Part 18

In cases of pathological changes in menstruation, a carefully arranged hygiene at the menstrual periods is of importance both for prophylactic and for therapeutic purposes, and in this connection I may refer to what I have written in the section on _Hygiene during the Menarche_. In cases of dysmenorrhœa a certain amount of repose and precaution are needed during the flow, with avoidance of chill, scrupulous cleanliness, and regulation of the bowels. In cases of amenorrhœa we must prescribe attention to the general nutrition by means of an easily digested roborant diet, as much fresh air as possible, and systematic bodily exercise. In these cases, bicycling, lawn tennis, and suitable gymnastics are often of value; also baths, in the form of warm general baths, hot sitz baths, and hot foot baths.

_Vicarious Menstruation._

In cases in which, in consequence of morbid conditions of the uterus, the ovaries, or the organism as a whole, the menstrual flow has at the time of the menarche either failed entirely to appear or been exceedingly scanty, hæmorrhages from other organs have since ancient times been witnessed, and these hæmorrhages have been regarded as vicarious menstruation. The congestion that occurs during menstruation is not limited to the genital organs, and when the flow of blood from the uterus fails to occur, the organism seeks another outlet, in order to restore the disturbed equilibrium of blood distribution, and vicarious hæmorrhages take place from the mouth, the nose, the intestines, the anus, the gums, the mammæ, the ears, and the lungs; or hæmorrhages occur in the brain, the nerves, or the eyes.

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

Thus, _Fricker_, _Fleischmann_, _Obermeier_, _Beigel_, _Withrow_, _Plyette_, and _Parsons_ observed vicarious epistaxis; _Watson_, _Decaisne_, _Edebohls_, _Fischel_, and _Seeligmann_, vicarious hæmatemesis; _Franchi_, _Hotte_, _Ratgen_, _Voigt_, and _Windmüller_, vicarious hæmoptysis; _Dunlap_, vicarious gingival hæmorrhage; _Law_ and _Petiteau_, vicarious otorrhagia; _Heusinger_ and _le Fort_, vicarious hæmorrhages, occurring variously from the anus, bladder, hand, ear, nipple, stomach, and nose; _Baumgarten_, vicarious hæmorrhage from the vocal cords and trachea; _Hahn_, from the bladder; _Kerley_, in the thyroid body; _Gallemairts_, in the eyes. _Puech_ found, in the cases he collected, that vicarious menstrual hæmorrhage occurred from the stomach thirty-eight times, from the mammary glands twenty-five times, from the lungs twenty-four times, and from the nasal mucous membrane eighteen times. In all the cases menstruation had long been in abeyance.

Regarding vicarious epistaxis, especially exact observations have been published, showing the mutual relationship between the genital and the nasal mucous membrane. A series of cases has been recorded by _Fliess_. In one of these a remarkably well-developed girl of fourteen, who complained at three-weekly intervals of molimina, in the form of languor, headache, and sacrache, after an interval of four weeks epistaxis occurred instead of the expected menstruation; three weeks later came another attack of epistaxis; and finally, after an interval of seven weeks, came the first menstruation, which henceforward recurred every three weeks. In another case, that of a girl aged fifteen, menstruation appeared once; four weeks later came an attack of epistaxis instead of menstruation, and these attacks of epistaxis were continually repeated, at intervals of twenty-nine days, in place of menstruation, until finally pregnancy occurred. During pregnancy the epistaxis ceased, to recur however six weeks after parturition; the attacks continued for eight monthly periods, when they ceased finally at the commencement of the second pregnancy.

Other similar cases are known in which epistaxis recurred with all the regularity of the menstruation it replaced _during_ pregnancy and ceased at parturition. Analogous cases occur in which epistaxis has persisted during pregnancy, during the puerperium, and at the climacteric period, replacing the physiologically suppressed menstrual flow. Similarly _Liégois_ has observed vicarious hæmoptysis during pregnancy. According to _Baumgarten_, in vicarious epistaxis the bleeding almost always proceeds from the region of the cartilaginous septum, and may become very violent; vicarious hæmorrhage from the larynx proceeds from the true and false vocal cords. Tracheal hæmorrhage is a much rarer occurrence.

Analogous to these cases are those in which the vicarious hæmorrhages occur after removal of the ovaries. Thus _Tauffer_ in one case saw epistaxis replace menstruation after this operation. _Schmalfuss_ reports a case in which a woman suffering from valvular disease of the heart, was said after oöphorectomy to have had almost daily attacks of hæmoptysis and epistaxis. _Glaevecke_ found in the post-operative history of forty-four cases of oöphorectomy that two patients suffered from vicarious hæmorrhages. The last-quoted author is of opinion that the suppression of menstruation resulting from oöphorectomy rarely leads to vicarious hæmorrhages, and that even when these do occur they are so inconsiderable in amount as to have no practical significance.

