CORNELL 
 
 UNIVERSITY 
 
 LIBRARY 
 
 GIFT OF 
 
 A. M. Drutmnond 
 
Cornell University 
 Library 
 
 The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924012165910 
 
Copyright 1916, by 
 MEDICAL AKT AGENCY 
 
 PRINTED IN AMERICA 
 
TABLE OF CONTENTS 
 
 rAGi 
 
 Introduction 1 
 
 I. THE SEXUAL EPOCH OF THE MENARCHE 
 
 (Puberty) 33 
 
 A. Europe 38 
 
 1. Northern Europe 38 
 
 2. Middle Europe 39 
 
 3. Southern Europe 40 
 
 B. Asia 40 
 
 C. Africa, Oceania, America 41 
 
 First Appearance of Menstruation 45 
 
 Menarche Precox et Tardiva (Precocious and 
 
 Retarded Menstrual Activity) 56 
 
 Inflammatory Processes 63 
 
 Disorders of H^matopoiesis 65 
 
 Cardiac Disorders 70 
 
 Diseases of the Nervous System 77 
 
 Masturbation 85 
 
 Disorders of Digestion 88 
 
 Diseases of the Respiratory Organs 89 
 
 Diseases of the Organs of the Senses 90 
 
 Hygiene During the Menarche 95 
 
 Menstruation , 120 
 
 Vicarious Menstruation ^ 129 
 
 The Sexual Impulse 130 
 
 II. THE SEXUAL EPOCH OF THE MEN ACME 149 
 
 Hygiene During the Menacme 159 
 
 Copulation and Conception 195 
 
 ' Cardiac Troubles due to Sexual Intercourse 203 
 
 Dyspareunia 206 
 
 iii 
 
TABLE OF CONTENTS iv 
 
 PAGB 
 
 Fertility in Women 224 
 
 The Restriction of Fertility and the Use of 
 Means for the Prevention of Pregnancy. . . 253 
 
 The Determination of Sex 280 
 
 - Sterility in Women 282 
 
 Incapacity for Ovulation 294 
 
 Sexual Sensibility in Women 307 
 
 Incapacity for Incubation of the Ovum 318 
 
 Only-Child-Sterility 336 
 
 III. SEXUAL EPOCH OF THE MENOPAUSE 340 
 
 The Menopause 340 
 
 Changes in the Female Reproductive Organs in 
 
 the Menopause 358 
 
 The Time of the Menopause 366 
 
 The Age at which the Menopause Occurs 366 
 
 i. Race , .' 367 
 
 2. The Age at which the Menarche Occurred . . 368 
 
 3. The Woman's Sexual Activity 372 
 
 4. The Social Circumstances of the Woman's 
 
 Life 374 
 
 5. General Constitutional and Pathological Con- 
 
 ditions 374 
 
 6. Premature Delayed and Sudden Onset of the 
 
 Menopause 376 
 
 Diseases of the Organs of Circulation 388 
 
 Diseases of the Digestive Organs 404 
 
 Diseases of the Skin 407 
 
 Disorders of Metabolism 411 
 
 Diseases of the Nervous System 414 
 
 Climacteric Psychoses 423 
 
 INDEX 461 
 
THE 
 SEXUAL LIFE OF WOMAN 
 
 INTRODUCTION 
 
 By the sexual life of woman we understand the re- 
 ciprocal 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 reproduc- 
 tive 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 : mpi TwaiKuris 
 ^vtreos,^ a treatise on the physiology and pathology of 
 woman; irepi A<j)opuv,^ which discusses sterility in 
 women; irept irapOeviuv,^ a treatise on the pathological 
 states of virgins. These writings of Hippocrates con- 
 
 1 Concerning the Feminine Constitution. 
 * Concernjng the Barren. 
 ' Concerning Virgins. 
 
 i 
 
2 THE SEXUAL LIFE OF WOMAN 
 
 tain some very remarkable observations on the influ- 
 ence 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 Aretaeus 
 and Galen on the diseases of women we find striking 
 observations, as for instance, in Galen's De Locis 
 Affectts* which contains a "Statement of the Simi- 
 larity and Dissimilarity of Man and Woman." An- 
 other notable work is that of Albertus Magnus, en- 
 titled De Secretis Mulierum.^ 
 
 The numerous works on the diseases of women pub- 
 lished 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 knowl- 
 edge 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-Laflfecteur, Essai sur 
 les Maladies Physiques et Morales des femmes,^ Paris, 
 1793; and also in Marie-Clement's Considerations 
 Physiologiques sur les Diverses Epoques, de la Vie 
 des Femmes,'' Paris, 1803. In the same connection we 
 must mention von Humboldt's treatise, Ueber den 
 Geschlechtsunterschied und dessen Einfluss auf die 
 organische Natur.^ The first comprehensive work in 
 which an exhaustive inquiry was made into the func- 
 tional disorders of the female genital organs and the 
 
 * On the Diseases of Regions. 
 
 . ? On the Secret Parts of Women. 
 
 « Essay on the Physical and Mental Diseases of Women 
 
 ' Physiological Considerations on the Diverse Epochs of the Life of 
 
 Woman. 
 
 j^J^Concerning Sexual Differentiation, and Its Influence on Organic 
 
INTRODUCTIOJSr 8 
 
 relation of these disorders to the female organism as 
 a whole and to the physical and 'mental peculiarities 
 of woman was Busch's: Des Geschlechtdeben des 
 Weibes,^ Leipzig, 1839. 
 
 In the second half of the nineteenth century a very 
 large number of monographs were published, investi- 
 gating and describing the reflex disturbances produced 
 alike in the individual organs and in the nervous sys- 
 tem as a whole by changes in the uterus and its annexa. 
 Many of these works will be mentioned more particu- 
 larly 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 enor- 
 mously 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 de- 
 velopment of the sexual organs, the act of copulation, 
 conception, pregnancy, parturition, and the puerperi- 
 um, finally the involuntary process which accom- 
 panies the cessation of menstruation at the climacteric 
 period — every one of these sexual phases entails con- 
 secutive physiological processes and pathological 
 
 9 The Sexual Life of Woman. 
 
4 THE SEXUAL LIFE OF WOMAN 
 
 changes alike in the individual organs and in the nu- 
 tritive condition of the entire organism, in the func- 
 tions 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. 
 
 Just as in a tree the process of growth is made mani- 
 fest to the superficial observer by the pleasure he feels 
 at the sight of the buds and blossoms, by the refresh- 
 ment 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 meno- 
 pause) , in which we see the gradual decline and ulti- 
 mate extinction of sexual power and all its manifesta- 
 tions. 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 in- 
 contestably apparent in all vital manifestations. What 
 Madame de Stael said of love is indeed true of the 
 entire sexual life of woman : I'amour n'est qu'une epi- 
 sode de la vie de I'homme; c'est I'histoire tout entiere 
 de la femme}° 
 
 The sexual life of woman is coextensive with the 
 peculiar vital activity of the fem ale sex, for it endures 
 
 ?±:^^ltoTlln::%'r '"''- '°^" '" ^^''='' '* -- -* ^y Byron R 
 "Man;s love is of man's life a thing apart: 
 T15 woman's whole existence." 
 
INTRODUCTION 
 
 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 nuniber 
 
 in 
 
 16-20 
 
 21-?'o. 
 
 26-30. 
 
 .31-35 
 
 36-40. 
 
 41-45 
 
 46-50 
 
 51-55 
 
 56 -oO 
 
 
 
 / 
 
 r 
 
 y 
 
 K 
 
 ■ 
 
 \ 
 
 XX 
 
 \ 
 
 \ 
 
 
 i 
 
 ^ 
 
 / 
 
 
 
 
 
 
 
 \ 
 
 \ 
 
 
 
 
 
 Curve of the sexual life of woman from the tenth to the sixtieth 
 year of life. 
 
 of women give birth to a child, and the age at which 
 menstruation ceases ; and reducing the figures to aver- 
 ages. * 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. 
 Not in this respect alone, however, is the sexual life 
 
6 THE SEXUAL LIFE OF WOMAN 
 
 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 cul- 
 ture, 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 re- 
 lated; 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 tempo- 
 rary and transient. The investigations of anthropolo- 
 gists 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, how- 
 ever, 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 
 
INTRODUCTION 1 
 
 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 levelling 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. 
 
 In classical antiquity, also, we see that woman rose 
 to some extent above the low position she had previ- 
 ously occupied in the family circle and in society at 
 large. Both among the Greeks and among the Ro- 
 mans, there was open to women a more intimate place 
 in social life and a more influential role in the life of 
 the family, than would have been their portion re- 
 garded merely in relation to their childbearing activity. 
 Amongst the Germans in the very earliest times, chastity 
 gave rise to purer and more moral sexual relations; 
 whereas among the Slavonic peoples the conception of 
 woman as the childbearer continued to dominate these . 
 relations. 
 
8 THE SEXUAL LIFE OF WOMAN 
 
 In consequence of the diflfusion of Christianity, wom- 
 an became man's companion and equal, and her life, the 
 sexual life included, acquired a deeper significance, 
 owing to the stress which that religion laid on chastity 
 as a virtue, and as a result of the educational influence 
 of woman in the family circle. 
 
 With the progress of civilization the sexual life of 
 woman comes to exhibit its activities only within the 
 bounds of morality and law, which in human society 
 have replaced the crude rule of nature, and have sup- 
 plied regulations adapted to the changing phases of 
 sexual vital manifestations. The wise adaptation of 
 these regulations requires, however, a full understand- 
 ing of the mental and physical processes, an exact 
 recognition of the bodily states and intellectual sensi- 
 bilities of woman regarded as a sexual being. 
 
 Modern culture and the social organization of the 
 present day, in association with the resulting sexual 
 neuropathy of women, have exercised on their sexual life 
 an influence as powerful as it is unfavorable, manifest- 
 ing itself in the overpowering frequency of the diseases 
 of women. In one of the most thoughtful books ever 
 written on the subject of woman, Michelet's UAmour}^ 
 the author remarks that every century is characterized 
 by the prevalence of certain diseases; thus, in the thir- 
 teenth century, leprosy was the dominant disease; the 
 fourteenth century was devastated by bubonic plague, 
 then known as the black death; the sixteenth century 
 witnessed the appearance of syphilis ; finally, as regards 
 the nineteenth century, "j^ decle sera nomme celut des 
 maladies de la matrice}^ It is certain that the educa- 
 tion and mode of life of the modern woman belonging 
 
 1' On Love. 
 
INTRODUCTION Q 
 
 to the so-called upper classes are, as far as sexual mat- 
 ters are concerned, in direct opposition to those that 
 are agreeable to nature and those that the laws of health 
 demand. 
 
 Even before sexual development begins, before the 
 physical ripening of the reproductive organs to func- 
 tional activity, the imagination of young girls is often 
 prematurely occupied with sexual ideas in consequence 
 of unsuitable literature, owing to visits to theatres and 
 exhibitions, or on account of social intercourse with 
 young men who are not overscrupulous in the selection 
 of topics for conversation. From the time of puberty 
 up to the time of marriage the growing woman is un- 
 der the influence of the now awakened sexual impulse, 
 which experiences ever-renewed stimulation. A seden- 
 tary mode of life, unsuitable nutriment, and the early 
 enjoyment of alcoholic beverages, exhibit their inevita- 
 ble result in the frequency with which, in this epoch 
 of the sexual life, chlorotic blood-changes, neurasthenic 
 conditions, and divers symptoms of irritation of the 
 genital organs, make their appearance. Thus, when 
 marriage, so often unduly postponed in consequence 
 of the condition of modern society, does at length take 
 place, it is apt to find the woman not only fully en- 
 lightened as regards sexual matters, but often in a state 
 of nervous weakness from sexual stimulation, one of the 
 type whose characteristics have been happily summed 
 up by the French writer Prevost in the expression 
 demi-verge}^ The conjunction of this state of affairs 
 in the bride with the frequent partial impotence of the 
 bridegroom, who has already dissipated the greater 
 part of his virile power before entering upon mar- 
 riage, leads often to the appearance of vaginismus and 
 other sexual neuroses in young married women. Even 
 
 ^* Half-virgin. 
 
10 THE SEXUAL LIFE OF WOMAN 
 
 more disastrous in its consequences as regards the future 
 sexual life of the wife is the ever-increasing frequency 
 of gonorrhoeal infection in the first days of marital in- 
 tercourse, with all the evil results of that infection. 
 
 On the other hand, an ever-larger proportion of girls 
 belonging to the "middle and upper classes," abstaining 
 alike from the good and the evil results of marriage, 
 falls under the yoke of sexual impulses denied satis- 
 faction or gratified by abnormal means, and suffers in 
 consequence both physically and mentally. Further 
 sources of injury arising from the conditions of modern 
 social life are to be found in the neglect by women 
 of the well-to-do classes of the duty of suckling their 
 children, and in the ever-increasing frequency with 
 which the women of these classes, after giving birth 
 to one or two children, resort to the use of measures 
 for the prevention of pregnancy, which result in seri- 
 ous consequences as regards both the nervous system 
 and the genital organs of the women concerned. Thus 
 there comes an accelerated ebb in the sexual life, lead- 
 ing to a premature appearance of the general pheno- 
 mena of senility, with a cessation of the menstrual flow. 
 The modern wife, who claims the right to lead the 
 life that best pleases her, will be more rapidly over- 
 taken by sexual death. 
 
 The psychical influences which proceed from the 
 female genital organs in the different periods of sexual 
 life have great significance for the organism as a whole. 
 Manifold impulses, both stimulating and depressing, 
 arising in the reproductive organs affect the workings 
 of the mind. The maiden at puberty is affected by 
 the knowledge of sexuality; the sexually mature wom- 
 an, by the desire for sexual satisfaction, and by the 
 yearning for motherhood; the wife, by the processes 
 of pregnancy, parturition, and suckling, or, on the other 
 
INTRODUCTION 11 
 
 hand by the distressing consciousness of sterility; the 
 woman at the climacteric period, by the knowledge of 
 the disappearance of her sexual potency. The mind 
 is further sympathetically influenced by the stimulation 
 of the terminals of the sensory nerves in the genital 
 organs. Through the increase of such stimulation, 
 through its spread to adjacent nerves and nerve tracts 
 and to the entire nervous system, the mind is affected, 
 directly by irradiation, or indirectly by vasomotor pro- 
 cesses and spinal hyperaesthesia. 
 
 Psychical manifestations and the nervous states as- 
 sociated with these are somewhat frequently, and even 
 actual psychoses occasionally, encountered in the vari- 
 ous phases of the sexual life of woman, sometimes tak- 
 ing the form of violent sexual storms, which may in- 
 deed, as ordinary menstrual reflexes, accompany every 
 catamenial period. 
 
 Of great interest are the facts which have, in recent 
 times especially, been scientifically established, point- 
 ing to a certain periodicity, to an undulatory movement 
 of the general bodily functions of the female organism, 
 dependent upon the sexual life. The observations of 
 Goodman, Jacobi, von Ott, Rabuteau, Reinl and Schi- 
 chareff, have shown tha,t in woman the principal vital 
 processes pursue a cycle made up of stages of increased 
 and diminished intensity, and that this periodicity of 
 the chief general processes of vital activity finds expres- 
 sion also in the functions of the reproductive organs. 
 Goodman has compared this play of general vital func- 
 tions to an undulatory movement. According to this 
 writer, a woman's life is passed in stages, each of which 
 corresponds in duration with a single menstrual cycle. 
 Each of these stages exhibits two distinct halves, in 
 which the vital processes are respectively ebbing and 
 flowing: in the latter we see an increase of all vital 
 
12 THE SEXUAL LIFE OF WOMAN 
 
 processes, a larger heat of production, a rise in blood- 
 pressure, and an increased excretion of urea; in the 
 former we see, on the contrary, that all these vital pro- 
 cesses display a diminished intensity. The moment 
 when the period of increased vital activity is at an end, 
 the moment when the ebb begins, corresponds, accord- 
 ing to Goodman, to the commencement of the cata- 
 menial discharge. 
 
 Goodman sought for verification of this undulatory 
 theory of the sexual life of woman in certain data re- 
 garding the bodily temperature and the blood-pressure. 
 A more extensive research was undertaken by Jacobi, 
 who, as the result of her observations, came to the fol- 
 lowing conclusions. In eight cases she noticed in the 
 premenstrual epoch a rise of temperature ranging from 
 0.05° C. to 0.44° C. (0.09° F. to 0.79" F.) ; and during 
 the catamenial discharge a gradual fall of 0.039° ^^ 
 to 0.25° C. (0.072" F. to 0.45° F.), never less, that is to 
 say, than a quarter of a degree Centigrade; but in the 
 majority of cases the temperature did not, while the 
 catamenia lasted, regain the normal mean. She further 
 observed in the generality of cases an increased excre- 
 tion of urea during the premenstrual epoch; and a 
 notable fall in blood-pressure during menstruation. 
 
 Reinl's observations on healthy women, in whom 
 menstruation ran a normal course, showed that in the 
 great majority of cases in the premenstrual epoch the 
 temperature was elevated as compared with that of the 
 interval, that in eleven out of twelve cases the tempera- 
 ture gradually declined during menstruation, to fall 
 in three-fourths of the cases below the mean tempera- 
 ture of the entire interval, and exhibiting in the post- 
 menstrual epoch a still further depression, giving place 
 however, to a somewhat higher mean temperature dur- 
 mg the first half of the interval. In the second half 
 
INTRODUCTION Ig 
 
 of the interval a higher mean temperature was observed 
 than in the first half. 
 
 If we make a graphic representation of the 
 mean differences in temperature commonly observed 
 throughout the various stages of an entire menstrual 
 cycle, we see that the curve does in fact take the form 
 of a wave. That drawn by ReinI is shown in the fol- 
 lowing figure: 
 
 Premenstrual epoch 
 
 7 Menstruation 
 
 Post-menstrual epoch 
 First half of the interral 
 
 The rising portion of the wave, the beginning of the 
 tidal flow, corresponds to the second half of the inter- 
 val ; the height of the tidal flow, the crest of the wave, 
 corresponds to the premenstrual epoch. As the flow 
 gives place to the ebb, as the wave begins to decline, 
 we come to the actual period of the catamenial dis- 
 charge; later in the ebb is the post-menstrual epoch, 
 and the lowest portion of the declining wave corre- 
 sponds to the first half of the interval. Rhythmic 
 changes corresponding to those observed in the temper- 
 ature have been recorded — at least in isolated stages 
 of the menstrual cycle — affecting the blood-pressure by 
 Jacobi and by von Ott, affecting the excretion of urea 
 by Jacobi and by Rabuteau, and affecting the pulse by 
 Hennig. It is evident that the vital activity of the 
 organism attains its maximum shortly before menstrua- 
 tion; and that with or immediately before the appear- 
 ance of the catamenial discharge, a decline of that 
 activity commences. 
 
14 THE SEXUAL LIFE OF WOMAN 
 
 Schrader, through his researches on metabolism dur- 
 ing menstruation in relation to the condition of the 
 bodily functions during this process, has established 
 that immediately before menstruation the elimination 
 of nitrogen in the faeces and the urine is at its lowest, 
 a fact which indicates that at this period of the men- 
 strual cycle the disintegration of albumin in the body 
 is notably diminished. 
 
 Von Ott found in thirteen cases out of fourteen that 
 at the beginning of the catamenial discharge, or just 
 before a considerable fall in blood-pressure occurred, 
 and that throughout the flow the pressure almost al- 
 ways remained below the mean, no rise taking place 
 till menstruation was finished; this fall in blood-pres- 
 sure during menstruation was more considerable than 
 could be accounted for by the moderate haemorrhage. 
 The same author, in conjunction with Schichareff, ex- 
 amined fifty-seven healthy women in respect of heat- 
 radiation, muscular power, respiratory capacity, ex- 
 piratory and inspiratory power, and tendon-reflexes. 
 
 He found that the energy of the functions of the 
 female body increased before the beginning of men- 
 struation, but declined with or immediately before the 
 appearance of the catamenial discharge. He exhibited 
 this rhythmical variation in the vital processes by means 
 of the following curve, in which the line AB repre- 
 sents these physiological variations, whilst on the ab- 
 scissa line c e, the days of observation are recorded, and 
 the interval m n represents the menstrual period. The 
 degree of intensity of the united functions is indicated 
 by the numbers o — loo on the ordinate. 
 
 Still another point of view from which the influ- 
 ences affecting the female organism as a whole may 
 be regarded has very recently become apparent in con- 
 sequence of the doctrine of Brown-Sequard relating to 
 
INTRODUCTION 15 
 
 the internal secretions of ductless glands. As regards 
 die female reproductive glands, which in consequence 
 of their structure must be referred to the group of 
 ductless glands, and yet owing to their secretory func- 
 tion must be classed among -secreting glands (so that 
 the nature of the ovary is that of a secreting gland 
 without an excretory duct) , it would appear that these 
 
 glands are not concerned only with the specific female 
 reproductive functions of menstruation and ovulation, 
 but that they also exercise a powerful influence on the 
 nutritive processes, on metabolism and haematopoiesis, 
 and on growth and development in their mental as well 
 as their physical relations. 
 
 It is supposed that these glands under normal con^ 
 ditions enrich the blood with certain substances, which 
 in part assist in haematopoiesis, and in part by regulate 
 ing the vascular tone in the various organs are con- 
 cerned in the normal processes of assimilation and 
 general metabolism. According to Etienne and De- 
 
16 THE SEXUAL LIFE OF WOMAN 
 
 mange, ovariin possesses an oxidizing power similar to 
 that possessed by spermin. Thus it becomes easy to 
 understand how disturbances in the functions of the 
 ovaries give rise to disturbances in the processes of 
 general metabolism and of assimilation. Some go 
 even farther, though in doing so they leave the ground 
 of assured fact, suggesting that the ovary in certain 
 circumstances produces toxins, or that the normal ovary 
 possesses an antitoxic functipn, and speaking of an 
 .occasional ovarian auto-intoxi^atioh of the body o^ of 
 a menstrual 'intoxication. Thus, chlorosis is by sbme 
 regarded as a disturbance of haematopoiesis, dependent 
 on an abnorinal condition of the female reprpduetiye 
 organs during the period of development, arid ' r^f ^r-; 
 able to a disturbance of the internal secretion of thfe 
 ovaries (Charrin, von Noorden,. Salmon, Etiepne, and 
 Demange). And it is now generally assumed, th^ as- 
 sumption being based on the bbsdrvations recfenll^ made 
 concerning the organotherapeutic employment of the 
 chemical constituents of the bviary, that many of the 
 disorders, and especially those' connected with the vaso- 
 motor system, common during the climacteric peiriod,- 
 are dependent on the deficiency of the products of the 
 internal secretion of the ovary that accompanies the 
 cessation of the menses. 
 
 The undulatory movement of the vital processes in 
 woman is apparently in some way dependent on ovula- 
 tion, though the nature of the connection has not hither- 
 to been fully elucidated. This view is confirmed by 
 the fact that no such rhythmic variation in the bodily 
 functions can be detected either in girls under thirteen 
 years of age, or in women from fifty-eight to eighty 
 years of age in whom menstrual activity has entirely 
 disappeared. The menstrual rhythm begins at puberty, 
 and ends when ovulation ceases. 
 
INTRODUCTION 17 
 
 'A further contribution to the doctrine of the un- 
 dulatory movement of the vital processes in woman 
 is to be found in my own observations that pathological 
 symptoms which have become manifest before and at 
 the time of the first onset of menstruation, and have 
 given but little trouble throughout the period of de- 
 veloped and regular sexual activity, are apt when 
 menstruation ceases to recrudesce, and to become as 
 prominent as they were at the commencement of the 
 sexual life. 
 
 Women who at the time of puberty suffered from 
 cardiac troubles, from digestive disturbances, or from 
 various forms of nervous irritation, and in whom 
 as they grew up these disorders passed more or less 
 into abeyance, are apt at the climacteric period to 
 exhibit, as I have frequently been able to observe, a 
 violent return of these symptoms, in the form, as the 
 case may be, of tachycardia, of dyspeptic troubles, or 
 of psychoneuroses. In this connection we may men- 
 tion an observation of Potain's, who distinguishes a 
 peculiar form of chlorosis, occurring in individuals of 
 delicate constitution, which, though apparently cured, 
 reappears at the menopause. 
 
 Related to the sexual life of woman is another attri- 
 bute, one intimately connected with the idea of the 
 female sex, and one which since the primeval days 
 of humanity has filled men with delight and poets with 
 inspiration — the attribute of beauty. 
 
 The beauty of woman, a prominent secondary sexual 
 chai-acter, niakes its first appearance at puberty, when 
 the girl's form, hitherto undifferentiated in its external 
 bodily configuration, begins to assume a soft and 
 rounded appearance, when the features become regu- 
 lar, the breasts enlarge, and the pubic hair begins 
 to grow — ^when, in short, to the primary sexual char- 
 
18 THE SEXUAL LIFE OF WOMAN 
 
 acters already existing, the secondary sexual characters 
 are superadded. 
 
 Feminine beauty continues to increase until the at- 
 tainment of sexual maturity. In her third decade 
 woman arrives at the acme of her sexual life and at 
 the same time attains the perfection of her beauty. 
 
 The ensuing sexual phases, pregnancy, parturition, 
 and lactation, entail a decline in beauty, not rapid 
 indeed, but advancing gradually, with the slow yet 
 sure-footed pace of time. The organic revolutions ac- 
 companying these processes leave traces recorded upon 
 the surface of the body in conspicuous and indelible 
 characters. The illnesses, also, which so often accom- 
 pany the fulfilment of sexual functions in injuring 
 health impair also beauty. 
 
 A woman who has given birth to and nursed an 
 infant begins to lay on fat, and this tendency to obesity 
 becomes more pronounced as the climacteric period 
 approaches. The breasts become inelastic and pen- 
 dent, the abdomen becomes ungracefully prominent; 
 the tonicity of the entire organism gradually declines, 
 and, in consequence of the loss of elasticity in the sub- 
 cutaneous cellular tissue, the dreaded wrinkles make 
 their appearance and the features become wizened. 
 Beauty is a thing of the past. With the cessation of 
 the sexual life the external secondary sexual characters 
 disappear, and the old woman is even farther removed 
 than the old man from our conception of beauty. 
 
 As Mantegazza insists, the beauties peculiar to wom- 
 en are one and all sexual; they depend, that is to Say, 
 upon the peculiar functions that nature has allotted 
 to woman in the great mystery of procreation. One 
 of the most vivid and poetical descriptions in ancient 
 or modern literature of these secondary sexual char- 
 
INTRODUCTION 19 
 
 acters on whieh feminine beauty depends is to be found 
 in the Song of Solomon. 
 
 "Behold, thou art fair, my love; behold, thou art 
 fair; thou hast doves' eyes within thy locks: thy hair 
 is as a flock of goats, that appear from Mount Gilead. 
 
 "Thy teeth are like a flock of sheep that are even 
 shorn, which come up from the washing; whereof every 
 one bear twins, and none is barren among them. 
 
 "Thy lips are like a thread of scarlet, and thy speech 
 is comely : thy temples are like a piece of a pomegranate 
 within thy locks. 
 
 "Thy neck is like the tower of David builded for an 
 armory, whereon there hang a thousand bucklers, all 
 shields of mighty men. 
 
 "Thy two breasts are like two young roes that are 
 twins, which feed among the lilies." 
 
 "How beautiful are thy feet with shoes, O prince's 
 daughter ! the joints of thy thighs are like jewels, the 
 work of the hands of a cunning workman. 
 
 "Thy navel is like a round goblet, which wanteth 
 not liquor; thy belly is like an heap of wheat set about 
 with lilies. 
 
 "Thine head upon thee is like Carmel, and the hair 
 of thine head like purple." 
 
 "This thy stature is like to a palm tree, and thy 
 breasts to clusters of grapes." 
 
 In the following figure the curve of beauty of womap 
 is given as drawn up by Stratz. In one case it may 
 rise very quickly, to decline with equal quickness — 
 the so-called beaute du diable/* in other cases, again, 
 the curve rises very slowly, and declines also very 
 slowly, the culmination of the curve being in this case 
 attained later, and when attained being absolutely 
 higher, than in the case of the steeper curve. 
 
 ** Beauty of the deviL 
 
20 THE SEXUAL LIFE OF WOMAN 
 
 The age at which the maximum of beauty is attained 
 is a very variable one. In the southern races this often 
 occurs as early as the fourteenth or fifteenth year of 
 life; but in the peoples of the Teutonic stock, Germans, 
 Dutch, Scandinavians, and English, not as a rule before 
 the twentieth year, and it may be even later. Stratz 
 has known cases in which women did not attain the 
 
 prime of their beauty until the thirtieth and even the 
 thirty-third year. The same author, a most competent 
 authority as regards the subject of feminine beauty, 
 -affirms that a beautiful woman is most beautiful when 
 the period of maximum beauty coincides in her case 
 with the first month of her first pregnancy. With the 
 commencement of pregnancy the processes of nutrition 
 are accelerated, all the tissues are tensely filled the skin 
 is more delicately and at the same time more brightly 
 tinted owing to the greater activity of the circulation, 
 the breasts become firmer and more elastic. Thus the 
 attractive characteristics of beauty at its fullest ma- 
 
INTRODUCTION 21 
 
 turity become enhanced, but for a short time only, since 
 the enlargement of the abdomen in the further course 
 of pregnancy impairs the harmony of the figure. Fi- 
 nally we must point out, before dismissing this subject, 
 that women of the so-called better classes arrive, as a 
 rule, at maturity later, and remain beautiful for a 
 longer period, than women of the working classes. 
 
 The degree to which the female organism as a whole 
 is influenced by the processes of the sexual life that 
 occur in the genital organ depends upon many of the 
 characteristics that combine to make up the individ- 
 uality. Inherited characteristics, teimperament, and 
 race, play a great part in this connection ; and not less 
 important than these are the social conditions, the en- 
 vironment, in which the women under consideration 
 pass^their life. Thus, among women belonging to the 
 poorer, laboring classes, the reflex manifestations in 
 other organs dependent upon the processes of the geni- 
 tal organs are less frequent and less intense than among 
 women belonging to the well-to-do strata of society and 
 to the cultured classes; less also in the country than 
 in large towns. In phlegmatic individuals, such mani- 
 festations exhibit less intensity than in those of an 
 active, ardent temperament; they are less frequent in 
 persons with a powerful constitution than in those en- 
 dowed by inheritance with an unstable nervous system. 
 Finally, they are less often encountered among families 
 whose upbringing has aimed at hardening the constitu- 
 tion and at inculcating the control of instinctive im- 
 pulses, than among those in whom from early child- 
 hood sensibility and impulsiveness have been given a 
 loose rein. 
 
 Extremely variable also are the sympathetic disturb- 
 ances and morbid states which depend on the processes 
 of the sexual life of woman. "Le cri de I'organe 
 
22 THE SEXUAL LIFE OF WOMAN 
 
 souflfrant ne vient pas de I'uterus mais de tout I'or- 
 ganisme,"*'' says Courty. And a large number of iso- 
 lated observations has shown how complex are the 
 relations between the healthy and unhealthy female 
 genital organs and the other organs of the body as well 
 as the organism as a whole. Precise and incontest- 
 able proofs exist of such relations between the female 
 genital organs and morbid changes in the eye and ear, 
 the skin, the respiratory organs, and the vascular and 
 nervous systems. 
 
 The influence exercised by the reproductive system 
 on the general vital processes of woman is indicated 
 also by the general statistics of mortality and the in- 
 cidence of disease. Mortality in women, the earliest 
 years of childhood being left out of consideration, is 
 at its highest precisely during the great sexual epochs, 
 namely at the time of puberty, during pregnancy, dur- 
 ing the puerperium, and at the climacteric period. 
 The complete performance of the reproductive func- 
 tions entails a higher proportion of illnesses and death; 
 and statistical records show that the mortality of mar- 
 ried women between twenty and forty years of age, 
 during the period, that is to say, in which in conse- 
 quence of marriage they fulfil the duties of sexual inter- 
 course and procreation, and are exposed to the dangers 
 connected with these sexual acts, is much higher than 
 the mortality of unmarried women of corresponding 
 ages. Infection with the gonococcus and with the 
 virus of syphilis, chronic salpingitis, metritis, and para- 
 metritis, the manifold diseases of pregnancy, the dis- 
 eases of the puerperium, the various displacements of 
 the uterus, osteomalacia — all these are pathological 
 states the dependence of which upon the sexual life 
 
 ""The cry of the suflFering organ comes not fromtiie uterus but from 
 the entire organism. 
 
INTRODUCTION 23 
 
 of the married or at any rate sexually active woman 
 is indisputable. But the complete renunciation of 
 se?cual activity appears also to exercise an injurious 
 influence on the health, and to give rise or at least 
 predispose to morbid manifestations. Hysteria, for 
 instance, chlorosis, uterine myomata, and various neu- 
 roses, have long been supposed to depend in part upon 
 such renunciation, though the causal connection cannot 
 be regarded as yet fully established. 
 
 Especially true as regards woman, indeed, is that 
 which Ribbing says concerning the sexual life in 
 general : "Since all human life and being has its origin 
 in sexual relations, these sexual relations may be re- 
 garded as the heart of humanity. We may work day 
 and night for the good of humanity, we may sacrifice 
 for that good our time and our blbod, but all this work 
 and all this sacrifice appear to me to remain useless 
 if we neglect and despise the sexual life, the eternally 
 self-renewing elementary school of true altruism." 
 
 From the vital phase in which, marked by the visible 
 manifestations of puberty and by the first appearance 
 of menstruation, ovulation is assumed to begin, the 
 sexual life of woman continues to the period of life 
 in which, marked by the climacteric cessation of men- 
 struation, ovulation also ceases. The total duration of 
 this sexual period in woman's life is usually about 
 thirty years ; but it is subject to great variations, from 
 six to forty-six years, according to the available statis- 
 tics, these variations depending upon climate, race, con- 
 stitution, and the sexual activity of the person under 
 consideration. 
 
 The duration and the intensity of the sexual life of 
 woman depends upon a series of external conditions 
 affecting the individual, but especially upon the in- 
 herited predispositions, upon the constitutional condi- 
 
24 THE SEXUAL LIFE OF WOMAN 
 
 tions, upon the varying vital power of the individual. 
 My own observations have led me to formulate, as a 
 general law, that the earlier a woman (climatic and 
 social conditions being similar in the cases under com- 
 parison) arrives at puberty, the earlier, that is to say, 
 that menstruation first makes its appearance, the greater 
 will be the intensity and the longer the duration of 
 sexual activity, the more will the woman in question 
 be predisposed to bear many children, the more power- 
 fully will the sexual impulse manifest itself in her, 
 and the later will the menopause appear. It seems 
 that in such women a more intense vitality animates 
 the reproductive system, bringing about an earlier 
 ripening of ova, a more favorable predisposition on 
 the part of these ova to fertilization by the sperma- 
 tozoa, a livelier manifestation of sexual sensibility, and 
 a longer duration of ovarian functional activity. 
 
 My general views on this subject are embodied in 
 the following propositions: 
 
 1. The duration of sexual activity is less in the wom- 
 an belonging to the countries of southern Europe than 
 in those belonging to the countries of northern Europe. 
 It would appear that in those climates in which ovula- 
 tion begins sooner and menstruation first appears at 
 an earlier age, the menopause also appears earlier; 
 but that, on the contrary, in those climates in which 
 puberty is late in its appearance, the decline of sexual 
 activity is similarly postponed. 
 
 2. Women in our mid-European climates, in whom 
 puberty appears at an early age, the first menstrua- 
 tion occurring between the ages of thirteen and six- 
 teen, exhibit a more prolonged duration of the sexual 
 life, of menstrual functional activity, than women in 
 whom menstruation begins late, between the ages of 
 seventeen and twenty. Extremely early appearance of 
 
INTRODUCTION 25 
 
 the first menstruation — so early as to be* altogether 
 abnormal— has, however, the same significance as ab- 
 normally late onset of menstruation -, both indicate that 
 the sexual life will be of short duration. 
 
 3. Women whose reproductive organs have been the 
 seat of a sufficient amount of functional activity, who 
 have had frequent sexual intercourse, have given birth 
 to several children, and have themselves suckled their 
 children, have a sexual life of longer duration, as mani- 
 fested by the continuance of menstruation, than Women 
 whose circumstances have been just the opposite of 
 these, unmarried women, for instance, women early 
 widowed, and barren women. Sexual intercourse at 
 a very early age, however, accelerates the onset of the 
 climacteric period and the termination of the sexual 
 life. The same result follows severe or too frequent 
 confinements. 
 
 4. The sexual life has a shorter duration in the 
 women of the laboring classes and belonging to the 
 lower strata of social life, as compared with upper class 
 and well-to-do women. Bodily hardships, grief, and 
 anxiety also hasten the onset of sexual death. 
 
 5. Women who are weakly and always ailing have 
 a shorter sexual life than women who are powerfully 
 built and always in good health. When irregularities 
 and disorders have appeared in the various sexual 
 phases, the decline of sexual activity occurs earlier than 
 in women whose functions have in this respect been 
 normal. Certain constitutional conditions, such as ex- 
 treme obesity, certain acute diseases, such -as typhoid 
 fever, malaria, and cholera, and certain diseases of the 
 uterus and its annexa, chronic inflammatory conditions 
 for instance, bring about a notable shortening of the 
 duration of the sexual life. 
 
 In addition to climate, nationality, and the age at 
 
26 THE SEXUAL LIFE OF WOMAN 
 
 which menstruation begins, the sexual activity of wom- 
 en also exercises an influence on the duration of their 
 sexual life, and of especial importance in this connec- 
 tion are the number of children born, and exercise or 
 neglect of the function of lactation. From my own 
 observations on this matter it appears, that in women 
 who are healthy and of powerful constitution, whose 
 reproductive organs have been sufficiently exefcised, 
 who have given birth to several children and have 
 suckled these children themselves, the duration of men- 
 strual activity is in general notably longer than in 
 women whose circumstances have been just the op- 
 posite in these respects. Among the women in my 
 own series of cases in whom menstrual activity lasted 
 longest, of the 177 women in whom menstruation ceased 
 between the forty-fifth and the fiftieth year of life, 
 
 1 only was unmarried, 2 were married but childless, 
 32 married with i or 2 children only, and 142 married 
 and with more than 2 children; of the 89 women in 
 whom menstruation ceased between the fiftieth and the 
 fifty-fifth year of life, none were either unmarried or 
 childless, 19 were married with i or 2 children, 17 
 married and with more than 2 children; of the 17 
 women in whom menstruation ceased later than the 
 fifty-fifth year of life, there were 2 only with less than 
 
 2 children, but 10 who had each given birth to from 
 6 to 8 children. A similar influence is exercised by 
 the function of lactation. Among 40 women who had 
 not suckled their children, the average duration of 
 menstrual activity was four years less than the general 
 mean. 
 
 As regards the conditions of life, L. Mayer afiirms 
 that the duration of sexual activity among well-to-do 
 women is on the average a year and a half longer than 
 among women of the working classes. 
 
INTRODUCTION 27 
 
 Metschnikoff has drawn attention to the remarkable 
 disharmony in the development of three of the phases 
 of the sexual life of/woman, inasmuch as the sexual 
 impulse, the union of the sexes, and the capacity for 
 procreation, which, considering their nature and pur- 
 pose, might have been expected to be attuned so as to 
 act in harmony, exhibit as a matter of fact no such 
 relation; the different factors of the sexual function 
 develop independently and unharmoniously. In a 
 child hot yet fitted to fulfil the function-of procrea- 
 tion, the sexual impulse will none the less make its 
 appearance, and be liable to misuse. In the girl the 
 pelvis does not attain that complete development which 
 fits it for thfe process of parturition until toward the 
 age of twenty, whilst puberty occurs at the age of six- 
 teen. "A girl of ten is capable of aspiring to play 
 the part of a woman, but not before the age of sixteen 
 is she fitted to play that part, nor indeed fitted to be- 
 come a mother before the age of twenty." 
 
 In general, we may say, regarding the women of 
 our own part of the world, that in those who are 
 healthy, who lead a regula:r life, are well fed, free 
 from the pressure of anxieties, with their sexual func- 
 tions sufficiently exercised, the duration of the sexual 
 life is longer than in women whose circumstances are 
 the reverse of those just enumerated. It is a sign of 
 decadence when women of the well-to-do classes, lead- 
 ing a life of ease, manifest a diminished dura:tion of 
 the sexual life. The greatest physical power and the 
 highest ethical development are associated with a 
 lengthening of life in general, and associated also with 
 a lengthening alike in the sexual life of woman and 
 the sexual potency of man. A decline in morals and 
 culture entails a diminution of sexual yital capacity, 
 this being true alike of individuals, of families, and 
 
28 THE SEXUAL LIFE OF WOMAN 
 
 of nations. Woman is venerated and valued the more, 
 the longer the duration of her sexual life; a woman 
 in whom the sexual life is short quickly loses value 
 and significance, both in domestic and in social circles. 
 
 The social significance of the sexual life of woman 
 is disproportionately greater and farther reaching than 
 the sexuality of the male, as the former is concerned 
 with the fundamental principles of human social life, 
 influencing the constitution of the family, and con- 
 trolling the good of the coming race. Sexual purity, 
 which to the youth is a romantic dream, is to the 
 maiden a vital condition of existence ; adultery, in the 
 husband a pardonable transgression, is in the wife an 
 overwhelming sin committed against family life. To 
 the freedom of the male in affairs of love is opposed 
 the strict restraint of the female, based on monogamic 
 marriage. The sexual needs and desires of the female 
 are transformed in an ideal manner by means of the 
 feeling of duty of the wife and mother; the violent 
 pressure of the sexual impulse is restrained by the 
 opposition of ethical forces. When this restraint fails, 
 the running ofif the rails that ensues has a far pro- 
 founder influence in the case of the female than of 
 the male, an influence not limited to her own per- 
 sonality, but dragging down the whole family into the 
 abyss of consequences, into the depths of moral and 
 physical destruction. 
 
 Though in nature everywhere the same, the sexual 
 life of woman exhibits in the various gradations of 
 social life different outward manifestations, from the 
 brutal sexual congress that does not greatly shun pub- 
 licity, to the modern would-be philosophical free love. 
 And throughout all variations the -two darkest points 
 remain, the illegitimate child and venereal infection, 
 both of which entail upon the woman the most un- 
 
INTRODUCTION 29 
 
 speakable anxieties and the greatest possible misery, 
 whilst the man, who is in either case to blame, passes 
 comparatively unscathed. 
 
 The social sexual position of woman suffers most at 
 the present day from the mature age at which under 
 existing social conditions men are alone able to marry 
 and from the ever-increasing number of cases of ven- 
 ereal infection. In both these directions social science 
 and medical skill must work hand in hand for the 
 amelioration of the sexual life of woman. 
 
 On the twentieth century falls the duty of furnish- 
 ing a solution for these problems. Contesting voices 
 are heard on all sides. Tolstoi's rigid demand for 
 complete sexual abstinence, the exhortation of the pro- 
 fessors of the German universities to their students in 
 favor of moral purity, the associations for the official 
 prevention of venereal diseases, the agitation among 
 young men in favor of abstinence from sexual inter- 
 course before marriage, finally, the clamorous voices 
 of the supporters of women's rights — all these are in- 
 fluences within the sphere of sexual morality which 
 must lead slowly but surely to extensive social changes 
 in the sexual life of women. 
 
 The discussion of the sexual life of woman, which 
 for many centuries was concealed by a thick veil from 
 the eyes of the profane, or was viewed only through 
 the frosted glass of poetical metaphor, has in recent 
 times assumed a quite revolting character. Not only 
 have the acquired liberties and the social aims of the 
 present day a tendency to give women in general a 
 freer and higher position, to emancipate them from 
 the bonds in which owing to the conditions of family 
 life they have so long been shackled, but some mem- 
 bers of the women's rights party go even farther, and 
 
30 THE SEXUAL LIFE OF WOMAN 
 
 demand for women greater freedom in the sphere of 
 
 sexual activity. 
 
 With this end in view the sexual life of woman is 
 used as the fulcrum of the lever, and is withdrawn 
 from the twilight into the open light of day, or indeed 
 too often into a dazzling and altogether false illumina- 
 tion. Women writers especially, who have hitherto 
 been accustomed to delude themselves and the world 
 with sensational representations of the feminine soul, 
 of feminine modesty, and the fineness of feminine sen- 
 sibility in matters sexual, now find their greatest joy 
 in unveiling themselves and their sisters before the 
 face of all the world, and in discussing in the plainest 
 language the most intimate processes of the genital 
 organs. In writings exhibiting but little good taste, 
 though all the more temperament, they emphasize 
 again and again one side only of the sexual life, to wit, 
 the sexual impulse, the force of which is intentionally 
 exaggerated to a high degree, so that it is described 
 as a mighty current of passion, which may with great 
 pains he held in check for a season, but must ultimately 
 break loose, and with devastating rage must overwhelm 
 everything which has hitherto been regarded as dis- 
 cipline and good morals. Young girls, even, step down 
 into the arena to take part in the contest concerning 
 the reform that is to take place in the relations between 
 men and women. 
 
 From a mistaken standpoint other supporters of 
 women's rights oppose the ideal method in sex-rela- 
 tions, life-long monogamy, and the ideal of sexual sen- 
 sibility, motherhood, and they put forward quite new 
 sexual pretensions on behalf of women, as belonging 
 to them by natural right. Upon these pretensions it 
 is the duty of physicians, who truly know and truly 
 prize womanhood, to pass their judgment, and that 
 
INTRODUCTION 31 
 
 judgment, which will find ample justification in the 
 ensuing descriptions of the individual phases of the 
 sexual life of woman, is that the modern movement on 
 behalf of the emancipation of women goes much too 
 far. We do not, however, mean to imply that this 
 movement is totally unjustified. 
 
 The growing girl must not, as has hitherto been 
 the case, be kept in a state of ignorance (which is in- 
 deed in most cases apparent merely) regarding the 
 sexual processes of her own body, she must no longer, 
 when she asks to be informed concerning these matters, 
 be put off with conventional lies and prevarication. 
 But her enlightenment must not be effected in such 
 a manner as to lead to excitement and excessive stimu- 
 lation, to the awakening of slumbering feelings, and 
 to the conversion of fantasy into a devouring flame. 
 Sexual enlightenment must not be made an excuse for 
 the unchaining of sensibility. When about to be 
 married, a woman should certainly be' instructed re- 
 garding her sexual duties and rights, and enter as 
 one well informed into the act in which she is to play 
 a leading part. But she" ought not, with the excessive 
 valuation of herself attained in recent times, to regard 
 the man as her enemy, as one whom she is always justi- 
 fied in fighting and always ready to fight with the equal 
 weapons of sexual transgression. It cannot be doubted 
 that the ideal of "pure marriage" at an early age is 
 one greatly to be prized as the foundation of a power- 
 ful future generation; but the real nature of the male 
 must not be overlooked, nor must his sexual honor be 
 put to too difficult a test. We regard as reasonable 
 the modern demand of woman that in marriage her 
 individuality should not be buried, and that space 
 should be given for the development of her personality; 
 but every sober-minded person will reject the "moral 
 
32 THE SEXUAL LIFE OF WOMAN 
 
 demand" for "ideal passion" in accordance with "en- 
 tire mutual freedom" in the sexual relation between 
 man and wife, and will regard such free love as social 
 insanity and as a barbaric retrogression toward the 
 rude sexual habits of savage peoples. Further, in view 
 of the continually increasing intensity of the struggle 
 for existence and in view of the difficulties of the task 
 of rearing children, we cannot fail to recognize that 
 it is not right for women to be overburdened with the 
 task of reproduction, and that she does not live simply 
 and solely for the bearing of children — but those rush 
 to the other extreme who undervalue motherhood and 
 the duties of maternity, who speak scornfully of the 
 woman who is "a mother, and a mother only," who 
 despise women whom they regard merely as "means 
 for the production of children," and who employ all 
 possible methods to free women from the pressing 
 claims of nature and of society. 
 
 In all social circumstances and in all times the great 
 principle of sexual morality must dominate the sexual 
 life of woman. As the ethical characteristics of the 
 three great epochs in that sexual life we recognize the 
 purity of the maiden, the faithfulness of the wife, and 
 the love of the mother. But within the limits imposed 
 by these demands it is still possible to satisfy the modern 
 claim for a free development of the personality, and to 
 accommodate the circumstances of the sexual life to 
 the individual vital needs and vital claims of the 
 present day. 
 
THE SEXUAL EPOCH OF THE MENARCHE 
 
 (puberty) 
 
 The term menarche was introduced by me into medi- 
 cal literature to denote the period of life in which, 
 as a sign of puberty, menstruation first makes its ap- 
 pearance. 
 
 The age at which this occurs is subject to variations 
 depending upon race, occupation, hereditary tenden- 
 cies, and climate; but in Germany and Austria the 
 average age at puberty is 14 or 15, the extreme limit 
 being 12 to 19. 
 
 Until about the age of 13, the physical differentiation 
 of the sexes, except for the anatomical peculiarities 
 of the genital organs, is in our climates a trifling one. 
 But at puberty the important changes occur by which 
 the sexes ar& so strikingly differentiated. Whereas in 
 the growing boy all physical change takes the form 
 of increasing strength an'd energy, in the development 
 of the girl, we note the appearances of the rounded 
 outlines so characteristic of womanhood. At the same 
 time the voice alters, becoming less sharp, with a softer 
 quality, and yet a fuller tone; and we may observe that 
 young brunettes have commonly a contralto voice, 
 young blondes, more often a soprano. The intellectual 
 changes undergone by the girl at puberty are no less 
 extensive and characteristic than the physical changes. 
 In brief, the undifferentiated, neuter girl is transformed 
 into a young woman, endowed with all the attributes, 
 mental and bodily, characteristic of fehiininity. 
 
 33 
 
34 THE SEXUAL LIFE OF WOMAN 
 
 As regards the age at which the menarche usually 
 occurs, and the manner in which its occurrence is anti- 
 cipated or retarded by the various influences already 
 mentioned, the following propositions may be put for- 
 ward, based on the available statistics and observations : 
 
 1. Climate is an important factor. In the torrid 
 zone, menstruation appears at a very early age, on 
 the average from ii to 14; in the temperate zone, it 
 appears later, on the average from the age of 13 to 
 16; in the frigid zone, later still, on the average from 
 the age of 15 to 18. The mean temperature of the 
 atmosphere appears to have a direct influence on the 
 age at which menstruation begins, the hotter the cli- 
 mate, the earlier being the menarche. The height of 
 the place of residence above the sea-level and its dis- 
 tance from the coast also have a certain influence. 
 
 2. Race and constitution have a distinct influence 
 upon the age at which menstruation makes its appear- 
 ance. In women of the Semitic races the menarche 
 occurs earlier than in women of the Aryan race. The 
 average age at which menstruation begins in Jewish 
 girls, from 14 to 15; in Magyar girls from 15 to 16; 
 in German girls from 16 to i6>4 ; and in Slavonic girls 
 irom 16 to 17. 
 
 In general the menarche is earlier in girls of a san- 
 guine, lively temperament and a powerful constitution 
 than in girls of a phlegmatic temperament and a weakly 
 constitution; further, other things being equal, men- 
 struation appears earlier in brunettes, girls with black 
 hair, thick skin, dark eyes, and a dark complexion, 
 than it appears in blondes, girls with light hair, thin 
 skin, blue eyes, and a fair complexion. 
 
 3. The age at which menstruation begins is also af- 
 fected by the conditions of life and the social circum- 
 stances. In the higher circles of society, in the upper, 
 
THE SEXUAL EPOCH OF THE MENARCHE 35 
 
 well-to-do classes, menstruation appears earlier than 
 among women of the laboring classes, who are com- 
 pelled to strive for their daily bread. Amongst upper- 
 class girls the menarche occurs at the age of 14 in one- 
 fourth of their number, whereas among lower-class girls 
 barely one-sixth begin to menstruate at the age of 14. 
 
 In large towns, again, menstruation appears earlier 
 than in small towns, whilst in the open country the me- 
 narche is still further delayed. In the women of Paris 
 the average age at the menarche is 14 years and 6 
 months, in the women of smaller French towns it is 
 14 years and 9 months, in French Countrywomen it is 
 14 years and 10 months. 
 
 How far the mode of nutrition is concerned in the 
 production of these results is not yet determined. 
 
 4. The time of the menarche appears to be influenced 
 by inheritance to this extent, that the daughters of 
 women who began to menstruate early begin themselves 
 to menstruate at an early age, whereas in other families 
 we observe that both mothers and daughters began to 
 menstruate late. But this relation is by no means a 
 constant one. 
 
 Ploss has collected observations made in various 
 countries and towns regarding the age at which men- 
 struation begins, and the mean results of these observa- 
 tions are given below. 
 
 The average age at which menstruation began was : 
 
 In Swedish Lapland 18 years, months, days. 
 
 In Christiania 16 years, 9 months, 25 days. 
 
 In Copenhagen 16 years, 9 months, 12 days. 
 
 In Munich 16 years, 5 months, 12 days. 
 
 In Gottingen 16 years, 2 months, 2 days. 
 
 In Vienna 15 years, 8 months, 15 days. 
 
 In Berlin 15 years, 7 months, 6 days. 
 
 In Stockholm 15 years, 6 months; 22 days. 
 
 In Manchester 15 years, 6 months, days. 
 
 In Warsaw 15 years, 1 month, 23 days. 
 
86 THE SEXUAL LIFE OF WOMAN 
 
 In London, between 15 years, 1 month, 4 days. 
 
 and 14 years, 9 months, 9 days. 
 
 In Paris, between 15 years, 7 months, 18 days. 
 
 and 14 years, 5 months, 17 days. 
 
 In Madeira 14 years, 3 months, days. 
 
 In Montpellier 14 years, 2 months, days. 
 
 In Corfu 14 years, months, days. 
 
 In Marseilles 13 years, 1 1 months, 1 1 days. 
 
 In Calcutta 12 years, 6 months, days. 
 
 In Egypt 10 years, months, days. 
 
 The collective results of the investigations of French 
 authors regarding the average age at which menstrua- 
 tion first appears are given in the following table: 
 
 I. In Temperate Climates : 
 
 Observer. 
 
 Place. 
 
 No. 
 
 De Soye Paris 
 
 Dubois Paris 
 
 Raciborski Paris 
 
 M. Despines. . . . Paris 
 
 Aran Paris 
 
 Courty Montpellier 
 
 Puech Nimes 
 
 M. Despines. . . .Toulon . . . . 
 
 M. Despines Marseilles . . 
 
 Puech Toulon . . . . 
 
 Grey London . . . . 
 
 Lee & Murphy. . London 
 
 Torisiano Corfu 
 
 Lebrun Warsaw . . . 
 
 of Cases. 
 
 Average Age. 
 
 1,000 
 
 15 years. 
 
 months. 
 
 600 
 
 15 years, 
 
 3 months. 
 
 200 
 
 14 years, 
 
 5 months. 
 
 85 
 
 14 years, 
 
 1 1 months. 
 
 100 
 
 15 years, 
 
 4 months. 
 
 600 
 
 14 years. 
 
 3 months. 
 
 941 
 
 14 years, 
 
 2 months. 
 
 43 
 
 14 years, 
 
 1 month. 
 
 25 
 
 14 years, 
 
 1 month. 
 
 144 
 
 14 years. 
 
 1 month. 
 
 1,498 
 
 15 years, 
 
 6 months. 
 
 1,719 
 
 15 years. 
 
 6 months. 
 
 33 
 
 14 years. 
 
 6 months. 
 
 100 
 
 15 years. 
 
 1 month. 
 
 from these observations we obtain an average of 15 
 years. 
 
 II. In Cold Climates: 
 
 Observer. Place. No. of Cases. 
 
 Ravn Copenhagen 3,840 
 
 Frugel Christiania 157 
 
 Dubois Russia 600 
 
 Faye Norway 100 
 
 Lundborg Esquimaux 16 
 
 Wistrand Stockholm 100 
 
 from these observations we 
 years and 3 months. 
 
 Average Age. 
 16 years, 9 months. 
 
 16 years, 
 16 years, 
 15 years, 
 1 5 years, 
 15 years, 
 
 6 months. 
 8 months. 
 6 months. 
 
 6 months. 
 
 7 months. 
 
 obtain an average of 16 
 
THE SEXUAL EPOCH OF THE MENARCHE 
 III. In Hot Climates: 
 
 37 
 
 Observer. Place. 
 
 Goodeye Calcutta 
 
 Lith Deccan . 
 
 Roberton Calcutta 
 
 Webb Calcutta 
 
 Dubois Asia .. . . 
 
 No. 
 
 of Cases. 
 
 Average Age. 
 
 239 
 
 12 years, 5 months. 
 
 217 
 
 13 years, 5 months 
 
 540 
 
 12 years, 6 months 
 
 39 
 
 12 years, 5 months 
 
 600 
 
 12 years, 11 months 
 
 from these observations we obtain an average of 12 
 years and 7 months. 
 
 In 6,550 cases collected by Krieger menstruation first 
 appeared : 
 
 At the age of : At the age of : 
 
 9 years in 1 instance. 20 years in 281 instances. 
 
 10 years in 7 instances. 21 years in 1 1 1 instances. 
 
 1 1 years in 43 instances. 22 years in 55 instances. 
 
 12 years in 184 instances. 23 years in 15 instances. 
 
 13 years in 605 instances. 24 years in 15 instances. 
 
 14 years in 1 193 instances. 25 years in 1 instance. 
 
 15 years in 1240 instances. 26 years in 4 instances. 
 
 16 years in 1026 instances. 27 years in 2 instances. 
 
 17 years in 758 instances. 28 years in 1 instance. 
 
 18 years in 582 instances. 29 years in 1 instance. 
 
 19 years in 425 instances. 
 
 From these figures it appears that in the 6,550 cases 
 under consideration, the age 15 was that at which the 
 first appearance of menstruation was most frequently 
 observed, namely in 1,240 instances, or 18.9 per cent. 
 The age 14 comes next, with 1,193 instances, or 18.2 
 per cent. The case in this series in which menstrua- 
 tion appeared earliest, namely in the ninth year, was 
 observed by Mayer, the girl being a blonde of average 
 height, good family, and German descent; the case 
 in which menstruation appeared latest, namely in the 
 twenty-ninth year, was that of a woman living in Ber- 
 lin, who was sickly and chlorotic up to the time of 
 her marriage, and in whom menstruation did not ap- 
 pear until some years after that event. 
 
38 
 
 THE SEXUAL LIFE OF WOMAN 
 
 As regards climatic influences, all the data at our 
 disposal prove that the hotter the climate the earlier 
 the menarche. According to Marc d'Espines the age 
 at puberty varies in an almost geometrical ratio with 
 the mean annual temperature. 
 
 The dependence of the menarche upon climatic in- 
 fluences is clearly shown by the statistical data col- 
 lected from various regions of the world. We append 
 the general compilation of Gebhard dealing with this 
 question. 
 
 A. Europe 
 
 For Europe the data furnished by Ploss are grouped 
 by Gebhard in the following manner. 
 
 I. Northern Europe 
 
 The average age at which menstruation first appears, 
 according to the older statistics, is in Swedish Lap- 
 land 1 8, in Norway, 16.12. In Copenhagen it is 16.75, 
 in St. Petersburg 14.5. 
 
 More recent statistics for Finland are furnished by 
 Engstrom. Among 3,500 women of pure Finnish de- 
 scent, he found that menstruation began: 
 
 At the age of 
 
 8 years 
 
 9 years 
 
 10 years 
 
 11 years 
 
 12 years 
 
 13 years 
 
 14 years 
 
 15 years 
 
 16 years 
 
 1 7 years 
 
 2 
 2 
 
 n 4 
 n 41 
 nl78 
 n458 
 n715 
 n778 
 n614 
 n369 
 
 instances, 
 instances, 
 instances, 
 instances, 
 instances, 
 instances, 
 instances, 
 instances, 
 instances, 
 instances. 
 
 At the age of : 
 
 18 years in 
 
 19 years in 
 
 20 years in 
 
 21 years in 
 
 22 years in 
 
 23 years in 
 
 24 years in 
 
 25 years in 
 
 26 years in 
 
 195 instances. 
 91 instances. 
 31 instances. 
 
 8 instances. 
 10 instances. 
 
 2 instances. 
 
 1 instance. 
 
 instance. 
 
 1 instance. 
 
 Thus, in nearly half of all Finnish women, men- 
 struation begins with the completion of the fourteenth 
 
THE SEXUAL EPOCH OF THE MENARCHE 39 
 
 and fifteenth years. The statistics include women of 
 all classes of society. 
 
 At the Pirogoff Congress Grusdeff furnished par- 
 ticulars of the first onset of menstruation in Russia 
 among 10,000 women. Menstruation began: 
 
 At the age of 
 9 years 
 
 10 years 
 
 1 1 years 
 
 12 years 
 
 13 years 
 
 14 years 
 
 15 years 
 
 16 years 
 
 17 years 
 
 n 1 
 in 4 
 n 31 
 n 244 
 n 864 
 n 1641 
 n 1795 
 n 2012 
 n 1692 
 
 instance. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 instances. 
 
 At the age of : 
 
 18 years in 
 
 19 years in 
 
 20 years in 
 
 21 years in 
 
 22 years in 
 
 23 years in 
 
 24 years in 
 32 years in 
 
 910 instances. 
 
 498 instances. 
 
 183 instances. 
 
 65 instances. 
 
 19 instances. 
 
 5 instances. 
 
 3 instances. 
 
 1 instance. 
 
 In women of German race living in Russia puberty 
 was earliest, occurring at the average age of 15.16 
 years ; in Finnish women it was latest, occurring at the 
 average age of 16.17 years. 
 
 2. Middle Europe 
 
 In Germany, according to the tables of Krieger and 
 L. Mayer, who have recorded 11,500 cases in all, men- 
 struation begins most commonly (in 18.931 per cent, 
 of the cases at the age of 15; the next most frequent 
 age is 14 (18.213 per cent, of the cases). 
 
 For Berlin, in a number of cases collected from the 
 lower classes of society, we find the average age for 
 the first appearance of menstruation to be 16.18 years. 
 
 Notwithstanding the more northerly situation of Ber- 
 lin, the average age at puberty is somewhat less than 
 in Munich, situated 4^^ degrees to the southward, for 
 the reason that the retardation dependent upon alti- 
 tude makes itself manifest in the latter town, which is 
 situate about 500 metres (1,640 feet) higher above the 
 sea-level. Whereas in Berlin 18 per cent, of all cases 
 
40 THE SEXUAL LIFE OF WOMAN 
 
 begin to menstruate at the age of 14, and 19 per cent, 
 at the age of 15, in Munich the two leading years are 
 15 with a percentage of ijyi, and 16 with a percentage 
 
 of i8M. 
 
 In Great Britain, according to Krieger, the average 
 age at which menstruation begins is 15 years, i month, 
 and 5 days. For Manchester the age given is 15 years, 
 6 months, and 23 days. In France, according to the 
 calculation of Brierre de Boismont, the most frequent 
 age for the first onset of menstruation is 16. In Paris 
 the average age is 14 years, 6 months, and 14 days. 
 Bohemia, Upper and Lower Austria, and Moravia 
 have an average age of 16 years and 2 to 3 months. 
 
 3. Southern Europe 
 
 In Southern Europe the influence of the higher mean 
 temperature manifests itself. The average age at which 
 Spanish girls begin to menstruate is 12. In Northern 
 and Middle Italy the most frequent age is 14; in 
 Southern Italy, 13. In Lyons the average age at which 
 menstruation begins is 14 years, 5 months, and 29 days; 
 in Marseilles and Toulon it is 13 years and 10 months. 
 For Hungary, Doktor gives the statistics of 9,600 cases. 
 In 22% per cent, menstruation begin at the age of 15; 
 in 20 J^ per cent, at the age of 16, and in 10 per cent, 
 at the age of 17. The earliest age among these cases 
 was 8 years; the latest, 33 years. (The latter must 
 no doubt be regarded as pathological.) 
 
 B. Asia 
 
 In Palestine puberty most commonly occurs at the 
 age of 13; in Turkey even as early as 10. Rouvier 
 calculated the average of 742 cases observed in Syria 
 to be the age of 12. As regards Persian women, the 
 
THE SEXUAL EPOCH OF THE MENARCHE 41 
 
 data vary between the age of 14 for the northern part 
 of the country and the age of 9 or 10 for the southern. 
 According to Joubert's data in 46.4 per cent, of the 
 indigens of India, menstruation begins at the age of 
 12 or 13. Similar figures are given for Ceylon and 
 for Siam. In Japan menstruation most frequently 
 begins at the age of 14, sometimes as early as 13; 
 mothers of 15 are by no means rarities in this country, 
 but for menstruation to begin before the age of 12 
 is considered a very exceptional occurrence. Accord- 
 ing to a table dealing with 584 women of Tokio men- 
 struation began: 
 
 At the age of : At the age of : 
 
 1 1 years in 2 instances. 16 years in 228 instances. 
 
 12 years in 2 instances. 17 years in 68 instances. 
 
 13 years in 26 instances. 18 years in 44 instances. 
 
 14 years in 78 instances. 19 years in 10 instances. 
 
 15 years in 224 instances. 20 years in 2 instances. 
 
 The data available regarding China are so exceed- 
 ingly variable that little importance can be attached 
 
 to them. 
 
 I 
 
 C. Africa^ Oceania, and America 
 
 The average age at which menstruation begins in 
 the negro women of Africa is from 10 to 13. In Al- 
 geria puberty occurs at 9 or 10 years. Among the 
 Australian indigens, menstruation commonly begins as 
 early as 8 years, and at the very latest at the age of 
 12 years. The data available concerning the indigens 
 of the Oceanic Archipelago are extremely variable and 
 inexact, but we cannot go far astray in stating the age 
 of puberty among these to be from 10 to 13. In tropi- 
 cal South America girls begin to menstruate from the 
 age of 9 to 14 years. The Indian wonien of North 
 America begin to menstruate at the ages of 12, 13, 14, 
 
42 THE SEXUAL LIFE OF WOMAN 
 
 or even as late as 1 8 or 20. In the Arctic zone of 
 North America and in Greenland the onset of men- 
 struation is delayed till 17 and even till 23 years. 
 
 As regards the position in life and the upbringing 
 years it has been shown by numerous observers that 
 among the well-to-do classes, whose mode of living is 
 luxurious, and whose social circumstances allow free 
 play to the imagination, menstruation begins at an 
 earlier age than among the working classes, whose 
 life is one of want and privation. According to the 
 statistical data of Mayer regarding 6poo women, 
 menstruation began: 
 
 In women of In women of 
 
 the upper classes, the lower classes. 
 
 At the age of 13 years 1 1.73 per cent. 7.06 per cent. 
 
 At the age of 14 years 23.90 per cent. 13.33 per cent. 
 
 At the age of 15 years 22.83 per cent. 14.56 per cent. 
 
 At the age of 16 years 14.10 per cent. 16.53 per cent. 
 
 At the age of 17 years 9.60 per cent. 13.33 per cent. 
 
 From this table we learn that in nearly one-fourth 
 of the girls of the upper classes puberty occurs at the 
 age of 14, whilst in girls of the lower classes barely 
 one-sixth begin to menstruate at this age. The average 
 age at the first menstruation in girls belonging to 
 the upper classes is seen to be 14.69 years, but in girls 
 belonging to the lower classes, 16.00 years. Accord- 
 ing to other observers the average age at the first men- 
 struation is: 
 
 Brierre de -.. jr~:.no^ l^^vn. 
 
 Boismont. ,r J' ^ ri^%^\ (Copen- 
 (Paris.) (London.} (Berhn.) ),^°^^» 
 
 Amongst gentle folk and 
 
 the rich 13y. 8m. 13y.5^m. 14y.lm. 14y.3ra. 
 
 Amongst the wellT-to-do 
 
 middle classes My. S m. 14y.3j4m, ISy.Sm. ISy.Sj^m. 
 
 Amongst the lower 
 
 classes 14y.l0m. 16y.8m. 16y.Sj4m. 
 
 Comparative observations on women living in towns 
 and women living in the country show also that in 
 
THE SEXUAL EPOCH OF THE MENARCHE 43 
 
 the former, menstruation begins on the average at an 
 earlier age. According to Brierre de Boismont, the 
 average age at the first menstruation is: 
 
 In Paris 14 years, 6 months. 
 
 In small towns 14 years, 9 months. 
 
 In country districts 14 years, 10 months. 
 
 Similarly it was found by Ravn that menstruation first 
 occurred : 
 
 In Copenhagen at the average age of 15 years, 7 months. 
 
 In industrial towns 15 years, 4 months. 
 
 In country districts 16 years, 5 months. 
 
 Mayer states that the average age at which the first 
 
 menstruation occurs is: 
 
 In townswomen 15.98 years. 
 
 In countrywomen 15.20 years. 
 
 In Italy, according to Calderini, in a thousand in- 
 stances, menstruation begins at the age of 14 in 280, 
 at the age of 15 in 219, at the age of 13 in 205, at the 
 age of 12 in 116, at the age of 16 in 89, at the age of 
 ^7 ^^ 55} ^t the age of 18 in 14, at the age of 11 in 7, 
 at the age of 10 in 6, and at the age of 20 in 6 instances. 
 In girls attending town schools, the first menstruation 
 most commonly occurs in the months of June and 
 August; but in girls attending country schools most 
 commonly in the spring months. 
 
 A certain hereditary predispositioir is so far deter- 
 minant in the matter of the early or late onset of the 
 first menstruation, that from a knowledge of the age 
 at which menstruation began in the mother, we are 
 able with great probability to predict the age at which 
 it will begin in the daughter. Among fifty cases which 
 I investigated with this point in view, I found forty- 
 one in which the daughters of mothers who had begun 
 to menstruate early began themselves to menstruate 
 early, usually indeed in about the same year of life; 
 
44 THE SEXUAL LIFE OF WOMAN 
 
 or conversely that when the mother had begun to men- 
 struate late, late onset of menstruation was usually to 
 be observed in the daughter also. Tilt relates a case 
 in which a woman began to menstruate at the age of 
 fourteen, and her daughter and granddaughter both 
 began to menstruate at the same age. Courty observed 
 a mother who began to menstruate at the age of eleven, 
 and whose eight daughters all began to menstruate at 
 the same age. 
 
 Gynecologists agree in stating that girls of sanguine 
 temperament and powerful constitution begin to men- 
 struate earlier than weakly and phlegmatic individuals. 
 Tilt describes a peculiar ovarian temperament, in 
 which menstruation begins early; such women have, 
 as a rule, striking nervous sensibilities, with a dark 
 complexion and glistening, longing eyes, always sur- 
 rounded by dark rings. 
 
 The opinion is general that in girls with black hair, 
 dark eyes, thick skin, and dark complexion, menstrua- 
 tion begins earlier than in blondes with blue eyes and 
 delicate white skin. Brierre de Boismont states in 
 this connection that not fair hair only, but also chest- 
 nut-tinted locks, indicate a late onset of menstruation. 
 L. Mayer found that: 
 
 Of blondes. Of brunettes. 
 
 17.20 per cent. 18.84 per cent, began to menstruate at the age of. . 14 
 
 16.89 per cent. 18.02 per cent, began to menstruate at the age of. . 15 
 
 15.14 per cent. 1 6.59 per cent, began to menstruate at the age of . . 16 
 
 According to the same author, the average age at 
 
 which menstruation begins is: 
 
 In blondes I5.55 years. 
 
 In brunettes 15.26 years. 
 
 As regards race, it is well known that in Jewesses 
 menstruation begins at an early age. According to 
 Joachim the age of puberty varies very greatly among 
 
THE SEXUAL EPOCH OF THE MENARCHE 45 
 
 the different races inhabiting Hungary. The first men- 
 struation appears: 
 
 In Slavonic girls between the ages of 16 and 17 
 
 In Magyar IS and 16 
 
 In Jewish 14 and 15 
 
 In Styrian 13 and 14 
 
 First Appearance of Menstruation 
 
 The first appearance of menstruation is commonly 
 preceded by various symptoms dependent on the in- 
 creased flow of blood to the genital organs. Such 
 symptoms are: Sacrache, dragging sensation in the 
 loins; an indefinite feeling of pressure in the lower 
 part of the belly, especially in the region of the uterus 
 and the ovaries, which region is sometimes also tender 
 on pressure; a slight feeling of weariness in the lower 
 extremities; sudden flushings or pallors; alternating 
 sensations of heat and chilliness, sometimes accom- 
 panied by actual though slight change of temperature. 
 In many cases also there are disturbances in the in- 
 testinal evacuations and urinary secretion, in the process 
 of cutaneous transpiration, and in the functional ac- 
 tivity of the gastro-intestinal canal. A frequently ob- 
 served symptom is an increased irritability of the entire 
 nervous system, with an inclination to melancholy and 
 indefinite amorous desires. 
 
 The nervous irritability manifests itself already be- 
 fore the appearance of the menstrual flow by head- 
 ache and moodiness, weariness, nervous irritability, and 
 low spirits ; further, by slight changes in the facial as- 
 pect, dark rings round the eyes, spontaneous blushing, 
 uneasy sensations, epigastric pain, loss of appetite, a 
 sensation of pressure in the abdomen, palpitation, 
 vertigo, dragging sensations passing from the loins to 
 the thighs, feeling of weakness and numbness in the 
 
46 THE SEXUAL LIFE OP WOMAN 
 
 lower extremities — symptoms which often endure for 
 several months and in such cases tend to lower the re- 
 sisting powers of the organism. 
 
 Courty enumerates as prodromal symptoms which 
 are observed in the majority of girls before the first 
 appearance of menstruation: swelling and tenderness 
 of the breasts, sensation of fulness and weight in the 
 hypogastric region, moderate intestinal meteorism, 
 sacrache, aqueo-mucous vaginal discharge, finally, an 
 itching sensation in the genital organs. These mani- 
 festations may also assume a morbid character, taking 
 the form of violent abdominal and lumbosacral pain, 
 general fatigue and weakness, dyspepsia and diarrhoea, 
 cephalalgia, various kinds of neuralgia, some degree 
 of moral aberration. After the first menstruation, two 
 or three months may elapse before the girl menstruates 
 again, but after the lapse of a year the flow usually 
 recurs at quite regular periods. Sometimes the early 
 periods are very violent and recur very frequently, 
 every twenty days, for instance. 
 
 The greatest increase in size and weight occurs in 
 the female sex at the time of the menarche. Amongst 
 the poorer classes the greatest development in size and 
 strength occurs between the ages of 13 and 15 years, 
 whereas in the upper classes of society, those who ulti- 
 mately attain the same weight exhibit their greatest 
 growth at the ages of 12, 13, and 14 years. Accord- 
 ing to Pagliani the greatest growth in the female sex 
 always precedes puberty, so that, for example, a girl 
 who begins to menstruate at the age of 12 will grow 
 most rapidly in the year preceding this, whereas a girl 
 who begins to menstruate at a more advanced age will 
 not undergo her most rapid phase of growth so early 
 as the age of 11. According to the observations of 
 Bowditch, A. Hey, Lombroso, Pagliani, and Floss, up 
 
THE SEXUAL EPOCH OF THE MENARCHE 4T 
 
 to the age of ii or 12 years the growth of girls exceeds 
 that of boys, but whereas in girls growth ceases sud- 
 denly at the age of 14, in boys growth proceeds regu- 
 larly up to the age of 16 years. At birth boys are 
 on the average i cm. (%") longer than girls; but dur- 
 ing puberty the female sex catches up to the male in 
 height, or even surpasses it. According to Ploss, a 
 girl of 16 or 17 years is as tall as a young man of 18 
 or 19 years. 
 
 The earlier development of the female as compared 
 with the male at the time of puberty is a constant 
 phenomenon, to be observed in all races, in every cli- 
 mate, and in all strata of society. According to the 
 statistical data published by the authors just quoted, 
 the age of greatest development in the respective 
 
 sexea is : 
 
 In the female. In the male. 
 
 As regards weight at the age of 12 to 14 years. 14 to 17 years. 
 
 As regards height at the age of 12 to 13 years. 12 to 15 years. 
 
 As regards respiratory capacity at the 
 
 age of 12 to 15 years. 15 to 17 years. 
 
 As regards muscular strength at the 
 
 age of 12 to 14 years. 14 to 15 years. 
 
 Puberty occurs in the female on the average about 
 two years earlier than in the male, and upon this dif- 
 ference the observed diflferences in growth also depend. 
 
 The menarche in the wider signification of the term 
 includes the development which occurs at the time of 
 puberty, and continues through a period of several 
 months, and even years, before complete sexual ma- 
 turity is attained; and includes also the time, which 
 may be considerable, following the first appearance of 
 the menses and before the regular rhythm of the men- 
 strual function is established and the full development 
 of the female genital organs is attained. This time, 
 which forms a notable phase of the sexual life of worn- 
 
48 THE SEXUAL LIFE OP WOMAN 
 
 an, is characterized by great changes in the genital 
 organs and in the vital processes connected therewith, 
 by a strong tendency to suffer from a series of very 
 various pathological changes and disorders of function 
 in the principal organs, and a lessened general resist- 
 ing power to disease — a change which finds its most 
 definite expression in the well-established fact that in 
 this period of life the mortality among females is much 
 greater than among males of corresponding age. Ac- 
 cording to the statistical data of Quetelet and Smits, 
 from the age of 14 to the age of 18 (the period of the 
 menarche) there are 128 deaths of females for every 
 100 deaths of males; and even in the four succeeding 
 years, from the age of 18 to the age of 22, the unfavor- 
 able conditions peculiar to sex are witnessed by 105 
 deaths of females to every 100 deaths of males. 
 
 Many authors draw a distinction between the age 
 of puberty, when the growth of the pubic hair occurs 
 as an external sign of sexual development, and the 
 age of nubility, when the individual becomes fitted for 
 marriage. The distinction is a partial one only, in- 
 asmuch as capacity for copulation is attained already 
 at puberty. The law, however, maintains such a dis- 
 tinction, the Austrian Penal Code, for example, re- 
 garding intercourse with a female less than fourteen 
 years old as rape, and the German Code likewise 
 punishing carnal knowledge of a girl under fourteen. 
 
 The signs of puberty in girls were noticed and ex- 
 plained in very early times. From the anthropological 
 studies of Ploss and Bartels we take the following data 
 regarding this matter. In the Bible we read (Ezekiel 
 xvi. 7) : "Thy breasts are fashioned and thine hair is 
 grown, whereas thou wast naked and bare." The early 
 Indian physician, Susruta, refers only to the regular 
 recurrence of menstruation as a sign of puberty. That 
 
THE SEXUAL EPOCH OF THE MENARCHE 49 
 
 a woman is menstruating may be known by the fact 
 that her face is swollen and bright. In the Roman 
 Empire Justinian ordained that all young women 
 should be examined as to the growth or absence of the 
 pubic hair in order to ascertain if they were ripe for 
 marriage. The early Chinese physicians recorded 
 that in every woman at the age of fourteen or fifteen 
 years a monthly flow of blood from the genital organs 
 began, the period of recurrence being thirty days. The 
 physicians of the Talmud express themselves variously 
 regarding puberty in women. In one place they ad- 
 vance as a sign of puberty the growth of the hair on 
 the genital organs; in another they speak of the notable 
 enlargement of the breasts, and mention as a sign of 
 more complete sexual development that the nipples 
 become elastic. Other Talmudists refer to the ap- 
 pearance of a dark brown coloration in the areola 
 and to the enlargement of the mons Veneris as signs 
 of puberty. Savage races regard the first appearance 
 of the menstrual flow as the only sign of puberty, and 
 among many such races this is the occasion of peculiar 
 ceremonial rites. The attainment of puberty in savage 
 tribes is often solemnized by the seclusion of the girls 
 from the time of the 'first menstruation; they fast dur- 
 ing the period of seclusion, which sometimes terminates 
 in an elaborate ritual of purification. 
 
 For two reasons in particular, the period of the 
 menarche is a time of storm and stress to women, first 
 on account of the developmental processes in the geni- 
 tal organs, and secondly on account of the intellectual 
 changes that occur at this period. 
 
 The local cause is to be found in the extensive trans- 
 formation of the ovaries and the uterus, by means of 
 which a peculiar and powerful stimulus, the menstrual 
 stimulus, is elaborated, which has a reflex influence 
 
50 THE SEXUAL LIFE OF WOMAN 
 
 upon heart and brain, vascular and nervous systems, 
 and secretory and nutritive processes. Since we know 
 that in every premenstrual period by the growth of 
 the follicles hyperaemia is excited in the ovary, by 
 means of which the liquor folliculi is increased in 
 amount, we can well understand that at the time of 
 the menarche the ripening of the graafian follicles is 
 accompanied by a considerable degree of hyperaemia 
 of the ovaries and of the whole of the genital organs, 
 now undergoing their fullest development, and we can 
 easily see how this hyperaemia may result in manifold 
 reflex disturbances. But in addition to these reflex 
 disturbances, we have once more to take into consider- 
 ation the as yet imperfectly known chemical processes 
 which are associated with the ripening and develop- 
 ment of the graafian follicles, and an abnormal course 
 of which may give rise to a disordered constitution of 
 the blood, manifesting itself as chlorosis or in other 
 ways. In connection with the growth and ripening 
 of the ova, extensive and novel demands are made on 
 the organism, and these may well endanger metabolic 
 processes which are not established on a very secure 
 foundation. 
 
 The other cause is to be found in the intellectual 
 processes which occur at this time in the youthfully 
 receptive, highly sensitive organ of mind, the brain. 
 The girl growing into womanhood, who with astonish- 
 ment and stress has witnessed the visible changes in her 
 body, the outward signs of puberty, as they gradually 
 make their appearance, receives powerful psychical 
 stimulation which cannot fail to exercise an influence 
 upon the entire nervous system and its complex inter- 
 lacements, alike in the sensory and in the motor sphere. 
 
