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diff --git a/old/63274-0.txt b/old/63274-0.txt deleted file mode 100644 index 805c830..0000000 --- a/old/63274-0.txt +++ /dev/null @@ -1,33847 +0,0 @@ -The Project Gutenberg EBook of The sexual life of woman in its -physiological, pathological and, by Enoch Heinrich Kisch - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - -Title: The sexual life of woman in its physiological, pathological and hygienic aspects - -Author: Enoch Heinrich Kisch - -Translator: Maurice Eden Paul - -Release Date: September 23, 2020 [EBook #63274] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK THE SEXUAL LIFE OF WOMAN *** - - - - -Produced by Richard Tonsing, Turgut Dincer, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - - - - THE - SEXUAL LIFE OF WOMAN - IN ITS - PHYSIOLOGICAL, PATHOLOGICAL AND HYGIENIC ASPECTS - - - BY - - E. HEINRICH KISCH, M. D. - - Professor of the German Medical Faculty of the University of Prague; - Physician to the Hospital and Spa of Marienbad; Member of the Board of - Health, Etc., Etc. - - ONLY AUTHORIZED TRANSLATION INTO THE ENGLISH LANGUAGE FROM THE GERMAN BY - - M. EDEN PAUL, M. D. - - WITH 97 ILLUSTRATIONS IN THE TEXT - -[Illustration] - - NEW YORK - REBMAN COMPANY - 1123 BROADWAY - - - - - COPYRIGHT, 1910, BY - REBMAN CO., NEW YORK - - ALL RIGHTS RESERVED - - - _Printed in America_ - - - - - TO MY ONLY SON - - FRANZ KISCH, M. D. - - AS A TOKEN OF PATERNAL AFFECTION - - I DEDICATE THIS BOOK - ------------------------------------------------------------------------- - - - - - PREFACE. - - -The sexual life of woman—the appearance of the first indications of -sexual activity, the development of that activity and its culmination in -sexual maturity, the decline of that activity and its ultimate -extinction in sexual death—the entire process of the most perfect work -of natural creation—has throughout all ages kindled the inspiration of -poets, aroused the enthusiasm of artists, and supplied thinkers with -inexhaustible material for reflection. - -In the following pages, this sexual life of woman will be considered -both in relation to the female genital organs, and in relation to the -feminine organism as a whole; in relation both to the physical and to -the mental development of the individual; and in relation alike to the -state of health and to the processes of disease. Thus from the -standpoint of clinical investigation and of practical experience, the -book will be a contribution towards the solution of the sexual problem, -nowadays recognized as one of supreme importance. - -It is thirty years since I published a work on the histological changes -that occur in the ovaries during the climacteric period (Archiv. für -Gynecologie, Vol. xii, Section 3); and ever since that time, the -influence exerted upon the general health of women by the physiological -and pathological processes occurring in their reproductive organs, has -been to me a favourite subject for observation and experiment. The -result of these studies is incorporated in my monographs, “The -Climacteric Period in Women” (Erlangen, 1874), “Sterility in Women” (2nd -Ed., Vienna, 1895), “The Uterus and the Heart” (Leipzig, 1898), and in -various contributions to medical periodicals. I now have a welcome -opportunity of drawing a general picture of sexual activity in women, -and of illuminating this picture both by the light of my own experience -and by numerous references to the works of other authors. In passing, I -have devoted considerable attention to questions of education and -personal hygiene, both of which are greatly influenced by the processes -of the sexual life. Thus, I hope, the work will be rendered more -interesting to the physician, and the general picture it is intended to -convey will be more fully characterized by contemporary actuality. - -Natural divisions of the subject are, I consider, furnished by the three -great landmarks of the sexual life of woman: the _onset_ of -menstruation—the _menarche_: the _culmination_ of sexual activity—the -_menacme_; and the _cessation_ of menstruation—the _menopause_. These -several sexual epochs are differentiated by characteristic anatomical -states of the reproductive organs, by the external configuration of the -feminine body, by functional effects throughout the entire organism, -and, finally, by pathological disturbances of the normal vital -processes. - -Thus in separate chapters a description is given of sexual processes, a -detailed exposition of which will be vainly sought in the textbooks of -gynecology, yet which are none the less of far-reaching importance in -relation to the physical, mental, and social well-being of women, and in -relation also to the development of human society; such topics are, the -sexual impulse, copulation, fertility, sterility, the employment of -means for the prevention of conception, the determination of sex, sexual -hygiene. To the topics of pregnancy, parturition, lying-in, and -lactation, since these are adequately discussed in works on midwifery, -but little space has here been allotted. - -It is my earnest hope that physicians and biologists may derive benefit -from the book equal in amount to the pleasure I have gained in the work -of writing it. - - E. HEINRICH KISCH. - - - - - TABLE OF CONTENTS. - - - PAGE - THE SEXUAL LIFE OF WOMAN—Introduction 1 - - I. THE SEXUAL EPOCH OF THE MENARCHE 37 - - First Appearance of Menstruation 45 - - Anatomical Changes in the Female Genital Organs at the - Period of the Menarche 50 - - Menarche Praecox et Tardiva 78 - Precocious and Retarded Menstrual Activity 78 - - Pathology of the Menarche 82 - Anomalies of Menstruation 83 - Inflammatory Processes 87 - Disorders of Haematopoiesis 89 - Cardiac Disorders 94 - Diseases of the Nervous System 99 - Masturbation 104 - Disorders of Digestion 107 - Diseases of the Respiratory Organs 107 - Diseases of the Organs of the Senses 108 - Hygiene during the Menarche 111 - Menstruation 128 - Pathology of Menstruation 143 - Amenorrhœa, Menorrhagia, and Dysmenorrhœa 160 - Vicarious Menstruation 164 - - The Sexual Impulse 166 - - Nymphomania, Anæsthesia and Psychopathia Sexualis 184 - - II. THE SEXUAL EPOCH OF THE MENACME 200 - - Anatomical Changes in the Female Genital Organs in the - Period of the Menacme 209 - - Pathology of the Menacme 218 - Dyspepsia Uterina 227 - Cardiopathia Uterina 235 - Nervous Diseases Secondary to Diseases of the Genital - Organs 243 - - Competence for Marriage of Women suffering from Disease 250 - - Hygiene during the Menacme 261 - - Copulation and Conception 284 - Copulation 284 - Conception 304 - Pathology of Copulation 323 - Vaginismus 337 - Cardiac Troubles Due to Sexual Intercourse 344 - Dyspareunia 347 - - Fertility in Women 363 - The Restriction of Fertility and the Use of Means for - the Prevention of Pregnancy 388 - - The Determination of Sex 420 - I. Statistical Investigations 422 - II. Anatomical Investigations 446 - III. Experimental Investigations 452 - - Sterility in Women 462 - Incapacity for Ovulation 470 - Interference with Conjugation, Conditions Preventing - Access of the Spermatozoa to the Ovum 487 - Diseases of the Ovaries and the Fallopian Tubes 489 - Diseases of the Uterus 494 - Pathological Changes in the Cervix Uteri 501 - Displacements of the Uterus 515 - Myoma of the Uterus 523 - Diseases of the Vagina and the Vulva 526 - Secretions of the Genital Organs 528 - A. Absolute 540 - B. Relative Sterility 540 - Sexual Sensibility in Women 542 - Incapacity for Incubation of the Ovum 549 - Only-Child-Sterility 561 - Operative Sterility 563 - Table Showing the Causes of Sterility in Women 569 - - III. THE SEXUAL EPOCH OF THE MENOPAUSE 571 - - The Menopause 571 - - Changes in the Female Reproductive Organs at the Menopause 583 - - The Time of the Menopause 593 - - The Age at which the Menopause occurs 593 - 1. Race 594 - 2. The Age at which the Menarche Occurred 595 - 3. The Woman’s Sexual Activity 597 - 4. The Social Circumstances of the Woman’s Life 599 - 5. General Constitutional and Pathological Conditions 599 - 6. Premature, Delayed, and Sudden Onset of the - Menopause 600 - - Pathology of the Menopause 608 - Diseases of the Genital Organs 608 - Diseases of the Organs of Circulation 620 - Diseases of the Digestive Organs 630 - Diseases of the Skin 632 - Disorders of Metabolism 635 - Diseases of the Nervous System 637 - Climacteric Psychoses 643 - - Hygiene during the Menopause 653 - - - - - LIST OF ILLUSTRATIONS (Kisch). - - - FIG. PAGE - 1. Curve of the sexual life of woman from the tenth to the - sixtieth year of life 4 - 2. Portion of the pelvic viscera in the female, etc. 9 - 3. The distribution of the pudic nerve in the female perineal and - pubic regions 11 - 4. The distribution of the lateral sacral arteries, etc. 14 - 5. Curve of menstrual cycle 19 - 6. Curve of rhythmical variations 20 - 7. Curve of beauty of woman. 24 - 8. Internal genital organs of new-born female infant 51 - 9. Reproductive organs of a new-born female infant 52 - 10. Internal genital organs of a girl aged eight years 52 - 11. Reproductive organs of a girl aged ten years 53 - 12. Female external genital organs of a virgin 54 - 13. The external genital organs of a virgin 55 - 14. Sagittal section of the female pelvis 56 - 15. Primitive follicles 58 - 16. Ripening follicles 61 - 17. Graafian follicles 62 - 18. Annular Hymen 64 - 19. Annular Hymen 64 - 20. Semilunar Hymen 65 - 21. Annular Hymen with Congenital Symmetrical Indentations 65 - 22. Fimbriate Hymen 65 - 23. Deflorated Fimbriate Hymen 65 - 24. Septate Annular Hymen 67 - 25. Septate Semilunar Hymen 67 - 26. Extremely tough Annular Hymen with an obliquely disposed - Septum 67 - 27. Septate Hymen with Apertures of unequal Size 67 - 28. Septate Hymen with Apertures of unequal Size 68 - 29. Hymen with rudimentary Septum 68 - 30. Hymen with posterior rudimentary Septum 68 - 31. Labiate Hymen with posterior rudimentary Septum 68 - 32. Hymen with anterior rudimentary Septum 69 - 33. Hymen with anterior rudimentary Septum projecting in a - opiniform Manner 69 - 34. Hymen with anterior and posterior rudimentary Septa 69 - 35. Hymen with filiform Process projecting from the anterior - Margin 69 - 36. Hymen in which there are two symmetrically disposed thinned - Areas. The left of these is perforated 69 - 37. Very unusual form of Hymen 70 - 38. Semilunar Hymen with cicatrized Lacerations in its Border 70 - 39. Deflorated Semilunar Hymen with laterally disposed symmetrical - Lacerations 70 - 40. Deflorated Annular Hymen with several cicatrized Lacerations 70 - 41. A. Septate Hymen in which defloration has been effected - through one of the Apertures. U. Urethra. Cl. Clitoris. H. - Cicatrized Margin. C. Septum. B. Lateral view of Septum 70 - 42. Deflorated Septate Hymen 71 - 43. Hymen with larger anterior and smaller posterior Apertures 71 - 44. Carunculæ Myrtiformes in a Primipara 71 - 45. Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes. - Slight Prolapse of Anterior and Posterior Vaginal Walls 71 - 46. The breast of a virgin aged eighteen years 73 - 47. Horizontal section through the female breast 75 - 48. The female pudendum, or vulva, with the labia majora 204 - 49. Vestibule of the vagina, with the labia minora or nymphæ, etc 205 - 50. The uterus, the left Fallopian tube and the left ovary, etc 207 - 51. Female internal genital organs in the fully developed state 208 - 52. Sagittal Section through the Cervix Uteri of a Woman - twenty-six years of age. Dendriform branched glands 217 - 53. Cervix of a Woman seventy-two years of age, with glands that - have undergone cystic degeneration 217 - 54. Sagittal Section through the Cervix Uteri of a Woman - sixty-five years of age. The glands have undergone cystic - degeneration 217 - 55. First Stage. A. Entrance of a Spermatozoon into the Ovum of - Ascaris Megalocephala. B. After preparations by M. Nussbaum. - (Half of the ova only are depicted) 306 - 56. Ovum of Asterakanthion ten minutes after Fertilization 306 - 57. Fusion of Male Pro-nucleus and Female Pro-nucleus to form the - Segmentation Nucleus of the Fertilized Ovum 306 - 58. Passage of Spermatozoon through the Zona Pellucida of the Ovum - of Asterakanthion 307 - 59. Ovum of Scorpæna Scrofa Thirty-five Minutes after - Fertilization 307 - 60. Male Pro-nucleus and Female Pro-nucleus in Fertilized Ovum of - Frog, prior to the Formation of the Segmentation Nucleus 307 - 61. a. b. c. Prostatic calculi from normal semen, d. Spermatozoa. - e. Large and small cells, some containing granules, as - morphological elements of semen. f. Spermatozoon distorted - by imbibition of water. g. Crystals (after Bizzozero) 311 - 62. Normal Semen 311 - 63. Semen consisting chiefly of sperm-crystals, cylindrical - epithelium, and small granules exhibiting molecular - movement—but containing _no_ spermatozoa 315 - 64. Oligozoöspermia. a. Living Spermatozoa, b. Dead Spermatozoa, - c. Pus Corpuscles, d. Erythrocyte, e. Seminal granules 317 - 65. Septate Hymen, the septum having a tendinous consistency 324 - 66. 326 - 67. Lipoma of the Right labium majus, including the Vaginal Inlet 328 - 68. “Hottentot Apron” in an adult Woman, hanging down between the - thighs (after Zweifel) 329 - 69. Elephantiasis of the Labia Majora 330 - 70. Congenital Atrophy of the Uterus (after Virchow), oi, Ostium - internum; oe, Ostium externum 500 - 71. 500 - 72. Normal Shape of the Portio Vaginalis 503 - 73. Conoidal Shape of the Portio Vaginalis 503 - 74. “Apron-Shaped” Vaginal Portion, a. Greatly elongated anterior - lip; b. Shorter posterior lip of the cervix 504 - 75. “Beak-Shaped” Vaginal Portion. Posterior aspect 504 - 76. Simple Hypertrophy of the Portio Vaginalis, which projected - from the Vulva 506 - 77. Elongated Cervix, bent upwards 506 - 78. Cervical Polypus, originating from an Ovulum Nabothi 510 - 79. Ectropium in a Case of Bilateral Laceration of the Cervix - (after A. Martin) 514 - 80. Anteflexio Uteri (after A. Martin) 518 - 81. Retroflexio Uteri (after A. Martin) 520 - 82. Mucus from the Cervical Canal, taken one hour after sexual - intercourse, from a woman suffering from chronic - endometritis. Among the epithelial cells, pus cells, and - finely granular masses, we see a few motionless, dead - spermatozoa 531 - 83. Uterine Mucous Membrane in Endometritis (after A. Martin) 554 - 84. Sagittal section through the ovary of a girl aged sixteen 583 - 85. Sagittal section through the ovary of a woman aged seventy-two - years 584 - 86. Diagrammatic Representation of the Graafian Follicle 585 - 87. Ovary of a Girl aged nineteen years (Normal Size) 585 - 88. Ovary of a Woman seventy-two years of age (Normal Size) 585 - 89. 586 - 90. 587 - 91. 588 - 92. Sagittal Section through the Cervix of a Woman twenty-six - years of age. Dendriform branched glands 588 - 93. Sagittal Section through the Cervix of a Woman sixty-five - years of age. Glands which have undergone Cystic - Degeneration 589 - 94. Cervix of a Woman seventy years of age. The Cervical Glands - have undergone Cystic Degeneration 589 - 95. Ovula Nabothi in the Portio Vaginalis 590 - 96. Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane 591 - 97. Mucous Glands undergoing Cystic Degeneration 592 - - - - - THE SEXUAL LIFE OF WOMAN. - - -By the _sexual life of woman_ we understand the reciprocal action -between the physiological functions and pathological states of the -female genital organs on the one hand and the entire female organism in -its physical and mental relations on the other; and the object of this -book is to give a complete account of the influence exercised by the -reproductive organs, during the time of their development, their -maturity, and their involution, on the life history of woman. - -From the earliest days of the medical art this sexual life of woman has -aroused in the leaders of medical thought the highest interest, and for -this reason great attention has been directed, not only to the anatomy -of the genital organs and to the diseases of the reproductive system, -but also to the individual manifestations of sexual activity and to the -influence exercised by these on the female organism as a whole. - -Several works by _Hippocrates_ are extant on this subject, among which -may be mentioned: περι Γυναικειης Φυσεος,[1] a treatise on the -physiology and pathology of woman; περι Αφορων,[2] which discusses -sterility in women; περι παρθενιων,[3] a treatise on the pathological -states of virgins. These writings of _Hippocrates_ contain some very -remarkable observations on the influence exercised by disorders of the -reproductive organs on the general health of women. - -_Aristotle_ wrote at some length on the functions of the female genital -organs. In the writings of _Aretæus_ and _Galen_ on the diseases of -women we find striking observations, as for instance, in _Galen’s De -Locis Affectis_,[4] which contains a “Statement of the Similarity and -Dissimilarity of Man and Woman.” Another notable work is that of -_Albertus Magnus_, entitled _De Secretis Mulierum_.[5] - -The numerous works on the diseases of women published in the sixteenth -century consisted for the most part of a repetition of the observations -of ancient writers. The gynecological treatises of the eighteenth -century, however, bore witness to an increased knowledge of the anatomy -of the female reproductive organs, and were illumined by _Haller’s_ -researches on the functions of these organs. - -The subject with which we are especially concerned is discussed in a -work by _Boireau-Laffecteur_, _Essai sur les Maladies Physiques et -Morales des femmes_,[6] Paris, 1793; and also in _Marie-Clement’s -Considerations Physiologiques sur les Diverses Epoques de la Vie des -Femmes_,[7] Paris, 1803. the same connection we must mention _von -Humboldt’s_ treatise, _Ueber den Geschlechtsunterschied und dessen -Einfluss auf die organische Natur_.[8] The first comprehensive work in -which an exhaustive inquiry was made into the functional disorders of -the female genital organs and the relation of these disorders to the -female organism as a whole and to the physical and mental peculiarities -of woman was _Busch’s: Das Geschlechtsleben des Weibes_,[9] Leipzig, -1839. - -In the second half of the nineteenth century a very large number of -monographs were published, investigating and describing the reflex -disturbances produced alike in the individual organs and in the nervous -system as a whole by changes in the uterus and its annexa. Many of these -works will be mentioned more particularly in the course of this -treatise. - -The sexual life, based upon the purpose, so important to every creature, -of the propagation of the species, possesses in the female sex a vital -significance enormously greater than sexual activity possesses in the -male. From the very beginning of sexuality, when the idea of a bisexual -differentiation dawns for the first time in the brain of the little -girl, down to the sexual death of the withered matron, who laments the -loss of her sexual potency, physical and mental activity, work and -thought, function and sensation, arise for the most part, wittingly or -unwittingly, from that germinal energy which is the manifestation of the -unalterable law that the existing organism endeavors to reproduce its -kind. - -Every phase of the sexual life of woman, from the threshold of puberty -to the extinction of sexual activity, the first appearance of -menstruation, the complete development of the sexual organs, the act of -copulation, conception, pregnancy, parturition, and the puerperium, -finally the involutionary process which accompanies the cessation of -menstruation at the climacteric period—every one of these sexual phases -entails consecutive physiological processes and pathological changes -alike in the individual organs and in the nutritive condition of the -entire organism, in the functions of the cardio-vascular apparatus, of -the brain and the nerves, of the skin and the sense-organs, in the -processes of digestion and general metabolism. Herein we see a striking -illustration of the old saying of _von Helmont_, _propter solum uterum -mulier est quod est_;[10] also of the similar aphorism of _Hippocrates_, -_uterus omnium causa morborum qui mulieres infestant_;[11] a conception -summed up by _Goethe_ in the words of Mephistopheles: - - “Es ist ihr ewig Weh und Ach - So tausendfach - Aus einem Punkte zu kurieren.” - -Just as in a tree the process of growth is made manifest to the -superficial observer by the pleasure he feels at the sight of the buds -and blossoms, by the refreshment he obtains from the fruit, and by the -sadness which the withering of the leaves causes him, so in the sexual -life of woman there are landmarks which no one can possibly overlook, by -means of which three great epochs are distinguished. These are: puberty -(the menarche), recognized by the first appearance of menstruation and -the awakening of the sexual impulse; sexual maturity (the menacme), in -the fully developed woman, characterized by the functions of copulation -and reproduction; and sexual involution (the menopause), in which we see -the gradual decline and ultimate extinction of sexual power and all its -manifestations. In all these three epochs the sexual life of woman not -only affects the hidden domain of the genital organs, but controls also -all the vegetative, physical, and mental processes of the body, and is -clearly and incontestably apparent in all vital manifestations. What -Madame de Staël said of love is indeed true of the entire sexual life of -woman: _l’amour n’est qu’unc épisode de la vie de l’homme; c’est -l’histoire tout entière de la femme_.[12]. - -The sexual life of woman is coextensive with the peculiar vital activity -of the female sex, for it endures from the moment when individuality -first begins to develop out of the indifferent stage of childhood until -the decline into the dead-level of senility. - -To illustrate this fact, I have drawn up a curve of the sexual life of -woman, making use of the statistical data available in central Europe -regarding the age at which menstruation first appears, the age at which -maidens marry, the age at which the largest number of women give birth -to a child, and the age at which menstruation ceases; and reducing the -figures to averages. * denotes the fifteenth year of life, as the -average age at the menarche; ** denotes the twenty-second year of life -as the average age at marriage; *** denotes the thirty-second year of -life, in which woman exhibits her maximum fecundity; **** denotes the -forty-sixth year of life as the average age at the menopause. (FIG. 1.) - -[Illustration: - - FIG. 1.—Curve of the sexual life of woman from the tenth to the - sixtieth year of life. -] - -Not in this respect alone, however, is the sexual life of woman of -paramount importance; it is, in addition, the mainspring of the -well-being and progress of the family, of the nation, of the entire -human race. In the evolution of man from the primitive state in which he -existed merely for the performance of vegetative functions up to the -highest stage of contemporary culture, in the history of all races and -of all times, the sexual life has been a most potent determining factor. -With that life, religion, philosophy, ethics, natural science, and -hygiene, have been most intimately related; for that life, they have -furnished precepts and laws. The history of the sexual life is identical -with the history of human culture. - -In a primitive condition of society, among people living in a state of -nature and among the lower races of mankind, the sexual life of woman -possesses no great general interest, the female being merely a chattel; -the ownership of this chattel, moreover, being often temporary and -transient. The investigations of anthropologists have shown that among -primitive people this form of property is neither highly esteemed nor -carefully safeguarded. In such societies no restraint is imposed on the -sexual impulse, which is gratified without shame and without formality. -No hindrance is offered to the mutual intercourse of the two sexes. -Chastity in the females is not prized by the males, nor do the latter -compete for the favors of the former. Procreation is no more than a -gregarious impulse of the masses among whom the common ownership of all -booty is a matter of tribal custom. The woman has no disposing power -over that which every one desires and which every one has the right to -demand. Very gradually, however, a change takes place in this respect, -so that in every period of social life since the very earliest, the -modesty of young girls, the high valuation put upon the preservation of -virginity, the ethical approbation of chastity in the wife, respect for -the duties and rights of the mother, the reverence felt for the -matron—all these, throughout the sexual life of woman, have had a -civilizing, ennobling, and elevating effect. Thus, as family life has -become developed, and as love and marriage have been more highly -esteemed, woman has become the much-prized embodiment of all that is -beautiful and good, of all that is summed up in the idea of the -“housewife,” and her sexual life has been more completely, more ideally -admired. The danger is not remote, however, that the leveling tendencies -of the present day, and an inclination to despise the sexual life of -woman, far from resulting in a further elevation of the social status of -womanhood, will result rather in its abasement. - -The Bible, as we may expect from the patriarchal relationships of the -women of that time, bears witness to the worth of woman, and, whilst -esteeming child-bearing, refers to yet higher duties. Precise religious -and social precepts are furnished for all the phases of sexual life. - -In classical antiquity, also, we see that woman rose to some extent -above the low position she had previously occupied in the family circle -and in society at large. Both among the Greeks and among the Romans, -there was open to women a more intimate place in social life and a more -influential rôle in the life of the family, than would have been their -portion regarded merely in relation to their child-bearing activity. -Amongst the Germans in the very earliest times, chastity gave rise to -purer and more moral sexual relations; whereas among the Slavonic -peoples the conception of woman as the childbearer continued to dominate -these relations. - -In consequence of the diffusion of Christianity, woman became man’s -companion and equal, and her life, the sexual life included, acquired a -deeper significance, owing to the stress which that religion laid on -chastity as a virtue, and as a result of the educational influence of -woman in the family circle. - -With the progress of civilization the sexual life of woman comes to -exhibit its activities only within the bounds of morality and law, which -in human society have replaced the crude rule of nature, and have -supplied regulations adapted to the changing phases of sexual vital -manifestations. The wise adaptation of these regulations requires, -however, a full understanding of the mental and physical processes, an -exact recognition of the bodily states and intellectual sensibilities, -of woman regarded as a sexual being. - -Modern culture and the social organization of the present day, in -association with the resulting sexual neuropathy of women, have -exercised on their sexual life an influence as powerful as it is -unfavorable, manifesting itself in the overpowering frequency of the -diseases of women. In one of the most thoughtful books ever written on -the subject of woman, _Michelet’s L’Amour_,[13] the author remarks that -every century is characterized by the prevalence of certain diseases: -thus, in the thirteenth century, leprosy was the dominant disease; the -fourteenth century was devastated by bubonic plague, then known as the -black death; the sixteenth century witnessed the appearance of syphilis; -finally, as regards the nineteenth century, “_se siècle sera nommé celui -des maladies de la matrice_”.[14] It is certain that the education and -mode of life of the modern woman belonging to the so-called upper -classes are, as far as sexual matters are concerned, in direct -opposition to those that are agreeable to nature and those that the laws -of health demand. - -Even before sexual development begins, before the physical ripening of -the reproductive organs to functional activity, the imagination of young -girls is often prematurely occupied with sexual ideas in consequence of -unsuitable literature, owing to visits to theatres and exhibitions, or -on account of social intercourse with young men who are not -overscrupulous in the selection of topics for conversation. From the -time of puberty up to the time of marriage the growing woman is under -the influence of the now awakened sexual impulse, which experiences -ever-renewed stimulation. A sedentary mode of life, unsuitable -nutriment, and the early enjoyment of alcoholic beverages, exhibit their -inevitable result in the frequency with which, in this epoch of the -sexual life, chlorotic blood-changes, neurasthenic conditions, and -diverse symptoms of irritation of the genital organs, make their -appearance. Thus, when marriage, so often unduly postponed in -consequence of the condition of modern society, does at length take -place, it is apt to find the woman not only fully enlightened as regards -sexual matters, but often in a state of nervous weakness from sexual -stimulation, one of the type whose characteristics have been happily -summed up by the French writer _Prévost_ in the expression -_demi-vierge_.[15] The conjunction of this state of affairs in the bride -with the frequent partial impotence of the bridegroom, who has already -dissipated the greater part of his virile power before entering upon -marriage, leads often to the appearance of vaginismus and other sexual -neuroses in young married women. Even more disastrous in its -consequences as regards the future sexual life of the wife is the -ever-increasing frequency of gonorrhœal infection in the first days of -marital intercourse, with all the evil results of that infection. On the -other hand, an ever-larger proportion of girls belonging to the “middle -and upper classes,” abstaining alike from the good and the evil results -of marriage, falls under the yoke of sexual impulses denied satisfaction -or gratified by abnormal means, and suffers in consequence both -physically and mentally. Further sources of injury arising from the -conditions of modern social life are to be found in the neglect by women -of the well-to-do classes of the duty of suckling their children, and in -the ever-increasing frequency with which the women of these classes, -after giving birth to one or two children, resort to the use of measures -for the prevention of pregnancy, which result in serious consequences as -regards both the nervous system and the genital organs of the women -concerned. Thus there comes an accelerated ebb in the sexual life, -leading to a premature appearance of the general phenomena of senility, -with a cessation of the menstrual flow. The modern wife, who claims the -right to lead the life that best pleases her, will be more rapidly -overtaken by sexual death. - -For the elucidation of the manifold reflex and other processes which are -dependent upon or accompany the sexual phases of woman, we must in the -first place consider the anatomical changes and physiological functions -of the female reproductive organs characteristic of the several periods -of sexual life which have already been distinguished. We must not fail -also to take into consideration the mental states which accompany and -characterize these respective phases. - -The anatomical changes which occur in the female genital organs during -these different phases of sexual life give rise to a number of manifold -local stimuli, increasing and decreasing, varying greatly in intensity -and area of distribution, upon which depend the reflex effects and -remote manifestations in the sphere of the nervous and circulatory -systems. - -We must first consider the changes in the ovaries, which play an -etiologically important part. At the onset of puberty, the follicular -masses of the ovary exhibit a more active growth, the follicles increase -in size, with their contained ova they approach the surface, and -finally, by the bursting of the follicles, the ova are extruded. Then, -in the life-phase in which conception occurs, and under the influence of -the hyperæmia of all the pelvic viscera that accompanies this process, a -notable development of the corpus luteum takes place, this latter body -reaching its maximum size in the eleventh week of pregnancy, -subsequently undergoing involution and leading to the formation of a -considerable scar. Finally, in the critical period of life in which the -menstrual flow ceases, a continually increasing growth and new formation -of connective tissue-stroma takes place in the ovaries at the expense of -their cellular constituents, and a regressive metamorphosis of the -graafian follicles occurs. - -In association with these sexual processes there ensues a series of -striking changes in the shape and consistency of the ovaries, affecting -both the surface and the parenchyma of these organs, and capable of -stimulating the nervous ramifications in their tissue. In this -connection it is worthy of note that the branches supplying the ovaries -from the spermatic plexuses of the sympathetic contain a considerable -proportion of sensory fibres. - -Quite as significant, moreover, as the changes in the ovaries, are those -which, in the course of the sexual life, the uterus undergoes, in shape -and size, in its muscular substance and mucous lining, and in its -vascular and nervous supply. - -[Illustration: - - FIG. 2.—Portion of the pelvic viscera in the female, and their - relation to the muscles of the pelvic outlet (or perineal muscles), - shown in the left half of the pelvis, seen from the right side.—The - parametrium. (From Toldt: Atlas of Human Anatomy.—Rebman Company, - New York.) -] - -At the time of puberty the infantile uterus undergoes changes affecting -both its external form and the shape of its interior cavity. The body of -the uterus enlarges to the size characteristic of sexual maturity, and -its mucous membrane becomes the seat of periodic changes. This waxing -and waning growth and transformation of the uterine mucous membrane -continues throughout the period of menstrual activity, the most -superficial layers of the membrane being shed during menstruation, a -process followed by regeneration, which is itself succeeded by the -premenstrual thickening. When conception occurs, still more extensive -changes ensue, the fertilized ovum becoming imbedded in the uterine -mucous membrane, and the pregnant uterus, in shape and structure and in -the respective relations of the body and neck of the organ, in the -increasing distension of its veins and the increasing size of its -nerves, becoming adapted to the important functions it has now to -fulfil. When these have been fulfilled, and, parturition having taken -place, the uterus is empty once more, the organ again adapts itself to -altered circumstances by the process of involution. Later, in the -climacteric period, a slow regressive process occurs, the outward -manifestation of which is the cessation of the menstrual flow, -characterized anatomically by atrophy of the muscular tissue of the -uterus and of its vascular apparatus, by the dessication of its mucous -membrane, by obliteration of the lumen of the uterine cavity, and -ultimately by senile degeneration and atrophy of the now entirely -functionless organ, so that it becomes an insignificant, cicatrized, -solid body. - -Next to the ovaries and the uterus, it is the pelvic fascia which in its -entire architectonic structure as well as in its individual parts -undergoes the most notable changes in consequence of the processes of -generation. - -A short account of the nerves and blood vessels of the female genital -organs appears indispensable, to facilitate the comprehension of the -manner in which sexual processes are influenced by the nervous system, -and to demonstrate the intimate connection between the blood-supply of -the genital apparatus and the general circulation. - -The complex nervous network of the female sexual organs is supplied by -spinal as well as by sympathetic fibres, the fibres from the two systems -anastomosing in a very intimate manner. - -[Illustration: - - FIG. 3.—The distribution of the pudic nerve, n. pudendus, in the - female perineal and pubic regions. The trunk of the pubic nerve, n. - pudendus, is covered by the gluteus maximus muscle. On the right - side of the body the branches of the inferior pudendal nerve, rami - perineales, nervi cutanei fermoris posterioris have been dissected - out; but the branches of this nerve to the labium majus have been - cut short. The formation of the anococcygeal or subcaudal nerves, - nn. anococcygei, out of the posterior primary division of the - coccygeal nerve and out of the perforating branches which arise from - the anterior primary divisions of the fourth and fifth sacral nerves - and the coccygeal nerve. (From Toldt: Atlas of Human Anatomy.—Rebman - Company, New York.) -] - -The greater number of the spinal nerves distributed to the genital -organs arise from the lumbar portion of the spinal cord, pass as rami -communicantes to the first four lumbar ganglia of the great sympathetic -cord, whence they proceed to the series of symmetrical (paired) and -asymmetrical (azygos) sympathetic plexuses in front of, and adjacent to -the abdominal aorta, which already contain afferent and efferent spinal -fibres derived from the pneumogastric, phrenic, and splanchnic nerves. A -small number only of coarse nerve-filaments, a larger number of fine -nerve-filaments, derived from the sacral nerves, proceed direct to the -internal genital organs; many of these fibres enter the lower extremity -of the pelvic or inferior hypogastric pleans, some pass to the cervical -ganglia of the uterus. Below the bifurcation of the aorta and in front -of the sacral promontory, a large number of the uterine nerves, both of -spinal and of sympathetic origin, unite to form an azygos plexus which -has been shown by experiment to possess great functional importance. -Anatomically this constitutes the upper undivided portion of the -hypogastric plexus, which is the downward continuation of the abdominal -aortic sympathetic plexus; but inasmuch as it is the principal channel -of nervous impulses to the uterus it is often known at the present day -as the great uterine plexus (_plexus uterinus magnus_). The nerves to -the ovary and Fallopian tube (ovarian nerves) are derived from the -spermatic (ovarian) plexus, an offshoot of the renal plexus; as the -spermatic plexus descends, it is reinforced by branches from the -abdominal aortic plexus, these branches often arising from a small -ganglion (spermatic ganglion). The hypogastric or great uterine plexus, -single and median above, divides below into the paired pelvic or -inferior hypogastric plexuses, which pass downward and forward on either -side of the rectum; these plexuses are reinforced by spinal elements -derived from the sacral nerves. Before the terminal expansions of the -pelvic or inferior hypogastric plexus enter the tissues of the internal -genital organs, the bladder, and the rectum, small masses of ganglionic -matter are interspersed among the nerve fibres. - -To the above general sketch, which has been based on the synoptical -description of _Chrobak von Rosthorn_, must be added a more detailed -account of the innervation of the ovaries, this branch of the subject -being of especial importance. The nerves of the ovary are derived from -the sympathetic system, in part from the spermatic ganglion, in part -from the second renal ganglion, and in part from the superior mesenteric -plexus. The nerves of the ovary are for the most part vascular nerves, -which unite before entering the ovary to form the ovarian plexus, and -then pass into the hilum with the vessels, envelop the vessels of the -medullary layer, and thence pass to the follicular region; exceedingly -numerous, they form a close-meshed network, surrounding all the vessels -up to the finest capillary ramifications; those fibres which terminate -in the capillary walls and those also which reach the follicles are -regarded by _Riese_ as sensory. The great trunks of the uterine nerves -are transversely disposed in relation to the great lateral vessels of -the uterus, and passing inward toward the mucous membrane they break up -into pencils of filaments; the uterine nerves proper are distributed for -the most part to the muscular substance. In the Fallopian tubes, the -nerves form arches around the lumen of the tube; some fibres also pass -to the longitudinal folds of the mucous membrane. - -This expansion of the nerves of the cerebrospinal and sympathetic -systems in the female reproductive organs manifests the multiple -interconnection of the two systems in this region, and proves beyond -doubt that the sensory nerves of the genital organs have manifold -connections with the motor tracts of the whole organism on the one hand -and with the sensory ganglia of the central nervous system on the other, -and in addition with the vasomotor centres and with efferent motor and -secretory fibres. - -As regards the vascular system of the female genital organs, the latter -are supplied by the internal iliac artery. One of the two terminal -branches of the common iliac, the internal iliac artery, descends into -the pelvis over the sacro-iliac synchondrosis. Its branches may be -arranged in four groups: anterior group, the hypogastric, iliolumbar, -and obturator arteries; posterior group, the lateral sacral, gluteal, -and sciatic arteries; internal group, the inferior vesical, uterine, and -middle haemorrhoidal arteries; inferior group, comprising a single -artery only, the internal pudic; the uterine artery supplies the uterus -and the vaginal fornices; the ovarian artery supplies the ovary, the -Fallopian tube, and the broad ligament of the uterus; the vaginal, -cervicovaginal, or vesico-vaginal artery supplies the vagina; the -internal pudic artery supplies the vestibule and the clitoris; the -superior and inferior external pudic arteries (branches of the femoral -artery) supply the labia majora. The veins of the female genital organs -correspond in general to the arteries in their course and nomenclature, -and empty their blood into the internal iliac vein. - -[Illustration: - - FIG. 4.—The distribution of the lateral sacral arteries, the superior - haemorrhoidal or superior rectal artery, the uterine artery, the - ovarian artery and the distal portion of the internal pudic artery. - (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) -] - -Attention must also be paid to the extremely rich lymphatic vascular -system of the female genital apparatus. The body of the uterus and the -annexa of that organ, the neck of the uterus and the vaginal fornices, -the middle segment of the vagina, the lower segment of the vagina, the -vestibule and the external genital organs—each of these possesses an -independent set of lymphatic vessels, leading moreover to independent -groups of lymphatic glands. It may be said that the lymph from the vulva -passes to the inguinal glands, that from the vagina and the neck of the -uterus to the internal and the external iliac lympathic glands, that -from the upper part of the uterus and also that from the ovaries and -Fallopian tubes to the median group of lumbar lymphatic glands (also -known, from their position in front of the aorta and the vena cava, as -the aortic lymphatic glands) (_Chrobak von Rosthorn_). - -The important influence which the genital processes exercise on the -female organism as a whole is established not only by the anatomical -relations just described but also by a number of physiological -investigations and experiments and by the result of operations on the -female genital organs. - -Thermic and mechanical stimulation of the female genitals has, as my own -experiments have shown, a notable influence on the heart and the general -circulation. In these experiments, when uterine douches were given at -temperatures of 4° C. (39° F.) and 45° C. (113° F.), the reflex nervous -impulse which resulted from these manipulations had a two-fold influence -on the circulation, manifesting itself first by an immediate and -considerable augmentation in the functional activity of the heart, the -frequency of which was increased in a degree proportional to the nervous -sensibility of the individual, and secondly by a notable rise in blood -pressure. - -With a view to determining the influence of stimulation of the ovary on -blood-pressure, _Röhrig_ carried out some experiments on bitches, from -which it appeared that electrical stimulation of the ovary invariably -produced a remarkable increase in the general blood-pressure, an -increase ranging from twelve to twenty-four millimeters of mercury. It -further appeared in the course of these experiments that toward the end -of the period of stimulation the rise in blood-pressure was always -followed by a decline; to which, however, a renewed rise of -blood-pressure succeeded after the stimulation was discontinued, -provided the duration of this had not been excessive. Only after this -second rise was the normal mean blood-pressure regained. Finally it was -established that the pronounced phenomena of vagus-irritation exhibited -by the curve during and immediately after the stimulation of the ovary -were invariable concomitants of the rise of blood-pressure produced by -such stimulation. - -According to the observations of _Federns_, the blood-pressure undergoes -a rhythmical change between one menstrual period and the next, the -pressure curve being normally at its lowest at the time of the -commencement of the flow, and at its highest at some time during the two -days immediately preceding the flow. This rhythmical change of -blood-pressure manifests itself also some time before the first onset of -menstruation, when the approach of puberty is indicated only by the -menstrual molimina. - -Observations made by _Kretschy_ in a patient with a gastric fistula have -proved the influence exercised on gastric digestion by the physiological -processes occurring in the female reproductive organs. In this patient, -his attention was especially directed to determining at what period of -digestion the secretion of acid by the stomach attains its maximum, and -how that secretion increases and diminishes. He observed that the -digestion of breakfast was completed in four and one-half hours, the -acid-maximum occurring in the fourth hour, and the reaction of the -gastric contents becoming neutral one and one-half hours later. This -apparently constant acid-curve began, however, to become irregular as -soon as the first symptoms of the approach of menstruation became -apparent. When the flow had actually begun, he found that the reaction -of the gastric contents remained acid throughout the entire day. As soon -as the flow was over, the normal acid-curve was immediately -reëstablished. - -These observations have been confirmed by _Fleischer_. This investigator -carried out his researches in menstruating women with normal stomachs, -and found that with the appearance of the catamenia the process of -digestion was almost always notably retarded, but that with the -diminution and cessation of the flow digestion returned to the normal. - -By stimulation of the central segment of the divided hypogastric or -great uterine plexus, _Cyon_ was able to provoke vomiting, a -confirmation of the well-known physiological fact that irritative -disturbances of the female reproductive organs have a reflex influence -on the vomiting centre. - -It is also clearly established that diverse stimulation of peripheral -nerves, those for instance of the mammary gland, of the internal -genitals, or of the epigastrium, is capable of affecting the motor -centre of the uterus. - -Worthy of note also are _Strassmann’s_ experiments, showing that rise of -pressure in the ovary causes swelling and structural changes in the -uterine mucous membrane. - -Striking also are _Neusser’s_ discoveries that during menstruation there -is an increase in the eosinophil cells of the blood, and that by the -intermediation of the sympathetic nervous system the ovaries exercise an -influence on the hæmatopoietic function of the red marrow of the bones. -Most noteworthy is the connection between the functional activity of the -ovaries and osteomalacia. In this disease of metabolism we have to do, -according to _Fehling’s_ now generally accepted assumption, with a -trophoneurosis of the bones, a stimulation of the vasodilator nerves of -the osteal vessels, dependent on a reflex impulse from the ovaries. The -connecting path between the ovaries and the bones _Neusser_ finds in -this case also in the sympathetic nervous system. - -The reflex influence exercised on the heart and the general circulation -has been shown also by the results of operations on the female genital -organs. In cases in which the ovaries have been removed, or in which -these organs have been roughly handled, _Hegar_ has noticed a great -diminution in the frequency of the pulse, sometimes even cessation of -the heart’s action. In similar circumstances _Champonière_ also observed -as a rule diminished frequency of the pulse, but in some cases increased -frequency. _Mariagalli_ and _Negri_ have described tachycardia following -laparotomy and the extirpation of double pyosalpinx. _Bonvalot_ has -published cases in which, in consequence of vaginal or intra-uterine -injections, in consequence of simple examination, and in consequence of -the performance of version, sudden death has resulted from cardiac -syncope. - -The psychical influences which proceed from the female genital organs in -the different periods of sexual life have also great significance for -the organism as a whole. Manifold impulses both stimulating and -depressing arising in the reproductive organs affect the workings of the -mind. The maiden at puberty is affected by the knowledge of sexuality; -the sexually mature woman, by the desire for sexual satisfaction, and by -the yearning for motherhood; the wife, by the processes of pregnancy, -parturition, and suckling, or, on the other hand by the distressing -consciousness of sterility; the woman at the climacteric period, by the -knowledge of the disappearance of her sexual potency. The mind is -further sympathetically influenced by the stimulation of the terminals -of the sensory nerves in the genital organs. Through the increase of -such stimulation, through its spread to adjacent nerves and nerve tracts -and to the entire nervous system, the mind is affected, directly by -irradiation, or indirectly by vasomotor processes and spinal -hyperæsthesia. - -Psychical manifestations and the nervous states associated with these -are somewhat frequently, and even actual psychoses occasionally, -encountered in the various phases of the sexual life of woman, sometimes -taking the form of violent sexual storms, which may indeed, as ordinary -menstrual reflexes, accompany every catamenial period. - -Of great interest are the facts which have, in recent times especially, -been scientifically established, pointing to a certain periodicity, to -an undulatory movement of the general bodily functions of the female -organism, dependent upon the sexual life. The observations of _Goodman_, -_Jacobi_, _von Ott_, _Rabuteau_, _Reinl_ and _Schichareff_, have shown -that in woman the principal vital processes pursue a cycle made up of -stages of increased and diminished intensity, and that this periodicity -of the chief general processes of vital activity finds expression also -in the functions of the reproductive organs. _Goodman_ has compared this -play of general vital functions to an undulatory movement. According to -this writer, a woman’s life is passed in stages, each of which -corresponds in duration with a single menstrual cycle. Each of these -stages exhibits two distinct halves, in which the vital processes are -respectively ebbing and flowing: in the latter we see an increase of all -vital processes, a larger heat production, a rise in blood-pressure, and -an increased excretion of urea; in the former we see, on the contrary, -that all these vital processes display a diminished intensity. The -moment when the period of increased vital activity is at an end, the -moment when the ebb begins, corresponds, according to _Goodman_, to the -commencement of the catamenial discharge. - -_Goodman_ sought for verification of this undulatory theory of the -sexual life of woman in certain data regarding the bodily temperature -and the blood-pressure. A more extensive research was undertaken by -_Jacobi_, who, as the result of her observations, came to the following -conclusions. In eight cases she noticed in the premenstrual epoch a rise -of temperature ranging from 0.05° C. to 0.44° C. (0.09° F.–0.79° F.); -and during the catamenial discharge a gradual fall of 0.039° C.–0.25° C. -(0.072° F.–0.45° F.), never less, that is to say, than a quarter of a -degree Centigrade; but in the majority of cases the temperature did not, -while the catamenia lasted, regain the normal mean. She further observed -in the generality of cases an increased excretion of urea during the -premenstrual epoch; and a notable fall in blood-pressure during -menstruation. - -_Reinl’s_ observations on healthy women, in whom menstruation ran a -normal course, showed that in the great majority of cases in the -premenstrual epoch the temperature was elevated as compared with that of -the interval, that in eleven out of twelve cases the temperature -gradually declined during menstruation, to fall in three-fourths of the -cases below the mean temperature of the entire interval, and exhibiting -in the post-menstrual epoch a still further depression, giving place, -however, to a somewhat higher mean temperature during the first half of -the interval. In the second half of the interval a higher mean -temperature was observed than in the first half. - -If we make a graphic representation of the mean differences in -temperature commonly observed throughout the various stages of an entire -menstrual cycle, we see that the curve does in fact take the form of a -wave. That drawn by _Reinl_ is shown in the following figure: (FIG. 5.) - -[Illustration: - - FIG. 5. -] - -The rising portion of the wave, the beginning of the tidal flow, -corresponds to the second half of the interval; the height of the tidal -flow, the crest of the wave, corresponds to the premenstrual epoch. As -the flow gives place to the ebb, as the wave begins to decline, we come -to the actual period of the catamenial discharge; later in the ebb is -the post-menstrual epoch, and the lowest portion of the declining wave -corresponds to the first half of the interval. Rhythmic changes -corresponding to those observed in the temperature have been recorded—at -least in isolated stages of the menstrual cycle—affecting the -blood-pressure by _Jacobi_ and by _von Ott_, affecting the excretion of -urea by _Jacobi_ and by _Rabuteau_, and affecting the pulse by _Hennig_. -It is evident that the vital activity of the organism attains its -maximum shortly before menstruation; and that with or immediately before -the appearance of the catamenial discharge, a decline of that activity -commences. - -_Schrader_, through his researches on metabolism during menstruation in -relation to the condition of the bodily functions during this process, -has established that immediately before menstruation the elimination of -nitrogen in the fæces and the urine is at its lowest, a fact which -indicates that at this period of the menstrual cycle the disintegration -of albumen in the body is notably diminished. - -_Von Ott_ found in thirteen cases out of fourteen that at the beginning -of the catamenial discharge or just before a considerable fall in -blood-pressure occurred, and that throughout the flow the pressure -almost always remained below the mean, no rise taking place till -menstruation was finished; this fall in blood-pressure during -menstruation was more considerable than could be accounted for by the -moderate hæmorrhage. The same author, in conjunction with _Schichareff_, -examined fifty-seven healthy women in respect of heat-radiation, -muscular power, respiratory capacity, expiratory and inspiratory power, -and tendon-reflexes. He found that the energy of the functions of the -female body increased before the beginning of menstruation, but declined -with or immediately before the appearance of the catamenial discharge. -He exhibited this rhythmical variation in the vital processes by means -of the following curve, in which the line _A B_ represents these -physiological variations, whilst on the abscissa line _c e_, the days of -observation are recorded, and the interval _m n_ represents the -menstrual period. The degree of intensity of the united functions is -indicated by the numbers 0–100 on the ordinate. - -[Illustration: - - FIG. 6. -] - -Still another point of view from which the influences affecting the -female organism as a whole may be regarded has very recently become -apparent in consequence of the doctrine of _Brown-Séquard_ relating to -the internal secretions of ductless glands. As regards the female -reproductive glands, which in consequence of their structure must be -referred to the group of ductless glands, and yet owing to their -secretory function must be classed among secreting glands (so that the -nature of the ovary is that of a secreting gland without an excretory -duct), it would appear that these glands are not concerned only with the -specific female reproductive functions of menstruation and ovulation, -but that they also exercise a powerful influence on the nutritive -processes, on metabolism and hæmatopoiesis, and on growth and -development in their mental as well as their physical relations. - -It is supposed that these glands under normal conditions enrich the -blood with certain substances, which in part assist in hæmatopoiesis, -and in part by regulating the vascular tone in the various organs are -concerned in the normal processes of assimilation and general -metabolism. According to _Etienne_ and _Demange_, ovariin possesses an -oxidising power similar to that possessed by spermin. Thus it becomes -easy to understand how disturbances in the functions of the ovaries give -rise to disturbances in the processes of general metabolism and of -assimilation. Some go even further, though in doing so they leave the -ground of assured fact, suggesting that the ovary in certain -circumstances produces toxins, or that the normal ovary possesses an -antitoxic function, and speaking of an occasional ovarian -auto-intoxication of the body or of a menstrual intoxication. Thus, -chlorosis is by some regarded as a disturbance of hæmatopoiesis, -dependent on an abnormal condition of the female reproductive organs -during the period of development, and referable to a disturbance of the -internal secretion of the ovaries (_Charrin_, _von Noorden_, _Salmon_, -_Etienne_, and _Demange_). And it is now generally assumed, the -assumption being based on the observations recently made concerning the -organo-therapeutic employment of the chemical constituents of the ovary, -that many of the disorders, and especially those connected with the -vasomotor system, common during the climacteric period, are dependent on -the deficiency of the products of the internal secretion of the ovary -that accompanies the cessation of the menses. - -Recent experimental investigations on this subject have shown that the -interconnection between the female genital organs and the organism as a -whole, between the functions of the reproductive organs and the -functions of other organs, does not depend on nervous influences only, -but that in this interconnection the blood vascular system and the -lymphatic vascular system also play their parts. _Goltz_ has proved by -actual experiment that the nervous influence on menstruation and -ovulation is not the only determinant. In a bitch, he divided the spinal -cord at the level of the first lumbar vertebra, and observed, as soon as -the animal had recovered from the operation, the appearance of the usual -signs of heat; the bitch was impregnated, and gave birth to one living -and two dead puppies; lactation and sucking took place as in a normal -animal. When the bitch was killed and the body examined it was found -that no reunion had taken place in the severed spinal cord. The -experiments of _Halban_ gave similar results. He found that in apes, if -the ovaries are removed from their normal situation and successfully -transplanted to some region remote from the genital organs, the animals -remain capable of menstruating. But if the ovaries, which have been -transplanted beneath the skin or beneath the peritoneum, are -subsequently entirely removed, menstruation, which has continued -regularly after the first operation, ceases altogether after the second. -It follows from these experiments that the cessation of the menstrual -process may be considered to be brought about through the intermediation -of the lymphatic or blood-vascular system, by the absence of a kind of -internal secretion. - -_Loewy_ and _Richter_ have further proved by experiment that in spayed -bitches the consumption of nitrogen is less by about 20 per cent. and -the entire gaseous interchange less by about 9 per cent., as compared -with what takes place in normal animals, and that this change in -respiratory metabolism lasts for a long time after the oöphorectomy, for -as much as nine to twelve months. If dried ovaries are given to such -animals in their food, the gaseous interchange rises to the former level -and even higher. - -The undulatory movement of the vital processes in woman is apparently in -some way dependent on ovulation, though the nature of the connection has -not hitherto been fully elucidated. This view is confirmed by the fact -that no such rhythmic variation in the bodily functions can be detected -either in girls under thirteen years of age, or in women from -fifty-eight to eighty years of age in whom menstrual activity has -entirely disappeared. The menstrual rhythm begins at puberty and ends -when ovulation ceases. - -A further contribution to the doctrine of the undulatory movement of the -vital processes in woman is to be found in my own observations that -pathological symptoms which have become manifest before and at the time -of the first onset of menstruation, and have given but little trouble -throughout the period of developed and regular sexual activity, are apt -when menstruation ceases to recrudesce, and to become as prominent as -they were at the commencement of the sexual life. Women who at the time -of puberty suffered from cardiac troubles, from digestive disturbances, -or from various forms of nervous irritation, and in whom as they grew up -these disorders passed more or less into abeyance, are apt at the -climacteric period to exhibit, as I have frequently been able to -observe, a violent return of these symptoms, in the form, as the case -may be, of tachycardia, of dyspeptic troubles, or of psychoneuroses. In -this connection we may mention an observation of _Potain’s_, who -distinguishes a peculiar form of chlorosis, occurring in individuals of -delicate constitution, which, though apparently cured, reappears at the -menopause. - -Related to the sexual life of woman is another attribute, one intimately -connected with the idea of the female sex, and one which since the -primeval days of humanity has filled men with delight and poets with -inspiration—the attribute of beauty. - -The beauty of woman, a prominent secondary sexual character, makes its -first appearance at puberty, when the girl’s form, hitherto -undifferentiated in its external bodily configuration, begins to assume -a soft and rounded appearance, when the features become regular, the -breasts enlarge, and the pubic hair begins to grow—when, in short, to -the primary sexual characters already existing, the secondary sexual -characters are superadded. - -Feminine beauty continues to increase until the attainment of sexual -maturity. In her third decade woman arrives at the acme of her sexual -life and at the same time attains the perfection of her beauty. - -The ensuing sexual phases, pregnancy, parturition, and lactation, entail -a decline in beauty, not rapid indeed, but advancing gradually, with the -slow yet sure-footed pace of time. The organic revolutions accompanying -these processes leave traces recorded upon the surface of the body in -conspicuous and indelible characters. The illnesses, also, which so -often accompany the fulfilment of sexual functions, in injuring health -impair also beauty. - -A woman who has given birth to and nursed an infant begins to lay on -fat, and this tendency to obesity becomes more pronounced as the -climacteric period approaches. The breasts become inelastic and pendent, -the abdomen becomes ungracefully prominent; the tonicity of the entire -organism gradually declines, and, in consequence of the loss of -elasticity in the subcutaneous cellular tissue, the dreaded wrinkles -make their appearance and the features become wizened. Beauty is a thing -of the past. With the cessation of the sexual life the external -secondary sexual characters disappear, and the old woman is even farther -removed than the old man from our conception of beauty. - -As _Mantegazza_ insists, the beauties peculiar to women are one and all -sexual; they depend, that is to say, upon the peculiar functions that -nature has allotted to woman in the great mystery of procreation. One of -the most vivid and poetical descriptions in ancient or modern literature -of these secondary sexual characters on which feminine beauty depends is -to be found in the Song of Solomon. - -In the following figure (FIG. 7) the curve of beauty of woman is given -as drawn up by _Stratz_. In one case it may rise very quickly, to -decline with equal quickness—the so-called _beauté du diable_;[16] in -other cases, again, the curve rises very slowly, and declines also very -slowly, the culmination of the curve being in this case attained later, -and when attained being absolutely higher, than in the case of the -steeper curve. - -[Illustration: - - FIG. 7. -] - -The age at which the maximum of beauty is attained is a very variable -one. In the southern races this often occurs as early as the fourteenth -or fifteenth year of life; but in the peoples of the Teutonic stock, -Germans, Dutch, Scandinavians, and English, not as a rule before the -twentieth year, and it may be even later. _Stratz_ has known cases in -which women did not attain the prime of their beauty until the thirtieth -and even the thirty-third year. The same author, a most competent -authority as regards the subject of feminine beauty, affirms that a -beautiful woman is most beautiful when the period of maximum beauty -coincides in her case with the first month of her first pregnancy. With -the commencement of pregnancy the processes of nutrition are -accelerated, all the tissues are tensely filled, the skin is more -delicately and at the same time more brightly tinted owing to the -greater activity of the circulation, the breasts become firmer and more -elastic. Thus the attractive characteristics of beauty at its fullest -maturity become enhanced, but for a short time only, since the -enlargement of the abdomen in the further course of pregnancy impairs -the harmony of the figure. Finally we must point out, before dismissing -this subject, that women of the so-called better classes arrive as a -rule at maturity later, and remain beautiful for a longer period, than -women of the working classes. - -The degree to which the female organism as a whole is influenced by the -processes of the sexual life that occur in the genital organ depends -upon many of the characteristics that combine to make up the -individuality. Inherited characteristics, temperament, and race, play a -great part in this connection; and not less important than these are the -social conditions, the environment, in which the women under -consideration pass their life. Thus, among women belonging to the -poorer, labouring classes, the reflex manifestations in other organs -dependent upon the processes of the genital organs are less frequent and -less intense than among women belonging to the well-to-do strata of -society and to the cultured classes; less also in the country than in -large towns. In phlegmatic individuals, such manifestations exhibit less -intensity than in those of an active, ardent temperament; they are less -frequent in persons with a powerful constitution than in those endowed -by inheritance with an unstable nervous system. Finally, they are less -often encountered among families whose upbringing has aimed at hardening -the constitution and at inculcating the control of instinctive impulses, -than among those in whom from early childhood sensibility and -impulsiveness have been given a loose rein. - -Extremely variable also are the sympathetic disturbances and morbid -states which depend on the processes of the sexual life of woman. “Le -cri de l’organe souffrant ne vient pas de l’utérus, mais de tout -l’organisme,”[17] says _Courty_. And a large number of isolated -observations has shown how complex are the relations between the healthy -and unhealthy female genital organs and the other organs of the body as -well as the organism as a whole. Precise and incontestable proofs exist -of such relations between the female genital organs and morbid changes -in the eye and ear, the skin, the respiratory organs, and the vascular -and nervous systems. - -The influence exercised by the reproductive system on the general vital -processes of woman is indicated also by the general statistics of -mortality and the incidence of disease. Mortality in women, the earliest -years of childhood being left out of consideration, is at its highest -precisely during the great sexual epochs, namely at the time of puberty, -during pregnancy, during the puerperium, and at the climacteric period. -The complete performance of the reproductive functions entails a higher -proportion of illnesses and death; and statistical records show that the -mortality of married women between twenty and forty years of age, during -the period, that is to say, in which in consequence of marriage they -fulfil the duties of sexual intercourse and procreation, and are exposed -to the dangers connected with these sexual acts, is much higher than the -mortality of unmarried women of corresponding ages. Infection with the -gonococcus and with the virus of syphilis, chronic salpingitis, -metritis, and parametritis, the manifold diseases of pregnancy, the -diseases of the puerperium, the various displacements of the uterus, -osteomalacia—all these are pathological states the dependence of which -upon the sexual life of the married or at any rate sexually active woman -is indisputable. But the complete renunciation of sexual activity -appears also to exercise an injurious influence on the health, and to -give rise or at least predispose to morbid manifestations. Hysteria, for -instance, chlorosis, uterine myomata, and various neuroses, have long -been supposed to depend in part upon such renunciation, though the -causal connection cannot be regarded as yet fully established. - -Especially true as regards woman, indeed, is that which _Ribbing_ says -concerning the sexual life in general: “Since all human life and being -has its origin in sexual relations, these sexual relations may be -regarded as the heart of humanity. We may work day and night for the -good of humanity, we may sacrifice for that good our time and our blood, -but all this work and all this sacrifice appear to me to remain useless -if we neglect and despise the sexual life, the eternally self-renewing -elementary school of true altruism.” - -From the vital phase in which, marked by the visible manifestations of -puberty and by the first appearance of menstruation, ovulation is -assumed to begin, the sexual life of woman continues to the period of -life in which, marked by the climacteric cessation of menstruation, -ovulation also ceases. The total duration of this sexual period in -woman’s life is usually about thirty years; but it is subject to great -variations, from six to forty-six years according to the available -statistics, these variations depending upon climate, race, constitution, -and the sexual activity of the person under consideration. - -The duration and the intensity of the sexual life of woman depends upon -a series of external conditions affecting the individual, but especially -upon the inherited predispositions, upon the constitutional conditions, -upon the varying vital power of the individual. My own observations have -led me to formulate, as a general law, that the earlier a woman -(climatic and social conditions being similar in the cases under -comparison) arrives at puberty, the earlier, that is to say, that -menstruation first makes its appearance, the greater will be the -intensity and the longer the duration of sexual activity, the more will -the woman in question be predisposed to bear many children, the more -powerfully will the sexual impulse manifest itself in her, and the later -will the menopause appear. It seems that in such women a more intense -vitality animates the reproductive system, bringing about an earlier -ripening of ova, a more favorable predisposition on the part of these -ova to fertilization by the spermatozoa, a livelier manifestation of -sexual sensibility, and a longer duration of ovarian functional -activity. - -My general views on this subject are embodied in the following -propositions: - -1. The duration of sexual activity is less in the women belonging to the -countries of southern Europe than in those belonging to the countries of -northern Europe. It would appear that in those climates in which -ovulation begins sooner and menstruation first appears at an earlier -age, the menopause also appears earlier; but that, on the contrary, in -those climates in which puberty is late in its appearance, the decline -of sexual activity is similarly postponed. - -2. Women in our mid-European climates, in whom puberty appears at an -early age, the first menstruation occurring between the ages of thirteen -and sixteen, exhibit a more prolonged duration of the sexual life, of -menstrual functional activity, than women in whom menstruation begins -late, between the ages of seventeen and twenty. Extremely early -appearance of the first menstruation—so early as to be altogether -abnormal—has, however, the same significance as abnormally late onset of -menstruation; both indicate that the sexual life will be of short -duration. - -3. Women whose reproductive organs have been the seat of a sufficient -amount of functional activity, who have had frequent sexual intercourse, -have given birth to several children, and have themselves suckled their -children, have a sexual life of longer duration, as manifested by the -continuance of menstruation, than women whose circumstances have been -just the opposite of these, unmarried women, for instance, women early -widowed, and barren women. Sexual intercourse at a very early age, -however, accelerates the onset of the climacteric period and the -termination of the sexual life. The same result follows severe or too -frequent confinements. - -4. The sexual life has a shorter duration in the women of the laboring -classes and belonging to the lower strata of social life, as compared -with upper class and well-to-do women. Bodily hardships, grief, and -anxiety also hasten the onset of sexual death. - -5. Women who are weakly and always ailing have a shorter sexual life -than women who are powerfully built and always in good health. When -irregularities and disorders have appeared in the various sexual phases, -the decline of sexual activity occurs earlier than in women whose -functions have in this respect been normal. Certain constitutional -conditions, such as extreme obesity, certain acute diseases, such as -typhoid fever, malaria, and cholera, and certain diseases of the uterus -and its annexa, chronic inflammatory conditions for instance, bring -about a notable shortening of the duration of the sexual life. - -In 500 cases that have come under my own observation, the women -concerned belonging to very various nationalities, the duration of the -sexual life, as witnessed by the continuance of menstruation, was as -follows: - -Menstruation continued for: - - 6 years in 1 woman. - 7 years in 1 woman. - 9 years in 2 women. - 11 years in 4 women. - 15 years in 6 women. - 16 years in 8 women. - 17 years in 12 women. - 18 years in 15 women. - 19 years in 9 women. - 20 years in 6 women. - 21 years in 18 women. - 22 years in 20 women. - 23 years in 24 women. - 24 years in 18 women. - 25 years in 16 women. - 26 years in 25 women. - 27 years in 26 women. - 28 years in 29 women. - 29 years in 36 women. - 30 years in 22 women. - 31 years in 32 women. - 32 years in 49 women. - 33 years in 31 women. - 34 years in 26 women. - 35 years in 12 women. - 36 years in 12 women. - 37 years in 10 women. - 38 years in 8 women. - 39 years in 6 women. - 40 years in 2 women. - 43 years in 2 women. - 45 years in 1 woman. - 46 years in 1 woman. - -Thus we see that the duration of the sexual life varies from 6 to 46 -years. The most frequent duration is one of 32 years, next to this one -of 29, next again, 31, 33, and 37 years, respectively. In 6 women only -did the duration of the sexual life exceed 40 years, and in 4 only was -it less than 11 years. In half of all my cases the duration of the -sexual life was between 27 and 34 years, and from these figures we -obtain an average duration of about 30 years. - -For North Germany, _Krieger_ gives data from which it appears that in -this region the average duration of the sexual life is 30.49 years. In -more than half of the 722 cases recorded by this writer the duration was -between 31 and 37 years. In isolated cases the duration was very short, -not exceeding 8, 9, or 10 years, or, on the other hand, as long as 47 -years; whilst the number of cases increased fairly regularly up to the -duration of 34 years, and thereafter again diminished. - -As regards Austria, _Szukits_ has collected information in the case of -269 women, and found, in these, that the duration of the sexual life -varied from 12 to 45 years. The average duration was 29.16 years; in -more than half of the women, the period of sexual activity lasted from -21 to 30 years; the shortest period observed was 12 years, the longest -45 years. - -The period of sexual activity lasted: - - 12 years in 2 women. - 14 years in 1 woman. - 15 years in 2 women. - 17 years in 3 women. - 19 years in 3 women. - 20 years in 17 women. - 21 years in 10 women. - 22 years in 7 women. - 23 years in 5 women. - 24 years in 17 women. - 25 years in 7 women. - 26 years in 13 women. - 27 years in 5 women. - 28 years in 26 women. - 29 years in 18 women. - 30 years in 17 women. - 31 years in 8 women. - 32 years in 8 women. - 33 years in 13 women. - 34 years in 8 women. - 35 years in 18 women. - 36 years in 19 women. - 37 years in 14 women. - 38 years in 9 women. - 39 years in 8 women. - 40 years in 1 woman. - 42 years in 1 woman. - 43 years in 1 woman. - 44 years in 2 women. - 45 years in 2 women. - -In Poland, according to _Raciborski_, the duration of sexual activity is -in Jewesses 23 years, but in women of Slavonic blood 31 years. - -In France, according to _Courty_ and _Puech_, the usual duration of the -sexual life is from 28 to 30 years. - -According to _Puech_, among 10 women menstrual activity lasted: - - 33 years in 2 women. - 35 years in 1 woman. - 36 years in 2 women. - 39 years in 2 women. - 43 years in 2 women. - 44½ years in 1 woman. - -_Brierre de Boismont_ gives the following particulars of the duration of -menstrual activity in 178 Frenchwomen: - - 5 years in 1 woman. - 6 years in 1 woman. - 8 years in 1 woman. - 11 years in 1 woman. - 16 years in 4 women. - 17 years in 4 women. - 18 years in 1 woman. - 19 years in 3 women. - 20 years in 3 women. - 21 years in 4 women. - 22 years in 3 women. - 23 years in 12 women. - 24 years in 8 women. - 25 years in 8 women. - 26 years in 11 women. - 27 years in 7 women. - 28 years in 6 women. - 29 years in 7 women. - 30 years in 13 women. - 31 years in 13 women. - 32 years in 9 women. - 33 years in 9 women. - 34 years in 7 women. - 35 years in 5 women. - 36 years in 10 women. - 37 years in 6 women. - 38 years in 5 women. - 39 years in 2 women. - 40 years in 7 women. - 41 years in 1 woman. - 42 years in 3 women. - 44 years in 2 women. - 48 years in 1 woman. - -For England, _Tilt_ gives the mean duration of menstrual activity, as -observed in 500 women, as 31.21 years; it varies between 11 and 47 -years; there are more cases with a period of 34 years than with any -other integral number of years. _Tilt_ found the duration to be: - - 11 years in 1 woman. - 13 years in 1 woman. - 15 years in 3 women. - 16 years in 1 woman. - 17 years in 2 women. - 18 years in 4 women. - 19 years in 1 woman. - 20 years in 3 women. - 21 years in 6 women. - 22 years in 11 women. - 23 years in 11 women. - 24 years in 10 women. - 25 years in 22 women. - 26 years in 11 women. - 27 years in 25 women. - 28 years in 29 women. - 29 years in 35 women. - 30 years in 36 women. - 31 years in 33 women. - 32 years in 38 women. - 33 years in 35 women. - 34 years in 49 women. - 35 years in 33 women. - 36 years in 26 women. - 37 years in 16 women. - 38 years in 15 women. - 39 years in 15 women. - 40 years in 6 women. - 41 years in 4 women. - 42 years in 7 women. - 43 years in 5 women. - 44 years in 3 women. - 45 years in 1 woman. - 46 years in 1 woman. - 47 years in 3 women. - -For London the average figure is 34 years; for Paris, 30 years; for -Vienna, 29 years; and for Berlin, 34 years. - -From the data of various observers obtained from diverse nationalities, -the following table has been compiled, exhibiting the mean duration of -the sexual life: - - _Comparative Table Showing the Duration of the Sexual Life in Various - Nationalities._ - - ┌───────────┬────────┬────────┬─────────┬──────────┬─────────┬───────┬───────┐ - │ │Germany.│Austria.│ France. │ England. │Denmark. │Norway.│Russia.│ - ├───────────┼────────┼────────┼─────────┼──────────┼─────────┼───────┼───────┤ - │Number of │ │ │ │ │ │ │ │ - │ Cases │ 722 │ 265 │ 178 │ 500 │ 312 │ 391 │ 100 │ - ├───────────┼────────┼────────┼─────────┼──────────┼─────────┼───────┼───────┤ - │Mean │ │ │ │ │ │ │ │ - │ duration │ │ │ │ │ │ │ │ - │ of │ │ │ │ │ │ │ │ - │ menstrual│ │ │ │ │ │ │ │ - │ activity,│ │ │ │ │ │ │ │ - │ in years │ 30.4 │ 29.1 │ 29.1 │ 31.8 │ 27.9 │ 32 │ 31 │ - ├───────────┼────────┼────────┼─────────┼──────────┼─────────┼───────┼───────┤ - │Observers’ │Krieger,│ │ Brierre │ │ │ │ │ - │ names │ L. │ │ de │ │ │Faye & │ │ - │ │ Mayer. │Szukits.│Boismont.│Whitehead.│Hannover.│ Vogt. │Lieven.│ - └───────────┴────────┴────────┴─────────┴──────────┴─────────┴───────┴───────┘ - -In the temperate zone the sexual life of woman lasts longer than in the -colder and subarctic regions. Still more favorable is the contrast -between the temperate zone and the countries of the tropics, in which -the duration of the period of menstrual activity is limited to eighteen -or twenty years. According to some isolated observations the duration of -sexual activity in Arabian women in Africa was as little as nine years. - -A certain influence on the duration of the sexual life is exercised by -the commencement of menstruation at an earlier or later age than the -average. The total duration of menstrual activity is more variable in -women who begin to menstruate early than in women who begin to -menstruate late, in whom the duration of the sexual life is a more -regular one. In those women who begin to menstruate early the mean -duration of the sexual life is about thirty-three years, in those who -begin to menstruate late it is about twenty-seven years. - -The following data, based on the observation of 250 cases, are published -by _W. Guy_, regarding the duration of the sexual life, that is to say -of menstrual activity, in women beginning to menstruate early and those -beginning to menstruate late, respectively: - - _Menstruation began._ _Duration of the sexual - life._ - In 5 cases in the 8th to the 10th year Averaging 36.60 years. - In 70 cases in the 11th to the 13th year Averaging 33.65 years. - In 110 cases in the 14th to the 16th year Averaging 30.85 years. - In 56 cases in the 17th to the 19th year Averaging 28.35 years. - In 9 cases in the 20th year or later Averaging 20.45 years. - -A further analysis of these 250 cases is given by Guy in the following -table: - - _First appearance of menstruation._ _Average age at _Duration of - which menstrual - menstruation activity._ - ceased, in - years._ - In 1 case in the 8th year 42 34 years. - In 2 cases in the 9th year 46 37 years. - In 2 cases in the 10th year 47 37 years. - In 10 cases in the 11th year 47.10 36.10 years. - In 29 cases in the 12th year 45.34 33.34 years. - In 31 cases in the 13th year 46.16 33.16 years. - In 39 cases in the 14th year 45.33 31.33 years. - In 40 cases in the 15th year 46.30 31.30 years. - In 41 cases in the 16th year 46.14 30.14 years. - In 26 cases in the 17th year 45.18 28.18 years. - In 19 cases in the 18th year 46.87 28.87 years. - In 11 cases in the 19th year 46.18 27.18 years. - In 5 cases in the 20th year 40.80 20.80 years. - In 3 cases in the 21st year 41.66 20.66 years. - In 1 case in the 23d year 41 18 years. - -_Hannover_ also gives data respecting the relation between the duration -of menstrual activity and the early or late appearance of menstruation. -These data are tabulated as follows: - - _First appearance of menstruation._ _Average age at _Duration of - which menstrual - menstruation activity._ - ceased, in - years._ - In 5 cases in the 12th year 47.80 35.80 years. - In 10 cases in the 13th year 45.89 32.89 years. - In 50 cases in the 14th year 44.98 30.98 years. - In 34 cases in the 15th year 45.56 30.56 years. - In 38 cases in the 16th year 44.13 29.13 years. - In 36 cases in the 17th year 43.00 26.00 years. - In 49 cases in the 18th year 44.96 26.96 years. - In 33 cases in the 19th year 44.79 25.79 years. - In 38 cases in the 20th year 45.36 25.36 years. - In 10 cases in the 21st year 44.10 23.10 years. - In 4 cases in the 22d year 43.50 21.50 years. - In 3 cases in the 23d year 44.33 21.33 years. - In 4 cases in the 24th year 39.50 15.50 years. - -Totals: In 412 cases the average age at the menopause was 44.82, and the -average duration of menstrual activity was 27.973 years. - -From the tables of _L. Mayer_, _Krieger_ has instituted a comparison -between the duration of menstrual activity in 101 women who began to -menstruate early and 180 women who began to menstruate late, finding in -the case of the former a mean duration of 33.673 years, and in the case -of the latter a mean duration of 27.344 years, showing therefore a -sexual life longer on an average by 6.429 years in those in whom puberty -was early as compared with those in whom puberty was late. - -From the tables of _Tilt_, based on the observation of 164 cases, 76 -women in whom menstruation appeared early and 88 in whom it appeared -late, we learn that among the former the shortest duration of menstrual -activity was 18 years, among the latter 12 years; among the former the -longest duration was 37 years, among the latter only 33. The majority of -those who began to menstruate early continued to menstruate for 28, 31, -32, 33, 34, 35, 36, 38, or 39 years; those who began to menstruate late, -for 23, 27, 28, 30, or 31 years. The mean duration of the sexual life in -those who began to menstruate early was 33.66 years; in those who began -to menstruate late it was 28.28 years. Since the average duration of the -menstrual function is given by _Tilt_ as 31.33 years, those who began to -menstruate early exceeded this average by 2.33 years, while those who -began to menstruate late exhibited a duration of menstrual activity of -at least three years less than the average. - -In addition to climate, nationality, and the age at which menstruation -begins, the sexual activity of women also exercises an influence on the -duration of their sexual life, and of especial importance in this -connection are the number of children born, and exercise or neglect of -the function of lactation. From my own observations on this matter it -appears, that in women who are healthy and of powerful constitution, -whose reproductive organs have been sufficiently exercised, who have -given birth to several children and have suckled these children -themselves, the duration of menstrual activity is in general notably -longer than in women whose circumstances have been just the opposite in -these respects. Among the women in my own series of cases in whom -menstrual activity lasted longest, of the 177 women in whom menstruation -ceased between the forty-fifth and the fiftieth year of life, 1 only was -unmarried, 2 were married but childless, 32 married with 1 or 2 children -only, and 142 married and with more than 2 children; of the 89 women in -whom menstruation ceased between the fiftieth and the fifty-fifth year -of life, none were either unmarried or childless, 19 were married with 1 -or 2 children, 17 married and with more than 2 children; of the 17 women -in whom menstruation ceased later than the fifty-fifth year of life, -there were 2 only with less than 2 children, but 10 who had each given -birth to from 6 to 8 children. A similar influence is exercised by the -function of lactation. Among 40 women who had not suckled their -children, the average duration of menstrual activity was 4 years less -than the general mean. - -As regards the conditions of life, _L. Mayer_ affirms that the duration -of sexual activity among well-to-do women is on the average a year and a -half longer than among women of the working classes. - -_Metschnikoff_ has drawn attention to the remarkable disharmony in the -development of three of the phases of the sexual life of woman, inasmuch -as the sexual impulse, the union of the sexes, and the capacity for -procreation, which, considering their nature and purpose, might have -been expected to be attuned so as to act in harmony, exhibit as a matter -of fact no such relation; the different factors of the sexual function -develop independently and unharmoniously. In a child not yet fitted to -fulfil the function of procreation, the sexual impulse will none the -less make its appearance, and be liable to misuse. In the girl the -pelvis does not attain that complete development which fits it for the -process of parturition until toward the age of twenty, whilst puberty -occurs at the age of sixteen. “A girl of ten is capable of aspiring to -play the part of a woman, but not before the age of sixteen is she -fitted to play that part, nor indeed fitted to become a mother before -the age of twenty.” - -In general, we may say, regarding the women of our own part of the -world, that in those who are healthy, who lead a regular life, are well -fed, free from the pressure of anxieties, with their sexual functions -sufficiently exercised, the duration of the sexual life is longer than -in women whose circumstances are the reverse of those just enumerated. -It is a sign of decadence when women of the well-to-do classes, leading -a life of ease, manifest a diminished duration of the sexual life. The -greatest physical power and the highest ethical development are -associated with a lengthening of life in general, and associated also -with a lengthening alike in the sexual life of woman and the sexual -potency of man. A decline in morals and culture entails a diminution of -sexual vital capacity, this being true alike of individuals, of -families, and of nations. Woman is venerated and valued the more, the -longer the duration of her sexual life; a woman in whom the sexual life -is short quickly loses value and significance, both in domestic and in -social circles. - -The social significance of the sexual life of woman is -disproportionately greater and farther reaching than the sexuality of -the male, as the former is concerned with the fundamental principles of -human social life, influencing the constitution of the family, and -controlling the good of the coming race. Sexual purity, which to the -youth is a romantic dream, is to the maiden a vital condition of -existence; adultery, in the husband a pardonable transgression, is in -the wife an overwhelming sin committed against family life. To the -freedom of the male in affairs of love is opposed the strict restraint -of the female, based on monogamic marriage. The sexual needs and desires -of the female are transformed in an ideal manner by means of the feeling -of duty of the wife and mother; the violent pressure of the sexual -impulse is restrained by the opposition of ethical forces. When this -restraint fails, the running off the rails that ensues has a far -profounder influence in the case of the female than of the male, an -influence not limited to her own personality, but dragging down the -whole family into the abyss of consequences, into the depths of moral -and physical destruction. - -Though in nature everywhere the same, the sexual life of woman exhibits -in the various gradations of social life different outward -manifestations, from the brutal sexual congress that does not greatly -shun publicity, to the modern would-be philosophical free love. And -throughout all variations the two darkest points remain, the -illegitimate child and venereal infection, both of which entail upon the -woman the most unspeakable anxieties and the greatest possible misery, -whilst the man who is in either case to blame passes comparatively -unscathed. - -The social sexual position of woman suffers most at the present day from -the mature age at which under existing social conditions men are alone -able to marry and from the ever-increasing number of cases of venereal -infection. In both these directions social science and medical skill -must work hand in hand for the amelioration of the sexual life of woman. - -On the twentieth century falls the duty of furnishing a solution for -these problems. Contesting voices are heard on all sides. _Tolstoi’s_ -rigid demand for complete sexual abstinence, the exhortation of the -professors of the German universities to their students in favor of -moral purity, the associations for the official prevention of venereal -diseases, the agitation among young men in favor of abstinence from -sexual intercourse before marriage, finally, the clamorous voices of the -supporters of women’s rights—all these are influences within the sphere -of sexual morality, which must lead slowly but surely to extensive -social changes in the sexual life of women. - -The discussion of the sexual life of woman, which for many centuries was -concealed by a thick veil from the eyes of the profane, or was viewed -only through the frosted glass of poetical metaphor, has in recent times -assumed a quite revolting character. Not only have the acquired -liberties and the social aims of the present day a tendency to give to -women in general a freer and higher position, to emancipate them from -the bonds in which owing to the conditions of family life they have so -long been shackled, but some members of the women’s rights party go even -farther, and demand for women greater freedom in the sphere of sexual -activity. - -With this end in view the sexual life of woman is used as the fulcrum of -the lever, and is withdrawn from the twilight into the open light of -day, or indeed too often into a dazzling and altogether false -illumination. Women writers especially, who have hitherto been -accustomed to delude themselves and the world with sensational -representations of the feminine soul, of feminine modesty, and the -fineness of feminine sensibility in matters sexual, now find their -greatest joy in unveiling themselves and their sisters before the face -of all the world, and in discussing in the plainest language the most -intimate processes of the genital organs. In writings exhibiting but -little good taste, though all the more temperament, they emphasize again -and again one side only of the sexual life, to wit, the sexual impulse, -the force of which is intentionally exaggerated to a high degree, so -that it is described as a mighty current of passion, which may with -great pains be held in check for a season, but must ultimately break -loose, and with devastating rage must overwhelm everything which has -hitherto been regarded as discipline and good morals. Young girls, even, -step down into the arena to take part in the contest concerning the -reform that is to take place in the relations between men and women. -Especially sensational in this connection was _Eine für Viele_. _Aus dem -Tagebuche eines Mädchens von Vera_,[18] a book which, totally ignoring -the biological differentiation of the sexes and their diverse -sociological course of development, goes so far as to insist that from -the man entering upon marriage, as from the woman, sexual purity and -virginity are to be demanded. (The heroine of the book commits suicide -because her lover has in earlier years had experience of sexual -intercourse.) - -From a mistaken standpoint other supporters of women’s rights oppose the -ideal method in sex-relations, life-long monogamy, and the ideal of -sexual sensibility, motherhood, and they put forward quite new sexual -pretensions on behalf of women, as belonging to them by natural right. -Upon these pretensions it is the duty of physicians, who truly know and -truly prize womanhood, to pass their judgment, and that judgment, which -will find ample justification in the ensuing descriptions of the -individual phases of the sexual life of woman, is that the modern -movement on behalf of the emancipation of women goes much too far. We do -not, however, mean to imply that this movement is totally unjustified. - -The growing girl must not, as has hitherto been the case, be kept in a -state of ignorance (which is indeed in most cases apparent merely) -regarding the sexual processes of her own body, she must no longer, when -she asks to be informed concerning these matters, be put off with -conventional lies and prevarication. But her enlightenment must not be -effected in such a manner as to lead to excitement and excessive -stimulation, to the awakening of slumbering feelings, and to the -conversion of fantasy into a devouring flame. Sexual enlightenment must -not be made an excuse for the unchaining of sensibility. When about to -be married, a woman should certainly be instructed regarding her sexual -duties and rights, and enter as one well informed into the act in which -she is to play a leading part. But she ought not, with the excessive -valuation of herself attained in recent times, to regard the man as her -enemy, as one whom she is always justified in fighting and always ready -to fight with the equal weapons of sexual transgression. It cannot be -doubted that the ideal of “pure marriage” at an early age is one greatly -to be prized as the foundation of a powerful future generation; but the -real nature of the male must not be overlooked, nor must his sexual -honor be put to too difficult a test. We regard as reasonable the modern -demand of woman that in marriage her individuality should not be buried, -and that space should be given for the development of her personality; -but every sober-minded person will reject the “moral demand” for “ideal -passion” in accordance with “entire mutual freedom” in the sexual -relation between man and wife, and will regard such free love as social -insanity and as a barbaric retrogression toward the rude sexual habits -of savage peoples. Further, in view of the continually increasing -intensity of the struggle for existence and in view of the difficulties -of the task of rearing children, we cannot fail to recognize that it is -not right for women to be overburdened with the task of reproduction, -and that she does not live simply and solely for the bearing of -children—but those rush to the other extreme who undervalue motherhood -and the duties of maternity, who speak scornfully of the woman who is “a -mother, and a mother only,” who despise women whom they regard merely as -“means for the production of children,” and who employ all possible -methods to free women from the pressing claims of nature and of society. - -In all social circumstances, and in all times the great principle of -sexual morality must dominate the sexual life of woman. As the ethical -characteristics of the three great epochs in that sexual life we -recognize the purity of the maiden, the faithfulness of the wife, and -the love of the mother. But within the limits imposed by these demands -it is still possible to satisfy the modern claim for a free development -of the personality, and to accommodate the circumstances of the sexual -life to the individual vital needs and vital claims of the present day. - - - - - I. THE SEXUAL EPOCH OF THE MENARCHE. - - (PUBERTY.) - - -The term _menarche_ (μήν, a month, ἀρχή, the beginning) was introduced -by me into medical literature to denote the period of life in which, as -a sign of puberty, menstruation first makes its appearance. - -The age at which this occurs is subject to variations depending upon -race, occupation, hereditary tendencies, and climate; but in Germany and -Austria the average age at puberty is 14 or 15, the extreme limits being -12 to 19. - -Until about the age of 13, the physical differentiation of the sexes, -except for the anatomical peculiarities of the genital organs, is in our -climates a trifling one. But at puberty the important changes occur by -which the sexes are so strikingly differentiated. Whereas in the growing -boy all physical change takes the form of increasing strength and -energy, in the development of the girl, we note the appearances of the -rounded outlines so characteristic of womanhood. At the same time the -voice alters, becoming less sharp, with a softer quality, and yet a -fuller tone; and we may observe that young brunettes have commonly a -contralto voice, young blondes, more often a soprano. The intellectual -changes undergone by the girl at puberty are no less extensive and -characteristic than the physical changes. In brief, the -undifferentiated, neuter girl is transformed into a young woman, endowed -with all the attributes, mental and bodily, characteristic of -femininity. - -As regards the age at which the menarche usually occurs, and the manner -in which its occurrence is anticipated or retarded by the various -influences already mentioned, the following propositions may be put -forward, based on the available statistics and observations: - -1. Climate is an important factor. In the torrid zone, menstruation -appears at a very early age, on the average from 11 to 14; in the -temperate zone, it appears later, on the average from the age of 13 to -16; in the frigid zone, later still, on the average from the age of 15 -to 18. The mean temperature of the atmosphere appears to have a direct -influence on the age at which menstruation begins, the hotter the -climate, the earlier being the menarche. The height of the place of -residence above the sea level and its distance from the coast also have -a certain influence. - -2. Race and constitution have a distinct influence upon the age at which -menstruation makes its appearance. In women of the Semitic races the -menarche occurs earlier than in women of the Aryan races. The average -age at which menstruation begins is in Jewish girls, from 14 to 15; in -Magyar girls from 15 to 16; in German girls from 16 to 16½; and in -Slavonic girls from 16 to 17. - -In general the menarche is earlier in girls of a sanguine, lively -temperament and a powerful constitution than in girls of a phlegmatic -temperament and a weakly constitution; further, other things being -equal, menstruation appears earlier in brunettes, girls with black hair, -thick skin, dark eyes, and a dark complexion, than it appears in -blondes, girls with light hair, thin skin, blue eyes, and a fair -complexion. - -3. The age at which menstruation begins is also affected by the -conditions of life and the social circumstances. In the higher circles -of society, in the upper, well-to-do classes, menstruation appears -earlier than among women of the laboring classes, who are compelled to -strive for their daily bread. Amongst upper-class girls the menarche -occurs at the age of 14 in one-fourth of their number, whereas among -lower-class girls barely one-sixth begin to menstruate at the age of 14. - -In large towns, again, menstruation appears earlier than in small towns, -whilst in the open country the menarche is still further delayed. In the -women of Paris the average age at the menarche is 14 years and 6 months, -in the women of smaller French towns it is 14 years and 9 months, in -French countrywomen it is 14 years and 10 months. - -How far the mode of nutrition is concerned in the production of these -results is not yet determined. - -4. The time of the menarche appears to be influenced by inheritance to -this extent, that the daughters of women who began to menstruate early -begin themselves to menstruate at an early age, whereas in other -families we observe that both mothers and daughters began to menstruate -late. But this relation is by no means a constant one. - -_Ploss_ has collected observations made in various countries and towns -regarding the age at which menstruation begins, and the mean results of -these observations are given below. - -The average age at which menstruation began was: - - In Swedish Lapland 18 years, 0 months, 0 days. - In Christiania 16 years, 9 months, 25 days. - In Copenhagen 16 years, 9 months, 12 days. - In Munich 16 years, 5 months, 12 days. - In Göttingen 16 years, 2 months, 2 days. - In Vienna 15 years, 8 months, 15 days. - In Berlin 15 years, 7 months, 6 days. - In Stockholm 15 years, 6 months, 22 days. - In Manchester 15 years, 6 months, 0 days. - In Warsaw 15 years, 1 month, 23 days. - In London, between 15 years, 1 month, 4 days. - and 14 years, 9 months, 9 days. - In Paris, between 15 years, 7 months, 18 days. - and 14 years, 5 months, 17 days. - In Madeira 14 years, 3 months, 0 days. - In Montpellier 14 years, 2 months, 0 days. - In Corfu 14 years, 0 months, 0 days. - In Marseilles 13 years, 11 months, 11 days. - In Calcutta 12 years, 6 months, 0 days. - In Egypt 10 years, 0 months, 0 days. - -The collective results of the investigations of French authors regarding -the average age at which menstruation first appears are given in the -following table: - - I. IN TEMPERATE CLIMATES: - - _Observer._ _Place._ _No. of _Average Age._ - Cases._ - - De Soye Paris 1,000 15 years, 0 months. - Dubois Paris 600 15 years, 3 months. - Raciborski Paris 200 14 years, 5 months. - M. Despines Paris 85 14 years, 11 months. - Arau Paris 100 15 years, 4 months. - Courty Montpellier 600 14 years, 3 months. - Puech Nîmes 941 14 years, 2 months. - M. Despines Toulon 43 14 years, 1 month. - M. Despines Marseilles 25 14 years, 1 month. - Puech Toulon 144 14 years, 1 month. - Grey London 1,498 15 years, 6 months. - Lee & Murphy London 1,719 15 years, 6 month - Torisiano Corfu 33 14 years, 6 months. - Lebrun Warsaw 100 15 years, 1 month. - -from these observations we obtain an average of 15 years. - - II. IN COLD CLIMATES: - - _Observer._ _Place._ _No. of _Average Age._ - Cases._ - - Ravn Copenhagen 3,840 16 years, 9 months. - Frugel Christiania 157 16 years, 6 months. - Dubois Russia 600 16 years, 8 months. - Faye Norway 100 15 years, 6 months. - Lundborg Esquimaux 16 15 years, 6 months. - Wistrand Stockholm 100 15 years, 7 months. - -from these observations we obtain an average of 16 years and 3 months. - - III. IN HOT CLIMATES: - - _Observer._ _Place._ _No. of _Average Age._ - Cases._ - - Goodeve Calcutta 239 12 years, 5 months. - Lith Deccan 217 13 years, 5 months. - Robertson Calcutta 540 12 years, 6 months. - Webb Calcutta 39 12 years, 5 months. - Dubois Asia 600 12 years, 11 months. - -from these observations we obtain an average of 12 years and 7 months. - -In 6,550 cases collected by _Krieger_ menstruation first appeared: - - At the age of: - - 9 years in 1 instance. - 10 years in 7 instances. - 11 years in 43 instances. - 12 years in 184 instances. - 13 years in 605 instances. - 14 years in 1193 instances. - 15 years in 1240 instances. - 16 years in 1026 instances. - 17 years in 758 instances. - 18 years in 582 instances. - 19 years in 425 instances. - 20 years in 281 instances. - 21 years in 111 instances. - 22 years in 55 instances. - 23 years in 15 instances. - 24 years in 15 instances. - 25 years in 1 instance. - 26 years in 4 instances. - 27 years in 2 instances. - 28 years in 1 instance. - 29 years in 1 instance. - -From these figures it appears that in the 6,550 cases under -consideration, the age 15 was that at which the first appearance of -menstruation was most frequently observed, namely in 1,240 instances, or -18.9 per cent. The age 14 comes next, with 1,193 instances, or 18.2 per -cent. The case in this series in which menstruation appeared earliest, -namely in the ninth year, was observed by _Mayer_, the girl being a -blonde of average height, good family, and German descent; the case in -which menstruation appeared latest, namely in the twenty-ninth year, was -that of a woman living in Berlin, who was sickly and chlorotic up to the -time of her marriage, and in whom menstruation did not appear until some -years after that event. - -As regards climatic influences, all the data at our disposal prove that -the hotter the climate the earlier the menarche. According to _Marc -d’Espine_ the age at puberty varies in an almost geometrical ratio with -the mean annual temperature. - -The dependence of the menarche upon climatic influences is clearly shown -by the statistical data collected from various regions of the world. We -append the general compilation of _Gebhard_ dealing with this question. - - - A. EUROPE. - -For Europe the data furnished by _Ploss_ are grouped by _Gebhard_ in the -following manner. - - - 1. _Northern Europe._ - -The average age at which menstruation first appears, according to the -older statistics, is in Swedish Lapland 18, in Norway, 16.12. In -Copenhagen it is 16.75, in St. Petersburg 14.5. - -More recent statistics for Finland are furnished by _Engström_. Among -3,500 women of pure Finnish descent, he found that menstruation began: - - At the age of: - - 8 years in 2 instances. - 9 years in 2 instances. - 10 years in 4 instances. - 11 years in 41 instances. - 12 years in 178 instances. - 13 years in 458 instances. - 14 years in 715 instances. - 15 years in 778 instances. - 16 years in 614 instances. - 17 years in 369 instances. - 18 years in 195 instances. - 19 years in 91 instances. - 20 years in 31 instances. - 21 years in 8 instances. - 22 years in 10 instances. - 23 years in 2 instances. - 24 years in 1 instance. - 25 years in 0 instance. - 26 years in 1 instance. - -Thus, in nearly half of all Finnish women, menstruation begins with the -completion of the fourteenth and fifteenth years. The statistics include -women of all classes of society. - -At the Pirogoff Congress _Grusdeff_ furnished particulars of the first -onset of menstruation in Russia among 10,000 women. Menstruation began: - - At the age of: - - 9 years in 1 instance. - 10 years in 4 instances. - 11 years in 31 instances. - 12 years in 244 instances. - 13 years in 864 instances. - 14 years in 1641 instances. - 15 years in 1795 instances. - 16 years in 2012 instances. - 17 years in 1692 instances. - 18 years in 910 instances. - 19 years in 498 instances. - 20 years in 183 instances. - 21 years in 65 instances. - 22 years in 19 instances. - 23 years in 5 instances. - 24 years in 3 instances. - 32 years in 1 instance. - -In women of German race living in Russia puberty was earliest, occurring -at the average age of 15.16 years; in Finnish women it was latest, -occurring at the average age of 16.17 years. - - - 2. _Middle Europe._ - -In Germany, according to the tables of _Krieger_ and _L. Mayer_, who -have recorded 11,500 cases in all, menstruation begins most commonly (in -18.931 per cent. of the cases) at the age of 15; the next most frequent -age is 14 (18.213 per cent. of the cases). - -For Berlin, in a number of cases collected from the lower classes of -society, we find the average age for the first appearance of -menstruation to be 16.18 years. - -Notwithstanding the more northerly situation of Berlin, the average age -at puberty is somewhat less than in Munich, situated 4½ degrees to the -southward, for the reason that the retardation dependent upon altitude -makes itself manifest in the latter town, which is situate about 500 -metres (1,640 feet) higher above the sea level. Whereas in Berlin 18 per -cent. of all cases begin to menstruate at the age of 14, and 19 per -cent. at the age of 15, in Munich the two leading years are 15 with a -percentage of 17½, and 16 with a percentage of 18¾. - -In Great Britain, according to _Krieger_, the average age at which -menstruation begins is 15 years, 1 month, and 5 days. For Manchester the -age given is 15 years, 6 months, and 23 days. In France, according to -the calculation of _Brierre de Boismont_, the most frequent age for the -first onset of menstruation is 16. In Paris the average age is 14 years, -6 months, and 14 days. Bohemia, Upper and Lower Austria, and Moravia -have an average age of 16 years and 2 to 3 months. - - - 3. _Southern Europe._ - -In Southern Europe the influence of the higher mean temperature -manifests itself. The average age at which Spanish girls begin to -menstruate is 12. In Northern and Middle Italy the most frequent age is -14; in Southern Italy, 13. In Lyons the average age at which -menstruation begins is 14 years, 5 months, and 29 days; in Marseilles -and Toulon it is 13 years and 10 months. For Hungary, _Doktor_ gives the -statistics of 9,600 cases. In 22⅓ per cent. menstruation began at the -age of 15; in 20½ per cent. at the age of 16, and in 10 per cent. at the -age of 17. The earliest age among these cases was 8 years; the latest, -33 years. (The latter must no doubt be regarded as pathological.) - - - B. ASIA. - -In Palestine puberty most commonly occurs at the age of 13; in Turkey -even as early as 10. _Rouvier_ calculated the average of 742 cases -observed in Syria to be the age of 12. As regards Persian women, the -data vary between the age of 14 for the northern part of the country and -the age of 9 or 10 for the southern. According to _Joubert’s_ data in -46.4 per cent. of the indigens of India, menstruation begins at the age -of 12 or 13. Similar figures are given for Ceylon and for Siam. In Japan -menstruation most frequently begins at the age of 14, sometimes as early -as 13; mothers of 15 are by no means rarities in this country, but for -menstruation to begin before the age of 12 is considered a very -exceptional occurrence. According to a table dealing with 584 women of -Tokio menstruation began: - - At the age of: - - 11 years in 2 instances. - 12 years in 2 instances. - 13 years in 26 instances. - 14 years in 78 instances. - 15 years in 224 instances. - 16 years in 228 instances. - 17 years in 68 instances. - 18 years in 44 instances. - 19 years in 10 instances. - 20 years in 2 instances. - -The data available regarding China are so exceedingly variable that -little importance can be attached to them. - - - C. AFRICA, OCEANIA, AND AMERICA. - -The average age at which menstruation begins in the negro women of -Africa is from 10 to 13. In Algeria puberty occurs at 9 or 10 years. -Among the Australian indigens, menstruation commonly begins as early as -8 years, and at the very latest at the age of 12 years. The data -available concerning the indigens of the Oceanic Archipelago are -extremely variable and inexact, but we cannot go far astray in stating -the age of puberty among these to be from 10 to 13. In tropical South -America girls begin to menstruate from the age of 9 to 14 years. The -Indian women of North America begin to menstruate at the ages of 12, 13, -14, or even as late as 18 or 20. In the Arctic zone of North America and -in Greenland the onset of menstruation is delayed till 17 and even till -23 years. - -As regards the position in life and the upbringing years it has been -shown by numerous observers that among the well-to-do classes, whose -mode of living is luxurious, and whose social circumstances allow free -play to the imagination, menstruation begins at an earlier age than -among the working classes, whose life is one of want and privation. -According to the statistical data of _Mayer’s_ regarding 6,000 women, -menstruation began: - - _In women of the upper _In women of the lower - classes._ classes._ - At the age of 13 years 11.73 per cent. 7.06 per cent. - At the age of 14 years 23.90 per cent. 13.33 per cent. - At the age of 15 years 22.83 per cent. 14.56 per cent. - At the age of 16 years 14.10 per cent. 16.53 per cent. - At the age of 17 years 9.60 per cent. 13.33 per cent. - -From this table we learn that in nearly one-fourth of the girls of the -upper classes puberty occurs at the age of 14, whilst in girls of the -lower classes barely one-sixth begin to menstruate at this age. The -average age at the first menstruation in girls belonging to the upper -classes is seen to be 14.69 years, but in girls belonging to the lower -classes, 16.00 years. According to other observers the average age at -the first menstruation is: - - _Brierre de _Tilt._ _Krieger._ _Ravn._ - Boismont._ (_London._) (_Berlin._) (_Copenhagen._) - (_Paris._) - Amongst gentle folk 13y. 8m. 13y. 5½m. 14y. 1m. 14y. 3m. - and the rich - Amongst the 14y. 5m. 14y. 3½m. 15y. 5m. 15y. 5½m. - well-to-do middle - classes - Amongst the lower 14y. 10m. 16y. 8m. 16y. 5½m. - classes - -Comparative observations on women living in towns and women living in -the country show also that in the former, menstruation begins on the -average at an earlier age. According to _Brierre de Boismont_, the -average age at the first menstruation is: - - In Paris 14 years, 6 months. - In small towns 14 years, 9 months. - In country districts 14 years, 10 months. - -Similarly it was found by _Ravn_ that menstruation first occurred: - - In Copenhagen at the average age of 15 years, 7 months. - In industrial towns 15 years, 4 months. - In country districts 16 years, 5 months. - -_Mayer_ states that the average age at which the first menstruation -occurs is: - - In townswomen 15.98 years. - In countrywomen 15.20 years. - -In Italy, according to _Calderini_, in a thousand instances, -menstruation begins at the age of 14 in 280, at the age of 15 in 219, at -the age of 13 in 205, at the age of 12 in 116, at the age of 16 in 89, -at the age of 17 in 55, at the age of 18 in 14, at the age of 11 in 7, -at the age of 10 in 6, and at the age of 20 in 6 instances. In girls -attending town schools, the first menstruation most commonly occurs in -the months of June and August; but in girls attending country schools -most commonly in the spring months. - -A certain hereditary predisposition is so far determinant in the matter -of the early or late onset of the first menstruation, that from a -knowledge of the age at which menstruation began in the mother, we are -able with great probability to predict the age at which it will begin in -the daughter. Among fifty cases which I investigated with this point in -view, I found forty-one in which the daughters of mothers who had begun -to menstruate early began themselves to menstruate early, usually indeed -in about the same year of life; or conversely that when the mother had -begun to menstruate late, late onset of menstruation was usually to be -observed in the daughter also. _Tilt_ relates a case in which a woman -began to menstruate at the age of fourteen, and her daughter and -granddaughter both began to menstruate at the same age. _Courty_ -observed a mother who began to menstruate at the age of eleven, and -whose eight daughters all began to menstruate at the same age. - -Gynecologists agree in stating that girls of sanguine temperament and -powerful constitution begin to menstruate earlier than weakly and -phlegmatic individuals. _Tilt_ describes a peculiar ovarian temperament, -in which menstruation begins early; such women have as a rule striking -nervous sensibilities, with a dark complexion and glistening, longing -eyes, always surrounded by dark rings. - -The opinion is general that in girls with black hair, dark eyes, thick -skin, and dark complexion, menstruation begins earlier than in blondes -with blue eyes and delicate white skin. _Brierre de Boismont_ states in -this connection that not fair hair only, but also chestnut-tinted locks, -indicate a late onset of menstruation. _L. Mayer_ found that: - - _Of blondes._ _Of brunettes._ - - 17.20 per cent. 18.84 per cent. began to menstruate at the age of 14 - 16.89 per cent. 18.02 per cent. began to menstruate at the age of 15 - 15.14 per cent. 16.59 per cent. began to menstruate at the age of 16 - -According to the same author, the average age at which menstruation -begins is: - - In blondes 15.55 years. - In brunettes 15.26 years. - -As regards race, it is well known that in Jewesses menstruation begins -at an early age. According to _Joachim_ the age of puberty varies very -greatly among the different races inhabiting Hungary. The first -menstruation appears: - - In Slavonic girls between the ages of 16 and 17 - In Magyar 15 and 16 - In Jewish 14 and 15 - In Styrian 13 and 14 - - - FIRST APPEARANCE OF MENSTRUATION. - -The first appearance of menstruation is commonly preceded by various -symptoms dependent on the increased flow of blood to the genital organs. -Such symptoms are: Sacrache; dragging sensation in the loins; an -indefinite feeling of pressure in the lower part of the belly, -especially in the region of the uterus and the ovaries, which region is -sometimes also tender on pressure; a slight feeling of weariness in the -lower extremities; sudden flushings or pallors; alternating sensations -of heat and chilliness, sometimes accompanied by actual though slight -change of temperature. In many cases also there are disturbances in the -intestinal evacuations and urinary secretion, in the process of -cutaneous transpiration, and in the functional activity of the -gastro-intestinal canal. A frequently observed symptom is an increased -irritability of the entire nervous system, with an inclination to -melancholy and indefinite amorous desires—symptoms which _Tilt_ denotes -by the term “ovarianismus,” _Emmet_ by the term “erection,” _Lecal_ by -the term “phlogose amoureuse,” and the older writers by the term -“molimina menstrualia.” - -The nervous irritability manifests itself already before the appearance -of the menstrual flow by headache and moodiness, weariness, nervous -irritability, and low spirits; further, by slight changes in the facial -aspect, dark rings round the eyes, spontaneous blushing, uneasy -sensations, epigastric pain, loss of appetite, a sensation of pressure -in the abdomen, palpitation, vertigo, dragging sensations passing from -the loins to the thighs, feeling of weakness and numbness in the lower -extremities—symptoms which often endure for several months and in such -cases tend to lower the resisting powers of the organism. - -_Courty_ enumerates as prodromal symptoms which are observed in the -majority of girls before the first appearance of menstruation: swelling -and tenderness of the breasts, sensation of fulness and weight in the -hypogastric region, moderate intestinal meteorism, sacrache, -aqueo-mucous vaginal discharge, finally, an itching sensation in the -genital organs. These manifestations may also assume a morbid character, -taking the form of violent abdominal and lumbo-sacral pain, general -fatigue and weakness, dyspepsia and diarrhœa, cephalalgia, various kinds -of neuralgia, some degree of moral aberration. After the first -menstruation, two or three months may elapse before the girl menstruates -again, but after the lapse of a year the flow usually recurs at quite -regular periods. Sometimes the early periods are very violent and recur -very frequently, every twenty days, for instance. - -The greatest increase in size and weight occurs in the female sex at the -time of the menarche. Amongst the poorer classes the greatest -development in size and strength occurs between the ages of 13 and 15 -years, whereas in the upper classes of society, those who ultimately -attain the same weight exhibit their greatest growth at the ages of 12, -13, and 14 years. According to _Pagliani_ the greatest growth in the -female sex always precedes puberty, so that for example a girl who -begins to menstruate at the age of 12 will grow most rapidly in the year -preceding this, whereas a girl who begins to menstruate at a more -advanced age will not undergo her most rapid phase of growth so early as -the age of 11. According to the observations of _Bowditch_, _A. Hey_, -_Lombroso_, _Pagliani_, and _Ploss_, up to the age of 11 or 12 years the -growth of girls exceeds that of boys, but whereas in girls growth ceases -suddenly at the age of 14, in boys growth proceeds regularly up to the -age of 16 years. At birth boys are on the average 1 cm. (⅖″) longer than -girls; but during puberty the female sex catches up the male in height, -or even surpasses it. According to _Ploss_, a girl of 16 or 17 years is -as tall as a young man of 18 or 19 years. - -The earlier development of the female as compared with the male at the -time of puberty is a constant phenomenon, to be observed in all races, -in every climate, and in all strata of society. According to the -statistical data published by the authors just quoted, the age of -greatest development in the respective sexes is: - - _In the female._ _In the male._ - - As regards weight at the age of 12 to 14 years. 14 to 17 years. - As regards height at the age of 12 to 13 years. 12 to 15 years. - As regards respiratory capacity at the age of 12 to 15 years. 15 to 17 years. - As regards muscular strength at the age of 12 to 14 years. 14 to 15 years. - -Puberty occurs in the female on the average about two years earlier than -in the male, and upon this difference the observed differences in growth -also depend. - -The menarche in the wider signification of the term includes the -development which occurs at the time of puberty, and continues through a -period of several months, and even years, before complete sexual -maturity is attained; and includes also the time, which may be -considerable, following the first appearance of the menses and before -the regular rhythm of the menstrual function is established and the full -development of the female genital organs is attained. This time, which -forms a notable phase of the sexual life of woman, is characterized by -great changes in the genital organs and in the vital processes connected -therewith, by a strong tendency to suffer from a series of very various -pathological changes and disorders of function in the principal organs, -and a lessened general resisting power to disease—a change which finds -its most definite expression in the well-established fact that in this -period of life the mortality among females is much greater than among -males of corresponding age. According to the statistical data of -_Quetelet_ and _Smits_, from the age of 14 to the age of 18 (the period -of the menarche) there are 128 deaths of females for every 100 deaths of -males; and even in the four succeeding years, from the age of 18 to the -age of 22, the unfavorable conditions peculiar to sex are witnessed by -105 deaths of females to every 100 deaths of males. - -Many authors draw a distinction between the age of puberty (from the -Latin _pubes_, _puberis_), when the growth of the pubic hair occurs as -an external sign of sexual development, and the age of nubility (from -the Latin _nubere_), when the individual becomes fitted for marriage. -The distinction is a partial one only, inasmuch as capacity for -copulation is attained already at puberty. The law, however, maintains -such a distinction, the Austrian Penal Code, for example, regarding -intercourse with a female less than fourteen years old as rape, and the -German Code likewise punishing carnal knowledge of a girl under -fourteen. - -The signs of puberty in girls were noticed and explained in very early -times. From the anthropological studies of _Ploss_ and _Bartels_ we take -the following data regarding this matter. In the Bible we read (Ezekiel, -xvi, 7): “Thy breasts are fashioned and thine hair is grown, whereas -thou wast naked and bare.” The early Indian physician, _Susruta_, refers -only to the regular recurrence of menstruation as a sign of puberty. -That a woman is menstruating may be known by the fact that her face is -swollen and bright. In the Roman Empire _Justinian_ ordained that all -young women should be examined as to the growth or absence of the pubic -hair in order to ascertain if they were ripe for marriage. The early -Chinese physicians recorded that in every woman at the age of fourteen -or fifteen years a monthly flow of blood from the genital organs began, -the period of recurrence being thirty days. The physicians of the Talmud -express themselves variously regarding puberty in women. In one place -they advance as a sign of puberty the growth of the hair on the genital -organs; in another they speak of the notable enlargement of the breasts, -and mention as a sign of more complete sexual development that the -nipples become elastic. Other Talmudists refer to the appearance of a -dark brown coloration in the areola and to the enlargement of the mons -Veneris as signs of puberty. Savage races regard the first appearance of -the menstrual flow as the only certain sign of puberty, and among many -such races this is the occasion of peculiar ceremonial rites. The -attainment of puberty in savage tribes is often solemnized by the -seclusion of the girls from the time of the first menstruation; they -fast during the period of seclusion, which sometimes terminates in an -elaborate ritual of purification. - -For two reasons in particular, the period of the menarche is a time of -storm and stress to women, first on account of the developmental -processes in the genital organs, and secondly on account of the -intellectual changes that occur at this period. - -The local cause is to be found in the extensive transformation of the -ovaries and the uterus, by means of which a peculiar and powerful -stimulus, the menstrual stimulus, is elaborated, which has a reflex -influence upon heart and brain, vascular and nervous systems, and -secretory and nutritive processes. Since we know that in every -premenstrual period by the growth of the follicles hyperæmia is excited -in the ovary, by means of which the liquor folliculi is increased in -amount, we can well understand that at the time of the menarche the -ripening of the graafian follicles is accompanied by a considerable -degree of hyperæmia of the ovaries and of the whole of the genital -organs, now undergoing their fullest development, and we can easily see -how this hyperæmia may result in manifold reflex disturbances. But in -addition to these reflex disturbances, we have once more to take into -consideration the as yet imperfectly known chemical processes which are -associated with the ripening and development of the graafian follicles, -and an abnormal course of which may give rise to a disordered -constitution of the blood, manifesting itself as chlorosis or in other -ways. In connection with the growth and ripening of the ova, extensive -and novel demands are made on the organism, and these may well endanger -metabolic processes which are not established on a very secure -foundation. - -The other cause is to be found in the intellectual processes which occur -at this time in the youthfully receptive, highly sensitive organ of -mind, the brain. The girl growing into womanhood, who with astonishment -and stress has witnessed the visible changes in her body, the outward -signs of puberty, as they gradually make their appearance, receives -powerful psychical stimulation which cannot fail to exercise an -influence upon the entire nervous system and its complex interlacements, -alike in the sensory and in the motor sphere. - -The degree to which these influences radiating from the genital organs -make themselves manifest is chiefly dependent upon the resisting power -of the nervous system as a whole, upon the temperament, the inherited -constitution, and the mode of education of the young girl. In children -belonging to families noted for sensibility and irritability, in -dwellers in large cities who have attended high schools for girls and -have at an early age lifted the veil that covers the sexual processes, -the reflex disturbances of the menarche will be more manifold and will -manifest themselves with greater intensity than in children brought up -in country districts, whose sensibilities are chiefly physical and whose -mind is less susceptible to the influence of external stimuli. - -A further important consideration is the time at which the menarche -occurs, and whether on the one hand it is at or near the average age, or -whether on the other, as precocious menstruation, it is unusually early, -anticipating the general bodily development, or again as retarded -menstruation it is unduly delayed. In some cases of retarded -menstruation, the external genital organs are thoroughly well developed, -and it is menstruation only that remains in abeyance; but in other cases -the external genitals are also backward in development, the pubes and -mons Veneris being but sparsely supplied with hair, and the breasts -remaining very small. - -In addition to these abnormal temporal relations of the menarche, -certain other irregularities at the commencement of menstruation are -worthy of note. Thus, the first menstruation may be normal, but -thereafter amenorrhœa may persist for several months, or if the flow -occurs it may be exceedingly scanty, or very pale in color; on the other -hand, menstruation may be very profuse, lasting many days. - -The environment in which the young girl is placed during the period of -her sexual development has a great influence on the processes of the -sexual life and on the pathological disturbances that affect these -processes. - -In working-class families the immoderate physical strain often thrown -upon girls, in many cases continuous movements of the upper extremities -whilst the lower extremities and the pelvis are absolutely quiescent, or -conversely, an excessive employment of the muscles of the lower -extremities—these circumstances in conjunction with insufficient -nutriment, night-work, association when at work with persons of the -opposite sex, and the frequent premature sexual stimulation, will -combine to have a most deleterious effect. - -Amongst country-folk, indeed, the girl has the enjoyment of fresh air, -and as a rule nutritive food, moreover, there are not so many occasions -of nervous stimulation; puberty therefore arrives more slowly and gives -rise to less disturbance; but the ignorance of the girls very frequently -leads to an early experience of coition, the natural and unnatural -consequences of which have then to be taken into account. - -Amongst the better classes of townspeople such hygienic regulations and -educational measures are in common employment that young girls during -the years of development usually receive reasonable care and -attention—but very frequently, intercourse with older girls, association -with young men, visits to theatres, evening-parties, and balls, and the -perusal of stimulating literature, form unfavorable features of urban -life which exercise their inevitable effects in the sexual sphere. In -some cases, fortunately sufficiently rare, the stimulation of the sexual -impulse and the longing for its satisfaction are so intense, that a kind -of _demi-vierge_ is brought into being, a young woman who is concerned -only to preserve the physical token of virginity, but whose thoughts and -fancies are anything but maidenly. It is to be feared that in -consequence of the excessive freedom in education and the emancipated -independence of feminine youth, these “half-virgins” are increasing both -in number and in intensity, a fact which cannot fail to increase also -the number of sexual maladies and perversions. - - - _Anatomical Changes in the Female Genital Organs in the Period of the - Menarche._ - -The female reproductive organs, which in childhood were in a -comparatively quiescent state, now become powerfully active, as is -witnessed by the changes that occur in the external genitals. - -The soft, hairless vulva of the child becomes enlarged at the time of -the menarche by the deposit of fat, and its substance becomes tough and -elastic. Some time before puberty, fine, pale hairs make their -appearance here and there, but not until puberty does the hairy covering -of the pubic region become more or less thick. The growth of the denser -pubic hair begins with the appearance of hairs along the middle of the -mons Veneris and at the margins of the labia majora. Early sexual -development is commonly indicated by an early and thick growth of the -pubic hair. In the virgin this hair is smoother and less curly than in -the later course of the sexual life. In certain tribes of negroes it is -the custom for the young unmarried girls to shave off the pubic hair, -which is not allowed to grow freely until after marriage. In some of the -tribes of South Sea Islanders it is customary at puberty to tattoo the -external genitals and the surrounding skin. - -[Illustration: - - FIG. 8.—Internal genital organs of a new-born, powerfully developed - female infant. (From Toldt: Atlas of Human Anatomy.—Rebman Company, - New York.) -] - -In young virgins the rima urogenitalis or vulval cleft is closed by the -accurate opposition of the labia majora; the labia minora or nymphæ are -delicate in texture, rose-red in color, hairless, free from fat, and -completely covered by the labia majora; whilst the clitoris is likewise -concealed. The sebaceous glands of the labia minora secrete a smegma -which collects especially around the glans clitoridis, and as it -undergoes decomposition diffuses a peculiar odor, resembling that of old -cheese. A wing-like elongation of the labia minora in young girls, with -free secretion and a generally moist appearance, leads to a suspicion of -the practice of masturbation. In the virgin the orifice of the vagina is -covered by the hymen. - -[Illustration: - - FIG. 9.—Reproductive organs of a new-born, powerfully developed female - infant in median sagittal section. (From Toldt: Atlas of Human - Anatomy.—Rebman Company, New York.) -] - -[Illustration: - - FIG. 10.—Internal genital organs of a girl aged eight years. Seen from - behind. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New - York.) -] - -The entrance to the vagina in the virgin is rounded, the posterior -border of the aperture being deeply concave, whilst the anterior border -is often slightly convex backwards. Where this feature is strongly -marked, the orifice has a semilunar shape. The posterior concave border -projects forward in the form of a fold, continuous above with the -posterior vaginal wall; this fold is the hymen. - -[Illustration: - - FIG. 11.—Reproductive organs of a girl aged ten years in median - sagittal section. Left half. (From Toldt: Atlas of Human - Anatomy.—Rebman Company, New York.) -] - -[Illustration: - - FIG. 12.—Female external genital organs of a virgin, attached to the - vagina which has been isolated and opened, and a portion of the - cervix uteri, Hymen, etc. (From Toldt: Atlas of Human - Anatomy.—Rebman Company, New York.) -] - -[Illustration: - - FIG. 13.—The external genital organs of a virgin, drawn apart - transversely (after von Preuschen). c. Clitoris. f. c. Frænum of the - clitoris. n. Nymphæ. l. Labia majora. o. u. Urethral orifice. h. - Hymen. f. n. Fossa navicularis. -] - -The infantile uterus is so proportioned that its neck (_collum vel -cervix uteri_) constitutes the larger part of the organ, as much indeed -as two-thirds. Owing to the small size of the body (_corpus uteri_), the -whole uterus is very flat, and its borders ascend in a direction almost -parallel to each other, diverging somewhat abruptly into the Fallopian -tubes, recalling in some degree the two-horned embryonic form of the -organ (_uterus bicornis_). The plicæ palmatæ on the surface of the -cervical canal, which make up the arbor vitæ uterina, are strongly -developed; the median longitudinal ridge bifurcates, and its divisions -can be traced on either side into the uterine orifice of the Fallopian -tube (_ostium uterinum tubæ_). The lips of the vaginal portion of the -cervix are comparatively speaking very large and terminate in sharp -angles. The vaginal mucous membrane is everywhere beset with long -papillæ. The development of the uterus shortly before puberty consists -chiefly in the enlargement of the body of the uterus, and the growth of -its walls in thickness. - -[Illustration: - - FIG. 14.—Sagittal section of the female pelvis (after Breiolei). -] - -At the time of puberty, according to _Toldt_, the body of the uterus in -the virgin has already increased till its length is half that of the -entire organ; and at the first appearance of menstruation the body and -neck of the virgin uterus are nearly equal, with perhaps a slight -preponderance in size of the cervix, and the walls of the uterus have -become convex. In consequence of this change the organ becomes -pear-shaped, and the uterine cavity (_cavum uteri_) assumes the form of -a triangle with moderately incurved sides. The cervical canal becomes -wider in the middle; the margin of the os uteri becomes smooth and -rounded. The walls of the virgin vagina are marked with numerous dentate -transverse ridges (_rugæ_), especially near the lower end and on the -anterior walls, the columns of the vagina (_columnæ rugarum_), from -which the transverse ridges run to either side at right angles, extend -half way up the vagina, and are of a hard consistence. - -The characteristic changes in the ovary at the time of the menarche -originate in the changes undergone by the ovarian follicles. A large -number of small separate follicles is to be found already in the ovary -of the new-born infant. These structures, known as primitive follicles, -are formed by detachment from the egg-tubes that grow down into the -stroma from the superficial germinal epithelium; they are spheroidal -vesicles, enveloped by a single layer of cubical cells, and their -interior is entirely filled by the primitive ovum or egg-cell. This -latter consists of very finely granulated protoplasm with spherical -nucleus and distinct nucleolus, but no trace of an investing membrane -can as yet be discerned. The further development of the ovarian -follicles takes according to _Toldt_ the following course: A rapid -multiplication of the cubical cells that form the wall of the follicle -occurs, so that the ovum is surrounded by two, three, or several layers -of cubical or rounded cells, and the whole follicle gradually increases -in size. At the same time the ovum assumes an eccentric position in the -interior of the follicle. At or near the middle of the follicle a -slit-shaped space now appears, filled with a clear colorless fluid. As -this space gradually enlarges, the follicle[19] becomes converted into a -vesicle filled with fluid, the wall of which is composed of small -cubical cells. Simultaneously with the growth of the follicle a -lamination of the elements of the surrounding stroma takes place, so -that a somewhat sharply defined capsule is formed. In this condition -these glandular structures of the ovary are known as graafian -follicles.[19] - -Before puberty, these graafian follicles are small vesicles of a -diameter of one to two millimetres, containing the large unicellular -ova. Each of these consists of an envelope, the zona pellucida (also -known as the zona radiata, or striated membrane of the ovum); an -external granular mass of protoplasm, the vitellus or yolk; a vesicular, -spherical nucleus, the germinal vesicle; and a nucleolus, which if -single is large and prominent, the macula germinativa or germinal spot. -As early as the second year of infancy every imaginable intermediate -stage between the primitive follicle and the fully-developed vesicular -graafian follicle can be observed. - -At the time of puberty certain larger follicles are always to be -distinguished, which have moved inward toward the interior layers of the -ovary, whereas the smaller follicles have a more peripheral situation; -thus, according to _Waldeyer_, we observe at this time in a section of -the ovary, proceeding from without inward, first the epithelium, next -the fibrous tunic, next the zone of younger follicles, and finally the -zone of older follicles. According to _Henle_ and _Waldeyer_, at the -commencement of puberty, there are in each ovary about 36,000 ova, -giving a total for the two of 72,000. - -[Illustration: - - FIG. 15.—Primitive follicles. -] - -In the further course of development of the graafian follicles at this -period, the most advanced now reapproach the surface of the ovary, so -that a fully-matured follicle comes to occupy almost the entire -thickness of the cortical substance, and may even give rise to a -localized bulging of the surface of the organ. In such a mature -follicle, which has attained nearly the size of a pea, we recognize an -outermost connective-tissue investment (_theca folliculi_), consisting -of condensed ovarian stroma, in which two layers are distinguished, -sometimes called simply _outer tunic_ and _inner tunic_, sometimes known -by the names of _tunica fibrosa_ (outer) and _tunica propria_ (inner), -respectively; within this is the cellular layer known as the _membrana -granulosa_ (or _stratum granulosum_), the portion of which, now greatly -enlarged, immediately surrounding the ovum is known as the _discus -proligerus_ (or _cumulus oöphorus_); the interspace between the _discus -proligerus_ and the membrana granulosa is filled with a clear fluid, the -_liquor folliculi_. In consequence of the continued increase in its -fluid contents, the graafian follicle ultimately bursts along the most -prominent portion of the superficial wall, and the ovum passes out -through the rupture, finding its way under normal conditions into the -Fallopian tube and through this into the uterus. The follicle itself -then undergoes a regressive metamorphosis, forming the _corpus luteum_, -the rent in the envelope of which, after the absorption of the yellowish -semi-fluid contents, undergoes cicatrization. Contemporaneously with -this development at puberty of the process of ovulation, menstruation -also for the first time makes its appearance, recurring thenceforward at -four-weekly intervals as the regular catamenial discharge. - -We append the account given by _Pfannenstiel_ regarding the ovarian -follicles. He writes: “In correspondence with the especial function of -the female reproductive gland, which is to bring to maturity and to -evacuate only after the lapse of a considerable period and at successive -intervals, the ova which it has contained from the very outset, we find -that primitive follicles continue to exist in the ovary up to the very -end of the period of sexual activity, though naturally in diminishing -numbers; and the size and shape of these primitive follicles remain -nearly identical throughout the various periods of life. As the follicle -ripens, the epithelium grows, the cells becoming cubical with a rounded -nucleus, and increasing in number by cell-division, so that several -layers are formed. As soon as these layers are three or four in number, -a space, at first slit-shaped, forms in the epithelium on the peripheral -surface of the ovum; this space is filled with fluid, known as the -liquor folliculi; the peripheral layer of cells, the membrana granulosa, -is thus separated from the mass of epithelial cells immediately -enveloping the ovum, the discus proligerus, which is situate in the side -of the follicle adjacent to the hilum of the ovary. By the increase of -the liquor folliculi the graafian follicle is formed, a vesicle the -envelope of which is formed by the multilaminar membrana granulosa, -whilst in the pole of the vesicle directed toward the hilum ovarii is -the ovum imbedded in the mass of cells forming the discus proligerus, a -mass which has the form of a truncated cone. The liquor folliculi is -formed by the epithelium, the nuclei of which disappear by chromatolysis -or by simple atrophy whilst the cell-bodies liquefy in consequence of -albuminous, not fatty, degeneration (_Schottländer_). Within the -epithelium of the follicle we find the faintly glistening epithelial -vacuoles of _Fleming_, likewise cells which liquefy and assist in -increasing the bulk of the liquor folliculi. This liquor is a thin, -serous fluid, and contains albumin. * * * Every graafian follicle has a -bilaminar investing membrane, which is formed by the ovarian -stroma. * * * The ovum of the growing follicle increases in size very -slowly indeed, attaining on the average, according to _Nagel_, a -diameter of 165 to 170 µ, it retains its zona pellucida, the greater -part of the protoplasm of the cell is transformed into deutoplasm -(food-yolk, or yolk-granules), the nucleus assumes an eccentric -position. Between the zona pellucida and the cell-body a narrow -perivitelline space appears. The ovum is then full-grown, but not yet -fully prepared for fertilization; for this, maturation is required, -certain changes in the germinal vesicle, which occur after the bursting -of the follicle. * * * As a rule each follicle contains a single ovum. -But two and even three ova have beyond doubt been observed in one -follicle.” - -According to _Waldeyer_, the bursting of the follicle is not to be -regarded as dependent upon a sudden rise of pressure in its interior, -but as the result of a gradual ripening process. At the deepest pole of -the follicle, which in the course of its development has now approached -the surface of the ovary, an exuberant growth takes place in the -internal layer (tunica propria) of the theca folliculi, with a profuse -formation of new vessels. Here numerous “epithelioid” cells, the -“lutein-cells,” make their appearance. In consequence of this -proliferation of the lutein-cells, the contents of the follicle are -gradually pressed toward the “stigma,” the superficial pole of the -follicle, and the follicle itself is pushed toward the surface until it -finally comes into contact with the germinal epithelium. Meanwhile the -follicular epithelium undergoes fatty degeneration, alike in the -membrana granulosa and in the discus proligerus. In consequence of the -proliferation of the lutein-cells, on the one hand, and the fatty -degeneration of the epithelium, on the other, the follicle opens at its -weakest point, the stigma, and the ovum is extruded, with the liquor -folliculi, and a number of cells belonging to the follicular epithelium. -(To illustrate these changes we have borrowed FIGS. 15, 16, and 17 from -the monograph, by _Pfannenstiel_ on _Diseases of the Ovary_, in _J. -Veits’ Handbook of Gynecology_.) - -The ovaries, which in the new-born female infant are flattened, -ribbon-like bodies one-half to one centimeter (0.2 to 0.4″) in length, -and in childhood are cylindrical, with a perfectly smooth surface, -assume at the time of puberty a more or less flattened form. During the -menarche they have an elongated oval shape, flattened from side to side, -their average length being 2.5 to 5.0 centimetres (1 to 2″), width 1.5 -to 3.0 centimetres (0.59 to 1.18″), thickness 0.6 to 1.4 centimetres -(0.24 to 0.55″), weight 5 to 8 grammes (77 to 123 grains). After the -repeated occurrence of ovulation, the surface of the ovary becomes more -and more uneven, being thickly covered with fossæ or scar-like fissures. - -[Illustration: - - FIG. 16.—Ripening follicles. -] - -The vagina during virgin girlhood is narrow, and its mucous surface is -beset with numerous rugæ, which may be plainly felt as well as seen. The -calibre of the vagina is proportionately less the younger the girl. The -examining finger is gripped by the vaginal wall as by an india-rubber -tube (_Maschka_). The vaginal portion of the cervix is felt in the form -of a truncated cone, with a smooth surface, rather dense in consistence; -the external os opens at the bottom of a small depression on its -surface, in the form of a short oval, the long axis of which is -transversely directed. Shortly before the menarche, Bartholin’s glands -become noticeable on either side of the lower end of the vagina between -the sphincter muscles. - -The clitoris in many cases attains a very large size, and this is apt to -lead to sexual malpractices. According to _Hyrtl_, in southern countries -the clitoris is larger than in temperate and cold climates. In the women -of Abyssinia and among the Mandingoes and the Ibboes, the size is -portentous, and amongst the first-named, circumcision of females is a -customary operation. It is said that female slaves belonging to these -races are greatly esteemed by the ladies of the harem, and are eagerly -sought for. In the anatomicopathological museum at Prague there is a -preparation of the female genital organs with a clitoris as large as the -penis of a full-grown man. - -[Illustration: - - FIG. 17.—Graafian follicles. -] - -_Sonini_ describes “as peculiar to women of Egyptian or Koptic descent, -the presence of a thick, fleshy, but soft and pendent outgrowth in the -pubic region, completely covered with hair,” which he compares to the -hanging caruncle on the bill of the male turkey. This appendage becomes -thicker and longer with advancing years. Sonini found such an appendage -one-half inch in length in a girl of eight years, one of more than four -inches in a woman of twenty to twenty-five years. Circumcision in girls -consists in the removal of this outgrowth, which hinders copulation; in -that part of the world the operation is usually effected in the seventh -or eighth year, just before puberty. - -The circumcision of girls as practiced by Mahommedan peoples in Africa -is said by _Ploss_ and _Bartels_ to consist in abscission of the labia -minora, the clitoris, and the præputium clitoridis. _Brehm_ is of -opinion that the object of the operation is to diminish the intensity of -the sexual impulse, so overpowering among these races; but others -believe that the great enlargement of the clitoris and the labia minora -usual in those countries is regarded as a serious defect in beauty, a -defect removed by the operation; whilst others again hold that the -circumcision is required for the removal of the hindrance to copulation -presented by the abnormally large clitoris. Closely related to the -operation of circumcision in females, according to _Ploss_ and -_Bartels_, is the custom peculiar to Africa of infibulation, wherein, -after a preliminary cutting operation like that for circumcision, the -fresh wound surfaces are brought into accurate opposition, either by -sutures or by appropriate bandages, so that when cicatrization occurs -the vulval cleft is closed except for a very small aperture. The object -of infibulation is to enforce on girls complete abstinence from sexual -intercourse. (Before marriage, the vulval cleft is reopened to an extent -corresponding with the size of the genital organs of the future husband; -and when pregnancy occurs, the opening is still further enlarged before -parturition; but after that event, the wound surfaces are refreshed, and -the whole opening is once more closed). On the other hand, in many -savage tribes, elongation of the labia minora and the clitoris is -artificially undertaken from the earliest years of girlhood, this -elongation being regarded as a beauty. - -The parts of the external reproductive organs of the female concerned in -sexual sensation, first described as such by _Kobelt_, are already fully -developed at the time of the menarche. Of these parts a small portion -only, the glans clitoridis, is visible externally, surrounded by the -præputium clitoridis, a prolongation of the labia minora, which passes -round the front of the clitoris, and sends from each side a fine process -behind the glans to become attached to its under surface, forming the -frænum of the clitoris. The erectile apparatus of the external genitals -is formed by the corpora cavernosa clitoridis. As two delicately -constructed trabecular masses of erectile tissue, the crura of the -clitoris, these are attached on either side to the inferior or -descending rami of the pubic bones; at first passing upwards parallel to -the bones, they subsequently curve downward as they converge and unite -to form the body of the clitoris; these masses of erectile tissue -embrace the sides and the front of the lower extremity of the vagina. -This erectile apparatus, when the supply of arterial blood is greatly -accelerated and at the same time the outflow of venous blood is -diminished, becomes distended with blood, enlarged and stiffened; the -process of erection plays an important part, as we shall explain more -fully later, in the production of sexual excitement and sexual pleasure -during the act of copulation. - -In the virgin and in the earlier phases of the sexual life, the hymen is -so characteristic an organ that its more minute description would seem -desirable. - -The hymen, a fold of mucous membrane, springing from the periphery of -the vaginal orifice, separates as a perforated diaphragm the vagina from -the vulva. Between the two epithelial layers of which, as a fold of -mucous membrane, the hymen consists, is a supporting layer of connective -tissue of variable strength; in other respects the mucous membrane of -the hymen has the same structure as the mucous membrane of the vagina. -On its inner surface the rugæ and folds of the vaginal mucous membrane -are prolonged. The shape of the hymen is very variable; most commonly -its aperture is more or less central, so that the hymen has a ringed or -semilunar shape. - -[Illustration: - - FIG. 18.—Annular Hymen. -] - -[Illustration: - - FIG. 19.—Annular Hymen. -] - -In the new-born female infant, the hymen has the appearance of a tubular -stopper closing the lower end of the vagina; according to _Dohrn_ it -exhibits as a rule one of three typical forms: _Hymen annularis_, -_denticulatus_, _et linguiformis_; the _annular_, the _denticulate_, and -the _linguiform_ (or _linguliform_) _hymen_. The transverse ridges on -the inner surface of the hymen, prolongations of the rugose columns of -the vagina, are strongly developed. During the girl’s further growth, in -association with the enlargement of the vagina, the hymen undergoes -important changes in form and structure. Its border becomes thinner and -more tense; and in the virgin at the time of the menarche, the annular -hymen is the fundamental type, subject, however, to extensive -variations. In most cases, at any rate, the aperture in the hymen is -more or less centrally situated; very commonly, however, this opening is -crescentic, when we have a semilunar hymen, the height of the border -posteriorly being much greater than anteriorly. The consistency of the -hymen, its extensibility, and its thickness, are as variable as its -shape. - -[Illustration: - - FIG. 20.—Semilunar Hymen. -] - -[Illustration: - - FIG. 21.—Annular Hymen with congenital Symmetrical Indentations. -] - -[Illustration: - - FIG. 22.—Fimbriate Hymen. -] - -[Illustration: - - FIG. 23.—Deflorated Fimbriate Hymen. -] - -In the normal position of the reproductive organs the hymen has very -rarely the appearance of a tense membrane; as a rule it is folded up, -and becomes plainly manifest only when the genital organs are stretched. -The margin of the hymeneal aperture, as a close examination shows, is -sometimes sharp and regular, sometimes lobulated, with small congenital -notches. These congenital notches are to be distinguished from the -lacerations resulting from defloration by the fact that the former have -a smooth border, which is of the same consistency as the general -substance of the hymen. In some instances the border of the aperture in -the hymen is beset with small, fine villi (villous hymen). - -The common varieties of the hymen are thus classified by _Maschka_: - -1. The _annular hymen_, in which the membrane when stretched is seen to -have a rounded aperture, which may be central or eccentric; very often, -indeed, the aperture is more toward the upper half of the hymen, in -which case it is not always circular, but frequently rather ovoid in -shape. - -2. The _semilunar_ or _crescentic hymen_, in which the aperture is -eccentrically placed in the upper half of the membrane, in such a manner -that the hymen exhibits a wide surface below the aperture, which surface -narrows at either side as it passes upwards until it disappears, the two -sides failing to reunite above the aperture. - -3. The _heart-shaped_ or _cordiform hymen_, the general shape of which -may be circular, ovoid, or even semilunar, but in which from the middle -of the upper or lower margin a three-cornered tongue projects across the -aperture, which is thus given the form of the conventional heart of a -pack of cards. - -4. _The infundibuliform hymen_ has the form of a small projecting funnel -resembling in appearance the invaginated end of the finger of a glove. - -_Maschka_ refers also to the rare condition in which the hymen is -sometimes said to be absent. As a matter of fact, however, in such -cases, it is represented by a very narrow annular eminence, the genitals -being in other respects normal. The smooth character of the eminence -will serve to differentiate it from the remains of a destroyed hymen. -Other rare forms are: - -1. The _imperforate hymen_, an occlusive membrane, entirely blocking the -vaginal orifice. In some cases, however, the hymen is not absolutely -imperforate, a very small, punctiform aperture being present. - -2. The _cribriform hymen_, a hymen which is “imperforate” in the sense -that there is no opening of a size approaching the normal, but in which -several minute apertures are present. - -3. The _septate_, _bridged_ or _divided hymen_ (_hymen bifenestratus_, -etc.), exhibits a strip of mucous membrane, most commonly running -directly from before backward, occasionally, however, somewhat -obliquely, across the aperture in the membrane, which is thus divided -into two equal or unequal parts. In some instances the process that -bridges the aperture of the hymen is expanded in the vertical plane to -form a septum which projects for some distance into the vagina. - -[Illustration: - - FIG. 24.—Septate Annular Hymen. -] - -[Illustration: - - FIG. 25.—Septate Semilunar Hymen. -] - -[Illustration: - - FIG. 26.—Extremely tough Annular Hymen, with an obliquely disposed - Septum. -] - -[Illustration: - - FIG. 27.—Septate Hymen with Apertures of unequal size. -] - -4. The _lobate_, _lobulated_, or _labiate hymen_, which consists of -several (two to four) lobes on either side, each overlapping the next -like the tiles in a roof, whilst the aperture between the two sides has -the form of an antero-posterior slit (FIG. 37); in some cases the lobes -of a lobulated hymen are so disposed that the membrane has the -appearance of a fold of mucous membrane with a central furrow. - -[Illustration: - - FIG. 28.—Septate Hymen with Apertures of unequal size. -] - -[Illustration: - - FIG. 29.—Hymen with rudimentary Septum. -] - -[Illustration: - - FIG. 30.—Hymen with posterior rudimentary Septum. -] - -[Illustration: - - FIG. 31.—Labiate Hymen with posterior rudimentary Septum. -] - -It is obvious that an imperforate or cribriform hymen, by the hindrance -it offers to the passage of the menstrual discharge, is liable at the -time of the menarche, and as soon as menstruation begins, to give rise -to serious disorder and to pathological states. - -[Illustration: - - FIG. 32.—Hymen with anterior rudimentary Septum. -] - -[Illustration: - - FIG. 33.—Hymen with anterior rudimentary Septum projecting in a - opiniform Manner. -] - -[Illustration: - - FIG. 34.—Hymen with anterior and posterior rudimentary Septa. -] - -[Illustration: - - FIG. 35.—Hymen with filiform process projecting from the anterior - margin. -] - -[Illustration: - - FIG. 36.—Hymen in which there are two symmetrically disposed thinned - areas. The left of these is perforated. -] - -The illustrations we append, showing the various forms of the hymen, are -taken from _von Hoffmann’s Handbook of Medical Jurisprudence_. (FIGS. -18–45.) - -[Illustration: - - FIG. 37.—Very unusual form of Hymen. -] - -[Illustration: - - FIG. 38.—Semilunar Hymen with cicatrized Lacerations in its Border. -] - -[Illustration: - - FIG. 39.—Deflorated Semilunar Hymen with laterally disposed - Symmetrical Lacerations. -] - -[Illustration: - - FIG. 40.—Deflorated Annular Hymen with several cicatrized Lacerations. -] - -[Illustration: - - FIG. 41.—A. Septate Hymen in which Defloration has been effected - through one of the Apertures. U. Urethra. Cl. Clitoris. H. - Cicatrized margin. C. Septum. B. Lateral View of Septum. -] - -In some cases the hymen is exceedingly thin and delicate, so that it is -liable to be torn if handled at all roughly; in other cases, on the -contrary, it may be very firm, thick, and fleshy, interlaced with -strands of connective tissue and muscle, so that it forms a veritable -cuirass for the protection of physical virginity. - -[Illustration: - - FIG. 42.—Deflorated Septate Hymen. -] - -[Illustration: - - FIG. 43.—Hymen with larger anterior and smaller posterior Apertures. -] - -[Illustration: - - FIG. 44.—Carunculæ Myrtiformes in a Primipara. -] - -[Illustration: - - FIG. 45.—Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes. - Slight Prolapse of anterior and posterior Vaginal Walls. -] - -As signs of virginity in the female, a knowledge of which is required, -not only for the purposes of medical jurisprudence, but for various -other reasons, we may enumerate the following anatomical characteristics -of the genital organs. The labia majora are elastic in consistence and -are in close apposition with one another; the labia minora or nymphæ are -covered by the labia majora and are but little pigmented; the vestibule -and the vaginal orifice are narrow, and the vagina itself is narrow, -tense, and markedly rugose; the hymen is normal and uninjured (this, of -course, is the most trustworthy of all the signs of virginity); the -breasts have the virgin conformation. In opposition to the plea that the -hymen can be destroyed by other causes than defloration, as by a fall, -especially a fall which brings the external genitals in contact with -some hard body, or by diphtheritic, variolous, or syphilitic ulceration, -_Maschka_ maintains that such occurrences are among the greatest -rarities. - -On the other hand it is sufficiently well known that the presence of an -uninjured hymen affords no certain assurance of actual virginity. Cases -enough are recorded, both in older and more recent medical literature, -in which even pregnancy occurred in women in whom the hymen had remained -intact, the explanation being that during copulation penetration of the -penis had failed to occur, the semen being ejaculated on the vulva. -_Scanzoni_ and _Zweifel_ have recorded cases in which the intact hymen -offered a hindrance to parturition. The first-named author explains -these occurrences by the assumption that the hymen was so stout that the -penis was unable to rupture it. _Veit_ remarks that both male and female -youth, in these days of the continued advance of knowledge, are well -acquainted with _coitus sine immissione penis_, and that very frequently -a woman who is informed that she is pregnant makes answer that this is -impossible, her paramour having assured her that pregnancy could not -occur. On the other hand, cases are met with in which the aperture in -the hymen is a very large one, so large that the penis can penetrate to -the vagina without lacerating the membrane. - -_Broudardel_ reports a case of rape in which the lacerated hymen healed -so completely that an expert maintained the integrity of the membrane, -until another pointed out the fine scar. - -In general, that we may be assured of the existence of virginity, we -must find the hymen uninjured; and, on the other hand, we must regard -the laceration of the membrane, unless known to be the result of -gynecological examination or other manipulation, as a proof of -defloration. - -In ancient times among savage races the integrity of the hymen was -prized as a proof of virginity, and in the Bible also great stress is -laid on this sign in connection with defloration, and its absence was -even regarded as a ground for the death punishment (Deut. xxii, 21). But -amongst other races the hymen was held in no particular esteem as a -token of virginity. - -[Illustration: - - FIG. 46.—Mamma, the breast of a virgin aged eighteen years. (From - Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) -] - -In ancient times, and even at the present day in the Philippine Islands, -the Ladrone Islands, and certain other islands of the Polynesian -Archipelago, also among many African tribes, the right of defloration -belonged, not to the bridegroom, but to every man belonging to the same -tribe; sometimes on the bridal night all the men of the tribe had access -to the bride, the bridegroom coming last, but thenceforward having -undisputed possession of his wife. Amongst certain other tribes a -similar custom prevails, differing however in this respect, that the -rite of defloration is performed by a priest or by one of the chiefs of -the tribe. In mediæval Europe, again, the great landed proprietors -exercised the well-known _jus primae noctis_ or _droit du seigneur_. - -In girls at the time of the menarche who have long practiced -masturbation, some of the following indications of the habit will be -found: Elongation, redness, and general enlargement of the clitoris; -elongation and thickening of the nymphæ, which are also of a tough -consistency and deeply pigmented; flaccidity of the labia majora; -redness of the vaginal orifice; flaccidity of the hymen, which also may -exhibit lacerations, caused by the forcible introduction of the finger -or of some hard foreign body. - -Not until the time of the menarche do the breasts attain the -hemispherical form which constitutes one of the graces of young -womanhood, and at the same time these organs assume a firm, elastic -consistency; their size of course varies in different individuals. The -nipple now has a rose-red color, darker in brunettes than in blondes; it -is usually small, sometimes quite inconspicuous, being withdrawn into a -cutaneous furrow. The two breasts when regarded from the front are seen -to diverge from the longitudinal axis of the body. In some cases even in -childhood, before the time of the menarche, the breasts are powerfully -developed, being as large as an apple or larger. This depends on -climate, race, and sexual excitement; as regards the last of these, -early sexual stimulation promotes premature mammary development. - -Although it is unusual for any secretion to appear in the mammary gland -before the occurrence of pregnancy, cases have certainly been observed -in which the breasts of virgins secreted a milk-like fluid, especially -in consequence of sexual excitement or during menstruation. Thus -_Maschka_ observed in a girl the condition of whose genital organs -showed her to be a _virgo intacta_ that pressure on the breast caused a -few drops of an opalescent fluid having the appearance of milk to exude -from the nipple. She acknowledged that amatory relations had long -subsisted between her and a lover who was in the habit of handling her -breasts, and that this always produced strong sexual excitement. -_Hofmann_ also reported that in two virgins who died during menstruation -he was able to express a drop of milk from the breast. - -The most important indication of the general changes occurring in the -external and internal genital organs, the proof that the young woman has -become fitted for the fulfilment of her reproductive vocation, is the -appearance of menstruation, a sanguineous discharge from the genital -organs recurring every four weeks as the external manifestation of the -internal process of ovulation. - -The anatomical changes that have already been described as occurring in -the genital organs at the time of the menarche will serve to elucidate -the numerous reflex processes that manifest themselves at this period of -life in so many departments of vital activity. - -It is especially the extensive developmental processes in the ovary, -influencing the nerves of that organ, which give rise to centripetal -stimuli and evoke reflex manifestations. In the working of the -circulatory system, such influences are apparent; and during the -menarche, some time already before the first onset of menstruation, -variations occur in the blood-pressure, and these during menstruation -take the form of a typical undulatory curve. - -[Illustration: - - FIG. 47.—Horizontal section through the female breast. (From Toldt: - Atlas of Human Anatomy.—Rebman Company, New York.) -] - -Thus it becomes comprehensible that even in healthy girls, the first -appearance of the catamenia and likewise the expectation of the flow -induce a certain modification and alteration in the whole nature and -disposition. Girls often lose their previous cheerful and lively -character, becoming quiet, self-absorbed, sometimes even melancholy; -they are disinclined for study, have a repugnance to all sustained -physical or mental activity, become annoyed and snappish on slight -occasion, are restless at night, consider themselves to be ailing, and -so on. During the first menstruation girls commonly appear pale and -anxious, they have blue lines beneath the eyes, the face has a tired -aspect, the movements lack energy, and a general want of tone combined -with an abnormal irritability may be noticed. Some days before the first -menstruation, the vulva, the labia majora and minora, and the vaginal -mucous membrane, are swollen, the clitoris becomes conspicuous in -consequence of erectile processes, a slight secretion appears in the -genital passage, and the breasts become sensitive and slightly turgid. -The urine deposits a thick sediment, and occasionally severe strangury -is observed. In many cases, also, digestive disturbances occur, loss of -appetite, constipation, or a tendency to diarrhœa. - -The first menstruation usually lasts four or five days. On the first day -the discharge is blood-stained mucus, thereafter becoming sanguineous. -In some cases, the bleeding at the first menstruation is profuse and of -long duration. - -It is not always after the first menstruation that the subsequent -discharges follow at the regular intervals of four weeks. In delicate, -anæmic girls the second menstruation may not occur till several months -have elapsed after the first; less often the second menstruation ensues -a fortnight after the first, or even earlier. - -At the time of the menarche the sexual impulse, which has hitherto been -dormant, becomes strongly developed. It is evoked at this time of life -by the anatomico-physiological changes undergone by the reproductive -glands; the stimulus aroused by these processes in the ovary, being -conducted to the brain, awakens passion. At the same time the -observation of the growth of the hairy covering on the genital organs, -the development of the breasts, and the appearance of menstruation, tend -to arouse erotic presentiments. The reading of romances, conversations -with female friends, and observation of the conduct of full-grown -persons, convert these presentiments into clear ideas, and excite the -impulse to the production of passionate sexual sensations, the sexual -impulse. How far these stimuli arising from the reproductive apparatus -are encouraged and accentuated, on the one hand, or repressed and -diminished, on the other, depends on external impressions of various -kinds. The environment is the determinant for the further transformation -of the as yet undifferentiated sexual impulse into the fully-developed -copulative and reproductive impulses. - -In his work on the _Physiology of Love_, _Mantegazza_ describes the -yearning and stress of the awakening sexual life, arising out of the -presentiments, hazy sensations, and impulses, which are felt in the very -earliest period of the developmental phase known as puberty. - -In general, in a young girl during the menarche, the sexual impulse -manifests itself rather in the form of semi-conscious reverie, of -platonic love. The adolescent girl exercises her imagination with the -circumstances of her chaste love, her mind turns to this subject when in -solitude, her mood is apt to become melancholy, and it is the perusal of -equivocal novels, or the educational assistance of sexually experienced -female friends, that transforms the sexual impulse to a vivid flame. - -Some authors believe that a sign of the awakening of the sexual impulse -when directed toward some particular man is a change of color on the -part of the girl when she sees this individual or hears him spoken of. -Palpitation of the heart comes on, the pulse is increased in frequency, -the respiration also, and the voice fails. In this manner, it is -asserted, _Galen_ discovered the love of a Roman lady, Justa, for the -dancer, Pylades. - -The psychological reaction of the sexual impulse at the time of puberty -manifests itself, as _von Krafft-Ebing_ points out, in manifold ways, -common to all of which, however, is the emotional state of the mind, and -the need that the strange and new feelings now experienced should find -some objective centre of interest. Such objective and emotional -interests lie ready to hand in religion and poetry, both of which, after -the period of sexual development is at an end, and the originally -incomprehensible desires and impulses have received an explanation, -continue to have intimate relations with the world of sexual experience. -Any one who doubts this must be reminded of the frequency with which -religious fanaticism makes its appearance at the time of puberty. No -less influential is the sexual factor in the awakening of æsthetic -feelings. This world of the ideal opens itself at the time when the -development of the sexual processes begins. * * * The love of early -youth, continues _von Krafft-Ebing_, has a romantic, idealizing -tendency. In its first manifestations it is platonic, and willingly -exercises itself in poetry and history. But as the sensibility awakens, -the danger arises that this passion, with its idealizing power, will be -transferred to persons of the opposite sex who in intellectual, -physical, and social relations are by no means all that could be wished. -Hence proceed misalliances, elopements, and seductions, with the entire -tragedy of impassioned love, which conflicts with the dictates of -morality and convention, and sometimes finds its bitter end in suicide -or a double self-destruction. Love in which the senses play too -prominent a part can never be a true and lasting love. For this reason, -first love is as a rule very transitory, since it is in most cases no -more than the first flare of passion. * * * Platonic love is a thing -without existence, a self-deception, a false description of sexual -sensations. - -_Bebel_ remarks that the number of suicides among women of the ages of -sixteen to twenty-one years is an exceptionally large one, and he refers -this chiefly to unsatisfied sexual impulse, unfortunate love, secret -pregnancy, and to betrayal by men. - - - MENARCHE PRAECOX ET TARDIVA. - - - (_Precocious and Retarded Menstrual Activity._) - -By the term _precocious menarche_ we understand the pathological state -in which a typical, four-weekly, sanguineous discharge from the female -genital organs sets in at an abnormally early age, and is to be regarded -as a symptom of a premature sexual development. Very commonly such -children with precocious menstruation and premature sexual development, -exhibit a comparatively high body-weight, great development of fat, -early dentition; they look older than their years; and they have genital -organs that also develop very early, with hair on the pubes and in the -axillæ; the labia majora and the breasts resemble those of full-grown -women, and the pelvis also has the adult form. Commonly also the sexual -impulse develops early, whilst, in other respects, the intellectual -development lags behind the physical. It is most probably a primary -hyperplasia of the ovaries that gives rise to precocious menstruation, -the ovarian follicles ripening earlier than usual. Frequently other -pathological processes are associated with this early sexual -development, such as general lipomatosis, rachitis, and new growths of -the ovaries. In several cases of this nature, early conception has also -been observed. According to oriental tradition, Khadijah was married at -the age of five years to the prophet Mohammed, who cohabited with her -three years later. - -Even if we except those cases in which in earliest infancy there is a -sanguineous discharge from the vagina which remains, however, an -isolated occurrence, or if repeated is repeated a few times only and at -quite unequal intervals (cases in which the bleeding cannot be regarded -as menstrual—such, for instance as were reported by _Eröss_ of six -new-born female infants in whom a sanguineous discharge from the vagina -appeared three or four days after birth and lasted two to five days, the -infants not remaining subsequently under observation),—numerous -well-authenticated cases yet remain in which menstrual hæmorrhage was -observed before the end of the first year of life. One case, even, is -recorded by _Bernard_ in which from the time of birth to the twelfth -year menstruation with molimina occurred every month, lasting two days; -from the twelfth to the fourteenth year menstruation ceased, recurring -subsequently at irregular intervals. - -In the recorded cases of such precocious menstruation the menstruation -recurred as a rule at regular intervals of four weeks; only in quite -exceptional cases were the intervals three to five months. - -Some of the most striking and well-authenticated cases of precocious -menstruation recorded in the recent literature of the subject are -appended. - -Observed by _Combys_: A girl aged 6 years and 2 months had the -appearance of a girl aged 14 or 15; she was a brunette, 3′ 10½″ in -height, with full, firm, rounded breasts, girth of chest 28⅓″, mons -Veneris covered with hair, uterus normal on rectal examination, hymen -intact; menstruation had occurred regularly since the second year of -life. Mother and five sisters began to menstruate between the ages of -twelve and fourteen. General condition good. - -Case recorded by _Diamant_: A girl aged 6 years, weight 75 pounds, -thighs, buttocks, and breasts developed like those of a sexually mature -woman, axillæ and mons Veneris covered with hair. Menstruation began at -the age of 2 and recurred regularly, the flow lasting 4 days. - -Case recorded by _Plyette_: A girl with precocious physical development -began to menstruate in the fourth year of life; menstruation continued -regularly with the exception of two monthly periods, when vicarious -epistaxis occurred. - -From the collection made by _Gebhard_ of the records of fifty-four cases -of precocious menstruation, giving the first appearance and the type of -menstruation, the development of the breasts, the other signs of -premature sexual development, and any complications that may have been -observed, we extract the age at which the first menstruation occurred. -This was: - - In a new-born infant in 1 case. - At the age of 2 weeks in 1 case. - At the age of 2 months in 1 case. - At the age of 3 months in 1 case. - At the age of 4 months in 1 case. - At the age of 5 months in 1 case. - At the age of 7 months in 1 case. - At the age of 9 months in 4 cases. - At the age of 10 months in 2 cases. - At the age of 12 months in 5 cases. - At the age of 15 months in 1 case. - At the age of 16 months in 1 case. - At the age of 18 months in 2 cases. - At the age of 19 months in 1 case. - At the age of 22 months in 1 case. - At the age of 2 years in 4 cases. - At the age of 2½ years in 1 case. - At the age of 2 years and 9 months in 1 case. - At the age of 3 years in 6 cases. - At the age of 3½ years in 1 case. - At the age of 4 years in 4 cases. - At the age of 4 years and 3 months in 1 case. - At the age of 5 years in 1 case. - At the age of 5½ years in 1 case. - At the age of 6 years in 1 case. - At the age of 6½ years in 1 case. - At the age of 7 years in 3 cases. - At the age of 9 years in 2 cases. - At the age of 11½ years in 1 case. - -From this collection of _Gebhard’s_ we learn that in one case -menstruation already existed at birth, and that in a large number of -cases it occurred before the expiration of the first year. In many cases -the development of the breasts preceded the appearance of menstruation, -and was noticed from the time of birth. The vulva also early exhibited -the characteristics seen in the sexually mature woman. Further, a high -body-weight, great development of fat, and early dentition, were usually -seen in these cases, in which, however, the intellectual development was -not in correspondence with that of the body. - -In several of these cases of premature puberty, moreover, sexual -intercourse and even parturition occurred at a very early age. A girl in -whom menstruation began at the age of one year, gave birth to a child -when she was ten years old (_Montgomery_). A girl who began to -menstruate at the age of nine years, became pregnant very shortly -afterward (_d’Outreport_). The well-known case recorded by _Haller_, in -which at birth the pubic hair was already grown, and in which -menstruation began at the age of two years, was also one of very early -pregnancy, the girl giving birth to a child when nine years old. Another -girl in whom at birth the pubes were already covered with hair began to -menstruate when four years old, copulated regularly from the age of -eight, and at nine years became pregnant, and was delivered of a -vesicular mole with an embryo (_Molitor_). A girl began to menstruate at -the age of two, had a growth of hair on the pubes and developed mammæ at -the age of three, and became pregnant at the age of eight (_Carus_). -With these cases must be classed that observed by _Martin_ in America of -a woman who was a grandmother at the age of twenty-six. _Lantier_, in -his Travels in Greece, speaks of a mother of twenty-five with a daughter -of thirteen. - -Observations made by _Kussmaul_ and by _Hofmeier_ prove that in many -cases changes in the ovaries form the probable cause of precocious -menstruation and the other phenomena of premature puberty. In one case -of _Hofmeier’s_, for instance, of a girl of five with precocious -menstruation, the removal of a rapidly growing ovarian tumor was -followed by the cessation of menstruation, and the pubic hair, which had -been shaved off, did not grow again. - -Abnormally early puberty related to the early practice of sexual -intercourse is seen in many prostitutes. This is shown by the following -figures relating to 150 prostitutes in Russia. Sexual intercourse began: - - In 1 prostitute at the age of 9 years. - In 1 prostitute at the age of 10 years. - In 4 prostitutes at the age of 12 years. - In 12 prostitutes at the age of 13 years. - In 14 prostitutes at the age of 14 years. - In 33 prostitutes at the age of 15 years. - In 36 prostitutes at the age of 16 years. - -Thus, among the 150 prostitutes, 65 were less than 16 years of age. - -_Parent-Duchatelet_ found among 3,517 prostitutes under official -observation, 5.6 per cent. under 17 years of age. There were: - - 2 prostitutes under 10 years of age. - 3 prostitutes under 11 years of age. - 3 prostitutes under 12 years of age. - 6 prostitutes under 13 years of age. - 20 prostitutes under 14 years of age. - 51 prostitutes under 15 years of age. - 111 prostitutes under 16 years of age. - -_Martineau’s_ observations also showed that in nearly all prostitutes -the first coitus took place in very early youth. Of 607 prostitutes -there were 489 in whom defloration had occurred between the ages of 5 -and 20 years. According to _Grimmaldi_ and _Gurrieri_ defloration -usually takes place in prostitutes before they attain the age of 10 -years. - -Sometimes we find increased sexuality in early life as a pathological -manifestation—psychopathia sexualis. Thus, _Esquirol_ records the case -of a little girl aged four years who undertook improper manipulations in -association with little boys. A female prisoner, _Lombroso_ writes, had -at the age of six years practiced mutual masturbation with her brother -aged seven, and at the age of eight years underwent defloration; another -murderess, while still a schoolgirl, had conducted herself after the -manner of an experienced prostitute. _Laurent_ reports the case of a -girl who from the age of ten was engaged in sexual malpractices with her -brothers and sisters, and finally underwent defloration at the age of -fifteen. - -In many cases premature sexual development is manifested by enlargement -of the breasts and growth of the axillary and pubic hair, and yet -menstruation fails to appear. Thus, _Kussmaul_ has observed girls who -while yet children exhibited all the external characteristics of -sexually mature women, but who had not yet begun to menstruate. _Ploss_ -has published a photograph showing in a girl five years of age the mons -Veneris and the labia majora developed like those of a full-grown young -woman, and covered with long thick hair; in this case, however, not only -had menstruation not yet begun, but the breasts were still in the -infantile condition. - -The opposite state to menarche praecox is that in which the first -appearance of menstruation is unduly delayed; it may be even till after -the age of twenty. Such a postponement of the menarche sometimes occurs -in girls who exhibit at this period of life an extraordinarily great -general fatty development of the body, or a notably severe chlorotic -state of the blood, or in whom during the years of development some -sudden and extensive change in the mode of life has occurred, as for -instance when the girl’s place of residence has been removed from the -country to the town, or when she has had to undertake some completely -new kind of physical or mental work. _Raciborski_ attributes the late -appearance of menstruation, at the ages of 20, 22, 24, or 26, in -otherwise healthy girls, to an “apathy of the sexual sense,” a phrase -which does not convey much meaning. - -According to _Marc d’Espine_, puberty occurs early in girls with dark -hair, grey eyes, a delicate white skin, and of a powerful build; late, -on the other hand, in girls with chestnut hair, greenish eyes, a coarse -darkly-pigmented skin, and of a delicate weakly build. - -The genitals of girls in whom the first appearance of menstruation is -delayed, frequently exhibit distinct signs of the backwardness of the -reproductive organs in their development. The external genitals, in such -cases, have little if any covering of hair, and are flabby and relaxed; -the body and the fundus of the uterus are shorter and more slender than -usual, the uterus as a whole is small and flaccid, sometimes anteflexed; -the vaginal portion of the cervix is small, often almost undeveloped, -its anterior lip barely projecting above the surface of the vaginal -fornix; the vagina is usually short and narrow. The ovaries also are -flaccid and inelastic, and occasionally are remarkably small. The -breasts are small, the nipples and areolæ undeveloped. - -In other cases, notwithstanding the delay in the appearance of the -menarche, the genital apparatus is developed to a degree quite in -correspondence with the age, but some pathological condition is present, -for instance, the mucous membrane secretes excessively, exhibits a -catarrhal tendency, there are erosions at the os uteri, etc. - - - PATHOLOGY OF THE MENARCHE. - -A series of disturbances of function and pathological changes in the -organs may occur at the time of the menarche, either directly connected -with the genital organs, or etiologically dependent upon the changes -occurring in these organs. - -The commencement of menstruation, as we have already mentioned, may -itself be abnormal in character, being either precocious (menarche -precox), or retarded (menarche tardiva). But even where menstruation -begins in a normal manner, the period of the menarche may be disturbed -by a great number of pathological phenomena, of which the developmental -processes occurring in the genital organs of the young girl must be -regarded as the cause. First of all, the menstrual hæmorrhage itself may -be abnormal in amount and duration. Then, again, functional disturbances -of the most various character may occur: especially prominent are, -disturbances 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 │ CONTAINS OF │ - │ │ Grammes. │ │ - ├───────────────┼────────────┼────────────┬────────────┬──────────────┤ - │ „ │ „ │ 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. - - - THE SEXUAL IMPULSE. - -By the term _sexual impulse_, we understand the impulse shared by women -and by men towards intimate physical contact and sexual intercourse with -individuals of the opposite sex. In the child this impulse slumbers, to -awaken at the menarche with the onset of puberty, to increase slowly at -first, and then more rapidly, after the manner of an avalanche, until it -becomes a powerful passion, dominant throughout the active sexual life -of the woman, and it may even continue far beyond this period. The -proper aim for whose attainment the sexual impulse in woman strives is -by no means (as is asserted in some quarters) the fulfilment of “the -impulse toward motherhood,” but is merely the complete satisfaction of -sensual passion by intercourse with the male. Still, the sexual impulse -is often satisfied by the minor degrees of sexual gratification in the -form of the mutual contact, so agreeable to the sense of touch, of -portions of the body, and even by the play of imagination and illusion -under the dominion of love. Finally, also, love amounts to what -_Buffon_, the celebrated naturalist, expressed with coarse incisiveness -in the phrase, “L’amour c’est le frôlement de deux intestins.” - -In the sexually mature woman, the sexual impulse always exists, though -its strength varies in accordance with individual inheritance, with -physical and mental condition, and with external circumstances, and -though its manifestation may be repressed by force of will. The -sensation of the sexual impulse in a maiden during the years of -development is described by _Goethe_ in a masterly manner in the -verses.