The first appearance of menstruation is commonly preceded by various
symptoms dependent on the increased flow of blood to the genital organs.
Such symptoms are: Sacrache; dragging sensation in the loins; an
indefinite feeling of pressure in the lower part of the belly,
especially in the region of the uterus and the ovaries, which region is
sometimes also tender on pressure; a slight feeling of weariness in the
lower extremities; sudden flushings or pallors; alternating sensations
of heat and chilliness, sometimes accompanied by actual though slight
change of temperature. In many cases also there are disturbances in the
intestinal evacuations and urinary secretion, in the process of
cutaneous transpiration, and in the functional activity of the
gastro-intestinal canal. A frequently observed symptom is an increased
irritability of the entire nervous system, with an inclination to
melancholy and indefinite amorous desires—symptoms which _Tilt_ denotes
by the term “ovarianismus,” _Emmet_ by the term “erection,” _Lecal_ by
the term “phlogose amoureuse,” and the older writers by the term
“molimina menstrualia.”
The nervous irritability manifests itself already before the appearance
of the menstrual flow by headache and moodiness, weariness, nervous
irritability, and low spirits; further, by slight changes in the facial
aspect, dark rings round the eyes, spontaneous blushing, uneasy
sensations, epigastric pain, loss of appetite, a sensation of pressure
in the abdomen, palpitation, vertigo, dragging sensations passing from
the loins to the thighs, feeling of weakness and numbness in the lower
extremities—symptoms which often endure for several months and in such
cases tend to lower the resisting powers of the organism.
_Courty_ enumerates as prodromal symptoms which are observed in the
majority of girls before the first appearance of menstruation: swelling
and tenderness of the breasts, sensation of fulness and weight in the
hypogastric region, moderate intestinal meteorism, sacrache,
aqueo-mucous vaginal discharge, finally, an itching sensation in the
genital organs. These manifestations may also assume a morbid character,
taking the form of violent abdominal and lumbo-sacral pain, general
fatigue and weakness, dyspepsia and diarrhœa, cephalalgia, various kinds
of neuralgia, some degree of moral aberration. After the first
menstruation, two or three months may elapse before the girl menstruates
again, but after the lapse of a year the flow usually recurs at quite
regular periods. Sometimes the early periods are very violent and recur
very frequently, every twenty days, for instance.
The greatest increase in size and weight occurs in the female sex at the
time of the menarche. Amongst the poorer classes the greatest
development in size and strength occurs between the ages of 13 and 15
years, whereas in the upper classes of society, those who ultimately
attain the same weight exhibit their greatest growth at the ages of 12,
13, and 14 years. According to _Pagliani_ the greatest growth in the
female sex always precedes puberty, so that for example a girl who
begins to menstruate at the age of 12 will grow most rapidly in the year
preceding this, whereas a girl who begins to menstruate at a more
advanced age will not undergo her most rapid phase of growth so early as
the age of 11. According to the observations of _Bowditch_, _A. Hey_,
_Lombroso_, _Pagliani_, and _Ploss_, up to the age of 11 or 12 years the
growth of girls exceeds that of boys, but whereas in girls growth ceases
suddenly at the age of 14, in boys growth proceeds regularly up to the
age of 16 years. At birth boys are on the average 1 cm. (⅖″) longer than
girls; but during puberty the female sex catches up the male in height,
or even surpasses it. According to _Ploss_, a girl of 16 or 17 years is
as tall as a young man of 18 or 19 years.
The earlier development of the female as compared with the male at the
time of puberty is a constant phenomenon, to be observed in all races,
in every climate, and in all strata of society. According to the
statistical data published by the authors just quoted, the age of
greatest development in the respective sexes is:
_In the female._ _In the male._
As regards weight at the age of 12 to 14 years. 14 to 17 years.
As regards height at the age of 12 to 13 years. 12 to 15 years.
As regards respiratory capacity at the age of 12 to 15 years. 15 to 17 years.
As regards muscular strength at the age of 12 to 14 years. 14 to 15 years.
Puberty occurs in the female on the average about two years earlier than
in the male, and upon this difference the observed differences in growth
also depend.
The menarche in the wider signification of the term includes the
development which occurs at the time of puberty, and continues through a
period of several months, and even years, before complete sexual
maturity is attained; and includes also the time, which may be
considerable, following the first appearance of the menses and before
the regular rhythm of the menstrual function is established and the full
development of the female genital organs is attained. This time, which
forms a notable phase of the sexual life of woman, is characterized by
great changes in the genital organs and in the vital processes connected
therewith, by a strong tendency to suffer from a series of very various
pathological changes and disorders of function in the principal organs,
and a lessened general resisting power to disease—a change which finds
its most definite expression in the well-established fact that in this
period of life the mortality among females is much greater than among
males of corresponding age. According to the statistical data of
_Quetelet_ and _Smits_, from the age of 14 to the age of 18 (the period
of the menarche) there are 128 deaths of females for every 100 deaths of
males; and even in the four succeeding years, from the age of 18 to the
age of 22, the unfavorable conditions peculiar to sex are witnessed by
105 deaths of females to every 100 deaths of males.
Many authors draw a distinction between the age of puberty (from the
Latin _pubes_, _puberis_), when the growth of the pubic hair occurs as
an external sign of sexual development, and the age of nubility (from
the Latin _nubere_), when the individual becomes fitted for marriage.
The distinction is a partial one only, inasmuch as capacity for
copulation is attained already at puberty. The law, however, maintains
such a distinction, the Austrian Penal Code, for example, regarding
intercourse with a female less than fourteen years old as rape, and the
German Code likewise punishing carnal knowledge of a girl under
fourteen.
The signs of puberty in girls were noticed and explained in very early
times. From the anthropological studies of _Ploss_ and _Bartels_ we take
the following data regarding this matter. In the Bible we read (Ezekiel,
xvi, 7): “Thy breasts are fashioned and thine hair is grown, whereas
thou wast naked and bare.” The early Indian physician, _Susruta_, refers
only to the regular recurrence of menstruation as a sign of puberty.