 The degree to which these influences radiating from 
 the genital organs make themselves manifest is chiefly 
 
THE SEXUAL EPOCH OF THE MENARCHE 51 
 
 dependent upon the resisting power of the nervous 
 system as a whole, upon the temperament, the inherited 
 constitution, and the mode of education of the young 
 girl. In children belonging to families noted for sensi- 
 bility and irritability, in dwellers in large cities who 
 have attended high schools for girls and have at an 
 early age lifted the veil that covers the sexual processes, 
 the reflex disturbances of the. menarche will be more 
 manifold and will manifest themselves with greater 
 intensity than in children brought up in country dis- 
 tricts, whose sensibilities are" chiefly physical and whose 
 mind is less susceptible to the influence of external 
 stimuli. 
 
 A further important consideration is the time at 
 which the menarche occurs, and whether on the one 
 hand it is at or near the average age, or whether on 
 the other, as precocious menstruation, it is unusually 
 early, anticipating the general bodily development, or 
 again as retarded menstruation it is unduly delayed. 
 In some cases of retarded menstruation, the external 
 genital organs are thoroughly well developed, and it 
 is menstruation only that remains in abeyance; but in 
 other cases the external genitals are also backward in 
 development, the pubes and mons Veneris being but 
 sparsely supplied with hair, and the breasts remaining 
 very sipall. 
 
 In addition to these abnormal temporal relations of 
 the menarche, certain other irregularities at the com- 
 mencement of menstruation are worthy of note. Thus, 
 the first menstruation may be normal, but thereafter 
 amenorrhcea may persist for several months, or if the 
 flow occurs it may be exceedingly scanty, or very pale 
 in color ; on the other hand, menstruation may be very 
 profuse, lasting many days. 
 
 The environment in which the young girl is placed 
 
52 THE SEXUAL LIFE OF WOMAN 
 
 during the period of her sexual development has a 
 great influence on the processes of the sexual life and 
 on the pathological disturbances that affect these pro- 
 cesses. 
 
 In working-class families the immoderate physical 
 strain often thrown upon girls, in many cases continu- 
 ous movements of the upper extremities whilst the 
 lower extremities and the pelvis are absolutely quies- 
 cent, or conversely, an excessive employment of the 
 muscles of the lower extremities — these circumstances 
 in conjunction with insufficient nutriment, night-work, 
 association when at work with persons of the opposite 
 sex, and the frequent premature sexual stimulation, 
 will combine to have a most deleterious effect. 
 
 Amongst country-folk, indeed, the girl has the en- 
 joyment of fresh air, and as a rule nutritive food; more- 
 over, there are not so many occasions of nervous stimu- 
 lation; puberty therefore arrives more slowly and gives 
 rise to less disturbance; but the ignorance of the girls 
 very frequently leads to an early experience of coition, 
 the natural and unnatural consequences of which have 
 then to be taken into account. 
 
 Amongst the better classes of townspeople such 
 hygienic regulations and educational measures are in 
 common employment that young girls during the years 
 of development usually receive reasonable care and at- 
 tention — but very frequently, intercourse with older 
 girls, association with young men, visits to theatres, 
 evening-parties, and balls, and the perusal of stimula- 
 ting literature, form unfavorable features of urban life 
 which exercise their inevitable effects in the sexual 
 sphere. In some cases, fortunately sufficiently rare, the 
 stimulation of the sexual impulse and the longing for 
 its satisfaction are so intense, that a kind of demi-vierge 
 is brought into being, a young woman who is concerned 
 
THE SEXUAL EPOCH OF THE MENARCHE 53 
 
 only to preserve the physical token of virginity, but 
 whose thoughts and fancies are anything but maidenly. 
 It is to be feared that in consequence of the excessive 
 freedom in education and the emancipated indepen- 
 dence of feminine youth, these "half -virgins" are in- 
 creasing both in number and in intensity, a fact which 
 cannot fail to increase also the number of sexual mala- 
 dies and perversions. 
 
 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 char- 
 acter, becoming quiet, self-absorbed, sometimes even 
 melancholy; they are disinclined for study, have a re- 
 pugnance 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 be- 
 fore the first menstruation, the vulva, the labia majora 
 and minora, and the vaginal mucous membrane, are 
 swollen, the clitoris becomes conspicuous in conse- 
 quence of erectile processes, a slight secretion appears 
 in the genital passage, and the breasts become sensitive 
 and slightly turgid. The urine deposits a thick sedi- 
 ment, and occasionally severe strangury is observed. 
 In many cases, also, digestive disturbances occur, loss 
 of appetite, constipation, or a tendency to diarrhoea. 
 
 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 
 
54 THE SEXUAL LIFE OF WOMAN 
 
 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, anaemic girls the second 
 menstruation may not occur till several months have 
 elapsed after the first; less often the second menstrua- 
 tion 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 de- 
 veloped. It is evoked at this time of life by the anato- 
 mico-physiological changes undergone by the repro- 
 ductive 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 men- 
 struation, 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 sensa- 
 tions, the sexual impulse. How far these stimuli aris- 
 ing from the reproductive apparatus are encouraged 
 and accentuated, on the one hand, or repressed and 
 diminished, on the other, depends on external impres- 
 sions of various kinds. The environment is the deter- 
 minant for the further transformation of the as yet 
 undifferentiated sexual impulse into the fully-devel- 
 oped copulative and reproductive impulses. 
 
 In his work on the Physiology of Love, Mantegazza 
 describes the yearning and stress of the awakening sex- 
 ual life, arising out of the presentiments, hazy sensa- 
 tions, and impulses, which are felt in the very earliest 
 period of the developmental phase known as puberty. 
 
THE SEXUAL EPOCH OF THE MENARCHE 65 
 
 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 adoles- 
 cent girl exercises her imagination with the circum- 
 stances of her chaste love, her mind turns to this sub- 
 ject when in solitudej her mood is apt to become melan- 
 choly, 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 par- 
 ticular 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 Krafift- 
 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 expe- 
 rienced 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 aesthetic feelings. This world of 
 the ideal opens itself at the time when the development 
 
66 THE SEXUAL LIFE OF WOMAN 
 
 of the sexual processes begins. * * * The love of 
 early youth, continues von Krafift-Ebing, has a roman- 
 tic, 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 misal- 
 liances, 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-destruc- 
 tion. Love in which the senses play too prominent a 
 part can never be a true and lasting love. For this rea- 
 son, 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 PRECOX ET TARDIVA 
 
 {Precocious and Retarded Menstrual Activity) 
 
 By the term precocious menarche we understand the 
 pathological state in which a typical, four-weekly, san- 
 guineous 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 
 
THE SEXUAL EPOCH OE THE MENAHCHE 57 
 
 and premature sexual development, exhibit a compara- 
 tively 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 axillae; the labia 
 majora and the breasts resemble those of full-grown 
 women, and the pelvis also has the adult form. Com- 
 monly al§o the sexual impulse develops early, whilst, 
 in other respects, the intellectual development lags be- 
 hind the physical. It is most probably a primary hy- 
 perplasia 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 con- 
 ception 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 va- 
 gina 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 mstance as were 
 reported by Eross of six new-born female infants in 
 whom a sanguineous discharge from the vagina ap- 
 peared three or four days after birth and lasted two 
 to five days, the infants not remaining subsequently un- 
 der observation), — numerous well-authenticated cases 
 yet remain in which menstrual haemorrhage was ob- 
 served 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 mo- 
 
58 THE SEXUAL LIFE OF WOMAN 
 
 limina 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 menstrua- 
 tion the menstruation recurred as a rule at regular in- 
 tervals of four weeks; only in quite exceptional cases 
 were the intervals three to five months. 
 
 In several of these cases of premature puberty, sex- 
 ual 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 men- 
 struate 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 be- 
 gan 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 (Moli- 
 tor) . A girl began to menstruate at the age of two, had 
 a growth of hair on the pubes ajid developed mamms 
 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 
 
THE SEXUAL EPOCH OF THE MENARCHE 59 
 
 of Hofmeier's, for instance, of a girl of five with pre- 
 cocious menstruation, the removal of a rapidly growing 
 ovarian tumor was followed by the cessation of men- 
 struation, and the pubic hair, which had been shaved 
 off, did not grow again. 
 
 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 oc- 
 curs in girls who exhibit at this period of life an ex- 
 traordinarily 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. 
 
 In some cases, notwithstanding the delay in the ap- 
 pearance 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. 
 
 Menstruation, after its first appearance in normal 
 fashion, may be suppressed in young girls in conse- 
 quence 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 inten- 
 sity but longer duration have a similar effect; some- 
 
60 THE SEXUAL LIFE OF WOMAN 
 
 times 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 act- 
 ual intercourse or it may be merely of too intimate an 
 embrace with a man, fears she has become pregnant, 
 and actually suffers from amenorrhoea though preg- 
 nancy does not really exist. I saw a case in which 
 amenorrhoea 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 be- 
 came regular. 
 
 Functional amenorrhoea may also occur in young 
 girls in consequence of a sudden change in the condi- 
 tions of life, a removal from town to country, for in- 
 stance, or the reverse, travel in regions where the cli- 
 matic conditions differ widely from those hitherto ex- 
 perienced, 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; menstrua- 
 tion began at the age of 13 and was regular thereafter; 
 on three successive occasions amenorrhoea 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 (2%"), both ovaries distinctly palpable. 
 
THE SEXUAL EPOCH OF THE MENARCHE 61 
 
 Such a form of amenorrhoea as this commonly disap- 
 pears when the girl removes from the conditions un- 
 favorable 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 insufliciently clothed lower extremities, and vaginal 
 injections with water at too low a temperature. Such 
 cases are common among the working classes, es- 
 pecially in washerwomen; but they are also observed 
 among the well-to^do. An example is given by Win- 
 ter: 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, amenorrhoea being complete for a year 
 and a half. Then menstruation recommenced, but was 
 irregular, sometimes anticipating, sometimes postpon- 
 ing 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 dys- 
 menorrhoea was severe. At each proper period, if the 
 flow failed to appear, severe molimina occurred in the 
 form of abdominal cramps and headache. Examina- 
 tion showed the uterus to be normal in shape, 4>^ centi- 
 metres (i%") in length, with a very thin wall; both 
 ovaries were palpable, but smaller than normal. 
 
 The commonest form of amenorrhoea at this period 
 of life is, however, the constitutional amenorrhoea as- 
 sociated with chlorosis. In chlorotic subjects we have 
 to do, not with a symptomatic absence of the menstrual 
 
62 THE SEXUAL LIFE OF WOMAN 
 
 discharge, but with a failure of the ovarian function, 
 the graafian follicles failing to ripen. We generally 
 find, according to Qebhard, that chlorotic girls begin 
 to menstruate at the usual age, or even earlier. Men- 
 struation recurs once or twice at irregular intervals, 
 and then gives place to complete amenorrhoea, it may 
 be suddenly, it may be gradually, the flow on each oc- 
 casion being scantier than before. In chlorotic pa- 
 tients, 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 amenorrhoea may be of short dura- 
 tion; 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 head- 
 ache, dizziness, syncope, feelings of oppression, disin- 
 clination for mental and physical exertion, and so on. 
 Since in such cases the ripening of the ovarian follicles 
 also fails to occur, when the amenorrhoea is complete 
 the menstrual molimina are generally wanting (Geb- 
 hard). 
 
 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 as- 
 sociated with the amenorrhoea, 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 manifesta- 
 tions. 
 
THE SEXUAL EPOCH OF THE MENARCHE 68 
 
 In chlorotic girls, at the times when menstruation is 
 due, a watery discharge often occurs, sometimes slight- 
 ly tinged with blood. Dysmenorrhoea 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 men- 
 strual period. Occasionally also menorrhagia may oc- 
 cur in association with chlorosis, to be distinguished 
 according to Virchow from a rare condition named by 
 him "menorrhagic chlorosis," characterized by exces- 
 sive menstruation of an anticipating type. The bleed- 
 ing 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, es- 
 pecially at the commencement of puberty, as of an 
 endoinfective nature dependent upon auto-intoxication. 
 The toxins lead to inflammatory and degenerative 
 changes in the muscular substance of the uterus. Ac- 
 cording tp Fraenkel in these cases the ovaries are usu- 
 ally enlarged, seldom smaller than normal. 
 
 Inflammatory Processes. 
 
 Chronic metro-endometritis, both corporal and cer- 
 vical, occurs occasionally in young girls during the 
 years of development. It is especially common in chlo- 
 rotic subjects; and next to these in girls who are care- 
 less 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, 
 
64 THi: SEXUAL' LIFE OF WOMAN 
 
 in those who have long practised 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 strik- 
 ing 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 cor- 
 poral metro-endometritis the discharge is of a thinner 
 consistence, milky in appearance, and not very abun^ 
 dant. As a result of the endometritis, the patient suf- 
 fers from various pains in the body, a feeling of ful- 
 ness, sacrache, general sense of fatigue, and divers 
 nervous manifestations; sometimes also from dysmen- 
 orrhoea, strangury, or obstinate constipation. In conse- 
 quence of the great thickening of the mucous mem- 
 brane that often occurs, menstruation becomes very 
 profuse and long-continued, lasting from one to two 
 weeks. 
 
 In consequence of long-continued masturbation, 
 other pathological changes may take place in the fe- 
 male genital organs, such as hypertrophy of the nym- 
 phae, proliferation or glandular hypertrophy of the 
 uterine mucous membrane, ovarian irritation, pains in 
 the ovarian region which, in severe attacks, may radi- 
 ate to the thighs. These pains become more severe at 
 the menstrual period, especially at the beginning of 
 that period; and are sometimes also especially trouble- 
 some 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 phy- 
 sicians, and it is more than sixty years since Bennet 
 
THE SEXUAL EPOCH OF THE MENARCHE 66 
 
 described the "virginal metritis" observed by him in 
 twenty-three virgins. Bonton published in 1887 a mon- 
 ograph on this condition. Gallard assigns masturba- 
 tion as its principal cause. 
 
 Retroflexion of the uterus is also sometimes observed 
 in virgins, induced by the bad habits which are so com- 
 mon in young girls of retaining the urine for excessive- 
 ly long periods and of neglecting constipation. The 
 prolonged distention of the bladder leads to a daily, 
 long-continued stretching of the ligamentous apparatus 
 of the uterus; the full bladder presses the uterus back- 
 ward, and after the viscus has been emptied, the flac- 
 cid ligaments are no longer able to restore the uterus 
 to its normal position of anteflexion. The organ is left 
 with its fundus directed backward, and the intra-ab- 
 dominal pressure keeps it permanently in this position; 
 at the same time, an accumulation of faeces in the rec- 
 tum, by pressing the cervix forward, favors this dis- 
 placement of the uterus. Moreover, when the uterine 
 tissues are flaccid through malnutrition in chlorotic or 
 anaemic subjects, the organ yields more readily to me- 
 chanical influences than it would if its muscular tone 
 was healthy. 
 
 Disorders of Hamatopoiesis 
 
 According to Virchow, two distinct forms of chloro- 
 sis are to be recognized, one form in which no great ab- 
 normalities of the reproductive apparatus exist, and 
 another form in which imperfections in the develop- 
 ment of the central portion of the vascular system are 
 associated with similar imperfections in the reproduc- 
 tive apparatus. In many cases of chlorosis, he found 
 the ovaries small and imperfectly developed, in an in- 
 fantile condition; in other cases, however, they were 
 three times the normal size; the development of the 
 
66 THE SEXUAL LIFE OF WOMAN 
 
 uterus in such cases usually corresponds with that of 
 the reproductive glands. With regard to the etiologi- 
 cal connection between chlorosis and developmental dis- 
 turbances, Virchow inclines to the view, that in chloro- 
 sis 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 dis- 
 order 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 re- 
 productive apparatus. 
 
 Stieda found that in chlorotics displacements of the 
 uterus were common, with abnormal narrowness of the 
 vagina, absence of the pubic hair, imperfect develop- 
 ment of the pelvis, and the growth of the breasts inter- 
 fered with to this extent, that the nipples and areolae 
 were abnormally small. He classifies these manifes- 
 tations 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 nor- 
 mally 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 disor- 
 der, 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 
 
THE SEXUAL EPOCH OF THE MENARCHE 67 
 
 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. Fraenkel is inclined 
 to regard a primary development disorder of the gen- 
 ital organs as the cause of many cases of chlorosis. 
 
 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 an- 
 tiquity, and has been widely held even by physicians, 
 that the disease is due to sexual abstinence in individ- 
 uals with powerful sexual impulse, and that for this 
 reason chlorosis is often cured by marriage. This result 
 of marriage, which, though apparently 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 appa- 
 rent 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. Ex- 
 perience also shows that chlorotic girls sometimes con- 
 tinue 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 puer- 
 perium — but in a wife it is no longer customary to 
 describe such symptoms by the name of chlorosis, they 
 are called anaemia, hysteria, nervousness, etc. Further, 
 
68 THE SEXUAL LIFE OF WOMAN 
 
 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, espe- 
 cially, for instance, amongst the lower classes, in 
 whom it is hardly customary to wait for marriage be- 
 fore beginning sexual intercourse. The connection be- 
 tween masturbation and chlorosis, which has also been 
 widely alleged from the etiological standpoint, is mor£- 
 over 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, espe- 
 cially in those who suffer from amenorrhoea or from 
 irregular menstruation, the anaemic form of obesity not 
 infrequently develops. Such patients at the time of 
 puberty exhibit signs of marked anaemia 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 
 oedematous ; the muscular system is generally feeble. 
 
 What especially characterizes this anaemic 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 oc- 
 cur even in the absence of any severe exertion or espe- 
 cial excitement, often also we see shortness of breath, 
 precordial pain, anxiety, respiratory distress, and sensa- 
 tions of chilliness and fatigue. 
 
 The principal cause of the obesity in these cases is to 
 be found in the anaemia, inasmuch as the diminution in 
 
THE SEXUAL EPOCH OF THE MENARCHE 69 
 
 the number of the erythrocytes is a diminution in the 
 number of the oxygen-carriers, and this entails defec- 
 tive 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 
 msufficient. An auxiliary factor' in producing obesity 
 in such anaemic 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 vi^ith 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 es- 
 pecially after severe physical exertion, mental applica- 
 tion, or emotional excitement, whilst the urine secreted 
 at night is usually free from albumin. The skin is pale, 
 the accessible mucous surfaces are comparatively color- 
 less, the face is puffy, the eyelids are oedematous; the 
 patients suffer from various nervous troubles, espe- 
 cially headache and dizziness, and they are also liable 
 to dyspeptic disorders. 
 
 When the period of the menarche is safely passed, 
 when the menses recur with regularity, and the chloro- 
 tic manifestations disappear, when the process of haema- 
 topoiesis 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-estab- 
 lished, the albuminuria of puberty ceases. It seems, 
 however, that those who have suffered in this way are 
 
70 THE SEXUAL LIFE OF WOMAN 
 
 predisposed to a return of the albuminuria at the cli- 
 macteric 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 anaemia 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 men- 
 struation; 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 per- 
 ceptible, 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 per- 
 cussion, no change is found in the area of cardiac dul- 
 ness. 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 asso- 
 
THE SEXUAI. EPOCH OF THE MENARCHE 71 
 
 ciated a sensation of strong pulsation in the great ves- 
 sels of the neck, and often there is pain on the left side 
 ^of the lower part of the chest, with a sensation of short- 
 ness 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 with- 
 out exciting cause, or with a cause so trifling that it 
 would not in a normal subject have produced any ner- 
 vous 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 recur- 
 ring at irregular intervals are paroxysmal attacks of 
 tachycardia, in which the frequency of the heart and 
 pulse is increased to an enormous extent. This disor- 
 der manifests itself a little time before the first appear- 
 ance of menstruation, thenceforward recurring regu- 
 larly every three or four weeks, accompanying men- 
 struation, or occurring at the proper menstrual period 
 if menstruation is in abeyance; the attack lasts several 
 days. This trouble also disappears a few months after 
 the establishment of menstruation. 
 
 Associated with these cardiac troubles are, not con- 
 stantly indeed, but in the majority of cases, disturbances 
 of the digestive organs. 
 
72 THE SEXUAL LIFE OF WOMAN 
 
 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 
 i8, 19, or 20 years, or in whom considerable irregulari- 
 ties have occurred in connection with the commence- 
 ment of menstruation. In such girls, in whom men- 
 struation 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, res- 
 piratory distress, and feeling of anxiety, on continued 
 exertion or even on very slight occasion. On percus- 
 sion, the heart is not found to be enlarged ; on ausculta- 
 tion, 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 hum- 
 ming-top murmur is audible. The pulse is increased 
 in frequency, at times arhythmical, and easily compres- 
 sible. The sphygmographic tracing usually shows a 
 subdicrotic or dicrotic character. The upstroke is not 
 high ; the downstroke descends low, almost to the low- 
 est level of the curve, before the enlarged dicrotic ele- 
 vation begins. The skin is always strikingly pale; pale 
 also are the visible mucous surfaces, the haemoglobin- 
 richness and the corpuscular richness of the blood are 
 considerably diminished, a feeling of fatigue and vari- 
 ous other nervous manifestations are constantly present 
 —in shott, in all cases we have to do with the well- 
 known chlorotic disposition, sometimes in association 
 with the manifestations of the anaemic form of lipoma- 
 tosis universalis. In several such cases, skin affections 
 
THE SEXUAL EPOCH OF THE MENARCHE T3 
 
 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 anaemic, 
 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 pal- 
 pitation, 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 out- 
 ward, the impulse is always heaving, abnormally pow- 
 erful and resistant, the heart-sounds, especially those of 
 the left ventricle, are louder than usual, the aortic 
 second sound accentuated, sometimes ringing, the caro- 
 tids 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. 
 
74 THE SEXUAL LIFE OF WOMAN 
 
 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 there- 
 fore 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 es- 
 pecially that in some way an increased resistance has 
 been offered to the work of the heart, and that thus the 
 hypertrophy has beeri 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 up- 
 per 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: 
 
 I. Nervous palpitation and paroxysmal tachycardia 
 
THE SEXUAL EPOCH OF THE MENARCHE 76 
 
 in persons in other respects in good healtli, the affec- 
 tion appearing shortly before the commencement of 
 menstruation, and disappearing soon after the flow is 
 regularly established. 
 
 2. Cardiac disorders occurring in young girls suffer- 
 ing from chlorosis, which itself results from the pro- 
 cesses of the menarche. 
 
 3. Cardiac hypertrophy developing at the time of 
 the menarche, and dependent on the circulatory dis- 
 turbances 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 cir- 
 culation 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. Accord- 
 ing to this writer, the growth of the heart is slow until 
 the age of fifteen years is attained, but becomes acceler- 
 ated 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 centi- 
 metres (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 pe- 
 riod 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. 
 
76 THE SEXUAL LIFE OF WOMAN 
 
 The comparatively great development which the 
 heart undergoes at the time of puberty is a phenomenon 
 so important alike in its physiological and its patho- 
 logical relations that it deserves the special designation 
 of the puberal development of the heart; the com- 
 mencement and the completion of puberty appear be- 
 yond question to be to a large extent dependent upon 
 this development of the heart and upon the simultane- 
 ous rise in the blood-pressure of the systemic circula- 
 tion 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 fre- 
 quently 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, 
 are supposed to be connected with the sexual processes 
 of this period of life. C. Heine maintains that in con- 
 sequence of puberty and of the sexual functions that 
 become established at this period, a teleangiectasis 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" 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 
 
THE SEXUAL EPOCH OF THE MENARCHE 77 
 
 established. In most of these cases the pulse is in- 
 creased and the patients complain of a sensation of anxi- 
 ety, 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 ac- 
 companying the heart-sounds; there are also venous 
 murmurs, especially when the heart-trouble is associa- 
 ted with anaemia or chlorosis. Of the cases of pseudo- 
 angina pectoris observed by Krieger, the attacks oc- 
 curred as prodromal manifestations before the first ap- 
 pearance 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. 
 
 Diseases of the Nervous System 
 
 The extensive transformatory processes occurring in 
 the genital organs of young girls at the time of the me- 
 narche, 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. 
 
 On the other hand, the first appearance of menstrua- 
 tion has sometimes a favorable influence in girls suffer- 
 ing from nervous or mental disorder. This is seen, for 
 
78 THE SEXUAL LIFE OF WOMAN 
 
 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. Accord- 
 ing to Warner, hemicrania made its first appearance: 
 
 In 1 girl of 3 to 4 years. In 4 girls of 10 to 11 years. 
 
 In 2 girls of 5 to 6 years. In 2 girls of 11 to 12 years. 
 
 In 1 girl of 6 to 7 years. In 4 girls of 12 to 13 years. 
 
 In 5 girls of 8 to 9 years. In 15 girls of 13 to 15 years. 
 
 In 5 girls of 9 to 10 years. 
 
 Toothache, according to Hollander, 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 sufifering 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, See, 
 and Steiner, show that the proportion of boys to girls 
 affected with chorea minor is i to 2.8, and that of all 
 ages 49 per cent, of the cases occurred at the ages of 6 
 to II years, 29.8 per cent, at the ages of 11 to 13 years. 
 In several cases, in quite young girls sufifering from 
 chorea, pathological changes were found in the genital 
 organs. Ovarian tenderness was manifested on palpa- 
 tion, and always on that side on which the chorea had 
 first manifested itself. Leonard found in a girl aged 
 eleven sufifering from chorea, adhesion of the praepu- 
 
THE SEXUAL EPOCH OF THE MENARCHE 79 
 
 tium 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 con- 
 firming the statement that, "no spinal reflex has such 
 widely-opened and easily accessible paths of conduc- 
 tion 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 gen- 
 erally, the inherited psychopathic tendency that espe- 
 cially 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 appear- 
 ance of mental disorders. The commonest of these are 
 mania and melancholia of the ordinary type, the prog- 
 nosis 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 Kahl- 
 baum as Hebephrenic,^ the prognosis of which is very 
 unfavorable, for it speedily terminates in dementia, 
 similarly to the dementia of puberty described by Svet- 
 lin, dependent upon or associated with premature syno- 
 stosis of the cranial bones. Very often we witness, at 
 
 ^ Hebephrenie. — ^There is no current English equivalent of this word, 
 used by Kahlbaum to denote a form of melancholia occurring at puberty, 
 and terminating in dementia. — Tr. 
 
80 THE SEXUAL LIFE OP WOMAN 
 
 puberty the beginning of the periodic varieties of men- 
 tal disorder, which develop into periodic menstrual 
 psychoses, manifesting themselves regularly at the re- 
 currence 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 uncontrolla- 
 ble and unconditioned attacks of laughing and crying, 
 globus hystericus, clavus hystericus, etc. ; hysteria ma- 
 jor, 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 com- 
 mencement of menstruation. It seems also that at the 
 time of puberty amenorrhceic and dysmenorrhoeic 
 manifestations may give rise to the development of 
 hysteria. In girls at this time of life, hysteria seldom 
 
THE SEXUAL EPOCH OF THE MENARCHE 81 
 
 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 anaesthesia, spasm, and paralysis. 
 On the threshold of puberty the girl with a heredi- 
 tarily neuropathic disposition may exhibit a tendency 
 to epilepsy. In such cases, as Kowalewski writes, the 
 patient has sudden attacks of loss of consciousness, com- 
 monly 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 remem- 
 bers 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 hap- 
 pened. 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 faint- 
 ing-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 
 
82 THE SEXUAL LIFE OF WOMAN 
 
 they must be treated. Binswanger points out that in 
 such cases, in which epilepsy first appears at the com- 
 mencement of menstruation, the attacks may continue 
 to accompany menstruation for several years thencefor- 
 ward. Already established epilepsy is said by some 
 authors, Lawson Tait, Tissot, and Marotte, for in- 
 stance, 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 favor- 
 able influence on the course of epilepsy, a view held 
 already by Hippocrates. 
 
 Not infrequently, attacks of precordial pain associa- 
 ted with tachycardia occur during the first menstrua- 
 tion. 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 de- 
 velopment of puberty; the tendency to acromegaly, it 
 is suggested, is produced by the remarkable transmi- 
 gration that occurs at puberty of the energy of growth 
 from its accustomed paths into new channels. The re- 
 lations which Neusser has shown to exist between the 
 ovaries on the one hand and the vegetative nervous sys- 
 tem and the process of haematopoiesis 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 
 
THE SEXUAL EPOCH OF THE MENARCHE 88 
 
 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 them- 
 selves in the first period of the commencement of men- 
 struation, sometimes melancholia, sometimes amentia 
 in the form of slight and transitory maniacal derange- 
 ment, more rarely a katatonic^ condition, may precede 
 the menarche, or may accompany or follow it. 
 
 A special form of psychosis is associated with the 
 menarche (von Kraflft-Ebing, Griesinger, Friedmann, 
 Schonthal). 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 men- 
 strual reflex. The last named of these influences is the 
 most potent. It manifests itself in the following man- 
 ner: Certain psychoses which develop before the com- 
 mencement 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 disturb- 
 
 1 Katatonia (Katatonie) is a term used in Germany to denote insanity 
 associated with muscular rigidity. — Tr. 
 
84 THE SEXUAL LIFE OF WOMAN 
 
 ance 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 Schonthal and also by Friedmann, who has de- 
 scribed 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, hered- 
 itarily well endowed, and the psychosis thus appeared 
 without warning, like a storm from a clear sky. Ex- 
 actly 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 promi- 
 nent, 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 ulti- 
 mate cure may coincide with the definite regularization 
 of menstruation; or, in cases in which menstruation is 
 restored but remains inadequate, the course of the dis- 
 order may become a gentle undulatory one, the violent 
 stimulus of total suppression being replaced by a more 
 moderate stimulus — here also, however, a cure ulti- 
 mately follows when menstruation at length becomes 
 free as well as regular. But during the height of the 
 malady a proper development of menstruation is al- 
 
THE SEXUAL EPOCH OF THE MENARCHE 85 
 
 ways 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 mas- 
 turbation. 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 masturba- 
 tion, and will do so earlier and more surely if the girl 
 is a neuropsychopath by inheritance. The local influ- 
 ence of menstrual congestion, however, also plays a 
 part in provoking the impulse toward masturbation, 
 since at every period a hyperaesthetic state recurs in the 
 genital organs. 
 
 Girls thus addicted have sometimes a very striking 
 general appearance. They are pale, with a weary ex- 
 pression 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 
 
86 THE SEXUAL LIFE OF WOMAN 
 
 I by no means wish to adduce as characteristic of 
 onanists. 
 
 Temperament and mode of life are decisive in de- 
 termining 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 awaken- 
 ing 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. 
 
 . An experienced physician, Gutceit, is of opinion that 
 in young girls of lo to i6 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 i8, 19, and 
 20 onward, "sexual self-gratification is almost univer- 
 sally practised by women, even if it be not always prac- 
 tised to excess," an opinion which cannot, however, be 
 regarded as conclusive. 
 
 L. Lowenfeld remarks that the manifestations of the 
 sexual impulse are not normally present in the days of 
 childhood. In consequence of pathological conditions, 
 
THE SEXUAL EPOCH OF THE MENARCHE 87 
 
 especially of such as affect the genital organs, in conse- 
 quence 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 as- 
 sociated with a certain degree of development, of ripe- 
 ness, of the reproductive organs. Physiologically, sex- 
 ual 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 onan- 
 ism) . 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 in- 
 troduced into the vagina for this purpose. Many fe- 
 males effect sexual self-gratification by rubbing and 
 pressing movements of the thighs one against the other, 
 in which the clitoris is implicated. In psychical onan- 
 ism, on the contrary, as Lowenfeld points out, the or- 
 gasm is produced solely by central stimulatory repre- 
 sentations, 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 mas- 
 turbation 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 Lowenfeld's opinion, 
 less widely practised than in the male; none the less, 
 it is in the former sex far commoner than is generally 
 
88 THE SEXUAL LIFE OF WOMAN 
 
 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, masturba- 
 tion rarely leads to the production of well-marked 
 nervous disturbances, and does so only when practised 
 to very great excess. Beard reports that in the power- 
 ful and full-blooded working-class girls of the Irish 
 race, masturbation, even when practised for many 
 years, did not result in anv notable disorder to health. 
 
 Disorders of Digestion 
 
 Disorders of the digestive apparatus are quite com- 
 mon 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 hyperaes- 
 thesia of the gastric mucous membrane, loss of appe- 
 tite, a disagreeable, pasty or acid taste, sometimes 
 bulimia, perverse sensations of taste, and pyrosis. 
 Especially in chlorotic girls, periodic attacks of pain 
 occur, localized in the epigastrium and its neighbor- 
 hood, 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. Intesti- 
 nal activity is usually depressed, peristalsis is dimin- 
 ished, 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. 
 
THE SEXUAL EPOCH Of THE MENARCHE 89 
 
 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 underdevel- 
 oped; 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 
 
 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 Neudorfer maintains that 
 precisely during the period of puberty to this body 
 must be assigned an important regulatory trophic sig- 
 nificance for the nourishment and growth of the re- 
 productive 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. Miiller states that in many regions, as for in- 
 stance in Canton Berne, in Switzerland, where the 
 school children exhibit with extraordinary frequency 
 a hereditary tendency to the formation of goitre, dur- 
 ing 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 time onward no further growth of the 
 thyroid body is observed, in girls at puberty the hyper- 
 trophy greatly increases, so that very large goitres are 
 formed. The same author recurs to the earlier ob- 
 
90 THE SEXUAL LIFE OF WOMAN 
 
 servations of Heidenreich and Schonlein, as well as 
 to those of Friedreich, by which this influence of pu- 
 berty 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 de- 
 tected; the swelling is greater if the menstrual dis- 
 charge 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 con- 
 nection. Of ocular troubles during the menarche, 
 iridochoroiditis, haemorrhages into the vitreous body, 
 long-continued blindness, and pannous keratitis, are 
 mentioned, which may either disappear with the re- 
 establishment of menstruation (spontaneous or artifi- 
 cially 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 exacerba- 
 tion of the ocular trouble coinciding with disordered 
 
THE SEXUAL EPOCH OF THE MENARCHE 91 
 
 menstruation, and cure taking place only when men- 
 struation has become perfectly regular. Vicarious 
 haemorrhages into the vitreous body also occur, as- 
 sociated with disturbances of menstruation, the relapses 
 ceasing as soon as menstruation becomes regular; such 
 a case was observed by Courserants in a girl of four- 
 teen years. 
 
 Disturbances of hearing have been observed at the 
 time of puberty in young girls addicted to masturba- 
 tion; the patients complain of subjective noises, rising 
 in intensity till actual hallucinations may be experi- 
 enced. Lichtenberg reports the case of a strong girl 
 eighteen years of age, in whom the congestion associ- 
 ated with puberty was followed by atrophy of the audi- 
 tory nerve. The same author, also A'shwell, Law, 
 Puech, Rossi, Stepanow, and Gilles de la Tourette, 
 have published cases of vicarious menstrual haemor- 
 rhage 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 men- 
 strual 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, some- 
 times of increased acuteness, and sometimes of per- 
 version, 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 
 
92 THE SEXUAL LIFE OF WOMAN 
 
 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 seven- 
 teen years of age, having a fatal termination. Accord- 
 ing to Mackenzie, sexual excitement leads to swelling 
 of the nasal mucous membrane, and habitual masturba- 
 tion 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 subaceous 
 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 — haematidrosis occurs; in some 
 cases, however, the hemorrhage takes place from areas 
 of skin altered and injured by disease, from wounds 
 or other injuries, from ulcers, or from excrescences. 
 Haemorrhage into the skin occurs also in the so-called 
 
THE SEXUAL EPOCH OF THE MENARCHE 93 
 
 stigmatization, in which condition also an etiological 
 role has been assigned to menstruation. 
 
 In the skin, remark Spietschka and Griinfeld, 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, 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 
 axillae. 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 dis- 
 eases of the skin. Thus arise the various forms of 
 seborrhoea. 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 seborrhoea, 
 the secretion is more fluid in consistence, and col- 
 lects on the surface of the skin, furnishing this with an 
 oily covering. 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 appear- 
 ance. Seborrhoea faciei is readily converted into 
 eczema. 
 
 With the puberal development of the external genital 
 
94 THE SEXUAL LIFE OF WOMAN 
 
 organs is associated an increase in the sebaceous secre- 
 tion 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 anaemic 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, weep- 
 ing spots are thus formed, and have a very disfiguring 
 appearance. Such eczema may occur also in connec- 
 tion with disturbances of menstruation, when the 
 menses are scanty and pale, or when dysmenorrhoea 
 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 stim- 
 ulation, 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 as- 
 sociation with disturbances of menstruation, acute 
 oedema or erythema are observed. 
 
 Finally, we must mention herpes progenitalis, a 
 rather uncommon acute condition in which, with vio- 
 lent itching and burning sensation, intense redness and 
 oedematous swelling of the skin, vesicles form on the 
 
THE SEXUAL EPOCH OF THE MENARCHE 95 
 
 praeputium clitoridis, the nymphae, and the inner sur- 
 face 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 de- 
 pressed 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 strength- 
 ening 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 abun- 
 dance 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 recom- 
 mended ; fruit, raw or cooked, should also be taken in 
 considerable quantities. The evening meaP 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 quan- 
 tities; only as a stomachic a glass of beer or of light 
 wine may be recommended. 
 
 Chlorotic patients should even at their first break- 
 fast^ have a meal rich in albumin, such as a consider- 
 
 1 It must be remembered that these dietetic directions are for German 
 and Austrian middle-class people, the arrangement of whose meals differs 
 from ours considerably. The usual meals and hours are : Early breakfast, 
 coffee and rolls, at 8 or earlier; second breakfast,, a more substantial meal, 
 at 10; mid-day dinner, the principal meal, at 1 or 2 p.m.; afternoon coffee, 
 at 4 ; supper at 8 p.m. — Tr. 
 
96 THE SEXUAL LIFE OP WOMAN 
 
 able helping of meat, or a beefsteak, with rolls, butter, 
 and tea or coffee. Milk should be taken in small quan- 
 tities 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 
 a I'Anglaise, ham; roasted venison, hare, partridge, 
 grouse, fieldfare, hazel-hen, ptarmigan, pheasant, 
 chicken, pigeon, turkey, oysters; asparagus, cauli- 
 flower, 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 sys- 
 tematic 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 anasmic 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, car- 
 rots, turnips, sweet fruits, grapes, dates, pippins, plums, 
 pears, and preserved fruits— all these must appear at 
 table more frequently than usual; beverages, in addi- 
 tion to milk, that are suitable are chocolate and cocoa. 
 Bavarian beer, and sweet, heavy wines. 
 
THE SEXUAL EPOCH OF THE MENARCHE 97 
 
 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 sau- 
 sage, ham, or roast meat. Mid-day dinner, i A.M. : 
 Soup, roast meat with vegetables and potatoes, or fish 
 may take the place of the soup, sweets to follow. After- 
 noon, 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 anaemic form of obesity, to 
 which chlorotic patients of the better classes are sub- 
 ject, in consequence of sedentary habits and overfeed- 
 ing, the diet must be so arranged that albumins pre- 
 dominate, whilst carbohydrates should be given spar- 
 ingly, 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 pos- 
 sible, since the deprivation of water may result in a 
 proportionate increase in the solid constituents of the 
 blood, and thus increase its haemoglobin richness. 
 
 The amount of physical exercise taken by young girls 
 at this period of life must vary according to the cir- 
 cumstances 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, Hay- 
 
98 THE SEXUAL LIFE OF WOMAN 
 
 em, 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. 
 
 I have drawn up the following diet-table for obese 
 chlorotic patients: 
 
 Quantity in f Contains of ^ 
 
 Grammes. Albumin. Fat. Carbohydrates. 
 Morning: 
 
 Beefsteak 100 38.2 1.7 
 
 A cup of tea 150 0.45 0.9 
 
 White bread 30 2.9 0.2 18.0 ■ 
 
 Mid-day: 
 
 Meat soup 100 1.1 1.5 5.7 
 
 Roast meat 200 76.4 3.4 
 
 Vegetables 50 0.8 0.2 4.2 
 
 White bread 50 4.8 0.4 30.0 
 
 Light wine 150 1.0 
 
 Afternoon : 
 
 A cup of coffee 120 0.2 0.67 1.7 
 
 White bread 25 2.4 0.2 15.0 
 
 Evening: 
 
 Roast meat 200 46.4 3.4 
 
 ^ Vegetables 25 0.4 0.1 2.1 
 
 Wine 150 1.0 
 
 White bread 30 2.9 0.2 18.0 
 
 Total 1380 206.97 1 1.92 97.6 
 
 Contains about 1300 calories. 
 
 For young girls at this period of life systematic gym- 
 nastic exercises are usually valuable, not only for 
 strengthening the muscular system and improving the 
 physique during these years of growth, but also for 
 assisting the functions of respiration, circulation, and 
 digestion. Beginning with the simplest and easiest 
 exercises of chamber gymnastics, the girl gradually 
 proceeds to more difficult and elaborate exercises and 
 to the use of medico-mechanical apparatus. 
 
THE SEXUAL EPOCH OF THE MENARCHE 99 
 
 The clothing of young girls at the time of the me- 
 narche must receive attention to this extent, that all 
 articles of clothing should be rejected which increase the 
 tendency already existing to hyperaemia of the genital 
 organs or offer any hindrance to the circulation in 
 general. Above all, the physician must take his part 
 in the contest so long and so vainly urged against the 
 corset. But further, all tight clothing, such as re- 
 stricts the freedom of movement of the thorax and the 
 abdomen, tight collars, and tight garters — all these 
 must be forbidden ; moreover excessively warm under- 
 clothing, of the lower extremities especially, which 
 may stimulate the genital organs, must also be pro- 
 hibited. 
 
 As regards the night hours, a thick feather bed is 
 unsuitable. The young girl should sleep on a hair 
 mattress, and the bed clothing should be light. Eight 
 to nine hours sleep is sufficient; in the words of the 
 English proverb, "early to bed and early to rise, is 
 the way to be healthy, and wealthy, and wise." 
 
 To live by rule, with regular hours of work and 
 suitable pauses for rest, is of great importance. 
 Among the well-to-do classes also care should be taken 
 that the adolescent girl takes moderate physical exer- 
 cise for several hours daily; she should go for a good 
 walk, and not spend hour after hour recumbent upon 
 a sofa in idle reverie. Sitting for too long a time, 
 whether engaged in sewing or at the piano, is harmful ; 
 working at the sewing-machine is permissible for short 
 periods only, and is indeed at this period of life better 
 altogether avoided. Bicycling is also an unsuitable 
 exercise at this age and readily leads to masturbation. 
 Lawn tennis and croquet, on the other hand, are very 
 suitable active open-air games; in winter, skating may 
 be indulged in if proper precautions are taken against 
 
100 THE SEXUAL LIFE OF WOMAN 
 
 chill; in summer, swimming and rowing. The read- 
 ing of light literature should be kept under supervision ; 
 equivocal novels, such as may give rise to erotic reverie 
 and sensual excitement, must be strictly forbidden. 
 A watch should be kept for any indications of the 
 habit of masturbation; and if the habit exists, appro- 
 priate measures should be taken. 
 
 Hydrotherapeutic procedures and baths are of great 
 hygienic and therapeutic importance for girls at the 
 menarche. In healthy girls at this period of life, a 
 cold sponge-bath lasting one or two minutes, the tem- 
 perature of the water ranging from io° to 20° C. (50° 
 to 63° F.), taken either on rising in the morning or 
 immediately before going to bed, is a valuable means 
 for hardening the whole body; equally useful are cold 
 shower-baths, lasting from a few seconds up to half 
 a minute. If the girl is somewhat anaemic, it will be 
 well for her to take a glass of warm milk or a cup of 
 tea half an hour before the bath, in order to guard 
 against too great an abstraction of heat. Cold bathing 
 in rivers, when available, may also be recommended. 
 In cases in which a considerable degree of anemia or 
 chlorosis is present, cold baths and every form of strong 
 mechanical stimulation by the use of water, douches 
 and the like, are to be avoided, since we have to fear 
 both excessive abstraction of heat and overstimulation 
 of the nerves. In such anaemic and chlorotic patients, 
 either partial washing with lukewarm water or general 
 lukewarm baths, the temperature of which may be 
 gradually and cautiously lowered, either on rising or 
 at bedtime, have a refreshing and stimulating effect. 
 
 In girls who are in other respects healthy, but in 
 whom the menarche is delayed, and in whom men- 
 struation, when begun, has been scanty and irregular, 
 cold sitz-baths of short duration, the abdomen being 
 
THE SEXUAL EPOCH OF THE MENARCHE 101 
 
 simultaneously douched from a considerable height, 
 or cold shower-baths in combination with powerful 
 abdominal douches, are often of value. 
 
 Recently, hot air and vapor baths have been espe- 
 cially recommended for girls suffering from chlorosis, 
 at first, by Scholz and Schubert, in association with 
 phlebotomy, but also without this. Kuhne, for ex- 
 ample, has seen the most satisfactory results follow the 
 simple use of sudatory baths in cases of chlorosis ; im- 
 provement was manifested by an increase in the corpus- 
 cular richness of the blood, an increase in the haemo- 
 globin-richness, and an increase in the body-weight. 
 In cases of chlorosis, Traugott also has seen favorable 
 results follow the use of hot-air baths and the con- 
 sequent diaphoresis. 
 
 Still more recently Dehio and especially Rosin have 
 recommended hot baths for girls suffering from chlor- 
 osis. In fifty cases of chlorosis, in which other methods 
 of treatment had given negative results. Rosin gave 
 three times a week baths at a temperature of 40° C. 
 (104° F.), lasting at first a quarter of an hour, but 
 later half an hour. After the bath, in those strong 
 enough to bear it, a very short cold douche or cold 
 sponging followed; then the patient had to lie down 
 for an hour. The treatment was carried out for from 
 four to six weeks. Each bath by itself had a notable 
 refreshing effect in these patients, and at the end of 
 the course most of the cases exhibited an improvement 
 in all their symptoms, such as other methods of treat- 
 ment had failed to produce. 
 
 The favorable influence exercised by these hot baths, 
 as by steam bath-cabinets, light baths, sun baths, wet 
 packing, and similar sudorific measures, may in part 
 be explained by the dehydration of the system that is 
 thus effected; whilst those who maintain the auto-in- 
 
102 THE SEXUAL LIFE OF WOMAN 
 
 toxication theory of chlorosis may regard the dia- 
 phoresis as a means for the elimination of noxious sub- 
 stances from the body. 
 
 Bathing in water aerated with carbonic acid may be 
 recommended for patients suffering from anaemia and 
 chlorosis at this period of life, for the reason that such 
 baths can be tolerated at a lower temperature than 
 baths of ordinary water. The natural mineral waters 
 containing free carbonic acid, and chalybeate waters 
 rich in carbonic acid, when used as baths, are efifective 
 principally in virtue of the carbonic acid they contain, 
 which stimulates the skin; this stimulus being con- 
 ducted by the nervous system from the periphery to 
 the nerve-centres, is reflected thence, and by irradia- 
 tion exercises a quickening effect on all the processes 
 of nutrition. These baths are usually taken at a tem- 
 perature progressively reduced from 32° C. to 25° C. 
 (90° F. to 77° F.), and each bath lasts from ten to 
 twenty minutes; they are in most cases taken every 
 other day only. For young girls in whom the me-, 
 narche is delayed, also for chlorotic patients with amen- 
 orrhoea and neuralgic manifestations, chalybeate peat 
 baths are indicated, which influence the peripheral 
 nerves by the exercise of a gentle yet considerable 
 thermic stimulus. These chalybeate peat baths have 
 further been shown to increase the haemoglobin-rich- 
 ness, the corpuscular richness, and the specific gravity 
 of the blood, transitorily after each bath, but to some 
 extent permanently also, a certain increase enduring 
 after the course is over. 
 
 Young girls suffering from disturbances of their 
 general health dependent upon a scrofulous or rachitic 
 habit of body may with advantage be sent to brine 
 baths, especially to such as are situated in the Alps or 
 other mountainous regions. These weakly, lymphatic. 
 
THE SEXUAL EPOCH OF THE MENARCHE 103 
 
 scrofulous girls, suffering from scanty or irregular 
 menstruation, may also practise sea-bathing with ad- 
 vantage, especially at watering-places on the sea-coast, 
 where the waves are powerful. In such cases, how- 
 ever, it is advisable in the first instance to take artifi- 
 cially warmed sea-water baths, before proceeding to 
 actual sea-bathing. 
 
 If the sensibility of a chlorotic patient is so great that 
 she can endure neither peat baths nor carbonic acid 
 containing mineral water baths, we must add to the 
 latter, in order to make their action milder, decoctions 
 of chamomile, wheat bran, malt, and the like. 
 
 In cases in which nervous symptoms predominate, 
 with an apathetic, melancholic frame of mind, aro- 
 matic herb baths are sometimes useful. For this pur- 
 pose such herbs should be employed as contain a no- 
 table quantity of ethereal oils, such as sage (salvia 
 officinalis), wild thyme (thymus serpyllum), hyssop 
 (hyssopus officinalis), wild marjoram (origanum vul- 
 gare), rue (ruta graveolens), archangel (archangelica 
 officinalis), levisticum (levisticum officinale). Equal- 
 ly useful are the balsamic pine needle baths, for which 
 the fluid obtained by the distillation of pine needles 
 (pinus sylvestris), freshly collected day by day, is 
 employed. 
 
 As regards the climatic conditions suitable for 
 adolescent girls suffering from the disorders of the 
 menarche, from the nervous conditions associated 
 therewith, and from chlorosis, residence either in the 
 mountains or at the seaside is especially to be recom- 
 mended. An altitude of about 1,200 metres (4,000 
 feet) is the most suitable, being that at which the 
 peculiar characteristics of mountain climates are most 
 fully developed. The influence of such a climate on 
 
104 THE SEXUAL LIFE OF WOMAN 
 
 haematopoiesis has to be taken into consideration, as 
 well as Its special influence on the menstrual function. 
 
 Even though it cannot yet be regarded as fully 
 determined whether the increase observed by Viault, 
 Egger, and Mercier, in the corpuscular richness and 
 haemoglobin-richness of the blood in consequence of 
 residence in a mountain climate, is lasting or merely 
 transitory, yet it is certain that the haematopoietic 
 organs are favorably influenced by such residence, and 
 that the good results are augmented by the stimulat- 
 ing effect mountain air exercises on the appetite and 
 the digestion. Lombard has moreover observed, that 
 at a high altitude the menstrual flow is more abundant 
 and dysmenorrhoea is less common. For young girls, 
 therefore, suffering from irritable conditions of the 
 heart, increased frequency of the pulse, or increased 
 arterial tension, and for those also in whom the resist- 
 ing power of the organism appears deficient, a visit 
 to a mountain health resort situated amid forests may 
 be recommended. For scrofulous girls a visit to the 
 sea side is especially suitable. For the slighter forms 
 of anaemia, a sea voyage, in which the benefits of sea 
 air can be obtained more fully, and for a longer period, 
 may be advised; but such a voyage is quite unsuitable 
 for those suffering from severe anaemia or chlorosis. 
 
 Such very weakly, intensely anaemic and chlorotic 
 patients should spendthe winter' in some southern 
 health resort. 
 
 The skin, in which disturbances so readily occur at 
 the time of the menarche, requires careful attention, 
 all the more because it is precisely at this age that 
 young girls have the greatest need of their personal 
 charms. The skin of the face, which is often dis- 
 figured by comedones and acne, must be carefully 
 guarded against the accumulation of sebum in the 
 
THE SEXUAL EPOCH OF THE MENARCHE 105 
 
 sebaceous glands by sedulous washing with warm water 
 and a good soap. If the seborrhoeic process in these 
 glands becomes at all severe, ordinary soaps are un- 
 suitable, and a potash soap must be used, such as sapo 
 viridis, or spiritus saponatus kalinus, which have great 
 power of dissolving fats. 
 
 The best way of dealing with seborrhoea is, according 
 to Spietschka and Griinf eld, the following : The wash- 
 ing is best effected in the evenings, when the skin will 
 not again for many hours be exposed to the fresh air, 
 to wind, or to dust. Pour into a basin about a pint 
 of warm water and add from one to two teaspoonfuls 
 of spirit of soap (equivalent to the linimentum saponis 
 of the British Pharmacopoeia) or as much soft soap as 
 can be taken up on the end of a table-knife. The water 
 is then stirred vigorously till a good lather is formed, 
 and with the water and the lather the face is thoroughly 
 washed. The skin must then be carefully dried, and 
 thereafter it is well to smear it with some greasy ma- 
 terial, such as boric vaseline, in order to prevent the 
 plugging of the pores with dust, and to protect the se- 
 bum subsequently exuded from desiccation. On the 
 next day the washing should be repeated only if the 
 face has become covered with sebum within an hour 
 or two after the first washing. If the exudation is less 
 free, the eyes only should be washed with fresh water, 
 whilst the rest of the face should not be wetted, but 
 merely be wiped with a dry face towel lightly dusted 
 with toilet powder, in order to remove any accumula- 
 tion of sebum. 
 
 The skin of the genital regions must be carefully 
 cleansed, especially in cases in which there is a tendency 
 to hypersecretion of the sebaceous glands, to eczema, 
 or to herpes progenitalis; subsequently it should be 
 powdered, and pads of absorbent cotton-wool dusted 
 
106 THE SEXUAL LIFE OF WOMAN 
 
 with toilet powder should be placed in the labial fur- 
 rows. 
 
 It is of great importarK;e that in girls at this time 
 of life gynecological examination should be undertaken 
 only in cases of the utmost need, and this restriction 
 should be especially inflexible in the case of girls with 
 a neuropathic predisposition. Instances have been ob- 
 served in which a vaginal examination, the introduc- 
 tion of a vaginal speculum, or the use of the uterine 
 sound, has determined the onset of a psychosis. Still 
 more does what has been said hold true of local treat- 
 ment in gynecological cases. Repeated passage of the 
 uterine sound, cauterization of the cervix, and the 
 manipulations of gynecological massage, make a very 
 deep impression upon the mind of a girl, and give 
 rise to morbid ideas and erotic storms, so that even 
 in those with a powerful constitution, various neuroses, 
 neurasthenic states, and even mental disorders may re- 
 sult. 
 
 If in such cases, especially in girls of a neuro- 
 pathic temperament, gynecological treatment is quite 
 indispensable, a single, though energetic, operative pro- 
 cedure is to be preferred to a number of successive, 
 though taken singly less extensive, manipulations of 
 and in the female genital organs. The importance 
 of this proposition has been repeatedly established. 
 Sanger, for instance, points out as a fact to be regretted 
 that uterine cauterization with mild caustics is far too 
 frequently undertaken; and Odebrecht, from the same 
 standpoint, proclaims the advantage of a single curet- 
 ting as compared with milder intra-uterine impres- 
 sions repeated during a course of treatment lasting 
 many months. On the other hand, the physician must 
 bear in mind the fact, established by the record of a 
 very large number of cases, that in women predisposed 
 
^^HE SEXUAL EPOCH OF THE MENARCHE 107 
 
 CO psychoses severe gynecological operations are apt 
 to lead to the actual appearance of mental disorders, 
 or to the exacerbation of mental disorders which have 
 previously been very mild or have merely threatened 
 to appear. Careful consideration is needed, on the 
 one hand as regards the severity of the disease of the 
 genital organs, and on the other as regards the resist- 
 ing power, temperament, and constitution of the girl 
 concerned, and in many cases a consultation between 
 the gynecologist and the neurologist is expedient. 
 
 A very powerful influence on the physical and moral 
 well-being of the girl at puberty is exercised by her 
 domestic upbringing. The general truth of Goethe's 
 saying, that the circumstances into which we are born 
 exercise a determining influence on the whole life, 
 being admitted, we have to remember that this applies 
 with especial force in the case of girls. 
 
 The educational views which obtain at the present 
 day among the upper ten thousand, are by no means 
 calculated for the production of a woman healthy in 
 body and sound in mind. From the time when the 
 young girl becomes sexually developed, the claims 
 which society makes upon her become pressing. Every 
 day, by a number of stimuli, her curiosity and her de- 
 sires are directed toward sexual matters. Visits to 
 museums, picture galleries and theatres, the perusal 
 of modern romances, the free mingling of the sexes in 
 all places of amusement — all these combine to awaken 
 prematurely an instinct to which the "old-fashioned" 
 methods of education allowed a much more prolonged 
 slumber. In other cases, the mother's supervision of 
 the developing girl is hindered and rendered insuffi- 
 cient because the mother herself is claimed by her 
 society duties and taken much away from her home. 
 In addition, the young brain is overburdened with 
 
108 THE SEXUAL LIFE OP WOMAN 
 
 mental work, the modern idea of the equality of the 
 sexes in matters of love is instilled, and a desire is 
 artificially evoked, and is matured by a certain idle 
 vanity, to indulge the "natural" instincts — to manifest 
 sexual passion and to indulge it to excess — and thus 
 the modesty so natural and so becoming to young girls 
 is completely lost. Nourished in such a soil, neu- 
 rasthenic and hysterical states, disorders of menstrua- 
 tion and masturbation, cannot fail to flourish. 
 
 In these respects also a change is requisite, and a 
 mode of upbringing must be inculcated from which 
 everything likely to inflame the sexual impulse is re- 
 moved. For the adolescent girl a systematic alterna- 
 tion of work and recreation must be arranged. From 
 great entertainments where she will mix with young 
 men, from theatres, evening parties and balls, the 
 young girl at the time of the menarche, at the period 
 when menstruation commences, must as far as possible 
 be kept away, and such pleasures must be reserved for 
 a more advanced stage of this period of development. 
 Intellectual overstrain, the overtaxing of the young 
 head, must be avoided ; the acquirement of knowledge 
 must take place gradually and slowly, and in a manner 
 adapted to individual peculiarities. Intercourse with 
 female friends also requires supervision in respect of 
 the moral characteristics of these latter. Religious 
 reverie must be avoided, but also to be avoided is the 
 modern nihilism in respect of religion and good morals. 
 Books must be carefully chosen in order that the imag- 
 ination may remain pure and in order that girlish 
 illusions may not be prematurely destroyed. Domestic 
 recreations in the way of games, music, singing, paint- 
 ing, and other forms of artistic culture, are of impor- 
 tance for the development of a strenuous faculty for 
 learning. Travel in regions where the scenerj is beauti- 
 
THE SEXUAL EPOCH OF THE MENARCHE 109 
 
 ful, forms a most valuable means for the ennoblement 
 of the intellect and the emotions. 
 
 Additional matters demanding attention are, as al- 
 ready mentioned, the suitability of the diet, and proper 
 physical exercise. All stimulating articles of food are 
 to be avoided, the excessive use of meat is to be for- 
 bidden, and a sufficient mixed diet, containing both 
 animal and vegetable substances, is to be prescribed. 
 Tea and coffee should be taken as sparingly as possible, 
 and alcoholic beverages must be absolutely prohibited. 
 The regulation of the bowels is of great importance. 
 Young girls should accustom themselves to evacuate 
 the bowels every day at a fixed hour, the best time 
 to adopt being either immediately on rising or just 
 after breakfast. Constipation is very apt to lead to 
 the production of irritable conditions of the genital 
 organs. 
 
 We can point out as a happy instance of modern 
 progress that the practice of certain physical exercises 
 has actually become the fashion for young girls. Gym- 
 nastics, with or without apparatus, swimming, skating, 
 and lawn tennis, involve a number of bodily move- 
 ments advantageous for the health; and in connection 
 with most of these the enjoyment of fresh air offers 
 an additional favorable influence. Bicycling, however, 
 at this period of life, is open to many objections, not 
 only on account of the likelihood of direct injury to 
 the genital organs now in course of development, but 
 also on account of the impulse it produces toward on- 
 anistic manipulations. 
 
 Especial attention must be paid to the clothing, re- 
 garding which the requirements of fashion so often 
 conflict with those of hygiene, the victory, unfortu- 
 nately, in most cases falling to the former. The period 
 of the menarche is indeed usually regarded as the 
 
110 THE SEXUAL LIFE OF WOMAN 
 
 proper time for the young girl to begin wearing a 
 corset, if it has not been worn before. In this con- 
 nection M. Runge makes the significant remark: "As 
 long as bodice and skirt form the two principal articles 
 of woman's clothing, the corset or some similar article 
 cannot be dispensed with. The vicious features in the 
 corset are its constriction of the thorax, with the object 
 of giving the woman a 'figure,' and the introduction 
 into its substance of strips of whalebone or steel in 
 order to give firmness to the figure. The harm done 
 by the former feature, the compression of the abdom- 
 inal viscera, the corset liver (lacing liver, constricted 
 liver, Ger. Schniirleber), the movable kidney, etc. — 
 all are so well known that they need not be particu- 
 larly described. But the strong pressure from above 
 has a deleterious effect upon the internal genital organs 
 also, leading to passive hyperaemia and to displace- 
 ments. The 'bones' of the corset take part in the com- 
 pression, and they replace the functions of the muscles 
 of the back. If a woman who has long worn a corset 
 lays it aside later in life, she complains that she is no 
 longer able to hold herself upright. In consequence 
 of insufficient work the muscles of the back have be- 
 come incapable of keeping the back straight. The 
 corset, then, must neither constrict the body, nor must 
 it contain 'bones.' An article of clothing analogous 
 to the corset is, however, required for the support of 
 the skirt and the petticoats that clothe the lower limbs. 
 These latter are usually fastened by means of bands 
 which encircle the body above the crest of the ilium. 
 In order to give these bands a sufficient hold, this region 
 of the body is compressed by the corset. The burden 
 of skirt and petticoats is thus borne by a furrow, above 
 the pelvis and below or in the region of the asternal or 
 false ribs, which is in great part artificially produced. 
 
THE SEXUAL EPOCH OF THE MENARCHE 111 
 
 All this is bad. In order to avoid the necessity for 
 any constriction, the petticoats should be fastened to 
 the corset, and this latter should be supported from 
 the shoulders by means of shoulder-straps or braces 
 crossing one another behind. No constriction of the 
 thorax then occurs, and if the corset has suitable sup- 
 porting pouches for the breasts, and the wearer is 
 accustomed to hold herself erect, the figure of a well- 
 formed woman thus attired is far from unpleasing, and 
 is, above all, natural. If the weight of skirt and petti- 
 coats is too great to be borne by the shoulders, the 
 burden can be divided, some being fastened to the cor- 
 set, others tied round the waist. This method is less 
 to be commended, but may be regarded as a permissible 
 middle course. If chemise and drawers are woven 
 in one piece, as in the 'combination' undergarment, 
 there is one article the less to be attached to the corset. 
 Recently a number of corsets and articles of clothing 
 have been made in accordance with these principles. 
 
 "The growing girl, then, may wear a soft corset with 
 shoulder-straps, made to measure, to which all the gar- 
 ments clothing the parts below the waist should be 
 made to fasten. It must unfortunately be admitted 
 that this rational mode of arranging the clothing can- 
 not be adapted to the 'low dress' which etiquette de- 
 mands on so many occasions for evening wear, since 
 with the latter the shoulder-straps cannot be worn. 
 
 "It is most unhygienic for women to wear, as they 
 so often do, drawers that are widely open. Both clean- 
 liness and the need for an equable warmth demand 
 that these garments should be closed between the 
 thighs, not to speak of other reasons." 
 
 In order to diminish the sexual impulse in girls at 
 the menarche, where this impulse has developed pre- 
 maturely or is abnormally intense, and even in later 
 
112 THE SEXUAL LIFE OP WOMAN 
 
 years with the same end in view, it is necessary, not 
 merely that the diet should be suitable and non-stimu- 
 lating, and that the educational environment should be 
 satisfactory, but above all that there should be regular 
 occupation and regular physical activity. Ribbing 
 rightly calls attention to his experience in dealing with 
 animals, that equally in the case of the stallion and of 
 the mare, the whole of life may without difficulty be 
 passed in complete abstinence from sexual gratification, 
 provided that the diet is suitable, being neither too 
 rich nor too meagre, and that the animal has regular 
 occupation of a nature and degree adapted to its 
 powers. In these animals a certain amount of disquiet, 
 of restlessness, of sulky irritability, etc., may indeed 
 be noticed at times, but these manifestations are to " 
 be overcome by mingled gentleness and firmness, aided 
 now and again also by mild chastisement, but alto- 
 gether without any severity. "Chastity," says Oester- 
 len, "is possible only when the mode of life is simple 
 and regular, and is characterized by appropriate self- 
 command and frugality. For this reason it is rarely 
 encountered in palaces and similar places, in which 
 from youth onward every one can do what he pleases ; 
 but just as little is it really practicable amid condi- 
 tions of lack of culture, rudeness, and poverty." 
 
 From the point of view of education, what Moreau 
 wrote a hundred years ago is of importance: "In the 
 ordinary course of nature the young woman at the 
 time of the first appearance of menstruation is still in 
 full possession of those amiable qualities of blameless- 
 ness and chastity which we are accustomed to denote 
 by the term moral virginity. To an honorable and 
 pure-minded man this beautiful attribute of budding 
 womanhood is much dearer and more estimable than 
 physical virginity. By libertines only is the latter re- 
 
THE SEXUAL EPOCH OF THE MENARCHE 113 
 
 garded as a most valuable possession, since it furnishes 
 a powerful stimulus to their jaded imaginations. But 
 moral virginity and physical virginity are not always 
 and necessarily associated, for either can be present in 
 the absence of the other. Physical virginity may be 
 destroyed by divers forms of violence, and yet moral 
 virginity may remain pure and uninjured amidst its 
 ruins. Thus the two are widely different one from 
 the other, widely different also are they in value and 
 significance." 
 
 What Eulenburg says regarding the prophylaxis of 
 sexual neurasthenia in general is true regarding the 
 sexual life of the girl at this period of life. "What 
 is needed," he writes, "is the control of educational 
 influences with these ends in view, that, on the one 
 hand, the sexual excitability of developing youth shall 
 be diminished and kept within bounds, and that never- 
 theless, on the other, the urgently needed enlighten- 
 ment shall be afforded to the young people at the 
 proper time and in a suitable form. How these aims 
 are to be effected cannot be explained in generally 
 applicable propositions. It is a matter which must 
 be left to the tact of the parents and of other mem- 
 bers of the family, who will be guided by the insight 
 they have acquired into the mental life of those con- 
 cerned. * * * Children inclined to onanism must 
 be carefully supervised by day and by night ; they must 
 be protected from all stimulating things and from bad 
 company; in boarding-schools it is the common dor- 
 mitories that require the most strict, most careful, and 
 most continuous control. In the case of auto-onanists, 
 female as well as male, we must inquire into the pos- 
 sible existence of local stimulating influences, among 
 which, in both sexes, oxyuris must be mentioned — 
 but in truth it is rare for such local conditions to 
 
114 THE SEXUAL LIFE OF WOMAN 
 
 be the exciting cause of masturbation. A healthy mode 
 of life in respect of clothing, sleep, and diet, and the 
 systematic practice of bodily exercises to the point of 
 considerable fatigue, are the most effectual means of 
 counteracting the noxious propensity to onanism." 
 
 A high degree of freedom permitted to girls from 
 a very early age is, as Rousseau already maintained, 
 by no means favorable to the preservation of virginity. 
 
 A wise mother or a wise instructress can do much 
 toward the preservation of physical and moral vir- 
 ginity, by enlightening her daughter or pupil at the 
 right time and in a proper manner as to the nature 
 of the sexual processes, and their significance for the 
 whole life of woman. Ignorance in this respect, 
 equally with pseudo-knowledge, entails many dangers. 
 I regard it as indispensable that the adolescent girl 
 should in good time learn from her mother the nature 
 of menstruation, lest she should first receive enlighten- 
 ment in an unfitting manner from some more experi- 
 enced female friend. The mother should explain that 
 the impending flow of blood is a natural process, un- 
 attended by danger, but indispensable to the sexual 
 life, and a characteristic part of the process of "grow- 
 ing up." 
 
 The knotty and important topic of how the young 
 girl may best receive sexual enlightenment from her 
 mother, is discussed by E. Stiehl in her notable work 
 A Maternal Duty} The authoress points out that 
 this enlightenment must not take place suddenly and 
 without apparent motive, but that the mother must 
 in a gentle and gradual manner introduce to her child 
 the secrets of nature. A beginning may be made by 
 teaching the child to observe the nature and growth 
 
 ^Eine Mutterpfiicht. 
 
THE SEXUAL EPOCH OF THE MENARCHE 115 
 
 of plants ; then she may be led to interest herself in the 
 family life of animals ; and thus an easy way is found 
 to answer the questions connected with reproduction — 
 to answer them in a manner at once true and befitting. 
 
 Let the mother indicate to her child the methods 
 employed by nature for the preservation of the life of 
 the young plant; let her demonstrate in a flower the 
 stamens and the pistil as male and female organs re- 
 spectively; and let her explain how when the pollen- 
 grain reaches and fertilizes the tiny ovule in the ovary, 
 this ovule becomes capable of development into a large 
 seed containing an active rudimentary plant, which 
 latter itself enlarges to become a new full-grown speci- 
 men of its kind. The opportunity may then be seized 
 to draw attention to the resemblance between the little 
 ovules in the ovary of the minute ova by means of 
 which all animal life reproduces its kind. Proceed- 
 ing farther, an earnest and thorough introduction to 
 the sanctity and responsibility, the perils and duties, 
 of the sexual life, is urgently required by the young 
 girl before she proceeds either to marriage or to an 
 economically independent mode of life. 
 
 Not only in America and England, but now also 
 in Germany, there exist excellent books which may 
 actually be put into the growing girl's own hands, by 
 means of which she will be introduced in an intelli- 
 gent manner to a knowledge of the method of repro- 
 duction in the human species. 
 
 Often enough, when the mother is lacking in intelli- 
 gence or sympathy, it will be the duty of the physician 
 to give this enlightenment to the young girl. The in- 
 terpreter of such tidings at the time of love's dawning 
 will be the family doctor, to whom the girl and her 
 family have been confidently accustomed to turn for 
 information regarding the bodily state and well-being. 
 
116 THE SEXUAL' LIFE OF WOMAN 
 
 He is accustomed to remove many a veil without any^ 
 oflfense to maidenly modesty. Many sexual disorders 
 and much sexual aberration may thus be prevented. 
 
 Certain definite hygienic rules must now be pre- 
 scribed. First of all, the strictest cleanliness must be 
 observed, not only in the intervals, but also during 
 menstruation. The prejudice against changing the 
 underlinen during the flow must be overcome, and care 
 must be taken that at this time the external genitals 
 are washed twice daily with water at a temperature 
 of 26° C. to 28° C. (about 80° F.), and a wad of ab- 
 sorbent cotton-wool or a piece of clean linen (sponges 
 are not to be used for this purpose) ; any article of 
 underclothing that becomes soiled with blood must be 
 changed. Most useful are the so-called "sanitary 
 towels," made of sterilized absorbent cotton-wool, 
 fastened to a linen band which surrounds the waist, 
 or simple pads of absorbent material may be used, kept 
 in place by means of a bandage. During menstrua- 
 tion, full baths, warm or cold, are to be avoided, like- 
 wise long walks, riding, long journeys by rail, gym- 
 nastics, with or without apparatus, skating, lawn tennis, 
 and bicycling; dancing, above all, must be prohibited, 
 since it involves a combination of several noxious in- 
 fluences — the very active movement, which produces 
 hyperaemia of the genital organs, sexual excitement, 
 loss of sleep, long hours spent in close rooms, prolonged 
 voluntary retention of urine, and the risk of a chill. 
 
 Singing, also, must be discontinued during menstrua- 
 tion, since otherwise an injury to the voice is very 
 likely to result. A certain limitation in respect of 
 physical and mental activity is indicated as a general 
 precautionary measure during menstruation, but this 
 measure must not be pushed to excess, so that the habit 
 is acquired of resting completely during the period, 
 
THE SEXUAL EPOCH OF THE MENARCHE 117 
 
 passing the days on a sofa. The favorite practice, in 
 cases of scanty menstruation, of taking hot foot-baths 
 is to be rejected. At the conclusion of each menstrual 
 period, however, a tepid bath should be taken. The 
 knowledge we have now acquired of the rhythmical 
 "menstrual wave" process (see p. 13 et seq.) points to 
 the practical conclusion that the physician should not 
 direct his attention to the actual menstrual period only, 
 but also, and more than has hitherto been customary, 
 to the premenstrual period, in which temperature, 
 blood-pressure, and excretion of urea attain their acme; 
 especially should this be done, with the aim of pre- 
 scribing suitable hygienic precautions, in cases in which 
 the menstrual discharge is very profuse or in which 
 nervous manifestations accompany menstruation. 
 
 Important is it also for the physician to take pre- 
 cautions against the practice by young girls of unduly 
 prolonged voluntary retention of the urine, resulting 
 in overdistention of the bladder; also against the per- 
 formance of very active movements and against power- 
 ful muscular efforts when the bladder is in a distended 
 state. All of these are liable to result in displacements 
 of the uterus. 
 
 During menstruation the diet should be sufficient, 
 but free from stimulating elements. When the men- 
 strual flow is greatly in excess, strong tea and coffee, 
 wine, and beer should be forbidden; conversely, when 
 menstruation is scanty, an invigorating diet is espe- 
 cially indicated, and the use of strong wines. According 
 to the investigations of T. Schrader, in order to main- 
 tain the nitrogenous balance during menstruation, it 
 is necessary to give the following daily diet, repre- 
 senting a heat value of 2,013 to 2,076 calories: 
 
118 THE SEXUAL LIFE OF WOMAN 
 
 125-150 grammes of fowl. 
 
 100 grammes of butter. 
 125-140 grammes of white bread. 
 150 grammes of brown bread. 
 70-80 grammes of eggs. 
 600 . grammes of coffee. 
 600 grammes of soup. 
 560 grammes of Seltzer water. 
 20 grammes of salt. 
 
 For chlorotic girls the following diet may be recom- 
 mended during menstruation. Before rising a pint of 
 milk should be taken slowly, in sips, during a period 
 not exceeding half an hour; for the first breakfast (see 
 note to p. 95, tea or coffee with an abundance of 
 milk, a considerable portion of meat (roast beef, cold 
 fowl, cutlets, or beefsteak; for the second breakfast, 
 a tumbler of milk, bread, butter, and a couple of eggs ; 
 for midday dinner, a good helping of fresh meat so 
 cooked as to be easily digested, green vegetables, pota- 
 toes, farinaceous pudding, stewed fruit, and a glass 
 of burgundy or claret; at 4 P.M., coffee and bread and 
 butter, or a tumbler of milk; at 7 P.M., a similar meal 
 to the midday dinner, but lighter; no supper. In this 
 diet-table, which represents a heat-value of about 2,200 
 calories, albumin and fat are present in abundance 
 (182.8 grammes albumin and 763 grammes fat), but 
 carbohydrates in small quantity only (176.9 grammes).' 
 
 For those chlorotic patients who find it difficult to 
 digest much butcher's meat, the necessary quantum of 
 albumin must be supplied by increasing the amount 
 of milk, soup, and the white varieties of fiesh (chicken 
 and the like), giving also a considerable amount of 
 the more easily digested vegetables, with fruit, beer, 
 and a little claret. For such cases Desque has drawn 
 up the following diet-table, representing 3,290 calo- 
 ries and containing 150 grammes of albumin, 110.7 
 
THE SEXUAL EPOCH OF THE MENARCHE 119 
 
 grammes of fat, and 449.6 grammes of carbohydrate; 
 meat is given once a day only: 
 
 7.30 A. M. — Half a pint of milk, 50 grammes roll, 10 grammes 
 butter. 
 10 A. M. — 300 grammes apples, strawberries, or cranberries, 50 
 grammes roll, lO grammes butter. 
 12.30 P. M. — 200 grammes of beefsteak, 100 grammes of macaroni, 
 300 grammes of bread, 400 grammes of spinach, 200 
 grammes of stewed apples or gooseberries. 
 4 P. M. — ^200 grammes vegetable-peptone-cocoa, 50 grammes roll, 
 10 grammes butter. 
 7 .30 P. M. — ^200 grammes rice-broth, 500 grammes buttermilk, 100 
 grammes bread, 10 grammes butter, 200 grammes 
 salad, 300 grammes uncooked pears, 40 grammes curds. 
 
 In cases of profuse metrorrhagia in girls, von 
 Winckel recommends in addition to rest in the recum- 
 bent posture, a diet containing large quantities of fluid, 
 and much easily assimilable albuminous nutrient ma- 
 terial, all stimulating articles and those likely to cause 
 nausea and vomiting being avoided. He gives the 
 following diet-table: 
 
 7 A. M. — 250 grammes of milk. 
 
 9 A. M. — 250 grammes of bouillon, 1 egg, 20 grammes of brandy. 
 11a. m. — 250 grammes of milk. 
 1 p. M. — 100 grammes of roast meat, 250 grammes of rice-broth 
 
 with 5 grammes of somatose, and 150 grammes of claret. 
 3 p. M. — 250 grammes of milk. 
 5 P. M. — 1 egg, 20 grammes of brandy. 
 7 P. M. — ^250 grammes of bouillon or white soup with 5 grammes 
 
 of somatose. 
 
 As a beverage in the intervals, weak cold tea is 
 allowed. When the haemorrhage has ceased, the follow- 
 ing beverages are suitable : oatmeal, cocoa, Pilsener beer 
 (one pint daily), milk (2 to 3 pints daily), claret 
 (a half bottle daily). For food, the lighter varieties 
 of meat, 200 to 300 grammes daily, sweet-bread, pigeon, 
 ham, nutrient and easily digestible vegetables, spinach, 
 carrots, and pea-soup, may be recommended. 
 
120 THE SEXUAL LlEE OF WOMAN 
 
 In cases of amenorrhcea or scanty menstruation, 
 especially when due to anaemia or to underfeeding, 
 mental excitement, or overexertion, warm baths at a 
 temperature of 28° to 29° R. (90° to 92° F.), rubbing 
 the body with wet towels, and warm sitz-baths, are 
 of good service. 
 
 [Note: Although in this translation the English equivalents of the 
 measures used on the Continent have as a rule been appended in paren- 
 thesis, this has not been thought necessary in the case of the diet-tables, 
 since even in English works these are commonly stated in terms of the 
 metric system. It may here be mentioned that, as regards fluid measures, 
 250 grammes (a quarter of a litre) is roughly equivalent to half a pint, an 
 ordinary tumblerful or breakfast-cupful; and that, as regards solid meas- 
 ures, 30 grammes are equivalent to a very little more than an avoirdupois 
 ounce.] 
 
 Menstruation 
 
 Menstruation is the name given to the process which 
 manifests itself in the human female after the age of 
 puberty by the discharge from the genital organs at 
 regular four-weekly intervals of a muco-sanguineous 
 secretion. This discharge is not merely the result of 
 a local hyperaemic condition; but is the expression of 
 a periodic excitation of the entire nervous system and 
 blood vascular system, intimately related with the whole 
 sexual life of woman; this excitation is itself dependent 
 upon the process of ovulation, an incident in the series 
 of manifestations that arise from the periodic undula- 
 tory movement in the vital processes of woman. 
 
 The Mosaic law regarded the process of menstrua- 
 tion as unclean in nature; the menstruating woman was 
 unclean, and must be purified in a prescribed manner. 
 In the fifteenth chapter of Leviticus, vv. 19-29, we 
 read: "And if a woman have an issue, and her issue 
 in her flesh be blood, she shall be put apart seven days: 
 and whosoever toucheth her shall be unclean until the 
 even. * * * Every bed whereon she lieth all the days 
 of her issue shall be unto her as the bed of her separa- 
 tion. * * * But if she be cleansed of her issue, then 
 
THE SEXUAL EPOCH OF THE MENARCHE 121 
 
 she shall number to herself seven days, and after that 
 she shall be clean. And on the eighth day she shall 
 take unto her two turtles, or two young pigeons, and 
 bring them unto the priest, to the door of the taber- 
 nacle of the congregation." 
 
 In a similar manner the adherents of the faith of 
 Islam regard a menstruating woman as unclean. 
 
 This view is found also in the earliest medical writ- 
 ings, alike in the early Indian book of Susruta and in 
 the later writings of Hippocrates, and it persists to 
 the present day in the use of the expression "monthly 
 purification." Susruta teaches that in India menstrua- 
 tion begins at the age of twelve, and recurs monthly, 
 the flow lasting three days. In the Jewish Talmud it 
 is asserted (see La Medecine du Talmud, by Dr. 
 Rabbinowicz) that menstruation begins as soon as the 
 girl has two hairs on the pubic region, or at the age 
 of twelve, even in the absence of any growth of the 
 pubic hair. The menstrual blood is quite peculiar in 
 its characters. Thus, Raschi relates, the mother of the 
 King of Persia exhibited sixty varieties of blood, and 
 among them Rabba was able to detect which was the 
 menstrual blood. According to a rabbinical authority, 
 a woman can become pregnant as soon as she has com- 
 pleted her twelfth year. As signs of puberty. Rabbi 
 Josse mentions the appearance of a fold beneath the 
 nipple. Rabbi Akiba, the erection of the nipples. Rabbi 
 d'Azai, the appearance of a dark areola around the 
 nipples. Rabbi Josse, the recession of the nipple under 
 pressure followed by its gradual protrusion when the 
 pressure is removed, also the softening of the mons 
 Veneris (in consequence of the deposit of fat in its 
 substance). As prodromal signs of the first appear- 
 ance of menstruation, theJjEiilmud-inentiojaa,^ pain in the 
 region of the umbiHcus and in the_uterus, flatulence. 
 
122 THE SEXUAL LIFE OF WOMAN 
 
 shivering, white flux, heaviness in the head and the 
 limbs, and nausea. 
 
 The blood discharged during menstruation has cer- 
 tain peculiar properties. It is always fluid, and rarely 
 contains fibrinous clots, it is always mixed with a larger 
 or smaller quantity of mucus', which gives it a sticky 
 character; the reaction is alkaline, the smell characteris- 
 tic. Only when the bleeding is very profuse are coagu- 
 lated masses evacuated. On microscopical examination 
 of menstrual blood, we detect erythrocytes and leuco- 
 cytes, the proportional number of the latter being great- 
 er than in pure blood; there is an admixture also of 
 epithelium from the genital mucous membranes, cylin- 
 drical cells from the uterus, flattened cells from the 
 superficial layers of the stratified scaly epithelium of the 
 vagina, also various micro-organisms and granular de- 
 tritus. At the beginning of each menstruation, the 
 admixture of mucus is greatest, so that the discharge 
 sometimes has the appearance of blood-stained mucus; 
 but during the height of the discharge the consistency 
 is almost that of pure blood. The quantity of blood 
 lost at each period is said to vary from 90 to 240 
 grammes (about 3 to 8 fluid ounces) ; but in tropical 
 climates the average is said to be 600 gralnmes (20 
 ounces). 
 