[33] - - “Meine Ruh ist hin - Mein Herz ist schwer, - Ich finde sie nimmer - Und nimmermehr. - Mein Busen drängt - Sich nach ihm hin, - Ach, dürft ich ihn fassen - Und halten ihn - Und küssen ihn, - So wie ich wollt, - An seinen Küssen - Vergehen sollt.” - -A resemblance to heat or rut in animals, who exhibit the sexual impulse -only at definite periods, those at which the ovules ripen, is manifested -in females of the human species only in so far as there is during -menstruation a more intense sexual sensibility; but the limitation of -the sexual impulse to definite periods, and its close association with -reproduction, are not found in women. Education and morality impose -artificial limitations on the sexual impulse in women, whilst nature -endows this impulse with a coercive power, a fact recognized by thinkers -of all times and all peoples. Thus, _Buddha_ wrote: “The sexual impulse -is stronger than the ankus with which the wild elephant is controlled, -it is hotter than flame, it is like unto an arrow driven into the spirit -of man.” In a similar sense _Luther_ writes: “He who wishes to restrain -the impulse of nature and not to allow it free play, as nature will and -must, what does he do but this, to insist that nature shall not be -nature, that fire shall not burn, that water shall not wet, that man -shall neither eat, drink, nor sleep.” _Schopenhaur_ describes the sexual -impulse as “the completest outward manifestation of the will to live, -the concentration, that is to say, of all wills. * * * The affirmation -of the will to live concentrates itself in the act of generation, and -this act is its most determined expression.” _Mainländer_ in his -_Philosophy of Deliverance_ makes the following statement: “In the -sexual impulse lies the centre of gravity of human life. To nothing does -man devote a more earnest attention than to the business of generation, -and in the pursuit of no other aim does he concentrate the intensity of -his will in so striking a manner as in the performance of the act of -generation.” _Debay_ similarly insists on the strength of the sexual -impulse, saying: “The union of the sexes is one of the great laws of -nature; to that law men and women are subordinated as completely as all -other creatures, they cannot escape its operation.” - -According to the general opinion, the sexual impulse is not so strongly -developed in women as it is in men. _Hegar_, _Litzmann_, _Lombroso_, _P. -Müller_, and many others, assume that the sexual sensibility of women is -less than that of men; _Fürbringer_ is inclined to attribute the -characteristic of sexual frigidity to the great majority of German -wives. I do not believe that this view, of the slight intensity of the -sexual impulse in women in general, is well grounded, and can admit only -this much, that in adolescent girls who are inexperienced in sexual -matters, the sexual impulse is less powerful than in youths of the same -age who have undergone sexual enlightenment. From the moment when the -woman also has been fully enlightened as to sexual affairs, and has -actually experienced sexual excitement, her impulse toward intimate -physical contact and toward copulation is just as powerful as that of -men. According, however, to the dominant artificial conditions, man -assumes it as his right to give free rein to his sexual desires and to -gratify them without regard to consequences, whereas woman, narrowly -confined within the boundaries imposed by law and convention, cannot so -readily yield to her inclination in the direction of physical love, and -must forcibly control that inclination. Moreover, a powerful check on -the free indulgence of the sexual impulse is imposed on woman by the -consequences of such indulgence, consequences which exist for woman -only. - -I may further indicate as differential characteristics, that in woman -the sexual impulse is more accessible to voluntary control than it is in -man, the ardor of female sexual passion is more readily diminished than -that of the male; and again that in the female the gratification of the -sexual impulse is less narrowly restricted than in the male. Excessive -sexual gratification on the one hand and suppression of sexual desire on -the other are, generally speaking, less harmful to the female organism -than to the male. In these differentiæ is to be found, in my opinion, -the influence which determines the type of sexuality in the respective -sexes. - -The following account is given by _Havelock Ellis_ of the differential -characters of the sexual impulse in the female: “In courtship, woman -plays a more passive part than man; in woman the physiological mechanism -of the sexual processes is more complicated, and the orgasm develops -more deliberately; the sexual impulse in woman needs more frequently to -be actively stimulated; the culmination of sexual activity is attained -later in the life of woman than in the life of man, the strength of -sexual desire in woman becomes greater after she has entered upon -regular sexual intercourse, women bear sexual excesses better than men; -the sexual sphere is larger and more widely diffused in women than it is -in men; finally, in woman the sexual impulse exhibits a distinct -tendency to periodic exacerbations, and it is in any case much more -variable than in man.” The same author, who has published several -notable biological studies on subjects connected with sex, maintains -that the source of erotic pleasure in the case of the male lies in -activity, but in the female in the passive state, in the experience of -compulsion, and he holds that sexual subordination is a necessary -element in the sexual enjoyment of women. - -_Hegar_ maintains that under the term _sexual impulse_ two distinct -conceptions are confounded: First, the impulse toward copulation, the -desire of carnal union with a member of the opposite sex; secondly, the -impulse toward reproduction, the desire for children. At the same time, -this author admits that it is questionable if we can properly speak of -an impulse toward reproduction, when reproduction is merely a -consequence of copulation; in the case of civilized man, at any rate, so -much reflection is connected with the idea of reproduction that it can -hardly be proper to speak of anything of the nature of an impulse. In -the case of woman, the expression is less unsuitable, since in woman -special organs exist for the maintenance of the ovum after -fertilization, and these organs may perhaps lead to the production of -this peculiar form of mental activity. - -According to _Darwin_, a comparatively less intensity of sexual desire -is common to the females of all species of the animal kingdom. The -female demands a prolonged courtship, and often endeavors for a -considerable time to elude the male. In the lowest classes of the animal -kingdom the female leads a separate existence as soon as she has been -fertilized by the male, the sexual functions being thus subordinated to -the maternal. Among birds at the pairing season the male is always the -more passionate and active of the two, whilst the female commonly -remains passive and occupies herself in building the nest. Among -mammals, it is difficult to determine whether sexual feeling is stronger -in the female or in the male; but it is certain that sexual relations -are seldom long lasting, they continue in most cases only during the -period of heat or rut, and at most only till the birth of the young. - -From these phenomena witnessed in the animal kingdom, many naturalists -have concluded that in females of the human species also, sexual -sensibility and the intensity of the sexual impulse are less than in the -males, and even that the sexual sense in general is but little developed -in the female sex, or sometimes entirely wanting. The complicated -apparatus which the primary and secondary sexual characters of the -female combine to make up, exists, according to this view, not for the -gratification of the sexual impulse, but for the fulfilment of the -function of motherhood. “Love in women,” says _Lombroso_, “is in its -fundamental nature no more than a secondary character of motherhood, and -all the feelings of affection that bind woman to man arise, not from -sexual impulses, but from the instincts, acquired by adaptation, of -subordination and self-surrender.” - -_Mantegazza_ lays stress on the fact that in the female, sexual desire -is very rarely accompanied by pains analogous to those which occur in -man, in whom sexual excitement manifests itself in painful tension of -the testicle and the seminal vesicles, or in spasmodic, long-continued -priapism. - -_Sergi_ writes to _Lombroso_: “The normal woman loves to be flattered -and wooed by man, but yields herself to his sexual desires only like an -animal at the sacrifice. It is well known how much pains must be taken, -how many caresses must be expended, before a woman will yield with -pleasure to a man’s desires, and will share his sexual passion. Without -the employment of these means, a woman remains cold and gives as little -satisfaction as she feels. There are girls who are quite obtuse to the -joys of love, and either resist energetically a man’s approaches, or -yield to him passively, without ardor and without enthusiasm. It is well -known, also, that among the lower races of mankind, means are employed -to stimulate the sexual sensibility in women, means that seem to us to -amount to torture; and that the male, with the same end in view, -undergoes the most painful operations, from which it is apparent that -the slight sexual sensibility of women in these lower grades of -civilization is fully recognized.” And again: “If a normal woman marries -for love, she hides that love deep in her heart, and even on the -wedding-day exhibits no great sexual excitement; she often complains -later that in her husband the love-fervor of the first days still -continues; the very moderate sexual needs of the wife form a natural and -most valuable check to the much more powerful passion of the male.” - -_Saint Prospêre_ expresses himself to a similar effect: “Women do not -fall in consequence of the excessive power of the senses—in this domain -they are overlords, in striking contrast to men, whose weakest side is -here. It is not by means of the senses that a woman is to be overcome; -her weakness lies elsewhere—in her heart, in her vanity.” And _de -Lambert_ wrote the epigram, “Women play with love, and yield themselves -to love, but they do not abandon themselves to love.” - -Well known also is the saying of _Dante_: - - “We know how speedily in women the fire of love is consumed - Unless eye and hand continually supply it with fresh fuel.” - -On the other hand, it is asserted in the laws of the Hindus that sexual -desire in women can as little be satisfied or fed full as a devouring -fire can be fed full of combustible materials, or as the ocean can be -overfilled by the rivers that pour their waters into it. - -_Lombroso_ finds a proof of the sexual indifference of women and of the -greater sexual needs of man, in the existence of prostitution, with -which can be contrasted the existence only among the degenerate classes -(both rich and poor) of a small group of male prostitutes (alfons, -souteneurs). This author also refers to the rarity and uniformity in -women of the sexual psychoses so frequent in men, as indications of the -minor intensity of sexual desire in the former; and he refers also to a -series of facts, as for instance, to the occurrence of platonic love, -which, though indeed often hypocritical, has a real existence more often -in the female sex than in the male; to the long-enduring chastity of -girls, and to vows of chastity, which are rarely made except by females; -moreover, the ready adaptation of women to polygamy, as well as their -scrupulous observance of monogamy, which latter for the male is nominal -rather than actual. If in general the opposite view concerning women -prevails, this is ascribed by _Lombroso_ to the fact, that love is the -most important circumstance in a woman’s life. The reason therefore, -however, is to be found, not in the erotic sphere, but in the desire for -the satisfaction of the maternal instinct, and in a woman’s need for -protection. A celebrated accoucheur, _Giordano_, has remarked: “Man -loves woman for the sake of the vulva; what woman loves in man is the -husband and the father. Comprehensively we may express the matter by -saying that woman has less eroticism and more sexuality.” - -As a rule, remarks _Erb_, it is believed that the sexual impulse is less -intense in women than in men. This is true enough, he writes, as regards -youthful and virgin individuals, who have not yet come into intimate -contact with men, and in whom sexual desire and sensibility have not yet -been directly excited; later, however, when sexual intercourse has been -begun, a change usually takes place, and the sexual needs become active -in women also, and demand satisfaction. It is well known that not a few -women experience powerful and uncontrolled sensual inclinations, just -like those of men. On the other hand, we must insist that quite a large -number of women possess the so-called _naturae frigidae_, and have no -sensual inclination to sexual intercourse, to which they are either -indifferent, or in some cases strongly averse, even regarding it with -horror. This lack of the sexual sense in women, is especially common in -hysterical subjects, and _Erb_ reports that he has encountered quite a -large number of cases of this character. Whether in quite healthy women -with normal sexual impulse, complete abstinence from sexual intercourse, -too often compulsory but sometimes voluntarily undertaken, is harmful in -its consequences—this, says _Erb_, is a question very difficult to -answer. Many such unfortunate women have assured him that they suffered -severely in consequence of their enforced continence; the majority of -these became neurasthenic or hysterical. The complication of purely -physical influences with mental influences, increases the difficulty of -the problem. Neurologists have observed women on whom continence was -forced either during marriage or after its dissolution, who thereupon -fell into a state of severe nervous exhaustion or nervous excitement, or -suffered from threatening or even actually developed psychoses. That -sexual abstinence is “absolutely harmless,” as moralists and many -physicians would so gladly believe, appears to _Erb_ a quite -unwarrantable assumption. - -“In the processes of reproduction,” continues Erb in his discussion of -this subject, “woman is the principal sufferer. With inhuman cruelty, -nature has condemned woman to a far more difficult rôle than man in the -intercourse of the sexes and in the preservation of the species; she is -overpowered and forced by man, she is compelled to make the most severe -sacrifices for the sake of the new generation, first when it is -germinating within her womb, and later when it is entrusted to her care; -and only too frequently she fails to find the respect and protection due -to her for the performance of these functions! Compared with the -sacrifices made by woman, the temporary continence which is all that is -demanded from man will be admitted to be a small matter! It is fortunate -that as a rule the young woman who has never come into intimate contact -with the male, appears to be endowed by nature with a relatively weak -sexual impulse! This unequal and unjust distribution of the male and -female rôles on the part of nature may be regretted, but it cannot be -altered.” - -The modern advocates of the rights of women, who demand that in the -sexual sphere also, woman should receive emancipation, oppose the view -that in the male the sexual impulse is stronger than in the female, and -also the view that whilst in the male the impulse is simply one toward -sexual congress, in the female the determining motive to intercourse is -furnished by the desire for motherhood. They complain of “the perverse -repression in woman of the sexual impulse and its physiological -gratification,” since sexual energy and sexual sensibility are equal in -intensity and identical in quality in the female and in the male. Thus, -_Johanna Elberskirchen_ writes (_Die Sexualempfindung bei Weib und -Mann_—Sexual Sensation in Woman and Man): “Body and soul, the whole -being is subordinated to a single powerful feeling and impulse, a single -will flows through nerves and blood, forcing and driving the female -toward the male with irresistible power; the yearning, the longing for -the relief of sexual tension, the craving for the euphoria and fleshly -delight that dominate the whole personality. And this elementary sexual -longing it is that clouds the woman’s brain, that drives her into the -man’s arms, that leads her to forget all the shame threatening her and -her child, that brings her to sexual union—not the longing for a child, -not the so-called impulse to motherhood.” And again: “Woman yearns for -love, all her love-organs cry out for love, soul and body * * *. We do -not long only for the rude sexual act. We spiritualise it—at least some -of us do so; at any rate we individualize it. It is one particular man -whom we desire, he alone can still our longing, our bodily and mental -hunger for love. He satisfies us with all his love-affinities.” -Naturally, also, the consequence is deduced, “a free course must be -given to sexual sensation in women, and to the satisfaction of sexual -desire, within physiological limits, within the bounds of physiological -necessity.” - -_Löwenfeld_ asserts that in the life of woman the sexual functions play -a comparatively much greater part than in the life of man, woman’s -thoughts and feelings are, that is to say, much more powerfully -influenced by sexual matters than those of men; but none the less he is -of opinion that in the normal woman the desire for sexual satisfaction -is on the average less keen than in the normal man. Distinctly greater -in woman is the erotic element only, the need to love and to be loved -after an ideal manner, which is excited by the reproductive glands just -as much as is the simple sensual desire. Very frequently, manifestations -of this ideal need are erroneously attributed to the sensual impulse, -yet this latter may be entirely absent in cases in which the erotic -element is strongly developed. According to _Löwenfeld_, the sexual -impulse is altogether wanting in young girls before the time of puberty, -and in elderly women (in the case of the latter we consider this -assertion most questionable); this lack of the sexual impulse persists -in girls for an indeterminate time even after puberty, as long as they -remain free from all experience of sexual stimulation. In this respect -they offer a notable contrast to males of the same age. In normal girls, -according to the same author, erotic dreams and similar occurrences are -entirely wanting, and specific sexual sensations therefore remain -absolutely unknown to them; hence it follows that the sexual impulse -cannot, properly speaking, arise in such individuals, and in so far as -they experience any desire for sexual intercourse it can only take the -form of a craving for some enjoyment, the nature of which is entirely -unknown. The absolute lack of the sexual impulse (complete frigidity) -persists, according to _Löwenfeld_, in a not inconsiderable proportion -of women even after their introduction to sexual intercourse—_Effertz_ -estimates that such complete frigidity is permanent in 10 per cent. of -all women—and in a still greater proportion of women the sensual impulse -never exceeds a certain minimal intensity (partial frigidity). It is -probable that in the higher classes of society, inherited -predisposition, education, and perhaps also higher intelligence, combine -to diminish the intensity of the sexual impulse. In contrast with these -women of frigid temperament, however, we meet with women, certainly in -very limited numbers, whose sexual passions are extremely powerful, and -whose needs no man can satisfy. - -_Hegar_, who considers that the sexual impulse in women is seldom very -powerful, draws the following conclusions in respect of the influence of -sexual gratification, on the one hand, or of continence, on the other, -on the duration of life and on physical and mental health: “As far as -comparisons between married women and women vowed to celibacy (nuns and -members of other celibate religious orders) justify any conclusion, -sexual activity and inactivity, respectively, would appear to have -little influence on the duration of life. Comparisons between married -and single women show, indeed, that the gratification of the sexual -impulse and the processes of reproduction are distinctly injurious when -experienced before the attainment of complete sexual maturity. In -married women up to the age of thirty, in some countries even up to the -age of forty, the mortality is greater than in unmarried women. The -notably smaller mortality of married women, as compared with unmarried, -after the age of forty, is usually explained as the result of the -complete fulfilment of the genital functions. It may, however, find a -truer explanation in the selection effected by marriage, especially when -we take into consideration that from the women thus selected the weaker -individuals have been previously weeded out by the processes of -reproduction: - -“The lesser mortality of married men from the age of twenty upwards is -to be explained by the selection of the fit which occurs in marriage, by -the smaller proportion of marriages among men engaged in hazardous -occupations, and by the deterioration in the quality of the unmarried -which results from emigration. Still the directly favorable influence of -marriage is undeniable, and, no doubt, the ethical factors of this -institution have a beneficial effect, whereas the gratification of the -sexual impulse hardly enters into the account. - -“Suicide is certainly very little dependent upon repression of the -sexual impulse, since all the motives arising out of the affairs of love -play together but a small part among the causes of suicide. - -“The beneficial influence of marriage in the prevention of insanity is -in part apparent merely, since, in the selection exercised by marriage, -those predisposed to mental disorder, and those in whom such disorder -has already manifested itself, are, for the most part, already excluded. -Still, as regards the male sex at any rate, the beneficial influence of -marriage is undeniable, and consists principally in the favorable -ethical factors of this state. In women, on the other hand, the -advantage of marriage is doubtful, since the nerve centres and the -nervous system as a whole are strongly affected by the processes of -reproduction. - -“Satyriasis, nymphomania, and hysteria are in no way dependent upon the -repression of the sexual impulse. - -“Criminality in the married is comparatively less common than in the -unmarried. In criminal assaults on young persons, repressed sexual -impulse plays a part. - -“Chlorosis is not in any way dependent on repression of the sexual -impulse. A disease apparently analogous to chlorosis, occurring in -unmarried women from twenty to thirty years of age, is dependent rather -on mental causes, and is relieved by other means than marriage, -especially by suitable occupation. Marriage and gestation are distinctly -injurious in cases of true chlorosis. - -“The satisfaction of the sexual impulse, and still more gestation, favor -in women the origin and growth of tumors, give rise often to mechanical -disturbances, and open the way for the invasion of toxic pathogenic -germs. - -“Osteomalacia occurs only in parous women.” - -_Moll_ divides the sexual impulse into two components: The impulse -toward intimate contact (in a sense both physical and mental) with a -person of the opposite sex, which he calls the contrectation-impulse -(_Kontrektationstrieb_); and the impulse to bring about a change in -the genital organs, which he calls the detumescence-impulse -(_Detumeszenztrieb_). The former impulse induces intimate physical and -mental contact between the two persons concerned, the latter impulse -induces the local processes of copulation. In women, detumescence -results from the passing off of local swelling and the release of -nervous tension in the genital organs, with the discharge of -indifferent glandular secretions, notably the secretion of Bartholin’s -glands, and perhaps also the secretion of the uterine glands. The -intensity of the detumescence-impulse in women varies greatly in -different individuals, these variations being more extensive than -those occurring in the male. In some women the impulse toward intimate -contact, the contrectation-impulse, is normal, though the -detumescence-impulse is wholly wanting (_vide_ Dyspareunia). - -_Runge_ defines the sexual impulse as the impulse which brings the sexes -together. This impulse is subservient to an instinct, namely the -instinct of reproduction; that is to say, the sexual impulse induces the -individual to perform actions which subserve the purpose of reproduction -without the agent’s being directly or chiefly concerned with this -purpose. - -The sexual impulse, as sensation, perception, and impulse, is, -according to _von Krafft-Ebing_, a function of the cerebral cortex; a -centre for the sexual sense has not as yet, however, been localized. -The close relations which obtain between the sexual life and the sense -of smell lead to the supposition that the sexual and the olfactory -spheres of the cerebral cortex are in close proximity one with the -other. The development of the sexual life has its beginnings in the -organic sensations of the developing reproductive glands. A mutual -dependence now arises between the cerebral cortex as place of origin -of sensations and perceptions, and the organs of generation. By -anatomico-physiological processes these now give rise to sexual -perceptions, representations, and impulses. The cerebral cortex, by -apperceived or reproduced sensuous perceptions, influences the organs -of generation. This influence is effected by the intermediation of the -centres of vascular innervation and ejaculation, which are situated in -the lumbar enlargement of the spinal cord, and are certainly in close -proximity one with the other. Both are reflex centres. - -The psycho-physiological process embraced in the conception of the -sexual impulse is according to _von Krafft-Ebing_ constituted in the -following manner: - -I. Of the central or peripherally aroused perceptions. - -II. Of the pleasurable sensations associated with these. - -Hence arises the impulse to sexual satisfaction (libido sexualis). This -impulse becomes stronger in proportion as cerebral excitement, -consequent on appropriate perceptions and the working of the -imagination, strengthens the intensity of these pleasurable sensations. -If the conditions are favorable to the performance of the sexual act by -means of which satisfaction is attained, the continually increasing -impulse finds expression in action; in other circumstances, inhibitory -perceptions intervene, sexual excitement diminishes, the activity of the -centre for erection is inhibited, and the sexual act itself is -prevented. In the case of civilized humanity the ready action of such -perceptions for the inhibition of the sexual impulse is necessary and -decisive. On the strength of the impulsive perceptions the constitution -and various organic processes have an important influence; on the -strength of the inhibitory perceptions, education and the cultivation of -self-control are powerfully operative. - -In addition to mental influences, all forms of local irritation of the -sensory nerves of the female genital organs and adjacent parts, by -internal processes or external friction, serve to increase the strength -of the sexual impulse. Among internal processes which stimulate the -erectile centre by centripetal impulses must be included, the stimulus -of the enlarged graafian follicle, stasis in various vascular areas of -the genital organs in consequence of a sedentary mode of life, abdominal -plethora from excessive consumption of food and stimulating drinks, and -habitual constipation. External friction may be in the form of -intentional manipulation, but it may be due to certain bodily attitudes -or to the arrangement of the clothing. - -In normally constituted individuals, the sexual impulse is by no means -constant in its intensity. Apart from the temporary indifference -resulting from sexual gratification, and apart from the decline in the -impulse that occurs after prolonged continence, ensuing after a certain -reactionary intensity of desire has been happily overcome, the mode of -life has a very great influence. The town-dweller, who is continually -reminded of sexual matters, and continually solicited to sexual -intercourse, is in any case more subject than the countryman to sexual -excitement. A sedentary and sheltered mode of life, a chiefly animal -diet, the free use of alcohol and of spices, and the like, have a -stimulating action on the sexual life. In the female, the sexual impulse -is stronger just after menstruation. In neuropathic women this increase -of excitement may occur to a pathological degree. Not infrequently also -in the climacteric period, women are subject to sexual excitement due to -pruritus, especially in those neuropathically predisposed. _Magnan_ -reports the case of a lady who was subject to matutinal accesses of -intense erethismus genitalis. The same author writes of a young lady who -since puberty had been subject to continually increasing sexual impulse, -which she gratified by masturbation. Gradually it came to pass that the -sight of a good-looking man produced violent sexual excitement, and on -these occasions, since she felt herself unable to answer for her own -conduct, she used to lock herself up in her bedroom till the storm had -passed away. Ultimately she surrendered herself to any available man in -order to obtain rest from her torturing desires, but neither intercourse -nor onanism gave her relief, so that she was finally sent to an asylum. - -As regards pathological increase of the sexual impulse, hyperæsthesia -sexualis, the constitution of the individual is, according to _von -Krafft-Ebing_ (Psychopathia Sexualis), of great importance. He writes: -“With a neuropathic constitution, a pathological increase of sexual -desire is often associated, and such individuals bear for the greater -part of their life the heavy burden of this constitutionally anomalous -sexual impulse. The intensity of the sexual impulse may be such as to -amount to an organic compulsion, and the freedom of the will may thus be -seriously imperilled. Non-satisfaction of this desire may induce a true -sexual heat (like that of lower animals), or a mental state -characterized by sensations of anxiety, in which the individual yields -to the impulse, and his responsibility for his action is most -questionable. Should the person so affected not give way to his desire, -he runs the danger, by this enforced abstinence, of injuring his nervous -system by the induction of neurasthenia, or of seriously aggravating -neurasthenia that already exists. - -“Excessive sexual desire may arise either from peripheral or from -central causes. The former variety is less common. Such cases as do -occur, may arise from pruritus of the genitals, from eczema, or from -substances which by their remote local action stimulate sexual desire, -such for instance as cantharides. - -“Sexual excitement of central origin is common in those suffering from -congenital neuropathic predisposition, in hysterical subjects, and in -states of mental exaltation. In such cases, when the cerebral cortex, -including the psychosexual centre, is in a state of hyperæsthesia -(abnormal excitability of the imagination, facilitated association of -ideas), not only optical and tactile sensations, but also auditory and -olfactory impressions, will arouse lascivious perceptions. - -“Sexual hyperæsthesia may be continuous, with exacerbations, or -intermittent, and even periodic. In the last case, according to _von -Krafft-Ebing_, it is either an independent cerebral neurosis, or else a -partial manifestation of a general condition of mental excitement -(mania, dementia paralytica, dementia senilis, etc.).” - -Erotogenic zones, the stimulation of which leads to an increase in the -intensity of the sexual impulse and of sexual sensibility, are in woman -first of all and principally the clitoris, which indeed is said to be -the only zone of this nature in the virgin state (an opinion held by -_von Krafft-Ebing_ and others, but certainly most improbable); next to -this comes the whole of the external genitals, and especially the parts -covered with hair; also the vagina by friction and inter coitum; finally -the nipple and its areola when stimulated by titillation—an increase of -the excitability of this region appears to result from suckling. - -According to _Hensen_, the direct stimulation of the sexual impulse -proceeds by way of the dorsal nerve of the (penis or) clitoris; he -assumes, however, that certain states of the reproductive glands are -able to induce an increase in the irritability of the centres connected -with the aforesaid nerves. In women it certainly appears that particular -states of the ovary have a stimulating or inhibiting influence -respectively on sexual excitement, so that we might ascribe to the -ovaries the rôle of a regulator of the sexual impulse. The processes -that occur in the ovary at the time of the ripening and rupture of the -graafian follicle, and the resulting tension of the follicular wall, -induce by stimulation of the ovarian nerves an increased sensibility of -the central zones, and produce in a menstruating female a condition of -increased sexual excitability, so that slight stimuli will give rise to -a powerful orgasm more readily than would otherwise be the case, when -the reflex irritability of the centre is less pronounced and the sexual -impulse is consequently less intense. Still more than during these -ordinary menstrual processes may this stimulation be effective at the -time of the menarche, when the changes in the ovary occur for the first -time and with the greatest intensity, so that at this time the -individual may be especially susceptible to sexual stimulation. - -At such times of sexual excitement, very slight external peripheral -stimuli, in the form either of tactile stimulation of the sensory nerves -of the skin and the external genital organs, or of stimulation of the -imaginative and perceptive faculties of the brain, suffice to induce a -powerful increase of the sexual impulse; whereas at other times, at -which no particular sexual excitement exists, much stronger stimuli are -needed to produce such an effect. Thus the sexual impulse in women is -more readily and more powerfully increased in proportion as the central -organ is in a condition of temporarily enhanced excitability in -consequence of the condition of the ovaries. - -The gratification of this impulse, the act of copulation, produces the -specific sensation of sexual pleasure; in the female this is effected -chiefly by friction of the glans clitoridis, the organ when erect -projecting downwards at a right angle, and pressing upon the intromitted -penis—the friction of the glans produces powerful mechanical stimulation -of the numerous plexuses of sensory nerve fibres, which terminate in the -genital corpuscles of _Krause_. In woman, then, we find in the ovary the -place of origin and the means of regulation of the sexual impulse, and -in the clitoris we find the seat of the specific sensation of sexual -pleasure. - -In the poorer classes of society, an increase of the sexual impulse -occurs in women chiefly in consequence of bad example and of unfavorable -domestic conditions, such as lead to persons of opposite sexes sleeping -in the same bed, and also in consequence of the abuse of alcohol. In the -well-to-do classes, it is the perusal of modern equivocal romances, -visits to theatres, balls, and evening parties, and, speaking generally, -idleness combined with luxurious living, that serve to stimulate the -sexual impulse in woman. - -A certain dependence of the sexual impulse upon seasonal variations -appears to exist also in the human species. At any rate in certain -months of the year, a definite increase in the number of conceptions -continues to recur, which indicates that during these months a larger -number of sexually mature individuals is engaged in the discharge of -sexual functions. _Rosenstadt_ regards this as the manifestation of a -“physiological custom,” immanent in the physical constitution of -civilized man, and inherited by him from his animal ancestors. He -explains it in the following terms: “Primitive man inherited from his -mammalian forefathers the peculiarity of reproducing his kind only -during a certain definite period, the period of heat or rut. After -humanity had entered upon this period, copulation was effected _en -masse_, as was easy in view of the primitive community of sexual -intercourse before the origin of marriage. In the course of his progress -toward civilization, however, man began to reproduce his kind -indifferently throughout the entire year; but the original -“physiological custom,” in accordance with which reproduction occurred -at definite seasons only, did not disappear, and persists, indeed, to a -certain extent even to the present day as a survival of earlier -mammalian life, and manifests itself in the annual recurrence in certain -months of an increase in the number of conceptions. The analogy in -structure and function between the genital organs of the human species -and those of other mammals (the female anthropoid apes do not merely -exhibit from time to time a period of heat, but are subject to a more or -less regular menstruation), which for the most part reproduce their kind -only at certain definite periods, leads to the conclusion that in the -human species also the sexual impulse may originally have awakened only -at a particular season of the year, and that the persistence of this -physiological custom in man, in spite of the fact that sexual -intercourse occurs all through the year, and notwithstanding that the -conditions necessary to awaken the sexual impulse are actually -perennial, must be ascribed to inheritance.” - -This view, which is maintained also by other gynecologists, finds -support in _Kulischer’s_ assumption, based upon ethnological -investigations, according to which coupling in primitive man took place -only at certain seasons, namely, at spring and at harvest-time. In -support of this view, which was held also by _von Hellwald_, _Kulischer_ -refers to a number of actual and symbolical practices among different -races, which make the assumption extremely probable. - -Sexual desire in women, the sexual impulse, outlasts the proper sexual -life, and manifests itself even after the cessation of menstruation, -when the possibility of conception has passed away; it appears, -therefore, to have no necessary connection with the function of -ovulation. - -This is indicated by the always respectable number of women who enter -upon marriage even after the climacteric age. Thus the percentage of -brides who were more than 45 years of age was: In Prussia, 2.58 per -cent.; in England, 1.38 per cent.; in Sweden, 1.53 per cent.; in -Ireland, 0.31 per cent. Of quite peculiar interest are the figures -relating to elderly women who marry men considerably younger than -themselves. Thus we learn from the tables of _Routh_ that in the space -of 10 years in Ireland: - - Women between the ages of 46 and 55 years married - Men below the age of 17 in 1 instance. - Men between the ages of 17 and 25 in 35 instances. - Men between the ages of 26 and 35 in 145 instances. - Men between the ages of 36 and 45 in 227 instances. - - And women of ages greater than 55 years married - Men below the age of 17 in 1 instance. - Men between the ages of 17 and 25 in 3 instances. - Men between the ages of 26 and 35 in 12 instances. - Men between the ages of 36 and 45 in 15 instances. - Men between the ages of 46 and 55 in 52 instances. - -In England during the year 1855 the age of the bride exceeded the -climacteric age in 778 instances. The brides were: - - From 46 to 50 years of age in 135 instances. - From 51 to 55 years of age in 219 instances. - From 56 to 60 years of age in 89 instances. - From 61 to 65 years of age in 22 instances. - From 66 to 70 years of age in 7 instances. - From 71 to 75 years of age in 3 instances. - From 76 to 80 years of age in 3 instances. - -In Bohemia in the year 1872 the oldest bride numbered no less than—86 -years. - -_Börner_ reports cases in which the sexual impulse remained in full -activity after the change of life, and in some cases was greatly -increased in intensity—these latter individuals being in a condition of -real torment, which induced them to masturbate to obtain relief. - -The sexual impulse may be present in cases in which the ovaries are -entirely wanting. Thus, _Hauff_ reports the case of a young girl who had -no ovaries, but was nevertheless excessively addicted to masturbation. -_Gläveke_ speaks of a puella publica in whom the uterus and the ovaries -were entirely absent, but who asserted that she experienced during -coitus active sexual sensation. Both _Kussmaul_ and _Puech_ report -similar experiences in cases of absence or arrested development of the -uterus. - -As regards the effect on the sexual impulse of the operation of -oöphorectomy, most authors state that no change occurs; still, there -remain many who express the opposite opinion. From the collective -summary of cases bearing on this question made by _Gläveke_, it appears -that after extirpation of the ovaries the sexual impulse remains -unchanged in the great majority of cases, or at most is but slightly -diminished in intensity. _Hegar_ states that he has often witnessed a -diminution of the sexual impulse after oöphorectomy, but that this -decline is by no means constant, indeed he states that one of his -patients assured him that in her case no decline in the intensity of the -sexual impulse had followed the operation. Similarly variable reports -were the experience of _Schmalfuss_. In one case he found there was but -little sexual inclination; in one case, disinclination; in one case -disinclination at first, followed by a return of inclination. _Bruntzel_ -reports that in four patients subjected to oöphorectomy, in two cases -the sexual impulse persisted, but in the remaining two it was -extinguished. _Köberle_ is of opinion that sexual inclination diminishes -as a result of this operation. _Peaslee_, on the contrary, asserts that -the patients remain striking examples of womanhood, in whom all the -qualities peculiar to their sex are preserved. _Péan_ observed as a rule -no difference in the sexual impulse to result from this operation, but -he considers that the patients are apt to describe in exaggerated terms -the amount of sexual feeling that remains to them. In one case, _Spencer -Wells_ observed after oöphorectomy an increase in sexual excitability; -_Tissier_ had the same experience, and this author believes that in -these cases the sexual impulse is generally preserved. On the other -hand, _Bailly_ observed a case, in which both ovaries were removed on -account of new growths, where the sexual impulse at first became -excessive, and then completely disappeared. _Anger_ and _Goodell_ speak -in the same sense. - -I am myself acquainted with a woman twenty-six years of age who in -girlhood underwent oöphorectomy on account of extremely severe nervous -troubles associated with menstruation; she had not experienced in -consequence any loss of the sexual impulse; she married a man belonging -to the upper strata of society, and consulted me four years later to -learn if she could by any means be rendered capable of bearing a child. -Two other cases have come within my personal experience in which young -women married after extirpation of the ovaries, and in whom sexual -desire and sexual sensation were all that could be wished. - -In twenty-seven women who had undergone the operation of oöphorectomy, -_Gläveke_ made inquiries regarding the three following points: First, -whether the sexual impulse had been affected by the operation; secondly, -whether during intercourse sexual pleasure was experienced to the same -degree as formerly; and thirdly, whether during intercourse any kind of -difference was observed as compared with pre-operative experience. He -obtained the following results: - - Sexual inclination was - Unaffected in 6 cases 22 per cent. - Diminished in 10 cases 37 per cent. - Extinguished in 11 cases 41 per cent. - Sexual pleasure during coitus was - Unaffected in 8 cases 31 per cent. - Diminished in 10 cases 38 per cent. - Extinguished in 8 cases 31 per cent. - -In a considerable number of cases the sexual impulse was thus found by -_Gläveke_, not indeed to be entirely extinguished, but still notably -diminished. In another set of cases, the sexual impulse was entirely -extinguished, but only in one case was there actual aversion to coitus. -The women readily permitted intercourse when their husbands desired it, -but remained themselves quite indifferent. The greater number of these -women stated that the specific sensation of pleasure during coitus was -markedly weakened, but not entirely lost; in a small proportion, this -sensation was completely extinguished. In the case of seven women who -complained that coitus was very painful, _Gläveke_ found that the -calibre of the vagina was much diminished. In these cases, the sensation -of pleasure during coitus was either greatly diminished or completely -extinguished. The women permitted intercourse very unwillingly, their -unwillingness arising, not from any actual aversion, but because they -dreaded the pain which coitus produced. An extremely hysterical woman, -affected with severe prolapse of the uterus, stated that every attempt -at intercourse was frustrated by violent hysterical convulsions. The -sexual impulse appears always to suffer first and most severely, and -only after this is the sensation of pleasure during coitus affected. In -a few women only, according to the experience of this author, was the -sexual impulse quite unaffected by the removal of the ovaries. - -Amputation of the clitoris appears notably to diminish both the sexual -impulse and the sensation of sexual pleasure, but the results of -clitoridectomy for the cure of masturbation are by no means always -favorable. In the women of the Russian sect of the _Skopstki_, the -clitoris, the nymphæ, and a part of the labia majora are removed, in -order to destroy sexual desire. According to _von Krafft-Ebing_ it is -probable that in the virgin the clitoris is the only erotogenic zone, -that is to say, that only by the stimulation of the clitoris can -erection, the orgasm, and the sensation of ejaculation be induced. It is -probable that the vagina becomes erotogenic only as a result of coitus; -thenceforward, however, the erotogenic significance of the clitoris is -notably lessened, and in multiparæ may entirely disappear. - - - NYMPHOMANIA, ANÆSTHESIA AND PSYCHOPATHIA SEXUALIS. - -The sexual impulse in women is subject to morbid changes, both in the -way of increase and of diminution, exhibiting abnormal violent increase -(nymphomania), or declining to the state of complete frigidity and -sexual indifference, or, finally, manifesting itself in some perverse -manner (psychopathia sexualis). - -Psychopathically increased sexual impulse in woman is known as -nymphomania or uteromania. In such women there is a dominant state of -psychical hyperæthesia, principally in the genital sphere. The most -indifferent perceptions give rise to erotic sensations and to lascivious -impulses. All sensory perceptions obtain a sexual content, and induce -stimulation of the cerebral cortex. All sensation and all activity in -such unhappy beings ultimately concentrates itself in the act of -copulation, or in some other form of sexual gratification, the greatest -perversities of sexual practice frequently arising, masturbation, -tribadism, and, for the most part, prostitution, even in the case of -married women. - -The nymphomaniacal woman, says _von Krafft-Ebing_, endeavors to allure -men by means of exposure of the genital organs or indecent gestures; the -sight of man produces intense sexual excitement, which is gratified by -masturbation or by stimulatory movements of the pelvis. According to -this author, nymphomania is not very infrequent at the climacteric -period; it may even occur in old age. Abstinence in association with -simultaneous excitement of the sexual sphere by mental or by peripheral -stimuli (pruritus pudendi, oxyuris, etc.), may induce these states, -probably, however, only in those hereditarily predisposed. - -The history of antiquity contains records of the corrupt practices of -nymphomaniacal empresses. Thus, Messalina furnishes a well-known -historical example of the abnormal violence of a pathologically -intensified sexual impulse in woman. She was given the agnomen of -_invicta_, having received the embraces of fourteen athletes. _Pliny_ -says of her, _die ac nocte superavit quinto et vicessimo concubitu_; and -_Juvenal_ writes of her the verses, - - ... tamen ultima cellam - Clausit, adhuc ardens rigidæ tintigine vulvæ - Et resupina jacens multorum absorbuit ictus - Et lassata viris, necdum satiata, recessit. - -In corrupt Rome, Messalina was not the only woman _necdum satiata_, ever -insatiable; we need only refer to the orgies of an Aggripina, a Livia, a -Mallonia, or a Poppæa; and _Seneca_ hurls against the women of his day -the reproach, _adeo perversum commentæ genus impudicitiæ viros ineunt_. -And of Cleopatra, the beautiful Egyptian queen, Marcus Antonius writes -in a letter to his physician, Soranus, that she had such violent sexual -desire as to lead to her having connection in a brothel with 106 men. - -Through the report of _Herodotus_ it is well known that the pyramid of -Cheops was built by the numerous lovers of the daughter of this king, -who raised this enormous monument in recognition of the innumerable -times she had yielded herself to their desires. On record also are the -sexual excesses of the Roman ladies at the festival of Saturn, the -festival of the Bona Dea, and the festival of Priapus; indeed, many of -these women allowed themselves to be debauched in the temples (_Ploss_ -and _Bartels_). - -But returning to the present day, both gynecologists and alienists -record numerous cases of great pathological increase in the intensity of -the sexual impulse in women. According to _Lombroso_, such continued -ardency of sexual desire occurs chiefly in women with an inherited -tendency to crime and to prostitution, whose natures exhibit a -commingling of lasciviousness with barbarism. He gives examples of such -women, one of whom surrendered herself to her husband’s laborers; -another had as her lovers all the desperadoes of Texas; a third had -intercourse with all the herdsmen of her village; a fourth, though her -husband occupied a good social position, led the life of a prostitute; a -fifth, a cultured and intelligent woman, entertained a common -bricklayer, and wrote to him letters full of shameless declarations of -her sexual passion; further he writes of a series of criminals, in whom, -indeed, increased sexual desire is a common phenomenon; one of these, a -thief, experienced sexual excitement at a mere glance at a good-looking -man; a murderess, in whom lascivious feeling induced masturbation -whenever she saw a man, and who made experiments in sexual intercourse -with dogs; another, who often took to bed with her, in addition to her -son, three or four men selected at random from the streets; and many -others. _Jolly_ reports the case of a widow, a celebrated _lionne_ of -the _demi-monde_, who kept in her desk, side by side with devotional -literature, a number of lascivious books and preparations of -cantharides, and entertained quite a number of powerfully-built lovers -drawn from the lowest _canaille_. - -In hysterical women the sexual impulse is frequently excessive, and may -increase to such a degree as to produce hallucinations of coitus; -sometimes, on the other hand, the impulse is extinguished, or -psychopathically metamorphosed, passing in a most paradoxical manner -from sexual frigidity to lascivious reflections and continuous -occupation with sexual affairs; not uncommon in such women are false -accusations of indecent assaults of which they assert themselves the -victims. - -_Lombroso_ gives several examples of the increase of the sexual impulse -in hysterical women: “A hysterical girl visited a physician, and said to -him: ‘I am still a virgin, take me;’ she submitted him to the utmost -extremity of provocation, and asserted afterward that she had been -violated. Another hysterical subject, a rich young lady, met a workman -in the street, offered herself to him, was accepted, and when she -returned home related the affair with laughter. A third sought men from -the street in order to find one suffering from syphilis, her object -being to infect her own husband with the disease.” - -According to the observations of _Schüle_, young married, hysterical -women not infrequently run away with a waiter during the honeymoon -journey. This author also points out that in women moral insanity is -especially apt to manifest itself during the first years of married -life. Many advocate a far-reaching libertinism, and threaten to enter a -brothel. In these forms we observe, in addition to ill-temper and -malignity, especially obscenity and tribadism. - -Such a case, observed by _Giraud_ and quoted by _von Krafft-Ebing_, is -the following: Marianne L., of Bordeaux, during the night, while her -master was sleeping soundly under the influence of narcotics she had -administered, was in the habit of giving up her master’s children to her -lover for his sexual gratification, and made them witnesses of the most -immoral scenes. It appeared that L. was hysterical, suffering from -hemianæsthesia and convulsive seizures, and that before her illness she -had been a sensible and trustworthy individual. After the illness, -however, she prostituted herself in the most shameless manner and -completely lost her moral sense. - -_Galen_ relates of his own mother that she suffered from nymphomania, -and that in the attacks she bit her female slaves like a wild animal. - -As a negative aspect of the sexual impulse in woman we must regard the -absence of the impulse, or anæsthesia sexualis, and also the deficiency -of the sensation of pleasure during the act of copulation, or -dyspareunia. - -Of dyspareunia we shall speak more at length later, in connection with -the pathology of copulation. As regards the entire lack of the sexual -impulse, however, in women whose genital organs are normally developed -and normal in the performance of their functions, and whose cerebral -condition is also normal, we must consider such lack an extremely rare -condition, if indeed it ever occurs. It is only in cases in which the -female genital organs are wanting, wholly or to a considerable extent, -or in which there are important cerebral disturbances or states of -mental degeneration, that the sexual impulse is wanting. - -Normally, in the young, sexually unspoiled girl, the sexual instinct[34] -slumbers in the cerebral cortex, but becomes active, as sensation, -perception, and impulse, as soon as the cerebral centre has been aroused -by mental impressions or by physical peripheral stimulation of the -genital organs and their environment. Among stimuli of the latter class -must be reckoned the menstrual stimulus, set on foot by the -developmental processes of puberty. These stimuli arouse in the cerebral -cortex sensations and perceptions which, rising to specific sexual -feelings, produce an impulse to increase the intensity of these feelings -by purposive action; thus is awakened the sexual impulse, the strength -of which is extremely variable. - -Only when the cerebral cortex, as the place of origin of sensations and -perceptions, fails to perform its functions in the manner just -described, or when the anatomico-physiological processes in the genital -organs which normally act as peripheral stimuli fail to occur, or when -there is a failure in the conducting tracts, are sexual perceptions and -impulses lacking. Such anomalies may be congenital. A milder form is -that, likewise congenital, in which a woman has a sexually “cold -nature;” in these cases the sexual impulse is not completely wanting, -but it is so slight in intensity that it can be awakened only by very -powerful stimuli, and in her normal state the woman so affected is quite -free from any wish for sexual gratification. - -Such congenital subnormal intensity or entire lack of the sexual impulse -may be due to very various causes. According to _von Krafft-Ebing_, -these causes may be organic or functional, mental or physical, and -central or peripheral. The declining intensity of the sexual impulse -with the advance of years, and the temporary disappearance of that -impulse after the sexual act, are both physiological occurrences. -Education and mode of life have a marked influence on the intensity of -the vita sexualis. Strenuous mental activity, earnest study, severe -physical exertion, mental depression, and sexual continence, notably -diminish the excitability of the sexual impulse. At first, indeed, -abstinence leads to an increase in the intensity of the impulse, but -sooner or later the functional activity of the organs of generation -declines, and therewith also the intensity of the sexual impulse. As -peripheral causes of diminution or disappearance of the sexual impulse, -_von Krafft-Ebing_ mentions oöphorectomy, degeneration of the -reproductive glands, marasmus, sexual excess, whether in the form of -coitus or of masturbation, and alcoholism. In like manner is to be -interpreted the disappearance of the sexual impulse in general disorders -of nutrition (diabetes, morphinism, etc.). - -A decline in the intensity of the sexual impulse in consequence of -degeneration of the conducting tracts, is found, according to _von -Krafft-Ebing_, in diseases of the brain and the spinal cord. Central -affection of the sexual impulse may be due to organic disease of the -cerebral cortex (dementia paralytica, general paralysis of the insane, -in the later stages), or it may be due to functional disorder, such as -hysteria, or to mental diseases (melancholia or hypochondriasis). - -Finally, in some instances, the sexual impulse in women manifests -itself, not in the normal manner with copulation with the male as its -goal, but in a form demanding some abnormal kind of gratification -(psychopathia sexualis), whether it be because sexual intercourse with -the male affords the woman no enjoyment, or simply because no -opportunity exists for such intercourse. - -Masturbation is very frequent; the habit having been acquired from bad -example by the girl during the menarche, it is sometimes continued by -the wife during married life. In these cases we often find distinct -changes in the genital organs, such as hypertrophy of the clitoris, -enlargement and bluish discoloration of the nymphæ, retroversion of the -uterus, tenderness and displacement of the ovaries, considerable vaginal -discharge, and sometimes menorrhagia. - -_Kussmaul_ draws attention to the connection between masturbation and -nymphomania, on the one hand, and imperfect development of the uterus -and the other genital organs, on the other. _Campbell_ records the case -of a woman addicted to masturbation, who had never menstruated, and who, -in addition to imperfectly developed genital organs, had a dermoid cyst -of the ovary. In a young woman who indulged in masturbation, _Aran_ -found that the uterus and its annexa were imperfectly developed. -_Vaddington_ also describes a case of abnormal sexual impulse which was -associated with absence of the uterus. - -_Troggler_ reports the case of a woman twenty years of age, who had been -six months married to a healthy, potent man, was herself healthy and -blooming, with a good family history, and had never suffered from any -severe illness. At the age of thirteen she had learned to masturbate, -effecting this by stimulation of the clitoris. Now she found no -gratification in coitus, so that she continued to masturbate, and during -coitus obtained satisfaction by manual friction of the clitoris. -Examination showed that the clitoris was strikingly large, the vagina -flaccid, and that there was some vaginal discharge; in other respects -the genital organs were normal. - -Not infrequent, it may be in those whose mental condition is in other -respects fairly normal or it may be in psychopathic subjects, is the -existence of contrary sexual sensation, or sexual inversion, a condition -which has been described by _Casper_, _Westphal_, _von Krafft-Ebing_, -and _Moll_, and has indeed been well known since the days of antiquity. -In the case of a considerable number of notable women, homosexual -practices have been recorded. According to the observations of -_Coffignon_, in Paris the homosexual instinct, when occurring in other -women than prostitutes, is found chiefly among the ladies of the -aristocracy. - -Of homosexually inclined women, some engage in the practice of -tribadism, familiar to the ancient world, and recorded by _Martial_ in a -satire, in which sexual gratification is obtained by mutual friction of -the genital organs, or by penetration of one woman’s clitoris into the -vagina of the other; whilst some indulge in the _amor lesbicus_, in -which gratification is obtained _lambendo linguâ genitalia_, a very -ancient practice indeed, transported from Phœnicia to Greece (where in -especial it was indulged in by the women of Lesbos), and later from -Syria to Italy, where it was widely diffused among the Romans of the -imperial age. _Sappho_, celebrated as the tenth muse, is supposed to -have been addicted to the practice of Lesbian love. - -All such homosexual (female) individuals are, then, endowed with the -perverse instinct toward sexual connection with women instead of with -men. In such cases, the genitals are usually quite normal; sometimes, -however, the woman thus affected is markedly of a male type, being -called by _von Krafft-Ebing_ a _gynandrist_, the affection itself being -termed _gynandry_; when the woman concerned not only possesses a -homosexual impulse, but also in other respects exhibits tendencies -properly characteristic of the male sex, she is called _virago_, and the -affection is termed _viraginity_. - -I had under my care such a woman, belonging to the upper circles of -society, who had been married sixteen years before, had lived a married -life for six years (during which she remained barren), and had then -separated from her husband. She was of a very masculine disposition, -smoked, gamed, drank like a student, and preferred to wear men’s -clothing, and she bestowed her affections on a female companion. -Examination of the genital organs disclosed no abnormality beyond a -slight vaginal catarrh. Menstruation was regular, and the general -appearance showed no departure, with the exception of a slight moustache -that shaded the upper lip, from that of a normal feminine beauty. - -_Mantegazza_ is of opinion that in the case of many unhappy marriages, -in which the source of the unhappiness is obscure, the trouble is to be -found in the homosexual inclination of the wife. _Martineau_ and _Moll_ -report that married women who are homosexually inclined, indulge in -sexual intercourse with other women behind their husbands’ back. -_Duhousset_, at a meeting of the Anthropological Society at Paris in -1877, related the almost incredible case of a married homosexual woman -who, in intercourse with another woman, transferred to the latter her -husband’s semen, so as to induce pregnancy. - -Many writers on forensic medicine, _Tardieu_, _Pfaff_, _Schauenstein_, -_Wald_, and _Mantegazza_, for instance, have recorded that in numerous -circles of European society women practice masturbation and tribadism -(sodomy, so called) with dogs and monkeys; and _Plutarch’s_ statement is -well known regarding Egyptian women and the sacred goat, Mendes, that -the women who were locked in with this animal practiced sodomy -therewith; and again it is asserted that the serpents in the temple of -Æsculapius and also in private houses were employed in the practice of -sodomy. - -_Von Maschka_ records a case which came before the courts a few years -ago in Prague, in which a woman forty-four years old confessed that “in -consequence of the very ardent temperament she possessed, she had, -perhaps, as often as six times indulged herself with her house dog, -which jumped between her legs and licked her; that she took the animal -between her bare legs, stroked its belly until its penis became erect; -then, supporting herself on the back of a chair, she pressed the animal -against herself, introduced its penis between her labia majora, and let -it continue its movements until its semen had been ejaculated.” -Examination of the genital organs of this woman disclosed no -abnormality. - -_Schauenstein_ reports the case of a girl who carried out unchaste -practices with a little dog to an utterly immoderate extent, so that -after the lapse of some years she died in an asylum. In a case recorded -by _Wald_, a maid servant was observed in lewd practices with a poodle; -she supported herself on elbows and knees, while the dog copulated with -her from behind. - -A woman about thirty years of age, who had lived with her husband in -sterile marriage for nine years, complained to me that she had not for a -long time had sexual intercourse, since during copulation she not only -experienced no sexual pleasure, but actually felt a loathing to the act; -on the other hand, she was subject to an uncontrollable impulse to -handle the genital organs of children, both of the male and of the -female sex, and this performance gave her sexual gratification; during -the menstrual period, this impulse overpowered her will. Local -examination in this patient showed that the uterus was enlarged and -retroflexed, and that there was anæsthesia of the vagina. - -_Anjel_ reports the following case of periodic psychopathia sexualis, -associated with menstruation. A lady of quiet disposition, near the -climacteric. Serious congenital predisposition. During youth suffered -from attacks of minor epilepsy. Married, but childless. Several years -ago, after violent emotional disturbance, she had a hystero-epileptic -seizure, followed by post-epileptic mania lasting several weeks. -Thereafter, insomnia for several months. As a sequel, continually -recurrent menstrual insomnia, accompanied by an impulse to embrace boys -under ten years of age, to kiss them, and to handle their genital -organs. Impulse toward coitus, to close sexual contact with a grown man, -non-existent at this time. The patient often speaks openly of her morbid -impulse, and begs that she may be supervised, as she feels unable to -answer for her own conduct. In the intervals, however, she carefully -avoids all reference to the matter, is strictly decent in her conduct, -and in no way sexually ardent. - -Tribadism is frequently mentioned by the writers of classical antiquity, -especially by those of Greece, where the cult of naked beauty encouraged -sexual excitement of this character. This form of unchastity was common -among the flute-playing girls of Greece, and at the secret festivals of -such associates Aphrodite Peribasia was invoked. _Lucian_, in his -dialogues of hetairai, depicts the intensely passionate nature of these -homosexual unions between girls. _Lombroso_ reproduces _Juvenal’s_ -description of such a love-feast. “When the flute calls to the dance, -the mænads, inflamed with wine and beer, loosen their long tresses, they -sigh languishingly and eagerly, and an ardent desire draws them one to -another, the desire and the passion of the dance gives their voices an -alluring sound; nothing now can serve to bridle their unrestrained -desires. _Lacasella_ swings her wreath, which she has won in the contest -of lascivious gestures and movements, but even she must give way before -Medullina with her ardent postures. About these games there is no trace -of unreality, and the most rigid Spartan, hardened from the very cradle, -even old Nestor himself, notwithstanding his hernia, could not fail to -be stimulated by such an inflammatory spectacle.” - -In the present day, also, the practice of tribadism is more widely -diffused than people in general imagine. I have often encountered -instances of it in ladies of good position, who were past their first -youth, who would not or could not marry, and who undertook extensive and -long-enduring journeys with a female “companion,” of similar age, or -perhaps a little younger. Their erotic needs, which could not be -gratified in normal fashion, led to this sexual perversion—a tendency -observable especially in persons with neuropathic predisposition, or -with a liability to hysteria or to epilepsy. Sometimes such girls, even -before puberty, show an inclination to wear boys’ clothes, to avoid all -feminine manual occupations, and to examine and to handle the genital -organs of their playmates. Even after puberty, such tribadists like to -make a parade of masculine attitudes, they have their hair cut short, -wear clothes of a masculine cut, smoke a great deal, and show in their -conversation, and still more in their letters, great exaltation of the -passions. It not infrequently happens that an elderly lady who has lived -well in her day, and from youth upward has had much intercourse with -men, comes at last to lament her worthlessness to men, and from this -proceeds to the idea of obtaining sexual enjoyment by means of -tribadism. The tribadistic union sometimes lasts for several years, but -in most cases the alliances are quickly and frequently changed. - -According to _Taxil_, tribadism is fairly common among the married women -of Paris, and in upper-class women is extremely prevalent. This author -describes with what industry and perseverance many elderly tribadists -endeavor to win for themselves and to seduce young girls, just as old -women often work hard to gain money for the enjoyment of the favored -person. - -In these unions, according to the descriptions of _Lombroso_, very -remarkable phenomena occur. A particular jargon arises with tender -designations for this or that bodily beauty; a violent jealousy -develops, and a newly united pair keep together as much as possible for -fear of losing one another’s affection; the “friends” tread always in -one another’s footsteps. This author rightly points out that the very -numerous romances describing relations of this kind prove the diffusion -of this vice in “high life.” Novels of this class are referred to by -_Mantegazza_ in his book, “Woman as Criminal and Prostitute.” He -mentions: _Diderot_, “La Religieuse;” _Balzac_, “La Fille aux Yeux -d’Or;” _Gautier_, “Mademoiselle de Maupin;” _Feydeau_, “Le Comtesse de -Cholis;” _Flaubert_, “Salammbô;” _Bélot_, “Mademoiselle Giraud ma -Femme;” _Willbraud_, “Fridolins Heimliche Ehe;” _Graf Stadion_, “Brick -and Brack;” _Sacher-Masoch_, “Venus im Pelz.” _Zola_, also, in “Nana” -and “La Curée,” and _Butti_ in “L’Antona,” make some reference to this -matter. - -_Sauval_ relates of the dissolute life at the court of the French king, -Francis I, that the women learned also to play the part of men; a -princess had a hermaphrodite maid-of-honor, and the court and all Paris -gossiped about the Lesbian-loving ladies, whose husbands were delighted, -since they were thus quite freed from jealousy, and prized their wives -above all on this account. Such a mode of life was so pleasing to many -ladies that they refused to marry, and refused also to allow their -“friends” to marry. - -Tribadism is very common among prostitutes. According to -_Parent-Duchatelet_, tribadism begins only after prostitution has long -been practised, between the twenty-fifth and the thirtieth year of life; -generally there is a notable difference in age and also in beauty -between the two women forming a tribadistic alliance, and as a rule the -younger and prettier of the pair is the more passionately sensitive and -the more constant. _Parent-Duchatelet_ endeavours to explain the origin -of tribadism by referring to the manner in which in brothels and -reformatories the women are closely packed together, to the enforced -abstinence from normal sexual intercourse (in prisons and -reformatories), to the loathing for men sometimes felt by prostitutes, -and to the opportunities for mutual observation of the most intimate -nudities. Even women who at first object to it most vehemently, commonly -give way to this vice after eighteen or twenty months. - -Among 103 prostitutes examined by _Lombroso_, he found tribadism to be -practiced by five. He considers the principal cause of tribadism to be -in the lascivious search for new and unnatural pleasures, and quotes in -illustration the characteristic remark of Catharine II, herself a -tribadist, “Why did not nature endow us with a sixth sense?” Female -criminals who seduce others to the practice of tribadism have usually -themselves acquired the vice during a long term of imprisonment—it is, -in fact, the long-sentence criminals, women with a congenital -inclination toward crime, that incline also to unnatural vice. The -influence of environment is, according to _Lombroso_, indicated by the -fact that the most confirmed criminals, in prisons for women, corrupt in -this manner so many of the inmates who are merely “criminaloids,” and -corrupt even the wardresses. Further, he is led to conclude, the -confinement in close association of so many extremely sensual and -prostituted women, leads to the origin of a kind of ferment of new -lascivious desires, and causes an increase of one form of degeneracy by -means of another. Prostitutes often see one another naked, sleep two or -three together in the same bed; similar things occur in -boarding-schools. In asylums also we may observe that the admission of a -tribadist will result in the infection of all the inmates with this -vice. - -According to _Moll’s_ estimate, 25 per cent. of the prostitutes of -Berlin practice tribadism. According to the experience of this author, -in cases in which tribadists live in concubinage, one of them is always -a prostitute; the active and the passive rôle are always played by the -same respective members of the alliance; the active member is called -“papa” or “uncle,” is usually a prostitute, and, like the man in the -married state, possesses great comparative freedom in sexual matters, -whilst the passive member, the “mother,” is not allowed to form any -sexual relations outside the concubinage. - -According to _Ricardi_, many frigid prostitutes practice with pleasure -clitoris-masturbation, cunnilictio, and, especially, sapphism, -preferring these perversions to the normal sexual act. Moreover, among -prostitutes and female criminals there is no lack of lovers of -martyrization, of flagellation, even to the drawing of blood, of -tyrannical treatment, and of the initiation of children into the -mysteries of sex. - -[For a detailed account of Sadism and Masochism, see _von -Krafft-Ebing’s_ “Psychopathia Sexualis.” These particular perversions, -common in men, are rare in women; hence but passing allusion is made to -them in the present work.] - -_Lombroso_ records on account of its rarity a case of masochism observed -by him in a woman thirty-five years of age, who liked being whipped. - -_Moraglia_ reports a remarkable instance of sexual perversion in a girl -of eighteen, who preferred to coitus, masturbation associated with the -stimulating influence of the odor of male urine; this peculiar form of -irritability was so powerful as to drive the girl to masturbation in -public urinals, notwithstanding the risk of arrest, which indeed often -occurred. - -According to _Carlier_, there are four or five brothels in Paris which -are not infrequently visited by rich ladies in search of tribadistic -enjoyments, and ladies of “high life” assemble there for communal -orgies; it is noteworthy that prostitutes surrender themselves for such -purposes to these women who are outside their own circle with great -reluctance, and only for a very high fee. - -Speaking generally, however, sexual perversion is rarer and less intense -in women than in men. This fact is explained by _Lombroso_ on the ground -that the erotic element in women’s nature is less active, and that women -are less often affected by epilepsy, the principal source of these -anomalies. In cases in which the genital organs are healthy we must, -with _Westphal_, conclude, with reference to contrary sexual sensation, -that the abnormal sexual feelings have a cortical origin. - -From _von Maschka’s_ elaborate account of unnatural offences, in his -_Handbook of Forensic Medicine_, we abstract the following passage -relating to the female sex: “Lascivious procedures liable under certain -circumstances to legal punishment may consist: 1. In handling or other -manipulation of the genitals, without actual intercourse. If the genital -organs of a female have merely been gently handled, without any more -violent manipulations, we shall not, as a rule, either in the case of -children or of adults, find any local changes as a result; contrariwise, -if the handling has been rough and brutal, if the fingers have been -forcibly thrust within the vulval cleft, or if the pudendum has been -pulled and rent, we may expect to find excoriations, redness, swelling, -laceration of the hymen, or even of the vagina and the perineum. 2. In -licking the female genitals (cunnilingere). An analogous process also -effected by members of the female sex, whether children or adults, is -_irrumare, id est, penem in os arrigere; fellare, id est, vel labiis vel -lingua perfricandi atque exsugendi officium penis præstare_. 3. In -introduction of the membrum virile into the rectum, either of children -or of adults, pæderasty.” That this form of sexual gratification is not -infrequently practiced upon women has been pointed out especially by -_Parent-Duchatelet_, and is asserted by _von Maschka_ from personal -knowledge of cases in which it has occurred. - -Tribadism and Lesbian love, unnatural vice practiced by two individuals -of the female sex, occur, according to _von Maschka’s_ description in -the following manner: _a._) By masturbation, either one person -gratifying the other by manipulation, or mutual masturbation. In a case -of this kind recorded by _Tardieu_, a wife still young repeatedly, and -by day as well as by night, introduced her finger deeply into the vagina -or the rectum of her little girl, moving it about there sometimes for as -long as an hour. According to the child’s account, the mother herself at -these times was in a condition of excitement, no doubt sexual, which she -gratified in this manner. In another case, several older girls engaged -with their own fingers and tongues in lascivious practices with the -genital organs of a little girl of seven. According to _Krausold_, among -female prisoners such “forbidden friendships” are extremely common, -formed for the purpose of mutual masturbation, and in connection with -which the bitterest jealousy and the most ardent love are exhibited. -_b._) With the assistance of an enlarged clitoris, with which one woman -performs the sexual act by introducing the organ within the vagina of -another. In France in the nineteenth century a woman is said to have -lived whose genital organs were so formed that, on the one hand, as a -woman she played the passive part in intercourse with men, and, on the -other hand, was able to give sexual gratification to women by assuming -the active part of the male. _c._) By the employment of an artificial -_membrum virile_. This mode of obtaining satisfaction of sexual desire -was known already to the ancients, and such a priapus was by the Greeks -termed ὸλισθος. The fact that such articles are manufactured and sold, -affords sufficient proof that their use is not unknown in our own day. -_Von Maschka_ describes such priapi as being made of india rubber, of -the size and shape of an erect penis, perforated longitudinally and -fitted at the lower end with a testicle-like attachment, to be filled -with warm water or milk, so that by squeezing it an ejaculation can be -counterfeited. This priapus is also so constructed that it can be -attached to the body by means of a girdle and can thus be employed for -the gratification of another individual. - -We have already referred to sodomy, unnatural intercourse with the lower -animals. _Von Maschka_ gives several instances of this, which we have -previously mentioned, and states also that some years before, during his -stay in Paris, a female was accustomed to hold a secret exhibition, the -entry to which cost ten francs, and at which she had sexual intercourse -with a bulldog trained for the purpose. - -According to _Lombroso_, even at the present day, the inmates of -licensed brothels frequently hold exhibitions, for admission to which a -fee is charged, of tribadistic couples in _poses plastiques_, and of -another prostitute in _coitus caninus_. - -In his widely-celebrated work on _Psychopathia Sexualis, von -Krafft-Ebing_ discusses these morbid sexual processes in women. We -select certain data from his exposition. Regarding the congenital morbid -phenomenon of the lack of sexual feeling in women, as contrasted with -perversion of sexual feeling, and the sexual impulse toward an -individual of the same sex (antipathic sexual feeling), _von -Krafft-Ebing_ writes: “The woman-loving woman feels herself sexually to -be a man, she rejoices in the exhibition of courage, of masculine -sentiments, since these characteristics make the man desirable to the -woman. The female _urning_,[35] therefore, likes to have her hair cut -short and her clothes of a masculine cut; and one of her greatest -pleasures is when opportunity offers to appear in male attire. Her -ideals are notable feminine personalities, distinguished by spirituality -and energy; in the theatre and in the circus, it is only the female -performers that attract her interest; and in the same way, in -collections of pictures and statues, it is only the representations of -women that awaken her æsthetic sense and her sensibility.” _Von -Krafft-Ebing_ insists that in nearly all cases of antipathic sexual -feeling in which a family history was attainable, that history was found -to exhibit instances of neuroses, psychoses, stigmata of degeneration, -etc. In hysteria, according to this author, the sexual life is -especially often abnormal; in cases with neuropathic inheritance, one -may say always: “All possible anomalies of the sexual functions occur in -such cases, with the utmost variety and the strangest commingling, based -upon hereditary degenerative processes, and accompanied by moral -imbecility in its most perverse manifestations. * * *. Frequently, in -hysterical subjects, the sexual life is morbidly excitable. This -excitement may be intermittent (? menstrual). Shameless prostitution may -result, even in married women. In cases of a milder type, the sexual -impulse is exhibited in the form of onanism, nude perambulations about -the room, wearing of male attire, etc. In cases of hysterical mental -disorder, the morbidly excited sexual life may manifest itself in the -form of maniacal jealousy, baseless complaints against men of indecent -assault, hallucinations of coitus, etc. Sometimes there may be -frigidity, with lack of sexual pleasure, commonly due to genital -anæsthesia.” - -Incest in women, dependent upon psychopathic causes, is also alluded to -by _von Krafft-Ebing_; it occurs in those in whom a partial imbecility -that leaves the sense of modesty undeveloped is combined with eroticism. -Thus, a case reported by _Schürmayer_ is mentioned, in which a mother -had, or attempted, intercourse with her son, aged five and one-half -years; and again a case reported by _Lafarque_, in which a girl of -seventeen laid her thirteen-year-old brother on herself for the -gratification _conjunctionis membrorum_, while simultaneously -masturbating her brother; _Magnan’s_ case, an unmarried woman -twenty-nine years of age, who could hardly resist the impulse toward -copulation with her nephews as long as they were quite young; -_Legrand’s_ cases, in one of which a girl fifteen years of age seduced -her brother to the performance of all possible sexual excesses on her -body; another, a married woman aged thirty-five, who committed incest -with her eighteen-year-old brother; and a third, a mother aged -thirty-nine, who committed incest with her son. - -According to _Moll_, women who suffer from antipathic sexual sensation -are, in many cases, married; it appears, however, that for the most part -they have no inclination to marry. In isolated cases there may exist a -psychical hermaphroditism, the woman thus affected having sexual -inclination both towards men and towards women. In the case of -homosexual women, normal intercourse appears not to furnish complete -satisfaction. As regards fetichistic, masochistic, and sadistic -inclinations on the part of women with antipathic sexual sensation, -_Moll_ was unable to obtain any trustworthy information. Sometimes in -women the perverse sexual impulse appears periodically, being then often -associated with the appearance of other psychical abnormalities. In some -women the perverse impulse is especially active at the menstrual -periods; whilst at other times these subjects, even though not quite -sexually normal, are still very much quieter. Antipathic sexual -sensation in women may depend upon inherited predisposition, and may -often be traced back to a very early age. In many cases an exciting -cause may be demonstrated. - -_Mantegazza_, who relates that homosexual practices are common among the -inmates of harems, believes that antipathic sexual feeling is readily -curable in women soon after marriage, but that later a cure is rare. - -A perverse form of sexual gratification sometimes met with in women is -flagellation. By chastisement with birches, straps, or whips on the bare -buttocks, the nerves of the sexual apparatus are stimulated, and these -organs become congested, with an effect resembling that of onanism. Such -flagellation was practiced by the wanton ladies of ancient Rome. In the -Middle Ages, hysterical women derived great pleasure from the -stimulatory effect of whippings. It is reported of Catharine de Medici, -that she had herself whipped, and that she delighted in seeing the -ladies of her court undergoing similar treatment. In the present day -many women derive intense sexual pleasure from being birched by their -lovers on bared portions of their bodies. In Paris and other large towns -there are special places of resort for those who pursue this form of -perverse sexual gratification. Sometimes such women are only the active -_fouetteuses_ for worn-out, perversely-feeling men. - -Among the Greeks, a woman who had remained barren during the early years -of marriage would visit the temple of Juno, in order to receive from a -priest of Pan the gift of fertility. She stripped naked, and, while thus -exposed to the flagellant priests, she received all over the back of her -body numerous blows inflicted with thongs of a he-goat’s hide—this -process being supposed to induce fertility. The object of this form of -flagellation would appear to be to induce an increase of sexual desire. - -Sexual neurasthenia is defined by _Eulenburg_ as a neuropsychosis of -chronic course, manifesting itself chiefly in the form of excessive -irritability of the sensory and psychosensory neuron-systems, in -association with excessive tendency to exhaustion of the motor and -psychomotor neuron-systems. This exhaustion occurs especially in -relation to the genital system, in which we see exhibited the phenomena -of irritable weakness, of increased excitability combined with increased -tendency to fatigue of the genital nerve apparatus—such chronic morbid -disturbances are, according to this author, comparatively rare in women, -that is to say, the developed typical picture of the disease does not -occur in women, or occurs very rarely. Among 168 patients suffering from -sexual neurasthenia, only six were women. Two of these latter were -addicted to masturbation, and in the anatomical sense both were still -virgins; the rest were married women, not receiving sufficient sexual -gratification in their married life, two of these were probably also -addicted to masturbation, two indulged in homosexual practices. - -Onanism, according to _Eulenburg_, is the cause of sexual neurasthenia -in women as well as in men. If, however, among the relatively very large -number of women addicted to masturbation, there appears to be such a -very small proportion of instances of sexual neurasthenia, this depends -on the fact that from the nature of onanism in women the physical and -also as a rule the psychical consequences are as a whole apt to be much -less severe than those arising from similar practices in men; but it -depends also on the circumstances that neuromental abnormalities of -other kinds and denoted by other names, such as dyspareunia, vaginismus, -sexual hysteria, nymphomania, feminine sadism, and tribadism, are apt to -arise in consequence of onanism. As regards onanism, so also may it be -in regard to sexual excesses and aberrations in general; they may be on -the one hand causes, but on the other symptoms and sequelæ, of sexual -neurasthenia. Early-acquired or inherited homosexual tendencies and -habits may, as _Eulenburg_ further points out, lead to sexual -neurasthenia only, but then very easily, when such individuals have -allowed themselves, against their nature but in obedience to -conventional points of view and to the advice of the relatives, to be -persuaded into marriage. That sexual abstinence alone is competent to -induce sexual neurasthenia must be dismissed as a fable. - - - - - II. THE SEXUAL EPOCH OF THE MENACME. - - -By the term _menacme_ I designate the culmination of the sexual -development of woman, during which the processes of reproduction, -copulation, conception, pregnancy, parturition, and lactation occur. - -The processes of puberty in woman are fully completed at the age of from -eighteen to twenty years, so that from this time forward she is fully -equipped for the performance of her sexual duties. The first act in the -fulfilment of these duties is copulation, which in civilized countries -is in the great majority of women first undertaken at the commencement -of married life. The average age at marriage in the women of this part -of the world is 22; but marriages at an earlier age are very common, and -in many circles of society the average age is as low as 20. The fullest -maturity of sexual activity in women occurs, however, in the -thirty-second year of life, this being the year in which on the average -the maximum fertility is attained. - -At the menacme, the beauty and energy of women attain their fullest -evolution, her sexual characteristics their strongest development. It is -this period of life, however, that entails the greatest dangers to -beauty and health in connection with the functions of the genital -organs. Copulation, the first act of sexual intercourse with the male, -often produces in the female injuries from which she never completely -recovers. Gonorrhœal infection has been a source of unspeakable miseries -to women. Motherhood itself entails the risk of a great number and -variety of illnesses, which, as puerperal sequelæ, affect this phase of -woman’s life. The struggle for existence, in which woman at her prime is -also involved, and the fulfilment of duties to husband and children, -further lead to the production of a series of changes, both physical and -mental, in the feminine organism, which influence all the functions. - -The great characteristic of this epoch is maternity. In maternity the -fully developed woman lives and has her being, but to maternity also she -often succumbs as a sacrifice to the fulfilment of her natural -functions. Inasmuch as in this sexual phase the functions of the genital -organs are of greater importance, to the same degree is enhanced the -importance of the mutual relations between these organs and the other -organs of the female body. - -Another influence of fundamental importance in the sexually mature woman -is that of the sexual impulse, the force of which is at times -overwhelming, so that its gratification is sometimes sought without -regard for the consequences to married and family life. - -The physiology and pathology of the menacme coincides with the normal -processes and pathological changes respectively of the female genital -organs consequent on their functional activity as organs of sexual -sensation and of reproduction. Woman as wife and mother stands at the -climax of her existence. - -In a quite astonishing manner, however, many of the advocates of the -modern movement for the emancipation of women contest the significance -of maternity to women. - -A modern authoress and supporter of women’s rights, _Ellen Key_, avows -that she was in error when at an earlier date she “regarded maternity as -the central point in woman’s existence.” She asserts that it lies within -the sphere of a woman’s individual rights, as of a man’s, to reject -marriage, or to accept marriage while rejecting maternity. “The grounds -for the rejection of maternity may as well be deeply altruistic as -deeply egoistic. It lies within the sphere of individual rights to -dispense with love or with maternity when either is regarded or both are -regarded from this point of view. It is entirely within a woman’s rights -to transform herself into a member of the ‘third sex,’ the sex of the -worker bee, of the neuter ant, if she finds therein her greatest -pleasure. * * * Women exist in whom erotic feeling is totally atrophied; -there are yet others who fail to find in intercourse with the modern man -that soulful and deep erotic harmony which they rightly desire; and -there are others still more numerous who desire love, but not maternity, -which indeed they dread.” - -A celebrated German authoress of the present day, _Gabriele Reuter_, -refers in similar terms to the justifiable fear with which so many -aspiring and hard-working women regard maternity, “the perpetual, -watchful, emotional dread of motherhood, a dread which causes them to -turn at bay. A dread, a hatred, it is, which has grown so strong, so -active, that one might almost regard it as an obscure perverse instinct, -awakened and developed and strengthened by bitter necessity. It is as if -in the innermost recesses of their nature such women had a belief that -should they pay their tribute to sex they would loose all the energy, -clearness, and brightness of mind, by means of which they have raised -themselves above the level of their sex. And perhaps women of a certain -type are justified in this fear.” - -Fortunately, however, the woman who does not prize maternity still -remains an exception. The great instinct for the preservation of the -species, which nature has planted deeply in every human being, still as -a rule in women remains much more powerful than the instinct of -self-preservation at every one else’s expense—more powerful than such -self-sufficient egoism. And now as ever it is the duty of humanity to -educate women for maternity from her youth upward, so that she is in -every way fitted for the supreme duty of her sexual nature, the renewal -of life from generation to generation. - -Against the significance and importance of maternity to woman, the -mountainous waves of the movement for the emancipation of women dash -themselves as vainly as against the solid rock. Much justification may -be found for the efforts of women in modern civilized communities to -engage in departments of activity to which hitherto men only have been -admitted; and as regards the intellectual capacity of women we may -acknowledge their competence for the higher scientific professions; but -while admitting this we must hold firmly to the physiological standpoint -and must more especially bear in mind the sexual life of woman. Such -professions only are suitable for a woman as do not entail a restriction -of the sphere of her reproductive activity, a hindrance to her principal -duty, that of maternity, an interference with the discharge of her -obligations to husband and children, or a diminution of her domestic -value and an evasion of her responsibilities in family life. As _L. von -Stein_ so justly remarks, the woman who spends the whole day at a desk, -in the law courts, or in a house of assembly, may be a most honorable -and most useful individual, but she is no longer a woman, she cannot be -a wife, she cannot be a mother. In the condition of our society, the -emancipation of woman is in its very nature the negation of marriage. - -We may not agree with the great misogynist, _Schopenhaur_, in his -depreciation of the female sex, or in his assertion that woman exists -simply and solely for the propagation of the species, and that “her life -should therefore flow more quietly, more inconspicuously, and more -gently than that of man toward its goal;” nor need we regard as -justified the severe sentence of the philosopher, _E. von Hartmann_, -that from the moral standpoint, “the greater number of women pass the -whole of their lives in a state of minority, and, therefore, to the end -stand in need of supervision and guidance;” but the statement made by -_Friedr. Nietsche_ in his book _Also sprach Zarathustra_ deserves -acceptation, “Everything in woman is a riddle, and everything in woman -has its answer: it is called pregnancy,” and again, “For woman, man is -only the means; the end is always the child.” - -Unsearchable in its judgments, nature has imposed on woman alone the -consequences of the act of generation; man has the pleasure, but not the -labor and the pain. We might indeed regard as highly unjust the -distribution of the rôles in the process of reproduction, were it not -that in a mother’s love and a mother’s joys, woman finds a compensatory -solace. The man’s part is a much easier one and costs far less than that -of woman; with the gratification of his sexual desire, man shakes off -any further responsibility, whereas the woman’s body becomes the -workshop in the wonderful act of creation of a new human life. - -Maternity, says _Lombroso_, is the characteristic function of the female -sex, upon which rests her whole organic and physical variability, and -this function is indeed throughout of an altruistic nature. Although -there is a certain antagonism between the sexual impulse and -maternity—according to _Icard_, the sexual impulse is extinguished in -women during pregnancy,—still, maternity appears to depend upon sexual -perceptions. For instance, the act of suckling the infant often arouses -voluptuous sensations, and _Icard_ mentions a case in which a woman -permitted fertilization to occur solely on account of the pleasure -obtained by suckling. The anatomical cause of this fact is to be found -in the connections between the nipple and the uterus by way of the -sympathetic nervous system. * * * It is likewise probable that in the -happy feeling of maternity there intermingle very gentle voluptuous -sensations derived from the genital organs. According to _Bain_ also, -very delicate sensations of contact form an element in maternal love. - -The epoch of the menacme is that in which, independently of maternity, -the sexual impulse often becomes so powerful in woman as to be entirely -dominant. The problems relating to marriage and to the sexual position -of woman, so widely discussed at the present day, are, therefore, of -especial importance in regard to women at this period of life. The -forcible repression and control of the sexual impulse inculcated by -moral and religious ordinances are now, according to the modern leaders, -both male and female, of the woman’s movement, to be abandoned; and it -is loudly asserted that every woman has the same right as man to -physical love and the happiness it produces. Hence, free love is -demanded. “Freedom in love, freedom for love—this is what the dignity of -the human race demands,” asserts the authoress of a book recently -published (_Elisabeta von Steinborn_, _The Sexual Position of Woman_). -With laws for the regulation of marriage, this section of the women’s -rights party will have nothing to do. A truly good and honorable man, -they contend, has as little need of laws to regulate his amorous -relations as he has of laws against murder and theft. In the first -place, love, the sexual relation between man and woman, must be free, -and humanity, freed from vexations and needless control, will then seek -and find the proper path, even if at the expense of a few errors by the -way. Only after this unrestrained sexual intercourse has lasted for a -long time, will free marriage become the rule. “Out of this phase will -develop the monogamic system willed by God, for which, in its most ideal -form, we are not yet sufficiently ripe.” It is hardly necessary to -discuss in detail the general deleterious influence of such unlimited, -unregulated free love upon the community, upon human society as a whole, -to describe the results of free love, to attempt to realize the chaos -which it would bring about in the social relations of civilized -humanity. We must rather indicate it as desirable from the medical -standpoint also, that such a change in general domestic economy shall be -aimed at as will enable the great majority of women to share in married -life and family happiness, and thus making allowance both for human -nature and the demands of social life, to effect a true harmony between -sexual morality and sexual practice. - -[Illustration: - - FIG. 48.—The female pudendum, or vulva, with the labia majora. The - vulval cleft. Female perineum. Mons veneris, with the pubic hair. - (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) -] - -We must point out that in so far as the modern woman’s movement aims at -dispensing with man and at basing the entire life of woman upon the -independent ego, that movement is in opposition to nature and its -eternal laws. A woman who thus seeks the solution of the woman’s -question in the direction of freedom and independence is one who -endeavors to avoid the burthen of womanhood. She desires to escape, -always from guardianship, often from maternity, and usually from the -restrictions, the unselfishness of womanhood. But none the less does she -remain unable to escape from her femininity. - -[Illustration: - - FIG. 49.—Vestibule of the vagina, with the labia minora or nymphæ, the - vaginal and urethral orifices, and the glans clitoridis. (From - Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) -] - -“The true significance of woman,” insists _Laura Marholm_ in opposition -to the modern tendency, “has at all times consisted rather in what she -is than in what she performs, and it is precisely in the former point -that the women of the present day seem so unusually wanting. Their -performances are indeed many and various, they study and they write -innumerable books, they are the directors or principals of all possible -concerns and collect funds for every possible object, they wear doctors’ -gowns, conduct agitations, and found clubs, and they come continually -more and more into publicity. And yet their public significance is after -all diminished. The greater the influence of woman in the mass and as a -numerical majority, the less is her influence as an individual, the -smaller is the triumph of her sex. She herself has induced man to sound -the trumpet note of the abhorrence of women. _Tolstoi_ in The _Kreuzer -Sonata_, _Strindberg_ in numerous dramas, _Huysmans_ in _En Ménage_, -write in this strain; and in the works of many lesser luminaries we -encounter this mistrust of love. * * * The modern system of education -for girls, with its polyglossia and polymathy, favors a superficial -development of the understanding, and produces women who are pretentious -without being profound.” - -Feminine beauty suffers during the menacme from the stress of the -demands made on the sexual activity as well as on the functional -capacity of the individual. Repeated, rapidly succeeding pregnancies and -confinements impair the beauty of the breasts and the abdomen, the -figure and the carriage. In consequence of suckling, the breasts, -hitherto firm and elastic, usually become more or less pendent and -wrinkled, sometimes also flabby and inelastic, sometimes nodular. -Diseases of the genital organs and the disorders of the general health -dependent thereon, leave disfiguring wrinkles in the face and other -traces in the whole structure of the body. Toil, anxiety, and grief also -write their horrible marks deeply on the appearance. The mature -working-class woman, through sharing in masculine labors, through -long-continued muscular exertion, and through neglect of bodily care, -frequently assumes in her features, her carriage, her figure, and her -whole appearance, a rather masculine type. - -The beauty and the youthful freshness of girls belonging to the -labouring classes seldom endure for long after the menarche, and in -cases in which the environment is one of poverty, they last through a -very short part only of the epoch of the menacme. The early appearance -of wrinkles in the face, the stiff, angular character of the movements, -the ungraceful carriage of the body, all these combine to make a woman -of five-and-twenty who groans under the burthen of toil appear at the -first glance an elderly woman, and a closer investigation shows what -damage has been wrought to the attributes of beauty, how the breasts are -flabby and flattened, the belly prominent, the buttocks pendulous, the -arms muscular. - -In the well-to-do classes, again, at this period of life, when generous -diet combines with insufficient exercise, an abundant deposit of adipose -tissue may already have occurred, resulting in a great impairment of -beauty, the body and limbs being enlarged, the gait and the carriage -correspondingly altered for the worse—changes which seem desirable only -to those orientals to whom such obesity, such exaggeration of -femininity, is sexually stimulating. If, however, this deposit of fat is -not excessive, this it is which endows women during these years of -fullest development with an imposing appearance and buxom form. In -favourable circumstances, beauty of this type may persist to the -fortieth year of life and even beyond, and it is of such a character as -to justify the proverb that woman’s first sexual epoch is dedicated to -love, her second to voluptuousness. - -[Illustration: - - FIG. 50.—The uterus, the left Fallopian tube and the left ovary, in - their connection with the broad ligament of the uterus, which has - been fully unfolded. Seen from behind. From a virgin, aged nineteen - years. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New - York.) -] - -“Bountiful nature,” writes _Mantegazza_, regarding woman at this sexual -epoch, “sends to woman an ingenious engineer, who enlarges the hills to -mountains and fills up the valleys with a soft alluvium of fat. The -commencing wrinkles disappear, being smoothed out under the beneficial -influence of this plastic material; the slender, elastic palm-tree stems -are converted into majestic columns of Parian marble; quality is -replaced by quantity, and if the eye has lost a few provinces, the hand -has gained just as many. * * * A certain number of chosen women -understand how to preserve for as long as ten years the unstable -equilibrium of the period which separates these two ages of life. There -are divine beings who with every oscillation of their tresses or rocking -of their hips, with every undulation of their bosom, every serpentine -movement of their limbs, instil desire. * * * They constitute our most -intense delight, and our intensest torment, they make our life a -blessing or a curse, they are the uttermost goal of human passion, of -human voluptuous desire.” - -[Illustration: - - FIG. 51.—Female internal genital organs in the fully developed state. - (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) -] - -Among the injuries to beauty effected by pregnancy, one above all -evident to the eye is the almost invariably ensuing change in the skin, -principally taking the form of a change in pigmentation, with the -appearance of spots varying in size and tint, on the face and especially -on the lips and the forehead; there is greatly increased pigmentation -also of the areola mammæ and the linea alba, and in addition of the -labia majora and minora and of the anal region. It is not certain -whether this chloasma uterinum is dependent, as _Jeamin_ assumes, on the -discontinuance of menstruation, or, as _Virchow_ believes, on changes in -the blood and the blood-pressure. Sometimes also, in pregnant women, we -observe on the face, chiefly on the nose and the cheeks, dilatations of -the small cutaneous vessels, often associated with acne nodules. - -A permanent disfigurement is caused by the _lineæ_ (vel _striæ_) -_albicantes_, white lines or streaks of varying length and resembling -scar tissue in appearance on the skin of the abdomen, the adjoining -parts of the buttocks and thighs, the lower part of the front of the -thorax, and the mammæ. They are not true scars, not being new formations -of connective tissue, being on the contrary dependent on solutions of -continuity, on relative diminution, that is to say, of the connective -tissue layer of the skin. They are formed in consequence of the fact -that the connective tissue bundles are not able to keep pace in their -superficial enlargement with the necessarily rapid extension of the -cutis, hence great meshes appear in the former, situate in the direction -of the greatest tension of the skin. (_Spietschka_ and _Grünfeld_). - -Transiently during pregnancy, but in some cases permanently also, the -beauty of the lower extremities is apt to be impaired by enlargements of -the veins, the formation of varices, and sometimes also by œdema; these -conditions depend upon the hindrance to the venous return caused by the -pressure of the pregnant uterus. Thick, vermicular, bluish strings or -nodular enlargements appear in the course of the great veins, with -consequent eczema and ulceration. In pregnant woman, eczema is common in -other regions, on the face, the hands, the forearms, and the genitals; -also erythema, urticaria, and the pustular eruption known as impetigo -herpetiformis. - -Parturition and lactation entail further disfigurement of the skin -through the production of various lesions, such as cracks and fissures -of the skin of the breast, dermatitis due to venous thrombosis in the -lower extremities, scarring of the breast after mastitis, etc. - -In the description of the sexual life of woman in the epoch of the -menacme, we shall consider at some length copulation and conception, the -relations of fertility and sterility, the important topic of the use of -measures for the prevention of pregnancy, and the interesting subject of -the determination of sex; on the other hand, pregnancy, parturition, and -the puerperal state, since these subjects are specially treated in the -ordinary textbooks on midwifery, we shall discuss only in so far as -certain relations between these reproductive processes and the organism -as a whole and its functions, appear to us especially worthy of note. - - - ANATOMICAL CHANGES IN THE FEMALE GENITAL ORGANS IN THE PERIOD OF THE - MENACME. - -In the fully-developed woman during the period of the menacme, the mons -Veneris forms a rounded elevation which consists of very dense -connective tissue containing large quantities of fat, while the -integument that covers it is usually coated with a thick growth of hair. -The form of this hairy covering, which by the Roman poets was designated -_Hebe_, by the Greeks _zunaikomustax_ (translated by _Albrecht Dürer_ as -_Weybsbart_—woman’s beard), by _Galen_ termed _ornamentum loci_, is -various, and, as an external sexual character, it deserves more accurate -observation than it has hitherto received from anatomists. - -The hairy covering of the female genital organs is in adults, and -especially in brunettes, very abundant; above, it is usually sharply -limited by a transverse line across the top of the mons Veneris, and it -extends outwards only a little beyond the labia majora, whilst below it -extends only to about the middle of the sides of the perineum. According -to _Bergh_, however, who made an exact study of this matter in 2,200 -women of ages for the most part between fourteen and thirty years, in -some cases the shape of the patch of hair (which is in such instances -always very thick) resembles that so common in the male, there being a -pointed process, usually rather narrow, extending upward toward the -navel. This masculine form of the pubic hair is by no means common in -women; according to _Lombroso_ it is met with more frequently in Italian -women than in those belonging to other European nations. In most women, -the thick hairy covering of the mons Veneris is sharply limited above by -the curved line that indicates the upper margin of the eminence, whereas -in men a strip of hair usually passes up from the mons pubis to the -umbilicus. Still, exceptions are met with. Thus, in 100 women, -_Schultze_ found five in whom the hairy covering extended up to the -navel. Sometimes other variations occur, for instance, the hair may -extend laterally into the groin, occasionally as far as the anterior -superior spine of the ilium, and across the upper part of the front of -the thigh, not infrequently in association with a thick growth of hair -along the sides of the perineum as far as the anus. Of women with the -hair growing in this fashion, not a few appeared to _Bergh_ to have -unusually strong sexual passion. - -In contradistinction to these cases in which the development of the -pubic hair is thick and even excessive, we meet with others in which it -is very scanty, and this not only in quite young individuals (at an age -from 15 to 18 years), with but slight development of the labia, but also -in older and fully developed women—for the most part blondes. - -The growth of the pubic hair is thickest and strongest near the median -line, whilst laterally the hairy covering is thinner and weaker. The -thickness is extremely variable. “In some women we find a flattened, -occasionally frizzled, turf-like covering; in others, a dense, elevated, -luxuriant bush of hair” (_Bergh_). The length of the pubic hair is -variable, but as a rule it is somewhat shorter in the female than in the -male. Still, cases have been known in women in which it reached to the -knees. - -The colour of the pubic hair commonly resembles that of the hair of the -head, but the pubic hair is usually the darker of the two. Blondes with -dark or black eyebrows have, according to _Bergh_, usually dark or black -pubic hair. The pubic hair turns grey late in life, later as a rule than -the hair of any other part, a fact known already to _Aristotle_; it is -rather late in life also that the pubic hair becomes thin, and in this -state it remains almost invariably up to an advanced age, even when the -scalp has become almost or quite bald. - -The pubic hair, according to the same author, is seldom straight, being -almost always curly, frizzled, or more or less rolled up into rings or -spirals, generally forming smaller or larger locks. Fairly often, we -meet with curled locks, either one pair or two, symmetrically disposed -on either side of the depression adjoining the præputium clitoridis; -these usually have an outward direction. Much more rarely we find -similar locks symmetrically attached further back on the labia. - -In the case of 1,000 adult women examined by _Eggel_ with regard to the -colour of the pubic hair, the colour of the eyes, and the colour of the -hair of the head, there were 239 with dark eyes, 333 with dark hair on -the head, and 329 with dark pubic hair; contrariwise, 761 had light -eyes, 667 light hair on the head, and 679 light pubic hair. Obviously, -then, a considerable number of women with light-coloured eyes must have -had dark pubic hair. _Roth_, in 1,000 North German women examined by -him, found the pubic hair blonde, but a rather dark blonde, in a large -majority of the cases; in red-haired women, the pubic hair was in all -cases bright red, in black-haired women the pubic hair was black in -two-thirds only of the cases, in nearly a third it was brown, in two -cases dark blonde; in Jewesses, in a large majority of instances, the -pubic hair is brown. The arrangement of the pubic hair is described by -_Roth_ as very variable. “Sometimes it is short and frizzly, sometimes a -luxuriant bushy growth; sometimes the hairs are scanty and thinly set; -sometimes they are irregularly distributed; sometimes we see only a -narrow strip of long hairs down the middle of the mons Veneris, which is -bare at the sides. In some the lateral boundaries of the pubic hair are -sharply defined, in others the hairy covering spreads beyond the usual -limits.” - -Among the ancient Greeks and Romans, it was customary for women to -remove the pubic hair, a custom even now observed by all oriental races; -for this reason in ancient art the nude female body is depicted without -pubic hair. According to _Stratz_, in the _Chansons de Bilitis_ it is -said of the priestesses of Astarte: “They never draw their hairs out, in -order that the dark triangle of the goddess shall represent on their -bodies the form of a temple.” - -The physiological purpose of the pubic hair is to prevent irritation of -the genital organs by the sweat that would otherwise run down upon them, -and to protect the skin from direct friction during the act of -copulation. - -The labia majora in women during the menacme are usually strongly -developed, their outer surface is hairy; in parous women we almost -invariably observe small or even large lacerations of the frænulum -pudendi or fourchette, in front of the posterior commissure of the -vulva. On the inner surface also of the labia majora, the general -characters of which are those of mucous membrane rather than of skin, -fine hairs are also to be found. In multiparæ, and even in women who -have frequently had sexual intercourse, these inner surfaces of the -labia majora are not usually any longer in mutual contact, so that the -rima urogenitalis or vulval cleft gapes more or less. In well-nourished -women who have led the “sheltered life,” the dense and fat-containing -connective tissue of the labia majora (continuous with and similar to -that of the mons Veneris) gives these structures a certain firmness and -elasticity, and the labia minora or nymphæ do not project beyond them. -But when the genital organs are not well preserved, projection of the -nymphæ occurs. In women whose genital organs are beautifully formed, the -nymphæ are of a soft, delicate consistency, and their mucous membrane is -of a pink color; but when the reproductive organs have been subjected to -excessive stimulation, the nymphæ are dry, hard, brown in color, and -they project from the vulval cleft. In women of the Hottentot and -Bosjesman races, the nymphæ attain, as is well known, an excessive -length, forming the so-called “Hottentot-apron;” and in certain other -indigenous races of Africa, the enormous size of these organs renders -resection necessary. - -During this sexual epoch, in women with strong sexual passion and having -frequent sexual intercourse, the clitoris is largely developed, and -sometimes the dorsum of the organ protrudes from between the anterior -extremities of the labia majora. - -The vaginal orifice gapes a little, so that the irregular carunculæ -myrtiformes are visible. In parous women, the vaginal orifice is -enlarged in such a manner that the wall of the vagina passes directly -and without limitation into the wall of the vestibule, and the external -orifice (meatus) of the urethra is situate immediately in front of the -anterior vaginal column, and thus lies within the vaginal orifice. - -The breasts of a strong, healthy woman who has attained complete sexual -maturity are more or less firm in consistency, and considerable in size, -exceeding now _Ovid’s_ demand concerning these organs, _ut sit quod -capiat nostra tegatque manus_. The normal hemispherical form and the -somewhat soft texture are subject to many variations, these being -dependent upon race, climate, and sexual activity and also upon the kind -of clothing worn. The nipple and its encircling areola are usually of a -brownish colour; but in beautiful women they sometimes retain the pink -colour characteristic of these structures in the virgin. In parous women -who have suckled their children, the breasts are usually pendent, and -often the left breast will be found to be somewhat larger than the -other; generally also in such women the nipples are longer and thicker -than normal. Not infrequently the nipples are withdrawn into a furrow of -the skin, and become prominent only on local stimulation or as a result -of sexual excitement. Sometimes in the region of the areola, especially -in brunettes, we see a circle of small glands, which produce eminences -beneath the skin. - -It is easy to understand that the breasts of such women in general no -longer have the virginal form of small hemispheres, but have matured to -a greater fulness and size. This, however, does not diminish their -beauty, for the ideal of beauty must take into account the natural -development of the body. Whereas at the present time, under the -influence of the modern negation or at any rate undervaluation of -maternity as the goal of woman’s life, it is the tendency of a certain -school of art to misprize the influence of that state on the form of the -breast, and to esteem the “flat bosom,” at an earlier day under the -influence of _Rousseau’s Emile_, a book in which mothers are strongly -urged to suckle their own children, the full bosom as a beauty was the -fashion in art. - -Only a perverted taste can find a woman beautiful without bosom—without -“that golden chalice, from which men quaff love, and children life” -(_Mantegazza_),—an angular, flat being, without a rounded form. Nothing -but a morbid desire for equality with man can induce woman herself to -endeavor to conceal also the external manifestation of her sexual -characteristics, and by her clothing to disguise, like a nun, the sexual -curves of her figure. - -Great deposit of fat, such as occurs from liberal feeding in conjunction -with a sedentary mode of life, or as a result of several pregnancies, -destroys the beautiful form of the breasts, which attain an immoderate -size, thus disturbing the grace and symmetry of the feminine figure, a -fact recognized already by the Romans. _Hyrtl_ condemns, from the point -of view of anatomical beauty, the nude female figures in the pictures of -Rubens, remarking that “the goddesses and angels of this painter are as -luxuriant in their development as a Flemish dairy-maid;” and the buxom -“goat’s-udder breast” prized by the Arabs does not represent any nobler -ideal of beauty. Sometimes these excessively large and fat breasts hang -down in a conical form, or, as more or less flattened hemispheres, reach -right down over the gastric region; moreover, the interspace between the -two breasts seems to disappear, and they touch or rub against one -another. - -According to _Ploss_ and _Bartels_, the various forms of breast -occurring in different races may be classified as follows: A. According -to size: 1, very large; 2, large; 3, medium; 4, small. B. According to -consistency and firmness: 1, high; 2, semi-pendent; 3, pendent. C. -According to shape: 1, shell-shaped (disc-shaped); 2, hemispherical; 3, -conical. The nipples also, according to these authors, exhibit -variations dependent upon race, being in some cases small and flat, like -a little knob, in some cases large and conical in shape, with a broad -base and a rounded extremity, and in some cases large and cylindrical, -having almost the shape of a finger-joint. The areola, finally, is in -some women quite pale in color, in some dark pink, in some brown and -even almost black from excess of pigment. - -The uterus of a woman who has attained complete sexual maturity, has -undergone such alterations in its proportions that the cervix and the -body are of almost the same length. The constriction, visible -externally, indicating the separation between these two segments of the -organ, is depressed somewhat toward the external os. In sexually active -women, a widening and an increased curvature of the region of the fundus -occur, the uterine extremities of the Fallopian tubes becoming more -widely separated; at the same time the posterior wall becomes more and -more convex. The more frequently the uterus has functioned as a -reproductive organ, the more strongly marked is the convexity of the -body of that organ. The relative lengths of the corporal and cervical -portions of the uterine cavity are now the reverse of those that obtain -in the uterus of the child; the transverse and antero-posterior -diameters have greatly increased. Transverse diameter at the fundus; -virgin, 4 centimetres (1.575″), multipara, 5.5–6.5 centimetres -(2.165–2.559″): sagittal (antero-posterior) diameter; virgin, 2 -centimetres (0.787″); multipara, 3–3.5 centimetres (1.181–1.378″). -(_Chrobak_ and _von Rosthorn_.) - -During the menacme, in consequence of the act of reproduction, the -uterus undergoes important changes in form. In a nulliparous married -woman, the uterus differs little from that of a virgin; the cavity is -somewhat more extensive, the convexity of the outer surface a little -greater, there is some increase in width in the neighborhood of the -fundus, the plicæ palmatæ (_arbor vitæ uterinum_) are confined to the -cervical canal; further, under the influence of copulation the -appearance of the vagina changes, it becomes larger, and its walls -become smoother, sometimes quite smooth, from the disappearance of the -rugæ of the mucous membrane and especially of those attached to the -posterior vaginal column. Much more extensive are the alterations in the -uterus of a multipara. According to _Toldt_, “the parts of the cavity -representing the cornua, which are pointed on either side as they pass -toward the Fallopian tubes, become completely included in the lower -undivided portion of the cavity, this change being effected chiefly by -means of the increasing outward curvature of the walls, so that the -cavity comes to assume an amygdaloid form; the cervical canal is also -enlarged, especially the lower part, where also the plicæ palmatæ -(_arbor vitæ uterinum_) becomes less distinct; the vaginal portion of -the cervix is shortened, the os uteri externum gapes, the lips of the -cervix are tumid, nearly equal in length, and usually beset with scarred -depressions.” In nulliparae, the vaginal portion of the cervix is, as in -a virgin, of a rather tough consistency, smooth on the surface, while -the external os is small, like a dimple, or transversely oval; the color -of the vaginal portion of the cervix is identical with that of the -vaginal mucous membrane in general. Through frequent copulation, -however, the form of the vaginal portion of the cervix is so far altered -inasmuch as it is more freely supplied with blood, and, therefore, -changes slightly, in consistency. In multiparæ, in consequence of -lacerations of the cervix, the os uteri externum changes to a wide -transverse fissure with tumid margins, justifying the old designation of -this orifice as _os tincæ_;, carp’s mouth. A large size of the external -and internal os, moderate enlargement of the cavity, rounding of the -upper angles adjacent to the uterine orifices of the Fallopian tubes, -increased convexity of the walls, and partial or complete effacement of -the plicæ palmatæ (_arbor vitæ uterinum_), are the characteristics of -the uterus of a multipara (_Chrobak_ and _von Rosthorn_). According to -_Hennig_, the vaginal portion of the cervix is longest in women who have -undergone defloration, and in nulliparae; widest in prostitutes; -narrowest in childless wives; thickest in young widows. This author -gives the following measurements of the external os, showing its -variations in accordance with age and sexual activity: - - In childhood, transversely oval 0.46–0.56 cm. (0.18–0.22″) - In the virgin, rounded 0.20–0.50 cm. (0.08–0.20″) - In prostitutes, transversely, oval 0.60–2.50 cm. (0.24–0.98″) - In sterile married women, round 0.16 cm. (0.06″) - In parous married women, transverse fissure 1.10 cm. (0.43″) - After the menopause 0.81 cm. (0.32″) - -In the fully-developed woman, the ovaries undergo changes in size, -shape, and consistency, these changes being dependent upon the -age, the sexual functional activity, and the constitutional -predispositions of the individual. The average length of the ovary -is 3–4 centimetres (1.18–1.58″); the average width, 2–3 -centimetres (0.79–1.18″); and the average thickness 1 centimetre -(0.39″). The surface of this organ gradually assumes a ragged -appearance, from the scarred depressions caused by the great -number of successive menstruations (ovulations)—sometimes the -appearance produced resembles that of a mulberry. - -In the vagina at this sexual epoch, the surface of the anterior and -posterior vaginal walls is rendered uneven and rugose by well-developed -vaginal columns (_columnæ rugarum_), which feel almost as hard as -cartilage, and project considerably above the general level of the wall; -the transverse ridges (_rugæ_) run horizontally outward from the -columns. By frequent copulation, the rugæ are partially effaced, and the -columns themselves become flatter and softer; still, except in cases in -which the genital functions are exercised to great excess, the vagina -remains tense and rugose until after several children have been born, -when it becomes soft, flaccid, and smooth. Even in women who have been -accustomed to frequent intercourse, the narrowest portion of the vagina -is still the orifice and the part of the passage lying immediately -within the orifice, which can be constricted by the levator ani muscle; -childbirth, however, brings about great and permanent distension of -these parts also. The widest and most distensible portion of the vagina -is the uppermost segment, the region of the fornices. - -A special significance must be attached to the glands of the cervix -uteri, which, according to my own observations, have the function of -providing a secretion that increases the mobility of the spermatozoa, -and this enables them more readily to find their way into the uterus. I -have endeavored, by a series of histological observations, to determine -the properties of these glands and the changes they undergo in the -different phases of sexual life. The most important results of these -researches may be stated as follows. These glands, which are lined with -columnar ciliated epithelium, are but slightly developed before puberty, -being then simple excavations; at the time of the menarche, they become -tubular; later, during the menacme, they become long, dendriform, -blind-ending glands, which during menstruation and under the influence -of sexual excitement, furnish a secretion, variable in quantity, and in -quality distinguished especially by its alkaline reaction; further, in -connection with a number of pathological disorders of the female genital -organs, these glands undergo various changes both in their anatomical -structure and in their secretory activity. At the time of the menopause -and after the climacteric age, these glands, which have hitherto -consisted of branched tubules, tend to undergo cystic degeneration, -leading to the formation of the vesicles known as _ovula Nabothi_. After -the climacteric, the existence of these cysts may be regarded as a -normal occurrence; and, sometimes arranged in grape-like clusters, they -often project so as to occupy the greater part of the lumen of the -cervical canal. - -[Illustration: - - FIG. 52.—Sagittal section through the cervix uteri of a woman 26 years - of age, dendriform branched glands. -] - -[Illustration: - - FIG. 53.—Cervix of a woman 72 years of age, with glands that have - undergone cystic degeneration. -] - -[Illustration: - - FIG. 54.—Sagittal section through the cervix uteri of a woman 65 years - of age. The glands have undergone cystic degeneration. -] - -Diseases of the uterine mucous membrane during the period of sexual -maturity often induce various pathological changes in these cervical -glands. In consequence of obstruction of their excretory ducts, they may -undergo cystic degeneration, forming follicles filled with mucus and -epithelium, or cavities containing blood, which pass through the -substance of the cervix in every direction; or they may give rise to the -formation of slowly-growing glandular polypi and other glandular new -formations—changes the general result of all of which is to interfere -with the secretory function of the glands. - - - PATHOLOGY OF THE MENACME. - -The full evolution of the sexual life brings in its train many dangers -to a woman’s life. This appears at first sight from a comparison of the -mortality of married women during the period of greatest sexual activity -with that of single women of similar age. Between the ages of 20 and 25 -years, the mortality of married women is in all races higher than that -of unmarried women; and the same is true between the ages of 25 and 30 -years, except in France, in which country from artificial causes -maternity ceases at a very early age. In Prussia, in the year 1880, of -every 10,000 married women, between the ages named, 21 died, of every -10,000 unmarried women, only 2. In Holland, Belgium, and Bavaria, this -excess in the mortality of married women continues up to the age of 40 -years; whilst in Prussia, from the age of 30 upward, the mortality of -married women and unmarried is practically the same. In many countries, -the mortality of married women at many ages exceeds even that of -unmarried men. - -This greater comparative mortality of married women is ascribed by -_Hegar_ to the satisfaction of the sexual impulse, and this authority -believes that the dangers attendant on this function would be manifested -yet more clearly if the contrast were made, not between married women -and single, but between those habituated to sexual indulgence and those -who are continent. We, however, are of opinion, that the satisfaction of -the sexual impulse is only harmful to this extent, that it exposes women -to the consequences of venereal infection, and also to the risk of -numerous puerperal and other diseases of the genital organs. This is -proved also by the statistical results of the investigations concerning -mortality during pregnancy, parturition, and the puerperium. According -to _Hegar_, adding deaths resulting from premature delivery to deaths -resulting from delivery at full term, we find the mortality of -childbirth in Germany to be about 0.6 per cent. - -Whilst _Bertillon_ and _Simpson_ believe that the lower mortality of -married women above forty years of age as compared with unmarried women -at the same period of life is dependent upon the advantage to the former -of the fulfilment of sexual functions, _Hegar_, on the contrary, gives -another explanation. He writes: “At the age of 40, the less powerful -married women have already been weeded out. At first, owing to the -selection exercised by marriage, the quality of the unmarried women was -inferior to that of the married women; the former, however, have not -been exposed to the dangers attendant on the reproductive process, and -so have passed through the time during which the body possesses the -greatest elasticity; but in the years in which a decline in the vital -powers naturally sets in, the originally inferior quality of the -unmarried women is manifested by a comparatively higher mortality. Also -we have to take into account among the unmarried, the consequences of -extra-marital sexual intercourse and of prostitution, and further the -lack of a family, of the support furnished by husband and children.” - -In addition to the far-reaching disturbances of health dependent on -sexual activity at this period of life, there are the minor domestic -troubles by which woman is depressed and by which her powers are -exhausted. The influence of these latter is admirably described by _G. -von Amyntor_: “How many millions of brave house-wives boil and scrub -away their vital energy, their rosy cheeks, their merry dimples, in the -performance of their household duties, until they become wrinkled, -worn-out, dried-up mummies. The ever-renewed question, ‘what must be -cooked for dinner to-day,’ the perpetually recurring necessity for -scouring and sweeping and dusting and washing-up—these are the continual -dropping which slowly but surely wears away soul and body. * * * On the -flaming altar on which the sauce-pan simmers, youth and simplicity, -beauty and good temper, are offered up; and who can recognize in the -old, hollow-eyed cook whose back is bent with toil and trouble, the once -blooming, energetic, chastely coquettish bride adorned with her myrtle -crown?” - -A great number of the diseases of the female genital organs occurring at -the epoch of the menacme need only a passing mention. Even coitus, in -cases in which there is great disproportion in size between the penis -and the vaginal orifice, or when the organ is very rapidly introduced or -the act is very roughly performed, may lead to injury to the vulva or -the vagina, a fact to which a very large number of recorded cases bears -witness. - -During the acme of the sexual life of woman, disturbances of the -menstrual function are also frequent. Menstruation may cease in -consequence of intercurrent diseases or constitutional anomalies; -amenorrhœa may occur during the convalescence from acute diseases, in -obese women, in those suffering from tuberculosis, diabetes, alcoholism, -or psychoses. On the other hand, severe menorrhagia or atypical -metrorrhagia may occur, the bleeding either being due to diseases of the -uterus, such as endometritis, retroflexion of the uterus, or uterine -myomata, or resulting from infectious diseases, disease of the heart or -kidney, or from general disturbance of the health by chill or -over-exertion. Or, again, dysmenorrhœa may arise, either as a symptom of -some local uterine disease or in consequence of external noxious -influences or weakness of the nervous system. - -During the life-epoch of the menacme, moreover, disturbances of the -nutrition of the uterus are of common occurrence, as, for example, -hyperplastic processes in the mucous membrane of the cervical canal and -of the cavity of the body of the uterus. Common also during the menacme -is chronic oöphoritis, which may be due to mal-regulation of marital -intercourse (especially to coitus too soon after childbirth), to -carelessness during menstruation (dancing, skating, or mountaineering), -to incomplete coitus (_congressus interruptus_), and not infrequently, -to gonococcal infection; or, finally, the oöphoritis may occur soon -after the puerperium in association with subinvolution of the uterus. - -Next we may mention inflammatory diseases of the Fallopian tubes. In the -etiology of these diseases in latter-day marriage, a dominant rôle must -be assigned to the gonococcus; but they also arise in many cases from -nutritive disturbances, infection (other than gonorrhœal), and -indiscretions during menstruation. Pelvic peritonitis owns similar -causation. - -In this phase of women’s life, the commonest new growths of the uterus, -myomata, also develop, most commonly between the ages of thirty-six and -forty-five, and they occur in strikingly larger proportion in unmarried -women; it is between the same ages also that cysto-adenomata of the -ovaries are of commonest occurrence. - -Sexual intercourse gives frequent opportunities for the introduction of -infective germs into the vagina, and for the origination of inflammatory -affections of the mucous membrane (_colpitis_), the intensity of which -depends upon the species, the quantity, and the virulence of the germs -in question, on the one hand, and upon the local and constitutional -predisposition of the infected person, upon the other. Especially grave -in its consequences is gonorrhœal infection transmitted by the male, for -this virus gives rise to a great variety of pathological processes in -the female genital organs. In the act of defloration, considerable -injuries are sometimes produced, and these readily supply a breach for -the invasion of infective organisms. The condition of passive hyperæmia -that occurs in the genital organs during pregnancy also provides a -favorable soil for their growth. - -Gonorrhœal infection of young married women is so frequent and so -serious an occurrence in the sexual life of woman, that it requires -special consideration. The cases in which the man entering upon marriage -is so unscrupulous and so brutal as to deflower his young wife and to -continue copulating with her, while suffering himself from a quite -recent and active gonorrhœa, are on the whole rare. More common is it -for the bridegroom to believe himself completely cured of his previous -claps, and he is declared cured by his physician. The disease is, -however, latent merely, the gonorrhœa has become chronic, the discharge -is so slight that it is overlooked; but by the stimulation of the -frequent acts of coition usual in the early days of marriage, the -disease is lighted up afresh, the gonococci multiply quickly and -intensely, the young wife is infected, and suffers from an acute -gonorrhœa, which may often escape observation for a considerable period. - -In a gonorrhœal marriage, one in which both husband and wife have -gonococci in their genital organs, very diverse phenomena may be -observed and very various conditions may result. On this subject _M. -Runge_ writes: “If the husband’s gonorrhœa is not cured, fresh, virulent -cocci are repeatedly transmitted to the wife, in whom, therefore, the -disease often gets worse by distinct stages. If the wife undergoes -treatment, the effect in these circumstances will naturally be nil, -since the husband is always supplying fresh infection. On the other -hand, the wife on her side returns the gonococci to her husband, and in -this way his gonorrhœa may undergo aggravation. If the husband is -compelled, by illness, for instance, or by absence, to abstain for a -long period from intercourse with his wife, the latter’s gonorrhœa may, -in favorable circumstances, undergo alleviation and cure. It may happen, -however, that in the husband, in consequence of sexual rest, the -gonorrhœa becomes latent, and even entirely disappears, whilst the wife -still suffers from infection. If now, after long abstinence, the husband -has renewed intercourse with his wife, he may be reinfected, and suffer -from an acute attack of gonorrhœa, though this is due to the descendants -of the very gonococci that he himself sometime before conveyed to the -genital organs of his wife—he reinfects himself, as people say. Such -cases have given rise to suspicions of unchastity on the part of the -wife, when the husband is in actual fact enjoying his own work in a new -edition. A further possibility is that both husband and wife have become -habituated to their own gonococcal interchange; that is to say, the -organisms produce no notable effect in either. But if the wife in such a -condition receives the embraces of a lover, the latter may be infected -with an acute gonorrhœa—a fact that has long been known.” - -The principal rôle in the etiology of the diseases of the female genital -organs must be assigned to pregnancy and childbirth. Anæmic women -readily suffer during pregnancy from a further decrease in the -corpuscular richness of the blood; those affected with valvular -incompetence find their troubles much aggravated by pregnancy; where the -kidneys are in an irritable condition, pregnancy not infrequently -results in the onset of nephritis, those with disordered digestion often -suffer from increased disturbance of the functions of the stomach and -the intestinal tract; those with gall-stones are apt to suffer from -exceptionally severe attacks of biliary colic, and acute yellow atrophy -of the liver is especially apt to occur during pregnancy. In women in -whom dilatations of the veins already exist, very great increase of the -enlargement is apt to occur during pregnancy; and in the same -circumstances, trifling telangiectases increase to extensive angiomata. -Enlargements of the thyroid body undergo rapid increase during -pregnancy, so that they may attain threatening proportions. In women in -whom the abdominal walls are flaccid, the viscera may protrude during -pregnancy through the enlarged lacunæ, giving rise to herniæ. The great -relaxation of the peritoneal and other ligamentous attachments of the -great abdominal glands, occurring during pregnancy and the puerperium -results in displacements of these organs; hepatoptosis (migrating or -movable liver), lienoptosis (splenoptosis or wandering spleen), -nephroptosis (ren mobile, floating or movable kidney), and other -varieties of enteroptosis (splanchnoptosis, visceroptosis, or Glénard’s -disease). During pregnancy, previously sound teeth are apt to become -carious, and already existing caries rapidly advances. New growths of -various kinds originate at this period, those previously present exhibit -rapid increase; and relapse after operations for the extirpation of -malignant tumors is especially apt to occur. Even the bones are -unfavorably influenced. A weakened nervous system is subject to a storm -of changing nervous troubles, in some cases so severe as to lead to the -outbreak of actual psychoses; while mental disorder already present -tends, as a rule, to be seriously aggravated during pregnancy. In the -eyes, serious disorders may occur, such as retinitis, and atrophy of the -choroid with complete amaurosis. As regards the hearing, tinnitus aurium -is not uncommon, and sometimes complete deafness occurs. Numerous -diseases of the skin are apt to occur during pregnancy; in addition to -the well-known pigmentation of the face, the areola mammæ, and other -parts, we may have herpes, eczema, or pruritus. - -The serious aggravation which pregnancy is liable to induce in many -disorders previously existent, is well known, and this exacerbation -provides in some cases an indication for the induction of artificial -abortion. This necessity may arise in severe cases of renal, cardiac, -pulmonary, or hepatic disease, in progressive anæmia, severe -osteomalacia, hæmophilia, and many other acute and chronic pathological -states, since, in exceptional cases, as pregnancy advances, the symptoms -of any one of these diseases may become so threatening, that the -patient’s life is either in immediate danger or is almost certain to be -in danger within a very short space of time—this may occur, for -instance, in diabetes, struma (goitre), or certain nervous diseases, -such as chorea, polyneuritis (multiple neuritis), or mental disorders. -Undoubtedly, in this connection, as _W. A. Freund_ insists, it is not -the actual nature of the disease that is of decisive importance, but -rather its intensity, and its influence on the health of the pregnant -women; these circumstances, considered in relation to the resisting -powers of the patient, must be determinative in the adoption of measures -for terminating the pregnancy. An indication for the induction of -artificial abortion is generally furnished also by uncontrollable -vomiting dependent on pregnancy and endangering the life of the patient; -irreducible incarceration of a retroflexed gravid uterus in the pouch of -Douglas, or of a gravid uterus in a hernia, or irreducible prolapse of a -gravid uterus will also necessitate abortion. - -_W. A. Freund_ gives an example of a common pathological state, usually -quite free from danger, but now and again, when associated with -pregnancy, seriously endangering life and rendering the induction of -artificial abortion absolutely necessary—this is acute _struma -vasculosa_—(vascular enlargement of the thyroid body), which may during -the first three months of pregnancy exhibit such rapid growth as to lead -to severe orthopnœa and cyanosis and so to imperil the patient’s life. - -In cases in which laryngeal tuberculosis exists as a complication of -pulmonary tuberculosis, the former disease sometimes progresses so -rapidly in the course of pregnancy that sudden death from œdema of the -glottis is by no means rare. _Freund_, therefore, sees in this -complication an absolute indication for the artificial termination of -the pregnancy. - -In cases of previously well-compensated valvular lesions of the heart, -disturbances of compensation not infrequently occur as a result of -pregnancy; whilst in cases in which cyanosis, dyspnœa, albuminuria, and -dropsy existed even before pregnancy, the latter condition is likely to -result in an aggravation of these symptoms to a degree that imperils -life. - -Parturition, to an even greater extent than pregnancy, may induce -serious injuries to the female organism. Thus, during parturition, -lacerations of the vagina are frequent, with consequent scar-formation -and stenosis; lacerations of the perineum are also common, causing great -inconvenience, and when complete, leading to incontinence of fæces with -all its unpleasant consequences. Great is the danger arising from septic -puerperal inflammations, such as pelvic peritonitis (perimetritis); -serious are the results of puerperal vesico-vaginal and recto-vaginal -fistulæ. - -A large part in the local pathology of the female genital organs is -played by the various displacements of the uterus, either arising in -consequence of inflammatory processes in their ligaments, or dependent -upon relaxation of these ligaments from subinvolution of the internal -generative organs, either following delivery at full term or following -abortion. - -The injury which women alike of the well-to-do and of the laboring -classes suffer in consequence of numerous and frequently repeated -pregnancies, is minutely described by _Hegar_. “We can,” he writes, -“calculate the danger to life to which such an unfortunate woman is -exposed by the act of reproduction. If we assume the ordinary mortality -of women in childbed to be 6 per mille, then, in a woman who within 15 -years has been delivered 16 times (whether prematurely or at full term), -the danger will be 16 times as great as that of a single delivery, and -the mortality will be 6 × 16 = 96 per mille; that is to say, of 1,000 -women who have all been pregnant that number of times, 96 will -die—nearly 1 in 10. Moreover, in this calculation the increased danger -consequent upon the unusually rapid sequence of the deliveries has not -been taken into consideration. And, again, only the immediate results of -the deliveries have been taken into the account. Not infrequently women -succumb at a later date to illnesses acquired in childbed; whilst -others, in consequence of repeated pregnancies, have their powers of -resistance so greatly diminished, that they are unequal to the contest -with incidental diseases. In any case, a woman who has experienced -numerous and rapidly successive pregnancies, has sustained damages which -will endure for the rest of her life. Her tissues have lost their -elasticity, the abdominal walls are flaccid, the abdomen is prominent, -the abdominal viscera are displaced, the vessels dilated, the -reproductive organs in a state of subinvolution, and are the seat of -structural alterations. The greatest dangers arise in cases in which the -pregnancies are consequences that have to be paid for illicit love, -since in such cases syphilitic and gonorrhœal infection are -exceptionally common. These complications, indeed, are not excluded in -the case of married women, since marital infidelities occur, and, again, -a premarital but not completely cured venereal illness may bear fruit in -marriage, the latter occurrence being almost always attributable to the -husband. Syphilitic or gonorrhœal infection may also arise in some other -way than by copulation, and to this women are more exposed than men, -owing to the greater size of the genital passage in the former.” - -Very numerous are the disorders of the nervous system referable to the -sexual functional activity of woman during this epoch of her sexual -life. - -_Freund_, in his description of a neurasthenic symptom-complex to which -he gives the name of _angst-neurosis_,[36] maintains that the cause of -these attacks of anxiety[36] is very frequently to be found in a number -of injurious influences in the sphere of the sexual life. In women, -these anxiety-neuroses occur: - -_a_) As virginal anxiety, or anxiety of adolescents. _Freund_ has -observed a number of unequivocal instances showing that a first -encounter with the sexual problem, a rather sudden unveiling of what has -hitherto been concealed, as, for instance, the sight of some sexual act, -or something read or heard in conversation, may, in a girl at the time -of puberty, give rise to an anxiety-neurosis, which is in a very typical -manner combined with hysteria. - -_b_) As anxiety of the newly married. Young wives who have been without -sexual feeling in their first experience of intercourse are not -infrequently attacked by an anxiety-neurosis, which, however, disappears -as soon as the sexual feeling becomes normal. Since, indeed, the -majority of young women who lack sexual feeling in their first -experience of sexual intercourse remain nevertheless quite healthy, it -is evident that some other cause must coöperate in arousing the -anxiety-neurosis. - -_c_) As anxiety in married women whose husbands suffer from _ejaculatio -praecox_ or from great diminution of sexual potency, or - -_d_) Whose husbands practice _coitus interruptus_ or _coitus -reservatus_. Cases in these two classes are closely associated, since it -is easy to ascertain, from the analysis of a sufficiently large number -of cases, that the really important question is, whether during coitus -the wife obtains or fails to obtain sexual satisfaction. In the latter -event, the condition requisite to arouse the anxiety-neurosis is -supplied. - -_e_) As anxiety in widows and in voluntary abstinents, not infrequently -in typical combination with impulsive ideas. - -_f_) As anxiety in the climacteric period, during the final flare-up of -sexual passion. - -Numerous anomalies of the genital organs which gave rise in the virgin -to no trouble whatever display their influence during the menacme by -unfavorably affecting the nervous system. Thus, in cases of -malformations of the external organs of generation, slight atresia of -the vagina, a rudimentary condition of the vagina, a rigid hymen, or -local changes in the vagina, it is only when sexual intercourse begins -that neuroses or hysteroneurasthenic troubles ensue. So also at times -nervous diseases which, though the disposition to them was present, were -latent in the girl, such as epilepsy and various mental disorders, first -become apparent in consequence of sexual intercourse. - -The mechanical irritation of the nerves of the pelvis that occurs in -sexual intercourse may, even in women whose reproductive organs are -healthy, arouse sensations of weight, pressure, and bearing-down, -various painful sensations in the sacral region, over the coccyx, in the -buttocks, or in the upper part of the thighs, and also “lumbar -enlargement symptoms,”[37] viz., weakness of the lower extremities, -abnormal sensations of fatigue in the lower extremities and the back, -sometimes also disorders of micturition and defæcation. - -Throughout the manifold diseases of women in or connected with the -reproductive system during the age of sexual maturity, associated mental -processes take place, which powerfully affect the nervous system. Such -processes are, melancholy and anxious thoughts concerning the possible -influence of the illness on the happiness of married life, concerning -childlessness, or concerning loss of a husband’s sexual esteem, or -again, fear that the affection will become cancerous, fear of some -necessary operative procedure, or vexation in consequence of the -limitation of her usefulness as housewife, wife, and mother. Thus in -women suffering from sexual affections, a state of general neurasthenia, -or some neurasthenic functional disturbance of other organs, very -commonly arises. - -The knowledge that she is suffering from an affection of the genital -organs, makes a deep and lasting impression on the mind of a woman who -takes a serious view of her duties as a wife, and whose thoughts and -feelings are concentrated in the sexual sphere. The result is, that -minor troubles are regarded through the magnifying lens of anxiety, and -the general sensibility is increased. This hyperæsthesia is not confined -to the affected region, but manifests itself in various other parts of -the body by numerous phenomena of a reflex character. In the first place -must be mentioned severe headaches, sacrache, sensations of pressure in -the abdomen, cardiac troubles, palpitation, stomach-ache, nausea and -retching and disorders of appetite and digestion. Capacity for work and -the enjoyment of life are destroyed by these disorders. - -We have further to take into account the numerous conditions liable to -disturb the mind at this period of life. In childless women, we have the -subject of their sterility, the continued yearning to be blessed with -children, the eager search for a remedy, and not rarely in these cases -the conflict between the reproductive impulse and the ethical principle -of conjugal fidelity. In fruitful mothers, on the other hand, we have -the anxiety lest, by too frequent child-bearing their beauty should be -impaired and the livelihood of the family endangered; these -considerations leading in many cases to the practice of _coitus -reservatus_, with its deleterious physical and moral consequences. In -the middle and working classes, we have the strain of the endeavor to be -a helpful companion to the husband and at the same time to assist in the -support and the education of the children. Last but not least, we have -the potent influence of local therapeutic measures, and the fear of -operative procedures, both of which have a most agitating effect on a -woman’s mind. In truth, the menacme is a period full of stormy -excitations and powerful revolutions. - -In addition to its influence on the genital organs themselves, the -sexual life of woman during the period of the menacme manifests its -powers for evil especially in relation to the digestive functions, and -to the functions of the heart and the nervous system. - -When we compare the various consequences which may be induced in the -principal organic systems as a result of functional disturbances and -organic diseases of the female genital organs, we find that in respect -of the frequency of their occurrence the diseases of the nervous system -occupy the first rank; next in frequency come the disorders of the -digestive organs that arise in sympathetic association with diseases of -the female reproductive organs; whilst the third rank in respect of -frequency and importance is occupied by the cardiac disorders that arise -in connection with changes in the female organs of generation, and take -the form either of disturbances of the heart’s functions or structural -changes in the heart’s muscle. - - - _Dyspepsia Uterina._ - -Although it has long been a familiar observation that pregnant women and -women suffering from diseases of the reproductive organs suffered from -various dyspeptic troubles, I was myself the first (in the _Berliner -Klinische Wochenschrift_, 1883) to bring together, and to describe under -the name of _dyspepsia uterina_, a peculiar group of dyspeptic -conditions which are dependent upon diseases of the female reproductive -organs. I dismissed from consideration organic diseases of the stomach -and intestine dependent upon anatomical changes in these organs, even -though these also might owe a similar etiology, and described only the -more frequent dyspepsias occurring without organic change in the -digestive apparatus, the origin of which is to be explained by the fact -that certain structural changes and displacements of the uterus (to be -discussed later) arouse centripetal impulses, and that these exercise a -reflex influence on digestive activity. - -This influence, according to my observations, affects the secretory and -muscular apparatus and also the nervous elements of the digestive tract, -and I regard the following conditions as characteristic of uterine -dyspepsia, though they do not necessarily all occur simultaneously: -changes in the gastric secretion, excitement of the vomiting centre, an -inhibitory influence on intestinal peristalsis, and hyperæsthesia of the -stomach. - -The symptoms of uterine dyspepsia may vary greatly in intensity, but not -infrequently become so severe as to disturb very seriously the general -health of the woman so affected. They may be enumerated as follows: The -appetite in uterine dyspepsia is variable, but is generally good; the -tongue is not usually coated to any great extent, nor does the mucous -membrane of the mouth commonly exhibit any notable change; pain in the -epigastrium is common after meals, with acid eructations and heartburn -(pyrosis);[38] sometimes there is violent vomiting, occurring after -every meal, or in the morning on an empty stomach; in addition, -constipation is an almost constant symptom, associated with excessive -development of gases in the intestinal canal. The pain is usually dull -in character, and somewhat relieved by pressure, but it may be severe -and lancinating, and may shoot along the intercostal spaces. The -accumulation of flatus within the abdomen gives rise to various painful -sensations, distension, a sense of fulness; and its expulsion is -attended with notable relief. - -As regards the composition of the gastric secretion, an increase of -acidity is sometimes noticed. Gastric digestion is retarded; -experimental evacuation of the stomach, after a simple test meal -(beefsteak and roll) showed that small quantities of undigested remnants -were to be found in the stomach as long as seven or eight hours -afterwards. The frequent eructations evacuate flatus, or else a watery -fluid with an acid reaction (_pyrosis_ or _water-brash_—see note 38). By -the act of vomiting, larger or smaller masses of the food that has been -taken are evacuated; in the vomit, sarcinæ in large numbers may -frequently be detected by the microscope. Constipation is present in -nearly all cases of uterine dyspepsia; and even in cases in which -attacks of diarrhœa occur from time to time, careful examination will -show that these are generally transient, being sequelæ of constipation -due to the irritation caused by the accumulated masses. In one case of -long-standing uterine dyspepsia, I observed, in the absence of any -gastric dilatation, the well-known phenomenon of “peristaltic -restlessness of the stomach” (_tormina ventriculi nervosa_), in which -the peristaltic activity of the stomach is greatly exalted, and becomes -visible to the naked eye in the form of large and powerful undulations -in the gastric region, moving from left to right. - -With these symptoms affecting the digestive organs are associated -variable nervous manifestations in different organs, such as neuralgia -of various nerves, palpitation of the heart, vertigo, headache, and -nervous asthma. The general nutrition of the body often suffers -considerably in cases of long-enduring uterine dyspepsia; excessive -emaciation and general marasmus may ensue; we see also mental -depression, melancholia, an irritable disposition, and disinclination -for every kind of work. - -Very important, but very difficult, is the differential diagnosis -between uterine dyspepsia, on the one hand, and, on the other, chronic -gastric catarrh, chronic ulcer of the stomach, nervous dyspepsia, and -sometimes even carcinoma of the stomach. - -As regards the distinction from chronic gastric catarrh, in this latter -disease loss of appetite and changes in the oral mucous membrane are -prominent symptoms; the vomit also usually contains much mucus. More -difficult is the differential diagnosis of chronic ulcer of the stomach, -in cases in which anæmic subjects complain of anomalies of menstruation, -associated with dyspeptic troubles and cardialgia. In severe cases of -uterine dyspepsia, the distinction from carcinoma of the stomach may be -very difficult—at any rate in cases in which no examination of the -genital organs has been made. Obstinate dyspeptic troubles, resisting -all curative measures (unless indeed these are directed to the relief of -the local disorder of the reproductive organs), progressive anæmia, -great emaciation, and pains localized in the stomach, are all conditions -common to both of these maladies. The absence of a tumor of the stomach, -careful examination of the vomit, and examination of the genital organs, -will lead to a correct diagnosis if the case is one of uterine -dyspepsia. A superficial investigation is exceedingly likely to result -in a case of uterine dyspepsia being regarded as one of nervous -dyspepsia (_von Leube_); none the less, even though a very close -resemblance exists between the symptoms of the two diseases, to -differentiate them is a matter of importance. In nervous dyspepsia, the -act of digestion influences the nervous system in such a manner that, -even when the chemical processes are normal, the organism as a whole is -sympathetically affected by a reflex from the stimulation of the nerves -of the stomach, and in return reacts on the mechanical process of -digestion in a more or less violent manner. In uterine dyspepsia, -however, the relationship that obtains is exactly the reverse of this, -inasmuch as the gastric activity is influenced by the nervous system, by -reflex impulses originating in the morbid processes in the reproductive -organs; moreover, in this form of dyspepsia, in direct contrast with -nervous dyspepsia, the chemistry of digestion is often disordered, and, -in addition, the process is not completed within the normal period. - -Oftentimes, the diagnosis of uterine dyspepsia can be made with -certainty only _ex juvantibus_.[39] For this disorder cannot be cured -unless the disease of the reproductive organs on which it depends is -first relieved; and, conversely, local measures for the relief of -uterine disease, will often at once remove all the dyspeptic troubles -from which the patient suffers. - -My own experience has led me to conclude that it is certain distinct -local mechanical stimuli affecting the female genital organs which, -acting for a long period on the sensory nerves of the uterus or its -annexa, induce by reflex action the before-mentioned digestive -disturbances. Diseases of the vulva and the vagina, catarrhal -inflammation, colpitis and leucorrhœa, and prolapse of the vagina, do -not by themselves lead to the occurrence of uterine dyspepsia; nor do -inflammations of the uterine mucous membrane, such as endometritis -(unless associated with parenchymatous changes of the whole uterus), -chronic catarrh of the mucous membrane, erosion and ulceration of the -cervix to an inconsiderable extent, or moderate perimetritic and -parametritic exudations. On the other hand, uterine dyspepsia frequently -ensues in cases of uterine displacements, flexions, or versions, or in -cases of structural changes of the uterus accompanied by enlargement of -the organ, chronic metritis, myomata, especially when intramural -(interstitial), displacement of the Fallopian tubes and the ovaries, -chronic oöphoritis, extensive inflammatory exudations, resulting from -pelvic peritonitis, and leading to dislocation, “compression” or -distortion of the uterus and its annexa, deep follicular or -carcinomatous ulceration of the cervix, or, finally, ovarian tumors. As -the commonest condition giving rise to dyspeptic disturbances of the -kind under consideration, retroflexion of an enlarged uterus must be -mentioned. - -Under the head of uterine dyspepsia, we may also classify dyspeptic -disturbances occurring at the time of puberty or of the menopause, and -in association with certain amenorrhoeic and dysmenorrhœic conditions, -and, in addition, the vomiting of pregnant women. - -The vomiting of pregnant women, which must be regarded as a reflex -disturbance of the stomach, occurs, with especial severity in first -pregnancies, in the early months of pregnancy, with such regularity that -it is regarded as one of the most typical signs of pregnancy. Thus, in -177 pregnant women, _Horwitz_ observed vomiting in 147 (83 of whom were -primiparæ, and 64 multiparæ), and in 29 only was this symptom wanting. -In this series of cases, it most commonly made its appearance between -the tenth and eleventh week of the pregnancy. The vomiting of pregnant -women occurs most commonly early in the morning, immediately after -rising (morning sickness), but also at other times of the day; it -usually takes place easily, without any great distress, and after it is -over the patient feels quite comfortable. It rarely continues later than -the fourth month of pregnancy. - -Very serious in its effect on the general state of nutrition is the -uncontrollable vomiting that sometimes occurs in pregnant women -(_hyperemesis gravidarum_), lasting throughout the whole term of -pregnancy. It must be regarded as an exaggeration of the physiological -vomiting of pregnant women, in patients whose nervous equilibrium is -profoundly disturbed; but equally with the ordinary “morning sickness” -is it dependent on the reflex stimulation of the nerves of the stomach -exercised by the growing uterus. One source of such stimulation may be -found in the stretching of the peritoneal investment of the uterus which -results from the enlargement of that organ; another, in certain -displacements of the uterus; but in addition to these local anomalies, -we must assume the existence of a peculiar predisposition on the part of -the nervous system, in virtue of which reflex irritability is increased, -while the power of reflex inhibition is diminished. - -The prognosis and treatment of uterine dyspepsia depend chiefly upon the -nature of the diseases of the female genital organs that have given rise -to the disturbances of digestion, and this pathological relationship -demands above all a careful investigation. The following instance from -my own case-book may be regarded as typical of cases of this class. Mrs. -N., aged 25, married 6 years, barren, complains of severe dyspeptic -trouble. Appetite fairly good, but after every meal severe gastralgia -occurred, with heartburn and acid eructations, and very often the food -was rejected; there was also obstinate constipation, and great distress -from the accumulation of flatus in the intestinal canal. No blood was -ever seen in the vomit. The patient was much emaciated, and was greatly -depressed in spirits. Neither in the lungs nor in the digestive organs -had any of the physicians under whose care the lady had been for the -last four years found any abnormal change to account for the stormy -manifestations. Now, at length, the gynecological examination, which had -hitherto been neglected, was undertaken. The uterus was found to be -strongly retroflexed and enlarged. Rectification of the position of this -organ was immediately followed by the disappearance of all the stomach -troubles; the vomiting ceased, some months later the woman became -pregnant, and pregnancy and parturition were quite normal; since then -there has been no return of the dyspepsia. - -Since the appearance of my work on dyspepsia uterina, numerous -observations have in recent years been published, proving even more -clearly the causal dependence of disturbances of the gastric function -upon diseases of the female genital apparatus. - -_Lamy_, for example, has made an elaborate study of one of the -above-mentioned symptoms of uterine dyspepsia, namely, excitement of the -vomiting centre. His conclusions are as follows: Among the general -symptoms of diseases of the uterus, dyspepsia, in all its forms and in -all degrees of intensity, occupies the first rank in respect of -frequency of occurrence. Among the accompaniments of these reflex -processes, uterine vomiting must be mentioned. It seldom occurs as the -sole symptom of disorder of the digestive organs; but when it does occur -alone, it is of great importance that the cause of the affection should -not be misunderstood. Diseases of the uterus and periuterine affections -are the conditions that most commonly give rise to this trouble, but in -a certain number of cases it is due to physiological changes in the -female genital organs. Such changes are those associated with the -functional activity of the reproductive apparatus at the time of -puberty, during menstruation, in connection with coitus, during -pregnancy, and at the change of life, the menopause. The vomiting of -pregnant women is of the same nature, and confirms our belief in the -uterine origin and pathogenesis of vomiting at other times than during -pregnancy. The diagnosis of the true cause of uterine vomiting cannot be -made from the nature of the latter, but only from a knowledge of the -conditions in which it occurs, just as with other uterine reflexes, such -as neuralgia or cough. The vomit may consist merely of the food last -taken, or it may contain bile, without the presence of this latter -constituent indicating the existence of any disease of the liver. The -treatment of this disorder, which indeed does not threaten life, but -does seriously impair the general state of nutrition, must be local, -directed against the disease of the genital organs: Thus, in one case of -this nature, a cure was effected by oöphorectomy. - -The majority of the women in whom _Lamy_ observed this symptom of -uterine dyspepsia were chloro-anæmic individuals with an irritable -nervous system, town-dwellers, young girls in whom frequent evening -parties and dances, ill-chosen diet, and a generally unsuitable mode of -life, had led to the development of a “virginal metritis.” The signs of -the disturbance of the gastric functions were in the first place a -retardation of gastric digestion while the appetite remained good. -Moreover, the stomach was often distended with flatus, and this caused -frequent gaseous eructations; there was also epigastric pain, which made -it difficult for the patient to bear the pressure of the clothing, and -sometimes great pain was aroused by the slightest contact. The attacks -of vomiting, which occurred in a characteristic manner with periodical -intervals of freedom, were usually preceded for a longer or shorter -period by dyspeptic symptoms. The vomiting itself, if it occurred -immediately after a meal, was not accompanied by nausea, a feeling of -faintness, or cold sweats, but rather resembled a kind of painless -regurgitation; but when the vomiting did not occur till some hours after -food had been taken, it was painful, and the vomit was then green-tinted -owing to the admixture of bile. - -The gastric troubles that occur during menstruation are regarded by _P. -Müller_ as a further indication of the intimate connection between the -genital organs and the digestive tract. In women who suffer from -hysterical manifestations, gastric disturbances, cardialgia, and nervous -dyspepsia, are very frequently associated with menstruation. These -gastric symptoms generally make their appearance a few days before -menstruation is due, and disappear as soon as the flow is established. -In other forms, again, the digestive troubles set in with the appearance -of the flow, to disappear during the later course of menstruation; and -in yet other cases the gastric disturbance begins even later, and ceases -only when the flow comes to an end. These symptoms may occur in women in -whom the genital organs are perfectly healthy and in whom menstruation -runs a regular course. More severe symptoms may, however, appear if -menstruation is disturbed for any reason, or if it is suppressed. Not -rarely such women, when they become pregnant, suffer, especially during -the early months, from dyspeptic symptoms; but similar dyspepsia may -occur in pregnant women who have previously been quite healthy. - -To the same category belong the cases formerly described by _von Leyden_ -under the designation of neuralgia and hyperæsthesia of the stomach, -which he observed in young girls as a sequel of menstrual disturbances, -and more particularly of _suppressio mensium_. In these circumstances, -the sensibility of the stomach may become so extreme that every time -food is taken the patient suffers from such severe pains, or from so -distressing a sense of anxiety and oppression, that she comes to eat -less and less, and an extreme degree of emaciation and marasmus results. -In one such case, congenital atrophy of the uterus was discovered on -gynecological examination. - -According to _R. Arndt_, it is especially in chloro-neurotic individuals -that the stimuli proceeding from morbid conditions of the reproductive -organs frequently induce, by reflex action, all kinds of disturbances of -the alimentary tract, such as constipation and flatulence, gastric -uneasiness and loss of appetite, weakness of digestion, cardialgia, and -stricture of the œsophagus. Even simple menstruation suffices to give -numerous proofs of this fact, but still more do such consequences arise -from serious diseases of the reproductive organs, such as changes in -form, displacements, and inflammatory states, and also, on the other -hand, more or less pronounced hypoplasia. - -_G. Braun_ has published three cases illustrating the connection between -neurosis of the stomach and uterine disorders. In the first of these -cases, severe digestive disturbances occurred after every meal, with -occasionally violent vomiting, in a woman, aged twenty-five years. No -changes were found in the stomach or other digestive organs, and the -symptoms obstinately resisted all direct treatment. Gynecological -examination showed extreme mobility of the uterus, and for the relief of -this a suitable pessary was introduced. The vomiting thereupon -immediately ceased, all the other digestive troubles passed completely -away, and the general state of nutrition, which had before been so much -impaired as to necessitate the use of nutrient enemata of meat-solution, -now became normal. The second case was that of a woman aged thirty, who, -since her last confinement two years before, had continually suffered -from disagreeable gastric sensations and from vomiting, which latter had -proved quite uncontrollable. Gynecological examination disclosed -extensive laceration of the cervix with ectropium of the mucous -membrane. An operation was performed for the relief of this condition, -and the vomiting of two years standing was also thereby cured. In the -third case, that of a woman twenty-eight years old, vomiting began three -months after her confinement, and recurred whenever the patient left the -recumbent posture, in which latter she felt quite well. On local -examination, the uterus was found to be prolapsed, the vaginal portion -of the cervix moderately enlarged and just within the vaginal orifice. -Amputation of the vaginal portion of the cervix cured the vomiting and -completely restored the patient’s health. - -The frequency of gastric affections in cases of retroflexion of the -uterus is insisted on by _Panecki_. In eight instances he found neuroses -of the stomach consequent upon such retroflexion, and in all cases a -cure immediately followed rectification of the position of the uterus. -He urges that if after the reposition of the retroflexed uterus the -gastric troubles should still persist, a careful local examination of -the stomach is indispensable. - -_Eisenhart_, in a woman forty-two years of age, corrected a mobile -retroflexion of the uterus, and thereupon very severe gastric symptoms -of several months’ duration soon disappeared. _Graily-Hewitt_, in an -unmarried woman twenty-seven years of age, cured by reposition of a -retroflexed uterus a gastric disorder which had subsisted for nine -years; _Elder_ and _Henrik_ report identical results in gastric troubles -consequent on retroflexion or retroversion of the uterus. _Jaffé_, in a -virgin, aged twenty-three, who had been brought near to death by gastric -disorder with vomiting, found on local examination that there was a -profuse, thick, purulent discharge from the interior of the uterus; -curetting, and irrigation of the uterine cavity with antiseptic -solutions, gave immediate relief to the stomach trouble. Similar -experiences are recorded by _C. van Tussenbeck_ and _Mendes de Leon_ in -cases of gastric disorder consequent on _endometritis fungosa_ and -_endometritis interstitialis parenchymatosa_; and by _Gottschalk_, in -cases consequent on sarcoma of the chorionic villi. _Lewy_ and -_Butler-Smythe_ have observed the relief of pernicious vomiting by -_Emmet’s_ operation (trachelorraphy). - -As regards the relations of gastro-intestinal affections to the diseases -of the reproductive organs, _Theilhaber_, in the cases observed by -himself, distinguishes three groups. In the first group of cases, the -gynecological abnormality was a chance accessory, and was not the cause -of the gastric trouble. In the second group, he regards the -gynecological trouble as dependent upon the affection of the -gastro-intestinal tract, believing that, in consequence of atony of the -intestine and an accumulation therein of fæces and flatus, a retardation -of the circulation occurs in the region of the inferior vena cava, -resulting in venous stasis in the uterus, and so giving rise to -metrorrhagia, dysmenorrhœa, and fluor albus. In the third group of -cases, _Theilhaber_ believes that the uterine trouble is the cause of -the disturbances in the stomach and intestine. He, like myself, has -found in all these patients an inhibition of the intestinal movements; -but he found, on the other hand, that the gastric secretions were more -commonly normal, and that only in a small proportion of the cases was -the vomiting centre excited. Further, in the majority of these women, -the course of the digestive processes was quite normal; and, finally, in -his series of cases, endometritis was one of the commonest causes of -consecutive gastric disorders. His observations led him to conclude that -“in consequence of affections of the uterus a large number of different -symptom-complexes of gastric trouble occur:” the pure nervous dyspepsia -of Leube, dependent on atony of the large intestine and atony of the -stomach, hyperchlorhydria and anacidity, periodic gastralgia without -anatomical cause, etc. - - - _Cardiopathia Uterina._ - -I use the term _cardiopathia uterina_ to denote the manifold cardiac -disorders which occur in women as reflex processes excited by the -physiological functions and the pathological disorders of the genital -organs, and take the form of very various disturbances of the cardiac -function. Every phase of the sexual life of women—that in which the -reproductive organs attain complete development and menstruation first -appears (the menarche); the commencement of sexual intercourse; -pregnancy, parturition, and the puerperium; finally the retrogressive -process at the climacteric age, of which the menopause is the outward -manifestation—may give rise to the occurrence of such cardiac troubles. -In order to explain these troubles as reflex in their nature, we must on -the one hand recur to the anatomical changes in the uterus and its -annexa that take place in every one of the above-mentioned phases of the -sexual life; and on the other hand we must take into consideration the -mental processes that accompany these anatomical changes, in order to -estimate their influence upon the motor and sensory nerves of the heart -(see the sections on the _Menarche_ and the _Menopause_). - -A certain predisposition to uterine cardiopathy exists in many -individuals and in many families. This predisposition may be manifested -in this way, that in women who at the time of the menarche have suffered -from cardiac disorder, similar cardiac disorder is likely to recur at -the time of the menopause, the symptoms of the recurrent attack being in -most cases identical with those that occurred during the menarche. In -the well-to-do and cultured circles of society, uterine cardiopathy is -far more frequently encountered than among the working classes. Both -unusually early and unusually late commencement of menstruation tend to -favor the occurrence of uterine cardiopathy. The most valuable -therapeutic measures that we can employ to combat these disorders are -suitable dietetic and hygienic regulations, in association with -favorable mental influences. - -Diseases of the female reproductive organs, including simple functional -disturbances, are very frequently accompanied—far more frequently than -has hitherto been supposed—by cardiac disorders. But whereas in some -cases these cardiac disorders are directly dependent upon the disease of -the genital organs; in other cases no such etiological relationship can -be shown to exist, and the association must, therefore, be regarded as -fortuitous. - -In cases of the former kind, the dependence of the cardiac disorder upon -the disease of the genital organs is very variable in its nature. - -Reflex manifestations on the part of the nervous system may be aroused -by pathological changes in the genital organs, in a manner similar to -that discussed in other parts of this work in regard to the cardiac -troubles that are liable to occur during the menarche and the menopause; -such cardiac disorders are indeed excited especially by changes in the -ovaries, by disturbances of menstrual activity, by suppression of the -menses—as manifestations, that is to say, of the menstrual reflex. The -cardiac disorder most commonly takes the form of tachycardiac paroxysms, -recurring periodically, either in association with the menstrual flow, -or, if this is in abeyance, at the times at which it ought to appear. We -must assume in these cases that the local stimuli aroused by the -pathological changes in the uterus and the ovaries have a reflex -influence upon the cardiac nerves, by means of which the heart’s action -is increased in frequency, without inquiring more particularly whether -the reflex influence is effective by inhibiting the normal action of the -vagus, or by stimulating the sympathetic, or, perhaps, by a combination -of these factors. Much more rarely do we notice, in association with -disorders of the reproductive system, a reflex decrease in the frequency -of the heart’s action, this effect being explicable in the same manner -as the well-known experiment of _Golz_, in which, if the abdomen of a -frog be laid bare, and the intestine be struck sharply with the handle -of a scalpel, the heart will stand still in diastole with all the -phenomena of vagus inhibition. - -In another group of diseases of the genital organs, the disturbances of -cardiac activity may be brought about by pressure which, in consequence -of the morbid processes in the reproductive organs, is exercised upon -individual nerves or upon an entire nerve plexus. Tumefied and prolapsed -ovaries, an enlarged and misplaced uterus, inflammatory nodules and -hyperplasias of the intrapelvic connective tissue, contractile processes -in the parametric connective tissue,[40] tumors of the uterus whether -intramural or in the interior of that organ, ovarian tumors, prolapse of -the uterus, and intrapelvic peritoneal adhesions resulting from -inflammatory processes—these are the principal conditions liable to -occasion reflex cardiac disorder; but certain tissue changes, such as -endometritis, erosions (chronic cervical catarrh), and ulcerations of -the genital passages, with or without exposure of nerve-endings, are -also competent to produce the same effect. Here the sympathetic nervous -system constitutes the channel by means of which the stimuli affecting -the nerves of the genital organs are conveyed to the central nervous -system, and by means of which also the reflex manifestations of this -stimulation are produced, taking the form, partly of disorder of the -cardiac action, of palpitation of the heart and paroxysmal tachycardia, -and partly of pains in the cardiac region and disturbances along the -course of the great vessels. - -Further, in cases of long-continued disease of the female genital organs -associated with severe hæmorrhage and in some cases fluor albus, -nutrition in general and hæmotopoiesis may be seriously affected, and -disturbances of cardiac activity may result, as, for instance, is -frequently witnessed in chloro-anæmic states. In such cases we have -palpitation of the heart, both subjective and objective, a weak and -compressible pulse, often irregularity of the heart’s action, singularly -clear heart sounds, often, however, systolic murmurs at various -orifices, increased frequency of heart and respiration to a -disproportionate degree on slight exertion, strong pulsation of the -carotids, and slight œdema of the ankles. - -Often, however, the disturbance of cardiac activity is dependent also -upon degenerative processes in the myocardium, upon fatty degeneration -and the consequent dilatation of the cavities, this degeneration being a -consequence of the growth of a uterine tumor and especially of uterine -myomata, or resulting from some constitutional disorder which is itself -dependent upon the affection of the genital organs. In such cases the -signs of degeneration of the heart are very striking: weakening of the -cardiac impulse, notable faintness of the sounds of the heart, -occasionally reduplication of the second sound, a galloping rhythm, -while percussion shows the existence of considerable dilatation of the -left, and still more frequently of the right ventricle; in many cases -also we have angina pectoris, passive hyperæmia of the lungs, the mucous -membranes, and the extremities; and sudden death sometimes ensues. - -No less important are the mental influences exercised by diseases of the -genital organs in which operation is proposed or actually performed, -also by long-lasting diseases of the reproductive organs and by the -disturbances these diseases produce in the reproductive functions, more -especially in relation to copulation and the actual process of -reproduction. In this way cardiac neuroses of various kinds may be -induced. - -Finally, cases have come under my notice in which the cardiac trouble -was not the direct result of the disease of the genital organs, but was -a consequence of the therapeutic measures employed for the relief of the -latter; and in this connection I must regard as especially blameworthy, -in addition to intra-uterine manipulations, such as sounding and -cauterization, the modern practice of gynecological massage. - -Not all diseases, however, of the female reproductive apparatus, tend in -a similar manner and with equal frequency to give rise to consecutive -cardiac disorders. According to my own observations, the diseases of the -vulva and the vagina, catarrhal inflammation, colpitis (vaginitis), -leucorrhœa, and prolapse of the vagina (cystocele and rectocele), are -those which most rarely induce cardiopathy; unless, indeed, the diseases -just enumerated have led to the occurrence of vaginismus, for in this -latter condition cardiac trouble not uncommonly ensues. More commonly -than by vulval and vaginal diseases, cardiac troubles are induced by -inflammation of the uterine mucous membrane, as by chronic endometritis, -by erosion and “ulceration” of the cervix (chronic cervical catarrh); -they also sometimes occur in connection with perimetritic and -parametritic exudations. Most frequently of all, and most severely, -cardiac disorders are aroused by displacements of the uterus, flexions -or versions; by structural changes of the uterus accompanied by -enlargement of that organ, such as chronic metritis and the growth of -myomata (especially intramural); by prolapse, enlargement, and tumor of -the ovary; by intrapelvic exudations which when extensive give rise to -displacement or compression of the uterus or its annexa. In cases of -carcinomatous or other malignant new growths affecting the reproductive -organs, I have in comparison very rarely observed the occurrence of -reflex cardiac disorders. - -Disturbances of menstrual activity, amenorrhœa, menorrhagia, and -dysmenorrhœa, owning the most varied causes, very frequently give rise -to cardiac trouble, a point on which we have already insisted. (See page -142, _et seq._) - -Very violent forms of cardiac neurosis have been observed by me in women -suffering from chronic disorder of the reproductive organs, who have -consulted one gynecologist after another and have been subjected to many -different methods of local treatment; also in women who have for a long -time suffered from some gynecological ailment hitherto believed to be -trifling, but who have at length suddenly been informed that some severe -operative procedure has become necessary. In such cases the cardiac -trouble took a paroxysmal form, the intervals being usually -considerable, several weeks or months in duration, and the general -system was as a rule seriously involved in the attacks. These latter -began with severe cardialgia, radiating from the cardiac region outward -along the intercostal spaces, upward to the shoulder and along the left -arm, sometimes indeed extending into both arms. At the same time the -heart’s action was greatly increased in frequency, there being sometimes -more than 200 beats per minute, the pulse was soft, small, difficult to -count, the respiration greatly increased in frequency, sometimes very -shallow, with respiratory anxiety, and exceptionally severe general -excitement and sense of impending death. In some cases also I observed -spasm of various groups of muscles, dizziness (with a sense that the -objects of vision were flickering), aphasia, and mental stupor. The -paroxysms lasted for some time, two or three hours, as a rule, and -gradually passed away. Their character was that of the cardiac disorder -variously described under the names of pseudo-angina and angina pectoris -hysteria. - -Such attacks as these are followed by a sense of severe general -depression and want of energy, and by a decline in body-weight. They are -distinguished from true angina pectoris by the absence of any signs of -arteriosclerosis or of degeneration of the myocardium. They may be -regarded as cardiac disorder of duplex causation, being partly dependent -on the disease of the genital organs, which gives rise to a number of -local afferent stimuli, and partly dependent on mental influences which -have a depressant, paralyzing influence on the cardiac nerves; it is -possible also that spasmodic contraction of the walls of the coronary -arteries or of the myocardium itself is induced as a reflex effect of -the local disorder of the reproductive organs. - -With regard to uterine myoma as the exciting cause of cardiac -degeneration, very numerous observations and experiments have recently -been made, and the reality of the occurrence is no longer open to -dispute, even if its significance is subject to various interpretations, -whilst no satisfactory explanation has yet been forthcoming. - -_L. Landau_ writes concerning the disturbances induced in the -circulatory apparatus by the growth of myomata in the uterus: “The -formation of varices, the occurrence of thrombosis, and, finally, the -onset of degeneration of the myocardium, are very common. Should the -last-named process result—and it is truly alarming to observe the -frequency with which cardiac affections are associated with uterine -myomata,—then, by a vicious circle, the uterine hæmorrhages become -continually more profuse, in consequence of increasing passive hyperæmia -dependent upon diminishing power of the cardiac pump. Venous congestion -in the province of the inferior vena cava results in ascites, and -sometimes in general œdema; and even in cases in which no increase of -the uterine hæmorrhages is observed, the patient may succumb in -consequence of secondary disease of the heart. * * * In the great -majority of cases, the myoma and the uterine hæmorrhages that result -from its growth are the primary cause of the morbus cordis. Naturally in -cases which come under observation only when both uterine and cardiac -disease are already present, it is difficult to determine with certainty -the true causal connection. When, however, a number of patients -suffering from uterine myomata are observed, in whom at first the heart -was found to be healthy, and subsequently to have become affected; and -when, on the other hand, we see patients affected with myoma uteri in -whom operation is undertaken notwithstanding the existence of cardiac -disease, and in whom, after the operation has been successfully -performed, the cardiac murmurs disappear as well also as the other signs -of heart disease, when dilatation can no longer be detected, when the -pulse-frequency declines to normal, whilst a previously feeble and -compressible pulse gains in tension and power—then it is impossible to -doubt that the heart disease was secondary, and was etiologically -dependent upon the primary myoma and the uterine hæmorrhages.” - -_Lehmann_ and _P. Strassmann_ examined the material of the -Charité-Policlinik at Berlin in order to throw light on the relation -between uterine myomata and diseases of the heart, a connection already -proved to exist alike by recent pathologico-anatomical researches, by -clinical experience of the results of operations (death from shock), -and, finally, by the subjective troubles of the patients (palpitation, -venous congestion, giddiness, and syncope). Examining 71 women suffering -from myoma uteri, _Lehmann_ and _Strassmann_ found in 29 (41%) that some -abnormality existed in the cardio-vascular system, such abnormalities -being extremely variable in character, as for instance: hypertrophy or -dilatation of the heart, irregularity of the cardiac action, passive -hyperaemias, œdema, albuminuria, angina pectoris, and cardiac asthma. -The next point was to determine the mutual relations between the heart -disease and the development of the uterine myoma. Hitherto it has been -assumed that the latter is the primary disease, and such a sequence is -certainly the commoner, more especially in cases in which hæmorrhage has -been profuse, with consecutive anæmia and fatty degeneration of the -heart. In these cases, a certain time after the commencement of the -severe hæmorrhages, cardiac troubles make their appearance; such -troubles are beyond question secondary, and they disappear as soon as -the hæmorrhage has been controlled. In other patients, however, we -obtain a history of the appearance of cardiac disorder at a date prior -to that when any symptoms occurred indicating the growth of a myoma; in -these cases, therefore, the heart disease has developed independently of -the uterine disease, and has run a parallel course to the latter; -perhaps, indeed, by leading to venous congestion or to rapid changes in -blood-pressure, the heart disease may have favored the growth of the -commencing or fully developed tumor. In some of the patients, operative -measures were followed by rapid recovery from the cardiac disorder -(cases of simple anæmia); in a second group of cases, however, the heart -disease was uninfluenced by operation (cases of irreparable anæmia, and -cases of heart disease independent of the myomata); and, finally, a -considerable number of patients remained, constituting a third group, in -whom, notwithstanding the removal of the tumor by operation, the heart -disease continued to grow worse (cases of progressive heart disease -independent of the myomata, especially cases of arteriosclerosis). - -Among 120 women of ages between 17 and 48, in whom I found very various -functional disorders of or pathological changes in the genital organs, -and in whom I made a particular investigation concerning the presence or -absence of heart disease and examined the heart carefully, I was able to -detect the presence of cardiac troubles in 38 instances. Thus, heart -trouble was found to exist in 32.7 per cent. of women suffering from -disease of the reproductive organs. - -In these 38 persons suffering from cardiac disorder, I found: - - Nervous Tachycardia in 21 instances, that - is, in about 55.2 per cent. of the cases. - Hypertrophy of the Heart in 4 instances, - that is, in about 10.4 per cent. of the cases. - Pseudo-Angina Pectoris in 3 instances, - that is, in about 7.8 per cent. of the cases. - Asthenia Cordis in 7 instances, that is, - in about 18.4 per cent. of the cases. - Mitral Incompetence in 1 instance, that - is, in about 2.6 per cent. of the cases. - Fatty Heart in 2 instances, that is, in - about 5.2 per cent. of the cases. - -As regards the varieties of functional and organic disease of the -genitals met with in the 120 cases, and the number of instances -complicated with heart trouble in each variety, I found: - - Chronic Metritis in 32 patients, complicated with cardiac - disorder in 13 instances. - Chronic Oöphoritis in 10 patients, complicated with - cardiac disorder in 4 instances. - Parametric Exudations in 14 patients, complicated with - cardiac disorder in 6 instances. - Chronic Endometritis in 16 patients, complicated with - cardiac disorder in 2 instances. - Flexions and Versions of the Uterus in 26 patients, - complicated with cardiac disorder in 9 instances. - Stenosis of the Cervix in 6 patients, complicated with - cardiac disorder in 0 instances. - Tumors of the Uterus and its Annexa in 8 patients, - complicated with cardiac disorder in 4 instances. - Infantile Uterus in 3 patients, complicated with cardiac - disorder in 0 instances. - Colpitis (Vaginitis) in 5 patients, complicated with - cardiac disorder in 0 instances. - -From these figures we obtain the following percentages, showing the -frequency with which heart trouble occurred as a complication of the -respective diseases of the genital organs: - - In Chronic Metritis, cardiac disorder was - found in 40.6 per cent. of the cases. - In Chronic Oöphoritis, cardiac disorder - was found in 40 per cent. of the cases. - In Parametric Exudations, cardiac disorder - was found in 42.8 per cent. of the cases. - In Chronic Endometritis, cardiac disorder - was found in 12.5 per cent. of the cases. - In Versions and Flexions of the Uterus, - cardiac disorder was found in 34.6 per cent. of the cases. - In Tumors of the Uterus and its Annexa, - cardiac disorder was found in 50 per cent. of the cases. - -To summarize the result of my observations regarding the cardiac -disorders secondary to diseases of the female genital organs: - -1. Tachycardial paroxysms in cases of amenorrhœa were premenstrual in -rhythm, the paroxysms occurred, that is to say, some days before the due -date of the suppressed flow. - -2. In cases of dysmenorrhœa, I observed heart trouble with severe -dyspnœa and feelings of anxiety, also in some cases symptoms of cardiac -asthenia; these symptoms were perhaps dependent upon acute dilatation of -the heart. The heart trouble associated with profuse menorrhagia -exhibited similar characters. - -3. Attacks of pseudo-angina pectoris occurred in women in whom local -treatment for disease of the genital organs had been carried out for a -long time, and in cases in which operative measures were in -contemplation. - -4. Paroxysms of tachycardia and cardiac distress were observed in -connexion with displacements of the uterus, and especially in cases of -retroflexion; also in association with oöphoritis and with parametric -exudations. - -5. Cases of degeneration of the myocardium, sometimes running a rapidly -fatal course, were found to be consecutive to tumors of the uterus and -its annexa, especially to myomata of the uterus. - - - _Nervous Diseases Secondary to Diseases of the Genital Organs._ - -In earlier chapters of this work we have frequently referred to the -reflex influence exercised upon the nervous system in general, alike by -the normal functions and the pathological states of the female genital -organs. We must now briefly explain the more intimate connection between -nervous diseases and diseases of the genital organs, the causal -dependence of local nervous disturbances and of general neuroses upon -diseases of the reproductive organs. - -The origination of a local nervous disease by a primary disease of the -genital organs is dependent upon a simple mechanical process, which is -explained by _Windscheid_ in the following terms: “In this connection, -the two principal mechanical factors are pressure and traction. Pressure -may affect individual nerves or an entire nerve plexus, and may be -exercised by a tumour, an exudation or a misplaced organ (_Hegar_); -further causes of pressure are furnished by inflammatory nodules, by -connective tissue hyperplasias, and, according to _Freund_, by -contractile processes in the organs themselves and in the ligaments. -Traction on the nerves results from displacements, as from prolapse of -the uterus or the ovaries, and, according to _Hegar_, from traction on -the pedicle of small tumours. A combination of pressure and traction -occurs especially in affections of the abdominal attachments of the -uterus, also where there is scarring of the neck of the uterus and of -the vaginal fornices. Great importance, also, in relation to the -production of local nervous disorders, must be attributed to the laying -bare of nerve-terminals by catarrhal and other inflammatory processes. -Abnormal mobility of the genital organs as a partial manifestation of -enteroptosis must also be mentioned as a cause of mechanical stimulation -of the nerves. Finally, in this connection, must be considered the -paresis of the abdominal walls that follows frequent and severe -confinements.” - -The symptoms of the local nervous disorders to which these mechanical -stimuli may give rise, are very various, but may, according to _Hegar_, -be comprised under the general designation of _lumbar enlargement -symptoms_ (_Lendenmarksymptome_), inasmuch as the local stimulation of -the intrapelvic nerves, affects the nerve-centres of the lumbar -enlargement of the spinal cord. Among the symptoms, severe pains are -prominent, either continuous or intermittent, within the pelvis and in -the sacral region, accompanied by a sense of weight and pressure in the -abdomen, or by dragging pain in the region of the hips, in the gluteal -region, in the outer and back parts of the thighs, in the inner surface -of the leg, in the calf, in the dorsum of the foot, the sole of the -foot, and the heel; or by coccydynia (pain over the coccyx and the lower -extremity of the sacrum), or hyperæsthesia and anæsthesia of the -external genitals in the region of the vaginal orifice, or, finally, by -disorder of the processes of micturition and defæcation. In some of -these cases, the weakness of the lower extremities is so severe that a -paralytic condition is simulated. Actual paralysis may however occur, in -consequence of the extension of peritoneal inflammation to the -nerve-plexuses of the pelvis, leading to the occurrence of neuritis. - -The development of a general neurosis in consequence of disease of the -genital organs, either as a complication dependent upon the nervous -stimulation excited by the primary disease, or as a reflex consequence -of this disease, implies, as _Windscheid_ strongly maintains, the -existence prior to the occurrence of the disease of the genital organs -of diminished power of resistance on the part of the nervous system. -This neuropathic constitution may be the result of inheritance, and, -according to _Engelhardt_, was so in 40 per cent. of his cases of women -suffering from nervous disease secondary to the disease of the genital -organs; or it may be acquired. Given this weakness of the nervous -system, a local disturbance of the genital organs may act as the -ultimate exciting cause of the onset of the neurosis in one of two -different ways (_Windscheid_). “1. The stimulus which the nerves of the -affected genital organ (or those of some adjacent area, affected by -direct extension) have received, proceeds upward from segment to segment -of the spinal cord, and ultimately passes to the highest centres. 