(_Precocious and Retarded Menstrual Activity._)
By the term _precocious menarche_ we understand the pathological state
in which a typical, four-weekly, sanguineous discharge from the female
genital organs sets in at an abnormally early age, and is to be regarded
as a symptom of a premature sexual development. Very commonly such
children with precocious menstruation and premature sexual development,
exhibit a comparatively high body-weight, great development of fat,
early dentition; they look older than their years; and they have genital
organs that also develop very early, with hair on the pubes and in the
axillæ; the labia majora and the breasts resemble those of full-grown
women, and the pelvis also has the adult form. Commonly also the sexual
impulse develops early, whilst, in other respects, the intellectual
development lags behind the physical. It is most probably a primary
hyperplasia of the ovaries that gives rise to precocious menstruation,
the ovarian follicles ripening earlier than usual. Frequently other
pathological processes are associated with this early sexual
development, such as general lipomatosis, rachitis, and new growths of
the ovaries. In several cases of this nature, early conception has also
been observed. According to oriental tradition, Khadijah was married at
the age of five years to the prophet Mohammed, who cohabited with her
three years later.
Even if we except those cases in which in earliest infancy there is a
sanguineous discharge from the vagina which remains, however, an
isolated occurrence, or if repeated is repeated a few times only and at
quite unequal intervals (cases in which the bleeding cannot be regarded
as menstrual—such, for instance as were reported by _Eröss_ of six
new-born female infants in whom a sanguineous discharge from the vagina
appeared three or four days after birth and lasted two to five days, the
infants not remaining subsequently under observation),—numerous
well-authenticated cases yet remain in which menstrual hæmorrhage was
observed before the end of the first year of life. One case, even, is
recorded by _Bernard_ in which from the time of birth to the twelfth
year menstruation with molimina occurred every month, lasting two days;
from the twelfth to the fourteenth year menstruation ceased, recurring
subsequently at irregular intervals.
In the recorded cases of such precocious menstruation the menstruation
recurred as a rule at regular intervals of four weeks; only in quite
exceptional cases were the intervals three to five months.
Some of the most striking and well-authenticated cases of precocious
menstruation recorded in the recent literature of the subject are
appended.
Observed by _Combys_: A girl aged 6 years and 2 months had the
appearance of a girl aged 14 or 15; she was a brunette, 3′ 10½″ in
height, with full, firm, rounded breasts, girth of chest 28⅓″, mons
Veneris covered with hair, uterus normal on rectal examination, hymen
intact; menstruation had occurred regularly since the second year of
life. Mother and five sisters began to menstruate between the ages of
twelve and fourteen. General condition good.
Case recorded by _Diamant_: A girl aged 6 years, weight 75 pounds,
thighs, buttocks, and breasts developed like those of a sexually mature
woman, axillæ and mons Veneris covered with hair. Menstruation began at
the age of 2 and recurred regularly, the flow lasting 4 days.
Case recorded by _Plyette_: A girl with precocious physical development
began to menstruate in the fourth year of life; menstruation continued
regularly with the exception of two monthly periods, when vicarious
epistaxis occurred.
From the collection made by _Gebhard_ of the records of fifty-four cases
of precocious menstruation, giving the first appearance and the type of
menstruation, the development of the breasts, the other signs of
premature sexual development, and any complications that may have been
observed, we extract the age at which the first menstruation occurred.
This was:
In a new-born infant in 1 case.
At the age of 2 weeks in 1 case.
At the age of 2 months in 1 case.
At the age of 3 months in 1 case.
At the age of 4 months in 1 case.
At the age of 5 months in 1 case.
At the age of 7 months in 1 case.
At the age of 9 months in 4 cases.
At the age of 10 months in 2 cases.
At the age of 12 months in 5 cases.
At the age of 15 months in 1 case.
At the age of 16 months in 1 case.
At the age of 18 months in 2 cases.
At the age of 19 months in 1 case.
At the age of 22 months in 1 case.
At the age of 2 years in 4 cases.
At the age of 2½ years in 1 case.
At the age of 2 years and 9 months in 1 case.
At the age of 3 years in 6 cases.
At the age of 3½ years in 1 case.
At the age of 4 years in 4 cases.
At the age of 4 years and 3 months in 1 case.
At the age of 5 years in 1 case.
At the age of 5½ years in 1 case.
At the age of 6 years in 1 case.
At the age of 6½ years in 1 case.
At the age of 7 years in 3 cases.
At the age of 9 years in 2 cases.
At the age of 11½ years in 1 case.
From this collection of _Gebhard’s_ we learn that in one case
menstruation already existed at birth, and that in a large number of
cases it occurred before the expiration of the first year. In many cases
the development of the breasts preceded the appearance of menstruation,
and was noticed from the time of birth. The vulva also early exhibited
the characteristics seen in the sexually mature woman. Further, a high
body-weight, great development of fat, and early dentition, were usually
seen in these cases, in which, however, the intellectual development was
not in correspondence with that of the body.
In several of these cases of premature puberty, moreover, sexual
intercourse and even parturition occurred at a very early age. A girl in
whom menstruation began at the age of one year, gave birth to a child
when she was ten years old (_Montgomery_). A girl who began to
menstruate at the age of nine years, became pregnant very shortly
afterward (_d’Outreport_). The well-known case recorded by _Haller_, in
which at birth the pubic hair was already grown, and in which
menstruation began at the age of two years, was also one of very early
pregnancy, the girl giving birth to a child when nine years old. Another
girl in whom at birth the pubes were already covered with hair began to
menstruate when four years old, copulated regularly from the age of
eight, and at nine years became pregnant, and was delivered of a
vesicular mole with an embryo (_Molitor_). A girl began to menstruate at
the age of two, had a growth of hair on the pubes and developed mammæ at
the age of three, and became pregnant at the age of eight (_Carus_).