_Quain_ records the case of a woman aged thirty-three, in whom uterus and ovaries were absent, and in whom for two years epistaxis recurred every month with considerable regularity.

In cases in which menstruation is in abeyance, we sometimes witness, instead of vicarious hæmorrhages, the occurrence of non-sanguineous vicarious discharges from various mucous membranes. Thus, vicarious leucorrhœa is seen, especially in chlorotic patients, in whom, from the time of the menarche onward, such a discharge may occur every month, instead of the delayed menstruation. Similarly, vicarious diarrhœa and vicarious salivation have been observed.

THE SEXUAL IMPULSE.

By the term _sexual impulse_, we understand the impulse shared by women and by men towards intimate physical contact and sexual intercourse with individuals of the opposite sex. In the child this impulse slumbers, to awaken at the menarche with the onset of puberty, to increase slowly at first, and then more rapidly, after the manner of an avalanche, until it becomes a powerful passion, dominant throughout the active sexual life of the woman, and it may even continue far beyond this period. The proper aim for whose attainment the sexual impulse in woman strives is by no means (as is asserted in some quarters) the fulfilment of “the impulse toward motherhood,” but is merely the complete satisfaction of sensual passion by intercourse with the male. Still, the sexual impulse is often satisfied by the minor degrees of sexual gratification in the form of the mutual contact, so agreeable to the sense of touch, of portions of the body, and even by the play of imagination and illusion under the dominion of love. Finally, also, love amounts to what _Buffon_, the celebrated naturalist, expressed with coarse incisiveness in the phrase, “L’amour c’est le frôlement de deux intestins.”

In the sexually mature woman, the sexual impulse always exists, though its strength varies in accordance with individual inheritance, with physical and mental condition, and with external circumstances, and though its manifestation may be repressed by force of will. The sensation of the sexual impulse in a maiden during the years of development is described by _Goethe_ in a masterly manner in the verses.[33]

“Meine Ruh ist hin Mein Herz ist schwer, Ich finde sie nimmer Und nimmermehr. Mein Busen drängt Sich nach ihm hin, Ach, dürft ich ihn fassen Und halten ihn Und küssen ihn, So wie ich wollt, An seinen Küssen Vergehen sollt.”

A resemblance to heat or rut in animals, who exhibit the sexual impulse only at definite periods, those at which the ovules ripen, is manifested in females of the human species only in so far as there is during menstruation a more intense sexual sensibility; but the limitation of the sexual impulse to definite periods, and its close association with reproduction, are not found in women. Education and morality impose artificial limitations on the sexual impulse in women, whilst nature endows this impulse with a coercive power, a fact recognized by thinkers of all times and all peoples. Thus, _Buddha_ wrote: “The sexual impulse is stronger than the ankus with which the wild elephant is controlled, it is hotter than flame, it is like unto an arrow driven into the spirit of man.” In a similar sense _Luther_ writes: “He who wishes to restrain the impulse of nature and not to allow it free play, as nature will and must, what does he do but this, to insist that nature shall not be nature, that fire shall not burn, that water shall not wet, that man shall neither eat, drink, nor sleep.” _Schopenhaur_ describes the sexual impulse as “the completest outward manifestation of the will to live, the concentration, that is to say, of all wills. * * * The affirmation of the will to live concentrates itself in the act of generation, and this act is its most determined expression.” _Mainländer_ in his _Philosophy of Deliverance_ makes the following statement: “In the sexual impulse lies the centre of gravity of human life. To nothing does man devote a more earnest attention than to the business of generation, and in the pursuit of no other aim does he concentrate the intensity of his will in so striking a manner as in the performance of the act of generation.” _Debay_ similarly insists on the strength of the sexual impulse, saying: “The union of the sexes is one of the great laws of nature; to that law men and women are subordinated as completely as all other creatures, they cannot escape its operation.”

According to the general opinion, the sexual impulse is not so strongly developed in women as it is in men. _Hegar_, _Litzmann_, _Lombroso_, _P. Müller_, and many others, assume that the sexual sensibility of women is less than that of men; _Fürbringer_ is inclined to attribute the characteristic of sexual frigidity to the great majority of German wives. I do not believe that this view, of the slight intensity of the sexual impulse in women in general, is well grounded, and can admit only this much, that in adolescent girls who are inexperienced in sexual matters, the sexual impulse is less powerful than in youths of the same age who have undergone sexual enlightenment. From the moment when the woman also has been fully enlightened as to sexual affairs, and has actually experienced sexual excitement, her impulse toward intimate physical contact and toward copulation is just as powerful as that of men. According, however, to the dominant artificial conditions, man assumes it as his right to give free rein to his sexual desires and to gratify them without regard to consequences, whereas woman, narrowly confined within the boundaries imposed by law and convention, cannot so readily yield to her inclination in the direction of physical love, and must forcibly control that inclination. Moreover, a powerful check on the free indulgence of the sexual impulse is imposed on woman by the consequences of such indulgence, consequences which exist for woman only.