 Both the quality and the quantity of the blood are sub- 
 ject to great variations. Thus, for instance, Bouchardat 
 estimates the solid constituents at 99.20 per mille, Vogel ' 
 at 161 per mille, and Simon at 215 per mille. The 
 amount of blood discharged during menstruation de- 
 pends upon the temperament, the constitution, and the 
 occupation of the woman concerned. It is greater in xi=— 
 vacious brunettes than in phlegmatic blondes, greater 
 in southern women than in those dwelling in the north, 
 greater in town dwellers than in women living in the 
 
THE SEXUAL EPOCH OP THE MENARCHE 123 
 
 open pLains,_greater in those whose mode of life is seden- 
 tary than in those engaged in some active occupation. 
 
 Similar considerations apply with regard to the dura- 
 tion of each period. The mean duration is in the great 
 majority of cases from four to five days, being generally 
 the same iii successive periods in the same individual; 
 in exceptional cases the flow may last a week or more. 
 Menstruation lasting more than eight days must be re- 
 garded as abnormal. 
 
 Krieger has collected data relating to the duration of 
 the individual periods. He found the duration constant 
 in the great majority of cases, i.e., 93.285 per cent; but 
 variable in a small minority, i.e., 6.715 per cent. 
 
 The periods in which the duration was regular did 
 not always last precisely the same number of days, the 
 duration in many cases being 3 to 4 days, 5 to 6 days, 
 etc. ; but the same duration recurred regularly at each 
 successive period, so that all these instances must be 
 reckoned among the periods of regular duration. The 
 duration must be regarded as irregular or variable in 
 those cases in which the variation was from 2 to 4 days, 
 3 to 8 days, etc. Sometimes a regular three-day or five- 
 day period becomes transformed into an eight-day pe- 
 riod ; or conversely an eight-day period into a four-day 
 period. 
 
 The interval between one menstruation and the next 
 (the period that elapses, that is to say, between the com- 
 mencement of one period and the commencement of the 
 next) is in the great majority of cases twenty-eight days. 
 The recurrence in many women is extraordinarily exact, 
 not merely as regards the day, but even as regards the 
 hour of the day. The twenty-eight-day type of menstru- 
 ation is found in about 70 per cent, of the cases ; in the 
 remainder, the thirty-day type is most frequent, and next 
 to that the twenty-one-day type. The periodicity of 
 
124 THE SEXUAL LIFE OF WOMAN 
 
 menstruation in any individual may, however, be very 
 irregular. 
 
 The amount of blood lost and the duration of the 
 flow are less in strong, healthy women, leading an occu- 
 pied, active, and regular life, especially in country- 
 women and in women who are poor and chaste, thanj t 
 is jn delicate, weakly women, leading a sedentary life, 
 whose diet is abundant and stimulating, and who are 
 accustomed to an ultra-luxurious and enervating exist- 
 ence. In nuns, for example, the quantity of the men- 
 strual discharge gradually declines ; shortly after their 
 entrance into the cloister, various irregularities are apt 
 to occur, but ultimately the flow becomes exceedingly 
 scanty and lasts for a single day only. Climate also has 
 a great influence, for in hot countries women usually 
 menstruate very abundantly, whilst in cold countries 
 the flow is scanty, and often appears only in the warmer 
 months of the year. Of the Lapp and Samoyede women 
 this was already reported by Linnaeus and Virey. Tilt 
 further relates that Eskimo women menstruate only dur- 
 ing the summer months, and even then scantily. In 
 southern France, according to Courty, the quantity va- 
 ries from I20 to 240 grammes (about 4 to 8 ounces) ; but 
 it may rise to 300, 350, and even 500 grammes (about 10, 
 12, and i6>^ fluid ounces). In the tropics, severe me- 
 norrhagia is said to be common; and the fact was al- 
 ready known to Blumbenbach, that women of European 
 descent born in the tropics not infrequently succumb to 
 hemorrhage during childbirth. 
 
 By menorrhagia we understand the occurrence of 
 typical discharges of blood from the uterus, occurring 
 at more or less regular intervals and differing from 
 normal menstruation in respect either of the greater 
 intensity or of the longer duration of the haemorrhage ; 
 whereas by metrorrhagia we understand the occurrence 
 
THE SEXUAL EPOCH OF THE MENARCHE 125 
 
 of atypical discharge of blood from the uterus, which 
 is related to menstruation neither in respect to its causa- 
 tion nor in respect to the time of its appearance. 
 
 Menorrhagia may be due to local changes in the geni- 
 tal organs, to organic diseases of other organs, and to 
 general diseases. 
 
 Local changes which may give rise to menorrhagia 
 are, active hyperaemia and passive hyperaemia (hyperae- 
 mia from engorgement) of the genital organs, such hy- 
 peremia being itself due Vo sexual excitement, especially 
 when ungratified, to violent physical exercise, or to chill 
 during menstruation ; menorrhagia is also liable to occur 
 when the abdominal circulation is disturbed by extreme 
 obesity or by the presence of tumors, also in connection 
 with endometritis, uterine myomata, erosions of the cer- 
 vix, etc. Diseases of organs other than those belonging 
 to the reproductive system which are especially likely 
 to give rise to severe bleeding are, disease of the heart, 
 such as valvular incompetence, lung disease, and nephri- 
 tis. General diseases in which menorrhagia may occur 
 are, anaemia, chlorosis, haemophilia, scurvy, scarlatina, 
 cholera, smallpox, influenza, and obesity. 
 
 Through severe loss of blood in menorrhagia, whether 
 the bleeding be sudden and profuse or more moderate 
 but long continued, a condition of chronic anaemia re- 
 sults, with all its threatening consequences to the health 
 and the life of the woman affected. She becomes pale 
 and weak, unfitted for any great physical or mental ex- 
 ertion, and is liable to attacks of cardiac enfeeblement 
 and to fainting fits ; in some cases degenerative changes 
 ensue in the cardiac muscle. 
 
 Dysmenorrhoea is characterized by severe pain occur- 
 ring before, during, and after menstruation. The pain 
 is caused either by abnormally powerful contractions of 
 the uterus or else by abnormal sensitiveness of that or- 
 
126 THE SEXUAL' LIFE OF WOMAN 
 
 gan. Abnormally powerful contractions are caused by 
 various mechanical hindrances to the normal processes 
 of menstruation; abnormal sensitiveness is due to in- 
 flammatory and congestive states of the uterus and its 
 annexa or to a general increase of nervous sensibility. 
 
 Schauta, therefore, distinguishes a mechanical, an in- 
 flammatory, and a nervous form of dysmenorrhoea. Me- 
 chanical dysmenorrhoea is most frequently due to ste- 
 nosis or flexion of the canal of the cervix in some part of 
 its course from the internal to the external os, dependent 
 upon malformation or flexion of the uterus, hyperplasia 
 of the mucous membrane, chronic metritis, scarring re- 
 sulting from operative procedures, uterine polypi, etc. 
 In inflammatory dysmenorrhoea we have to do "either 
 with an inflammatory process or with excessive tension 
 of the intrapelvic organs, dependent upon abnormal dis- 
 tention of the blood vessels." To the same category be- 
 long ovarian dysmenorrhoea, and dysmenorrhoea due to 
 inflammatory changes in the Fallopian tubes and to pel- 
 vic peritonitis. In nervous dysmenorrhoea, no anatomi- 
 cal cause is apparent, but the uterine contractions nor- 
 mally occurring during menstruation, and the normal 
 congestive distention of the intrapelvic organs at that 
 period, become extremely-painful, in consequence of a 
 morbid increase in the sensibility of the nervous system. 
 
 The influence of dysmenorrhoea on the general con- 
 dition of the woman suffering from it is often a very 
 potent one. 
 
 The normal undulatory course of the bodily tempera- 
 ture — ^which as Reinl has shown, undergoes a gradual 
 rise until shortly before the appearance of the menstrual 
 flow, gradually falls during menstruation, and continues 
 to fall for a time after menstruation is over — undergoes 
 a change in cases of dysmenorrhoea due to anteflexion of 
 the uterus, parametritis, or salpingitis, inasmuch as in 
 
THE SEXUAL EPOCH OF THE MENARCHE 127 
 
 Aese cases the acme of the temperature curve is reached 
 actually during menstruation and the decline of tem- 
 perature comes, not at the commencement of the men- 
 strual flow, but often only after the flow has ceased. 
 The curve of blood pressure and the curve indicating 
 the excretion of urea are similarly affected in these cases. 
 
 As symptoms in other organs occurring in cases of 
 dysmenorrhoea Schauta mentions "sensations of heat, 
 coldness of the feet, retching and vomiting, cramps of 
 the stomach and of the voluntary muscles, general dis- 
 orders of nutrition, loss of appetite, strangury, constipa- 
 tion, dyspepsia, headache, and finally hysteria. As 
 symptoms of the latter affection we may notice, anaes- 
 thesia, hyperaesthesia of certain parts of the abdomen, 
 attacks of cramp, paralysis, uterine cough, hiccough, 
 spasm of the glottis, and epileptiform seizures. The re- 
 peated severe attacks of pain may seriously disturb the 
 nervous system, leading to the appearance of general 
 neuroses and psychoses. Frequently we observe, as a pe- 
 culiar accompaniment of dysmenorrhoea, changes in the 
 fulness of the blood vessels of the face and also in other 
 regions of the skin, in consequence of vascular paralysis. 
 In other cases, actual effusion of blood occurs, and, as 
 a sequel of this, deposits of pigment; and the semicircles 
 beneath the eyes may become so dark as to look as if 
 they had been artificially tinted (Macnaughton Jones). 
 In one case, during menstruation periodic swelling of 
 the gums was observed (Regnier) . Finally, in associa- 
 tion with dysmenorrhoea, various forms of neuralgia, 
 changes in refraction, and slight attacks of neuritis and 
 retinitis may occur." 4< . * 1^;;;^^-^^ 
 
 One of the commonest symptoms and sequelae is head- 
 ache, sometimes in the form of hemicrania, which may 
 be associated with dyspeptic manifestations, sometimes 
 diffused over the whole surface of the skull. 
 
128 THE SEXUAL LIFE OF WOMAN 
 
 Dyspepsia is a very frequent associate of dysmenor- 
 rhoea. Thus we meet with pain and tenderness in the 
 gastric region, nausea, vomiting, and also cardialgia. 
 Sometimes the liver becomes enlarged and tender on 
 pressure; in many cases also jaundice is witnessed. 
 
 Gebhard refers to another phenomenon which may 
 be classed under the head of dysmenorrhoea, from the 
 character of the pain that is experienced, even though 
 this pain is not felt at the menstrual periods, but in the 
 intermenstrual epoch. This is the so-called intermediate 
 dysmenorrhoea (intermenstrual pain, Ger. Mittel- 
 schmerz). In the character of the localized pain, in- 
 termediate dysmenorrhoea closely resembles ordinary 
 dysmenorrhoea; it recurs often with precise regularity 
 on certain days during the intermenstrual interval. 
 
 Croom distinguishes three forms of intermediate dys- 
 menorrhoea; that in which there is no discharge at all 
 from the uterus, that in which there is a sanguineous 
 discharge, and that in which there is a clear watery 
 discharge. The first form he attributes to asynchronism 
 in the processes of ovulation and menstruation; the 
 second form, to endometritis with disintegration of the 
 mucous membrane; the third, to a kind of hydrops 
 tubae profluens (profluent dropsy of the Fallopian 
 tubes — hydrosalpinx in which the fluid accumulates in 
 the tube, and at a certain stage of its accumulation flows 
 into the uterus) . Cases of intermediate dysmenorrhoea 
 are somewhat rare, if we eliminate the cases in which 
 pains occur in the intermenstrual epoch in consequence 
 of disease of the uterine annexa. Inflammatory mani- 
 festations may be discovered in nearly all typical cases 
 of intermediate dysmenorrhoea. 
 
 Long-continued dysmenorrhoea may give rise to 
 numerous hysterical troubles, general convulsive sei- 
 zures, local muscular spasm and paralysis, hiccough, 
 
THE SEXUAL EPOCH OF THE MENARCHE 129 
 
 spasm of the glottis, uterine cough, twitching and spasmij 
 of various groups of voluntary muscles. In some caseSj 
 we see fully developed epileptic convulsions, with 
 complete loss of consciousness and immobility of the 
 pupils. Finally, psychoses may arise in association 
 with dysmenorrhoea. 
 
 In cases of pathological changes in menstruation, a 
 carefully arranged hygiene at the menstrual periods is 
 of importance, both for prophylactic and for thera- 
 peutic purposes, and in this connection I may refer 
 to what I have written in the section on Hygiene Dur- 
 ing the Menarche. In cases of dysmenorrhoea a cer- 
 tain amount of repose and precaution are needed dur- 
 ing the flow, with avoidance of chill, scrupulous 
 cleanliness, and regulation of the bowels. In cases 
 of amenorrhoea we must prescribe attention to the 
 general nutrition by means of an easily digested robor- 
 ant 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 condi- 
 tions of the uterus, the ovaries, or the organism as a 
 whole, the menstrual flow has at the time of the me- 
 narche either failed entirely to appear or been exceed- 
 ingly scanty, haemorrhages from other organs have since 
 ancient times been witnessed, and these haemorrhages 
 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 equilib- 
 
130 THE SEXUAL' LIFE OF WOMAN 
 
 rium of blood distribution, and vicarious haemorrhages 
 take place from the mouth, the nose, the intestines, the 
 anus, the gums, the mammae, the ears, and the lungs; 
 or haemorrhages occur in the brain, the nerves, or the 
 eyes. 
 
 Although it must be admitted that confusion has 
 often occurred between vicarious menstruation and 
 haemorrhages dependent on pre-existing genuine or- 
 ganic disease, such as haemoptysis due to pulmonary 
 tuberculosis, or haematemesis due to gastric ulcer, still 
 the existence of a true vicarious menstruation must 
 be regarded as fully established. 
 
 In cases in which menstruation is in abeyance, we 
 sometimes witness, instead of vicarious haemorrhages, 
 the occurrence of non-sanguineous vicarious discharges 
 from various mucous membranes. Thus, vicarious 
 leucorrhoea 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 diarrhoea 
 and vicarious salivation have been observed. 
 
 The Sexual Impulse 
 
 By the term sexual impulse, we understand the im- 
 pulse shared by women and by men toward intimate 
 physical contact and sexual intercourse with individ- 
 uals 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 be- 
 comes a powerful passion, dominant throughout the 
 active sexual life of the woman, and it may evert con- 
 tirtue 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 
 
THE SEXUAL EPOCH OF THE MENARCHE 131 
 
 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 gratifi- 
 cation 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. 
 
 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, though its 
 manifestation may be repressed by force of will. 
 
 According to the general opinion, the sexual impulse 
 is not so strongly developed in women as it is in men. 
 Hegar, Litzmann, Lombroso, P. Miiller, and many 
 others, assume that the sexual sensibility of women is 
 less than that of men; Fiirbringer is inclined to attrib- 
 ute 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 inexperi- 
 enced 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 con- 
 tact and toward copulation is just as powerful as that 
 of men. According, however, to the dominant arti- 
 ficial conditions, man assumes it as his right to give 
 free rein to his sexual desires and to gratify them with- 
 out regard to consequences, whereas woman, narrowly 
 confined within the boundaries imposed by law and 
 
132 THE SEXUAL LIFE OF WOMAN 
 
 convention, cannot so readily yield to her inclination 
 in the direction of physical love, and must forcibly con- 
 trol 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 mofe 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 gratifi- 
 cation 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 differentiae is to 
 be found, in my opinion, the influence which deter- 
 mines the type of sexuality in the respective sexes, 
 
 Hegar maintains that under the term sexual impulse 
 two distinctconceptions are confounded: First, the im- 
 pulse toward copulation, the desire of carnal union 
 with a member of the opposite sex; secondly, the im- 
 pulse toward reproduction, the desire for children. 
 'At the same time, this author admits that it is question- 
 able if we can properly speak of an impulse toward 
 reproduction, when reproduction is merely a conse- 
 quence 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 per- 
 haps lead to the production of this peculiar form of 
 mental activity. 
 
THE SEXUAL EPOCH OF THE MENARCHE 133 
 
 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 pro- 
 longed courtship, and often endeavors for a consider- 
 able 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 occu- 
 pies herself in building the nest. Among mammals, 
 it is difficult to determine whether sexual feeling is 
 stronger in the female than in the male ; but it is certain 
 that sexual relations are seldom long lasting, they con- 
 tinue 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 king- 
 dom, 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 en- 
 tirely 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 mother- 
 hood, 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. 
 
134 THE SEXUAL LIFE OF WOMAN 
 
 sexual desire is very rarely accompanied by pains an- 
 alogous 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 employ- 
 ment 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 pas- 
 sively, without ardor and without enthusiasm. It is 
 well known, also, that among the lower races of man- 
 kind, means are employed to stimulate the sexual sen- 
 sibility 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 hus- 
 band 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 Prospere expresses himself to a similar effect: 
 "Women do not fall in consequence oi the excessive 
 power of the senses — in this domain they are overlords, 
 
THE SEXUAL EPOCH OF THE MENARCHE 135 
 
 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 over- 
 filled by the rivers that pour their waters into it. 
 
 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 con- 
 tact with men, and in whom sexual desire and sensi- 
 bility have not yet been directly excited; later, how- 
 ever, 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 naturee frigi- 
 dce, and have no sensual inclination to sexual inter- 
 course, 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 
 
136 THE SEXUAL LIFE OF WOMAN 
 
 normal sexual impulse, complete abstinence from sex- 
 ual 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 in- 
 fluences with mental influences, increases the difficulty 
 of the problem. Neurologists have observed women 
 on whom continence was forced either during mar- 
 riage or after its dissolution, who thereupon fell into a 
 state of severe nervous exhaustion or nervous excite- 
 ment, or suffered from threatening or even actually de- 
 veloped psychoses. That sexual abstinence is "abso- 
 lutely harmless," as moralists and many physicians 
 would so gladly believe, appears to Erb quite unwar- 
 rantable assumption. 
 
 "In the processes of reproduction," continues Erb 
 in his discussion of this subject, "woman is the princi- 
 pal sufferer. With inhuman cruelty, nature has con- 
 demned woman to a far more difficult role 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 germi- 
 nating 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 perform- 
 ance 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 fiature with a rela- 
 
,THE SEXUAL EPOCH OF THE MENARCHE 137 
 
 tively weak sexual impulse ! This unequal and unjust 
 distribution of the male and female roles on the part 
 of nature may be regretted, but it cannot be altered." 
 
 The modern advocates of the rights of women, who 
 demand that in the sexual sphere also, woman should 
 receive emancipation, oppose the view that in the male 
 the sexual impulse is stronger than in the female, and 
 also the view that whilst in the male the impulse is 
 simply one toward sexual congress, in the female the 
 determining motive to intercourse is furnished by the 
 desire for motherhood. They complain of "the per- 
 verse repression in woman of the sexual impulse and 
 its physiological gratification," since sexual energy and 
 sexual sensibility are equal in intensity and identical 
 in quality in the female and in the male. 
 
 Lowenfeld asserts that in the life of woman the 
 sexual functions play a comparatively much greater 
 part than in the life of man, woman's thoughts and 
 feelings are, that is to say, much more powerfully in- 
 fluenced by sexual matters than those of men ; but none 
 the less he is of opinion that in the normal woman 
 the desire for sexual satisfaction is on the average less 
 keen than in the normal man. Distinctly greater in 
 woman is the erotic element only, the need to love and 
 to be loved after an ideal manner, which is excited by 
 the reproductive glands just as much as is the simple 
 sensual desire. Very frequently, manifestations of this 
 ideal need are erroneously attributed to the sensual im- 
 pulse, yet this latter may be entirely absent in cases 
 in which the erotic element is strongly developed. 
 
 'According to Lowenfeld, the sexual impulse is alto- 
 gether wanting in young girls before the time of pu- 
 berty, and in elderly women (in the case of the latter 
 we consider this assertion most questionable) ; this lack 
 of the sexual impulse persists in girls for an indeter- 
 
138 THE SEXUAL LIFE OF WOMAN 
 
 minate time even after puberty, as long as they remain 
 free from all experience of sexual stimulation. In this 
 respect they offer a notable contrast to males of the 
 same age. In normal girls, according to the same au- 
 thority, erotic dreams and similar occurrences are en- 
 tirely wanting, and specific sexual sensations therefore 
 remain absolutely unknown to them; hence it follows 
 that the sexual impulse cannot, properly speaking, arise 
 in such individuals, and in so far as they experience 
 any desire for sexual intercourse, it can only take the 
 form of a craving for some enjoyment, the nature of 
 which is entirely unknown. The absolute lack of the 
 sexual impulse (complete frigidity) persists, according 
 to Lowenfeld, in a not inconsiderable proportion of 
 women even after their introduction to sexual inter- 
 course — Effertz estimates that such complete frigidity 
 is permanent in lo per cent, of all women — and in a 
 still greater proportion of women the sensual impulse 
 never exceeds a certain minimal intensity (partial 
 frigidity). It is probable that in the higher classes 
 of society, inherited predisposition, education, and per- 
 haps also higher intelligence, combine to diminish the 
 intensity of the sexual impulse. In contrast with these 
 women of frigid temperament, however, we meet with 
 women, certainly in very limited numbers, whose sexual 
 passions are extremely powerful, and whose needs no 
 man can satisfy. 
 
 Hegar, who considers that the sexual impulse in 
 women is seldom very powerful, draws the following 
 conclusions in respect to the influence of sexual gratifi- 
 cation,, on the one hand, or of continence, on the other, 
 on the duration of life and on physical and mental 
 health : "As far as comparisons between married wom- 
 en and women vowed to celibacy (nuns and members 
 of other celibate religious orders) justify any conclu- 
 
THE SEXUAL EPOCH OF THE MENARCHE 139 
 
 sion, sexual activity and inactivity, respectively, would 
 appear to have little influence on the duration of life. 
 Comparisons between married and single women show, 
 indeed, that the gratification of the sexual impulse and 
 the processes of reproduction are distinctly injurious 
 when experienced before the attainment of complete 
 sexual maturity. In married women up to the age of 
 thirty, in some countries even up to the age of forty, 
 the mortality is greater than in unmarried women. 
 The* notably smaller mortality of married women, as 
 compared with unmarried, after the age of forty, is 
 usually explained as the result of the complete fulfil- 
 ment of the genital functions. It may, however, find 
 a truer explanation in the selection effected by mar- 
 riage, especially when we take into consideration that 
 from the women thus selected the weaker individuals 
 have been previously weeded out by the processes of 
 reproduction. 
 
 "The lesser mortality of married men from the age 
 of twenty upward is to be explained by the selection 
 of the fit which occurs in marriage, by the smaller 
 proportion of marriages among men engaged in hazard- 
 ous occupations, and by the deterioration in the quality 
 of the unmarried which results from emigration. Still 
 the directly favorable influence of marriage is undeni- 
 able, and, no doubt, the ethical factors of this institu- 
 tion have a beneficial effect, whereas the gratification 
 of the sexual impulse hardly enters into the account. 
 
 "Suicide is certainly very little dependent upon re- 
 pression of the sexual impulse, since all the motives 
 arising out of the affairs of love play together but a 
 small part among the causes of suicide. 
 
 "The beneficial influence of marriage in the pre- 
 vention of insanity is in part apparent merely, since, 
 in the selection exercised by marriage, those predis- 
 
140 THE SEXUAL LIFE OF WOMAN 
 
 posed to mental disorder, and those in whom such dis- 
 order has already manifested itself, are, for the most 
 part, already excluded. Still, as regards the male sex 
 at any rate, the beneficial influence of marriage is 
 undeniable, and consists principally in the favorable 
 ethical factors of this state. In women, on the other 
 hand, the advantage of marriage is doubtful, since the 
 nerve centres and the nervous system as a whole are 
 strongly aflfected by the processes of reproduction. 
 
 "Criminality in the married is comparatively less 
 common than in the unmarried. In criminal assaults 
 on young persons, repressed sexual impulse plays a 
 part. 
 
 "Chlorosis is not in any way dependent on repres- 
 sion of the sexual impulse. A disease apparently an- 
 alogous to chlorosis, occurring in unmarried women 
 from twenty to thirty years of age, is dependent rather 
 on mental causes, and is relieved by other means than 
 marriage, especially by suitable occupation. Mar- 
 riage and gestation are distinctly injurious in cases of 
 true chlorosis. 
 
 "The satisfaction of the sexual impulse, and still 
 more gestation, favor in women the origin and growth 
 of tumors, give rise often to mechanical disturbances, 
 and open the way for the invasion of toxic pathogenic 
 germs." 
 
 Moll divides the sexual impulse into two compo- 
 nents: The impulse toward intimate contact (in a sense 
 both physical and mental) with a person of the op- 
 posite sex, which he calls the contrectation-impulse 
 (Kontrektationstrieb) ; and the impulse to bring about 
 a change in the genital organs, which he calls the de- 
 tumescence-impulse {Detiimeszenztrieb). The former 
 impulse induces intimate physical and mental contact 
 between the two persons concerned, the latter impulse 
 
THE SEXUAL EPOCH OF THE MENARCHE 141 
 
 induces the local processes of copulation. In women, 
 detumescence results from the passing off of local swell- 
 ing and the release of nervous tension in the genital 
 organs, with the discharge of indifferent glandular 
 secretions, notably the secretion of Bartholin's glands, 
 and perhaps also the secretion of the uterine glands. 
 The intensity of the detumescence-impulse in women 
 varies greatly in different individuals, these variations 
 being more extensive than those occurring in the male. 
 In some women the impulse toward intimate contact, 
 the contrectation-impulse, is normal, though the detu- 
 mescence-impulse is wholly wanting. 
 
 Runge defines the sexual impulse as the impulse 
 which brings the sexes together. This impulse is sub- 
 servient to an instinct, namely, the instinct of repro- 
 duction; that is to say, the sexual impulse induces the 
 individual to perform actions which subserve the pur- 
 pose of reproduction without the agent's being directly 
 or chiefly concerned with this purpose. 
 
 The sexual impulse, as sensation, perception, and 
 impulse, is, according to von Krafft-Ebing, a function 
 of the cerebral cortex; a centre for the sexual sense 
 has not as yet, however, been localized. The close rela- 
 tions which obtain between the sexual life and the 
 sense of smell lead to the supposition that the sexual 
 and the olfactorjr Spheres of the cerebral cortex are in 
 close proximity one with the other. The development 
 of the sexual life has its beginnings in the organic 
 sensations of the developing reproductive glands. A 
 mutual dependence now arises between the cerebral 
 cortex as a place of origin of sensations and percep- 
 tions, and the organs of generation. By anatomico- 
 physiological processes these now give rise to sexual 
 perceptions, representations, and impulses. The cere- 
 bral cortex, by apperceived or reproduced sensuous per- 
 
142 THE SEXUAL LIFE OF WOMAN 
 
 ceptions, influences the organs of generation. This in- 
 fluence is effected by the intermediation of the centres 
 of vascular innervation and ejaculation, which are 
 situated in the lumbar enlargement of the spinal cord, 
 and are certainly in close proximity one with the other. 
 Both are reflex centres. 
 
 The psycho-physiological process embraced in the 
 conception of the sexual impulse is, according to von 
 Krafft-Ebing, constituted in the following manner: 
 
 I. Of the central or peripherally aroused percep- 
 tions. 
 
 II. Of the pleasurable sensations associated with 
 these. 
 
 Hence arises the impulse to sexual satisfaction. This 
 impulse becomes stronger in proportion as cerebral 
 excitement, consequent on appropriate perceptions and 
 the working of the imagination, strengthens the in- 
 tensity of these pleasurable sensations. If the condi- 
 tions are favorable to the performance of the sexual 
 act by means of which satisfaction is attained, the 
 continually increasing impulse finds expression in 
 action; in other circumstances, inhibitory perceptions 
 intervene, sexual excitement diminishes, the activity of 
 the centre for erection is inhibited, and the sexual act 
 itself is prevented. In the case of civilized humanity 
 the ready action of such perceptions for the inhibition 
 of the sexual impulse is necessary and decisive. On 
 the strength of the impulsive perceptions the constitu- 
 tion and various organic processes have an important 
 influence; on the strength of the inhibitory percep- 
 tions, education and the cultivation of self-control are 
 powerfully operative. 
 
 In addition to mental influences, all forms of local 
 irritation of the sensory nerves of the female genital 
 organs and adjacent parts, by internal processes or ex- 
 
THE SEXUAL EPOCH OF THE MENARCHE 143 
 
 ternal friction, serve to increase the strength of the 
 sexual impulse. Among internal processes which stim- 
 ulate the erectile centre by centripetal impulses must 
 be included, the stimulus of the enlarged graafian fol- 
 licle, stasis in various vascular areas of the genital 
 organs in consequence of a sedentary mode of life, 
 abdominal plethora from excessive consumption of 
 food and stimulating drinks, and habitual constipa- 
 tion. External friction may be in the form of in- 
 tentional manipulation, but it may be due to certain 
 bodily attitudes or to the arrangement of the clothing. 
 In normally constituted individuals, the sexual im- 
 pulse is by no means constant in its intensity. Apart 
 from the temporary indifference resulting from sexual 
 gratification, and apart from the decline in the im- 
 pulse that occurs after prolonged continence, ensuing 
 after a certain reactionary intensity of desire has been 
 happily overcome, the mode of life has a very great 
 influence. The town-dweller, who is continually re- 
 minded of sexual matters, and continually solicited to 
 sexual intercourse, is in any case more subject than 
 the countryman to sexual excitement. A sedentary 
 and sheltered mode of life, a chiefly animal diet, the 
 free use of alcohol and of spices, and the like, have a 
 stimulating action on the sexual life. In the female, 
 the sexual impulse is stronger just after menstruation. 
 In neuropathic women this increase of excitement may 
 occur to a pathological degree. Not infrequently also 
 in the climacteric period, women are subject to sexual 
 excitement due to pruritus, especially in those neuro- 
 pathically predisposed. Magnan reports the case of 
 a lady who was subject to matutinal accesses of intense 
 erethismus genitalis. The same author writes of a 
 young lady who since puberty had been subject to 
 continually increasing sexual impulse, which she 
 
144 THE SEXUAL LIFE OF WOMAN 
 
 gratified by masturbation. Gradually it came to pass 
 that the sight of a good-looking man produced violent 
 sexual excitement, and on these occasions, since she 
 felt herself unable to answer for her own conduct, she 
 used to lock herself up in her bedroom till the storm 
 had passed away. Ultimately she surrendered herself 
 to any available man in order to obtain rest from her 
 torturing desires, but neither intercourse nor onanism 
 gave her relief, so that she was finally sent to an asylum. 
 
 'As regards pathological increase of the sexual im- 
 pulse, hyperesthesia sexualis, the constitution of the 
 individual is, according to von Krafft-Ebing, of great 
 importance. He writes: "With a neuropathic con- 
 stitution, a pathological increase of sexual desire is 
 often associated, and such individuals bear for the 
 greater part of their life the heavy burden of this con- 
 stitutionally anomalous sexual impulse. The intensity 
 of the sexual impulse may be such as to amount to 
 an organic compulsion, and the freedom of the will 
 may thus be seriously imperilled. Non-satisfaction pf 
 this desire may induce a true sexual heat (like that of 
 lower animals), or a mental state characterized by 
 sensations of anxiety, in which the individual yields 
 to the impulse, and his responsibility for his action 
 is most questionable. Should the person so affected 
 not give way to his desire, he runs the danger, by this 
 enforced abstinence, of injuring his nervous system by 
 the induction of neurasthenia, or of seriously aggravat- 
 ing neurasthenia that already exists. 
 
 "Excessive sexual desire may arise either from pe- 
 ripheral or from central causes. The former variety 
 is less common. Such cases as do occur, may arise 
 from pruritus of the genitals, from eczema, or from 
 substances which by their remote local action stimulate 
 sexual desire, such, for instance, as cantharides. 
 
THE SEXUAL EPOCH OF THE MENARCHE 145 
 
 "Sexual excitement of central origin is common in 
 those suffering from congenital neuropathic predisposi- 
 tion, in hysterical subjects, and in states of mental ex- 
 altation. In such cases, when the cerebral cortex, 
 including the psychosexual centre, is in a state of hy- 
 peraesthesia (abnormal excitability of the imagination, 
 facilitated association of ideas), not only optical and 
 tactile sensations, but also auditory and olfactory im- 
 pressions, will arouse lascivious perceptions. 
 
 "Sexual hyperesthesia may be continuous, with ex- 
 acerbations, or intermittent, and even periodic. In the 
 last case, according to von Krafft-Ebing, it is either an 
 independent cerebral neurosis, or else a partial mani- 
 festation of a general condition of mental excite- 
 
 ment." 
 
 In the poorer classes of society, an increase of the 
 sexual impulse occurs in women chiefly in conse- 
 quence of bad example and of unfavorable domestic 
 conditions, such as lead to persons of opposite sexes 
 sleeping in the same bed, and also in consequence of the 
 abuse of alcohol. In the well-to-do classes, it is the 
 perusal of modern equivocal romances, visits to 
 theatres, balls, and evening parties, and, speaking gen- 
 erally, idleness combined with luxurious living, that 
 serve to stimulate the sexual impulse in woman. 
 
 A certain dependence of the sexual impulse upon 
 seasonal variations appears to exist also in the human 
 species. At any rate in certain months of the year, 
 a definite increase in the number of conceptions con- 
 tinues to recur, which indicates that during these 
 months a larger number of sexually mature individuals 
 is engaged in the discharge of sexual functions. Rosen- 
 stadt regards this as the manifestation of a "physio- 
 logical custom," immanent in the physical constitution 
 of civilized man, and inherited by him from his animal 
 
146 THE SEXUAL LIFE OF WOMAN 
 
 ancestors. He explains it in the following terms: 
 "Primitive man inherited from his mammalian fore- 
 fathers the peculiarity of reproducing his kind only 
 during a certain definite period, the period of heat or 
 rut. After humanity had entered upon this period, 
 copulation was effected en masse, as was easy in view 
 of the primitive community of sexual intercourse be- 
 fore the origin of marriage. In the course of his 
 progress toward civilization, however, man began to 
 reproduce his kind indifferently throughout the entire 
 year; but the original 'physiological custom,' in ac- 
 cordance with which reproduction occurred at definite 
 seasons only, did not disappear, and persists, indeed, 
 to a certain extent even to the present day as a survival 
 of earlier mammalian life, and manifests itself in the 
 annual recurrence in certain months of an increase in 
 the number of conceptions. The analogy in structure 
 and function between the genital organs of the human 
 species and those of other mammals (the female anthro- 
 poid apes do not merely exhibit from time to time a 
 period of heat, but are subject to a more or less regular 
 menstruation), which for the most part reproduce their 
 kind only at certain definite periods, leads to the con- 
 clusion that in the human species also the sexual im- 
 pulse may originally have awakened only at a particu- 
 lar season of the year, and that the persistence of this 
 physielogical custom in man, in spite of the fact that 
 sexual intercourse occurs all through the year, and not- 
 withstanding that the conditions necessary to awaken 
 the sexual impulse are actually perennial, must be 
 ascribed to inheritance." 
 
 Sexual desire in women, the sexual impulse, outlasts 
 the proper sexual life, and manifests itself even after 
 the cessation of menstruation, when the possibility of 
 conception has passed away; it appears, therefore, to 
 
THE SEXUAL EPOCH OF THE MENARCHE 147 
 
 have.no necessary connection with the function of ovu- 
 lation. 
 
 This is indicated by the always respectable number 
 of women who enter upon marriage even after the cli- 
 macteric age. Thus the percentage of brides who were 
 more than 45 years of age was: In Prussia, 2.58 per 
 cent; in England, 1.38 per cent.; in Sweden, 1.53 per 
 cent; in Ireland, 0.31 per cent Of quite peculiar in- 
 terest are the figures relating to elderly women who 
 marry men considerably younger than themselves. 
 Thus we learn from the tables of Routh that in the 
 space of 10 years in Ireland: 
 
 Women between the ages of 46 and 55 years married 
 
 Men below the age of 17 in 1 instance. 
 
 Men between the ages of 17 and 25 in 35 instances. 
 
 Men between the ages of 26 and 35 in 145 instances. 
 
 Men between the ages of 36 and 45 in 227 instances. 
 
 And women of ages greater than 55 years married 
 
 Men below the age of 17 in 1 instance. 
 
 Men between the ages of 17 and 25 in 3 instances. 
 
 Men between the ages of 26 and 35 in 12 instances. 
 
 Men between the ages of 36 and 45 in 15 instances. 
 
 Men between the ages of 46 and 55 in 52 instances. 
 
 In England during the year 1855 the age of the bride 
 
 exceeded the climacteric age in 778 instances. The 
 
 brides were : 
 
 From 46 to 50 years of age in 135 instances. 
 
 From 51 to 55 years of age in 219 instances. 
 
 From 56 to 60 years of age in 89 instances. 
 
 From 61 to 65 years of age in 22 instances. 
 
 From 66 to 70 years of age in 7 instances. 
 
 From 71 to 75 years of age in 3 instances. 
 
 From 76 to 80 years of age in 3 instances. 
 
 In Bohemia in the year 1872 the oldest bride num- 
 bered no less than — 86 years. 
 
 Borner reports cases in which the sexual impulse re- 
 
148 THE SEXUAL LIFE OF WOMAN 
 
 mained in full activity after the change of life, and in 
 some cases was greatly increased in intensity — these lat- 
 ter individuals being in a condition of real torment, 
 which induced them to masturbate to obtain relief. 
 
II 
 
 THE SEXUAL EPOCH OF THE MENACME 
 
 By the term menacme I designate the culmination of 
 the sexual development of woman, during which the 
 processes of reproduction, copulation, conception, 
 pregnancy, parturition, and lactation occur. 
 
 The processes of puberty in woman are fully com- 
 pleted at the age of from eighteen to twenty years, so 
 that from this time forward she is fully equipped for 
 the performance of her sexual duties. The first act in 
 the fulfilment of these duties is copulation, which in 
 civilized countries is in the great majority of women 
 first undertaken at the commencement of married life. 
 The average age at marriage in the women in Central 
 Europe is 22; but marriages at an earlier age are 
 very common, and in many circles of society the aver- 
 age is as low as 20. The fullest maturity of sexual 
 activity in women occurs, however, in the thirty-second 
 year of life, this being the year in which on the average 
 the maximum fertility is attained. 
 
 At the menacme, the beauty and energy of woman at- 
 tain their fullest evolution, her sexual characteristics 
 their strongest development. It is this period of life, 
 however, that entails the greatest dangers to beauty and 
 health in connection with the functions of the genital 
 organs. Copulation, the first act of sexual intercourse 
 with the male, often produces in the female injuries 
 from which she never completely recovers. Gonor- 
 rhoeal infection has been a source of unspeakable mis- 
 
 149 
 
150 THE SEXUAL LIFE OF WOMAN 
 
 eries to women. Motherhood itself entails the risk of 
 a great number and variety of illnesses, which, as puer- 
 peral sequelae, affect this phase of woman's life. The 
 struggle for existence, in which woman at her prime 
 is also involved, and the fulfilment of duties to hus- 
 band and children, further lead to the production of 
 a series of changes, both physical and mental, in the 
 feminine organism, which influence all the functions. 
 
 The great characteristic of this epoch is maternity. 
 In maternity the fully developed woman lives and has 
 her being, but to maternity also she often succumbs as 
 a sacrifice to the fulfilment of her natural functions. 
 Inasmuch as in this sexual phase the functions of the 
 genital organs are of greater importance, to the same 
 degree is enhanced the importance of the mutual rela- 
 tions between these organs and the other organs of the 
 female body. 
 
 Another influence of fundamental importance in the 
 sexually mature woman is that of the sexual impulse, 
 the force of which is at times overwhelming, so that its 
 gratification is sometimes sought without regard for the 
 consequences to married and family life. 
 
 The physiology and pathology of the menacme co- 
 incides with the normal processes and pathological 
 changes respectively of the female genital organs conse- 
 quent on their functional activity as organs of sexual 
 sensation and of reproduction. Woman as wife and 
 mother stands at the climax of her existence. 
 
 In a quite astonishing manner, however, many of 
 the advocates of the modern movement for the emanci- 
 pation of women contest the significance of maternity 
 to women, 
 
 A modern authoress and supporter of women's 
 rights, Ellen Key, avows that she was in error when 
 at an earlier date she "regarded maternity as the cen- 
 
THE SEXUAL EPOCH OF THE MENACME 151 
 
 tral point in woman's existence." She asserts that it 
 lies within the sphere of a woman's individual rights, 
 as of a man's, to reject marriage, or to accept marriage 
 while rejecting maternity. "The grounds for the rejec- 
 tion of maternity may as well be deeply altruistic as 
 deeply egoistic. It lies within the sphere of individual 
 rights to dispense with love or with maternity when 
 either is regarded or both are regarded from this point 
 of view. It is entirely within a woman's rights to trans- 
 form herself into a member of the 'third sex,' the sex 
 of the worker bee, of the neuter ant, if she finds therein 
 her greatest pleasure. * * * Women exist in whom 
 erotic feeling is totally atrophied ; there are yet others 
 who fail to find in intercourse with the modern man 
 that soulful and deep erotic harmony which they 
 rightly desire; and there are others still more numer- 
 ous who desire love, but not maternity, which indeed 
 they dread." 
 
 A celebrated German authoress of the present day, 
 Gabriele Reuter, refers in similar terms to the justi- 
 fiable fear with which so many aspiring and hard- 
 working women regard maternity, "the perpetual, 
 watchful, emotional dread of motherhood, a dread 
 which causes them to turn at bay. A dread, a hatred, 
 it is, which has grown so strong, so active, that one 
 might almost regard it as an obscure perverse instinct, 
 awakened and developed and strengthened by bitter 
 necessity. It is as if in the innermost recesses of their 
 nature such women had a belief that should they pay 
 their tribute to sex they would lose all the energy, 
 clearness, and brightness of mind, by means of which 
 they have raised themselves above the level of their 
 sex. And perhaps women of a certain type are justified 
 in this fear." 
 
 Fortunately, however, the woman who does not prize 
 
152 THE SEXUAL LIFE OF WOMAN 
 
 maternity still remains an exception. The great in- 
 stinct for the preservation of the species, which nature 
 has planted deeply in every human being, still, as a rule, 
 in women remains much more powerful than the in- 
 stinct of self-preservation at every one else's expense — 
 more powerful than such self-sufBcient egoism. And 
 now as ever it is the duty of humanity to educate 
 women for maternity from her youth upward, so that 
 she is in every way fitted for the supreme duty of her 
 sexual nature, the renewal of life from generation to 
 generation. 
 
 Against the significance and importance of mater- 
 nity to woman, the mountainous waves of the move- 
 ment for the emancipation of women dash themselves 
 as vainly as against the solid rock. Much justifica- 
 tion may be found for the efforts of women in modern 
 civilized communities to engage in departments of ac- 
 tivity to which hitherto men only have been admitted ; 
 and as regards the intellectual capacity of women we 
 may acknowledge their competence for the higher sci- 
 entific professions; but while admitting this we must 
 hold firmly to the physiological standpoint and must 
 more especially bear in mind the sexual life of woman. 
 Such professions only are suitable for a woman as do 
 not entail a restriction of the sphere of her reproductive 
 activity, a hindrance to her principal duty, that of ma- 
 ternity, an interference with the discharge of her obli- 
 gations to husband and children, or a diminution of 
 her domestic value and an evasion of her responsibili- 
 ties in family life. As L. von Stein so justly remarks, 
 the woman who spends. the whole day at a desk, in the 
 law courts, or in a house of assembly, may be a most 
 honorable and most useful individual, but she is no lon- 
 ger a woman, she cannot be a wife, she cannot be a 
 mother. In the condition of our society, the emancipa- 
 
THE SEXUAL EPOCH OP THE" MENAOME 153 
 
 tion of woman is in its very nature the negation of 
 marriage. 
 
 We may not agree with the great misogynist, Scho- 
 penhauer, in his depreciation of the female sex, or in his 
 assertion that woman exists simply and solely for the 
 propagation of the species, and that "her life should 
 therefore flow more quietly, more inconspicuously, and 
 more gently than that of man toward its goal;" nor 
 need we regard as justified the severe sentence of the 
 philosopher, E. von Hartmann, that from the moral 
 standpoint, "the greater number of women pass the 
 whole of their lives in a state of minority, and, there- 
 fore, to the end stand in need of supervision and guid- 
 ance" ; but the statement made by Friedr. Nietzsche in 
 his book Also sprach Zarathustra deserves acceptation, 
 "Everything in woman is a riddle, and everything in 
 woman has its answer: it is called pregnancy," and 
 again, "For woman, man is only the means; the end 
 is always the child." 
 
 Unsearchable in its judgments, nature has imposed 
 on woman alone the consequences of the act of genera- 
 tion; man has the pleasure, but not the labor and the 
 pain. We might indeed regard as highly unjust the 
 distribution of the roles in the process of reproduction, 
 were it not that in a mother's love and a mother's joys, 
 woman finds a compensatory solace. The man's part 
 is a much easier one and costs far less than that of 
 woman; with the gratification of his sexual desire, man 
 shakes ofif any further responsibility, whereas the wom- 
 an's body becomes the workshop in the wonderful act 
 of creation of a new human life. 
 
 "Maternity," says Lombroso, "is the characteristic 
 function of the female sex, upon which rests her whole 
 organic and physical variability, and this function is 
 indeed throughout of an altruistic nature. Although 
 
154 THE SEXUAL LIFE OP WOMAN 
 
 there is a certain antagonism between the sexual im- 
 pulse and maternity — according to Icard, the sexual 
 impulse is extinguished in women during pregnancy, 
 — still, maternity appears to depend upon sexual per- 
 ceptions. For instance, the act of suckling the infant 
 often arouses voluptuous sensations, and Icard men- 
 tions a case in which a woman permitted fertilization 
 to occur solely on account of the pleasure obtained by 
 suckling. The anatomical cause of this fact is to be 
 found in the connections between the nipple and the 
 uterus by way of the sympathetic nervous system. 
 * * * It is likewise probable that in the happy 
 feeling of maternity there intermingle very gentle vo- 
 luptuous sensations derived from the genital organs." 
 According to Bain, also, very delicate sensations of con- 
 tact form an element in maternal love. 
 
 The epoch of the menacme is that in which, inde- 
 pendently of maternity, the sexual impulse often be- 
 comes so powerful in woman as to be entirely domi- 
 nant. The problems relating to marriage and to the 
 sexual position of woman, so widely discussed at the 
 present day, are, therefore, of especial importance in 
 regard to women at this period of life. The forcible 
 repression and control of the sexual impulse inculcated 
 by moral and religious ordinances are now, according 
 to the modern leaders, both male and female, of the 
 woman's movement, to be abandoned ; and it is loudly 
 asserted that every woman has the same right as man 
 to physical love and the happiness it produces. Hence, 
 free love is demanded. "Freedom in love, freedom for 
 love — this is what the dignity of the human race de- 
 mands," asserts the authoress of a book recently pub- 
 lished (Elisabeta von Steinborn, The Sexual Position 
 of Woman). With laws for the regulation of mar- 
 riage, this section of the women's rights party will have 
 
THE SEXUAL EPOCH OF THE MENACME 155 
 
 nothing to do. A truly good and honorable man, they 
 contend, has as little need of laws to regulate. his amor- 
 ous relations as he has of laws against murder and theft. 
 In the first place, love, the sexual relation between man 
 and woman, must be free, and humanity, freed from 
 vexations and needless control, will then seek and find 
 the proper path, even if at the expense of a few errors 
 by the way. Only after this unrestrained sexual inter- 
 course has lasted for a long time, will free marriage be- 
 come the rule. "Out of this phase will develop the 
 monogamic system willed by God, for which, in its 
 most ideal form, we are not yet sufficiently ripe." It 
 is hardly necessary to discuss in detail the general dele- 
 terious influence of such unlimited, unregulated free 
 love upon the community, upon human society as a 
 whole, to describe the results of free love, to attempt 
 to realize the chaos which it would bring about in the 
 social relations of civilized humanity. We must rather 
 indicate it as desirable from the medical standpoint, 
 also, that such a change in general domestic economy 
 shall be aimed at as will enable the great majority of 
 women to share in married life and family happiness, 
 and thus making allowance both for human nature and 
 the demands of social life, to effect a true harmony 
 between sexual morality and sexual practice. 
 
 We must point out that in so far as the modern wom- 
 an's movement aims at dispensing with man and at bas- 
 ing the entire life of woman upon the independent ego, 
 that movement is in opposition to nature and its eternal 
 laws. A woman who thus seeks the solution of the 
 woman's question in the direction of freedom and in- 
 dependence is one who endeavors to avoid the bur- 
 den of womanhood. She desires to escape, always from 
 guardianship, often from maternity, and usually from 
 the restrictions, the unselfishness of womanhood. But 
 
156 THE SEXUAL LIFE OF WOMAN 
 
 none the less does she remain unable to escape from 
 her femininity. 
 
 "The true significance of woman," insists Laura 
 Marholm in opposition to the modern tendency, "has 
 at all times consisted rather in what she is than in what 
 she performs, and it is precisely in the former point 
 that the women of the present day seem so unusually 
 wanting. Their performances are indeed many and 
 various, they study and they write innumerable books, 
 they are the directors or principals of all possible con- 
 cerns and collect funds for every possible object, they 
 wear doctors' gowns, conduct agitations, and found 
 clubs, and they come continually more and more into 
 publicity. And yet their public significance is after all 
 diminished. The greater the influence of woman in the 
 mass and as a numerical majority, the less is her influ- 
 ence as an individual, the smaller is the triumph of her 
 sex. She herself has induced man to sound the trumpet 
 note of the abhorrence of women. Tolstoi in The Kreut- 
 zer Sonata, Strindberg in numerous dramas, Huys- 
 mans in En Menage, write in this strain; and in the 
 works of many lesser luminaries we encounter this mis- 
 trust of love. * * * The modern system of educa- 
 tion for girls, with its polyglossia and polymathy, fav- 
 ors a superficial development of the understanding, 
 and produces women who are pretentious without be- 
 ing profound." 
 
 Feminine beauty suffers during the menacme from 
 the stress of the demands made on the sexual activity 
 as well as on the functional capacity of the individual. 
 Repeated, rapidly succeeding pregnancies and confine- 
 ments impair the beauty of the breasts and the abdo- 
 men, the figure and the carriage. In consequence of 
 suckling, the breasts, hitherto firm and elastic, usually 
 become more or less pendent and wrinkled, sometimes 
 
THE SEXUAL EPOCH OF THE MENACME 157" 
 
 also flabby and inelastic, sometimes nodular. Diseases 
 of the genital organs and the disorders of the general 
 health dependent thereon, leave disfiguring wrinkles in 
 the face and other traces in the whole structure of the 
 body. Toil, anxiety, and grief also write their horrible 
 marks deeply on the appearance. The mature work- 
 ing-class woman, through sharing in masculine la- 
 bors, through long-continued muscular exertion, and 
 through neglect of bodily care, frequently assumes in 
 her features, her carriage, her figure, and her whole 
 appearance, a rather masculine type. 
 
 The beauty and the youthful freshness of girls be- 
 longing to the laboring classes seldom endure for long 
 after the menarche, and in cases in which the environ- 
 ment is one of poverty, they last through a very short 
 part only of the epoch of the menacme. The early ap- 
 pearance of wrinkles in the face, the stiff, angular char- 
 acter of the movements, the ungraceful carriage of the 
 body, all these combine to make a woman of five-and- 
 twenty who groans under the burthen of toil appear at 
 the first glance an elderly woman, and a closer investi- 
 gation shows what damage has been wrought to the at- 
 tributes of beauty, how the breasts are flabby and flat- 
 tened, the belly prominent, the buttocks pendulous, the 
 arms muscular. 
 
 in the well-to-do classes, again, at this period of life, 
 when generous diet combines with insufficient exercise, 
 an abundant deposit of adipose tissue may already 
 have occurred, resulting in a great impairment of 
 beauty, the body and limbs being enlarged, the gait and 
 the carriage correspondingly altered for the worse — 
 changes which seem desirable only to those orientals to 
 whom such obesity, such exaggeration of femininity, is 
 sexually stimulating; If, however, this deposit of fat 
 is not excessive, this it is which endows women during 
 
158 THE SEXUAL LIFE OF WOMAN 
 
 these years of fullest developinent with an imposing 
 appearance and buxom form. In favorable circum- 
 stances, beauty of this type may persist to the fortieth 
 year of life and even beyond, and it is of such a char- 
 acter as to justify the proverb that w^oman's first sexual 
 epoch is dedicated to love, her second to voluptuous- 
 ness. 
 
 "Bountiful nature," w^rites Mantegazza, regarding 
 woman at this sexual epoch, "sends to woman an in- 
 genious engineer, who enlarges the hills to mountains 
 and fills up the valleys with a soft alluvium of fat. The 
 commencing wrinkles disappear, being smoothed out 
 under the beneficial influence of this plastic material; 
 the slender, elastic palm-tree stems are converted into 
 majestic columns of Parian marble ; quality is replaced 
 by quantity, and if the eye has lost a few provinces, 
 the hand has gained just as many. * * * A cer- 
 tain number of chosen women understand how to pre- 
 serve for as long as ten years the unstable equilibrium 
 of the period which separates these two ages of life. 
 These are divine beings who with every oscillation of 
 their tresses or rocking of their hips, with every undu- 
 lation of their bosom, every serpentine movement of 
 their limbs, instil desire. * * * They constitute our 
 most intense delight, and our intensest torment, they 
 make our life a blessing or a curse, they are the utter- 
 most goal of human passion, of human voluptuous 
 desire." 
 
 Among the injuries to beauty effected by pregnancy, 
 one above all evident to the eye is the almost invariably 
 ensuing change in the skin, principally taking the form 
 of a change in pigmentation, with the appearance of 
 spots varying in size and tint, on the face and especially 
 on the lips and forehead; there is greatly increased pig- 
 mentation also of the areola mammae and the linea 
 
THE SEXUAL EPOCH OF THE MENACME 169 
 
 alba, and in addition of the labia majora and minora 
 and of the anal region. It is not certain whether this 
 chloasma uterinum is dependent, as Jeamin assumes, 
 on the discontinuance of menstruation, or, as Virchow 
 believes, on changes in the blood and the blood-pres- 
 sure. Sometimes, also, in pregnant women, we observe 
 on the face, chiefly on the nose and the cheeks, dilata- 
 tions of the small cutaneous vessels, often associated 
 with acne nodules. 
 
 Transiently during pregnancy, but in some cases per- 
 manently also, the beauty of the lower extremities is 
 apt to be impaired by enlargements of the veins, the 
 formation of varices, and sometimes also by oedema; 
 these conditions depend upon the hindrance to the ve- 
 nous return caused by the pressure of the pregnant 
 uterus. Thick, vermicular, bluish strings or nodular 
 enlargements appear in the course of the great veins, 
 with consequent eczema and ulceration. In pregnant 
 woman, eczema is common in other regions, on the 
 face, the hands, the forearms, and the genitals; also 
 erythema, urticaria, and the pustular eruption known 
 as impetigo herpetiformis. 
 
 Parturition and lactation entdjil further disfigure- 
 ment of the skin through the production of various le- 
 sions, such as cracks and fissures of the skin of the 
 breast, dermatitis due to venous thrombosis in the lower 
 extremities, scarring of the breast after mastitis, etc. 
 
 Hygiene During the Menacme 
 
 During the sexual epoch of the menacme a wom- 
 an's principal hygienic need is marriage completely 
 satisfactory alike to body and to mind. It cannot be 
 denied that sufficient sexual gratification, regular, of 
 course, and free from all excess, such as is usually ex- 
 perienced in married life, is very advantageous to the 
 
160 THE SEXUAL LIFE OF WOMAN 
 
 health of a woman who has attained sexual maturity — 
 even though we admit that the drawbacks of sexual 
 abstinence, regarded as a cause of disease of the female 
 genital organs and the nervous system have been, as a 
 rule, greatly exaggerated. 
 
 The inability to marry always makes a deep impres- 
 sion on the mental life of woman, and in many cases 
 also gives rise to burning desire and tormenting yearn- 
 ing of an erotic nature. The unmarried miss life's true 
 goal and fail to enjoy the natural exercise of their func- 
 tional capacities; alike in the cultured lady and in the 
 poor working woman who has failed to marry, the 
 thoughts and feelings return again and again to her 
 own condition in a self-tormenting manner. 
 
 The physical and mental disadvantages entailed by 
 sexual gratification when obtained by an unmarried 
 woman, one who, according to modern phraseology, 
 "wishes to secure her natural share of the joys of love," 
 and who regards voluntary chastity as "a sacrifice to 
 meaningless prejudices" — need not be more particu- 
 larly described. 
 
 Free love, moreover, is the most important dissemi- 
 nator of gonorrhoeal infection. "In any future com- 
 monwealth," says Runge, "in which marriage is aban- 
 doned in favor of the general practice of free love, the 
 human race will be overwhelmed by gonococci in a 
 manner now hardly conceivable, and the reproductive 
 capacity in both sexes will be diminished by the results 
 of gonorrhoea to a very serious extent." 
 
 Frequently enough, also, free love leads to prostitu- 
 tion, which at the present day is so widely prevalent. 
 Various reasons have been suggested to account for the 
 increase of prostitution. Among these are: The 
 growth of modern industry, with the consequent aggre- 
 gation of the population in large towns ; the decline in 
 
THE SEXUAL EPOCH OF THE MENACME 161 
 
 the marriage rate; the postponement of marriage; uni- 
 versal military service; the freer mutual companion- 
 ship of the sexes; and many others. At any rate, the 
 fact would appear to be established, that in the case of 
 wornan the determining cause of prostitution is hunger 
 rather than the sexual impulse. The worst paid classes 
 of workwomen are shown by official statistics to furnish 
 the largest number of recruits to the ranks of prosti- 
 tutes; and it is during times of deficient employment 
 that the number of women practicing occasional pros- 
 titution increases. Thus, material need is the most im- 
 portant of the causes of prostitution. 
 
 This remains true even though the doctrine of Lom- 
 broso and Tarnowsky should find fuller justification, 
 the doctrine that the practice of prostitution by women 
 is the natural expression of a congenital morbid pre- 
 disposition, "which impels them, in defiance of their 
 direct advantage, of reason, and of all counter-advice, 
 to adopt this accursed mode of life." Prostitution, in 
 this view, is to be regarded as the inevitable outcome 
 of congenital moral insanity. This is certainly true of 
 a small proportion of prostitutes,- but is as certainly 
 false of the great majority, in whom unfavorable, dif- 
 ficult conditions of life form the determining cause. 
 A certain inherited or acquired mental disposition may, 
 indeed, be assumed to exist in these cases also — an un- 
 stable moral equilibrium, an insufficient development 
 of the force of the will and of the power of resistance. 
 
 The hygienic requirement of married life for wom- 
 an during the menacme is undoubtedly sometimes hard 
 to fulfil in our day, when the more elaborate and ex- 
 pensive standard of life has increased the difficulty of 
 supporting a family; but from the medical point of 
 view it is necessary to insist forcibly on this categori- 
 cal imperative, in opposition to the view advanced by 
 
162 THE SEXUAL LIFE OF WOMAN 
 
 the modern women's rights' party, that "love is moral 
 also in the absence of legal marriage" (Ellen Key) ; 
 in opposition to the yet more extreme opinion of 
 George Sand and of Almquist, who, regardless of con- 
 sequences, declare marriage to be immoral ; and, final- 
 ly, in opposition to the advocates of "free love," who 
 wish woman to be as free as man in sexual relations. 
 
 Much as we may wish that man and wife should be 
 in complete harmony in marriage, and that they should 
 feel themselves to be firmly united alike by mutual love 
 and by a reciprocal sense of duty, none the less we must 
 consider the modern maiden ripe for marriage as un- 
 justified in demanding, before undertaking marriage, 
 "perfect love as typifying the inner yearning of two be- 
 ings to become one ;" and we must regard the latter-day 
 woman as extravagant in insisting that the man shall 
 enter upon marriage in a condition as virgin as that of 
 his contemplated wife. "Perfect love" is as rare and 
 as little to be expected as perfect beauty; and the sex- 
 ual life of man differs entirely in nature and in the 
 course of its development from the sexual activity of 
 woman. 
 
 Doubtless they spring deep from the soul of woman, 
 the demands expressed by the writer of the book 
 Vera, and by her numerous imitators, the apostles 
 of "Veraism," — the demands of the maiden entering 
 upon marriage that her husband shall be as chaste and 
 sexually as unspotted as herself. Difficult of fulfilment 
 as they are, if fulfilment is even possible, these demands 
 must none the less be regarded as characteristic of the 
 sexual life of modern womanhood. "Is man's sexual 
 honor," exclaims Vera, "then altogether different from 
 that of woman? Is not the alleged necessity for sex- 
 ual gratification in youth either a well-organized fraud 
 or an enormous error on the part of physicians? Is 
 
THE SEXUAL EPOCH OF THE MENACME 163 
 
 it possible that chastity can entail diseases as terrible, 
 as destructive to life and happiness as those that re- 
 sult from unchastity? And is it not a crying sin, even 
 if some of these fears are justified, to ruin both mental- 
 ly and physically the whole race of women? * * * 
 Man demands from the girl of his choice, not chas- 
 tity alone, but an absolutely unblemished character. 
 And rightly so. But the wife must share her husband 
 with street-walkers? She must bear the pangs of ma- 
 ternity, while fortified by the terrible knowledge that 
 the father of her children has wasted his youthful vi- 
 rility in purchased embraces, that he has not recoiled 
 from impurity, that he has exposed himself to the risk 
 of infection with the most horrible diseases, that he 
 has squandered his virginity in the most bestial sen- 
 suality? * * * We girls must also be granted the 
 right to demand from the man of our choice the same 
 purity, the same unspottedness by sensuality, that he so 
 rigorously demands from ourselves! We must no lon- 
 ger content ourselves with the remnants that are left 
 for us by others! We must no longer be satisfied with 
 man's moral inferiority! Then there will be more hap- 
 piness, more love, more health and joy of life!" 
 
 These accusations and demands so boldly made are 
 not to be disposed of by mere mockery. With deep sor- 
 row we must admit the absolute truth of the charge that 
 too many men clamber out of the abyss of debauchery 
 to a blighted marriage. But the demand for equal mo- 
 ral rights, for the abandonment of the hitherto preva- 
 lent bisexual ethical standards, is in vain conflict with 
 actuality, with the defensive instincts of young men, 
 with the difficulties entailed by the struggle for exist- 
 ence, with the increasing pretensions (to sexual free- 
 dom) of women themselves; but above all is it in con- 
 flict with the thousand-year-old notions of sexual honor 
 
164 THE SEXUAL LIFE OF WOMAN 
 
 in the male and the female respectively, and with the 
 undeniable fact that the mature man is capable of ele- 
 vating himself out of the base intoxication of the senses 
 characteristic of youth, to attain the noblest and most 
 intimate married love, whereas the girl who has once 
 descended into such an abyss sinks therein and is be- 
 yond the possibility of rescue. Thus early marriage 
 with equal purity of husband and wife remains a pos- 
 tulate which the present can hardly be expected to sat- 
 isfy, and one whose fulfilment must be left to the 
 future. 
 
 In consequence of modern writings and discussions 
 concerning the erotic problem, there has arisen a hy- 
 persensibility on the part of women in respect of the 
 conditions, in which they pass their married life, lead- 
 ing them to demand greater independence, a greater 
 expansion of their own individuality; this tendency 
 must, however, be resisted, if the marriage is to be a 
 happy one, with mutual comfort and reciprocal consid- 
 eration, one suitable, not for exceptional beings in an 
 ideal state, but for men and women as they really are. 
 In such a marriage, affection and a sense of duty will 
 strengthen love and preserve fidelity. A prudent, 
 clever woman will always understand how, notwith- 
 standing all necessary self-surrender, to preserve the 
 freedom of her own individuality and the esteem of 
 her husband. 
 
 Marriages based upon true inclination usually re- 
 sult in the birth of stronger and more beautiful chil- 
 dren than marriages in which the money-bags were the 
 sole or the principal determining cause. In England, 
 where people commonly marry when still quite young, 
 beautiful and healthy children are more often seen than 
 in France, where marriages of expediency form the 
 great majority. According to Bertillon, of i,ooo young 
 
THE SEXUAL EPOCH OF THE MENACME 165 
 
 men from 20 to 25 years of age, in England 1 20 marry, 
 but in France less than half that number, viz., 57 only. 
 'And 100 wives between the ages of 15 and 40 give birth 
 annually, in England to 39 children, in France to 26 
 only, a number less by one-third. 
 
 In deciding upon marriage, hereditary influences 
 deserve careful consideration in respect alike of the 
 family of the prospective husband and that of the pros- 
 pective wife. For it is well established that the law of 
 inheritance relates not only to the peculiarities of ex- 
 ternal configuration, to the features, the stature, the tint 
 of the skin, but also that children inherit from their pa- 
 rents their mode of bodily development, the functional 
 activity of their organs, the duration of their life, their 
 predisposition to disease, and even their intellectual 
 and moral qualities. As regards hereditary predisposi- 
 tion to disease, the most important are, as is well 
 known, the predisposition to tuberculosis, that to ma- 
 lignant tumors, and that to mental disorders. 
 
 Great disparity in the respective ages of prospective 
 husband and wife entail various kinds of unsuitability 
 for marriage. An elderly man who marries a young 
 girl, even if he still possesses a certain amount of viril- 
 ity, is unlikely to procreate healthy and powerful chil- 
 dren; and these latter for the most part will be weakly, 
 scrofulous, cachectic, endowed with deficient powers of 
 resistance, and often badly equipped from the intellec- 
 tual standpoint. Similar considerations prevail in re- 
 spect of marriages in which the husband has been ex- 
 hausted by earlier sexual excesses, so that he retains no 
 more than remnants of virility, whilst his semen is of 
 doubtful fertilizing power. 
 
 Plato maintains that before every marriage the man 
 and the woman should both undergo official examina- 
 tion to determine their fitness or unfitness for the mar- 
 
166 THE SEXUAL LIFE OF WOMAN 
 
 ried state, the man being absolutely nude, and the wom- 
 an stripped to the waist, for the examination. This au- 
 thor goes so far as to regard it as "a form of homicide 
 for a man- to embrace a woman when he is incapable 
 of fertilizing her." How rarely it happens in our day, 
 however, that the physician, the official with the requis- 
 ite knowledge to fulfil Plato's requirements, is asked 
 for his opinion regarding the desirability of a contem- 
 plated marriage! The only occasion on which this is 
 likely to occur is when a man intending to marry wishes 
 to be assured that he is completely cured from an ear- 
 lier infection with syphilis, and, therefore, runs no risk 
 of transmitting the disease to his wife or to possible 
 offspring. But it never occurs to the parents of a girl 
 about to marry to ask the physician whether she is phv- 
 sically suitable for marriage. 
 
 In deciding on marriage, however, care should be- 
 fore all be taken to determine that the girl has attained 
 complete physical and especially complete sexual de- 
 velopment. The age at which woman attains complete 
 sexual maturity is in our climate and race coincident 
 on the average with the twentieth year of life. 
 
 For the hygiene of marriage it is necessary that the 
 bride should not be extremely youthful. Notwith- 
 standing the fact that the legal codes of civilized coun- 
 tries nowhere demand for girls a greater age than fif- 
 teen years before permitting marriage, this limit is, 
 generally speaking, fixed far too low. Before becom- 
 ing a wife, the girl should not merely have attained 
 complete physical development, with her reproductive 
 organs in a state of maturity, but she must also be devel- 
 oped intellectually to such an extent that she is fully 
 capable of understanding the nature and significance of 
 marriage. At the age at which marriage is legally per- 
 missible, a girl is still far from having attained physical 
 
THE SEXUAL EPOCH OF THE MENACME 167 
 
 and mental ripeness for marriage, reproduction, and 
 maternity. 
 
 Especially with reference to the last consideration is 
 't inadvisable that in our climates a girl should marry 
 earlier than from 1 8 to 20 years of age, and preferably 
 even she should first attain the age of from 20 to 22. In 
 that case her happiness as a mother will be more se- 
 cure, and there will be a greater probability of her pro- 
 ducing a healthy progeny. In the East, indeed, quite 
 diflferent views prevail. According to the laws of Ma- 
 nus, a girl might marry on attaining the age of eight 
 years ; if within three years thereafter her father failed 
 to provide her with a husband, she might choose one 
 for herself. Among the Hindus it is regarded as a 
 disgrace to the parents if a girl does not marry quite 
 young, indeed before the first appearance of menstrua- 
 tion. Atri and Kasypa state that if a girl begins to 
 menstruate before she leaves her father's house, the 
 latter must be punished as if he had destroyed a foetus, 
 while the daughter herself loses caste. Marriage de- 
 layed till after the appearance of menstruation being 
 regarded as sinful, girls are married while still chil- 
 dren, in order to prevent the loss of mature ova, which 
 is regarded as equivalent to infanticide. Very early 
 marriage has thus in India been legally ordained for 
 thousands of years. The Hindus, who even now re- 
 gard every menstruation which has not been preceded 
 by coitus in the light of infanticide, marry their daugh- 
 ters before the age of puberty. 
 
 According to oriental tradition, Mahomet married 
 Khadijah when five years of age, and cohabited with 
 her three years later. In the Bible, numerous similar 
 examples are recorded.. Among many savage tribes, 
 as, for instance, among some of the aborigines of India, 
 and among the indigens of Australia, copulation is usu- 
 
168 THE SEXUAL LIFE OF WOMAN 
 
 ally effected before girls reach the age of puberty; 
 in India, indeed, according to Ploss and Bartels {Das 
 Weib in der Natur und Volkerkunde), marriage with 
 immature girls is a widely diffused custom, and in Aus- 
 tralia a child of ten or eleven is often found to be the 
 wife of a man of fifty or the concubine of a sailor. In 
 general, according to these authors, we find that the 
 age of nubility in girls is lower in proportion to the 
 lowness of the stage of civilization attained by the race 
 or people to which they belong. Among the ancient 
 Romans, girls were commonly married between the 
 ages of thirteen and sixteen years. 
 
 In the Talmud, Rabbi Joshua gives the following ad- 
 vice regarding early marriage in Jewish girls: "If 
 your daughter has attained puberty and is twelve years 
 and six months old, she must be married at any cost. 
 If no other means are available, manumit one of your 
 slaves, and give her to the f reedman to wife." 
 
 Experience proves, however, that in our climate, 
 at any rate, girls who marry at a very early age are in- 
 ferior in fertility to those who refrain from marriage 
 until the genital organs have attained complete matur- 
 ity; and statistics show that those women who marry 
 before attaining the age of twenty must wait longer for 
 their first pregnancy than those who marry between the 
 ages of twenty and twenty-four. At the higher age 
 also, women bear parturition and its consequences more 
 easily than those who marry very young. A similar 
 influence in marriage to that resulting from undue ju- 
 venility is exercised by its opposite, marriage when a 
 woman is already elderly; in this case fertility is lim- 
 ited, and health also is especially apt to suffer. When 
 the indications of the climacteric are clearly apparent, 
 marriage is contra-indicated, not only on account of the 
 impossibility of fertilization, but also in respect of its 
 
THE SEXUAL EPOCH OF THE MENACME 169 
 
 general unsuitability in the closing stage of the sexual 
 life. 
 
 Not only is the absolute age of the woman of im- 
 portance in deciding on the advisability of marriage, 
 but the relative ages of the proposed -husband and wife 
 must also be taken into account, first of all in respect 
 of the wife's possible fertility, and secondly in respect 
 of her general health. The most suitable arrangement 
 is that in which there is no marked difference in age. 
 The husband may be, and indeed in existing social cir- 
 cumstances almost necessarily is, somewhat older than 
 his wife, as much perhaps as eight or ten years. But 
 a very great disparity of age (in either direction) is a 
 serious error. If a very young girl marries an elderly 
 man, or a developed matron marries a young man, the 
 true purpose of marriage is unfulfilled, the eternal laws 
 of nature and all ethical principles are infringed. In 
 the breeding of animals, the fundamental principle has 
 long prevailed that the animals chosen for coupling 
 should be well suited each to the other and should be 
 in perfect physical condition; and breeders are also fa- 
 miliar both with the favorable influence of good nour- 
 ishment and with the advantage of the opportune cross- 
 ing of distinct varieties. The same principles are 
 equally applicable to the human race, neglected as they 
 commonly are in practice. 
 
 With regard to the marriage of near kin, we can only 
 remark that the marriage of those closely related by 
 blood should, as far as possible, be avoided, and that 
 such a marriage must be absolutely prohibited when 
 in both families there is a history of tuberculosis, men- 
 tal disorders, diabetes, and the like. When first cou- 
 sins contemplate marriage, it is indispensable, not only 
 that both individuals should be in perfect health, but 
 a^SQ/hat on neither side there should be any serious 
 
170 THE SEXUAL LIFE OF WOMAN 
 
 family history of transmissible disease or transmissible 
 morbid tendency; and, further, it is absolutely neces- 
 sary that no such marriage of near kin should have tak- 
 en place in the proximate ancestry of the cousins, i.e., 
 their cousinship must not be a double one, derived both 
 from the paternal side and the maternal. It is indeed 
 to be recommended, with a view to the production of 
 a healthy and powerful posterity, that marriage should 
 bring about a crossing of healthy individuals proceed- 
 ing from different families, different places, and differ- 
 ent constitutional types. An instance of the advantage 
 to be found in this practice is pointed out by Ribbing, 
 who shows that the most powerful aristocracy in Eu- 
 rope, that of England, by the gradual creation of new 
 peers, on the one hand, and by the gradual decline 
 of younger sons and their descendants into the middle 
 class, on the other, has undergone a continual crossing 
 with less exalted but originally sounder stocks; in this 
 way its vigor and fertility have been maintained, in 
 contrast to the nobility of many continental states, 
 which has so largely perished, in consequence of its ex- 
 clusiveness in the matter of marriage. 
 
 "In this connection," continues Ribbing, "we must 
 bear in mind, that blood-relationship is not the only 
 matter that has to be considered; in the interest alike 
 of the family, and of society, it is necessary to demand 
 that certain degrees of relationship by marriage alone, 
 should fall within the 'prohibited degrees' of love and 
 marriage. There are certain groups related by mar- 
 riage and held together by the bond of affection, from 
 which foster-parents and guardians may most suitably 
 be selected to fulfil the duties as regards education and 
 training of children who have been orphaned in early 
 years. For such a purpose none seem better adapted 
 than the brothers and sisters of the deceased parents; 
 
THE SEXUAL EPOCH OF THE MENACME 171 
 
 but the upbringing of the children can be confidently 
 entrusted to the former only if the relationship between 
 the older and the younger branches of the family is one 
 regarded by law, and still more by morality and custom, 
 as one precluding the possibility of the occurrence of 
 sexual love and marriage." 
 
 Mobius, writing on The Ennobling of the Human 
 Race by Selection in Marriage, observes: "The most 
 important aim of natural development is the perfection 
 of humanity. The qualities of the coming generation 
 depend for the most part upon the qualities of the pa- 
 rents. Marriage from affection insures the fulfilment 
 of nature's aims with more security than marriage from 
 reason ; since what we have to think of is not the happi- 
 ness of the married pair but the quality of their chil- 
 dren. Of great importance, also, to the development of 
 the human race are the conditions during the com- 
 mencement of life, and the mode of education. The 
 improvement of the race has not hitherto been the con- 
 scious aim of the generality of people. The law does 
 not as yet, as it should, take into account the advantage 
 of posterity. Capital punishment is fully justified and 
 purposive. Criminals should not be allowed to marry. 
 The perpetuation of disease by inheritance should be 
 checked by the utmost powers of the state. Any one 
 marrying while suffering from any venereal disease still 
 in an infective condition should be punished. The mar- 
 riage of persons suffering from tuberculosis should be 
 prohibited. For the prevention of disease is more im- 
 portant than its cure. The most important factor in 
 preventive medicine is an improvement in the condi- 
 tions of life. The human ideal should be, goodness of 
 heart in association with physical and mental health. 
 Goodness, beauty, and strength should be simultaneous- 
 ly pursued. Since,, however, man is made by birth far 
 
172 THE SEXUAL LIFE OF WOMAN 
 
 more than by education, selection in marriage is of fun- 
 damental importance. In the choice of a partner, at- 
 tention is rightly paid to beauty, since beauty and 
 health are fundamentally identical; moreover, a hu- 
 man being endowed with beauty is usually also more 
 moral than one devoid of that attribute. Equality of 
 birth is, as a rule, desirable in marriage; but not the 
 family only is to be considered in determining the ex- 
 istence of such equality, individual characteristics must 
 likewise be taken into account. Whether the crossing 
 of races is desirable is not yet certainly determined." 
 
 From the hygienic standpoint it is necessary that in 
 marriage also the frequency and the manner of sexual 
 intercourse should be regulated. 
 
 Wise men and law-givers of all the nations of antiq- 
 uity have insisted upon the necessity of certain in- 
 tervals between the acts of intercourse. Thus, Maho- 
 met prescribed 8 days, Zoroaster 9 days, Solon 10 days, 
 Socrates also 10 days. Moses forbade intercourse dur- 
 ing menstruation and for a week after the cessation 
 of the flow. Luther prescribed intercourse "twice a 
 week." 
 
 Birds and many mammals are competent to perform 
 intercourse at exceedingly short intervals. A well-bred 
 cock will repeat this act 50 times daily; a sparrow, 20 
 times in an hour; a bull, 3 to 4 times in an hour. In 
 the human species, however, too rapid repetition of in- 
 tercourse is deleterious not only to the male, but to the 
 female also, though the latter certainly suffers in less 
 degree. For in this act the female plays a more pas- 
 sive part, and for this reason can repeat it with im- 
 punity more frequently than the male, who loses semen 
 at each repetition. It is not possible, however, to lay 
 down precise rules as to the permissible frequency of 
 
THE SEXUAL EPOCH OF THE MEN ACME 173 
 
 intercourse in either sex ; the matter must depend upon 
 physical needs. Moderate and regular indulgence in 
 sexual intercourse is unquestionably advantageous to 
 woman both physically and mentally, regulating all 
 the functions of the body, and tending to produce a 
 contented and cheerful frame of mind. 
 
 During menstruation, a woman should refrain from 
 intercourse. By the Mosaic law the death punishment 
 was allotted both to the man and to the woman who in- 
 dulged in coitus while the latter was menstruating. As 
 a matter of fact, considerations alike of hygienic clean- 
 liness and of sanitary precaution prohibit the perform- 
 ance of coitus during this period. Severe menorrhagia, 
 perimetritic irritation, and parametritic inflamma- 
 tions, have been observed to follow such indiscretions. 
 On the other hand, it is more than doubtful whether, 
 in the event of pregnancy resulting from intercourse 
 performed during menstruation (and conception is es- 
 pecially apt to occur at this time), the child is likely, 
 as earlier authors maintained, to be unfavorably af- 
 fected, and to suffer from cachexia, scrofula or rickets. 
 
 After the act of intercourse, a woman should rest; 
 and indeed sleep for some hours is especially to be 
 recommended. A vaginal douche should not be ad- 
 ministered until several hours have elapsed, otherwise 
 there will be a risk of preventing fertilization of the 
 ovum. The water employed for vaginal irrigation 
 should never be quite cold; a temperature of 79° to 
 82° F. (26° to 28° C.) is best. 
 
 All measures for the purpose of artificially increas- 
 ing sexual desire, such as alcoholic beverages (especial- 
 ly champagne), and certain drugs (especially canthari- 
 des), are even more harmful to women than they are to 
 men. The woman who conceives while in a state of in- 
 toxication commits a great sin against the coming gen- 
 
174 THE SEXUAL LIFE OF WOMAN 
 
 eration.^ Just as harmful, however, are the anaphrodi- 
 siacs sometimes employed to diminish the intensity of 
 sexual desire when this cannot be gratified. When af- 
 fected with intense sexual excitement, a woman is much 
 more unfavorably situated than a man, since man 
 claims the right to indulge in sexual intercourse when- 
 ever he feels disposed, and has, moreover, ample oppor- 
 tunity for sexual gratification. A woman, however, 
 properly endowed with self-respect, will understand 
 how to bridle her senses. Bodily exercise, moderate, 
 unstimulating diet, intellectual occupation with serious 
 matters, the avoidance of equivocal literature and of 
 sensual dramatic representations, cold bathing, and the 
 use of a hard mattress and light bed-clothing'— these 
 means will cooperate powerfully toward the preven- 
 tion of excessive sexual desire. Horace already re- 
 marked: "Otia si tolles, periere Cupidinis arcus." 
 
 The wife should know how to bridle, not her own 
 desires only, but also those of her husband. She must 
 not demand too much during the intoxication of youth- 
 ful vigor; she must prevent the complete combustion 
 of the flames of masculine passion, and must keep 
 sparks glowing in the ashes. Economy during the sex- 
 ual prime preserves sexual power, enables a man to con- 
 tinue intercourse to a ripe age, and avoids premature 
 exhaustion and satiety. When the husband is drawing 
 near the end of his sixth decade, the wife must accustom 
 herself to see in him rather the father of her children 
 
 1 The statement is so often made that conception occurring when one or 
 both parents are intoxicated is likely to be harmful to the offspring, that 
 it seems expedient to point out that neither the author of this work, nor 
 any other author known to me, has ever brought forward any rigorous 
 scientific evidence in proof of the alleged fact. It is one of those crude 
 generalizations whose superficial verisimilitude leads to their continued 
 though unsupported reassertion. The fact that the notion of procreation 
 by inebriated progenitors is repugnant to our aesthetic sensibilities has, of 
 course, nothing whatever to do with the logical proof of the assertion that 
 such an act is harmful to the fruit of conception. — Tr. 
 