That a woman is menstruating may be known by the fact that her face is
swollen and bright. In the Roman Empire _Justinian_ ordained that all
young women should be examined as to the growth or absence of the pubic
hair in order to ascertain if they were ripe for marriage. The early
Chinese physicians recorded that in every woman at the age of fourteen
or fifteen years a monthly flow of blood from the genital organs began,
the period of recurrence being thirty days. The physicians of the Talmud
express themselves variously regarding puberty in women. In one place
they advance as a sign of puberty the growth of the hair on the genital
organs; in another they speak of the notable enlargement of the breasts,
and mention as a sign of more complete sexual development that the
nipples become elastic. Other Talmudists refer to the appearance of a
dark brown coloration in the areola and to the enlargement of the mons
Veneris as signs of puberty. Savage races regard the first appearance of
the menstrual flow as the only certain sign of puberty, and among many
such races this is the occasion of peculiar ceremonial rites. The
attainment of puberty in savage tribes is often solemnized by the
seclusion of the girls from the time of the first menstruation; they
fast during the period of seclusion, which sometimes terminates in an
elaborate ritual of purification.
For two reasons in particular, the period of the menarche is a time of
storm and stress to women, first on account of the developmental
processes in the genital organs, and secondly on account of the
intellectual changes that occur at this period.
The local cause is to be found in the extensive transformation of the
ovaries and the uterus, by means of which a peculiar and powerful
stimulus, the menstrual stimulus, is elaborated, which has a reflex
influence upon heart and brain, vascular and nervous systems, and
secretory and nutritive processes. Since we know that in every
premenstrual period by the growth of the follicles hyperæmia is excited
in the ovary, by means of which the liquor folliculi is increased in
amount, we can well understand that at the time of the menarche the
ripening of the graafian follicles is accompanied by a considerable
degree of hyperæmia of the ovaries and of the whole of the genital
organs, now undergoing their fullest development, and we can easily see
how this hyperæmia may result in manifold reflex disturbances. But in
addition to these reflex disturbances, we have once more to take into
consideration the as yet imperfectly known chemical processes which are
associated with the ripening and development of the graafian follicles,
and an abnormal course of which may give rise to a disordered
constitution of the blood, manifesting itself as chlorosis or in other
ways. In connection with the growth and ripening of the ova, extensive
and novel demands are made on the organism, and these may well endanger
metabolic processes which are not established on a very secure
foundation.
The other cause is to be found in the intellectual processes which occur
at this time in the youthfully receptive, highly sensitive organ of
mind, the brain. The girl growing into womanhood, who with astonishment
and stress has witnessed the visible changes in her body, the outward
signs of puberty, as they gradually make their appearance, receives
powerful psychical stimulation which cannot fail to exercise an
influence upon the entire nervous system and its complex interlacements,
alike in the sensory and in the motor sphere.
The degree to which these influences radiating from the genital organs
make themselves manifest is chiefly dependent upon the resisting power
of the nervous system as a whole, upon the temperament, the inherited
constitution, and the mode of education of the young girl. In children
belonging to families noted for sensibility and irritability, in
dwellers in large cities who have attended high schools for girls and
have at an early age lifted the veil that covers the sexual processes,
the reflex disturbances of the menarche will be more manifold and will
manifest themselves with greater intensity than in children brought up
in country districts, whose sensibilities are chiefly physical and whose
mind is less susceptible to the influence of external stimuli.
A further important consideration is the time at which the menarche
occurs, and whether on the one hand it is at or near the average age, or
whether on the other, as precocious menstruation, it is unusually early,
anticipating the general bodily development, or again as retarded
menstruation it is unduly delayed. In some cases of retarded
menstruation, the external genital organs are thoroughly well developed,
and it is menstruation only that remains in abeyance; but in other cases
the external genitals are also backward in development, the pubes and
mons Veneris being but sparsely supplied with hair, and the breasts
remaining very small.
In addition to these abnormal temporal relations of the menarche,
certain other irregularities at the commencement of menstruation are
worthy of note. Thus, the first menstruation may be normal, but
thereafter amenorrhœa may persist for several months, or if the flow
occurs it may be exceedingly scanty, or very pale in color; on the other
hand, menstruation may be very profuse, lasting many days.
The environment in which the young girl is placed during the period of
her sexual development has a great influence on the processes of the
sexual life and on the pathological disturbances that affect these
processes.
In working-class families the immoderate physical strain often thrown
upon girls, in many cases continuous movements of the upper extremities
whilst the lower extremities and the pelvis are absolutely quiescent, or
conversely, an excessive employment of the muscles of the lower
extremities—these circumstances in conjunction with insufficient
nutriment, night-work, association when at work with persons of the
opposite sex, and the frequent premature sexual stimulation, will
combine to have a most deleterious effect.
Amongst country-folk, indeed, the girl has the enjoyment of fresh air,
and as a rule nutritive food, moreover, there are not so many occasions
of nervous stimulation; puberty therefore arrives more slowly and gives
rise to less disturbance; but the ignorance of the girls very frequently
leads to an early experience of coition, the natural and unnatural
consequences of which have then to be taken into account.
Amongst the better classes of townspeople such hygienic regulations and
educational measures are in common employment that young girls during
the years of development usually receive reasonable care and
attention—but very frequently, intercourse with older girls, association
with young men, visits to theatres, evening-parties, and balls, and the
perusal of stimulating literature, form unfavorable features of urban
life which exercise their inevitable effects in the sexual sphere. In
some cases, fortunately sufficiently rare, the stimulation of the sexual
impulse and the longing for its satisfaction are so intense, that a kind
of _demi-vierge_ is brought into being, a young woman who is concerned
only to preserve the physical token of virginity, but whose thoughts and
fancies are anything but maidenly. It is to be feared that in
consequence of the excessive freedom in education and the emancipated
independence of feminine youth, these “half-virgins” are increasing both
in number and in intensity, a fact which cannot fail to increase also
the number of sexual maladies and perversions.
_Anatomical Changes in the Female Genital Organs in the Period of the
Menarche._
The female reproductive organs, which in childhood were in a
comparatively quiescent state, now become powerfully active, as is
witnessed by the changes that occur in the external genitals.