I may further indicate as differential characteristics, that in woman the sexual impulse is more accessible to voluntary control than it is in man, the ardor of female sexual passion is more readily diminished than that of the male; and again that in the female the gratification of the sexual impulse is less narrowly restricted than in the male. Excessive sexual gratification on the one hand and suppression of sexual desire on the other are, generally speaking, less harmful to the female organism than to the male. In these differentiæ is to be found, in my opinion, the influence which determines the type of sexuality in the respective sexes.

The following account is given by _Havelock Ellis_ of the differential characters of the sexual impulse in the female: “In courtship, woman plays a more passive part than man; in woman the physiological mechanism of the sexual processes is more complicated, and the orgasm develops more deliberately; the sexual impulse in woman needs more frequently to be actively stimulated; the culmination of sexual activity is attained later in the life of woman than in the life of man, the strength of sexual desire in woman becomes greater after she has entered upon regular sexual intercourse, women bear sexual excesses better than men; the sexual sphere is larger and more widely diffused in women than it is in men; finally, in woman the sexual impulse exhibits a distinct tendency to periodic exacerbations, and it is in any case much more variable than in man.” The same author, who has published several notable biological studies on subjects connected with sex, maintains that the source of erotic pleasure in the case of the male lies in activity, but in the female in the passive state, in the experience of compulsion, and he holds that sexual subordination is a necessary element in the sexual enjoyment of women.

_Hegar_ maintains that under the term _sexual impulse_ two distinct conceptions are confounded: First, the impulse toward copulation, the desire of carnal union with a member of the opposite sex; secondly, the impulse toward reproduction, the desire for children. At the same time, this author admits that it is questionable if we can properly speak of an impulse toward reproduction, when reproduction is merely a consequence of copulation; in the case of civilized man, at any rate, so much reflection is connected with the idea of reproduction that it can hardly be proper to speak of anything of the nature of an impulse. In the case of woman, the expression is less unsuitable, since in woman special organs exist for the maintenance of the ovum after fertilization, and these organs may perhaps lead to the production of this peculiar form of mental activity.

According to _Darwin_, a comparatively less intensity of sexual desire is common to the females of all species of the animal kingdom. The female demands a prolonged courtship, and often endeavors for a considerable time to elude the male. In the lowest classes of the animal kingdom the female leads a separate existence as soon as she has been fertilized by the male, the sexual functions being thus subordinated to the maternal. Among birds at the pairing season the male is always the more passionate and active of the two, whilst the female commonly remains passive and occupies herself in building the nest. Among mammals, it is difficult to determine whether sexual feeling is stronger in the female or in the male; but it is certain that sexual relations are seldom long lasting, they continue in most cases only during the period of heat or rut, and at most only till the birth of the young.

From these phenomena witnessed in the animal kingdom, many naturalists have concluded that in females of the human species also, sexual sensibility and the intensity of the sexual impulse are less than in the males, and even that the sexual sense in general is but little developed in the female sex, or sometimes entirely wanting. The complicated apparatus which the primary and secondary sexual characters of the female combine to make up, exists, according to this view, not for the gratification of the sexual impulse, but for the fulfilment of the function of motherhood. “Love in women,” says _Lombroso_, “is in its fundamental nature no more than a secondary character of motherhood, and all the feelings of affection that bind woman to man arise, not from sexual impulses, but from the instincts, acquired by adaptation, of subordination and self-surrender.”

_Mantegazza_ lays stress on the fact that in the female, sexual desire is very rarely accompanied by pains analogous to those which occur in man, in whom sexual excitement manifests itself in painful tension of the testicle and the seminal vesicles, or in spasmodic, long-continued priapism.

_Sergi_ writes to _Lombroso_: “The normal woman loves to be flattered and wooed by man, but yields herself to his sexual desires only like an animal at the sacrifice. It is well known how much pains must be taken, how many caresses must be expended, before a woman will yield with pleasure to a man’s desires, and will share his sexual passion. Without the employment of these means, a woman remains cold and gives as little satisfaction as she feels. There are girls who are quite obtuse to the joys of love, and either resist energetically a man’s approaches, or yield to him passively, without ardor and without enthusiasm. It is well known, also, that among the lower races of mankind, means are employed to stimulate the sexual sensibility in women, means that seem to us to amount to torture; and that the male, with the same end in view, undergoes the most painful operations, from which it is apparent that the slight sexual sensibility of women in these lower grades of civilization is fully recognized.” And again: “If a normal woman marries for love, she hides that love deep in her heart, and even on the wedding-day exhibits no great sexual excitement; she often complains later that in her husband the love-fervor of the first days still continues; the very moderate sexual needs of the wife form a natural and most valuable check to the much more powerful passion of the male.”

