states of the uterus and its annexa or to a general increase of nervous sensibility.

Schauta, therefore, distinguishes a mechanical, an inflammatory, and a nervous form of dysmenorrhœa. Mechanical dysmenorrhœa is most frequently due to stenosis or flexion of the canal of the cervix in some part of its course from the internal to the external os, dependent upon malformation or flexion of the uterus, hyperplasia of the mucous membrane, chronic metritis, scarring resulting from operative procedures, uterine polypi, etc. In inflammatory dysmenorrhœa we have to do “either with an inflammatory process or with excessive tension of the intrapelvic organs, dependent upon abnormal distension of their blood vessels.” To the same category belong ovarian dysmenorrhœa, and dysmenorrhœa due to inflammatory changes in the Fallopian tubes and to pelvic peritonitis. In nervous dysmenorrhœa, no anatomical cause is apparent, but the uterine contractions normally occurring during menstruation, and the normal congestive distension of the intrapelvic organs at that period, become extremely painful, in consequence of a morbid increase in the sensibility of the nervous system.

163The influence of dysmenorrhœa on the general condition of the woman suffering from it is often a very potent one.

The normal undulatory course of the bodily temperature—which as Reinl has shown, undergoes a gradual rise until shortly before the appearance of the menstrual flow, gradually falls during menstruation, and continues to fall for a time after menstruation is over—undergoes a change in cases of dysmenorrhœa due to anteflexion of the uterus, parametritis, or salpingitis, inasmuch as in these cases the acme of the temperature curve is reached actually during menstruation and the decline of temperature comes, not at the commencement of the menstrual flow, but often only after the flow has ceased. The curve of blood pressure and the curve indicating the excretion of urea are similarly affected in these cases.

As symptoms in other organs occurring in cases of dysmenorrhœa Schauta mentions “sensations of heat, coldness of the feet, retching and vomiting, cramps of the stomach and of the voluntary muscles, general disorders of nutrition, loss of appetite, strangury, constipation, dyspepsia, headache, and finally hysteria. As symptoms of the latter affection we may notice, anæsthesia, hyperæthesia of certain parts of the abdomen, attacks of cramp, paralysis, uterine cough, hiccough, spasm of the glottis, epileptiform seizures. The repeated severe attacks of pain may seriously disturb the nervous system, leading to the appearance of general neuroses and psychoses. Frequently we observe, as a peculiar accompaniment of dysmenorrhœa, changes in the fulness of the blood vessels of the face and also in other regions of the skin, in consequence of vascular paralysis. In other cases, actual effusion of blood occurs, and, as a sequel of this, deposits of pigment; and the semicircles beneath the eyes may become so dark as to look as if they had been artificially tinted (Macnaughton Jones). In one case, during menstruation periodic swelling of the gums was observed (Regnier). Finally, in association with dysmenorrhœa, various forms of neuralgia, changes in refraction, and slight attacks of neuritis and retinitis may occur.”

One of the commonest symptoms and sequelæ is headache, sometimes in the form of hemicrania, which may be associated with dyspeptic manifestations, sometimes diffused over the whole surface of the skull.

Dyspepsia is a very frequent associate of dysmenorrhœa. Thus we meet with pain and tenderness in the gastric region, nausea, vomiting, and also cardialgia. Sometimes the liver becomes enlarged and tender on pressure; in many cases also jaundice is witnessed.

Gebhard refers to another phenomenon which may be classed under the head of dysmenorrhœa, from the character of the pain 164that is experienced, even though this pain is not felt at the menstrual periods, but in the intermenstrual epoch. This is the so-called intermediate dysmenorrhœa (intermenstrual pain, Ger. Mittelschmerz). In the character of the localized pain, intermediate dysmenorrhœa closely resembles ordinary dysmenorrhœa; it recurs often with precise regularity on certain days during the intermenstrual interval. Croom distinguishes three forms of intermediate dysmenorrhœa; that in which there is no discharge at all from the uterus, that in which there is a sanguineous discharge, and that in which there is a clear watery discharge. The first form he attributes to asynchronism in the processes of ovulation and menstruation; the second form, to endometritis with disintegration of the mucous membrane; the third, to a kind of hydrops tubæ profluens (profluent dropsy of the Fallopian tubes—hydrosalpinx in which the fluid accumulates in the tube, and at a certain stage of its accumulation flows into the uterus). Cases of intermediate dysmenorrhœa are somewhat rare, if we eliminate the cases in which pains occur in the intermenstrual epoch in consequence of disease of the uterine annexa. Inflammatory manifestations may be discovered in nearly all typical cases of intermediate dysmenorrhœa.

Long-continued dysmenorrhœa may give rise to numerous hysterical troubles, general convulsive seizures, local muscular spasm and paralysis, hiccough, spasm of the glottis, uterine cough, twitching and spasm of various groups of voluntary muscles. In some cases we see fully developed epileptic convulsions, with complete loss of consciousness and immobility of the pupils. Finally, psychoses may arise in association with dysmenorrhœa.

In cases of pathological changes in menstruation, a carefully arranged hygiene at the menstrual periods is of importance both for prophylactic and for therapeutic purposes, and in this connection I may refer to what I have written in the section on Hygiene during the Menarche. In cases of dysmenorrhœa a certain amount of repose and precaution are needed during the flow, with avoidance of chill, scrupulous cleanliness, and regulation of the bowels. In cases of amenorrhœa we must prescribe attention to the general nutrition by means of an easily digested roborant diet, as much fresh air as possible, and systematic bodily exercise. In these cases, bicycling, lawn tennis, and suitable gymnastics are often of value; also baths, in the form of warm general baths, hot sitz baths, and hot foot baths.

Vicarious Menstruation.

In cases in which, in consequence of morbid conditions of the uterus, the ovaries, or the organism as a whole, the menstrual flow has at the time of the menarche either failed entirely to appear or 165been exceedingly scanty, hæmorrhages from other organs have since ancient times been witnessed, and these hæmorrhages have been regarded as vicarious menstruation. The congestion that occurs during menstruation is not limited to the genital organs, and when the flow of blood from the uterus fails to occur, the organism seeks another outlet, in order to restore the disturbed equilibrium of blood distribution, and vicarious hæmorrhages take place from the mouth, the nose, the intestines, the anus, the gums, the mammæ, the ears, and the lungs; or hæmorrhages occur in the brain, the nerves, or the eyes.

Although it must be admitted that confusion has often occurred between vicarious menstruation and hæmorrhages dependent on pre-existing genuine organic disease, such as hæmoptysis due to pulmonary tuberculosis, or hæmatemesis due to gastric ulcer, still the existence of a true vicarious menstruation must be regarded as fully established.

Thus, Fricker, Fleischmann, Obermeier, Beigel, Withrow, Plyette, and Parsons observed vicarious epistaxis; Watson, Decaisne, Edebohls, Fischel, and Seeligmann, vicarious hæmatemesis; Franchi, Hotte, Ratgen, Voigt, and Windmüller, vicarious hæmoptysis; Dunlap, vicarious gingival hæmorrhage; Law and Petiteau, vicarious otorrhagia; Heusinger and le Fort, vicarious hæmorrhages, occurring variously from the anus, bladder, hand, ear, nipple, stomach, and nose; Baumgarten, vicarious hæmorrhage from the vocal cords and trachea; Hahn, from the bladder; Kerley, in the thyroid body; Gallemairts, in the eyes. Puech found, in the cases he collected, that vicarious menstrual hæmorrhage occurred from the stomach thirty-eight times, from the mammary glands twenty-five times, from the lungs twenty-four times, and from the nasal mucous membrane eighteen times. In all the cases menstruation had long been in abeyance.

Regarding vicarious epistaxis, especially exact observations have been published, showing the mutual relationship between the genital and the nasal mucous membrane. A series of cases has been recorded by Fliess. In one of these a remarkably well-developed girl of fourteen, who complained at three-weekly intervals of molimina, in the form of languor, headache, and sacrache, after an interval of four weeks epistaxis occurred instead of the expected menstruation; three weeks later came another attack of epistaxis; and finally, after an interval of seven weeks, came the first menstruation, which henceforward recurred every three weeks. In another case, that of a girl aged fifteen, menstruation appeared once; four weeks later came an attack of epistaxis instead of menstruation, and these attacks of epistaxis were continually repeated, at intervals of twenty-nine days, 166in place of menstruation, until finally pregnancy occurred. During pregnancy the epistaxis ceased, to recur however six weeks after parturition; the attacks continued for eight monthly periods, when they ceased finally at the commencement of the second pregnancy.

Other similar cases are known in which epistaxis recurred with all the regularity of the menstruation it replaced during pregnancy and ceased at parturition. Analogous cases occur in which epistaxis has persisted during pregnancy, during the puerperium, and at the climacteric period, replacing the physiologically suppressed menstrual flow. Similarly Liégois has observed vicarious hæmoptysis during pregnancy. According to Baumgarten, in vicarious epistaxis the bleeding almost always proceeds from the region of the cartilaginous septum, and may become very violent; vicarious hæmorrhage from the larynx proceeds from the true and false vocal cords. Tracheal hæmorrhage is a much rarer occurrence.

Analogous to these cases are those in which the vicarious hæmorrhages occur after removal of the ovaries. Thus Tauffer in one case saw epistaxis replace menstruation after this operation. Schmalfuss reports a case in which a woman suffering from valvular disease of the heart, was said after oöphorectomy to have had almost daily attacks of hæmoptysis and epistaxis. Glaevecke found in the post-operative history of forty-four cases of oöphorectomy that two patients suffered from vicarious hæmorrhages. The last-quoted author is of opinion that the suppression of menstruation resulting from oöphorectomy rarely leads to vicarious hæmorrhages, and that even when these do occur they are so inconsiderable in amount as to have no practical significance.

Quain records the case of a woman aged thirty-three, in whom uterus and ovaries were absent, and in whom for two years epistaxis recurred every month with considerable regularity.

In cases in which menstruation is in abeyance, we sometimes witness, instead of vicarious hæmorrhages, the occurrence of non-sanguineous vicarious discharges from various mucous membranes. Thus, vicarious leucorrhœa is seen, especially in chlorotic patients, in whom, from the time of the menarche onward, such a discharge may occur every month, instead of the delayed menstruation. Similarly, vicarious diarrhœa and vicarious salivation have been observed.

The Sexual Impulse.

By the term sexual impulse, we understand the impulse shared by women and by men towards intimate physical contact and sexual intercourse with individuals of the opposite sex. In the child this impulse slumbers, to awaken at the menarche with the onset of puberty, 167to increase slowly at first, and then more rapidly, after the manner of an avalanche, until it becomes a powerful passion, dominant throughout the active sexual life of the woman, and it may even continue far beyond this period. The proper aim for whose attainment the sexual impulse in woman strives is by no means (as is asserted in some quarters) the fulfilment of “the impulse toward motherhood,” but is merely the complete satisfaction of sensual passion by intercourse with the male. Still, the sexual impulse is often satisfied by the minor degrees of sexual gratification in the form of the mutual contact, so agreeable to the sense of touch, of portions of the body, and even by the play of imagination and illusion under the dominion of love. Finally, also, love amounts to what Buffon, the celebrated naturalist, expressed with coarse incisiveness in the phrase, “L’amour c’est le frôlement de deux intestins.”

In the sexually mature woman, the sexual impulse always exists, though its strength varies in accordance with individual inheritance, with physical and mental condition, and with external circumstances, and though its manifestation may be repressed by force of will. The sensation of the sexual impulse in a maiden during the years of development is described by Goethe in a masterly manner in the verses.^[33]

A resemblance to heat or rut in animals, who exhibit the sexual impulse only at definite periods, those at which the ovules ripen, is manifested in females of the human species only in so far as there 168is during menstruation a more intense sexual sensibility; but the limitation of the sexual impulse to definite periods, and its close association with reproduction, are not found in women. Education and morality impose artificial limitations on the sexual impulse in women, whilst nature endows this impulse with a coercive power, a fact recognized by thinkers of all times and all peoples. Thus, Buddha wrote: “The sexual impulse is stronger than the ankus with which the wild elephant is controlled, it is hotter than flame, it is like unto an arrow driven into the spirit of man.” In a similar sense Luther writes: “He who wishes to restrain the impulse of nature and not to allow it free play, as nature will and must, what does he do but this, to insist that nature shall not be nature, that fire shall not burn, that water shall not wet, that man shall neither eat, drink, nor sleep.” Schopenhaur describes the sexual impulse as “the completest outward manifestation of the will to live, the concentration, that is to say, of all wills. * * * The affirmation of the will to live concentrates itself in the act of generation, and this act is its most determined expression.” Mainländer in his Philosophy of Deliverance makes the following statement: “In the sexual impulse lies the centre of gravity of human life. To nothing does man devote a more earnest attention than to the business of generation, and in the pursuit of no other aim does he concentrate the intensity of his will in so striking a manner as in the performance of the act of generation.” Debay similarly insists on the strength of the sexual impulse, saying: “The union of the sexes is one of the great laws of nature; to that law men and women are subordinated as completely as all other creatures, they cannot escape its operation.”

According to the general opinion, the sexual impulse is not so strongly developed in women as it is in men. Hegar, Litzmann, Lombroso, P. Müller, and many others, assume that the sexual sensibility of women is less than that of men; Fürbringer is inclined to attribute the characteristic of sexual frigidity to the great majority of German wives. I do not believe that this view, of the slight intensity of the sexual impulse in women in general, is well grounded, and can admit only this much, that in adolescent girls who are inexperienced in sexual matters, the sexual impulse is less powerful than in youths of the same age who have undergone sexual enlightenment. From the moment when the woman also has been fully enlightened as to sexual affairs, and has actually experienced sexual excitement, her impulse toward intimate physical contact and toward copulation is just as powerful as that of men. According, however, to the dominant artificial conditions, man assumes it as his right to give free rein to his sexual desires and 169to gratify them without regard to consequences, whereas woman, narrowly confined within the boundaries imposed by law and convention, cannot so readily yield to her inclination in the direction of physical love, and must forcibly control that inclination. Moreover, a powerful check on the free indulgence of the sexual impulse is imposed on woman by the consequences of such indulgence, consequences which exist for woman only.

I may further indicate as differential characteristics, that in woman the sexual impulse is more accessible to voluntary control than it is in man, the ardor of female sexual passion is more readily diminished than that of the male; and again that in the female the gratification of the sexual impulse is less narrowly restricted than in the male. Excessive sexual gratification on the one hand and suppression of sexual desire on the other are, generally speaking, less harmful to the female organism than to the male. In these differentiæ is to be found, in my opinion, the influence which determines the type of sexuality in the respective sexes.

The following account is given by Havelock Ellis of the differential characters of the sexual impulse in the female: “In courtship, woman plays a more passive part than man; in woman the physiological mechanism of the sexual processes is more complicated, and the orgasm develops more deliberately; the sexual impulse in woman needs more frequently to be actively stimulated; the culmination of sexual activity is attained later in the life of woman than in the life of man, the strength of sexual desire in woman becomes greater after she has entered upon regular sexual intercourse, women bear sexual excesses better than men; the sexual sphere is larger and more widely diffused in women than it is in men; finally, in woman the sexual impulse exhibits a distinct tendency to periodic exacerbations, and it is in any case much more variable than in man.” The same author, who has published several notable biological studies on subjects connected with sex, maintains that the source of erotic pleasure in the case of the male lies in activity, but in the female in the passive state, in the experience of compulsion, and he holds that sexual subordination is a necessary element in the sexual enjoyment of women.

Hegar maintains that under the term sexual impulse two distinct conceptions are confounded: First, the impulse toward copulation, the desire of carnal union with a member of the opposite sex; secondly, the impulse toward reproduction, the desire for children. At the same time, this author admits that it is questionable if we can properly speak of an impulse toward reproduction, when reproduction is merely a consequence of copulation; in the case of civilized man, at any rate, so much reflection is connected with the idea of 170reproduction that it can hardly be proper to speak of anything of the nature of an impulse. In the case of woman, the expression is less unsuitable, since in woman special organs exist for the maintenance of the ovum after fertilization, and these organs may perhaps lead to the production of this peculiar form of mental activity.

According to Darwin, a comparatively less intensity of sexual desire is common to the females of all species of the animal kingdom. The female demands a prolonged courtship, and often endeavors for a considerable time to elude the male. In the lowest classes of the animal kingdom the female leads a separate existence as soon as she has been fertilized by the male, the sexual functions being thus subordinated to the maternal. Among birds at the pairing season the male is always the more passionate and active of the two, whilst the female commonly remains passive and occupies herself in building the nest. Among mammals, it is difficult to determine whether sexual feeling is stronger in the female or in the male; but it is certain that sexual relations are seldom long lasting, they continue in most cases only during the period of heat or rut, and at most only till the birth of the young.

From these phenomena witnessed in the animal kingdom, many naturalists have concluded that in females of the human species also, sexual sensibility and the intensity of the sexual impulse are less than in the males, and even that the sexual sense in general is but little developed in the female sex, or sometimes entirely wanting. The complicated apparatus which the primary and secondary sexual characters of the female combine to make up, exists, according to this view, not for the gratification of the sexual impulse, but for the fulfilment of the function of motherhood. “Love in women,” says Lombroso, “is in its fundamental nature no more than a secondary character of motherhood, and all the feelings of affection that bind woman to man arise, not from sexual impulses, but from the instincts, acquired by adaptation, of subordination and self-surrender.”

Mantegazza lays stress on the fact that in the female, sexual desire is very rarely accompanied by pains analogous to those which occur in man, in whom sexual excitement manifests itself in painful tension of the testicle and the seminal vesicles, or in spasmodic, long-continued priapism.

Sergi writes to Lombroso: “The normal woman loves to be flattered and wooed by man, but yields herself to his sexual desires only like an animal at the sacrifice. It is well known how much pains must be taken, how many caresses must be expended, before a woman will yield with pleasure to a man’s desires, and will share his sexual passion. Without the employment of these means, a woman remains cold and gives as little satisfaction as she feels. There are girls 171who are quite obtuse to the joys of love, and either resist energetically a man’s approaches, or yield to him passively, without ardor and without enthusiasm. It is well known, also, that among the lower races of mankind, means are employed to stimulate the sexual sensibility in women, means that seem to us to amount to torture; and that the male, with the same end in view, undergoes the most painful operations, from which it is apparent that the slight sexual sensibility of women in these lower grades of civilization is fully recognized.” And again: “If a normal woman marries for love, she hides that love deep in her heart, and even on the wedding-day exhibits no great sexual excitement; she often complains later that in her husband the love-fervor of the first days still continues; the very moderate sexual needs of the wife form a natural and most valuable check to the much more powerful passion of the male.”

Saint Prospêre expresses himself to a similar effect: “Women do not fall in consequence of the excessive power of the senses—in this domain they are overlords, in striking contrast to men, whose weakest side is here. It is not by means of the senses that a woman is to be overcome; her weakness lies elsewhere—in her heart, in her vanity.” And de Lambert wrote the epigram, “Women play with love, and yield themselves to love, but they do not abandon themselves to love.”

Well known also is the saying of Dante:

On the other hand, it is asserted in the laws of the Hindus that sexual desire in women can as little be satisfied or fed full as a devouring fire can be fed full of combustible materials, or as the ocean can be overfilled by the rivers that pour their waters into it.

Lombroso finds a proof of the sexual indifference of women and of the greater sexual needs of man, in the existence of prostitution, with which can be contrasted the existence only among the degenerate classes (both rich and poor) of a small group of male prostitutes (alfons, souteneurs). This author also refers to the rarity and uniformity in women of the sexual psychoses so frequent in men, as indications of the minor intensity of sexual desire in the former; and he refers also to a series of facts, as for instance, to the occurrence of platonic love, which, though indeed often hypocritical, has a real existence more often in the female sex than in the male; to the long-enduring chastity of girls, and to vows of chastity, which are rarely made except by females; moreover, the ready adaptation of women to polygamy, as well as their scrupulous observance of monogamy, which latter for the male is nominal rather than 172actual. If in general the opposite view concerning women prevails, this is ascribed by Lombroso to the fact, that love is the most important circumstance in a woman’s life. The reason therefore, however, is to be found, not in the erotic sphere, but in the desire for the satisfaction of the maternal instinct, and in a woman’s need for protection. A celebrated accoucheur, Giordano, has remarked: “Man loves woman for the sake of the vulva; what woman loves in man is the husband and the father. Comprehensively we may express the matter by saying that woman has less eroticism and more sexuality.”

As a rule, remarks Erb, it is believed that the sexual impulse is less intense in women than in men. This is true enough, he writes, as regards youthful and virgin individuals, who have not yet come into intimate contact with men, and in whom sexual desire and sensibility have not yet been directly excited; later, however, when sexual intercourse has been begun, a change usually takes place, and the sexual needs become active in women also, and demand satisfaction. It is well known that not a few women experience powerful and uncontrolled sensual inclinations, just like those of men. On the other hand, we must insist that quite a large number of women possess the so-called naturae frigidae, and have no sensual inclination to sexual intercourse, to which they are either indifferent, or in some cases strongly averse, even regarding it with horror. This lack of the sexual sense in women, is especially common in hysterical subjects, and Erb reports that he has encountered quite a large number of cases of this character. Whether in quite healthy women with normal sexual impulse, complete abstinence from sexual intercourse, too often compulsory but sometimes voluntarily undertaken, is harmful in its consequences—this, says Erb, is a question very difficult to answer. Many such unfortunate women have assured him that they suffered severely in consequence of their enforced continence; the majority of these became neurasthenic or hysterical. The complication of purely physical influences with mental influences, increases the difficulty of the problem. Neurologists have observed women on whom continence was forced either during marriage or after its dissolution, who thereupon fell into a state of severe nervous exhaustion or nervous excitement, or suffered from threatening or even actually developed psychoses. That sexual abstinence is “absolutely harmless,” as moralists and many physicians would so gladly believe, appears to Erb a quite unwarrantable assumption.

“In the processes of reproduction,” continues Erb in his discussion of this subject, “woman is the principal sufferer. With inhuman cruelty, nature has condemned woman to a far more difficult rôle than man in the intercourse of the sexes and in the preservation of the species; she is overpowered and forced by man, she is compelled 173to make the most severe sacrifices for the sake of the new generation, first when it is germinating within her womb, and later when it is entrusted to her care; and only too frequently she fails to find the respect and protection due to her for the performance of these functions! Compared with the sacrifices made by woman, the temporary continence which is all that is demanded from man will be admitted to be a small matter! It is fortunate that as a rule the young woman who has never come into intimate contact with the male, appears to be endowed by nature with a relatively weak sexual impulse! This unequal and unjust distribution of the male and female rôles on the part of nature may be regretted, but it cannot be altered.”

The modern advocates of the rights of women, who demand that in the sexual sphere also, woman should receive emancipation, oppose the view that in the male the sexual impulse is stronger than in the female, and also the view that whilst in the male the impulse is simply one toward sexual congress, in the female the determining motive to intercourse is furnished by the desire for motherhood. They complain of “the perverse repression in woman of the sexual impulse and its physiological gratification,” since sexual energy and sexual sensibility are equal in intensity and identical in quality in the female and in the male. Thus, Johanna Elberskirchen writes (Die Sexualempfindung bei Weib und Mann—Sexual Sensation in Woman and Man): “Body and soul, the whole being is subordinated to a single powerful feeling and impulse, a single will flows through nerves and blood, forcing and driving the female toward the male with irresistible power; the yearning, the longing for the relief of sexual tension, the craving for the euphoria and fleshly delight that dominate the whole personality. And this elementary sexual longing it is that clouds the woman’s brain, that drives her into the man’s arms, that leads her to forget all the shame threatening her and her child, that brings her to sexual union—not the longing for a child, not the so-called impulse to motherhood.” And again: “Woman yearns for love, all her love-organs cry out for love, soul and body * * *. We do not long only for the rude sexual act. We spiritualise it—at least some of us do so; at any rate we individualize it. It is one particular man whom we desire, he alone can still our longing, our bodily and mental hunger for love. He satisfies us with all his love-affinities.” Naturally, also, the consequence is deduced, “a free course must be given to sexual sensation in women, and to the satisfaction of sexual desire, within physiological limits, within the bounds of physiological necessity.”

Löwenfeld asserts that in the life of woman the sexual functions play a comparatively much greater part than in the life of man, 174woman’s thoughts and feelings are, that is to say, much more powerfully influenced by sexual matters than those of men; but none the less he is of opinion that in the normal woman the desire for sexual satisfaction is on the average less keen than in the normal man. Distinctly greater in woman is the erotic element only, the need to love and to be loved after an ideal manner, which is excited by the reproductive glands just as much as is the simple sensual desire. Very frequently, manifestations of this ideal need are erroneously attributed to the sensual impulse, yet this latter may be entirely absent in cases in which the erotic element is strongly developed. According to Löwenfeld, the sexual impulse is altogether wanting in young girls before the time of puberty, and in elderly women (in the case of the latter we consider this assertion most questionable); this lack of the sexual impulse persists in girls for an indeterminate time even after puberty, as long as they remain free from all experience of sexual stimulation. In this respect they offer a notable contrast to males of the same age. In normal girls, according to the same author, erotic dreams and similar occurrences are entirely wanting, and specific sexual sensations therefore remain absolutely unknown to them; hence it follows that the sexual impulse cannot, properly speaking, arise in such individuals, and in so far as they experience any desire for sexual intercourse it can only take the form of a craving for some enjoyment, the nature of which is entirely unknown. The absolute lack of the sexual impulse (complete frigidity) persists, according to Löwenfeld, in a not inconsiderable proportion of women even after their introduction to sexual intercourse—Effertz estimates that such complete frigidity is permanent in 10 per cent. of all women—and in a still greater proportion of women the sensual impulse never exceeds a certain minimal intensity (partial frigidity). It is probable that in the higher classes of society, inherited predisposition, education, and perhaps also higher intelligence, combine to diminish the intensity of the sexual impulse. In contrast with these women of frigid temperament, however, we meet with women, certainly in very limited numbers, whose sexual passions are extremely powerful, and whose needs no man can satisfy.

Hegar, who considers that the sexual impulse in women is seldom very powerful, draws the following conclusions in respect of the influence of sexual gratification, on the one hand, or of continence, on the other, on the duration of life and on physical and mental health: “As far as comparisons between married women and women vowed to celibacy (nuns and members of other celibate religious orders) justify any conclusion, sexual activity and inactivity, respectively, would appear to have little influence on the duration of life. Comparisons between married and single women show, 175indeed, that the gratification of the sexual impulse and the processes of reproduction are distinctly injurious when experienced before the attainment of complete sexual maturity. In married women up to the age of thirty, in some countries even up to the age of forty, the mortality is greater than in unmarried women. The notably smaller mortality of married women, as compared with unmarried, after the age of forty, is usually explained as the result of the complete fulfilment of the genital functions. It may, however, find a truer explanation in the selection effected by marriage, especially when we take into consideration that from the women thus selected the weaker individuals have been previously weeded out by the processes of reproduction:

“The lesser mortality of married men from the age of twenty upwards is to be explained by the selection of the fit which occurs in marriage, by the smaller proportion of marriages among men engaged in hazardous occupations, and by the deterioration in the quality of the unmarried which results from emigration. Still the directly favorable influence of marriage is undeniable, and, no doubt, the ethical factors of this institution have a beneficial effect, whereas the gratification of the sexual impulse hardly enters into the account.

“Suicide is certainly very little dependent upon repression of the sexual impulse, since all the motives arising out of the affairs of love play together but a small part among the causes of suicide.

“The beneficial influence of marriage in the prevention of insanity is in part apparent merely, since, in the selection exercised by marriage, those predisposed to mental disorder, and those in whom such disorder has already manifested itself, are, for the most part, already excluded. Still, as regards the male sex at any rate, the beneficial influence of marriage is undeniable, and consists principally in the favorable ethical factors of this state. In women, on the other hand, the advantage of marriage is doubtful, since the nerve centres and the nervous system as a whole are strongly affected by the processes of reproduction.

“Satyriasis, nymphomania, and hysteria are in no way dependent upon the repression of the sexual impulse.

“Criminality in the married is comparatively less common than in the unmarried. In criminal assaults on young persons, repressed sexual impulse plays a part.

“Chlorosis is not in any way dependent on repression of the sexual impulse. A disease apparently analogous to chlorosis, occurring in unmarried women from twenty to thirty years of age, is dependent rather on mental causes, and is relieved by other means than marriage, especially by suitable occupation. Marriage and gestation are distinctly injurious in cases of true chlorosis.

176“The satisfaction of the sexual impulse, and still more gestation, favor in women the origin and growth of tumors, give rise often to mechanical disturbances, and open the way for the invasion of toxic pathogenic germs.

“Osteomalacia occurs only in parous women.”

Moll divides the sexual impulse into two components: The impulse toward intimate contact (in a sense both physical and mental) with a person of the opposite sex, which he calls the contrectation-impulse (Kontrektationstrieb); and the impulse to bring about a change in the genital organs, which he calls the detumescence-impulse (Detumeszenztrieb). The former impulse induces intimate physical and mental contact between the two persons concerned, the latter impulse induces the local processes of copulation. In women, detumescence results from the passing off of local swelling and the release of nervous tension in the genital organs, with the discharge of indifferent glandular secretions, notably the secretion of Bartholin’s glands, and perhaps also the secretion of the uterine glands. The intensity of the detumescence-impulse in women varies greatly in different individuals, these variations being more extensive than those occurring in the male. In some women the impulse toward intimate contact, the contrectation-impulse, is normal, though the detumescence-impulse is wholly wanting (vide Dyspareunia).

Runge defines the sexual impulse as the impulse which brings the sexes together. This impulse is subservient to an instinct, namely the instinct of reproduction; that is to say, the sexual impulse induces the individual to perform actions which subserve the purpose of reproduction without the agent’s being directly or chiefly concerned with this purpose.

The sexual impulse, as sensation, perception, and impulse, is, according to von Krafft-Ebing, a function of the cerebral cortex; a centre for the sexual sense has not as yet, however, been localized. The close relations which obtain between the sexual life and the sense of smell lead to the supposition that the sexual and the olfactory spheres of the cerebral cortex are in close proximity one with the other. The development of the sexual life has its beginnings in the organic sensations of the developing reproductive glands. A mutual dependence now arises between the cerebral cortex as place of origin of sensations and perceptions, and the organs of generation. By anatomico-physiological processes these now give rise to sexual perceptions, representations, and impulses. The cerebral cortex, by apperceived or reproduced sensuous perceptions, influences the organs of generation. This influence is effected by the intermediation of the centres of vascular innervation and ejaculation, which are situated in the lumbar enlargement of the spinal 177cord, and are certainly in close proximity one with the other. Both are reflex centres.

The psycho-physiological process embraced in the conception of the sexual impulse is according to von Krafft-Ebing constituted in the following manner:

I. Of the central or peripherally aroused perceptions.

II. Of the pleasurable sensations associated with these.

Hence arises the impulse to sexual satisfaction (libido sexualis). This impulse becomes stronger in proportion as cerebral excitement, consequent on appropriate perceptions and the working of the imagination, strengthens the intensity of these pleasurable sensations. If the conditions are favorable to the performance of the sexual act by means of which satisfaction is attained, the continually increasing impulse finds expression in action; in other circumstances, inhibitory perceptions intervene, sexual excitement diminishes, the activity of the centre for erection is inhibited, and the sexual act itself is prevented. In the case of civilized humanity the ready action of such perceptions for the inhibition of the sexual impulse is necessary and decisive. On the strength of the impulsive perceptions the constitution and various organic processes have an important influence; on the strength of the inhibitory perceptions, education and the cultivation of self-control are powerfully operative.

In addition to mental influences, all forms of local irritation of the sensory nerves of the female genital organs and adjacent parts, by internal processes or external friction, serve to increase the strength of the sexual impulse. Among internal processes which stimulate the erectile centre by centripetal impulses must be included, the stimulus of the enlarged graafian follicle, stasis in various vascular areas of the genital organs in consequence of a sedentary mode of life, abdominal plethora from excessive consumption of food and stimulating drinks, and habitual constipation. External friction may be in the form of intentional manipulation, but it may be due to certain bodily attitudes or to the arrangement of the clothing.

In normally constituted individuals, the sexual impulse is by no means constant in its intensity. Apart from the temporary indifference resulting from sexual gratification, and apart from the decline in the impulse that occurs after prolonged continence, ensuing after a certain reactionary intensity of desire has been happily overcome, the mode of life has a very great influence. The town-dweller, who is continually reminded of sexual matters, and continually solicited to sexual intercourse, is in any case more subject than the countryman to sexual excitement. A sedentary and sheltered mode of life, a chiefly animal diet, the free use of alcohol and of spices, 178and the like, have a stimulating action on the sexual life. In the female, the sexual impulse is stronger just after menstruation. In neuropathic women this increase of excitement may occur to a pathological degree. Not infrequently also in the climacteric period, women are subject to sexual excitement due to pruritus, especially in those neuropathically predisposed. Magnan reports the case of a lady who was subject to matutinal accesses of intense erethismus genitalis. The same author writes of a young lady who since puberty had been subject to continually increasing sexual impulse, which she gratified by masturbation. Gradually it came to pass that the sight of a good-looking man produced violent sexual excitement, and on these occasions, since she felt herself unable to answer for her own conduct, she used to lock herself up in her bedroom till the storm had passed away. Ultimately she surrendered herself to any available man in order to obtain rest from her torturing desires, but neither intercourse nor onanism gave her relief, so that she was finally sent to an asylum.

As regards pathological increase of the sexual impulse, hyperæsthesia sexualis, the constitution of the individual is, according to von Krafft-Ebing (Psychopathia Sexualis), of great importance. He writes: “With a neuropathic constitution, a pathological increase of sexual desire is often associated, and such individuals bear for the greater part of their life the heavy burden of this constitutionally anomalous sexual impulse. The intensity of the sexual impulse may be such as to amount to an organic compulsion, and the freedom of the will may thus be seriously imperilled. Non-satisfaction of this desire may induce a true sexual heat (like that of lower animals), or a mental state characterized by sensations of anxiety, in which the individual yields to the impulse, and his responsibility for his action is most questionable. Should the person so affected not give way to his desire, he runs the danger, by this enforced abstinence, of injuring his nervous system by the induction of neurasthenia, or of seriously aggravating neurasthenia that already exists.

“Excessive sexual desire may arise either from peripheral or from central causes. The former variety is less common. Such cases as do occur, may arise from pruritus of the genitals, from eczema, or from substances which by their remote local action stimulate sexual desire, such for instance as cantharides.

“Sexual excitement of central origin is common in those suffering from congenital neuropathic predisposition, in hysterical subjects, and in states of mental exaltation. In such cases, when the cerebral cortex, including the psychosexual centre, is in a state of hyperæsthesia (abnormal excitability of the imagination, facilitated association 179of ideas), not only optical and tactile sensations, but also auditory and olfactory impressions, will arouse lascivious perceptions.

“Sexual hyperæsthesia may be continuous, with exacerbations, or intermittent, and even periodic. In the last case, according to von Krafft-Ebing, it is either an independent cerebral neurosis, or else a partial manifestation of a general condition of mental excitement (mania, dementia paralytica, dementia senilis, etc.).”

Erotogenic zones, the stimulation of which leads to an increase in the intensity of the sexual impulse and of sexual sensibility, are in woman first of all and principally the clitoris, which indeed is said to be the only zone of this nature in the virgin state (an opinion held by von Krafft-Ebing and others, but certainly most improbable); next to this comes the whole of the external genitals, and especially the parts covered with hair; also the vagina by friction and inter coitum; finally the nipple and its areola when stimulated by titillation—an increase of the excitability of this region appears to result from suckling.

According to Hensen, the direct stimulation of the sexual impulse proceeds by way of the dorsal nerve of the (penis or) clitoris; he assumes, however, that certain states of the reproductive glands are able to induce an increase in the irritability of the centres connected with the aforesaid nerves. In women it certainly appears that particular states of the ovary have a stimulating or inhibiting influence respectively on sexual excitement, so that we might ascribe to the ovaries the rôle of a regulator of the sexual impulse. The processes that occur in the ovary at the time of the ripening and rupture of the graafian follicle, and the resulting tension of the follicular wall, induce by stimulation of the ovarian nerves an increased sensibility of the central zones, and produce in a menstruating female a condition of increased sexual excitability, so that slight stimuli will give rise to a powerful orgasm more readily than would otherwise be the case, when the reflex irritability of the centre is less pronounced and the sexual impulse is consequently less intense. Still more than during these ordinary menstrual processes may this stimulation be effective at the time of the menarche, when the changes in the ovary occur for the first time and with the greatest intensity, so that at this time the individual may be especially susceptible to sexual stimulation.

At such times of sexual excitement, very slight external peripheral stimuli, in the form either of tactile stimulation of the sensory nerves of the skin and the external genital organs, or of stimulation of the imaginative and perceptive faculties of the brain, suffice to induce a powerful increase of the sexual impulse; whereas at 180other times, at which no particular sexual excitement exists, much stronger stimuli are needed to produce such an effect. Thus the sexual impulse in women is more readily and more powerfully increased in proportion as the central organ is in a condition of temporarily enhanced excitability in consequence of the condition of the ovaries.

The gratification of this impulse, the act of copulation, produces the specific sensation of sexual pleasure; in the female this is effected chiefly by friction of the glans clitoridis, the organ when erect projecting downwards at a right angle, and pressing upon the intromitted penis—the friction of the glans produces powerful mechanical stimulation of the numerous plexuses of sensory nerve fibres, which terminate in the genital corpuscles of Krause. In woman, then, we find in the ovary the place of origin and the means of regulation of the sexual impulse, and in the clitoris we find the seat of the specific sensation of sexual pleasure.

In the poorer classes of society, an increase of the sexual impulse occurs in women chiefly in consequence of bad example and of unfavorable domestic conditions, such as lead to persons of opposite sexes sleeping in the same bed, and also in consequence of the abuse of alcohol. In the well-to-do classes, it is the perusal of modern equivocal romances, visits to theatres, balls, and evening parties, and, speaking generally, idleness combined with luxurious living, that serve to stimulate the sexual impulse in woman.

A certain dependence of the sexual impulse upon seasonal variations appears to exist also in the human species. At any rate in certain months of the year, a definite increase in the number of conceptions continues to recur, which indicates that during these months a larger number of sexually mature individuals is engaged in the discharge of sexual functions. Rosenstadt regards this as the manifestation of a “physiological custom,” immanent in the physical constitution of civilized man, and inherited by him from his animal ancestors. He explains it in the following terms: “Primitive man inherited from his mammalian forefathers the peculiarity of reproducing his kind only during a certain definite period, the period of heat or rut. After humanity had entered upon this period, copulation was effected en masse, as was easy in view of the primitive community of sexual intercourse before the origin of marriage. In the course of his progress toward civilization, however, man began to reproduce his kind indifferently throughout the entire year; but the original “physiological custom,” in accordance with which reproduction occurred at definite seasons only, did not disappear, and persists, indeed, to a certain extent even to the present day as a survival of earlier mammalian life, and manifests itself in the annual recurrence in certain months of an increase in the number of conceptions. 181The analogy in structure and function between the genital organs of the human species and those of other mammals (the female anthropoid apes do not merely exhibit from time to time a period of heat, but are subject to a more or less regular menstruation), which for the most part reproduce their kind only at certain definite periods, leads to the conclusion that in the human species also the sexual impulse may originally have awakened only at a particular season of the year, and that the persistence of this physiological custom in man, in spite of the fact that sexual intercourse occurs all through the year, and notwithstanding that the conditions necessary to awaken the sexual impulse are actually perennial, must be ascribed to inheritance.”

This view, which is maintained also by other gynecologists, finds support in Kulischer’s assumption, based upon ethnological investigations, according to which coupling in primitive man took place only at certain seasons, namely, at spring and at harvest-time. In support of this view, which was held also by von Hellwald, Kulischer refers to a number of actual and symbolical practices among different races, which make the assumption extremely probable.

Sexual desire in women, the sexual impulse, outlasts the proper sexual life, and manifests itself even after the cessation of menstruation, when the possibility of conception has passed away; it appears, therefore, to have no necessary connection with the function of ovulation.

This is indicated by the always respectable number of women who enter upon marriage even after the climacteric age. Thus the percentage of brides who were more than 45 years of age was: In Prussia, 2.58 per cent.; in England, 1.38 per cent.; in Sweden, 1.53 per cent.; in Ireland, 0.31 per cent. Of quite peculiar interest are the figures relating to elderly women who marry men considerably younger than themselves. Thus we learn from the tables of Routh that in the space of 10 years in Ireland:

In England during the year 1855 the age of the bride exceeded the climacteric age in 778 instances. The brides were:

In Bohemia in the year 1872 the oldest bride numbered no less than—86 years.

Börner reports cases in which the sexual impulse remained in full activity after the change of life, and in some cases was greatly increased in intensity—these latter individuals being in a condition of real torment, which induced them to masturbate to obtain relief.

The sexual impulse may be present in cases in which the ovaries are entirely wanting. Thus, Hauff reports the case of a young girl who had no ovaries, but was nevertheless excessively addicted to masturbation. Gläveke speaks of a puella publica in whom the uterus and the ovaries were entirely absent, but who asserted that she experienced during coitus active sexual sensation. Both Kussmaul and Puech report similar experiences in cases of absence or arrested development of the uterus.

As regards the effect on the sexual impulse of the operation of oöphorectomy, most authors state that no change occurs; still, there remain many who express the opposite opinion. From the collective summary of cases bearing on this question made by Gläveke, it appears that after extirpation of the ovaries the sexual impulse remains unchanged in the great majority of cases, or at most is but slightly diminished in intensity. Hegar states that he has often witnessed a diminution of the sexual impulse after oöphorectomy, but that this decline is by no means constant, indeed he states that one of his patients assured him that in her case no decline in the intensity of the sexual impulse had followed the operation. Similarly variable reports were the experience of Schmalfuss. In one case he found there was but little sexual inclination; in one case, disinclination; in one case disinclination at first, followed by a return of inclination. Bruntzel reports that in four patients subjected to oöphorectomy, in two cases the sexual impulse persisted, but in the remaining two it was extinguished. Köberle is of opinion that sexual inclination diminishes as a result of this operation. Peaslee, on the contrary, asserts that the patients remain striking examples of womanhood, in whom all the qualities peculiar to their sex are preserved. Péan observed as a rule no difference in the sexual impulse to result from this operation, but he considers that the patients are apt to describe in exaggerated terms the amount of sexual feeling that remains to them. In one case, Spencer Wells observed after oöphorectomy an increase in sexual excitability; 183Tissier had the same experience, and this author believes that in these cases the sexual impulse is generally preserved. On the other hand, Bailly observed a case, in which both ovaries were removed on account of new growths, where the sexual impulse at first became excessive, and then completely disappeared. Anger and Goodell speak in the same sense.

I am myself acquainted with a woman twenty-six years of age who in girlhood underwent oöphorectomy on account of extremely severe nervous troubles associated with menstruation; she had not experienced in consequence any loss of the sexual impulse; she married a man belonging to the upper strata of society, and consulted me four years later to learn if she could by any means be rendered capable of bearing a child. Two other cases have come within my personal experience in which young women married after extirpation of the ovaries, and in whom sexual desire and sexual sensation were all that could be wished.

