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A. M. Drutmnond 

Cornell University 

The original of this book is in 
the Cornell University Library. 

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Copyright 1916, by 




Introduction 1 


(Puberty) 33 

A. Europe 38 

1. Northern Europe 38 

2. Middle Europe 39 

3. Southern Europe 40 

B. Asia 40 

C. Africa, Oceania, America 41 

First Appearance of Menstruation 45 

Menarche Precox et Tardiva (Precocious and 

Retarded Menstrual Activity) 56 

Inflammatory Processes 63 

Disorders of H^matopoiesis 65 

Cardiac Disorders 70 

Diseases of the Nervous System 77 

Masturbation 85 

Disorders of Digestion 88 

Diseases of the Respiratory Organs 89 

Diseases of the Organs of the Senses 90 

Hygiene During the Menarche 95 

Menstruation , 120 

Vicarious Menstruation ^ 129 

The Sexual Impulse 130 


Hygiene During the Menacme 159 

Copulation and Conception 195 

' Cardiac Troubles due to Sexual Intercourse 203 

Dyspareunia 206 




Fertility in Women 224 

The Restriction of Fertility and the Use of 
Means for the Prevention of Pregnancy. . . 253 

The Determination of Sex 280 

- Sterility in Women 282 

Incapacity for Ovulation 294 

Sexual Sensibility in Women 307 

Incapacity for Incubation of the Ovum 318 

Only-Child-Sterility 336 


The Menopause 340 

Changes in the Female Reproductive Organs in 

the Menopause 358 

The Time of the Menopause 366 

The Age at which the Menopause Occurs 366 

i. Race , .' 367 

2. The Age at which the Menarche Occurred . . 368 

3. The Woman's Sexual Activity 372 

4. The Social Circumstances of the Woman's 

Life 374 

5. General Constitutional and Pathological Con- 

ditions 374 

6. Premature Delayed and Sudden Onset of the 

Menopause 376 

Diseases of the Organs of Circulation 388 

Diseases of the Digestive Organs 404 

Diseases of the Skin 407 

Disorders of Metabolism 411 

Diseases of the Nervous System 414 

Climacteric Psychoses 423 

INDEX 461 



By the sexual life of woman we understand the re- 
ciprocal 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 reproduc- 
tive 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 : mpi TwaiKuris 
^vtreos,^ a treatise on the physiology and pathology of 
woman; irepi A<j)opuv,^ which discusses sterility in 
women; irept irapOeviuv,^ a treatise on the pathological 
states of virgins. These writings of Hippocrates con- 

1 Concerning the Feminine Constitution. 
* Concernjng the Barren. 
' Concerning Virgins. 



tain some very remarkable observations on the influ- 
ence 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 Aretaeus 
and Galen on the diseases of women we find striking 
observations, as for instance, in Galen's De Locis 
Affectts* which contains a "Statement of the Simi- 
larity and Dissimilarity of Man and Woman." An- 
other notable work is that of Albertus Magnus, en- 
titled De Secretis Mulierum.^ 

The numerous works on the diseases of women pub- 
lished 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 knowl- 
edge 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-Laflfecteur, Essai sur 
les Maladies Physiques et Morales des femmes,^ Paris, 
1793; and also in Marie-Clement's Considerations 
Physiologiques sur les Diverses Epoques, de la Vie 
des Femmes,'' Paris, 1803. In the same connection we 
must mention von Humboldt's treatise, Ueber den 
Geschlechtsunterschied und dessen Einfluss auf die 
organische Natur.^ The first comprehensive work in 
which an exhaustive inquiry was made into the func- 
tional disorders of the female genital organs and the 

* On the Diseases of Regions. 

. ? On the Secret Parts of Women. 

« Essay on the Physical and Mental Diseases of Women 

' Physiological Considerations on the Diverse Epochs of the Life of 


j^J^Concerning Sexual Differentiation, and Its Influence on Organic 


relation of these disorders to the female organism as 
a whole and to the physical and 'mental peculiarities 
of woman was Busch's: Des Geschlechtdeben des 
Weibes,^ Leipzig, 1839. 

In the second half of the nineteenth century a very 
large number of monographs were published, investi- 
gating and describing the reflex disturbances produced 
alike in the individual organs and in the nervous sys- 
tem as a whole by changes in the uterus and its annexa. 
Many of these works will be mentioned more particu- 
larly 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 enor- 
mously 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 de- 
velopment of the sexual organs, the act of copulation, 
conception, pregnancy, parturition, and the puerperi- 
um, finally the involuntary process which accom- 
panies the cessation of menstruation at the climacteric 
period — every one of these sexual phases entails con- 
secutive physiological processes and pathological 

9 The Sexual Life of Woman. 


changes alike in the individual organs and in the nu- 
tritive condition of the entire organism, in the func- 
tions 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. 

Just as in a tree the process of growth is made mani- 
fest to the superficial observer by the pleasure he feels 
at the sight of the buds and blossoms, by the refresh- 
ment 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 meno- 
pause) , in which we see the gradual decline and ulti- 
mate extinction of sexual power and all its manifesta- 
tions. 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 in- 
contestably apparent in all vital manifestations. What 
Madame de Stael said of love is indeed true of the 
entire sexual life of woman : I'amour n'est qu'une epi- 
sode de la vie de I'homme; c'est I'histoire tout entiere 
de la femme}° 

The sexual life of woman is coextensive with the 
peculiar vital activity of the fem ale sex, for it endures 

?±:^^ltoTlln::%'r '"''- '°^" '" ^^''='' '* -- -* ^y Byron R 
"Man;s love is of man's life a thing apart: 
T15 woman's whole existence." 


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 nuniber 










56 -oO 















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

of women give birth to a child, and the age at which 
menstruation ceases ; and reducing the figures to aver- 
ages. * 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. 
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 cul- 
ture, 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 re- 
lated; 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 tempo- 
rary and transient. The investigations of anthropolo- 
gists 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, how- 
ever, 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 levelling 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 previ- 
ously occupied in the family circle and in society at 
large. Both among the Greeks and among the Ro- 
mans, there was open to women a more intimate place 
in social life and a more influential role in the life of 
the family, than would have been their portion re- 
garded merely in relation to their childbearing 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 . 


In consequence of the diflfusion of Christianity, wom- 
an 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 sup- 
plied regulations adapted to the changing phases of 
sexual vital manifestations. The wise adaptation of 
these regulations requires, however, a full understand- 
ing of the mental and physical processes, an exact 
recognition of the bodily states and intellectual sensi- 
bilities 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, manifest- 
ing 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 UAmour}^ 
the author remarks that every century is characterized 
by the prevalence of certain diseases; thus, in the thir- 
teenth 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, "j^ decle sera nomme celut des 
maladies de la matrice}^ It is certain that the educa- 
tion and mode of life of the modern woman belonging 

1' On Love. 


to the so-called upper classes are, as far as sexual mat- 
ters are concerned, in direct opposition to those that 
are agreeable to nature and those that the laws of health 

Even before sexual development begins, before the 
physical ripening of the reproductive organs to func- 
tional 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 un- 
der the influence of the now awakened sexual impulse, 
which experiences ever-renewed stimulation. A seden- 
tary mode of life, unsuitable nutriment, and the early 
enjoyment of alcoholic beverages, exhibit their inevita- 
ble result in the frequency with which, in this epoch 
of the sexual life, chlorotic blood-changes, neurasthenic 
conditions, and divers 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 en- 
lightened 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 Prevost in the expression 
demi-verge}^ 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 mar- 
riage, leads often to the appearance of vaginismus and 
other sexual neuroses in young married women. Even 

^* Half-virgin. 


more disastrous in its consequences as regards the future 
sexual life of the wife is the ever-increasing frequency 
of gonorrhoeal infection in the first days of marital in- 
tercourse, 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 satis- 
faction 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 seri- 
ous 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, lead- 
ing to a premature appearance of the general pheno- 
mena 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 over- 
taken by sexual death. 

The psychical influences which proceed from the 
female genital organs in the different periods of sexual 
life have 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 wom- 
an, 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 pro- 
cesses and spinal hyperaesthesia. 

Psychical manifestations and the nervous states as- 
sociated with these are somewhat frequently, and even 
actual psychoses occasionally, encountered in the vari- 
ous phases of the sexual life of woman, sometimes tak- 
ing the form of violent sexual storms, which may in- 
deed, as ordinary menstrual reflexes, accompany every 
catamenial period. 

Of great interest are the facts which have, in recent 
times especially, been scientifically established, point- 
ing 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 Schi- 
chareff, have shown tha,t 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 expres- 
sion also in the functions of the reproductive organs. 
Goodman has compared this play of general vital func- 
tions 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 of production, a rise in blood- 
pressure, and an increased excretion of urea; in the 
former we see, on the contrary, that all these vital pro- 
cesses display a diminished intensity. The moment 
when the period of increased vital activity is at an end, 
the moment when the ebb begins, corresponds, accord- 
ing to Goodman, to the commencement of the cata- 
menial discharge. 

Goodman sought for verification of this undulatory 
theory of the sexual life of woman in certain data re- 
garding 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 fol- 
lowing 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. to 0.79" F.) ; and during 
the catamenial discharge a gradual fall of 0.039° ^^ 
to 0.25° C. (0.072" F. to 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 excre- 
tion 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 tempera- 
ture gradually declined during menstruation, to fall 
in three-fourths of the cases below the mean tempera- 
ture of the entire interval, and exhibiting in the post- 
menstrual epoch a still further depression, giving place 
however, to a somewhat higher mean temperature dur- 
mg 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 ReinI is shown in the fol- 
lowing figure: 

Premenstrual epoch 

7 Menstruation 

Post-menstrual epoch 
First half of the interral 

The rising portion of the wave, the beginning of the 
tidal flow, corresponds to the second half of the inter- 
val ; 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 dis- 
charge; later in the ebb is the post-menstrual epoch, 
and the lowest portion of the declining wave corre- 
sponds to the first half of the interval. Rhythmic 
changes corresponding to those observed in the temper- 
ature 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 menstrua- 
tion; and that with or immediately before the appear- 
ance of the catamenial discharge, a decline of that 
activity commences. 


Schrader, through his researches on metabolism dur- 
ing 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 faeces and the urine is at its lowest, 
a fact which indicates that at this period of the men- 
strual cycle the disintegration of albumin 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 al- 
ways remained below the mean, no rise taking place 
till menstruation was finished; this fall in blood-pres- 
sure during menstruation was more considerable than 
could be accounted for by the moderate haemorrhage. 
The same author, in conjunction with Schichareff, ex- 
amined fifty-seven healthy women in respect of heat- 
radiation, muscular power, respiratory capacity, ex- 
piratory and inspiratory power, and tendon-reflexes. 

He found that the energy of the functions of the 
female body increased before the beginning of men- 
struation, 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 AB repre- 
sents these physiological variations, whilst on the ab- 
scissa 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 o — loo on the ordinate. 

Still another point of view from which the influ- 
ences affecting the female organism as a whole may 
be regarded has very recently become apparent in con- 
sequence of the doctrine of Brown-Sequard relating to 


the internal secretions of ductless glands. As regards 
die female reproductive glands, which in consequence 
of their structure must be referred to the group of 
ductless glands, and yet owing to their secretory func- 
tion 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 haematopoiesis, 
and on growth and development in their mental as well 
as their physical relations. 

It is supposed that these glands under normal con^ 
ditions enrich the blood with certain substances, which 
in part assist in haematopoiesis, and in part by regulate 
ing the vascular tone in the various organs are con- 
cerned in the normal processes of assimilation and 
general metabolism. According to Etienne and De- 


mange, ovariin possesses an oxidizing 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 farther, 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 functipn, and speaking of an 
.occasional ovarian auto-intoxi^atioh of the body o^ of 
a menstrual 'intoxication. Thus, chlorosis is by sbme 
regarded as a disturbance of haematopoiesis, dependent 
on an abnorinal condition of the female reprpduetiye 
organs during the period of development, arid ' r^f ^r-; 
able to a disturbance of the internal secretion of thfe 
ovaries (Charrin, von Noorden,. Salmon, Etiepne, and 
Demange). And it is now generally assumed, th^ as- 
sumption being based on the bbsdrvations recfenll^ made 
concerning the organotherapeutic employment of the 
chemical constituents of the bviary, that many of the 
disorders, and especially those' connected with the vaso- 
motor system, common during the climacteric peiriod,- 
are dependent on the deficiency of the products of the 
internal secretion of the ovary that accompanies the 
cessation of the menses. 

The undulatory movement of the vital processes in 
woman is apparently in some way dependent on ovula- 
tion, though the nature of the connection has not hither- 
to 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 un- 
dulatory 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 de- 
veloped 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 men- 
tion 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 attri- 
bute, 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 
chai-acter, niakes 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 regu- 
lar, the breasts enlarge, and the pubic hair begins 
to grow — ^when, in short, to the primary sexual char- 


acters already existing, the secondary sexual characters 
are superadded. 

Feminine beauty continues to increase until the at- 
tainment 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 ac- 
companying these processes leave traces recorded upon 
the surface of the body in conspicuous and indelible 
characters. The illnesses, also, which so often accom- 
pany 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 pen- 
dent, the abdomen becomes ungracefully prominent; 
the tonicity of the entire organism gradually declines, 
and, in consequence of the loss of elasticity in the sub- 
cutaneous 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 wom- 
en 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 char- 


acters on whieh feminine beauty depends is to be found 
in the Song of Solomon. 

"Behold, thou art fair, my love; behold, thou art 
fair; thou hast doves' eyes within thy locks: thy hair 
is as a flock of goats, that appear from Mount Gilead. 

"Thy teeth are like a flock of sheep that are even 
shorn, which come up from the washing; whereof every 
one bear twins, and none is barren among them. 

"Thy lips are like a thread of scarlet, and thy speech 
is comely : thy temples are like a piece of a pomegranate 
within thy locks. 

"Thy neck is like the tower of David builded for an 
armory, whereon there hang a thousand bucklers, all 
shields of mighty men. 

"Thy two breasts are like two young roes that are 
twins, which feed among the lilies." 

"How beautiful are thy feet with shoes, O prince's 
daughter ! the joints of thy thighs are like jewels, the 
work of the hands of a cunning workman. 

"Thy navel is like a round goblet, which wanteth 
not liquor; thy belly is like an heap of wheat set about 
with lilies. 

"Thine head upon thee is like Carmel, and the hair 
of thine head like purple." 

"This thy stature is like to a palm tree, and thy 
breasts to clusters of grapes." 

In the following figure the curve of beauty of womap 
is given as drawn up by Stratz. In one case it may 
rise very quickly, to decline with equal quickness — 
the so-called beaute du diable/* 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. 

** Beauty of the deviL 


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 ma- 


turity 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. Fi- 
nally 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 individ- 
uality. Inherited characteristics, teimperament, and 
race, play a great part in this connection ; and not less 
important than these are the social conditions, the en- 
vironment, in which the women under consideration 
pass^their life. Thus, among women belonging to the 
poorer, laboring classes, the reflex manifestations in 
other organs dependent upon the processes of the geni- 
tal 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 mani- 
festations exhibit less intensity than in those of an 
active, ardent temperament; they are less frequent in 
persons with a powerful constitution than in those en- 
dowed by inheritance with an unstable nervous system. 
Finally, they are less often encountered among families 
whose upbringing has aimed at hardening the constitu- 
tion and at inculcating the control of instinctive im- 
pulses, than among those in whom from early child- 
hood sensibility and impulsiveness have been given a 
loose rein. 

Extremely variable also are the sympathetic disturb- 
ances and morbid states which depend on the processes 
of the sexual life of woman. "Le cri de I'organe 


souflfrant ne vient pas de I'uterus mais de tout I'or- 
ganisme,"*'' says Courty. And a large number of iso- 
lated 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 incontest- 
able 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 in- 
cidence 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, dur- 
ing the puerperium, and at the climacteric period. 
The complete performance of the reproductive func- 
tions entails a higher proportion of illnesses and death; 
and statistical records show that the mortality of mar- 
ried women between twenty and forty years of age, 
during the period, that is to say, in which in conse- 
quence of marriage they fulfil the duties of sexual inter- 
course 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 para- 
metritis, the manifold diseases of pregnancy, the dis- 
eases of the puerperium, the various displacements of 
the uterus, osteomalacia — all these are pathological 
states the dependence of which upon the sexual life 

""The cry of the suflFering organ comes not fromtiie uterus but from 
the entire organism. 


of the married or at any rate sexually active woman 
is indisputable. But the complete renunciation of 
se?cual 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 neu- 
roses, 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 re- 
garded 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 blbod, 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 men- 
struation, 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 statis- 
tics, these variations depending upon climate, race, con- 
stitution, and the sexual activity of the person under 

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 in- 
herited predispositions, upon the constitutional condi- 


tions, 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 com- 
parison) 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 power- 
fully 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 sperma- 
tozoa, 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 wom- 
an 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 ovula- 
tion 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 menstrua- 
tion occurring between the ages of thirteen and six- 
teen, 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 ab- 
normally 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 mani- 
fested 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 

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 ex- 
treme 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 addition to climate, nationality, and the age at 


which menstruation begins, the sexual activity of wom- 
en also exercises an influence on the duration of their 
sexual life, and of especial importance in this connec- 
tion 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 exefcised, 
who have given birth to several children and have 
suckled these children themselves, the duration of men- 
strual activity is in general notably longer than in 
women whose circumstances have been just the op- 
posite 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 i 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 i 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 four years less than the general 

As regards the conditions of life, L. Mayer afiirms 
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 pur- 
pose, 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 hot yet fitted to fulfil the function-of procrea- 
tion, 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 thfe process of parturition until toward the 
age of twenty, whilst puberty occurs at the age of six- 
teen. "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 be- 
come 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 regula:r life, are well fed, free 
from the pressure of anxieties, with their sexual func- 
tions 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, lead- 
ing a life of ease, manifest a diminished dura:tion 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 yital 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 con- 
trolling 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 ofif the rails that ensues has a far pro- 
founder influence in the case of the female than of 
the male, an influence not limited to her own per- 
sonality, 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 pub- 
licity, 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 un- 


speakable 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 ven- 
ereal 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 furnish- 
ing a solution for these problems. Contesting voices 
are heard on all sides. Tolstoi's rigid demand for 
complete sexual abstinence, the exhortation of the pro- 
fessors 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 inter- 
course before marriage, finally, the clamorous voices 
of the supporters of women's rights — all these are in- 
fluences 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 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 mem- 
bers 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 illumina- 
tion. 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 sen- 
sibility 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 he held in check for a season, but must ultimately 
break loose, and with devastating rage must overwhelm 
everything which has hitherto been regarded as dis- 
cipline 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. 

From a mistaken standpoint other supporters of 
women's rights oppose the ideal method in sex-rela- 
tions, life-long monogamy, and the ideal of sexual sen- 
sibility, 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 in- 
deed 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 stimu- 
lation, 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 re- 
garding 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 justi- 
fied 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 power- 
ful 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 "en- 
tire mutual freedom" in the sexual relation between 
man and wife, and will regard such free love as social 
insanity and as a barbaric retrogression toward the 
rude sexual habits of savage peoples. Further, in view 
of the continually increasing intensity of the struggle 
for existence and in view of the difficulties of the task 
of rearing children, we cannot fail to recognize that 
it is not right for women to be overburdened with the 
task of reproduction, and that she does not live simply 
and solely for the bearing of children — but those rush 
to the other extreme who undervalue motherhood and 
the duties of maternity, who speak scornfully of the 
woman who is "a mother, and a mother only," who 
despise women whom they regard merely as "means 
for the production of children," and who employ all 
possible methods to free women from the pressing 
claims of nature and of society. 

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



The term menarche was introduced by me into medi- 
cal literature to denote the period of life in which, 
as a sign of puberty, menstruation first makes its ap- 

The age at which this occurs is subject to variations 
depending upon race, occupation, hereditary tenden- 
cies, and climate; but in Germany and Austria the 
average age at puberty is 14 or 15, the extreme limit 
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 ar& so strikingly differentiated. Whereas in 
the growing boy all physical change takes the form 
of increasing strength an'd 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 fehiininity. 



As regards the age at which the menarche usually 
occurs, and the manner in which its occurrence is anti- 
cipated or retarded by the various influences already 
mentioned, the following propositions may be put for- 
ward, 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 ii 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 cli- 
mate, the earlier being the menarche. The height of 
the place of residence above the sea-level and its dis- 
tance from the coast also have a certain influence. 

2. Race and constitution have a distinct influence 
upon the age at which menstruation makes its appear- 
ance. In women of the Semitic races the menarche 
occurs earlier than in women of the Aryan race. The 
average age at which menstruation begins in Jewish 
girls, from 14 to 15; in Magyar girls from 15 to 16; 
in German girls from 16 to i6>4 ; and in Slavonic girls 
irom 16 to 17. 

In general the menarche is earlier in girls of a san- 
guine, lively temperament and a powerful constitution 
than in girls of a phlegmatic temperament and a weakly 
constitution; further, other things being equal, men- 
struation 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 af- 
fected by the conditions of life and the social circum- 
stances. 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 com- 
pelled 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 me- 
narche 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 men- 
struation begins, and the mean results of these observa- 
tions are given below. 

The average age at which menstruation began was : 

In Swedish Lapland 18 years, months, 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 Gottingen 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, 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, days. 

In Montpellier 14 years, 2 months, days. 

In Corfu 14 years, months, days. 

In Marseilles 13 years, 1 1 months, 1 1 days. 

In Calcutta 12 years, 6 months, days. 

In Egypt 10 years, months, days. 

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

I. In Temperate Climates : 




De Soye Paris 

Dubois Paris 

Raciborski Paris 

M. Despines. . . . Paris 

Aran Paris 

Courty Montpellier 

Puech Nimes 

M. Despines. . . .Toulon . . . . 

M. Despines Marseilles . . 

Puech Toulon . . . . 

Grey London . . . . 

Lee & Murphy. . London 

Torisiano Corfu 

Lebrun Warsaw . . . 

of Cases. 

Average Age. 


15 years. 



15 years, 

3 months. 


14 years, 

5 months. 


14 years, 

1 1 months. 


15 years, 

4 months. 


14 years. 

3 months. 


14 years, 

2 months. 


14 years, 

1 month. 


14 years, 

1 month. 


14 years. 

1 month. 


15 years, 

6 months. 


15 years. 

6 months. 


14 years. 

6 months. 


15 years. 

1 month. 

from these observations we obtain an average of 15 

II. In Cold Climates: 

Observer. Place. No. of Cases. 

Ravn Copenhagen 3,840 

Frugel Christiania 157 

Dubois Russia 600 

Faye Norway 100 

Lundborg Esquimaux 16 

Wistrand Stockholm 100 

from these observations we 
years and 3 months. 

Average Age. 
16 years, 9 months. 

16 years, 
16 years, 
15 years, 
1 5 years, 
15 years, 

6 months. 
8 months. 
6 months. 

6 months. 

7 months. 

obtain an average of 16 

III. In Hot Climates: 


Observer. Place. 

Goodeye Calcutta 

Lith Deccan . 

Roberton Calcutta 

Webb Calcutta 

Dubois Asia .. . . 


of Cases. 

Average Age. 


12 years, 5 months. 


13 years, 5 months 


12 years, 6 months 


12 years, 5 months 


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 : At the age of : 

9 years in 1 instance. 20 years in 281 instances. 

10 years in 7 instances. 21 years in 1 1 1 instances. 

1 1 years in 43 instances. 22 years in 55 instances. 

12 years in 184 instances. 23 years in 15 instances. 

13 years in 605 instances. 24 years in 15 instances. 

14 years in 1 193 instances. 25 years in 1 instance. 

15 years in 1240 instances. 26 years in 4 instances. 

16 years in 1026 instances. 27 years in 2 instances. 

17 years in 758 instances. 28 years in 1 instance. 

18 years in 582 instances. 29 years in 1 instance. 

19 years in 425 instances. 

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 menstrua- 
tion 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 Ber- 
lin, who was sickly and chlorotic up to the time of 
her marriage, and in whom menstruation did not ap- 
pear 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'Espines the age 
at puberty varies in an almost geometrical ratio with 
the mean annual temperature. 

The dependence of the menarche upon climatic in- 
fluences is clearly shown by the statistical data col- 
lected from various regions of the world. We append 
the general compilation of Gebhard dealing with this 

A. Europe 

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

I. Northern Europe 

The average age at which menstruation first appears, 
according to the older statistics, is in Swedish Lap- 
land 1 8, in Norway, 16.12. In Copenhagen it is 16.75, 
in St. Petersburg 14.5. 

More recent statistics for Finland are furnished by 
Engstrom. Among 3,500 women of pure Finnish de- 
scent, he found that menstruation began: 

At the age of 

8 years 

9 years 

10 years 

11 years 

12 years 

13 years 

14 years 

15 years 

16 years 

1 7 years 


n 4 
n 41 


At the age of : 

18 years in 

19 years in 

20 years in 

21 years in 

22 years in 

23 years in 

24 years in 

25 years in 

26 years in 

195 instances. 
91 instances. 
31 instances. 

8 instances. 
10 instances. 

2 instances. 

1 instance. 


1 instance. 

Thus, in nearly half of all Finnish women, men- 
struation 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 par- 
ticulars of the first onset of menstruation in Russia 
among 10,000 women. Menstruation began: 

At the age of 
9 years 

10 years 

1 1 years 

12 years 

13 years 

14 years 

15 years 

16 years 

17 years 

n 1 
in 4 
n 31 
n 244 
n 864 
n 1641 
n 1795 
n 2012 
n 1692 










At the age of : 

18 years in 

19 years in 

20 years in 

21 years in 

22 years in 

23 years in 

24 years in 
32 years in 

910 instances. 

498 instances. 

183 instances. 

65 instances. 

19 instances. 

5 instances. 

3 instances. 

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, men- 
struation 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 Ber- 
lin, the average age at puberty is somewhat less than 
in Munich, situated 4^^ degrees to the southward, for 
the reason that the retardation dependent upon alti- 
tude 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 ijyi, and 16 with a percentage 

of i8M. 

In Great Britain, according to Krieger, the average 
age at which menstruation begins is 15 years, i 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 22% per cent, menstruation begin at the age of 15; 
in 20 J^ 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. Accord- 
ing to a table dealing with 584 women of Tokio men- 
struation began: 

At the age of : At the age of : 

1 1 years in 2 instances. 16 years in 228 instances. 

12 years in 2 instances. 17 years in 68 instances. 

13 years in 26 instances. 18 years in 44 instances. 

14 years in 78 instances. 19 years in 10 instances. 

15 years in 224 instances. 20 years in 2 instances. 

The data available regarding China are so exceed- 
ingly 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 Al- 
geria 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 tropi- 
cal South America girls begin to menstruate from the 
age of 9 to 14 years. The Indian wonien of North 
America begin to menstruate at the ages of 12, 13, 14, 


or even as late as 1 8 or 20. In the Arctic zone of 
North America and in Greenland the onset of men- 
struation 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 regarding 6poo women, 
menstruation began: 

In women of In women of 

the upper classes, the lower classes. 

At the age of 13 years 1 1.73 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. Accord- 
ing to other observers the average age at the first men- 
struation is: 

Brierre de -..^ l^^vn. 

Boismont. ,r J' ^ ri^%^\ (Copen- 
(Paris.) (London.} (Berhn.) ),^°^^» 

Amongst gentle folk and 

the rich 13y. 8m. 13y.5^m. 14y.lm. 14y.3ra. 

Amongst the wellT-to-do 

middle classes My. S m. 14y.3j4m, ISy.Sm. ISy.Sj^m. 

Amongst the lower 

classes 14y.l0m. 16y.8m. 16y.Sj4m. 

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 in- 
stances, 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 
^7 ^^ 55} ^t 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 predispositioir is so far deter- 
minant 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 men- 
struate 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 men- 
struate 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 sur- 
rounded by dark rings. 

The opinion is general that in girls with black hair, 
dark eyes, thick skin, and dark complexion, menstrua- 
tion 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 chest- 
nut-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. 1 6.59 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 I5.55 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 men- 
struation appears: 

In Slavonic girls between the ages of 16 and 17 

In Magyar IS 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 in- 
creased 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 accom- 
panied by actual though slight change of temperature. 
In many cases also there are disturbances in the in- 
testinal evacuations and urinary secretion, in the process 
of cutaneous transpiration, and in the functional ac- 
tivity of the gastro-intestinal canal. A frequently ob- 
served symptom is an increased irritability of the entire 
nervous system, with an inclination to melancholy and 
indefinite amorous desires. 

The nervous irritability manifests itself already be- 
fore the appearance of the menstrual flow by head- 
ache and moodiness, weariness, nervous irritability, and 
low spirits ; further, by slight changes in the facial as- 
pect, 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 re- 
sisting 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 mani- 
festations may also assume a morbid character, taking 
the form of violent abdominal and lumbosacral pain, 
general fatigue and weakness, dyspepsia and diarrhoea, 
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 ulti- 
mately attain the same weight exhibit their greatest 
growth at the ages of 12, 13, and 14 years. Accord- 
ing 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 Floss, up 


to the age of ii or 12 years the growth of girls exceeds 
that of boys, but whereas in girls growth ceases sud- 
denly at the age of 14, in boys growth proceeds regu- 
larly up to the age of 16 years. At birth boys are 
on the average i cm. (%") longer than girls; but dur- 
ing puberty the female sex catches up to 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 cli- 
mate, 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 

sexea 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 dif- 
ference the observed diflferences 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 ma- 
turity 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 men- 
strual 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 worn- 


an, 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 resist- 
ing 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. Ac- 
cording 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 unfavor- 
able 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, when the growth of the pubic hair occurs 
as an external sign of sexual development, and the 
age of nubility, when the individual becomes fitted for 
marriage. The distinction is a partial one only, in- 
asmuch as capacity for copulation is attained already 
at puberty. The law, however, maintains such a dis- 
tinction, the Austrian Penal Code, for example, re- 
garding 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 ex- 
plained 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 ad- 
vance 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 ap- 
pearance 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 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 dur- 
ing 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 geni- 
tal organs, and secondly on account of the intellectual 
changes that occur at this period. 

The local cause is to be found in the extensive trans- 
formation 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 hyperaemia 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 hyperaemia 
of the ovaries and of the whole of the genital organs, 
now undergoing their fullest development, and we can 
easily see how this hyperaemia may result in manifold 
reflex disturbances. But in addition to these reflex 
disturbances, we have once more to take into consider- 
ation the as yet imperfectly known chemical processes 
which are associated with the ripening and develop- 
ment 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 

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 astonish- 
ment 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 inter- 
lacements, 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 sensi- 
bility 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 dis- 
tricts, whose sensibilities are" chiefly physical and whose 
mind is less susceptible to the influence of external 

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 sipall. 

In addition to these abnormal temporal relations of 
the menarche, certain other irregularities at the com- 
mencement of menstruation are worthy of note. Thus, 
the first menstruation may be normal, but thereafter 
amenorrhcea 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 pro- 

In working-class families the immoderate physical 
strain often thrown upon girls, in many cases continu- 
ous movements of the upper extremities whilst the 
lower extremities and the pelvis are absolutely quies- 
cent, 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 en- 
joyment of fresh air, and as a rule nutritive food; more- 
over, there are not so many occasions of nervous stimu- 
lation; 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 at- 
tention — but very frequently, intercourse with older 
girls, association with young men, visits to theatres, 
evening-parties, and balls, and the perusal of stimula- 
ting 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 indepen- 
dence of feminine youth, these "half -virgins" are in- 
creasing both in number and in intensity, a fact which 
cannot fail to increase also the number of sexual mala- 
dies and perversions. 

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 char- 
acter, becoming quiet, self-absorbed, sometimes even 
melancholy; they are disinclined for study, have a re- 
pugnance 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 be- 
fore the first menstruation, the vulva, the labia majora 
and minora, and the vaginal mucous membrane, are 
swollen, the clitoris becomes conspicuous in conse- 
quence of erectile processes, a slight secretion appears 
in the genital passage, and the breasts become sensitive 
and slightly turgid. The urine deposits a thick sedi- 
ment, and occasionally severe strangury is observed. 
In many cases, also, digestive disturbances occur, loss 
of appetite, constipation, or a tendency to diarrhoea. 

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 

It is not always after the first menstruation that the 
subsequent discharges follow at the regular intervals 
of four weeks. In delicate, anaemic girls the second 
menstruation may not occur till several months have 
elapsed after the first; less often the second menstrua- 
tion 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 de- 
veloped. It is evoked at this time of life by the anato- 
mico-physiological changes undergone by the repro- 
ductive 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 men- 
struation, 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 sensa- 
tions, the sexual impulse. How far these stimuli aris- 
ing from the reproductive apparatus are encouraged 
and accentuated, on the one hand, or repressed and 
diminished, on the other, depends on external impres- 
sions of various kinds. The environment is the deter- 
minant for the further transformation of the as yet 
undifferentiated sexual impulse into the fully-devel- 
oped copulative and reproductive impulses. 

In his work on the Physiology of Love, Mantegazza 
describes the yearning and stress of the awakening sex- 
ual life, arising out of the presentiments, hazy sensa- 
tions, 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 adoles- 
cent girl exercises her imagination with the circum- 
stances of her chaste love, her mind turns to this sub- 
ject when in solitudej her mood is apt to become melan- 
choly, 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 

Some authors believe that a sign of the awakening 
of the sexual impulse when directed toward some par- 
ticular 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 Krafift- 
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 expe- 
rienced 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 aesthetic 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 Krafift-Ebing, has a roman- 
tic, 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 misal- 
liances, 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-destruc- 
tion. Love in which the senses play too prominent a 
part can never be a true and lasting love. For this rea- 
son, first love is as a rule very transitory, since it is in 
most cases no more than the first flare of passion. 
* * * Platonic love is a thing without existence, a 
self-deception, a false description of sexual sensations. 
Bebel remarks that the number of suicides among 
women of the ages of sixteen to twenty-one years is an 
exceptionally large one, and he refers this chiefly to 
unsatisfied sexual impulse, unfortunate love, secret 
pregnancy, and to betrayal by men. 


{Precocious and Retarded Menstrual Activity) 

By the term precocious menarche we understand the 
pathological state in which a typical, four-weekly, san- 
guineous 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 compara- 
tively 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 axillae; the labia 
majora and the breasts resemble those of full-grown 
women, and the pelvis also has the adult form. Com- 
monly al§o the sexual impulse develops early, whilst, 
in other respects, the intellectual development lags be- 
hind the physical. It is most probably a primary hy- 
perplasia 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 con- 
ception 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 va- 
gina 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 mstance as were 
reported by Eross of six new-born female infants in 
whom a sanguineous discharge from the vagina ap- 
peared three or four days after birth and lasted two 
to five days, the infants not remaining subsequently un- 
der observation), — numerous well-authenticated cases 
yet remain in which menstrual haemorrhage was ob- 
served 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 mo- 


limina 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 menstrua- 
tion the menstruation recurred as a rule at regular in- 
tervals of four weeks; only in quite exceptional cases 
were the intervals three to five months. 