THE SEXUAL EPOCH OF THE MENACME 176 
 
 than her own husband, and must reduce her sexual 
 demands to that measure which will not be injurious to 
 his health. Demosthenes, writing of the sexual life of 
 the Athenians of his time, said: "In order to obtain 
 legitimate offspring and to provide a faithful guardian 
 of our household, we marry a wife; for our service 
 and for the performance of daily household duties, we 
 keep concubines; for the joys of love, we seek the he- 
 tairai." The task is extremely difficult, but a clever and 
 virtuous modern wife must endeavor to combine in her 
 single personality the sensual attractiveness of an As- 
 pasia, the chastity of a Lucrece, and the intellectual 
 greatness of a Cornelia; she must bear in mind the epi- 
 gram of Bacon, "A wife must be a young man's mis- 
 tress, a middle-aged man's companion, an old man's 
 
 nurse." 
 
 In the act of intercourse the woman must always 
 play the more passive part; she must be desired, rather 
 than desire. Woman's modesty increases man's desire. 
 By this coquetry, permissible because natural, the wom- 
 an can bind the man to herself, and can give the lie to 
 the assertion that marriage is the grave of love. Par- 
 tial concealment of her desire on the part of the woman 
 is more stimulating to the man than an open manifesta- 
 tion of the sexual impulse; and a certain amount of 
 modest reluctance is more alluring to him than a plain 
 invitation. Plenty of room must be left for the play 
 of fancy and imagination. Schiller makes Fiesco say 
 to the Countess Julia, as he covers up her bosom, "The 
 senses must be blind letter-carriers only, and must not 
 be aware of that which nature and the imagination 
 communicate each to the other. The best of news is 
 stale as soon as it has become the talk of the town." 
 
 For this reason, also, it is more suitable that inter- 
 course should take place, not by day, consequent on the 
 
17.6 THE SEXUAL LIFE OF WOMAN 
 
 brutal prompting of vision, but by night only, beneath 
 the protecting veil of darkness. A night's rest, more- 
 over, will serve to restore the exhausted nerves, and to 
 replace the expended secretions. Less advisable is co- 
 itus in the morning, on awaking from sleep, since the 
 labors of the day must immediately thereafter be un- 
 dertaken. Partially impotent men only, who wake up 
 with an erected penis, endeavor to avail themselves 
 without delay of this favorable opportunity, bearing in. 
 mmd the French proverb, "On aime quand on peut, 
 et non pas quand on veut." 
 
 The French custom, in accordance with which the 
 married pair sleep 'together in a double-bed is unde- 
 sirable on several hygienic grounds, and, in the first 
 place, for the reason that this continuous nocturnal 
 proximity is likely to give rise to the habit of indulging 
 in excessively frequent acts of intercourse. The best 
 and most affectionate of men has neither disposition 
 nor capacity to play the part of Romeo every night, 
 and thus the value and enjoyment of marital duties be- 
 comes lessened. The fulfilment of his desires should 
 not be rendered quite so easy to the husband ; he should 
 always appear the lover, one who seeks a woman's fa- 
 vors because he longs for her; he should not be the 
 master, exacting an unquestioned right. For this rea- 
 son, separate beds are advisable for the married pair, 
 and, when possible, even separate bedrooms. 
 
 Among the ancients, Lycurgus, the Spartan law- 
 giver, regarded maternity as woman's principal attri- 
 bute, and considered the sexual impulse to be the means 
 merely by which healthy citizens were provided for the 
 state. In accordance with this view, the sanctity of 
 marriage was violated, and every powerful, handsome, 
 and valiant Spartan had the right to request the privi- 
 lege of intercourse with the wife of another, in order 
 
THE SEXUAL EPOCH OF THE MENACME 177 
 
 to enrich that other's family with his seed. Elderly, 
 impotent men conducted well-formed young men into 
 the arms of their own wives. The girls, like the young 
 men, went through a course of gymnastic exercises, in 
 order to harden their bodies, and to fit them for the 
 bearing of strong and healthy children. No man 
 might marry before attaining the age of thirty, no 
 woman before attaining the age of twenty. Girls ripe 
 for marriage were assembled in a dark place, and there 
 the young men chose their brides, as chance might di- 
 rect. The young men were allowed to visit their wives 
 by night only, and secretly, in order that the vigor of 
 the sexual impulse might be increased and maintained. 
 
 Among the Spartans, it happened quite frequently, 
 that a man whose wife had remained childless, and 
 who believed himself to be at fault in the matter, would 
 beg one of his fellow-countrymen, or even a foreigner, 
 to come to his assistance. It was enacted by one of So- 
 lon's laws, to prevent a man from neglecting his marital 
 duties, that he should have intercourse with his wife not 
 less than three times monthly. According to another of 
 Solon's laws, an Athenian heiress might call upon her 
 nearest relative for the gratification of her sexual de- 
 sires. 
 
 The bluntest contrast to this Spartan simplicity is 
 furnished by the unbridled lasciviousness that prevailed 
 in Rome under the Caesars, when women's sole desire 
 was sexual enjoyment, while maternity was a state to 
 be avoided. To such an extreme was this carried, that 
 the Roman ladies of that day preferred to marry eu- 
 nuchs, and further, as Pliny reports, hermaphrodites 
 were in great request. Juvenal writes: "There are 
 women who prize the infertile embraces of base eu- 
 nuchs; thus they are able to dispense with the use of 
 abortifacients." 
 
178 THE SEXUAL LIFE OF WOMAN 
 
 The hygiene of the nuptial night deserves from the 
 physician more attention than it has hitherto generally 
 received. He should warn and enlighten the young 
 husband, in order that the brutality with which the act 
 of defloration is apt to be performed may be lessened, 
 and further in order that mistakes in this connection,' 
 resulting from ignorance and likely to have serious 
 consequences, may be avoided. It is well known that 
 lacerations of the hymen and its environment, and even 
 serious injuries of the genital organs, may result from 
 maladroit attempts at penetration. The physician will 
 admonish the husband in the words of Michelet: "Bear 
 in mind in this hour that thou art an enemy, a tender, 
 considerate, and gentle enemy!" 
 
 The young woman entering upon marriage should 
 receive instruction from her mother regarding all the 
 sexual processes of copulation, instruction at once ear- 
 nest and complete. By such enlightenment, the young 
 bride will be spared much suffering, and a sudden dis- 
 illusionment which might seriously affect the whole 
 of her future life will be avoided ; complete ignorance, 
 on the other hand, may lead, not merely to needless 
 mental and physical suffering, but to the most tragic 
 consequences on the bridal night. In one case known 
 to me, the young wife, who before marriage was utter-' 
 ly ignorant of the nature of physical love, was so com- 
 pletely overwhelmed in her ideals by the somewhat 
 energetic procedure of the bridegroom as soon as he 
 found himself alone with his wife, that she fled from 
 her home then and there in the night, and by no per- 
 suasions could be induced to return. 
 
 In that decisive moment in which the maiden loses 
 her virginity, she must find in her husband, not the 
 brutal man who forcibly takes possession of her body, 
 
THE SEXUAL EPOCH OF THE MENACME 179 
 
 but the chosen man of all, to whom her love can refuse 
 nothing. 
 
 "Delicate foresight and restraint," writes Ribbing, 
 "are needful above all at the commencement of mar- 
 ried life. The young wife, coming to the bridal bed 
 a pure virgin^ is not, like her husband, fully prepared 
 for what is to take place. In all cases she is somewhat 
 fearful of the new experience. The first act of inter- 
 course involves for her a certain amount of pain, and 
 this pain is not solely physical. * * * Moreover, 
 we must remember that the entire change in her mode 
 of life makes a deep impression upon a woman's mind; 
 time and quiet are needed before she can find herself 
 at home in the novel surroundings, before she can adapt 
 to the changed circumstances her moral and religious 
 convictions, and before she can 'think true love acted 
 simple modesty' (Romeo and Juliet, III, 2.16). Im- 
 patient husbands, through want of knowledge and lack 
 of consideration during the honeymoon, have often 
 ruined the happiness of subsequent married life." 
 
 It happens often, unfortunately, that the wife has 
 reason to complain of the reckless manner in which her 
 husband has used, or misused, his sexual powers. Fre- 
 quently enough, on the bridal'night, the man proceeds 
 with such violence in his assault on the virgin reproduc- 
 tive organs of his newly-wedded wife, that we must 
 actually speak of him as ravishing an ignorant and timid 
 girl. Later, when the stimulus of novelty has passed 
 away, the husband often performs intercourse in a man- 
 ner more calculated to awaken his wife's sexual desires, 
 but in seeking his own lordly gratification and obtain- 
 ing it he is still apt to leave out of the reckoning the 
 need for effecting coitus in such a way as will give 
 complete satisfaction also to his wife. 
 
 The wedding journey likewise deserves considera- 
 
180 THE SEXUAL LIFE OF WOMAN 
 
 tion from the hygienic standpoint. Much is to be said 
 in favor of such a journey, inasmuch as it endows the 
 necessarily somewhat brutal first act of intercourse witH 
 an aspect of romance. The removal to a foreign 
 country, to a strange environment, will spare the chaste 
 maiden much shame and vexation. On the journey, 
 moreover, the young couple are much in each other's 
 company, and the process of mutual adaptation is agree- 
 ably favored. And yet this modern custom of making 
 a wedding journey entails certain serious disadvantages. 
 
 The young- woman leaves her home and her nearest 
 relatives, and is in a moment involved in the excitement 
 of travel, an excitement liable to increase to the degree 
 of morbid anxiety. The fatigues of railway-travel, of 
 wandering about strange towns, of visits to museums 
 and picture-galleries, are apt to cause general loss of 
 nervous tone, and also local hyperjemia of the genital 
 organs. In addition, false modesty and the prescribed 
 arrangements for the journey may lead the onset of 
 menstruation to be ignored and the customary rest at 
 this period to be dispensed with. Still more, the pos- 
 sibility of the occurrence of conception and of the com- 
 mencement of pregnancy is usually left altogether out 
 of the account. Many an attack of menorrhagia, of 
 perimetritis, and of endometritis, many a miscarriage, 
 and many instances of protracted sterility, are depen- 
 dent upon the hygienic mistakes of the wedding jour- 
 ney, and less, indeed, upon the abuses arising out of 
 the intoxication of passion, than upon the fatigues of 
 excessive travel both by day and by night. The bride 
 who on her wedding-day was young, healthy, and full 
 of vitality, not infrequently returns from the wedding 
 journey a sickly and debilitated woman. 
 
 With regard to wedding journeys in relation to the 
 causation of chronic metritis, Scanzoni has expressed 
 
THE SEXUAL EPOCH OF THE MENACME 181 
 
 an authoritative opinion. "After many weeks of un- 
 satisfied sexual desire, the young married pair, now 
 freed from all restraint, give themselves up to the joys 
 of love; the intense sexual excitement causes great 
 stimulation and hyperaemia of the female sexual or- 
 gans ; in addition, the noxious influences of travel make 
 themselves felt, and also hygienic indiscretions are per- 
 petrated, dependent upon the young wife's modesty; 
 it is, therefore, by no means to be wondered at that, 
 having left home a perfectly healthy woman, she re- 
 turns from her wedding journey with the germs of an 
 illness from which she never fully recove'rs, and which 
 is the source of unending suffering, and more particu- 
 larly of a sterile marriage." 
 
 Sexual hygiene demands a certain moderation in the 
 enjoyment of physical love, and also a certain con- 
 stancy, such as may be expected in a happy marriage. 
 
 It is not possible to lay down a general rule with 
 regard to the frequency of sexual intercourse, notwith- 
 standing the earnestness with which religious zealots, 
 physicians, and moral teachers have in all ages en- 
 deavored to determine how often it was proper for a 
 man to cohabit with his wife. The rules that have been 
 prescribed by the various authorities had in view, for 
 the most part, the protection of the wife from excessive 
 demands on the part of her husband; sometimes, how- 
 ever, by the establishment of a minimum period, a cer- 
 tain amount of sexual gratification was secured to the 
 wife ; finally, also, the generation of a healthy posterity 
 had to be taken into consideration. Ribbing, how- 
 ever, justly observes: "Sexual intercourse results from 
 a natural impulse, and he whose senses are unimpaired, 
 and who has learned, at the same time, amid the tumult 
 of his sensations, to preserve proper consideration for 
 his wife — such a man runs little danger of makilrig any 
 
182 THE SEXUAL LIFE OF WOMAN 
 
 mistake. In opposition to the opinion of many, I re- 
 gard it as entirely right and reasonable that husband 
 and wife should have intercourse whenever physically 
 and mentally impelled to that act. Nor do I see any 
 reason why, during the first period in which they are 
 able to enjoy without intermission the pleasures of 
 sexual intercourse, they should, in accordance with any 
 theory whatever, impose on themselves further re- 
 straints than those demanded by care for their physical 
 and mental health. The touchstone of marital hy- 
 giene is this, that on the day following intercourse both 
 husband and -wife should feel perfectly fresh, vigor- 
 ous, and lively, alike in body and mind — even more 
 so, perhaps, than on other days. In the absence of such 
 feelings, we may feel assured of the occurrence of 
 sexual excesses." The same author quotes a saying of 
 Pomeroy's : "We may quaff the nectar as freely as we 
 will— nature herself mixes the draught and holds the 
 goblet to our lips; if, however, we drink too much, 
 she first dilutes the draught with water, later adds 
 gall, and ultimately perhaps deadly poison." 
 
 The occupation, trade, or profession, and the nutri- 
 tive condition and physical constitution of the married 
 pair, have an important bearing on the frequency with 
 which, without detriment to health, cohabitation is per- 
 missible. The rules of the Hebrew Talmud already 
 take these circumstances into account, ordering as they 
 do that young and powerful men not engaged in any 
 regular occupation shall have intercourse with their 
 wives daily; manual laborers, on the other hand, once 
 a week only; whilst brain-workers, finally, or those 
 whose work is extremely arduous, should allow an in- 
 terval of one or more months to elapse between the 
 acts of intercourse. Acton also prescribes that in the 
 case of brain-workers and of those manual workers 
 
THE SEXUAL EPOCH OF THE MENACME 188 
 
 whose labors are exhausting, intercourse must not occur 
 more frequently than once every week or ten days. 
 
 The married couple should understand how to im- 
 pose on themselves a certain restraint in the matter of 
 marital intercourse, without, however, going so far as 
 on altogether trifling grounds to refuse the husband 
 access to his wife. In this respect, also, the opinions 
 that have recently come to prevail concerning the rights 
 of women have had an influence. W. Acton relates a 
 case that came under his observation in which the wife 
 refused to allow her husband any voice in determi- 
 ning when and how often intercourse should take place ; 
 the wife, she maintained without hesitation, since she 
 had to bear the consequences of intercourse, was fully 
 justified, whenever she thought fit, in refusing her hus- 
 band's embraces. 
 
 The dangers to the sexual life of woman which are 
 involved by the modern woman's rights agitation are 
 seen already in the changes which the emancipation 
 of women in North America has produced in the func- 
 tions of woman as wife and mother. In that part of 
 the world, everything possible has been done "to trans- 
 form" (to quote the words of a brilliant journalist) 
 "the doll into an independent existence, to enable the 
 helpless woman to earn her own subsistence, and the 
 result of these endeavors has been most striking. The 
 American woman has obtained the right to enter every 
 profession and to follow every kind of occupation 
 which have hitherto been reserved for men ; she is phy- 
 sician, lawyer, merchant, professor; her boudoir has 
 become an office, often connected with the stock ex- 
 change by a private wire. Legally, also, she now pos- 
 sesses the same rights as man; in many States she has 
 both the suffrage and the right of entering the House 
 of Representatives; she has fully emancipated herself 
 
184 THE SEXUAL' LIFE OF WOMAN 
 
 from her former condition of tutelage, and in her 
 shrillest tones can cry to heaven *I am free, I am inde- 
 pendent, I am emancipated, I am myself!' And ob- 
 serve, as the result of all these attempts at the con- 
 version of woman into man, that in the matter of 
 marriage also she acts as if she were no longer woman. 
 The American woman no longer marries ; perhaps, in- 
 deed, because she no longer has the capacity. So long 
 and so eagerly has she given herself up to masculine 
 occupations, that her inward feminine nature has also 
 perhaps undergone transformation, so that she has be- 
 come affected with a kind of neutral lack of desire. 
 Unquestionably, the desire for marriage on the part of 
 this modern 'emancipated' woman has vanished in the 
 most alarming manner, there is a notable fall in the 
 birth-rate, and the indigenous (white) population actu- 
 ally threatens to disappear." 
 
 The wife acts wisely, not oil hygienic grounds alone, 
 in not always acceding at once and unconditionally to 
 her husband's demand for the repetition of intercourse. 
 Her modest reluctance enhances her desirability in the 
 eyes of her amorous husband. Thus, Shakespeare 
 makes Posthumus exclaim (Cymbeline, Act II., So. 
 5, I- 9) : 
 
 "Me of my lawful pleasure she restrained 
 And prey'd me oft forbearance; did it with 
 A pudency so rosy the sweet view on't 
 Might well have warmed old Saturn." 
 
 Especially justified is such refusal when coitus has been 
 already once or twice performed, or when the con- 
 sumption of alcoholic beverages has made the husband 
 unduly lustful. On the other hand, the refusal of in- 
 tercourse when demanded by the husband should never 
 depend upon baseless feminine caprice, or upon the 
 now so frequently asserted "rights of women." 
 
THE SEXUAL EPOCH OP THE MENACME 166 
 
 Experience has long ago established as a fact that 
 unduly frequent satisfaction of the sexual impulse en- 
 tails serious consequences to the health of the individ- 
 ual. And in the case of the wife these consequences 
 may be especially disastrous when intercourse is in- 
 dulged in recklessly during menstruation, during all 
 stages of pregnancy, and even during the puerperium. 
 "Incontinence during menstruation leads to serious cir- 
 culatory disturbances and to the consequences of these 
 disturbances; during pregnancy it is likely -to give rise 
 to miscarriage; during the puerperium, to congestions 
 and inflammations. Should conception occur as a re- 
 sult of intercourse during the lying-in period (and this 
 may happen very shortly after childbirth), abortion, 
 and even more serious consequences, are likely to ensue. 
 By intercourse during lactation, the premature recur- 
 rence of the menstrual flow is induced, and the gradual 
 reversion of the reproductive apparatus to the condi- 
 tion in which it was before pregnancy (the process of 
 involution) is hindered; moreover, the secretion of 
 milk is diminished or even entirely suppressed." In 
 these terms Hegar depicts the consequences of prema- 
 ture resumption of marital intercourse, taking perhaps 
 a somewhat extreme view of the matter. 
 
 Nevertheless, this author is undoubtedly right in de- 
 claring that one of the principal disadvantages to a 
 woman of excessively frequent sexual intercourse is 
 that pregnancy occurs too often. It is astonishing to 
 observe the number of full-term deliveries and mis- 
 carriages that a woman will experience within a com- 
 paratively short period of time, as is seen too fre- 
 quently among the laboring classes and more especially 
 among factory workers. "If we assume the ordinary 
 mortality of childbirth to be 6 per mille, a woman 
 who in the course of 15 years undergoes labor (at 
 
186 THE SEXUAL LIFE OF WOMAN 
 
 full term or prematurely) i6 times, runs a risk of death 
 to be expressed by the ratio of 6X16^96 per mille; 
 that is to say, on the average, of 1,000 women who be- 
 come pregnant as often as this, nearly i in 10 will 
 die in childbed." 
 
 Young men who have previously suffered from gon- 
 orrhoea and who wish to marry, must, unless they wish 
 to cause unspeakable misery, undergo an exact and 
 thorough examination; not only must the physician 
 inquire as to the presence of certain symptoms, such 
 as smarting during micturition, adhesion of the lips 
 of the urethral meatus, "clap-threads" in the urine, etc., 
 but during a considerable period of time repeated 
 microscopical examinations of the urine must be under- 
 taken, and the filaments, if present, must be examined 
 for gonococci. The physician will also have to deter- 
 mine whether any vestiges remain of epididymitis, and 
 whether the quality of the semen has been impaired 
 by the attack of gonorrhoea. Unfortunately, it is not 
 yet within our power absolutely to forbid marriage 
 to a man exhibiting all the symptoms of chronic gon- 
 orrhoea; but it is the duty of the physician to explain 
 to such a man the scientific views regarding this matter 
 that now prevail, in- order to furnish him with the 
 grounds for a decision. 
 
 It is not possible, when discussing the hygiene of 
 married life, to preserve silence respecting the ex- 
 tremely pressing question of the use of measures for 
 the prevention of conception, for in recent years their 
 use has become extraordinarily general, chiefly, in- 
 deed, in the upper and middle classes of society, but 
 to some extent also among the working-class popula- 
 tion. We must here express the opinion that, except 
 in certain instances in which their employment can be 
 justified on carefully weighed and well-established 
 
THE SEXUAL EPOCH OF THE MENACME 187 
 
 medical grounds, the use of any mechanical or chemical 
 means for the prevention of conception must be dis- 
 countenanced as injurious to health. The wife who 
 wishes to preserve her psychical purity and moral 
 chastity, which is not only possible in marriage, but 
 also greatly to be desired, must not concern herself 
 much with the technique of the sexual life, but must 
 give herself up to sexual enjoyment only as the result 
 of a delicate and immediate bodily and mental desire. 
 Not only for reasons of national economy regarding 
 the means of providing for the family, but also for 
 well-grounded personal reasons regarding the wife's 
 health, must the latter be spared an unduly rapid suc- 
 cession of pregnancies and confinements. And this 
 should be effected by a certain degree of continence 
 and by the observation of extensive periods of sexual 
 quiescence. 
 
 To preserve a woman's health during the acme of 
 her sexual activity, a careful general hygiene is an 
 , important requisite. The dwelling should be dry and 
 roomy; above all, the bedroom should not be too small, 
 neither damp nor dark, and it should be well ventilated. 
 The wife's occupations should be so arranged as to 
 afford a suitable alternation of activity and repose, and 
 there should be as little night work as possible. Cer- 
 tain occupations are especially potent in the causation 
 of the diseases peculiar to women, principally for the 
 reason that they do not permit of the requisite repose 
 during menstruation. Thus, washerwomen, vocalists, 
 and sewing-machine operatives, suffer with especial 
 frequency from diseases of the genital organs. 
 
 Great care in the cleansing of the genital organs is 
 indispensable in the case of women; the vulva and 
 its environment should be frequently and carefully 
 washed; and an occasional vaginal injection is ad- 
 
188 THE SEXUAL LIFE OP WOMAN 
 
 vantageous. As regards the last-named measure, how- 
 ever, we must point out that it is possible to err by 
 excess as well as by defect, and that a daily vaginal 
 douche can by no means be regarded as a necessary 
 part of the hygiene of the reproductive organs. For 
 recent researches have shown, on the one hand, that 
 the vagina constitutes a natural mechanism for the 
 destruction of pathogenic organisms, and on the other 
 hand, that complete disinfection of the vagina is ex- 
 tremely difficult to effect. Inflammations, of the vulva, 
 which are somewhat frequent in consequence of exces- 
 sive perspiration and undue discharge from the genital 
 canal, demand careful cleansing with soap and water 
 and the use of a soft brush. The addition to the water 
 of lysol (in the proportion oi }i to }i per cent.) is 
 advantageous. A general bath or a local sitz-bath, the 
 water being moderately warm (95° to 99° F. ; 35° to 37° 
 C), may be recommended on grounds of beauty as 
 well as of health, and should be taken at least once a 
 week. 
 
 The regular use of lukewarm sitz-baths is a most 
 valuable hygienic measure for the prevention of vari- 
 ous general or local disturbances consequent upon in- 
 creased flow of blood to the genital organs. These 
 local baths are best taken at a temperature of 95° F. 
 (35° C.), and should last twenty minutes; they should 
 be taken just before going to bed, and while sitting in 
 the hip bath the skin of the abdomen and of the lower 
 part of the back should be rubbed with the hand en- 
 cased in a friction-glove. The bather on leaving the bath 
 should get straight into bed, and should dry herself 
 beneath the bedclothes, rubbing the skin till it glows. 
 Such sitz-baths serve also to keep the external genitals 
 clean, and to guard against infection. For vaginal 
 douching, water sterilized by boiling should, be em- 
 ployed, and where any catarrh of the vaginal mucous 
 
THE SEXUAL EPOCH OF THE MENACME 189 
 
 membrance is present, some alum, permanganate of 
 potassium, or boric acid may be added with advantage; 
 the pressure of water, when a vaginal douche is given, 
 should never be high, the reservoir of the irrigator 
 being raised not more than twenty inches above the 
 outlet of the nozzle; as a rule, the water should be 
 lukewarm ; the patient should be in the recumbent pos- 
 ture. The reservoir of the irrigator and the intra- 
 vaginal nozzle are most suitably made of glass, to in- 
 sure cleanliness; the nozzle should not be thrust too 
 far in, two inches being quite sufficient. After the use 
 of the douche, the woman should remain ten or fifteen 
 minutes in the recumbent posture. 
 
 In addition to the hygienic employment of such full 
 baths and local baths, a number of mineral baths have 
 important therapeutic applications in cases of disease 
 of the female genital organs, the traditional value of 
 such baths having been scientifically endorsed by the 
 modern science of balneo-therapeutics. By means of 
 suitably selected mineral water baths, a powerful deri- 
 vative stimulus may be given to the skin, and the 
 affected reproductive organs may thus be beneficially 
 influenced. Further, in acute inflammatory conditions 
 or hyperaemia of the uterus or its annexa, these baths 
 have an antiphlogistic influence; on the other hand, 
 when intrapelvic exudations have formed, the baths 
 promote the absorption of these inflammatory products; 
 again, in congestive states of the female genital organs, 
 with relaxation, thickening, and hypersecretion of the 
 genital mucous membrane, the baths have an astringent 
 and tonic influence on the tissues; finally, they have a 
 favorable effect on the innervation and nutrition, not 
 only of the reproductive apparatus, but of the entire 
 organism. It is easy to understand why women during 
 the menacme are frequent visitors to spas. 
 
190 THE SEXUAL LIFE OF WOMAN 
 
 At this period of life, and especially in women 
 who lead luxurious "society" lives, the thoughts tend 
 strongly in the sexual direction; to avoid this, and to 
 prevent the ever more and more frequent breaches of 
 marital fidelity, the best means are the practice of 
 vigorous bodily exercises, and active employment, 
 either in household affairs or in intellectual occupa- 
 tions. Cold sponging of the body or cold full baths 
 will also be found an excellent measure for the preven- 
 tion of sexual excess. In such cases also the diet 
 should be limited, strong and stimulating food should 
 be avoided, but little butcher's meat should be taken, 
 whilst green vegetables and raw and cooked fruits 
 should be liberally consumed; at the same time, all 
 alcoholic beverages must be rigidly prohibited. More- 
 over, care must be taken that during the night there 
 should be no undue physical stimulation in consequence 
 of excessively warm and soft bedding; hair mattresses 
 are to be preferred to feather beds, with light down 
 quilts for a covering. Finally, no stimulation of an 
 erotic character should be offered to the imagination, 
 and for this reason equivocal literature and lascivious 
 dramatic representations must be avoided. By a suffi- 
 ciency of occupation, regular, interesting, and demand- 
 ing a considerable expenditure of physical energy, a 
 woman may be enabled to a great extent to escape 
 the inconvenience and distress attendant on entire or 
 partial lack of gratification of the sexual impulse. 
 
 It cannot be disputed that a certain and moderate 
 amount of sexual gratification is requisite for the per- 
 fect maintenance of physical health in woman, and that 
 the absence of this gratification, or the gratification of 
 the impulse in an abnormal or incomplete manner, en- 
 tails disturbance of alike the mental and the physical 
 equilibrium; but, on the other hand, the deleterious 
 
THE SEXUAL EPOCH OF THE MENACME 191 
 
 consequences of sexual abstinence have been greatly 
 exaggerated by many writers— both by physicians and 
 social economists. Owing to the fact that to the culti- 
 vated woman sexual gratification is possible only in 
 the married state, whilst social conditions render mar- 
 riage impossible to many women greatly in need of such 
 gratification ; in consequence, also, of the modern and 
 ever more widely diffused practice by husbands of coi- 
 tus interruptus — altogether regardless of the woman's 
 need for complete sexual gratification — there arise in 
 women numerous local disorders and nervous disturb- 
 ances, hysteria and even insanity being results by no 
 means infrequent. The significance of ungratified 
 sexual impulse in the pathogenesis of nervous dis- 
 orders has been established by von Krafft-Ebing, who 
 points out that in unmarried women insanity most 
 frequently occurs between the ages of twenty-five and 
 thirty-five years, during the decade, that is to say, in 
 which youthful bloom and the hopes of marriage 
 simultaneously disappear; whereas in the male sex the 
 greatest incidence of insanity is between the ages of 
 thirty-five and fifty years, the period of life in which 
 the struggle for existence is fiercest. 
 
 Hegar, on the other hand, is a firm opponent of the 
 view that the favorable influence of marriage is over- 
 rated. According to this author, the favorable effect 
 of marriage in respect of mental disorders is to be 
 found, not in the gratification of the sexual impulse, 
 but in the ethical factors of marriage. Statistics show 
 that even in the favorable circumstances of marriage, 
 sexual gratification has in women an unfavorable in- 
 fluence, inasmuch as the proportion of sufferers from 
 mental disorders is higher among married women than 
 it is among married men. A study of the mental dis- 
 orders which in women are especially associated with 
 
192 THE SEXUAL LIFE OF WOMAN 
 
 the process of reproduction (puerperal mania) con- 
 firms this impression. Hegar insists that he has never 
 seen nymphomania arise in women in consequence of 
 forcible repression of the sexual impulse, but that he 
 has not infrequently seen this disorder result from un- 
 natural excesses or from long-continued sexual irrita- 
 tion, especially in hereditarily predisposed persons. 
 
 Such unnatural stimulation of the female is not in- 
 frequently practised by the male — by the lover and 
 even by the husband — it may be because he himself 
 derives pleasure from such perverted practices, and 
 wishes to obtain sexual gratification without the risk 
 of impregnation, or because he is himself incompetent 
 for normal complete intercourse. Hegar is further of 
 opinion that in the causation of hysteria and also in 
 that of chlorosis the repression of the sexual impulse 
 plays a quite subordinate role. And he regards as pure 
 fable the belief that continence in women is liable to 
 lead to the formation of mammary, uterine, or ovarian 
 tumors. He would more readily incline to the con- 
 trary opinion; the reproductive process being in this 
 respect distinctly disadvantageous to. the female sex. 
 The unfavorable influence of the reproductive process 
 is shown most clearly in the case of carcinoma of the 
 uterus ; the majority of the patients suffering from this 
 disease are either married or widowed, and many of 
 them have given birth to a large number of children. 
 "Gratification of the sexual impulse, and more particu- 
 larly the reproductive process, give rise in women to 
 the formation and growth of tumors, cause numerous 
 mechanical disturbances, and open the way to infection 
 with various pathogenic organisms." 
 
 Hegar considers that there is hygienic justification 
 for the limitation of the number of children to which 
 a woman gives birth. The most suitable age for 
 
THE SEXUAL EPOCH OF THE MENACME 193 
 
 motherhood lies in his opinion between the ages of 
 twenty and forty years. Childbirth in women younger 
 or older than this entails too much danger both to 
 mother and child. At least two and a half years ought 
 to elapse between two successive births; and these 
 figures give us eight as the maximum family. If we 
 assume that the duration of pregnancy is nine months, 
 and that of lactation nine to twelve months (or in cases 
 in which the mother does not nurse her own infant, 
 that a like period must be devoted to the careful super- 
 vision of the wet-nurse or of the methods of artificial 
 feeding) , we cannot consider it unreasonable to devote 
 a further period of from six to nine months to the 
 complete re-establishment of the woman's health. 
 "Moreover, woman does not exist solely for the purpose 
 of subserving during two decades of her life the pro- 
 cesses of reproduction. And to permit the maximum 
 number of children to be as great as eight, we must 
 presuppose that the woman is in perfect health, and 
 that she lives in a perfectly healthy environment. Any 
 illness or infirmity which renders the duties of house- 
 keeping and the rearing of the existing family unduly 
 difficult, indicates the need for a further limitation of 
 childbearing. And if the reproductive function is to 
 be rationally controlled, we must above all attend to 
 the age and the health of the parents. Occupation, 
 habitation, and general environment have also to be 
 considered. The correct ideal is indeed not difficult 
 to discover." 
 
 Hegar concludes that strict moderation and even 
 absolute continence in sexual matters are often, and 
 for long periods of time, a pressing duty. '"The numer- 
 ous and various disasters which are brought upon the 
 world by unbridled and unregulated sexual passion 
 can be prevented only by enlightenment, moderation. 
 
194 THE SEXUAL LIFE OF WOMAN 
 
 and continence. If marriage were postponed until the 
 attainment of complete physical maturity, in women 
 till the age of 20, in men till the agfe of 25, while 
 at the same time procreation were no longer undertaken 
 by women above the age of 40 or by men above the 
 age of 45 to 50 years; if, again, between successive 
 pregnancies a sufficient pause for the woman's recu- 
 peration were insisted upon, and intercurrent illnesses 
 and states of debility were taken into account; and if, 
 finally, sickly individuals, those hereditarily predis- 
 posed to disease, and those in any way below par either 
 mentally or physically, were more than heretofore pre- 
 vented from marrying, then the increase of population, 
 which in Germany is unquestionably too rapid, would 
 to some extent be checked. Thoroughgoing regulation 
 of the reproductive process will not, however, be thus 
 attained without the adoption of a method of selection 
 too rigorous for present-day notions; and for a further 
 advance we must in the meantime depend upon modera- 
 tion and continence." As regards the modern demand 
 of the "right to love," the same experienced gynecolo- 
 gist writes: "Whoever preaches to mankind the doc- 
 trine that 'a man sins against his own personality if he 
 neglects to exercise every limb he possesses, and if he 
 denies himself the gratification of every natural im- 
 pulse,' or the doctrine that 'it is the duty of every human 
 being to gratify all his natural impulses, since these 
 are most intimately inter-connected with his person- 
 ality — are indeed his personality itself ; such a preacher 
 does harm to his kind. Such rights and such duties 
 are chimerical for this reason, if for no other, because 
 two persons are necessary in the case of sexual gratifica- 
 tion, and sometimes — though not as often as might be 
 wished — Hansel fails to find his Gretel, without any 
 consequent loss to society at large." 
 
THE SEXUAL EPOCH OF THE MENACME 195 
 
 An especially important chapter in the history of 
 woman at this period of life relates to the dietetics of 
 pregnancy and parturition, and to the regulations to 
 be observed for the maintenance of health at this time 
 and in connection with the processes of pregnancy, 
 parturition, puerperal invplution of the uterus, and 
 lactation. This subject cannot now, however, be con- 
 sidered at length, and for our present purposes it is 
 sufficient to point out how important it is alike for 
 mother and child, alike for family and society, that 
 the ever more and more widely and generally diffused 
 practice of the artificial feeding of infants should be 
 abandoned, and that there should be a return to the 
 natural method according to which each mother nurses 
 her own infant. The prevailing custom costs every 
 year thousands of mothers their health, and thousands 
 of children their lives. 
 
 Copulation and Conception 
 
 Copulation 
 
 The reproduction of the species is effected by means 
 of an act of copulation on the part of a male and a 
 female individual, both of whom must have attained 
 complete sexual development. In all the sequence of 
 reproductive processes it is copulation alone that is a 
 voluntary act, all the other processes being indepen- 
 dent of the will and even of consciousness. 
 
 A characteristic difference between man and the 
 lower animals lies in the fact that in the human species 
 sexual pleasure and the act of copulation may occur 
 at any season of the year; and a further characteristic 
 difiference may perhaps be found in the fact that in the 
 great majority of individuals of the human species the 
 psychical process of "love" plays a determinative part. 
 
196 THE SEXUAL LIFE OF WOMAN 
 
 Voltaire pointed out that to man alone among animals 
 are known the embrace and the joy of the kiss. 
 
 In this act of conjugation between two individuals 
 of the same species, differentiated each from the other 
 by the characteristics of sex, the active, provocative 
 role is allotted to the male, the passive, receptive role, 
 to the female. The modest and coy reluctance char- 
 acteristic alike of the maiden and of the wife, promote 
 an increase of sexual excitement in the opposite sex, 
 and this not only in a man of purely sensual character, 
 whose vanity is stimulated by his being the chosen one 
 among many — a circumstance which, in view of the 
 great dependence of the sexual act upon psychical 
 processes and imaginative influences, is by no means 
 devoid of importance. The woman's coy reluctance 
 must be overcome by means of a tender strategy before 
 she is willing to grant the final possession of her body; 
 and the act of copulation forms at the same time the 
 conclusion of the physical and mental yearnings of the 
 lover, and the commencement of the new-coming 
 being. 
 
 Conception 
 
 The union between ovum and spermatozoon, where- 
 by fertilization is effected, appears to occur in the 
 human species, as a rule, in the outer third of the Fallo- 
 pian tube, the ampulla of this structure serving to store 
 the semen for a considerable period; in the lower ani- 
 mals, the usual occurrence of fertilization in this region 
 has been established by direct observation. The open 
 mouth of the tube receives the mature ovum, guided 
 thither from the ovary by appropriate movements of 
 the ovarian fimbriae; these movements have been seen 
 in active occurrence in the guinea-pig by Hensen. 
 Onee within the tube, the onward movement of the 
 
THE SEXUAL EPOCH OF THE MENACME 197 
 
 ovum is effected by the cilia of the epithelium lining 
 of the canal. 
 
 His has formulated the theory that in the human 
 species fertilization is possible only in the uppermost 
 segment of the tube; an assumption that is probable 
 enough, but cannot be regarded as definitely established. 
 An analogy certainly exists among the lower divisions 
 of the animal kingdom, for Coste, His, and Ohlschlager 
 have proved that an ovum which passes through the 
 Fallopian tube without being fertilized, undergoes no- 
 table alterations. Further, Coste has shown, in the case 
 of the ovum of the domestic fowl, that this is no longer 
 capable of being fertilized after it has passed through 
 the upper segment of the oviduct. Other authorities, 
 however, namely Lowenthal, Mayrhofer, and Wyder, 
 oppose the extension of this rule to the human species. 
 Lowenthal assumes that in the human female, fertiliza- 
 tion ordinarily occurs in the cavity of the uterus, in the 
 wall of which the unfertilized ovum has already em- 
 bedded itself; and he supports his contention by the 
 statement that spermatozoa are not to be found in 
 the Fallopian tubes or on the surface of the ovaries. 
 Mayrhofer and Wyder point out that the movement of 
 the cilia of the ciliated epithelium is in the interior of 
 the uterus in an upward direction, but in the Fallopian 
 tubes is downward in the direction of the uterus. 
 
 The contention of Lowenthal was disproved by Birch 
 and Hirschfeld, who, in a prostitute dying during the 
 act of intercourse, found, fifteen hours after death, liv- 
 ing spermatozoa in the Fallopian tubes. On the other 
 hand, more recent investigations, those, for instance, 
 of Hofmeier, Mandl, and Bonn, have confirmed the 
 data given above with regard to the direction of the 
 ciliary movement in the interior of the genital pas- 
 sages. Moreover, O. Becker has shown that the cili- 
 
198 THE SEXUAL LIFE OF WOMAN 
 
 ated epithelium of the tubes extends over the fimbriae 
 and even on to the adjoining pavement epithelium of 
 the peritoneum ; and he believes that the ciliary move- 
 ment of this region keeps up a constant current, the 
 purpose of which is to sweep the ovum into the ostium 
 of the tube, and thence down toward the uterus. Lode 
 has adduced positive experimental evidence of the oc- 
 currence of such a movement of translation. 
 
 The general result of anatomical investigation is, that 
 the conjugation of the ovum with the spermatozoon 
 takes place in the ampulla of the Fallopian tube; but 
 it is established that fertilization may also take place 
 lower down in the tubes, or in the uterine cavity, or 
 even on the surface of the ovary, i.e., in the abdominal 
 cavity. 
 
 The fertilization of the mature ovum — ^maturation 
 having occurred within the ovarian follicle before its 
 rupture — has been shown by numerous researches on 
 the ova of other animals to consist in the fusion of the 
 male and the female nuclear substance; and it appears 
 that of the enormous number of spermatozoa, estimated 
 by Lode at 226 million at a single ejaculation, that enter 
 the female genital passage, but a single one penetrates 
 the ovum. Toward the head of this spermatozoon 
 there extends from the surface of the ovum a process, 
 flat at first, but becoming more and more prominent, 
 until it surrounds the head, and fuses with it. The 
 motile tail of the spermatozoon disappears, whilst the 
 head, which has now passed through the vitelline mem- 
 brane and entered the ovum, assumes the appearance 
 of a nucleus, and is called the male pro-nucleus. The 
 original nucleus of the -ovum has previously prepared 
 itself for fertilization by the extrusion through the 
 vitelline membrane of portions of its substance (known 
 as polar globules), and now constitutes the female pro- 
 
THE SEXUAL EPOCH OF THE MENACME 199 
 
 nucleus. Toward this latter, situated somewhere near 
 the centre of the cell, the male pro-nucleus continues 
 to move, the vitelline granules meanwhile being dis- 
 posed round about it in radiating lines, forming a star- 
 shaped figure. Having come into contact, the two 
 pro-nuclei fuse completely to form a new nucleus, the 
 nucleus of the now fertilized egg-cell. The result of 
 fertilization is the formation of the first segmentation- 
 sphere, from which, by further subdivision, the new in- 
 dividual is formed. Thus is effected that which Hip- 
 pocrates describes in the words: "The seed possessed 
 both by man and by woman, flow together from- all 
 parts of the body; the fruit is formed by the mingling 
 of the two seeds." 
 
 The most favorable period for the occurrence of 
 fertilization appears to be when intercourse takes place 
 from eight to ten days after the termination of the 
 menstrual flow. In 248 instances in which the date of 
 the fruitful coitus was exactly known, it was ascer- 
 tained by Hasler that in SaJ^ per cent, of all cases, 
 conception was effected in the fourteen days succeed- 
 ing the menstrual period. In general it may be stated 
 that the theory of the periodicity of ovulation and of 
 the causal relation of this process to menstruation, has 
 not been shaken by the result of researches recently 
 undertaken by opponents of that theory; hence it ap- 
 pears that the fertilized ovum is the ovum of the last 
 completed menstruation. 
 
 [Already in the writings of the old Indian physician 
 Susruta, we find expression of the view that the period 
 that immediately succeeds the cessation of the menstrual 
 flow is one most favorable to conception. "The time 
 of generation," he says, "is the twelfth night after the 
 commencement of menstruation." In the Jewish Tal- 
 mud, the day before the onset of menstruation, and the 
 
200 THE SEXUAL LIFE OF WOMAN 
 
 days immediately succeeding the cessation of the flow, 
 are indicated as those most favorable to the occurrence 
 of conception; moreover, in the Talmud, notwithstand- 
 ing the fact that intercourse during menstruation is 
 prohibited on pain of death, and that coitus is not re- 
 garded as permissible until the lapse of twelve clear 
 days after the cessation of the flow, nevertheless the 
 assertion is made that intercourse during menstrua- 
 tion may lead to conception. 
 
 Soranus writes to a similar effect: "Just as the soil 
 is suitable only at certain seasons for the reception of 
 the seed, so also in the human race intercourse does 
 not always take place at a time suited for the reception 
 of the semen. To be effective, coitus must occur at 
 the proper time. . . . The act of intercourse that is i 
 to lead to conception may best occur either just before ( 
 or just after the menstrual flow, when, moreover, there 
 is strong desire for the sexual embrace, and neither 
 when the body is fasting, nor when it is full of drink 
 and undigested food. The time before menstruation 
 is, however, unsuitable, for then the womb is heavy 
 from the flow of blood, and two conflicting tendencies 
 will come into operation, one for the absorption of 
 material and the other for its outflow. During men- 
 struation, again, conception is unlikely to occur, for 
 then the semen is wetted and washed away by the flow- 
 ing blood. The sole proper time is that immediately 
 after the flow, when the womb has freed itself from 
 its humors, and warmth and moisture stand in har- 
 monious relationship." 
 
 Among many of the castes of Hindustan, it is a 
 religious ordinance that on the fourth day of menstrua- j 
 tion a man shall have intercourse with his wife; "since \ 
 this day is that on which conception is most likely to 
 occur." Indian physicians advise, in order to bring 
 
THE SEXUAL EPOCH OF THE MENACME 201 
 
 about conception, "that coitus be effected always as soon 
 as the menstrual flow has ceased, at the end of the day, 
 and when the lotus has closed." In Japan, medical 
 opinion is to the effect that a woman is capable of 
 conceiving during the first ten days after menstruation, 
 but not later (Ploss and Bartels). 
 
 The view that the first days of the inter-menstrual 
 interval are those most favorable to the occurrence of 
 conception, is further confirmed by the statistical data 
 collected by Lowenfeld, Ahlfeld, Hecker, and Veit; 
 and it appears that as the date of the next menstrua- 
 tion is approached, there is a continual decline in the 
 frequency of conception; just before the flow, con- 
 ception hardly ever occurs. Hensen, from the records 
 of 248 conceptions in which the date of the fruitful 
 intercourse was exactly known, draws the following 
 conclusions : 
 
 1. The greatest number of conceptions follow coitus 1 
 effected during the first days after the cessation of the I 
 menstrual flow. 
 
 2. When coitus is effected during menstruation, the 
 probability of conception increases day by day as the 
 end of the flow approaches. 
 
 3. The number of conceptions following coitus 
 effected shortly before menstruation is minimal. 
 
 4. However, there is no single day either of the men- 
 strual flow or of the inter-menstrual interval, on which 
 the possibility of the occurrence of conception can be 
 excluded. 
 
 Feokstitow has drawn up from statistical data an 
 ideal "conception-curve," which teaches that concep- 
 tion most readily ensues upon coitus effected soon after 
 the end of the menstrual flow, in the first week, that 
 is to say, of the inter-menstrual interval; moreover, the 
 curve shows that the highest percentage of conceptions 
 
202 THE SEXUAL LIFE OF WOMAN . 
 
 occurs on the first day after the cessation of the 
 \ flow, and that after this day the percentage of concep- 
 tions declines. The percentage frequency of concep- 
 tions from coitus effected on the last day of menstrua- 
 tion, and on the first, ninth, eleventh, and twenty- third 
 days, respectively, of the inter-menstrual interval, is ex- 
 pressed by the ratio of 48: 62:13 : 9:1 ; and between the 
 points given, the course of the curve is almost rectili- 
 near. The probability of the occurrence of concep- 
 tion on the twenty-third day of the interval (on which 
 day the curve reaches its lowest point), is one-sixty- 
 second of the maximum probability. 
 
 Normal semen is a whitish, semi-transparent fluid, 
 of the consistency of thin cream. It contains aggrega- 
 tions of a nearly spherical shape, consisting of a vitre- 
 ous, transparent, colorless or light yellow, gelatinous, 
 elastic substance. Under the microscope this substance 
 has a hyaline appearance, and exhibits in its interior 
 innumerable clear spaces of varying size, which are 
 apparently filled with a clear fluid. Not infrequently, 
 these spaces are extremely narrow and therewith greatly 
 elongated and disposed in parallels, so that the whole 
 substance thus obtains a striated appearance. When 
 treated with water, this material becomes whitish and 
 non-transparent, and assumes under the microscope a 
 finely granular aspect. When allowed to stand with- 
 out agitation for twenty-four hours, this substance dis- 
 solves and becomes so intimately mingled with the 
 seminal fluid that it can no longer be clearly differ- 
 entiated therefrom. In all probability it is merely a 
 secretory product of the seminal vesicles. The semen 
 contains spermatozoa in countless numbers. 
 
THE SEXUAL EPOCH OP THE MENACME 203 
 
 Cardiac Troubles Due to Sexual Intercourse 
 
 Among the troubles from which women at times suf- 
 fer as a result of sexual intercourse, certain cardiac 
 disorders are especially worthy of attention. 
 
 Every act of sexual intercourse in a young and sensi- 
 tive .woman exercises an exciting influence on the ner- 
 vous mechanism controlling the cardiac movements, 
 and this influence is more clearly manifested in a degree 
 directly proportional to the intensity of the sexual 
 orgasm. The heart's action is markedly increased in 
 frequency, the cardiac impulse is more powerful, the 
 large arteries of the neck are seen to pulsate far more 
 vigorously, the conjunctiva is markedly injected, the 
 respiration is increased in frequency, the respiratory 
 movements £ure more superficial and have a panting 
 character. 
 
 But when, in a woman who is sexually irritable in 
 an excessive degree, the peripheral stimulation occur- 
 ring in the act of sexual intercourse is unusually power- 
 ful, there may result a notable increase or modifica- 
 tion of the reflex manifestations which normally occur 
 during sexual intercourse in the province of cardiac 
 activity; similar results ensue when there is a summa- 
 tion of stimuli owing to excessive sexual intercourse, 
 or contrariwise when the act of intercourse is broken 
 off just before its physiological climax and the natural 
 termination of the orgasm fails to occur. 
 
 The former cause is not infrequent in young wives 
 during the period of the honeymoon. The latter cause 
 is in operation when there are diseases of the female 
 reproductive organs preventing the physiological com- 
 pletion of intercourse; but especially in consequence 
 of the modern practice of coitus interruptus, in which 
 the man breaks off the act of intercourse the moment 
 
204 THE SEXUAL LIFE OF WOMAN 
 
 he feels that ejaculation is imminent, without troubling 
 himself regarding the natural course of sexual excite- 
 ment in the woman. Yet another cause of excessive 
 cardiac reflex manifestations in women is incomplete 
 potency of the male, which may either cause a pre- 
 mature ejaculation of semen, or may lead to incom- 
 plete penetration of the penis. 
 
 In all such cases, as a result of sexual intercourse, 
 there may arise cardiac disorders of various kinds; 
 among these, tachycardial paroxysms are the most fre- 
 quent, occurring either inter actum, or at a longer or 
 shorter interval after intercourse. 
 
 In several cases of vaginismus occurring in young- 
 married women which have come under my notice, 
 it was observed that the attempts at intercourse gave 
 rise to violent involuntary spasmodic contractions of 
 the constrictor cunni and the other muscles of the uro- 
 genital and anal regions, and in addition it was found 
 that these attempts were followed by tachycardial par- 
 oxysms with dyspnoeic manifestations, lasting for a con- 
 siderable period, it might be as long as one or two 
 hours. 
 
 In women who had practised coitus reservatus for a 
 prolonged period, in fact for several years, in such a 
 manner that, notwithstanding the occurrence of intense 
 voluptuous excitement, complete sexual gratification 
 rarely, if ever, occurred — in such women, in whom 
 these marital malpractices seemed to have pi-ofoundly 
 influenced their psychical life, I have frequently wit- 
 nessed a form of reflex cardiac disorder which I must 
 regard as a variety of the multiform neurasthenia cordis 
 vasomotoria. In such women, still at the climax of 
 their physical powers and of their sexual needs, attacks 
 of palpitation suddenly occur at irregular intervals, 
 several times daily or less frequently. Associated with 
 
THE SEXUAL EPOCH OF THE MENACME 205 
 
 this increased frequency of the cardiac activity are an 
 extremely distressing feeling of anxiety, a sensation of 
 faintness, headache, vertigo, a weakness of the muscular 
 system, and at times actual attacks of syncope. Phy- 
 sically, the women are extremely depressed, irritable, 
 inclined to weep, unhappy, and weary of life. At the 
 same time, digestion is impaired, the appetite is small, 
 and there is constipation. The pulse is in most cases 
 feeble, small, of low tension, easily compressible, in- 
 creased in frequency, often intermittent, sometimes 
 more distinctly arhythmical. The heart is found to 
 be sound on physical examination, nor can any abnor- 
 mality be detected in the great vessels. The lower ex- 
 tremities are free from oedema; the urine does not 
 contain albumin. 
 
 Women thus affected are sometimes believed to be 
 suflfering from cardiac disorder, in other cases they are 
 subjected to various modes of gynecological treatment; 
 until at length the physician, by appropriate questions, 
 becomes enlightened regarding the true cause of the 
 cardiac disorder, namely, coitus interruptus. If it is 
 possible to prohibit effectually this unwholesome prac- 
 tice, the cardiac symptoms soon cease to recur. 
 
 Finally, in women at the climacteric age, cardiac 
 troubles sometimes ensue, which are dependent on in- 
 terference with sexual intercourse in consequence of 
 anatomical changes in the vagina ; changes of this char- 
 acter frequently occur at the time of the menopause; 
 owing to hyperaemic or inflammatory processes, a 
 partial or general stricture of the vaginal passage re- 
 sults; in many cases this passage becomes narrower, 
 shorter, and almost conical in shape, whilst the vaginal 
 inlet is greatly diminished in size. Such a vaginal 
 stricture, which Hegar has also seen in younger women 
 after an artificial climacteric (oophorectomy), inter- 
 
206 THE SEXUAL LIFE OF WOMAN 
 
 feres with sexual intercourse; and the incomplete sexual 
 gratification gives rise to a series of nervous manifesta- 
 tions, and, among others, to the above described reflex 
 cardiac neurosis. 
 
 Whether, and in vs^hich cases, the cardiac disorders 
 evoked as a result of the local stimulatory influences 
 of sexual intercourse, are dependent on a reflex stimula- 
 tion of the sympathetic nerve on the one hand, or upon 
 a transient paresis of the inhibitory centre of the heart 
 and of the vasomotor centre on the other, cannot here 
 be fully discussed ; just as little can we consider in what 
 manner the psyche is sympathetically affected by the 
 irritative processes in the genital organs, and its func- 
 tional activity thus impaired. 
 
 Here I can do no more than briefly state that experi- 
 ence has taught me that sexual intercourse is competent 
 to originate cardiac troubles in women. 
 
 1. In extremely sensitive, sexually very irritable 
 women, tachycardial paroxysms may result from 
 sexual excesses. 
 
 2. Tachycardial paroxysms with dyspnoea occur in 
 young women affected with vaginismus ; also in women 
 at the climacteric with constrictive changes in the 
 vagina. 
 
 3. Cardiac troubles, characterized mainly by symp- 
 toms indicating diminished vascular tone, occur in 
 women who have long practised coitus interruptus with 
 incomplete gratification of their voluptuous desires. 
 
 Dyspareunia 
 
 In normal conditions the act of sexual Intercourse 
 is accompanied in women, as in men, by a voluptuous 
 sensation, and this sensation must be regarded as a 
 necessary link in the chain of those processes by which 
 
THE SEXUAL EPOCH OP THE MENACME 207 
 
 gratification of the sexual impulse — the most powerful 
 of all our natural impulses — is obtained. The absence 
 of this voluptuous sensation in a woman, the state in 
 which she experiences during coitus no voluptuous sen- 
 sations, but feels either apathy, or positive distaste, is 
 termed dyspareunia : in former times it was also known 
 as anaphrodisia. This abnormal state of sexual sensi- 
 bility, which up to the present is hardly alluded to 
 in gynecological text-books, has received remarkably 
 little attention from the medical standpoint, and its 
 importance has been underestimated. Most unfor- 
 tunately so, for dyspareunia is an important symptom, 
 exercising a powerful influence on the general health 
 of the woman who suffers from it, upon her social 
 status in marriage, and, as is easy to understand, upon 
 her procreative capacity. 
 
 Dyspareunia must be clearly distinguished from two 
 somewhat similar conditions, with which at first sight 
 it is liable to be confused, namely, from anaesthesia 
 sexualis, and from vaginismus. By sexual anesthesia 
 we understand, as previously explained, the absence of 
 the sexual impulse, a symptom which, when the repro- 
 ductive organs are normal in structure and function, 
 is either of Central nervous origin, a result of disease 
 of the brain or spinal cord, or else is due to general 
 nutritive disorders such as diabetes, morphinism, or 
 alcoholism. A woman affected with dyspareunia does, 
 however, experience the sexual impulse, it may be very 
 actively, but sexual intercourse brings about no gratifi- 
 cation of her desires. In vaginismus, on the other 
 hand, the introduction of a foreign body, that is to say 
 of the membrum virile, into the vagina, gives rise to 
 painful reflex cramps of the sphincter vaginae, or of the 
 muscles of the pelvic floor, whereby the completion 
 oi coitus is rendered impossible: whereas in dyspa- 
 
208 THE SEXUAL LIFE OF WOMAN 
 
 reunia coitus can be effected, but gives rise to no 
 voluptuous sensations. 
 
 The pleasure which normally occurs in woman dur- 
 ing sexual intercourse is brought about in this way, 
 that contact with and friction by the penis stimulates 
 the sensory nerves of the clitoris, the vulva, the vesti- 
 bule, and the vagina; this stimulus is propagated to 
 the cerebral cortex, where it gives rise to voluptuous 
 sensations, and then, by reflex stimulation of the genito- 
 spinal centre, gives rise to a series of reflex discharges. 
 The pudic nerve, a branch of the sacral plexus, sup- 
 plies the female external genital organs. Some of its 
 branches pass in the clitoris to a peculiar form of ner- 
 vous end-organ discovered by W. Krause, Krause's 
 genital corpuscles: the structure of these corpuscles 
 appears to fit them exceptionally well for the transmis- 
 sion of stimulatory waves to the nerve centres. "When 
 this stimulus," says Hensen, in his work on the phy- 
 siology of reproduction, "in addition to other effects, 
 also gives rise to a voluptuous sensation, the cause must 
 be sought in central nervous connections and apparatus. 
 Similar relations are to be found in connection with 
 the mechanism of nutrition, for example, in the associa- 
 tion of hunger, appetite, agreeable sensations of taste, 
 the act of mastication, and the secretion of saliva." 
 
 By means of this stimulus, several reflex processes are 
 originated in the reproductive canal, the most notable 
 of which are the erection of the clitoris, and the ejacu- 
 lation of the secretions of various gland?. The cav- 
 ernous tissue of the clitoris is connected with that of 
 the bulbus vestibuli, and the dorsal nerve of the clitoris 
 is one of the principal nerves of voluptuous sensation. 
 The venous plexus constituting the bulb of the vesti- 
 bule lies at either side along the margin of the vesti- 
 bule at the boundary between the labium majus and the 
 
THE SEXUAL EPOCH OF THE MENACME 209 
 
 labium minus, and laterally it is covered by the con- 
 strictor cunni^ muscle. During coitus the blood is 
 driven out of this bulb into the glans clitoridis, and 
 thus the sensibility and the erection of the glans are 
 increased. The constrictor cunni and ischiocavernosus 
 muscles draw the clitoris, which is bent at a right angle 
 downward, into contact with the penis. By means of 
 the pressure of the constrictor cunni, the mucous secre- 
 tion of Bartholin's glands, which open into the vulva 
 at the back of the labia majora, is expressed. 
 
 'As additional reflex actions, dependent upon the 
 activity of the reflex centre in the lumbar enlarge- 
 ment of the spinal cord, there ensue contractions of 
 the vagina, peristaltic movement of the tubes, some 
 descent of the uterus, relaxation of the os uteri and 
 rounding of this orifice, and induration of the portio 
 vaginalis, whereby the tubal and uterine mucus and 
 the secretion of the cervical glands are expressed. This 
 process of ejaculation constitutes the culminating point 
 of the voluptuous sensation occurring in the sexual act; 
 this act thus exhibits two phases — the sensation of fric- 
 tion, and the- sensation of ejaculation. 
 
 With regard to voluptuous sensations, and processes 
 analogous to pollutions, occurring in women, we ap- 
 pend an extract from von Krafft-Ebing. 
 
 "The occurrence of voluptuous excitement during 
 coitus is dependent in the woman, just as in the man, 
 upon: 
 
 "i. The peripheral influence of the intensity and 
 duration of the sensory stimulation (anaesthesia of the 
 genital passage may be the cause of the absence of 
 voluptuous sensation). 2. The condition of excita- 
 
 ^ Constrictor Cunni Muscle. — In women the hulbocavernosus muscles, 
 right and left, form, as it were, a sphincter to the vaginal outlet. Hence 
 the alternative names of sphincter vagina and constrictor cunni muscle. 
 The latter name is in common use in Germany, but, though appropriate, is 
 rarely employed in England. — Transl. 
 
210 THE SEXUAL LIFE OF WOMAN 
 
 bility of the reflex (ejaculation) centre in the lumbar 
 spinal cord. The activity of this centre varies within 
 wide limits, not merely in different individuals, but 
 in the same individual at different times. There are, 
 indeed, women in whom it seems as if this centre were 
 always in vigorous activity. In normal women, the 
 irritability of the centre appears to be most marked 
 at the menstrual epoch, and to decline rapidly soon 
 after menstruation. In pathological conditions', the 
 activity of the centre may be temporarily in abeyance 
 (organic inhibitory processes, such as are seen in cer- 
 tain cases of hysteria with temporary frigidity) ; or 
 again the centre may be abnormally active owing to 
 irritable weakness (neurasthenia sexualis), in conse- 
 quence .of which ejaculation may, just as in the male in 
 similar circumstances, occur too easily. 3. The occur- 
 rence of the voluptuous sensation in women is unfavor- 
 ably influenced by psychical inhibitory perceptions 
 (analogous to the inhibitory influence of psychical 
 processes in the male, such as, for example, fear of 
 incapacity to perform sexual intercourse) . As ex- 
 amples of such inhibitory perceptions in women may 
 be mentioned, dislike of the man, physical loathing to 
 sexual intercourse, etc." 
 
 Gutceit records interesting experiences, which are 
 readily intelligible in view of what we have already 
 quoted. He finds that of ten women after defloration, 
 two only immediately experience full sexual pleasure. 
 Of the eight others, four only have an agreeable sen- 
 sation produced by the friction during coitus: but the 
 sensation of ejaculation does not make its appearance 
 until the lapse of at least six months, or it may be even 
 several years, after marriage. In the remaining four 
 women, pleasure during sexual intercourse may never 
 become properly established. The women of the first 
 
THE SEXUAL EPOCH OF THE MENACME 211 
 
 class are described by the author as being of a very 
 ardent temperament, and passionately attached to their 
 husbands. In such women, the sensation of ejaculation 
 occurs during intercourse with any man toward whom 
 they are sympathetic. Women of the second class are 
 of a less ardent temperament, and are often compara- 
 tively indifferent toward the man with whom they 
 cohabit. Women of the third class have little or no 
 amatory feeling, and they either hate the man with 
 whom they are cohabiting, or at least feel physical 
 repulsion to the idea of intercourse with him. Gutceit 
 considers that meretrices usually belong to the third 
 category. In the practice of their trade, they make a 
 counterfeit of voluptuous enjoyment, and only experi- 
 ence real sexual gratification in intercourse with the 
 man of their choice. 
 
 It is of great practical interest, alike from the gyne- 
 cological and from the neuropathological standpoint, 
 to determine the consequences in women of ungratify- 
 ing sexual intercourse. In the present state of our 
 experience it must be assumed that the effect of ab- 
 normal sexual intercourse, that is of intercourse which 
 does not culminate in gratification produced by the 
 sensation of ejaculation, is deleterious. This is ex- 
 plained by the fact that, owing to the absence of the 
 muscular contraction of the genital passage, the latter 
 remains engorged with blood ; the resultant hyperaemia 
 passes away very slowly, and, when frequently repeated, 
 gives rise to chronic tissue changes, manifesting them- 
 selves as diseases of the reproductive organs. Injury 
 to the nervous system ensues, partly in consequence of 
 these organic changes, partly also in consequence of 
 psychical non-gratification in the widest sense of the 
 term. The nervous disorders thus produced are typi- 
 cal forms of (sexual) neurasthenia; and in cases in 
 
212 THE SEXUAL LIFE OF WOMAN ^ 
 
 which the pathogenesis is predominantly psychical 
 (antipathy to the husband, etc.) hysterical types of dis- 
 order are especially frequent. Von Krafft-Ebing be- 
 lieves that incomplete coitus, that is, coitus not cul- 
 minating in the sensation of ejaculation, is a frequent 
 cause of hysterical disorders in women. 
 
 When once the clinical picture of neurasthenia sexu- 
 alis is fully developed, each act of intercourse (like 
 pollutions or coitus in the sexually neurasthenic male) 
 gives rise to renewed troubles, which are easily recog- 
 nized as symptoms of venous stasis in the reproductive 
 organs (sacrache, sensations of weight and bearing- 
 down in the pelvis, fiuor albus) : in addition we ob- 
 serve exacerbations of the lumbar spinal disorder, in 
 the form of spinal irritation, irradiating pains in the 
 sacral plexus, etc. In this way general neurasthenia 
 develops. The conditions found in such cases on gyne- 
 cological examination (chronic endometritis, metritis, 
 oophoritis, etc.) are produced by the same cause as the 
 nervous symptoms, namely, by an unhygienic mode 
 of sexual intercourse. They are not the cause of the 
 neurosis, but important concomitant disorders; and 
 their effect in rendering the nervous disturbances more 
 severe must be freely admitted. 
 
 'Among important causes of ungratifying coitus must 
 be enumerated: weak erection and ejaculatio praecox 
 in the male, rendering the stimulation inefficient; in 
 addition, coitus reservatus, coitus interruptus, and coi- 
 tus condomatus. If the noxious influence is frequently 
 repeated, the occurrence of neurasthenia sexualis and 
 its consequences is greatly to be feared, and in women 
 of neuropathic constitution it is practically inevitable. 
 
 Unsympathetic coitus appears to act, not merely in 
 a somatic manner, but mainly upon the psyche, and 
 to originate states of hystero-neurasthenia or pure 
 
THE SEXUAL EPOCH OF THE MENACME 213 
 
 hysteria. If the influence of such unhygienic condi- 
 tions of the vita sexualis co-operates with that of in- 
 herited or acquired sensuality, further dangers ensue: 
 in cases of ungratifying sexual intercourse, the danger 
 of manustupration ; in cases of unsympathetic inter- 
 course, the danger of psychical onanism or that of 
 marital infidelity. 
 
 Although until recently the matter received but little 
 attention, it must now be regarded as a well-established 
 fact, that in the female (as in the male) the climax 
 of voluptuous sensation in sexual intercourse is nor- 
 mally characterized by a process of ejaculation, ac- 
 companied by a voluptuous sensation of ejaculation, 
 dependent upon the acme of excitement of a reflex 
 centre in the lumbar enlargement of the spinal cord. 
 
 Just as in the male, this centre may be excited to 
 action, not only by local stimulation of the genital 
 organs, but also by (psychical) stimuli proceeding 
 from the brain (pollutions), so also in the female a 
 similar process may occur, and for this reason it is 
 correct to speak of "pollutions in the female." Rosen- 
 thal appears to have been the first writer to speak of 
 pollutions in women. In his clinical study of nervous 
 diseases, Rosenthal described processes of the nature 
 of pollutions, originated in erotically over-stimulated 
 women by lascivious dreams. In one case he detected 
 the outflow of a "mucous-like" fluid from the appar- 
 ently intact genital organs; he believed this to proceed 
 from the ducts of Bartholin's glands, and from the 
 mucous glands surrounding the urethral orifice. Fere 
 reports the case of a patient who had an erogenic zone 
 in the region of the upper part of the sternum; pres- 
 sure on. this zone gave rise to a profuse secretion of 
 vulvo-yaginal fluid. In this connection we may also 
 recall the "clitoris-crises" to which tabetic women are 
 
214 THE SEXUAL LIFE OF WOMAN 
 
 subject. Gutceit described the process of pollution 
 in women in the following words: "It is remarkable 
 that in dreams such women experience the sensation 
 of ejaculation." 
 
 The psychical preliminary is invariably constituted 
 by lascivious dream perceptions. It merely remains 
 open to question whether this process, which in the 
 male is indisputably physiological, in the female may 
 be said to occur within physiological limits. The re- 
 searches published by von Krafift-Ebing more than 
 twenty years ago, under the title "Concerning Processes 
 Analogous to Pollutions Occurring in the Female," 
 gave negative results as far as healthy individuals were 
 concerned ; on the other hand, the phenomenon in ques- 
 tion was by no means rare in nervously disordered, and 
 above all, in sexually asthenic women. The neurosis 
 was in part found as a result of psychical or manual 
 onanism in virgins with morbidly intensified libido: 
 in part in married women, as a result of ungratifying 
 coitus, as previously described: in part, also, in married 
 women with powerful libido and enforced abstinence 
 from intercourse, owing to acquired impotence or 
 death of the husband. 
 
 Just as in the case of the neurasthenic male, these 
 pollutions made the primary neurosis more severe, and 
 relief from the nervous trouble was not obtained until 
 the factor of the "pollutions" had been recognized, 
 and made the object of special treatment. In excep- 
 tional cases the "pollutions" appeared to be the start- 
 ing point of the entire neurosis. 
 
 It was further remarkable, again here displaying 
 analogy with what occurs in the male, how much 
 stronger and more deleterious was the shock-effect of 
 an inadequate process of ejaculation occurring in a 
 sexual dream, as compared with the far less deleterious 
 
THE SEXUAL EPOCH OF THE MENACME 215 
 
 influence of similar incomplete ejaculation when occur- 
 ring via coitus. In very severe degrees of neurasthenia 
 sexualis, just as in the male, the waking imagination 
 may give rise to a "pollution." In such cases the shock- 
 effect on the nerve centres tends to be excessively 
 severe. A still higher degree of irritability of the 
 genital system appears to exist in cases in which ex- 
 citement and orgasm of the reproductive organs may 
 culminate in a "pollution" by purely spinal paths, 
 without the intervention of the imagination. The sig- 
 nificance of this fact would appear to be considerable 
 for the proper comprehension and for the treatment of 
 certain conditions of neurasthenia (sexualis) in the 
 female. The "pollution" may here be the actual cause 
 of the neurosis. But in any case, in the female, the 
 occurrence of pollutions is an extremely important 
 symptom as regards both diagnosis and therapeutics. 
 It is extremely probable that hallucinations of coitus, 
 and the complaints made by insane women of attempted 
 violation during the night, are really dependent upon 
 such "pollutions." 
 
 The frequent occurrence of pollutions in women, the 
 so-called vulvo-vaginal crises and clitoris-crises, is re- 
 garded by Eulenburg as a striking manifestation of 
 sexual neurasthenia in woman ; in such cases a lascivious 
 dream is spontaneously followed by a more or less 
 abundant discharge of the clear gelatino-mucous secre- 
 tion of Bartholin's glands. In women who masturbate, 
 and in tribadists, a profuse and even violent secretion 
 of these glands is produced by touching the clitoris or 
 the erogenic zones at the entrance to the vagina, close 
 to the orifices of Bartholin's ducts. 
 
 Dyspareunia, the absence of voluptuous sensation in 
 women during coitus, may be referred to three funda- 
 mental causes: 
 
216 THE SEXUAL LIFE OF WOMAN 
 
 1. Insufficient or completely wanting peripheral 
 stimulation of the sensory nerve terminals in the female 
 reproductive canal : in these cases the conducting tracts 
 to the nerve centres never become active. 
 
 2. Diminution or cessation of the excitability of the 
 reflex centre in the lumbar enlargement of the spinal 
 cord: this leads to failure of the sensation of ejaculation. 
 
 3. Inhibitory influences proceeding from the cere- 
 bral cortex, whereby voluptuous sensations and per- 
 ceptions are_^ checked. 
 
 The first-named of these etiological influences is in 
 my experience the commonest. Incomplete or quite 
 inadequate stimulation of the sensory nerves of the 
 genital canal may be due to the maladroit perform- 
 ance of copulation on the part of the male, owing to 
 inexperience, or it may depend on gross dispropor- 
 tion in size between the reproductive organs of the 
 man and the woman; in other cases it may be due to 
 disease of the reproductive organs in either sex, in- 
 fluencing unfavorably the sensibility to stimulation of 
 the nerves of the genital canal. Awkward or incom- 
 plete performance of coitus may thus leard to failure 
 of voluptuous sensation, and this may ultimately pass 
 into permanent dyspareunia. Temporary dyspareunia 
 is very common in young wives during the first months 
 of married life, ensuing on the pains of defloration; 
 and very gradually gives place to normal voluptuous 
 sensation. It may be one or two years after marriage 
 before the sensation of ejaculation is first experienced. 
 Not infrequently, dyspareunia depends on incomplete 
 potency in the husband, who is incompetent to arouse 
 voluptuous sensation in his wife. For this reason, 
 dyspareunia is common in young women married to 
 elderly men; but is common also, where (as is so fre- 
 quent among Russo-Polish Jews) the men also marry 
 
THE gEXUAL EPOCH OF THE MENACME 217 
 
 very young, at an age of from sixteen to seventeen 
 years, and where, moreover, the husband has often be- 
 fore marriage impaired his potency by masturbation ; 
 finally dyspareunia is common when girls still unde- 
 veloped sexually are married to powerfully built men. 
 
 Regarding the pathological conditions of the female 
 reproductive organs which counteract the peripheral 
 sensory excitants of voluptuous sensation, we exclude 
 from further consideration the obvious causes, absence 
 and atrophy of the reproductive organs, and senile 
 marasmus. Of prime importance as a cause of the 
 failure of sexual sensibility in the early period of 
 married life must be mentioned inflammation of the 
 fossa navicularis, due to awkward attempts at inter- 
 course. Other causes of deficient sensibility are : com- 
 plete or partial persistence of the hymen, lesions of the 
 vaginal inlet, acute or chronic vulvitis in consequence 
 of irritating abundant secretion, especially as a sequel 
 of gonorrhoeal vaginitis. The last named infective 
 disorder is especially harmful, because Bartholin's 
 glands are involved in the associated vulvitis. Even 
 after the cure of the vulvitis, permanent dyspareunia 
 may remain. Perineal fissures may result in the stimu- 
 lant effect of coitus being insufficient, owing to the 
 slight friction possible at the vaginal inlet in these 
 cases. Not less serious sometimes are small, hardly 
 discernible fissures in the vagina. Additional causes 
 of deficient sexual sensibility are recto-vaginal, and 
 vesico-vaginal fistulae. 
 
 The second cause of dyspareunia, diminution or com- 
 plete lack of irritability of the reflex centre of the 
 lumbar enlargement of the spinal cord, appears to 
 be less frequently operative. We must, however, as- 
 sume that certain nervous disorders, such as hysteria 
 and pathological changes in the spinal cord, are 
 
218 THE SEXUAL LIFE OF WOMAN 
 
 responsible in this connection. The activity of the 
 lumbar sexual centre appears in women to be normally 
 subject to variation within certain limits; and seems 
 usually to attain its maximum irritability during men- 
 struation. But normally these variations are never so 
 great as to produce in women complete though merely 
 temporary dyspareunia; in this respect offering a 
 marked contrast to what occurs in other animals at 
 other times than the rutting season, and of which every 
 bitch not on heat furnishes an example when she refuses 
 the sexual advances of the dog. 
 
 As regards the third causal influence in the produc- 
 tion of dyspareunia, the influence of the brain, this, 
 though important, is less frequently in operation. 
 Diseases of the brain, degenerative processes, may con- 
 stitute a cerebral cause for the failure of sexual sensa- 
 tion. But more frequently, certain cortical percep- 
 tions, such as dislike or hatred of the cohabiting male, 
 an ardent passion for some other lover, grief and 
 trouble, exercise inhibitory influences, which render 
 the occurrence of voluptuous pleasure during the sexual 
 act difficult or quite impossible. 
 
 A condition like dyspareunia, our knowledge of 
 which depends entirely upon the subjective sensations 
 of the woman concerned, is naturally one regarding 
 whose existence accurate information is diflicult to 
 obtain. Very rarely does it happen that women spon- 
 taneously approach the physician with complaints of 
 this condition; indeed, in my experience, they do so 
 only when they are sterile, and when they assume, in 
 accordance with the widespread popular belief, that 
 their sterility is connected with the absence of voluptu- 
 ous sensation during sexual intercourse. More com- 
 monly, however, it is the husband who feels it his duty 
 to confide to the medical man the remarkable apathy 
 
THE SEXUAL EPOCH OP THE MENACME 219 
 
 of his wife in sexual intercourse. But when once the 
 medical man's attention has been directed to this ques- 
 tion, and when he institutes inquiries among his patients 
 in a scientific, passionless manner, one making due al- 
 lowance for a woman's modesty, as the moral impor- 
 tance of the subject demands, he will be astonished at 
 the frequency of dyspareunia, and he will find herein 
 the explanation of many obscure phenomena in the 
 life of woman. On the other hand, it must never be 
 forgotten that a certain number of women complain 
 of dyspareunia without any justification whatever, in 
 order to arouse interest and sympathy, by representing 
 themselves as unwilling sacrifices on the marital altar: 
 the experienced gynecologist will readily detect the 
 cases in which he is being misinformed; he can, more- 
 over, always check the wife's statements by conversa- 
 tion with the husband. 
 
 The constant sign of dyspareunia is the failure of 
 ejaculation during coitus. We have previously de- 
 scribed the muscular contractions which lead to ejacu- 
 lation of the secretion of Bartholin's glands and to 
 the expulsion of the uterine and cervical mucus, as 
 reflex actions evoked by the sensory stimulus dependent 
 on friction of the female genital organs. The voluptu- 
 ous sensation of ejaculation, associated with these 
 muscular contractions, which the woman whose sensi- 
 bility is normal experiences as the culminating point 
 of her sexual "gratification," is either quite unknown 
 to a woman affected by dyspareunia, or is experienced 
 by her only in a voluptuous dream, as a pollution, in 
 which the sexual dream-perceptions act as the psychi- 
 cal stimuli by which the reflex discharge is origi- 
 nated. It has repeatedly happened to me, that on 
 inquiring of women suffering from dyspareunia re- 
 garding their experience of the sensation of ejacula- 
 
220 THE SEXUAL LIFE OF WOMAN 
 
 tion, I have been informed that such sensations are 
 known to them only from the descriptions of their 
 female friends, or occasionally from dreams from which 
 they have awakened with a feeling of moisture in the 
 external genitals. Von Kraflft-Ebing refers this proc- 
 ess to a peristaltic contraction of the muscular fibres 
 of the Fallopian tubes and the uterus, "whereby the 
 tubal and uterine mucus is expressed"; whereas, for 
 my part, I am of opinion, that ejaculation affects in 
 the first place and principally the glands of Bartholin, 
 the secretion of which is expressed by the contraction 
 of the constrictor cunni muscles, and secondarily only 
 affects the cervical glands of the uterus. 
 
 As a second sign of dyspareunia, I recognize a re- 
 markably rapid outflow of the male semen from the 
 female genital canal, immediately after coitus {proflu- 
 vium seminis). The woman thus affected complains, 
 when suitably questioned, that she is unable to retain 
 the'semen, and that it flows out of the vagina immedi- 
 ately after ejaculation. The cause of this remarkable 
 phenomenon, no doubt, lies in the fact that, owing to 
 the absence of the voluptuous sensation, the reflex con- 
 tractions of the muscles of the female genital organs, 
 normally accompanying this sensation during inter- 
 course, fail to. occur. At the vaginal inlet, in normal 
 conditions, the constrictor cunni muscle contracts, and 
 farther up in the vagina a peristaltic contraction of 
 the circularly disposed muscular fibres of the tunica 
 media occurs: in this way the semen ejaculated into the 
 vagina is for a time retained under a certain pressure. 
 But in the absence of these muscular contractions, as 
 well as of the muscular contraction of the pelvic floor, 
 retention of the semen fails to occur. Cattle-breeders 
 and horse-breeders have made similar observations re- 
 garding cows and mares, namely, that these animals 
 
THE SEXUAL EPOCH OF THE MENACME 221 
 
 are sometimes unable to retain the semen after coitus, 
 and it is suggested that in these cases the animals are 
 not properly on heat. Experienced cattle-breeders 
 recommend in such cases that the retention of the semen 
 should be promoted by douching the root of the tail 
 and the external genitals with cold water. It is well 
 known that by stimulating the peripheral sensory 
 nerves in the neighborhood of the genital organs, a 
 reflex excitement of the lumbar sexual nerve centre is 
 produced, as is seen, for example, in the practice of 
 flagellation of the buttocks, for the increase of sexual 
 desire. 
 
 Passing to the consideration of the pathological 
 changes to be found in the reproductive organs of 
 women suffering from dyspareunia, the nature of these 
 will for the most part be obvious in relation to the 
 etiology of the disorder. Most frequent, in my experi- 
 ence, were chronic inflammatory states of the vulva 
 and of the vaginal and uterine mucous membrane, 
 chronic metritis and parametritis. A very frequent 
 appearance, and one practically characteristic of dys- 
 pareunia when of long standing, is a marked total 
 relaxation of the reproductive apparatus. The uterus 
 is extremely mobile, usually retroverted and partially 
 prolapsed, thin, with lax walls, and usually an en- 
 larged cavity; the portio vaginalis is flaccid, and runs 
 to a point; the vagina is roomy; there is marked hyper- 
 secretion of the mucous membrane of the entire genital 
 canal ; there is great flaccidity of the constrictor cunni 
 and levator ani muscles, and of the perineum. In 
 several women with dyspareunia, I found old unhealed 
 lacerations of the perineum. In some cases, the very 
 small size of the clitoris is noteworthy. In one case 
 amenorrhoea was present with an infantile uterus. In 
 a large proportion of the cases I was able to detect a 
 
222 THE SEXUAL LIFE OF WOMAN 
 
 diminution both of the tactile and algic sensibility of 
 the vaginal mucous membrane. The women were for 
 the most part anaemic ; many were extremely obese, and 
 of lymphatic constitution. In some cases, however, no 
 pathological changes whatever could be detected in 
 the reproductive apparatus. 
 