In twenty-seven women who had undergone the operation of oöphorectomy, Gläveke made inquiries regarding the three following points: First, whether the sexual impulse had been affected by the operation; secondly, whether during intercourse sexual pleasure was experienced to the same degree as formerly; and thirdly, whether during intercourse any kind of difference was observed as compared with pre-operative experience. He obtained the following results:

In a considerable number of cases the sexual impulse was thus found by Gläveke, not indeed to be entirely extinguished, but still notably diminished. In another set of cases, the sexual impulse was entirely extinguished, but only in one case was there actual aversion to coitus. The women readily permitted intercourse when their husbands desired it, but remained themselves quite indifferent. The greater number of these women stated that the specific sensation of pleasure during coitus was markedly weakened, but not entirely lost; in a small proportion, this sensation was completely extinguished. In the case of seven women who complained that coitus was very painful, Gläveke found that the calibre of the vagina was much diminished. In these cases, the sensation of pleasure during coitus was either greatly diminished or completely extinguished. The women permitted intercourse very unwillingly, their unwillingness 184arising, not from any actual aversion, but because they dreaded the pain which coitus produced. An extremely hysterical woman, affected with severe prolapse of the uterus, stated that every attempt at intercourse was frustrated by violent hysterical convulsions. The sexual impulse appears always to suffer first and most severely, and only after this is the sensation of pleasure during coitus affected. In a few women only, according to the experience of this author, was the sexual impulse quite unaffected by the removal of the ovaries.

Amputation of the clitoris appears notably to diminish both the sexual impulse and the sensation of sexual pleasure, but the results of clitoridectomy for the cure of masturbation are by no means always favorable. In the women of the Russian sect of the Skopstki, the clitoris, the nymphæ, and a part of the labia majora are removed, in order to destroy sexual desire. According to von Krafft-Ebing it is probable that in the virgin the clitoris is the only erotogenic zone, that is to say, that only by the stimulation of the clitoris can erection, the orgasm, and the sensation of ejaculation be induced. It is probable that the vagina becomes erotogenic only as a result of coitus; thenceforward, however, the erotogenic significance of the clitoris is notably lessened, and in multiparæ may entirely disappear.

Nymphomania, Anæsthesia and Psychopathia Sexualis.

The sexual impulse in women is subject to morbid changes, both in the way of increase and of diminution, exhibiting abnormal violent increase (nymphomania), or declining to the state of complete frigidity and sexual indifference, or, finally, manifesting itself in some perverse manner (psychopathia sexualis).

Psychopathically increased sexual impulse in woman is known as nymphomania or uteromania. In such women there is a dominant state of psychical hyperæthesia, principally in the genital sphere. The most indifferent perceptions give rise to erotic sensations and to lascivious impulses. All sensory perceptions obtain a sexual content, and induce stimulation of the cerebral cortex. All sensation and all activity in such unhappy beings ultimately concentrates itself in the act of copulation, or in some other form of sexual gratification, the greatest perversities of sexual practice frequently arising, masturbation, tribadism, and, for the most part, prostitution, even in the case of married women.

The nymphomaniacal woman, says von Krafft-Ebing, endeavors to allure men by means of exposure of the genital organs or indecent gestures; the sight of man produces intense sexual excitement, which is gratified by masturbation or by stimulatory movements of the pelvis. According to this author, nymphomania is not very infrequent 185at the climacteric period; it may even occur in old age. Abstinence in association with simultaneous excitement of the sexual sphere by mental or by peripheral stimuli (pruritus pudendi, oxyuris, etc.), may induce these states, probably, however, only in those hereditarily predisposed.

The history of antiquity contains records of the corrupt practices of nymphomaniacal empresses. Thus, Messalina furnishes a well-known historical example of the abnormal violence of a pathologically intensified sexual impulse in woman. She was given the agnomen of invicta, having received the embraces of fourteen athletes. Pliny says of her, die ac nocte superavit quinto et vicessimo concubitu; and Juvenal writes of her the verses,

In corrupt Rome, Messalina was not the only woman necdum satiata, ever insatiable; we need only refer to the orgies of an Aggripina, a Livia, a Mallonia, or a Poppæa; and Seneca hurls against the women of his day the reproach, adeo perversum commentæ genus impudicitiæ viros ineunt. And of Cleopatra, the beautiful Egyptian queen, Marcus Antonius writes in a letter to his physician, Soranus, that she had such violent sexual desire as to lead to her having connection in a brothel with 106 men.

Through the report of Herodotus it is well known that the pyramid of Cheops was built by the numerous lovers of the daughter of this king, who raised this enormous monument in recognition of the innumerable times she had yielded herself to their desires. On record also are the sexual excesses of the Roman ladies at the festival of Saturn, the festival of the Bona Dea, and the festival of Priapus; indeed, many of these women allowed themselves to be debauched in the temples (Ploss and Bartels).

But returning to the present day, both gynecologists and alienists record numerous cases of great pathological increase in the intensity of the sexual impulse in women. According to Lombroso, such continued ardency of sexual desire occurs chiefly in women with an inherited tendency to crime and to prostitution, whose natures exhibit a commingling of lasciviousness with barbarism. He gives examples of such women, one of whom surrendered herself to her husband’s laborers; another had as her lovers all the desperadoes of Texas; a third had intercourse with all the herdsmen of her village; a fourth, though her husband occupied a good social position, led the life of a prostitute; a fifth, a cultured and 186intelligent woman, entertained a common bricklayer, and wrote to him letters full of shameless declarations of her sexual passion; further he writes of a series of criminals, in whom, indeed, increased sexual desire is a common phenomenon; one of these, a thief, experienced sexual excitement at a mere glance at a good-looking man; a murderess, in whom lascivious feeling induced masturbation whenever she saw a man, and who made experiments in sexual intercourse with dogs; another, who often took to bed with her, in addition to her son, three or four men selected at random from the streets; and many others. Jolly reports the case of a widow, a celebrated lionne of the demi-monde, who kept in her desk, side by side with devotional literature, a number of lascivious books and preparations of cantharides, and entertained quite a number of powerfully-built lovers drawn from the lowest canaille.

In hysterical women the sexual impulse is frequently excessive, and may increase to such a degree as to produce hallucinations of coitus; sometimes, on the other hand, the impulse is extinguished, or psychopathically metamorphosed, passing in a most paradoxical manner from sexual frigidity to lascivious reflections and continuous occupation with sexual affairs; not uncommon in such women are false accusations of indecent assaults of which they assert themselves the victims.

Lombroso gives several examples of the increase of the sexual impulse in hysterical women: “A hysterical girl visited a physician, and said to him: ‘I am still a virgin, take me;’ she submitted him to the utmost extremity of provocation, and asserted afterward that she had been violated. Another hysterical subject, a rich young lady, met a workman in the street, offered herself to him, was accepted, and when she returned home related the affair with laughter. A third sought men from the street in order to find one suffering from syphilis, her object being to infect her own husband with the disease.”

According to the observations of Schüle, young married, hysterical women not infrequently run away with a waiter during the honeymoon journey. This author also points out that in women moral insanity is especially apt to manifest itself during the first years of married life. Many advocate a far-reaching libertinism, and threaten to enter a brothel. In these forms we observe, in addition to ill-temper and malignity, especially obscenity and tribadism.

Such a case, observed by Giraud and quoted by von Krafft-Ebing, is the following: Marianne L., of Bordeaux, during the night, while her master was sleeping soundly under the influence of narcotics she had administered, was in the habit of giving up her 187master’s children to her lover for his sexual gratification, and made them witnesses of the most immoral scenes. It appeared that L. was hysterical, suffering from hemianæsthesia and convulsive seizures, and that before her illness she had been a sensible and trustworthy individual. After the illness, however, she prostituted herself in the most shameless manner and completely lost her moral sense.

Galen relates of his own mother that she suffered from nymphomania, and that in the attacks she bit her female slaves like a wild animal.

As a negative aspect of the sexual impulse in woman we must regard the absence of the impulse, or anæsthesia sexualis, and also the deficiency of the sensation of pleasure during the act of copulation, or dyspareunia.

Of dyspareunia we shall speak more at length later, in connection with the pathology of copulation. As regards the entire lack of the sexual impulse, however, in women whose genital organs are normally developed and normal in the performance of their functions, and whose cerebral condition is also normal, we must consider such lack an extremely rare condition, if indeed it ever occurs. It is only in cases in which the female genital organs are wanting, wholly or to a considerable extent, or in which there are important cerebral disturbances or states of mental degeneration, that the sexual impulse is wanting.

Normally, in the young, sexually unspoiled girl, the sexual instinct^[34] slumbers in the cerebral cortex, but becomes active, as sensation, perception, and impulse, as soon as the cerebral centre has been aroused by mental impressions or by physical peripheral stimulation of the genital organs and their environment. Among stimuli of the latter class must be reckoned the menstrual stimulus, set on foot by the developmental processes of puberty. These stimuli arouse in the cerebral cortex sensations and perceptions which, rising to specific sexual feelings, produce an impulse to increase the intensity of these feelings by purposive action; thus is awakened the sexual impulse, the strength of which is extremely variable.

Only when the cerebral cortex, as the place of origin of sensations 188and perceptions, fails to perform its functions in the manner just described, or when the anatomico-physiological processes in the genital organs which normally act as peripheral stimuli fail to occur, or when there is a failure in the conducting tracts, are sexual perceptions and impulses lacking. Such anomalies may be congenital. A milder form is that, likewise congenital, in which a woman has a sexually “cold nature;” in these cases the sexual impulse is not completely wanting, but it is so slight in intensity that it can be awakened only by very powerful stimuli, and in her normal state the woman so affected is quite free from any wish for sexual gratification.

Such congenital subnormal intensity or entire lack of the sexual impulse may be due to very various causes. According to von Krafft-Ebing, these causes may be organic or functional, mental or physical, and central or peripheral. The declining intensity of the sexual impulse with the advance of years, and the temporary disappearance of that impulse after the sexual act, are both physiological occurrences. Education and mode of life have a marked influence on the intensity of the vita sexualis. Strenuous mental activity, earnest study, severe physical exertion, mental depression, and sexual continence, notably diminish the excitability of the sexual impulse. At first, indeed, abstinence leads to an increase in the intensity of the impulse, but sooner or later the functional activity of the organs of generation declines, and therewith also the intensity of the sexual impulse. As peripheral causes of diminution or disappearance of the sexual impulse, von Krafft-Ebing mentions oöphorectomy, degeneration of the reproductive glands, marasmus, sexual excess, whether in the form of coitus or of masturbation, and alcoholism. In like manner is to be interpreted the disappearance of the sexual impulse in general disorders of nutrition (diabetes, morphinism, etc.).

A decline in the intensity of the sexual impulse in consequence of degeneration of the conducting tracts, is found, according to von Krafft-Ebing, in diseases of the brain and the spinal cord. Central affection of the sexual impulse may be due to organic disease of the cerebral cortex (dementia paralytica, general paralysis of the insane, in the later stages), or it may be due to functional disorder, such as hysteria, or to mental diseases (melancholia or hypochondriasis).

Finally, in some instances, the sexual impulse in women manifests itself, not in the normal manner with copulation with the male as its goal, but in a form demanding some abnormal kind of gratification (psychopathia sexualis), whether it be because sexual intercourse with the male affords the woman no enjoyment, or simply because no opportunity exists for such intercourse.

Masturbation is very frequent; the habit having been acquired 189from bad example by the girl during the menarche, it is sometimes continued by the wife during married life. In these cases we often find distinct changes in the genital organs, such as hypertrophy of the clitoris, enlargement and bluish discoloration of the nymphæ, retroversion of the uterus, tenderness and displacement of the ovaries, considerable vaginal discharge, and sometimes menorrhagia.

Kussmaul draws attention to the connection between masturbation and nymphomania, on the one hand, and imperfect development of the uterus and the other genital organs, on the other. Campbell records the case of a woman addicted to masturbation, who had never menstruated, and who, in addition to imperfectly developed genital organs, had a dermoid cyst of the ovary. In a young woman who indulged in masturbation, Aran found that the uterus and its annexa were imperfectly developed. Vaddington also describes a case of abnormal sexual impulse which was associated with absence of the uterus.

Troggler reports the case of a woman twenty years of age, who had been six months married to a healthy, potent man, was herself healthy and blooming, with a good family history, and had never suffered from any severe illness. At the age of thirteen she had learned to masturbate, effecting this by stimulation of the clitoris. Now she found no gratification in coitus, so that she continued to masturbate, and during coitus obtained satisfaction by manual friction of the clitoris. Examination showed that the clitoris was strikingly large, the vagina flaccid, and that there was some vaginal discharge; in other respects the genital organs were normal.

Not infrequent, it may be in those whose mental condition is in other respects fairly normal or it may be in psychopathic subjects, is the existence of contrary sexual sensation, or sexual inversion, a condition which has been described by Casper, Westphal, von Krafft-Ebing, and Moll, and has indeed been well known since the days of antiquity. In the case of a considerable number of notable women, homosexual practices have been recorded. According to the observations of Coffignon, in Paris the homosexual instinct, when occurring in other women than prostitutes, is found chiefly among the ladies of the aristocracy.

Of homosexually inclined women, some engage in the practice of tribadism, familiar to the ancient world, and recorded by Martial in a satire, in which sexual gratification is obtained by mutual friction of the genital organs, or by penetration of one woman’s clitoris into the vagina of the other; whilst some indulge in the amor lesbicus, in which gratification is obtained lambendo linguâ genitalia, a very ancient practice indeed, transported from Phœnicia to Greece (where in especial it was indulged in by the women of Lesbos), and later 190from Syria to Italy, where it was widely diffused among the Romans of the imperial age. Sappho, celebrated as the tenth muse, is supposed to have been addicted to the practice of Lesbian love.

All such homosexual (female) individuals are, then, endowed with the perverse instinct toward sexual connection with women instead of with men. In such cases, the genitals are usually quite normal; sometimes, however, the woman thus affected is markedly of a male type, being called by von Krafft-Ebing a gynandrist, the affection itself being termed gynandry; when the woman concerned not only possesses a homosexual impulse, but also in other respects exhibits tendencies properly characteristic of the male sex, she is called virago, and the affection is termed viraginity.

I had under my care such a woman, belonging to the upper circles of society, who had been married sixteen years before, had lived a married life for six years (during which she remained barren), and had then separated from her husband. She was of a very masculine disposition, smoked, gamed, drank like a student, and preferred to wear men’s clothing, and she bestowed her affections on a female companion. Examination of the genital organs disclosed no abnormality beyond a slight vaginal catarrh. Menstruation was regular, and the general appearance showed no departure, with the exception of a slight moustache that shaded the upper lip, from that of a normal feminine beauty.

Mantegazza is of opinion that in the case of many unhappy marriages, in which the source of the unhappiness is obscure, the trouble is to be found in the homosexual inclination of the wife. Martineau and Moll report that married women who are homosexually inclined, indulge in sexual intercourse with other women behind their husbands’ back. Duhousset, at a meeting of the Anthropological Society at Paris in 1877, related the almost incredible case of a married homosexual woman who, in intercourse with another woman, transferred to the latter her husband’s semen, so as to induce pregnancy.

Many writers on forensic medicine, Tardieu, Pfaff, Schauenstein, Wald, and Mantegazza, for instance, have recorded that in numerous circles of European society women practice masturbation and tribadism (sodomy, so called) with dogs and monkeys; and Plutarch’s statement is well known regarding Egyptian women and the sacred goat, Mendes, that the women who were locked in with this animal practiced sodomy therewith; and again it is asserted that the serpents in the temple of Æsculapius and also in private houses were employed in the practice of sodomy.

Von Maschka records a case which came before the courts a few years ago in Prague, in which a woman forty-four years old confessed 191that “in consequence of the very ardent temperament she possessed, she had, perhaps, as often as six times indulged herself with her house dog, which jumped between her legs and licked her; that she took the animal between her bare legs, stroked its belly until its penis became erect; then, supporting herself on the back of a chair, she pressed the animal against herself, introduced its penis between her labia majora, and let it continue its movements until its semen had been ejaculated.” Examination of the genital organs of this woman disclosed no abnormality.

Schauenstein reports the case of a girl who carried out unchaste practices with a little dog to an utterly immoderate extent, so that after the lapse of some years she died in an asylum. In a case recorded by Wald, a maid servant was observed in lewd practices with a poodle; she supported herself on elbows and knees, while the dog copulated with her from behind.

A woman about thirty years of age, who had lived with her husband in sterile marriage for nine years, complained to me that she had not for a long time had sexual intercourse, since during copulation she not only experienced no sexual pleasure, but actually felt a loathing to the act; on the other hand, she was subject to an uncontrollable impulse to handle the genital organs of children, both of the male and of the female sex, and this performance gave her sexual gratification; during the menstrual period, this impulse overpowered her will. Local examination in this patient showed that the uterus was enlarged and retroflexed, and that there was anæsthesia of the vagina.

Anjel reports the following case of periodic psychopathia sexualis, associated with menstruation. A lady of quiet disposition, near the climacteric. Serious congenital predisposition. During youth suffered from attacks of minor epilepsy. Married, but childless. Several years ago, after violent emotional disturbance, she had a hystero-epileptic seizure, followed by post-epileptic mania lasting several weeks. Thereafter, insomnia for several months. As a sequel, continually recurrent menstrual insomnia, accompanied by an impulse to embrace boys under ten years of age, to kiss them, and to handle their genital organs. Impulse toward coitus, to close sexual contact with a grown man, non-existent at this time. The patient often speaks openly of her morbid impulse, and begs that she may be supervised, as she feels unable to answer for her own conduct. In the intervals, however, she carefully avoids all reference to the matter, is strictly decent in her conduct, and in no way sexually ardent.

Tribadism is frequently mentioned by the writers of classical antiquity, especially by those of Greece, where the cult of naked 192beauty encouraged sexual excitement of this character. This form of unchastity was common among the flute-playing girls of Greece, and at the secret festivals of such associates Aphrodite Peribasia was invoked. Lucian, in his dialogues of hetairai, depicts the intensely passionate nature of these homosexual unions between girls. Lombroso reproduces Juvenal’s description of such a love-feast. “When the flute calls to the dance, the mænads, inflamed with wine and beer, loosen their long tresses, they sigh languishingly and eagerly, and an ardent desire draws them one to another, the desire and the passion of the dance gives their voices an alluring sound; nothing now can serve to bridle their unrestrained desires. Lacasella swings her wreath, which she has won in the contest of lascivious gestures and movements, but even she must give way before Medullina with her ardent postures. About these games there is no trace of unreality, and the most rigid Spartan, hardened from the very cradle, even old Nestor himself, notwithstanding his hernia, could not fail to be stimulated by such an inflammatory spectacle.”

In the present day, also, the practice of tribadism is more widely diffused than people in general imagine. I have often encountered instances of it in ladies of good position, who were past their first youth, who would not or could not marry, and who undertook extensive and long-enduring journeys with a female “companion,” of similar age, or perhaps a little younger. Their erotic needs, which could not be gratified in normal fashion, led to this sexual perversion—a tendency observable especially in persons with neuropathic predisposition, or with a liability to hysteria or to epilepsy. Sometimes such girls, even before puberty, show an inclination to wear boys’ clothes, to avoid all feminine manual occupations, and to examine and to handle the genital organs of their playmates. Even after puberty, such tribadists like to make a parade of masculine attitudes, they have their hair cut short, wear clothes of a masculine cut, smoke a great deal, and show in their conversation, and still more in their letters, great exaltation of the passions. It not infrequently happens that an elderly lady who has lived well in her day, and from youth upward has had much intercourse with men, comes at last to lament her worthlessness to men, and from this proceeds to the idea of obtaining sexual enjoyment by means of tribadism. The tribadistic union sometimes lasts for several years, but in most cases the alliances are quickly and frequently changed.

According to Taxil, tribadism is fairly common among the married women of Paris, and in upper-class women is extremely prevalent. This author describes with what industry and perseverance many elderly tribadists endeavor to win for themselves and to seduce 193young girls, just as old women often work hard to gain money for the enjoyment of the favored person.

In these unions, according to the descriptions of Lombroso, very remarkable phenomena occur. A particular jargon arises with tender designations for this or that bodily beauty; a violent jealousy develops, and a newly united pair keep together as much as possible for fear of losing one another’s affection; the “friends” tread always in one another’s footsteps. This author rightly points out that the very numerous romances describing relations of this kind prove the diffusion of this vice in “high life.” Novels of this class are referred to by Mantegazza in his book, “Woman as Criminal and Prostitute.” He mentions: Diderot, “La Religieuse;” Balzac, “La Fille aux Yeux d’Or;” Gautier, “Mademoiselle de Maupin;” Feydeau, “Le Comtesse de Cholis;” Flaubert, “Salammbô;” Bélot, “Mademoiselle Giraud ma Femme;” Willbraud, “Fridolins Heimliche Ehe;” Graf Stadion, “Brick and Brack;” Sacher-Masoch, “Venus im Pelz.” Zola, also, in “Nana” and “La Curée,” and Butti in “L’Antona,” make some reference to this matter.

Sauval relates of the dissolute life at the court of the French king, Francis I, that the women learned also to play the part of men; a princess had a hermaphrodite maid-of-honor, and the court and all Paris gossiped about the Lesbian-loving ladies, whose husbands were delighted, since they were thus quite freed from jealousy, and prized their wives above all on this account. Such a mode of life was so pleasing to many ladies that they refused to marry, and refused also to allow their “friends” to marry.

Tribadism is very common among prostitutes. According to Parent-Duchatelet, tribadism begins only after prostitution has long been practised, between the twenty-fifth and the thirtieth year of life; generally there is a notable difference in age and also in beauty between the two women forming a tribadistic alliance, and as a rule the younger and prettier of the pair is the more passionately sensitive and the more constant. Parent-Duchatelet endeavours to explain the origin of tribadism by referring to the manner in which in brothels and reformatories the women are closely packed together, to the enforced abstinence from normal sexual intercourse (in prisons and reformatories), to the loathing for men sometimes felt by prostitutes, and to the opportunities for mutual observation of the most intimate nudities. Even women who at first object to it most vehemently, commonly give way to this vice after eighteen or twenty months.

Among 103 prostitutes examined by Lombroso, he found tribadism to be practiced by five. He considers the principal cause of tribadism to be in the lascivious search for new and unnatural pleasures, and 194quotes in illustration the characteristic remark of Catharine II, herself a tribadist, “Why did not nature endow us with a sixth sense?” Female criminals who seduce others to the practice of tribadism have usually themselves acquired the vice during a long term of imprisonment—it is, in fact, the long-sentence criminals, women with a congenital inclination toward crime, that incline also to unnatural vice. The influence of environment is, according to Lombroso, indicated by the fact that the most confirmed criminals, in prisons for women, corrupt in this manner so many of the inmates who are merely “criminaloids,” and corrupt even the wardresses. Further, he is led to conclude, the confinement in close association of so many extremely sensual and prostituted women, leads to the origin of a kind of ferment of new lascivious desires, and causes an increase of one form of degeneracy by means of another. Prostitutes often see one another naked, sleep two or three together in the same bed; similar things occur in boarding-schools. In asylums also we may observe that the admission of a tribadist will result in the infection of all the inmates with this vice.

According to Moll’s estimate, 25 per cent. of the prostitutes of Berlin practice tribadism. According to the experience of this author, in cases in which tribadists live in concubinage, one of them is always a prostitute; the active and the passive rôle are always played by the same respective members of the alliance; the active member is called “papa” or “uncle,” is usually a prostitute, and, like the man in the married state, possesses great comparative freedom in sexual matters, whilst the passive member, the “mother,” is not allowed to form any sexual relations outside the concubinage.

According to Ricardi, many frigid prostitutes practice with pleasure clitoris-masturbation, cunnilictio, and, especially, sapphism, preferring these perversions to the normal sexual act. Moreover, among prostitutes and female criminals there is no lack of lovers of martyrization, of flagellation, even to the drawing of blood, of tyrannical treatment, and of the initiation of children into the mysteries of sex.

[For a detailed account of Sadism and Masochism, see von Krafft-Ebing’s “Psychopathia Sexualis.” These particular perversions, common in men, are rare in women; hence but passing allusion is made to them in the present work.]

Lombroso records on account of its rarity a case of masochism observed by him in a woman thirty-five years of age, who liked being whipped.

Moraglia reports a remarkable instance of sexual perversion in a girl of eighteen, who preferred to coitus, masturbation associated with the stimulating influence of the odor of male urine; this peculiar form of irritability was so powerful as to drive the girl to masturbation 195in public urinals, notwithstanding the risk of arrest, which indeed often occurred.

According to Carlier, there are four or five brothels in Paris which are not infrequently visited by rich ladies in search of tribadistic enjoyments, and ladies of “high life” assemble there for communal orgies; it is noteworthy that prostitutes surrender themselves for such purposes to these women who are outside their own circle with great reluctance, and only for a very high fee.

Speaking generally, however, sexual perversion is rarer and less intense in women than in men. This fact is explained by Lombroso on the ground that the erotic element in women’s nature is less active, and that women are less often affected by epilepsy, the principal source of these anomalies. In cases in which the genital organs are healthy we must, with Westphal, conclude, with reference to contrary sexual sensation, that the abnormal sexual feelings have a cortical origin.

From von Maschka’s elaborate account of unnatural offences, in his Handbook of Forensic Medicine, we abstract the following passage relating to the female sex: “Lascivious procedures liable under certain circumstances to legal punishment may consist: 1. In handling or other manipulation of the genitals, without actual intercourse. If the genital organs of a female have merely been gently handled, without any more violent manipulations, we shall not, as a rule, either in the case of children or of adults, find any local changes as a result; contrariwise, if the handling has been rough and brutal, if the fingers have been forcibly thrust within the vulval cleft, or if the pudendum has been pulled and rent, we may expect to find excoriations, redness, swelling, laceration of the hymen, or even of the vagina and the perineum. 2. In licking the female genitals (cunnilingere). An analogous process also effected by members of the female sex, whether children or adults, is irrumare, id est, penem in os arrigere; fellare, id est, vel labiis vel lingua perfricandi atque exsugendi officium penis præstare. 3. In introduction of the membrum virile into the rectum, either of children or of adults, pæderasty.” That this form of sexual gratification is not infrequently practiced upon women has been pointed out especially by Parent-Duchatelet, and is asserted by von Maschka from personal knowledge of cases in which it has occurred.

Tribadism and Lesbian love, unnatural vice practiced by two individuals of the female sex, occur, according to von Maschka’s description in the following manner: a.) By masturbation, either one person gratifying the other by manipulation, or mutual masturbation. In a case of this kind recorded by Tardieu, a wife still young repeatedly, and by day as well as by night, introduced her 196finger deeply into the vagina or the rectum of her little girl, moving it about there sometimes for as long as an hour. According to the child’s account, the mother herself at these times was in a condition of excitement, no doubt sexual, which she gratified in this manner. In another case, several older girls engaged with their own fingers and tongues in lascivious practices with the genital organs of a little girl of seven. According to Krausold, among female prisoners such “forbidden friendships” are extremely common, formed for the purpose of mutual masturbation, and in connection with which the bitterest jealousy and the most ardent love are exhibited. b.) With the assistance of an enlarged clitoris, with which one woman performs the sexual act by introducing the organ within the vagina of another. In France in the nineteenth century a woman is said to have lived whose genital organs were so formed that, on the one hand, as a woman she played the passive part in intercourse with men, and, on the other hand, was able to give sexual gratification to women by assuming the active part of the male. c.) By the employment of an artificial membrum virile. This mode of obtaining satisfaction of sexual desire was known already to the ancients, and such a priapus was by the Greeks termed ὸλισθος. The fact that such articles are manufactured and sold, affords sufficient proof that their use is not unknown in our own day. Von Maschka describes such priapi as being made of india rubber, of the size and shape of an erect penis, perforated longitudinally and fitted at the lower end with a testicle-like attachment, to be filled with warm water or milk, so that by squeezing it an ejaculation can be counterfeited. This priapus is also so constructed that it can be attached to the body by means of a girdle and can thus be employed for the gratification of another individual.

We have already referred to sodomy, unnatural intercourse with the lower animals. Von Maschka gives several instances of this, which we have previously mentioned, and states also that some years before, during his stay in Paris, a female was accustomed to hold a secret exhibition, the entry to which cost ten francs, and at which she had sexual intercourse with a bulldog trained for the purpose.

According to Lombroso, even at the present day, the inmates of licensed brothels frequently hold exhibitions, for admission to which a fee is charged, of tribadistic couples in poses plastiques, and of another prostitute in coitus caninus.

In his widely-celebrated work on Psychopathia Sexualis, von Krafft-Ebing discusses these morbid sexual processes in women. We select certain data from his exposition. Regarding the congenital morbid phenomenon of the lack of sexual feeling in women, 197as contrasted with perversion of sexual feeling, and the sexual impulse toward an individual of the same sex (antipathic sexual feeling), von Krafft-Ebing writes: “The woman-loving woman feels herself sexually to be a man, she rejoices in the exhibition of courage, of masculine sentiments, since these characteristics make the man desirable to the woman. The female urning,^[35] therefore, likes to have her hair cut short and her clothes of a masculine cut; and one of her greatest pleasures is when opportunity offers to appear in male attire. Her ideals are notable feminine personalities, distinguished by spirituality and energy; in the theatre and in the circus, it is only the female performers that attract her interest; and in the same way, in collections of pictures and statues, it is only the representations of women that awaken her æsthetic sense and her sensibility.” Von Krafft-Ebing insists that in nearly all cases of antipathic sexual feeling in which a family history was attainable, that history was found to exhibit instances of neuroses, psychoses, stigmata of degeneration, etc. In hysteria, according to this author, the sexual life is especially often abnormal; in cases with neuropathic inheritance, one may say always: “All possible anomalies of the sexual functions occur in such cases, with the utmost variety and the strangest commingling, based upon hereditary degenerative processes, and accompanied by moral imbecility in its most perverse manifestations. * * *. Frequently, in hysterical subjects, the sexual life is morbidly excitable. This excitement may be intermittent (? menstrual). Shameless prostitution may result, even in married women. In cases of a milder type, the sexual impulse is exhibited in the form of onanism, nude perambulations about the room, wearing of male attire, etc. In cases of hysterical mental disorder, the morbidly excited sexual life may manifest itself in the form of maniacal jealousy, baseless complaints against men of indecent assault, hallucinations of coitus, etc. Sometimes there may be frigidity, with lack of sexual pleasure, commonly due to genital anæsthesia.”

Incest in women, dependent upon psychopathic causes, is also alluded to by von Krafft-Ebing; it occurs in those in whom a partial imbecility that leaves the sense of modesty undeveloped is combined with eroticism. Thus, a case reported by Schürmayer is mentioned, in which a mother had, or attempted, intercourse with her son, aged five and one-half years; and again a case reported by Lafarque, in which a girl of seventeen laid her thirteen-year-old brother on herself for the gratification conjunctionis membrorum, while simultaneously 198masturbating her brother; Magnan’s case, an unmarried woman twenty-nine years of age, who could hardly resist the impulse toward copulation with her nephews as long as they were quite young; Legrand’s cases, in one of which a girl fifteen years of age seduced her brother to the performance of all possible sexual excesses on her body; another, a married woman aged thirty-five, who committed incest with her eighteen-year-old brother; and a third, a mother aged thirty-nine, who committed incest with her son.

According to Moll, women who suffer from antipathic sexual sensation are, in many cases, married; it appears, however, that for the most part they have no inclination to marry. In isolated cases there may exist a psychical hermaphroditism, the woman thus affected having sexual inclination both towards men and towards women. In the case of homosexual women, normal intercourse appears not to furnish complete satisfaction. As regards fetichistic, masochistic, and sadistic inclinations on the part of women with antipathic sexual sensation, Moll was unable to obtain any trustworthy information. Sometimes in women the perverse sexual impulse appears periodically, being then often associated with the appearance of other psychical abnormalities. In some women the perverse impulse is especially active at the menstrual periods; whilst at other times these subjects, even though not quite sexually normal, are still very much quieter. Antipathic sexual sensation in women may depend upon inherited predisposition, and may often be traced back to a very early age. In many cases an exciting cause may be demonstrated.

Mantegazza, who relates that homosexual practices are common among the inmates of harems, believes that antipathic sexual feeling is readily curable in women soon after marriage, but that later a cure is rare.

A perverse form of sexual gratification sometimes met with in women is flagellation. By chastisement with birches, straps, or whips on the bare buttocks, the nerves of the sexual apparatus are stimulated, and these organs become congested, with an effect resembling that of onanism. Such flagellation was practiced by the wanton ladies of ancient Rome. In the Middle Ages, hysterical women derived great pleasure from the stimulatory effect of whippings. It is reported of Catharine de Medici, that she had herself whipped, and that she delighted in seeing the ladies of her court undergoing similar treatment. In the present day many women derive intense sexual pleasure from being birched by their lovers on bared portions of their bodies. In Paris and other large towns there are special places of resort for those who pursue this form of perverse sexual gratification. Sometimes such women are only the active fouetteuses for worn-out, perversely-feeling men.

199Among the Greeks, a woman who had remained barren during the early years of marriage would visit the temple of Juno, in order to receive from a priest of Pan the gift of fertility. She stripped naked, and, while thus exposed to the flagellant priests, she received all over the back of her body numerous blows inflicted with thongs of a he-goat’s hide—this process being supposed to induce fertility. The object of this form of flagellation would appear to be to induce an increase of sexual desire.

Sexual neurasthenia is defined by Eulenburg as a neuropsychosis of chronic course, manifesting itself chiefly in the form of excessive irritability of the sensory and psychosensory neuron-systems, in association with excessive tendency to exhaustion of the motor and psychomotor neuron-systems. This exhaustion occurs especially in relation to the genital system, in which we see exhibited the phenomena of irritable weakness, of increased excitability combined with increased tendency to fatigue of the genital nerve apparatus—such chronic morbid disturbances are, according to this author, comparatively rare in women, that is to say, the developed typical picture of the disease does not occur in women, or occurs very rarely. Among 168 patients suffering from sexual neurasthenia, only six were women. Two of these latter were addicted to masturbation, and in the anatomical sense both were still virgins; the rest were married women, not receiving sufficient sexual gratification in their married life, two of these were probably also addicted to masturbation, two indulged in homosexual practices.

Onanism, according to Eulenburg, is the cause of sexual neurasthenia in women as well as in men. If, however, among the relatively very large number of women addicted to masturbation, there appears to be such a very small proportion of instances of sexual neurasthenia, this depends on the fact that from the nature of onanism in women the physical and also as a rule the psychical consequences are as a whole apt to be much less severe than those arising from similar practices in men; but it depends also on the circumstances that neuromental abnormalities of other kinds and denoted by other names, such as dyspareunia, vaginismus, sexual hysteria, nymphomania, feminine sadism, and tribadism, are apt to arise in consequence of onanism. As regards onanism, so also may it be in regard to sexual excesses and aberrations in general; they may be on the one hand causes, but on the other symptoms and sequelæ, of sexual neurasthenia. Early-acquired or inherited homosexual tendencies and habits may, as Eulenburg further points out, lead to sexual neurasthenia only, but then very easily, when such individuals have allowed themselves, against their nature but in obedience to conventional points of view and to the advice of the relatives, to be persuaded into marriage. That sexual abstinence alone is competent to induce sexual neurasthenia must be dismissed as a fable.

By the term menacme I designate the culmination of the sexual development of woman, during which the processes of reproduction, copulation, conception, pregnancy, parturition, and lactation occur.

The processes of puberty in woman are fully completed at the age of from eighteen to twenty years, so that from this time forward she is fully equipped for the performance of her sexual duties. The first act in the fulfilment of these duties is copulation, which in civilized countries is in the great majority of women first undertaken at the commencement of married life. The average age at marriage in the women of this part of the world is 22; but marriages at an earlier age are very common, and in many circles of society the average age is as low as 20. The fullest maturity of sexual activity in women occurs, however, in the thirty-second year of life, this being the year in which on the average the maximum fertility is attained.

At the menacme, the beauty and energy of women attain their fullest evolution, her sexual characteristics their strongest development. It is this period of life, however, that entails the greatest dangers to beauty and health in connection with the functions of the genital organs. Copulation, the first act of sexual intercourse with the male, often produces in the female injuries from which she never completely recovers. Gonorrhœal infection has been a source of unspeakable miseries to women. Motherhood itself entails the risk of a great number and variety of illnesses, which, as puerperal sequelæ, affect this phase of woman’s life. The struggle for existence, in which woman at her prime is also involved, and the fulfilment of duties to husband and children, further lead to the production of a series of changes, both physical and mental, in the feminine organism, which influence all the functions.

The great characteristic of this epoch is maternity. In maternity the fully developed woman lives and has her being, but to maternity also she often succumbs as a sacrifice to the fulfilment of her natural functions. Inasmuch as in this sexual phase the functions of the genital organs are of greater importance, to the same degree is enhanced the importance of the mutual relations between these organs and the other organs of the female body.

201Another influence of fundamental importance in the sexually mature woman is that of the sexual impulse, the force of which is at times overwhelming, so that its gratification is sometimes sought without regard for the consequences to married and family life.

The physiology and pathology of the menacme coincides with the normal processes and pathological changes respectively of the female genital organs consequent on their functional activity as organs of sexual sensation and of reproduction. Woman as wife and mother stands at the climax of her existence.

In a quite astonishing manner, however, many of the advocates of the modern movement for the emancipation of women contest the significance of maternity to women.

A modern authoress and supporter of women’s rights, Ellen Key, avows that she was in error when at an earlier date she “regarded maternity as the central point in woman’s existence.” She asserts that it lies within the sphere of a woman’s individual rights, as of a man’s, to reject marriage, or to accept marriage while rejecting maternity. “The grounds for the rejection of maternity may as well be deeply altruistic as deeply egoistic. It lies within the sphere of individual rights to dispense with love or with maternity when either is regarded or both are regarded from this point of view. It is entirely within a woman’s rights to transform herself into a member of the ‘third sex,’ the sex of the worker bee, of the neuter ant, if she finds therein her greatest pleasure. * * * Women exist in whom erotic feeling is totally atrophied; there are yet others who fail to find in intercourse with the modern man that soulful and deep erotic harmony which they rightly desire; and there are others still more numerous who desire love, but not maternity, which indeed they dread.”

A celebrated German authoress of the present day, Gabriele Reuter, refers in similar terms to the justifiable fear with which so many aspiring and hard-working women regard maternity, “the perpetual, watchful, emotional dread of motherhood, a dread which causes them to turn at bay. A dread, a hatred, it is, which has grown so strong, so active, that one might almost regard it as an obscure perverse instinct, awakened and developed and strengthened by bitter necessity. It is as if in the innermost recesses of their nature such women had a belief that should they pay their tribute to sex they would loose all the energy, clearness, and brightness of mind, by means of which they have raised themselves above the level of their sex. And perhaps women of a certain type are justified in this fear.”

Fortunately, however, the woman who does not prize maternity still remains an exception. The great instinct for the preservation 202of the species, which nature has planted deeply in every human being, still as a rule in women remains much more powerful than the instinct of self-preservation at every one else’s expense—more powerful than such self-sufficient egoism. And now as ever it is the duty of humanity to educate women for maternity from her youth upward, so that she is in every way fitted for the supreme duty of her sexual nature, the renewal of life from generation to generation.

Against the significance and importance of maternity to woman, the mountainous waves of the movement for the emancipation of women dash themselves as vainly as against the solid rock. Much justification may be found for the efforts of women in modern civilized communities to engage in departments of activity to which hitherto men only have been admitted; and as regards the intellectual capacity of women we may acknowledge their competence for the higher scientific professions; but while admitting this we must hold firmly to the physiological standpoint and must more especially bear in mind the sexual life of woman. Such professions only are suitable for a woman as do not entail a restriction of the sphere of her reproductive activity, a hindrance to her principal duty, that of maternity, an interference with the discharge of her obligations to husband and children, or a diminution of her domestic value and an evasion of her responsibilities in family life. As L. von Stein so justly remarks, the woman who spends the whole day at a desk, in the law courts, or in a house of assembly, may be a most honorable and most useful individual, but she is no longer a woman, she cannot be a wife, she cannot be a mother. In the condition of our society, the emancipation of woman is in its very nature the negation of marriage.

We may not agree with the great misogynist, Schopenhaur, in his depreciation of the female sex, or in his assertion that woman exists simply and solely for the propagation of the species, and that “her life should therefore flow more quietly, more inconspicuously, and more gently than that of man toward its goal;” nor need we regard as justified the severe sentence of the philosopher, E. von Hartmann, that from the moral standpoint, “the greater number of women pass the whole of their lives in a state of minority, and, therefore, to the end stand in need of supervision and guidance;” but the statement made by Friedr. Nietsche in his book Also sprach Zarathustra deserves acceptation, “Everything in woman is a riddle, and everything in woman has its answer: it is called pregnancy,” and again, “For woman, man is only the means; the end is always the child.”

Unsearchable in its judgments, nature has imposed on woman alone the consequences of the act of generation; man has the pleasure, but not the labor and the pain. We might indeed regard as highly 203unjust the distribution of the rôles in the process of reproduction, were it not that in a mother’s love and a mother’s joys, woman finds a compensatory solace. The man’s part is a much easier one and costs far less than that of woman; with the gratification of his sexual desire, man shakes off any further responsibility, whereas the woman’s body becomes the workshop in the wonderful act of creation of a new human life.

Maternity, says Lombroso, is the characteristic function of the female sex, upon which rests her whole organic and physical variability, and this function is indeed throughout of an altruistic nature. Although there is a certain antagonism between the sexual impulse and maternity—according to Icard, the sexual impulse is extinguished in women during pregnancy,—still, maternity appears to depend upon sexual perceptions. For instance, the act of suckling the infant often arouses voluptuous sensations, and Icard mentions a case in which a woman permitted fertilization to occur solely on account of the pleasure obtained by suckling. The anatomical cause of this fact is to be found in the connections between the nipple and the uterus by way of the sympathetic nervous system. * * * It is likewise probable that in the happy feeling of maternity there intermingle very gentle voluptuous sensations derived from the genital organs. According to Bain also, very delicate sensations of contact form an element in maternal love.

The epoch of the menacme is that in which, independently of maternity, the sexual impulse often becomes so powerful in woman as to be entirely dominant. The problems relating to marriage and to the sexual position of woman, so widely discussed at the present day, are, therefore, of especial importance in regard to women at this period of life. The forcible repression and control of the sexual impulse inculcated by moral and religious ordinances are now, according to the modern leaders, both male and female, of the woman’s movement, to be abandoned; and it is loudly asserted that every woman has the same right as man to physical love and the happiness it produces. Hence, free love is demanded. “Freedom in love, freedom for love—this is what the dignity of the human race demands,” asserts the authoress of a book recently published (Elisabeta von Steinborn, The Sexual Position of Woman). With laws for the regulation of marriage, this section of the women’s rights party will have nothing to do. A truly good and honorable man, they contend, has as little need of laws to regulate his amorous relations as he has of laws against murder and theft. In the first place, love, the sexual relation between man and woman, must be free, and humanity, freed from vexations and needless control, will then seek and find the proper path, even if at the expense of a few 204errors by the way. Only after this unrestrained sexual intercourse has lasted for a long time, will free marriage become the rule. “Out of this phase will develop the monogamic system willed by God, for which, in its most ideal form, we are not yet sufficiently ripe.” It is hardly necessary to discuss in detail the general deleterious influence of such unlimited, unregulated free love upon the community, upon human society as a whole, to describe the results of free love, to attempt to realize the chaos which it would bring about in the social relations of civilized humanity. We must rather indicate it as desirable from the medical standpoint also, that such a change in general domestic economy shall be aimed at as will enable the great majority of women to share in married life and family happiness, and thus making allowance both for human nature and the demands of social life, to effect a true harmony between sexual morality and sexual practice.