In several of these cases of premature puberty, sex- 
ual 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 men- 
struate 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 be- 
gan 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 (Moli- 
tor) . A girl began to menstruate at the age of two, had 
a growth of hair on the pubes ajid developed mamms 
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 pre- 
cocious menstruation, the removal of a rapidly growing 
ovarian tumor was followed by the cessation of men- 
struation, and the pubic hair, which had been shaved 
off, did not grow again. 

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 oc- 
curs in girls who exhibit at this period of life an ex- 
traordinarily 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 

In some cases, notwithstanding the delay in the ap- 
pearance 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. 

Menstruation, after its first appearance in normal 
fashion, may be suppressed in young girls in conse- 
quence 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 inten- 
sity but longer duration have a similar effect; some- 


times 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 act- 
ual intercourse or it may be merely of too intimate an 
embrace with a man, fears she has become pregnant, 
and actually suffers from amenorrhoea though preg- 
nancy does not really exist. I saw a case in which 
amenorrhoea 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 be- 
came regular. 

Functional amenorrhoea may also occur in young 
girls in consequence of a sudden change in the condi- 
tions of life, a removal from town to country, for in- 
stance, or the reverse, travel in regions where the cli- 
matic conditions differ widely from those hitherto ex- 
perienced, 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; menstrua- 
tion began at the age of 13 and was regular thereafter; 
on three successive occasions amenorrhoea 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 (2%"), both ovaries distinctly palpable. 


Such a form of amenorrhoea as this commonly disap- 
pears when the girl removes from the conditions un- 
favorable 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 insufliciently clothed lower extremities, and vaginal 
injections with water at too low a temperature. Such 
cases are common among the working classes, es- 
pecially in washerwomen; but they are also observed 
among the well-to^do. An example is given by Win- 
ter: 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, amenorrhoea being complete for a year 
and a half. Then menstruation recommenced, but was 
irregular, sometimes anticipating, sometimes postpon- 
ing 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 dys- 
menorrhoea was severe. At each proper period, if the 
flow failed to appear, severe molimina occurred in the 
form of abdominal cramps and headache. Examina- 
tion showed the uterus to be normal in shape, 4>^ centi- 
metres (i%") in length, with a very thin wall; both 
ovaries were palpable, but smaller than normal. 

The commonest form of amenorrhoea at this period 
of life is, however, the constitutional amenorrhoea as- 
sociated 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 Qebhard, that chlorotic girls begin 
to menstruate at the usual age, or even earlier. Men- 
struation recurs once or twice at irregular intervals, 
and then gives place to complete amenorrhoea, it may 
be suddenly, it may be gradually, the flow on each oc- 
casion being scantier than before. In chlorotic pa- 
tients, 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 amenorrhoea may be of short dura- 
tion; 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 head- 
ache, dizziness, syncope, feelings of oppression, disin- 
clination for mental and physical exertion, and so on. 
Since in such cases the ripening of the ovarian follicles 
also fails to occur, when the amenorrhoea is complete 
the menstrual molimina are generally wanting (Geb- 

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 as- 
sociated with the amenorrhoea, 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 manifesta- 


In chlorotic girls, at the times when menstruation is 
due, a watery discharge often occurs, sometimes slight- 
ly tinged with blood. Dysmenorrhoea 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 men- 
strual period. Occasionally also menorrhagia may oc- 
cur in association with chlorosis, to be distinguished 
according to Virchow from a rare condition named by 
him "menorrhagic chlorosis," characterized by exces- 
sive menstruation of an anticipating type. The bleed- 
ing 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, es- 
pecially at the commencement of puberty, as of an 
endoinfective nature dependent upon auto-intoxication. 
The toxins lead to inflammatory and degenerative 
changes in the muscular substance of the uterus. Ac- 
cording tp Fraenkel in these cases the ovaries are usu- 
ally enlarged, seldom smaller than normal. 

Inflammatory Processes. 

Chronic metro-endometritis, both corporal and cer- 
vical, occurs occasionally in young girls during the 
years of development. It is especially common in chlo- 
rotic subjects; and next to these in girls who are care- 
less 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 practised 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 strik- 
ing 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 cor- 
poral metro-endometritis the discharge is of a thinner 
consistence, milky in appearance, and not very abun^ 
dant. As a result of the endometritis, the patient suf- 
fers from various pains in the body, a feeling of ful- 
ness, sacrache, general sense of fatigue, and divers 
nervous manifestations; sometimes also from dysmen- 
orrhoea, strangury, or obstinate constipation. In conse- 
quence of the great thickening of the mucous mem- 
brane that often occurs, menstruation becomes very 
profuse and long-continued, lasting from one to two 

In consequence of long-continued masturbation, 
other pathological changes may take place in the fe- 
male genital organs, such as hypertrophy of the nym- 
phae, proliferation or glandular hypertrophy of the 
uterine mucous membrane, ovarian irritation, pains in 
the ovarian region which, in severe attacks, may radi- 
ate to the thighs. These pains become more severe at 
the menstrual period, especially at the beginning of 
that period; and are sometimes also especially trouble- 
some 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 phy- 
sicians, 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 mon- 
ograph on this condition. Gallard assigns masturba- 
tion as its principal cause. 

Retroflexion of the uterus is also sometimes observed 
in virgins, induced by the bad habits which are so com- 
mon in young girls of retaining the urine for excessive- 
ly long periods and of neglecting constipation. The 
prolonged distention of the bladder leads to a daily, 
long-continued stretching of the ligamentous apparatus 
of the uterus; the full bladder presses the uterus back- 
ward, and after the viscus has been emptied, the flac- 
cid ligaments are no longer able to restore the uterus 
to its normal position of anteflexion. The organ is left 
with its fundus directed backward, and the intra-ab- 
dominal pressure keeps it permanently in this position; 
at the same time, an accumulation of faeces in the rec- 
tum, by pressing the cervix forward, favors this dis- 
placement of the uterus. Moreover, when the uterine 
tissues are flaccid through malnutrition in chlorotic or 
anaemic subjects, the organ yields more readily to me- 
chanical influences than it would if its muscular tone 
was healthy. 

Disorders of Hamatopoiesis 

According to Virchow, two distinct forms of chloro- 
sis are to be recognized, one form in which no great ab- 
normalities of the reproductive apparatus exist, and 
another form in which imperfections in the develop- 
ment of the central portion of the vascular system are 
associated with similar imperfections in the reproduc- 
tive apparatus. In many cases of chlorosis, he found 
the ovaries small and imperfectly developed, in an in- 
fantile 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 etiologi- 
cal connection between chlorosis and developmental dis- 
turbances, Virchow inclines to the view, that in chloro- 
sis 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 dis- 
order 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 re- 
productive apparatus. 

Stieda found that in chlorotics displacements of the 
uterus were common, with abnormal narrowness of the 
vagina, absence of the pubic hair, imperfect develop- 
ment of the pelvis, and the growth of the breasts inter- 
fered with to this extent, that the nipples and areolae 
were abnormally small. He classifies these manifes- 
tations 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 nor- 
mally 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 disor- 
der, 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. Fraenkel is inclined 
to regard a primary development disorder of the gen- 
ital organs as the cause of many cases of chlorosis. 

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 an- 
tiquity, and has been widely held even by physicians, 
that the disease is due to sexual abstinence in individ- 
uals with powerful sexual impulse, and that for this 
reason chlorosis is often cured by marriage. This result 
of marriage, which, though apparently 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 appa- 
rent 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. Ex- 
perience also shows that chlorotic girls sometimes con- 
tinue 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 puer- 
perium — but in a wife it is no longer customary to 
describe such symptoms by the name of chlorosis, they 
are called anaemia, 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, espe- 
cially, for instance, amongst the lower classes, in 
whom it is hardly customary to wait for marriage be- 
fore beginning sexual intercourse. The connection be- 
tween masturbation and chlorosis, which has also been 
widely alleged from the etiological standpoint, is mor£- 
over 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, espe- 
cially in those who suffer from amenorrhoea or from 
irregular menstruation, the anaemic form of obesity not 
infrequently develops. Such patients at the time of 
puberty exhibit signs of marked anaemia 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 
oedematous ; the muscular system is generally feeble. 

What especially characterizes this anaemic 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 oc- 
cur even in the absence of any severe exertion or espe- 
cial excitement, often also we see shortness of breath, 
precordial pain, anxiety, respiratory distress, and sensa- 
tions of chilliness and fatigue. 

The principal cause of the obesity in these cases is to 
be found in the anaemia, inasmuch as the diminution in 


the number of the erythrocytes is a diminution in the 
number of the oxygen-carriers, and this entails defec- 
tive 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 
msufficient. An auxiliary factor' in producing obesity 
in such anaemic 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 vi^ith 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 es- 
pecially after severe physical exertion, mental applica- 
tion, or emotional excitement, whilst the urine secreted 
at night is usually free from albumin. The skin is pale, 
the accessible mucous surfaces are comparatively color- 
less, the face is puffy, the eyelids are oedematous; the 
patients suffer from various nervous troubles, espe- 
cially headache and dizziness, and they are also liable 
to dyspeptic disorders. 

When the period of the menarche is safely passed, 
when the menses recur with regularity, and the chloro- 
tic manifestations disappear, when the process of haema- 
topoiesis 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-estab- 
lished, 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 cli- 
macteric 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 anaemia 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 men- 
struation; 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 per- 
ceptible, 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 per- 
cussion, no change is found in the area of cardiac dul- 
ness. 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 asso- 


ciated a sensation of strong pulsation in the great ves- 
sels of the neck, and often there is pain on the left side 
^of the lower part of the chest, with a sensation of short- 
ness 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 with- 
out exciting cause, or with a cause so trifling that it 
would not in a normal subject have produced any ner- 
vous 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 recur- 
ring at irregular intervals are paroxysmal attacks of 
tachycardia, in which the frequency of the heart and 
pulse is increased to an enormous extent. This disor- 
der manifests itself a little time before the first appear- 
ance of menstruation, thenceforward recurring regu- 
larly every three or four weeks, accompanying men- 
struation, or occurring at the proper menstrual period 
if menstruation is in abeyance; the attack lasts several 
days. This trouble also disappears a few months after 
the establishment of menstruation. 

Associated with these cardiac troubles are, not con- 
stantly 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 
i8, 19, or 20 years, or in whom considerable irregulari- 
ties have occurred in connection with the commence- 
ment of menstruation. In such girls, in whom men- 
struation 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, res- 
piratory distress, and feeling of anxiety, on continued 
exertion or even on very slight occasion. On percus- 
sion, the heart is not found to be enlarged ; on ausculta- 
tion, 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 hum- 
ming-top murmur is audible. The pulse is increased 
in frequency, at times arhythmical, and easily compres- 
sible. The sphygmographic tracing usually shows a 
subdicrotic or dicrotic character. The upstroke is not 
high ; the downstroke descends low, almost to the low- 
est level of the curve, before the enlarged dicrotic ele- 
vation begins. The skin is always strikingly pale; pale 
also are the visible mucous surfaces, the haemoglobin- 
richness and the corpuscular richness of the blood are 
considerably diminished, a feeling of fatigue and vari- 
ous other nervous manifestations are constantly present 
—in shott, in all cases we have to do with the well- 
known chlorotic disposition, sometimes in association 
with the manifestations of the anaemic form of lipoma- 
tosis 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 anaemic, 
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 pal- 
pitation, 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 out- 
ward, the impulse is always heaving, abnormally pow- 
erful and resistant, the heart-sounds, especially those of 
the left ventricle, are louder than usual, the aortic 
second sound accentuated, sometimes ringing, the caro- 
tids 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 there- 
fore 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 es- 
pecially that in some way an increased resistance has 
been offered to the work of the heart, and that thus the 
hypertrophy has beeri 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 up- 
per 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: 

I. Nervous palpitation and paroxysmal tachycardia 


in persons in other respects in good healtli, the affec- 
tion appearing shortly before the commencement of 
menstruation, and disappearing soon after the flow is 
regularly established. 

2. Cardiac disorders occurring in young girls suffer- 
ing from chlorosis, which itself results from the pro- 
cesses of the menarche. 

3. Cardiac hypertrophy developing at the time of 
the menarche, and dependent on the circulatory dis- 
turbances 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 cir- 
culation 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. Accord- 
ing to this writer, the growth of the heart is slow until 
the age of fifteen years is attained, but becomes acceler- 
ated 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 centi- 
metres (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 pe- 
riod 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 


The comparatively great development which the 
heart undergoes at the time of puberty is a phenomenon 
so important alike in its physiological and its patho- 
logical relations that it deserves the special designation 
of the puberal development of the heart; the com- 
mencement and the completion of puberty appear be- 
yond question to be to a large extent dependent upon 
this development of the heart and upon the simultane- 
ous rise in the blood-pressure of the systemic circula- 
tion 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 fre- 
quently 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, 
are supposed to be connected with the sexual processes 
of this period of life. C. Heine maintains that in con- 
sequence of puberty and of the sexual functions that 
become established at this period, a teleangiectasis 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" 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 in- 
creased and the patients complain of a sensation of anxi- 
ety, 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 ac- 
companying the heart-sounds; there are also venous 
murmurs, especially when the heart-trouble is associa- 
ted with anaemia or chlorosis. Of the cases of pseudo- 
angina pectoris observed by Krieger, the attacks oc- 
curred as prodromal manifestations before the first ap- 
pearance 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 

Diseases of the Nervous System 

The extensive transformatory processes occurring in 
the genital organs of young girls at the time of the me- 
narche, 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. 

On the other hand, the first appearance of menstrua- 
tion has sometimes a favorable influence in girls suffer- 
ing 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. Accord- 
ing to Warner, hemicrania made its first appearance: 

In 1 girl of 3 to 4 years. In 4 girls of 10 to 11 years. 

In 2 girls of 5 to 6 years. In 2 girls of 11 to 12 years. 

In 1 girl of 6 to 7 years. In 4 girls of 12 to 13 years. 

In 5 girls of 8 to 9 years. In 15 girls of 13 to 15 years. 

In 5 girls of 9 to 10 years. 

Toothache, according to Hollander, 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 sufifering from disturbance of the menstrual 

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, See, 
and Steiner, show that the proportion of boys to girls 
affected with chorea minor is i to 2.8, and that of all 
ages 49 per cent, of the cases occurred at the ages of 6 
to II years, 29.8 per cent, at the ages of 11 to 13 years. 
In several cases, in quite young girls sufifering from 
chorea, pathological changes were found in the genital 
organs. Ovarian tenderness was manifested on palpa- 
tion, and always on that side on which the chorea had 
first manifested itself. Leonard found in a girl aged 
eleven sufifering from chorea, adhesion of the praepu- 


tium 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 con- 
firming the statement that, "no spinal reflex has such 
widely-opened and easily accessible paths of conduc- 
tion 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 gen- 
erally, the inherited psychopathic tendency that espe- 
cially 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 appear- 
ance of mental disorders. The commonest of these are 
mania and melancholia of the ordinary type, the prog- 
nosis 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 Kahl- 
baum as Hebephrenic,^ the prognosis of which is very 
unfavorable, for it speedily terminates in dementia, 
similarly to the dementia of puberty described by Svet- 
lin, dependent upon or associated with premature syno- 
stosis of the cranial bones. Very often we witness, at 

^ 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. 


puberty the beginning of the periodic varieties of men- 
tal disorder, which develop into periodic menstrual 
psychoses, manifesting themselves regularly at the re- 
currence 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 uncontrolla- 
ble and unconditioned attacks of laughing and crying, 
globus hystericus, clavus hystericus, etc. ; hysteria ma- 
jor, 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 com- 
mencement of menstruation. It seems also that at the 
time of puberty amenorrhceic and dysmenorrhoeic 
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 anaesthesia, spasm, and paralysis. 
On the threshold of puberty the girl with a heredi- 
tarily neuropathic disposition may exhibit a tendency 
to epilepsy. In such cases, as Kowalewski writes, the 
patient has sudden attacks of loss of consciousness, com- 
monly 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 remem- 
bers 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 hap- 
pened. 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 faint- 
ing-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 com- 
mencement of menstruation, the attacks may continue 
to accompany menstruation for several years thencefor- 
ward. Already established epilepsy is said by some 
authors, Lawson Tait, Tissot, and Marotte, for in- 
stance, 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 favor- 
able influence on the course of epilepsy, a view held 
already by Hippocrates. 

Not infrequently, attacks of precordial pain associa- 
ted with tachycardia occur during the first menstrua- 
tion. 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 de- 
velopment of puberty; the tendency to acromegaly, it 
is suggested, is produced by the remarkable transmi- 
gration that occurs at puberty of the energy of growth 
from its accustomed paths into new channels. The re- 
lations which Neusser has shown to exist between the 
ovaries on the one hand and the vegetative nervous sys- 
tem and the process of haematopoiesis 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 them- 
selves in the first period of the commencement of men- 
struation, sometimes melancholia, sometimes amentia 
in the form of slight and transitory maniacal derange- 
ment, more rarely a katatonic^ condition, may precede 
the menarche, or may accompany or follow it. 

A special form of psychosis is associated with the 
menarche (von Kraflft-Ebing, Griesinger, Friedmann, 
Schonthal). 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 men- 
strual reflex. The last named of these influences is the 
most potent. It manifests itself in the following man- 
ner: Certain psychoses which develop before the com- 
mencement 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 disturb- 

1 Katatonia (Katatonie) is a term used in Germany to denote insanity 
associated with muscular rigidity. — Tr. 


ance in the development of menstruation may be not 
merely the exciting cause, but the efficient cause of the 

In cases of the last kind, which have been observed 
by Schonthal and also by Friedmann, who has de- 
scribed 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, hered- 
itarily well endowed, and the psychosis thus appeared 
without warning, like a storm from a clear sky. Ex- 
actly 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 promi- 
nent, 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 

Friedmann enumerates a number of the peculiarities 
that characterize these attacks. The general course of 
the malady is an exceptionally stormy one. The ulti- 
mate cure may coincide with the definite regularization 
of menstruation; or, in cases in which menstruation is 
restored but remains inadequate, the course of the dis- 
order may become a gentle undulatory one, the violent 
stimulus of total suppression being replaced by a more 
moderate stimulus — here also, however, a cure ulti- 
mately follows when menstruation at length becomes 
free as well as regular. But during the height of the 
malady a proper development of menstruation is al- 


ways 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 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 mas- 
turbation. 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 masturba- 
tion, and will do so earlier and more surely if the girl 
is a neuropsychopath by inheritance. The local influ- 
ence of menstrual congestion, however, also plays a 
part in provoking the impulse toward masturbation, 
since at every period a hyperaesthetic state recurs in the 
genital organs. 

Girls thus addicted have sometimes a very striking 
general appearance. They are pale, with a weary ex- 
pression 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 

Temperament and mode of life are decisive in de- 
termining 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 awaken- 
ing 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. 

. An experienced physician, Gutceit, is of opinion that 
in young girls of lo to i6 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 i8, 19, and 
20 onward, "sexual self-gratification is almost univer- 
sally practised by women, even if it be not always prac- 
tised to excess," an opinion which cannot, however, be 
regarded as conclusive. 

L. Lowenfeld 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 affect the genital organs, in conse- 
quence 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 as- 
sociated with a certain degree of development, of ripe- 
ness, of the reproductive organs. Physiologically, sex- 
ual 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 onan- 
ism) . 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 in- 
troduced into the vagina for this purpose. Many fe- 
males effect sexual self-gratification by rubbing and 
pressing movements of the thighs one against the other, 
in which the clitoris is implicated. In psychical onan- 
ism, on the contrary, as Lowenfeld points out, the or- 
gasm is produced solely by central stimulatory repre- 
sentations, 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 mas- 
turbation 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 Lowenfeld's opinion, 
less widely practised 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, masturba- 
tion rarely leads to the production of well-marked 
nervous disturbances, and does so only when practised 
to very great excess. Beard reports that in the power- 
ful and full-blooded working-class girls of the Irish 
race, masturbation, even when practised for many 
years, did not result in anv notable disorder to health. 

Disorders of Digestion 

Disorders of the digestive apparatus are quite com- 
mon 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 hyperaes- 
thesia of the gastric mucous membrane, loss of appe- 
tite, a disagreeable, pasty or acid taste, sometimes 
bulimia, perverse sensations of taste, and pyrosis. 
Especially in chlorotic girls, periodic attacks of pain 
occur, localized in the epigastrium and its neighbor- 
hood, 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. Intesti- 
nal activity is usually depressed, peristalsis is dimin- 
ished, 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 underdevel- 
oped; 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 

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 Neudorfer maintains that 
precisely during the period of puberty to this body 
must be assigned an important regulatory trophic sig- 
nificance for the nourishment and growth of the re- 
productive 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. Miiller states that in many regions, as for in- 
stance in Canton Berne, in Switzerland, where the 
school children exhibit with extraordinary frequency 
a hereditary tendency to the formation of goitre, dur- 
ing 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 time onward no further growth of the 
thyroid body is observed, in girls at puberty the hyper- 
trophy greatly increases, so that very large goitres are 
formed. The same author recurs to the earlier ob- 


servations of Heidenreich and Schonlein, as well as 
to those of Friedreich, by which this influence of pu- 
berty 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 de- 
tected; the swelling is greater if the menstrual dis- 
charge 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 con- 
nection. Of ocular troubles during the menarche, 
iridochoroiditis, haemorrhages into the vitreous body, 
long-continued blindness, and pannous keratitis, are 
mentioned, which may either disappear with the re- 
establishment of menstruation (spontaneous or artifi- 
cially 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 exacerba- 
tion of the ocular trouble coinciding with disordered 


menstruation, and cure taking place only when men- 
struation has become perfectly regular. Vicarious 
haemorrhages into the vitreous body also occur, as- 
sociated with disturbances of menstruation, the relapses 
ceasing as soon as menstruation becomes regular; such 
a case was observed by Courserants in a girl of four- 
teen years. 

Disturbances of hearing have been observed at the 
time of puberty in young girls addicted to masturba- 
tion; the patients complain of subjective noises, rising 
in intensity till actual hallucinations may be experi- 
enced. Lichtenberg reports the case of a strong girl 
eighteen years of age, in whom the congestion associ- 
ated with puberty was followed by atrophy of the audi- 
tory nerve. The same author, also A'shwell, Law, 
Puech, Rossi, Stepanow, and Gilles de la Tourette, 
have published cases of vicarious menstrual haemor- 
rhage 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 men- 
strual 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, some- 
times of increased acuteness, and sometimes of per- 
version, 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 seven- 
teen years of age, having a fatal termination. Accord- 
ing to Mackenzie, sexual excitement leads to swelling 
of the nasal mucous membrane, and habitual masturba- 
tion 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 subaceous 
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 — haematidrosis occurs; in some 
cases, however, the hemorrhage takes place from areas 
of skin altered and injured by disease, from wounds 
or other injuries, from ulcers, or from excrescences. 
Haemorrhage 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 Griinfeld, 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, 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 
axillae. 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 dis- 
eases of the skin. Thus arise the various forms of 
seborrhoea. 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 seborrhoea, 
the secretion is more fluid in consistence, and col- 
lects on the surface of the skin, furnishing this with an 
oily covering. 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 appear- 
ance. Seborrhoea faciei is readily converted into 

With the puberal development of the external genital 


organs is associated an increase in the sebaceous secre- 
tion 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 anaemic 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, weep- 
ing spots are thus formed, and have a very disfiguring 
appearance. Such eczema may occur also in connec- 
tion with disturbances of menstruation, when the 
menses are scanty and pale, or when dysmenorrhoea 
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 stim- 
ulation, 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 as- 
sociation with disturbances of menstruation, acute 
oedema or erythema are observed. 

Finally, we must mention herpes progenitalis, a 
rather uncommon acute condition in which, with vio- 
lent itching and burning sensation, intense redness and 
oedematous swelling of the skin, vesicles form on the 


praeputium clitoridis, the nymphae, and the inner sur- 
face 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 de- 
pressed 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 strength- 
ening 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 abun- 
dance 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 recom- 
mended ; fruit, raw or cooked, should also be taken in 
considerable quantities. The evening meaP 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 quan- 
tities; only as a stomachic a glass of beer or of light 
wine may be recommended. 

Chlorotic patients should even at their first break- 
fast^ have a meal rich in albumin, such as a consider- 

1 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. 


able helping of meat, or a beefsteak, with rolls, butter, 
and tea or coffee. Milk should be taken in small quan- 
tities 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 
a I'Anglaise, ham; roasted venison, hare, partridge, 
grouse, fieldfare, hazel-hen, ptarmigan, pheasant, 
chicken, pigeon, turkey, oysters; asparagus, cauli- 
flower, and spinach. For variety, fish or shellfish 
may occasionally be taken. Sweetbread in soup or 
with sauce forms a very delicious and easily digestible 

Kahane recommends for chlorotic patients the sys- 
tematic 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 anasmic 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, car- 
rots, turnips, sweet fruits, grapes, dates, pippins, plums, 
pears, and preserved fruits— all these must appear at 
table more frequently than usual; beverages, in addi- 
tion 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 sau- 
sage, ham, or roast meat. Mid-day dinner, i A.M. : 
Soup, roast meat with vegetables and potatoes, or fish 
may take the place of the soup, sweets to follow. After- 
noon, 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 anaemic form of obesity, to 
which chlorotic patients of the better classes are sub- 
ject, in consequence of sedentary habits and overfeed- 
ing, the diet must be so arranged that albumins pre- 
dominate, whilst carbohydrates should be given spar- 
ingly, 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 pos- 
sible, since the deprivation of water may result in a 
proportionate increase in the solid constituents of the 
blood, and thus increase its haemoglobin richness. 

The amount of physical exercise taken by young girls 
at this period of life must vary according to the cir- 
cumstances 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, Hay- 


em, 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 f Contains of ^ 

Grammes. Albumin. Fat. Carbohydrates. 

Beefsteak 100 38.2 1.7 

A cup of tea 150 0.45 0.9 

White bread 30 2.9 0.2 18.0 ■ 


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 


Roast meat 200 46.4 3.4 

^ Vegetables 25 0.4 0.1 2.1 

Wine 150 1.0 

White bread 30 2.9 0.2 18.0 

Total 1380 206.97 1 1.92 97.6 

Contains about 1300 calories. 

For young girls at this period of life systematic gym- 
nastic 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 me- 
narche must receive attention to this extent, that all 
articles of clothing should be rejected which increase the 
tendency already existing to hyperaemia 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 re- 
stricts the freedom of movement of the thorax and the 
abdomen, tight collars, and tight garters — all these 
must be forbidden ; moreover excessively warm under- 
clothing, of the lower extremities especially, which 
may stimulate the genital organs, must also be pro- 

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 exer- 
cise 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 read- 
ing 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, appro- 
priate 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 tem- 
perature of the water ranging from io° 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 anaemic, 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 anemia 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 anaemic 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 men- 
struation, 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 espe- 
cially recommended for girls suffering from chlorosis, 
at first, by Scholz and Schubert, in association with 
phlebotomy, but also without this. Kuhne, for ex- 
ample, has seen the most satisfactory results follow the 
simple use of sudatory baths in cases of chlorosis ; im- 
provement was manifested by an increase in the corpus- 
cular richness of the blood, an increase in the haemo- 
globin-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 con- 
sequent diaphoresis. 

Still more recently Dehio and especially Rosin have 
recommended hot baths for girls suffering from chlor- 
osis. 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 treat- 
ment 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-in- 


toxication theory of chlorosis may regard the dia- 
phoresis as a means for the elimination of noxious sub- 
stances from the body. 

Bathing in water aerated with carbonic acid may be 
recommended for patients suffering from anaemia 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 efifective 
principally in virtue of the carbonic acid they contain, 
which stimulates the skin; this stimulus being con- 
ducted by the nervous system from the periphery to 
the nerve-centres, is reflected thence, and by irradia- 
tion exercises a quickening effect on all the processes 
of nutrition. These baths are usually taken at a tem- 
perature 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 me-, 
narche is delayed, also for chlorotic patients with amen- 
orrhoea 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 haemoglobin-rich- 
ness, 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 practise sea-bathing with ad- 
vantage, especially at watering-places on the sea-coast, 
where the waves are powerful. In such cases, how- 
ever, it is advisable in the first instance to take artifi- 
cially 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, aro- 
matic herb baths are sometimes useful. For this pur- 
pose such herbs should be employed as contain a no- 
table quantity of ethereal oils, such as sage (salvia 
officinalis), wild thyme (thymus serpyllum), hyssop 
(hyssopus officinalis), wild marjoram (origanum vul- 
gare), rue (ruta graveolens), archangel (archangelica 
officinalis), levisticum (levisticum officinale). Equal- 
ly 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 

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 recom- 
mended. 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 


haematopoiesis 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 
haemoglobin-richness of the blood in consequence of 
residence in a mountain climate, is lasting or merely 
transitory, yet it is certain that the haematopoietic 
organs are favorably influenced by such residence, and 
that the good results are augmented by the stimulat- 
ing 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 dysmenorrhoea 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 resist- 
ing 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 
sea side is especially suitable. For the slighter forms 
of anaemia, 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 anaemia or chlorosis. 

Such very weakly, intensely anaemic and chlorotic 
patients should spendthe 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 dis- 
figured 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 seborrhoeic process in these 
glands becomes at all severe, ordinary soaps are un- 
suitable, 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 seborrhoea is, according 
to Spietschka and Griinf eld, the following : The wash- 
ing 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 Pharmacopoeia) 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 ma- 
terial, such as boric vaseline, in order to prevent the 
plugging of the pores with dust, and to protect the se- 
bum subsequently exuded from desiccation. 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 accumula- 
tion 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 fur- 

It is of great importarK;e 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 ob- 
served in which a vaginal examination, the introduc- 
tion 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 treat- 
ment 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 re- 

If in such cases, especially in girls of a neuro- 
pathic temperament, gynecological treatment is quite 
indispensable, a single, though energetic, operative pro- 
cedure 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. 
Sanger, 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 curet- 
ting as compared with milder intra-uterine impres- 
sions 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 


CO 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 resist- 
ing 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 Goethe'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 de- 
sires 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 insuffi- 
cient 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, neu- 
rasthenic and hysterical states, disorders of menstrua- 
tion 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 re- 
moved. For the adolescent girl a systematic alterna- 
tion 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 imag- 
ination may remain pure and in order that girlish 
illusions may not be prematurely destroyed. Domestic 
recreations in the way of games, music, singing, paint- 
ing, and other forms of artistic culture, are of impor- 
tance for the development of a strenuous faculty for 
learning. Travel in regions where the scenerj is beauti- 


ful, forms a most valuable means for the ennoblement 
of the intellect and the emotions. 

Additional matters demanding attention are, as al- 
ready 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 for- 
bidden, 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 

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. Gym- 
nastics, with or without apparatus, swimming, skating, 
and lawn tennis, involve a number of bodily move- 
ments 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 on- 
anistic manipulations. 

Especial attention must be paid to the clothing, re- 
garding which the requirements of fashion so often 
conflict with those of hygiene, the victory, unfortu- 
nately, 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 con- 
nection 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 abdom- 
inal viscera, the corset liver (lacing liver, constricted 
liver, Ger. Schniirleber), the movable kidney, etc. — 
all are so well known that they need not be particu- 
larly described. But the strong pressure from above 
has a deleterious effect upon the internal genital organs 
also, leading to passive hyperaemia and to displace- 
ments. The 'bones' of the corset take part in the com- 
pression, 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 be- 
come 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 sup- 
porting 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 petti- 
coats is too great to be borne by the shoulders, the 
burden can be divided, some being fastened to the cor- 
set, 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' undergarment, 
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 gar- 
ments clothing the parts below the waist should be 
made to fasten. It must unfortunately be admitted 
that this rational mode of arranging the clothing can- 
not be adapted to the 'low dress' which etiquette de- 
mands 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 clean- 
liness 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 pre- 
maturely 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-stimu- 
lating, 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 alto- 
gether without any severity. "Chastity," says Oester- 
len, "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 onward every one can do what he pleases ; 
but just as little is it really practicable amid condi- 
tions 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 blameless- 
ness 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 re- 


garded 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 divers 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 

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 never- 
theless, on the other, the urgently needed enlighten- 
ment 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 mem- 
bers of the family, who will be guided by the insight 
they have acquired into the mental life of those con- 
cerned. * * * 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 dor- 
mitories that require the most strict, most careful, and 
most continuous control. In the case of auto-onanists, 
female as well as male, we must inquire into the pos- 
sible 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 
toward the preservation of physical and moral vir- 
ginity, 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 enlighten- 
ment in an unfitting manner from some more experi- 
enced female friend. The mother should explain that 
the impending flow of blood is a natural process, un- 
attended by danger, but indispensable to the sexual 
life, and a characteristic part of the process of "grow- 
ing 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} 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 

^Eine Mutterpfiicht. 


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 re- 
spectively; 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 speci- 
men of its kind. The opportunity may then be seized 
to draw attention to the resemblance between the little 
ovules in the ovary of the minute ova by means of 
which all animal life reproduces its kind. Proceed- 
ing farther, 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 intelli- 
gent manner to a knowledge of the method of repro- 
duction in the human species. 

Often enough, when the mother is lacking in intelli- 
gence or sympathy, it will be the duty of the physician 
to give this enlightenment to the young girl. The in- 
terpreter 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^ 
oflfense to maidenly modesty. Many sexual disorders 
and much sexual aberration may thus be prevented. 

Certain definite hygienic rules must now be pre- 
scribed. First of all, the strictest cleanliness must be 
observed, not only in the intervals, but also during 
menstruation. The prejudice against changing the 
underlinen 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 ab- 
sorbent 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 menstrua- 
tion, full baths, warm or cold, are to be avoided, like- 
wise long walks, riding, long journeys by rail, gym- 
nastics, with or without apparatus, skating, lawn tennis, 
and bicycling; dancing, above all, must be prohibited, 
since it involves a combination of several noxious in- 
fluences — the very active movement, which produces 
hyperaemia 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 menstrua- 
tion, 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. 13 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 pre- 
scribing 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 pre- 
cautions against the practice by young girls of unduly 
prolonged voluntary retention of the urine, resulting 
in overdistention of the bladder; also against the per- 
formance of very active movements and against power- 
ful 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 men- 
strual flow is greatly in excess, strong tea and coffee, 
wine, and beer should be forbidden; conversely, when 
menstruation is scanty, an invigorating diet is espe- 
cially indicated, and the use of strong wines. According 
to the investigations of T. Schrader, in order to main- 
tain the nitrogenous balance during menstruation, it 
is necessary to give the following daily diet, repre- 
senting 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 recom- 
mended 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. 95, 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 midday dinner, a good helping of fresh meat so 
cooked as to be easily digested, green vegetables, pota- 
toes, 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 midday 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 fiesh (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 Desque has drawn 
up the following diet-table, representing 3,290 calo- 
ries 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 
10 A. M. — 300 grammes apples, strawberries, or cranberries, 50 
grammes roll, lO 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 recum- 
bent posture, a diet containing large quantities of fluid, 
and much easily assimilable albuminous nutrient ma- 
terial, 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. 
11a. 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 haemorrhage has ceased, the follow- 
ing 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, sweet-bread, pigeon, 
ham, nutrient and easily digestible vegetables, spinach, 
carrots, and pea-soup, may be recommended. 