The soft, hairless vulva of the child becomes enlarged at the time of
the menarche by the deposit of fat, and its substance becomes tough and
elastic. Some time before puberty, fine, pale hairs make their
appearance here and there, but not until puberty does the hairy covering
of the pubic region become more or less thick. The growth of the denser
pubic hair begins with the appearance of hairs along the middle of the
mons Veneris and at the margins of the labia majora. Early sexual
development is commonly indicated by an early and thick growth of the
pubic hair. In the virgin this hair is smoother and less curly than in
the later course of the sexual life. In certain tribes of negroes it is
the custom for the young unmarried girls to shave off the pubic hair,
which is not allowed to grow freely until after marriage. In some of the
tribes of South Sea Islanders it is customary at puberty to tattoo the
external genitals and the surrounding skin.
[Illustration:
FIG. 8.—Internal genital organs of a new-born, powerfully developed
female infant. (From Toldt: Atlas of Human Anatomy.—Rebman Company,
New York.)
]
In young virgins the rima urogenitalis or vulval cleft is closed by the
accurate opposition of the labia majora; the labia minora or nymphæ are
delicate in texture, rose-red in color, hairless, free from fat, and
completely covered by the labia majora; whilst the clitoris is likewise
concealed. The sebaceous glands of the labia minora secrete a smegma
which collects especially around the glans clitoridis, and as it
undergoes decomposition diffuses a peculiar odor, resembling that of old
cheese. A wing-like elongation of the labia minora in young girls, with
free secretion and a generally moist appearance, leads to a suspicion of
the practice of masturbation. In the virgin the orifice of the vagina is
covered by the hymen.
[Illustration:
FIG. 9.—Reproductive organs of a new-born, powerfully developed female
infant in median sagittal section. (From Toldt: Atlas of Human
Anatomy.—Rebman Company, New York.)
]
[Illustration:
FIG. 10.—Internal genital organs of a girl aged eight years. Seen from
behind. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New
York.)
]
The entrance to the vagina in the virgin is rounded, the posterior
border of the aperture being deeply concave, whilst the anterior border
is often slightly convex backwards. Where this feature is strongly
marked, the orifice has a semilunar shape. The posterior concave border
projects forward in the form of a fold, continuous above with the
posterior vaginal wall; this fold is the hymen.
[Illustration:
FIG. 11.—Reproductive organs of a girl aged ten years in median
sagittal section. Left half. (From Toldt: Atlas of Human
Anatomy.—Rebman Company, New York.)
]
[Illustration:
FIG. 12.—Female external genital organs of a virgin, attached to the
vagina which has been isolated and opened, and a portion of the
cervix uteri, Hymen, etc. (From Toldt: Atlas of Human
Anatomy.—Rebman Company, New York.)
]
[Illustration:
FIG. 13.—The external genital organs of a virgin, drawn apart
transversely (after von Preuschen). c. Clitoris. f. c. Frænum of the
clitoris. n. Nymphæ. l. Labia majora. o. u. Urethral orifice. h.
Hymen. f. n. Fossa navicularis.
]
The infantile uterus is so proportioned that its neck (_collum vel
cervix uteri_) constitutes the larger part of the organ, as much indeed
as two-thirds. Owing to the small size of the body (_corpus uteri_), the
whole uterus is very flat, and its borders ascend in a direction almost
parallel to each other, diverging somewhat abruptly into the Fallopian
tubes, recalling in some degree the two-horned embryonic form of the
organ (_uterus bicornis_). The plicæ palmatæ on the surface of the
cervical canal, which make up the arbor vitæ uterina, are strongly
developed; the median longitudinal ridge bifurcates, and its divisions
can be traced on either side into the uterine orifice of the Fallopian
tube (_ostium uterinum tubæ_). The lips of the vaginal portion of the
cervix are comparatively speaking very large and terminate in sharp
angles. The vaginal mucous membrane is everywhere beset with long
papillæ. The development of the uterus shortly before puberty consists
chiefly in the enlargement of the body of the uterus, and the growth of
its walls in thickness.
[Illustration:
FIG. 14.—Sagittal section of the female pelvis (after Breiolei).
]
At the time of puberty, according to _Toldt_, the body of the uterus in
the virgin has already increased till its length is half that of the
entire organ; and at the first appearance of menstruation the body and
neck of the virgin uterus are nearly equal, with perhaps a slight
preponderance in size of the cervix, and the walls of the uterus have
become convex. In consequence of this change the organ becomes
pear-shaped, and the uterine cavity (_cavum uteri_) assumes the form of
a triangle with moderately incurved sides. The cervical canal becomes
wider in the middle; the margin of the os uteri becomes smooth and
rounded. The walls of the virgin vagina are marked with numerous dentate
transverse ridges (_rugæ_), especially near the lower end and on the
anterior walls, the columns of the vagina (_columnæ rugarum_), from
which the transverse ridges run to either side at right angles, extend
half way up the vagina, and are of a hard consistence.
The characteristic changes in the ovary at the time of the menarche
originate in the changes undergone by the ovarian follicles. A large
number of small separate follicles is to be found already in the ovary
of the new-born infant. These structures, known as primitive follicles,
are formed by detachment from the egg-tubes that grow down into the
stroma from the superficial germinal epithelium; they are spheroidal
vesicles, enveloped by a single layer of cubical cells, and their
interior is entirely filled by the primitive ovum or egg-cell. This
latter consists of very finely granulated protoplasm with spherical
nucleus and distinct nucleolus, but no trace of an investing membrane
can as yet be discerned. The further development of the ovarian
follicles takes according to _Toldt_ the following course: A rapid
multiplication of the cubical cells that form the wall of the follicle
occurs, so that the ovum is surrounded by two, three, or several layers
of cubical or rounded cells, and the whole follicle gradually increases
in size. At the same time the ovum assumes an eccentric position in the
interior of the follicle. At or near the middle of the follicle a
slit-shaped space now appears, filled with a clear colorless fluid. As
this space gradually enlarges, the follicle[19] becomes converted into a
vesicle filled with fluid, the wall of which is composed of small
cubical cells. Simultaneously with the growth of the follicle a
lamination of the elements of the surrounding stroma takes place, so
that a somewhat sharply defined capsule is formed. In this condition
these glandular structures of the ovary are known as graafian
follicles.[19]
Before puberty, these graafian follicles are small vesicles of a
diameter of one to two millimetres, containing the large unicellular
ova. Each of these consists of an envelope, the zona pellucida (also
known as the zona radiata, or striated membrane of the ovum); an
external granular mass of protoplasm, the vitellus or yolk; a vesicular,
spherical nucleus, the germinal vesicle; and a nucleolus, which if
single is large and prominent, the macula germinativa or germinal spot.