Fig. 48.—The female pudendum, or vulva, with the labia majora. The vulval cleft. Female perineum. Mons veneris, with the pubic hair. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

205We must point out that in so far as the modern woman’s movement aims at dispensing with man and at basing the entire life of woman upon the independent ego, that movement is in opposition to nature and its eternal laws. A woman who thus seeks the solution of the woman’s question in the direction of freedom and independence is one who endeavors to avoid the burthen of womanhood. She desires to escape, always from guardianship, often from maternity, and usually from the restrictions, the unselfishness of womanhood. But none the less does she remain unable to escape from her femininity.

Fig. 49.—Vestibule of the vagina, with the labia minora or nymphæ, the vaginal and urethral orifices, and the glans clitoridis. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

“The true significance of woman,” insists Laura Marholm in opposition to the modern tendency, “has at all times consisted rather in what she is than in what she performs, and it is precisely in the former point that the women of the present day seem so unusually wanting. Their performances are indeed many and various, they study and they write innumerable books, they are the directors or principals of all possible concerns and collect funds for every possible object, they wear doctors’ gowns, conduct agitations, and found clubs, and they come continually more and more into publicity. And yet their public significance is after all diminished. The greater the influence of woman in the mass and as a numerical 206majority, the less is her influence as an individual, the smaller is the triumph of her sex. She herself has induced man to sound the trumpet note of the abhorrence of women. Tolstoi in The Kreuzer Sonata, Strindberg in numerous dramas, Huysmans in En Ménage, write in this strain; and in the works of many lesser luminaries we encounter this mistrust of love. * * * The modern system of education for girls, with its polyglossia and polymathy, favors a superficial development of the understanding, and produces women who are pretentious without being profound.”

Feminine beauty suffers during the menacme from the stress of the demands made on the sexual activity as well as on the functional capacity of the individual. Repeated, rapidly succeeding pregnancies and confinements impair the beauty of the breasts and the abdomen, the figure and the carriage. In consequence of suckling, the breasts, hitherto firm and elastic, usually become more or less pendent and wrinkled, sometimes also flabby and inelastic, sometimes nodular. Diseases of the genital organs and the disorders of the general health dependent thereon, leave disfiguring wrinkles in the face and other traces in the whole structure of the body. Toil, anxiety, and grief also write their horrible marks deeply on the appearance. The mature working-class woman, through sharing in masculine labors, through long-continued muscular exertion, and through neglect of bodily care, frequently assumes in her features, her carriage, her figure, and her whole appearance, a rather masculine type.

The beauty and the youthful freshness of girls belonging to the labouring classes seldom endure for long after the menarche, and in cases in which the environment is one of poverty, they last through a very short part only of the epoch of the menacme. The early appearance of wrinkles in the face, the stiff, angular character of the movements, the ungraceful carriage of the body, all these combine to make a woman of five-and-twenty who groans under the burthen of toil appear at the first glance an elderly woman, and a closer investigation shows what damage has been wrought to the attributes of beauty, how the breasts are flabby and flattened, the belly prominent, the buttocks pendulous, the arms muscular.

In the well-to-do classes, again, at this period of life, when generous diet combines with insufficient exercise, an abundant deposit of adipose tissue may already have occurred, resulting in a great impairment of beauty, the body and limbs being enlarged, the gait and the carriage correspondingly altered for the worse—changes which seem desirable only to those orientals to whom such obesity, such exaggeration of femininity, is sexually stimulating. If, however, this deposit of fat is not excessive, this it is which endows 207women during these years of fullest development with an imposing appearance and buxom form. In favourable circumstances, beauty of this type may persist to the fortieth year of life and even beyond, and it is of such a character as to justify the proverb that woman’s first sexual epoch is dedicated to love, her second to voluptuousness.

Fig. 50.—The uterus, the left Fallopian tube and the left ovary, in their connection with the broad ligament of the uterus, which has been fully unfolded. Seen from behind. From a virgin, aged nineteen years. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

“Bountiful nature,” writes Mantegazza, regarding woman at this sexual epoch, “sends to woman an ingenious engineer, who enlarges the hills to mountains and fills up the valleys with a soft alluvium of fat. The commencing wrinkles disappear, being smoothed out under the beneficial influence of this plastic material; the slender, elastic palm-tree stems are converted into majestic columns of Parian marble; quality is replaced by quantity, and if the eye has lost a few provinces, the hand has gained just as many. * * * A certain number of chosen women understand how to preserve for as long as ten years the unstable equilibrium of the period which separates these two ages of life. There are divine beings who with every oscillation of their tresses or rocking of their hips, with every undulation of their bosom, every serpentine movement of their limbs, instil desire. * * * They constitute our most intense 208delight, and our intensest torment, they make our life a blessing or a curse, they are the uttermost goal of human passion, of human voluptuous desire.”

Fig. 51.—Female internal genital organs in the fully developed state. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)

Among the injuries to beauty effected by pregnancy, one above all evident to the eye is the almost invariably ensuing change in the skin, principally taking the form of a change in pigmentation, with the appearance of spots varying in size and tint, on the face and especially on the lips and the forehead; there is greatly increased pigmentation also of the areola mammæ and the linea alba, and in addition of the labia majora and minora and of the anal region. It is not certain whether this chloasma uterinum is dependent, as Jeamin assumes, on the discontinuance of menstruation, or, as Virchow believes, on changes in the blood and the blood-pressure. Sometimes also, in pregnant women, we observe on the face, chiefly on 209the nose and the cheeks, dilatations of the small cutaneous vessels, often associated with acne nodules.

A permanent disfigurement is caused by the lineæ (vel striæ) albicantes, white lines or streaks of varying length and resembling scar tissue in appearance on the skin of the abdomen, the adjoining parts of the buttocks and thighs, the lower part of the front of the thorax, and the mammæ. They are not true scars, not being new formations of connective tissue, being on the contrary dependent on solutions of continuity, on relative diminution, that is to say, of the connective tissue layer of the skin. They are formed in consequence of the fact that the connective tissue bundles are not able to keep pace in their superficial enlargement with the necessarily rapid extension of the cutis, hence great meshes appear in the former, situate in the direction of the greatest tension of the skin. (Spietschka and Grünfeld).

Transiently during pregnancy, but in some cases permanently also, the beauty of the lower extremities is apt to be impaired by enlargements of the veins, the formation of varices, and sometimes also by œdema; these conditions depend upon the hindrance to the venous return caused by the pressure of the pregnant uterus. Thick, vermicular, bluish strings or nodular enlargements appear in the course of the great veins, with consequent eczema and ulceration. In pregnant woman, eczema is common in other regions, on the face, the hands, the forearms, and the genitals; also erythema, urticaria, and the pustular eruption known as impetigo herpetiformis.

Parturition and lactation entail further disfigurement of the skin through the production of various lesions, such as cracks and fissures of the skin of the breast, dermatitis due to venous thrombosis in the lower extremities, scarring of the breast after mastitis, etc.

In the description of the sexual life of woman in the epoch of the menacme, we shall consider at some length copulation and conception, the relations of fertility and sterility, the important topic of the use of measures for the prevention of pregnancy, and the interesting subject of the determination of sex; on the other hand, pregnancy, parturition, and the puerperal state, since these subjects are specially treated in the ordinary textbooks on midwifery, we shall discuss only in so far as certain relations between these reproductive processes and the organism as a whole and its functions, appear to us especially worthy of note.

Anatomical Changes in the Female Genital Organs in the Period of the Menacme.

In the fully-developed woman during the period of the menacme, the mons Veneris forms a rounded elevation which consists of very 210dense connective tissue containing large quantities of fat, while the integument that covers it is usually coated with a thick growth of hair. The form of this hairy covering, which by the Roman poets was designated Hebe, by the Greeks zunaikomustax (translated by Albrecht Dürer as Weybsbart—woman’s beard), by Galen termed ornamentum loci, is various, and, as an external sexual character, it deserves more accurate observation than it has hitherto received from anatomists.

The hairy covering of the female genital organs is in adults, and especially in brunettes, very abundant; above, it is usually sharply limited by a transverse line across the top of the mons Veneris, and it extends outwards only a little beyond the labia majora, whilst below it extends only to about the middle of the sides of the perineum. According to Bergh, however, who made an exact study of this matter in 2,200 women of ages for the most part between fourteen and thirty years, in some cases the shape of the patch of hair (which is in such instances always very thick) resembles that so common in the male, there being a pointed process, usually rather narrow, extending upward toward the navel. This masculine form of the pubic hair is by no means common in women; according to Lombroso it is met with more frequently in Italian women than in those belonging to other European nations. In most women, the thick hairy covering of the mons Veneris is sharply limited above by the curved line that indicates the upper margin of the eminence, whereas in men a strip of hair usually passes up from the mons pubis to the umbilicus. Still, exceptions are met with. Thus, in 100 women, Schultze found five in whom the hairy covering extended up to the navel. Sometimes other variations occur, for instance, the hair may extend laterally into the groin, occasionally as far as the anterior superior spine of the ilium, and across the upper part of the front of the thigh, not infrequently in association with a thick growth of hair along the sides of the perineum as far as the anus. Of women with the hair growing in this fashion, not a few appeared to Bergh to have unusually strong sexual passion.

In contradistinction to these cases in which the development of the pubic hair is thick and even excessive, we meet with others in which it is very scanty, and this not only in quite young individuals (at an age from 15 to 18 years), with but slight development of the labia, but also in older and fully developed women—for the most part blondes.

The growth of the pubic hair is thickest and strongest near the median line, whilst laterally the hairy covering is thinner and weaker. The thickness is extremely variable. “In some women we find a flattened, occasionally frizzled, turf-like covering; in others, 211a dense, elevated, luxuriant bush of hair” (Bergh). The length of the pubic hair is variable, but as a rule it is somewhat shorter in the female than in the male. Still, cases have been known in women in which it reached to the knees.

The colour of the pubic hair commonly resembles that of the hair of the head, but the pubic hair is usually the darker of the two. Blondes with dark or black eyebrows have, according to Bergh, usually dark or black pubic hair. The pubic hair turns grey late in life, later as a rule than the hair of any other part, a fact known already to Aristotle; it is rather late in life also that the pubic hair becomes thin, and in this state it remains almost invariably up to an advanced age, even when the scalp has become almost or quite bald.

The pubic hair, according to the same author, is seldom straight, being almost always curly, frizzled, or more or less rolled up into rings or spirals, generally forming smaller or larger locks. Fairly often, we meet with curled locks, either one pair or two, symmetrically disposed on either side of the depression adjoining the præputium clitoridis; these usually have an outward direction. Much more rarely we find similar locks symmetrically attached further back on the labia.

In the case of 1,000 adult women examined by Eggel with regard to the colour of the pubic hair, the colour of the eyes, and the colour of the hair of the head, there were 239 with dark eyes, 333 with dark hair on the head, and 329 with dark pubic hair; contrariwise, 761 had light eyes, 667 light hair on the head, and 679 light pubic hair. Obviously, then, a considerable number of women with light-coloured eyes must have had dark pubic hair. Roth, in 1,000 North German women examined by him, found the pubic hair blonde, but a rather dark blonde, in a large majority of the cases; in red-haired women, the pubic hair was in all cases bright red, in black-haired women the pubic hair was black in two-thirds only of the cases, in nearly a third it was brown, in two cases dark blonde; in Jewesses, in a large majority of instances, the pubic hair is brown. The arrangement of the pubic hair is described by Roth as very variable. “Sometimes it is short and frizzly, sometimes a luxuriant bushy growth; sometimes the hairs are scanty and thinly set; sometimes they are irregularly distributed; sometimes we see only a narrow strip of long hairs down the middle of the mons Veneris, which is bare at the sides. In some the lateral boundaries of the pubic hair are sharply defined, in others the hairy covering spreads beyond the usual limits.”

Among the ancient Greeks and Romans, it was customary for women to remove the pubic hair, a custom even now observed by all oriental races; for this reason in ancient art the nude female body 212is depicted without pubic hair. According to Stratz, in the Chansons de Bilitis it is said of the priestesses of Astarte: “They never draw their hairs out, in order that the dark triangle of the goddess shall represent on their bodies the form of a temple.”

The physiological purpose of the pubic hair is to prevent irritation of the genital organs by the sweat that would otherwise run down upon them, and to protect the skin from direct friction during the act of copulation.

The labia majora in women during the menacme are usually strongly developed, their outer surface is hairy; in parous women we almost invariably observe small or even large lacerations of the frænulum pudendi or fourchette, in front of the posterior commissure of the vulva. On the inner surface also of the labia majora, the general characters of which are those of mucous membrane rather than of skin, fine hairs are also to be found. In multiparæ, and even in women who have frequently had sexual intercourse, these inner surfaces of the labia majora are not usually any longer in mutual contact, so that the rima urogenitalis or vulval cleft gapes more or less. In well-nourished women who have led the “sheltered life,” the dense and fat-containing connective tissue of the labia majora (continuous with and similar to that of the mons Veneris) gives these structures a certain firmness and elasticity, and the labia minora or nymphæ do not project beyond them. But when the genital organs are not well preserved, projection of the nymphæ occurs. In women whose genital organs are beautifully formed, the nymphæ are of a soft, delicate consistency, and their mucous membrane is of a pink color; but when the reproductive organs have been subjected to excessive stimulation, the nymphæ are dry, hard, brown in color, and they project from the vulval cleft. In women of the Hottentot and Bosjesman races, the nymphæ attain, as is well known, an excessive length, forming the so-called “Hottentot-apron;” and in certain other indigenous races of Africa, the enormous size of these organs renders resection necessary.

During this sexual epoch, in women with strong sexual passion and having frequent sexual intercourse, the clitoris is largely developed, and sometimes the dorsum of the organ protrudes from between the anterior extremities of the labia majora.

The vaginal orifice gapes a little, so that the irregular carunculæ myrtiformes are visible. In parous women, the vaginal orifice is enlarged in such a manner that the wall of the vagina passes directly and without limitation into the wall of the vestibule, and the external orifice (meatus) of the urethra is situate immediately in front of the anterior vaginal column, and thus lies within the vaginal orifice.

213The breasts of a strong, healthy woman who has attained complete sexual maturity are more or less firm in consistency, and considerable in size, exceeding now Ovid’s demand concerning these organs, ut sit quod capiat nostra tegatque manus. The normal hemispherical form and the somewhat soft texture are subject to many variations, these being dependent upon race, climate, and sexual activity and also upon the kind of clothing worn. The nipple and its encircling areola are usually of a brownish colour; but in beautiful women they sometimes retain the pink colour characteristic of these structures in the virgin. In parous women who have suckled their children, the breasts are usually pendent, and often the left breast will be found to be somewhat larger than the other; generally also in such women the nipples are longer and thicker than normal. Not infrequently the nipples are withdrawn into a furrow of the skin, and become prominent only on local stimulation or as a result of sexual excitement. Sometimes in the region of the areola, especially in brunettes, we see a circle of small glands, which produce eminences beneath the skin.

It is easy to understand that the breasts of such women in general no longer have the virginal form of small hemispheres, but have matured to a greater fulness and size. This, however, does not diminish their beauty, for the ideal of beauty must take into account the natural development of the body. Whereas at the present time, under the influence of the modern negation or at any rate undervaluation of maternity as the goal of woman’s life, it is the tendency of a certain school of art to misprize the influence of that state on the form of the breast, and to esteem the “flat bosom,” at an earlier day under the influence of Rousseau’s Emile, a book in which mothers are strongly urged to suckle their own children, the full bosom as a beauty was the fashion in art.

Only a perverted taste can find a woman beautiful without bosom—without “that golden chalice, from which men quaff love, and children life” (Mantegazza),—an angular, flat being, without a rounded form. Nothing but a morbid desire for equality with man can induce woman herself to endeavor to conceal also the external manifestation of her sexual characteristics, and by her clothing to disguise, like a nun, the sexual curves of her figure.

Great deposit of fat, such as occurs from liberal feeding in conjunction with a sedentary mode of life, or as a result of several pregnancies, destroys the beautiful form of the breasts, which attain an immoderate size, thus disturbing the grace and symmetry of the feminine figure, a fact recognized already by the Romans. Hyrtl condemns, from the point of view of anatomical beauty, the nude female figures in the pictures of Rubens, remarking that “the goddesses 214and angels of this painter are as luxuriant in their development as a Flemish dairy-maid;” and the buxom “goat’s-udder breast” prized by the Arabs does not represent any nobler ideal of beauty. Sometimes these excessively large and fat breasts hang down in a conical form, or, as more or less flattened hemispheres, reach right down over the gastric region; moreover, the interspace between the two breasts seems to disappear, and they touch or rub against one another.

According to Ploss and Bartels, the various forms of breast occurring in different races may be classified as follows: A. According to size: 1, very large; 2, large; 3, medium; 4, small. B. According to consistency and firmness: 1, high; 2, semi-pendent; 3, pendent. C. According to shape: 1, shell-shaped (disc-shaped); 2, hemispherical; 3, conical. The nipples also, according to these authors, exhibit variations dependent upon race, being in some cases small and flat, like a little knob, in some cases large and conical in shape, with a broad base and a rounded extremity, and in some cases large and cylindrical, having almost the shape of a finger-joint. The areola, finally, is in some women quite pale in color, in some dark pink, in some brown and even almost black from excess of pigment.

The uterus of a woman who has attained complete sexual maturity, has undergone such alterations in its proportions that the cervix and the body are of almost the same length. The constriction, visible externally, indicating the separation between these two segments of the organ, is depressed somewhat toward the external os. In sexually active women, a widening and an increased curvature of the region of the fundus occur, the uterine extremities of the Fallopian tubes becoming more widely separated; at the same time the posterior wall becomes more and more convex. The more frequently the uterus has functioned as a reproductive organ, the more strongly marked is the convexity of the body of that organ. The relative lengths of the corporal and cervical portions of the uterine cavity are now the reverse of those that obtain in the uterus of the child; the transverse and antero-posterior diameters have greatly increased. Transverse diameter at the fundus; virgin, 4 centimetres (1.575″), multipara, 5.5–6.5 centimetres (2.165–2.559″): sagittal (antero-posterior) diameter; virgin, 2 centimetres (0.787″); multipara, 3–3.5 centimetres (1.181–1.378″). (Chrobak and von Rosthorn.)

During the menacme, in consequence of the act of reproduction, the uterus undergoes important changes in form. In a nulliparous married woman, the uterus differs little from that of a virgin; the cavity is somewhat more extensive, the convexity of the outer surface a little greater, there is some increase in width in the neighborhood 215of the fundus, the plicæ palmatæ (arbor vitæ uterinum) are confined to the cervical canal; further, under the influence of copulation the appearance of the vagina changes, it becomes larger, and its walls become smoother, sometimes quite smooth, from the disappearance of the rugæ of the mucous membrane and especially of those attached to the posterior vaginal column. Much more extensive are the alterations in the uterus of a multipara. According to Toldt, “the parts of the cavity representing the cornua, which are pointed on either side as they pass toward the Fallopian tubes, become completely included in the lower undivided portion of the cavity, this change being effected chiefly by means of the increasing outward curvature of the walls, so that the cavity comes to assume an amygdaloid form; the cervical canal is also enlarged, especially the lower part, where also the plicæ palmatæ (arbor vitæ uterinum) becomes less distinct; the vaginal portion of the cervix is shortened, the os uteri externum gapes, the lips of the cervix are tumid, nearly equal in length, and usually beset with scarred depressions.” In nulliparae, the vaginal portion of the cervix is, as in a virgin, of a rather tough consistency, smooth on the surface, while the external os is small, like a dimple, or transversely oval; the color of the vaginal portion of the cervix is identical with that of the vaginal mucous membrane in general. Through frequent copulation, however, the form of the vaginal portion of the cervix is so far altered inasmuch as it is more freely supplied with blood, and, therefore, changes slightly, in consistency. In multiparæ, in consequence of lacerations of the cervix, the os uteri externum changes to a wide transverse fissure with tumid margins, justifying the old designation of this orifice as os tincæ;, carp’s mouth. A large size of the external and internal os, moderate enlargement of the cavity, rounding of the upper angles adjacent to the uterine orifices of the Fallopian tubes, increased convexity of the walls, and partial or complete effacement of the plicæ palmatæ (arbor vitæ uterinum), are the characteristics of the uterus of a multipara (Chrobak and von Rosthorn). According to Hennig, the vaginal portion of the cervix is longest in women who have undergone defloration, and in nulliparae; widest in prostitutes; narrowest in childless wives; thickest in young widows. This author gives the following measurements of the external os, showing its variations in accordance with age and sexual activity:

216In the fully-developed woman, the ovaries undergo changes in size, shape, and consistency, these changes being dependent upon the age, the sexual functional activity, and the constitutional predispositions of the individual. The average length of the ovary is 3–4 centimetres (1.18–1.58″); the average width, 2–3 centimetres (0.79–1.18″); and the average thickness 1 centimetre (0.39″). The surface of this organ gradually assumes a ragged appearance, from the scarred depressions caused by the great number of successive menstruations (ovulations)—sometimes the appearance produced resembles that of a mulberry.

In the vagina at this sexual epoch, the surface of the anterior and posterior vaginal walls is rendered uneven and rugose by well-developed vaginal columns (columnæ rugarum), which feel almost as hard as cartilage, and project considerably above the general level of the wall; the transverse ridges (rugæ) run horizontally outward from the columns. By frequent copulation, the rugæ are partially effaced, and the columns themselves become flatter and softer; still, except in cases in which the genital functions are exercised to great excess, the vagina remains tense and rugose until after several children have been born, when it becomes soft, flaccid, and smooth. Even in women who have been accustomed to frequent intercourse, the narrowest portion of the vagina is still the orifice and the part of the passage lying immediately within the orifice, which can be constricted by the levator ani muscle; childbirth, however, brings about great and permanent distension of these parts also. The widest and most distensible portion of the vagina is the uppermost segment, the region of the fornices.

A special significance must be attached to the glands of the cervix uteri, which, according to my own observations, have the function of providing a secretion that increases the mobility of the spermatozoa, and this enables them more readily to find their way into the uterus. I have endeavored, by a series of histological observations, to determine the properties of these glands and the changes they undergo in the different phases of sexual life. The most important results of these researches may be stated as follows. These glands, which are lined with columnar ciliated epithelium, are but slightly developed before puberty, being then simple excavations; at the time of the menarche, they become tubular; later, during the menacme, they become long, dendriform, blind-ending glands, which during menstruation and under the influence of sexual excitement, furnish a secretion, variable in quantity, and in quality distinguished especially by its alkaline reaction; further, in connection with a number of pathological disorders of the female genital organs, these glands undergo various changes both in their anatomical structure and in their secretory activity. At the time of the menopause and 217after the climacteric age, these glands, which have hitherto consisted of branched tubules, tend to undergo cystic degeneration, leading to the formation of the vesicles known as ovula Nabothi. After the climacteric, the existence of these cysts may be regarded as a normal occurrence; and, sometimes arranged in grape-like clusters, they often project so as to occupy the greater part of the lumen of the cervical canal.

Fig. 52.—Sagittal section through the cervix uteri of a woman 26 years of age, dendriform branched glands.

Fig. 53.—Cervix of a woman 72 years of age, with glands that have undergone cystic degeneration.

Fig. 54.—Sagittal section through the cervix uteri of a woman 65 years of age. The glands have undergone cystic degeneration.

Diseases of the uterine mucous membrane during the period of sexual maturity often induce various pathological changes in these cervical glands. In consequence of obstruction of their excretory 218ducts, they may undergo cystic degeneration, forming follicles filled with mucus and epithelium, or cavities containing blood, which pass through the substance of the cervix in every direction; or they may give rise to the formation of slowly-growing glandular polypi and other glandular new formations—changes the general result of all of which is to interfere with the secretory function of the glands.

Pathology of the Menacme.

The full evolution of the sexual life brings in its train many dangers to a woman’s life. This appears at first sight from a comparison of the mortality of married women during the period of greatest sexual activity with that of single women of similar age. Between the ages of 20 and 25 years, the mortality of married women is in all races higher than that of unmarried women; and the same is true between the ages of 25 and 30 years, except in France, in which country from artificial causes maternity ceases at a very early age. In Prussia, in the year 1880, of every 10,000 married women, between the ages named, 21 died, of every 10,000 unmarried women, only 2. In Holland, Belgium, and Bavaria, this excess in the mortality of married women continues up to the age of 40 years; whilst in Prussia, from the age of 30 upward, the mortality of married women and unmarried is practically the same. In many countries, the mortality of married women at many ages exceeds even that of unmarried men.

This greater comparative mortality of married women is ascribed by Hegar to the satisfaction of the sexual impulse, and this authority believes that the dangers attendant on this function would be manifested yet more clearly if the contrast were made, not between married women and single, but between those habituated to sexual indulgence and those who are continent. We, however, are of opinion, that the satisfaction of the sexual impulse is only harmful to this extent, that it exposes women to the consequences of venereal infection, and also to the risk of numerous puerperal and other diseases of the genital organs. This is proved also by the statistical results of the investigations concerning mortality during pregnancy, parturition, and the puerperium. According to Hegar, adding deaths resulting from premature delivery to deaths resulting from delivery at full term, we find the mortality of childbirth in Germany to be about 0.6 per cent.

Whilst Bertillon and Simpson believe that the lower mortality of married women above forty years of age as compared with unmarried women at the same period of life is dependent upon the advantage to the former of the fulfilment of sexual functions, Hegar, on the contrary, gives another explanation. He writes: “At the 219age of 40, the less powerful married women have already been weeded out. At first, owing to the selection exercised by marriage, the quality of the unmarried women was inferior to that of the married women; the former, however, have not been exposed to the dangers attendant on the reproductive process, and so have passed through the time during which the body possesses the greatest elasticity; but in the years in which a decline in the vital powers naturally sets in, the originally inferior quality of the unmarried women is manifested by a comparatively higher mortality. Also we have to take into account among the unmarried, the consequences of extra-marital sexual intercourse and of prostitution, and further the lack of a family, of the support furnished by husband and children.”

In addition to the far-reaching disturbances of health dependent on sexual activity at this period of life, there are the minor domestic troubles by which woman is depressed and by which her powers are exhausted. The influence of these latter is admirably described by G. von Amyntor: “How many millions of brave house-wives boil and scrub away their vital energy, their rosy cheeks, their merry dimples, in the performance of their household duties, until they become wrinkled, worn-out, dried-up mummies. The ever-renewed question, ‘what must be cooked for dinner to-day,’ the perpetually recurring necessity for scouring and sweeping and dusting and washing-up—these are the continual dropping which slowly but surely wears away soul and body. * * * On the flaming altar on which the sauce-pan simmers, youth and simplicity, beauty and good temper, are offered up; and who can recognize in the old, hollow-eyed cook whose back is bent with toil and trouble, the once blooming, energetic, chastely coquettish bride adorned with her myrtle crown?”

A great number of the diseases of the female genital organs occurring at the epoch of the menacme need only a passing mention. Even coitus, in cases in which there is great disproportion in size between the penis and the vaginal orifice, or when the organ is very rapidly introduced or the act is very roughly performed, may lead to injury to the vulva or the vagina, a fact to which a very large number of recorded cases bears witness.

During the acme of the sexual life of woman, disturbances of the menstrual function are also frequent. Menstruation may cease in consequence of intercurrent diseases or constitutional anomalies; amenorrhœa may occur during the convalescence from acute diseases, in obese women, in those suffering from tuberculosis, diabetes, alcoholism, or psychoses. On the other hand, severe menorrhagia or atypical metrorrhagia may occur, the bleeding either being due to diseases of the uterus, such as endometritis, retroflexion of the 220uterus, or uterine myomata, or resulting from infectious diseases, disease of the heart or kidney, or from general disturbance of the health by chill or over-exertion. Or, again, dysmenorrhœa may arise, either as a symptom of some local uterine disease or in consequence of external noxious influences or weakness of the nervous system.

During the life-epoch of the menacme, moreover, disturbances of the nutrition of the uterus are of common occurrence, as, for example, hyperplastic processes in the mucous membrane of the cervical canal and of the cavity of the body of the uterus. Common also during the menacme is chronic oöphoritis, which may be due to mal-regulation of marital intercourse (especially to coitus too soon after childbirth), to carelessness during menstruation (dancing, skating, or mountaineering), to incomplete coitus (congressus interruptus), and not infrequently, to gonococcal infection; or, finally, the oöphoritis may occur soon after the puerperium in association with subinvolution of the uterus.

Next we may mention inflammatory diseases of the Fallopian tubes. In the etiology of these diseases in latter-day marriage, a dominant rôle must be assigned to the gonococcus; but they also arise in many cases from nutritive disturbances, infection (other than gonorrhœal), and indiscretions during menstruation. Pelvic peritonitis owns similar causation.

In this phase of women’s life, the commonest new growths of the uterus, myomata, also develop, most commonly between the ages of thirty-six and forty-five, and they occur in strikingly larger proportion in unmarried women; it is between the same ages also that cysto-adenomata of the ovaries are of commonest occurrence.

Sexual intercourse gives frequent opportunities for the introduction of infective germs into the vagina, and for the origination of inflammatory affections of the mucous membrane (colpitis), the intensity of which depends upon the species, the quantity, and the virulence of the germs in question, on the one hand, and upon the local and constitutional predisposition of the infected person, upon the other. Especially grave in its consequences is gonorrhœal infection transmitted by the male, for this virus gives rise to a great variety of pathological processes in the female genital organs. In the act of defloration, considerable injuries are sometimes produced, and these readily supply a breach for the invasion of infective organisms. The condition of passive hyperæmia that occurs in the genital organs during pregnancy also provides a favorable soil for their growth.

Gonorrhœal infection of young married women is so frequent and so serious an occurrence in the sexual life of woman, that it requires special consideration. The cases in which the man entering upon 221marriage is so unscrupulous and so brutal as to deflower his young wife and to continue copulating with her, while suffering himself from a quite recent and active gonorrhœa, are on the whole rare. More common is it for the bridegroom to believe himself completely cured of his previous claps, and he is declared cured by his physician. The disease is, however, latent merely, the gonorrhœa has become chronic, the discharge is so slight that it is overlooked; but by the stimulation of the frequent acts of coition usual in the early days of marriage, the disease is lighted up afresh, the gonococci multiply quickly and intensely, the young wife is infected, and suffers from an acute gonorrhœa, which may often escape observation for a considerable period.

In a gonorrhœal marriage, one in which both husband and wife have gonococci in their genital organs, very diverse phenomena may be observed and very various conditions may result. On this subject M. Runge writes: “If the husband’s gonorrhœa is not cured, fresh, virulent cocci are repeatedly transmitted to the wife, in whom, therefore, the disease often gets worse by distinct stages. If the wife undergoes treatment, the effect in these circumstances will naturally be nil, since the husband is always supplying fresh infection. On the other hand, the wife on her side returns the gonococci to her husband, and in this way his gonorrhœa may undergo aggravation. If the husband is compelled, by illness, for instance, or by absence, to abstain for a long period from intercourse with his wife, the latter’s gonorrhœa may, in favorable circumstances, undergo alleviation and cure. It may happen, however, that in the husband, in consequence of sexual rest, the gonorrhœa becomes latent, and even entirely disappears, whilst the wife still suffers from infection. If now, after long abstinence, the husband has renewed intercourse with his wife, he may be reinfected, and suffer from an acute attack of gonorrhœa, though this is due to the descendants of the very gonococci that he himself sometime before conveyed to the genital organs of his wife—he reinfects himself, as people say. Such cases have given rise to suspicions of unchastity on the part of the wife, when the husband is in actual fact enjoying his own work in a new edition. A further possibility is that both husband and wife have become habituated to their own gonococcal interchange; that is to say, the organisms produce no notable effect in either. But if the wife in such a condition receives the embraces of a lover, the latter may be infected with an acute gonorrhœa—a fact that has long been known.”

The principal rôle in the etiology of the diseases of the female genital organs must be assigned to pregnancy and childbirth. Anæmic women readily suffer during pregnancy from a further decrease 222in the corpuscular richness of the blood; those affected with valvular incompetence find their troubles much aggravated by pregnancy; where the kidneys are in an irritable condition, pregnancy not infrequently results in the onset of nephritis, those with disordered digestion often suffer from increased disturbance of the functions of the stomach and the intestinal tract; those with gall-stones are apt to suffer from exceptionally severe attacks of biliary colic, and acute yellow atrophy of the liver is especially apt to occur during pregnancy. In women in whom dilatations of the veins already exist, very great increase of the enlargement is apt to occur during pregnancy; and in the same circumstances, trifling telangiectases increase to extensive angiomata. Enlargements of the thyroid body undergo rapid increase during pregnancy, so that they may attain threatening proportions. In women in whom the abdominal walls are flaccid, the viscera may protrude during pregnancy through the enlarged lacunæ, giving rise to herniæ. The great relaxation of the peritoneal and other ligamentous attachments of the great abdominal glands, occurring during pregnancy and the puerperium results in displacements of these organs; hepatoptosis (migrating or movable liver), lienoptosis (splenoptosis or wandering spleen), nephroptosis (ren mobile, floating or movable kidney), and other varieties of enteroptosis (splanchnoptosis, visceroptosis, or Glénard’s disease). During pregnancy, previously sound teeth are apt to become carious, and already existing caries rapidly advances. New growths of various kinds originate at this period, those previously present exhibit rapid increase; and relapse after operations for the extirpation of malignant tumors is especially apt to occur. Even the bones are unfavorably influenced. A weakened nervous system is subject to a storm of changing nervous troubles, in some cases so severe as to lead to the outbreak of actual psychoses; while mental disorder already present tends, as a rule, to be seriously aggravated during pregnancy. In the eyes, serious disorders may occur, such as retinitis, and atrophy of the choroid with complete amaurosis. As regards the hearing, tinnitus aurium is not uncommon, and sometimes complete deafness occurs. Numerous diseases of the skin are apt to occur during pregnancy; in addition to the well-known pigmentation of the face, the areola mammæ, and other parts, we may have herpes, eczema, or pruritus.

The serious aggravation which pregnancy is liable to induce in many disorders previously existent, is well known, and this exacerbation provides in some cases an indication for the induction of artificial abortion. This necessity may arise in severe cases of renal, cardiac, pulmonary, or hepatic disease, in progressive anæmia, severe osteomalacia, hæmophilia, and many other acute and chronic pathological states, since, in exceptional cases, as pregnancy advances, the 223symptoms of any one of these diseases may become so threatening, that the patient’s life is either in immediate danger or is almost certain to be in danger within a very short space of time—this may occur, for instance, in diabetes, struma (goitre), or certain nervous diseases, such as chorea, polyneuritis (multiple neuritis), or mental disorders. Undoubtedly, in this connection, as W. A. Freund insists, it is not the actual nature of the disease that is of decisive importance, but rather its intensity, and its influence on the health of the pregnant women; these circumstances, considered in relation to the resisting powers of the patient, must be determinative in the adoption of measures for terminating the pregnancy. An indication for the induction of artificial abortion is generally furnished also by uncontrollable vomiting dependent on pregnancy and endangering the life of the patient; irreducible incarceration of a retroflexed gravid uterus in the pouch of Douglas, or of a gravid uterus in a hernia, or irreducible prolapse of a gravid uterus will also necessitate abortion.

W. A. Freund gives an example of a common pathological state, usually quite free from danger, but now and again, when associated with pregnancy, seriously endangering life and rendering the induction of artificial abortion absolutely necessary—this is acute struma vasculosa—(vascular enlargement of the thyroid body), which may during the first three months of pregnancy exhibit such rapid growth as to lead to severe orthopnœa and cyanosis and so to imperil the patient’s life.

In cases in which laryngeal tuberculosis exists as a complication of pulmonary tuberculosis, the former disease sometimes progresses so rapidly in the course of pregnancy that sudden death from œdema of the glottis is by no means rare. Freund, therefore, sees in this complication an absolute indication for the artificial termination of the pregnancy.

In cases of previously well-compensated valvular lesions of the heart, disturbances of compensation not infrequently occur as a result of pregnancy; whilst in cases in which cyanosis, dyspnœa, albuminuria, and dropsy existed even before pregnancy, the latter condition is likely to result in an aggravation of these symptoms to a degree that imperils life.

Parturition, to an even greater extent than pregnancy, may induce serious injuries to the female organism. Thus, during parturition, lacerations of the vagina are frequent, with consequent scar-formation and stenosis; lacerations of the perineum are also common, causing great inconvenience, and when complete, leading to incontinence of fæces with all its unpleasant consequences. Great is the danger arising from septic puerperal inflammations, such as pelvic peritonitis (perimetritis); serious are the results of puerperal vesico-vaginal and recto-vaginal fistulæ.

224A large part in the local pathology of the female genital organs is played by the various displacements of the uterus, either arising in consequence of inflammatory processes in their ligaments, or dependent upon relaxation of these ligaments from subinvolution of the internal generative organs, either following delivery at full term or following abortion.

The injury which women alike of the well-to-do and of the laboring classes suffer in consequence of numerous and frequently repeated pregnancies, is minutely described by Hegar. “We can,” he writes, “calculate the danger to life to which such an unfortunate woman is exposed by the act of reproduction. If we assume the ordinary mortality of women in childbed to be 6 per mille, then, in a woman who within 15 years has been delivered 16 times (whether prematurely or at full term), the danger will be 16 times as great as that of a single delivery, and the mortality will be 6 × 16 = 96 per mille; that is to say, of 1,000 women who have all been pregnant that number of times, 96 will die—nearly 1 in 10. Moreover, in this calculation the increased danger consequent upon the unusually rapid sequence of the deliveries has not been taken into consideration. And, again, only the immediate results of the deliveries have been taken into the account. Not infrequently women succumb at a later date to illnesses acquired in childbed; whilst others, in consequence of repeated pregnancies, have their powers of resistance so greatly diminished, that they are unequal to the contest with incidental diseases. In any case, a woman who has experienced numerous and rapidly successive pregnancies, has sustained damages which will endure for the rest of her life. Her tissues have lost their elasticity, the abdominal walls are flaccid, the abdomen is prominent, the abdominal viscera are displaced, the vessels dilated, the reproductive organs in a state of subinvolution, and are the seat of structural alterations. The greatest dangers arise in cases in which the pregnancies are consequences that have to be paid for illicit love, since in such cases syphilitic and gonorrhœal infection are exceptionally common. These complications, indeed, are not excluded in the case of married women, since marital infidelities occur, and, again, a premarital but not completely cured venereal illness may bear fruit in marriage, the latter occurrence being almost always attributable to the husband. Syphilitic or gonorrhœal infection may also arise in some other way than by copulation, and to this women are more exposed than men, owing to the greater size of the genital passage in the former.”

Very numerous are the disorders of the nervous system referable to the sexual functional activity of woman during this epoch of her sexual life.

225Freund, in his description of a neurasthenic symptom-complex to which he gives the name of angst-neurosis,^[36] maintains that the cause of these attacks of anxiety^[36] is very frequently to be found in a number of injurious influences in the sphere of the sexual life. In women, these anxiety-neuroses occur:

a) As virginal anxiety, or anxiety of adolescents. Freund has observed a number of unequivocal instances showing that a first encounter with the sexual problem, a rather sudden unveiling of what has hitherto been concealed, as, for instance, the sight of some sexual act, or something read or heard in conversation, may, in a girl at the time of puberty, give rise to an anxiety-neurosis, which is in a very typical manner combined with hysteria.

b) As anxiety of the newly married. Young wives who have been without sexual feeling in their first experience of intercourse are not infrequently attacked by an anxiety-neurosis, which, however, disappears as soon as the sexual feeling becomes normal. Since, indeed, the majority of young women who lack sexual feeling in their first experience of sexual intercourse remain nevertheless quite healthy, it is evident that some other cause must coöperate in arousing the anxiety-neurosis.

c) As anxiety in married women whose husbands suffer from ejaculatio praecox or from great diminution of sexual potency, or

d) Whose husbands practice coitus interruptus or coitus reservatus. Cases in these two classes are closely associated, since it is easy to ascertain, from the analysis of a sufficiently large number of cases, that the really important question is, whether during coitus the wife obtains or fails to obtain sexual satisfaction. In the latter event, the condition requisite to arouse the anxiety-neurosis is supplied.

e) As anxiety in widows and in voluntary abstinents, not infrequently in typical combination with impulsive ideas.

f) As anxiety in the climacteric period, during the final flare-up of sexual passion.

Numerous anomalies of the genital organs which gave rise in the virgin to no trouble whatever display their influence during the menacme by unfavorably affecting the nervous system. Thus, in cases of malformations of the external organs of generation, slight atresia of the vagina, a rudimentary condition of the vagina, a rigid hymen, or local changes in the vagina, it is only when sexual intercourse begins that neuroses or hysteroneurasthenic troubles ensue. 226So also at times nervous diseases which, though the disposition to them was present, were latent in the girl, such as epilepsy and various mental disorders, first become apparent in consequence of sexual intercourse.

The mechanical irritation of the nerves of the pelvis that occurs in sexual intercourse may, even in women whose reproductive organs are healthy, arouse sensations of weight, pressure, and bearing-down, various painful sensations in the sacral region, over the coccyx, in the buttocks, or in the upper part of the thighs, and also “lumbar enlargement symptoms,”^[37] viz., weakness of the lower extremities, abnormal sensations of fatigue in the lower extremities and the back, sometimes also disorders of micturition and defæcation.

Throughout the manifold diseases of women in or connected with the reproductive system during the age of sexual maturity, associated mental processes take place, which powerfully affect the nervous system. Such processes are, melancholy and anxious thoughts concerning the possible influence of the illness on the happiness of married life, concerning childlessness, or concerning loss of a husband’s sexual esteem, or again, fear that the affection will become cancerous, fear of some necessary operative procedure, or vexation in consequence of the limitation of her usefulness as housewife, wife, and mother. Thus in women suffering from sexual affections, a state of general neurasthenia, or some neurasthenic functional disturbance of other organs, very commonly arises.

The knowledge that she is suffering from an affection of the genital organs, makes a deep and lasting impression on the mind of a woman who takes a serious view of her duties as a wife, and whose thoughts and feelings are concentrated in the sexual sphere. The result is, that minor troubles are regarded through the magnifying lens of anxiety, and the general sensibility is increased. This hyperæsthesia is not confined to the affected region, but manifests itself in various other parts of the body by numerous phenomena of a reflex character. In the first place must be mentioned severe headaches, sacrache, sensations of pressure in the abdomen, cardiac troubles, palpitation, stomach-ache, nausea and retching and disorders of appetite and digestion. Capacity for work and the enjoyment of life are destroyed by these disorders.

We have further to take into account the numerous conditions liable to disturb the mind at this period of life. In childless women, we have the subject of their sterility, the continued yearning to be blessed with children, the eager search for a remedy, and not rarely in these cases the conflict between the reproductive impulse and the ethical principle of conjugal fidelity. In fruitful mothers, on the 227other hand, we have the anxiety lest, by too frequent child-bearing their beauty should be impaired and the livelihood of the family endangered; these considerations leading in many cases to the practice of coitus reservatus, with its deleterious physical and moral consequences. In the middle and working classes, we have the strain of the endeavor to be a helpful companion to the husband and at the same time to assist in the support and the education of the children. Last but not least, we have the potent influence of local therapeutic measures, and the fear of operative procedures, both of which have a most agitating effect on a woman’s mind. In truth, the menacme is a period full of stormy excitations and powerful revolutions.