In cases of amenorrhcea or scanty menstruation, 
especially when due to anaemia or to underfeeding, 
mental excitement, or overexertion, 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 paren- 
thesis, 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 meas- 
ures, 30 grammes are equivalent to a very little more than an avoirdupois 


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 muco-sanguineous 
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 undula- 
tory movement in the vital processes of woman. 

The Mosaic law regarded the process of menstrua- 
tion 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 separa- 
tion. * * * 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 taber- 
nacle 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 writ- 
ings, 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 menstrua- 
tion begins at the age of twelve, and recurs monthly, 
the flow lasting three days. In the Jewish Talmud it 
is asserted (see La Medecine 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 com- 
pleted her twelfth year. As signs of puberty. Rabbi 
Josse 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 Josse, 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 appear- 
ance of menstruation, theJjEiilmud-inentiojaa,^ pain in the 
region of the umbiHcus and in the_uterus, flatulence. 


shivering, white flux, heaviness in the head and the 
limbs, and nausea. 

The blood discharged during menstruation has cer- 
tain 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 characteris- 
tic. Only when the bleeding is very profuse are coagu- 
lated masses evacuated. On microscopical examination 
of menstrual blood, we detect erythrocytes and leuco- 
cytes, the proportional number of the latter being great- 
er than in pure blood; there is an admixture also of 
epithelium from the genital mucous membranes, cylin- 
drical cells from the uterus, flattened cells from the 
superficial layers of the stratified scaly epithelium of the 
vagina, also various micro-organisms and granular de- 
tritus. 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 gralnmes (20 

Both the quality and the quantity of the blood are sub- 
ject 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 de- 
pends upon the temperament, the constitution, and the 
occupation of the woman concerned. It is greater in xi=— 
vacious 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 seden- 
tary than in those engaged in some active occupation. 

Similar considerations apply with regard to the dura- 
tion of each period. The mean duration is in the great 
majority of cases from four to five days, being generally 
the same iii 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 re- 
garded 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 pe- 
riod ; or conversely an eight-day period into a four-day 

The interval between one menstruation and the next 
(the period that elapses, that is to say, between the com- 
mencement 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 menstru- 
ation 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 

The amount of blood lost and the duration of the 
flow are less in strong, healthy women, leading an occu- 
pied, active, and regular life, especially in country- 
women and in women who are poor and chaste, thanj t 
is jn delicate, weakly women, leading a sedentary life, 
whose diet is abundant and stimulating, and who are 
accustomed to an ultra-luxurious and enervating exist- 
ence. In nuns, for example, the quantity of the men- 
strual 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 Linnaeus and Virey. Tilt 
further relates that Eskimo women menstruate only dur- 
ing the summer months, and even then scantily. In 
southern France, according to Courty, the quantity va- 
ries from I20 to 240 grammes (about 4 to 8 ounces) ; but 
it may rise to 300, 350, and even 500 grammes (about 10, 
12, and i6>^ fluid ounces). In the tropics, severe me- 
norrhagia is said to be common; and the fact was al- 
ready known to Blumbenbach, that women of European 
descent born in the tropics not infrequently succumb to 
hemorrhage during childbirth. 

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 haemorrhage ; 
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 causa- 
tion nor in respect to the time of its appearance. 

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

Local changes which may give rise to menorrhagia 
are, active hyperaemia and passive hyperaemia (hyperae- 
mia from engorgement) of the genital organs, such hy- 
peremia being itself due Vo 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 cer- 
vix, 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 nephri- 
tis. General diseases in which menorrhagia may occur 
are, anaemia, chlorosis, haemophilia, 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 anaemia re- 
sults, 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 ex- 
ertion, and is liable to attacks of cardiac enfeeblement 
and to fainting fits ; in some cases degenerative changes 
ensue in the cardiac muscle. 

Dysmenorrhoea is characterized by severe pain occur- 
ring before, during, and after menstruation. The pain 
is caused either by abnormally powerful contractions of 
the uterus or else by abnormal sensitiveness of that or- 


gan. Abnormally powerful contractions are caused by 
various mechanical hindrances to the normal processes 
of menstruation; abnormal sensitiveness is due to in- 
flammatory and congestive states of the uterus and its 
annexa or to a general increase of nervous sensibility. 

Schauta, therefore, distinguishes a mechanical, an in- 
flammatory, and a nervous form of dysmenorrhoea. Me- 
chanical dysmenorrhoea is most frequently due to ste- 
nosis 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 re- 
sulting from operative procedures, uterine polypi, etc. 
In inflammatory dysmenorrhoea we have to do "either 
with an inflammatory process or with excessive tension 
of the intrapelvic organs, dependent upon abnormal dis- 
tention of the blood vessels." To the same category be- 
long ovarian dysmenorrhoea, and dysmenorrhoea due to 
inflammatory changes in the Fallopian tubes and to pel- 
vic peritonitis. In nervous dysmenorrhoea, no anatomi- 
cal cause is apparent, but the uterine contractions nor- 
mally occurring during menstruation, and the normal 
congestive distention 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 dysmenorrhoea on the general con- 
dition of the woman suffering from it is often a very 
potent one. 

The normal undulatory course of the bodily tempera- 
ture — ^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 dysmenorrhoea due to anteflexion of 
the uterus, parametritis, or salpingitis, inasmuch as in 


Aese cases the acme of the temperature curve is reached 
actually during menstruation and the decline of tem- 
perature comes, not at the commencement of the men- 
strual 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 
dysmenorrhoea Schauta mentions "sensations of heat, 
coldness of the feet, retching and vomiting, cramps of 
the stomach and of the voluntary muscles, general dis- 
orders of nutrition, loss of appetite, strangury, constipa- 
tion, dyspepsia, headache, and finally hysteria. As 
symptoms of the latter affection we may notice, anaes- 
thesia, hyperaesthesia of certain parts of the abdomen, 
attacks of cramp, paralysis, uterine cough, hiccough, 
spasm of the glottis, and epileptiform seizures. The re- 
peated severe attacks of pain may seriously disturb the 
nervous system, leading to the appearance of general 
neuroses and psychoses. Frequently we observe, as a pe- 
culiar accompaniment of dysmenorrhoea, 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 associa- 
tion with dysmenorrhoea, various forms of neuralgia, 
changes in refraction, and slight attacks of neuritis and 
retinitis may occur." 4< . * 1^;;;^^-^^ 

One of the commonest symptoms and sequelae is head- 
ache, 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 dysmenor- 
rhoea. 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 dysmenorrhoea, 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 
dysmenorrhoea (intermenstrual pain, Ger. Mittel- 
schmerz). In the character of the localized pain, in- 
termediate dysmenorrhoea closely resembles ordinary 
dysmenorrhoea; it recurs often with precise regularity 
on certain days during the intermenstrual interval. 

Croom distinguishes three forms of intermediate dys- 
menorrhoea; 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 
tubae 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 dysmenorrhoea 
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 mani- 
festations may be discovered in nearly all typical cases 
of intermediate dysmenorrhoea. 

Long-continued dysmenorrhoea may give rise to 
numerous hysterical troubles, general convulsive sei- 
zures, local muscular spasm and paralysis, hiccough, 


spasm of the glottis, uterine cough, twitching and spasmij 
of various groups of voluntary muscles. In some caseSj 
we see fully developed epileptic convulsions, with 
complete loss of consciousness and immobility of the 
pupils. Finally, psychoses may arise in association 
with dysmenorrhoea. 

In cases of pathological changes in menstruation, a 
carefully arranged hygiene at the menstrual periods is 
of importance, both for prophylactic and for thera- 
peutic purposes, and in this connection I may refer 
to what I have written in the section on Hygiene Dur- 
ing the Menarche. In cases of dysmenorrhoea a cer- 
tain amount of repose and precaution are needed dur- 
ing the flow, with avoidance of chill, scrupulous 
cleanliness, and regulation of the bowels. In cases 
of amenorrhoea we must prescribe attention to the 
general nutrition by means of an easily digested robor- 
ant 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 condi- 
tions of the uterus, the ovaries, or the organism as a 
whole, the menstrual flow has at the time of the me- 
narche either failed entirely to appear or been exceed- 
ingly scanty, haemorrhages from other organs have since 
ancient times been witnessed, and these haemorrhages 
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 equilib- 


rium of blood distribution, and vicarious haemorrhages 
take place from the mouth, the nose, the intestines, the 
anus, the gums, the mammae, the ears, and the lungs; 
or haemorrhages occur in the brain, the nerves, or the 

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

In cases in which menstruation is in abeyance, we 
sometimes witness, instead of vicarious haemorrhages, 
the occurrence of non-sanguineous vicarious discharges 
from various mucous membranes. Thus, vicarious 
leucorrhoea 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 diarrhoea 
and vicarious salivation have been observed. 

The Sexual Impulse 

By the term sexual impulse, we understand the im- 
pulse shared by women and by men toward intimate 
physical contact and sexual intercourse with individ- 
uals 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 be- 
comes a powerful passion, dominant throughout the 
active sexual life of the woman, and it may evert con- 
tirtue 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 gratifi- 
cation 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. 

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, though its 
manifestation may be repressed by force of will. 

According to the general opinion, the sexual impulse 
is not so strongly developed in women as it is in men. 
Hegar, Litzmann, Lombroso, P. Miiller, and many 
others, assume that the sexual sensibility of women is 
less than that of men; Fiirbringer is inclined to attrib- 
ute 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 inexperi- 
enced 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 con- 
tact and toward copulation is just as powerful as that 
of men. According, however, to the dominant arti- 
ficial conditions, man assumes it as his right to give 
free rein to his sexual desires and to gratify them with- 
out 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 con- 
trol 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 mofe 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 gratifi- 
cation 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 differentiae is to 
be found, in my opinion, the influence which deter- 
mines the type of sexuality in the respective sexes, 

Hegar maintains that under the term sexual impulse 
two distinctconceptions are confounded: First, the im- 
pulse toward copulation, the desire of carnal union 
with a member of the opposite sex; secondly, the im- 
pulse toward reproduction, the desire for children. 
'At the same time, this author admits that it is question- 
able if we can properly speak of an impulse toward 
reproduction, when reproduction is merely a conse- 
quence 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 per- 
haps 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 pro- 
longed courtship, and often endeavors for a consider- 
able 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 occu- 
pies herself in building the nest. Among mammals, 
it is difficult to determine whether sexual feeling is 
stronger in the female than in the male ; but it is certain 
that sexual relations are seldom long lasting, they con- 
tinue 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 king- 
dom, 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 en- 
tirely 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 mother- 
hood, 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 

Mantegazza lays stress on the fact that in the female. 


sexual desire is very rarely accompanied by pains an- 
alogous 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 employ- 
ment 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 pas- 
sively, without ardor and without enthusiasm. It is 
well known, also, that among the lower races of man- 
kind, means are employed to stimulate the sexual sen- 
sibility 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 hus- 
band 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 Prospere expresses himself to a similar effect: 
"Women do not fall in consequence oi 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 over- 
filled by the rivers that pour their waters into it. 

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 con- 
tact with men, and in whom sexual desire and sensi- 
bility have not yet been directly excited; later, how- 
ever, 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 naturee frigi- 
dce, and have no sensual inclination to sexual inter- 
course, 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 sex- 
ual 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 in- 
fluences with mental influences, increases the difficulty 
of the problem. Neurologists have observed women 
on whom continence was forced either during mar- 
riage or after its dissolution, who thereupon fell into a 
state of severe nervous exhaustion or nervous excite- 
ment, or suffered from threatening or even actually de- 
veloped psychoses. That sexual abstinence is "abso- 
lutely harmless," as moralists and many physicians 
would so gladly believe, appears to Erb quite unwar- 
rantable assumption. 

"In the processes of reproduction," continues Erb 
in his discussion of this subject, "woman is the princi- 
pal sufferer. With inhuman cruelty, nature has con- 
demned woman to a far more difficult role 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 germi- 
nating 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 perform- 
ance 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 fiature with a rela- 


tively weak sexual impulse ! This unequal and unjust 
distribution of the male and female roles 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 per- 
verse 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. 

Lowenfeld 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 in- 
fluenced 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 im- 
pulse, yet this latter may be entirely absent in cases 
in which the erotic element is strongly developed. 

'According to Lowenfeld, the sexual impulse is alto- 
gether wanting in young girls before the time of pu- 
berty, 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 indeter- 


minate 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 au- 
thority, erotic dreams and similar occurrences are en- 
tirely 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 Lowenfeld, in a not inconsiderable proportion of 
women even after their introduction to sexual inter- 
course — Effertz estimates that such complete frigidity 
is permanent in lo 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 per- 
haps 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 to the influence of sexual gratifi- 
cation,, 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 wom- 
en and women vowed to celibacy (nuns and members 
of other celibate religious orders) justify any conclu- 


sion, 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 fulfil- 
ment of the genital functions. It may, however, find 
a truer explanation in the selection effected by mar- 
riage, especially when we take into consideration that 
from the women thus selected the weaker individuals 
have been previously weeded out by the processes of 

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

"Suicide is certainly very little dependent upon re- 
pression 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 pre- 
vention of insanity is in part apparent merely, since, 
in the selection exercised by marriage, those predis- 


posed to mental disorder, and those in whom such dis- 
order 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 aflfected by the processes of reproduction. 

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

"Chlorosis is not in any way dependent on repres- 
sion of the sexual impulse. A disease apparently an- 
alogous 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. Mar- 
riage 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 

Moll divides the sexual impulse into two compo- 
nents: The impulse toward intimate contact (in a sense 
both physical and mental) with a person of the op- 
posite sex, which he calls the contrectation-impulse 
(Kontrektationstrieb) ; and the impulse to bring about 
a change in the genital organs, which he calls the de- 
tumescence-impulse {Detiimeszenztrieb). 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 swell- 
ing 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 detu- 
mescence-impulse is wholly wanting. 

Runge defines the sexual impulse as the impulse 
which brings the sexes together. This impulse is sub- 
servient to an instinct, namely, the instinct of repro- 
duction; that is to say, the sexual impulse induces the 
individual to perform actions which subserve the pur- 
pose 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 rela- 
tions which obtain between the sexual life and the 
sense of smell lead to the supposition that the sexual 
and the olfactorjr 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 a place of origin of sensations and percep- 
tions, and the organs of generation. By anatomico- 
physiological processes these now give rise to sexual 
perceptions, representations, and impulses. The cere- 
bral cortex, by apperceived or reproduced sensuous per- 


ceptions, influences the organs of generation. This in- 
fluence 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 percep- 

II. Of the pleasurable sensations associated with 

Hence arises the impulse to sexual satisfaction. This 
impulse becomes stronger in proportion as cerebral 
excitement, consequent on appropriate perceptions and 
the working of the imagination, strengthens the in- 
tensity of these pleasurable sensations. If the condi- 
tions 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 constitu- 
tion and various organic processes have an important 
influence; on the strength of the inhibitory percep- 
tions, 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 ex- 


ternal friction, serve to increase the strength of the 
sexual impulse. Among internal processes which stim- 
ulate the erectile centre by centripetal impulses must 
be included, the stimulus of the enlarged graafian fol- 
licle, 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 constipa- 
tion. External friction may be in the form of in- 
tentional manipulation, but it may be due to certain 
bodily attitudes or to the arrangement of the clothing. 
In normally constituted individuals, the sexual im- 
pulse is by no means constant in its intensity. Apart 
from the temporary indifference resulting from sexual 
gratification, and apart from the decline in the im- 
pulse 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 re- 
minded 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 neuro- 
pathically 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 im- 
pulse, hyperesthesia sexualis, the constitution of the 
individual is, according to von Krafft-Ebing, of great 
importance. He writes: "With a neuropathic con- 
stitution, 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 con- 
stitutionally 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 pf 
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 aggravat- 
ing neurasthenia that already exists. 

"Excessive sexual desire may arise either from pe- 
ripheral 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 predisposi- 
tion, in hysterical subjects, and in states of mental ex- 
altation. In such cases, when the cerebral cortex, 
including the psychosexual centre, is in a state of hy- 
peraesthesia (abnormal excitability of the imagination, 
facilitated association of ideas), not only optical and 
tactile sensations, but also auditory and olfactory im- 
pressions, will arouse lascivious perceptions. 

"Sexual hyperesthesia may be continuous, with ex- 
acerbations, 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 mani- 
festation of a general condition of mental excite- 


In the poorer classes of society, an increase of the 
sexual impulse occurs in women chiefly in conse- 
quence 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 gen- 
erally, 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 con- 
tinues to recur, which indicates that during these 
months a larger number of sexually mature individuals 
is engaged in the discharge of sexual functions. Rosen- 
stadt regards this as the manifestation of a "physio- 
logical 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 fore- 
fathers 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 be- 
fore 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 ac- 
cordance 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 anthro- 
poid 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 con- 
clusion that in the human species also the sexual im- 
pulse may originally have awakened only at a particu- 
lar season of the year, and that the persistence of this 
physielogical custom in man, in spite of the fact that 
sexual intercourse occurs all through the year, and not- 
withstanding that the conditions necessary to awaken 
the sexual impulse are actually perennial, must be 
ascribed to inheritance." 

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 

THE SEXUAL EPOCH OF THE MENARCHE 147 necessary connection with the function of ovu- 

This is indicated by the always respectable number 
of women who enter upon marriage even after the cli- 
macteric 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 in- 
terest 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 num- 
bered no less than — 86 years. 

Borner reports cases in which the sexual impulse re- 


mained in full activity after the change of life, and in 
some cases was greatly increased in intensity — these lat- 
ter individuals being in a condition of real torment, 
which induced them to masturbate to obtain relief. 



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 com- 
pleted 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 in Central 
Europe is 22; but marriages at an earlier age are 
very common, and in many circles of society the aver- 
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 woman at- 
tain 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. Gonor- 
rhoeal infection has been a source of unspeakable mis- 



eries to women. Motherhood itself entails the risk of 
a great number and variety of illnesses, which, as puer- 
peral sequelae, 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 hus- 
band 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 rela- 
tions 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 co- 
incides with the normal processes and pathological 
changes respectively of the female genital organs conse- 
quent 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 emanci- 
pation 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 cen- 


tral 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 rejec- 
tion 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 trans- 
form 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 numer- 
ous 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 justi- 
fiable 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 lose 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 in- 
stinct 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 in- 
stinct of self-preservation at every one else's expense — 
more powerful than such self-sufBcient 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 

Against the significance and importance of mater- 
nity to woman, the mountainous waves of the move- 
ment for the emancipation of women dash themselves 
as vainly as against the solid rock. Much justifica- 
tion may be found for the efforts of women in modern 
civilized communities to engage in departments of ac- 
tivity to which hitherto men only have been admitted ; 
and as regards the intellectual capacity of women we 
may acknowledge their competence for the higher sci- 
entific 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 ma- 
ternity, an interference with the discharge of her obli- 
gations to husband and children, or a diminution of 
her domestic value and an evasion of her responsibili- 
ties 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 lon- 
ger a woman, she cannot be a wife, she cannot be a 
mother. In the condition of our society, the emancipa- 


tion of woman is in its very nature the negation of 

We may not agree with the great misogynist, Scho- 
penhauer, 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, there- 
fore, to the end stand in need of supervision and guid- 
ance" ; but the statement made by Friedr. Nietzsche 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 genera- 
tion; man has the pleasure, but not the labor and the 
pain. We might indeed regard as highly unjust the 
distribution of the roles 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 ofif any further responsibility, whereas the wom- 
an'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 im- 
pulse and maternity — according to Icard, the sexual 
impulse is extinguished in women during pregnancy, 
— still, maternity appears to depend upon sexual per- 
ceptions. For instance, the act of suckling the infant 
often arouses voluptuous sensations, and Icard men- 
tions 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 vo- 
luptuous sensations derived from the genital organs." 
According to Bain, also, very delicate sensations of con- 
tact form an element in maternal love. 

The epoch of the menacme is that in which, inde- 
pendently of maternity, the sexual impulse often be- 
comes so powerful in woman as to be entirely domi- 
nant. 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 de- 
mands," asserts the authoress of a book recently pub- 
lished (Elisabeta von Steinborn, The Sexual Position 
of Woman). With laws for the regulation of mar- 
riage, 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 amor- 
ous 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 inter- 
course has lasted for a long time, will free marriage be- 
come 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 dele- 
terious 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. 

We must point out that in so far as the modern wom- 
an's movement aims at dispensing with man and at bas- 
ing 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 in- 
dependence is one who endeavors to avoid the bur- 
den 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. 

"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 con- 
cerns 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 influ- 
ence 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 Kreut- 
zer Sonata, Strindberg in numerous dramas, Huys- 
mans in En Menage, write in this strain; and in the 
works of many lesser luminaries we encounter this mis- 
trust of love. * * * The modern system of educa- 
tion for girls, with its polyglossia and polymathy, fav- 
ors a superficial development of the understanding, 
and produces women who are pretentious without be- 
ing 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 confine- 
ments impair the beauty of the breasts and the abdo- 
men, 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 work- 
ing-class woman, through sharing in masculine la- 
bors, 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 be- 
longing to the laboring classes seldom endure for long 
after the menarche, and in cases in which the environ- 
ment is one of poverty, they last through a very short 
part only of the epoch of the menacme. The early ap- 
pearance of wrinkles in the face, the stiff, angular char- 
acter 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 investi- 
gation shows what damage has been wrought to the at- 
tributes of beauty, how the breasts are flabby and flat- 
tened, 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 developinent with an imposing 
appearance and buxom form. In favorable circum- 
stances, beauty of this type may persist to the fortieth 
year of life and even beyond, and it is of such a char- 
acter as to justify the proverb that w^oman's first sexual 
epoch is dedicated to love, her second to voluptuous- 

"Bountiful nature," w^rites Mantegazza, regarding 
woman at this sexual epoch, "sends to woman an in- 
genious 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 cer- 
tain number of chosen women understand how to pre- 
serve for as long as ten years the unstable equilibrium 
of the period which separates these two ages of life. 
These are divine beings who with every oscillation of 
their tresses or rocking of their hips, with every undu- 
lation 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 utter- 
most goal of human passion, of human voluptuous 

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 forehead; there is greatly increased pig- 
mentation also of the areola mammae 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-pres- 
sure. Sometimes, also, in pregnant women, we observe 
on the face, chiefly on the nose and the cheeks, dilata- 
tions of the small cutaneous vessels, often associated 
with acne nodules. 

Transiently during pregnancy, but in some cases per- 
manently 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 oedema; 
these conditions depend upon the hindrance to the ve- 
nous 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 entdjil further disfigure- 
ment of the skin through the production of various le- 
sions, 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. 

Hygiene During the Menacme 

During the sexual epoch of the menacme a wom- 
an'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 ex- 
perienced 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 impres- 
sion on the mental life of woman, and in many cases 
also gives rise to burning desire and tormenting yearn- 
ing of an erotic nature. The unmarried miss life's true 
goal and fail to enjoy the natural exercise of their func- 
tional 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 particu- 
larly described. 

Free love, moreover, is the most important dissemi- 
nator of gonorrhoeal infection. "In any future com- 
monwealth," says Runge, "in which marriage is aban- 
doned in favor 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 gonorrhoea to a very serious extent." 

Frequently enough, also, free love leads to prostitu- 
tion, 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 aggre- 
gation of the population in large towns ; the decline in 


the marriage rate; the postponement of marriage; uni- 
versal military service; the freer mutual companion- 
ship of the sexes; and many others. At any rate, the 
fact would appear to be established, that in the case of 
wornan 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 prosti- 
tutes; and it is during times of deficient employment 
that the number of women practicing occasional pros- 
titution increases. Thus, material need is the most im- 
portant of the causes of prostitution. 

This remains true even though the doctrine of Lom- 
broso and Tarnowsky should find fuller justification, 
the doctrine that the practice of prostitution by women 
is the natural expression of a congenital morbid pre- 
disposition, "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, dif- 
ficult 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 un- 
stable moral equilibrium, an insufficient development 
of the force of the will and of the power of resistance. 

The hygienic requirement of married life for wom- 
an during the menacme is undoubtedly sometimes hard 
to fulfil in our day, when the more elaborate and ex- 
pensive 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 categori- 
cal 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 con- 
sequences, declare marriage to be immoral ; and, final- 
ly, 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 un- 
justified in demanding, before undertaking marriage, 
"perfect love as typifying the inner yearning of two be- 
ings 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 sex- 
ual life of man differs entirely in nature and in the 
course of its development from the sexual activity of 

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 sex- 
ual 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 re- 
sult from unchastity? And is it not a crying sin, even 
if some of these fears are justified, to ruin both mental- 
ly and physically the whole race of women? * * * 
Man demands from the girl of his choice, not chas- 
tity 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 ma- 
ternity, while fortified by the terrible knowledge that 
the father of her children has wasted his youthful vi- 
rility 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 sen- 
suality? * * * 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 lon- 
ger 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 hap- 
piness, 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 sor- 
row 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 mo- 
ral rights, for the abandonment of the hitherto preva- 
lent bisexual ethical standards, is in vain conflict with 
actuality, with the defensive instincts of young men, 
with the difficulties entailed by the struggle for exist- 
ence, with the increasing pretensions (to sexual free- 
dom) of women themselves; but above all is it in con- 
flict 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 ele- 
vating 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 be- 
yond the possibility of rescue. Thus early marriage 
with equal purity of husband and wife remains a pos- 
tulate which the present can hardly be expected to sat- 
isfy, and one whose fulfilment must be left to the 

In consequence of modern writings and discussions 
concerning the erotic problem, there has arisen a hy- 
persensibility on the part of women in respect of the 
conditions, in which they pass their married life, lead- 
ing 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 consid- 
eration, 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, notwith- 
standing all necessary self-surrender, to preserve the 
freedom of her own individuality and the esteem of 
her husband. 

Marriages based upon true inclination usually re- 
sult in the birth of stronger and more beautiful chil- 
dren 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 i,ooo young 


men from 20 to 25 years of age, in England 1 20 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 pros- 
pective wife. For it is well established that the law of 
inheritance relates not only to the peculiarities of ex- 
ternal configuration, to the features, the stature, the tint 
of the skin, but also that children inherit from their pa- 
rents 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 predisposi- 
tion to disease, the most important are, as is well 
known, the predisposition to tuberculosis, that to ma- 
lignant 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 viril- 
ity, is unlikely to procreate healthy and powerful chil- 
dren; and these latter for the most part will be weakly, 
scrofulous, cachectic, endowed with deficient powers of 
resistance, and often badly equipped from the intellec- 
tual standpoint. Similar considerations prevail in re- 
spect of marriages in which the husband has been ex- 
hausted by earlier sexual excesses, so that he retains no 
more than remnants of virility, whilst his semen is of 
doubtful fertilizing power. 

Plato maintains that before every marriage the man 
and the woman should both undergo official examina- 
tion to determine their fitness or unfitness for the mar- 


ried state, the man being absolutely nude, and the wom- 
an stripped to the waist, for the examination. This au- 
thor 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 requis- 
ite knowledge to fulfil Plato's requirements, is asked 
for his opinion regarding the desirability of a contem- 
plated 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 ear- 
lier 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 phv- 
sically suitable for marriage. 

In deciding on marriage, however, care should be- 
fore all be taken to determine that the girl has attained 
complete physical and especially complete sexual de- 
velopment. 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. Notwith- 
standing the fact that the legal codes of civilized coun- 
tries nowhere demand for girls a greater age than fif- 
teen years before permitting marriage, this limit is, 
generally speaking, fixed far too low. Before becom- 
ing 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 devel- 
oped 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 per- 
missible, a girl is still far from having attained physical 


and mental ripeness for marriage, reproduction, and 

Especially with reference to the last consideration is 
't inadvisable that in our climates a girl should marry 
earlier than from 1 8 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 se- 
cure, and there will be a greater probability of her pro- 
ducing a healthy progeny. In the East, indeed, quite 
diflferent views prevail. According to the laws of Ma- 
nus, 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 menstrua- 
tion. 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 foetus, 
while the daughter herself loses caste. Marriage de- 
layed till after the appearance of menstruation being 
regarded as sinful, girls are married while still chil- 
dren, 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 re- 
gard every menstruation which has not been preceded 
by coitus in the light of infanticide, marry their daugh- 
ters 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 usu- 


ally effected before girls reach the age of puberty; 
in India, indeed, according to Ploss and Bartels {Das 
Weib in der Natur und Volkerkunde), marriage with 
immature girls is a widely diffused custom, and in Aus- 
tralia 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 ad- 
vice 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 f reedman to wife." 

Experience proves, however, that in our climate, 
at any rate, girls who marry at a very early age are in- 
ferior in fertility to those who refrain from marriage 
until the genital organs have attained complete matur- 
ity; 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 ju- 
venility is exercised by its opposite, marriage when a 
woman is already elderly; in this case fertility is lim- 
ited, 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 

Not only is the absolute age of the woman of im- 
portance 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 cir- 
cumstances 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 fa- 
miliar both with the favorable influence of good nour- 
ishment and with the advantage of the opportune cross- 
ing 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, men- 
tal disorders, diabetes, and the like. When first cou- 
sins contemplate marriage, it is indispensable, not only 
that both individuals should be in perfect health, but 
a^SQ/hat on neither side there should be any serious 


family history of transmissible disease or transmissible 
morbid tendency; and, further, it is absolutely neces- 
sary that no such marriage of near kin should have tak- 
en 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 proceed- 
ing from different families, different places, and differ- 
ent 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 Eu- 
rope, 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 ex- 
clusiveness 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 mar- 
riage 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." 

Mobius, 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 pa- 
rents. Marriage from affection insures the fulfilment 
of nature's aims with more security than marriage from 
reason ; since what we have to think of is not the happi- 
ness of the married pair but the quality of their chil- 
dren. Of great importance, also, to the development of 
the human race are the conditions during the com- 
mencement of life, and the mode of education. The 
improvement of the race has not hitherto been the con- 
scious 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 mar- 
riage of persons suffering from tuberculosis should be 
prohibited. For the prevention of disease is more im- 
portant than its cure. The most important factor in 
preventive medicine is an improvement in the condi- 
tions of life. The human ideal should be, goodness of 
heart in association with physical and mental health. 
Goodness, beauty, and strength should be simultaneous- 
ly pursued. Since,, however, man is made by birth far 


more than by education, selection in marriage is of fun- 
damental importance. In the choice of a partner, at- 
tention is rightly paid to beauty, since beauty and 
health are fundamentally identical; moreover, a hu- 
man 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 ex- 
istence 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 law-givers of all the nations of antiq- 
uity have insisted upon the necessity of certain in- 
tervals between the acts of intercourse. Thus, Maho- 
met prescribed 8 days, Zoroaster 9 days, Solon 10 days, 
Socrates also 10 days. Moses forbade intercourse dur- 
ing menstruation and for a week after the cessation 
of the flow. Luther prescribed intercourse "twice a 

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 in- 
tercourse 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 pas- 
sive part, and for this reason can repeat it with im- 
punity 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 
woman 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 in- 
dulged in coitus while the latter was menstruating. As 
a matter of fact, considerations alike of hygienic clean- 
liness and of sanitary precaution prohibit the perform- 
ance of coitus during this period. Severe menorrhagia, 
perimetritic irritation, and parametritic inflamma- 
tions, 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 es- 
pecially apt to occur at this time), the child is likely, 
as earlier authors maintained, to be unfavorably af- 
fected, 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 ad- 
ministered 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° to 
82° F. (26° to 28° C.) is best. 

All measures for the purpose of artificially increas- 
ing sexual desire, such as alcoholic beverages (especial- 
ly champagne), and certain drugs (especially canthari- 
des), are even more harmful to women than they are to 
men. The woman who conceives while in a state of in- 
toxication commits a great sin against the coming gen- 


eration.^ Just as harmful, however, are the anaphrodi- 
siacs sometimes employed to diminish the intensity of 
sexual desire when this cannot be gratified. When af- 
fected with intense sexual excitement, a woman is much 
more unfavorably situated than a man, since man 
claims the right to indulge in sexual intercourse when- 
ever he feels disposed, and has, moreover, ample oppor- 
tunity 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 cooperate powerfully toward the preven- 
tion of excessive sexual desire. Horace already re- 
marked: "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 youth- 
ful vigor; she must prevent the complete combustion 
of the flames of masculine passion, and must keep 
sparks glowing in the ashes. Economy during the sex- 
ual prime preserves sexual power, enables a man to con- 
tinue 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 

1 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 aesthetic 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. 


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 he- 
tairai." 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 As- 
pasia, the chastity of a Lucrece, and the intellectual 
greatness of a Cornelia; she must bear in mind the epi- 
gram of Bacon, "A wife must be a young man's mis- 
tress, a middle-aged man's companion, an old man's 


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 wom- 
an can bind the man to herself, and can give the lie to 
the assertion that marriage is the grave of love. Par- 
tial concealment of her desire on the part of the woman 
is more stimulating to the man than an open manifesta- 
tion 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 inter- 
course 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, more- 
over, will serve to restore the exhausted nerves, and to 
replace the expended secretions. Less advisable is co- 
itus in the morning, on awaking from sleep, since the 
labors of the day must immediately thereafter be un- 
dertaken. Partially impotent men only, who wake up 
with an erected penis, endeavor to avail themselves 
without delay of this favorable opportunity, bearing in. 
mmd 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 unde- 
sirable 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 be- 
comes 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 fa- 
vors because he longs for her; he should not be the 
master, exacting an unquestioned right. For this rea- 
son, 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 attri- 
bute, 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 privi- 
lege 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 di- 
rect. 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 So- 
lon'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 de- 

The bluntest contrast to this Spartan simplicity is 
furnished by the unbridled lasciviousness that prevailed 
in Rome under the Caesars, 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 eu- 
nuchs, and further, as Pliny reports, hermaphrodites 
were in great request. Juvenal writes: "There are 
women who prize the infertile embraces of base eu- 
nuchs; thus they are able to dispense with the use of 


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 ear- 
nest and complete. By such enlightenment, the young 
bride will be spared much suffering, and a sudden dis- 
illusionment 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 utter-' 
ly ignorant of the nature of physical love, was so com- 
pletely 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 home then and there in the night, and by no per- 
suasions 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 

"Delicate foresight and restraint," writes Ribbing, 
"are needful above all at the commencement of mar- 
ried 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 inter- 
course 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). Im- 
patient 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. Fre- 
quently enough, on the bridal'night, the man proceeds 
with such violence in his assault on the virgin reproduc- 
tive 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 man- 
ner more calculated to awaken his wife's sexual desires, 
but in seeking his own lordly gratification and obtain- 
ing 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 considera- 


tion 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 agree- 
ably 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 hyperjemia 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 pos- 
sibility of the occurrence of conception and of the com- 
mencement 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 depen- 
dent upon the hygienic mistakes of the wedding jour- 
ney, 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 un- 
satisfied 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 hyperaemia of the female sexual or- 
gans ; in addition, the noxious influences of travel make 
themselves felt, and also hygienic indiscretions are per- 
petrated, 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 re- 
turns from her wedding journey with the germs of an 
illness from which she never fully recove'rs, and which 
is the source of unending suffering, and more particu- 
larly of a sterile marriage." 

