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 of 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 affecting 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 among 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 of 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.
Inflammatory Processes.
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 entirely 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 chlorotic 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 may 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 of 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 regard 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 at 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 of 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 in 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 are 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.
The 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 of 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 fully 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 fully 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:
| In | 1 girl of | 3 to | 4 years. |
| In | 2 girls of | 5 to | 6 years. |
| In | 1 girl of | 6 to | 7 years. |
| In | 5 girls of | 8 to | 9 years. |
| In | 5 girls of | 9 to | 10 years. |
| In | 4 girls of | 10 to | 11 years. |
| In | 2 girls of | 11 to | 12 years. |
| In | 4 girls of | 12 to | 13 years. |
| In | 15 girls of | 13 to | 15 years. |
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 hitherto 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:
| 4 cases of hysteria occurring at the ages of | 1 to 10 years. |
| 45 cases of hysteria occurring at the ages of | 10 to 15 years. |
| 105 cases of hysteria occurring at the ages of | 15 to 20 years. |
| 80 cases of hysteria occurring at the ages of | 20 to 25 years. |
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 manifestations 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 authors, 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 a 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 processes 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.
L. 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 Löwenfeld, 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 body 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 coinciding 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 disfigurements 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 commonly 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, among 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 cream; 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.
I have drawn up the following diet-table for obese chlorotic patients:
| Quantity in Grammes. | Contains of | |||
|---|---|---|---|---|
| Albumin. | Fat. | Carbohydrates. | ||
| Morning: | ||||
| Beefsteak | 100 | 38.2 | 1.7 | |
| A cup of tea | 150 | 0.45 | 0.9 | |
| White bread | 30 | 2.9 | 0.2 | 18.0 |
| Mid-day: | ||||
| Meat soup | 100 | 1.1 | 1.5 | 5.7 |
| Roast meat | 200 | 76.4 | 3.4 | |
| Vegetables | 50 | 0.8 | 0.2 | 4.2 |
| White bread | 50 | 4.8 | 0.4 | 30.0 |
| Light wine | 150 | 1.0 | ||
| Afternoon: | ||||
| A cup of coffee | 120 | 0.2 | 0.67 | 1.7 |
| White bread | 25 | 2.4 | 0.2 | 15.0 |
| Evening: | ||||
| Roast meat | 200 | 46.4 | 3.4 | |
| Vegetables | 25 | 0.4 | 0.1 | 2.1 |
| Wine | 150 | |||
| White bread | 30 | 2.9 | 0.2 | 18.0 |
| Total | 1380 | 206.97 | 11.92 | 97.6 |
| Contains about 1300 calories. | ||||
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.
As 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 is 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. to 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 corpuscular 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 dust, 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 girl 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 avoided, 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 former 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, drawers 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 period 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 and 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 that 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 during menstruation, it is necessary to give the following daily diet, representing a heat value of 2,013 to 2,076 calories:
| 125–150 | grammes of fowl. |
| 100 | grammes of butter. |
| 125–140 | grammes of white bread. |
| 150 | grammes of brown bread. |
| 70–80 | grammes of eggs. |
| 600 | grammes of coffee. |
| 600 | grammes of soup. |
| 560 | grammes of Seltzer water. |
| 20 | grammes of salt. |
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.
In 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.
The 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 blood, 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:
| Total solid constituents | 175.00 | |||
| Comprising | ||||
| Fat | 3.90 | |||
| Blood-corpuscles | 64.40 | |||
| Albumin | 48.30 | |||
| Extractives | 1.10 | |||
| Salts | 12.00 | |||
| Mucus | 45.30 | |||
| Water | 825.00 | |||
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.
The 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
| Most frequently to 8 days, in | 26.695 per cent. |
| Next in frequency was a duration of 3 days, in | 20.762 per cent. |
| Next, a duration of 4 days, in | 16.949 per cent. |
| Next, a duration of 5 days, in | 11.864 per cent. |
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:
| 8 days in | 1182 women, that is in | 26.024 per cent. |
| 4 days in | 829 women, that is in | 18.252 per cent. |
| 3 days in | 731 women, that is in | 16.094 per cent. |
| 5 days in | 730 women, that is in | 16.072 per cent. |
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:
| A duration of a few hours only in | 95 women, that is in | 9.38 per cent. |
| A duration of 1 to 2 days in | 66 women, that is in | 6.51 per cent. |
| A duration of 3 days in | 407 women, that is in | 40.17 per cent. |
| A duration of 4 days in | 171 women, that is in | 16.88 per cent. |
| A duration of 5 to 6 days in | 115 women, that is in | 11.35 per cent. |
| A duration of 7 to 8 days in | 118 women, that is in | 11.63 per cent. |
| A duration of 9 days and upwards in | 41 women, that is in | 4.05 per cent. |
The mean duration in these cases was 3.87 days.
