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Part 1

THE SEXUAL LIFE OF WOMAN IN ITS PHYSIOLOGICAL, PATHOLOGICAL AND HYGIENIC ASPECTS

E. HEINRICH KISCH, M. D.

Professor of the German Medical Faculty of the University of Prague; Physician to the Hospital and Spa of Marienbad; Member of the Board of Health, Etc., Etc.

ONLY AUTHORIZED TRANSLATION INTO THE ENGLISH LANGUAGE FROM THE GERMAN BY

M. EDEN PAUL, M. D.

WITH 97 ILLUSTRATIONS IN THE TEXT

[Illustration]

NEW YORK REBMAN COMPANY 1123 BROADWAY

_Printed in America_

TO MY ONLY SON

FRANZ KISCH, M. D.

AS A TOKEN OF PATERNAL AFFECTION

I DEDICATE THIS BOOK

------------------------------------------------------------------------

PREFACE.

The sexual life of woman—the appearance of the first indications of sexual activity, the development of that activity and its culmination in sexual maturity, the decline of that activity and its ultimate extinction in sexual death—the entire process of the most perfect work of natural creation—has throughout all ages kindled the inspiration of poets, aroused the enthusiasm of artists, and supplied thinkers with inexhaustible material for reflection.

In the following pages, this sexual life of woman will be considered both in relation to the female genital organs, and in relation to the feminine organism as a whole; in relation both to the physical and to the mental development of the individual; and in relation alike to the state of health and to the processes of disease. Thus from the standpoint of clinical investigation and of practical experience, the book will be a contribution towards the solution of the sexual problem, nowadays recognized as one of supreme importance.

It is thirty years since I published a work on the histological changes that occur in the ovaries during the climacteric period (Archiv. für Gynecologie, Vol. xii, Section 3); and ever since that time, the influence exerted upon the general health of women by the physiological and pathological processes occurring in their reproductive organs, has been to me a favourite subject for observation and experiment. The result of these studies is incorporated in my monographs, “The Climacteric Period in Women” (Erlangen, 1874), “Sterility in Women” (2nd Ed., Vienna, 1895), “The Uterus and the Heart” (Leipzig, 1898), and in various contributions to medical periodicals. I now have a welcome opportunity of drawing a general picture of sexual activity in women, and of illuminating this picture both by the light of my own experience and by numerous references to the works of other authors. In passing, I have devoted considerable attention to questions of education and personal hygiene, both of which are greatly influenced by the processes of the sexual life. Thus, I hope, the work will be rendered more interesting to the physician, and the general picture it is intended to convey will be more fully characterized by contemporary actuality.

Natural divisions of the subject are, I consider, furnished by the three great landmarks of the sexual life of woman: the _onset_ of menstruation—the _menarche_: the _culmination_ of sexual activity—the _menacme_; and the _cessation_ of menstruation—the _menopause_. These several sexual epochs are differentiated by characteristic anatomical states of the reproductive organs, by the external configuration of the feminine body, by functional effects throughout the entire organism, and, finally, by pathological disturbances of the normal vital processes.

Thus in separate chapters a description is given of sexual processes, a detailed exposition of which will be vainly sought in the textbooks of gynecology, yet which are none the less of far-reaching importance in relation to the physical, mental, and social well-being of women, and in relation also to the development of human society; such topics are, the sexual impulse, copulation, fertility, sterility, the employment of means for the prevention of conception, the determination of sex, sexual hygiene. To the topics of pregnancy, parturition, lying-in, and lactation, since these are adequately discussed in works on midwifery, but little space has here been allotted.

It is my earnest hope that physicians and biologists may derive benefit from the book equal in amount to the pleasure I have gained in the work of writing it.

E. HEINRICH KISCH.

TABLE OF CONTENTS.

PAGE THE SEXUAL LIFE OF WOMAN—Introduction 1

I. THE SEXUAL EPOCH OF THE MENARCHE 37

First Appearance of Menstruation 45

Anatomical Changes in the Female Genital Organs at the Period of the Menarche 50

Menarche Praecox et Tardiva 78 Precocious and Retarded Menstrual Activity 78

Pathology of the Menarche 82 Anomalies of Menstruation 83 Inflammatory Processes 87 Disorders of Haematopoiesis 89 Cardiac Disorders 94 Diseases of the Nervous System 99 Masturbation 104 Disorders of Digestion 107 Diseases of the Respiratory Organs 107 Diseases of the Organs of the Senses 108 Hygiene during the Menarche 111 Menstruation 128 Pathology of Menstruation 143 Amenorrhœa, Menorrhagia, and Dysmenorrhœa 160 Vicarious Menstruation 164