Sexual hygiene demands a certain moderation in the 
enjoyment of physical love, and also a certain con- 
stancy, 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, notwith- 
standing the earnestness with which religious zealots, 
physicians, and moral teachers have in all ages en- 
deavored 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, how- 
ever, by the establishment of a minimum period, a cer- 
tain amount of sexual gratification was secured to the 
wife ; finally, also, the generation of a healthy posterity 
had to be taken into consideration. Ribbing, how- 
ever, 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 makilrig any 


mistake. In opposition to the opinion of many, I re- 
gard 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 re- 
straints than those demanded by care for their physical 
and mental health. The touchstone of marital hy- 
giene is this, that on the day following intercourse both 
husband and -wife should feel perfectly fresh, vigor- 
ous, 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 nutri- 
tive condition and physical constitution of the married 
pair, have an important bearing on the frequency with 
which, without detriment to health, cohabitation is per- 
missible. 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 laborers, on the other hand, once 
a week only; whilst brain-workers, finally, or those 
whose work is extremely arduous, should allow an in- 
terval 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 labors are exhausting, intercourse must not occur 
more frequently than once every week or ten days. 

The married couple should understand how to im- 
pose 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 determi- 
ning 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 hus- 
band'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 func- 
tions of woman as wife and mother. In that part of 
the world, everything possible has been done "to trans- 
form" (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 phy- 
sician, lawyer, merchant, professor; her boudoir has 
become an office, often connected with the stock ex- 
change by a private wire. Legally, also, she now pos- 
sesses 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 inde- 
pendent, I am emancipated, I am myself!' And ob- 
serve, as the result of all these attempts at the con- 
version 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, in- 
deed, 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 be- 
come 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 actu- 
ally threatens to disappear." 

The wife acts wisely, not oil 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., So. 
5, I- 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 con- 
sumption of alcoholic beverages has made the husband 
unduly lustful. On the other hand, the refusal of in- 
tercourse 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 en- 
tails serious consequences to the health of the individ- 
ual. And in the case of the wife these consequences 
may be especially disastrous when intercourse is in- 
dulged in recklessly during menstruation, during all 
stages of pregnancy, and even during the puerperium. 
"Incontinence during menstruation leads to serious cir- 
culatory 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 re- 
sult 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 recur- 
rence of the menstrual flow is induced, and the gradual 
reversion of the reproductive apparatus to the condi- 
tion 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 prema- 
ture resumption of marital intercourse, taking perhaps 
a somewhat extreme view of the matter. 

Nevertheless, this author is undoubtedly right in de- 
claring 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 mis- 
carriages that a woman will experience within a com- 
paratively short period of time, as is seen too fre- 
quently among the laboring classes and more especially 
among factory workers. "If we assume the ordinary 
mortality of childbirth to be 6 per mille, a woman 
who in the course of 15 years undergoes labor (at 


full term or prematurely) i6 times, runs a risk of death 
to be expressed by the ratio of 6X16^96 per mille; 
that is to say, on the average, of 1,000 women who be- 
come pregnant as often as this, nearly i in 10 will 
die in childbed." 

Young men who have previously suffered from gon- 
orrhoea 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 under- 
taken, and the filaments, if present, must be examined 
for gonococci. The physician will also have to deter- 
mine whether any vestiges remain of epididymitis, and 
whether the quality of the semen has been impaired 
by the attack of gonorrhoea. Unfortunately, it is not 
yet within our power absolutely to forbid marriage 
to a man exhibiting all the symptoms of chronic gon- 
orrhoea; 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 ex- 
tremely pressing question of the use of measures for 
the prevention of conception, for in recent years their 
use has become extraordinarily general, chiefly, in- 
deed, in the upper and middle classes of society, but 
to some extent also among the working-class popula- 
tion. 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 dis- 
countenanced 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 suc- 
cession of pregnancies and confinements. And this 
should be effected by a certain degree of continence 
and by the observation of extensive periods of sexual 

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. Cer- 
tain 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 ad- 


vantageous. As regards the last-named measure, how- 
ever, 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 ex- 
tremely difficult to effect. Inflammations, of the vulva, 
which are somewhat frequent in consequence of exces- 
sive 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 oi }i to }i per cent.) is 
advantageous. A general bath or a local sitz-bath, the 
water being moderately warm (95° to 99° F. ; 35° to 37° 
C), may be recommended on grounds of beauty as 
well as of health, and should be taken at least once a 

The regular use of lukewarm sitz-baths is a most 
valuable hygienic measure for the prevention of vari- 
ous general or local disturbances consequent upon in- 
creased 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 en- 
cased 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 em- 
ployed, and where any catarrh of the vaginal mucous 


membrance 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 pos- 
ture. The reservoir of the irrigator and the intra- 
vaginal nozzle are most suitably made of glass, to in- 
sure 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 deri- 
vative stimulus may be given to the skin, and the 
affected reproductive organs may thus be beneficially 
influenced. Further, in acute inflammatory conditions 
or hyperaemia 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 occupa- 
tions. Cold sponging of the body or cold full baths 
will also be found an excellent measure for the preven- 
tion 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. More- 
over, 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 suffi- 
ciency of occupation, regular, interesting, and demand- 
ing 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 per- 
fect 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, en- 
tails 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 culti- 
vated woman sexual gratification is possible only in 
the married state, whilst social conditions render mar- 
riage 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 coi- 
tus interruptus — altogether regardless of the woman's 
need for complete sexual gratification — there arise in 
women numerous local disorders and nervous disturb- 
ances, hysteria and even insanity being results by no 
means infrequent. The significance of ungratified 
sexual impulse in the pathogenesis of nervous dis- 
orders 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 favorable influence of marriage is over- 
rated. According to this author, the favorable 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 favorable circumstances of marriage, 
sexual gratification has in women an unfavorable in- 
fluence, 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 dis- 
orders which in women are especially associated with 


the process of reproduction (puerperal mania) con- 
firms 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 un- 
natural excesses or from long-continued sexual irrita- 
tion, especially in hereditarily predisposed persons. 

Such unnatural stimulation of the female is not in- 
frequently practised 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 role. 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 con- 
trary 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 particu- 
larly 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 super- 
vision 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 re-establishment of the woman's health. 
"Moreover, woman does not exist solely for the purpose 
of subserving during two decades of her life the pro- 
cesses 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 house- 
keeping and the rearing of the existing family unduly 
difficult, indicates the need for a further limitation of 
childbearing. 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 numer- 
ous 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 agfe 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 recu- 
peration were insisted upon, and intercurrent illnesses 
and states of debility were taken into account; and if, 
finally, sickly individuals, those hereditarily predis- 
posed to disease, and those in any way below par either 
mentally or physically, were more than heretofore pre- 
vented 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 modera- 
tion and continence." As regards the modern demand 
of the "right to love," the same experienced gynecolo- 
gist writes: "Whoever preaches to mankind the doc- 
trine 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 im- 
pulse,' 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 person- 
ality — 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 gratifica- 
tion, and sometimes — though not as often as might be 
wished — Hansel fails to find his Gretel, 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 invplution of the uterus, and 
lactation. This subject cannot now, however, be con- 
sidered 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 


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 indepen- 
dent 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 
difiference 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. 

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 
role is allotted to the male, the passive, receptive role, 
to the female. The modest and coy reluctance char- 
acteristic 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 


The union between ovum and spermatozoon, where- 
by fertilization is effected, appears to occur in the 
human species, as a rule, in the outer third of the Fallo- 
pian tube, the ampulla of this structure serving to store 
the semen for a considerable period; in the lower ani- 
mals, 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. 
Onee 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 Ohlschlager 
have proved that an ovum which passes through the 
Fallopian tube without being fertilized, undergoes no- 
table 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 Lowenthal, Mayrhofer, and Wyder, 
oppose the extension of this rule to the human species. 
Lowenthal assumes that in the human female, fertiliza- 
tion ordinarily occurs in the cavity of the uterus, in the 
wall of which the unfertilized ovum has already em- 
bedded 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 downward in the direction of the uterus. 

The contention of Lowenthal was disproved by Birch 
and Hirschfeld, who, in a prostitute dying during the 
act of intercourse, found, fifteen hours after death, liv- 
ing 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 pas- 
sages. Moreover, O. Becker has shown that the cili- 


ated 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 move- 
ment 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 toward the uterus. Lode 
has adduced positive experimental evidence of the oc- 
currence of such a movement of translation. 

The general result of anatomical investigation is, that 
the conjugation of the ovum with the spermatozoon 
takes place 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 

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. Toward the head of this spermatozoon 
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 spermatozoon disappears, whilst the 
head, which has now passed through the vitelline mem- 
brane 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. Toward this latter, situated somewhere near 
the centre of the cell, the male pro-nucleus continues 
to move, the vitelline granules meanwhile being dis- 
posed round about it in radiating lines, forming a star- 
shaped figure. Having come into contact, the two 
pro-nuclei 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 in- 
dividual is formed. Thus is effected that which Hip- 
pocrates 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." 

The most favorable period for the occurrence of 
fertilization appears to be when intercourse takes place 
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 ascer- 
tained by Hasler that in SaJ^ per cent, of all cases, 
conception was effected in the fourteen days succeed- 
ing 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 ap- 
pears 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 favorable to conception. "The time 
of generation," he says, "is the twelfth night after the 
commencement of menstruation." In the Jewish Tal- 
mud, the day before the onset of menstruation, and the 


days immediately succeeding the cessation of the flow, 
are indicated as those most favorable to the occurrence 
of conception; moreover, in the Talmud, notwithstand- 
ing the fact that intercourse during menstruation is 
prohibited on pain of death, and that coitus is not re- 
garded as permissible until the lapse of twelve clear 
days after the cessation of the flow, nevertheless the 
assertion is made that intercourse during menstrua- 
tion may lead to conception. 

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 i 
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 men- 
struation, again, conception is unlikely to occur, for 
then the semen is wetted and washed away by the flow- 
ing blood. The sole proper time is that immediately 
after the flow, when the womb has freed itself from 
its humors, and warmth and moisture stand in har- 
monious relationship." 

Among many of the castes of Hindustan, it is a 
religious ordinance that on the fourth day of menstrua- j 
tion 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 inter-menstrual 
interval are those most favorable to the occurrence of 
conception, is further confirmed by the statistical data 
collected by Lowenfeld, Ahlfeld, Hecker, and Veit; 
and it appears that as the date of the next menstrua- 
tion is approached, there is a continual decline in the 
frequency of conception; just before the flow, con- 
ception 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 1 
effected during the first days after the cessation of the I 
menstrual flow. 

2. When coitus is effected during menstruation, the 
probability of conception increases day by day as the 
end of the flow approaches. 

3. The number of conceptions following coitus 
effected shortly before menstruation is minimal. 

4. However, there is no single day either of the men- 
strual flow or of the inter-menstrual interval, on which 
the possibility of the occurrence of conception can be 

Feokstitow has drawn up from statistical data an 
ideal "conception-curve," which teaches that concep- 
tion most readily ensues upon coitus effected soon after 
the end of the menstrual flow, in the first week, that 
is to say, of the inter-menstrual interval; moreover, the 
curve shows that the highest percentage of conceptions 


occurs on the first day after the cessation of the 
\ flow, and that after this day the percentage of concep- 
tions declines. The percentage frequency of concep- 
tions from coitus effected on the last day of menstrua- 
tion, and on the first, ninth, eleventh, and twenty- third 
days, respectively, of the inter-menstrual interval, is ex- 
pressed by the ratio of 48: 62:13 : 9:1 ; and between the 
points given, the course of the curve is almost rectili- 
near. The probability of the occurrence of concep- 
tion 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. 

Normal semen is a whitish, semi-transparent fluid, 
of the consistency of thin cream. It contains aggrega- 
tions of a nearly spherical shape, consisting of a vitre- 
ous, transparent, colorless 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 with- 
out agitation for twenty-four hours, this substance dis- 
solves and becomes so intimately mingled with the 
seminal fluid that it can no longer be clearly differ- 
entiated therefrom. In all probability it is merely a 
secretory product of the seminal vesicles. The semen 
contains spermatozoa in countless numbers. 


Cardiac Troubles Due to Sexual Intercourse 

Among the troubles from which women at times suf- 
fer as a result of sexual intercourse, certain cardiac 
disorders are especially worthy of attention. 

Every act of sexual intercourse in a young and sensi- 
tive .woman exercises an exciting influence on the ner- 
vous 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 £ure more superficial and have a panting 

But when, in a woman who is sexually irritable in 
an excessive degree, the peripheral stimulation occur- 
ring in the act of sexual intercourse is unusually power- 
ful, there may result a notable increase or modifica- 
tion of the reflex manifestations which normally occur 
during sexual intercourse in the province of cardiac 
activity; similar results ensue when there is a summa- 
tion 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 com- 
pletion 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 excite- 
ment in the woman. Yet another cause of excessive 
cardiac reflex manifestations in women is incomplete 
potency of the male, which may either cause a pre- 
mature ejaculation of semen, or may lead to incom- 
plete 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 fre- 
quent, 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 uro- 
genital and anal regions, and in addition it was found 
that these attempts were followed by tachycardial par- 
oxysms with dyspnoeic manifestations, lasting for a con- 
siderable period, it might be as long as one or two 

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 pi-ofoundly 
influenced their psychical life, I have frequently wit- 
nessed 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. Phy- 
sically, 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, in- 
creased in frequency, often intermittent, sometimes 
more distinctly arhythmical. The heart is found to 
be sound on physical examination, nor can any abnor- 
mality be detected in the great vessels. The lower ex- 
tremities are free from oedema; the urine does not 
contain albumin. 

Women thus affected are sometimes believed to be 
suflfering 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 prac- 
tice, the cardiac symptoms soon cease to recur. 

Finally, in women at the climacteric age, cardiac 
troubles sometimes ensue, which are dependent on in- 
terference with sexual intercourse in consequence of 
anatomical changes in the vagina ; changes of this char- 
acter frequently occur at the time of the menopause; 
owing to hyperaemic or inflammatory processes, a 
partial or general stricture of the vaginal passage re- 
sults; 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 (oophorectomy), inter- 


feres with sexual intercourse; and the incomplete sexual 
gratification gives rise to a series of nervous manifesta- 
tions, and, among others, to the above described reflex 
cardiac neurosis. 

Whether, and in vs^hich cases, the cardiac disorders 
evoked as a result of the local stimulatory influences 
of sexual intercourse, are dependent on a reflex stimula- 
tion 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 func- 
tional activity thus impaired. 

Here I can do no more than briefly state that experi- 
ence 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 dyspnoea occur in 
young women affected with vaginismus ; also in women 
at the climacteric with constrictive changes in the 

3. Cardiac troubles, characterized mainly by symp- 
toms indicating diminished vascular tone, occur in 
women who have long practised coitus interruptus with 
incomplete gratification of their voluptuous desires. 


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 sen- 
sations, but feels either apathy, or positive distaste, is 
termed dyspareunia : in former times it was also known 
as anaphrodisia. This abnormal state of sexual sensi- 
bility, which up to the present is hardly alluded to 
in gynecological text-books, has received remarkably 
little attention from the medical standpoint, and its 
importance has been underestimated. Most unfor- 
tunately 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 anaesthesia 
sexualis, and from vaginismus. By sexual anesthesia 
we understand, as previously explained, the absence of 
the sexual impulse, a symptom which, when the repro- 
ductive 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 gratifi- 
cation 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 vaginae, or of the 
muscles of the pelvic floor, whereby the completion 
oi coitus is rendered impossible: whereas in dyspa- 


reunia coitus can be effected, but gives rise to no 
voluptuous sensations. 

The pleasure which normally occurs in woman dur- 
ing 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 vesti- 
bule, 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, sup- 
plies the female external genital organs. Some of its 
branches pass in the clitoris to a peculiar form of ner- 
vous end-organ discovered by W. Krause, Krause's 
genital corpuscles: the structure of these corpuscles 
appears to fit them exceptionally well for the transmis- 
sion of stimulatory waves to the nerve centres. "When 
this stimulus," says Hensen, in his work on the phy- 
siology 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 associa- 
tion 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 ejacu- 
lation of the secretions of various gland?. The cav- 
ernous 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 vesti- 
bule lies at either side along the margin of the vesti- 
bule at the boundary between the labium majus and the 


labium minus, and laterally it is covered by the con- 
strictor cunni^ 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 
downward, into contact with the penis. By means of 
the pressure of the constrictor cunni, the mucous secre- 
tion 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 enlarge- 
ment 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 fric- 
tion, and the- sensation of ejaculation. 

With regard to voluptuous sensations, and processes 
analogous to pollutions, occurring in women, we ap- 
pend an extract from von Krafft-Ebing. 

"The occurrence of voluptuous excitement during 
coitus is dependent in the woman, just as in the man, 

"i. The peripheral influence of the intensity and 
duration of the sensory stimulation (anaesthesia of the 
genital passage may be the cause of the absence of 
voluptuous sensation). 2. The condition of excita- 

^ Constrictor Cunni Muscle. — In women the hulbocavernosus muscles, 
right and left, form, as it were, a sphincter to the vaginal outlet. Hence 
the alternative names of sphincter vagina and constrictor cunni muscle. 
The latter name is in common use in Germany, but, though appropriate, is 
rarely employed in England. — Transl. 


bility 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 cer- 
tain cases of hysteria with temporary frigidity) ; or 
again the centre may be abnormally active owing to 
irritable weakness (neurasthenia sexualis), in conse- 
quence .of which ejaculation may, just as in the male in 
similar circumstances, occur too easily. 3. The occur- 
rence of the voluptuous sensation in women is unfavor- 
ably 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 ex- 
amples 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 sen- 
sation 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 compara- 
tively 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 experi- 
ence real sexual gratification in intercourse with the 
man of their choice. 

It is of great practical interest, alike from the gyne- 
cological and from the neuropathological standpoint, 
to determine the consequences in women of ungratify- 
ing sexual intercourse. In the present state of our 
experience it must be assumed that the effect of ab- 
normal sexual intercourse, that is of intercourse which 
does not culminate in gratification produced by the 
sensation of ejaculation, is deleterious. This is ex- 
plained by the fact that, owing to the absence of the 
muscular contraction of the genital passage, the latter 
remains engorged with blood ; the resultant hyperaemia 
passes away very slowly, and, when frequently repeated, 
gives rise to chronic tissue changes, manifesting them- 
selves 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 typi- 
cal forms of (sexual) neurasthenia; and in cases in 


which the pathogenesis is predominantly psychical 
(antipathy to the husband, etc.) hysterical types of dis- 
order are especially frequent. Von Krafft-Ebing be- 
lieves that incomplete coitus, that is, coitus not cul- 
minating in the sensation of ejaculation, is a frequent 
cause of hysterical disorders in women. 

When once the clinical picture of neurasthenia sexu- 
alis is fully developed, each act of intercourse (like 
pollutions or coitus in the sexually neurasthenic male) 
gives rise to renewed troubles, which are easily recog- 
nized as symptoms of venous stasis in the reproductive 
organs (sacrache, sensations of weight and bearing- 
down in the pelvis, fiuor albus) : in addition we ob- 
serve 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 gyne- 
cological examination (chronic endometritis, metritis, 
oophoritis, 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 coi- 
tus 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 condi- 
tions of the vita sexualis co-operates with that of in- 
herited or acquired sensuality, further dangers ensue: 
in cases of ungratifying sexual intercourse, the danger 
of manustupration ; in cases of unsympathetic inter- 
course, 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 nor- 
mally characterized by a process of ejaculation, ac- 
companied 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." Rosen- 
thal 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 "mucous-like" fluid from the appar- 
ently intact genital organs; he believed this to proceed 
from the ducts of Bartholin's glands, and from the 
mucous glands surrounding the urethral orifice. Fere 
reports the case of a patient who had an erogenic zone 
in the region of the upper part of the sternum; pres- 
sure on. this zone gave rise to a profuse secretion of 
vulvo-yaginal 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 re- 
searches published by von Krafift-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 ques- 
tion 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 excep- 
tional cases the "pollutions" appeared to be the start- 
ing 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 occur- 
ring via 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 ex- 
citement and orgasm of the reproductive organs may 
culminate in a "pollution" by purely spinal paths, 
without the intervention of the imagination. The sig- 
nificance 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." 

The frequent occurrence of pollutions in women, the 
so-called vulvo-vaginal crises and clitoris-crises, is re- 
garded 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 secre- 
tion 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 funda- 
mental 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 cere- 
bral cortex, whereby voluptuous sensations and per- 
ceptions 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 perform- 
ance of copulation on the part of the male, owing to 
inexperience, or it may depend on gross dispropor- 
tion 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, in- 
fluencing unfavorably the sensibility to stimulation of 
the nerves of the genital canal. Awkward or incom- 
plete performance of coitus may thus leard 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 is so fre- 
quent 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 be- 
fore marriage impaired his potency by masturbation ; 
finally dyspareunia is common when girls still unde- 
veloped 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 inter- 
course. Other causes of deficient sensibility are : com- 
plete 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 gonorrhoeal 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 stimu- 
lant 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 fistulae. 

The second cause of dyspareunia, diminution or com- 
plete lack of irritability of the reflex centre of the 
lumbar enlargement of the spinal cord, appears to 
be less frequently operative. We must, however, as- 
sume 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 men- 
struation. 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 produc- 
tion of dyspareunia, the influence of the brain, this, 
though important, is less frequently in operation. 
Diseases of the brain, degenerative processes, may con- 
stitute a cerebral cause for the failure of sexual sensa- 
tion. But more frequently, certain cortical percep- 
tions, 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 diflicult to 
obtain. Very rarely does it happen that women spon- 
taneously 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 voluptu- 
ous sensation during sexual intercourse. More com- 
monly, 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 ques- 
tion, and when he institutes inquiries among his patients 
in a scientific, passionless manner, one making due al- 
lowance for a woman's modesty, as the moral impor- 
tance 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 woman. 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, more- 
over, always check the wife's statements by conversa- 
tion with the husband. 

The constant sign of dyspareunia is the failure of 
ejaculation during coitus. We have previously de- 
scribed the muscular contractions which lead to ejacu- 
lation 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 voluptu- 
ous sensation of ejaculation, associated with these 
muscular contractions, which the woman whose sensi- 
bility 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 psychi- 
cal stimuli by which the reflex discharge is origi- 
nated. It has repeatedly happened to me, that on 
inquiring of women suffering from dyspareunia re- 
garding their experience of the sensation of ejacula- 


tion, 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 Kraflft-Ebing refers this proc- 
ess 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 re- 
markably rapid outflow of the male semen from the 
female genital canal, immediately after coitus {proflu- 
vium 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 immedi- 
ately 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 con- 
tractions of the muscles of the female genital organs, 
normally accompanying this sensation during inter- 
course, 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 re- 
garding 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 neighborhood 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 

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 experi- 
ence, 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 dys- 
pareunia 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 en- 
larged cavity; the portio vaginalis is flaccid, and runs 
to a point; the vagina is roomy; there is marked hyper- 
secretion 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 
amenorrhoea 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 anaemic ; 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 dyspa- 
reunia was relative only.) Apart from this, the ab- 
sence of sexual gratification gives rise to a series of 
nervous troubles, presenting either the variable char- 
acters of hysteria, or else the symptoms of neurasthenia. 
Finally, the frequently repeated incomplete coitus, in- 
complete inasmuch as the woman does not experience 
the sensation of ejaculation, induces chronic hyperaemia 
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, oophoritis, disorders 
of menstruation, menorrhagia, and atypical uterine 
haemorrhages. The possibility cannot be disproved, 
that in this way new-growths of the reproductive 
organs may also originate. The act of sexual inter- 
course, which at first may be to the woman a matter 


of comparative indiflference, 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 inter- 
course, such as sacrache, sensations of weight and pres- 
sure 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 mas- 
turbate, sometimes indulge in amor lesbicus, etc. 

Of great importance appears to me the relation be- 
tween 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 re- 
markable 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 pro- 
portion of the cases. Among 69 sterile women whom 
I questioned regarding dyspareunia, the latter condi- 
tion was present in 26, that is to say, in 38 per cent, 
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, favoring 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 favor the passage of the sper- 
matozoa 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 hus- 
band, 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. 

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 ob- 
tained by drawing a ratio between the number of mar- 


riages 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, exterrds 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 preg- 
nancy; and as they influence the" duration of menstrual 
activity, so also do they influence the duration of 

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. 

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's case, preg- 
nancy 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. Riittel 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 fol- 
lowed 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 wom- 
en, 465 were delivered at ages between 50 and 55 years. 
In Sweden, of 10,000 mothers, 300 gave birth to chil- 
dren 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 ideal of fertility in women is that the first com- 
pleted 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 occur- 
rence in human beings. Moreover, in no single mar- 
riage is the reproductive capacity of the wife utilized 
to the full, up to the time of extinction of her genera- 
tive 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, dur- 
ing the period of active sexual life, a woman re- 
quires 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 hus- 
bands 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 con- 
ditions of marriage, by social circumstances, by con- 
siderations relating to the health of husband or wife, 
by actual illnesses, and by voluntary limitation of fer- 
tility. Generally speaking, according to the investiga- 
tions 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 re- 
sult of a statistical inquiry 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 per cent, of the cases the 
first delivery occurred within i J4 years after marriage; 
in 15.6 per cent, within 10 months; and in 19.9 per cent, 
within 15 months after marriage; and 11.5 per cent, of 
the cases, the first delivery was more than ij4 years 
and less than 2 years after marriage; in 6 per cent, 
it was between 2 and 3 years after marriage; and in 
2.6 per cent., the first delivery did not occur until more 
than 3 years after marriage. 

From examination of the birth registers of Edin- 
burgh 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 com- 
plete 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, accord- 
ing 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 considera- 
tion the influence of lactation, inasmuch as mothers who 


do not suckle their children become pregnant consider- 
ably 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 lacta- 
tion 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 West. 
Indies informed me that for this jeason 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, inas- 
much 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 con- 
ception than women who marry before the age of 20. 
Womeft 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 

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 mar- 
riage 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. 


Divergent results as regards the fertility of married 
women at dififerent ages were obtained by Goehlert 
from the examination of 5,290 cases from the reigning 
families of Europe. In the favorable position as re- 
gards 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 under- 
goes 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 1 1.5% 

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 Korosi, regarding the percentage fertility 

The sexual epoch of the menacme 231 

of recently married women, and that of married women 
in general, will be found of interest: 

Recently All 

Married Married 

Women Women 

At ages 20 to 35 years 32.0% 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 al- 
ready 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 fer- 
tility; whereas the conditions most favorable 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 mar- 
riages 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 per- 
centage fertility is 32 ; at the age of 30 years, the fer- 


tility is 24 per cent.; at the age of 35, 17 per cent; at 
the age of 40 years barely 10 per cent.; at the age of 
45, 7 per cent; at ages 45 to 50, o.i per cent 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 per cent (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 g}^ per cent ; at 55, 2.2 per 
cent; at 65, }4 per cent (Korosi-Blaschko). 

Whereas hitherto we have considered only the mono- 
genous 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 fer- 
tility of the wife, as is proved by the following figures 
published by Korosi: 

Age op the Mother 

Age OF THE Father 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% 


Age of the Father 

Age OF THE 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% ll.S^o 6.7% 

40 to 45 years 6.6% 6.1% 3.0% 

We learn from these figures that the maximum fer- 
tility is exhibited by a woman i8 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 stand- 
point of the difference between the ages of husband and 
wife respectively. In this connection, Korosi 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 maxi- 


mum fertility differs in the two sexes, and those mar- 
riages 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 i8 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 chil- 
dren born, that is, what proportion of those born sur- 
vive. According to Korosi's interesting papers regard- 
ing the fertility of the inhabitants of Buda-Pesth, we 
learn that for every 100 marriages which have per- 
sisted 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 excep- 
tionally favored by fortune. 

Social position, occupation, and religion, have, ac- 
cording 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 rear- 
ing children, for among them the marriages of more 
than 30 years' duration had 61% per cent, of the chil- 
dren still living; among the Protestants 57% per cent, 
survived; and among the Catholics only 52% per cent. 
It thus appears that the surviving offspring per 100 
marriages of 30 years' duration were, among the Catho- 


lies 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 Korosi'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 per cent., among Jews 33 per cent; 
married at 17, Catholic mortality 44 per cent., Jewish 
30 per cent; married at 18, Catholic mortality 42 per 
cent, Jewish 32 per cent; married at 19, Catholic 
mortality 41 per cent, Jewish 29 per cent; married 
at 20, Catholic mortality 40 per cent, Jewish 26 per 
cent Of the children whose fathers had married at 
the age of 24, 32 per cent had died; of those whose 
fathers had married at 23, 37 per cent had died; of 
those whose fathers had married at 20, 42 per cent had 
died; and of those whose fathers had married before 
20, actually 44 per cent 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. 
( Korosi. ) 

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 mam- 
nialia; 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 con- 
trast, 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 domesti- 
cated 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 gray 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 com- 
parison 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 domesti- 
cated mammals the well-fed are more fertile than the 

■ 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 chil- 
dren born is considerably greater than in normal condi- 
tions ; 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 favorable nutritive 
conditions cause an increase, that unfavorable nutritive 
conditions cause a decrease, of population. Hardships 
and exhausting occupations diminish the fertility of 
women. The remarkable fertility of the Kaffirs is re- 
ferred 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, 
favors also human fertility, notwithstanding the fact 
that certain statistical data seem to conflict with this 
proposition. Sadler, for instance, concludes that an in- 
crease 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 there- 
fore 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 Villerme 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 distri- 
buted 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 nutri- 
tive elements, we find that these also influence fertility. 
Above all, it has been proved that alcohol notably 
diminishes the fertility of women. Lippich states tfiat 
of 100 women in Karnten 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 oophoritis 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 favor reproduction ; compare, for instance, the 
fertility of the Hindoos, who abstain entirely from ani- 
mal 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 associa- 
tion 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 unfavorable 
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 dis- 
tinguished by their great fertility. 

In his History of Civilization in England, Buckle 
writes: "The population of a country, although in- 
fluenced 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, cooperate with or countervail the influ- 
ence 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 con- 
sideration 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 cli- 
mate and of season upon fertility. Heat appears to 
favor 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 tempera- 
ture. Lower animals also, when brought from a colder 
to a warmer neighborhood, exhibit an earlier and more 
frequently recurring "heat." In Europe, however, the 
Northern races appear more fertile than those of the 

Of the seasons, spring is the one especially favorable 
to fertility. Quetelet, who proves by numerous sta- 
tistical 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. 
Villerme, 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 quan- 
tity, 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 favoring 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- 

Every marked and sudden change in the mode of 
life has an unfavorable 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. Accord- 
ing. to Virchow, the fertility of European women who 
become acclimatized in the tropics declines very gradu- 
ally, 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 co- 
pulate, the number of the offspring is below the aver- 
age. 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 boa:r, which in inter- 
course 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 num- 
bering 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 inbreed- 
ing are similar in the human species, that the mar- 
riages 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 fer- 
tility 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 Phoeni- 
cians, a son might marry his mother, and a father his 


daughter; and among the ancient Arabs it was the legal 
daty 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 unfavorable to fertility. Of 97 such mar- 
riages, 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 unfavorable to fertility, found, 
nevertheless, that among 512 marriages of near kin, 
only 8 to 9 per cent, 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. 

Gohlert made a statistical investigation of the fer- 
tility of the reigning families of Europe, in order to 
throw light on this question. In, the jCapet 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 
I 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 per cent, remained 
sterile. Further, in the Hapsburg-Lothringen dynasty, 
of no marriages, 25 were marriages of near kin, and 
of these 33 per cent, 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 phy- 
sical constitution and temperament between husband 
and wife is favorable 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 hus- 
band and wife both extremely active, or both of ex- 
tremely phlegmatic temperament. 

Toussaint Loua published the following figures re- 
garding the fertility of the women of the various 
countries of Europe; 


Number of 

births per Fertility of Women Between 
hundred the Ages of 15 and 45 Years. 

Hungary 4.94 

Russia 4.12 

Austria 3.93 

Germany 3.77 

Italy 3.67 

Holland 3.67 

Finland 3.63 

England 3.58 

Scotland 3.53 

Belgium 3.25 

Denmark 3.12 

Roumania 3.12 

Norway 3.10 

Sweden 3.05 

Switzerland 3.04 

Greece 2.96 

Ireland 2.69 

France ,,.,,,.., 2.63 



































■ ■ ■ ■ 










In towns, conjugal fertility is less, extra-conjugal 
fertility greater, than in the country. An increase in 
factory-labor gives rise to in increase in the popula- 
tion, 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 agri- 
cultural labor has precisely the opposite effect. The 
influence of war upon fertility is unfavorable both 
quantitatively, and qualitatively. According to Tschou- 
riloff, the introduction of universal military service, 
by withdrawing for a time all the most vigorous men 
from domestic life; tends to diminish fertility. Ex- 
tensive emigration froni a country in which the soil 
is fertile, and where the vital conditions are generally 
favorable, 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. 

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 1880 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 popu- 
lation 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 fol- 

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 

Tallquist, who has published a statistical investigation 
concerning the modern tendency to diminished fer- 
tility, arrives at lower figures than Hellstenius. Ac- 
cording 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 obtainejl 
figures showing that each family of the higher aristo- 
cracy has on the average the following number of 

In France 2.0 

Italy 3.0 

Germany 4.8 

England 4.9 

Russia 5.1 

According to the figures we have published, the fer- 
tility of women suffices for the production during the 
sexual life of a small number only of children, averag- 


ing, 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, Korosi found 300 mothers who had had 15 chil- 
dren 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 Bo- 
hemian 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 com- 
monly 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 aver- 
age per family of 2.1 children only. Similar condi- 
tions 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 projsperity 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 preg- 
nancy 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 Sta- 
tistics) . 