With these cases must be classed that observed by _Martin_ in America of
a woman who was a grandmother at the age of twenty-six. _Lantier_, in
his Travels in Greece, speaks of a mother of twenty-five with a daughter
of thirteen.
Observations made by _Kussmaul_ and by _Hofmeier_ prove that in many
cases changes in the ovaries form the probable cause of precocious
menstruation and the other phenomena of premature puberty. In one case
of _Hofmeier’s_, for instance, of a girl of five with precocious
menstruation, the removal of a rapidly growing ovarian tumor was
followed by the cessation of menstruation, and the pubic hair, which had
been shaved off, did not grow again.
Abnormally early puberty related to the early practice of sexual
intercourse is seen in many prostitutes. This is shown by the following
figures relating to 150 prostitutes in Russia. Sexual intercourse began:
In 1 prostitute at the age of 9 years.
In 1 prostitute at the age of 10 years.
In 4 prostitutes at the age of 12 years.
In 12 prostitutes at the age of 13 years.
In 14 prostitutes at the age of 14 years.
In 33 prostitutes at the age of 15 years.
In 36 prostitutes at the age of 16 years.
Thus, among the 150 prostitutes, 65 were less than 16 years of age.
_Parent-Duchatelet_ found among 3,517 prostitutes under official
observation, 5.6 per cent. under 17 years of age. There were:
2 prostitutes under 10 years of age.
3 prostitutes under 11 years of age.
3 prostitutes under 12 years of age.
6 prostitutes under 13 years of age.
20 prostitutes under 14 years of age.
51 prostitutes under 15 years of age.
111 prostitutes under 16 years of age.
_Martineau’s_ observations also showed that in nearly all prostitutes
the first coitus took place in very early youth. Of 607 prostitutes
there were 489 in whom defloration had occurred between the ages of 5
and 20 years. According to _Grimmaldi_ and _Gurrieri_ defloration
usually takes place in prostitutes before they attain the age of 10
years.
Sometimes we find increased sexuality in early life as a pathological
manifestation—psychopathia sexualis. Thus, _Esquirol_ records the case
of a little girl aged four years who undertook improper manipulations in
association with little boys. A female prisoner, _Lombroso_ writes, had
at the age of six years practiced mutual masturbation with her brother
aged seven, and at the age of eight years underwent defloration; another
murderess, while still a schoolgirl, had conducted herself after the
manner of an experienced prostitute. _Laurent_ reports the case of a
girl who from the age of ten was engaged in sexual malpractices with her
brothers and sisters, and finally underwent defloration at the age of
fifteen.
In many cases premature sexual development is manifested by enlargement
of the breasts and growth of the axillary and pubic hair, and yet
menstruation fails to appear. Thus, _Kussmaul_ has observed girls who
while yet children exhibited all the external characteristics of
sexually mature women, but who had not yet begun to menstruate. _Ploss_
has published a photograph showing in a girl five years of age the mons
Veneris and the labia majora developed like those of a full-grown young
woman, and covered with long thick hair; in this case, however, not only
had menstruation not yet begun, but the breasts were still in the
infantile condition.
The opposite state to menarche praecox is that in which the first
appearance of menstruation is unduly delayed; it may be even till after
the age of twenty. Such a postponement of the menarche sometimes occurs
in girls who exhibit at this period of life an extraordinarily great
general fatty development of the body, or a notably severe chlorotic
state of the blood, or in whom during the years of development some
sudden and extensive change in the mode of life has occurred, as for
instance when the girl’s place of residence has been removed from the
country to the town, or when she has had to undertake some completely
new kind of physical or mental work. _Raciborski_ attributes the late
appearance of menstruation, at the ages of 20, 22, 24, or 26, in
otherwise healthy girls, to an “apathy of the sexual sense,” a phrase
which does not convey much meaning.
According to _Marc d’Espine_, puberty occurs early in girls with dark
hair, grey eyes, a delicate white skin, and of a powerful build; late,
on the other hand, in girls with chestnut hair, greenish eyes, a coarse
darkly-pigmented skin, and of a delicate weakly build.
The genitals of girls in whom the first appearance of menstruation is
delayed, frequently exhibit distinct signs of the backwardness of the
reproductive organs in their development. The external genitals, in such
cases, have little if any covering of hair, and are flabby and relaxed;
the body and the fundus of the uterus are shorter and more slender than
usual, the uterus as a whole is small and flaccid, sometimes anteflexed;
the vaginal portion of the cervix is small, often almost undeveloped,
its anterior lip barely projecting above the surface of the vaginal
fornix; the vagina is usually short and narrow. The ovaries also are
flaccid and inelastic, and occasionally are remarkably small. The
breasts are small, the nipples and areolæ undeveloped.
In other cases, notwithstanding the delay in the appearance of the
menarche, the genital apparatus is developed to a degree quite in
correspondence with the age, but some pathological condition is present,
for instance, the mucous membrane secretes excessively, exhibits a
catarrhal tendency, there are erosions at the os uteri, etc.