The Sexual Impulse 166

Nymphomania, Anæsthesia and Psychopathia Sexualis 184

II. THE SEXUAL EPOCH OF THE MENACME 200

Anatomical Changes in the Female Genital Organs in the Period of the Menacme 209

Pathology of the Menacme 218 Dyspepsia Uterina 227 Cardiopathia Uterina 235 Nervous Diseases Secondary to Diseases of the Genital Organs 243

Competence for Marriage of Women suffering from Disease 250

Hygiene during the Menacme 261

Copulation and Conception 284 Copulation 284 Conception 304 Pathology of Copulation 323 Vaginismus 337 Cardiac Troubles Due to Sexual Intercourse 344 Dyspareunia 347

Fertility in Women 363 The Restriction of Fertility and the Use of Means for the Prevention of Pregnancy 388

The Determination of Sex 420 I. Statistical Investigations 422 II. Anatomical Investigations 446 III. Experimental Investigations 452

Sterility in Women 462 Incapacity for Ovulation 470 Interference with Conjugation, Conditions Preventing Access of the Spermatozoa to the Ovum 487 Diseases of the Ovaries and the Fallopian Tubes 489 Diseases of the Uterus 494 Pathological Changes in the Cervix Uteri 501 Displacements of the Uterus 515 Myoma of the Uterus 523 Diseases of the Vagina and the Vulva 526 Secretions of the Genital Organs 528 A. Absolute 540 B. Relative Sterility 540 Sexual Sensibility in Women 542 Incapacity for Incubation of the Ovum 549 Only-Child-Sterility 561 Operative Sterility 563 Table Showing the Causes of Sterility in Women 569

III. THE SEXUAL EPOCH OF THE MENOPAUSE 571

The Menopause 571

Changes in the Female Reproductive Organs at the Menopause 583

The Time of the Menopause 593

The Age at which the Menopause occurs 593 1. Race 594 2. The Age at which the Menarche Occurred 595 3. The Woman’s Sexual Activity 597 4. The Social Circumstances of the Woman’s Life 599 5. General Constitutional and Pathological Conditions 599 6. Premature, Delayed, and Sudden Onset of the Menopause 600

Pathology of the Menopause 608 Diseases of the Genital Organs 608 Diseases of the Organs of Circulation 620 Diseases of the Digestive Organs 630 Diseases of the Skin 632 Disorders of Metabolism 635 Diseases of the Nervous System 637 Climacteric Psychoses 643

Hygiene during the Menopause 653

LIST OF ILLUSTRATIONS (Kisch).