In addition to its influence on the genital organs themselves, the sexual life of woman during the period of the menacme manifests its powers for evil especially in relation to the digestive functions, and to the functions of the heart and the nervous system.

When we compare the various consequences which may be induced in the principal organic systems as a result of functional disturbances and organic diseases of the female genital organs, we find that in respect of the frequency of their occurrence the diseases of the nervous system occupy the first rank; next in frequency come the disorders of the digestive organs that arise in sympathetic association with diseases of the female reproductive organs; whilst the third rank in respect of frequency and importance is occupied by the cardiac disorders that arise in connection with changes in the female organs of generation, and take the form either of disturbances of the heart’s functions or structural changes in the heart’s muscle.

Dyspepsia Uterina.

Although it has long been a familiar observation that pregnant women and women suffering from diseases of the reproductive organs suffered from various dyspeptic troubles, I was myself the first (in the Berliner Klinische Wochenschrift, 1883) to bring together, and to describe under the name of dyspepsia uterina, a peculiar group of dyspeptic conditions which are dependent upon diseases of the female reproductive organs. I dismissed from consideration organic diseases of the stomach and intestine dependent upon anatomical changes in these organs, even though these also might owe a similar etiology, and described only the more frequent dyspepsias occurring without organic change in the digestive apparatus, the origin of which is to be explained by the fact that certain structural changes and displacements of the uterus (to be discussed later) arouse centripetal impulses, and that these exercise a reflex influence on digestive activity.

228This influence, according to my observations, affects the secretory and muscular apparatus and also the nervous elements of the digestive tract, and I regard the following conditions as characteristic of uterine dyspepsia, though they do not necessarily all occur simultaneously: changes in the gastric secretion, excitement of the vomiting centre, an inhibitory influence on intestinal peristalsis, and hyperæsthesia of the stomach.

The symptoms of uterine dyspepsia may vary greatly in intensity, but not infrequently become so severe as to disturb very seriously the general health of the woman so affected. They may be enumerated as follows: The appetite in uterine dyspepsia is variable, but is generally good; the tongue is not usually coated to any great extent, nor does the mucous membrane of the mouth commonly exhibit any notable change; pain in the epigastrium is common after meals, with acid eructations and heartburn (pyrosis);^[38] sometimes there is violent vomiting, occurring after every meal, or in the morning on an empty stomach; in addition, constipation is an almost constant symptom, associated with excessive development of gases in the intestinal canal. The pain is usually dull in character, and somewhat relieved by pressure, but it may be severe and lancinating, and may shoot along the intercostal spaces. The accumulation of flatus within the abdomen gives rise to various painful sensations, distension, a sense of fulness; and its expulsion is attended with notable relief.

As regards the composition of the gastric secretion, an increase of acidity is sometimes noticed. Gastric digestion is retarded; experimental evacuation of the stomach, after a simple test meal (beefsteak and roll) showed that small quantities of undigested remnants were to be found in the stomach as long as seven or eight hours afterwards. The frequent eructations evacuate flatus, or else a watery fluid with an acid reaction (pyrosis or water-brash—see note 38). By the act of vomiting, larger or smaller masses of the food that has been taken are evacuated; in the vomit, sarcinæ in large numbers may frequently be detected by the microscope. Constipation is present in nearly all cases of uterine dyspepsia; and even in cases in which attacks of diarrhœa occur from time to time, careful examination will show that these are generally transient, being sequelæ of constipation due to the irritation caused by the accumulated masses. In one case of long-standing uterine dyspepsia, I observed, in the absence of any gastric dilatation, the well-known 229phenomenon of “peristaltic restlessness of the stomach” (tormina ventriculi nervosa), in which the peristaltic activity of the stomach is greatly exalted, and becomes visible to the naked eye in the form of large and powerful undulations in the gastric region, moving from left to right.

With these symptoms affecting the digestive organs are associated variable nervous manifestations in different organs, such as neuralgia of various nerves, palpitation of the heart, vertigo, headache, and nervous asthma. The general nutrition of the body often suffers considerably in cases of long-enduring uterine dyspepsia; excessive emaciation and general marasmus may ensue; we see also mental depression, melancholia, an irritable disposition, and disinclination for every kind of work.

Very important, but very difficult, is the differential diagnosis between uterine dyspepsia, on the one hand, and, on the other, chronic gastric catarrh, chronic ulcer of the stomach, nervous dyspepsia, and sometimes even carcinoma of the stomach.

As regards the distinction from chronic gastric catarrh, in this latter disease loss of appetite and changes in the oral mucous membrane are prominent symptoms; the vomit also usually contains much mucus. More difficult is the differential diagnosis of chronic ulcer of the stomach, in cases in which anæmic subjects complain of anomalies of menstruation, associated with dyspeptic troubles and cardialgia. In severe cases of uterine dyspepsia, the distinction from carcinoma of the stomach may be very difficult—at any rate in cases in which no examination of the genital organs has been made. Obstinate dyspeptic troubles, resisting all curative measures (unless indeed these are directed to the relief of the local disorder of the reproductive organs), progressive anæmia, great emaciation, and pains localized in the stomach, are all conditions common to both of these maladies. The absence of a tumor of the stomach, careful examination of the vomit, and examination of the genital organs, will lead to a correct diagnosis if the case is one of uterine dyspepsia. A superficial investigation is exceedingly likely to result in a case of uterine dyspepsia being regarded as one of nervous dyspepsia (von Leube); none the less, even though a very close resemblance exists between the symptoms of the two diseases, to differentiate them is a matter of importance. In nervous dyspepsia, the act of digestion influences the nervous system in such a manner that, even when the chemical processes are normal, the organism as a whole is sympathetically affected by a reflex from the stimulation of the nerves of the stomach, and in return reacts on the mechanical process of digestion in a more or less violent manner. In uterine dyspepsia, however, the relationship that obtains is exactly the reverse of this, 230inasmuch as the gastric activity is influenced by the nervous system, by reflex impulses originating in the morbid processes in the reproductive organs; moreover, in this form of dyspepsia, in direct contrast with nervous dyspepsia, the chemistry of digestion is often disordered, and, in addition, the process is not completed within the normal period.

Oftentimes, the diagnosis of uterine dyspepsia can be made with certainty only ex juvantibus.^[39] For this disorder cannot be cured unless the disease of the reproductive organs on which it depends is first relieved; and, conversely, local measures for the relief of uterine disease, will often at once remove all the dyspeptic troubles from which the patient suffers.

My own experience has led me to conclude that it is certain distinct local mechanical stimuli affecting the female genital organs which, acting for a long period on the sensory nerves of the uterus or its annexa, induce by reflex action the before-mentioned digestive disturbances. Diseases of the vulva and the vagina, catarrhal inflammation, colpitis and leucorrhœa, and prolapse of the vagina, do not by themselves lead to the occurrence of uterine dyspepsia; nor do inflammations of the uterine mucous membrane, such as endometritis (unless associated with parenchymatous changes of the whole uterus), chronic catarrh of the mucous membrane, erosion and ulceration of the cervix to an inconsiderable extent, or moderate perimetritic and parametritic exudations. On the other hand, uterine dyspepsia frequently ensues in cases of uterine displacements, flexions, or versions, or in cases of structural changes of the uterus accompanied by enlargement of the organ, chronic metritis, myomata, especially when intramural (interstitial), displacement of the Fallopian tubes and the ovaries, chronic oöphoritis, extensive inflammatory exudations, resulting from pelvic peritonitis, and leading to dislocation, “compression” or distortion of the uterus and its annexa, deep follicular or carcinomatous ulceration of the cervix, or, finally, ovarian tumors. As the commonest condition giving rise to dyspeptic disturbances of the kind under consideration, retroflexion of an enlarged uterus must be mentioned.

Under the head of uterine dyspepsia, we may also classify dyspeptic disturbances occurring at the time of puberty or of the menopause, and in association with certain amenorrhoeic and dysmenorrhœic conditions, and, in addition, the vomiting of pregnant women.

The vomiting of pregnant women, which must be regarded as a reflex disturbance of the stomach, occurs, with especial severity in first pregnancies, in the early months of pregnancy, with such regularity that it is regarded as one of the most typical signs of pregnancy. 231Thus, in 177 pregnant women, Horwitz observed vomiting in 147 (83 of whom were primiparæ, and 64 multiparæ), and in 29 only was this symptom wanting. In this series of cases, it most commonly made its appearance between the tenth and eleventh week of the pregnancy. The vomiting of pregnant women occurs most commonly early in the morning, immediately after rising (morning sickness), but also at other times of the day; it usually takes place easily, without any great distress, and after it is over the patient feels quite comfortable. It rarely continues later than the fourth month of pregnancy.

Very serious in its effect on the general state of nutrition is the uncontrollable vomiting that sometimes occurs in pregnant women (hyperemesis gravidarum), lasting throughout the whole term of pregnancy. It must be regarded as an exaggeration of the physiological vomiting of pregnant women, in patients whose nervous equilibrium is profoundly disturbed; but equally with the ordinary “morning sickness” is it dependent on the reflex stimulation of the nerves of the stomach exercised by the growing uterus. One source of such stimulation may be found in the stretching of the peritoneal investment of the uterus which results from the enlargement of that organ; another, in certain displacements of the uterus; but in addition to these local anomalies, we must assume the existence of a peculiar predisposition on the part of the nervous system, in virtue of which reflex irritability is increased, while the power of reflex inhibition is diminished.

The prognosis and treatment of uterine dyspepsia depend chiefly upon the nature of the diseases of the female genital organs that have given rise to the disturbances of digestion, and this pathological relationship demands above all a careful investigation. The following instance from my own case-book may be regarded as typical of cases of this class. Mrs. N., aged 25, married 6 years, barren, complains of severe dyspeptic trouble. Appetite fairly good, but after every meal severe gastralgia occurred, with heartburn and acid eructations, and very often the food was rejected; there was also obstinate constipation, and great distress from the accumulation of flatus in the intestinal canal. No blood was ever seen in the vomit. The patient was much emaciated, and was greatly depressed in spirits. Neither in the lungs nor in the digestive organs had any of the physicians under whose care the lady had been for the last four years found any abnormal change to account for the stormy manifestations. Now, at length, the gynecological examination, which had hitherto been neglected, was undertaken. The uterus was found to be strongly retroflexed and enlarged. Rectification of the position of this organ was immediately followed by the disappearance of all the stomach troubles; the vomiting ceased, some months 232later the woman became pregnant, and pregnancy and parturition were quite normal; since then there has been no return of the dyspepsia.

Since the appearance of my work on dyspepsia uterina, numerous observations have in recent years been published, proving even more clearly the causal dependence of disturbances of the gastric function upon diseases of the female genital apparatus.

Lamy, for example, has made an elaborate study of one of the above-mentioned symptoms of uterine dyspepsia, namely, excitement of the vomiting centre. His conclusions are as follows: Among the general symptoms of diseases of the uterus, dyspepsia, in all its forms and in all degrees of intensity, occupies the first rank in respect of frequency of occurrence. Among the accompaniments of these reflex processes, uterine vomiting must be mentioned. It seldom occurs as the sole symptom of disorder of the digestive organs; but when it does occur alone, it is of great importance that the cause of the affection should not be misunderstood. Diseases of the uterus and periuterine affections are the conditions that most commonly give rise to this trouble, but in a certain number of cases it is due to physiological changes in the female genital organs. Such changes are those associated with the functional activity of the reproductive apparatus at the time of puberty, during menstruation, in connection with coitus, during pregnancy, and at the change of life, the menopause. The vomiting of pregnant women is of the same nature, and confirms our belief in the uterine origin and pathogenesis of vomiting at other times than during pregnancy. The diagnosis of the true cause of uterine vomiting cannot be made from the nature of the latter, but only from a knowledge of the conditions in which it occurs, just as with other uterine reflexes, such as neuralgia or cough. The vomit may consist merely of the food last taken, or it may contain bile, without the presence of this latter constituent indicating the existence of any disease of the liver. The treatment of this disorder, which indeed does not threaten life, but does seriously impair the general state of nutrition, must be local, directed against the disease of the genital organs: Thus, in one case of this nature, a cure was effected by oöphorectomy.

The majority of the women in whom Lamy observed this symptom of uterine dyspepsia were chloro-anæmic individuals with an irritable nervous system, town-dwellers, young girls in whom frequent evening parties and dances, ill-chosen diet, and a generally unsuitable mode of life, had led to the development of a “virginal metritis.” The signs of the disturbance of the gastric functions were in the first place a retardation of gastric digestion while the appetite remained good. Moreover, the stomach was 233often distended with flatus, and this caused frequent gaseous eructations; there was also epigastric pain, which made it difficult for the patient to bear the pressure of the clothing, and sometimes great pain was aroused by the slightest contact. The attacks of vomiting, which occurred in a characteristic manner with periodical intervals of freedom, were usually preceded for a longer or shorter period by dyspeptic symptoms. The vomiting itself, if it occurred immediately after a meal, was not accompanied by nausea, a feeling of faintness, or cold sweats, but rather resembled a kind of painless regurgitation; but when the vomiting did not occur till some hours after food had been taken, it was painful, and the vomit was then green-tinted owing to the admixture of bile.

The gastric troubles that occur during menstruation are regarded by P. Müller as a further indication of the intimate connection between the genital organs and the digestive tract. In women who suffer from hysterical manifestations, gastric disturbances, cardialgia, and nervous dyspepsia, are very frequently associated with menstruation. These gastric symptoms generally make their appearance a few days before menstruation is due, and disappear as soon as the flow is established. In other forms, again, the digestive troubles set in with the appearance of the flow, to disappear during the later course of menstruation; and in yet other cases the gastric disturbance begins even later, and ceases only when the flow comes to an end. These symptoms may occur in women in whom the genital organs are perfectly healthy and in whom menstruation runs a regular course. More severe symptoms may, however, appear if menstruation is disturbed for any reason, or if it is suppressed. Not rarely such women, when they become pregnant, suffer, especially during the early months, from dyspeptic symptoms; but similar dyspepsia may occur in pregnant women who have previously been quite healthy.

To the same category belong the cases formerly described by von Leyden under the designation of neuralgia and hyperæsthesia of the stomach, which he observed in young girls as a sequel of menstrual disturbances, and more particularly of suppressio mensium. In these circumstances, the sensibility of the stomach may become so extreme that every time food is taken the patient suffers from such severe pains, or from so distressing a sense of anxiety and oppression, that she comes to eat less and less, and an extreme degree of emaciation and marasmus results. In one such case, congenital atrophy of the uterus was discovered on gynecological examination.

According to R. Arndt, it is especially in chloro-neurotic individuals that the stimuli proceeding from morbid conditions of the reproductive organs frequently induce, by reflex action, all kinds 234of disturbances of the alimentary tract, such as constipation and flatulence, gastric uneasiness and loss of appetite, weakness of digestion, cardialgia, and stricture of the œsophagus. Even simple menstruation suffices to give numerous proofs of this fact, but still more do such consequences arise from serious diseases of the reproductive organs, such as changes in form, displacements, and inflammatory states, and also, on the other hand, more or less pronounced hypoplasia.

G. Braun has published three cases illustrating the connection between neurosis of the stomach and uterine disorders. In the first of these cases, severe digestive disturbances occurred after every meal, with occasionally violent vomiting, in a woman, aged twenty-five years. No changes were found in the stomach or other digestive organs, and the symptoms obstinately resisted all direct treatment. Gynecological examination showed extreme mobility of the uterus, and for the relief of this a suitable pessary was introduced. The vomiting thereupon immediately ceased, all the other digestive troubles passed completely away, and the general state of nutrition, which had before been so much impaired as to necessitate the use of nutrient enemata of meat-solution, now became normal. The second case was that of a woman aged thirty, who, since her last confinement two years before, had continually suffered from disagreeable gastric sensations and from vomiting, which latter had proved quite uncontrollable. Gynecological examination disclosed extensive laceration of the cervix with ectropium of the mucous membrane. An operation was performed for the relief of this condition, and the vomiting of two years standing was also thereby cured. In the third case, that of a woman twenty-eight years old, vomiting began three months after her confinement, and recurred whenever the patient left the recumbent posture, in which latter she felt quite well. On local examination, the uterus was found to be prolapsed, the vaginal portion of the cervix moderately enlarged and just within the vaginal orifice. Amputation of the vaginal portion of the cervix cured the vomiting and completely restored the patient’s health.

The frequency of gastric affections in cases of retroflexion of the uterus is insisted on by Panecki. In eight instances he found neuroses of the stomach consequent upon such retroflexion, and in all cases a cure immediately followed rectification of the position of the uterus. He urges that if after the reposition of the retroflexed uterus the gastric troubles should still persist, a careful local examination of the stomach is indispensable.

Eisenhart, in a woman forty-two years of age, corrected a mobile retroflexion of the uterus, and thereupon very severe gastric symptoms of several months’ duration soon disappeared. Graily-Hewitt, 235in an unmarried woman twenty-seven years of age, cured by reposition of a retroflexed uterus a gastric disorder which had subsisted for nine years; Elder and Henrik report identical results in gastric troubles consequent on retroflexion or retroversion of the uterus. Jaffé, in a virgin, aged twenty-three, who had been brought near to death by gastric disorder with vomiting, found on local examination that there was a profuse, thick, purulent discharge from the interior of the uterus; curetting, and irrigation of the uterine cavity with antiseptic solutions, gave immediate relief to the stomach trouble. Similar experiences are recorded by C. van Tussenbeck and Mendes de Leon in cases of gastric disorder consequent on endometritis fungosa and endometritis interstitialis parenchymatosa; and by Gottschalk, in cases consequent on sarcoma of the chorionic villi. Lewy and Butler-Smythe have observed the relief of pernicious vomiting by Emmet’s operation (trachelorraphy).

As regards the relations of gastro-intestinal affections to the diseases of the reproductive organs, Theilhaber, in the cases observed by himself, distinguishes three groups. In the first group of cases, the gynecological abnormality was a chance accessory, and was not the cause of the gastric trouble. In the second group, he regards the gynecological trouble as dependent upon the affection of the gastro-intestinal tract, believing that, in consequence of atony of the intestine and an accumulation therein of fæces and flatus, a retardation of the circulation occurs in the region of the inferior vena cava, resulting in venous stasis in the uterus, and so giving rise to metrorrhagia, dysmenorrhœa, and fluor albus. In the third group of cases, Theilhaber believes that the uterine trouble is the cause of the disturbances in the stomach and intestine. He, like myself, has found in all these patients an inhibition of the intestinal movements; but he found, on the other hand, that the gastric secretions were more commonly normal, and that only in a small proportion of the cases was the vomiting centre excited. Further, in the majority of these women, the course of the digestive processes was quite normal; and, finally, in his series of cases, endometritis was one of the commonest causes of consecutive gastric disorders. His observations led him to conclude that “in consequence of affections of the uterus a large number of different symptom-complexes of gastric trouble occur:” the pure nervous dyspepsia of Leube, dependent on atony of the large intestine and atony of the stomach, hyperchlorhydria and anacidity, periodic gastralgia without anatomical cause, etc.

Cardiopathia Uterina.

I use the term cardiopathia uterina to denote the manifold cardiac disorders which occur in women as reflex processes excited by the 236physiological functions and the pathological disorders of the genital organs, and take the form of very various disturbances of the cardiac function. Every phase of the sexual life of women—that in which the reproductive organs attain complete development and menstruation first appears (the menarche); the commencement of sexual intercourse; pregnancy, parturition, and the puerperium; finally the retrogressive process at the climacteric age, of which the menopause is the outward manifestation—may give rise to the occurrence of such cardiac troubles. In order to explain these troubles as reflex in their nature, we must on the one hand recur to the anatomical changes in the uterus and its annexa that take place in every one of the above-mentioned phases of the sexual life; and on the other hand we must take into consideration the mental processes that accompany these anatomical changes, in order to estimate their influence upon the motor and sensory nerves of the heart (see the sections on the Menarche and the Menopause).

A certain predisposition to uterine cardiopathy exists in many individuals and in many families. This predisposition may be manifested in this way, that in women who at the time of the menarche have suffered from cardiac disorder, similar cardiac disorder is likely to recur at the time of the menopause, the symptoms of the recurrent attack being in most cases identical with those that occurred during the menarche. In the well-to-do and cultured circles of society, uterine cardiopathy is far more frequently encountered than among the working classes. Both unusually early and unusually late commencement of menstruation tend to favor the occurrence of uterine cardiopathy. The most valuable therapeutic measures that we can employ to combat these disorders are suitable dietetic and hygienic regulations, in association with favorable mental influences.

Diseases of the female reproductive organs, including simple functional disturbances, are very frequently accompanied—far more frequently than has hitherto been supposed—by cardiac disorders. But whereas in some cases these cardiac disorders are directly dependent upon the disease of the genital organs; in other cases no such etiological relationship can be shown to exist, and the association must, therefore, be regarded as fortuitous.

In cases of the former kind, the dependence of the cardiac disorder upon the disease of the genital organs is very variable in its nature.

Reflex manifestations on the part of the nervous system may be aroused by pathological changes in the genital organs, in a manner similar to that discussed in other parts of this work in regard to the cardiac troubles that are liable to occur during the menarche and the menopause; such cardiac disorders are indeed excited especially by changes in the ovaries, by disturbances of menstrual activity, 237by suppression of the menses—as manifestations, that is to say, of the menstrual reflex. The cardiac disorder most commonly takes the form of tachycardiac paroxysms, recurring periodically, either in association with the menstrual flow, or, if this is in abeyance, at the times at which it ought to appear. We must assume in these cases that the local stimuli aroused by the pathological changes in the uterus and the ovaries have a reflex influence upon the cardiac nerves, by means of which the heart’s action is increased in frequency, without inquiring more particularly whether the reflex influence is effective by inhibiting the normal action of the vagus, or by stimulating the sympathetic, or, perhaps, by a combination of these factors. Much more rarely do we notice, in association with disorders of the reproductive system, a reflex decrease in the frequency of the heart’s action, this effect being explicable in the same manner as the well-known experiment of Golz, in which, if the abdomen of a frog be laid bare, and the intestine be struck sharply with the handle of a scalpel, the heart will stand still in diastole with all the phenomena of vagus inhibition.

In another group of diseases of the genital organs, the disturbances of cardiac activity may be brought about by pressure which, in consequence of the morbid processes in the reproductive organs, is exercised upon individual nerves or upon an entire nerve plexus. Tumefied and prolapsed ovaries, an enlarged and misplaced uterus, inflammatory nodules and hyperplasias of the intrapelvic connective tissue, contractile processes in the parametric connective tissue,^[40] tumors of the uterus whether intramural or in the interior of that organ, ovarian tumors, prolapse of the uterus, and intrapelvic peritoneal adhesions resulting from inflammatory processes—these are the principal conditions liable to occasion reflex cardiac disorder; but certain tissue changes, such as endometritis, erosions (chronic cervical catarrh), and ulcerations of the genital passages, with or without exposure of nerve-endings, are also competent to produce the same effect. Here the sympathetic nervous system constitutes the channel by means of which the stimuli affecting the nerves of the genital organs are conveyed to the central nervous system, and by means of which also the reflex manifestations of this stimulation are produced, taking the form, partly of disorder of the cardiac action, of palpitation of the heart and paroxysmal tachycardia, and partly of pains in the cardiac region and disturbances along the course of the great vessels.

Further, in cases of long-continued disease of the female genital 238organs associated with severe hæmorrhage and in some cases fluor albus, nutrition in general and hæmotopoiesis may be seriously affected, and disturbances of cardiac activity may result, as, for instance, is frequently witnessed in chloro-anæmic states. In such cases we have palpitation of the heart, both subjective and objective, a weak and compressible pulse, often irregularity of the heart’s action, singularly clear heart sounds, often, however, systolic murmurs at various orifices, increased frequency of heart and respiration to a disproportionate degree on slight exertion, strong pulsation of the carotids, and slight œdema of the ankles.

Often, however, the disturbance of cardiac activity is dependent also upon degenerative processes in the myocardium, upon fatty degeneration and the consequent dilatation of the cavities, this degeneration being a consequence of the growth of a uterine tumor and especially of uterine myomata, or resulting from some constitutional disorder which is itself dependent upon the affection of the genital organs. In such cases the signs of degeneration of the heart are very striking: weakening of the cardiac impulse, notable faintness of the sounds of the heart, occasionally reduplication of the second sound, a galloping rhythm, while percussion shows the existence of considerable dilatation of the left, and still more frequently of the right ventricle; in many cases also we have angina pectoris, passive hyperæmia of the lungs, the mucous membranes, and the extremities; and sudden death sometimes ensues.

No less important are the mental influences exercised by diseases of the genital organs in which operation is proposed or actually performed, also by long-lasting diseases of the reproductive organs and by the disturbances these diseases produce in the reproductive functions, more especially in relation to copulation and the actual process of reproduction. In this way cardiac neuroses of various kinds may be induced.

Finally, cases have come under my notice in which the cardiac trouble was not the direct result of the disease of the genital organs, but was a consequence of the therapeutic measures employed for the relief of the latter; and in this connection I must regard as especially blameworthy, in addition to intra-uterine manipulations, such as sounding and cauterization, the modern practice of gynecological massage.

Not all diseases, however, of the female reproductive apparatus, tend in a similar manner and with equal frequency to give rise to consecutive cardiac disorders. According to my own observations, the diseases of the vulva and the vagina, catarrhal inflammation, colpitis (vaginitis), leucorrhœa, and prolapse of the vagina (cystocele and rectocele), are those which most rarely induce cardiopathy; 239unless, indeed, the diseases just enumerated have led to the occurrence of vaginismus, for in this latter condition cardiac trouble not uncommonly ensues. More commonly than by vulval and vaginal diseases, cardiac troubles are induced by inflammation of the uterine mucous membrane, as by chronic endometritis, by erosion and “ulceration” of the cervix (chronic cervical catarrh); they also sometimes occur in connection with perimetritic and parametritic exudations. Most frequently of all, and most severely, cardiac disorders are aroused by displacements of the uterus, flexions or versions; by structural changes of the uterus accompanied by enlargement of that organ, such as chronic metritis and the growth of myomata (especially intramural); by prolapse, enlargement, and tumor of the ovary; by intrapelvic exudations which when extensive give rise to displacement or compression of the uterus or its annexa. In cases of carcinomatous or other malignant new growths affecting the reproductive organs, I have in comparison very rarely observed the occurrence of reflex cardiac disorders.

Disturbances of menstrual activity, amenorrhœa, menorrhagia, and dysmenorrhœa, owning the most varied causes, very frequently give rise to cardiac trouble, a point on which we have already insisted. (See page 142, et seq.)

Very violent forms of cardiac neurosis have been observed by me in women suffering from chronic disorder of the reproductive organs, who have consulted one gynecologist after another and have been subjected to many different methods of local treatment; also in women who have for a long time suffered from some gynecological ailment hitherto believed to be trifling, but who have at length suddenly been informed that some severe operative procedure has become necessary. In such cases the cardiac trouble took a paroxysmal form, the intervals being usually considerable, several weeks or months in duration, and the general system was as a rule seriously involved in the attacks. These latter began with severe cardialgia, radiating from the cardiac region outward along the intercostal spaces, upward to the shoulder and along the left arm, sometimes indeed extending into both arms. At the same time the heart’s action was greatly increased in frequency, there being sometimes more than 200 beats per minute, the pulse was soft, small, difficult to count, the respiration greatly increased in frequency, sometimes very shallow, with respiratory anxiety, and exceptionally severe general excitement and sense of impending death. In some cases also I observed spasm of various groups of muscles, dizziness (with a sense that the objects of vision were flickering), aphasia, and mental stupor. The paroxysms lasted for some time, two or three hours, as a rule, and gradually passed away. Their character was 240that of the cardiac disorder variously described under the names of pseudo-angina and angina pectoris hysteria.

Such attacks as these are followed by a sense of severe general depression and want of energy, and by a decline in body-weight. They are distinguished from true angina pectoris by the absence of any signs of arteriosclerosis or of degeneration of the myocardium. They may be regarded as cardiac disorder of duplex causation, being partly dependent on the disease of the genital organs, which gives rise to a number of local afferent stimuli, and partly dependent on mental influences which have a depressant, paralyzing influence on the cardiac nerves; it is possible also that spasmodic contraction of the walls of the coronary arteries or of the myocardium itself is induced as a reflex effect of the local disorder of the reproductive organs.

With regard to uterine myoma as the exciting cause of cardiac degeneration, very numerous observations and experiments have recently been made, and the reality of the occurrence is no longer open to dispute, even if its significance is subject to various interpretations, whilst no satisfactory explanation has yet been forthcoming.

L. Landau writes concerning the disturbances induced in the circulatory apparatus by the growth of myomata in the uterus: “The formation of varices, the occurrence of thrombosis, and, finally, the onset of degeneration of the myocardium, are very common. Should the last-named process result—and it is truly alarming to observe the frequency with which cardiac affections are associated with uterine myomata,—then, by a vicious circle, the uterine hæmorrhages become continually more profuse, in consequence of increasing passive hyperæmia dependent upon diminishing power of the cardiac pump. Venous congestion in the province of the inferior vena cava results in ascites, and sometimes in general œdema; and even in cases in which no increase of the uterine hæmorrhages is observed, the patient may succumb in consequence of secondary disease of the heart. * * * In the great majority of cases, the myoma and the uterine hæmorrhages that result from its growth are the primary cause of the morbus cordis. Naturally in cases which come under observation only when both uterine and cardiac disease are already present, it is difficult to determine with certainty the true causal connection. When, however, a number of patients suffering from uterine myomata are observed, in whom at first the heart was found to be healthy, and subsequently to have become affected; and when, on the other hand, we see patients affected with myoma uteri in whom operation is undertaken notwithstanding the existence of cardiac disease, and in whom, after the 241operation has been successfully performed, the cardiac murmurs disappear as well also as the other signs of heart disease, when dilatation can no longer be detected, when the pulse-frequency declines to normal, whilst a previously feeble and compressible pulse gains in tension and power—then it is impossible to doubt that the heart disease was secondary, and was etiologically dependent upon the primary myoma and the uterine hæmorrhages.”

Lehmann and P. Strassmann examined the material of the Charité-Policlinik at Berlin in order to throw light on the relation between uterine myomata and diseases of the heart, a connection already proved to exist alike by recent pathologico-anatomical researches, by clinical experience of the results of operations (death from shock), and, finally, by the subjective troubles of the patients (palpitation, venous congestion, giddiness, and syncope). Examining 71 women suffering from myoma uteri, Lehmann and Strassmann found in 29 (41%) that some abnormality existed in the cardio-vascular system, such abnormalities being extremely variable in character, as for instance: hypertrophy or dilatation of the heart, irregularity of the cardiac action, passive hyperaemias, œdema, albuminuria, angina pectoris, and cardiac asthma. The next point was to determine the mutual relations between the heart disease and the development of the uterine myoma. Hitherto it has been assumed that the latter is the primary disease, and such a sequence is certainly the commoner, more especially in cases in which hæmorrhage has been profuse, with consecutive anæmia and fatty degeneration of the heart. In these cases, a certain time after the commencement of the severe hæmorrhages, cardiac troubles make their appearance; such troubles are beyond question secondary, and they disappear as soon as the hæmorrhage has been controlled. In other patients, however, we obtain a history of the appearance of cardiac disorder at a date prior to that when any symptoms occurred indicating the growth of a myoma; in these cases, therefore, the heart disease has developed independently of the uterine disease, and has run a parallel course to the latter; perhaps, indeed, by leading to venous congestion or to rapid changes in blood-pressure, the heart disease may have favored the growth of the commencing or fully developed tumor. In some of the patients, operative measures were followed by rapid recovery from the cardiac disorder (cases of simple anæmia); in a second group of cases, however, the heart disease was uninfluenced by operation (cases of irreparable anæmia, and cases of heart disease independent of the myomata); and, finally, a considerable number of patients remained, constituting a third group, in whom, notwithstanding the removal of the tumor by operation, the heart disease continued to grow worse (cases of progressive heart disease independent of the myomata, especially cases of arteriosclerosis).

242Among 120 women of ages between 17 and 48, in whom I found very various functional disorders of or pathological changes in the genital organs, and in whom I made a particular investigation concerning the presence or absence of heart disease and examined the heart carefully, I was able to detect the presence of cardiac troubles in 38 instances. Thus, heart trouble was found to exist in 32.7 per cent. of women suffering from disease of the reproductive organs.

In these 38 persons suffering from cardiac disorder, I found:

As regards the varieties of functional and organic disease of the genitals met with in the 120 cases, and the number of instances complicated with heart trouble in each variety, I found:

From these figures we obtain the following percentages, showing the frequency with which heart trouble occurred as a complication of the respective diseases of the genital organs:

243To summarize the result of my observations regarding the cardiac disorders secondary to diseases of the female genital organs:

1. Tachycardial paroxysms in cases of amenorrhœa were premenstrual in rhythm, the paroxysms occurred, that is to say, some days before the due date of the suppressed flow.

2. In cases of dysmenorrhœa, I observed heart trouble with severe dyspnœa and feelings of anxiety, also in some cases symptoms of cardiac asthenia; these symptoms were perhaps dependent upon acute dilatation of the heart. The heart trouble associated with profuse menorrhagia exhibited similar characters.

3. Attacks of pseudo-angina pectoris occurred in women in whom local treatment for disease of the genital organs had been carried out for a long time, and in cases in which operative measures were in contemplation.

4. Paroxysms of tachycardia and cardiac distress were observed in connexion with displacements of the uterus, and especially in cases of retroflexion; also in association with oöphoritis and with parametric exudations.

5. Cases of degeneration of the myocardium, sometimes running a rapidly fatal course, were found to be consecutive to tumors of the uterus and its annexa, especially to myomata of the uterus.

Nervous Diseases Secondary to Diseases of the Genital Organs.

In earlier chapters of this work we have frequently referred to the reflex influence exercised upon the nervous system in general, alike by the normal functions and the pathological states of the female genital organs. We must now briefly explain the more intimate connection between nervous diseases and diseases of the genital organs, the causal dependence of local nervous disturbances and of general neuroses upon diseases of the reproductive organs.

The origination of a local nervous disease by a primary disease of the genital organs is dependent upon a simple mechanical process, which is explained by Windscheid in the following terms: “In this connection, the two principal mechanical factors are pressure and traction. Pressure may affect individual nerves or an entire nerve plexus, and may be exercised by a tumour, an exudation or a misplaced organ (Hegar); further causes of pressure are furnished by inflammatory nodules, by connective tissue hyperplasias, and, according to Freund, by contractile processes in the organs themselves and in the ligaments. Traction on the nerves results from displacements, as from prolapse of the uterus or the ovaries, and, according to Hegar, from traction on the pedicle of small tumours. A combination of pressure and traction occurs especially in affections 244of the abdominal attachments of the uterus, also where there is scarring of the neck of the uterus and of the vaginal fornices. Great importance, also, in relation to the production of local nervous disorders, must be attributed to the laying bare of nerve-terminals by catarrhal and other inflammatory processes. Abnormal mobility of the genital organs as a partial manifestation of enteroptosis must also be mentioned as a cause of mechanical stimulation of the nerves. Finally, in this connection, must be considered the paresis of the abdominal walls that follows frequent and severe confinements.”

The symptoms of the local nervous disorders to which these mechanical stimuli may give rise, are very various, but may, according to Hegar, be comprised under the general designation of lumbar enlargement symptoms (Lendenmarksymptome), inasmuch as the local stimulation of the intrapelvic nerves, affects the nerve-centres of the lumbar enlargement of the spinal cord. Among the symptoms, severe pains are prominent, either continuous or intermittent, within the pelvis and in the sacral region, accompanied by a sense of weight and pressure in the abdomen, or by dragging pain in the region of the hips, in the gluteal region, in the outer and back parts of the thighs, in the inner surface of the leg, in the calf, in the dorsum of the foot, the sole of the foot, and the heel; or by coccydynia (pain over the coccyx and the lower extremity of the sacrum), or hyperæsthesia and anæsthesia of the external genitals in the region of the vaginal orifice, or, finally, by disorder of the processes of micturition and defæcation. In some of these cases, the weakness of the lower extremities is so severe that a paralytic condition is simulated. Actual paralysis may however occur, in consequence of the extension of peritoneal inflammation to the nerve-plexuses of the pelvis, leading to the occurrence of neuritis.

The development of a general neurosis in consequence of disease of the genital organs, either as a complication dependent upon the nervous stimulation excited by the primary disease, or as a reflex consequence of this disease, implies, as Windscheid strongly maintains, the existence prior to the occurrence of the disease of the genital organs of diminished power of resistance on the part of the nervous system. This neuropathic constitution may be the result of inheritance, and, according to Engelhardt, was so in 40 per cent. of his cases of women suffering from nervous disease secondary to the disease of the genital organs; or it may be acquired. Given this weakness of the nervous system, a local disturbance of the genital organs may act as the ultimate exciting cause of the onset of the neurosis in one of two different ways (Windscheid). “1. The stimulus which the nerves of the affected genital organ (or those 245of some adjacent area, affected by direct extension) have received, proceeds upward from segment to segment of the spinal cord, and ultimately passes to the highest centres. 2. Or, on the other hand, the local nerves are not directly involved in the morbid process in the genital organs, but this latter acts as a source of reflex disturbance, a disturbance which must also pass through nervous channels. To this latter class of cases belong the instances, comparatively so frequent, in which, for example, a trifling retroflexion of the uterus must be regarded as the exciting cause of the neurosis.” The commonest neurosis of those that may be excited by local disease of the genital organs is undoubtedly hysteria, next in frequency come chorea and epileptic seizures.

Schauta draws attention to the important fact that hereditarily predisposed, neurasthenic individuals bear very badly repeated gynecological examinations and long-continued local treatment, inasmuch as, in such persons, a notable increase in the severity of the nervous affection may result, and even the outbreak of actual mental disorder; and he further points out that in hereditarily predisposed individuals, psychoses not infrequently occur in consequence of the performance of gynecological operations.

The processes of pregnancy make a deep impression on woman’s entire nervous system, and more especially on her mental functions. This is especially noticeable in the case of primiparæ. The fact is easily understood, for a woman is filled with expectation and anxiety concerning the unknown event, the complete revolution in her organization, the powerful impressions on her physical ego, the formation of a new being within her womb. How many joyful hopes, how many distressing fears, are connected with that which is about to take place, with the act of creation within her bosom; what changeful glimpses into the future, on the one hand the gladness, on the other the terror, of motherhood; often, also, the anxious doubts as to the probable sex of the newcomer. Consider, too, the stormy sensations experienced by a woman who, unmarried, has become pregnant contrary to her desires and expectations, especially one in a poverty-stricken condition—consider the agonizing thoughts in such a case regarding the consequences of giving birth to a child. It is only to be expected that in pregnant women in general there will almost always be increased irritability of the nervous system combined with a tendency to the rapid variation of emotional states. Neumann found, in almost all the pregnant women he examined in respect to the point, that there was an increase of the knee-jerks, as a manifestation of the general increase of nervous irritability. Nor does this change depend upon mental influences exclusively; there are other factors, such as the reflex 246processes aroused by the enlargement of the uterus, and also the changes in the composition of the blood which occur during pregnancy, and cannot fail to have an influence on the nutrition of the brain. Finally, also, the deposit of carbonate of lime on the inner surfaces of the cranial bones (the parietal and frontal bones) which occurs during pregnancy, may be regarded as having some casual connection with the changes in the nervous system; and, again many authors assume that the cerebral circulation is influenced by the formation of the placental circulation.

The pathological consequences of pregnancy, as far as they affect the nervous system, take the form of neuralgia and of peripheral neuritis of various nerves, of chorea, of disturbances of the sense organs, and of actual psychoses.

Peripheral neuritis in pregnant women affects chiefly the lower extremities, but has been observed in the arms also; it is characterized by muscular wasting with reaction of degeneration, by trophic disturbances, and by disorders of sensation. A cure may ensue even during the pregnancy, but in other cases the illness persists until after parturition and on into the puerperium. To the same cause Windscheid assigns the paræsthesias of pregnancy, burning, prickling, and numb sensations of the finger-tips, less commonly of the toe-tips; these sensations are continuous, not paroxysmal, and cause very great suffering.

Pregnancy favors the occurrence of chorea, a circumstance explicable by the increased irritability of certain nerve centres characteristic of the pregnant woman. The chorea of pregnancy occurs for the most part in primiparæ, it is commoner in young than in older pregnant women, and appears especially in the early months of pregnancy. In the majority of cases the disease undergoes spontaneous cure before the end of the pregnancy, but cases with a fatal termination have been observed.

On the other hand, a curative influence in previously subsisting hysteria has been assigned to pregnancy. This in fact only occurs in cases in which the hysterical manifestations have been evoked by influences which are counteracted or removed by the occurrence of pregnancy, such, for instance, as intense longing to bear a child, dissatisfaction with the existing circumstances of married life, etc. Conversely, it is by no means unusual to observe that, in patients who have previously suffered from hysteria, the attacks become more frequent during pregnancy, and that other nervous disturbances associated with the hysteria become more prominent; hysterical paralysis, even, may appear. Very variable also is the influence of pregnancy in epileptics. Most commonly, indeed, a certain quiescence sets in, the attacks becoming less frequent and less severe; 247but the reverse of this is at times observed. In the domain of the sense organs we observe amblyopia and hemianopia, deafness, and tinnitus aurium, and disorders of taste; all these appear as pure nervous disturbances without known anatomical basis (Windscheid).

Finally, among neuroses, tetany may be mentioned. In women, this disease occurs almost exclusively during pregnancy and the puerperal state, in the form of paroxysmal spasm, affecting chiefly the extremities, and especially the hands; the spasm is bilateral, tonic in character, and painful. The tetany of pregnancy usually runs a favourable course.

The slighter forms of mental disorder consist of perversions of taste and smell. Of actual psychoses occurring during pregnancy, the commonest forms are melancholia and mania. The former condition, which, according to Ripping, occurs in 84.4 per cent. of the cases, is usually very severe, and is characterized by a peculiar dreamy condition; it often leads to suicide, or to infanticide immediately after parturition. The psychoses of pregnancy are seen with greater frequency in the second half of pregnancy, they occur especially in primiparæ, and are also commoner in unmarried women. The prognosis is on the whole an unfavorable one; sometimes, indeed, the mental disorder terminates with the pregnancy, but in other cases it continues during the puerperium. Mental alienation occurring in the early months of pregnancy is apt to be less severe and to permit of a more favorable prognosis, than that which makes its appearance during the later months or at the end of the pregnancy.

In 32 cases of insanity of pregnancy recorded by Ripping, 8 cases occurred in the first pregnancy, 5 in the second, 6 in the third, 3 in the fourth, 4 in the fifth, 1 in the sixth, 1 in the seventh, 3 in the eighth, 1 in the tenth. Of these women

The neuralgias of pregnancy affect the most diverse nerve tracts, and may occur either spontaneously, without any discernible local exciting cause, or in consequence of the pressure exercised by the 248enlarging uterus. To the former class of cases belong severe trigeminal neuralgia, the familiar toothache affecting quite sound teeth at the very beginning of pregnancy, intercostal neuralgia, and paroxysms of mastodynia. The pressure neuralgias affect chiefly the domain of the great sciatic nerve, manifesting themselves by the occurrence of pain down the back of the thigh, in the calf, and on the dorsum of the foot, sometimes associated with formication and other kinds of paræsthesia.

Parturition, by its powerful effect on the emotional nature in combination with intense physical suffering, may give rise to numerous nervous disturbances. The chief of these are, neuralgia, occasioned by the pressure of the fœtal head as it passes through the pelvis of the mother, paræsthesias, convulsions, maniacal paroxysms, transitory mental alienation, cerebral hæmorrhages, and eclampsia.