The mean duration of the menstrual flow is:
| In Paris | 5 | days. |
| In London | 4.6 | days. |
| In Berlin | 4.5 | days. |
| In Copenhagen | 4.3 | days (according to Mayer, 5.3 days). |
| In Austria | 3.8 | days. |
The 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.
Of 4,542 women questioned by Mayer in regard to this matter, there were:
2,998, that is 66.006 per cent., in whom the composition was regular.
1,544, that is 33.994 per cent., in whom the composition was irregular.
and among the latter the discharge was
| Scanty and for the most part pale in | 511; that is | 12.250 per cent. |
| Profuse or profuse and coagulated in | 838; that is | 18.428 per cent. |
| Variable in | 196; that is | 4.315 per cent. |
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 is 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
| The constant type in 4,981 women, that is in | 87.83 per cent. |
| The inconstant type in 690 women, that is in | 12.16 per cent. |
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:
| 28 days in | 70.80 per cent. |
| 30 days in | 13.74 per cent. |
| 21 days in | 1.66 per cent. |
| 27 days in | 1.45 per cent. |
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:
| Every 28 to 30 days in | 642 women. |
| Every 8 to 21 days in | 169 women. |
| Every 35 to 56 days in | 128 women. |
| And was quite irregular in | 74 women. |
In 500 Jewish women, Hirsch found that menstruation occurred:
| 23 days after the beginning of the last menstruation in | 19 |
| 24 days after the beginning of the last menstruation in | 29 |
| 25 days after the beginning of the last menstruation in | 36 |
| 26 days after the beginning of the last menstruation in | 56 |
| 27 days after the beginning of the last menstruation in | 62 |
| 28 days after the beginning of the last menstruation in | 73 |
| 275 | |
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:
| Every 4 weeks in | 61 women. |
| Every 3 weeks in | 28 women. |
| Every 2 weeks in | 1 woman. |
| And at various irregular periods in | 10 women. |
Tilt found among 100 women that menstruation recurred:
| Every 4 weeks in | 77 women. |
| Every 3 weeks in | 17 women. |
| Every 2 weeks in | 1 woman. |
| Every 6 weeks in | 5 women. |
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, that 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, and, 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 occurrence. 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 that 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 in 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. This 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 mortem, 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 away 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 either 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, blood 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, at 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 disorder 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 connection 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.
In 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 the 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 without 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.
Cases 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 stimulus 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; the influence is merely somewhat weaker in so far as the woman has learned to endure and to be patient. The menstrual state, in nervously predisposed women, evokes the particular neurosis to which the individual happens to be liable. The disorders most commonly met with in this association are, hysteria, hemicrania, swimming in the head, epileptic paroxysms, toothache, and neurasthenia.”
Especially frequent during menstruation is hemicrania. Sometimes hemicrania may begin a day or two before menstruation, as a prodromal sign, and may accompany its whole course, becoming, however, less severe toward the end of the flow. Hysteria most commonly manifests itself in association with menstruation by a depressed emotional state, by tearfulness, by complaints made without sufficient grounds, by globus hystericus or clavus hystericus; sometimes also by paroxysms of muscular spasm; very rarely by hystero-epileptic seizures. Epilepsy may occur either by day or by night. Nocturnal seizures usually occur without any apparent external cause, as a result of the central stimulus; diurnal attacks, on the other hand, have usually some external exciting cause. Often, however, years may elapse without any attack of major epilepsy occurring, the disease manifesting itself in one or more of the many varieties of the minor form (petit mal), as transient absences of mind, attacks of vertigo, etc.
The nervous disturbance in a menstruating woman may be so great as to lead to the production of psychoses. The question of the existence of a menstrual insanity sui generis has been answered by many alienists in the affirmative; by others, however, who see in the alleged cases nothing specific, it has been answered in the negative. The relation of menstruation to the mental disorder may be a double one: 1, menstruation may occur repeatedly in the course of an already established mental disorder; 2, menstruation and its morbid variations may favor the occurrence of psychoses that exist already in a latent form, and may lead to the origination of psychoses to which the organism is predisposed.
In the former connection, Brierre de Boismont undertook an investigation which showed that in women suffering from mental disorder, an exacerbation of that disorder was to be observed during menstruation. Schlager, who regards the menstrual process as possessing when anomalous a high significance for the development and course of mental disturbances, observed that in 33 per cent. of women suffering from mental disorder, the menstrual state had an unfavorable influence upon the course of that disorder, inasmuch as it led to an increased irritability; in the rest of the cases, however, menstruation was without influence upon the course of the ordinary chronic psychoses. In the cases that were unfavorably influenced, epileptic attacks usually became more frequent, and chronic melancholia became much more profound. Schröder observed in chronic forms of melancholia that during menstruation the sadness became intolerable and was associated with a suicidal tendency; in chronic maniacal forms of mental disorder, the excitement underwent an increase during menstruation. Von Krafft-Ebing, as a result of his investigations into insanity during menstruation, came to similar conclusions with regard to the unfavorable influence of the menstrual process. Algeri likewise states that menstruation notably aggravates the cerebral symptoms in the course of mental disorders.