As early as the second year of infancy every imaginable intermediate
stage between the primitive follicle and the fully-developed vesicular
graafian follicle can be observed.
At the time of puberty certain larger follicles are always to be
distinguished, which have moved inward toward the interior layers of the
ovary, whereas the smaller follicles have a more peripheral situation;
thus, according to _Waldeyer_, we observe at this time in a section of
the ovary, proceeding from without inward, first the epithelium, next
the fibrous tunic, next the zone of younger follicles, and finally the
zone of older follicles. According to _Henle_ and _Waldeyer_, at the
commencement of puberty, there are in each ovary about 36,000 ova,
giving a total for the two of 72,000.
[Illustration:
FIG. 15.—Primitive follicles.
]
In the further course of development of the graafian follicles at this
period, the most advanced now reapproach the surface of the ovary, so
that a fully-matured follicle comes to occupy almost the entire
thickness of the cortical substance, and may even give rise to a
localized bulging of the surface of the organ. In such a mature
follicle, which has attained nearly the size of a pea, we recognize an
outermost connective-tissue investment (_theca folliculi_), consisting
of condensed ovarian stroma, in which two layers are distinguished,
sometimes called simply _outer tunic_ and _inner tunic_, sometimes known
by the names of _tunica fibrosa_ (outer) and _tunica propria_ (inner),
respectively; within this is the cellular layer known as the _membrana
granulosa_ (or _stratum granulosum_), the portion of which, now greatly
enlarged, immediately surrounding the ovum is known as the _discus
proligerus_ (or _cumulus oöphorus_); the interspace between the _discus
proligerus_ and the membrana granulosa is filled with a clear fluid, the
_liquor folliculi_. In consequence of the continued increase in its
fluid contents, the graafian follicle ultimately bursts along the most
prominent portion of the superficial wall, and the ovum passes out
through the rupture, finding its way under normal conditions into the
Fallopian tube and through this into the uterus. The follicle itself
then undergoes a regressive metamorphosis, forming the _corpus luteum_,
the rent in the envelope of which, after the absorption of the yellowish
semi-fluid contents, undergoes cicatrization. Contemporaneously with
this development at puberty of the process of ovulation, menstruation
also for the first time makes its appearance, recurring thenceforward at
four-weekly intervals as the regular catamenial discharge.
We append the account given by _Pfannenstiel_ regarding the ovarian
follicles. He writes: “In correspondence with the especial function of
the female reproductive gland, which is to bring to maturity and to
evacuate only after the lapse of a considerable period and at successive
intervals, the ova which it has contained from the very outset, we find
that primitive follicles continue to exist in the ovary up to the very
end of the period of sexual activity, though naturally in diminishing
numbers; and the size and shape of these primitive follicles remain
nearly identical throughout the various periods of life. As the follicle
ripens, the epithelium grows, the cells becoming cubical with a rounded
nucleus, and increasing in number by cell-division, so that several
layers are formed. As soon as these layers are three or four in number,
a space, at first slit-shaped, forms in the epithelium on the peripheral
surface of the ovum; this space is filled with fluid, known as the
liquor folliculi; the peripheral layer of cells, the membrana granulosa,
is thus separated from the mass of epithelial cells immediately
enveloping the ovum, the discus proligerus, which is situate in the side
of the follicle adjacent to the hilum of the ovary. By the increase of
the liquor folliculi the graafian follicle is formed, a vesicle the
envelope of which is formed by the multilaminar membrana granulosa,
whilst in the pole of the vesicle directed toward the hilum ovarii is
the ovum imbedded in the mass of cells forming the discus proligerus, a
mass which has the form of a truncated cone. The liquor folliculi is
formed by the epithelium, the nuclei of which disappear by chromatolysis
or by simple atrophy whilst the cell-bodies liquefy in consequence of
albuminous, not fatty, degeneration (_Schottländer_). Within the
epithelium of the follicle we find the faintly glistening epithelial
vacuoles of _Fleming_, likewise cells which liquefy and assist in
increasing the bulk of the liquor folliculi. This liquor is a thin,
serous fluid, and contains albumin. * * * Every graafian follicle has a
bilaminar investing membrane, which is formed by the ovarian
stroma. * * * The ovum of the growing follicle increases in size very
slowly indeed, attaining on the average, according to _Nagel_, a
diameter of 165 to 170 µ, it retains its zona pellucida, the greater
part of the protoplasm of the cell is transformed into deutoplasm
(food-yolk, or yolk-granules), the nucleus assumes an eccentric
position. Between the zona pellucida and the cell-body a narrow
perivitelline space appears. The ovum is then full-grown, but not yet
fully prepared for fertilization; for this, maturation is required,
certain changes in the germinal vesicle, which occur after the bursting
of the follicle. * * * As a rule each follicle contains a single ovum.
But two and even three ova have beyond doubt been observed in one
follicle.”
According to _Waldeyer_, the bursting of the follicle is not to be
regarded as dependent upon a sudden rise of pressure in its interior,
but as the result of a gradual ripening process. At the deepest pole of
the follicle, which in the course of its development has now approached
the surface of the ovary, an exuberant growth takes place in the
internal layer (tunica propria) of the theca folliculi, with a profuse
formation of new vessels. Here numerous “epithelioid” cells, the
“lutein-cells,” make their appearance. In consequence of this
proliferation of the lutein-cells, the contents of the follicle are
gradually pressed toward the “stigma,” the superficial pole of the
follicle, and the follicle itself is pushed toward the surface until it
finally comes into contact with the germinal epithelium. Meanwhile the
follicular epithelium undergoes fatty degeneration, alike in the
membrana granulosa and in the discus proligerus. In consequence of the
proliferation of the lutein-cells, on the one hand, and the fatty
degeneration of the epithelium, on the other, the follicle opens at its
weakest point, the stigma, and the ovum is extruded, with the liquor
folliculi, and a number of cells belonging to the follicular epithelium.
