Part 8
Not until the time of the menarche do the breasts attain the hemispherical form which constitutes one of the graces of young womanhood, and at the same time these organs assume a firm, elastic consistency; their size of course varies in different individuals. The nipple now has a rose-red color, darker in brunettes than in blondes; it is usually small, sometimes quite inconspicuous, being withdrawn into a cutaneous furrow. The two breasts when regarded from the front are seen to diverge from the longitudinal axis of the body. In some cases even in childhood, before the time of the menarche, the breasts are powerfully developed, being as large as an apple or larger. This depends on climate, race, and sexual excitement; as regards the last of these, early sexual stimulation promotes premature mammary development.
Although it is unusual for any secretion to appear in the mammary gland before the occurrence of pregnancy, cases have certainly been observed in which the breasts of virgins secreted a milk-like fluid, especially in consequence of sexual excitement or during menstruation. Thus _Maschka_ observed in a girl the condition of whose genital organs showed her to be a _virgo intacta_ that pressure on the breast caused a few drops of an opalescent fluid having the appearance of milk to exude from the nipple. She acknowledged that amatory relations had long subsisted between her and a lover who was in the habit of handling her breasts, and that this always produced strong sexual excitement. _Hofmann_ also reported that in two virgins who died during menstruation he was able to express a drop of milk from the breast.
The most important indication of the general changes occurring in the external and internal genital organs, the proof that the young woman has become fitted for the fulfilment of her reproductive vocation, is the appearance of menstruation, a sanguineous discharge from the genital organs recurring every four weeks as the external manifestation of the internal process of ovulation.
The anatomical changes that have already been described as occurring in the genital organs at the time of the menarche will serve to elucidate the numerous reflex processes that manifest themselves at this period of life in so many departments of vital activity.
It is especially the extensive developmental processes in the ovary, influencing the nerves of that organ, which give rise to centripetal stimuli and evoke reflex manifestations. In the working of the circulatory system, such influences are apparent; and during the menarche, some time already before the first onset of menstruation, variations occur in the blood-pressure, and these during menstruation take the form of a typical undulatory curve.
[Illustration:
FIG. 47.—Horizontal section through the female breast. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]
Thus it becomes comprehensible that even in healthy girls, the first appearance of the catamenia and likewise the expectation of the flow induce a certain modification and alteration in the whole nature and disposition. Girls often lose their previous cheerful and lively character, becoming quiet, self-absorbed, sometimes even melancholy; they are disinclined for study, have a repugnance to all sustained physical or mental activity, become annoyed and snappish on slight occasion, are restless at night, consider themselves to be ailing, and so on. During the first menstruation girls commonly appear pale and anxious, they have blue lines beneath the eyes, the face has a tired aspect, the movements lack energy, and a general want of tone combined with an abnormal irritability may be noticed. Some days before the first menstruation, the vulva, the labia majora and minora, and the vaginal mucous membrane, are swollen, the clitoris becomes conspicuous in consequence of erectile processes, a slight secretion appears in the genital passage, and the breasts become sensitive and slightly turgid. The urine deposits a thick sediment, and occasionally severe strangury is observed. In many cases, also, digestive disturbances occur, loss of appetite, constipation, or a tendency to diarrhœa.
The first menstruation usually lasts four or five days. On the first day the discharge is blood-stained mucus, thereafter becoming sanguineous. In some cases, the bleeding at the first menstruation is profuse and of long duration.
It is not always after the first menstruation that the subsequent discharges follow at the regular intervals of four weeks. In delicate, anæmic girls the second menstruation may not occur till several months have elapsed after the first; less often the second menstruation ensues a fortnight after the first, or even earlier.
At the time of the menarche the sexual impulse, which has hitherto been dormant, becomes strongly developed. It is evoked at this time of life by the anatomico-physiological changes undergone by the reproductive glands; the stimulus aroused by these processes in the ovary, being conducted to the brain, awakens passion. At the same time the observation of the growth of the hairy covering on the genital organs, the development of the breasts, and the appearance of menstruation, tend to arouse erotic presentiments. The reading of romances, conversations with female friends, and observation of the conduct of full-grown persons, convert these presentiments into clear ideas, and excite the impulse to the production of passionate sexual sensations, the sexual impulse. How far these stimuli arising from the reproductive apparatus are encouraged and accentuated, on the one hand, or repressed and diminished, on the other, depends on external impressions of various kinds. The environment is the determinant for the further transformation of the as yet undifferentiated sexual impulse into the fully-developed copulative and reproductive impulses.