FIG. PAGE 1. Curve of the sexual life of woman from the tenth to the sixtieth year of life 4 2. Portion of the pelvic viscera in the female, etc. 9 3. The distribution of the pudic nerve in the female perineal and pubic regions 11 4. The distribution of the lateral sacral arteries, etc. 14 5. Curve of menstrual cycle 19 6. Curve of rhythmical variations 20 7. Curve of beauty of woman. 24 8. Internal genital organs of new-born female infant 51 9. Reproductive organs of a new-born female infant 52 10. Internal genital organs of a girl aged eight years 52 11. Reproductive organs of a girl aged ten years 53 12. Female external genital organs of a virgin 54 13. The external genital organs of a virgin 55 14. Sagittal section of the female pelvis 56 15. Primitive follicles 58 16. Ripening follicles 61 17. Graafian follicles 62 18. Annular Hymen 64 19. Annular Hymen 64 20. Semilunar Hymen 65 21. Annular Hymen with Congenital Symmetrical Indentations 65 22. Fimbriate Hymen 65 23. Deflorated Fimbriate Hymen 65 24. Septate Annular Hymen 67 25. Septate Semilunar Hymen 67 26. Extremely tough Annular Hymen with an obliquely disposed Septum 67 27. Septate Hymen with Apertures of unequal Size 67 28. Septate Hymen with Apertures of unequal Size 68 29. Hymen with rudimentary Septum 68 30. Hymen with posterior rudimentary Septum 68 31. Labiate Hymen with posterior rudimentary Septum 68 32. Hymen with anterior rudimentary Septum 69 33. Hymen with anterior rudimentary Septum projecting in a opiniform Manner 69 34. Hymen with anterior and posterior rudimentary Septa 69 35. Hymen with filiform Process projecting from the anterior Margin 69 36. Hymen in which there are two symmetrically disposed thinned Areas. The left of these is perforated 69 37. Very unusual form of Hymen 70 38. Semilunar Hymen with cicatrized Lacerations in its Border 70 39. Deflorated Semilunar Hymen with laterally disposed symmetrical Lacerations 70 40. Deflorated Annular Hymen with several cicatrized Lacerations 70 41. A. Septate Hymen in which defloration has been effected through one of the Apertures. U. Urethra. Cl. Clitoris. H. Cicatrized Margin. C. Septum. B. Lateral view of Septum 70 42. Deflorated Septate Hymen 71 43. Hymen with larger anterior and smaller posterior Apertures 71 44. Carunculæ Myrtiformes in a Primipara 71 45. Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes. Slight Prolapse of Anterior and Posterior Vaginal Walls 71 46. The breast of a virgin aged eighteen years 73 47. Horizontal section through the female breast 75 48. The female pudendum, or vulva, with the labia majora 204 49. Vestibule of the vagina, with the labia minora or nymphæ, etc 205 50. The uterus, the left Fallopian tube and the left ovary, etc 207 51. Female internal genital organs in the fully developed state 208 52. Sagittal Section through the Cervix Uteri of a Woman twenty-six years of age. Dendriform branched glands 217 53. Cervix of a Woman seventy-two years of age, with glands that have undergone cystic degeneration 217 54. Sagittal Section through the Cervix Uteri of a Woman sixty-five years of age. The glands have undergone cystic degeneration 217 55. First Stage. A. Entrance of a Spermatozoon into the Ovum of Ascaris Megalocephala. B. After preparations by M. Nussbaum. (Half of the ova only are depicted) 306 56. Ovum of Asterakanthion ten minutes after Fertilization 306 57. Fusion of Male Pro-nucleus and Female Pro-nucleus to form the Segmentation Nucleus of the Fertilized Ovum 306 58. Passage of Spermatozoon through the Zona Pellucida of the Ovum of Asterakanthion 307 59. Ovum of Scorpæna Scrofa Thirty-five Minutes after Fertilization 307 60. Male Pro-nucleus and Female Pro-nucleus in Fertilized Ovum of Frog, prior to the Formation of the Segmentation Nucleus 307 61. a. b. c. Prostatic calculi from normal semen, d. Spermatozoa. e. Large and small cells, some containing granules, as morphological elements of semen. f. Spermatozoon distorted by imbibition of water. g. Crystals (after Bizzozero) 311 62. Normal Semen 311 63. Semen consisting chiefly of sperm-crystals, cylindrical epithelium, and small granules exhibiting molecular movement—but containing _no_ spermatozoa 315 64. Oligozoöspermia. a. Living Spermatozoa, b. Dead Spermatozoa, c. Pus Corpuscles, d. Erythrocyte, e. Seminal granules 317 65. Septate Hymen, the septum having a tendinous consistency 324 66. 326 67. Lipoma of the Right labium majus, including the Vaginal Inlet 328 68. “Hottentot Apron” in an adult Woman, hanging down between the thighs (after Zweifel) 329 69. Elephantiasis of the Labia Majora 330 70. Congenital Atrophy of the Uterus (after Virchow), oi, Ostium internum; oe, Ostium externum 500 71. 500 72. Normal Shape of the Portio Vaginalis 503 73. Conoidal Shape of the Portio Vaginalis 503 74. “Apron-Shaped” Vaginal Portion, a. Greatly elongated anterior lip; b. Shorter posterior lip of the cervix 504 75. “Beak-Shaped” Vaginal Portion. Posterior aspect 504 76. Simple Hypertrophy of the Portio Vaginalis, which projected from the Vulva 506 77. Elongated Cervix, bent upwards 506 78. Cervical Polypus, originating from an Ovulum Nabothi 510 79. Ectropium in a Case of Bilateral Laceration of the Cervix (after A. Martin) 514 80. Anteflexio Uteri (after A. Martin) 518 81. Retroflexio Uteri (after A. Martin) 520 82. Mucus from the Cervical Canal, taken one hour after sexual intercourse, from a woman suffering from chronic endometritis. Among the epithelial cells, pus cells, and finely granular masses, we see a few motionless, dead spermatozoa 531 83. Uterine Mucous Membrane in Endometritis (after A. Martin) 554 84. Sagittal section through the ovary of a girl aged sixteen 583 85. Sagittal section through the ovary of a woman aged seventy-two years 584 86. Diagrammatic Representation of the Graafian Follicle 585 87. Ovary of a Girl aged nineteen years (Normal Size) 585 88. Ovary of a Woman seventy-two years of age (Normal Size) 585 89. 586 90. 587 91. 588 92. Sagittal Section through the Cervix of a Woman twenty-six years of age. Dendriform branched glands 588 93. Sagittal Section through the Cervix of a Woman sixty-five years of age. Glands which have undergone Cystic Degeneration 589 94. Cervix of a Woman seventy years of age. The Cervical Glands have undergone Cystic Degeneration 589 95. Ovula Nabothi in the Portio Vaginalis 590 96. Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane 591 97. Mucous Glands undergoing Cystic Degeneration 592