 Dyspareunia is a condition which affects a woman's 
 whole nature, powerfully influences her mental life, 
 and thus gives rise to greater psychical than physical 
 damage. The consciousness of being deprived of the 
 greatest joy of physical love produces great emotional 
 depression, even in a woman by no means sensually 
 inclined, and gives rise to a hypochondriacal state, at 
 times even to melancholia. In other cases, the idea, 
 not infrequently suggested by more happily situated 
 women friends, that the woman herself is not to blame 
 for this condition, has a demoralizing effect upon her, 
 and destroys the, happiness of married life. (It has 
 been confessed to me, in isolated cases, that the dyspa- 
 reunia was relative only.) Apart from this, the ab- 
 sence of sexual gratification gives rise to a series of 
 nervous troubles, presenting either the variable char- 
 acters of hysteria, or else the symptoms of neurasthenia. 
 Finally, the frequently repeated incomplete coitus, in- 
 complete inasmuch as the woman does not experience 
 the sensation of ejaculation, induces chronic hyperaemia 
 in the female reproductive organs, passing on into 
 blood stasis, and ultimately into chronic inflammatory 
 tissue changes ; in this way arise metritis, perimetritis, 
 and parametritis, salpingitis, oophoritis, disorders 
 of menstruation, menorrhagia, and atypical uterine 
 haemorrhages. The possibility cannot be disproved, 
 that in this way new-growths of the reproductive 
 organs may also originate. The act of sexual inter- 
 course, which at first may be to the woman a matter 
 
THE SEXUAL EPOCH OF THE MENACME 223 
 
 of comparative indiflference, and in which she plays 
 her part merely from a sense of duty, becomes, in 
 cases of long-standing dyspareunia, something to which 
 she feels a positive dislike, and is recognized by her 
 as the actual cause of the troubles that ensue upon inter- 
 course, such as sacrache, sensations of weight and pres- 
 sure in the pelvis, strangury, fluor albus, a feeling of 
 exhaustion, etc. 
 
 At times, perverse sexual sensation is associated with 
 dyspareunia. Women who find no enjoyment in 
 normal sexual intercourse with a male, sometimes mas- 
 turbate, sometimes indulge in amor lesbicus, etc. 
 
 Of great importance appears to me the relation be- 
 tween dyspareunia and sterility in women. As already 
 pointed out, dyspareunia comes chiefly under medical 
 observation in cases in which it is associated with 
 sterility. The husband, seeking advice concerning his 
 wife's failure to conceive, complains of her frigidity 
 in sexual intercourse as the probable cause; or the wife 
 comes to seek advice, saying that she never experiences 
 sexual gratification, and that for this reason she has 
 failed to become pregnant. As a matter of actual fact, 
 dyspareunia and sterility are associated with such re- 
 markable frequency, that my own experience leads me 
 to believe in the existence of an etiological connection 
 between the two conditions, at least in a certain pro- 
 portion of the cases. Among 69 sterile women whom 
 I questioned regarding dyspareunia, the latter condi- 
 tion was present in 26, that is to say, in 38 per cent, 
 of the cases. Matthews Duncan reported that of 191 
 sterile women, 62 did not experience sexual enjoyment. 
 Sexual excitement of the woman during copulation 
 would certainly appear to have a definite bearing upon 
 the occurrence of conception, for we know that by the 
 voluptuous sensation reflex actions are aroused in the 
 
224 THE SEXUAL LIFE OF WOMAN 
 
 genital canal, favoring the retention of semen and its 
 passage through the os to the interior of the uterus, 
 and perhaps also giving rise to reflex changes in the 
 cervical secretion which favor the passage of the sper- 
 matozoa into the uterine cavity. 
 
 In cases of relative dyspareunia, the influence of this 
 condition in producing sterility is also manifested, the 
 unfaithful wife being impregnated by her lover though 
 she has remained sterile in intercourse with the hus- 
 band, to whom she is indifferent. To dyspareunia of 
 this nature (dependent upon sexual disharmony), we 
 may also refer the sterility of a married pair who have 
 for some time lived together in unfruitful intercourse, 
 whereas, after divorce and the contraction of fresh 
 unions, both the man and the woman prove normally 
 fertile. Such cases have been personally known to me; 
 and similar instances aroused the attention of the natural 
 philosophers of antiquity, for instance, that of Aristotle. 
 The importance of voluptuous sensation in promoting 
 conception is also manifest from the fact that in the 
 majority of women, after the pains of defloration, 
 dyspareunia usually persists for a season during the 
 early period of married life ; and, corresponding with 
 this, the first conception is usually deferred for some 
 little time after marriage, to a period corresponding 
 with the awakening of the sensation of ejaculation. 
 
 Fertility in Women 
 
 Fertility in women is the basis of the fecundity of 
 a nation, of its growth, its power, and its importance. 
 It is especially the fertility of married women which 
 enters here into consideration, and forms the source of 
 the statistical data of fertility; these are usually ob- 
 tained by drawing a ratio between the number of mar- 
 
THE SEXUAL EPOCH OF THE MENACME 225 
 
 riages contracted in a given period, and the number 
 of children born in the same period. 
 
 The fertility of women is a function beginning at 
 an age varying in dependence on many conditions, and 
 undergoing extinction at a definite period of life. It 
 is, in fact, associated with the duration of the sexual 
 life of woman, and, generally speaking, exterrds from 
 the sixteenth to the fiftieth year of life. Climate, race, 
 constitution, and morbid conditions, influence alike the 
 first appearance of menstruation and the first preg- 
 nancy; and as they influence the" duration of menstrual 
 activity, so also do they influence the duration of 
 fertility. 
 
 In the Bible are recorded numerous instances of the 
 early commencement of fertility. At the present time, 
 also, in warm climates we meet with many examples 
 of early motherhood. 
 
 Moreover, in the records of European countries, we 
 find numerous instances of very early motherhood. 
 Molitor's case, a girl nine years old giving birth to a 
 vesicular mole with an embryo; von Haller's case, 
 pregnancy in the ninth year of life; Carus's case, preg- 
 nancy at the age of eight. Caspar saw a girl in Berlin 
 who became pregnant at the age of twelve, and was 
 delivered of a living child. Riittel saw a girl nine 
 years of age pregnant. King attended the confinement 
 of a girl who at the time of her delivery was not yet 
 eleven years old. Taylor reports the case of a girl 
 twelve years and six months of age who was then in 
 the last month of pregnancy. Koblanck attended a girl 
 of fourteen who was delivered of a child weighing 
 four and a half pounds. 
 
 In most of these cases the premature fertility is fol- 
 lowed by a premature cessation of fertility. And there 
 is more or less truth in Bruce's statement regarding the 
 
226 THE SEXUAL LIFE OF WOMAN 
 
 Arab women in Africa, that those who began to bear 
 children at the age of eleven were seldom still fertile 
 at the age of twenty. 
 
 At times we may observe a remarkable extension of 
 fertility beyond the average age, that is, beyond the age 
 of fifty years. 
 
 In northern Europe pregnancy at a comparatively 
 advanced age is by no means rare. From the official 
 statistics of Denmark we learn that among 10,000 wom- 
 en, 465 were delivered at ages between 50 and 55 years. 
 In Sweden, of 10,000 mothers, 300 gave birth to chil- 
 dren when more than 50 years of age. In Ireland, the 
 proportion of mothers over 50 was 345 per 10,000. In 
 England the official figures dealing with the delivery 
 of 483,613 women, showed that 7,022 were between 45 
 and 50 years of age, and 167 over 50 years of age. 
 
 The ideal of fertility in women is that the first com- 
 pleted act of sexual intercourse should be followed 
 immediately by conception, that the pregnancy should 
 terminate after the normal lapse of time in the birth 
 of a child, and that the same process should be repeated 
 at intervals of about ten months until the end of active 
 sexual life. In actual experience, however, this never 
 occurs. Fertilization as an immediate consequence of 
 the first act of sexual intercourse (which in the lower 
 animals is regarded as the rule) is a very rare occur- 
 rence in human beings. Moreover, in no single mar- 
 riage is the reproductive capacity of the wife utilized 
 to the full, up to the time of extinction of her genera- 
 tive faculty; either because the potency of the male 
 partner undergoes a gradual decline, or, it may be, 
 because, after a while, sexual intercourse becomes less 
 frequent, or because precautions against procreation 
 are taken. 
 
 The number of children to which during the three 
 
THE SEXUAL EPOCH OF THE MENACME 227 
 
 decades of her sexual life, from the menarche to the 
 menopause, a woman might theoretically give birth, 
 is never actually born. If we assume that, dur- 
 ing the period of active sexual life, a woman re- 
 quires a period of fifteen months to two years for 
 each pregnancy, parturition, and lactation, a woman 
 could easily during this period have fifteen or 
 sixteen children, and this figure would represent the 
 normal product of the normal fertility of the human 
 female. There are, indeed, women who, it may be in 
 consequence of an exceptionally long period of sexual 
 activity, or through giving birth repeatedly to twins 
 or triplets, or because they have married several hus- 
 bands in succession, have given birth to twenty-four 
 children or even more. In Berlin, in the year 1901, 
 there lived a woman 41 years of age who had had 23 
 children; there were three women, aged respectively 
 40, 43, and 46 years, who had had each 21 children; 
 246 women with families numbering 13 to 20; and 169 
 women each of whom had given birth to 12 children. 
 In the very great majority of cases, however, the 
 fertility of the wife of the present day is never fully 
 developed. It is modified in various ways by the con- 
 ditions of marriage, by social circumstances, by con- 
 siderations relating to the health of husband or wife, 
 by actual illnesses, and by voluntary limitation of fer- 
 tility. Generally speaking, according to the investiga- 
 tions of Quetelet, Sadler, and Finlayson, the fertility 
 of women is greatest in marriages in which the husband 
 is as old as the wife, or a little older, but without 
 marked difference in age. Marriages contracted at a 
 very early age are less fruitful; the highest fertility 
 is found in marriages contracted when the husband is 
 23 and the wife 26 years of age. 
 Conception does not generally take place until sexual 
 
228 THE SEXUAL LIFE OF WOMAN 
 
 intercourse has been frequently repeated. As the re- 
 sult of a statistical inquiry of my own, relating to 556 
 fruitful marriages, I ascertained that in these the first 
 delivery occurred. 
 
 Within 10 months after marriage in 156 cases. 
 Within 11 to 15 months after marriage in 199 cases. 
 Within 16 to 24 months after marriage in 115 cases. 
 Within 2 to 3 years after marriage in 60 cases. 
 More than 3 years after marriage in 26 cases. 
 
 Thus we learn that in 35.5 per cent, of the cases the 
 first delivery occurred within i J4 years after marriage; 
 in 15.6 per cent, within 10 months; and in 19.9 per cent, 
 within 15 months after marriage; and 11.5 per cent, of 
 the cases, the first delivery was more than ij4 years 
 and less than 2 years after marriage; in 6 per cent, 
 it was between 2 and 3 years after marriage; and in 
 2.6 per cent., the first delivery did not occur until more 
 than 3 years after marriage. 
 
 From examination of the birth registers of Edin- 
 burgh and Glasgow, Matthews Duncan determined the 
 mean interval between marriage and the birth of a 
 living child to be seventeen months. In the majority 
 of cases, the first delivery does not occur until a com- 
 plete year has elapsed since marriage; in fact, in nearly 
 two-thirds of the instances the first delivery occurs 
 during the second year of married life. 
 
 The interval between two successive births is, accord- 
 ing to Matthews Duncan, on the average 18 to 24 
 months, according to Goehlert, 24 to 26 months; the 
 latter, however, points out that in cases in which the 
 child dies very soon after birth, the birth of the next 
 child ensues on the average in 16 to 18 months. In 
 this connection, we must not fail to take into considera- 
 tion the influence of lactation, inasmuch as mothers who 
 
THE SEXUAL EPOCH OF THE MENACME 229 
 
 do not suckle their children become pregnant consider- 
 ably earlier, on the average, than those who undertake 
 this duty. In reigning families, for instance, it is by 
 no means uncommon for the consort to be delivered 
 twice within a single year. The degree to which lacta- 
 tion hinders conception is so widely known, that women 
 often suckle their infant for a very long period, with 
 the definite aim of preventing the speedy recurrence 
 of pregnancy. A high official from the Dutch West. 
 Indies informed me that for this jeason the native 
 women were accustomed to suckle their infants for 
 several years, and that it was by no means uncommon 
 to see a small boy running about smoking a cigar, and 
 then hurrying to his mother in order to be suckled. 
 
 The age at which a woman contracts marriage has 
 also to this extent an influence upon her fertility, inas- 
 much as it appears that those who marry very young 
 are far less fertile than those who marry between the 
 ages of 20 and 25 years; the latter, moreover, have, on 
 the average, a shorter time to wait for their first con- 
 ception than women who marry before the age of 20. 
 Womeft who marry after the age of 25 have to wait 
 longer after marriage for their first delivery; in fact, 
 the older the woman after 25, the greater, on the 
 average, the interval between marriage and the first 
 delivery. 
 
 The fertility of married women increases steadily 
 up to the age of 35 years, but after this age it begins 
 to decline. What a marked influence the age at mar- 
 riage has upon fertility is shown by the comparison 
 of the figures relating to married women with those 
 relating to unmarried women ; the fertility of unmarried 
 mothers attains its maximum at the ages of 20 to 25 
 years. In the countries under consideration the average 
 age of women at the time of marriage is 25 to 27 years. 
 
230 THE SEXUAL LIFE OF WOMAN 
 
 Divergent results as regards the fertility of married 
 women at dififerent ages were obtained by Goehlert 
 from the examination of 5,290 cases from the reigning 
 families of Europe. In the favorable position as re- 
 gards means of subsistence occupied by the members 
 of these families, marriage naturally occurs, in most 
 cases, much earlier in life, the mean age at marriage 
 being between 19 and 22 years — the youngest mother 
 (in the Capet dynasty) was only 13 years of age — and 
 for this reason the figures relating to the younger age- 
 classes are larger than in the previous tables. But as 
 a result of this, the reproductive capacity also under- 
 goes an earlier extinction, so that of these women, not 
 one gave birth to a child when she was over 50 years 
 of age. Goehlert gives the following table, compiled 
 from these 5,290 instances: 
 
 Under 20 years 8.8% 
 
 From 20 to 25 years ^ 25.4% 
 
 From 25 to 30 years 29.4% 
 
 From 30 to 35 years 21.6% 
 
 From 35 to 40 years 1 1.5% 
 
 Over 40 years 3.3% 
 
 In these cases the maximum fertility was obtained 
 at the age of 27. 
 
 The physiological fertility of women is much more 
 clearly manifested when we compare the fertility of 
 women who have been married a few years only, with 
 the fertility of women in the later years of married 
 life. In the earlier period, the effective fertility more 
 nearly approaches the physiological fertility, because 
 at this time the various influences by means of which 
 fertility is later so greatly diminished have not yet come 
 into operation. In this connection the following data, 
 published by Korosi, regarding the percentage fertility 
 
The sexual epoch of the menacme 231 
 
 of recently married women, and that of married women 
 in general, will be found of interest: 
 
 Recently All 
 
 Married Married 
 
 Women Women 
 
 At ages 20 to 35 years 32.0% 20.6% 
 
 At ages 35 to 40 years 32.7% 14.7% 
 
 At ages 40 to 45 years 21.4% 5.9% 
 
 Inasmuch as we learn from this table that in the 
 case of women aged 40 and upward, the newly-married 
 exhibit a fertility of four times as great as that of 
 married women in general, in whom pregnancy has al- 
 ready become rare, we can infer the influence upon 
 fertility of abstinence and of artificial measures for the 
 prevention of conception. 
 
 On the average, the maximum fertility of woman, 
 that is, the maximum of effective fertility, is attained 
 at the age of 18 to 20 years. Extreme youthfulness, 
 and also the opposite condition, too advanced an age, 
 when marriage is entered on, impair a woman's fer- 
 tility; whereas the conditions most favorable to fertility 
 are that, at the time of marriage, the uterus should have 
 attained its fullest development, and the ovaries also 
 should be completely mature; this is not usually the 
 case at puberty, but rather at the age of 20, 21, or 
 22 years. In Austria-Hungary, of 100 marriages in 
 which the wife's age at marriage was less than 18 
 years, the average offspring in the course of a single 
 year were 36 to 38 children; in the case of 100 mar- 
 riages in which the wife's age at marriage was 18 to 
 20 years, the average offspring in a year were 40; this 
 being the maximum fertility, the number of offspring 
 in a year per hundred marriages {i.e., the percentage 
 fertility) , now undergoes a regular decline as the wife's 
 age at marriage increases; at an age of 25, the per- 
 centage fertility is 32 ; at the age of 30 years, the fer- 
 
232 THE SEXUAL LIFE OF WOMAN 
 
 tility is 24 per cent.; at the age of 35, 17 per cent; at 
 the age of 40 years barely 10 per cent.; at the age of 
 45, 7 per cent; at ages 45 to 50, o.i per cent Thus, 
 from the last figure, we see that of a thousand women 
 marrying at the age of 50 years, one only gives birth 
 to a child. Men obtain their maximum fertility {i.e., 
 procreative capacity) at the age of 25 or 26 years; at 
 this age their fertility amounts to 35 per cent (that is, 
 of 100 marriages at this age, 35 children will on the 
 average be born within a single year) ; at the age of 
 35 years, the percentage fertility of men falls to 23; 
 at the age of 45 years, it is g}^ per cent ; at 55, 2.2 per 
 cent; at 65, }4 per cent (Korosi-Blaschko). 
 
 Whereas hitherto we have considered only the mono- 
 genous fertility of married women, we must remember 
 that the figures relating to their biogenous fertility 
 are also of interest — that is to say, the changes which 
 a woman's fertility experiences in married life in 
 respect of the peculiarities of her husband; and of these 
 peculiarities, the easiest to make the object of statistical 
 investigation is the husband's age. The age of the 
 husband exercises an important influence upon the fer- 
 tility of the wife, as is proved by the following figures 
 published by Korosi: 
 
 Age op the Mother 
 
 Age OF THE Father 25 Years 30 Years 35 Years 
 
 25 to 30 years 35.6% 25.0% 21.2% 
 
 30 to 35 years 31.2% 23.6% 19.9% 
 
 35 to 40 years 27.5% 21.8% 19.4% 
 
 40 to 45 years 16.7% 14.0% 
 
 45 to 50 years 14.4% 10.9% 
 
 50 to 55 years 10.9% 
 
THE SEXUAL EPOCH OF THE MENACME 233 
 Also: 
 
 Age of the Father 
 
 Age OF THE Mother 25 Years 35 Years 45 Years 55 Years 
 
 Under 20 years 49.1 % 
 
 20 to 25 years 43.0% 31.3% 16.0% 
 
 25 to 30 years 30.8% 27.3% 18.5% 
 
 30 to 35 years 33.5% 23.7% 14.4% 8.1% 
 
 35 to 40 years 18.9% ll.S^o 6.7% 
 
 40 to 45 years 6.6% 6.1% 3.0% 
 
 We learn from these figures that the maximum fer- 
 tility is exhibited by a woman i8 years of age, when 
 married to a man 25 years of age; less fertile is a 
 woman 25 to 30 years of age married to a man 28 
 years of age; still less fertile is a woman 35 years of 
 age married to a man 29 years of age. Neither the 
 age of the mother alone, nor that of the father alone, 
 is determinative of the fertility of the marriage, for 
 the fertility of young wives married to elderly husbands 
 is quite different from that of young wives married to 
 young husbands. Very various age-combinations are 
 possible, and each exhibits an average fertility peculiar 
 to itself. 
 
 We can also regard the question from the stand- 
 point of the difference between the ages of husband and 
 wife respectively. In this connection, Korosi is led 
 by his tables to the conclusion that wives between the 
 ages of 18 and 20 years attain their maximum fertility 
 when married to men 7 years older than themselves; 
 women of 25 years when married to men 3 years older 
 than themselves; women of 29 years when married to 
 men of the same age ; women of 30 years and upward 
 attain their maximum fertility only when married to 
 men younger than themselves. Men, on the contrary, 
 always attain their maximum fertility when married 
 to women younger than themselves. The age of maxi- 
 
234 THE SEXUAL LIFE OF WOMAN 
 
 mum fertility differs in the two sexes, and those mar- 
 riages will be most fruitful in which husband and wife 
 are each of the age most favorable to fertility. This 
 will be the case when the age of the wife is i8 to 20 
 years, and that of the husband 24 to 26 or perhaps 
 29 years. 
 
 In connection with the question of fertility, we have 
 also to take into consideration the vitality of the chil- 
 dren born, that is, what proportion of those born sur- 
 vive. According to Korosi's interesting papers regard- 
 ing the fertility of the inhabitants of Buda-Pesth, we 
 learn that for every 100 marriages which have per- 
 sisted for thirty years and upward, there were born, 
 on the average, 539 children, of whom during this 
 period 241 died, so that the percentage of survivals 
 was 55.28. Parents who have lost one only of several 
 children must, therefore, regard themselves as excep- 
 tionally favored by fortune. 
 
 Social position, occupation, and religion, have, ac- 
 cording to the last-quoted author, a notable influence 
 on fertility. His investigations showed that the Roman 
 Catholics and the Jews exhibited the greatest fertility; 
 among the Catholics there were 541 children, and 
 among the Jews 557 children, per 100 marriages. 
 Amongst 100 Protestant families, on the other hand, 
 only 479 children had been born. It will be seen that 
 the theory of the comparatively enormous fertility of 
 the Jewish race is not supported by these statistics. 
 The Jews do, however, exhibit a greater power of rear- 
 ing children, for among them the marriages of more 
 than 30 years' duration had 61% per cent, of the chil- 
 dren still living; among the Protestants 57% per cent, 
 survived; and among the Catholics only 52% per cent. 
 It thus appears that the surviving offspring per 100 
 marriages of 30 years' duration were, among the Catho- 
 
THE SEXUAL EPOCH OF THE MENACME 235 
 
 lies 278, among the Protestants 252, and among the 
 Jews 349. 
 
 The question whether, and to what extent, the age 
 of the parents has an influence on the vitality of the 
 children, is answered by Korosi's mortality statistics 
 in the sense that mothers below 20 years of age give 
 birth to a larger proportion of children deficient in 
 vital power. Where the mothers had married at the 
 age of 16, the mortality of their offspring was, among 
 Catholics 43 per cent., among Jews 33 per cent; 
 married at 17, Catholic mortality 44 per cent., Jewish 
 30 per cent; married at 18, Catholic mortality 42 per 
 cent, Jewish 32 per cent; married at 19, Catholic 
 mortality 41 per cent, Jewish 29 per cent; married 
 at 20, Catholic mortality 40 per cent, Jewish 26 per 
 cent Of the children whose fathers had married at 
 the age of 24, 32 per cent had died; of those whose 
 fathers had married at 23, 37 per cent had died; of 
 those whose fathers had married at 20, 42 per cent had 
 died; and of those whose fathers had married before 
 20, actually 44 per cent had died. It thus appears 
 that the children alike of very young mothers and of 
 very young fathers have a lessened chance of survival. 
 
 Inasmuch as the fertility of the wife is a product of 
 two factors, her own peculiar fertility, and that of the 
 procreating male, the question of the fertility of women 
 cannot be accurately treated independently of this 
 second consideration; hereby, however, is introduced 
 a multiplicity of obscure combinations, by which the 
 value of all the statistical data of fertility in women 
 is seriously impaired. 
 
 These data give as the measure of fertility, the 
 number of children per marriage actually brought up, 
 embracing fruitful marriages, sterile marriages, and 
 those not yet fruitful. In Berlin, in Copenhagen, and 
 
236 THE SEXUAL LIFE OP WOMAN 
 
 in Buda-Pesth, the average thus attained was slightly 
 less than three births to each family, whilst the number 
 of children actually living averaged two per family. 
 !A more accurate representation of fertility is obtained 
 by ascertaining the number of children born, and the 
 number of children living in relation to the duration 
 of marriages reckoned in years, that is, beginning with 
 marriages of one year's duration, and proceeding year 
 by year to the highest recorded duration of marriage. 
 In this way interesting statistics have been obtained; 
 for example, one who has completed thirty years of 
 married life may count on the average that five or six 
 children will have been born to him, but may also 
 reckon on having buried two or three at least of these. 
 ( Korosi. ) 
 
 Fertility is, as many facts indicate, also dependent 
 on nutrition. A distinct proof, says Spencer, writing 
 on the "Coincidence Between High Nutrition and 
 Genesis," that abundant nutriment increases the number 
 of births, and vice versa, is found among the mam- 
 nialia; compare, for instance, the litter of the dog with 
 that of the wolf and the fox. Whilst the dog's litter 
 numbers 6 to 14, that of the wolf numbers 5 to 7, that 
 of the fox 4 to 6. The wild cat gives birth to 4 or 5 
 kittens once a year, the domesticated cat to 5 or 6, 
 twice or thrice annually. The most remarkable con- 
 trast, in this respect, exists between the wild and the 
 domesticated breeds of swine. The wild sow gives 
 birth once a year to a litter of 4, 8, or 10 pigs (the 
 number increasing in successive litters) ; the domesti- 
 cated sow has often as many as 17 in a single litter, 
 whilst in two years five litters, each numbering 10 pigs, 
 are commonly born. 
 
 Darwin also draws attention to the fact that animals 
 under domestication, being fed more abundantly and 
 
THE SEXUAL EPOCH OF THE MENACME 237 
 
 regularly than their wild allies, procreate at shorter 
 intervals and are markedly more fertile than the latter. 
 He states that the wild rabbit has four litters annually, 
 each numbering 4 to 8 young; whereas the tame rabbit 
 reproduces its kind six to seven times annually, and 
 gives birth to litters numbering 4 to 11. Among birds, 
 analogous phenomena are observed. The wild duck, 
 for instance, lays 5 to 10 eggs in the course of the 
 year, whereas the tame duck lays from 80 to 100; the 
 wild gray goose lays 5 to 8 eggs, the domesticated goose 
 13 to 18. 
 
 It must be added that this exceptional fertility is 
 manifested in animals that are quite inactive in com- 
 parison with their wild allies; not only are they richly 
 fed, but they get their food without working for it. 
 Moreover, it is easy to observe that among the domesti- 
 cated mammals the well-fed are more fertile than the 
 ill-fed. 
 
 ■ That in the human species also, fertility is influenced 
 to a notable degree by nutritive conditions, is shown 
 by statistical investigation. After years distinguished 
 by an exceptionally good harvest the number of chil- 
 dren born is considerably greater than in normal condi- 
 tions ; whereas after a famine the opposite is observed. 
 Malthus's law of population states, inter alia, that the 
 population increases when the amount of available 
 nutriment increases, that is, that favorable nutritive 
 conditions cause an increase, that unfavorable nutritive 
 conditions cause a decrease, of population. Hardships 
 and exhausting occupations diminish the fertility of 
 women. The remarkable fertility of the Kaffirs is re- 
 ferred to the fact that this people, possessing large herds 
 of cattle, lead a life comparatively free from care; it 
 is no less true that the Boer women, who lead a life 
 of well-fed leisure, have very large families; whereas 
 
238 THE SEXUAL LIFE OF WOMAN 
 
 the Hottentot women, poor, ill-nourished, and hard 
 working, seldom bear more than three children. 
 
 Generally speaking, it may be said that fertility of 
 the soil, in connection with an easily gained livelihood, 
 favors also human fertility, notwithstanding the fact 
 that certain statistical data seem to conflict with this 
 proposition. Sadler, for instance, concludes that an in- 
 crease in the price of the necessaries of life does not 
 per se check fertility, but, indeed, rather increases it; 
 he considers that the apparent decline in fertility is 
 due to the fact that the number of marriages diminishes, 
 owing to the rise in prices. We must, however, point 
 out, that an increase in price of the necessaries of life 
 is often associated with a rise in wages, and is there- 
 fore not necessarily identified with deficient nutrition; 
 when, however, such a rise in prices leads to actual 
 want, a limitation of fertility will certainly result; this 
 has been proved by Legoyt and Villerme with regard 
 to failure of the crops. Famine and disease lower the 
 number of births; a less severe deficiency of nutriment 
 often lowers only the quality of those born. Malthus 
 was of opinion that the population of a country at any 
 time was related to the quantity of nutriment produced 
 or imported therein, on the one hand, and, on the other, 
 to the liberality with which this nutriment was distri- 
 buted to the individual. In countries where corn forms 
 the principal crop, we find a thicker population than 
 in pasture lands; and where rice is the principal crop, 
 the population is even more abundant than it is in corn 
 growing countries. 
 
 Passing to the consideration of the individual nutri- 
 tive elements, we find that these also influence fertility. 
 Above all, it has been proved that alcohol notably 
 diminishes the fertility of women. Lippich states tfiat 
 of 100 women in Karnten and Krain suffering from 
 
THE SEXUAL EPOCH OF THE MENACME 239 
 
 chronic alcoholism, 28.3 were barren. In England, 
 where the abuse of alcoholic beverages is also very 
 frequently observed in women, the same phenomenon 
 has been noted. Matthews Duncan held that alcohol 
 exercised a specific deleterious influence on fertility. 
 Moreover, in addition to the constitutional disturbances 
 produced by the abuse of alcohol, this beverage also 
 exercises a well-known pathogenetic influence upon the 
 female reproductive organs;. with especial frequency, 
 chronic oophoritis may be shown to depend on this 
 exciting cause. 
 
 A diet consisting mainly of fish is known to increase 
 the sexual impulse, and is said also to increase fertility. 
 Further, a diet consisting mainly of potatoes or rice 
 is said to favor reproduction ; compare, for instance, the 
 fertility of the Hindoos, who abstain entirely from ani- 
 mal food, and of the Chinese, who live chiefly on rice. 
 Davy maintained that the women of races living chiefly 
 on fish were handsomer and more fertile than others: 
 and Montesquieu suggested that there was an associa- 
 tion between the abundant population of sea-ports and 
 also of Japan and China, and the large quantity of fish 
 consumed in those places. On the other hand, a diet 
 consisting chiefly of meat is said to have an unfavorable 
 influence in this direction ; in support of this view it is 
 pointed out that races living by the chase, and living, 
 therefore, almost entirely on meat, have very small 
 families. This generalization is invalidated by the 
 fact that Englishwomen, who eat far more meat than 
 the women of the Latin races, are nevertheless dis- 
 tinguished by their great fertility. 
 
 In his History of Civilization in England, Buckle 
 writes: "The population of a country, although in- 
 fluenced by many other conditions, unquestionably rises 
 and falls in proportion as the supply of nutriment is 
 
240 THE SEXUAL LIEE OE WOMAN 
 
 abundant or the reverse." Herbert Spencer also states 
 that "every increment in the supply of nutriment is 
 followed by an increment in fertility." 
 
 It must not be forgotten that, in addition to the 
 more or less abundant supply of nutriment, there are 
 always other influences affecting fertility; the general 
 mode of life, race, climatic conditions, etc., may, in 
 various ways, cooperate with or countervail the influ- 
 ence of nutritive conditions. If, with the best possible 
 supply of nutriment, there is associated a luxurious and 
 enervating mode of life, the abuse of alcohol, severe 
 intellectual exertion, or sexual excesses, the general 
 result will be a diminution in fertility. And it is easy 
 to understand why Cros, although perhaps with little 
 justification, goes so far as to regard easy circumstances 
 as an active cause of depopulation. "It is the poor," 
 he writes, "and the less wealthy departments of France, 
 in which we find the most children." In estimating 
 fertility, however, we must never fail to 'take into con- 
 sideration the more extensive employment of means for 
 the prevention of pregnancy among the upper classes 
 of society. 
 
 To a certain extent we can trace the influence of cli- 
 mate and of season upon fertility. Heat appears to 
 favor fertility; Haycraft's figures for the eight largest 
 towns of Scotland show clearly how the number of 
 conceptions rises and falls pari passu with the tempera- 
 ture. Lower animals also, when brought from a colder 
 to a warmer neighborhood, exhibit an earlier and more 
 frequently recurring "heat." In Europe, however, the 
 Northern races appear more fertile than those of the 
 south. 
 
 Of the seasons, spring is the one especially favorable 
 to fertility. Quetelet, who proves by numerous sta- 
 tistical data that the maximum of conceptions occurs 
 
THE SEXUAL EPOCH OF THE MENACME 241 
 
 in May, attributes this fact to a general increase in the 
 vital forces occurring in spring, after the cold of winter. 
 Villerme, however, goes back to the older explanation, 
 that the increase in the number of conceptions in May 
 and June is due to social and economic conditions. 
 The return of spring, especially the end of spring and 
 the beginning of summer, a time of year in which the 
 means of subsistence are provided in exceptional quan- 
 tity, and of especially good quality, the season also of 
 festivals and social reunion, when the two sexes are 
 brought into more intimate contact and when the 
 majority of marriages occur — these are the conditions 
 associated with the season of greatest fertility. The 
 figures of Wappaeus also confirm the influence of 
 spring in favoring fertility. He found, however, that 
 there were two seasons of maximal fertility. The first 
 at the end of spring and the beginning of summer; the 
 second in winter, especially in December. Mid-winter 
 is for most people a period of domestic amusement and 
 relaxation, one of exceptionally good nutrition, and of 
 social reunion; the spring increase in fertility is a part 
 of the awakening and increase of the reproductive 
 forces of nature at large, which recurs every spring- 
 time. 
 
 Every marked and sudden change in the mode of 
 life has an unfavorable influence on fertility. , Darwin 
 reports that mares who have for some time been stall- 
 fed with dry fodder and are then put out to grass are 
 at first infertile after the change. Europeans going to 
 reside in the tropics experience a notable decline in 
 fertility as a result of the change of climate. Accord- 
 ing. to Virchow, the fertility of European women who 
 become acclimatized in the tropics declines very gradu- 
 ally, but in the course of a few generations is almost 
 completely annulled. 
 
242 THE SEXUAL LIFE OF WOMAN 
 
 The marriage of near kin is believed also to diminish 
 fertility. As regards inbreeding in the lower animals, 
 it is well known that when nearly related animals co- 
 pulate, the number of the offspring is below the aver- 
 age. Nathusius paired a sow with its own uncle, the 
 boar having proved productive in intercourse with 
 other sows ; the litter numbered five to six only. This 
 sow, which belonged to the great Yorkshire race, was 
 then paired with a small black boa:r, which in inter- 
 course with sows of its own variety had procreated 
 litters numbering six or seven; as a result of her first 
 pairing with the black boar, the sow cast a litter num- 
 bering twenty-one, whilst the second attempt produced 
 a litter of eighteen. Similar results were obtained by 
 Crampe, in his experiments in the inbreeding of rats. 
 
 Some authorities declare that the results of inbreed- 
 ing are similar in the human species, that the mar- 
 riages of near kin are less fruitful than the average. 
 Darwin writes in this connection: "With regard to 
 human beings, the question whether breeding in-and-in 
 is also deleterious, will probably never receive a direct 
 answer, for man reproduces his kind so very slowly, 
 and cannot be made the object of experiment. The 
 very general disinclination of nearly all races to the 
 marriage of near kin, which has existed from the very 
 earliest times, is of weight in relation to this question. 
 Indeed, we appear almost justified in applying to the 
 human race the experience gained by experiment on 
 the higher mammals." 
 
 Darwin's assumption regarding the effect upon fer- 
 tility of the marriage of near kin in the human species, 
 cannot, however, be accepted without qualification. 
 In ancient times there was no uniformity of opinion 
 on this topic. It is well known that among the Phoeni- 
 cians, a son might marry his mother, and a father his 
 
THE SEXUAL EPOCH OF THE MENACME 243 
 
 daughter; and among the ancient Arabs it was the legal 
 daty of the son to marry his widowed mother. Moses, 
 on the contrary, forbade marriages between parents and 
 children, between brothers and sisters, also marriage 
 with a father's sister, with a wife's mother, and with 
 an uncle's widow. 
 
 Darwin considered that the marriage of first cousins 
 was not unfavorable to fertility. Of 97 such mar- 
 riages, 14 were sterile, whilst of 217 marriages of those 
 not akin, 35 were sterile; the percentage in both cases 
 being almost identical. Mantegazza, who regards 
 kinship in marriage as unfavorable to fertility, found, 
 nevertheless, that among 512 marriages of near kin, 
 only 8 to 9 per cent, were sterile. It is widely believed 
 that the dying out of many aristocratic families is 
 dependent on the inbreeding so common in this class 
 — but it must be admitted that scientific evidence in 
 support of this belief is lacking. Incest in the human 
 species may certainly result in fertilization. Among 
 the Jews, marriages of near kin are very common, and 
 often prove extremely fruitful. 
 
 Gohlert made a statistical investigation of the fer- 
 tility of the reigning families of Europe, in order to 
 throw light on this question. In, the jCapet dynasty, 
 118 marriages of near kin took place^ and of these 41 
 were sterile; in the Wettin dynasty (Saxony), there 
 were 28 such marriages, of which 7 were sterile, and 
 I produced one child only; in the Wittelsbach dynasty 
 (Bavaria), 29 such marriages, of which 9 were sterile, 
 and 3 produced only one child each. Thus of 175 
 marriages of near kin, 57, or 32.6 per cent, remained 
 sterile. Further, in the Hapsburg-Lothringen dynasty, 
 of no marriages, 25 were marriages of near kin, and 
 of these 33 per cent, remained sterile. 
 
 It has been assumed since the days of antiquity that 
 
244 
 
 THE SEXUAL LIFE OF WOMAN 
 
 temperament and constitution exercise some influence 
 on fertility. Hippocrates, Soranus, and Diokles, are 
 among the ancient authors who refer to this matter. 
 Soranus says very justly: "Since most marriages are 
 contracted, not from love, but for the procreation of 
 children, it is irrational, when choosing a wife, to have 
 regard, not to her probable fruitfulness, but instead of 
 this to the social position and the wealth of her parents." 
 
 It would appear that a certain dissimilarity in phy- 
 sical constitution and temperament between husband 
 and wife is favorable to the fertility of the marriage. 
 For instance, a vivacious, dark husband, and a lethargic, 
 fair wife, are better suited to one another than a hus- 
 band and wife both extremely active, or both of ex- 
 tremely phlegmatic temperament. 
 
 Toussaint Loua published the following figures re- 
 garding the fertility of the women of the various 
 countries of Europe; 
 
 Country. 
 
 Number of 
 
 births per Fertility of Women Between 
 hundred the Ages of 15 and 45 Years. 
 inhabitants. 
 
 Hungary 4.94 
 
 Russia 4.12 
 
 Austria 3.93 
 
 Germany 3.77 
 
 Italy 3.67 
 
 Holland 3.67 
 
 Finland 3.63 
 
 England 3.58 
 
 Scotland 3.53 
 
 Belgium 3.25 
 
 Denmark 3.12 
 
 Roumania 3.12 
 
 Norway 3.10 
 
 Sweden 3.05 
 
 Switzerland 3.04 
 
 Greece 2.96 
 
 Ireland 2.69 
 
 France ,,.,,,.., 2.63 
 
 Married 
 
 Unmarried 
 
 Average 
 17.8 
 20.5 
 16.4 
 
 34.8 
 
 2.9 
 
 17.7 
 
 28.8 
 
 2.4 
 
 16.1 
 
 35.3 
 
 1.0 
 
 16.0 
 
 
 
 15.8 
 
 29.7 
 
 1.6 
 
 15.5 
 
 32.8 
 
 2.5 
 
 15.8 
 
 33.7 
 
 1.8 
 
 14.8 
 
 28.5 
 
 2.8 
 
 14.4 
 13.5 
 
 29.3 
 
 2.2 
 
 14.0 
 
 29.1 
 
 2.5 
 
 13.7 
 
 29.7 
 
 1.1 
 
 13.1 
 
 ■ ■ ■ ■ 
 
 . 
 
 13.2 
 
 29.8 
 
 0.5 
 
 12.3 
 
 20.3 
 
 1.8 
 
 11.6 
 
THE SEXUAL EPOCH OF THE MENACME 245 
 
 In towns, conjugal fertility is less, extra-conjugal 
 fertility greater, than in the country. An increase in 
 factory-labor gives rise to in increase in the popula- 
 tion, but to a decline in the vitality of the offspring; 
 that is to say, it causes a quantitative increase, and a 
 qualitative decrease, in fertility. An increase in agri- 
 cultural labor has precisely the opposite effect. The 
 influence of war upon fertility is unfavorable both 
 quantitatively, and qualitatively. According to Tschou- 
 riloff, the introduction of universal military service, 
 by withdrawing for a time all the most vigorous men 
 from domestic life; tends to diminish fertility. Ex- 
 tensive emigration froni a country in which the soil 
 is fertile, and where the vital conditions are generally 
 favorable, is stated by Bertillon to cause an increased 
 fertility in the mother country; he further states that 
 an increase in the number of the proprietors of the soil 
 is followed by diminished fertility, and vice versa. 
 
 Conjugal fertility, that is to say, the ratio between 
 legitimate births and the number of married women 
 between the ages of 15 and 50 years, has declined in 
 Germany during the last decades. It was: 
 
 During the years 1872 to 1875 29.7% 
 
 During the years 1879 to 1882 27.4% 
 
 During the years 1880 to 1892 26.5% 
 
 This decline is small, but it is much more manifest 
 in urban than in rural districts. This fact is shown 
 by the following figures, relating to fertility in Prussia : 
 
 1872 to 1879. 1894 to 1897. 
 
 In all towns 26.9 24.0 
 
 In Berlin 23.8 16.9 
 
 In other large towns 26.7 23.5 
 
 In rural districts 28.8 29.0 
 
 This difference depends principally on the fact that 
 in the large towns of Germany (and still more in those 
 
246 THE SEXUAL LIFE OF WOMAN 
 
 of France) the use of means for the prevention of 
 pregnancy is continually increasing, whereas the popu- 
 lation of the rural districts is as yet less familiar with 
 the use of these measures. 
 
 According to Hellstenius, conjugal fertility, that is, 
 the number of children per married couple, is as fol- 
 lows: 
 
 In the Netherlands 4.88 
 
 Norway 4.70 
 
 Prussia 4.60 
 
 Bavaria 4.55 
 
 Sweden 4.52 
 
 Saxony 4.35 
 
 England 4.33 
 
 Belgium 4.23 
 
 Denmark 4.18 
 
 France 3.46 
 
 Tallquist, who has published a statistical investigation 
 concerning the modern tendency to diminished fer- 
 tility, arrives at lower figures than Hellstenius. Ac- 
 cording to him, conjugal fertility is : 
 
 In Prussia 4.11 
 
 England 4.10 
 
 Belgium 4.12 
 
 France 2.09 
 
 In various States of the American Union 2.5 to 3.0 
 
 From the Almanach de Gotha Vacher obtainejl 
 figures showing that each family of the higher aristo- 
 cracy has on the average the following number of 
 children: 
 
 In France 2.0 
 
 Italy 3.0 
 
 Germany 4.8 
 
 England 4.9 
 
 Russia 5.1 
 
 According to the figures we have published, the fer- 
 tility of women suffices for the production during the 
 sexual life of a small number only of children, averag- 
 
THE SEXUAL EPOCH OF THE MENACME 247 
 
 ing, in fact, 4 to 5 children per marriage. Many 
 mothers, however, give birth to a very large number 
 of children. Among 73,000 families inhabiting Buda- 
 Pesth, Korosi found 300 mothers who had had 15 chil- 
 dren or more; 7 mothers who had each had 21 children; 
 and 3 mothers who had given birth respectively to 
 22, 23 and 24 children. 
 
 A newspaper report states that the wife of a citizen 
 of Buda-Pesth, during the 43 years of her married life, 
 gave birth to 32 children. In the year 1902, a Bo- 
 hemian woman gave birth to her twenty-fourth child. 
 Stieda reports the cases of two mothers, one of whom 
 had 21, and the other 23 children. The wife of the 
 German Emperor, Albrecht I., and the wife of Prince 
 Jost of Lippe-Biesterfeld, each bore 21 children. 
 
 The so-called two-children-system obtains most com- 
 monly in France. 
 
 It is true that even in France there are on an average 
 nearly three children born per marriage; but if we take 
 into account surviving children only we find an aver- 
 age per family of 2.1 children only. Similar condi- 
 tions obtain in New England, and in Transylvania; 
 and the same practice is spreading throughout the 
 United States. Another way in which the attempt is 
 made to keep down the population is that customary 
 in Alsace, where, if there are several children in a 
 family one only marries, in order to avoid a division 
 of the family property. It cannot be denied that in 
 France, doubtless in consequence of the two-children 
 system, a somewhat widely diffused prosperity exists, 
 a projsperity which is lacking in the rare districts in 
 France, such as Brittany, in which limitation of the 
 family is not practised. What a disastrous influence 
 the general use of measures for the prevention of preg- 
 nancy exercises on the military power and political 
 
248 THE SEXUAL LIFE OF WOMAN 
 
 Status of a nation has, however, in recent years been 
 made especially manifest in the case of France. In 
 that country, of ten million families, two million are 
 absolutely childless, and two million have only one 
 child each, so that two-fifths of the French families 
 are as good as inactive in maintaining the population 
 of the country. The injury thus done to France is 
 shown still more clearly by a tabular comparison of 
 the excess of births over deaths in the German and 
 French nations, respectively, during the two decades 
 1874 to 1894 (from G. von Mayr's Population Sta- 
 tistics) . 
 
 Year Germany. France. 
 
 1874 + 13.4 +4.8 
 
 1875 13.0 2.9 
 
 1876 14.6 3.6 
 
 1877 13.6 3.9 
 
 1878 12.7 2.6 
 
 1879 13.3 2.5 
 
 1880 11.6 1.7 
 
 1881 11.5 2.9 
 
 1882 11.5 2.6 
 
 1883 11.7' 2.6 
 
 1884 11.2 2.3 
 
 1885 11.3 1.4 
 
 1886 10.8 1.5 
 
 1887 12.7 1.3 
 
 1888 12.9 2.5 
 
 1889 12.7 1.2 
 
 1890 11.3 —0.3 
 
 1891 13.6 —0.5 
 
 1892 11.7 +0.1 
 
 1893 12.2 —1.2 
 
 1894 13.6 —0.4 
 
 To what an extent in all times, and among all peoples, 
 the fertility of women was esteemed, is shown by relig- 
 ious writings and traditional customs which aimed at 
 enabling a wife who had had no children by her own 
 husband, to seek other conjugal embraces. Among the 
 Jews, it was the duty of a man to marry his widowed 
 
THE SEXUAL EPOCH OP tHE MfiNACMfi 24§ 
 
 and childless sister-in-law; if he were unwilling or 
 unable to perform this duty he was compelled to take 
 a part in a ritual termed "chaliza," in which his foot 
 was bared and the bereaved woman spat upon him, 
 because he was unwilling to maintain his brother's 
 house. In the law book of the Hindoos of Manus, 
 we read, "If husband and wife have no children, it is 
 proper for them to obtain the desired offspring by a 
 union between the wife and the husband's brother, or 
 some other relative." The child obtained in this way 
 was legally regarded as the child of the husband. Con- 
 fucius wrote: "If your wife is barren, take a second 
 wife; she must be subordinate to the first wife, for 
 her only duty is the bearing of children." An analogy 
 to this ordinance is to be found in the Bible; Abraham's 
 barren wife Sarai says to Abraham : "Behold now, the 
 Lord hath restrained me from bearing: I pray thee, go 
 in unto my maid ; it may be that I may obtain children 
 by her. And Abraham hearkened to the voice of 
 Sarai." In the same way the barren Rachel speaks 
 to her husband Jacob, "Behold my maid Billah, go in 
 unto her; and she shall bear upon my knees, that I 
 may also have children by her." 
 
 Luther, in his treatise on marital love published in 
 the year 1522, bases, doubtless on the above biblical 
 precedents, the following statement regarding fertility: 
 "If a sexually potent woman is married to an impotent 
 man, if she is unable to take any other man openly, yet 
 is unwilling to do anything dishonorable, she should 
 say to her husband, 'Dear husband, you cannot fulfil 
 your duty to me, and you have deceived my young body, 
 you have endangered my honor and my happiness, and 
 in the eye of God our marriage is null, forgive me, 
 therefore, if I form a secret union with your brother 
 or with your nearest friend; the fruit of this union 
 
250 THE SEXUAL LIFE OF WOMAN 
 
 will be yours in name, thus your possessions will not 
 fall to strangers, and you will willingly allow me to 
 deceive you, because involuntarily you have deceived 
 me." 
 
 In ethnography, the term endogamy is used to de- 
 note a law or custom by which marriage is allowed 
 only within the limits of a specified race, tribe, or 
 caste; thus, in the Old Testament, Jews are forbidden 
 to marry women of other races. The ethnographical 
 term exogamy indicates the prohibition of marriage be- 
 tween persons who are more closely allied, as, for in- 
 stance, the Mosaic prohibition of marriage within cer- 
 tain degrees of blood-relationship. Such exogamic 
 prohibitions persist even in the legislation of the present 
 day. In many ecclesiastical and national laws we find 
 the marriage of first cousins and of uncle or aunt with 
 niece or nephew forbidden; and even a prohibition 
 of the marriage of a man with his deceased wife's sister. 
 
 Hegar considers the danger of inbreeding to be very 
 great in the human species; for whereas in the lower 
 animals breeders employ a methodical and carefully 
 considered selection of the best specimens, nothing of 
 this kind occurs among human beings; and the health 
 of modern civilized man is such that there are few 
 families without a skeleton in the closet. "Not only 
 in families, but also in villages, in small and large 
 towns, even in classes, and in entire nations, certain 
 peculiar qualities, morbid tendencies, and predisposi- 
 tions, are handed down from generation to generation. 
 We have, for instance, the tendency of the Jews to 
 nervous disorders and diabetes, that of the English to 
 gout, that of the Germans to myopia." Strahan has, 
 therefore, employed the term "social consanguinity," 
 to indicate that by means of common customs, environ- 
 ment, occupation, and mode of nutrition, a similarity in 
 
THE SEXUAL EPOCH OF THE MENACME 2S1 
 
 type is produced, leading to a similar predisposition to 
 disorders and diseases transmissible from father to son. 
 
 The dangers of inbreeding are believed by Hegar to 
 be, under present-day conditions, so considerable that 
 he would allow the marriage of near kin in exceptional 
 cases only, and where the circumstances are peculiarly 
 favorable — for instance, where both parties to the pro- 
 jected marriage are in excellent health, and where there 
 is no great similarity between them in feature or mental 
 type. Certain anomalies transmitted from remote an- 
 cestors, dependent on deeply-marked peculiarities of 
 the germ cells, may be so developed by inbreeding 
 as to become absolutely fixed characteristics. If the 
 morbid manifestations can be traced back for several 
 generations, if the bodily defects and disturbances of 
 development (the so-called stigmata of degeneration), 
 are well marked and numerous, if the functional dis- 
 orders of the nervous system and of the sense organs 
 are pronounced, leading to idiocy, insanity, epilepsy, 
 congenital deafmutism, blindness, instinctive crimi- 
 nality, — there is in such cases little or no hope of the 
 regeneration of the family. It dies out, because the 
 members are sterile; because they are confined in 
 prisons or asylums ; or because the children, if any are 
 born, are deficient in vitality, and fail to reach maturity. 
 
 According to the brief summary of the subject given 
 by Hegar, the peculiarities of the offspring at the time 
 of birth depend upon: 
 
 Factors which give rise to peculiarities of the germ- 
 cells : 
 
 I. Germinal rudiments derived from the an- 
 cestors ; 
 II. Influences acting on the germ-cells within the 
 parent organism; 
 
^52 THE SEXUAL LIFE OF WOMAN 
 
 a. Owing to peculiarities of the fluids and 
 
 tissues of the parental body; 
 
 b. Owing to substances which penetrate the 
 
 parental body and reach the germ. 
 Germinal rudiments altered by the conjugation of 
 the male and female reproductive cells: 
 I. On the mother's side; 
 
 a. Owing to peculiariti'es of the fluids and 
 
 tissues of the maternal body; 
 
 b. Owing to substances which penetrate the 
 
 maternal organism and reach the fertil- 
 ized ovum. 
 II. On the father's side, owing to substances which 
 
 adhere to the paternal reproductive cells, 
 
 or are enclosed within these. 
 The number of consanguineous marriages at the 
 present day is not less than 53^ to 6>^ per 1,000; the 
 fertility of these marriages appears to be identical with 
 the fertility of ordinary marriages. Mayet has made 
 a statistical investigation to determine the influence of 
 consanguineous marriages in the pathogenesis of mental 
 disease. He finds that the number of those congenit- 
 ally affected with mental disorder is twice as great in 
 the offspring of consanguineous marriages as in the off- 
 spring of crossed marriages; in the case of simple 
 mental disorder, of paralytic dementia, and of epileptic 
 dementia, the ratio is actually greater than two to one 
 (the actual figures are 218, 257, 208 : 100). Thus we 
 see that when there exists any cause of inheritable 
 mental disorder, blood-relationship of the parents more 
 than doubles the danger to the children. In the case 
 of imbecility and idiocy the danger is less in this respect 
 (the ratio is 150 : 100) ; the factor of inheritance plays 
 a less prominent part than in the case of other psychoses. 
 It was remarkable that among the offspring of mar- 
 
THE SEXUAL EPOCH OF THE MENACME 253 
 
 riages of nephew and aunt, cases of mental disorder 
 were almost entirely lacking.- Among the offspring of 
 marriages of uncle and niece, the inheritance of mental 
 disorder was more prominent than among the children 
 of first cousins. It is interesting to determine the in- 
 fluence of blood-relationship in cases in which the exist- 
 ence of inheritable predisposition could not be proved. 
 In these cases, as regards simple insanity, paralytic 
 dementia, and epileptic dementia, the number of cases 
 among the offspring of consanguineous marriages was 
 only one-half as compared with the offspring of crossed 
 marriages ; whereas in the case of imbecility and idiocy 
 this ratio was reversed. In idiocy, where inheritance, 
 generally speaking, plays a small part, the origination 
 of the disease would often appear to depend directly 
 on the blood- relationship of the parents; whilst as Re- 
 gards other forms of mental disorder, if there is no 
 inheritable predisposition, blood relationship in the 
 parents appears to be a positive advantage; where, 
 however, a family predisposition to insanity exists the 
 likelihood of actual insanity appearing in the offspring 
 is notably enhanced by a consanguineous marriage. 
 
 The Restriction of Fertility and the Use of Means for 
 the Prevention of Pregnancy 
 
 As we have already pointed out, a restriction of the 
 fertility of women occurs in the majority of marriages, 
 to this extent, that the potential reproductive powers 
 of the wife are not fully utilized. In recent times, 
 however, the restriction of fertility, by the deliberate 
 use of measures for the prevention of pregnancy, has 
 become so widely diffused, that it appears unwise from 
 the scientific standpoint simply to ignore the question, 
 and it has become indispensable to study how the 
 practice developed, and to consider what are its actual 
 
254- THE SEXUAL LIFE OF WOMAN 
 
 results. From our own point of view, it is the more 
 necessary to do this, for the reason that the use of pre- 
 ventive measures has come to play an important part 
 in the sexual life of woman, and therefore deserves the 
 fullest attention, not merely from the standpoint of 
 the sociologist, but in addition from the purely medical 
 point of view. 
 
 In many divisions of the population, and even in 
 entire nationalities, the prevention of pregnancy, not 
 merely in illicit intercourse, but also in married life, 
 has become so general a practice that the fertility of 
 the nation as a whole has been profoundly modified. 
 Thus, in France at the present day, the average number 
 of children per marriage is less than two; and the 
 two-children-system is almost universally practised in 
 Transylvania and Norway, whilst it is very rapidly 
 spreading in North America. In the principal towns 
 of the whole of Europe, this system is largely on the 
 increase among the upper classes of society. The mar- 
 riages of the poor, partly owing to ignorance and 
 partly to indolence, are as yet comparatively little 
 affected by this depopulative principle. 
 
 In the days of antiquity, many lawgivers endeavored 
 to set bounds to excessive fertility, and artificial abor- 
 tion was methodically practised by those who wished 
 to avoid an inconveniently large family. Even among 
 savage peoples, we find that certain preventive meas- 
 ures are occasionally employed in sexual intercourse. 
 Among civilized peoples, however, until the beginning 
 of the nineteenth century, religious and moral ideas 
 derived from the Bible continued to dominate the 
 sexual life. It is well known that Old Testament law 
 and Christian morality alike forbid any artificial re- 
 striction of human increase. "Increase and multiply" 
 was the command given in Genesis to the first parents 
 
THE SEXUAL EPOCH OF THE MENACME 255 
 
 of the race; and the psalmist exclaims, "Happy is the 
 man that hath his quiver full". of children. 
 
 A remarkable revolution in thought was initiated 
 toward the beginning of the nineteenth century by the 
 great philanthropist and powerful thinker, Thomas 
 Robert Malthus, founder of the doctrine of the pro- 
 priety of checking the increase of population, author 
 of the work "An Essay on the Principle of Population," 
 London, 1798, whose Law of Population soon attracted 
 world-wide attention. Modern civilization having 
 greatly increased the cost of bringing up a family, while 
 simultaneously there has been a general rise in the 
 price of the necessaries of life, there has resulted an 
 extraordinary diffusion of Malthusianism; in compari- 
 son with the causes just alluded to for the use of pre- 
 ventive measures, diseases which render renewal of 
 pregnancy dangerous to the mother's life have com- 
 paratively little to do with the causation of voluntary 
 sterility. 
 
 In his Essay on the Principle of Population;, 
 Malthus indicates, as the cause which has hitherto 
 hindered mankind in the pursuit of happiness, the 
 unceasing tendency of all organic life to increase in 
 excess of the means of subsistence. In the case of 
 plants and of unreasoning animals, the natural process 
 is a very simple one. Both animals and plants are" 
 impelled by a powerful instinct to reproduce their 
 kind, and the operation of this instinct is quite undis- 
 turbed by any anxiety regarding the livelihood of their 
 offspring. The reproductive function is thus exercised 
 at every available opportunity, and the superfluous in- 
 dividuals of the next generation are destroyed by lack 
 of space and nutriment. In the human species the re- 
 striction of population is effected by a more complex 
 mode of operation. Man is impelled to reproduce his 
 kind by an instinct not less powerful than that of other 
 
256 THE SEXUAL LIFE OF WOMAN 
 
 animals ; but the gratification of this instinct is checked 
 by reason, which makes him ask himself whether he 
 is not about to bring into the world beings for whom 
 he will be unable to provide the means of subsistence. 
 If he is influenced by this consideration, the resulting 
 restriction of population may often entail serious conse- 
 quences ; if, on the other hand, he gratifies his instinct, 
 regardless of the appeal of reason, the human species 
 will inevitably tend to increase more rapidly than the 
 means of subsistence. 
 
 Malthus declared that population, when its increase 
 was unrestricted, doubled itself every twenty-five years, 
 and therefore increased in a geometrical progression; 
 he considered that in the most favorable circumstances 
 the means of subsistence could not possibly increase 
 more rapidly than in an arithmetical progression. The 
 contrast between these two modes of increase will be 
 more striking if we write out the actual figures. Ac- 
 cording to the theory of Malthus, the increase of human 
 population would be represented by the figures i, 2, 
 4, 8, 16, 32, 64, 128, 256, whereas the simultaneous 
 increase in the means of subsistence would be repre- 
 sented by the figures i, 2, 3, 4, 5, 6, 7, 8, 9. Such an 
 increase in population is, however, always prevented 
 by certain checks, classed by Malthus as of two kinds, 
 preventive checks and positive checks. 
 
 A preventive check, in so far as it is voluntary, is 
 peculiar to the human species, and originates in the 
 intellectual faculty which enables man to foresee the 
 consequences of his actions. A man who looks around 
 him, and sees the poverty into which those with large 
 families so often fall, who reckons up his present prop- 
 erty or earnings, which barely suffice to provide for 
 his own personal necessities, cannot fail, when he con- 
 siders how hardly they would suffice for seven or eight 
 
THE SEXUAL EPOCH OF THE MENACME 257 
 
 additional persons, to doubt whether it would be pos- 
 sible for him to provide for the offspring he might 
 bring into the world. Such considerations as these 
 are likely to lead a large number of persons of all 
 civilized nations to resist their natural instincts, and 
 to refrain from early marriage. If abstinence entailed 
 no serious consequences, it would be the least of all 
 evils resulting from the principle of population. 
 
 The positive checks to increase of population are 
 manifold, and embrace all the causes which are com- 
 petent to lessen the natural duration of human life. 
 Among these we may enumerate: all unhealthy occu- 
 pations, severe toil, climatic conditions, poverty, errors 
 in the rearing of children, town life, excesses of all 
 kinds, the whole army of illnesses and epidemics, war, 
 pestilence, and famine. In all countries, preventive 
 and positive checks are more or less powerfully opera- 
 tive, and yet there are few in which the population 
 is not continually tending to increase beyond the means 
 of subsistence. As a further consequence of this ten- 
 dency of population to increase, we observe the wider 
 diffusion of poverty among the lower classes, so that 
 any permanent improvement in their condition is ren- 
 dered impossible. 
 
 After Malthus had carefully stated his thesis, he gave 
 a summary record of the conditions of population in 
 nearly all nations of the past and of his own time, in 
 order to show how in all alike the three principal means 
 of limiting population, moral restraint, disease and 
 poverty, had been in continuous operation. 
 
 He showed, for instance, how the population of the 
 South Sea Islands had been limited by certain condi- 
 tions, cannibalism, castration of the males, infibulation 
 of the females, late marriages, the sanctification of 
 virginity, contempt for marriage, etc. 
 
258 THE SEXUAL LIFE OF WOMAN 
 
 In ancient Greece, Solon's laws permitted infanti- 
 cide. Plato, in "The Republic," asserts that it is the 
 duty of the Government to regulate the number of the 
 citizens, and to prevent an immoderate increase; men 
 and women should be allowed to procreate only during 
 their period of maximum strength, all weakly children 
 should be killed. Aristotle advised that men should 
 not be allowed to marry before the age of 37, and 
 women before the age of 18; the women should give 
 birth to a limited number of children only; if,' after 
 this, they again became pregnant, abortion should be in- 
 duced. He maintained that if all were at liberty, as 
 was the case in most countries, to bring into the world 
 as many children as they pleased, poverty, the mother 
 of crime and insurrection, must inevitably ensue. 
 
 Among the Romans war was as a positive check un- 
 ceasingly operative: in this time of the Empire, pre- 
 ventive methods came into general use, in the form of 
 various kinds of sexual perversity. Juvenal complains 
 of the skilled methods employed in the induction of 
 abortion; during the later period of the Roman Em- 
 pire, sexual morality became so degenerate that mar- 
 riage was hated and despised. 
 
 Passing to the consideration of the checks on popula- 
 tion among the nations of modern Europe, Malthus 
 examined the registers of marriages and deaths, and 
 came to the conclusion that in few countries is the 
 mass of people sufficiently capable of self-restraint to 
 postpone marriage until they are reasonably assured of 
 being able to provide for all the children they are likely 
 to have; still, he ascertained that at the present day 
 positive checks on population were less active, and 
 preventive checks more active, than in earlier times and 
 among savage races. 
 
 Malthus did not base upon his conclusions the advice 
 
THE SEXUAL EPOCH OF THE MENACME 259 
 
 that in sexual intercourse means of preventing preg- 
 nancy should be employed, as the modern "Malthusi- 
 ans" advise ; in his eyes, moral restraint, that is to say, 
 sexual abstinence, w^as the only remedy for the pre- 
 vention of poverty and the other evil consequences of 
 the principle of population. Moral restraint was, in 
 his opinion, the only virtuous method of avoiding the 
 evils of excessive fertility. It is a man's duty not to 
 marry until he had a definite prospect of being able 
 to maintain his children ; the interval between puberty 
 and marriage must be passed in strict chastity. Man's 
 duty is not the mere reproduction of his species, but 
 the reproduction of virtue and happiness, and if he 
 is not able to do the latter, he has no right whatever 
 to do the former. Malthus lays great stress on educat- 
 ing the people in this matter; "in addition to the or- 
 dinary subjects of instruction, it is necessary to explain 
 the principle of population, and the manner in which 
 it gives rise to poverty." In the nature of" the case, 
 no lasting and general improvement in the condition 
 of the poor is possible without an increase in the pre- 
 ventive restriction of population. 
 
 The Malthusian doctrine of the law of population 
 gave rise to an enormous sensation, and some of his 
 disciples soon proceeded to translate his conclusions 
 into practice; such authorities as James Mill and 
 Francis Place recommended measures by means of 
 which, "without any injury to health, or to the feminine 
 sense of delicacy, conception can be prevented:" the 
 avowed aim of these measures was to prevent the in- 
 crease of population beyond the means of subsistence. 
 Physicians and physiologists joined the ranks of these 
 innovators; among others Raciborski, Robert Dale 
 Owen in his Moral Physiology, Richard Carlile in his 
 Book of Woman, the first work to give an exact de- 
 
260 THE SEXUAL LIFE OF WOMAN 
 
 scription of the means to employ for the prevention 
 of conception, Knowlton in his Fruits of Philosophy. 
 In the year 1827 in the northern counties of England 
 leaflets were for the first time distributed among the 
 working classes to instruct them in the use of preventive 
 measures. Bradlaugh founded the Malthusian So- 
 ciety, which aimed at the dissemination of instruction 
 in the use of preventive methods. There is now in 
 England a "Malthusian League," numbering leading 
 physicians among its members; this supplies to all 
 classes the means by which, the family can be artificially 
 limited. A new edition of the above-mentioned book, 
 The Fruits of Philosophy^ was circulated in London in 
 an edition of several hundred thousand copies, and 
 prominent persons spoke at congresses on the subject 
 of Neo-Malthusianism. In Germany, also, a "Union 
 of Social Harmony" was founded, for the free distri- 
 bution of a hand-book on the use of measures for the 
 prevention of conception, and for an investigation re- 
 garding the results of these. 
 
 We do not propose here to subject the teaching of 
 Malthus to a critical examination; he has found for- 
 midable opponents, who have endeavored to prove that 
 his fundamental assumption is false; they maintain that 
 work or the power of work increases in direct ratio with 
 the population; and they also assert that population 
 tends to increase, not, as Malthus maintained, in a 
 geometrical, but simply in an arithmetical progression. 
 We shall merely quote Liebig's reply to the law of 
 Malthus*, "when human labor and manure are pro- 
 vided in sufficient quantity, the soil is inexhaustible, 
 and will continue to yield unceasingly, the most abun- 
 dant harvests"; and Rodbertus' remark that "agri- 
 cultural chemistry will ultimately be competent to 
 create nutritive materials; this will some day be just 
 
THE SEXUAL EPOCH OF THE MENACME 261 
 
 as much within the power of society, as it is at present 
 to provide any requisite quantity of textiles, given the 
 necessary amount of raw material." The celebrated 
 socialist Bebel, is a strong opponent of Malthus. He 
 writes: "The earth is doubtless thickly populated, but 
 none the less only a small fraction of its surface is 
 occupied and utilized. Not merely could Great Brit- 
 ain produce, as has been proved, a far larger supply 
 of nutritive materials than at present, but the same is 
 true of France, Germany and Austria, and in a still 
 higher degree of the other countries of Europe. 
 European Russia, were it as thickly populated as Ger- 
 many, could support, instead of ninety millions, as at 
 present, a population of four hundred and seventy-five 
 millions. For the purposes of the higher civilization, 
 toward which we are striving, we have to-day in 
 Europe, and shall have for a long time to come, not 
 an excess of population, but an insufficiency, and every 
 day brings new discoveries and inventions whereby the 
 means of subsistence are potentially increased. In 
 other parts of the world, the insufficiency of population 
 and the superfluity of ground are even more noticeable. 
 Carey is of opinion that the single valley of the Ori- 
 noco, fifteen hundred miles in length, would suffice to 
 provide nutritive material in sufficient quantities to feed 
 the whole existing population of the world. Central 
 and South America, and more especially Brazil, have 
 a soil of extraordinary fertility, but are as yet prac- 
 tically unutilized by the world. To increase, not to 
 diminish, the numbers of the human race, that is the 
 appeal made by civilization to mankind!" A similar 
 position on this question was recently taken by Roose- 
 velt, ex-President of the United States, himself the 
 father of six children, in a letter ,to two American 
 women, Mrs. J. and M. Van Vorst, authors of the 
 
262 THE SEXUAL LIFE OF WOMAN 
 
 book Woman Who Toils {Factory Life in America). 
 In this book, the writers prove that in the United States 
 the average size of the family is now less than in any 
 other country of the world, France alone excepted. 
 
 Roosevelt, in his letter, declared himself an ar- 
 dent supporter of the biblical injunction, "increase 
 and multiply!" He writes: "Whoever evades his 
 responsibilities, through desire for independence, con- 
 venience, and luxury, commits a crime against the race 
 to which he belongs, and should be an object of con- 
 tempt and horror to a healthy nation. When men 
 avoid becoming fathers of families, and when women 
 cease to regard motherhood as the most important 
 career open to them, the nation to which these men 
 and women belong has cause for uneasiness about its 
 future. To the American woman marriage is no longer 
 a life-duty, a profession, as it is to her sisters who are 
 members of the older civilizations. A woman who 
 manages an extensive business, who supervises her own 
 landed property, or who plays her own part in the 
 world of finance, — for such as these, the 'lottery of 
 marriage' is naturally something they dread rather than 
 desire." 
 
 Eliot, ex-President of Harvard University, has ex- 
 pressed similar views in a speech on this subject. He 
 deplores the late marriages and small families of the 
 cultured Americans. According to the last census, an 
 American family has on the average less than three 
 children; twenty years ago the average number was 
 from four to five children. 
 
 I pass now to consider the medical point of view 
 of this question of the prevention of pregnancy. It is 
 my opinion that the physician as such should intervene 
 in the matter, not in any case for the relief of the 
 dominant economic parental dread of insufficient means 
 
THE SEXUAL EPOCH OF THE MENACME 263 
 
 for the upbringing of children, but only on account of 
 the purely medical consideration of the physical dangers 
 of motherhood. That is to say, the physician should 
 lend his skilled assistance toward the attainment of 
 facultative sterility, only when his own special scientific 
 knowledge leads him to consider this urgently neces- 
 sary; it is not his province to assist in preventing the 
 birth of an immoderate number of offspring; his inter- 
 vention is justified only when deliberate reflection has 
 convinced him that his patient's health or life would 
 be endangered by pregnancy or child-birth. A wom- 
 an's life and well-being must appear to him of greater 
 importance than the existence or non-existence of a 
 possible infant. That this view is morally sound, is 
 shown by the fact that public opinion justifies the ac- 
 coucheur in the destruction of an already living child, 
 when the mother's life is endangered. In this connec- 
 tion we may recall the words of the great Napoleon: 
 The physician Dubois, attending Marie Louise in a 
 difficult confinement, asked Napoleon whether, if mat- 
 ters came to an extremity, he should save the mother 
 or the child ; Napoleon, notwithstanding his strong de- 
 sire for the birth of an heir to his dynasty, replied, 
 "The mother, it is her right." 
 
 In isolated cases, which deserve always very serious 
 consideration, some pathological condition in the wife 
 may justify the prevention of pregnancy. In certain 
 very serious general disorders, in diseases of the heart 
 or of the lungs, in pelvic deformity, and in pathological 
 changes of the female reproductive organs, it may be 
 right to employ means for the prevention of preg- 
 nancy — not merely sexual abstinence, but actual meas- 
 ures to prevent fertilization. 
 
 The misuse of medical knowledge for the recom- 
 mendation or employment of preventive measures, on 
 
264 THE SEXUAL LIFE OF WOMAN 
 
 the ground of humanitarian sentiment or social and 
 economic considerations, must, however, be strongly 
 resisted. Even leading gynecologists have erred in this 
 way. Sanger writes, "Scientifically-trained accoucheurs 
 will do much more to promote the health and well- 
 being of women, and to protect them from sexual and 
 other diseases, than the humanitarian efforts of the 
 Neo-Malthusians, who transfer a purely scientific ques- 
 tion, such as the disproportion between the number of 
 births and the supply of nutritive material, to the sphere 
 of medicine, regarding themselves as justified in pre- 
 venting conception whenever they please, independently 
 of considerations relating to the health of the mother. 
 *»******^ woman exhausted by frequent 
 child-bearing, anaemic and suffering, is certainly a figure 
 to arouse everyone's sympathy; in so far as she is ill 
 in consequence of injury received in childbirth, it is 
 our duty to prevent further injury, and to relieve to 
 the best of our ability that which has already occurred; 
 in so far, however, as she is not suffering from any 
 affection of the reproductive organs, but is ill owing 
 to the lack of sufficient food, or from overwork, it is 
 the duty of society to render assistance. Here we have 
 to do with the social problem; the solution of which 
 will be brought no nearer by the use of the occlusive 
 pessary." Fehling also maintained that a text-book of 
 gynecology is not the proper place in which to pass 
 judgment on so important a socio-political question. 
 The business of the gynecologist in this matter is merely 
 to say a word of caution against the use of various 
 measures which are so often recommended as harmless, 
 but are in fact dangerous to the woman who uses them. 
 Kleinwachter, who declares that he is far from rec- 
 ommending the use of preventive measures when a 
 healthy woman wishes to save herself the trouble of 
 
THE SEXUAL EPOCH OE THE MENACME 265 
 
 child-bearing, gives as legitimate indications for their 
 use: I, the various forms of severe pelvic deformity; 
 2, certain tumors in the pelvic cavity; 3, after the re- 
 moval of malignant tumors of the reproductive organs, 
 certain general disorders, recently arrested pulmonary 
 tuberculosis, organic heart disease, etc. Regarding 
 these cases, Kleinwachter writes: "The wife's life 
 would be endangered by pregnancy, which must there- 
 fore be prevented without forbidding coitus, and avoid- 
 ing the practice of coitus interruptus, which endangers 
 her health, or of any mode of intercourse repugnant 
 to the feelings of wife or husband." 
 
 The most trustworthy, but unquestionably at the same 
 time the least practicable method, for the prevention 
 of pregnancy, is that of Malthus — permanent sexual 
 continence. This recommendation, to which Tolstoi 
 in The Kreutzer Sonata gives his adhesion, has re- 
 cently found an advocate in a modified sense in a dis- 
 tinguished gynecologist, Hegar, who considers that the 
 great fertility of the modern civilized countries of 
 Europe entails many disadvantages — inferior physical 
 development, increased general mortality, emigration, 
 an unfavorable distribution of population in relation 
 to dwelling and occupation, occasional famine — and 
 who sees the only effective remedy in a "regulation of 
 reproduction," whereby the tendency to marriage and 
 the number of births are to be diminished. The ques- 
 tion "when is the number of children in a family too 
 large?" is answered by Hegar as follows: "A maximal 
 limit is easy to establish. The most suitable age for 
 child-bearing is from twenty to forty. At an earlier 
 and a later age than this, both the mother and the off- 
 spring are liable to suffer. Between two successive 
 births there should be an interval of about two and a 
 half years; this would leave time for the birth of eight 
 
266 THE SEXUAL LIFE OF WOMAN 
 
 children. If we assume that pregnancy lasts nine 
 nxonths, that lactation is continued from nine to twelve 
 months after delivery (and if the mother does not her- 
 self nurse the child, artificial feeding or careful super- 
 vision of the wet-nurse will occupy her for a like 
 period), to devote an additional period of six months 
 to nine months to the complete restoration of the 
 mother's health cannot be regarded as excessive. For 
 this maximum family we assume a perfect state of 
 health on the part of the mother, a pure atmosphere, 
 and a sufficient supply of all the necessaries of life. 
 Illnesses, weakness, or infirmity of the mother, often 
 indicates that the number of children should be further 
 limited. It is easier to provide a suitable dwelling 
 and a pure atmosphere for a small family than for 
 a large one. The same thing is true as regards the 
 means of subsistence. 
 
 "If the reproductive function is to be intelligently 
 controlled," continues Hegar, "above all it is necessary 
 to devote attention to the age and health of the parents ; 
 but occupation, dwelling, and general environment, 
 must also not be overlooked. Among the cultured 
 classes of our Fatherland, people are gradually learn- 
 ing to form sound opinions about these matters. 
 Among the working classes, on the other hand, especial- 
 ly among those engaged in factory labor, the heedless 
 gratification of the sexual impulse is responsible for 
 untold misery." Hegar's advice may be summarized 
 as follows : If the marriage takes place after the attain- 
 ment of complete maturity, in the wife at twenty and 
 in the husband at twenty-five, and if procreation is 
 discontinued in the wife at forty and in the husband 
 at forty-five to fifty, if between successive deliveries 
 the intervals necessary for the wife's restoration to 
 health are maintained, if illness and states of debility 
 
THE SEXUAL EPOCH OF THE MENACME 267 
 
 are taken into account, if sickly, hereditarily-tainted 
 individuals are forbidden to marry — the excessive in- 
 crease in population, as far as Germany is concerned, 
 will cease to give cause for anxiety. The regulation 
 of reproduction will, however, still be incomplete, un- 
 less we enforce a selection too rigorous for our present 
 views. Moderation and continence must aid as far 
 as may be necessary in preventing an undue increase 
 in population. Hegar does not fail to point out the 
 evil effects of an excessive limitation of the family. 
 
 In a marriage when only one child is born, this child 
 is the object of unceasing anxiety and attention, and 
 real or imaginary dangers assume an excessive impor- 
 tance in the morbidly excited imagination of the 
 parents. Hence we find a continuous excess of watch- 
 fulness and over-education in the case of the only child, 
 to whom independent thought and action are entirely 
 unknown. Boys become milksops, girls nervous and 
 hysterical. In the two-children-system, again, one or 
 both of the children may die when the age of the 
 parents is already considerably advanced. Still, in 
 those districts of France in which this system obtains 
 the population is well-to-do, and an exceptionally large 
 proportion of the males are fit for military service. 
 The use of various measures for the prevention of con- 
 ception is considered by Hegar to be harmful, at any 
 rate in the case of young women; this practice gives 
 rise to anaemic conditions, and to nervous weakness and 
 irritability, seldom, however, to more serious disorders, 
 as, indeed, is apparent from the fact that the mortality 
 of married women as compared with unmarried women 
 is lower in France than in other countries. 
 
 Grafe, with referen<:e to the view that if for any 
 reason conception must be prevented, this should be 
 done by abstinence from sexual intercourse, remarks: 
 
268 THE SEXUAL LIFE OP WOMAN 
 
 "Doubtless an ideal demand, but one which even those 
 with exceptional strength of will are unlikely to satisfy. 
 And the worst of it is, that even a single indiscretion 
 will often result in impregnation. Moreover, it is 
 distinctly contrary to natural conditions, that a healthy 
 married couple united by an intimate affection should 
 live together abstaining completely from sexual inter- 
 course. The question has already been much discussed, 
 both in speech and writing, and this will continue in 
 the future, without altering the fact that the physician 
 will be asked, and will be compelled to give, advice 
 regarding the use of means for the prevention of preg- 
 nancy." 
 
 Ribbing writes, "Although the sexual impulse is the 
 product of a powerful natural developmental force, 
 still the temporary, and sometimes even the permanent, 
 control of this impulse is a moral civilizing force of 
 enormous importance." This writer is opposed to the 
 use of artificial preventive measures; he considers them 
 untrustworthy and dangerous to health. Untrust- 
 worthy, for the reason that nature has endowed living 
 organisms with a strong impulse toward conjugation 
 and has equipped with very powerful forces the proc- 
 esses by which fertilization is effected. Every phy- 
 sician is familiar with cases in which preventive meas- 
 ures have proved ineffective. This fact is proved also 
 by the statistics of prostitution. Although prostitutes 
 are fully instructed in the use of preventive measures, 
 which they almost universally employ, nevertheless 
 every year a smaller or larger number of prostitutes 
 become pregnant. These measures are dangerous to 
 health, partly because of their interference with natural 
 functions, because many of them are clumsy and ill 
 adapted; and partly, again, because owing to their use 
 the woman fails to enjoy the natural periods of repose 
 
THE SEXUAL EPOCH OF THE MENACME 269 
 
 which are entailed by pregnancy, parturition, and lacta- 
 tion. Noteworthy, also, are the psychical considera- 
 tions adduced by Ribbing against the use of preventive 
 measures. The majority of well-bred women feel 
 deeply wounded if they believe themselves to be re- 
 garded merely as a means of enjoyment, not as individ- 
 uals, as persons with inalienable rights. For the man 
 also there is danger, for it is easy for him to acquire 
 a dislike to the wife who, even though on his own initia- 
 tive, occupies herself with the technique of the sexual 
 life in a manner which he feels instinctively to be 
 opposed to the chastity and pure-mindedness demanded 
 by every man from his wife. Ribbing, therefore, ad- 
 vises a certain measure of sexual abstinence in married 
 life. 
 
 Max Nordau also insists on the moral disadvantages 
 of the wide diffusion of the use of preventive measures. 
 "If a race or nation has reached this point in its down- 
 ward career, the individuals of which it is composed 
 lose the capacity of loving in a healthy and natural 
 manner. The sense of the family disappears; the men 
 will not marry, because they find it inconvenient to 
 burden themselves with the responsibility for another 
 human life, and to care for any other creature than 
 themselves; the women dread the pains and inconven- 
 iences of motherhood, and if they marry, they endeavor, 
 by the employment of the most immoral means, to in- 
 sure barrenness. The reproductive instinct, of which 
 reproduction has ceased to be the aim, is in some an- 
 nulled, whilst in others it degenerates into the most 
 peculiar and irrational perversities. The act of sexual 
 union, the most sublime function of the organism, is 
 degraded into a profligate act of lust; it is no longer 
 undertaken in the interest of the perpetuation of the 
 species, but exclusively for the pleasure of the individ- 
 
270 THE SEXUAL' LIFE OF WOMAN 
 
 ual, and without any relation to the needs of the com- 
 munity." 
 
 Alfred Russel Wallace has advocated sexual conti- 
 nence as a preventive measure during the period of 
 maximum vitality and strength ; he advises that the age 
 of marriage of women should be considerably ad- 
 vanced, in order to diminish their fertility. If wom- 
 an's average age at marriage were 29, instead of 20 
 years, the fertility of marriages would be reduced in 
 the ratio of 8:5. 
 
 The desired goal of artificial sterility will not, how- 
 ever, be reached through the advocacy of moderation 
 and continence. The numerous additional measures 
 employed for this purpose may be classified as physio- 
 logical and artificial; the latter class may be further 
 subdivided into mechanical and operative. 
 
 By physiological means for the prevention of con- 
 ception, we understand measures which aim at produc- 
 ing sterility by reducing the number of acts of inter- 
 course and by restricting these acts to certain defined 
 periods of time. The physiological preventive meas- 
 ures, apart from the higher ethical value they possess 
 in comparison with artificial measures, have the ad- 
 vantage that they may be regarded as harmless to the 
 general health of the woman and to the integrity of her 
 reproductive organs in particular; they have, however, 
 this very serious dis'advantage, that the results of their 
 use are very uncertain, so that they offer no more than 
 a probability, and often a very moderate probability, 
 that conception will be prevented. 
 