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 relig- 
ious 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. Con- 
fucius 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 hath 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 to 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 dishonorable, 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 honor 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 

In ethnography, the term endogamy is used to de- 
note 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 be- 
tween persons who are more closely allied, as, for in- 
stance, the Mosaic prohibition of marriage within cer- 
tain 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 predisposi- 
tions, 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, environ- 
ment, 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 
favorable — for instance, where both parties to the pro- 
jected marriage are in excellent health, and where there 
is no great similarity between them in feature or mental 
type. Certain anomalies transmitted from remote an- 
cestors, 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 dis- 
orders of the nervous system and of the sense organs 
are pronounced, leading to idiocy, insanity, epilepsy, 
congenital deafmutism, blindness, instinctive crimi- 
nality, — 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 an- 
cestors ; 
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 peculiariti'es of the fluids and 

tissues of the maternal body; 

b. Owing to substances which penetrate the 

maternal organism and reach the fertil- 
ized 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 53^ to 6>^ 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 congenit- 
ally affected with mental disorder is twice as great in 
the offspring of consanguineous marriages as in the off- 
spring 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 mar- 


riages 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 in- 
fluence of blood-relationship in cases in which the exist- 
ence 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 Re- 
gards 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 pre- 
ventive 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 mar- 
riages 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 endeavored 
to set bounds to excessive fertility, and artificial abor- 
tion was methodically practised by those who wished 
to avoid an inconveniently large family. Even among 
savage peoples, we find that certain preventive meas- 
ures 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 re- 
striction 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 pro- 
priety 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 compari- 
son with the causes just alluded to for the use of pre- 
ventive measures, diseases which render renewal of 
pregnancy dangerous to the mother's life have com- 
paratively little to do with the causation of voluntary 

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 undis- 
turbed by any anxiety regarding the livelihood of their 
offspring. The reproductive function is thus exercised 
at every available opportunity, and the superfluous in- 
dividuals of the next generation are destroyed by lack 
of space and nutriment. In the human species the re- 
striction 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 conse- 
quences ; 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 favorable 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. Ac- 
cording to the theory of Malthus, the increase of human 
population would be represented by the figures i, 2, 
4, 8, 16, 32, 64, 128, 256, whereas the simultaneous 
increase in the means of subsistence would be repre- 
sented by the figures i, 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 prop- 
erty or earnings, which barely suffice to provide for 
his own personal necessities, cannot fail, when he con- 
siders how hardly they would suffice for seven or eight 


additional persons, to doubt whether it would be pos- 
sible 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 com- 
petent to lessen the natural duration of human life. 
Among these we may enumerate: all unhealthy occu- 
pations, 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 opera- 
tive, 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 ten- 
dency of population to increase, we observe the wider 
diffusion of poverty among the lower classes, so that 
any permanent improvement in their condition is ren- 
dered 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 condi- 
tions, 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 infanti- 
cide. 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 in- 
duced. 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 un- 
ceasingly operative: in this time of the Empire, pre- 
ventive 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 Em- 
pire, sexual morality became so degenerate that mar- 
riage was hated and despised. 

Passing to the consideration of the checks on popula- 
tion 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 preg- 
nancy should be employed, as the modern "Malthusi- 
ans" advise ; in his eyes, moral restraint, that is to say, 
sexual abstinence, w^as the only remedy for the pre- 
vention 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 is 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 educat- 
ing the people in this matter; "in addition to the or- 
dinary 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 pre- 
ventive 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 in- 
crease 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 de- 


scription 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 So- 
ciety, 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 distri- 
bution of a hand-book on the use of measures for the 
prevention of conception, and for an investigation re- 
garding the results of these. 

We do not propose here to subject the teaching of 
Malthus to a critical examination; he has found for- 
midable opponents, who have endeavored 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 labor and manure are pro- 
vided in sufficient quantity, the soil is inexhaustible, 
and will continue to yield unceasingly, the most abun- 
dant harvests"; and Rodbertus' remark that "agri- 
cultural 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 Brit- 
ain 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 Ger- 
many, 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 Ori- 
noco, 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 prac- 
tically 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 Roose- 
velt, ex-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. 

Roosevelt, in his letter, declared himself an ar- 
dent supporter of the biblical injunction, "increase 
and multiply!" He writes: "Whoever evades his 
responsibilities, through desire for independence, con- 
venience, and luxury, commits a crime against the race 
to which he belongs, and should be an object of con- 
tempt 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. 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 

Eliot, ex-President of Harvard University, has ex- 
pressed 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 neces- 
sary; it is not his province to assist in preventing the 
birth of an immoderate number of offspring; his inter- 
vention is justified only when deliberate reflection has 
convinced him that his patient's health or life would 
be endangered by pregnancy or child-birth. A wom- 
an'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 ac- 
coucheur in the destruction of an already living child, 
when the mother's life is endangered. In this connec- 
tion we may recall the words of the great Napoleon: 
The physician Dubois, attending Marie Louise in a 
difficult confinement, asked Napoleon whether, if mat- 
ters came to an extremity, he should save the mother 
or the child ; Napoleon, notwithstanding his strong de- 
sire 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 preg- 
nancy — not merely sexual abstinence, but actual meas- 
ures to prevent fertilization. 

The misuse of medical knowledge for the recom- 
mendation 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. Sanger 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 ques- 
tion, 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 pre- 
venting conception whenever they please, independently 
of considerations relating to the health of the mother. 
*»******^ woman exhausted by frequent 
child-bearing, anaemic 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. 
Kleinwachter, who declares that he is far from rec- 
ommending 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: I, the various forms of severe pelvic deformity; 
2, certain tumors in the pelvic cavity; 3, after the re- 
moval of malignant tumors of the reproductive organs, 
certain general disorders, recently arrested pulmonary 
tuberculosis, organic heart disease, etc. Regarding 
these cases, Kleinwachter writes: "The wife's life 
would be endangered by pregnancy, which must there- 
fore be prevented without forbidding coitus, and avoid- 
ing 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 Kreutzer Sonata gives his adhesion, has re- 
cently found an advocate in a modified sense in a dis- 
tinguished 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 unfavorable 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 ques- 
tion "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 off- 
spring 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 
nxonths, that lactation is continued from nine to twelve 
months after delivery (and if the mother does not her- 
self nurse the child, artificial feeding or careful super- 
vision 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 
indicates 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 learn- 
ing to form sound opinions about these matters. 
Among the working classes, on the other hand, especial- 
ly among those engaged in factory labor, 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 attain- 
ment 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 in- 
crease in population, as far as Germany is concerned, 
will cease to give cause for anxiety. The regulation 
of reproduction will, however, still be incomplete, un- 
less 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 only one child is born, this child 
is the object of unceasing anxiety and attention, and 
real or imaginary dangers assume an excessive impor- 
tance in the morbidly excited imagination of the 
parents. Hence we find a continuous excess of watch- 
fulness 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 con- 
ception is considered by Hegar to be harmful, at any 
rate in the case of young women; this practice gives 
rise to anaemic 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. 

Grafe, with referen<:e 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 inter- 
course. 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 for the prevention of preg- 

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. Untrust- 
worthy, for the reason that nature has endowed living 
organisms with a strong impulse toward conjugation 
and has equipped with very powerful forces the proc- 
esses by which fertilization is effected. Every phy- 
sician is familiar with cases in which preventive meas- 
ures 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 lacta- 
tion. Noteworthy, also, are the psychical considera- 
tions adduced by Ribbing against the use of preventive 
measures. The majority of well-bred women feel 
deeply wounded if they believe themselves to be re- 
garded merely as a means of enjoyment, not as individ- 
uals, 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 initia- 
tive, occupies herself with the technique of the sexual 
life in a manner which he feels instinctively to be 
opposed to the chastity and pure-mindedness demanded 
by every man from his wife. Ribbing, therefore, ad- 
vises a certain measure of sexual abstinence in married 

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 down- 
ward 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 inconven- 
iences of motherhood, and if they marry, they endeavor, 
by the employment of the most immoral means, to in- 
sure barrenness. The reproductive instinct, of which 
reproduction has ceased to be the aim, is in some an- 
nulled, 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 individ- 


ual, and without any relation to the needs of the com- 

Alfred Russel Wallace has advocated sexual conti- 
nence as a preventive measure during the period of 
maximum vitality and strength ; he advises that the age 
of marriage of women should be considerably ad- 
vanced, in order to diminish their fertility. If wom- 
an'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, how- 
ever, be reached through the advocacy of moderation 
and continence. The numerous additional measures 
employed for this purpose may be classified as physio- 
logical and artificial; the latter class may be further 
subdivided into mechanical and operative. 

By physiological means for the prevention of con- 
ception, we understand measures which aim at produc- 
ing sterility by reducing the number of acts of inter- 
course and by restricting these acts to certain defined 
periods of time. The physiological preventive meas- 
ures, apart from the higher ethical value they possess 
in comparison with artificial measures, have the ad- 
vantage 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 dis'advantage, 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 im- 
pregnated by intercourse on any single day of the inter- 
menstrual 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 diminu- 
tion of procreative capacity and of fertility by regula- 
tion 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 com- 
pelled, for a couple of thousand years, to listen to ser- 
mons informing them that to occupy themselves about 
sexual matters is 'improper' and 'immoral.' There is 
no doubt whatever that the modfc 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 con- 
nection, 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. How- 
ever, it must not be forgotten that pre-conjugal inter- 
course, 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 un- 
willing to bear a large number of children. She will 
wish to enjoy a measure of personal freedom and in- 
dependence, 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 unwhole- 
some 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 efifected. 

Tolstoi, in his widely celebrated book The Kreutzer 
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 endeavor to live in a natural way, 
but they must consume no alcohol, eat with great mod- 
eration, 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 mar- 
riage 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, be- 
cause 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 "con- 
tinue to pray to be delivered from temptation, and 
must endeavor 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; Lowenfeld, 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 wom- 
an, as in the lower animals, the capacity for concep- 
tion was associated with a particular season of the year, 
that there was, in fact, an individual time of predilec- 
tion 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 birth- 
days 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 sea- 
sons are especially favorable to conception, that a maxi- 


mum of conceptions occurs in the spring, and a second 
much smaller maximum in the winter ; but these varia- 
tions in the number of conceptions depend mainly on 
social factors, as, for instance, upon the customary sea- 
son for marriage, opportunity for intercourse between 
the sexes, common labors in the house or in the open, 
etc. This alleged time of predilection for conception 
cannot, therefore, seriously be considered in the dis- 
cussion 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 dur- 
ing intercourse, either spontaneous, or when the woman 
intentionally remains "cold," the reflex actions by 
which the upward passage of the spermatozoa is 
favored, fail to occur; there is a good deal of evidence 
in favor 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 avoid- 
ing impregnation." Von Krafft-Ebing points out that 
prostitutes, when having sexual intercourse with men 
to whom they are attached, experience voluptuous ex- 
citement, 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 cir- 
cumstances for it to be possible to employ such volun- 
tary control as a trustworthy means of preventioH. 
Allied to this is the previously-mentioned Chinese 
practice of Kong-fou, a kind of hypnosis, in which 
during sexual intercourse the thoughts are concen- 
trated 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, amen- 
orrhoea persists, and sexual intercourse remains unfruit- 
ful. 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 pre- 
vent 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 effica- 


cious 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 inter ruptus leads 
in my experience — in addition to the injury to the ner- 
vous system as a whole in consequence of the intense 
hyperaemia of the uterus and the uterine annexa, un- 
relieved by the occurrence of the orgasm — to a condi- 
tion 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), 
oophoritis and perimetritis. As a result of certain re- 
markable observations, I must even regard it as not 
improbable, although actual proof is still lacking, that 
the recent striking increase in the frequency of neoplas- 
mata of the female reproductive organs is causally de- 
pendent on the ever-increasing employment in all 
circles of society of means for the prevention of preg- 

The evil efifects 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. Ow- 
ing to the failure of ejaculation to occur, the blood, 
which during the stage of sexual excitement has accu- 
mulated 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 Kraflft-Ebing to 
give rise to functional disorders, and also to serious 
tissue changes. The functional disorders take the form 
of hyperaemia 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 re- 
productive 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, main- 
tains 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 in- 
tercourse; 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 possi- 
bility 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 in- 

Hirt considers that even when marital intercourse 
is carefully regulated in respect of frequency, con- 
gressus interruptus may lead to neurasthenic mani- 

Von Hosslin believes it to be indisputable that pre- 


ventive methods of sexual intercourse may cause ner- 
vous 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, en- 

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 con- 
cerning himself about the woman's state of sexual ex- 
citement. If, on the other hand, the man waits until 
the woman's sexual gratification is complete, the sig- 
nificance 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 conse- 
quences of preventive methods of sexual intercourse. 
"It is habitual excess," says Fiirbringer, "which does 
the mischief, not the unnatural character of the isolated 
act." Lowehfeld, 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 pes- 
saries and similar appliances does not in any way inter- 
fere with the normal development of sexual gratifica- 
tion 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 Lowen- 
feld, harmful to the woman only when, owing to defi- 
cient 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 peri- 
metritis result from this practice; Grafe enumerates, 
as consequences of frequently repeated coitus inter- 
ruptus, chronic hyperaemia of the uterus and oophoritis ; 
Goodell observed elongation of the cervix uteri ; Men- 
singa, infarction of the uterus, oedema of the portio 
vaginalis, ulceration of the cervix, hysterical parox- 
ysms, 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 Klein- 
wachter, 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 prac- 
tised 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 

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 in- 
stances 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 

The Determination of Sex 

The problem of the determination of sex in the 
human species is one which has occupied natural phi- 
losophers from the very earliest times, and has always 
greatly interested all classes of the population. 

The interest awakened by the subject depends princi- 
pally 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 loi, 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 maintain- 
ing 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 knowl- 
edge, 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 de- 
pends; there are therefore male and female ova, and 
the process of fertilization exercises no influence what- 
ever 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 fer- 
tilization by the reciprocal interaction of male and 
female, of zoosperm 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 .likeness upon the fertilized product. Accord- 
ing to another view, however, sex is not directly trans- 
mitted 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 ele^ 
ment in the act of reproduction tends to favor the 
determination of the male sex. 

III. That sex is not determined until after fertiliza- 
tion, 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 endeavored to solve this 
problem by statistical investigations, by anatomical 
demonstration, and finally by experiment. 

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 honorable 
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 em- 
ployed 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 wom- 
an 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 chil- 
dren 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 con- 
tempt, 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 suc- 
ceed in obtaining another husband, for she is regarded 
as one whose body is not properly developed. Accord- 
ing to old German law, barrenness in a wife and impo- 
tence in a husband were both grounds for divorce. 

The code of the Emperor Justinian allowed of di- 
vorce in cases in which for the space of two years a hus- 
band had been unable to fulfil his marital duties, and 
such a union was termed innuptce nuptee. Among the 
ancient Romans, although they regarded barrenness as 
a mark of the divine disfavor, 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 ste- 
rility 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 equiva- 
lent to "hermaphrodite." The Jewish view of the 
matter is expressed in the Talmudic rabbinical saying: 
"A wife's duties are beauty, gentleness, and the bear- 
ing 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 delib- 
erate intention of having no children, incurs the guilt 
of murder." In the Koran we find the fatalistic ex- 
pression, "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 dur- 
ing 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 mul- 
tiply, and replenish the earth," we find frequent refer- 
ences to barrenness as a state equally dishonorable and 
unfortunate, and the use of certain plants is recom- 
mended 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 recommenda- 


tions. 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 ste- 

Among the writers of the first century of our era, 
Soranus discusses exhaustively the capacity for con- 
ception 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, nor- 
mal 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 al- 
ways failed to ensue; it is termed acquired (or rela- 
tive), 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 ex- 
perienced 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, notwith- 
standing prolonged and repeated sexual intercourse, in 
circumstances favorable to procreation, she has failed 
to give birth to a living and viable infant. 


English authors also make a special distinction re- 
garding 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 con- 
ception; 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 as three years. This limita- 
tion is based upon the statistical data which I gave re- 
garding 556 fruitful marriages on page 228. 

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 fol- 
lowed in due course by the birth of a child, is, lik& 
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 un- 
usual 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 

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 com- 


mencement of the first pregnancy is delayed for more 
than sixteen months after marriage, there is consider- 
able 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 i : 8.87. 
But in other circles of society, in so far as data relat- 
ing to the matter were obtainable in my practice, the 
statistics of infertility were by no means so unfavorable, 
the ratio working out at about i barren to 10 fruitful 
unions. I must point out, however, that these statistics, 
like all statistics of fertility, are to a degree invali- 
dated 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 i : 8.5 (in 1,252 in- 
stances). In the English aristocracy, where the mar- 
riages are for the most part restricted among the mem- 
bers 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 i : 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 mar- 
riages of persons in all classes of society, 11.5 per cent, 
are barren. Prochownick found among 2,500 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 per cent, had failed to conceive. 

According to Frank and Burdach, who do not pub- 
lish the figures upon which their estimate is based, 
only I marriage in 50 proves barren. Lever, who also 
gives merely his percentage result, states that 5 per 
cent, of married women are completely infertile. 
Hedin, dealing with a Swedish community of 800 per- 
sons, 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 
per cent, were sterile; in the Wittelsbach dynasty 
(Bavaria), among 177 marriages, 23.7 per cent, were 
sterile; and among the ruling families of Germany 
(more than 600 marriages), 20.5 per cent, 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 2,799 marriages, 8.4 per cent, 
were barren, but in this instance also stillbirths were 

Ansell reports that of 1,919 marriages of women be- 
longing to the upper classes, their mean age being 25 
years, 152 proved barren, a proportion of 1:12, or 
about 8 per cent. 

Matthews Duncan communicates the following data: 


In the year 1855, in the cities of Edinburgh and Glas- 
gow, 4,447 marriages were contracted, and of these 725 
proved barren, a proportion of i : 6.1 ; 75 of these may, 
however, be excluded from consideration, inasmuch 
as the wives were already at the age of 45 or upward. 
Among the remaining 4,372 marriages, 662 proved 
barren, a proportion of i : 6.6. In other words, 15 per 
cent, 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 mil- 
lion 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 per cent, are entirely barren, 
while 24 per cent, 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 


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 

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 ste- 
rility, the proportion of barren to fruitful marriages 
becomes even more unfavorable, and the proportion 
increases enormously if, with Griinewaldt, we number 
among the barren women those who fail to continue 
childbearing up to the normal climacteric period. 
Griinewaldt, dealing with about 1,500 women suffer- 
ing from affections of the reproductive organs, ex- 
cluded all those who were either virgins or widows, 
and also all those who at the time of the observed bar- 
renness were over 35 years of age; this left more than 
900 women suffering from affections of the repro- 
ductive organs, all of whom were sexually mature, 
and were living in marital intercourse; of these, nearly 
500 were barren, 300 being instances of acquired ste- 
rility, and 190 instances of congenital sterility. Thus, 
according to this observer, disease of the reproductive 
organs in women led in more than 50 per cent, 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 dis- 
ease of the reproductive organs; and among every five 
gynecological patients of the condition already speci- 
fied 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 appeairance 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 

The manner in which, in the human species, fertili- 
zation is effected, is still far from clear in all its details ; 
hence it is easy to understand, that the etiology of ste- 
rility remains in many respects obscure. It is impos- 
sible 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 
favorable 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 me- 
chanical obstruction, according to which sterility in 
women depends upon mechanical obstacles to the pas- 
sage of the spermatozoa toward, 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 


Griinewaldt with a doctrine in which special 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 
insufRcient, we cannot regard a third theory, that of 
Matthews Duncan, as filling the gaps in our knowl- 
edge. 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 in- 
comprehensible 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; contrari- 
wise, the male genital organs are commonly blamed 
for the affection, which is in the overwhelming ma- 
iUi^ of cases supposed to be due to azoospermia, usu- 
ally dependent upon gonorrhoeal infection; compare 


with this the fact that afifections of the female repro- 
ductive 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 gonorrhoea 
in the male plays in the cause 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 use- 
fully 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 nor- 
mal ova (conjugation of male and female pronuclei) ; 

3. that the uterus is properly adapted for the gesta- 
tion of the fertilized ovum. 

My classification of the varieties of sterility corre- 
sponds 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 


Incapacity for Ovulation 
Incapacity for ovulation, the first and most decisive 
cause of sterility in women, may be absolute and ir- 
remediable, or relative and transient. We have to do 
with the former in cases in which the ovaries are en- 
tirely wanting, or when they are affected with organic 
disease to such a degree that they have become in- 
capable of fulfilling their function of' ovulation; in- 
capacity for ovulation is, on the other hand, relative 
and transient in certain pat hological states of the ovar y 
a nd neighbo ring organs, ~when there ii incomplete 
development or parBal atrophy of the ovaries, when 
there are new-growths of the ovaries, in cases of 
oophoritis and perioophoritis, in consequence of dis- 
turbances of innervation, diseases' of the central arid 
'^ellpheral nervous system, violent emotional distur b- 
ance, constitutional disorders, such as syphilis, chlor- 
osis, anaemia, universal lipomatosis, scrofula, alco- 
holism, and morphinism, als o in consequence of change s 
in. the^upply of nutriment_and in jhe generaljnode 
o f livin g, or of senile changes, and^_£naliyLin_conse- 
q uence of hereditary influence s^ 

The diagnosis of the etiological influence of sup- 
pressed 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 func- 
tion of ovulation; but the variations in this fimction 
give no certain information as to whether a woman 
is fertile or infertile. Knowing, as we do, that, gener- 
ally speaking, an intimate connection subsists between 
menstruation and ovulation, we are indeed able to 
assert that regular menstruation and fertility in worn- 


en 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 explora- 
tion 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 intra-pelvic disorders. In this way we have 
been enabled to recognize a number of pathological 
states of the ovaries which affect the functions of these 

In some cases also there are general symptoms 
which furnish us with the means of drawing con- 
clusions, more or less trustworthy, regarding the state 
of the ovarian functions; for instance, the general de- 
velopment 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 fetal 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 con- 
genital 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, 
weire 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 em- 
bedded 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; more- 
over, there was a monthly recurrent epistaxis. 

The atrophy of the ovaries which normally takes 
place at the climacteric period, has constitutional 


effects similar to those dependent upon absence or con- 
genital 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 amen- 
orrhoea, 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 pas- 

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 ca- 
pacity 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 for- 
merly, 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 lupinars 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 animals, 
it appears to be the rule that when the reproductive 
glands are removed in early youthTevery^raice of sexual 
desire disappears. 

Incomplete development of the ovaries, with conse- 
quent 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 in- 
habitants of regions in which child-marriage is com' 

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 
connection, women in whom puberty is comparatively 
early, are less often sterile than those in whom puberty 
is comparatively late. Emmet, in an investigation em- 
bracing 2,330 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 menstrua- 
tion 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 frequent; 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 post- 

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-con- 
tinued 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 


amenorrhoea 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 pneu- 
monia and chronic dysentery, and in adults as a sequel 
of typhoid, and in one instance as a sequel of puerperal 

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 al- 
buginea 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 ste- 
rility, 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, car- 
cinomata, dermoid cysts, cystomata, sarcomata, and 
fibromata. In many cases of these disorders, however, 
the ovarian follicles may for long periods remain un- 
affected; and in these instances, ovulation, menstrua- 
tion, 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 nor- 
mally 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 tumors 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 
tumors, 390 were childless. But these results are chal- 
lenged by other observers. Veit's estimates, based upon 
a compilation of the figures of Lee, Scanzoni, and 
West, is that 34 per cent, of women with ovarian tumor 
are sterile. On the other hand, Negroni's collection 
of 400 cases of ovarian tumor, including both married 
and unmarried, contained 43 only who had never been 
pregnant. Other lists show: 13 sterile women among 
45 suffering from ovarian tumor (von Scanzoni) ; i 
sterile among 21 (Nussbaum) ; 8 sterile among 63 
(Olshausen). Winckel, among 150 sterile married 
women, found 32 suffering from ovarian tumor, which 
in two of these cases only was bilateral. Atlee, in 15 
cases of ovarian tumor, observed premature cessation 
of menstruation at the ages of 30, 39, 40 and 42, 

Although in many cases sterility develops coinci- 
dently with the growth of an ovarian cystoma, yet in 
many other women such tumors have no influence in 
diminishing fertility. Martin, in a case in which ste- 


rility existed in connection with a unilateral ovarian 
cystoma, the other ovary being healthy, observed preg- 
nancy 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 dropsi- 
cal follicle which had attained nearly the size of a 
walnut. Pregnancy in this case also followed the 
resumption of marital intercourse. Miiller reports 
that in his clinic within recent years pregnancy, com- 
plicated with ovarian tumor, 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. Hoist 
reports the case of a multipara 43 years of age who 
died in the i8th 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 medul- 
lary 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 tumors; in a wom- 
an aged 42, who died four weeks after her eleventh 
confinement, both ovaries were found to be transformed 
into nodular carcinomatous tumors, each larger than a 
child's head; in none of these ovaries was any nor- 
mal 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 5,620 grammes, the other 480 

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 microscopi- 
cal examination. That under the influence of preg- 
nancy, existing ovarian tumors often take on extremely 
rapid growth, is also indicated bv some of the above 

Among the causes of sterility, these three conditions : 
anaemia, chlorosis, and scrofula (tuberculosis), play a 
leading part; indeed, their importance in this connec- 
tion has hitherto been underestimated, more especially 
in regard to the comparative frequency with which they 
cause sterility. A large part of the favorable influ-. 
ence in the relief of sterility in women which is exer- 
cised by the "cures" at various watering-places, de- 
pends 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 de- 
cisive 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 

THE SE:^UAL epoch of the MENACME 303 

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 contribu- 
tory cause of sterility. 

Certain drugs, more especially quinine and mor- 
phine, are reputed to cause sterility. Davies, revi/ing 
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 psy- 
chical disorders in checking ovulation has been estab- 
lished. Thus, de Montyel has recently shown 'that in 
families subject to hereditary mental disorders, there is 
an unusual' large proportion (1:7) of barren mar- 

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 con- 
cerned with external influences affecting unfavorably 
nutrition and innervation, and therewith also ovula- 
tion; also near kinship between the parties to the act 
of intercourse; and finally hereditary predisposition. 
In animals, captivity, exposure to cold, overexertion, 
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 favors 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 confine- 
ment. 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 un- 

"Convincing proofs," writes Darwin, "have been 
obtained to the effect that wild animals which have 
recently lost their freedom have their fertility dimin- 
ished to a most remarkable extent. This infertility is 
not dependent upon any degeneration of the reproduc- 
tive 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 numbqrs which are un- 
questionably 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 unfavorable condi- 
tions of temperature, either excessive heat or excessive 
cold, is very great. In the case of pigeons, for in- 
stance, 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 
is 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 influ- 
ence 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 — para- 
doxical 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 fertiliza- 
tion outside the body of the mother, he ascertained that 
the cells derived from the discus proligerus, surround- 
ing the ovum in immediate contact with the zona pellu- 
cida, 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 condi- 
tion of the ovum, so unfavorable 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 re- 
mained 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 heir- 
esses {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 ap- 
paratus. John Hunter (Animal Economy) ascertained 
that in the case of twin calves of opposed sex, the 
genital organs of the female twin were almost invari- 
ably 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 Edin- 
burgh, 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 10 per 
cent, of the women born in such circumstances prove 
barren — a ratio which corresponds closely with the 
ratio of infertility in general. 

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 over- 
looked, 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 cohditions 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 like- 
wise favor 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 men- 
tioned above, namely, because such excitement leads 
to the occurrence of reflex secretion of the cervical 
glands, the secretion thus produced maintaining or en- 
hancing the activity of the spermatozoa; and contrari- 
wise, 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 favor- 
ing 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 ner- 
vous influences. It is, moreover, a familiar experience 


that factory girls, who from early youth are exposed 
to sexual stimulation, attain sexual maturity at an ex- 
tremely 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 inter- 
course with foreigners, "but during such intercourse 
they remain quite passive, in order to avoid impregna- 
tion." 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 feel- 
ing 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 im- 
pregnation, 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 

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 connection 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 anaemic, 
delicate lady, who has never experienced the sense of 
ejaculation. The semen flows away from the vagina 
immediately after the completion of coitus. No ab- 
normality to be detected on gynecological examina- 
tion. Mrs. S., aged 24, married 5 years, sterile; dur- 
ing intercourse remains completely cold, and has ex- 
perienced 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 de- 
livery 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, mar- 
ried 6 years, sterile; amenorrhoeic, has never experi- 
enced the sense of ejaculation, and finds sexual inter- 
course 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 

. 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 posi- 
tion permits him frequent glimpses of what passes be- 
hind 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 im- 
pregnated by her lover than by the husband to whom 
she is indifferent or whom she actually dislikes. 


To relative dyspareunia dependent upon sexual dis- 
harmony 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 "harmonic 

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 in- 
stance, 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 phy- 
sical 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 main- 
tains, 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 mani- 

Analogous phenomena have been noted, and with 
much greater distinctness, in the animal world. Dar- 
win, 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 in- 
formed me that frequently a mare, which in other 
seasons with other stallions has proved fertile, may be 
coupled with a stallion likewise of proved reproduc- 
tive potency, and will fail to be impregnated; yet this 
same mare will shortly afterward be impregnated by 
another stallion." 

Pfliiger reports that he has often seen a thorough- 
bred 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 ap- 
pearance 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.^ 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 some- 
times happens, as Pfliiger himself has seen, that the 
stallion, becoming aware of the deception, refuses to 
complete the coitus, withdraws his penis, and immedi- 
ately turns to the mare of his choice. 

Matthews Duncan, among 191 sterile women, found 
that 39 had no sexual appetite, and 62 had no voluptu- 
ous sensations during coitus. He regards abnormal 
sexual appetite as one of the principal causes of ste- 

Notwithstanding these facts, it must not be forgotten 
that many cases are recorded in medical literature of 

' Compare stanzas 46 and 47 of "Venus and Adonis" : 

His ears up-prick'd; his braided hanging mane i 

Upon his conipass'd crest pow stands on end ; 

His nostrils drink the air, and forth again. 

As from a furnace, vapors 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." 


women conceiving after intercourse effected against 
their wishes, as by rape, or when they were in a state 
of intoxication, or asleep, or iii the entire absence of 
all voluptuous sensation. Moreover, the erection of 
the vaginal portion of the cervix, and the reflex move- 
ments 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 in- 
tercourse 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 connection that the 
Chinese physicians enumerate among the causes of 
sterility the practice of "congfu" 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 

A proof of the importance of specific sexual sensa- 
tion for the attainment of conception is afforded by 


the fact that in the majority of women voluptuous ex- 
citement 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, in- 
deed, also depend upon the fact that at first coitus is 
apt to be incompletely effected, and for this both hus- 
band 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, mani- 
fest its significance. Thus, in some instances, the in- 
fluence of stimulation of the clitoris in leading to con- 
ception has been clearly shown ; in others, the perform- 
ance 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 be- 
come pregnant. 

Finally, perverse sexual impulse must be mentioned 
as a possible cause of sterility. This may be an ac- 


quired 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 de- 
generation 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 exam- 
ination 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 exam- 
ination 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: hyper- 
trophy of the clitoris, enlargement and a bluish colora- 
tion of the labia minora, retroversion of the uterus, 
neuralgia and displacement of the ovaries, leucorrhcea, 
and menorrhagia. 

The question has been mooted by Cohnstein, whether, 
as is commonly asserted, a woman is capable of be- 
coming 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 prema- 
turely of a stillborn 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, sug- 
gestions 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 preg- 
nancy would have fallen, and found that this was the 
middle of February; he therefore inferred that .inter- 
course 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, con- 
tradicted 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 tumors of the urethra, bleeding piles, fistula, 
fissure, and prolapse of the anus, schirrus of the rectum, 
ascarides. "These diseases produce sterility in conse- 
quence 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 re- 


ports 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 repoi^ted 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 
harbored for many years, gave rise to dysmenorrhceal 
troubles. The complete expulsion of the worm re- 
lieved the dysmenorrhoea, the woman became pregnant, 
and gave birth to a child at full term ; since then men- 
struation has been painless." The presence of the tape- 
worm may have had an unfavorable 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 de- 
scribed, probably effected in man, as in other mam- 
mals, 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 conpletely from the uterine cavity. Thus 


the ovum comes to be entirely imbedded in the sub- 
stance 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 im- 
plantation 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 ellipti-. 
cal form. The movement of the cilia is directed down- 
ward. 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 por- 
tions of the surface of the membrane are cast ofif. 

Very numerous are the morbid states of the uterus 
and its annexa whereby the implantation and incuba- 
tion of the ovum are prevented; and incapacity of the 
uterus for the fulfilment of these functions is there- 
fore 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 under- 
go the enlargement necessary to pregnancy. Tissue 
changes in the uterine musculature may likewise pre- 
vent the implantation of.the ovum, or the proper de- 
velopment of the uterus during pregnancy. New- 
growths of the uterus or its neighborhood 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 steril- 
ity. All those inflammatory states which lead either 
to softening or to induration of the uterine paren- 
chyma, or to swelling and thickening of the endome- 
trium 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 ges- 
tandi, 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 neigh- 
boring 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 connection, examination 
of the uterine secretion is of especial importance : a 
purely mucous, transparent, vitreous, tenacious secre- 
tion in the os and in the cervical canal, indicates the 
existence of catarrhal endometritis; a markedly haemor- 
rhagic secretion signifies hyperplastic endometritis; 
profuse purulent secretion containing gonococci, indi- 
cates gonorrhoeal endometritis ; the discharge of pieces 
of membrane shows that there is exfoliative endome- 
tritis; the discovery of fragments of carcinomatous tis- 
sue indicates the breaking down of a malignant tumor 
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 labors (in cases of acquired sterility) ; any 
pathological conditions in other organs should be in- 
vestigated; and the condition of the blood and the 
state of general nutrition should receive attention. 
Chlorosis, anaemia, and scrofula often give rise to ca- 
tarrhal endometritis; severe disease of the heart may 
lead to congestive troubles of the genital organs; after 
abortion or difficult labor, chronic metritis or endo- 
metritis are common. Further, the differential diag- 
nosis 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 micturi- 
tion, appearing soon after marriage, and lasting o'ften 
a few days only, will indicate the probability of gonor- 
rhoeal infection, etc. 