In his work on the _Physiology of Love_, _Mantegazza_ describes the yearning and stress of the awakening sexual life, arising out of the presentiments, hazy sensations, and impulses, which are felt in the very earliest period of the developmental phase known as puberty.
In general, in a young girl during the menarche, the sexual impulse manifests itself rather in the form of semi-conscious reverie, of platonic love. The adolescent girl exercises her imagination with the circumstances of her chaste love, her mind turns to this subject when in solitude, her mood is apt to become melancholy, and it is the perusal of equivocal novels, or the educational assistance of sexually experienced female friends, that transforms the sexual impulse to a vivid flame.
Some authors believe that a sign of the awakening of the sexual impulse when directed toward some particular man is a change of color on the part of the girl when she sees this individual or hears him spoken of. Palpitation of the heart comes on, the pulse is increased in frequency, the respiration also, and the voice fails. In this manner, it is asserted, _Galen_ discovered the love of a Roman lady, Justa, for the dancer, Pylades.
The psychological reaction of the sexual impulse at the time of puberty manifests itself, as _von Krafft-Ebing_ points out, in manifold ways, common to all of which, however, is the emotional state of the mind, and the need that the strange and new feelings now experienced should find some objective centre of interest. Such objective and emotional interests lie ready to hand in religion and poetry, both of which, after the period of sexual development is at an end, and the originally incomprehensible desires and impulses have received an explanation, continue to have intimate relations with the world of sexual experience. Any one who doubts this must be reminded of the frequency with which religious fanaticism makes its appearance at the time of puberty. No less influential is the sexual factor in the awakening of æsthetic feelings. This world of the ideal opens itself at the time when the development of the sexual processes begins. * * * The love of early youth, continues _von Krafft-Ebing_, has a romantic, idealizing tendency. In its first manifestations it is platonic, and willingly exercises itself in poetry and history. But as the sensibility awakens, the danger arises that this passion, with its idealizing power, will be transferred to persons of the opposite sex who in intellectual, physical, and social relations are by no means all that could be wished. Hence proceed misalliances, elopements, and seductions, with the entire tragedy of impassioned love, which conflicts with the dictates of morality and convention, and sometimes finds its bitter end in suicide or a double self-destruction. Love in which the senses play too prominent a part can never be a true and lasting love. For this reason, first love is as a rule very transitory, since it is in most cases no more than the first flare of passion. * * * Platonic love is a thing without existence, a self-deception, a false description of sexual sensations.
_Bebel_ remarks that the number of suicides among women of the ages of sixteen to twenty-one years is an exceptionally large one, and he refers this chiefly to unsatisfied sexual impulse, unfortunate love, secret pregnancy, and to betrayal by men.
MENARCHE PRAECOX ET TARDIVA.
(_Precocious and Retarded Menstrual Activity._)
By the term _precocious menarche_ we understand the pathological state in which a typical, four-weekly, sanguineous discharge from the female genital organs sets in at an abnormally early age, and is to be regarded as a symptom of a premature sexual development. Very commonly such children with precocious menstruation and premature sexual development, exhibit a comparatively high body-weight, great development of fat, early dentition; they look older than their years; and they have genital organs that also develop very early, with hair on the pubes and in the axillæ; the labia majora and the breasts resemble those of full-grown women, and the pelvis also has the adult form. Commonly also the sexual impulse develops early, whilst, in other respects, the intellectual development lags behind the physical. It is most probably a primary hyperplasia of the ovaries that gives rise to precocious menstruation, the ovarian follicles ripening earlier than usual. Frequently other pathological processes are associated with this early sexual development, such as general lipomatosis, rachitis, and new growths of the ovaries. In several cases of this nature, early conception has also been observed. According to oriental tradition, Khadijah was married at the age of five years to the prophet Mohammed, who cohabited with her three years later.
Even if we except those cases in which in earliest infancy there is a sanguineous discharge from the vagina which remains, however, an isolated occurrence, or if repeated is repeated a few times only and at quite unequal intervals (cases in which the bleeding cannot be regarded as menstrual—such, for instance as were reported by _Eröss_ of six new-born female infants in whom a sanguineous discharge from the vagina appeared three or four days after birth and lasted two to five days, the infants not remaining subsequently under observation),—numerous well-authenticated cases yet remain in which menstrual hæmorrhage was observed before the end of the first year of life. One case, even, is recorded by _Bernard_ in which from the time of birth to the twelfth year menstruation with molimina occurred every month, lasting two days; from the twelfth to the fourteenth year menstruation ceased, recurring subsequently at irregular intervals.
