The complexity of causation in such instances may be well illustrated by the following case, that I select on account of its great resemblance to the type described by Dr. Clarke.

A young girl of sixteen consulted me on account of menstrual hæmorrhage so excessive as to induce complete exhaustion, bordering upon syncope. She had menstruated for two years—during the first, in quite a normal manner—but during the second, had become subject to these menorrhagic accidents, since residence at boarding-school. It would have been easy to decide that the disturbance was directly due to the severity of the mental efforts exacted by the régime of the school. But on further inquiry it appeared: first, that the mother of the girl had always been subject to menorrhagia, and it is well known that this often occurs exclusively as the result of hereditary predisposition. Second, that just before the entrance to school, and the disturbance of menstruation, the girl had been living in a malarial district, and had suffered from malarial infection, which is again a frequent cause of menorrhagia. Third, that the studies pursued at school were unusually rudimentary for a girl of sixteen, and indeed, below the natural capacity of her intelligence, had this been properly trained. But the hours of study were so ill-arranged, that the pupils were kept over their books, or at the piano, nearly all day, and even in the intervals allowed for recreation, no exercise was enforced. It was therefore frequently neglected, and the girl, with hereditary predisposition to menorrhagia, increased by malarial infection, and also by certain rheumatic tendencies, was allowed to expend upon elementary text-books an amount of time, attention, and nervous energy, that would have been deemed excessive for the most valuable intellectual pursuits.

All physicians are aware of the frequent dependence of menorrhagia upon anemia, not only acquired, but congenital. The existence of anemia, or of an imperfect elaboration of the blood and vascular system, previous to the occurrence of the first menstruation, is a possible condition of menstrual disorder that must always be very carefully eliminated before any other cause be assigned. It is, moreover, extremely frequent. Others exist, but are more rare—as peculiar congenital predisposition to hæmorrhages, with or without true hemophilia[45].

With such causes (anemia, rheumatism, malarial infection, hereditary predisposition), the observance of rest during the menstrual week would be quite ineffectual so long as the régime of the other three weeks remain uselessly unhygienic. If the menstrual crisis finds the uterine blood-vessels already deprived of tonicity through nervous exhaustion or other cause, hæmorrhage is as likely to occur as if that tonicity were only exhausted at the epoch of menstruation. In the cases described by Dr. Clarke, the cure was effected, when at all, not by an intermittence of study, which does not seem to have been tried, but by its complete cessation, together with that of all the conditions by which it was accompanied.

Again, therefore, it may be said, that wherever such intermittence is not superfluous, it would be inadequate for the purpose for which it is designed.

But this conclusion may seem to be much more severe, and, to those interested in the education of girls, much more disagreeable than that formulated by Dr. Clarke. We firmly believe, however, that truth never can be disagreeable when it is really understood in all its bearings and all its consequences, and conversely, that any proposition framed with a view to supposed desirableness rather than veracity, is almost certain to lead in the end to consequences quite undesirable. We will not, therefore, try to decide whether it may be more agreeable to believe that the health of adolescent girls requires general and permanent supervision, or that all responsibility may be discharged by confining them to a sofa and a novel for one week out of every four; to believe that a certain number of women, as of men, are always unfit for intellectual exertion, or that all women are inevitably rendered so unfit during one quarter of their lives at times unknown to outsiders, and which, therefore, may be at any time; to believe that the increased delicacy of women in civilized societies depends on a cultivated predominance of their ganglionic nervous system and emotional functions, or on the excessive stimulus of the cerebro-spinal system and on intellectual cultivation.

More useful than such discussion is the consideration of the methods that might be proposed, instead of that suggested by Dr. Clarke in the third proposition we have formulated from his book. Dr. Clarke's method is to provide regular intermittences in the education of girls, “conceding to Nature her moderate but inexorable demand for rest, during one week out of four.” The method that we believe to be suggested by the foregoing considerations would be more complex, but, we think, at once more effectual and less inconvenient. It may be stated in the following formula: “Secure the predominance of the cerebro-spinal system over the activity of the ganglionic.” Since the activity of the cerebro-spinal system may be roughly[46] divided into a twofold direction, intellectual and muscular, this predominance is to be secured by assiduous cultivation of the intellect as compared with the emotions, and of the muscles of the limbs as compared with the muscular fibre of the blood-vessels. In other words, the evil effects of school competition, and of the emotional excitement natural to adolescence, are to be combated by a larger, wider, slower, and more complete intellectual education than at present falls to the lot of either boys or girls. And the dangers incident to the development of new activity in the ganglionic nervous system by the functions of the ovaries, the dangers of irregular circulation, vaso-motor spasm and paralysis, are to be averted by systematic physical exercise, that shall stimulate the spinal nerves, quicken the external circulation, and favor the development of muscles at the moment that their activity threatens to be overpowered.

The effect of systematic training on the spinal nervous system, and on the bones and muscles dependent upon it, has been often enough described. Far less attention has been given to the equally positive development that can be secured for the brain, under the influence of prolonged and systematic exercise of its functions. An immense increase of functional capacity is possible, even without marked anatomical alteration; but even this is observed under circumstances that seem to indicate that it is rather the effect than the cause of changes in function. Retzius (Muller's Archives, 1845, p. 89[47]) observes that the female cranium varies in size much more than the male: “Female crania of the higher and middle classes are in general much smaller relatively than is the case among the peasants, a fact which probably depends on the different mode of life and occupation. The skull of the Norway female peasants is as large and strong as that of the men.” Welcker himself makes a somewhat analogous observation in regard to the crania of different races, the differences between the sexes being more marked in proportion to the civilization of the race—that is, to the degree of specialization of education, and mental occupation. He gives the following table:

CRANIAL CAPACITY.
WOMAN.MAN.
Asiatic Caucasian11.27.
European11.17.
Mongols11.13.
Malays11.08.
Americans11.08.
Negroes11.07.

Besides the prominent fact upon which Welcker insists, this table indicates two others. First, that the anatomical difference in the higher races is too little to explain the general difference in intellectual achievement really observed between the two sexes of these races. Second, that the difference is not in precise proportion to the maximum intelligence attained by the race, but to the social inferiority and subjection of the women; for the Asiatics (Hindoos) stand highest on the scale, the Europeans only second; and the excess of the first over the second, in regard to the point in question, is greater than the excess of the Europeans over the other races named.