Von Griinewaldt has vigorously insisted upon the 
fact that the notion of sterility, i.e., impotentia gene- 


randi in women, is not coincident with the notion of 
impotentia concipiendi, and there is an important dis- 
tinction 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 au- 
thor'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 con- 
cipiendi is of quite minor importance as compared with 
incapacity on the part of the uterus for the implanta- 
tion 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 sper- 
matozoon should be possible, but further, that the 
uterus should be in a condition favorable for the im- 
plantation and further development of the ovum sub- 
sequent 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 Griinewaldt that these diseases are the 
principal cause of reproductive incapacity in women. 
Various metritic processes, and also venous hyperae- 
mia consequent upon heart disease, may lead to atro- 
phy of the uterine mucous membrane, which then ap- 
pears 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 character- 
ized 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 endo- 
metritic catarrhal processes; to venous hyperaemia, es- 
pecially in cases of valvular heart disease; to subin- 
volution, 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 mu- 
cous membrane in cases of extensive uterine hyperpla- 
sia (it commonly becomes atrophic and discharges 
a watery secretion), interfere with the reproductive 

In all cases of chronic metritis, the hyperaemia and 
hyperplasia of the uterus may give rise to haemor- 
rhages; 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 devel- 
opment 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 Griinewaldt 
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 displace- 
ment, no exudation or swelling, and no relevant affec- 
tion of the endometrium. But the characteristic fea- 
ture of these cases is, according to von Griinewaldt, 
that after her last full-time delivery, a woman has had 
a miscarriage or a premature delivery, and subse- 
quently has been completely sterile. The degenera- 
tive process is at first partial, so that it does not pre- 
vent conception, but renders it impossible for the 
pregnancy to go on to full term; subsequently it ex- 
tends 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, sub- 
involution 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 phy- 
sician 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 down- 
ward 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 snioothnes^ 


of the surface of the atrophied mucous membrane, 
render the lodgment of the ovum in the uterus very 
unlikely. A further powerful obstacle to impregna- 
tion 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 color, rendered cloudy by admix- 
ture 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, bacte- 
ria and cocci — and, if the endometritis is of gonor» 
rhoeal origin, the gonococcus of Neisser. This secre- 
tion, 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 consti- 
tutes 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 endome- 
tritis, whereby the uterus is rendered unfit for the 
implantation and incubation of the ovum, are the fol- 
lowing. The epithelial cells, as usual in cases of con- 
tinued catarrh, change in form, the ciliated cells dis- 
appear, 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. Ultimately 
the rriucovts menibrane undergoes atrophy, its glands 


disappear, and it comes to resemble a thin stratum of 
connective tissue. 

Thus, in severe and long-continued endometritis, the 
changes that occur in the uterine mucous membrane 
render the implantation of the ovum and the forma- 
tion of normal decidua impossible ; even if conception 
does occur, the fertilized ovum is speedily discharged. 
Frequently, in cases of endometritis, there is consecu- 
tive displacement of the uterus which acts as a con- 
tributory cause of sterility. When endometritis lasts 
a long time, proliferation of connective tissue in the 
uterine parenchyma also occurs, leading often to hy- 
pertrophy 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 gonorrhceal 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 occur- 
rence of gonorrhceal cervical and corporal endometri- 
tis, of perimetritis, and secondary parenchymatous 
metritis. Still, under appropriate treatment, the in- 
flammatory changes consequent on gonorrhceal infec- 
tion are in manj; cases curable, and, after absorption 
of the exudations and restoration of the normal nutri- 
tive 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 ob- 
served cases in which beyond question conception has 


occurred, notwithstanding the existence of gonorrhoea! 

In my own experience, whilst gonorrhoea! endome- 
tritis is, among inflammations of the endometrium, the 
most frequent cause of sterility, the place of next im- 
portance in this connection is occupied by exfoliative 
endometritis, or membranous dysmenorrhoea. This 
name is given to a pathological condition in which 
from time to time, usually during menstruation, frag- 
ments 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 dysmenorrhoea membra- 
nacea; in two cases it existed from the time of mar- 
riage — 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 curet- 
tage of the uterus, but quite without avail. In other 
cases, the sterility was acquired, the membranous dys- 
menorrhoea 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 aflfection, I am compelled to re- 
gard it as one of the most severe hindrances to con- 

As a general rule, exfoliative endometritis termi- 
nates 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 en- 
sue, cases of this nature having been observed by Solo- 
wieflf, 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 com- 
moner than in other diseases of the uterus. Char- 
pignon, Hennig, and Bordier have also observed con- 
ception occur in the course of this disease. In 42 cases 
of membranous dysmenorrhoea collected by Klein- 
wachter, pregnancy occurred in four during the ex- 
istence of the disease. Lohlein also reports that, among 
27 patients affected with membranous dysmenorrhoea, 
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 be- 
fore the first appearance of the exfoliative endometri- 
tis; subsequently they became pregnant and were de- 
livered 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 veiy 
speedily on the operation, could a causal connection be 
inferred. In two of the cases the mothers of the pa- 
tient had also suffered from the affection. 

It has been asserted by B. Schultze and others that 
curettage of the uterus renders it difficult or impossi- 
ble for pregnancy subsequently to occur. There is, 
however, no evidence to justify such an opinion. 

Especial attention should be given to inflammatory 
process in the perimetrium and the parametrium as 
diseases giving rise to sterility in women. They are 
extremely common, and at times are so insidious, run- 
ning 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 


tumor-growths, they may yet be overlooked. Hence 
their pathological significance in the causation of ster- 
ility 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 retro- 
posed, and painful when the uterus is moved; inflam- 
matory 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 parame- 
tric tissue, the blood and lymphatic vessels of the para- 
metrium are compressed, and in part obliterated, and 
the intimate connection between the pelvic cellular tis- 
sue and the uterus readily leads to the onset of en- 
dometritis, 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, para- 
metritis, and pelvic peritonitis that result from gonor- 
rhceal infection have thus an especially disastrous influ- 
ence, for the reason that in these cases cervical metritis 
and endometritis with blennorrhoea are commonly su- 
peradded. 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 in- 
flammation are to be found in the bodies of 58.4 per 
cent, of parous women, and 33.3 per cent, of the bodies 
of women (married or unmarried) who have had ex- 
perience 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 ster- 
ility in women. In the nulloparae mentioned above, 
Bundl 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 aflfected with 
azoospermia. The connection between azoospermia in 
men and the discovery of inflammatory residues in 
their childless wives, is a very intimate one. The hus- 
band 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 became sterile, the 
limitation of fertility depended chiefly upon inflamma- 
tory residues in and around the ovaries and the tubes. 
In the majority of such cases, pregnancy is not ren- 
dered impossible, but merely difficult, for, notwith- 
standing 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 intra-pelvic 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 mem- 
brane, 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 sper- 
matozoon. The cases are numerous in which preg- 
nancy has been observed, notwithstanding extensive 
carcinomatous disease of the cervix, with necrosis of 
the tumor tissue; and Cohnstein even asserts, though 
in this he goes too far, that cancer of the cervix ac- 
tually favors 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 con- 

Winckel summarizes in the three following propo- 
sitions his experience regarding the relation between 
uterine carcinoma and sterility: i. 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 con- 
trary, the women affected with this disease have gen- 
erally been exceptionally fertile. 

Other tumors of the uterus cause sterility, not 
merely by giving risp 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 im- 
plantation 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 
tumors, there is also interference with the implanta- 
tion 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 dif- 
ficult. 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 tumors 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 fol- 
lows, for the reason that the rupture of the hypertroph- 
ied capillaries in the growths themselves and in the 
neighboring tissues, prevents the normal development 
of the embryo. Horwitz has, however, described a 
case in which pregnancy went on to full term, notwith- 
standing 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. Pfankuch, collecting information re- 
garding 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 Griinewaldt, who published the following fig- 
ures as a result, of his investigations. Of 56 women 
affected with chronic metritis, 46.4 per cent, were 
sterile; in 19.2 per cent, of these the sterility was con- 
genital, in 80.7 per cent, it was acquired. Of 134 
women suffering from myometritis and its conse- 
quences, 71.6 per cent, were sterile; in 17.7 of these 
the sterility was congenital, and in 82.2 per cent, 
it was acquired. On the other hand, of 321 women 
suffering from endometritis, 29.5 per cent, were ster- 
ile; in 28.4 per cent, of these the sterility was con- 
genital, and in 71.5 per cent, it was acquired. 

Lier and Ascher also insist upon the importance of 
puerperal diseases in the causation of acquired steril- 
ity, basing their opinion upon Prochownick's clinical 
material. They draw, however, the following dis- 
tinction. 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 se- 
vere in its course — the v^omen thus aflfected 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 peri- 
toneum, in the majority of cases the women thus af- 
fected will prove sterile for a long time or in per- 
petuity. 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 propo- 
sitions are laid down by Lier and Ascher: i. 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 upward 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 enlarge- 
ment 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 an- 
other 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 Griinewaldt 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 the whole a 
greater part in the causation of sterility than the vari- 
ous conditions previously described which interfere 
with contact of ovum and spermatozoon. But in this, 
we think, he goes too far. 

Finally, in this connection, must be mentioned 
among the hindrances to fertilization, sexual excesses, 
such as are so common during the first weeks of mar- 
ried 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 fre- 
quency 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 develop- 
ment 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 devel- 
opment, myxoma of the chorion and the like. In rare 
cases, vi^omen 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 con- 
ception, 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 prin- 
cipal conditions in which abortion occurs. They are: 
various tissue disorders of the uterus, chronic hyper- 
aemia of the mucosa, displacement of the uterus with 
fixation, parametric and perimetric exudations, lacer- 
ation of the cervix with ectropium; further, various 
constitutional disorders, such as the specific fevers, 
acute .infective processes, chronic circulatory disturb- 
ances consequent upon cardiac, pulmonary, renal and 
hepatic disease, syphilis, anaemia, chlorosis, diabetes, 

Only-Ch ild-Sterility 

Until recently, only-child-sterility had received at- 
tention in England only, for the reason that it is com- 
paratively common in that country; but this form 
of relative sterility is by no means rare either in 
Germany or in Austria. I had a collection made in 
Austria of the number of children resulting from 2,000 
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 i : 19. But the fig- 
ures are untrustworthy, since abortions and deaths in 
infancy were not taken into account. Ansell found 
that in England, among 1,767 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 bar- 
ren, 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 ex- 
planation 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 de- 
livery is the one which entails the greatest dangers to 
the mother, and that the subsequent sterility is attrib- 
utable 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, anaemic, 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 
tumor which beyond others renders the recurrence 
of pregnancy difficult and unlikely. This form of 
sterility has been seen also in cases in which compara- 


tively 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 considei-ation 
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 hus- 
band, 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 pre- 
vention of pregnancy after the first child has been 

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 unf ruitfulness ; it was ob- 
vious that in each case the elderly husband's reproduc- 
tive 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 in- 
sufficient; having succeeded in obtaining the child she 
desires, the wife does not again wander in strange 
pastures, and consequently remains sterile. 


According to Kleinwachter — ^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 i,o8i gyneco- 
logical cases, he observed it in 90, that is, in 8.32 per 
cent, of the cases. In these 90 cases, there were 69 in- 
stances in which the sterility ensued upon full term 
delivery, and 21 instances in which it followed abor- 
tion or premature delivery. Kleinwachter, 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 pro- 
duction 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 im- 
pregnation 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 puer- 
peral infection, gonorrhoeal infection, perimetritis, 
tubo-ovarian tumors, etc. 




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 func- 
tions, is not a sudden one, the symptoms of sexual 
retrogression making their appearance gradually, un- 
til 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 vari- 
ous changes may be detected already before the cessa- 
tion 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 phe- 
nomena, and to manifestations of decay of manifold 

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. occur- 
rence of a number of nervous disturbances, vaso- 
motor 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 be- 
come 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 climac- 
teric 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 involvel 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 be- 
lieve that, if due allowance is made for the natural in- 
crease in mortality with advancing years, no impor- 
tant increase in the mortality of women can be traced 
as due to the troubles and disturbances of the climac- 
teric period. 


N The age at which a woman's last sexual epoch be- 
gins 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 va- 
riable are the intensity and the general distribution of 
the symptoms which mark the climacteric. 

The external configuration of woman at the climac- 
teric age is usually characterized by signs of over- 
ripeness, and these changes appear to exercise upon 
certain men — more especially very young men — a pe- 
culiar kind of erotic stimulus. Many women remain 
long at this period- quite fresh looking, with a vivid, 
youthful coloring; others, however, early manifest 
alterations in their finer feminine characteristics, hairs, 
for instance, sprouting on the chin, and the voice be- 
coming deeper in tone. 

The outward characters of senescence, with wither- 
ing 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 tis- 
sue in the supraclavicular region gives to these ex- 
tremely obese women an appearance of such a short- 
ening 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 subhyoid 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 an- 
terior abdominal wall projecting more especially in 
the hypogastric region, hanging down in two or three 
horizontal rolls over the tops of the thighs, and push- 
ing the mons veneris downward, so that this latter 
itself projects over the genital fissure. The posterior 
projection of the buttocks is also greatly increased, un- 
til they form a huge elastic cushion, of which the sen- 
sual 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." Occa- 
sionally, 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 fis- 
sure is hidden by the projection of the mons veneris. 
The labia majora are also greatly enlarged by the de- 
posit of fat, so that they look like two great cylinders 
lying side by side. Another way in which the charac- 
teristic 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 counte- 
nance; 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 I'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 commit- 
ted suicide. A young abbe 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 conscious- 
ness that she is about to lose her feminine attractions, 
and to decline in sexual esteem, and that her reproduc- 
tive capacity is now to be extinguished. She realizes 
vividly that the beautiful past, the loving and beloved 
womanhood, is now to be left behind forever, 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'etais 
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 fam- 
ily 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 un- 
married 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 employ- 
ment for the powers set free by their sexual non-activ- 
ity in services of neighborly affection, in works of be- 
nevolence, and in the performance of social duties; 
women less happily endowed will display their hos- 
tility to the world in ill-nature, scandal-mongering, 
and intrigue, thus giving vent to their inward bitter- 
ness; while those, finally, with hereditary predisposi- 
tion 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 com- 
mon at the commencement of the climacteric, in asso- 
ciation 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 ap- 
pearances 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, while sacrache is not infrequent, 
and peristaltic movements of the intestines are mis- 
taken 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 her- 
self, 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 cessa- 
tion of menstruation. On the contrary, we have ob- 
served it to be the rule that shortly before and at the 
commencement of the climacteric there is a consid- 
erable 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 man- 
ner 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 per- 
form 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 meno- 
pause, when senile changes in the genital organs are 
far advanced, the sexual impulse may still be re- 
markably active. There is an interesting analogy in 
the fact that Glaevecke observed that the sexual im- 
pulse 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 ova- 
ries, so that after the artificial menopause, voluptas 


coeundi for the first time made its appearance. Other 
authors, Goodell, for instance, report that libido sex- 
ualis is retained only for a short time after oophorec- 
tomy, 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 particu- 
larly 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 free- 
dom 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 aban- 
doned, was standing sorrowfully by. Here we have 
a symbolic representation of the sexual epoch of the 

In a recently published romance, "Les Demi-Vi- 
eilles," 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 endeavor 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 

Sooner or later, after the completion of the meno- 
pause, the signs of senile marasmus become apparent. 
The soft, feminine configuration of the face disap- 
pears, 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 com- 
plete 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 de- 
pendent, and sometimes atrophied to become mere 
cutaneous folds. The nipples project more promi- 
nently, they are darker in color, 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 nymphae, until these lat- 
ter 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 re- 
moved, experiences at first little change in external 
configuration, beyond a somewhat exaggerated ten- 


dency 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 dis- 
turbance, so that in a moment, as it were, the meno- 
pause is effected, without any period of transition. 
Rarely, even, do we meet with cases in which the 
peculiar manifestations foreshadowing or accompany- 
ing 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 regular- 
ity), 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, me- 
teorism, epistaxis, haemorrhoidal flux, congestions of 
the head, increasing fugitive sensations of heat (Ger. 
fliegende Hitze), and a tendency to profuse perspi- 

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 intermen- 
strual 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 lo months, then again the 
flow will occur every two or three weeks; in excep- 
tional 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, last- 
ing for many months, menstruation recurs, and con- 
tinues at regular intervals for a long time, until the 
final cessation of menstrual activity. 

The mode of cessation which is most favorable to a 
woman's general health is for the duration of the in- 
termenstrual interval gradually to increase, while pari 
passu with this increase, the amount of the flow pro- 
gressively decreases, until it ceases altogether. In such 
cases, the general constitutional disturbance is reduced 
to a minimum. On the other hand, the sudden cessa- 
tion 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 termina- 
tion of the flow, there persists a more or less regular 
recurrence of certain symptoms referrible to the com- 
tinuance of ovulation. Sacrache, a sense of abdominal 
tension, a feeling of heat and fulness in the pelvis, 
dragging pain in the hypogastrium, and general irri- 
tability, occur at intervals, so that the woman thus 
affected sometimes describes herself as suffering from 
the continuance of a "bloodless menstruation." 


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 tumors, more especially to 
carcinomatous disease of the ovaries, the uterus, and 
the mammae. 

With regard to the question whether, in any par- 
ticular individual, the course of the menopause is 
likely to be favorable or unfavorably, 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 dis- 
turbances of the general condition. In every individ- 
ual there appears to be a certain connection between 
the manifestations attending the menarche and those 
attending the menopause, of such a nature that ac- 
cording as puberty has been passed through with little 
or with much disturbance of the general condition, a 
similar favorable or unfavorable course of the meno- 
pause 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 

The woman's state of general health is likewise of 
importance in determining whether the course of the 


menopause will be favorable or unfavorable. Per- 
fectly healthy women, with a quiescent temperament, 
and in favorable circumstances of life, will pass most 
easily through the climacteric period without dis- 
turbance of their general condition. Every departure 
from normal health has an unfavorable 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 hy- 
peraemia. Chlorotic and anaemic women are more 
prone than others to suffer at the time of the meno- 
pause from uterine haemorrhages. Women of a san- 
guino-erethistic constitutional disposition often mani- 
fest 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 favor- 
able 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 com- 
plain of severe haemorrhages and various other patho- 
logical 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 favorable influ- 
ence 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 oc- 
currence of conception, a form of sexual immorality 
which has become extrordinarily common during the 
last few decades, has an unfavorable influence upon 
the course of the climacteric. Unfavorable, 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 birtli to a child 
shortly before this time, commonly experience very se- 
vere disturbances during the menopause. Prostitutes 
who continue the active pursuit of their profession un- 
til the climacteric age have at this time much to suf- 
fer. Women who have had difficult deliveries, or 
several miscarriages, or severe puerperal illness— and 
indeed, speaking generally, those women who have been 
subject to any kind of disease of the reproductive or- 
gans — 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 cessa- 
tion of menstruation, or very sudden •interruption of 
this function, has a deleterious effect, manifesting 
itself both by local disorders of the reproductive or- 
gans, and by general disturbances in the nervous sys- 
tem and in the circulatory organs. On the other hand,, 
a late menopause and a gradual cessation of menstrua- 
tion are both usually accompanied by a favorable 
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 sex- 


ual irregularity, and who therefore enter upon the 
menopause with flaccid and deteriorated rep'fbductive 
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 

After an artificial menopause, induced by the opera- 
tive removal of the ovaries, similar manifestations oc- 
cur 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; 
moroever, 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 con- 
dition of the genital organs at the time when the opera- 
tion is performed. We note, moreover, that, just as 
in the physiological menopause, the attendant troubles 
are most violent in the initial period, and then grad- 
ually 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 sex- 


ual life, from the very first diminution in ovarian ac- 
tivity 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 circu- 
lation may occur: hyperaemic states of the central 
nervous system, flushings of the face, the so-called 
fugitive heats (Ger. fliegende Hitze) , a tendency to epi- 
staxis, to haemorrhoidal flux, and to profuse perspira- 
tion. The changes which take place in the reproduc- 
tive 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, giv- 
ing rise to various dyspeptic manifestations, and at 
times, when severe, even to actual gastric and intes- 
tinal catarrh. Hyperaemia of the liver may also arise. 
In this case, the pressure of the distended blood-vessels 
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 over- 
filling of the haemorrhoidal veins, and hence to bleed- 
ing 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 conges- 
tion, impaired vision, etc. 

Congestion of a more active nature arises from an in- 
creased and usually accelerated flow of blood throu^'i 


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 characteris- 
tic symptom of the menopause known as ardor fugax 
— fugitive heat — one link in the long chain of vaso- 
motor manifestations occurring at this period of life. 

Fugitive heats are commonly most clearly marked in 
the face, head, and neck, in which region there sud- 
denly 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 period ; 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 imme- 
diately succeeded by a similar attack in some other 
part of the body, or by vasomotor phenomena of a 
slightly dififerent 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 pru- 
ritus of the extremities, by palpitation of the heart, or 
by an attack of pseud-angina. 

A further consequence of active hyperjemia is the 
onset of those confused states, so common in the cli- 
macteric 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, while sleep is restless, and much disturbed by 
dreams; and again states of dizziness, a sense of men- 
tal 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 sensa- 
tion, and various kinds of hyperaesthesia, frequently 
associated with disturbances of tactile sensation. We 
observe also muscular twitchings, and general weak- 
ness of the organs 'of locomotion. 

In association with the passive and active hyperae- 
mias 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, in- 
creased excretion of urinary deposits, and increased 
secretion by the skin. Symptoms which are common 
at the menarche, and frequently recur at the meno- 
pause, are: headache, migraine, a state of pseudo-nar- 
cotism, slight hysterical attacks, indications of moral 
insanity, lumbo-abdominal neuralgias, neuralgia of 
the breasts, leucorrhcea, and various skin eruptions. 

According to Tilt, the changes occurring in the or- 
ganism at the climacteric period may be summarized 
under the following heads: 

1. Increased elimination of carbonic acid by the 

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 acjd 


begins already in the 36th year of life; in old age the 
quantity eliminated is greatly reduced in both sexes 

Changes in the Female Reproductive Organs at 
THE Menopause 

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 cli- 
macteric, with its various manifestations antecedent to 
and associated with the irregularity and ultimate ces- 
sation of menstruation, from the condition of old age 
in which menstruation has actually and completely 
ceased, in which the menopause has been fully accom- 
plished, 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 fol- 
low 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 ova- 
ries of women at ages varying from 42 to 75 years 
{Archiv fur Gynecologie, Bd. XII., Heft 3). 

Throughout these years a slow but continuously 
progressive atrophy proceeds in the ovaries; they be- 
come smaller and denser, diminishing especially in 
height and width; their surface becomes extremely un- 
even; 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. 
The histological characteristic of the changes in the 
ovary which proceed gradually from the commence- 


merit 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 retro- 
gressive metamorphosis of the graafian follicles. 

The connective tissue ground substances of the ovary 
increases from the periphery toward 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 mem- 
brana propria (the theca folliculi) of the follicle re- 
mains 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 ovoid form. 

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 be- 
ing formed by the theca folliculi. The cavity of the 
follicle is reduced to a mere cleft filled with a trans- 
parent 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. 

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 orig- 
inal 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. 

The three stages I have observed in the retrogres- 
sion of the follicle, of which I have given a summary 
account above, may, I think, be explained in the fol- 
lowing manner: When the woman's reproductive ac- 
tivity ceases, the graafian follicles become subject to a 
retrogressive metamorphosis, a fatty degeneration set- 
ting 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 increas- 
ing quantities, until finally the entire follicle is trans- 
formed into a firm fibrous mass. 

Thus we are led to infer that the gradual but ex- 
tensive 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 pe- 
riod, 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 func- 
tion at the time of the menopause. It is reasonable to 
assume that the resistance of this thickened tunica al- 
buginea is responsible for the fact that the interval be- 
tween 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 com- 
monest ways in which the onset of the menopause is 
first manifested. Another phenomenon connected with 
the onset of the menopause also finds a plausible ex- 
planation in the anatomical grounds just mentioned. 
As already pointed out, in parous women the meno- 
pause sets in later than in nulliparae. At every preg- 
nancy, the ovaries share in the more abundant nutri- 
tion of all the reproductive organs, due to the general 
dilatation of the intra-pelvic vessels which accom- 
panies this process; hence the ovaries become larger, 
richer in lymph, and therefore softer, the cellular ele- 
ments 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 climac- 
teric epoch would appear also to depend upon the 
hyperplasia of the ovarian stroma which we have ob- 
served to be the characteristic anatomical change in 
the ovaries at this period of life. 

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- 
Sequard has especially maintained that the ovaries se- 
crete a substance which enters the blood, a substance 


which, notwithstanding the fact that its presence can- 
not 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 ^ are dependent upon the cessation of this 
internal secretion of the ovary — disturbances which 
rise to a maximum as the atrophy of the ovary pro- 
ceeds, 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 

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 sur- 
rounding these cysts being extremely hard, dense, and 

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 upward. 
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 

■* Note. — In Germany, the term Ausfalherscheinungen is used as a gen- 
eral name for the various disorders of the climacteric period. The word 
Ausfall means literally o falling out, or shedding, as of the hair. No pre- 
cise English equivalent of the term is known to me, nor is one really 
needed, the phrase disorders of the climacteric being sufficiently distinctive. 
— Transl. 


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 to undergo a cystic degeneration, 
and hence arise the cysts which are so commonly met 
with on the portio vaginalis of women at this time of 
lifCj 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 oc- 
cupy the lumen of the cervical canal. 

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 be- 
tween the plicae palmatae, sometimes isolated, some- 
times grouped. 

Sometimes in old women no trace of a vaginal por- 
tion 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 meno- 
pause 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 

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 intra-mural 
haemorrhages usually occur in the fundus; the friable 
uterine substance has then a blackish-red appearance, 
infarcted with extravasafed blood; sometimes the ute- 
rine 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. 

Wendeler found that the initial change of the cli- 
macteric in the ovary is a chronic and progressive en- 
darteritis obliterans; the resulf of this process is, in 
addition to the obliteration of the follicles, a contin- 
ually increasing hyaline degeneration of the smallest 
arteries and the arterioles, especially along the line of 


transition between the cortical and the medullary sub- 
stance 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. 

The gradual atrophy of the uterus after the extinc- 
tion of its sexual activity leafls to a diminution in all 
the diameters of the organ, so that in old women it 
becomes flattened as in childhood, all its curves hav- 
ing 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 aerobically on alkaline 
agar plates. In exceptional cases, however, such bac- 
teria are found, and may even be sufficiently vigorous 
to produce pyogenic infection. According to Stroga- 
moff, 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 pe- 
riod 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, v^^hether on agar or gelatine. 

The Time of the Menopause 

The age at v^^hich 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 dur- 
ing 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 meno- 
pause 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 a:bnormally 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 cir- 
cumstances : 

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 condi- 

I. Race 

From the statistical data regarding the age at which 
the menopause occurs among the women of the vari- 
ous 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 Ger- 
many, 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 coun- 
tries the cessation of menstruation occurs at an earlier 
age than in northern countries, as the following com- 
parison shows: Northern countries: England (Tilt), 
48 to 50; France (Courty)j 50; North Germany 
(Mayer), 50; Austria (Szukits), 42; southern coun- 
tries: 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 observa- 
tion 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 


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 wom- 
en of Sclavonic nationality, menstruation ceased re- 
markably late as compared with women of German 

Brierre de Boismont, Tilt, Courty, and various other 
observers, have published statistical data regarding the 
age at which menstruation ceases in women of differ- 
ent nationalities. Krieger, compiling from several au- 
thors, statistics relating to 2,291 women (European) 
gives the following average results: menstruation 

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 

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 oc- 
cur; 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 men- 
struate 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 activ- 
ity, 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 menopaue 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 me- 
narche 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 me- 
narche occurred at an abnormally early age, i.e., be- 
fore 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 upward. 
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 en- 
ergies 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 Salpetriere, Raciborski ob- 
served 29 in whom menstruation had begun at the ex- 
ceptionally early age of 12 years, and who, notwith- 
standing this, all experienced a very late menopause. 
Three of them were still menstruating at the age of 
S7, I 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 mar- 
ried, 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 be- 
gin 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 some- 
times 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, vaso- 
motor symptoms, congestions, cardiac troubles, albu- 
minuria, 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 occur- 
rence of hysteria and epilepsy before t)oth these im- 
portant epochs in a woman's life, whilst in the inter- 
vening 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 diar- 
rhoea, 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 connection 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 repro- 
ductive organs have been adequately and properly ex- 
ercised, who have had a physiological amount of sexual 
intercourse, have given birth to several children, and 
have suckled these children, the cessation of the men- 
strual 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 de- 
liveries, the later does the menopause ensue. 

Especially striking is the influence of the number 
of deliveries upon the time of occurrence of the meno- 
pause. In women who have given birth to a number 
of children, menstruation, as a rule, continues for sev- 
eral 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 fol- 
lowing 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, i 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 nienopause 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 laboring classes, whose livelihood is so 
often precarious, and who are apt to sufifer from habit- 
ual 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 climac- 
teric thus occurs earlier among the lower than among 
the upper classes, the difference is not a considerable 

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 ear- 
lier than among the lower classes, by an amount which 
averages 1.3 1 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 he- 
reditary predisposition of the woman, by her constitu- 
tional state, and by certain illnesses from which she has 
suffered. Women who by inheritance are constitution- 
ally weakly and delicate, in whom the menstrual flow 
has always been pale and scanty, in whom the inter- 
menstrual intervals have been excessive, and who have 


a slender habit of body, attain the climacteric age ear- 
lier 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 men- 
struate earlier than women of more normal propor- 
tions; blondes earlier than brunettes; women of phleg- 
matic 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 labor, great sorrow, wearisome occupations, 
severe menstrual losses, rapidly succeeding pregnan- 
cies, and abortions ; also a number of pathological gen- 
eral states shortly to be discussed, as well as local dis- 
eases 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 abun- 
dant menstrual flow, those with retroflexion, with hy- 
pertrophy of the portio vaginalis, or chronic endocer- 
vicitis 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 cessa- 
tion 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 mani- 
festations 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, how- 


ever, 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 

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 

Premature cessation of menstrual activity, in the 
third or the fourth decennium of life — ^very rarely in- 
deed before the third decade — depends in part upon 
disturbances of metabolism and of haematopoiesis, and 
in part upon diseases of the female reproductive or- 
gans; 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, lipoma- 
tosis universalis, occupies the first place. Next in order 
of importance come a chloro-anaemic condition of the 
blood, pernicious anaemia, splenic leukaemia, certain of 
the acute infectious disorders — typhoid, cholera, scar- 
latina, acute articular rheumatism — further pulmonary 
tuberculosis, diabetes mellitus. Graves' disease, Addi- 
son's disease, and myxcedema. These various condi- 
tions may give rise, in part by infective processes, and 
in part in consequence of the general cachectic condi- 
tion, to atrophy of the ovaries with destruction of the 


graafian follicles, and to adipose 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 men- 
tioned, 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 meno- 
pause 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 com- 
petent to give rise to a premature cessation of men- 
strual activity, the most important are the puerperal 
infective processes and other inflammatory states of the 
reproductive organs, with their results — chronic me- 
tritis, 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 mu- 
cosa, permanent and irreparable atrophy of the uterus, 
and suppuration and atrophy of the ovaries — condi- 
tions which result in an extinction of menstrual activ- 
ity. A similar result may ensue upon the persistent 
and long-continued pressure upon the uterus and the 
ovaries of a large intra-pelvic exudation; such exuda- 


tion being commonly post-puerperal, but occasionally 
arising in the absence of pregnancy. Further, accord- 
ing to Freund, chronic atrophic parametritis may give 
rise to an incurable atrophy of the uterus, by inter- 
ference 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. Tumors 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 be- 
long the cases, according to Kleinwachter of no extreme 
rarity, in which perfectly healthy women are attacked 
by profuse uterine haemorrhage during the course of 
a normal, full-term labor, or during miscarriage; sub- 
sequently, though the lying-in period is passed with- 
out 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 atro- 
phy follows normal labor or abortion without the oc- 
currence of any excessive haemorrhage. 

Much more frequently do we find that rapidly suc- 
cessive pregnancies, with long-continued exercise of the 
lacteal function, in badly nourished, anaemic 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 "lactation- 
atrophy" 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 perma- 
nent, to a premature menopause. 

Trauma of the genital organs may also lead to uter- 
ine atrophy and to premature menopause. 

By many authors it is believed that too-early mar- 
riage, sexual excesses, and prostitution, -may be the 
cause of cessatio praecox. In some cases, there is un- 
questionably a hereditary predisposition to a prema- 
ture climacteric, since the mothers of the w^omen in 
whom it occurs have themselves been similarly affected. 
In a remarkable case which came under my own ob- 
servation, of a woman from Smyrna, there was hered- 
itary predisposition. This woman began to menstru- 
ate when 12 years of age; menstruation was always 
scanty; she married -when 15 years of age; and she 
ceased to menstruate forever at the age of 19. In 
other cases we find there is a family tendency for men- 
struation to be delayed in its first appearance to a com- 
paratively advanced age, and to cease at the usual time. 

In cases of cessatio mensium praecox (unless the fail- 
ure 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 at- 
tending the change are commonly more severe and 
more enduring than those that occur at the natural 


menopause. Especially is this the case when the pre- 
mature menopause is quite a sudden occurrence, but 
this phenomenon is rare. Most commonly the prema- 
ture menopause is gradual in onset; the flow becomes 
more scanty month by month, until at last it fails alto- 
gether to appear. Irregularity in the menstrual rhythm 
is not often seen in such cases. Early senescence is ex- 
ceptional in these women in whom a premature meno- 
pause occurs. Emaciation, grayness of the hair, wrin- 
kling 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 precox being usually similar to 
those seen in women of corresponding age in whom 
menstruation still continues. 

Tilt inquired regarding the cause of cessatio praecox 
in 27 instances, with the following results : 

In 3 instances, parturition and lactation. 

In I instance, abortion. 

In 2 instances, a fall on the sacrum during men- 

In 2 instances, suppression of menstruation from 

In I instance, haemorrhage from the arm during 

In I instance, celebration of nuptials during men- 

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 I case Tilt saw cessation of menstruation occur 
at the age of 29, in consequence of metritis. Atlee, in 
15 cases of ovarian tumor, saw the menopause occur at 


the 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. Bloridel reports a casd 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 .Kleinwachter, 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, i case 
at 23; Brierre de Boismont, i case at 24; Mayer, 2 
cases at 25 ; Brierre de Boismont, i case at 26, and i case 
at 27; Guy and Tilt, each i case at the age of 27; 
Brierre de Boismont, Courty, and Guy, each i case at 
the age of 28; Brierre de Boismont, Courty, and Mayer, 
each I case at the age of 29 ; Guy and Tilt, each i 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 ex- 
tremely 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 com- 
mon precisely at this age of life, due either to textural 
changes in the uterus, or to neoplasmata — more espe- 
cially 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 ques- 
tion recurs at the intervals and in association with the 
general symptoms to which the woman thus affected 
has been accustomed during her previous menstrua- 


tions, 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 men- 
strual and pathological uterine haemorrhage, quite re- 
cently numerous incontestible cases of enduring sexual 
vitality have been put on record. 

I have myself seen no less than io6 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; i in which it was 59; and i in which 
it was 60. Tilt records 128 cases of menopause occur- 
ring after 50; among these there were 4 in which the 
woman was 56 when menstruation ceased ; 2 who were 
57 ; 4 who were 58 ; i who was 59 ; i who was 60 ; and 2 
who were 61. Courty reports a case in which menstrua- 
tion persisted after the age of 65; Mayer, 3 cases of 
menopause at 64; Beigel, 2 cases, i in which menstrua- 
tion continued to the age of 65, the ether to the age of 
72. Kleinwachter observed 33 cases in which menstrua- 
tion 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, haemor- 


rhage 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 extrava- 
sation 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 in- 
sufficiency, 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 matura- 
tion of ova; the uterus was enlarged, the mucous mem- 
brane hyperaemic, and the cavitv contained a recent 

Not infrequently, t^e haemorrhages attributed to the 
persistence of menstruation are really due to senile 
arteriosclerosis — to rigidity and brittleness of the uter- 
ine 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 compara- 
tively 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 haemor- 
rhages, 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 exam- 
inations 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, as- 
serts that when four years have elapsed since the meno- 
pause, 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 

I have myself seen several cases in which the meno- 
pause occurred at 35, 38, 39, and ^2 years, respectively; 
3, 4, or 5 years later, as a result of hydropathic treat- 
ment, 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 re- 
ported 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 ob- 
served the following case: A strong working-class 
woman, 33 years of age, had begun to menstruate regu- 
larly 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 per- 
sistent leucorrhoea, but no trace of menstrual haemor- 
rhage; 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 men- 
struate at the age of 20, had her first child when 47 
years old, and gave birth to the last of her eight chil- 
dren when 60 years of age. 