_Saint Prospêre_ expresses himself to a similar effect: “Women do not fall in consequence of the excessive power of the senses—in this domain they are overlords, in striking contrast to men, whose weakest side is here. It is not by means of the senses that a woman is to be overcome; her weakness lies elsewhere—in her heart, in her vanity.” And _de Lambert_ wrote the epigram, “Women play with love, and yield themselves to love, but they do not abandon themselves to love.”

Well known also is the saying of _Dante_:

“We know how speedily in women the fire of love is consumed Unless eye and hand continually supply it with fresh fuel.”

On the other hand, it is asserted in the laws of the Hindus that sexual desire in women can as little be satisfied or fed full as a devouring fire can be fed full of combustible materials, or as the ocean can be overfilled by the rivers that pour their waters into it.

_Lombroso_ finds a proof of the sexual indifference of women and of the greater sexual needs of man, in the existence of prostitution, with which can be contrasted the existence only among the degenerate classes (both rich and poor) of a small group of male prostitutes (alfons, souteneurs). This author also refers to the rarity and uniformity in women of the sexual psychoses so frequent in men, as indications of the minor intensity of sexual desire in the former; and he refers also to a series of facts, as for instance, to the occurrence of platonic love, which, though indeed often hypocritical, has a real existence more often in the female sex than in the male; to the long-enduring chastity of girls, and to vows of chastity, which are rarely made except by females; moreover, the ready adaptation of women to polygamy, as well as their scrupulous observance of monogamy, which latter for the male is nominal rather than actual. If in general the opposite view concerning women prevails, this is ascribed by _Lombroso_ to the fact, that love is the most important circumstance in a woman’s life. The reason therefore, however, is to be found, not in the erotic sphere, but in the desire for the satisfaction of the maternal instinct, and in a woman’s need for protection. A celebrated accoucheur, _Giordano_, has remarked: “Man loves woman for the sake of the vulva; what woman loves in man is the husband and the father. Comprehensively we may express the matter by saying that woman has less eroticism and more sexuality.”

As a rule, remarks _Erb_, it is believed that the sexual impulse is less intense in women than in men. This is true enough, he writes, as regards youthful and virgin individuals, who have not yet come into intimate contact with men, and in whom sexual desire and sensibility have not yet been directly excited; later, however, when sexual intercourse has been begun, a change usually takes place, and the sexual needs become active in women also, and demand satisfaction. It is well known that not a few women experience powerful and uncontrolled sensual inclinations, just like those of men. On the other hand, we must insist that quite a large number of women possess the so-called _naturae frigidae_, and have no sensual inclination to sexual intercourse, to which they are either indifferent, or in some cases strongly averse, even regarding it with horror. This lack of the sexual sense in women, is especially common in hysterical subjects, and _Erb_ reports that he has encountered quite a large number of cases of this character. Whether in quite healthy women with normal sexual impulse, complete abstinence from sexual intercourse, too often compulsory but sometimes voluntarily undertaken, is harmful in its consequences—this, says _Erb_, is a question very difficult to answer. Many such unfortunate women have assured him that they suffered severely in consequence of their enforced continence; the majority of these became neurasthenic or hysterical. The complication of purely physical influences with mental influences, increases the difficulty of the problem. Neurologists have observed women on whom continence was forced either during marriage or after its dissolution, who thereupon fell into a state of severe nervous exhaustion or nervous excitement, or suffered from threatening or even actually developed psychoses. That sexual abstinence is “absolutely harmless,” as moralists and many physicians would so gladly believe, appears to _Erb_ a quite unwarrantable assumption.

“In the processes of reproduction,” continues Erb in his discussion of this subject, “woman is the principal sufferer. With inhuman cruelty, nature has condemned woman to a far more difficult rôle than man in the intercourse of the sexes and in the preservation of the species; she is overpowered and forced by man, she is compelled to make the most severe sacrifices for the sake of the new generation, first when it is germinating within her womb, and later when it is entrusted to her care; and only too frequently she fails to find the respect and protection due to her for the performance of these functions! Compared with the sacrifices made by woman, the temporary continence which is all that is demanded from man will be admitted to be a small matter! It is fortunate that as a rule the young woman who has never come into intimate contact with the male, appears to be endowed by nature with a relatively weak sexual impulse! This unequal and unjust distribution of the male and female rôles on the part of nature may be regretted, but it cannot be altered.”