A series of disturbances of function and pathological changes in the
organs may occur at the time of the menarche, either directly connected
with the genital organs, or etiologically dependent upon the changes
occurring in these organs.
The commencement of menstruation, as we have already mentioned, may
itself be abnormal in character, being either precocious (menarche
precox), or retarded (menarche tardiva). But even where menstruation
begins in a normal manner, the period of the menarche may be disturbed
by a great number of pathological phenomena, of which the developmental
processes occurring in the genital organs of the young girl must be
regarded as the cause. First of all, the menstrual hæmorrhage itself may
be abnormal in amount and duration. Then, again, functional disturbances
of the most various character may occur: especially prominent are,
disturbances of hæmatopoiesis, of the cardiac functions, and of the
nervous system, and constitutional anomalies, which deserve attentive
consideration; in addition we have to mention disorders of digestion and
disorders of the sense-organs, among which latter certain changes in the
skin especially deserve attention.
The diseases of the female genital organs at the time of the menarche
are very various in nature. Whereas during infancy and early childhood
the uterus and its annexa are in a state of complete quiescence, so that
nothing occurs in them to attract attention, at the approach of puberty
these organs emerge from obscurity, and the percentage of diseases of
the reproductive organs suddenly rises to a great height. In very young
girls, among diseases of these organs, we observe only malformations,
malignant tumors, and gonorrhœal infections, and these pathological
states, even, are quite rare; but at puberty all this is altered, and we
have to do with disturbances of the menstrual function and their
consequences, and with various inflammatory processes, and the period of
sexual maturity offers us an overplus of diseases connected with the
reproductive system, justifying the epigram of the French gynecologist
who defined a sexually mature woman as “_un uterus servi par des
organes_.”[20]
_Anomalies of Menstruation._
Not infrequently, though the catamenial flow has appeared at the usual
age and has for a time been regular, pathological disturbances of this
function ensue.
Amenorrhœa at the time of the menarche may depend on complete aplasia of
the ovaries, associated with a rudimentary and imperfect development of
the uterus. In such girls, the development of whose reproductive system
is thus imperfect, the continually expected menstrual flow fails to
appear, in spite of the fact that a recurrent menstrual discomfort,
evoked by the congestion of the genital organs, recurs at intervals of
four weeks; as, for instance, colicky pains in the abdomen, irritable,
nervous states, and mental disturbances. Further, amenorrhœa may be due
to one of the various forms of atresia of the genital organs, as for
instance to vaginal or hymeneal atresia. In such individuals the first
period passes by without anything to attract attention. But at the
second period, distress will usually be manifested; and from this time
forward, painful contractions of the uterus will continue to occur at
four-weekly intervals, and to become more violent as period succeeds
period, whilst the menstrual discharge is wanting, or, to speak
strictly, fails to find an outlet. The blood collects behind the seat of
atresia, and the accumulation gives rise to pressure symptoms affecting
the bladder and the rectum, and ultimately also the sacral nerves.
Menstruation, after its first appearance in normal fashion, may be
suppressed in young girls in consequence of mental impressions, such as
sudden fright; such cases are observed after an escape from a fire, or
after a railway accident. Mental stimuli of less intensity but longer
duration have a similar effect; sometimes these take the form of
auto-suggestion. A well-known instance of the latter phenomenon is
furnished by the case of a girl who, in consequence either of actual
intercourse or it may be merely of too intimate an embrace with a man,
fears she has become pregnant, and actually suffers from amenorrhœa
though pregnancy does not really exist. I saw a case in which amenorrhœa
was thus produced in a girl seventeen years of age, whose ideas on the
process of sexual intercourse were still far from clear. She had
permitted a young man to kiss her repeatedly and fervently, and to clasp
her in a close embrace. She was then afraid that she had become
pregnant; the catamenial flow, which had been regular since she was
fifteen years old, ceased to appear; and it was not until at length I
was consulted, was able to assure myself that the girl was essentially
virgin, and was, therefore, in a position to reassure her as to her own
condition, that menstruation again became regular.
Functional amenorrhœa may also occur in young girls in consequence of a
sudden change in the conditions of life, a removal from town to country,
for instance, or the reverse, travel in regions where the climatic
conditions differ widely from those hitherto experienced, or a change
from an active to a sedentary kind of occupation. Of this nature is the
following case observed by _Winter_: Miss Q., aged 20; menstruation
began at the age of 13 and was regular thereafter; on three successive
occasions amenorrhœa occurred during a visit to Berlin, in one case
lasting 3 months, another 2 months, and a third 6 weeks, whereas when at
home menstruation was regular though somewhat scanty. There were no
molimina. Examination showed the wall of the uterus to be thin, length
of this organ 7 centimetres (2¾″), both ovaries distinctly palpable.
Such a form of amenorrhœa as this, commonly disappears when the girl
removes from the conditions unfavorable to the fulfilment of her sexual
functions to the conditions favorable to that function.
Not infrequently a chill is in young girls the cause of suppression of
the menstrual flow that has hitherto been quite regular, especially
effective in this respect being, standing in cold water, getting the
feet wet, the influence of rain and wind at the menstrual period on the
insufficiently clothed lower extremities, and vaginal injections with
water at too low a temperature. Such cases are common among the working
classes, especially in washerwomen; but they are also observed among the
well-to-do. An example is given by _Winter_: Miss H., aged 19;
menstruation began at the age of 13, regular, at intervals of 4 weeks,
the flow lasting 2 to 3 days, and being normal in amount. Several years
ago the patient caught a severe cold through paddling in cold water
during the period. Suppression of the menses resulted, amenorrhœa being
complete for a year and a half. Then menstruation recommenced, but was
irregular, sometimes anticipating, sometimes postponing the proper
period, the interval being occasionally as long as four months; when it
occurred, the flow was represented by a drop or two of blood only, and
dysmenorrhœa was severe. At each proper period, if the flow failed to
appear, severe molimina occurred in the form of abdominal cramps and
headache. Examination showed the uterus to be normal in shape, 4½
centimetres (1¾″) in length, with a very thin wall; both ovaries were
palpable, but smaller than normal.
The commonest form of amenorrhœa at this period of life is, however, the
constitutional amenorrhœa associated with chlorosis. In chlorotic
subjects we have to do, not with a symptomatic absence of the menstrual
discharge, but with a failure of the ovarian function, the graafian
follicles failing to ripen. We generally find, according to _Gebhard_,
that chlorotic girls begin to menstruate at the usual age, or even
earlier. Menstruation recurs once or twice at irregular intervals, and
then gives place to complete amenorrhœa, it may be suddenly, it may be
gradually, the flow on each occasion being scantier than before. In
chlorotic patients, the menstrual discharge, when present, is very thin
and watery, and often contains a large admixture of mucus derived from
the cervical canal and the cavity of the uterus. The amenorrhœa may be
of short duration; or it may last for a long time; so that it is not
until after the lapse of months or years, and as a rule in consequence
of suitable treatment, that menstruation recurs, being henceforward
either normal in frequency and strength, or on the other hand
permanently scanty and of the postponing type. The associated disorders
from which the patients suffer take the form of headache, dizziness,
syncope, feelings of oppression, disinclination for mental and physical
exertion, and so on. Since in such cases the ripening of the ovarian
follicles also fails to occur, when the amenorrhœa is complete the
menstrual molimina are generally wanting (_Gebhard_).
_Stephenson_ also states that in girls who have been chlorotic for a
longer or a shorter time, menstruation frequently begins very early, in
any case earlier than in healthy girls.
Usually in these cases various other disorders are associated with the
amenorrhœa, such as colicky pains in the abdomen, sensitiveness of the
abdominal wall to contact or pressure, headaches, attacks of hemicrania,
general mental depression, and hysterical manifestations.
In chlorotic girls, at the times when menstruation is due, a watery
discharge often occurs, sometimes slightly tinged with blood.
Dysmenorrhœa may also occur at such times.
Attacks of menorrhagia in young girls are usually dependent on
disturbances of the nervous system. Sometimes such an attack occurs at
the very first menstrual period. Occasionally also menorrhagia may occur
in association with chlorosis, to be distinguished according to
_Virchow_ from a rare condition named by him “menorrhagic chlorosis,”
characterized by excessive menstruation of an anticipating type. The
bleeding is in such cases seldom very profuse, however, but the periods
are very long, and the intervals exceedingly short. _Castan_ regards
such profuse menorrhagia and metrorrhagia occurring in young chlorotic
girls, especially at the commencement of puberty, as of an endoïnfective
nature dependent upon auto-intoxication. The toxins lead to inflammatory
and degenerative changes in the muscular substance of the uterus.
According to _Frænkel_ in these cases the ovaries are usually enlarged,
seldom smaller than normal.