2. Or, -on the other hand, the local nerves are not directly involved in the -morbid process in the genital organs, but this latter acts as a source -of reflex disturbance, a disturbance which must also pass through -nervous channels. To this latter class of cases belong the instances, -comparatively so frequent, in which, for example, a trifling -retroflexion of the uterus must be regarded as the exciting cause of the -neurosis.” The commonest neurosis of those that may be excited by local -disease of the genital organs is undoubtedly hysteria, next in frequency -come chorea and epileptic seizures. - -_Schauta_ draws attention to the important fact that hereditarily -predisposed, neurasthenic individuals bear very badly repeated -gynecological examinations and long-continued local treatment, inasmuch -as, in such persons, a notable increase in the severity of the nervous -affection may result, and even the outbreak of actual mental disorder; -and he further points out that in hereditarily predisposed individuals, -psychoses not infrequently occur in consequence of the performance of -gynecological operations. - -The processes of pregnancy make a deep impression on woman’s entire -nervous system, and more especially on her mental functions. This is -especially noticeable in the case of primiparæ. The fact is easily -understood, for a woman is filled with expectation and anxiety -concerning the unknown event, the complete revolution in her -organization, the powerful impressions on her physical ego, the -formation of a new being within her womb. How many joyful hopes, how -many distressing fears, are connected with that which is about to take -place, with the act of creation within her bosom; what changeful -glimpses into the future, on the one hand the gladness, on the other the -terror, of motherhood; often, also, the anxious doubts as to the -probable sex of the newcomer. Consider, too, the stormy sensations -experienced by a woman who, unmarried, has become pregnant contrary to -her desires and expectations, especially one in a poverty-stricken -condition—consider the agonizing thoughts in such a case regarding the -consequences of giving birth to a child. It is only to be expected that -in pregnant women in general there will almost always be increased -irritability of the nervous system combined with a tendency to the rapid -variation of emotional states. _Neumann_ found, in almost all the -pregnant women he examined in respect to the point, that there was an -increase of the knee-jerks, as a manifestation of the general increase -of nervous irritability. Nor does this change depend upon mental -influences exclusively; there are other factors, such as the reflex -processes aroused by the enlargement of the uterus, and also the changes -in the composition of the blood which occur during pregnancy, and cannot -fail to have an influence on the nutrition of the brain. Finally, also, -the deposit of carbonate of lime on the inner surfaces of the cranial -bones (the parietal and frontal bones) which occurs during pregnancy, -may be regarded as having some casual connection with the changes in the -nervous system; and, again many authors assume that the cerebral -circulation is influenced by the formation of the placental circulation. - -The pathological consequences of pregnancy, as far as they affect the -nervous system, take the form of neuralgia and of peripheral neuritis of -various nerves, of chorea, of disturbances of the sense organs, and of -actual psychoses. - -Peripheral neuritis in pregnant women affects chiefly the lower -extremities, but has been observed in the arms also; it is characterized -by muscular wasting with reaction of degeneration, by trophic -disturbances, and by disorders of sensation. A cure may ensue even -during the pregnancy, but in other cases the illness persists until -after parturition and on into the puerperium. To the same cause -_Windscheid_ assigns the paræsthesias of pregnancy, burning, prickling, -and numb sensations of the finger-tips, less commonly of the toe-tips; -these sensations are continuous, not paroxysmal, and cause very great -suffering. - -Pregnancy favors the occurrence of chorea, a circumstance explicable by -the increased irritability of certain nerve centres characteristic of -the pregnant woman. The chorea of pregnancy occurs for the most part in -primiparæ, it is commoner in young than in older pregnant women, and -appears especially in the early months of pregnancy. In the majority of -cases the disease undergoes spontaneous cure before the end of the -pregnancy, but cases with a fatal termination have been observed. - -On the other hand, a curative influence in previously subsisting -hysteria has been assigned to pregnancy. This in fact only occurs in -cases in which the hysterical manifestations have been evoked by -influences which are counteracted or removed by the occurrence of -pregnancy, such, for instance, as intense longing to bear a child, -dissatisfaction with the existing circumstances of married life, etc. -Conversely, it is by no means unusual to observe that, in patients who -have previously suffered from hysteria, the attacks become more frequent -during pregnancy, and that other nervous disturbances associated with -the hysteria become more prominent; hysterical paralysis, even, may -appear. Very variable also is the influence of pregnancy in epileptics. -Most commonly, indeed, a certain quiescence sets in, the attacks -becoming less frequent and less severe; but the reverse of this is at -times observed. In the domain of the sense organs we observe amblyopia -and hemianopia, deafness, and tinnitus aurium, and disorders of taste; -all these appear as pure nervous disturbances without known anatomical -basis (_Windscheid_). - -Finally, among neuroses, tetany may be mentioned. In women, this disease -occurs almost exclusively during pregnancy and the puerperal state, in -the form of paroxysmal spasm, affecting chiefly the extremities, and -especially the hands; the spasm is bilateral, tonic in character, and -painful. The tetany of pregnancy usually runs a favourable course. - -The slighter forms of mental disorder consist of perversions of taste -and smell. Of actual psychoses occurring during pregnancy, the commonest -forms are melancholia and mania. The former condition, which, according -to _Ripping_, occurs in 84.4 per cent. of the cases, is usually very -severe, and is characterized by a peculiar dreamy condition; it often -leads to suicide, or to infanticide immediately after parturition. The -psychoses of pregnancy are seen with greater frequency in the second -half of pregnancy, they occur especially in primiparæ, and are also -commoner in unmarried women. The prognosis is on the whole an -unfavorable one; sometimes, indeed, the mental disorder terminates with -the pregnancy, but in other cases it continues during the puerperium. -Mental alienation occurring in the early months of pregnancy is apt to -be less severe and to permit of a more favorable prognosis, than that -which makes its appearance during the later months or at the end of the -pregnancy. - -In 32 cases of insanity of pregnancy recorded by _Ripping_, 8 cases -occurred in the first pregnancy, 5 in the second, 6 in the third, 3 in -the fourth, 4 in the fifth, 1 in the sixth, 1 in the seventh, 3 in the -eighth, 1 in the tenth. Of these women - - 3 became affected in the 1st month[41] of pregnancy. - 4 became affected in the 2d month of pregnancy. - 1 became affected in the 3d month of pregnancy. - 2 became affected in the 4th month of pregnancy. - 1 became affected in the 5th month of pregnancy. - 0 became affected in the 6th month of pregnancy. - 5 became affected in the 7th month of pregnancy. - 5 became affected in the 8th month of pregnancy. - 5 became affected in the 9th month of pregnancy. - 6 became affected in the 10th month of pregnancy. - -The neuralgias of pregnancy affect the most diverse nerve tracts, and -may occur either spontaneously, without any discernible local exciting -cause, or in consequence of the pressure exercised by the enlarging -uterus. To the former class of cases belong severe trigeminal neuralgia, -the familiar toothache affecting quite sound teeth at the very beginning -of pregnancy, intercostal neuralgia, and paroxysms of mastodynia. The -pressure neuralgias affect chiefly the domain of the great sciatic -nerve, manifesting themselves by the occurrence of pain down the back of -the thigh, in the calf, and on the dorsum of the foot, sometimes -associated with formication and other kinds of paræsthesia. - -Parturition, by its powerful effect on the emotional nature in -combination with intense physical suffering, may give rise to numerous -nervous disturbances. The chief of these are, neuralgia, occasioned by -the pressure of the fœtal head as it passes through the pelvis of the -mother, paræsthesias, convulsions, maniacal paroxysms, transitory mental -alienation, cerebral hæmorrhages, and eclampsia. - -The nervous disturbances dependent upon the processes of the puerperium -are numerous and severe. According to _Windscheid_, four types of -affection of the motor nerves may arise at this period. 1. -Pressure-paralysis may occur in cases of generally contracted pelvis, or -even in the absence of such contraction in cases of prolonged labor, -from the pressure exercised by the child’s head upon the intrapelvic -nerves, and above all on the great sciatic nerve; pressure-paralysis may -also result from obstetric operations, and especially from forceps -delivery. The symptoms of pressure-paralysis consist chiefly of -paralysis of the extensors of the feet and the toes; sensory symptoms -are usually wanting. 2. Inflammatory infective paralyses, due to the -extension to adjacent nerves of puerperal inflammation of the pelvic -connective tissue. 3. Acute multiple neuritis, occurring either during -the latter half of pregnancy or a few days after delivery, and affecting -not only the nerves of the lower extremities, but those of remote -regions, even the cranial nerves. 4. The rare puerperal hemiplegia due -to cerebral hæmorrhage, occurring usually at the time the patient leaves -her bed after delivery; puerperal hemiplegia may also arise from -embolism consecutive to endocarditis, which may itself have originated -before the termination of the pregnancy. - -Other puerperal diseases of the nervous system requiring mention are, on -the one hand, tetany, occurring during lactation, and permitting of a -favorable prognosis, and on the other, the infective puerperal tetanus, -the prognosis of which is exceedingly unfavorable. Finally, the -puerperal state has to be considered as a factor in determining the -onset of psychoses. - -The puerperal psychoses are for the most part dependent upon the great -loss of blood occurring during delivery, leading to anæmia and increased -irritability of the brain, in association also with the circulatory -disturbances that arise in the central nervous organs in consequence of -the sudden emptying of the abdomen by the act of childbirth; but -additional causes of mental disorders are to be found in the changes in -the composition of the blood that occur during pregnancy, and the -influence of these changes upon the nutrition of the brain. Inherited -predisposition plays its usual part in these cases; and accessory -factors in producing mental disturbance during the puerperal state are -to be found in puerperal infection, eclampsia, osteomalacia, and -emotional shock. - -Thus, for example, among 49 cases of puerperal psychoses, _Hansen_ found -that in 42 instances there was puerperal infection; and among 200 cases -of puerperal eclampsia, _Olshausen_ found 11 patients suffering from -mental disorder. The principal forms of insanity occurring at the -puerperium are mania and melancholia, next in frequency come monomania -(Ger. _Verrücktheit_), dementia (Ger. _Blödsinn_), alternating or -circular insanity (_folie circulaire_), hallucinatory paranoia (chronic -delusional insanity with hallucinations), and hysterical mental -disorder. - -According to _Windscheid_, the commonest cases are those which are -purely puerperal, the rarest those in which the insanity of pregnancy -continues during the puerperal state; the age at which puerperal -psychoses most commonly occur varies between 31 and 35 years, the -average age being 29.1; multiparæ are more often affected than -primiparæ; the outbreak of mental disorder most commonly occurs within a -week after the birth of the child; there is nothing specific about the -various forms of puerperal insanity, which are identical with the -respective varieties owning another etiology. According to this author, -before an attack of puerperal mania, prodromal symptoms usually occur, -such as headache, dizziness (Ger. _Augenflimmern_), feelings of anxiety, -insomnia, followed by various congestive symptoms, and either by great -restlessness or by great apathy, and very often by indifference to the -infant; to these symptoms succeeds the period of motor excitability, -characterized by great bodily restlessness and by continued -talkativeness; the culmination takes the form of a maniacal outburst, in -which infanticide even may occur; the delirium runs mostly in erotic and -religious channels. Puerperal melancholia also exhibits the usual -clinical picture of this form of mental disorder; after prodromal -headache, stupor sets in, often associated with attacks of anxiety and -with hallucinations of sense, and always characterized by great loss of -appetite and by a suicidal tendency. - -In relation to the puerperal psychoses, it appears that the first -menstruation after the birth of the child has, like the very first -appearance of the menstrual flow during the menarche, a tendency to -favor the onset of mental disorder. According to _Marcé_, this first -post-puerperal menstruation has a very definite significance in the -causation of psychoses. Among forty-four cases of puerperal psychoses, -there were eleven instances in which the mental disorder made its -appearance six weeks after childbirth, exactly at the moment, that is to -say, in which, had the mothers not given suck to their children, -menstruation ought to have reappeared. In those who did not nurse their -infants, and in whom menstruation recommenced at the due date, the -psychosis usually began on the first day of menstruation, less often on -the fourth or fifth day. In some instances the psychosis appeared at the -time at which menstruation might have been expected to occur, but when -the flow was still in abeyance. And in some women who suckled their -children for a time and then weaned them, the psychosis made its -appearance at the time of the first recurrence of menstruation. - -Among diseases of the sense-organs occurring during the menacme, ocular -lesions are by no means rare as sequels of pathological changes in the -genital organs. Thus, in cases of displacements of the uterus, -especially prolapse, retroflexion, and retroversion, we sometimes see -retinal hyperæsthesia and reflex amblyopia, photophobia and -lachrymation, and accommodative or muscular asthenopia. Inflammation of -the pelvic connective tissue, perimetritic and parametritic exudations, -and especially parametritis atrophicans, may give rise to functional -disorders of the eye, reflex hyperæmia of the trigeminal and optic -nerves, various painful sensations, and photophobia. Severe metrorrhagia -may also cause disturbances of vision, either by inducing local anæmia -and consequent functional failure of the nervous apparatus, or by -leading to serious infiltration of the optic nerve which manifests -itself also in the retina in the form of a transudation. In cases alike -of congenital and of acquired atrophy of the uterus, and frequently, -therefore, in sterile women, optic nerve atrophy may occur. - - - COMPETENCE FOR MARRIAGE OF WOMEN SUFFERING FROM DISEASE. - -In this section we must consider the competence for marriage of women -suffering from heart disease, of those suffering from hereditary -tendency to mental disorders and neurasthenic states, and, finally, of -those affected with tuberculosis. - -Every doctor is confronted during the practice of his profession by the -problem whether a young woman known to suffer from heart disease is -justified in entering upon marriage and in exposing herself to the -dangers entailed on her diseased heart by copulation, pregnancy, -parturition, and the puerperium. The solution of this problem is as -important as it is difficult. On the one hand, it determines the whole -future course of a human life which is still ascending the upward path -of its vital career, and a negative decision often annuls in a moment -the young woman’s ideals and hopes; on the other hand, an affirmative -decision involves the responsibility for the consequences of marriage, -often grave in these cases. - -The consequences are in fact apt to be very serious indeed. The normal -act of intercourse, in a young and sensitive woman, has already an -exciting influence on the nerve apparatus by which the movements of the -heart are controlled. The frequency of the heart’s action is greatly -increased, the cardiac impulse becomes much stronger, there is marked -pulsation of the peripheral arteries, the conjunctiva is injected, the -respiration more frequent. These manifestations, which normally are -quite transient, attain a greater intensity and exhibit a longer -duration in persons affected with heart disease. In some instances, -violent tachycardial paroxysms occur, with considerable dyspnœa, pains -in the cardiac region, headache, and even syncopal attacks. - -Pregnancy, in consequence of the extensive changes undergone not only by -the reproductive apparatus but also by the general system, and further -in consequence of the vital needs of the developing embryo, involves -extensive claims upon the cardiac activity. It is easy to understand -that the diseased heart must be taxed more severely than the healthy -heart by the extension of existing vascular areas, the addition of new -vascular areas, and the increase in the quantity of the blood, during -pregnancy; and it is not surprising if the overtaxed organ threatens -sometimes to give way under the strain. Thus, during pregnancy in women -affected with morbus cordis, we observe numerous troubles in the way of -disturbances of cardiac activity and passive congestion of various -organs, culminating at times in abortion. - -Parturition and the puerperium, moreover, bring several factors into -play which tend to affect unfavorably even a heart that is quite normal; -and in cases in which there is disease either of the heart or of the -great vessels, these factors may lead to the occurrence of most alarming -symptoms. In this connection we may refer to endocarditis, to fatty -degeneration of the myocardium, and to the rupture of atheromatous -arteries. - -From the time of _Galen_ onwards all medical writers have agreed that -the heart is unfavorably influenced by pregnancy and its -consequences—but from this incontestable proposition to deduce the -general conclusion that young women affected with heart disease must be -forbidden to marry is in my opinion too great a jump, and altogether too -sweeping a statement. The apophthegm of _Peters_, an author to whom we -are certainly indebted for some of our knowledge of the _accidents -gravido-cardiaques_, that in the case of women suffering from morbus -cordis the rule must be enforced, _fille pas de mariage_, _femme pas de -grossesse_, _mère pas d’allaitement_, has a fine air of apodictic -brevity, but is entirely devoid of justification. No such rigid -prohibition is advanced by recent writers on heart disease, such as -_Huchard_, _von Leyden_, and _Rosenbach_; not, at least, without -qualifications. - -The question as to the permissibility of marriage to girls and women -affected with heart disease cannot, in fact, be answered by any general -proposition; and each case demands separate inquiry and a careful -balancing of individual considerations. I have known cases in which the -marriage of young girls suffering from morbus cordis was equivalent to a -sentence of death, the execution of which was delayed for a few months -only. On the other hand, I have known many women belonging to the upper -classes and suffering from cardiac defects to pass through numerous -pregnancies and to give birth to a number of children with no more than -trifling disturbances of compensation. I am acquainted with a lady who -when a young girl was urgently advised against marriage, on account of -extensive aortic valvular incompetency, by two celebrated physicians. -The advice was disregarded, and this lady is now the mother of four -children, the eldest of whom is twenty-two years of age, and her general -condition is in no way worse than it was before her marriage. The -dangers of marriage in women suffering from morbus cordis are in my -opinion generally overrated. - -The degree to which a woman affected with heart disease will be injured -by married life, will depend on the nature of the cardiac affection, on -the time it has already existed, on the adequacy of compensation or the -intensity of existing disturbances of compensation, on the general state -of nutrition of the patient, on the more or less favorable social -position, and on the manner in which sexual intercourse is regulated. - -My own opinions in respect of this question may be summed up as follows: -A woman who has comparatively recently (within a few years) acquired a -valvular defect, and in whom the disease has run such a course that, in -consequence of dilatation of certain chambers of the heart and of -hypertrophy of those segments of the myocardium on which increased work -has been thrown, and thus in consequence of adaptation of the -cardio-vascular apparatus to the new conditions, the circulation and -distribution of the blood take place in a manner closely resembling that -in which these functions are effected in a normal, healthy individual—in -a word, a woman in whom the valvular disease appears to be adequately -compensated,—if, in addition, the patient is well nourished, if the -hæmatopoietic function has not undergone any notable disturbance, if the -muscular system is powerful and the nervous system possesses sufficient -power of resistance—then marriage may be permitted without hesitation. -In the case of such a girl or woman, we can confidently assume that the -adequate compensation of the valvular disease will enable the heart to -meet with success the claims made upon its reserve energies by sexual -intercourse, by pregnancy, and by parturition, and that these processes -will not involve any excessive danger to life. - -A woman with valvular heart disease, even when that disease is well -compensated, will indeed during pregnancy and still more during -parturition and the early days of the puerperium, be liable to suffer -from various manifestations of cardiac disorder. The action of her heart -will be subject to paroxysmal increase in frequency and force, sometimes -also there may be transient attacks of cardiac asthenia; at the same -time the breathing will become more frequent and deeper, and -occasionally, even, there may be severe dyspnœa. Perhaps also symptoms -of venous congestion may manifest themselves, digestive disturbances, -sense of pressure in the head, swelling of the feet, œdema of the -abdominal wall, even slight albuminuria. Just after childbirth, -moreover, an abnormally intense depression of the circulation with -infrequency of the heart’s action will be liable to ensue. In the great -majority of cases, however, in which the conditions detailed above are -fulfilled, the disturbances of compensation occasioned by pregnancy and -the puerperal state will not seriously threaten life; and as soon as the -puerperal period has been safely passed through, the heart will again be -competent for its duties and will do its work as well as before. - -These statements apply, not only to cases of well-compensated valvular -disease, especially mitral insufficiency, mitral stenosis, and aortic -insufficiency, but also to cases in which the heart has made a good -recovery after an attack of pericarditis, and to cases of moderately -extensive disease of the myocardium consequent on acute articular -rheumatism or the acute infections. - -As indispensable conditions for such a favorable prognosis, we naturally -assume that the pregnant woman is in a position to command the extreme -bodily care that in her condition is doubly needful, that she is able to -avoid all severe physical exertion, and that she will be subjected to -continuous medical supervision in respect of the adoption of suitable -dietetic and hygienic measures. - -Such a favorable prospect as regards marriage in cases of -well-compensated heart disease will, however, be clouded in the case of -women who are either very anæmic or predisposed to nervous disorders; -nor is the prognosis favorable as regards women in whom the heart -disease is either congenital, or acquired in early youth, or as regards -women contemplating marriage when already well up in years. - -For in very anæmic women, even when the heart is quite sound, frequently -recurring attacks of tachycardia often occur during pregnancy, in the -absence of any obvious exciting cause; œdema of the lower extremities, -and the formation of extensive varices, are also common. Increased -nervous reflex irritability has also an unfavorable influence upon -cardiac innervation. In cases, again, in which the heart disease is of -long standing, the functional capacity of the heart is so notably -depressed that the organ is likely to prove incompetent to meet the -increased demands made upon it by the processes of pregnancy. Finally, -in elderly women, superadded to the valvular defects, we have the -dangers dependent upon the already beginning arteriosclerotic changes in -the bloodvessels. In all such cases, therefore, it will be the duty of -the physician to advise his patient not to marry; and in any case to -impress upon her mind the extreme probability, amounting almost to -certainty, of serious aggravation of the heart disease by marriage, with -permanent impairment of the general health. - -In cases of valvular disease accompanied by serious disturbances of -compensation, and in cases of notable degeneration of the myocardium in -which pronounced symptoms of cardiac muscular insufficiency have made -their appearance, marriage must be absolutely forbidden, as directly -imperilling life. When even moderate bodily exertion suffices to cause -palpitation, increased frequency of the pulse, and shortness of breath, -when extensive œdema of the lower extremities is present and fails to -disappear even after the patient has been strictly confined to bed, when -the pulse very readily becomes irregular both in rhythm and force, -whilst the urine is often scanty and contains variable quantities of -albumin, when conditions of cardiac asthenia readily arise, -characterized by a small, irregular pulse, coldness of the extremities, -cyanotic tint, nausea, respiratory need,[42] and syncopal attacks—in all -such cases, whether the symptoms just described are dependent upon -valvular defects, upon pathological changes in the arteries, or upon -diseases of the myocardium, in all alike the occurrence of pregnancy is -a true disaster, which in the vast majority of cases causes a great and -enduring aggravation of the disease, and frequently enough costs the -patient her life. - -Even in such cases as were previously described, in which, the heart -disease not being severe, the patient was told that marriage was -permissible, it is the duty of the physician to lay down certain rigid -rules regarding sexual activity. - -Women suffering from heart disease should not have sexual intercourse -frequently, because, if the peripheral nervous stimulation of the -genital organs is excessive in consequence of too frequent acts of -coitus, cardiac activity is likely to be influenced powerfully in a -reflex manner, leading to the occurrence of attacks of cardiac asthenia. -Again, sexual intercourse must always be effected in such a manner that -the act attains its physiological conclusion, and that in the woman as -well as in the man the orgasm has its normal outcome, that is to say -that at the conclusion of the act the woman’s cervical glands are -evacuated with the accompaniment of the sense of ejaculation. The -_congressus interruptus_, which precisely in these cases in which the -wife suffers from heart disease is so frequently practiced by the -husband with a view to preventing conception, must be strictly -forbidden, since this mode of intercourse tends to give rise to various -forms of reflex cardiac disturbance, most commonly to paroxysms in which -the cardiac action becomes unduly frequent, in association with -diminution of vascular tone, vasomotor disturbances, and states of -mental depression; and where organic heart disease already exists, these -reflex functional disturbances involve various dangers. - -The physician is further justified in advising that a woman with organic -heart disease should not give birth to more than one or two children. -This advice is the more needful for the reason that with each successive -pregnancy the functional capacity of the woman’s diseased heart -diminishes according to a geometrical ratio, and to a corresponding -degree the danger to life increases. These are cases in which in my -opinion it is the physician’s duty to concern himself with the -subject—in general so equivocal—of the use of preventive measures, and, -having regard for the preservation of a woman’s life, and uninfluenced -by any false delicacy, but with moral earnestness, to inform his patient -with respect to the needful prophylactic measures. The artificial -termination of pregnancy, which unquestionably is often justified in -women suffering from heart disease, but which unfortunately is apt to -have very unfavorable results, will rarely need to be discussed if by -the proper employment of preventive measures care is taken that -pregnancy does not recur too frequently. - -To enable us to answer the question whether, in the case of neurasthenic -and hysterical young women, and in those hereditarily predisposed to the -occurrence of mental disorders, the physician shall advise for or -against marriage, attention must in the first instance be directed to -the established facts relating to the favorable or unfavorable -influence, as the case may be, of sexual intercourse and its -consequences (pregnancy and childbirth) upon existing nervous disorders -and upon the predisposition to their occurrence. - -Without regarding as fully justified the opinion that in the female sex -sexual abstinence has in all circumstances an unfavorable influence upon -the nervous system or even that such abstinence is to be regarded as the -principal cause of nervous and hysterical troubles, we must consider it -fully proved that in a number of the commonest varieties of nervous -disease occurring in neurasthenically predisposed subjects, such as -neurasthenia, hysteria and neurosis of anxiety[43], the lack of sexual -satisfaction aggravates these troubles, whilst suitably regulated sexual -intercourse has an actively beneficial effect. Not, indeed, that it is -an infallible means, but none the less the effects are often striking, -as I have frequently had occasion to observe, both in young women so -affected entering upon marriage for the first time, and also in young -widows who have remarried. Especially is this true of women in whom the -sexual impulse is exceedingly powerful, and even pathologically -increased to the extent of marked sexual hyperæsthesia; likewise also in -women whose social circumstances and manner of life induce increased -sexual appetite. Be it understood, I refer here to regular and moderate -sexual intercourse, and not to sexual excesses, which latter, by -inducing nervous exhaustion, may have a distinctly deleterious effect. -In many cases, however, we observe in women suffering from sexual -neurasthenia, that sexual intercourse, even when practiced at long -intervals, gives rise to nervous prostration with deep emotional -depression and long-lasting aggravation of the existing nervous -disorder. This statement applies with especial force to very hysterical -epileptic girls with hereditary predisposition to mental disorder. - -From the fact that among persons hereditarily predisposed to mental -disorder, the unmarried are on the average more often affected with -insanity than the married, the inference has been drawn that marriage -may be recommended to such persons as a measure likely to counteract -their hereditary tendency to insanity. The argument, however, lacks -validity, more especially as regards women; among whom, moreover, from -the age of sixteen to the age of thirty, insanity is proportionately -more prevalent among the married, though above the age of thirty it is -more prevalent among the unmarried. - -In the great majority of neurasthenic women, normal sexual intercourse, -practiced in moderation, has, according to _Löwenfeld_, no deleterious -effect; often, indeed, as a consequence of unaccustomed abstinence, an -aggravation of existing nervous troubles may be observed. But, as this -author maintains, nervous exhaustion may result in the complete -disappearance of the orgasm during sexual intercourse, or in great -difficulty in its production; this circumstance suffices for the most -part to explain the fact that in women suffering from great depression -of the nervous functions, the fulfilment of their sexual duties has -sometimes an unfavorable influence on their general condition. As -regards hysteria, it cannot be denied, that in many hysterical women -marriage results in a favorable change in the general condition; we -must, however, be careful not to overrate the significance of such -observations. As a rule all that actually takes place is a diminution in -the intensity or even a disappearance of certain morbid manifestations -previously present, without, however, an eradication of the hysterical -temperament. - -In epileptic young women, the first experience of sexual intercourse may -precipitate a fit. Cases are indeed on record in which, in hereditarily -predisposed girls, the first coitus was the exciting cause of the first -epileptic fit, the fits recurring every time sexual intercourse was -repeated. - -It is a comparatively frequent occurrence in psychopathically -predisposed girls for severe mental disturbances to make their -appearance during the honeymoon, after the first experience of sexual -intercourse; when this occurs, it is doubtless to be accounted for by -the combined influence upon the mind of all the changes in the -circumstances of life which have resulted from the marriage. In the case -of two newly married women, one of whom had well-marked hereditary -predisposition, whilst in the other there was no known family history of -mental disorder, _Löwenfeld_ observed shortly after marriage the onset -of severe melancholia, with refusal of food. The delicate, nervous -temperament of these two women, on the one hand, and, on the other, -possibly, a somewhat too eager and passionate attitude on the part of -their respective husbands, led their first experience of sexual -intercourse to result in a nervous impression of the nature of shock, -which their nervous system was too weak to resist. - -Frequently recurring pregnancy and childbirth may, according to -_Krönig_, act as the predisposing cause in the production of -neurasthenia. In regard to hysteria also we must admit that the onset of -some disease of the organs of generation frequently leads previously -latent hysteria to manifest itself openly, and further we have to -recognize that diseases of the reproductive system often give the -clinical picture of hysteria a quite distinctive coloration; the -physiological course of the functions of the generative organs is also -competent to produce both of these effects. _Krönig_, however, rejects -the view that the lack of sexual intercourse has an unfavorable -influence upon the nervous system in women, and gives rise to hysterical -and neurasthenic disorders. The favorable influence which marriage is -often observed to exercise upon the course of nervous disorders is -explicable with reference to psychical considerations of a very -different nature. Sexual abuses, masturbation, and the use of preventive -measures, give rise in women far less often than in men to neurasthenic -and hysterical conditions. - -_Féré_ asserts that in certain neurasthenic patients sexual intercourse -induces a general blunting of the senses, and especially of hearing and -sight. Actual amaurosis of short duration may even be observed; also -cutaneous anæsthesias, paralytic conditions of the extremities taking -the form either of hemiplegia or paraplegia, convulsive attacks, and -somnolent paroxysms. - -_Delasiauve_ observed that epileptic patients, who during residence in -an asylum had remained almost entirely free from fits, after returning -home and resuming sexual intercourse, even in strict moderation, -suffered from a recrudescence of the convulsive seizures; when -intercourse was excessive, the relapse was naturally even more severe. - -In two instances, in women who in a single night had practiced -intercourse to very great excess, _Hammond_ observed paralysis of both -legs to ensue; he saw also in numerous cases spinal irritation and other -nervous disturbances as a consequence of sexual excesses. - -_Von Krafft-Ebing_ points out, with reference to the prophylactic -influence of marriage in respect of mental disorder, that in men early -marriage diminishes the danger of the occurrence of such disorder, -whereas in women marriage is undesirable before the attainment of -complete physical maturity. - -With regard to marriage in the case of persons suffering from nervous -diseases, _Ribbing_ lays down the rule that when such diseases have been -severe and have occurred in numerous members of a family, whilst a few -only in the family have remained healthy, when, moreover, the illness -has been accustomed to make its first appearance only after the -attainment of maturity, no indications of its onset being noticeable in -childhood or youth—one belonging to a family thus afflicted should be -advised not to marry. Where, however, the hereditary tendency is to a -disease likely to manifest itself in childhood or youth, a member of -such a family who has been fortunate enough to pass through the years of -development without exhibiting any pronounced disturbance of the nervous -system, may be permitted to marry if certain precautions are observed. A -woman with a tendency to alcoholism should in no circumstances be -allowed to marry. In the cases, fortunately rare, in which the -drink-craving exists in women, marriage is even more undesirable than it -is in the case of men similarly afflicted, for the female drunkard is in -a position in which she can mishandle and neglect her children -throughout the entire day; and, moreover, this affection appears to be -even more obstinately incurable in women than it is in men. - -_Löwenfeld_ very rightly insists that in deciding on the advisability of -marriage in the case of neurasthenic and hysterical girls the -anticipated influence of sexual intercourse must not be the sole -determinant. “Regulated sexual intercourse, such as is rendered possible -by marriage, has often a favorable influence on previously existing -states of nervous weakness. But we should go too far if we were to -attribute the beneficial effect of married life on such conditions -solely to sexual intercourse. This latter is but one factor among -several, the others being no less important. These others are: The -pleasures of an orderly domestic activity; the withdrawal of the -patient’s attention from her own condition, partly by domestic duties -and difficulties, and partly by the novelty of marital companionship; -the gratification, especially strong in women, at having obtained a -support in life; and, finally, the joyful expectation of motherhood. -These factors, however, are not present in every marriage. When their -presence cannot reasonably be anticipated, when, in consequence of -insufficient means, the marriage is likely to entail increasing -troubles, or when, owing to the want of suitability of temperament, -annoyances and quarrels are likely to occur, we must throw the weight of -our advice into the scale against the proposed marriage, since the -advantages of regulated sexual intercourse are not likely to outweigh -the disadvantages just detailed. Even when means are ample and the -characters of the couple contemplating marriage are unquestionably -harmonious, we must nevertheless (temporarily, at any rate) advise -against marriage, we must, that is to say, advise the postponement of -marriage, if the bride is suffering from severe hysterical or -neurasthenic states. Where, further, such neurasthenic or hysterical -troubles occur in a woman with pronounced hereditary predisposition to -nervous disease, we must, both for the sake of the possible progeny and -on account of the uncertain influence of married life on the health of -the patient, absolutely and unconditionally prohibit marriage. In cases -also in which severe hereditary predisposition to mental disorder exists -(especially when derived from both parents), and in addition stigmata of -psychopathic degeneration are actually apparent in the patient, or she -has already suffered from the development of a psychosis, we must -decisively object to the patient’s marriage.” - -As regards the marriage of young women suffering from tuberculosis, we -must take into consideration a fact that medical experience has -conclusively established, namely, that the processes of generation have -an unfavorable influence upon pulmonary phthisis. Girls with an -inherited predisposition to tubercular disease, sometimes first manifest -the symptoms of pulmonary tuberculosis at the time of the menarche. In -cases of developed tuberculosis, copulation and the excitement of the -vascular system associated therewith have a more or less unfavorable -influence—and all the more inasmuch as, in accordance with the saying -_omnis phthisicus salax_, women affected with tuberculosis often exhibit -a very lively sexual impulse, an almost insatiable sexual appetite. -Sexual excesses are, moreover, very likely to lead to the occurrence of -hæmoptysis. - -In former days it was believed that conception and pregnancy, when -occurring in women suffering from tuberculosis, had a restraining -influence on the progress of the pulmonary disease, a view which found -expression in the assertion of _Baumes_ and _Rosières de la Chassagne_ -that of two women affected with tuberculosis to the same degree of -severity, one who became pregnant would always outlive the other who -failed to become so. Careful and sufficient observations on the part of -physicians and gynecologists have, however, shown that this view was -fallacious, and, on the contrary, that during pregnancy tuberculosis -advances with more rapid strides, that pregnancy, and lying-in -accelerate the fatal event (_Grisolle_, _Lebert_), that tuberculosis -acquired shortly before pregnancy or in the course of that condition, -progresses with exceptional rapidity (_Larcher_), and that the lying-in -period is especially perilous to these patients (_A. Hanau_). In some -cases of consumption it is the first pregnancy that is the most -perilous, but in other cases a later pregnancy proves more destructive. - -_Ribbing_ goes even further, insisting that neither man nor woman -affected with pulmonary consumption should marry. “If, indeed,” he -writes, “consumptives desire to enter upon marriage, merely with the aim -of being faithful to one another and assisting one another for the short -time that remains to them, I should offer no opposition. But there must -be a complete mutual understanding of the facts of the case, and an -unalterable determination on the part of both to carry out the -resolutions made prior to marriage, for failing this the consequences -will be most disastrous. In most cases, however, the course adopted by -_Bulwer’s Pilgrims of the Rhine_ is to be preferred, the lovers -contenting themselves with the condition of a betrothed pair, and in -that state awaiting the approach of death—or, if exceptionally -fortunate, proceeding to marriage only after restoration to health.” - -It would certainly appear that in the case of girls suffering from -pronounced phthisis, we are justified in advising against marriage, on -account of the great danger which this state entails of a rapid advance -in the pulmonary disease. - -Based upon the observations of _Schauta_ and _Fellner_, the latter -author advances the rule that in the case of a woman suffering from -disease, marriage should be forbidden only when the mortality from the -disease in question is not less than 10 per cent. In this category we -must include severe cases only of pulmonary tuberculosis; whilst cases -of laryngeal tuberculosis will, according to this rule, be absolutely -unfitted for marriage. Among heart-affections contra-indicating -marriage, he includes mitral stenosis, other valvular affections in -which there is serious disturbance of compensation, and myocarditis; he -considers marriage inadmissible also in cases of chronic nephritis, and, -among surgical affections, in cases of malignant tumour. In cases in -which during a previous pregnancy the patient has been affected by one -of the following diseases, viz., severe chorea, mental disorders, severe -epilepsy, pulmonary tuberculosis which progressed much during the -pregnancy, morbus cordis with considerable disturbance of compensation, -severe heart trouble due to Graves’ disease—in all such cases, a -repetition of pregnancy should be avoided. - - - HYGIENE DURING THE MENACME. - -During the sexual epoch of the menacme a woman’s principal hygienic need -is marriage completely satisfactory alike to body and to mind. It cannot -be denied that sufficient sexual gratification, regular, of course, and -free from all excess, such as is usually experienced in married life, is -very advantageous to the health of a woman who has attained sexual -maturity—even though we admit that the drawbacks of sexual abstinence, -regarded as a cause of disease of the female genital organs and the -nervous system have been as a rule greatly exaggerated. - -The inability to marry always makes a deep impression on the mental life -of woman, and in many cases also gives rise to burning desire and -tormenting yearning of an erotic nature. The unmarried miss life’s true -goal and fail to enjoy the natural exercise of their functional -capacities; alike in the cultured lady and in the poor working woman who -has failed to marry, the thoughts and feelings return again and again to -her own condition in a self-tormenting manner. - -The physical and mental disadvantages entailed by sexual gratification -when obtained by an unmarried woman, one who, according to modern -phraseology, “wishes to secure her natural share of the joys of love,” -and who regards voluntary chastity as “a sacrifice to meaningless -prejudices”—need not be more particularly described. - -Free love, moreover, is the most important disseminator of gonorrhœal -infection. “In any future commonwealth,” says _Runge_, “in which -marriage is abandoned in favour of the general practice of free love, -the human race will be overwhelmed by gonococci in a manner now hardly -conceivable, and the reproductive capacity in both sexes will be -diminished by the results of gonorrhœa to a very serious extent.” - -Frequently enough, also, free love leads to prostitution, which at the -present day is so widely prevalent. Various reasons have been suggested -to account for the increase of prostitution. Among these are: The growth -of modern industry, with the consequent aggregation of the population in -large towns; the decline in the marriage rate; the postponement of -marriage; universal military service; the freer mutual companionship of -the sexes; and many others. At any rate, the fact would appear to be -established, that in the case of woman the determining cause of -prostitution is hunger rather than the sexual impulse. The worst paid -classes of workwomen are shown by official statistics to furnish the -largest number of recruits to the ranks of prostitutes; and it is during -times of deficient employment that the number of women practicing -occasional prostitution increases. Thus, material need is the most -important of the causes of prostitution. - -This remains true even though the doctrine of _Lombroso_ and _Tarnowsky_ -should find fuller justification, the doctrine that the practice of -prostitution by women is the natural expression of a congenital morbid -predisposition, “which impels them, in defiance of their direct -advantage, of reason, and of all counter-advice, to adopt this accursed -mode of life.” Prostitution, in this view, is to be regarded as the -inevitable outcome of congenital moral insanity. This is certainly true -of a small proportion of prostitutes, but is as certainly false of the -great majority, in whom unfavorable, difficult conditions of life form -the determining cause. A certain inherited or acquired mental -disposition may, indeed, be assumed to exist in these cases also—an -unstable moral equilibrium, an insufficient development of the force of -the will and of the power of resistance. - -The hygienic requirement of married life for woman during the menacme is -undoubtedly sometimes hard to fulfil in our day, when the more elaborate -and expensive standard of life has increased the difficulty of -supporting a family; but from the medical point of view it is necessary -to insist forcibly on this categorical imperative, in opposition to the -view advanced by the modern women’s rights’ party, that “love is moral -also in the absence of legal marriage” (_Ellen Key_); in opposition to -the yet more extreme opinion of _George Sand_ and of _Almquist_, who, -regardless of consequences, declare marriage to be immoral; and, -finally, in opposition to the advocates of “free love,” who wish woman -to be as free as man in sexual relations. - -Much as we may wish that man and wife should be in complete harmony in -marriage, and that they should feel themselves to be firmly united alike -by mutual love and by a reciprocal sense of duty, none the less we must -consider the modern maiden ripe for marriage as unjustified in -demanding, before undertaking marriage, “perfect love as typifying the -inner yearning of two beings to become one;” and we must regard the -latter-day woman as extravagant in insisting that the man shall enter -upon marriage in a condition as virgin as that of his contemplated wife. -“Perfect love” is as rare and as little to be expected as perfect -beauty; and the sexual life of man differs entirely in nature and in the -course of its development from the sexual activity of women. - -Doubtless they spring deep from the soul of woman, the demands expressed -by the writer of the book “_Vera_” and by her numerous imitators, the -apostles of “Veraism,”—the demands of the maiden entering upon marriage -that her husband shall be as chaste and sexually as unspotted as -herself. Difficult of fulfilment as they are, if fulfilment is even -possible, these demands must none the less be regarded as characteristic -of the sexual life of modern womanhood. “Is man’s sexual honor,” -exclaims _Vera,_ “then altogether different from that of woman? Is not -the alleged necessity for sexual gratification in youth either a -well-organized fraud or an enormous error on the part of physicians? Is -it possible that chastity can entail diseases as terrible, as -destructive to life and happiness as those that result from unchastity? -And is it not a crying sin, even if some of these fears are justified, -to ruin both mentally and physically the whole race of women? * * * Man -demands from the girl of his choice, not chastity alone, but an -absolutely unblemished character. And rightly so. But the wife must -share her husband with street-walkers? She must bear the pangs of -maternity, while fortified by the terrible knowledge that the father of -her children has wasted his youthful virility in purchased embraces, -that he has not recoiled from impurity, that he has exposed himself to -the risk of infection with the most horrible diseases, that he has -squandered his virginity in the most bestial sensuality? * * * We girls -must also be granted the right to demand from the man of our choice the -same purity, the same unspottedness by sensuality, that he so rigorously -demands from ourselves! We must no longer content ourselves with the -remnants that are left for us by others! We must no longer be satisfied -with man’s moral inferiority! Then there will be more happiness, more -love, more health and joy of life!” - -These accusations and demands so boldly made are not to be disposed of -by mere mockery. With deep sorrow we must admit the absolute truth of -the charge that too many men clamber out of the abyss of debauchery to a -blighted marriage. But the demand for equal moral rights, for the -abandonment of the hitherto prevalent bisexual ethical standards, is in -vain conflict with actuality, with the defensive instincts of young men, -with the difficulties entailed by the struggle for existence, with the -increasing pretensions (to sexual freedom) of women themselves; but -above all is it in conflict with the thousand-year-old notions of sexual -honor in the male and the female respectively, and with the undeniable -fact that the mature man is capable of elevating himself out of the base -intoxication of the senses characteristic of youth, to attain the -noblest and most intimate married love, whereas the girl who has once -descended into such an abyss sinks therein and is beyond the possibility -of rescue. Thus early marriage with equal purity of husband and wife -remains a postulate which the present can hardly be expected to satisfy, -and one whose fulfilment must be left to the future. - -In consequence of modern writings and discussions concerning the erotic -problem, there has arisen a hypersensibility on the part of women in -respect of the conditions in which they pass their married life, leading -them to demand greater independence, a greater expansion of their own -individuality; this tendency must, however, be resisted, if the marriage -is to be a happy one, with mutual comfort and reciprocal consideration, -one suitable, not for exceptional beings in an ideal state, but for men -and women as they really are. In such a marriage, affection and a sense -of duty will strengthen love and preserve fidelity. A prudent, clever -woman will always understand how, notwithstanding all necessary -self-surrender, to preserve the freedom of her own individuality and the -esteem of her husband. - -Marriages based upon true inclination usually result in the birth of -stronger and more beautiful children than marriages in which the -money-bags were the sole or the principal determining cause. In England, -where people commonly marry when still quite young, beautiful and -healthy children are more often seen than in France, where marriages of -expediency form the great majority. According to _Bertillon_, of 1,000 -young men from 20 to 25 years of age, in England 120 marry, but in -France less than half that number, viz., 57 only. And 100 wives between -the ages of 15 and 40 give birth annually, in England to 39 children, in -France to 26 only, a number less by one-third. - -In deciding upon marriage, hereditary influences deserve careful -consideration in respect alike of the family of the prospective husband -and that of the prospective wife. For it is well established that the -law of inheritance relates not only to the peculiarities of external -configuration, to the features, the stature, the tint of the skin, but -also that children inherit from their parents their mode of bodily -development, the functional activity of their organs, the duration of -their life, their predisposition to disease, and even their intellectual -and moral qualities. As regards hereditary predisposition to disease, -the most important are, as is well known, the predisposition to -tuberculosis, that to malignant tumors, and that to mental disorders. - -Great disparity in the respective ages of prospective husband and wife -entail various kinds of unsuitability for marriage. An elderly man who -marries a young girl, even if he still possesses a certain amount of -virility, is unlikely to procreate healthy and powerful children; and -these latter for the most part will be weakly, scrofulous cachectic, -endowed with deficient powers of resistance, and often badly equipped -from the intellectual standpoint. Similar considerations prevail in -respect of marriages in which the husband has been exhausted by earlier -sexual excesses, so that he retains no more than remnants of virility, -whilst his semen is of doubtful fertilizing power. _D. Richard_ relates -that Louis XIV asked his physician why it was that the children he (the -king) had by his wife were delicate and deformed, whilst those he had by -his mistresses were beautiful and powerful. “Sire,” was the answer, -“c’est parce que vous ne donnez à la reine que les rincures.” - -_Plato_ maintains that before every marriage the man and the woman -should both undergo official examination to determine their fitness or -unfitness for the married state, the man being absolutely nude, and the -woman stripped to the waist, for the examination. This author goes so -far as to regard it as “a form of homicide for a man to embrace a woman -when he is incapable of fertilizing her.” How rarely it happens in our -day, however, that the physician, the official with the requisite -knowledge to fulfil _Plato’s_ requirements, is asked for his opinion -regarding the desirability of a contemplated marriage! The only occasion -on which this is likely to occur is when a man intending to marry wishes -to be assured that he is completely cured from an earlier infection with -syphilis, and, therefore, runs no risk of transmitting the disease to -his wife or to possible offspring. But it never occurs to the parents of -a girl about to marry to ask the physician whether she is physically -suitable for marriage. - -In deciding on marriage, however, care should before all be taken to -determine that the girl has attained complete physical and especially -complete sexual development. The age at which woman attains complete -sexual maturity is in our climate and race coincident on the average -with the twentieth year of life. - -For the hygiene of marriage it is necessary that the bride should not be -extremely youthful. Notwithstanding the fact that the legal codes of -civilized countries nowhere demand for girls a greater age than fifteen -years before permitting marriage, this limit is, generally speaking, -fixed far too low. Before becoming a wife, the girl should not merely -have attained complete physical development, with her reproductive -organs in a state of maturity, but she must also be developed -intellectually to such an extent that she is fully capable of -understanding the nature and significance of marriage. At the age at -which marriage is legally permissible, a girl is still far from having -attained physical and mental ripeness for marriage, reproduction, and -maternity. - -Especially with reference to the last consideration is it inadvisable -that in our climates a girl should marry earlier than from 18 to 20 -years of age, and preferably even she should first attain the age of -from 20 to 22. In that case her happiness as a mother will be more -secure, and there will be a greater probability of her producing a -healthy progeny. In the East, indeed, quite different views prevail. -According to the laws of _Manus_, a girl might marry on attaining the -age of eight years; if within three years thereafter her father failed -to provide her with a husband, she might choose one for herself. Among -the Hindus it is regarded as a disgrace to the parents if a girl does -not marry quite young, indeed before the first appearance of -menstruation. _Atri_ and _Kasypa_ state that if a girl begins to -menstruate before she leaves her father’s house, the latter must be -punished as if he had destroyed a fœtus, while the daughter herself -loses caste. Marriage delayed till after the appearance of menstruation -being regarded as sinful, girls are married while still children, in -order to prevent the loss of mature ova, which is regarded as equivalent -to infanticide. Very early marriage has thus in India been legally -ordained for thousands of years. The Hindus, who even now regard every -menstruation which has not been preceded by coitus in the light of -infanticide, marry their daughters before the age of puberty. - -According to oriental tradition, Mahomet married Khadijah when five -years of age, and cohabited with her three years later. In the Bible, -numerous similar examples are recorded. Among many savage tribes, as, -for instance, among some of the aborigines of India, and among the -indigens of Australia, copulation is usually effected before girls reach -the age of puberty; in India, indeed, according to _Ploss_ and _Bartels_ -(_Das Weib in der Natur und Völkerkunde_), marriage with immature girls -is a widely diffused custom, and in Australia a child of ten or eleven -is often found to be the wife of a man of fifty or the concubine of a -sailor. In general, according to these authors, we find that the age of -nubility in girls is lower in proportion to the lowness of the stage of -civilization attained by the race or people to which they belong. Among -the ancient Romans, girls were commonly married between the ages of -thirteen and sixteen years. - -In the Talmud, _Rabbi Joshua_ gives the following advice regarding early -marriage in Jewish girls: “If your daughter has attained puberty and is -twelve years and six months old, she must be married at any cost. If no -other means are available, manumit one of your slaves, and give her to -the freedman to wife.” - -Experience proves, however, that in our climate, at any rate, girls who -marry at a very early age are inferior in fertility to those who refrain -from marriage until the genital organs have attained complete maturity; -and statistics show that those women who marry before attaining the age -of twenty must wait longer for their first pregnancy than those who -marry between the ages of twenty and twenty-four. At the higher age -also, women bear parturition and its consequences more easily than those -who marry very young. A similar influence in marriage to that resulting -from undue juvenility is exercised by its opposite, marriage when a -woman is already elderly; in this case fertility is limited, and health -also is especially apt to suffer. When the indications of the -climacteric are clearly apparent, marriage is contra-indicated, not only -on account of the impossibility of fertilization, but also in respect of -its general unsuitability in the closing stage of the sexual life. - -Not only is the absolute age of the woman of importance in deciding on -the advisability of marriage, but the relative ages of the proposed -husband and wife must also be taken into account, first of all in -respect of the wife’s possible fertility, and secondly in respect of her -general health. The most suitable arrangement is that in which there is -no marked difference in age. The husband may be, and indeed in existing -social circumstances almost necessarily is, somewhat older than his -wife, as much perhaps as eight or ten years. But a very great disparity -of age (in either direction) is a serious error. If a very young girl -marries an elderly man, or a developed matron marries a young man, the -true purpose of marriage is unfulfilled, the eternal laws of nature and -all ethical principles are infringed. In the breeding of animals, the -fundamental principle has long prevailed that the animals chosen for -coupling should be well suited each to the other and should be in -perfect physical condition; and breeders are also familiar both with the -favorable influence of good nourishment and with the advantage of the -opportune crossing of distinct varieties. The same principles are -equally applicable to the human race, neglected as they commonly are in -practice. - -With regard to the marriage of near kin, we can only remark that the -marriage of those closely related by blood should as far as possible be -avoided, and that such a marriage must be absolutely prohibited when in -both families there is a history of tuberculosis, mental disorders, -diabetes, and the like. When first cousins contemplate marriage, it is -indispensable, not only that both individuals should be in perfect -health, but also that on neither side there should be any serious family -history of transmissible disease or transmissible morbid tendency; and, -further, it is absolutely necessary that no such marriage of near kin -should have taken place in the proximate ancestry of the cousins, _i. -e._, their cousinship must not be a double one, derived both from the -paternal side and the maternal. It is indeed to be recommended, with a -view to the production of a healthy and powerful posterity, that -marriage should bring about a crossing of healthy individuals proceeding -from different families, different places, and different constitutional -types. An instance of the advantage to be found in this practice is -pointed out by _Ribbing_, who shows that the most powerful aristocracy -in Europe, that of England, by the gradual creation of new peers, on the -one hand, and by the gradual decline of younger sons and their -descendants into the middle class, on the other, has undergone a -continual crossing with less exalted but originally sounder stocks; in -this way its vigor and fertility have been maintained, in contrast to -the nobility of many continental states, which has so largely perished, -in consequence of its exclusiveness in the matter of marriage. - -“In this connection,” continues _Ribbing_, “we must bear in mind, that -blood-relationship is not the only matter that has to be considered; in -the interest alike of the family, and of society, it is necessary to -demand that certain degrees of relationship by marriage alone, should -fall within the ‘prohibited degrees’ of love and marriage. There are -certain groups related by marriage and held together by the bond of -affection, from which foster-parents and guardians may most suitably be -selected to fulfil the duties as regards education and training of -children who have been orphaned in early years. For such a purpose none -seem better adapted than the brothers and sisters of the deceased -parents; but the upbringing of the children can be confidently entrusted -to the former only if the relationship between the older and the younger -branches of the family is one regarded by law, and still more by -morality and custom, as one precluding the possibility of the occurrence -of sexual love and marriage.” - -_Möbius_, writing on “The Ennobling of the Human Race by Selection in -Marriage,” observes: “The most important aim of natural development is -the perfection of humanity. The qualities of the coming generation -depend for the most part upon the qualities of the parents. Marriage -from affection ensures the fulfilment of nature’s aims with more -security than marriage from reason; since what we have to think of is -not the happiness of the married pair but the quality of their children. -Of great importance, also, to the development of the human race are the -conditions during the commencement of life, and the mode of education. -The improvement of the race has not hitherto been the conscious aim of -the generality of people. The law does not as yet, as it should, take -into account the advantage of posterity. Capital punishment is fully -justified and purposive. Criminals should not be allowed to marry. The -perpetuation of disease by inheritance should be checked by the utmost -powers of the state. Any one marrying while suffering from any venereal -disease still in an infective condition should be punished. The marriage -of persons suffering from tuberculosis should be prohibited. For the -prevention of disease is more important than its cure. The most -important factor in preventive medicine is an improvement in the -conditions of life. The human ideal should be, goodness of heart in -association with physical and mental health. Goodness, beauty, and -strength should be simultaneously pursued. Since, however, man is made -by birth far more than by education, selection in marriage is of -fundamental importance. In the choice of a partner, attention is rightly -paid to beauty, since beauty and health are fundamentally identical; -moreover, a human being endowed with beauty is usually also more moral -than one devoid of that attribute. Equality of birth is as a rule -desirable in marriage; but not the family only is to be considered in -determining the existence of such equality, individual characteristics -must likewise be taken into account. Whether the crossing of races is -desirable is not yet certainly determined.” - -From the hygienic standpoint it is necessary that in marriage also the -frequency and the manner of sexual intercourse should be regulated. - -Wise men and lawgivers of all the nations of antiquity have insisted -upon the necessity of certain intervals between the acts of intercourse. -Thus, _Mahomet_ prescribed 8 days, _Zoroaster_ 9 days, _Solon_ 10 days, -_Socrates_ also 10 days. _Moses_ forbade intercourse during menstruation -and for a week after the cessation of the flow. _Luther_ prescribed -intercourse “twice a week.” - -Birds and many mammals are competent to perform intercourse at -exceedingly short intervals. A well-bred cock will repeat this act 50 -times daily; a sparrow, 20 times in an hour; a bull, 3 to 4 times in an -hour. In the human species, however, too rapid repetition of intercourse -is deleterious not only to the male, but to the female also, though the -latter certainly suffers in less degree. For in this act the female -plays a more passive part, and for this reason can repeat it with -impunity more frequently than the male, who loses semen at each -repetition. It is not possible, however, to lay down precise rules as to -the permissible frequency of intercourse in either sex; the matter must -depend upon physical needs. Moderate and regular indulgence in sexual -intercourse is unquestionably advantageous to women both physically and -mentally, regulating all the functions of the body, and tending to -produce a contented and cheerful frame of mind. - -During menstruation, a woman should refrain from intercourse. By the -Mosaic law the death punishment was allotted both to the man and to the -woman who indulged in coitus while the latter was menstruating. As a -matter of fact, considerations alike of hygienic cleanliness and of -sanitary precaution prohibit the performance of coitus during this -period. Severe menorrhagia, perimetritic irritation, and parametritic -inflammations, have been observed to follow such indiscretions. On the -other hand, it is more than doubtful whether, in the event of pregnancy -resulting from intercourse performed during menstruation (and conception -is especially apt to occur at this time), the child is likely, as -earlier authors maintained, to be unfavorably affected, and to suffer -from cachexia, scrofula, or rickets. - -After the act of intercourse, a woman should rest; and indeed sleep for -some hours is especially to be recommended. A vaginal douche should not -be administered until several hours have elapsed, otherwise there will -be a risk of preventing fertilization of the ovum. The water employed -for vaginal irrigation should never be quite cold; a temperature of -79°–82° F. (26°–28° C.) is best. - -All measures for the purpose of artificially increasing sexual desire, -such as alcoholic beverages (especially champagne), and certain drugs -(especially cantharides), are even more harmful to women than they are -to men. The woman who conceives while in a state of intoxication commits -a great sin against the coming generation.[44] Just as harmful, however, -are the anaphrodisiacs sometimes employed to diminish the intensity of -sexual desire when this cannot be gratified. When affected with intense -sexual excitement, a woman is much more unfavorably situated than a man, -since man claims the right to indulge in sexual intercourse whenever he -feels disposed, and has, moreover, ample opportunity for sexual -gratification. A woman, however, properly endowed with self-respect, -will understand how to bridle her senses. Bodily exercise, moderate, -unstimulating diet, intellectual occupation with serious matters, the -avoidance of equivocal literature and of sensual dramatic -representations, cold bathing, and the use of a hard mattress and light -bed-clothing—these means will coöperate powerfully toward the prevention -of excessive sexual desire. _Horace_ already remarked: “Otia si tolles, -periere Cupidinis arcus.” - -The wife should know how to bridle, not her own desires only, but also -those of her husband. She must not demand too much during the -intoxication of youthful vigor; she must prevent the complete combustion -of the flames of masculine passion, and must keep sparks glowing in the -ashes. Economy during the sexual prime preserves sexual power, enables a -man to continue intercourse to a ripe age, and avoids premature -exhaustion and satiety. When the husband is drawing near the end of his -sixth decade, the wife must accustom herself to see in him rather the -father of her children than her own husband, and must reduce her sexual -demands to that measure which will not be injurious to his health. -_Demosthenes_, writing of the sexual life of the Athenians of his time, -said: “In order to obtain legitimate offspring and to provide a faithful -guardian of our household, we marry a wife; for our service and for the -performance of daily household duties, we keep concubines; for the joys -of love, we seek the hetairai.” The task is extremely difficult, but a -clever and virtuous modern wife must endeavor to combine in her single -personality the sensual attractiveness of an Aspasia, the chastity of a -Lucrece, and the intellectual greatness of a Cornelia; she must bear in -mind the epigram of _Bacon_, “A wife must be a young man’s mistress, a -middle-aged man’s companion, an old man’s nurse.” - -In the act of intercourse the woman must always play the more passive -part; she must be desired, rather than desire. Woman’s modesty increases -man’s desire. By this coquetry, permissible because natural, the woman -can bind the man to herself, and can give the lie to the assertion that -marriage is the grave of love. Partial concealment of her desire on the -part of the woman is more stimulating to the man than an open -manifestation of the sexual impulse; and a certain amount of modest -reluctance is more alluring to him than a plain invitation. Plenty of -room must be left for the play of fancy and imagination. _Schiller_ -makes Fiesco say to the Countess Julia, as he covers up her bosom, “The -senses must be blind letter-carriers only, and must not be aware of that -which nature and the imagination communicate each to the other. The best -of news is stale as soon as it has become the talk of the town.” - -For this reason, also, it is more suitable that intercourse should take -place, not by day, consequent on the brutal prompting of vision, but by -night only, beneath the protecting veil of darkness. A night’s rest, -moreover, will serve to restore the exhausted nerves, and to replace the -expended secretions. Less advisable is coitus in the morning, on awaking -from sleep, since the labors of the day must immediately thereafter be -undertaken. Partially impotent men only, who wake up with an erected -penis, endeavour to avail themselves without delay of this favorable -opportunity, bearing in mind the French proverb, “On aime quand on peut, -et non pas quand on veut.” - -The French custom, in accordance with which the married pair sleep -together in a double-bed is undesirable on several hygienic grounds, -and, in the first place, for the reason that this continuous nocturnal -proximity is likely to give rise to the habit of indulging in -excessively frequent acts of intercourse. The best and most affectionate -of men has neither disposition nor capacity to play the part of Romeo -every night, and thus the value and enjoyment of marital duties becomes -lessened. The fulfilment of his desires should not be rendered quite so -easy to the husband; he should always appear the lover, one who seeks a -woman’s favours because he longs for her; he should not be the master, -exacting an unquestioned right. For this reason, separate beds are -advisable for the married pair, and, when possible, even separate -bedrooms. - -Among the ancients, _Lycurgus_, the Spartan law-giver, regarded -maternity as woman’s principal attribute, and considered the sexual -impulse to be the means merely by which healthy citizens were provided -for the state. In accordance with this view, the sanctity of marriage -was violated, and every powerful, handsome, and valiant Spartan had the -right to request the privilege of intercourse with the wife of another, -in order to enrich that other’s family with his seed. Elderly, impotent -men conducted well-formed young men into the arms of their own wives. -The girls, like the young men, went through a course of gymnastic -exercises, in order to harden their bodies, and to fit them for the -bearing of strong and healthy children. No man might marry before -attaining the age of thirty, no woman before attaining the age of -twenty. Girls ripe for marriage were assembled in a dark place, and -there the young men chose their brides, as chance might direct. The -young men were allowed to visit their wives by night only, and secretly, -in order that the vigor of the sexual impulse might be increased and -maintained. - -Among the Spartans, it happened quite frequently, that a man whose wife -had remained childless, and who believed himself to be at fault in the -matter, would beg one of his fellow-countrymen, or even a foreigner, to -come to his assistance. It was enacted by one of Solon’s laws, to -prevent a man from neglecting his marital duties, that he should have -intercourse with his wife not less than three times monthly. According -to another of Solon’s laws, an Athenian heiress might call upon her -nearest relative for the gratification of her sexual desires. - -The bluntest contrast to this Spartan simplicity is furnished by the -unbridled lasciviousness that prevailed in Rome under the Cæsars, when -women’s sole desire was sexual enjoyment, while maternity was a state to -be avoided. To such an extreme was this carried, that the Roman ladies -of that day preferred to marry eunuchs, and further, as _Pliny_ reports, -hermaphrodites were in great request. _Juvenal_ writes: “There are women -who prize the infertile embraces of base eunuchs; thus they are able to -dispense with the use of abortifacients.” - -The hygiene of the nuptial night deserves from the physician more -attention than it has hitherto generally received. He should warn and -enlighten the young husband, in order that the brutality with which the -act of defloration is apt to be performed may be lessened, and further -in order that mistakes in this connection, resulting from ignorance and -likely to have serious consequences, may be avoided. It is well known -that lacerations of the hymen and its environment, and even serious -injuries of the genital organs, may result from maladroit attempts at -penetration. The physician will admonish the husband in the words of -_Michelet_: “Bear in mind in this hour that thou art an enemy, a tender, -considerate, and gentle enemy!” - -The young woman entering upon marriage should receive instruction from -her mother regarding all the sexual processes of copulation, instruction -at once earnest and complete. By such enlightenment, the young bride -will be spared much suffering, and a sudden disillusionment which might -seriously affect the whole of her future life will be avoided; complete -ignorance, on the other hand may lead, not merely to needless mental and -physical suffering, but to the most tragic consequences on the bridal -night. In one case known to me, the young wife, who before marriage was -utterly ignorant of the nature of physical love, was so completely -overwhelmed in her ideals by the somewhat energetic procedure of the -bridegroom as soon as he found himself alone with his wife, that she -fled from her new home then and there in the night, and by no -persuasions could be induced to return. - -In that decisive moment in which the maiden loses her virginity, she -must find in her husband, not the brutal man who forcibly takes -possession of her body, but the chosen man of all, to whom her love can -refuse nothing. - -“Delicate foresight and restraint,” writes _Ribbing_, “are needful above -all at the commencement of married life. The young wife, coming to the -bridal bed a pure virgin, is not, like her husband, fully prepared for -what is to take place. In all cases she is somewhat fearful of the new -experience. The first act of intercourse involves for her a certain -amount of pain, and this pain is not solely physical. * * * Moreover, we -must remember that the entire change in her mode of life makes a deep -impression upon a woman’s mind; time and quiet are needed before she can -find herself at home in the novel surroundings, before she can adapt to -the changed circumstances her moral and religious convictions, and -before she can ‘think true love acted simple modesty’ (Romeo and Juliet, -III, 2.16). Impatient husbands, through want of knowledge and lack of -consideration during the honeymoon, have often ruined the happiness of -subsequent married life.” - -It happens often, unfortunately, that the wife has reason to complain of -the reckless manner in which her husband has used, or misused, his -sexual powers. Frequently enough, on the bridal night, the man proceeds -with such violence in his assault on the virgin reproductive organs of -his newly-wedded wife, that we must actually speak of him as ravishing -an ignorant and timid girl. Later, when the stimulus of novelty has -passed away, the husband often performs intercourse in a manner more -calculated to awaken his wife’s sexual desires, but in seeking his own -lordly gratification and obtaining it he is still apt to leave out of -the reckoning the need for effecting coitus in such a way as will give -complete satisfaction also to his wife. - -The wedding journey likewise deserves consideration from the hygienic -standpoint. Much is to be said in favor of such a journey, inasmuch as -it endows the necessarily somewhat brutal first act of intercourse with -an aspect of romance. The removal to a foreign country, to a strange -environment, will spare the chaste maiden much shame and vexation. On -the journey, moreover, the young couple are much in each other’s -company, and the process of mutual adaptation is agreeably favored. And -yet this modern custom of making a wedding journey entails certain -serious disadvantages. The young woman leaves her home and her nearest -relatives, and is in a moment involved in the excitement of travel, an -excitement liable to increase to the degree of morbid anxiety. The -fatigues of railway-travel, of wandering about strange towns, of visits -to museums and picture-galleries, are apt to cause general loss of -nervous tone, and also local hyperæmia of the genital organs. In -addition, false modesty and the prescribed arrangements for the journey -may lead the onset of menstruation to be ignored and the customary rest -at this period to be dispensed with. Still more, the possibility of the -occurrence of conception and of the commencement of pregnancy is usually -left altogether out of the account. Many an attack of menorrhagia, of -perimetritis, and of endometritis, many a miscarriage, and many -instances of protracted sterility, are dependent upon the hygienic -mistakes of the wedding journey, and less, indeed, upon the abuses -arising out of the intoxication of passion, than upon the fatigues of -excessive travel both by day and by night. The bride who on her -wedding-day was young, healthy, and full of vitality, not infrequently -returns from the wedding journey a sickly and debilitated woman. - -With regard to wedding journeys in relation to the causation of chronic -metritis, _Scanzoni_ has expressed an authoritative opinion. “After many -weeks of unsatisfied sexual desire, the young married pair, now freed -from all restraint, give themselves up to the joys of love; the intense -sexual excitement causes great stimulation and hyperæmia of the female -sexual organs; in addition, the noxious influences of travel make -themselves felt, and also hygienic indiscretions are perpetrated, -dependent upon the young wife’s modesty; it is, therefore, by no means -to be wondered at that, having left home a perfectly healthy woman, she -returns from her wedding journey with the germs of an illness from which -she never fully recovers, and which is the source of unending suffering, -and more particularly of a sterile marriage.” - -Sexual hygiene demands a certain moderation in the enjoyment of physical -love, and also a certain constancy, such as may be expected in a happy -marriage. - -It is not possible to lay down a general rule with regard to the -frequency of sexual intercourse, notwithstanding the earnestness with -which religious zealots, physicians, and moral teachers have in all ages -endeavored to determine how often it was proper for a man to cohabit -with his wife. The rules that have been prescribed by the various -authorities had in view, for the most part, the protection of the wife -from excessive demands on the part of her husband; sometimes, however, -by the establishment of a minimum period, a certain amount of sexual -gratification was secured to the wife; finally, also, the generation of -a healthy posterity had to be taken into consideration. _Ribbing_, -however, justly observes: “Sexual intercourse results from a natural -impulse, and he whose senses are unimpaired, and who has learned, at the -same time, amid the tumult of his sensations, to preserve proper -consideration for his wife—such a man runs little danger of making any -mistake. In opposition to the opinion of many, I regard it as entirely -right and reasonable that husband and wife should have intercourse -whenever physically and mentally impelled to that act. Nor do I see any -reason why, during the first period in which they are able to enjoy -without intermission the pleasures of sexual intercourse, they should, -in accordance with any theory whatever, impose on themselves further -restraints than those demanded by care for their physical and mental -health. The touchstone of marital hygiene is this, that on the day -following intercourse both husband and wife should feel perfectly fresh, -vigorous, and lively, alike in body and mind—even more so, perhaps, than -on other days. In the absence of such feelings, we may feel assured of -the occurrence of sexual excesses.” The same author quotes a saying of -_Pomeroy’s_: “We may quaff the nectar as freely as we will—nature -herself mixes the draught and holds the goblet to our lips; if, however, -we drink too much, she first dilutes the draught with water, later adds -gall, and ultimately perhaps deadly poison.” - -The occupation, trade, or profession, and the nutritive condition and -physical constitution of the married pair, have an important bearing on -the frequency with which, without detriment to health, cohabitation is -permissible. The rules of the Hebrew Talmud already take these -circumstances into account, ordering as they do that young and powerful -men not engaged in any regular occupation shall have intercourse with -their wives daily; manual labourers, on the other hand, once a week -only; whilst brain-workers, finally, or those whose work is extremely -arduous, should allow an interval of one or more months to elapse -between the acts of intercourse. _Acton_ also prescribes that in the -case of brain-workers and of those manual workers whose labours are -exhausting, intercourse must not occur more frequently than once every -week or ten days. - -The married couple should understand how to impose on themselves a -certain restraint in the matter of marital intercourse, without, -however, going so far as on altogether trifling grounds to refuse the -husband access to his wife. In this respect also, the opinions that have -recently come to prevail concerning the rights of women have had an -influence. _W. Acton_ relates a case that came under his observation in -which the wife refused to allow her husband any voice in determining -when and how often intercourse should take place; the wife, she -maintained without hesitation, since she had to bear the consequences of -intercourse, was fully justified, whenever she thought fit, in refusing -her husband’s embraces. - -The dangers to the sexual life of woman which are involved by the modern -woman’s rights agitation are seen already in the changes which the -emancipation of women in North America has produced in the functions of -woman as wife and mother. In that part of the world, everything possible -has been done “to transform” (to quote the words of a brilliant -journalist) “the doll into an independent existence, to enable the -helpless woman to earn her own subsistence, and the result of these -endeavors has been most striking. The American woman has obtained the -right to enter every profession and to follow every kind of occupation -which have hitherto been reserved for men; she is physician, lawyer, -merchant, professor; her boudoir has become an office, often connected -with the stock exchange by a private wire. Legally, also, she now -possesses the same rights as man; in many States she has both the -suffrage and the right of entering the house of representatives; she has -fully emancipated herself from her former condition of tutelage, and in -her shrillest tones can cry to heaven ‘I am free, I am independent, I am -emancipated, I am myself!’ And observe, as the result of all these -attempts at the conversion of woman into man, that in the matter of -marriage also she acts as if she were no longer woman. The American -woman no longer marries; perhaps, indeed, because she no longer has the -capacity. So long and so eagerly has she given herself up to masculine -occupations, that her inward feminine nature has also perhaps undergone -transformation, so that she has become affected with a kind of neutral -lack of desire. Unquestionably, the desire for marriage on the part of -this modern ‘emancipated’ woman has vanished in the most alarming -manner, there is a notable fall in the birth-rate, and the indigenous -(white) population actually threatens to disappear.” - -The wife acts wisely, not on hygienic grounds alone, in not always -acceding at once and unconditionally to her husband’s demand for the -repetition of intercourse. Her modest reluctance enhances her -desirability in the eyes of her amorous husband. Thus, _Shakespeare_ -makes Posthumus exclaim (Cymbeline, Act II., Sc. 5, l. 9): - - “Me of my lawful pleasure she restrained - And prey’d me oft forbearance; did it with - A pudency so rosy the sweet view on’t - Might well have warmed Old Saturn.” - -Especially justified is such refusal when coitus has been already once -or twice performed, or when the consumption of alcoholic beverages has -made the husband unduly lustful. On the other hand, the refusal of -intercourse when demanded by the husband should never depend upon -baseless feminine caprice, or upon the now so frequently asserted -“rights of women.” - -Experience has long ago established as a fact that unduly frequent -satisfaction of the sexual impulse entails serious consequences to the -health of the individual. And in the case of the wife these consequences -may be especially disastrous when intercourse is indulged in recklessly -during menstruation, during all stages of pregnancy, and even during the -puerperium. “Incontinence during menstruation leads to serious -circulatory disturbances and to the consequences of these disturbances; -during pregnancy it is likely to give rise to miscarriage; during the -puerperium, to congestions and inflammations. Should conception occur as -a result of intercourse during the lying-in period (and this may happen -very shortly after childbirth), abortion, and even more serious -consequences, are likely to ensue. By intercourse during lactation, the -premature recurrence of the menstrual flow is induced, and the gradual -reversion of the reproductive apparatus to the condition in which it was -before pregnancy (the process of involution) is hindered; moreover, the -secretion of milk is diminished or even entirely suppressed.” In these -terms _Hegar_ depicts the consequences of premature resumption of -marital intercourse, taking perhaps a somewhat extreme view of the -matter. - -Nevertheless, this author is undoubtedly right in declaring that one of -the principal disadvantages to a woman of excessively frequent sexual -intercourse is that pregnancy occurs too often. It is astonishing to -observe the number of full-term deliveries and miscarriages that a woman -will experience within a comparatively short period of time, as is seen -too frequently among the labouring classes and more especially among -factory workers. “If we assume the ordinary mortality of childbed to be -6 per mille, a woman who in the course of 15 years undergoes labour (at -full term or prematurely) 16 times, runs a risk of death to be expressed -by the ratio of 6 × 16 = 96 per mille; that is to say, on the average, -of 1,000 women who become pregnant as often as this, nearly 1 in 10 will -die in childbed.” - -Young men who have previously suffered from gonorrhœa and who wish to -marry, must, unless they wish to cause unspeakable misery, undergo an -exact and thorough examination; not only must the physician inquire as -to the presence of certain symptoms, such as smarting during -micturition, adhesion of the lips of the urethral meatus, “clap-threads” -in the urine, etc., but during a considerable period of time repeated -microscopical examinations of the urine must be undertaken, and the -filaments, if present, must be examined for gonococci. The physician -will also have to determine whether any vestiges remain of epididymitis, -and whether the quality of the semen has been impaired by the attack of -gonorrhœa. Unfortunately, it is not yet within our power absolutely to -forbid marriage to a man exhibiting all the symptoms of chronic -gonorrhœa; but it is the duty of the physician to explain to such a man -the scientific views regarding this matter that now prevail, in order to -furnish him with the grounds for a decision. - -It is not possible, when discussing the hygiene of married life, to -preserve silence respecting the extremely pressing question of the use -of measures for the prevention of conception, for in recent years their -use has become extraordinarily general, chiefly, indeed, in the upper -and middle classes of society, but to some extent also among the -working-class population. Although we devote a special chapter to this -topic, we must here express the opinion that, except in certain -instances in which their employment can be justified on carefully -weighed and well-established medical grounds, the use of any mechanical -or chemical means for the prevention of conception must be -discountenanced as injurious to health. The wife who wishes to preserve -her psychical purity and moral chastity, which is not only possible in -marriage but also greatly to be desired, must not concern herself much -with the technique of the sexual life, but must give herself up to -sexual enjoyment only as the result of a delicate and immediate bodily -and mental desire. Not only for reasons of national economy regarding -the means of providing for the family, but also for well-grounded -personal reasons regarding the wife’s health, must the latter be spared -an unduly rapid succession of pregnancies and confinements. And this -should be effected by a certain degree of continence and by the -observation of extensive periods of sexual quiescence. - -To preserve a woman’s health during the acme of her sexual activity, a -careful general hygiene is an important requisite. The dwelling should -be dry and roomy; above all the bedroom should not be too small, neither -damp nor dark, and it should be well ventilated. The wife’s occupations -should be so arranged as to afford a suitable alternation of activity -and repose, and there should be as little night work as possible. -Certain occupations are especially potent in the causation of the -diseases peculiar to women, principally, for the reason that they do not -permit of the requisite repose during menstruation. Thus, washerwomen, -vocalists, and sewing-machine operatives, suffer with especial frequency -from diseases of the genital organs. - -Great care in the cleansing of the genital organs is indispensable in -the case of women; the vulva and its environment should be frequently -and carefully washed; and an occasional vaginal injection is -advantageous. As regards the last-named measure, however, we must point -out that it is possible to err by excess as well as by defect, and that -a daily vaginal douche can by no means be regarded as a necessary part -of the hygiene of the reproductive organs. For recent researches have -shown, on the one hand, that the vagina constitutes a natural mechanism -for the destruction of pathogenic organisms, and on the other hand, that -complete disinfection of the vagina is extremely difficult to effect. -Inflammations of the vulva, which are somewhat frequent in consequence -of excessive perspiration and undue discharge from the genital canal, -demand careful cleansing with soap and water and the use of a soft -brush. The addition to the water of lysol (in the proportion of ¼ to ½ -per cent.) is advantageous. A general bath or a local sitz bath, the -water being moderately warm (95°–99° F.; 35°–37° C.), may be recommended -on grounds of beauty as well as of health, and should be taken at least -once a week. - -The regular use of lukewarm sitz baths is a most valuable hygienic -measure for the prevention of various general or local disturbances -consequent upon increased flow of blood to the genital organs. These -local baths are best taken at a temperature of 95° F. (35° C.), and -should last twenty minutes; they should be taken just before going to -bed, and while sitting in the hip bath the skin of the abdomen and of -the lower part of the back should be rubbed with the hand encased in a -friction-glove. The bather on leaving the bath should get straight into -bed, and should dry herself beneath the bedclothes, rubbing the skin -till it glows. Such sitz baths serve also to keep the external genitals -clean, and to guard against infection. For vaginal douching, water -sterilized by boiling should be employed, and where any catarrh of the -vaginal mucous membrane is present, some alum, permanganate of -potassium, or boric acid may be added with advantage; the pressure of -water, when a vaginal douche is given, should never be high, the -reservoir of the irrigator being raised not more than twenty inches -above the outlet of the nozzle; as a rule the water should be lukewarm; -the patient should be in the recumbent posture. The reservoir of the -irrigator and the intra-vaginal nozzle are most suitably made of glass, -to insure cleanliness; the nozzle should not be thrust too far in, two -inches being quite sufficient. After the use of the douche, the woman -should remain ten or fifteen minutes in the recumbent posture. - -In addition to the hygienic employment of such full baths and local -baths, a number of mineral baths have important therapeutic applications -in cases of disease of the female genital organs, the traditional value -of such baths having been scientifically endorsed by the modern science -of balneo-therapeutics. By means of suitably selected mineral water -baths, a powerful derivative stimulus may be given to the skin, and the -affected reproductive organs may thus be beneficially influenced. -Further, in acute inflammatory conditions or hyperæmia of the uterus or -its annexa, these baths have an antiphlogistic influence; on the other -hand, when intrapelvic exudations have formed, the baths promote the -absorption of these inflammatory products; again, in congestive states -of the female genital organs, with relaxation, thickening, and -hypersecretion of the genital mucous membrane, the baths have an -astringent and tonic influence on the tissues; finally, they have a -favorable effect on the innervation and nutrition, not only of the -reproductive apparatus, but of the entire organism. It is easy to -understand why women during the menacme are frequent visitors to spas. - -At this period of life, and especially in women who lead luxurious -“society” lives, the thoughts tend strongly in the sexual direction; to -avoid this, and to prevent the ever more and more frequent breaches of -marital fidelity, the best means are the practice of vigorous bodily -exercises, and active employment, either in household affairs or in -intellectual occupations. Cold sponging of the body or cold full baths -will also be found an excellent measure for the prevention of sexual -excess. In such cases also the diet should be limited, strong and -stimulating food should be avoided, but little butcher’s meat should be -taken, whilst green vegetables and raw and cooked fruits should be -liberally consumed; at the same time, all alcoholic beverages must be -rigidly prohibited. Moreover, care must be taken that during the night -there should be no undue physical stimulation in consequence of -excessively warm and soft bedding; hair mattresses are to be preferred -to feather beds, with light down quilts for a covering. Finally, no -stimulation of an erotic character should be offered to the imagination, -and for this reason equivocal literature and lascivious dramatic -representations must be avoided. By a sufficiency of occupation, -regular, interesting, and demanding a considerable expenditure of -physical energy, a woman may be enabled to a great extent to escape the -inconvenience and distress attendant on entire or partial lack of -gratification of the sexual impulse. - -It cannot be disputed that a certain and moderate amount of sexual -gratification is requisite for the perfect maintenance of physical -health in woman, and that the absence of this gratification, or the -gratification of the impulse in an abnormal or incomplete manner, -entails disturbance of alike the mental and the physical equilibrium; -but, on the other hand, the deleterious consequences of sexual -abstinence have been greatly exaggerated by many writers—both by -physicians and social economists. Owing to the fact that to the -cultivated woman sexual gratification is possible only in the married -state, whilst social conditions render marriage impossible to many women -greatly in need of such gratification; in consequence, also, of the -modern and ever more widely diffused practice by husbands of coitus -interruptus altogether regardless of the woman’s need for complete -sexual gratification—there arise in women numerous local disorders and -nervous disturbances, hysteria and even insanity being results by no -means infrequent. The significance of ungratified sexual impulse in the -pathogenesis of nervous disorders has been established by _von -Krafft-Ebing_, who points out that in unmarried women insanity most -frequently occurs between the ages of twenty-five and thirty-five years, -during the decade, that is to say, in which youthful bloom and the hopes -of marriage simultaneously disappear; whereas in the male sex the -greatest incidence of insanity is between the ages of thirty-five and -fifty years, the period of life in which the struggle for existence is -fiercest. - -_Hegar_, on the other hand, is a firm opponent of the view that the -favourable influence of marriage is overrated. According to this author, -the favourable effect of marriage in respect of mental disorders is to -be found, not in the gratification of the sexual impulse, but in the -ethical factors of marriage. Statistics show that even in the favourable -circumstances of marriage, sexual gratification has in women an -unfavourable influence, inasmuch as the proportion of sufferers from -mental disorders is higher among married women than it is among married -men. A study of the mental disorders which in women are especially -associated with the process of reproduction (puerperal mania) confirms -this impression. _Hegar_ insists that he has never seen nymphomania -arise in women in consequence of forcible repression of the sexual -impulse; but that he has not infrequently seen this disorder result from -unnatural excesses or from long-continued sexual irritation, especially -in hereditarily predisposed persons. Such unnatural stimulation of the -female is not infrequently practiced by the male—by the lover and even -by the husband—it may be because he himself derives pleasure from such -perverted practices, and wishes to obtain sexual gratification without -the risk of impregnation, or because he is himself incompetent for -normal complete intercourse. _Hegar_ is further of opinion that in the -causation of hysteria and also in that of chlorosis the repression of -the sexual impulse plays a quite subordinate rôle. And he regards as -pure fable the belief that continence in women is liable to lead to the -formation of mammary, uterine, or ovarian tumors. He would more readily -incline to the contrary opinion; the reproductive process being in this -respect distinctly disadvantageous to the female sex. The unfavorable -influence of the reproductive process is shown most clearly in the case -of carcinoma of the uterus; the majority of the patients suffering from -this disease are either married or widowed, and many of them have given -birth to a large number of children. “Gratification of the sexual -impulse, and more particularly the reproductive process, give rise in -women to the formation and growth of tumors, cause numerous mechanical -disturbances, and open the way to infection with various pathogenic -organisms.” - -_Hegar_ considers that there is hygienic justification for the -limitation of the number of children to which a woman gives birth. The -most suitable age for motherhood lies in his opinion between the ages of -twenty and forty years. Childbirth in women younger or older than this -entails too much danger both to mother and child. At least two and a -half years ought to elapse between two successive births; and these -figures give us eight as the maximum family. If we assume that the -duration of pregnancy is nine months, and that of lactation nine to -twelve months (or in cases in which the mother does not nurse her own -infant, that a like period must be devoted to the careful supervision of -the wet-nurse or of the methods of artificial feeding), we cannot -consider it unreasonable to devote a further period of from six to nine -months to the complete reestablishment of the woman’s health. “Moreover, -woman does not exist solely for the purpose of subserving during two -decades of her life the processes of reproduction. And to permit the -maximum number of children to be as great as eight, we must presuppose -that the woman is in perfect health, and that she lives in a perfectly -healthy environment. Any illness or infirmity which renders the duties -of housekeeping and the rearing of the existing family unduly difficult, -indicates the need for a further limitation of child-bearing. And if the -reproductive function is to be rationally controlled, we must above all -attend to the age and the health of the parents. Occupation, habitation, -and general environment have also to be considered. The correct ideal is -indeed not difficult to discover.” - -_Hegar_ concludes that strict moderation and even absolute continence in -sexual matters are often, and for long periods of time, a pressing duty. -“The numerous and various disasters which are brought upon the world by -unbridled and unregulated sexual passion can be prevented only by -enlightenment, moderation, and continence. If marriage were postponed -until the attainment of complete physical maturity, in women till the -age of 20, in men till the age of 25, while at the same time procreation -were no longer undertaken by women above the age of 40 or by men above -the age of 45 to 50 years; if, again, between successive pregnancies a -sufficient pause for the woman’s recuperation were insisted upon, and -intercurrent illnesses and states of debility were taken into account; -and if, finally, sickly individuals, those hereditarily predisposed to -disease, and those in any way below par either mentally or physically, -were more than heretofore prevented from marrying; then the increase of -population, which in Germany is unquestionably too rapid, would to some -extent be checked. Thoroughgoing regulation of the reproductive process -will not, however, be thus attained without the adoption of a method of -selection too rigorous for present-day notions; and for a further -advance we must in the meantime depend upon moderation and continence.” -As regards the modern demand of the “right to love,” the same -experienced gynecologist writes: “Whoever preaches to mankind the -doctrine that ‘a man sins against his own personality if he neglects to -exercise every limb he possesses, and if he denies himself the -gratification of every natural impulse,’ or the doctrine that ‘it is the -duty of every human being to gratify all his natural impulses, since -these are most intimately inter-connected with his personality—are -indeed his personality itself;’ such a preacher does harm to his kind. -Such rights and such duties are chimerical for this reason if for no -other, because two persons are necessary in the case of sexual -gratification, and sometimes—though not as often as might be wished—Hans -fails to find his Grete, without any consequent loss to society at -large.” - -An especially important chapter in the history of woman at this period -of life relates to the dietetics of pregnancy and parturition, and to -the regulations to be observed for the maintenance of health at this -time and in connection with the processes of pregnancy, parturition, -puerperal involution of the uterus, and lactation. This subject cannot -now however be considered at length, and for our present purposes it is -sufficient to point out how important it is alike for mother and child, -alike for family and society, that the ever more and more widely and -generally diffused practice of the artificial feeding of infants should -be abandoned, and that there should be a return to the natural method -according to which each mother nurses her own infant. The prevailing -custom costs every year thousands of mothers their health, and thousands -of children their lives. - - - COPULATION AND CONCEPTION. - - - _Copulation._ - -The reproduction of the species is effected by means of an act of -copulation on the part of a male and a female individual, both of whom -must have attained complete sexual development. In all the sequence of -reproductive processes it is copulation alone that is a voluntary act, -all the other processes being independent of the will and even of -consciousness. - -A characteristic difference between man and the lower animals lies in -the fact that in the human species sexual pleasure and the act of -copulation may occur at any season of the year; and a further -characteristic difference may perhaps be found in the fact that in the -great majority of individuals of the human species the psychical process -of “love” plays a determinative part. _Voltaire_ pointed out that to man -alone among animals are known the embrace and the joy of the kiss. - -The significance of the kiss is depicted by _Grillparzer_ in the -following verses: - - Auf die Hände küsst die Achtung, - Auf die Wangen Wohlgefallen, - Seelige Liebe auf den Mund. - Auf den Nacken das Verlangen; - Uberall sonsthin Raserei.[45] - -In this act of conjugation between two individuals of the same species, -differentiated each from the other by the characteristics of sex, the -active, provocative rôle is allotted to the male, the passive, receptive -rôle, to the female. The modest and coy reluctance characteristic alike -of the maiden and of the wife, promote an increase of sexual excitement -in the opposite sex, and this not only in a man of purely sensual -character, whose vanity is stimulated by his being the chosen one among -many—a circumstance which, in view of the great dependence of the sexual -act upon psychical processes and imaginative influences, is by no means -devoid of importance. The woman’s coy reluctance must be overcome by -means of a tender strategy before she is willing to grant the final -possession of her body; and the act of copulation forms at the same time -the conclusion of the physical and mental yearnings of the lover, and -the commencement of the new-coming being. There is thus a physiological -reason for the advice given by the celebrated surgeon, _Ambroise Paré_, -that a man, before completing coitus, should employ some of the delicate -and sensually stimulating manipulations of the earlier stages of -courtship, for, he writes, “aucunes femmes ne sont pas si promptes à ce -jeu que les hommes.” - -The potency for intercourse of the sexually mature man, his capacity for -the introduction of the erect penis during the act of copulation, is -dependent on the fact that sexual excitement gives rise to a sufficient -stimulus which, acting on the erection centre (and presuming that the -centre and its afferent and efferent tracts are normal), leads to an -increased flow of arterial blood to the penis and a diminished outflow -through the veins of that organ, and consequently to its erection. The -cerebrum is the organ in which the sensation of libido sexualis, of -sexual excitement, has its seat; with this higher centre is connected by -means of intercentral nerve tracts a lower, mechanical, reflex centre, -situated in the lumbar enlargement of the spinal cord, and presiding -over the performance of the act of copulation; it is moreover probable -that nerve fibres proceed from the spinal cord direct to the blood -vessels of the erectile tissue, by means of which the calibre of these -vessels can be lessened or their extensibility diminished. The relation -of the erector nerves (nervi erigentes) to the penis is by many -physiologists compared to the relation of the vagus nerve to the heart. -In the quiescent state the small arteries of the penis and perhaps also -the cavernous spaces of that organ are in a state of mean contraction, -so that they offer a considerable resistance to the passage of the blood -current. When now the nervi erigentes are excited to activity, the -hitherto tonically contracted vessels of the penis undergo, according to -the school of physiologists just mentioned, relaxation, so that they -dilate under the pressure of the blood within their walls, and, the -previous resistance to the flow being now removed, the blood pours -freely into the cavernous spaces of the penis, and distends these to the -uttermost. In this manner erection is effected, rendering possible the -insertion of the penis into the genital passage of the female; with the -culmination of the sexual act, the semen is ejaculated, the muscles of -the prostate and the membranous portion of the urethra together with the -ischiocavernosus and bulbocavernosus muscles, all acting strongly and -simultaneously. - -By the contraction of the muscular apparatus just described, the penis -is constricted in the neighborhood of the pubic symphysis, and this -further hinders the outflow of the blood from the corpora cavernosa, -increasing the intensity of the state of erection of the penis. Should -the relaxation of the corpora cavernosa, dependent upon the stimulation -of the nervi erigentes, be incomplete, it is not possible for sufficient -blood to pass into the cavernous spaces to exercise considerable -pressure upon the efferent veins, and thus complete erection fails to -occur. If, again, the contraction of the muscular apparatus at the root -of the penis is insufficiently vigorous, complete erection likewise -fails to occur; the organ becomes semi-erect only, or erect for a period -too short to permit of the completion of intercourse. - -Since, physiologically speaking, conception is the purpose with which -copulation is effected, the ejaculation of the semen must be regarded as -the principal object of that act; now in normal conditions, ejaculation -takes place only when the penis is fully erect. Associated with the -erection of the corpora cavernosa is a swelling of the caput -gallinaginis, whereby the orifices of the ejaculatory ducts are directed -forwards toward the membranous portion of the urethra, and at the same -time the backward passage to the bladder is cut off. By this mechanism, -the urethra, which usually serves as the canal for the outflow of urine, -is made for the time being solely subservient to the purposes of the -sexual act. That the outlet from the bladder is obstructed by the -swollen caput gallinaginis when the penis is erect, is shown by the -familiar fact that a man whose penis is erect cannot pass water, -although the way is freely open for the ejaculation of the semen. - -Before ejaculation begins, the urethral glands already begin to secrete; -and when erection is powerful and prolonged, this secretion often makes -its appearance at the urethral orifice in the form of drops of a clear -somewhat tenacious fluid. _Ultzmann_ considers that the function of this -secretion is probably to moisten the walls of the urethra, over which -the acid urinary secretion is continually flowing, with a protective -alkaline fluid, and thus to prepare the canal for the passage of the -semen. An analogy may be found in the secretion of the cervical glands -of the uterus in the female, for this secretion has been found to -enhance the activity of the movements of the spermatozoa. If now during -copulation the moment of ejaculation begins, the male experiences at the -same time a sense of voluptuous pleasure and a feeling of muscular spasm -in the perineal region, and this indicates the commencing evacuation of -the contents of the seminal vesicles through the ejaculatory ducts. -Simultaneously, the secretion of the prostate is poured into the -urethra. The semen now gradually passes out through the narrow -ejaculatory ducts, and, since in consequence of the swelling of the -caput gallinaginis, it cannot pass backwards towards the bladder, it -runs forwards, and accumulates in the bulb of the urethra, the -physiological excavation of that tube. As soon as a considerable -quantity of the semen has collected in this situation, so that the bulb -of the urethra becomes distended, reflex contractions of the -bulbocavernosus muscles ensue, by means of which the seminal fluid is -forced out of the urethral orifice. In cases in which this muscular -apparatus does not function properly, as in the paralytic form of -impotence, the semen during ejaculation is not ejected in a forcible -jet, but rather flows slowly, as from a lax tube partially filled with -fluid, from the urethral orifice. - -We are indebted to _Roubaud_ for a classical description of the -phenomena of copulation, and this description is here appended. It runs -as follows: “As soon as the penis enters the vaginal vestibule, it first -of all pushes against the glans clitoridis, which yields and bends -before it. After this preliminary stimulation of the two chief centres -of sexual sensibility, the glans penis glides over the inner surfaces of -the two vaginal bulbs; the collum and the body of the penis are then -grasped between the projecting surfaces of the vaginal bulbs, but the -glans penis itself, which has passed further onward, is now in contact -with the fine and delicate surface of the vaginal mucous membrane, which -membrane itself, owing to the presence of erectile tissue between its -layers, is now in an elastic, resilient condition. This elasticity, -which enables the vagina to adapt itself to the size of the penis, -increases at once the turgescence and the sensibility of the clitoris, -inasmuch as the blood that is driven out of the vessels of the vaginal -wall passes thence to those of the vaginal bulbs and the clitoris. On -the other hand, the turgescence and the sensitiveness of the glans penis -itself are heightened by compression of that organ, in consequence of -the ever increasing fulness of the vessels of the vaginal mucous -membrane and the two vaginal bulbs. - -“At the same time the clitoris is pressed downward by the anterior -portion of the compressor muscle, so that it is brought into contact -with the dorsal surface of the glans and of the body of the penis; in -this way a reciprocal friction between these two organs takes place, -repeated at each copulatory movement made by the two parties to the -action, until at length the voluptuous sensation rises to its highest -intensity and culminates in the sexual orgasm, marked in the male by the -ejaculation of the seminal fluid, and in the female by the aspiration of -that fluid into the gaping external orifice of the cervical canal; so -true, indeed, is this, that it is a difficult matter to give a picture -at once accurate and complete of the phenomena attending the normal act -of copulation. Whilst in one individual the sense of sexual pleasure -amounts to no more than a barely perceptible titillation, in another -that sense reaches the acme of both mental and physical exaltation. - -“Between these two extremes we meet with innumerable states of -transition. In cases of intense exaltation, various pathological -symptoms make themselves manifest, such as quickening of the general -circulation, and violent pulsation of the arteries; the venous blood, -being retained in the larger vessels by general muscular contractions, -leads to an increased warmth of the body; and further, this venous -stagnation, which is still more marked in the brain in consequence of -the contraction of the cervical muscles and the backward flexion of the -neck, may cause cerebral congestion, during which the consciousness and -all mental manifestations are momentarily in abeyance. The eyes, -reddened by injection of the conjunctiva, become fixed, and the -expression becomes vacant; lids close conclusively, to exclude the -light. In some, the breathing becomes panting and labouring; but in -others, it is temporarily suspended, in consequence of laryngeal spasm, -and the air, after being pent up for a time in the lungs, is finally -forcibly expelled, and they utter incoherent and incomprehensible -words.” - -The impulses proceeding from the congested nerve-centres are confused. -There is an indescribable disorder both of motion and of sensation, the -extremities are affected with convulsive twitchings, and may be either -moved in various directions or extended straight and stiff; the jaws are -pressed together so that the teeth grind against each other; and certain -individuals are affected by erotic delirium to such as an extent that -they will seize the unguarded shoulder, for instance, of their partner -in the sexual act, and bite it till the blood flows. - -A period of exhaustion follows, which is the more intense in proportion -to the intensity of the preceding excitement. The sudden fatigue, the -general sense of weakness, and the inclination to sleep, which -habitually affect the male after the act of intercourse, are in part to -be ascribed to the loss of semen; for in the female, however energetic -the part she may have played in the sexual act, a mere transient fatigue -is observed, much less in degree than that which affects the male, and -permitting far sooner of a repetition of the act. “_Triste est omne -animal post coitum, praeter mulierem gallumque_,” wrote _Galen_, and the -axiom is essentially true, at any rate so far as the human species is -concerned. - -The question has been mooted, and many earnest inquirers have devoted -much thought thereto, whether in this moment of most intense sexual -gratification it is the male or the female that experiences the greatest -amount of pleasure. As in the case of all questions the data for the -solution of which are at once very various and very variable, so in this -case also, very different opinions have been put forward. “In fact,” -writes _Roubaud_, “when we take into consideration all the circumstances -by which the intensity of sexual sensation is influenced, it may well be -doubted if it is at all possible to find an a priori solution for the -problem. When we take into consideration the influence exercised by -temperament, constitution, and a large number of conditions both general -and special, on sexual sensibility, we cannot fail to be convinced that -this problem, in consequence of all the complicated characteristics it -presents, is actually insoluble.” - -In regard to the pleasure experienced in the act of intercourse, a -remarkable distinction is drawn by _Gutceit_. The male, in every case -and with every woman, experiences the full degree of pleasure; and even -though from the mental point of view this pleasure may be enhanced by -inclination, attraction, and mutual love, from the physical point of -view there is no difference between different acts of intercourse, so -that the cynical old Roman was right when he wrote. “_Sublata lucerna -nullum discrimen inter foeminas._” But in the case of the female it is -very different. Her first experience of sexual relations is a very -painful one, and this pain prevents all enjoyment as long as it -continues, as it does in many women for one, two, or even four weeks. -And when this period is once over, not more than two women in every ten -experience the pleasure of sexual intercourse in its full intensity. Of -the remaining eight, four have indeed an agreeable sensation during the -rubbing movements of the sexual act, but it is a long time before they -experience a sensation analogous in its intensity to that which in man -accompanies the act of ejaculation. In some women it may be six months -after marriage before the true sexual orgasm is experienced, in others -it may be a year, or even several years; in a considerable number this -does not happen until after they have given birth to several children. -As a result of numerous observations on this point, _Gutceit_ asserts -that in women sexual pleasure is experienced only in intercourse with a -man who is beloved, or against whom, at least, no repulsion is felt; and -that no pleasure is felt by a woman in intercourse with a man towards -whom she feels an actual dislike. Further, he maintains, that a woman, -loving another man, and feeling pleasure in intercourse with him, has on -the other hand no voluptuous sensations during intercourse with her -husband, whose embraces she permits only from a sense of duty. Thus in -the male, intercourse is always pleasurable, while in the female, -pleasure is experienced only when certain conditions are fulfilled. - -Contact with the male genital organs stimulates in the female the -sensory nerves of the vulva, the vestibule, and the vagina; the nervous -stimulus is transmitted to the cerebral cortex, where it gives rise to -the sensation of sexual pleasure, and causes, through the intermediation -of the genito-spinal centre, a number of reflex actions. As sensory -nerve terminals of such reflex arcs, the final ramifications of the -pudic branch of the sciatic plexus play the most important part; in the -clitoris these nerves are beset with a peculiar kind of end-bulbs, the -genital corpuscles discovered by _W. Krause_; from their structure these -corpuscles seem admirably adapted to respond to the very slightest -stimulation, producing voluptuous sensations and perceptions, and giving -rise to various reflex manifestations. The first part of the path of the -afferent impulses by which sexual pleasure is aroused is constituted by -the dorsal nerves of the clitoris. The reflex changes consequent upon -sexual excitement begin already in the vestibule, inasmuch as the -secretion of Bartholin’s glands, which are compressed by the action of -the constrictor cunni muscle, is expelled during coitus, the secretion, -owing to the situation of the orifices of Bartholin’s ducts, passing -over the external genitals. The clitoris becomes erect; the blood in the -bulbs of the vestibule, the venous plexus situated around the margin of -the vestibule along the boundary between the labia majora and the labia -minora, is pressed into the glans clitoridis, the erection and -sensibility of this structure being proportionately heightened. By the -action of the constrictor cunni and ischiocavernosus muscles, the -clitoris, the distal extremity of which is bent downwards at a right -angle, is drawn down and pressed against the penis. - -At the entrance of the vagina is the sphincter vaginæ muscle, whose -action is reinforced by muscular fibres running in the middle coat of -the vagina itself. It is probable that the muscular activity of the -vagina and the uterus facilitates the entrance of the semen into the -cavity of the uterus. - -Dorsal decubitus is rightly regarded as the most correct position, -physiologically speaking, for the woman to assume during coitus. That -from the earliest times and in the most diverse races, this position has -been customary, is shown by numerous antique paintings and statues, and -by the reports of those who have studied the customs of savage races. -Various other positions are, however, occasionally assumed; thus, -_Ploss_ and _Bartels_ report, that among the Soudanese, coitus is -practiced in the erect posture, with the man standing behind the woman; -that among the Inuits (Eskimo), the act is performed in the manner usual -among quadrupeds; that among the Swahelis in Zanzibar, and among the -indigens of Kamschatka, the lateral posture is customary; and that among -the Australian blacks, coitus is usually effected in the crouching -posture, both parties squatting on their hams. The same writers remind -us, that in the old calendars of the fifteenth, sixteenth, seventeenth, -and eighteenth centuries, definite commands and prohibitions for the -conduct of marital intercourse are to be found, and that lucky and -unlucky days, respectively, are specified for the performance of the -act. These recommendations would appear to be relics of antiquity, for -in the Sanscrit work _Kokkogam_, under the heading “_Sexual Intercourse -According to the Days of the Month_,” exact instructions are given for -the proper performance of coitus. - -In the _Kamasutra_ (the Indian _ars amatoria_, a work only in recent -days rendered accessible to European readers in the translation of _R. -Schmidt_), several chapters are devoted to the detailed description of -the various methods of copulation, and rules are given for the carnal -union of man and wife. But, as the Indian author justly remarks, “Rules -are of value only for the control of moderate desire; when the wheel of -passion has once begun to roll, to prescribe a course is no longer of -any avail.” In this work, sixty-four varieties of erotic enjoyment are -enumerated, and we find an _explicatio coitus secundum mensuram, tempus, -naturam, de modis inter coitum procumbendi, de minis coitibus, de coitu -inverso, de viri inter coitum consuetudinibus_. - -At times, in order that coitus may be effective, some other position -than the natural one is indispensable. Such a necessity has been -recognized even by theologians, by whom any divergence from nature in -this matter has usually been regarded as sinful. For instance, in the -work of _Craisson_, _De Rebus Venereis ad Usum Confessariorum_, we read: -“_Situs naturalis est ut mulier sit succuba et vir incubus, hic enim -modus aptior est effusionis seminis virilis et receptioni in vas -femineum ad prolem procreandum. Unde si coitus aliter fiat, nempe -sedendo, stando, de latere, vel praepostere (more pecudum), vel si vir -sit succubus et mulier incuba, innaturalis est.... Sed tamen minime -peccant conjuges si ex justa causa situm mutent, nempe ob aegritudinem, -vel viri pinquetudinem, vel ob periculum abortus; quandoque ait St. -Thomas, sine peccato esse potest quando dispositio corporis alium modum -non patitur._” - -In certain pathological states, as for the prevention of sterility, an -abnormal posture during coitus may advantageously be recommended, in -order to favour the entrance of the semen into the cervical canal, and -to allow the semen to stay longer in the vagina before it flows out. An -old and often efficacious means for this purpose is the performance of -coitus with the woman in the knee-elbow posture. In order to favour the -entrance of the semen into the deeper portion of the genital tract, -_Hegar_ and _Kaltenbach_ recommend that after coitus the woman should -remain for some time in the knee-elbow posture, while the man from time -to time gently presses up the anterior abdominal wall, and then abruptly -relaxes the pressure.—In the _Talmud_, coitus was regarded as unfruitful -if performed when the woman was in the erect posture. - -_Casper_ reports the case of a woman with severe scoliosis, who had long -remained sterile, and who only conceived (and was subsequently happily -delivered) after performing coitus in the abdominal decubitus. - -_Guéneau de Mussy_ suggests the following, very characteristic, method -of ensuring fertilization, one which also certainly dates from great -antiquity: “_Sed haud illicitum mihi visum est, si post diversa -tentamina diutius uxor infecunda manserit, ipsum maritum digitum post -coitum in vaginam immittere, et ita receptum semen uteri osteo admovere. -Et cum ostiolo uteri haeret, ut in pervium canalem spermatozoidum -motibus faventibus, prodeat, sperare non absurdum._” _Eustache_ reports -a case, the wife of a physician, in which this manoeuvre was effective -in ensuring conception. - -A similar procedure has been employed with success by Kehrer, in a case -of enfeebled potency on the part of the male, leading to premature -ejaculation. A speculum was introduced into the vagina, and through this -instrument the semen, ejaculated in consequence of sexual excitement, -was introduced into the vaginal fornix; conception ensued. In an -analogous manner, _A. Peyer_ recommended, in a case of partial -impotence, in which special manipulations were needed to bring about -ejaculation, that conception should be favoured in the following manner: -Erection having been effected by ordinary sexual contact, the -manipulations needed to produce ejaculation were carried out, and the -penis was intromitted into the vagina the moment before ejaculation -occurred. This has been done with fruitful results. _Englisch_ reports -the case of a hypospadiac who, in order to render coitus effective, used -a condom in the anterior extremity of which he made an aperture. In this -way he became the father of three children. - -In very obese men with extremely protuberant abdomens, we may recommend -for the furtherance of conception that they should have intercourse with -their wives _a parte posteriori_; and the same recommendation may be -made in cases in which the wife herself is extremely obese. In -Australia, it is said that among the indigens, coitus is usually -practiced _a posteriori_; and there is a saying in the Talmud to the -effect that sexual intercourse performed in the ordinary manner does not -lead to the conception of infants so good, wise, talented, and promising -as those whose conception is the result of coitus _a posteriori_. -Mohammed, on the other hand, declares, “Your wives are your tillage, go -therefore unto it in whatsoever manner ye will.” - -In cases of retroflexion of the uterus, with a markedly forward -direction of the vaginal portion of the cervix, I have recommended to -the husband that he should perform coitus with his wife in the upright -sitting posture. In this posture the fundus uteri passes downwards and -forwards, whilst the vaginal portion of the cervix passes upwards and -backwards. - -In cases of retroversion of the uterus with the formation of a -cul-de-sac in the posterior vaginal fornix, _Pajot_ recommends, with the -aim of temporarily restoring the uterus to a position in which the -occurrence of conception is favored, that for three or four days prior -to coitus the patient should retain the fæces, eating the while freely -of eggs and rice, and taking a small opium pill every evening; in cases -of anteversion, the patient should retain her urine for a considerable -time—five or six hours—before coitus; and in cases of lateral version he -recommends that the patient should have intercourse while lying on that -side towards which the vaginal portion of the cervix is directed. - -_Edis_ recommends that in cases in which there is sterility dependent -upon backward displacements of the uterus, that the organ should be -replaced while the patient is in the genu-pectoral posture, and a -pessary inserted; coitus should then be effected without the patient’s -changing her posture. - -In the human species as compared with the lower animals, there has been -a notable diminution in the frequency of the separate acts of -intercourse, a diminution dependent upon the higher vital aims of the -former. _Burdach_ formulates as a physiological law that the frequency -of sexual intercourse is inversely related to the duration of the act. - -Amongst all civilized races, sexual intercourse ceases during -menstruation, since in the normal man there is aversion to intercourse -with a menstruating female. - -By the Mosaic law, intercourse with a woman during menstruation and for -seven days after the cessation of the flow, was forbidden under pain of -death. The _Talmud_ further ordains that a purifying bath shall be taken -by the woman a week after menstruation. By intercourse itself, moreover, -both man and woman were rendered unclean to the evening; and, according -to the Mosaic law, both must bathe after the act of coitus. In the -_Koran_, also, intercourse is forbidden during menstruation, and until -the woman has been purified with water. The law’s of Islam demand from a -man who marries a virgin that he shall have intercourse with her the -first seven nights in succession; whilst he who marries a wife no longer -virgin, needs to visit her only the first three nights in succession. -Subsequently, during married life, the Mohammedan shall have intercourse -with his wife regularly once a week. Amongst many savage races, -intercourse is forbidden with a woman during pregnancy, the puerperium, -and lactation. - -The first act of intercourse is difficult and painful to the virgin. At -times the rupture of the hymen is exceedingly difficult. Even after -this, it is some time before genuine pleasure is experienced in sexual -intercourse. - -To the female, intercourse is harmful when performed with undue -frequency, or during menstruation, or indiscriminately throughout -pregnancy, or during the puerperium, or incompletely or in an unnatural -manner, or finally when performed in an unsuitable bodily attitude. - -“Unduly frequent performance of the act of coitus,” writes _Hegar_, -“which is liable to occur either in marital or in illicit intercourse, -gives rise to anæmia, defective nutrition, muscular weakness, -intellectual and nervous exhaustion. Young and healthy individuals -recuperate rapidly after excesses of brief duration, as is often seen in -young married pairs. Sickly and elderly persons, on the other hand, are -much more severely affected by sexual excess, and recover therefrom but -slowly if at all. Long continued sexual excesses ultimately wear out -even the strongest.” - -Intercourse effected by force, or with a girl of immature age, is -distinguished as rape, a punishable offence both in Germany and in -Austria. The offence is defined as extra-marital intercourse with a -female under the age of fourteen years, with or without the latter’s -consent; or extra-marital intercourse with a female of any age against -her will or deprived of the power of resistance—either by the use of -actual force, by the employment of threats, or by loss of consciousness. -With regard to the last specification, the law regards as rape -intercourse with a woman unable to resist through loss of consciousness, -whether that loss of consciousness is or is not produced by the direct -action of the violator. - -In the female, the act of intercourse, alike physically, in its natural -consequences, and mentally, is at once more difficult and of more -enduring results than in the male. A writer of the new school, who -according to his own admission has no other interest than the study of -the sexual life, writes of himself: “I have often enough had intercourse -with members of the other sex, in a few cases, indeed, out of pure -inclination; but in all cases alike the aim and the result were the -same—as soon as I had gained my end, the affair was finished. Passion, a -bestial act, exhaustion, commonly a feeling of loathing; in the best -possible case a fugitive but not an agreeable memory; voilà tout.” To -women, such a description, happily, is applicable only in the most -exceptional cases. - -With the completion of coitus, the voluntary and conscious action of the -two parties to the act is at an end; the subsequent stages of the -function of generation are independent alike of consciousness and will. - -When complete intromission of the penis has been effected, and -ejaculation takes place, the semen is usually deposited at the os uteri -or in the immediate neighborhood of that orifice. During the act of -ejaculation, a peristaltic contraction of the vagina occurs, by means of -which the semen at the os uteri is subjected to a moderate degree of -pressure; the contraction and the pressure may perhaps persist for some -little time after the completion of the coitus. In rabbits on heat, such -contractions of the vagina, by means of which the semen was forced under -pressure into the interior of the uterus, have been actually observed. - -During coitus, the uterine muscle is also active. During strong sexual -excitement, the uterus descends in the pelvis, the downward movement -being increased by the pressure on the woman’s abdomen. The os uteri -externum is drawn open, and the aperture, hitherto flattened, now -becomes rounded. At the same time, the secretion of the cervical glands -is expelled, and small quantities of semen are sucked into the cervical -canal. The _plicae palmatae_ offer a certain hindrance to the entrance -of the semen; but the surface of the interior of the canal is rendered -much smoother by the free secretion of mucus by the cervical glands. -Further, it appears highly probable that during the excitement of -coitus, the mouths of the Fallopian tubes, ordinarily more or less -tightly closed, become widely opened, so that the entrance of the -spermatozoa is favored. - -The muscular movements of the uterus were observed by _J. Beck_ in a -woman suffering from prolapse. During sexual excitement, the os uteri -opened and closed rapidly five or six times in succession, remaining at -last firmly closed. Further, in bitches on heat, _Basch_ and _Hoffmann_ -observed the vaginal portion of the cervix to descend in the vagina, the -os uteri opened, mucus was extruded, and the os was then retracted. - -_Hohl_, _Litzmann_, and others have reported, that in women endowed with -great nervous susceptibility, friction of the vaginal portion of the -cervix with the finger arouses sexual sensation, with rounding of the os -uteri externum, descent of the uterus, and hardening of the vaginal -portion; this latter is regarded by _Graily Hewitt_ and by _Wernich_ as -a necessary accompaniment of copulation. _Henle_ believes that the -hardening and protrusion of the vaginal portion of the cervix are due to -a change in the tension of the delicate vessels of this structure, which -have an exceptionally thick muscular coat; _Rouget_ compares the -mechanism with that by which erection of the penis is produced. These -authors consider that sexual excitement is indispensable for the -erection of the vaginal portion of the cervix. - -Thus, _Hohl_ writes: “Numerous observations have shown that in females -endowed with a considerable degree of nervous susceptibility, and -especially in nulliparae, during examination and during any increasing -irritation, not only is there an increased secretion of the vaginal -mucus, but also a momentary descent of the uterus and an opening of the -os uteri externum, so that this orifice has the appearance for the -instant of the open mouth of a tube.” _Litzmann_ reports that during the -vaginal examination of a young, extremely erethistic woman, the uterus -suddenly assumed a more vertical position, and came lower down in the -pelvis; at the same time, the lips of the cervix became equal in length, -the os uteri externum became rounded, soft, and penetrable by the -finger; whilst the breathing and the voice indicated the occurrence of -intense sexual excitement. _Rouget_ assumes that the body and the fundus -of the uterus constitute an erectile organ, which however possesses -capability for erection only during the period of ovulation; _Hewitt_, -on the other hand, considers it extremely probable that the erection may -occur at any time during sexual intercourse, whether ovulation is -proceeding or not. _A. Wernich_ considers, basing his views in part on -personal observations, that erection of the lower segment of the uterus -occurs, like erection of the penis, whenever a moderate degree of sexual -excitement is experienced; in women, however, he believes that erection -is seldom extreme, and that it declines with the other symptoms of -sexual excitement, viz., flushing of the face, moisture and glistening -of the eyes, peculiar groaning expiration, etc. Whereas during -ovulation, erection is merely a necessary concomitant of the other -menstrual processes; during coitus, erection not only occurs much more -powerfully, but it is also an important—perhaps the most -important—contributory factor in effecting fertilization. - -It is no longer possible to accept the view of earlier physiologists -that the purpose of this erection of the lower segment of the uterus is -“to constitute with the penis a continuous canal between the male and -the female genital organs.” Contact between the glans penis and the os -uteri externum is not indeed an occurrence of extreme rarity; but, on -the other hand, it is in no sense a constant nor even a frequent -incident of sexual intercourse. It is ejaculation, especially, which is -subserved by the erection of the vaginal portion of the cervix. In the -female, ejaculation occurs at the moment of the most intense sexual -pleasure, and is marked by the evacuation from the os uteri externum of -a moderate quantity of mucous fluid with an alkaline reaction. In some -cases, in which a chronic discharge of this cervical mucus occurs, it -forms an elongated coagulum of delicate vitreous jelly, the -“mucus-string” of _Kristeller_. The last-mentioned author is of opinion -that the spermatozoa slowly, but by active movements, find their way -along this string into the cavity of the uterus. This assumption, -however, is met by _C. Mayer_ and _Marion Sims_ with the objection, that -_Kristeller’s_ observations were for the most part carried out on women -who were out of health, and that a gelatinous secretion of this -character obstructs the orifice of the cervical canal, and hinders the -occurrence of conception. From the erection of the portio vaginalis -during sexual excitement, and its sudden relaxation post cohabitationem, -_Wernich_ deduces the occurrence of a process of aspiration, by which -the semen is drawn up through the cervical canal into the cavity of the -uterus; a process which has been seen in actual occurrence in vivisected -animals. It is said that to many women this feeling of a process of -suction is so well known, that thereon, in association with the -consequent almost complete absence of mucus and seminal fluid from the -vagina, they are accustomed to base a belief that conception will occur. -It is said that this aspiratory activity on the part of the uterus may -be perceived during coitus by the male also (?). It is assumed by -_Grohe_ that the wave motion of the cilia of the epithelium lining the -cervical canal, is of importance in promoting the ascent of the -spermatozoa; it may be that the vibration of the cilia exercises a -motile stimulus on the spermatozoa, it may be that the continually -repeated stroke of the cilia serves to prevent the permanent -agglutination of the spermatozoa into groups. - -According to _Sims_, the aspiratory action of the uterus is effected in -the following manner: By the contraction of the constrictor vaginae -superior muscle, the cervix is pressed downwards against the glans -penis, and by this pressure its contents are evacuated; the parts then -relax, the uterus suddenly returns to its normal state, and thus the -seminal fluid with which the vagina is filled is drawn into the interior -of the cervical canal. - -_Eichstadt_ also attributes to the uterus an aspiratory force, dependent -upon coitus, and competent to force into the interior of the uterus the -semen ejaculated into the os uteri. The changes in the uterus which are -the necessary antecedents of this aspiration, namely, an engorgement -with blood whereby the flattened form of the uterus gives place to a -more rounded form, and the cavity of the organ is increased in capacity, -take place, in the opinion of this author, only when during intercourse -the woman has attained the acme of sexual gratification, by which alone -can the aforesaid change in the uterus be brought about. _E. Martin_ and -_Chrobak_ have also directed attention to the fact, that some importance -in this connexion must be attached to the facultative enlargement in the -size of the os uteri externum. - -_Lott_, by his researches into the behaviour of the cervix uteri in -relation to the act of conception, is led to the conclusion that the -locomotive capacity of the spermatozoa forms the principal factor in -effecting a fertilizing contact between the spermatozoa and the ovum. -This locomotive capacity may be increased or diminished by a number of -conditions, among which the principal are: the activity of the cervix -uteri (the ciliated epithelium); the character of the secretions; and -the position, shape, and size of the cervix. Thus, this author -concludes, the part played in conception by the normal cervical canal is -a purely passive one, with the sole exception of the activity of the -ciliated epithelium—and the influence of this factor must be regarded as -extremely doubtful. That during ejaculation the external orifice of the -male urethra and the os uteri externum are in close apposition, is -denied by _Lott_, who adduces in support of his views data derived from -comparative investigations on various animals. In the dog, the -configuration of the genital organs is such that it is impossible to -suppose that any apposition can occur; the same is the case with the -sheep; and still more so with the rabbit, who possesses two quite -distinct portions vaginales, projecting freely into the vagina. In the -human species also, the character of the walls of the cervical canal, -where in the normal state the plicae palmatae may almost be said to -interlock, separated only by a thin stratum of mucus, offers a hindrance -to the entrance of the ejaculated semen by the direct force of -ejaculation itself. As regards the independent motile powers of the -spermatozoa, the researches of _Lott_ showed that not only can they -overcome strong capillary currents, and can traverse the width of a -coverglass (18mm.—about ¾ in.) in about five minutes; but further that -they are capable of migration through the finest interstices (those of -an animal membrane) provided that the fluid with which the membrane is -moistened is one favourable to their vital activity. - -_Kehrer_, who in general supports the view that the _modus coeundi_ and -an active attitude on the part of the female have an important influence -on the occurrence of conception, assumes that independent contractions -of the cervix occur, whereby is expelled the delicate plug of mucus that -fills the cervical canal and offers an obstacle to the passage of the -spermatozoa. He believes that the duration of the act of intercourse, -the mechanical relations between the penis and the vagina, the activity -of the uterine muscle, the secretory activity of the utero-vaginal -mucosa during the act, and the posture of the female _post coitum_, are -all important factors in the occurrence of conception. Thus, he believes -that if during intercourse there is a failure of the uterine -contractions, which should expel the plug of cervical mucus, the semen -flows away without effecting fertilization; if an unsuitable posture is -assumed during intercourse the woman remains sterile, but can be -fertilized without difficulty by coitus effected in the proper manner. - -_Haussmann_ has shown, that in the same woman, and in similar -conditions, spermatozoa will on one occasion be found in the cervical -canal, and on another occasion will not be found there; and he has -further shown, that in some women we fail to find spermatozoa in the -cervical canal in circumstances in which, in other women, we regularly -find them in that situation. - -Far as we may be from a complete knowledge of the conditions upon which -conception depends, this at least is certain, that the passage of -spermatozoa through the os uteri externum is a sine qua non of -fertilization. Indeed, it would seem that we must accept as true the -assumption of _Meyerhofer_, that fertilization is possible only if the -semen passes at once into the cervical canal, mingles, that is, at once -with the alkaline cervical mucus—unless, indeed, the coitus takes place -during the catamenial flow, when the blood has neutralized the acid -reaction in the vagina, or takes place when some morbid condition has -had the same result. The theory of _Johann Müller_, regarding the -piston-like action of the penis during coitus, by which the semen is -actually forced through the cervix, must be rejected; equally unsound is -_Holst’s_ assumption that during intercourse the semen is ejaculated -through the enlarged cervical canal directly into the cavity of the -uterus. It would appear, however, to be a necessary condition of -fertilization, that the semen should be ejaculated into the uppermost -segment of the vagina, so that the fluid comes into actual contact with -the os uteri externum; it may be that the alleged aspiratory force of -the uterus then comes into play, by means of which the semen is sucked -into the cavity of that organ; it may be, on the other hand, that -_Beigel_ is right in his theory of the existence of a _receptaculum -seminis_, formed by the anterior and posterior lips of the cervix uteri -and the uppermost segment of the vagina—in this space, he supposes, a -part of the semen is retained in contact with the orifice of the -cervical canal. - -It is, also, exceedingly probable that during coitus a reflex nervous -mechanism becomes active, by means of which the uterine orifices of the -Fallopian tubes are opened, the vaginal portion of the cervix descends -in the vagina, the os uteri externum enlarges, the orifice becoming -rounded where before it was flattened, and finally small quantities of -semen may be aspirated into the cavity of the uterus. - -I further regard it as important in promoting conception, that -simultaneously with the changes above described, the reflex nervous -stimulation should lead to the secretion by the cervical glands of a -gelatinous material, alkaline in reaction, and therefore adapted to -increase the locomotive powers of the spermatozoa, so that these latter, -aided by the activity of the ciliated epithelium lining the cervical -canal, will gain the interior of the cavity of the uterus, and thence -pass onwards to the Fallopian tubes. The significance of the glands in -the mucous membrane lining the cervical canal has hitherto been -underestimated in this connexion. - -Whereas in the primitive state of mankind, among savage races at the -present day, as among our own prehistoric ancestry, nakedness is the -rule, so also intercourse in these circumstances is effected altogether -without any regulation by law or custom, on the mere prompting of -unbridled natural passion, and, moreover, there is the fullest -promiscuity in sexual relations; but civilization has led man to impose -restraints upon sexual intercourse, and has introduced marriage as a -sacred institution. Among certain primitive peoples, however, among whom -the wives are common to all the men, transitory pairings nevertheless -occur, especially when a woman becomes pregnant; to cease, however, -during the period of lactation. “This is the origin of marriage, which -has evolved from rape and prostitution, as law has evolved from crime” -(_Lombroso_). This author makes an interesting observation when -describing the entire freedom of sexual intercourse that obtains among -the Red Indians of North America, to the effect that “often, times of -general promiscuity occur, as with rutting animals, generally in the -warm season of the year, when nutriment is abundant; it is difficult to -indicate any distinction between the tumultuous orgies of the baboon, -and those of the Australian Blackfellows, among whom the sexes keep -apart during the greater part of the year, to intermingle like rutting -beasts during the season of the yam-harvest.” - -The paths of civilization, from the complete promiscuity of sexual -intercourse to the lofty ideal of life-long monogamic union, has not -been a straightforward one, but has been marked by various aberrations -of sexual relationship; hetairism, prostitution, polyandry, incest, -rape, the _jus primae noctis_, etc. The anthropologist is able to trace -the successive stages of the development of the institution of monogamic -marriage; the community of wives within the clan; free sale of wives and -daughters; bestowal of a man’s wife or concubine for the honour of a -guest; ritual prostitution for the honour of the gods and at numerous -religious festivals; æsthetic and literary hetairism, with bestowal of -favours according to free inclination; community of wives among all -males of the same family; the claim of the wife to as many as five or -six husbands; the right of brothers to their sisters; the defloration of -virgins by the priests in heathen temples; the temporary possession of -the wife by the chief of the community, prior to her possession by her -permanent husband; defloration of the bride by the bonze before her -marriage; the feudal right of the mediæval seigneur to the _prima nox_ -of the bride of his retainer. - -In the lower stages of civilization, copulation appears so natural an -action that it is performed in public entirely without shame. Thus, -_Cook_, in his first voyage, describes having seen an indigen engage in -sexual intercourse with a girl of eleven years, under the very eyes of -the queen, with whom _Cook_ was then having audience; the sexual act -was, according to _Cook_, the favourite topic of conversation between -the sexes. _Herodotus_ reports that many peoples of antiquity had no -regard for privacy in sexual intercourse, but that, like the lower -animals, they had connexion in any company. In the _Bible_, also, it is -recorded that sexual intercourse was practised in public: “So they -spread Absalom a tent upon the top of the house; and Absalom went in -unto his father’s concubines in the sight of all Israel.” (II. _Samuel_, -XVI. 22.) According to _Athenaeus_, the Etruscans, at their public -banquets, were equally unrestrained. _Plutarch_ reports that among the -Spartans the maidens and the young men went about naked together. Even, -indeed, after the sense of modesty had begun to develop, it was long -before any secret was made about the act of intercourse. In classical -antiquity, it was very frequently the subject of pictorial and plastic -representation. Even in more recent days, there have been artists who -have not hesitated to depict the sexual act: thus we have the _Venus -with a Faun_ by _Caracci_; the _Jupiter and Io_ of _Correggio_; the -_Leda and the Swan_ of _Tintoretto_; and similar pictures by _Luca -Giordano_, _Rubens_, _Titian_, and _Franceschini_. - -Even in the early centuries of the Christian era, the sect of the -Adamites practised intercourse openly in the light of day, on the ground -that that which was right in the dark, could not be wrong in the light. -The same is reported of the sect of Turlupins, in France in the -fourteenth century. We cannot refrain from quoting at length from -_Lombroso_ and _Ferrero_ a passage relating to the evolution of sexual -manners in the female sex (_Woman as Criminal and Prostitute_): “In the -lowest stages of development, the feeling of modesty is entirely -wanting; limitless freedom in sexual intercourse is the general rule; -and even where no system of promiscuity prevails, marriage rather -fosters than discourages prostitution, especially in countries in which -husbands are accustomed to expose their wives for sale. This fact may be -brought into relation with the well known lasciviousness of apes and -other animals high in the scale, showing that sexual excitability -increases _pari passu_ with intelligence, so that to man it is as -impossible as to an ape to satisfy his sexual needs with a single -female. Whilst among the apes, a single male possesses a number of -wives, we find in the gregarious life of primitive man that community of -wives has taken the place of polygamy, which institution, however, -reappears in a higher stage of culture for the benefit of the more -powerful masculine natures. - -“To the dominion of prostitution as a normal institution succeeds the -period in which it persists as a variously metamorphosed survival: it -may be as the duty of the wife to surrender her person to any other -male of the same family; or the woman may have to bestow her favors on -a religious or political chief, as in the institution of -temple-prostitution, where the wife must give herself, it may be to -any one and at any time, or it may be to defined persons only and at -stated festivals. Frequently we meet with another development of -prostitution, finding that while the wife must remain chaste, the -unmarried woman is allowed unrestricted intercourse; or, again, the -wife at certain definite periods may dispense with fidelity to her -husband, and return to the primitive condition of promiscuity. In -certain instances prostitution is combined with the duties of -hospitality, and marriage, though approximating to the monogamic -ideal, must tolerate the intrusion of the guest into the marriage -bed.” - -“In a third period, prostitution no longer fills the place of a -traditional survival, but is a morbid manifestation confined to a -certain class of the community. But bridging this transition of -prostitution from a normal to a morbid manifestation, we have the -remarkable phenomenon of æsthetic prostitution. Thus, in India and in -Japan, an agreeable class of prostitutes practices the arts of singing -and dancing, and forms a privileged caste; similarly, in the most -flourishing period of Grecian culture, the leading men of the time -formed a social circle around the hetairæ, from whom they derived a -fruitful stimulus to intellectual and political activity. In this -respect, history repeated itself in Italy in the sixteenth century. -Alike in classical Greece and in mediæval Italy, this æsthetic -prostitution fanned the flames of a period of intense spiritual -activity—for in individuals as in races, intellectual quickening is ever -accompanied by erotic excitability.” - -The unbridled passion of the primitive races of mankind, the coercive -love of beauty felt by the ancient Greeks, the swelling flood of erotism -of the great mass of people of all times, is gradually guided into the -quiet channel of the marriage bed; and even though monogamic marriage is -incapable of fully providing for all manifestations of sexual passion, -still, from the medical point of view, we must maintain that marriage is -for women the most hygienic and the most proper means of gratification -of the sexual impulse. - - - _Conception._ - -The union between ovum and spermatozoön, whereby fertilization is -effected, appears to occur in the human species as a rule in the outer -third of the Fallopian tube, the ampulla of this structure -(_receptaculum seminis_ in _Henle’s_ terminology) serving to store the -semen for a considerable period; in the lower animals, the usual -occurrence of fertilization in this region has been established by -direct observation. The open mouth of the tube receives the mature ovum, -guided thither from the ovary by appropriate movements of the ovarian -fimbriae; these movements have been seen in active occurrence in the -guinea pig by _Hensen_. Once within the tube, the onward movement of the -ovum is effected by the cilia of the epithelium lining of the canal. - -_His_ has formulated the theory that in the human species fertilization -is possible only in the uppermost segment of the tube; an assumption -that is probable enough, but cannot be regarded as definitely -established. An analogy certainly exists among the lower divisions of -the animal kingdom, for _Coste_, _His_, and _Ohlschläger_ have proved -that an ovum which passes through the Fallopian tube without being -fertilized, undergoes notable alterations. Further, _Coste_ has shown, -in the case of the ovum of the domestic fowl, that this is no longer -capable of being fertilized after it has passed through the upper -segment of the oviduct. Other authorities, however, namely _Löwenthal_, -_Mayrhofer_, and _Wyder_, oppose the extension of this rule to the human -species. _Löwenthal_ assumes that in the human female, fertilization -ordinarily occurs in the cavity of the uterus, in the wall of which the -unfertilized ovum has already embedded itself; and he supports his -contention by the statement that spermatozoa are not to be found in the -Fallopian tubes or on the surface of the ovaries. _Mayrhofer_ and -_Wyder_ point out that the movement of the cilia of the ciliated -epithelium is in the interior of the uterus in an upward direction, but -in the Fallopian tubes is downwards in the direction of the uterus. - -The contention of _Löwenthal_ was disproved by _Birch_ and _Hirschfeld_, -who, in a prostitute dying during the act of intercourse, found, fifteen -hours after death, living spermatozoa in the Fallopian tubes. On the -other hand, more recent investigations, those, for instance, of -_Hofmeier_, _Mandl_, and _Bonn_, have confirmed the data given above -with regard to the direction of the ciliary movement in the interior of -the genital passages. Moreover, _O. Becker_ has shown that the ciliated -epithelium of the tubes extends over the fimbriae and even on to the -adjoining pavement epithelium of the peritoneum; and he believes that -the ciliary movement of this region keeps up a constant current, the -purpose of which is to sweep the ovum into the ostium of the tube, and -thence down towards the uterus. _Lode_ has adduced positive experimental -evidence of the occurrence of such a movement of translation. - -The general result of anatomical investigation is, that the conjugation -of the ovum with the spermatozoön takes places in the ampulla of the -Fallopian tube; but it is established that fertilization may also take -place lower down in the tubes, or in the uterine cavity, or even on the -surface of the ovary, _i. e._, in the abdominal cavity. - -The fertilization of the mature ovum—maturation having occurred within -the ovarian follicle before its rupture—has been shown by numerous -researches on the ova of other animals to consist in the fusion of the -male and the female nuclear substance; and it appears that of the -enormous number of spermatozoa, estimated by _Lode_ at 226 million at a -single ejaculation, that enter the female genital passage, but a single -one penetrates the ovum. Towards the head of this spermatozoön there -extends from the surface of the ovum a process, flat at first, but -becoming more and more prominent, until it surrounds the head, and fuses -with it. The motile tail of the spermatozoön disappears, whilst the -head, which has now passed through the vitelline membrane and entered -the ovum, assumes the appearance of a nucleus, and is called the _male -pro-nucleus_. The original nucleus of the ovum has previously prepared -itself for fertilization by the extrusion through the vitelline membrane -of portions of its substance (known as _polar globules_), and now -constitutes the _female pro-nucleus_. Towards this latter, situated -somewhere near the centre of the cell, the male pro-nucleus continues to -move, the vitelline granules meanwhile being disposed round about it in -radiating lines, forming a star-shaped figure. Having come into contact, -the two pronuclei fuse completely to form a new nucleus, the nucleus of -the now fertilized egg-cell. The result of fertilization is the -formation of the first _segmentation-sphere_, from which, by further -subdivision, the new individual is formed. Thus is effected that which -_Hippocrates_ describes in the words: “The seed possessed both by man -and by woman, flow together from all parts of the body; the fruit is -formed by the mingling of the two seeds.” - -[Illustration: - - FIG. 55A.—First Stage. FIG. 55B.—Second Stage. - - Entrance of a spermatozoon into the ovum of ascaris megalocephala. - After preparations by M. Nussbaum. (Half of the ova only are - depicted.) -] - -[Illustration: - - FIG. 56.—Ovum of Asterakanthion ten minutes after fertilization. -] - -[Illustration: - - FIG. 57.—Fusion of male pro-nucleus and female pro-nucleus to form the - segmentation nucleus of the fertilized ovum. -] - -The most favourable period for the occurrence of fertilization appears -to be when intercourse takes places from eight to ten days after the -termination of the menstrual flow. In 248 instances in which the date of -the fruitful coitus was exactly known, it was ascertained by Hasler that -in 82½ per cent. of all cases, conception was effected in the fourteen -days succeeding the menstrual period. In general it may be stated that -the theory of the periodicity of ovulation and of the causal relation of -this process to menstruation, has not been shaken by the result of -researches recently undertaken by opponents of that theory; hence it -appears that the fertilized ovum is the ovum of the last completed -menstruation. - -Already in the writings of the old Indian physician _Susruta_, we find -expression of the view that the period that immediately succeeds the -cessation of the menstrual flow is one most favourable to conception. -“The time of generation,” he says, “is the twelfth night after the -commencement of menstruation.” In the Jewish _Talmud_, the day before -the onset of menstruation, and the days immediately succeeding the -cessation of the flow, are indicated as those most favourable to the -occurrence of conception; moreover, in the _Talmud_, notwithstanding the -fact that intercourse during menstruation is prohibited on pain of -death, and that coitus is not regarded as permissible until the lapse of -twelve clear days after the cessation of the flow, nevertheless the -assertion is made that intercourse during menstruation may lead to -conception. - -[Illustration: - - FIG. 58. —Passage of spermatozoon through the zona pellucida of the - ovum of asterakanthion. -] - -[Illustration: - - FIG. 59.—Ovum of scorpæna scrofa thirty-five minutes after - fertilization. -] - -[Illustration: - - FIG. 60.—Male pro-nucleus and female pro-nucleus in fertilized ovum of - frog, prior to the formation of the segmentation nucleus. -] - -_Hippocrates_ writes: _Hae nempe post menstruam purgationem utero -concipat_. _Aristotle_ says: _Plerasque post mensum fluxum nonnullas -vero fluentibus adhuc menstruis_. _Galen_ writes: _Hoc autem -conceptionis tempus est vel incipientibus vel cessantibus menstruis_. - -_Soranus_ writes to a similar effect: Just as the soil is suitable only -at certain seasons for the reception of the seed, so also in the human -race intercourse does not always take place at a time suited for the -reception of the semen. To be effective, coitus must occur at the proper -time.... The act of intercourse that is to lead to conception may best -occur either just before or just after the menstrual flow, when, -moreover, there is strong desire for the sexual embrace, and neither -when the body is fasting, nor when it is full of drink and undigested -food. The time before menstruation is, however, unsuitable, for then the -womb is heavy from the flow of blood, and two conflicting tendencies -will come into operation, one for the absorption of material and the -other for its outflow. During menstruation, again, conception is -unlikely to occur, for then the semen is wetted and washed away by the -flowing blood. The sole proper time is that immediately after the flow, -when the womb has freed itself from its humours, and warmth and moisture -stand in harmonious relationship. - -Among many of the castes of Hindustan, it is a religious ordinance that -on the fourth day of menstruation a man shall have intercourse with his -wife, “since this day is that on which conception is most likely to -occur.” Indian physicians advise, in order to bring about conception, -“that coitus be effected always as soon as the menstrual flow has -ceased, at the end of the day, and when the lotus has closed.” In Japan, -medical opinion is to the effect that a woman is capable of conceiving -during the first ten days after menstruation, but not later (_Ploss_ and -_Bartels_). - -The view that the first days of the intermenstrual interval are those -most favourable to the occurrence of conception, is further confirmed by -the statistical data collected by _Löwenfeld_, _Ahlfeld_, _Hecker_, and -_Veit_; and it appears that as the date of the next menstruation is -approached, there is a continual decline in the frequency of conception; -just before the flow, conception hardly ever occurs. _Hensen_, from the -records of 248 conceptions in which the date of the fruitful intercourse -was exactly known, draws the following conclusions: - -1. The greatest number of conceptions follow coitus effected during the -first days after the cessation of the menstrual flow. - -2. When coitus is effected during menstruation, the probability of -conception increases day by day as the end of the flow is approached. - -3. The number of conceptions following coitus effected shortly before -menstruation is minimal. - -4. However, there is no single day either of the menstrual flow or of -the intermenstrual interval, on which the possibility of the occurrence -of conception can be excluded. - -_Feokstitow_ has drawn up from statistical data an ideal -“conception-curve,” which teaches that conception most readily ensues -upon coitus effected soon after the end of the menstrual flow, in the -first week, that is to say, of the intermenstrual interval; moreover, -the curve shows that the highest percentage of conceptions occurs on the -very first day after the cessation of the flow, and that after this day -the percentage of conceptions declines. The percentage frequency of -conceptions from coitus effected on the last day of menstruation, and on -the first, ninth, eleventh, and twenty-third days, respectively, of the -intermenstrual interval, is expressed by the ratio 48 : 62 : 13 : 9 : 1; -and between the points given, the course of the curve is almost -rectilinear. The probability of the occurrence of conception on the -twenty-third day of the interval (on which day the curve reaches its -lowest point), is one-sixty-second of the maximum probability. - -The proper performance of coitus depends upon the _potentia coeundi_ of -the male; the attainment of conception depends upon his _potentia -generandi_. The _potentia generandi_ demands from the man the functional -competence of the testicles, the perviousness of the seminal passages -(namely, of the vasa deferentia and the urethra), the secretion of a -normal semen, and, finally, a proper formation of the penis, whereby -during ejaculation the semen may be deposited in sufficient proximity to -the os uteri externum. - -Normal semen is a whitish, semi-transparent fluid, of the consistency of -thin cream. It contains aggregations of a nearly spherical shape, -consisting of a vitreous, transparent, colourless or light yellow, -gelatinous, elastic substance. Under the microscope this substance has a -hyaline appearance, and exhibits in its interior innumerable clear -spaces of varying size, which are apparently filled with a clear fluid. -Not infrequently, these spaces are extremely narrow and therewith -greatly elongated and disposed in parallels, so that the whole substance -thus obtains a striated appearance. When treated with water, this -material becomes whitish and non-transparent, and assumes under the -microscope a finely granular aspect. When allowed to stand without -agitation for twenty-four hours, this substance dissolves and becomes so -intimately mingled with the seminal fluid that it can no longer be -clearly differentiated therefrom. In all probability it is merely a -secretory product of the seminal vesicles. - -The truly fluid portion of the semen contains the following -morphological elements: - -1. Microscopic aggregations of hyaline substance, variously shaped. - -2. Very numerous granules, small and extremely pale, albuminous in their -nature, and disappearing on treatment with acetic acid. - -3. A small number of rounded or oval cells, about the size of -leucocytes, containing one, or sometimes two small round nuclei. - -4. Prostatic calculi. These are an inconstant constituent, but are very -frequently met with after repeated coitus. According to some observers -they are derived also from the bladder and urethra. They are -distinguished by their yellowish colour, their irregular form (sometimes -triangular, sometimes rounded or oval), and by their characteristic -structure. They are composed of a substance arranged in concentric -laminæ, which in the centre has a granulated appearance; they often -exhibit one or more oval nuclei. - -5. Spermatozoa in countless numbers. - -In exceptional cases we find as additional morphological -elements, especially in elderly people, scattered erythrocytes, -cylinder-epithelium cells, and masses or granules of yellow pigment. - -The spermatozoa are about fifty micromillimetres in length. Two parts -may be distinguished in each, a head and a tail. The head, four or five -micromillimetres in length, is flattened, and differs in apparent -shape—though generally more or less pear-shaped—according as to whether -it is seen sideways or on the flat. - -The tail, which is about forty-five micromillimetres in length, narrows -from before backwards. The fine posterior extremity is said to contain -the contractile element, so that it is upon this portion that the -familiar movements of the spermatozoa depend (Fig. 61). - -The spermatozoa are made up of a substance very rich in sodium chloride, -and strongly resistent to reagents and to putrefaction. In consequence -of their richness in mineral constituents, the ash, when they are -calcined, retains their original form. - -The movements of the spermatozoa can be properly observed only in fresh, -pure semen (Fig. 62). - -If freshly ejaculated semen is treated with water, the movements of the -spermatozoa very shortly cease, and their tails become rolled up in a -spiral form. - -[Illustration: - - FIG. 61.—a. b. c. Prostatic calculi from normal semen. d. Spermatozoa. - e. Large and small cells, some containing granules, as morphological - elements of semen. f. Spermatozoon distorted by imbibition of water. - g. Crystals. (After Bizzozero.) -] - -[Illustration: - - FIG. 62.