THE SEXUAL LIFE OF WOMAN.

By the _sexual life of woman_ we understand the reciprocal action between the physiological functions and pathological states of the female genital organs on the one hand and the entire female organism in its physical and mental relations on the other; and the object of this book is to give a complete account of the influence exercised by the reproductive organs, during the time of their development, their maturity, and their involution, on the life history of woman.

From the earliest days of the medical art this sexual life of woman has aroused in the leaders of medical thought the highest interest, and for this reason great attention has been directed, not only to the anatomy of the genital organs and to the diseases of the reproductive system, but also to the individual manifestations of sexual activity and to the influence exercised by these on the female organism as a whole.

Several works by _Hippocrates_ are extant on this subject, among which may be mentioned: περι Γυναικειης Φυσεος,[1] a treatise on the physiology and pathology of woman; περι Αφορων,[2] which discusses sterility in women; περι παρθενιων,[3] a treatise on the pathological states of virgins. These writings of _Hippocrates_ contain some very remarkable observations on the influence exercised by disorders of the reproductive organs on the general health of women.

_Aristotle_ wrote at some length on the functions of the female genital organs. In the writings of _Aretæus_ and _Galen_ on the diseases of women we find striking observations, as for instance, in _Galen’s De Locis Affectis_,[4] which contains a “Statement of the Similarity and Dissimilarity of Man and Woman.” Another notable work is that of _Albertus Magnus_, entitled _De Secretis Mulierum_.[5]

The numerous works on the diseases of women published in the sixteenth century consisted for the most part of a repetition of the observations of ancient writers. The gynecological treatises of the eighteenth century, however, bore witness to an increased knowledge of the anatomy of the female reproductive organs, and were illumined by _Haller’s_ researches on the functions of these organs.

The subject with which we are especially concerned is discussed in a work by _Boireau-Laffecteur_, _Essai sur les Maladies Physiques et Morales des femmes_,[6] Paris, 1793; and also in _Marie-Clement’s Considerations Physiologiques sur les Diverses Epoques de la Vie des Femmes_,[7] Paris, 1803. the same connection we must mention _von Humboldt’s_ treatise, _Ueber den Geschlechtsunterschied und dessen Einfluss auf die organische Natur_.[8] The first comprehensive work in which an exhaustive inquiry was made into the functional disorders of the female genital organs and the relation of these disorders to the female organism as a whole and to the physical and mental peculiarities of woman was _Busch’s: Das Geschlechtsleben des Weibes_,[9] Leipzig, 1839.

In the second half of the nineteenth century a very large number of monographs were published, investigating and describing the reflex disturbances produced alike in the individual organs and in the nervous system as a whole by changes in the uterus and its annexa. Many of these works will be mentioned more particularly in the course of this treatise.

The sexual life, based upon the purpose, so important to every creature, of the propagation of the species, possesses in the female sex a vital significance enormously greater than sexual activity possesses in the male. From the very beginning of sexuality, when the idea of a bisexual differentiation dawns for the first time in the brain of the little girl, down to the sexual death of the withered matron, who laments the loss of her sexual potency, physical and mental activity, work and thought, function and sensation, arise for the most part, wittingly or unwittingly, from that germinal energy which is the manifestation of the unalterable law that the existing organism endeavors to reproduce its kind.

Every phase of the sexual life of woman, from the threshold of puberty to the extinction of sexual activity, the first appearance of menstruation, the complete development of the sexual organs, the act of copulation, conception, pregnancy, parturition, and the puerperium, finally the involutionary process which accompanies the cessation of menstruation at the climacteric period—every one of these sexual phases entails consecutive physiological processes and pathological changes alike in the individual organs and in the nutritive condition of the entire organism, in the functions of the cardio-vascular apparatus, of the brain and the nerves, of the skin and the sense-organs, in the processes of digestion and general metabolism. Herein we see a striking illustration of the old saying of _von Helmont_, _propter solum uterum mulier est quod est_;[10] also of the similar aphorism of _Hippocrates_, _uterus omnium causa morborum qui mulieres infestant_;[11] a conception summed up by _Goethe_ in the words of Mephistopheles:

“Es ist ihr ewig Weh und Ach So tausendfach Aus einem Punkte zu kurieren.”