The nervous disturbances dependent upon the processes of the puerperium are numerous and severe. According to Windscheid, four types of affection of the motor nerves may arise at this period. 1. Pressure-paralysis may occur in cases of generally contracted pelvis, or even in the absence of such contraction in cases of prolonged labor, from the pressure exercised by the child’s head upon the intrapelvic nerves, and above all on the great sciatic nerve; pressure-paralysis may also result from obstetric operations, and especially from forceps delivery. The symptoms of pressure-paralysis consist chiefly of paralysis of the extensors of the feet and the toes; sensory symptoms are usually wanting. 2. Inflammatory infective paralyses, due to the extension to adjacent nerves of puerperal inflammation of the pelvic connective tissue. 3. Acute multiple neuritis, occurring either during the latter half of pregnancy or a few days after delivery, and affecting not only the nerves of the lower extremities, but those of remote regions, even the cranial nerves. 4. The rare puerperal hemiplegia due to cerebral hæmorrhage, occurring usually at the time the patient leaves her bed after delivery; puerperal hemiplegia may also arise from embolism consecutive to endocarditis, which may itself have originated before the termination of the pregnancy.

Other puerperal diseases of the nervous system requiring mention are, on the one hand, tetany, occurring during lactation, and permitting of a favorable prognosis, and on the other, the infective puerperal tetanus, the prognosis of which is exceedingly unfavorable. Finally, the puerperal state has to be considered as a factor in determining the onset of psychoses.

The puerperal psychoses are for the most part dependent upon the great loss of blood occurring during delivery, leading to anæmia and increased irritability of the brain, in association also with the 249circulatory disturbances that arise in the central nervous organs in consequence of the sudden emptying of the abdomen by the act of childbirth; but additional causes of mental disorders are to be found in the changes in the composition of the blood that occur during pregnancy, and the influence of these changes upon the nutrition of the brain. Inherited predisposition plays its usual part in these cases; and accessory factors in producing mental disturbance during the puerperal state are to be found in puerperal infection, eclampsia, osteomalacia, and emotional shock.

Thus, for example, among 49 cases of puerperal psychoses, Hansen found that in 42 instances there was puerperal infection; and among 200 cases of puerperal eclampsia, Olshausen found 11 patients suffering from mental disorder. The principal forms of insanity occurring at the puerperium are mania and melancholia, next in frequency come monomania (Ger. Verrücktheit), dementia (Ger. Blödsinn), alternating or circular insanity (folie circulaire), hallucinatory paranoia (chronic delusional insanity with hallucinations), and hysterical mental disorder.

According to Windscheid, the commonest cases are those which are purely puerperal, the rarest those in which the insanity of pregnancy continues during the puerperal state; the age at which puerperal psychoses most commonly occur varies between 31 and 35 years, the average age being 29.1; multiparæ are more often affected than primiparæ; the outbreak of mental disorder most commonly occurs within a week after the birth of the child; there is nothing specific about the various forms of puerperal insanity, which are identical with the respective varieties owning another etiology. According to this author, before an attack of puerperal mania, prodromal symptoms usually occur, such as headache, dizziness (Ger. Augenflimmern), feelings of anxiety, insomnia, followed by various congestive symptoms, and either by great restlessness or by great apathy, and very often by indifference to the infant; to these symptoms succeeds the period of motor excitability, characterized by great bodily restlessness and by continued talkativeness; the culmination takes the form of a maniacal outburst, in which infanticide even may occur; the delirium runs mostly in erotic and religious channels. Puerperal melancholia also exhibits the usual clinical picture of this form of mental disorder; after prodromal headache, stupor sets in, often associated with attacks of anxiety and with hallucinations of sense, and always characterized by great loss of appetite and by a suicidal tendency.

In relation to the puerperal psychoses, it appears that the first menstruation after the birth of the child has, like the very first appearance of the menstrual flow during the menarche, a tendency 250to favor the onset of mental disorder. According to Marcé, this first post-puerperal menstruation has a very definite significance in the causation of psychoses. Among forty-four cases of puerperal psychoses, there were eleven instances in which the mental disorder made its appearance six weeks after childbirth, exactly at the moment, that is to say, in which, had the mothers not given suck to their children, menstruation ought to have reappeared. In those who did not nurse their infants, and in whom menstruation recommenced at the due date, the psychosis usually began on the first day of menstruation, less often on the fourth or fifth day. In some instances the psychosis appeared at the time at which menstruation might have been expected to occur, but when the flow was still in abeyance. And in some women who suckled their children for a time and then weaned them, the psychosis made its appearance at the time of the first recurrence of menstruation.

Among diseases of the sense-organs occurring during the menacme, ocular lesions are by no means rare as sequels of pathological changes in the genital organs. Thus, in cases of displacements of the uterus, especially prolapse, retroflexion, and retroversion, we sometimes see retinal hyperæsthesia and reflex amblyopia, photophobia and lachrymation, and accommodative or muscular asthenopia. Inflammation of the pelvic connective tissue, perimetritic and parametritic exudations, and especially parametritis atrophicans, may give rise to functional disorders of the eye, reflex hyperæmia of the trigeminal and optic nerves, various painful sensations, and photophobia. Severe metrorrhagia may also cause disturbances of vision, either by inducing local anæmia and consequent functional failure of the nervous apparatus, or by leading to serious infiltration of the optic nerve which manifests itself also in the retina in the form of a transudation. In cases alike of congenital and of acquired atrophy of the uterus, and frequently, therefore, in sterile women, optic nerve atrophy may occur.

Competence for Marriage of Women Suffering from Disease.

In this section we must consider the competence for marriage of women suffering from heart disease, of those suffering from hereditary tendency to mental disorders and neurasthenic states, and, finally, of those affected with tuberculosis.

Every doctor is confronted during the practice of his profession by the problem whether a young woman known to suffer from heart disease is justified in entering upon marriage and in exposing herself to the dangers entailed on her diseased heart by copulation, pregnancy, parturition, and the puerperium. The solution of this problem is as important as it is difficult. On the one hand, it determines 251the whole future course of a human life which is still ascending the upward path of its vital career, and a negative decision often annuls in a moment the young woman’s ideals and hopes; on the other hand, an affirmative decision involves the responsibility for the consequences of marriage, often grave in these cases.

The consequences are in fact apt to be very serious indeed. The normal act of intercourse, in a young and sensitive woman, has already an exciting influence on the nerve apparatus by which the movements of the heart are controlled. The frequency of the heart’s action is greatly increased, the cardiac impulse becomes much stronger, there is marked pulsation of the peripheral arteries, the conjunctiva is injected, the respiration more frequent. These manifestations, which normally are quite transient, attain a greater intensity and exhibit a longer duration in persons affected with heart disease. In some instances, violent tachycardial paroxysms occur, with considerable dyspnœa, pains in the cardiac region, headache, and even syncopal attacks.

Pregnancy, in consequence of the extensive changes undergone not only by the reproductive apparatus but also by the general system, and further in consequence of the vital needs of the developing embryo, involves extensive claims upon the cardiac activity. It is easy to understand that the diseased heart must be taxed more severely than the healthy heart by the extension of existing vascular areas, the addition of new vascular areas, and the increase in the quantity of the blood, during pregnancy; and it is not surprising if the overtaxed organ threatens sometimes to give way under the strain. Thus, during pregnancy in women affected with morbus cordis, we observe numerous troubles in the way of disturbances of cardiac activity and passive congestion of various organs, culminating at times in abortion.

Parturition and the puerperium, moreover, bring several factors into play which tend to affect unfavorably even a heart that is quite normal; and in cases in which there is disease either of the heart or of the great vessels, these factors may lead to the occurrence of most alarming symptoms. In this connection we may refer to endocarditis, to fatty degeneration of the myocardium, and to the rupture of atheromatous arteries.

From the time of Galen onwards all medical writers have agreed that the heart is unfavorably influenced by pregnancy and its consequences—but from this incontestable proposition to deduce the general conclusion that young women affected with heart disease must be forbidden to marry is in my opinion too great a jump, and altogether too sweeping a statement. The apophthegm of Peters, an 252author to whom we are certainly indebted for some of our knowledge of the accidents gravido-cardiaques, that in the case of women suffering from morbus cordis the rule must be enforced, fille pas de mariage, femme pas de grossesse, mère pas d’allaitement, has a fine air of apodictic brevity, but is entirely devoid of justification. No such rigid prohibition is advanced by recent writers on heart disease, such as Huchard, von Leyden, and Rosenbach; not, at least, without qualifications.

The question as to the permissibility of marriage to girls and women affected with heart disease cannot, in fact, be answered by any general proposition; and each case demands separate inquiry and a careful balancing of individual considerations. I have known cases in which the marriage of young girls suffering from morbus cordis was equivalent to a sentence of death, the execution of which was delayed for a few months only. On the other hand, I have known many women belonging to the upper classes and suffering from cardiac defects to pass through numerous pregnancies and to give birth to a number of children with no more than trifling disturbances of compensation. I am acquainted with a lady who when a young girl was urgently advised against marriage, on account of extensive aortic valvular incompetency, by two celebrated physicians. The advice was disregarded, and this lady is now the mother of four children, the eldest of whom is twenty-two years of age, and her general condition is in no way worse than it was before her marriage. The dangers of marriage in women suffering from morbus cordis are in my opinion generally overrated.

The degree to which a woman affected with heart disease will be injured by married life, will depend on the nature of the cardiac affection, on the time it has already existed, on the adequacy of compensation or the intensity of existing disturbances of compensation, on the general state of nutrition of the patient, on the more or less favorable social position, and on the manner in which sexual intercourse is regulated.

My own opinions in respect of this question may be summed up as follows: A woman who has comparatively recently (within a few years) acquired a valvular defect, and in whom the disease has run such a course that, in consequence of dilatation of certain chambers of the heart and of hypertrophy of those segments of the myocardium on which increased work has been thrown, and thus in consequence of adaptation of the cardio-vascular apparatus to the new conditions, the circulation and distribution of the blood take place in a manner closely resembling that in which these functions are effected in a normal, healthy individual—in a word, a woman in whom the valvular disease appears to be adequately compensated,—if, 253in addition, the patient is well nourished, if the hæmatopoietic function has not undergone any notable disturbance, if the muscular system is powerful and the nervous system possesses sufficient power of resistance—then marriage may be permitted without hesitation. In the case of such a girl or woman, we can confidently assume that the adequate compensation of the valvular disease will enable the heart to meet with success the claims made upon its reserve energies by sexual intercourse, by pregnancy, and by parturition, and that these processes will not involve any excessive danger to life.

A woman with valvular heart disease, even when that disease is well compensated, will indeed during pregnancy and still more during parturition and the early days of the puerperium, be liable to suffer from various manifestations of cardiac disorder. The action of her heart will be subject to paroxysmal increase in frequency and force, sometimes also there may be transient attacks of cardiac asthenia; at the same time the breathing will become more frequent and deeper, and occasionally, even, there may be severe dyspnœa. Perhaps also symptoms of venous congestion may manifest themselves, digestive disturbances, sense of pressure in the head, swelling of the feet, œdema of the abdominal wall, even slight albuminuria. Just after childbirth, moreover, an abnormally intense depression of the circulation with infrequency of the heart’s action will be liable to ensue. In the great majority of cases, however, in which the conditions detailed above are fulfilled, the disturbances of compensation occasioned by pregnancy and the puerperal state will not seriously threaten life; and as soon as the puerperal period has been safely passed through, the heart will again be competent for its duties and will do its work as well as before.

These statements apply, not only to cases of well-compensated valvular disease, especially mitral insufficiency, mitral stenosis, and aortic insufficiency, but also to cases in which the heart has made a good recovery after an attack of pericarditis, and to cases of moderately extensive disease of the myocardium consequent on acute articular rheumatism or the acute infections.

As indispensable conditions for such a favorable prognosis, we naturally assume that the pregnant woman is in a position to command the extreme bodily care that in her condition is doubly needful, that she is able to avoid all severe physical exertion, and that she will be subjected to continuous medical supervision in respect of the adoption of suitable dietetic and hygienic measures.

Such a favorable prospect as regards marriage in cases of well-compensated heart disease will, however, be clouded in the case of women who are either very anæmic or predisposed to nervous disorders; nor is the prognosis favorable as regards women in whom the heart disease is either congenital, or acquired in early youth, or 254as regards women contemplating marriage when already well up in years.

For in very anæmic women, even when the heart is quite sound, frequently recurring attacks of tachycardia often occur during pregnancy, in the absence of any obvious exciting cause; œdema of the lower extremities, and the formation of extensive varices, are also common. Increased nervous reflex irritability has also an unfavorable influence upon cardiac innervation. In cases, again, in which the heart disease is of long standing, the functional capacity of the heart is so notably depressed that the organ is likely to prove incompetent to meet the increased demands made upon it by the processes of pregnancy. Finally, in elderly women, superadded to the valvular defects, we have the dangers dependent upon the already beginning arteriosclerotic changes in the bloodvessels. In all such cases, therefore, it will be the duty of the physician to advise his patient not to marry; and in any case to impress upon her mind the extreme probability, amounting almost to certainty, of serious aggravation of the heart disease by marriage, with permanent impairment of the general health.

In cases of valvular disease accompanied by serious disturbances of compensation, and in cases of notable degeneration of the myocardium in which pronounced symptoms of cardiac muscular insufficiency have made their appearance, marriage must be absolutely forbidden, as directly imperilling life. When even moderate bodily exertion suffices to cause palpitation, increased frequency of the pulse, and shortness of breath, when extensive œdema of the lower extremities is present and fails to disappear even after the patient has been strictly confined to bed, when the pulse very readily becomes irregular both in rhythm and force, whilst the urine is often scanty and contains variable quantities of albumin, when conditions of cardiac asthenia readily arise, characterized by a small, irregular pulse, coldness of the extremities, cyanotic tint, nausea, respiratory need,^[42] and syncopal attacks—in all such cases, whether the symptoms just described are dependent upon valvular defects, upon pathological changes in the arteries, or upon diseases of the myocardium, in all alike the occurrence of pregnancy is a true disaster, which in the vast majority of cases causes a great and enduring aggravation of the disease, and frequently enough costs the patient her life.

Even in such cases as were previously described, in which, the heart disease not being severe, the patient was told that marriage was permissible, it is the duty of the physician to lay down certain rigid rules regarding sexual activity.

Women suffering from heart disease should not have sexual intercourse 255frequently, because, if the peripheral nervous stimulation of the genital organs is excessive in consequence of too frequent acts of coitus, cardiac activity is likely to be influenced powerfully in a reflex manner, leading to the occurrence of attacks of cardiac asthenia. Again, sexual intercourse must always be effected in such a manner that the act attains its physiological conclusion, and that in the woman as well as in the man the orgasm has its normal outcome, that is to say that at the conclusion of the act the woman’s cervical glands are evacuated with the accompaniment of the sense of ejaculation. The congressus interruptus, which precisely in these cases in which the wife suffers from heart disease is so frequently practiced by the husband with a view to preventing conception, must be strictly forbidden, since this mode of intercourse tends to give rise to various forms of reflex cardiac disturbance, most commonly to paroxysms in which the cardiac action becomes unduly frequent, in association with diminution of vascular tone, vasomotor disturbances, and states of mental depression; and where organic heart disease already exists, these reflex functional disturbances involve various dangers.

The physician is further justified in advising that a woman with organic heart disease should not give birth to more than one or two children. This advice is the more needful for the reason that with each successive pregnancy the functional capacity of the woman’s diseased heart diminishes according to a geometrical ratio, and to a corresponding degree the danger to life increases. These are cases in which in my opinion it is the physician’s duty to concern himself with the subject—in general so equivocal—of the use of preventive measures, and, having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with moral earnestness, to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently.

To enable us to answer the question whether, in the case of neurasthenic and hysterical young women, and in those hereditarily predisposed to the occurrence of mental disorders, the physician shall advise for or against marriage, attention must in the first instance be directed to the established facts relating to the favorable or unfavorable influence, as the case may be, of sexual intercourse and its consequences (pregnancy and childbirth) upon existing nervous disorders and upon the predisposition to their occurrence.

256Without regarding as fully justified the opinion that in the female sex sexual abstinence has in all circumstances an unfavorable influence upon the nervous system or even that such abstinence is to be regarded as the principal cause of nervous and hysterical troubles, we must consider it fully proved that in a number of the commonest varieties of nervous disease occurring in neurasthenically predisposed subjects, such as neurasthenia, hysteria and neurosis of anxiety^[43], the lack of sexual satisfaction aggravates these troubles, whilst suitably regulated sexual intercourse has an actively beneficial effect. Not, indeed, that it is an infallible means, but none the less the effects are often striking, as I have frequently had occasion to observe, both in young women so affected entering upon marriage for the first time, and also in young widows who have remarried. Especially is this true of women in whom the sexual impulse is exceedingly powerful, and even pathologically increased to the extent of marked sexual hyperæsthesia; likewise also in women whose social circumstances and manner of life induce increased sexual appetite. Be it understood, I refer here to regular and moderate sexual intercourse, and not to sexual excesses, which latter, by inducing nervous exhaustion, may have a distinctly deleterious effect. In many cases, however, we observe in women suffering from sexual neurasthenia, that sexual intercourse, even when practiced at long intervals, gives rise to nervous prostration with deep emotional depression and long-lasting aggravation of the existing nervous disorder. This statement applies with especial force to very hysterical epileptic girls with hereditary predisposition to mental disorder.

From the fact that among persons hereditarily predisposed to mental disorder, the unmarried are on the average more often affected with insanity than the married, the inference has been drawn that marriage may be recommended to such persons as a measure likely to counteract their hereditary tendency to insanity. The argument, however, lacks validity, more especially as regards women; among whom, moreover, from the age of sixteen to the age of thirty, insanity is proportionately more prevalent among the married, though above the age of thirty it is more prevalent among the unmarried.

In the great majority of neurasthenic women, normal sexual intercourse, practiced in moderation, has, according to Löwenfeld, no deleterious effect; often, indeed, as a consequence of unaccustomed abstinence, an aggravation of existing nervous troubles may be observed. But, as this author maintains, nervous exhaustion may result in the complete disappearance of the orgasm during sexual intercourse, or in great difficulty in its production; this circumstance suffices for the 257most part to explain the fact that in women suffering from great depression of the nervous functions, the fulfilment of their sexual duties has sometimes an unfavorable influence on their general condition. As regards hysteria, it cannot be denied, that in many hysterical women marriage results in a favorable change in the general condition; we must, however, be careful not to overrate the significance of such observations. As a rule all that actually takes place is a diminution in the intensity or even a disappearance of certain morbid manifestations previously present, without, however, an eradication of the hysterical temperament.

In epileptic young women, the first experience of sexual intercourse may precipitate a fit. Cases are indeed on record in which, in hereditarily predisposed girls, the first coitus was the exciting cause of the first epileptic fit, the fits recurring every time sexual intercourse was repeated.

It is a comparatively frequent occurrence in psychopathically predisposed girls for severe mental disturbances to make their appearance during the honeymoon, after the first experience of sexual intercourse; when this occurs, it is doubtless to be accounted for by the combined influence upon the mind of all the changes in the circumstances of life which have resulted from the marriage. In the case of two newly married women, one of whom had well-marked hereditary predisposition, whilst in the other there was no known family history of mental disorder, Löwenfeld observed shortly after marriage the onset of severe melancholia, with refusal of food. The delicate, nervous temperament of these two women, on the one hand, and, on the other, possibly, a somewhat too eager and passionate attitude on the part of their respective husbands, led their first experience of sexual intercourse to result in a nervous impression of the nature of shock, which their nervous system was too weak to resist.

Frequently recurring pregnancy and childbirth may, according to Krönig, act as the predisposing cause in the production of neurasthenia. In regard to hysteria also we must admit that the onset of some disease of the organs of generation frequently leads previously latent hysteria to manifest itself openly, and further we have to recognize that diseases of the reproductive system often give the clinical picture of hysteria a quite distinctive coloration; the physiological course of the functions of the generative organs is also competent to produce both of these effects. Krönig, however, rejects the view that the lack of sexual intercourse has an unfavorable influence upon the nervous system in women, and gives rise to hysterical and neurasthenic disorders. The favorable influence which marriage is often observed to exercise upon the course of nervous disorders is explicable with reference to psychical considerations 258of a very different nature. Sexual abuses, masturbation, and the use of preventive measures, give rise in women far less often than in men to neurasthenic and hysterical conditions.

Féré asserts that in certain neurasthenic patients sexual intercourse induces a general blunting of the senses, and especially of hearing and sight. Actual amaurosis of short duration may even be observed; also cutaneous anæsthesias, paralytic conditions of the extremities taking the form either of hemiplegia or paraplegia, convulsive attacks, and somnolent paroxysms.

Delasiauve observed that epileptic patients, who during residence in an asylum had remained almost entirely free from fits, after returning home and resuming sexual intercourse, even in strict moderation, suffered from a recrudescence of the convulsive seizures; when intercourse was excessive, the relapse was naturally even more severe.

In two instances, in women who in a single night had practiced intercourse to very great excess, Hammond observed paralysis of both legs to ensue; he saw also in numerous cases spinal irritation and other nervous disturbances as a consequence of sexual excesses.

Von Krafft-Ebing points out, with reference to the prophylactic influence of marriage in respect of mental disorder, that in men early marriage diminishes the danger of the occurrence of such disorder, whereas in women marriage is undesirable before the attainment of complete physical maturity.

With regard to marriage in the case of persons suffering from nervous diseases, Ribbing lays down the rule that when such diseases have been severe and have occurred in numerous members of a family, whilst a few only in the family have remained healthy, when, moreover, the illness has been accustomed to make its first appearance only after the attainment of maturity, no indications of its onset being noticeable in childhood or youth—one belonging to a family thus afflicted should be advised not to marry. Where, however, the hereditary tendency is to a disease likely to manifest itself in childhood or youth, a member of such a family who has been fortunate enough to pass through the years of development without exhibiting any pronounced disturbance of the nervous system, may be permitted to marry if certain precautions are observed. A woman with a tendency to alcoholism should in no circumstances be allowed to marry. In the cases, fortunately rare, in which the drink-craving exists in women, marriage is even more undesirable than it is in the case of men similarly afflicted, for the female drunkard is in a position in which she can mishandle and neglect her children throughout the entire day; and, moreover, this affection appears to be even more obstinately incurable in women than it is in men.

259Löwenfeld very rightly insists that in deciding on the advisability of marriage in the case of neurasthenic and hysterical girls the anticipated influence of sexual intercourse must not be the sole determinant. “Regulated sexual intercourse, such as is rendered possible by marriage, has often a favorable influence on previously existing states of nervous weakness. But we should go too far if we were to attribute the beneficial effect of married life on such conditions solely to sexual intercourse. This latter is but one factor among several, the others being no less important. These others are: The pleasures of an orderly domestic activity; the withdrawal of the patient’s attention from her own condition, partly by domestic duties and difficulties, and partly by the novelty of marital companionship; the gratification, especially strong in women, at having obtained a support in life; and, finally, the joyful expectation of motherhood. These factors, however, are not present in every marriage. When their presence cannot reasonably be anticipated, when, in consequence of insufficient means, the marriage is likely to entail increasing troubles, or when, owing to the want of suitability of temperament, annoyances and quarrels are likely to occur, we must throw the weight of our advice into the scale against the proposed marriage, since the advantages of regulated sexual intercourse are not likely to outweigh the disadvantages just detailed. Even when means are ample and the characters of the couple contemplating marriage are unquestionably harmonious, we must nevertheless (temporarily, at any rate) advise against marriage, we must, that is to say, advise the postponement of marriage, if the bride is suffering from severe hysterical or neurasthenic states. Where, further, such neurasthenic or hysterical troubles occur in a woman with pronounced hereditary predisposition to nervous disease, we must, both for the sake of the possible progeny and on account of the uncertain influence of married life on the health of the patient, absolutely and unconditionally prohibit marriage. In cases also in which severe hereditary predisposition to mental disorder exists (especially when derived from both parents), and in addition stigmata of psychopathic degeneration are actually apparent in the patient, or she has already suffered from the development of a psychosis, we must decisively object to the patient’s marriage.”

As regards the marriage of young women suffering from tuberculosis, we must take into consideration a fact that medical experience has conclusively established, namely, that the processes of generation have an unfavorable influence upon pulmonary phthisis. Girls with an inherited predisposition to tubercular disease, sometimes first manifest the symptoms of pulmonary tuberculosis at the time of the menarche. In cases of developed tuberculosis, copulation 260and the excitement of the vascular system associated therewith have a more or less unfavorable influence—and all the more inasmuch as, in accordance with the saying omnis phthisicus salax, women affected with tuberculosis often exhibit a very lively sexual impulse, an almost insatiable sexual appetite. Sexual excesses are, moreover, very likely to lead to the occurrence of hæmoptysis.

In former days it was believed that conception and pregnancy, when occurring in women suffering from tuberculosis, had a restraining influence on the progress of the pulmonary disease, a view which found expression in the assertion of Baumes and Rosières de la Chassagne that of two women affected with tuberculosis to the same degree of severity, one who became pregnant would always outlive the other who failed to become so. Careful and sufficient observations on the part of physicians and gynecologists have, however, shown that this view was fallacious, and, on the contrary, that during pregnancy tuberculosis advances with more rapid strides, that pregnancy, and lying-in accelerate the fatal event (Grisolle, Lebert), that tuberculosis acquired shortly before pregnancy or in the course of that condition, progresses with exceptional rapidity (Larcher), and that the lying-in period is especially perilous to these patients (A. Hanau). In some cases of consumption it is the first pregnancy that is the most perilous, but in other cases a later pregnancy proves more destructive.

Ribbing goes even further, insisting that neither man nor woman affected with pulmonary consumption should marry. “If, indeed,” he writes, “consumptives desire to enter upon marriage, merely with the aim of being faithful to one another and assisting one another for the short time that remains to them, I should offer no opposition. But there must be a complete mutual understanding of the facts of the case, and an unalterable determination on the part of both to carry out the resolutions made prior to marriage, for failing this the consequences will be most disastrous. In most cases, however, the course adopted by Bulwer’s Pilgrims of the Rhine is to be preferred, the lovers contenting themselves with the condition of a betrothed pair, and in that state awaiting the approach of death—or, if exceptionally fortunate, proceeding to marriage only after restoration to health.”

It would certainly appear that in the case of girls suffering from pronounced phthisis, we are justified in advising against marriage, on account of the great danger which this state entails of a rapid advance in the pulmonary disease.

Based upon the observations of Schauta and Fellner, the latter author advances the rule that in the case of a woman suffering from disease, marriage should be forbidden only when the mortality from 261the disease in question is not less than 10 per cent. In this category we must include severe cases only of pulmonary tuberculosis; whilst cases of laryngeal tuberculosis will, according to this rule, be absolutely unfitted for marriage. Among heart-affections contra-indicating marriage, he includes mitral stenosis, other valvular affections in which there is serious disturbance of compensation, and myocarditis; he considers marriage inadmissible also in cases of chronic nephritis, and, among surgical affections, in cases of malignant tumour. In cases in which during a previous pregnancy the patient has been affected by one of the following diseases, viz., severe chorea, mental disorders, severe epilepsy, pulmonary tuberculosis which progressed much during the pregnancy, morbus cordis with considerable disturbance of compensation, severe heart trouble due to Graves’ disease—in all such cases, a repetition of pregnancy should be avoided.

Hygiene During the Menacme.

During the sexual epoch of the menacme a woman’s principal hygienic need is marriage completely satisfactory alike to body and to mind. It cannot be denied that sufficient sexual gratification, regular, of course, and free from all excess, such as is usually experienced in married life, is very advantageous to the health of a woman who has attained sexual maturity—even though we admit that the drawbacks of sexual abstinence, regarded as a cause of disease of the female genital organs and the nervous system have been as a rule greatly exaggerated.

The inability to marry always makes a deep impression on the mental life of woman, and in many cases also gives rise to burning desire and tormenting yearning of an erotic nature. The unmarried miss life’s true goal and fail to enjoy the natural exercise of their functional capacities; alike in the cultured lady and in the poor working woman who has failed to marry, the thoughts and feelings return again and again to her own condition in a self-tormenting manner.

The physical and mental disadvantages entailed by sexual gratification when obtained by an unmarried woman, one who, according to modern phraseology, “wishes to secure her natural share of the joys of love,” and who regards voluntary chastity as “a sacrifice to meaningless prejudices”—need not be more particularly described.

Free love, moreover, is the most important disseminator of gonorrhœal infection. “In any future commonwealth,” says Runge, “in which marriage is abandoned in favour of the general practice of free love, the human race will be overwhelmed by gonococci in a manner now hardly conceivable, and the reproductive capacity in 262both sexes will be diminished by the results of gonorrhœa to a very serious extent.”

Frequently enough, also, free love leads to prostitution, which at the present day is so widely prevalent. Various reasons have been suggested to account for the increase of prostitution. Among these are: The growth of modern industry, with the consequent aggregation of the population in large towns; the decline in the marriage rate; the postponement of marriage; universal military service; the freer mutual companionship of the sexes; and many others. At any rate, the fact would appear to be established, that in the case of woman the determining cause of prostitution is hunger rather than the sexual impulse. The worst paid classes of workwomen are shown by official statistics to furnish the largest number of recruits to the ranks of prostitutes; and it is during times of deficient employment that the number of women practicing occasional prostitution increases. Thus, material need is the most important of the causes of prostitution.

This remains true even though the doctrine of Lombroso and Tarnowsky should find fuller justification, the doctrine that the practice of prostitution by women is the natural expression of a congenital morbid predisposition, “which impels them, in defiance of their direct advantage, of reason, and of all counter-advice, to adopt this accursed mode of life.” Prostitution, in this view, is to be regarded as the inevitable outcome of congenital moral insanity. This is certainly true of a small proportion of prostitutes, but is as certainly false of the great majority, in whom unfavorable, difficult conditions of life form the determining cause. A certain inherited or acquired mental disposition may, indeed, be assumed to exist in these cases also—an unstable moral equilibrium, an insufficient development of the force of the will and of the power of resistance.

The hygienic requirement of married life for woman during the menacme is undoubtedly sometimes hard to fulfil in our day, when the more elaborate and expensive standard of life has increased the difficulty of supporting a family; but from the medical point of view it is necessary to insist forcibly on this categorical imperative, in opposition to the view advanced by the modern women’s rights’ party, that “love is moral also in the absence of legal marriage” (Ellen Key); in opposition to the yet more extreme opinion of George Sand and of Almquist, who, regardless of consequences, declare marriage to be immoral; and, finally, in opposition to the advocates of “free love,” who wish woman to be as free as man in sexual relations.

Much as we may wish that man and wife should be in complete harmony in marriage, and that they should feel themselves to be 263firmly united alike by mutual love and by a reciprocal sense of duty, none the less we must consider the modern maiden ripe for marriage as unjustified in demanding, before undertaking marriage, “perfect love as typifying the inner yearning of two beings to become one;” and we must regard the latter-day woman as extravagant in insisting that the man shall enter upon marriage in a condition as virgin as that of his contemplated wife. “Perfect love” is as rare and as little to be expected as perfect beauty; and the sexual life of man differs entirely in nature and in the course of its development from the sexual activity of women.

Doubtless they spring deep from the soul of woman, the demands expressed by the writer of the book “Vera” and by her numerous imitators, the apostles of “Veraism,”—the demands of the maiden entering upon marriage that her husband shall be as chaste and sexually as unspotted as herself. Difficult of fulfilment as they are, if fulfilment is even possible, these demands must none the less be regarded as characteristic of the sexual life of modern womanhood. “Is man’s sexual honor,” exclaims Vera, “then altogether different from that of woman? Is not the alleged necessity for sexual gratification in youth either a well-organized fraud or an enormous error on the part of physicians? Is it possible that chastity can entail diseases as terrible, as destructive to life and happiness as those that result from unchastity? And is it not a crying sin, even if some of these fears are justified, to ruin both mentally and physically the whole race of women? * * * Man demands from the girl of his choice, not chastity alone, but an absolutely unblemished character. And rightly so. But the wife must share her husband with street-walkers? She must bear the pangs of maternity, while fortified by the terrible knowledge that the father of her children has wasted his youthful virility in purchased embraces, that he has not recoiled from impurity, that he has exposed himself to the risk of infection with the most horrible diseases, that he has squandered his virginity in the most bestial sensuality? * * * We girls must also be granted the right to demand from the man of our choice the same purity, the same unspottedness by sensuality, that he so rigorously demands from ourselves! We must no longer content ourselves with the remnants that are left for us by others! We must no longer be satisfied with man’s moral inferiority! Then there will be more happiness, more love, more health and joy of life!”

These accusations and demands so boldly made are not to be disposed of by mere mockery. With deep sorrow we must admit the absolute truth of the charge that too many men clamber out of the abyss of debauchery to a blighted marriage. But the demand 264for equal moral rights, for the abandonment of the hitherto prevalent bisexual ethical standards, is in vain conflict with actuality, with the defensive instincts of young men, with the difficulties entailed by the struggle for existence, with the increasing pretensions (to sexual freedom) of women themselves; but above all is it in conflict with the thousand-year-old notions of sexual honor in the male and the female respectively, and with the undeniable fact that the mature man is capable of elevating himself out of the base intoxication of the senses characteristic of youth, to attain the noblest and most intimate married love, whereas the girl who has once descended into such an abyss sinks therein and is beyond the possibility of rescue. Thus early marriage with equal purity of husband and wife remains a postulate which the present can hardly be expected to satisfy, and one whose fulfilment must be left to the future.

In consequence of modern writings and discussions concerning the erotic problem, there has arisen a hypersensibility on the part of women in respect of the conditions in which they pass their married life, leading them to demand greater independence, a greater expansion of their own individuality; this tendency must, however, be resisted, if the marriage is to be a happy one, with mutual comfort and reciprocal consideration, one suitable, not for exceptional beings in an ideal state, but for men and women as they really are. In such a marriage, affection and a sense of duty will strengthen love and preserve fidelity. A prudent, clever woman will always understand how, notwithstanding all necessary self-surrender, to preserve the freedom of her own individuality and the esteem of her husband.

Marriages based upon true inclination usually result in the birth of stronger and more beautiful children than marriages in which the money-bags were the sole or the principal determining cause. In England, where people commonly marry when still quite young, beautiful and healthy children are more often seen than in France, where marriages of expediency form the great majority. According to Bertillon, of 1,000 young men from 20 to 25 years of age, in England 120 marry, but in France less than half that number, viz., 57 only. And 100 wives between the ages of 15 and 40 give birth annually, in England to 39 children, in France to 26 only, a number less by one-third.

In deciding upon marriage, hereditary influences deserve careful consideration in respect alike of the family of the prospective husband and that of the prospective wife. For it is well established that the law of inheritance relates not only to the peculiarities of external configuration, to the features, the stature, the tint of the skin, but also that children inherit from their parents their mode of bodily development, the functional activity of their organs, the duration 265of their life, their predisposition to disease, and even their intellectual and moral qualities. As regards hereditary predisposition to disease, the most important are, as is well known, the predisposition to tuberculosis, that to malignant tumors, and that to mental disorders.

Great disparity in the respective ages of prospective husband and wife entail various kinds of unsuitability for marriage. An elderly man who marries a young girl, even if he still possesses a certain amount of virility, is unlikely to procreate healthy and powerful children; and these latter for the most part will be weakly, scrofulous cachectic, endowed with deficient powers of resistance, and often badly equipped from the intellectual standpoint. Similar considerations prevail in respect of marriages in which the husband has been exhausted by earlier sexual excesses, so that he retains no more than remnants of virility, whilst his semen is of doubtful fertilizing power. D. Richard relates that Louis XIV asked his physician why it was that the children he (the king) had by his wife were delicate and deformed, whilst those he had by his mistresses were beautiful and powerful. “Sire,” was the answer, “c’est parce que vous ne donnez à la reine que les rincures.”

Plato maintains that before every marriage the man and the woman should both undergo official examination to determine their fitness or unfitness for the married state, the man being absolutely nude, and the woman stripped to the waist, for the examination. This author goes so far as to regard it as “a form of homicide for a man to embrace a woman when he is incapable of fertilizing her.” How rarely it happens in our day, however, that the physician, the official with the requisite knowledge to fulfil Plato’s requirements, is asked for his opinion regarding the desirability of a contemplated marriage! The only occasion on which this is likely to occur is when a man intending to marry wishes to be assured that he is completely cured from an earlier infection with syphilis, and, therefore, runs no risk of transmitting the disease to his wife or to possible offspring. But it never occurs to the parents of a girl about to marry to ask the physician whether she is physically suitable for marriage.

In deciding on marriage, however, care should before all be taken to determine that the girl has attained complete physical and especially complete sexual development. The age at which woman attains complete sexual maturity is in our climate and race coincident on the average with the twentieth year of life.

For the hygiene of marriage it is necessary that the bride should not be extremely youthful. Notwithstanding the fact that the legal codes of civilized countries nowhere demand for girls a greater age 266than fifteen years before permitting marriage, this limit is, generally speaking, fixed far too low. Before becoming a wife, the girl should not merely have attained complete physical development, with her reproductive organs in a state of maturity, but she must also be developed intellectually to such an extent that she is fully capable of understanding the nature and significance of marriage. At the age at which marriage is legally permissible, a girl is still far from having attained physical and mental ripeness for marriage, reproduction, and maternity.

Especially with reference to the last consideration is it inadvisable that in our climates a girl should marry earlier than from 18 to 20 years of age, and preferably even she should first attain the age of from 20 to 22. In that case her happiness as a mother will be more secure, and there will be a greater probability of her producing a healthy progeny. In the East, indeed, quite different views prevail. According to the laws of Manus, a girl might marry on attaining the age of eight years; if within three years thereafter her father failed to provide her with a husband, she might choose one for herself. Among the Hindus it is regarded as a disgrace to the parents if a girl does not marry quite young, indeed before the first appearance of menstruation. Atri and Kasypa state that if a girl begins to menstruate before she leaves her father’s house, the latter must be punished as if he had destroyed a fœtus, while the daughter herself loses caste. Marriage delayed till after the appearance of menstruation being regarded as sinful, girls are married while still children, in order to prevent the loss of mature ova, which is regarded as equivalent to infanticide. Very early marriage has thus in India been legally ordained for thousands of years. The Hindus, who even now regard every menstruation which has not been preceded by coitus in the light of infanticide, marry their daughters before the age of puberty.

According to oriental tradition, Mahomet married Khadijah when five years of age, and cohabited with her three years later. In the Bible, numerous similar examples are recorded. Among many savage tribes, as, for instance, among some of the aborigines of India, and among the indigens of Australia, copulation is usually effected before girls reach the age of puberty; in India, indeed, according to Ploss and Bartels (Das Weib in der Natur und Völkerkunde), marriage with immature girls is a widely diffused custom, and in Australia a child of ten or eleven is often found to be the wife of a man of fifty or the concubine of a sailor. In general, according to these authors, we find that the age of nubility in girls is lower in proportion to the lowness of the stage of civilization attained by the race or people to which they belong. Among the 267ancient Romans, girls were commonly married between the ages of thirteen and sixteen years.

In the Talmud, Rabbi Joshua gives the following advice regarding early marriage in Jewish girls: “If your daughter has attained puberty and is twelve years and six months old, she must be married at any cost. If no other means are available, manumit one of your slaves, and give her to the freedman to wife.”

Experience proves, however, that in our climate, at any rate, girls who marry at a very early age are inferior in fertility to those who refrain from marriage until the genital organs have attained complete maturity; and statistics show that those women who marry before attaining the age of twenty must wait longer for their first pregnancy than those who marry between the ages of twenty and twenty-four. At the higher age also, women bear parturition and its consequences more easily than those who marry very young. A similar influence in marriage to that resulting from undue juvenility is exercised by its opposite, marriage when a woman is already elderly; in this case fertility is limited, and health also is especially apt to suffer. When the indications of the climacteric are clearly apparent, marriage is contra-indicated, not only on account of the impossibility of fertilization, but also in respect of its general unsuitability in the closing stage of the sexual life.

Not only is the absolute age of the woman of importance in deciding on the advisability of marriage, but the relative ages of the proposed husband and wife must also be taken into account, first of all in respect of the wife’s possible fertility, and secondly in respect of her general health. The most suitable arrangement is that in which there is no marked difference in age. The husband may be, and indeed in existing social circumstances almost necessarily is, somewhat older than his wife, as much perhaps as eight or ten years. But a very great disparity of age (in either direction) is a serious error. If a very young girl marries an elderly man, or a developed matron marries a young man, the true purpose of marriage is unfulfilled, the eternal laws of nature and all ethical principles are infringed. In the breeding of animals, the fundamental principle has long prevailed that the animals chosen for coupling should be well suited each to the other and should be in perfect physical condition; and breeders are also familiar both with the favorable influence of good nourishment and with the advantage of the opportune crossing of distinct varieties. The same principles are equally applicable to the human race, neglected as they commonly are in practice.

With regard to the marriage of near kin, we can only remark that the marriage of those closely related by blood should as far 268as possible be avoided, and that such a marriage must be absolutely prohibited when in both families there is a history of tuberculosis, mental disorders, diabetes, and the like. When first cousins contemplate marriage, it is indispensable, not only that both individuals should be in perfect health, but also that on neither side there should be any serious family history of transmissible disease or transmissible morbid tendency; and, further, it is absolutely necessary that no such marriage of near kin should have taken place in the proximate ancestry of the cousins, i. e., their cousinship must not be a double one, derived both from the paternal side and the maternal. It is indeed to be recommended, with a view to the production of a healthy and powerful posterity, that marriage should bring about a crossing of healthy individuals proceeding from different families, different places, and different constitutional types. An instance of the advantage to be found in this practice is pointed out by Ribbing, who shows that the most powerful aristocracy in Europe, that of England, by the gradual creation of new peers, on the one hand, and by the gradual decline of younger sons and their descendants into the middle class, on the other, has undergone a continual crossing with less exalted but originally sounder stocks; in this way its vigor and fertility have been maintained, in contrast to the nobility of many continental states, which has so largely perished, in consequence of its exclusiveness in the matter of marriage.

“In this connection,” continues Ribbing, “we must bear in mind, that blood-relationship is not the only matter that has to be considered; in the interest alike of the family, and of society, it is necessary to demand that certain degrees of relationship by marriage alone, should fall within the ‘prohibited degrees’ of love and marriage. There are certain groups related by marriage and held together by the bond of affection, from which foster-parents and guardians may most suitably be selected to fulfil the duties as regards education and training of children who have been orphaned in early years. For such a purpose none seem better adapted than the brothers and sisters of the deceased parents; but the upbringing of the children can be confidently entrusted to the former only if the relationship between the older and the younger branches of the family is one regarded by law, and still more by morality and custom, as one precluding the possibility of the occurrence of sexual love and marriage.”

