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                                  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_.