_Frœlich_ has discussed this subject exhaustively in his monograph on
_Menorrhagia of Young Girls and Hypertrophy of the Cervix Uteri_.[21] He
states that the cases of menorrhagia in young girls at the time of the
menarche may be arranged in two groups. In one of these the patients are
chlorotic, and menstruation is normal neither in amount nor in duration,
but it is the long continuance of the flow rather than its profuseness
that gives rise to danger; in the cases belonging to the other group the
patients are in excellent health at the commencement of puberty, but
menstruation soon takes the form of long-continued and profuse
menorrhagia. Cases of the latter kind are due to hypertrophy of the
cervix uteri and fungous metritis. Such attacks of menorrhagia in young
girls are seen also in cases of infectious disorders, as in smallpox,
measles, scarlatina, and above all, influenza. The hæmorrhage often
begins in the first days of the infection, and even during the period of
incubation, one or two days before the appearance of the general
symptoms. If the patient is attacked by influenza while menstruating,
the menstrual flow may assume the character of a true menorrhagia. More
often, however, in such cases, we have to do with an extra-menstrual
hæmorrhage, such as may indeed be observed in girls who have not yet
begun to menstruate.
_Inflammatory Processes._
Chronic metro-endometritis, both corporal and cervical, occurs
occasionally in young girls during the years of development. It is
especially common in chlorotic subjects; and next to these in girls who
are careless about the observance of hygienic precautionary measures
during the menstruation. Thus it may result from physical exertion among
the working classes; and from dancing, skating, riding, or
mountaineering, among girls belonging to the well-to-do classes, during
menstruation. Again, we meet with it in girls who work very hard at the
sewing-machine; and, finally, in those who have long practiced
masturbation. Through uncleanliness at the time of menstruation, the
blood with which chemise and drawers are stained and the pubic hair
soiled, undergoes decomposition, and this may lead to catarrhal
inflammation of the vulva and vagina and of the endometrium. The most
striking symptom in persons thus affected is the discharge of mucus,
which in cervical metro-endometritis leads to a very moist condition of
the external genitals, and leaves greenish-yellow spots on the
under-linen; in corporal metro-endometritis the discharge is of a
thinner consistence, milky in appearance, and not very abundant. As a
result of the endometritis, the patient suffers from various pains in
the body, a feeling of fulness, sacrache, general sense of fatigue, and
diverse nervous manifestations; sometimes also from dysmenorrhœa,
strangury, or obstinate constipation. In consequence of the great
thickening of the mucous membrane that often occurs, menstruation
becomes very profuse and long-continued, lasting from one to two weeks.
A form of chronic vulvitis, sometimes, though indeed quite rarely, met
with in girls at this time of life, is inflammation of the external
genitals dependent on masturbation. As characteristic signs of this we
may observe an elongation of the nymphæ, the clitoris, or the præputium
clitoridis, and at the same time on the inner surface of the greatly
stretched labiæ we may notice a great increase in the sebaceous glands,
so that the yellowish spots formed by these structures may be seen
beneath the mucous membrane with the unassisted eye—the mucous surface,
indeed, may be slightly uneven in consequence of their enlargement, so
that they resemble small retention-cysts. The mucous membrane of the
vulva between the margin of the hymen and the nymphæ is moreover,
according to _Veit’s_ description of masturbatory vulvitis, often beset
with small pointed excrescences, the soft furrow between the clitoris
and the external orifice of the urethra being very commonly marked by
swelling of the mucous membrane and the presence of these little
outgrowths; but sometimes also the parts lying to either side of the
urethral orifice may exhibit similar changes. These small structures
differ entirely from pointed condylomata—they do not branch, they occur
only upon the vulval surface proper, not upon the parts exhibiting the
characters of true skin, and they are non-infecting. More particularly,
it must be remembered, we find these changes principally in virgins in
whom on account of obscure symptoms an examination of the genital organs
has been undertaken, and who suffer in addition from nervous and
hysterical manifestations. The hymen, when intact, as it usually is in
these cases, furnishes objective evidence that sexual intercourse is not
the cause of the patient’s trouble, and indeed a distinctly
ascertainable cause is hard to find. The patient usually exhibits
abnormal sensitiveness and excessive prudery. _Veit_ is of opinion that
the association of all these symptoms justifies the diagnosis of
masturbation as the exciting cause of the chronic vulvitis; in such
cases we may at one time find the mucous membrane pale, but at a later
examination fiery red, and we often see a clear, transparent secretion
exuding from the ducts of Bartholin’s glands.
In consequence of long-continued masturbation, other pathological
changes may take place in the female genital organs, such as hypertrophy
of the nymphæ, proliferation or glandular hypertrophy of the uterine
mucous membrane, ovarian irritation, pains in the ovarian region which,
in severe attacks, may radiate to the thighs. These pains become more
severe at the menstrual period, especially at the beginning of that
period; and are sometimes also especially troublesome in the middle of
the intermenstrual interval, in this case usually as a result of great
bodily exertion.
These morbid processes in the genital organs of young girls have long
attracted the attention of physicians, and it is more than sixty years
since _Bennet_ described the “virginal metritis” observed by him in
twenty-three virgins. _Bonton_ published in 1887 a monograph on this
condition. _Gallard_ assigns masturbation as its principal cause.
Retroflexion of the uterus is also sometimes observed in virgins,
induced by the bad habits which are so common in young girls of
retaining the urine for excessively long periods and of neglecting
constipation. The prolonged distension of the bladder leads to a daily,
long-continued stretching of the ligamentous apparatus of the uterus;
the full bladder presses the uterus backwards, and after the viscus has
been emptied, the flaccid ligaments are no longer able to restore the
uterus to its normal position of anteflexion. The organ is left with its
fundus directed backwards, and the intra-abdominal pressure keeps it
permanently in this position; at the same time, an accumulation of fæces
in the rectum, by pressing the cervix forward, favors this displacement
of the uterus. Moreover, when the uterine tissues are flaccid through
malnutrition in chlorotic or anæmic subjects, the organ yields more
readily to mechanical influences than it would if its muscular tone was
healthy.
_Disorders of Hæmatopoiesis._
Chlorosis is in general rightly regarded as a disease of the period of
puberty etiologically dependent on the processes that at this time of
life occur in the genital organs. Its appearance generally coincides
with the menarche, occurring at the age of 14 to 16, or even later, at
the age of 19 to 21. As regards the composition of the blood in
chlorosis, investigations have shown that its hæmoglobin-richness is
always diminished; its specific gravity is proportionately lessened, but
the specific gravity of the serum is normal. The erythrocytes are normal
in number, or only slightly diminished; their shape is sometimes normal,
sometimes, however, poikilocytosis is present. The leucocytes are
generally normal both as regards number and form; myelocytes
(_Markzellen_) are also described as present in the blood of chlorotic
patients (_Neusser_, _Hammerschlag_, _Gilbert_, _Weil_); the
blood-plates are normal in number, the alkalinity of the blood also
normal, the isotonicity of the erythrocytes rather low.
The relation of chlorosis to the menarche is variously explained.
_Kahane_, in his elaborate monograph on chlorosis, regards it as an
independent disease belonging to the group of “disorders of vegetation”
(_Kundrat_), one which “according to its essential nature is an
expression of the disharmony that obtains between the congenitally
inefficient hæmatopoietic apparatus and the demands made upon the
feminine organism by the processes of puberty.”
An insufficiency of the hæmatopoietic organs as regards their functional
capacity is believed by _Kahane_ to be in the case of women so far
physiological inasmuch as their blood is inferior to that of men in
hæmoglobin-richness and corpuscular richness to the extent of about 10
per cent. In this way the predisposition of the female sex to chlorosis
may perhaps be explained. A further fact which must be taken into
consideration is the difference between the development undergone by the
respective sexes at puberty. In the female sex, this development is
quickly completed, and has the characteristics of a revolution; but in
the male, the development is a more gradual one, and has the
characteristics of an evolution.
_F. A. Hoffmann_ also regards chlorosis as associated with the
development of the uterus and the establishment of menstruation. It is
possible that these processes exercise some reflex influence; but we
must also remember that the chemical processes involved in the growth
and maturation of the ovarian follicles are still insufficiently
understood, and that it is quite possible that these too may have
powerful and unaccustomed effects on the organism such as may well
disturb metabolic processes of a somewhat unstable character.
_Grawitz_, who regards chlorosis as a vasomotor neurosis in which
disturbances arise in the interchange of fluids between the tissues and
the vessels, refers the appearance of chlorosis at puberty to the
general disposition to disorder exhibited at this age by the vasomotor
system.
Other authors consider chlorosis to be an ovarian auto-intoxication,
believing that under certain conditions the ovaries give off into the
organism certain poisons; or, on the other hand, supposing that a
certain antitoxic function, normally possessed by the ovary, fails. _Von
Noorden_, for instance, regards chlorosis as a disorder of blood
formation referable to a disturbance of the internal secretion of the
ovary during the developmental period.