The sudden and permanent cessation of menstrua- 
tion, whether at the normal climacteric age, or earlier 
in life, is always a pathological occurrence. As com- 
pared with the normal, gradual disappearance of men- 
struation, associated with the usual climacteric symp- 
toms, 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 labor or abortion with profuse haemorrhage. 


or after cholera or typhoid; we must assume that in 
such cases the anaemia of the genital organs has dis- 
turbed 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 meno- 
pause is also a premature one. 

Tilt reports a case in which a sudden menopause en- 
sued upon phlebotomy during menstruation; several 
cases also in which women dt 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, con- 
sequent 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 pernianent cessation of menstruation. Mayer re- 
ports 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 forever to men- 
struate ; 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 13, and in whom at the age 
of 23 a sudden menopause ensued upon a nervous at- 
tack; 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' amenorrhoea 


in consequence of sorrow at the death of one of her 
children. The following remarkable case is reported 
by Brierre de Boismont: A seamstress began to men- 
struate 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 condi- 
tion of the woman who experiences it, is manifested 
chiefly by violent circulatory disturbances, hyperaemia 
and congestion of the brain, lungs, and abdominal or- 
gans, 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 func- 
tional 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 


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, excep- 
tionally not till after the complete cessation of men- 
struation, 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 par- 
oxysms 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 dur- 
ing sleep. The subjective sensation aroused by the in- 
creased 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 toward the end 
of the attack there is a sense of flickering before the 
eyes (as of muscae volitantes), tinnitus aurium, dizzi- 
ness, 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. Sphygmo- 
graphic 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 commence- 
ment of the dicrotic elevation, which latter was ex- 
ceptionally large; the predicrotic elevations, on the 
other hand, were but slightly developed. On ausculta- 
tion, 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, dis- 
appearing more gradually after lasting a few minutes 
— this appearance was associated with a burning sen- 
sation 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 in- 
capacity for regular work, sleep uneasy and much dis- 
turbed by dreams, great general nervous irritability, 
or signs of passive congestion in various organs ; occa- 
sionally there is oedema of the lower extremities; the 
urine remains free from albumin. 

In most of the cases of this nature which came under 
my own observation, a certain plethora was notice- 
able ; 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 — no, 115, or even 120, as 


compared with a haemoglobin richness of 93 in normal 
woman. Several of my patients presented ' the clini- 
cal picture of the plethoric form of lipomatosis uni- 

In all, during ten years, I observed 67 cases of par- 
oxysmal 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 

As a general rule, women live in great dread of all 
manifestations of bodily disorder during the meno- 
pause; those who become affected with paroxysmal 
tachycardia are exceptionally anxious, and regard 
themselves as threatened by a "stroke." This pessi- 
mistic view is, however, by no means justified. These 
cardiac disorders may make their appearance some 
time before the menopause, they may persist through- 
out 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 favorable results from the following 
measures: The systematic employment of mild pur- 
gatives, combined with suitable dietetic and hygienic 
regulations (bland diet, regular and strenuous exer- 
cise, cold ablutions, and wet compresses surrounding 
the abdomen). 


When we inquire regarding the cause of the tachy- 
cardiac 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 im- 
pulse 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 repro- 
ductive organs. This view receives support from the 
fact that after oophorectomy, 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 dys- 

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 tachy- 
cardia, the irritable state of the accelerator nerves must 
also depend in part upon that general nervous hyper- 
excitability which is so often a characteristic feature 
of the climacteric period in women, manifesting itself 
in manifold hyperagsthesias, 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 jlist de- 

But in addition to the causes of climacteric tachy- 
cardia already enumerated, we have to take into con- 
sideration the results of recent investigations con- 
cerning 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 dis- 
turbance of the vasomotor centre in the medulla oblon- 

In some cases, the tachycardiac paroxysms appear 
to be connected with the erotic excitement to which 
women are sometimes subject at the climacteric, volup- 
tuous 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 ques- 
tion depend upon the liability to an increased deposit 
of adipose tissue in the body at the time of the meno- 
pause, and in this connection the plethoric form of 
lipomatosis universalis almost invariably predomi- 
nates. 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 hither- 
to been extremely lean are apt to become quite plump 
at the climacteric period. Chiefly in consequence of 
this increasing obesity, there occurs in climacteric wom- 
en 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 palpita- 
tion; appetite, digestion, and sleep remain usually un- 
affected 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. Miiller, 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 the 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 be- 
come competent to meet very various demands upon 
its powers. 

Only in women who. from youth onward have ex- 
hibited 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 at- 
tacks of cardiac asthma are frequent. In consequence 
of the diminished propulsive power of the heart, cir- 


culatory difficulties make their appearance in the most 
widely divergent venous areas; the forms most com- 
monly 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, 
albumin 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 some- 
what weakened, with a moderate enlargement of the 
area of percussion-dulness, whilst the impulse is dis- 
placed a little outward, and is weaker than normal. 
In some cases, however, a marked dulness on percus- 
sion 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 horizon- 
tal 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 redu- 

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 anaemic 
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 haemor- 
rhages, 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 
compiressible, and sometimes intermittent or arhythmi- 
cal. 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 albumin. 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 cli- 
macteric, 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 sufiferings. 

In several cases of this kind, I found that the haemor- 
rhages were due to a relaxation of the uterine tissues, 
and that this relaxation was itself referable to intra- 
pelvic circulatory disturbances, dependent upon ob- 
struction 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 meno- 
pause, 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 retro- 
flexion of the uterus, to prolapse of that organ, or to 
tumor, 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 blood- 
vessels are clearly marked : the cardiac impulse is heav- 
ing, the second sound of the heart is accentuated; the 
pulse is full and large, usually giving a very power- 
ful blow to the examining finger, whilst its sphygmo- 
graphic 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 albumin may 
be found in the urine. 


We may thus summarize the cardiac disorders met 
with at the menopause, and more or less directly de- 
pendent 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 readi- 
ness by impressions proceeding from the reproductive 

3. Cardiac disorder due to the obesity so conimonly 
occurring as a part of the general metabolic changes 
of the menopause, but more particularly dependent 
upon a deposit of fat in the neighborhood of the heart 

4. Symptoms of cardiac failure, due to excessive 
losses of blood at the menopause, either as an exaggera- 
tion 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 meno- 
pause occurs at an unusually advanced age, and de- 
pendent upon arteriosclerosis. 

Particular consideration must be given to a symptom 
not infrequently occurring in association with the car- 
diac 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 her own body, or else of her visible 
and palpable environment; with this is associated a 


sensation of disturbance of equilibrium, flickering be- 
fore the eyes (muscae volitantes) , tinnitus aurium, palpi- 
tation 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 par- 
oxysms, 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 meno- 
pause. Both anaemia 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 mani- 
festation 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 arterio- 
sclerotic changes in the blood vessels, such as are al- 
ready by no means rare at the age at which the meno- 
pause 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 men- 
struation 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 continu- 
ance of periodic maturation of the graafian follicles 
associated with congestion of the intra-pelvic organs, 
in the absence of the periodic relief to that congestion 
afforded by the menstrual flux, there results a summa- 
tion 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 men- 
struate 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 sup- 
pressed, 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. Ex- 
perience clearly shows that a certain connection exists 
between the manifestations that accompany the com- 
mencement of sexual activity, and those that accompany 
the decline and extinction of that activity; and a phy- 
sician 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 unfavorable or a favorable 
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 repro- 
ductive 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 

Again, women with a sanguine and erethistic tem- 
perament are more inclined to suffer from cardiac 
troubles at the menopause than women of a tranquil 
temperament and those endowed with an unimpression- 
able 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 cli- 
macteric 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 menstrua- 
tion became once more established, and the pulse-fre- 
quency 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. Clement describes a peculiar form of disturb- 
ance of the functions of the heart at the climacteric 
period, to which he gives the name of Cardiopathie 
de la Menopause, 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 rheuma- 


tism nor 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 menstrua- 
tion, 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 at- 
tack 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 dis- 
turbed by paroxysms of palpitation and severe pre- 
cordial 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 re- 
sults. 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 mur- 
mur; 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 addi- 


tion 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, dis- 
turbance of digestion ensues, the appetite is lost, and 
the general vigor declines. Recovery ultimately occurs, 
but very gradually. Clement refers the disease to 
a profound disturbance of the cardiac innervation 
through the sympathetic nerves, but believes that 
anaemia constitutes a contributory cause of the cardiac 

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 unfavorable. The functional dis- 
turbances of the cardio-vascular apparatus which com- 
monly accompany the menopause, readily lead, should 
organic heart disease exist, to the onset of severe cardiac 
weakness, which may have a rapidly fatal termina- 
tion. In 55.5 per cent, 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 compen- 
sation — 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, hyperemia 
of the liver, hyperaemia of the mucous membrane of 
the bladder, catarrh of the bladder, distention of the 
haemorrhoidal veins, and the various symptoms depen- 
dent 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 inter- 
mittent. 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 intes- 
tine may, if not too violent, exercise a favorable in- 
fluence upon the congestive states of the climacteric, 
by relieving the distention 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 favorable 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 diar- 
rhoeas occurring at the climacteric, and have warned 
against their suppression. According to Tilt, diar- 
rhoea occurred in 12 per cent, of all women of this 
age coming under his observation ; in 4 per cent, of the 
climacteric women, this diarrhoea recurred at regular 
monthly intervals, whilst in 8 per cent, the recurrence 
was irregular. In 500 women during the climacteric 
age, Tilt observed the following abdominal disorders : 

Swollen haemorrhoids in 62 cases 

DiarrhcEa 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 

Hasmatemesis in 4 cases 

Monthly intestinal hsemorrhages 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. Some- 
times, 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 lubri- 
cated, and the constipation gives place to diarrhoea 
lasting perhaps for several days. This is the explana- 
tion of many cases in which there is a periodic recur- 
rence of diarrhoea. 

Dyspeptic disturbances are rarely absent during the 
climacteric period. Most often we see disordered ap- 
petite, 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 distention of the stomach. A very dis- 
tressing symptom is an excessive formation of gas 
within the intestine. At times such meteorism is ex- 
treme, 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 breath- 
ing 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 tumor. 

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 exces- 
sive production of gastric juice, perhaps altered in 
quality as well as quantity, combined with some other 
disorder of gastric innervation (hyperaesthesia, or hy- 
perkinesia) 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 in- 
nervation (Boerner). 

Disturbances of the biliary secretion, icterus of 
greater or less severity, are by no means rare manifesta- 
tions of the abdominal congestion of climacteric wom- 
en, and such disorders have alsd 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 hyperhy- 
drosis, an excessive secretion of sweat. Almost invari- 
ably, 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 
J3i the body, and at times this secretion is extremely 

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 eqzema. 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 per- 
sists after the climacteric eczema has begun, menstrua- 
tion 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. Cli- 
macteric 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 fore- 
arms or the backs of the feet; it never appears on the 
trunk. With regard to the types of eczema occurring 
in connection with the menopause, we see almost ex- 
clusively the squamous and the weeping forms of the 

In general, at the climacteric period, the skin is ex- 


tremely sensitive, and devoid of powers of resistance 
to outward noxious influences. Alternations of damp- 
ness and dryness or of heat and cold readily give rise 
to redness, infrltration, and the formation of scales and 
fissures of the skin; sometimes this occurs merely after 
cold ablutions. These acute stages of swelling, red- 
ness, 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 seborrhoeic mani- 
festations. 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 in- 
flammation 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 ap- 
pearance 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-colored 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 in- 
terior of the vagina; also it may pass backward 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 re- 
lieved 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 vio- 
lent 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 

The frequent recurrence of pruritus vulvae leads 
ultimately to the formation of nodules and papular 

Many authors state that they have observed the fre- 
quent occurrence of erysipelas during the climacteric 
period; others assert that furunculosis, prurigo, urti- 
caria, and herpes zoster, are seen with especial fre- 
quency at this period of life. 

Tilt, in his 500 cases of women at the climacteric 
age, made the following observations: 

201, or 40.2 per cent, suffered from heats and ten- 
dency to perspiration. 

2, or 0.4 per cent, suffered from monthly recurrence 
of periods of perspiration. 

84, or 16.8 per cent, suffered from profuse perspira- 


13, or 2.6 per cent., suffered from cold sweats. 

14, or 2.8 per cent., sufifered from dry heats (dry 
flushes) . 

186, or 37.2 per cent, remained free from such at- 
tacks of heat or perspiration. 

Krieger gives as an example of the "occurrence of 
new troubles" at the change of life, f urunculosis ; so 
also does Boerner. "The discoloration of the face, 
occurring usually in connection 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." Wil- 
son regarded prurigo and eczema as the commonest 
skin diseases of the climacteric period; whilst Boerner 
draws attention to a connection 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 univer- 
salis), 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 to 50 years, is the one especially favorable in wom- 
en to the extensive deposit of fat in the tissues. 

In 200 cases of great obesity (lipomatosis univer- 
salis) in women, in which I instituted inquiries re- 
garding the age at which an excessive deposit of fat 
in the tissues had first been noticed, I obtained the fol- 
lowing results: 


In early childhood in l9 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 " cases 

We learn from these figures that it is between the 
ages of 40 and 50 years that there is the greatest ten- 
dency 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 connection 
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 thickening 
of the subcutaneous tissues and of the great peritoneal 
folds — especially of the great omentum — a marked pro- 
trusion occurs, whilst the umbilicus becomes more 
deeply hollowed, and ultimately funnel-shaped. In 
some instances, the deposit of fat around the navel 
favors the occurrence of umbilical hernia. After an 
artificial menopause, induced by oophorectomy, it has 
also been noticed in from 42 to 52 per cent, 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 myo- 


cardium, 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 favors the occur- 
rence of menorrhagia. 

On examining 282 women, 5 years after the com- 
plete 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 

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 associa- 
tion 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 dis- 
posed 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 corre- 
sponding age. 

It is in obese women, with a soft, white, and lax 
integument, with a pallid, somewhat bloated counte- 
nance, a poorly developed muscular system, extensive 
varicosities of the veins of the legs, marked dyspeptic 
troubles, and habitual constipation, that during the pre- 
climacteric 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 com- 
pared with four men of corresponding age. Tilt pub- 
lishes the following figures showing the mortality of 
women from gout in England: 

At ages irom 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 

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 compara- 
tively 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 integu- 
ment. The commonest and the most distressing form 
of this disorder during the menopause is pruritus 

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 objec- 
tively by the rapid appearance and no less rapid sub- 
sidence of a red coloration 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 rota- 
tory 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 as- 
sociated 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 dura- 
tion, varying from one to fifteen minutes. It is especi- 
ally 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-Nar- 
cotism" of climacteric women, characterized by a sense 
of swimming movements, uncertainty in the gait, va- 
cancy 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 consider- 
able effort. The women thus affected state that they 
feel as if they had had too much to drink, as if some- 
thing 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 frrom 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 exer- 
tion, and their memory and all other intellectual powers 
are impaired. 

Boerner maintains that the attacks of vertigo so fre- 
quently occurring at the menopause are in a minority 
of cases only dependent upon hyperaemic states (aris- 
ing 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 anaemia. In his opinion, vertiginous attacks 
dependent upon cerebral anaemia are very common in- 
deed during the climacteric period, and even for a 
long time afterward ; 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 daytime feel compafatively 
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 rest- 
lessly 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 superfi- 
cial neuralgias, hemicrania and intercostal neuralgia 
are those which occur most often during the climacteric 

During the change of life, hemicrania most com- 
monly occurs in typical association with menstruation ; 
or, if the flow has already ceased, the attacks of hemi- 
crania recur at what should be the menstrual periods. 
This affection is characterized by the paroxysmal oc- 
currence of a severe boring pain in the side of the 
head, more often the left side than the right, affect- 
ing the temporal, the parietal, or the occipital region, 
ot the entire side of the calvaria at once, usually accom- 


panied 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 feelingof general malaise. 

Of the intercostal neuralgias, one form deserves 
especial mention in this connection: I refer to masto- 
dynia, which is both physically and mentally one of the 
most distressing affefctions to which women are sub- 
ject 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 founda- 
tion. In this manner, partly in consequence of the 
directly depressing effect of the pains, which are com- 
monly intensely severe, and partly owing to the dis- 
turbance 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 pain- 
ful sensations of the climacteric period, pains in the 
lower extremities are of somewhat frequent occurrence. 
Day after day the patient suffers from distressing tear- 
ing 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 ex- 
tremities, the back, the spinal column, and more par- 
ticularly 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 medi- 
cal advice. The sacrache is equally severe when the 
patient is standing, sitting, or recumbent; it often radi- 
ates into the lower extremities. Boerner draws atten- 
tion to the fact that in many cases the pains in the 
sacrum or higher up in the back may be due to exces- 
sive tension of the abdominal parietes in consequence 
of the great accumulation of fat. Among motor mani- 
festations, Windscheid draws especial attention to a cer- 
tain 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 dis- 
orders 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 com- 
plaints 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 con- 
centrated 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 haemor- 
rhoidal nerves. 

The opinion expressed by several authorities, that 
the menopause favors the occurrence of cerebral apo- 
plexy, 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 haemor- 
rhage is due. It appears, however, to be a fact that 
the menopause favors the onset of progressive paralysis. 
[A-Ccording to Jung, 60 per cent., and according to von 
Krafft-Ebing, 27 per cent, of women affected with par- 
alysis were first affected in this way during the cli- 
macteric period. Von Krafft-Ebing explains this oc- 
currence 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 cli- 
macteric period we must reckon the at times excessive 
increase of the sexual impulse. We have already in- 
sisted 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 de- 
sire 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 en- 
hanced 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 vagina. 

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 suc- 
cession 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 feel- 
ing, 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 de- 
sire becomes greatly diminished in intensity, or even 
entirely disappears; more often, however, the desire 
persists throughout this epoch; finally, in many in- 
stances, 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, harmonizing as it does with the general extinc- 
tion 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 in- 
crease of libido sexualis at the climacteric epoch, 
Boerner found that there existed anatomical abnor- 
malities 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 alto- 
gether excessive, may be regarded as one manifesta- 
tion 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 in- 
stances the trouble begins at the very first appearance 
of the menstrual irregularities which foreshadow the 

Windscheid draws attention to the fact that occa- 
sionally 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 ap- 
proach of the menopause. "When the menstrual 
anomalies begin," continues Windscheid, "that is to 
say, at the commencement of the climacteric, the ner- 
vous troubles may have already attained their maxi- 
mum 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 dis- 
turbances 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 out- 
set 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 cli- 
macteric neurosis occur, as Windscheid rightly insists, 
most frequently in the sphere of the psyche. "We ob- 
serve a change in the disposition, which usually be- 
comes more excitable. A woman previously calm and 


composed becomes irritable, inclined to emotional dis- 
turbance 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 odors. Frequently, also, 
in such cases, we see great intolerance to alcohol, quite 
small doses giving rise to extremely disagreeable sensa- 
tions in the head." 

Climacteric Psychoses 

The powerful influence which the changes occurring 
at the climacteric period has in the origination of psy- 
choses, has long been recognized, the menopause, in 
fact, being a favorable 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 pre- 
sent 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 efifect 
upon the psyche, and that disturbances of menstrual 
activity are competent to exercise a pathogenic influ- 
ence 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 equilib- 


rium 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 menstrua- 
tion, 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 sufifering from mental disorder, 
the menopause will be likely to bring about an aggrava- 
tion 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 
a 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 catas- 
trophic 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 cli- 
macteric period, but nevertheless the psychoses occur- 
ring at this time of life do exhibit certain striking and 
characteristic features, more especially in this respect, 
that states of mental depression with melancholia pre- 
doniinate, 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 de- 
pression, states of anxiety, limitation of the powers of 
conception and judgment, indecisiveness, low-spirited- 
ness, 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 de- 
veloped mania. 

As with regard to the other disorders attending the 
climacteric, so also in respect of the climacteric psy- 
choses, 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 favorably situated, are far more immune, than 
women whose sexual circumstances have been the op- 
posite 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 pre- 
ventive measures, or have remained sexually unsatis- 
fied, 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 unfavorable 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, melan- 
cholic 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, psy- 
chical disturbances are by no means rare, and are some- 
times very severe. Such disturbance of the mental bal- 
ance is seen after oophorectomy, 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 en- 
sue. 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 rec- 
ognition 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 dis- 


turbances is as follows: soon after the commence- 
ment 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, be- 
comes mistrustful, suspicious, full of complaints, im- 
agines that the most insignificant annoyances are due 
to intentional slights ; at the same time she complains 
of continued sleeplessness, palpitation, various inde- 
scribable sensations, and of headache. Occasionally, 
congestions of the head occur, with alarming dreams, 
and the moodiness may increase greatly; in this condi- 
tion 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 cli- 
macteric 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; exception- 
ally, 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 insuncts. The same author publishes the follow- 
ing 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 ob- 
tained 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 com- 
mitted 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 suffer- 
ing from dementia, a moiety had first come under treat- 
ment during the climacteric age. The same author 
published the following data regarding the age-inci- 
dence 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 sufifering 
from mental disorder, there were: 

At ages to 10 years 9 cases 

At ages 10 to 20 years ".*."' 73 years 

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 psy- 
choses 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 
labors 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 work- 
ing 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 chil- 
dren, her labors 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-for-nothing, and a burden. The family life 
is dominated by quarrelsomeness, disorder, and insuffi- 
ciency 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 develop- 
ment 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, how- 


ever, the case is complicated by hereditary predisposi- 
tion to insanity, and by the occurrence of actual degen- 
erative charrges in the central nervous system, instead 
of the passive depression of melancholia, we shall 
rather see the ideas of persecution of the paranoiac. 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 cli- 
macteric 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 con- 
ditions 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 eflfect, that these memories alone constitute 
the casual 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 toward their environment, of quarrelsome- 
ness, scandalmongering, 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, in- 
valuable 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 phy- 
sically. 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 under- 
gone complete atrophy. They suffer from simple mel- 
ancholia 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, quarrel- 
some, 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 imagina- 
tion. Under the influence of such abnormal conditions 
of life, these women frequently become affected by 
nervous disorders; migraine, neuralgia, cephalalgia, 
nervous depression, rachialgia, debility, anaemia, dis- 
eases 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 audi- 
tory hallucinations, delusions of similar character,, in- 
creased 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 climac- 
teric period, that the term 'climacteric insanity' has 
now become established in the literature of mental 
alienation. In almost all the text-books 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 with- 
out influence upon the manifestation of the disease — 
its stamp is imprinted upon the clinical picture, it en- 
dues 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 men- 
strual 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 connection 
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 pseudo-men- 
strual insanity." 

The psychoses dependent upon the climacteric influ- 
ences 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 ab- 
solutely 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 perio- 
dicity, corresponding with that of the expected men- 
struation. The same feature is observable in the perio- 
dic 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 

Mania is comparatively rare at the climacteric 


period; when it does occur, it commonly assumes a 
sexual form — sexual impulses, hallucinations, and de- 
lusions, 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 eroti- 

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 per- 
secuting them. Often this morbid mental state is as- 
sociated with sexual malpractices, masturbation, etc. 

Not rarely, such degenerates are affected with las,- 
civious 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 inter- 
course with them. These relations are supposed to be 
effected in most cases by means of spiritualism, hyp- 
notism, 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 provid- 
ing 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 some- 
times giving rise to serious scandal. With such a men- 
tal state we often see associated sexual hallucinations 
and delusions; the patient believes herself to be preg- 
nant, imagines herself to have been violated, or to be 
living in carnal intercourse with a man — someone, it 
may be, with whom she is not even acquainted. Medi- 
cal men are especially apt to suffer from the accusa- 
tions of such women, whom they may have examined 
in private in entire ignorance of the patient's mental 
condition. Frequently, such ideas of sexual persecu- 
tion are associated with paroxysms of violent nympho- 
mania, and in this way also the unwary physician may 
find himself placed in an extremely unpleasant posi- 
tion. It occasionally happens in such patients that 
abnormalities of the sexual instinct arise, and they 


begin to feel desire toward individuals of their own 

Such delusions of persecution by means of hypno- 
tism, spiritualism, the telephone, etc., in association with 
sexual delusions and nymphomania, are so frequent 
during the climacteric period, that they may be re- 
garded as preeminently constituting climacteric in- 
sanity. 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 cli- 
macteric insanity and more particularly of climacteric 
paranoia. A second characteristic of climacteric in- 
sanity 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, klep- 
tomania, pyromania; exhibitionism; irresistible im- 
pulse to suicide, homicide, infanticide, etc. Such par- 
oxysmal impulsive manifestations are, according to 
Kowalewski, commonly associated with menstrual dis- 
turbances ; 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 unfavorable; unfavorable 
vital conditions are associated with retrogressive meta- 
morphosis 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, ac- 
cording to Schiller, there is during the climacteric 
period an especial dangei: of the development of atro- 
phic cerebral processes (Encephalitis atheromatosa) 
with apoplectic and epileptic seizures. Schlager also 
regards the prognosis of climacteric insanity as un- 
favorable; but Merson, on the other hand, observed 
among women suffering from climacteric psychoses a 
recovery rate of over 50 per cent. On previously exist- 
ent psychoses in women, the onset of the climacteric 
exercises in most cases an unfavorable 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 some- 
what excessive excitability and inclination to violence 
remained, however, as vestiges of the former insanity. 
Matusch, keeping under observatidh 60 women af- 
fected 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 under- 


went 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 unfavorable one, a hitherto changeable and irrita- 
tive form of mental disease becoming transformed into 
chronic insanity with inalterable delusions, or into de- 
mentia. The course of mental disorder, such as melan- 
cholia, first making its appearance at the climacteric 
epoch, was also regarded by Griesinger as likely to be 

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 repro- 
ductive organs during the climacteric period; its en- 
deavor 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, when- 
ever such measures are called for by the manifold in- 
dications of increased irritability; further, by the use 
of baths we can influence thei circulation of the blood, 
we can increase the sudatory activity of the skin, and 
in various additional ways we can afifect heat produc- 
tion and metabolism, thus modifying the processes oc- 
curring in the' reproductive, organs, making the condi- 
tions favorable for the absorption of exudations, and 
promoting a healthy tissue-change in the mucous mem- 
brane 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° R), of moderate 
duration, 15 to 20 minutes, the bath being one of simple 
immersion, not of douche or affusion, and the tempera- 
ture 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 cli- 
macteric epoch; and they lessen |he almost constant 
tendency to perspirations and to the development of 
diseases of the skin (the commonest of which is cli- 
macteric 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 de- 
pendent upon an influence exerted through the inter- 
mediation 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 cli- 
macteric 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 in- 


fluence also upon the visceral neuralgias and psychical 

In climacteric women suffering from abnormal sensi- 
tiveness 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 oesophagus, the 
stomach, and the intestinal tract; in women with dis- 
tressing sensations of itching and burning in the re- 
productive 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 indif- 
ferent temperature, best taken immediately before re- 
tiring to rest, we shall often succeed in inducing both 
local and general repose, in diminishing the spontane- 
ous 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 de- 
rived from hot immersion baths, taken at a temperature 
well above blood heat (37° €.—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 gen- 
eral processes of tissue-change. This method of treat- 
ment is suitable for cases in which at the commencement 
of the menopause there are already pathological condi- 
tions 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 intra-pelvic connective tissue and 
of the pelvic peritoneum; and one of the first aims of 
treatment must be to promote the softening and subse- 
quent absorption of these inflammatory products. 

In cases in which the climacteric troubles, dependent 
in part on increased general arterial blood-pressure, 
manifest themselves chiefly in the form of active con- 
gestions, 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 blood- 
vessels and consequent lovi^ering of arterial blood-pres- 
sure. Further, in cases of compensatory fluxes, periodic 
diarrhoeas, periodic leucorrhcea, following the suppres- 
sion of the menstrual flow, in cases of vicarious haemor- 
rhage (especially periodic epistaxis and periodical 
haemorrhoidal bleedings) , the use of hot baths is often 
competent to restore the functional activity of the ova- 
ries when this has undergone premature cessation. In 
addition, their use assists us in our endeavors to coun- 
teract 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 cu- 
taneous 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 ow- 
ing 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 cli- 
macteric period, for baths at a temperature consider- 
ably below the indifferent point, and other hydrothera- 
peutic procedures in which cold water is used, stimu- 
late the nervous jystem 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 1 8° C. (64° F.) or less, are contraindicated, 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 last- 
ing 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 tempera- 
ture is permissible, 20° to 25° C. (68° to ']']° F.) ; but 
the duration should not exceed five minutes, moderate 
mechanical manipulations being carried out mean- 
while ; 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 r6° 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. Rave 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 air 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, a 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. -.i 

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 exer- 
cise 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 
aill with a blanket. When the skin chaps readily, in- 
unction 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 
defecation, but after each act of urination as well, the 
external genital organs and the anus should be care- 
fully washed over with a pad of clean absorbent wool 
moistened with lukewarm water. After the washing, 
either powder or ointment should be applied, the for- 
mer 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 nutri- 


tive 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 symp- 
toms 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 fav- 
orable influence also upon the nervous system, the func- 
tional 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 ap- 
propriate active exercise, regular daily walks, which 
should include walking up a moderate incline. As a 
preparation for such exercise (in persons hitherto un- 
accustomed 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 
favorable 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 mjjs- 
cular movements are effected against a resistance. 6ut 
in all cases extreme care must be taken to avoid over- 
fatigue and overexertion. A graduated form of bodily 
exercise combined with passive gymnastics, suitable for 
climacteric women, is massage, in which by mechani- 
cal stimulation, by pressure and friction of the whole 
body or of certain parts, the nutrition of the muscles is 
favorably 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 stretch- 
ing and rubbing of the skin of the lower extremities, 
the back, and the abdomen, followed by gentle knead- 
ing of the muscles. Massage of the internal reproduc- 
tive organ (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 bf the fre- 
quency 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 exer- 
cise 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 cup- 
ping, namely, to overcome the abnormality in the con- 
stitution 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 con- 
gestions; and in addition to subdue the great general 
nervous irritability, the sensibility to external stimuli, 


the inclination to excessive reflex manifestations, char- 
acteristic 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 

'As regards quantity, the main general principle of 
dietetics for climacteric women is that overnutrition 
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 ad- 
vanced period of life, whose physical labors 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 at the climac- 
teric age is 60 kilograms, the heat-equivalent of the 
food required daily by such a woman may be esti- 
mated at 2,100 to 2,400 calories. This will be approxi- 
mately supplied by a diet consisting of 100 grams 
albumin, 60 grams fat, and 350 grams carbohydrate. 
The customary preference for a large amount of ni- 
trogenous food is, however, not dependent upon physio- 
logical requirements, and provided that the needful 
minimum of albumin is supplied (about 1.5 grams per 
body-kilogram per diem) , the requisite number of cal- 
ories 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 albumin 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 in- 


dividual, 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 pos- 
sible, 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 albumins), the cli- 
macteric woman should avoid those containing con- 
siderable quantities of nucleo-albumin or of deleterious 
products of tissue-change; in the case of the latter 
(vegetable albumins), 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 sub- 
stances 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 flavors 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 connection between the 
ingestion of nuclein and the formation of uric acid, 
albumins rich in nuclein are to be forbidden; such are 
the various foods consisting chiefly of gland-cells — 
«weatbread, liver, brain, kidneys, etc. As well as from 
the appropriate flesh-foods, the requisite albumin may 
most suitably be obtained from eggs and milk (includ- 
ing buttermilk) ; on the other hand, caviare is unsuit- 
able 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 un- 
suitable. Suitable vegetable foods for the supply of 
albumin (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 recom- 
mend 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 secre- 
tion. 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 liquors 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 pos- 
sible; 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 ex- 
cessively hot or extremely cold. 

The individual meals are preferably small ones and 
they must therefore be taken at comparatively short in- 


tervals, 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.^ 

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 nu- 
trose, but with the 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, had- 
dock, 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 Savories: Green peas, spin- 
ach, cauliflower, carrots, turnips, buttered eggs, ome- 
lette, 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 acidu- 
lated with various fruit-juices and essences (as lemon- 

1 In his discussion of the details of diet for women during the 
climacteric period, hours of meals, actual dishes, etc., the author refers ex- 
clusively to Austrian and German customs in these matters. The trans- 
lator 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. 


ade, etc.), weak tea with plenty of milk, cocoa, choco- 
late. To be forbidden are: beer, strong and sweet 
wines, distilled spirits. 

An example is subjoined of a simple diet-table com- 
piled on the above principles: 

Quantity Carba- 
rn grains. Albumin. Fat, hydrate. 
Afternoon : 

A cup of mUk ISO 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 


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, three 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 

Changes in the above diet-table could very readily 
be effected, whereby the quantity of carbohydrate could 
be increased and the quantity of albumin 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 foUowing: Avoidance of all overfeeding, re- 
duction of the quantity of food taken below the former 
average amount, with retention, however, of a suffi- 
ciency 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 re- 
duced 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 suit- 
able average diet would contain 160 grams albumin, 
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 Carbo- 

Breakfast: '" ^'■''""- ^'^'""*"- ^'"- *^''''''"- 

A cup of weak tea. . . ; 150 0.45 ^ 

with milk, but no 

„ sugar 30 1.29 0.9 1.2 

White bread 50 4.8 0.4 30.0 

Lean cold meat SO 19.1 0.9 

Dinner (Mid-Day) : 

Sniall cup of clear soup lOO 1.1 1.5 57 

Lean beef 200 76.4 3.4 

Green vegetables, salad, 

etc 100 1.6 0.4 8.4 

Fruit 100 3.0 .... 15.0 

Roll 35 2.4 0.2 19.6 


Afternoon : 

A cup of weak tea 150 0.45 .... 0.9 

with milk, but no 
sugar 30 1.29 0.9 1.2 


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 cli- 
macteric women it must be our aim to stimulate in- 
testinal 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 

Most suitable are those articles of diet which con- 
tain 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 consti- 
pating) , 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 un- 
cooked 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 methodi- 
cal milk-cure carried on for several weeks most bene- 
ficial. 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 defi- 
nite 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 midday dinner, consisting 
of soup, roasted white meat, young green vegetables, 
and a little fruit. In some instances, to prevent con- 
stipation, 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 main- 
tain 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 prac- 
tice of coitus, inasmuch as at this time of life there 
already exists a strong tendency toward occurrence 
of hyperaemia of the reproductive organs; and sexual 
intercourse, increasing as it inevitably must this ten- 
dency to hyperaemia, should be indulged in as little 
as possible. And yet precisely in women of the cli- 
macteric 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 — pro- 
vided that both have attained a like stage of sexual 
decline. "But," writes Tilt, "a union between frosty 
January and bloomiag May is likely to be as danger- 
bus 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 occu- 
pation, are thus of great advantage to climacteric 
women. Plato, indeed, pointed out that women at this 
time of their lives should occupy themselves with liter- 
ature and intellectual culture. 