Just as in a tree the process of growth is made manifest to the superficial observer by the pleasure he feels at the sight of the buds and blossoms, by the refreshment he obtains from the fruit, and by the sadness which the withering of the leaves causes him, so in the sexual life of woman there are landmarks which no one can possibly overlook, by means of which three great epochs are distinguished. These are: puberty (the menarche), recognized by the first appearance of menstruation and the awakening of the sexual impulse; sexual maturity (the menacme), in the fully developed woman, characterized by the functions of copulation and reproduction; and sexual involution (the menopause), in which we see the gradual decline and ultimate extinction of sexual power and all its manifestations. In all these three epochs the sexual life of woman not only affects the hidden domain of the genital organs, but controls also all the vegetative, physical, and mental processes of the body, and is clearly and incontestably apparent in all vital manifestations. What Madame de Staël said of love is indeed true of the entire sexual life of woman: _l’amour n’est qu’unc épisode de la vie de l’homme; c’est l’histoire tout entière de la femme_.[12].

The sexual life of woman is coextensive with the peculiar vital activity of the female sex, for it endures from the moment when individuality first begins to develop out of the indifferent stage of childhood until the decline into the dead-level of senility.

To illustrate this fact, I have drawn up a curve of the sexual life of woman, making use of the statistical data available in central Europe regarding the age at which menstruation first appears, the age at which maidens marry, the age at which the largest number of women give birth to a child, and the age at which menstruation ceases; and reducing the figures to averages. * denotes the fifteenth year of life, as the average age at the menarche; ** denotes the twenty-second year of life as the average age at marriage; *** denotes the thirty-second year of life, in which woman exhibits her maximum fecundity; **** denotes the forty-sixth year of life as the average age at the menopause. (FIG. 1.)

[Illustration:

FIG. 1.—Curve of the sexual life of woman from the tenth to the sixtieth year of life. ]

Not in this respect alone, however, is the sexual life of woman of paramount importance; it is, in addition, the mainspring of the well-being and progress of the family, of the nation, of the entire human race. In the evolution of man from the primitive state in which he existed merely for the performance of vegetative functions up to the highest stage of contemporary culture, in the history of all races and of all times, the sexual life has been a most potent determining factor. With that life, religion, philosophy, ethics, natural science, and hygiene, have been most intimately related; for that life, they have furnished precepts and laws. The history of the sexual life is identical with the history of human culture.

In a primitive condition of society, among people living in a state of nature and among the lower races of mankind, the sexual life of woman possesses no great general interest, the female being merely a chattel; the ownership of this chattel, moreover, being often temporary and transient. The investigations of anthropologists have shown that among primitive people this form of property is neither highly esteemed nor carefully safeguarded. In such societies no restraint is imposed on the sexual impulse, which is gratified without shame and without formality. No hindrance is offered to the mutual intercourse of the two sexes. Chastity in the females is not prized by the males, nor do the latter compete for the favors of the former. Procreation is no more than a gregarious impulse of the masses among whom the common ownership of all booty is a matter of tribal custom. The woman has no disposing power over that which every one desires and which every one has the right to demand. Very gradually, however, a change takes place in this respect, so that in every period of social life since the very earliest, the modesty of young girls, the high valuation put upon the preservation of virginity, the ethical approbation of chastity in the wife, respect for the duties and rights of the mother, the reverence felt for the matron—all these, throughout the sexual life of woman, have had a civilizing, ennobling, and elevating effect. Thus, as family life has become developed, and as love and marriage have been more highly esteemed, woman has become the much-prized embodiment of all that is beautiful and good, of all that is summed up in the idea of the “housewife,” and her sexual life has been more completely, more ideally admired. The danger is not remote, however, that the leveling tendencies of the present day, and an inclination to despise the sexual life of woman, far from resulting in a further elevation of the social status of womanhood, will result rather in its abasement.

The Bible, as we may expect from the patriarchal relationships of the women of that time, bears witness to the worth of woman, and, whilst esteeming child-bearing, refers to yet higher duties. Precise religious and social precepts are furnished for all the phases of sexual life.