_Blondel_, who also regards ovarian auto-intoxication as causal, is of
opinion that chlorosis is induced by products of decomposition formed in
the organism during the process of growth. As in childhood the thymus
gland, so later in life the ovary, renders these products innocuous.
When this peculiar functional activity of the ovary is retarded in its
appearance, the intoxication effected by the products of decomposition
formed during the process of growth gives rise to chlorosis.
_Meinert_, in an interesting manner, brings the harmfulness of wearing a
corset during the years of development into etiological relations with
chlorosis. In the transitional period between childhood and the age of
puberty the wearing of the corset usually begins. Now _Meinert_
discovered that in chlorosis, as a result of wearing a corset, a
vertical or subvertical position of the stomach ensues as a partial
manifestation of enteroptosis, leading to tension on the abdominal
plexus of the sympathetic, which in turn results in changes in the
blood, and other nervous symptoms. According to this view, chlorosis is
a peculiar general neurosis dependent upon an artificially induced
gastroptosis; this form of enteroptosis being due, not to relaxation of
the suspensory ligaments of the abdominal viscera, but to pressure
exercised by adjacent organs in consequence of a change in the form of
the thorax, which has been permanently constricted by tight-lacing
(_fixierter Schnurthorax_).
Of importance is the fact that in girls suffering from chlorosis a
condition of hypoplasia of the genital organs is not infrequently met
with. It would seem, not only that imperfect development of the female
genital organs may be a cause of chlorotic changes in the blood, as
appears possible in view of the relations between the ovaries and the
hæmatopoietic organs through the intermediation of the sympathetic
system; but also that genuine chlorosis and the anomalies of the genital
organs met with in this disease, may perhaps be common manifestations of
some more general disturbance.
According to _Virchow_, two distinct forms of chlorosis are to be
recognized, one form in which no great abnormalities of the reproductive
apparatus exist, and another form in which imperfections in the
development of the central portion of the vascular system are associated
with similar imperfections in the reproductive apparatus. In many cases
of chlorosis, he found the ovaries small and imperfectly developed, in
an infantile condition; in other cases, however, they were three times
the normal size; the development of the uterus in such cases usually
corresponds with that of the reproductive glands. With regard to the
etiological connection between chlorosis and developmental disturbances,
_Virchow_ inclines to the view, that in chlorosis a predisposition,
either congenital or else acquired in early youth, must be assumed to
exist, but that this does not manifest itself by the production of
actual disorder until the arrival of puberty; and he considers it likely
that primary deficiencies of the blood and the vascular apparatus hinder
the development of the reproductive apparatus.
_Stieda_ found that in chlorotics displacements of the uterus were
common, with abnormal narrowness of the vagina, absence of the pubic
hair, imperfect development of the pelvis, and the growth of the breasts
interfered with to this extent, that the nipples and areolæ were
abnormally small. He classifies these manifestations as disturbances of
development in the sense that they are among the so-called stigmata of
degeneration. If in chlorotics the breasts in certain cases have a
normally full and rounded appearance, this appearance is sometimes
deceptive, the fulness being due, not to a proper growth of the
parenchymatous mammary tissue, but to an excessive deposit of fat.
Genuine chlorosis, therefore, not referable to some other primary
disorder, is a developmental disorder, in the sense in which various
other stigmata of degeneration met with in the human body are
developmental disorders, and is indeed frequently associated with other
stigmata of degeneration, or with malformations due to arrest of
development, as for instance, an infantile type of pelvis or of genital
organs, abnormalities of the cranial bones, vaulted palate, the root of
the nose broad and depressed, extreme prognathism.
_Hegar_ also maintains the view that chlorosis is in most cases a
developmental disturbance, the origin of which is not limited to the
so-called years of puberty; it often arises from noxious influences
which are either strictly inherited or began to operate when the infant
was still in her mother’s womb. _Frænkel_ is inclined to regard a
primary developmental disorder of the genital organs as the cause of
many cases of chlorosis.
Recently, _Breuer_ and _Seiler_ have undertaken experiments on bitches,
which they spayed at the outset of puberty, and from the results of
these experiments it seems probable that a disordered influence
exercised by the ovaries on the blood plays a part, at least, in the
pathological mechanism by which chlorosis is induced.
The intimate relationship believed to exist between chlorosis and the
sexual life of woman finds expression in the opinion, which dates back
to the days of antiquity, and has been widely held even by physicians,
that the disease (hence designated _morbus virgineus_ or _febris
amatoria_) is due to sexual abstinence in individuals with powerful
sexual impulse, and that for this reason chlorosis is often cured by
marriage. This result of marriage, which, though apparent merely, may
indeed often be witnessed, is explained by _Kahane_ on the ground, that
in very many cases, the symptoms of chlorosis become less severe after
the first five years have elapsed since the commencement of puberty, the
improvement occurring quite independently of the marriage or continued
celibacy of the sufferer. The influence of marriage in curing chlorosis
is thus apparent merely to this extent, that a very common age for
marriage in women is precisely in the twentieth, twenty-first, or
twenty-second year, when five years have passed since menstruation
began. By this time the organism will to a large extent have become
accommodated to the demands made upon it by the processes of puberty.
Experience also shows that chlorotic girls sometimes continue to suffer
from the various symptoms of chlorosis even after they have become
wives, and that chlorosis is not infrequently rendered more severe by
the puerperium—but in a wife it is no longer customary to describe such
symptoms by the name of chlorosis, they are called anæmia, hysteria,
nervousness, etc. Further, in order to give the doctrine of morbus
virgineus its death-stroke, _Kahane_ directs attention to the fact that
numerous cases of chlorosis are met with in young girls who are far from
practicing sexual abstinence, especially, for instance, amongst the
lower classes, amongst whom it is hardly customary to wait for marriage
before beginning sexual intercourse. The connection between masturbation
and chlorosis, which has also been widely alleged from the etiological
standpoint, is moreover one that cannot be admitted. On the other hand
it is easy to understand that the erotic reveries which are so often
seen in chlorotic girls are very likely to induce the habit of
masturbation.
In young girls at the time of the menarche, especially in those who
suffer from amenorrhœa or from irregular menstruation, the anæmic form
of obesity not infrequently develops. Such patients at the time of
puberty exhibit signs of marked anæmia in association with a notable
increase in fat. The skin in such cases is always strikingly pale and of
a whitish-yellow color; in bodies which are in other respects beautiful
the bust may have the appearance of a marble statue. Such girls are
strikingly stout, but the fatty tissue is flaccid, soft, and spongy, and
dependent parts readily become œdematous; the muscular system is
generally feeble.
What especially characterises this anæmic form of lipomatosis in young
girls is, that, even in mild forms of the affection, cardiac symptoms
are apt to become prominent. Frequent and violent palpitation will occur
even in the absence of any severe exertion or especial excitement, often
also we see shortness of breath, precordial pain, anxiety, respiratory
distress, and sensations of chilliness and fatigue.
The principal cause of the obesity in these cases is to be found in the
anæmia, inasmuch as the diminution in the number of the erythrocytes is
a diminution in the number of the oxygen-carriers, and this entails
defective and insufficient oxidation. The deficiency in the albuminous
constituents of the body also gives rise to a rapid and extensive
deposit of fat, the power for the combustion of the fats absorbed from
the food being insufficient. An auxiliary factor in producing obesity in
such anæmic girls is their disinclination to physical exercise,
dependent on the speedy onset of sensations of fatigue. The
long-continued repose of the muscles, and the remaining almost
continuously in close rooms insufficiently supplied with oxygen, also
result in the withdrawal from the blood of the circulating fat and its
deposit as adipose tissue.
Albuminuria at the time of the menarche is a disease of development
which is not infrequently met with in chlorotic girls, as in adolescent
boys. On examination of the urine in such young girls we detect the
presence of a variable quantity of albumin, which is present especially
after severe physical exertion, mental application, or emotional
excitement, whilst the urine secreted at night is usually free from
albumin. The skin is pale, the accessible mucous surfaces are
comparatively colorless, the face is puffy, the eyelids are œdematous;
the patients suffer from various nervous troubles, especially headache
and dizziness, and they are also liable to dyspeptic disorders.
The cause of this albuminuria of puberty is according to _von Leube_ in
part disordered hæmatopoiesis, in part a slight degree of cardiac
insufficiency with a tendency to stasis. At the time when the processes
of development and the growth of the body in height are most active,
there is not a corresponding increase in the energy of hæmatopoiesis,
and the heart also fails to keep pace with the growth of the body and to
meet the demands thus made upon it by vigorous growth and increased
energy. In general the capacity of the heart in such individuals is
indeed sufficient to maintain the circulation through the kidneys; but
as soon as the functional activity of the heart is more strongly taxed
and the energy of the circulation consequently declines, albuminuria
occurs—and occurs all the more readily in consequence of the fact that,
the hæmoglobin-richness of the blood having been lowered by the
customary anæmia, the epithelium of the renal glomeruli is badly
nourished and functionally inadequate.