(To illustrate these changes we have borrowed FIGS. 15, 16, and 17 from
the monograph, by _Pfannenstiel_ on _Diseases of the Ovary_, in _J.
Veits’ Handbook of Gynecology_.)
The ovaries, which in the new-born female infant are flattened,
ribbon-like bodies one-half to one centimeter (0.2 to 0.4″) in length,
and in childhood are cylindrical, with a perfectly smooth surface,
assume at the time of puberty a more or less flattened form. During the
menarche they have an elongated oval shape, flattened from side to side,
their average length being 2.5 to 5.0 centimetres (1 to 2″), width 1.5
to 3.0 centimetres (0.59 to 1.18″), thickness 0.6 to 1.4 centimetres
(0.24 to 0.55″), weight 5 to 8 grammes (77 to 123 grains). After the
repeated occurrence of ovulation, the surface of the ovary becomes more
and more uneven, being thickly covered with fossæ or scar-like fissures.
[Illustration:
FIG. 16.—Ripening follicles.
]
The vagina during virgin girlhood is narrow, and its mucous surface is
beset with numerous rugæ, which may be plainly felt as well as seen. The
calibre of the vagina is proportionately less the younger the girl. The
examining finger is gripped by the vaginal wall as by an india-rubber
tube (_Maschka_). The vaginal portion of the cervix is felt in the form
of a truncated cone, with a smooth surface, rather dense in consistence;
the external os opens at the bottom of a small depression on its
surface, in the form of a short oval, the long axis of which is
transversely directed. Shortly before the menarche, Bartholin’s glands
become noticeable on either side of the lower end of the vagina between
the sphincter muscles.
The clitoris in many cases attains a very large size, and this is apt to
lead to sexual malpractices. According to _Hyrtl_, in southern countries
the clitoris is larger than in temperate and cold climates. In the women
of Abyssinia and among the Mandingoes and the Ibboes, the size is
portentous, and amongst the first-named, circumcision of females is a
customary operation. It is said that female slaves belonging to these
races are greatly esteemed by the ladies of the harem, and are eagerly
sought for. In the anatomicopathological museum at Prague there is a
preparation of the female genital organs with a clitoris as large as the
penis of a full-grown man.
[Illustration:
FIG. 17.—Graafian follicles.
]
_Sonini_ describes “as peculiar to women of Egyptian or Koptic descent,
the presence of a thick, fleshy, but soft and pendent outgrowth in the
pubic region, completely covered with hair,” which he compares to the
hanging caruncle on the bill of the male turkey. This appendage becomes
thicker and longer with advancing years. Sonini found such an appendage
one-half inch in length in a girl of eight years, one of more than four
inches in a woman of twenty to twenty-five years. Circumcision in girls
consists in the removal of this outgrowth, which hinders copulation; in
that part of the world the operation is usually effected in the seventh
or eighth year, just before puberty.
The circumcision of girls as practiced by Mahommedan peoples in Africa
is said by _Ploss_ and _Bartels_ to consist in abscission of the labia
minora, the clitoris, and the præputium clitoridis. _Brehm_ is of
opinion that the object of the operation is to diminish the intensity of
the sexual impulse, so overpowering among these races; but others
believe that the great enlargement of the clitoris and the labia minora
usual in those countries is regarded as a serious defect in beauty, a
defect removed by the operation; whilst others again hold that the
circumcision is required for the removal of the hindrance to copulation
presented by the abnormally large clitoris. Closely related to the
operation of circumcision in females, according to _Ploss_ and
_Bartels_, is the custom peculiar to Africa of infibulation, wherein,
after a preliminary cutting operation like that for circumcision, the
fresh wound surfaces are brought into accurate opposition, either by
sutures or by appropriate bandages, so that when cicatrization occurs
the vulval cleft is closed except for a very small aperture. The object
of infibulation is to enforce on girls complete abstinence from sexual
intercourse. (Before marriage, the vulval cleft is reopened to an extent
corresponding with the size of the genital organs of the future husband;
and when pregnancy occurs, the opening is still further enlarged before
parturition; but after that event, the wound surfaces are refreshed, and
the whole opening is once more closed). On the other hand, in many
savage tribes, elongation of the labia minora and the clitoris is
artificially undertaken from the earliest years of girlhood, this
elongation being regarded as a beauty.
The parts of the external reproductive organs of the female concerned in
sexual sensation, first described as such by _Kobelt_, are already fully
developed at the time of the menarche. Of these parts a small portion
only, the glans clitoridis, is visible externally, surrounded by the
præputium clitoridis, a prolongation of the labia minora, which passes
round the front of the clitoris, and sends from each side a fine process
behind the glans to become attached to its under surface, forming the
frænum of the clitoris. The erectile apparatus of the external genitals
is formed by the corpora cavernosa clitoridis. As two delicately
constructed trabecular masses of erectile tissue, the crura of the
clitoris, these are attached on either side to the inferior or
descending rami of the pubic bones; at first passing upwards parallel to
the bones, they subsequently curve downward as they converge and unite
to form the body of the clitoris; these masses of erectile tissue
embrace the sides and the front of the lower extremity of the vagina.
This erectile apparatus, when the supply of arterial blood is greatly
accelerated and at the same time the outflow of venous blood is
diminished, becomes distended with blood, enlarged and stiffened; the
process of erection plays an important part, as we shall explain more
fully later, in the production of sexual excitement and sexual pleasure
during the act of copulation.
In the virgin and in the earlier phases of the sexual life, the hymen is
so characteristic an organ that its more minute description would seem
desirable.
The hymen, a fold of mucous membrane, springing from the periphery of
the vaginal orifice, separates as a perforated diaphragm the vagina from
the vulva. Between the two epithelial layers of which, as a fold of
mucous membrane, the hymen consists, is a supporting layer of connective
tissue of variable strength; in other respects the mucous membrane of
the hymen has the same structure as the mucous membrane of the vagina.
On its inner surface the rugæ and folds of the vaginal mucous membrane
are prolonged. The shape of the hymen is very variable; most commonly
its aperture is more or less central, so that the hymen has a ringed or
semilunar shape.