In the recorded cases of such precocious menstruation the menstruation recurred as a rule at regular intervals of four weeks; only in quite exceptional cases were the intervals three to five months.
Some of the most striking and well-authenticated cases of precocious menstruation recorded in the recent literature of the subject are appended.
Observed by _Combys_: A girl aged 6 years and 2 months had the appearance of a girl aged 14 or 15; she was a brunette, 3′ 10½″ in height, with full, firm, rounded breasts, girth of chest 28⅓″, mons Veneris covered with hair, uterus normal on rectal examination, hymen intact; menstruation had occurred regularly since the second year of life. Mother and five sisters began to menstruate between the ages of twelve and fourteen. General condition good.
Case recorded by _Diamant_: A girl aged 6 years, weight 75 pounds, thighs, buttocks, and breasts developed like those of a sexually mature woman, axillæ and mons Veneris covered with hair. Menstruation began at the age of 2 and recurred regularly, the flow lasting 4 days.
Case recorded by _Plyette_: A girl with precocious physical development began to menstruate in the fourth year of life; menstruation continued regularly with the exception of two monthly periods, when vicarious epistaxis occurred.
From the collection made by _Gebhard_ of the records of fifty-four cases of precocious menstruation, giving the first appearance and the type of menstruation, the development of the breasts, the other signs of premature sexual development, and any complications that may have been observed, we extract the age at which the first menstruation occurred. This was:
In a new-born infant in 1 case. At the age of 2 weeks in 1 case. At the age of 2 months in 1 case. At the age of 3 months in 1 case. At the age of 4 months in 1 case. At the age of 5 months in 1 case. At the age of 7 months in 1 case. At the age of 9 months in 4 cases. At the age of 10 months in 2 cases. At the age of 12 months in 5 cases. At the age of 15 months in 1 case. At the age of 16 months in 1 case. At the age of 18 months in 2 cases. At the age of 19 months in 1 case. At the age of 22 months in 1 case. At the age of 2 years in 4 cases. At the age of 2½ years in 1 case. At the age of 2 years and 9 months in 1 case. At the age of 3 years in 6 cases. At the age of 3½ years in 1 case. At the age of 4 years in 4 cases. At the age of 4 years and 3 months in 1 case. At the age of 5 years in 1 case. At the age of 5½ years in 1 case. At the age of 6 years in 1 case. At the age of 6½ years in 1 case. At the age of 7 years in 3 cases. At the age of 9 years in 2 cases. At the age of 11½ years in 1 case.
From this collection of _Gebhard’s_ we learn that in one case menstruation already existed at birth, and that in a large number of cases it occurred before the expiration of the first year. In many cases the development of the breasts preceded the appearance of menstruation, and was noticed from the time of birth. The vulva also early exhibited the characteristics seen in the sexually mature woman. Further, a high body-weight, great development of fat, and early dentition, were usually seen in these cases, in which, however, the intellectual development was not in correspondence with that of the body.
In several of these cases of premature puberty, moreover, sexual intercourse and even parturition occurred at a very early age. A girl in whom menstruation began at the age of one year, gave birth to a child when she was ten years old (_Montgomery_). A girl who began to menstruate at the age of nine years, became pregnant very shortly afterward (_d’Outreport_). The well-known case recorded by _Haller_, in which at birth the pubic hair was already grown, and in which menstruation began at the age of two years, was also one of very early pregnancy, the girl giving birth to a child when nine years old. Another girl in whom at birth the pubes were already covered with hair began to menstruate when four years old, copulated regularly from the age of eight, and at nine years became pregnant, and was delivered of a vesicular mole with an embryo (_Molitor_). A girl began to menstruate at the age of two, had a growth of hair on the pubes and developed mammæ at the age of three, and became pregnant at the age of eight (_Carus_). With these cases must be classed that observed by _Martin_ in America of a woman who was a grandmother at the age of twenty-six. _Lantier_, in his Travels in Greece, speaks of a mother of twenty-five with a daughter of thirteen.
Observations made by _Kussmaul_ and by _Hofmeier_ prove that in many cases changes in the ovaries form the probable cause of precocious menstruation and the other phenomena of premature puberty. In one case of _Hofmeier’s_, for instance, of a girl of five with precocious menstruation, the removal of a rapidly growing ovarian tumor was followed by the cessation of menstruation, and the pubic hair, which had been shaved off, did not grow again.