When the period of the menarche is safely passed, when the menses recur
with regularity, and the chlorotic manifestations disappear, when the
process of hæmatopoiesis has improved in quality, and the growth of the
body is completed—when, in short, the functional equilibrium of all the
vital processes becomes re-established, the albuminuria of puberty
ceases. It seems, however, that those who have suffered in this way are
predisposed to a return of the albuminuria at the climacteric period,
when the metabolic balance is once more disturbed.
_Cardiac Disorders._
The commonest cardiac disorder at this period of life is nervous
palpitation, occurring in young girls who are in other respects in good
health, being free from anæmia and from any discoverable disease of the
heart or vessels. That this disorder is dependent on the sexual
processes is indicated by the fact that it first manifests itself in a
stormy manner some time, weeks it may be or months, before the first
appearance of menstruation; recurring at irregular intervals, the
attacks continue till after the first menstruation, and cease soon after
the regular return of the period. Objectively, the palpitation of the
heart manifests itself by an increase in the frequency and strength of
the cardiac impulse, and increased frequency and tension of the pulse;
in a few cases, however, it is perceived subjectively only by the
patient, as a distressing sensation of excessively frequent and powerful
cardiac action. In the former group of cases, the enhanced activity of
the heart is perceptible, not only by auscultation, by which we usually
find the heart-sounds quite pure, but also by inspection, which shows us
the violent agitation of the thoracic wall and increased pulsation of
the carotids. On percussion, no change is found in the area of cardiac
dulness. The frequency of the pulse is increased, usually reaching 120
to 140 beats per minute; it is full, and may be intermittent or
irregular. In those cases in which the palpitation of the heart is a
purely subjective sensation, we find no increase either in the frequency
or in the strength of the pulse, which may indeed be less frequent than
normal. With the palpitation is associated a sensation of strong
pulsation in the great vessels of the neck, and often there is pain on
the left side of the lower part of the chest, with a sensation of
shortness of breath, respiratory distress, precordial pain, and a
feeling of pressure upon the chest. Respiration is shallow, and
abnormally frequent. The attacks of palpitation recur daily in some
patients, in others at intervals of several days; they may occur
entirely without exciting cause, or with a cause so trifling that it
would not in a normal subject have produced any nervous excitement; the
duration of the attacks varies from a few minutes to several hours, and
they may occur either by day or by night; in the intervals between the
attacks the functions of the heart and the arteries are conducted in a
normal manner. The pulse-curves I have obtained during the attacks of
palpitation, in those cases in which the manifestations were objective
as well as subjective, exhibit a high pulse-wave, the upstroke being
rapid and steep, the downstroke also sudden and steep, the predicrotic
elevation but little marked, the dicrotic elevation often very distinct.
Less frequent than such attacks of palpitation recurring at irregular
intervals are paroxysmal attacks of tachycardia, in which the frequency
of the heart and pulse is increased to an enormous extent. This disorder
manifests itself a little time before the first appearance of
menstruation, thenceforward recurring regularly every three or four
weeks, accompanying menstruation, or occurring at the proper menstrual
period if menstruation is in abeyance; the attacks last several days.
This trouble also disappears a few months after the establishment of
menstruation.
Associated with these cardiac troubles are, not constantly indeed, but
in the majority of cases, disturbances of the digestive organs.
From the heart-troubles already described, another group of cases must
be distinguished, which are also observed at the time of the menarche.
They occur in girls in whom the first appearance of menstruation is
strikingly delayed, not having yet begun at the ages of 18, 19, or 20
years, or in whom considerable irregularities have occurred in
connection with the commencement of menstruation. In such girls, in whom
menstruation has appeared late and been irregular, or who are perhaps
entirely amenorrhoeic, cardiac troubles may be so pronounced that the
physician may be led to suspect the presence of organic disease of the
heart. The most prominent symptom is frequent and violent palpitation,
with strong pulsation in the carotids, respiratory distress, and feeling
of anxiety, on continued exertion or even on very slight occasion. On
percussion, the heart is not found to be enlarged; on auscultation, the
heart-sounds are found to be very loud, often with a systolic murmur in
the mitral region, whilst over the lower end of the internal jugular
vein, the humming-top murmur (_bruit de diable_) is audible. The pulse
is increased in frequency, at times arhythmical, and easily
compressible. The sphygmographic tracing usually shows a subdicrotic or
dicrotic character. The upstroke is not high; the downstroke descends
low, almost to the lowest level of the curve, before the enlarged
dicrotic elevation begins. The skin is always strikingly pale, pale also
are the visible mucous surfaces, the hæmoglobin-richness and the
corpuscular richness of the blood are considerably diminished, a feeling
of fatigue and various other nervous manifestations are constantly
present—in short, in all cases we have to do with the well-known
chlorotic disposition, sometimes in association with the manifestations
of the anæmic form of lipomatosis universalis. In several such cases,
skin affections were also present. Some suffered from acne vulgaris of
the face with the usual comedones; others perspired profusely from the
palms of the hands and the soles of the feet; others exhibited a bluish
coloration of the nose and the ears.
There is yet a third form of heart trouble, much rarer indeed than the
forms already described, from which young girls sometimes suffer at the
time of the menarche. It occurs in girls who just before the first
appearance of menstruation have grown very rapidly, “shooting up to a
great height.” They are not anæmic, nor do they appear “nervous;” but
they are extremely thin, and they have grown enormously in height during
the previous year. These individuals also, who in the previous course of
their life have been free from heart trouble, now complain of cardiac
distress. As in the cases previously described, they complain of severe
palpitation, a feeling of fulness in the chest, shortness of breath on
exertion, etc.; but the results of the objective examination are very
different. The cardiac dulness is increased in area, especially in
vertical extent, the apex-beat may be normal in position or displaced
outwards, the impulse is always heaving, abnormally powerful and
resistant, the heart-sounds, especially those of the left ventricle, are
louder than usual, the aortic second sound accentuated, sometimes
ringing, the carotids pulsate visibly. The radial pulse, the tension of
which is abnormally high, can be compressed by the finger only with
difficulty; sometimes it is jerky in character. The sphygmographic
tracing shows a rapid and steep upstroke; in the downstroke, the
predicrotic elevation is much larger than normal and also nearer the
summit of the curve. Thus we see that all the signs of cardiac
hypertrophy are present, hypertrophy, that is to say, of the left
ventricle.
The cases of this nature that have come under my observation have not
been in girls of the working classes, but among the well-to-do. We
cannot therefore regard them as due to overstrain of the heart in
consequence of excessive bodily exertions, comparable to the cases met
with in young recruits after long marches and violent exercise. We must
rather assume that the development of the female genital organs has
evoked a storm in the cardio-vascular system, more especially that in
some way an increased resistance has been offered to the work of the
heart, and that thus the hypertrophy has been brought about; though we
may suppose that other unfavorable influences have also been in
operation. Such an influence, in these cases, is the rapid growth of the
body, which makes enhanced demands on the work of the heart; another is
furnished by the almost universally worn unhygienic article of clothing,
the cuirass-like corset, which offers a rigid hindrance to the rapid
growth of the female body, to the development of the breasts, the
thorax, and the upper abdominal organs, and which fails to accommodate
itself to the changing conditions of growth, so that much extra work is
thrown upon the heart. In such young girls we have very frequently found
tight stays, which were worn unchanged without regard to the growth of
the body in length, and which, by pressure on the epigastric region,
elevation of the diaphragm, and limitation of the respiratory movements
of the thorax, actually offered such considerable resistances to the
driving power of the heart, as ultimately to lead to hypertrophy of the
cardiac muscle.
Summing up our observations, we find that at the time of the menarche
cardiac disorders occur in young girls which may be arranged in three
groups of cases:
1. Nervous palpitation and paroxysmal tachycardia in persons in other
respects in good health, the affection appearing shortly before the
commencement of menstruation, and disappearing soon after the flow is
regularly established.
2. Cardiac disorders occurring in young girls suffering from chlorosis,
which itself results from the processes of the menarche.
3. Cardiac hypertrophy developing at the time of the menarche, and
dependent on the circulatory disturbances associated with that process,
its appearance being favored also by rapid growth of the girl and by
unsuitable clothing (tight lacing).
With respect to the activity of the heart and the circulation of the
blood at the time of the menarche, the little-known observations made by
Beneke, on the growth of the heart and arteries in the various stages of
development, deserve especial attention. According to this writer, the
growth of the heart is slow until the age of fifteen years is attained,
but becomes accelerated at the commencement of puberty. During this time
of puberty, the blood-pressure attains its highest level, being
comparatively low in childhood and later in life. The development at
puberty of the female heart is less extensive than that of the male
heart, and for this reason throughout adult life the capacity of a
woman’s heart is on the average 25 to 30 cubic centimeters (1.5 to 1.8
cubic inches) less than that of a man. In women, also, the great
arteries are on the average somewhat smaller than in men. The various
arteries do not develop with equal rapidity throughout the period of
growth; after puberty the common carotid grows very much more slowly
than the common iliac artery, the former vessel being the only large
trunk which has already nearly reached its maximum size at puberty.