—Normal semen. -] - -If semen is left undisturbed for twenty-four hours or longer, the -vitreous substance dissolves in the surrounding fluid, and this latter -separates into two layers, an upper which is thinner, and a lower, which -is thicker and non-transparent. In the former, the morphological -elements are found but sparingly, whilst in the latter, they are -plentiful. In addition to the elements already described, we find often -two varieties of crystals. One of these varieties, which appears only -when decomposition is far advanced, consists of ammonium magnesium -phosphate. The other variety has a chemical composition not yet -determined. These crystals belong to the monoclinic system, forming -prisms or pyramids, often with curved surfaces; they are colourless or -light yellow; they lie superimposed, often forming beautiful star-shaped -figures. They are soluble in mineral and vegetable acids, and in -ammonia, but are insoluble in alcohol, ether, and chloroform; they are -remarkably resistent to the solvent powers of cold water, but not so to -those of boiling water. _Shreiner_ has proved that these crystals -consist of a phosphate of a base which is represented by the formula C2. -H5. N. According to _Fürbringer_, these crystals are produced as a -result of the action of the semen upon the prostatic secretion. - -The quantity of semen ejaculated during coitus is very variable, -depending upon the age and size of the individual and the formation of -his testicles, upon his individual sexual capacity, and upon the -question whether antecedently there has been sexual excess on the one -hand or long continued continence on the other. In general, the quantity -of semen ejaculated at one time varies between 0.75 and 6 c.c. (10 to -100 minims). - -If healthy, normal semen, with adequate fertilizing potency, is properly -preserved from cold and light, we may, even after the lapse of -twenty-four hours, find under the microscope spermatozoa still engaged -in active movement. _Ultzmann_ employs for the description of a drop of -fresh semen, the comparison that it is full of movement, “like a stirred -up ant-heap.” Influenced by the whiplike lashings of the tail, the -spermatozoön moves steadily forwards, finding its way through the -narrowest passages on the microscopic field without striking any of the -cellular structures that may lie in its path. The longer the semen -remains under observation, the less active are these movements of the -spermatozoa, for after ejaculation they gradually die, exhibiting after -death an extended, or at most a slightly curved tail; those spermatozoa, -on the other hand, that were dead before ejaculation, have the tail -spirally twisted, rolled up, or acutely bent. In the case of spermatozoa -which have been destroyed by the action of some other deleterious -secretion, as by urine or by acid vaginal secretion, such a condition of -the tail is very commonly seen. When the semen is treated with water, -the movements of the spermatozoa soon cease, and the ends of their tails -frequently roll up to form loops. By the addition, however, of -concentrated solutions of neutral salts, of albumen, of urea, etc., it -is possible to reanimate these motionless spermatozoa, so that they once -more are seen to perform active movements. Moderately concentrated -animal secretions of an alkaline reaction are favourable to the motor -activity of the spermatozoa, whilst on the other hand dilute and acid -secretions, such as urine, acid mucus (including the acid vaginal -mucus), and catarrhal secretions, even when alkaline in reaction, have a -depressant influence on this activity. Caustic potash and caustic soda -stimulate the movements of the spermatozoa. When they are cooled down to -a temperature below 15° C. (59° F.), the movements cease entirely. Salts -of the heavy metals, and mineral acids in solution, also bring their -movements to a pause. Frequent repetition of coitus causes a diminution -in the number and in the motor activity of the spermatozoa. - -Semen which contains no spermatozoa, or in which the spermatozoa are -motionless, is absolutely devoid of fertilizing power; in the case of -such semen, it makes no difference whatever that the external genitals -of the man generating it are strongly formed, that his testicles are of -normal size, and that erection and ejaculation take place promptly. Of -very little value, though not absolutely sterile, is semen containing -very few living spermatozoa, or, among very numerous motionless -spermatozoa, containing a few only that are engaged in active movement. -Suspect, is semen which does not possess the normal light greyish white -tint, but is brownish-red, brownish-yellow, yellow, or violet; these -variations in colour indicating an admixture with the semen of varying -quantities of blood or pus, in consequence of disease of the urethra, -the prostate, the seminal vesicles, or some other part of the uropoietic -system; such admixtures seriously impair the quality of the semen. An -unfavourable judgment must also be passed on semen which, at each -successive ejaculation, is voided in very small quantities only—from -half a drachm to a drachm. When thus scanty, semen is often found to -contain an exceptionally large proportion of dead spermatozoa. We may -regard very favourably semen which is voided in quantities considerably -in excess of the average; sometimes, when there is a veritable -polyspermia, there may be an ounce or upwards, more than three times as -much as normal—provided, of course, that this semen so richly voided is -of a satisfactory quality, and contains an ample proportion of active -spermatozoa. The most valuable characteristic in semen is exhibited when -the spermatozoa it contains are not only very numerous and vigorously -active, but when they are also very long-lived, when, that is to say, -they retain the power of active movement sometimes for as long as three -days. A decisive opinion as to the quality of a man’s semen can be given -only as the result of precise and repeated microscopic examinations, and -the medical man must be most careful, when in his first examination he -has not been able to detect the presence of any living spermatozoa, to -abstain from giving, on that account alone, an adverse decision—from -pronouncing sentence of death on the man’s reproductive potency. - -It has not hitherto been accurately determined how long spermatozoa can -continue to live in the interior of the uterus, although the point is of -great importance, not only in relation to conception, but also in regard -to the theory of menstruation. _Percy_ has published a case in which, -eight and a half days after the last coitus, he saw living spermatozoa -emerge from the os uteri externum. _Sims_ bases upon his own researches -the decisive opinion that in the vaginal mucus, spermatozoa can never -survive longer than twelve hours, but states that in the mucus of the -cervical canal they can live much longer. If thirty-six to forty hours -after coitus, we examine the cervical mucus under the microscope, we -commonly find living and dead spermatozoa in about equal numbers. Many -of the living ones will survive their removal from the cervix for as -much as six hours longer. - -Of especial interest are the conditions which are liable to deprive a -man of the power to produce fertilizing semen. In the first place must -be mentioned congenital absence of both testicles—a condition which, in -otherwise normally formed male individuals, is one of extreme rarity. -Congenital absence of _one_ testicle is less rare, and is usually -accompanied by absence also of the epidydimis, vas deferens, and seminal -vesicle of the same side. The potentia gestandi of a monorchid depends -upon the proper development of his single testicle, and the functional -capacity of this organ must be ascertained by a careful microscopic -examination of his semen. Much more frequent than absence of the -testicle, though still sufficiently rare, is the condition of -cryptorchism, non-descent of one or both testicles, a state not -necessarily associated with functional incapacity of the organ. Most -commonly, however, an undescended testis is an imperfectly developed -testis, and in the very great majority of cases the ejaculated fluid -contains no spermatozoa. - -A further cause of the lack of potent semen is atrophy of the testicles -with notable diminution in the size of the glands, and more or less -complete disappearance of the seminiferous tubules and their cellular -contents. This state is rarely congenital, being nearly always acquired: -in consequence of inflammatory conditions affecting the testicle proper -or the epididymis (syphilitic inflammation, especially, is apt to lead -to overgrowth of the interstitial connective tissue and to gradual -destruction by pressure of the seminal tubules)[46]; or in consequence -of the pressure of a hernia, a varicocele, a hydrocele, or a tubercular, -carcinomatous, or other new growth; or in consequence of constitutional -disorders, especially long-lasting, severe, and exhausting diseases, -such as diphtheria, diabetes, or chronic alcoholism; in consequence of -diseases affecting that portion of the central nervous system from which -the nerves supplying the genital organs arise; in consequence of -degenerative changes resulting from sexual excesses; or, finally, in -consequence of senile changes, such as fatty changes in the cells of the -seminiferous tubules. Certain drugs also, digitalis, salicylic acid, -mercury, iodide of potassium, arsenic, and morphine, have an -unfavourable influence alike on the quality of the testicular secretion -and on the potency of the individual. _Von Gyurkovechky_ reports that in -Bosnia a plant locally known as “neven” is employed among the peasantry -for the temporary suppression of sexual potency, wives giving it to -their husbands when the latter are about to leave them and go upon a -journey, and sprinkling the leaves of the plant among the underclothing. - -[Illustration: - - FIG. 63—Semen consisting chiefly of sperm-crystals, cylindrical - epithelium and small granules exhibiting molecular movement—but - containing _no_ spermatozoa. -] - -By the name of azoospermia is denoted a condition whose existence can be -determined only by microscopic examination. - -The subject of this affection has normal potentia coeundi, the semen is -ejaculated in quite normal fashion, and it is its constitution only that -is faulty. In appearance it is extremely fluid, and is somewhat cloudy; -its sediment contains molecular detritus and spermatic crystals, but no -spermatozoa (Fig. 63). If the medical man makes it his rule, in all -cases in which he is consulted on account of sterility, in deciding how -far this sterility is dependent on the condition of the husband, not to -confine himself solely to the customary questions, whether intercourse -is regularly practised, whether before or after menstruation, etc.—but -if in every case he makes a careful examination of the semen under the -microscope, he will be astonished to learn the comparative frequency -with which he will note the complete or nearly complete absence of -spermatozoa. This condition of azoospermia may be permanent or -transitory. - -To _Kehrer_ belongs the credit of having pointed out that sterility is -less often due to impotence or to aspermatism than to azoospermia—a -condition often unsuspected by husband and wife, and one to be diagnosed -by the physician only after repeated microscopic examinations of the -semen. For this reason, indeed, its existence is often overlooked. -_Kehrer_ believes himself to be justified in asserting that one-fourth -of all cases of sterility (if not indeed more) must be referred to -conditions affecting the husband, and most often to azoospermia; hence -he concludes, that the husband must still more often be regarded as the -one to blame for the occurrence of sterility, when the cases are borne -in mind in which a man marries with an imperfectly healed gonorrhœa, and -infects his wife, giving rise to a chronic tubo-uterine blennorrhœa, and -ultimately to sealing up of the tubes and to sterility. - -Complete absence or marked scarcity of spermatozoa in the semen may -occur also without any change in the testicle that can be detected by an -external examination, as a consequence of contusions of the testicle, or -of gonorrhœal inflammation of the epididymis or vas deferens; further as -a sequel of severe general diseases, long-continued physical exertion, -or great sexual excess. - -In some cases, a microscopical examination reveals, not azoospermia, but -oligozoöspermia, that is to say, the number of living spermatozoa in the -semen is remarkably small. Or, again, the anomaly may be of this -character that the spermatozoa are smaller than normal, that they are -motionless, and that their tails are broken off—such are the -peculiarities, as a rule, of the semen of old men. - -A less common condition than azoospermia, but one the pathological -importance of which is equally great, is aspermatism, in which the man, -neither during coitus, nor in any other form of sexual excitement, is -able to ejaculate any semen. This condition may be congenital or -acquired; it may be permanent, or transitory (lasting a few weeks or -months). In these cases we have to do with organic changes in the -testicles, diseases of the prostate, gonorrhœal processes, or nervous -disturbances resulting in a loss of irritability in the reflex centre -for ejaculation. Aspermatism in the narrower sense of the term, a -condition, that is to say, in which there is total suspension of the -activity of all the three glands which combine to secrete the composite -fluid known as semen, namely, of the testicle, the prostate, and the -seminal vesicles—is, according to _Fürbringer_, probably non-existent. -The pathological state underlying aspermatism would rather appear to be, -not a failure to secrete semen, but a failure to ejaculate it. - -[Illustration: - - FIG. 64.—Oligozoöspermia. a. Living spermatozoa, b. Dead spermatozoa, - c. Pus corpuscles, d. Erythrocyte, e. Seminal granules. -] - -Last of all, we have to speak of conception without copulation, of -artificial fertilization. In consequence of the mechanical hindrances -which in many cases prevent the entrance of the semen into the interior -of the uterus, the idea has arisen to introduce the semen by means of -instruments directly into the cervical canal, dispensing with the -natural act of copulation. Experience long ago gained in artificial -pisciculture, no doubt gave rise to this idea. _Spallanzani_ and _Rossi_ -by means of a syringe injected the semen of a dog into the vagina of a -bitch, the procedure resulting in impregnation. _Girault_ appears to -have been the first,[47] in the year 1838, to introduce semen -artificially into the human uterus, if we leave out of consideration the -experiment of _Léseurs_, who introduced a tampon moistened with semen -into the interior of the vagina. The procedure employed by _Girault_ is -thus described: The patient having been placed in the position usually -employed for gynecological examination, a canula resembling a male -catheter with the eye in its point, and with a funnel-shaped enlargement -at the opposite extremity, is introduced into the uterus, this -instrument having first been prepared by moistening its interior with -mucilage and filling it with semen; by insufflation, the semen is now -expelled into the uterine cavity. It is stated that neither uterine -colic nor any other dangerous symptom has ever been brought on by this -procedure. The experiments were made at various periods between the year -1838 and the year 1861; they were ten in number, and of these eight -proved successful, two unsuccessful. In the ten cases, the total number -of insufflations made was twenty-one—the minimum number in any single -case being one, the maximum five. In one case, the insufflation was -effected immediately after the cessation of menstruation; in the -majority, from one to four days after the cessation of menstruation; in -one case twelve days, in one case twenty-three days, after the cessation -of the flow. _Gautier_, instead of insufflations, has employed -injections of semen, using two injections in each case, one just before -menstruation was expected, the other a day or two after the cessation of -the flow. _Marion Sims_ endeavoured in twenty-seven cases to bring about -conception by the injection of semen into the uterus; in one of these -cases only was the desired result obtained. In this latter instance the -patient was twenty-eight years of age, had been married for nine years, -but had remained barren. Throughout her menstrual life, she had suffered -more or less from dysmenorrhœa, often accompanied by severe -constitutional disturbance, such as syncope, vomiting, and headache. -Local examination disclosed the existence of retroversion of the uterus -with hypertrophy of the posterior wall, an indurated, conical cervix, -with stricture of the cervical canal, especially in the region of the os -uteri internum. In addition to all these mechanical obstacles to -conception, it was found that the semen was never retained in the vagina -after coitus. _Sims_ examined the patient immediately after coitus had -taken place, but never found a single drop of semen in the vagina, -notwithstanding the fact that this fluid had been ejaculated in -abundance. _Sim’s_ first care was to bring about reposition of the -uterus, and to keep the organ in its proper place by the insertion of a -suitable pessary. Injections of semen were then undertaken, and were -continued throughout a period of nearly twelve months. In two instances, -the injection was effected immediately before the onset of the menstrual -flow; in eight instances it was effected at varying times (two to seven -days) after the cessation of the flow. At first, three drops of semen -were injected, but later only half a drop. The semen (first ejaculated -into the vagina during normal intercourse) was injected by means of a -glass syringe, which was kept in a vessel of warm water at a temperature -of 98° F. Since during the removal of the instrument from the water and -its insertion into the vagina, some fall in temperature necessarily -occurred in the vagina, _Sims_ allowed the syringe to remain for some -minutes in the vagina before he drew the semen into it, in order that he -might feel assured that syringe and vagina had regained the temperature -most adapted to the vital activity of the spermatozoa. The nozzle of the -syringe was then carefully introduced into the cervical canal, and half -a drop of semen was slowly injected into the uterine cavity. For two or -three hours after the operation, the patient remained lying quiet in -bed. After the tenth experiment, conception ensued—the first recorded -case of artificial fertilization in the human species. - -With right, however, this case of _Sim’s_ was not regarded as -conclusive, since both before and after the injection, ordinary coitus -had been effected, and it is therefore impossible to determine whether -the fertilizing spermatozoön was one of those introduced by means of the -syringe, or in the antecedent or subsequent coitus—more especially in -view of the fact that by the insertion of a pessary _Sims_ had, -previously to undertaking the injections, restored the uterus to a -position more suited to the occurrence of conception in the natural -manner. - -In a case which a priori seemed exceedingly well adapted for the -performance of artificial fertilization, one of marked hypospadias in a -man whose semen was abundant and contained a large number of vigorously -moving spermatozoa, I saw this experiment fail, in spite of all possible -care in its performance. In fact, not a single conclusive instance of -successful artificial fertilization in the human species is known to me, -though I have seen reports of numerous disagreeable and even dangerous -results of attempts to effect it. Both parametritis and perimetritis -have occurred in such cases; and semen, being a material in a state of -most intense molecular movement, may be regarded as extremely liable to -noxious transformations. - -_Sim’s_ procedure has been modified by other gynecologists. Thus, -_Courty’s_ plan was that during coitus the semen should be collected in -a condom, fitting not too closely, from which receptacle it was drawn up -into a syringe and carefully injected into the cervical canal. _Pajot’s_ -plan was that the semen should be ejaculated into the vagina in natural -coitus, and should thence be pressed into the uterine cavity by means of -a piston-like instrument introduced into the vagina. - -In London, _Harley_ frequently made the experiment of injecting semen -into the uterine cavity, but in all cases without any result. - -_P. Muller_, in two cases, on account of extreme anteflexion of the -uterus, performed this experiment. Though the general conditions were in -both cases extremely favourable, in neither instance was there any -result. It must, however, be mentioned that in one of his cases only had -there been any preliminary examination of the semen under the -microscope. - -_Fritsch_ reports a case in which gonorrhœal secretion was injected in -place of semen. Peritonitis, which for a month endangered life, was the -result. - -In Paris, _Lutaud_ has earnestly advocated artificial impregnation in -cases of sterility in which all other means have failed. It is obvious -that it would be useless to employ this measure after the menopause, or -in women in whom menstrual activity has ceased prematurely, with -simultaneous disappearance of all menstrual molimina. Equally useless -would it be in uterine atrophy and in cases of irremediable malformation -of the female genitals. Further contra-indications, according to -_Lutaud_, are offered by chronic pelvic peritonitis, since here, on -account of the obliteration of the lumen of the Fallopian tubes, the -operation is foredoomed to failure. Chronic inflammatory states of the -uterus and its mucous membrane, will also render the attempt useless. -Moreover, it is a condition indispensable to success that the semen to -be employed shall have been examined microscopically, and shall have -been found to be thoroughly healthy. The operation has the greatest -prospect of success when undertaken from three to two days before the -due date of menstruation. The method employed is that of _Sims_. If -after the first attempt, the due menstruation should begin, the -injection should be repeated a week after the flow has ceased; the -attempt should not, however, be repeated more than about six times in -all, since the probability of success rapidly diminishes with each -successive endeavour. Before the operation is undertaken, the -permeability of the cervical canal must be ascertained. Further, in -order that the spermatozoa shall be placed in conditions in which they -have the best possible chance of survival, a weak alkaline solution, -such as 1 per cent. of potassium bicarbonate, should as a preliminary -measure be injected into the vagina. - -_Lutaud_ thus describes the procedure he employs. Immediately after the -woman has had intercourse with her husband, a Fergusson’s speculum is -introduced into the vagina, the patient remaining in the dorsal -decubitus. As the speculum passes in, its margin scrapes the surface of -the vagina, and by this means the semen is collected in the vicinity of -the cervix. The semen is then drawn up into a Pravaz syringe or an -analogous instrument, such as a uterine catheter armed at one end with a -rubber ball. The fluid is then carefully injected into the cervical -canal, or preferably into the uterine cavity, great care being taken not -to injure the mucous membrane in any way, since the slightest bleeding -may nullify the whole procedure. Finally, a small tampon of absorbent -cotton-wool is inserted into the os uteri externum. For some hours the -woman must remain quiet in bed; the tampon is not removed for ten hours. -As regards results, _Lutaud_ informs us that he has in this way treated -twenty-six cases. In twenty-two of these, failure was complete; in one -case, success was partial—the patient was impregnated, but abortion -occurred two weeks later; in another case, abortion occurred after three -months pregnancy; finally, in two cases, success was complete. - -Indications for the employment of artificial impregnation are: first, -the existence of stenosis in the upper part of the cervical canal, -especially stenosis from flexion, provided, of course, that other -measures are contra-indicated or have been fruitlessly employed; -secondly, a deleterious character of the secretion of the cervical -canal; thirdly, extreme cases of hypospadias in the male. _Haussmann_ -recommends the employment of artificial impregnation in cases in which -the spermatozoa are found to enter the cervical canal, but fail to pass -through the os uteri internum. Whilst artificial impregnation is -theoretically a sound measure, yet in the practice the indications for -its performance are by no means easy to establish. For, in cases in -which there is some mechanical hindrance to the contact of the -spermatozoön with the ovum (and it is for such cases only that this -method of artificial fertilization can properly be employed), it is -often extremely difficult, and may even be quite impossible, to exclude -the possibility of there being some failure in ovulation itself, or in -the maturation of the ova; or, again, sterility may depend, not on the -fact that no ova are fertilized, but on the fact that when fertilized -they always fail, for some reason, to find a resting place in the -uterus; in a word, in any case in which sterility appears to be due to -mechanical obstacles to conception, it may in reality be due to some -other disease which has escaped recognition, some organic disease of the -uterus, the tubes, the ovaries, of the periuterine tissues. - -Finally, it must be remembered that the manipulation is far from easy in -its performance. Above all, the semen must be subjected to a most -rigorous microscopical examination in respect of its fertilizing -capacity. But this examination cannot be made in the case of the semen -that is actually used for the attempt at artificial fertilization; it -can only be done with an earlier specimen from the same man. If the -semen contains no living spermatozoa, or very few only and these -sluggish in their movements, still more if it contains pus corpuscles or -gonococci, all idea of its employment for artificial fertilization must -be rejected. - -The method employed by _Sims_, in which the semen is drawn into a -syringe inserted into the vagina post coitum, is one which I am not able -to recommend, since in this way together with the semen some vaginal -mucus is drawn up, thus, instead of pure semen, we inject into the -vagina semen mixed with various impurities, and more especially with an -acid secretion known to be unfavourable to the life of the spermatozoa—a -circumstance that will doubtless explain many of the failures that have -hitherto taken place. It is certainly better that the semen of the -husband should be collected in a rubber condom. The preservation of the -material to be injected at a suitable temperature (the normal -body-temperature), is by no means easy. The syringe, an ordinary Braun’s -uterine syringe, is first disinfected, and then lies ready in water of -the proper temperature. The semen is rapidly drawn up into the syringe, -the nozzle of which is then passed down to the fundus uteri. Quite a -small quantity of semen will suffice. After the manipulation, which -should of course be undertaken at the time most favourable to -conception, just after menstruation, the woman should lie quiet in bed -for some hours. - -In considering the probability of a successful issue to any such attempt -to secure artificial fertilization, we cannot leave out of consideration -the likelihood that that result may be prejudiced by the lack of all -normal sexual feeling on the part of the wife; concerning the -significance of such feeling in relation to the sexual act, we have -however as yet no certain knowledge. - -That this procedure of artificial fertilization is extremely -disagreeable to all concerned therein, the physician not excepted, and -that various moral and social considerations can be alleged against it, -is incontestable. It is indeed recorded that in Bordeaux a legal penalty -was inflicted on a medical man who undertook to bring about artificial -fertilization. The Society of Medical Jurists debated this matter, and -came to the conclusion that, whilst a medical man was not justified in -recommending the practice, neither was he justified in refusing to -undertake it when requested by his patients. In Paris, a candidate for -the degree of Doctor of Medicine made artificial fecundation the subject -of his thesis, and maintained that its practice, when effected with all -proper social precautions and according to scientific principles, was -possible, reasonable, useful, and moral, and that in many instances it -should be recommended by the physician. After a long and stormy debate, -the Faculty of Medicine determined to reject the thesis and to destroy -all specimens of it already printed, on the ground that “they feared, if -they gave their sanction to the practice, that a number of more or less -unscrupulous physicians would make that sanction the basis of improper -practices, dangerous alike to the family and to the state, since the -operative method under consideration was one likely to be eagerly -exploited by the whole tribe of medical charlatans.” This weighty -pronouncement would appear to be sufficient ground for rejecting -artificial fecundation as a matter of routine practice; still, very -exceptional cases may be encountered in which it may be seized as an -ultimum refugium. - - - _Pathology of Copulation._ - -The act of copulation may be interfered with or entirely prevented by -pathological conditions affecting the genital canal of the woman, and -also by disturbances of the nervous system—naturally also by any -abnormality affecting the performance of the male partner in the act. - -Abnormality of the hymen, such as excessive strength and rigidity, -rendering the organ unduly persistent, is a not infrequent hindrance to -intercourse, one that sometimes is not overcome even after years of -married life; to such a state of affairs ignorance on the part of the -married pair in respect to the proper method of intercourse, lack of -sufficient sexual power on the part of the male, or inflammation of the -fossa navicularis brought on by maladroit attempts at penetration, may -contribute, likewise undue passivity on the part of the female partner. - -[Illustration: - - FIG. 65.—Septate Hymen, the septum having a tendinous consistency. -] - -A notable and sometimes an insuperable obstacle (of which it has been -written, _nec Hannibal quidem has portas perfringere valuisset_) is -constituted by that abnormality of the hymen in which the aperture in -that membrane is guarded by a sagittally placed or sometimes oblique -septum, dense and almost tendinous in structure. In a woman of -twenty-four years, who for two years had lived in sterile wedlock, I -found such a tendinous hymen septum. She had menstruated regularly since -the age of seventeen years, but always painfully. She complained that -her husband was “very weak,” inasmuch as on her bridal night he was -unable to succeed in completing intercourse, and since then whenever he -attempted intercourse, premature ejaculation resulted, before -penetration of the penis had been effected. In consequence of this -repeated ineffectual sexual excitement, she had herself become very -nervous. On local examination, I found an elongated oval hymen, not -completely covering the vaginal orifice, rather strong and thick, and -divided in two halves by a median sagittal septum, of a densely -tendinous consistency. On either side of the septum, the vaginal orifice -would admit no more than the head of an ordinary uterine sound. I -divided this septum, and was informed later that the woman had become -pregnant as a result of the first subsequent act of intercourse (Fig. -65). - -A remarkable case of abnormality of the hymen is recorded by -_Heitzmann_, having been observed by him in a woman aged twenty-seven -years. In this instance, the hymen was represented by a swelling, smooth -on the surface and separated from the nymphæ by a deep furrow. Behind -this swelling, between it and the posterior commissure, there was a deep -depression, into which the finger could be passed to a depth of an inch -and a half or more. Anteriorly, the very firm and fleshy prominence was -bounded by a ridge, from the middle of which to the urethral orifice ran -a short but strong and tense septum. Right and left of this septum were -small apertures, with difficulty admitting the point of a probe. Between -the anterior extremity of the septum and the urethral orifice was a -nodular representative of the swelling normally present in this -situation. Surrounding the urethral orifice were two or three additional -small nodules. The two lateral margins of the hymen were prolonged -around the urethral orifice, and united in front thereof to form a -raphe, which could be traced as far as the base of the clitoris. The -young woman had been married for some months, and asserted that she had -repeatedly had intercourse. With such a condition of the female -genitals, penetration of the penis into the vagina was however quite -impossible. During coitus, the penis must have been inserted into the -aforesaid depression behind the swelling, which was sufficiently -extensible for the purpose. - -A less serious hindrance to intercourse, but one more frequently -encountered, is a partial persistence of the septum of the hymeneal -orifice, in such a manner that there is a projecting tongue of membrane -from the anterior and posterior margins of the orifice, partially -blocking this latter; or there may be a single median projection only, -either in front or behind. Such processes may be remarkable alike for -their size and their shape. _Liman_ describes a cordiform hymeneal -orifice, constituted by an anterior or posterior protection of the kind -here described. - -In cases of imperforate hymen in which the occlusion of the vagina is -not complete, impregnation may in rare instances occur, even though -proper intromission of the penis is quite impossible. Cases of this kind -have been observed by _Scanzoni_, _Horton_, _K. Braun_, _Leopold_, -_Brill_, _Breisky_, and others. - -[Illustration: - - FIG. 66. -] - -In most of these cases there was a thick, dense, “imperforate,” or -rather _persistent_ hymen, with an orifice no larger than the head of an -ordinary probe, notwithstanding which pregnancy had occurred. The cases -reported by _Brill_ were of a different character, being those of two -young unmarried Russian girls, with normal undestroyed hymens, who were -found to be pregnant. According to _Brill_, such cases are by no means -uncommon among the peasantry of Little Russia, where the barbarous -practice prevails of adolescent girls and boys sleeping together. In -these circumstances, sexual intercourse takes place, but, from fear of -consequences, it is often incomplete. Hence, in occasional cases, -results pregnancy in a young girl with intact hymen. - -In the first complete act of intercourse, the defloration of the virgin, -the hymen is as a rule torn in several directions, and in consequence -there is usually moderate bleeding. The lacerations of the hymen soon -skin over. When the initial coitus is effected maladroitly or roughly, -more extensive lacerations are apt to occur, and the injury may not be -limited to the hymen, but may extend longitudinally along the vaginal -wall, and even involve the posterior vaginal fornix. Or, again, without -any such extensive laceration, there may result very profuse bleeding, -in consequence of abnormally profuse vascularization of the hymen. Cases -are also recorded in which (presumably not from normal coitus alone, but -from other, unacknowledged manipulations), whilst the hymen has been -left intact, false passages have been made, leading to the formation of -fistulæ, with subsequent death from haemorrhage or sepsis. - -Apart from impotence in the male, the hymen may remain intact when it is -not touched at all during coitus. Inexperience, as _Veit_ remarks, will -in this matter lead to results almost incredible. This author has been -informed by such inexperienced married couples, that in attempts at -intercourse “the penis of the man is introduced between the thighs of -the woman, which are closely pressed together, the man having his legs -on either side. Naturally, in this method of intercourse, the hymen -escapes destruction. In such attempts at coitus, things are done which -can hardly be compared with the normal act of copulation.” - -In isolated instances, the introduction of the penis is prevented by -congenital or acquired defects in the formation of the external -genitals. Adhesion between the labia majora and the labia minora is -sometimes met with a congenital deformity, which may or may not be -associated with atresia of the urethral orifice; in some cases the -adhesion is dependent merely upon a superficial epithelial continuity, -but in others the labia are firmly adherent throughout. Less rare are -acquired adhesions, the result of accident, between the labia majora and -the labia minora, leading to atresia of the vulva, and thus making -copulation impossible. - -Intromission of the penis may be rendered quite impossible by excessive -size of the labia majora, consequent upon elephantiasis, in which -disease there is enormous hypertrophy of the subcutaneous connective -tissue. New growths may have the same result, fibroids, for instance, -lipomata, and cysts, which may attain a remarkable size in the cellular -tissue of the labia, the mons veneris, and the perineum, and also in the -nymphæ and in the cellular tissue between the clitoris and the urethral -orifice. In a very obese woman twenty-eight years of age I saw a lipoma -attached to the right labium majus. In the course of six years it had -grown to such an enormous size, that it extended downwards over the -thigh, blocked the entrance to the vagina, and made coitus absolutely -impossible (Fig. 67). Various forms of labial hernia are also competent -to occlude the vaginal orifice. - -[Illustration: - - FIG. 67.—Lipoma of the right labium majus, occluding the vaginal - inlet. -] - -Hypertrophy of the nymphæ, which, as the so-called _Hottentot Apron_ has -to be regarded as a racial peculiarity, is known also in Europe as a -pathological condition which may at times constitute a hindrance to -sexual intercourse (Fig. 68). According to _Otto_ there are three -fundamental forms of the Hottentot apron, viz., excessive enlargement of -the nymphæ, overgrowth of the labia majora, and, lastly, the formation -of a peculiar lobe of flesh and skin, attached to the mons veneris by a -pedicle, containing the clitoris, and covering the genital fissure as -with a valve. Hypertrophy of the nymphæ is said to be common also in -Turkish and in Persian women. Owing to the obstacle to intercourse -presented by hypertrophied nymphæ, it is among certain races an -established custom to amputate clitoris and nymphæ together. _Virey_ -writes: “The Portuguese Jesuit missionaries to Abyssinia in the -sixteenth century, endeavoured to abolish this practice of the -circumcision of women, which they regarded as a relic of Mohammedanism; -the uncircumcised maidens, however, could find no husbands, owing to the -inconvenient length of their nymphæ. The pope sent surgeons to the -country, to enquire into the matter, and their reports were in such -sense that circumcision was permitted as necessary.” Davis reports -observations made by Sonini on the female indigens of lower Egypt, in -whom the vulva hangs down in the form of a loose, flabby mass of flesh, -of striking length and thickness, completely covering the genital -fissure. He believes that the circumcision that was practised on the -women of ancient Egypt consisted in the removal of this hypertrophied -vulva. - -[Illustration: - - FIG. 68.—“Hottentot apron” in an adult woman, hanging down between the - thighs. (After Zweifel.) -] - -_Courty_ saw a case in which the remarkable length of the labia minora, -which when an attempt was made to introduce the penis, covered the -vaginal orifice, had rendered coitus ineffective, and had caused -sterility for five years. Resection of the labia minora was followed by -successful intercourse and conception. - -The lipomatous form, especially, of elephantiasis vulvae often attains a -gigantic size. Growths of this nature, of the size of a child’s head, -weighing six or seven kilo (thirteen to fifteen pounds), and reaching -down to below the knee, are by no means rare. I have known several cases -in which an excessive accumulation of fat in the vulva associated with -pendulous belly has constituted a mechanical obstacle to the completion -of sexual intercourse. - -[Illustration: - - FIG. 69.—Elephantiasis of the labia majora -] - -Hypertrophy of the clitoris may constitute an obstacle to coitus. In -exceptional cases, this organ is as large as the male penis, and hangs -down over the genital fissure like a valve. _Hyrtl_ relates that in -certain African races, this congenital enlargement of the clitoris is so -enormous, that the organ, made fast to the perineum with rings, serves -for the protection of virginity. _Schönfeld_ describes the case of a -woman aged twenty-eight years, in whom the vaginal orifice was almost -completely occluded by a dry and firm growth, with a granulated surface. -Close observation proved this growth to be produced by a hypertrophied -and degenerated clitoris, which had attained the size of a child’s head. -Elephantiasis of the clitoris is especially inconvenient in consequence -of the hindrance which the enlarged organ offers to sexual intercourse. -_Bainbridge_ describes a case of tumour of the clitoris measuring 8 cm. -(3.2 in.) in length and 5 cm. (2 in.) in width. The following remarkable -case is recorded by _Oesterlen_: A young man wished to break off his -engagement on the ground that his intended wife was a hermaphrodite. -Examination, however, disclosed the existence of a strong intact hymen, -a very large clitoris, and pregnancy of the twentieth week. - -Injuries of the vagina resulting from coitus are, generally speaking, -rare. The usual cause of such injuries is disproportion in size between -the erect penis and the calibre of the vagina, or else brutal violence -in the performance of coitus; sometimes, however, it is dependent on the -pathological state of the female genital organs, which have undergone -senile atrophy. - -To the first group belongs the case reported by _Albert_, in which a -girl of eleven years was found to have a laceration of the vagina -communicating with the peritoneal cavity, the injury resulting from -coitus. To the second group belongs the case reported by _Böhm_, of -lacerations of the vaginal mucous membrane resulting from forcible -coitus in elderly women. _E. Frank_ reports a case of injury due to -violent coitus in a woman in whom the vagina was already greatly -stretched by retroflexion; and another case in which injury occurred -during intercourse in a woman with vagina duplex—in this case, not only -was the hymen of the right vagina torn, but also the septum between the -two vaginae. - -By no means extremely rare are injuries to the vagina in the act of -defloration, causing severe hemorrhage. _Martin_ records a fatal case of -this nature. _Maschka_ and _Hofmann_, the authorities on Forensic -Medicine, deny that vaginal laceration is the result of simple coitus, -and _Hofmann_ maintains that such serious injury can occur only from -digital manipulations; in fact, these writers believe that the penis -alone cannot be employed with sufficient force to cause laceration. -_Barthel_ and _Anderson_, however, saw vaginal lacerations in -nulliparous women; and _Zeis_ records a case of vaginal laceration in a -woman twenty-five years of age, with whom, six weeks after parturition, -her husband, then in a state of intoxication, had had intercourse in the -position _à la vache_. - -Anomalies of the vagina, absence, stricture, duplication, and abnormal -apertures, also diseases of the vaginal tissues, may induce incapacity -for sexual intercourse. In frequency as in significance, among these -disorders, absence of the vagina and stenosis and atresia of the canal, -stand in the first rank. Congenital atresia may be complete or only -partial, according as the two ducts of _Müller_ from the fusion of which -the tube is formed, remain totally or only partially solid—or, having -duly canalized, subsequently, by a foetal inflammatory process, become -transformed into a thick, more or less solid cord. If the obliteration -of the vagina is at the lower extremity of the canal, coitus is -impossible, unless, as sometimes happens, by frequent attempts at -intercourse, the short blind sac representing the lower end of the -vagina has been stretched upwards in the form of a pouch. When the -obliteration of the ducts of _Müller_ is complete, we have total atresia -of the vagina, in which case the uterus is also as a rule wanting, or is -but imperfectly represented. In some cases, from the ducts of _Müller_, -instead of the normal vagina, there is formed a tract of membrane of -varying density and width, through which passes a small canal for the -passage of the menstrual discharge; this condition is known as atresia -vaginalis membranacea. - -When, notwithstanding malformation of the external genital organs and -partial absence of the vagina, there is no defect in the internal -genital organs, conceptions may sometimes be effected through some -abnormal channel, as for instance through a communication established -per anum; or, again, some operative procedure may bring relief. _Rossi_ -reports a case of congenital absence of the external genital organs, in -which an incision was made in the region of the absent vagina, and an -artificial vagina was thus constructed; copulation was in this way -rendered possible, and conception ensued. In this connection, we may -turn with interest to the essay by _Louis_, entitled _Deficiente Vagina, -Possuntne per Rectum Concipere Mulieres?_ Here we are told of a case in -which vulva and vagina were absent, and there was a monthly discharge of -blood per anum; the woman’s lover employed this passage also _ad -immissionem penis_, and the woman became pregnant. Pope Benedict XIV -expressly allowed to women suffering from _imperforatio vaginae_ the -practice of _coitus parte posteriori_. - -Further, in cases of atresia vaginae in which the genital canal -terminates in the urethra, conception can result from urethral coitus, -as is proved by cases recorded by _K. von Braun_, _Weinbaum_, and -_Wyder_. In _Weinbaum’s_ case, the obliteration of the vagina was -complete, neither eye nor finger could detect the slightest aperture; -the woman having become pregnant after _coitus per urethram_, delivery -was effected by Caesarian section. In _Wyder’s_ case, the vaginal -orifice was closed, with the exception of a minute aperture, by means of -dense fibrous tissue; the woman was in labour and the head of the child -was in the pelvis. Under anæsthesia, the septum, which was nearly an -inch thick, was divided, the opening was enlarged, and the child was -extracted by forceps. An investigation disclosed that the husband had -always had intercourse by introducing his penis into the dilated -urethra; it was evident that the semen had passed through the urethra -into the bladder, and thence had found its way through a vesico-vaginal -fistula into the vagina and uterus. - -Acquired obliteration and stricture of the vagina from the contraction -of scar tissue, in consequence of deep ulceration, especially when -croupous or diphtheritic in nature, following typhus or typhoid, -pyaemia, puerperal sepsis, and the acute exanthemata (especially -variola)—may likewise serve as obstacles to coitus. Syphilitic -affections also, through contraction of exudations, the adhesion of -ulcerated opposing surfaces, condylomata, etc., may give rise to -stricture or obliteration of the vagina. The same conditions may be -induced by trauma, as by wounds, by attempts at rape, or by the use of -caustic acids and alkalis. - -Thus, _Ahlfeld_ saw severe stricture of the vagina as a sequel of the -excision of four large condylomata. _Hennig_ the same, after variola, -and again in lunatics who had introduced caustic fluids into the vagina. -By _L. Mayer_, atresia vaginae was seen as a sequel of typhoid; by -_Weiss_ as a sequel of diphtheria; by _Martin_ from the action of -irritant secretions in cases of uterine tumour; by _Billroth_ as a -result of continued irrigation of the vagina with alkaline urine after -lithotomy or urethrotomy, and in cases of vesico-vaginal fistula. -Ulcerative processes set up by the long continued action of a vaginal -tampon, a pessary, or some other foreign body, have been noted as -leading to consecutive obliteration of the vagina. - -Such stenosis, when partial only, may prevent complete coitus, and yet -allow conception to occur. Cases illustrating this fact have been -numerously recorded. Thus, _van Swieten_ already reported the case of a -girl aged sixteen years, whose vagina was strictured to such an extent -that the passage would barely admit a crow-quill; nevertheless she -became pregnant, and was successfully delivered. Similar cases are -mentioned by _von Scanzoni_, _Kennedy_, _Devilliers_, _Varge_, _Moreau_, -and _Plenk_. - -Serious obstacles to coitus, of a nature analogous to acquired stenosis -of the vagina, are constituted by the irregular ligamentous bridges -which sometimes arise in the vagina from the adhesion of a strip torn -from the mucous membrane on one side of the vagina to the other side of -that tube—or, again, a portion of a lacerated cervix may adhere to the -wall of the vagina. An interesting case of this nature came under my own -observation. It was a woman aged thirty-two years, who had twice had -difficult deliveries, the last time nine years before. Since then she -had been barren. On local examination I found in the vagina a fleshy -bridge, about 4 cm. (1.6 in.) wide and 6 cm. (2.4 in.) long, extending -from the left side of the portio vaginalis to the right wall of the -vagina; this mass of tissue was so placed that the intromitted penis -must necessarily have slipped past it into a blind sac, such as the -French name _une poche copulatrice_. Similar membranes in the vagina -have been described by _Breisky_, _Murphy_, and _Thomson_. - -Various tumours may narrow or even completely close the vaginal passage, -myoma, sarcoma, carcinoma, and especially the polypoid form of -fibromyoma, which may even project without the vaginal orifice. And even -when tumours of or in the vagina do not actually hinder coitus by the -space they occupy, they may affect that operation by bleeding whenever -it is undertaken, a manifestation extremely alarming to young married -persons. - -The vagina may also be partially occupied, and coitus may be impeded, by -elongation of the hypertrophied cervix uteri, by inversion or prolapse -of the uterus, by cystocele or rectocele, and by uterine polypi. -_Horwitz_ records the case of a woman aged twenty-two years in whom -_impotentia coeundi_ was dependent upon the occlusion of the vaginal -orifice by a rounded, strongly projecting body, which proved on closer -examination to be a hypertrophied vaginal bulb. - -Tumours of the rectum and other intrapelvic growths may encroach upon -the vaginal passage and impede coitus. Closure of the vagina has been -brought about even by abnormal size and abnormal toughness of the -perineum. - -Finally, in extreme degrees of pelvic contraction, the vagina may be so -much narrowed as to interfere with coitus. _Von Hofmann_ records a case -of this nature: In a woman thirty years of age, affected with -kypho-scoliosis, who suffered extreme pain whenever her husband -attempted sexual intercourse, the pelvis was twisted and narrowed to -such an extent that the conjugate measured barely one inch, and the -vagina was so small as barely to admit the finger. - -Duplication of the vagina will constitute an obstacle to coitus when -both halves of the passage are too narrow to allow of intromission of -the penis. Difficulty in intercourse will also be caused by abnormal -termination of the vagina, as by its termination in the rectum, likewise -by severe perineal laceration which has converted the lower parts of the -vagina and rectum into a cloaca, likewise by recto-vaginal and -vesico-vaginal fistulæ; in the case of all these latter states a feeling -of disgust is apt to be aroused in the male which may effectually check -sexual desire. Still, coitus, and even conception, are quite possible in -these conditions. _Kroner_, among sixty cases of vaginal fistula, -observed six in which conception took place while the fistula was -actually open. - -Apart from all local pathological conditions, coitus may be interfered -with by general nervous disturbances, manifesting themselves locally, -and depriving the woman so affected of potentia coeundi. First among -such states must be mentioned vaginismus, a condition so important as to -demand discussion in a separate chapter. - -An important and by no means rare obstacle to the completion of -intercourse, affecting the male partner in the act, is partial or -complete incapacity for erection of the penis. Even excessive smallness -of the penis may render coitus inadequate; still more so, however, -organic diseases of the membrum, such as obliteration of the corpora -cavernosa, or of some of the trabecular channels of these bodies, -nodular formations resulting from injury, or cavernitis from gonorrhoea. -In such cases, erection is extremely irregular, and the erect penis is -sharply bent (chordee) instead of being straight, a condition which -renders intromission mechanically difficult if not impossible. A similar -effect is produced by ossification of some part of the tunica albuginea -of the corpora cavernosa—the so-called penis bone. Mechanical obstacles -to coitus are also offered by inguinal and scrotal hernias; and by -excessive obesity, where the increase in thickness of the panniculus -adiposus of the abdominal wall and the mons pubis, whilst the penis -itself remains as slender as before, causes the organ almost to -disappear from view. - -Psychical impotence in the male is much more frequently observed than -organic impotence. We meet with this condition especially in -neurasthenically predisposed individuals, or in men who have been given -to excessive venery or have masturbated excessively in youth, and who, -when entering upon married life, fear they will be unable to satisfy the -legitimate desires of their wives; or in newly married men who have -suffered often from gonorrhoeal inflammations, such as prostatitis, -vesical catarrh, and epididymitis. The fear and anxiety from which such -persons suffer has an inhibitory influence upon the erection of the -penis. In some instances, this inhibitory influence is partial only, and -the man thus affected, while perfectly competent in intercourse with a -prostitute, who employs means of sexual stimulation to which he has -become accustomed, is unable to complete intercourse with his wife, who -is ignorant and innocent, and assumes a purely passive role; or it may -be that erection is not sufficiently powerful to bring about rupture of -the hymen, and thus to overcome the difficulties _primae noctis_. - -As regards gonorrhoeal infection, it appears that in men who in other -respects are perfectly competent, this disease has an inhibitory -influence upon the nervous mechanism concerned in producing erection of -the penis. - -_Psychical impotence_ is usually transitory, but it may endure for a -very long time; and it may be many months before the husband, whose -nervousness has led to failure in the decisive moment at the outset of -married life, is able to command an erection sufficiently powerful to -bring about the defloration of his wife. Occasionally such psychical -impotence is not absolute but relative, it relates, that is to say, to -one particular woman—unfortunately, as a rule, a man’s own lawful -wife,—whilst coitus with another woman, even in default of any measures -for artificial sexual stimulation, is easily effected. This fatal -misfortune is especially liable to occur in cases in which a man fully -experienced in sexual matters marries a woman whom he dislikes or for -whom he has no regard; the marriage being determined by material -considerations. From such women I have heard the painful confession that -the husband, a man renowned for his gallantries, played a very poor part -in the bridal bed. - -The impotence of _irritable weakness_ is characterized by premature, and -therefore fruitless ejaculation. A man thus affected has a powerful -erection of the penis, preparatory to coitus, but at the moment of -contact with the female genital organs, before there has been time for -penetration to occur, ejaculation takes place, and is immediately -followed by relaxation of the penis. Such irritative impotence is often -met with in young men at the outset of their sexual career, in -beginners, whose sexual passion is very readily excited, whose -imagination shoots forward to the goal, and who are unable to restrain -themselves. This form of impotence can also be cured by wisely chosen -measures. - -The _paralytic_ form of impotence, on the other hand, is characterized -by the entire absence of erections of the penis, both overnight in bed, -and during the early morning hours; the penis always remains flaccid, or -at most becomes semi-erect only, insufficiently rigid for penetration. -Ejaculation is much retarded or altogether wanting. - -Impotentia coeundi in the male may be _complete_, in cases in which the -erection-apparatus is entirely inactive, and in which even an attempt at -intercourse is out of the question; or, and this is more frequently met -with, it may be partial only, and manifests itself in various degrees of -imperfection in the performance of coitus. - -This latter form may often escape the woman’s notice. Whilst complete -impotentia coeundi, in which intromission of the penis is impossible, is -a state about which neither husband and wife can fail to be fully -informed, cases of partial impotence, with semi-erection of the penis or -premature ejaculation, are often glozed over by the husband, ignored by -the wife, and underestimated by the physician—and yet such incomplete -intercourse entails a series of ill-consequences alike upon the genital -organs and upon the nervous system of the wife. Erection is incomplete, -and thus the penis passes into the vestibule only, and not deep into the -vagina; even if penetration is more thorough, the venous return of the -blood from the corpora cavernosa is not checked sufficiently to distend -the penis to its full size, and to bring it into close contact with the -vaginal walls; or ejaculation occurs prematurely, before the sexual -organism of the wife has attained that supreme degree which is needful -alike for the attainment of sexual gratification and for the occurrence -of conception. - - - _Vaginismus._ - -_Vaginismus_ is a disordered state, characterized by hyperaesthesia of -the hymen and of the entrance to the vagina, so extreme that, even -though the organs may be entirely free from any anatomical abnormality, -coitus is prevented, whenever attempted, by violent, involuntary -spasmodic contractions of the constrictor cunni and the other muscles of -the urogenital and anal region. - -The centripetal paths of the reflex spasm characteristic of vaginismus, -run through the branches of the inferior hypogastric plexus, and -especially through the utero-vaginal plexus. The spinal nerves connected -with this part of the sympathetic are the 2d, 3d, and 4th sacral. The -plexuses are constituted by fibres in part from sympathic and in part -from the 2d, 3d, and 4th sacral nerves. Through the same nerves passes -the centripetal motor tract for the transversus perinei muscle, and for -the sphincter and levator ani muscles. According to _Eulenburg_, the -centre for this reflex is to be found at the level of the first sacral -nerve; when the disturbance irradiates more widely, the lumbar and -sacral plexuses as a whole are involved. The constrictor cunni -(sphincter vaginæ or bulbocavernosus muscle) is supplied by the perineal -branch of the pudic nerve. The symptom-complex of vaginismus consists of -violent spastic contraction, for a term varying greatly in duration, of -the constrictor cunni (bulbocavernosus), sphincter ani, levator ani, and -transversus perinei muscles, the spasm spreading, in severe cases, to -other muscles in the neighbourhood, and especially to the adductor -muscles of the thigh; the spasm comes on when any attempt at intercourse -is made, and even when the genitals are merely touched. - -In young married couples especially, vaginismus is an extremely -distressing condition, and one that entails very serious consequences, -inasmuch as the pains and reflex spasms which result from any attempt at -coitus, and even from the mere approximation of the penis to the female -genital organs, render sexual intercourse absolutely impossible. The -cause of this pathological manifestation is in part to be found in -unskilful attempts at intercourse, which have stimulated the female -genital organs at some improper region. It may be that the young husband -is not fully instructed in sexual matters, and does not really know how -coitus ought to be effected; in other cases there is some abnormality of -the hymen, which has rendered the rupture of that membrane extremely -difficult; in some cases there is partial impotence in the male, whose -penis becomes semi-erect only, so that ever-renewed attempts at -intercourse are followed by ever-renewed failure. Any of these causes -may suffice, in susceptible women, to originate vaginismus. The sufferer -in these cases will usually be found on enquiry to be hereditarily -predisposed to nervous disorder, and to be extremely sensitive to pain. -By the fruitless efforts of her ignorant or partially impotent husband, -she is sensually excited without ever being satisfied; the injured -nervous system responds by these local spasms, whilst ultimately, in -some of these cases, an actual psychosis ensues. - -In a certain number of cases, however, the husband is in no way -responsible for the origin of vaginismus, which may depend on -pathological states of the female external genitals, leading to -hyperaesthesia; or, again, on primary hyperaesthesia of the pudic nerve -and its branches; or, finally, on general neurasthenia and hysteria, on -excessive sensibility and lack of self-control on the part of a young -girl, who has entered upon married life under the dominion of -extravagant ideas. Vaginismus dependent upon general neurasthenia -especially in cases in which there is no strong affection for the -husband to give the spur to desire, and to enable the woman to bear with -fortitude the pangs which form the necessary introduction to the joys of -wedded life. It must not be forgotten, as throwing light on the origin -of vaginismus, that in the digital vaginal examination of a virgin or -even of a young wife, unless extreme care is taken, pain and painful -muscular spasms are liable to be evoked. - -The local pathological conditions of the female genital organs that are -most often met with in cases of vaginismus are: a very rigid state of -the hymen; inflammation and excoriation of the hymen and its -surroundings; fissures at the vaginal orifice; inflammatory affections -of the vaginal follicles; inflammation of the carunculæ myrtiformes; a -peculiar formation of the vulva, which extends forwards over the pubic -symphysis, whereby the urethral orifice and the hymeneal aperture come -to lie upon the pubic symphysis or the subpubic ligament; vulvitis; -herpes or eczema of the vulva; colpitis; urethritis; fissure of the -anus; papillary growths; pruritus papules; urethral caruncle; -inflammation of Bartholin’s glands; at times gonorrhoeal infection. - -A case came under my own observation in which a newly married woman -suffered from vaginismus. The husband believed the cause of the trouble -was his own partial impotence, consequent upon youthful venereal -excesses, and yielded to the desire of his wife and her relatives that a -divorce should be obtained. A year later, the woman remarried, when, to -her horror, the symptoms returned in full force. Now for the first time -she consulted me, and on local examination I could detect no abnormality -whatever. The vaginismus was in this instance a pure neurosis, the only -possible cause of which was to be found in bygone overstimulation of the -vaginal orifice, the wife admitting previous onanistic excesses. In -another case known to me, vaginismus in the wife made the husband an -involuntary sodomite. The movements of the wife when the spasm came on -led to the introduction of the penis per anum, and coitus had repeatedly -been effected by this abnormal route, when the fact first became -apparent as the result of a local examination. - -_Le Fort_ reports the case of a young Russian wedded pair who were -spending their honeymoon in Paris. The husband took so much to heart his -inability to fulfil his marital obligations in consequence of the -vaginismus from which his wife suffered, that he shot himself through -the heart. The distressing situation of a husband whose wife suffers -from vaginismus, rendering coitus impossible, is depicted in the -well-known French romance, “_Mademoiselle Giraud, Ma Femme_.” From a -false shame, women often continue to suffer from vaginismus for months -and even years, without a single effective coitus having ever taken -place; it is only the consequent sterility which at last leads to -medical advice being sought. The physician then usually ascertains that -the hymen is still intact, or at least incompletely destroyed, that on -this membrane and on various parts of the vulva there are erosions, and -that the whole of the external genitals outside the hymen are in a state -of inflammation more or less acute. In other cases, however, neither -excoriations, erosions, nor inflammation can be detected, and the -existence of vaginismus can be proved only by the pain and the muscular -spasm set up by contact with the vagina. Often, indeed, the cause of -this most distressing affection cannot be discovered. - -Introduction of the penis may be rendered impossible by spasm of the -constrictor cunni (bulbocavernosus) muscle, but equally so by spasm of -the transversus perinei or the levator ani muscle. Sometimes the spasm -affects all three muscular groups; in which case the narrowing of the -vagina is extreme, and extends for some way up into the canal. When the -levator ani alone is affected by the spasm, the penis can, indeed, be -introduced into the vagina, to encounter a powerful obstacle in the -interior of that canal; and it may happen, when the spasm comes on and -affects the levator ani only after complete intromission of the penis, -that the glans is retained in the vaginal fornix by the active -contraction of the pelvic floor. - -More or less credible instances of _penis captivus_ thus brought about -are on record. The following history is by _Davis_: A gentleman entering -his stable found therein his coachman and a servant-maid in a most -compromising position. All endeavours of the pair thus surprised to -separate proved ineffectual, and their attempts to draw apart caused -them intense pain. _Davis_ was sent for, and ordered an iced douche, -which, however, failed to liberate the imprisoned penis. Release was -impossible until the woman had been placed under chloroform. The swollen -and livid penis exhibited two strangulation-furrows, a proof that two -distinct areas of the levator ani muscle had been spasmodically -contracted. - -_Hildebrand_ records three cases observed by himself in which there was -spasm of the upper part only of the vagina, unaccompanied by vaginismus -(_i. e._, by pain). In two of these cases, the spasm was originated by -the contact of the examining finger with very painful ulcers of the -portio vaginalis; the third patient had a very sensitive prolapsed -ovary. _Fritsch_ reports having had on one occasion to give a woman -chloroform for the release of a swollen and imprisoned penis. - -_Hildebrand_ suggests that vaginismus may be caused by an abnormal size -of the penis, or by a condition occurring in weaklings and alcoholic -subjects, in whom the greatest swellings of the glans penis occurs -before intromission, whilst this greatest swelling is normally deferred -until towards the end of the act, when the glans is in the vaginal -fornix. - -_Schröder_ writes as follows regarding the etiology of vaginismus: “The -affection is dependent upon trauma, sustained in maladroit, frequently -repeated attempts at sexual intercourse; for this reason it is met with, -in the great majority of cases in young, newly married women. Impotence -in the male is by no means necessary for its production, and such -impotence is not even a frequent antecedent. Abnormal narrowness of the -vagina, or extreme firmness of the hymen, is occasionally found, but -neither is in any way necessary; all that can be said in this connection -of a small vaginal orifice is, that it _predisposes_ to vaginismus. If -the husband is devoid of previous experience in sexual matters, -maladroit attempts at intercourse are exceedingly likely to occur. The -penis is thrust in the wrong direction, pressing against either the -anterior or the posterior commissure of the vulva. Very often, moreover, -the position of the vulva, which is subject to very striking individual -variations, is concerned in the production of vaginismus. There are many -women in whom the vulva lies in part in front of the symphysis pubis, so -that the lower border of the symphysis lies below the urethral orifice. -In such cases the penis is directed too far backwards, and instead of -passing into the vaginal orifice, slips into the fossa navicularis. The -frequent repetition of such maladroit attempts at intercourse gives rise -to a gradually increasing sensitiveness of the parts concerned, with the -formation of excoriations. It now results that, on the one hand, the -woman dreads attempts at intercourse on account of the pain to which -they give rise; she shrinks away from the man, so that penetration of -the vagina by the penis is rendered even more difficult than it was -before; and, on the other hand, ungratified sexual desire leads to the -frequent repetition of attempts at complete intercourse (from which, -moreover, if conception should ensue, a cure of the trouble is -expected). In this way, the trauma is rendered more severe, the -congestion and excoriation of the fossa navicularis or of the urethral -region are aggravated, and the sensitiveness of the parts increases to -such a degree that the woman thus affected screams out when the vulva is -merely touched. Ultimately reflex cramps set in whenever intercourse is -attempted, and we then have the fully developed clinical picture of -vaginismus.” - -_Winckel_ maintains that in most cases there are two principal elements -in the causation of vaginismus. In the first place, in consequence of -more or less pronounced anatomical changes, there is undue sensitiveness -and tenderness of the vaginal inlet and its neighbourhood, and in -exceptional cases also of the upper part of the vagina, the uterus, and -the ovaries. In the second place, the patient manifests an increased -general sensitiveness and nervous irritability; this is in some cases -primary, but in others it is entirely the result of the repeated -stimulation; and in either case it is heightened by the effects of -ungratified sexual desire. - -_A. Martin_ points out that the spasm of the muscles of the pelvic -floor, and especially of the levator ani muscle, upon which vaginismus -depends, may be due in some cases to the influence of chill, since the -same cause will lead to pathological contractions in other muscular -areas. But in such cases it is always open to question if masturbation -or some other sexual perversion is not the true cause of the disorder. -In some instances vaginismus is merely a symptom, in extremely sensitive -women, of various diseases of the reproductive organs, and is brought on -by the increased pain which in such cases is caused by attempts at -intercourse; when produced in this way, vaginismus is usually a -transient manifestation. - -_Veit_ considers that among the pathological conditions giving rise to -vaginismus, we must also enumerate diseases of the internal pelvic -organs, such as chronic metritis, displacements of the uterus, -oöphoritis, etc.; but he also attaches great importance to nervous -predisposition, consequent upon previous sexual stimulation, and upon -pre-existing inflammatory changes due to gonorrhœal infection. A -peculiar form of vaginismus is, according to _Veit_, sometimes observed -after the birth of the first child; happily the duration of this is -usually brief. After parturition the vulval mucous membrane remains for -a time very tender, and when cohabitation is resumed, often too soon, -and perhaps, after the enforced abstinence, too frequently repeated at -brief intervals, fissures are readily produced. Moreover, vaginismus -which has existed prior to parturition may, in some cases, recur after -that event. An unusual position of the vulva, undue smallness of the -vaginal inlet, and relative impotence of the man, may combine to cause -such a recurrence. Finally, vaginismus often persists throughout -pregnancy, and manifests itself during parturition. The magical effect -which chloroform has in some primiparæ, when the head is delayed at the -vulva, is explicable only by the supposition of vaginismus. - -According to _Arndt_, vaginismus is not purely a local disorder, but is -in many cases the local manifestation of a neuropathic diathesis, which -may in some instances lead to general mental disorder. - -_Olshausen_ regards hyperæsthesia and vaginismus as different stages of -a single disease; he believes that the excessive sensitiveness is seated -chiefly in the hymen; he explains the spasm as the reflex result of -fissures and inflammatory changes. _Pozzi_ considers that excessive -nervous irritability and an irritable state of the vulva are the -indispensable preliminaries to the occurrence of vaginismus. _Herman_ -distinguishes between excessive smallness of the vaginal inlet and -vaginismus; he regards the latter as a nervous disorder, characterized -by hyperæsthesia of the vulva, and by spasmodic contraction of the -levator ani and adjoining muscles. _Frost_ distinguishes vaginodynia -from vaginismus; in vaginodynia the pain is so intense as to cause -syncope, and the muscular spasm involves the entire length of the -vagina. - -It is a notable fact, to which _Veit_ has especially drawn attention, -that among the poorer classes of the population, vaginismus is -practically unknown. Among women of these classes, their sexual needs, -not having been so much lessened by “culture,” suffice to withdraw their -attention even from the pains of defloration, which would otherwise -often be very severe; whereas the sexually neurasthenic woman of the -upper classes, filled with dread at the idea of the pain she expects to -suffer, and not infrequently in a condition of hyperexcitability or -hypersensibility dependent upon previously employed abnormal means of -sexual gratification, is unable to endure the pains of defloration even -when these might be expected to prove far from severe. - -In some cases, painful contractions of the vagina, to which we cannot -properly give the name of vaginismus, arise from organic diseases of the -uterus and the uterine annexa; these painful contractions render -copulation impossible. _Von Hofmann_ reports the case of a young -prostitute, who found herself unable to continue the practice of her -profession owing to the severe pain she suffered during intercourse; she -died, and the post mortem examination disclosed bilateral salpingitis, -with reproductive organs in other respects normal. - -Maladroit and incomplete attempts at intercourse, and the consequent -repeated failure to obtain complete sexual gratification, affect a -woman’s nervous system to a varying degree; but apart from this, in -women who have long cohabited with men of deficient sexual potency, we -often find a remarkable condition of complete relaxation of the genital -organs, associated with great hypersecretion of the mucous membrane, -flaccidity of the muscles of the pelvic floor, and displacements of the -uterus. Moreover, the nervous shock to which the repeated but -unsatisfying attempts at intercourse give rise, affects the spinal cord -in such a manner that symptoms of spinal irritation ensue. The patient -complains of pains in the back, the loins, and the nape of the neck; -these pains also radiate round the front of the abdomen and along the -intercostal spaces; hyperæsthetic points may be detected when the finger -is passed along the spine; there is weakness of the limbs with a -sensation of numbness; and neuralgic manifestations of varying nature -occur. - -The dangers which sexual intercourse may entail upon women—over and -above the irritable conditions and inflammatory disorders of the female -reproductive organs, dependent upon impetuous or unduly frequent coitus, -or upon coitus practised during menstruation—are principally due to -gonorrhœal and syphilitic infection transmitted by the cohabitating -male. - - - _Cardiac Troubles Due to Sexual Intercourse._ - -Among the troubles from which women at times suffer as a result of -sexual intercourse, certain cardiac disorders are especially worthy of -attention. - -Every act of sexual intercourse in a young and sensitive woman exercises -an exciting influence on the nervous mechanism controlling the cardiac -movements, and this influence is more clearly manifested in a degree -directly proportional to the intensity of the sexual orgasm. The heart’s -action is markedly increased in frequency, the cardiac impulse is more -powerful, the large arteries of the neck are seen to pulsate far more -vigorously, the conjunctiva is markedly injected, the respiration is -increased in frequency, the respiratory movements are more superficial -and have a panting character. - -But when, in a woman who is sexually irritable in an excessive degree, -the peripheral stimulation occurring in the act of sexual intercourse is -unusually powerful, there may result a notable increase or modification -of the reflex manifestations which normally occur during sexual -intercourse in the province of cardiac activity; similar results ensue -when there is a summation of stimuli owing to excessive sexual -intercourse, or contrariwise when the act of intercourse is broken off -just before its physiological climax and the natural termination of the -orgasm fails to occur. - -The former cause is not infrequent in young wives during the period of -the honeymoon. The latter cause is in operation when there are diseases -of the female reproductive organs preventing the physiological -completion of intercourse; but especially in consequence of the modern -practice of coitus interruptus, in which the man breaks off the act of -intercourse the moment he feels that ejaculation is imminent, without -troubling himself regarding the natural course of sexual excitement in -the woman. Yet another cause of excessive cardiac reflex manifestations -in women is incomplete potency of the male, which may either cause a -premature ejaculation of semen, or may lead to incomplete penetration of -the penis. - -In all such cases, as a result of sexual intercourse, there may arise -cardiac disorders of various kinds; among these, tachycardial paroxysms -are the most frequent, occurring either _inter actum_, or at a longer or -shorter interval after intercourse. - -In several cases of vaginismus occurring in young married women which -have come under my notice, it was observed that the attempts at -intercourse gave rise to violent involuntary spasmodic contractions of -the constrictor cunni and the other muscles of the urogenital and anal -regions, and in addition it was found that these attempts were followed -by tachycardial paroxysms with dyspnœic manifestations, lasting for a -considerable period, it might be as long as one or two hours. - -In women who had practised coitus reservatus for a prolonged period, in -fact for several years, in such a manner that, notwithstanding the -occurrence of intense voluptuous excitement, complete sexual -gratification rarely, if ever, occurred—in such women, in whom these -marital malpractices seemed to have profoundly influenced their -psychical life, I have frequently witnessed a form of reflex cardiac -disorder which I must regard as a variety of the multiform neurasthenia -cordis vasomotoria. In such women, still at the climax of their physical -powers and of their sexual needs, attacks of palpitation suddenly occur -at irregular intervals, several times daily or less frequently. -Associated with this increased frequency of the cardiac activity are an -extremely distressing feeling of anxiety, a sensation of faintness, -headache, vertigo, a weakness of the muscular system, and at times -actual attacks of syncope. Physically, the women are extremely -depressed, irritable, inclined to weep, unhappy, and weary of life. At -the same time, digestion is impaired, the appetite is small, and there -is constipation. The pulse is in most cases feeble, small, of low -tension, easily compressible, increased in frequency, often -intermittent, sometimes more distinctly arhythmical. The heart is found -to be sound on physical examination, nor can any abnormality be detected -in the great vessels. The lower extremities are free from œdema; the -urine does not contain albumen. - -Women thus affected are sometimes believed to be suffering from cardiac -disorder, in other cases they are subjected to various modes of -gynecological treatment; until at length the physician, by appropriate -questions, becomes enlightened regarding the true cause of the cardiac -disorder, namely, coitus interruptus. If it is possible to prohibit -effectually this unwholesome practice, the cardiac symptoms soon cease -to recur. - -Finally, in women at the climacteric age, cardiac troubles sometimes -ensue, which are dependent on interference with sexual intercourse in -consequence of anatomical changes in the vagina; changes of this -character frequently occur at the time of the menopause; owing to -hyperaemic or inflammatory processes, a partial or general stricture of -the vaginal passage results; in many cases this passage becomes -narrower, shorter, and almost conical in shape, whilst the vaginal inlet -is greatly diminished in size. Such a vaginal stricture, which _Hegar_ -has also seen in younger women after an artificial climacteric -(oöphorectomy), interferes with sexual intercourse; and the incomplete -sexual gratification gives rise to a series of nervous manifestations, -and, among others, to the above described reflex cardiac neurosis. - -Whether, and in which cases, the cardiac disorders evoked as a result of -the local stimulatory influences of sexual intercourse, are dependent on -a reflex stimulation of the sympathetic nerve on the one hand, or upon a -transient paresis of the inhibitory centre of the heart and of the -vasomotor centre on the other, cannot here be fully discussed; just as -little can we consider in what manner the psyche is sympathetically -affected by the irritative processes in the genital organs, and its -functional activity thus impaired. - -Here I can do no more than briefly state that experience has taught me -that sexual intercourse is competent to originate cardiac troubles in -women. - -1. In extremely sensitive, sexually very irritable women, tachycardial -paroxysms may result from sexual excesses. - -2. Tachycardial paroxysms with dyspnœa occur in young women affected -with vaginismus; also in women at the climacteric with constrictive -changes in the vagina. - -3. Cardiac troubles, characterized mainly by symptoms indicating -diminished vascular tone, occur in women who have long practised coitus -interruptus with incomplete gratification of their voluptuous desires. - - - _Dyspareunia._ - -In normal conditions the act of sexual intercourse is accompanied in -women, as in men, by a voluptuous sensation, and this sensation must be -regarded as a necessary link in the chain of those processes by which -gratification of the sexual impulse—the most powerful of all our natural -impulses—is obtained. The absence of this voluptuous sensation in a -woman, the state in which she experiences during coitus no voluptuous -sensations, but feels either apathy, or positive distaste, is termed -dyspareunia: in former times it was also known as anaphrodisia. This -abnormal state of sexual sensibility, which up to the present is hardly -alluded to in gynecological textbooks, has received remarkably little -attention from the medical standpoint, and its importance has been -underestimated. Most unfortunately so, for dyspareunia is an important -symptom, exercising a powerful influence on the general health of the -woman who suffers from it, upon her social status in marriage, and, as -is easy to understand, upon her procreative capacity. - -Dyspareunia must be clearly distinguished from two somewhat similar -conditions, with which at first sight it is liable to be confused, -namely, from anæsthesia sexualis, and from vaginismus. By sexual -anæsthesia we understand, as previously explained, the absence of the -sexual impulse, a symptom which, when the reproductive organs are normal -in structure and function, is either of central nervous origin, a result -of disease of the brain or spinal cord, or else is due to general -nutritive disorders such as diabetes, morphinism, or alcoholism. A woman -affected with dyspareunia does, however, experience the sexual impulse, -it may be very actively, but sexual intercourse brings about no -gratification of her desires. In vaginismus, on the other hand, the -introduction of a foreign body, that is to say of the membrum virile, -into the vagina, gives rise to painful reflex cramps of the sphincter -vaginæ, or of the muscles of the pelvic floor, whereby the completion of -coitus is rendered impossible: whereas in dyspareunia coitus can be -effected, but gives rise to no voluptuous sensations. - -The pleasure which normally occurs in woman during sexual intercourse is -brought about in this way, that contact with and friction by the penis -stimulates the sensory nerves of the clitoris, the vulva, the vestibule, -and the vagina; this stimulus is propagated to the cerebral cortex, -where it gives rise to voluptuous sensations, and then, by reflex -stimulation of the genito-spinal centre, gives rise to a series of -reflex discharges. The pudic nerve, a branch of the sacral plexus, -supplies the female external genital organs. Some of its branches pass -in the clitoris to a peculiar form of nervous end-organ discovered by -_W. Krause_, Krause’s genital corpuscles: the structure of these -corpuscles appears to fit them exceptionally well for the transmission -of stimulatory waves to the nerve centres. “When this stimulus,” says -_Hensen_, in his work on the physiology of reproduction, “in addition to -other effects, also gives rise to a voluptuous sensation, the cause must -be sought in central nervous connections and apparatus. Similar -relations are to be found in connection with the mechanism of nutrition, -for example, in the association of hunger, appetite, agreeable -sensations of taste, the act of mastication, and the secretion of -saliva.” By means of this stimulus, several reflex processes are -originated in the reproductive canal, the most notable of which are the -erection of the clitoris, and the ejaculation of the secretions of -various glands. The cavernous tissue of the clitoris is connected with -that of the bulbus vestibuli, and the dorsal nerve of the clitoris is -one of the principal nerves of voluptuous sensation. The venous plexus -constituting the bulb of the vestibule lies at either side along the -margin of the vestibule at the boundary between the labium majus and the -labium minus, and laterally it is covered by the constrictor cunni[48] -muscle. During coitus the blood is driven out of this bulb into the -glans clitoridis, and thus the sensibility and the erection of the glans -are increased. The constrictor cunni and ischiocavernosus muscles draw -the clitoris, which is bent at a right angle downwards, into contact -with the penis. By means of the pressure of the constrictor cunni, the -mucous secretion of Bartholin’s glands, which open into the vulva at the -back of the labia majora, is expressed. - -As additional reflex actions, dependent upon the activity of the reflex -centre in the lumbar enlargement of the spinal cord, there ensue -contractions of the vagina, peristaltic movement of the tubes, some -descent of the uterus, relaxation of the os uteri and rounding of this -orifice, and induration of the portio vaginalis, whereby the tubal and -uterine mucus and the secretion of the cervical glands are expressed. -This process of _ejaculation_ constitutes the culminating point of the -voluptuous sensation occurring in the sexual act; this act thus exhibits -two phases, the sensation of friction, and the sensation of ejaculation. - -With regard to voluptuous sensations, and processes analogous to -pollutions, occurring in women, we append an extract from _von -Krafft-Ebing_. - -“The occurrence of voluptuous excitement during coitus is dependent in -the women, just as in the man, upon: - -“1. The peripheral influence of the intensity and duration of the -sensory stimulation (anæsthesia of the genital passage may be the cause -of the absence of voluptuous sensation). 2. The condition of -excitability of the reflex (ejaculation) centre in the lumbar spinal -cord. The activity of this centre varies within wide limits, not merely -in different individuals, but in the same individual at different times. -There are, indeed, women in whom it seems as if this centre were always -in vigorous activity. In normal women, the irritability of the centre -appears to be most marked at the menstrual epoch, and to decline rapidly -soon after menstruation. In pathological conditions, the activity of the -centre may be temporarily in abeyance (organic inhibitory processes, -such as are seen in certain cases of hysteria with temporary frigidity); -or again the centre may be abnormally active owing to irritable weakness -(neurasthenia sexualis), in consequence of which ejaculation may, just -as in the male in similar circumstances, occur too easily. 3. The -occurrence of the voluptuous sensation in woman is unfavourably -influenced by psychical inhibitory perceptions (analogous to the -inhibitory influence of psychical processes in the male, such as, for -example, fear of incapacity to perform sexual intercourse). As examples -of such inhibitory perceptions in women may be mentioned, dislike of the -man, physical loathing to sexual intercourse, etc.” - -_Gutceit_ records interesting experiences, which are readily -intelligible in view of what we have already quoted. He finds that of -ten women after defloration, two only immediately experience full sexual -pleasure. Of the eight others, four only have an agreeable sensation -produced by the friction during coitus: but the sensation of ejaculation -does not make its appearance until the lapse of at least six months, or -it may be even several years, after marriage. In the remaining four -women, pleasure during sexual intercourse may never become properly -established. The women of the first class are described by the author as -being of a very ardent temperament, and passionately attached to their -husbands. In such women, the sensation of ejaculation occurs during -intercourse with any man toward whom they are sympathetic. Women of the -second class are of a less ardent temperament, and are often -comparatively indifferent toward the man with whom they cohabit. Women -of the third class have little or no amatory feeling, and they either -hate the man with whom they are cohabiting, or at least feel physical -repulsion to the idea of intercourse with him. _Gutceit_ considers that -meretrices usually belong to the third category. In the practice of -their trade, they make a counterfeit of voluptuous enjoyment, and only -experience real sexual gratification in intercourse with the man of -their choice. - -It is of great practical interest, alike from the gynecological and from -the neuropathological standpoint, to determine the consequences in women -of ungratifying sexual intercourse. In the present state of our -experience it must be assumed that the effect of abnormal sexual -intercourse, that is of intercourse which does not culminate in -gratification produced by the sensation of ejaculation, is deleterious. -This is explained by the fact that, owing to the absence of the muscular -contraction of the genital passage, the latter remains engorged with -blood; the resultant hyperæmia passes away very slowly, and, when -frequently repeated, gives rise to chronic tissue changes, manifesting -themselves as diseases of the reproductive organs. Injury to the nervous -system ensues, partly in consequence of these organic changes, partly -also in consequence of psychical non-gratification in the widest sense -of the term. The nervous disorders thus produced are typical forms of -(sexual) neurasthenia; and in cases in which the pathogenesis is -predominantly psychical (antipathy to the husband, etc.) hysterical -types of disorder are especially frequent. _Von Krafft-Ebing_ believes -that incomplete coitus, that is, coitus not culminating in the sensation -of ejaculation, is a frequent cause of hysterical disorders in women. - -When once the clinical picture of neurasthenia sexualis is fully -developed, each act of intercourse (like pollutions or coitus in the -sexually neurasthenic male) gives rise to renewed troubles, which are -easily recognized as symptoms of venous stasis in the reproductive -organs (sacrache, sensations of weight and bearing-down in the pelvis, -fluor albus): in addition we observe exacerbations of the lumbar spinal -disorder, in the form of spinal irritation, irradiating pains in the -sacral plexus, etc. In this way general neurasthenia develops. The -conditions found in such cases on gynecological examination (chronic -endometritis, metritis, oöphoritis, etc.) are produced by the same cause -as the nervous symptoms, namely, by an unhygienic mode of sexual -intercourse. They are not the cause of the neurosis, but important -concomitant disorders; and their effect in rendering the nervous -disturbances more severe must be freely admitted. - -Among important causes of ungratifying coitus must be enumerated: weak -erection and ejaculatio praecox in the male, rendering the stimulation -inefficient; in addition, coitus reservatus, coitus interruptus, and -coitus condomatus. If the noxious influence is frequently repeated, the -occurrence of neurasthenia sexualis and its consequences is greatly to -be feared, and in women of neuropathic constitution it is practically -inevitable. - -Unsympathetic coitus appears to act, not merely in a somatic manner, but -mainly upon the psyche, and to originate states of hystero-neurasthenia -or pure hysteria. If the influence of such unhygienic conditions of the -vita sexualis co-operates with that of inherited or acquired sensuality, -further dangers ensue: in cases of ungratifying sexual intercourse, the -danger of manustupration; in cases of unsympathetic intercourse, the -danger of psychical onanism, or that of marital infidelity. - -Although until recently the matter received but little attention, it -must now be regarded as a well-established fact, that in the female (as -in the male) the climax of voluptuous sensation in sexual intercourse is -normally characterized by a process of ejaculation, accompanied by a -voluptuous sensation of ejaculation, dependent upon the acme of -excitement of a reflex centre in the lumbar enlargement of the spinal -cord. - -Just as in the male, this centre may be excited to action, not only by -local stimulation of the genital organs, but also by (psychical) stimuli -proceeding from the brain (pollutions), so also in the female a similar -process may occur, and for this reason it is correct to speak of -“pollutions in the female.” _Rosenthal_ appears to have been the first -writer to speak of pollutions in women. In his clinical study of nervous -diseases, _Rosenthal_ described processes of the nature of pollutions, -originated in erotically over-stimulated women by lascivious dreams. In -one case he detected the outflow of a “mucus-like” fluid from the -apparently intact genital organs; he believed this to proceed from the -ducts of Bartholin’s glands, and from the mucous glands surrounding the -urethral orifice. _Féré_ reports the case of a patient who had an -erogenic zone in the region of the upper part of the sternum; pressure -on this zone gave rise to a profuse secretion of vulvo-vaginal fluid. In -this connection we may also recall the “clitoris-crises” to which -tabetic women are subject. _Gutceit_ described the process of pollution -in women in the following words: “It is remarkable that in dreams such -women experience the sensation of ejaculation.” - -The psychical preliminary is invariably constituted by lascivious dream -perceptions. It merely remains open to question whether this process, -which in the male is indisputably physiological, in the female may be -said to occur within physiological limits. The researches published by -_von Krafft-Ebing_ more than twenty years ago, under the title -“Concerning Processes Analogous to Pollutions Occurring in the Female,” -gave negative results as far as healthy individuals were concerned; on -the other hand, the phenomenon in question was by no means rare in -nervously disordered, and above all in sexually asthenic women. The -neurosis was in part found as a result of psychical or manual onanism in -virgins with morbidly intensified libido: in part in married women, as a -result of ungratifying coitus, as previously described: in part, also, -in married women with powerful libido and enforced abstinence from -intercourse, owing to acquired impotence or death of the husband. - -Just as in the case of the neurasthenic male, these pollutions made the -primary neurosis more severe, and relief from the nervous trouble was -not obtained until the factor of the “pollutions” had been recognized, -and made the object of special treatment. In exceptional cases the -“pollutions” appeared to be the starting point of the entire neurosis. - -It was further remarkable, again here displaying analogy with what -occurs in the male, how much stronger and more deleterious was the -shock-effect of an inadequate process of ejaculation occurring in a -sexual dream, as compared with the far less deleterious influence of -similar incomplete ejaculation when occurring _viâ coitus_. In very -severe degrees of neurasthenia sexualis, just as in the male, the waking -imagination may give rise to a “pollution.” In such cases the -shock-effect on the nerve centres tends to be excessively severe. A -still higher degree of irritability of the genital system appears to -exist in cases in which excitement and orgasm of the reproductive organs -may culminate in a “pollution” by purely spinal paths, without the -intervention of the imagination. The significance of this fact would -appear to be considerable for the proper comprehension and for the -treatment of certain conditions of neurasthenia (sexualis) in the -female. The “pollution” may here be the actual cause of the neurosis. -But in any case, in the female, the occurrence of pollutions is an -extremely important symptom as regards both diagnosis and therapeutics. -It is extremely probable that hallucinations of coitus, and the -complaints made by insane women of attempted violation during the night, -are really dependent upon such “pollutions.” - -_Von Krafft-Ebing_ reports the following characteristic case. Miss X., -thirty years of age, belonging to a family predisposed to insanity, and -herself neuropathic since early childhood, declared that since she was -six years old she had been subject to lascivious imaginations, to which -she became continually more liable as she grew older. Ultimately, -typical psychical onanism developed, and in recent years her trouble -assumed the form of sexual neurasthenia. The patient herself suspected -there was a connection between her nervous disorder and her evil habit. -The popular work by _Bock_ finally brought her full enlightenment, -associated with severe emotional disturbance. This latter was now -increased by misfortunes from which the family suffered. The patient -then relinquished her bad habit, but her state of health nevertheless -became worse. She was nervously extremely irritable; her sleep was -insufficient, unrefreshing, and disturbed by lascivious dreams; she -suffered from spinal irritation, anæmia, scanty and painful -menstruation. Inclination toward the opposite sex and toward marriage, -hitherto but slight, now sank to a minimum: on the other hand, the -patient, in spite of all efforts to the contrary became more and more -subject to a condition analogous to priapism in the male, a genital -orgasm by no means voluptuous in character, and often indeed actually -painful. Associated therewith, nocturnal pollutions occurred, the -patient awaking from lascivious dreams with a voluptuous sensation and -moistness of the external genital organs. After such pollutions, -throughout the ensuing day, she felt extremely weary and depressed and -suffered from severe spinal irritation. After a time, the nocturnal -pollutions occurred without being preceded by lascivious dreams, and -ultimately analogous states were experienced in the daytime. With much -difficulty the patient now made up her mind to seek medical advice. She -was anæmic, emaciated, emotional, and moody. The lumbar and cervical -regions of the spine were extremely sensitive to pressure. Sleep was -scanty and unrefreshing, the patient felt weary and miserable, she -complained of dragging sensation and other paralgic sensations, in the -regions supplied by the lumbar and sacral plexuses. The deep reflexes -were increased. She dreaded the onset of disease of the spinal cord, and -believed that the cause of her illness was to be found in the prolonged -indulgence in psychical onanism. The perusal of _Bock’s_ book had first -made her understand the true nature of her misconduct. She had never -practised manual masturbation. Her principal complaint was of an almost -unceasing uneasiness and excitement in the genital organs. She compared -it to the uneasiness in the stomach produced by hunger. In the genital -organs (which on examination appeared quite normal), she had a -distressing sense of burning heat, of pulsation, of disquiet as if there -were a clockwork mechanism working there. Very rarely now were these -sensations associated with voluptuous ideas. This sexual neurosis had an -intensely depressing constitutional effect. She had transient relief -only when the local sensations culminated in pollution; but this, on the -other hand, increased her general neuropathic troubles. She suffered -most severely during the menstrual period. She was ordered sitz-baths at -a temperature of 23° to 19° R. (84° to 75° F.), suppositories of -monobromide of camphor, 0.6 (9 grains), with extr. belladon. 0.04 (⅗ -gr.), sodium bromide 3.0 to 4.0 (45 to 60 grains), every evening; also -powders containing camphor 0.1 (1½ grains), lupulin 0.05 (¾ grain), -extr. secal 0.08 (1¼ grains), twice daily. This treatment gave the -patient great relief, and secured complete ease during the daytime. -Therewith returned her greatly impaired trust in the future, and her -emotional calm was restored. - -The frequent occurrence of pollutions in women, the so-called -vulvo-vaginal crises and clitoris-crises, is regarded by _Eulenburg_ as -a striking manifestation of sexual neurasthenia in woman; in such cases -a lascivious dream is spontaneously followed by a more or less abundant -discharge of the clear gelatino-mucous secretion of Bartholin’s glands. -In women who masturbate, and in tribadists, a profuse and even violent -secretion of these glands is produced by touching the clitoris or the -erogenic zones at the entrance to the vagina, close to the orifices of -Bartholin’s ducts. - -Dyspareunia, the absence of voluptuous sensation in women during coitus, -may be referred to three fundamental causes: - -1. Insufficient or completely wanting peripheral stimulation of the -sensory nerve terminals in the female reproductive canal: in these cases -the conducting tracts to the nerve centres never become active. - -2. Diminution or cessation of the excitability of the reflex centre in -the lumbar enlargement of the spinal cord: this leads to failure of the -sensation of ejaculation. - -3. Inhibitory influences proceeding from the cerebral cortex whereby -voluptuous sensations and perceptions are checked. - -The first-named of these etiological influences is in my experience the -commonest. Incomplete or quite inadequate stimulation of the sensory -nerves of the genital canal may be due to the maladroit performance of -copulation on the part of the male, owing to inexperience, or it may -depend on gross disproportion in size between the reproductive organs of -the man and the woman; in other cases it may be due to disease of the -reproductive organs in either sex, influencing unfavourably the -sensibility to stimulation of the nerves of the genital canal. Awkward -or incomplete performance of coitus may thus lead to failure of -voluptuous sensation, and this may ultimately pass into permanent -dyspareunia. Temporary dyspareunia is very common in young wives during -the first months of married life, ensuing on the pains of defloration; -and very gradually gives place to normal voluptuous sensation. It may be -one or two years after marriage before the sensation of ejaculation is -first experienced. Not infrequently, dyspareunia depends on incomplete -potency in the husband, who is incompetent to arouse voluptuous -sensation in his wife. For this reason, dyspareunia is common in young -women married to elderly men; but is common also, where (as so -frequently among Russo-Polish Jews) the men also marry very young, at an -age of from sixteen to seventeen years, and where, moreover, the husband -has often before marriage impaired his potency by masturbation: finally -dyspareunia is common when girls still undeveloped sexually are married -to powerfully built men. - -Regarding the pathological conditions of the female reproductive organs -which counteract the peripheral sensory excitants of voluptuous -sensation, we exclude from further consideration the obvious causes, -absence and atrophy of the reproductive organs, and senile marasmus. Of -prime importance as a cause of the failure of sexual sensibility in the -early period of married life must be mentioned inflammation of the fossa -navicularis, due to awkward attempts at intercourse. Other causes of -deficient sensibility are: complete or partial persistence of the hymen, -lesions of the vaginal inlet, acute or chronic vulvitis in consequence -of irritating abundant secretion, especially as a sequel of gonorrhœal -vaginitis. The last named infective disorder is especially harmful, -because Bartholin’s glands are involved in the associated vulvitis. Even -after the cure of the vulvitis, permanent dyspareunia may remain. -Perineal fissures may result in the stimulant effect of coitus being -insufficient, owing to the slight friction possible at the vaginal inlet -in these cases. Not less serious sometimes are small, hardly discernible -fissures in the vagina. Additional causes of deficient sexual -sensibility are recto-vaginal, and vesico-vaginal fistulæ. - -The second cause of dyspareunia, diminution or complete lack of -irritability of the reflex centre of the lumbar enlargement of the -spinal cord, appears to be less frequently operative. We must, however, -assume that certain nervous disorders, such as hysteria and pathological -changes in the spinal cord, are responsible in this connection. The -activity of the lumbar sexual centre appears in women to be normally -subject to variation within certain limits; and seems usually to attain -its maximum irritability during menstruation. But normally these -variations are never so great as to produce in women complete though -merely temporary dyspareunia; in this respect offering a marked contrast -to what occurs in other animals at other times than the rutting season, -and of which every bitch not on heat furnishes an example when she -refuses the sexual advances of the dog. - -As regards the third causal influence in the production of dyspareunia, -the influence of the brain, this, though important, is less frequently -in operation. Diseases of the brain, degenerative processes, may -constitute a cerebral cause for the failure of sexual sensation. But -more frequently, certain cortical perceptions, such as dislike or hatred -of the cohabiting male, an ardent passion for some other lover, grief -and trouble, exercise inhibitory influences, which render the occurrence -of voluptuous pleasure during the sexual act difficult or quite -impossible. - -A condition like dyspareunia, our knowledge of which depends entirely -upon the subjective sensations of the woman concerned, is naturally one -regarding whose existence accurate information is difficult to obtain. -Very rarely does it happen that women spontaneously approach the -physician with complaints of this condition; indeed, in my experience, -they do so only when they are sterile, and when they assume, in -accordance with the widespread popular belief, that their sterility is -connected with the absence of voluptuous sensation during sexual -intercourse. More commonly, however, it is the husband who feels it his -duty to confide to the medical man the remarkable apathy of his wife in -sexual intercourse. But when once the medical man’s attention has been -directed to this question, and when he institutes enquiries among his -patients in a scientific, passionless manner, one making due allowance -for a woman’s modesty, as the moral importance of the subject demands, -he will be astonished at the frequency of dyspareunia, and he will find -herein the explanation of many obscure phenomena in the life of women. -On the other hand, it must never be forgotten that a certain number of -women complain of dyspareunia without any justification whatever, in -order to arouse interest and sympathy, by representing themselves as -unwilling sacrifices on the marital altar: the experienced gynecologist -will readily detect the cases in which he is being misinformed; he can, -moreover, always check the wife’s statements by conversation with the -husband. - -The constant sign of dyspareunia is the failure of ejaculation during -coitus. We have previously described the muscular contractions which -lead to ejaculation of the secretion of Bartholin’s glands and to the -expulsion of the uterine and cervical mucus, as reflex actions evoked by -the sensory stimulus dependent on friction of the female genital organs. -The voluptuous sensation of ejaculation, associated with these muscular -contractions, which the woman whose sensibility is normal experiences as -the culminating point of her sexual “gratification,” is either quite -unknown to a woman affected by dyspareunia, or is experienced by her -only in a voluptuous dream, as a pollution, in which the sexual -dream-perceptions act as the psychical stimuli by which the reflex -discharge is originated. It has repeatedly happened to me, that on -enquiring of women suffering from dyspareunia regarding their experience -of the sensation of ejaculation, I have been informed that such -sensations are known to them only from the descriptions of their female -friends, or occasionally from dreams from which they have awakened with -a feeling of moisture in the external genitals. _Von Krafft-Ebing_ -refers this process to a peristaltic contraction of the muscular fibres -of the Fallopian tubes and the uterus, “whereby the tubal and uterine -mucus is expressed;” whereas, for my part, I am of opinion, that -ejaculation affects in the first place and principally the glands of -Bartholin, the secretion of which is expressed by the contraction of the -constrictor cunni muscles, and secondarily only affects the cervical -glands of the uterus. - -As a second sign of dyspareunia, I recognize a remarkably rapid outflow -of the male semen from the female genital canal, immediately after -coitus (_profluvium seminis_). The woman thus affected complains, when -suitably questioned, that she is unable to retain the semen, and that it -flows out of the vagina immediately after ejaculation. The cause of this -remarkable phenomenon no doubt lies in the fact, that, owing to the -absence of the voluptuous sensation, the reflex contractions of the -muscles of the female genital organs, normally accompanying this -sensation during intercourse, fail to occur. At the vaginal inlet, in -normal conditions, the constrictor cunni muscle contracts, and farther -up in the vagina a peristaltic contraction of the circularly disposed -muscular fibres of the tunica media occurs: in this way the semen -ejaculated into the vagina is for a time retained under a certain -pressure. But in the absence of these muscular contractions, as well as -of the muscular contraction of the pelvic floor, retention of the semen -fails to occur. Cattle-breeders and horse-breeders have made similar -observations regarding cows and mares, namely, that these animals are -sometimes unable to retain the semen after coitus, and it is suggested -that in these cases the animals are not properly on heat. Experienced -cattle-breeders recommend in such cases that the retention of the semen -should be promoted by douching the root of the tail and the external -genitals with cold water. It is well known that by stimulating the -peripheral sensory nerves in the neighbourhood of the genital organs, a -reflex excitement of the lumbar sexual nerve centre is produced, as is -seen, for example, in the practice of flagellation of the buttocks, for -the increase of sexual desire. - -Passing to the consideration of the pathological changes to be found in -the reproductive organs of women suffering from dyspareunia, the nature -of these will for the most part be obvious in relation to the etiology -of the disorder. Most frequent, in my experience, were chronic -inflammatory states of the vulva and of the vaginal and uterine mucous -membrane, chronic metritis and parametritis. A very frequent appearance, -and one practically characteristic of dyspareunia when of long standing, -is a marked total relaxation of the reproductive apparatus. The uterus -is extremely mobile, usually retroverted and partially prolapsed, thin, -with lax walls, and usually an enlarged cavity; the portio vaginalis is -flaccid, and runs to a point; the vagina is roomy; there is marked -hypersecretion of the mucous membrane of the entire genital canal; there -is great flaccidity of the constrictor cunni and levator ani muscles, -and of the perineum. In several women with dyspareunia, I found old -unhealed lacerations of the perineum. In some cases, the very small size -of the clitoris is noteworthy. In one case amenorrhœa was present with -an infantile uterus. In a large proportion of the cases I was able to -detect a diminution both of the tactile and algic sensibility of the -vaginal mucous membrane. The women were for the most part anæmic; many -were extremely obese, and of lymphatic constitution. In some cases, -however, no pathological changes whatever could be detected in the -reproductive apparatus. - -Dyspareunia is a condition which affects a woman’s whole nature, -powerfully influences her mental life, and thus gives rise to greater -psychical than physical damage. The consciousness of being deprived of -the greatest joy of physical love produces great emotional depression, -even in a woman by no means sensually inclined, and gives rise to a -hypochondriacal state, at times even to melancholia. In other cases, the -idea, not infrequently suggested by more happily situated women friends, -that the woman herself is not to blame for this condition, has a -demoralizing effect upon her, and destroys the happiness of married -life. (It has been confessed to me, in isolated cases, that the -dyspareunia was relative only.) Apart from this, the absence of sexual -gratification gives rise to a series of nervous troubles, presenting -either the variable characters of hysteria, or else the symptoms of -neurasthenia. Finally, the frequently repeated incomplete coitus, -incomplete inasmuch as the woman does not experience the sensation of -ejaculation, induces chronic hyperæmia in the female reproductive -organs, passing on into blood stasis, and ultimately into chronic -inflammatory tissue changes; in this way arise metritis, perimetritis, -and parametritis, salpingitis, oöphoritis, disorders of menstruation, -menorrhagia, and atypical uterine hæmorrhages. The possibility cannot be -disproved, that in this way new-growths of the reproductive organs may -also originate. The act of sexual intercourse, which at first may be to -the woman a matter of comparative indifference, and in which she plays -her part merely from a sense of duty, becomes, in cases of long-standing -dyspareunia, something to which she feels a positive dislike, and is -recognized by her as the actual cause of the troubles that ensue upon -intercourse, such as sacrache, sensations of weight and pressure in the -pelvis, strangury, fluor albus, a feeling of exhaustion, etc. - -At times, perverse sexual sensation is associated with dyspareunia. -Women who find no enjoyment in normal sexual intercourse with a male, -sometimes masturbate, sometimes indulge in amor lesbicus, etc. - -Of great importance appears to me the relation between dyspareunia and -sterility in women. As already pointed out, dyspareunia comes chiefly -under medical observation in cases in which it is associated with -sterility. The husband, seeking advice concerning his wife’s failure to -conceive, complains of her frigidity in sexual intercourse as the -probable cause; or the wife comes to seek advice, saying that she never -experiences sexual gratification, and that for this reason she has -failed to become pregnant. As a matter of actual fact, dyspareunia and -sterility are associated with such remarkable frequency, that my own -experience leads me to believe in the existence of an etiological -connection between the two conditions, at least in a certain proportion -of the cases. Among 69 sterile women whom I questioned regarding -dyspareunia, the latter condition was present in 26, that is to say, in -38% of the cases. _Matthews Duncan_ reported that of 191 sterile women, -62 did not experience sexual enjoyment. Sexual excitement of the woman -during copulation would certainly appear to have a definite bearing upon -the occurrence of conception, for we know that by the voluptuous -sensation reflex actions are aroused in the genital canal, favouring the -retention of semen and its passage through the os to the interior of the -uterus, and perhaps also giving rise to reflex changes in the cervical -secretion which favour the passage of the spermatozoa into the uterine -cavity. - -In cases of relative dyspareunia, the influence of this condition in -producing sterility is also manifested, the unfaithful wife being -impregnated by her lover though she has remained sterile in intercourse -with the husband to whom she is indifferent. To dyspareunia of this -nature (dependent upon sexual disharmony), we may also refer the -sterility of a married pair who have for some time lived together in -unfruitful intercourse, whereas, after divorce and the contraction of -fresh unions, both the man and the woman prove normally fertile. Such -cases have been personally known to me; and similar instances aroused -the attention of the natural philosophers of antiquity, for instance, -that of Aristotle. The importance of voluptuous sensation in promoting -conception is also manifest from the fact that in the majority of women, -after the pains of defloration, dyspareunia usually persists for a -season during the early period of married life; and, corresponding with -this, the first conception is usually deferred for some little time -after marriage, to a period corresponding with the awakening of the -sensation of ejaculation. In this connection, _Courty_ reports the case -of a lady who, although in blooming health, remained sterile during the -first fifteen years of her married life; she then gave birth to a child -whose father was unquestionably her lover; and after this in succession -to two other children whose progenitor was the legal husband. This lady -had never experienced voluptuous sensation in intercourse prior to the -time of her first conception. Similar circumstances with an even clearer -significance have been frequently observed among the lower animals; and -_Darwin_ records several striking observations of this character. Taking -all the evidence into consideration, we are compelled to regard -dyspareunia as a condition capable of causing sterility in women, -although the sequence is not an absolutely necessary or invariable one. - -In order to excite voluptuous sensation during intercourse, savage races -make use of various means, some of which we here transcribe from the -work of _Ploss-Bartels_. In Abyssinia, and on the Zanzibar coast, young -girls receive instruction in certain rotary muscular movements known by -the name of duk-duk, which they employ during coitus for the increase of -sexual pleasure. Many Daiaks perforate the glans penis with a silver -needle from above downwards; this needle is kept in place like a seton, -until a permanent canal is formed through the glans: in order during -coitus to stimulate the woman more powerfully, into this canal, just -before coitus, various small articles are inserted, such as little rods -of brass, ivory, silver, or bamboo, or silver instruments ending in -small bundles of bristles; these project from the surface of the glans, -and exercise a more powerful friction of the vagina, thus increasing the -sexual pleasure of the woman. Men without such an apparatus are rejected -by the women, whilst those who have made several such canals in the -glans, and can therefore insert several instruments, are especially -sought after and prized by the women. Such an apparatus is known as an -ampallang, and in a symbolic manner the woman indicates to a man of her -choice her desire that he should make use of one; he finds in his bowl -of rice a rolled-up leaf, enclosing a cigarette which represents the -size of the desired ampallang. Among the Alfurs of North Celebes, in -order to increase the voluptuous pleasure of the woman during -intercourse, the men bind round the corona glandis the eyelids of a -goat, beset with the eyelashes, thus forming a bristly collar; in Java -and in Sunda, before coitus, the men surround the penis with strips of -goat-skin, leaving the glans free. In China they wind round the corona -glandis torn fragments of a bird’s wing; these also project like -bristles and increase the friction. Among the Batta of Sumatra, -travelling medicine-men perform an operation by means of which they -insert, beneath the skin of the penis, small stones, sometimes to the -number of ten, at times also angular fragments of gold or silver; these -heal in beneath the skin, and increase the stimulus of coitus for the -women. Among the Malays of Borneo the penis is perforated, and some fine -brass wire with the ends turned inwards is inserted: before coitus, the -sharp ends of the wire are drawn out so as to project from the skin. - -In our own part of the world, voluptuaries make use of an india-rubber -ring beset with spines, which before coitus is passed over the corona -glandis, in order to promote sexual gratification in the woman during -intercourse. In cases of diminished potency in the male, in order to -produce sufficient sexual excitement in the female by more powerful -erection of the penis, various mechanical means are now employed. For -instance, in such a partially impotent man, a constricting band of -india-rubber may be passed over the root of the penis, whereby the -reflux of blood from the corpora cavernosa is hindered, and a more -complete and more enduring erection is induced. Elderly men have -frequently declared to me that they were well satisfied by the -employment of this simple measure, whilst behind their backs, their -wives have assured me that the results were far from satisfactory. The -apparatus described by _Roubaud_ for the enlargement of the penis is no -longer employed. Partially impotent men make use, however, of an -instrument known by the name of “schlitten,” made of gold, silver, or -white-metal; it consists of two delicate laminæ, united at the base by a -metal ring, and at the upper end by an india rubber ring. This small -apparatus, which must be made exactly to measure, renders possible the -introduction of the imperfectly erect penis into the vagina; it supports -the penis, and readily accommodates itself to the change in size of the -organ as it slowly becomes erect. - - - FERTILITY IN WOMEN. - -Fertility in women is the basis of the fecundity of a nation, of its -growth, its power, and its importance. It is especially the fertility of -married women which enters here into consideration, and forms the source -of the statistical data of fertility; these are usually obtained by -drawing a ratio between the number of marriages contracted in a given -period, and the number of children born in the same period. - -The fertility of women is a function beginning at an age varying in -dependence on many conditions, and undergoing extinction at a definite -period of life. It is, in fact, associated with the duration of the -sexual life of woman, and, generally speaking, extends from the -sixteenth to the fiftieth year of life. Climate, race, constitution, and -morbid conditions, influence alike the first appearance of menstruation -and the first pregnancy; and as they influence the duration of menstrual -activity, so also do they influence the duration of fertility. - -In the Bible are recorded numerous instances of the early commencement -of fertility. At the present time also, in warm climates we meet with -many examples of early motherhood. From the great work of -_Ploss-Bartels_, from which we have already frequently quoted, we -extract and summarize the following ethnographical details. Among the -wives of the Bosjesman, mothers aged ten are frequently seen; travellers -in New Zealand often saw mothers of eleven years, and mothers of the -same age among the Samoyedes and in Palestine; mothers of twelve in -British Guiana, in Jamaica, among the Schangallas, at Shiraz in Persia, -among the Copts in Egypt; mothers aged thirteen in Cuba, among the Sioux -and the Dakotas, and in New Caledonia; mothers aged fourteen among the -Negroes of Gaboon. - -According to the observations of Robertson, of sixty-five Indian women -there gave birth for the first time: - - At the age of 10 years 1 - At the age of 11 years 4 - At the age of 12 years 11 - At the age of 13 years 11 - At the age of 14 years 18 - At the age of 15 years 12 - At the age of 16 years 7 - At the age of 17 years 1 - -Moreover, in the records of European countries, we find numerous -instances of very early motherhood. _Molitor’s_ case, a girl nine years -old giving birth to a vesicular mole with an embryo; _von Haller’s_ -case, pregnancy in the ninth year of life; _Carus’_ case, pregnancy at -the age of eight. _Caspar_ saw a girl in Berlin who became pregnant at -the age of twelve, and was delivered of a living child. _Rüttel_ saw a -girl nine years of age pregnant. _King_ attended the confinement of a -girl who at the time of her delivery was not yet eleven years old. -_Taylor_ reports the case of a girl twelve years and six months of age -who was then in the last month of pregnancy. _Koblanck_ attended a girl -of fourteen who was delivered of a child weighing four and a half -pounds. - -In most of these cases the premature fertility is followed by a -premature cessation of fertility. And there is more or less truth in -_Bruce’s_ statement regarding the Arab women in Africa, that those who -began to bear children at the age of eleven were seldom still fertile at -the age of twenty. - -At times we may observe a remarkable extension of fertility beyond the -average age, that is, beyond the age of fifty years. - -In northern Europe pregnancy at a comparatively advanced age is by no -means rare. From the official statistics of Denmark we learn that among -10,000 women, 465 were delivered at ages between 50 and 55 years. In -Sweden, of 10,000 mothers, 300 gave birth to children when more than 50 -years of age. In Ireland, the proportion of mothers over 50 was 345 per -10,000. In England the official figures dealing with the delivery of -483,613 women, showed that 7,022 were between 45 and 50 years of age, -and 167 over 50 years of age. - -The Surgical Academy of Paris, in an authoritative statement regarding -the late age at which conception could take place, alluded to the fact -that Cornelia, of the family of the Scipios, gave birth to Volusius -Saturninus when sixty years of age, that the physician _Marsa_ in Venice -recorded the existence of pregnancy in a woman of sixty, that _de la -Motte_ recorded pregnancy in a woman of fifty-one, and that he believed -it to be true that another Parisian woman had given birth to a girl at -the age of sixty-three, and had herself suckled the infant. - -In an important case, however, which came before the Court of Chancery -in England, the court held that there was no definite evidence of the -possibility of pregnancy in a woman sixty years of age; but that the -greatest age at which, in England, pregnancy had indisputably occurred, -was 54. - -Among 4,925 deliveries occurring in the Prague Maternity Hospital, -Schwing reports that there were 9 women delivered for the first time -when over 40 years of age. Of these: - - 3 were 41 years of age. - 2 were 42 years of age. - 1 was 43 years of age. - 2 were 44 years of age. - 1 was 47 years of age. - -_Haller_ reports the cases of two women who gave birth to children, one -at the age of 63, the other at the age of 70 years. _Meissner_ delivered -a woman of 60 years of her seventh child; _Rush_ attended the delivery -of a woman aged 60; _Dewees_ that of a woman aged 61. _Mende_ and -_Bernstein_ report cases of delivery at the age of 60. _Marion Sims_ -saw, in the state of Alabama, a negro woman 58 to 60 years of age, who -gave birth to a child at this age, at an interval of twenty years since -her last pregnancy. _Nieden_ reports a case in which the first pregnancy -occurred 26 years after marriage. When married, the wife was 18 years of -age, the husband 30; during their first twenty-five years of married -life there was no sign of pregnancy, but when the wife was 44 years of -age, menstruation, hitherto regular, suddenly ceased; the cause of the -cessation proved to be pregnancy, and at term a healthy girl weighing -nine pounds was born; the mother was able to nurse the child herself. -_Smith_ attended a woman aged 52 who was delivered of twins; the -youngest of her eight other children, who were then all living, was ten -years of age. - -_Rodzewitsch_ collected from the Russian literature of the years 1872 to -1881, eleven cases in which women aged 50 to 55 had given birth to -children. _Talquist_ reports that in Finland, in the year 1883, a woman -58 years of age was delivered; whilst _Ansell_ records the case of an -Englishwoman who became a mother when 59 years of age. _John Kennedy_ -records the case of a woman of 62 who was normally delivered at this -age; she had begun to menstruate at the age of 13, and since the age of -20 had previously given birth to 21 children, the last five when she was -47, 49, 51, 53, and 56 years of age, respectively. _Prior_ even reports -the case of a woman 72 years of age, who not only menstruated, but had -an abortion(!) - -The ideal of fertility in women is that the first completed act of -sexual intercourse should be followed immediately by conception, that -the pregnancy should terminate after the normal lapse of time in the -birth of a child, and that the same process should be repeated at -intervals of about ten months until the end of active sexual life. In -actual experience, however, this never occurs. Fertilization as an -immediate consequence of the first act of sexual intercourse (which in -the lower animals is regarded as the rule) is a very rare occurrence in -human beings. Moreover, in no single marriage is the reproductive -capacity of the wife utilized to the full, up to the time of extinction -of her generative faculty; either because the potency of the male -partner undergoes a gradual decline, or, it may be, because, after a -while, sexual intercourse becomes less frequent, or because precautions -against procreation are taken. - -The number of children to which during the three decades of her sexual -life, from the menarche to the menopause, a woman might theoretically -give birth, is never actually born. If we assume that, during the period -of active sexual life, a woman requires a period of fifteen months to -two years for each pregnancy, parturition, and lactation, a woman could -easily during this period have fifteen or sixteen children, and this -figure would represent the normal product of the normal fertility of the -human female. There are indeed, women who, it may be in consequence of -an exceptionally long period of sexual activity, or through giving birth -repeatedly to twins or triplets, or because they have married several -husbands in succession, have given birth to twenty-four children or even -more. In Berlin, in the year 1901, there lived a woman 41 years of age -who had had 23 children; there were three women, aged respectively 40, -43, and 46 years, who had had each 21 children; 246 women with families -numbering 13 to 20; and 169 women each of whom had given birth to 12 -children. In the very great majority of cases, however, the fertility of -the wife of the present day is never fully developed. It is modified in -various ways by the conditions of marriage, by social circumstances, by -considerations relating to the health of husband or wife, by actual -illnesses, and by voluntary limitation of fertility. Generally speaking, -according to the investigations of _Quetelet_, _Sadler_, and -_Finlayson_, the fertility of women is greatest in marriages in which -the husband is as old as the wife, or a little older, but without marked -difference in age. Marriages contracted at a very early age are less -fruitful; the highest fertility is found in marriages contracted when -the husband is 23 and the wife 26 years of age. - -Conception does not generally take place until sexual intercourse has -been frequently repeated. As the result of a statistical enquiry of my -own, relating to 556 fruitful marriages, I ascertained that in these the -first delivery occurred: - - Within 10 months after marriage in 156 cases. - Within 11 to 15 months after marriage in 199 cases. - Within 16 to 24 months after marriage in 115 cases. - Within 2 to 3 years after marriage in 60 cases. - More than 3 years after marriage in 26 cases. - -Thus we learn that in 35.5% of the cases the first delivery occurred -within 1¼ years after marriage; in 15.6% within 10 months; and in 19.9% -within 15 months after marriage; and 11.5% of the cases, the first -delivery was more than 1¼ years and less than 2 years after marriage; in -6.0% it was between 2 and 3 years after marriage; and in 2.6%, the first -delivery did not occur until more than 3 years after marriage. - -From examination of the birth registers of Edinburgh and Glasgow, -_Matthews Duncan_ determined the mean interval between marriage and the -birth of a living child to be seventeen months. In the majority of -cases, the first delivery does not occur until a complete year has -elapsed since marriage; in fact, in nearly two-thirds of the instances -the first delivery occurs during the second year of married life. - -The interval between two successive births is, according to _Matthews -Duncan_, on the average 18 to 24 months, according to Goehlert, 24 to 26 -months; the latter, however, points out that in cases in which the child -dies very soon after birth, the birth of the next child ensues on the -average in 16 to 18 months. In this connection, we must not fail to take -into consideration the influence of lactation, inasmuch as mothers who -do not suckle their children become pregnant considerably earlier, on -the average, than those who undertake this duty. In reigning families, -for instance, it is by no means uncommon for the consort to be delivered -twice within a single year. The degree to which lactation hinders -conception is so widely known, that women often suckle their infant for -a very long period, with the definite aim of preventing the speedy -recurrence of pregnancy. A high official from the Dutch Indies informed -me that for this reason the native women were accustomed to suckle their -infants for several years, and that it was by no means uncommon to see a -small boy running about smoking a cigar, and then hurrying to his mother -in order to be suckled. - -The age at which a woman contracts marriage has also to this extent an -influence upon her fertility, inasmuch as it appears that those who -marry very young are far less fertile than those who marry between the -ages of 20 and 25 years; the latter moreover have, on the average, a -shorter time to wait for their first conception than women who marry -before the age of 20. Women who marry after the age of 25 have to wait -longer after marriage for their first delivery; in fact the older the -woman after 25, the greater, on the average, the interval between -marriage and the first delivery. - -Arranging the data already referred to, regarding 556 fruitful women, in -relation to this point of view, it appears that the first birth ensued: - - ═════════════════════╤═════════╤═════════╤═════════╤═════════╤═════════ - │ │ │15 months│ │ - │ │10 to 15 │ to 2 │ 2 to 3 │More than - │Within 10│ months │ years │ years │ 3 years - │months of│ after │ after │ after │ after - │marriage.│marriage.│marriage.│marriage.│marriage. - ─────────────────────┼─────────┼─────────┼─────────┼─────────┼───────── - In 163 women marrying│ │ │ │ │ - at ages 15 to 20 │ │ │ │ │ - years │ 36│ 53│ 46│ 18│ 10 - In 313 women marrying│ │ │ │ │ - at ages 20 to 25 │ │ │ │ │ - years │ 98│ 113│ 56│ 32│ 14 - In 70 women marrying │ │ │ │ │ - at ages 25 to 33 │ │ │ │ │ - years │ 18│ 30│ 12│ 9│ 1 - In 10 women marrying │ │ │ │ │ - at ages over 33 │ │ │ │ │ - years │ 4│ 3│ 1│ 1│ 1 - ═════════════════════╧═════════╧═════════╧═════════╧═════════╧═════════ - -To give percentages, the first birth occurred, - - ═════════════════════╤═════════╤═════════╤═════════╤═════════╤═════════ - │ │ │15 months│ │ - │ │10 to 15 │ to 2 │ 2 to 3 │More than - │Within 10│ months │ years │ years │ 3 years - │months of│ after │ after │ after │ after - │marriage.│marriage.│marriage.│marriage.│marriage. - ─────────────────────┼─────────┼─────────┼─────────┼─────────┼───────── - Women marrying at │ │ │ │ │ - ages 15 to 20 │ │ │ │ │ - years, in │ 22.0%│ 32.5%│ 28.2%│ 11.0%│ 8.1% - Women marrying at │ │ │ │ │ - ages 20 to 25 │ │ │ │ │ - years, in │ 31.3%│ 36.1%│ 17.8%│ 10.2%│ 4.4% - Women marrying at │ │ │ │ │ - ages 25 to 33 │ │ │ │ │ - years, in │ 25.7%│ 42.8%│ 17.1%│ 12.8%│ 1.4% - Women marrying at │ │ │ │ │ - ages over 33 years,│ │ │ │ │ - in │ 40.0%│ 30.0%│ 10.0%│ 10.0%│ 10.0% - ═════════════════════╧═════════╧═════════╧═════════╧═════════╧═════════ - -Thus whereas in women who contracted marriage between the ages of 15 and -20 years, only 54.5% were confined for the first time within 15 months -after marriage, in women who contracted marriage between the ages of 20 -and 25 years, in 67.4% the first delivery occurred within 15 months of -marriage. And whereas in those who married at the earlier age, the -percentage of first deliveries occurring between 15 months and 2 years -after marriage was 28.2, in those who married between the ages of 20 and -25, the percentage of first deliveries after the stated interval was -only 17.8. - -The figures compiled by _Whitehead_ and _Pfannkuch_ give similar -results. Of 700 women who married between the ages of 15 to 20 years, -there were 306 only who gave birth to a child within the first two years -after marriage; whereas of 1,835 women who married between the ages of -20 and 25 years, no less than 1,661 gave birth to a child within two -years after marriage—a percentage of 43.7 in the former case, and 90.6 -in the latter case. _Pfannkuch_, as the result of a very large -collection of figures relating to this question, found that in women -marrying before the age of 20 years, the average number of months before -the first delivery was 26; whereas in women marrying after the age of 20 -years, the average number of months before the first delivery was 20. - -According to _Matthews Duncan_ - - ═══════════════════════════════════╤═══════════════════════════════════ - OF EVERY 100 WOMEN WHO MARRY │ THERE BECOME MOTHERS - ───────────────────────────────────┼─────────────────┬───────────────── - „ │ In the 1st year │In the 2d year of - │of married life. │ married life. - ───────────────────────────────────┼─────────────────┼───────────────── - Between the ages of 15 and 20 years│ 13.71│ 43.70 - Between the ages of 20 and 25 years│ 18.48│ 90.51 - Between the ages of 25 and 30 years│ 12.41│ 75.80 - Between the ages of 30 and 35 years│ 11.44│ 62.93 - Between the ages of 35 and 40 years│ 9.27│ 40.97 - ═══════════════════════════════════╧═════════════════╧═════════════════ - -_Sadler_ examined the relationship between the age at which marriage was -contracted and the number of offspring in the case of the wives of -English peers. He obtained the following results: - - Age at marriage. Births per marriage. - 12 to 16 years 4.40 - 16 to 20 years 4.63 - 20 to 24 years 5.21 - 24 to 28 years 5.43 - -From exact statistical data of births in the Scandinavian countries of -Europe (Denmark, Sweden and Norway), _Goehlert_ compiled the following -table, showing the percentages of fertility at various ages: - - ═════════════════╤══════════════════════════╤══════════════════════════ - AGES. │ MARRIED WOMEN. │ UNMARRIED WOMEN. - ─────────────────┼────────┬────────┬────────┼────────┬────────┬──────── - „ │Denmark.│Sweden. │Norway. │Denmark.│Sweden. │Norway. - ─────────────────┼────────┼────────┼────────┼────────┼────────┼──────── - Under 20 years. │ 1.0│ 1.0│ 0.7│ 9.1│ 7.0│ 4.9 - From 20 to 25 │ 13.9│ 12.8│ 11.9│ 43.9│ 35.1│ 37.0 - years. │ │ │ │ │ │ - From 25 to 30 │ 26.5│ 24.7│ 24.7│ 28.1│ 27.9│ 32.4 - years. │ │ │ │ │ │ - From 30 to 35 │ 26.7│ 26.1│ 25.3│ 11.4│ 16.8│ 14.9 - years. │ │ │ │ │ │ - From 35 to 40 │ 21.0│ 21.6│ 21.3│ 5.4│ 9.0│ 7.1 - years. │ │ │ │ │ │ - ─────────────────┼────────┼────────┼────────┼────────┼────────┼──────── - From 40 to 45 │ 9.9│ 12.0│ 13.0│ } 2.1│ 4.2│ 3.7 - years. │ │ │ │ │ │ - Over 45 years. │ 1.1│ 1.8│ 3.1│ „ │ „ │ „ - ─────────────────┴────────┴────────┴────────┴────────┴────────┴──────── - -From this table it appears that the fertility of married women increases -steadily up to the age of 35 years, but after this age it begins to -decline. What a marked influence the age at marriage has upon fertility -is shown by the comparison of the figures relating to married women with -those relating to unmarried women; the fertility of unmarried mothers -attains its maximum at the ages of 20 to 25 years. In the countries -under consideration the average age of women at the time of marriage is -25 to 27 years. - -In order to obtain a still clearer picture of the fertility of women in -relation to age, _Goehlert_ has combined the figures relating to the -married and the unmarried, and then calculated the percentages, with the -following results: - - ════════════════════════════════════════════╤══════════════════════════ - AGES. │ MARRIED AND UNMARRIED - │ WOMEN. - ────────────────────────────────────────────┼────────┬────────┬──────── - „ │Denmark.│Sweden. │Norway. - ────────────────────────────────────────────┼────────┼────────┼──────── - Under 20 years. │ 1.7│ 1.6│ 1.1 - From 20 to 25 years. │ 16.6│ 15.1│ 14.1 - From 25 to 30 year │ 26.6│ 25.0│ 25.3 - From 30 to 35 years. │ 25.3│ 25.1│ 24.4 - From 35 to 40 years. │ 19.6│ 20.4│ 20.0 - From 40 to 45 years. │ 9.2│ 11.2│ 12.2 - ────────────────────────────────────────────┼────────┼────────┼──────── - From 45 to 50 years. │ } 1.0│ 1.6│ 2.9 - Over 50 years. │ „ │ „ │ „ - ────────────────────────────────────────────┴────────┴────────┴──────── - -If, finally, we combine into a single table the figures relating to all -three of these countries, we obtain the following results: - - Under 20 years 1.5% - From 20 to 25 years 15.3% - From 25 to 30 years 25.6% - From 30 to 35 years 24.9% - From 35 to 40 years 20.0% - From 40 to 45 years 10.9% - Over 45 years 1.8% - -From these figures it appears that the maximum fertility of married -women is attained, in Denmark at the age of 31, in Norway at the age of -31.7, and in Sweden at the age of 32 years. In the case of unmarried -women, the maximum fertility is at the ages of 24 to 26 years. In the -Austrian Empire, the maximum fertility of women is attained at about the -age of 30 years; in England it is attained between the ages of 20 and 25 -years. - -Divergent results as regards the fertility of married women at different -ages were obtained by _Goehlert_ from the examination of 5,290 cases -from the reigning families of Europe. In the favourable position as -regards means of subsistence occupied by the members of these families, -marriage naturally occurs, in most cases, much earlier in life, the mean -age at marriage being between 19 and 22 years—the youngest mother (in -the Capet dynasty) was only 13 years of age—and for this reason the -figures relating to the younger age-classes are larger than in the -previous tables. But as a result of this, the reproductive capacity also -undergoes an earlier extinction, so that of these women, not one gave -birth to a child when she was over 50 years of age. _Goehlert_ gives the -following table, compiled from these 5,290 instances: - - Under 20 years 8.8% - From 20 to 25 years 25.4% - From 25 to 30 years 29.4% - From 30 to 35 years 21.6% - From 35 to 40 years 11.5% - Over 40 years 3.3% - -In these cases the maximum fertility was obtained at the age of 27. - -The physiological fertility of women is much more clearly manifested -when we compare the fertility of women who have been married a few years -only, with the fertility of women in the later years of married life. In -the earlier period, the effective fertility more nearly approaches the -physiological fertility, because at this time the various influences by -means of which fertility is later so greatly diminished have not yet -come into operation. In this connection the following data, published by -_Körösi_, regarding the percentage fertility of recently married women, -and that of married women in general, will be found of interest: - - ═══════════════════════╤═══════════════════════╤═══════════════════════ - │Recently-married women.│ All married women. - ───────────────────────┼───────────────────────┼─────────────────────── - At ages 20 to 35 years.│ 32.9%│ 20.6% - At ages 35 to 40 years.│ 32.7%│ 14.7% - At ages 40 to 45 years.│ 21.4%│ 5.9% - ═══════════════════════╧═══════════════════════╧═══════════════════════ - -Inasmuch as we learn from this table that in the case of women aged 40 -and upward, the newly married exhibit a fertility of four times as great -as that of married women in general, in whom pregnancy has already -become rare, we can infer the influence upon fertility of abstinence and -of artificial measures for the prevention of conception. - -On the average, the maximum fertility of woman, that is, the maximum -of effective fertility, is attained at the age of 18 to 20 years. -Extreme youthfulness, and also the opposite condition, too advanced an -age, when marriage is entered on, impair a woman’s fertility; whereas -the conditions most favourable to fertility are that, at the time of -marriage, the uterus should have attained its fullest development, and -the ovaries also should be completely mature; this is not usually the -case at puberty, but rather at the age of 20, 21, or 22 years. In -Austria-Hungary, of 100 marriages in which the wife’s age at marriage -was less than 18 years, the average offspring in the course of a -single year were 36 to 38 children; in the case of 100 marriages in -which the wife’s age at marriage was 18 to 20 years, the average -offspring in a year were 40; this being the maximum fertility, the -number of offspring in a year per hundred marriages (i. e., the -percentage fertility), now undergoes a regular decline as the wife’s -age at marriage increases; at an age of 25, the percentage fertility -is 32; at the age of 30 years, the fertility is 24%; at the age of 35, -17%; at the age of 40 years barely 10%; at the age of 45, 7%; at ages -45 to 50, 0.1%. Thus, from the last figure, we see that of a thousand -women marrying at the age of 50 years, one only gives birth to a -child. Men obtain their maximum fertility (i. e., procreative -capacity) at the age of 25 or 26 years; at this age their fertility -amounts to 35% (that is, of 100 marriages at this age, 35 children -will on the average be born within a single year); at the age of 35 -years, the percentage fertility of men falls to 23; at the age of 45 -years, it is 9½%; at 55, 2.2%; at 65, ½% (_Körösi-Blaschko_). - -Whereas hitherto we have considered only the monogenous fertility of -married women, we must remember that the figures relating to their -biogenous fertility are also of interest—that is to say, the changes -which a woman’s fertility experiences in married life in respect of the -peculiarities of her husband; and of these peculiarities, the easiest to -make the object of statistical investigation is the husband’s age. The -age of the husband exercises an important influence upon the fertility -of the wife, as is proved by the following figures published by -_Körösi_: - - ════════════════════════════╤════════════════════════════════════════════ - AGE OF THE FATHER. │ AGE OF THE MOTHER. - ────────────────────────────┼──────────────┬──────────────┬────────────── - „ │ 25 years. │ 30 years. │ 35 years. - ────────────────────────────┼──────────────┼──────────────┼────────────── - 25 to 30 years │ 35.6%│ 25.0%│ 21.2% - 30 to 35 years │ 31.2%│ 23.6%│ 19.9% - 35 to 40 years │ 27.5%│ 21.8%│ 19.4% - 40 to 45 years │ │ 16.7%│ 14.0% - 45 to 50 years │ │ 14.4%│ 10.9% - 50 to 55 years │ │ │ 10.9% - ════════════════════════════╧══════════════╧══════════════╧══════════════ - -Also: - - ══════════════╤═══════════════════════════════════════════════════════════ - AGE OF THE │ AGE OF THE FATHER. - MOTHER. │ - ──────────────┼──────────────┬──────────────┬──────────────┬────────────── - „ │ 25 years. │ 35 years. │ 45 years. │ 55 years. - ──────────────┼──────────────┼──────────────┼──────────────┼────────────── - Under 20 years│ 49.1%│ │ │ - 20 to 25 years│ 43.0%│ 31.3%│ 16.0%│ - 25 to 30 years│ 30.8%│ 27.3%│ 18.5%│ - 30 to 35 years│ 33.5%│ 23.7%│ 14.4%│ 8.1% - 35 to 40 years│ │ 18.9%│ 11.8%│ 6.7% - 40 to 45 years│ │ 6.6%│ 6.1%│ 3.0% - ══════════════╧══════════════╧══════════════╧══════════════╧══════════════ - -We learn from these figures that the maximum fertility is exhibited by a -woman 18 years of age, when married to a man 25 years of age; less -fertile is a woman 25 to 30 years of age married to a man 28 years of -age; still less fertile is a woman 35 years of age married to a man 29 -years of age. Neither the age of the mother alone, nor that of the -father alone, is determinative of the fertility of the marriage, for the -fertility of young wives married to elderly husbands is quite different -from that of young wives married to young husbands. Very various -age-combinations are possible, and each exhibits an average fertility -peculiar to itself. - -We can also regard the question from the standpoint of the _difference_ -between the ages of husband and wife respectively. In this connection, -_Körösi_ is led by his tables to the conclusion that wives between the -ages of 18 and 20 years attain their maximum fertility when married to -men 7 years older than themselves; women of 25 years when married to men -3 years older than themselves; women of 29 years when married to men of -the same age; women of 30 years and upward attain their maximum -fertility only when married to men younger than themselves. Men, on the -contrary, always attain their maximum fertility when married to women -younger than themselves. The age of maximum fertility differs in the two -sexes, and those marriages will be most fruitful in which husband and -wife are each of the age most favorable to fertility. This will be the -case when the age of the wife is 18 to 20 years, and that of the husband -24 to 26 or perhaps 29 years. - -In connection with the question of fertility, we have also to take into -consideration the vitality of the children born, that is, what -proportion of those born survive. According to _Körösi’s_ interesting -papers regarding the fertility of the inhabitants of Buda-Pesth, we -learn that for every 100 marriages which have persisted for thirty years -and upward, there were born, on the average, 539 children, of whom -during this period 241 died, so that the percentage of survivals was -55.28. Parents who have lost one only of several children must, -therefore, regard themselves as exceptionally favoured by fortune. - -Social position, occupation, and religion, have, according to the -last-quoted author, a notable influence on fertility. His investigations -showed that the Roman Catholics and the Jews exhibited the greatest -fertility; among the Catholics there were 541 children, and among the -Jews 557 children, per 100 marriages. Amongst 100 Protestant families, -on the other hand, only 479 children had been born. It will be seen that -the theory of the comparatively enormous fertility of the Jewish race is -not supported by these statistics. The Jews do, however, exhibit a -greater power of rearing children, for among them the marriages of more -than 30 years’ duration had 61⅔ % of the children still living; among -the Protestants 57¾% survived; and among the Catholics only 52–⅗%. It -thus appears that the surviving offspring per 100 marriages of 30 years’ -duration were, among the Catholics 278, among the Protestants 252, and -among the Jews 349. - -The question whether, and to what extent, the age of the parents has an -influence on the vitality of the children, is answered by _Körösi’s_ -mortality statistics in the sense that mothers below 20 years of age -give birth to a larger proportion of children deficient in vital power. -Where the mothers had married at the age of 16, the mortality of their -offspring was, among Catholics 43%, among Jews 33%; married at 17, -Catholic mortality 44%, Jewish 30%; married at 18, Catholic mortality -42%, Jewish 32%; married at 19, Catholic mortality 41%, Jewish 29%; -married at 20, Catholic mortality 40%, Jewish 26%. Of the children whose -fathers had married at the age of 24, 32% had died; of those whose -fathers had married at 23, 37% had died; of those whose fathers had -married at 20, 42% had died; and of those whose fathers had married -before 20, actually 44% had died. It thus appears that the children -alike of very young mothers and of very young fathers have a lessened -chance of survival. - -Inasmuch as the fertility of the wife is a product of two factors, her -own peculiar fertility, and that of the procreating male, the question -of the fertility of women cannot be accurately treated independently of -this second consideration; hereby, however, is introduced a multiplicity -of obscure combinations, by which the value of all the statistical data -of fertility in women is seriously impaired. - -These data give as the measure of fertility, the number of children per -marriage actually brought up, embracing fruitful marriages, sterile -marriages, and those not yet fruitful. In Berlin, in Copenhagen, and in -Buda-Pesth, the average thus attained was slightly less than three -births to each family, whilst the number of children actually living -averaged two per family. A more accurate representation of fertility is -obtained by ascertaining the number of children born, and the number of -children living in relation to the duration of marriages reckoned in -years, that is beginning with marriages of one year’s duration, and -proceeding year by year to the highest recorded duration of marriage. In -this way interesting statistics have been obtained; for example, one who -has completed thirty years of married life may count on the average that -five or six children will have been born to him, but may also reckon on -having buried two or three at least of these. (_Körösi._) - -Fertility is, as many facts indicate, also dependent on nutrition. A -distinct proof, says _Spencer_, writing on the “Coincidence between high -Nutrition and Genesis,” that abundant nutriment increases the number of -births, and vice versa, is found among the mammalia; compare, for -instance, the litter of the dog with that of the wolf and the fox. -Whilst the dog’s litter numbers 6 to 14, that of the wolf numbers 5 to -7, that of the fox 4 to 6. The wild cat gives birth to 4 or 5 kittens -once a year, the domesticated cat to 5 or 6, twice or thrice annually. -The most remarkable contrast, in this respect, exists between the wild -and the domesticated breeds of swine. The wild sow gives birth once a -year to a litter of 4, 8, or 10 pigs (the number increasing in -successive litters); the domesticated sow has often as many as 17 in a -single litter, whilst in two years five litters, each numbering 10 pigs, -are commonly born. - -_Darwin_ also draws attention to the fact that animals under -domestication, being fed more abundantly and regularly than their wild -allies, procreate at shorter intervals and are markedly more fertile -than the latter. He states that the wild rabbit has four litters -annually, each numbering 4 to 8 young; whereas the tame rabbit -reproduces its kind six to seven times annually, and gives birth to -litters numbering 4 to 11. Among birds, analogous phenomena are -observed. The wild duck, for instance, lays 5 to 10 eggs in the course -of the year, whereas the tame duck lays from 80 to 100; the wild grey -goose lays 5 to 8 eggs, the domesticated goose 13 to 18. - -It must be added that this exceptional fertility is manifested in -animals that are quite inactive in comparison with their wild allies; -not only are they richly fed, but they get their food without working -for it. Moreover, it is easy to observe that among the domesticated -mammals the well-fed are more fertile than the ill-fed. - -That in the human species also, fertility is influenced to a notable -degree by nutritive conditions, is shown by statistical investigation. -After years distinguished by an exceptionally good harvest the number of -children born is considerably greater than in normal conditions; whereas -after a famine the opposite is observed. _Malthus’s_ law of population -states, _inter alia_, that the population increases when the amount of -available nutriment increases, that is, that favourable nutritive -conditions cause an increase, that unfavourable nutritive conditions -cause a decrease, of population. Hardships and exhausting occupations -diminish the fertility of women. The remarkable fertility of the Kaffirs -is referred to the fact that this people, possessing large herds of -cattle, lead a life comparatively free from care; it is no less true -that the Boer women, who lead a life of well-fed leisure, have very -large families; whereas the Hottentot women, poor, ill-nourished, and -hard working, seldom bear more than three children. - -Generally speaking, it may be said that fertility of the soil, in -connection with an easily gained livelihood, favours also human -fertility, notwithstanding the fact that certain statistical data seem -to conflict with this proposition. _Sadler_, for instance, concludes -that an increase in the price of the necessaries of life does not _per -se_ check fertility, but, indeed, rather increases it; he considers that -the apparent decline in fertility is due to the fact that the number of -marriages diminishes, owing to the rise in prices. We must, however, -point out, that an increase in price of the necessaries of life is often -associated with a rise in wages, and is therefore not necessarily -identified with deficient nutrition; when, however, such a rise in -prices leads to actual want, a limitation of fertility will certainly -result; this has been proved by _Legoyt_ and _Villermé_ with regard to -failure of the crops. Famine and disease lower the number of births; a -less severe deficiency of nutriment often lowers only the quality of -those born. _Malthus_ was of opinion that the population of a country at -any time was related to the quantity of nutriment produced or imported -therein, on the one hand, and, on the other, to the liberality with -which this nutriment was distributed to the individual. In countries -where corn forms the principal crop, we find a thicker population than -in pasture lands; and where rice is the principal crop, the population -is even more abundant than it is in corn growing countries. - -Passing to the consideration of the individual nutritive elements, we -find that these also influence fertility. Above all, it has been proved -that alcohol notably diminishes the fertility of women. _Lippich_ states -that of 100 women in Kärnten and Krain suffering from chronic -alcoholism, 28.3 were barren. In England, where the abuse of alcoholic -beverages is also very frequently observed in women, the same phenomenon -has been noted. _Matthews Duncan_ held that alcohol exercised a specific -deleterious influence on fertility. Moreover, in addition to the -constitutional disturbances produced by the abuse of alcohol, this -beverage also exercises a well-known pathogenetic influence upon the -female reproductive organs; with especial frequency, chronic oöphoritis -may be shown to depend on this exciting cause. - -A diet consisting mainly of fish is known to increase the sexual -impulse, and is said also to increase fertility. Further, a diet -consisting mainly of potatoes or rice is said to favour reproduction; -compare, for instance, the fertility of the Hindoos, who abstain -entirely from animal food, and of the Chinese, who live chiefly on rice. -_Davy_ maintained that the women of races living chiefly on fish were -handsomer and more fertile than others: and _Montesquieu_ suggested that -there was an association between the abundant population of sea-ports -and also of Japan and China, and the large quantity of fish consumed in -those places. On the other hand, a diet consisting chiefly of meat is -said to have an unfavourable influence in this direction; in support of -this view it is pointed out that races living by the chase, and living -therefore almost entirely on meat, have very small families. This -generalization is invalidated by the fact that Englishwomen, who eat far -more meat than the women of the Latin races, are nevertheless -distinguished by their great fertility. - -In his “History of Civilisation in England” _Buckle_ writes: “The -population of a country, although influenced by many other conditions, -unquestionably rises and falls in proportion as the supply of nutriment -is abundant or the reverse.” _Herbert Spencer_ also states that “every -increment in the supply of nutriment is followed by an increment in -fertility.” - -It must not be forgotten that, in addition to the more or less abundant -supply of nutriment, there are always other influences affecting -fertility; the general mode of life, race, climatic conditions, etc., -may, in various ways, co-operate with or countervail the influence of -nutritive conditions. If, with the best possible supply of nutriment, -there is associated a luxurious and enervating mode of life, the abuse -of alcohol, severe intellectual exertion, or sexual excesses, the -general result will be a diminution in fertility. And it is easy to -understand why _Cros_, although perhaps with little justification, goes -so far as to regard easy circumstances as an active cause of -depopulation. “It is the poor,” he writes, “and the less wealthy -departments of France, in which we find the most children.” In -estimating fertility, however, we must never fail to take into -consideration the more extensive employment of means for the prevention -of pregnancy among the upper classes of society. - -To a certain extent we can trace the influence of climate and of season -upon fertility. Heat appears to favour fertility; _Haycraft’s_ figures -for the eight largest towns of Scotland show clearly how the number of -conceptions rises and falls _pari passu_ with the temperature. Lower -animals also, when brought from a colder to a warmer neighbourhood, -exhibit an earlier and more frequently recurring “heat.” In Europe, -however, the Northern races appear more fertile than those of the south. - -Of the seasons, spring is the one especially favourable to fertility. -_Quetelet_, who proves by numerous statistical data that the maximum of -conceptions occurs in May, attributes this fact to a general increase in -the vital forces occurring in spring, after the cold of winter. -_Villermé_, however, goes back to the older explanation, that the -increase in the number of conceptions in May and June is due to social -and economic conditions. The return of spring, especially the end of -spring and the beginning of summer, a time of year in which the means of -subsistence are provided in exceptional quantity, and of especially good -quality, the season also of festivals and social reunion, when the two -sexes are brought into more intimate contact and when the majority of -marriages occur—these are the conditions associated with the season of -greatest fertility. The figures of _Wappaeus_ also confirm the influence -of spring in favouring fertility. He found, however, that there were two -seasons of maximal fertility. The first at the end of spring and the -beginning of summer; the second in winter, especially in December. -Mid-winter is for most people a period of domestic amusement and -relaxation, one of exceptionally good nutrition, and of social reunion; -the spring increase in fertility is a part of the awakening and increase -of the reproductive forces of nature at large, which recurs every -spring-time. - -Every marked and sudden change in the mode of life has an unfavourable -influence on fertility. _Darwin_ reports that mares who have for some -time been stall-fed with dry fodder and are then put out to grass are at -first infertile after the change. Europeans going to reside in the -tropics experience a notable decline in fertility as a result of the -change of climate. According to _Virchow_, the fertility of European -women who become acclimatized in the tropics declines very gradually, -but in the course of a few generations is almost completely annulled. - -The marriage of near kin is believed also to diminish fertility. As -regards inbreeding in the lower animals, it is well known that when -nearly related animals copulate, the number of the offspring is below -the average. _Nathusius_ paired a sow with its own uncle, the boar -having proved productive in intercourse with other sows; the litter -numbered five to six only. This sow, which belonged to the great -Yorkshire race, was then paired with a small black boar, which in -intercourse with sows of its own variety had procreated litters -numbering six or seven; as a result of her first pairing with the black -boar, the sow cast a litter numbering twenty-one whilst the second -attempt produced a litter of eighteen. Similar results were obtained by -_Crampe_, in his experiments in the inbreeding of rats. - -Some authorities declare that the results of inbreeding are similar in -the human species, that the marriages of near kin are less fruitful than -the average. _Darwin_ writes in this connection: “With regard to human -beings, the question whether breeding in-and-in is also deleterious, -will probably never receive a direct answer, for man reproduces his kind -so very slowly, and cannot be made the object of experiment. The very -general disinclination of nearly all races to the marriage of near kin, -which has existed from the very earliest times, is of weight in relation -to this question. Indeed we appear almost justified in applying to the -human race the experience gained by experiment on the higher mammals.” - -_Darwin’s_ assumption regarding the effect upon fertility of the -marriage of near kin in the human species, cannot, however, be accepted -without qualification. In ancient times there was no uniformity of -opinion on this topic. It is well known that among the Phœnicians, a son -might marry his mother, and a father his daughter; and among the ancient -Arabs it was the legal duty of the son to marry his widowed mother. -Moses, on the contrary, forbade marriages between parents and children, -between brothers and sisters, also marriage with a father’s sister, with -a wife’s mother, and with an uncle’s widow. - -_Darwin_ considered that the marriage of first cousins was not -unfavourable to fertility. Of 97 such marriages, 14 were sterile, whilst -of 217 marriages of those not akin, 35 were sterile; the percentage in -both cases being almost identical. _Mantegazza_, who regards kinship in -marriage as unfavourable to fertility, found nevertheless that among 512 -marriages of near kin, only 8 to 9% were sterile. It is widely believed -that the dying out of many aristocratic families is dependent on the -inbreeding so common in this class—but it must be admitted that -scientific evidence in support of this belief is lacking. Incest in the -human species may certainly result in fertilization. Among the Jews, -marriages of near kin are very common, and often prove extremely -fruitful. - -_Göhlert_ made a statistical investigation of the fertility of the -reigning families of Europe, in order to throw light on this question. -In the Capet dynasty, 118 marriages of near kin took place, and of these -41 were sterile; in the Wettin dynasty (Saxony), there were 28 such -marriages, of which 7 were sterile, and 1 produced one child only; in -the Wittelsbach dynasty (Bavaria), 29 such marriages, of which 9 were -sterile, and 3 produced only one child each. Thus of 175 marriages of -near kin, 57, or 32.6% remained sterile. Further, in the -Habsburg-Lothringen dynasty, of 110 marriages, 25 were marriages of near -kin, and of these 33% remained sterile. - -It has been assumed since the days of antiquity that temperament and -constitution exercise some influence on fertility. _Hippocrates_, -_Soranus_, and _Diokles_, are among the ancient authors who refer to -this matter. _Soranus_ says very justly: “Since most marriages are -contracted, not from love, but for the procreation of children, it is -irrational, when choosing a wife, to have regard, not to her probable -fruitfulness, but instead of this to the social position and the wealth -of her parents.” - -It would appear that a certain dissimilarity in physical constitution -and temperament between husband and wife is favourable to the fertility -of the marriage. For instance, a vivacious, dark husband, and a -lethargic, fair wife, are better suited to one another than a husband -and wife both extremely active, or both of extremely phlegmatic -temperament. - -_Toussaint Loua_ published the following figures regarding the fertility -of the women of the various countries of Europe: - - ══════════════╤═════════════╤═════════════════════════════════════════ - │ Number of │ - COUNTRY. │ births per │FERTILITY OF WOMEN BETWEEN THE AGES OF 15 - │ hundred │ AND 45 YEARS. - │inhabitants. │ - ──────────────┼─────────────┼─────────────┬─────────────┬───────────── - „ │ „ │ Married. │ Unmarried. │ Average. - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - Hungary │ 4.94│ │ │ 17.8 - Russia │ 4.12│ │ │ 20.5 - Austria │ 3.93│ │ │ 16.4 - Germany │ 3.77│ 34.8│ 2.9│ 17.7 - Italy │ 3.67│ 28.8│ 2.4│ 16.1 - Holland │ 3.67│ 35.3│ 1.0│ 16.0 - Finland │ 3.63│ │ │ 15.8 - England │ 3.58│ 29.7│ 1.6│ 15.5 - Scotland │ 3.53│ 32.8│ 2.5│ 15.8 - Belgium │ 3.25│ 33.7│ 1.8│ 14.8 - Denmark │ 3.12│ 28.5│ 2.8│ 14.4 - Roumania │ 3.12│ │ │ 13.5 - Norway │ 3.10│ 29.3│ 2.2│ 14.0 - Sweden │ 3.05│ 29.1│ 2.5│ 13.7 - Switzerland │ 3.04│ 29.7│ 1.1│ 13.1 - Greece │ 2.96│ │ │ 13.2 - Ireland │ 2.69│ 29.8│ 0.5│ 12.3 - France │ 2.63│ 20.3│ 1.8│ 11.6 - ══════════════╧═════════════╧═════════════╧═════════════╧═════════════ - -In towns, conjugal fertility is less, extra-conjugal fertility greater, -than in the country. An increase in factory labour gives rise to an -increase in the population, but to a decline in the vitality of the -offspring; that is to say, it causes a quantitative increase, and a -qualitative decrease, in fertility. An increase in agricultural labour -has precisely the opposite effect. The influence of war upon fertility -is unfavourable both quantitatively, and qualitatively. According to -_Tschouriloff_, the introduction of universal military service, by -withdrawing for a time all the most vigorous men from domestic life, -tends to diminish fertility. Extensive emigration from a country in -which the soil is fertile, and where the vital conditions are generally -favourable, is stated by _Bertillon_ to cause an increased fertility in -the mother country; he further states that an increase in the number of -the proprietors of the soil is followed by diminished fertility, and -vice versa. - -Prostitutes show as a rule a very low fertility. According to the data -of _Tarnowskaja_, the fertility of prostitutes in Russia is 34%, whilst -married women of similar ages in Russia exhibit a fertility of 51.8%. -_Gurrieri_ found 60% of prostitutes childless. - -The fertility of female criminals was found by _Lombroso_ to be -undiminished. On the average, poisoners had given birth to 4.5 children, -other murderesses to 3.2 children, child-murderesses to 2 children; thus -the prisoners whose crime is commonly dependent on an abnormal eroticism -had a fertility above the average. - -The diminished fertility of prostitutes depends in part upon frequent -venereal infection, in part upon the unfavourable influence of the -mercury and iodide of potassium administered for the cure of such -infection, also upon the frequency with which they consume excessive -quantities of alcohol, upon the excessive frequency of coitus, which -exercises a traumatic influence, upon the irregular mode of life, and -upon their disinclination to be burdened with children. - -Conjugal fertility, that is to say, the ratio between legitimate births -and the number of married women between the ages of 15 and 50 years, has -declined in Germany during the last decades. It was: - - During the years 1872 to 1875 29.7% - During the years 1879 to 1882 27.4% - During the years 1889 to 1892 26.5% - -This decline is small, but it is much more manifest in urban than in -rural districts. This fact is shown by the following figures, relating -to fertility in Prussia: - - 1872 to 1879. 