[Illustration:
FIG. 18.—Annular Hymen.
]
[Illustration:
FIG. 19.—Annular Hymen.
]
In the new-born female infant, the hymen has the appearance of a tubular
stopper closing the lower end of the vagina; according to _Dohrn_ it
exhibits as a rule one of three typical forms: _Hymen annularis_,
_denticulatus_, _et linguiformis_; the _annular_, the _denticulate_, and
the _linguiform_ (or _linguliform_) _hymen_. The transverse ridges on
the inner surface of the hymen, prolongations of the rugose columns of
the vagina, are strongly developed. During the girl’s further growth, in
association with the enlargement of the vagina, the hymen undergoes
important changes in form and structure. Its border becomes thinner and
more tense; and in the virgin at the time of the menarche, the annular
hymen is the fundamental type, subject, however, to extensive
variations. In most cases, at any rate, the aperture in the hymen is
more or less centrally situated; very commonly, however, this opening is
crescentic, when we have a semilunar hymen, the height of the border
posteriorly being much greater than anteriorly. The consistency of the
hymen, its extensibility, and its thickness, are as variable as its
shape.
[Illustration:
FIG. 20.—Semilunar Hymen.
]
[Illustration:
FIG. 21.—Annular Hymen with congenital Symmetrical Indentations.
]
[Illustration:
FIG. 22.—Fimbriate Hymen.
]
[Illustration:
FIG. 23.—Deflorated Fimbriate Hymen.
]
In the normal position of the reproductive organs the hymen has very
rarely the appearance of a tense membrane; as a rule it is folded up,
and becomes plainly manifest only when the genital organs are stretched.
The margin of the hymeneal aperture, as a close examination shows, is
sometimes sharp and regular, sometimes lobulated, with small congenital
notches. These congenital notches are to be distinguished from the
lacerations resulting from defloration by the fact that the former have
a smooth border, which is of the same consistency as the general
substance of the hymen. In some instances the border of the aperture in
the hymen is beset with small, fine villi (villous hymen).
The common varieties of the hymen are thus classified by _Maschka_:
1. The _annular hymen_, in which the membrane when stretched is seen to
have a rounded aperture, which may be central or eccentric; very often,
indeed, the aperture is more toward the upper half of the hymen, in
which case it is not always circular, but frequently rather ovoid in
shape.
2. The _semilunar_ or _crescentic hymen_, in which the aperture is
eccentrically placed in the upper half of the membrane, in such a manner
that the hymen exhibits a wide surface below the aperture, which surface
narrows at either side as it passes upwards until it disappears, the two
sides failing to reunite above the aperture.
3. The _heart-shaped_ or _cordiform hymen_, the general shape of which
may be circular, ovoid, or even semilunar, but in which from the middle
of the upper or lower margin a three-cornered tongue projects across the
aperture, which is thus given the form of the conventional heart of a
pack of cards.
4. _The infundibuliform hymen_ has the form of a small projecting funnel
resembling in appearance the invaginated end of the finger of a glove.
_Maschka_ refers also to the rare condition in which the hymen is
sometimes said to be absent. As a matter of fact, however, in such
cases, it is represented by a very narrow annular eminence, the genitals
being in other respects normal. The smooth character of the eminence
will serve to differentiate it from the remains of a destroyed hymen.
Other rare forms are:
1. The _imperforate hymen_, an occlusive membrane, entirely blocking the
vaginal orifice. In some cases, however, the hymen is not absolutely
imperforate, a very small, punctiform aperture being present.
2. The _cribriform hymen_, a hymen which is “imperforate” in the sense
that there is no opening of a size approaching the normal, but in which
several minute apertures are present.
3. The _septate_, _bridged_ or _divided hymen_ (_hymen bifenestratus_,
etc.), exhibits a strip of mucous membrane, most commonly running
directly from before backward, occasionally, however, somewhat
obliquely, across the aperture in the membrane, which is thus divided
into two equal or unequal parts. In some instances the process that
bridges the aperture of the hymen is expanded in the vertical plane to
form a septum which projects for some distance into the vagina.
[Illustration:
FIG. 24.—Septate Annular Hymen.
]
[Illustration:
FIG. 25.—Septate Semilunar Hymen.
]
[Illustration:
FIG. 26.—Extremely tough Annular Hymen, with an obliquely disposed
Septum.
]
[Illustration:
FIG. 27.—Septate Hymen with Apertures of unequal size.
]
4. The _lobate_, _lobulated_, or _labiate hymen_, which consists of
several (two to four) lobes on either side, each overlapping the next
like the tiles in a roof, whilst the aperture between the two sides has
the form of an antero-posterior slit (FIG. 37); in some cases the lobes
of a lobulated hymen are so disposed that the membrane has the
appearance of a fold of mucous membrane with a central furrow.
[Illustration:
FIG. 28.—Septate Hymen with Apertures of unequal size.
]
[Illustration:
FIG. 29.—Hymen with rudimentary Septum.
]
[Illustration:
FIG. 30.—Hymen with posterior rudimentary Septum.
]
[Illustration:
FIG. 31.—Labiate Hymen with posterior rudimentary Septum.
]
It is obvious that an imperforate or cribriform hymen, by the hindrance
it offers to the passage of the menstrual discharge, is liable at the
time of the menarche, and as soon as menstruation begins, to give rise
to serious disorder and to pathological states.
[Illustration:
FIG. 32.—Hymen with anterior rudimentary Septum.
]
[Illustration:
FIG. 33.—Hymen with anterior rudimentary Septum projecting in a
opiniform Manner.
]
[Illustration:
FIG. 34.—Hymen with anterior and posterior rudimentary Septa.
]
[Illustration:
FIG. 35.—Hymen with filiform process projecting from the anterior
margin.
]
[Illustration:
FIG. 36.—Hymen in which there are two symmetrically disposed thinned
areas. The left of these is perforated.
]
The illustrations we append, showing the various forms of the hymen, are
taken from _von Hoffmann’s Handbook of Medical Jurisprudence_. (FIGS.
18–45.)
[Illustration:
FIG. 37.—Very unusual form of Hymen.
]
[Illustration:
FIG. 38.—Semilunar Hymen with cicatrized Lacerations in its Border.