The comparatively great development which the heart undergoes at the
time of puberty is a phenomenon so important alike in its physiological
and its pathological relations that it deserves the special designation
of the _puberal development of the heart_; the commencement and the
completion of puberty appear beyond question to be to a large extent
dependent upon this development of the heart and upon the simultaneous
rise in the blood-pressure of the systemic circulation due to the
comparative diminution in the calibre of the arteries.
In the literature of this subject of cardiac disorders during the
menarche, we find only short annotations on palpitation of the heart in
young adolescent girls, and on cardiac manifestations in chlorotic
subjects. Further, the statistical fact that valvular lesions of the
heart are commoner in women than in men is by many authors explained on
the ground that the disturbances of the time of puberty, which certainly
occur more frequently and are more severe in the female sex than in the
male, play an important part in their causation. Changes also in the
vessel, such as cirsoid aneurysm (_angioma arteriale racemosum_), are
supposed to be connected with the sexual processes of this period of
life. _C. Heine_ maintains that in consequence of puberty and of the
sexual functions that become established at this period, a
telangiectases will not infrequently undergo transformation into a
cirsoid aneurysm; especially in cases in which menstruation is scanty
and irregular, angiectatic tumors may exhibit a vicarious periodic
increase.
_Krieger_ describes nervous palpitation and also “cramps of the
heart”[22] as occurring in girls who have not yet begun to menstruate,
in the form of prodromal manifestations; similar attacks may occur also
at every menstrual period in girls in whom menstruation is fully
established. In most of these cases the pulse is increased in the
patients who complain of a sensation of anxiety, and speak of feeling
the heart roll, tremble, or flutter, to which is sometimes superadded a
sensation of sudden cessation in its activity. Not infrequently there is
a blowing adventitious sound, masking or accompanying the heart-sounds;
there are also venous murmurs, especially when the heart-trouble is
associated with anæmia or chlorosis. Of the cases of pseudo-angina
pectoris[22] observed by _Krieger_, the attacks occurred as prodromal
manifestations before the first appearance of menstruation in 22 per
cent. of the cases, after menstruation was fully established in 78 per
cent. of the cases; as regards the relation of the attacks, in cases of
the latter group, to the menstrual period, they occurred before the flow
in 33 per cent., during the flow in 67 per cent.; menstruation was
irregular in 10 per cent. of the cases under observation, in most of the
other cases menstruation had been irregular, but was now regular.
_Hennig_ records a case in which he observed as a prodromal symptom
before the establishment of menstruation the regular recurrence of
congestion of the pelvic organs associated with cardiac disorder.
_Diseases of the Nervous System._
The extensive transformatory processes occurring in the genital organs
of young girls at the time of the menarche, and the powerful impression
which the new thoughts, hopes, and fears excited at this period of life
cannot fail to exercise on the nervous and emotional life, will enable
us to understand how it is that the appearance of the first menstruation
may give rise, especially in neurasthenic or psychopathic subjects, to
manifold nervous disturbances and also to disorders of the mind.
Amongst the severe neuroses and psychoses liable to occur at the
menarche in those suffering from congenital nervous weakness, in those
the conditions of whose life are very unfavorable, and in those affected
by some sudden disagreeable and powerful influences, we may enumerate:
Hemicrania, precordial pain, hysteria, and epilepsy; impulsive
manifestations, such as bulimia, longings for various unsuitable things,
kleptomania, and pyromania; severe feelings of anxiety; various forms of
psychoses.
On the other hand, the first appearance of menstruation has sometimes a
favorable influence in girls suffering from nervous or mental disorder.
This is seen, for example, in cases of chorea in fully developed,
rapidly growing girls who have not yet begun to menstruate; in such
subjects the chorea sometimes disappears as soon as menstruation is
regularly established.
Quite frequently, the first appearance of hemicrania in young girls
coincides with the menarche. According to _Warner_, hemicrania made its
first appearance:
In 1 girl of 3 to 4 years.
In 2 girls of 5 to 6 years.
In 1 girl of 6 to 7 years.
In 5 girls of 8 to 9 years.
In 5 girls of 9 to 10 years.
In 4 girls of 10 to 11 years.
In 2 girls of 11 to 12 years.
In 4 girls of 12 to 13 years.
In 15 girls of 13 to 15 years.
Toothache, according to _Holländer_, in the early days of puberty
sometimes exhibits the twenty-eight-day type of menstruation. The same
periodicity has been recorded in cases of vicarious bleeding from the
gums in girls suffering from disturbance of the menstrual function.
In the period of the menarche and before this period, chorea minor
occurs, as a functional disturbance of the motor region of the nervous
system, and especially in girls is it associated with the processes of
the period of physical development. The statistical data supplied by a
number of authors, _Hughes_, _Pye-Smith_, _Russ_, _Sée_, and _Steiner_,
show that the proportion of boys to girls affected with chorea minor is
1 to 2.8, and that of all ages 49 per cent. of the cases occurred at the
ages of 6 to 11 years, 29.8 per cent. at the ages of 11 to 13 years. In
several cases, in quite young girls suffering from chorea, pathological
changes were found in the genital organs. Thus, in 24 out of 27 girls
from the age of 9 to 15 years affected with chorea, _Marie_ found the
symptom-complex designated by _Charcot_ as _ovarie_. Ovarian tenderness
was manifested on palpation, and always on that side on which the chorea
had first manifested itself. _Leonard_ found in a girl aged eleven
suffering from chorea, adhesion of the præputium clitoridis; after the
separation of the prepuce, the chorea disappeared.
As in respect of various nervous affections, so also in respect of
various mental abnormalities, we witness at the time of the menarche
numerous manifestations confirming the statement that, “no spinal reflex
has such widely-opened and easily accessible paths of conduction toward
the organ of mind, as the sexual reflex.” “The menstrual process,”
continues _Friedmann_, “is the only bodily process in relation to which
the organ of mind somewhat readily loses the remarkable stability of its
equilibrium.”
In the experience of all alienists, it is, speaking generally, the
inherited psychopathic tendency that especially manifests itself at
the time of puberty; and it appears that this predisposition, the
manifestations of which the resisting powers of childhood have
hitherto been competent to suppress, undergoes a sudden and stormy
development in consequence of the action of the menstrual stimulus,
leading to the unexpected appearance of mental disorders. The
commonest of these are mania and melancholia of the ordinary type, the
prognosis in first attacks being favorable; next in frequency to these
are the psychoses characterized by fixed ideas, which usually
terminate favorably after a short time; finally, we meet with the
moral psychoses of puberty, and the form of melancholia distinguished
by _Kahlbaum_ as _Hebephrenie_,[23] the prognosis of which is very
unfavorable, for it speedily terminates in dementia, similarly to the
dementia of puberty described by _Svetlin_, dependent upon or
associated with premature synostosis of the cranial bones. Very often
we witness at puberty the beginning of the periodic varieties of
mental disorder, which develop into periodic menstrual psychoses,
manifesting themselves regularly at the recurrence of every menstrual
period.
The fact that hysteria often first manifests itself at the time of the
first appearance of menstruation was noticed already by _Hippocrates_,
who indeed believed that the association was sufficiently explained by
the well-known manifold relations between this nervous disease and
disturbances in the female genital organs. The first hysterical attack
often coincides with the first menstruation; or the first menstruation
may lead to the recrudescence of hysteria which had manifested itself
previously, but had passed into abeyance. We have to deal chiefly with
the minor forms, such as uncontrollable and unconditioned attacks of
laughing and crying, globus hystericus, clavus hystericus, etc.;
hysteria major, on the other hand, is very seldom observed at the time
of the menarche. As regards the frequency of hysteria at the time of
puberty, we append certain statistical data.
_Landouzy_ found:
4 cases of hysteria occurring at the ages of 1 to 10 years.
45 cases of hysteria occurring at the ages of 10 to 15 years.
105 cases of hysteria occurring at the ages of 15 to 20 years.
80 cases of hysteria occurring at the ages of 20 to 25 years.
After the age of twenty-five is attained, the frequency of hysteria
declines very rapidly.
According to _Bernutz_, all the statistical data prove that hysteria in
more than half the cases first manifests itself either just before or
simultaneously with the commencement of menstruation. It seems also that
at the time of puberty amenorrhoeic and dysmenorrhœic manifestations may
give rise to the development of hysteria. In girls at this time of life,
hysteria seldom takes the form of the great hystero-epileptic crisis,
manifesting itself rather as nervous and moody states of mind, moral
changes, weakness of will, in association with various forms of
anæsthesia, spasm, and paralysis.