1894 to 1897. - In all towns 26.9 24.0 - In Berlin 23.8 16.9 - In other large towns 26.7 23.5 - In rural districts 28.8 29.0 - -This difference depends principally on the fact that in the large towns -of Germany (and still more in those of France) the use of means for the -prevention of pregnancy is continually increasing, whereas the -population of the rural districts is as yet less familiar with the use -of these measures. - -According to _Hellstenius_, conjugal fertility, that is, the number of -children per married couple, is as follows: - - In the Netherlands 4.88 - Norway 4.70 - Prussia 4.60 - Bavaria 4.55 - Sweden 4.52 - Saxony 4.35 - England 4.33 - Belgium 4.23 - Denmark 4.18 - France 3.46 - -_Talquist_, who has published a statistical investigation concerning the -modern tendency to diminished fertility, arrives at lower figures than -_Hellstenius_. According to him, conjugal fertility is: - - In Prussia 4.11 - England 4.10 - Belgium 4.12 - France 2.09 - In various States of the American Union 2.5 to 3.0 - -From the Almanach de Gotha _Vacher_ obtained figures showing that each -family of the higher aristocracy has on the average the following number -of children. - - In France 2.0 - Italy 3.0 - Germany 4.8 - England 4.9 - Russia 5.1 - -According to the figures we have published, the fertility of women -suffices for the production during the sexual life of a small number -only of children, averaging, in fact, 4 to 5 children per marriage. Many -mothers, however, give birth to a very large number of children. Among -73,000 families inhabiting Buda-Pesth, _Körösi_ found 300 mothers who -had had 15 children or more; 7 mothers who had each had 21 children; and -3 mothers who had given birth respectively to 22, 23 and 24 children. - -A newspaper report states that the wife of a citizen of Buda-Pesth, -during the 43 years of her married life, gave birth to 32 children. In -the year 1902, a Bohemian woman gave birth to her twenty-fourth child. -_Stieda_ reports the cases of two mothers, one of whom had 21, and the -other 23 children. The wife of the German Emperor, Albrecht I, and the -wife of Prince Jost of Lippe-Biesterfeld, each bore 21 children. - -The so-called _two-children-system_ obtains most commonly in France. - -It is true that even in France there are on an average nearly three -children born per marriage; but if we take into account surviving -children only we find an average per family of 2.1 children only. -Similar conditions obtain in New England, and in Transylvania; and the -same practice is spreading throughout the United States. Another way in -which the attempt is made to keep down the population is that customary -in Alsace, where, if there are several children in a family one only -marries, in order to avoid a division of the family property. It cannot -be denied that in France, doubtless in consequence of the two-children -system, a somewhat widely diffused prosperity exists, a prosperity which -is lacking in the rare districts in France, such as Brittany, in which -limitation of the family is not practised. What a disastrous influence -the general use of measures for the prevention of pregnancy exercises on -the military power and political status of a nation has, however, in -recent years been made especially manifest in the case of France. In -that country, of ten million families, two million are absolutely -childless, and two million have only one child each, so that two-fifths -of the French families are as good as inactive in maintaining the -population of the country. The injury thus done to France is shown still -more clearly by a tabular comparison of the excess of births over deaths -in the German and French nations, respectively, during the two decades -1874 to 1894 (from _G. von Mayr’s_ _Population Statistics_). - - Year. Germany. France. - 1874 +13.4 +4.8 - 1875 13.0 2.9 - 1876 14.6 3.6 - 1877 13.6 3.9 - 1878 12.7 2.6 - 1879 13.3 2.5 - 1880 11.6 1.7 - 1881 11.5 2.9 - 1882 11.5 2.6 - 1883 11.7 2.6 - 1884 11.2 2.3 - 1885 11.3 1.4 - 1886 10.8 1.5 - 1887 12.7 1.3 - 1888 12.9 2.5 - 1889 12.7 1.2 - 1890 11.3 –0.3 - 1891 13.6 –0.5 - 1892 11.7 +0.1 - 1893 12.2 –1.2 - 1894 13.6 –0.4 - -To what an extent in all times, and among all peoples, the fertility of -women was esteemed, is shown by religious writings and traditional -customs which aimed at enabling a wife who had had no children by her -own husband, to seek other conjugal embraces. Among the Jews, it was the -duty of a man to marry his widowed and childless sister-in-law; if he -were unwilling or unable to perform this duty he was compelled to take a -part in a ritual termed “chaliza,” in which his foot was bared and the -bereaved woman spat upon him, because he was unwilling to maintain his -brother’s house. In the law book of the Hindoos of _Manus_, we read, “If -husband and wife have no children, it is proper for them to obtain the -desired offspring by a union between the wife and the husband’s brother, -or some other relative;” the child obtained in this way was legally -regarded as the child of the husband. _Confucius_ wrote: “If your wife -is barren, take a second wife; she must be subordinate to the first -wife, for her only duty is the bearing of children.” An analogy to this -ordinance is to be found in the Bible; Abraham’s barren wife Sarai says -to Abraham: “Behold now, the Lord has restrained me from bearing: I pray -thee, go in unto my maid; it may be that I may obtain children by her. -And Abraham hearkened unto the voice of Sarai.” In the same way the -barren Rachel speaks to her husband Jacob, “Behold my maid Billah, go in -unto her; and she shall bear upon my knees, that I may also have -children by her.” - -_Luther_, in his treatise on marital love published in the year 1522, -bases, doubtless on the above biblical precedents, the following -statement regarding fertility: “If a sexually potent woman is married to -an impotent man, if she is unable to take any other man openly, yet is -unwilling to do anything dishonourable, she should say to her husband, -“Dear husband, you cannot fulfil your duty to me, and you have deceived -my young body, you have endangered my honour and my happiness, and in -the eye of God our marriage is null, forgive me therefore if I form a -secret union with your brother or with your nearest friend; the fruit of -this union will be yours in name, thus your possessions will not fall to -strangers, and you will willingly allow me to deceive you, because -involuntarily you have deceived me.”” - -In ethnography, the term _endogamy_ is used to denote a law or custom by -which marriage is allowed only within the limits of a specified race, -tribe, or caste; thus, in the Old Testament, Jews are forbidden to marry -women of other races. The ethnographical term _exogamy_ indicates the -prohibition of marriage between persons who are more closely allied, as, -for instance, the Mosaic prohibition of marriage within certain degrees -of blood-relationship. Such exogamic prohibitions persist even in the -legislation of the present day. In many ecclesiastical and national laws -we find the marriage of first cousins and of uncle or aunt with niece or -nephew forbidden; and even a prohibition of the marriage of a man with -his deceased wife’s sister. - -_Hegar_ considers the danger of inbreeding to be very great in the human -species; for whereas in the lower animals breeders employ a methodical -and carefully considered selection of the best specimens, nothing of -this kind occurs among human beings; and the health of modern civilized -man is such that there are few families without a skeleton in the -closet. “Not only in families, but also in villages, in small and large -towns, even in classes, and in entire nations, certain peculiar -qualities, morbid tendencies, and predispositions, are handed down from -generation to generation. We have, for instance, the tendency of the -Jews to nervous disorders and diabetes, that of the English to gout, -that of the Germans to myopia.” _Strahan_ has therefore employed the -term “social consanguinity,” to indicate that by means of common -customs, environment, occupation, and mode of nutrition, a similarity in -type is produced, leading to a similar predisposition to disorders and -diseases transmissible from father to son. - -The dangers of inbreeding are believed by _Hegar_ to be, under -present-day conditions, so considerable that he would allow the marriage -of near kin in exceptional cases only, and where the circumstances are -peculiarly favourable—for instance, where both parties to the projected -marriage are in excellent health, and where there is no great similarity -between them in feature or mental type. Certain anomalies transmitted -from remote ancestors, dependent on deeply-marked peculiarities of the -germ cells, may be so developed by inbreeding as to become absolutely -fixed characteristics. If the morbid manifestations can be traced back -for several generations, if the bodily defects and disturbances of -development (the so-called stigmata of degeneration), are well marked -and numerous, if the functional disorders of the nervous system and of -the sense organs are pronounced, leading to idiocy, insanity, epilepsy, -congenital deafmutism, blindness, instinctive criminality,—there is in -such cases little or no hope of the regeneration of the family. It dies -out, because the members are sterile; because they are confined in -prisons or asylums; or because the children, if any are born, are -deficient in vitality, and fail to reach maturity. - -According to the brief summary of the subject given by _Hegar_, the -peculiarities of the offspring at the time of birth depend upon: - -Factors which give rise to peculiarities of the germ-cells: - - I. Germinal rudiments derived from the ancestors; - - II. Influences acting on the germ-cells within the parent organism; - - a. Owing to peculiarities of the fluids and tissues of the parental - body; - - b. Owing to substances which penetrate the parental body and reach - the germ. - -Germinal rudiments altered by the conjugation of the male and female -reproductive cells: - - I. On the mother’s side; - - a. Owing to peculiarities of the fluids and tissues of the maternal - body; - - b. Owing to substances which penetrate the maternal organism and - reach the fertilized ovum. - -II. On the father’s side, owing to substances which adhere to the -paternal reproductive cells, or are enclosed within these. - -The number of consanguineous marriages at the present day is not less -than 5½ to 6½ per 1,000; the fertility of these marriages appears to be -identical with the fertility of ordinary marriages. _Mayet_ has made a -statistical investigation to determine the influence of consanguineous -marriages in the pathogenesis of mental disease. He finds that the -number of those congenitally affected with mental disorder is twice as -great in the offspring of consanguineous marriages as in the offspring -of crossed marriages; in the case of simple mental disorder, of -paralytic dementia, and of epileptic dementia, the ratio is actually -greater than two to one (the actual figures are 218, 257, 208 : 100). -Thus we see that when there exists any cause of inheritable mental -disorder, blood-relationship of the parents more than doubles the danger -to the children. In the case of imbecility and idiocy the danger is less -in this respect (the ratio is 150 : 100); the factor of inheritance -plays a less prominent part than in the case of other psychoses. - -It was remarkable that among the offspring of marriages of nephew and -aunt, cases of mental disorder were almost entirely lacking. Among the -offspring of marriages of uncle and niece, the inheritance of mental -disorder was more prominent than among the children of first cousins. It -is interesting to determine the influence of blood-relationship in cases -in which the existence of inheritable predisposition could not be -proved. In these cases, as regards simple insanity, paralytic dementia, -and epileptic dementia, the number of cases among the offspring of -consanguineous marriages was only one-half as compared with the -offspring of crossed marriages; whereas in the case of imbecility and -idiocy this ratio was reversed. In idiocy, where inheritance generally -speaking plays a small part, the origination of the disease would often -appear to depend directly on the blood-relationship of the parents; -whilst as regards other forms of mental disorder, if there is no -inheritable predisposition, blood relationship in the parents appears to -be a positive advantage; where, however, a family predisposition to -insanity exists the likelihood of actual insanity appearing in the -offspring is notably enhanced by a consanguineous marriage. - - -_The Restriction of Fertility and the Use of Means for the Prevention of - Pregnancy._ - -As we have already pointed out, a restriction of the fertility of women -occurs in the majority of marriages, to this extent, that the potential -reproductive powers of the wife are not fully utilized. In recent times, -however, the restriction of fertility, by the deliberate use of measures -for the prevention of pregnancy, has become so widely diffused, that it -appears unwise from the scientific standpoint simply to ignore the -question, and it has become indispensable to study how the practice -developed, and to consider what are its actual results. From our own -point of view, it is the more necessary to do this, for the reason that -the use of preventive measures has come to play an important part in the -sexual life of woman, and therefore deserves the fullest attention, not -merely from the standpoint of the sociologist, but in addition from the -purely medical point of view. - -In many divisions of the population, and even in entire nationalities, -the prevention of pregnancy, not merely in illicit intercourse, but also -in married life, has become so general a practice that the fertility of -the nation as a whole has been profoundly modified. Thus, in France at -the present day, the average number of children per marriage is less -than two; and the two-children-system is almost universally practised in -Transylvania and Norway, whilst it is very rapidly spreading in North -America. In the principal towns of the whole of Europe, this system is -largely on the increase among the upper classes of society. The -marriages of the poor, partly owing to ignorance, and partly to -indolence, are as yet comparatively little affected by this depopulative -principle. - -In the days of antiquity, many lawgivers endeavoured to set bounds to -excessive fertility, and artificial abortion was methodically practised -by those who wished to avoid an inconveniently large family. Even among -savage peoples, we find that certain preventive measures are -occasionally employed in sexual intercourse. Among civilized peoples, -however, until the beginning of the nineteenth century, religious and -moral ideas derived from the Bible continued to dominate the sexual -life. It is well known that Old Testament law and Christian morality -alike forbid any artificial restriction of human increase. “Increase and -multiply” was the command given in Genesis to the first parents of the -race; and the psalmist exclaims, “Happy is the man that hath his quiver -full” of children. - -A remarkable revolution in thought was initiated toward the beginning of -the nineteenth century by the great philanthropist and powerful thinker, -_Thomas Robert Malthus_, founder of the doctrine of the propriety of -checking the increase of population, author of the work “An Essay on the -Principle of Population,” London, 1798, whose Law of Population soon -attracted world-wide attention. Modern civilization having greatly -increased the cost of bringing up a family, while simultaneously there -has been a general rise in the price of the necessaries of life, there -has resulted an extraordinary diffusion of Malthusianism; in comparison -with the causes just alluded to for the use of preventive measures, -diseases which render renewal of pregnancy dangerous to the mother’s -life have comparatively little to do with the causation of voluntary -sterility. - -In his “Essay on the Principle of Population,” _Malthus_ indicates, as -the cause which has hitherto hindered mankind in the pursuit of -happiness, the unceasing tendency of all organic life to increase in -excess of the means of subsistence. In the case of plants and of -unreasoning animals, the natural process is a very simple one. Both -animals and plants are impelled by a powerful instinct to reproduce -their kind, and the operation of this instinct is quite undisturbed by -any anxiety regarding the livelihood of their offspring. The -reproductive function is thus exercised at every available opportunity, -and the superfluous individuals of the next generation are destroyed by -lack of space and nutriment. In the human species the restriction of -population is effected by a more complex mode of operation. Man is -impelled to reproduce his kind by an instinct not less powerful than -that of other animals; but the gratification of this instinct is checked -by reason, which makes him ask himself whether he is not about to bring -into the world beings for whom he will be unable to provide the means of -subsistence. If he is influenced by this consideration, the resulting -restriction of population may often entail serious consequences; if, on -the other hand, he gratifies his instinct, regardless of the appeal of -reason, the human species will inevitably tend to increase more rapidly -than the means of subsistence. - -_Malthus_ declared that population, when its increase was unrestricted, -doubled itself every twenty-five years, and therefore increased in a -geometrical progression; he considered that in the most favourable -circumstances the means of subsistence could not possibly increase more -rapidly than in an arithmetical progression. The contrast between these -two modes of increase will be more striking if we write out the actual -figures. According to the theory of _Malthus_, the increase of human -population would be represented by the figures 1, 2, 4, 8, 16, 32, 64, -128, 256, whereas the simultaneous increase in the means of subsistence -would be represented by the figures 1, 2, 3, 4, 5, 6, 7, 8, 9. Such an -increase in population is, however, always prevented by certain checks, -classed by _Malthus_ as of two kinds, preventive checks and positive -checks. - -A preventive check, in so far as it is voluntary, is peculiar to the -human species, and originates in the intellectual faculty which enables -man to foresee the consequences of his actions. A man who looks around -him, and sees the poverty into which those with large families so often -fall, who reckons up his present property or earnings, which barely -suffice to provide for his own personal necessities, cannot fail, when -he considers how hardly they would suffice for seven or eight additional -persons, to doubt whether it would be possible for him to provide for -the offspring he might bring into the world. Such considerations as -these are likely to lead a large number of persons of all civilized -nations to resist their natural instincts, and to refrain from early -marriage. If abstinence entailed no serious consequences, it would be -the least of all evils resulting from the principle of population. - -The positive checks to increase of population are manifold, and embrace -all the causes which are competent to lessen the natural duration of -human life. Among these we may enumerate: all unhealthy occupations, -severe toil, climatic conditions, poverty, errors in the rearing of -children, town life, excesses of all kinds, the whole army of illnesses -and epidemics, war, pestilence, and famine. In all countries, preventive -and positive checks are more or less powerfully operative, and yet there -are few in which the population is not continually tending to increase -beyond the means of subsistence. As a further consequence of this -tendency of population to increase, we observe the wider diffusion of -poverty among the lower classes, so that any permanent improvement in -their condition is rendered impossible. - -After _Malthus_ had carefully stated his thesis, he gave a summary -record of the conditions of population in nearly all nations of the past -and of his own time, in order to show how in all alike the three -principal means of limiting population, moral restraint, disease, and -poverty, had been in continuous operation. - -He showed, for instance, how the population of the South Sea Islands had -been limited by certain conditions, cannibalism, castration of the -males, infibulation of the females, late marriages, the sanctification -of virginity, contempt for marriage, etc. - -In ancient Greece, Solon’s laws permitted infanticide. _Plato_, in “The -Republic” asserts that it is the duty of the Government to regulate the -number of the citizens, and to prevent an immoderate increase; men and -women should be allowed to procreate only during their period of maximum -strength, all weakly children should be killed. _Aristotle_ advised that -men should not be allowed to marry before the age of 37, and women -before the age of 18; the women should give birth to a limited number of -children only; if, after this, they again became pregnant, abortion -should be induced. He maintained that if all were at liberty, as was the -case in most countries, to bring into the world as many children as they -pleased, poverty, the mother of crime and insurrection, must inevitably -ensue. - -Among the Romans war was as a positive check unceasingly operative: in -this time of the Empire, preventive methods came into general use, in -the form of various kinds of sexual perversity. _Juvenal_ complains of -the skilled methods employed in the induction of abortion; during the -later period of the Roman Empire, sexual morality became so degenerate -that marriage was hated and despised. - -Passing to the consideration of the checks on population among the -nations of modern Europe, _Malthus_ examined the registers of marriages -and deaths, and came to the conclusion that in few countries is the mass -of people sufficiently capable of self-restraint to postpone marriage -until they are reasonably assured of being able to provide for all the -children they are likely to have; still, he ascertained that at the -present day positive checks on population were less active, and -preventive checks more active, than in earlier times and among savage -races. - -_Malthus_ did not base upon his conclusions the advice that in sexual -intercourse means of preventing pregnancy should be employed, as the -modern “Malthusians” advise; in his eyes, moral restraint, that is to -say, sexual abstinence, was the only remedy for the prevention of -poverty and the other evil consequences of the principle of population. -Moral restraint was in his opinion the only virtuous method of avoiding -the evils of excessive fertility. It was a man’s duty not to marry until -he had a definite prospect of being able to maintain his children; the -interval between puberty and marriage must be passed in strict chastity. -Man’s duty is not the mere reproduction of his species, but the -reproduction of virtue and happiness, and if he is not able to do the -latter, he has no right whatever to do the former. _Malthus_ lays great -stress on educating the people in this matter; “in addition to the -ordinary subjects of instruction, it is necessary to explain the -principle of population, and the manner in which it gives rise to -poverty.” In the nature of the case, no lasting and general improvement -in the condition of the poor is possible without an increase in the -preventive restriction of population. - -The _Malthusian_ doctrine of the law of population gave rise to an -enormous sensation, and some of his disciples soon proceeded to -translate his conclusions into practice; such authorities as _James -Mill_ and _Francis Place_ recommended measures by means of which, -“without any injury to health, or to the feminine sense of delicacy, -conception can be prevented:” the avowed aim of these measures was to -prevent the increase of population beyond the means of subsistence. -Physicians and physiologists joined the ranks of these innovators; among -others _Raciborski_, _Robert Dale Owen_ in his “Moral Physiology,” -_Richard Carlile_ in his “Book of Woman,” the first work to give an -exact description of the means to employ for the prevention of -conception, _Knowlton_ in his “Fruits of Philosophy.” In the year 1827 -in the Northern counties of England leaflets were for the first time -distributed among the working classes to instruct them in the use of -preventive measures. _Bradlaugh_ founded the Malthusian Society, which -aimed at the dissemination of instruction in the use of preventive -methods. There is now in England a “Malthusian League,” numbering -leading physicians among its members; this supplies to all classes the -means by which the family can be artificially limited. A new edition of -the above-mentioned book, “The Fruits of Philosophy,” was circulated in -London in an edition of several hundred thousand copies, and prominent -persons spoke at congresses on the subject of Neo-Malthusianism. In -Germany, also, a “Union of Social Harmony” was founded, for the free -distribution of a hand-book on the use of measures for the prevention of -conception, and for an investigation regarding the results of these. - -We do not propose here to subject the teaching of _Malthus_ to a -critical examination; he has found formidable opponents, who have -endeavoured to prove that his fundamental assumption is false; they -maintain that work or the power of work increases in direct ratio with -the population; and they also assert that population tends to increase, -not, as _Malthus_ maintained, in a geometrical, but simply in an -arithmetical progression. We shall merely quote _Liebig’s_ reply to the -law of Malthus, “when human labour and manure are provided in sufficient -quantity, the soil is inexhaustible, and will continue to yield -unceasingly, the most abundant harvests;” and _Rodbertus’_ remark that -“agricultural chemistry will ultimately be competent to create nutritive -materials; this will some day be just as much within the power of -society, as it is at present to provide any requisite quantity of -textiles, given the necessary amount of raw material.” The celebrated -socialist _Bebel_, is a strong opponent of _Malthus_. He writes: “The -earth is doubtless thickly populated, but none the less only a small -fraction of its surface is occupied and utilized. Not merely could Great -Britain produce, as has been proved, a far larger supply of nutritive -materials than at present, but the same is true of France, Germany and -Austria, and in a still higher degree of the other countries of Europe. -European Russia, were it as thickly populated as Germany, could support, -instead of ninety millions, as at present, a population of four hundred -and seventy-five millions. For the purposes of the higher civilization, -toward which we are striving, we have to-day in Europe, and shall have -for a long time to come, not an excess of population, but an -insufficiency, and every day brings new discoveries and inventions -whereby the means of subsistence are potentially increased. In other -parts of the world, the insufficiency of population and the superfluity -of ground are even more noticeable. _Carey_ is of opinion that the -single valley of the Orinoco, fifteen hundred miles in length, would -suffice to provide nutritive material in sufficient quantities to feed -the whole existing population of the world. Central and South America, -and more especially Brazil, have a soil of extraordinary fertility, but -are as yet practically unutilized by the world. To increase, not to -diminish, the numbers of the human race, that is the appeal made by -civilization to mankind!” A similar position on this question was -recently taken by Roosevelt, the President of the United States, himself -the father of six children, in a letter to two American women, _Mrs. J._ -and _M. Van Vorst_, authors of the book “Woman Who Toils (Factory Life -in America).” In this book, the writers prove that in the United States -the average size of the family is now less than in any other country of -the world, France alone excepted. President Roosevelt, in his letter, -declares himself an ardent supporter of the biblical injunction, -“increase and multiply!” He writes: “Whoever evades his -responsibilities, through desire for independence, convenience, and -luxury, commits a crime against the race to which he belongs, and should -be an object of contempt and horror to a healthy nation. When men avoid -becoming fathers of families, and when women cease to regard motherhood -as the most important career open to them, the nation to which these men -and women belong has cause for uneasiness about its future.” President -Roosevelt continues: “To the American woman marriage is no longer a -life-duty, a profession, as it is to her sisters who are members of the -older civilizations. A woman who manages an extensive business, who -supervises her own landed property, or who plays her own part in the -world of finance,—for such as these, the ‘lottery of marriage’ is -naturally something they dread rather than desire.” President Elliott, -of Harvard College, has expressed similar views in a speech on this -subject. He deplores the late marriages and small families of the -cultured Americans. According to the last census, an American family has -on the average less than three children; twenty years ago the average -number was from four to five children. - -I pass now to consider the medical point of view of this question of the -prevention of pregnancy. It is my opinion that the physician as such -should intervene in the matter, not in any case for the relief of the -dominant economic parental dread of insufficient means for the -upbringing of children, but only on account of the purely medical -consideration of the physical dangers of motherhood. That is to say, the -physician should lend his skilled assistance toward the attainment of -facultative sterility, only when his own special scientific knowledge -leads him to consider this urgently necessary; it is not his province to -assist in preventing the birth of an immoderate number of offspring; his -intervention is justified only when deliberate reflection has convinced -him that his patient’s health or life would be endangered by pregnancy -or childbirth. A woman’s life and well-being must appear to him of -greater importance than the existence or non-existence of a possible -infant. That this view is morally sound, is shown by the fact that -public opinion justifies the accoucheur in the destruction of an already -living child, when the mother’s life is endangered. In this connection -we may recall the words of the great Napoleon; the physician Dubois, -attending Marie Louise in a difficult confinement, asked Napoleon -whether, if matters came to an extremity, he should save the mother or -the child; Napoleon, notwithstanding his strong desire for the birth of -an heir to his dynasty, replied, “The mother, it is her right.” - -In isolated cases, which deserve always very serious consideration, some -pathological condition in the wife may justify the prevention of -pregnancy. In certain very serious general disorders, in diseases of the -heart or of the lungs, in pelvic deformity, and in pathological changes -of the female reproductive organs, it may be right to employ means for -the prevention of pregnancy—not merely sexual abstinence, but actual -measures to prevent fertilization. - -The misuse of medical knowledge for the recommendation or employment of -preventive measures, on the ground of humanitarian sentiment or social -and economic considerations, must, however, be strongly resisted. Even -leading gynecologists have erred in this way. _Saenger_ writes, -“Scientifically-trained accoucheurs will do much more to promote the -health and well-being of women, and to protect them from sexual and -other diseases, than the humanitarian efforts of the Neo-Malthusians, -who transfer a purely scientific question, such as the disproportion -between the number of births and the supply of nutritive material, to -the sphere of medicine, regarding themselves as justified in preventing -conception whenever they please, independently of considerations -relating to the health of the mother * * * * * * * * A woman exhausted -by frequent child-bearing, anæmic and suffering, is certainly a figure -to arouse everyone’s sympathy; in so far as she is ill in consequence of -injury received in childbirth, it is our duty to prevent further injury, -and to relieve to the best of our ability that which has already -occurred; in so far, however, as she is not suffering from any affection -of the reproductive organs, but is ill owing to the lack of sufficient -food, or from overwork, it is the duty of society to render assistance. -Here we have to do with the social problem; the solution of which will -be brought no nearer by the use of the occlusive pessary.” _Fehling_ -also maintained that a text-book of gynecology is not the proper place -in which to pass judgment on so important a socio-political question. -The business of the gynecologist in this matter is merely to say a word -of caution against the use of various measures which are so often -recommended as harmless, but are in fact dangerous to the woman who uses -them. - -_Kleinwächter_, who declares that he is far from recommending the use of -preventive measures when a healthy woman wishes to save herself the -trouble of child-bearing, gives as legitimate indications for their use: -1, the various forms of severe pelvic deformity; 2, certain tumours in -the pelvic cavity; 3, after the removal of malignant tumours of the -reproductive organs, certain general disorders, recently arrested -pulmonary tuberculosis, organic heart disease, etc. Regarding these -cases, _Kleinwächter_ writes: “The wife’s life would be endangered by -pregnancy, which must therefore be prevented without forbidding coitus, -and avoiding the practice of coitus interruptus, which endangers her -health, or of any mode of intercourse repugnant to the feelings of wife -or husband.” - -The most trustworthy, but unquestionably at the same time the least -practicable method, for the prevention of pregnancy, is that of -_Malthus_—permanent sexual continence. This recommendation, to which -_Tolstoi_ in “The Kreuzer Sonata” gives his adhesion, has recently found -an advocate in a modified sense in a distinguished gynecologist, -_Hegar_, who considers that the great fertility of the modern civilized -countries of Europe entails many disadvantages—inferior physical -development, increased general mortality, emigration, an unfavourable -distribution of population in relation to dwelling and occupation, -occasional famine—and who sees the only effective remedy in a -“regulation of reproduction,” whereby the tendency to marriage and the -number of births are to be diminished. The question “when is the number -of children in a family too large?” is answered by _Hegar_ as follows “A -maximal limit is easy to establish. The most suitable age for -child-bearing is from twenty to forty. At an earlier and a later age -than this, both the mother and the offspring are liable to suffer. -Between two successive births there should be an interval of about two -and a half years; this would leave time for the birth of eight children. -If we assume that pregnancy lasts nine months, that lactation is -continued from nine to twelve months after delivery, (and if the mother -does not herself nurse the child, artificial feeding or careful -supervision of the wet-nurse will occupy her for a like period), to -devote an additional period of six months to nine months to the complete -restoration of the mother’s health cannot be regarded as excessive. For -this maximum family we assume a perfect state of health on the part of -the mother, a pure atmosphere, and a sufficient supply of all the -necessaries of life. Illnesses, weakness, or infirmity of the mother, -often indicate that the number of children should be further limited. It -is easier to provide a suitable dwelling and a pure atmosphere for a -small family than for a large one. The same thing is true as regards the -means of subsistence. - -“If the reproductive function is to be intelligently controlled,” -continues _Hegar_, “above all it is necessary to devote attention to the -age and health of the parents; but occupation, dwelling, and general -environment, must also not be overlooked. Among the cultured classes of -our Fatherland, people are gradually learning to form sound opinions -about these matters. Among the working classes, on the other hand, -especially among those engaged in factory labour, the heedless -gratification of the sexual impulse is responsible for untold misery.” -_Hegar’s_ advice may be summarized as follows: If the marriage takes -place after the attainment of complete maturity, in the wife at twenty -and in the husband at twenty-five, and if procreation is discontinued in -the wife at forty and in the husband at forty-five to fifty, if between -successive deliveries the intervals necessary for the wife’s restoration -to health are maintained, if illness and states of debility are taken -into account, if sickly, hereditarily-tainted individuals are forbidden -to marry—the excessive increase in population, as far as Germany is -concerned, will cease to give cause for anxiety. The regulation of -reproduction will, however, still be incomplete, unless we enforce a -selection too rigorous for our present views. Moderation and continence -must aid as far as may be necessary in preventing an undue increase in -population. _Hegar_ does not fail to point out the evil effects of an -excessive limitation of the family. In a marriage when one child only is -born, this child is the object of unceasing anxiety and attention, and -real or imaginary dangers assume an excessive importance in the morbidly -excited imagination of the parents. Hence we find a continuous excess of -watchfulness and over-education in the case of the only child, to whom -independent thought and action are entirely unknown. Boys become -milksops, girls nervous and hysterical. In the two-children-system, -again, one or both of the children may die when the age of the parents -is already considerably advanced. Still in those districts of France in -which this system obtains the population is well-to-do, and an -exceptionally large proportion of the males are fit for military -service. The use of various measures for the prevention of conception is -considered by _Hegar_ to be harmful, at any rate in the case of young -women; this practice gives rise to anæmic conditions, and to nervous -weakness and irritability, seldom, however, to more serious disorders, -as indeed is apparent from the fact that the mortality of married women -as compared with unmarried women is lower in France than in other -countries. - -_Gräfe_, with reference to the view that if for any reason conception -must be prevented, this should be done by abstinence from sexual -intercourse, remarks: “Doubtless an ideal demand, but one which even -those with exceptional strength of will are unlikely to satisfy. And the -worst of it is, that even a single indiscretion will often result in -impregnation. Moreover, it is distinctly contrary to natural conditions, -that a healthy married couple united by an intimate affection should -live together abstaining completely from sexual intercourse. The -question has already been much discussed, both in speech and writing, -and this will continue in the future, without altering the fact that the -physician will be asked, and will be compelled to give, advice regarding -the use of means of the prevention of pregnancy.” - -_Ribbing_ writes, “Although the sexual impulse is the product of a -powerful natural developmental force, still the temporary, and sometimes -even the permanent, control of this impulse is a moral civilizing force -of enormous importance.” This writer is opposed to the use of artificial -preventive measures; he considers them untrustworthy and dangerous to -health. Untrustworthy, for the reason that nature has endowed living -organisms with a strong impulse toward conjugation and has equipped with -very powerful forces the processes by which fertilization is effected. -Every physician is familiar with cases in which preventive measures have -proved ineffective. This fact is proved also by the statistics of -prostitution. Although prostitutes are fully instructed in the use of -preventive measures, which they almost universally employ, nevertheless -every year a smaller or larger number of prostitutes become pregnant. -These measures are dangerous to health, partly because of their -interference with natural functions, because many of them are clumsy and -ill adapted; and partly, again, because owing to their use the woman -fails to enjoy the natural periods of repose which are entailed by -pregnancy, parturition, and lactation. Noteworthy also are the psychical -considerations adduced by _Ribbing_ against the use of preventive -measures. The majority of well-bred women feel deeply wounded if they -believe themselves to be regarded merely as a means of enjoyment, not as -individuals, as persons with inalienable rights. For the man also there -is danger, for it is easy for him to acquire a dislike to the wife who, -even though on his own initiative, occupies herself with the technique -of the sexual life in a manner which he feels instinctively to be -opposed to the chastity and puremindedness demanded by every man from -his wife. _Ribbing_ therefore advises a certain measure of sexual -abstinence in married life. - -_Max Nordau_ also insists on the moral disadvantages of the wide -diffusion of the use of preventive measures. “If a race or nation has -reached this point in its downward career, the individuals of which it -is composed lose the capacity of loving in a healthy and natural manner. -The sense of the family disappears; the men will not marry, because they -find it inconvenient to burden themselves with the responsibility for -another human life, and to care for any other creature than themselves; -the women dread the pains and inconveniences of motherhood, and if they -marry, they endeavour, by the employment of the most immoral means, to -ensure barrenness. The reproductive instinct, of which reproduction has -ceased to be the aim, is in some annulled, whilst in others it -degenerates into the most peculiar and irrational perversities. The act -of sexual union, the most sublime function of the organism, is degraded -into a profligate act of lust; it is no longer undertaken in the -interest of the perpetuation of the species, but exclusively for the -pleasure of the individual, and without any relation to the needs of the -community.” - -_Alfred Russel Wallace_ has advocated sexual continence as a preventive -measure during the period of maximum vitality and strength; he advises -that the age of marriage of women should be considerably advanced, in -order to diminish their fertility. If woman’s average age at marriage -were 29, instead of 20 years, the fertility of marriages would be -reduced in the ratio of 8 : 5. - -The desired goal of artificial sterility will not, however, be reached -through the advocacy of moderation and continence. The numerous -additional measures employed for this purpose may be classified as -_physiological_ and _artificial_; the latter class may be further -subdivided into _mechanical_ and _operative_. - -By physiological means for the prevention of conception, we understand -measures which aim at producing sterility by reducing the number of acts -of intercourse and by restricting these acts to certain defined periods -of time. The physiological preventive measures, apart from the higher -ethical value they possess in comparison with artificial measures, have -the advantage that they may be regarded as harmless to the general -health of the woman and to the integrity of her reproductive organs in -particular; they have, however, this very serious disadvantage, that the -results of their use are very uncertain, so that they offer no more than -a probability, and often a very moderate probability that conception -will be prevented. - -As a physiological measure for the attainment of facultative sterility -“without breaking any moral law,” _Capellmann_ advised abstinence from -coitus during a period of fourteen days after menstruation and three to -four days before the commencement of the flow. Without laying too much -stress on the fact that by following this recommendation the period -during which the intercourse is permissible would be extremely -restricted, it is necessary to point out that, whilst in this way the -occurrence of conception may be rendered less probable, its prevention -is by no means guaranteed, for it is an established fact that a woman -may be impregnated by intercourse on any single day of the -intermenstrual interval. _Capellmann’s_ advice, embodying, as he -expresses it, the “only morally permissible” means for the prevention of -conception, was not original, for the same recommendation was given at -an earlier date by _Raciborski_, who, however, regarded the measure as -very uncertain. _Capellmann_ is of opinion that it is sufficiently -trustworthy for practical purposes. - -_Bebel_, who is a declared opponent of Malthusianism, none the less lays -down positive rules for the diminution of procreative capacity and of -fertility by regulation of the diet. He refers to the example of the -bees, which, by a change of nutriment, can produce a new queen-bee at -will. “Thus the bees,” he says, “are in advance of human beings in their -knowledge of sexual development. Presumably they have not been -compelled, for a couple of thousand years, to listen to sermons -informing them that to occupy themselves about sexual matters is -‘improper’ and ‘immoral.’ There is no doubt whatever that the mode of -nutrition has an influence on the composition of the male semen, and -also on the susceptibility to fertilization of the female ovum; hence -the increase in population must to a very important extent depend on the -mode of nutrition. If this could be definitely established, we should -have, in the supply of nutriment, a means of regulating the population. -As an example of the effect, in this connection, of the mode of -nutrition in the human species, it is reported that in consequence of -the fatty and nutritious diet of the old Bavarian peasants, who lived -chiefly on very rich puddings, the marriages of the well-to-do peasants -were frequently childless. However, it must not be forgotten that -pre-conjugal intercourse, which was customary in that part of the world, -and was somewhat promiscuous in character, may have contributed to cause -this sterility.” Finally, _Bebel_ points out that the woman of the -future “will be unwilling to bear a large number of children. She will -wish to enjoy a measure of personal freedom and independence, and will -not consent to pass half or three-quarters of the best years of her life -either pregnant, or with a child at her breast. From this it will result -that the population will be regulated, without unwholesome sexual -abstinence, and without the employment of unpleasant preventive -measures.” However, _Bebel_ gives us no details as to the precise manner -in which this regulation is to be effected. - -_Tolstoi_, in his widely celebrated book “The Kreuzer Sonata,” condemns -absolutely the gratification of the sexual impulse. He demands the -recognition of the fact that “sexual congress, in which a man either -avoids the natural consequences—the birth of children,—or else throws -the whole burden of these consequences on the woman, is opposed to the -simplest demands of morality, is in fact utterly base.” To render -possible the sexual abstinence he regards as morally necessary, men must -not only endeavour to live in a natural way, but they must consume no -alcohol, eat with great moderation, abstain from meat, and not be afraid -of hard work. _Tolstoi_ even demands that men and women shall be so -brought up “that both before and after marriage they may regard love, -and the sensual passion associated therewith, not as they do at present, -as a sublime and poetical state, but as a bestial condition degrading to -humanity.” _Tolstoi_ is, however, utterly opposed to the use of -preventive measures: “first, because they liberate men from the cares -and sorrows entailed by having children, which must be regarded as the -penance to be paid for sensual love; and, secondly, because their use is -closely allied to the crime most repugnant to the human conscience, the -crime of murder.” Chastity is no less a duty after marriage than before; -after marriage man and wife must “continue to pray to be delivered from -temptation, and must endeavour to replace sensual love by the pure -relationship of brother and sister.” - -_Eulenburg_ regards the modern diffusion and the continuous increase in -the use of preventive measures as signs of decadence; _Löwenfeld_, on -the other hand, regarding the social conditions of the present day as -the principal source of the use of preventive measures, sees therein no -moral decay, but on the contrary rather a rise in the moral standard of -life. - -Another physiological means of prevention is to be found in avoiding -cohabitation in that season or month in which, judging by the woman’s -previous deliveries, she would appear to have been peculiarly -susceptible to impregnation. _Cohnstein_ maintained that in woman, as in -the lower animals, the capacity for conception was associated with a -particular season of the year, that there was, in fact, an individual -time of predilection for impregnation. The assumption that there is such -a time of predilection is, however, traversed by the fact, familiar to -all who have recorded the birthdays of children in large families, that -these occur in the most diverse months of the year. It has, indeed, been -statistically proved that certain months and seasons are especially -favourable to conception, that a maximum of conceptions occurs in the -spring, and a second much smaller maximum in the winter; but these -variations in the number of conceptions depend mainly on social factors, -as, for instance, upon the customary season for marriage, opportunity -for intercourse between the sexes, common labours in the house or in the -open, etc. This alleged time of predilection for conception cannot, -therefore, seriously be considered in the discussion of measures for the -prevention of pregnancy. - -As a physiological means for preventing conception, passivity of the -woman during sexual intercourse has also been recommended. It is well -known that an active participation on the part of the woman in the -sexual act, by increasing her voluptuous sensations, gives rise to -certain reflex actions, viz., descent of the uterus, rounding of the os -uteri, induration of the portio vaginalis, and, finally, ejaculation of -the secretion of the cervical glands and of the glands of Bartholin; -these changes accelerate the entrance of the semen into the cavity of -the uterus, and increase the motility of the spermatozoa. Upon this fact -is based the assumption, that, in consequence of deficient sexual -excitement during intercourse, either spontaneous, or when the woman -intentionally remains “cold,” the reflex actions by which the upward -passage of the spermatozoa is favoured, fail to occur; there is a good -deal of evidence in favour of the truth of this view. _Riedel_ reports -regarding the women of the Island of Buru, that they often have sexual -intercourse with strange men, “but during sexual congress in such cases -they maintain a passive and indifferent state, for the purpose of -avoiding impregnation.” _Von Krafft-Ebing_ points out that prostitutes, -when having sexual intercourse with men to whom they are attached, -experience voluptuous excitement, whilst in intercourse with men to whom -they are indifferent they remain entirely passive. From this it would -appear that these uterine reflexes are under the dominion of the -conscious will; but sufficient dependence cannot be placed on this fact -in all circumstances for it to be possible to employ such voluntary -control as a trustworthy means of prevention. Allied to this is -previously-mentioned Chinese practice of Kong-fou, a kind of hypnosis, -in which during sexual intercourse the thoughts are concentrated on some -other matter, and thereby conception is supposed to be prevented. - -Artificial protraction of the period of lactation is an old and -well-known method, practised by many savage peoples, for the prevention -of fertilization. As a general rule, as long as lactation continues, -amenorrhœa persists, and sexual intercourse remains unfruitful. But this -rule also is not universally valid. - -Artificial means for the attainment of facultative sterility are those -by which the attempt is made to prevent pregnancy by some mechanical -hindrance to the contact of the semen with the ovum, since without this -contact conception cannot possibly occur. - -The oldest of these means is that described in the book of Genesis (ch. -xxxviii, verses 9, 10), congressus interruptus, where, however, the -practice was punished by death, “And Onan knew that the seed should not -be his; and it came to pass, when he went in unto his brother’s wife, -that he spilled it on the ground, lest that he should give seed to his -brother. And the thing which he did displeased the Lord, wherefore he -slew him.” This mode of preventing pregnancy, in which the membrum -virile is completely withdrawn from the vagina before the ejaculation of -the semen takes place, is at the present time a very widely diffused -practice; and, when properly carried out, it is thoroughly efficacious -in the production of sterility. _Thompson_ relates that this practice is -employed by the Massai youths, who are allowed free intercourse with the -girls, but if a girl becomes pregnant she is put to death. - -The prolonged practice of coitus interruptus leads in my experience—in -addition to the injury to the nervous system as a whole in consequence -of the intense hyperæmia of the uterus and the uterine annexa, -unrelieved by the occurrence of the orgasm—to a condition of stasis in -the female reproductive organs; and this ultimately passes on into -chronic metritis (with relaxation of the uterus, retroflexion or -anteflexion, catarrhal disease of the mucous membrane, erosions, and -follicular ulceration of the portio vaginalis), oöphoritis and -perimetritis. As a result of certain remarkable observations, I must -even regard it as not improbable, although actual proof is still -lacking, that the recent striking increase in the frequency of -neoplasmata of the female reproductive organs is causally dependent on -the ever-increasing employment in all circles of society of means for -the prevention of pregnancy. - -The evil effects of coitus interruptus for a woman are dependent on the -fact that the woman fails to obtain complete sexual gratification, and -that this has an important influence upon her entire organism. Owing to -the failure of ejaculation to occur, the blood, which during the stage -of sexual excitement has accumulated in the erectile structures and -cavernous spaces of the genital passage, does not, as in normal -conditions, flow rapidly away; but the congestion persists for an -indefinite period, and is said by _von Krafft-Ebing_ to give rise to -functional disorders, and also to serious tissue changes. The functional -disorders take the form of hyperæmia of the pelvic organs, and probably -also of the lumbar portion of the spinal cord (dull pain in the sacral -region, a sensation of pain and dragging in the pelvis and in the lower -extremities, lassitude); these symptoms often continue for several hours -after intercourse. If this ungratifying coitus is frequently repeated, -in a voluptuous woman, disorders of the reproductive organs ensue; and -even more frequently, nervous disorders, in the form of neurasthenia -sexualis. This author considers that, more especially in women, coitus -interruptus, and unphysiological modes of sexual intercourse in general, -are extremely potent causes of sexual neurasthenia—as potent as -masturbation. - -_Beard_, in his work on sexual neurasthenia, maintains that the sudden -interruption of coitus (and also the use of condoms and similar -appliances) is not only far more deleterious than unduly frequent normal -intercourse; but he points out that it is necessary also to take into -account the fact that (inasmuch as, owing to the unnatural mode of -sexual intercourse, the possibility of fertilization is almost -completely prevented) sexual intercourse is apt, in such cases, to be -indulged in far more frequently, and often to gross excess. More -particularly in such circumstances are evil effects on the nervous -system likely to ensue, since we have a combination of excessively -prolonged and frequent sexual intercourse, and of interference with -complete sexual gratification. - -_Mantegazza_ believes that organic diseases of the spinal cord may -actually result from congressus interruptus. - -_Hirt_ considers that even when marital intercourse is carefully -regulated in respect of frequency, congressus interruptus may lead to -neurasthenic manifestations. - -_Von Hösslin_ believes it to be indisputable that preventive methods of -sexual intercourse may cause nervous troubles, and more particularly -neurasthenic disorders, manifesting themselves chiefly in the sphere of -the reproductive organs. - -_Eulenburg_ also declares that coitus interruptus is already a frequent -cause of sexual neurasthenia in women, and that its evil influence in -this respect is becoming more and more frequently manifest. He publishes -two typical cases, in which, from this cause, in the one case, -functional neuropathy, and in the other, local disorder of the -reproductive organs, ensued. - -_Freud_ describes an “anxiety-neurosis,” which is due to incomplete -gratification of the woman during sexual intercourse. Coitus interruptus -is almost invariably harmful to the man; to the woman it is harmful if -the man thinks only of himself, and interrupts the coitus as soon as -ejaculation is imminent, without concerning himself about the woman’s -state of sexual excitement. If, on the other hand, the man waits until -the woman’s sexual gratification is complete, the significance of such -an interrupted coitus as far as the woman is concerned is that of normal -intercourse. - -Isolated authorities, as for instance _Stille_ and _Thompson_, have -contested the alleged evil consequences of preventive methods of sexual -intercourse. “It is habitual excess,” says _Fürbringer_, “which does the -mischief, not the unnatural character of the isolated act.” _Löwenfeld_, -who considers the opposition of medical men to “Malthusianism” not -wholly justified, and believes that the dangers to health “which occur -in isolated cases” are not very serious, maintains none the less that -the medical man must advise his patients not to practise coitus -interruptus. The mode in which conception is prevented is not, he -thinks, a matter of indifference to the woman. The use of occlusive -pessaries and similar appliances does not in any way interfere with the -normal development of sexual gratification and cannot, therefore, have -any direct influence in the production of nervous disturbances. A -forgotten occlusive pessary, however, has in many cases caused local -disorder in the vagina. When the man is fully potent the use of condoms -can do no harm to the woman, since the only effect of the condom (in a -very excitable woman) is to render the development of the orgasm a -little more difficult, but not to prevent it. Congressus interruptus -itself is, according to _Löwenfeld_, harmful to the woman only when, -owing to deficient potency in the male or to deficient excitability in -the female, the interruption takes place before the occurrence of the -orgasm. - -_Valenta_ declared that coitus interruptus was one of the chief causes -of chronic metritis. _Elischer_ saw perimetritis result from this -practice; _Gräfe_ enumerates, as consequences of frequently repeated -coitus interruptus, chronic hyperæmia of the uterus and oöphoritis; -_Goodell_ observed elongation of the cervix uteri; _Mensinga_, -infarction of the uterus, œdema of the portio vaginalis, ulceration of -the cervix, hysterical paroxysms, convulsions, cephalalgias, -cardialgias, etc. _Lier_ reports a case in which, after three years’ -continued practice of coitus interruptus, the menopause set in, with -atrophy of the uterus; _Ascher_, in a similar case, saw chronic metritis -ensue. According to _Kleinwächter_, coitus interruptus is harmful to the -woman to an extent by no means trifling, whereas the man, in whom -ejaculation occurs, suffers comparatively little. _Fehling_ believes -that when coitus interruptus is practised only a small proportion of -women experience sexual excitement. _Neugebauer_ states that among the -very numerous cases of uterine carcinoma he has treated, the majority of -the patients admitted having practised coitus interruptus. _Pigeolot_ -makes a similar statement. - -It must, however, be admitted that a certain number of medical men -absolutely deny the dangers of coitus interruptus, whilst others -consider them altogether trifling. Just as the trend of modern opinion -is to believe that in normal men and women the dangers of masturbation -are far less serious than was formerly maintained, so also many are now -found to maintain that coitus interruptus is harmful only to those with -hereditary neuropathic predisposition. Still more unwilling are many to -admit that other preventive methods do women any harm. Thus _Wille_ -maintains that the continued fear of pregnancy will in most instances do -more injury to the feminine nervous system than all the preventive -measures in the world. To the nervously weak woman a trustworthy -preventive of pregnancy is therefore often necessary and most helpful. - -An artificial method for the prevention of the ejaculation of semen was -communicated to me by a celebrated anatomist. It is practised in -Transylvania and in France. During intercourse the woman, just before -the male ejaculation begins, presses forcibly with her finger on the -base of the erect penis just in front of the prostate; the urethra is -occluded by this digital compression, the semen regurgitates into the -bladder and is subsequently evacuated with the urine. - -This practice may be compared with the mechanical expulsion of the semen -from the female genital passage immediately after coitus. _Tairi_ -reports that women of the poorer classes in Italy sit upright in bed -immediately after intercourse, and by coughing, in conjunction with -pressure on the abdomen, effect the expulsion of the semen. _Morton_ -informs us that the native women of Northern Australia, when they have -had intercourse with a white man and wish to avoid impregnation, -likewise deliberately effect the outflow of the semen _post actum_. The -woman squats upright, with the legs widely separated, and by a sinuous -movement of the perineum and a simultaneous powerful bearing-down -pressure she expels the semen on to the ground. - -Another way in which the attempt is made to avoid impregnation is by the -use of vaginal injections; a fluid lethal to the spermatozoa being used -for this purpose immediately after coitus. Douches of cold water, ½ to -1% solution of copper sulphate, 1% solution of alum, ¼% solution of -sulphate of quinine, are the fluids most commonly employed; but all -these are quite untrustworthy, for it is impossible to be sure that all -the spermatozoa will be acted on and destroyed. _Allbutt_, who as -medical secretary of the Malthusian League in London has unquestionably -had a very wide experience, agrees with _Haussmann_ in denying that the -widely advocated cold water douche can be relied on for the prevention -of pregnancy. The sudden driving of the blood out of the vessels of the -genital passage at the very moment when they are intensely congested, -which must inevitably result from a cold douche, is, moreover, likely to -give rise to metritis, perimetritis and oöphoritis. - -More trustworthy are the various apparatus, the aim of which is to -prevent the contact of the semen with the ova by the interposition of an -artificial wall. Although even as regards these we must bear in mind the -observation of _Lott_, who found that spermatozoa were capable of -passing through the intact membrane in favourable regions in as short a -time as ten minutes. The commonest of all these apparatus is the article -known as a condom, which envelops the penis with a membrane, variously -consisting of isinglass, the lamb’s cæcum, or caoutchouc. Condoms, if -made of suitable material, and if carefully used, are the most -trustworthy of all preventives. Moreover, the injury caused by their use -to the woman’s health is trifling, for they do no more than diminish to -a degree the intensity of the stimulus, thus necessitating a somewhat -longer duration of its action in order to effect the most intense -orgasm, and thus to induce the natural physiological termination of the -nervous excitement. In fact, though somewhat delayed, the normal -reaction takes place in the reproductive organs. The evil effect of the -use of the condom bears no comparison with that of coitus interruptus. -There is, however, some justification for _Ricord’s_ well-known epigram, -that the condom is “a spider’s web for the prevention of danger, and a -cuirass for the prevention of voluptuous pleasure.” - -When the gynecologist, from well-considered reasons based on some -pathological condition affecting his patient, feels justified in -recommending the prevention of pregnancy, it is my opinion that the most -trustworthy and least harmful measure at present available, and one -preferable to all other mechanical apparatus, is a carefully selected -and well-made condom. - -The condom was already in use in Italy in the middle of the sixteenth -century, in the form of a linen investment adapted to the shape of the -penis; subsequently, according to _Grünfeld_, condoms were made from the -cæcum of the lamb; while later still, isinglass was employed for this -purpose. According to _Hans Ferdy_, the cæcal condom is made from the -connective-tissue layer of the cæcum of the sheep or of the calf (a very -young animal); to a less extent, also, the cæca of the goat, the stag, -and the roe-deer, are employed for this purpose. The different varieties -of cæcal condom are distinguished chiefly by variations in the thickness -and the softness of the membrane. _Ferdy_ states that the four best -kinds are made from the cæcum of the sheep; these have a thickness: I. -0.008 to 0.01 mm. (0.00032 to 0.0004 in.); II. 0.012 to 0.015 mm. -(0.00048 to 0.0006 in.); III. 0.017 to 0.023 mm. (0.00068 to 0.00092 -in.); IV. 0.025 to 0.03 mm. (0.001 to 0.0012 in.) Next in quality come -four varieties obtained from the calf, varying in thickness from 0.015 -to 0.04 mm. (0.006 to 0.016 in.) Finally we have three varieties -obtained from the three other animals already mentioned. Thus there are -in all eleven varieties of cæcal condom, and in so far as during the -process of manufacture the membrane has remained free from any injury, -they are sold as “undamaged.” But if in the process of preparation a -hole has been made in the membrane, this aperture is closed by sticking -on a small patch of membrane. Such patched condoms are naturally quite -useless, since the patch is readily loosened by the moisture to which it -is exposed, and falls off, when the protective and preventive functions -are entirely destroyed; nevertheless, such defective condoms are often -sold. Rubber condoms, continues _Ferdy_, are prepared from a caoutchouc -membrane 0.03 to 0.1 mm. (0.0012 to 0.04 in.) in thickness; but these, -he says, are not hygienic, for “such a rubber membrane, which both in -the man and in the woman completely covers the erogenic zones normally -stimulated in coitus, deadens the necessary stimulation, so that the -sensations during coitus are seriously dulled by the interposition of -this foreign body; by nervously predisposed individuals, this kind of -condom cannot be used regularly for a long period, without rendering -probable the onset of serious functional disturbances of the genital -apparatus.” This opinion appears to me to be unfounded. We must also -mention the “glans-condom,” made of rubber membrane, which serves to -cover the glans penis only during coitus, and to retain the seminal -secretion; its grave defect, however, consists in this, that in the act -of withdrawing the penis, the condom is very likely to be peeled off, -when the semen will, after all, pass into the vagina. - -Passing now to the consideration of apparatus which are inserted into -the woman’s genital canal, in order to prevent impregnation, we may -first mention sponges, which have long been in use; after thorough -cleaning, these may be rendered aseptic by immersion in carbolic acid or -lysol solution. These sponges should be very soft; they are cut into -balls of 3 to 7 cm. (1.2 to 2.8 in.) in diameter; before coitus they are -introduced into the vagina and after coitus they are withdrawn by means -of the tape which should always be attached to them. This method is, -however, quite untrustworthy, for the sponge offers no impermeable wall -to the passage of the spermatozoa, and on its withdrawal, some of the -semen may very likely be left in the vagina. The same objection must be -made to the similarly constructed anti-conceptional cotton-wool plugs; -sometimes these are moistened with a fluid intended to destroy the -spermatozoa. Recently _Gunzburg_ has recommended the introduction into -the vagina of a cotton-wool plug moistened with a three per cent. -solution of carbolic acid in glycerine; he considers this method safe, -because the spermatozoa are immediately destroyed on contact with the -weakest carbolic acid solutions. - -To destroy the vitality of the spermatozoa, vaginal suppositories made -of cocoa-butter medicated with hydrochlorate of quinine have also been -employed; these, the so-called “security-pessaries” or “security-ovals,” -are inserted into the vagina half an hour before coitus; the -cocoa-butter is melted by the body heat, and the vaginal mucous membrane -and the os uteri are covered with the medicated fatty material, by which -the spermatozoa are (or should be) destroyed. This method is one easy to -employ, but it is extremely uncertain. - -Even more uncertain are the insufflators charged with various powders -(boric acid, citric acid, thymol, etc.); the tube of the insufflator -having been passed into the vagina, the powder is blown over the vaginal -mucous membrane and the portio vaginalis. This procedure may sometimes -be followed by symptoms of intoxication; and in any case, owing to the -desiccative effect which the powder has upon the vaginal mucous -membrane, it exercises a disturbing influence on coitus. - -_Kleinwächter_, in cases in which pregnancy must be prevented in the -interest of a woman’s health or her life, has recommended the -introduction into the vagina of globules of which the active constituent -is boric acid. - -A rationally constructed apparatus, and one which in general appears to -fulfil its purpose very well, is the _pessarium occlusivum_ constructed -by _Mensinga_, and now manufactured in various modifications. The -occlusive pessary is a hollowed hemisphere of rubber membrane, around -the margin of which passes a steel ring. The size of the pessary must be -adapted to the individual case. It is introduced into the vagina in such -a way that the outer surface of the hemisphere occupies the vaginal -fornix, while the steel ring touches the vaginal wall all round; by this -means, the vaginal fornices and the os uteri are completely shut off -from the lower part of the vagina. The disadvantage of this instrument -is, that either the woman must wear it continuously, which involves -numerous inconveniences, or else it must be introduced by the skilled -hand immediately before coitus—and not every woman becomes competent to -adjust it herself, even after careful explanation, since the pessary -must be accurately placed with the anterior margin of the ring -immediately behind the pubic symphysis, and the posterior margin of the -ring behind the os uteri. Moreover, the instrument may easily be -displaced by violent movements, coughing, sneezing, etc. In any case, -the pessary must be carefully selected to correspond within the -configuration of the vagina, as otherwise it may exercise a deleterious -pressure upon the vaginal walls, and may give rise to other bad -consequences, such as are apt to attend the wearing of any pessary for a -prolonged period—excoriations, erosions, fluor albus, etc. In the -majority of cases it will be found that the woman herself is not -competent to introduce the occlusive pessary. The skilled hand is needed -for the proper adjustment of the surrounding ring. - -_Gall’s balloon-occlusive-pessary_ consists of a soft elastic rubber -disc, surrounded by a thin-walled rubber ring, the interior of which is -connected by means of a fine tube with an inflating rubber ball. The -woman can herself insert the instrument and inflate the ring; it -occludes the vaginal passage without exercising any deleterious -pressure. - -Other pessaries consist of hollow rubber balls containing some fluid -lethal to the spermatozoa, which can be discharged into the vagina on -opening a valve by pulling a string. These, however, are as insecure as -the above-mentioned vaginal discs and the insufflators. The -duplex-occlusive-pessary has the form of a truncated cone with double -walls; in its base are a number of rounded apertures, and a single -elongated aperture; through this latter a boric acid tablet is -introduced into the cavity of the cone. By means of the cone the passage -to the uterus is mechanically occluded; the semen passes through the -apertures in the base into the interior of the instrument, and as the -boric acid tablet is dissolved by the moisture to which it is now -exposed, the vitality of the spermatozoa is destroyed. The management of -this apparatus is, however, not easily effected by the woman herself. -The “Matrisalus-Pessary” differs but little from other occlusive -pessaries. The latest instrument for the prevention of impregnation is -known as the “Venus-Apparatus;” it consists of a syringe with two balls, -a large and a small one, at either end of a rubber tube; by pressure on -the larger ball, and subsequent relaxation of pressure, the smaller ball -is filled with a fluid for the destruction of the spermatozoa (prepared -by the solution of one of the “Venus-powders” sold with the instrument); -when filled, this smaller ball is introduced into the vagina and remains -connected by means of the tube with the larger ball, which lies between -the woman’s thighs. At the moment of the male ejaculation the woman -presses on this ball, and by this means the fluid filling the smaller -ball is expressed into her vagina. - -All these mechanical occlusive pessaries are open to the objection that -they are apt to give rise to irritative conditions of the genital -organs, causing offensive discharges, pruritus, etc. (Recently in order -to diminish this drawback, the pessary has been constructed of -vulcanized cambric, instead of rubber, and appears then to have a less -irritating effect.) Still worse is the injury to the uterus and to the -cervical mucous membrane caused by certain intra-uterine instruments -which have been recommended for the prevention of conception. The latest -of these is an “obturator,” consisting of a silver or silver-gilt tube, -which is passed through the os uteri into the interior of the uterus, -and left _in situ_. It is claimed for it that “it allows the menstrual -discharge to flow freely away, but renders the entrance of the -spermatozoa extremely difficult.” _Biermer_ reports five cases in which -serious injury to health followed the use of one of these obturators. In -one of these cases in which there were very severe pains and a discharge -from the uterus, _Biermer_ removed from the interior of the uterus a -broken wing of the obturator; the patient died, however, and the autopsy -disclosed perforation of the uterus. In another of the cases the -apparatus was also broken. - -Less dangerous is the recently invented tampon-speculum. This is passed -into the vagina by the woman herself, in order that through it she may, -by means of a special introducer, insert a tablet of boric acid, -hydrochlorate of quinine, citric acid, or some other substance lethal to -the spermatozoa. Without some such instrument, the introduction of these -“ovals” to the proper place is often found difficult by women. - -A very remarkable means of bringing about artificial sterility, one -resembling the operative procedures sometimes adopted in western -countries, is employed in various parts of the world, and notably in the -East Indies and in the Sunda Islands, namely, the induction of an -artificial malposition of the uterus, more especially of anteversion. -Thus, _van der Burg_ writes from the Dutch Indies: “In the girls the -sexual impulse develops very early, and is gratified without fear of -consequences, when the services of certain skilled elderly women have -been requisitioned.” These women appear, in fact, to understand, by -means of pressure, rubbing, and kneading, through the abdominal walls -(not by the vaginal route), how to induce anteversion or retroversion of -the uterus, to such an extent as to prevent the occurrence of -conception. It is said that the only inconvenient consequences of this -procedure are trifling pains in the lumbo-sacral and inguinal regions, -and some trouble in passing water during the first few days after the -manipulations have been effected. Later, when a girl who has been -treated in this way wishes to marry and become a mother, by a reversal -of the manipulations the uterus is restored to its natural position. It -is said that these skilled women have been called in by European women -in the Dutch Indies, who did not wish to have many children; but it -appears that in a woman who has once given birth to a child, the result -of the manipulations is less to be depended upon, than in the case of a -virgin. - -A means of ensuring artificial sterility, which in all civilized states -is punishable as a criminal offence, and which is nevertheless very -frequently practised, is the artificial induction of abortion. -Especially in North America it would appear that there exist regular -professional abortionists. In this connection, _Thomas_, the well-known -American gynecologist, writes as follows: “Statistics showing the -frequency of criminal abortion are not, and probably never will be, -available, for this crime cannot be adequately controlled by human -society, and commonly eludes legal punishment. It seems a hard saying, -but it is a true one, to assert, that the law pursues unremittingly him -who has killed his fellow-man, while it leaves immune him who has killed -the embryo in the mother’s womb. On my table there lies at this moment -one of the most widely circulated, most respected, and most carefully -edited daily newspapers of New York—a paper which finds its way into the -best circles of society, and also into the hands of girls and women -throughout the country. In its columns I find fifteen advertisements -which emanate beyond all question from professional abortionists—from -men and women who gain their livelihood by child-murder.” - -_O. Reyher_ remarks also that in American newspapers advertisements such -as the following are of every-day occurrence: “Pills for the regulation -of the periods. Ladies expecting to be confined are warned not to use -them on any account, for if they do so abortion will infallibly ensue.” - -_Emmet_, in his “Textbook of Gynecology” also complains of the terrible -frequency of criminal abortion, so that “every day we see more -unhappiness and misery result from the misuse of conjugal relationships -than we see in an entire month as a result of births which take place in -a natural manner.” - -_Pomeroy_ also says that “The prevention of conception and the -destruction of the unborn life are pre-eminently American sins;” and he -adds that if no bounds are set to their spread, “they must, sooner or -later, lead to universal misfortune. In the course of our practices we -come into contact with women who would hesitate to kill a fly, but who -think nothing of having destroyed half a dozen or more of their own -unborn children.” - -The American Medical Congress offered a prize for a brief and readable -essay, suitable for diffusion among women, showing the criminality and -the physical harmfulness of artificial abortion. The prize was awarded -to _Storer’s_ essay, entitled “Why Not?” - -Among the ancient Greeks, the fear of over-population led to the -practice of homosexual intercourse. The states of ancient Greece were in -most cases of a very small area, so that a very moderate increase in -population would render the means of subsistence insufficient. Hence -intercourse with women was avoided, and the sexual impulse was gratified -in unnatural ways. Inspired by this fear of over-population, Aristotle -urged upon men that they avoid women, and should indulge in the love of -men and boys, and at an earlier date, Socrates had celebrated the love -of boys as a mark of higher culture. The most notable men of classical -Greece practised homosexual intercourse; authors and poets celebrated -the love of boys. Stimulated by their example, Sappho of Lesbos became -the inspired poetess of the love of women for members of their own sex -(Lesbian love). - -Among the Romans it was rather satiety in consequence of sexual excesses -which led in that country to the diffusion of the Greek love of boys; -the consequent childlessness diminished to such an extent the numbers of -the Roman burghers and patricians, that Augustus, in the year 16 B. C., -enacted the Julian law, by which the procreation of children was -rewarded, whilst celibacy became a punishable offence. - -At the present day the fear of an excessively large number of children, -in relation to the property possessed by the parents and in regard to -nutritive possibilities, has led among whole classes, and even among -entire nations, to the adoption of preventive measures in sexual -intercourse; these measures have, in fact, been developed into a system, -which finds adherents among all strata of the population, but more -especially, as it is easy to understand, among certain well-to-do -sections of the community. In France this system has been adopted to -such an extent as to amount to a national calamity. - -In few countries of the civilized world, remarks _Bebel_, are marriages -so frequent, relatively to the population, as they are in France, whilst -in no country is the average number of children per marriage so small, -or the increase of population so slow. The French bourgeoisie long ago -adopted this system, and the peasantry and the artizan classes are -following their example. In many parts of Germany the same causes have -led to the same results. In France, in addition to the prevention of -pregnancy and the practice of artificial abortion, infanticide and the -exposure of children are also actually employed to keep down the -population. - -Operative measures for the production of artificial sterility have been -practised from very ancient times, and by civilized and savage peoples -alike. According to _Strabo_, the ancient Egyptians and Lydians were -acquainted with the art of removing the ovaries from girls and women. -The kings of Lydia, Andromytes and Gyges, had the women of their harems -castrated, _ut iis semper ætate et forma florentibus uteretur_. _Von -Micklucho-Mackay_ reports that in some parts of Australia the indigens -remove the ovaries of certain girls, in order to provide their young men -with hetairæ who cannot possibly become pregnant. _M. Gillirray_ saw at -Cape York a native deaf and dumb woman whose ovaries had been removed, -to prevent her procreating deaf and dumb infants. - -We cannot refrain from reference to the astounding proposal of _C. A. -Weinhold_, contained in his work upon the over-population of Central -Europe and its consequences to the countries concerned and to -civilization in general. He advises, “as a general and urgently required -measure, the widespread practice of a sort of infibulation, which is to -be undertaken at the age of fourteen and preserved until marriage, and -is to be performed in the case of all those individuals who can be -proved not to possess sufficient property for the upbringing of an -infant, if they should become pregnant as a result of extra-conjugal -intercourse. And in those who never attained a financial position in -which they might be able to bring up a family, the infibulated condition -should be allowed to persist throughout life!” - -This proposal is, in fact, no novelty, inasmuch as the bringing about of -an artificial adhesion of the labia with a view to the prevention of -conception—the operation of _infibulation_—is practised by many savage -peoples. According to the detailed account given by _Ploss-Bartels_, -this operation, in which the inner surfaces of the labia majora are -freshened, stitched together, and allowed to adhere, is practised by the -Bedschas, the Gallas, the Somalis, the inhabitants of Harrar, at -Massaua, etc. The purpose of this practice is to preserve the chastity -of the girls until marriage, when the reverse operative procedure is -undertaken. If the husband goes away on a journey, in many cases the -operation of infibulation is once more performed upon his wives. -Slave-dealers also make use of this operation so as to prevent their -slaves from becoming pregnant. It is reported, however, that the -operation does not invariably produce the desired effect. _Hartmann_ -informs us that in Nubia, in Senaar, and in part of Kordofan, the -præputium clitoridis or the entire clitoris is cut away, and the margins -of the nymphæ are then freshened and stitched together, so that the only -aperture left is one sufficiently large for the outflow of the urine. - -_Brehm_ states that the operation is performed by old women, who make -the necessary incisions with razors; shortly before marriage, the -bridegroom sends the girl’s relatives a model of his penis, carved in -wood, according to the size of which an aperture is made between the -adherent nymphæ; when the woman becomes pregnant, the incision is still -further enlarged. In the kingdom of Darfur, the labia majora as well as -the nymphæ are freshened and stitched together. In the Berber country, -_Werne_ became acquainted with a young widow whose husband had had her -submitted to the operation of infibulation no less than seven times. -Another somewhat less brutal method of performing infibulation is -described by _Ploss_, as being practised by many Eastern races; a ring -is fastened through the labia in such a way as to guard the introitus -vaginæ In Europe, during the Middle Ages, such and similar apparatus -(“girdles of chastity”) are said to have been employed for the -protection of the honour of an absent husband. - -Of gynecologists who have advised operative measures for the prevention -of pregnancy, in women in whom that condition involved serious dangers, -the first, as far as I know, was _Blundell_. As a result of experiments -made on rabbits, he suggested division of the Fallopian tubes as the -best way of attaining this end. Later, _Froriep_ and _Kocks_ also -endeavoured to induce artificial sterility in women by occlusion of the -Fallopian tubes. _Froriep’s_ idea was to bring about obliteration of the -lumen of the tubes by means of cauterization with nitrate of silver; -_Kocks_ constructed for the same purpose a galvano-caustic uterine -sound. But, in the first place, both the methods advocated are too -uncertain to be relied upon; and, in the second place, their application -is neither easy, nor devoid of serious risk. - -Much more effective, however, is the method recommended by _Kehrer_ for -the sterilization of women, namely, division of the Fallopian tubes by -the vaginal route. _Kehrer_ considers that the physician is justified in -preventing the occurrence of pregnancy in a number of morbid -conditions—incurable nervous, cardiac, pulmonary, gastric, and renal -disorders; various constitutional affections; and, finally, in cases of -pelvic deformity of such a degree that the delivery of a living child is -impossible except by means of Cæsarean section, but the patient does not -wish to be exposed to the risks of this operation. He believes, -moreover, that all the methods commonly recommended for the prevention -of pregnancy are untrustworthy. So powerful, however, is the sexual -impulse, that, as experience shows, the mere prohibition of sexual -intercourse, however earnestly made, invariably proves ineffectual. For -coitus interruptus to be effective, the interruption must occur at the -right moment; and this does not always take place. Cold water douches -after coitus are unhygienic; douches of warm water, medicated with -sublimate, alcohol, and other drugs lethal to the spermatozoa, are -indeed rationally conceived, but often fail of their effect, either -because they are deferred until too late, or else because they fail to -irrigate all parts of the vagina. Plugs of cotton wool, sponges, etc., -are not always introduced in such a way as effectually to occlude the -vaginal passage. A suitable and properly introduced occlusive pessary -is, indeed, a relatively trustworthy preventive apparatus, but if worn -continuously it is apt to become very foul. A thorough douching of the -genital passage with an antiseptic solution, performed by the skilled -hand, immediately after coitus, would doubtless destroy the spermatozoa -with the like certainty with which the same procedure destroys -micro-organisms when performed prior to a gynecological operation—but -when carried out by the layman, the value of the method is more than -doubtful. The operation, for a time actually fashionable, of extirpation -of the uterine annexa, certainly gives rise to sterility, but entails -the serious disadvantage that the consequent premature menopause is -attended by the same disturbances as the natural change of life. On the -other hand, section and ligature of the Fallopian tubes is considered by -_Kehrer_ to induce sterility without in any other way disturbing the -functions of the female reproductive organs. By means of anterior -colpotomy we obtain a suitable route for the ligature and section of -both tubes at the isthmi. When carried out with the proper antiseptic -precautions the operation is almost entirely free from risk; and when -the organs are healthy the closure of both the upper and the lower -segments of the tubes is effected, and no retention of secretions need -be feared as a result of the operation. - -With regard to the indications for the performance of this operation, -_Kehrer_ insists that it should be undertaken only in cases of serious -disease, and when the pros and cons have been conscientiously weighed. A -consultation is also indispensable. Moreover, it is essential that -husband and wife should both fully understand the nature of the proposed -operation, and should form an unbiassed judgment regarding its -advisability. To avoid any possibility of subsequent reproaches, -_Kehrer_ advises that a written report should be drawn up, giving the -reasons for undertaking the sterilization, and that this should be -subscribed by the physicians in consultation, by the patient herself, -and by her husband. - -_Arndt_ considers that in cases in which there already exists serious -constitutional disease, the performance of this operation may lead to -fever, severe hæmorrhage, injury to adjacent organs, and even death. He -holds, therefore, that in such cases the physician should advise the use -of some of the more ordinary methods of preventing conception (if simple -abstinence from intercourse cannot be practised). Only in women with -pelvic contraction of the second or third degree, in whom previous -children have been still-born, or subjected to craniotomy, is operative -sterilization by _Kehrer’s_ method justifiable. But in preference to -anterior colpotomy, as recommended by _Kehrer_, he prefers the -longitudinal incision in the posterior vaginal fornix advised by -_Boileux_. If the uterus is drawn down firmly, and the portio vaginalis -then pushed forward against the pubic symphysis, it is easy, at any rate -with the assistance of a little abdominal pressure, to draw part of the -Fallopian tubes into the vaginal incision. - -Recently _Pincus_ has recommended the cauterization of the uterine -cavity with superheated steam (_atmocausis_, _castratio uterina_). He -advises it only in women who are incurably ill (tuberculosis, morbus -Brightii, hæmophilia), so that pregnancy and parturition would involve -almost certain death. - -_Kossmann_ considers that when pregnancy and parturition will endanger a -woman’s health and life, it is the physician’s duty to acquaint both -husband and wife with this fact; but having done so his duty is fully -discharged. “If, after being warned, the married pair choose to indulge -in sexual intercourse, they have knowingly and voluntarily run into -danger, and for this the physician is in no way responsible.” - -As indications for facultative sterility _Levy_ enumerates tubercular -disease of the lungs, mental disorders, severe organic or functional -diseases of the central nervous system, active syphilis (in certain -circumstances), pernicious anæmia, hæmophilia, diabetes mellitus, severe -heart disease, chronic disease of the kidneys or liver, certain pelvic -deformities, and the tendency to habitual abortion. - -I have myself before now stated my opinion that it is the duty of the -physician, in the case of a married woman suffering from heart disease, -with due regard to the danger which pregnancy will entail upon her, to -give needful advice in the matter of the prevention of conception. In -women affected with valvular heart disease, and in whom there are -serious disturbances of compensation, conception is absolutely to be -avoided; also in conditions of marked cardiac degeneration, and when -there are distinct symptoms of insufficiency of the heart muscle. When, -on slight exertion, palpitation, increased frequency of the pulse, and -respiratory need (“air-hunger”), ensue; when there is extensive œdema of -the lower extremities which persists even after confinement to bed; when -the pulse readily becomes arhythmical both in respect of the strength -and the temporal succession of the beats; when the urine is scanty and -contains varying quantities of albumen; when there are frequent attacks -of heart-weakness, with a small irregular pulse, coldness of the -extremities, a cyanotic tint of complexion, nausea, dyspnœa, sense of -faintness, or actual syncope—in all such cases, whether dependent upon -valvular disease, on pathological changes in the arteries, or upon -disease of the myocardium, the occurrence of pregnancy is a true -disaster, giving rise in most cases to a grave aggravation of the heart -trouble and often enough costing the patient her life. I further regard -it as a sound medical axiom that in cases of cardiac disorder of a less -severe type than that just described the woman thus affected should not -have more than one or two children. This is the more necessary because -with each successive pregnancy the functional capacity of the diseased -heart decreases in geometrical progression and the danger to life -proportionately increases. But in such cases of heart disease the -prevention of pregnancy must never be effected by the interruption of -coitus by the man before ejaculation, for the reason that this procedure -gives rise to manifold reflex cardiac troubles, and especially to -paroxysms of tachycardia, with simultaneous diminution in vascular tone, -vasomotor disturbances, and states of mental depression—and these entail -exceptional dangers in women suffering from heart disease. - - - THE DETERMINATION OF SEX. - -The problem of the determination of sex in the human species is one -which has occupied natural philosophers from the very earliest times, -and has always greatly interested all classes of the population. - -The interest awakened by the subject depends principally on the fact -that female children have usually been less desired than male in all -periods of history and among almost all races. In the uppermost circles -of society the truth of this statement is manifested by the fact that -the birth of a prince is announced by a salute of 101 guns, that of a -princess by a salute of 35 guns only. - -It would serve no useful purpose to transcribe here the opinions, or -rather guesses, which were ventured on this topic in earlier days when -the very nature of the reproductive process was still entirely unknown, -and we shall merely mention that the curious will find various -references to the determination of sex in the works of _Hippocrates_, -_Aristotle_, _Plutarch_, _Soranus_, _Susruta_ and _Galen_. - -Broadly speaking, the earlier theories may be said to diverge in two -main directions, some holding that the sex of the infant was in some way -determined by the mode of intermixture of the male and the female -elements in the act of generation, and others maintaining that sex was -already inalterably predetermined at the time of intercourse either in -the male or in the female sexual elements. - -_Pari passu_ with the modern development of the theory of evolution, and -with the enormous increase in recent days in anatomical and -physiological knowledge, the theory of the determination of sex has been -very widely extended. The rival views may be briefly arranged in the -four following categories: - -I. That sex is already inalterably predetermined in the ovum, upon the -constitution of which it solely depends; there are therefore male and -female ova, and the process of fertilization exercises no influence -whatever upon the determination of sex. The alternative theory to the -above, that sex is determined solely by the constitution of the -fertilizing spermatozoon—_i. e._, that the spermatozoa, and not the ova, -are male and female, respectively—is one which in recent years has -tended more and more to disappear from the field. - -II. That sex is determined in the moment of fertilization by the -reciprocal interaction of male and female, of zoösperm and ovum. One -variant of this theory maintains that each reproductive element strives -for the reproduction of its own sex; that a struggle takes place and -that the victor in the contest stamps its own sex-likeness upon the -fertilized product. According to another view, however, sex is not -directly transmitted in this manner; it is supposed that the more -powerful the proper reproductive element (according to this theory the -ovum) the more strongly does it tend to determine the reproduction of a -stronger, _i. e._, a male organism; thus the greater potency of the -female element in the act of reproduction tends to favour the -determination of the male sex. - -III. That sex is not determined until after fertilization, during the -early stages of the development of the embryo; the determining causes -are supposed to be various factors capable of influencing the developing -organism during this period, and more particularly the nutritive -conditions of the mother. - -IV. That the determination of sex is not dependent solely upon the -action of any single one of the factors above enumerated, but arises as -a resultant effect of the operation on the germ of all three of these -acting in temporal succession. - -Modern physiology has endeavoured to solve this problem by statistical -investigations, by anatomical demonstration, and finally by experiment. - - - _I. Statistical Investigations._ - -Statistical data have been collected showing the ratios between male and -female births in the most varied conditions possible, and from these -data the attempt has been made to draw valid conclusions regarding the -causes of the determination of sex. Now in the first place it is above -all necessary to bear in mind that such statistical data cannot possibly -have any value unless they relate to very numerous instances, and even -then they are liable to be invalidated by various sources of fallacy. We -may with advantage quote in this connection the remarks of _Hensen_ in -his work on the “Physiology of Reproduction:” “Each individual instance -is rendered unique in kind by the interaction of certain incommensurable -elements; for instance the state of health of the individual organs in -their innumerable combinations, variations in the general health of the -parents, the frequency of coitus and the time at which it took place, -the desire of the parents to have a son and then no more children, their -social position—in these ways innumerable complications are introduced -into the problem, and the difficulty of drawing valid conclusions is -rendered almost insuperable, unless the number of instances dealt with -is enormously large.” - -One fact definitely established is that more boys are born than girls, -the proportion between the two, known as the sexual ratio, being -106 : 100. Statistics relating to the half of Europe (_Oesterlen_) and -dealing with 59,350,000 births, showed a ratio of 106.3 male to 100 -female births; in individual countries variations from this mean are -found to occur, but these are not very extensive, the highest ratio -being 107.2 : 100, and the lowest ratio 105.2 : 100. - -From the works of _Hofacker_ (“Ueber die Eigenschaften welche sich -bei Menschen und Tieren von den Eltern auf die Nachkommen -vererben”—Concerning the Qualities transmitted from Parents to -Offspring in Men and Animals—Tuebingen, 1828) and _Sadler_ (“Law of -Population,” London, 1830) conclusions have been drawn regarding the -effect of a variation in the age ratio of the parents on the -determination of sex. The deductions in question, known as -_Hofacker_ and _Sadler’s_ law, are as follows: - -1. If the husband is older than the wife more boys are born than girls. - -2. If husband and wife are the same age somewhat fewer boys are born -than girls. - -3. If the wife is older than the husband the excess of female births is -larger still. - -_Hofacker’s_ actual figures were the following: - - Father younger than mother 90.1 boys to 100 girls. - Father same age as mother 93.3 boys to 100 girls. - Father 4 to 6 years older than mother 108.8 boys to 100 girls. - Father 6 to 9 years older than mother 124.7 boys to 100 girls. - Father 9 to 12 years older than mother 143.7 boys to 100 girls. - -Sadler’s results were closely similar: - - Father younger than mother 86 boys to 100 girls. - Father same age as mother 94 boys to 100 girls. - Father 1 to 6 years older than mother 103 boys to 100 girls. - Father 6 to 11 years older than mother 126 boys to 100 girls. - Father 11 to 16 years older than mother 147 boys to 100 girls. - Father 16 years and more older than mother 163 boys to 100 girls. - -_Goehlert_ found that the offspring of marriages in which the husband -was younger than the wife were 71 boys and 86 girls; of marriages in -which husband and wife were of the same age, 263 boys and 282 girls; and -of marriages in which the husband was older than the wife, 2,017 boys -and 1,865 girls. - -_Wappaeus_, combining the data supplied by these three investigators, -_Hofacker_, _Sadler_ and _Goehlert_, obtained the following sexual -ratios for the entire 8,000 cases (_i. e._, the number of boys born to -each 100 girls born): When the husband was younger than the wife, 88.2; -when husband and wife were of the same age, 93.5; when the husband was -older than the wife, 113.0. - -It will be observed that the mean sexual ratio of these 8,000 cases is -109.6; whilst, as we saw above, when a sufficiently large number of -instances is taken, the sexual ratio always closely approximates to -106.3. From this it appears that the numbers dealt with by _Hofacker_, -_Sadler_ and _Goehlert_ in their investigations were too small for the -deduction of trustworthy averages. - -The same criticism is applicable to the observations of _Ahlfeld_, -_Breslau_ and _Noirot_, whose results conflict with those just given. -According to _Ahlfeld_, in the case of 1,376 births where the father was -at least 10 years older than the mother, the sexual ratio was only 98.2. -According to _Noirot’s_ data, in cases in which the father was older -than the mother, this ratio was 99.7. - -_Oesterlen_ gives the following brief summary of the researches made for -the establishment and confirmation of the law of _Hofacker_ and -_Sadler_: - - ═══════════════╤══════════╤══════════╤══════════╤══════════╤══════════ - │ Father │Father and│ Mother │ Sexual │Number of - AUTHOR. │older than│ mother │older than│ ratio. │instances. - │ mother. │same age. │ father. │ │ - ───────────────┼──────────┼──────────┼──────────┼──────────┼────────── - Hofacker │ 117.8│ 92.0│ 90.6│ 107.5│ 1,996 - Sadler │ 121.4│ 94.8│ 86.5│ 114.7│ 2,008 - Goehlert │ 108.2│ 93.3│ 82.6│ 105.3│ 4,584 - Noirot │ 99.7│ │ 116.0│ 103.5│ 4,000 - Legoyt (Calais)│ 109.9│ 107.9│ 101.6│ 107.9│ 6,006 - Legoyt (Paris) │ 104.4│ 102.1│ 97.5│ 102.9│ 52,311 - Breslau │ 103.9│ 103.1│ 117.6│ 106.6│ 8,084 - ═══════════════╧══════════╧══════════╧══════════╧══════════╧══════════ - -The law of _Hofacker_ and _Sadler_ cannot be regarded as possessing -universal validity, although the figures on which it is based seem to -show pretty clearly that we are justified in regarding the mutual -interaction of the male and female reproductive elements at the moment -of fertilization as effective in the determination of sex. In the -investigations to which we have hitherto alluded it is only the relative -ages of husband and wife that have been taken into account; but other -researches have shown that the absolute age alike of the husband and of -the wife has an influence in the determination of sex. - -The influence of the absolute age of the mother in the determination of -sex has been very clearly established. _Ahlfeld_ was the first to draw -attention to the fact that among the children of elderly primiparæ there -was always to be found an excess of boys, and that there was an increase -in this excess proportionate to the greater age of the mother. Among 102 -children born to primiparæ over 32 years of age the sexual ratio was -137 : 100; and a later investigation made by the same author in -conjunction with _Schramm_ showed that among 1,038 children born to -primiparæ over 28 years of age the sexual ratio was 124 : 100. - -_Hecker_ obtained similar results. Among 432 children born to primiparæ -over thirty years of age the sexual ratio was 133 : 100. _Winckel_, -dealing with primiparæ of the same ages, found a sexual ratio of -136.8 : 100. - -_Düsing_, examining the records of the lying-in hospitals of Leipzig, -Dresden and Jena and thus obtaining a very large number of instances -whereon to base his conclusions, confirmed the view that elderly -primiparæ give birth to an excess of boys, and further that the older -they are the larger the excess of male births. He drew up the following -table: - - ══════════╤════════════╤════════════╤════════════╤════════════╤═══════════ - Age of │ Leipzig. │ Dresden. │ Jena. │ Total Nos. │ Sexual - primiparæ.│Boys. Girls.│Boys. Girls.│Boys. Girls.│Boys. Girls.│ ratio. - ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── - 15 │ 1 : −│ 1 : 2│ 1 : −│ 3 : 2│} 549 : 494 - │ │ │ │ │ = 111.1 - 16 │ 4 : 4│ 6 : 10│ 2 : 2│ 12 : 16│ „ - 17 │ 23 : 13│ 20 : 15│ 9 : 7│ 52 : 35│ „ - 18 │ 67 : 55│ 103 : 100│ 17 : 13│ 187 : 168│ „ - 19 │ 110 : 103│ 152 : 141│ 33 : 29│ 295 : 273│ „ - ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── - 20 │ 148 : 147│ 187 : 185│ 32 : 45│ 367 : 377│} 807 : 781 - │ │ │ │ │ = 103.3 - 21 │ 157 : 145│ 241 : 201│ 42 : 57│ 440 : 404│ „ - ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── - 22 │ 120 : 133│ 191 : 207│ 48 : 53│ 359 : 393│} 903 : 962 - │ │ │ │ │ = 93.9 - 23 │ 106 : 108│ 168 : 149│ 51 : 51│ 325 : 308│ „ - 24 │ 71 : 105│ 111 : 118│ 37 : 38│ 219 : 261│ „ - ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── - 25 │ 79 : 57│ 73 : 72│ 35 : 27│ 187 : 156│} 531 : 469 - │ │ │ │ │ = 113.2 - 26 │ 45 : 35│ 30 : 43│ 20 : 20│ 125 : 98│ „ - 27 │ 31 : 35│ 52 : 55│ 10 : 12│ 93 : 102│ „ - 28 │ 32 : 33│ 26 : 33│ 19 : 16│ 77 : 72│ „ - 29 │ 19 : 10│ 26 : 18│ 4 : 13│ 49 : 41│ „ - ──────────┼────────────┼────────────┼────────────┼────────────┼─────────── - 30 │ 9 : 15│ 30 : 13│ 9 : 6│ 48 : 34│} 155 : 104 - │ │ │ │ │ = 150.0 - 31 │ 3 : 8│ 15 : 11│ 3 : 3│ 21 : 22│ „ - 32 │ 5 : 6│ 12 : 9│ 7 : 3│ 24 : 18│ „ - 33 │ 2 : 2│ 5 : 5│ 5 : 2│ 12 : 9│ „ - 34 │ 4 : −│ 8 : 5│ 2 : −│ 14 : 5│ „ - 35 │ 2 : −│ 9 : 3│ 2 : 1│ 13 : 4│ „ - 36 │ 1 : −│ 3 : 3│ 1 : 1│ 5 : 4│ „ - 37 │ 4 : 1│ 4 : 3│ 1 : −│ 9 : 4│ „ - 38 │ − : −│ − : 1│ 1 : −│ 1 : 1│ „ - 39 │ − : −│ 4 : −│ 1 : −│ 5 : −│ „ - 40 │ 1 : 1│ 2 : 1│ 1 : −│ 4 : 2│ „ - 41 │ − : −│ − : 1│ − : −│ − : 1│ „ - ──────────┴────────────┴────────────┴────────────┴────────────┴─────────── - -As an explanation of this statistically proved fact, that elderly -primiparæ gave birth to a large excess of boys, _Düsing_ suggests that -these women who conceive for the first time comparatively late in life, -are, prior to the conception, in a state corresponding with that of a -lower animal species suffering from a deficiency of males, and for this -reason exhibit a tendency to procreate a larger number of individuals of -the deficient sex. In multiparæ also it is possible to trace the -influence of a deficiency of male individuals. When there is such a -deficiency the interval between successive births is unduly protracted. -_Düsing_ found (once more from the records of the lying-in hospitals of -Dresden, Leipzig and Jena) that the longer the interval between one -parturition and the next the longer, that is to say, the mother has had -to wait for her next conception, the greater is the excess of male -births. _Düsing_ therefore lays down the law: “Delayed impregnation -gives rise to an excess of male births.” - - ═══════════╤════════════╤════════════╤════════════╤════════════╤═══════ - Age of │ Leipzig. │ Dresden. │ Jena. │ Total Nos. │Sexual - primiparæ. │Boys. Girls.│Boys. Girls.│Boys. Girls.│Boys. Girls.│ratio. - ───────────┼────────────┼────────────┼────────────┼────────────┼─────── - 1 │ 162 : 158 │ 194 : 178 │ 58 : 45 │ 414 : 381 │ 108.6 - 2 │ 366 : 307 │ 374 : 361 │ 168 : 145 │ 908 : 813 │ 111.6 - 3 │ 198 : 196 │ 207 : 194 │ 116 : 94 │ 521 : 484 │ 107.7 - ───────────┼────────────┼────────────┼────────────┼────────────┼─────── - 4 │ 127 : 109 │ 132 : 106 │ 59 : 45 │ 318 : 260 │} 115.7 - 5 │ 59 : 54 │ 55 : 54 │ 38 : 38 │ 152 : 146 │ „ - ───────────┼────────────┼────────────┼────────────┼────────────┼─────── - 6 │ 61 : 62 │ 52 : 49 │ 49 : 24 │ 162 : 135 │} 121.9 - 8, 9 and 10│ 18 : 16 │ 41 : 23 │ 16 : 24 │ 75 : 63 │ „ - 11 and more│ 5 : 15 │ 12 : 9 │ 4 : 6 │ 41 : 30 │ „ - ───────────┴────────────┴────────────┴────────────┴────────────┴─────── - Totals: 4,903 births, 2,591 m.; 2,312 f.; sexual ratio = 112.06. - -_Bidder_ considers that his own observations entitle him to modify -_Ahlfeld’s_ dictum regarding the influence of age in primiparæ in giving -rise to an excess of male births. He tabulates his results as follows: - - ═════════════════╤═════════════════╤═════════════════ - AGE OF MOTHER. │Number of cases. │ Sexual ratio. - ─────────────────┼─────────────────┼───────────────── - 17 to 20 │ 80│ 122.2 - 20 to 22 │ 405│ 130.1 - 22 to 24 │ 369│ 109.9 - 24 to 26 │ 1,138│ 104.6 - 26 to 30 │ 2,049│ 105.5 - 30 to 32 │ 878│ 112.5 - 32 to 36 │ 1,120│ 119.6 - 36 to 39 │ 676│ 123.1 - 40 and upward │ 215│ 131.5 - ═════════════════╧═════════════════╧═════════════════ - -and formulates the following thesis: Very young primiparæ give birth to -an excess of boys; primiparæ in the first bloom of womanhood give birth -to an excess of girls; later, however, as the age of the primiparæ -increases the excess of male births soon reappears and rapidly -increases. - -_Hofacker’s_ data and the researches of _Hampe_ agree with those of -_Bidder_ in showing that to very young primiparæ, as well as to elderly -primiparæ, an excess of boys is born. Among the offspring of 363 -mothers, at ages varying from 16 to 26 years, _Hofacker_ found the -sexual ratio to be 121; among the offspring of 1,056 mothers, at ages 26 -to 36, the ratio was 101; and among the offspring of 567 mothers at ages -36 to 46, the ratio was 111. _Hampe_ tabulated 5,992 instances as -follows: - - ═══════════════════════╤═══════════════════════╤═══════════════════════ - AGE OF MOTHER. │ Number of instances. │ Sexual ratio. - ───────────────────────┼───────────────────────┼─────────────────────── - Below 20 years │ 56│ 107.7 - 20 to 25 years │ 871│ 90.6 - 25 to 30 years │ 1,633│ 114.9 - 30 to 35 years │ 1,631│ 108.3 - 35 to 40 years │ 1,185│ 117.1 - Over 40 years │ 616│ 124.0 - ═══════════════════════╧═══════════════════════╧═══════════════════════ - -We learn, therefore, that if the age of the progenitors is to be -regarded as one of the causes by which sex is determined, we must take -into consideration not only the relative ages of husband and wife but, -in addition, the absolute age of the wife. - -_Goehlert_ undertook a statistical investigation in which the absolute -age of the husband was taken into consideration as well as that of the -wife. From this it appeared that the maximum sexual ratio was exhibited -when the father was between the ages of 30 and 35 years. When the age of -the mother is treated as the determining influence, we find the maximum -sexual ratio in the offspring of mothers between the ages of 25 and 30 -years. _Goehlert_ believes, however, that the paternal influence is more -powerful than the maternal in the determination of sex. The respective -influences are compared in the following table: - - ══════════════╤═══════════════════════════════════════════════════════ - AGE OF FATHER.│ AGE OF MOTHER. - ──────────────┼─────────────┬─────────────┬─────────────┬───────────── - „ │ 20 to 30 │ 30 to 40 │ Over 40 │ Totals. - │ years. │ years. │ years. │ - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - 25 to 35 years│ 105.76│ 107.87│ 109.14│ 106.6 - 35 to 45 years│ 102.8│ 105.1│ 105.3│ 104.7 - Over 45 years │ │ 104.3│ 103.9│ 109.1 - In general │ 105.25│ 105.97│ 104.9│ 105.5 - ══════════════╧═════════════╧═════════════╧═════════════╧═════════════ - -_Geissler_, studying the data obtainable regarding the sexual ratio -during a 10–year period in the Kingdom of Saxony, ascertained that in -families possessing two children or more there was a very definite -distribution of the possible sex-combinations. Where there was an even -number of children those families were in the majority in which the -number of boys and girls was identical. If the number of children in the -family is an unequal one, those combinations are most frequent in which -the number of boys exceeds the number of girls by one; next in frequency -are those combinations reversed to this, _i. e._, in which the number of -girls exceeds the number of boys by one. All other combinations are -comparatively infrequent in proportion as the discrepancy in number -between boys and girls is larger. Rarest of all are families in which -the children are all of the same sex; and among these, again, the most -unusual are those consisting of boys only. - -This distribution of the sex-combination is believed by _Geissler_ to -depend upon the fact that in the first birth and all the subsequent -births there is generally speaking a slight advantage in favour of the -male sex. It has not been proved that the sex of the first-born -exercises a determining influence on the sex of the subsequent children. -It does, however, seem clear that in the case of parents who have given -birth in succession to several children of one sex only, there exists -some definite obstacle to the procreation of children of the opposite -sex. Putting these exceptions out of consideration, there seems to exist -a tendency in the later births of a series toward the procreation, more -especially of that sex which has been absent or deficient in the earlier -births of the series. The strength of this equalizing tendency increases -as soon as it has for the first time manifest itself. It is always -greater when the sex deficient in the earlier births of the series has -been the male. - -I have myself undertaken a statistical investigation of the births -occurring in the reigning families of Europe and in the families of the -leading members of the aristocracy. The necessary particulars are to be -obtained from the genealogical court calendars; and it is my belief that -the data obtained regarding these uppermost strata of society are -comparatively free from many sources of error by which the ordinary -statistics of the subject are apt to be invalidated. For 556 marriages -there were 1,972 births, comprising 1,023 boys and 949 girls, and thus -exhibiting a sexual ratio of 107.7. - -In relation to the relative ages of the parents, the following table was -drawn up: - - ══════════════════════════════════════════════════╤══════╤══════╤══════ - │ │ │Sexual - │Boys. │Girls.│ratio. - ──────────────────────────────────────────────────┼──────┼──────┼────── - Husband older than wife by one to five years │ 294│ 283│ 103.8 - Husband older than wife by more than five and less│ │ │ - than ten years │ 327│ 306│ 106.8 - Husband older than wife by more than ten and less │ │ │ - than fifteen years │ 190│ 167│ 113.7 - Husband older than wife by more than fifteen years│ 138│ 113│ 122.1 - Husband same age as wife │ 34│ 42│ 80.9 - Husband younger than wife │ 40│ 38│ 105.2 - ══════════════════════════════════════════════════╧══════╧══════╧══════ - -From these figures we may deduce the following conclusions, which are -not wholly concordant with the law of _Hofacker_ and _Sadler_: When the -husband is older than the wife the excess of male births among the -offspring is greater than it is in the case of an average drawn from the -offspring of all marriages (in my cases the difference was 111.8 as -compared with 107.7). But a closer analysis shows the difference to be -less simple than at first sight appears. If the husband is older than -the wife by one to five years, the excess of male births among their -offspring (103.8) is less than in the average of all marriages (107.7); -the same is true of the offspring of marriages in which the husband is -more than five and less than ten years older than the wife, though the -difference here is very trifling (106.8 as compared with 107.7). It is -not till we come to the offspring of marriages in which the husband is -from ten to fifteen years older than the wife that the increase in the -excess of male births becomes notable (113.7 as compared with 107.7); -and when the husband is more than fifteen years older than the wife the -excess of males is higher still (122.1). - -If we arrange these data so as to show, in cases in which the husband is -older than the wife, the additional influence of the absolute age of the -wife, we obtain results which partially conflict with those of _Bidder_, -as follows: - - ══════════════════════════════════════════════════╤══════╤══════╤══════ - HUSBAND OLDER THAN WIFE. │ │ │Sexual - │Boys. │Girls.│ratio. - ──────────────────────────────────────────────────┼──────┼──────┼────── - Wife’s age, 15 to 20 years │ 280│ 287│ 97.6 - Wife’s age, 20 to 26 years │ 595│ 513│ 116.0 - Wife’s age, 26 to 33 years │ 74│ 69│ 110.1 - ══════════════════════════════════════════════════╧══════╧══════╧══════ - -Thus we see that when the wife is very young, i e., less than twenty -years of age, even though the husband is older than the wife, there is -among their offspring no excess of male births, but the contrary—a -sexual ratio of 97.6 only. Most marked is the excess of boys in cases in -which the husband is older than the wife, and the age of the wife is -from twenty to twenty-five years. When the husband is older than the -wife, and the wife’s age lies between twenty-five and thirty-two years, -the excess of male births is not so great, though still considerable. - -Hence it appears that the law of _Hofacker_ and _Sadler_, which cannot -be regarded as fully valid in the terms in which it was originally -expressed, must be modified as follows: If the husband is at least 10 -years older than the wife, and the latter is at an age when her -reproductive capacity is at its maximum (twenty to twenty-five years), -the offspring exhibit a notable excess of male births. There is still a -considerable excess of male births in the offspring of marriages in -which the husband is at least ten years older than the wife, and the -wife is more than twenty-five years of age. On the other hand fewer boys -are born than girls as the offspring of marriages in which, although the -husband is older than the wife, the wife has not yet attained the age of -maximum reproductive capacity—_i. e._, is less than twenty years of age. -The excess of female births is most marked when the husband and wife are -of the same age. When the wife is older than the husband there is a -moderate excess of male births. - -I admit, however, that the figures upon which I have based these -conclusions are, like those of _Hofacker_, too few in number for the -foundation of trustworthy inferences. The instances in my computation -number 1,972; those in that of _Hofacker_, 1,996; but, as I have already -remarked, there are reasons for believing that the data I have employed -admit of the introduction of fewer sources of error. - -The influence of the absolute age of the mother in the determination of -sex having been statistically proved, many have inferred that this -determination is not effected during the instant of fertilization, but -occurs at a later stage of intra-uterine life, and is influenced by the -manner in which the embryo is nourished by the maternal organism. It is -suggested that elderly and immature mothers are unable to furnish the -embryo with nutriment so well as those mothers who are at the age of -maximum reproductive capacity, and that upon this fact depends the -excess of male births in the latter case. (We shall return to this -matter—the influence of deficient nutrition in relation to the excess of -male births). But the proof of the fact that the absolute age of the -father has also an influence in the determination of the sex of the -offspring offers a ground for opposing this assumption that the sex of -the embryo is determined during intra-uterine life subsequent to -fertilization, and suggests that the father also exercises a determining -influence in the origination of sex during the act of fertilization. - -The absolute age of the husband seems also to have some influence upon -the sexual ratio. The absolute age, like the relative age, of the father -appears favourable to the procreation of a greater excess of boys. Thus, -_Hofacker_ found in 1,193 cases, in which the age of the father was from -twenty-four to thirty-six years, that the sexual ratio was 100; in 683 -cases in which the age of the father was from thirty-six to forty-eight -years, the sexual ratio was 114; and in 105 cases, in which the age of -the father was from forty-eight to sixty years, the sexual ratio was -169. - -In investigations based upon larger collections of cases _Schumann_ and -_Düsing_ have endeavoured to determine the variation in the sexual ratio -according to the absolute age of the father. - -_Düsing_ examined the statistics of births in Norway, Alsace-Lorraine -and Berlin, and from the data thus obtained he compiled the following -table: - - ════════╤════════════════════╤════════════════════╤════════════════════ - AGE OF │ 30 TO 35 YEARS. │ 25 TO 30 YEARS. │ 20 TO 25 YEARS. - MOTHER. │ │ │ - ────────┼──────┬──────┬──────┼──────┬──────┬──────┼──────┬──────┬────── - AGE OF │Boys. │Girls.│Sexual│Boys. │Girls.│Sexual│Boys. │Girls.│Sexual - FATHER. │ │ │ratio.│ │ │ratio.│ │ │ratio. - ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── - 15 to 30│ 8,525│ 7,887│ 108.1│27,389│25,843│ 106.0│21,560│20,330│ 106.0 - years │ │ │ │ │ │ │ │ │ - 30 to 35│23,283│21,823│ 106.9│23,394│23,486│ 103.9│ 7,954│ 7,469│ 106.5 - years │ │ │ │ │ │ │ │ │ - 35 to 40│17,885│17,070│ 104.7│10,272│ 9,838│ 104.2│ 2,426│ 2,416│ 100.4 - years │ │ │ │ │ │ │ │ │ - ────────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼──────┼────── - 40 to 45│ 7,972│ 7,681│ 103.8│ 3,165│ 3,058│ 103.5│ }│ 1,100│ 105.0 - years │ │ │ │ │ │ │ 1,154│ │ - Over 45 │ 4,220│ 3,997│ 105.6│ 1,734│ 1,525│ 113.8│ „ │ „ │ „ - years │ │ │ │ │ │ │ │ │ - ────────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴──────┴────── - -In this table we find the births arranged in relation to varying ages of -the fathers and in relation to mothers whose ages are tabulated in three -classes, the ages of the latter being those at which they are most -prolific. The table shows clearly that the excess of boys is larger at -the beginning and at the end of each column. Thus, the age of the mother -remaining constant, young fathers and elderly fathers procreate a larger -proportion of boys than do fathers of intermediate age. - -But I find in this table, which is based upon a very large number of -instances indeed, a confirmation of the thesis which I stated above, for -the highest sexual ratio of 113.8 is in this table found in the case of -fathers over forty-five years of age who are married to mothers of ages -twenty-five to thirty years; this is, as I said, the case in which “the -husband is at least ten years older than the wife, and the latter is at -the age at which her reproductive capacity is at its maximum.” - -From such figures as these, which seem to show the influence of the -absolute age of the father upon the determination of sex, it has by many -been inferred that the man exercises a preponderating influence upon the -determination of the sex of the embryo, impressing his own sex upon it, -and that the greater the sexual potency of the begetter the more -powerful also is the influence exercised by the latter; that the point -of first importance in this connection is the sexual capacity of the -man; and that the excess of male births increases _pari passu_ with the -increase in the potency of the procreating male. - -Two additional considerations have been adduced to demonstrate the -influence of the father in determining the sex of the offspring. The -first of these is a comparison of the ratio between male and female -births in towns and in rural districts, respectively; and the second is -a comparison between the ratio of males to females in the offspring of -married and of unmarried parents, respectively. - -In towns the excess of male births is smaller than it is in the country. -The average sexual ratio in Prussia during the five-year period, 1875 to -1880, is given by _Düsing_ as follows: - - In Berlin 105.70 - In other large towns 105.72 - In medium sized towns 105.44 - In small towns 106.17 - In rural districts 106.62 - -The indisputable fact that in towns more girls are born than in rural -districts is referred to the fact that in the country the husband -usually enters on marriage with his virile powers completely unimpaired, -whereas in towns many men only marry after they have for many years -expended their best forces in irregular sexual intercourse, and thus -reserve for their wives only the dregs. But, as we shall show presently, -the difference between town and country in this respect is susceptible -of a different interpretation. - -It has also been asserted (_Horn_) that extra-conjugal sexual -intercourse is favourable to the procreation of boys, the suggestion -being that the greater sexual vigour in the former case determines a -preponderance of males in the offspring; but this assumption is -invalidated by the statistical evidence which now accumulates, that -among illegitimate offspring there is a smaller excess of boys than -among legitimate offspring. _Babbage_, for instance, came to this -conclusion as a result of the comparison of 1,000,000 illegitimate -births with 14,000,000 legitimate births. On the other hand, the -following utterance of _Ploss_ appears extremely artificial: “In a -country in which illegitimate births are very numerous, in which the -illegitimate children are for the most part begotten by enervated -debauchees, the excess of male births is smaller; but in a country in -which the illegitimate births are less numerous, and in which the -illegitimate infants are for the most part the fruit of love and are -begotten by youthful lovers, the excess of male offspring is larger.” - -Next to the age of the progenitors, their nutritive condition is shown -by statistical investigations to exercise an important influence in the -determination of sex. The following proposition has, in fact, been -established: Where the supply of nutriment is deficient, the offspring -contains an excessive proportion of boys. - -_Ploss_, in an article on “The Causes of Variations in the Sexual -Ratio,” published in twelfth volume of the “Berliner geburtsh. -Monatsheft,” has collected a number of statistical data to demonstrate -that the determination of sex is principally dependent upon the -nutritive condition of the mother. In his opinion the determination of -the sex of the embryo depends neither upon the quality of the ovum nor -upon that of the spermatozoon, nor again upon the reciprocal influences -exerted by ovum and spermatozoon on one another. During the earliest -time after fertilization the embryo is sexually neutral and only later, -as a result of some new influence acting upon it, does it receive an -impulse toward the formation either of the male or of the female sex. -Among all the external conditions which are capable during this period -of exercising a determinative influence the most important are the -nutritive conditions, for nutrition is the most important factor in -determining the form of the young animal, and most of the other outward -conditions, such as light, heat, and chemical changes, affect the embryo -in a mediate manner only, through the changes they are respectively -capable of inducing in its nutrition and metabolism. But _Ploss_ is not -content with asserting that the nutritive condition of the mother is of -great importance in determining the sex of the embryo; he goes further -than this, and declares that it is scanty nutrition of the mother which -especially gives rise to the birth of males, whereas abundant nutrition -of the mother tends to give rise to the birth of females. He refers to -observations made in respect of other animals than man. _St. Hilaire_ -observed that among the underfed animals in menageries there was an -excess of male births. _Hofacker_ and _Girou de Bazarcingues_ have noted -similar phenomena in the case of domestic animals; they found that when -these were richly fed they gave birth to an excess of females, but that -when they were poorly nourished they gave birth, on the contrary, to an -excess of males. Among sheep, with whom the number of male and of female -births is approximately identical, _Martegoute_ found that those animals -which had given birth to female lambs had on the average a greater -weight than those ewes which had given birth to male lambs. During the -period of lactation, also, the former lost weight more than the latter. - -When _Ploss_ had further ascertained that among those engaged in the -fur-trade it is the established belief that from fruitful regions the -skins chiefly of female animals will be obtained, but from barren -regions, on the other hand, among the skins obtained those of male -animals will preponderate, it appeared to him that he was justified in -drawing the conclusion that among the mammalia a well-nourished mother, -one capable of providing abundant nutriment for her offspring, is, on -the whole, more likely to give birth to a female than to a male, and -conversely. He then endeavoured, by reference to the statistics of -population, to show that in the case of human beings also, when the -mother is exceptionally well nourished, there is especial likelihood of -a girl being born; whereas when the mother is ill nourished she is more -likely to give birth to a boy—odd as it may seem, at first sight, that a -rich diet should determine the production of the so-called less powerful -sex, the female; and conversely. (_Ploss_, be it noted however, denies -that male new-born infants are more powerful than female.) The fact that -in the country, comparatively speaking, many more boys are born than in -towns (_vide supra_) is explained by _Ploss_ as dependent on the fact -that townswomen are on the whole better nourished than the countrywomen, -owing to the greater consumption of meat by the former. - -The circumstance again (likewise alluded to above), that in the case of -illegitimate births almost always the excess of male births is less -marked than in the case of the offspring of legal unions, is regarded by -_Ploss_ as offering further proof of the influence of nutritive -conditions upon the determination of sex. Illegitimate mothers are on -the average women at the very best age for child-bearing, women who have -worked vigorously, are themselves well nourished, and are therefore -better able to nourish their unborn offspring than (on the average) -married women. Further, it is a remarkable fact that in Saxony, regions -of which the elevation above the sea-level is less than 1,000 feet, -produce comparatively more girls than regions at an altitude of 1,000 to -2,000 feet above the sea. This _Ploss_ refers to the worse nutrition of -the women living at the higher altitude, for the fact is well known that -the higher we go above the sea the less fertile is the soil and the more -limited is its produce. - -Starting from the view that the lower classes of the population are in -good years better nourished than they are in bad years, _Ploss_ compared -statistically the rise and fall of the prices of foodstuffs, in Saxony, -with the variations of the sexual ratio in the same kingdom; and he -found, in correspondence with his theory, that in bad times there was a -greater excess of male births than there was during periods in which -food was cheaper. Moreover, the consumption of meat appeared to have -more influence upon the variations in the sexual ratio than was -exercised by the consumption of vegetable foodstuffs. _Ploss_ -endeavoured to show graphically that with an increase in the price of -provisions there corresponded an increase in the excess of male births, -and _vice versa_. - -That after times of great wars, pestilence, and emigration, in which the -male portion of the population has been decimated, there occurs a -notable increase in the excess of male births, is explained by _Ploss_ -by the assumption that in consequence of the deficiency of male labour, -the general supply of provisions is deficient, just as it is after years -of bad harvests; hence, in consequence of the scanty nutrition of the -mothers, the number of female births is depressed and the number of male -births increases. Those countries which in general possess a more -thriving population, such as Saxony, England, Belgium, Prussia, etc., -exhibit a smaller excess of male births when compared with those -countries in which a more widespread poverty exists, such as Russia, -Lombardy, Bohemia, and even France. With increasing prosperity, -fruitfulness increases, and there is an increase also in the proportion -of female births. - -These views of _Ploss’s_ are, however, rightly contested by _Breslau_ -and _Wappaeus_. - -_Breslau_ (“The Causes of the Determination of Sex”) offers in the first -place theoretical objections to the view that nutritive conditions in -the mother are determinative in the production of the sex of the -offspring; and he then proceeds to quote statistical data which are -opposed to any such theory. He rightly insists, in the first place, -that, inasmuch as it is unquestionable that in the act of fertilization -the spermatozoon induces in the ovum certain changes, the effect of -which is manifested in days far later than those of intra-uterine life, -by the production of the most manifold and various somatic and psychical -resemblances to the father, it is obvious that this single occurrence of -the fusion of the spermatozoon, the bearer of the paternal influences, -with the ovum is competent to induce in the ovum a molecular arrangement -upon which the determination of sex may be supposed to depend—it is not -necessary to suppose that for this determination, repeated actions, or a -prolonged period of time, is requisite. - -In this connection a reference to birds is instructive, for in this -division of the animal kingdom we seem absolutely compelled to assume -that the sex of the offspring is irrevocably determined in the moment of -fertilization. “In birds, who lay an egg every day, eggs which are kept -all at the same temperature during the period of incubation, and some of -which develop into cock and others into hen birds—how is it possible to -imagine that the nutritive condition of the parent is determinative of -the sex of the offspring, since this nutritive condition cannot -reasonably be supposed to change to any notable extent from one day to -the next and then back again?” - -The paternal influence in the determination of sex is regarded by -_Breslau_ as likely to be at least as important as that exercised by the -mother. Unquestionably the semen is subject to certain variations in -quality and in quantity, and it is possible that these variations may -make themselves felt in the subsequent development of the embryo. Of the -semen, as of all secretions, we can assume with some probability that in -certain conditions (conditions which are, indeed, but little -understood), it may exhibit a greater or less intensity in its -stimulating qualities, and that in this way it may be subject to -changes, according to which it will tend to influence the development of -the embryo, now in the female, and now in the male direction. Again, in -view of the continued interchange of nutritive materials between the -embryo and the maternal organism, it is probable enough that the -constitution of the maternal organism and likewise that of the ovum, at -the moment of fertilization, are not matters of indifference to the -determination of sex. But to attribute to the nutritive condition of the -maternal organism the sole or even the principal influence in the -determination of the sex is an unjustifiable assumption. - -The proofs alleged by _Ploss_ from the animal world in support of his -thesis, viz., that in the case of poorly nourished animals there is a -marked excess of male offspring, are justly controverted by _Breslau_ -with the remark that the observations on animals are but few in number, -and further that we know nothing whatever regarding the normal sexual -ratios among the offspring of such animals as lions, tigers, hyænas, -bears, etc., in the free state. - -If, again, domestic animals when well nourished give birth to an excess -of female offspring, and when ill nourished and overworked to an excess -of male offspring, in the former case we can only regard the excess of -female births as a pathological phenomenon, inasmuch as a superabundant -supply of nutriment is not that which furnishes the highest powers or is -most suited to the preservation of life. Again, the accounts given by -fur-dealers are quite untrustworthy, since these men commonly obtain -their goods at third and fourth hand; moreover, most of the animals -whose pelts form articles of commerce, are beasts of prey, such as the -otter, the lynx, the bear, the wolf, the fox, etc.—and these animals -have no “pasturage.” Among vegetable-feeding animals the females are no -doubt found on the pasturage more often than the males, for the reason -that the females have to nourish both themselves and their young, -whereas the males, which have themselves only to provide for, are -contented with less food and inhabit chiefly more retired and less -fertile regions; they are also shyer and are less easily shot and -trapped. Regarding statistical data relating to the influence of -nutrition on the production of boys, _Breslau_ shows, from the figures -of the Canton of Zurich, that with few exceptions, the years in which -the price of corn was lowest were the years in which the production of -boys was greatest, and _vice versa_—the exact opposite of the results -obtained by _Ploss_ from his examination of the figures relating to -births and the price of provisions in Saxony. - -_Wappaeus_ contests the conclusions of _Ploss_ even more vigorously, and -adduces the statistics of Sweden in the 20–year period 1770 to 1790, in -which period this kingdom repeatedly suffered from famine in consequence -of failure of the crops, so that the births and deaths were largely -affected. It appeared, however, that the more abundant or more scanty -nutrition of the inhabitants of Sweden during this period had no marked -influence upon the sexual ratio. - -If scanty nutrition of the mother had, in fact, any influence upon the -determination of the sex of the embryo in the direction alleged by -_Ploss_, viz., so as to bring about the birth of a greater excess of -boys, this influence should be manifested with exceptional clearness in -the case of twins, for it is obvious that the nutriment that is -insufficient for one embryo would be still scantier for two. Hence -various statistical investigations have been undertaken to determine the -sexual ratio in the case of twin births. _Ploss_ found that in Saxony, -in the case of 23,420 twin births, the sexual ratio was 106.7 boys to -100 girls; _Moser_ gives the sexual ratio in the case of twin births as -106; _Meckel von Hemsbach_ gives it as 105.4; _Hecker_, 116 and 122; -_Sickel_, 112.3. _Düsing_ combined the figures relating to twin births -in various lying-in hospitals, published by _Hecker_, _Sickel_, -_Baillarger_, _Siebold_, _Elsässer_, and _Levy_, respectively, and thus -obtained a sexual ratio of 121.5 boys to 100 girls. This excess of boys -is notably greater than among births in general. - -But other statistical data are available which show a reversed -condition, viz., that in the case of twin births the sexual ratio is -lower than usual. According to _von Frick’s_ collection of twin births -in Prussia, the sexual ratio was 104.7 boys to 100 girls; whereas in the -case of single births in the same country the sexual ratio was 106.35 to -100. _Riecke_, in Württemberg, in the case of 60 twin births found 58 -boys and 62 girls. In the case of twin births observed by _Braun_, -_Chiari_, and _Späth_, 94 in all, the children were in 64 of these of -identical sexes, namely, in 30 instances boys, and in 34 instances -girls. According to _Breslau_, in the case of twin births in the Canton -Zurich, the sexual ratio was 104.1 to 100; whereas in the case of single -births the sexual ratio was 106.2 to 100. - -As regards triplets the reports of the sexual ratio vary from -111.76 : 100 (_Meckel von Hemsbach_) to 104.55 : 100 (_Neefe_). - -It is obvious that the statistical data at present available regarding -the sexual ratio in the case of multiple births are far too variable for -it to be possible to base upon them any valid conclusions as to the -influence of the nutritive condition of the mother upon the -determination of the sex of the offspring. And taken as a whole the -statistical data hitherto available do not enable us to infer with -confidence that nutritive conditions, and more especially the nutritive -state of the maternal organism, exercise any effect upon the -determination of the sex of the offspring. - -Another attempt at the utilization of statistics has been to ascertain -whether the time of fertilization in relation to menstruation, (in the -first days after the flow, or later in the intermenstrual interval) has -any influence upon the determination of sex. The starting point in this -investigation was the earlier view that sex depends upon the state of -the ovum, and the belief that a very favourable state of ovum and sperm -favours the production of the female sex. The ovum, after its discharge -from the ovary, like the spermatozoon after its discharge from the -testicle, tends sooner or later toward death, and the only thing that -can save either from this ultimate fate, is for the two to unite to form -a new organism. Precisely what moment in the history of the detached -ovum is the most favourable, is a matter regarding which we have no -exact information, but it is probable that at the moment of its -discharge from the ruptured follicle, it is at the zenith of its vital -powers. On this theory the determination of sex depends upon the period -at which, after its liberation from the follicle, the ovum encounters a -spermatozoon; the ovum which is fertilized early in its career becomes a -female embryo; the ovum, on the other hand, which is not fertilized -until it has become comparatively old, becomes a male embryo. But, as -_Hensen_ points out, a spermatozoon, according to _its_ condition, may -either fail sufficiently to fortify an ovum which itself is in good -condition; or, on the other hand, a powerful spermatozoon may fortify an -ovum of deficient vitality. But it is difficult to say precisely on what -considerations the greater or less vitality of the spermatozoon -depends—or, to speak more in accordance with the terms of the theory, we -do not know exactly what makes it a good spermatozoon or the reverse. It -may be “bad,” either because it has remained too long in the testicle or -because it has been discharged too quickly, is too recently secreted; -moreover, a long sojourn of the spermatozoon in the uterus will -doubtless suffice to lower its vitality. - -The Jews, more especially, whose religious ordinances forbid them to -have sexual intercourse either during or shortly after menstruation, and -among whom there is a great excess of male births, have been adduced as -a proof of the thesis that sexual intercourse during the later part of -the intermenstrual interval tends to favour the procreation of boys. In -Leviticus xv. 19, we read: “And if a woman have an issue, and her issue -in her flesh be blood, she shall be put apart seven days.” From the -commentary in the Talmud it appears that these seven days are to be -reckoned from the commencement of the flow. Statistical reports from -various countries show that among the Jews there is a greater excess of -male births than among the other inhabitants of the respective -countries. The overplus of male births exhibited by the Jews varies from -1 to 15%, the difference probably depending on the fact that the number -of instances under consideration is too small for uniform results to be -possible. In Prussia, during the period 1820 to 1834, the sexual ratio -among the Jewish births was 111 : 100; during the period 1849 to 1852 it -was 106 : 100; in Hungary during the period 1835 to 1855 it was -117.1 : 100; in Sweden, 1851 to 1855, it was 108 : 100. Among -illegitimate children of the Jewish community the sexual ratio was, in -Austria, 123.9, in Prussia, 118.6. - -_Fürst_, examining the cases in _von Braun’s_ clinic, and making a -statistical collection of the days of conception and of delivery, has -endeavoured to prove that “there is an excess of boys when conception -occurs during the period of post-menstrual anæmia.” His figures show, in -fact, a very notable excess of boys in cases in which conception has -occurred during the five days immediately following the cessation the -menstrual flow; and an excess of girls when conception has occurred -during the later part of the intermenstrual interval. Thus, in the -former case the excess of boys is represented by the figures 37 : 12; in -the latter case the excess of girls is represented by the figures 79 -(girls) : 65 (boys). These figures are explained by _Fürst_ on the -theory that in the human species conception during the period of -post-menstrual anæmia probably leads to an enormous excess of male -conceptions (owing to the fact that the unfertilized ovum is badly -nourished during the days just before conception); whereas in the later -part of the intermenstrual interval the better nourishment of the ovum -probably leads to the procreation of an excess of girls—hypotheses which -are based on a quite inadequate number of instances. _Fürst_ gives the -following table: - - ═════════════════╤═════════════════╤═════════════════╤═════════════════ - NUMBER OF DAYS │ Number of boys │ Number of girls │ Boys and girls - BETWEEN REPUTED │ born. │ born. │ together. - END OF │ │ │ - MENSTRUATION AND │ │ │ - REPUTED │ │ │ - OCCURRENCE OF │ │ │ - CONCEPTION. │ │ │ - ─────────────────┼─────────────────┼─────────────────┼───────────────── - 1│ 7│ 1│ 8 - 2│ 6│ 3│ 9 - 3│ 9│ 5│ 14 - 4│ 15│ 3│ 18 - 5│ 3│ 6│ 9 - 6│ 5│ 6│ 11 - 7│ 6│ 5│ 11 - 8│ 2│ 8│ 10 - 9│ 4│ 5│ 9 - 10│ 6│ 4│ 10 - 11│ 6│ 5│ 11 - 12│ 3│ 6│ 9 - 13│ 4│ 5│ 9 - 14│ 6│ 5│ 13 - 15│ 1│ 2│ 3 - 16│ 2│ 5│ 7 - 17│ 2│ 3│ 5 - 18│ 3│ │ 3 - 19│ 1│ 3│ 4 - 20│ 1│ 2│ 2 - 21│ 1│ 1│ 2 - 22│ 4│ 1│ 5 - 23│ │ 1│ 1 - 24│ 1│ │ 1 - 25│ │ 2│ 2 - 26│ 2│ │ 2 - 27│ │ 1│ 1 - 28│ 1│ 1│ 2 - 31│ 1│ │ 1 - ─────────────────┼─────────────────┼─────────────────┼───────────────── - │ 102│ 91│ 193 - ═════════════════╧═════════════════╧═════════════════╧═════════════════ - -_Baust_ gives a report, based, he says, upon “thoroughly trustworthy -data,” furnished by personal friends, regarding 14 cases, which show, in -his opinion, that every conception occurring in a week after the -cessation of the menstrual flow leads to the birth of a girl; but that -when conception occurs on the fifth or sixth day after menstruation the -result varies as regard sex. _Swift_, from a report of 20 cases, draws -the conclusion that in the intermenstrual interval, boys, in the latter -part of the interval girls are conceived. - -The influence of the strength of menstruation upon the determination of -sex has also been studied by the statistical method, starting with the -idea that menstruation, in proportion to its strength, affords on the -average a measure for the subsequent nutrition of the embryo, and this -nutrition is further supposed to determine the sex. _Düsing_ therefore -arranged the births occurring in the lying-in hospitals of Dresden, -Leipzig and Jena, according to the information given regarding -menstruation in the clinical history of each case; it appeared that when -menstruation was comparatively scanty, there was a greater excess of -boys than when menstruation was comparatively abundant. The actual -figures were the following: - - ═══════════════╤═══════════════════════════╤═══════════════════════════ - │ Abundant menstruation. │ Scanty menstruation. - ───────────────┼─────────────┬─────────────┼─────────────┬───────────── - Dresden │ 902│ 847│ 495│ 431 - Jena │ 66│ 69│ 56│ 45 - Leipzig │ 21│ 22│ 239│ 211 - ───────────────┼─────────────┼─────────────┼─────────────┼───────────── - Totals │ 989│ 938│ 790│ 687 - Sexual ratio │ 105.4 │ 114.7 - ═══════════════╧═══════════════════════════╧═══════════════════════════ - -Here also we may append the figures obtained by _Düsing_ regarding the -births of foals at the Prussian stud-farms, which he regards as -supporting his view that by natural selection all animals have acquired -the faculty, whenever stronger demands are made upon their sexual -capacity, of procreating a larger number of individuals of their own -sex. In the tables we learn how many mares on an average a stallion had -covered in each year, that is, we learn how great were the demands made -upon the sexual capacity of the stallion in that particular breeding -stable in that year. The figures relating to the years 1859 to 1892 were -tabulated and averages were drawn with the following results: - - ═════════════════╤═══════════════════════════════════╤═════════════════ - NUMBER OF MARES │ NUMBER OF FOALS BORN. │ Sexual ratio. - SERVED. │ │ - ─────────────────┼─────────────────┬─────────────────┼───────────────── - „ │ Colts. │ Fillies. │ „ - ─────────────────┼─────────────────┼─────────────────┼───────────────── - 60–70 │ 42,445│ 41,933│ 101.22 - 55–59 │ 56,511│ 66,226│ 100.49 - 50–54 │ 59,940│ 61,096│ 98.18 - 45–49 │ 57,077│ 59,216│ 96.39 - 40–44 │ 59,967│ 62,007│ 96.71 - 35–39 │ 38,348│ 40,181│ 95.44 - 20–34 │ 26,354│ 27,069│ 97.35 - ═════════════════╧═════════════════╧═════════════════╧═════════════════ - -From these figures, which relate a very large number of instances -indeed, we learn that when greater demands are made upon the stallion, -more males are procreated. In fact, except for two slight divergencies, -the rise in the sexual ratio proceeds strictly _pari passu_ with the -increase in the number of mares covered. - -I must, however, draw attention to the fact that this assumption when -applied to the human species, that the man on whom whose sexual capacity -especially extensive demands are made, procreates an especially large -number of male children, is not confirmed by the sexual ratio among the -offspring of polygamous marriages in which unquestionably greater -demands are made upon the husband’s sexual powers than is the case in -monogamic unions. - -The reports of travellers of earlier days, to the effect that in -Oriental countries more girls are born than boys, have recently been -confirmed by several observers. _Campbell_ states that in the harems of -Siam the number of boys and girls born is equal. _Clarke_ states that -among the Mohammedan Indians more girls are born than boys. According to -_McLennan_ Indian experience teaches us that where polyandry prevails -male offspring predominate in numbers; but where polygamy prevails there -is, on the contrary, an excess of female infants. The following data -collected by _Goehlert_ from historical reports and from genealogical -writings, regarding the progeny of notable persons living in polygamous -unions, show certainly a large excess of female offspring over male: - - ═════════════════╤═══════════════════════════════════╤═════════════════ - │ CHILDREN. │ Sexual ratio. - ─────────────────┼─────────────────┬─────────────────┼───────────────── - „ │ Male. │ Female. │ „ - ─────────────────┼─────────────────┼─────────────────┼───────────────── - Morocco: Muley │ 24│ 124│ 19.4 - Scherif │ │ │ - Palestine: │ │ │ - Rehoboam, King │ 28│ 60│ 46.6 - of the Jews │ │ │ - Arabia: Imon of │ 14│ 74│ 18.9 - Sana │ │ │ - Turkey: nine │ 110│ 128│ 85.9 - sultans │ │ │ - ═════════════════╧═════════════════╧═════════════════╧═════════════════ - -According to _Tousenel_, love marriages give rise to more daughters than -sons, whereas among the offspring of conventional or compulsory -marriages, male children predominate. Further, among the offspring of -legitimate unions, the excess of males is greater than among the -offspring of illegitimate unions. A physician, _V. J. Cook_, maintains -that boys are procreated in the evenings (before midnight), but girls -during the early morning hours—at which latter time women are less -“impressionable” than during the evening hours. - -_Düsing_, starting from the common belief that all animals have the -faculty, when there is a lack of individuals of one sex, of procreating -an excess of offspring of the sex which is deficient and thus of -restoring the balance between the sexes, maintains that numerous -factors, through the co-operation of which the sexual ratio is -regulated, act in temporal succession. He shows that the individuality -of the mother has an influence upon the sex. But this finds expression -through the qualitative constitution of the ovum; hence already before -fertilization there must exist a tendency toward the development of one -sex or the other—for example, younger ova tend to become females; older -ova, on the contrary, to become males. It has further been shown that -the individuality of the father, that is to say, the qualitative -constitution of the sperm, has an influence in the determination of sex. -Thus, by means of the influence of the sperm, the already-mentioned -pre-existing tendency of the ovum can in some instances be counteracted -and overpowered. The influences in the personality of the father and of -the mother, which during fertilization find expression in the -qualitative constitution of the sperm and of the ovum, respectively, can -thus bring about a resultant tendency, acting in one direction or the -other with varying force. Thus, after fertilization, we have this -resultant tendency toward the formation of a male or female embryo. - -But, _Düsing_ continues, at this time the sex is not definitely -determined. The influence of the nutritive condition in which the -fertilized ovum finds itself has yet to make itself felt. This influence -on the determination of sex through the maternal nutrition, continues -(in the human embryo) for as long as three months, but even when the -reproductive organs of the embryo have definitely begun to diverge in -the direction of the masculine or the feminine type, as the case may be, -some nutritive influence, if it is sufficiently powerful, may yet turn -the balance in the other direction, so that a partial or complete -hermaphrodite results, a being uniting the characteristics of both -sexes. - -Actual inheritance of sex, of which people used to speak, cannot, in -_Düsing’s_ opinion, possibly occur. The mode in which one sex or the -other develops is indeed inherited; but the decision which sex shall -develop does not depend upon inheritance, but is determined by the -co-operation of several outward influences. The qualities by which this -is effected are acquired by adaptation to general or special vital -conditions. - -_Wilckens_ (“A study of the Sexual Ratio and of the Causes of the -Determination of Sex in Domestic Animals”) opposes the views of Düsing, -on account of the results of his own investigations, relating to the -births of 30,000 domestic animals. He formed the following conclusions: - -1. _Locality_ (soil and climate) has an influence upon the sexual ratio -and upon the determination of sex in domestic animals, but this -influence is probably indirect only, being exerted through the -intermediation of the nutrition of the embryo _in utero_. - -2. _The season_ in which the domestic animal is conceived affects the -sex; the hot season favours the production of males, the cold season -that of females; in the hot season, in general, the appetite and -nutrition of domestic animals diminish, whereas in the cold season these -increase. - -3. Regarding the _male progenitor_, neither his age, nor his sexual -energy, nor the demand made upon that energy, nor the age of the semen, -has any influence upon the sexual ratio or the determination of the sex -of the offspring. - -4. The age of the _female progenitor_ influences the sexual ratio and -the determination of the sex of the offspring in this way, that in -general, primiparæ and young mothers conceive a larger number of female -offspring. This influence of age may be referred to the fact that in -general young mothers nourish their offspring _in utero_ better than -older mothers. - -5. The _nutrition of the fruit in utero_ influences the determination of -sex, speaking generally, in the following way, that better nutrition -favours the determination of the female sex, worse nutrition favours the -determination of the male sex. - -6. In addition to the influence of nutrition of the fruit upon the -determination of sex, _other influences_, whose nature still remains -_obscure_, must also co-operate, because one and the same progenitor in -similar nutritive conditions does not always procreate offspring of the -same sex. - -7. Owing to the operation of these _unknown influences_, prediction of -the sex of the offspring, and voluntary determination of the sex of the -offspring, remain impossible. All we can say is that there is some -probability that young and well-nourished mothers will procreate a -comparatively larger number of female offspring, whilst elderly and -ill-nourished mothers will procreate a comparatively larger number of -male offspring. - - - _II. Anatomical Investigations._ - -Of anatomical investigations and discoveries, those more especially -relating to the sex-relationships of twins and triplets have been -applied to the elucidation of the problem of the determination of sex. - -The first and most important fact in this connection, one that is not -merely a rule confirmed again and again by anatomists and gynecologists, -but is further, as _Mayrhofer_ has demonstrated as a result of his -researches in _von Braun’s_ clinic, a “natural law,” is this, that twins -and triplets enclosed in a common chorion are invariably of the same -sex. The sex-identity of such twins has been referred to the similarity -of their nutritive conditions (_Leuckart_, _Ploss_), and more especially -to the communication between their bloodvessels; and an intimate -connection between these relationships and the determination of sex has -been believed to exist. - -_Mayrhofer_, however, opposes this assumption by the following -deductions (“The Determination of Sex in the Human Species”); “Fœtuses -enclosed within a single chorion always possess a common placenta, in -which the blood-channels from both umbilical cords frequently, in the -case of twins perhaps invariably, communicate. It might therefore be -supposed that the sex-identity of embryos enclosed within a single -chorion is due to the intermixture of their blood in the placenta. -_Hyrtl_, however, describes a triplet’s placenta, in which, though all -three fœtuses were enclosed within a single chorion, the vessels passing -to the umbilical cord of one of the fœtuses were entirely distinct from -the vascular area common to the two other fœtuses; it is therefore -probable that in the case also of twins enclosed within a single chorion -there is not _necessarily_ any communication between their bloodvessels -in the common placenta. But even if it were proved that in the case of -twins enclosed within a single chorion their bloodvessels always do -communicate in the common placenta, we could not therefore infer that -the intermixture of the blood of the two fœtuses is the cause of their -sexual identity. - -“For the intermixture of the blood of the two fœtuses in the common -placenta could never lead to a complete identity in the composition of -the blood of the two; it could only lead to a diminution of the -differences which would exist between the bloods if their placental -circulations were entirely distinct, and the similarity in the bloods -thus established could not be expected to do more than make it a general -rule that such twins or triplets should be of the same sex; but to this -rule exceptions might be expected to occur in certain cases, as when -hæmatopoiesis in the two (or three) fœtuses was very different, or when -the circulation through the intercommunicating bloodvessels was -interfered with through the pressure of fibrinous deposits—differences -between the bloods would then arise sufficient to cause differences in -sex (if identical composition of the bloods is presumed to be the cause -of the sexual identity). - -“Experience teaches us that the existence of communicating vessels in -the placenta does not suffice to induce a close similarity of growth and -of the formation of the organs in twin fœtuses; nor does it prevent the -illness and death of one fœtus leaving the health of the other -undisturbed, although the communicating channels remain open; so that, -if we except acardiac monsters, it is correct to say that each fœtus -pursues a secluded life, uninfluenced by the life of its neighbour. -Acardiac monsters, on the other hand, always receive blood which has -already served for the nutrition of the normal fœtus, and the result of -this is an arrested development and a striking preponderance of -connective tissue in the acardiac twin. But notwithstanding the fact -that the failure of its own proper circulation (which is indeed rendered -possible by the existence of the communicating vessels in the placenta) -leads to its defective nutrition with a blood inferior to that supplied -to the normal fœtus, the acardiac monster is always of the same sex as -the normal twin.” - -From these considerations _Mayrhofer_ rightly infers that the identity -of sex of two fœtuses contained in a single chorion, since it does not -depend upon the existence of communicating vessels in the placenta, must -arise from a developmental tendency already existing in the two germs at -the time of conception—or, in other words, that at the time of -conception their sex is already inalterably determined. - -This conclusion with respect to the sex of twins contained in a single -chorion may very readily be extended to the inference that in the case -of all human fœtuses the sex is already determined at the time of -conception. - -Another anatomical fact is that many twins are contained in a single -chorion for this reason, that they originate from two germinal vesicles -within a single ovum. It is an open question whether it is not possible -for two embryos contained in separate chorions to come to lie in a -single chorion through atrophy of the intermediate wall. If this is -indeed possible, the invariable identity of sex in the case of fœtuses -lying in a single chorion must lead us to agree with _Mayrhofer_ in -inferring that two ova lying within a single follicle, simultaneously -fertilized, give rise to embryos of identical sex. - -_B. S. Schultze_ and _Ahlfeld_, as a result of the investigations -regarding twins, also came to the conclusion that the sexual identity of -twins depends upon their derivation from a single ovum. If, in -accordance with what has been said above, an explanation of the sexual -identity of certain twins is to be found in the fact that for such twins -there has been a single conception only, and hence the influence, -whatever it may be, by which sex is determined acts on both germs at the -same time—still the sexual identity of twins in general is remarkable -and has not yet been fully explained. The sexual identity in fact occurs -much more frequently than appears to correspond to the percentage of -twins derived from a single ovum. _Von Fricks_ examined the data -relating to multiple births in Prussia during the period of 1826 to 1879 -and compiled the following table: - - ══════════════╤═════════════╤═════════════╤═════════════╤═════════════ - Per Cent. │ Twins. │ Triplets. │Quadruplets. │Quintuplets. - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - Boys only │ 32.6│ 24.5│ 14.3│ 33.3 - Girls only │ 30.3│ 22.5│ 19.4│ - Boys and girls│ 37.1│ 53.0│ 66.3│ 66.7 - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - │ 2 B. 1 G. │ 28.5│ │ - │ 1 B. 2 G. │ 24.5│ │ - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - │ │ 2 B. 2 G. │ 23.4│ - │ │ 3 B. 1 G. │ 19.5│ - │ │ 1 B. 3 G. │ 23.4│ - ──────────────┼─────────────┼─────────────┼─────────────┼───────────── - │ │ │ 4 B. 1 G. │ 33.3 - │ │ │ 3 B. 2 G. │ 33.3 - ══════════════╧═════════════╧═════════════╧═════════════╧═════════════ - -According to _Ahlfeld_, of twin births in general, the ratio of those -with a common chorion to those with separate chorions is 1 : 8.15. If, -however, we wished to explain the frequency with which twins are of -identical sex from the occurrence of such twins derived from a single -ovum, we should expect to find a very different ratio, namely, 1 : 3.84; -that is to say, twins with a common chorion would have to be nearly -three times as common as they actually are. From these facts _Düsing_ -endeavours to draw the conclusion that external conditions have an -influence upon the determination of sex, for very many external -conditions are identical in the case of twins; as, for instance, the age -of the father, the age of the mother, the nutritive conditions of the -ova and of the spermatozoa, the nutrition of the embryo, etc.—all of -these would influence both the twins in the same direction. A difference -in the sex of twins, on the other hand, might be due to two successive -fertilizations. - -_B. S. Schultze_ has been led by his embryological studies to the -conclusion that there are male and female ova. Thus he believes that -sexually identical twins originate from a single ovum with two germinal -vesicles, thus assuming that a double fertilization of such ova is -possible. But since in such cases the sexes of the resulting twins are -always identical the spermatozoon can have no influence upon the -determination of sex, but the conditions leading to the development of -one sex or the other must pre-exist in the ovum—_i. e._, there must be -male and female ova. - -That as a matter of actual fact in some cases the female progenitor -exercises an overwhelming influence on the determination of sex, and -that the opinion held by so many that this determination depends upon -the mother alone is sometimes supported by facts, is shown by the -incident recorded by _Darwin_ (“Descent of Man,” Vol. I.), that an Arab -mare was delivered seven times successively of a filly, never of a colt, -although she was covered by seven different stallions. On the other -hand, the circumstance, if it is not to be attributed to pure chance, -can also be explained by the constitutional vigour of this mare -(_Hensen_) without adopting the above hypothesis. - -Recently _Upjohn_ has maintained that there are two kinds of -spermatozoa, male and female; the latter are the commonest, but the -former are the more energetic. - -An interesting anatomical fact bearing upon this question has been -discovered by _M. Nussbaum_, namely, that in ascaris megalocephala the -reproductive glands are indicated already before the separation of the -germinal layers; and _Nussbaum_ suggests that this is also the case in -all animals, although the proof cannot be obtained in every instance. - -_Semper_ has shown also in the case of some of the plagiostomata that -long before the beginning of the definitive development of the -reproductive organs, the apparently hermaphrodite embryo already -possesses at least the tendency toward the constitution of one sex or -the other. For in these animals, at a time so early that as yet the -reproductive glands exhibit no sexual differentiation whatever, the -sexes can nevertheless be distinguished by what appears to be a -secondary sexual character. In the female, namely, one ovary only is -developed; and very early indeed in the embryos destined to become -females we can observe an asymmetrical development of the two germinal -furrows. By this characteristic the two sexes can be distinguished far -earlier than it is possible to do so by the recognition of a -histological differentiation of the reproductive glands. - -According to _Mayrhofer_ the prepotency of the male gives rise to the -procreation of an excess of males in this way, that physical prosperity -of the male probably leads to the generation of boys, whereas prosperity -of the female tends to give rise to the generation of girls. Moreover, -economizing of the semen by infrequent sexual intercourse tends to -originate offspring of the male sex. In this connection _Hensen_ -remarks, apropos of the greater excess of male offspring among the Jews: -“We might ask whether, in consequence of the comparative sexual -continence of the Jews which demands a definite power of endurance on -the part of the ova, there may not be effected a certain selection of -the ova; and thus we may perhaps explain how it is that in this race an -exceptional vigour is somewhat more often to be observed than in other -races.” _Bock_ assumes that “thinner semen,” such as results from more -frequent sexual intercourse, favours the procreation of the female sex, -whereas when intercourse is less frequent a larger number of boys is -likely to be born. _Janke_ indicates as two important fundamental -principles of scientific physiology that, (1) sexual intercourse -represents as it were a contest between the two parties to the sexual -act as to which shall transmit his or her sexual influence to the child, -the victor in the contest determining the sex of the offspring, and (2) -that a crossed inheritance occurs, inasmuch as whichever progenitor -proves stronger in this contest transmits to the child the sex other -than his or her own. He therefore advises women who long to have a boy -to drink a glass of champagne before fulfilling their conjugal duties in -order to gain increased sexual vigour. - -_Fiquet_ also expresses the opinion that when a vigorous, passionate, -and sanguine male progenitor has intercourse with a frigid and -phlegmatic woman there will be a preponderant tendency for the offspring -to be female; whereas, when the conditions are the opposite of these, -the male progenitor being phlegmatic and cold, the female on the -contrary sanguine, passionate, and ardent, the offspring will probably -be of the male sex. - -In opposition to these opinions of _Fiquet_ and _Janke_, to the effect -that the temperament and the sexual vigour of the progenitors have a -determining influence in the origination of the sex of the offspring, -_Düsing_ insists that the quality of the reproductive products are alone -influential. _Düsing_ lays down the following proposition: “The greater -the scarcity of individuals of one sex is, the more extensive -consequently the demands made upon the sexual capacities of the -individuals of that sex, the more rapidly their reproductive products -are employed; and the younger these products therefore are when employed -the more individuals of their own sex will appear among the offspring.” - -_Richarz_ believes, on the contrary, that the prepotency of the male -gives rise to the procreation of more girls; a mother of high -reproductive capacity will have more boys, one of less reproductive -capacity, on the other hand, more girls. - -_Starkweather_ (“The Law of Sex,” London, 1883) states his view in the -proposition: “The superior parent produces the opposite sex;” and he -holds the quaint view that this superiority is displayed in certain -anatomical characters of the face of the progenitor. He endeavours from -the shape of the head and from the facial expression to deduce the -superiority of the male and the female progenitor respectively. A high, -square forehead, with prominent supra-ciliary ridges, constitutes, -according to _Starkweather_, one of the principal symptoms of this -superiority; important also are a strongly developed middle third to the -nose, narrow lips, etc. He declares that in families known to him the -possession of this Roman nose in the father is signalized by the -possession also of a large number of daughters, while a Roman-nosed -mother has many sons. The more the parents’ noses resemble each other -the more equal will be the distribution of the sexes among the -offspring. He connects this fact (!) also with the fact that the -possessor of the aquiline nose is the ruler of the family. Men of great -strength of character procreate chiefly daughters; women, on the other -hand, with a powerful character and a firm will bring into the world a -notable excess of boys. In the Southern States of the American union -_Starkweather_ found confirmation of his theory, since he observed there -that among the offspring of white fathers and coloured mothers there was -an excess of girls amounting to 12 to 15 per cent. Among the half-castes -of Java, the so-called Lipplapps, in the third generation girls only are -born, and these are sterile. The excess of girls in these cases depends -upon the superiority of the white father; this superiority is -transmitted to the few sons of the second generation, and these -therefore procreate girls only to constitute the third generation; the -latter are not powerful enough to bear children at all. - -_Roth_ has revived the old view that one ovary provides the germs for -the male offspring, the other those for the female offspring. He -believes further that in the process of cohabitation the mechanical -impressions and stimuli received by one-half of the external genital -organs, reinforced by contact with and pulling on the pubic hair, are -transmitted through the pudic nerve and the hypogastric plexus to the -corresponding half of the vagina and the uterus, to the Fallopian tube -of that side and to the corresponding ovary. If, now, we can consider it -as established (?), that in the human female one ovary discharges male -ova only and the other female ova only, it seems to him that it is the -corresponding half of the external genital organs, when specifically -stimulated in sexual intercourse, and the consequently increased vital -activity in the pudic nerve and its connections with the hypogastric -plexus, that must be regarded as the organ by means of which sex is -determined. _Roth_ has also been informed by laymen that when for some -time they have procreated daughters only they subsequently procreated -sons, “when, having been accustomed to sleep on one side of their wife, -they adopted the practice of sleeping on the other.” - -_Ricardi_ reports that in Modena the peasants say that a man whose wife -has hitherto had daughters only, must, if he wishes to have a son, -assume some other posture than usual in the performance of coitus. - - - _III. Experimental Investigations._ - -A considerable number of years ago, _Thury_ attacked the problem of the -determination of sex by the experimental method. In his series of -experiments he ascertained, using 29 cows, that in the case of 22 of -these, which were served early in their heat, the calves were without -exception heifers, while in the case of the remaining 7, which were -served late in their heat, the calves were equally without exception -bull-calves (_Thury_, “The Law of the Determination of the Sexes,” -Leipzig, 1863); in the record of these experiments no mention is made of -the age of the cows. _Thury_ concluded that the sex was determined -according to the fertilization of the ovum soon or late after its -liberation from the ovary; namely, that an ovum fertilized soon after -its discharge produced a female, whilst an ovum which had become -comparatively old before it was fertilized became a male. - -_Thury’s_ sensational experiments gave rise to a succession of similar -experiments, made mostly by cattle-breeders, above all in agricultural -colleges and in stud-farms. - -Some of these experiments were made in the agricultural colleges at -Proskau and Eldera. The cows, which according to _Thury’s_ views should -have been delivered of heifers, were served as soon as their heat was -observed (the heat lasted as a rule from 24 to 30 hours); these were -delivered of 5 heifers and 5 bull-calves (in Proskau) and of 3 heifers -and 5 bull-calves (in Eldera); the sexual ratio in these cases was -therefore normal. On the other hand, cows which were not served until -their heat had lasted for 20 hours were delivered (in Proskau) of 1 -heifer and 4 bull-calves. - -Further experiments (in Waldau) gave the result that cows served early -were delivered of 1 heifer and 1 bull-calf. In another series (in -Eldera) 9 cows served as soon as heat was observed (or, speaking -strictly, in from ½ to 1½ hours of this), gave birth to 7 heifers and 2 -bull-calves. - -Experiments made at the Royal Friedrich Wilhelm Stud-Farm gave the -following results: In the case of 20 mares, which if _Thury’s_ theory -had been correct should all have given birth to fillies, 11 only -fulfilled this expectation; but 10, on the other hand, were colts. -_Touchon_, in his experiments at Hohenhau, obtained 11 calves and 2 -foals, exhibiting the sex expected in accordance with _Thury’s_ theory. - -_Düsing_ made a compilation of the figures given in all the experiments -made to test _Thury’s_ theory, with the following results: Cows -fertilized early were delivered of 13 bull-calves and 29 heifers; mares -fertilized early were delivered of 10 colts and 13 fillies; cows -fertilized late were delivered of 5 bull-calves and 2 heifers. - -_Gerbe_ made experiments on rabbits, putting the buck to some -doe-rabbits soon after the beginning of their heat, but to others as -late as possible in their heat. On examining the young in the horns of -the uterus, from the ovary downward, the distribution of the sexes was -found to be approximately equal. - -Whilst _Coste’s_ experiments on a hen gave results contradictory to -_Thury’s_ theory, _Albini’s_ experiments, made also on the common fowl, -gave results in agreement with that theory. He found that the hens began -again to lay fertilized eggs 3 to 6 days after intercourse with the cock -(from which they had previously been kept separate); on the average, the -distribution of the sexes in the chickens hatched from these eggs was -approximately equal, with, however, a slight preponderance of cock -birds. On the ninth and tenth days after separation from the cock the -eggs laid were half fertilized and half unfertilized; on the twelfth day -after separation from the cock the unfertilized eggs were in a great -majority; but even as late as the eighteenth day after separation some -of the eggs laid were still fertilized. The fertilized eggs laid from -the tenth to the fifteenth day after separation when incubated produced -a great preponderance of hen birds. - -We have to thank breeders for a large number of experiments, such as -those made by the breeder _Fiquet_, at Houston in Texas, who found that -a bull upon whose sexual capacities excessive demands were made, -procreated bull-calves exclusively; whereas in herds containing numerous -bulls there were found among the calves born a preponderance of heifers. -In thirty experiments on cattle _Fiquet_ always found that the larger -the number of cows a bull had to serve, and the longer they were kept in -service, the larger was the proportion of bull-calves among their -offspring. On the other hand, if certain cows had their sexual desires -first satisfied by a gelded animal and were then served by a vigorous -and lusty bull, an excessive proportion of heifers was born to these -animals. - -_Janke_ obtained similar results in the breeding of sheep. In a report -made to _Düsing_ he states that in the early part of the lambing season -more ewe-lambs are born than rams; in the latter part of the lambing -season, on the contrary, more rams than ewes. The explanation he gives -is that at the commencement of the pairing the rams are fresh and lusty, -whilst later their potency is comparatively exhausted. In stud-farms, -according to the same observer, it is a familiar experience that the -most vigorous stallions serving a mare in the morning commonly procreate -a filly; but if later in the day they serve a second mare they almost -always procreate a colt. This, he thinks, finds its explanation in the -fact that the stallion, when he serves the second mare, is in a -condition of comparative sexual exhaustion, the more so because he -usually covers the first mare twice. - -_Maritegoute’s_ breeding experiments at the sheep-farm of Blanc -(Haut-Garonne), on the other hand, gave divergent results. In the early -part of the pairing season, as long as the ram’s sexual powers were -completely unimpaired, he procreated more male than female lambs. But -when a few days later a great number of the ewes were simultaneously on -heat and the ram, owing to very frequent acts of intercourse, began to -be sexually exhausted, the procreation of female lambs was in excess. -But when, finally, this period of maximum demands upon the ram’s powers -was past, and the number of ewes on heat became once more small, the -procreation of male lambs in preference to female was again observed. - -The data obtained by _Düsing_ from the Prussian stud-farms, in which, -when greater sexual demands were made on the stallions, more males were -procreated, have been already mentioned. - -_Fiquet_ made interesting experiments on cows and believed that in this -way he was able to demonstrate the influence of nutrition upon the -determination of sex—to such a degree, indeed, that he believed it was -possible to breed calves of either sex at will. The following method -gave him positive results in more than thirty instances. He never had -the cow served by the bull at the first heat, but only at the second (if -a cow is left unserved when on heat, the heat recurs after an interval -of three weeks). The interval of three weeks was utilized in the -preparation of cow and bull for the copulatory act. If a bull-calf was -wanted the cow was supplied with the most invigorating fodder and was -kept on the richest pasture available. The bull, on the other hand, that -was to serve this cow was turned out to graze on the poorest pasture and -was given poor fodder. At the end of the three weeks, when the cow came -on heat for the second time, its sexual appetite was as intense as -possible, whereas the bull showed but slight inclination to the sexual -act. If the bull now served the cow a bull-calf was procreated. The -opposite procedure led to the procreation of a heifer. For this purpose -_Fiquet_ kept the cow on low diet during the interval between the first -and second heats, and had her first served by a castrated animal. When -in this way, and by the low diet, the sexual appetite of the cow had -been sufficiently diminished, it was served by a lusty bull, which for a -long time had not been put to any cow, and the sexual potency of which -had been increased to the uttermost by feeding it for several weeks on -the most invigorating fodder. - -The results of these experiments, according to which the nutrition of -the parent-animals before the copulatory act has an influence upon the -determination of sex, is explained by _Düsing_ in this way, that -nutrition influences also the quality of the reproductive products. -“Poor nutrition gives rise to diminished functional capacity of the -genital apparatus. Thus, for example, the production of semen is -lessened. It can, in fact, hardly be replaced as quickly as it is used -up. This occurs when there is a lack of adequate means of subsistence, -and also when there is a lack of comparatively young males. In both -cases alike we trace the effects in the birth of an excess of males. -Converse conditions give rise to an excess of female offspring.” - -Passing now to consider investigations made by physiologists, _Born_, at -the anatomical institute at Breslau, has endeavoured to solve the -problem of the determination of sex by means of experiment. He employed -for this purpose _rana fusca_, an animal with which positive results can -be obtained in a comparatively short period of time. He examined the sex -both of the frogs in the free state (165), and also of larvæ which he -had bred in specially arranged aquaria. Whereas among the frogs -developing in the open, the numbers of the sexes appeared to be -approximately equal (there was an excess of females amounting to 2 or 3 -per cent.); among those bred in the aquaria there was an enormous -preponderance of females (96 per cent.). This remarkable result is -referred by _Born_ to the inadequate supply of nutriment in the case of -the larvæ bred by him (he fed them on hydræ and on putrefying frog and -tadpole meat); from an examination of the alimentary canal of tadpoles -caught in the open _Born_ ascertained that their normal food was the mud -of the pools in which they were hatched, containing infusoria, -radiolariæ, diatoms, algæ, etc. The accuracy of this explanation -appeared to _Born_ to be more convincingly shown by the results in the -case of one of his twenty-one aquaria. In this one alone the percentage -of males was as high as 28 per cent., and the tadpoles in this attained -the same size as those developed under natural conditions in the open, -whilst in all the other aquaria the tadpoles remained abnormally small. -This particular aquarium, owing to an oversight, had pond-mud on its -floor, whilst all the other aquaria were floored with clean sand. - -_A. von Griesheim_ disputes _Born’s_ results and believes that the -latter, determining the sex of the tadpoles by means of a hand lens, -must have mistaken a great many female tadpoles for males. He himself, -by repeated enumerations of a large number of tadpoles (685), part -caught in the open and part taken from a large aquarium, found that the -ratio between the sexes in the case of _rana fusca_ was regularly 36.7 -males to 63.3 per cent. females. - -_E. Pflüger_ refers the divergence between _Born’s_ results and his own -and those of _von Griesheim_ not to any error made by _Born_ in the -diagnosis of the sex of the tadpoles, but to the fact that in the -latter’s aquaria the mortality of the male tadpoles was probably greater -than that of the females. _Pflüger_ endeavoured to ascertain whether the -concentration of the semen might have an influence in the determination -of sex. A quantity of frog-spawn was fertilized with concentrated semen, -taken direct from the seminal vesicles, and another quantity of spawn -was fertilized with diluted semen, obtained by making an aqueous extract -of the incised testicles. The ratio between the sexes in the case of the -two lots of tadpoles, which were kept in separate aquaria, proved, -however, to be mathematically identical. But another experiment showed -that the number of males was very different, according to the kind or -race from which the animals were derived. He therefore believes that for -the character of the development of the reproductive organs, the race of -the parent animals is determinative. There is very little likelihood of -being able to modify this inherited sexual ratio by means of outward -influences affecting the ova and the ripe semen prior to fertilization, -and just as little by means of a number of abnormal influences (change -of climate, of water, of nutriment, etc.) acting on the fertilized ova. - -_Düsing_,—who in his work on “The Regulation of the Sexual Ratio” (Jena, -1884) most ingeniously advocates the thesis that all animals have the -power, when there is a lack of individuals of one sex, of procreating an -excess of individuals of this deficient sex, or, to put it in another -way, that an excess of one sex determines the procreation of an excess -of the other sex,—instituted experimental investigations regarding the -determination of sex in the following manner (in accordance with a -suggestion made by _Pflüger_): About ninety guinea-pigs were distributed -in two pens in such a way that in one pen there was a great deficiency -of males and a great excess of females, whilst in the other there was a -deficiency of females and an excess of males. Thus the sexual ratios in -the two stalls were opposed. In accordance with _Düsing’s_ theory, -therefore, more males should have been born in the first pen and more -females in the second pen. Every week each pen was examined once or -twice, the sex of the new-born young was ascertained, and they were -distinguished by small incisions in the margin of the ear. A week later, -when the young animals had developed a little further, they were -re-examined to make sure that no mistake had been made. - -At first, in the pen containing the original excess of females, there -occurred a quite remarkable excess of male births. This, however, was -merely the result of chance, for soon the relationships of the sexes -among the new born was reversed, and thenceforward many more females -were born than males. But if all the births occurring in this experiment -are taken into consideration the number is still far too small to allow -trustworthy conclusions to be drawn. - -_Düsing_ emphasizes the fact that such an experiment as this, in order -to furnish results worth consideration, must be continued until the -sexual ratio has become constant, so that it is no longer subject to -alteration by chance variations. If we assume that _Düsing’s_ theory is -false, the results obtained would be the following: In both the pens, in -that in which there was originally an excess of females and in that in -which there was originally an excess of males, the births, if observed -through a sufficient period, would present a definite sexual ratio which -would be the same in both the pens. But if the theory is well founded -the sexual ratio of the new born would vary in the two pens: in the -stall in which there had originally been a deficiency of males there -would be an excess of births of males over females; whereas in the pen -in which there had originally been a deficiency of females there would -on the contrary be an excess of births of females over males. _Düsing_ -recommends that for such experiments even more fruitful animals, such as -rats and mice, should be utilized. - -Institutes for pisciculture would also be extremely suitable for such -experiments in breeding for the determination of the matter under -discussion because, owing to the fact that in these animals -fertilization is effected outside of the body of the parents, a direct -examination of the ova and the semen used in the experiments can be -undertaken, and the fertilization can be made to occur under conditions -subjected to various alterations; also we can employ the roe and the -sperm of fishes whose age, life history, weight and size are accurately -known. - -Much attention has recently been paid to the theory of _Schenk_, based, -as he states, upon numerous experiments regarding the influences by -which sex is determined. This observer also starts from the principle -that ovulation is not independent of the influences of nutrition and -metabolism. He believes that in the cases in which combustion in the -body is effected in such a manner that remnants of unconsumed -substances, still capable of heat-production, make their appearance in -the urine, the ovum of the human female in process of formation is not -so far advanced in its development as it is in cases in which the urine -is entirely free from sugar, or at any rate is free from any -demonstrable traces of the presence of this body. In the former case we -shall find that the ovum is not only less mature, but also that it is -presumably less well nourished. In his view such an ovum is less -completely endowed in respect of the indwelling qualities and forces of -its protoplasm, and it appears for this reason to be adapted only for -the development of a female individual. But when, on the contrary, in -the maternal individual, all the substances formed in and assimilated by -the organism have undergone combustion so completely that there is no -sugar in the urine, not even in the minutest discernible traces, the -maternal body is in a condition suitable for the development of an ovum -adapted to become a male individual. From these inferences, weak though -the chain of argument is, _Schenk_ draws the conclusion, that by the -regulation of the nutritive material supplied to the organism, and by -the suitable choice of that material, we are to a considerable extent -enabled to support an ovum in its process of maturation in such a manner -as to cause it to develop into a male individual. - -The nutritive material selected for this purpose must be of such a -nature that the elimination in the urine of even the minutest quantities -of sugar may be prevented; the urine must appear free from sugar even -when the phenyl-hydrazine test is employed. Thus in every case in which -we wish to influence a woman’s nutrition in such a way as to lead to the -procreation of a male individual we must above all ascertain whether, in -the woman in question, the normal quantity of sugar is present in the -urine. If after the most careful examination no trace of sugar can be -found in the urine, and if reducing substances are present in this -excretion in abundance, no change need be made in the diet, and all we -have to do is to recommend that the requisite fertilization should be -effected as soon as possible, since there is every probability that in -this condition the embryo will prove to be of the male sex. But when, on -the other hand the “normal” quantity of sugar is present in the urine, -or when even traces only of that substance can be detected, it is -necessary by changes in the diet to cause the disappearance from the -urine of every trace of sugar, and at the same time to bring about the -appearance in that fluid of an abundance of reducing substances. -_Schenk_ claims by the experiments he has made along these lines to have -obtained results which show that it is possible in this way to influence -the determination of sex. - -His method is to nourish the mother mainly on nitrogenous materials and -fat, and to give in addition only so much carbohydrate as is necessary -to prevent the absence of this from being seriously felt. This diet -should be continued for a considerable period, at best for two or three -months before the fertilization is effected. After conception also, the -same diet should be continued. In such a manner we are able in certain -cases to bring about the procreation of male offspring. On the other -hand, the desire for the procreation of female offspring remains one -which as yet we have no direct means of fulfilling. - -These vague experiments and ill-grounded theories of _Schenk’s_ do not, -as a matter of fact, constitute an important advance in the theory of -the voluntary determination of the sex of the human offspring. What in -reality are the decisive influences in the determination of sex, and how -the final impulsion in one direction or the other is actually effected, -remain altogether obscure. Prediction of the sex of the offspring, and -the voluntary procreation of male or female infants, remain problems for -the solution of which the most essential data are still lacking. - -_Ernest Hæckel_ writes regarding _Schenk’s_ theory: “This important -‘discovery,’ which at the time of its first announcement attracted -throughout the world an attention rarely given to true scientific -advances, has now dwindled to the incomplete demonstration that the -nutritive condition of the mother exercises a certain influence upon the -determination of the sex of the child. But we knew this much a long time -ago. _Düsing_ and others, partly by physiological experiments and partly -by statistical demonstrations, had shown that changes in the quantity -and the quality of the nutriment supplied to either parent is capable of -influencing the procreation of boys or girls. But if what _Professor -Schenk_ maintains were really true peoples living chiefly upon meat (as, -for instance, in the pampas of South America) should have an -exceptionally large proportion of male offspring; whereas those living -mainly on a proteid-free diet (on meal, sugar, and other carbohydrates), -should have an exceptionally large proportion of female offspring (as, -for example, the rice-eating Indian and Mongolian nations). But this is -by no means the case. And many other well-known facts are likewise -opposed to the ‘epoch-making’ theory of _Schenk_. Whether the fertilized -ovum develops into a boy or a girl, depends, I am convinced, upon far -more complex, and to a large extent still entirely unknown, -physiological causes. The final judgment upon the ‘Schenk theory’ must -be, ‘Much Ado About Nothing.’” - -Our exposition of the present standpoint of the doctrine of the -origination of sex in the human species, has, in fact, shown that -hitherto by statistical work, nor by anatomical investigations, nor, -finally, by the experimental method, have results been obtained which -render it possible to predict the sex of the unborn infant. And even in -respect of the study of those influences which exercise a determining -influence upon the origination of sex, no positive, indisputable -conclusions have been reached. We can only say it appears probable that -there exist _several_ causes of the determination of sex the -_co-operative_ action of which proves effectual. Not in the ovum alone, -nor in the spermatozoon alone, but in the reciprocal influence they -exert one upon the other in the act of conception is sex determined. In -the latter connection the relative and absolute ages of the progenitors -appear to have a certain influence in the determination of the sex of -the embryo; of importance also is the greater or less demand made upon -the sexual capacity of the begetter; of influence too is the time at -which the ovum is fertilized after its discharge from the ovary. It -appears to be fairly well established that when the husband is at least -ten years older than the wife, while the latter is at the age at which a -woman’s reproductive powers are at a maximum, more boys are conceived -than girls (_Kisch_); also that one of the progenitors upon whose sexual -capacities the greater demands are made, tends to procreate an excess of -individuals of his or her own sex (_Piquet_, _Düsing_); and, finally, -that intercourse a considerable time after the cessation of the -menstrual flow (in the second week of the intermenstrual interval or -later) is favourable to the procreation of a male infant (_Thury_, -_Hensen_). The influence of nutritive conditions in the determination of -sex is less clearly established. - -Statistical evidence has proved beyond dispute that given a sufficiently -large number of instances in varying conditions the sexual ratio is 106, -and this fact suggests that the determination of sex is dependent upon -the interaction of two influences operating in opposite directions -within narrow limits, in such a manner that the chances of the birth of -a male infant preponderate over the chances of the birth of a female -infant in the proportion of 106 to 100. In elucidation of this fact -_Hensen_ makes the following comparison: “Let us imagine a balance the -beam of which has two arms of equal length; from the two extremities of -this beam two balls of nearly equal weight begin to roll toward one -another; if one ball rolls more quickly than the other, if one is -lighter than the other, or if one starts to roll before the other, the -opposite end of the beam will sink. The three influences are variously -distributed; one influence may reinforce another, or may counteract -another; but a decisive sinking of one end of the beam will always -ultimately ensue. A minimal shortening or lightening of one arm of the -balance will make the chance that the other arm will descend -correspondingly greater.” - - - STERILITY IN WOMEN. - -When we study the history of human civilization we find that sterility -in women is regarded, not merely as a misfortune, but as a reproach. -Among savage races, and in the Orient, where the position of women is -one of strict subordination, she does not attain an honourable status -until she becomes a mother. In Persia, a sterile woman is always -divorced by her husband. In India, also, when a sterile married woman -has in vain employed the various religious measures advocated for the -relief of her barren condition she is sent back to her parents. Both in -China and Japan, a barren woman is regarded as a most miserable -creature. Among the negro races, a woman who fails to bear children is -the object of scorn and contempt. Among the Dualla negroes, a man whose -wife fails to bear children demands from her parents the return of the -sum which he paid for her at the time of marriage. Many of the -indigenous tribes of South America also make a practice of divorcing a -sterile wife. Among the better-class Circassians, the women do not -attain an assured position until they have borne a child. In Angola a -barren woman is the object of universal contempt, and she often feels -the ignominy of her position so keenly that she commits suicide. Alike -among the Jews and among the Turks, barrenness in a wife is a recognized -ground for divorce, and the woman who has been divorced for this reason -will hardly ever succeed in obtaining another husband, for she is -regarded as one whose body is not properly developed. According to old -German law, barrenness in a wife and impotence in a husband were both -grounds for divorce. The code of the Emperor Justinian allowed of -divorce in cases in which for the space of two years a husband had been -unable to fulfil his marital duties, and such a union was termed -_innuptæ nuptæ_. Among the ancient Romans, although they regarded -barrenness as a mark of the divine disfavour, according to the laws of -Augustus failure to bear children was a punishable offence, and such a -punishment was incurred by any married woman who had attained the age of -20 years without having become a mother. In ancient Greece also, -divorces due to the barrenness of the wife were by no means uncommon. -Among the Slavonic peoples sterility was so greatly despised that there -is a Slavonic proverb which runs: “A woman is no woman until she has -borne a child”: and in Istria a sterile woman is known by the nickname -“Scirke,” which is equivalent to “hermaphrodite.” The Jewish view of the -matter is expressed in the Talmudic rabbinical saying: “A wife’s duties -are beauty, gentleness, and the bearing of children”; and again, “the -poor, the leprous, the blind, and the childless, are like the dead”; -and, finally, “he who refrains from marriage with the deliberate -intention of having no children, incurs the guilt of murder.” In the -Koran we find the fatalistic expression, “God makes a woman barren in -accordance with his will.” - -We can therefore readily understand that in the most ancient medical -writings the question of sterility in women is a matter of earnest -consideration. In the works of the early physicians of Hindustan we find -several apt remarks on the subject. _Susruta_ says: “Pregnancy most -readily results from intercourse during menstruation. At this time the -os uteri is open, like the flower of the water lily in the sunshine.” In -the Old Testament, in which the newly-created human couples receive the -command, “Be fruitful and multiply, and replenish the earth,” we find -frequent references to barrenness as a state equally dishonourable and -unfortunate, and the use of certain plants is recommended as a means of -cure. The Talmud contains several essays dealing with the causes and -treatment of sterility. - -The _Hippocratic_ collection of writings contains a number of passages -dealing with the causes of sterility and with the means to be employed -for its relief. We shall have occasion later to refer to these -recommendations. _Celsus_, on the other hand, has little to say on this -subject. In the works of _Pliny_, and also in those of _Aristotle_, -there are references to the topic of sterility. - -Among the writers of the first century of our era, _Soranus_ discusses -exhaustively the capacity for conception and sterility. In his work we -find, among other passages, the unquestionably accurate remark: “Since -the majority of marriages are concluded, not from love, but in order to -procreate children, it is difficult to understand why, in the choice of -a wife, less regard is paid to her probable fertility than to the -worldly wealth of her parents.” - -In the middle ages, _Paulus Agineta_ more especially treats of the -diseases of women, and among these, of sterility in women. That in -Arabian medicine much attention was paid to this question, we can learn -from the writings of Maimonides. - -By sterility in women we understand the pathological state in which a -woman who is sexually mature fails to conceive, notwithstanding -frequently repeated, normal sexual intercourse throughout a considerable -period of time. - -Sterility is termed _congenital_ (or _absolute_) when, notwithstanding -repeated intercourse throughout a long period (not less than three -years), pregnancy has always failed to ensue; it is termed _acquired_ -(or _relative_), when women who have already been pregnant once or more -often, cease to conceive, although they are still quite young enough to -do so, and have experienced regular sexual intercourse for a long period -(not less than three years). In a wider sense of the term, we say that a -woman is sterile, when, notwithstanding prolonged and repeated sexual -intercourse, in circumstances favourable to procreation, she has failed -to give birth to a living and viable infant. - -English authors also make a special distinction regarding that form of -acquired sterility (which is no great rarity), in which a woman gives -birth to a single infant and subsequently remains sterile (“_only-child -sterility_”). - -The civilization of the present day, with its shady side, has made it -necessary for us to pay an increasing attention to _facultative -sterility_, dependent upon the use during intercourse of means for the -prevention of conception; and very recently the surgical tendency of -modern gynecology has brought into being a new variety of sterility in -women, viz., operative sterility. - -The period which must elapse after marriage, before the absence of -pregnancy must lead us to regard a woman as sterile, is fixed at three -years. This limitation is based upon the statistical data which (see -Table on page 368) I gave regarding 556 fruitful marriages. - -The ideal state of fertility, that in which conception is the immediate -result of the first act of intercourse between husband and wife, the -conception being followed in due course by the birth of a child, is, -like most other ideals, one very rarely attained. In the human species, -conception as the immediate result of the first act of sexual -intercourse, is an extremely unusual occurrence. To invoke medical -assistance for women who have failed to conceive during the first three -months of married life, which my experience shows to be more frequently -done now than formerly, is devoid of all justification; and still worse -is it, in this period of “early love” to subject women, as has often -been done recently by overenergetic gynecologists, to local treatment, -even to the extent of operative procedures. - -We are not justified in speaking of the existence of actual sterility -until three years of marital intercourse have failed to result in -conception; still, when the commencement of the first pregnancy is -delayed for more than sixteen months after marriage, there is -considerable probability that the woman is sterile; and this probability -increases month by month till the expiry of the second year, whilst as -the end of the third year approaches, it becomes tantamount to -certainty. - -Sterility is one of the commonest of the functional disorders of women, -and one of those which most often demand gynecological assistance. - -By a statistical study of the marriages of the royal and princely -families of Europe and of the marriages of the highest families of the -aristocracy, I learned that of 626 marriages, 70 were barren; thus the -ratio of fruitless to fruitful marriages proved to be as 1 : 8.87. But -in other circles of society, in so far as data relating to the matter -were obtainable in my practice, the statistics of infertility were by no -means so unfavourable, the ratio working out at about 1 barren to 10 -fruitful unions. I must point out, however, that these statistics, like -all statistics of fertility, are to a degree invalidated by the fact -that in a certain number of the instances included among the barren, an -unnoticed abortion may have occurred. - -_Simpson_, in his investigation regarding the frequency of sterile -unions, found a ratio of 1 : 8.5 (in 1252 instances). In the English -aristocracy, where the marriages are for the most part restricted among -the members of a comparatively small number of families, the ratio was -1 : 6.11 (495 instances); on the other hand, among the population of -Grangemouth and Bathgate, consisting chiefly of persons engaged in -seafaring and agricultural occupations, the ratio of barren to fruitful -unions was as 1 : 10.5. - -_Spencer Wells_ and _Marion Sims_, as a result of their investigations, -give a ratio of 1 : 8. - -According to _Seeligmann_, in Hamburg, among marriages of persons in all -classes of society, 11.5% are barren. _Prochownick_ found among 2500 -women, all of whom had been married for eighteen months or more, and -none of whom were more than 40 years of age, that 9% had failed to -conceive. - -According to _Frank_ and _Burdach_, who do not publish the figures upon -which their estimate is based, only 1 marriage in 50 proves barren. -_Lever_, who also gives merely his percentage result, states that 5% of -married women are completely infertile. _Hedin_, dealing with a Swedish -community of 800 persons, states that the percentage of sterile unions -is barely 10. - -According to _Goehlert’s_ statistical investigations, in the dynasty of -the Capets, among 450 marriages, 19.7% were sterile: in the Wittelsbach -dynasty (Bavaria), among 177 marriages, 23.7% were sterile; and among -the ruling families of Germany (more than 600 marriages), 20.5% were -sterile. In this investigation, however, no attention is paid to the age -of husband or wife; marriages and remarriages are classed together -without discrimination; and those marriages only in which a living child -was born are counted as fruitful, so that the unions counted as sterile -must contain many in which abortion or stillbirth occurred. In three -Esthonian communities in Livonia, _Oehren_ found that among 2799 -marriages, 8.4% were barren, but in this instance also stillbirths were -ignored. - -_Ansell_ reports that of 1919 marriages of women belonging to the upper -classes, their mean age being 25 years, 152 proved barren, a proportion -of 1 : 12, or about 8%. - -_Matthews Duncan_ communicates the following data. In the year 1855, in -the cities of Edinburgh and Glasgow, 4447 marriages were contracted, and -of these 725 proved barren, a proportion of 1 : 6.1; 75 of these may -however be excluded from consideration, inasmuch as the wives were -already at the age of 45 or upwards. Among the remaining 4372 marriages, -662 proved barren, a proportion of 1 : 6.6. In other words, 15% of all -marriages of women between the ages of 15 and 44 proved sterile. - -From France we obtain figures showing a much higher proportion of -sterile unions. According to _Rochard_, in France in the year 1888, of -ten million families, two million had no child at all, and two million -had each an only child, so that two fifths of the families of France -were taking no practical part in the maintenance of the population. -According to _Chevin_, the proportion in France of barren to fruitful -marriages is as 1 : 5. 20% are entirely barren, while 24% exhibit -only-child-sterility. - -From Massachusetts, _Morton_ reports that according to the last census -returns, one fifth of all married women are childless. - -In England, numerous trustworthy statistics can be obtained regarding -the frequency of sterile marriages. The average proportion of barren to -fruitful unions was: - - Among the patients in St. Bartholomew’s Hospital 1 : 8 - Among the inhabitants of Grangemouth 1 : 10 - Among the inhabitants of Bathgate 1 : 10 - Among the British peerage 1 : 6 - Among the upper classes 1 : 12 - Among the inhabitants of Edinburgh and Glasgow 1 : 7 - -_Matthews Duncan_ compiled the following table relating to 504 -absolutely sterile women met with in his practice: - - ═════════╤═══════════════════════════════════════════════════════════════ - AGE AT │ NUMBER OF YEARS MARRIED. - MARRIAGE.│ - ─────────┼───────┬───────┬───────┬───────┬───────┬───────┬───────┬─────── - „ │ Less │4 to 8.│ 9 to │ 14 to │ 19 to │ 24 to │ 29. │Totals. - │than 3.