 As a physiological measure for the attainment of 
 facultative sterility "without breaking any moral law," 
 Capellmann advised abstinence from coitus during a 
 period of fourteen days after menstruation and three 
 to four days before the commencement of the flow. 
 
THE SEXUAL EPOCH OP THE MENACME 27! 
 
 Without laying too much stress on the fact that by 
 following this recommendation the period during 
 which the intercourse is permissible would be extremely 
 restricted, it is necessary to point out that, whilst in 
 this way the occurrence of conception may be rendered 
 less probable, its prevention is by no means guaranteed, 
 for it is an established fact that a woman may be im- 
 pregnated by intercourse on any single day of the inter- 
 menstrual interval. Capellmann's advice, embodying, 
 as he expresses it, the "only morally permissible" means 
 for the prevention of conception, was not original, for 
 the same recommendation was given at an earlier date 
 by Raciborski, who, however, regarded the measure as 
 very uncertain. Capellmann is of opinion that it is 
 sufficiently trustworthy for practical purposes. 
 
 Bebel, who is a declared opponent of Malthusianism, 
 none the less lays down positive rules for the diminu- 
 tion of procreative capacity and of fertility by regula- 
 tion of the diet. He refers to the example of the bees, 
 which, by a change of nutriment, can produce a new 
 queen-bee at will. "Thus the bees," he says, "are in 
 advance of human beings in their knowledge of sexual 
 development. Presumably they have not been com- 
 pelled, for a couple of thousand years, to listen to ser- 
 mons informing them that to occupy themselves about 
 sexual matters is 'improper' and 'immoral.' There is 
 no doubt whatever that the modfc of nutrition has an 
 influence on the composition of the male semen, and 
 also on the susceptibility to fertilization of the female 
 ovum ; hence the increase in population must to a very 
 important extent depend on the mode of nutrition. If 
 this could be definitely established, we should have, in 
 the supply of nutriment, a means of regulating the 
 population. As an example of the effect, in this con- 
 nection, of the mode of nutrition in the human species, 
 
272 THE SEXUAt LIFE OF WOMAN 
 
 it is reported that in consequence of the fatty and 
 nutritious diet of the old Bavarian peasants, who lived 
 chiefly on very rich puddings, the marriages of the 
 well-to-do peasants were frequently childless. How- 
 ever, it must not be forgotten that pre-conjugal inter- 
 course, which was customary in that part of the world^ 
 and was somewhat promiscuous in character, may have 
 contributed to cause this sterility." Finally, Bebel 
 points out that the woman of the future "will be un- 
 willing to bear a large number of children. She will 
 wish to enjoy a measure of personal freedom and in- 
 dependence, and will not consent to pass half or three- 
 quarters of the best years of her life either pregnant, 
 or with a child at her breast. From this it will result 
 that the population will be regulated, without unwhole- 
 some sexual abstinence, and without the employment 
 of unpleasant preventive measures." However, Bebel 
 gives us no details as to the precise manner in which 
 this regulation is to be efifected. 
 
 Tolstoi, in his widely celebrated book The Kreutzer 
 Sonata, condemns absolutely the gratification of the 
 sexual impulse. He demands the recognition of the 
 fact that "sexual congress, in which a man either avoids 
 the natural consequences — the birth of children, — or 
 else throws the whole burden of these consequences on 
 the woman, is opposed to the simplest demands of 
 morality, is, in fact, utterly base." To render possible 
 the sexual abstinence he regards as morally necessary, 
 men must not only endeavor to live in a natural way, 
 but they must consume no alcohol, eat with great mod- 
 eration, abstain from meat, and not be afraid of hard 
 work. Tolstoi even demands that men and women 
 shall be so brought up "that both before and after mar- 
 riage they may regard love, and the sensual passion 
 associated therewith, not as they do at present, as a 
 
THE SEXUAL EPOCH OF THE MENACME 273 
 
 sublime and poetical state, but as a bestial condition 
 degrading to humanity.'^ Tolstoi is, however, utterly 
 opposed to the use of preventive measures: "first, be- 
 cause they liberate men from the cares and sorrows 
 entailed by having children, which must be regarded 
 as the penance to be paid for sensual love; and, 
 secondly, because their use is closely allied to the crime 
 most repugnant to the human conscience, the crime 
 of murder." Chastity is no less a duty after marriage 
 than before; after marriage man and wife must "con- 
 tinue to pray to be delivered from temptation, and 
 must endeavor to replace sensual love by the pure 
 relationship of brother and sister." 
 
 Eulenburg regards the modern diffusion and the 
 continuous increase in the use of preventive measures 
 as signs of decadence; Lowenfeld, on the other hand, 
 regarding the social conditions of the present day as 
 the principal source of the use of preventive measures, 
 sees therein no moral decay, but on the contrary rather 
 a rise in the moral standard of life. 
 
 Another physiological means of prevention is to be 
 found in avoiding cohabitation in that season or month 
 in which, judging by the woman's previous deliveries, 
 she would appear to have been peculiarly susceptible 
 to impregnation. Cohnstein maintained that in wom- 
 an, as in the lower animals, the capacity for concep- 
 tion was associated with a particular season of the year, 
 that there was, in fact, an individual time of predilec- 
 tion for impregnation. The assumption that there is 
 such a time of predilection is, however, traversed by 
 the fact, familiar to all who have recorded the birth- 
 days of children in large families, that these occur in 
 the most diverse months of the year. It has, indeed, 
 been statistically proved that certain months and sea- 
 sons are especially favorable to conception, that a maxi- 
 
274 THE SEXUAL LIFE OF WOMAN 
 
 mum of conceptions occurs in the spring, and a second 
 much smaller maximum in the winter ; but these varia- 
 tions in the number of conceptions depend mainly on 
 social factors, as, for instance, upon the customary sea- 
 son for marriage, opportunity for intercourse between 
 the sexes, common labors in the house or in the open, 
 etc. This alleged time of predilection for conception 
 cannot, therefore, seriously be considered in the dis- 
 cussion of measures for the prevention of pregnancy. 
 As a physiological means for preventing conception, 
 passivity of the woman during sexual intercourse has 
 also been recommended. It is well known that an 
 active participation on the part of the woman in the 
 sexual act, by increasing her voluptuous sensations, 
 gives rise to certain reflex actions, viz., descent of the 
 uterus, rounding of the os uteri, induration of the portio 
 vaginalis, and, finally, ejaculation of the secretion of 
 the cervical glands and of the glands of Bartholin; 
 these changes accelerate the entrance of the semen into 
 the cavity of the uterus, and increase the motility of the 
 spermatozoa. Upon this fact is based the assumption, 
 that, in consequence of deficient sexual excitement dur- 
 ing intercourse, either spontaneous, or when the woman 
 intentionally remains "cold," the reflex actions by 
 which the upward passage of the spermatozoa is 
 favored, fail to occur; there is a good deal of evidence 
 in favor of the truth of this view. Riedel reports 
 regarding the women of the Island of Buru, that they 
 often have sexual intercourse with strange men, "but 
 during sexual congress in such cases they maintain a 
 passive and indifferent state, for the purpose of avoid- 
 ing impregnation." Von Krafft-Ebing points out that 
 prostitutes, when having sexual intercourse with men 
 to whom they are attached, experience voluptuous ex- 
 citement, whilst in intercourse with men to whom they 
 
THE SEXUAL EPOCH OF THE MENACME 276 
 
 are indifferent they remain entirely passive. From 
 this it would appear that these uterine reflexes are 
 under the dominion of the conscious will ; but sufficient 
 dependence cannot be placed on this fact in all cir- 
 cumstances for it to be possible to employ such volun- 
 tary control as a trustworthy means of preventioH. 
 Allied to this is the previously-mentioned Chinese 
 practice of Kong-fou, a kind of hypnosis, in which 
 during sexual intercourse the thoughts are concen- 
 trated on some other matter, and thereby conception 
 is supposed to be prevented. 
 
 Artificial protraction of the period of lactation is 
 an old and well-known method, practised by many 
 savage peoples, for the prevention of fertilization. As 
 a general rule, as long as lactation continues, amen- 
 orrhoea persists, and sexual intercourse remains unfruit- 
 ful. But this rule also is not universally valid. 
 
 Artificial means for the attainment of facultative 
 sterility are those by which the attempt is made to pre- 
 vent pregnancy by some mechanical hindrance to the 
 contact of the semen with the ovum, since without this 
 contact conception cannot possibly occur. 
 
 The oldest of these means is that described in the 
 book of Genesis (ch. xxxviii, verses 9, 10), congressus 
 interruptus, where, however, the practice was punished 
 by death, "And Onan knew that the seed should not be 
 his; and it came to pass, when he went in unto his 
 brother's wife, that he spilled it on the ground, lest that 
 he should give seed to his brother. And the thing 
 which he did displeased the Lord, wherefore he slew 
 him." This mode of preventing pregnancy, in which 
 the membrum virile is completely withdrawn from the 
 vagina before the ejaculation of the semen takes place, 
 is at the present time a very widely diffused practice; 
 and, when properly carried out, it is thoroughly effica- 
 
276 THE SEXUAL LIFE OF WOMAN 
 
 cious in the production of sterility. Thompson relates 
 that this practice is employed by the Massai youths, 
 who are allowed free intercourse with the girls, but if 
 a girl becomes pregnant she is put to death. 
 
 The prolonged practice of coitus inter ruptus leads 
 in my experience — in addition to the injury to the ner- 
 vous system as a whole in consequence of the intense 
 hyperaemia of the uterus and the uterine annexa, un- 
 relieved by the occurrence of the orgasm — to a condi- 
 tion of stasis in the female reproductive organs; and 
 this ultimately passes on into chronic metritis (with 
 relaxation of the uterus, retroflexion or anteflexion, 
 catarrhal disease of the mucous membrane, erosions, 
 and follicular ulceration of the portio vaginalis), 
 oophoritis and perimetritis. As a result of certain re- 
 markable observations, I must even regard it as not 
 improbable, although actual proof is still lacking, that 
 the recent striking increase in the frequency of neoplas- 
 mata of the female reproductive organs is causally de- 
 pendent on the ever-increasing employment in all 
 circles of society of means for the prevention of preg- 
 nancy. 
 
 The evil efifects of coitus interruptus for a woman 
 are dependent on the fact that the woman fails to 
 obtain complete sexual gratification, and that this has 
 an important influence upon her entire organism. Ow- 
 ing to the failure of ejaculation to occur, the blood, 
 which during the stage of sexual excitement has accu- 
 mulated in the erectile structures and cavernous spaces 
 of the genital passage, does not, as in normal conditions, 
 flow rapidly away; but the congestion persists for an 
 indefinite period, and is said by von Kraflft-Ebing to 
 give rise to functional disorders, and also to serious 
 tissue changes. The functional disorders take the form 
 of hyperaemia of the pelvic organs, and probably also 
 
THE SEXUAL EPOCH OF THE MENACME 277 
 
 of the lumbar portion of the spinal cord (dull pain 
 in the sacral region, a sensation of pain and dragging 
 in the pelvis and in the lower extremities, lassitude) ; 
 these symptoms often continue for several hours after 
 intercourse. If this ungratifying coitus is frequently 
 repeated, in a voluptuous woman, disorders of the re- 
 productive organs ensue; and even more frequently, 
 nervous disorders, in the form of neurasthenia sexualis. 
 This author considers that, more especially in women, 
 coitus interruptus, and unphysiological modes of sexual 
 intercourse in general, are extremely potent causes of 
 sexual neurasthenia — as potent as masturbation. 
 
 Beard, in his work on sexual neurasthenia, main- 
 tains that the sudden interruption of coitus (and also 
 the use of condoms and similar appliances) is not only 
 far more deleterious than unduly frequent normal in- 
 tercourse; but he points out that it is necessary also to 
 take into account the fact that (inasmuch as, owing 
 to the unnatural mode of sexual intercourse, the possi- 
 bility of fertilization is almost completely prevented) 
 sexual intercourse is apt, in such cases, to be indulged 
 in far more frequently, and often to gross excess. More 
 particularly in such circumstances are evil effects on 
 the nervous system likely to ensue, since we have a 
 combination of excessively prolonged and frequent 
 sexual intercourse, and of interference with complete 
 sexual gratification. 
 
 Mantegazza believes that organic diseases of the 
 spinal cord may actually result from congressus in- 
 terruptus. 
 
 Hirt considers that even when marital intercourse 
 is carefully regulated in respect of frequency, con- 
 gressus interruptus may lead to neurasthenic mani- 
 festations. 
 
 Von Hosslin believes it to be indisputable that pre- 
 
278 THE SEXUAL IJFE OF WOMAN 
 
 ventive methods of sexual intercourse may cause ner- 
 vous troubles, and more particularly neurasthenic 
 disorders, manifesting themselves chiefly in the sphere 
 of the reproductive organs. 
 
 Eulenburg also declares that coitus interruptus is 
 already a frequent cause of sexual neurasthenia in 
 women, and that its evil influence in this respect is 
 becoming more and more frequently manifest. He 
 publishes two typical cases, in which, from this cause, 
 in the one case, functional neuropathy, and in the 
 other, local disorder of the reproductive organs, en- 
 sued. 
 
 Freud describes an "anxiety-neurosis," which is due 
 to incomplete gratification of the woman during sexual 
 intercourse. Coitus interruptus is almost invariably 
 harmful to the man; to the woman it is harmful if 
 the man thinks only of himself, and interrupts the 
 coitus as soon as ejaculation is imminent, without con- 
 cerning himself about the woman's state of sexual ex- 
 citement. If, on the other hand, the man waits until 
 the woman's sexual gratification is complete, the sig- 
 nificance of such an interrupted coitus as far as the 
 woman is concerned is that of normal intercourse. 
 
 Isolated authorities, as, for instance, Stille and 
 Thompson, have contested the alleged evil conse- 
 quences of preventive methods of sexual intercourse. 
 "It is habitual excess," says Fiirbringer, "which does 
 the mischief, not the unnatural character of the isolated 
 act." Lowehfeld, who considers the opposition of 
 medical men to "Malthusianism" not wholly justified, 
 and believes that the dangers to health "which occur 
 in isolated cases" are not very serious, maintains none 
 the less that the medical man must advise his patients 
 not to practise coitus interruptus. The mode in which 
 conception is prevented is not, he thinks, a matter of 
 
THE SEXUAL EPOCH OF THE MENACME 279 
 
 indifference to the woman. The use of occlusive pes- 
 saries and similar appliances does not in any way inter- 
 fere with the normal development of sexual gratifica- 
 tion and cannot, therefore, have any direct influence in 
 the production of nervous disturbances. A forgotten 
 occlusive pessary, however, has in many cases caused 
 local disorder in the vagina. When the man is fully 
 potent the use of condoms can do no harm to the 
 woman, since the only effect of the condom (in a very 
 excitable woman) is to render the development of the 
 orgasm a little more difficult, but not to prevent it. 
 Congressus interruptus itself is, according to Lowen- 
 feld, harmful to the woman only when, owing to defi- 
 cient potency in the male or to deficient excitability in 
 the female, the interruption takes place before the 
 occurrence of the orgasm. 
 
 Valenta declared that coitus interruptus was one of 
 the chief causes of chronic metritis. Elischer saw peri- 
 metritis result from this practice; Grafe enumerates, 
 as consequences of frequently repeated coitus inter- 
 ruptus, chronic hyperaemia of the uterus and oophoritis ; 
 Goodell observed elongation of the cervix uteri ; Men- 
 singa, infarction of the uterus, oedema of the portio 
 vaginalis, ulceration of the cervix, hysterical parox- 
 ysms, convulsions, cephalalgias, cardialgias, etc. Lier 
 reports a case in which, after three years' continued 
 practice of coitus interruptus, the menopause set in, 
 with atrophy of the uterus; Ascher, in a similar case, 
 saw chronic metritis ensue. According to Klein- 
 wachter, coitus interruptus is harmful to the woman to 
 an extent by no means trifling, whereas the man, in 
 whom ejaculation occurs, suffers comparatively little. 
 Fehling believes that when coitus interruptus is prac- 
 tised only a small proportion of women experience 
 sexual excitement. Neugebauer states that among the 
 
280 THE SEXUAL LIFE OF WOMAN 
 
 very numerous cases of uterine carcinoma he has 
 treated, the majority of the patients admitted having 
 practised coitus interruptus. Pigeolot makes a similar 
 statement. 
 
 It must, however, be admitted that a certain number 
 of medical men absolutely deny the dangers of coitus 
 interruptus, whilst others consider them altogether 
 trifling. Just as the trend of modern opinion is to 
 believe that in normal men and women the dangers 
 of masturbation are far less serious than was formerly 
 maintained, so also many are now found to maintain 
 that coitus interruptus is harmful only to those with 
 hereditary neuropathic predisposition. Still more 
 unwilling are many to admit that other preventive 
 methods do women any harm. Thus Wille maintains 
 that the continued fear of pregnancy will in most in- 
 stances do more injury to the feminine nervous system 
 than all the preventive measures in the world. To 
 the nervously weak woman a trustworthy preventive 
 of pregnancy is therefore often necessary and most 
 helpful. 
 
 The Determination of Sex 
 
 The problem of the determination of sex in the 
 human species is one which has occupied natural phi- 
 losophers from the very earliest times, and has always 
 greatly interested all classes of the population. 
 
 The interest awakened by the subject depends princi- 
 pally on the fact that female children have usually been 
 less desired than male in all periods of history and 
 among almost all races. In the uppermost circles of 
 society the truth of this statement is manifested by the 
 fact that the birth of a prince is announced by a salute 
 of loi, that of a princess by a salute of 35 guns only. 
 
THE SEXUAL EPOCH OP THE MENACME 281 
 
 It would serve no useful purpose to transcribe here 
 the opinions, or rather guesses, which were ventured 
 on this topic in earlier days when the very nature of 
 the reproductive process was still entirely unknown, 
 and we shall merely mention that the curious will find 
 various references to the determination of sex in the 
 works of Hippocrates, Aristotle, Plutarch, Soranus, 
 Susruta and Galen. 
 
 Broadly speaking, the earlier theories may be said 
 to diverge in two main directions, some holding that 
 the sex of the infant was in some way determined by 
 the mode of intermixture of the male and the female 
 elements in the act of generation, and others maintain- 
 ing that sex was already inalterably predetermined at 
 the time of intercourse either in the male or in the 
 female sexual elements. 
 
 Pari passu with the modern development of the 
 theory of evolution, and with the enormous increase in 
 recent days in anatomical and physiological knowl- 
 edge, the theory of the determination of sex has been 
 very widely extended. The rival views may be briefly 
 arranged in the four following categories: 
 
 I. That sex is already inalterably predetermined in 
 the ovum, upon the constitution of which it solely de- 
 pends; there are therefore male and female ova, and 
 the process of fertilization exercises no influence what- 
 ever upon the determination of sex. The alternative 
 theory to the above, that sex is determined solely by 
 the constitution of the fertilizing spermatozoon — i.e., 
 that the spermatozoa, and not the ova, are male and 
 female, respectively — is one which in recent years has 
 tended more and more to disappear from the field. 
 
 II. That sex is determined in the moment of fer- 
 tilization by the reciprocal interaction of male and 
 female, of zoosperm and ovum. One variant of this 
 
282 THE SEXUAL LIFE OP WOMAN 
 
 theory maintains that each reproductive element strives 
 for the reproduction of its own sex; that a struggle 
 takes place and that the victor in the contest stamps 
 its own .likeness upon the fertilized product. Accord- 
 ing to another view, however, sex is not directly trans- 
 mitted in this manner; it is supposed that the more 
 powerful the proper reproductive element (according 
 to this theory the ovum) the more strongly does it tend 
 to determine the reproduction of a stronger, i.e., a male 
 organism; thus the greater potency of the female ele^ 
 ment in the act of reproduction tends to favor the 
 determination of the male sex. 
 
 III. That sex is not determined until after fertiliza- 
 tion, during the early stages of the development of the 
 embryo; the determining causes are supposed to be 
 various factors capable of influencing the developing 
 organism during this period, and more particularly the 
 nutritive conditions of the mother. 
 
 IV. That the determination of sex is not dependent 
 solely upon the action of any single one of the factors 
 above enumerated, but arises as a resultant effect of 
 the operation on the germ of all three of these acting 
 in temporal succession. 
 
 Modern physiology has endeavored to solve this 
 problem by statistical investigations, by anatomical 
 demonstration, and finally by experiment. 
 
 Sterility in Women 
 
 When we study the history of human civilization we 
 find that sterility in women is regarded, not merely as 
 a misfortune, but as a reproach. Among savage races, 
 and in the Orient, where the position of women is one 
 of strict subordination, she does not attain an honorable 
 status until she becomes a mother. In Persia, a sterile 
 woman is always divorced by her husband. In India, 
 
THE SEXUAL EPOCH OF THE MENACME 283 
 
 also, when a sterile married woman has in vain em- 
 ployed the various religious measures advocated for 
 the relief of her barren condition, she is sent back to 
 her parents. Both in China and Japan, a barren wom- 
 an is regarded as a most miserable creature. Among 
 the negro races, a woman who fails to bear children 
 is the object of scorn and contempt. Among the 
 Dualla negroes, a man whose wife fails to bear chil- 
 dren demands from her parents the return of the sum 
 which he paid for her at the time of marriage. Many 
 of the indigenous tribes of South America also make 
 a practice of divorcing a sterile wife. Among the 
 better-class Circassians, the women do not attain an 
 assured position until they have borne a child. In 
 Angola a barren woman is the object of universal con- 
 tempt, and she often feels the ignominy of her position 
 so keenly that she commits suicide. Alike among the 
 Jews and among the Turks, barrenness in a wife is a 
 recognized ground for divorce, and the woman who 
 has been divorced for this reason will hardly ever suc- 
 ceed in obtaining another husband, for she is regarded 
 as one whose body is not properly developed. Accord- 
 ing to old German law, barrenness in a wife and impo- 
 tence in a husband were both grounds for divorce. 
 
 The code of the Emperor Justinian allowed of di- 
 vorce in cases in which for the space of two years a hus- 
 band had been unable to fulfil his marital duties, and 
 such a union was termed innuptce nuptee. Among the 
 ancient Romans, although they regarded barrenness as 
 a mark of the divine disfavor, according to the laws of 
 Augustus failure to bear children was a punishable 
 offence, and such a punishment was incurred by any 
 married woman who had attained the age of 20 years 
 without having become a mother. In ancient Greece, 
 also, divorces due to the barrenness of the wife were by ' 
 
284 THE SEXUAL LIFE OP WOMAN 
 
 no means uncommon. Among the Slavonic peoples ste- 
 rility was so greatly despised that there is a Slavonic 
 proverb which runs : "A woman is no woman until 
 she has borne a child"; and in Istria a sterile woman 
 is known by the nickname "Scirke," which is equiva- 
 lent to "hermaphrodite." The Jewish view of the 
 matter is expressed in the Talmudic rabbinical saying: 
 "A wife's duties are beauty, gentleness, and the bear- 
 ing of children"; and again, "the poor, the leprous, 
 the blind, and the childless, are like the dead"; and, 
 finally, "he who refrains from marriage with the delib- 
 erate intention of having no children, incurs the guilt 
 of murder." In the Koran we find the fatalistic ex- 
 pression, "God makes a woman barren in accordance 
 with his will." 
 
 We can, therefore, readily understand that in the 
 most ancient medical writings the question of sterility 
 in women is a matter of earnest consideration. In the 
 works of the early physicians of Hindustan we find 
 several apt remarks on the subject. Susruta says: 
 "Pregnancy most readily results from intercourse dur- 
 ing menstruation. At this time the os uteri is open, 
 like the flower of the water lily in the sunshine." In 
 the Old Testament, in which the newly-created human 
 couples receive the command, "Be fruitful and mul- 
 tiply, and replenish the earth," we find frequent refer- 
 ences to barrenness as a state equally dishonorable and 
 unfortunate, and the use of certain plants is recom- 
 mended as a means of cure. The Talmud contains 
 several essays dealing with the causes and treatment 
 of sterility. 
 
 The Hippocratic collection of writings contains a 
 number of passages dealing with the causes of sterility 
 and with the means to be employed for its relief. We 
 shall have occasion later to refer to these recommenda- 
 
THE SEXUAL EPOCH OP THE MENACME 285 
 
 tions. Celsus, on the other hand, has little to say on 
 this subject. In the works of Pliny, and also in those 
 of Aristotle, there are references to the topic of ste- 
 rility. 
 
 Among the writers of the first century of our era, 
 Soranus discusses exhaustively the capacity for con- 
 ception and sterility. In his work we find, among 
 other passages, the unquestionably accurate remark: 
 "Since the majority of marriages are concluded, not 
 from love, but in order to procreate children, it is 
 difficult to understand why, in the choice of a wife, 
 less regard is paid to her probable fertility than to the 
 worldly wealth of her parents." 
 
 In the Middle Ages, Paulus Agineta more especially 
 treats of the diseases of women, and among these, of 
 sterility in women. That in Arabian medicine much 
 attention was paid to this question, we can learn from 
 the writings of Maimonides. 
 
 By sterility in women we understand the pathological 
 state in which a woman who is sexually mature fails 
 to conceive, notwithstanding frequently repeated, nor- 
 mal sexual intercourse throughout a considerable period 
 of time. 
 
 Sterility is termed congenital (or absolute) when, 
 notwithstanding repeated intercourse throughout a long 
 period (not less than three years), pregnancy has al- 
 ways failed to ensue; it is termed acquired (or rela- 
 tive), when women who have already been pregnant 
 once or more often, cease to conceive, although they 
 are still quite young enough to do so, and have ex- 
 perienced regular sexual intercourse for a long period 
 (not less than three years). In a wider sense of the 
 term, we say that a woman is sterile, when, notwith- 
 standing prolonged and repeated sexual intercourse, in 
 circumstances favorable to procreation, she has failed 
 to give birth to a living and viable infant. 
 
286 THE SEXUAL LIFE OF WOMAN 
 
 English authors also make a special distinction re- 
 garding that form of acquired sterility (which is no 
 great rarity) , in which a woman gives birth to a single 
 infant and subsequently remains sterile {"only-child 
 sterility") . 
 
 The civilization of the present day, with its shady 
 side, has made it necessary for us to pay an increasing 
 attention to facultative sterility, dependent upon the use 
 during intercourse of means for the prevention of con- 
 ception; and very recently the surgical tendency of 
 modern gynecology has brought into being a new 
 variety of sterility in women, viz., operative sterility. 
 
 The period which must elapse after marriage, before 
 the absence of pregnancy must lead us to regard a 
 woman as sterile, is fixed as three years. This limita- 
 tion is based upon the statistical data which I gave re- 
 garding 556 fruitful marriages on page 228. 
 
 The ideal state of fertility, that in which conception 
 is the immediate result of the first act of intercourse 
 between husband and wife, the conception being fol- 
 lowed in due course by the birth of a child, is, lik& 
 most other ideals, one very rarely attained. In the 
 human species, conception as the immediate result of 
 the first act of sexual intercourse, is an extremely un- 
 usual occurrence. To invoke medical assistance for 
 women who have failed to conceive during the first 
 three months of married life, which my experience 
 shows to be more frequently done now than formerly, 
 is devoid of all justification; and still worse is it, in 
 this period of "early love" to subject women, as has 
 often been done recently by overenergetic gynecologists, 
 to local treatment, even to the extent of operative 
 procedures. 
 
 We are not justified in speaking of the existence of 
 actual sterility until three years of marital intercourse 
 have failed to result in conception ; still, when the com- 
 
THE SEXUAI. EPOCH OF THE MENACME 287 
 
 mencement of the first pregnancy is delayed for more 
 than sixteen months after marriage, there is consider- 
 able probability that the woman is sterile; and this 
 probability increases month by month till the expiry 
 of the second year, whilst as the end of the third year 
 approaches, it becomes tantamount to certainty. 
 
 Sterility is one of the commonest of the functional 
 disorders of women, and one of those which most often 
 demand gynecological assistance. 
 
 By a statistical study of the marriages of the royal- 
 and princely families of Europe and of the marriages 
 of the highest families of the aristocracy, I learned that 
 of 626 marriages, 70 were barren; thus the ratio of 
 fruitless to fruitful marriages proved to be as i : 8.87. 
 But in other circles of society, in so far as data relat- 
 ing to the matter were obtainable in my practice, the 
 statistics of infertility were by no means so unfavorable, 
 the ratio working out at about i barren to 10 fruitful 
 unions. I must point out, however, that these statistics, 
 like all statistics of fertility, are to a degree invali- 
 dated by the fact that in a certain number of the 
 instances included among the barren, an unnoticed 
 abortion may have occurred. 
 
 Simpson, in his investigation regarding the frequency 
 of sterile unions, found a ratio of i : 8.5 (in 1,252 in- 
 stances). In the English aristocracy, where the mar- 
 riages are for the most part restricted among the mem- 
 bers of a comparatively small number of families, the 
 ratio was 1:6.11 (495 instances) ; on the other hand, 
 among the population of Grangemouth and Bathgate, 
 consisting chiefly of persons engaged in seafaring and 
 agricultural occupations, the ratio of barren to fruitful 
 unions was as i : 10.5. 
 
 Spencer Wells and Marion Sims, as a result of their 
 investigations, give a ratio of 1:8. 
 
288 THE SEXUAL LIFE OF WOMAN 
 
 According to Seeligmann, in Hamburg, among mar- 
 riages of persons in all classes of society, 11.5 per cent, 
 are barren. Prochownick found among 2,500 women, 
 all of whom had been married for eighteen months 
 or more, and none of whom were more than 40 years 
 of age, that 9 per cent, had failed to conceive. 
 
 According to Frank and Burdach, who do not pub- 
 lish the figures upon which their estimate is based, 
 only I marriage in 50 proves barren. Lever, who also 
 gives merely his percentage result, states that 5 per 
 cent, of married women are completely infertile. 
 Hedin, dealing with a Swedish community of 800 per- 
 sons, states that the percentage of sterile unions is 
 barely 10. 
 
 According to Goehlert's statistical investigations, in 
 the dynasty of the Capets, among 450 marriages, 19.7 
 per cent, were sterile; in the Wittelsbach dynasty 
 (Bavaria), among 177 marriages, 23.7 per cent, were 
 sterile; and among the ruling families of Germany 
 (more than 600 marriages), 20.5 per cent, were sterile. 
 In this investigation, however, no attention is paid to 
 the age of husband or wife; marriages and remarriages 
 are classed together without discrimination; and those 
 marriages only in which a living child was born are 
 counted as fruitful, so that the unions counted as sterile 
 must contain many in which abortion or stillbirth 
 occurred. In three Esthonian communities in Livonia, 
 Oehren found that among 2,799 marriages, 8.4 per cent, 
 were barren, but in this instance also stillbirths were 
 ignored. 
 
 Ansell reports that of 1,919 marriages of women be- 
 longing to the upper classes, their mean age being 25 
 years, 152 proved barren, a proportion of 1:12, or 
 about 8 per cent. 
 
 Matthews Duncan communicates the following data: 
 
THE SEXUAL EPOCH OF THE MENACME 289 
 
 In the year 1855, in the cities of Edinburgh and Glas- 
 gow, 4,447 marriages were contracted, and of these 725 
 proved barren, a proportion of i : 6.1 ; 75 of these may, 
 however, be excluded from consideration, inasmuch 
 as the wives were already at the age of 45 or upward. 
 Among the remaining 4,372 marriages, 662 proved 
 barren, a proportion of i : 6.6. In other words, 15 per 
 cent, of all marriages of women between the ages of 
 15 and 44 proved sterile. 
 
 From France we obtain figures showing a much 
 higher proportion of sterile unions. According to 
 Rochard, in France in the year 1888, of ten million 
 families, two million had no child at all, and two mil- 
 lion had each an only child, so that two-fifths of the 
 families of France were taking no practical part in 
 the maintenance of the population. According to 
 Chevin, the proportion in France of barren to fruitful 
 marriages is as 1:5; 20 per cent, are entirely barren, 
 while 24 per cent, exhibit only-child-sterility. 
 
 From Massachusetts, Morton reports that according 
 to the last census returns one-fifth of all married 
 women are childless. 
 
 In England, numerous trustworthy statistics can be 
 obtained regarding the frequency of sterile marriages. 
 The average proportion of barren to fruitful unions 
 was: 
 
 • 
 
 Among the patients in St. Bartholomew's Hospital 1:8 
 
 Among the inhabitants of Grangemouth 1:10 
 
 Among the inhabitants of Bathgate 1:10 
 
 Among the British peerage 1:6 
 
 Among the upper classes 1 : 12 
 
 Among the inhabitants of Edinburgh and Glasgow 1:7 
 
 Ansell bases upon the observations made by him in 
 the case of 152 sterile women the conclusion that there 
 
290 THE SEXUAL LIFE OF WOMAN 
 
 is no longer any chance of the occurrence of pregnancy 
 if a woman is : 
 
 More than 48 years old, and has had no child for 2 years 
 
 More than 47 years old, and has had no child for 3 years 
 
 More than 46 years old, and has had no child for 4 years 
 
 More than 45 years old, and has had no child for 6 years 
 
 More than 44 years old, and has had no child for 8 years 
 
 Less than 44 years old, and has had no child for 10 years 
 
 If we take into account also cases of acquired ste- 
 rility, the proportion of barren to fruitful marriages 
 becomes even more unfavorable, and the proportion 
 increases enormously if, with Griinewaldt, we number 
 among the barren women those who fail to continue 
 childbearing up to the normal climacteric period. 
 Griinewaldt, dealing with about 1,500 women suffer- 
 ing from affections of the reproductive organs, ex- 
 cluded all those who were either virgins or widows, 
 and also all those who at the time of the observed bar- 
 renness were over 35 years of age; this left more than 
 900 women suffering from affections of the repro- 
 ductive organs, all of whom were sexually mature, 
 and were living in marital intercourse; of these, nearly 
 500 were barren, 300 being instances of acquired ste- 
 rility, and 190 instances of congenital sterility. Thus, 
 according to this observer, disease of the reproductive 
 organs in women led in more than 50 per cent, of the 
 cases to disturbance of the reproductive capacity; about 
 one in every three women* previously competent to 
 bear children, became barren when affected with dis- 
 ease of the reproductive organs; and among every five 
 gynecological patients of the condition already speci- 
 fied as regards age and sexual intercourse, one proves 
 congenitally sterile. 
 
 It must not, however, be forgotten, that sooner or 
 later after marriage artificial sterility tends to come 
 
THE SEXUAL EPOCH OF THE MENACME 291 
 
 into being, its early or late appeairance depending upon 
 the degree of civilization and upon the national and 
 economical conditions of the people and the individuals 
 concerned. This fact must not be left out of the 
 account. 
 
 The manner in which, in the human species, fertili- 
 zation is effected, is still far from clear in all its details ; 
 hence it is easy to understand, that the etiology of ste- 
 rility remains in many respects obscure. It is impos- 
 sible in every case to find a definite cause. Whereas, 
 on the one hand, notwithstanding, the existence of 
 apparently insuperable obstacles, impregnation may 
 nevertheless be effected ; so, on the other hand, sterility 
 may exist in cases in which all the circumstances appear 
 favorable to the occurrence of conception. Hence a 
 classification of the different varieties of sterility from 
 the etiological standpoint is a very difficult task, and 
 the conclusions thus obtained are often vitiated. 
 
 Although it cannot be denied that mechanical causes 
 are competent to lead to sterility in women, Sims, in 
 his advocacy of the mechanical doctrine of sterility, 
 widely overshoots the mark. His authority, however, 
 has led to a general acceptance of this doctrine, which 
 is by no means justified by facts. The theory of me- 
 chanical obstruction, according to which sterility in 
 women depends upon mechanical obstacles to the pas- 
 sage of the spermatozoa toward, the ovaries, is from 
 time to time strikingly illustrated by cases coming 
 under our notice — cases the nature of which can hardly 
 be overlooked; but it is quite wrong to suppose that 
 this causation accounts for the majority of instances 
 of sterility in women, and strict limitations should be 
 placed upon the employment of surgical measures 
 based upon this mechanical theory of sterility. 
 
 The mechanical view has been counterposed by 
 
292 THE SEXUAL LIFE OF WOMAN 
 
 Griinewaldt with a doctrine in which special stress is 
 laid upon obstacles to utero-gestation, sterility being 
 regarded as a functional disorder brought about by 
 affections of the female reproductive organs rendering 
 the uterus unfit for the incubation of the ovum. It 
 cannot be denied that the elucidation of this casual 
 influence was a valuable contribution to the theory of 
 sterility, and it is unquestionable that many morbid 
 conditions of the uterus exist capable of giving rise 
 to sterility in this manner; but we must avoid the error 
 of regarding this doctrine as a full explanation of the 
 cause of sterility. 
 
 If, however, both of these theories of sterility are 
 insufRcient, we cannot regard a third theory, that of 
 Matthews Duncan, as filling the gaps in our knowl- 
 edge. It would be most unfortunate if this author 
 were right in maintaining that all our knowledge of 
 the causes of sterility is to be summed up in the phrase 
 "deficient reproductive energy"; we cannot agree with 
 Duncan in his belief that "Sterility is an imperfection 
 devoid of all perceptible, measurable characteristics"; 
 nor can we follow him when he maintains that local 
 causes, whether they are such as hinder conception, 
 or such as hinder utero-gestation, have a very limited 
 sphere of activity. Matthews Duncan adopts an in- 
 comprehensible standpoint when he regards sterility as 
 dependent upon a law of nature, as a condition which 
 may affect distinct classes or an entire population. 
 
 According to the latest doctrine of sterility, only 
 in quite exceptional instances is the woman regarded, 
 as responsible for the occurrence of sterility; contrari- 
 wise, the male genital organs are commonly blamed 
 for the affection, which is in the overwhelming ma- 
 iUi^ of cases supposed to be due to azoospermia, usu- 
 ally dependent upon gonorrhoeal infection; compare 
 
THE SEXUAL EPOCH OF THE MENACME 293 
 
 with this the fact that afifections of the female repro- 
 ductive organs are said to play a quite subordinate 
 role in the etiology of sterility. But for my part, 
 though I recognize the important share that gonorrhoea 
 in the male plays in the cause of sterility, I am of 
 opinion that the extreme view just mentioned is by no 
 means justified by the facts. 
 
 Sterility, a functional disturbance of an extremely 
 complicated nature, can, in my opinion, be most use- 
 fully elucidated from the etiological standpoint by 
 starting with the assumption that three conditions are 
 absolutely essential to procreation: 
 
 1. That ovulation proceeds in a perfectly normal 
 manner, the maturation of the discharged ova being 
 complete ; 
 
 2. that normal spermatozoa have access to these nor- 
 mal ova (conjugation of male and female pronuclei) ; 
 
 3. that the uterus is properly adapted for the gesta- 
 tion of the fertilized ovum. 
 
 My classification of the varieties of sterility corre- 
 sponds to these conditions of procreation: 
 
 1. Sterility due to incapacity for ovulation; 
 
 2. sterility due to some hindrance to the conjugation 
 of ovum and spermatozoon (under this head come also 
 those cases in which the male is at fault — azoospermia, 
 and the like) ; 
 
 3. sterility due to incapacity for gestation. 
 
 It must also be admitted that there are additional 
 causes of sterility, causes which lie beyond our control. 
 Moreover, as I have already mentioned, in most cases 
 of sterility, we have to do, not with a single cause, 
 but with the resultant of two or more cooperating 
 causes. 
 
294 THE SEXUAL LIFE OF WOMAN 
 
 Incapacity for Ovulation 
 Incapacity for ovulation, the first and most decisive 
 cause of sterility in women, may be absolute and ir- 
 remediable, or relative and transient. We have to do 
 with the former in cases in which the ovaries are en- 
 tirely wanting, or when they are affected with organic 
 disease to such a degree that they have become in- 
 capable of fulfilling their function of' ovulation; in- 
 capacity for ovulation is, on the other hand, relative 
 and transient in certain pat hological states of the ovar y 
 a nd neighbo ring organs, ~when there ii incomplete 
 development or parBal atrophy of the ovaries, when 
 there are new-growths of the ovaries, in cases of 
 oophoritis and perioophoritis, in consequence of dis- 
 turbances of innervation, diseases' of the central arid 
 '^ellpheral nervous system, violent emotional distur b- 
 ance, constitutional disorders, such as syphilis, chlor- 
 osis, anaemia, universal lipomatosis, scrofula, alco- 
 holism, and morphinism, als o in consequence of change s 
 in. the^upply of nutriment_and in jhe generaljnode 
 o f livin g, or of senile changes, and^_£naliyLin_conse- 
 q uence of hereditary influence s^ 
 
 The diagnosis of the etiological influence of sup- 
 pressed or incomplete ovulation in the production of 
 sterility in women is at times beset with great and even 
 insuperable difficulties. The state of the menstrual 
 function, suppression of the flow, or the regularity or 
 irregularity of its occurrence, serve indeed to inform 
 us as to the general activity or inactivity of the func- 
 tion of ovulation; but the variations in this fimction 
 give no certain information as to whether a woman 
 is fertile or infertile. Knowing, as we do, that, gener- 
 ally speaking, an intimate connection subsists between 
 menstruation and ovulation, we are indeed able to 
 assert that regular menstruation and fertility in worn- 
 
THE SEXUAL EPOCH OF THE MENACME 295 
 
 en run a parallel course, and further, that the greater 
 the irregularity of the menstrual function, the greater 
 the tendency to sterility. Recently, great advances 
 have been made in the technique of manual explora- 
 tion of the ovaries, and by means of vaginal and rectal 
 bimanual examination, we are now able to obtain 
 accurate information regarding abnormalities in the 
 size, shape, and position of these organs, and regarding 
 any other intra-pelvic disorders. In this way we have 
 been enabled to recognize a number of pathological 
 states of the ovaries which affect the functions of these 
 organs. 
 
 In some cases also there are general symptoms 
 which furnish us with the means of drawing con- 
 clusions, more or less trustworthy, regarding the state 
 of the ovarian functions; for instance, the general de- 
 velopment of a woman's body, the condition of the 
 external genitals, the vulva, the mons veneris, the pubic 
 hair, the clitoris, and the mammae. Again, we can 
 derive information from various troubles of which 
 women complain; such as sacrache; a sense of weight 
 and pressure in the pelvis; feelings of tension and 
 shooting pains in the breasts; flushings of the face; 
 haemorrhage from the nose, mouth, or rectum, recurring 
 at regular intervals and vicarious in nature. In many 
 instances, however, it will only be by obtaining data 
 regarding the age, mode of life, and family history, 
 of the person affected, that it will be possible to draw 
 conclusions as to the cause of the sterility. 
 
 The female reproductive glands, the ovaries, may, 
 owing to developmental disturbances during fetal life, 
 either be entirely wanting, or they may merely be 
 deprived of certain structural constituents, especially 
 their epithelial elements. In the former case, we have 
 congenital complete unilateral or bilateral absence of 
 
296 THE SEXUAL LIFE OF WOMAN 
 
 the ovary, a condition most commonly associated with 
 the absence or with a rudimentary condition of other 
 portions of the reproductive apparatus; in the latter 
 case, we have the condition somewhat inappropriately 
 named congenital atrophy of the ovary. 
 
 Complete absence of both ovaries necessarily leads 
 to absolute sterility. Both congenital absence and con- 
 genital atrophy of the ovaries, will usually be found 
 in association with other anomalies of the sexual organs. 
 Absence of one ovary, on the other hand, by no means 
 entails sterility; on the contrary, when a single well- 
 formed ovary exists, ovulation usually proceeds in a 
 perfectly normal manner. When such women marry, 
 pregnancy usually follows in the normal proportion 
 of cases; and, in complete opposition to one of the 
 theories of the determination of sex to which allusion 
 has been made, such women bear children of both sexes. 
 
 Morgagni described a case of congenital absence of 
 both ovaries in a woman 66 years of age, in whom the 
 external genital organs, the vagina, and the uterus, 
 weire imperfectly developed, but the Fallopian tubes 
 were of normal size. Careful examination of the 
 upper borders of the broad ligaments of the uterus 
 disclosed no trace of ovary on either side. 
 
 Quain, in a virgin 33 years of age, found the vagina 
 rudimentary, with its mucous membrane- but slightly 
 corrugated; at the upper end of this passage was a 
 semilunar fold which probably represented the uterus. 
 The ovaries were absent; a small gland-like body em- 
 bedded in the left wall of the vagina was regarded by 
 him as a rudimentary ovary. The configuration of the 
 body was feminine, feminine also the disposition; more- 
 over, there was a monthly recurrent epistaxis. 
 
 The atrophy of the ovaries which normally takes 
 place at the climacteric period, has constitutional 
 
THE SEXUAL EPOCH OF THE MENACME 297 
 
 effects similar to those dependent upon absence or con- 
 genital atrophy of the ovaries. 
 
 A rudimentary condition of both ovaries, or bilateral 
 atrophy of these organs, with or without associated 
 atrophy of the entire reproductive system, commonly 
 entails sterility. In such cases, in addition to amen- 
 orrhoea, we usually find that the breasts are but slightly 
 developed, the pubic hair is scanty, the labia majora 
 and labia minora are small, whilst sexual appetite is 
 deficient, and during coitus the woman is entirely pas- 
 sive. 
 
 On the other hand, we must not make the mistake 
 of inferring from the fact that the sexual appetite 
 is keen and coitus pleasurable, that therefore the ca- 
 pacity for ovulation is normal. Even after operative 
 removal of both ovaries, some women have assured me, 
 not only that the sexual impulse was as strong as for- 
 merly, but even that they continued to experience the 
 sexual orgasm in its full intensity. This is analogous 
 to the well known fact that men who have undergone 
 castration after arriving at sexual maturity may remain 
 capable of performing coitus. It is a matter of history 
 that in the lupinars of ancient Rome, castrated men 
 were kept to enable women to enjoy the pleasures of 
 sexual intercourse without fear of consequences; and 
 it is said that such men are to be found in Italian 
 brothels to this day. In the case of the lower animals, 
 it appears to be the rule that when the reproductive 
 glands are removed in early youthTevery^raice of sexual 
 desire disappears. 
 
 Incomplete development of the ovaries, with conse- 
 quent defective ovulation, may result from marriage 
 in girls who are still immature — a fact already known 
 to Aristotle, who wrote, "premature marriage leads to 
 a scanty progeny — that this is the case in man as well 
 
298 THE SEXUAL LIFE OF WOMAN 
 
 as the lower animals is witnessed by the weakly in- 
 habitants of regions in which child-marriage is com' 
 mon." 
 
 It is shown by statistical data that the age at which 
 puberty occurs, the age, that is, at which the menstrual 
 flow begins, has a relation to sterility; and the same 
 is true as regards the age at marriage. In the former 
 connection, women in whom puberty is comparatively 
 early, are less often sterile than those in whom puberty 
 is comparatively late. Emmet, in an investigation em- 
 bracing 2,330 cases, showed that in our climate the 
 average age at which the first menstruation occurred 
 was 14.23 years, and that in the case of women who 
 subsequently proved fertile, the first flow took place 
 on an average 26 days earlier than in the case of women 
 who subsequently proved barren. We also learn from 
 Emmet's tables that the mean duration of menstrua- 
 tion and the mean quantity of the flow are larger in 
 fertile than in barren women. 
 
 As regards the influence of the age at marriage upon 
 fertility, in women who marry between the ages of 20 
 and 24 years, sterility is most frequent; it is commoner 
 in women who marry between the ages of 14 and 20; 
 after the age of 25, the proportion of sterile women 
 increases with each year to which marriage is post- 
 poned. 
 
 Premature atrophy of the ovaries, with consequent 
 incapacity for ovulation, may occur in a great variety 
 of conditions ; it has been observed in scrofula, diabetes, 
 rickets, phthisis, and malarial cachexia; it also occurs 
 in certain chronic intoxications, as from the long-con- 
 tinued use of opium or morphine, and from the abuse 
 of alcoholic beverages. According to the observation 
 of Burkart, Levinstein, and Erlenmeyer, morphinism 
 is a condition which may be relied upon to bring about 
 
THE SEXUAL EPOCH OF THE MENACME 299 
 
 amenorrhoea and temporary sterility from cessation of 
 ovulation. It has been asserted but by no means 
 proved, that the long-continued administration of ' 
 quinine hinders ovulation. As a result of various acute 
 and chronic disorders, a simple atrophy of the ovarian 
 follicles can be detected, dependent upon simple fatty 
 degeneration; this has been seen by Grohe in children 
 as a result of general atrophy, and also following 
 caseous and suppurative diseases of the respiratory 
 organs; by Slavjansky in children after chronic pneu- 
 monia and chronic dysentery, and in adults as a sequel 
 of typhoid, and in one instance as a sequel of puerperal 
 septicaemia. 
 
 Hyperplasia of the ovarian stroma, in slighter 
 degrees of the affection, leads to menstrual disturbances, 
 partly of nervous and partly of inflammatory nature, 
 and in more severe degrees leads to sterility dependent 
 upon the hindrances which the thickened tunica al- 
 buginea offers to the bursting of the mature follicles. 
 Klebs believes that this anomaly is always due to a 
 disposition acquired very early in life, and perhaps at 
 the time when the ovaries are first developed. 
 
 Follicular cysts of the ovary, which are formed 
 mostly at the time of puberty, and originate under 
 the influence of menstrual congestion, from graafian 
 follicles near to ripeness, are competent to cause ste- 
 rility, owing to the pressure they exercise upon the 
 superficially placed rudimentary follicles, leading to 
 the atrophy of these latter. Other new-growths of the 
 ovaries have similar effects, such as adenomata, car- 
 cinomata, dermoid cysts, cystomata, sarcomata, and 
 fibromata. In many cases of these disorders, however, 
 the ovarian follicles may for long periods remain un- 
 affected; and in these instances, ovulation, menstrua- 
 tion, and even conception, may proceed undisturbed. 
 
300 THE SEXUAL LIFE OF WOMAN 
 
 Even in cases in which a neoplasm attains a great size, 
 if it affects one ovary only, ovulation may occur nor- 
 mally in the other, and conception may ensue; and 
 even in the diseased ovary, if small portions of its tissue 
 remain unaffected, ovules may be discharged from these 
 portions. The minutest portion of healthy ovarian 
 tissue, though all the remainder has been destroyed 
 by disease, may suffice to bring about conception. 
 
 Ovarian tumors appear with considerable frequency 
 to be complicated with sterility; but in such cases the 
 question always remains open, whether in the majority 
 of instances the sterility is to be regarded as the cause 
 or as the consequence of the ovarian disease. Boinet's 
 figures dealing with this problem are the most striking 
 of all. He states that of 500 women with ovarian 
 tumors, 390 were childless. But these results are chal- 
 lenged by other observers. Veit's estimates, based upon 
 a compilation of the figures of Lee, Scanzoni, and 
 West, is that 34 per cent, of women with ovarian tumor 
 are sterile. On the other hand, Negroni's collection 
 of 400 cases of ovarian tumor, including both married 
 and unmarried, contained 43 only who had never been 
 pregnant. Other lists show: 13 sterile women among 
 45 suffering from ovarian tumor (von Scanzoni) ; i 
 sterile among 21 (Nussbaum) ; 8 sterile among 63 
 (Olshausen). Winckel, among 150 sterile married 
 women, found 32 suffering from ovarian tumor, which 
 in two of these cases only was bilateral. Atlee, in 15 
 cases of ovarian tumor, observed premature cessation 
 of menstruation at the ages of 30, 39, 40 and 42, 
 respectively. 
 
 Although in many cases sterility develops coinci- 
 dently with the growth of an ovarian cystoma, yet in 
 many other women such tumors have no influence in 
 diminishing fertility. Martin, in a case in which ste- 
 
THE SEXUAL EPOCH OF THE MENACME 301 
 
 rility existed in connection with a unilateral ovarian 
 cystoma, the other ovary being healthy, observed preg- 
 nancy as a sequel of the removal of the diseased ovary. 
 In one of these cases, after removal of the ovarian 
 cystoma, Martin punctured in the other ovary a dropsi- 
 cal follicle which had attained nearly the size of a 
 walnut. Pregnancy in this case also followed the 
 resumption of marital intercourse. Miiller reports 
 that in his clinic within recent years pregnancy, com- 
 plicated with ovarian tumor, has been observed in 7 
 instances; in one of these cases the pregnancy occurred 
 notwithstanding the fact that the new-growth was so 
 large as almost to fill the abdominal cavity. Hoist 
 reports the case of a multipara 43 years of age who 
 died in the i8th to the 20th week of pregnancy; at 
 the post-mortem examination the left ovary was found 
 to be transformed into three cysts, each the size of an 
 apple, whilst in place of the right ovary was a medul- 
 lary carcinoma the size of a man's head; on neither 
 side could a trace of normal ovarian tissue be detected. 
 Spiegelberg, in a woman who died shortly after giving 
 birth to her second child, found that both ovaries were 
 transformed into myxo-sarcomatous tumors; in a wom- 
 an aged 42, who died four weeks after her eleventh 
 confinement, both ovaries were found to be transformed 
 into nodular carcinomatous tumors, each larger than a 
 child's head; in none of these ovaries was any nor- 
 mal stroma to be found. Ruge reports the case of a 
 woman 36 years of age, who miscarried in the sixth 
 month of pregnancy; she had myxo-sarcoma of both 
 ovaries, one weighing 5,620 grammes, the other 480 
 grammes. 
 
 All these cases indicate that, notwithstanding the 
 existence of extensive degeneration of both ovaries, 
 some minute remaining fragment of healthy ovarian 
 
302 THE SEXUAL LIFE OF WOMAN 
 
 Stroma is competent to produce normal mature ova — 
 a fact which has often been proved also by microscopi- 
 cal examination. That under the influence of preg- 
 nancy, existing ovarian tumors often take on extremely 
 rapid growth, is also indicated bv some of the above 
 cases. 
 
 Among the causes of sterility, these three conditions : 
 anaemia, chlorosis, and scrofula (tuberculosis), play a 
 leading part; indeed, their importance in this connec- 
 tion has hitherto been underestimated, more especially 
 in regard to the comparative frequency with which they 
 cause sterility. A large part of the favorable influ-. 
 ence in the relief of sterility in women which is exer- 
 cised by the "cures" at various watering-places, de- 
 pends upon the amelioration which is thus effected in 
 the aforesaid constitutional disorders. 
 
 It has been assumed that diabetes, which renders 
 men impotent, is competent also to cause sterility in 
 women. Hofmeier reports a case which appears de- 
 cisive on this point. In a woman 20 years of age, who 
 had menstruated regularly since she was 14 until a 
 year previously, when the flow had ceased, he found 
 the uterus extremely small, barely 5 cm. (2 in.) in 
 length, extremely atrophied, the ovaries also atrophied 
 and very small; the urine contained large quantities 
 of sugar. Here was doubtless a case of atrophy of the 
 reproductive organs secondary to diabetes. 
 
 In England, where the excessive use of alcohol is 
 observed very frequently in women as well as in men, 
 sterility has frequently been regarded as a result of 
 chronic alcoholism. Matthews Duncan reports cases 
 which lead to the belief that alcohol has a specifically 
 deleterious effect upon fertility. Apart from the 
 general or constitutional disturbances dependent upon 
 the abuse of alcohol, this agent has in many cases a 
 
THE SE:^UAL epoch of the MENACME 303 
 
 well-recognized pathogenic influence upon the female 
 reproductive organs, the morbid condition which is 
 most frequently and most readily assignable to this 
 cause being chronic oophoritis. The obesity which so 
 frequently results from alcoholic excess is a contribu- 
 tory cause of sterility. 
 
 Certain drugs, more especially quinine and mor- 
 phine, are reputed to cause sterility. Davies, revi/ing 
 an old opinion, considers that of all drugs tannin is the 
 most effective in leading to sterility, and he considers 
 tea-drinking as responsible for this effect. 
 
 The influence of certain cerebral affections and psy- 
 chical disorders in checking ovulation has been estab- 
 lished. Thus, de Montyel has recently shown 'that in 
 families subject to hereditary mental disorders, there is 
 an unusual' large proportion (1:7) of barren mar- 
 riages. 
 
 In addition, there are many influences which are 
 known to prevent or to diminish ovulation in the case 
 of the lower animals, and which may therefore be 
 assumed with considerable probability to have a similar 
 effect in women. More especially we are here con- 
 cerned with external influences affecting unfavorably 
 nutrition and innervation, and therewith also ovula- 
 tion; also near kinship between the parties to the act 
 of intercourse; and finally hereditary predisposition. 
 In animals, captivity, exposure to cold, overexertion, 
 insufficient or unsuitable food, and inbreeding, have 
 been proved to result in infertility. 
 
 Doubleday asserted that "a too abundant supply of 
 nutriment hinders reproduction, whereas on the other 
 hand insufficient or improper food favors reproductive 
 activity and increases the number of the offspring." 
 Spencer, however, rightly points out that the infertility 
 noticed in these circumstances is not the direct result 
 
304 THE SEXUAL LIFE OF WOMAN 
 
 of prosperity, but depends upon the pathological obesity 
 which is thus engendered by overfeeding. 
 
 No less interesting are the observations that have 
 been made regarding sterility in animals in confine- 
 ment. In such animals there are wide differences. 
 Some refuse to cohabit, or have lost sexual desire; 
 others, again, show excessive sexual desire and cohabit 
 too often, without any result; or even if fertilization 
 occurs, abortion often ensues. In yet other cases, 
 though conception follows intercourse, and the animals 
 go on to full term before delivery, the young are still- 
 born, or are weakly and misshapen. Caged birds often 
 lay no eggs at all or very few; or if they do lay, they 
 neglect their eggs; or if incubated, the eggs fail to 
 hatch out. In France, experiments regarding this 
 matter were made with domestic fowls. If the hens 
 were given great freedom, 20 per cent, only of the eggs 
 remained unhatched; with less freedom, 40 per cent, 
 of the eggs were failures; whilst if the fowls were 
 kept in a coop, 60 per cent, of the eggs were un- 
 hatched. 
 
 "Convincing proofs," writes Darwin, "have been 
 obtained to the effect that wild animals which have 
 recently lost their freedom have their fertility dimin- 
 ished to a most remarkable extent. This infertility is 
 not dependent upon any degeneration of the reproduc- 
 tive organs. There are many animals of the most 
 diverse species, which, whilst they copulate freely in 
 confinement, fail in these circumstances to conceive; 
 others again, even if they conceive and have living 
 young, give birth to these in numbqrs which are un- 
 questionably much smaller than would be the case were 
 the parents in the free state." 
 
 Interesting observations have been made by pigeon 
 breeders. They state that when pigeons brought up 
 
THE SEXUAL EPOCH OF THE MENACME 305 
 
 in the same nest pair, the number of their offspring is 
 usually very small. 
 
 The influence upon fertility of unfavorable condi- 
 tions of temperature, either excessive heat or excessive 
 cold, is very great. In the case of pigeons, for in- 
 stance, if the pigeon cot is adjacent to the heated wall 
 of a dwelling house, the pigeons sometimes begin to 
 lay as early as January, and may have young as often 
 as eight times in a single year. When the dovecot is 
 cold, on the other hand, the number of broods is 
 smaller. In general, the procreative capacity is greater 
 is summer than in winter. 
 
 As regards inbreeding, many facts are on record 
 showing the influence of this practice in leading to the 
 birth of malformed offspring and to sterility. Darwin 
 writes, "if in a pure race, characterized by a certain 
 tendency to sterility, we allowed only brothers and 
 sisters to pair, in a few generations the stock would 
 become extinct." If animals closely related by blood 
 pair, the number of their offspring is always less than 
 the average. 
 
 In the case of the human species, however, the influ- 
 ence of the marriage of near kin in diminishing fertility 
 cannot be regarded as definitely proved. 
 
 Occasionally the incapacity for ovulation and the 
 sterility dependent thereupon are hereditary — para- 
 doxical as this may appear. It is necessary to assume, 
 that just as the sperm is at times unsuited for effective 
 fertilization, so also the ova may be in a less or greater 
 degree insusceptible of fertilization. In the present 
 state of our knowledge, indeed, we are not in a position 
 to be precise as to the exact nature of such incapacity. 
 It is possible that the enveloping membrane of the 
 ovum varies in its resistance to penetration, as Schenk 
 claims to have proved in respect of certain of the lower 
 
306 THE SEXUAL LIFE OF WOMAN 
 
 mammals. In his experiments on artificial fertiliza- 
 tion outside the body of the mother, he ascertained that 
 the cells derived from the discus proligerus, surround- 
 ing the ovum in immediate contact with the zona pellu- 
 cida, are in some instances easily separable one from 
 another, so that the spermatozoa can readily obtain 
 access to the zona pellucida ; whereas in other instances, 
 in which the ovum is of the same size and apparently 
 in the same stage of maturation as before, these cells 
 remain closely attached each to the other, and thus 
 prevent the passage of the spermatozoa. This condi- 
 tion of the ovum, so unfavorable to fertilization, may 
 be hereditary in certain families, and its transmission 
 may render certain members of the stock infertile. 
 
 Such instances as the following from my own practice 
 are by no means rare. Of three sisters, whose family 
 life was intimately known to me, one had one child 
 only, a girl, whilst the two others remained childless. 
 The girl of the second generation married and re- 
 mained childless. In England it is well established 
 that when, in cases of only-child-sterility, the offspring 
 is of the female sex, this child will probably herself 
 be barren. Galton found that in the case of 14 heir- 
 esses {i.e., the only children of wealthy parents), all 
 of whom were married, 8 remained absolutely barren, 
 whilst of the others, 2 had each an only child. 
 
 It was formerly believed that when a woman gave 
 birth to twins of opposed sexes, the female infant would 
 prove to be barren, this barrenness being associated 
 with defective development of her reproductive ap- 
 paratus. John Hunter (Animal Economy) ascertained 
 that in the case of twin calves of opposed sex, the 
 genital organs of the female twin were almost invari- 
 ably imperfectly developed. But the supposition that 
 this is true also of the human species has not been 
 
THE SEXUAL EPOCH OF THE MENACME 307 
 
 confirmed by experience. I know several married 
 women who had twin brothers, and these women have 
 borne normal children; however, the number of their 
 offspring is remarkably small. Simpson, in Edin- 
 burgh, recorded the results of the marriage of 113 
 women who had been born with twin brothers ; of these, 
 103 had proved fruitful, and 10 {i.e., about one-eleventh 
 of the whole) barren, although of these latter women, 
 one had been married upwards of 5 years, and the 
 remaining 9 for periods ranging from 10 to 40 years. 
 Simpson also gave the history of four women who 
 were all the fruit of triple births, some of which had 
 consisted of two boys and one girl, others of two girls 
 and one boy. All four of these women were parous. 
 Again, a woman who had been one of a quadruple 
 birth (three boys and one girl), herself gave birth to 
 triplets. A collection of all the figures accessible to 
 me relating to this subject, indicates that about 10 per 
 cent, of the women born in such circumstances prove 
 barren — a ratio which corresponds closely with the 
 ratio of infertility in general. 
 
 Sexual Sensibility in Women 
 
 In our consideration of the various influences by 
 which the contact of ovum and spermatozoon may be 
 prevented, the degree of sexual excitement experienced 
 by the woman during the sexual act must ,not be over- 
 looked, for this plays a part not to be underestimated, 
 even though it is a matter on which it is difficult to 
 obtain accurate information. 
 
 It is extremely probable that an active participation 
 on the part of the woman in coitus has an important 
 influence upon the attainment of fertilization, i.e., that 
 sexual excitement in the woman is a link in the chain 
 of cohditions leading to conception. This excitement 
 
308 THE SEXUAL LIFE OF WOMAN 
 
 has a reflex influence, but the influence may be exercised 
 in either (or both) of two ways: first, it may cause 
 certain reflex changes in the cervical secretion, whereby 
 the passage of the spermatozoa is facilitated; or, 
 secondly, it may give rise to reflex changes in the 
 vaginal portion of the cervix, to a rounding of the 
 OS uteri externum and a hardening of the consistency 
 of the cervix (changes of an erectile nature) coupled 
 with a slight descent of the uterus-^changes which like- 
 wise favor the entrance of the semen into the uterine 
 cavity. Theopold goes so far as to say that it is only 
 women who experience erotic excitement who are 
 capable of being impregnated. 
 
 My own opinion is that considerable importance is 
 to be attached to voluptuous excitement of the woman 
 during coitus, for the former of the two reasons men- 
 tioned above, namely, because such excitement leads 
 to the occurrence of reflex secretion of the cervical 
 glands, the secretion thus produced maintaining or en- 
 hancing the activity of the spermatozoa; and contrari- 
 wise, in the absence of voluptuous excitement on the 
 woman's part there is a failure of the reflex secretion, 
 and the passage of the spermatozoa into the uterine 
 cavity is consequently less easily effected. That sexual 
 excitement has great influence upon the production of 
 the first appearance of menstruation, has frequently 
 been shown ; and an analogy between such an influence 
 and the suggested effect of sexual excitement in favor- 
 ing the occurrence of conception, must not lightly be 
 rejected. It is well known that the first menstruation 
 occurs at an earlier age in girls living in towns than 
 in those living in the country; not solely (if at all) 
 in consequence of the better nutriment and easier life 
 of the former, but also, unquestionably, owing to ner- 
 vous influences. It is, moreover, a familiar experience 
 
THE SEXUAL EPOCH OF THE MENACME 309 
 
 that factory girls, who from early youth are exposed 
 to sexual stimulation, attain sexual maturity at an ex- 
 tremely early age. Again, from early times it has been 
 the prevailing opinion of the common people that for 
 the impregnation of a woman it was necessary for her 
 to experience voluptuous excitement, or at least, that 
 in the absence of such excitement, conception was 
 rendered difficult. Riedel relates of the indigens of 
 the Island of Buru, that they often have sexual inter- 
 course with foreigners, "but during such intercourse 
 they remain quite passive, in order to avoid impregna- 
 tion." It is not an unusual experience in gynecological 
 practice for a sterile woman, in the absence of any 
 prompting, to complain that during coitus she has no 
 "feeling" whatever, and to attribute to this lack of feel- 
 ing her failure to conceive. 
 
 A cultured lady, the mother of several children, 
 assured me, not only that she was always aware whether 
 an act of intercourse would or would not lead to im- 
 pregnation, but, further, that it was within her power 
 to determine whether the intercourse should or should 
 not be fruitful. If she was passive during intercourse, 
 or if, to use her own expression, her attitude was one 
 of "laisser faire, laisser aller," conception would not 
 occur; but if, on the other hand, she took an active 
 part in the coitus, so that she experienced a powerful 
 voluptuous sensation, pregnancy would result from the 
 intercourse. 
 
 In some cases, the previously described condition of 
 dyspareunia is the cause of the sterility. In fact, the 
 combination of dyspareunia with sterility is so strikingly 
 common, that my own observations have led me to infer 
 that there is a casual connection between the two states, 
 at least in a considerable proportion of cases. 
 
 I append a short note of a few instances of this kind : 
 
310 THE SEXUAL LIFE OF WOMAN 
 
 Mrs. G., aged 27, married 6 years, sterile; an anaemic, 
 delicate lady, who has never experienced the sense of 
 ejaculation. The semen flows away from the vagina 
 immediately after the completion of coitus. No ab- 
 normality to be detected on gynecological examina- 
 tion. Mrs. S., aged 24, married 5 years, sterile; dur- 
 ing intercourse remains completely cold, and has ex- 
 perienced the sense of ejaculation in dreams only. 
 Gynecological examination disclosed the existence of 
 slight cervical catarrh, but no other abnormality. Mrs. 
 E., aged 30, married 10 years, had a child 9 years 
 previously, a difficult delivery followed by puerperal 
 disease, since then sterile; she states that since her de- 
 livery she has not experienced the sense of ejaculation, 
 with which she was formerly familiar; further, since 
 that time she has suffered from profluvium seminis. 
 On gynecological examination the uterus was found to 
 be enlarged and retroflexed. Mrs. K., aged 28, mar- 
 ried 6 years, sterile; amenorrhoeic, has never experi- 
 enced the sense of ejaculation, and finds sexual inter- 
 course so unpleasant that, "in order to be left in peace," 
 she has herself begged her husband to keep a mistress. 
 Examination showed the uterus to be in an infantile 
 condition. 
 
 . Whilst I have notes of numerous cases similar to 
 those just quoted, I must also insist upon the fact that 
 I have sometimes had complaints of dyspareunia from 
 wives whose fertility has been proved by the birth of 
 numerous children. And, again, anyone whose posi- 
 tion permits him frequent glimpses of what passes be- 
 hind the scenes of married life, will from time to time 
 have noticed as signs of relative dyspareunia instances 
 in which the faithless wife is far more readily im- 
 pregnated by her lover than by the husband to whom 
 she is indifferent or whom she actually dislikes. 
 
THE SEXUAL EPOCH OF THE MENACME 311 
 
 To relative dyspareunia dependent upon sexual dis- 
 harmony we must refer also those instances in which 
 a man and a woman prove sterile while living together 
 for a considerable period as man and wife, but after 
 separation both prove fertile in fresh unions. Several 
 such cases have come within my own experience, and 
 similar instances attracted the attention of the observers 
 of antiquity — Aristotle, for example. Haller, for this 
 reason, lays stress on the lack of mutual affection as a 
 cause of sterility; and Virey, also, believes that sterility 
 may often depend upon the absence of the "harmonic 
 d'amour." 
 
 It is possible that the custom, which in certain rural 
 districts has persisted into quite recent times, of a 
 temporary experimental cohabitation of candidates for 
 matrimony, was based on an attempt to discover the 
 existence of such a sexual harmony. Ploss, for in- 
 stance, reports that in East Prussia, in 1864, he was 
 informed that among the Mazurs this custom of an 
 experimental year of cohabitation was in force. If 
 during this year the woman became pregnant, the young 
 couple were married ; but if pregnancy failed to occur, 
 they separated, considering they were not formed for 
 one another. 
 
 A well-known historical example of relative sterility 
 is furnished by the two marriages of Napoleon I. His 
 first marriage to Josephine remained sterile, though 
 Josephine had children by Beauharnais ; and Napoleon, 
 remarried to Marie Louise, had a son by the latter. 
 
 Von Gutceit, a physician of wide experience, points 
 out that "sensitive women, who have a mental or phy- 
 sical antipathy to cohabitation, or who have a secret 
 but ardent affection for some other man, often fail to 
 conceive as a result of intercourse with their husbands; 
 but when, in illicit intercourse, they experience the 
 
312 THE SEXUAL LIFE OF WOMAN 
 
 voluptuous sensations to which they have hitherto been 
 strangers, pregnancy often speedily ensues." He main- 
 tains, further, "that such women, in consequence of the 
 stimulation of the genital organs in the absence of 
 sexual gratification, become affected with all kinds of 
 menstrual irregularities, with fluor albus, prolapse 
 of the uterus, and chronic metritis; they suffer from 
 digestive disturbances and constipation, leading to 
 emaciation; and they are prone to hysterical mani- 
 festations." 
 
 Analogous phenomena have been noted, and with 
 much greater distinctness, in the animal world. Dar- 
 win, writing on this subject, remarks: "It is by no 
 means a rare occurrence, that certain males and females 
 will not be fruitful in intercourse together, whilst the 
 same individuals prove perfectly fertile in intercourse 
 with other members of their species — and this in cases 
 in which there is no evidence that the subsequent 
 fertility is due to any change in the conditions of life. 
 The cause is probably to be found in an innate sexual 
 disharmony between the infertile pair. A very large 
 number of instances of this kind have been reported 
 to me by well-known breeders of horses, cattle, pigs, 
 dogs, and pigeons. Sometimes a breeder will fail to 
 obtain offspring from a male and a female of known 
 fertility whom he wishes to couple for some special 
 reasons. The most celebrated living horse-breeder in- 
 formed me that frequently a mare, which in other 
 seasons with other stallions has proved fertile, may be 
 coupled with a stallion likewise of proved reproduc- 
 tive potency, and will fail to be impregnated; yet this 
 same mare will shortly afterward be impregnated by 
 another stallion." 
 
 Pfliiger reports that he has often seen a thorough- 
 bred stallion, which was fully prepared, at a moment's 
 
THE SEXUAL EPOCH OP THE MENACME 318 
 
 notice, to serve a thoroughbred mare, prove extremely 
 unwilling to serve a common mare on heat, and only 
 induced to do so with the greatest difficulty, and indeed 
 by a trick. The stallion is placed in the central one 
 of three stalls, on one side of him is the thoroughbred 
 mare, whilst in the third stall is the common mare, 
 covered with a cloth. The stallion's head is turned to 
 show him the thoroughbred mare; immediately his ap- 
 pearance undergoes a change. Every muscle of his 
 body appears to quiver, and never does a fine animal 
 appear more beautiful than at such a moment, full of 
 pride, fire, and vitality.^ As soon as the stallion makes 
 ready to serve the mare, he is rapidly led to the other 
 stall, and suitably assisted to the actual commencement 
 of intercourse with the substituted mare. But it some- 
 times happens, as Pfliiger himself has seen, that the 
 stallion, becoming aware of the deception, refuses to 
 complete the coitus, withdraws his penis, and immedi- 
 ately turns to the mare of his choice. 
 
 Matthews Duncan, among 191 sterile women, found 
 that 39 had no sexual appetite, and 62 had no voluptu- 
 ous sensations during coitus. He regards abnormal 
 sexual appetite as one of the principal causes of ste- 
 rility. 
 
 Notwithstanding these facts, it must not be forgotten 
 that many cases are recorded in medical literature of 
 
 ' Compare stanzas 46 and 47 of "Venus and Adonis" : 
 
 His ears up-prick'd; his braided hanging mane i 
 
 Upon his conipass'd crest pow stands on end ; 
 
 His nostrils drink the air, and forth again. 
 
 As from a furnace, vapors does he send : 
 
 His eye, which scornfully glisters like fire, 
 Shows his hot courage and his high desire. 
 
 Sometimes he trots, as if he told the steps, 
 
 With gentle majesty and modest pride; 
 
 Anon he rears upright, curvets and leaps. 
 
 As who should say, "Lo! thus my strength is tried; 
 
 And this I do to captivate the eye 
 
 Of the fair breeder that is standing by." 
 
314 THE SEXUAL LIFE OF WOMAN 
 
 women conceiving after intercourse effected against 
 their wishes, as by rape, or when they were in a state 
 of intoxication, or asleep, or iii the entire absence of 
 all voluptuous sensation. Moreover, the erection of 
 the vaginal portion of the cervix, and the reflex move- 
 ments and secretory changes in the uterus, may also 
 occur independently of sexual desire and voluptuous 
 sensation ; but such cases are certainly exceptional, and 
 their credibility is frequently open to suspicion. In 
 numerous instances in which conception is stated to 
 have followed intercourse in a state of unconsciousness, 
 judicial proceedings have elicited the fact that the in- 
 tercourse was not entirely involuntary on the woman's 
 part, and that the alleged force was no more than a 
 vis grata. Von Maschka reports a case in which a girl 
 asserted that she had been violated whilst in a condition 
 of epileptic unconsciousness, but she remembered every 
 detail of the act with precision. Casper, again, in a 
 case in which it was asserted that defloration had been 
 forcibly effected whilst the girl was in a state of 
 alcoholic coma, showed that there had been no more 
 than moderate intoxication combined with great sexual 
 excitement. Assertions that pregnancy has resulted 
 from intercourse effected during sleep, in a state of 
 unconsciousness, or in the "magnetic" or "hypnotic" 
 state, should always be accepted with reserve. 
 
 It is interesting to note in this connection that the 
 Chinese physicians enumerate among the causes of 
 sterility the practice of "congfu" by the man, this name 
 being given to a manipulation analogous to hypnotism, 
 whereby the voluptuous sensation during intercourse 
 is diminished or abolished by distracting the attention 
 elsewhere. 
 
 A proof of the importance of specific sexual sensa- 
 tion for the attainment of conception is afforded by 
 
THE SEXUAL EPOCH OF THE MENACME 315 
 
 the fact that in the majority of women voluptuous ex- 
 citement is absent at the first act of intercourse, and 
 only gradually develops thereafter; in correspondence 
 with this, we find that the first conception does not 
 usually occur until some time after marriage, and that 
 the period of its occurrence frequently coincides with 
 the full development of voluptuous sensation during 
 intercourse. Thus, even in the woman fully fitted for 
 conception, the actual capacity for impregnation is only 
 developed gradually, and after a sufficient experience 
 of intercourse. 
 
 This transient incapacity for conception may, in- 
 deed, also depend upon the fact that at first coitus is 
 apt to be incompletely effected, and for this both hus- 
 band and wife are to blame ; but unquestionably in many 
 cases the reason is the one first mentioned. 
 
 In some cases, certain psychical influences which 
 affect the intensity of the voluptuous sensation, mani- 
 fest its significance. Thus, in some instances, the in- 
 fluence of stimulation of the clitoris in leading to con- 
 ception has been clearly shown ; in others, the perform- 
 ance of coitus in some unusual position, varying with 
 the woman concerned, is alone competent to arouse 
 sexual sensibility to its full extent, and to bring about 
 the orgasm. One occasionally receives confidential 
 information from a husband that his wife experiences 
 a voluptuous sensation only when coitus is performed 
 in the lateral posture, or more bestiarum, or in the situs 
 inversus, etc., etc. 
 
 Excessive frequency of intercourse, prolonged and 
 repeated sexual excitement, on the other hand, induce 
 sterility, as is well seen in prostitutes, who rarely be- 
 come pregnant. 
 
 Finally, perverse sexual impulse must be mentioned 
 as a possible cause of sterility. This may be an ac- 
 
316 THE SEXUAL LIFE OF WOMAN 
 
 quired perversion, due to the fact that at the epoch of 
 the menarche, the commencement of puberty, owing 
 to the strength of sexual desire whilst intercourse is 
 an impossibility, or simply from evil example, the girl 
 has become a confirmed onanist, and continues the 
 habit even after marriage. In other cases we have 
 to do with a psychopathic state, a form of mental de- 
 generation due to very various causes, or in some cases 
 inverted sexual sensibility exists in a person whose 
 mind is in other respects normal. In women with 
 sexual inversion, ordinary copulation with the male is 
 insufficient to arouse the sexual orgasm, and for this 
 reason, as well as because persons thus affected avoid 
 coitus as much as possible, sterility commonly ensues. 
 
 In sterile homosexual women, and equally so in 
 women addicted to masturbation, gynecological exam- 
 ination may disclose no abnormality whatever; but in 
 other cases of the kind we may find a contributory 
 cause of sterility in the fact that the internal genital 
 organs are imperfectly developed, or even completely 
 absent. In sterile women, if on gynecological exam- 
 ination we find certain characteristic changes in the 
 reproductive organs, a strong suspicion will be aroused 
 that the sterility is due to abnormal modes of sexual 
 gratification. The changes in question are: hyper- 
 trophy of the clitoris, enlargement and a bluish colora- 
 tion of the labia minora, retroversion of the uterus, 
 neuralgia and displacement of the ovaries, leucorrhcea, 
 and menorrhagia. 
 
 The question has been mooted by Cohnstein, whether, 
 as is commonly asserted, a woman is capable of be- 
 coming pregnant at any time during the year, or 
 whether, as in the lower animals, the reproductive 
 capacity can be exercised only at certain seasons, or 
 again, whether there may not be individual moments 
 
THE SEXUAL EPOCH OP THE MENACME 317 
 
 of predilection for the occurrence of conception. He 
 found that in the great majority of women there were 
 such seasons of predilection, and only in a minority 
 could conception be effected indifferently at any time 
 of the year. As a proof of this assertion, he appends 
 the following case: A married woman, 33 years of 
 age, had several years before been delivered prema- 
 turely of a stillborn child, and since then had not again 
 been pregnant. Her reproductive organs were normal. 
 The husband's semen was examined, and also found 
 to be quite free from abnormality. In the course of 
 the three following years an attempt was made to cure 
 the sterility by dilatation of the cervical canal, sug- 
 gestions for the proper regulation of sexual intercourse, 
 etc., but all without effect. Cohnstein now calculated 
 the date at which the full term of the previous preg- 
 nancy would have fallen, and found that this was the 
 middle of February; he therefore inferred that .inter- 
 course effected at the beginning of May would result 
 in impregnation. As a fact, the woman conceived at 
 this time, and at full term gave birth to a healthy girl. 
 The assumption that such a time of predilection for 
 the occurrence of conception exists is, however, con- 
 tradicted by the well known fact that in the case of 
 large families the children's birthdays are irregularly 
 distributed throughout the year. 
 
 Baker-Brown describes a special form of sterility 
 due to "sympathetic or reflex action." It depends upon 
 diseases of the organs adjoining the uterus, such as 
 vascular tumors of the urethra, bleeding piles, fistula, 
 fissure, and prolapse of the anus, schirrus of the rectum, 
 ascarides. "These diseases produce sterility in conse- 
 quence of the loss of blood, the menstrual disturbances, 
 the morbid congestion of the uterine system, and the 
 reflex neuroses, to which they give rise." Courty re- 
 
318 THE SEXUAL LIFE OF WOMAN 
 
 ports a case belonging to this category in which in a 
 young married lady sterility was due to fissure of the 
 anus, which had long existed without recognition ; after 
 the fissure had healed, conception occurred. Palmay 
 recently repoi^ted a case in which "taenia solium was 
 the cause of sterility. In a woman 20 years of age, 
 who had lived in sterile wedlock for three years, the 
 presence in the intestine of a tapeworm, which she had 
 harbored for many years, gave rise to dysmenorrhceal 
 troubles. The complete expulsion of the worm re- 
 lieved the dysmenorrhoea, the woman became pregnant, 
 and gave birth to a child at full term ; since then men- 
 struation has been painless." The presence of the tape- 
 worm may have had an unfavorable influence upon 
 the blood-supply and the innervation of the uterus. 
 But cases of this nature do not constitute a special form 
 of sterility; they must be classed, either with cases due 
 to interference with ovulation, or with those due to 
 prevention of the contact of ovum and spermatozoon. 
 