On the threshold of puberty the girl with a hereditarily neuropathic
disposition may exhibit a tendency to epilepsy. In such cases, as
_Kowalewski_ writes, the patient has sudden attacks of loss of
consciousness, commonly ushered in by a wild scream; during the attacks,
tonic and clonic muscular spasms occur, the patient is completely
insensible, the pupils are dilated and do not react to light, the
pulse-frequency is increased—in short, the typical phenomena of an
epileptic fit are exhibited. The loss of consciousness lasts from two to
three minutes; and when the girl recovers, she remembers nothing of what
has occurred during the fit. Though consciousness has returned, the mind
is still at first somewhat disordered; but this disorder soon passes
off, the girl becomes calm, and forgets what has happened. The physician
is summoned, but in ninety-nine cases out of a hundred, he assures the
relatives that “the attack is nothing of any consequence—a simple
fainting-fit, the result of menstruation—a transient trouble merely.” A
second “fainting-fit” disturbs the calm of the parents, but the
reiterated authoritative assurance of the physician that “the trouble
will soon pass away” restores their confidence; and they gradually
become accustomed to the “fainting-fits” from which their daughter
suffers at each successive menstrual period. The daughter marries, and
gives birth to neuropathic and psychopathic children, and every one
wonders what can be the cause of this misfortune. Hence it is necessary
to pay careful attention to these “fainting-fits during menstruation.”
In the great majority of cases they are in fact epileptic seizures, and
as such they must be treated. _Binswanger_ points out that in such
cases, in which epilepsy first appears at the commencement of
menstruation, the attacks may continue to accompany menstruation for
several years thenceforward. Already established epilepsy is said by
some authors, _Lawson Tait_, _Tissot_, and _Marotte_, for instance, to
undergo at puberty in young girls an increase both in the severity and
in the frequency of the attack; _Esquirol_, on the contrary, attributes
to puberty a favorable influence on the course of epilepsy, a view held
already by _Hippocrates_.
Not infrequently, attacks of precordial pain associated with tachycardia
occur during the first menstruation. These attacks are usually of short
duration.
Acromegaly, a disease regarded as a trophoneurosis, also requires
mention here, this disturbance of growth being considered by several
authors, and especially by _W. Freund_, to be in some way connected with
the development of puberty; the tendency to acromegaly, it is suggested,
is produced by the remarkable transmigration that occurs at puberty of
the energy of growth from its accustomed paths into new channels. The
relations which _Neusser_ has shown to exist between the ovaries on the
one hand and the vegetative nervous system and the process of
hæmatopoiesis on the other, give a certain amount of support to this
hypothesis, even though we have no intimate knowledge of disturbances
occurring in the reproductive system during the period of development,
which might have an influence in the causation of acromegaly.
Of old and of recent observations on the psychoses connected with the
menarche, there is no lack. From the time of _Hippocrates_ down to the
present day, the authorities have continued to report cases in which the
commencement of menstruation proved the exciting cause of the appearance
of psychoses. _Rousseau_ writes of a girl at the time of the menarche,
who before the first appearance of menstruation suffered from attacks of
melancholia and a tendency to pyromania, and under the influence of the
latter tendency she twice committed acts of incendiarism.
According to _Kirn_, the psychoses that manifest themselves in the first
period of the commencement of menstruation, sometimes melancholia,
sometimes amentia in the form of slight and transitory maniacal
derangement, more rarely a katatonic[24] condition, may precede the
menarche, or may accompany or follow it.
A special form of psychosis is associated with the menarche (_von
Krafft-Ebing_, _Griesinger_, _Friedmann_, _Schönthal_). The influence
exercised by puberty in this direction manifests itself in various ways,
and is the more powerful for the reason that several factors are in
operation, each of which exercises an individual influence upon the type
of the psychical affection; these factors are, childhood, the
development of puberty, and the periodicity of the disturbance exercised
by the menstrual reflex. The last named of these influences is the most
potent. It manifests itself in the following manner: Certain psychoses
which develop before the commencement of menstruation or during the
suppression of the flow, undergo modification when menstruation appears;
further, in the typical menstrual psychoses of psychopathically
predisposed girls, the attacks recur either at the beginning of each
period, or, when the flow is in abeyance, at the dates when it should
appear—the menstrual stimulus thus being the exciting cause of the
successive attacks in an organ of mind whose resisting powers are
deficient; and, finally a disturbance in the development of menstruation
may be, not merely the exciting cause, but the efficient cause of the
psychosis.
In cases of the last kind, which have been observed by _Schönthal_ and
also by _Friedmann_, who has described them very fully under the name of
primordial menstrual psychosis, we have to do with young girls in whom
the appearance of menstruation is retarded, or in whom the flow has been
suppressed very soon after its commencement. The girls were as a rule
hereditarily well endowed, and the psychosis thus appeared without
warning, like a storm from a clear sky. Exactly periodical in form and
character, the period of recurrence being three or four weeks, this
psychosis clearly showed its dependence upon menstruation; the
individual attacks usually lasted a few days only, and were
characterized by distinct mental disorder, in the form either of
maniacal restlessness, or of dominant depression; vasomotor disturbances
were very prominent, with disordered pulse, as for instance, a rapid
rise in the pulse-wave just before the onset of the attack, succeeded
during the attack by a correspondingly rapid decline.
_Friedmann_ enumerates a number of the peculiarities that characterize
these attacks. The general course of the malady is an exceptionally
stormy one. The ultimate cure may coincide with the definite
regularization of menstruation; or, in cases in which menstruation is
restored but remains inadequate, the course of the disorder may become a
gentle undulatory one, the violent stimulus of total suppression being
replaced by a more moderate stimulus—here also, however, a cure
ultimately follows when menstruation at length becomes free as well as
regular. But during the height of the malady a proper development of
menstruation is always wanting. The total duration of the malady may
vary from as little as two to as long as nine months, or even longer.
The cure is, however, ultimately a complete one. The combination of a
disturbed and delayed development of menstruation with a stormy periodic
cycle of attacks of mental disorder, and the ultimately favorable
termination, constitute according to _Friedmann_ the peculiar
characteristics of this form of puberal psychosis.
_Masturbation._
Masturbation is sometimes practised in very early childhood, being then
commonly due to local irritation of some kind, as for instance when
threadworms find their way into the vagina. Itching results, leading the
child to rub the genital organs. This rubbing produces a pleasurable
sensation, and gives rise to repeated masturbation. But in adolescent
girls at the time of the menarche, a vague impulse arises to handle the
genital organs, depending upon cerebral processes which are themselves
the result of sexual sentiments, of reading, or of conversations with
sexually instructed female friends. This vague impulse may lead to
masturbation, and will do so earlier and more surely if the girl is a
neuropsychopath by inheritance. The local influence of menstrual
congestion, however, also plays a part in provoking the impulse toward
masturbation, since at every period a hyperæsthetic state recurs in the
genital organs.
Girls thus addicted have sometimes a very striking general appearance.
They are pale, with a weary expression of countenance, their eyes are
dull-looking and darkly ringed, their movements are sluggish, they like
to spend a long time in bed—signs, however, which I by no means wish to
adduce as characteristic of onanists.
Temperament and mode of life are decisive in determining the greater or
less frequency of the habit of masturbation in young girls. Girls of a
passionate temperament, those also who from early childhood have been
accustomed to mix much with young persons of the opposite sex, and
those, finally, in whom from conversation on the subject with female
friends or from the perusal of erotic literature, sexual enlightenment
has occurred at an early age, experience the awakening of the sexual
impulse earlier and with greater force, than phlegmatic girls, than
those who have grown up apart from boys, and than those who have been
strictly and carefully brought up. Masturbation may arise either
instinctively or from instruction.
In young girls masturbation is usually effected by friction of the
clitoris; less often by intra-vaginal manipulation, since this is liable
to lead to injury to the hymen. For the former purpose the finger may be
used; or some other article, such as a knot tied in the nightgown, or a
rounded projection on some article of furniture; in one case the
friction was effected by the naked heel. If two female onanists come
together, they practice tribadism, presently to be described.
Opportunity for this practice occurs especially in institutions in which
young girls occupy a common dormitory, and sleep together without adult
supervision.
An experienced physician, _Gutceit_, is of opinion that in young girls
of 10 to 16 years of age masturbation is on the whole less common than
in boys of the same age, but that on the other hand from the ages of 18,
19, and 20 onward, “sexual self-gratification is almost universally
practiced by women, even if it be not always practiced to excess,” an
opinion which cannot, however, be regarded as conclusive. As
consequences of masturbation in the female sex, this author has
observed: Fluor albus, menorrhagia, enlargement and prolapse of the
uterus, pains in one or other ovary, hysterical paroxysms, great pallor.