│ │ 13. │ 18. │ 23. │ 28. │ │ - ─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼─────── - 15 to 19 │ 12│ 19│ 15│ 4│ 7│ 2│ 1│ 60 - 20 to 24 │ 70│ 66│ 37│ 24│ 13│ 9│ │ 219 - 25 to 29 │ 47│ 51│ 20│ 8│ 8│ │ │ 134 - 30 to 34 │ 26│ 20│ 8│ │ 1│ │ │ 59 - 35 to 39 │ 6│ 13│ 4│ │ │ │ │ 23 - 40 to 45 │ 6│ 3│ │ │ │ │ │ 9 - ─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼─────── - Totals │ 167│ 172│ 84│ 40│ 29│ 11│ 1│ 504 - ═════════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════ - -_Ansell_ bases upon the observations made by him in the case of 152 -sterile women the conclusion that there is no longer any chance of the -occurrence of pregnancy if a woman is: - - More than 48 years old, and has had no child for 2 years - More than 47 years old, and has had no child for 3 years - More than 46 years old, and has had no child for 4 years - More than 45 years old, and has had no child for 6 years - More than 44 years old, and has had no child for 8 years - Less than 44 years old, and has had no child for 10 years - -If we take into account also cases of acquired sterility, the proportion -of barren to fruitful marriages becomes even more unfavourable, and the -proportion increases enormously if, with _Grünewaldt_, we number among -the barren women those who fail to continue child-bearing up to the -normal climacteric period. _Grünewaldt_, dealing with about 1500 women -suffering from affections of the reproductive organs, excluded all those -who were either virgins or widows, and also all those who at the time of -the observed barrenness were over 35 years of age; this left more than -900 women suffering from affections of the reproductive organs, all of -whom were sexually mature, and were living in marital intercourse; of -these, nearly 500 were barren, 300 being instances of acquired -sterility, and 190 instances of congenital sterility. Thus, according to -this observer, disease of the reproductive organs in women led in more -than 50% of the cases to disturbance of the reproductive capacity; about -one in every three women, previously competent to bear children, became -barren when affected with disease of the reproductive organs; and among -every five gynecological patients of the condition already specified as -regards age and sexual intercourse, one proves congenitally sterile. - -It must not, however, be forgotten, that sooner or later after marriage -artificial sterility tends to come into being, its early or late -appearance depending upon the degree of civilization and upon the -national and economical conditions of the people and the individuals -concerned. This fact must not be left out of the account. - -The manner in which, in the human species, fertilization is effected, is -still far from clear in all its details; hence it is easy to understand, -that the etiology of sterility remains in many respects obscure. It is -impossible in every case to find a definite cause. Whereas, on the one -hand, notwithstanding the existence of apparently insuperable obstacles, -impregnation may nevertheless be effected; so, on the other hand, -sterility may exist in cases in which all the circumstances appear -favourable to the occurrence of conception. Hence a classification of -the different varieties of sterility from the etiological standpoint, is -a very difficult task, and the conclusions thus obtained are often -vitiated. - -Although it cannot be denied that mechanical causes are competent to -lead to sterility in women, _Sims_, in his advocacy of the mechanical -doctrine of sterility, widely overshoots the mark. His authority, -however, has led to a general acceptance of this doctrine, which is by -no means justified by facts. The theory of mechanical obstruction, -according to which sterility in women depends upon mechanical obstacles -to the passage of the spermatozoa towards the ovaries, is from time to -time strikingly illustrated by cases coming under our notice—cases the -nature of which can hardly be overlooked; but it is quite wrong to -suppose that this causation accounts for the _majority_ of instances of -sterility in women, and strict limitations should be placed upon the -employment of surgical measures based upon this mechanical theory of -sterility. - -The mechanical view has been counterposed by _Von Grünewaldt_ with a -doctrine in which especial stress is laid upon obstacles to -utero-gestation, sterility being regarded as a functional disorder -brought about by affections of the female reproductive organs rendering -the uterus unfit for the incubation of the ovum. It cannot be denied -that the elucidation of this casual influence was a valuable -contribution to the theory of sterility, and it is unquestionable that -many morbid conditions of the uterus exist capable of giving rise to -sterility in this manner; but we must avoid the error of regarding this -doctrine as a full explanation of the cause of sterility. - -If, however, both of these theories of sterility are insufficient, we -cannot regard a third theory, that of _Matthews Duncan_, as filling the -gaps in our knowledge. It would be most unfortunate if this author were -right in maintaining that all our knowledge of the causes of sterility -is to be summed up in the phrase “deficient reproductive energy;” we -cannot agree with _Duncan_ in his belief that “Sterility is an -imperfection devoid of all perceptible, measurable characteristics;” nor -can we follow him when he maintains that local causes, whether they are -such as hinder conception, or such as hinder utero-gestation, have a -very limited sphere of activity. _Matthews Duncan_ adopts an -incomprehensible standpoint when he regards sterility as dependent upon -a law of nature, as a condition which may affect distinct classes or an -entire population. - -According to the latest doctrine of sterility, only in quite exceptional -instances is the woman regarded as responsible for the occurrence of -sterility; contrariwise, the male genital organs are commonly blamed for -the affection, which is in the overwhelming majority of cases supposed -to be due to azoospermia, usually dependent upon gonorrhœal infection; -compare with this, affections of the female reproductive organs are said -to play a quite subordinate role in the etiology of sterility. But for -my part, though I recognize the important share that gonorrhœa in the -male plays in the causation of sterility, I am of opinion that the -extreme view just mentioned is by no means justified by the facts. - -Sterility, a functional disturbance of an extremely complicated nature, -can, in my opinion, be most usefully elucidated from the etiological -standpoint by starting with the assumption that three conditions are -absolutely essential to procreation: - -1. that ovulation proceeds in a perfectly normal manner, the maturation -of the discharged ova being complete; - -2. that normal spermatozoa have access to these normal ova (conjugation -of male and female pronuclei); - -3. that the uterus is properly adapted for the gestation of the -fertilized ovum. - -My classification of the varieties of sterility corresponds to these -conditions of procreation: - -1. sterility due to incapacity for ovulation; - -2. sterility due to some hindrance to the conjugation of ovum and -spermatozoon (under this head come also those cases in which the male is -at fault—azoospermia, and the like); - -3. sterility due to incapacity for gestation. - -It must also be admitted that there are additional causes of sterility, -causes which lie beyond our control. Moreover, as I have already -mentioned, in most cases of sterility, we have to do, not with a single -cause, but with the resultant of two or more cooperating causes. - - - _Incapacity for Ovulation._ - -Incapacity for ovulation, the first and most decisive cause of sterility -in women, may be absolute and irremediable, or relative and transient. -We have to do with the former in cases in which the ovaries are entirely -wanting, or when they are affected with organic disease to such a degree -that they have become incapable of fulfilling their function of -ovulation; incapacity for ovulation is, on the other hand, relative and -transient in certain pathological states of the ovary and neighbouring -organs, when there is incomplete development or partial atrophy of the -ovaries, when there are new-growths of the ovaries, in cases of -oophoritis and perioophoritis, in consequence of disturbances of -innervation, diseases of the central and peripheral nervous system, -violent emotional disturbance, constitutional disorders, such as -syphilis, chlorosis, anæmia, universal lipomatosis, scrofula, -alcoholism, and morphinism, also in consequence of changes in the supply -of nutriment and in the general mode of living, or of senile changes, -and finally in consequence of hereditary influences. - -The diagnosis of the etiological influence of suppressed or incomplete -ovulation in the production of sterility in women is at times beset with -great and even insuperable difficulties. The state of the menstrual -function, suppression of the flow, or the regularity or irregularity of -its occurrence, serve indeed to inform us as to the general activity or -inactivity of the function of ovulation; but the variations in this -function give no certain information as to whether a woman is fertile or -infertile. Knowing as we do that generally speaking an intimate -connexion subsists between menstruation and ovulation, we are indeed -able to assert that regular menstruation and fertility in women run a -parallel course, and further, that the greater the irregularity of the -menstrual function, the greater the tendency to sterility. Recently, -great advances have been made in the technique of manual exploration of -the ovaries, and by means of vaginal and rectal bimanual examination, we -are now able to obtain accurate information regarding abnormalities in -the size, shape, and position of these organs, and regarding any other -intrapelvic disorders. In this way we have been enabled to recognize a -number of pathological states of the ovaries which affect the functions -of these organs. In some cases also there are general symptoms which -furnish us with the means of drawing conclusions, more or less -trustworthy, regarding the state of the ovarian functions; for instance, -the general development of a woman’s body, the condition of the external -genitals, the vulva, the mons veneris, the pubic hair, the clitoris, and -the mammae. Again, we can derive information from various troubles of -which women complain; such as sacrache; a sense of weight and pressure -in the pelvis; feelings of tension and shooting pains in the breasts; -flushings of the face; haemorrhage from the nose, mouth, or rectum, -recurring at regular intervals and vicarious in nature. In many -instances, however, it will only be by obtaining data regarding the age, -mode of life, and family history, of the person affected, that it will -be possible to draw conclusions as to the cause of the sterility. - -The female reproductive glands, the ovaries, may, owing to developmental -disturbances during foetal life, either be entirely wanting, or they may -merely be deprived of certain structural constituents, especially their -epithelial elements. In the former case, we have congenital complete -unilateral or bilateral absence of the ovary, a condition most commonly -associated with the absence or with a rudimentary condition of other -portions of the reproductive apparatus; in the latter case, we have the -condition somewhat inappropriately named congenital atrophy of the -ovary. - -Complete absence of both ovaries necessarily leads to absolute -sterility. Both congenital absence and congenital atrophy of the -ovaries, will usually be found in association with other anomalies of -the sexual organs. Absence of one ovary, on the other hand, by no means -entails sterility; on the contrary, when a single well-formed ovary -exists, ovulation usually proceeds in a perfectly normal manner. When -such women marry, pregnancy usually follows in the normal proportion of -cases; and, in complete opposition to one of the theories of the -determination of sex to which allusion has been made, such women bear -children of both sexes. - -_Morgagni_ described a case of congenital absence of both ovaries in a -woman 66 years of age, in whom the external genital organs, the vagina, -and the uterus, were imperfectly developed, but the Fallopian tubes were -of normal size. Careful examination of the upper borders of the broad -ligaments of the uterus disclosed no trace of ovary on either side. - -_Quain_, in a virgin 33 years of age, found the vagina rudimentary, with -its mucous membrane but slightly corrugated; at the upper end of this -passage was a semilunar fold which probably represented the uterus. The -ovaries were absent; a small gland-like body embedded in the left wall -of the vagina was regarded by him as a rudimentary ovary. The -configuration of the body was feminine, feminine also the disposition; -moreover, there was a monthly recurrent epistaxis. - -The atrophy of the ovaries which normally takes place at the climacteric -period, to be more minutely described in the section on the menopause, -has constitutional effects similar to those dependent upon absence or -congenital atrophy of the ovaries. - -A rudimentary condition of both ovaries, or bilateral atrophy of these -organs, with or without associated atrophy of the entire reproductive -system, commonly entails sterility. In such cases, in addition to -amenorrhœa, we usually find that the breasts are but slightly developed, -the pubic hair is scanty, the labia majora and labia minora are small, -whilst sexual appetite is deficient, and during coitus the woman is -entirely passive. On the other hand, we must not make the mistake of -inferring from the fact that the sexual appetite is keen and coitus -pleasurable, that therefore the capacity for ovulation is normal. Even -after operative removal of both ovaries, some women have assured me, not -only that the sexual impulse was as strong as formerly, but even that -they continued to experience the sexual orgasm in its full intensity. -This is analogous to the well known fact that men who have undergone -castration after arriving at sexual maturity may remain capable of -performing coitus. It is a matter of history that in the lupanars of -ancient Rome, castrated men were kept to enable women to enjoy the -pleasures of sexual intercourse without fear of consequences; and it is -said that such men are to be found in Italian brothels to this day. In -the case of the lower mammals, it appears to be the rule that when the -reproductive glands are removed in early youth, every trace of sexual -desire disappears. - -Incomplete development of the ovaries, with consequent defective -ovulation, may result from marriage in girls who are still immature—a -fact already known to _Aristotle_, who wrote, “premature marriage leads -to a scanty progeny—that this is the case in man as well as the lower -animals is witnessed by the weakly inhabitants of regions in which -child-marriage is common.” - -It is shown by statistical data that the age at which puberty occurs, -the age, that is, at which the menstrual flow begins, has a relation to -sterility; and the same is true as regards the age at marriage. In the -former connexion, women in whom puberty is comparatively early, are less -often sterile than those in whom puberty is comparatively late. _Emmet_, -in an investigation embracing 2330 cases, showed that in our climate the -average age at which the first menstruation occurred was 14.23 years, -and that in the case of women who subsequently proved fertile, the first -flow took place on an average 26 days earlier than in the case of women -who subsequently proved barren. We also learn from _Emmet’s_ tables that -the mean duration of menstruation and the mean quantity of the flow are -larger in fertile than in barren women. - -As regards the influence of the age at marriage upon fertility, in women -who marry between the ages of 20 and 24 years, sterility is most -infrequent; it is commoner in women who marry between the ages of 14 and -20; after the age of 25, the proportion of sterile women increases with -each year to which marriage is postponed. - -Premature atrophy of the ovaries, with consequent incapacity for -ovulation, may occur in a great variety of conditions; it has been -observed in scrofula, diabetes, rickets, phthisis, and malarial -cachexia; it also occurs in certain chronic intoxications, as from the -long-continued use of opium or morphine, and from the abuse of alcoholic -beverages. According to the observation of _Burkart_, _Levinstein_, and -_Erlenmeyer_, morphinism is a condition which may be relied upon to -bring about amenorrhœa and temporary sterility from cessation of -ovulation. It has been asserted but by no means proved, that the -long-continued administration of quinine hinders ovulation. As a result -of various acute and chronic disorders, a simple atrophy of the ovarian -follicles can be detected, dependent upon simple fatty degeneration; -this has been seen by _Grohe_ in children as a result of general -atrophy, and also following caseous and suppurative diseases of the -respiratory organs; by _Slavjansky_ in children after chronic pneumonia -and chronic dysentery, and in adults as a sequel of typhoid, and in one -instance as a sequel of puerperal septicaemia. - -Hyperplasia of the ovarian stroma, in slighter degrees of the affection, -leads to menstrual disturbances, partly of nervous and partly of -inflammatory nature, and in more severe degrees leads to sterility -dependent upon the hindrances which the thickened tunica albuginea -offers to the bursting of the mature follicles. _Klebs_ believes that -this anomaly is always due to a disposition acquired very early in life, -and perhaps at the time when the ovaries are first developed. - -Follicular cysts of the ovary, which are formed mostly at the time of -puberty, and originate under the influence of menstrual congestion, from -graafian follicles near to ripeness, are competent to cause sterility, -owing to the pressure they exercise upon the superficially placed -rudimentary follicles, leading to the atrophy of these latter. Other -new-growths of the ovaries have similar effects, such as adenomata, -carcinomata, dermoid cysts, cystomata, sarcomata, and fibromata. In many -cases of these disorders, however, the ovarian follicles may for long -periods remain unaffected; and in these instances, ovulation, -menstruation, and even conception, may proceed undisturbed. Even in -cases in which a neoplasm attains a great size, if it affects one ovary -only, ovulation may occur normally in the other, and conception may -ensue; and even in the diseased ovary, if small portions of its tissue -remain unaffected, ovules may be discharged from these portions. The -minutest portion of healthy ovarian tissue, though all the remainder has -been destroyed by disease, may suffice to bring about conception. - -Ovarian tumours appear with considerable frequency to be complicated -with sterility; but in such cases the question always remains open, -whether in the majority of instances the sterility is to be regarded as -the cause or as the consequence of the ovarian disease. _Boinet’s_ -figures dealing with this problem are the most striking of all. He -states that of 500 women with ovarian tumours, 390 were childless. But -these results are challenged by other observers. _Veit’s_ estimates, -based upon a compilation of the figures of _Lee_, _Scanzoni_, and -_West_, is that 34% of women with ovarian tumour are sterile. On the -other hand, _Negroni’s_ collection of 400 cases of ovarian tumour, -including both married and unmarried, contained 43 only who had never -been pregnant. Other lists show: 13 sterile women among 45 suffering -from ovarian tumour (_von Scanzoni_); 1 sterile among 21 (_Nussbaum_); 8 -sterile among 63 (_Olshausen_). _Winckel_, among 150 sterile married -women, found 32 suffering from ovarian tumour, which in two of these -cases only was bilateral. _Atlee_, in 15 cases of ovarian tumour, -observed premature cessation of menstruation at the ages of 30, 39, 40 -and 42, respectively. - -Although in many cases sterility develops coincidently with the growth -of an ovarian cystoma, yet in many other women such tumours have no -influence in diminishing fertility. _Martin_ in a case in which -sterility existed in connexion with a unilateral ovarian cystoma, the -other ovary being healthy, observed pregnancy as a sequel of the removal -of the diseased ovary. In one of these cases, after removal of the -ovarian cystoma, _Martin_ punctured in the other ovary a dropsical -follicle which had attained nearly the size of a walnut. Pregnancy in -this case also followed the resumption of marital intercourse. _Müller_ -reports that in his clinique within recent years pregnancy complicated -with ovarian tumour has been observed in 7 instances; in one of these -cases the pregnancy occurred notwithstanding the fact that the -new-growth was so large as almost to fill the abdominal cavity. _Holst_ -reports the case of a multipara 43 years of age who died in the 18th to -the 20th week of pregnancy; at the post mortem examination the left -ovary was found to be transformed into three cysts each the size of an -apple, whilst in place of the right ovary was a medullary carcinoma the -size of a man’s head; on neither side could a trace of normal ovarian -tissue be detected. _Spiegelberg_, in a woman who died shortly after -giving birth to her second child, found that both ovaries were -transformed into myxo-sarcomatous tumours; in a woman aged 42, who died -four weeks after her eleventh confinement, both ovaries were found to be -transformed into nodular carcinomatous tumours each larger than a -child’s head; in none of these ovaries was any normal stroma to be -found. _Ruge_ reports the case of a woman 36 years of age, who -miscarried in the sixth month of pregnancy; she had myxo-sarcoma of both -ovaries, one weighing 5620 grammes the other 480 grammes. - -All these cases indicate that, notwithstanding the existence of -extensive degeneration of both ovaries, some minute remaining fragment -of healthy ovarian stroma is competent to produce normal mature ova—a -fact which has often been proved also by microscopical examination. That -under the influence of pregnancy, existing ovarian tumours often take on -extremely rapid growth, is also indicated by some of the above cases. - -Castration (oöphorectomy, spaying, _Battey’s_ operation), the removal of -both ovaries, naturally results in sterility. If in the literature of -the subject cases are to be found in which, after this operation, not -menstruation merely, but even pregnancy has occurred, this is to be -explained either by the fact that in the stump there was left a fragment -of the ovary, still containing tissue capable of producing mature ova; -or else by the existence of a supernumerary ovary. _Schatz_ reports the -case of a woman in whom pregnancy occurred after double oöphorectomy. In -the month of February, 1880, this operation was performed on a girl -twenty years of age; she married in April, 1884; and in May, 1885, she -was delivered of a mature female infant. The history of the case and the -details of the operation showed clearly that the left ovary had been -completely removed, with the outermost third of the left Fallopian tube; -the right ovary was cut away in such a manner that a strip of tissue of -at most two millimetres (one twelfth of an inch) in width was left in -the body, whilst the right Fallopian tube was left intact. This case -teaches us that the smallest remnant of the ovary is competent to render -normal pregnancy possible; and further, that a small size of the ovary -no more constitutes a hindrance to the proper reception of the ovum in -the Fallopian tube, than does an abnormally large size of the ovary, or -an unusual shape of this organ. - -_Miklucho-Mackay_ relates that among the indigens of Australia the -removal of the ovaries is often practised, in order to create a special -kind of hetairæ incapable of becoming mothers. _McGillivray_ saw at Cape -York a native girl whose ovaries had been removed because she was a -congenital deaf-mute, with the object of preventing her giving birth to -deaf-mute infants. In the beginning of the last century there existed in -Sayn-Wittgenstein a small religious sect whose custom it was always to -conclude their religious services by indiscriminate carnal union among -the members of the community; when women and girls were first admitted -as members of this sect, an attempt was made to render them unfitted for -conception “by means of a painful and dangerous compression of the -ovaries.” (_Ploss_.) - -A transient, relative hindrance to ovulation may be brought about by -various pathological states of the ovaries. Acute oophoritis usually -suspends the ovarian functions; chronic oophoritis has sometimes a -similar effect, not only because the profound changes that take place in -the ovary hinder the formation of the ovules, but also because, as we -shall later explain more fully, the expulsion of the ova and their -reception by the Fallopian tubes are hindered. In severe oophoritis and -perioophoritis, more especially in parenchymatous inflammation, -sterility may be brought about by an absorption of the finely granular -contents of the follicles, which collapse, with adhesion of their walls; -when all or most of the follicles are thus affected, the ovaries become -small and hard. - -In perioophoritis, the exudation leads to the formation of cord-shaped -or ribbon-shaped adhesions between the ovaries and the broad ligaments, -the uterus, and the peritoneal folds of the neighbourhood. The ovary in -such cases may also be displaced, or may undergo atrophy from pressure. - -In the case of 200 sterile women, I found in 46 instances chronic -oophoritis and perioophoritis. _Olshausen_ reports that of 12 married -women suffering from chronic oophoritis, five were barren, whilst of the -remaining 7, three only had given birth to more than one child. -_Matthews Duncan_, on the other hand, saw pregnancy in a case of -bilateral ovarian inflammation, in which the organs were considerably -enlarged. - -Further, local or general peritonitis may lead to parenchymatous -inflammation of the ovaries, and this, spreading from the periphery -towards the centre of the organ, attacks the follicles irrespective of -their ripeness. Again, during the puerperium, the interstitial form of -oophoritis is by no means rare, and this may at times lead to permanent -sterility in either of two ways: it may be in consequence of the onset -of a secondary parenchymatous inflammation, which destroys all the -follicles; it may be because a thick and tough layer of sclerosed tissue -forms around the periphery of the ovary, which mechanically prevents the -maturation and rupture of the follicles. According to _Slavjansky_, -puerperal disease is the principal cause of this form of oophoritis. -_Olshausen_ indicates as the most frequent cause of primary -perioophoritis, an inflammation propagated from the Fallopian tubes, -leading to the formation of masses of exudation, which envelop the -ovary, and by the pressure they cause, and by interfering with the -blood-supply, lead to atrophy of the gland. - -Sometimes the chronic inflammatory induration by means of which the -stroma of the ovary is rendered denser and firmer, is due to changes in -the vessels, and depends upon valvular defects of the heart—upon venous -congestion. In this way, heart disease may hinder ovulation and bring -about sterility. Both syphilis and gonorrhoea may give rise to chronic -inflammatory changes in the ovary, usually leading to premature -contraction of the tissues and to the formation of numerous adhesions. -According to _Olshausen_, amenorrhœa is not a common feature of ovarian -disease, except in cases of defective development of these organs, of -cirrhosis of the ovaries, and of bilateral new-growths. Disease -affecting only a single ovary, even tumour of considerable size, rarely -causes amenorrhœa until profound constitutional disturbance has ensued. -An exception to this rule is found in the case of carcinomatous tumours -of the ovary; these, indeed, are commonly bilateral; but even when -confined to a single ovary, amenorrhœa is a comparatively early symptom. -According to the same author, sterility is a common consequence of -chronic oophoritis and its sequelae, and is usual also in cases of -bilateral new-growths; on the other hand, tumours affecting a single -ovary often fail to prevent conception even though they have attained a -great size. - -Syphilis in women must be regarded as a frequent cause of sterility, by -interference with ovulation, but is in this regard by no means an -absolute bar to the occurrence of pregnancy. According to _Parent_ and -_Duchatelet_, under whose observation during the space of 12 years there -came annually an average number of 2625 syphilitic prostitutes, the -average annual of births in these cases was 63 only. According to _Marc -d’Espine_, 2000 prostitutes gave birth on an average to two or three -children in all during a year. (That there are other causes besides -syphilis for the remarkable infertility of women of the town, will be -explained later). According to _Bednar, Mayr_, and others, -constitutional syphilis in women invariably leads to sterility; others, -as for instance _Zeissl_, believe that women suffering from inveterate -syphilis are commonly, but not invariably, sterile; whilst according to -_Rosen_, conception only takes place in syphilitic women in whom the -disease has passed into the tertiary form. Experience shows, however, -that neither early nor late forms of syphilis necessarily lead to -sterility in women. It must also be pointed out, that syphilis in the -male _may_ be the cause of sterility, and _must_ be the cause thereof -when the disease is localised in the testicles, and the consequent -degeneration of the glandular substance leads to the occurrence of -azoospermia, more particularly when syphilitic or gummatous orchitis is -bilateral. According to _Lewin_, we fail to find spermatozoa in 50% of -men, otherwise powerful, suffering from syphilitic dyscrasia. _Hanc_, on -the other hand, failed to find azoospermia in any one of ten men -suffering from lues. In animals also syphilis is said to cause -sterility. - -The manner in which certain anomalies of the blood (anæmia and -chlorosis), general disturbances of the nervous system, febrile states, -and such constitutional disorders as scrofula, have a temporary or -permanent influence in checking ovulation, is far from being understood; -but the fact that ovulation is checked by such conditions, has been -established beyond question by numerous observations. It is well known -that severe fevers, more especially typhoid, suspend the ovarian -function; that in various chronic disorders of an enfeebling nature, and -notably in chlorosis, all signs of menstrual activity disappear; and -that in certain nutritive disturbances, as in extreme obesity, -amenorrhœa also occurs; finally, numerous cases are on record in which -some sudden affection of the nervous system has instantaneously -inhibited ovarian activity. - -In anæmia and chlorosis, it is probable that the degree of menstrual -congestion is insufficient to ensure the bursting of the graafian -follicle. The sterility often observed as a sequel of typhoid, malaria, -the acute exanthemata, cholera, and septicaemia, is probably due in most -cases to the occurrence of parenchymatous oophoritis, with consequent -destruction of the ovarian follicles. The researches of _Slavjansky_ -have shown that in acute disorders inflammatory changes often occur in -the graafian follicles. When infectious disorders ran an acute course, -this observer usually found that the parenchymatous inflammation of the -ovary had occurred near the periphery, in the cortical layer, the -destruction being limited almost exclusively to the primitive follicles; -when the course of the primary disorder was more chronic, the mature or -nearly mature graafian follicles were the ones destroyed. When -inflammation of a follicle has led to its destruction, it is replaced by -a linear scar. _Lebedinsky_ found similar changes in the ovary after -scarlatina—destruction of a lesser or greater number of follicles, with -formation of scars. Thus, parenchymatous oophoritis as a sequel of acute -diseases, may, if severe, lead to destruction of all the rudimentary -follicles, with consequent sterility. In the post mortem examination of -such cases, the condition of the ovaries is similar to that which is -elsewhere in this work described as characteristic of these organs after -the menopause: the ovary is diminished in size, its surface is furrowed, -the tissue is indurated in consequence of overgrowth of fibroid tissue; -often not a single follicle is to be detected on section of the organ. - -Immoderate obesity is a disorder of nutrition favoring the occurrence of -sterility. - -In very obese women of an age which normally is the reproductive prime, -amenorrhœa or scanty menstruation is a very common accompaniment. In 215 -such cases which came under my own observation, amenorrhœa was present -in 49, and menstruation was scanty in 116; thus in nearly three fourths -of these obese women menstruation was either deficient or entirely -wanting. Very remarkable also is the high percentage of sterile women -among the obese. In the 215 cases already mentioned (all married women), -48 were sterile—a percentage of 21. Whilst the ordinary ratio of barren -to fruitful marriages is 1 : 10 or 1 : 9, in the cases in which the -wives, or both wives and husbands, are extremely obese, the ratio is -according to my own observations, 1 : 5—or, if we include cases of -only-child-sterility, 1 : 4. - -We cannot wonder at this great frequency of sterility in obese women -when we remember that, apart from the menstrual deficiencies which so -commonly accompany this disorder of nutrition, obesity is apt to entail -many other disorders of the reproductive organs, as for instance a -morbid state of the uterine and vaginal secretions, chronic metritis, -and displacements of the uterus; still, it cannot be denied, that in -many instances we are unable in such obese women to detect any disorder -of the reproductive organs competent to account for the sterility, and -we must therefore assume that the excessive development of fat has some -direct influence in preventing ovulation, or at least that it in some -way exercises an unfavourable influence upon the reproductive process. - -That excessive obesity hinders fertility, is shown by experience both as -regards the vegetable and the animal kingdom. All animal-breeders are -familiar with the fact that undue production of fat limits fertility. -Thus, equally in the case of turkeys and in the case of the common fowl, -if the hens are overfed and become fat, they cease to lay. - -_Hippocrates_ already indicated obesity as a cause of sterility. Writing -of the wives of the Scythians, he pointed out as a proof that their -excessive obesity was the cause of the sterility from which they -commonly suffered, the fact that their female slaves, who were thin, -were readily impregnated by intercourse with the Scythian males. The oft -repeated dwindling and disappearance of ruling families in India and in -Egypt, has doubtless in part depended upon the extreme obesity of the -female consorts of such rulers. - -In many instances, indeed, a great accumulation of fat on the front of -the abdomen and in the vulva, suffices to cause a simply mechanical -hindrance to the proper performance of a fertilizing coitus. It is -possible also that the phlegmatic temperament of very fat women is a -contributory cause to their sterility—if indeed it is in general true -that frigidity during sexual intercourse is unfavourable to conception, -as is expressed by the old proverb, _quo salacior mulier, eo -foecundior_. It is unquestionable that in very obese women sexual -sensibility is commonly greatly deficient, and that their husbands often -complain of their coldness and lack of passion. In several cases that -have come under my observation, dyspareunia occurred in obese and -sterile women. - -The dependence of sterility upon obesity is often proved in the most -striking manner _ex juvantibus_. A “cure” for the reduction of fat often -results favourably in respect also of rendering the woman who undergoes -it readily impregnable—a result by no means ardently desired. - -It must also be pointed out that very obese women form a considerable -section of those suffering from only-child sterility, and this largely -in consequence of their strong predisposition towards abortion. As the -impregnated uterus enlarges, the space for its accommodation is -insufficient, owing to the great development of the panniculus adiposus, -and thus obesity, like intra-abdominal tumour, predisposes to abortion. -The excessive accumulation of fat within the abdomen, by exercising -pressure upon the inferior vena cava or on its principal tributaries, -hinders the venous return, and gives rise to a chronic stasis in the -uterine bloodvessels, those alike of the muscle and of the mucous -membrane. - -Notwithstanding the fact that sterility is so common in very obese -women, the fact remains that some such women are remarkably fertile, and -have very large families indeed. - -_Towers-Smith_, _Duke_, and _Rodriguez_, who have recently all been -engaged in examining the relations between obesity and sterility, agree -in asserting that sterility due to obesity may be cured by dietetic -treatment for the relief of the primary disorder of metabolism. - -Though menstruation is usually deficient or absent in obese sterile -women, and though it is commonly supposed that amenorrhœa implies -sterility, it is necessary to point out that whilst failure of -menstruation is a frequent and important sign of suppression of -ovulation, it by no means invariably has this significance. It is an -established fact, and one borne out by my personal experience, that -women who have never menstruated have nevertheless become pregnant; -others, again, have become pregnant although they have ceased to -menstruate for several years, and this has even occurred in women at a -comparatively advanced age. Hence, from the fact that amenorrhœa exists, -we cannot with certainty infer that a woman is sterile. Moreover, we -must remember that physiologically amenorrhoeic women often enough -conceive—during lactation. Although we hold the opinion that there is an -intimate connexion between ovulation and menstruation, yet it is always -possible in cases in which menstruation fails to occur, that ovulation -has taken place, but that the stimulus which that process has exercised -upon the reproductive organs has been insufficient to give rise to the -customary flow of blood. - -The following remarkable case came under my own observation: Mrs. B., 26 -years of age, had lived in sterile wedlock for six years, had never -menstruated, nor had she ever had any sanguineous discharge from the -genitals. The body was delicately formed, the breasts were fairly well -developed, the external genital organs showed no abnormality. For some -weeks before consulting me, this woman, hitherto childless, and living -in regular sexual intercourse with her husband, had noticed a remarkable -enlargement of the abdomen. Another medical man whom she had consulted -had diagnosed ovarian tumor and had urged operation. A more careful -examination of the pelvis showed, however, that the woman was in the -sixth month of pregnancy, a diagnosis which was duly confirmed by the -delivery of a full-time child. In another of my cases, a woman married -at the age of 45 years, having ceased to menstruate two years -previously. She became pregnant and gave birth to a child in quite -normal fashion. The following instructive case also came under my own -observation: The wife of one of my colleagues, living in sterile wedlock -for 17 years, extremely obese, had since puberty menstruated but -scantily and with great irregularity. The menstrual interval was several -months, and when the discharge did appear, it was pale in colour and -small in quantity; it lasted moreover but a day or two. Last winter, the -flow as usual failed to appear for several months, and since the woman -had at the same time become fatter than ever, Turkish baths and -energetic muscular movements were prescribed. The result of this -treatment was a striking one—abortion. After 17 years of marital -intercourse she had for the first time become pregnant. - -In the case of sterile women who are amenorrhoeic, even when the -amenorrhœa has never been interrupted by a menstrual discharge, or when -it appears entirely dependent upon obesity, it is nevertheless necessary -to be extremely cautious in making a diagnosis, and above all in -employing an intra-uterine sound. In such cases I have known the most -eminent gynecologists unwittingly bring about abortion. - -_Cleveland_, _Godefroy_, _Haschek_, _Ritschie_, _Sommerus_, _Stark_, -_Taylor_, and _Young_, have all reported cases in which pregnancy -occurred in women suffering from amenorrhœa; but all such cases must be -regarded as quite exceptional. _Szukits_ examined 8000 sexually mature -women, and found among them fourteen only who had never menstruated. Of -these, four were multiparae. - -_Saint Moulin_ reports the case of a woman 24 years of age who had never -menstruated, but who none the less became pregnant and gave birth to a -fine girl. One of the most striking cases of this nature is the one -reported by _Rodzewitsch_, regarding a woman who first began to -menstruate at the age of 36 years. This woman had however been married -when fifteen years of age, and in the subsequent twenty-one years she -gave birth to 15 children, remaining the whole time amenorrhoeic. - -_Puech_ reports the case of a woman who ceased to menstruate at the age -of 40 years, and remained amenorrhoeic for the subsequent six years. -Then menstruation recurred for a year, and finally ceased definitively -in consequence of the occurrence of pregnancy, which terminated in the -normal birth of a healthy boy. _Loewy_, in a woman 31 years of age, who -had previously been amenorrhoeic all her life, saw menstruation appear -for the first time shortly after the birth of her sixth child. _Ahlfeld_ -had under observation the case of a woman who was the mother of eight -children, and had never menstruated. - -_Krieger_ reports the case observed by _Mayer_, of the wife of an -artizan, who between the ages of 17 and 28 years had given birth to five -children, and had had one abortion. After the age of 22, she had no -trace of menstrual discharge, but notwithstanding this, she subsequently -gave birth to three children. _Krieger_ himself saw a woman who had had -her last child at the age of 33, and in whom now, at the age of 48, -menstruation had just ceased entirely. Two years later, irregular -menstrual discharges recommenced; when these ceased, it appeared that -the woman was once more pregnant, and she was normally delivered of a -full-time girl. - -_Renaudin_ relates the case of a lady 60 years of age who gave birth to -a child, menstruation having ceased 12 years earlier. _Deshhayes_ saw -the delivery of a woman 50 years of age, two years subsequent to the -occurrence of a normal menopause. _Capwron_, quotes the ease of a woman -who became pregnant at the age of 65 years. In this case menstruation -had recurred, having ceased many years before in a normal menopause. -This woman aborted at three months, and the foetus was well-formed. - -In such cases of late conception, which occur after the normal cessation -of menstrual activity, we cannot be certain whether we have to do with a -simple persistence of ovarian activity, associated with temporary or -permanent cessation of menstruation; or whether both functions, -ovulation and menstruation, had ceased, and were aroused to renewed -activity by some determinate cause. It is possible that in coitus we -have such a stimulus, capable of reawakening the slumbering ovarian -functions. That this may be the case, we are led to suppose by the fact -that pregnancy at an unusually advanced age most frequently occurs as a -result of marriage late in life. In Scandinavian countries, where the -difficulties of providing for a family are so great that a very large -number of marriages are inevitably postponed till comparatively late in -life, the number of pregnancies occurring in elderly women is -correspondingly large. However, pregnancy late in life occurs also in -women who have married early, and the most probable assumption to -account for such cases is that ovulation has occurred in the absence of -menstruation. - -Although by these cases the proposition is established that amenorrhœa -is by no means equivalent to incapacity for ovulation, still, the former -must indubitably be regarded as in general a most important indication -of disturbed ovulation. When a woman attains the age of 20 years without -having ever menstruated, or even having experienced menstrual molimina, -we may in the great majority of such cases infer with justice that there -is complete or partial failure of development of the ovaries and the -reproductive apparatus generally. In some of these cases, examination -discloses the fact that the uterus is in an infantile condition. When we -are able to bring about the regular establishment of menstruation, we -may hope also to remove the sterility dependent upon the defective -ovarian functional capacity. General tonic treatment for the relief of -chlorotic amenorrhœa quite as often, in the case of previously barren -married women, results in the occurrence of pregnancy, as happens in -cases of amenorrhœa and sterility due to obesity, when this latter -condition has been relieved and menstruation has been re-established by -suitable dietetic treatment. Much less often is it possible to relieve -the sterility of scrofulous (tuberculous) persons, for in the majority -of such cases, in consequence of the scrofulous (tuberculous) -constitutional disorders, pathological changes have occurred in the -ovaries already in early youth, and these it is difficult or more often -impossible to remove. - -Scrofula (tuberculosis) is, according to my own experience, the -constitutional disorder which of all most frequently and most seriously -affects ovulation; and it appears that the ovaries are subject to -changes produced by this disease similar to those which occur in other -glandular organs. In cases in which no cause of the existing sterility -is ascertainable, the presence of scars due to scrofulous (tuberculous) -changes in the lymphatic glands may serve as an indicator to show that -the capacity for ovulation has been annihilated or seriously diminished -in early life by scrofulous (tuberculosis) disease. - -Among the causes of sterility, these three conditions: anæmia, -chlorosis, and scrofula (tuberculosis), play a leading part; indeed, -their importance in this connexion has hitherto been underestimated, -more especially in regard to the comparative frequency with which they -cause sterility. A large part of the favourable influence in the relief -of sterility in women which is exercised by the “cures” at various -watering places, depends upon the amelioration which is thus effected in -the aforesaid constitutional disorders. - -It has been assumed that diabetes, which renders men impotent, is -competent also to cause sterility in women. _Hofmeier_ reports a case -which appears decisive on this point. In a woman 20 years of age, who -had menstruated regularly since she was 14 until a year previously, when -the flow had ceased, he found the uterus extremely small, barely 5 cm. -(2 in.) in length, extremely atrophied, the ovaries also atrophied and -very small; the urine contained large quantities of sugar. Here was -doubtless a case of atrophy of the reproductive organs secondary to -diabetes. - -In England, where the excessive use of alcohol is observed very -frequently in women as well as in men, sterility has frequently been -regarded as a result of chronic alcoholism. _Matthews Duncan_ reports -cases which lead to the belief that alcohol has a specifically -deleterious effect upon fertility. Apart from the general or -constitutional disturbances dependent upon the abuse of alcohol, this -agent has in many cases a well-recognized pathogenic influence upon the -female reproductive organs, the morbid condition which is most -frequently and most readily assignable to this cause being chronic -oophoritis. The obesity which so frequently results from alcoholic -excess is a contributory cause of sterility. - -Certain drugs, more especially quinine and morphine, are reputed to -cause sterility. _Davies_, reviving an old opinion, considers that of -all drugs tannin is the most effective in leading to sterility, and he -considers tea-drinking as responsible for this effect. - -The influence of certain cerebral affections and psychical disorders in -checking ovulation has been established. Thus, _de Montyel_ has recently -shown that in families subject to hereditary mental disorders, there is -an unusually large proportion (1 : 7) of barren marriages. - -In addition, there are many influences which are known to prevent or to -diminish ovulation in the case of the lower animals, and which may -therefore be assumed with considerable probability to have a similar -effect in women. More especially we are here concerned with external -influences affecting unfavourably nutrition and innervation, and -therewith also ovulation; also near kinship between the parties to the -act of intercourse; and finally hereditary predisposition. In animals, -captivity, exposure to cold, over-exertion, insufficient or unsuitable -food, and inbreeding, have been proved to result in infertility. - -_Doubleday_ asserted that “a too abundant supply of nutriment hinders -reproduction, whereas on the other hand insufficient or improper food -favours reproductive activity and increases the number of the -offspring.” _Spencer_, however, rightly points out that the infertility -noticed in these circumstances is not the direct result of prosperity, -but depends upon the pathological obesity which is thus engendered by -overfeeding. - -No less interesting are the observations that have been made regarding -sterility in animals in confinement. In such animals there are wide -differences. Some refuse to cohabit, or have lost sexual desire; others, -again, show excessive sexual desire and cohabit too often, without any -result; or even if fertilization occurs, abortion often ensues. In yet -other cases, though conception follows intercourse, and the animals go -on to full term before delivery, the young are still-born, or are weakly -and misshapen. Caged birds often lay no eggs at all or very few; or if -they do lay, they neglect their eggs; or if incubated, the eggs fail to -hatch out. In France, experiments regarding this matter were made with -domestic fowls. If the hens were given great freedom, 20 per cent only -of the eggs remained unhatched; with less freedom, 40 per cent of the -eggs were failures; whilst if the fowls were kept in a coop, 60 per cent -of the eggs were unhatched. - -“Convincing proofs,” writes _Darwin_, “have been obtained to the effect -that wild animals which have recently lost their freedom have their -fertility diminished to a most remarkable extent. This infertility is -not dependent upon any degeneration of the reproductive organs. There -are many animals of the most diverse species, which, whilst they -copulate freely in confinement, fail in these circumstances to conceive; -others again, even if they conceive and have living young, give birth to -these in numbers which are unquestionably much smaller than would be the -case were the parents in the free state.” - -Interesting observations have been made by pigeon breeders. They state -that when pigeons brought up in the same nest pair, the number of their -offspring is usually very small. - -The influence upon fertility of unfavourable conditions of temperature, -either excessive heat or excessive cold, is very great. In the case of -pigeons, for instance, if the pigeon cot is adjacent to the heated wall -of a dwelling house, the pigeons sometimes begin to lay as early as -January, and may have young as often as eight times in a single year. -When the dovecot is cold, on the other hand, the number of broods is -smaller. In general, the procreative capacity is greater in summer than -in winter. - -As regards inbreeding, many facts are on record showing the influence of -this practice in leading to the birth of malformed offspring and to -sterility. _Darwin_ writes, “if in a pure race, characterized by a -certain tendency to sterility, we allowed only brothers and sisters to -pair, in a few generations the stock would become extinct.” If animals -closely related by blood pair, the number of their offspring is always -less than the average. - -In the case of the human species, however, the influence of the marriage -of near kin in diminishing fertility cannot be regarded as definitely -proved. - -Occasionally the incapacity for ovulation and the sterility dependent -thereupon are hereditary—paradoxical as this may appear. It is necessary -to assume, that just as the sperm is at times unsuited for effective -fertilization, so also the ova may be in a less or greater degree -insusceptible of fertilization. In the present state of our knowledge, -indeed, we are not in a position to be precise as to the exact nature of -such incapacity. It is possible that the enveloping membrane of the ovum -varies in its resistance to penetration, as _Schenk_ claims to have -proved in respect of certain of the lower mammals. In his experiments on -artificial fertilization outside the body of the mother, he ascertained -that the cells derived from the discus proligerus, surrounding the ovum -in immediate contact with the zona pellucida, are in some instances -easily separable one from another, so that the spermatozoa can readily -obtain access to the zona pellucida; whereas in other instances, in -which the ovum is of the same size and apparently in the same stage of -maturation as before, these cells remain closely attached each to the -other, and thus prevent the passage of the spermatozoa. This condition -of the ovum, so unfavourable to fertilization, may be hereditary in -certain families, and its transmission may render certain members of the -stock infertile. Such instances as the following from my own practice -are by no means rare. Of three sisters, whose family life was intimately -known to me, one had one child only, a girl, whilst the two others -remained childless. The girl of the second generation married and -remained childless. In England it is well established that when, in -cases of only-child-sterility, the offspring is of the female sex, this -child will probably herself be barren. _Galton_ found that in the case -of 14 heiresses (i. e. the only children of wealthy parents), all of -whom were married, 8 remained absolutely barren, whilst of the others, 2 -had each an only child. - -It was formerly believed that when a woman gave birth to twins of -opposed sexes, the female infant would prove to be barren, this -barrenness being associated with defective development of her -reproductive apparatus. _John Hunter_ (Animal Economy) ascertained that -in the case of twin calves of opposed sex, the genital organs of the -female twin were almost invariably imperfectly developed. But the -supposition that this is true also of the human species has not been -confirmed by experience. I know several married women who had twin -brothers, and these women have borne normal children; however, the -number of their offspring is remarkably small. _Simpson_, in Edinburgh, -recorded the results of the marriage of 113 women who had been born with -twin brothers; of these, 103 had proved fruitful, and 10 (i. e., about -one eleventh of the whole) barren, although of these latter women, one -had been married upwards of 5 years, and the remaining 9 for periods -ranging from 10 to 40 years. _Simpson_ also gave the history of four -women who were all the fruit of triple births, some of which had -consisted of two boys and one girl, others of two girls and one boy. All -four of these women were parous. Again, a woman who had been one of a -quadruple birth (three boys and one girl), herself gave birth to -triplets. A collection of all the figures accessible to me relating to -this subject, indicates that about ten per cent of the women born in -such circumstances prove barren—a ratio which corresponds closely with -the ratio of infertility in general. - - - _Interference with Conjugation, Conditions Preventing Access of the - Spermatozoa to the Ovum._ - -A condition essential to fertilization is a material union between the -sexual products of the male and the female respectively—the act of -conjugation. Thus, all conditions which prevent the spermatozoa from -obtaining access to the ova, bring about sterility. - -Spermatozoon and ovum being normal, a great variety of pathological -conditions may prevent the one from gaining access to the other. It is -necessary for fertilization that the mature ovum should leave the ovary, -enter the Fallopian tube, and there come into contact with the male -sperm. Interference with any one of these essentials may lead to -sterility. - -Thus, the constitution of the ovum itself may be at fault; or the -entrance of the ovum into the Fallopian tube may not be normally -effected; defects in these earliest stages of the process of -fertilization are precisely the commonest and the most important. The -emergence of the ovum from the graafian follicle may be rendered -difficult or entirely prevented by pathological states of the ovary; -again, by inflammatory processes in the ovary, the tubes, or the -ligaments, by developmental defects in the tube, and by obstructions in -its interior, the entrance of the ovum into the tube, and its free -passage along the tube may be prevented. Numerous abnormalities and -diseases of the uterus may on the one hand prevent the entrance of the -ovum into the uterine cavity, and on the other may prevent the upward -passage of the spermatozoa to their goal. Amongst conditions competent -to produce these effects we must enumerate: displacements of the uterus, -structural changes in this organ and its annexa, and other congenital -defects and acquired states; more particularly must be mentioned, uterus -infantilis, acquired atrophy of the uterus, flexions and versions of the -uterus, new-growths and inflammatory states of that organ, abnormalities -in the shape or size of the cervix uteri, and, finally, all conditions -of the vagina or vulva which hinder the proper performance of the act of -intercourse. - -In diagnosing the cause of sterility, in determining whether in any -particular instance it is due to some hindrance to the indispensable -conjugation between the male and female reproductive elements, we have -in the first place to ascertain the presence or absence of any of the -numerous conditions which interfere with the proper passage of the ovum -from the ovary through the Fallopian tube to the interior of the uterus. -The simpler mechanical hindrances to conception, such as displacements -of the uterus, or tumours of that organ or its annexa, are easily -recognized; and the same is true of atresia of the cervix uteri, and of -congenital or acquired stenosis of the vagina. When obliteration or -stricture of the genital tract exists, a very careful examination, -visual, digital, and instrumental, must be made, rectal examination not -being forgotten. Not infrequently, amenorrhœa is attributed to ovarian -disease, and only subsequently on local examination is the cause -ascertained to be hymeneal atresia, with haematocolpos; many a woman has -believed herself to be pregnant, until examination has disclosed the -fact that the hymen is still intact, and that coitus has hitherto been -effected through the urethra. The importance of these stenotic -conditions as causes of sterility must not, however, be overestimated, -for, although they are common among the hindrances to conception, the -obstacle is by no means always insuperable. - -Morbid changes in the secretions of the genital passages, whereby the -vitality of the spermatozoa may be destroyed before they have time to -reach the ovum and effect fertilization, are hard to diagnose, for the -conditions upon which such changes depend have not as yet been -adequately investigated. - - - _Diseases of the Ovaries and the Fallopian Tubes._ - -Among the conditions which, although the maturation of the ovum proceeds -normally to a conclusion, may prevent conjugation between the male and -female elements, we must in the first place consider an abnormal -condition of the tunica albuginea of the ovary, a thickening of this -membrane in consequence of inflammatory processes or of new formation of -connective tissue, whereby the dehiscence of the follicle is rendered -difficult or entirely prevented. Such thickenings of the ovarian -envelope are the residue of perioophoritic processes. - -Such a hindrance to conception may be permanent or transient, and thus -the sterility dependent thereupon may be relative or absolute. Similar -is the effect of inflammatory processes affecting the peritoneal -investment of the uterus, the broad ligaments, and the peritoneum -clothing the floor of the pelvis; these conditions, perimetritis, -perisalpingitis, and pelvic peritonitis, resulting in the formation of -thick and extensive pseudomembranous bands, or in less severe cases -leaving merely slight adhesions and filaments, which drag the uterus and -the ovaries out of place, and thus render conception difficult or -impossible. - -Perimetritic adhesions are apt to lead to dislocation of the tubes -either forwards or backwards, and most commonly into the pouch of -Douglas, thus giving rise to sterility. _Rokitansky_ and _Virchow_ -already insisted on the great importance of perimetritic processes in -causing sterility. - -That congenital defects of the Fallopian tubes may lead to sterility, is -indeed a possible, but certainly a rare occurrence. The defect may be -unilateral or bilateral; or it may be that merely a portion of one tube -may be wanting. Bilateral absence of the Fallopian tubes is usually -associated with defective development of the uterus, while the ovaries -may be apparently normal. Such a case is described by _Foerster_ and -_Kussmaul_. The vagina opened into the urethra, the uterus was not -calibrated, and diverged above into two solid horns, to which the round -ligaments and the ovaries were attached. A congenital cause of sterility -is to be found also in atresia of the tubes, the abdominal extremities -of which are closed; this condition is met with also in other mammals. -It is also assumed, with less accuracy, that a supernumerary ostium -tubae may lead to sterility, in consequence of the ovum, which has found -its way into the normal ostium, returning into the abdominal cavity -through the supernumerary orifice. An unfavourable influence upon -fertility is exercised also by a form of hyperplasia of the tubes which -sometimes arises in consequence of erroneous development at the time of -puberty; the tubes, increasing unduly in length, become serpentine in -form instead of being nearly straight; this tends to lead to -accumulation of the secretions, and renders the passage of the ovum -difficult. (_Freund_.) Yet another defect of development which, as -_Klebs_ has pointed out, may lead to sterility, is absence of the -fimbria which normally retains the abdominal orifice of the Fallopian -tube in proximity with the ovary, in which case these structures may be -separated by a wide interval. - -The entry of the ovum into the tube may thus be rendered difficult by -abnormalities of the abdominal orifice of the tube or of the fimbriae; -but still more is this the case when the mucous membrane of the tube is -diseased. The fringed border of the tubal orifice has a distinct -tendency to independent disease. As _Klebs’s_ anatomicopathological -studies have shown, inflammatory changes are common in this region, -leading to contraction. The free margin of the tube then appears to be -strictured by overgrowth of fibrous tissue on the serous surface, the -opening being thus narrowed or even entirely closed, whilst the fimbriae -themselves may be drawn within the aperture. In other cases, the ring of -fimbriae is adherent to some neighbouring part, especially to the ovary -itself, when this also is diseased. Further, on the fringed margin of -the tube we see papillary growths, telangiectases, or oedema with -formation of cystic cavities. - -In the interior of the tubes also, pathological processes occur, -catarrhal inflammations, haemorrhagic or purulent exudations, sealing up -the passage completely. In some cases these exudations lead to great -distension and even to rupture of the tube. Thus, among the causes of -sterility must be enumerated: simple catarrh of the tube, with swelling -of the mucous membrane; purulent catarrh, leading to its distension with -pus—pyosalpinx; serous effusion into the tube, hydrosalpinx; and -haemorrhagic effusion, haematosalpinx; further, that peculiar form of -tubal inflammation, described by _Chiari_ and _Schauta_ under the name -of salpingitis isthmica nodosa, in which hyperplasia of the muscular -coat of the tube occurs at irregular intervals, so that it appears to be -beset with nodes. Special mention must also be made of gonorrhoeal -salpingitis, which will subsequently be described in detail. - -Inflammatory states of the tube may hinder conception, either -mechanically, by swelling of the mucous membrane, or by obstruction of -the lumen of the tube by exudations, by injury or destruction of the -ciliated epithelium, by lesion of the musculature of the tube, affecting -its peristaltic movements—all these hindering or entirely preventing the -passage of the ovum downwards or of the spermatozoa upwards; or, again, -chemically, by the deleterious influence of many of the morbid -secretions that are formed in these conditions upon the vitality of ova -or spermatozoa. These inflammatory states of the tubes may also lead to -stricture or obliteration of their abdominal extremities, or to -displacement of the ostia, and thus lead to sterility; in other cases -these same conditions, leading to distortion and displacement of the -tube, may prevent the downward passage of the ovum while leaving -possible the upward passage of the spermatozoa, and thus give rise to -tubal gestation—a condition which we shall not now consider. - -It must not be forgotten that tuberculosis of the genital canal attacks -the tubes with especial frequency; in these organs we may find miliary -tubercles, and more commonly diffuse caseous masses, completely filling -the lumen of the canal. Finally we have to mention the diverse forms of -saccular dilatation of the tubes (Ger. “_Tubensäcke_”), all of which -possess the common pathological characteristics of enlargement of the -tubes and their conversion into saccular cavities; the contents of these -distended tubes may, however, be extremely various, and such conditions -may depend upon manifold mechanical disturbances and inflammatory -processes of the uterus and its annexa. - -When we consider how common, during the sexual life of women, are -perioophoritic inflammations, more or less intense, but often without -severe symptoms (and hence apt to be overlooked); when we remember that -the very process of ovulation and also the puerperal state furnish -opportunities for slight or severe pelvic peritonitis to arise; and when -we further take into account the frequency and importance of gonorrhoeal -pelvic peritonitis—we cannot fail to admit that the results of these -morbid conditions, such as adhesions between the ovary and the ostium -tubae, or closure of the tube with consequent hydro- or pyosalpinx, must -be reckoned among the principal causes of sterility. If the frequency -and importance of these conditions is still underestimated, two reasons -can be adduced for this: first, that the slighter degrees of intrapelvic -inflammation often, as previously mentioned, elude diagnosis; and, -secondly, that even when the treatment is expectant merely, the -exudations are frequently absorbed, the adhesions give way, and the -capacity for conception is gradually fully restored. - -When considering the etiology of acquired sterility, especial attention -must be devoted to gonorrhoeal pyosalpinx, the most important and the -most dangerous of the morbid manifestations of gonorrhoeal infection in -the female. Gonorrhoeal salpingitis and perisalpingitis are very serious -affections, in the first place because they are apt to give rise to -oophoritis and perioophoritis, as well as to pelvic peritonitis, and -other local inflammatory states. The minuteness of the uterine orifice -of the Fallopian tube, and the downward direction of the ciliary -movement in the interior of the tube, combine to safeguard against the -entrance of gonococci, but none the less they too often find their way -up the tube, and small quantities of gonorrhoeal pus enter the pelvic -cavity and give rise to inflammations, in which the ovary partakes. - -According to _Saenger_, this gonorrhoeal disease of the uterine annexa -is found with especial frequency in women either wholly sterile or -affected with only-child-sterility, and is to be regarded as the cause -of their infertility; “infertility is indeed the rule, fertility the -exception, in all cases in which gonorrhoeal disease has passed upwards -beyond the os uteri externum.” The same author maintains that, putting -aside tuberculosis and actinomycosis, if, in a case of infective -inflammation of the uterine annexa, septic infection can be excluded, -and more especially when the disease affects both tubes, when it is -reluctant to yield to treatment, and when relapses are frequent, we have -no option but to believe that the affection is of gonorrhoeal origin. - -In 155 cases of chronic inflammatory disease of the Fallopian tubes, -_von Rosthorn_ was able in 37 instances to prove that the affection was -the direct result of gonorrhoeal infection. - -Recently, however, _Noble_ has published cases which lead us to believe -that even pyosalpinx does not necessarily prevent the occurrence of -pregnancy. In operating for the relief of a unilateral pyosalpinx, the -uterus was opened, and a seven months’ foetus was removed. In another -case, the autopsy on a woman who had succumbed to severe peritonitis -arising immediately post partum, disclosed a large pyosalpinx. - -Closure of the ostium may also be brought about by chronic metritis and -endometritis, by chronic catarrhal states of the uterine mucous -membrane, and in general by pathological changes in that membrane -associated with local hyperaemia or abnormal secretions. In some cases, -salpingitis with consequent sterility is the result of puerperal -infection; and such a sequence of events is especially common after an -abortion followed by retroflexion of the uterus, leading to elongation -and kinking of the tubes. - -An important hindrance to the entry of the ovum into the uterus is -sometimes offered by uterine polypi or myomata; growing from the fundus, -these may so fill the uterine cavity that the uterine orifices of the -tubes appear to be completely occluded. - -At times, also, quite small myomata, growing close to the tubes, may -push these latter upwards, closing them, and thus giving rise to -sterility; such myomata may also lead to saccular dilatation of the -tubes, as occurred in the following case: - -Mrs. S., aged 39 years, had one child when 20 years of age, but since -then had been barren. For several years she had suffered from profuse -menorrhagia. Owing to the enormous thickening of the abdominal wall, -bimanual examination of the uterus was impossible; the vagina was -relaxed, enlarged, and contained an excess of mucous secretion. The -uterus was high up in the pelvis, anteverted, enlarged, movable, -sensitive to pressure; the portio vaginalis was enlarged, soft, and -excoriated; no tumour could be detected either in the uterus or in the -uterine annexa. The menstrual flow recurred at intervals of from two to -three weeks, lasting from one to two weeks, and being extremely profuse; -menstruation was painful. Whilst the patient was under my observation an -excessive menstrual haemorrhage came on quite suddenly, with slight rise -of evening temperature (38.2° C.—100.8° F.), but severe general -disturbance; there were paroxysms of intense abdominal pain, violent -vomiting of greenish bilious masses, which after a time became -haemorrhagic, the abdomen was tense and sensitive to pressure, there was -cardiac weakness with general failure of strength; treatment proved -unavailing, and the patient died in collapse on the third day. The -autopsy disclosed: fibroma uteri submucosum, parietale, et subserosum, -haematosalpinx dextra, pyosalpinx sinistra, peritonitis. The subserous -myoma, of about the size of a pea, was in the middle of the fundus -uteri; the submucous myoma, of about the size of a chestnut, filling the -uterine cavity, sprang from the posterior wall of the body of the -uterus; the intramural myoma, of about the size of a bean, was in the -right wall of the corpus uteri. Both tubes were greatly elongated, -exhibiting serpentine windings. The right tube was much distended, -filled with sanguineous fluid; the left, partially collapsed, contained -greyish-green purulent material, having an extremely offensive odour; -some of this fluid had flowed through the ostium abdominale into the -abdominal cavity. Death in this case ensued with great rapidity in -consequence of rupture of the pyosalpinx, and evacuation of its contents -into the abdominal cavity. - -Cystic formations in the round ligament (hydrocele of the round -ligament) sometimes lead to sterility. In the form of elongated tumours -of about the size of a hen’s egg they may fill the inguinal canal, and -even pass forwards into the labia majora. When as large as this, they -demand operative interference. _Hennig_ records a case in which such -hydrocele of the round ligament was the cause of sterility lasting 14 -years, the woman becoming pregnant after the tumour had been removed by -operation. Similarly, infertility may depend upon solid tumours of the -round ligaments—myomata, fibromyomata, or sarcomata. - -Retro-uterine haematocele often gives rise to sterility. As a rule, -prior to the formation of a blood-tumour in the pouch of Douglas, -various menstrual disturbances occur, more especially menorrhagia; or it -may be preceded by some puerperal disease, especially perimetritis, -which by itself, indeed, seriously limits the fertility of the woman -thus affected; but when haematocele is superadded, her child-bearing -capacity is much more gravely impaired, owing to the permanent -displacement of the uterus, to the perimetritic exudations, to the -adhesions formed around the ovary, and to stricture or occlusion of the -tubes. Still, sterility is by no means an inevitable consequence of -haematocele. - -By many it is assumed that in cases in which the tubes are perfectly -normal, disturbances of innervation are competent to cause sterility (or -tubal gestation). It is supposed that nervous influences affect the -functions of the Fallopian tubes by leading to spastic contractures of -the circular muscular fibres of these structures, or in other cases to -paralysis; in this way nervous disorder may lead to the retention within -the tube of the unfertilized (or already fertilized) ovum. - - - _Diseases of the Uterus._ - -Pathological changes in the uterus may in various ways lead to sterility -dependent upon prevention of conjugation (physical contact of the male -and female reproductive elements). Thus, the incapacity for -fertilization may, on the one hand, depend on hindrances to the passage -of the ovum from the tube to the interior of the uterus; or on the -other, on some abnormal condition of the vaginal portion of the cervix, -whereby the passage of the spermatozoa from the vagina into the uterus -is prevented; or, finally, upon displacements of the uterus or -pathological structural changes in that organ, whereby the implantation -of the fertilized ovum in the uterine cavity and its development therein -are impeded. - -The uterus may be entirely absent, but this is an extremely rare -condition; much less infrequent is a rudimentary condition of that -organ. In the latter case, it is either represented by a nodular -rudiment, or else it is conical or bicorned; whatever its shape, it is a -solid mass of muscular and connective tissue. In association with -absence or a rudimentary condition of the uterus, the vagina also may be -wanting, or may be represented merely by a small, blind pouch; the -Fallopian tubes may in such cases either be normally developed or -rudimentary. The number of instances of this kind that have been -observed is very large (_Kussmaul_, _Klebs_, _Cusco_, _Klinkosch-Hill_, -_Cruise_, _Freund_, _Fürst_, _Engel_, _Gusserow_, _Nega_, _Kiwisch_, -_Rokitansky_, _Braid_, _Jackson_, _Lucas_, _Duplay_, _Dupuytren_, -_Renaudin_, _Crédé_, _Saexinger_, and many others). - -The uterus and the vagina may be absent in cases in which the vulva is -developed in a perfectly normal manner, with a mons veneris projecting -as usual, and covered with a proper growth of hair. _Ormerod_ and -_Quain_ have reported cases of this kind, in which the external sexual -characters were those of a fully mature, perfectly developed woman, but -in whom the uterus and ovaries were entirely wanting. - -These defects of development necessarily entail complete sterility. -Sometimes during life the cause of the sterility is entirely overlooked, -and only discovered by chance or in post mortem examination. Although -the vagina usually shares to a marked extent in the defects of the -uterus, and at puberty undergoes a rudimentary development merely, the -marital intercourse of such individuals commonly appears to be perfectly -normal. As a result of frequently repeated and vigorous attempts at -intercourse, the rudimentary vagina becomes accommodated to the needs of -the case; and even when the vagina is absent, the rudimentary depression -by which it is represented becomes distended into a large blind sac -capable of accommodating the erect penis. In other such cases, the penis -finds for itself some abnormal channel, and the husband may continue to -indulge in intercourse for a long period without discovering that there -is anything unusual. Sometimes it is the urethra which becomes dilated -and takes on in part the function of the vagina; in other cases -intercourse is effected per anum. - -The following most remarkable case came under my own observation. The -patient’s husband was a physician, who nevertheless was in complete -ignorance of his wife’s abnormalities. The woman was 26 years of age, of -medium stature, somewhat obese, breasts moderately well developed, pubic -hair well grown. She stated that before marriage she had menstruated -regularly, and that it was only after she had married four years -previously that menstruation had ceased—statements which were -unquestionably false. She consulted me on account of amenorrhœa and -sterility, which her husband believed to depend upon her increasing -obesity. Examination showed that the vagina admitted two fingers and was -10 cm. (4″) in length; but it was completely blind, and the mucous -membrane was strikingly smooth. On bimanual examination, only a rudiment -of the uterus could be detected, a mass no larger than a hazel-nut; the -ovaries could not be felt. - -A similar case is recorded by _Heppner_. A Finnish peasant woman 31 -years of age consulted him on account of amenorrhœa and sterility. She -had been married for 12 years, and neither before marriage nor since had -menstruated or had had any periodic vicarious bleeding. The pubes and -the labia majora were thinly covered with hair; the latter were very -flaccid and but slightly prominent; the nymphæ hung down like an apron -for as much as an inch below the genital fissure, and were very thin; -the clitoris was but slightly developed. The urethral papilla was of -normal size, the lacunæ around it were extremely well marked; the -urethral orifice had the form of a zigzag slit. Behind this latter was -an aperture environed by radiating folds, and this was the entrance to a -blind passage about two inches in length; this aperture could not, -however, be identified as the introitus vaginae, for the reason that -there were no carunculæ myrtiformes, and moreover the callosity of the -mucous membrane characteristic of the vaginal orifice was wanting. -Behind the strongly projecting commissura labiorum, however, the fossa -navicularis appears as a separate depression. The blind passage was -clothed with a soft, pale-red mucous membrane, and was entirely devoid -of any trace of columnæ rugarum; at the extremity of this passage there -was neither scar nor induration. On rectal exploration, no trace of -uterus, normal vagina, or ovaries could be felt, notwithstanding the -fact that the abdominal walls were very flaccid and examination was -therefore easy. The general configuration was feminine, the breasts were -flabby and dependent, the waist and hips were those of a woman. - -_Tauffer_ reports the case of a woman 25 years of age, married 2½ years, -absolutely amenorrhoeic; on examination she was found to have atresia -vaginae with rudimentary development of the uterus. The breasts were -small, the mons veneris was deficient in fat, but thickly covered with -hair, the labiæ and the clitoris were normal. - -_R. Levi_ describes a case in which, in a patient 19 years of age, the -uterus was wanting, though the general physical development was that of -a normal woman. The breasts were well formed, and so also were the -external genital organs; a blind passage 4 cm. (1.6 in.) in length, and -admitting two fingers, represented the vagina. In the position normally -occupied by the ovaries, were two bodies which were doubtless the -rudiments of these organs. Menstrual molimina had never been -experienced. - -_Von Hoffmann_, in making a post mortem examination on an elderly -married woman, found that the vagina ended blindly at a depth of 6 cm. -(2.4 in.), whilst the uterus was represented merely by a pyramidally -arranged bundle of fibres in the broad ligament. _Lissner_ reports a -case in which the physician was the first to draw the husband’s -attention to the fact that his wife had no uterus. - -_Ziehl_, in a married woman 57 years of age, found that the uterus was -completely wanting; the vagina ended blindly half an inch from the -surface; the tubes and ovaries were present. _Boyd_, in a married woman -72 years of age, found a blind vagina half an inch in length, and the -uterus represented by a nodular rudiment on the posterior wall of the -bladder. - -Rare cases are also recorded in the literature of the subject, in which, -notwithstanding the absence of the uterus, normal ovaries were present, -and in these latter periodic ripening of the graafian follicles took -place. A case of this kind was described by _Burggraeve_. - -Complete sterility is entailed also by a persistence of the foetal -condition of the uterus. In these cases, the uterus retains the form it -possessed at the beginning of the second half of intra-uterine life. The -portio vaginalis projects but slightly into the vagina, and the os uteri -externum appears as a small rounded opening. The cervix is comparatively -long and wide, and the folds on the mucous membrane of the cervical -canal are fully formed. The body of the uterus is imperfectly developed, -triangular in shape, with thin walls; it is shorter than the cervix, and -its interior is marked by folds of mucous membrane converging towards -the os. In these cases menstruation is absent or scanty; the other -reproductive organs, including the breasts, are usually in a state of -arrested development. Women with foetal uterus are capable of sexual -intercourse, and carry on most of the functions of their sexual life in -a manner apparently normal; they are, however, invariably sterile. - -An analogous cause of sterility is presented by the condition known as -uterus infantilis, in which at puberty the uterus fails to undergo the -changes proper to this period, and remains in the condition -characteristic of infancy. The cervix is disproportionately large, -whilst the body of the uterus is cylindrical in form, and the mucous -membrane lining its cavity is always smooth. The muscular substance is -unduly thin. The vagina may be normal, sometimes, however, it is narrow, -and the mucous membrane is less rugose than normal. Associated with an -infantile condition of the uterus we find commonly, but by no means -invariably, imperfect development of the external genital organs, the -labia, the clitoris, and the vagina; the mons veneris is but thinly -covered with hair; the breasts are small. As a rule, menstruation is -entirely wanting. Occasionally the ovaries are wanting. This infantile -condition of the uterus is by no means extremely rare. According to -_Beigel’s_ figures, among 155 sterile women, in four the uterus was -infantile. - -Among 200 cases of sterility in which it was possible for me to make a -searching enquiry for the cause, I found 16 instances of infantile -uterus. Neither in the general physical configuration of these women, -nor in the state of their menstrual functions, was there any striking -abnormality; in the condition of the external genital organs, however, -in cases of defective development of the uterus and ovaries, certain -striking peculiarities were, in my experience, almost invariable, and -deserving therefore of close attention. The mons veneris was extremely -small, sometimes completely bald, or covered very thinly with hair; and -the hair when present, did not exhibit the curliness usually seen in the -pubic hair of married women. On examination, the uterus, small in all -its diameters from arrest of development, could in every case be -detected. - -How exceptional it is in adult females with well developed internal -reproductive organs for the pubic hair to be scanty or completely -wanting, has been shown by the investigation recently made by _R. Bergh_ -on this hitherto neglected subject. In 2200 individuals engaged in -clandestine prostitution, he found the pubic hair extremely scanty in -148, and the genital region nearly or completely bald in 6. He states -that early vigorous growth of the pubic hair is a trustworthy sign of -early sexual development; but he remarks that the opinion of _Aristotle_ -that women in whom the pubic hair is slight or absent are always -sterile, is erroneous. - - Note.—The author’s statement regarding the extreme infrequency of - absence or deficiency of the pubic hair in women with properly - developed internal reproductive organs, while true of European - women, does not apply to all races. In Japanese women, for instance, - the pubic hair is as a rule much scantier than in European women; - and baldness, complete or nearly complete, of the mons veneris is by - no means uncommon. It is the exception, in Japanese prostitutes, to - find a thick and vigorous growth of genital hair.—_Transl._ - -In the Talmud, there is an interesting reference to this subject, to the -effect that it may be assumed that a woman is sterile if by the 20th -year of her life the pubic region be not yet covered with hair, if the -breasts be not developed, if coitus be difficult, and if the tone of the -voice be masculine. - -Madame _Boivin_, _Dugès_, _Lumpe_, and _Pfau_, maintain that the -development of the uterus from the infantile condition to that -characteristic of the sexually mature virgin, often occurs very late and -very slowly; and that women in whom we find the uterus in an infantile -condition, may later begin to menstruate and may become pregnant. It has -been suggested that in these cases there has been confusion with primary -acquired atrophy of the uterus. Still, that it is necessary to be most -cautious in cases of infantile uterus in asserting that a woman is -permanently sterile, has recently been forcibly impressed on me by a -remarkable instance. A married woman consulted me some years ago on -account of amenorrhœa and sterility; examination showed clearly that the -uterus was in the infantile condition, and for this reason, not I alone, -but several leading gynecologists, assured her that there was no hope of -her ever becoming a mother; recently, however, after ten years of -sterile wedlock, she was safely delivered of a healthy child. - -A sub-variety is constituted by the uterus pubescens, a uterus which -indeed at puberty has undergone a certain degree of development, but has -failed to attain the normal size; in such cases the menses are regular, -but sometimes painful. This form of arrest of development of the uterus -may occasion sterility, which, however, often proves curable when by -frequent sexual intercourse and the congestion dependent thereon, the -genital organs have been stimulated to the completion of the process of -development; the muscular strength of the uterus then becomes adequate, -and the dysmenorrhœic troubles disappear. In general it may be said that -if the rudimentary or imperfectly developed uterus is at all competent -to carry out the function of gestation, the necessary changes sometimes -occur in the organ with remarkable rapidity, and result in normal -pregnancy and parturition. - -Uterus unicornis, when occurring alone, and not associated with other -defects or errors in development, is not a cause of sterility. Women -with a uterus unicornis, with or without an accessory horn, menstruate, -conceive, and pass through pregnancy and parturition, in a perfectly -normal manner; indeed, some women with this developmental defect have -given birth to twins. The assumption that uterus unicornis predisposes -to abortion does not always hold good. If, however, pregnancy occurs in -a rudimentary horn, rupture of the membranes is inevitable, and the ovum -or embryo passes into the abdominal cavity, with the usual accompaniment -of fatal haemorrhage. The rupture commonly occurs between the third and -the fourth month of foetal life (months of four weeks each). - -The uterus bicornis, with which may or may not be associated duplication -of the vagina, does not as a rule offer any hindrance to conception; and -the same statement is true also of the uterus bilocularis or septus. -Women with these defects of development may give birth to healthy -children; and some such women have had twins, each foetus occupying a -separate half of the uterus. Still, births in cases of double uterus and -vagina are rare occurrences. Such cases have been published by -_Lasarewitsch_, _Litschkus_, and _Készmarsky_. In very rare cases of -uterus bicornis associated with double vagina, an obstacle to conception -is offered by the fact that one side only of the double vagina, the -larger, is utilized in sexual intercourse, and that this is a blind -passage. - -In cases of uterus bilocularis seu septus, the conditions as regards -pregnancy and parturition are similar to those that obtain in cases of -uterus bicornis. The twin uterus, uterus didelphys, the condition in -which the uterus is represented by two completely separated halves, each -of which has developed into an independent organ, has been observed, as -_P. Müller_ has shown, in adults as well as in infants; this condition -offers no obstacle to conception, unless, indeed, as occurred in a case -of _Tauffer’s_, the vagina is rudimentary, so that normal sexual -intercourse is impossible. _Satschoma_ reports a case of uterus -didelphys in which pregnancy occurred simultaneously in both uterine -cavities. - -A careful distinction must be made between the congenital condition -known as the infantile uterus (i. e., congenital atrophy) and acquired -atrophy of the uterus, affecting the whole organ, or either of its -segments, the body or the cervix; the latter condition may offer merely -a transient and curable obstacle to conception. - -Acquired primary atrophy of the uterus occurs in weakly girls who, just -before the age at which the uterus normally undergoes its transformation -into the adult state, have suffered from constitutional disorders, from -chlorosis or anæmia, or from some other exhausting affection. The uterus -is then small, limp, and flaccid, it is usually anteflexed, with a -small, often insignificant portio vaginalis; the anterior lip of this -structure failing to project from the vaginal fornix; the vagina is -usually short and narrow. This form of atrophy of the uterus is -distinguished from the foetal and from the infantile uterus more -especially by the fact that no disproportion exists between body and -cervix, that the muscular wall is better developed, and that the general -configuration of the uterus is rather that characteristic of the normal -uterus of the sexually mature woman. Persons with primary atrophy of the -uterus, are, moreover, backwards in the general development of their -sexual characters; the breasts are small, the pubic hair is scanty, the -menstrual flow is insufficient or entirely wanting, whilst severe -dysmenorrhœal manifestations are usual. - -[Illustration: - - FIG. 70.—Congenital Atrophy of the Uterus (after Virchow), oi, Ostium - internum; oe, Ostium Externum. -] - -[Illustration: - - FIG. 71. -] - -In favourable circumstances, when the constitution becomes more -powerful, in these cases of primary atrophy of the uterus, improvement -takes place; the uterus undergoes further development, menstruation -becomes more abundant, and the woman may become pregnant. Such a -favourable prognosis cannot, however, be entertained if a severe flexion -of the uterus is associated with the atrophy of the organ; or if the -ovaries are also atrophied. - -Sterility results also from puerperal atrophy of the uterus. This -condition is a sequel of severe puerperal diseases, metritis, -parametritis, and perimetritis; sometimes, even in the absence of such -inflammatory processes, it is due to puerperal hyperinvolution, -occurring especially in women previously weak in constitution, and -manifested by the fact that, notwithstanding the weaning of the child, -the menstrual flow remains for months in abeyance. The uterus loses its -firm consistency; it is sometimes shortened, sometimes of normal length, -but the walls are always greatly thinned, so that, as _Schroeder_ points -out, the sound can be readily felt, through the abdominal wall. -Puerperal atrophy is a curable condition, so that the sterility -dependent upon this disease is not necessarily permanent. Thus, in a -case of _P. Müller’s_, a woman in whom a twin delivery had been followed -by extreme atrophy of the uterus, with well-marked symptoms both -objective and subjective, became once more pregnant eighteen months -after the termination of the twin pregnancy. - -Other forms of atrophy of the uterus have a similar deleterious effect -to that exercised by puerperal atrophy, as, for instance, atrophy from -the pressure of tumours of the uterus, or of solid ovarian tumours; or, -again, atrophy due to defective innervation of the pelvic organs, -occurring in various forms of paralysis, and characterised by amenorrhœa -and extreme smallness of the uterus. _Von Scanzoni_ has seen several -cases in which young women, previously healthy and menstruating with -regularity, have been attacked by paralysis of the lower extremities, -and thenceforwards have suffered from amenorrhœa and great contraction -of the uterus; in some of these cases a post mortem examination was -made, and disclosed the existence of true atrophy of the uterus. -_Jaquet_ saw a similar case of atrophy of the uterus in a lady who had -been frightened by witnessing the storming of a barricade in front of -her dwelling; she was then in her 22nd year, and had given birth to her -second child 1½ years previously; thenceforwards she was completely -amenorrhoeic, and her uterus measured only 3 cm. (1.2 in.) in length. - -Displacements of the uterus (flexions and versions), and abnormalities -in the cervix uteri, are among the conditions which lead to sterility by -interfering with conjugation—by preventing the necessary physical -contact between the male and the female reproductive elements. The -frequency with which these diseases give rise to sterility is, however, -far from being so great as is commonly asserted by those who maintain a -mechanical theory of conception. - - - _Pathological Changes in the Cervix Uteri._ - -In very early times, the attention of physicians was directed to -abnormalities in the shape of the cervix uteri, as offering hindrances -to the entry of the semen into the uterus. Amongst the writers of -antiquity who have alluded to this matter, the names of _Hippocrates_ -and _Soranus_ must especially be mentioned. - -The normal cervix uteri (Fig. 72) has the form of a flattened ellipsoid, -perforated throughout its longitudinal axis. On making a longitudinal -section of the cervical canal, we see that it is dilated in the middle, -and tapers towards either extremity, having thus the shape of a spindle; -the internal os is, however, somewhat smaller than the external. The -latter (os uteri externum, os tincæ, often referred to without -qualification as “the os”), has normally the form of a transverse -fissure, which, however, tends more towards the circular form, the -smaller it is, and the more widely its margins are separated. In -childhood, in consequence of the infolding of its margins, the external -os has usually a radiated form, later it becomes rounded, and only with -the attainment of sexual maturity does it assume the form of a -transverse slit. This form is maintained throughout the epoch of active -sexual life; but after the climacteric, owing to the separation of the -margins of the orifice, it becomes once more rounded. - -With regard to the greatly varying size and shape of the portio -vaginalis, it may be said that in general its anterior lip _appears_ the -shorter of the two, owing to the lesser depth of the anterior vaginal -fornix, but that in reality the anterior wall of the cervical canal is -longer than the posterior; the actual length of the anterior lip of the -portio vaginalis, measured from the summit of the anterior fornix, is -from ½ to 1 cm. (0.2 to 0.4 in.), whilst the posterior lip, from the -summit of the posterior fornix to the end of the lip measures 1½ cm. -(0.6 in.) and upwards. The position of the cervix is such that, owing to -the oblique direction of the long axis of the uterus, superadded to the -absolutely greater length of the anterior lip of the cervix, the plane -across the extremities of the two lips faces almost straight backwards. -The axis of the portio vaginalis forms a right angle with the axis of -the vagina; the cervical canal, however, is not usually straight, but -has a slight S-shaped curvature. The mean length of the cervical canal -in the virgin uterus is 3 cm. (1.2 in.). (_Lott_.) - -The “ideal” form of the cervix uteri and of the os uteri externum is -described by _Sims_ in the following terms: “The vaginal portion should -measure about one fifth, certainly not more than one fourth, of the -entire length of the cervix uteri; that is, the anterior lip should have -a length of one-fourth to one-third of an inch, and the posterior lip -should be a fraction longer. The cervical canal should either be -straight, or have a forwardly directed curve; the cervical axis should -form a right angle with the vaginal axis; the cervix should not be -markedly anteverted or retroverted.” _Sims_ is of opinion that every -woman whose uterus is in this condition will conceive within three or -four months from the time when she first enters upon conjugal -intercourse; he adds, however, the important proviso, “be it understood, -that all else is in order.” - -[Illustration: - - FIG. 72.—Normal Portio Vaginalis. -] - -[Illustration: - - FIG. 73.—Conoidal Portio Vaginalis. -] - -In conception, the cervix uteri subserves the important function of -providing for the free passage of the spermatozoa to the interior of the -uterus; and when we consider the nature of the processes of sexual -intercourse and fertilization, and more especially when we bear in mind -that normally the two lips of the cervix and the upper segment of the -vagina form a chamber for the retention of a portion of the seminal -fluid in contact with the os uteri externum, we are readily led to -assume that any great abnormality, in size of the cervix (enlargement or -diminution), in its shape (malformation), or in its position -(displacements—flexion, version, or prolapse), or, finally, stenosis of -the cervical canal,—may offer mechanical hindrances to conception. And -experience shows that this assumption is justified, at any rate as -regards conical elongation of the portio vaginalis (Fig. 73), as regards -an apron-shaped or beak-shaped hypertrophy of the anterior lip of the -cervix (Figs. 74 and 75), as regards flexion upwards of the elongated -cervix, and also as regards stenosis or obliteration of the external or -the internal os; although the reservation must be made that no matter -how unfavourable the shape of the portio vaginalis, no matter how -extensive the changes in the cervix uteri, as long as a permeable upward -passage for the spermatozoa exists, conception is still possible, and in -exceptional cases may occur. - -[Illustration: - - FIG. 74.—“Apron-shaped” Vaginal Portion. a. Greatly elongated anterior - lip; b. Shorter posterior lip of the cervix. -] - -[Illustration: - - FIG. 75.—“Beak-shaped” Vaginal Portion. Posterior aspect. -] - -When the cervix is hypertrophic and greatly enlarged, and the vaginal -fornix consequently much elongated, conception is rendered difficult, -for the reason that in such cases, either the semen rapidly flows out of -the vagina, or else a proper juxtaposition between the penis and the -external os no longer occurs, and the semen is ejaculated at some -distance from the os. The change in the shape of the portio vaginalis, -and also the elongation of the cervical canal, are additional obstacles -to the entrance of the spermatozoa into the interior of the uterus; as -regards the former condition, in nulliparae the portio vaginalis is -commonly conical, or pointed, whilst the external os is very small, thus -rendering the passage of the spermatozoa a difficult matter; but in -parous women, it is lobulated, owing to the presence of deep fissures, -whereby the penis is conducted into the vaginal fornix, and the -ejaculation of the semen in this locality is facilitated. Hence, such -hypertrophy of the cervix and the portio vaginalis often coincides with -the occurrence of sterility. The hypertrophy is less apt to cause -sterility when it is limited to one lip of the cervix, unless, indeed, -the affected lip (more commonly the anterior) is so greatly enlarged -that it bends over and occludes the external os, whilst conducting the -penis into the fornix and away from the orifice. Cases have been known -in which a single lip of the cervix was hypertrophied to such an extent -as to protrude between the labia. - -The commonest malformation of the cervix is the conical cervix, when the -cervix is not merely elongated, but tapering; associated with this -condition is usually found a notable diminution in size of the os uteri -externum. According to _Sims_ we find “conical cervix in 85% of all -cases of natural sterility.” According to the same author, even in the -absence of the conical form of cervix, “sterility is probable in cases -in which the portio vaginalis projects fully half an inch into the -vagina; if the cervix projects more than one inch, sterility almost -inevitably results; whilst if elongation is even greater than this, so -that the vaginal portion measures from one and a half to two inches, -sterility is absolutely certain.” - -On the other hand, congenital smallness of the portio vaginalis, the -condition in which this organ appears merely as a slightly projecting -nodule on the upper part of the anterior wall of the vagina, the -anterior vaginal fornix being almost non-existent, and the posterior -fornix very extensive—a wide cul-de-sac—is also unfavourable to -conception. The probable reason is that, in consequence of this -deformity, the semen, after being ejaculated into the posterior fornix, -flows away down the posterior wall of the vagina, without coming into -contact with the short portio vaginalis. - -According to _Beigel_, another frequent cause of sterility is to be -found in the existence of the so called “apron-shaped” portio vaginalis, -the condition in which, either from congenital deformity, or else from -hypertrophy or some other disease, one lip of the vaginal portion is so -formed as greatly to exceed the other in length. - -In consequence of hypertrophy, the portio vaginalis may assume other, -very various forms; in some cases it may increase in size to such an -extent that it projects into the vagina as a thick, hard ball, and thus -offers a serious obstacle to the reception of the semen; or, again, in -the form of the elongated, slender cervix, it may become doubled upon -itself, and in this way hinder the passage of the spermatozoa (Figs. 76 -and 77). Deformities of the cervix due to hypertrophy of the portio -vaginalis, rarely cause congenital sterility, but more commonly the -acquired form; for such hypertrophy is hardly ever congenital, occurs -but rarely in virgins, and is usually met with in married women who have -had difficult deliveries, and consequently have suffered from uterine -disease. - -Another deformity of the vaginal portion of the cervix which is -important in its relations to sterility is the “snout-shaped cervix.” -Here the cervix is thinnest immediately at its insertion into the -vaginal fornix, and thickens gradually below, so that the organ -resembles a swine’s snout in form. As a rule, this deformity is due to -diffuse hypertrophy of the connective tissue of the cervix, the result -of chronic endometritis and cervicitis. - -[Illustration: - - FIG. 76.—Simple Hypertrophy of the Portio Vaginalis, which projected - from the Vulva. -] - -[Illustration: - - FIG. 77.—Elongated Cervix, bent upwards. -] - -_Fritsch_, however, in two cases of characteristic _col tapiroid_, saw -pregnancy occur after the relief of the previously existing uterine -catarrh; in one of these cases the condition of the organs was virginal, -so that it was hardly possible to believe that the patient was a -multipara; even after she had had three children, the os uteri externum -with difficulty admitted the passage of the uterine sound. - -_Pajot_ has devoted especial attention to the hindrances that are -offered to the entrance of the spermatozoa by displacements of the -cervix. In these cases, during coitus, the extremity of the glans penis -is not in contact with the os uteri externum, but passes into a kind of -cul-de-sac; in retroversion the posterior fornix; in anteversion, the -anterior fornix; in lateral version, the lateral fornix of the side -opposed to that towards which the lower extremity of the cervix points. - -Complete absence of the vaginal portion of the cervix puts difficulties, -though not very serious ones, in the way of conception, since the -segment of the uterus which combines with the upper segment of the -vagina to form a receptaculum seminis, is wanting. How important in -predisposing to fertilization is efficient contact of the external -orifice of the vaginal portion with the ejaculated semen during and -immediately after intercourse, seems to be established by my own -observation, that women of small stature married to men of average -height exhibit much higher proportional fertility than women of average -stature. In the case of these small women, the favourable circumstance -is obvious, inasmuch as intimate contact is facilitated between glans -penis and portio vaginalis. I have frequently heard complaints, from the -husbands of such women, that a single coitus is sufficient to ensure -conception; and again and again I have been informed by such women that -they have had 10, 12, or 16 children. In one such instance known to me, -the wife had been pregnant 23 times, and had given birth to 19 normal -children. Contrariwise, women with a very long vagina, and with a high -position of the portio vaginalis, do not so easily become pregnant. - -Of special importance in the causation of sterility is stenosis of the -cervical canal. This may be congenital, and then usually affects the -whole length of the canal; or it may be acquired, being dependent upon -inflammation of the mucous membrane. In these latter cases, the swollen -follicles of the mucous membrane burst, and their granulating walls -adhere. Other causes of acquired stenosis are trauma, severe operative -procedures during parturition, puerperal inflammations, syphilitic -ulceration, adhesion of the opposed granulating surfaces after operative -measures (as, for instance, after severe cauterization, or after -amputation of the portio vaginalis), and, in short, from scar-formations -however caused. - -General swelling of the tissues leading to stenosis occurs at the -external os in hyperplastic uteri of virgin configuration; the small -round orifice characteristic of the virgin uterus becomes narrowed, or -even completely occluded, by the swelling of the tissues of the vaginal -portion. True adhesion of the walls does not occur in these cases, but -the minute aperture left by the swelling of the walls of the canal is -plugged by the epithelium, so that a small blind depression in the -centre of the portio vaginalis is all that remains of the cervical -canal. Such a condition is seen with especial frequency in cases of -prolapse of the vaginal portion, and is often erroneously regarded as an -obliteration of the os uteri externum by epithelial adhesion (_Klebs_). -Finally, stenosis of the cervical canal may be caused by tumours, and -also by the flexions and versions of the uterus presently to be -discussed. - -Congenital atresia of the uterus is generally associated with other -developmental anomalies of the reproductive organs. In some cases, all -that is at fault is that the mucous covering of the vaginal portion -passes uninterruptedly from one lip to the other; but in others, the -cervix is unperforated throughout, and the vaginal portion is but -slightly developed. - -Acquired obliteration of the cervical canal may affect either the -external or the internal os, with a shorter or longer portion of the -rest of the canal. When very extensive necrosis of tissue has occurred, -as a sequel of difficult delivery, the adhesion may include the -adjoining segment of the vagina (utero-vaginal atresia). - -The more marked the stenosis of the cervical canal, the smaller the -passage by which the vagina communicates with the uterus, the more -difficult will it be for the passage of the spermatozoa to be effected, -so that of the millions of spermatozoa deposited in the neighbourhood of -the os uteri, thousands will, as in normal cases, find their way to the -uterine orifices of the Fallopian tubes. So much the more, then, is the -contact between spermatozoon and ovum rendered difficult, and so much -the more unlikely is it that conception will occur. Moreover, in -consequence of the stenosis, there is retention of the cervical mucus, -which becomes thick and glutinous, and offers a further obstacle to the -passage of the spermatozoa. The unfavourable influence upon the -possibility of conception is, finally, increased if, as is often the -case, in association with the stenosis, the cervix becomes elongated and -assumes a conical form (these secondary changes probably resulting from -the inflammatory states of the cervix common in cases of stenosis); and -an additional obstacle is offered to conception by the association with -the stenosis of flexion or version of the uterus. It is in such -complicated cases that we so often have the associated symptoms of -dysmenorrhœa and sterility; the dysmenorrhœa being due to the fact that -the menstrual discharge, if abundant, is unable to flow away with -sufficient rapidity through the greatly narrowed cervical canal; exuding -from the vessels of the uterine mucous membrane more rapidly than it can -be discharged, it accumulates in the uterine cavity, and gives rise to -painful contractions of the uterus. - -Precisely what degree of narrowing of the cervical canal it is which -constitutes pathological stenosis, is in practice by no means easy to -define; and only in regard to extreme cases of pathological constriction -can there be no possibility of dispute. In cases of congenital stenosis -of the cervical canal, the diagnosis is very easy, for the os uteri -externum is then always extremely small; often the aperture is no larger -than a small pin’s head, a very fine probe can be passed through it with -considerable difficulty and its passage is opposed all the way up to the -internal os. But in cases of acquired stenosis of moderate severity, the -diagnosis is often difficult. Owing to the small size of the orifice, -and to the distensibility of the soft parts by which it is surrounded, -exact measurements are impossible. When the os is with difficulty -detected by the skilled finger, when the sound is not readily introduced -by the experienced hand, slipping past again and again, and inserted -only after repeated efforts—such an os is, as _Olshausen_ insists, -always pathological. The normal virgin os uteri permits the easy passage -of a thick uterine sound with a diameter of 3 to 4 millimeters (⅛ to ⅙ -in.); but there are cases in which, though a sound of this normal size -can be passed, the os gives to the examining finger the sensation of -being contracted. If, in such a case there is typical mechanical -dysmenorrhœa with sterility, _Olshausen_ considers that we are justified -in assuming the existence of pathological stenosis of the os uteri, and -in treating the case accordingly. - -However, as _Kehrer_ insists, it may be one of the greatest difficulties -in diagnosis—a difficulty not always to be resolved even when all the -attendant circumstances have received the fullest and most painstaking -consideration—to determine whether in any individual case an anomaly of -the cervix, such as stenosis of the external os or of the whole cervical -canal, is or is not to be regarded as a cause of sterility. When -stenosis is extreme, there need be no two opinions about the matter; the -difficulty is in cases lying somewhere between a moderate degree of -contraction and the lower physiological limit of smallness. Every -experienced gynecologist will have seen such cases as _Kehrer_ -describes, in which before marriage the os appeared extremely small, and -yet soon after marriage the woman became pregnant. For this reason we -are justified, with _O. Johannsen_, in reverting rather to the -functional than to the anatomical conception of stenosis, and in -maintaining that so long as the cervical canal is sufficiently large to -permit the uterine secretions to flow freely away, any stenosis that may -exist is devoid of pathological significance. Only when the outlet for -the uterine secretions is insufficient, so that the uterine cavity -becomes distended (as manifested by an elongation of the canal in the -supravaginal portion of the uterus, and by various disorders, amongst -others chronic endometritis), is the stenosis with its consecutive -dilatation of the uterus a serious obstacle to conception. “In such -cases, the contractions of the uterus during coitus will not suffice to -express the secretions it contains through the narrowed os, and the -inevitable consequence of the incomplete evacuation of the uterus is -that the aspiratory phase of the orgasm fails to occur.” - -According to _Winckel_, stenosis of the external or of the internal os -is a cause of sterility only in cases in which it arises from a -follicular inflammation of the cervical mucous membrane; in such cases, -the os, (internal or external, as the case may be), being greatly -narrowed by the numerous retention cysts, offers an obstruction to the -evacuation of the glutinous secretion of the follicles yet remaining -open. This secretion may offer an insuperable hindrance to the passage -of the spermatozoa; but in the absence of catarrh of this character, a -moderate degree of contraction of the cervical canal will not prevent -the outflow of the menstrual discharge, or the upward passage of the -spermatozoa. - -The experience of horse and cattle-breeders also shows the etiological -importance of stenosis of the cervix in the production of sterility: and -in the case of mares and cows who are unfruitful from this cause, -artificial dilatation of the cervix has often been performed, with -resulting restoration of fertility. - -Swelling of the follicles of the mucous membrane of the cervical canal -or of the cavity of the uterus, a condition which often results from -cervical catarrh, will, equally with stenosis of the cervical canal, -lead to sterility; pushing the mucous membrane before them, and becoming -pedunculated, these swollen follicles ultimately enlarge to form polypi -of the cervical canal or the uterine cavity, and may at times completely -occlude the uterine canal. In Fig. 78 is depicted a polypus of this -kind, which I removed from the cervix of a barren woman 30 years of age. -On the apex of the polypus was a large ovulum Nabothi. - -[Illustration: - - FIG. 78.—Cervical Polypus, originating from an Ovulum Nabothi. -] - -Long-standing cervical catarrh readily leads to stenosis of the cervical -canal, and consequently to sterility. The swelling and hypersecretion of -the cervical mucous membrane the more readily hinders the entrance of -the semen, inasmuch as the mucous folds on the anterior and posterior -walls of the cervical canal which combine to form the _plicae palmatae_ -are in the normal state already sufficiently prominent; but in cases of -catarrhal swelling they may project to such an extent as completely to -occlude the canal. Stagnation of the thickened secretion offers in these -cases a further hindrance to the passage of the spermatozoa, a -stagnation which becomes aggravated if in course of time the os becomes -stenosed by overgrowth of scar tissue. Ultimately, also, in cases of -chronic catarrh, a flexion of the enlarged and flabby corpus uteri -readily occurs, and this imposes an additional difficulty in the way of -conception. - -It is for these reasons that those women who in girlhood have suffered -from prolonged cervical catarrh, so often remain childless. The sequence -of events is that already described: follicular catarrh, stagnation of -secretions, stenosis of the cervical canal, enlargement and loss of tone -of the uterus; the thin-walled, enlarged, and flaccid uterus ultimately -gives way before the intra-abdominal pressure, bending back, usually, -into the pouch of Douglas. Thus, retroflexion of the uterus is a common -sequel of cervical catarrh (_Hildebrand_). In some cases of sterility -dependent upon cervical catarrh, this sequence of troubles has not -occurred, and it is merely the mucus in the canal which prevents the -passage of the spermatozoa. _B. Schultze_ reports the case of a woman -who had lived for 13 years in sterile wedlock, but became pregnant after -a single removal of the cervical mucus. - -The significance of chronic cervical catarrh in the causation of -sterility explains how it is that in many cases of barren marriage the -blame ultimately rests upon the husband, who, when he married, was -suffering from “latent gonorrhoea,” the inconspicuous relic of an acute -attack, undergone, it may be, months and even years previously, and -infected his wife with the disease. Such a gonorrhoeal catarrh is in -women especially apt to assume a chronic form, and will then induce all -the secondary morbid conditions previously described, and thus lead to -sterility. - -Gonorrhoea in women frequently results in sterility. In addition to the -effect of cervical stenosis and of a morbid condition of the cervical -mucus in preventing the upward passage of the spermatozoa, this disease -may lead to many other changes inimical to fertility. Thus, gonorrhoeal -infection in women often leads to inflammatory manifestations in the -peritoneum, the perimetrium, and the parametrium, and to catarrhal -changes in the Fallopian tubes (salpingitis, hydrosalpinx, pyosalpinx); -these prevent the contact of spermatozoon and ovum, or cause -pathological distortions of the walls or calibre of the tubes, which -constitute permanent hindrances to the occurrence of conception. Young -married women, whose husbands at the time of marriage were the subjects -of incompletely cured gonorrhoea, and who shortly after marriage suffer -from cervical catarrh, the discharge from the inflamed mucous membrane -not infrequently having a suspicious greenish colour analogous to that -seen in recent gonorrhoea in the male, often remain sterile for long -periods, owing to this gonorrhoeal cervical catarrh, endometritis, and -tubal catarrh. For the diagnosis in such cases, in addition to noticing -the virulent character of the inflammation of the vulva, urethra, and -vagina, we must invoke the aid of the microscope; and it will often be -possible to decide at once that the inflammation is gonorrhoeal by -finding Neisser’s diplococci enclosed within the pus cells of the -cervical secretion. - -The influence of “latent gonorrhoea” in diminishing the fertility of -women has been especially asserted—and overestimated—by _Nöggerath_. -From the fact that about 90% of sterile women are married to men who -have suffered from gonorrhoea either before or during their married -life, he infers that the sterility is due to latent gonorrhoea -communicated from husband to wife. If this inference were justified, -sterility would be far commoner than it actually is. _Nöggerath_ makes -use of the term “latent gonorrhoea” because the woman becomes infected -without the obvious outbreak of any acute phase of the disorder. The -disease remains latent, and a radical cure is not to be expected until -the menopause. According to _Nöggerath_, there are four varieties of -this disease: acute, recurrent, and chronic perimetritis, and -oophoritis, always accompanied by catarrh of the mucous membrane of the -genital organs. - -_Saenger_, also, has asserted that 12% of all cases needing -gynecological treatment are of gonorrhoeal origin; and he even considers -that the consequences of gonorrhoea are in women more dangerous and -destructive than those of syphilis. _E. Martin_ has also maintained that -endocervicitis leading to stenosis of the os uteri externum and of the -cervical canal is, in the majority of sterile young wives, due to -gonorrhoeal infection derived from a chronic, unhealed, but -inconspicuous, gonorrhoea in the husband. He further considers it -possible that various kinds of mechanical stimulation, for example, -intra-vaginal onanism, may, in certain conditions, give rise to -inflammation eventuating in cervical stenosis. - -Of great interest are the mutual relations between dysmenorrhœa and -sterility, a matter to which some allusion has already been made. A high -degree of stenosis of the cervical canal is competent to produce both -these symptoms; but dysmenorrhœa may arise from many other causes which -have no direct influence in preventing conception. - -Too much stress has, in fact, been laid upon the association of -dysmenorrhœa with sterility, and I must therefore point out that I have -seen numerous instances of dysmenorrhœa, including the so-called -spasmodic form of the disease, in women who have given birth to many -children; that objectively, in such cases, there was an absence of that -rigidity of the cervix to which _Matthews Duncan_ attached so much -importance; and, finally, that even when the dysmenorrhœal pains had -subjectively all the character of labour pains, the introduction of the -sound could be effected without using any great force, and without -giving rise to any severe pain. - -Unquestionably, those authors, with _Sims_ at their head, go too far, -who regard dysmenorrhœa as a constant sign of stenosis of the cervical -canal, and hence infer that in all cases in which sterility is -associated with dysmenorrhœa, the sterility is due to such stenosis—an -opinion contested by _Schultze_ on the ground of anatomical -investigations. Dysmenorrhœa gives no indisputable sign that the cervix -is stenosed to such a degree as to hinder the occurrence of conception; -and _Sims’s_ view, that in the great majority of cases dysmenorrhœa is -due to mechanical obstruction, is not supported by experience. Women who -suffer from severe dysmenorrhœa, frequently become pregnant, though -later, it may be, than women in whom menstruation is normal and -painless. Dysmenorrhœa is not due solely to contraction of the cervical -canal, but also to a variety of other pathological conditions. The -anomalies of the genital organs which give rise to dysmenorrhœa do not, -for the most part, offer any obstacle to conception; and, on the other -hand, stenosis of the cervical canal may exist in women who are entirely -free from dysmenorrhœa. - -In order to test _Sims’s_ theory of the mutual interdependence of -dysmenorrhœa and sterility, _Kehrer_ conducted an investigation into the -state of menstruation both before and after marriage in relation to the -fertility or infertility of the marriage. He ascertained that in sterile -women virginal dysmenorrhœa had only been a very little commoner than in -fruitful women. Hence, the changes in the reproductive organs upon which -the occurrence of dysmenorrhœa depends, must not be regarded as -necessarily constituting hindrances also to conception. - -English gynecologists differ from those of Germany in believing that -there is an intimate causal relation between dysmenorrhœa, and more -especially spasmodic dysmenorrhœa, and sterility. The assumption is, -that the contractions of the uterus, which by their violence during -menstruation give rise to pains like those of labour, occur also during -coitus; by these contractions, the entry of the semen into the uterus is -prevented, or, if the semen does enter the uterus, it is speedily -expelled. This spasmodic dysmenorrhœa has also been called mechanical or -obstructive dysmenorrhœa, in order to call attention to the theory that -the aim of the cramp-like contractions of the uterus is the expulsion of -the menstrual blood which has accumulated in the uterine cavity; -although _Duncan_ himself is compelled to admit that neither the alleged -mechanical obstruction, nor the accumulation of menstrual blood, nor yet -the dilatation of the uterine cavity, can actually be proved to occur. - - NOTE.—The author is not quite correct in his contrast between - “English” and “German” opinion in this matter. Most English - gynecologists follow Matthews Duncan in calling attention to the - fact that, as Herman puts it, “spasmodic dysmenorrhœa is often - associated with sterility”; but almost all careful writers insist - that while the association is proved, the nature of the causal - connexion, if such exists, has not been elucidated. For instance, - writing on this very question of the association of dysmenorrhœa - with sterility, Hart and Barbour remark, “after a careful survey of - the literature, we come to the conclusion that any discussion of - sterility in which mechanical considerations have a prominent place, - must be inadequate, and will always be bootless.” It is true that - Matthews Duncan writes (_Diseases of Women_, Lecture on - _Sterility_), “The most generally recognized cause of sterility is - spasmodic dysmenorrhœa”; but a careful perusal of the whole lecture - will show that Duncan is saying more than he really means in using - the word “cause,” and that what he wishes to insist upon is the - frequent and indisputable association of the two conditions. In the - lecture on _Spasmodic Dysmenorrhœa_ he writes, “Latterly it has been - generally described as obstructive or mechanical dysmenorrhœa; these - words ‘obstructive’ and ‘mechanical’ implying a theory of the - disease which ... I am sure is quite erroneous.” Obviously, then, - Kisch does injustice to Matthews Duncan when he writes that the - latter is “compelled to admit” (_obgleich Duncan selbst zugeben - muss_), what he was as a fact one of the first to maintain, in the - face of considerable opposition!—_Transl._ - -[Illustration: - - FIG. 79.—Ectropium in a Case of Bilateral Laceration of the Cervix. - After A. Martin. -] - -_Duncan_ goes so far as to maintain that no actual or suspected local -disturbance has such significance in connexion with the doctrine of -sterility as spasmodic dysmenorrhœa. It possesses this significance -owing to the probable connexion between the dysmenorrhœic neurosis and -the outflow of the semen, the deficiency of the sexual impulse and of -sexual pleasure, and other disturbances of sexual excitement during -coitus. With the relief of the dysmenorrhœa, we have, _Duncan_ holds, -made a long stride towards the cure of the sterility. Among 332 married -women who were absolutely sterile, _Duncan_ found 159, nearly half of -the total number, who were affected with spasmodic dysmenorrhœa. - -_Burton_, in order to ascertain with certain beyond question whether -stenosis of the external or internal os gives rise to dysmenorrhœic -troubles, examined six women during menstruation and at the time when -they were experiencing the greatest pain; he found in no one of them any -trace of narrowing of the canal. Owing to the congestion that occurs at -this time, the uterus becomes erect, and any moderate flexion that may -exist is temporarily straightened. In all the cases, the sound could be -passed with extreme ease. - -Ectropium of the lips of the cervix (“granular erosion”) constitutes a -hindrance to conception which is by no means rare; the condition is due -to deep lateral lacerations of the cervix. The gaping of the cervical -canal arising from such old-standing, often overlooked, cervical -lacerations and from the parametric scars associated therewith, causes -various irritative manifestations: blenorrhoea, blennorrhagia, cystic -degeneration of the mucous membrane, and these secondary conditions may -be contributory causes of sterility; but lacerations of the cervix with -ectropium interfere in a manner purely mechanical with the proper -constitution of a receptaculum seminis and with the aspiration of the -semen into the cervical canal. (Fig. 79.) In an earlier section of this -work I laid stress on the fact that in the act of conception the -musculature of the cervix had in a sense an active part to play; and the -proper performance of this role is prevented by cervical lacerations. -The cervical glands also suffer in cases of ectropium, and their -function in facilitating the entrance of the spermatozoa into the -uterine cavity is no longer properly performed. Finally, it is worthy of -note that sexual gratification, the sensation of voluptuous pleasure -during the sexual act, seems to be diminished in women with cervical -lacerations, a fact noted especially by _Mundé_ and _Ill_. The -last-named found that in 34 women thus affected, sexual gratification -was no longer experienced in intercourse; whilst in 27 of these cases, -restoration of the integrity of the cervix by operation was followed by -return of normal sexual feeling. In women who have given birth to one or -two children, and then for a long time have remained barren, we not -infrequently find deep cervical lacerations. _Breisky_, _Spiegelberg_, -_Schultze_, and _Goodell_ have operated in such cases, and shortly after -the operation pregnancy has recurred. - - - _Displacements of the Uterus._ - -With less justice than in the case of the pathological changes in the -cervix above described, it is maintained that displacements of the -uterus form a very frequent cause of mechanical hindrances to -conception, and thus give rise to sterility. - -It certainly cannot be denied that displacements of the uterus are found -very commonly in sterile women; and, on the other hand, among women with -pathological flexion of the uterus, the percentage of the sterile is far -higher than among women with a uterus normal in position and shape—but -from these facts it would be erroneous to infer the general conclusion -that displacements of the uterus offer a mechanical hindrance to -conception. The casual connexion is less simple than this as a rule. In -most cases in which displacements of the uterus are associated with -sterility, there are additional pathological states of the uterus and -its environment, relics of previous inflammation in the uterus, the -uterine annexa, or the parametrium, or displacements of the uterine -annexa; these changes may be either the cause or the result of the -existing displacement of the uterus, and it is upon them, and not -primarily upon the displacement, that the sterility depends. The -accuracy of this view is proved by the experience, by no means an -uncommon one, that in such cases, when the actual cause of the sterility -is removed, the woman will become pregnant, although the displacement of -the uterus persists. - -How difficult it is, in a particular case, to determine whether the -pathological anteflexion is the true obstacle to conception, or the -antecedent parametritis posterior and the concomitant metritis and -endometritis! How can we decide whether a retroflexion is the simple -mechanical cause of sterility, or whether the latter condition does not -rather depend upon complicating perimetritis and oophoritis? - -On the other hand, we must not fly to the other extreme, and absolutely -deny that a displacement of the uterus can be the mechanical cause of -sterility. We meet with cases in which we are forced to assume that the -flexion interferes both with the outflow of the menstrual blood and with -the ingress of the seminal fluid. And this is true, not merely of -flexion to an acute angle, often associated with infantile dimensions of -the cervical canal or of the external or internal os, but also of those -advanced degrees of flexion in which, doubtless in part also from the -accompanying catarrh, complete stenosis of the os uteri externum has -resulted. The combination of displacement of the uterus with stenosis of -the cervix, is in these cases the essential hindrance to conception. -When the os is reasonably large, a moderate flexion of the uterus -forwards, backwards, or to one side or the other, will not often prevent -conception, for the action of the muscular bands in the various -ligaments of the uterus will retain the os in a sufficiently favourable -position. But if a contracted os is associated with flexion, sterility -is very likely; and almost inevitable, if fixation of the flexed uterus -has occurred from inflammatory exudation and fibrosis in one of the -broad ligaments. - -That the belief that displacements of the uterus constitute an obstacle -to conception is a widely diffused one, is shown by the fact that among -certain nations a means employed for the prevention of pregnancy is the -artificial production of displacements of the uterus. - -Of the displacements of the uterus, the versions, anteversion, -retroversion, and lateral version, have a more pronounced influence in -hindering conception than the flexions; for, in the case of version of -the uterus, the uterus moves as a whole round a horizontal axis, so that -when the fundus moves in one direction, the portio vaginalis moves in -the opposite. When the neck of the uterus is thus displaced, the tip of -the glans penis fails during coitus to come into contact with the os -uteri externum, as it normally should do, and passes into a vaginal -cul-de-sac, in retroversion, the posterior fornix, in anteversion, the -anterior fornix, and in lateral version the lateral fornix of the side -opposite to that towards which the cervix uteri is directed. In high -degrees of this malposition, the vaginal fornix covers up the os -externum as with a valve. (_Beigel._) - -_Von Scanzoni_ has especially insisted upon the frequency with which -sterility results from chronic metritis complicated with anteversion. In -59 sterile women affected with chronic metritis, he found in 34 -instances more or less pronounced anteversion, and hence was led to -infer that this particular combination of disorders plays a great part -in the production of sterility. - -Especially frequent is sterility in cases of anteversion of the uterus, -if in addition there is some contraction, even though moderate in -degree, of the os uteri externum; this combination of disorders is one -extremely unfavourable to the entrance of the spermatozoa into the -uterus. - -Flexion of the uterus offers less hindrance than version to the entrance -of the spermatozoa, for the reason that in the former condition the -relations between the vaginal portion and the glans penis during coitus -are not affected. But when the flexion is extreme in degree, the -cervical or uterine canal may at some point become absolutely impassable -for the spermatozoa; and further, extreme flexion is apt to lead to the -occurrence of parametritis and perimetritis. But, generally speaking, -flexions of the uterus are far less often the cause of sterility, than -was formerly supposed. It used to be believed that flexion of the uterus -was followed by stenosis of the os uteri externum, by which the outflow -of the menstrual blood and the ingress of the semen were equally -prevented. It is true that infantile acute-angled flexion of the uterus -is often associated with infantile stenosis of the cervical canal or of -the internal or external os; and it is also true that extreme degrees of -flexion associated with uterine catarrh, favour the occurrence of -stenosis and obliteration of the external os; but _B. Schultze_ rightly -insists that in most of the cases in which a diagnosis is made of -stenosis of the uterine canal associated with a flexion of the sexually -mature uterus, the supposed “stenosis” merely represents the difficulty -which has been experienced in passing the customary rigid uterine sound -past the angle in the uterine canal. Still, the fact remains, that among -women with uterine flexion there is a larger percentage of sterile -individuals than among women whose uterus is normal. - -[Illustration: - - FIG. 80.—Anteflexio Uteri. After A. Martin. -] - -As regards anteflexion of the uterus, either the congenital, -uncomplicated anteflexion of the uterus, due to developmental anomaly, -or the acquired form, due either to subinvolution of the uterus during -the puerperium, or to parametritic or perimetritic processes,—may offer -mechanical obstacles to conception, and thus give rise to sterility; -sterility with anteflexion occurs especially in cases in which the -anteflexion is dependent upon parametritis posterior, associated with -metritis and endometritis, or when any other complication is present to -make the flexion a severe one. In some sterile women, we find -anteflexion associated with supravaginal elongation of the portio, and -in such cases both states would appear to result from catarrh of the -uterine mucosa. How frequent is the combination of anteflexion of the -uterus with sterility, is shown by the figures published by _Sims_, who -in 250 cases of congenital sterility found 103 cases of anteversion, and -in 255 cases of acquired sterility found 61 cases of anteversion. - -_Fritsch_ writes in the following terms regarding the difficulty with -which impregnation is effected in women suffering from anteflexion of -the uterus: “In cases of anteflexion of the uterus, the vagina is -remarkably long, the portio vaginalis often badly formed; the ejaculated -semen flows away rapidly from the contracted vagina, without, perhaps, -ever coming into contact with the portio vaginalis.” He states it as a -fact that women with anteversion conceive less readily than those with -retroversion of the uterus (when this latter is moderate in degree); for -in slighter degrees of retroversion, the axis of the uterus is a -continuation of the axis of the vagina, so that the orifice of the male -urethra and the os uteri externum will be in contact during -intercourse—more especially because in such cases, owing to the portio -vaginalis being low in the pelvis, the vagina is short; in cases of -anteversion, on the other hand, the cervix is high up, and the vagina is -long and narrow. _Fritsch_ considers that generally speaking the fact -that the internal or the external os is small is of little importance; -but the serious factors, those leading to sterility in cases of -anteversion—apart from all other considerations—are the unfavourable -high position of the portio vaginalis, the occlusion of the os by the -close application of the posterior vaginal wall, and the presence of -glutinous mucus in the cervical canal. Since in cases of anteflexion we -very commonly find hypersecretion of the uterine mucous membrane, -whilst, owing to the narrowing of the external os, the mucus is unable -to flow freely away, but accumulates and becomes inspissated, we have -the uterine mucous membrane covered with a tenacious coating, which may -perhaps render the implantation of the ovum a very difficult matter, -even though the upward passage of the spermatozoa be still possible. The -clinical association of pain produced by drawing forward the portio -vaginalis, with marked anteflexion of the uterus, dysmenorrhœa, and -sterility, is a strikingly common one. - -_Schröder_ points out that, although sterility is common in cases of -anteflexion, cases are yet seen in which, notwithstanding the existence -of extreme anteflexion, conception occurs very speedily after marriage. -The fact that in cases of anteflexion we have difficulty, not -impossibility, of conception, explains how it is that of two women -suffering from anteflexion of the same severity, one will readily become -pregnant, whilst the other remains permanently barren. - -Retroversion and retroflexion offer obstacles to conception chiefly in -cases in which this displacement is a congenital anomaly, or when it has -developed immediately after puberty; or when complications exist, -especially when the retroflexed uterus is fixed by exudation. In -nulliparae, these deviations backwards will not rarely be found to be -the cause of the sterility. Much less often does sterility ensue when -retroversion or retroflexion occurs in women who have already given -birth to several children, i. e., when the displacement is a puerperal -disorder; the reason why such cases are not often sterile, is to be -found in the fact that the wide cervical canal favours the passage of -the spermatozoa, and the softness of the tissues prevents any serious -obstacle to their upward progress being offered at the angle of flexion; -on the other hand, severe retroflexion in a woman who has not yet borne -a child offers a serious hindrance to conception, on account of the -smallness of the cervical canal, and the sharp flexion of the more rigid -uterus. - -In general, then, retroflexion can be regarded as offering but a slight -hindrance to conception. In fact, many women with retroflexion become -pregnant again and again, and may abort several times in a single year. -When in parous women suffering from retroflexion, sterility ultimately -occurs, _B. Schultze_ considers that it is not the retroflexion which is -primarily to blame, but rather the secondary consequences so common in -this disorder: uterine catarrh; the general constitutional debility due -to such catarrh, and to the accompanying menorrhagia; perimetritis, and -oophoritis. - -[Illustration: - - FIG. 81.—Retroflexio Uteri. After A. Martin. -] - -Retroflexion and retroversion of the uterus occur chiefly in women who -have previously given birth to children; the bend is commonly obtuse or -right-angled, and above the upper end of the cervical canal; sterility -in such cases, usually acquired, has a favourable prospect of cure. As -_Kehrer_ points out, sterility appears to be constant only in cases of -retroflexion in which the uterus is fixed; the reason probably is that -by the backward inflexion of the uterus the abdominal orifice of the -Fallopian tube is dragged away from the ovary, and thus the ovum, when -it is discharged from the follicle, fails to find its way into the tube. - -Among 57 cases of retroflexion of the gravid uterus, _E. Martin_ found -that in 6 the patient was pregnant for the first time, from which it may -be inferred that the anomaly existed prior to the occurrence of -conception. - -That in some cases of sterility it is the retroflexion of the uterus -that is to blame, is shown very clearly _ex juvantibus_, inasmuch as -reposition of the uterus and maintenance of the organ in its proper -position relieves sterility perhaps of long standing, together with all -the other troubles secondary to the displacement of the uterus. As an -example, I quote one case from among several of the kind of which I have -notes. Mrs. N., 25 years of age, married 6 years, childless, suffers -from severe dyspeptic troubles, leading to emaciation and profound -depression. She has been treated fruitlessly for gastric catarrh, but -has not previously been subjected to gynecological examination. I -insisted on making such an examination, and found the uterus somewhat -enlarged and completely retroflexed. The successful replacement of the -organ was followed by the cessation of the previously constant vomiting -after meals, and by the disappearance of the other dyspeptic troubles; -shortly afterwards the lady became pregnant, and pregnancy ran a normal -course. Since then, she has had three children; there has been no -recurrence of the dyspepsia. - -According to _Sims_, retroversion of the uterus is frequently associated -with sterility. Among 250 married women who had never been pregnant, we -found no less than 68 cases of retroversion; among 255 women who had had -one or more children, but had then ceased to be fruitful, he found 111 -cases of retroversion; and in some of these cases the retroversion was -uncomplicated. _Grenser_ and _Vedeler_ also found retroflexion to be a -common cause of sterility; the last-named, examining 7 nulliparous -married women, found retroversion in 5; in these cases, however, there -was associated disease of the uterus or of its environment. - -Inversion of the uterus, even in the minor degrees of the affection, in -which coitus is still possible, almost invariably causes sterility, -owing to the occlusion of the uterine orifices of the Fallopian tubes. -Moreover, in inversion of the uterus, the position assumed by the os -uteri externum is such as to render the entrance of the semen almost -impossible. Finally, when the uterus is inverted, the mucous membrane -undergoes changes which render it unfit for the implantation of the -ovum; the researches of _P. Ruge_ show that it is thinned and that the -epithelium is cast off and replaced by granulation tissue. In cases in -which the inverted uterus has long projected through the genital -fissure, its surface becomes covered by a multilaminar pavement -epithelium; at the same time, the glandular apparatus undergoes atrophy, -only the fundi of the glands being preserved, and the muscular substance -is hypertrophied. None the less, in exceptional cases, which have been -reported by _Emmet_, _Macdonald_, and _Tyler-Smith_, pregnancy has -occurred after long-enduring inversion of the uterus. _Lauenstein_ had a -patient in whom an inverted uterus was replaced after a year and a half; -the following week she became pregnant. _Stevens_ saw a case in which -the woman became pregnant six months after the reduction of an inversion -of the uterus of nine months’ standing. - -Prolapse of the uterus is seldom the cause of sterility, inasmuch as -during coitus replacement of the organ is effected. It may even be said -that in cases of prolapse, the low position of the uterus and the -enlargement of the os uteri externum, favour the direct ejaculation of -the semen into the cervical canal (likewise enlarged), and that thus the -conditions are advantageous for impregnation. In fact, conception more -commonly occurs in cases of prolapse than might have been anticipated in -view of the various consecutive disorders apt to complicate this -affection—chronic metritis and endometritis, erosion, hypertrophy of the -cervix, displacement and laceration of the annexa, etc. The extent to -which the capacity for conception is unfavourably affected in cases of -prolapse of the uterus, is proportional to the amount of descent -undergone by the uterus, for the nearer the os approximates to the -vaginal orifice, the farther removed from the os will be the point at -which the semen is ejaculated. In cases of complete prolapsus it has -happened that coitus has been effected directly through the everted os -uteri, and has resulted in conception; a case of this kind is reported -by Hervey. - -Unbiassed gynecological experience in no way supports the views of -_Sims_ and _Hewitt_ regarding the frequency with which displacements of -the uterus constitute mechanical causes of sterility. _Sims_ supports -his views with the figures previously quoted, from which the following -table is compiled: - - _No. of _Total cases - cases._ _Anteversion._ _Retroversion._ of - displacement._ - First class 250 103 68 171 - Second class 255 61 111 172 - ——— ——— ——— ——— - Totals 505 164 179 343 - === === === === - -From this it appears that in the 1st class, among 250 married women who -had never given birth to a child, there were 103 cases of anteversion, -and 68 cases of retroversion; whilst in the 2nd class, among 255 women, -who had had children, but for one reason or another had become -unfruitful earlier than the natural age for this occurrence, there were -61 cases of anteversion, and 111 cases of retroversion. - -The general result of these figures is to show that two-thirds of all -sterile women, without regard to the especial cause of the displacement, -suffer from one form or the other of uterine displacement, and that the -relative frequency of anteversions and retroversions is reversed in the -two classes, the nulliparous married women, and the married women -previous parous but latterly become sterile, respectively. - -_Hewitt_ similarly regards malpositions of the uterus as frequent causes -of sterility. He analysed 296 cases of flexion and version of the uterus -treated by him at University College Hospital during the years 1865 to -1869, partly in the wards, and partly in the out-patient department. Of -these 296 women, 235 were married; 100 were cases of retroflexion, and -135 were cases of anteflexion. Of the 235, 81 had had no full-term -children, 57 of the 81 having never been pregnant, and the remaining 24 -having had miscarriages only. Of the remaining 154, married and parous -women, a large proportion were sterile at the time when they applied for -treatment; though in the years immediately after marriage they had given -birth to one or more children, they had subsequently ceased to be -fruitful. - -All that these figures prove to an unbiassed judgment is, however, that -displacements of the uterus are apt to render conception difficult; or -that, in addition to other pathological states of the pelvic organs, -they are frequently met with in sterile women—but in and by themselves, -displacements of the uterus do not offer any very serious or very -frequently occurring obstacle to conception. - -That conception is possible in spite of the very notable mechanical -hindrances which certain displacements of the uterus may offer to the -occurrence of pregnancy, is shown by many striking examples in -gynecological literature. _Winckel_, _Olshausen_, and _Holst_ have all -seen pregnancy occur in women who at the time of conception were wearing -intra-uterine pessaries; and _von Scanzoni_ has published cases in which -fertilization took place, notwithstanding extreme anteversion which -stenosis of the os uteri, and in another instance, notwithstanding the -presence of a polypus filling the external os. - - - _Myoma of the Uterus._ - -Among the mechanical obstacles to conception which act by preventing or -rendering difficult the contact of spermatozoon and ovum, must be -enumerated uterine myomata, and these must therefore be included among -the causes of sterility. - -According to their number, their size and their situation, uterine -myomata give rise to different and manifold mechanical disturbances. -When there are numerous intramural myomata, even when these are of a -moderate size, the uterine cavity becomes bent and narrowed, and -retention of the secretions may ensue, often lasting for a lengthy -period. Submucous fibromyomata, when situated low down, near the -internal os, may occlude this orifice completely; when implanted higher -up in the uterine cavity, they are apt to cause flexion of the uterus; -large, pedunculated fibromyomata of the uterus may descend into the -vagina and narrow this passage. - -Myomata interfere with conception in very various ways. Mechanically, -they may occlude the uterine orifices of the Fallopian tubes, or may -give rise to displacement of either tubes or ovaries, or, again, by -blocking the uterine cavity, they may hinder the descent of the ovum and -the upward passage of the spermatozoa; their presence may cause -catarrhal disease of the uterine mucous membrane, or give rise to -profuse hemorrhage, and either of these secondary changes may interfere -with the implantation of the ovum; and there is yet another way in which -myomata may interfere with conception, and give rise to sterility—this -is a subject to which especial attention has been given by _Winckel_, -and to which we may here most conveniently allude. The continued growth -of small submucous myomata often gives rise to a hyperæsthetic state of -the genital organs analogous to vaginismus, and this interferes with -coitus. Large myomata, on the other hand, give rise to catarrhal states -of the uterine cavity and to hyperplasia of the mucous membrane, -constituting hindrances alike to conception, and to the implantation and -further development of the embryo if fertilization should be effected; -moreover, the growth of large myomata often causes perimetritis, -perisalpingitis, and perioophoritis, and these, partly by abnormal -fixation of the uterus, and partly by closing up the tubes and so -thickening the tunics of the ovary as to prevent the rupture of the -graafian follicles, give rise to sterility. - -The existing statistics regarding the relation of the growth of myomata -of the uterus to fertility, incomplete as they are and lacking in -exactitude, suffice nevertheless to show that the fruitfulness of women -suffering from uterine myomata is notably diminished by the growth of -these tumours; more particularly, we learn that whilst the number of -women with uterine myomata who have one child is sufficiently large, the -number of multiparae thus affected falls greatly below the average of -fertility. A characteristic feature of the influence of myomata in -producing sterility is clearly shown by the statistics, inasmuch as -pregnancy is comparatively common in the case of women with subserous -myomata, in whom the uterine cavity and mucous membrane are as a rule -least affected, whilst fertility is far more seriously impaired in the -case of women with submucous myomata. - -_West_, in the case of 43 married women with myomata of the uterus, -found 7 childless; the remaining 36 had in all given birth to only 61 -children, and 20 of these had only one child each. Of _Beigel’s_ -patients, 86 married women with uterine myomata, 21 were sterile; of -_McClintock’s_ 21 patients similarly situated, 10 were sterile. _Von -Scanzoni’s_ investigation showed 38 sterile women among 60 married women -suffering from myoma uteri; _Michel_, 26 sterile among 127; _Winckel_, -134 sterile among 415. From a table showing the number of children born -to each of 108 women with myoma uteri of whom 46 were observed by -_Winckel_, and 62 were in _Süsserott’s_ collection, it appears that on -an average 2.7 children were born to each woman thus affected, whereas -in Saxony the average number of children born to each married woman is -4.5. - -Many other gynecologists have published statistics regarding this -matter, _Gusserow_, _Röhrig_, _Schröder_, _E. von Flamerdinghe_, and -others, some of them dealing with a very large number of cases, and all -show that 30% and upwards of married women with uterine myomata remain -sterile. - -On the other hand, _Hofmeier_ maintains, in opposition to the prevailing -view, that in the great majority of cases myomata are not to be regarded -as giving rise to sterility. His investigation embraced 313 persons, of -whom 25% were unmarried, and 75% married, and of these latter, 25 to 30% -were sterile. (It must be pointed out that compared with the average -percentage of sterile marriages—about 10%, this figure of 25 to 30% is a -very high one.) From a comparison of the age of the sterile married -woman with the duration of married life in each case, _Hofmeier_ is led -to believe that it is not the myomata which have exercised an influence -unfavourable to fertility, and that the occurrence of sterility in these -cases is referable to other causes. The origination of myomata he -regards as etiologically independent of the exercise or non-exercise of -the sexual act. The apparently overwhelming preponderance of the -occurrence of myomata in unmarried and in sterile married women is, he -thinks, to be explained by the fact that unmarried women and nulliparous -married women seldom have occasion to consult a gynecologist, but that -the one condition that renders it necessary for them to do so is the -growth of a uterine myoma. Generally speaking, pregnancy seldom occurs -after the age of 35 years, precisely the age at which the growth of -uterine myomata begins to be common. If, however, at this comparatively -late age pregnancy does occur, it is so often found to be complicated by -the presence of a uterine myoma, that _Hofmeier_ is even led to infer -that the presence of such a tumour must have a certain favouring -influence upon the occurrence of conception; the facilitation of -conception in these cases he explains by the fact that the growth of the -tumour renders the blood-supply of the whole reproductive apparatus more -active than is normally the case, and protracts the duration of ovarian -activity. - - - _Diseases of the Vagina and the Vulva._ - -Various pathological states of the vagina and vulva may cause incapacity -for fertilization by rendering copulation impossible. Such states may be -either congenital or acquired. - -In rare cases the hindrance consists in abnormal smallness of the vulva, -but this condition is usually associated with other defects in -development of the reproductive organs, which combine to give rise to -sterility. Congenital adhesion of the labia minora and majora is -sometimes met with, with or without atresia of the urethral orifice, the -connexion between the labia may be superficial and epithelial merely, as -in a case recorded by _Ziemssen_; or the labia may be firmly united -throughout their whole thickness. Much less common is acquired adhesion -of the labia, causing atresia vulvae, and rendering coitus difficult or -entirely impossible. Various other abnormalities of the reproductive -organs which may give rise to sterility have already been described in -the section on the pathology of cohabitation, these are: abnormalities -of the hymen; anomalous formation and hypertrophy of the labia; -excessive size of the clitoris; anomalies of the vagina, its absence, -stenosis, atresia, duplication, and abnormal termination. - -More detailed mention must, however, be made here of vesico-vaginal -fistula as leading to sterility. Such a fistula is rightly regarded as -one of the conditions preventing conception, but it does not render the -occurrence of pregnancy absolutely impossible. It will readily be -understood that the unpleasant symptoms commonly met with in these -cases, will be apt to deprive both husband and wife of inclination -toward sexual intercourse; again, apart from this psychical influence, -the functions of the female reproductive apparatus are commonly -disturbed to a very serious degree by the existence of a vesico-vaginal -fistula; and, finally, the unfavourable influence of the urine on the -semen must also be taken into consideration, for, as an acid fluid, the -urine will notably check the activity of the movements of the -spermatozoa—still, notwithstanding all these unfavourable influences, -conception will sometimes nevertheless occur in such cases. But of those -who acquire a vesico-vaginal fistula as the result of a difficult -labour, a very small proportion only will again become pregnant. - -_Freund_ draws attention to _Simon’s_ experiences, reminding us that the -latter, in his cases in which women with vesico-vaginal fistula become -pregnant, invariably saw the pregnancy terminate in abortion or -premature labour; but still, _Freund_ quotes also a case of _Schmitt’s_, -and mentions another of his own, showing that this premature termination -of the pregnancy is not absolutely inevitable in such circumstances. -_Schröder_, indeed, goes far in the opposite direction, and writes: -“Such women not rarely become pregnant, and their pregnancy usually runs -a normal course.” _Kroner_ made a statistical investigation of the -question, and found that of 60 women suffering from vesico-vaginal -fistula, 6 became pregnant during the persistence of the fistula. -_Winckel_ reports a remarkable case in which, after the ordinary means -of curing the fistula had been vainly tried, transverse obliteration of -the vagina was undertaken; the operation was not completely successful, -as a small passage remained patent; the patient returned home for a -time, and became pregnant, the spermatozoa having found their way -through this passage. _Simon_ reports another noteworthy case, that of a -woman 57 years of age, with a vesico-vaginal fistula close to the -external os; during the 26 years the fistula had lasted she had -complained of cessatio mensium; when the fistula was closed by -operation, she again began to menstruate. - -Sometimes we meet with abnormalities of the vagina—not strictly speaking -morbid states—which, though they may not at first sight appear to be of -much significance, yet suffice to render conception difficult, or even -impossible. One of these conditions is extreme shortness of the vagina, -leading to the formation of a “poche copulatrice” (Courty), in which -during coitus the semen is ejaculated at a distance from the os uteri -externum; another is excessive length and width of the vagina; another, -some displacement of the vagina which diminishes the prospect that the -semen will enter the cervical canal. Such vaginal false passages, -“fausses routes vaginales,” have been described more especially by -_Pajot_ as causes of sterility. - -Another cause of sterility is the rapid outflow of the semen after -coitus, either in consequence of dyspareunia, or on account of some -abnormality in the configuration of the vagina, or, finally, owing to -deficient action of the constrictor cunni (or bulbocavernosus muscle) -and the muscles of the pelvic diaphragm. In cases of profluvium seminis, -the woman herself will often call the physician’s attention to the -defect. - -Many cases of sterility depend upon a cause the recognition of which in -this connexion is comparatively recent, namely, the hermaphroditism of -the person concerned. Witness the following case described by _Dohrn_: -The individual had been baptised and brought up as a girl. At the age of -twenty years she began to suffer from a distressing sensation of -pressure, recurring at intervals of four weeks. A local examination was -made by a physician, who assured the mother that “there was no hindrance -to menstruation, but that when she married an incision would become -necessary.” After a time she became engaged and was married; and shortly -afterwards her husband demanded a renewed gynecological examination. -This was undertaken by _Dohrn_, who declared that the supposed girl was -of the male sex. The external reproductive organs had the feminine form. -The labia majora were large and well-formed; in the anterior extremity -of each labium was a rounded, sensitive, soft body, of the size of a -large bean, which was capable of being drawn forwards towards the -abdomen; the labia were beset with muscular fibres; the clitoris was 4 -cm. (1.6 in.) in length, resembling an imperforate infantile penis, it -was slightly erectile; in the vestibule there were two openings, the -anterior of which was the urethra, the posterior led into a blind -passage 2 cm. (0.8 in.) in length, representing the fused lower -extremities of the ducts of _Müller_; per rectum no trace could be found -of vagina, uterus, or ovaries, but also no trace of prostate. The -marriage, in which this individual declared himself to be happy, was -annulled. _Leopold_ observed a similar case, in which the individual had -lived as a wife for the space of 25 years. Another striking case is -recorded by _Steglehner_. As _Zweifel_ remarks, to decide the true sex -of such individuals is often extremely difficult. “At the present day, -indeed,” he continues, “it is no longer the fate of those who from no -fault of their own have had imposed on them the name and upbringing of -another sex than that which is truly theirs, and who have thus been led -to contract marriage with one who in reality is of their own sex, to be -treated with the horrible injustice which was meted out to them in the -middle ages, when, as we learn from contemporary writers, they were -haled before the bar of “ecclesiastical justice,” charged with profaning -the sacrament of marriage, and threatened with death at the stake—but -even now a mistake in the decision of an infant’s sex entails in later -life a thousand distresses and inconveniences.” - -Recently, _Neugebauer_ has made as complete a collection as possible of -all the recorded cases of hermaphroditism. - - - _Secretions of the Genital Organs._ - -The constitution of the secretion of the vaginal mucous membrane, or of -the secretion formed in the cervical canal, or both of these in -combination, may constitute hindrances to the normal contact of -spermatozoon and ovum. - -The secretions of the female genital organs are manifold. The outer -surface of the labia majora is covered with skin, containing sebaceous -and sweat glands; but the inner surface of the labia majora and the rest -of the external genital organs are covered with mucous membrane, the -outer stratum of which consists of stratified pavement epithelium; this -epithelium contains sebaceous glands and mucus glands. The intermixture -of the secretions of these glands with the epithelial scales which are -constantly being cast off in large numbers, constitutes the whitish -material with which this region is smeared, known as “smegma.” A mucus -secretion of a fluid consistency is discharged from the vulvo-vaginal -glands known by the name of Bartholin’s glands. - -The mucous lining of the vagina is poor in glands; it contains very -numerous papillæ, which do not, however, project from the surface of the -membrane, since the depressions between the papillæ are filled in by the -stratified epithelium with which the entire extent of the vaginal mucous -membrane is covered. The secretion of the vaginal mucous membrane is a -fluid of thin consistency with an acid reaction; the admixture of -numerous morphological elements, in the form of epithelial cells cast -off from the superficial layers of the stratified epithelium, often, -however, makes the vaginal secretion thick and opaque. The epithelial -lamellae are frequently covered with heaps of lepthothrix granules, and -among the granules are seen vibriones and bacteria and also numerous -lepthothrix threads of varying length. - -The same stratified epithelium extends on to the neck of the uterus to a -distance which varies in different individuals; gradually, however, the -number of layers diminishes, the flattened cells give place to thicker, -prismatic cells, until we have a single-layered prismatic epithelium; -finally the cells become columnar and ciliated, and this columnar -ciliated epithelium covers the whole of the interior of the uterus. The -mucous lining of the cervical canal contains numerous mucous glands, -some of which are simple tubular glands, whilst others are racemose; -they are lined with columnar ciliated epithelium, and secrete a dense, -gelatinous, alkaline mucus, containing a few epithelial cells and -occasional leucocytes. The mucous membrane of the uterine cavity is -beset with simple tubular glands, lined with a single layer of prismatic -epithelium; these glands secrete a grayish alkaline fluid. The secretion -formed in the uterine cavity is thinner in consistency than that formed -in the cervical canal. - -Normally, the secretion of the vaginal mucous membrane is not more than -is sufficient to keep the surface of the canal moist and slippery; it is -a thin fluid of an acid reaction, and almost as clear as water. Shortly -before and after menstruation, the secretion of the vaginal mucous -membrane becomes more abundant; it is even thinner than at other times; -the reaction remains acid. The secretion of the cervical canal is -normally, in the absence of sexual intercourse, small in amount, so that -a free flow of secretion from the os uteri externum is by itself -sufficient to indicate that the mucous membrane of the canal is in an -abnormal condition. The vitreous, gelatinous, alkaline mucus secreted by -the glands of the cervical canal is normally retained within the canal, -and is seen on examination with the speculum to fill the os uteri -externum. In consequence of the congestion of the uterus that occurs -during menstruation, and for the same reason during sexual excitement, -the secretion of the cervical canal is more abundant, it also becomes -less tenacious, and flows out through the os into the vagina. But this -evacuation of the cervical secretion through the os is a normal -occurrence only during menstruation and as a result of sexual -intercourse; in these circumstances it appears in the form of a clear or -somewhat yellowish drop of fluid exuding through the os uteri externum. - -In catarrhal states, the secretions of the genital passage, like those -of other mucous membranes, become abnormal. There is an increase in the -number both of epithelial elements and of leucocytes; and in very acute -catarrhs, erythrocytes also mingle with the secretion. On microscopical -examination we find that the catarrhal secretion differs in its -characters according to the part from which it is derived: the mucus -from the cervical canal forms gelatinous accumulations; that from the -vaginal mucous membrane forms thick opaque masses; and in the mixed -secretion which exudes from the vulva, we find also smegma from the -external genital organs. In addition to cells from the laminated -epithelium, we see often young cells, somewhat oval or polyhedral in -form, with granular protoplasm, and a vesicular nucleus. In some -inflammatory states, pus corpuscles will also make their appearance. -Various micro-organisms are in addition to be found in the catarrhal -secretions. - -The reaction of the vaginal secretion is normally faintly acid; should -it become strongly acid, the movements of the spermatozoa are -immediately suspended. The mucus of the cervical canal, the alkaline -reaction of which is extremely favourable to the onward movement of the -spermatozoa, may, owing to catarrhal processes, be so altered that it -becomes acid; it then destroys the spermatozoa, and gives rise to -sterility. This fact can sometimes be proved by microscopical -examination. In several cases in which endometritis existed in sterile -women I made a microscopical examination of the cervical mucus shortly -after the completion of sexual intercourse; and in a number of these, no -living spermatozoa were to be seen, but only dead, motionless -spermatozoa (Fig. 82). I had, of course, in these cases, previously -assured myself that the husband’s semen was normally active. - -[Illustration: - - FIG. 82. - - Mucus from the Cervical Canal, taken one hour after sexual - intercourse, from a woman suffering from chronic endometritis. - - Among the epithelial cells, pus cells, and finely granular masses, we - see a few motionless, dead spermatozoa. -] - -According to _Nöggerath_, in cases of uterine catarrh, we may find one -of three different varieties of secretion. In some cases it is small in -amount, and very thin in consistency; in others, it is moderate in -amount, very thick, non-transparent, bright yellow, and gelatinous in -consistency; in the third class of cases, we have numerous degrees of -variation, starting from the normal, purely mucus, transparent -secretion, mixed with yellow flocculae, up to a secretion which has -almost the aspect of pure pus. The first described variety is, according -to _Nöggerath_, met with chiefly in women whose uteri are small, with -indurated tissues, and its discharge seems to depend upon commencing -atrophy of the mucous membrane. The second form is the most obstinate, -the catarrh being situated chiefly in the cervical and probably also the -uterine glands; whereas the first variety of secretion is rather a -serous transudation, and contains very few formed elements. The third -form is characterized by extensive denudation of the superficial -epithelium, and is mixed with a smaller or larger quantity of pus. - -_Levy_, who made microscopical examinations in sterile women (39 cases), -gives it as a “constant fact” that when the cervical secretion contains -epithelial and pus cells in large quantities, the spermatozoa never -retain for long their power of movement. Whereas in examinations made -repeatedly on healthy women 25 hours after sexual intercourse, he found -numerous spermatozoa still in active movement, in women having a -catarrhal discharge with the characters just mentioned, five hours after -intercourse the movements of the spermatozoa had almost entirely ceased. - -Not only may the secretions of the genital passage be injurious to the -spermatozoa by their quality, but further a very abundant secretion may -interfere with fertilization. In the first place a very abundant -secretion is apt to be very dilute, and if the spermatozoa are immersed -in a fluid of which the specific gravity is too low, they swell up from -imbibition of water, and their movements are suspended. But excessive -secretion, such as is sometimes met with in cases of cervical catarrh, -may also have a purely mechanical deleterious action, by washing away -the semen out of the vagina. If, again, the quantity of the ejaculated -semen is unusually small, contact with the normally acid vaginal mucus -may suffice to render the spermatozoa speedily motionless. Finally, when -the cervical secretion is of a too tenacious consistency, so that it -fills the os as with a plug, the upward passage of the spermatozoa may -be barred. - -Such tenacious cervical mucus will give rise to sterility especially in -women who have not previously born children; whereas in parous women, -owing to the more patulous condition of the os, the entrance of the -spermatozoa is not so effectually prevented. The same distinction -between nulliparous and parous women must be made, as _von Scanzoni_ has -pointed out, also as regards the production of sterility by -hypersecretion of uterine mucus. Women who become affected with uterine -blenorrhoea only after having had one or more children, will readily -become pregnant again; but when such blenorrhoea affects a woman who has -never been pregnant, sterility almost invariably results. - -_Von Grünewaldt_ has drawn attention to a somewhat rare form of chronic -endometritis with tenacious secretion, leading to sterility. The shape, -size, and consistency of the uterus appear normal, the organ is often -virginal, but with the speculum we see exuding from the os a greyish -green, extremely tenacious secretion, which is wiped away with -difficulty. He saw 24 women affected with this disease; 10 of these had -lived in marital intercourse for many years without ever having become -pregnant; in 10 others there was acquired sterility, i. e., they had at -first borne children after marriage, but had subsequently ceased to be -fruitful; in the remaining 4 it was not possible to ascertain whether -they were fruitful or sterile, since two of them were living apart from -their husbands, whilst in the case of the other two only two years had -elapsed since the birth of the last child. In any case, not one of the -women thus affected had ever become pregnant subsequent to the time at -which she acquired this form of endometritis, notwithstanding the fact -that in several of the cases the symptoms were alleviated by treatment. - -We must here consider also the effect of gonorrhoeal infection in giving -rise to sterility in women. Sterility may arise from gonorrhoea in women -in various ways. Sometimes the abundance of the cervical secretion is -alone sufficient to prevent the entrance of the spermatozoa into the -uterus; in other cases the hindrance to fertility depends upon the -inflammatory conditions in the pelvis that so frequently result from -gonorrhoeal infection—perimetritis and parametritis; it may be catarrhal -changes in the tubes—salpingitis, hydrosalpinx, and pyosalpinx—by which -the contact between spermatozoon and ovum is prevented. Chronic -gonorrhoeal endometritis may give rise to such changes in the uterine -mucous membrane as to unfit it permanently for the implantation of the -ovum, even should there be no obstacle to fertilization. Finally, double -gonorrhoeal oophoritis may result in rendering the formation of mature -ovum an entire impossibility—bringing about a condition analogous to -azoospermia in the male, and causing absolute sterility. Although in -many cases the detection of the gonococcus affords indisputable evidence -of the existence of gonorrhoeal infection, it must be remembered that it -is often difficult, and sometimes entirely impossible, to make the -diagnosis with certainty; and for this reason it is possible that -gonorrhoeal infection plays a much larger part in the causation of -sterility than has until lately been believed. - -The observant physician will in cases of sterile marriage frequently -find in husband or wife or both, evidence of previous or still existent -gonorrhoea; but he will cautiously weigh all the circumstances before -deciding that such gonorrhoeal infection is the efficient cause of the -sterility. In many cases, however, the etiological relation is too -obvious to be overlooked, and we can trace all the distresses of the -unfortunate wife to the injury she unwittingly received upon the -momentous wedding night. - -Still, we have to remember how extraordinarily common, more especially -in the so-called upper classes of society, is gonorrhoeal infection, -and what an enormous percentage of men entering upon married life have -previously experienced one or more attacks of the disease—so that were -sterility a frequent sequel of such infection, fertility would be the -exception rather than the rule. By inquiry among friends and patients -as to whether when they married they had previously suffered from -gonorrhoea, in conjunction with information regarding the fruitfulness -of their marriages, I have been led to the conclusion, which appears -to me to be one of considerable importance, that the proportion of -sterile to fruitful women among the wives of men who have suffered -from gonorrhoea before marriage, is about the same as the proportional -fertility of all marriages considered independently of gonorrhoeal -infection, viz. 1 : 10. This depends, as it appears to me, not only -upon the fact that very frequently in men gonorrhoea is completely -cured, but also upon the fact that in women gonorrhoeal infection does -not necessarily cause sterility. It may indeed be regarded as -definitely established that women actually suffering from gonorrhoea -may become pregnant, and that the pregnancy may proceed to its natural -termination. The recent investigations regarding the frequency with -which gonococci may be detected in the genital secretions of pregnant -and parturient women—and they are to be found in a surprisingly large -percentage—suffice to prove that gonorrhoeal infection offers no -insuperable obstacle to conception. That the discovery of gonococci in -a man’s urethra does not justify us with apodictic certainty in -forbidding the man thus affected to marry is in fact proved by the -following remarkable case, which came within my own experience. A -young man who had had several attacks of acute gonorrhoea, wishing to -marry, had himself examined by two specialists in genito-urinary -disease. Both detected gonococci in his urethra, and both forbade him -to marry. The patient, however, would not be advised, and married the -lady of his choice; now, six years after marriage, he is the happy -father of four blooming children, and his wife is in perfect health. - -_Gosselin_, in an elaborate work published in 1853, was the first to -point out the serious consequences as regards a man’s future potentia -generandi which are entailed by an attack of gonorrhoea followed by -epididymitis. He insisted that the inflammation might lead to the -obliteration at some point of the vas deferens, whereby the secretion of -the testicle was prevented from mixing with the secretions of the -prostate, Cowper’s gland, and the seminal vesicle; and hence the -ejaculated sperm was lacking in its principal constituent. In such -cases, either in the epididymis (usually in the globus minor of that -organ), or else in the course of the vas deferens, somewhere between the -epididymis and the vesicula seminalis, some relic of the former -inflammation is usually to be detected, the globus gonorrhoeicus, and -this usually represents the seat of strangulation of the excretory duct -of the testicle. - -In the year 1872 _Nöggerath_ published his book, written with flaming -fiery zeal, entitled “Latent Gonorrhoea in the Female Sex.” In the most -startling colours he depicted all the misery and distress which formed -the wedding gift of the gonorrhoea-infected husband to his wife; when -sowing his wild oats, such a husband is preparing for the crop by which -his young wife’s happiness is destroyed, her health ruined, her life -endangered, and her hopes of offspring annulled. While we may admit that -_Nöggerath’s_ motives were of the noblest, we cannot but wonder that the -wickedness of the male sex has not yet entailed the destruction of the -whole human race, overwhelmed as by a new fall of Sodom and Gomorrah. - -_Nöggerath_ maintained that 90% of men infected with gonorrhoea remained -uncured; and that of the women married by men thus permanently infected -with gonorrhoea, barely 10% remained free from the disease. It is -gonorrhoeal infection, of which this author gives so gloomy a picture, -which is, in his opinion, the principle cause of sterility in women. -According to his observations, of 81 women thus infected, 49 remained -absolutely sterile; only 31 became pregnant; 23 were delivered at full -term, 3 had miscarriages, and 5 premature delivery. Thus, not so many as -1 in 3 of these women had a full-time child. Of the 23 who were -delivered at full term, 12 never had more than 1 child each; 7 had 2 -children each; 3 had 3 children each; 1 only had 4 children, the normal -average fruit of healthy marriages. In all, the 81 women had only 39 -children. If we take 4 to be the average number of the offspring of a -healthy married pair, there was but one normal woman among the whole 81. -Forty-nine were absolutely sterile; 11 of the remainder had 1 child, and -did not again conceive during periods ranging from 3 to 18 years after -the recorded delivery; thus there were 60 sterile women among 81. - -_Nöggerath’s_ doctrine regarding the relation between gonorrhoeal -infection and sterility obtained at first little credence—perhaps for -the reason that he drew such far-reaching conclusions from so limited a -material—_Schröder_ mentions _Nöggerath’s_ opinions only to dismiss them -as extravagant; but the idea that the husband was mainly to blame for -the occurrence of sterility in marriage continued to form the topic of -scientific discussion. The indignation which _Nöggerath’s_ assertions, -unquestionably too sweeping, had aroused in gynecological circles, -gradually subsided, as every gynecologist devoted his attention to -supporting or refuting _Nöggerath’s_ conclusions. - -It soon became evident, that gonorrhoea in the male had a deleterious -influence upon the fertilizing quality of the semen, and this far more -frequently than had previously been supposed. _Fürbringer_, as a result -of the examination of 124 cases, laid down the important proposition, -that when epididymitis or funiculitis gonorrhoeica duplex had been -observed to occur, the probability that the patient would be an -azoospermist was expressed by the ratio of 9 : 1, and this in direct -opposition to the views of _Zeissl_, who had maintained that in this -respect the consequences of gonorrhoea were trifling. - -_Seeligmann_ conducted a pathologico-anatomical investigation which led -him to conclude that in cases of gonorrhoeal epididymitis, in addition -to the inflammation of the epididymis, phlebitis and periphlebitis of -the plexus pampiniformis occurs, and also lymphangitis of the extensive -system of lymphatic vessels which pass through the spermatic cord from -the testicle; the changes left in the blood and lymphatic vessels by the -inflammation, result in the testicle being for the future imperfectly -nourished, and often therefore lead to impairment of the functions of -this organ; thus the oligospermia so frequently seen as a sequel of -gonorrhoeal epididymitis (the ejaculated semen containing but few -spermatozoa, and these with little or no vitality), is not always due to -a complete obliteration of the vasa deferentia by the inflammation, but -in many cases to the functional derangements of the testicle brought -about in the manner above described. It is probable also that lues may -give rise to azoospermia as a result of endarteritic processes. The -remarkable result of _Seeligmann’s_ investigations was that in as many -as 75% of the sterile marriages that came under his observation, the -husband was the one to blame. - -Latterly, the view that gonorrhoeal infection plays a very considerable -part in the etiology of sterility in women, has been widely accepted. -Among German gynecologists, _Olshausen_, a man of enormous experience, -considers that _Nöggerath’s_ book, notwithstanding much exaggeration, is -substantially accurate in its main conclusions. A similar view of -_Nöggerath’s_ work is taken by _E. Schwartz_, _Bandl_, _A. Martin_, and -_Hofmeier_. - -According to the exhaustive work of _E. Schwartz_, gonorrhoea is in -women one of the commonest causes of sterility. Sterility due to this -disease may be either primary or secondary. In some cases no ovum can -find its way into the uterus, either because the ovaries are completely -enveloped in masses of exudation and pseudo-membranes, or on account of -dislocation of the ovaries and the Fallopian tubes, or because the tubes -have been rendered impermeable by inflammatory stenosis or flexion, or -by loss of their ciliated epithelium; in other cases the ovum, indeed, -enters the uterus, but fails to be implanted upon the diseased mucous -membrane; again, it is conceivable that even when ovum and spermatozoon -are properly formed and encounter one another in the normal manner in -the tube or in the uterine cavity, and when the uterine mucous membrane -is in a condition suitable for the implantation of the fertilized ovum, -contact with gonorrhoeal secretions may have impaired the vitality of -the ovum or of the spermatozoon, or of both, to such a degree, that -either fertilization fails to occur, or the fertilized ovum is incapable -of further development. In some instances, sterility dates from the -first infection of the wife; but more commonly it does not develop until -after the completion of one or more pregnancies. - -_Hofmeier_ rightly points out that whilst gonorrhoeal infection in women -may cause sterility, such sterility is by no means an inevitable -consequence of the disease. - -Other gynecologists are even more reserved in admitting the importance -of gonorrhoea as a cause of sterility in women. _Fritsch_ is of opinion -that in many cases a casual relation is believed to exist, when in -reality there is nothing more than a coincidence. Sterility and slight -perimetritis, he remarks, are common in women; gonorrhoea is common in -men. But it does not follow that the frequent gonorrhoea of the husbands -is the sole cause of the frequent sterility and perimetritis of the -wives. “For several years,” he continues, “I have examined all the men I -possibly could for evidence of the existence of gonorrhoea, and have -enquired for a history of previous attacks of the disease. To my -astonishment I discovered that the fathers of many children, whose wives -had come to consult me for some quite disconnected condition, had quite -as often suffered formerly from gonorrhoea as the husbands of sterile -wives.” - -_M. Saenger_ is one who very vigorously upholds _Nöggerath’s_ views. He -insists that, excluding _puellae publicae_ from consideration, no less -than 12% of all gynecological disorders depend upon pathological -processes referable to gonorrhoeal infection of the female genital -organs. To establish this thesis, it is not necessary to prove that -_Neisser’s_ gonococcus is or has been present; the diagnosis must be -based principally upon clinical considerations. Chronic vaginitis and -urethritis, inflammation of the uterine mucous membrane, tubal -suppuration, oophoritis, and perimetritic adhesions (especially those -which unite all the lateral pelvic organs into a shapeless knot)—these -are conditions thoroughly characteristic of gonorrhoea. - -No less unfavourable an influence of gonorrhoeal infection upon -fertility is shown by the observations of _Glünder_. Women numbering 87 -were in attendance at the gynecological department of the _Policlinik_ -of the University of Berlin, all of them seeking advice on account of -sterility. In the case of 24 of these, the husband was also present; 19 -of these men admitted having previously suffered from gonorrhoea; the -remaining 5 denied such infection, although the wives of all of these -had symptoms pointing unmistakably to gonorrhoeal infection; among the -other 63 women, there were 8 only in whom the genital organs were found -perfectly normal, whilst in 38 of them there were signs of previous -gonorrhoeal infection. Thus we see that of these 87 sterile women, 62 -(71.3%) had had gonorrhoea; and _Glünder_, assuming that in these cases -the gonorrhoea was the efficient cause of the sterility, and regarding -the average percentage of sterile marriages as 12.34 in every 100 -contracted, is led to the conclusion that of every eleven or twelve -marriages, one is rendered sterile in consequence of gonorrhoea. - -To the same opinion, that gonorrhoea is the principal cause of -sterility, _Lier_ and _Ascher_ were led by an investigation of numerous -clinical histories. Moreover, they believe that in the large majority of -sterile marriages, the husband is directly or indirectly responsible. -Directly, in so far as a very large percentage of men have their -reproductive capacity annihilated by gonorrhoea; indirectly, because, of -those who retain their fertilizing powers, so large a number infect -their wives with gonorrhoea, and thus render them incapable of -conceiving, that chronic gonorrhoea—in the female harder to eradicate -even than in the male—must be regarded as the arch-enemy of fertility. -Of 80 men affected with azoospermia, all cases observed by _Prochownik_, -in 75 the disease was the sequel of gonorrhoea; of the remaining 5 -cases, two were due to syphilitic disease of the testicles, one to -tubercular disease of the same, whilst two were due to long continued -masturbation, with consecutive atrophy of the testis and epididymis. - -But that the obstacle offered to conception by gonorrhoeal infection is -by no means so powerful as _Nöggerath_ and his supporters believed, is -shown by the investigations of _Oppenheimer_, who, in _Kehrer’s_ -clinique at Heidelberg, examined 108 pregnant women for the presence of -gonococci, and found these organisms, pathognomonic of gonorrhoeal -infection, in no less than 30 of them, that is, in 27.7%. Thus, in this -large number of cases, pregnancy had occurred notwithstanding the -presence of gonorrhoea. _Lower_, again, in _Schröeder’s_ clinique, -examined 32 patients during the lying-in period, and detected the -presence of gonococci in 26; an experience which also proves that -gonorrhoeal infection is no bar to pregnancy. _Dunstone_ has recently -recorded 5 cases in which, notwithstanding the existence of gonorrhoea, -the women became pregnant once or several times. - -In the “Medical Brief” the question was mooted, “Can a woman have -children subsequently to being infected with gonorrhoea?” Numerous -affirmative answers were received; and among them one mentioning the -case of a woman who was infected with gonorrhoea at the age of 18, and -subsequently gave birth to 8 children. - -The question of sterility in prostitutes has also attracted attention, -since these women may be regarded as invariably infected with -gonorrhoea. _Meissner_ and _Jeannel_ speak of the infertility of -prostitutes as a well-known fact; and the latter states that, whereas, -according to _Montesquieu_, to every 100 women in France, on an average -341 children are born, of which 200 grow up, to 100 prostitutes in -Bordeaux there were born 60 children only, and of these but 21 attained -maturity. _Marc d’Espine_ affirms that among 2,000 prostitutes not more -than two or three will have children in a year. _Parent-Duchatelet_, on -the other hand, regards the sterility of these women as a purely -temporary affair, and writes: “les prostituées conçoivent souvent, mais -elles avortent fréquement;”[49] and this frequency of abortion he -attributes to two causes, in the first place to deliberate induction of -abortion, and in the second place, to their mode of life. He continues: -“cette fécondité a lieu surtout lorsque, quittant leur mettier, elles se -marient ou s’attachent à un seul homme; dans ce cas les grossesses se -succèdent, elles sont toujours heureuses et les infants qui en -proviennent sont aussi vivaces que les autres;”[50] thus, in his opinion -the sterility of prostitutes lasts only as long as they pursue their -occupation. - -The question as to what influence, if any, gonorrhoeal secretion has -_per se_ upon the semen, has often been asked, but not yet -satisfactorily answered. We have no certain knowledge whether the -gonococci, the pus cells, or one of the toxins of the secretion, -exercises a deleterious influence upon the vitality of the spermatozoa; -it is certainly possible that this may be the case, for the diplococci, -just as much as streptococci and staphylococci, are found not only -within the cells, but also in the intercellular fluid and in the -detritus, and so must be brought into intimate contact with the -spermatozoa; but inasmuch as quite a number of persons who are at the -time actually suffering from gonorrhoea beget children, we are compelled -to assume that for the harmful influence, if any such exists, to be -exercised, a prolonged contact of the semen with the gonorrhoeal pus is -necessary. In cases of gonorrhoeal epididymitis and prostatitis, and -also in gonorrhoeal urethritis, no such prolonged contact occurs; but -when the vas deferens or the vesicula seminalis is inflamed, the contact -is more prolonged, and may suffice to destroy the vitality of the -spermatozoa, which are extremely sensitive to chemical stimuli. In 8 -cases observed by _Kroner_, the fruitful coitus was unquestionably -effected when the husband was suffering from still active gonorrhoea; in -all the cases the children were born at full term, and all suffered from -conjunctival blenorrhoea. That gonorrhoea often fails to induce -sterility, is shown by the familiar fact that a woman frequently has one -child after another, all infected with this conjunctival form of -gonorrhoea, showing that the mother remains fertile notwithstanding the -persistency of the gonorrhoeal infection. - -Upon the investigation of 60 carefully written clinical histories, -dealing with the relation between proved gonorrhoeal infection and a -sterile marriage, _Grechen_ has drawn up the following table, showing -the various ways in which chronic gonorrhoea may give rise to sterility: - - - _A. Absolute Sterility._ - -a. Owing to impossibility of fertilization, in consequence of defective -formation of spermatozoon or ovum: - - I. In the male: - 1. Aspermatism. - 2. Azoospermia. - II. In the female: - Oophoritis glandularis. - -b. Owing to impossibility of pregnancy, although semen and ovum may be -normal, and fertilization can be effected: - -Gonorrhoeal endometritis of atrophic character. - - - _B. Relative Sterility._ - -a. Owing to mechanical interference with the conjugation of spermatozoon -and ovum: - - I. In the male: - 1. Epididymitis duplex. - 2. Strictura impermeabilis urethrae. - II. In the female: - I. Perioophoritis and perimetritis, and their results, viz., - adhesions and displacements of the reproductive organs. 