Möbius, writing on “The Ennobling of the Human Race by Selection in Marriage,” observes: “The most important aim of natural development is the perfection of humanity. The qualities of the coming generation depend for the most part upon the qualities of the parents. Marriage from affection ensures the fulfilment of 269nature’s aims with more security than marriage from reason; since what we have to think of is not the happiness of the married pair but the quality of their children. Of great importance, also, to the development of the human race are the conditions during the commencement of life, and the mode of education. The improvement of the race has not hitherto been the conscious aim of the generality of people. The law does not as yet, as it should, take into account the advantage of posterity. Capital punishment is fully justified and purposive. Criminals should not be allowed to marry. The perpetuation of disease by inheritance should be checked by the utmost powers of the state. Any one marrying while suffering from any venereal disease still in an infective condition should be punished. The marriage of persons suffering from tuberculosis should be prohibited. For the prevention of disease is more important than its cure. The most important factor in preventive medicine is an improvement in the conditions of life. The human ideal should be, goodness of heart in association with physical and mental health. Goodness, beauty, and strength should be simultaneously pursued. Since, however, man is made by birth far more than by education, selection in marriage is of fundamental importance. In the choice of a partner, attention is rightly paid to beauty, since beauty and health are fundamentally identical; moreover, a human being endowed with beauty is usually also more moral than one devoid of that attribute. Equality of birth is as a rule desirable in marriage; but not the family only is to be considered in determining the existence of such equality, individual characteristics must likewise be taken into account. Whether the crossing of races is desirable is not yet certainly determined.”

From the hygienic standpoint it is necessary that in marriage also the frequency and the manner of sexual intercourse should be regulated.

Wise men and lawgivers of all the nations of antiquity have insisted upon the necessity of certain intervals between the acts of intercourse. Thus, Mahomet prescribed 8 days, Zoroaster 9 days, Solon 10 days, Socrates also 10 days. Moses forbade intercourse during menstruation and for a week after the cessation of the flow. Luther prescribed intercourse “twice a week.”

Birds and many mammals are competent to perform intercourse at exceedingly short intervals. A well-bred cock will repeat this act 50 times daily; a sparrow, 20 times in an hour; a bull, 3 to 4 times in an hour. In the human species, however, too rapid repetition of intercourse is deleterious not only to the male, but to the female also, though the latter certainly suffers in less degree. For in this act the female plays a more passive part, and for this reason 270can repeat it with impunity more frequently than the male, who loses semen at each repetition. It is not possible, however, to lay down precise rules as to the permissible frequency of intercourse in either sex; the matter must depend upon physical needs. Moderate and regular indulgence in sexual intercourse is unquestionably advantageous to women both physically and mentally, regulating all the functions of the body, and tending to produce a contented and cheerful frame of mind.

During menstruation, a woman should refrain from intercourse. By the Mosaic law the death punishment was allotted both to the man and to the woman who indulged in coitus while the latter was menstruating. As a matter of fact, considerations alike of hygienic cleanliness and of sanitary precaution prohibit the performance of coitus during this period. Severe menorrhagia, perimetritic irritation, and parametritic inflammations, have been observed to follow such indiscretions. On the other hand, it is more than doubtful whether, in the event of pregnancy resulting from intercourse performed during menstruation (and conception is especially apt to occur at this time), the child is likely, as earlier authors maintained, to be unfavorably affected, and to suffer from cachexia, scrofula, or rickets.

After the act of intercourse, a woman should rest; and indeed sleep for some hours is especially to be recommended. A vaginal douche should not be administered until several hours have elapsed, otherwise there will be a risk of preventing fertilization of the ovum. The water employed for vaginal irrigation should never be quite cold; a temperature of 79°–82° F. (26°–28° C.) is best.

All measures for the purpose of artificially increasing sexual desire, such as alcoholic beverages (especially champagne), and certain drugs (especially cantharides), are even more harmful to women than they are to men. The woman who conceives while in a state of intoxication commits a great sin against the coming generation.^[44] Just as harmful, however, are the anaphrodisiacs sometimes employed to diminish the intensity of sexual desire when this cannot be gratified. When affected with intense sexual excitement, a woman is much more unfavorably situated than a man, since man claims the right to indulge in sexual intercourse whenever he feels disposed, 271and has, moreover, ample opportunity for sexual gratification. A woman, however, properly endowed with self-respect, will understand how to bridle her senses. Bodily exercise, moderate, unstimulating diet, intellectual occupation with serious matters, the avoidance of equivocal literature and of sensual dramatic representations, cold bathing, and the use of a hard mattress and light bed-clothing—these means will coöperate powerfully toward the prevention of excessive sexual desire. Horace already remarked: “Otia si tolles, periere Cupidinis arcus.”

The wife should know how to bridle, not her own desires only, but also those of her husband. She must not demand too much during the intoxication of youthful vigor; she must prevent the complete combustion of the flames of masculine passion, and must keep sparks glowing in the ashes. Economy during the sexual prime preserves sexual power, enables a man to continue intercourse to a ripe age, and avoids premature exhaustion and satiety. When the husband is drawing near the end of his sixth decade, the wife must accustom herself to see in him rather the father of her children than her own husband, and must reduce her sexual demands to that measure which will not be injurious to his health. Demosthenes, writing of the sexual life of the Athenians of his time, said: “In order to obtain legitimate offspring and to provide a faithful guardian of our household, we marry a wife; for our service and for the performance of daily household duties, we keep concubines; for the joys of love, we seek the hetairai.” The task is extremely difficult, but a clever and virtuous modern wife must endeavor to combine in her single personality the sensual attractiveness of an Aspasia, the chastity of a Lucrece, and the intellectual greatness of a Cornelia; she must bear in mind the epigram of Bacon, “A wife must be a young man’s mistress, a middle-aged man’s companion, an old man’s nurse.”

In the act of intercourse the woman must always play the more passive part; she must be desired, rather than desire. Woman’s modesty increases man’s desire. By this coquetry, permissible because natural, the woman can bind the man to herself, and can give the lie to the assertion that marriage is the grave of love. Partial concealment of her desire on the part of the woman is more stimulating to the man than an open manifestation of the sexual impulse; and a certain amount of modest reluctance is more alluring to him than a plain invitation. Plenty of room must be left for the play of fancy and imagination. Schiller makes Fiesco say to the Countess Julia, as he covers up her bosom, “The senses must be blind letter-carriers only, and must not be aware of that which nature and the imagination communicate each to the other. The best of news is stale as soon as it has become the talk of the town.”

272For this reason, also, it is more suitable that intercourse should take place, not by day, consequent on the brutal prompting of vision, but by night only, beneath the protecting veil of darkness. A night’s rest, moreover, will serve to restore the exhausted nerves, and to replace the expended secretions. Less advisable is coitus in the morning, on awaking from sleep, since the labors of the day must immediately thereafter be undertaken. Partially impotent men only, who wake up with an erected penis, endeavour to avail themselves without delay of this favorable opportunity, bearing in mind the French proverb, “On aime quand on peut, et non pas quand on veut.”

The French custom, in accordance with which the married pair sleep together in a double-bed is undesirable on several hygienic grounds, and, in the first place, for the reason that this continuous nocturnal proximity is likely to give rise to the habit of indulging in excessively frequent acts of intercourse. The best and most affectionate of men has neither disposition nor capacity to play the part of Romeo every night, and thus the value and enjoyment of marital duties becomes lessened. The fulfilment of his desires should not be rendered quite so easy to the husband; he should always appear the lover, one who seeks a woman’s favours because he longs for her; he should not be the master, exacting an unquestioned right. For this reason, separate beds are advisable for the married pair, and, when possible, even separate bedrooms.

Among the ancients, Lycurgus, the Spartan law-giver, regarded maternity as woman’s principal attribute, and considered the sexual impulse to be the means merely by which healthy citizens were provided for the state. In accordance with this view, the sanctity of marriage was violated, and every powerful, handsome, and valiant Spartan had the right to request the privilege of intercourse with the wife of another, in order to enrich that other’s family with his seed. Elderly, impotent men conducted well-formed young men into the arms of their own wives. The girls, like the young men, went through a course of gymnastic exercises, in order to harden their bodies, and to fit them for the bearing of strong and healthy children. No man might marry before attaining the age of thirty, no woman before attaining the age of twenty. Girls ripe for marriage were assembled in a dark place, and there the young men chose their brides, as chance might direct. The young men were allowed to visit their wives by night only, and secretly, in order that the vigor of the sexual impulse might be increased and maintained.

Among the Spartans, it happened quite frequently, that a man whose wife had remained childless, and who believed himself to be 273at fault in the matter, would beg one of his fellow-countrymen, or even a foreigner, to come to his assistance. It was enacted by one of Solon’s laws, to prevent a man from neglecting his marital duties, that he should have intercourse with his wife not less than three times monthly. According to another of Solon’s laws, an Athenian heiress might call upon her nearest relative for the gratification of her sexual desires.

The bluntest contrast to this Spartan simplicity is furnished by the unbridled lasciviousness that prevailed in Rome under the Cæsars, when women’s sole desire was sexual enjoyment, while maternity was a state to be avoided. To such an extreme was this carried, that the Roman ladies of that day preferred to marry eunuchs, and further, as Pliny reports, hermaphrodites were in great request. Juvenal writes: “There are women who prize the infertile embraces of base eunuchs; thus they are able to dispense with the use of abortifacients.”

The hygiene of the nuptial night deserves from the physician more attention than it has hitherto generally received. He should warn and enlighten the young husband, in order that the brutality with which the act of defloration is apt to be performed may be lessened, and further in order that mistakes in this connection, resulting from ignorance and likely to have serious consequences, may be avoided. It is well known that lacerations of the hymen and its environment, and even serious injuries of the genital organs, may result from maladroit attempts at penetration. The physician will admonish the husband in the words of Michelet: “Bear in mind in this hour that thou art an enemy, a tender, considerate, and gentle enemy!”

The young woman entering upon marriage should receive instruction from her mother regarding all the sexual processes of copulation, instruction at once earnest and complete. By such enlightenment, the young bride will be spared much suffering, and a sudden disillusionment which might seriously affect the whole of her future life will be avoided; complete ignorance, on the other hand may lead, not merely to needless mental and physical suffering, but to the most tragic consequences on the bridal night. In one case known to me, the young wife, who before marriage was utterly ignorant of the nature of physical love, was so completely overwhelmed in her ideals by the somewhat energetic procedure of the bridegroom as soon as he found himself alone with his wife, that she fled from her new home then and there in the night, and by no persuasions could be induced to return.

In that decisive moment in which the maiden loses her virginity, she must find in her husband, not the brutal man who forcibly takes 274possession of her body, but the chosen man of all, to whom her love can refuse nothing.

“Delicate foresight and restraint,” writes Ribbing, “are needful above all at the commencement of married life. The young wife, coming to the bridal bed a pure virgin, is not, like her husband, fully prepared for what is to take place. In all cases she is somewhat fearful of the new experience. The first act of intercourse involves for her a certain amount of pain, and this pain is not solely physical. * * * Moreover, we must remember that the entire change in her mode of life makes a deep impression upon a woman’s mind; time and quiet are needed before she can find herself at home in the novel surroundings, before she can adapt to the changed circumstances her moral and religious convictions, and before she can ‘think true love acted simple modesty’ (Romeo and Juliet, III, 2.16). Impatient husbands, through want of knowledge and lack of consideration during the honeymoon, have often ruined the happiness of subsequent married life.”

It happens often, unfortunately, that the wife has reason to complain of the reckless manner in which her husband has used, or misused, his sexual powers. Frequently enough, on the bridal night, the man proceeds with such violence in his assault on the virgin reproductive organs of his newly-wedded wife, that we must actually speak of him as ravishing an ignorant and timid girl. Later, when the stimulus of novelty has passed away, the husband often performs intercourse in a manner more calculated to awaken his wife’s sexual desires, but in seeking his own lordly gratification and obtaining it he is still apt to leave out of the reckoning the need for effecting coitus in such a way as will give complete satisfaction also to his wife.

The wedding journey likewise deserves consideration from the hygienic standpoint. Much is to be said in favor of such a journey, inasmuch as it endows the necessarily somewhat brutal first act of intercourse with an aspect of romance. The removal to a foreign country, to a strange environment, will spare the chaste maiden much shame and vexation. On the journey, moreover, the young couple are much in each other’s company, and the process of mutual adaptation is agreeably favored. And yet this modern custom of making a wedding journey entails certain serious disadvantages. The young woman leaves her home and her nearest relatives, and is in a moment involved in the excitement of travel, an excitement liable to increase to the degree of morbid anxiety. The fatigues of railway-travel, of wandering about strange towns, of visits to museums and picture-galleries, are apt to cause general loss of nervous tone, and also local hyperæmia of the genital organs. In 275addition, false modesty and the prescribed arrangements for the journey may lead the onset of menstruation to be ignored and the customary rest at this period to be dispensed with. Still more, the possibility of the occurrence of conception and of the commencement of pregnancy is usually left altogether out of the account. Many an attack of menorrhagia, of perimetritis, and of endometritis, many a miscarriage, and many instances of protracted sterility, are dependent upon the hygienic mistakes of the wedding journey, and less, indeed, upon the abuses arising out of the intoxication of passion, than upon the fatigues of excessive travel both by day and by night. The bride who on her wedding-day was young, healthy, and full of vitality, not infrequently returns from the wedding journey a sickly and debilitated woman.

With regard to wedding journeys in relation to the causation of chronic metritis, Scanzoni has expressed an authoritative opinion. “After many weeks of unsatisfied sexual desire, the young married pair, now freed from all restraint, give themselves up to the joys of love; the intense sexual excitement causes great stimulation and hyperæmia of the female sexual organs; in addition, the noxious influences of travel make themselves felt, and also hygienic indiscretions are perpetrated, dependent upon the young wife’s modesty; it is, therefore, by no means to be wondered at that, having left home a perfectly healthy woman, she returns from her wedding journey with the germs of an illness from which she never fully recovers, and which is the source of unending suffering, and more particularly of a sterile marriage.”

Sexual hygiene demands a certain moderation in the enjoyment of physical love, and also a certain constancy, such as may be expected in a happy marriage.

It is not possible to lay down a general rule with regard to the frequency of sexual intercourse, notwithstanding the earnestness with which religious zealots, physicians, and moral teachers have in all ages endeavored to determine how often it was proper for a man to cohabit with his wife. The rules that have been prescribed by the various authorities had in view, for the most part, the protection of the wife from excessive demands on the part of her husband; sometimes, however, by the establishment of a minimum period, a certain amount of sexual gratification was secured to the wife; finally, also, the generation of a healthy posterity had to be taken into consideration. Ribbing, however, justly observes: “Sexual intercourse results from a natural impulse, and he whose senses are unimpaired, and who has learned, at the same time, amid the tumult of his sensations, to preserve proper consideration for his wife—such a man runs little danger of making any mistake. In 276opposition to the opinion of many, I regard it as entirely right and reasonable that husband and wife should have intercourse whenever physically and mentally impelled to that act. Nor do I see any reason why, during the first period in which they are able to enjoy without intermission the pleasures of sexual intercourse, they should, in accordance with any theory whatever, impose on themselves further restraints than those demanded by care for their physical and mental health. The touchstone of marital hygiene is this, that on the day following intercourse both husband and wife should feel perfectly fresh, vigorous, and lively, alike in body and mind—even more so, perhaps, than on other days. In the absence of such feelings, we may feel assured of the occurrence of sexual excesses.” The same author quotes a saying of Pomeroy’s: “We may quaff the nectar as freely as we will—nature herself mixes the draught and holds the goblet to our lips; if, however, we drink too much, she first dilutes the draught with water, later adds gall, and ultimately perhaps deadly poison.”

The occupation, trade, or profession, and the nutritive condition and physical constitution of the married pair, have an important bearing on the frequency with which, without detriment to health, cohabitation is permissible. The rules of the Hebrew Talmud already take these circumstances into account, ordering as they do that young and powerful men not engaged in any regular occupation shall have intercourse with their wives daily; manual labourers, on the other hand, once a week only; whilst brain-workers, finally, or those whose work is extremely arduous, should allow an interval of one or more months to elapse between the acts of intercourse. Acton also prescribes that in the case of brain-workers and of those manual workers whose labours are exhausting, intercourse must not occur more frequently than once every week or ten days.

The married couple should understand how to impose on themselves a certain restraint in the matter of marital intercourse, without, however, going so far as on altogether trifling grounds to refuse the husband access to his wife. In this respect also, the opinions that have recently come to prevail concerning the rights of women have had an influence. W. Acton relates a case that came under his observation in which the wife refused to allow her husband any voice in determining when and how often intercourse should take place; the wife, she maintained without hesitation, since she had to bear the consequences of intercourse, was fully justified, whenever she thought fit, in refusing her husband’s embraces.

The dangers to the sexual life of woman which are involved by the modern woman’s rights agitation are seen already in the changes which the emancipation of women in North America has produced 277in the functions of woman as wife and mother. In that part of the world, everything possible has been done “to transform” (to quote the words of a brilliant journalist) “the doll into an independent existence, to enable the helpless woman to earn her own subsistence, and the result of these endeavors has been most striking. The American woman has obtained the right to enter every profession and to follow every kind of occupation which have hitherto been reserved for men; she is physician, lawyer, merchant, professor; her boudoir has become an office, often connected with the stock exchange by a private wire. Legally, also, she now possesses the same rights as man; in many States she has both the suffrage and the right of entering the house of representatives; she has fully emancipated herself from her former condition of tutelage, and in her shrillest tones can cry to heaven ‘I am free, I am independent, I am emancipated, I am myself!’ And observe, as the result of all these attempts at the conversion of woman into man, that in the matter of marriage also she acts as if she were no longer woman. The American woman no longer marries; perhaps, indeed, because she no longer has the capacity. So long and so eagerly has she given herself up to masculine occupations, that her inward feminine nature has also perhaps undergone transformation, so that she has become affected with a kind of neutral lack of desire. Unquestionably, the desire for marriage on the part of this modern ‘emancipated’ woman has vanished in the most alarming manner, there is a notable fall in the birth-rate, and the indigenous (white) population actually threatens to disappear.”

The wife acts wisely, not on hygienic grounds alone, in not always acceding at once and unconditionally to her husband’s demand for the repetition of intercourse. Her modest reluctance enhances her desirability in the eyes of her amorous husband. Thus, Shakespeare makes Posthumus exclaim (Cymbeline, Act II., Sc. 5, l. 9):

Especially justified is such refusal when coitus has been already once or twice performed, or when the consumption of alcoholic beverages has made the husband unduly lustful. On the other hand, the refusal of intercourse when demanded by the husband should never depend upon baseless feminine caprice, or upon the now so frequently asserted “rights of women.”

Experience has long ago established as a fact that unduly frequent satisfaction of the sexual impulse entails serious consequences to the health of the individual. And in the case of the wife these 278consequences may be especially disastrous when intercourse is indulged in recklessly during menstruation, during all stages of pregnancy, and even during the puerperium. “Incontinence during menstruation leads to serious circulatory disturbances and to the consequences of these disturbances; during pregnancy it is likely to give rise to miscarriage; during the puerperium, to congestions and inflammations. Should conception occur as a result of intercourse during the lying-in period (and this may happen very shortly after childbirth), abortion, and even more serious consequences, are likely to ensue. By intercourse during lactation, the premature recurrence of the menstrual flow is induced, and the gradual reversion of the reproductive apparatus to the condition in which it was before pregnancy (the process of involution) is hindered; moreover, the secretion of milk is diminished or even entirely suppressed.” In these terms Hegar depicts the consequences of premature resumption of marital intercourse, taking perhaps a somewhat extreme view of the matter.

Nevertheless, this author is undoubtedly right in declaring that one of the principal disadvantages to a woman of excessively frequent sexual intercourse is that pregnancy occurs too often. It is astonishing to observe the number of full-term deliveries and miscarriages that a woman will experience within a comparatively short period of time, as is seen too frequently among the labouring classes and more especially among factory workers. “If we assume the ordinary mortality of childbed to be 6 per mille, a woman who in the course of 15 years undergoes labour (at full term or prematurely) 16 times, runs a risk of death to be expressed by the ratio of 6 × 16 = 96 per mille; that is to say, on the average, of 1,000 women who become pregnant as often as this, nearly 1 in 10 will die in childbed.”

Young men who have previously suffered from gonorrhœa and who wish to marry, must, unless they wish to cause unspeakable misery, undergo an exact and thorough examination; not only must the physician inquire as to the presence of certain symptoms, such as smarting during micturition, adhesion of the lips of the urethral meatus, “clap-threads” in the urine, etc., but during a considerable period of time repeated microscopical examinations of the urine must be undertaken, and the filaments, if present, must be examined for gonococci. The physician will also have to determine whether any vestiges remain of epididymitis, and whether the quality of the semen has been impaired by the attack of gonorrhœa. Unfortunately, it is not yet within our power absolutely to forbid marriage to a man exhibiting all the symptoms of chronic gonorrhœa; but it is the duty of the physician to explain to such a man the scientific 279views regarding this matter that now prevail, in order to furnish him with the grounds for a decision.

It is not possible, when discussing the hygiene of married life, to preserve silence respecting the extremely pressing question of the use of measures for the prevention of conception, for in recent years their use has become extraordinarily general, chiefly, indeed, in the upper and middle classes of society, but to some extent also among the working-class population. Although we devote a special chapter to this topic, we must here express the opinion that, except in certain instances in which their employment can be justified on carefully weighed and well-established medical grounds, the use of any mechanical or chemical means for the prevention of conception must be discountenanced as injurious to health. The wife who wishes to preserve her psychical purity and moral chastity, which is not only possible in marriage but also greatly to be desired, must not concern herself much with the technique of the sexual life, but must give herself up to sexual enjoyment only as the result of a delicate and immediate bodily and mental desire. Not only for reasons of national economy regarding the means of providing for the family, but also for well-grounded personal reasons regarding the wife’s health, must the latter be spared an unduly rapid succession of pregnancies and confinements. And this should be effected by a certain degree of continence and by the observation of extensive periods of sexual quiescence.

To preserve a woman’s health during the acme of her sexual activity, a careful general hygiene is an important requisite. The dwelling should be dry and roomy; above all the bedroom should not be too small, neither damp nor dark, and it should be well ventilated. The wife’s occupations should be so arranged as to afford a suitable alternation of activity and repose, and there should be as little night work as possible. Certain occupations are especially potent in the causation of the diseases peculiar to women, principally, for the reason that they do not permit of the requisite repose during menstruation. Thus, washerwomen, vocalists, and sewing-machine operatives, suffer with especial frequency from diseases of the genital organs.

Great care in the cleansing of the genital organs is indispensable in the case of women; the vulva and its environment should be frequently and carefully washed; and an occasional vaginal injection is advantageous. As regards the last-named measure, however, we must point out that it is possible to err by excess as well as by defect, and that a daily vaginal douche can by no means be regarded as a necessary part of the hygiene of the reproductive organs. For recent researches have shown, on the one hand, that the vagina constitutes 280a natural mechanism for the destruction of pathogenic organisms, and on the other hand, that complete disinfection of the vagina is extremely difficult to effect. Inflammations of the vulva, which are somewhat frequent in consequence of excessive perspiration and undue discharge from the genital canal, demand careful cleansing with soap and water and the use of a soft brush. The addition to the water of lysol (in the proportion of ¼ to ½ per cent.) is advantageous. A general bath or a local sitz bath, the water being moderately warm (95°–99° F.; 35°–37° C.), may be recommended on grounds of beauty as well as of health, and should be taken at least once a week.

The regular use of lukewarm sitz baths is a most valuable hygienic measure for the prevention of various general or local disturbances consequent upon increased flow of blood to the genital organs. These local baths are best taken at a temperature of 95° F. (35° C.), and should last twenty minutes; they should be taken just before going to bed, and while sitting in the hip bath the skin of the abdomen and of the lower part of the back should be rubbed with the hand encased in a friction-glove. The bather on leaving the bath should get straight into bed, and should dry herself beneath the bedclothes, rubbing the skin till it glows. Such sitz baths serve also to keep the external genitals clean, and to guard against infection. For vaginal douching, water sterilized by boiling should be employed, and where any catarrh of the vaginal mucous membrane is present, some alum, permanganate of potassium, or boric acid may be added with advantage; the pressure of water, when a vaginal douche is given, should never be high, the reservoir of the irrigator being raised not more than twenty inches above the outlet of the nozzle; as a rule the water should be lukewarm; the patient should be in the recumbent posture. The reservoir of the irrigator and the intra-vaginal nozzle are most suitably made of glass, to insure cleanliness; the nozzle should not be thrust too far in, two inches being quite sufficient. After the use of the douche, the woman should remain ten or fifteen minutes in the recumbent posture.

In addition to the hygienic employment of such full baths and local baths, a number of mineral baths have important therapeutic applications in cases of disease of the female genital organs, the traditional value of such baths having been scientifically endorsed by the modern science of balneo-therapeutics. By means of suitably selected mineral water baths, a powerful derivative stimulus may be given to the skin, and the affected reproductive organs may thus be beneficially influenced. Further, in acute inflammatory conditions or hyperæmia of the uterus or its annexa, these baths have an antiphlogistic influence; on the other hand, when intrapelvic exudations 281have formed, the baths promote the absorption of these inflammatory products; again, in congestive states of the female genital organs, with relaxation, thickening, and hypersecretion of the genital mucous membrane, the baths have an astringent and tonic influence on the tissues; finally, they have a favorable effect on the innervation and nutrition, not only of the reproductive apparatus, but of the entire organism. It is easy to understand why women during the menacme are frequent visitors to spas.

At this period of life, and especially in women who lead luxurious “society” lives, the thoughts tend strongly in the sexual direction; to avoid this, and to prevent the ever more and more frequent breaches of marital fidelity, the best means are the practice of vigorous bodily exercises, and active employment, either in household affairs or in intellectual occupations. Cold sponging of the body or cold full baths will also be found an excellent measure for the prevention of sexual excess. In such cases also the diet should be limited, strong and stimulating food should be avoided, but little butcher’s meat should be taken, whilst green vegetables and raw and cooked fruits should be liberally consumed; at the same time, all alcoholic beverages must be rigidly prohibited. Moreover, care must be taken that during the night there should be no undue physical stimulation in consequence of excessively warm and soft bedding; hair mattresses are to be preferred to feather beds, with light down quilts for a covering. Finally, no stimulation of an erotic character should be offered to the imagination, and for this reason equivocal literature and lascivious dramatic representations must be avoided. By a sufficiency of occupation, regular, interesting, and demanding a considerable expenditure of physical energy, a woman may be enabled to a great extent to escape the inconvenience and distress attendant on entire or partial lack of gratification of the sexual impulse.

It cannot be disputed that a certain and moderate amount of sexual gratification is requisite for the perfect maintenance of physical health in woman, and that the absence of this gratification, or the gratification of the impulse in an abnormal or incomplete manner, entails disturbance of alike the mental and the physical equilibrium; but, on the other hand, the deleterious consequences of sexual abstinence have been greatly exaggerated by many writers—both by physicians and social economists. Owing to the fact that to the cultivated woman sexual gratification is possible only in the married state, whilst social conditions render marriage impossible to many women greatly in need of such gratification; in consequence, also, of the modern and ever more widely diffused practice by husbands of coitus interruptus altogether regardless of the woman’s need for complete sexual gratification—there arise in women numerous 282local disorders and nervous disturbances, hysteria and even insanity being results by no means infrequent. The significance of ungratified sexual impulse in the pathogenesis of nervous disorders has been established by von Krafft-Ebing, who points out that in unmarried women insanity most frequently occurs between the ages of twenty-five and thirty-five years, during the decade, that is to say, in which youthful bloom and the hopes of marriage simultaneously disappear; whereas in the male sex the greatest incidence of insanity is between the ages of thirty-five and fifty years, the period of life in which the struggle for existence is fiercest.

Hegar, on the other hand, is a firm opponent of the view that the favourable influence of marriage is overrated. According to this author, the favourable effect of marriage in respect of mental disorders is to be found, not in the gratification of the sexual impulse, but in the ethical factors of marriage. Statistics show that even in the favourable circumstances of marriage, sexual gratification has in women an unfavourable influence, inasmuch as the proportion of sufferers from mental disorders is higher among married women than it is among married men. A study of the mental disorders which in women are especially associated with the process of reproduction (puerperal mania) confirms this impression. Hegar insists that he has never seen nymphomania arise in women in consequence of forcible repression of the sexual impulse; but that he has not infrequently seen this disorder result from unnatural excesses or from long-continued sexual irritation, especially in hereditarily predisposed persons. Such unnatural stimulation of the female is not infrequently practiced by the male—by the lover and even by the husband—it may be because he himself derives pleasure from such perverted practices, and wishes to obtain sexual gratification without the risk of impregnation, or because he is himself incompetent for normal complete intercourse. Hegar is further of opinion that in the causation of hysteria and also in that of chlorosis the repression of the sexual impulse plays a quite subordinate rôle. And he regards as pure fable the belief that continence in women is liable to lead to the formation of mammary, uterine, or ovarian tumors. He would more readily incline to the contrary opinion; the reproductive process being in this respect distinctly disadvantageous to the female sex. The unfavorable influence of the reproductive process is shown most clearly in the case of carcinoma of the uterus; the majority of the patients suffering from this disease are either married or widowed, and many of them have given birth to a large number of children. “Gratification of the sexual impulse, and more particularly the reproductive process, give rise in women to the 283formation and growth of tumors, cause numerous mechanical disturbances, and open the way to infection with various pathogenic organisms.”

Hegar considers that there is hygienic justification for the limitation of the number of children to which a woman gives birth. The most suitable age for motherhood lies in his opinion between the ages of twenty and forty years. Childbirth in women younger or older than this entails too much danger both to mother and child. At least two and a half years ought to elapse between two successive births; and these figures give us eight as the maximum family. If we assume that the duration of pregnancy is nine months, and that of lactation nine to twelve months (or in cases in which the mother does not nurse her own infant, that a like period must be devoted to the careful supervision of the wet-nurse or of the methods of artificial feeding), we cannot consider it unreasonable to devote a further period of from six to nine months to the complete reestablishment of the woman’s health. “Moreover, woman does not exist solely for the purpose of subserving during two decades of her life the processes of reproduction. And to permit the maximum number of children to be as great as eight, we must presuppose that the woman is in perfect health, and that she lives in a perfectly healthy environment. Any illness or infirmity which renders the duties of housekeeping and the rearing of the existing family unduly difficult, indicates the need for a further limitation of child-bearing. And if the reproductive function is to be rationally controlled, we must above all attend to the age and the health of the parents. Occupation, habitation, and general environment have also to be considered. The correct ideal is indeed not difficult to discover.”

Hegar concludes that strict moderation and even absolute continence in sexual matters are often, and for long periods of time, a pressing duty. “The numerous and various disasters which are brought upon the world by unbridled and unregulated sexual passion can be prevented only by enlightenment, moderation, and continence. If marriage were postponed until the attainment of complete physical maturity, in women till the age of 20, in men till the age of 25, while at the same time procreation were no longer undertaken by women above the age of 40 or by men above the age of 45 to 50 years; if, again, between successive pregnancies a sufficient pause for the woman’s recuperation were insisted upon, and intercurrent illnesses and states of debility were taken into account; and if, finally, sickly individuals, those hereditarily predisposed to disease, and those in any way below par either mentally or physically, were more than heretofore prevented from marrying; then the increase of population, which in Germany is unquestionably 284too rapid, would to some extent be checked. Thoroughgoing regulation of the reproductive process will not, however, be thus attained without the adoption of a method of selection too rigorous for present-day notions; and for a further advance we must in the meantime depend upon moderation and continence.” As regards the modern demand of the “right to love,” the same experienced gynecologist writes: “Whoever preaches to mankind the doctrine that ‘a man sins against his own personality if he neglects to exercise every limb he possesses, and if he denies himself the gratification of every natural impulse,’ or the doctrine that ‘it is the duty of every human being to gratify all his natural impulses, since these are most intimately inter-connected with his personality—are indeed his personality itself;’ such a preacher does harm to his kind. Such rights and such duties are chimerical for this reason if for no other, because two persons are necessary in the case of sexual gratification, and sometimes—though not as often as might be wished—Hans fails to find his Grete, without any consequent loss to society at large.”

An especially important chapter in the history of woman at this period of life relates to the dietetics of pregnancy and parturition, and to the regulations to be observed for the maintenance of health at this time and in connection with the processes of pregnancy, parturition, puerperal involution of the uterus, and lactation. This subject cannot now however be considered at length, and for our present purposes it is sufficient to point out how important it is alike for mother and child, alike for family and society, that the ever more and more widely and generally diffused practice of the artificial feeding of infants should be abandoned, and that there should be a return to the natural method according to which each mother nurses her own infant. The prevailing custom costs every year thousands of mothers their health, and thousands of children their lives.

Copulation and Conception.

Copulation.

The reproduction of the species is effected by means of an act of copulation on the part of a male and a female individual, both of whom must have attained complete sexual development. In all the sequence of reproductive processes it is copulation alone that is a voluntary act, all the other processes being independent of the will and even of consciousness.

A characteristic difference between man and the lower animals lies in the fact that in the human species sexual pleasure and the act of copulation may occur at any season of the year; and a 285further characteristic difference may perhaps be found in the fact that in the great majority of individuals of the human species the psychical process of “love” plays a determinative part. Voltaire pointed out that to man alone among animals are known the embrace and the joy of the kiss.

The significance of the kiss is depicted by Grillparzer in the following verses:

In this act of conjugation between two individuals of the same species, differentiated each from the other by the characteristics of sex, the active, provocative rôle is allotted to the male, the passive, receptive rôle, to the female. The modest and coy reluctance characteristic alike of the maiden and of the wife, promote an increase of sexual excitement in the opposite sex, and this not only in a man of purely sensual character, whose vanity is stimulated by his being the chosen one among many—a circumstance which, in view of the great dependence of the sexual act upon psychical processes and imaginative influences, is by no means devoid of importance. The woman’s coy reluctance must be overcome by means of a tender strategy before she is willing to grant the final possession of her body; and the act of copulation forms at the same time the conclusion of the physical and mental yearnings of the lover, and the commencement of the new-coming being. There is thus a physiological reason for the advice given by the celebrated surgeon, Ambroise Paré, that a man, before completing coitus, should employ some of the delicate and sensually stimulating manipulations of the earlier stages of courtship, for, he writes, “aucunes femmes ne sont pas si promptes à ce jeu que les hommes.”

The potency for intercourse of the sexually mature man, his capacity for the introduction of the erect penis during the act of copulation, is dependent on the fact that sexual excitement gives rise to a sufficient stimulus which, acting on the erection centre (and presuming that the centre and its afferent and efferent tracts are normal), leads to an increased flow of arterial blood to the penis 286and a diminished outflow through the veins of that organ, and consequently to its erection. The cerebrum is the organ in which the sensation of libido sexualis, of sexual excitement, has its seat; with this higher centre is connected by means of intercentral nerve tracts a lower, mechanical, reflex centre, situated in the lumbar enlargement of the spinal cord, and presiding over the performance of the act of copulation; it is moreover probable that nerve fibres proceed from the spinal cord direct to the blood vessels of the erectile tissue, by means of which the calibre of these vessels can be lessened or their extensibility diminished. The relation of the erector nerves (nervi erigentes) to the penis is by many physiologists compared to the relation of the vagus nerve to the heart. In the quiescent state the small arteries of the penis and perhaps also the cavernous spaces of that organ are in a state of mean contraction, so that they offer a considerable resistance to the passage of the blood current. When now the nervi erigentes are excited to activity, the hitherto tonically contracted vessels of the penis undergo, according to the school of physiologists just mentioned, relaxation, so that they dilate under the pressure of the blood within their walls, and, the previous resistance to the flow being now removed, the blood pours freely into the cavernous spaces of the penis, and distends these to the uttermost. In this manner erection is effected, rendering possible the insertion of the penis into the genital passage of the female; with the culmination of the sexual act, the semen is ejaculated, the muscles of the prostate and the membranous portion of the urethra together with the ischiocavernosus and bulbocavernosus muscles, all acting strongly and simultaneously.

By the contraction of the muscular apparatus just described, the penis is constricted in the neighborhood of the pubic symphysis, and this further hinders the outflow of the blood from the corpora cavernosa, increasing the intensity of the state of erection of the penis. Should the relaxation of the corpora cavernosa, dependent upon the stimulation of the nervi erigentes, be incomplete, it is not possible for sufficient blood to pass into the cavernous spaces to exercise considerable pressure upon the efferent veins, and thus complete erection fails to occur. If, again, the contraction of the muscular apparatus at the root of the penis is insufficiently vigorous, complete erection likewise fails to occur; the organ becomes semi-erect only, or erect for a period too short to permit of the completion of intercourse.

Since, physiologically speaking, conception is the purpose with which copulation is effected, the ejaculation of the semen must be regarded as the principal object of that act; now in normal conditions, ejaculation takes place only when the penis is fully erect. 287Associated with the erection of the corpora cavernosa is a swelling of the caput gallinaginis, whereby the orifices of the ejaculatory ducts are directed forwards toward the membranous portion of the urethra, and at the same time the backward passage to the bladder is cut off. By this mechanism, the urethra, which usually serves as the canal for the outflow of urine, is made for the time being solely subservient to the purposes of the sexual act. That the outlet from the bladder is obstructed by the swollen caput gallinaginis when the penis is erect, is shown by the familiar fact that a man whose penis is erect cannot pass water, although the way is freely open for the ejaculation of the semen.

Before ejaculation begins, the urethral glands already begin to secrete; and when erection is powerful and prolonged, this secretion often makes its appearance at the urethral orifice in the form of drops of a clear somewhat tenacious fluid. Ultzmann considers that the function of this secretion is probably to moisten the walls of the urethra, over which the acid urinary secretion is continually flowing, with a protective alkaline fluid, and thus to prepare the canal for the passage of the semen. An analogy may be found in the secretion of the cervical glands of the uterus in the female, for this secretion has been found to enhance the activity of the movements of the spermatozoa. If now during copulation the moment of ejaculation begins, the male experiences at the same time a sense of voluptuous pleasure and a feeling of muscular spasm in the perineal region, and this indicates the commencing evacuation of the contents of the seminal vesicles through the ejaculatory ducts. Simultaneously, the secretion of the prostate is poured into the urethra. The semen now gradually passes out through the narrow ejaculatory ducts, and, since in consequence of the swelling of the caput gallinaginis, it cannot pass backwards towards the bladder, it runs forwards, and accumulates in the bulb of the urethra, the physiological excavation of that tube. As soon as a considerable quantity of the semen has collected in this situation, so that the bulb of the urethra becomes distended, reflex contractions of the bulbocavernosus muscles ensue, by means of which the seminal fluid is forced out of the urethral orifice. In cases in which this muscular apparatus does not function properly, as in the paralytic form of impotence, the semen during ejaculation is not ejected in a forcible jet, but rather flows slowly, as from a lax tube partially filled with fluid, from the urethral orifice.

We are indebted to Roubaud for a classical description of the phenomena of copulation, and this description is here appended. It runs as follows: “As soon as the penis enters the vaginal vestibule, it first of all pushes against the glans clitoridis, which yields 288and bends before it. After this preliminary stimulation of the two chief centres of sexual sensibility, the glans penis glides over the inner surfaces of the two vaginal bulbs; the collum and the body of the penis are then grasped between the projecting surfaces of the vaginal bulbs, but the glans penis itself, which has passed further onward, is now in contact with the fine and delicate surface of the vaginal mucous membrane, which membrane itself, owing to the presence of erectile tissue between its layers, is now in an elastic, resilient condition. This elasticity, which enables the vagina to adapt itself to the size of the penis, increases at once the turgescence and the sensibility of the clitoris, inasmuch as the blood that is driven out of the vessels of the vaginal wall passes thence to those of the vaginal bulbs and the clitoris. On the other hand, the turgescence and the sensitiveness of the glans penis itself are heightened by compression of that organ, in consequence of the ever increasing fulness of the vessels of the vaginal mucous membrane and the two vaginal bulbs.

“At the same time the clitoris is pressed downward by the anterior portion of the compressor muscle, so that it is brought into contact with the dorsal surface of the glans and of the body of the penis; in this way a reciprocal friction between these two organs takes place, repeated at each copulatory movement made by the two parties to the action, until at length the voluptuous sensation rises to its highest intensity and culminates in the sexual orgasm, marked in the male by the ejaculation of the seminal fluid, and in the female by the aspiration of that fluid into the gaping external orifice of the cervical canal; so true, indeed, is this, that it is a difficult matter to give a picture at once accurate and complete of the phenomena attending the normal act of copulation. Whilst in one individual the sense of sexual pleasure amounts to no more than a barely perceptible titillation, in another that sense reaches the acme of both mental and physical exaltation.

“Between these two extremes we meet with innumerable states of transition. In cases of intense exaltation, various pathological symptoms make themselves manifest, such as quickening of the general circulation, and violent pulsation of the arteries; the venous blood, being retained in the larger vessels by general muscular contractions, leads to an increased warmth of the body; and further, this venous stagnation, which is still more marked in the brain in consequence of the contraction of the cervical muscles and the backward flexion of the neck, may cause cerebral congestion, during which the consciousness and all mental manifestations are momentarily in abeyance. The eyes, reddened by injection of the conjunctiva, become fixed, and the expression becomes vacant; lids close conclusively, 289to exclude the light. In some, the breathing becomes panting and labouring; but in others, it is temporarily suspended, in consequence of laryngeal spasm, and the air, after being pent up for a time in the lungs, is finally forcibly expelled, and they utter incoherent and incomprehensible words.”

The impulses proceeding from the congested nerve-centres are confused. There is an indescribable disorder both of motion and of sensation, the extremities are affected with convulsive twitchings, and may be either moved in various directions or extended straight and stiff; the jaws are pressed together so that the teeth grind against each other; and certain individuals are affected by erotic delirium to such as an extent that they will seize the unguarded shoulder, for instance, of their partner in the sexual act, and bite it till the blood flows.

A period of exhaustion follows, which is the more intense in proportion to the intensity of the preceding excitement. The sudden fatigue, the general sense of weakness, and the inclination to sleep, which habitually affect the male after the act of intercourse, are in part to be ascribed to the loss of semen; for in the female, however energetic the part she may have played in the sexual act, a mere transient fatigue is observed, much less in degree than that which affects the male, and permitting far sooner of a repetition of the act. “Triste est omne animal post coitum, praeter mulierem gallumque,” wrote Galen, and the axiom is essentially true, at any rate so far as the human species is concerned.

The question has been mooted, and many earnest inquirers have devoted much thought thereto, whether in this moment of most intense sexual gratification it is the male or the female that experiences the greatest amount of pleasure. As in the case of all questions the data for the solution of which are at once very various and very variable, so in this case also, very different opinions have been put forward. “In fact,” writes Roubaud, “when we take into consideration all the circumstances by which the intensity of sexual sensation is influenced, it may well be doubted if it is at all possible to find an a priori solution for the problem. When we take into consideration the influence exercised by temperament, constitution, and a large number of conditions both general and special, on sexual sensibility, we cannot fail to be convinced that this problem, in consequence of all the complicated characteristics it presents, is actually insoluble.”

In regard to the pleasure experienced in the act of intercourse, a remarkable distinction is drawn by Gutceit. The male, in every case and with every woman, experiences the full degree of pleasure; and even though from the mental point of view this pleasure may be enhanced by inclination, attraction, and mutual love, from the 290physical point of view there is no difference between different acts of intercourse, so that the cynical old Roman was right when he wrote. “Sublata lucerna nullum discrimen inter foeminas.” But in the case of the female it is very different. Her first experience of sexual relations is a very painful one, and this pain prevents all enjoyment as long as it continues, as it does in many women for one, two, or even four weeks. And when this period is once over, not more than two women in every ten experience the pleasure of sexual intercourse in its full intensity. Of the remaining eight, four have indeed an agreeable sensation during the rubbing movements of the sexual act, but it is a long time before they experience a sensation analogous in its intensity to that which in man accompanies the act of ejaculation. In some women it may be six months after marriage before the true sexual orgasm is experienced, in others it may be a year, or even several years; in a considerable number this does not happen until after they have given birth to several children. As a result of numerous observations on this point, Gutceit asserts that in women sexual pleasure is experienced only in intercourse with a man who is beloved, or against whom, at least, no repulsion is felt; and that no pleasure is felt by a woman in intercourse with a man towards whom she feels an actual dislike. Further, he maintains, that a woman, loving another man, and feeling pleasure in intercourse with him, has on the other hand no voluptuous sensations during intercourse with her husband, whose embraces she permits only from a sense of duty. Thus in the male, intercourse is always pleasurable, while in the female, pleasure is experienced only when certain conditions are fulfilled.