Just as it is the duty of the physician, more especi- 
ally 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 deca- 
dence. 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 

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 inquiries re- 
garding certain symptoms, will be enabled to gain early 
information about the occurrence of abnormal pro- 
cesses at this period of life, and will in this way detect 
the first beginnings of many diseases which are amena- 
ble to treatment only at the very outset of their course. 
For example, Brierre de Boismont, an early and ac- 
curate 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 in- 
clination for sexual intercourse, nineteen times out of 
twenty a local examination will disclose the existence 
of some disease of the reproductive apparatus. Simi- 
larly, 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. 


Abdominal plethora, 143 
Abortifacients, 177 
Abortion, 288 

artificial, 254 

induction of, 258 
Abuse of alcohol, 240 
Accumulation of fatty tissue, 342 
Acne, 104 

nodules, 159 
Acromegaly, 82 
Active congestion, 442 
Acute delirium, 438 
Adenomata, 299 
Aerated waters, 451 
Esthetic feelings, 55 
Africa, 41 
Age of parents influences vitality of 

children, 235 
Agricultural chemistry, 260 

labor, 245 
Albumin, animal, 450 

in the urine, 394 
Albuminuria, 69, 371 
Alcohol, 95, 109, 190, 238, 298, 302, 

423, 451 
Alcoholism, 294 
Alkaloidal drinks, 451 
Alternating insanity, 437 
Amenorrhoea, 275, 297, 299, 386 

functional, 60 
Amentia, 434, 435 
America, 41 
Amor lesbicus, 223 
Anaemia, 294, 302, 395, 433 
Anaemic women, 378 
Anaphrodisia, 207 
Anaphrodisiacs, 174 
Anatomico-physiological changes, 54 
Angina pectoris, 395 
Angst, 388 
Animal soups, 450 
Antipathy to husband, 212 
Anthropoid apes, 146 
Anus, fissure of, 317 

fistula of, 317 

prolapse of, 317 
Anxiety, 388 

neurosis, 278 
Apathy of the sexual sense, 59 
Apoplexia uteri, 364 
Apoplexy, 437 

Apples, 452 

Archangel, 103 

Ardor fugax, 391, 399, 407 

Arrhythmia cordis, 404 

Arteriosclerosis, 396 

senile, 383 
Arthritis, acute gouty, 414 

urica, 411, 413 
Artificial feeding of infants, 195 

menopause, 346 
Ascarides, 317 
Asia, 40 
Asparagus, 96 
Atresia, 322, 363 
Atrophic changes, 340 

conditions, 354 
Atrophy of ovaries, 298 

uterus, 279 
Ausfallserscheinungen, 362 
Auto-onanist, 113 
Azoospermia, 293, 330 

Balls, 108 
Barley, 452 
Barrenness, 283 
Baths, 100, 439 
Bavarian beer, 96 
Beans, 95, 452 
Bearing-down in pelvis, 212 
Beaute du diable, 19 
Beauty, 17 

of the devil, 19 
Bedding, soft, 190 

warm, 190 
Bedroom, 187 
Beef, lean, 452 
Beefsteak, 96 
Beer, 95, 451, 453 

Beneficial influence of marriage, 139 
Bicycling, 99, 109, 448 
Biliary secretion, 405 
Birds, 450 
Biscuits, 452 
Bleeding piles, 317 
Blennorrhoea, 329 
Blindness, 251 
Blondes, 44, 375 
Boer women, 237 
Books, 108 
Bowels, 109 




Brain, 450 

diseases of, 218 
Bread, 451 

Breast of chicken, 456 
Breeding in-and-in, 242 
Bridal night, 179 
Brides, age of, 147 
Broths, 452 
Brunettes, 44, 375 
Bubonic plague, 8 
Bulbocavernosus muscle, 209 
Butter, 96, 456 
Buttered eggs, 452 
Buttermilk, 450 

Cachexia, malarial, 298 
Caged birds, 304 
Cannibalism, 257 
Cantharides, 144, 173 
Capet dynasty, 243 
Carcinoma, 299, 354 

uterine, 192, 280 
Carcinomatous diseases of matnmse, 

ovaries, 351 

uterus, 35t 
Cardiac disorders, 70, 75, 397 

hypertrophy, 75 

asthma, 393, 395 

insufficiency, 393, 395 

failure, 397 

troubles, 371 

troubles due to sexual intercourse, 
Cardialgias, 279, 417, 419 
Cardiopathie de la Menopause, 401 
Carrots, 452, 456 
Caseous diseases, 299 
Castration, 257 
Catalepsy, 427 
Cauliflower, 96, 452, 456 
Caviare, 450 

Celibate, religious orders, 138 
Central perceptions, 142 
Centripetal impulses, 143 
Cephalalgias, 279, 433 
Cereals, 451 
Cerebral anxmia, 417 

apoplexy, 420 

excitement, 142 
Cervical lacerations, 335 
Cessatio praecox, 379 
Chaliza, 249 

Chalybeate peat baths, 102 
Chamomile, 103 
Champagne, 173, 451 
Change of life, 340 
Changes in refraction, 127 
Chastity, 6, 112, 273 
Cheese, 451 

Chemical processes, 50 

Cherries, 456 

Chicken, 96, 452 

Childless wife, 344 

Chloasma uterinum, 411 

Chlorosis, 65, 68, 103, 140, 192, 294, 

302, 395, 400 
Chocolate, 96, 453 
Cholera, 381, 386 
Chorea, 78, 427 
Clap-threads, 186 
Cleanliness, 116, 187 
Climacteric age, 341 

insanity, 423 

insanity pseudo menstrual, 434 

manifestations, duration of, 376 

neurosis, 398 

period, 340 

psychoses, 423 

vertigo, 398 
Climate, 34 

Climatic conditions, 103, 240 
Climax, 340 
Clitoris, 208 

crises, 213 

hypertrophy of, 316 
Clothing, 99, 109 
Coccus, 365 
Cocoa, 96, 453 
Coffee, 96, 109, 451 
Coitus, awkward performance of, 216 

condomatus, 212 

incomplete performance of, 216 

interruptus, 203, 212, 265 

prohibitive, 352 

reservatus, 204, 212 

too frequent, 335 

ungratifying, 212 

unsympathetic, 212 
Cold bathing in rivers, 100 

full baths, 190 
Combination undergarment. 111 
Comedones, 93, 104 
Complete frigidity, 138 
Concentric atrophy, 363 
Conception, 195, 196 

curve, 201 

time of, 227 
Concubines, 175 
Conditions of life, 34 
Condoms, 277 
Congenital atrophy, 296 
Congestions, 371 

of the head, 349 

of the lungs, 394 
Congfu, 314 

Congressus interruptus, 275 
Constancy, 181 
Constipation, 109, 349 
Constitution, 34 
Constricted liver, 110 



Constrictor cunni, 204, 209 

muscle, 209 
Continence, 270 

Continuous nocturnal proximity, 176 
Contrectation-impulse, 140 
Convulsive seizures, 128 
Convulsions, 279 
Copulation, 195 
Corpora albicantia, 365 

fibrosa, 365 

lutea, 384 
Corset, 110 
Counterfeit of voluptuous enjoyment, 

Country-folk, 52 
Crabs, 452 

Cramps of the heart, 76 
Cream, 452 

Criminality in the married, 140 
Critical age, 340, 458 

period, 341 
Croquet, 99 
Crossing of races, 172 
Cry of the su£Eering organ, 22 
Curettage, 3^ 
Currant cakes, 452 
Curve of beauty of woman, 20 
Curve of the sexual life of woman, 5 
Cystoma, 299 

ovarian, 300, 301 
Cysts, 363 

dermoid, 299 

follicular, 299 

Dangers of the sexual life of woman, 

Deafmutism, 251 
Debility, 433 

Deficient reproductive energy, 292 
Delirium, 425, 427 
Delusions, 432 
Dementia, 79 
Demi-Vieilks, 347 

-vierge, 9, 52 
Desire for children, 132 

of carnal union, 132 
Dermatitis, 409 
Desque's diet-table, 118 
Detumeszenztrieb, 140 
Detumescence-impulse, 140 
Developmental disturbances, 66 
Diabetes, 250, 298 

climacteric, 414 

mellitus, 414 
Diarrhoea, 371, 404, 442 
Dicrotic elevation, 389 
Diet, 190 

tables, 117, 118, 119, 453, 455 
Dietetics of parturition, 195 

pregnancy, 195 

Difference between ages of husband 

and wife, 233 
Differences in temperature during the 

menstrual cycle, 13 

Digestion, disorders of, 88 

Digestive disturbances, 349 

organs, diseases of, 404 

Dilatation of the heart, 403 

small cutaneous vessels, 159 
Diplococcus, 365 
Dipsomania, 437 
Discus proligerus, 306 
Disorders of the climacteric, 362 
Disparity in ageSj 165 
Dissimilarity in physical constitution, 

Distilled spirits, 453 
Domestic recreations, 108 

upbringing, 107 
Domesticated breeds of animals, 236 
Double chin, 342 
Douches, 100 
Down quilts, 190 
Dropsy, 354 
Dwellings, 187 
Dysentery, chronic, 299 
Dysmenorrhoea, 63, 125 
Dyspareunia, 206, 216, 309, 346 
Dyspepsia, 128, 371 
uterine, 391 

Early love, 286 

senescence, 380 
Ecchymoses, 92 
Eczema, 94, 144, 159, 371, 408, 411, 

Educational views of the present, 107 
Eels, 452 
Eggs, 95, 450 
Ejaculation, 209, 213 

prsecox, 212 
Electric light baths, 443 
Electricity, 436 

Elongation of the cervix uteri, 279 
Emancipated woman, 184 
Embonpoint, 413 
Embrace, 196 
Embryo, 282 
Emigration, 265 
Encephalitis atheromatosa, 438 
Endocervicitis, 375 
Endogamy, 250 
Endometritis, 212, 3^,375 
Enduring sexual activity, 382 
Enervating mode of life, 240 
Enforced abstinence, 214 
Enlargements, 354 
Enlightening the daughter, 114 
Entertainments, 108 
Environment, 51 
Epididymitis, 186 



Epilepsy, 251, 371, 437 
Epistaxis, 349, 35S, 371, 442 
Equivocal literature, 190 
Erethismus genitalis, 143 
Erethistic temperament, 400 
Erotic excitement, 456 

feeling, 151 

harmony, 151 

problem, 164 

stimulus, 342 
Eroticism, 435, 437 
Eructation, 405 
Erysipelas, 410 
Erythema, 159, 407 
Ethnography, 250 
Eunuchs, 177 
Europe, 38 
Evening parties, 108 
Evolution, 281 

Exhausting occupations diminish fer- 
tility, 237 
Excentric atrophy, 364 
Excito-motor fibres, 391 
Exhibitionism, 437 
Exogamy, 250 

Experimental cohabitation, 311 
Extractives, 450 
Eye, affections of, 90 

Figs, 454 ■ 

Figure, woman's, 110 
First cousins, 169 
.: marriage, 243 
Fish, 96, 450 

diet, 239 
Fistulae, recto-vaginal, 217 

vesico-vaginal, 217 
Fixed ideas, 79 
Flesh foods, 450, 452 
Flexions, 421 
Fliegende Hitze, 349, 355 
Fluor albus, 212. 223 
Fluxes, haemorrnagic, 354 

mucous, 354 
Free love, 160 

marriage, 155 
Freedom for love, 154 

in love, 154 
French rolls, 452 

Frequency of sexual intercourse, 181 
Fruits, 95, 451 
Fruit cakes, 452 
Fruit-ices, 452 
Fugitive heat, 349, 355, 388, 399, 407, 

Furuncles, 371 
Furunculosis, 410 

Fainting fit, 81 
Famine, 265 

restrains progeny, 237 
Farinaceous foods, 96 
Fat-coMtainin|r foods, 96 
Fat, increase in, 68 

reducing diet, 454 

rump, 343 
Feather beds, 99, 190 
Female reproductive organs, changes 

in, 358 
Feminine sense of delicacy, 259 
fertility, conjugal, 245 

extraconjugal, 245 

ideal, 226 

in woman, 224 

of married women, 229 

premature, 225 

restriction of, 253 
Fertility of women, biogenous, 232 

influence of climate, 240 

influence of constitution, 244 

Influence of season, 240 

influence of temperament, 244 

maximum, 231 

monogenous, 232 

physiological, 230 
Fertilization, 197, 291, 307 
Fertilized ovum, 252 
Fibromata, 299, 421 
Field fare, 96 

Galactorrhcea, 3S1 
Game, 450 

Gastric innervation, 407 
General mode of life, 240 

hygiene during acme of sexual ac- 
tivity, 187 

constitutional conditions, 374 

pathological conditions, 374 
Genital corpuscles, 208 
Genitals, diseases of, 377 

pruritus, 446 

trauma of, 379 
Germans, 7 

Germinal rudiments, 251 
Glottis, spasm of, 129 
Goitre, 89 

Gonocoecus, 186, 325 
Gonorrhoea, 186 
Gonorrhoeal infection, 149, 160 
Good harvests increase childbirth, 237 
Goose, 452 
Gout, 411 
Grapes, 454 

Gratification, sexual, 219 
Greeks, 7 
Green peas, 456 
Green vegetaMes, 451 
Grief, 218 
Grouse, 96 ' 
Gymnastics, 109, 447 
Gynecological examination, 106 



Habitual excess, 278 
Haddock, 452 
Hamatemesis, 130, 405 
Haematometra, 322 
Hxtnatopoiesis, disorders of, 65 
Haemoptysis, 130 
Haemorrhage, 129 

atypical uterine, 222 

into the skin, 92 
Haemorrhoidal bleeding, 386, 442 

flux, 349, 355 

hyperplasia, 410 
Haemorrhoids, 405 
Hair mattress, 99, 190 
Half-old, 347 

virgin, 9, S3 
Hallucinations, 425, 432 
Ham, 96 

Hapsburg-Lothringen djTiasty, 243 
Hardships diminish fertility, 237 
Hare, 96, 452 
Harmonic d'amour, 311 
Hazel-hen, 96 
Headache, 357 

Hearing, disturbances of, 91 
Heart-trouble, 456 
Hebephrenie, 79 
Hemicrania,127,-417 - 
Hereditary influences, 294 
Hermaphrodites, 177, 284 
Herpes progenitalis, 94 

zoster, 410 
Herring, 452 
Hetairai, 175 
Hiccough, 128 
High altitudes, 104 
Higher civilization, 261 
Homicide, 437 
Homosexual women, 316 
Honey, 456 
Honeymoon, 179 
Hot-air baths, 101 
Hottentot women, 238 
Housewife, 7 
Hyaline degeneration, 364 
Hydrometra, 322 
Hydrotherapeutics, 100, 439 
Hygiene during the menarche, 95 

of marriage, 166 
Hyperaemia, 125, 276, 355 

chronic, 279 
Hyperaesthesia, 391, 406, 414, 440 
Hyperhydrosis, 406 
Hyperkinesia, 391, 406, 414 
Hyperplasia, 299, 323 
Hypnotic state, 314 
Hypnotism, 436 
Hypochondriacal moods, 425 
Hypochondriasis, 427 
Hypogastric neuralgia, 417 
Hyssop, 103 

Hysteria, 80, 192 

pure, 213 
Hysterical attacks, 357 

paroxysms, 27,9 

troubles, 128 
Hystero-epileptic crisis, 81 

neurasthenic, 212 

Icterus, 405 

Idea of persecution, 431 

Ideal passion, 32 

Ideas of sexual persecution, 436 

Ideational influences, 424 

Idiocy, 251 

Idiopathic neurosis, 410 

Ill-nature, 345 . 

Impetigo herpetiformis, 159 

Impotence in husband, 283 

Impotentia concipiendi, 322 

generandi, 321 

gestandi, 320, 323 
Impulse to sexual satisfaction, 142 

toward copulation, 132 

toward intimate contact, 140 

toward motherhood, 131 

toward reproduction,- 132 
■ aiigratified .sexual; 191 : . .' 

Impulsive insanity, 427, 437 '' 
Inbreeding, 242 

Incapacity for jticubation ' of the 
ovum, 318 

ovulation, 305 
Incest, 243 

Incontinence during menstruation, 185 
Individual nutritive elements, 238 
Indurations, 354 
Infanticide, 167, 258, 437 
Infective fever, 338 

puerperal processes, 377 
Infibulation, 257 
Inflammatory processes, 63 
Influence of lactation, 228 
Inheritance, 35 
Inhibitory influence, 210 

perceptions, 210 

process, 210 
Innate sexual disharmony, 312 
Innuptae nuptae, 283 
Insanity, 251 

in unmarried women, 191 

in the male sex, 191 
Instinctive criminality, 251 
Intellectual culture, 458 

processes, S0_ 
Intercourse during lactation, 185 
Intermenstrual pain, 128 
Intrapelvic disorders, 295 
Intrigue, 345 
Introduction, 1 
Irish baths, 443 
Iron-beer, 96 



Irritable breast, 418 
Irritant phenomena, 340 
Ischiocavernosus muscle, 209 

Jealous delusions, 437 

emotions, 437 
Juicy fruits, 456 
June weddings, 241 

Kaffir women, 237 
Katatonia, 83 
Kefir, 451 
Kidneys, 450 
Kiss, 196 
Kleptomania, 437 
Kongfou, 275 
Kontrektationstrieb, 140 
Koumiss, 451 
Kreatin, 450 

Labium majus, 208 

minus, 208 
Lacerations of hymen, 178 
Lacing^ liver, 110 
Lactation atrophy, 378 
La femme demi-vieille, 457 
Lascivious dramatic representations, 

dreams, 435 
Lassitude, 277 
Lawn tennis, 99, 109 
Legumes, 451 
Lemonade, 452 
Lentils, 95, 452 
Leprosy, 8 
Lettuce, 456 

Leucorrhcea, 130, 316, 357, 385, 442 
Levisticum, 103 
Light baths, 101 
Limitation of the number of children, 

Lipomatosis, 68, 294 

universalis, 390, 411 
Liquid foods, 452 
Literary occupation, 458 
Literature, 458 
Liver, 450 
Lobster, 452 
Lqcaj baths, 188 

irritation of the sensory nerves, 
Loss of memory, 423 
Love, 195 

in women, 133 
Lumbo-abdominal neuralgia, 357 
Lupinar, 297 
Luxurious society life, 190, 240 

Macaroni, 452 
Magiietic state, 314 
Malaise, 418 

Malignant tumors, 351 

Malt, 103 

Malthusian doctrine, 259 

society, 260 

league, 260 
Malthusianism, 278 
Malthusians, 259 
Mammals, 450 
Mania, 79, 425, 427, 437 
Manifestations of decay, 340 
Marasmus, senile, 217 
Marjoram, 103 
Marriage, barren, 303 

consanguineous, 253 

contempt for, 257 

first cousins, 243 

fruitful, 289 

hated, 258 

late, 257 

near, 242 

of the poor, 254 

premature, 297 

sterile, 289 
Massage, 447 
Mastodynia, 418 

Masturbation, 64, 68, 85, 99, 216, 277, 
280, 316, 392, 435 

peripheral-mechanical, 87 
Maternal body, 252 

duty, 114 

organism, 252 
Maternity, 150 
Maximum family, 266 
May weddings, 241 
Means for prevention, 246 
Measures for prevention, 186, 247 
Meat, 95, 239 

extracts, 450 
Mechanical obstruction, 291 
Medical point of view, 254 
Melancholia, 79, 345, 418, 427, 437 
Melancholic mental disturbances, 426 
Menacme, 149 

hygiene during, 159 

physiology of, 150 

pathology of, 150 
Menarche, age at which it occurred, 

prscox, 56 

tardiva, 56 
Menopause, 340 

age at which it occurs, 366 

delayed, 376 

hygiene during, 439 

premature, 376 

sudden, 376 

race, 367 

time of, 366 
Menorrhagia, 124, 222, 316, 413, 445 
Menorrhagic chlorosis, 63 
Mensinga, 279 



Menstrual psychoses, 398 

wave, 117 
Menstruation, 120 

bloodless, 350 

first appearance of, 45 

sudden cessation of, 350 

vicarious, 129 
Mental aberration, 391 

shock, 386 

excitement, 456 
Mesometritis, 324 
Metabolism, disorders of, 376, 411 
Meteorism, 349, 406 
Metritis, 212 

chronic, 180, 221, 222, 279, 320 

vaginal, 65 
Middle Europe, 39 
Mid-winter, 241 
Migraine, 357, 433 
Milk, 95, 450 
Milk-cure, 456 
Mineral baths, 189 

waters, 102 
Miscarriage, 185 

Mitral valvular insuflSciency, 383 
Mittelschmerz, 128 
Moderation, 270 

enjoyment of physical love, 181 
Modern culture, 8 
Moral demand, 32 

insanity, 357 

virginity, 112 
Morphine, 298, 303 
Morphinism, 294 
Mortality, general increased, 265 

of childhood, 185 

of married men, 139 
Mother's joys, 153 

love, 153 
Movable kidney, 110 
Muscae volantes, 388, 398, 416 
Muscular exercise, 447 

spasm, 128 
Mutton, 452 
Mutual freedom, 32 
Myoma, 375 
Myopia, 250 

Nature frigidae, 135 
Natural instincts, 108 

method of feeding of infants, 195 
Near kin marriage, 242 
Neo-Malthusians, 264 
Neoplasmata, 354 
Nervous degeneration, 345 

depression, 433 

disturbances, 361 

end-organ, 208 

palpitation, 74 

system, diseases of, 77, 414 

Neuralgia, 127, 391, 433, 440 

intercostal, 4l7 

of the breasts, 357 

superficial, 417 
Neurasthenia sexualis, 144, 210. 211, 

212, 215, 277, 437 
Neuritis, 127 
Nitrogenous balance, 117 

equilibrium, 450 
Northern Europe, 38 
Nubility in girls, 168 
Nucleo-albumin, 450 

vegetable, 451 
Nuns, 138 
Nutriment affects number of births, 

Nuts, 451 
Nymphomania, 192, 436 

Oats, 95 

Oatmeal, 452 

Obesity, 68, 97, 98, 411 

excessive, 376 
Obscene conduct, 435 
Occlusive pessary, 264, 279 
Occupation, 234 
Oceania, 41 
CEdema, 279 

of the feet, 394 
Official examination, 165 
Old-fashioned methods of education, 

maids, 425, 431,. 435 
Olfactory sense, disturbances of, 91 
Omelettes, 95, 452 
Onanism, 275 

mental, 87 
Only child, 267 

sterility, 306, 336 
Oophorectomy, 205, 346, 412, 426 
Oophoritis, 212, 222, 279, 294 
Opium, 298 
Oranges, 454 
Organic heart disease, 265 
Organs of the senses, diseases of, 90 

circulation, diseases of, 388 
Ossifications, 354 
Ovaries, 294 

anatomical changes in, 358 

displacement of, 316 

neuralgia of, 316 

removal of, 354 
Overnutrition, 449 
Ovulation, 293 

cessation of, 299 

incapacity of, 294 
Ovum, 196 

female, 281 

gestation of the fertilized, 293 

male, 281 
Oysters, 96, 452 



Palpitation, 68 

of the heart, 389 

paroxysms of, 388 
Paralytic dementia, 437 
Paralysis, 128 
Parametric exudations, 320 
Parametritis, chronic, 221, 222 
Paranoia, 431, 433, 437 
Parent organism, 251 
Parental body, 252 
Paroxysmal tachycardia, 74 
Paroxysms, 425 

epileptic, 434 

hysterical, 434 
Partial frigidity, 138 
Partridge, 96 

Patriarchal relationship of woman, 7 
Pears, 454 
Peas, 452 

Pelvic deformity, 265 
Pepper, 451 
Perch, 452 

Percussion dulness, 394 
Perfect love, 162 
Perimetritis, 222, 279, 320 
Perineal fissures, 217 
Perioophoritis, 294 
Peripherally aroused perceptions, 142 
Peristalsis, 455 - 
Peritonitis, 329 
Perverse sexual impulse, 315 
Perversion of the moral instincts, 

Pheasant, 96 
Phlebectasis, 394 
Phlebotomy, 386 
Phthisis, 298 
Physical changes, 33 

development inferior, 265 

exercise, 97, 99, 109 

loathing of overwork, 374 

sexual intercourse, 210 
Physiological custom, 145 
Physiology of love, 54 
Pigeon, 96, 304, 452 
Pike, 452 
Piles, 394 

Pine needle baths, 103 
Platonic love, 56 
Pleasurable sensations, 142 
Plethora abdominalis, 404 
Plums, 456 

Pneumonia, chronic, 299 
Polar globules, 198 
Pollutions in the female, 213 
Polyglossia, 156 
Polymathy, 156 
Polypus, 363, 383 
Population, excessive increase of, 267 

distribution, unfavorable of, 265 

increase of human, 256 

Population, increase of human, checks 
to, 257 

law of, 255 

principle of, 255 
Pork, 452 
Porridge, 451 
Potatoes, 239, 452 
Potted meats, 450 
Precocious menstrual activity, 56 
Precordial anxiety, 434 

pain, 71 
Predicrotic elevation, 389 
Predilection, 273 
Predisi)osition hereditary, 374 

individual, 374 
Pregnancy, 153 

prevention of, 253 
Preserved meats, 450 
Prevention, measures of, artificial, 

mechanical, 270 

operative, 270 

physiological, 270 
Previous delivery, 333 
Primary insanity, 438 
Primitive man, 146 

state, 6 
Process of growing up, 114 

involution, 185 
Procreation, 293 
Profluvium seminis, 220 
Profuse perspiration, 349, 355 
Progressive endarteritis obliterans, 

Prolapse, 354 
Prolonged courtship, 133 
Pronuclei, conjugation of, 293 
Pro-nucleus, female, 198 

male, 198 
Prostitution, 268 
Proteids, animal, 450 

vegetable, 450 
Protracted mens,truation, 382 
Prurigo, 410 
Pruritus, 143, 144 

genitalium, 409 

vaginae, 421 

vulvae, 410, 415, 421 
Pseud-angina, 356 
Pseudo-membranes, 330 

narcotism, 357, 398, 416 
Psychical disturbances, 426 

influences, 10 

stimuli proceeding from the brain, 
Psychoses of puberty, 79 
Ptarmigan, 96 

Puberal development of the heart, 76 
Puberty, 33 
Puddings, 452 
Pudic nerve, 208 



Puerperal diseases, 333 

inflammation, 334 

mania, 192 
Pulmonary tuberculosis, 265 
Pulse, frequency of, 70 
Pure marriage, 31 
Pyogenic infection, 365 
Pyromania, 437 
Pyrosis, 405 

Quality of semen, 186 
Quarrelsomeness, 432 
Quinine, 303 

Rachialgia, 433 

Race, 34, 240 

Rachitic habit of body, 102 

Rape, 314 

Reflex action, 317 

cramps of sphincter vaginae, 207 
Regulation of the reproductive 

process, 194 
Reigning families, 229 
Relig^ion, 234 
Religious fanaticism, 55 

reverie, .108 
Reproduction, regulation of, 265 
Reproductive cells, 252 

glands, female, 295 
Respiratory distress, 71 

organs, diseases of, 89 ^ 
Retarded menstrual activity, 56 
Retention of the urine, 117 
Retinitis, 127 

Retrogressive metamorphosis, 359 
Rh3rthmical variation in the vital 

processes, 14 
Rice, 239, 452 
Rickets, 298 
Right to love, 194 
Roast beef, 96 
Rod forms, 365 
Roman baths, 443 
Romans, 7 
Roseola, 407 
Rowing, 100 
Rue, 103 
Rusks, 452 
Russian baths, 443 
Rye meal, 452 

Sacrache, 212, 223 

Sage, 103 

Salads, 452 

Salmon, 452 

Salpingitis, 222 

Salt, 451 

Sanitary towels, 116 

Sanguine temperament, 400 

Sarcomata, 299 

Satisfaction of the sexual impulse, 

Sausa^^es, 450 
Savones, 452 

Scandal-mongering, 345, 432 
Scanty progeny, 297 
Scarlatina, 338 
Schirrus of rectum, 317 
Schniirleber, 116 
Schrader's diet-table, 118 
Scirke, 284 
Sclerosis, 443 
Scrofula, 294, 298, 302 
Scrofulous habit of body, 102 
Sea side, 104 

voyage, 104 
Season of predilection, 317 
Seborrhoea, 93 

treatment of, 105 
Second wife, 249 
Segmentation-sphere, 199 
Selection in marriage, 171 
Self-deception, 345 
Self-sufiicient egoism, 152 
Semen, 202 
Senescence, 342 
Senile changes, 294 

degeneration, 362 

marasmus, 348 
Sensations of weight, 212 
Sense organs, 25l 
Separate beds, 176 
Septicaemia, puerperal, 299 
Severe intelfecfual exertion, 240 
Sex, determination of, 280 
Sexual abstinence, 136, 263 

activity in woman, 372 

desire, artificial increase of, 173 

disharmony, 224 

dream-perceptions, 219 

epoch of the menacme, 149 

epoch of the menarche, 33 

erethism, 346 

excesses, 240, 335 

freedom, 163 

heat, 144 

honor, 163 

hyperaesthesia, 145 

impulse, 130, 435 

inactivity, 348 

intercourse, frequency of, 172 

intercourse, in state of intoxication, 

intercourse, manner of, 172 

malpractice, 435 

maturity (at what age), 166 

position of woman, 154 

retrogression, 340 

sensibility in woman, 307 
Sexually asthenic women, 214 
Shellfish, 96 



Shortness of breath, 393 
Shower-baths, 100, 444 
Singing, 116 ' 

Sitting, 99 

Sitz-baths, 100, 188, 444 
Skating, 99, 109 
Skin diseases, 92, 407 

eruption, 357 
Slavonic people, 7 
Smoked fish, 450 

flesh, 450 
Social consanguinity, 250 

circumstances, 34, 374 

organisation, 8 

position, 234 
Sociologist, 254 
Sole, 4f2 
Solon's law, 177 
Song of Solomon, 19 
Soups, 452 
Southern Europe, 40 
Spartan law, 176 
Spasms, 129 
Spermatozoon, 196, 293 
Sphincter vaginae, 209 
Spices, 451 
Spinach, 95, 452 
Spirit of soap, 105 
Spiritualism, 436 
Sponge-baths, 100 
Sponging of body, 190 
Springtime, 240 
Spring water, 451 
Spurious pregnancy, 346 
State of minority, 153 
Steam bath-cabinets, 101 
Steatopyga, 343 
Sterility, absolute, 285 

acquired, 285, 321 

artificial, 270 

congenital, 285 

facultative, 286 

in women, 282 

only-child, 286, 306, 336 

relative, 285, 337 
Stigmata of degeneration, 251 
Stillbirth, 288 
Stomach, ulcer of, 88 
Strangury, 223 
Stroke, 390 

Suckling the infant, 154 
Sudatory baths, 101 
Sugar, 451 

Suicide, 139, 426, 428, 437 
Sun baths, 101 
Suppurative diseases, 299 

processes, 354 
Surgical measures, 291 
Sweetbreads, 96, 450 
Sweets, 452 
Swimming, 100, 109 

Sympathetic action, 317 

Syncope, 388 

Synostosis of the cranial bones, 79 

Syphilis, 8, 294 

Systolic murmur, 395 

Tachycardia, 401, 448 

Tachycardial paroxysms, 204, 390 

Taenia solium, 318 

Tannin, 303 

Tapeworm, 318 

Tea, 96, 109, 303, 451, 453 

Theatres, 108 

Thyme, 103 

Tight collars, 99 

Tight garters, 99 

Tinnitus aurium, 398, 416 

Tonsils, hypertrophy of, 88 

Toothache, 78 

Trout, 452 

Touchstone of marital hygiene, 182 

Townspeople, 52 

Travels, 108 

Tribadists, 215 

Trophoneurosis, 82 

Tropics, 241 

Trouble, 218 

Tuberculosis, 302 

Tumors, in pelvic cavity, 265 

malignant, 265 

mammary, 192 

ovarian, 192, 265 

uterine, 192 
Turkey, 96 
Turnips, 452, 456 
Twitchings, 129 

Two-children-system, 247, 254, 267 
Typhoid, 299, 338, 386 

Umbilical hernia, 412 
Union of Neo-Malthusianism, 260 
Universal military service, 245 
Unphysiological modes of sexual in- 
tercourse, 277 
Urethra, vascular tumors of, 317 
Urticaria, 94, 159, 410 
Uterine cough, 129 

neoplasm, 459 

polypi, 331 
Uterus, bicameratus vetularum, 364 

carcinoma of, 330 ' 

fibromyoma, 332 

hyperplasia of, 333 

myoma of, 332 

new growths of, 320 

retroversion of, 316 

tumors of, 331 

Vagina, disinfection of, 188 
fissures in, 217 



Vaginal douche, 173, 188 

injection, 187 

refrigerator, 445 
Vaginismus, 204 
Vaginitis, gonorrhoeal, 217 
Vapor baths, 101 
Varices, 159, 394 
Vasomotor disturbances, 84, 456 

symptoms, 371 
Veal, 96, 450 
Vegetables, 95, 452 
Vena cava, 396 
Venesection, 448 
Venison, 96, 452 
Venous engorgement, 394 

hy^ersemia, 322 
Veraism, 162 
Vermicelli, 452 
Vertigo, 371, 415, 442, 456 
Vestibule, bulb of, 208 

margin of, 208 
Vicarious bleeding from the gums, 78 
Vinegar, 451 , 

Virginity, sanctification of, 257 
Vis grata, 314 
Vitality of children, 234 

Voluptas cceundi, 346 

Voluptuous excitement, 308 
sensations, 208 

Vulva, inflammations of, 188 
Vulvitis, acute, 217 
chronic, 217 

Weak erection, 212 
Wedding journey, 179 
Wet-capping, 448 

nurse, 193 

packing, 101 
Wettin dynasty, 243 
Wheat bran, 103 

bread, 452 

meal, 452 
White meat, 456 
Widows, 435 
Wife's occupations, 187 
Wild breeds of animals, 236 

duck, 452 
Winckel's diet table, 119 
Wines, 95, 453 
Wittelsbach dynasty, 243 
Woman a chattel, 6 
Working class, 52 
Works of benevolence, 458 
Wrinkles in the face, 157 

Xantbin, 450 

Zona pellucida, 306 
Zoosperm, 281