 Incapacity for Incubation of the Ovum 
 
 The fertilization of the ovum is, as previously de- 
 scribed, probably effected in man, as in other mam- 
 mals, in the upper third of the Fallopian tube. The 
 fertilized ovum is then swept down into the uterus by 
 the action of the cilia which line the tube, assisted 
 by the peristaltic movement of the muscular wall of 
 the canal. The uterine mucous membrane at this time 
 is thickened and thrown into folds, and in these latter 
 the fertilized ovum is entangled; by its presence the 
 ovum now exerts a reflex stimulus leading to a still 
 greater proliferation of the cells of the uterine mucous 
 membrane, which grows up over the ovum and soon 
 shuts it off conpletely from the uterine cavity. Thus 
 
THE SEXUAL EPOCH OF THE MENACME 319 
 
 the ovum comes to be entirely imbedded in the sub- 
 stance of the mucous membrane. 
 
 Thus for the implantation of the ovum, it is first 
 of all necessary that, the uterine mucous membrane 
 should be in a normal condition; pathological changes 
 in this membrane, and indeed any morbid structural 
 alteration in the uterine tissues, may prevent the im- 
 plantation and incubation of the ovum, and may thus 
 give rise to sterility. 
 
 The uterine cavity is normally lined with ciliated 
 epithelium, the cells of which have an elongated ellipti-. 
 cal form. The movement of the cilia is directed down- 
 ward. The epithelium is perforated by the orifices 
 of the uterine glands; these glands are simple tubular 
 glands, passing through the mucous membrane with an 
 S-shaped or corkscrew curve; between the glands lies 
 a rich germinal tissue, made up of rounded cells. The 
 rounded connective tissue cells have processes which 
 build up the scaffolding of the mucous membrane. 
 Among the connective tissue cells of the uterine mucous 
 membrane, wandering leucocytes are almost always to 
 be seen. Menstruation is characterized by a swelling 
 of the mucous membrane, and by enlargement of the 
 uterine glands. At the same time, blood extravasations 
 appear between the more superficial layers of the 
 membrane, and on its free surface, and various por- 
 tions of the surface of the membrane are cast ofif. 
 
 Very numerous are the morbid states of the uterus 
 and its annexa whereby the implantation and incuba- 
 tion of the ovum are prevented; and incapacity of the 
 uterus for the fulfilment of these functions is there- 
 fore a common cause of sterility in women. 
 
 That developmental defects of the uterus, even when 
 they are not such as render conception impossible, 
 may yet often give, rise to sterility, has been already 
 
320 THE SEXUAL LIFE OF WOMAN 
 
 explained in writing of the conditions of the uterus 
 which prevent the contact of ovum and spermatozoon; 
 for defects of development which are not sufficiently 
 severe to prevent this contact, may yet suffice to render 
 the uterus unfit for the implantation and incubation of 
 the fertilized ovum. Inflammatory disorders, such as 
 perimetritis and the formation of exudations in the 
 parametrium, may render the uterus unable to under- 
 go the enlargement necessary to pregnancy. Tissue 
 changes in the uterine musculature may likewise pre- 
 vent the implantation of.the ovum, or the proper de- 
 velopment of the uterus during pregnancy. New- 
 growths of the uterus or its neighborhood may bring 
 the development of the fertilized ovum to an untimely 
 conclusion. Above all, however, it is diseases of the 
 uterine mucous membrane which unfit the organ for the 
 implantation of the ovum, and thus give rise to steril- 
 ity. All those inflammatory states which lead either 
 to softening or to induration of the uterine paren- 
 chyma, or to swelling and thickening of the endome- 
 trium or parametrium, may offer a hindrance more or 
 less serious to the normal incubation of the ovum. 
 
 The diagnosis whether in an individual case we have 
 to do with sterility dependent upon impotentia ges- 
 tandi, is often difficult, because the conditions which 
 cause it are frequently associated with those which 
 cause sterility by preventing the contact of ovum and 
 spermatozoon. In any case, a careful examination of 
 the pelvic organs must be made, not only to determine 
 whether there is any displacement or enlargement of 
 the uterus, chronic metritis or perimetritis, parametric 
 exudations, or new-growths of the uterus or of neigh- 
 boring organs, but also, if necessary, by dilating the 
 cervical canal, to ascertain the condition of the uterine 
 
THE SEXUAL EPOCH OF THE MENACME 321 
 
 mucous membrane, and whether there is hyperplasia 
 or atrophy thereof. In this connection, examination 
 of the uterine secretion is of especial importance : a 
 purely mucous, transparent, vitreous, tenacious secre- 
 tion in the os and in the cervical canal, indicates the 
 existence of catarrhal endometritis; a markedly haemor- 
 rhagic secretion signifies hyperplastic endometritis; 
 profuse purulent secretion containing gonococci, indi- 
 cates gonorrhoeal endometritis ; the discharge of pieces 
 of membrane shows that there is exfoliative endome- 
 tritis; the discovery of fragments of carcinomatous tis- 
 sue indicates the breaking down of a malignant tumor 
 of this nature, etc. 
 
 Finally, it is necessary to obtain a careful history of 
 the case, asking whether there have been menstrual 
 irregularities, or miscarriages, and the characters of 
 previous labors (in cases of acquired sterility) ; any 
 pathological conditions in other organs should be in- 
 vestigated; and the condition of the blood and the 
 state of general nutrition should receive attention. 
 Chlorosis, anaemia, and scrofula often give rise to ca- 
 tarrhal endometritis; severe disease of the heart may 
 lead to congestive troubles of the genital organs; after 
 abortion or difficult labor, chronic metritis or endo- 
 metritis are common. Further, the differential diag- 
 nosis between erosion and carcinoma of the portio 
 vaginalis, must often depend upon consideration of the 
 patient's age and general health, and upon the nature 
 and duration of the haemorrhage. Pain on micturi- 
 tion, appearing soon after marriage, and lasting o'ften 
 a few days only, will indicate the probability of gonor- 
 rhoeal infection, etc. 
 
 Von Griinewaldt has vigorously insisted upon the 
 fact that the notion of sterility, i.e., impotentia gene- 
 
322 THE SEXUAL LIFE OF WOMAN 
 
 randi in women, is not coincident with the notion of 
 impotentia concipiendi, and there is an important dis- 
 tinction between cases in which it is impossible that 
 fertilization should be effected, and cases in which, 
 though fertilization may take place, the implantation 
 and incubation of the ovum fail to ensue. In this au- 
 thor's opinion, the only absolute mechanical hindrance 
 to the entrance of the semen is to be found in atresia 
 of the genital passage, and the role of impotentia con- 
 cipiendi is of quite minor importance as compared with 
 incapacity on the part of the uterus for the implanta- 
 tion and incubation of the ovum, an opinion, which, 
 notwithstanding the record of exceptional cases in 
 which pregnancy has occurred in spite of the existence 
 of mechanical obstacles to conception, I must regard 
 as altogether beyond the mark. On the other hand, it 
 is indisputable that for the occurrence of pregnancy it 
 is necessary, not only that contact of ovum and sper- 
 matozoon should be possible, but further, that the 
 uterus should be in a condition favorable for the im- 
 plantation and further development of the ovum sub- 
 sequent to fertilization. For this reason, diseases of 
 the uterine tissues must play an important part in the 
 causation of sterility, though we cannot go so far as to 
 admit with von Griinewaldt that these diseases are the 
 principal cause of reproductive incapacity in women. 
 Various metritic processes, and also venous hyperae- 
 mia consequent upon heart disease, may lead to atro- 
 phy of the uterine mucous membrane, which then ap- 
 pears thin and smooth, whilst the uterine glands are 
 destroyed, or transformed into small cysts. The same 
 condition may result from retention of secretions in 
 the uterine cavity — hydrometra and haematometra. In 
 all these cases, the epithelium probably loses its cilia. 
 The process has a serious influence antagonistic to the 
 
THE SEXUAL EPOCH OF THE MENACME 323 
 
 reproductive capacity inasmuch as the implantation 
 of the chorionic villi is rendered difficult (Klebs). 
 
 Hyperplasia of the uterine parenchyma, affecting 
 either the whole organ or a large part, and character- 
 ized either by enlargement of the entire organ, or only 
 by thickening and elongation of the cervix, may hinder 
 the incubation of the ovum. It may be due to endo- 
 metritic catarrhal processes; to venous hyperaemia, es- 
 pecially in cases of valvular heart disease; to subin- 
 volution, and sometimes to excessive sexual stimulation, 
 as in prostitutes. Both the change in the shape of the 
 cervix, and the changes undergone by the uterine mu- 
 cous membrane in cases of extensive uterine hyperpla- 
 sia (it commonly becomes atrophic and discharges 
 a watery secretion), interfere with the reproductive 
 capacity. 
 
 In all cases of chronic metritis, the hyperaemia and 
 hyperplasia of the uterus may give rise to haemor- 
 rhages; these sweep away the ovum, and thus lead to 
 impotentia gestandi. And the nutritive changes in the 
 mucous membrane that occur in chronic metritis also 
 interfere with the implantation and incubation of the 
 ovum. Moreover, it is well known that in these cases, 
 even if conception is effected, abortion is extremely 
 apt to occur, owing to the pathological state of the 
 endometrium, which interferes with the normal devel- 
 opment of the decidua. Haemorrhages occur in the 
 decidua, and are followed by abortion. And further, 
 the replacement of portions of the muscular tissue of 
 the uterine wall by fibrous tissue, a change which is apt 
 to occur in long-continued metritis, interferes with the 
 proper expansion of the uterus during pregnancy, and 
 thus leads to abortion. 
 
 On the other hand, it cannot be denied that frequently 
 enough patients with well marked chronic metritis 
 
824 THE SEXUAL LIFE OF WOMAN 
 
 nevertheless conceive in a normal manner, and give 
 birth to a healthy child; and this not once only, but 
 again and again. 
 
 As sterility due to mesometritis, von Griinewaldt 
 classes the numerous cases in which sterility ensues 
 upon a confinement in which the patient reports that 
 inflammation followed delivery — or sometimes in 
 which nothing abnormal was noticed. The results of 
 local examination are negative: there is no displace- 
 ment, no exudation or swelling, and no relevant affec- 
 tion of the endometrium. But the characteristic fea- 
 ture of these cases is, according to von Griinewaldt, 
 that after her last full-time delivery, a woman has had 
 a miscarriage or a premature delivery, and subse- 
 quently has been completely sterile. The degenera- 
 tive process is at first partial, so that it does not pre- 
 vent conception, but renders it impossible for the 
 pregnancy to go on to full term; subsequently it ex- 
 tends throughout the mesometrium and conception is 
 no longer possible. 
 
 Cole, of San Francisco, regards as the most frequent 
 cause of sterility ensuing upon a single delivery, sub- 
 involution of the uterus, most commonly due to rising 
 too early after delivery. He therefore considers it of 
 especial importance after a first delivery that the phy- 
 sician should satisfy himself that no serious injury has 
 been effected by the process. 
 
 'Chronic endometritis is a very frequent cause of 
 sterility; in the first place, the catarrhal swelling of 
 the mucous membrane, which often extends from the 
 OS uteri externum to the ostium abdominale of the 
 Fallopian tubes, offers an obstacle alike to the down- 
 ward passage of the ovum and the upward passage of 
 the spermatozoa ; and secondly, in long-standing cases, 
 the large size of the uterine cavity and the snioothnes^ 
 
THE SEXUAL EPOCH OF THE MENACME 325 
 
 of the surface of the atrophied mucous membrane, 
 render the lodgment of the ovum in the uterus very 
 unlikely. A further powerful obstacle to impregna- 
 tion in cases of endometritis is offered by the profuse 
 muco-purulent secretion which usually, though not 
 invariably, accompanies that disease. This secretion, 
 in some cases flowing freely over the surface of the 
 membrane, but in others adhering to it with tenacity, 
 whitish-yellow in color, rendered cloudy by admix- 
 ture of pus, or tinted red by admixture of blood, 
 sometimes of a gelatinous consistency with a strongly 
 alkaline reaction, contains globules of mucus, ciliated 
 and cylindrical epithelial cells, pus corpuscles, bacte- 
 ria and cocci — and, if the endometritis is of gonor» 
 rhoeal origin, the gonococcus of Neisser. This secre- 
 tion, when profuse and thinly fluid, pours out through 
 the OS, and sweeps away the semen; when tenacious 
 and gelatinous, it fills up the dilated cervical canal 
 above the constricted os uteri externum, and consti- 
 tutes a powerful barrier to the upward passage of the 
 spermatozoa; when purulent, it is destructive to the 
 vital activity of the spermatozoa. The changes in the 
 mucous membrane in cases of long-standing endome- 
 tritis, whereby the uterus is rendered unfit for the 
 implantation and incubation of the ovum, are the fol- 
 lowing. The epithelial cells, as usual in cases of con- 
 tinued catarrh, change in form, the ciliated cells dis- 
 appear, and are replaced, first by cylindrical cells, 
 later by polymorphic cells, approaching in type those 
 of pavement epithelium. The mucous membrane is 
 swelled, the vessels are dilated, there is hyperplasia of 
 the glands, with a moderate amount of small-celled 
 infiltration of the interglandular tissue. Ultimately 
 the rriucovts menibrane undergoes atrophy, its glands 
 
326 THE SEXUAL LIFE OF WOMAN 
 
 disappear, and it comes to resemble a thin stratum of 
 connective tissue. 
 
 Thus, in severe and long-continued endometritis, the 
 changes that occur in the uterine mucous membrane 
 render the implantation of the ovum and the forma- 
 tion of normal decidua impossible ; even if conception 
 does occur, the fertilized ovum is speedily discharged. 
 Frequently, in cases of endometritis, there is consecu- 
 tive displacement of the uterus which acts as a con- 
 tributory cause of sterility. When endometritis lasts 
 a long time, proliferation of connective tissue in the 
 uterine parenchyma also occurs, leading often to hy- 
 pertrophy of the cervix, and to stenosis of the cervical 
 canal. Since in so many different ways endometritis 
 may give rise to sterility, the importance that must be 
 attached to this condition is evident. 
 
 The great significance of gonorrhceal infection in 
 relation to sterility in women depends, not only on the 
 changes this disease causes in the Fallopian tubes, 
 leading to interference with the necessary contact of 
 ovum and spermatozoon, but further, upon the occur- 
 rence of gonorrhceal cervical and corporal endometri- 
 tis, of perimetritis, and secondary parenchymatous 
 metritis. Still, under appropriate treatment, the in- 
 flammatory changes consequent on gonorrhceal infec- 
 tion are in manj; cases curable, and, after absorption 
 of the exudations and restoration of the normal nutri- 
 tive conditions of the tissues, conception may take 
 place. Fritsch, who points out that in the woman 
 infected with gonorrhoea, sterility ensues in a manner 
 analogous to that in which it occurs in the male (for 
 in the latter it is not the primary urethritis, the disease 
 of the passage, but the secondary inflammation of the 
 testicle that leads to sterility), States that he has ob- 
 served cases in which beyond question conception has 
 
THE SEXUAL EPOCH OF THE MENACME 327 
 
 occurred, notwithstanding the existence of gonorrhoea! 
 endometritis. 
 
 In my own experience, whilst gonorrhoea! endome- 
 tritis is, among inflammations of the endometrium, the 
 most frequent cause of sterility, the place of next im- 
 portance in this connection is occupied by exfoliative 
 endometritis, or membranous dysmenorrhoea. This 
 name is given to a pathological condition in which 
 from time to time, usually during menstruation, frag- 
 ments of membrane, or even an entire sac-like cast of 
 the uterine cavity, are expelled from the uterus; since 
 this condition is apt to hinder the incubation of the 
 ovum, it is commonly associated with sterility — a fact 
 mentioned already by Denman in 1790, and since then 
 confirmed by numerous observers. I have had under 
 observation several cases of dysmenorrhoea membra- 
 nacea; in two cases it existed from the time of mar- 
 riage — in one case 14 years, in the other 8 years — and 
 in both sterility was absolute. In the latter of the two 
 cases, vigorous treatment was undertaken, even curet- 
 tage of the uterus, but quite without avail. In other 
 cases, the sterility was acquired, the membranous dys- 
 menorrhoea having begun after the woman had already 
 had one or more children; but as I have never seen a 
 case in which a woman became pregnant after the 
 development of this aflfection, I am compelled to re- 
 gard it as one of the most severe hindrances to con- 
 ception. 
 
 As a general rule, exfoliative endometritis termi- 
 nates only with the onset of the climacteric age; in 
 very exceptional cases, however, a cure may take place 
 earlier. In cases in which this premature termination 
 has been observed, pregnancy has been known to en- 
 sue, cases of this nature having been observed by Solo- 
 wieflf, Fordyce Barker, and Thomas. And recently, 
 
328 THE SEXUAL LIFE OF WOMAN 
 
 cases have been reported, in which the disease has 
 returned after such a pregnancy. Fritsch, indeed, is 
 of opinion that exfoliative endometritis does not cause 
 sterility, and that in this disease abortion is no com- 
 moner than in other diseases of the uterus. Char- 
 pignon, Hennig, and Bordier have also observed con- 
 ception occur in the course of this disease. In 42 cases 
 of membranous dysmenorrhoea collected by Klein- 
 wachter, pregnancy occurred in four during the ex- 
 istence of the disease. Lohlein also reports that, among 
 27 patients affected with membranous dysmenorrhoea, 
 six became pregnant, after the symptoms had been 
 clear and unmistakable for a shorter or longer period. 
 Two of these patients had been already pregnant be- 
 fore the first appearance of the exfoliative endometri- 
 tis; subsequently they became pregnant and were de- 
 livered at full term. The other four had suffered for 
 varying periods and with varying severity from the 
 affection, before they first became pregnant. In three 
 of these cases curettage of the uterus was performed; 
 but in one only, in which pregnancy ensued veiy 
 speedily on the operation, could a causal connection be 
 inferred. In two of the cases the mothers of the pa- 
 tient had also suffered from the affection. 
 
 It has been asserted by B. Schultze and others that 
 curettage of the uterus renders it difficult or impossi- 
 ble for pregnancy subsequently to occur. There is, 
 however, no evidence to justify such an opinion. 
 
 Especial attention should be given to inflammatory 
 process in the perimetrium and the parametrium as 
 diseases giving rise to sterility in women. They are 
 extremely common, and at times are so insidious, run- 
 ning their course without giving rise either to pain 
 or to fever, that even when very extensive, and even 
 when they have led to the formation of secondary 
 
THE SEXUAL EPOCH OF THE MENACME 329 
 
 tumor-growths, they may yet be overlooked. Hence 
 their pathological significance in the causation of ster- 
 ility in women is still underestimated. Chronic pelvic 
 peritonitis and parametritis may lead to the onset of 
 sterility in various ways: changes may occur in the 
 cervix, this organ becoming indurated, fixed and retro- 
 posed, and painful when the uterus is moved; inflam- 
 matory changes may affect the body of the uterus, the 
 ligaments of the ovary, and various portions of the 
 pelvic peritoneum; displacement of the uterus may 
 occur; one or both ovaries or tubes may be dislocated 
 and fixed, either to the side of the uterus, or behind 
 it, in the pouch of Douglas; all kinds of adhesions or 
 inflammatory nodules may result from these processes. 
 
 Further, in the scarred, contracted, sclerosed parame- 
 tric tissue, the blood and lymphatic vessels of the para- 
 metrium are compressed, and in part obliterated, and 
 the intimate connection between the pelvic cellular tis- 
 sue and the uterus readily leads to the onset of en- 
 dometritis, whereby the implantation of the ovum is 
 interfered with. The occurrence of sterility in cases 
 of pelvic peritonitis and parametritis, depends in part 
 on the indirect effects of the inflammatory exudations, 
 and in part on the direct result of the extension of the 
 inflammation to other regions. The perimetritis, para- 
 metritis, and pelvic peritonitis that result from gonor- 
 rhceal infection have thus an especially disastrous influ- 
 ence, for the reason that in these cases cervical metritis 
 and endometritis with blennorrhoea are commonly su- 
 peradded. This is the principal cause of the almost 
 invariable sterility of prostitutes, in whom, however, we 
 must also take into consideration the influence of the 
 absence of voluptuous sensation in an act which to 
 them has become a mere matter of business. 
 
 The investigations of Bandl in the post-mortem room 
 
330 THE SEXUAL LIFE OF WOMAN 
 
 show that residues of perimetritic and parametritic in- 
 flammation are to be found in the bodies of 58.4 per 
 cent, of parous women, and 33.3 per cent, of the bodies 
 of women (married or unmarried) who have had ex- 
 perience of sexual intercourse but have never had a 
 child. This, he thinks, is the explanation of the great 
 frequency of childless marriages and of relative ster- 
 ility in women. In the nulloparae mentioned above, 
 Bundl commonly found an indurated, functionless, in 
 places cicatrized, narrowed cervix, paraoophoritic and 
 perisalpingitic residues, and morbid changes in the 
 tubes and the ovaries. In some cases also the husbands 
 of such sterile women were found to be aflfected with 
 azoospermia. The connection between azoospermia in 
 men and the discovery of inflammatory residues in 
 their childless wives, is a very intimate one. The hus- 
 band at the time of marriage was suffering from an 
 imperfectly cured gonorrhoea, and infected his wife. 
 
 In the other class of cases, in which the women had 
 had children, and subsequently became sterile, the 
 limitation of fertility depended chiefly upon inflamma- 
 tory residues in and around the ovaries and the tubes. 
 In the majority of such cases, pregnancy is not ren- 
 dered impossible, but merely difficult, for, notwith- 
 standing the presence of very extensive inflammatory 
 residues, the tubes are often pervious, and the ovaries 
 fully or partially functional. Therefore, even in cases 
 in which intra-pelvic inflammation has been very 
 severe, we must be cautious in giving a prognosis that 
 pregnancy has been rendered impossible, for the cases 
 in which both ovaries are imbedded completely in 
 pseudo-membranes, or in which both tubes have been 
 rendered impervious, are unquestionably rare. 
 
 Carcinoma of the uterus rarely causes sterility. In 
 its initial stages, in which there is merely papillary 
 
THE SEXUAL EPOCH OF THE MENACME 331 
 
 proliferation of the portio vaginalis, or carcinomatous 
 infiltration of the deeper layers of the mucous mem- 
 brane, no hindrance is offered to conception; but even 
 in the later stages of the disease, when ulceration has 
 occurred, and when there is extensive necrosis of the 
 cancerous masses, there is not necessarily any absolute 
 impossibility of the occurrence of conception, so long 
 as cohabitation remains possible, and no insuperable 
 hindrance has risen to the contact of ovum and sper- 
 matozoon. The cases are numerous in which preg- 
 nancy has been observed, notwithstanding extensive 
 carcinomatous disease of the cervix, with necrosis of 
 the tumor tissue; and Cohnstein even asserts, though 
 in this he goes too far, that cancer of the cervix ac- 
 tually favors impregnation. Among 127 cases of this 
 kind, there were 21 in which the disease had existed 
 for a year or more before the occurrence of con- 
 ception. 
 
 Winckel summarizes in the three following propo- 
 sitions his experience regarding the relation between 
 uterine carcinoma and sterility: i. Married women 
 form the very large majority of those affected with 
 carcinoma of the uterus. 2. The marriage of such 
 women has very rarely proved sterile. 3. On the con- 
 trary, the women affected with this disease have gen- 
 erally been exceptionally fertile. 
 
 Other tumors of the uterus cause sterility, not 
 merely by giving risp to mechanical interference with 
 the necessary contact of ovum and spermatozoon, but 
 also by leading to catarrhal states and hyperplasia of 
 the mucous membrane, which interfere with the im- 
 plantation of the ovum, even when fertilization has 
 been effected. Uterine polypi give rise to mechanical 
 - obstruction of the os uteri externum or of the cervical 
 canal ; but they predispose to sterility in an additional 
 
332 THE SEXUAL LIFE OF WOMAN 
 
 way, inasmuch as in a woman affected with such a 
 new-growth any vigorous bodily movement is apt to 
 cause profuse uterine haemorrhage. 
 
 In cases of myoma of the uterus, apart from the 
 mechanical hindrances to conception imposed by these 
 tumors, there is also interference with the implanta- 
 tion of the ovum. When numerous myomata have 
 formed in the uterine wall, the mucous membrane is 
 usually smooth and atrophied, and discharges a watery 
 secretion, and for these reasons the imbedding of the 
 ovum in the uterine cavity is rendered extremely dif- 
 ficult. But that there is often an additional cause of 
 sterility in cases of myomata uteri, has been shown by 
 the researches of Schorler, who examined 822 patients 
 affected with fibromyoma of the uterus. He found 
 that in most of those in whom sterility was observed, 
 the tumors were not submucous but subserous, and 
 that the sterility was to be explained in these cases by 
 the frequent occurrence of partial peritonitis, with its 
 evil results to the uterine annexa. 
 
 Schorler appends the following table: 
 
 Sterile. Percentage. 
 
 Of 85 women with interstitial myoma 21 24.7 
 
 Of 92 women with subserous myoma 44 47.8 
 
 Of 18 women with submucous myoma 7 38.8 
 
 Of 44 women with polypous myoma 4 9.0 
 
 Of 14 women with cervical myoma 3 18.7 
 
 253 79 31.2 
 
 When there are polypous new formations in the 
 uterine cavity, even if .conception occurs, abortion fol- 
 lows, for the reason that the rupture of the hypertroph- 
 ied capillaries in the growths themselves and in the 
 neighboring tissues, prevents the normal development 
 of the embryo. Horwitz has, however, described a 
 case in which pregnancy went on to full term, notwith- 
 standing the existence of growths of this nature. 
 
THE SEXUAL EPOCH OF THE MENACME 333 
 
 Owing to the frequency with which chronic metritis 
 and endometritis ensue upon parturition, it can readily 
 be understood that delivery itself is often the primary 
 cause of subsequent sterility. A temporary sterility 
 often follows the first delivery. It is well known that 
 the birth of boys is in general more difficult than the 
 birth of girls. Pfankuch, collecting information re- 
 garding the first and second deliveries of 300 married 
 women, ascertained that after 166 of the first deliveries 
 in which boys were born, the average lapse of time to 
 the second delivery was 30.2 months, whereas after 
 134 of the first deliveries in which girls were born, 
 the average lapse of time to the second delivery was 
 only 27.4 months. 
 
 The importance of previous delivery in leading to 
 sterility, in consequence of mesometritis and diffuse 
 connective tissue hyperplasia of the uterus, is shown 
 by von Griinewaldt, who published the following fig- 
 ures as a result, of his investigations. Of 56 women 
 affected with chronic metritis, 46.4 per cent, were 
 sterile; in 19.2 per cent, of these the sterility was con- 
 genital, in 80.7 per cent, it was acquired. Of 134 
 women suffering from myometritis and its conse- 
 quences, 71.6 per cent, were sterile; in 17.7 of these 
 the sterility was congenital, and in 82.2 per cent, 
 it was acquired. On the other hand, of 321 women 
 suffering from endometritis, 29.5 per cent, were ster- 
 ile; in 28.4 per cent, of these the sterility was con- 
 genital, and in 71.5 per cent, it was acquired. 
 
 Lier and Ascher also insist upon the importance of 
 puerperal diseases in the causation of acquired steril- 
 ity, basing their opinion upon Prochownick's clinical 
 material. They draw, however, the following dis- 
 tinction. If the puerperal infection takes place' by 
 way of the external organs of reproduction, through 
 
334. THE SEXUAL LIFE OF WOMAN 
 
 the vagina to the cervix and thence to the connective 
 tissue of the pelvis — the most common form, that 
 which occurs soonest after delivery, and the most se- 
 vere in its course — the v^omen thus aflfected are likely 
 soon to become pregnant again; if, on the other hand, 
 the disease is pelvic peritonitis, the exciting cause of 
 the inflammation proceeding from the interior of the 
 uterus through the Fallopian tubes to reach the peri- 
 toneum, in the majority of cases the women thus af- 
 fected will prove sterile for a long time or in per- 
 petuity. In almost all the cases in which sterility 
 resulted, the pelvic peritoneum had been severely 
 affected by the puerperal inflammation. Regarding 
 sterility in women, the two following general propo- 
 sitions are laid down by Lier and Ascher: i. Hardly 
 any single cause of sterility in women is so severe as 
 to be competent by itself to render sterility inevitable 
 throughout the period of sexual maturity, with the 
 exception of defects of development and premature 
 cessation of sexual activity. 2. Most of the hindrances 
 to conception in women depend upon affections of the 
 internal superficies of the reproductive organs, from 
 the vulval mucous membrane upward to the pelvic 
 peritoneum ; of these, the most important are affections 
 of the endometrium. 
 
 On the other hand, it must not be forgotten, that the 
 general tendency of a previous delivery is to increase 
 the capacity for impregnation. Olshausen especially 
 insists upon the well-known gynecological fact, that as 
 a result of the first delivery, there occurs an enlarge- 
 ment of the OS uteri, which facilitates conception 
 throughout the remainder of the period of sexual 
 maturity. This is well shown by the not infrequent 
 cases in which sterility persists for several years after 
 marriage, and then, with or without artificial aid. the 
 
THE SEXUAL EPOCH OF THE MENACME 333 
 
 first pregnancy occurs; thereafter one child after an- 
 other appears in rapid succession. 
 
 Spiegelberg has pointed out that cervical lacerations 
 may give rise to sterility by interference with the 
 incubation of the ovum. Olshausen maintains that this 
 affection is liable to cause abortion, for the reason that 
 by the gaping of the cervical canal the inferior pole 
 of the ovum is from time to time exposed, and this 
 gives rise to reflex contractions of the uterus. 
 
 Von Griinewaldt publishes figures in support of his 
 opinion that disturbances of the integrity of the uterus, 
 whereby the implantation and further development of 
 the ovum are interfered with, play on the whole a 
 greater part in the causation of sterility than the vari- 
 ous conditions previously described which interfere 
 with contact of ovum and spermatozoon. But in this, 
 we think, he goes too far. 
 
 Finally, in this connection, must be mentioned 
 among the hindrances to fertilization, sexual excesses, 
 such as are so common during the first weeks of mar- 
 ried life. Too frequent coitus gives rise to enduring 
 congestion of the uterus, and hence to an irritable 
 state of the uterine mucous membrane, whereby the 
 implantation of the ovum is rendered difficult. In 
 prostitutes chronic metritis, due to the excessive fre- 
 quency of intercourse, may be a contributory cause of 
 the sterility which is almost invariable in these 
 women; doubtless, however, the principal cause of 
 their sterility is gonorrhoeal perimetritis. 
 
 As a variety of the third kind of sterility, sterility 
 due to incapacity for implantation or further develop- 
 ment of the ovum, must be classed the cases in which, 
 though conception and implantation of the ovum are 
 known to occur, and the first stages of development of 
 the embryo certainly take place, the woman proves 
 
336 THE SEXUAL LIFE OF WOMAN 
 
 incapable of giving birth to a viable infant. Some 
 of these cases depend upon abnormal modes of devel- 
 opment, myxoma of the chorion and the like. In rare 
 cases, vi^omen abort every month, discharging every 
 four weeks a fully developed decidua vera, in which 
 sometimes no trace of ovum can be detected. But this 
 monthly abortion ceases as soon as marital relations 
 are interrupted. 
 
 It would be passing beyond the scope of this work 
 to discuss the pathological processes which lead to 
 premature interruption of the pregnancy, after con- 
 ception, implantation, of the ovum, and the first stages 
 of development, have occurred in a normal manner-— 
 to discuss, in short, the causes of abortion. Moreover, 
 these pathological processes are outside the concept 
 of sterility. It is sufficient here to enumerate the prin- 
 cipal conditions in which abortion occurs. They are: 
 various tissue disorders of the uterus, chronic hyper- 
 aemia of the mucosa, displacement of the uterus with 
 fixation, parametric and perimetric exudations, lacer- 
 ation of the cervix with ectropium; further, various 
 constitutional disorders, such as the specific fevers, 
 acute .infective processes, chronic circulatory disturb- 
 ances consequent upon cardiac, pulmonary, renal and 
 hepatic disease, syphilis, anaemia, chlorosis, diabetes, 
 etc. 
 
 Only-Ch ild-Sterility 
 
 Until recently, only-child-sterility had received at- 
 tention in England only, for the reason that it is com- 
 paratively common in that country; but this form 
 of relative sterility is by no means rare either in 
 Germany or in Austria. I had a collection made in 
 Austria of the number of children resulting from 2,000 
 fruitful unions, and found that among these there 
 
THE SEXUAL EPOCH OF THE MENACME 337 
 
 were 105 marriages in which one child only had been 
 born; thus the ratio of these marriages to those which 
 proved fully fruitful was about i : 19. But the fig- 
 ures are untrustworthy, since abortions and deaths in 
 infancy were not taken into account. Ansell found 
 that in England, among 1,767 fruitful marriages in 
 which the mean age of the wives at marriage had been 
 25, there were 131 cases of only-child-sterility, giving 
 a ratio of the latter to the fully fruitful unions of 
 1 : 13. 
 
 This form of relative sterility, in which the wife 
 gives birth to one child, and thereafter remains bar- 
 ren, was referred by Matthews Duncan, either to a 
 premature exhaustion of the reproductive capacity, 
 the general bodily powers remaining unaffected, or 
 else to a simultaneous weakening of the sexual powers 
 and of the constitutional force in general. This ex- 
 planation is a very inadequate one. The significant 
 fact upon which an understanding of the nature of 
 only-child-sterility must be based, is that the first de- 
 livery is the one which entails the greatest dangers to 
 the mother, and that the subsequent sterility is attrib- 
 utable to the difficult delivery, and to the illnesses 
 that follow in its train. In fact, only-child-sterility 
 is observed chiefly after difficult deliveries, followed 
 by long enduring inflammatory processes of the uterus 
 and the uterine annexa, which seriously affect the 
 woman's reproductive capacity. It occurs especially 
 in delicately organized, anaemic, scrofulous women, 
 whose powers of resistance have been undermined by 
 a single pregnancy and parturition. Finally, it is met 
 with in women suffering from myoma uteri, a form of 
 tumor which beyond others renders the recurrence 
 of pregnancy difficult and unlikely. This form of 
 sterility has been seen also in cases in which compara- 
 
338 THE SEXUAL LIFE OF WOMAN 
 
 tively soon after the birth of her first child, the 
 mother has suffered from typhoid, scarlatina, or some 
 other severe infective fever, which appears in some 
 way to interfere for the future with the development 
 of normal ova. We must also take into considei-ation 
 the fact that at the time of the wife's first confinement, 
 when the love which brought about the union has 
 often already begun to diminish in intensity, the hus- 
 band, finding too irksome the continence enforced 
 upon him by his wife's condition, is not unlikely to 
 go elsewhere for temporary sexual gratification, and 
 to acquire a venereal disease, which he subsequently 
 transmits to his wife, and which is responsible for the 
 latter's future sterility. And we must not forget to 
 take into account the adoption of means for the pre- 
 vention of pregnancy after the first child has been 
 born. 
 
 Again, I saw three cases of only-child-sterility in 
 which the husbands were respectively 24, 26, and 
 29 years older than their wives, and in these instances 
 no profound search was needful for the discovery 
 of the cause of the wife's unf ruitfulness ; it was ob- 
 vious that in each case the elderly husband's reproduc- 
 tive powers had sufficed for the procreation of a 
 single child, but had then been completely exhausted. 
 My experience in the mysteries of sterility in women 
 has informed me of yet another cause of only-child- 
 sterility, met with in cases in which the only child 
 was born after several years of unsuccessful marital 
 intercourse. In most of these cases, the wife has 
 finally been impelled to seek a substitute for her 
 husband, whose reproductive powers have proved in- 
 sufficient; having succeeded in obtaining the child she 
 desires, the wife does not again wander in strange 
 pastures, and consequently remains sterile. 
 
THE SEXUAL EPOCH OF THE MENACME 339 
 
 According to Kleinwachter — ^who gives a somewhat 
 wider significance to the term "only-child-sterility," 
 including as he does cases of premature interruption 
 of the first and only pregnancy, since these even more 
 frequently entail permanent sterilization — only-child- 
 sterility is by no means rare. Among i,o8i gyneco- 
 logical cases, he observed it in 90, that is, in 8.32 per 
 cent, of the cases. In these 90 cases, there were 69 in- 
 stances in which the sterility ensued upon full term 
 delivery, and 21 instances in which it followed abor- 
 tion or premature delivery. Kleinwachter, moreover, 
 on the basis of his personal experience, supports my 
 view of the importance of the sterilizing influence of 
 the first delivery; but he has been unable to determine 
 whether early marriage has any influence in the pro- 
 duction of only-child-sterility. 
 
 Lier and Ascher also class as instances of only-child- 
 sterility those cases in which a woman has had a single 
 miscarriage, and subsequently remained sterile, since 
 by this miscarriage the capacity of the woman for im- 
 pregnation has been proved, and the question of 
 capacity for full-term delivery has nothing to do with 
 that of capacity for conception. As causes of this 
 form of sterility, they lay especial stress upon puer- 
 peral infection, gonorrhoeal infection, perimetritis, 
 tubo-ovarian tumors, etc. 
 
Ill 
 
 SEXUAE EPOCH OF THE MENOPAUSE 
 
 THE MENOPAUSE 
 
 That time in a woman's life at which her sexual 
 activities come to their natural termination, marked 
 by the cessation of menstruation, is known as the 
 menopause, climax, or climacteric period. 
 
 This "change of life," from a condition of sexual 
 maturity to a condition of quiescence of sexual func- 
 tions, is not a sudden one, the symptoms of sexual 
 retrogression making their appearance gradually, un- 
 til the cessation of the monthly recurring menstrual 
 flow indicates that the termination of sexual activity 
 has arrived, and that sexual death is taking place. 
 
 The influence of this period of life is not manifested 
 by the sexual organs alone — in these latter indeed vari- 
 ous changes may be detected already before the cessa- 
 tion of menstruation, whilst after that cessation the 
 atrophic changes characteristic of old age proceed in 
 these organs with a slow but continuous advance — but 
 the disturbances evoked by the climacteric involve the 
 entire organism and affect the functions of numerous 
 organs, giving rise to a true storm of irritant phe- 
 nomena, and to manifestations of decay of manifold 
 nature. 
 
 The stormy manifestations, the occurrence of which 
 led the ancients to denote this period as the "critical 
 age" of a woman's life, are in the first place due to 
 changes in the ovaries; the tissue changes in these 
 
 340 
 
SEXUAL EPOCH OF THE MENOPAUSE 341 
 
 organs give rise to a powerful ovarian stimulus, which, 
 by irradiation and reflex action, leads to the. occur- 
 rence of a number of nervous disturbances, vaso- 
 motor manifestations, and circulatory disorders ; whilst 
 owing to the cessation of the internal secretions of the 
 ovaries, numerous and intense pathological disorders 
 of metabolism arise. These various symptoms be- 
 come apparent at the very outset of the menopause, 
 when the oncoming entire cessation of menstruation 
 is already foreshadowed by irregularity in the periods, 
 gradual diminution in the quantity of the flow, and 
 variations in the number of days during which the 
 flow on each occasion persists. 
 
 The manifestations of the menopause are in fact so 
 striking, that from ancient times down to the present 
 day a widespread belief has prevailed that especial 
 danger to a woman's life is threatened by the climac- 
 teric age! The statistics available on this subject are, 
 however, of dubious significance. Although it cannot 
 be denied that the changes in the entire organism 
 which attend the extinction of sexual activity bring 
 numerous dangerous influences into play, yet I feel 
 bound to maintain that these dangers are by no means 
 so great as those which are involvel by the sexual life 
 in its ripest period of development — the dangers of 
 pregnancy, parturition, and the puerperium. 
 
 It is often asserted that in this "critical period" of 
 the menopause the mortality of the female sex is 
 notably increased. The data available are somewhat 
 conflicting, but a careful examination leads us to be- 
 lieve that, if due allowance is made for the natural in- 
 crease in mortality with advancing years, no impor- 
 tant increase in the mortality of women can be traced 
 as due to the troubles and disturbances of the climac- 
 teric period. 
 
342 THE SEXUAL LIFE OF WOMAN 
 
 N The age at which a woman's last sexual epoch be- 
 gins is a very variable one. The duration of the 
 "change of life," the length of time during which the 
 occurrence of the "change" is manifested by local and 
 general disturbances, also varies greatly. Not less va- 
 riable are the intensity and the general distribution of 
 the symptoms which mark the climacteric. 
 
 The external configuration of woman at the climac- 
 teric age is usually characterized by signs of over- 
 ripeness, and these changes appear to exercise upon 
 certain men — more especially very young men — a pe- 
 culiar kind of erotic stimulus. Many women remain 
 long at this period- quite fresh looking, with a vivid, 
 youthful coloring; others, however, early manifest 
 alterations in their finer feminine characteristics, hairs, 
 for instance, sprouting on the chin, and the voice be- 
 coming deeper in tone. 
 
 The outward characters of senescence, with wither- 
 ing of the tissues, are not commonly manifested at 
 this time, but first make their appearance in later years, 
 after the completion of the menopause. 
 
 A tendency to the excessive accumulation of fatty 
 tissue is one of the most distinctive characteristics of 
 the menopause, varying, however, greatly in degree 
 according to race, family predisposition, and nutritive 
 conditions. The dominant tone is thus given to the 
 physical configuration by the deposit of fat. The face 
 comes to have a rounded, spherical appearance, the 
 eyes looking smaller in proportion, whilst the furrows 
 and folds which form the natural boundaries between 
 the features become indistinct. The formation of the 
 "double chin," and the abundant deposit of fatty tis- 
 sue in the supraclavicular region gives to these ex- 
 tremely obese women an appearance of such a short- 
 ening of the neck that head and thorax seem to be 
 
SEXUAL EPOCH OF THE MENOPAUSE 343 
 
 connected, as it were, by a great mass of fat, marked 
 by furrows in the thyroid and subhyoid regions. The 
 breasts sometimes attain an enormous size, hanging 
 down to the gastric and even to the umbilical region. 
 The abdomen is greatly enlarged, the fat in the an- 
 terior abdominal wall projecting more especially in 
 the hypogastric region, hanging down in two or three 
 horizontal rolls over the tops of the thighs, and push- 
 ing the mons veneris downward, so that this latter 
 itself projects over the genital fissure. The posterior 
 projection of the buttocks is also greatly increased, un- 
 til they form a huge elastic cushion, of which the sen- 
 sual orientals, who regard obesity in women as a 
 beauty, poetically write: "Her face is like the full 
 moon, and her buttocks are like two pillows." Occa- 
 sionally, so huge a mass of fat forms beneath the 
 tuberosity of the ischium that the configuration of the 
 nates reminds us of the well-known steatopyga or fat- 
 rump of the Hottentot and Bosjesman women. In the 
 genital organs, as already mentioned, the genital fis- 
 sure is hidden by the projection of the mons veneris. 
 The labia majora are also greatly enlarged by the de- 
 posit of fat, so that they look like two great cylinders 
 lying side by side. Another way in which the charac- 
 teristic sexual beauty is often lost in extremely obese 
 women is by the falling out of the pubic hair. 
 
 Moreau, in his work on The Natural History of 
 Woman, describes the changes occurring in a woman 
 at the climacteric in similar terms, and concludes: 
 "The only elements of a woman's beauty that may 
 sometimes be saved from the wreck, to persist for a 
 shorter or longer time after the climacteric, are, the 
 abundance of her hair, the vivacity of her glance, and 
 sometimes also the amiable expression of her counte- 
 nance; gradually, however, even these last remnants 
 
344 THE SEXUAL LIFE OF WOMAN 
 
 of beauty disappear, and old age takes possession with 
 its irresistible force." 
 
 None the less, some women may preserve substantial 
 elements of beauty for a long time after the menopause. 
 A classical example of this fact is furnished by Ninon 
 de I'Enclos. When she died, at the age of 90, she 
 was still beautiful. At the age of 65 she aroused the 
 passionate love of a young man, who, unfortunately, 
 was her own son. When informed of this, he commit- 
 ted suicide. A young abbe fell in love with her when 
 she was 75 years old. 
 
 The psychical life of woman is profoundly affected 
 by the stormy physical changes of the climacteric. 
 Not merely does a woman entertain the disturbing 
 thought that the critical age has begun, bringing in its 
 train certain dreaded dangers to her health and even 
 her life, but she is further depressed by the conscious- 
 ness that she is about to lose her feminine attractions, 
 and to decline in sexual esteem, and that her reproduc- 
 tive capacity is now to be extinguished. She realizes 
 vividly that the beautiful past, the loving and beloved 
 womanhood, is now to be left behind forever, and by 
 this an intelligent and sensitive woman cannot fail to 
 be profoundly affected. Her feelings at this time were 
 never more characteristically expressed than by the 
 Frenchwoman who said "Autrefois quand j'etais 
 femme." If, indeed, a woman has been so fortunate 
 as to have made a happy marriage, to have borne 
 healthy children, and to be living a satisfactory fam- 
 ily life, she will be enabled to bear with comparative 
 equanimity the disappearance of her sexual life; but 
 it is different with the childless wife and with the un- 
 married woman, who, at the onset of the climacteric, 
 must bury all their sexual aspirations, and who see the 
 remainder of their lives stretch before them without 
 
SEXUAL EPOCH OP THE MENOPAUSE 345 
 
 hopes for the future. The psychical predisposition 
 and the intellectual education of the woman concerned 
 will now determine whether she will bear the onset of 
 the menopause with composure and resignation, or 
 whether she will become a prey to melancholia. 
 Women of the former kind will seek to find employ- 
 ment for the powers set free by their sexual non-activ- 
 ity in services of neighborly affection, in works of be- 
 nevolence, and in the performance of social duties; 
 women less happily endowed will display their hos- 
 tility to the world in ill-nature, scandal-mongering, 
 and intrigue, thus giving vent to their inward bitter- 
 ness; while those, finally, with hereditary predisposi- 
 tion to nervous degeneration, will become the prey of 
 veritable psychoses. 
 
 A by no means rare result of the excited fantasy 
 and of the eager desire not to grow old, is displayed 
 at the climacteric in the form of self-deception. The 
 women thus affected cannot understand, and cannot be 
 made to believe, that the cessation of menstruation is 
 the natural sign of their sexual decadence, they trick 
 themselves into believing that in their case it is a sign 
 that they have become pregnant. We must not indeed 
 forget that the enlargement of the abdomen, so com- 
 mon at the commencement of the climacteric, in asso- 
 ciation with the unexpected failure of the menstrual 
 flow to appear, the frequent dyspeptic troubles, and 
 the enlargement of the breasts in consequence of the 
 deposit of fat in these organs, often enough lead to ap- 
 pearances which have a deceptive resemblance to the 
 clinical picture of early pregnancy. The mistake is 
 the more readily made because the breasts sometimes 
 secrete a serous fluid, while sacrache is not infrequent, 
 and peristaltic movements of the intestines are mis- 
 taken for the movements of the foetus. Cases of this 
 
346 THE SEXUAL LIFE OF WOMAN 
 
 kind, in which all the objective signs of pregnancy 
 appear to be present, and in which it is impossible to 
 convince the woman that she has been deceiving her- 
 self, and that all the signs and symptoms are due to 
 the menopause, are mentioned already by very early 
 writers, and have been frequently reported by modern 
 gynecologists. [An example of spurious pregnancy, 
 especially familiar to English readers, is that of Mary 
 I, Queen of England.— Transl.] 
 
 Sexual desire in woman by no means reaches its 
 physiological term with the climacteric and the cessa- 
 tion of menstruation. On the contrary, we have ob- 
 served it to be the rule that shortly before and at the 
 commencement of the climacteric there is a consid- 
 erable increase in the libido sexualis, and at the same 
 time an increase in sexual sensibility during coitus. 
 This sexual erethism makes its appearance in a man- 
 ner often extremely surprising to the husband— and 
 especially surprising in the case of women who have 
 previously been characterized by a certain frigidity in 
 sexual matters, and who have, perhaps, always needed 
 strong persuasion before they would consent to per- 
 form their marital duties. It is by no means rare for 
 the increased sexual impulse to manifest itself in some 
 pathological form. Even some time after the meno- 
 pause, when senile changes in the genital organs are 
 far advanced, the sexual impulse may still be re- 
 markably active. There is an interesting analogy in 
 the fact that Glaevecke observed that the sexual im- 
 pulse was persistent in women in whom an artificial 
 menopause had been induced by oophorectomy; and 
 that Lawson Tait and L. Smith have reported cases in 
 which dyspareunia, which had existed prior to the 
 operation, passed away after the removal of the ova- 
 ries, so that after the artificial menopause, voluptas 
 
SEXUAL EPOCH OP THE MENOPAUSE 347 
 
 coeundi for the first time made its appearance. Other 
 authors, Goodell, for instance, report that libido sex- 
 ualis is retained only for a short time after oophorec- 
 tomy, but subsequently disappears, as in the course of 
 the physiological menopause, and that at the same time 
 the voluptas coeundi is entirely extinguished. 
 
 When the menopause is fully established, and the 
 processes of involution in the reproductive organs have 
 taken place in a normal manner, the woman has had 
 time to acquiesce in the inevitableness of the changes 
 that have occurred, and she often attains a state of 
 emotional repose which was quite unknown to her in 
 the earlier phases of her sexual life. More particu- 
 larly those women, who hitherto during menstruation, 
 and for some days before and after the flow, have been 
 the prey of numerous nervous symptoms and troubles, 
 rejoice, after the menopause, at their new-won free- 
 dom from these pains and disquiets, at their delivery 
 from the excitements of the reproductive system, at 
 their now uninterrupted state of well-being. 
 
 I once saw a group of statuary by Pietro Balestra, 
 entitled "Time carries off Beauty." A beautiful 
 woman was striving in vain to resist the overwhelming 
 might of Chronos, whilst Cupid, about to be aban- 
 doned, was standing sorrowfully by. Here we have 
 a symbolic representation of the sexual epoch of the 
 menopause. 
 
 In a recently published romance, "Les Demi-Vi- 
 eilles," Yvette Guilbert has described in a manner 
 most true to nature the feelings of the "Half-Old," 
 the mental condition of women at the climacteric, 
 "They endeavor to remain young, to hide their defects, 
 they seek once again the intoxication of love. But 
 that which aforetime in hours of depression they have 
 foreseen, now becomes a dreadful reality. When the 
 
348 THE SEXUAL LIFE OF WOMAN 
 
 lemon has been squeezed dry, the skin is thrown 
 away." 
 
 Sooner or later, after the completion of the meno- 
 pause, the signs of senile marasmus become apparent. 
 The soft, feminine configuration of the face disap- 
 pears, the features become coarser, approaching the 
 masculine type, hairs appear on the upper lip and on 
 the chin. The voice becomes deeper and harsher. 
 As decrepitude begins, the breasts wither, a change 
 that occurs sooner in proportion to the degree in which 
 their functions have been in previous years exercised 
 by suckling; but also sometimes after a life of com- 
 plete sexual inactivity. Even in cases in which the 
 loss of substance of the breasts is apparently small, the 
 glandular tissue of the organs has really disappeared, 
 and has been replaced by fat. In advanced age, the 
 breasts become quite small, wrinkled, flaccid, and de- 
 pendent, and sometimes atrophied to become mere 
 cutaneous folds. The nipples project more promi- 
 nently, they are darker in color, and their surface is 
 wrinkled. In the genital organs, the fat disappears 
 from the mons veneris, which becomes flattened, whilst 
 the pubic hair ceases to be curly, and much or all of 
 it is ultimately shed. The labia majora become thin 
 and flaccid, until they are mere empty folds of skin; 
 they are widely separated, so that the vaginal orifice 
 is closed only by the withered nymphae, until these lat- 
 ter are themselves ultimately indicated by mere traces. 
 Where the menopause has been artificially induced, 
 the signs of senescence do not appear immediately 
 after the removal of the ovaries; their development is 
 a very gradual one. The sexually mature woman, 
 from whom these tokens of femininity have been re- 
 moved, experiences at first little change in external 
 configuration, beyond a somewhat exaggerated ten- 
 
SEXUAL EPOCH OF THE MENOPAUSE 349 
 
 dency to the deposit of fat; the other changes described 
 do not usually set in until the physiological climacteric 
 age is attained. A few cases only have been observed 
 in which after oophorectomy a rapid change to the 
 masculine configuration has been observed. 
 
 Seldom if ever does it happen that menstruation 
 suddenly ceases without any notable constitutional dis- 
 turbance, so that in a moment, as it were, the meno- 
 pause is effected, without any period of transition. 
 Rarely, even, do we meet with cases in which the 
 peculiar manifestations foreshadowing or accompany- 
 ing the cessation of menstruation last for no more than 
 a few weeks. Most commonly the irregularities of the 
 menstrual function (of which the most noteworthy 
 characteristic has hitherto been its extreme regular- 
 ity), and the associated symptoms of the climacteric 
 period, endure for months, and occasionally for years. 
 According to my own observations, the mean duration 
 of the climacteric manifestations is from two to three 
 years, the limits of variation in individual cases being, 
 however, exceedingly wide. 
 
 The manifestations which accompany the cessation 
 of menstruation are, as a rule, the following: The 
 woman is for some months in an irritable condition, 
 complains of digestive disturbances, constipation, me- 
 teorism, epistaxis, haemorrhoidal flux, congestions of 
 the head, increasing fugitive sensations of heat (Ger. 
 fliegende Hitze), and a tendency to profuse perspi- 
 ration. 
 
 The length of the intermenstrual interval commonly 
 increases, to as much as six or eight weeks ; the flow 
 itself becomes scantier. In other cases, however, the 
 flow becomes much more abundant, and the intermen- 
 strual intervals much shorter than normal. In some 
 cases, the regularity of the flow is altogether lost, it 
 
350 THE SEXUAL LIFE OF WOMAN 
 
 appears now soon, now late, and is now scanty, now 
 profuse. Sometimes the intervals are several months, 
 it may be 6, 8, and even lo months, then again the 
 flow will occur every two or three weeks; in excep- 
 tional cases, a scanty flow persists right through what 
 should be the interval, so that menstruation becomes 
 continuous, with periodic increases in the flow. Not 
 infrequently, after a sudden cessation of the flow, last- 
 ing for many months, menstruation recurs, and con- 
 tinues at regular intervals for a long time, until the 
 final cessation of menstrual activity. 
 
 The mode of cessation which is most favorable to a 
 woman's general health is for the duration of the in- 
 termenstrual interval gradually to increase, while pari 
 passu with this increase, the amount of the flow pro- 
 gressively decreases, until it ceases altogether. In such 
 cases, the general constitutional disturbance is reduced 
 to a minimum. On the other hand, the sudden cessa- 
 tion of menstruation gives rise to profound disturbance 
 of the domestic economy of the feminine organism, and 
 causes violent changes therein. But even the gradual 
 cessation of menstruation causes notable disturbance of 
 the woman's mental and physical equilibrium, if the 
 irregularities in the menstrual process are very great 
 and spread over a very long period — more especially 
 when the loss of blood is extensive. 
 
 Even after the menopause, after the final termina- 
 tion of the flow, there persists a more or less regular 
 recurrence of certain symptoms referrible to the com- 
 tinuance of ovulation. Sacrache, a sense of abdominal 
 tension, a feeling of heat and fulness in the pelvis, 
 dragging pain in the hypogastrium, and general irri- 
 tability, occur at intervals, so that the woman thus 
 affected sometimes describes herself as suffering from 
 the continuance of a "bloodless menstruation." 
 
SEXUAL EPOCH OF THE MENOPAUSE 351 
 
 The two principal dangers of the climacteric period 
 in women are, first, the great tendency to profuse 
 uterine haemorrhages, and, secondly, the liability to the 
 occurrence of malignant tumors, more especially to 
 carcinomatous disease of the ovaries, the uterus, and 
 the mammae. 
 
 With regard to the question whether, in any par- 
 ticular individual, the course of the menopause is 
 likely to be favorable or unfavorably, there are, in my 
 experience, four considerations of principal prognostic 
 significance: the condition of the woman during the 
 menarche, the state of the general health at the time 
 of commencement of the menopause, the degree to 
 which the sexual functions have been and are being 
 exercised, and the manner in which the cessation of 
 menstruation takes place. 
 
 As a rule, the disturbances and pathological states 
 of the climacteric period will be especially frequent 
 and severe in women whose sexual development at the 
 time of the menarche was accompanied by severe dis- 
 turbances of the general condition. In every individ- 
 ual there appears to be a certain connection between 
 the manifestations attending the menarche and those 
 attending the menopause, of such a nature that ac- 
 cording as puberty has been passed through with little 
 or with much disturbance of the general condition, a 
 similar favorable or unfavorable course of the meno- 
 pause may be prognosticated. If, at the time of the 
 menarche, there were severe nervous manifestations, 
 or heart troubles of a serious kind, the passage of the 
 menopause may be expected to give rise to neuropathic 
 affections and to cardiac disturbances in a similar 
 manner. 
 
 The woman's state of general health is likewise of 
 importance in determining whether the course of the 
 
352 THE SEXUAL LIFE OF WOMAN 
 
 menopause will be favorable or unfavorable. Per- 
 fectly healthy women, with a quiescent temperament, 
 and in favorable circumstances of life, will pass most 
 easily through the climacteric period without dis- 
 turbance of their general condition. Every departure 
 from normal health has an unfavorable influence upon 
 the course of the climacteric. In women of a plethoric 
 habit of body, there is an especial tendency at this 
 time to the occurrence of symptoms of stasis and hy- 
 peraemia. Chlorotic and anaemic women are more 
 prone than others to suffer at the time of the meno- 
 pause from uterine haemorrhages. Women of a san- 
 guino-erethistic constitutional disposition often mani- 
 fest at this epoch a tendency to neuroses and psychoses. 
 Those women have the best prospect of a smooth and 
 undisturbed passage through the climacteric age who 
 enter upon it in a state of perfect health. Less favor- 
 able is the prognosis in the case of those women who 
 already some time before the climax, at the outset of 
 the fourth decade of their lives, have begun to com- 
 plain of severe haemorrhages and various other patho- 
 logical states. 
 
 Regarding the influence which the sexual activity of 
 a woman during the menacme exercises upon the 
 course of the climacteric, it may be said, generally 
 speaking, that a previous free exercise of the sexual 
 functions in normal conditions has a favorable influ- 
 ence upon the state of health during the menopause. 
 Women who have been married for many years, who 
 have had many children, and who have suckled these 
 children, pass through the changes of the climacteric 
 much more easily than old maids, than women who 
 have lived for many years in continent widowhood, or 
 than women who have had very few children or none 
 at all. The practice of prohibitive coitus, i.e., the use 
 
SEXUAL EPOCH OF THE MENOPAUSE . 353 
 
 during intercourse of methods of preventing the oc- 
 currence of conception, a form of sexual immorality 
 which has become extrordinarily common during the 
 last few decades, has an unfavorable influence upon 
 the course of the climacteric. Unfavorable, also, is the 
 effect of great sexual activity during the four or five 
 years immediately preceding the menopause. Women 
 who marry shortly before the commencement of the 
 climacteric, and those who have given birtli to a child 
 shortly before this time, commonly experience very se- 
 vere disturbances during the menopause. Prostitutes 
 who continue the active pursuit of their profession un- 
 til the climacteric age have at this time much to suf- 
 fer. Women who have had difficult deliveries, or 
 several miscarriages, or severe puerperal illness— and 
 indeed, speaking generally, those women who have been 
 subject to any kind of disease of the reproductive or- 
 gans — are apt to suffer from serious disturbances of 
 the general health during the climacteric period. 
 
 The mode in which the cessation of menstruation 
 takes place is also causally connected with the easy or 
 difficult course of the menopause. Premature cessa- 
 tion of menstruation, or very sudden •interruption of 
 this function, has a deleterious effect, manifesting 
 itself both by local disorders of the reproductive or- 
 gans, and by general disturbances in the nervous sys- 
 tem and in the circulatory organs. On the other hand,, 
 a late menopause and a gradual cessation of menstrua- 
 tion are both usually accompanied by a favorable 
 course of the climacteric phenomena. 
 
 The influence of sexual activity upon the course of 
 the climacteric is described by Busch in the following 
 terms : "Women who have led an exhausting mode of 
 life, who have had intercourse too frequently, those 
 who have been given to onanism or to some other sex- 
 
354 THE SEXUAL LIFE OF WOMAN 
 
 ual irregularity, and who therefore enter upon the 
 menopause with flaccid and deteriorated rep'fbductive 
 organs, are liable to haemorrhagic and mucous fluxes, 
 to prolapse, carcinoma, dropsies, enlargements, and 
 suppurative processes. Women, on the other hand, 
 who have lived a life of strict isolation, and who have 
 forcibly repressed all sexual inclinations, frequently 
 suffer from ossifications, indurations, and atrophic 
 conditions of the reproductive organs, and also from 
 neoplasmata." 
 
 After an artificial menopause, induced by the opera- 
 tive removal of the ovaries, similar manifestations oc- 
 cur to those witnessed during the natural menopause. 
 Similar disturbances and troubles occur in both cases, 
 but in the artificial menopause they are commonly 
 more severe than in the natural; they last also for a 
 longer time, varying usually from three to six years; 
 moroever, in the artificial menopause, as in the natural, 
 the disturbance of health is more severe and lasts 
 longer in proportion to the youth of the individual. 
 Further, in the artificial menopause also, the intensity 
 and the duration of the climacteric manifestations are 
 influenced by the constitutional state and by the con- 
 dition of the genital organs at the time when the opera- 
 tion is performed. We note, moreover, that, just as 
 in the physiological menopause, the attendant troubles 
 are most violent in the initial period, and then grad- 
 ually subside, so also after the induction of an artificial 
 menopause by the removal of the ovaries, the resultant 
 disturbances rapidly increase in severity, to attain their 
 maximum in from three to six months, and then, after 
 lasting for a year or so, they gradually become less 
 severe, until they are ultimately extinguished. 
 
 The extensive process of transformation which goes 
 on in a woman's system during this period of the sex- 
 
SEXUAL EPOCH OF THE MENOPAUSE 355 
 
 ual life, from the very first diminution in ovarian ac- 
 tivity to the complete extinction of the reproductive 
 functions, manifests itself throughout the organism by 
 means of a series of changes which can for the most 
 part be referred either to states of blood-stasis and 
 their consequences — congestion of various organs, 
 haemorrhages, and disorders of secretion — or else to 
 perversions of nervous function. 
 
 The most manifold symptoms of disordered circu- 
 lation may occur: hyperaemic states of the central 
 nervous system, flushings of the face, the so-called 
 fugitive heats (Ger. fliegende Hitze) , a tendency to epi- 
 staxis, to haemorrhoidal flux, and to profuse perspira- 
 tion. The changes which take place in the reproduc- 
 tive organs at the time of the menopause give rise 
 to venous engorgement and to collateral congestions. 
 Such a condition of venous hyperaemia may occur in 
 the gastric and the intestinal mucous membrane, giv- 
 ing rise to various dyspeptic manifestations, and at 
 times, when severe, even to actual gastric and intes- 
 tinal catarrh. Hyperaemia of the liver may also arise. 
 In this case, the pressure of the distended blood-vessels 
 on the biliary ducts may interfere with the outflow of 
 the bile, and thus give rise to a slight icterus. Further, 
 the intra-abdominal venous congestion leads to over- 
 filling of the haemorrhoidal veins, and hence to bleed- 
 ing piles. 
 
 When the congestion is long-lasting, various further 
 morbid changes may arise, pulmonary hyperaemia may 
 eventuate in bronchitis, hyperaemia of the cerebral 
 meninges may cause very severe headache, there may 
 be syncopal attacks, tinnitus aurium, choroidal conges- 
 tion, impaired vision, etc. 
 
 Congestion of a more active nature arises from an in- 
 creased and usually accelerated flow of blood throu^'i 
 
356 THE SEXUAL LIFE OP WOMAN 
 
 the vessels of a part in which the resistance to the 
 blood stream has been lowered proportionately to its 
 propulsive force. In this way arises that characteris- 
 tic symptom of the menopause known as ardor fugax 
 — fugitive heat — one link in the long chain of vaso- 
 motor manifestations occurring at this period of life. 
 
 Fugitive heats are commonly most clearly marked in 
 the face, head, and neck, in which region there sud- 
 denly occurs a reddening of the skin, with diffuse and 
 increasing subjective sensation of heat. At the same 
 time there is often a sense of tension, as if the part 
 were about to burst. Actual slight swelling may be 
 noticed, the eyes sparkle and are somewhat prominent, 
 the head feels heavy, stupid, and dizzy. Sometimes 
 these symptoms last for a considerable period ; at other 
 times they terminate speedily and suddenly with a 
 local perspiration or with an attack of epistaxis. Not 
 infrequently, after lasting a short time in one region, 
 they pass away as rapidly as they came, but are imme- 
 diately succeeded by a similar attack in some other 
 part of the body, or by vasomotor phenomena of a 
 slightly dififerent kind. Thus, such a flushing and heat 
 of the face may be replaced by a sudden sense of heat 
 in the small of the back or in the sacral region, by pru- 
 ritus of the extremities, by palpitation of the heart, or 
 by an attack of pseud-angina. 
 
 A further consequence of active hyperjemia is the 
 onset of those confused states, so common in the cli- 
 macteric age, of mental and bodily disquiet, which 
 find expression, now in states of excitement, and now 
 in states of depression. So we often observe change 
 of disposition, associated with incapacity for regular 
 work, while sleep is restless, and much disturbed by 
 dreams; and again states of dizziness, a sense of men- 
 tal uneasiness and confusion, and even actual delirium. 
 
SEXUAL EPOCH OF THE MENOPAUSE 357 
 
 In the skin, in addition to the fugitive heats, we often 
 have a peculiar pricking, itching, or stabbing sensa- 
 tion, and various kinds of hyperaesthesia, frequently 
 associated with disturbances of tactile sensation. We 
 observe also muscular twitchings, and general weak- 
 ness of the organs 'of locomotion. 
 
 In association with the passive and active hyperae- 
 mias of the menopause, we frequently see increase or 
 some qualitative change in the various secretions. 
 Above all, these changes affect the various secretions 
 of the different reproductive organs, but we have also 
 increased intestinal secretion, leading to diarrhoea, in- 
 creased excretion of urinary deposits, and increased 
 secretion by the skin. Symptoms which are common 
 at the menarche, and frequently recur at the meno- 
 pause, are: headache, migraine, a state of pseudo-nar- 
 cotism, slight hysterical attacks, indications of moral 
 insanity, lumbo-abdominal neuralgias, neuralgia of 
 the breasts, leucorrhcea, and various skin eruptions. 
 
 According to Tilt, the changes occurring in the or- 
 ganism at the climacteric period may be summarized 
 under the following heads: 
 
 1. Increased elimination of carbonic acid by the 
 lungs. 
 
 2. Increased elimination of uric acid in the urine. 
 
 3. Increased perspiration. 
 
 4. Increased mucous flux. 
 
 5. Haemorrhages from various organs. 
 
 As regards the first point, the extensive researches 
 of Andral and Gavaret have shown that in the female 
 sex the quantity of carbonic acid eliminated by the 
 lungs diminishes when menstruation first appears at 
 puberty, but increases again at the climacteric age, 
 when menstruation ceases — ^whereas in the male a 
 gradual diminution in the elimination of carbonic acjd 
 
358 THE SEXUAL LIFE OF WOMAN 
 
 begins already in the 36th year of life; in old age the 
 quantity eliminated is greatly reduced in both sexes 
 alike. 
 
 Changes in the Female Reproductive Organs at 
 THE Menopause 
 
 In considering the changes that take place in the 
 female reproductive organs at this period of life, we 
 must distinguish between the proper period of the cli- 
 macteric, with its various manifestations antecedent to 
 and associated with the irregularity and ultimate ces- 
 sation of menstruation, from the condition of old age 
 in which menstruation has actually and completely 
 ceased, in which the menopause has been fully accom- 
 plished, and in which the changes of senescence have 
 set in at once in the organs of the reproductive system 
 and in the organism as a whole. 
 
 The most important and most significant changes of 
 this sexual epoch are unquestionably the anatomical 
 alterations in the ovaries. A good many years ago I 
 undertook an investigation whose purpose was to fol- 
 low the natural involution of the graafian follicles 
 from the time of the climax on into old age, and for 
 this purpose I examined a very large number of ova- 
 ries of women at ages varying from 42 to 75 years 
 {Archiv fur Gynecologie, Bd. XII., Heft 3). 
 
 Throughout these years a slow but continuously 
 progressive atrophy proceeds in the ovaries; they be- 
 come smaller and denser, diminishing especially in 
 height and width; their surface becomes extremely un- 
 even; and in extreme old age they wither away until 
 no more is left in the region formerly occupied by the 
 ovaries than a flattened fibro-vascular thickening. 
 The histological characteristic of the changes in the 
 ovary which proceed gradually from the commence- 
 
SEXUAL EPOCH OF THE MENOPAUSE 369 
 
 merit of the menopause to extreme old age, may be 
 summed up as consisting in a continual increase and 
 new formation of the connective tissue stroma at the 
 expense of the cellular layer, accompanied by retro- 
 gressive metamorphosis of the graafian follicles. 
 
 The connective tissue ground substances of the ovary 
 increases from the periphery toward the centre, and 
 progressively compresses the epithelial structures of 
 the organ. In the outermost layer of the ovarian 
 stroma, the so-called tunica albuginea, the strata of 
 short, dense connective tissue fibres increase notably in 
 number, so that whereas at first three layers at most 
 could be distinguished, the tunic ultimately comes. to 
 consist of from six to eight layers ; at the same time also 
 the interior ovarian stroma becomes exceedingly dense, 
 so that numerous well-defined interlacing bundles of 
 fibres can be made out in its substance. 
 
 The first retrogressive metamorphosis which can be 
 observed in the graafian follicles is fatty degeneration, 
 the formation of granule spheres. Whilst the mem- 
 brana propria (the theca folliculi) of the follicle re- 
 mains quite unaltered, we observe in the membrana 
 granulosa, in addition to the ovum, and the ordinary 
 cells of this layer, spherical aggregates of fat droplets, 
 the granule spheres, which continually increase in size, 
 until ultimately of the cellular contents of the follicle 
 nothing whatever remains, and it now appears full of 
 granule spheres and fluid. The theca folliculi has 
 now lost its spherical shape, and assumes an ovoid form. 
 
 In a later stage of the degeneration of the graafian 
 follicle, it appears as a vesicular body with a relaxed 
 wall, thrown into numerous folds, this folded wall be- 
 ing formed by the theca folliculi. The cavity of the 
 follicle is reduced to a mere cleft filled with a trans- 
 parent substance, and the space between this cleft and 
 
360 THE SEXUAL LIFE OF WOMAN 
 
 the inner surface of the theca folliculi is occupied by 
 round cells and a fibrous intercellular substance, and 
 is traversed by a vascular network. This second stage 
 of the retrogression of the follicle may therefore be 
 designated the stage of vesicular degeneration. 
 
 In the last stage of this retrogressive metamorphosis, 
 we find the follicle completely transformed to a 
 fibrous mass. It appears as an elongated oval body, 
 much lobulated, connected with the surrounding 
 stroma by thick strands of fibres; a trace of the orig- 
 inal cavity can still be distinguished in the form of a 
 narrow cleft, without distinguishable contents. The 
 tissue of this body consists of connective tissue fibres, 
 with interspersed nuclei and nuclear fibres. 
 
 The three stages I have observed in the retrogres- 
 sion of the follicle, of which I have given a summary 
 account above, may, I think, be explained in the fol- 
 lowing manner: When the woman's reproductive ac- 
 tivity ceases, the graafian follicles become subject to a 
 retrogressive metamorphosis, a fatty degeneration set- 
 ting in in the cells of the membrana granulosa and in 
 the ovum, until ultimately the whole of the granular 
 epithelium has undergone atrophy. The follicle now 
 undergoes a vesicular transformation with shrinkage 
 of its cavity, and with the formation of a new tissue 
 which appears to- be young connective tissue. As time 
 goes on, this new connective tissue is formed in increas- 
 ing quantities, until finally the entire follicle is trans- 
 formed into a firm fibrous mass. 
 
 Thus we are led to infer that the gradual but ex- 
 tensive thickening of the tunica albuginea (i.e., the 
 outer, condensed layer of the ovarian stroma), which, 
 as we have seen, always occurs at the climacteric pe- 
 riod, offers a hindrance to the bursting of the follicles 
 as they mature, and in this we find the explanation of 
 
SEXUAL EPOCH OF THE MENOPAUSE 361 
 
 the irregularity of menstruation and of the various 
 troubles which attend the performance of that func- 
 tion at the time of the menopause. It is reasonable to 
 assume that the resistance of this thickened tunica al- 
 buginea is responsible for the fact that the interval be- 
 tween the bursting of the successive follicles is now 
 greater than normal, as much as six or eight weeks — 
 this retardation of menstruation being one of the com- 
 monest ways in which the onset of the menopause is 
 first manifested. Another phenomenon connected with 
 the onset of the menopause also finds a plausible ex- 
 planation in the anatomical grounds just mentioned. 
 As already pointed out, in parous women the meno- 
 pause sets in later than in nulliparae. At every preg- 
 nancy, the ovaries share in the more abundant nutri- 
 tion of all the reproductive organs, due to the general 
 dilatation of the intra-pelvic vessels which accom- 
 panies this process; hence the ovaries become larger, 
 richer in lymph, and therefore softer, the cellular ele- 
 ments increase in size, and perhaps also in number, 
 and it is readily conceivable that in such ovaries the 
 cellular elements are able for a longer time to resist 
 the induration and the new formation of connective 
 tissue which occur at the climacteric. 
 
 The numerous nervous disturbances of the climac- 
 teric epoch would appear also to depend upon the 
 hyperplasia of the ovarian stroma which we have ob- 
 served to be the characteristic anatomical change in 
 the ovaries at this period of life. 
 
 Associated with the fibrous transformation of the 
 graafian follicles there is, however, a failure of the so- 
 called internal secretion of the ovaries, a matter to 
 which much attention has recently been paid. Brown- 
 Sequard has especially maintained that the ovaries se- 
 crete a substance which enters the blood, a substance 
 
362 THE SEXUAL LIFE OF WOMAN 
 
 which, notwithstanding the fact that its presence can- 
 not be proved either by chemical or any other means 
 known to us, yet is of considerable importance for the 
 maintenance of the equilibrium of mental and physical 
 well-being. It is supposed that the various profound 
 disturbances of the general system occurring at the 
 menopause ^ are dependent upon the cessation of this 
 internal secretion of the ovary — disturbances which 
 rise to a maximum as the atrophy of the ovary pro- 
 ceeds, and which only gradually pass away after a 
 considerable lapse of time. 
 
 After the menopause is completely over, in the 
 ovaries, as in other parts of the female reproductive 
 organs, the signs of senile degeneration make their 
 appearance. 
 
 In old women, we find the ovaries either shrunken 
 to the form of small fibrous cords, or else degenerated 
 to form cysts of smaller or larger size, the stroma sur- 
 rounding these cysts being extremely hard, dense, and 
 tough. 
 
 Whereas at the commencement of the climacteric 
 period the uterus commonly exhibits a slight increase 
 in size, owing to the condition of passive hyperaemia 
 already described, subsequently a gradual diminution 
 in the size of the organ may be observed. This atrophy 
 begins with the portio vaginalis and proceeds upward. 
 Whilst the body still appears undiminished in size, the 
 vaginal portion will be found already shorter, more 
 slender, and more flaccid. Gradually, however, the 
 entire organ is involved in the atrophic process. The 
 uterus is then smaller than formerly, its walls are 
 
 ■* Note. — In Germany, the term Ausfalherscheinungen is used as a gen- 
 eral name for the various disorders of the climacteric period. The word 
 Ausfall means literally o falling out, or shedding, as of the hair. No pre- 
 cise English equivalent of the term is known to me, nor is one really 
 needed, the phrase disorders of the climacteric being sufficiently distinctive. 
 — Transl. 
 
SEXUAI. EPOCH OF THE MENOPAUSE 363 
 
 thinner, its cavity reduced in size. Its vascularity and 
 its sensibility are alike diminished. The external os 
 is smaller, and the internal os is sometimes entirely' 
 obliterated. There is a tendency at the climacteric 
 period for the tubulo-racemose glands of the cervical 
 mucous membrane to undergo a cystic degeneration, 
 and hence arise the cysts which are so commonly met 
 with on the portio vaginalis of women at this time of 
 lifCj cysts varying in size from that of a millet seed to 
 that of a pea. In advanced life, the formation of such 
 cysts may be regarded as normal, and sometimes in the 
 form of grape-like clusters they almost completely oc- 
 cupy the lumen of the cervical canal. 
 
 Not infrequently these cysts lead to the formation of 
 polypi, by enlarging until the mucous membrane 
 projects so far that a stalk is formed. 
 
 Examining the bodies of 47 women who died at 
 ages varying from 42 to 80 years, I found in 28 ovula 
 Nabothi in the cervical mucous membrane, for the 
 most part at the os uteri externum, but in some cases 
 also extending up to the os internum, sometimes be- 
 tween the plicae palmatae, sometimes isolated, some- 
 times grouped. 
 
 Sometimes in old women no trace of a vaginal por- 
 tion remains, and the uterus is found to be transformed 
 to a small, thin-walled, shrunken body, no more than 
 one-fourth of its original size; in such cases the saying 
 of Graaf appears to be justified, that after the meno- 
 pause the uterus returns to the size it has in the young 
 girl. In the majority of such cases, the cavity of the 
 uterus is also contracted (concentric atrophy). It 
 sometimes happens, however, that in old age the os 
 externum and the os internum are the seat of atresia, 
 whilst the intermediate portion of the cervical canal 
 remains unaffected. In this way, especially when the 
 
THE SEXUAL LIFE OP WOMAN 
 
 cervical canal and the cavity of the body of the uterus 
 are distended with mucus or with fungous growths, is 
 produced what is known as the uterus bicameratus 
 vetularum. 
 
 In many cases, when the cervical canal has been 
 obliterated, we find the uterine cavity distended with 
 mucous secretion (excentric atrophy). The substance 
 of the uterine wall is in old age commonly dense and 
 tough, but occasionally, in extreme old age, less firm 
 than formerly, withered and friable, and traversed by 
 degenerated arteries, and in this state it is predisposed 
 to haemorrhages (apoplexia uteri). Such intra-mural 
 haemorrhages usually occur in the fundus; the friable 
 uterine substance has then a blackish-red appearance, 
 infarcted with extravasafed blood; sometimes the ute- 
 rine cavity is also filled with blood. In general, it 
 may be said that when the menopause is completely 
 over, when uterine activity has entirely ceased, the 
 uterus returns to the state in which it was before the 
 menarche — it is physiologically dead. 
 
 The tubes become flaccid, thinner, shorter, and are 
 at times obliterated. In the mucous membrane of the 
 tubes in old women we no longer find any trace of the 
 glands described by Hennig; the epithelial cells have 
 also lost their cilia. 
 
 During the climacteric period, the vagina is usually 
 relaxed and roomy, the mucous membrane is smooth, 
 injected and secretes freely; subsequently, in old age, 
 it becomes firm, tough and dry. 
 
 Wendeler found that the initial change of the cli- 
 macteric in the ovary is a chronic and progressive en- 
 darteritis obliterans; the resulf of this process is, in 
 addition to the obliteration of the follicles, a contin- 
 ually increasing hyaline degeneration of the smallest 
 arteries and the arterioles, especially along the line of 
 
SEXUAU EPOCH OF THE MENOPAUSE 365 
 
 transition between the cortical and the medullary sub- 
 stance of the organ; this degeneration extends to the 
 surrounding connective tissue, and thus leads to the 
 formation of peculiar, vitreous, translucent foci of 
 sclerotic connective tissue, containing few cells or 
 none; these are the so-called corpora fibrosa or corpora 
 albicantia. Only subsequently to the formation of 
 these bodies does the characteristic wrinkling of the 
 surface of the ovary occur, with general shrinkage of 
 the organ, these changes being due to the contraction 
 that sets in in the numerous scattered foci of connective 
 tissue, which, as already mentioned, are situated in 
 close proximity to the cortex. 
 
 The gradual atrophy of the uterus after the extinc- 
 tion of its sexual activity leafls to a diminution in all 
 the diameters of the organ, so that in old women it 
 becomes flattened as in childhood, all its curves hav- 
 ing disappeared; the muscular substance is replaced 
 by connective tissue ; and the portio vaginalis dwindles 
 and even entirely disappears. 
 
 As regards the bacterial flora of the genital organs 
 of elderly women, Menge and Koenig find that the 
 vagina for the most part contains bacteria which do 
 not thrive when cultivated aerobically on alkaline 
 agar plates. In exceptional cases, however, such bac- 
 teria are found, and may even be sufficiently vigorous 
 to produce pyogenic infection. According to Stroga- 
 moff, the vagina in all circumstances contains a great 
 variety of micro-organisms — cocci, diplococci and rod- 
 forms. Rod-forms are the prevailing types found in 
 normal conditions in elderly women, but they are 
 much smaller than in women who are still in the pe- 
 riod of reproductive activity. Organisms liquefying 
 gelatine were found in one instance only, a case of 
 vaginal prolapse. In one-half of the cases examined, 
 
366 THE SEXUAL LIFE OF WOMAN 
 
 there was no development of culture media inoculated 
 from the cervix uteri, v^^hether on agar or gelatine. 
 
 The Time of the Menopause 
 
 The age at v^^hich the menopause begins is one which 
 varies owing to manifold conditions, congenital and 
 acquired, owing to the local influences which have 
 been brought to bear on the reproductive organs dur- 
 ing the menacme, and to the general circumstances 
 of life during this period. In Northern Europe it 
 commonly begins some time between the ages of 40 
 and 50 years. According to the most trustworthy 
 statistical data, the commonest age for the onset of 
 the menopause is between the ages of 45 and 50 
 years. Next to these in frequency we find the meno- 
 pause commencing between the ages of 40 and 45 
 years. If, however, the menopause does not begin 
 during the fifth decennium, it is more apt to occur 
 during the quinquennium after 50 than during the 
 quinquennium preceding 40 years of age; that is to 
 say, an a:bnormally late menopause is more often met 
 with than an abnormally early menopause. In a very 
 small proportion of women does the menopause begin 
 either after the age of 55 or before the age of 35. 
 