Other authors, Marcé and Kowalewski for instance, whilst emphasizing the powerful influence exerted by menstruation on any existing psychosis, point out that in some instances, as in states of mental and physical depression, this influence is for the worse; but in other instances, especially in states of maniacal excitement, the condition of the patient undergoes notable amelioration during menstruation. Schäfer also, in his researches into the relations between the processes of menstruation and psychoses, discovered that anomalies in the course of menstruation ran almost parallel with anomalies in the course of mental activity.
In psychopathically predisposed women, disorders of menstruation, such as amenorrhœa, delayed menstruation, and dysmenorrhœa, are more effective than the normal process of menstruation in evoking manifestations of psychical abnormalities previously latent, and in leading to attacks of precordial anxiety, pathological emotional states, melancholic seizures, epilepsy in all its varieties, and impulsive manifestations, such as pyromania, kleptomania, infanticide, homicide, etc. As results of a special predisposition may appear in this connection, congenital imbecility, idiocy, melancholia, and chronic weak-mindedness.
A rich literature exists of cases in which mental abnormalities occurred in psychopathically predisposed individuals as a result of menstruation. Thus, von Krafft-Ebing reports a case in which, during menstruation, a mentally undeveloped woman murdered her husband; and another case in which to chronic weak-mindedness and chronic delusional insanity were superadded during menstruation peculiar attacks having the character of psychical storms. Tuke reports a case in which a mother, in a state of alcoholic excess during menstruation, murdered her daughter. Pelmann records acts of pyromania committed during menstruation by a girl seventeen years of age. Mabille records a case in which a woman suffering from severe mental disorder was affected during menstruation by impulsive kleptomania, whilst after the periods the memory of what had happened passed away. Philo-Indicus records the case of a woman suffering from severe neuropathy who at the menstrual periods exhibited great irritability, experienced marked sexual excitement, and had suicidal impulses, and who on one occasion attempted to murder a female friend who had refused to assist her in the practice of sexual aberrations. Giraud describes a woman suffering from passive melancholia, in whom during menstruation horrible fantastic ideas occurred. Ball records the case of a woman who suffered always from acute mental disorder during menstruation, and who, in one of these attacks, murdered her son. Kowalewski reports a case of chronic imbecility, in which during menstruation attacks of precordial anxiety developed, and in the course of one of these attacks the patient set fire to her own house. “In such cases,” remarks Kowalewski, “menstruation represents the last drop that makes the full goblet overflow.”
In addition, we meet with cases in which the influence of menstruation is so powerful that it must be regarded as the principal cause of the psychosis. We must then speak of a true menstrual psychosis, the impulse to which is supplied by the normal or abnormal changes occurring in the process of menstruation, and characterized by the menstrual periodicity and the brief duration of the attacks. These are the characteristics of the menstrual psychoses of the menarche and of the climacteric period; and such cases occur also during the period of full menstrual activity.
The menstrual psychosis most commonly makes its appearance shortly before the flow, becomes less severe with the establishment of the flow, and disappears when the flow ceases; in other cases, the psychosis appears toward the end of menstruation, and speedily passes away; or, again, in amenorrhoeic cases, the attacks of mental disorder replace the proper menstrual flow, and become less severe or disappear entirely as soon as the flow is regularly re-established. The commonest forms of these menstrual psychoses are, melancholia, mania, irresistible impulses, acute amentia, in rare cases alternating insanity (folie circulaire) in which the periods of alternation assume the menstrual rhythm. The duration of these psychoses is usually short, from a few days up to a fortnight; there may be only a single attack, or there may be a number of attacks presenting precisely similar characters.
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 constantly 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 about 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:
| 4 patients between the ages of | 15 and 20 years. |
| 6 patients between the ages of | 20 and 25 years. |
| 2 patients between the ages of | 25 and 30 years. |
| 6 patients between the ages of | 30 and 35 years. |
| 2 patients above the age of | 35 years. |
The same author insists that for the development of a menstrual psychosis a predisposition on the part of the brain must exist, either in 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
| 12 | were hereditarily predisposed. |
| 4 | had previously exhibited great nervousness during menstruation. |
| 7 | suffered from primary mental weakness. |
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, Menorrhagia, and Dysmenorrhœa.
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 weeks 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, especially 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.
The 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 that 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 been 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, in 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.