]
[Illustration:
FIG. 39.—Deflorated Semilunar Hymen with laterally disposed
Symmetrical Lacerations.
]
[Illustration:
FIG. 40.—Deflorated Annular Hymen with several cicatrized Lacerations.
]
[Illustration:
FIG. 41.—A. Septate Hymen in which Defloration has been effected
through one of the Apertures. U. Urethra. Cl. Clitoris. H.
Cicatrized margin. C. Septum. B. Lateral View of Septum.
]
In some cases the hymen is exceedingly thin and delicate, so that it is
liable to be torn if handled at all roughly; in other cases, on the
contrary, it may be very firm, thick, and fleshy, interlaced with
strands of connective tissue and muscle, so that it forms a veritable
cuirass for the protection of physical virginity.
[Illustration:
FIG. 42.—Deflorated Septate Hymen.
]
[Illustration:
FIG. 43.—Hymen with larger anterior and smaller posterior Apertures.
]
[Illustration:
FIG. 44.—Carunculæ Myrtiformes in a Primipara.
]
[Illustration:
FIG. 45.—Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes.
Slight Prolapse of anterior and posterior Vaginal Walls.
]
As signs of virginity in the female, a knowledge of which is required,
not only for the purposes of medical jurisprudence, but for various
other reasons, we may enumerate the following anatomical characteristics
of the genital organs. The labia majora are elastic in consistence and
are in close apposition with one another; the labia minora or nymphæ are
covered by the labia majora and are but little pigmented; the vestibule
and the vaginal orifice are narrow, and the vagina itself is narrow,
tense, and markedly rugose; the hymen is normal and uninjured (this, of
course, is the most trustworthy of all the signs of virginity); the
breasts have the virgin conformation. In opposition to the plea that the
hymen can be destroyed by other causes than defloration, as by a fall,
especially a fall which brings the external genitals in contact with
some hard body, or by diphtheritic, variolous, or syphilitic ulceration,
_Maschka_ maintains that such occurrences are among the greatest
rarities.
On the other hand it is sufficiently well known that the presence of an
uninjured hymen affords no certain assurance of actual virginity. Cases
enough are recorded, both in older and more recent medical literature,
in which even pregnancy occurred in women in whom the hymen had remained
intact, the explanation being that during copulation penetration of the
penis had failed to occur, the semen being ejaculated on the vulva.
_Scanzoni_ and _Zweifel_ have recorded cases in which the intact hymen
offered a hindrance to parturition. The first-named author explains
these occurrences by the assumption that the hymen was so stout that the
penis was unable to rupture it. _Veit_ remarks that both male and female
youth, in these days of the continued advance of knowledge, are well
acquainted with _coitus sine immissione penis_, and that very frequently
a woman who is informed that she is pregnant makes answer that this is
impossible, her paramour having assured her that pregnancy could not
occur. On the other hand, cases are met with in which the aperture in
the hymen is a very large one, so large that the penis can penetrate to
the vagina without lacerating the membrane.
_Broudardel_ reports a case of rape in which the lacerated hymen healed
so completely that an expert maintained the integrity of the membrane,
until another pointed out the fine scar.
In general, that we may be assured of the existence of virginity, we
must find the hymen uninjured; and, on the other hand, we must regard
the laceration of the membrane, unless known to be the result of
gynecological examination or other manipulation, as a proof of
defloration.
In ancient times among savage races the integrity of the hymen was
prized as a proof of virginity, and in the Bible also great stress is
laid on this sign in connection with defloration, and its absence was
even regarded as a ground for the death punishment (Deut. xxii, 21). But
amongst other races the hymen was held in no particular esteem as a
token of virginity.
[Illustration:
FIG. 46.—Mamma, the breast of a virgin aged eighteen years. (From
Toldt: Atlas of Human Anatomy.—Rebman Company, New York.)
]
In ancient times, and even at the present day in the Philippine Islands,
the Ladrone Islands, and certain other islands of the Polynesian
Archipelago, also among many African tribes, the right of defloration
belonged, not to the bridegroom, but to every man belonging to the same
tribe; sometimes on the bridal night all the men of the tribe had access
to the bride, the bridegroom coming last, but thenceforward having
undisputed possession of his wife. Amongst certain other tribes a
similar custom prevails, differing however in this respect, that the
rite of defloration is performed by a priest or by one of the chiefs of
the tribe. In mediæval Europe, again, the great landed proprietors
exercised the well-known _jus primae noctis_ or _droit du seigneur_.
In girls at the time of the menarche who have long practiced
masturbation, some of the following indications of the habit will be
found: Elongation, redness, and general enlargement of the clitoris;
elongation and thickening of the nymphæ, which are also of a tough
consistency and deeply pigmented; flaccidity of the labia majora;
redness of the vaginal orifice; flaccidity of the hymen, which also may
exhibit lacerations, caused by the forcible introduction of the finger
or of some hard foreign body.
Not until the time of the menarche do the breasts attain the
hemispherical form which constitutes one of the graces of young
womanhood, and at the same time these organs assume a firm, elastic
consistency; their size of course varies in different individuals. The
nipple now has a rose-red color, darker in brunettes than in blondes; it
is usually small, sometimes quite inconspicuous, being withdrawn into a
cutaneous furrow. The two breasts when regarded from the front are seen
to diverge from the longitudinal axis of the body. In some cases even in
childhood, before the time of the menarche, the breasts are powerfully
developed, being as large as an apple or larger. This depends on
climate, race, and sexual excitement; as regards the last of these,
early sexual stimulation promotes premature mammary development.
Although it is unusual for any secretion to appear in the mammary gland
before the occurrence of pregnancy, cases have certainly been observed
in which the breasts of virgins secreted a milk-like fluid, especially
in consequence of sexual excitement or during menstruation. Thus
_Maschka_ observed in a girl the condition of whose genital organs
showed her to be a _virgo intacta_ that pressure on the breast caused a
few drops of an opalescent fluid having the appearance of milk to exude
from the nipple. She acknowledged that amatory relations had long
subsisted between her and a lover who was in the habit of handling her
breasts, and that this always produced strong sexual excitement.
_Hofmann_ also reported that in two virgins who died during menstruation
he was able to express a drop of milk from the breast.