2. Tubal - catarrh, pyosalpinx, kinking and other forms of obstruction of the - tubes. - -b. Owing to extension of the gonorrhoeal process to the decidua, causing -abortion in the early period of pregnancy: - -Endometritis gonorrhoeica chronica, and endometritis decidualis. - -_Benzler_ has endeavoured to elucidate the problem of the relations -between gonorrhoea and sterility by a collective investigation in the -army. The investigation was concerned with 474 men who during their -period of service with the colours had been treated for gonorrhoea, and -who subsequently had married. Dealing with all cases alike, without -regard to complications which had been observed in some cases but not in -others, of the 474 wives, there were 64 who never became pregnant = -13.5%; 78 who had one child only = 16.5%; total, 142 = 30%. - -Leaving out of consideration the cases in which epididymitis had been -observed, there remained 363 cases of uncomplicated urethritis; of the -363 wives of these men, there were 38 who never became pregnant = 10.5%; -63 who had one child only = 17.3%; total 101 = 27.8%. - -Thus, in the cases in which the husbands had had uncomplicated -urethritis, the percentage of absolute sterility was only 10.5; while in -the unselected cases of gonorrhoea, it was no more than 13.5. The -figures show clearly that the influence of uncomplicated gonorrhoea is -but trifling; indeed, it is obvious that this must be the case, for it -is probable that not less than 80% of men experience at least one attack -of gonorrhoea, and did this give rise to sterility, either directly by -its influence on the men themselves, or indirectly by transmission to -their wives, the human race would soon die out. Moreover, the frequent -occurrence of ophthalmia neonatorum is a sufficient proof that -notwithstanding gonorrhoeal infection in all these cases, pregnancy and -delivery have taken place. - -To sum up, it is my opinion that in recent years the influence of -gonorrhoeal infection in inducing sterility in women has been painted in -far too gloomy colours, and it is time that these extreme views should -be abandoned. - -This is a convenient place to insist upon the fact that in cases which -are by no means rare, in the absence of aspermatism and azoospermia, and -altogether independently of gonorrhoeal infection, it is the husband who -is responsible for the occurrence of sterility; in such cases the -sterility is due to failure of conjugation between spermatozoon and -ovum, dependent upon congenital or acquired defects of the penis. The -great majority of cases of this kind are due to hypospadias. - -A case of sterile marriage is reported by _Lier_ and _Ascher_, in which -the husband had suffered from hypospadias and had been operated upon for -the relief of that condition. Although erection of the penis was normal, -and coitus terminated in the usual orgasm, with sense of ejaculation, -the semen did not find its way into the vagina; it accumulated in the -artificial cul-de-sac between the former abnormal urethral orifice and -the artificially constructed meatus, and after coitus the semen had to -be expelled from this region by digital pressure. - -_Miclucho-Mackay_ reports that among the Australian aborigines, -hypospadias is artificially induced, in order to prevent fertilization. -In young boys, an incision is made through the lower wall of the urethra -from the meatus as far up as the scrotum, and care is taken that the -several surfaces do not reunite. During coitus, the semen flows away -without entering the vagina. This mutilation is practised, not only in -South and Central Australia, but also by the indigens of Port Darwin. - -That hypospadias does not in all cases offer an insuperable obstacle to -impregnation, is, however, shown by a striking case which came under the -notice of _Labalbary_. He saw a hypospadiac who, in micturating, had to -crouch down in the feminine posture, because he was unable to project -the stream of urine forwards; in coitus, he deposited his semen only on -his wife’s vulva. But his wife gave birth to two sons, about whose -paternity there could be no reasonable doubt, since both exhibited the -same malformation as their putative father. - -Occasionally, phimosis offers an obstacle to impregnation, and only -after relief of the condition by operation, is the wish for offspring -fulfilled. A case of this nature is recorded by _Amussat_. - -In cases of severe stricture of the urethra, sterility may result, -although the constitution of the semen is perfectly normal. During -erection of the penis, the stricture is completely closed, and the semen -accumulates in the urethra above it; when the penis becomes flaccid, the -semen flows away, outside the vagina. In some such cases, the semen -regurgitates into the bladder, and is not discharged until the patient -makes water. Although the supposition is not one in which strict proof -is obtainable, it is probable that the man is at fault in cases in which -the wives of two or more brothers fail to conceive. I have seen several -instances of the kind. Three brothers, all quite healthy, and of virile -aspect, were married to women in whom on gynecological examination no -significant abnormality could be detected; they had been married -respectively for 14, 9, and 8 years; all were childless. Three brothers, -two of whom were practising physicians, had lived a number of years (20, -4, and 14, respectively) in sterile wedlock; one of them (a physician) -informed me that he ejaculated always a very small quantity of semen, -and thought it possible that this was the cause of the sterility. Of -four brothers, two had lived long in barren wedlock; the third had no -child for 14 years after marriage, when at last his wife became pregnant -after a visit to a spa; the fourth brother is a misogynist and a -confirmed bachelor. - - - _Sexual Sensibility in Women._ - -In our consideration of the various influences by which the contact of -ovum and spermatozoon may be prevented, the degree of sexual excitement -experienced by the woman during the sexual act must not be overlooked, -for this plays a part not to be underestimated, even though it is a -matter on which it is difficult to obtain accurate information. - -It is extremely probable that an active participation on the part of the -woman in coitus has an important influence upon the attainment of -fertilization, i. e., that sexual excitement in the woman is a link in -the chain of conditions leading to conception. This excitement has a -reflex influence, but the influence may be exercised in either (or both) -of two ways: first, it may cause certain reflex changes in the cervical -secretion, whereby the passage of the spermatozoa is facilitated; or, -secondly, it may give rise to reflex changes in the vaginal portion of -the cervix, to a rounding of the os uteri externum and a hardening of -the consistency of the cervix (changes of an erectile nature) coupled -with a slight descent of the uterus—changes which likewise favour the -entrance of the semen into the uterine cavity. _Theopold_ goes so far as -to say that it is only women who experience erotic excitement who are -capable of being impregnated. - -My own opinion is that considerable importance is to be attached to -voluptuous excitement of the woman during coitus, for the former of the -two reasons mentioned above, namely, because such excitement leads to -the occurrence of reflex secretion of the cervical glands, the secretion -thus produced maintaining or enhancing the activity of the spermatozoa; -and contrariwise, in the absence of voluptuous excitement on the woman’s -part there is a failure of the reflex secretion, and the passage of the -spermatozoa into the uterine cavity is consequently less easily -effected. That sexual excitement has great influence upon the production -of the first appearance of menstruation, has frequently been shown; and -an analogy between such an influence and the suggested effect of sexual -excitement in favouring the occurrence of conception, must not lightly -be rejected. It is well known that the first menstruation occurs at an -earlier age in girls living in towns than in those living in the -country; not solely (if at all) in consequence of the better nutriment -and easier life of the former, but also, unquestionably, owing to -nervous influences. It is, moreover, a familiar experience that factory -girls, who from early youth are exposed to sexual stimulation, attain -sexual maturity at an extremely early age. Again, from early times it -has been the prevailing opinion of the common people that for the -impregnation of a woman it was necessary for her to experience -voluptuous excitement, or at least, that in the absence of such -excitement, conception was rendered difficult. _Riedel_ relates of the -indigens of the Island of Buru, that they often have sexual intercourse -with foreigners, “but during such intercourse they remain quite passive, -in order to avoid impregnation.” It is not an unusual experience in -gynecological practice for a sterile woman, in the absence of any -prompting, to complain that during coitus she has no “feeling” whatever, -and to attribute to this lack of feeling her failure to conceive. - -A cultured lady, the mother of several children, assured me, not only -that she was always aware, whether an act of intercourse would or would -not lead to impregnation, but further, that it was within her power to -determine whether the intercourse should or should not be fruitful. If -she was passive during intercourse, or if, to use her own expression, -her attitude was one of “laisser faire, laisser aller,” conception would -not occur; but if, on the other hand, she took an active part in the -coitus, so that she experienced a powerful voluptuous sensation, -pregnancy would result from the intercourse. - -In some cases, the previously described condition of dyspareunia is the -cause of the sterility. In fact, the combination of dyspareunia with -sterility is so strikingly common, that my own observations have led me -to infer that there is a casual connexion between the two states, at -least in a considerable proportion of cases. - -I append a short note of a few instances of this kind: Mrs. G., aged 27, -married 6 years, sterile; an anæmic, delicate lady, who has never -experienced the sense of ejaculation. The semen flows away from the -vagina immediately after the completion of coitus. No abnormality to be -detected on gynecological examination. Mrs. S., aged 24, married 5 -years, sterile; during intercourse remains completely cold, and has -experienced the sense of ejaculation in dreams only. Gynecological -examination disclosed the existence of slight cervical catarrh, but no -other abnormality. Mrs. E., aged 30, married 10 years, had a child 9 -years previously, a difficult delivery followed by puerperal disease, -since then sterile; she states that since her delivery she has not -experienced the sense of ejaculation, with which she was formerly -familiar; further, since that time she has suffered from profluvium -seminis. On gynecological examination the uterus was found to be -enlarged and retroflexed. Mrs. K., aged 28, married 6 years, sterile; -amenorrhoeic, has never experienced the sense of ejaculation, and finds -sexual intercourse so unpleasant that, “in order to be left in peace,” -she has herself begged her husband to keep a mistress. Examination -showed the uterus to be in an infantile condition. - -Whilst I have notes of numerous cases similar to those just quoted, I -must also insist upon the fact that I have sometimes had complaints of -dyspareunia from wives whose fertility has been proved by the birth of -numerous children. And, again, anyone whose position permits him -frequent glimpses of what passes behind the scenes of married life, will -from time to time have noticed as signs of relative dyspareunia -instances in which the faithless wife is far more readily impregnated by -her lover than by the husband to whom she is indifferent or whom she -actually dislikes. - -To relative dyspareunia dependent upon sexual disharmony we must refer -also those instances in which a man and a woman prove sterile while -living together for a considerable period as man and wife, but after -separation both prove fertile in fresh unions. Several such cases have -come within my own experience, and similar instances attracted the -attention of the observers of antiquity—_Aristotle_, for example. -_Haller_, for this reason, lays stress on the lack of mutual affection -as a cause of sterility; and _Virey_, also, believes that sterility may -often depend upon the absence of the “harmonie d’amour.” - -It is possible that the custom, which in certain rural districts has -persisted into quite recent times, of a temporary experimental -cohabitation of candidates for matrimony, was based on an attempt to -discover the existence of such a sexual harmony. _Ploss_, for instance, -reports that in East Prussia, in 1864, he was informed that among the -Mazurs this custom of an experimental year of cohabitation was in force. -If during this year the woman became pregnant, the young couple were -married; but if pregnancy failed to occur, they separated, considering -they were not formed for one another. - -A well-known historical example of relative sterility is furnished by -the two marriages of Napoleon I. His first marriage to Josephine -remained sterile, though Josephine had children by Beauharnais; and -Napoleon, remarried to Marie Louise, had a son by the latter. - -_Von Gutceit_, a physician of wide experience, points out that -“sensitive women, who have a mental or physical antipathy to -cohabitation, or who have a secret but ardent affection for some other -man, often fail to conceive as a result of intercourse with their -husbands; but when, in illicit intercourse, they experience the -voluptuous sensations to which they have hitherto been strangers, -pregnancy often speedily ensues.” He maintains, further, “that such -women, in consequence of the stimulation of the genital organs in the -absence of sexual gratification, become affected with all kinds of -menstrual irregularities, with fluor albus, prolapse of the uterus, and -chronic metritis; they suffer from digestive disturbances and -constipation, leading to emaciation; and they are prone to hysterical -manifestations.” - -Analogous phenomena have been noted, and with much greater distinctness, -in the animal world. _Darwin_, writing on this subject, remarks: “It is -by no means a rare occurrence, that certain males and females will not -be fruitful in intercourse together, whilst the same individuals prove -perfectly fertile in intercourse with other members of their species—and -this in cases in which there is no evidence that the subsequent -fertility is due to any change in the conditions of life. The cause is -probably to be found in an innate sexual disharmony between the -infertile pair. A very large number of instances of this kind have been -reported to me by well-known breeders of horses, cattle, pigs, dogs, and -pigeons. Sometimes a breeder will fail to obtain offspring from a male -and a female of known fertility whom he wishes to couple for some -special reasons. The most celebrated living horse-breeder informed me -that frequently a mare, which in other seasons with other stallions has -proved fertile, may be coupled with a stallion likewise of proved -reproductive potency, and will fail to be impregnated; yet this same -mare will shortly afterwards be impregnated by another stallion.” - -_Pflüger_ reports that he has often seen a thoroughbred stallion, which -was fully prepared, at a moment’s notice, to serve a thoroughbred mare, -prove extremely unwilling to serve a common mare on heat, and only -induced to do so with the greatest difficulty, and indeed by a trick. -The stallion is placed in the central one of three stalls, on one side -of him is the thoroughbred mare, whilst in the third stall is the common -mare, covered with a cloth. The stallion’s head is turned to show him -the thoroughbred mare; immediately his appearance undergoes a change. -Every muscle of his body appears to quiver, and never does a fine animal -appear more beautiful than at such a moment, full of pride, fire, and -vitality.[51] As soon as the stallion makes ready to serve the mare, he -is rapidly led to the other stall, and suitably assisted to the actual -commencement of intercourse with the substituted mare. But it sometimes -happens, as _Pflüger_ himself has seen, that the stallion becoming aware -of the deception, refuses to complete the coitus, withdraws his penis, -and immediately turns to the mare of his choice. - -_Matthews Duncan_, among 191 sterile women, found that 39 had no sexual -appetite, and 62 had no voluptuous sensations during coitus. He regards -abnormal sexual appetite as one of the principal causes of sterility. - -Notwithstanding these facts, it must not be forgotten that many cases -are recorded in medical literature of women conceiving after intercourse -effected against their wishes, as by rape, or when they were in a state -of intoxication, or asleep, or in the entire absence of all voluptuous -sensation. Moreover, the erection of the vaginal portion of the cervix, -and the reflex movements and secretory changes in the uterus, may also -occur independently of sexual desire and voluptuous sensation; but such -cases are certainly exceptional, and their credibility is frequently -open to suspicion. In numerous instances in which conception is stated -to have followed intercourse in a state of unconsciousness, judicial -proceedings have elicited the fact that the intercourse was not entirely -involuntary on the woman’s part, and that the alleged force was no more -than a _vis grata_. _Von Maschka_ reports a case in which a girl -asserted that she had been violated whilst in a condition of epileptic -unconsciousness, but she remembered every detail of the act with -precision. _Casper_, again, in a case in which it was asserted that -defloration had been forcibly effected whilst the girl was in a state of -alcoholic coma, showed that there had been no more than moderate -intoxication combined with great sexual excitement. Assertions that -pregnancy has resulted from intercourse effected during sleep, in a -state of unconsciousness, or in the “magnetic” or “hypnotic” state, -should always be accepted with reserve. - -It is interesting to note in this connexion that the Chinese physicians -enumerates among the causes of sterility the practice of “congfou” by -the man, this name being given to a manipulation analogous to hypnotism, -whereby the voluptuous sensation during intercourse is diminished or -abolished by distracting the attention elsewhere. - -A proof of the importance of specific sexual sensation for the -attainment of conception is afforded by the fact that in the majority of -women voluptuous excitement is absent at the first act of intercourse, -and only gradually develops thereafter; in correspondence with this, we -find that the first conception does not usually occur until some time -after marriage, and that the period of its occurrence frequently -coincides with the full development of voluptuous sensation during -intercourse. Thus, even in the woman fully fitted for conception, the -actual capacity for impregnation is only developed gradually, and after -a sufficient experience of intercourse. - -This transient incapacity for conception may, indeed, also depend upon -the fact that at first coitus is apt to be incompletely effected, and -for this both husband and wife are to blame; but unquestionably in many -cases the reason is the one first mentioned. - -In some cases, certain psychical influences which affect the intensity -of the voluptuous sensation, manifest its significance. Thus, in some -instances, the influence of stimulation of the clitoris in leading to -conception has been clearly shown; in others, the performance of coitus -in some unusual position, varying with the woman concerned, is alone -competent to arouse sexual sensibility to its full extent, and to bring -about the orgasm. One occasionally receives confidential information -from a husband that his wife experiences a voluptuous sensation only -when coitus is performed in the lateral posture, or _more bestiarum_, or -in the _situs inversus_, etc., etc. - -Excessive frequency of intercourse, prolonged and repeated sexual -excitement, on the other hand, induce sterility, as is well seen in -prostitutes, who rarely become pregnant. - -Finally, perverse sexual impulse must be mentioned as a possible cause -of sterility. This may be an acquired perversion, due to the fact that -at the epoch of the menarche, the commencement of puberty, owing to the -strength of sexual desire whilst intercourse is an impossibility, or -simply from evil example, the girl has become a confirmed onanist, and -continues the habit even after marriage. In other cases we have to do -with a psychopathic state, a form of mental degeneration due to very -various causes, or in some cases inverted sexual sensibility exists in a -person whose mind is in other respects normal. In women with sexual -inversion, ordinary copulation with the male is insufficient to arouse -the sexual orgasm, and for this reason, as well as because persons thus -affected avoid coitus as much as possible, sterility commonly ensues. - -In sterile homosexual women, and equally so in women addicted to -masturbation, gynecological examination may disclose no abnormality -whatever; but in other cases of the kind we may find a contributory -cause of sterility in the fact that the internal genital organs are -imperfectly developed, or even completely absent. In sterile women, if -on gynecological examination we find certain characteristic changes in -the reproductive organs, a strong suspicion will be aroused that the -sterility is due to abnormal modes of sexual gratification. The changes -in question are: hypertrophy of the clitoris, enlargement and a bluish -colouration of the labia minora, retroversion of the uterus, neuralgia -and displacement of the ovaries, leucorrhoea, and menorrhagia. - -The question has been mooted by _Cohnstein_, whether, as is commonly -assumed, a woman is capable of becoming pregnant at any time during the -year, or whether, as in the lower animals, the reproductive capacity can -be exercised only at certain seasons, or again, whether there may not be -individual moments of predilection for the occurrence of conception. He -found that in the great majority of women there were such seasons of -predilection, and only in a minority could conception be effected -indifferently at any time of the year. As a proof of this assertion, he -appends the following case: A married woman, 33 years of age, had -several years before been delivered prematurely of a still-born child, -and since then had not again been pregnant. Her reproductive organs were -normal. The husband’s semen was examined, and also found to be quite -free from abnormality. In the course of the three following years an -attempt was made to cure the sterility by dilatation of the cervical -canal, suggestions for the proper regulation of sexual intercourse, -etc., but all without effect. _Cohnstein_ now calculated the date at -which the full term of the previous pregnancy would have fallen, and -found that this was the middle of February; he therefore inferred that -intercourse effected at the beginning of May would result in -impregnation. As a fact, the woman conceived at this time, and at full -term gave birth to a healthy girl. The assumption that such a time of -predilection for the occurrence of conception exists is, however, -contradicted by the well known fact that in the case of large families -the children’s birthdays are irregularly distributed throughout the -year. - -_Baker-Brown_ describes a special form of sterility due to “sympathetic -or reflex action.” It depends upon diseases of the organs adjoining the -uterus, such as vascular tumours of the urethra, bleeding piles, -fistula, fissure, and prolapse of the anus, schirrus of the rectum, -ascarides. “These diseases produce sterility in consequence of the loss -of blood, the menstrual disturbances, the morbid congestion of the -uterine system, and the reflex neuroses, to which they give rise.” -_Courty_ reports a case belonging to this category in which in a young -married lady sterility was due to fissure of the anus, which had long -existed without recognition; after the fissure had healed, conception -occurred. _Palmay_ recently reported a case in which “taenia solium was -the cause of sterility. In a woman 20 years of age, who had lived in -sterile wedlock for three years, the presence in the intestine of a -tapeworm, which she had harboured for many years, gave rise to -dysmenorrhœal troubles. The complete expulsion of the worm relieved the -dysmenorrhœa, the woman became pregnant, and gave birth to a child at -full term; since then menstruation has been painless.” The presence of -the tapeworm may have had an unfavourable influence upon the -blood-supply and the innervation of the uterus. But cases of this nature -do not constitute a special form of sterility; they must be classed, -either with cases due to interference with ovulation, or with those due -to prevention of the contact of ovum and spermatozoon. - - - _Incapacity for Incubation of the Ovum._ - -The fertilization of the ovum is, as previously described, probably -effected in man, as in other mammals, in the upper third of the -Fallopian tube. The fertilized ovum is then swept down into the uterus -by the action of the cilia which line the tube, assisted by the -peristaltic movement of the muscular wall of the canal. The uterine -mucous membrane at this time is thickened and thrown into folds, and in -these latter the fertilized ovum is entangled; by its presence the ovum -now exerts a reflex stimulus leading to a still greater proliferation of -the cells of the uterine mucous membrane, which grows up over the ovum -and soon shuts it off completely from the uterine cavity. Thus the ovum -comes to be entirely imbedded in the substance of the mucous membrane. - -Thus for the implantation of the ovum, it is first of all necessary that -the uterine mucous membrane should be in a normal condition; -pathological changes in this membrane, and indeed any morbid structural -alteration in the uterine tissues, may prevent the implantation and -incubation of the ovum, and may thus give rise to sterility. - -The uterine cavity is normally lined with ciliated epithelium, the cells -of which have an elongated elliptical form. The movement of the cilia is -directed downwards. The epithelium is perforated by the orifices of the -uterine glands; these glands are simple tubular glands, passing through -the mucous membrane with an S-shaped or corkscrew curve; between the -glands lies a rich germinal tissue, made up of rounded cells. The -rounded connective tissue cells have processes which build up the -scaffolding of the mucous membrane. Among the connective tissue cells of -the uterine mucous membrane, wandering leucocytes are almost always to -be seen. Menstruation is characterized by a swelling of the mucous -membrane, and by enlargement of the uterine glands. At the same time, -blood extravasations appear between the more superficial layers of the -membrane, and on its free surface, and various portions of the surface -of the membrane are cast off. - -Very numerous are the morbid states of the uterus and its annexa whereby -the implantation and incubation of the ovum are prevented; and -incapacity of the uterus for the fulfilment of these functions is -therefore a common cause of sterility in women. - -That developmental defects of the uterus, even when they are not such as -render conception impossible, may yet often give rise to sterility, has -been already explained in writing of the conditions of the uterus which -prevent the contact of ovum and spermatozoon; for defects of development -which are not sufficiently severe to prevent this contact, may yet -suffice to render the uterus unfit for the implantation and incubation -of the fertilized ovum. Inflammatory disorders, such as perimetritis and -the formation of exudations in the parametrium, may render the uterus -unable to undergo the enlargement necessary to pregnancy. Tissue changes -in the uterine musculature may likewise prevent the implantation of the -ovum, or the proper development of the uterus during pregnancy. -New-growths of the uterus or its neighbourhood may bring the development -of the fertilized ovum to an untimely conclusion. Above all, however, it -is diseases of the uterine mucous membrane which unfit the organ for the -implantation of the ovum, and thus give rise to sterility. All those -inflammatory states which lead either to softening or to induration of -the uterine parenchyma, or to swelling and thickening of the endometrium -or parametrium, may offer a hindrance more or less serious to the normal -incubation of the ovum. - -The diagnosis whether in an individual case we have to do with sterility -dependent upon _impotentia gestandi_, is often difficult, because the -conditions which cause it are frequently associated with those which -cause sterility by preventing the contact of ovum and spermatozoon. In -any case, a careful examination of the pelvic organs must be made, not -only to determine whether there is any displacement or enlargement of -the uterus, chronic metritis or perimetritis, parametric exudations, or -new growths of the uterus or of neighbouring organs, but also, if -necessary by dilating the cervical canal, to ascertain the condition of -the uterine mucous membrane, and whether there is hyperplasia or atrophy -thereof. In this connexion, examination of the uterine secretion is of -especial importance: a purely mucous, transparent, vitreous, tenacious -secretion in the os and in the cervical canal, indicates the existence -of catarrhal endometritis; a markedly haemorrhagic secretion signifies -hyperplastic endometritis; profuse purulent secretion containing -gonococci, indicates gonorrhoeal endometritis; the discharge of pieces -of membrane shows that there is exfoliative endometritis; the discovery -of fragments of carcinomatous tissue indicates the breaking down of a -malignant tumour of this nature; etc. - -Finally, it is necessary to obtain a careful history of the case, asking -whether there have been menstrual irregularities, or miscarriages, and -the characters of previous labours (in cases of acquired sterility); any -pathological conditions in other organs should be investigated; and the -condition of the blood and the state of general nutrition should receive -attention. Chlorosis, anæmia, and scrofula often give rise to catarrhal -endometritis; severe disease of the heart may lead to congestive -troubles of the genital organs; after abortion or difficult labour, -chronic metritis or endometritis are common. Further, the differential -diagnosis between erosion and carcinoma of the portio vaginalis, must -often depend upon consideration of the patient’s age and general health, -and upon the nature and duration of the haemorrhage. Pain on -micturition, appearing soon after marriage, and lasting often a few days -only, will indicate the probability of gonorrhoeal infection, etc. - -_Von Grünewaldt_ has vigorously insisted upon the fact that the notion -of sterility, i. e., _impotentia generandi_ in women, is not coincident -with the notion of _impotentia concipiendi_, and there is an important -distinction between cases in which it is impossible that fertilization -should be effected, and cases in which, though fertilization may take -place, the implantation and incubation of the ovum fail to ensue. In -this author’s opinion, the only absolute mechanical hindrance to the -entrance of the semen is to be found in atresia of the genital passage, -and the role of _impotentia concipiendi_ is of quite minor importance as -compared with incapacity on the part of the uterus for the implantation -and incubation of the ovum, an opinion, which, notwithstanding the -record of exceptional cases in which pregnancy has occurred in spite of -the existence of mechanical obstacles to conception, I must regard as -altogether beyond the mark. On the other hand, it is indisputable that -for the occurrence of pregnancy it is necessary, not only that contact -of ovum and spermatozoon should be possible, but further, that the -uterus should be in a condition favourable for the implantation and -further development of the ovum subsequent to fertilization. For this -reason, diseases of the uterine tissues must play an important part in -the causation of sterility, though we cannot go so far as to admit with -_von Grünewaldt_ that these diseases are the _principal_ cause of -reproductive incapacity in women. - -Various metritic processes, and also venous hyperaemia consequent upon -heart disease, may lead to atrophy of the uterine mucous membrane, which -then appears thin and smooth, whilst the uterine glands are destroyed, -or transformed into small cysts. The same condition may result from -retention of secretions in the uterine cavity—hydrometra and -haematometra. In all these cases, the epithelium probably loses its -cilia. The process has a serious influence antagonistic to the -reproductive capacity inasmuch as the implantation of the chorionic -villi is rendered difficult (_Klebs_). - -Hyperplasia of the uterine parenchyma, affecting either the whole organ -or a large part, and characterized either by enlargement of the entire -organ, or only by thickening and elongation of the cervix, may hinder -the incubation of the ovum. It may be due to endometritic catarrhal -processes; to venous hyperaemia, especially in cases of valvular heart -disease; to subinvolution; and sometimes to excessive sexual -stimulation, as in prostitutes. Both the change in the shape of the -cervix, and the changes undergone by the uterine mucous membrane in -cases of extensive uterine hyperplasia (it commonly becomes atrophic and -discharges a watery secretion), interfere with the reproductive -capacity. - -In all cases of chronic metritis, the hyperaemia and hyperplasia of the -uterus may give rise to haemorrhages; these sweep away the ovum, and -thus lead to _impotentia gestandi_. And the nutritive changes in the -mucous membrane that occur in chronic metritis also interfere with the -implantation and incubation of the ovum. Moreover, it is well known that -in these cases, even if conception is effected, abortion is extremely -apt to occur, owing to the pathological state of the endometrium, which -interferes with the normal development of the decidua. Haemorrhages -occur in the decidua, and are followed by abortion. And further, the -replacement of portions of the muscular tissue of the uterine wall by -fibrous tissue, a change which is apt to occur in long continued -metritis, interferes with the proper expansion of the uterus during -pregnancy, and thus leads to abortion. - -On the other hand, it cannot be denied that frequently enough patients -with well marked chronic metritis nevertheless conceive in a normal -manner, and give birth to a healthy child; and this not once only, but -again and again. - -As sterility due to mesometritis, _von Grünewaldt_ classes the numerous -cases in which sterility ensues upon a confinement in which the patient -reports that inflammation followed delivery—or sometimes in which -nothing abnormal was noticed. The results of local examination are -negative: there is no displacement, no exudation or swelling, and no -relevant affection of the endometrium. But the characteristic feature of -these cases is, according to _von Grünewaldt_, that after her last -full-time delivery, a woman has had a miscarriage or a premature -delivery, and subsequently has been completely sterile. The degenerative -process is at first partial, so that it does not prevent conception, but -renders it impossible for the pregnancy to go on to full term; -subsequently it extends throughout the mesometrium, and conception is no -longer possible. - -_Cole_ of San Francisco regards as the most frequent cause of sterility -ensuing upon a single delivery, subinvolution of the uterus, most -commonly due to rising too early after delivery. He therefore considers -it of especial importance after a first delivery that the physician -should satisfy himself that no serious injury has been effected by the -process. - -Chronic endometritis is a very frequent cause of sterility: in the first -place, the catarrhal swelling of the mucous membrane, which often -extends from the os uteri externum to the ostium abdominale of the -Fallopian tubes, offers an obstacle alike to the downward passage of the -ovum and the upward passage of the spermatozoa; and secondly, in long -standing cases, the large size of the uterine cavity and the smoothness -of the surface of the atrophied mucous membrane, render the lodgment of -the ovum in the uterus very unlikely. A further powerful obstacle to -impregnation in cases of endometritis is offered by the profuse -muco-purulent secretion which usually, though not invariably, -accompanies that disease. This secretion, in some cases flowing freely -over the surface of the membrane, but in others adhering to it with -tenacity, whitish-yellow in colour, rendered cloudy by admixture of pus, -or tinted red by admixture of blood, sometimes of a gelatinous -consistency with a strongly alkaline reaction, contains globules of -mucus, ciliated and cylindrical epithelial cells, pus corpuscles, -bacteria and cocci,—and, if the endometritis is of gonorrhoeal origin, -the gonococcus of _Neisser_. This secretion, when profuse and thinly -fluid, pours out through the os, and sweeps away the semen; when -tenacious and gelatinous, it fills up the dilated cervical canal above -the constricted os uteri externum, and constitutes a powerful barrier to -the upward passage of the spermatozoa; when purulent, it is destructive -to the vital activity of the spermatozoa. The changes in the mucous -membrane in cases of long standing endometritis whereby the uterus is -rendered unfit for the implantation and incubation of the ovum, are the -following. The epithelial cells, as usual in cases of continued catarrh, -change in form, the ciliated cells disappear, and are replaced, first by -cylindrical cells, later by polymorphic cells, approaching in type those -of pavement epithelium. The mucous membrane is swelled, the vessels are -dilated, there is hyperplasia of the glands, with a moderate amount of -small-celled infiltration of the interglandular tissue (Fig. 83). -Ultimately the mucous membrane undergoes atrophy, its glands disappear, -it comes to resemble a thin stratum of connective tissue. - -[Illustration: - - FIG. 83.—Uterine Mucous Membrane in Endometritis. (After A. Martin.) -] - -Thus, in severe and long-continued endometritis, the changes that occur -in the uterine mucous membrane render the implantation of the ovum and -the formation of normal decidua impossible; even if conception does -occur, the fertilized ovum is speedily discharged. Frequently, in cases -of endometritis, there is consecutive displacement of the uterus which -acts as a contributory cause of sterility. When endometritis lasts a -long time, proliferation of connective tissue in the uterine parenchyma -also occurs, leading often to hypertrophy of the cervix, and to stenosis -of the cervical canal. Since in so many different ways endometritis may -give rise to sterility, the importance that must be attached to this -condition is evident. - -The great significance of gonorrhoeal infection in relation to sterility -in women depends, not only on the changes this disease causes in the -Fallopian tubes, leading to interference with the necessary contact of -ovum and spermatozoon, but further, upon the occurrence of gonorrhoeal -cervical and corporal endometritis, of perimetritis, and secondary -parenchymatous metritis. Still, under appropriate treatment, the -inflammatory changes consequent on gonorrhoeal infection are in many -cases curable, and, after absorption of the exudations and restoration -of the normal nutritive conditions of the tissues, conception may take -place. _Fritsch_, who points out that in the woman infected with -gonorrhoea, sterility ensues in a manner analogous to that in which it -occurs in the male (for in the latter it is not the primary urethritis, -the disease of the passage, but the secondary inflammation of the -testicle that leads to sterility), states that he has observed cases in -which beyond question conception has occurred, notwithstanding the -existence of gonorrhoeal endometritis. - -In my own experience, whilst gonorrhoeal endometritis is, among -inflammations of the endometrium, the most frequent cause of sterility, -the place of next importance in this connexion is occupied by -exfoliative endometritis, or membranous dysmenorrhœa. This name is given -to a pathological condition in which from time to time, usually during -menstruation, fragments of membrane, or even an entire sac-like cast of -the uterine cavity, are expelled from the uterus; since this condition -is apt to hinder the incubation of the ovum, it is commonly associated -with sterility—a fact mentioned already by _Denman_ in 1790, and since -then confirmed by numerous observers. I have had under observation -several cases of dysmenorrhœa membranacea; in two cases it existed from -the time of marriage—in one case 14 years, in the other 8 years—and in -both sterility was absolute. In the latter of the two cases, vigorous -treatment was undertaken, even curettage of the uterus, but quite -without avail. In other cases, the sterility was acquired, the -membranous dysmenorrhœa having begun after the woman had already had one -or more children; but as I have never seen a case in which a woman -became pregnant after the development of this affection, I am compelled -to regard it as one of the most severe hindrances to conception. - -As a general rule, exfoliative endometritis terminates only with the -onset of the climacteric age; in very exceptional cases, however, a cure -may take place earlier. In cases in which this premature termination has -been observed, pregnancy has been known to ensue, cases of this nature -having been observed by _Solowieff_, _Fordyce Barker_, and _Thomas_. And -recently, cases have been reported, in which the disease has returned -after such a pregnancy. _Fritsch_, indeed, is of opinion that -exfoliative endometritis does not cause sterility, and that in this -disease abortion is no commoner than in other diseases of the uterus. -_Charpignon_, _Hennig_, and _Bordier_ have also observed conception -occur in the course of this disease. In 42 cases of membranous -dysmenorrhœa collected by _Kleinwächter_, pregnancy occurred in four -during the existence of the disease. _Löhlein_ also reports that, among -27 patients affected with membranous dysmenorrhœa, six became pregnant, -after the symptoms had been clear and unmistakable for a shorter or -longer period. Two of these patients had been already pregnant before -the first appearance of the exfoliative endometritis; subsequently they -became pregnant and were delivered at full term. The other four had -suffered for varying periods and with varying severity from the -affection, before they first became pregnant. In three of these cases -curettage of the uterus was performed; but in one only, in which -pregnancy ensued very speedily on the operation, could a causal -connexion be inferred. In two of the cases the mothers of the patient -had also suffered from the affection. - -It has been asserted by _B. Schultze_ and others that curettage of the -uterus renders it difficult or impossible for pregnancy subsequently to -occur. There is, however, no evidence to justify such an opinion. - -Especial attention should be given to inflammatory processes in the -perimetrium and the parametrium as diseases giving rise to sterility in -women. They are extremely common, and at times are so insidious, running -their course without giving rise either to pain or to fever, that even -when very extensive, and even when they have led to the formation of -secondary tumour-growths, they may yet be overlooked. Hence their -pathological significance in the causation of sterility in women is -still underestimated. Chronic pelvic peritonitis and parametritis may -lead to the onset of sterility in various ways: changes may occur in the -cervix, this organ becoming indurated, fixed, and retroposed, and -painful when the uterus is moved; inflammatory changes may affect the -body of the uterus, the ligaments of the ovary, and various portions of -the pelvic peritoneum; displacement of the uterus may occur; one or both -ovaries or tubes may be dislocated and fixed, either to the side of the -uterus, or behind it, in the pouch of Douglas; all kinds of adhesions or -inflammatory nodules may result from these processes. Further, in the -scarred, contracted, sclerosed parametric tissue, the blood and -lymphatic vessels of the parametrium are compressed, and in part -obliterated, and the intimate connexion between the pelvic cellular -tissue and the uterus readily leads to the onset of endometritis, -whereby the implantation of the ovum is interfered with. The occurrence -of sterility in cases of pelvic peritonitis and parametritis, depends in -part on the indirect effects of the inflammatory exudations, and in part -on the direct result of the extension of the inflammation to other -regions. The perimetritis, parametritis, and pelvic peritonitis that -result from gonorrhoeal infection have thus an especially disastrous -influence, for the reason that in these cases cervical metritis and -endometritis with blenorrhoea are commonly superadded. This is the -principal cause of the almost invariable sterility of prostitutes, in -whom, however, we must also take into consideration the influence of the -absence of voluptuous sensation in an act which to them has become a -mere matter of business. The investigations of _Bandl_ in the post -mortem room show that residues of perimetritic and parametritic -inflammation are to be found in the bodies of 58.4% of parous women, and -33.3% of the bodies of women (married or unmarried) who have had -experience of sexual intercourse but have never had a child. This, he -thinks, is the explanation of the great frequency of childless marriages -and of relative sterility in women. In the nulliparae mentioned above, -_Bandl_ commonly found an indurated, functionless, in places cicatrized, -narrowed cervix, paraoophoritic and perisalpingitic residues, and morbid -changes in the tubes and the ovaries. In some cases also the husbands of -such sterile women were found to be affected with azoospermia. The -connexion between azoospermia in men and the discovery of inflammatory -residues in their childless wives, is a very intimate one. The husband -at the time of marriage was suffering from an imperfectly cured -gonorrhoea, and infected his wife. In the other class of cases, in which -the women had had children, and subsequently become sterile, the -limitation of fertility depended chiefly upon inflammatory residues in -and around the ovaries and the tubes. In the majority of such cases, -pregnancy is not rendered impossible, but merely difficult, for, -notwithstanding the presence of very extensive inflammatory residues, -the tubes are often pervious, and the ovaries fully or partially -functional. Therefore, even in cases in which intrapelvic inflammation -has been very severe, we must be cautious in giving a prognosis that -pregnancy has been rendered impossible, for the cases in which both -ovaries are imbedded completely in pseudo-membranes, or in which both -tubes have been rendered impervious, are unquestionably rare. - -Carcinoma of the uterus rarely causes sterility. In its initial stages, -in which there is merely papillary proliferation of the portio -vaginalis, or carcinomatous infiltration of the deeper layers of the -mucous membrane, no hindrance is offered to conception; but even in the -later stages of the disease, when ulceration has occurred, and when -there is extensive necrosis of the cancerous masses, there is not -necessarily any absolute impossibility of the occurrence of conception, -so long as cohabitation remains possible, and no insuperable hindrance -has risen to the contact of ovum and spermatozoon. The cases are -numerous in which pregnancy has been observed, notwithstanding extensive -carcinomatous disease of the cervix, with necrosis of the tumour tissue; -and _Cohnstein_ even asserts, though in this he goes too far, that -cancer of the cervix actually favours impregnation. Among 127 cases of -this kind, there were 21 in which the disease had existed for a year or -more before the occurrence of conception. - -_Winckel_ summarizes in the three following propositions his experience -regarding the relation between uterine carcinoma and sterility: 1. -Married women form the very large majority of those affected with -carcinoma of the uterus; 2. The marriage of such women has very rarely -proved sterile; 3. On the contrary, the women affected with this disease -have generally been exceptionally fertile. - -Other tumours of the uterus cause sterility, not merely by giving rise -to mechanical interference with the necessary contact of ovum and -spermatozoon, but also by leading to catarrhal states and hyperplasia of -the mucous membrane, which interfere with the implantation of the ovum, -even when fertilization has been effected. Uterine polypi give rise to -mechanical obstruction of the os uteri externum or of the cervical -canal; but they predispose to sterility in an additional way, inasmuch -as in a woman affected with such a new growth any vigorous bodily -movement is apt to cause profuse uterine haemorrhage. - -In cases of myoma of the uterus, apart from the mechanical hindrances to -conception imposed by these tumours, there is also interference with the -implantation of the ovum. When numerous myomata have formed in the -uterine wall, the mucous membrane is usually smooth and atrophied, and -discharges a watery secretion, and for these reasons the imbedding of -the ovum in the uterine cavity is rendered extremely difficult. But that -there is often an additional cause of sterility in cases of myomata -uteri, has been shown by the researches of _Schorler_, who examined 822 -patients affected with fibromyoma of the uterus. He found that in most -of those in whom sterility was observed, the tumours were not submucous -but subserous, and that the sterility was to be explained in these cases -by the frequent occurrence of partial peritonitis, with its evil results -to the uterine annexa. - -_Schorler_ appends the following table: - - _Sterile._ _Percentage._ - Of 85 women with interstitial myoma 21 24.7 - Of 92 women with subserous myoma 44 47.8 - Of 18 women with submucous myoma 7 38.8 - Of 44 women with polypous myoma 4 9.0 - Of 14 women with cervical myoma 3 18.7 - ——— —— ———— - 253 79 31.2 - -When there are polypous new formations in the uterine cavity, even if -conception occurs, abortion follows, for the reason that the rupture of -the hypertrophied capillaries in the growths themselves and in the -neighbouring tissues, prevents the normal development of the embryo. -_Horwitz_ has, however, described a case in which pregnancy went on to -full term, notwithstanding the existence of growths of this nature. - -Owing to the frequency with which chronic metritis and endometritis -ensue upon parturition, it can readily be understood that delivery -itself is often the primary cause of subsequent sterility. A temporary -sterility often follows the first delivery. It is well known that the -birth of boys is in general more difficult than the birth of girls; -_Pfannkuch_ collecting information regarding the first and second -deliveries of 300 married women, ascertained that after 166 of the first -deliveries, in which boys were born, the average lapse of time to the -second delivery was 30.2 months, whereas after 134 of the first -deliveries in which girls were born, the average lapse of time to the -second delivery was only 27.4 months. - -The importance of previous delivery in leading to sterility, in -consequence of mesometritis and diffuse connective tissue hyperplasia of -the uterus, is shown by _von Grünewaldt_, who published the following -figures as a result of his investigations. Of 56 women affected with -chronic metritis, 46.4% were sterile; in 19.2% of these the sterility -was congenital, in 80.7% it was acquired. Of 134 women suffering from -myometritis and its consequences, 71.6% were sterile; in 17.7 of these -the sterility was congenital, and in 82.2% it was acquired. On the other -hand, of 321 women suffering from endometritis, 29.5% were sterile; in -28.4% of these the sterility was congenital, and in 71.5% it was -acquired. - -_Lier_ and _Ascher_ also insist upon the importance of puerperal -diseases in the causation of acquired sterility, basing their opinion -upon _Prochownick’s_ clinical material. They draw, however, the -following distinction. If the puerperal infection takes place by way of -the external organs of reproduction, through the vagina to the cervix -and thence to the connective tissue of the pelvis—the most common form, -that which occurs soonest after delivery, and the most severe in its -course—the women thus affected are likely soon to become pregnant again; -if, on the other hand, the disease is pelvic peritonitis, the exciting -cause of the inflammation proceeding from the interior of the uterus -through the Fallopian tubes to reach the peritoneum, in the majority of -cases the women thus affected will prove sterile for a long time or in -perpetuity. In almost all the cases in which sterility resulted, the -pelvic peritoneum had been severely affected by the puerperal -inflammation. Regarding sterility in women, the two following general -propositions are laid down by _Lier_ and _Ascher_: 1. Hardly any single -cause of sterility in women is so severe as to be competent by itself to -render sterility inevitable throughout the period of sexual maturity, -with the exception of defects of development and premature cessation of -sexual activity. 2. Most of the hindrances to conception in women depend -upon affections of the internal superficies of the reproductive organs, -from the vulval mucous membrane upwards to the pelvic peritoneum; of -these, the most important are affections of the endometrium. - -On the other hand, it must not be forgotten, that the general tendency -of a previous delivery is to increase the capacity for impregnation. -_Olshausen_ especially insists upon the well-known gynecological fact, -that as a result of the first delivery, there occurs an enlargement of -the os uteri, which facilitates conception throughout the remainder of -the period of sexual maturity. This is well shown by the not infrequent -cases in which sterility persists for several years after marriage, and -then, with or without artificial aid, the first pregnancy occurs; -thereafter one child after another appears in rapid succession. - -_Spiegelberg_ has pointed out that cervical lacerations may give rise to -sterility by interference with the incubation of the ovum. _Olshausen_ -maintains that this affection is liable to cause abortion, for the -reason that by the gaping of the cervical canal the inferior pole of the -ovum is from time to time exposed, and this gives rise to reflex -contractions of the uterus. - -_Von Grünewaldt_ publishes figures in support of his opinion that -disturbances of the integrity of the uterus, whereby the implantation -and further development of the ovum are interfered with, play on a whole -a greater part in the causation of sterility than the various conditions -previously described which interfere with contact of ovum and -spermatozoon. But in this, we think, he goes too far. - -Finally, in this connexion, must be mentioned among the hindrances to -fertilization, sexual excesses, such as are so common during the first -weeks of married life. Too frequent coitus gives rise to enduring -congestion of the uterus, and hence to an irritable state of the uterine -mucous membrane, whereby the implantation of the ovum is rendered -difficult. In prostitutes chronic metritis, due to the excessive -frequency of intercourse, may be a contributory cause of the sterility -which is almost invariable in these women; doubtless, however, the -principal cause of their sterility is gonorrhoeal perimetritis. - -As a variety of the third kind of sterility, sterility due to incapacity -for implantation or further development of the ovum, must be classed the -cases in which, though conception and implantation of the ovum are known -to occur, and the first stages of development of the embryo certainly -take place, the woman proves incapable of giving birth to a viable -infant. Some of these cases depend upon abnormal modes of development, -myxoma of the chorion and the like. In rare cases, women abort every -month, discharging every four weeks a fully developed decidua vera, in -which sometimes no trace of ovum can be detected. But this monthly -abortion ceases as soon as marital relations are interrupted. - -It would be passing beyond the scope of this work to discuss the -pathological processes which lead to premature interruption of the -pregnancy, after conception, implantation of the ovum, and the first -stages of development, have occurred in a normal manner; to discuss, in -short, the causes of abortion. Moreover, these pathological processes -are outside the concept of sterility. It is sufficient here to enumerate -the principal conditions in which abortion occurs. They are: various -tissue disorders of the uterus, chronic hyperaemia of the mucosa, -displacement of the uterus with fixation, parametric and perimetric -exudations, laceration of the cervix with ectropium; further, various -constitutional disorders, such as the specific fevers, acute infective -processes, chronic circulatory disturbances consequent upon cardiac, -pulmonary, renal and hepatic disease, syphilis, anæmia, chlorosis, -diabetes, etc. - - - _Only-Child-Sterility._ - -Until recently, only-child-sterility had received attention in England -only, for the reason that it is comparatively common in that country; -but this form of relative sterility is by no means rare with us (in -Germany and Austria) also. I had a collection made in Austria of the -number of children resulting from 2000 fruitful unions, and found that -among these there were 105 marriages in which one child only had been -born; thus the ratio of these marriages to those which proved fully -fruitful was about 1 : 19. But the figures are untrustworthy, since -abortions and deaths in infancy were not taken into account. _Ansell_ -found that in England, among 1767 fruitful marriages in which the mean -age of the wives at marriage had been 25, there were 131 cases of -only-child-sterility, giving a ratio of the latter to the fully fruitful -unions of 1 : 13. - -This form of relative sterility, in which the wife gives birth to one -child, and thereafter remains barren, was referred by _Matthews Duncan_, -either to a premature exhaustion of the reproductive capacity, the -general bodily powers remaining unaffected, or else to a simultaneous -weakening of the sexual powers and of the constitutional force in -general. This explanation is a very inadequate one. The significant fact -upon which an understanding of the nature of only-child-sterility must -be based, is that the first delivery is the one which entails the -greatest dangers to the mother, and that the subsequent sterility is -attributable to the difficult delivery, and to the illnesses that follow -in its train. In fact, only-child-sterility is observed chiefly after -difficult deliveries, followed by long enduring inflammatory processes -of the uterus and the uterine annexa, which seriously affect the woman’s -reproductive capacity. It occurs especially in delicately organized, -anæmic, scrofulous women, whose powers of resistance have been -undermined by a single pregnancy and parturition. Finally, it is met -with in women suffering from myoma uteri, a form of tumour which beyond -others renders the recurrence of pregnancy difficult and unlikely. This -form of sterility has been seen also in cases in which comparatively -soon after the birth of her first child, the mother has suffered from -typhoid, scarlatina, or some other severe infective fever, which appears -in some way to interfere for the future with the development of normal -ova. We must also take into consideration the fact that at the time of -the wife’s first confinement, when the love which brought about the -union has often already begun to diminish in intensity, the husband, -finding too irksome the continence enforced upon him by his wife’s -condition, is not unlikely to go elsewhere for temporary sexual -gratification, and to acquire a venereal disease, which he subsequently -transmits to his wife, and which is responsible for the latter’s future -sterility. And we must not forget to take into account the adoption of -means for the prevention of pregnancy after the first child has been -born. Again, I saw three cases of only-child-sterility in which the -husbands were respectively 24, 26, and 29 years older than their wives, -and in these instances no profound search was needful for the discovery -of the cause of the wife’s unfruitfulness; it was obvious that in each -case the elderly husband’s reproductive powers had sufficed for the -procreation of a single child, but had then been completely exhausted. -My experience in the mysteries of sterility in women has informed me of -yet another cause of only-child-sterility, met with in cases in which -the only child was born after several years of unsuccessful marital -intercourse. In most of these cases, the wife has finally been impelled -to seek a substitute for her husband, whose reproductive powers have -proved insufficient; having succeeded in obtaining the child she -desires, the wife does not again wander in strange pastures, and -consequently remains sterile. - -According to _Kleinwächter_—who gives a somewhat wider significance to -the term “only-child-sterility,” including as he does cases of premature -interruption of the first and only pregnancy, since these even more -frequently entail permanent sterilization—only-child-sterility is by no -means rare. Among 1081 gynecological cases, he observed it in 90, that -is, in 8.32% of the cases. In these 90 cases, there were 69 instances in -which the sterility ensued upon full term delivery, and 21 instances in -which it followed abortion or premature delivery. _Kleinwächter_, -moreover, on the basis of his personal experience, supports my view of -the importance of the sterilizing influence of the first delivery; but -he has been unable to determine whether early marriage has any influence -in the production of only-child-sterility. - -_Lier_ and _Ascher_ also class as instances of only-child-sterility -those cases in which a woman has had a single miscarriage, and -subsequently remained sterile, since by this miscarriage the capacity of -the woman for impregnation has been proved, and the question of capacity -for full-term delivery has nothing to do with that of capacity for -conception. As causes of this form of sterility, they lay especial -stress upon puerperal infection, gonorrhoeal infection, perimetritis, -tubo-ovarian tumours, etc. - - - _Operative Sterility._ - -Finally, in order to complete the etiologically classified series of -forms of sterility, we must allude to yet another variety of sterility -which is due to the surgical direction of modern gynecology, viz., -operative sterility. However much we may prize the gains we owe to -modern operative gynecology, it cannot be denied that the new -developments have brought many evils in their train. Not the least of -these is operative sterility, due to operative procedures involving the -female reproductive organs, by which, whether intentionally or -unintentionally the reproductive capacity is destroyed. Doubtless, in -certain severe organic diseases of the female reproductive apparatus, in -which the use of the knife is indicated, the fact that by operating we -are sterilizing the patient cannot even be taken into consideration; but -many sins have been committed in this kind, and with a ready hand, and, -be it openly admitted, with an easy conscience, many an eager operator -has undertaken the destruction of a woman’s potentialities for -motherhood, without having given the careful consideration that is -demanded by the irreparable character of his undertaking. Happily, -however, the time has nearly passed away, in which it could be said of -many a gynecologist, that no ovaries and no Fallopian tubes were safe -from his operative zeal, and from his desire to heap up a mountain of -statistics. - -Three operative measures very commonly undertaken at the present day are -responsible for the production of operative sterility: ovariotomy, -oophorectomy, and salpingotomy. - -The removal of the ovaries, with the object of permitting to the women -concerned unbridled sexual indulgence without risk of consequences, was -performed, according to _Strabo_, by the ancient Egyptians and Lydians. -The same practice is described by modern writers as occurring in -Hindustan (_Roberts_), and in Australia (_Miklucho-Mackay_). - -With a curative aim, the removal of the ovaries was first undertaken in -the early years of the nineteenth century, although the operation had -already been discussed as a possibility by leading physicians of the -eighteenth century. The first ovariotomy for the removal of an ovarian -tumour was performed by _MacDowell_ in the year 1809. During the last -three or four decades, the operation has become an extremely common one, -and is performed by the surgeons of all nations. Removal of a single -ovary, as long as the other ovary is healthy, does not necessarily lead -to any impairment of fertility; but when both ovaries are removed, -operative sterility is the necessary result. In order to avoid this, -_Schröder_ has recommended that a fragment, at least, of healthy ovarian -tissue should be left behind, in order to preserve the reproductive -capacity. In discussing the subject of impaired ovulation, we have -already mentioned cases in which pregnancy has occurred after bilateral -removal of the ovaries, a circumstance explicable only on one of two -assumptions, either that a fragment of ovarian tissue was left behind, -or else that a supernumerary ovary existed. - -The extirpation of healthy ovaries, or at any rate, of ovaries which are -not notably enlarged, is known as oophorectomy (spaying, _Battey’s_ -operation, in Germany, castration). It dates from the year 1869 -(_Koeberlé_); but in the strictly modern sense the operation was first -performed by _Hegar_ in the year 1872. [_Lawson Tait_ removed both -ovaries for pain in October, 1871. _Battey’s_ first operation of this -kind was _successfully_ performed on August 17th, 1872; this was three -weeks subsequent to the first performance of the operation by _Hegar_ of -Freiburg. But _Hegar’s_ patient died from the operation, and _Hegar_ did -not publish the case at the time—Transl.] The aim of ovariotomy is to -remove an ovarian cystoma; if the other, apparently healthy, ovary is -removed, it is with the object of removing an ovarian tumour in the -initial stage. Oophorectomy has an altogether different purpose, namely, -to relieve or cure pathological manifestations in other organs which are -believed to depend on the periodical recurrence of ovulation, to cure -them by instituting a premature menopause. At one period, when -overzealous operators performed oophorectomy for the supposed relief of -comparatively unimportant nervous affections, and the statistics of the -operation began to assume gigantic proportions, operative sterility -actually came to play no inconspicuous part on the stage of sterility in -general. But a reaction inevitably followed; severe diseases were alone -considered as furnishing sufficient indications for the operation; of -late it has been performed chiefly in cases in which the primary -disorder has already rendered the occurrence of pregnancy impossible, or -at any rate very unlikely, or, finally, if probable, yet to be avoided, -on account of the dangers it would entail. In short, the fertility of -women is no longer seriously threatened by this operation. - -Some years ago, I was consulted by a beautiful married woman, 26 years -of age, of a blooming and healthy aspect. When a young girl, she had -suffered every month at the time of the menstrual flow from violent -vomiting, accompanied by various spasmodic troubles. Just at this time, -oophorectomy was the fashionable operation for the relief of nervous -troubles; this girl was subjected to the operation, and the vomiting at -the periods ceased, but the other nervous symptoms persisted without -alleviation—indeed were at times worse than before. Since then, she had -married a man belonging to the upper circles of society; and now, after -living for four years in sterile wedlock, she came to me to ask my -advice as to whether anything could be done to enable her to have a -child! Two other cases have come within my own knowledge, in which women -whose ovaries had been removed on account of nervous troubles, had -subsequently married, and felt most unhappy owing to their hopeless -state of sterility. - -It is impossible to make even an approximate estimate of the number of -women who in recent years have had their ovaries removed during the -period of sexual maturity, and who have thus been made the subjects of -operative sterility; nor is it possible to ascertain in what proportion -of cases the healthy ovaries, the normal female reproductive glands, -have been removed for the problematical relief of nervous troubles or of -uterine haemorrhage, and in what proportion of cases there has existed a -genuine indication, owing to the presence of fibromyoma of the uterus, -for the induction of an artificial and premature menopause. -Unquestionably, the number of women thus operated on during the menacme -is by no means a small one. In a work by _Hermes_, “On the Results of -Oophorectomy in Cases of Myoma of the Uterus,” _Archiv für Gynecologie_, -1894, we find that, among 55 women whose ovaries were removed on account -of myoma of the uterus, there were 52 who were between the ages of 21 -and 45, i. e., in the period of sexual maturity. The assumption that all -these patients were already sterile before the operation, on account of -a degenerate condition of the uterine annexa, cannot be justified. - -_Keppler_, indeed, puts forward a very remarkable defence of the removal -of the ovaries of women who are competent to become mothers, asserting -that such oophorectomy offers no obstacle to marriage, and that many -women who have been operated on in this manner are extremely happy in -conjugal life. Marriage with a wife whose ovaries have been removed is -the ideal Malthusian marriage, the one way in which Malthusianism can be -practised without endangering the health and life-happiness of the -participators! - -Another danger soon appeared, one which threatened the fertility of -women to an even greater extent, in the form of operations on the -uterine annexa—the first salpingotomy was performed by _Hegar_ in 1877. -As knowledge advanced of the various diseases of the Fallopian tubes, -salpingitis, hydrosalpinx, and pyosalpinx, whilst at the same time the -development of the antiseptic method rendered operative gynecology -continually bolder and bolder in its undertakings, there was disclosed -an extensive field for radical measures in removal of the tubes, -generally combined with removal of the ovaries, since these latter -organs commonly were found to have suffered from association in the -destructive inflammatory process. The operation of salpingo-oophorectomy -soon became a very common one; and since patients with diseased tubes -are for the most part still comparatively young, in the period of sexual -maturity, there arose a new and frequent variety of operative sterility, -and one which the zeal of American gynecologists made especially common -on the other side of the Atlantic. An American gynecologist, indeed, has -sarcastically observed that “It is the dish-full of excised tubes that -shows the master gynecologist”; and _Landau_ has been impelled to lament -that “salpingotomy has been performed on a very large number of women -who have complained of nothing more serious than uterine haemorrhages, -or of insignificant pains, and even on some women who have come to the -gynecologist with no other complaint than that—they are sterile”! -_Fritsch_, also, writing of the too rapidly formed diagnosis “tumor of -the annexa,” and the consequent resort to operation, remarks: “I know -many a happy mother who at one time had worn every variety of pessary, -had been through every kind of ‘cure,’ and had visited every accessible -spa; until, at last, she came to consult me, with the express wish to -have her ovaries removed. Latterly, she had been advised to this course -by every physician she had consulted. I agreed, in such cases, to -perform the operation, with the stipulation that first of all, for the -space of an entire year, the patient should not see a single doctor, -should visit no spa, should take no medicine, and, in short, should pay -no attention whatever to her health. The success of this course of -‘treatment’ was often extraordinary. As soon as the reproductive organs -were left in peace, recovery ensued.” The conservative tendencies of the -surgery of the last decade, have manifested themselves also in the -department of gynecology, for the happy protection of woman and her -reproductive capacity. Operative measures are now commonly restricted to -the relief of certain severe forms of disease of the uterine annexa; in -cases of chronic inflammation of the annexa, the surgeon often contents -himself with dividing or breaking down the adhesions, and leaves the -organs in situ; even in cases of bilateral disease, one tube only may be -removed; whilst in the most recent method of all, after opening the -abdomen, and separating the pelvic organs from their adhesions, an -aperture is made in the closed tube, and this artificial ostium is -brought into apposition with the ovary by the insertion of sutures. In a -word, surgeons have come to realize that they have in the past been too -ready to sterilize their patients by the performance of double -salpingo-oophorectomy, and are much more reluctant than formerly to -sacrifice the ovaries and the Fallopian tubes. - -_Porro’s_ operation is another cause of operative sterility, excision of -the ovaries being combined with the partial excision of the uterus, -whereas sterility was seldom the consequence of the older method of -Caesarian section. Indeed, _Porro’s_ operation has been extolled -precisely on this account, that, indicated as it is for the relief of -extremely difficult labour, it renders it impossible for the same -difficulty and danger ever to recur. - -The classical operation of Caesarian section, if the patient makes a -favourable recovery, does not involve sterility, unless in very -exceptional cases (as in one described by _Lecluyse_, in which, after -the Caesarian section, a communication persisted between the uterine -cavity and the cavity of the abdomen, through which the semen passed -during coitus). Occasionally, also, in performing the older operation, -the operator has thought it right to prevent the future recurrence of -pregnancy by adding an oophorectomy to the primary operation. - -Pregnancy and parturition are still possible after the healing of -spontaneous or traumatic ruptures of the uterus; but it must be -remembered that after such serious injuries, as after extensive -operative procedures on the pelvic organs, widespread peritoneal -inflammation is apt to occur, with perimetritic and parametritic -exudations, leading commonly to sterility. - -Amputation of the vaginal portion of the cervix, an operation sometimes -undertaken for the relief of sterility in cases of hypertrophy of the -cervix, may on the other hand lead to sterility in cases in which a -cicatricial stenosis of the cervical canal results from the operation. - -By the too frequent application of caustics to the cervical canal, or by -the employment of these agents in too powerful a form, occlusion of the -os externum may be caused, or even adhesion of the opposing walls of the -vagina just below the cervix, thus giving rise to sterility. Rough use, -also, of the uterine sound, and maladroit and violent gynecological -massage, have often enough been responsible for the occurrence of -sterility, by giving rise to perimetritic inflammation. _Landau_ -enumerates among the causes of intrapelvic abscesses, “whereby the -specific functions of womanhood are nullified in consequence of -degeneration of the tubes or the ovaries,” “certain therapeutic -procedures,” and more especially, intra-uterine therapy, (the use of the -sound, curettage, injections, cauterization), and operations on the -cervix or the vagina, on which intrapelvic inflammation and even -suppuration has ensued. How easily pelvic peritonitis and its -consequences lead to sterility in women, has been shown many times in -the course of our exposition of this subject. - -Finally, we must class with operative sterility the result of surgical -procedure undertaken by gynecologists to save women, whose lives have -already been seriously threatened by pregnancy or parturition, from a -repetition of this experience. In such cases, _Blundell_ recommends -division of the Fallopian tubes, having found from experiments upon -rabbits that this is a safe and certain means for the prevention of -conception. _Frorieps_ and _Kocks_ have both frequently brought about an -artificial sterility in women by closure of the tubes, the first-named -by cauterization with nitrate of silver—the caustic being attached to -the end of a piece of whalebone and introduced through a canula into the -uterine orifice of the Fallopian tube—whilst _Kocks_ has constructed for -the same purpose a galvano-caustic uterine sound, which is only rendered -red-hot by passage of the current after it has been introduced into the -uterine ostium of the tube. Both these methods are in the first place -too uncertain to be relied upon for the attainment of the desired end, -and in the second place their employment appears to be neither easy, nor -free from danger. - -As the importance of conservative methods of procedure becomes once more -fully recognized in modern gynecology, cases of operative sterility will -become ever more and more rare. - - - TABLE SHOWING THE CAUSES OF STERILITY IN WOMEN. - - - I. STERILITY DUE TO INCAPACITY FOR OVULATION. - - - ABSOLUTE AND IRREMEDIABLE. - - Complete absence of the ovaries. - - Congenital atrophy of both ovaries. - - Premature atrophy of the ovaries, in consequence of infectious - disorders, constitutional diseases, and toxic influences. - - New-growths of the ovaries, destroying _all_ the follicles. - - Senile changes in the ovaries. - - Complete oophorectomy, or any equivalent form of operative sterility. - - - RELATIVE AND TRANSIENT. - - Incomplete development of the ovaries. - - Imperfect formation of ova, owing to marriage when still too young - (amenorrhœa). - - Ovarian tumours and oophorectomy, whereby, however, a remnant of - _healthy_ ovarian tissue is spared. - - Chronic oophoritis and perioophoritis; syphilitic disease of the - ovaries. - - Excessive obesity, anæmia, chlorosis, scrofula, morphinism, - alcoholism, various conditions affecting unfavourably the - innervation or nutrition of the ovary; change of climate or mode of - life; emotional disturbance; inbreeding, hereditary predisposition. - - - II. STERILITY DUE TO INTERFERENCE WITH THE CONTACT OF NORMAL - SPERMATOZOON AND OVUM. - - - _A. On the Part of the Wife._ - - - ABSOLUTE AND IRREMEDIABLE. - - Congenital or acquired universal thickening of the tunica albuginea of - the ovaries, preventing the dehiscence of the follicles. - - Absence of both tubes, developmental defects of these organs. - - Absence or rudimentary condition of the uterus. Foetal uterus. - - Congenital atresia of the uterus with arrest of development. - - Complete absence of the vagina. - - Extreme contraction of the pelvis, whereby the vagina is rendered - inaccessible. - - Hermaphroditism. - - - RELATIVE AND TRANSIENT. - - Remediable thickening of the tunica albuginea, inflammatory remnants - of perioophoritic processes, diseases of the cervical glands, - dislocations and adhesions of the tubes, narrowing or obliteration - of the ostia, inflammation of the tubes, pyosalpinx, obliteration of - the lumen of the tube. - - Retro-uterine haematocele. - - New growths in the uterine cavity. - - Infantile and pubescent uterus. - - Primary atrophy of the uterus. - - Puerperal atrophy of the uterus. - - Displacements of the uterus—versions and flexions. - - Hypertrophy or atrophy or changes in the shape of the cervix, cervical - stenosis. - - Cervical catarrh, especially when gonorrhoeal. - - Ectropium of the cervix. - - Spasmodic dysmenorrhœa. - - Atresia of the vagina, obliteration of the canal by scars or tumours. - - Abnormal termination of the vagina—vesico-vaginal and recto-vaginal - fistula. - - Absence of the external organs of generation and partial absence of - the vagina, without defect of the internal organs of generation. - - Abnormalities of the hymen. - - Pathological states of the genital secretions. - - Vaginismus. - - Dyspareunia. - - Perversion of the sexual impulse. - - - _B. On the Part of the Husband._ - - - ABSOLUTE AND IRREMEDIABLE. - - Diseases of the central nervous system, and certain constitutional - diseases. - - Congenital or acquired absence of both testicles. - - Atrophy of the testicles. - - Complete azoospermia and aspermatism. - - Senile impotence. - - - RELATIVE AND TRANSIENT. - - Developmental defects of the penis, and acquired deformities of that - organ. - - Stricture of the urethra. - - Oligozoöspermia. - - Nervous impotence. - - Gonorrhoeal and syphilitic infection. - - The employment of measures for the prevention of pregnancy - (facultative sterility). - - - III. STERILITY DUE TO INCAPACITY FOR THE IMPLANTATION AND FURTHER - DEVELOPMENT OF THE OVUM. - - - ABSOLUTE AND IRREMEDIABLE. - - Arrested development of the uterus. - - Complete atrophy of the uterine mucous membrane. - - - RELATIVE AND TRANSIENT. - - Chronic metritis. - - Chronic endometritis, especially gonorrhoeal and exfoliative - endometritis. - - Perimetritis, parametritis, pelvic peritonitis; the consequence of - these inflammations. - - Tumours of the uterus. - - Displacements of the uterus. - - - - - III. SEXUAL EPOCH OF THE MENOPAUSE. - - - THE MENOPAUSE. - -That time in a woman’s life at which her sexual activities come to their -natural termination, marked by the cessation of menstruation, is known -as the menopause, climax, or climacteric period. - -This “change of life,” from a condition of sexual maturity to a -condition of quiescence of sexual functions, is not a sudden one, the -symptoms of sexual retrogression making their appearance gradually, -until the cessation of the monthly recurring menstrual flow indicates -that the termination of sexual activity has arrived, and that sexual -death is taking place. - -The influence of this period of life is not manifested by the sexual -organs alone—in these latter indeed various changes may be detected -already before the cessation of menstruation, whilst after that -cessation, the atrophic changes characteristic of old age proceed in -these organs with a slow but continuous advance,—but the disturbances -evoked by the climacteric involve the entire organism and affect the -functions of numerous organs, giving rise to a true storm of irritant -phenomena, and to manifestations of decay of manifold nature. - -The stormy manifestations, the occurrence of which led the ancients to -denote this period as the “critical age” of a woman’s life, are in the -first place due to changes in the ovaries; the tissue changes in these -organs give rise to a powerful ovarian stimulus, which, by irradiation -and reflex action, leads to the occurrence of a number of nervous -disturbances, vasomotor manifestations, and circulatory disorders; -whilst owing to the cessation of the internal secretions of the ovaries, -numerous and intense pathological disorders of metabolism arise. These -various symptoms become apparent at the very outset of the menopause, -when the oncoming entire cessation of menstruation is already -foreshadowed by irregularity in the periods, gradual diminution in the -quantity of the flow, and variations in the number of days during which -the flow on each occasion persists. - -The manifestations of the menopause are in fact so striking, that from -ancient times down to the present day a widespread belief has prevailed -that especial danger to a woman’s life is threatened by the climacteric -age. The statistics available on this subject are, however, of dubious -significance. Although it cannot be denied that the changes in the -entire organism which attend the extinction of sexual activity, bring -numerous dangerous influences into play, yet I feel bound to maintain -that these dangers are by no means so great as those which are involved -by the sexual life in its ripest period of development—the dangers of -pregnancy, parturition, and the puerperium. - -It is often asserted that in this “critical period” of the menopause, -the mortality of the female sex is notably increased. The data available -are somewhat conflicting, but a careful examination leads us to believe -that, if due allowance is made for the natural increase in mortality -with advancing years, no important increase in the mortality of women -can be traced as due to the troubles and disturbances of the climacteric -period. - -The age at which a woman’s last sexual epoch begins is a very variable -one. The duration of the “change of life,” the length of time during -which the occurrence of the “change” is manifested by local and general -disturbances, also varies greatly. Not less variable are the intensity -and the general distribution of the symptoms which mark the climacteric. - -The external configuration of woman at the climacteric age is usually -characterized by signs of over-ripeness, and these changes appear to -exercise upon certain men—more especially very young men—a peculiar kind -of erotic stimulus. Many women remain long at this period quite fresh -looking, with a vivid, youthful colouring; others, however, early -manifest alterations in their finer feminine characteristics, hairs, for -instance sprouting on the chin, and the voice becoming deeper in tone. - -The outward characters of senescence, with withering of the tissues, are -not commonly manifested at this time, but first make their appearance in -later years, after the completion of the menopause. - -A tendency to the excessive accumulation of fatty tissue is one of the -most distinctive characteristics of the menopause, varying, however, -greatly in degree according to race, family predisposition, and -nutritive conditions. The dominant tone is thus given to the physical -configuration by the deposit of fat. The face comes to have a rounded, -spherical appearance, the eyes looking smaller in proportion, whilst the -furrows and folds which form the natural boundaries between the features -become indistinct. The formation of the “double chin,” and the abundant -deposit of fatty tissue in the supraclavicular region, gives to these -extremely obese women an appearance of such a shortening of the neck, -that head and thorax seem to be connected as it were by a great mass of -fat, marked by furrows in the thyroid and sub-hyoid regions. The breasts -sometimes attain an enormous size, hanging down to the gastric and even -to the umbilical region. The abdomen is greatly enlarged, the fat in the -anterior abdominal wall projecting more especially in the hypogastric -region, hanging down in two or three horizontal rolls over the tops of -the thighs, and pushing the mons veneris downwards, so that this latter -itself projects over the genital fissure. The posterior projection of -the buttocks is also greatly increased, until they form a huge elastic -cushion, of which the sensual orientals, who regard obesity in women as -a beauty, poetically write: “Her face is like the full moon, and her -buttocks are like two pillows.” Occasionally, so huge a mass of fat -forms beneath the tuberosity of the ischium, that the configuration of -the nates reminds us of the well-known _steatopyga_ or fat-rump of the -Hottentot and Bosjesman women. In the genital organs, as already -mentioned, the genital fissure is hidden by the projection of the mons -veneris. The labia majora are also greatly enlarged by the deposit of -fat, so that they look like two great cylinders lying side by side. -Another way in which the characteristic sexual beauty is often lost in -extremely obese women, is by the falling out of the pubic hair. - -_Moreau_, in his work on _The Natural History of Woman_, describes the -changes occurring in a woman at the climacteric in similar terms, and -concludes: “The only elements of a woman’s beauty that may sometimes be -saved from the wreck, to persist for a shorter or longer time after the -climacteric, are, the abundance of her hair, the vivacity of her glance, -and sometimes also the amiable expression of her countenance; gradually, -however, even these last remnants of beauty disappear, and old age takes -possession with its irresistible force.” - -None the less, some women may preserve substantial elements of beauty -for a long time after the menopause. A classical example of this fact is -furnished by _Ninon de l’Enclos_. When she died, at the age of 90, she -was still beautiful. At the age of 65 she aroused the passionate love of -a young man, who, unfortunately, was her own son. When informed of this, -he committed suicide. A young abbé fell in love with her when she was 75 -years old. - -The psychical life of woman is profoundly affected by the stormy -physical changes of the climacteric. Not merely does a woman entertain -the disturbing thought that the critical age has begun, bringing in its -train certain dreaded dangers to her health and even her life, but she -is further depressed by the consciousness that she is about to lose her -feminine attractions, and to decline in sexual esteem, and that her -reproductive capacity is now to be extinguished. She realizes vividly -that the beautiful past, the loving and beloved womanhood, is now to be -left behind for ever, and by this an intelligent and sensitive woman -cannot fail to be profoundly affected. Her feelings at this time were -never more characteristically expressed than by the Frenchwoman who said -“Autrefois quand j’étais femme.” If, indeed, a woman has been so -fortunate as to have made a happy marriage, to have borne healthy -children, and to be living a satisfactory family life, she will be -enabled to bear with comparative equanimity the disappearance of her -sexual life; but it is different with the childless wife and with the -unmarried woman, who, at the onset of the climacteric, must bury all -their sexual aspirations, and who see the remainder of their lives -stretch before them without hopes for the future. The psychical -predisposition and the intellectual education of the woman concerned, -will now determine whether she will bear the onset of the menopause with -composure and resignation, or whether she will become a prey to -melancholia. Women of the former kind will seek to find employment for -the powers set free by their sexual non-activity, in services of -neighbourly affection, in works of benevolence, and in the performance -of social duties; women less happily endowed will display their -hostility to the world in ill-nature, scandal-mongering, and intrigue, -thus giving vent to their inward bitterness; whilst those, finally, with -hereditary predisposition to nervous degeneration, will become the prey -of veritable psychoses. - -A by no means rare result of the excited fantasy and of the eager desire -not to grow old, is displayed at the climacteric in the form of -self-deception. The women thus affected cannot understand, and cannot be -made to believe, that the cessation of menstruation is the natural sign -of their sexual decadence, they trick themselves into believing that in -their case it is a sign that they have become pregnant. We must not -indeed forget that the enlargement of the abdomen, so common at the -commencement of the climacteric, in association with the unexpected -failure of the menstrual flow to appear, the frequent dyspeptic -troubles, and the enlargement of the breasts in consequence of the -deposit of fat in these organs, often enough lead to appearance which -have a deceptive resemblance to the clinical picture of early pregnancy. -The mistake is the more readily made because the breasts sometimes -secrete a serous fluid, whilst sacrache is not infrequent, and -peristaltic movements of the intestines are mistaken for the movements -of the foetus. Cases of this kind, in which all the objective signs of -pregnancy appear to be present, and in which it is impossible to -convince the woman that she has been deceiving herself, and that all the -signs and symptoms are due to the menopause, are mentioned already by -very early writers, and have been frequently reported by modern -gynecologists. (An example of spurious pregnancy especially familiar to -English readers is that of Mary I, Queen of England. Transl.) - -Sexual desire in woman by no means reaches its physiological term with -the climacteric and the cessation of menstruation. On the contrary, we -have observed it to be the rule that shortly before and at the -commencement of the climacteric, there is a considerable increase in the -libido sexualis, and at the same time an increase in sexual sensibility -during coitus. This sexual erethism makes its appearance in a manner -often extremely surprising to the husband—and especially surprising in -the case of women who have previously been characterized by a certain -frigidity in sexual matters, and who have, perhaps, always needed strong -persuasion before they would consent to perform their marital duties. It -is by no means rare for the increased sexual impulse to manifest itself -in some pathological form. Even some time after the menopause, when -senile changes in the genital organs are far advanced, the sexual -impulse may still be remarkably active. There is an interesting analogy -in the fact that _Glaevecke_ observed that the sexual impulse was -persistent in women in whom an artificial menopause had been induced by -oophorectomy; and that _Lawson Tait_ and _L. Smith_ have reported cases -in which dyspareunia, which had existed prior to the operation, passed -away after the removal of the ovaries, so that after the artificial -menopause, voluptas coeundi for the first time made its appearance. -Other authors, _Goodell_, for instance, report that libido sexualis is -retained only for a short time after oophorectomy, but subsequently -disappears, as in the course of the physiological menopause, and that at -the same time the voluptas coeundi is entirely extinguished. - -When the menopause is fully established, and the processes of involution -in the reproductive organs have taken place in a normal manner, the -woman has had time to acquiesce in the inevitableness of the changes -that have occurred, and she often attains a state of emotional repose -which was quite unknown to her in the earlier phases of her sexual life. -More particularly, those women who hitherto during menstruation, and for -some days before and after the flow, have been the prey of numerous -nervous symptoms and troubles, rejoice, after the menopause, at their -new-won freedom from these pains and disquiets, at their delivery from -the excitements of the reproductive system, at their now uninterrupted -state of well-being. - -I once saw a group of statuary by _Pietro Balestra_, entitled “Time -carries off Beauty.” A beautiful woman was striving in vain to resist -the overwhelming might of Chronos, whilst Cupid, about to be abandoned, -was standing sorrowfully by. Here we have a symbolic representation of -the sexual epoch of the menopause. - -In a recently published romance, “_Les Demi-Vieilles_,” _Yvette -Guilbert_ has described in a manner most true to nature the feelings of -the “Half-Old,” the mental condition of women at the climacteric, “They -endeavour to remain young, to hide their defects, they seek once again -the intoxication of love. But that which aforetime in hours of -depression they have foreseen, now becomes a dreadful reality. When the -lemon has been squeezed dry, the skin is thrown away.” - -Sooner or later after the completion of the menopause, the signs of -senile marasmus become apparent. The soft, feminine configuration of the -face disappears, the features become coarser, approaching the masculine -type, hairs appear on the upper lip and on the chin. The voice becomes -deeper and harsher. As decrepitude begins, the breasts wither, a change -that occurs sooner in proportion to the degree in which their functions -have been in previous years exercised by suckling; but also sometimes -after a life of complete sexual inactivity. Even in cases in which the -loss of substance of the breasts is apparently small, the glandular -tissue of the organs has really disappeared, and has been replaced by -fat. In advanced age, the breasts become quite small, wrinkled, flaccid, -and dependent, and sometimes atrophied to become mere cutaneous folds. -The nipples project more prominently, they are darker in colour, and -their surface is wrinkled. In the genital organs, the fat disappears -from the mons veneris, which becomes flattened, whilst the pubic hair -ceases to be curly, and much or all of it is ultimately shed. The labia -majora become thin and flaccid, until they are mere empty folds of skin; -they are widely separated, so that the vaginal orifice is closed only by -the withered nymphæ, until these latter are themselves ultimately -indicated by mere traces. - -Where the menopause has been artificially induced, the signs of -senescence do not appear immediately after the removal of the ovaries; -their development is a very gradual one. The sexually mature woman, from -whom these tokens of femininity have been removed, experiences at first -little change in external configuration, beyond a somewhat exaggerated -tendency to the deposit of fat; the other changes described do not -usually set in until the physiological climacteric age is attained. A -few cases only have been observed in which after oophorectomy a rapid -change to the masculine configuration has been observed. - -Seldom if ever does it happen that menstruation suddenly ceases without -any notable constitutional disturbance, so that in a moment, as it were, -the menopause is effected, without any period of transition. Rarely, -even, do we meet with cases in which the peculiar manifestations -foreshadowing or accompanying the cessation of menstruation last for no -more than a few weeks. Most commonly the irregularities of the menstrual -function (of which the most noteworthy characteristic has hitherto been -its extreme regularity), and the associated symptoms of the climacteric -period, endure for months, and occasionally for years. According to my -own observations, the mean duration of the climacteric manifestations is -from two to three years, the limits of variation in individual cases -being, however, exceedingly wide. - -The manifestations which accompany the cessation of menstruation are as -a rule the following: The woman is for some months in an irritable -condition, complains of digestive disturbances, constipation, meteorism, -epistaxis, haemorrhoidal flux, congestions of the head, increasing -fugitive sensations of heat (Ger. _fliegende Hitze_), and a tendency to -profuse perspiration. - -The length of the intermenstrual interval commonly increases, to as much -as six or eight weeks; the flow itself becomes scantier. In other cases, -however, the flow becomes much more abundant, and the intermenstrual -intervals much shorter than normal. In some cases, the regularity of the -flow is altogether lost, it appears now soon, now late, and is now -scanty, now profuse. Sometimes the intervals are several months, it may -be 6, 8, and even 10 months, then again the flow will occur every two or -three weeks; in exceptional cases, a scanty flow persists right through -what should be the interval, so that menstruation becomes continuous, -with periodic increases in the flow. Not infrequently, after a sudden -cessation of the flow lasting for many months, menstruation recurs, and -continues at regular intervals for a long time, until the final -cessation of menstrual activity. - -The mode of cessation which is most favourable to a woman’s general -health, is for the duration of the intermenstrual interval gradually to -increase, whilst pari passu with this increase, the amount of the flow -progressively decreases, until it ceases altogether. In such cases, the -general constitutional disturbance is reduced to a minimum. On the other -hand, the _sudden_ cessation of menstruation gives rise to profound -disturbance of the domestic economy of the feminine organism, and causes -violent changes therein. But even the gradual cessation of menstruation -causes notable disturbance of the woman’s mental and physical -equilibrium, if the irregularities in the menstrual process are very -great and spread over a very long period—more especially when the loss -of blood is extensive. - -Even after the menopause, after the final termination of the flow, there -persists a more or less regular recurrence of certain symptoms referable -to the continuance of ovulation. Sacrache, a sense of abdominal tension, -a feeling of heat and fullness in the pelvis, dragging pain in the -hypogastrium, and general irritability, occur at intervals, so that the -woman thus affected sometimes describes herself as suffering from the -continuance of a “bloodless menstruation.” - -_Tilt_ made observations in 637 women, in order to ascertain the various -modes in which the menopause occurs, and obtained the following results. -The menopause occurred: - - By gradual diminution of the amount of - the flow in 171 women, or 26.84 per cent. - By sudden interruption of the flow in 94 women, or 14.76 per cent. - By sudden interruption and a terminal - attack of metrorrhagia in 43 women, or 6.75 per cent. - By a terminal attack of metrorrhagia in 82 women, or 12.87 per cent. - By a series of attacks of metrorrhagia in 56 women, or 8.79 per cent. - By alternations of very profuse and - very scanty menstruation in 36 women, or 5.65 per cent. - By irregular recurrence of - menstruation, at intervals exceeding - 21 days in 99 women, or 15.54 per cent. - By irregular recurrence of - menstruation, at intervals of less - than 21 days in 33 women, or 5.18 per cent. - By irregular recurrence of - menstruation, the intervals being - sometimes longer and sometimes - shorter than 21 days in 23 women, or 3.61 per cent. - ——— ————— - Totals 637 99.99 - -The two principal dangers of the climacteric period in women are, first, -the great tendency to profuse uterine haemorrhages, and, secondly, the -liability to the occurrence of malignant tumours, more especially to -carcinomatous disease of the ovaries, the uterus, and the mammae. - -With regard to the question whether, in any particular individual, the -course of the menopause is likely to be favourable or unfavourable, -there are, in my experience, four considerations of principal prognostic -significance: the condition of the woman during the menarche, the state -of the general health at the time of commencement of the menopause, the -degree to which the sexual functions have been and are being exercised, -and the manner in which the cessation of menstruation takes place. - -As a rule, the disturbances and pathological states of the climacteric -period will be especially frequent and severe in women whose sexual -development at the time of the menarche was accompanied by severe -disturbances of the general condition. In every individual, there -appears to be a certain connexion between the manifestations attending -the menarche and those attending the menopause, of such a nature that -according as puberty has been passed through with little or with much -disturbance of the general condition, a similar favourable or -unfavourable course of the menopause may be prognosticated. If, at the -time of the menarche, there were severe nervous manifestations, or heart -troubles of a serious kind, the passage of the menopause may be expected -to give rise to neuropathic affections and to cardiac disturbances in a -similar manner. - -The woman’s state of general health is likewise of importance in -determining whether the course of the menopause will be favourable or -unfavourable. Perfectly healthy women, with a quiescent temperament, and -in favourable circumstances of life, will pass most easily through the -climacteric period without disturbance of their general condition. Every -departure from normal health has an unfavourable influence upon the -course of the climacteric. In women of a plethoric habit of body, there -is an especial tendency at this time to the occurrence of symptoms of -stasis and hyperaemia. Chlorotic and anæmic women are more prone than -others to suffer at the time of the menopause from uterine haemorrhages. -Women of a sanguino-erethistic constitutional disposition often manifest -at this epoch a tendency to neuroses and psychoses. Those women have the -best prospect of a smooth and undisturbed passage through the -climacteric age, who enter upon it in a state of perfect health. Less -favourable is the prognosis in the case of those women who already some -time before the climax, at the outset of the fourth decade of their -lives, have begun to complain of severe haemorrhages and various other -pathological states. - -Regarding the influence which the sexual activity of a woman during the -menacme exercises upon the course of the climacteric, it may be said, -generally speaking, that a previous free exercise of the sexual -functions in normal conditions has a favourable influence upon the state -of health during the menopause. Women who have been married for many -years, who have had many children, and who have suckled these children, -pass through the changes of the climacteric much more easily than old -maids, than women who have lived for many years in continent widowhood, -or than women who have had very few children or none at all. The -practice of prohibitive coitus, i. e., the use during intercourse of -methods of preventing the occurrence of conception, a form of sexual -immorality which has become extraordinarily common during the last few -decades, has an unfavourable influence upon the course of the -climacteric. Unfavourable, also, is the effect of great sexual activity -during the four or five years immediately preceding the menopause. Women -who marry shortly before the commencement of the climacteric, and those -who have given birth to a child shortly before this time, commonly -experience very severe disturbances during the menopause. Prostitutes -who continue the active pursuit of their profession until the -climacteric age, have at this time much to suffer. Women who have had -difficult deliveries, or several miscarriages, or severe puerperal -illnesses—and indeed, speaking generally, those women who have been -subject to any kind of disease of the reproductive organs—are apt to -suffer from serious disturbances of the general health during the -climacteric period. - -The mode in which the cessation of menstruation takes place, is also -causally connected with the easy or difficult course of the menopause. -Premature cessation of menstruation, or very sudden interruption of this -function, has a deleterious effect, manifesting itself both by local -disorders of the reproductive organs, and by general disturbances in the -nervous system and in the circulatory organs. On the other hand, a late -menopause and a gradual cessation of menstruation, are both usually -accompanied by a favourable course of the climacteric phenomena. - -The influence of sexual activity upon the course of the climacteric is -described by _Busch_ in the following terms: “Women who have led an -exhausting mode of life, who have had intercourse too frequently, those -who have been given to onanism or to some other sexual irregularity, and -who therefore enter upon the menopause with flaccid and deteriorated -reproductive organs, are liable to haemorrhagic and mucous fluxes, to -prolapse, carcinoma, dropsies, enlargements, and suppurative processes. -Women, on the other hand, who have lived a life of strict isolation, and -who have forcibly repressed all sexual inclinations, frequently suffer -from ossifications, indurations, and atrophic conditions of the -reproductive organs, and also from neoplasmata.” - -After an artificial menopause, induced by the operative removal of the -ovaries, similar manifestations occur to those witnessed during the -natural menopause. Similar disturbances and troubles occur in both -cases, but in the artificial menopause they are commonly more severe -than in the natural; they last also for a longer time, varying usually -from three to six years; moreover, in the artificial menopause, as in -the natural, the disturbance of health is more severe and lasts longer -in proportion to the youth of the individual. Further, in the artificial -menopause also, the intensity and the duration of the climacteric -manifestations are influenced by the constitutional state and by the -condition of the genital organs at the time when the operation is -performed. We note, moreover, that, just as in the physiological -menopause, the attendant troubles are most violent in the initial -period, and then gradually subside, so also after the induction of an -artificial menopause by the removal of the ovaries, the resultant -disturbances rapidly increase in severity, to attain their maximum in -from three to six months, and then, after lasting for a year or so, they -gradually become less severe, until they are ultimately extinguished. - -The extensive process of transformation which goes on in a woman’s -system during this period of the sexual life, from the very first -diminution in ovarian activity to the complete extinction of the -reproductive functions, manifests itself throughout the organism by -means of a series of changes which can for the most part be referred -either to states of blood-stasis and their consequences—congestion of -various organs, haemorrhages, and disorders of secretion—or else to -perversions of nervous function. - -The most manifold symptoms of disordered circulation may occur: -hyperaemic states of the central nervous system, flushings of the face, -the so-called fugitive heats (Ger. _fliegende Hitze_), a tendency to -epistaxis, to haemorrhoidal flux, and to profuse perspiration. The -changes which take place in the reproductive organs at the time of the -menopause give rise to venous engorgement and to collateral congestions. -Such a condition of venous hyperaemia may occur in the gastric and the -intestinal mucous membrane, giving rise to various dyspeptic -manifestations, and at times, when severe, even to actual gastric and -intestinal catarrh. Hyperaemia of the liver may also arise. In this -case, the pressure of the distended bloodvessels on the biliary ducts -may interfere with the outflow of the bile, and thus give rise to a -slight icterus. Further, the intra-abdominal venous congestion leads to -overfilling of the haemorrhoidal veins, and hence to bleeding piles. - -When the congestion is long-lasting, various further morbid changes may -arise, pulmonary hyperaemia may eventuate in bronchitis, hyperaemia of -the cerebral meninges may cause very severe headache, there may be -syncopal attacks, tinnitus aurium, choroidal congestion, impaired -vision, etc. - -Congestion of a more active nature arises from an increased and usually -accelerated flow of blood through the vessels of a part in which the -resistance to the blood stream has been lowered proportionately to its -propulsive force. In this way arises that characteristic symptom of the -menopause known as ardor fugax—fugitive heat—one link in the long chain -of vasomotor manifestations occurring at this period of life. Fugitive -heats are commonly most clearly marked in the face, head, and neck, in -which region there suddenly occurs a reddening of the skin, with diffuse -and increasing subjective sensation of heat. At the same time there is -often a sense of tension, as if the part were about to burst. Actual -slight swelling may be noticed, the eyes sparkle and are somewhat -prominent, the head feels heavy, stupid, and dizzy. Sometimes these -symptoms last for a considerable time; at other times they terminate -speedily and suddenly with a local perspiration or with an attack of -epistaxis. Not infrequently, after lasting a short time in one region, -they pass away as rapidly as they came, but are immediately succeeded by -a similar attack in some other part of the body, or by vasomotor -phenomena of a slightly different kind. Thus, such a flushing and heat -of the face may be replaced by a sudden sense of heat in the small of -the back or in the sacral region, by pruritus of the extremities, by -palpitation of heart, or by an attack of pseud-angina. - -A further consequence of active hyperaemia is the onset of those -confused states, so common in the climacteric age, of mental and bodily -disquiet, which find expression, now in states of excitement, and now in -states of depression. So we often observe change of disposition, -associated with incapacity for regular work, whilst sleep is restless, -and much disturbed by dreams; and again states of dizziness, a sense of -mental uneasiness and confusion, and even actual delirium. - -In the skin, in addition to the fugitive heats, we often have a peculiar -pricking, itching, or stabbing sensation, and various kinds of -hyperaesthesia, frequently associated with disturbances of tactile -sensation. We observe also muscular twitchings, and general weakness of -the organs of locomotion. - -In association with the passive and active hyperaemias of the menopause, -we frequently see increase or some qualitative change in the various -secretions. Above all, these changes affect the various secretions of -the different reproductive organs, but we have also increased intestinal -secretion, leading to diarrhoea, increased excretion of urinary -deposits, and increased secretion by the skin. Symptoms which are common -at the menarche, and frequently recurs at the menopause, are: headache, -migraine, a state of pseudo-narcotism, slight hysterical attacks, -indications of moral insanity, lumbo-abdominal neuralgias, neuralgia of -the breasts, leucorrhoea, and various skin eruptions. - -According to _Tilt_, the changes occurring in the organism at the -climacteric period may be summarized under the following heads: - - 1. Increased elimination of carbonic acid by the lungs, - - 2. Increased elimination of uric acid in the urine, - - 3. Increased perspiration, - - 4. Increased mucous flux, - - 5. Haemorrhages from various organs. - -As regards the first point, the extensive researches of _Andral_ and -_Gavaret_ have shown that in the female sex the quantity of carbonic -acid eliminated by the lungs diminishes when menstruation first appears -at puberty, but increases again at the climacteric age, when -menstruation ceases—whereas in the male a gradual diminution in the -elimination of carbonic acid begins already in the 36th year of life; in -old age the quantity eliminated is greatly reduced in both sexes alike. - - - CHANGES IN THE FEMALE REPRODUCTIVE ORGANS AT THE MENOPAUSE. - -[Illustration: - - FIG. 84.—Sagittal section through the ovary of a girl aged 16. -] - -In considering the changes that take place in the female reproductive -organs at this period of life, we must distinguish between the proper -period of the _climacteric_, with its various manifestations antecedent -to and associated with the irregularity and ultimate cessation of -menstruation, from the condition of _old age_ in which menstruation has -actually and completely ceased, in which the menopause has been fully -accomplished, and in which the changes of senescence have set in at once -in the organs of the reproductive system and in the organism as a whole. - -The most important and most significant changes of this sexual epoch are -unquestionably the anatomical alterations in the ovaries. A good many -years ago I undertook an investigation whose purpose was to follow the -natural involution of the graafian follicles from the time of the climax -on into old age, and for this purpose I examined a very large number of -ovaries of women at ages varying from 42 to 75 years (Archiv. für -Gynecologie, Bd, XII., Heft 3). - -Throughout these years a slow but continuously progressive atrophy -proceeds in the ovaries; they become smaller and denser, diminishing -especially in height and width; their surface becomes extremely uneven; -and in extreme old age they wither away until no more is left in the -region formerly occupied by the ovaries than a flattened fibro-vascular -thickening (Figs. 84–88). The histological characteristic of the changes -in the ovary which proceed gradually from the commencement of the -menopause to extreme old age, may be summed up as consisting in a -continual increase and new formation of the connective tissue stroma at -the expense of the cellular layer, accompanied by retrogressive -metamorphosis of the graafian follicles. - -[Illustration: - - FIG. 85.—Sagittal section through the ovary of a woman aged 72 years. -] - -The connective tissue ground substance of the ovary increases from the -periphery towards the centre, and progressively compresses the -epithelial structures of the organ. In the outermost layer of the -ovarian stroma, the so-called tunica albuginea, the strata of short, -dense connective tissue fibres increase notably in number, so that -whereas at first three layers at most could be distinguished, the tunic -ultimately comes to consist of from six to eight layers; at the same -time also the interior ovarian stroma becomes exceedingly dense, so that -numerous well-defined interlacing bundles of fibres can be made out in -its substance. - -The first retrogressive metamorphosis which can be observed in the -graafian follicles is fatty degeneration, the formation of granule -spheres. Whilst the membrana propria (the theca folliculi) of the -follicle remains quite unaltered, we observe in the membrana granulosa, -in addition to the ovum, and the ordinary cells of this layer, spherical -aggregates of fat droplets, the granule spheres, which continually -increase in size, until ultimately of the cellular contents of the -follicle nothing whatever remains, and it now appears full of granule -spheres and fluid. The theca folliculi has now lost its spherical shape, -and assumes an ovid form (Fig. 89). - -In a later stage of the degeneration of the graafian follicle, it -appears as a vesicular body with a relaxed wall, thrown into numerous -folds, this folded wall being formed by the theca folliculi. The cavity -of the follicle is reduced to a mere cleft, filled with a transparent -substance, and the space between this cleft and the inner surface of the -theca folliculi is occupied by round cells and a fibrous intercellular -substance, and is traversed by a vascular network. This second stage of -the retrogression of the follicle may therefore be designated the stage -of vesicular degeneration (Fig. 90). - -[Illustration: - - FIG. 86.—Diagrammatic representation of the Graafian Follicle. -] - -[Illustration: - - FIG. 87.—Ovary of a girl aged 19 years. (Normal size.) -] - -[Illustration: - - FIG. 88.—Ovary of a woman 72 years of age. (Normal size.) -] - -In the last stage of this retrogressive metamorphosis, we find the -follicle completely transformed to a fibrous mass. It appears as an -elongated oval body, much lobulated, connected with the surrounding -stroma by thick strands of fibres; a trace of the original cavity can -still be distinguished in the form of a narrow cleft, without -distinguishable contents. The tissue of this body consists of connective -tissue fibres, with interspersed nuclei and nuclear fibres (Fig. 91). - -The three stages I have observed in the retrogression of the follicle, -of which I have given a summary account above, may, I think, be -explained in the following manner: When the woman’s reproductive -activity ceases, the graafian follicles become subject to a -retrogressive metamorphosis, a fatty degeneration setting in in the -cells of the membrana granulosa and in the ovum, until ultimately the -whole of the granular epithelium has undergone atrophy. The follicle now -undergoes a vesicular transformation with shrinkage of its cavity, and -with the formation of a new tissue which appears to be young connective -tissue. As time goes on, this new connective tissue is formed in -increasing quantities, until finally the entire follicle is transformed -into a firm fibrous mass. - -[Illustration: - - FIG. 89. -] - -Thus we are led to infer that the gradual but extensive thickening of -the tunica albuginea (i. e., the outer, condensed layer of the ovarian -stroma), which, as we have seen, always occurs at the climacteric -period, offers a hindrance to the bursting of the follicles as they -mature, and in this we find the explanation of the irregularity of -menstruation and of the various troubles which attend the performance of -that function at the time of the menopause. It is reasonable to assume -that the resistance of this thickened tunica albuginea is responsible -for the fact that the interval between the bursting of the successive -follicles is now greater than normal, as much as six or eight weeks—this -retardation of menstruation being one of the commonest ways in which the -onset of the menopause is first manifested. Another phenomenon connected -with the onset of the menopause also finds a plausible explanation in -the anatomical grounds just mentioned. As already pointed out, in parous -women the menopause sets in later than in nulliparae. At every -pregnancy, the ovaries share in the more abundant nutrition of all the -reproductive organs, due to the general dilatation of the intrapelvic -vessels which accompanies this process; hence the ovaries become larger, -richer in lymph, and therefore softer, the cellular elements increase in -size, and perhaps also in number, and it is readily conceivable that in -such ovaries the cellular elements are able for a longer time to resist -the induration and the new formation of connective tissue which occur at -the climacteric. - -The numerous nervous disturbances of the climacteric epoch would appear -also to depend upon the hyperplasia of the ovarian stroma which we have -observed to be the characteristic anatomical change in the ovaries at -this period of life. - -[Illustration: - - FIG. 90. -] - -Associated with the fibrous transformation of the graafian follicles -there is, however, a failure of the so-called internal secretion of the -ovaries, a matter to which much attention has recently been paid. -_Brown-Séquard_ has especially maintained that the ovaries secrete a -substance which enters the blood, a substance which, notwithstanding the -fact that its presence cannot be proved either by chemical or any other -means known to us, yet is of considerable importance for the maintenance -of the equilibrium of mental and physical well-being. It is supposed -that the various profound disturbances of the general system occurring -at the menopause[52] are dependent upon the cessation of this internal -secretion of the ovary—disturbances which rise to a maximum as the -atrophy of the ovary proceeds, and which only gradually pass away after -a considerable lapse of time. - -After the menopause is completely over, in the ovaries, as in other -parts of the female reproductive organs, the signs of senile -degeneration make their appearance. - -In old women, we find the ovaries either shrunken to the form of small -fibrous cords, or else degenerated to form cysts of smaller or larger -size, the stroma surrounding these cysts being extremely hard, dense, -and tough. - -[Illustration: - - FIG. 91. -] - -[Illustration: - - FIG. 92.—Sagittal section through the Cervix of a woman 26 years of - age. Dendriform branched Glands. -] - -[Illustration: - - FIG. 93.—Sagittal section through the Cervix of a woman 65 years of - age. Glands which have undergone Cystic Degeneration. -] - -[Illustration: - - FIG. 94.—Cervix of a woman 70 years of age. The Cervical glands have - undergone Cystic Degeneration. -] - -Whereas at the commencement of the climacteric period, the uterus -commonly exhibits a slight increase in size, owing to the condition of -passive hyperaemia already described, subsequently a gradual diminution -in the size of the organ may be observed. This atrophy begins with the -portio vaginalis and proceeds upwards. Whilst the body still appears -undiminished in size, the vaginal portion will be found already shorter, -more slender, and more flaccid. Gradually, however, the entire organ is -involved in the atrophic process. The uterus is then smaller than -formerly, its walls are thinner, its cavity reduced in size. Its -vascularity and its sensibility are alike diminished. The external os is -smaller, and the internal os is sometimes entirely obliterated. There is -a tendency at the climacteric period for the tubulo-racemose glands of -the cervical mucous membrane (Fig. 92) to undergo a cystic degeneration -(Fig. 93), and hence arise the cysts which are so commonly met with on -the portio vaginalis of women at this time of life, cysts varying in -size from that of a millet seed to that of a pea. In advanced life, the -formation of such cysts may be regarded as normal, and sometimes in the -form of grape-like clusters they almost completely occupy the lumen of -the cervical canal. (Figs. 94, 95, 96, and 97). - -Not infrequently, these cysts lead to the formation of polypi, by -enlarging until the mucous membrane projects so far that a stalk is -formed. - -Examining the bodies of 47 women who died at ages varying from 42 to 80 -years, I found in 28 ovula Nabothi in the cervical mucous membrane, for -the most part at the os uteri externum, but in some cases also extending -up to the os internum, sometimes between the plicae palmatae, sometimes -isolated, sometimes grouped. - -Sometimes in old women no trace of a vaginal portion remains, and the -uterus is found to be transformed to a small, thin-walled, shrunken -body, no more than one-fourth of its original size; in such cases the -saying of Graaf appears to be justified, that after the menopause the -uterus returns to the size it has in the young girl. In the majority of -such cases, the cavity of the uterus is also contracted (concentric -atrophy). It sometimes happens, however, that in old age the os externum -and the os internum are the seat of atresia, whilst the intermediate -portion of the cervical canal remains unaffected. In this way, -especially when the cervical canal and the cavity of the body of the -uterus are distended with mucus or with fungous growths, is produced -what is known as the _uterus bicameratus vetularum_. - -[Illustration: - - FIG. 95.—Ovula Nabothi in the Portio Vaginalis. -] - -In many cases, when the cervical canal has been obliterated, we find the -uterine cavity distended with mucous secretion (excentric atrophy). The -substance of the uterine wall is in old age commonly dense and tough, -but occasionally, in extreme old age, less firm than formerly, withered -and friable, and traversed by degenerated arteries, and in this state it -is predisposed to haemorrhages (apoplexia uteri). Such intramural -haemorrhages usually occur in the fundus; the friable uterine substance -has then a blackish-red appearance, infarcted with extravasated blood; -sometimes the uterine cavity is also filled with blood. In general it -may be said that when the menopause is completely over, when uterine -activity has entirely ceased, the uterus returns to the state in which -it was before the menarche—it is physiologically dead. - -The tubes become flaccid, thinner, shorter, and are at times -obliterated. In the mucous membrane of the tubes in old women we no -longer find any trace of the glands described by Hennig; the epithelial -cells have also lost their cilia. - -During the climacteric period, the vagina is usually relaxed and roomy, -the mucous membrane is smooth, injected and secretes freely; -subsequently, in old age, it becomes firm, tough and dry. - -[Illustration: - - FIG. 96.—Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane. -] - -_Wendeler_ found that the initial change of the climacteric in the ovary -is a chronic and progressive endarteritis obliterans; the result of this -process is, in addition to the obliteration of the follicles, a -continually increasing hyaline degeneration of the smallest arteries and -the arterioles, especially along the line of transition between the -cortical and the medullary substance of the organ; this degeneration -extends to the surrounding connective tissue, and thus leads to the -formation of peculiar, vitreous, translucent foci of sclerotic -connective tissue, containing few cells or none; these are the so-called -_corpora fibrosa_ or _corpora albicantia_. Only subsequently to the -formation of these bodies does the characteristic wrinkling of the -surface of the ovary occur, with general shrinkage of the organ, these -changes being due to the contraction that sets in in the numerous -scattered foci of connective tissue, which, as already mentioned, are -situated in close proximity to the cortex. - -[Illustration: - - FIG. 97.—Mucous glands undergoing Cystic Degeneration. -] - -The gradual atrophy of the uterus after the extinction of its sexual -activity leads to a diminution in all the diameters of the organ, so -that in old women it becomes flattened as in childhood, all its curves -having disappeared; the muscular substance is replaced by connective -tissue; and the portio vaginalis dwindles and even entirely disappears. - -As regards the bacterial flora of the genital organs of elderly women, -_Menge_ and _Koenig_ find that the vagina for the most part contains -bacteria which do not thrive when cultivated aërobically on alkaline -agar plates. In exceptional cases, however, such bacteria are found, and -may even be sufficiently vigorous to produce pyogenic infection. -According to _Strogamoff_, the vagina in all circumstances contains a -great variety of micro-organisms—cocci, diplococci and rod-forms. -Rod-forms are the prevailing types found in normal conditions in elderly -women, but they are much smaller than in women who are still in the -period of reproductive activity. Organisms liquefying gelatine were -found in one instance only, a case of vaginal prolapse. In one half of -the cases examined, there was no development of culture media inoculated -from the cervix uteri, whether on agar or gelatine. - - - THE TIME OF THE MENOPAUSE. - -The age at which the menopause begins is one which varies owing to -manifold conditions, congenital and acquired, owing to the local -influences which have been brought to bear on the reproductive organs -during the menacme, and to the general circumstances of life during this -period. In Northern Europe it commonly begins some time between the ages -of 40 and 50 years. According to the most trustworthy statistical data, -the commonest age for the onset of the menopause is between the ages of -45 and 50 years. Next to these in frequency we find the menopause -commencing between the ages of 40 and 45 years. If, however, the -menopause does not begin during the fifth decennium, it is more apt to -occur during the quinquennium after 50 than during the quinquennium -preceding 40 years of age; that is to say, an abnormally late menopause -is more often met with than an abnormally early menopause. In a very -small proportion of women does the menopause begin either after the age -of 55 or before the age of 35. - - - THE AGE AT WHICH THE MENOPAUSE OCCURS. - -My own observations show that the age at which the menopause begins is -affected by the following circumstances: - -1. The race (nationality) of the woman. - -2. The age at which the menarche occurred. - -3. The sexual activity of the woman during the period of the menacme, -the number of her pregnancies, the exercise or neglect of the function -of lactation. - -4. The social circumstances of the woman’s life. - -5. General constitutional and pathological conditions. - - - _1. Race._ - -From the statistical data regarding the age at which the menopause -occurs among the women of the various nations of Northern Europe, it -appears that the latest average age for the cessation of menstruation is -met with in Lapland, namely 49.4 years; next comes Norway, where the -average age is 48.9; next Germany, where the average age is 47; next -England, 46.1; next Russia, 44; and finally Austria, 42.2. In the four -principal capital cities, the average age is: in London, 45.5; in Paris, -43.65; in Vienna, 43, and in Berlin, 47. Generally speaking, in southern -countries the cessation of menstruation occurs at an earlier age than in -northern countries, as the following comparison shows: northern -countries: England (Tilt), 48 to 50; France (Courty), 50; North Germany -(Mayer), 50; Austria (Szukits), 42; southern counties: Persia (Chardin), -27; Java, 30; various Asiatic races, 30 to 40. - -In the case of 500 women of various nationalities in whom I was able to -ascertain by personal observation the age at which menstruation ceased, -I found that the menopause occurred: - - In the quinquennium 35 to 40 in 48 women - In the quinquennium 40 to 45 in 141 women - In the quinquennium 45 to 50 in 177 women - In the quinquennium 50 to 55 in 89 women - ——— - 455 - -Thus we see that in about one tenth of my cases, menstruation ceased -between the ages of 35 and 40; in more than one-fourth, between the ages -of 40 and 45; in more than one-third between the ages of 45 and 50; and -in about one-sixth between the ages of 50 and 55. In 267, that is, in -more than one-half of the 500, menstruation ceased between the ages of -42 and 51. In 28 women, menstruation ceased before the age of 35; and in -17, after the age of 55. In a very large majority of my 500 cases the -women were of German or Austro-Hungarian nationality; next, in order of -frequency, came Poles, Russians, women of various southern countries, -Swedish women. In women of Slavonic nationality, menstruation ceased -remarkably late as compared with women of German nationality. - -_Brierre de Boismont_, _Tilt_, _Courty_, and various other observers, -have published statistical data regarding the age at which menstruation -ceases in women of different nationalities. _Krieger_, compiling from -several authors, statistics relating to 2291 women (European) gives the -following average results: menstruation ceased - - Between the ages of 35 and 40 in 272 women 11.87 per cent. - Between the ages of 40 and 45 in 595 women 25.97 per cent. - Between the ages of 45 and 50 in 940 women 41.03 per cent. - Between the ages of 50 and 55 in 334 women 14.58 per cent. - Before 35 and after 55 in 150 women 6.54 per cent. - ———— ————— - 2291 99.99 - -We append a statistical table showing the average age at which -menstruation ceases in women of different European nationalities: - - ══════════════╤════════╤════════════════╤════════╤═════════ - │Germany.│Austria-Hungary.│ France │ England - │ │ │(Paris).│(London). - ──────────────┼────────┼────────────────┼────────┼───────── - Number of │ 824│ 256│ 178│ 500 - cases │ │ │ │ - Average age at│ │ │ │ - the │ 47.0│ 42.2│ 44.0│ 46.1 - cessation of│ │ │ │ - menstruation│ │ │ │ - │ │ │Brierre │ - Observer │ Magar │ Szukits │ de │ Tilt - │ │ │Boismont│ - ══════════════╧════════╧════════════════╧════════╧═════════ - - ══════════════╤═══════╤════════╤═══════╤════════ - │Russia.│Denmark.│Norway.│Lapland. - │ │ │ │ - ──────────────┼───────┼────────┼───────┼──────── - Number of │ 100│ 312│ 391│ 34 - cases │ │ │ │ - Average age at│ │ │ │ - the │ 45.9│ 44.8│ 48.9│ 49.4 - cessation of│ │ │ │ - menstruation│ │ │ │ - │ │ │ Faye │ - Observer │Lieven │Hannover│ and │ Vogt - │ │ │ Vogt │ - ══════════════╧═══════╧════════╧═══════╧════════ - - - _2. The Age at Which the Menarche Occurred._ - -Until recently, it was generally believed that the earlier the age at -which menstruation first made its appearance, the earlier also would the -menopause occur; and that, on the other hand, the later the age at which -the flow began, the later also would it cease. _Virey_ summarized this -opinion in the saying: prius pubescentes prius senescunt. This view of -the matter is, however, true only in respect of the influence of climate -upon sexual development. In a cold climate, a woman begins to menstruate -late and ceases to menstruate late; in a hot climate the opposite -conditions prevail. But if we make our comparison between women living -in similar conditions as regards latitude and climate, we find that -_Virey’s_ saying is far from accurately describing the facts. - -In general, and climatic influences apart, it may be said that the -earlier in any woman the age at which menstruation first occurs, the -later will be the age at which menstruation ceases. - -In order to ascertain the influence of the age at the menarche upon the -disappearance of menstrual activity, I placed in comparison first the -cases of 50 women in whom menstruation had first appeared between the -ages of 12 and 16—i. e., cases of early menarche; and secondly the cases -of 50 women in whom menstruation had begun between the ages of 16 and -20—i. e., cases of late menarche. The result was the following: - -In the 50 women in whom the menarche had been early, the menopause -occurred - - At ages 35 to 40 in 5 instances - At ages 40 to 45 in 12 instances - At ages 45 to 50 in 25 instances - At ages 50 to 55 in 8 instances - -On the other hand, in the 50 women in whom the menarche had been late, -the menopause occurred - - At ages 35 to 40 in 9 instances - At ages 40 to 45 in 28 instances - At ages 45 to 50 in 10 instances - At ages 50 to 55 in 3 instances - -Thus whilst among the women in whom the menarche had been late, there -were thirteen only who continued to menstruate until they were at least -45 years of age; among those in whom the menarche had been early, the -number in whom menstruation thus continued up to the age of 45 or beyond -was 33, nearly three times as great. - -On the other hand, in those cases in which the menarche occurred at an -_abnormally_ early age, i. e., before the age of 12 years, the menopause -was also a remarkably early one. The menopause also came on very early -in women in whom the menarche had been extremely retarded, until the age -of 20 and upwards. An extremely early and an extremely late menarche -alike tend to be followed by a premature menopause. - -To this rule there are, however, exceptions, and we occasionally meet -with women whose reproductive energies are so powerful, that the -menarche occurs at an unusually early age, and the menopause is -postponed to an age considerably beyond the average. Thus, among 100 -women in the _Salpetrière_, _Raciborski_ observed 29 in whom -menstruation had begun at the exceptionally early age of 12 years, and -who, notwithstanding this, all experienced a very late menopause. Three -of them were still menstruating at the age of 57, 1 at 56, 2 at 52, 2 at -50, 3 at 48, 3 at 45, and 13 at an age less than 45. - -_Brierre de Boismont_ reports the case of a woman who began to -menstruate in her 12th year; she married, had several children, and -continued to menstruate regularly until she was 60 years of age. - -The results obtained by _W. Guy_, who examined a series of 250 cases, -confirm the proposition stated above, that the earlier menstruation -begins (the extremely early cases being excluded), the later it ceases. - -According to _Cohnstein_, who bases his conclusions upon the observation -of 400 cases, in women who begin to menstruate early, the menopause -occurs on an average three years later, than in women who begin to -menstruate late. _Puech_ also states that menstruation lasts longer in -women who begin to menstruate early, than in those who begin to -menstruate late. According to _Scanzoni_, in women who begin to -menstruate in _very_ early youth, the climacteric age is commonly -reached earlier, than in those in whom puberty occurs at the normal -age—commonly between the ages of 40 and 42 years. - -The homology between the pathological states which, in any particular -individual, occur at the respective periods of the menarche and the -menopause, is sometimes extremely remarkable; the very same symptoms by -which the first appearance of menstruation was preceded, recur as -antecedents of the menopause. This is seen in the case of certain -eczematous conditions of the skin, of dyspeptic manifestations, -epistaxis, nervous disturbances, hysterical and epileptic seizures, -vasomotor symptoms, congestions, cardiac troubles, albuminuria, etc. -_Alibert_ pointed out that certain skin-diseases may appear twice only -during life, once shortly before the commencement of menstruation, and -the second time shortly before the cessation of menstrual activity. -_Brierre de Boismont_ alludes to the occurrence of hysteria and epilepsy -before both these important epochs in a woman’s life, whilst in the -intervening period the patient had remained entirely free from such -troubles. _H. Marsh_ records the observation that women who just before -puberty have suffered from repeated attacks of epistaxis, have suffered -from the same trouble as a predominant symptom of the climacteric -period. _Tilt_ has seen in several cases the outbreak of numerous -furuncles with subsequent diarrhoea, and still more frequently peculiar -attacks of severe vertigo, occurring in women just before the two -critical epochs in her life, whilst in the intervening period there has -been no trace of such troubles, either in connexion with menstruation, -with the puerperium, or with lactation. - - - _3. The Woman’s Sexual Activity._ - -An important influence upon the early or late onset of the menopause is -exerted by the degree to which a woman’s reproductive functions have -been exercised during the menarche. My personal observations have shown -me that in women who are in good health and of a powerful build, whose -menstrual flow has always been regular and sufficient in quantity, whose -reproductive organs have been adequately and properly exercised, who -have had a physiological amount of sexual intercourse, have given birth -to several children, and have suckled these children, the cessation of -the menstrual flow generally occurs much later than in women in whom the -conditions of the sexual life have been the opposite of those just -mentioned. The more regular menstruation has been, and the more normal -the deliveries, the later does the menopause ensue. - -Especially striking is the influence of the number of deliveries upon -the time of occurrence of the menopause. In women who have given birth -to a number of children, menstruation as a rule continues for several -years later than in sterile women, or in those who have had one or two -children only. If a woman suckles her children, the date of the -menopause appears also to be postponed. Deliveries late in life seem -likewise to delay the onset of the menopause, whereas abortions -accelerate its occurrence. If, however, pregnancy succeeds pregnancy at -extremely short intervals, the menopause is likely to occur early; the -same result is brought about by sexual intercourse at too early an age. -The menopause occurs latest in women who have begun to menstruate early, -who have married, have given birth to more than three children, and have -been delivered of their last child at full term when 38 to 42 years of -age. - -As regards the 500 women previously mentioned, in whom I made personal -observation as to the age at which the menopause occurred and the -circumstances by which its onset was influenced, the effect of marriage -and the number of children born is shown by the following details: - -Of the 48 women in whom the menopause occurred between the ages of 35 -and 40, 16 were unmarried, 6 married and childless, 18 married with one -or two children, 8 married with more than two children. - -Of the 141 women in whom the menopause occurred between the ages of 40 -and 45, 3 were unmarried, 4 married and childless, 46 married with one -or two children, 88 married with more than two children. - -Of the 177 women in whom the menopause occurred between the ages of 45 -and 50, 1 was unmarried, 2 were married and childless, 32 married with -one or two children, 142 married with more than two children. - -Of the 89 in whom the menopause occurred between the ages of 50 and 55, -none were unmarried, none were childless, 19 were married with one or -two children, 70 were married with more than two children. - -Of the 17 women in whom the menopause occurred at an age above 55 years, -there were two only who had not had more than two children, whilst there -were 10 who had had six to eight children. - -The influence of lactation is shown by the fact that in the case of 40 -women who had not suckled their children, the mean duration of menstrual -activity was four years less than the established mean duration of 27 -years. - - - _4. The Social Circumstances of the Woman’s Life._ - -The conditions in which a woman passes her life are not without -influence upon the time of onset of the menopause. In general it may be -said that among the women of the labouring classes, whose livelihood is -so often precarious, and who are apt to suffer from habitual physical -overwork, menstruation ceases at an earlier age than among the women of -the well-to-do classes and those who lead an easier life. But though the -climacteric thus occurs earlier among the lower than among the upper -classes, the difference is not a considerable one. - -According to _Mayer’s_ calculation, the mean age at which menstruation -ceases is, in upper class women, 47.13 years, in lower class women, -46.97 years. Small as this difference appears, amounting on the average -to no more than two months, it must not be forgotten that among the -upper classes, menstruation begins earlier than among the lower classes, -by an amount which averages 1.31 years. Thus the total duration of -sexual activity is almost one and a half years longer in the upper than -in the lower classes. - - - _5. General Constitutional and Pathological Conditions._ - -An important influence upon the time of occurrence of the menopause is -exerted by the individual and hereditary predisposition of the woman, by -her constitutional state, and by certain illnesses from which she has -suffered. Women who by inheritance are constitutionally weakly and -delicate, in whom the menstrual flow has always been pale and scanty, in -whom the intermenstrual intervals have been excessive, and who have a -slender habit of body, attain the climacteric age earlier than women -with vigorous bodily development and powerful muscles, with large -breasts, and in whom menstruation has always been regular and abundant. -Women with a great tendency to obesity cease to menstruate earlier than -women of more normal proportions; blondes earlier than brunettes; women -of phlegmatic temperament earlier than women of a sanguine and ardent -temperament. - -In general it may be said, that all influences which have a weakening -effect upon the feminine organism, tend also to accelerate the onset of -the menopause: such are, severe labour, great sorrow, wearisome -occupations, severe menstrual losses, rapidly succeeding pregnancies, -and abortions; also a number of pathological general states shortly to -be discussed, as well as local diseases of the reproductive organs. - -_Fritsch_ points out that menstruation continues to a later age in -proportion as the woman’s state of general nutrition is a good one. He -also asserts that women with a very large uterus, who have always had an -abundant menstrual flow, those with retroflexion, with hypertrophy of -the portio vaginalis, or chronic endocervicitis and endometritis, and -those with small myomata which have given rise to no marked symptoms, -often continue to menstruate far beyond the usual age. - -The mean duration of the climacteric phenomena, from the commencement of -these until the final cessation of menstruation, is about two years. -This mean is made up of extremely wide individual variations; in a small -proportion of the cases the climacteric manifestations may last no more -than a month or two, whilst at the other end of the scale we meet with -cases in which the duration extends to 4, 6, 8, and even 18 years. - -In considerably more than half of all the cases, however, the duration -of the climacteric manifestations varies between six months and three -years. Thus, in _Tilt’s_ series of cases, the duration of the “change of -life” was - - 6 months in 12.07 of all cases - 1 year in 22.64 of all cases - 2 years in 18.62 of all cases - 3 years in 9.43 of all cases - - - _6. Premature, Delayed and Sudden Onset of the Menopause._ - -In exceptional cases, the menopause, instead of taking place between the -fortieth and the fiftieth year of life, occurs at an abnormally early or -an abnormally late age. - -Premature cessation of menstrual activity, in the third or the fourth -decennium of life—very rarely indeed before the third decade—depends in -part upon disturbances of metabolism and of haematopoiesis, and in part -upon diseases of the female reproductive organs; in some cases, however, -it may be due to some hereditary constitutional peculiarity; or it may -occur suddenly, in consequence of some violent shock to the nervous -system. - -Among the disorders of metabolism which may lead to a premature -menopause, excessive adiposity, lipomatosis universalis, occupies the -first place. Next in order of importance come a chloro-anæmic condition -of the blood, pernicious anæmia, splenic leukaemia, certain of the acute -infectious disorders—typhoid, cholera, scarlatina, acute articular -rheumatism,—further pulmonary tuberculosis, diabetes mellitus, Graves’ -disease, Addison’s disease, and myxoedema. These various conditions may -give rise, in part by infective processes, and in part in consequence of -the general cachectic condition, to atrophy of the ovaries with -destruction of the graafian follicles, and to atrophic processes in the -uterus, and these changes lead to the premature cessation of menstrual -activity. - -Excessive obesity has a restrictive influence upon ovarian activity, -manifested in part, as already mentioned, by the occurrence of -sterility, but in part also, in very obese women, by the onset of a -premature menopause. Among 215 cases of extreme obesity in women, I -found 49 in which the menopause occurred at a remarkably early age. In -these cases the menopause occurred at the following age: - - In 1 woman at the age of 17 years - In 14 women at the age of 20 to 25 years - In 11 women at the age of 25 to 30 years - In 9 women at the age of 30 to 35 years - In 14 women at the age of 35 to 40 years - -In none of these cases did the local examination of the reproductive -organs disclose the existence of any noteworthy disease. - -Of the diseases of the genital organs which are competent to give rise -to a premature cessation of menstrual activity, the most important are -the puerperal infective processes and other inflammatory states of the -reproductive organs, with their results—chronic metritis, perimetritic -and parametritic exudations, chronic oophoritis, atrophy of the uterus -and the ovaries. - -After infective puerperal processes, it sometimes happens that there is -far-reaching destruction of the uterine musculature, degeneration of the -uterine mucosa, permanent and irreparable atrophy of the uterus, and -suppuration and atrophy of the ovaries—conditions which result in an -extinction of menstrual activity. A similar result may ensue upon the -persistent and long-continued pressure upon the uterus and the ovaries -of a large intrapelvic exudation; such exudation being commonly -post-puerperal, but occasionally arising in the absence of pregnancy. -Further, according to _Freund_, chronic atrophic parametritis may give -rise to an incurable atrophy of the uterus, by interference with the -circulation of the blood through the broad ligaments, and consequent -impairment of the nutrition of the uterus. Gonorrhoeal inflammation may -also lead to the termination of menstrual activity, when it gives rise -to intramural inflammatory deposits in the uterus, and to chronic -inflammatory processes in the ovaries. Tumours of the uterus and the -uterine annexa may likewise induce a premature menopause. - -We also meet with cases in which after a pregnancy, to all appearance -normal in its course and termination, a premature menopause results. To -this category belong the cases, according to _Kleinwächter_ of no -extreme rarity, in which perfectly healthy women are attacked by profuse -uterine haemorrhage during the course of a normal, full-term labour, or -during miscarriage; subsequently, though the lying-in period is passed -without further misadventure or abnormality, and in the absence of -lactation, the patient becomes permanently amenorrhoeic. The normal -involution of the uterus passes on into hyperinvolution, and ultimately -complete atrophy of uterus and ovaries results. In some cases, moreover, -such hyperinvolution with consecutive atrophy follows normal labour or -abortion without the occurrence of any excessive haemorrhage. - -Much more frequently do we find that rapidly successive pregnancies, -with long-continued exercise of the lacteal function, in badly -nourished, anæmic women, give rise to a premature menopause, due to -permanent atrophy of the uterus and ovaries, which are in such cases so -poorly supplied with blood. This “lactationatrophy” is described by -_Frommel_ and _Thorn_ as a concentric atrophy first of all affecting the -corpus uteri, and to this, if the disease advances, there succeeds a -general atrophy of the muscular, connective, and fatty tissues of the -parametrium, the vagina, the pelvic floor, and ultimately of the -ovaries, leading, when permanent, to a premature menopause. - -Trauma of the genital organs may also lead to uterine atrophy and to -premature menopause. - -By many authors it is believed that too-early marriage, sexual excesses, -and prostitution, may be the cause of cessatio praecox. In some cases, -there is unquestionably a hereditary predisposition to a premature -climacteric, since the mothers of the women in whom it occurs have -themselves been similarly affected. In the remarkable case which came -under my own observation, of a woman from Smyrna, there was hereditary -predisposition. This woman began to menstruate when 12 years of age; -menstruation was always scanty; she married when 15 years of age; and -she ceased to menstruate for ever at the age of 19. In other cases we -find there is a family tendency for menstruation to be delayed in its -first appearance to a comparatively advanced age, and to cease at the -usual time. - -In cases of cessatio mensium praecox (unless the failure of menstruation -has been quite a sudden one), and after the premature menopause is fully -established, we find in the uterus and the ovaries anatomical changes -similar to those met with after the natural climacteric—diminution in -the size of the uterus with thinning of its walls, density and firmness -of the tissues of the organ, smallness and a soft consistency of the -ovaries; sometimes, also, the mammae are atrophic. - -In cases of premature menopause, the troubles attending the change are -commonly more severe and more enduring than those that occur at the -natural menopause. Especially is this the case when the premature -menopause is quite a sudden occurrence, but this phenomenon is rare. -Most commonly the premature menopause is gradual in onset; the flow -becomes more scanty month by month, until at last it fails altogether to -appear. Irregularity in the menstrual rhythm is not often seen in such -cases. Early senescence is exceptional in these women in whom a -premature menopause occurs. Emaciation, greyness of the hair, wrinkling -of the skin, the growth of hairs on the face, etc., are not usually -associated with the atrophy of the reproductive organs; the physiognomy -and figure of women with cessatio praecox being usually similar to those -seen in women of corresponding age in whom menstruation still continues. - -_Tilt_ enquired regarding the cause of cessatio praecox in 27 instances, -with the following results: - - In 3 instances, parturition and lactation. In 1 instance, abortion. - In 2 instances, a fall on the sacrum during menstruation. In 2 - instances, suppression of menstruation from chill. In 1 instance, - haemorrhage from the arm during menstruation. In 1 instance, - celebration of nuptials during menstruation. In 2 instances, - severe medicinal purgation. In 2 instances, cholera. In 2 - instances, rheumatic fever. In 2 instances, febrile bronchitis. - In 9 instances, intermittent fever. - -In 1 case _Tilt_ saw cessation of menstruation occur at the age of 29, -in consequence of metritis. _Atlee_, in 15 cases of ovarian tumour, saw -the menopause occur at ages of 30, 39, 40 and 42. _Puech_ saw a -premature menopause at the age of 30 in 3 cases, in each a sequel of -cholera. _Blondel_ reports a case of cessatio praecox after prolonged -galactorrhoea, although the woman had not suckled her infant; -_Gottschalk_ and _Rokitansky_, cases following injury to the cervix -uteri; _Kiwisch_, _Simpson_, and _Kleinwächter_, cases following -full-time, normal deliveries, in which, however, severe losses of blood -had taken place. - -_Courty_ and _Brierre de Boismont_ report cases in which the menopause -occurred as early as the age of 21; _Mayer_, 2 cases at the age of 22; -_Krieger_, 1 case at 23; _Brierre de Boismont_, 1 case at 24; _Mayer_, 2 -cases at 25; _Brierre de Boismont_, 1 case at 26, and 1 case at 27; -_Guy_ and _Tilt_, each 1 case at the age of 27; _Brierre de Boismont_, -_Courty_, and _Guy_, each 1 case at the age of 28; _Brierre de -Boismont_, _Courty_, and _Mayer_, each 1 case at the age of 29; _Guy_ -and _Tilt_, each 1 case at the age of 30; and _Mayer_, 5 cases at the -age of 30. - -An unusually late climacteric, the continuance of menstruation beyond -the age of 50 years, is not an extremely rare occurrence, but is less -often seen than cessatio praecox. There is, however, in these cases a -difficulty which must not be underestimated, namely, to distinguish -between a genuine menstrual bleeding and the other uterine haemorrhages -which are common precisely at this age of life, due either to textural -changes in the uterus, or to neoplasmata—more especially because in -these non-menstrual haemorrhages also a certain periodicity may often be -detected. When on careful examination no abnormality can be discovered -in the reproductive organs, when the bleeding in question recurs at the -intervals and in association with the general symptoms to which the -woman thus affected has been accustomed during her previous -menstruations, and when the amount of blood discharged is not abnormal, -it is permissible to conclude that we have to do with a persistence of -true menstruation, even though the woman has some time since completed -the fifth decennium of her life. In some women, in fact, the -reproductive system is so energetic, that ovulation continues to an age -far beyond the average, and such women are to be regarded as sexually -long-lived. - -Although the instances of protracted menstruation contained in the older -literature of the subject are open to suspicion, owing to the fact that -at that time it was not possible to distinguish with certainty between -menstrual and pathological uterine haemorrhage, quite recently numerous -incontestable cases of enduring sexual vitality have been put on record. - -I have myself seen no less than 106 cases in which the menopause did not -occur until after the age of 50 years; among these there were 4 in which -the age at the menopause was 56; 5 in which it was 57; 2 in which it was -58; 1 in which it was 59; and 1 in which it was 60. _Tilt_ records 128 -cases of menopause occurring after 50; among these there were 4 in which -the woman was 56 when menstruation ceased; 2 who were 57; 4 who were 58; -1 who was 59; 1 who was 60; and 2 who were 61. _Courty_ reports a case -in which menstruation persisted after the age of 65; _Mayer_, 3 cases of -menopause at 64; _Beigel_, 2 cases, 1 in which menstruation continued to -the age of 65, the other, to the age of 72. _Kleinwächter_ observed 33 -cases in which menstruation continued to an age varying from 50 to 57 -years. _Emmet_, in the year 1886, published the case of a woman who was -then 70 years old, and who at this advanced age continued to menstruate -regularly. - -That not every case in which after the age of 50 years there is -recurrent, more or less periodic, haemorrhage from the genital organs, -is to be regarded as an instance of delayed menopause, we are taught by -the records of post mortem examination in several cases of the kind. -_Scanzoni_ reports the case of a woman who at the age of 60 was affected -with a fairly regular periodic discharge of blood from the vagina. -During one of these haemorrhages, she died of pneumonia, and the autopsy -showed that the ovaries were completely atrophied and transformed into -dense scar tissue, and contained no trace of corpus luteum or of fresh -extravasation of blood, whilst in the upper part of the cervical canal -there were two mucous polypi each of about the size of a bean. In -another case, that of a woman 64 years of age, periodic losses of blood, -at intervals of from three to four weeks, continued to the time of her -death. This woman suffered from mitral valvular insufficiency, and it -was clear that the haemorrhages had been due to the venous engorgement -consequent upon imperfect compensation. The ovaries were completely -atrophied, and showed no trace of any recent maturation of ova; the -uterus was enlarged, the mucous membrane hyperaemic, and the cavity -contained a recent clot. - -Not infrequently, the haemorrhages attributed to the persistence of -menstruation are really due to senile arteriosclerosis—to rigidity and -brittleness of the uterine arteries; in other cases they arise from -varicosity of the veins of the cervical canal. A common cause of such -bleedings from the genital passage in comparatively advanced life, is to -be found in the growth of uterine myomata. - -To myoma uteri we must attribute a part, though by no means all, of the -cases in which menstruation seems to recur some years after the -menopause has, to all appearance, been fully established. In most of -these cases, indeed, we have to do with pathological haemorrhages, the -cause of which is, however, but too often obscure. Still, cases -certainly occur in which, two or three years or even longer after the -menopause, some unknown stimulus leads to the regular recurrence of -menstruation. The possibility of such an occurrence is, in my opinion, -fully proved by post mortem examinations of the bodies of elderly women -in whom the menopause has been fully established and yet the ovaries are -found to contain follicles of various degrees of ripeness, and also -fresh corpora lutea—signs that ovulation may persist for a considerable -time after the complete cessation of menstruation. Another proof of the -last fact is the well known experience that women who have some time ago -ceased to menstruate, may nevertheless become pregnant. _Waldeyer_, -indeed, asserts that when four years have elapsed since the menopause, -follicles are never to be found in the ovaries, but this negative -experience is not decisive, especially as regards the cases in which -regular menstruation is resumed some time after the occurrence of a -premature menopause. - -I have myself seen several cases in which the menopause occurred at 35, -38, 39, and 42 years, respectively; 3, 4, or 5 years later, as a result -of hydropathic treatment, regular menstruation recurred. In one case, a -woman who had ceased to menstruate ten years before, gave birth to a -child at the age of 45. - -Numerous indisputable cases of this kind are reported in the recent -literature of the subject. _Krieger_ had under his personal observation -a woman of a robust habit of body, in whom menstruation ceased at the -age of 48 years, her eighth child having been born fifteen years before. -Two years later irregular menstruation recurred, and on the cessation of -these haemorrhages, it appeared that the woman was once more gravid; she -was delivered at full term of a girl. _Mayer_ observed the following -case: A strong working-class woman 33 years of age had begun to -menstruate regularly when 13 years old; between the ages of 17 and 28 -she gave birth to five children, and in addition had one miscarriage -when 19 years old. Widowed at the age of 29, she fell ill, and on -examination the uterus was found to be small and relaxed, whilst the -vaginal portion of the cervix was reduced to a mere rudiment. Since she -had been 22 years of age she had had persistent leucorrhoea, but no -trace of menstrual haemorrhage; yet since that age she had had three -children. _Renaudin_ delivered a woman 61 years of age, who had ceased -to menstruate 12 years earlier. _Meissner_ reports a case in which a -woman first began to menstruate at the age of 20, had her first child -when 47 years old, and gave birth to the last of her eight children when -60 years of age. - -The sudden and permanent cessation of menstruation, whether at the -normal climacteric age, or earlier in life, is always a pathological -occurrence. As compared with the normal, gradual disappearance of -menstruation, associated with the usual climacteric symptoms, such a -sudden extinction of menstrual activity is, moreover, quite rare. When -it does occur, the cause is to be found in one of various pathological -general states, such as one of the acute infectious disorders, or some -other exhausting disease, or sometimes in some local disease of the -reproductive organs; occasionally, however, it may occur in perfect -health, in consequence of some powerful physical or mental stimulus, -such as a severe blow or intense fright. - -This sudden menopause has been observed after severe labour or abortion -with profuse haemorrhage, or after cholera or typhoid; we must assume -that in such cases the anæmia of the genital organs has disturbed the -function of ovulation; whilst in cases due to mental shock, the -interference with ovulation must be through the intermediation of the -nervous system. Frequently, of course, in these cases, the sudden -menopause is also a premature one. - -_Tilt_ reports a case in which a sudden menopause ensued upon phlebotomy -during menstruation; several cases also in which women at ages varying -from 30 to 34, or 39 years, ceased to menstruate suddenly and -permanently in consequence of grief at the unexpected death of the -husband; and another case of sudden menopause due to a fall down stairs. -_Courty_ reports three cases of sudden menopause at the age of 30, -consequent upon an attack of cholera. _Dusourd_ has seen three cases in -which, in women aged 40 to 43 years, severe haemorrhoidal bleeding was -followed by sudden and permanent cessation of menstruation. _Mayer_ -reports the case of a delicate middle-class woman 34 years of age, who -had begun to menstruate at the age of 14, had married at the age of 20, -and at the age of 21 after a normal delivery, ceased for ever to -menstruate; and another case of a working-class woman 34 years of age -who first menstruated at the age of 13 years, married at the age of 20, -had two children in rapid succession, and finally ceased to menstruate, -in consequence of a fright, at the age of 30 years. _Krieger_ reports -the case of a very nervous woman who first menstruated at the age of -thirteen, and in whom at the age of 23 a sudden menopause ensued upon a -nervous attack; in another case reported by the same observer, a sudden -menopause occurred in a delicate woman 41 years of age owing to her -husband’s death—this woman had previously experienced six months -amenorrhœa in consequence of sorrow at the death of one of her children. -The following remarkable case is reported by _Brierre de Boismont_: A -sempstress began to menstruate at the age of 13 years; she married very -soon after this, and gave birth to four children, the last when 21 years -of age. In the course of the following year there was a fire in the -house, and owing to this fright a sudden menopause occurred. Similar -cases have been reported quite recently by _Bossi_ and _Walter_. - -The harmful influence which the occurrence of a sudden menopause -exercises upon the general condition of the woman who experiences it, is -manifested chiefly by violent circulatory disturbances, hyperaemia and -congestion of the brain, lungs, and abdominal organs, and by states of -excitement and depression of the nervous system. Of the vicarious -haemorrhages which are apt to ensue upon such a sudden menopause, we -have already spoken. - -Generally speaking, women in middle life, in whom the whole organism is -accustomed to the onset and decline of the menstrual hyperaemia, endure -the functional disturbances induced by a sudden and complete cessation -of menstruation much more easily than women who have already entered -upon the climacteric age, or have nearly attained that age. The -climacteric age is one in which women are already predisposed to -circulatory disturbances in the pelvic organs, and it will readily be -understood that in them the sudden interruption of the menstrual -haemorrhages will have more serious consequences than in women in the -prime of their sexual life, and therefore endowed with a greater power -of resisting disturbances of the normal functions. - - - PATHOLOGY OF THE MENOPAUSE. - - - _Diseases of the Genital Organs._ - -Among the commonest of the symptoms of the sexual epoch of the menopause -is menorrhagia. It occurs especially in plethoric women, in those who -during the prime of their sexual life have been accustomed to menstruate -abundantly, and in those who have given birth to many children or had -many miscarriages; but it is seen also in weakly and delicate -individuals, in whom the tissues of the genital organs have become -extremely flaccid and loose in texture. A luxurious mode of life, more -especially a free consumption of alcoholic beverages, and also frequent -sexual intercourse during the climacteric period, appear to favour the -occurrence of menorrhagia at this epoch. - -Not infrequently, menorrhagia is the first sign of the commencement of -the climacteric, menstruation having been hitherto regular, and not -excessive in amount. Generally, when this climacteric menorrhagia -begins, the intervals also become shorter, the menstrual period being -reduced to three or even two weeks. At times, however, the more profuse -menstruation recurs at longer intervals, six weeks, two months, or even -longer. In any case, the occurrence at the climacteric age of a severe -or atypical haemorrhage, renders it the imperative duty of the physician -to undertake a local examination of the genital organs; for it is -necessary to ascertain without delay whether such a haemorrhage is a -true climacteric phenomenon, or whether it is due to some actual disease -of the reproductive organs—a neoplasm, or the like. - -If the haemorrhage is due solely to the change of life, the vaginal -portion of the cervix will usually be found soft and flaccid, bleeding -readily on slight injury, and sometimes eroded; there is generally -associated leucorrhoea. This relaxation and loss of firmness in the -uterine tissues at the time of the menopause is the cause of the -predisposition to excessive haemorrhage. An additional cause exists in -the circulatory disturbances in the pelvic organs. We presume that women -affected with menorrhagia at this time of life suffer from some -persistent disturbance in the region of the inferior vena cava, whereby -the outflow of blood from the veins of the pelvis is hindered, and a -chronic condition of stasis in the uterus is conditioned. Hence arises -distension of the vessels of the uterine mucous membrane, and this -rhexis is relieved by the excessive haemorrhages. In these -considerations lies the explanation of the fact that women who have had -many children or many miscarriages, are especially prone to suffer from -climacteric menorrhagia; and also women who for any reason are -predisposed to intra-abdominal stasis. - -Another cause of climacteric menorrhagia is to be found in the frequent -occurrence at this epoch of advanced arteriosclerotic changes in the -uterine blood vessels, the disease being in some cases limited to the -uterine arteries, and in others part of a general arterial degeneration. -The blood may be derived from ruptured sclerotic capillaries of the -mucous membrane; but in other cases it exudes in consequence of passive -hyperaemia, without actual rupture of the bloodvessels. To such -haemorrhages from atheromatous vessels we must refer many of the attacks -of uterine haemorrhage that occur in elderly women, such as were -formerly, before their true nature was understood, commonly regarded as -instances of a very late return of menstruation. By careful examination -the exact source of the blood can often be detected in such cases. - -According to _Theilhaber_, one cause of the haemorrhages occurring at -the climacteric is to be found in the atrophy of the uterine muscle -which takes place at this period of life. Except during pregnancy and -the puerperium, the uterus is usually in a state of moderate -contraction; during the height of the menstrual flux, however, the -uterus is relaxed. Then, as contraction of the muscle sets in, the -menstrual hyperaemia and consequent haemorrhage are gradually brought to -an end. When this contraction is insufficient, the hyperaemia and -swelling of the uterus are more enduring. In association with the -atrophy of the uterine muscle at the climacteric, there usually occurs a -notable diminution in the size of the uterine vessels, so that, -notwithstanding the diminished strength of the muscular contractions, -any excessive loss of blood is prevented. But if this diminution in the -calibre of the vessels fails to take place, the atony of the uterine -muscle leads to hyperaemia, to haemorrhage, and often, in addition, to -oedema of the organ, with elongation and thickening of its -walls—hyperplasia uteri preclimacterica. - -Among diseases of the uterus which during the climacteric may give rise -to severe haemorrhage, and may lead to the mistaken opinion that -menstruation still continues, we must in the first place mention -carcinomatous disease of the cervix and of the body of the uterus; next -in importance come myoma and fibrous polypi; less frequent causes of -such haemorrhages are fungous endometritis, erosions, mucous polypi, -prolapse of the uterus, and ovarian cystoma. - -The climacteric age gives rise to a predisposition, not only to -bleeding, but also to other pathological changes in the reproductive -organs. We can by no means endorse the opinion of _Currier_—one long ago -expressed also by _Brierre de Boismont_—that women during the sexual -epoch of the menopause are less disposed to diseases of all kinds, and -among them to diseases of the genital organs, than younger women, for -the reason that their tissues are endowed with less vitality, and are, -therefore, more resistent to all the causes of disease. On the contrary, -the number of pathological disorders liable to affect the reproductive -organs precisely at this period of life, is strikingly large. Among my -500 cases of women at the climacteric age, there were 440 who complained -of such symptoms, the diseases from which they suffered being, in order -of frequency: - - Profuse haemorrhages in 286 cases - Chronic metritis in 79 cases - Leucorrhoea in 327 cases - Displacements of the uterus 117 cases - viz., prolapsus in 65 cases - anteflexion and retroflexion in 52 cases - Genital pruritus in 46 cases - Vaginismus in 12 cases - Carcinoma uteri in 3 cases - Myoma uteri in 5 cases - Tumor mammae in 8 cases - -I need hardly point out that in many individuals more than one of these -diseases were present at the same time. - -The most obvious feature of these statistics is the extraordinary -frequency of uterine haemorrhage and of leucorrhoea in climacteric -women. The former condition was present in more than half my cases; the -latter actually in three-fourths. - -The same two pathological states were also those most frequently -recorded in _Tilt’s_ statistics. This author, in 446 women at the -climacteric, found the following diseases of the reproductive apparatus: - - Haemorrhages in 138 cases - Leucorrhoea recurring at irregular intervals in 146 cases - Leucorrhoea recurring monthly in 12 cases - Remittent menstruation in 33 cases - Vaginitis in 4 cases - Follicular inflammation of the vulva in 10 cases - Inflammation of the labia in 4 cases - Ulceration of the cervix uteri in 9 cases - Prolapsus uteri in 5 cases - Uterine polypi in 4 cases - Fibrous tumours of the uterus in 4 cases - Cancer of the uterus in 4 cases - Chronic ovarian tumours in 3 cases - Irritation and swelling of the breasts in 14 cases - Lacteal or gelatinous secretion in breasts in 2 cases - Hard, non-malignant tumour of the breast in 2 cases - Chancre of the breast in 1 case - Frequent sedimentation in the urine in 49 cases - Difficult and painful micturition in 9 cases - Incontinence of urine in 4 cases - Haematuria in 2 cases - Perineal abscess in 2 cases - -Chronic metritis and endometritis come under observation with -considerable frequency during the climacteric age, but as a rule these -diseases have originated during the period of sexual maturity, and in -exceptional instances only does the cessation of the menses appear to be -the etiological starting point of these disorders. In fact, this occurs -only when the menopause is premature, or when it is quite sudden in -onset, whether this be due to noxious influences or to constitutional -disorder. For the menstrual process quite normally gives rise to a -certain congestion of the genital organs; and should menstruation be -suddenly suppressed, the blood-stasis in the uterus becomes so extreme -that morbid tissue changes are very likely to ensue. And when chronic -metritis has occurred before, the congestion and stasis in the uterus at -the climacteric will usually suffice to light up the inflammatory -process afresh. This is the explanation of the fact that symptoms of -slight metritis make their appearance at the very beginning of the -climax, manifested by thickening of the corpus uteri and of the portio -vaginalis of the cervix, by swelling and softening of the mucous -membrane, and by abundant secretion. In those who, either after -full-term delivery or after abortion, have suffered formerly from -chronic metritis or endometritis, but who have been quite free from any -symptoms of these troubles for many years prior to the climacteric, it -often happens that the change of life is ushered in by symptoms of -congestion of the uterus with associated leucorrhoea. With the -completion of the menopause, however, the resulting involution of the -uterus exerts a favourable influence upon all such chronic inflammatory -processes in the genital organs; as the atrophy progresses, the periodic -attacks of congestion cease to recur. Thus it happens that women who for -years have suffered from haemorrhages, from inflammatory disorders of -the genital organs, and from various other troubles of a similar nature, -will, once the menopause is fully over, feel quite well up to an -advanced period of life—they seem as it were to begin life afresh. - -According to _Bennet_, the characteristic signs of climacteric metritis -are that the inflammatory symptoms are less pronounced, that the pains -are less severe, that elongation of the cervix is less often seen, and -that fungous changes are less marked, than is the case in the chronic -metritis of younger women. On the contrary, the cervix appears smaller, -often somewhat lobulated, it is harder, granulations are numerous, -ulceration is rare, the enlargement of the uterine cavity is but slight. -_Bennet’s_ views are, however, opposed by _Scanzoni_, who maintains that -there is no notable difference between the chronic metritis of younger -women and the disease as it occurs in women at the climacteric. - -In fact, the chronic metritis and endometritis of women during the -climacteric age, differs in no important respect from these diseases as -they are seen in women during their sexual prime. We merely note that -the enlargement of the uterus is less marked; but the thickening and -extreme hyperaemia of the mucous membrane are the same in both cases, -the secretion is increased in quantity, the vaginal portion of the -cervix is elongated, and usually displays erosions, excoriations, or -ulcers. The subjective troubles appear less pronounced than in the case -of the metritis of the menacme. The prognosis is as a rule a more -favourable one than in the earlier years of sexual life, for as soon as -the series of involuntary processes is completed, when the retrogressive -changes in the genital organs are at an end, when senile atrophy of the -uterus and the uterine annexa has set in, a cure of the troubles -formerly so obstinate and so enduring speedily takes place. - -Quite recently, much has been written upon the subject of a peculiar -senile endometritis (_Patru_, _Skene_, _Mundé_, _Rüder_, _Sheldon_, -_Herman_, and others), and it has been described as “a peculiar form of -senile, haemorrhagic, leucocytal hyperplasia of the uterine mucous -membrane” (_Gottschalk_). According to _Maurange_ and _Lorain_ it occurs -in as many as 7.2% of elderly women. It is seen especially in women who -earlier in life have suffered from diseases of the genital organs, more -especially those who have previously suffered from endometritis; at -times a senile vulvitis or vaginitis is the cause of the disease. -Displacements of the uterus with kinking of its canal, whereby retention -of the secretion and its decomposition are induced, has been assigned as -an additional cause of the disorder, also prolapse of the uterus, and, -in isolated instances, necrotic fibromata. According to the degree to -which the atrophy of the tissues has proceeded, and according as the -mucous membrane is still partly retained or entirely destroyed, and -according to the extent to which the uterine vessels have been affected -with the sclerotic processes of old age, does the pathologico-anatomical -picture of senile endometritis vary. It may affect the body only of the -uterus, it may extend also to the cervix, the vagina, and even the -vulva; upwards it may pass to the uterine annexa and to the peritoneum. -The first and most important symptom of this senile endometritis is the -outflow, usually intermittent, rarely continuous, of a sero-purulent, -and sometimes sanguineous discharge, with a powerful foetid smell; there -are colicky pains, which pass off when the uterus has emptied itself; -often, also, there are atypical bleedings, which are not profuse. The -uterus is usually found to be larger than the atrophy general at the -patient’s age would have led us to expect, it is often retroflexed, the -cervix is thickened, the lips of the os uteri are usually everted and -raw. When persistent, this senile endometritis causes profound -constitutional disturbance, and is often difficult to differentiate from -carcinoma of the uterus. - -Under the name of senile irritation of the uterus, _Maxwell_ has -described a disease occurring at the climacteric, characterized by an -enormously increased irritability of the uterus, with marked reflex -manifestations; in these cases also we may perhaps have to do with a -senile endometritis. The most pronounced symptom is a severe and -constant uterine pain, to which in the course of the disease are -superadded pains in the gastric and cardiac regions, the rectum, and the -spinal column; these pains lasted a long time, and their severity was -such that it became necessary in some cases to remove the uterus. - -Hydrometra is a disease which makes its appearance principally late in -the climacteric period, when menstruation has already completely ceased, -and when the adhesions associated with the climacteric atrophy of the -uterus have led to atresia of the cervical canal. Among 74 cases of -hydrometra (from the material of the Pathologico-Anatomical Institute of -Prague, in the years 1868 to 1871) not one of the women was less than 40 -years of age; the age distribution of the cases was in fact the -following: - - Quinquennium 40 to 45 3 cases - Quinquennium 45 to 50 2 cases - Quinquennium 50 to 55 2 cases - Quinquennium 55 to 60 8 cases - Quinquennium 60 to 65 18 cases - Quinquennium 65 to 70 12 cases - Quinquennium 70 to 75 11 cases - Quinquennium 75 to 80 8 cases - Quinquennium 80 to 85 4 cases - Quinquennium 85 to 90 6 cases - -In 40 of these cases, the occlusion was in the region of the os -internum, in 23 it was in the region of the os externum, in 9 cases the -whole length of the cervical canal was obliterated, and in 2 both the -internal and the external os were occluded, the intervening portion of -the cervical canal being still patent. In the two latter cases, there -was hydrometra bicamerata, with retroflexion of the uterus. - -Late in the climacteric period, haematometra also occurs, though less -often than hydrometra. When, in cases in which the os uteri externum is -occluded, in consequence of adhesion between the vaginal walls and the -vaginal portion of the cervix, as a sequel of the vaginitis ulcerosa -adhesiva of elderly women, there is haemorrhage from the atheromatous -vessels of the uterus or the tubes, the blood necessarily distends the -uterine cavity. - -During the climacteric period, leucorrhoea is so extraordinarily -frequent, as the figures previously given show, that the assumption is -justified that with the diminution or cessation of the menstrual flow, -this hypersecretion from the genital mucous membranes forms as it were a -kind of vicarious flux. Sometimes, as in 12 cases recorded by _Tilt_, we -actually have a periodic “menstrual leucorrhoea”; in one of these cases -the discharge recurred at regular monthly intervals for 12 months, in -another for 18 months, in several for 2 years, and in one for as long as -7 years. It is only by careful examination that the exact source of the -discharge can be determined, for during the climacteric also, as well as -earlier in life, leucorrhoea may be due either to endometritis or to -colpitis. A muco-serous or sanguino-serous secretion may also be due to -slight vulvitis. - -A peculiar form of inflammation occurring after the completion of the -menopause, and after the atrophic process in the vagina is considerably -advanced, is known as colpitis senilis. In this disease, ulceration -readily occurs, followed by cicatricial adhesion between the anterior -and posterior walls of the vagina (vaginitis adhaesiva vetularum); in -other cases herpetiform eruptions arise, with a tendency to pustule -formation; occlusion of the vagina may lead to hydrometra and pyometra; -sometimes the obliteration of the vagina is complete, so that there is -neither outlet for blood from the uterus, nor inlet for the penis during -coitus. This vaginitis adhaesiva vetularum is by no means rare in the -climacteric period; as a rule it does not give rise to very serious -trouble, the most prominent symptom being usually somewhat persistent -haemorrhage, unaccompanied by any evil odour. On local examination, the -characteristic strings of scar tissue are felt, passing from the portio -vaginalis to the narrowed, senile vaginal fornix; from the cervical -canal there exudes a usually somewhat vitreous mucus, mixed with blood. -The cervix itself is thin and atrophied, the uterus also is greatly -diminished in size. - -The frequency at the time of the menopause of such catarrhal -inflammatory processes in the vagina and vulva is said by _Duprès_ to -depend on the weakness or paresis of the bladder which is so common in -women at this time of life. Owing to the incomplete evacuation of the -urine, cystitis very readily ensues; the urine is evacuated -involuntarily during sleep, and some of this fluid passes through the -vaginal orifice, giving rise all the more readily to colpitis, because -the secretion of the atrophic mucous membrane no longer possesses the -normal acid bactericidal properties. According to _Scott_, vulvitis may -also arise as a sequel of calculus-formation in the glands of Bartholin, -a frequent occurrence in elderly life, followed by inflammation and -abscess-formation in these glands. Among the diseases of the genital -organs at the climacteric period, _Fritsch_ also enumerates urethral -caruncle and carcinoma of the clitoris. - -_Displacements of the Uterus._—Among the commonest of the displacements -of the uterus occurring during and after the menopause, is prolapse of -the organ. Previously existing descent of the uterus is apt to be -greatly aggravated at the climacteric, a partial prolapse, for instance, -becoming complete; or prolapse of the uterus may first set in at this -period of life. - -There are several contributory causes of the liability to prolapse at -this particular epoch, especially in women who have had a great many -children, and in those with either enlargement of the uterus or with -lacerated perineum; the most powerful of these causes being the -weakening of the uterine supports in consequence of the general -relaxation of the pelvic tissues. At the menopause, the connective -tissue by means of which the uterus is attached to surrounding -structures, withers; simultaneously the vagina atrophies, and this -source of support is weakened; the whole pelvic floor loses its firmness -and power of support. For these reasons, a uterus which has hitherto -been in correct position readily becomes retroverted and to some extent -prolapsed; whilst one that was already thus far displaced prior to the -menopause, will now be apt to descend still further till it rests upon -the perineum. With the disappearance from the vulva and the perineum of -the adipose tissue on which their firmness so largely depends, complete -prolapse of the uterus is now likely to ensue. Prolapse of the urethra -may also result from senile involution of the pelvic contents. - -Among my 500 cases of women at the climacteric, there were 65 instances -of more or less severe prolapse of the uterus. The frequency of prolapse -in women at the climacteric and in those at a more advanced age, is -shown by the following figures, which are compiled from the post mortem -statistics of the Pathologico-Anatomical Institute of Prague (years 1868 -to 1871). Prolapse of the uterus was found: - - In the quinquennium 30 to 35 in 2 women - In the quinquennium 35 to 40 in 2 women - In the quinquennium 40 to 45 in 6 women - In the quinquennium 45 to 50 in 3 women - In the quinquennium 50 to 55 in 6 women - In the quinquennium 55 to 60 in 8 women - In the quinquennium 60 to 65 in 6 women - In the quinquennium 65 to 70 in 4 women - In the quinquennium 70 to 75 in 4 women - In the quinquennium 75 to 80 in 4 women - In the quinquennium 80 to 85 in 2 women - -Flexions and versions of the uterus, common as they are at the time of -the menopause, have no longer the same importance that they possessed -during the prime of the sexual life. For on the one part the size of the -uterus is greatly diminished, in consequence of the lessened -blood-supply and of senile involution of the organ; and on the other, -after the cessation of menstruation, the profuse haemorrhages and severe -colicky pains which for the most part occurred during menstruation in -these cases of kinking of the uterine canal, and which gave rise to such -severe general disturbance, now no longer occur. Herein lies the -explanation of the fact, well known to all experienced practitioners, -that women who have for many years suffered from retroflexion or -retroversion of the uterus associated with severe and painful symptoms, -cease to suffer after the menopause is established, and regain excellent -health, although the local condition of the uterus remains unrelieved. - -_Neoplasmata of the Uterus and of the Uterine Annexa._—The most serious -danger to the life of a woman during the climacteric period is to be -found in the strong tendency to the occurrence of carcinomatous disease -of the uterus—a predisposition so marked that not less than one-half of -all illnesses affecting the reproductive organs of women at this age are -cases of carcinoma of the uterus. The disease occurs especially at the -beginning of the climacteric, between the ages of 45 and 50 years, most -often in the form of carcinoma of the portio vaginalis, whereas after -the completion of the menopause, carcinoma of the body of the uterus is -the preponderant form. The true reason for the frequency of the -occurrence of carcinoma at this period of life will only become clear to -us when we are more fully acquainted with the nature and origin of this -form of malignant disease. Meanwhile, it would seem that the -predisposition to cancer during and shortly after the menopause depends -upon the anatomical changes in the reproductive organs at the time of -involution, which render these organs a more suitable soil for the -proliferation of malignant growths; and further it is probable that the -loss of the acid, bactericidal quality of the vaginal secretion, opens -the door for the entrance of pathogenic micro-organisms. Noteworthy is -the observation of _Baer_ and _Leopold_, that very frequently a -preclimacteric or climacteric fungous endometritis forms the stage of -transition to the development of carcinoma of the body of the uterus. At -the time of the menopause there is also an increased liability to the -occurrence of cancer of the ovaries. Numerous statistical data have been -published regarding the frequency with which carcinoma of the uterus -occurs at various periods in women’s lives, and, notwithstanding all -variations, one fact stands out clearly, namely, that this disease -occurs most frequently in the fourth and fifth decennia, and above all -during the climacteric period. - -From _Gusserow’s_ collection of 526 cases, observed by _Lebert_, -_Kiwisch_, _Chiari_, _Scanzoni_, and _Saexinger_, the following table -has been drawn up, and it shows very clearly the great preponderance of -the disease in the fifth decennium of a woman’s life: - - At ages of from 20 to 30 there were 12 cases - At ages of from 30 to 40 there were 161 cases - At ages of from 40 to 50 there were 217 castes - At ages of from 50 to 60 there were 102 cases - At ages of from 60 to 70 there were 38 cases - At ages of from 70 and upwards