Contact with the male genital organs stimulates in the female the sensory nerves of the vulva, the vestibule, and the vagina; the nervous stimulus is transmitted to the cerebral cortex, where it gives rise to the sensation of sexual pleasure, and causes, through the intermediation of the genito-spinal centre, a number of reflex actions. As sensory nerve terminals of such reflex arcs, the final ramifications of the pudic branch of the sciatic plexus play the most important part; in the clitoris these nerves are beset with a peculiar kind of end-bulbs, the genital corpuscles discovered by W. Krause; from their structure these corpuscles seem admirably adapted to respond to the very slightest stimulation, producing voluptuous sensations and perceptions, and giving rise to various reflex manifestations. The first part of the path of the afferent impulses by which sexual pleasure is aroused is constituted by the dorsal nerves of the clitoris. The reflex changes consequent upon sexual excitement begin already in the vestibule, inasmuch as the secretion of Bartholin’s glands, which are compressed by the action of the 291constrictor cunni muscle, is expelled during coitus, the secretion, owing to the situation of the orifices of Bartholin’s ducts, passing over the external genitals. The clitoris becomes erect; the blood in the bulbs of the vestibule, the venous plexus situated around the margin of the vestibule along the boundary between the labia majora and the labia minora, is pressed into the glans clitoridis, the erection and sensibility of this structure being proportionately heightened. By the action of the constrictor cunni and ischiocavernosus muscles, the clitoris, the distal extremity of which is bent downwards at a right angle, is drawn down and pressed against the penis.

At the entrance of the vagina is the sphincter vaginæ muscle, whose action is reinforced by muscular fibres running in the middle coat of the vagina itself. It is probable that the muscular activity of the vagina and the uterus facilitates the entrance of the semen into the cavity of the uterus.

Dorsal decubitus is rightly regarded as the most correct position, physiologically speaking, for the woman to assume during coitus. That from the earliest times and in the most diverse races, this position has been customary, is shown by numerous antique paintings and statues, and by the reports of those who have studied the customs of savage races. Various other positions are, however, occasionally assumed; thus, Ploss and Bartels report, that among the Soudanese, coitus is practiced in the erect posture, with the man standing behind the woman; that among the Inuits (Eskimo), the act is performed in the manner usual among quadrupeds; that among the Swahelis in Zanzibar, and among the indigens of Kamschatka, the lateral posture is customary; and that among the Australian blacks, coitus is usually effected in the crouching posture, both parties squatting on their hams. The same writers remind us, that in the old calendars of the fifteenth, sixteenth, seventeenth, and eighteenth centuries, definite commands and prohibitions for the conduct of marital intercourse are to be found, and that lucky and unlucky days, respectively, are specified for the performance of the act. These recommendations would appear to be relics of antiquity, for in the Sanscrit work Kokkogam, under the heading “Sexual Intercourse According to the Days of the Month,” exact instructions are given for the proper performance of coitus.

In the Kamasutra (the Indian ars amatoria, a work only in recent days rendered accessible to European readers in the translation of R. Schmidt), several chapters are devoted to the detailed description of the various methods of copulation, and rules are given for the carnal union of man and wife. But, as the Indian 292author justly remarks, “Rules are of value only for the control of moderate desire; when the wheel of passion has once begun to roll, to prescribe a course is no longer of any avail.” In this work, sixty-four varieties of erotic enjoyment are enumerated, and we find an explicatio coitus secundum mensuram, tempus, naturam, de modis inter coitum procumbendi, de minis coitibus, de coitu inverso, de viri inter coitum consuetudinibus.

At times, in order that coitus may be effective, some other position than the natural one is indispensable. Such a necessity has been recognized even by theologians, by whom any divergence from nature in this matter has usually been regarded as sinful. For instance, in the work of Craisson, De Rebus Venereis ad Usum Confessariorum, we read: “Situs naturalis est ut mulier sit succuba et vir incubus, hic enim modus aptior est effusionis seminis virilis et receptioni in vas femineum ad prolem procreandum. Unde si coitus aliter fiat, nempe sedendo, stando, de latere, vel praepostere (more pecudum), vel si vir sit succubus et mulier incuba, innaturalis est.... Sed tamen minime peccant conjuges si ex justa causa situm mutent, nempe ob aegritudinem, vel viri pinquetudinem, vel ob periculum abortus; quandoque ait St. Thomas, sine peccato esse potest quando dispositio corporis alium modum non patitur.”

In certain pathological states, as for the prevention of sterility, an abnormal posture during coitus may advantageously be recommended, in order to favour the entrance of the semen into the cervical canal, and to allow the semen to stay longer in the vagina before it flows out. An old and often efficacious means for this purpose is the performance of coitus with the woman in the knee-elbow posture. In order to favour the entrance of the semen into the deeper portion of the genital tract, Hegar and Kaltenbach recommend that after coitus the woman should remain for some time in the knee-elbow posture, while the man from time to time gently presses up the anterior abdominal wall, and then abruptly relaxes the pressure.—In the Talmud, coitus was regarded as unfruitful if performed when the woman was in the erect posture.

Casper reports the case of a woman with severe scoliosis, who had long remained sterile, and who only conceived (and was subsequently happily delivered) after performing coitus in the abdominal decubitus.

Guéneau de Mussy suggests the following, very characteristic, method of ensuring fertilization, one which also certainly dates from great antiquity: “Sed haud illicitum mihi visum est, si post diversa tentamina diutius uxor infecunda manserit, ipsum maritum digitum post coitum in vaginam immittere, et ita receptum semen uteri osteo admovere. Et cum ostiolo uteri haeret, ut in pervium 293canalem spermatozoidum motibus faventibus, prodeat, sperare non absurdum.” Eustache reports a case, the wife of a physician, in which this manoeuvre was effective in ensuring conception.

A similar procedure has been employed with success by Kehrer, in a case of enfeebled potency on the part of the male, leading to premature ejaculation. A speculum was introduced into the vagina, and through this instrument the semen, ejaculated in consequence of sexual excitement, was introduced into the vaginal fornix; conception ensued. In an analogous manner, A. Peyer recommended, in a case of partial impotence, in which special manipulations were needed to bring about ejaculation, that conception should be favoured in the following manner: Erection having been effected by ordinary sexual contact, the manipulations needed to produce ejaculation were carried out, and the penis was intromitted into the vagina the moment before ejaculation occurred. This has been done with fruitful results. Englisch reports the case of a hypospadiac who, in order to render coitus effective, used a condom in the anterior extremity of which he made an aperture. In this way he became the father of three children.

In very obese men with extremely protuberant abdomens, we may recommend for the furtherance of conception that they should have intercourse with their wives a parte posteriori; and the same recommendation may be made in cases in which the wife herself is extremely obese. In Australia, it is said that among the indigens, coitus is usually practiced a posteriori; and there is a saying in the Talmud to the effect that sexual intercourse performed in the ordinary manner does not lead to the conception of infants so good, wise, talented, and promising as those whose conception is the result of coitus a posteriori. Mohammed, on the other hand, declares, “Your wives are your tillage, go therefore unto it in whatsoever manner ye will.”

In cases of retroflexion of the uterus, with a markedly forward direction of the vaginal portion of the cervix, I have recommended to the husband that he should perform coitus with his wife in the upright sitting posture. In this posture the fundus uteri passes downwards and forwards, whilst the vaginal portion of the cervix passes upwards and backwards.

In cases of retroversion of the uterus with the formation of a cul-de-sac in the posterior vaginal fornix, Pajot recommends, with the aim of temporarily restoring the uterus to a position in which the occurrence of conception is favored, that for three or four days prior to coitus the patient should retain the fæces, eating the while freely of eggs and rice, and taking a small opium pill every evening; in cases of anteversion, the patient should retain her urine for 294a considerable time—five or six hours—before coitus; and in cases of lateral version he recommends that the patient should have intercourse while lying on that side towards which the vaginal portion of the cervix is directed.

Edis recommends that in cases in which there is sterility dependent upon backward displacements of the uterus, that the organ should be replaced while the patient is in the genu-pectoral posture, and a pessary inserted; coitus should then be effected without the patient’s changing her posture.

In the human species as compared with the lower animals, there has been a notable diminution in the frequency of the separate acts of intercourse, a diminution dependent upon the higher vital aims of the former. Burdach formulates as a physiological law that the frequency of sexual intercourse is inversely related to the duration of the act.

Amongst all civilized races, sexual intercourse ceases during menstruation, since in the normal man there is aversion to intercourse with a menstruating female.

By the Mosaic law, intercourse with a woman during menstruation and for seven days after the cessation of the flow, was forbidden under pain of death. The Talmud further ordains that a purifying bath shall be taken by the woman a week after menstruation. By intercourse itself, moreover, both man and woman were rendered unclean to the evening; and, according to the Mosaic law, both must bathe after the act of coitus. In the Koran, also, intercourse is forbidden during menstruation, and until the woman has been purified with water. The law’s of Islam demand from a man who marries a virgin that he shall have intercourse with her the first seven nights in succession; whilst he who marries a wife no longer virgin, needs to visit her only the first three nights in succession. Subsequently, during married life, the Mohammedan shall have intercourse with his wife regularly once a week. Amongst many savage races, intercourse is forbidden with a woman during pregnancy, the puerperium, and lactation.

The first act of intercourse is difficult and painful to the virgin. At times the rupture of the hymen is exceedingly difficult. Even after this, it is some time before genuine pleasure is experienced in sexual intercourse.

To the female, intercourse is harmful when performed with undue frequency, or during menstruation, or indiscriminately throughout pregnancy, or during the puerperium, or incompletely or in an unnatural manner, or finally when performed in an unsuitable bodily attitude.

“Unduly frequent performance of the act of coitus,” writes Hegar, “which is liable to occur either in marital or in illicit intercourse, 295gives rise to anæmia, defective nutrition, muscular weakness, intellectual and nervous exhaustion. Young and healthy individuals recuperate rapidly after excesses of brief duration, as is often seen in young married pairs. Sickly and elderly persons, on the other hand, are much more severely affected by sexual excess, and recover therefrom but slowly if at all. Long continued sexual excesses ultimately wear out even the strongest.”

Intercourse effected by force, or with a girl of immature age, is distinguished as rape, a punishable offence both in Germany and in Austria. The offence is defined as extra-marital intercourse with a female under the age of fourteen years, with or without the latter’s consent; or extra-marital intercourse with a female of any age against her will or deprived of the power of resistance—either by the use of actual force, by the employment of threats, or by loss of consciousness. With regard to the last specification, the law regards as rape intercourse with a woman unable to resist through loss of consciousness, whether that loss of consciousness is or is not produced by the direct action of the violator.

In the female, the act of intercourse, alike physically, in its natural consequences, and mentally, is at once more difficult and of more enduring results than in the male. A writer of the new school, who according to his own admission has no other interest than the study of the sexual life, writes of himself: “I have often enough had intercourse with members of the other sex, in a few cases, indeed, out of pure inclination; but in all cases alike the aim and the result were the same—as soon as I had gained my end, the affair was finished. Passion, a bestial act, exhaustion, commonly a feeling of loathing; in the best possible case a fugitive but not an agreeable memory; voilà tout.” To women, such a description, happily, is applicable only in the most exceptional cases.

With the completion of coitus, the voluntary and conscious action of the two parties to the act is at an end; the subsequent stages of the function of generation are independent alike of consciousness and will.

When complete intromission of the penis has been effected, and ejaculation takes place, the semen is usually deposited at the os uteri or in the immediate neighborhood of that orifice. During the act of ejaculation, a peristaltic contraction of the vagina occurs, by means of which the semen at the os uteri is subjected to a moderate degree of pressure; the contraction and the pressure may perhaps persist for some little time after the completion of the coitus. In rabbits on heat, such contractions of the vagina, by means of which the semen was forced under pressure into the interior of the uterus, have been actually observed.

During coitus, the uterine muscle is also active. During strong 296sexual excitement, the uterus descends in the pelvis, the downward movement being increased by the pressure on the woman’s abdomen. The os uteri externum is drawn open, and the aperture, hitherto flattened, now becomes rounded. At the same time, the secretion of the cervical glands is expelled, and small quantities of semen are sucked into the cervical canal. The plicae palmatae offer a certain hindrance to the entrance of the semen; but the surface of the interior of the canal is rendered much smoother by the free secretion of mucus by the cervical glands. Further, it appears highly probable that during the excitement of coitus, the mouths of the Fallopian tubes, ordinarily more or less tightly closed, become widely opened, so that the entrance of the spermatozoa is favored.

The muscular movements of the uterus were observed by J. Beck in a woman suffering from prolapse. During sexual excitement, the os uteri opened and closed rapidly five or six times in succession, remaining at last firmly closed. Further, in bitches on heat, Basch and Hoffmann observed the vaginal portion of the cervix to descend in the vagina, the os uteri opened, mucus was extruded, and the os was then retracted.

Hohl, Litzmann, and others have reported, that in women endowed with great nervous susceptibility, friction of the vaginal portion of the cervix with the finger arouses sexual sensation, with rounding of the os uteri externum, descent of the uterus, and hardening of the vaginal portion; this latter is regarded by Graily Hewitt and by Wernich as a necessary accompaniment of copulation. Henle believes that the hardening and protrusion of the vaginal portion of the cervix are due to a change in the tension of the delicate vessels of this structure, which have an exceptionally thick muscular coat; Rouget compares the mechanism with that by which erection of the penis is produced. These authors consider that sexual excitement is indispensable for the erection of the vaginal portion of the cervix.

Thus, Hohl writes: “Numerous observations have shown that in females endowed with a considerable degree of nervous susceptibility, and especially in nulliparae, during examination and during any increasing irritation, not only is there an increased secretion of the vaginal mucus, but also a momentary descent of the uterus and an opening of the os uteri externum, so that this orifice has the appearance for the instant of the open mouth of a tube.” Litzmann reports that during the vaginal examination of a young, extremely erethistic woman, the uterus suddenly assumed a more vertical position, and came lower down in the pelvis; at the same time, the lips of the cervix became equal in length, the os uteri externum became rounded, soft, and penetrable by the finger; 297whilst the breathing and the voice indicated the occurrence of intense sexual excitement. Rouget assumes that the body and the fundus of the uterus constitute an erectile organ, which however possesses capability for erection only during the period of ovulation; Hewitt, on the other hand, considers it extremely probable that the erection may occur at any time during sexual intercourse, whether ovulation is proceeding or not. A. Wernich considers, basing his views in part on personal observations, that erection of the lower segment of the uterus occurs, like erection of the penis, whenever a moderate degree of sexual excitement is experienced; in women, however, he believes that erection is seldom extreme, and that it declines with the other symptoms of sexual excitement, viz., flushing of the face, moisture and glistening of the eyes, peculiar groaning expiration, etc. Whereas during ovulation, erection is merely a necessary concomitant of the other menstrual processes; during coitus, erection not only occurs much more powerfully, but it is also an important—perhaps the most important—contributory factor in effecting fertilization.

It is no longer possible to accept the view of earlier physiologists that the purpose of this erection of the lower segment of the uterus is “to constitute with the penis a continuous canal between the male and the female genital organs.” Contact between the glans penis and the os uteri externum is not indeed an occurrence of extreme rarity; but, on the other hand, it is in no sense a constant nor even a frequent incident of sexual intercourse. It is ejaculation, especially, which is subserved by the erection of the vaginal portion of the cervix. In the female, ejaculation occurs at the moment of the most intense sexual pleasure, and is marked by the evacuation from the os uteri externum of a moderate quantity of mucous fluid with an alkaline reaction. In some cases, in which a chronic discharge of this cervical mucus occurs, it forms an elongated coagulum of delicate vitreous jelly, the “mucus-string” of Kristeller. The last-mentioned author is of opinion that the spermatozoa slowly, but by active movements, find their way along this string into the cavity of the uterus. This assumption, however, is met by C. Mayer and Marion Sims with the objection, that Kristeller’s observations were for the most part carried out on women who were out of health, and that a gelatinous secretion of this character obstructs the orifice of the cervical canal, and hinders the occurrence of conception. From the erection of the portio vaginalis during sexual excitement, and its sudden relaxation post cohabitationem, Wernich deduces the occurrence of a process of aspiration, by which the semen is drawn up through the cervical canal into the cavity of the uterus; a process which has been seen 298in actual occurrence in vivisected animals. It is said that to many women this feeling of a process of suction is so well known, that thereon, in association with the consequent almost complete absence of mucus and seminal fluid from the vagina, they are accustomed to base a belief that conception will occur. It is said that this aspiratory activity on the part of the uterus may be perceived during coitus by the male also (?). It is assumed by Grohe that the wave motion of the cilia of the epithelium lining the cervical canal, is of importance in promoting the ascent of the spermatozoa; it may be that the vibration of the cilia exercises a motile stimulus on the spermatozoa, it may be that the continually repeated stroke of the cilia serves to prevent the permanent agglutination of the spermatozoa into groups.

According to Sims, the aspiratory action of the uterus is effected in the following manner: By the contraction of the constrictor vaginae superior muscle, the cervix is pressed downwards against the glans penis, and by this pressure its contents are evacuated; the parts then relax, the uterus suddenly returns to its normal state, and thus the seminal fluid with which the vagina is filled is drawn into the interior of the cervical canal.

Eichstadt also attributes to the uterus an aspiratory force, dependent upon coitus, and competent to force into the interior of the uterus the semen ejaculated into the os uteri. The changes in the uterus which are the necessary antecedents of this aspiration, namely, an engorgement with blood whereby the flattened form of the uterus gives place to a more rounded form, and the cavity of the organ is increased in capacity, take place, in the opinion of this author, only when during intercourse the woman has attained the acme of sexual gratification, by which alone can the aforesaid change in the uterus be brought about. E. Martin and Chrobak have also directed attention to the fact, that some importance in this connexion must be attached to the facultative enlargement in the size of the os uteri externum.

Lott, by his researches into the behaviour of the cervix uteri in relation to the act of conception, is led to the conclusion that the locomotive capacity of the spermatozoa forms the principal factor in effecting a fertilizing contact between the spermatozoa and the ovum. This locomotive capacity may be increased or diminished by a number of conditions, among which the principal are: the activity of the cervix uteri (the ciliated epithelium); the character of the secretions; and the position, shape, and size of the cervix. 299Thus, this author concludes, the part played in conception by the normal cervical canal is a purely passive one, with the sole exception of the activity of the ciliated epithelium—and the influence of this factor must be regarded as extremely doubtful. That during ejaculation the external orifice of the male urethra and the os uteri externum are in close apposition, is denied by Lott, who adduces in support of his views data derived from comparative investigations on various animals. In the dog, the configuration of the genital organs is such that it is impossible to suppose that any apposition can occur; the same is the case with the sheep; and still more so with the rabbit, who possesses two quite distinct portions vaginales, projecting freely into the vagina. In the human species also, the character of the walls of the cervical canal, where in the normal state the plicae palmatae may almost be said to interlock, separated only by a thin stratum of mucus, offers a hindrance to the entrance of the ejaculated semen by the direct force of ejaculation itself. As regards the independent motile powers of the spermatozoa, the researches of Lott showed that not only can they overcome strong capillary currents, and can traverse the width of a coverglass (18mm.—about ¾ in.) in about five minutes; but further that they are capable of migration through the finest interstices (those of an animal membrane) provided that the fluid with which the membrane is moistened is one favourable to their vital activity.

Kehrer, who in general supports the view that the modus coeundi and an active attitude on the part of the female have an important influence on the occurrence of conception, assumes that independent contractions of the cervix occur, whereby is expelled the delicate plug of mucus that fills the cervical canal and offers an obstacle to the passage of the spermatozoa. He believes that the duration of the act of intercourse, the mechanical relations between the penis and the vagina, the activity of the uterine muscle, the secretory activity of the utero-vaginal mucosa during the act, and the posture of the female post coitum, are all important factors in the occurrence of conception. Thus, he believes that if during intercourse there is a failure of the uterine contractions, which should expel the plug of cervical mucus, the semen flows away without effecting fertilization; if an unsuitable posture is assumed during intercourse the woman remains sterile, but can be fertilized without difficulty by coitus effected in the proper manner.

Haussmann has shown, that in the same woman, and in similar conditions, spermatozoa will on one occasion be found in the cervical 300canal, and on another occasion will not be found there; and he has further shown, that in some women we fail to find spermatozoa in the cervical canal in circumstances in which, in other women, we regularly find them in that situation.

Far as we may be from a complete knowledge of the conditions upon which conception depends, this at least is certain, that the passage of spermatozoa through the os uteri externum is a sine qua non of fertilization. Indeed, it would seem that we must accept as true the assumption of Meyerhofer, that fertilization is possible only if the semen passes at once into the cervical canal, mingles, that is, at once with the alkaline cervical mucus—unless, indeed, the coitus takes place during the catamenial flow, when the blood has neutralized the acid reaction in the vagina, or takes place when some morbid condition has had the same result. The theory of Johann Müller, regarding the piston-like action of the penis during coitus, by which the semen is actually forced through the cervix, must be rejected; equally unsound is Holst’s assumption that during intercourse the semen is ejaculated through the enlarged cervical canal directly into the cavity of the uterus. It would appear, however, to be a necessary condition of fertilization, that the semen should be ejaculated into the uppermost segment of the vagina, so that the fluid comes into actual contact with the os uteri externum; it may be that the alleged aspiratory force of the uterus then comes into play, by means of which the semen is sucked into the cavity of that organ; it may be, on the other hand, that Beigel is right in his theory of the existence of a receptaculum seminis, formed by the anterior and posterior lips of the cervix uteri and the uppermost segment of the vagina—in this space, he supposes, a part of the semen is retained in contact with the orifice of the cervical canal.

It is, also, exceedingly probable that during coitus a reflex nervous mechanism becomes active, by means of which the uterine orifices of the Fallopian tubes are opened, the vaginal portion of the cervix descends in the vagina, the os uteri externum enlarges, the orifice becoming rounded where before it was flattened, and finally small quantities of semen may be aspirated into the cavity of the uterus.

I further regard it as important in promoting conception, that simultaneously with the changes above described, the reflex nervous stimulation should lead to the secretion by the cervical glands of a gelatinous material, alkaline in reaction, and therefore adapted 301to increase the locomotive powers of the spermatozoa, so that these latter, aided by the activity of the ciliated epithelium lining the cervical canal, will gain the interior of the cavity of the uterus, and thence pass onwards to the Fallopian tubes. The significance of the glands in the mucous membrane lining the cervical canal has hitherto been underestimated in this connexion.

Whereas in the primitive state of mankind, among savage races at the present day, as among our own prehistoric ancestry, nakedness is the rule, so also intercourse in these circumstances is effected altogether without any regulation by law or custom, on the mere prompting of unbridled natural passion, and, moreover, there is the fullest promiscuity in sexual relations; but civilization has led man to impose restraints upon sexual intercourse, and has introduced marriage as a sacred institution. Among certain primitive peoples, however, among whom the wives are common to all the men, transitory pairings nevertheless occur, especially when a woman becomes pregnant; to cease, however, during the period of lactation. “This is the origin of marriage, which has evolved from rape and prostitution, as law has evolved from crime” (Lombroso). This author makes an interesting observation when describing the entire freedom of sexual intercourse that obtains among the Red Indians of North America, to the effect that “often, times of general promiscuity occur, as with rutting animals, generally in the warm season of the year, when nutriment is abundant; it is difficult to indicate any distinction between the tumultuous orgies of the baboon, and those of the Australian Blackfellows, among whom the sexes keep apart during the greater part of the year, to intermingle like rutting beasts during the season of the yam-harvest.”

The paths of civilization, from the complete promiscuity of sexual intercourse to the lofty ideal of life-long monogamic union, has not been a straightforward one, but has been marked by various aberrations of sexual relationship; hetairism, prostitution, polyandry, incest, rape, the jus primae noctis, etc. The anthropologist is able to trace the successive stages of the development of the institution of monogamic marriage; the community of wives within the clan; free sale of wives and daughters; bestowal of a man’s wife or concubine for the honour of a guest; ritual prostitution for the honour of the gods and at numerous religious festivals; æsthetic and literary hetairism, with bestowal of favours according to free inclination; community of wives among all males of the same family; the 302claim of the wife to as many as five or six husbands; the right of brothers to their sisters; the defloration of virgins by the priests in heathen temples; the temporary possession of the wife by the chief of the community, prior to her possession by her permanent husband; defloration of the bride by the bonze before her marriage; the feudal right of the mediæval seigneur to the prima nox of the bride of his retainer.

In the lower stages of civilization, copulation appears so natural an action that it is performed in public entirely without shame. Thus, Cook, in his first voyage, describes having seen an indigen engage in sexual intercourse with a girl of eleven years, under the very eyes of the queen, with whom Cook was then having audience; the sexual act was, according to Cook, the favourite topic of conversation between the sexes. Herodotus reports that many peoples of antiquity had no regard for privacy in sexual intercourse, but that, like the lower animals, they had connexion in any company. In the Bible, also, it is recorded that sexual intercourse was practised in public: “So they spread Absalom a tent upon the top of the house; and Absalom went in unto his father’s concubines in the sight of all Israel.” (II. Samuel, XVI. 22.) According to Athenaeus, the Etruscans, at their public banquets, were equally unrestrained. Plutarch reports that among the Spartans the maidens and the young men went about naked together. Even, indeed, after the sense of modesty had begun to develop, it was long before any secret was made about the act of intercourse. In classical antiquity, it was very frequently the subject of pictorial and plastic representation. Even in more recent days, there have been artists who have not hesitated to depict the sexual act: thus we have the Venus with a Faun by Caracci; the Jupiter and Io of Correggio; the Leda and the Swan of Tintoretto; and similar pictures by Luca Giordano, Rubens, Titian, and Franceschini.

Even in the early centuries of the Christian era, the sect of the Adamites practised intercourse openly in the light of day, on the ground that that which was right in the dark, could not be wrong in the light. The same is reported of the sect of Turlupins, in France in the fourteenth century. We cannot refrain from quoting at length from Lombroso and Ferrero a passage relating to the evolution of sexual manners in the female sex (Woman as Criminal and Prostitute): “In the lowest stages of development, the feeling of modesty is entirely wanting; limitless freedom in sexual intercourse is the general rule; and even where no system of 303promiscuity prevails, marriage rather fosters than discourages prostitution, especially in countries in which husbands are accustomed to expose their wives for sale. This fact may be brought into relation with the well known lasciviousness of apes and other animals high in the scale, showing that sexual excitability increases pari passu with intelligence, so that to man it is as impossible as to an ape to satisfy his sexual needs with a single female. Whilst among the apes, a single male possesses a number of wives, we find in the gregarious life of primitive man that community of wives has taken the place of polygamy, which institution, however, reappears in a higher stage of culture for the benefit of the more powerful masculine natures.

“To the dominion of prostitution as a normal institution succeeds the period in which it persists as a variously metamorphosed survival: it may be as the duty of the wife to surrender her person to any other male of the same family; or the woman may have to bestow her favors on a religious or political chief, as in the institution of temple-prostitution, where the wife must give herself, it may be to any one and at any time, or it may be to defined persons only and at stated festivals. Frequently we meet with another development of prostitution, finding that while the wife must remain chaste, the unmarried woman is allowed unrestricted intercourse; or, again, the wife at certain definite periods may dispense with fidelity to her husband, and return to the primitive condition of promiscuity. In certain instances prostitution is combined with the duties of hospitality, and marriage, though approximating to the monogamic ideal, must tolerate the intrusion of the guest into the marriage bed.”

“In a third period, prostitution no longer fills the place of a traditional survival, but is a morbid manifestation confined to a certain class of the community. But bridging this transition of prostitution from a normal to a morbid manifestation, we have the remarkable phenomenon of æsthetic prostitution. Thus, in India and in Japan, an agreeable class of prostitutes practices the arts of singing and dancing, and forms a privileged caste; similarly, in the most flourishing period of Grecian culture, the leading men of the time formed a social circle around the hetairæ, from whom they derived a fruitful stimulus to intellectual and political activity. In this respect, history repeated itself in Italy in the sixteenth century. Alike in classical Greece and in mediæval Italy, this æsthetic prostitution fanned the flames of a period of intense spiritual activity—for 304in individuals as in races, intellectual quickening is ever accompanied by erotic excitability.”

The unbridled passion of the primitive races of mankind, the coercive love of beauty felt by the ancient Greeks, the swelling flood of erotism of the great mass of people of all times, is gradually guided into the quiet channel of the marriage bed; and even though monogamic marriage is incapable of fully providing for all manifestations of sexual passion, still, from the medical point of view, we must maintain that marriage is for women the most hygienic and the most proper means of gratification of the sexual impulse.

Conception.

The union between ovum and spermatozoön, whereby fertilization is effected, appears to occur in the human species as a rule in the outer third of the Fallopian tube, the ampulla of this structure (receptaculum seminis in Henle’s terminology) serving to store the semen for a considerable period; in the lower animals, the usual occurrence of fertilization in this region has been established by direct observation. The open mouth of the tube receives the mature ovum, guided thither from the ovary by appropriate movements of the ovarian fimbriae; these movements have been seen in active occurrence in the guinea pig by Hensen. Once within the tube, the onward movement of the ovum is effected by the cilia of the epithelium lining of the canal.

His has formulated the theory that in the human species fertilization is possible only in the uppermost segment of the tube; an assumption that is probable enough, but cannot be regarded as definitely established. An analogy certainly exists among the lower divisions of the animal kingdom, for Coste, His, and Ohlschläger have proved that an ovum which passes through the Fallopian tube without being fertilized, undergoes notable alterations. Further, Coste has shown, in the case of the ovum of the domestic fowl, that this is no longer capable of being fertilized after it has passed through the upper segment of the oviduct. Other authorities, however, namely Löwenthal, Mayrhofer, and Wyder, oppose the extension of this rule to the human species. Löwenthal assumes that in the human female, fertilization ordinarily occurs in the cavity of the uterus, in the wall of which the unfertilized ovum has already embedded itself; and he supports his contention by the statement that spermatozoa are not to be found in the Fallopian tubes or on the surface of the ovaries. Mayrhofer and Wyder point out that 305the movement of the cilia of the ciliated epithelium is in the interior of the uterus in an upward direction, but in the Fallopian tubes is downwards in the direction of the uterus.

The contention of Löwenthal was disproved by Birch and Hirschfeld, who, in a prostitute dying during the act of intercourse, found, fifteen hours after death, living spermatozoa in the Fallopian tubes. On the other hand, more recent investigations, those, for instance, of Hofmeier, Mandl, and Bonn, have confirmed the data given above with regard to the direction of the ciliary movement in the interior of the genital passages. Moreover, O. Becker has shown that the ciliated epithelium of the tubes extends over the fimbriae and even on to the adjoining pavement epithelium of the peritoneum; and he believes that the ciliary movement of this region keeps up a constant current, the purpose of which is to sweep the ovum into the ostium of the tube, and thence down towards the uterus. Lode has adduced positive experimental evidence of the occurrence of such a movement of translation.

The general result of anatomical investigation is, that the conjugation of the ovum with the spermatozoön takes places in the ampulla of the Fallopian tube; but it is established that fertilization may also take place lower down in the tubes, or in the uterine cavity, or even on the surface of the ovary, i. e., in the abdominal cavity.

The fertilization of the mature ovum—maturation having occurred within the ovarian follicle before its rupture—has been shown by numerous researches on the ova of other animals to consist in the fusion of the male and the female nuclear substance; and it appears that of the enormous number of spermatozoa, estimated by Lode at 226 million at a single ejaculation, that enter the female genital passage, but a single one penetrates the ovum. Towards the head of this spermatozoön there extends from the surface of the ovum a process, flat at first, but becoming more and more prominent, until it surrounds the head, and fuses with it. The motile tail of the spermatozoön disappears, whilst the head, which has now passed through the vitelline membrane and entered the ovum, assumes the appearance of a nucleus, and is called the male pro-nucleus. The original nucleus of the ovum has previously prepared itself for fertilization by the extrusion through the vitelline membrane of portions of its substance (known as polar globules), and now constitutes the female pro-nucleus. Towards this latter, situated somewhere near the centre of the cell, the male pro-nucleus continues to move, the vitelline granules meanwhile being disposed 306round about it in radiating lines, forming a star-shaped figure. Having come into contact, the two pronuclei fuse completely to form a new nucleus, the nucleus of the now fertilized egg-cell. The result of fertilization is the formation of the first segmentation-sphere, from which, by further subdivision, the new individual is formed. Thus is effected that which Hippocrates describes in the words: “The seed possessed both by man and by woman, flow together from all parts of the body; the fruit is formed by the mingling of the two seeds.”

Fig. 55A.—First Stage.       Fig. 55B.—Second Stage.

Entrance of a spermatozoon into the ovum of ascaris megalocephala. After preparations by M. Nussbaum. (Half of the ova only are depicted.)

Fig. 56.—Ovum of Asterakanthion ten minutes after fertilization.

Fig. 57.—Fusion of male pro-nucleus and female pro-nucleus to form the segmentation nucleus of the fertilized ovum.

The most favourable period for the occurrence of fertilization appears to be when intercourse takes places from eight to ten days after the termination of the menstrual flow. In 248 instances in which the date of the fruitful coitus was exactly known, it was ascertained by Hasler that in 82½ per cent. of all cases, conception was effected in the fourteen days succeeding the menstrual period. In general it may be stated that the theory of the periodicity of ovulation and of the causal relation of this process to menstruation, has not been shaken by the result of researches recently undertaken 307by opponents of that theory; hence it appears that the fertilized ovum is the ovum of the last completed menstruation.

Already in the writings of the old Indian physician Susruta, we find expression of the view that the period that immediately succeeds the cessation of the menstrual flow is one most favourable to conception. “The time of generation,” he says, “is the twelfth night after the commencement of menstruation.” In the Jewish Talmud, the day before the onset of menstruation, and the days immediately succeeding the cessation of the flow, are indicated as those most favourable to the occurrence of conception; moreover, in the Talmud, notwithstanding the fact that intercourse during menstruation is prohibited on pain of death, and that coitus is not regarded as permissible until the lapse of twelve clear days after the cessation of the flow, nevertheless the assertion is made that intercourse during menstruation may lead to conception.

Fig. 58. —Passage of spermatozoon through the zona pellucida of the ovum of asterakanthion.

Fig. 59.—Ovum of scorpæna scrofa thirty-five minutes after fertilization.

Fig. 60.—Male pro-nucleus and female pro-nucleus in fertilized ovum of frog, prior to the formation of the segmentation nucleus.

Hippocrates writes: Hae nempe post menstruam purgationem utero concipat. Aristotle says: Plerasque post mensum fluxum nonnullas vero fluentibus adhuc menstruis. Galen writes: Hoc autem conceptionis tempus est vel incipientibus vel cessantibus menstruis.

308Soranus writes to a similar effect: Just as the soil is suitable only at certain seasons for the reception of the seed, so also in the human race intercourse does not always take place at a time suited for the reception of the semen. To be effective, coitus must occur at the proper time.... The act of intercourse that is to lead to conception may best occur either just before or just after the menstrual flow, when, moreover, there is strong desire for the sexual embrace, and neither when the body is fasting, nor when it is full of drink and undigested food. The time before menstruation is, however, unsuitable, for then the womb is heavy from the flow of blood, and two conflicting tendencies will come into operation, one for the absorption of material and the other for its outflow. During menstruation, again, conception is unlikely to occur, for then the semen is wetted and washed away by the flowing blood. The sole proper time is that immediately after the flow, when the womb has freed itself from its humours, and warmth and moisture stand in harmonious relationship.

Among many of the castes of Hindustan, it is a religious ordinance that on the fourth day of menstruation a man shall have intercourse with his wife, “since this day is that on which conception is most likely to occur.” Indian physicians advise, in order to bring about conception, “that coitus be effected always as soon as the menstrual flow has ceased, at the end of the day, and when the lotus has closed.” In Japan, medical opinion is to the effect that a woman is capable of conceiving during the first ten days after menstruation, but not later (Ploss and Bartels).

The view that the first days of the intermenstrual interval are those most favourable to the occurrence of conception, is further confirmed by the statistical data collected by Löwenfeld, Ahlfeld, Hecker, and Veit; and it appears that as the date of the next menstruation is approached, there is a continual decline in the frequency of conception; just before the flow, conception hardly ever occurs. Hensen, from the records of 248 conceptions in which the date of the fruitful intercourse was exactly known, draws the following conclusions:

1. The greatest number of conceptions follow coitus effected during the first days after the cessation of the menstrual flow.

2. When coitus is effected during menstruation, the probability of conception increases day by day as the end of the flow is approached.

3. The number of conceptions following coitus effected shortly before menstruation is minimal.

3094. However, there is no single day either of the menstrual flow or of the intermenstrual interval, on which the possibility of the occurrence of conception can be excluded.

Feokstitow has drawn up from statistical data an ideal “conception-curve,” which teaches that conception most readily ensues upon coitus effected soon after the end of the menstrual flow, in the first week, that is to say, of the intermenstrual interval; moreover, the curve shows that the highest percentage of conceptions occurs on the very first day after the cessation of the flow, and that after this day the percentage of conceptions declines. The percentage frequency of conceptions from coitus effected on the last day of menstruation, and on the first, ninth, eleventh, and twenty-third days, respectively, of the intermenstrual interval, is expressed by the ratio 48 : 62 : 13 : 9 : 1; and between the points given, the course of the curve is almost rectilinear. The probability of the occurrence of conception on the twenty-third day of the interval (on which day the curve reaches its lowest point), is one-sixty-second of the maximum probability.

The proper performance of coitus depends upon the potentia coeundi of the male; the attainment of conception depends upon his potentia generandi. The potentia generandi demands from the man the functional competence of the testicles, the perviousness of the seminal passages (namely, of the vasa deferentia and the urethra), the secretion of a normal semen, and, finally, a proper formation of the penis, whereby during ejaculation the semen may be deposited in sufficient proximity to the os uteri externum.

Normal semen is a whitish, semi-transparent fluid, of the consistency of thin cream. It contains aggregations of a nearly spherical shape, consisting of a vitreous, transparent, colourless or light yellow, gelatinous, elastic substance. Under the microscope this substance has a hyaline appearance, and exhibits in its interior innumerable clear spaces of varying size, which are apparently filled with a clear fluid. Not infrequently, these spaces are extremely narrow and therewith greatly elongated and disposed in parallels, so that the whole substance thus obtains a striated appearance. When treated with water, this material becomes whitish and non-transparent, and assumes under the microscope a finely granular aspect. When allowed to stand without agitation for twenty-four hours, this substance dissolves and becomes so intimately mingled with the seminal fluid that it can no longer be clearly differentiated therefrom. In all probability it is merely a secretory product of the seminal vesicles.

310The truly fluid portion of the semen contains the following morphological elements:

1. Microscopic aggregations of hyaline substance, variously shaped.

2. Very numerous granules, small and extremely pale, albuminous in their nature, and disappearing on treatment with acetic acid.

3. A small number of rounded or oval cells, about the size of leucocytes, containing one, or sometimes two small round nuclei.

4. Prostatic calculi. These are an inconstant constituent, but are very frequently met with after repeated coitus. According to some observers they are derived also from the bladder and urethra. They are distinguished by their yellowish colour, their irregular form (sometimes triangular, sometimes rounded or oval), and by their characteristic structure. They are composed of a substance arranged in concentric laminæ, which in the centre has a granulated appearance; they often exhibit one or more oval nuclei.

5. Spermatozoa in countless numbers.

In exceptional cases we find as additional morphological elements, especially in elderly people, scattered erythrocytes, cylinder-epithelium cells, and masses or granules of yellow pigment.

The spermatozoa are about fifty micromillimetres in length. Two parts may be distinguished in each, a head and a tail. The head, four or five micromillimetres in length, is flattened, and differs in apparent shape—though generally more or less pear-shaped—according as to whether it is seen sideways or on the flat.

The tail, which is about forty-five micromillimetres in length, narrows from before backwards. The fine posterior extremity is said to contain the contractile element, so that it is upon this portion that the familiar movements of the spermatozoa depend (Fig. 61).

The spermatozoa are made up of a substance very rich in sodium chloride, and strongly resistent to reagents and to putrefaction. In consequence of their richness in mineral constituents, the ash, when they are calcined, retains their original form.

The movements of the spermatozoa can be properly observed only in fresh, pure semen (Fig. 62).

If freshly ejaculated semen is treated with water, the movements of the spermatozoa very shortly cease, and their tails become rolled up in a spiral form.

311

Fig. 61.—a. b. c. Prostatic calculi from normal semen. d. Spermatozoa. e. Large and small cells, some containing granules, as morphological elements of semen. f. Spermatozoon distorted by imbibition of water. g. Crystals. (After Bizzozero.)

Fig. 62.—Normal semen.

If semen is left undisturbed for twenty-four hours or longer, the vitreous substance dissolves in the surrounding fluid, and this latter separates into two layers, an upper which is thinner, and a lower, which is thicker and non-transparent. In the former, the morphological elements are found but sparingly, whilst in the latter, they are plentiful. In addition to the elements already described, we find often two varieties of crystals. One of these varieties, which appears only when decomposition is far advanced, consists of ammonium magnesium phosphate. The other variety has a chemical composition not yet determined. These crystals belong to the monoclinic system, forming prisms or pyramids, often with curved surfaces; they are colourless or light yellow; they lie superimposed, 312often forming beautiful star-shaped figures. They are soluble in mineral and vegetable acids, and in ammonia, but are insoluble in alcohol, ether, and chloroform; they are remarkably resistent to the solvent powers of cold water, but not so to those of boiling water. Shreiner has proved that these crystals consist of a phosphate of a base which is represented by the formula C2. H5. N. According to Fürbringer, these crystals are produced as a result of the action of the semen upon the prostatic secretion.

The quantity of semen ejaculated during coitus is very variable, depending upon the age and size of the individual and the formation of his testicles, upon his individual sexual capacity, and upon the question whether antecedently there has been sexual excess on the one hand or long continued continence on the other. In general, the quantity of semen ejaculated at one time varies between 0.75 and 6 c.c. (10 to 100 minims).