_L. Löwenfeld_ remarks that the manifestations of the sexual impulse are
not normally present in the days of childhood. In consequence of
pathological conditions, especially of such as effect the genital
organs, in consequence of chance impressions, or in consequence of a bad
example, sexual passion may indeed be awakened in children in its
fullest intensity. Normally, however, the distinct manifestation of the
sexual impulse is associated with a certain degree of development, of
ripeness, of the reproductive organs. Physiologically, sexual passion is
entirely wanting in young girls before the age of puberty.
As regards the act of sexual self-gratification, this author
distinguishes two forms of masturbation: (a) Peripheral-mechanical; (b)
mental (psychical onanism). In the former class of cases, the sexual
orgasm is produced solely or chiefly by mechanical stimulation of the
skin or mucous membrane of the genital organs. In the female sex, in
addition to manual stimulation, an extraordinary variety of hard and
soft articles are introduced into the vagina for this purpose. Many
females effect sexual self-gratification by rubbing and pressing
movements of the thighs one against the other, in which the clitoris is
implicated. In psychical onanism, on the contrary, as _Löwenfeld_ points
out, the orgasm is produced solely by central stimulatory
representations, without the assistance of any manipulation of the
genital organs. The ideas that have this effect are for the most part
lascivious trains of thought or the recollection of previous sexual
experiences, on which the attention is concentrated. If we wish to
estimate the harmfulness of the different forms of masturbation as
regards the mind and the nervous system, psychical onanism must
incontestably be regarded as the most deleterious.
In the female sex onanism is, in _Löwenfeld’s_ opinion, less widely
practiced than in the male; none the less, it is in the former sex far
commoner than is generally believed, a fact on which _Eulenburg_
likewise insists. Frequently, also, in females, a congenital neuropathic
tendency plays a part in the causation of masturbation, in so far as
this tendency takes the form of premature sexual excitement or of
excessive intensity of the sexual impulse. In the absence of this
tendency, masturbation rarely leads to the production of well-marked
nervous disturbances, and does so only when practiced to very great
excess. _Beard_ reports that in the powerful and full-blooded
working-class girls of the Irish race, masturbation, even when practiced
for many years, did not result in any notable disorder to health.
As regards the nature of the nervous manifestations met with in women as
a result of masturbation, there develops, according to _Löwenfeld_, in
one group of the cases, the sexual form of myelasthenia, characterized
principally by sacrache and lumbago, hyperæsthesia and paræsthesia in
the domain of the genital organs (ovarie,[25] pruritus vulvæ et vaginæ,
etc.), irritable bladder, coccygodynia, weakness and paræsthesia of the
legs (feelings of fatigue and chilliness), finally, the onset of erotic
dreams. In many cases, in the course of time, to these symptoms are
superadded the manifestations of cerebral and visceral neurasthenia
(headache, insomnia, nervous dyspepsia, palpitation), so that the
clinical picture comes to be one of general neurasthenia. In addition to
the neurasthenic troubles, manifold hysterical manifestations may occur.
_Disorders of Digestion._
Disorders of the digestive apparatus are quite common in girls during
the period of puberty, and usually take the form of nervous dyspepsia.
Disturbances of sensibility predominate, with a sensation of pressure
after meals, sometimes increasing to nausea, retching, and vomiting, as
manifestations of general hyperæsthesia of the gastric mucous membrane,
loss of appetite, a pasty or acid disagreeable taste, sometimes bulimia,
perverse sensations of taste, and pyrosis. Especially in chlorotic
girls, periodic attacks of pain occur, localized in the epigastrium and
its neighbourhood, and exhibiting no relation to the ingestion of food.
The free hydrochloric acid varies in amount, being now normal, now
diminished, sometimes also increased. In chlorotic cases, the symptoms
of round ulcer of the stomach are sometimes observed. Intestinal
activity is usually depressed, peristalsis is diminished, so that more
or less obstinate constipation is one of the most frequent symptoms.
Hypertrophy of the tonsils at the time of puberty is in some way related
to the menstrual processes, whether by the intermediation of the nervous
system or by that of the blood. _Eisenhart_ quotes observations made by
_Chassaignac_, of girls eighteen or nineteen years of age with
hypertrophy of the tonsils, associated with retarded puberty,
menstruation having begun late and being scanty, and the breasts being
underdeveloped; in one young girl with tonsillar hypertrophy, one of the
breasts had failed to develop properly, but after the removal of the
tonsils it speedily grew to the normal size.
_Diseases of the Respiratory Organs._[26]
Not uncommonly at this period of life the growth of a goitre is
observed. The influence of puberty on the growth of the thyroid body has
indeed been asserted by several authors; and _Neudörfer_ maintains that
precisely during the period of puberty to this body must be assigned an
important regulatory trophic significance for the nourishment and growth
of the reproductive organs. _Steinberger_ and _Sloan_ record the
observation of cases occurring in young girls in whom, menstruation
having first been regular, but having been suddenly suppressed in
consequence of external noxious influences, a rapidly growing goitre
suddenly appeared.
_P. Müller_ states that in many regions, as for instance in Canton Berne
in Switzerland, where the school children exhibit with extraordinary
frequency a hereditary tendency to the formation of goitre, during the
years of childhood these growths are much less frequent in girls than in
boys. At the time of puberty, however, this relation is entirely
changed. Whereas in boys from this time onward no further growth of the
thyroid body is observed, in girls at puberty the hypertrophy greatly
increases, so that very large goitres are formed. The same author recurs
to the earlier observations of _Heidenreich_ and _Schönlein_, as well as
to those of _Friedreich_, by which this influence of puberty is
strikingly manifested, and he believes it to be established by
experience that sexual excitement can produce a transient swelling of
the thyroid body. He alludes also to the remarkable fact that a swelling
of the thyroid body, to which a number of animals show a tendency,
occurs chiefly at the time of heat or rut; this is especially well known
to occur in the case of stags. Similarly, during menstruation, a
transient swelling of the thyroid body can sometimes be detected; the
swelling is greater if the menstrual discharge fails to occur.
_Diseases of the Organs of the Senses._
At the time of the menarche in cases in which there is retardation or
some other disturbance in the regular appearance of menstruation,
affections of the eye are observed, which are in part functional,
dependent on reflex influences proceeding directly from the genital
organs without organic changes, and in part are due to circulatory
disturbances. _Mooren_, _S. Cohn_, and _Power_ have discussed the
relations between the uterus and the eyes in general, and also in this
especial connection. Of ocular troubles during the menarche,
iridochoroiditis, hæmorrhages into the vitreous body, long-continued
blindness, and pannous keratitis, are mentioned, which may either
disappear with the reestablishment of menstruation (spontaneous or
artificially effected), or may exhibit in such circumstances a notable
alleviation. Chronic inflammatory states of the conjunctiva, usually of
an eczematous nature, which frequently occur at the time of puberty,
often exhibit a relation to the menstrual process, a monthly
exacerbation of the ocular trouble coinciding with disordered
menstruation, and cure taking place only when menstruation has become
perfectly regular. Vicarious hæmorrhages into the vitreous body also
occur, associated with disturbances of menstruation, the relapses
ceasing as soon as menstruation becomes regular; such a case was
observed by _Courserants_ in a girl of fourteen years.
Disturbances of hearing have been observed at the time of puberty in
young girls addicted to masturbation; the patients complain of
subjective noises, rising in intensity till actual hallucinations may be
experienced. _Lichtenberg_ reports the case of a strong girl eighteen
years of age, in whom the congestion associated with puberty was
followed by atrophy of the auditory nerve. The same author, also
_Ashwell_, _Law_, _Puech_, _Rossi_, _Stepanow_, and _Gilles de la
Tourette_, have published cases of vicarious menstrual hæmorrhage from
the external auditory meatus, occurring in girls of ages varying from 14
to 16, 17, 20, and 22 years. Amongst these cases, in some the auditory
organ was in a healthy condition, but in others there was associated
purulent discharge; the bleeding took place from the ears at the
menstrual periods, the proper menstrual discharge being absent or
scanty; after the ear trouble was cured, menstruation was normal. Of 200
cases of vicarious menstruation, there were, according to _Puech_, six
in which the vicarious bleeding was from the ears.
Disturbances of the olfactory sense, taking the form, sometimes of
diminished acuteness of this sense, sometimes of increased acuteness,
and sometimes of perversion, also anomalies in the secretion of the
nasal mucous membrane, either abnormal dryness, or greatly increased
secretion of mucus, come under observation at this period of life,
either as reflex manifestations through the intermediation of vasomotor
nerves at the time of the first appearance of menstruation, or in
consequence of chronic nasal catarrh, which may be connected with
masturbation. In cases in which the menarche is retarded, vicarious
epistaxis may also occur, the bleeding sometimes being very profuse, in
one case, indeed, reported by _Fricke_, in a girl seventeen years of
age, having a fatal termination. According to _Mackenzie_, sexual
excitement leads to swelling of the nasal mucous membrane, and habitual
masturbation to chronic nasal catarrh; the same author asserts that
during menstruation, swelling of the turbinate bodies may always be
observed, and that in this lies the explanation of the fact that many
women complain of a monthly cold in the head as an accompaniment of
menstruation.