there were 5 cases - -From the mortality statistics we obtain a similar result as regards the -age incidence of carcinoma of the uterus. Thus, in England there died of -this disease in one year: - - Women at ages of from 15 to 25 44 - Women at ages of from 25 to 35 184 - Women at ages of from 35 to 45 717 - Women at ages of from 45 to 55 1110 - Women at ages of from 55 to 65 1116 - Women at ages of from 65 to 75 876 - -Coming now to the consideration of fibromyomata of the uterus, we cannot -share the opinion that at the climacteric age there is a special -predisposition to the origination of such tumours, or that the climax -favours the growth of already existing fibromyomata. It appears to us -that in the preclimacteric epoch and the commencement of the -climacteric, the symptoms of existing fibromyomata become more -troublesome, the haemorrhages are more severe, the pains more violent; -but that as the menopause is established, these troublesome symptoms -decline progressively in intensity, and not only is there an arrest in -the growth of the tumours, but often an actual diminution in their size. - -I have myself repeatedly observed such cases, in which I had the -opportunity of watching the growth of the myomata during a period of ten -years or more. Other cases, indeed, show that myomata may increase in -size after the menopause, at times with remarkable rapidity, and further -that at this period of life a malignant degeneration may occur in such -tumours. Carcinomatous, sarcomatous, and myxomatous degeneration have -been observed, and also the transformation of a myoma into a soft -fibrocystic tumour. - -Atrophy of fibromyomatous tumours at the menopause, associated with the -atrophy of the uterus that then occurs, has been observed by _Playfair_ -and by _Doran_. The tumour shrinks, its muscle-cells become smaller, and -undergo fatty degeneration, there is an increase in the interstitial -connective tissue, so that ultimately the fibromyoma is transformed into -a firm and dense fibroid swelling. Cases in the older literature and -also a recent observation of _Yamagiron_ have shown that calcification -of uterine fibromyomata sometimes occurs, leading to the formation of -the so-called “uterine calculi.” In the case of pure myomata, the -diminution in size occurring at the climacteric is generally due to -resorption and fatty degeneration, whereas in the case of fibromyoma it -depends on induration and atrophy. It remains uncertain whether the -growth of purely fibrous tumours is also affected by the climacteric. - -Whilst the influence of the climacteric on the growth of fibromyomata is -thus usually advantageous to the patient, exceptions occur, as is shown -by cases recorded by _Lawson Tait_, _Schorler_, and _Boerner_; the -last-named author points out that at the climacteric there is a tendency -for the transformation of fibromyomata into sarcomata. - -_Kleinwächter_ had under observation 78 cases of fibromyomata of the -uterus in women who were older than 45 years; in only 8 of these was a -diminution in the size of the tumour observed at the menopause; in 11 -cases at this time, the tumour increased in size more or less rapidly; -in 3 cases, a carcinomatous change occurred in the tumour; in 3 cases, -the tumour was first observed at the time of the menopause; in 13 cases, -the haemorrhages appeared to undergo a complete arrest at the menopause, -but the size of the tumour was not affected; in the remaining 48 cases, -no influence, either favourable or unfavourable, appeared to be -exercised by the menopause on the fibromyoma of the uterus. - -Cases reported by _Rogival_, _Simpson_, and _Gusserow_ indicate the -existence of a certain predisposition to the growth of sarcomata of the -uterus at the climacteric period. _Gusserow_ more particularly insists -on the fact that we must bear in mind the likelihood of the origination -of a fibrosarcoma or of the sarcomatous transformation of a fibromyoma, -in all cases in which a fibrous tumour of the uterus first attracts -attention at the climacteric period; or in which a tumour hitherto small -and inconspicuous and giving little or no trouble, begins at this time -to increase in size or to give rise to troublesome symptoms. - -_Neuroses of the Reproductive Organs._—One of the commonest neuroses of -the reproductive organs at the climacteric period is pruritus vaginae et -vulvae, and it is one of the most distressing symptoms of which women of -this age complain. The disorder depends upon a hyperaesthesia of the -sensory nerves of the vagina and the external organs of generation. It -is characterized by enduring sensations of itching and burning, which -may be either periodic (and then usually nocturnal) or continuous; at -times it becomes so severe that the women thus affected have an -unceasing desire to scratch, avoid all society, and ultimately find life -quite unbearable. In the slighter degrees of pruritus, no objective -changes are to be observed in the genital organs, or at most some slight -hyperaemia of the vaginal orifice. In the more severe forms, however, -there are local nutritive changes: the labia are swollen, their surface -has an erythematous blush, a number of the hair-follicles are enlarged -and prominent; the vaginal orifice is abnormally sensitive, it is -scarlet or livid-red in colour and here and there denuded of epithelium, -and there are scattered mucous follicles distended with a serous or -purulent fluid; these small vessels are to be seen chiefly on the inner -surfaces of the labia minora and around the clitoris. At the same time, -the vulva secretes an acid, burning fluid, which greatly increases the -patent’s sufferings, and at times impels her irresistibly to the -practice of masturbation. In cases of long standing, we find -hypertrophy, elongation, and deformity of the nymphæ, and pigmentation -of these organs, with the formation of varices. - -According to _Fritsch_, in exceptional cases pollutions are the -originating cause of the pruritus, and this may be the case in women who -are not sexually passionate. It occurs, indeed, especially in matrons -who have not had sexual intercourse for years, and who have quite ceased -to think about sexual matters; during the night, such a woman will begin -to have voluptuous dreams, associated with a degree of sexual -stimulation which is described as being actually painful. The woman -often suffers greatly from these lascivious sensations. She complains -that she cannot understand how it is that she has become affected with -such utterly undesired feelings. She becomes profoundly depressed. -Coitus often gives no relief whatever; but many women thus affected -declare, as _Fritsch_ points out, that by powerful, almost involuntary -scratching, the stimulus is speedily subdued, and that for this reason -they are absolutely compelled to scratch. It will readily be understood, -that in this way persistent pruritus will arise, with local effects of -scratching, and vulval eczema. According to the same author, in some -instances pruritus is due to great insufficiency of secretion, such as -occurs in the endometritis atrophicans which he was the first to -describe. This scanty secretion, as it passes over the external genital -organs, gives rise to irritation and itching. Haemorrhoids also play a -part in the etiology of pruritus. - -_Diseases of the Mammae._—The sympathy which in the earlier phases of -the sexual life—during the menarche, during pregnancy, and during the -puerperium—so obviously exists between the breasts and the uterus, is -seen also during the climacteric period. It now finds expression chiefly -in the marked tendency to new growths in the mammae, a matter to which -attention was already drawn by _Galen_. The commonest of these -neoplasmata is carcinoma mammae, a disease which occurs chiefly during -the climacteric epoch. In the great majority of cases, cancer of the -breast is a primary disorder; in exceptional cases, however, the -carcinoma of the breast arises by metastasis from a cancer of the uterus -or the ovary. Sometimes the breast tumour is preceded by Paget’s disease -of the nipple. For several years the patient suffers from what appears -to be a chronic dermatitis of the nipple, the areola mammae, and the -surrounding skin; but ultimately, and hardly ever before the -commencement of the menopause, carcinoma of the breast ensues. - -The older statistical enquiries of _Birkett_, _Lebert_, _Scanzoni_, and -_Velpeau_, showed that carcinoma mammae most commonly occurred between -the ages of 40 and 50 years, and next to that in frequency between the -ages of 50 and 60 years. - -A general hypertrophy of the mammary gland, affecting not only the -enveloping and intra-lobular adipose and connective tissue, but also the -proper glandular substance, is very rarely observed during the -climacteric period; but in the preclimacteric epoch and in the early -part of the climacteric, we not uncommonly see a hyperplasia of the -adipose tissue of the breast, either as a local manifestation of a -developing general obesity, lipomatosis universalis, or as a purely -local excessive deposit of fat. In such circumstances, the mammae may at -times be transformed into monstrous tumours. - - - _Diseases of the Organs of Circulation._ - -Among the cardiac disorders of the menopause, the earliest and the -commonest is, in my own experience, the following. At the time of the -menopause, exceptionally not till after the complete cessation of -menstruation, but usually at the commencement of this period of life, -some time, that is to say, between the age of 40 and 50, either when -menstruation has become irregular, the intermenstrual interval having -become longer or shorter than has hitherto been the case, or when the -discharge has become abnormal in character, a woman who has not before -suffered from any kind of cardiac disorder, will begin to complain of -paroxysms of palpitation. - -In some cases the attacks of palpitation occur in the absence of any -discoverable exciting cause; in others, some trifling stimulus gives -rise to them. They may arise when the patient is in any position, -walking, standing, sitting, or recumbent; sometimes even during sleep. -The subjective sensation aroused by the increased force and frequency of -the cardiac action is described as extremely distressing; it is -associated with a feeling of anxiety (Angst), with a sense of pressure -in the chest, with forcible pulsation of the carotids and of the -abdominal aorta; frequently also with a feeling of a rush of blood to -the head, with fugitive heats, and severe headache; sometimes towards -the end of the attack there is a sense of flickering before the eyes (as -of muscae volitantes), tinnitus aurium, dizziness, and in rare cases -actual syncope. - -Objectively, during the paroxysm, a notable increase in the frequency of -the heart’s action can be detected, the pulse-rate rising to 120 or even -150 per minute. In most of my cases, the pulse throughout the attack -remained strong, well-filled, and regular. Sphygmographic tracings taken -during the seizures showed a remarkably high pulse-wave, the ascending -limb of the curve rose rapidly and suddenly, the descending limb fell -with corresponding steepness and rapidity, and it reached an unusually -low level before the commencement of the dicrotic elevation, which -latter was exceptionally large; the predicrotic elevations, on the other -hand, were but slightly developed. On auscultation, the tones of the -heart were pure, but were louder than normal. - -Sometimes during a paroxysm a sudden reddening of the face was -noticeable, extending often to the neck and the thorax. In the areas -mentioned, vivid red patches would suddenly make their appearance, -disappearing more gradually after lasting a few minutes—this appearance -was associated with a burning sensation of the affected areas. In some -cases during the paroxysm there was an outbreak of perspiration on the -head and the back. - -Associated with these cardiac troubles of women at the climacteric we -usually find a state of physical and mental disquiet; less common -associations are, an incapacity for regular work, sleep uneasy and much -disturbed by dreams, great general nervous irritability, or signs of -passive congestion in various organs; occasionally there is oedema of -the lower extremities; the urine remains free from albumen. - -In most of the cases of this nature which came under my own observation, -a certain plethora was noticeable; among women at the menopause, it was -especially the well-nourished, powerful, sanguine individuals, that were -liable to palpitation of the heart. Direct examination of the blood -sometimes showed a very high haemoglobin richness—110, 115, or even 120, -as compared with a haemoglobin-richness of 93 in normal woman. Several -of my patients presented the clinical picture of the plethoric form of -lipomatosis universalis. - -In all, during ten years, I observed 67 cases of paroxysmal tachycardia -in climacteric women. The age distribution was the following: - - 36 years of age 1 woman - 38 years of age 1 woman - 39 years of age 2 women - 40 to 45 years of age 37 women - 45 to 50 years of age 28 women - Over 50 years of age 8 women - -Five of the patients were unmarried, three were married but childless, -the remaining 59 were parous women. - -As a general rule, women live in great dread of all manifestations of -bodily disorder during the menopause; those who become affected with -paroxysmal tachycardia are exceptionally anxious, and regard themselves -as threatened by a “stroke.” This pessimistic view is however, by no -means justified. These cardiac disorders may make their appearance some -time before the menopause, they may persist throughout the period during -which menstruation is irregular, they may even endure for some time -after the total cessation of the flow—but serious consequences of this -climacteric tachycardia have never come under my observation. As regards -treatment of the disorder, I have seen very favourable results from the -following measures: The systematic employment of mild purgatives, -combined with suitable dietetic and hygienic regulations (bland diet, -regular and strenuous exercise, cold ablutions, and wet compresses -surrounding the abdomen). - -When we enquire regarding the cause of the tachycardiac paroxysms -occurring at the menopause, we must first of all bear in mind that in -the cases which have come under my own observation, the cardiac impulse -was powerful, the pulse strong and well-filled, that signs of general -vasomotor disturbance (ardor fugax, etc.) accompanied the tachycardiac -seizures,—hence we are led to infer that we have to do with a -stimulation of the excito-motor nerve fibres, which would appear to be -due to the climacteric changes previously described as occurring in the -female reproductive organs. This view receives support from the fact -that after oöphorectomy, when, as in the normal climacteric, atrophic -processes occur in the internal reproductive organs, paroxysms of -nervous palpitation are frequently observed. The same explanation -applies to the fact that in women at the climacteric affected with these -tachycardiac troubles, we frequently see in association therewith the -symptoms of uterine dyspepsia. - -But in addition to these local anatomical changes in the reproductive -organs, to which an etiological role must be assigned in the production -of climacteric tachycardia, the irritable state of the accelerator -nerves must also depend in part upon that general nervous -hyperexcitability which is so often a characteristic feature of the -climacteric period in women, manifesting itself in manifold -hyperaesthesias, hyperkinesias, neuralgias, and, in extreme cases, -mental aberration. The sensory nerves are more irritable than in their -normal state, so that every stimulus acting upon them evokes a greater -central effect than heretofore, and upon this ensues an exaggeration of -various reflex manifestations, which appear altogether disproportionate -to the strength of the exciting cause; among these disproportionate -reflex effects, is to be numbered the tachycardia just described. - -But in addition to the causes of climacteric tachycardia already -enumerated, we have to take into consideration the results of recent -investigations concerning the organo-therapeutic employment of the -chemical constituents of the ovarian tissue; it would seem that when at -the menopause the ovaries undergo atrophy, so that their internal -secretion is no longer poured into the blood, the resulting alteration -in the chemical constitution of that fluid gives rise to a disturbance -of the vasomotor centre in the medulla oblongata. - -In some cases, the tachycardiac paroxysms appear to be connected with -the erotic excitement to which women are sometimes subject at the -climacteric, voluptuous crises and ejaculation occurring; it is possible -that in some of these cases masturbation plays a part. - -A second group of cardiac troubles occurring in climacteric women -consists of cases which are very common, but not often very severe. The -cases in question depend upon the liability to an increased deposit of -adipose tissue in the body at the time of the menopause, and in this -connexion the plethoric form of lipomatosis universalis almost -invariably predominates. It is a well-known fact that between the ages -of 40 and 50 years women have an excessive tendency to obesity, and that -even those women who have hitherto been extremely lean are apt to become -quite plump at the climacteric period. Chiefly in consequence of this -increasing obesity, there occurs in climacteric women a series of -cardiac troubles of very variable intensity. If the deposit of fat is -effected very gradually, and if the obesity does not become extreme, it -is only after vigorous bodily exercise, such as fast walking or going -upstairs, and after meals, that the patient is troubled with a little -shortness of breath and moderate palpitation; appetite, digestion, and -sleep remain usually unaffected in cases of this degree of severity. -Definite attacks of cardiac asthma, and well-marked signs of cardiac -insufficiency affecting the entire circulatory system, will very rarely -occur in such persons. - -It is an interesting fact, that the troubles which arise from fatty -deposits around the heart are in general far less severe in climacteric -women than they are in obese men of corresponding age. This may be due -to the circumstance discovered by _W. Müller_, in the course of his -investigations on the proportions of the human heart, that in the -development of general obesity, the pericardial fat increases -proportionately to a greater extent in the male than in female. But in -my opinion the true explanation is to be found in the fact that -variations in the amount of fat in the body are normally far more -extensive in women than in men; at puberty, during pregnancy, and during -lactation, extensive though gradually effected changes in the amount of -adipose tissue in various parts of the body occur, so that experience -has rendered the organism ready to adapt itself to the further changes -that take place at the climacteric—above all, the heart has become -competent to meet very various demands upon its powers. - -Only in women who from youth onwards have exhibited a marked tendency to -obesity, and in whom at the climacteric age such obesity has become -extreme, do the cardiac troubles attendant on the menopause become very -severe. In such persons, palpitation and shortness of breath occur on -slight exertion, and attacks of cardiac asthma are frequent. In -consequence of the diminished propulsive power of the heart, circulatory -difficulties make their appearance in the most widely divergent venous -areas; the forms most commonly met with are, varices in the veins of the -lower extremities, permanent dilatation of certain of the small -superficial veins of the skin, phlebectases of the rectal veins (i. e. -“piles”), and ultimately we see the well-known series of symptoms of -venous engorgement—oedema of the feet, passive congestion of the lungs, -albumen in the urine, etc. - -When such cardiac troubles are present, the objective examination of the -heart shows in the early stage no gross abnormality; at most the -heart-tones seem somewhat weakened, with a moderate enlargement of the -area of percussion-dulness, whilst the impulse is displaced a little -outwards, and is weaker than normal. In some cases, however, a marked -dulness on percussion over the sternum indicates an extensive deposit of -fat in the mediastinal tissues. In the second stage of the fatty heart, -when the symptoms have become more severe, we find a considerable -enlargement of the area of cardiac dulness both in the vertical and the -horizontal extent; the cardiac impulse is diffused as well as feeble. -The sounds of the heart are usually pure but faint—in some cases they -remain loud and clear. Exceptionally, a short blowing murmur is heard -with the first sound; and sometimes this sound is reduplicated. - -Whilst in the first stage the pulse is hardly abnormal, in the second -stage, very various changes occur; often it is subdicrotic or dicrotic -in character. - -In the great majority of instances, in these cases of cardiac disorder -at the menopause, provided a suitable dietetic regimen is early adopted -and perseveringly carried out, we may give a hopeful prognosis. - -A third, less common but far more serious form of cardiac disorder -occurring at the menopause, displays the well-known symptoms of cardiac -failure. Those thus affected are usually slightly built, delicate women, -who during the years of development suffered from chlorosis, who in -adult life were troubled with anæmic symptoms, and in whom the menopause -was ushered in by very severe losses of blood; sometimes, again, they -are women who throughout their sexual prime have been accustomed to -menstruate very abundantly, who have had numerous and severe deliveries, -or who have had frequent miscarriages—it is in those who have thus been -weakened by frequent and profuse haemorrhages, that the symptoms of -cardiac failure ensue at the climacteric period. The women thus affected -also frequently suffer from palpitation of the heart; the pulse is -abnormally frequent, small, low, and easily compressible, and sometimes -intermittent or arrhythmical. The heart’s action is weak and devoid of -energy. The heart-sounds are usually obscure, and sometimes a systolic -murmur is audible. The patients are short of breath and are subject to -attacks of cardiac asthma, not infrequently associated with angina -pectoris. In conjunction with these symptoms, we see signs of venous -congestion: sudden attacks of coldness in the hands and feet, often also -oedema of the feet; the urine at times contains albumen. The -haemoglobin-richness of the blood is always notably diminished. I need -not discuss in further detail the well-known symptoms of cardiac -insufficiency, and I need only insist that when these symptoms are met -with in women at the climacteric, it is of the greatest importance, -alike from the prognostic and from the therapeutic standpoint, to make a -careful examination of the reproductive organs, so as to determine the -exact source of the recurrent bleedings which usually constitute the -primary cause of the patient’s sufferings. - -In several cases of this kind, I found that the haemorrhages were due to -a relaxation of the uterine tissues, and that this relaxation was itself -referable to intrapelvic circulatory disturbances, dependent upon -obstruction in the vena cava inferior, whereby the venous return from -the pelvis was rendered difficult, and an engorgement of the uterine -vessels was brought about. - -In some instances of cardiac failure at the menopause, chronic -inflammation within the pelvis is to blame for the menorrhagia upon -which the cardiac failure depends. Often, again, the haemorrhages are -referable to vasomotor influences, such as are liable during the -menopause to affect various vascular areas. In other cases, the -recurrent bleeding is due to retroflexion of the uterus, to prolapse of -that organ, or to tumour, it may be myoma, polypus, or carcinoma. - -Finally, during the menopause, more especially in women in whom -menstruation has continued up to or beyond the fiftieth year, or in -those who have given birth to a large number of children or have lived -lives of severe bodily exertion, cardiac troubles may arise dependent -upon arteriosclerosis of the great vessels. The signs of such changes in -the walls of the bloodvessels are clearly marked: the cardiac impulse is -heaving, the second sound of the heart is accentuated; the pulse is full -and large, usually giving a very powerful blow to the examining finger, -whilst its sphygmographic tracing exhibits characteristic signs in the -exceptional height and great distinctness of the first predicrotic -elevation. The subjective troubles are in these cases very severe; -dyspnoea and attacks of asthma or of vertigo are common, and sometimes -albumen may be found in the urine. - -We may thus summarize the cardiac disorders met with at the menopause, -and more or less directly dependent upon the changes undergone by the -feminine organism at that period of life: - -1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric -changes in the ovaries. - -2. Nervous palpitation in women who were similarly affected at the time -of the menarche, and in whom the trouble is merely the expression of a -very unstable nervous system, and one influenced with especial readiness -by impressions proceeding from the reproductive organs. - -3. Cardiac disorder due to the obesity so commonly occurring as a part -of the general metabolic changes of the menopause, but more particularly -dependent upon a deposit of fat in the neighbourhood of the heart -itself. - -4. Symptoms of cardiac failure, due to excessive losses of blood at the -menopause, either as an exaggeration at this time of menstrual -processes, or as a result of some actual disease within the pelvis. - -5. Cardiac disorder in women in whom the menopause occurs at an -unusually advanced age, and dependent upon arteriosclerosis. - -Particular consideration must be given to a symptom not infrequently -occurring in association with the cardiac troubles of climacteric women, -and referable to the circulatory disturbances characteristic of this -period of life, namely, vertigo. The attack in some cases comes on -without apparent cause, in others it occurs on the performance of some -unusual movement or the adoption of some peculiar posture (stooping, or -the like); the patient is suddenly seized with a sense of rotation, -either of his own body, or else of his visible and palpable environment; -with this is associated a sensation of disturbance of equilibrium, -flickering before the eyes (muscae volitantes), tinnitus aurium, -palpitation of the heart, increased frequency of the pulse, which may be -either full or small, redness or pallor of the face, coldness of the -hands and feet, muscular twitchings, a sense of great anxiety, and the -outbreak of a cold perspiration. The vertigo occurs in paroxysms, -usually of short duration—a few minutes to a quarter of an hour. It is -especially plethoric and obese women who are liable at the climacteric -to suffer from this disorder. - -A somewhat similar condition is described by _Tilt_ under the name of -“pseudo-narcotism,” as frequently occurring in climacteric women. _Tilt_ -indeed states that in 500 such women, he noted its presence in no less -than 277. - -Many hypotheses have been promulgated to account for the vertigo that so -frequently occurs at the menopause. Both anæmia and hyperaemia of the -brain have been assumed as causes, alike dependent upon the irregularity -of menstruation, which is supposed to have a reflex influence upon the -cerebral circulation. Others regard the vertigo as a climacteric -neurosis, since it occasionally occurs before the menstrual -irregularities begin, and in such cases a reflex disturbance of the -cerebral circulation cannot be supposed to have arisen. According to -_Matusch_, climacteric vertigo is a manifestation of epilepsy—an -explanation which has been often extended to include all the menstrual -psychoses. _Windscheid_ believes that in many of the cases the vertigo -is to be explained by the existence of arteriosclerotic changes in the -blood vessels, such as are already by no means rare at the age at which -the menopause usually occurs; whilst in other cases, he believes, the -vertigo is to be regarded as one of the symptoms of a nervous disorder. -That in any case the vertigo is dependent in some way upon the changes -that occur in the reproductive organs at the climacteric period, is -shown by the fact that after the final cessation of menstrual activity -the patient as a rule ceases to suffer from this symptom. - -To the circulatory disturbances consequent upon the menopause we must -also refer ardor fugax, fugitive heat, the sudden rushes of blood to -which women are prone at this period of life. - -The cardiac troubles of the menopause are seen especially in women in -whom the cessation of menstruation occurs quite suddenly, and in those -in whom menstrual activity ceases at an exceptionally early age. It -would seem that in such cases, owing to the continuance of periodic -maturation of the graafian follicles associated with congestion of the -intrapelvic organs, in the absence of the periodic relief to that -congestion afforded by the menstrual flux, there results a summation of -stimuli, whereby the accelerator nerves of the heart are very powerfully -affected. - -Thus, I had under my care a lady from Smyrna 36 years of age. She had -begun to menstruate when 12 years of age and menstruation was always -scanty; she married when 15 years old, and finally ceased to menstruate -when 19 years of age; she was sterile, and no abnormality could be -detected on physical examination of her reproductive organs. Every month -she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of -blood to the head, perspiration of the face, etc. - -In another case, that of a woman 45 years of age, menstruation, hitherto -regular, was suddenly suppressed, during the flow, in consequence of a -severe fright. The next month the flow failed to appear at the usual -time, but instead the patient was affected with severe cardiac distress, -accompanied by sudden sensations of heat in the face, palpitation of the -heart, and vertigo; these symptoms lasted for several days, and since -then have recurred at intervals of three or four weeks. - -The cardiac troubles of the menopause are seen with especial frequency -in women who were affected with similar disturbances at the time of the -menarche. Experience clearly shows that a certain connexion exists -between the manifestations that accompany the commencement of sexual -activity, and those that accompany the decline and extinction of that -activity; and a physician will rarely be mistaken if he bases on the -fact that the general health was or was not seriously affected at the -age of puberty, a prognosis that the course of the climacteric will be -an unfavourable or a favourable one, respectively. In other words, in -women whose nervous system is an unstable one, and in those with -hereditary predisposition to the occurrence of cardiac disorder, the -changes that take place in the reproductive organs both during the -menarche and during the menopause, are likely during these vital phases -to arouse reflex disturbances of the cardiac functions. The facts thus -noted are analogous to those observed by _Potain_, who distinguishes a -peculiar form of chlorosis, occurring in delicate individuals at the age -of puberty, and, though apparently cured during the menacme, recurring -in its primitive severity at the time of the menopause. - -Again, women with a sanguine and erethistic temperament are more -inclined to suffer from cardiac troubles at the menopause than women of -a tranquil temperament and those endowed with an unimpressionable -nervous system. - -Finally, elderly virgins, women who have for many years lived in chaste -widowhood, sterile women, women who have married shortly before the -menopause, or who at this time have recently been delivered, are all -more inclined to the cardiac troubles of the climacteric period than -women whose sexual life has been of a less abnormal character. - -In the literature of the subject, we find numerous references to the -fact that among the disorders of the climacteric, circulatory -disturbances play a part. But a full and accurate account of these -disorders is lacking alike in the literature of gynecology and in that -relating to diseases of the heart—and this is true even of the most -recent publications. - -Among striking individual cases, one recorded by _Moon_ may be mentioned -here, a case of tachycardia consequent upon a sudden menopause: “In a -woman 35 years of age the menses were suppressed owing to chill; the -pulse-frequency increased from 80 to 200, without any apparent change in -the heart or its valves; the symptom lasted for several days, when -menstruation became once more established, and the pulse-frequency fell -again to the normal.” - -_Tilt_ expresses the opinion that the heart is but little involved in -the disturbances of the climacteric, his experience coinciding with that -of _Quain_. _Boerner_ and _Glaevecke_, on the contrary, describe the -heart troubles of the climacteric in terms very similar to those -employed by myself. - -_A. Clément_ describes a peculiar form of disturbance of the functions -of the heart at the climacteric period, to which he gives the name of -Cardiopathie de la Ménopause, and of which he has seen four cases. The -age of his patients varied from 46 to 50 years. They were all vigorous -women, free from hysterical symptoms, and they had never suffered from -rheumatism or from any functional disturbance of the heart. In all these -cases the cardiac disorder occurred at a time of life when menstruation -still continued, but had already become somewhat irregular. Usually the -trouble in question makes its first appearance during the flow, or, if -occurring independently of menstruation, becomes more severe at that -time. Prior to the development of the actual heart symptoms, we observe -for a time, two or three months it may be, signs of general exhaustion -and weakness. Then occurs an attack of palpitation of the heart, rapidly -succeeded by faintness, sense of precordial anxiety, and dyspnoea. -During repose the patient does not usually suffer from any difficulty in -breathing, but sleep is apt to be disturbed by paroxysms of palpitation -and severe precordial anxiety. As the disease advances, dyspnoea is -observed on the slightest exertion. Ultimately, the symptoms mentioned, -palpitation, precordial anxiety and dyspnoea, become permanent, but are -less severe when the patient is at rest. Constant now is also the -feeling of weakness and faintness, which from time to time increases to -actual syncope with complete loss of consciousness, and coldness of the -entire surface of the body. Examination of the heart gives negative -results. The cardiac impulse is a little stronger than normal; the -cardiac rhythm may be either regular or irregular, but actual -intermission of the beats does not occur. The heart-sounds are pure, -there is no murmur; the first sound, if altered at all, will be -stronger, not weaker than normal. Neither swelling of the jugular veins -nor venous pulsation is to be observed. The most striking symptom of -heart affection, indeed the only positive physical sign, is the great -increase in the frequency of the heart’s action, the pulse rate often -being as much as 150 or 160 per minute, and in addition weak and -somewhat variable in strength. At the outset of the disease, no oedema -of the lower extremities is to be observed, and it only appears after -three or four attacks. In all the patients the extreme pallor of the -face is a striking feature. An increased quantity of urine is -eliminated. The course of the disease is characterized by a series of -successive paroxysms, separated by periods of almost complete remission. -At first, these remissions last for a month or two, but they gradually -become shorter and shorter, whereas the duration of the attacks -continually increases, until it is as much as seven or eight days. At -this stage, disturbance of digestion ensues, the appetite is lost, and -the general vigour declines. Recovery ultimately occurs, but very -gradually. _Clément_ refers the disease to a profound disturbance of the -cardiac innervation through the sympathetic nerves, but believes that -anæmia constitutes a contributory cause of the cardiac disorder. - -_Kostkewitsch_ has made observations regarding the influence of the -climacteric upon previously existing heart-disease, and has thereby been -led to conclude that the influence is unfavourable. The functional -disturbances of the cardio-vascular apparatus which commonly accompany -the menopause, readily lead, should organic heart-disease exist, to the -onset of severe cardiac weakness, which may have a rapidly fatal -termination. In 55.5% of the women who enter the climacteric period with -organic disease of the heart, the menopause gives rise to a failure of -compensation. Such failure of compensation is especially likely to occur -in women suffering from valvular insufficiency; it is least probable in -cases of arteriosclerosis without valvular defect. The symptoms of -defective compensation—dilatation of the heart, increased frequency of -the pulse, arrhythmia cordis, etc.—are manifested especially during the -menstrual flow. - - - _Diseases of the Digestive Organs._ - -The congestions which, as we have already pointed out, constitute the -pathological basis of the majority of the disorders of the climacteric, -manifest themselves in the abdominal organs in the well-known form of -plethora abdominalis, chronic venous congestion of the gastric and -intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the -mucous membrane of the bladder, catarrh of the bladder, distension of -the haemorrhoidal veins, and the various symptoms dependent upon these -several forms of congestion. - -Bleeding from the haemorrhoidal veins and chronic diarrhoea are two of -the troubles proceeding from the above mentioned congestion of the -intra-abdominal vessels, which occur so frequently during the -climacteric period that since the days of antiquity they have been -regarded as critical manifestations of the menopause, the object of -which is to afford a vicarious outlet for the menstrual flux, now become -irregular and intermittent. It can, indeed, be readily understood that a -discharge of blood and an increased secretion from the mucous membrane -of the lower part of the intestine may, if not too violent, exercise a -favourable influence upon the congestive states of the climacteric, by -relieving the distension of the abdominal vessels—by a local -blood-letting which regulates the disordered circulation. In this way, -even though we have ceased to regard it as a “critical” manifestation, -haemorrhoidal bleeding, accompanied by an increased secretion from the -intestinal mucous membrane, may at the climacteric period have a -distinctly favourable influence upon a woman’s general condition. - -_Hippocrates_ already in his aphorisms pointed out the salutary effect -of epistaxis and of diarrhoea in women suffering from suppression of the -menses. Other authors have assigned a critical significance to -diarrhoeas occurring at the climacteric, and have warned against their -suppression. According to _Tilt_, diarrhoea occurred in 12% of all women -of this age coming under his observation; in 4% of the climacteric -women, this diarrhoea recurred at regular monthly intervals, whilst in -8%, the recurrence was irregular. In 500 women during the climacteric -age, _Tilt_ observed the following abdominal disorders: - - Swollen haemorrhoids in 62 cases - Diarrhoea in 60 cases - Enduring disturbance of the biliary secretion in 56 cases - Bleeding haemorrhoids in 24 cases - Intestinal haemorrhages in 20 cases - Icterus in 6 cases - Hæmatemesis in 4 cases - Monthly intestinal haemorrhages in 2 cases - Monthly bleeding from haemorrhoids in 1 case - -In my own observation, constipation is more frequent in climacteric -women than diarrhoea, the constipation being also a symptom of abdominal -congestion. Sometimes, when diarrhoea occurs, it is really secondary to -constipation. The accumulation of the faecal masses stimulates the -intestinal mucous membrane, and gives rise to a profuse aqueo-mucous -secretion; the firm faecal masses are then liquefied, the intestinal -wall is lubricated, and the constipation gives place to diarrhoea -lasting perhaps for several days. This is the explanation of many cases -in which there is a periodic recurrence of diarrhoea. - -Dyspeptic disturbances are rarely absent during the climacteric period. -Most often we see disordered appetite, sluggish digestion, pyrosis, -eructation, at times nausea and retching, and actual vomiting of a -watery or bilious fluid. Occasionally, an abnormal sensation of hunger -follows each meal, associated, however, with a feeling of distension of -the stomach. A very distressing symptom is an excessive formation of gas -within the intestine. At times such meteorism is extreme, and it then -gives rise to very severe abdominal pain. The gas is evacuated slowly -and with difficulty, the patient is compelled to loosen all her -clothing; more especially after a meal she is compelled to take off her -stays and undo all the bands of her petticoats and skirt. At the same -time we see difficulty in breathing and tachycardia. Such an -accumulation of gas within the abdomen may give rise to serious errors -in diagnosis, the swelling being attributed to pregnancy or to abdominal -tumour. - -Noteworthy also at the time of the menopause is the occurrence of -vomiting, either as an isolated symptom, or in association with some -other well-known climacteric disorder. When this vomiting is associated -with some unmistakable form of excessive secretory activity -(hyperhydrosis, etc.), we may readily suppose that the vomiting is due -to undue secretory activity on the part of the gastric mucous membrane. -An excessive production of gastric juice, perhaps altered in quality as -well as quantity, combined with some other disorder of gastric -innervation (hyperaesthesia, or hyperkinesia) will sufficiently explain -the occurrence of the sometimes excessive vomiting, even though in many -of the cases there may be no reason to suppose that there exists any -primary stimulation of the vomiting centre. In other cases, however, it -is probable that the trouble is really due to a primary disorder of that -centre; and a careful study of the clinical features of the case will be -needed to show how far there may be associated with this other disorders -of gastric innervation (_Boerner_). - -Disturbances of the biliary secretion, icterus of greater or less -severity, are by no means rare manifestations of the abdominal -congestion of climacteric women, and such disorders have also been -regarded as vicarious processes originated by the cessation of the -menstrual flux (_Aran_, _Bennet_, _Henoch_, and others.) _Frerichs_ also -has pointed out that with the cessation of menstruation at the -climacteric we not infrequently observe swelling of the liver, which -disappears when, after a considerable period, the menstrual flow -recurs—a sequence of symptoms which may be repeated again and again for -a considerable time. - - - _Diseases of the Skin._ - -The most characteristic symptom of disorder of the skin met with at the -climacteric period—one which, indeed, may be said to be never absent—is -ardor fugax, fugitive heat; and scarcely less common is hyperhydrosis, -an excessive secretion of sweat. Almost invariably, at the commencement -of the menopause, women complain of a feeling of burning heat, rising up -from the breast to the face; and if they are kept under observation we -see from time to time a sudden redness of the face, and sometimes also -of the neck and chest, associated with the outbreak of a thin -perspiration. Moreover, in nearly all climacteric women, we notice an -increased secretion of sweat over the whole surface of the body, and at -times this secretion is extremely profuse. - -In association with these symptoms we often see the hyperaemic processes -in the skin known by the names of erythema and roseola, taking the form -of larger or smaller bright red patches, which are most frequently seen -on the sides of the neck, the front of the chest, and the face. - -In many women, at the menstrual periods, when the flow has become scanty -or has already entirely ceased, we observe the occurrence of eczematous -eruptions, which have for this reason received the distinctive name of -climacteric eczema. In the majority of these cases, the eczema does not -make its appearance until the regular menstrual flux has completely -ceased to occur; and in the less common cases in which the flow persists -after the climacteric eczema has begun, menstruation is rarely regular, -but has begun to exhibit the variability and disorder characteristic of -the time of the menopause. If the eczema comes on after the menopause is -completely established, it usually appears in from six to twelve months -after the cessation of the flow; but in some cases, the eruption appears -very soon after the menopause, whilst in others, its onset may be -delayed for as long as four or five years. Climacteric eczema is -obstinate, and shows no tendency to spontaneous cure. With regard to the -localization of the eruption, _Bohn_ found that in three-fourths of the -cases it affected the hairy scalp and the ears; _Rayer_ and _Hebra_ also -state that the eczema of the menopause is most frequently seen in these -two situations, whilst the next commonest site for the eruption is the -face. As regards other parts of the skin, it is only that of the -extremities that is ever affected by this disease, especially the hands -and the fingers, less often the forearms or the backs of the feet; it -never appears on the trunk. With regard to the types of eczema occurring -in connexion with the menopause, we see almost exclusively the squamous -and the weeping forms of the disease. - -In general, at the climacteric period, the skin is extremely sensitive, -and devoid of powers of resistance to outward noxious influences. -Alternations of dampness and dryness or of heat and cold readily give -rise to redness, infiltration, and the formation of scales and fissures -of the skin; sometimes this occurs merely after cold ablutions. These -acute stages of swelling, redness, and vesiculation of the skin, readily -pass on into chronic and obstinate dermatitis. - -Not infrequently, during the climacteric, as during the menarche, -inflammation of the sebaceous glands occurs, acne, at times accompanied -by seborrhœic manifestations. In other cases, we see disfigurations of -the face in consequence of vascular dilatations, especially on the nose -and on the adjoining portions of the cheeks, rosacea, in which disease -also there is associated inflammation of the sebaceous glands. Another -disorder of the skin of the face which is greatly dreaded by women at -this time of life, owing to the unsightly appearance it produces, is the -development of sinuous dilatations of some of the superficial vessels, -at times associated with connective tissue proliferation in the form of -red or violet-coloured painless nodules. - -An extremely distressing affection, and one which is especially apt to -attack women during the change of life, is the previously mentioned -pruritus genitalium. The itching is in some cases confined to the -external genital organs, whilst in others it extends into the interior -of the vagina; also it may pass backwards over the perineum, and on into -the gluteal folds. In some cases, some local pathological condition will -be found to account for the disorder: catarrh of the vagina or of the -cervix uteri; displacements, inflammations, or new-growths of the -uterus; anomalies of the ovary, the bladder, or the urethra. _Cohnstein_ -draws attention to a circular hyperplasia of the vaginal portion of the -cervix, occurring during the menopause, and, “owing to the vascular -dilation by which it is characterized, possessing close analogies with -haemorrhoids;” the worst symptom of this affection is pruritus. That in -these cases the pruritus is actually dependent upon the “haemorrhoidal -hyperplasia” of the portio vaginalis, _Cohnstein_ considers to be proved -by the fact that, whilst local applications give no more than momentary -relief to the itching, this symptom is completely relieved by the -abstraction of blood from the cervix. But in addition to such cases as -these, we have from time to time to deal with patients suffering from -violent genital pruritus during the climacteric period, in whom we shall -vainly seek for any local pathological changes, to the cure of which our -therapeutic zeal may be directed. Analogy with some other disorders of -the climacteric leads us to conclude that in these cases also we have to -do with an idiopathic neurosis (_Boerner_). - -The frequent recurrence of pruritus vulvae leads ultimately to the -formation of nodules and papular eruptions. - -Many authors state that they have observed the frequent occurrence of -erysipelas during the climacteric period; others assert that -furunculosis, prurigo, urticaria, and herpes zoster, are seen with -especial frequency at this period of life. - -_Tilt_, in his 500 cases of women at the climacteric age, made the -following observations: - -201, or 40.2%, suffered from heats and tendency to perspiration. - -2, or 0.4%, suffered from monthly recurrence of periods of perspiration. - - 84, or 16.8%, suffered from profuse perspirations. - 13, or 2.6%, suffered from cold sweats. - 14, or 2.8%, suffered from dry heats (dry flushes). - 186, or 37.2%, remained free from such attacks of heat or perspiration. - -_Krieger_ gives as an example of the “occurrence of new troubles” at the -change of life, furunculosis; so also does _Boerner_. “The -discolouration of the face, occurring usually in connexion with -pregnancy or with diseases of the reproductive organs, and known as -chloasma uterinum,” has been seen by _Cohnstein_, during the climacteric -period, “chiefly in cases in which, owing to some degree of failure of -general nutrition, the skin has been thrown into folds.” _Wilson_ -regarded prurigo and eczema as the commonest skin-diseases of the -climacteric period; whilst _Boerner_ draws attention to a connexion -between climacteric conditions and the outbreak of herpes zoster. - - - _Disorders of Metabolism._ - -Among the disorders of metabolism to which women are especially prone at -the climacteric period, we must in the first place allude to obesity -(lipomatosis universalis), and to gout (arthritis urica). - -Numerous observations have shown us that the time of the change of life, -the period between the ages of 40 and 50 years, is the one especially -favourable in women to the extensive deposit of fat in the tissues. - -In 200 cases of great obesity (lipomatosis universalis) in women, in -which I instituted enquiries regarding the age at which an excessive -deposit of fat in the tissues had first been noticed, I obtained the -following results: - - In early childhood in 19 cases - At the age between 15 and 20 years in 30 cases - At the age between 20 and 30 years in 45 cases - At the age between 30 and 40 years in 52 cases - At the age between 40 and 50 years in 54 cases - At ages over 50 years 0 cases - -We learn from these figures that it is between the ages of 40 and 50 -years that there is the greatest tendency in women for the accumulation -of fat; but that as early as between the ages of 30 and 40 years this -accumulation may in many instances begin. Speaking generally, there is -in women an obvious connexion between the development of obesity and the -state of the reproductive functions, inasmuch as at puberty, during the -puerperium, and above all at the climacteric, there is a special -tendency to the accumulation of fat in the subcutaneous tissues. At the -commencement of the menopause, it is more especially in the abdominal -wall, the breasts, and the buttocks, that we witness the deposit of fat. -In the abdomen, owing to the thickening of the subcutaneous tissues and -of the great peritoneal folds—especially of the great omentum—a marked -protrusion occurs, whilst the umbilicus becomes more deeply hollowed, -and ultimately funnel-shaped. In some instances, the deposit of fat -around the navel favours the occurrence of umbilical hernia. After an -artificial menopause, induced by oöphorectomy, it has also been noticed -in from 42 to 52% of the cases that a marked general deposit of fat has -occurred, affecting especially the breasts and the buttocks. - -This obesity in climacteric women, not only impairs to a serious extent -their good looks, but brings in its train a number of troubles, and -gives rise to manifold morbid manifestations, and among these, changes -in the heart, which may readily threaten the patient’s life. In -consequence of extensive fatty deposits in the myocardium, associated -with actual fatty degeneration of the muscular fibres, cardiac -insufficiency ensues, with all its distressing and disastrous -consequences. It is further necessary to insist upon the fact that -obesity during the climacteric very definitely favours the occurrence of -menorrhagia. - -On examining 282 women, 5 years after the complete cessation of the -menstrual flow, _Tilt_ found that - - 121 had become stouter than before, - 71 were unchanged in this respect, and that - 90 were thinner than formerly. - -Alike in the third class and in the first were a very large proportion -of women in whom the change of life had entailed much illness and -suffering; but in the first class, the women who had been thus affected -had at that time lost weight, and only in the latter half of the -climacteric period, when their troubles had become less severe, had the -condition of embonpoint made its appearance. - -Passing now to the consideration of arthritis urica in women at the -climacteric, it is worthy of mention that _Hippocrates_ was so much -struck by the association that he went so far as to deny that gout -occurred at all in women before the menopause. The fact of the matter is -that whilst women are in general less disposed than men to the -occurrence of gout, the tendency of women to this disease during the -climacteric period is so marked, that at this epoch of life the disease -is far more common in women than it is in men of corresponding age. - -It is in obese women, with a soft, white, and lax integument, with a -pallid, somewhat bloated countenance, a poorly developed muscular -system, extensive varicosities of the veins of the legs, marked -dyspeptic troubles, and habitual constipation, that during the -preclimacteric and climacteric periods, gout is especially apt to make -its appearance. It is then characterized by the following symptoms. From -time to time the woman suffers from tearing or shooting pains in the -joints, lasting at first a short time only, and returning after longer -or shorter intervals. With the frequent return of the pains, the -affected joints become swollen; and finally the patient suffers from the -characteristic attacks of acute gouty arthritis, with the well-known -consecutive symptoms of this affection. - -According to the observations of _Geist_, during the climacteric period, -28 women suffer from gout as compared with 4 men of corresponding age. -_Tilt_ publishes the following figures showing the mortality of women -from gout in England: - - At ages from 20 to 30 years 56 women - At ages from 30 to 40 years 121 women - At ages from 40 to 50 years 291 women - - At ages from 50 to 60 years 152 women - At ages from 60 to 70 years 104 women - -Regarding diabetes mellitus during the menopause, _Lawson Tait_, who -maintained there was a distinct form of climacteric diabetes, asserted -that this disorder of metabolism was less severe, and runs a longer -course during the climacteric period than at other times of life. - - - _Diseases of the Nervous System._ - -The disturbances of the nervous system that occur during the climacteric -period, manifest themselves chiefly in the form of hyperaesthesia and -hyperkinesia. The sensory nerves appear to me for the most part to be -more irritable than normal, inasmuch as every stimulus by which they are -affected arouses a comparatively greater sensation, and gives rise to an -excessive reaction in the sphere of consciousness. The cutaneous -hyperaesthesia of climacteric women is shown in very various ways, the -commonest being the anomaly of sensation which gives rise to the symptom -known as pruritus, characterized by paroxysms of itching in more or less -extensive areas of skin, with consecutive nutritive changes in the -affected portions of the integument. The commonest and the most -distressing form of this disorder during the menopause is pruritus -vulvae. - -In addition to such manifestations of cutaneous hyperaesthesia, -vasomotor disturbances of the skin are of frequent occurrence, -characterized by redness, rise of temperature, and sometimes the -formation of nodules in the affected areas. Almost without exception, at -the outset of the climacteric period, and sometimes also in the -preclimacteric epoch, women complain of a very distressing feeling of -fugitive heat in various portions of the surface of the body, manifested -objectively by the rapid appearance and no less rapid subsidence of a -red colouration of the skin of the face, the neck, and the chest. Such -fugitive heats are due to disturbances of vasomotor innervation giving -rise to sudden variations in the amount of blood passing through the -vessels of the affected areas of skin. - -Hardly less frequent during the climacteric are the sensations of -imaginary movement which give rise to the subjective symptom known as -vertigo. Often in women at this time of life it occurs quite without -apparent cause, but in other cases on the performance of some unusual -movement or the adoption of some unusual posture; there is a sudden -perception of rotatory movement, either of the patient’s own body or -else of her visible and palpable environment. With this feeling of -disturbed equilibrium, there is often associated optical and auditory -hyperaesthesia, flickering before the eyes (muscae volitantes), tinnitus -aurium, painful sensations in the head and more especially in the -occipital region, nausea, vomiting, sense of anxiety, cold sweats, -muscular twitchings, alternating redness and pallor of the face, and -coldness of the feet. The vertigo occurs in paroxysms, usually of short -duration, varying from one to fifteen minutes. It is especially in -plethoric and obese women that climacteric vertigo occurs. - -A peculiar form of this climacteric vertigo is that described by _Tilt_ -under the name of “Pseudo-Narcotism” of climacteric women, characterized -by a sense of swimming movements, uncertainty in the gait, vacancy of -expression, a confused look in the eyes like those of a drunken person, -and a kind of mental stupor which the patient cannot shake off without -considerable effort. The women thus affected state that they feel as if -they had had too much to drink, as if something had gone to their heads; -indeed their great fear is that they will be supposed to be intoxicated -by those who see them walking in the streets; they feel even that they -must refuse to receive the visits of their acquaintances if they wish to -preserve their reputation for sobriety. They suffer also from great -drowsiness, from a disagreeable sense of weight or pressure in the head, -from a feeling “as if the brain was clouded, or needed to have some -cobwebs swept away.” They feel a disinclination to both mental and -physical exertion, and their memory and all other intellectual powers -are impaired. - -_Boerner_ maintains that the attacks of vertigo so frequently occurring -at the menopause are in a minority of cases only dependent upon -hyperaemic states (arising from the cessation of the menstrual flow); on -the contrary, he believes that the cause more often lies in hysteria, in -chronic disorder of the digestive tract, or, finally, in anæmia. In his -opinion, vertiginous attacks dependent upon cerebral anæmia are very -common indeed during the climacteric period, and even for a long time -afterwards; and he believes that their nature is often completely -misinterpreted. - -Another very unpleasant indication of disordered nervous function during -the climacteric period is the sleeplessness that is so common at this -time of life. Women who during the day time feel comparatively well, -suffer at night, sometimes periodically at exactly the same hour night -after night, from a state of general restlessness, and for this reason -are unable to obtain the sleep for which they long. They throw -themselves uneasily from side to side of the bed, or wander restlessly -about the room, and before long, owing to this want of sufficient -repose, become greatly depressed. - -Among the neuroses of the sensory apparatus, the various kinds of -cutaneous neuralgia are less common than during the menarche and the -menacme; but on the other hand, in my personal experience at any rate, -the visceral neuralgias are commoner, more especially cardialgia and -hypogastric neuralgia. Of the superficial neuralgias, hemicrania and -intercostal neuralgia are those which occur most often during the -climacteric period. - -During the change of life, hemicrania most commonly occurs in typical -association with menstruation; or, if the flow has already ceased, the -attacks of hemicrania recur at what should be the menstrual periods. -This affection is characterized by the paroxysmal occurrence of a severe -boring pain in the side of the head, more often the left side than the -right, affecting the temporal, the parietal, or the occipital region, or -the entire side of the calvaria at once, usually accompanied with -redness and local rise of temperature of the painful part; the duration -of the paroxysms varies in different cases from one or two to many -hours; with the pain are associated chilliness, nausea, exhaustion, and -a severe feeling of general malaise. - -Of the intercostal neuralgias, one form deserves especial mention in -this connexion: I refer to mastodynia, which is both physically and -mentally one of the most distressing affections to which women are -subject during the climacteric period. For a middle-aged woman suffering -from mastodynia—the “irritable breast” of _Cooper_—almost invariably -feels assured that these pains localized in the breast and its immediate -vicinity are indications of a commencing cancer of the breast; and it is -an exceedingly difficult matter, in most cases, to convince her that her -fears are without foundation. In this manner, partly in consequence of -the directly depressing effect of the pains, which are commonly -intensely severe, and partly owing to the disturbance of mind produced -by the belief that an incurably fatal disorder has begun, I have in -several instances seen cases of profound melancholia originate. - -According to _Windscheid_, among the enduring painful sensations of the -climacteric period, pains in the lower extremities are of somewhat -frequent occurrence. Day after day the patient suffers from distressing -tearing or lancinating sensations in the legs; the trouble is -insusceptible of more exact description, but is none the less a very -severe one. In addition to the lower extremities, the back, the spinal -column, and more particularly the lumbo-sacral region, are often the -seats of incessant pain. In the thoracic region of the back, the pain is -usually diffuse; when confined to the spinal column, however, it is -commonly limited to individual vertebrae, the spinous processes of those -affected being also sensitive to pressure. The sacral pains may in some -cases predominate to such an extent, that it is on this ground alone -that the patient comes to seek medical advice. The sacrache is equally -severe when the patient is standing, sitting, or recumbent; it often -radiates into the lower extremities. _Boerner_ draws attention to the -fact that in many cases the pains in the sacrum or higher up in the back -may be due to excessive tension of the abdominal parietes in consequence -of the great accumulation of fat. Among motor manifestations, -_Windscheid_ draws especial attention to a certain degree of weakening -of the muscles of the lower extremities. Although on examination no -abnormality can be detected, fatigue and functional incapacity, more -especially in the lower extremities, ensue in a manner altogether -disproportionate to the exertion, so that the patient is most unwilling -to take even a short walk, to go upstairs, etc. In pronounced cases, the -patient will never go out walking without carrying a campstool, so that -she can sit down to rest directly she begins to feel fatigued. In -association with these disorders of motility we most commonly see the -above-mentioned painful sensations in the legs, and by these latter the -functional incapacity of the lower limbs is of course increased. -Weakness of the arms is far less frequently observed; but occasionally -we hear complaints that on the performance of domestic duties, -needlework, etc., which previously could be carried out quite easily, -the arms and hands are now speedily fatigued, and rendered functionally -incapable. - -Of the visceral neuralgias, cardialgia is by no means rare during the -climacteric period; the pain is concentrated in the epigastric region, -but not infrequently radiates to the back and to the chest. Hypogastric -neuralgia is also not uncommon, pain in the lower part of the abdomen, -associated with a sense of pressure in the bladder, the uterus, and the -rectum, and sometimes radiating to the thighs and to the region of the -haemorrhoidal nerves. - -The opinion expressed by several authorities, that the menopause favours -the occurrence of cerebral apoplexy, must, according to _Windscheid_, be -received with caution; we have to remember that with advancing years -atheromatous changes are apt to occur in the cerebral arteries, and it -is to these changes, altogether independently of the climacteric, that -cerebral haemorrhage is due. It appears, however, to be a fact that the -menopause favours the onset of progressive paralysis. According to -_Jung_, 60%, and according to _von Krafft-Ebing_, 27%, of women affected -with paralysis were first affected in this way during the climacteric -period. _Von Krafft-Ebing_ explains this occurrence by the fact that -during the menopause fluxions of vasomotor origin are common, and these -serve as the starting point of transudative processes. - -Among the neuropathic manifestations of the climacteric period we must -reckon the at times excessive increase of the sexual impulse. We have -already insisted upon the fact that the sexual impulse is not normally -extinguished in women at the time of the cessation of menstruation; on -the contrary, sexual desire commonly persists long after the menopause, -and on this fact is largely dependent the frequency with which elderly -women espouse quite young men. But in some cases, the sexual impulse is -enormously enhanced during the climacteric period, and the patient -experiences paroxysms of intense voluptuous sensation, associated with -manifestations of abnormal reflex and psychical reaction, with increased -frequency of the pulse and the respiration, emotional excitement, it may -be loss of consciousness, and even general convulsions. Some of these -cases of disordered sexuality occur in those previously affected with -pruritus vulvae et vaginae. - -More particularly _Guenceau de Mussy_ and _Boerner_ have described cases -of such excessive libido sexualis during the climacteric period, -voluptuous crises with pollutions, occurring independently of any -external cause; the women thus affected have a continued succession of -erotic ideas, they experience an itching and burning sensation in the -genital organs, and from time to time this culminates in a paroxysm of -sexual feeling, with orgasm, and increased secretion from the glands of -the vulva. - -_Boerner_ has observed that characteristic variations in the libido -sexualis commonly occur at the climacteric period. Not infrequently at -this time the sexual desire becomes greatly diminished in intensity, or -even entirely disappears; more often, however, the desire persists -throughout this epoch; finally, in many instances, the desire undergoes -an increase, at times to a degree amounting to positive torment. The -first of these changes, the decline in the intensity of the sexual -desire, harmonising as it does with the general extinction of the sexual -functions at the change of life, might have been expected to be the -normal occurrence. And it is a fact that in many cases characterized by -an increase of libido sexualis at the climacteric epoch, _Boerner_ found -that there existed anatomical abnormalities in the reproductive organs -(fibromata, flexions, etc.). Be this as it may, an increase in the -intensity of sexual desire, as long as that increase is not altogether -excessive, may be regarded as one manifestation of the visceral -hyperaesthesias so general at this time of life. In the excessive -degrees of this affection, however, those in which at times the sexual -crisis is associated with general convulsions, we must, with _Romberg_, -recognize the existence of a direct neuralgic state of the spermatic -plexus. It is especially before the commencement of an actual menstrual -period, or before a due period which fails to occur, that during the -critical years complaint is made of this state of excessive sexual -desire and sensibility; and in many instances the trouble begins at the -very first appearance of the menstrual irregularities which foreshadow -the menopause. - -_Windscheid_ draws attention to the fact that occasionally the nervous -manifestations may make their appearance prior to the occurrence of any -menstrual irregularity, so that it is by the nervous disturbance that -the woman or her physician is warned of the approach of the menopause. -“When the menstrual anomalies begin,” continues _Windscheid_, “that is -to say, at the commencement of the climacteric, the nervous troubles may -have already attained their maximum and have begun to decline in -intensity. As a general rule, however, the appearance of the nervous -disturbances coincides with the commencement of the menstrual -irregularities. It may happen that these disturbances are intensified -with each recurring period, but this is not the rule. Sometimes, -however, we may observe that when menstruation occurs with excessive -frequency—a by no means rare phenomenon at the outset of the -climacteric—the nervous disturbances become more severe; and especially -is this the case when the unduly frequent flow is also abnormally -profuse, as indeed often happens.” The manifestations of climacteric -neurosis occur, as _Windscheid_ rightly insists, most frequently in the -sphere of the psyche. “We observe a change in the disposition, which -usually becomes more excitable. A woman previously calm and composed -becomes irritable, inclined to emotional disturbance and to fits of -temper, and unable to bear with equanimity the pinpricks so frequent in -daily life, and especially in the daily life of a housewife. In other -cases, however, the disturbance of the psyche is rather in the direction -of depression: we observe a kind of spiritual inhibition, a deficiency -of vital energy, an indifference to things which formerly gave pleasure. -Almost always, also, complaints of loss of memory are among the -indications of such depression. To these intellectual anomalies are -superadded disturbances of sensibility. There is excessive sensitiveness -to bright lights, loud noises, and strong odours. Frequently, also, in -such cases, we see great intolerance to alcohol, quite small doses -giving rise to extremely disagreeable sensations in the head.” - - - _Climacteric Psychoses._ - -The powerful influence which the changes occurring at the climacteric -period has in the origination of psychoses, has long been recognized, -the menopause, in fact, being a favourable soil for the cultivation of -mental disease. The fact is embodied in medical terminology, since many -authors speak of “climacteric insanity,” assuming that the psychoses of -this period of life present a definite and characteristic clinical -picture. - -In an earlier part of this work it was shown that the process of -menstruation has generally a marked effect upon the psyche, and that -disturbances of menstrual activity are competent to exercise a -pathogenic influence upon the mental condition of the woman who suffers -from them; still greater and more intense is the influence of the -cessation of menstrual activity, with its powerful and widespread -disturbance of the entire organism, with its destructive oscillations of -equilibrium in the spheres of sensation, perception, ideation, and -volition. It is easy to understand how the rarer recurrence of -menstruation, the occasional profuse losses of blood, the complete -suppression of menstruation, the conditions peculiar to the climacteric -period of stasis and congestive hyperaemia of the brain, are competent, -more especially in hereditarily predisposed persons, to give rise to the -development of psychoses; whilst in those already suffering from mental -disorder, the menopause will be likely to bring about an aggravation in -their symptoms. At this time of life, also, we have to take into account -the effect of certain ideational influences to which allusion has -already been made, the thought that womanhood and its joys are passing -away for ever, and the fear of the dangers attendant upon this critical -period of the change of life. A French proverb alludes to “le diable de -quarante ans, si habille à tourmenter les femmes.” - -Mental disorder will be more likely to ensue at the climacteric period -in those women whose nervous systems have always been unduly irritable, -and in those affected with hereditary predisposition to insanity. -Further, it is more likely to occur in those in whom the menopause takes -place quite suddenly, in a catastrophic manner, than in those in whom -the climacteric proceeds gradually, and unaccompanied by any stormy -manifestations in the organism at large. - -It is not in my opinion possible to recognize any specific form of -mental disorder peculiar to the climacteric period, but nevertheless the -psychoses occurring at this time of life do exhibit certain striking and -characteristic features, more especially in this respect, that states of -mental depression with melancholia predominate, whilst erotic influences -are manifest in their etiology. In the slighter forms, volition and -ideation are unaffected, and the trouble manifests itself in the form of -hypochondriacal moods, associated with bodily troubles. In more severe -cases we see emotional depression, states of anxiety, limitation of the -powers of conception and judgment, indecisiveness, low-spiritedness, and -apathy; or on the other hand, restlessness, an inclination to continued -moving about, the eager pursuit of continually varying occupations, -loquacity, etc.; finally, if the mental disorder becomes still more -severe, hallucinations, delirium, paroxysms of intense excitement, and -in exceptional instances, fully developed mania. - -As with regard to the other disorders attending the climacteric, so also -in respect of the climacteric psychoses, women who have been or are -married, who have had a reasonable number of children, and have been -accustomed to a sufficiency of sexual activity, are more favourably -situated, are far more immune, than women whose sexual circumstances -have been the opposite of those mentioned, who have had one or two -children only, who have indulged in intercourse only when protected from -pregnancy by the use of preventive measures, or have remained sexually -unsatisfied, and, finally, women who have never married, and those who -for many years prior to the commencement of the menopause have lived in -chaste widowhood. In “old maids,” to the somatic effects of sexual -abstinence (or in some cases of abnormal sexual gratification), are -superadded the effects of the intellectual and emotional recognition of -a wasted life. Again, it by no means rarely comes under our observation -that women who in youth, at the time of the menarche, suffered from -psychical disturbances, are apt once again to be affected with -transitory mental disorder at the change of life. Once, however, the -menopause is completely at an end, a condition of mental quiescence is -as a rule established, and then it may happen that previously existent -mental disorders undergo amelioration; but on the other hand we have in -all cases to reckon with the possibility that they may take an -unfavourable turn in the direction of the development of senile -psychoses. - -Of considerable interest is the fact, first pointed out by _Glaevecke_, -and subsequently confirmed by other observers, that in cases of -artificial menopause, melancholic mental disturbances not infrequently -follow the operation, in some instances so severe as to lead to -weariness of life and actual suicide; and in general, after the -artificial induction of the menopause, psychical disturbances are by no -means rare, and are sometimes very severe. Such disturbance of the -mental balance is seen after oöphorectomy especially in women who are -still comparatively young, and whose sexual powers are still in a ripe -state; whereas when the operation is performed in women of a more -advanced age, whose ovaries were already nearly or completely -functionless, no psychopathic changes are likely to ensue. In women -belonging to the former category, the same etiological influences come -into operation as in the physiological menopause, the patient, that is, -is affected by the psychical influences of the removal of the -ovaries—not only by the cessation of menstruation and the disappearance -of the internal secretion of the reproductive glands, leading to a -disturbance of the physical equilibrium, but also by the intellectual -recognition of the loss of sexual potency, and a consequent disturbance -of the mental balance. - -In _Schlager’s_ opinion the climacteric has a potent influence in -promoting the development of psychical disturbances in women, even when -the involution occurs at the normal age. The course of these -disturbances is as follows: soon after the commencement of the process -of involution, when for a few months already the menstrual periodicity -has been irregular, or the flow has been unduly profuse, a change of -disposition makes its appearance, at first hardly noticeable, but after -a little time manifesting itself clearly in the form of an increase in -irritability. The woman finds fault with everything and everybody, -becomes mistrustful, suspicious, full of complaints, imagines that the -most insignificant annoyances are due to intentional slights; at the -same time she complains of continued sleeplessness, palpitation, various -indescribable sensations, and of headache. Occasionally, congestions of -the head occur, with alarming dreams, and the moodiness may increase -greatly; in this condition three such patients of _Schlager’s_ were -impelled to attempts at suicide. _Schlager_ further draws attention to -the fact that in 22 cases known to him in which suicide was performed or -unsuccessfully attempted by women, in eleven of these the patient was at -the climacteric age. He believes that the most important etiological -influence in the production of climacteric mental disorder in such cases -is the sudden suppression of menstruation. In the majority of these -instances, the mental disorder takes the form of mania; exceptionally, -however, the form of chorea or of catalepsy. - -By _Tilt_ the following forms of “climacteric insanity” are -distinguished: delirium, mania, hypochondriasis, melancholia, impulsive -insanity, and perversion of the moral instincts. The same author -publishes the following table showing the age incidence in 1,320 cases -of mental disorder in women, from which it appears that during the age -of the menopause, a very considerable number of the cases originate, but -that after the change of life comparatively few cases occur. - -In these 1,320 cases the women were: - - Under 15 years of age in 9 instances - Over 15 and under 20 years in 61 instances - Over 20 and under 25 years in 216 instances - Over 25 and under 30 years in 223 instances - Over 30 and under 35 years in 217 instances - Over 35 and under 40 years in 218 instances - Over 40 and under 45 years in 162 instances - Over 45 and under 50 years in 153 instances - Over 50 and under 55 years in 122 instances - Over 55 and under 60 years in 57 instances - Over 60 and under 65 years in 55 instances - Over 65 and under 70 years in 27 instances - -_Fuchs_ tabulated the ages of 26.300 insane persons. Reducing his -results to the ratios per 10,000, he obtained the following results: - - Women. Men. - At ages under 20 563 649 - At ages over 20 and under 30 1,895 2,132 - At ages over 30 and under 40 2,557 2,614 - At ages over 40 and under 50 2,180 2,080 - At ages over 50 and under 60 1,362 1,247 - At ages over 60 1,443 1,278 - -According to _Esquirol_, among 198 women who committed suicide, there -were 77 between the ages of 40 and 50 years—a number considerably larger -than those in any other age-decade. Among 235 women suffering from -dementia, a moiety had first come under treatment during the climacteric -age. The same author published the following data regarding the -age-incidence of insanity in the case of 6.713 female patients: - - At ages under 20 years 348 cases - Between the ages of 20 and 25 563 cases - Between the ages of 25 and 30 727 cases - Between the ages of 30 and 40 1,607 cases - Between the ages of 40 and 50 1,479 cases - Between the ages of 50 and 60 954 cases - At ages above 60 years 1,035 cases - -_Matusch_ found that among 551 women suffering from mental disorder, -there were: - - At ages 0 to 10 years 9 cases - At ages 10 to 20 years 73 cases - At ages 20 to 30 years 140 cases - At ages 30 to 40 years 114 cases - At ages 40 to 50 years 107 cases - At ages over 50 years 38 cases - -According to _von Krafft-Ebing_, among 858 insane women, there were -about 60 in whom the disorder of the mind appeared to depend upon the -influence of the climacteric, and in 25 of these there was hereditary -predisposition to mental disease. - -From _Kowalewski’s_ interesting work on the psychoses of the -climacteric, we quote the following: - -“In women, the climacteric has a distinct influence upon the mental -life, and that influence is strongly manifested more especially in cases -in which during the age of puberty mental disturbance had previously -been noticed. The mental condition in which women approach the change of -life is a very variable one, and it is one largely dependent upon the -circumstances in which the active years of the sexual life have been -passed. In some cases, a woman has been so fortunate as to marry early -and from affection, and her whole married life has been passed without -disturbance; her labours have not been exhausting, and her children have -enjoyed good health; all have passed through the years of childhood -without untoward incident, and their development has been a happy and -successful one; in a word—everything has gone well with her and hers. -Such a woman will give thanks to God for the rare felicity she has -enjoyed; and quietly, patiently, and with understanding will endure the -inevitable end of her sexual life. For such a woman, more especially if -she comes of a healthy stock, the changes which occur in her -reproductive organs at the epoch of the climacteric, need not entail any -serious shock to her nervous system, nor need they form the culture -ground for morbid manifestations in her nervous system or in her mind. -Even if any anomalies in nervous working should occur, it will be such -only as are aroused by the disturbance of the normal menstrual rhythm; -in such cases, they will rarely prove of a serious or enduring -character. - -“But look, on the other hand, upon this picture. A woman has married -without affection and from pure necessity. Her husband has been a -drunkard, and rough and unfaithful. She has had a great many children, -her labours have been tedious and difficult and accompanied with severe -losses of blood. Some of the children fell sick and died; those that -survived proved idle, good-fornothing, and a burthen. The family life is -dominated by quarrelsomeness, disorder, and insufficiency of means. The -mother is affected with some chronic disorder of the reproductive -organs, and is hardly ever out of the doctor’s hands. After 25 or 30 -years of a life of this kind, the woman enters upon the change of life. -Physically exhausted, weary of life, never having known happiness, after -an existence full of trouble and wretchedness, with nothing joyful -either in her memories of the past or in her prospect of the future—the -chief hope of such a woman is that her troubles may soon end with her -life. Where the soil is thus physically and mentally exhausted, the -development of a neurosis or a psychosis is only too probable on the -most trifling exciting cause. Her life seems of so little worth, that -thoughts of suicide are likely to be very near at hand. Thus, when the -climacteric alterations in the reproductive organs are superadded, -melancholia is very likely to supervene. When, however, the case is -complicated by hereditary predisposition to insanity, and by the -occurrence of actual degenerative changes in the central nervous system, -instead of the passive depression of melancholia, we shall rather see -the ideas of persecution of paranoia. As an actual fact, these two -psychoses, melancholia and paranoia, are the commonest forms of mental -disorder at this period of a woman’s life. - -“These are the two extremes in woman’s mental state at the time when the -physical changes of the climacteric period begin in her reproductive -organs. It will, of course, be readily understood that between these two -extremes lies a series of combinations any one of which may in -individual cases occur. - -“The conditions of life during earlier years have thus a strong -determinative influence in the production of mental disorder; and not -infrequently in these conditions alone shall we find the efficient cause -of the mental degeneration. At times, the memories of her own life have -in a woman at the climacteric age so serious an effect, that these -memories alone constitute the causal agent of the development of a -psychosis, or at least so influence the soil as to make it a suitable -culture-ground for the development of mental disorder, the actual -exciting cause of the pathological state being a disturbance of the -ordinary menstrual rhythm. - -“In considering the mental condition of women at the outset of the -climacteric period, we must not forget those who are called ‘old maids.’ -In their youth these maidens also have had their ideals, their hopes, -their plans, and their sorrows. They also had a natural impulse to love -and to be loved in return; they hoped to become wives and mothers. But -life has failed to fulfil their hopes and their wishes, and their -longings have remained unsatisfied. Some of them have taken up their -cross without murmuring, and have devoted their talents, their -intelligence, and their love to the service of those nearest to them. -But others make an active protest against fate in the form of vindictive -feelings towards their environment, of quarrelsomeness, -scandal-mongering, etc. Here we see contrasted the two principal types -of such women. On the one hand are those who devote their intellectual -and spiritual powers to the service of society; these are unselfish -sisters-of-mercy, untiring medical women, invaluable school-teachers and -governesses, fanatical political agents, etc. Such as these have ceased -to live for themselves. In the fullest sense of the words, they mortify -the flesh, and guide their conduct by lofty moral principles. They have -killed their sexual life, and they remain for ever virgins—both morally -and physically. If, owing to a pathological inheritance, faulty -conditions of life, exhausting illnesses, etc., a psychosis develops, -the hallucinations and delusions from which they suffer very rarely -assume a sexual character, nor are they of a degrading type. The sexual -side of life seems, in fact, be they sane or insane, to have undergone -complete atrophy. They suffer from simple melancholia with stupor, or -their insanity takes a religious turn, but very rarely indeed has it an -erotic character. - -“Very different is it with old maids of the second type. They are -dissatisfied with life, irritable, quarrelsome, envious, and malicious. -They are spiteful and revengeful, gossips and scandalmongers, boast of -their own chaste and innocent lives, and never forgive any real or -imaginary attempt upon their spotless virtue. At the same time they -never lose hope for the future, and are full of imaginary love-affairs, -in which they pass through scenes by no means chaste or innocent; they -do not shrink from self-abuse and the abnormal gratification of the -sexual needs, in which the lacking partner in the sexual act is supplied -by the imagination. Under the influence of such abnormal conditions of -life, these women frequently become affected by nervous disorders; -migraine, neuralgia, cephalalgia, nervous depression, rachialgia, -debility, anæmia, diseases of the reproductive organs, etc. Thus, when -they enter the climacteric age, the soil is fully prepared for the -development of mental disorder, which in such individuals is often -characterized by hallucinations of sexual sensation and perception, -erotic visual and auditory hallucinations, delusions of similar -character, increased sexual irritability, a search for abnormal means of -sexual gratification, a propensity to obscene speech and conduct, etc. - -“Mental disorder is so common during the climacteric period, that the -term ‘climacteric insanity’ has now become established in the literature -of mental alienation. In almost all the textbooks of the subject we find -an allusion to this form of mental disease, but there is no real ground -for _Maudsley’s_ assumption that there is a climacteric insanity sui -generis. At the climacteric, very various forms of mental disorder may -occur—paranoia, melancholia, and mania; the only common feature in the -attacks, owing to which they are classed as ‘climacteric insanity’ being -the fact that the final determining cause in each case is the onset of -the change of life. In fact, this period is not without influence upon -the manifestation of the disease—its stamp is imprinted upon the -clinical picture, it endues the disease with certain characteristic -features—but still, the peculiarities common to the cases of mental -disorder occurring at this time of life in women are not so great as to -justify us in describing them as a separate variety of psychosis.” - -According to _Kowalewski_, this so-called climacteric insanity is met -with in two principal forms: in many cases the mental disorder recurs in -periodic paroxysms, associated either with the commencement of the -menstrual flow, or having the periodicity of menstruation after the flow -has already ceased to appear; in the other class of cases the psychosis -has no direct connexion with menstruation, and is dependent upon the -joint influence of all the manifestations of the climacteric period. -Cases belonging to the former class have been distinguished by _Bartel_ -as “climacteric pseudomenstrual insanity.” - -The psychoses dependent upon the climacteric influences may, according -to _Kowalewski_, appear in almost all the known forms of mental -disorder: precordial anxiety, melancholia, mania, amentia, paranoia, -etc.; and although they exhibit no features which are absolutely -characteristic, or which, as already said, enable us to distinguish a -specific “climacteric insanity,” yet they all bear a common imprint by -means of which we are enabled to detect in their causation the influence -of this critical period of life. Thus, precordial anxiety occurs in -paroxysms having a more or less regular periodicity, corresponding with -that of the expected menstruation. The same feature is observable in the -periodic exacerbations of hysterical and epileptic paroxysms. Often, -also, there occur at this time sudden changes in the emotional -disposition and in the character, in one direction or the other, without -the development of actual melancholia or mania. The melancholia of the -climacteric period occurs chiefly in married women, more especially in -those whose circumstances are unhappy; and it is often manifested by -attempts at suicide. - -Mania is comparatively rare at the climacteric period; when it does -occur, it commonly assumes a sexual form—sexual impulses, -hallucinations, and delusions, and obscene conduct. Such manifestations -are seen most often in widows, in “old maids” whose morals are not above -reproach, and, speaking generally, in those whose sexual needs have -remained partially or completely ungratified, and in those who have -greatly erred in the conduct of this side of life. Amentia also occurs -at this time of life; rarely in maniacal form, more frequently in -association with menstruation as a periodic psychosis, or as a -continuous disorder of mind with exacerbations corresponding to the -menstrual periods; it is often characterized by pronounced eroticism. - -Much more frequent during the climacteric period is the occurrence of -paranoia, as _Kowalewski_ rightly insists. It is most often met with in -“old maids” with psychopathic predisposition. The imagination of such -individuals is always concentrated upon men; they imagine that men in -general, but more particularly certain individuals of the opposite sex, -are continually regarding them, making eyes at them, making signs to -them, in some way or other striving to attract their attention. The most -ordinary and invariable forms of polite intercourse are regarded by -these women, whose powers of observation are morbidly stimulated, as -being indications of a special “attention” paid to themselves. They -persecute these men with their own attentions, and imagine that it is -the men who are persecuting them. Often this morbid mental state is -associated with sexual malpractices, masturbation, etc. Not rarely, such -degenerates are affected with lascivious dreams. Often they experience -hallucinations of sexual perception in the form of supposed assaults on -their virginity. All these states are apt speedily to develop into a -condition of general suspiciousness and ideas of persecution. The ideas -of persecution assume a peculiar form, one especially characteristic of -the climacteric period. The patients believe that a man, often -personally unknown to them, and perhaps living in another town, enters -into spiritual and bodily intercourse with them. These relations are -supposed to be effected in most cases by means of spiritualism, -hypnotism, or electricity. The patient importunes the man in question -with letters, supposes herself to be legally united with him, and not -infrequently wishes to give him the pleasure of paying her bills and -providing her with money. It is a very common occurrence for a Catholic -priest to be worried by such a woman, her delusion being grounded upon -the fact that the priest is supposed to assume an exceptionally intimate -spiritual relationship with members of his flock. The patient with ideas -of persecution often herself becomes an actual persecutor, not only -pestering her victim with innumerable letters, but in her jealousy -making “scenes” whenever she can encounter him, and sometimes giving -rise to serious scandal. With such a mental state we often see -associated sexual hallucinations and delusions; the patient believes -herself to be pregnant, imagines herself to have been violated, or to be -living in carnal intercourse with a man—some one, it may be, with whom -she is not even acquainted. Medical men are especially apt to suffer -from the accusations of such women, whom they may have examined in -private in entire ignorance of the patient’s mental condition. -Frequently, such ideas of sexual persecution are associated with -paroxysms of violent nymphomania, and in this way also the unwary -physician may find himself placed in an extremely unpleasant position. -It occasionally happens in such patients that abnormalities of the -sexual instinct arise, and they begin to feel desire towards individuals -of their own sex. - -Such delusions of persecution by means of hypnotism, spiritualism, the -telephone, etc., in association with sexual delusions and nymphomania, -are so frequent during the climacteric period, that they may be regarded -as pre-eminently constituting climacteric insanity. Frequently some old -hysterical state underlies this form of mental disorder. - -Thus these peculiar manifestations of eroticism must be regarded as the -distinctive characteristics of climacteric insanity and more -particularly of climacteric paranoia. A second characteristic of -climacteric insanity is, according to _Garat_, the marked development of -jealous emotions and delusions. - -In addition to these fully developed psychoses, there occur in -degenerates at the climacteric age paroxysms of impulsive insanity in -the form of dipsomania, kleptomania, pyromania; exhibitionism; -irresistible impulse to suicide, homicide, infanticide, etc. Such -paroxysmal impulsive manifestations are, according to _Kowalewski_, -commonly associated with menstrual disturbances; they occur most -frequently at the due dates of menstruation when the flow fails to -appear. - -One hundred and sixty-nine cases of climacteric psychosis were -classified by _Matusch_ as follows: - - Melancholia 36 cases - Mania 2 cases - Melancholia passing on into paranoia 28 cases - Melancholia passing on into secondary dementia 17 cases - Paranoia 43 cases - Neurasthenia during the climacteric period followed by mental - disorder 19 cases - Neurasthenia prior to the climacteric period, followed by - mental disorder during the climacteric period 10 cases - Apoplexy, cerebral abscess, dementia 6 cases - Epilepsy 2 cases - Alternating insanity 3 cases - Paralytic dementia 5 cases - -_Von Krafft-Ebing_ classified 60 cases of climacteric psychosis as -follows: - - Melancholia 4 cases - Alternating insanity 1 case - Acute delirium 1 case - Primary insanity: - _a._ With primordial delirium 36 cases - _b._ Paralytic dementia 12 cases - -The prognosis in cases of climacteric psychosis is regarded by -_Kowalewski_ as unfavourable; unfavourable vital conditions are -associated with retrogressive metamorphosis of the tissues, hence mental -disorder arising at this time of life is hardly less serious than that -due to actual degeneration of cerebral tissues. Indeed, according to -_Schüle_ there is during the climacteric period an especial danger of -the development of atrophic cerebral processes (Encephalitis -atheromatosa) with apoplectic and epileptic seizures. _Schlager_ also -regards the prognosis of climacteric insanity as unfavourable; but -_Merson_, on the other hand, observed among women suffering from -climacteric psychoses a recovery rate of over 50%. On previously -existent psychoses in women, the onset of the climacteric exercises in -most cases an unfavourable influence, and very exceptionally only at -this time do we observe the cure or remission of a chronic mental -disorder to occur. _Kowalewski_ has seen cases of chronic mania in which -a cure was obtained at the climacteric period; a somewhat excessive -excitability and inclination to violence remained, however, as vestiges -of the former insanity. _Matusch_, keeping under observation 60 women -affected with chronic mental disorder as they attained the climacteric -period, noticed that in 14 instances the mental condition changed for -the worse at this period, whilst in 13 the character of the mental -disease underwent a change, excitement giving place to apathy and -dementia. _Griesinger_ had earlier pointed out that at the time of the -cessation of menstruation there would occasionally occur amelioration, -and even cure, of a previously existing chronic mental disorder; more -often, however, the influence of the menopause was an unfavourable one, -a hitherto changeable and irritative form of mental disease becoming -transformed into chronic insanity with inalterable delusions, or into -dementia. The course of mental disorder, such as melancholia, first -making its appearance at the climacteric epoch, was also regarded by -_Griesinger_ as likely to be unfavourable. - - - HYGIENE DURING THE MENOPAUSE. - -During the critical years of a woman’s life it is the aim of hygiene to -employ all the means available to counteract the changes in the -circulation of the blood, the disturbances in the working of the nervous -system, and the nutritive disorders, which are in various ways dependent -upon the changes occurring in the reproductive organs during the -climacteric period; its endeavour should be so to regulate the conduct -of life in this epoch that the important episode of the gradual decline -and ultimate extinction of sexual productivity shall be effected with as -few local troubles as possible, and as slight variations in the general -condition. - -By means of baths of various temperature, duration, mode of application, -and composition, and by other selected hydrotherapeutic procedures, we -are enabled during the disturbances of the menopause to exert upon the -skin a powerful derivative influence, and in this way to diminish the -passive hyperaemia of the uterus and the uterine annexa; by the same -means we can exercise a sedative influence on the peripheral nerves and -thus further upon the entire nervous system, whenever such measures are -called for by the manifold indications of increased irritability; -further, by the use of baths we can influence the circulation of the -blood, we can increase the sudatory activity of the skin, and in various -additional ways we can affect heat production and metabolism, thus -modifying the processes occurring in the reproductive organs, making the -conditions favourable for the absorption of exudations, and promoting a -healthy tissue-change in the mucous membrane of the genital passages. - -In climacteric women, the most usual indications are for the employment -of water-baths at an indifferent temperature. 35 to 37° C. (95 to 98° -F.), of moderate duration, 15 to 20 minutes, the bath being one of -simple immersion, not of douche or affusion, and the temperature being -kept constant by continuous inflow of a sufficient quantity of hot -water. Such baths as these promote in a mild but continuously efficient -manner the functions of the skin—so important during the climacteric -epoch; and they lessen the almost constant tendency to perspirations and -to the development of diseases of the skin (the commonest of which is -climacteric eczema). The moderate degree of thermic stimulus exercised -by baths at such an indifferent temperature leads them to have an -equable sedative effect upon the nervous system, which is probably -dependent upon an influence exerted through the intermediation of the -sensory nerve-terminals in the skin; and this is most beneficial in -lessening the increased general irritability, both spontaneous and -reflex, so commonly manifested by the nervous system at the climacteric -period. In women at this time of life, such baths are most useful in -allaying the common cutaneous hyperaesthesias and neuralgias, and have a -reflex influence also upon the visceral neuralgias and psychical -hyperaesthesias. - -In climacteric women suffering from abnormal sensitiveness to sensory -impressions, to strong light and loud noises, or from painful sensations -in the most diverse nerve areas; in those subject to palpitation of the -heart after some trivial exciting cause; in those affected with -cramp-like seizures in the pharynx, the œsophagus, the stomach, and the -intestinal tract; in women with distressing sensations of itching and -burning in the reproductive organs, or in those in whom there is a great -increase in the intensity of the sexual impulse—in all these common -disturbances of the menopause, by the daily use of such immersion baths -of water at an indifferent temperature, best taken immediately before -retiring to rest, we shall often succeed in inducing both local and -general repose, in diminishing the spontaneous and reflex irritability -of the nervous system, and in inducing quiet and restorative sleep. - -In other cases of disturbances of health during the climacteric period, -however, more benefit may be derived from hot immersion baths, taken at -a temperature well above blood heat, (37° C.—98.4° F.) and lasting -longer than the warm baths just described. These are indicated when we -wish to increase the activity of the circulation through the skin, to -give rise to hyperaemia of the superficial structures of the body, to -stimulate powerfully the cutaneous nerves, to promote cutaneous -perspiration—in short, to exercise a powerful derivative effect, to -promote resorption, and to accelerate the general processes of -tissue-change. This method of treatment is suitable for cases in which -at the commencement of the menopause there are already pathological -conditions of the reproductive organs, the morbid states being now -aggravated by the processes of the climacteric—such conditions are -metritis and endometritis, chronic inflammations of the intrapelvic -connective tissue and of the pelvic peritoneum; and one of the first -aims of treatment must be to promote the softening and subsequent -absorption of these inflammatory products. Again, in cases in which the -climacteric troubles, dependent in part on increased general arterial -blood-pressure, manifest themselves chiefly in the form of active -congestions, fugitive heats, vertigo, etc., the employment of hot baths -is likely to be most useful by leading to a notable enlargement of the -cutaneous capillary bloodvessels and consequent lowering of arterial -blood-pressure. Further, in cases of compensatory fluxes, periodic -diarrhoeas, periodic leucorrhoea, following the suppression of the -menstrual flow, in cases of vicarious haemorrhage (especially periodic -epistaxis and periodical haemorrhoidal bleedings), the use of hot baths -is often competent to restore the functional activity of the ovaries -when this has undergone _premature_ cessation. In addition, their use -assists us in our endeavours to counteract excessive obesity and gouty -disorders, diseases which tend especially to make their appearance in -women at the epoch of the menopause, disorders of metabolism intimately -associated with the disturbances of the uterine and ovarian functions -characteristic of the change of life. - -In all the conditions just enumerated, if we desire a still more -powerful influence than that exerted by ordinary hot baths, it is in our -power to employ hot mineral water baths, by means of which a chemical, -and perhaps also an electrical, stimulation of the cutaneous nerves is -superadded to the simple thermic stimulus conveyed by the hot water. The -different effects of the various mineral baths depends upon both the -saline and the gaseous constituents of the different springs, and upon -the peculiar physical properties of the mineral waters. - -Sudorific baths are of various kinds. Some, Russian baths, consist of -hot air saturated with moisture; others, Roman-Irish baths, consist of -dry hot air; the most recent of all are the electric light baths, in -which the radiant heat of electric lamps is utilized. But owing to the -great increase in the body temperature which they cause, with consequent -increased frequency of pulse and breathing, and still more on account of -the rapid and extensive increase in blood-pressure to which they give -rise, these powerful sudorific baths are rarely suitable for climacteric -women, and if used at all in such cases the greatest caution must be -employed. Their use is indicated only in women in whom at the time of -the menopause the rapid onset of obesity has given rise to serious -troubles, but in whom the heart is perfectly sound and in whom the blood -vessels show no trace of sclerosis. - -Far less often than warm or hot baths, or mineral water baths, are cold -baths employed during the climacteric period, for baths at a temperature -considerably below the indifferent point, and other hydrotherapeutic -procedures in which cold water is used, stimulate the nervous system so -powerfully and give rise to so great an increase in blood-pressure, that -their use is generally to be avoided in climacteric women, since indeed -it is apt to entail serious dangers both physical and mental. Immersion -baths, plunge baths, or sponge baths, in which the water employed is at -a temperature of 18° C. (64° F.) or less, are contra-indicated, for they -act too energetically, abstract heat too powerfully, to be safely -employed at this epoch of life. If we seek by means of hydrotherapeutic -measures to counteract states of congestion at the time of the -menopause, and at the same time to bring about a general invigoration of -the patient’s nervous system, immersion baths the water of which is not -below 20° C. (68° F.), and lasting from five to fifteen minutes, would -appear to be indicated. In the majority of such cases, however, a -somewhat higher temperature is preferable, from 26 to 28° C. (79 to 82° -F.), the patient lying at full length in the bath, immersed to above the -shoulders, and the water not being agitated except by a moderate rubbing -of the surface of the body whilst the patient is in the bath. When, -however, the patient sits in the bath, the water covering only the lower -half of the body as high as the navel, a somewhat lower temperature is -permissible, 20 to 25° C. (68 to 77° F.); but the duration should not -exceed five minutes, moderate mechanical manipulations being carried out -meanwhile; such baths appear to reduce nervous irritability and to have -a sedative effect in the manifold nervous disturbances of the -climacteric period. Sitz-baths, again, of a longer duration, twenty to -sixty minutes, the water reaching only to the navel, and being at a -temperature varying from 16 to 25° C. (60 to 77° F.), are useful in -relieving chronic inflammatory states of the reproductive organs and the -associated erotic states and abdominal pain and irritability. Colder -sitz-baths, even of brief duration, should, on the other hand, be -avoided. Similarly, a shower-bath of water at a temperature of 18 to 24° -C. (64 to 75° F.), lasting one to two minutes, and the water falling -only from a very slight elevation above the head, have a valuable -sedative action; but, on the other hand, a colder shower-bath, of water -falling from a greater height, has an exciting action, and is to be -avoided at this time of life. When there are severe congestive symptoms, -friction of the hands and feet for a short time with water at a -temperature from 12 to 17° C. (54 to 63° F.), followed by a quarter of -an hour’s rest in bed, may be recommended; also immersion of the feet -for a minute in water at a temperature of 10° C. (50° F.), the feet -being vigorously rubbed the while, followed by a walk in the open for -five or ten minutes. In cases of sleeplessness at the menopause due to -congestion, a useful method is to dip the feet for twenty or thirty -seconds in water at a temperature of 8 to 10° C. (46 to 50° F.), the -feet being briskly rubbed whilst in the water, or moved rapidly up and -down with treading movements; after withdrawal, they are quickly dried, -and the patient immediately goes to bed. Another useful mild soporific -measure is to apply before going to bed bandages wrung out of cold -water; these reach from the foot to the knee, and are left on for the -whole night. In cases of climacteric menorrhagia, my vaginal -refrigerator should be used for the direct application of cold to the -reproductive organs; this is a cylindrical apparatus introduced into the -vagina, cold water flows through the interior of the apparatus without -wetting the vaginal mucous membrane. This cooling apparatus is useful -also in troublesome cases of genital pruritus; cold douches to the vulva -for one or two minutes at a time are likewise valuable in the relief of -this affection. - -For climacteric women, cold sea-bathing is as little to be recommended -as other cold hydrotherapeutic measures, owing to its powerful -refrigerative effect, and the great mechanical influence of the moving -water in the waves. But in certain cases, in which sea-air is likely to -be beneficial, lukewarm sea-baths may also be recommended; their effect -is similar to that of weak brine-baths at a similar temperature. - -During the climacteric period, especial attention must be paid to the -care of the skin. Owing to the extreme sensitiveness of the skin at this -time of life to outward noxious influences, it is necessary to exercise -great care to dry the skin very thoroughly after ordinary ablutions of -the face and hands; irritating soaps should be avoided, and a bland -powder should be applied after drying. During the earlier part of the -climacteric period, when menstruation has already ceased, and senile -changes in the skin with atrophy of the subcutaneous tissues have -commenced, the extreme dryness of the skin may be relieved by lukewarm -baths with wet packs to follow; after the bath, the woman is enveloped -in moist linen cloths and then covered over all with a blanket. When the -skin chaps readily, inunction of lanolin ointment will be found useful. - -Cleanliness of the genital organs, at all times of importance, is doubly -so during the climacteric period, for the reason that neglect in this -respect is apt to lead to the onset of genital pruritus. Not only after -defæcation, but after each act of urination as well, the external -genital organs and the anus should be carefully washed over with a pad -of clean absorbent wool moistened with lukewarm water. After the -washing, either powder or ointment should be applied, the former in -cases in which the skin of the parts is usually damp from a natural -tendency to excessive secretion, the latter in cases in which the skin -is dry and tends to crack. - -Bodily exercise, carefully selected and regulated to suit the -individuality of each patient, is a powerful means of relieving the -disturbances of the menopause. Regular and methodical bodily exercise—to -which it must be remembered, women at the climacteric period commonly -feel considerable aversion—manifests its good effects in the form of -improvement in the nutritive conditions and functional activity of all -the organs, and increased activity of all metabolic changes, which are -commonly sluggish in women at the change of life. Moreover, muscular -exercise, by increasing the volume of blood passing through the muscles, -has a beneficial derivative influence in diminishing the congestion of -the brain and the other troublesome congestive symptoms which are liable -to occur in women during the menopause. Again, in cases of excessive -obesity such as so commonly occur in women at the change of life, the -increased combustion of fat promoted by regular muscular exercise, -cannot fail to have a beneficial effect. Finally, suitably selected -muscular exercise has a favourable influence also upon the nervous -system, the functional activity of which it facilitates, while at the -same time it strengthens the powers of the will. - -It is therefore of importance that at the time of the menopause women -should continue to undertake appropriate active exercise, regular daily -walks, which should include walking up a moderate incline. As a -preparation for such exercise (in persons hitherto unaccustomed to walk -much), or in bad weather, or, again, when there are special reasons -against open air exercise, and finally as a supplementary exercise to -walking, gymnastics and massage may be employed. Such gymnastic -procedures are to be chosen as will serve to deplete the vessels of the -head, will have a favourable influence upon the portal circulation, and -will withdraw the blood-stream from the pelvic organs; such are, in -addition to general gymnastic exercises, methodical deep breathing, -methodical exercise of the abdominal muscles, exercises involving the -extensors of the back and the abductors and external rotators of the -thigh, and exercises of the extremities. Various gymnastic apparatus may -be employed with advantage, and more especially those in which the -various muscular movements are effected against a resistance. But in all -cases extreme care must be taken to avoid over-fatigue and -over-exertion. A graduated form of bodily exercise combined with passive -gymnastics, suitable for climacteric women, is massage, in which by -mechanical stimulation, by pressure and friction of the whole body or of -certain parts, the nutrition of the muscles is favourably influenced, -and the activity of the general circulation is increased. In the use of -massage also, in climacteric women, all undue excitation of the nervous -system is to be carefully avoided, a mild form of this powerful agent -must alone be employed; gentle stretching and rubbing of the skin of the -lower extremities, the back, and the abdomen, followed by gentle -kneading of the muscles. Massage of the internal reproductive organs -(the method of Thure Brandt), in view of the common tendency to sexual -excitability in women at the climacteric, is mentioned only to be -prohibited. For the same reason, and also on account of the frequency -with which at the time of the menopause women suffer from tachycardia -and from other disorders of the heart, bicycling is in most cases an -unsuitable exercise at this time of life. - -A matter of great importance is the regulation of the diet of women -during this phase of life, the aim of such regulation being one which -the older physicians sought to fulfil by means of venesection and wet -cupping, namely, to overcome the abnormality in the constitution of the -blood which arises from the cessation of the internal secretion of the -ovaries, and further to relieve the symptom-complex of abdominal -plethora and the various passive hyperaemias and collateral congestions; -and in addition to subdue the great general nervous irritability, the -sensibility to external stimuli, the inclination to excessive reflex -manifestations, characteristic in women during the climacteric period. - -The diet must be regulated in respect both of quality and quantity, and -it is obvious that the regulation must be thoughtfully adapted to the -needs of each individual case. - -As regards quantity, the main general principle of dietetics for -climacteric women is that over-nutrition is to be avoided, that the -quantity of nutriment must be reduced to the absolute minimum necessary -to supply the needs of the tissues. In view of the fact that we are -concerned with women at a comparatively advanced period of life, whose -physical labours are not as a rule exhausting, that quantity of food -will usually be sufficient which is competent to furnish 35 to 40 -calories per body-kilogram per diem. If we assume that the mean -body-weight of a woman as the climacteric age is 60 kilograms, the -heat-equivalent of the food required daily by such a woman may be -estimated at 2,100 to 2,400 calories. This will be approximately -supplied by a diet consisting of 100 grams albumen, 60 grams fat, and -350 grams carbohydrate. The customary preference for a large amount of -nitrogenous food is, however, not dependent upon physiological -requirements, and provided that the needful minimum of albumen is -supplied (about 1.5 gram per body-kilogram per diem), the requisite -number of calories may be furnished by very various combinations of the -different nutritive elements. - -The general principles of the qualitative regulation of the diet of -climacteric women are: first that after the necessary minimum of albumen -has been supplied, there shall be added an amount of carbohydrate and of -fat varying in relative proportions and quantities according to the -physiological requirements of the individual, but taken together -sufficient to supply the necessary heat-equivalent; secondly, that there -should be an abundant consumption of water; thirdly, that stimulating -dietetic adjuvants should as far as possible be avoided. - -The nitrogenous equilibrium of the body may be maintained either by -animal or by vegetable proteids; in the case of the former (animal -albumens), the climacteric woman should avoid those containing -considerable quantities of nucleo-albumen or of deleterious products of -tissue-change; in the case of the latter (vegetable albumens), she -should avoid those likely to cause undue stimulation of the intestinal -tract. Of flesh foods (mammals, birds, and fishes), those kinds are to -be preferred which contain small quantities only of extractives -(kreatin, xanthin, etc.) since these substances are supposed to have a -stimulating influence upon the nerves and the heart. Hence, boiled meat -is better than roasted, and the flesh of young animals (veal, for -instance) and fish are to be preferred to game, and the last-mentioned -is to be avoided especially for this reason, that the flavours for which -it is valued by the gourmet are products of partial decomposition -arising from prolonged hanging; for similar reasons, meat extracts, -animal soups, sausages, smoked flesh and fish, and preserved (potted) -meats, should all be avoided. From the intimate connexion between the -ingestion of nuclein and the formation of uric acid, albumens rich in -nuclein are to be forbidden; such are the various foods consisting -chiefly of gland-cells—sweetbread, liver, brain, kidneys, etc. As well -as from the appropriate flesh-foods, the requisite albumen may most -suitably be obtained from eggs and milk (including buttermilk); on the -other hand, caviare is unsuitable owing to its stimulant action on the -genital organs, cheese because it contains large quantities of the -products of decomposition of casein and milk-fat; the fermented milks, -koumiss and kefir, are likewise unsuitable. Suitable vegetable foods for -the supply of albumen (in addition to carbohydrates) are porridge, -bread, and the leguminosae; nuts, on the other hand, cause too much -irritation of the stomach and intestines. - -For women during the climacteric period we recommend a mixed diet -moderate in quantity; the amount of flesh and fat in the diet should not -be large, whilst cereals, green vegetables, and fruit may be taken in -greater abundance; irritant vegetable foods must be avoided, and -especially those which tend to stimulate unduly intestinal muscular -activity and intestinal secretion. It is important that an abundance of -water should be taken, not less than two or three pints daily, and a -pure, fresh, spring water is preferable to the aerated waters, natural -or artificial. Alcoholic beverages are to be avoided, and more -especially those which are rich in extractives as well as in alcohol. -For this latter reason, beer and champagne are harmful, whilst spirits -and liqueurs are to be condemned on account of the high percentage of -alcohol they contain. The stimulating alkaloidal drinks, tea and coffee, -are also to be avoided, or if taken at all, only in a very dilute form. -With regard to the preparation of the food, the cardinal principle is -that it should be as little irritant as possible; neither mechanically -irritating the alimentary tract by an excess of indigestible or -undigested residue, nor irritating it chemically by an excessive -admixture of sugar, salt, vinegar, pepper and other spices; nor, -finally, giving rise to thermal irritation by being excessively hot or -extremely cold. - -The individual meals are preferably small ones and they must therefore -be taken at comparatively short intervals, five times daily, the -principal meal being taken at one or two o’clock in the afternoon, and -the supper (which should be small) comparatively early, at seven or -eight o’clock. - - NOTE.—In his discussion of the _details_ of diet for women during - the climacteric period, hours of meals, actual dishes, etc., the - author refers exclusively to Austrian and German customs in these - matters. The translator has not attempted to adapt the following - pages to the needs of English readers, as he feels that the general - principles already given will enable the English medical man to - construct without serious difficulty suitable diet-tables for the - cases with which he has to deal. - -Suitable articles of food are the following: - -Soups, Broths, and other Liquid Foods: Soups and broths made from the -flesh or bones of beef, mutton, veal, chicken, or pigeon, _without_ the -addition of meat extract, or of meat juices, peptones, somatose or -nutrose, but _with_ _t_he addition of barley, oatmeal, rice, wheatmeal, -ryemeal, peas, beans, lentils, vermicelli, or macaroni; also broths or -porridge made from any kind of ground cereal, or from potatoes, or from -peas, beans, or lentils. - -Flesh Foods: Lean beef, veal, mutton, roast or boiled, pigeon, chicken; -certain fresh fish—pike, haddock, sole, perch, and trout. _Unsuitable_ -are: pork, goose, eels, salmon, herrings, oysters, caviare, lobster, -crab, smoked meat, hare, venison, wild-duck, brain, liver, kidneys. - -Vegetables, Sweets, and Savouries: Green peas, spinach, cauliflower, -carrots, turnips, buttered eggs, omelette, boiled and baked puddings, -rice boiled in milk, apples and rice, whipped cream, salads, wheaten -bread, French rolls, biscuits, and rusks. - -Fruits: Almost all fruits may be taken, raw, cooked, or preserved; also -in the form of currant and other fruit cakes, and as fruit-ices. - -Beverages: Milk, buttermilk, water, the same acidulated with various -fruit-juices and essences (as lemonade, etc.), weak tea with plenty of -milk, cocoa, chocolate. To be _forbidden_ are: beer, strong and sweet -wines, distilled spirits. - -An example is subjoined of a simple diet-table compiled on the above -principles: - - _Quantity _Albumen._ _Fat._ _Carbohydrate._ - in grams._ - AFTERNOON: - A cup of milk 150 5.4 5.4 7.5 - Roll and butter 70 4.9 0.4 39.2 - MIDDLE OF MORNING: - Soup 100 1.1 1.5 5.7 - Roll 70 4.9 0.4 39.2 - MID-DAY MEAL: - Soup 100 1.1 1.5 5.7 - Roast meat 100 38.2 1.7 - Green vegetables 100 1.6 0.4 8.4 - Pudding 200 17.4 30.0 57.8 - Fruit 100 3.0 15.0 - Bread 35 2.4 0.2 19.0 - BREAKFAST: - A cup of milk 150 5.4 5.4 7.5 - Roll 70 4.9 0.4 39.2 - SUPPER: - Soup 100 1.1 1.5 5.7 - Two soft eggs 90 11.2 10.8 0.4 - Bread 70 4.9 0.4 39.2 - Fruit 100 3.0 15.0 - ————— ————— ———— ————— - Total 1,617 110.5 69.9 304.5 - ===== ===== ==== ===== - - In addition, water, _ad libitum_, and perhaps a little light wine. - -In many cases, however, a mainly vegetarian diet may be more suitable, -and more particularly a mainly fruit diet, in order to diminish -persistent congestive symptoms. In such cases the following diet-table -may be recommended for _short_ periods: - -First breakfast: An apple and an orange. - -Second breakfast: 25 grams of white bread with butter and three baked -apples. - -Dinner (mid-day): 100 grams fish or meat, potatoes, green vegetables, 3 -boiled or baked apples. - -Afternoon: An orange, or an apple, or a pear, or some grapes. - -Supper: Milk, apples and rice, oranges, grapes, figs. - -Beverages: Water, with or without fruit juices or essences. - -Changes in the above diet-table could very readily be effected, whereby -the quantity of carbohydrate could be increased and the quantity of -albumen lessened. - -In women of sanguine temperament and full habit of body, who at the time -of the menopause very rapidly become obese, important changes in the -diet become necessary. The main principles of a fat-reducing diet are -the following: Avoidance of all overfeeding, reduction of the quantity -of food taken below the former average amount, with retention, however, -of a sufficiency of nutrient material to maintain the metabolic -equilibrium of the essential tissues; the maintenance of this metabolic -equilibrium demands a sufficiency of nitrogenous foods, but the fats in -the diet may be reduced to a minimum, and the carbohydrates may also be -very greatly diminished. At the same time, there must be systematic -bodily exercise, and the hours of sleep must not exceed a nightly -average of seven. - -For obese women at the climacteric period, a suitable average diet would -contain 160 grams albumen, 12 grams fat, and 120 grams carbohydrate, -yielding a daily heat-equivalent of 1,250 to 1,300 calories. - -A sample diet-table constructed on these principles is appended: - - _Quantity _Albumen._ _Fat._ _Carbohydrate._ - in grams._ - BREAKFAST: - A cup of weak 150 0.45 0.9 - tea - With milk, but 30 1.29 0.9 1.2 - no sugar - White bread 50 4.8 0.4 30.0 - Lean cold meat 50 19.1 0.9 - DINNER (Mid-Day): - Small cup of 100 1.1 1.5 5.7 - clear soup - Lean beef 200 76.4 3.4 - Green 100 1.6 0.4 8.4 - vegetables, - salad, etc. - Fruit 100 3.0 15.0 - Roll 35 2.4 0.2 19.6 - AFTERNOON: - A cup of weak 150 0.45 0.9 - tea - With milk, but 30 1.29 0.9 1.2 - no sugar - SUPPER: - Soup 100 1.1 1.5 5.7 - Lean roast meat 100 38.2 1.7 - Roll 50 4.8 0.4 30.0 - ————— ————— ———— ————— - Total 1,245 155.9 13.2 118.6 - ===== ===== ==== ===== - -In the selection of individual articles of diet, it is important to bear -in mind the fact that in all climacteric women it must be our aim to -stimulate intestinal muscular activity (peristalsis) and intestinal -secretion to a moderate extent, for by more active intestinal secretion -abdominal congestion is to some extent relieved, and by intestinal -transudation and by diminution of the lateral pressure the circulation -through the abdominal vessels is facilitated. By thus lowering the -intra-abdominal blood-pressure, we shall assist in relieving a number of -chronic hyperaemic states of the pelvic and various other organs, from -which women are prone to suffer at the menopause. Hence all articles of -diet must be forbidden which have a tendency to give rise to -constipation. But we must also forbid all substances which leave -extensive undigested residues, such as the rinds of fruits, large -quantities of porridge, etc., hard meats, nuts, and the like. Most -suitable are those articles of diet which contain large percentages of -fluid constituents, such as milk, thin soups, weak tea (infused only a -short time, so as to contain little tannic acid, which is very -constipating), white meat—veal, breast of chicken, etc. Of vegetables, -those are best which contain plenty of water and an abundance of the -organic acids, young, fresh garden produce, lettuce, cauliflower, young -green peas, young carrots, turnips, etc. Juicy fruits are good, apples, -pears, cherries, and plums. Butter and honey are also excellent. In many -persons suffering from constipation, all that is necessary for their -relief is to give a tumblerful of cold water the first thing in the -morning; with others, the use in addition of whole-meal bread with -plenty of butter and honey and uncooked fruit, is required. - -In women suffering from the various disturbances of the climacteric -period in an aggravated form, either because the menopause occurs at an -unusually early age, or because the suppression of menstruation has -taken place suddenly instead of gradually—especially in cases of -heart-trouble, severe vertigo, pronounced vasomotor disturbances, or -mental excitement (also erotic excitement), I have sometimes found a -methodical milk-cure carried on for several weeks most beneficial. By -this I do not mean an exclusive diet of milk, but a diet consisting -chiefly of milk and milk-foods; owing to the absence of all irritation -of the nervous and vascular systems, this diet has a very definite -sedative influence in such cases. The milk should be skimmed, and should -be given four times daily in gradually increasing quantities, the total -amount rising from ten ounces to fifty ounces daily. The only other meal -should be a substantial mid-day dinner, consisting of soup, roasted -white meat, young green vegetables, and a little fruit. In some -instances, to prevent constipation, it is necessary to add ten grams of -milk sugar to each glass of milk; in other cases it is necessary to -dilute the milk with water. It is obvious that the quantity of milk -given is not alone sufficient to maintain the metabolic equilibrium of -the body; but the defect in this respect is made up by the substantial -meal given at mid-day. - -Among the stimulating influences which during the sexual epoch of the -menopause are as far as possible to be avoided we must unhesitatingly -include the practice of coitus, inasmuch as at this time of life there -already exists a strong tendency towards the occurrence of hyperaemia of -the reproductive organs; and sexual intercourse, increasing as it -inevitably must this tendency to hyperaemia, should be indulged in as -little as possible. And yet precisely in women of the climacteric age, -in “la femme demi-vieille” there often exists a strong desire to drain -the cup of sexual pleasure to its dregs. Not infrequently, therefore, -the physician is asked to advise regarding the proposed marriage of a -woman in whom the menopause is drawing near, the desired husband being -young, or at least still fully virile. If the advice is given in all -sincerity with a sole eye to the woman’s health, the medical man will -definitely forbid the marriage. - -When, however, the changes of the menopause are fully completed, when -the woman’s reproductive organs have undergone complete senile atrophy, -there is no medical reason why a couple who wish to give a tenderer name -to an intimate friendship between man and woman, should refrain from -marriage—provided that both have attained a like stage of sexual -decline. “But,” writes _Tilt_, “a union between frosty January and -blooming May is likely to be as dangerous to the health as it is to the -happiness of both.” - -Whilst attending to the regulation of the physical diet of his -climacteric patient, the physician should not overlook her psychical -regimen. A woman’s mind is very powerfully affected by the processes of -the menopause. On the one hand, her fears are stimulated by the thought -that she is entering upon the “critical age,” of whose dangers she has -often been warned; and, on the other hand, she is mentally depressed by -the knowledge that she is about to lose the charms of womanhood, and to -decline in sexual esteem. It is well, therefore, for women during the -years of change, to have some kind of employment, which fills their -hours, occupies their thoughts, and—leaves a certain scope for the -exercise of feminine vanity. Works of benevolence or of general utility, -and literary occupations, are thus of great advantage to climacteric -women. _Plato_, indeed, pointed out that women at this time of their -lives should occupy themselves with literature and intellectual culture. - -Just as it is the duty of the physician, more especially of the family -physician, to enlighten the maiden on the threshold of her sexual -development regarding the processes of the awakening sexual life, and to -give her the necessary instruction concerning the hygienic measures -which it is proper for her to adopt—so also is it his duty to convey -medical information to the woman who stands on the threshold of sexual -decadence. A woman’s ignorance is often equally profound at both these -epochs of the sexual life. A woman in the early forties often does not -suspect, or at least refuses to acknowledge, that she is gradually -drawing near to the end of her sexual life; and she is still farther -from the knowledge that definite rules of general and sexual hygiene -must be observed by her if she wishes to minimize the dangers of the -critical period. - -The medical friend, in an earnest though far from gloomy manner, will -expound to her the nature of the physiological processes of the -menopause, and will instruct her regarding the corresponding preventive -measures—diet, exercise, clothing, care of the skin, and the regulation -of sexual intercourse. Moreover, the physician, by means of skilfully -directed enquiries regarding certain symptoms, will be enabled to gain -early information about the occurrence of abnormal processes at this -period of life, and will in this way detect the first beginnings of many -diseases which are amenable to treatment only at the very outset of -their course. For example, _Brierre do Boismont_, an early and accurate -observer of this sexual epoch in the life of woman, points out that in -cases in which, during the change of life, a woman experiences an -increased inclination for sexual intercourse, nineteen times out of -twenty, a local examination will disclose the existence of some disease -of the reproductive apparatus. Similarly, every gynecologist is now -familiar with the fact that unusually free, atypical haemorrhages during -the climacteric period, are commonly indications of the existence of a -uterine neoplasm. - -Much evil may be avoided, and much suffering can be diminished if the -physician, in accordance with the advice of Hippocrates, does not limit -his activities strictly to the exercise of the healing art, but stands -by a woman’s side as her mentor and confidant during the troublesome -years of her sexual decline. And he will best fulfil these functions, if -he succeeds in convincing the climacteric woman of the profound truth -embodied in the saying of the great French philosopher: - - Qui n’a pas l’esprit de son âge, - De son âge a tout le malheur. - - - - - INDEX - - - [References are to pages.] - - Abdominal pains, 46. - - Abdominal pressure, 46. - - Aberration, moral, 46. - - Absence of mind, 154. - - Absence of ovaries, 182. - - Abnormalities, mental, 155. - - Abortion, 223, 414. - - Abstinence, 256, 398. - - Acromegaly, 102. - - Act of intercourse, 84. - - Activity, sexual in women, 597. - - _Acton_, 276. - - Actual intercourse, 84. - - Adamites, 302. - - Africa, 43, 45. - - Age, average, at marriage, 200. - - _Agineta_, 464. - - _Ahlfeld_, 308, 333, 424, 448. - - Air hunger, 419. - - _Albert_, 331. - - _Albertus Magnus_, 1. - - _Albini_, 454. - - Albuminuria, 93. - - Alcohol, 155, 258, 270. - - _Algeri_, 155. - - _Alibert_, 408, 597. - - _Almquist_, 262. - - _Ahlfeld_, 482. - - Amenorrhœa, 84, 128, 160. - - Amentia, 103. - - America, 43. - - Amputation of clitoris, 184. - - _Amussat_, 542. - - _Amyntor_, 219. - - Anæsthesia, 184, 187. - - Anatomical changes, 8, 50, 141, 209. - - _Anderson_, 331. - - _Andral_, 582. - - Aneurysm, 98. - - Anger, 183. - - Angina pectoris, 240. - - _Anjel_, 191. - - Anomalies of vagina, 331. - - Antipathic sexuality, 194. - - Antitoxic functions, 21. - - _Ansell_, 365, 466, 561. - - _Ansty_, 135. - - Anxiety neurosis, 405. - - Apes, 22. - - Appetite, loss of, 46, 107. - - Aqueo-mucous vaginal discharge, 46. - - Arabian women, 30. - - _Aran_, 632. - - Areola mammae, 208. - - _Aretæus_, 1. - - _Aristotle_, 1, 211, 392, 420, 463, 473, 498, 544. - - _Arius_, 502. - - _Arndt_, 233, 343, 418. - - Arthritis, 635. - - Artificial fertilization, 317. - - _Asher_, 406, 538, 541, 559, 563. - - _Ashwell_, 109. - - Asia, 42. - - Aspermatism, 317. - - _Athenaeus_, 302. - - _Atlee_, 474, 603. - - Atmocausis, 419. - - _Atri_, 266. - - Atrophy, concentric, 590. - - Atrophy, excentric, 590. - - Atrophy, gradual, 592. - - Atrophy of uterine muscle, 609. - - Azoospermia, 316. - - - _Babbage_, 433. - - _Bacon_, 271. - - Bacterial flow, 593. - - _Baer_, 616. - - _Bain_, 203. - - _Bailly_, 183. - - _Baillarger_, 438. - - _Bainbridge_, 331. - - _Baker-Brown_, 546. - - _Balestra_, 575. - - _Ball_, 156. - - _Balzac_, 193. - - _Bandl_, 536, 557. - - _Barker_, 556. - - _Barnes_, 161. - - _Bartels_, 47, 331. - - Bartholin’s gland, 529. - - _Basch_, 296. - - Baths, 116, 117, 280, 654. - - _Battey_, 475, 564. - - _Baumes_, 260. - - _Baumgarten_, 166. - - _Baust_, 441. - - _Bazaraignes_, 434. - - _Beard_, 106, 405. - - Beauty, attribute of, 23. - - Beauty, curve of, 24. - - Beauty, decline in, 23. - - Beauty of woman, 200, 206. - - _Bebel_, 77, 394, 401, 415. - - _Beck_, 296. - - _Becker_, 305. - - _Bednar_, 478. - - _Beer_, 161. - - _Beigel_, 165, 300, 496, 505, 517, 525, 604. - - _Bélot_, 193. - - _Bennet_, 64, 88, 632. - - _Benzler_, 540. - - _Bergh_, 210, 496. - - _Bernard_, 78. - - _Bernstein_, 365. - - _Bertillon_, 218, 264, 382. - - _Berwitz_, 101. - - _Bidder_, 436, 439. - - _Biermer_, 412. - - _Billroth_, 337. - - _Birch_, 305. - - _Birkett_, 619. - - _Birsmont_, 29, 42, 45, 135, 594, 603, 607, 666. - - _Bischoff_, 136, 140. - - Bladder, irritable, 107. - - Blindness, 108. - - Blondes, 45. - - Blood, anomalies of, 478. - - Blood pressure, 16. - - _Blumbenbach_, 132. - - _Blundell_, 90, 417, 568, 603. - - Blushing, spontaneous, 46. - - _Bock_, 353. - - Bodily exercise, 658. - - _Brehm_, 62, 331. - - _Bömer_, 182, 618, 629, 632, 640. - - _Bohn_, 635. - - _Boileux_, 419. - - _Boinet_, 474. - - _Boireau_, 2. - - _Boivin_, 498. - - _Bonton_, 88. - - _Bonvalot_, 17. - - Books, 121. - - _Bordier_, 556. - - _Born_, 305, 456. - - _Bottermund_, 146. - - _Bossi_, 607. - - _Bouchardat_, 130. - - _Bowditch_, 46. - - Bowels, regulation of, 121. - - _Boyd_, 496. - - _Bradlaugh_, 393. - - _Braid_, 494. - - _Braun_, 234, 326, 332, 438, 446. - - Breasts, 213. - - _Brehm_, 416. - - _Breisky_, 326, 334, 515. - - _Breslau_, 423, 435, 437. - - _Breuer_, 92. - - _Brill_, 326. - - _Broudardel_, 72. - - _Brown-Sequard_, 20, 587. - - _Bruce_, 364. - - Brunettes, 45. - - _Bruntzel_, 182. - - _Buckle_, 378. - - Buddha, 168. - - _Buffon_, 167. - - _Bulimia_, 107. - - _Bulwer_, 260. - - _Burdach_, 294, 466. - - _Burg_, 413. - - _Burggraeve_, 496. - - _Burkart_, 473. - - _Burton_, 515. - - _Busch_, 2, 580. - - _Butlin-Smythe_, 235. - - _Butti_, 193. - - - Cæsarean section, 567. - - _Calderini_, 44. - - _Campbell_, 443. - - Cantharides, 186. - - _Capellmann_, 400. - - _Capwron_, 482. - - Cardiac disorders, 94, 97, 236, 243, 344, 626. - - Cardiopathie de la ménopause, 629. - - Cardiopathy, uterine, 235. - - Care of genital organs, 279. - - Care of skin, 658. - - _Carey_, 394. - - _Carlile_, 393. - - _Carlier_, 195. - - _Carus_, 80, 364. - - _Casper_, 189, 292, 547. - - _Castan_, 86. - - Castration, 419, 475. - - Catamenial flow, 83. - - Catarrh, gastric, 229. - - Catarrh in vagina, 614. - - Catarrh in vulva, 614. - - Cattle-breeders, 358. - - Causes of early development of menarche, 49. - - Causes for lack of sexual impulse, 188. - - Causes for intensity of sexual impulse, 188. - - Causes of ungratifying coitus, 357. - - Caustics, 119, 568. - - Cavum uteri, 56. - - Celibacy, 173. - - _Celsus_, 463. - - Cervix uteri, absence of, 506. - - Cervix uteri, deformities of, 503. - - Cervix uteri, hypertrophy of, 334. - - Cervix uteri, ideal form of, 502. - - Cervix uteri, normal form of, 502. - - Cervix uteri, pathological changes of, 501. - - _Charpignon_, 556. - - _Champonière_, 17. - - Change of life, 571. - - Changes in the skin, 148, 208. - - Characteristics, inherited, 25. - - _Charcot_, 100. - - _Charrin_, 21. - - _Chassaignac_, 107. - - _Chassagne_, 260. - - Chastity, 123. - - _Chazan_, 138. - - Checks to increase of population, 391. - - _Chevin_, 466. - - _Chiari_, 438, 490, 616. - - Chlorosis, 21, 86, 91. - - Christianity, diffusion of, 6. - - _Chrobak_, 214, 298. - - Chronic endometritis, 87. - - Chronic metrometritis, 87. - - Circulatory organs, 149, 240, 620. - - Circumcision of women, 328. - - Civilization, progress of, 6. - - _Clarke_, 443. - - Cleanliness of genital organs, 658. - - Cleft, vulval, 51. - - _Clément_, 629. - - _Cleveland_, 482. - - Climacteric insanity, 643. - - Climacteric phenomena, 600. - - Climacteric psychoses, 643. - - Climacteric psychoses, prognosis of, 653. - - Climacterium, 571. - - Climacterium, dangers of, 578. - - Climatic conditions, 27, 37, 117, 132. - - Clitoris, 74, 330. - - Clitoris crises, 352. - - Clothing, 114, 121. - - Coccygodynia, 107. - - Coffee, 121. - - _Coffignon_, 189. - - _Cohen_, 108. - - _Cohn_, 148. - - _Cohnstein_, 402, 548, 558, 634, - - Coitus interruptus, 345. - - Coitus, obstacles to completion of, 335. - - Coitus, prohibitive, 529. - - Coitus, undue frequency of, 294. - - Cold nature, 188. - - Cold sponging, 281. - - _Cole_, 553. - - _Collins_, 139. - - Colpotomy, 418. - - _Combys_, 79. - - Comedones, 110. - - Compensation, disturbances of, 254. - - Competence for marriage, 250. - - Conception, 137, 299, 304, 308, 366, 483. - - Conditions essential to procreation, 469. - - Condoms, 405, 409. - - _Confucius_, 385. - - Congestion, premenstrual, 142. - - Congfou, 403, 547. - - Congressus interruptus, 220, 225. - - Congressus reservatus, 225, 227. - - Conjugation, interference with, 487. - - Conjunction, 108. - - Conservants, 109. - - Constipation, 107, 228. - - Constitution, 38. - - Constitutional conditions and menopause, 599. - - Constrictor cunni muscle, 348. - - Consumption of nitrogen, 22. - - Continence, sexual, 400. - - Continence, sexual, enforced, 172. - - Contraction, pelvic, 334. - - Contrectation, 176. - - Control of instinctive impulses, 25. - - Control of reproductive function, 397. - - Convulsions, 152. - - _Cook_, 302, 443. - - _Cooper_, 639. - - Copulation, 200, 284, 323. - - Corpora albicantia, 592. - - Corpora fibrosa, 592. - - Corpus luteum, 59. - - Corset liver, 122. - - Corsets, 90, 122. - - Cosmophil nerves, 17. - - _Coste_, 136, 304, 454. - - _Courty_, 25, 29, 46, 132, 329, 361, 549, 594, 603, 607. - - _Craisson_, 292. - - _Crampe_, 380. - - _Crédé_, 494. - - Crimes committed during menstruation, 159. - - Critical age, 571. - - Critical period, 572. - - _Croom_, 164. - - _Cros_, 378. - - _Cruise_, 494. - - Culture, modern, 6. - - Curetting, 119. - - _Currier_, 609. - - Curve of the sexual life of woman, 4. - - _Cyon_, 16. - - Cysts, 588. - - - Dangers to sexual life, 276. - - _Dante_, 171. - - Dark rings around the eyes, 46. - - _Darwin_, 170, 376, 379, 380, 449, 485, 545. - - _Davis_, 340, 484. - - _Decaisne_, 165. - - Defloration, 326. - - Degeneration, stigmata of, 387. - - _De Graaf_, 136. - - _Debay_, 168, 482. - - _Dehio_, 116. - - _De la Motte_, 364. - - Delivery, previous, 560. - - _Delusianne_, 258. - - _Demange_, 21. - - _Demosthenes_, 271. - - _Denis_, 130. - - _Denman_, 555. - - Dental transverse ridges, 57. - - Derangement, 103. - - _D’Espine_, 40, 82, 477, 538. - - _Desqué_, 128. - - Determinants as to marriage, 259. - - Determination of sex, 420. - - Determination of sex, influences on, 421, 436, 445. - - Detumescence, 176. - - _De Villeneuve_, 144. - - _Devilliers_, 337. - - _Dewees_, 365. - - _Diamant_, 79, 158. - - Diarrhœa, 144. - - _Diderot_, 192. - - Diet, 112, 127, 659. - - Diet, regulation of, 660. - - Digestion, disorders of, 107. - - Digestive organs, 145, 630. - - Diminution of procreative capacity, 401. - - _Diokles_, 381. - - Disinclination to physical exercise, 93. - - Disorders, various, 85. - - Disparity in age, 265. - - Disturbances, nervous, 587. - - Disturbances of general system, 587. - - _Dohm_, 527. - - _Doran_, 617. - - Double chin, 572. - - _Doubleday_, 485. - - _D’Outreport_, 80. - - Dragging sensations, 46. - - Dreams, erotic, 107. - - _Dubois_, 135. - - _Duchatelet_, 477. - - _Duerer_, 210. - - _Duesing_, 231, 424, 442, 449, 453. - - _Dugès_, 498. - - _Duhousset_, 190. - - _Duke_, 480. - - _Duncan_, 146, 360, 367, 377, 466, 484, 513, 546, 562. - - _Dunlap_, 165. - - _Dunn_, 161. - - _Duplay_, 494. - - _Duprès_, 614. - - _Dupruyten_, 494. - - Duration of sexual period, 26, 30, 130, 181. - - Dysmenorrhœa, 160. - - Dysmenorrhœa, inflammatory, 162. - - Dysmenorrhœa, intermediate, 164. - - Dysmenorrhœa, mechanical, 162. - - Dysmenorrhœa, nervous, 162. - - Dysmenorrhœa, symptoms of, 163. - - Dyspareunia, 187, 347, 355, 358, 359. - - Dyspepsia, 23, 107, 227, 229, 631. - - - _Edebohls_, 165. - - _Edis_, 294. - - Effects of marriage on hysteria, 257. - - _Effertz_, 173. - - _Egger_, 118. - - _Eggle_, 211. - - _Eichstadt_, 298. - - _Eisenhart_, 107, 234. - - Ejaculatio praecox, 225. - - Ejaculation, 349. - - _Elberskirchen_, 173. - - _Elder_, 235. - - Elephantiasis of labia, 530. - - _Elliott_, 395. - - _Ellis_, 169. - - _Elsaesser_, 438. - - Emancipation, 200. - - Embrace, intimate, 84. - - _Emmet_, 45, 150, 414, 473, 522, 604. - - _Endogamy_, 386. - - Endometritis, 87, 235, 611. - - Energy of woman, 200. - - Engagement, 142. - - _Engel_, 494. - - _Engelhardt_, 244. - - _Engelmann_, 137, 142. - - _English_, 293. - - _Engstroem_, 40. - - Enlightenment of young girls, 35, 124, 273. - - Enteroptosis, 90. - - Epilepsy, 102, 257. - - Epithelioid cells, 60. - - Epistaxis, 165. - - Equal moral rights, 264. - - Equilibrium, mental, 153. - - _Erb_, 172. - - Erethism, sexual, 575. - - _Erlmeyer_, 473. - - _Eroess_, 78. - - Erotic dreams, 107. - - Erotic element, 173. - - Erotic problem, 264. - - Erotic sphere, 172. - - Eroticism, 652. - - Erysipelas, 634. - - _Esquirol_, 81, 646. - - _Etienne_, 21. - - Exogamy, 386. - - _Eulenburg_, 123, 199, 338, 354, 402, 405. - - Europe, middle, 41. - - Europe, southern, 42. - - _Eustache_, 293. - - Excess, habitual, 406. - - Excess, sexual, 560. - - Excessive prudery, 88. - - Excessive sexual desire, 178. - - _Ezekiel_, 47. - - - Facial aspect, 46. - - Fainting fit, 102. - - Fallopian tube, 489, 568. - - False shame, 340. - - Family life, 5. - - Febris amatoria, 92. - - _Federns_, 16. - - Feeling of weakness, 46. - - Feeling of numbness, 46. - - _Fehling_, 17, 396, 407. - - _Fellner_, 260. - - Female companion, 192. - - Female organs, diseases of, 83. - - _Feokstitow_, 309. - - _Ferdy_, 409. - - _Féré_, 258. - - _Ferrero_, 302. - - Fertility in woman, 363. - - Fertility, conjugal, 382. - - Fertility, ideal of, 365. - - Fertility, influences on, 374, 378. - - Fertility, maximum, 373. - - Fertility, monogenous, 373. - - Fertility of female criminals, 382. - - Fertility of prostitutes, 382. - - Fertility, physiological, 365. - - Fertility, restriction of, 388. - - Fertilization, 137, 300, 305, 317, 321, 322. - - _Feydeau_, 193. - - _Finkelstein_, 148. - - _Finlayson_, 366. - - _Fiquet_, 450, 454. - - _Fischel_, 165. - - _Flamerdinghe_, 525. - - _Flaubert_, 193. - - _Fleischer_, 16. - - _Fleischmann_, 146, 165. - - Flow, suppression of, 103. - - Follicles, graafian, 57. - - Follicles, primitive, 57. - - Follicles, ripening, 61. - - Foods suitable for menopause, 662. - - _Foerster_, 489. - - _Fordyce_, 556. - - Forensic significance of women during menses, 159. - - _Foster_, 135. - - _Frænkel_, 86, 91. - - _Franchi_, 165. - - _Frank_, 331, 466. - - Free love, 261. - - Free secretions, 51. - - Freedom of the male, 33. - - Freedom, sexual, 264. - - _Frerichs_, 632. - - _Freud_, 405. - - _Freund_, 103, 223, 225, 490, 494, 527, 601. - - _Fricke_, 109, 438, 448. - - _Fricker_, 165. - - _Friedmann_, 100, 104, 157. - - _Friedreich_, 108. - - “Friends,” 193. - - Frigidity, partial, 173. - - _Fritsch_, 143, 320, 341, 506, 519, 537, 555, 566, 600, 614, 619. - - _Froehlich_, 86. - - _Frommel_, 602. - - _Froriep_, 417, 568. - - _Frost_, 343. - - _Fuchs_, 646. - - _Fürbringer_, 168, 312, 317, 406, 535. - - _Fürst_, 440, 491. - - Function, sexual, 173. - - - _Galen_, 1, 77, 135, 187, 210, 251, 420. - - _Gallard_, 88. - - _Gallemairts_, 165. - - _Garat_, 652. - - Gastric secretion, 228. - - Gastro-intestinal affections, 235. - - _Gautier_, 193, 318. - - _Gavaret_, 582. - - _Gebhard_, 40, 79, 138, 142, 163. - - _Geissler_, 427. - - _Geist_, 637. - - _Gendrin_, 136. - - General disturbances, 145. - - General fatigue, 46. - - General weakness, 46. - - Genital organs, diseases of, 529. - - Genital organs, secretions of, 528. - - Genital organs, secretions of, reactions of, 529. - - _Gerbe_, 453. - - _Gilbert_, 89. - - _Gilles de la Tourette_, 109. - - _Gillirray_, 415. - - _Giordano_, 172. - - _Giraud_, 156, 186, 318. - - Girdles of chastity, 417. - - _Girdwood_, 136. - - _Glaevecke_, 138, 166, 182, 575, 629, 644. - - Glands, reproductive, 20. - - Glands, sebaceous, 51. - - Globules, polar, 305. - - _Glünder_, 537. - - _Godefroy_, 482. - - _Goehlert_, 370, 380, 423, 427, 443, 466. - - _Goethe_, 3, 120, 167. - - Goitre, 108. - - _Goltz_, 21, 237. - - Gonococcus, 26. - - Gonorrhea, 200, 220, 278, 511. - - Gonorrheal infection, 533, 553. - - _Goodell_, 183, 406, 515, 575. - - _Goodman_, 18. - - _Gosselin_, 534. - - _Gottschalk_, 235, 603, 612. - - Graafian follicles, 57, 584, 587. - - _Gräfe_, 398, 406. - - _Graily-Hewit_, 234, 296. - - _Grawitz_, 90. - - Great uterine plexus, 16. - - _Grechen_, 539. - - Greeks, unchastity of, 192. - - _Grenser_, 521. - - _Griesheim_, 456. - - _Griesinger_, 105, 653. - - _Grillparzer_, 285. - - _Grimmaldi_, 81. - - _Grisolle_, 260. - - _Grohe_, 298, 473. - - _Grünewaldt_, 467, 532, 551, 559. - - _Grünfeld_, 110, 118, 209, 409. - - _Grusdeff_, 41. - - _Gunzburg_, 410. - - _Gurrieri_, 87, 382. - - _Gusserow_, 494, 525, 616. - - _Gutceit_, 105, 289, 350, 545. - - _Guy_, 30, 596, 603. - - Gynandry, 190. - - Gynecological examination, 119. - - _Gyurkovechky_, 315. - - - _Hæckel_, 460. - - Hæmicrania, 100, 154. - - Hæmmorhages, 604. - - Hæmotopoiesis, 21, 89. - - _Hahn_, 165. - - Hair, pubic, 51, 110. - - _Haller_, 80. - - “Half old,” 576. - - _Haller_, 2, 364, 544. - - _Hammerschlag_, 89. - - _Hammond_, 258. - - _Hampe_, 426. - - _Hanau_, 260, 478. - - _Hang_, 148. - - _Hannover_, 31. - - Hardening of constitution, 25. - - _Harley_, 320. - - _Hartmann_, 202, 416. - - _Haschek_, 482. - - _Hasler_, 306. - - _Hauff_, 182. - - _Haussmann_, 299, 331, 408. - - _Haycraft_, 378. - - _Hayem_, 113. - - Headache, 107. - - Heart, degeneration of, 238. - - Heart, female, at puberty, 98. - - Heart, puberal development, 98. - - Heart, spasms of, 98. - - Heat, 136, 139. - - Heat, fugitive, 577, 581. - - Hebe, 210. - - Hebephrenie, 101. - - _Heber_, 148. - - _Hebra_, 146, 634. - - _Hecker_, 308, 424, 438. - - _Hedin_, 466. - - _Hegar_, 17, 91, 140, 168, 173, 182, 218, 224, 243, 278, 282, 292, 346, - 386, 397, 564. - - _Heidenreich_, 108. - - _Heinberger_, 108. - - _Heine_, 98. - - _Heitzmann_, 147, 325. - - _Hellwald_, 181. - - _Helmont_, 2. - - _Hemsbach_, 438. - - _Henle_, 58, 597. - - _Hennig_, 19, 99, 215, 333, 493, 556. - - _Henoch_, 632. - - _Henrik_, 235. - - _Hensen_, 137, 179, 249, 304, 308, 348, 422, 439, 449. - - _Heusinger_, 165. - - _Heppner_, 495. - - Hereditary predisposition, 245. - - _Herman_, 343, 612. - - _Hermes_, 565. - - _Herodotus_, 185, 301. - - _Herpes_, 111. - - _Hettstenius_, 383. - - _Hewitt_, 522. - - _Hey_, 46. - - _Hildebrand_, 341, 511. - - _Hippocrates_, 1, 101, 103, 129, 135, 306, 381, 420, 480, 502, 631. - - _Hirsch_, 135. - - _Hirschfeld_, 305. - - _Hirt_, 405. - - _His_, 304. - - _Hoesslin_, 405. - - _Hofacker_, 422, 426, 429, 434. - - _Hoffmann_, 69, 74, 89, 296, 331, 334, 344, 496. - - _Hofmeier_, 80, 305, 484, 525, 536. - - _Hohl_, 296. - - _Hollaender_, 100. - - _Holst_, 300, 475, 523. - - Homosexuality, 189, 198, 548. - - _Horace_, 271. - - _Horn_, 432. - - Horse breeders, 358. - - _Hortle_, 165. - - _Horton_, 326. - - Hottentot apron, 212, 328. - - _Huchard_, 252. - - _Hughes_, 100. - - _Humbold_, 2. - - Humming top murmur, 96. - - _Hunter_, 486. - - Hydrometra, 613. - - Hydrotherapeutics, 115. - - Hygiene during menacme, 261. - - Hygiene during menarche, 111. - - Hygiene during menopause, 653. - - Hygiene of marriage, 265. - - Hygiene, rules of, 125. - - Hymen, 63, 333. - - Hymen, various forms, 66, 67. - - Hyperæmia, 581. - - Hyperæsthesia, 107, 178. - - Hyperplasia, 612. - - _Hyrtl_, 61, 213, 330, 446. - - _Huysmans_, 206. - - Hysteria, 154, 245. - - - _Icard_, 203. - - Ideal passion, 36. - - _Ill_, 515. - - Impotence, complete, 337. - - Impotence, paralytic, 336. - - Impotence, psychical, 335. - - Impotentia concipiendi, 551. - - Impotentia generandi, 551. - - Impulse, sexual, 76, 123, 166, 168, 169, 182, 190, 201. - - Impulse, sexual, inverted, 548. - - Impulse, sexual, perverted, 548. - - Impulse toward reproduction, 169. - - Inability to marry, effects of, 261. - - Inbreeding, 386, 486. - - Incapacity for inoculation of ovum, 549. - - Incapacity for inoculation, causes for, 552. - - Incest, 197. - - Incontinence, 278. - - Indifference, sexual, 171. - - Individual variations, 133. - - Infective germs, 220. - - Infibulation, 416. - - Infidelity, marital, 357. - - Inflammatory processes, 87, 238. - - Influences on female organism, 15. - - Injuries in parturition, 223. - - Injuries in parturition, complications, 224. - - Injuries to vagina, 331. - - Inner tunic, 59. - - Insanity, 152, 249. - - Insomnia, 107. - - Instinct for preservation of species, 201. - - Intensity of sexual life, 26. - - Intercourse, sexual, at early age, 27. - - Intercourse, sexual, during menstruation, 140. - - Intercourse, sexual, frequency of, 275. - - Intercourse, sexual, lack of, 257. - - Intercourse, sexual, need of, 281. - - Intercourse, sexual, promiscuous, 301. - - Intercourse, sexual, restraint in, 276, 301. - - Intermenstrual pain, 164. - - Intermenstrual period, 140. - - Interval between periods, 132. - - Intestinal meteorism, 46. - - Investigations, anatomical, 446. - - Investigations, experimental, 452. - - Investigations, statistical, 422. - - Iridochoroiditis, 108. - - Irritable weakness, 336. - - Irritation, senile, 613. - - _Islam_, 129. - - Itching sensation in genital organs, 46. - - - _Jackson_, 494. - - _Jacobi_, 18. - - _Jaffé_, 235. - - _Janovsky_, 147. - - _Jarowski_, 112. - - Jealousy, 651. - - _Jeamin_, 208. - - _Jeannel_, 538. - - Jewesses, 45. - - _Joachim_, 45. - - _Johannsen_, 509. - - _Johnstone_, 138. - - _Jolly_, 186. - - _Joseph_, 147. - - _Joubert_, 42. - - _Jung_, 641. - - _Janke_, 450, 454. - - _Justinian_, 48. - - _Juvenal_, 192, 273, 392. - - - _Kahane_, 89, 112. - - _Kahlbaum_, 101. - - _Kahlden_, 141. - - _Kaltenbach_, 292. - - _Kapysa_, 266. - - Katatonia, 103. - - _Kehrer_, 293, 299, 316, 417, 509, 513, 521, 538. - - _Kennedy_, 337, 365. - - Keratitis, 108. - - _Keppler_, 566. - - _Kerley_, 165. - - _Készmarsky_, 499. - - _Key, Ellen_, 201, 262. - - Kidney, movable, 122. - - _King_, 364. - - _Kirn_, 103. - - Kiss, 285. - - _Kiwisch_, 494, 603, 616. - - _Klebs_, 473, 490, 494, 507, 552. - - _Kleinwaechter_, 396, 406, 410, 556, 563, 601, 618. - - _Klinkosch-Hill_, 494. - - _Koblanck_, 364. - - _Kocks_, 417, 568. - - _Koeberlé_, 182, 564. - - _Koenig_, 593. - - _Koeroesi_, 372, 375, 384. - - _Kokkogam_, 291. - - Koran, 294. - - _Kossmann_, 419. - - _Kostkewitsch_, 630. - - _Kowalewski_, 102, 155, 647, 653. - - _Krafft-Ebing_, 77, 103, 155, 159, 176, 184, 186, 189, 196, 258, 282, - 349, 353, 358, 403, 641, 647. - - _Krause_, 290, 348. - - _Krausold_, 195. - - _Kretschy_, 16. - - _Krieger_, 28, 31, 40, 43, 98, 130, 134, 145, 482, 594, 603. - - _Kristeller_, 297. - - _Krönig_, 257. - - _Kroner_, 335, 539. - - _Krugenstein_, 159. - - _Kuehne_, 116. - - _Kulischer_, 181. - - _Kundrat_, 89, 137, 142. - - _Kussmaul_, 81, 182, 189, 489, 494. - - - _Labalbary_, 541. - - Labia, 212. - - Labial hernia, 328. - - Laboring classes, 27. - - _Lacasella_, 192. - - Lactation, 139, 403. - - _Lafarque_, 197. - - _Lambert_, 191. - - _Lamy_, 232. - - _Landau_, 143, 240, 566, 568. - - _Lantier_, 80. - - _Larcher_, 260. - - _Lasarewitsch_, 499. - - Lascivious procedures, 195. - - Lateral sacral arteries, 14. - - _Lauenstein_, 522. - - _Laurent_, 81. - - _Laval_, 146. - - _Law_, 109, 165. - - _Lawrence_, 161. - - _Lawson Tait_, 102, 139, 564, 618, 637. - - _Lebedinsky_, 479. - - _Lebert_, 260, 616, 619. - - _Lecal_, 45. - - _L’Eclos_, 573. - - _Lecluyse_, 567. - - _Lee_, 474. - - _Le Fort_, 165, 339. - - _Legoyt_, 377. - - _Legrand du Saulle_, 159, 198. - - Legs, paræsthesia of, 107. - - _Lehmann_, 241. - - _Leopold_, 137, 141, 326, 528, 616. - - _Léseurs_, 318. - - _Leube_, 93. - - _Leuckart_, 446. - - _Lever_, 466. - - _Levi_, 496. - - _Levinstein_, 473. - - _Levy_, 419, 438, 531. - - _Lewin_, 478. - - _Lewy_, 235. - - _Leyden_, 233, 252. - - Libido sexualis, 641. - - _Lichtenberg_, 109. - - _Liebig_, 393. - - _Liégois_, 166. - - _Lier_, 406, 538, 541, 559, 563. - - Limitation of offspring, 283. - - Linea alba, 208. - - _Linnæus_, 132. - - Lipomatosis, 93, 635. - - _Lippich_, 377. - - Liquor folliculi, 59. - - _Litschkuss_, 499. - - _Litzmann_, 168, 296. - - Local causes, 48. - - Local disturbances, 145. - - Local irritations, 177. - - _Lode_, 305. - - _Loehlein_, 556. - - _Loewenfeld_, 106, 173, 256, 308, 402, 406. - - _Loewenhardt_, 137. - - _Loewenthal_, 304. - - _Loewy_, 22, 482. - - _Lombard_, 118. - - _Lombroso_, 46, 81, 159, 170, 186, 192, 203, 210, 262, 301, 382. - - _Lona_, 381. - - _Lorain_, 612. - - _Lott_, 408, 502. - - _Louis_, 332. - - Love, free, 305. - - Love in woman, 170, 285. - - Love, Lesbian, 189, 415. - - Love of early youth, 77. - - Love, perfect, 263. - - Love, platonic, 171. - - _Lower_, 538. - - _Lucas_, 494. - - _Lucian_, 192. - - Lumbar enlargement, 226. - - Lumbar pain, 46. - - _Lumpe_, 498. - - _Lutaud_, 320. - - Lutein cells, 60. - - _Luther_, 168, 269, 385. - - _Lycurgus_, 272. - - Lymphatic vascular system, 15. - - - _Mabille_, 155. - - _Mackenzie_, 109. - - _Macnaughton Jones_, 161, 163. - - _McClintock_, 525. - - _Macdonald_, 522. - - _MacDowell_, 564. - - _McGillivray_, 476. - - _McLennan_, 443. - - _Magnan_, 178, 198. - - Mahommedan people, 62. - - _Mahomet_, 269. - - _Mainländer_, 168. - - _Mairet_, 158. - - Male, prepotency of, 450. - - _Malthus_, 376, 389. - - Malthusian League, 393. - - Mamma, 73, 75, 619. - - _Mandl_, 142, 235. - - Mania, 249, 650. - - Manipulations, intra-uterine, 238. - - _Mantegazza_, 23, 76, 170, 190, 193, 198, 207, 213, 380, 405. - - _Manus_, 266, 385. - - Marasmus, senile, 576. - - _Marcé_, 155, 250. - - _Marie-Clement_, 2. - - _Marholm_, 205. - - _Mariagalli_, 17. - - _Marilegoute_, 434, 455. - - Markzellen, 89. - - _Marotte_, 102. - - Marriage, at what age, 266. - - Marriage, consanguineous, 387. - - Marriage, immoral, 262. - - Marriage of near kin, 267. - - Marriage, premature, 473. - - _Marsa_, 364. - - _Marsh_, 597. - - _Martial_, 189. - - _Martin_, 80, 139, 299, 331, 337, 342, 474, 512, 536. - - _Martineau_, 81, 190. - - _Maschka_, 61, 66, 72, 190, 195, 331, 547. - - Masochism, 194. - - Masturbation, 88, 104, 124. - - Maternity, 200. - - Maturation, 140, 188. - - _Matusch_, 627, 646, 652. - - _Maxwell_, 613. - - _Mayer_, 31, 40, 45, 131, 297, 332, 384, 478, 599, 603. - - _Mayet_, 382. - - Means for exciting voluptuous sensations, 361. - - _Meinert_, 90. - - _Meissner_, 365, 538, 606. - - Melancholia, 103, 257. - - Membrane, uterine mucous, 217. - - Menacme, pathology of, 218. - - Menacme, physiology of, 201. - - Menacme, sexual epoch of, 200. - - Menarche, 37. - - Menarche and menopause, 595. - - Menarche, pathology of, 82. - - Menarche praecox, 78, 82. - - Menarche tardiva, 78, 82. - - _Mende_, 365. - - _Mendes de Leon_, 142, 235. - - _Menge_, 593. - - Menopause, 571. - - Menopause and race, 594. - - Menopause, artificial, 580. - - Menopause, changes in, 582. - - Menopause delayed, 600. - - Menopause, pathology of, 608. - - Menopause, premature, 600. - - Menopause, sudden, 600. - - Menopause, time of, 593. - - Menorrhagia, 86, 160, 608. - - Menses, suppression of, 233. - - _Mensinga_, 406, 411. - - Menstrual blood, 129, 130. - - Menstrual cycle, 19. - - Menstrual psychoses, 193. - - Menstrual stimulus, 103. - - Menstrual style, 148. - - Menstruation, 124. - - Menstruation, anomalies of, 83. - - Menstruation and age, 32, 38. - - Menstruation and climate, 32. - - Menstruation and nationality, 32. - - Menstruation, beginning of, 30. - - Menstruation, bloodless, 578. - - Menstruation, cardiac activity during, 143. - - Menstruation, cessation of, 576. - - Menstruation, disorders during, 144. - - Menstruation, disturbances of, 219. - - Menstruation, first appearance, 45, 82. - - Menstruation, irregular, 134. - - Menstruation, late, 483. - - Menstruation, pathology of, 143. - - Menstruation, praecox, 79. - - Menstruation, regular type of, 134. - - Menstruation, remittent, 135. - - Menstruation, vicarious, 164. - - Mental disturbances, 145, 161. - - Mental stimuli, 84. - - _Mercier_, 118. - - _Merson_, 653. - - _Messalina_, 185. - - Metabolic balance, 94. - - Metabolism, 19, 635. - - Metamorphosis, retrogressive, 584. - - Metritis, chronic, 611. - - Metritis, virginal, 232. - - Metrorrhagia, 86. - - _Metschnikoff_, 32. - - _Meyerhofer_, 300, 304, 446. - - _Michel_, 525. - - _Michelet_, 6, 273. - - _Micklucho-Mackay_, 415, 476, 541, 564. - - _Mill_, 393. - - _Miller_, 108. - - Mind, disturbances of, 226. - - Minor troubles, 226. - - Misuse of medical science, 395. - - _Moebius_, 268. - - _Moericke_, 141. - - Moist appearance, 51, - - _Molitor_, 80. - - _Moll_, 175, 189, 194, 198. - - Mons veneris, 210. - - _Montesquieu_, 378, 538. - - _Montgomery_, 80. - - _Mooren_, 108, 160. - - _Moraglia_, 194. - - Moral demand, 36. - - Morality, sexual, 36. - - Morbus virgineus, 92. - - _Moreau_, 122, 332, 573. - - _Morgagni_, 472. - - _Morityel_, 484. - - Morning sickness, 231. - - Morphological elements of semen, 310. - - Mortality of married men, 174. - - Mortality of married women, 218. - - _Morton_, 407, 466. - - Mosaic law, 129, 270. - - _Moser_, 438. - - Motherhood, dread of, 201. - - Mother’s supervision, 120. - - _Moulin_, 478. - - _Maurange_, 612. - - Mucus, alkaline cervical, 133. - - _Mueller_, 168, 233, 300, 320, 332, 475, 499, 528, 623. - - _Mundé_, 515, 612. - - Murmurs, systolic, 149. - - _Murphy_, 334. - - Museums, 120. - - _Mussy_, 292, 641. - - Myoma, 240. - - - _Naegele_, 137. - - _Nagel_, 60. - - _Napier_, 161. - - _Nathusius_, 379. - - Natural frigidity, 172. - - Natural instincts, 120. - - Nausea, 107. - - _Neefe_, 438. - - _Nega_, 494. - - _Negri_, 17. - - _Negroni_, 474. - - _Neisser_, 537, 554. - - Nerves, 10. - - Nervous disturbances, 150, 161, 248. - - Nervous diseases, 243, 244, 637. - - Nervous irritability, 145. - - Nervous system, 99. - - _Neudoerfer_, 108. - - _Neugebauer_, 407, 528. - - _Neumann_, 245. - - Neuralgia, 151. - - Neurasthenia, 107. - - Neurasthenia, sexual, 123. - - Neuroses, 149, 225. - - _Neusser_, 17, 89. - - _Nieden_, 365. - - _Nietsche_, 202. - - _Noble_, 492. - - _Noegerath_, 512, 531, 534, 537. - - _Noirot_, 423. - - _Noorden_, 21, 90. - - _Nordau_, 399. - - _Nothnagel_, 113. - - Novels, 120. - - _Nussbaum_, 449, 474. - - Nutrition and genesis, 376. - - Nymphomania, 184. - - - Obesity, 23, 92, 479, 636. - - _Obermeier_, 165. - - Obturator, 412. - - Ocular trouble, 108. - - Oceania, 43. - - _Odebrecht_, 119. - - _Oehlschlaeger_, 304. - - _Oehlshausen_, 249, 343, 474, 476, 509, 523, 537, 560. - - _Oesterlen_, 122, 331, 422. - - Official examination before marriage, 265. - - Old maids, 644. - - Olfactory sense, 109. - - Oligozoöspermia, 316. - - Onanism, 199, 404. - - Onanism, mechanical, 106. - - Onanism, mental, 106. - - Onanism, peripheral, 106. - - Onanism, psychical, 351. - - Only-child-sterility, 464. - - Oöphorectomy, 139, 475. - - Operative measures, 415. - - _Oppenheimer_, 538. - - Organ of hearing, 148. - - Organ of vision, 148. - - _Ormerod_, 494. - - Ostium uterinum tubæ, 56. - - _Ott_, 18, 20, 146. - - _Otto_, 328. - - Outer tunic, 59. - - Ovals, 413. - - Ovarian tenderness, 100. - - Ovaries, 216, 471, 473, 474. - - Ovaries, anatomical alterations, 583. - - Ovaries, atrophy of, 583. - - Ovaries, changes in, 8. - - Ovaries, diseases of, 489. - - Ovaries, extirpation of, 564. - - Overstrain, intellectual, 120. - - _Ovid_, 213. - - Ovulation, 136, 470. - - Ovum, discharge of, 136, 304, 306, 307. - - _Owen_, 393. - - - _Paget_, 619. - - _Pagliani_, 46. - - _Pajot_, 293, 506, 527. - - _Pajot-Négrier_, 135. - - _Palmay_, 549. - - Palpitation, 46, 95, 97, 107. - - _Panecki_, 234. - - Papa, 194. - - Paranoia, 152. - - _Paré_, 285. - - _Parent-Duchatelet_, 81, 193, 477, 538. - - _Parsons_, 165. - - Pathological conditions in woman’s life, 599. - - Patriarchical relationship of woman, 5. - - _Patru_, 610. - - _Pauli_, 147. - - _Péan_, 182. - - _Pelmann_, 155. - - Pelvic viscera, 9. - - Penis captivus, 340. - - _Percy_, 314. - - Period of sexual pleasure, 350. - - Peripheral nerves, 16. - - Peristalsis, 107, 229. - - Perversion, sexual, 195, 360. - - Pessaries, 406, 411. - - _Petiteau_, 165. - - _Peyer_, 293. - - _Pfaff_, 190. - - _Pfannenstiel_, 59. - - _Pfannkuch_, 369, 559. - - _Pfau_, 498. - - _Pflueger_, 136, 475, 546. - - Philo-Indicus, 156. - - Physical disturbances, 153. - - Physical exercise, 113. - - Physician’s duty to enlighten girls, 125. - - Picture galleries, 120. - - _Pigeolot_, 407. - - Pigmentation, 161. - - _Pincus_, 419. - - Pisciculture, 458. - - _Place_, 393. - - _Plato_, 265, 391, 666. - - Pleasurable sensations, 177. - - _Plenk_, 333. - - Plicæ palmetæ, 296. - - _Pliny_, 185, 273, 463. - - _Plon_, 38, 46, 62, 81, 185, 214, 291, 308, 361, 416, 433, 446, 476, - 545. - - _Plutarch_, 190, 302, 420. - - _Plyette_, 79, 165. - - Pollutions, 352. - - Polypus, 510, 590. - - _Pomeroy_, 276, 414. - - Porro’s operation, 567. - - Portio vaginalis, 503. - - Position, different modes of, 291. - - _Potain_, 150, 628. - - Potentia coeundi, 309. - - Potentia generandi, 309. - - _Pouchet_, 136. - - _Power_, 108. - - _Pozzi_, 343. - - Pregnancy, 139, 245, 247. - - Preventive measures, 255, 292, 388, 399, 410. - - _Prévost_, 7. - - Prima nox, 302. - - Primitive conditions of society, 5. - - _Prior_, 365. - - _Prochownick_, 559. - - _Prochownik_, 538. - - Profluvium seminis, 358. - - Prohibited degrees, 268. - - Pro-nucleus, female, 305. - - Pro-nucleus, male, 305. - - Prostitution, 195, 262. - - Pruritus, vaginal, 107. - - Pruritus, vulvæ, 107, 634. - - Pseudo-narcotism, 626, 638. - - Psychical influences, 17. - - Psychical manifestations, 18. - - Psycho-neuroses, 23. - - Psychopathia sexualis, 184, 257. - - Psychopathic states, 152. - - Psychoses, 155. - - Puberty, 37, 200. - - Pudendum, female, 204. - - Pudic nerve, 111, 348. - - _Puech_, 29, 109, 165, 182, 478, 597, 603. - - Pulse, 94, 96, 144. - - _Pye-Smith_, 100. - - Pyrosis, 107, 228. - - - _Quain_, 166, 472, 494, 629. - - _Quetelet_, 366, 379. - - - _Rabba_, 129. - - _Rabbi Akita_, 129. - - _Rabbi d’Azai_, 129. - - _Rabbi José_, 129. - - _Rabbi Joshua_, 266. - - _Rabbinowicz_, 129. - - _Rabuteau_, 18, 19. - - Race, 38. - - Rachitis, 117. - - _Raciborski_, 26, 122, 247, 258, 260, 268, 274, 399. - - Railway accidents, 84. - - Rape, 295. - - _Raschi_, 129. - - _Ratgen_, 165. - - Ratios between male and female births, 422. - - _Ravn_, 43. - - _Rayer_, 633. - - Recreation, domestic, 121. - - Reflex disturbances, 230. - - Regeneration, post-menstrual, 143. - - _Regnier_, 163. - - Regulation of sexual intercourse, 269. - - _Reichert_, 137. - - _Reine_, 18, 163. - - Relations of healthy and unhealthy female organs to other organs of the - body, 25. - - _Renaudin_, 482, 494. - - Reproductive organs of girl of ten, 53. - - Reproductive organs of new born, 52. - - Reproductive organs of virgin, 55. - - Respiratory organs, 107, 146, 254. - - Rest cure, 113. - - Retching, 107. - - Retroflexion, 88, 230. - - _Reuter-Gabriele_, 201. - - _Reyher_, 414. - - _Rheinstein_, 143. - - Rhythmical variations, 20. - - _Ribbing_, 26, 122, 247, 258, 268, 274, 399. - - _Ricardi_, 194, 452. - - _Richard_, 265. - - _Richarz_, 451. - - _Richter_, 22. - - _Ricord_, 408. - - _Riecke_, 13. - - _Riedel_, 403, 544. - - _Riese_, 438. - - Rights of physical love, 203. - - Rights of women, 173. - - _Ritschie_, 482. - - _Roberts_, 564. - - _Rochard_, 466. - - _Rodbertus_, 393. - - _Rodriguez_, 480. - - _Rodzewitsch_, 365, 482. - - _Roehrig_, 15, 525. - - _Rogival_, 618. - - _Rokitansky_, 489, 494, 603. - - _Romberg_, 642. - - _Roosevelt_, 394. - - _Rosen_, 478. - - _Rosenbach_, 252. - - _Rosenthal_, 352. - - _Rosenstadt_, 180. - - _Rosin_, 116. - - _Rossi_, 109, 317, 332. - - _Rosthorn_, 12, 214, 492. - - _Roth_, 211, 452. - - _Roubaud_, 287, 289, 362. - - _Rouget_, 296. - - _Rousseau_, 103, 124, 213. - - _Routh_, 181. - - _Rouvier_, 42. - - _Rueder_, 612. - - _Ruettel_, 364. - - Rugæ, 216. - - _Ruge_, 475, 522. - - _Runge_, 121, 176, 221, 261. - - _Rush_, 365. - - _Russ_, 100. - - Rut, 136, 139. - - - _Sacher-Masoch_, 193. - - Sacrache, 46. - - Sadism, 194. - - _Sadler_, 366, 369, 377, 422, 430. - - _Saenger_, 119, 396, 492, 512, 537. - - _Saexinger_, 494, 616. - - _St. Hilaire_, 434. - - _St. Prospêre_, 171. - - _Salmon_, 21. - - _Sand_, 262. - - _Sappho_, 190. - - _Satschoma_, 499. - - _Scanzoni_, 72, 275, 326, 474, 517, 523, 597, 604, 616, 619. - - _Schaefer_, 155. - - _Schatz_, 475. - - _Schauenstein_, 191. - - _Schauta_, 144, 147, 162, 245, 260, 490. - - _Schenk_, 458, 486. - - _Schichareff_, 18, 20. - - _Schiller_, 271. - - _Schlager_, 154, 645, 653. - - _Schlesinger_, 141. - - _Schmalfuss_, 166, 182. - - _Schmidt_, 29, 365. - - Schnürleber, 122. - - Schnurthorax, 90. - - _Schoeltz_, 116. - - _Schoenfeld_, 330. - - _Schönlein_, 108. - - _Schopenhaur_, 168, 202. - - _Schorler_, 559. - - _Schottlaender_, 60. - - _Schrader_, 19, 126, 146. - - _Shreiner_, 312. - - _Schroeder_, 155, 341, 521, 525, 538, 564. - - _Schubert_, 116. - - _Schüle_, 153, 186, 653. - - _Schuermayer_, 197. - - _Schultze_, 210, 448, 556. - - _Schwartz_, 536. - - _Schwing_, 147, 365. - - _Scott_, 614. - - Scrofula, 117, 484. - - Seaside, 117. - - Seasonal variations, 180. - - Seborrhœa, 110, 118. - - Sebum, 110, 118. - - _Sée_, 100. - - _Seeligmann_, 165, 466, 535. - - Segmentation sphere, 306. - - _Seiler_, 92. - - Self-deception, 574. - - _Semper_, 450. - - _Senator_, 146. - - Senescence, 572. - - Sensation of fulness in hypogastric region, 46. - - Senses, organs of, 108, 145, 250. - - Sensibility, sexual, in women, 542. - - _Sergi_, 170. - - Sex combination, 427. - - Sex relations, 35. - - Sex, third, 201. - - Sexual abuses, 258. - - Sexual impulse, 179. - - Sexual life, central perceptions of, 177. - - Sexual life, development of, 176. - - Sexual needs, 33. - - Sexual neurasthenia, 199. - - Sexual satisfaction, 177. - - _Shakespeare_, 277. - - _Sheldon_, 612. - - Sheltered life, 212. - - _Sickel_, 438. - - Signs, prodromal, 129. - - _Siebold_, 438. - - _Simon_, 130, 527. - - _Simpson_, 218, 465, 487, 603, 618. - - _Sims_, 297, 314, 318, 365, 466, 513, 521. - - _Sinéty_, 141. - - _Sintemma_, 136. - - _Skene_, 612. - - Skin, diseases of, 146, 632. - - Skin, eruptions of, 146. - - Skopstki, 184. - - _Slavjansky_, 473. - - Sleep, 115. - - _Sloan_, 108. - - Smegma, 51, 529. - - Soaps, 118. - - Social circumstances, 599. - - Social significance of sexual life, 33. - - _Socrates_, 269. - - Sodomy, 190. - - _Solanieff_, 556. - - _Solon_, 269, 273. - - _Sommerus_, 482. - - Song of Solomon, 23. - - _Soranus_, 308, 381, 420, 463, 502. - - _Spaeth_, 438. - - _Spallanzani_, 317. - - Spartan custom, 272. - - Spasms, clonic, 102. - - Spasms, tonic, 102. - - _Spencer Wells_, 182, 376, 466, 485. - - Spermatozoa, 304, 306, 310. - - _Spiegelberg_, 475, 515, 560. - - _Spietschka_, 110, 118, 209. - - _Stadion_, 193. - - _Staël_, 3. - - _Stark_, 482. - - _Starkweather_, 451. - - Stays, tight, 97. - - Steatopyga, 573. - - _Steglehner_, 528. - - _Stein_, 202. - - _Steinbow_, 203. - - _Steiner_, 100. - - Stenokardia, 98. - - _Stepanow_, 109. - - _Stephenson_, 85. - - Sterility, absolute, 540, 569. - - Sterility, artificial, 413, 462, 464, 468, 484. - - Sterility, one-child, 561. - - Sterility, operative, 563. - - Sterility, relative, 540, 569. - - Sterility, varieties of, 470, 569, 570. - - _Stevens_, 522. - - _Stieda_, 91, 384. - - _Stiehl_, 124. - - _Stille_, 406. - - _Stiller_, 147. - - Stimulation, local, 237. - - Stimulation, mechanical, 15. - - Stimulation, thermic, 15. - - Stomach, ulcer of, 107. - - _Storer_, 414. - - _Strabo_, 415, 564. - - _Strahan_, 386. - - _Strassmann_, 16, 138, 140, 143, 241. - - _Stratz_, 24, 212. - - Striæ, 209. - - _Strindberg_, 206. - - _Strogamoff_, 593. - - Sudden frights, 84. - - _Suesserot_, 525. - - Suicide, 174. - - Suppression of menses, 158. - - _Susruta_, 48, 129, 307, 420, 463. - - _Swieten_, 333. - - _Swift_, 441. - - Sympathetic action, 549. - - Sympathetic nervous system, 237. - - Syncope, 150. - - _Synkits_, 482. - - _Szukits_, 28, 131, 134. - - - Tachycardia, 23, 345. - - _Tairi_, 407. - - _Talmud_, 129, 276, 292, 294, 307. - - _Talquist_, 365, 383. - - _Tardieu_, 190, 195. - - _Tarnowskaja_, 382. - - _Tarnowsky_, 262. - - _Tassenbroek_, 142. - - Taste, acid, 107. - - Taste, pasty, 107. - - Taste, perverse, 107. - - _Tauffer_, 166, 496, 499. - - _Taxil_, 192. - - _Taylor_, 364, 482. - - Tea, 121. - - Tenderness of breasts, 46. - - Tetany, 247. - - Theaters, 120. - - _Theilhaber_, 235, 609. - - _Theopold_, 543. - - _Thiery_, 452. - - _Thomas_, 413. - - _Thompson_, 334, 404, 406. - - _Thorn_, 602. - - _Thyroid_, 108. - - _Tilt_, 29, 31, 43, 135, 518, 582, 594, 600, 626, 629, 631, 634, 666. - - _Timan_, 325. - - _Tissier_, 183. - - _Tissot_, 102. - - _Toldt_, 215. - - _Tolstoi_, 34, 206, 397, 401. - - Tonsils, hypertrophy of, 107. - - _Touchon_, 453. - - _Tousenel_, 443. - - Towels, sanitary, 125. - - _Towers-Smith_, 480. - - _Traugott_, 116. - - Travels, 121. - - Tribadism, 190. - - _Troggler_, 187. - - Troubles, domestic, 219. - - _Tschowuloff_, 382. - - Tuberculosis, 259. - - _Tuke_, 155. - - Tumors of rectum, 334. - - Tunica propria, 60. - - _Tussenbeck_, 235. - - Two-children-system, 384. - - _Tyler-Smith_, 522. - - - _Ultzmann_, 287, 312. - - Uncle, 194. - - Underwear, 122. - - Undulatory movement, 18. - - Uneasy sensations, 46. - - Unhappy marriages, 190. - - Union of Social Harmony, 393. - - Upbringing, domestic, 120. - - _Upjohn_, 449. - - Urinary organs, 146. - - Urine, retention of, 126. - - Urnings, 197. - - Uterine annexa, 566. - - Uteromania, 184. - - Uterus, 91, 214, 297, 494, 499, 500, 515, 523, 558, 590, 614, 617. - - - _Vacher_, 383. - - Vagina, 216, 526. - - Vaginal stricture, 346. - - Vaginismus, 335, 337, 341, 345. - - Vaginodynia, 343. - - _Valenta_, 406. - - _Varge_, 333. - - Vascular system, 13. - - Vasomotor disturbances, 104, 151. - - _Vedeler_, 521. - - Veins, 13. - - _Veit_, 60, 87, 308, 327, 342. - - _Velpeau_, 619. - - Venus apparatus, 412. - - Venus powder, 412. - - _Vera_, 35. - - Veraism, 263. - - Vertigo, 46, 154. - - _Viault_, 118. - - _Villermé_, 377, 379. - - Viraginity, 190. - - _Virchow_, 86, 91, 208, 379, 489. - - _Virey_, 132, 328, 545, 595. - - Virginity, moral, 123. - - Visceral neuralgia, 640. - - Vitreous body, 108. - - _Vogel_, 130. - - _Voigt_, 165. - - _Voltaire_, 285. - - Voluptuous sensations, 203. - - Vomiting, 107, 230. - - _Vorst_, 394. - - Vulva, 526. - - - _Wald_, 191. - - _Waldeyer_, 58, 60, 605. - - _Wallace_, 400. - - _Walter_, 607. - - _Wappaeus_, 379, 423, 435. - - Waterbrash, 228. - - Waters, natural, 116. - - Waters, mineral, 116. - - _Watson_, 165. - - Weakly women, 28. - - Weight at age of puberty, 47. - - _Weinbrunn_, 332. - - _Weinhold_, 416. - - _Weiss_, 333. - - _Wendeler_, 591. - - _Werne_, 416. - - _Wernich_, 296. - - _West_, 474, 525. - - _Westphal_, 142, 158, 189, 195. - - Weybsbart, 210. - - _Whitehead_, 369. - - _Wilhelm_, 147. - - _Wilkins_, 445. - - _Willbraud_, 193. - - _Wille_, 157, 407. - - _Williams_, 137. - - _Wilson_, 635. - - _Windmueller_, 165. - - _Windscheid_, 150, 243, 247, 627, 640, 642. - - _Winkel_, 128, 342, 474, 509, 523, 527, 558. - - _Winter_, 84. - - _Winterhalter_, 138. - - _Withrow_, 165. - - Woman, influence of, 206. - - Women writers, 34. - - _Wyder_, 304, 332. - - - _Yamagiron_, 217. - - _Young_, 482. - - - _Zarathustra_, 202. - - _Zeis_, 331. - - _Zeissl_, 478, 535. - - _Ziehl_, 496. - - _Ziemssen_, 526. - - _Zola_, 193. - - _Zoroaster_, 269. - - _Zunaikornustax_, 210. - - _Zweifel_, 72, 528. - ------ - -Footnote 1: - - Concerning the Feminine Constitution. - -Footnote 2: - - Concerning the Barren. - -Footnote 3: - - Concerning Virgins. - -Footnote 4: - - On the Diseases of Regions. - -Footnote 5: - - On the Secret Parts of Women. - -Footnote 6: - - Essay on the Physical and Mental Diseases of Women. - -Footnote 7: - - Physiological Considerations on the Diverse Epochs of the Life of - Woman. - -Footnote 8: - - Concerning Sexual Differentiation, and Its Influence on Organic - Nature. - -Footnote 9: - - The Sexual Life of Woman. - -Footnote 10: - - On account of the womb alone is woman what she is. - -Footnote 11: - - The womb is the cause of all the diseases from which women suffer. - -Footnote 12: - - “Love is an episode merely in the life of man; of woman, it is the - entire history.” But this epigram of Madame de Staël’s will, to - English readers, be more familiar in the form in which it was cast by - Byron (_Don Juan_, canto i, stanza 194): - - “Man’s love is of man’s life a thing apart; - ’Tis woman’s whole existence.” - -Footnote 13: - - On Love. - -Footnote 14: - - “This century will be known as the century of the diseases of the - uterus.” - -Footnote 15: - - Half-virgin. - -Footnote 16: - - Beauty of the devil. - -Footnote 17: - - “The cry of the suffering organ comes not from the uterus but from the - entire organism.” - -Footnote 18: - - “One for Many. Leaves from the Diary of a Maiden of Vera.” - -Footnote 19: - - It is by a certain abuse of terminology that the name _follicle_ is - given to these structures even before the appearance of fluid in their - interior, the word _folliculus_ meaning properly a _little bag_ or - _sack_. The author’s limitation of the term _graafian follicle_ to the - later, full-grown stage of these structures, though historically - accurate, is not usual in England.—TR. - -Footnote 20: - - “A uterus served by organs.” - -Footnote 21: - - _Menorrhage des Jeunes Filles et Hypertrophie du Col Utérin._ - -Footnote 22: - - The German word used is _Herzkrampf_; in the first line of the - paragraph it is used in the plural, and in inverted commas. Angina - pectoris proper, the severe and often fatal disease met with chiefly - in elderly men, is sometimes known in Germany as _Herzkrampf_, but the - established and distinctive German name for the affection is - _Stenokardia_. It is evident, however, that Krieger’s cases are not - cases of true angina, and it is probable that they would be classed by - English physicians under the heading of _pseudo-angina pectoris_.—TR. - -Footnote 23: - - _Hebephrenie._—There is no current English equivalent of this word, - used by Kahlbaum to denote a form of melancholia occurring at puberty, - and terminating in dementia.—TR. - -Footnote 24: - - Katatonia (_Katatonie_) is a term used in Germany to denote insanity - associated with muscular rigidity.—TR. - -Footnote 25: - - A term introduced by Charcot. See page 97. - -Footnote 26: - - The author’s classification is adhered to. It is not usual, I believe, - in Germany, to class the thyroid body among the organs of respiration. - But the only disease mentioned under the above heading is goitre.—TR. - -Footnote 27: - - In Germany the term _Lanugo_, or _Wollhaar_, is used to denote the - rudimentary hairy covering of the body throughout life, as - distinguished from the specialized and fully developed hairs of the - head, beard, axillæ, etc. In England the use of the term _lanugo_ is - usually restricted to denote the downy crop of hair with which an - infant is covered at birth, which is shed in a few months thereafter. - See the English edition of Toldt’s Atlas of Human Anatomy, Part VI., - Appendix, note 503.—TR. - -Footnote 28: - - It will be noticed that the author uses the term _seborrhœa_ as a - general term for diseases of the sebaceous glands, including acne. In - England acne, and its preliminary stage, the formation of comedones, - are separately considered, the signification of the term seborrhœa - being limited to denote cases in which the secretion of the glands - forms an oily, waxy, or scaly accumulation on the surface. _Seborrhœa - oleosa_ is defined by Crocker as that form of the affection in which - the olein is in excess.—TR. - -Footnote 29: - - It must be remembered that these dietetic directions are for German - and Austrian middle-class people, the arrangement of whose meals - differs from ours considerably. The usual meals and hours are: Early - breakfast, coffee and rolls, at 8 or earlier; second breakfast, a more - substantial meal, at 10; mid-day dinner, the principal meal, at 1 or 2 - P. M.; afternoon coffee, at 4; supper at 8 P. M.—TR. - -Footnote 30: - - Regarding the significance attached by the author to the words - _seborrhœa_ and _seborrhœis_, see note to page 107. - -Footnote 31: - - _Eine Mutterpflicht._ - -Footnote 32: - - See note 26 to p. 107. - -Footnote 33: - - My peace is lost, - My heart is heavy, - I find it never - And nevermore. - My bosom presses - Towards him, - Ah, could I seize him - And embrace him, - And kiss him, - As I long to do, - In his kisses - I should pass away. - -Footnote 34: - - It seems expedient to point out that whilst in this work the German - word _Geschlechtstrieb_ has in the great majority of cases been - rendered in English by the term _sexual impulse_, on two or three - occasions, as here, the author speaks of the _Geschlechtstrieb_ as - composed of _sensation_, _perception_, and _impulse_ (_Drang_), when - for obvious reasons the rendering _sexual instinct_ becomes necessary. - Though the term _sexual impulse_ is, I think, in more general use than - the term _sexual instinct_, it must not be forgotten that the - inclination towards sexual congress is composite in nature, and that - an _impulse_ in the strict sense of the term is only one element in - its composition.—TR. - -Footnote 35: - - This word _urning_, used to denote individuals exhibiting this - particular type of homosexuality, belongs to the terminology now - generally adopted by writers on sexual pathology, and has been used by - English writers on the subject—Havelock Ellis, for instance. - -Footnote 36: - - The German word _Angst_, here translated anxiety, is used in various - senses, ranging from _anxiety_ to _anguish_, according as the mental - element or the element of pure feeling predominates in the conception. - In the case of the _angst-neurosis_, however, a condition of _mental_ - uneasiness would appear to be connoted, and therefore _anxiety_ is the - best rendering.—TR. - -Footnote 37: - - German, _Lendenmarksymptome_. - -Footnote 38: - - German, _saures Aufstossen und Sodbrennen_; for the latter noun - _heartburn_ would appear to be the most precise English equivalent, - since the term _pyrosis_ is sometimes employed to denote the _acid - eructation_ (or _water-brash_) and sometimes the accompanying - sensation at the pit of the stomach—_heartburn_ or _cardialgia_. - Etymologically, of course, the latter sense of _pyrosis_ is correct - (Greek, πῦρ, fire).—TR. - -Footnote 39: - - By consideration of the results of treatment. - -Footnote 40: - - Ger. _in den Parametrien_. The reasons for preferring the phrase - _parametric connective tissue_ to the noun _parametrium_ will be found - in the English edition of Toldt’s _Atlas of Human Anatomy_, Part IV, - App. note 84. - -Footnote 41: - - It is usual of the Continent of Europe to divide the course of - pregnancy into ten “months” of four weeks each. This fact must never - be forgotten when comparisons are made between English and Continental - tables, respectively, of the events of pregnancy. - -Footnote 42: - - Ger. _Lufthunger_. - -Footnote 43: - - See note 36 on p. 225. - -Footnote 44: - - The statement is so often made that conception occurring when one or - both parents are intoxicated is likely to be harmful to the offspring, - that it seems expedient to point out that neither the author of this - work, nor any other author known to me, has ever brought forward any - rigorous scientific evidence in proof of the alleged fact. It is one - of those crude generalizations whose superficial verisimilitude leads - to their continued though unsupported reassertion. The fact that the - notion of procreation by inebriated progenitors is repugnant to our - æsthetic sensibilities has, of course, nothing whatever to do with the - logical proof of the assertion that such an act is harmful to the - fruit of conception.—TR. - -Footnote 45: - - Respect kisses the hand, - Affection kisses the cheek, - Spiritual love kisses the mouth. - Desire the neck; - Amatory frenzy kisses the whole body. - -Footnote 46: - - The author omits special reference to the metastatic orchitis that so - frequently complicates epidemic parotitis (mumps) when that disease - occurs after puberty. Though usually benign in character, the - inflammation very often results in atrophy of the testicle. - Fortunately, bilateral atrophy from this cause is very rare; and even - when it does occur, both testicles being extremely small, _potentia - coeundi_ and _potentia gestandi_ may nevertheless remain. But when - double atrophy from this cause takes place _before_ puberty (happily - an occurrence of the utmost rarity), sexual development is usually - arrested, the sufferer being in effect a eunuch.—TR. - -Footnote 47: - - It is recorded of John Hunter that in a case of hypospadias, he - advised the patient to draw his semen into a syringe and inject it - into his wife’s vagina, with fruitful result.—TR. - -Footnote 48: - - _Constrictor Cunni Muscle._—In women the _bulbocavernosus muscles_, - right and left, form, as it were, a sphincter to the vaginal outlet. - Hence the alternative names of _sphincter vaginæ_ and _constrictor - cunni muscle_. The latter name is in common use in Germany, but, - though appropriate, is rarely employed in England.—TRANSL. - -Footnote 49: - - “Prostitutes conceive often, but abort frequently.” - -Footnote 50: - - “Prostitutes become fecund when, abandoning their profession, they - marry, or pass under the protection of a single man; in such cases - they become pregnant, they are always happy, and their children are as - healthy as those of other women.” - -Footnote 51: - - Compare stanzas 46 and 47 of “Venus and Adonis”: - - His ears up-prick’d; his braided hanging mane - Upon his compass’d crest now stands on end; - His nostrils drink the air, and forth again, - As from a furnace, vapours does he send: - His eye, which scornfully glisters like fire, - Shows his hot courage and his high desire. - - Sometimes he trots, as if he told the steps, - With gentle majesty and modest pride; - Anon he rears upright, curvets and leaps, - As who should say, “Lo! thus my strength is tried; - And this I do to captivate the eye - Of the fair breeder that is standing by.” - -Footnote 52: - - NOTE.—In Germany, the term _Ausfallserscheinungen_ is used as a - general name for the various disorders of the climacteric period. The - word _Ausfall_ means literally _a falling out_, or _shedding_, as of - the hair. No precise English equivalent of the term is known to me, - nor is one really needed, the phrase _disorders of the climacteric_ - being sufficiently distinctive.—TRANSL. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - -Changes made to medical terms, proper names, or foreign words. Does not -include the index which was always corrected to agree with the text. In -case of multiple changes only the first is listed: - - Page Original Text Changed Text - vii etc. Amenorrhoea Amenorrhœa - vii etc. Dysmenorrhoea Dysmenorrhœa - vii Anaesthesia Anæsthesia - x Asterahanthion Asterakanthion - x etc. Oligozoospermia Oligozoöspermia - x Uteras Uterus - 2 climateric climacteric - 3 coëxtensive coextensive - 8 manfestations manifestations - 13 hæmorrhoidal haemorrhoidal - 23 chorosis chlorosis - 39 Roberton Robertson - 55 Fraenum Frænum - 55 etc. Nymphae Nymphæ - 60 dentoplasm deutoplasm - 71 etc. Carunculae Carunculæ - 73 primæ primae - 78 etc. Præcox Praecox - 95 etc. amenorrhœic amenorrhoeic - 96 venticle ventricle - 98 teleangiectasis telangiectases - 99 patients complain patients who complain - 104 phychosis psychosis - 105 sexual sexually - 110 suderiferous sudoriferous - 116 hæmaglobin hæmoglobin - 119 Sænger Saenger - 128 etc. hyperæmic hyperaemic - 138 Strassman Strassmann - 148 chloasmia chloasma - 148 meatas meatus - 154 organism in predisposed organism is predisposed - 166 larnyx larynx - 194 Riccardi Ricardi - 207 overy ovary - 209 Spietshka Spietschka - 211 etc. Rothe Roth - 212 etc. uretha urethra - 215 etc. nulliparæ nulliparae - 220 organims organisms - 222 teleangiectases telangiectases - 222 splanchoptosis splanchnoptosis - 223 vulvular valvular - 240 hysterica hysteria - 240 hæmorhages hæmorrhages - 241 hyperæmias hyperaemias - 260 Rozières Rosières - 280 hygenic hygienic - 291 constictor constrictor - 291 ishiocavernosus ischiocavernosus - 291 Zanibar Zanzibar - 299 Hausmann Haussmann - 303 etc. aesthetic æsthetic - 303 etc. hetairae hetairæ - 303 etc. mediaeval mediæval - 306 mezalocephala megalocephala - 306 Nusbaum Nussbaum - 310 laminae laminæ - 310 speramatozoa spermatozoa - 314 spematozoa spermatozoa - 315 etc. azoöspermia azoospermia - 316 blenorrhœa blennorrhœa - 326 Brille Brill - 327 fistulae fistulæ - 332 foetaltal foetal - 334 cyctocele cystocele - 339 urethal urethral - 339 hymenal hymeneal - 339 kolpitis colpitis - 354 lupulin 0.5 (¾ grain) lupulin 0.05 (¾ grain) - 365 Rodsewitsch Rodzewitsch - 383 Tallquist Talquist - 396 Sänger Saenger - 404 cartarrhal catarrhal - 412 vaginia vagina - 414 Pomerey Pomeroy - 418 Arendt Arndt - 456 infusioria infusoria - 456 acquaria aquaria - 470 etc. anaemia anæmia - 472 climateric climacteric - 472 lupinars lupanars - 477 perenchymatous parenchymatous - 488 haematokolpos haematocolpos - 492 catarrahal catarrhal - 494 Güsserow Gusserow - 494 Renauldin Renaudin - 495 lacunae lacunæ - 496 columnae columnæ - 496 labiae labiæ - 499 dysmenorrhoeic dysmenorrhœic - 500 dysmenorrhoeal dysmenorrhœal - 502 tincae tincæ - 511 Hildebrandt Hildebrand - 513 Germany is believing Germany in believing - 515 blenorrhagia blennorrhagia - 516 parameterium parametrium - 524 hyperaesthetic hyperæsthetic - 529 etc. papillae papillæ - 539 avortment avortent - 539 sout sont - 539 conjuctival conjunctival - 540 urethae urethrae - 541 hyspospadias hypospadias - 541 hvpospadiac hypospadiac - 544 etc. anaemic anæmic - 549 dysmenorrhoeal dysmenorrhœal - 559 Pfankuch Pfannkuch - 564 overian ovarian - 580 mucuous mucous - 603 physionognomy physiognomy - 612 Munde Mundé - 631 Haematemesis Hæmatemesis - 633 seborrhoeic seborrhœic - 648 the casual agent the causal agent - 650 paroxyms paroxysms - 654 oesophagus œsophagus - 658 defaecation defæcation - - 1. Silently corrected typographical errors and variations in spelling. - 2. Archaic, non-standard, and uncertain spellings retained as printed. - 3. There are references to temperatures in Rankine units. I doubt this - would be meaningful when referring to human temperatures but I did - not alter them. - 4. Footnotes were re-indexed using numbers and collected together at - the end of the last chapter. - 5. Enclosed italics font in _underscores_. - - - - - -End of the Project Gutenberg EBook of The sexual life of woman in its -physiological, pathological and, by Enoch Heinrich Kisch - -*** END OF THIS PROJECT GUTENBERG EBOOK THE SEXUAL LIFE OF WOMAN *** - -***** This file should be named 63274-0.txt or 63274-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/6/3/2/7/63274/ - -Produced by Richard Tonsing, Turgut Dincer, and the Online -Distributed Proofreading Team at https://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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