If healthy, normal semen, with adequate fertilizing potency, is properly preserved from cold and light, we may, even after the lapse of twenty-four hours, find under the microscope spermatozoa still engaged in active movement. Ultzmann employs for the description of a drop of fresh semen, the comparison that it is full of movement, “like a stirred up ant-heap.” Influenced by the whiplike lashings of the tail, the spermatozoön moves steadily forwards, finding its way through the narrowest passages on the microscopic field without striking any of the cellular structures that may lie in its path. The longer the semen remains under observation, the less active are these movements of the spermatozoa, for after ejaculation they gradually die, exhibiting after death an extended, or at most a slightly curved tail; those spermatozoa, on the other hand, that were dead before ejaculation, have the tail spirally twisted, rolled up, or acutely bent. In the case of spermatozoa which have been destroyed by the action of some other deleterious secretion, as by urine or by acid vaginal secretion, such a condition of the tail is very commonly seen. When the semen is treated with water, the movements of the spermatozoa soon cease, and the ends of their tails frequently roll up to form loops. By the addition, however, of concentrated solutions of neutral salts, of albumen, of urea, etc., it is possible to reanimate these motionless spermatozoa, so that they once more are seen to perform active movements. Moderately concentrated animal secretions of an alkaline reaction are favourable to the motor activity of the spermatozoa, whilst on the other hand dilute and acid secretions, such as urine, acid mucus (including the 313acid vaginal mucus), and catarrhal secretions, even when alkaline in reaction, have a depressant influence on this activity. Caustic potash and caustic soda stimulate the movements of the spermatozoa. When they are cooled down to a temperature below 15° C. (59° F.), the movements cease entirely. Salts of the heavy metals, and mineral acids in solution, also bring their movements to a pause. Frequent repetition of coitus causes a diminution in the number and in the motor activity of the spermatozoa.

Semen which contains no spermatozoa, or in which the spermatozoa are motionless, is absolutely devoid of fertilizing power; in the case of such semen, it makes no difference whatever that the external genitals of the man generating it are strongly formed, that his testicles are of normal size, and that erection and ejaculation take place promptly. Of very little value, though not absolutely sterile, is semen containing very few living spermatozoa, or, among very numerous motionless spermatozoa, containing a few only that are engaged in active movement. Suspect, is semen which does not possess the normal light greyish white tint, but is brownish-red, brownish-yellow, yellow, or violet; these variations in colour indicating an admixture with the semen of varying quantities of blood or pus, in consequence of disease of the urethra, the prostate, the seminal vesicles, or some other part of the uropoietic system; such admixtures seriously impair the quality of the semen. An unfavourable judgment must also be passed on semen which, at each successive ejaculation, is voided in very small quantities only—from half a drachm to a drachm. When thus scanty, semen is often found to contain an exceptionally large proportion of dead spermatozoa. We may regard very favourably semen which is voided in quantities considerably in excess of the average; sometimes, when there is a veritable polyspermia, there may be an ounce or upwards, more than three times as much as normal—provided, of course, that this semen so richly voided is of a satisfactory quality, and contains an ample proportion of active spermatozoa. The most valuable characteristic in semen is exhibited when the spermatozoa it contains are not only very numerous and vigorously active, but when they are also very long-lived, when, that is to say, they retain the power of active movement sometimes for as long as three days. A decisive opinion as to the quality of a man’s semen can be given only as the result of precise and repeated microscopic examinations, and the medical man must be most careful, when in his first examination he has not been able to detect the presence of any living 314spermatozoa, to abstain from giving, on that account alone, an adverse decision—from pronouncing sentence of death on the man’s reproductive potency.

It has not hitherto been accurately determined how long spermatozoa can continue to live in the interior of the uterus, although the point is of great importance, not only in relation to conception, but also in regard to the theory of menstruation. Percy has published a case in which, eight and a half days after the last coitus, he saw living spermatozoa emerge from the os uteri externum. Sims bases upon his own researches the decisive opinion that in the vaginal mucus, spermatozoa can never survive longer than twelve hours, but states that in the mucus of the cervical canal they can live much longer. If thirty-six to forty hours after coitus, we examine the cervical mucus under the microscope, we commonly find living and dead spermatozoa in about equal numbers. Many of the living ones will survive their removal from the cervix for as much as six hours longer.

Of especial interest are the conditions which are liable to deprive a man of the power to produce fertilizing semen. In the first place must be mentioned congenital absence of both testicles—a condition which, in otherwise normally formed male individuals, is one of extreme rarity. Congenital absence of one testicle is less rare, and is usually accompanied by absence also of the epidydimis, vas deferens, and seminal vesicle of the same side. The potentia gestandi of a monorchid depends upon the proper development of his single testicle, and the functional capacity of this organ must be ascertained by a careful microscopic examination of his semen. Much more frequent than absence of the testicle, though still sufficiently rare, is the condition of cryptorchism, non-descent of one or both testicles, a state not necessarily associated with functional incapacity of the organ. Most commonly, however, an undescended testis is an imperfectly developed testis, and in the very great majority of cases the ejaculated fluid contains no spermatozoa.

A further cause of the lack of potent semen is atrophy of the testicles with notable diminution in the size of the glands, and more or less complete disappearance of the seminiferous tubules and their cellular contents. This state is rarely congenital, being nearly always acquired: in consequence of inflammatory conditions affecting the testicle proper or the epididymis (syphilitic inflammation, especially, is apt to lead to overgrowth of the interstitial connective tissue and to gradual destruction by pressure of the seminal tubules)^[46]; 315or in consequence of the pressure of a hernia, a varicocele, a hydrocele, or a tubercular, carcinomatous, or other new growth; or in consequence of constitutional disorders, especially long-lasting, severe, and exhausting diseases, such as diphtheria, diabetes, or chronic alcoholism; in consequence of diseases affecting that portion of the central nervous system from which the nerves supplying the genital organs arise; in consequence of degenerative changes resulting from sexual excesses; or, finally, in consequence of senile changes, such as fatty changes in the cells of the seminiferous tubules. Certain drugs also, digitalis, salicylic acid, mercury, iodide of potassium, arsenic, and morphine, have an unfavourable influence alike on the quality of the testicular secretion and on the potency of the individual. Von Gyurkovechky reports that in Bosnia a plant locally known as “neven” is employed among the peasantry for the temporary suppression of sexual potency, wives giving it to their husbands when the latter are about to leave them and go upon a journey, and sprinkling the leaves of the plant among the underclothing.

Fig. 63—Semen consisting chiefly of sperm-crystals, cylindrical epithelium and small granules exhibiting molecular movement—but containing no spermatozoa.

By the name of azoospermia is denoted a condition whose existence can be determined only by microscopic examination.

316The subject of this affection has normal potentia coeundi, the semen is ejaculated in quite normal fashion, and it is its constitution only that is faulty. In appearance it is extremely fluid, and is somewhat cloudy; its sediment contains molecular detritus and spermatic crystals, but no spermatozoa (Fig. 63). If the medical man makes it his rule, in all cases in which he is consulted on account of sterility, in deciding how far this sterility is dependent on the condition of the husband, not to confine himself solely to the customary questions, whether intercourse is regularly practised, whether before or after menstruation, etc.—but if in every case he makes a careful examination of the semen under the microscope, he will be astonished to learn the comparative frequency with which he will note the complete or nearly complete absence of spermatozoa. This condition of azoospermia may be permanent or transitory.

To Kehrer belongs the credit of having pointed out that sterility is less often due to impotence or to aspermatism than to azoospermia—a condition often unsuspected by husband and wife, and one to be diagnosed by the physician only after repeated microscopic examinations of the semen. For this reason, indeed, its existence is often overlooked. Kehrer believes himself to be justified in asserting that one-fourth of all cases of sterility (if not indeed more) must be referred to conditions affecting the husband, and most often to azoospermia; hence he concludes, that the husband must still more often be regarded as the one to blame for the occurrence of sterility, when the cases are borne in mind in which a man marries with an imperfectly healed gonorrhœa, and infects his wife, giving rise to a chronic tubo-uterine blennorrhœa, and ultimately to sealing up of the tubes and to sterility.

Complete absence or marked scarcity of spermatozoa in the semen may occur also without any change in the testicle that can be detected by an external examination, as a consequence of contusions of the testicle, or of gonorrhœal inflammation of the epididymis or vas deferens; further as a sequel of severe general diseases, long-continued physical exertion, or great sexual excess.

In some cases, a microscopical examination reveals, not azoospermia, but oligozoöspermia, that is to say, the number of living spermatozoa in the semen is remarkably small. Or, again, the anomaly may be of this character that the spermatozoa are smaller than normal, that they are motionless, and that their tails are broken off—such are the peculiarities, as a rule, of the semen of old men.

317A less common condition than azoospermia, but one the pathological importance of which is equally great, is aspermatism, in which the man, neither during coitus, nor in any other form of sexual excitement, is able to ejaculate any semen. This condition may be congenital or acquired; it may be permanent, or transitory (lasting a few weeks or months). In these cases we have to do with organic changes in the testicles, diseases of the prostate, gonorrhœal processes, or nervous disturbances resulting in a loss of irritability in the reflex centre for ejaculation. Aspermatism in the narrower sense of the term, a condition, that is to say, in which there is total suspension of the activity of all the three glands which combine to secrete the composite fluid known as semen, namely, of the testicle, the prostate, and the seminal vesicles—is, according to Fürbringer, probably non-existent. The pathological state underlying aspermatism would rather appear to be, not a failure to secrete semen, but a failure to ejaculate it.

Fig. 64.—Oligozoöspermia. a. Living spermatozoa, b. Dead spermatozoa, c. Pus corpuscles, d. Erythrocyte, e. Seminal granules.

Last of all, we have to speak of conception without copulation, of artificial fertilization. In consequence of the mechanical hindrances which in many cases prevent the entrance of the semen into the interior of the uterus, the idea has arisen to introduce the semen by means of instruments directly into the cervical canal, dispensing with the natural act of copulation. Experience long ago gained in artificial pisciculture, no doubt gave rise to this idea. Spallanzani and Rossi by means of a syringe injected the semen of a dog into the vagina of a bitch, the procedure resulting in impregnation. 318Girault appears to have been the first,^[47] in the year 1838, to introduce semen artificially into the human uterus, if we leave out of consideration the experiment of Léseurs, who introduced a tampon moistened with semen into the interior of the vagina. The procedure employed by Girault is thus described: The patient having been placed in the position usually employed for gynecological examination, a canula resembling a male catheter with the eye in its point, and with a funnel-shaped enlargement at the opposite extremity, is introduced into the uterus, this instrument having first been prepared by moistening its interior with mucilage and filling it with semen; by insufflation, the semen is now expelled into the uterine cavity. It is stated that neither uterine colic nor any other dangerous symptom has ever been brought on by this procedure. The experiments were made at various periods between the year 1838 and the year 1861; they were ten in number, and of these eight proved successful, two unsuccessful. In the ten cases, the total number of insufflations made was twenty-one—the minimum number in any single case being one, the maximum five. In one case, the insufflation was effected immediately after the cessation of menstruation; in the majority, from one to four days after the cessation of menstruation; in one case twelve days, in one case twenty-three days, after the cessation of the flow. Gautier, instead of insufflations, has employed injections of semen, using two injections in each case, one just before menstruation was expected, the other a day or two after the cessation of the flow. Marion Sims endeavoured in twenty-seven cases to bring about conception by the injection of semen into the uterus; in one of these cases only was the desired result obtained. In this latter instance the patient was twenty-eight years of age, had been married for nine years, but had remained barren. Throughout her menstrual life, she had suffered more or less from dysmenorrhœa, often accompanied by severe constitutional disturbance, such as syncope, vomiting, and headache. Local examination disclosed the existence of retroversion of the uterus with hypertrophy of the posterior wall, an indurated, conical cervix, with stricture of the cervical canal, especially in the region of the os uteri internum. In addition to all these mechanical obstacles to conception, it was found that the semen was never retained in the vagina after coitus. Sims examined the patient immediately 319after coitus had taken place, but never found a single drop of semen in the vagina, notwithstanding the fact that this fluid had been ejaculated in abundance. Sim’s first care was to bring about reposition of the uterus, and to keep the organ in its proper place by the insertion of a suitable pessary. Injections of semen were then undertaken, and were continued throughout a period of nearly twelve months. In two instances, the injection was effected immediately before the onset of the menstrual flow; in eight instances it was effected at varying times (two to seven days) after the cessation of the flow. At first, three drops of semen were injected, but later only half a drop. The semen (first ejaculated into the vagina during normal intercourse) was injected by means of a glass syringe, which was kept in a vessel of warm water at a temperature of 98° F. Since during the removal of the instrument from the water and its insertion into the vagina, some fall in temperature necessarily occurred in the vagina, Sims allowed the syringe to remain for some minutes in the vagina before he drew the semen into it, in order that he might feel assured that syringe and vagina had regained the temperature most adapted to the vital activity of the spermatozoa. The nozzle of the syringe was then carefully introduced into the cervical canal, and half a drop of semen was slowly injected into the uterine cavity. For two or three hours after the operation, the patient remained lying quiet in bed. After the tenth experiment, conception ensued—the first recorded case of artificial fertilization in the human species.

With right, however, this case of Sim’s was not regarded as conclusive, since both before and after the injection, ordinary coitus had been effected, and it is therefore impossible to determine whether the fertilizing spermatozoön was one of those introduced by means of the syringe, or in the antecedent or subsequent coitus—more especially in view of the fact that by the insertion of a pessary Sims had, previously to undertaking the injections, restored the uterus to a position more suited to the occurrence of conception in the natural manner.

In a case which a priori seemed exceedingly well adapted for the performance of artificial fertilization, one of marked hypospadias in a man whose semen was abundant and contained a large number of vigorously moving spermatozoa, I saw this experiment fail, in spite of all possible care in its performance. In fact, not a single conclusive instance of successful artificial fertilization in the human species is known to me, though I have seen reports of numerous 320disagreeable and even dangerous results of attempts to effect it. Both parametritis and perimetritis have occurred in such cases; and semen, being a material in a state of most intense molecular movement, may be regarded as extremely liable to noxious transformations.

Sim’s procedure has been modified by other gynecologists. Thus, Courty’s plan was that during coitus the semen should be collected in a condom, fitting not too closely, from which receptacle it was drawn up into a syringe and carefully injected into the cervical canal. Pajot’s plan was that the semen should be ejaculated into the vagina in natural coitus, and should thence be pressed into the uterine cavity by means of a piston-like instrument introduced into the vagina.

In London, Harley frequently made the experiment of injecting semen into the uterine cavity, but in all cases without any result.

P. Muller, in two cases, on account of extreme anteflexion of the uterus, performed this experiment. Though the general conditions were in both cases extremely favourable, in neither instance was there any result. It must, however, be mentioned that in one of his cases only had there been any preliminary examination of the semen under the microscope.

Fritsch reports a case in which gonorrhœal secretion was injected in place of semen. Peritonitis, which for a month endangered life, was the result.

In Paris, Lutaud has earnestly advocated artificial impregnation in cases of sterility in which all other means have failed. It is obvious that it would be useless to employ this measure after the menopause, or in women in whom menstrual activity has ceased prematurely, with simultaneous disappearance of all menstrual molimina. Equally useless would it be in uterine atrophy and in cases of irremediable malformation of the female genitals. Further contra-indications, according to Lutaud, are offered by chronic pelvic peritonitis, since here, on account of the obliteration of the lumen of the Fallopian tubes, the operation is foredoomed to failure. Chronic inflammatory states of the uterus and its mucous membrane, will also render the attempt useless. Moreover, it is a condition indispensable to success that the semen to be employed shall have been examined microscopically, and shall have been found to be thoroughly healthy. The operation has the greatest prospect of success when undertaken from three to two days before the due date of menstruation. The method employed is that of Sims. If 321after the first attempt, the due menstruation should begin, the injection should be repeated a week after the flow has ceased; the attempt should not, however, be repeated more than about six times in all, since the probability of success rapidly diminishes with each successive endeavour. Before the operation is undertaken, the permeability of the cervical canal must be ascertained. Further, in order that the spermatozoa shall be placed in conditions in which they have the best possible chance of survival, a weak alkaline solution, such as 1 per cent. of potassium bicarbonate, should as a preliminary measure be injected into the vagina.

Lutaud thus describes the procedure he employs. Immediately after the woman has had intercourse with her husband, a Fergusson’s speculum is introduced into the vagina, the patient remaining in the dorsal decubitus. As the speculum passes in, its margin scrapes the surface of the vagina, and by this means the semen is collected in the vicinity of the cervix. The semen is then drawn up into a Pravaz syringe or an analogous instrument, such as a uterine catheter armed at one end with a rubber ball. The fluid is then carefully injected into the cervical canal, or preferably into the uterine cavity, great care being taken not to injure the mucous membrane in any way, since the slightest bleeding may nullify the whole procedure. Finally, a small tampon of absorbent cotton-wool is inserted into the os uteri externum. For some hours the woman must remain quiet in bed; the tampon is not removed for ten hours. As regards results, Lutaud informs us that he has in this way treated twenty-six cases. In twenty-two of these, failure was complete; in one case, success was partial—the patient was impregnated, but abortion occurred two weeks later; in another case, abortion occurred after three months pregnancy; finally, in two cases, success was complete.

Indications for the employment of artificial impregnation are: first, the existence of stenosis in the upper part of the cervical canal, especially stenosis from flexion, provided, of course, that other measures are contra-indicated or have been fruitlessly employed; secondly, a deleterious character of the secretion of the cervical canal; thirdly, extreme cases of hypospadias in the male. Haussmann recommends the employment of artificial impregnation in cases in which the spermatozoa are found to enter the cervical canal, but fail to pass through the os uteri internum. Whilst artificial impregnation is theoretically a sound measure, yet in the practice the indications for 322its performance are by no means easy to establish. For, in cases in which there is some mechanical hindrance to the contact of the spermatozoön with the ovum (and it is for such cases only that this method of artificial fertilization can properly be employed), it is often extremely difficult, and may even be quite impossible, to exclude the possibility of there being some failure in ovulation itself, or in the maturation of the ova; or, again, sterility may depend, not on the fact that no ova are fertilized, but on the fact that when fertilized they always fail, for some reason, to find a resting place in the uterus; in a word, in any case in which sterility appears to be due to mechanical obstacles to conception, it may in reality be due to some other disease which has escaped recognition, some organic disease of the uterus, the tubes, the ovaries, of the periuterine tissues.

Finally, it must be remembered that the manipulation is far from easy in its performance. Above all, the semen must be subjected to a most rigorous microscopical examination in respect of its fertilizing capacity. But this examination cannot be made in the case of the semen that is actually used for the attempt at artificial fertilization; it can only be done with an earlier specimen from the same man. If the semen contains no living spermatozoa, or very few only and these sluggish in their movements, still more if it contains pus corpuscles or gonococci, all idea of its employment for artificial fertilization must be rejected.

The method employed by Sims, in which the semen is drawn into a syringe inserted into the vagina post coitum, is one which I am not able to recommend, since in this way together with the semen some vaginal mucus is drawn up, thus, instead of pure semen, we inject into the vagina semen mixed with various impurities, and more especially with an acid secretion known to be unfavourable to the life of the spermatozoa—a circumstance that will doubtless explain many of the failures that have hitherto taken place. It is certainly better that the semen of the husband should be collected in a rubber condom. The preservation of the material to be injected at a suitable temperature (the normal body-temperature), is by no means easy. The syringe, an ordinary Braun’s uterine syringe, is first disinfected, and then lies ready in water of the proper temperature. The semen is rapidly drawn up into the syringe, the nozzle of which is then passed down to the fundus uteri. Quite a small quantity of semen will suffice. After the manipulation, which should of course be undertaken at the time most 323favourable to conception, just after menstruation, the woman should lie quiet in bed for some hours.

In considering the probability of a successful issue to any such attempt to secure artificial fertilization, we cannot leave out of consideration the likelihood that that result may be prejudiced by the lack of all normal sexual feeling on the part of the wife; concerning the significance of such feeling in relation to the sexual act, we have however as yet no certain knowledge.

That this procedure of artificial fertilization is extremely disagreeable to all concerned therein, the physician not excepted, and that various moral and social considerations can be alleged against it, is incontestable. It is indeed recorded that in Bordeaux a legal penalty was inflicted on a medical man who undertook to bring about artificial fertilization. The Society of Medical Jurists debated this matter, and came to the conclusion that, whilst a medical man was not justified in recommending the practice, neither was he justified in refusing to undertake it when requested by his patients. In Paris, a candidate for the degree of Doctor of Medicine made artificial fecundation the subject of his thesis, and maintained that its practice, when effected with all proper social precautions and according to scientific principles, was possible, reasonable, useful, and moral, and that in many instances it should be recommended by the physician. After a long and stormy debate, the Faculty of Medicine determined to reject the thesis and to destroy all specimens of it already printed, on the ground that “they feared, if they gave their sanction to the practice, that a number of more or less unscrupulous physicians would make that sanction the basis of improper practices, dangerous alike to the family and to the state, since the operative method under consideration was one likely to be eagerly exploited by the whole tribe of medical charlatans.” This weighty pronouncement would appear to be sufficient ground for rejecting artificial fecundation as a matter of routine practice; still, very exceptional cases may be encountered in which it may be seized as an ultimum refugium.

Pathology of Copulation.

The act of copulation may be interfered with or entirely prevented by pathological conditions affecting the genital canal of the woman, and also by disturbances of the nervous system—naturally also by any abnormality affecting the performance of the male partner in the act.

324Abnormality of the hymen, such as excessive strength and rigidity, rendering the organ unduly persistent, is a not infrequent hindrance to intercourse, one that sometimes is not overcome even after years of married life; to such a state of affairs ignorance on the part of the married pair in respect to the proper method of intercourse, lack of sufficient sexual power on the part of the male, or inflammation of the fossa navicularis brought on by maladroit attempts at penetration, may contribute, likewise undue passivity on the part of the female partner.

Fig. 65.—Septate Hymen, the septum having a tendinous consistency.

A notable and sometimes an insuperable obstacle (of which it has been written, nec Hannibal quidem has portas perfringere valuisset) is constituted by that abnormality of the hymen in which the aperture in that membrane is guarded by a sagittally placed or sometimes oblique septum, dense and almost tendinous in structure. In a woman of twenty-four years, who for two years had lived in sterile wedlock, I found such a tendinous hymen septum. She had menstruated regularly since the age of seventeen years, but always painfully. She complained that her husband was “very weak,” inasmuch as on her bridal night he was unable to succeed in completing intercourse, and since then whenever he attempted intercourse, premature ejaculation resulted, before penetration of the penis had been effected. In consequence of this repeated ineffectual sexual excitement, she had herself become very nervous. On local examination, I found an elongated oval hymen, not completely 325covering the vaginal orifice, rather strong and thick, and divided in two halves by a median sagittal septum, of a densely tendinous consistency. On either side of the septum, the vaginal orifice would admit no more than the head of an ordinary uterine sound. I divided this septum, and was informed later that the woman had become pregnant as a result of the first subsequent act of intercourse (Fig. 65).

A remarkable case of abnormality of the hymen is recorded by Heitzmann, having been observed by him in a woman aged twenty-seven years. In this instance, the hymen was represented by a swelling, smooth on the surface and separated from the nymphæ by a deep furrow. Behind this swelling, between it and the posterior commissure, there was a deep depression, into which the finger could be passed to a depth of an inch and a half or more. Anteriorly, the very firm and fleshy prominence was bounded by a ridge, from the middle of which to the urethral orifice ran a short but strong and tense septum. Right and left of this septum were small apertures, with difficulty admitting the point of a probe. Between the anterior extremity of the septum and the urethral orifice was a nodular representative of the swelling normally present in this situation. Surrounding the urethral orifice were two or three additional small nodules. The two lateral margins of the hymen were prolonged around the urethral orifice, and united in front thereof to form a raphe, which could be traced as far as the base of the clitoris. The young woman had been married for some months, and asserted that she had repeatedly had intercourse. With such a condition of the female genitals, penetration of the penis into the vagina was however quite impossible. During coitus, the penis must have been inserted into the aforesaid depression behind the swelling, which was sufficiently extensible for the purpose.

A less serious hindrance to intercourse, but one more frequently encountered, is a partial persistence of the septum of the hymeneal orifice, in such a manner that there is a projecting tongue of membrane from the anterior and posterior margins of the orifice, partially blocking this latter; or there may be a single median projection only, either in front or behind. Such processes may be remarkable alike for their size and their shape. Liman describes a cordiform hymeneal orifice, constituted by an anterior or posterior protection of the kind here described.

In cases of imperforate hymen in which the occlusion of the vagina is not complete, impregnation may in rare instances occur, 326even though proper intromission of the penis is quite impossible. Cases of this kind have been observed by Scanzoni, Horton, K. Braun, Leopold, Brill, Breisky, and others.

Fig. 66.

In most of these cases there was a thick, dense, “imperforate,” or rather persistent hymen, with an orifice no larger than the head of an ordinary probe, notwithstanding which pregnancy had occurred. The cases reported by Brill were of a different character, being those of two young unmarried Russian girls, with normal undestroyed hymens, who were found to be pregnant. According to Brill, such cases are by no means uncommon among the peasantry of Little Russia, where the barbarous practice prevails of adolescent girls and boys sleeping together. In these circumstances, sexual intercourse takes place, but, from fear of consequences, it is often incomplete. Hence, in occasional cases, results pregnancy in a young girl with intact hymen.

In the first complete act of intercourse, the defloration of the virgin, the hymen is as a rule torn in several directions, and in consequence there is usually moderate bleeding. The lacerations of 327the hymen soon skin over. When the initial coitus is effected maladroitly or roughly, more extensive lacerations are apt to occur, and the injury may not be limited to the hymen, but may extend longitudinally along the vaginal wall, and even involve the posterior vaginal fornix. Or, again, without any such extensive laceration, there may result very profuse bleeding, in consequence of abnormally profuse vascularization of the hymen. Cases are also recorded in which (presumably not from normal coitus alone, but from other, unacknowledged manipulations), whilst the hymen has been left intact, false passages have been made, leading to the formation of fistulæ, with subsequent death from haemorrhage or sepsis.

Apart from impotence in the male, the hymen may remain intact when it is not touched at all during coitus. Inexperience, as Veit remarks, will in this matter lead to results almost incredible. This author has been informed by such inexperienced married couples, that in attempts at intercourse “the penis of the man is introduced between the thighs of the woman, which are closely pressed together, the man having his legs on either side. Naturally, in this method of intercourse, the hymen escapes destruction. In such attempts at coitus, things are done which can hardly be compared with the normal act of copulation.”

In isolated instances, the introduction of the penis is prevented by congenital or acquired defects in the formation of the external genitals. Adhesion between the labia majora and the labia minora is sometimes met with a congenital deformity, which may or may not be associated with atresia of the urethral orifice; in some cases the adhesion is dependent merely upon a superficial epithelial continuity, but in others the labia are firmly adherent throughout. Less rare are acquired adhesions, the result of accident, between the labia majora and the labia minora, leading to atresia of the vulva, and thus making copulation impossible.

Intromission of the penis may be rendered quite impossible by excessive size of the labia majora, consequent upon elephantiasis, in which disease there is enormous hypertrophy of the subcutaneous connective tissue. New growths may have the same result, fibroids, for instance, lipomata, and cysts, which may attain a remarkable size in the cellular tissue of the labia, the mons veneris, and the perineum, and also in the nymphæ and in the cellular tissue between the clitoris and the urethral orifice. In a very obese woman twenty-eight years of age I saw a lipoma attached to the right 328labium majus. In the course of six years it had grown to such an enormous size, that it extended downwards over the thigh, blocked the entrance to the vagina, and made coitus absolutely impossible (Fig. 67). Various forms of labial hernia are also competent to occlude the vaginal orifice.

Fig. 67.—Lipoma of the right labium majus, occluding the vaginal inlet.

Hypertrophy of the nymphæ, which, as the so-called Hottentot Apron has to be regarded as a racial peculiarity, is known also in Europe as a pathological condition which may at times constitute a hindrance to sexual intercourse (Fig. 68). According to Otto there are three fundamental forms of the Hottentot apron, viz., excessive enlargement of the nymphæ, overgrowth of the labia majora, and, lastly, the formation of a peculiar lobe of flesh and skin, attached to the mons veneris by a pedicle, containing the clitoris, and covering the genital fissure as with a valve. Hypertrophy of the nymphæ is said to be common also in Turkish and in Persian women. Owing to the obstacle to intercourse presented by hypertrophied nymphæ, it is among certain races an established custom to amputate clitoris and nymphæ together. Virey writes: “The Portuguese Jesuit missionaries to Abyssinia in the sixteenth century, endeavoured to abolish this practice of the circumcision of women, which they regarded as a relic of Mohammedanism; the uncircumcised maidens, however, could find no husbands, owing to the inconvenient length of their nymphæ. The pope sent surgeons 329to the country, to enquire into the matter, and their reports were in such sense that circumcision was permitted as necessary.” Davis reports observations made by Sonini on the female indigens of lower Egypt, in whom the vulva hangs down in the form of a loose, flabby mass of flesh, of striking length and thickness, completely covering the genital fissure. He believes that the circumcision that was practised on the women of ancient Egypt consisted in the removal of this hypertrophied vulva.

Fig. 68.—“Hottentot apron” in an adult woman, hanging down between the thighs. (After Zweifel.)

Courty saw a case in which the remarkable length of the labia minora, which when an attempt was made to introduce the penis, covered the vaginal orifice, had rendered coitus ineffective, and had 330caused sterility for five years. Resection of the labia minora was followed by successful intercourse and conception.

The lipomatous form, especially, of elephantiasis vulvae often attains a gigantic size. Growths of this nature, of the size of a child’s head, weighing six or seven kilo (thirteen to fifteen pounds), and reaching down to below the knee, are by no means rare. I have known several cases in which an excessive accumulation of fat in the vulva associated with pendulous belly has constituted a mechanical obstacle to the completion of sexual intercourse.

Fig. 69.—Elephantiasis of the labia majora

Hypertrophy of the clitoris may constitute an obstacle to coitus. In exceptional cases, this organ is as large as the male penis, and hangs down over the genital fissure like a valve. Hyrtl relates that in certain African races, this congenital enlargement of the clitoris is so enormous, that the organ, made fast to the perineum with rings, serves for the protection of virginity. Schönfeld describes the case of a woman aged twenty-eight years, in whom the vaginal orifice was almost completely occluded by a dry and firm growth, with a granulated surface. Close observation proved this growth to be produced by a hypertrophied and degenerated clitoris, which had attained the size of a child’s head. Elephantiasis of the clitoris 331is especially inconvenient in consequence of the hindrance which the enlarged organ offers to sexual intercourse. Bainbridge describes a case of tumour of the clitoris measuring 8 cm. (3.2 in.) in length and 5 cm. (2 in.) in width. The following remarkable case is recorded by Oesterlen: A young man wished to break off his engagement on the ground that his intended wife was a hermaphrodite. Examination, however, disclosed the existence of a strong intact hymen, a very large clitoris, and pregnancy of the twentieth week.

Injuries of the vagina resulting from coitus are, generally speaking, rare. The usual cause of such injuries is disproportion in size between the erect penis and the calibre of the vagina, or else brutal violence in the performance of coitus; sometimes, however, it is dependent on the pathological state of the female genital organs, which have undergone senile atrophy.

To the first group belongs the case reported by Albert, in which a girl of eleven years was found to have a laceration of the vagina communicating with the peritoneal cavity, the injury resulting from coitus. To the second group belongs the case reported by Böhm, of lacerations of the vaginal mucous membrane resulting from forcible coitus in elderly women. E. Frank reports a case of injury due to violent coitus in a woman in whom the vagina was already greatly stretched by retroflexion; and another case in which injury occurred during intercourse in a woman with vagina duplex—in this case, not only was the hymen of the right vagina torn, but also the septum between the two vaginae.

By no means extremely rare are injuries to the vagina in the act of defloration, causing severe hemorrhage. Martin records a fatal case of this nature. Maschka and Hofmann, the authorities on Forensic Medicine, deny that vaginal laceration is the result of simple coitus, and Hofmann maintains that such serious injury can occur only from digital manipulations; in fact, these writers believe that the penis alone cannot be employed with sufficient force to cause laceration. Barthel and Anderson, however, saw vaginal lacerations in nulliparous women; and Zeis records a case of vaginal laceration in a woman twenty-five years of age, with whom, six weeks after parturition, her husband, then in a state of intoxication, had had intercourse in the position à la vache.

Anomalies of the vagina, absence, stricture, duplication, and abnormal apertures, also diseases of the vaginal tissues, may induce incapacity for sexual intercourse. In frequency as in significance, among these disorders, absence of the vagina and stenosis and atresia 332of the canal, stand in the first rank. Congenital atresia may be complete or only partial, according as the two ducts of Müller from the fusion of which the tube is formed, remain totally or only partially solid—or, having duly canalized, subsequently, by a foetal inflammatory process, become transformed into a thick, more or less solid cord. If the obliteration of the vagina is at the lower extremity of the canal, coitus is impossible, unless, as sometimes happens, by frequent attempts at intercourse, the short blind sac representing the lower end of the vagina has been stretched upwards in the form of a pouch. When the obliteration of the ducts of Müller is complete, we have total atresia of the vagina, in which case the uterus is also as a rule wanting, or is but imperfectly represented. In some cases, from the ducts of Müller, instead of the normal vagina, there is formed a tract of membrane of varying density and width, through which passes a small canal for the passage of the menstrual discharge; this condition is known as atresia vaginalis membranacea.

When, notwithstanding malformation of the external genital organs and partial absence of the vagina, there is no defect in the internal genital organs, conceptions may sometimes be effected through some abnormal channel, as for instance through a communication established per anum; or, again, some operative procedure may bring relief. Rossi reports a case of congenital absence of the external genital organs, in which an incision was made in the region of the absent vagina, and an artificial vagina was thus constructed; copulation was in this way rendered possible, and conception ensued. In this connection, we may turn with interest to the essay by Louis, entitled Deficiente Vagina, Possuntne per Rectum Concipere Mulieres? Here we are told of a case in which vulva and vagina were absent, and there was a monthly discharge of blood per anum; the woman’s lover employed this passage also ad immissionem penis, and the woman became pregnant. Pope Benedict XIV expressly allowed to women suffering from imperforatio vaginae the practice of coitus parte posteriori.

Further, in cases of atresia vaginae in which the genital canal terminates in the urethra, conception can result from urethral coitus, as is proved by cases recorded by K. von Braun, Weinbaum, and Wyder. In Weinbaum’s case, the obliteration of the vagina was complete, neither eye nor finger could detect the slightest aperture; the woman having become pregnant after coitus per urethram, delivery was effected by Caesarian section. In Wyder’s case, the vaginal orifice was closed, with the exception of a minute aperture, by 333means of dense fibrous tissue; the woman was in labour and the head of the child was in the pelvis. Under anæsthesia, the septum, which was nearly an inch thick, was divided, the opening was enlarged, and the child was extracted by forceps. An investigation disclosed that the husband had always had intercourse by introducing his penis into the dilated urethra; it was evident that the semen had passed through the urethra into the bladder, and thence had found its way through a vesico-vaginal fistula into the vagina and uterus.

Acquired obliteration and stricture of the vagina from the contraction of scar tissue, in consequence of deep ulceration, especially when croupous or diphtheritic in nature, following typhus or typhoid, pyaemia, puerperal sepsis, and the acute exanthemata (especially variola)—may likewise serve as obstacles to coitus. Syphilitic affections also, through contraction of exudations, the adhesion of ulcerated opposing surfaces, condylomata, etc., may give rise to stricture or obliteration of the vagina. The same conditions may be induced by trauma, as by wounds, by attempts at rape, or by the use of caustic acids and alkalis.

Thus, Ahlfeld saw severe stricture of the vagina as a sequel of the excision of four large condylomata. Hennig the same, after variola, and again in lunatics who had introduced caustic fluids into the vagina. By L. Mayer, atresia vaginae was seen as a sequel of typhoid; by Weiss as a sequel of diphtheria; by Martin from the action of irritant secretions in cases of uterine tumour; by Billroth as a result of continued irrigation of the vagina with alkaline urine after lithotomy or urethrotomy, and in cases of vesico-vaginal fistula. Ulcerative processes set up by the long continued action of a vaginal tampon, a pessary, or some other foreign body, have been noted as leading to consecutive obliteration of the vagina.

Such stenosis, when partial only, may prevent complete coitus, and yet allow conception to occur. Cases illustrating this fact have been numerously recorded. Thus, van Swieten already reported the case of a girl aged sixteen years, whose vagina was strictured to such an extent that the passage would barely admit a crow-quill; nevertheless she became pregnant, and was successfully delivered. Similar cases are mentioned by von Scanzoni, Kennedy, Devilliers, Varge, Moreau, and Plenk.

Serious obstacles to coitus, of a nature analogous to acquired stenosis of the vagina, are constituted by the irregular ligamentous bridges which sometimes arise in the vagina from the adhesion of a 334strip torn from the mucous membrane on one side of the vagina to the other side of that tube—or, again, a portion of a lacerated cervix may adhere to the wall of the vagina. An interesting case of this nature came under my own observation. It was a woman aged thirty-two years, who had twice had difficult deliveries, the last time nine years before. Since then she had been barren. On local examination I found in the vagina a fleshy bridge, about 4 cm. (1.6 in.) wide and 6 cm. (2.4 in.) long, extending from the left side of the portio vaginalis to the right wall of the vagina; this mass of tissue was so placed that the intromitted penis must necessarily have slipped past it into a blind sac, such as the French name une poche copulatrice. Similar membranes in the vagina have been described by Breisky, Murphy, and Thomson.

Various tumours may narrow or even completely close the vaginal passage, myoma, sarcoma, carcinoma, and especially the polypoid form of fibromyoma, which may even project without the vaginal orifice. And even when tumours of or in the vagina do not actually hinder coitus by the space they occupy, they may affect that operation by bleeding whenever it is undertaken, a manifestation extremely alarming to young married persons.

The vagina may also be partially occupied, and coitus may be impeded, by elongation of the hypertrophied cervix uteri, by inversion or prolapse of the uterus, by cystocele or rectocele, and by uterine polypi. Horwitz records the case of a woman aged twenty-two years in whom impotentia coeundi was dependent upon the occlusion of the vaginal orifice by a rounded, strongly projecting body, which proved on closer examination to be a hypertrophied vaginal bulb.

Tumours of the rectum and other intrapelvic growths may encroach upon the vaginal passage and impede coitus. Closure of the vagina has been brought about even by abnormal size and abnormal toughness of the perineum.

Finally, in extreme degrees of pelvic contraction, the vagina may be so much narrowed as to interfere with coitus. Von Hofmann records a case of this nature: In a woman thirty years of age, affected with kypho-scoliosis, who suffered extreme pain whenever her husband attempted sexual intercourse, the pelvis was twisted and narrowed to such an extent that the conjugate measured barely one inch, and the vagina was so small as barely to admit the finger.

Duplication of the vagina will constitute an obstacle to coitus when both halves of the passage are too narrow to allow of intromission 335of the penis. Difficulty in intercourse will also be caused by abnormal termination of the vagina, as by its termination in the rectum, likewise by severe perineal laceration which has converted the lower parts of the vagina and rectum into a cloaca, likewise by recto-vaginal and vesico-vaginal fistulæ; in the case of all these latter states a feeling of disgust is apt to be aroused in the male which may effectually check sexual desire. Still, coitus, and even conception, are quite possible in these conditions. Kroner, among sixty cases of vaginal fistula, observed six in which conception took place while the fistula was actually open.

Apart from all local pathological conditions, coitus may be interfered with by general nervous disturbances, manifesting themselves locally, and depriving the woman so affected of potentia coeundi. First among such states must be mentioned vaginismus, a condition so important as to demand discussion in a separate chapter.

An important and by no means rare obstacle to the completion of intercourse, affecting the male partner in the act, is partial or complete incapacity for erection of the penis. Even excessive smallness of the penis may render coitus inadequate; still more so, however, organic diseases of the membrum, such as obliteration of the corpora cavernosa, or of some of the trabecular channels of these bodies, nodular formations resulting from injury, or cavernitis from gonorrhoea. In such cases, erection is extremely irregular, and the erect penis is sharply bent (chordee) instead of being straight, a condition which renders intromission mechanically difficult if not impossible. A similar effect is produced by ossification of some part of the tunica albuginea of the corpora cavernosa—the so-called penis bone. Mechanical obstacles to coitus are also offered by inguinal and scrotal hernias; and by excessive obesity, where the increase in thickness of the panniculus adiposus of the abdominal wall and the mons pubis, whilst the penis itself remains as slender as before, causes the organ almost to disappear from view.

Psychical impotence in the male is much more frequently observed than organic impotence. We meet with this condition especially in neurasthenically predisposed individuals, or in men who have been given to excessive venery or have masturbated excessively in youth, and who, when entering upon married life, fear they will be unable to satisfy the legitimate desires of their wives; or in newly married men who have suffered often from gonorrhoeal inflammations, such as prostatitis, vesical catarrh, and epididymitis. The fear and anxiety from which such persons suffer has an inhibitory influence upon 336the erection of the penis. In some instances, this inhibitory influence is partial only, and the man thus affected, while perfectly competent in intercourse with a prostitute, who employs means of sexual stimulation to which he has become accustomed, is unable to complete intercourse with his wife, who is ignorant and innocent, and assumes a purely passive role; or it may be that erection is not sufficiently powerful to bring about rupture of the hymen, and thus to overcome the difficulties primae noctis.

As regards gonorrhoeal infection, it appears that in men who in other respects are perfectly competent, this disease has an inhibitory influence upon the nervous mechanism concerned in producing erection of the penis.

Psychical impotence is usually transitory, but it may endure for a very long time; and it may be many months before the husband, whose nervousness has led to failure in the decisive moment at the outset of married life, is able to command an erection sufficiently powerful to bring about the defloration of his wife. Occasionally such psychical impotence is not absolute but relative, it relates, that is to say, to one particular woman—unfortunately, as a rule, a man’s own lawful wife,—whilst coitus with another woman, even in default of any measures for artificial sexual stimulation, is easily effected. This fatal misfortune is especially liable to occur in cases in which a man fully experienced in sexual matters marries a woman whom he dislikes or for whom he has no regard; the marriage being determined by material considerations. From such women I have heard the painful confession that the husband, a man renowned for his gallantries, played a very poor part in the bridal bed.

The impotence of irritable weakness is characterized by premature, and therefore fruitless ejaculation. A man thus affected has a powerful erection of the penis, preparatory to coitus, but at the moment of contact with the female genital organs, before there has been time for penetration to occur, ejaculation takes place, and is immediately followed by relaxation of the penis. Such irritative impotence is often met with in young men at the outset of their sexual career, in beginners, whose sexual passion is very readily excited, whose imagination shoots forward to the goal, and who are unable to restrain themselves. This form of impotence can also be cured by wisely chosen measures.

The paralytic form of impotence, on the other hand, is characterized by the entire absence of erections of the penis, both overnight in bed, and during the early morning hours; the penis always remains 337flaccid, or at most becomes semi-erect only, insufficiently rigid for penetration. Ejaculation is much retarded or altogether wanting.

Impotentia coeundi in the male may be complete, in cases in which the erection-apparatus is entirely inactive, and in which even an attempt at intercourse is out of the question; or, and this is more frequently met with, it may be partial only, and manifests itself in various degrees of imperfection in the performance of coitus.

This latter form may often escape the woman’s notice. Whilst complete impotentia coeundi, in which intromission of the penis is impossible, is a state about which neither husband and wife can fail to be fully informed, cases of partial impotence, with semi-erection of the penis or premature ejaculation, are often glozed over by the husband, ignored by the wife, and underestimated by the physician—and yet such incomplete intercourse entails a series of ill-consequences alike upon the genital organs and upon the nervous system of the wife. Erection is incomplete, and thus the penis passes into the vestibule only, and not deep into the vagina; even if penetration is more thorough, the venous return of the blood from the corpora cavernosa is not checked sufficiently to distend the penis to its full size, and to bring it into close contact with the vaginal walls; or ejaculation occurs prematurely, before the sexual organism of the wife has attained that supreme degree which is needful alike for the attainment of sexual gratification and f