Diseases of the skin are not uncommon in young girls at the time of the
menarche, and later as an accompaniment of each successive menstruation.
It is a well-known fact that at puberty girls sometimes lose a hitherto
beautiful complexion, and suffer from various disfigurements of the skin
of the face. These are produced especially by the profuse secretion of
sweat, and by the excessive secretion of the sebaceous glands, which so
often results in acne, an inflammation of these glands. Ecchymoses also,
effusions of blood into the skin, are observed, especially, as a form of
vicarious menstruation, in cases in which menstruation is irregular.
When actual bleeding occurs from the intact skin, the blood finds its
way out through the sudoriferous ducts—hæmatidrosis occurs; in some
cases, however, the hæmorrhage takes place from areas of skin altered
and injured by disease, from wounds or other injuries, from ulcers, or
from excrescences. Hæmorrhage into the skin occurs also in the so-called
stigmatization, in which condition also an etiological role has been
assigned to menstruation.
In the skin, remark _Spietschka_ and _Grünfeld_, a new life begins at
the time of the development of puberty, and it is this which first gives
to human beings the external characteristics of sexual maturity. In
certain regions which have hitherto been covered only by fine downy
hairs,[27] thick, strong hairs develop, and at the same time the general
growth of hair becomes more active. These regions are, the genital
region, and the axillæ. This increased growth of hair is accompanied by
a stronger secretion of the sebaceous glands, which very often is in
excess of actual requirements, and may thus lead to cosmetic
disturbances and to various diseases of the skin. Thus arise the various
forms of seborrhœa.[28] The commonest of these is the formation of
comedones, which, at the time of puberty, may make their appearance
especially on the nose, the forehead, and below the corners of the
mouth, but also on other parts of the face or on the back and the
breast; in those regions, that is to say, in which the sebaceous glands
attain a considerable size. The retention of the sebum may give rise to
inflammation, which the access of micro-organisms converts into
suppuration. Thus arises acne vulgaris. In another form of
seborrhœa,[28] the secretion is more fluid in consistence, and collects
on the surface of the skin, furnishing this with an oily
covering—seborrhœa oleosa.[28] This most commonly occurs on the face; if
the fatty layer is removed, the skin remains dry for a brief period
only, and soon becomes greasy and shiny once more. Dust readily adheres
to the greasy surface, and this gives the face a dirty appearance.
Seborrhœa faciei is readily converted into eczema.
With the puberal development of the external genital organs is
associated an increase in the sebaceous secretion of these regions. On
the clitoris and its prepuce, and on the folds and in the furrows of the
vulva, in consequence of insufficient cleanliness, an accumulation of
sebum and cast-off epidermic scales readily occurs; such an accumulation
may become rancid, may irritate the skin, and may thus give rise to
erosions and to purulent secretion.
In chlorotic girls at the time of puberty, on account of the anæmic
condition of the blood, eczema is not uncommon, especially on the hands
and the face. On the face, or on the forehead, red papules appear on
circumscribed areas, and become vesicular; raw, weeping spots are thus
formed, and have a very disfiguring appearance. Such eczema may occur
also in connection with disturbances of menstruation, when the menses
are scanty and pale, or when dysmenorrhœa is present.
At the time when menstruation ought to appear, but fails to do so,
sometimes also, when menstruation is regular, with each successive
period, an eruption of urticaria takes place; it usually disappears
quickly, but in some cases is more persistent; owing to the intense
itching it is always an extremely distressing complaint. Sometimes it
takes the form of urticaria factitia, in which the skin reacts to every
kind of mechanical stimulation, such as rubbing, scratching, or
pressure, all of which alike lead to the formation of weals, which may
be diffused all over the body. Less often in association with
disturbances of menstruation, acute œdema or erythema are observed.
Finally, we must mention herpes progenitalis, a rather uncommon acute
condition in which, with violent itching and burning sensation, intense
redness and œdematous swelling of the skin, vesicles form on the
præputium clitoridis, the nymphæ, and the inner surface of the labia
majora.
_Hygiene During the Menarche._
It is the object of rational hygiene to increase the resisting power of
the organism, which has been depressed by the processes of the menarche,
in order that the increased demands made by the awakened sexual life may
be adequately met.
The principal means for this purpose are, suitable diet, a suitable mode
of life, and the employment of physical therapeutic measures, among
which strengthening and hardening measures are to be preferred.
The diet should be at once as richly albuminous as possible and readily
digestible, there should be several, four or five, meals every day; in
chlorotic patients food should be taken at regular intervals of two to
three hours. Meat should be a predominant article in the diet, but fresh
vegetables should also be eaten in abundance for the sake of the
nutritive salts they contain; the vegetables rich in compounds of iron,
such as spinach, oats, beans, and lentils, are to be recommended; fruit,
raw or cooked, should also be taken in considerable quantities. The
evening meal[29] should not be too succulent or too plentiful; it may
best consist of soft-boiled eggs, an omelette, or milk. Alcoholic
beverages should be avoided or taken in minimal quantities; only as a
stomachic may a glass of beer or of light wine be recommended.
Chlorotic patients should even at their first breakfast[29] have a meal
rich in albumin, such as a considerable helping of meat, or a beefsteak,
with rolls, butter, and tea or coffee. Milk should be taken in small
quantities only, not more than a pint to a pint and a half daily; only
when solid food cannot be tolerated should milk be given freely. Beer
and wine are often of value in chlorotic girls from their stimulant
action on digestion and circulation. Half an hour’s rest before and
after meals is useful.
For the bill of fare of these patients I recommend especially: Roast
beef and veal, underdone beefsteak à l’Anglaise, ham; roasted venison,
hare, partridge, grouse, fieldfare, hazel-hen, ptarmigan, pheasant,
chicken, pigeon, turkey, oysters; asparagus, cauliflower, and spinach.
For variety, fish or shellfish may occasionally be taken. Sweetbread in
soup or with sauce forms a very delicious and easily digestible dish.
_Kahane_ recommends for chlorotic patients the systematic use of
Bavarian beer, to the amount of about two pints daily; it should, he
says, be a beer rather dark in tint, full-brewed, rich in malt, but
containing a comparatively small proportion of hops, alcohol, and
carbonic acid. _Jaworski_ has recommended a dietetic iron-beer,
containing 4.7 per cent. of alcohol and from 0.0317 to 0.0644 per cent.
of iron.
When girls are at the same time anæmic and very thin, fat-containing
foods must be taken in abundance, such as milk, butter, and cream; also
large quantities of carbohydrates. Farinaceous foods, rice, potatoes,
arrowroot, sago, tapioca, oatmeal, barley meal, carrots, turnips, sweet
fruits, grapes, dates, pippins, plums, pears, and preserved fruits—all
these must appear at table more frequently than usual; beverages, in
addition to milk, that are suitable are chocolate and cocoa, Bavarian
beer, and sweet, heavy wines.
The diet-table of such thin chlorotic patients should be as follows:
First breakfast, 7.30 to 8 A. M.: Coffee or cocoa with milk, or a pint
of milk, white bread and butter, honey. Second breakfast, 10 A. M.: Half
a pint to a pint of milk, egg and bread and butter, or sandwiches of
sausage, ham, or roast meat. Mid-day dinner, 1 P. M.: Soup, roast meat
with vegetables and potatoes, or fish may take the place of the soup,
sweets to follow. Afternoon, 4 P. M.: Coffee with milk, or a pint of
milk, with bread and butter. Supper, 7.30 P. M.: A plate of meat with
accessories. Evening, 9 P. M.: A glass of milk.
In the treatment of the anæmic form of obesity, to which chlorotic
patients of the better classes are subject, in consequence of sedentary
habits and overfeeding, the diet must be so arranged that albumins
predominate, whilst carbohydrates should be given sparingly, and as
little fat as possible. As the average quantities of the food elements
required in such cases, I suggest, 200 grammes of albumin, 12 grammes of
fat, and 100 grammes of carbohydrate.
The quantity of fluid taken must be as small as possible, since the
deprivation of water may result in a proportionate increase in the solid
constituents of the blood, and thus increase its hæmoglobin-richness.
The amount of physical exercise taken by young girls at this period of
life must vary according to the circumstances of each individual case.
In general, we may recommend for them much active movement, especially
in the open air, in order to counteract the effects of sedentary habits
and confinement in close rooms. Chlorotic patients must, however, be
careful to avoid overdoing their exercise, and in some cases it will be
necessary to limit the amount of this very strictly. In severe cases of
chlorosis, _Nothnagel_, _Hayem_, and other authorities recommend
complete rest in bed for from four to six weeks. This rest-cure can be
carried out as far as possible in the open air, and can be combined with
systematic massage and the use of passive movements.