Abnormally early puberty related to the early practice of sexual intercourse is seen in many prostitutes. This is shown by the following figures relating to 150 prostitutes in Russia. Sexual intercourse began:
In 1 prostitute at the age of 9 years. In 1 prostitute at the age of 10 years. In 4 prostitutes at the age of 12 years. In 12 prostitutes at the age of 13 years. In 14 prostitutes at the age of 14 years. In 33 prostitutes at the age of 15 years. In 36 prostitutes at the age of 16 years.
Thus, among the 150 prostitutes, 65 were less than 16 years of age.
_Parent-Duchatelet_ found among 3,517 prostitutes under official observation, 5.6 per cent. under 17 years of age. There were:
2 prostitutes under 10 years of age. 3 prostitutes under 11 years of age. 3 prostitutes under 12 years of age. 6 prostitutes under 13 years of age. 20 prostitutes under 14 years of age. 51 prostitutes under 15 years of age. 111 prostitutes under 16 years of age.
_Martineau’s_ observations also showed that in nearly all prostitutes the first coitus took place in very early youth. Of 607 prostitutes there were 489 in whom defloration had occurred between the ages of 5 and 20 years. According to _Grimmaldi_ and _Gurrieri_ defloration usually takes place in prostitutes before they attain the age of 10 years.
Sometimes we find increased sexuality in early life as a pathological manifestation—psychopathia sexualis. Thus, _Esquirol_ records the case of a little girl aged four years who undertook improper manipulations in association with little boys. A female prisoner, _Lombroso_ writes, had at the age of six years practiced mutual masturbation with her brother aged seven, and at the age of eight years underwent defloration; another murderess, while still a schoolgirl, had conducted herself after the manner of an experienced prostitute. _Laurent_ reports the case of a girl who from the age of ten was engaged in sexual malpractices with her brothers and sisters, and finally underwent defloration at the age of fifteen.
In many cases premature sexual development is manifested by enlargement of the breasts and growth of the axillary and pubic hair, and yet menstruation fails to appear. Thus, _Kussmaul_ has observed girls who while yet children exhibited all the external characteristics of sexually mature women, but who had not yet begun to menstruate. _Ploss_ has published a photograph showing in a girl five years of age the mons Veneris and the labia majora developed like those of a full-grown young woman, and covered with long thick hair; in this case, however, not only had menstruation not yet begun, but the breasts were still in the infantile condition.
The opposite state to menarche praecox is that in which the first appearance of menstruation is unduly delayed; it may be even till after the age of twenty. Such a postponement of the menarche sometimes occurs in girls who exhibit at this period of life an extraordinarily great general fatty development of the body, or a notably severe chlorotic state of the blood, or in whom during the years of development some sudden and extensive change in the mode of life has occurred, as for instance when the girl’s place of residence has been removed from the country to the town, or when she has had to undertake some completely new kind of physical or mental work. _Raciborski_ attributes the late appearance of menstruation, at the ages of 20, 22, 24, or 26, in otherwise healthy girls, to an “apathy of the sexual sense,” a phrase which does not convey much meaning.
According to _Marc d’Espine_, puberty occurs early in girls with dark hair, grey eyes, a delicate white skin, and of a powerful build; late, on the other hand, in girls with chestnut hair, greenish eyes, a coarse darkly-pigmented skin, and of a delicate weakly build.
The genitals of girls in whom the first appearance of menstruation is delayed, frequently exhibit distinct signs of the backwardness of the reproductive organs in their development. The external genitals, in such cases, have little if any covering of hair, and are flabby and relaxed; the body and the fundus of the uterus are shorter and more slender than usual, the uterus as a whole is small and flaccid, sometimes anteflexed; the vaginal portion of the cervix is small, often almost undeveloped, its anterior lip barely projecting above the surface of the vaginal fornix; the vagina is usually short and narrow. The ovaries also are flaccid and inelastic, and occasionally are remarkably small. The breasts are small, the nipples and areolæ undeveloped.
In other cases, notwithstanding the delay in the appearance of the menarche, the genital apparatus is developed to a degree quite in correspondence with the age, but some pathological condition is present, for instance, the mucous membrane secretes excessively, exhibits a catarrhal tendency, there are erosions at the os uteri, etc.
PATHOLOGY OF THE MENARCHE.
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.