The most important indication of the general changes occurring in the
external and internal genital organs, the proof that the young woman has
become fitted for the fulfilment of her reproductive vocation, is the
appearance of menstruation, a sanguineous discharge from the genital
organs recurring every four weeks as the external manifestation of the
internal process of ovulation.
The anatomical changes that have already been described as occurring in
the genital organs at the time of the menarche will serve to elucidate
the numerous reflex processes that manifest themselves at this period of
life in so many departments of vital activity.
It is especially the extensive developmental processes in the ovary,
influencing the nerves of that organ, which give rise to centripetal
stimuli and evoke reflex manifestations. In the working of the
circulatory system, such influences are apparent; and during the
menarche, some time already before the first onset of menstruation,
variations occur in the blood-pressure, and these during menstruation
take the form of a typical undulatory curve.
[Illustration:
FIG. 47.—Horizontal section through the female breast. (From Toldt:
Atlas of Human Anatomy.—Rebman Company, New York.)
]
Thus it becomes comprehensible that even in healthy girls, the first
appearance of the catamenia and likewise the expectation of the flow
induce a certain modification and alteration in the whole nature and
disposition. Girls often lose their previous cheerful and lively
character, becoming quiet, self-absorbed, sometimes even melancholy;
they are disinclined for study, have a repugnance to all sustained
physical or mental activity, become annoyed and snappish on slight
occasion, are restless at night, consider themselves to be ailing, and
so on. During the first menstruation girls commonly appear pale and
anxious, they have blue lines beneath the eyes, the face has a tired
aspect, the movements lack energy, and a general want of tone combined
with an abnormal irritability may be noticed. Some days before the first
menstruation, the vulva, the labia majora and minora, and the vaginal
mucous membrane, are swollen, the clitoris becomes conspicuous in
consequence of erectile processes, a slight secretion appears in the
genital passage, and the breasts become sensitive and slightly turgid.
The urine deposits a thick sediment, and occasionally severe strangury
is observed. In many cases, also, digestive disturbances occur, loss of
appetite, constipation, or a tendency to diarrhœa.
The first menstruation usually lasts four or five days. On the first day
the discharge is blood-stained mucus, thereafter becoming sanguineous.
In some cases, the bleeding at the first menstruation is profuse and of
long duration.
It is not always after the first menstruation that the subsequent
discharges follow at the regular intervals of four weeks. In delicate,
anæmic girls the second menstruation may not occur till several months
have elapsed after the first; less often the second menstruation ensues
a fortnight after the first, or even earlier.
At the time of the menarche the sexual impulse, which has hitherto been
dormant, becomes strongly developed. It is evoked at this time of life
by the anatomico-physiological changes undergone by the reproductive
glands; the stimulus aroused by these processes in the ovary, being
conducted to the brain, awakens passion. At the same time the
observation of the growth of the hairy covering on the genital organs,
the development of the breasts, and the appearance of menstruation, tend
to arouse erotic presentiments. The reading of romances, conversations
with female friends, and observation of the conduct of full-grown
persons, convert these presentiments into clear ideas, and excite the
impulse to the production of passionate sexual sensations, the sexual
impulse. How far these stimuli arising from the reproductive apparatus
are encouraged and accentuated, on the one hand, or repressed and
diminished, on the other, depends on external impressions of various
kinds. The environment is the determinant for the further transformation
of the as yet undifferentiated sexual impulse into the fully-developed
copulative and reproductive impulses.
In his work on the _Physiology of Love_, _Mantegazza_ describes the
yearning and stress of the awakening sexual life, arising out of the
presentiments, hazy sensations, and impulses, which are felt in the very
earliest period of the developmental phase known as puberty.
In general, in a young girl during the menarche, the sexual impulse
manifests itself rather in the form of semi-conscious reverie, of
platonic love. The adolescent girl exercises her imagination with the
circumstances of her chaste love, her mind turns to this subject when in
solitude, her mood is apt to become melancholy, and it is the perusal of
equivocal novels, or the educational assistance of sexually experienced
female friends, that transforms the sexual impulse to a vivid flame.
Some authors believe that a sign of the awakening of the sexual impulse
when directed toward some particular man is a change of color on the
part of the girl when she sees this individual or hears him spoken of.
Palpitation of the heart comes on, the pulse is increased in frequency,
the respiration also, and the voice fails. In this manner, it is
asserted, _Galen_ discovered the love of a Roman lady, Justa, for the
dancer, Pylades.
The psychological reaction of the sexual impulse at the time of puberty
manifests itself, as _von Krafft-Ebing_ points out, in manifold ways,
common to all of which, however, is the emotional state of the mind, and
the need that the strange and new feelings now experienced should find
some objective centre of interest. Such objective and emotional
interests lie ready to hand in religion and poetry, both of which, after
the period of sexual development is at an end, and the originally
incomprehensible desires and impulses have received an explanation,
continue to have intimate relations with the world of sexual experience.
Any one who doubts this must be reminded of the frequency with which
religious fanaticism makes its appearance at the time of puberty. No
less influential is the sexual factor in the awakening of æsthetic
feelings. This world of the ideal opens itself at the time when the
development of the sexual processes begins. * * * The love of early
youth, continues _von Krafft-Ebing_, has a romantic, idealizing
tendency. In its first manifestations it is platonic, and willingly
exercises itself in poetry and history. But as the sensibility awakens,
the danger arises that this passion, with its idealizing power, will be
transferred to persons of the opposite sex who in intellectual,
physical, and social relations are by no means all that could be wished.
Hence proceed misalliances, elopements, and seductions, with the entire
tragedy of impassioned love, which conflicts with the dictates of
morality and convention, and sometimes finds its bitter end in suicide
or a double self-destruction. Love in which the senses play too
prominent a part can never be a true and lasting love. For this reason,
first love is as a rule very transitory, since it is in most cases no
more than the first flare of passion. * * * Platonic love is a thing
without existence, a self-deception, a false description of sexual
sensations.
_Bebel_ remarks that the number of suicides among women of the ages of
sixteen to twenty-one years is an exceptionally large one, and he refers
this chiefly to unsatisfied sexual impulse, unfortunate love, secret
pregnancy, and to betrayal by men.