 The Age at Which the Menopause Occurs 
 
 My own observations show that the age at which 
 the menopause begins is affected by the following cir- 
 cumstances : 
 
 1. The race (nationality) of the woman. 
 
 2. The age at which the menarche occurred. 
 
 3. The sexual activity of the woman during the 
 period of the menacme, the number of her pregnancies, 
 the exercise or neglect of the function of lactation. 
 
SEXUAL EPOCH OF THE MENOPAUSE 867 
 
 4. The social circumstances of the woman's life. 
 
 5. General constitutional and pathological condi- 
 tions. 
 
 I. Race 
 
 From the statistical data regarding the age at which 
 the menopause occurs among the women of the vari- 
 ous nations of Northern Europe, it appears that the 
 latest average age for the cessation of menstruation 
 is met with in Lapland, namely 49.4 years ; next comes 
 Norway, where the average age is 48.9; next Ger- 
 many, where the average age is 47; next England, 
 46.1; next Russia, 44; and finally Austria, 42.2. In 
 the four principal capital cities, the average age is: 
 in London, 45.5; in Paris, 43.65; in Vienna, 43, and 
 in Berlin, 47. Generally speaking, in southern coun- 
 tries the cessation of menstruation occurs at an earlier 
 age than in northern countries, as the following com- 
 parison shows: Northern countries: England (Tilt), 
 48 to 50; France (Courty)j 50; North Germany 
 (Mayer), 50; Austria (Szukits), 42; southern coun- 
 tries: Persia (Chardin), 27; Java, 30; various Asiatic 
 races, 30 to 40. 
 
 In the case of 500 women of various nationalities in 
 whom I was able to ascertain by personal observa- 
 tion the age at which menstruation ceased, I found 
 that the menopause occurred: 
 
 In the quinquennium 35 to 40 in 48 women 
 
 In the quinquennium 40 to 45 in 141 women 
 
 In the quinquennium 45 to 50 in 177 women 
 
 In the quinquennium 50 to 55 in 89 women 
 
 ~455 
 
 Thus we see that in about one-tenth of my cases, 
 menstruation ceased between the ages of 35 and 40; 
 in more than one-fourth, between the ages of 40 and 
 
368 THE SEXUAL LIFE OF WOMAN 
 
 45; in more than one-third between the ages of 45 
 and 50; and in about one-sixth between the ages of 
 50 and 55. In 267, that is, in more than one-half of 
 the 500, menstruation ceased between the ages of 42 
 and 51. In 28 women, menstruation ceased before 
 the age of 35; and in 17, after the age of 55. In a 
 very large majority of my 500 cases the women were 
 of German or Austro-Hungarian nationality; next, in 
 order of frequency, came Poles, Russians, women of 
 various southern countries, Swedish women. In wom- 
 en of Sclavonic nationality, menstruation ceased re- 
 markably late as compared with women of German 
 nationality. 
 
 Brierre de Boismont, Tilt, Courty, and various other 
 observers, have published statistical data regarding the 
 age at which menstruation ceases in women of differ- 
 ent nationalities. Krieger, compiling from several au- 
 thors, statistics relating to 2,291 women (European) 
 gives the following average results: menstruation 
 ceased 
 
 Between the ages of 35 and 40 in 272 women 11.87 per cent. 
 
 Between the ages of 40 and 45 in 595 women 25.97 per cent. 
 
 Between the ages of 45 and 50 in 940 women 41.03 per cent. 
 
 Between the ages of 50 and 55 in 334 women 14.58 per cent. 
 
 Before 35 and after 55 in 150 women 6.54 per cent. 
 
 2291 99.99 
 
 2. The Age at Which the Menarche Occurred 
 
 Until recently, it was generally believed that the 
 earlier the age at which menstruation first made its 
 appearance, the earlier also would the menopause oc- 
 cur; and that, on the other hand, the later the age at 
 which the flow began, the later also would it cease. 
 Virey summarized this opinion in the saying: prius 
 pubescentes prius senescunt. This view of the matter 
 
SEXUAL EPOCH OF THE MENOPAUSE 869 
 
 is, however, true only in respect of the influence of 
 climate upon sexual development. In a cold climate, 
 a woman begins to menstruate late and ceases to men- 
 struate late; in a hot climate the opposite conditions 
 prevail. But if we make our comparison between 
 women living in similar conditions as regards latitude 
 and climate, we find that Virey's saying is far from 
 accurately describing the facts. 
 
 In general, and climatic influences apart, it may be 
 said that the earlier in any woman the age at which 
 menstruation first occurs, the later will be the age at 
 which menstruation ceases. 
 
 In order to ascertain the influence of the age at the 
 menarche upon the disappearance of menstrual activ- 
 ity, I placed in comparison first the cases of 50 women 
 in whom menstruation had first appeared between the 
 ages of 12 and 16 — i.e., cases of early menarche; and 
 secondly, the cases of 50 women in whom menstruation 
 had begun between the ages of 16 and 20 — i.e., cases 
 of late menarche. The result was the following: 
 
 In the 50 women in whom the menarche had been 
 early, the menopaue occurred 
 
 At ages 35 to 40 in 5 instances. 
 At ages 40 to 45 in 12 instances. 
 At ages 45 to 50 in 25 instances. 
 At ages 50 to 55 in 8 instances. 
 
 On the other hand, in the 50 women in whom the 
 menarche had been late, the menopause occurred 
 
 At ages 35 to 40 in 9 instances. 
 At ages 40 to 45 in 28 instances. 
 At ages 45 to 50 in 10 instances. 
 At ages 50 to 55 in 3 instances. 
 
 Thus whilst among the women in whom the me- 
 narche had been late, there were thirteen only who 
 continued to menstruate until they were at least 45 
 
870 THE SEXUAL LIFE OF WOMAN 
 
 years of age, among those in whom the menarche had 
 been early, the number in whom menstruation thus 
 continued up to the age of 45 or beyond was 33, nearly 
 three times as great. 
 
 On the other hand, in those cases in which the me- 
 narche occurred at an abnormally early age, i.e., be- 
 fore the age of 12 years, the menopause was also a 
 remarkably early one. The menopause also came on 
 very early in women in whom the menarche had been 
 extremely retarded, until the age of 20 and upward. 
 An extremely early and an extremely late menarche 
 alike tend to be followed by a premature menopause. 
 
 To this rule there are, however, exceptions, and we 
 occasionally meet with women whose reproductive en- 
 ergies are so powerful that the menarche occurs at 
 an unusually early age, and the menopause is postponed 
 to an age considerably beyond the average. Thus, 
 among 100 women in the Salpetriere, Raciborski ob- 
 served 29 in whom menstruation had begun at the ex- 
 ceptionally early age of 12 years, and who, notwith- 
 standing this, all experienced a very late menopause. 
 Three of them were still menstruating at the age of 
 S7, I at 56, 2 at 52, 2 at 50, 3 at 48, 3 at 45, and 13 at 
 an age less than 45. 
 
 Brierre de Boismont reports the case of a woman 
 who began to menstruate in her 12th year; she mar- 
 ried, had several children, and continued to menstruate 
 regularly until she was 60 years of age. 
 
 The results obtained by W. Guy, who examined a 
 series of 250 cases, confirm the proposition stated above, 
 that the earlier menstruation begins (the extremely 
 early cases being excluded), the later it ceases. 
 
 According to Cohnstein, who bases his conclusions 
 upon the observation of 400 cases, in women who be- 
 gin to menstruate early, the menopause occurs on an 
 
SEXUAL EPOCH OF THE MENOPAUSE 371 
 
 average three years later than in women who begin to 
 menstruate late. Puech also states that menstruation 
 lasts longer in women who begin to menstruate early 
 than in those who begin to menstruate late. According 
 to Scanzoni, in women who begin to menstruate in 
 very early youth, the climacteric age is commonly 
 reached earlier than in those in whom puberty occurs 
 at the normal age — commonly between the ages of 40 
 and 42 years. 
 
 The homology between the pathological states which", 
 in any particular individual, occur at the respective 
 periods of the menarche and the menopause, is some- 
 times extremely remarkable; the very same symptoms 
 by which the first appearance of menstruation was 
 preceded, recur as antecedents of the menopause. This 
 is seen in the case of certain eczematous conditions of 
 the skin, of dyspeptic manifestations, epistaxis, nervous 
 disturbances, hysterical and epileptic seizures, vaso- 
 motor symptoms, congestions, cardiac troubles, albu- 
 minuria, etc. Alibert pointed out that certain skin 
 diseases may appear twice only during life, once shortly 
 before the commencement of menstruation, and the 
 second time shortly before the cessation of menstrual 
 activity. Brierre de Boismont alludes to the occur- 
 rence of hysteria and epilepsy before t)oth these im- 
 portant epochs in a woman's life, whilst in the inter- 
 vening period the patient had remained entirely free 
 from such troubles. H. Marsh records the observation 
 that women who just before puberty have suffered 
 from repeated attacks of epistaxis, have suffered from 
 the same trouble as a predominant symptom of the 
 climacteric period. Tilt has seen in several cases the 
 outbreak of numerous furuncles with subsequent diar- 
 rhoea, and still more frequently peculiar attacks of 
 severe vertigo, occurring in women just before the two 
 
872 THE SEXUAL LIFE OF WOMAN 
 
 critical epochs in her life, whilst in the intervening 
 period there has been no trace of such troubles, either 
 in connection with menstruation, with the puerperium, 
 or with lactation. 
 
 3. The Woman's Sexual Activity 
 
 An important influence upon the early or late onset 
 of the menopause is exerted by the degree to which a 
 woman's reproductive functions have been exercised 
 during the menarche. My personal observations have 
 shown me that in women who are in good health and of 
 a powerful build, whose menstrual flow has always 
 been regular and sufficient in quantity, whose repro- 
 ductive organs have been adequately and properly ex- 
 ercised, who have had a physiological amount of sexual 
 intercourse, have given birth to several children, and 
 have suckled these children, the cessation of the men- 
 strual flow generally occurs much later than in women 
 in whom the conditions of the sexual life have been the 
 opposite of those just mentioned. The more regular 
 menstruation has been, and the more normal the de- 
 liveries, the later does the menopause ensue. 
 
 Especially striking is the influence of the number 
 of deliveries upon the time of occurrence of the meno- 
 pause. In women who have given birth to a number 
 of children, menstruation, as a rule, continues for sev- 
 eral years later than in sterile women, or in those who 
 have had one or two children only. If a woman suckles 
 her children, the date of the menopause appears also 
 to be postponed. Deliveries late in life seem likewise 
 to delay the onset of the menopause, whereas abortions 
 accelerate its occurrence. If, however, pregnancy 
 succeeds pregnancy at extremely short intervals, the 
 menopause is likely to occur early; the same result is 
 brought about by sexual intercourse at too early an 
 
SEXUAU EPOCH OF THE MENOPAUSE 373 
 
 age. The menopause occurs latest in women who have 
 begun to menstruate early, who have married, have 
 given birth to more than three children, and have been 
 delivered of their last child at full term when 38 to 
 42 years of age. 
 
 As regards the 500 women previously mentioned, in 
 whom I made personal observation as to the age at 
 which the menopause occurred and the circumstances 
 by which its onset was influenced, the effect of marriage 
 and the number of children born is shown by the fol- 
 lowing details: 
 
 Of the 48 women in whom the menopause occurred 
 between the ages of 35 and 40, 16 were unmarried, 6 
 married and childless, 18 married with one or two 
 children, 8 married with more than two children. 
 
 Of the 141 women in whom the menopause occurred 
 between the ages of 40 and 45, 3 were unmarried, 4 
 married and childless, 46 married with one or two 
 children, 88 married with more than two children. 
 
 Of the 177 women in whom the menopause occurred 
 between the ages of 45 and 50, i was unmarried, 2 were 
 married and childless, 32 married with one or two 
 children, 142 married with more than two children. 
 
 Of the 89 in whom the menopause occurred between 
 the ages of 50 and 55, none were unmarried, none were 
 childless, 19 were married with one or two children, 
 70 were married with more than two children. 
 
 Of the 17 women in whom the nienopause occurred 
 at an age above 55 years, there were two only who had 
 not had more than two children, whilst there were 10 
 who had had six to eight children. 
 
 The influence of lactation is shown by the fact that 
 in the case of 40 women who had not suckled their 
 children, the mean duration of menstrual activity was 
 
374 THE SEXUAL LIFE OF WOMAN 
 
 four years less than the established mean duration of 
 27 years. 
 
 4. The Social Circumstances of the Woman's Life 
 
 The conditions in which a woman passes her life are 
 not without influence upon the time of onset of the 
 menopause. In general it may be said that among the 
 women of the laboring classes, whose livelihood is so 
 often precarious, and who are apt to sufifer from habit- 
 ual physical overwork, menstruation ceases at an earlier 
 age than among the women of the well-to-do classes and 
 those who lead an easier life. But though the climac- 
 teric thus occurs earlier among the lower than among 
 the upper classes, the difference is not a considerable 
 one. 
 
 According to Mayer's calculation, the mean age at 
 which menstruation ceases is, in upper class women, 
 47.13 years, in lower class women, 46.97 years. Small 
 as this difference appears, amounting on the average 
 to no more than two months, it must not be forgotten 
 that among the upper classes menstruation begins ear- 
 lier than among the lower classes, by an amount which 
 averages 1.3 1 years. Thus the total duration of sexual 
 activity is almost one and a half years longer in the 
 upper than in the lower classes. 
 
 5. General Constitutional and Pathological Conditions 
 
 An important influence upon the time of occurrence 
 of the menopause is exerted by the individual and he- 
 reditary predisposition of the woman, by her constitu- 
 tional state, and by certain illnesses from which she has 
 suffered. Women who by inheritance are constitution- 
 ally weakly and delicate, in whom the menstrual flow 
 has always been pale and scanty, in whom the inter- 
 menstrual intervals have been excessive, and who have 
 
SEXUAL EPOCH OF THE MENOPAUSE 375 
 
 a slender habit of body, attain the climacteric age ear- 
 lier than women with vigorous bodily development and 
 powerful muscles, with large breasts, and in whom 
 menstruation has always been regular and abundant. 
 Women with a great tendency to obesity cease to men- 
 struate earlier than women of more normal propor- 
 tions; blondes earlier than brunettes; women of phleg- 
 matic temperament earlier than women of a sanguine 
 and ardent temperament. 
 
 In general it may be said, that all influences which 
 have a weakening effect upon the feminine organism, 
 tend also to accelerate the onset of the menopause : such 
 are, severe labor, great sorrow, wearisome occupations, 
 severe menstrual losses, rapidly succeeding pregnan- 
 cies, and abortions ; also a number of pathological gen- 
 eral states shortly to be discussed, as well as local dis- 
 eases of the reproductive organs. 
 
 Fritsch points out that menstruation continues to a 
 later age in proportion as the woman's state of general 
 nutrition is a good one. He also asserts that women 
 with a very large uterus, who have always had an abun- 
 dant menstrual flow, those with retroflexion, with hy- 
 pertrophy of the portio vaginalis, or chronic endocer- 
 vicitis and endometritis, and those with small myomata 
 which have given rise to no marked symptoms, often 
 continue to menstruate far beyond the usual age. 
 
 The mean duration of the climacteric phenomena, 
 from the commencement of these until the final cessa- 
 tion of menstruation, is about two years. This mean is 
 made up of extremely wide individual variations ; in a 
 small proportion of the cases the climacteric mani- 
 festations may last no more than a month or two, whilst 
 at the other end of the scale we meet with cases in which 
 the duration extends to 4, 6, 8, and even 18 years. 
 
 In considerably more than half of all the cases, how- 
 
376 THE SEXUAL LIFE OF WOMAN 
 
 ever, the duration of the climacteric manifestations 
 varies between six months and three years. Thus, in 
 Tilt's series of cases, the duration of the "change of 
 life" was 
 
 6 months in 12.07 of all cases 
 
 1 year in 22.64 of all cases 
 
 2 years in 18.62 of all cases 
 
 3 years in 9.43 of all cases 
 
 6. Premature, Delayed and Sudden Onset of the 
 Menopause 
 
 In exceptional cases, the menopause, instead of taking 
 place between the fortieth and the fiftieth year of life, 
 occurs at an abnormally early or an abnormally late 
 age. 
 
 Premature cessation of menstrual activity, in the 
 third or the fourth decennium of life — ^very rarely in- 
 deed before the third decade — depends in part upon 
 disturbances of metabolism and of haematopoiesis, and 
 in part upon diseases of the female reproductive or- 
 gans; in some cases, however, it may be due to some 
 hereditary constitutional peculiarity; or it may occur 
 suddenly, in consequence of some violent shock to the 
 nervous system. 
 
 Among the disorders of metabolism which may lead 
 to a premature menopause, excessive adiposity, lipoma- 
 tosis universalis, occupies the first place. Next in order 
 of importance come a chloro-anaemic condition of the 
 blood, pernicious anaemia, splenic leukaemia, certain of 
 the acute infectious disorders — typhoid, cholera, scar- 
 latina, acute articular rheumatism — further pulmonary 
 tuberculosis, diabetes mellitus. Graves' disease, Addi- 
 son's disease, and myxcedema. These various condi- 
 tions may give rise, in part by infective processes, and 
 in part in consequence of the general cachectic condi- 
 tion, to atrophy of the ovaries with destruction of the 
 
SEXUAL EPOCH OF THE MENOPAUSE 377 
 
 graafian follicles, and to adipose processes in the uterus, 
 and these changes lead to the premature cessation of 
 menstrual activity. 
 
 Excessive obesity has a restrictive influence upon 
 ovarian activity, manifested in part, as already men- 
 tioned, by the occurrence of sterility, but in part also, 
 in very obese women, by the onset of a premature 
 menopause. Among 215 cases of extreme obesity in 
 women, I found 49 in which the menopause occurred 
 at a remarkably early age. In these cases the meno- 
 pause occurred at the following age: 
 
 In 1 woman at the age of 17 years 
 
 In 14 women at the age of 20 to 25 years 
 
 In 11 women at the age of 25 to 30 years 
 
 In 9 women at the age of 30 to 35 years 
 
 In 14 women at the age of 35 to 40 years 
 
 In none of these cases did the local examination of 
 the reproductive organs disclose the existence of any 
 noteworthy disease. 
 
 Of the diseases of the genital organs which are com- 
 petent to give rise to a premature cessation of men- 
 strual activity, the most important are the puerperal 
 infective processes and other inflammatory states of the 
 reproductive organs, with their results — chronic me- 
 tritis, perimetritic and parametritic exudations, chronic 
 oophoritis, atrophy of the uterus and the ovaries. 
 
 After infective puerperal processes, it sometimes 
 happens that there is far-reaching destruction of the 
 uterine musculature, degeneration of the uterine mu- 
 cosa, permanent and irreparable atrophy of the uterus, 
 and suppuration and atrophy of the ovaries — condi- 
 tions which result in an extinction of menstrual activ- 
 ity. A similar result may ensue upon the persistent 
 and long-continued pressure upon the uterus and the 
 ovaries of a large intra-pelvic exudation; such exuda- 
 
378 THE SEXUAL LIFE OF WOMAN 
 
 tion being commonly post-puerperal, but occasionally 
 arising in the absence of pregnancy. Further, accord- 
 ing to Freund, chronic atrophic parametritis may give 
 rise to an incurable atrophy of the uterus, by inter- 
 ference with the circulation of the blood through the 
 broad ligaments, and consequent impairment of the 
 nutrition of the uterus. Gonorrhoeal inflammation may 
 also lead to the termination of menstrual activity, when 
 it gives rise to intramural inflammatory deposits in the 
 uterus, and to chronic inflammatory processes in the 
 ovaries. Tumors of the uterus and the uterine annexa 
 may likewise induce a premature menopause. 
 
 We also meet with cases in which after a pregnancy, 
 to all appearance normal in its course and termination, 
 a premature menopause results. To this category be- 
 long the cases, according to Kleinwachter of no extreme 
 rarity, in which perfectly healthy women are attacked 
 by profuse uterine haemorrhage during the course of 
 a normal, full-term labor, or during miscarriage; sub- 
 sequently, though the lying-in period is passed with- 
 out further misadventure or abnormality, and in the 
 absence of lactation, the patient becomes permanently 
 amenorrhoeic. The normal involution of the uterus 
 passes on into hyperinvolution, and ultimately complete 
 atrophy of uterus and ovaries results. In some cases, 
 moreover, such hyperinvolution with consecutive atro- 
 phy follows normal labor or abortion without the oc- 
 currence of any excessive haemorrhage. 
 
 Much more frequently do we find that rapidly suc- 
 cessive pregnancies, with long-continued exercise of the 
 lacteal function, in badly nourished, anaemic women, 
 give rise to a premature menopause, due to permanent 
 atrophy of the uterus and ovaries, which are in such 
 cases so poorly supplied with blood. This "lactation- 
 atrophy" is described by Frommel and Thorn as a 
 
SEXUAL EPOCH OF THE MENOPAUSE 379 
 
 concentric atrophy first of all affecting the corpus uteri, 
 and to this, if the disease advances, there succeeds a 
 general atrophy of the muscular, connective, and fatty 
 tissues of the parametrium, the vagina, the pelvic floor, 
 and ultimately of the ovaries, leading, when perma- 
 nent, to a premature menopause. 
 
 Trauma of the genital organs may also lead to uter- 
 ine atrophy and to premature menopause. 
 
 By many authors it is believed that too-early mar- 
 riage, sexual excesses, and prostitution, -may be the 
 cause of cessatio praecox. In some cases, there is un- 
 questionably a hereditary predisposition to a prema- 
 ture climacteric, since the mothers of the w^omen in 
 whom it occurs have themselves been similarly affected. 
 In a remarkable case which came under my own ob- 
 servation, of a woman from Smyrna, there was hered- 
 itary predisposition. This woman began to menstru- 
 ate when 12 years of age; menstruation was always 
 scanty; she married -when 15 years of age; and she 
 ceased to menstruate forever at the age of 19. In 
 other cases we find there is a family tendency for men- 
 struation to be delayed in its first appearance to a com- 
 paratively advanced age, and to cease at the usual time. 
 
 In cases of cessatio mensium praecox (unless the fail- 
 ure of menstruation has been quite a sudden one), and 
 after the premature menopause is fully established, we 
 find in the uterus and the ovaries anatomical changes 
 similar to those met with after the natural climacteric 
 — diminution in the size of the uterus with thinning 
 of its walls, density and firmness of the tissues of the 
 organ, smallness and a soft consistency of the ovaries; 
 sometimes, also, the mammae are atrophic. 
 
 In cases of premature menopause, the troubles at- 
 tending the change are commonly more severe and 
 more enduring than those that occur at the natural 
 
380 THE SEXUAL LIFE OF WOMAN 
 
 menopause. Especially is this the case when the pre- 
 mature menopause is quite a sudden occurrence, but 
 this phenomenon is rare. Most commonly the prema- 
 ture menopause is gradual in onset; the flow becomes 
 more scanty month by month, until at last it fails alto- 
 gether to appear. Irregularity in the menstrual rhythm 
 is not often seen in such cases. Early senescence is ex- 
 ceptional in these women in whom a premature meno- 
 pause occurs. Emaciation, grayness of the hair, wrin- 
 kling of the skin, the growth of hairs on the face, etc., 
 are not usually associated with the atrophy of the 
 reproductive organs; the physiognomy and figure of 
 women with cessatio precox being usually similar to 
 those seen in women of corresponding age in whom 
 menstruation still continues. 
 
 Tilt inquired regarding the cause of cessatio praecox 
 in 27 instances, with the following results : 
 
 In 3 instances, parturition and lactation. 
 
 In I instance, abortion. 
 
 In 2 instances, a fall on the sacrum during men- 
 struation. 
 
 In 2 instances, suppression of menstruation from 
 chill. 
 
 In I instance, haemorrhage from the arm during 
 menstruation. 
 
 In I instance, celebration of nuptials during men- 
 struation. 
 
 In 2 instances, severe medicinal purgation. 
 
 In 2 instances, cholera. 
 
 In 2 instances, rheumatic fever. - 
 
 In 2 instances, febrile bronchitis. ' ; 
 
 In 9 instances, intermittent fever. 
 
 In I case Tilt saw cessation of menstruation occur 
 at the age of 29, in consequence of metritis. Atlee, in 
 15 cases of ovarian tumor, saw the menopause occur at 
 
SEXUAL EPOCH OF THE MENOPAUSE 381 
 
 the ages of 30, 39, 40 and 42. Puech saw a premature 
 menopause at the age of 30 in 3 cases, in each a sequel 
 of cholera. Bloridel reports a casd of cessatio praecox 
 after prolonged galactorrhoea, although the woman had 
 not suckled her infant; Gottschalk and Rokitansky, 
 cases following injury to the cervix uteri; Kiwisch, 
 Simpson and .Kleinwachter, cases following full-time, 
 normal deliveries, in which, however, severe losses of 
 blood had taken place. 
 
 Courty and Brierre de Boismont report cases in 
 which the menopause occurred as early as the age of 
 21; Mayer, 2 cases at the age of 22; Krieger, i case 
 at 23; Brierre de Boismont, i case at 24; Mayer, 2 
 cases at 25 ; Brierre de Boismont, i case at 26, and i case 
 at 27; Guy and Tilt, each i case at the age of 27; 
 Brierre de Boismont, Courty, and Guy, each i case at 
 the age of 28; Brierre de Boismont, Courty, and Mayer, 
 each I case at the age of 29 ; Guy and Tilt, each i case 
 at the age of 30; and Mayer, 5 cases at the age of 30. 
 
 An unusually late climacteric, the continuance of 
 menstruation beyond the age of 50 years, is not an ex- 
 tremely rare occurrence, but is less often seen than 
 cessatio praecox. There is, however, in these cases a 
 difficulty which must not be underestimated, namely, 
 to distinguish between a genuine menstrual bleeding 
 and the other uterine haemorrhages which are com- 
 mon precisely at this age of life, due either to textural 
 changes in the uterus, or to neoplasmata — more espe- 
 cially because in these non-menstrual haemorrhages also 
 a certain periodicity may often be detected. When on 
 careful examination no abnormality can be discovered 
 in the reproductive organs, when the bleeding in ques- 
 tion recurs at the intervals and in association with the 
 general symptoms to which the woman thus affected 
 has been accustomed during her previous menstrua- 
 
382 THE SEXUAL LIFE OF WOMAN 
 
 tions, and when the amount of blood discharged is not 
 abnormal, it is permissible to conclude that we have 
 to do with a persistence of true menstruation, even 
 though the woman has some time since completed the 
 fifth decennium of her life. In some women, in fact, 
 the reproductive system is so energetic, that ovulation 
 continues to an age far beyond the average, and such 
 women are to be regarded as sexually long-lived. 
 
 Although the instances of protracted menstruation 
 contained in the older literature of the subject are open 
 to suspicion, owing to the fact that at that time it was 
 not possible to distinguish with certainty between men- 
 strual and pathological uterine haemorrhage, quite re- 
 cently numerous incontestible cases of enduring sexual 
 vitality have been put on record. 
 
 I have myself seen no less than io6 cases in which 
 the menopause did not occur until after the age of 50 
 years; among these there were 4 in which the age at 
 the menopause was 56; 5 in which it was 57; 2 in 
 which it was 58; i in which it was 59; and i in which 
 it was 60. Tilt records 128 cases of menopause occur- 
 ring after 50; among these there were 4 in which the 
 woman was 56 when menstruation ceased ; 2 who were 
 57 ; 4 who were 58 ; i who was 59 ; i who was 60 ; and 2 
 who were 61. Courty reports a case in which menstrua- 
 tion persisted after the age of 65; Mayer, 3 cases of 
 menopause at 64; Beigel, 2 cases, i in which menstrua- 
 tion continued to the age of 65, the ether to the age of 
 72. Kleinwachter observed 33 cases in which menstrua- 
 tion continued to an age varying from 50 to 57 years. 
 Emmet, in the year 1886, published the case of a woman 
 who was then 70 years old, and who at this advanced 
 age continued to menstruate regularly. 
 
 That not every case in which after the age of 50 
 years there is recurrent, more or less periodic, haemor- 
 
SEXUAL EPOCH OF THE MENOPAUSE 383 
 
 rhage from the genital organs, is to be regarded as 
 an instance of delayed menopause, we are taught by 
 the records of post-mortem examination in several cases 
 of the kind. Scanzoni reports the case of a woman 
 who at the age of 60 was affected with a fairly regular 
 periodic discharge of blood from the vagina. During 
 one of these haemorrhages, she died of pneumonia, and 
 the autopsy showed that the ovaries were completely 
 atrophied and transformed into dense scar tissue, and 
 contained no trace of corpus luteum or of fresh extrava- 
 sation of blood, whilst in the upper part of the cervical 
 canal there were two mucous polypi each of about the 
 size of a bean. In another case, that of a woman 64 
 years of age, periodic losses of blood, at intervals of 
 from three to four weeks, continued to the time of her 
 death. This woman suffered from mitral valvular in- 
 sufficiency, and it was clear that the haemorrhages had 
 been due to the venous engorgement consequent upon 
 imperfect compensation. The ovaries were completely 
 atrophied, and showed no trace of any recent matura- 
 tion of ova; the uterus was enlarged, the mucous mem- 
 brane hyperaemic, and the cavitv contained a recent 
 clot. 
 
 Not infrequently, t^e haemorrhages attributed to the 
 persistence of menstruation are really due to senile 
 arteriosclerosis — to rigidity and brittleness of the uter- 
 ine arteries; in other cases they arise from varicosity 
 of the veins of the cervical canal. A common cause of 
 such bleedings from the genital passage in compara- 
 tively advanced life, is to be found in the growth of 
 uterine myomata. 
 
 To myoma uteri we must attribute a part, though by 
 no means all, of the cases in which menstruation seems 
 to recur some years after the menopause has, to all 
 appearance, been fully established. In most of these 
 
384 THE SEXUAL LIFE OP WOMAN 
 
 cases, indeed, we have to do with pathological haemor- 
 rhages, the cause of which is, however, but too often 
 obscure. Still, cases certainly occur in which, two or 
 three years or even longer after the menopause, some 
 unknown stimulus leads to the regular recurrence of 
 menstruation. The possibility of such an occurrence 
 is, in my opinion, fully proved by post-mortem exam- 
 inations of the bodies of elderly women in whom the 
 menopause has been fully established and yet the 
 ovaries are found to contain follicles of various degrees 
 of ripeness, and also fresh corpora lutea — signs that 
 ovulation may persist for a considerable time after the 
 complete cessation of menstruation. Another proof of 
 the last fact is the well known experience that women 
 who have some time ago ceased to menstruate, may 
 nevertheless become pregnant. Waldeyer, indeed, as- 
 serts that when four years have elapsed since the meno- 
 pause, follicles are never to be found in the ovaries, 
 but this negative experience is not decisive, especially 
 as regards the cases in which regular menstruation is 
 resumed some time after the occurrence of a premature 
 menopause. 
 
 I have myself seen several cases in which the meno- 
 pause occurred at 35, 38, 39, and ^2 years, respectively; 
 3, 4, or 5 years later, as a result of hydropathic treat- 
 ment, regular menstruation recurred. In one case, a 
 woman who had ceased to menstruate ten years before, 
 gave birth to a child at the age of 45. 
 
 Numerous indisputable cases of this kind are re- 
 ported in the recent literature of the subject. Krieger 
 had under his personal observation a woman of a robust 
 habit of body, in whom menstruation ceased at the age 
 of 48 years, 'her eighth child having been born fifteen 
 years before. Two years later irregular menstruation 
 recurred, and on the cessation of these haemorrhages, 
 
SEXUAU EPOCH OF THE MENOPAUSE 385 
 
 it appeared that the woman was once more gravid; 
 she was delivered at full term of a girl. Mayer ob- 
 served the following case: A strong working-class 
 woman, 33 years of age, had begun to menstruate regu- 
 larly when 13 years old; between the ages of 17 and 
 28 she gave birth to five children, and in addition had 
 one miscarriage when 19 years old. Widowed at the 
 age of 29, she fell ill, and on examination the uterus 
 was found to be small and relaxed, whilst the vaginal 
 portion of the cervix was reduced to a mere rudiment. 
 Since she had been 22 years of age she had had per- 
 sistent leucorrhoea, but no trace of menstrual haemor- 
 rhage; yet since that age she had had three children. 
 Renaudin delivered a woman 61 years of age, who 
 had ceased to menstruate 12 years earlier. Meissner 
 reports a case in which a woman first began to men- 
 struate at the age of 20, had her first child when 47 
 years old, and gave birth to the last of her eight chil- 
 dren when 60 years of age. 
 
 The sudden and permanent cessation of menstrua- 
 tion, whether at the normal climacteric age, or earlier 
 in life, is always a pathological occurrence. As com- 
 pared with the normal, gradual disappearance of men- 
 struation, associated with the usual climacteric symp- 
 toms, such a sudden extinction of menstrual activity is, 
 moreover, quite rare. When it does occur, the cause 
 is to be found in one of various pathological general 
 states, such as one of the acute infectious disorders, 
 or some other exhausting disease, or sometimes in some 
 local disease of the reproductive organs; occasionally, 
 however, it may occur in perfect health in consequence 
 of some powerful physical or mental stimulus, such as 
 a severe blow or intense fright. 
 
 This sudden menopause has been observed after 
 severe labor or abortion with profuse haemorrhage. 
 
386 THE SEXUAL LIFE OF WOMAN 
 
 or after cholera or typhoid; we must assume that in 
 such cases the anaemia of the genital organs has dis- 
 turbed the function of ovulation; whilst in cases due 
 to mental shock, the interference with ovulation must 
 be through the intermediation of the nervous system. 
 Frequently, of course, in- these cases, the sudden meno- 
 pause is also a premature one. 
 
 Tilt reports a case in which a sudden menopause en- 
 sued upon phlebotomy during menstruation; several 
 cases also in which women dt ages varying from 30 
 to 34, or 39 years, ceased to menstruate suddenly and 
 permanently in consequence of grief at the unexpected 
 death of the husband; and another case of sudden 
 menopause due to a fall down-stairs. Courty reports 
 three cases of sudden menopause at the age of 30, con- 
 sequent upon an attack of cholera. Dusourd has seen 
 three cases in which, in women aged 40 to 43 years, 
 severe haemorrhoidal bleeding was followed by sudden 
 and pernianent cessation of menstruation. Mayer re- 
 ports the case of a delicate middle-class woman 34 
 years of age, who had begun to menstruate at the age 
 of 14, had married at the age of 20, and at the age 
 of 21 after a normal delivery, ceased forever to men- 
 struate ; and another case of a working-class woman 34 
 years of age who first menstruated at the age of 13 
 years, married at the age of 20, had two children in 
 rapid succession, and finally ceased to menstruate, in 
 consequence of a fright, at the age of 30 years. Krieger 
 reports the case of a very nervous woman who first 
 menstruated at the age of 13, and in whom at the age 
 of 23 a sudden menopause ensued upon a nervous at- 
 tack; in another case reported by the same observer, 
 a sudden menopause occurred in a delicate woman 41 
 years of age owing to her husband's death — this woman 
 had previously experienced six months' amenorrhoea 
 
SEXUAL EPOCH OF THE MENOPAUSE 387 
 
 in consequence of sorrow at the death of one of her 
 children. The following remarkable case is reported 
 by Brierre de Boismont: A seamstress began to men- 
 struate at the age of 13 years; she married very soon 
 after this, and gave birth to four children, the last 
 when 21 years of age. In the course of the following 
 year there was a fire in the house, and owing to this 
 fright a sudden menopause occurred. Similar cases 
 have been reported quite recently by Bossi and Walter. 
 
 The harmful influence which the occurrence of a 
 sudden menopause exercises upon the general condi- 
 tion of the woman who experiences it, is manifested 
 chiefly by violent circulatory disturbances, hyperaemia 
 and congestion of the brain, lungs, and abdominal or- 
 gans, and by states of excitement and depression of 
 the nervous system. Of the vicarious haemorrhages 
 which are apt to ensue upon such a sudden menopause, 
 we have already spoken. 
 
 Generally speaking, women in middle life, in whom 
 the whole organism is accustomed to the onset and 
 decline of the menstrual hyperaemia, endure the func- 
 tional disturbances induced by a sudden and complete 
 cessation of menstruation much more easily than 
 women who have already entered upon the climacteric 
 age, or have nearly attained that age. The climacteric 
 age is one in which women are already predisposed 
 to circulatory disturbances in the pelvic organs, and it 
 will readily be understood that in them the sudden 
 interruption of the menstrual haemorrhages will have 
 more serious consequences than in women in the prime 
 of their sexual life, and therefore endowed with a 
 greater power of resisting disturbances of the normal 
 functions. 
 
388 THE SEXUAL LIFE OF WOMAN 
 
 Diseases of the Organs of Circulation 
 
 Among the cardiac disorders of the menopause, the 
 earliest and the commonest is, in my own experience, 
 the following: At the time of the menopause, excep- 
 tionally not till after the complete cessation of men- 
 struation, but usually at the commencement of this 
 period of life, some time, that is to say, between the 
 age of 40 and 50, either when menstruation has become 
 irregular, the intermenstrual interval having become 
 longer or shorter than has hitherto been the case, or 
 when the discharge has become abnormal in character, 
 a woman who has not before suffered from any kind 
 of cardiac disorder, will begin to complain of par- 
 oxysms of palpitation. 
 
 In some cases the attacks of palpitation occur in the 
 absence of any discoverable exciting cause; in others, 
 some trifling stimulus gives rise to them. They may 
 arise when the patient is in any position, walking, 
 standing, sitting, or recumbent; sometimes even dur- 
 ing sleep. The subjective sensation aroused by the in- 
 creased force and frequency of the cardiac action is 
 described as extremely distressing; it is associated with 
 a feeling of anxiety (Angst), with a sense of pressure 
 in the chest, with forcible pulsation of the carotids 
 and of the abdominal aorta; frequently also with a 
 feeling of a rush of blood to the head, with fugitive 
 heats, and severe headache; sometimes toward the end 
 of the attack there is a sense of flickering before the 
 eyes (as of muscae volitantes), tinnitus aurium, dizzi- 
 ness, and in rare cases actual syncope. 
 
 Objectively, during the paroxysm, a notable increase 
 in the frequency of the heart's action can be detected, 
 the pulse- rate rising to 120 or even 150 per minute. 
 In most of my cases, the pulse throughout the attack 
 
SEXUAL EPOCH OF THE MENOPAUSE 389 
 
 remained strong, well-filled, and regular. Sphygmo- 
 graphic tracings taken during the seizures showed a 
 remarkably high pulse-wave, the ascending limb of the 
 curve rose rapidly and suddenly, the descending limb 
 fell with corresponding steepness and rapidity, and it 
 reached an unusually low level before the commence- 
 ment of the dicrotic elevation, which latter was ex- 
 ceptionally large; the predicrotic elevations, on the 
 other hand, were but slightly developed. On ausculta- 
 tion, the tones of the heart were pure but were louder 
 than normal. 
 
 Sometimes during a paroxysm a sudden reddening 
 of the face was noticeable, extending often to the neck 
 and the thorax. In the areas mentioned, vivid red 
 patches would suddenly make their appearance, dis- 
 appearing more gradually after lasting a few minutes 
 — this appearance was associated with a burning sen- 
 sation of the affected areas. In some cases during the 
 paroxysm there was an outbreak of perspiration on 
 the head and the back 
 
 Associated with these cardiac troubles of women at 
 the climacteric we usually find a state of physical and 
 mental disquiet; less common associations are, an in- 
 capacity for regular work, sleep uneasy and much dis- 
 turbed by dreams, great general nervous irritability, 
 or signs of passive congestion in various organs ; occa- 
 sionally there is oedema of the lower extremities; the 
 urine remains free from albumin. 
 
 In most of the cases of this nature which came under 
 my own observation, a certain plethora was notice- 
 able ; among women at the menopause, it was especially 
 the well-nourished, powerful, sanguine individuals, 
 that were liable to palpitation of the heart. Direct 
 examination of the blood sometimes showed a very 
 high haemoglobin richness — no, 115, or even 120, as 
 
390 THE SEXUAL LIFE OF WOMAN 
 
 compared with a haemoglobin richness of 93 in normal 
 woman. Several of my patients presented ' the clini- 
 cal picture of the plethoric form of lipomatosis uni- 
 versalis. 
 
 In all, during ten years, I observed 67 cases of par- 
 oxysmal tachycardia in climacteric women. The age 
 distribution was the following: 
 
 36 years of age 1 woman 
 
 38 years of age 1 woman 
 
 39 years of age 2 women 
 
 40 to 45 years of age 37 women 
 
 45 to 50 years of age 28 women 
 
 Over 50 years of age 8 women 
 
 Five of the patients were unmarried, three were 
 married but childless, the remaining 59 were parous 
 women. 
 
 As a general rule, women live in great dread of all 
 manifestations of bodily disorder during the meno- 
 pause; those who become affected with paroxysmal 
 tachycardia are exceptionally anxious, and regard 
 themselves as threatened by a "stroke." This pessi- 
 mistic view is, however, by no means justified. These 
 cardiac disorders may make their appearance some 
 time before the menopause, they may persist through- 
 out the period during which menstruation is irregular, 
 they may even endure for some time after the total 
 cessation of the flow— but serious consequences of this 
 climacteric tachycardia have never come under my 
 observation. As regards treatment of the disorder, I 
 have seen very favorable results from the following 
 measures: The systematic employment of mild pur- 
 gatives, combined with suitable dietetic and hygienic 
 regulations (bland diet, regular and strenuous exer- 
 cise, cold ablutions, and wet compresses surrounding 
 the abdomen). 
 
SEXUAL EPOCH OF THE MENOPAUSE 391 
 
 When we inquire regarding the cause of the tachy- 
 cardiac paroxysms occurring at the menopause, we 
 must first of all bear in mind that in the cases which 
 have come under my own observation, the cardiac im- 
 pulse was powerful, the pulse strong and well-filled, 
 that signs of general vasomotor disturbance (ardor 
 fugax, etc.) accompanied the tachycardiac seizures, — 
 hence we are led to infer that we have to do with a 
 stimulation of the excito-motor nerve fibres, which 
 would appear to be due to the climacteric changes 
 previously described as occurring in the female repro- 
 ductive organs. This view receives support from the 
 fact that after oophorectomy, when, as in the normal 
 climacteric, atrophic processes occur in the internal 
 reproductive organs, paroxysms of nervous palpitation 
 are frequently observed. The same explanation applies 
 to the fact that in women at the climacteric affected 
 with these tachycardiac troubles, we frequently see in 
 association therewith the symptoms of uterine dys- 
 pepsia. 
 
 But in addition to these local anatomical changes in 
 the reproductive organs, to which an etiological role 
 must be assigned in the production of climacteric tachy- 
 cardia, the irritable state of the accelerator nerves must 
 also depend in part upon that general nervous hyper- 
 excitability which is so often a characteristic feature 
 of the climacteric period in women, manifesting itself 
 in manifold hyperagsthesias, hyperkinesias, neuralgias, 
 and, in extreme cases, mental aberration. The sensory 
 nerves are more irritable than in their normal state, so 
 that every stimulus acting upon them evokes a greater 
 central effect than heretofore, and upon this ensues an 
 exaggeration of various reflex manifestations, which 
 appear altogether disproportionate to the strength of 
 the exciting cause; among these disproportionate reflex 
 
392 THE SEXUAL LIFE OF WOMAN 
 
 effects, is to be numbered the tachycardia jlist de- 
 scribed. 
 
 But in addition to the causes of climacteric tachy- 
 cardia already enumerated, we have to take into con- 
 sideration the results of recent investigations con- 
 cerning the organo-therapeutic employment of the 
 chemical constituents of the ovarian tissue; it would 
 seem that when at the menopause the ovaries undergo 
 atrophy, so that their internal secretion is no longer 
 poured into the blood, the resulting alteration in the 
 chemical constitution of that fluid gives rise to a dis- 
 turbance of the vasomotor centre in the medulla oblon- 
 gata. 
 
 In some cases, the tachycardiac paroxysms appear 
 to be connected with the erotic excitement to which 
 women are sometimes subject at the climacteric, volup- 
 tuous crises and ejaculation occurring; it is possible 
 that in some of these cases masturbation plays a part. 
 
 A second group of cardiac troubles occurring in 
 climacteric women consists of cases which are very 
 common, but not often very severe. The cases in ques- 
 tion depend upon the liability to an increased deposit 
 of adipose tissue in the body at the time of the meno- 
 pause, and in this connection the plethoric form of 
 lipomatosis universalis almost invariably predomi- 
 nates. It is a well-known fact that between the ages 
 of 40 and 50 years women have an excessive tendency 
 to obesity, and that even those women who have hither- 
 to been extremely lean are apt to become quite plump 
 at the climacteric period. Chiefly in consequence of 
 this increasing obesity, there occurs in climacteric wom- 
 en a series of cardiac troubles of very variable intensity. 
 If the deposit of fat is effected very gradually, and 
 if the obesity does not become extreme, it is only after 
 vigorous bodily exercise, such as fast walking or going 
 
SEXUAU EPOCH OF THE MENOPAUSE 393 
 
 upstairs, and after meals, that the patient is troubled 
 with a little shortness of breath and moderate palpita- 
 tion; appetite, digestion, and sleep remain usually un- 
 affected in cases of this degree of severity. Definite 
 attacks of cardiac asthma, and well-marked signs of 
 cardiac insufficiency affecting the entire circulatory 
 system, will very rarely occur in such persons. 
 
 It is an interesting fact, that the troubles which arise 
 from fatty deposits around the heart are in general far 
 less severe in climacteric women than they are in obese 
 men of corresponding age. This may be due to the 
 circumstance discovered by W. Miiller, in the course 
 of his investigations on the proportions of the human 
 heart, that in the development of general obesity, the 
 pericardial fat increases proportionately to a greater 
 extent in the male than in the female. But in my 
 opinion the true explanation is to be found in the fact 
 that variations in the amount of fat in the body are 
 normally far more extensive in women than in men; 
 at puberty, during pregnancy, and during lactation, 
 extensive though gradually effected changes in the 
 amount of adipose tissue in various parts of the body 
 occur, so that experience has rendered the organism 
 ready to adapt itself to the further changes that take 
 place at the climacteric — above all, the heart has be- 
 come competent to meet very various demands upon 
 its powers. 
 
 Only in women who. from youth onward have ex- 
 hibited a marked tendency to obesity, and in whom at 
 the climacteric age such obesity has become extreme, 
 do the cardiac troubles attendant on the menopause 
 become very severe. In such persons, palpitation and 
 shortness of breath occur on slight exertion, and at- 
 tacks of cardiac asthma are frequent. In consequence 
 of the diminished propulsive power of the heart, cir- 
 
394 THE SEXUAL LIFE OE WOMAN 
 
 culatory difficulties make their appearance in the most 
 widely divergent venous areas; the forms most com- 
 monly met with are, varices in the veins of the lower 
 extremities, permanent dilatation of certain of the small 
 superficial veins of the skin, phlebectases of the rectal 
 veins (i.e., "piles"), and ultimately we see the well- 
 known series of symptoms of venous engorgement — 
 oedema of the feet, passive congestion of the lungs, 
 albumin in the urine, etc. 
 
 When such cardiac troubles are present, the objective 
 examination of the heart shows in the early stage no 
 gross abnormality; at most the heart-tones seem some- 
 what weakened, with a moderate enlargement of the 
 area of percussion-dulness, whilst the impulse is dis- 
 placed a little outward, and is weaker than normal. 
 In some cases, however, a marked dulness on percus- 
 sion over the sternum indicates an extensive deposit of 
 fat in the mediastinal tissues. In the second stage of 
 the fatty heart, when the symptoms have become more 
 severe, we find a considerable enlargement of the area 
 of cardiac dulness both in the vertical and the horizon- 
 tal extent; the cardiac impulse is diffused as well as 
 feeble. The sounds of the heart are usually pure but 
 faint — in some cases they remain loud and clear. 
 Exceptionally, a short blowing murmur is heard with 
 the first sound; and sometimes this sound is redu- 
 plicated. 
 
 Whilst in the first stage the pulse is hardly abnormal, 
 in the second stage, very various changes occur; often 
 it is subdicrotic or dicrotic in character. 
 
 In the great majority of instances, in these cases of 
 cardiac disorder at the menopause, provided a suitable 
 dietetic regimen is early adopted and perseveringly 
 carried out, we may give a hopeful prognosis. 
 
SEXUAU EPOCH OF THE MENOPAUSE 395 
 
 A third, less common but far more serious form of 
 cardiac disorder occurring at the menopause, displays 
 the well-known symptoms of cardiac failure. Those 
 thus affected are usually slightly built, delicate women, 
 who during the years of development suffered from 
 chlorosis, who in adult life were troubled with anaemic 
 symptoms, and in whom the menopause was ushered in 
 by very severe losses of blood; sometimes, again, they 
 are women who throughout their sexual prime have 
 been accustomed to menstruate very abundantly, who 
 have had numerous and severe deliveries, or who have 
 had frequent miscarriages — it is in those who have 
 thus been weakened by frequent and profuse haemor- 
 rhages, that the symptoms of cardiac failure ensue at 
 the climacteric period. The women thus affected also 
 frequently suffer from palpitation of the heart; the 
 pulse is abnormally frequent, small, low, and easily 
 compiressible, and sometimes intermittent or arhythmi- 
 cal. The heart's action is weak and devoid of energy. 
 The heart-sounds are usually obscure, and sometimes 
 a systolic murmur is audible. The patients are short 
 of breath and are subject to attacks of cardiac asthma, 
 not infrequently associated with angina pectoris. In 
 conjunction with these symptoms, we see signs of venous 
 congestion: sudden attacks of coldness in the hands 
 and feet, often also oedema of the feet; the urine at 
 times contains albumin. The haemoglobin- richness of 
 the blood is always notably diminished. I need not 
 discuss in further detail the well-known symptoms of 
 cardiac insufficiency, and I need only insist that when 
 these symptoms are met with in women at the cli- 
 macteric, it is of the greatest importance, alike from 
 the prognostic and from the therapeutic standpoint, to 
 make a careful examination of the reproductive organs, 
 so as to determine the exact source of the recurrent 
 
396 THE SEXUAL LIFE OF WOMAN 
 
 bleedings which usually constitute the primary cause 
 of the patient's sufiferings. 
 
 In several cases of this kind, I found that the haemor- 
 rhages were due to a relaxation of the uterine tissues, 
 and that this relaxation was itself referable to intra- 
 pelvic circulatory disturbances, dependent upon ob- 
 struction in the vena cava inferior, whereby the venous 
 return from the pelvis was rendered difficult, and an 
 engorgement of the uterine vessels was brought about. 
 
 In some instances of cardiac failure at the meno- 
 pause, chronic inflammation within the pelvis is to 
 blame for the menorrhagia upon which the cardiac 
 failure depends. Often, again, the haemorrhages are 
 referable to vasomotor influences, such as are liable 
 during the menopause to affect various vascular areas. 
 In other cases, the recurrent bleeding is due to retro- 
 flexion of the uterus, to prolapse of that organ, or to 
 tumor, it may be myoma, polypus, or carcinoma. 
 
 Finally, during the menopause, more especially in 
 women in whom menstruation has continued up to or 
 beyond the fiftieth year, or in those who have given 
 birth to a large number of children or have lived lives 
 of severe bodily exertion, cardiac troubles may arise 
 dependent upon arteriosclerosis of the great vessels. 
 The signs of such changes in the walls of the blood- 
 vessels are clearly marked : the cardiac impulse is heav- 
 ing, the second sound of the heart is accentuated; the 
 pulse is full and large, usually giving a very power- 
 ful blow to the examining finger, whilst its sphygmo- 
 graphic tracing exhibits characteristic signs in the 
 exceptional height and great distinctness of the first 
 predicrotic elevation. The subjective troubles are in 
 these cases very severe ; dyspnoea and attacks of asthma 
 or of vertigo are common, and sometimes albumin may 
 be found in the urine. 
 
SEXUAL EPOCH OF THE MENOPAUSE 397 
 
 We may thus summarize the cardiac disorders met 
 with at the menopause, and more or less directly de- 
 pendent upon the changes undergone by the feminine 
 organism at that period of life: 
 
 1. Paroxysmal tachycardia, a reflex neurosis due to 
 the climacteric changes in the ovaries. 
 
 2. Nervous palpitation in women who were similarly 
 affected at the time of the menarche, and in whom the 
 trouble is merely the expression of a very unstable 
 nervous system, and one influenced with especial readi- 
 ness by impressions proceeding from the reproductive 
 organs. 
 
 3. Cardiac disorder due to the obesity so conimonly 
 occurring as a part of the general metabolic changes 
 of the menopause, but more particularly dependent 
 upon a deposit of fat in the neighborhood of the heart 
 itself 
 
 4. Symptoms of cardiac failure, due to excessive 
 losses of blood at the menopause, either as an exaggera- 
 tion at this time of menstrual processes, or as a result 
 of some actual disease within the pelvis. 
 
 5. Cardiac disorder in women in whom the meno- 
 pause occurs at an unusually advanced age, and de- 
 pendent upon arteriosclerosis. 
 
 Particular consideration must be given to a symptom 
 not infrequently occurring in association with the car- 
 diac troubles of climacteric women, and referable to 
 the circulatory disturbances characteristic of this 
 period of life, namely, vertigo. The attack in some 
 cases comes on without apparent cause, in others it 
 occurs on the performance of some unusual movement 
 or the adoption of some peculiar posture (stooping, 
 or the like) ; the patient is suddenly seized with a sense 
 of rotation, either of her own body, or else of her visible 
 and palpable environment; with this is associated a 
 
398 THE SEXUAL LIFE OP WOMAN 
 
 sensation of disturbance of equilibrium, flickering be- 
 fore the eyes (muscae volitantes) , tinnitus aurium, palpi- 
 tation of the heart, increased frequency of the pulse, 
 which may be either full or small, redness or pallor 
 of the face, coldness of the hands and feet, muscular 
 twitchings, a sense of great anxiety, and the outbreak 
 of a cold perspiration. The vertigo occurs in par- 
 oxysms, usually of short duration — a few minutes to a 
 quarter of an hour. It is especially plethoric and 
 obese women who are liable at the climacteric to suffer 
 from this disorder. 
 
 A somewhat similar condition is described by Tilt 
 under the name of "pseudo-narcotism," as frequently 
 occurring in climacteric women. Tilt, indeed, states 
 that in 500 such women, he noted its presence in no 
 less than 277. 
 
 Many hypotheses have been promulgated to account 
 for the vertigo that so frequently occurs at the meno- 
 pause. Both anaemia and hyperaemia of the brain have 
 been assumed as causes, alike dependent upon the 
 irregularity of menstruation, which is supposed to have 
 a reflex influence upon the cerebral circulation. Others 
 regard the vertigo as a climacteric neurosis, since it 
 occasionally occurs before the menstrual irregularities 
 begin, and in such cases a reflex disturbance of the 
 cerebral circulation cannot be supposed to have arisen. 
 According to Matusch, climacteric vertigo is a mani- 
 festation of epilepsy — an explanation which has been 
 often extended to include all the menstrual psychoses. 
 Windscheid believes that in many of the cases the 
 vertigo is to be explained by the existence of arterio- 
 sclerotic changes in the blood vessels, such as are al- 
 ready by no means rare at the age at which the meno- 
 pause usually occurs; whilst in other cases, he believes, 
 the vertigo is to be regarded as one of the symptoms 
 
SEXUAL EPOCH OF THE MENOPAUSE 399 
 
 of a nervous disorder. That in any case the vertigo 
 is dependent in some way upon the changes that occur 
 in the reproductive organs at the climacteric period, 
 is shown by the fact that after the final cessation of 
 menstrual activity the patient, as a rule, ceases to suffer 
 from this symptom. 
 
 To the circulatory disturbances consequent upon the 
 menopause we must also refer ardor fugax, fugitive 
 heat, the sudden rushes of blood to which women are 
 prone at this period of life. 
 
 The cardiac troubles of the menopause are seen 
 especially in women in whom the cessation of men- 
 struation occurs quite suddenly, and in those in whom 
 menstrual activity ceases at an exceptionally early age. 
 It would seem that in such cases, owing to the continu- 
 ance of periodic maturation of the graafian follicles 
 associated with congestion of the intra-pelvic organs, 
 in the absence of the periodic relief to that congestion 
 afforded by the menstrual flux, there results a summa- 
 tion of stimuli, whereby the accelerator nerves of the 
 heart are very powerfully affected. 
 
 Thus, I had under my care a lady from Smyrna, 36 
 years of age. She had begun to menstruate when 12 
 years of age and menstruation was always scanty; she 
 married when 15 years old, and finally ceased to men- 
 struate when 19 years of age; she was sterile, and no 
 abnormality could be detected on physical examination 
 of her reproductive organs. Every month she suffered 
 from severe paroxysmal tachycardia, with dyspnoea, 
 rush of blood to the head, perspiration of the face, etc. 
 
 In another case, that of a woman 45 years of age, 
 menstruation, hitherto regular, was suddenly sup- 
 pressed, during the flow, in consequence of a severe 
 fright. The next month the flow failed to appear at 
 the usual time, but instead the patient was affected 
 
400 THE SEXUAL LIFE OF WOMAN 
 
 with severe cardiac distress, accompanied by sudden 
 sensations of heat in the face, palpitation of the heart, 
 and vertigo; these symptoms lasted for several days, 
 and since then have recurred at intervals of three or 
 four weeks. 
 
 The cardiac troubles of the menopause are seen with 
 especial frequency in women who were affected with 
 similar disturbances at the time of the menarche. Ex- 
 perience clearly shows that a certain connection exists 
 between the manifestations that accompany the com- 
 mencement of sexual activity, and those that accompany 
 the decline and extinction of that activity; and a phy- 
 sician will rarely be mistaken if he bases on the fact 
 that the general health was or was not seriously affected 
 at the age of puberty, a prognosis that the course of 
 the climacteric will be an unfavorable or a favorable 
 one, respectively. In other words, in women whose 
 nervous system is an unstable one, and in those with 
 hereditary predisposition to the occurrence of cardiac 
 disorder, the changes that take place in the repro- 
 ductive organs both during the menarche and during 
 the menopause, are likely during these vital phases 
 to arouse reflex disturbances of the cardiac functions. 
 The facts thus noted are analogous to those observed by 
 Potain, who distinguishes a peculiar form of chlorosis, 
 occurring in delicate individuals at the age of puberty, 
 and, though apparently cured during the menacme, 
 recurring in its primitive severity at the time of the 
 menopause. 
 
 Again, women with a sanguine and erethistic tem- 
 perament are more inclined to suffer from cardiac 
 troubles at the menopause than women of a tranquil 
 temperament and those endowed with an unimpression- 
 able nervous system. 
 
 Finally, elderly virgins, women who have for many 
 
SEXUAL EPOCH OF THE MENOPAUSE 401 
 
 years lived in chaste widowhood, sterile women, women 
 who have married shortly before the menopause, or 
 who at this time have recently been delivered, are 
 all more inclined to the cardiac troubles of the cli- 
 macteric period than women whose sexual life has 
 been of a less abnormal character. 
 
 In the literature of the subject, we find numerous 
 references to the fact that among the disorders of 
 the climacteric, circulatory disturbances play a part. 
 But a full and accurate account of these disorders is 
 lacking alike in the literature of gynecology and in 
 that relating to diseases of the heart — and this is true 
 even of the most recent publications. 
 
 Among striking individual cases, one recorded by 
 Moon may be mentioned here, a case of tachycardia 
 consequent upon a sudden menopause: "In a woman 
 35 years of age the menses were suppressed owing to 
 chill; the pulse-frequency increased from 80 to 200, 
 without any apparent change in the heart or its valves; 
 the symptom lasted for several days, when menstrua- 
 tion became once more established, and the pulse-fre- 
 quency fell again to the normal." 
 
 Tilt expresses the opinion that the heart is but little 
 involved in the disturbances of the climacteric, his 
 experience coinciding with that of Quain. Boerner 
 and Glaevecke, on the contrary, describe the heart 
 troubles of the climacteric in terms very similar to 
 those employed by myself. 
 
 A. Clement describes a peculiar form of disturb- 
 ance of the functions of the heart at the climacteric 
 period, to which he gives the name of Cardiopathie 
 de la Menopause, and of which he has seen four cases. 
 The age of his patients varied from 46 to 50 years. 
 They were all vigorous women, free from hysterical 
 symptoms, and they had never suffered from rheuma- 
 
402 THE SEXUAL LIFE OF WOMAN 
 
 tism nor from any functional disturbance of the heart. 
 In all these cases the cardiac disorder occurred at a 
 time of life when menstruation still continued, but 
 had already become somewhat irregular. Usually the 
 trouble in question makes its first appearance during 
 the flow, or, if occurring independently of menstrua- 
 tion, becomes more severe at that time. Prior to the 
 development of the actual heart symptoms, we observe 
 for a time, two or three months it may be, signs of 
 general exhaustion and weakness. Then occurs an at- 
 tack of palpitation of the heart, rapidly succeeded by 
 faintness, sense of precordial anxiety, and dyspnoea. 
 During repose the patient does not usually suffer from 
 any difficulty in breathing, but sleep is apt to be dis- 
 turbed by paroxysms of palpitation and severe pre- 
 cordial anxiety. As the disease advances, dyspnoea is 
 observed on the slightest exertion. Ultimately, the 
 symptoms mentioned, palpitation, precordial anxiety 
 and dyspnoea, become permanent, but are less severe 
 when the patient is at rest. Constant now is also the 
 feeling of weakness and faintness, which from time to 
 time increases to actual syncope with complete loss of 
 consciousness, and coldness of the entire surface of the 
 body. Examination of the heart gives negative re- 
 sults. The cardiac impulse is a little stronger than 
 normal; the cardiac rhythm may be either regular or 
 irregular, but actual intermission of the beats does not 
 occur. The heart-sounds are pure, there is no mur- 
 mur; the first sound, if altered at all, will be stronger, 
 not weaker, than normal. Neither swelling of the 
 jugular veins nor venous pulsation is to be observed. 
 The most striking symptom of heart affection, indeed 
 the only positive physical sign, is the great increase in 
 the frequency of the heart's action, the pulse-rate often 
 being as much as 150 or 160 per minute, and in addi- 
 
SEXUAL EPOCH OF THE MENOPAUSE 408 
 
 tion weak and somewhat variable in strength. At the 
 outset of the disease, no oedema of the lower extremities 
 IS to be observed, and it only appears after three or 
 four attacks. In all the patients the extreme pallor of 
 the face is a striking feature. An increased quantity 
 of urine is eliminated. The course of the disease is 
 characterized by a series of successive paroxysms, 
 separated by periods of almost complete remission. 
 At first, these remissions last for a month or two, but 
 they gradually become shorter and shorter, whereas the 
 duration of the attacks continually increases, until it 
 is as much as seven or eight days. At this stage, dis- 
 turbance of digestion ensues, the appetite is lost, and 
 the general vigor declines. Recovery ultimately occurs, 
 but very gradually. Clement refers the disease to 
 a profound disturbance of the cardiac innervation 
 through the sympathetic nerves, but believes that 
 anaemia constitutes a contributory cause of the cardiac 
 disorder. 
 
 Kostkewitsch has made observations regarding the 
 influence of the climacteric upon previously existing 
 heart disease, and has thereby been led to conclude 
 that the influence is unfavorable. The functional dis- 
 turbances of the cardio-vascular apparatus which com- 
 monly accompany the menopause, readily lead, should 
 organic heart disease exist, to the onset of severe cardiac 
 weakness, which may have a rapidly fatal termina- 
 tion. In 55.5 per cent, of the women who enter the 
 climacteric period with organic disease of the heart, 
 the menopause gives rise to a failure of compensation. 
 Such failure of compensation is especially likely to 
 occur in women suffering from valvular insufficiency; 
 it is least probable in cases of arteriosclerosis without 
 valvular defect. The symptoms of defective compen- 
 sation — dilatation of the heart, increased frequency 
 
404 THE SEXUAL LIFE OF WOMAN 
 
 of the pulse, arrhythmia cordis, etc. — are manifested 
 especially during the menstrual flow. 
 
 Diseases of the Digestive Organs 
 The congestions which, as we have already pointed 
 out, constitute the pathological basis of the majority 
 of the disorders of the climacteric, manifest themselves 
 in the abdominal organs in the well-known form of 
 plethora abdominalis, chronic venous congestion of the 
 gastric and intestinal mucous membrane, hyperemia 
 of the liver, hyperaemia of the mucous membrane of 
 the bladder, catarrh of the bladder, distention of the 
 haemorrhoidal veins, and the various symptoms depen- 
 dent upon these several forms of congestion. 
 
 Bleeding from the haemorrhoidal veins and chronic 
 diarrhoea are two of the troubles proceeding from the 
 above-mentioned congestion of the intra-abdominal 
 vessels, which occur so frequently during the climacteric 
 period that since the days of antiquity they have been 
 regarded as critical manifestations of the menopause, 
 the object of which is to afford a vicarious outlet for 
 the menstrual flux, now become irregular and inter- 
 mittent. It can, indeed, be readily understood that 
 a discharge of blood and an increased secretion from 
 the mucous membrane of the lower part of the intes- 
 tine may, if not too violent, exercise a favorable in- 
 fluence upon the congestive states of the climacteric, 
 by relieving the distention of the abdominal vessels-— 
 by a local blood-letting which regulates the disordered 
 circulation. In this way, even though we have ceased 
 to regard it as a "critical" manifestation, haemorrhoidal 
 bleeding, accompanied by an increased secretion from 
 the intestinal mucous membrane, may at the climacteric 
 period have a distinctly favorable influence upon a 
 woman's general condition. 
 
SEXUAL EPOCH OF THE MENOPAUSE 405 
 
 Hippocrates already in his aphorisms pointed out the 
 salutary effect of epistaxis and of diarrhoea in women 
 suffering from suppression of the menses. Other 
 authors have assigned a critical significance to diar- 
 rhoeas occurring at the climacteric, and have warned 
 against their suppression. According to Tilt, diar- 
 rhoea occurred in 12 per cent, of all women of this 
 age coming under his observation ; in 4 per cent, of the 
 climacteric women, this diarrhoea recurred at regular 
 monthly intervals, whilst in 8 per cent, the recurrence 
 was irregular. In 500 women during the climacteric 
 age, Tilt observed the following abdominal disorders : 
 
 Swollen haemorrhoids in 62 cases 
 
 DiarrhcEa in 60 cases 
 
 Enduring disturbance of the biliary secretion in 56 cases 
 
 Bleeding haemorrhoids in 24 cases 
 
 Intestinal haemorrhages in 20 cases 
 
 Icterus in 6 cases 
 
 Hasmatemesis in 4 cases 
 
 Monthly intestinal hsemorrhages in 2 cases 
 
 Monthly bleeding from haemorrhoids in 1 case 
 
 In my own observation, constipation is more frequent 
 in climacteric women than diarrhoea, the constipation 
 being also a symptom of abdominal congestion. Some- 
 times, when diarrhoea occurs, it is really secondary to 
 constipation. The accumulation of the faecal masses 
 stimulates the intestinal mucous membrane, and gives 
 rise to a profuse aqueo-mucous secretion; the firm faecal 
 masses are then liquefied, the intestinal wall is lubri- 
 cated, and the constipation gives place to diarrhoea 
 lasting perhaps for several days. This is the explana- 
 tion of many cases in which there is a periodic recur- 
 rence of diarrhoea. 
 
 Dyspeptic disturbances are rarely absent during the 
 climacteric period. Most often we see disordered ap- 
 petite, sluggish digestion, pyrosis, eructation, at times 
 
406 THE SEXUAL LIFE OF WOMAN 
 
 nausea and retching, and actual vomiting of a watery 
 or bilious fluid. Occasionally, an abnormal sensation 
 of hunger follows each meal, associated, however, with 
 a feeling of distention of the stomach. A very dis- 
 tressing symptom is an excessive formation of gas 
 within the intestine. At times such meteorism is ex- 
 treme, and it then gives rise to very severe abdominal 
 pain. The gas is evacuated slowly and with difficulty, 
 the patient is compelled to loosen all her clothing; 
 more especially after a meal she is compelled to take 
 off her stays and undo all the bands of her petticoats 
 and skirt. At the same time we see difficulty in breath- 
 ing and tachycardia. Such an accumulation of gas 
 within the abdomen may give rise to serious errors in 
 diagnosis, the swelling being attributed to pregnancy 
 or to abdominal tumor. 
 
 Noteworthy also at the time of the menopause is 
 the occurrence of vomiting, either as an isolated 
 symptom, or in association with some other well-known 
 climacteric disorder. When this vomiting is associated 
 with some unmistakable form of excessive secretory 
 activity (hyperhydrosis, etc.), we may readily suppose 
 that the vomiting is due to undue secretory activity on 
 the part of the gastric mucous membrane. An exces- 
 sive production of gastric juice, perhaps altered in 
 quality as well as quantity, combined with some other 
 disorder of gastric innervation (hyperaesthesia, or hy- 
 perkinesia) will sufficiently explain the occurrence of 
 the sometimes excessive vomiting, even though in many 
 of the cases there may be no reason to suppose that 
 there exists any primary stimulation of the vomiting 
 centre. In other cases, however, it is probable that 
 the trouble is really due to a primary disorder of that 
 centre; and a careful study of the clinical features 
 of the case will be needed to show how far there may 
 
SEXUAL EPOCH OF THE MENOPAUSE 407 
 
 be associated with this other disorders of gastric in- 
 nervation (Boerner). 
 
 Disturbances of the biliary secretion, icterus of 
 greater or less severity, are by no means rare manifesta- 
 tions of the abdominal congestion of climacteric wom- 
 en, and such disorders have alsd been regarded as 
 vicarious processes originated by the cessation of the 
 menstrual flux (Aran, Bennet, Henoch, and others). 
 Frerichs also has pointed- out that with the cessation of 
 menstruation at the climacteric we not infrequently 
 observe swelling of the liver, which disappears when, 
 after a considerable period, the menstrual flow recurs 
 — a sequence of symptoms which may be repeated again 
 and again for a considerable time. 
 
 Diseases of the Skin 
 
 The most characteristic symptom of disorder of the 
 skin met with at the climacteric period — one which, 
 indeed, may be said to be never absent — is ardor fugax, 
 fugitive heat; and scarcely less common is hyperhy- 
 drosis, an excessive secretion of sweat. Almost invari- 
 ably, at the commencement of the menopause, women 
 complain of a feeling of burning heat, rising up from 
 the breast to the face; and if they are kept under 
 observation we see from time to time a sudden redness 
 of the face, and sometimes also of the neck and chest, 
 associated with the outbreak of a thin perspiration. 
 Moreover, in nearly all climacteric women, we notice 
 an increased secretion of sweat over the whole surface 
 J3i the body, and at times this secretion is extremely 
 profuse. 
 
 In association with these symptoms we often see the 
 hyperaemic processes in the skin known by the names 
 of erythema and roseola, taking the form of larger or 
 smaller bright red patches, which are most frequently 
 
408 THE SEXUAL LIFE OF WOMAN 
 
 seen on the sides of the neck, the front of the chest, 
 and the face. 
 
 In many women, at the menstrual periods, when the 
 flow has become scanty or has already entirely ceased, 
 we observe the occurrence of eczematous eruptions, 
 which have for this reason received the distinctive name 
 of climacteric eqzema. In the majority of these cases, 
 the eczema does not make its appearance until the 
 regular menstrual flux has completely ceased to occur; 
 and in the less common cases in which the flow per- 
 sists after the climacteric eczema has begun, menstrua- 
 tion is rarely regular, but has begun to exhibit the 
 variability and disorder characteristic of the time of 
 the menopause. If the eczema comes on after the 
 menopause is completely Established, it usually appears 
 in from six to twelve months after the cessation of 
 the flow; but in some cases,, the eruption appears very 
 soon after the menopause, whilst in others, its onset 
 may be delayed for as long as four or five years. Cli- 
 macteric eczema is obstinate, and shows no tendency to 
 spontaneous cure. With regard to the localization of 
 the eruption, Bohn found that in three-fourths of the 
 cases it affected the hairy scalp and the ears; Rayer 
 and Hebra also state that the eczema of the menopause 
 is most frequently seen in these two situations, whilst 
 the next commonest site for the eruption is the face. 
 As regards other parts of the skin, it is only that of 
 the extremities that is ever affected by this disease, 
 especially the hands and the fingers, less often the fore- 
 arms or the backs of the feet; it never appears on the 
 trunk. With regard to the types of eczema occurring 
 in connection with the menopause, we see almost ex- 
 clusively the squamous and the weeping forms of the 
 disease. 
 
 In general, at the climacteric period, the skin is ex- 
 
SEXUAU EPOCH OP THE MENOPAUSE 409 
 
 tremely sensitive, and devoid of powers of resistance 
 to outward noxious influences. Alternations of damp- 
 ness and dryness or of heat and cold readily give rise 
 to redness, infrltration, and the formation of scales and 
 fissures of the skin; sometimes this occurs merely after 
 cold ablutions. These acute stages of swelling, red- 
 ness, and vesiculation of the skin readily pass on into 
 chronic and obstinate dermatitis. 
 
 Not infrequently, during the climacteric, as during 
 the menarche, inflammation of the sebaceous glands 
 occurs, acne, at times accompanied by seborrhoeic mani- 
 festations. In other cases, we see disfigurations of the 
 face in consequence of vascular dilatations, especially 
 on the nose and on the adjoining portions of the cheeks, 
 rosacea, in which disease also there is associated in- 
 flammation of the sebaceous glands. Another disorder 
 of the skin of the face which is greatly dreaded by 
 women at this time of life, owing to the unsightly ap- 
 pearance it produces, is the development of sinuous 
 dilatations of some of the superficial vessels, at times 
 associated with connective tissue proliferation in the 
 form of red or violet-colored painless nodules. 
 
 An extremely distressing affection, and one which is 
 especially apt to attack women during the change of 
 life, is the previously mentioned pruritus genitalium. 
 The itching is in some cases confined to the external 
 genital organs, whilst in others it extends into the in- 
 terior of the vagina; also it may pass backward over 
 the perineum, and on into the gluteal folds. In some 
 cases, some local pathological condition will be found 
 to account for the disorder: catarrh of the vagina or 
 of the cervix uteri; displacements, inflammations, or 
 new-growths of the uterus ; anomalies of the ovary, 
 the bladder, or the urethra. Cohnstein draws attention 
 to a circular hyperplasia of the vaginal portion of the 
 
410 THE SEXUAL LIFE OF WOMAN 
 
 cervix, occurring during the menopause, and, "owing 
 to the vascular dilation by which it is characterized, 
 possessing close analogies with haemorrhoids"; the 
 worst symptom of this affection is pruritus. That in 
 these cases the pruritus is actually dependent upon the 
 "haemorrhoidal hyperplasia" of the portio vaginalis, 
 Cohnstein considers to be proved by the fact that, 
 whilst local applications give no more than momentary 
 relief to the itching, this symptom is completely re- 
 lieved by the abstraction of blood from the cervix. 
 But in addition to such cases as these, we have from 
 time to time to deal with patients suffering from vio- 
 lent genital pruritus during the climacteric period, in 
 whom we shall vainly seek for any local pathological 
 changes, to the cure of which our therapeutic zeal 
 may be directed. Analogy with some other disorders 
 of the climacteric leads us to conclude that in these 
 cases also we have to do with an idiopathic neurosis 
 (Boerner). 
 
 The frequent recurrence of pruritus vulvae leads 
 ultimately to the formation of nodules and papular 
 eruptions. 
 
 Many authors state that they have observed the fre- 
 quent occurrence of erysipelas during the climacteric 
 period; others assert that furunculosis, prurigo, urti- 
 caria, and herpes zoster, are seen with especial fre- 
 quency at this period of life. 
 
 Tilt, in his 500 cases of women at the climacteric 
 age, made the following observations: 
 
 201, or 40.2 per cent, suffered from heats and ten- 
 dency to perspiration. 
 
 2, or 0.4 per cent, suffered from monthly recurrence 
 of periods of perspiration. 
 
 84, or 16.8 per cent, suffered from profuse perspira- 
 tions. 
 
SEXUAL' EPOCH OP THE MENOPAUSE 411 
 
 13, or 2.6 per cent., suffered from cold sweats. 
 
 14, or 2.8 per cent., sufifered from dry heats (dry 
 flushes) . 
 
 186, or 37.2 per cent, remained free from such at- 
 tacks of heat or perspiration. 
 
 Krieger gives as an example of the "occurrence of 
 new troubles" at the change of life, f urunculosis ; so 
 also does Boerner. "The discoloration of the face, 
 occurring usually in connection with pregnancy or 
 with diseases of the reproductive organs, and known 
 as chloasma uterinum, has been seen by Cohnstein, 
 during the climacteric period, "chiefly in cases in 
 which, owing to some degree of failure of general 
 nutrition, the skin has been thrown into folds." Wil- 
 son regarded prurigo and eczema as the commonest 
 skin diseases of the climacteric period; whilst Boerner 
 draws attention to a connection between climacteric 
 conditions and the outbreak of herpes zoster. 
 
 Disorders of Metabolism 
 
 Among the disorders of metabolism to which women 
 are especially prone at the climacteric period, we must 
 in the first place allude to obesity (lipomatosis univer- 
 salis), and to gout (arthritis urica). 
 
 Numerous observations have shown us that the time 
 of the change of life, the period between the ages of 
 40 to 50 years, is the one especially favorable in wom- 
 en to the extensive deposit of fat in the tissues. 
 
 In 200 cases of great obesity (lipomatosis univer- 
 salis) in women, in which I instituted inquiries re- 
 garding the age at which an excessive deposit of fat 
 in the tissues had first been noticed, I obtained the fol- 
 lowing results: 
 
412 THE SEXUAL LIFE OF WOMAN 
 
 In early childhood in l9 cases 
 
 At the age between 15 and 20 years in 30 cases 
 
 At the age between 20 and 30 years in 45 cases 
 
 At the age between 30 and 40 years in 52 cases 
 
 At the age between 40 and 50 years in 54 cases 
 
 At ages over 50 years " cases 
 
 We learn from these figures that it is between the 
 ages of 40 and 50 years that there is the greatest ten- 
 dency in women for the accumulation of fat; but that 
 as early as between the ages of 30 and 40 years this 
 accumulation may in many instances begin. Speaking 
 generally, there is in women an obvious connection 
 between the development of obesity and the state of 
 the reproductive functions, inasmuch as at puberty, 
 during the puerperium, and above all at the climacteric, 
 there is a special tendency to the accumulation of fat 
 in the subcutaneous tissues. At the commencement of 
 the menopause it is more especially in the abdominal 
 wall, the breasts, and the buttocks, that we witness the 
 deposit of fat. In the abdomen, owing to thickening 
 of the subcutaneous tissues and of the great peritoneal 
 folds — especially of the great omentum — a marked pro- 
 trusion occurs, whilst the umbilicus becomes more 
 deeply hollowed, and ultimately funnel-shaped. In 
 some instances, the deposit of fat around the navel 
 favors the occurrence of umbilical hernia. After an 
 artificial menopause, induced by oophorectomy, it has 
 also been noticed in from 42 to 52 per cent, of the 
 cases that a marked general deposit of fat has occurred, 
 affecting especially the breasts and the buttocks. 
 
 This obesity in climacteric women, not only impairs 
 to a serious extent their good looks, but brings in its 
 train a number of troubles, and gives rise to manifold 
 morbid manifestations, and among these, changes in 
 the heart, which may readily threaten the patient's life. 
 In consequence of extensive fatty deposits in the myo- 
 
SEXUAL EPOCH OP THE MENOPAUSE 413 
 
 cardium, associated with actual fatty degeneration of 
 the muscular fibres, cardiac insufficiency ensues, with 
 all its distressing and disastrous consequences. It is 
 further necessary to insist upon the fact that obesity 
 during the climacteric very definitely favors the occur- 
 rence of menorrhagia. 
 
 On examining 282 women, 5 years after the com- 
 plete cessation of the menstrual flow, Tilt found that 
 121 had become stouter than before, 71 were unchanged 
 in this respect, and that 90 were thinner than formerly. 
 
 Alike in the third class and in the first were a very 
 large proportion of women in whom the change of life 
 had entailed much illness and suffering; but in the 
 first class, the women who had been thus affected had 
 at that time lost weight, and only in the latter half of 
 the climacteric period, when their troubles had become 
 less severe, had the condition of embonpoint made its 
 appearance. 
 
 Passing now to the consideration of arthritis urica 
 in women at the climacteric, it is worthy of mention 
 that Hippocrates was so much struck by the associa- 
 tion that he went so far as to deny that gout occurred 
 at all in women before the menopause. The fact of 
 the matter is that whilst women are in general less dis- 
 posed than men to the occurrence of gout, the tendency 
 of women to this disease during the climacteric period 
 is so marked, that at this epoch of life the disease is 
 far more common in women than it is in men of corre- 
 sponding age. 
 
 It is in obese women, with a soft, white, and lax 
 integument, with a pallid, somewhat bloated counte- 
 nance, a poorly developed muscular system, extensive 
 varicosities of the veins of the legs, marked dyspeptic 
 troubles, and habitual constipation, that during the pre- 
 climacteric and climacteric periods, gout is especially 
 
414i THE SEXUAL LIFE OF WOMAN 
 
 apt to make its appearance. It is then characterized 
 by the following symptoms. From time to time the 
 woman suffers from tearing or shooting pains in the 
 joints, lasting at first a short time only, and returning 
 after longer or shorter intervals. With the frequent 
 return of the pains, the affected joints become swollen; 
 and finally the patient suffers from the characteristic 
 attacks of acute gouty arthritis, with the well-known 
 consecutive symptoms of this affection. 
 
 According to the observations of Geist, during the 
 climacteric period, 28 women suffer from gout as com- 
 pared with four men of corresponding age. Tilt pub- 
 lishes the following figures showing the mortality of 
 women from gout in England: 
 
 At ages irom 20 to 30 years 56 women 
 
 At ages from 30 to 40 years 121 women 
 
 At ages from 40 to 50 years 291 women 
 
 At ages from 50 to 60 years 152 women 
 
 At ages from 60 to 70 years * 104 women 
 
 Regarding diabetes mellitus during the menopause, 
 Lawson Tait, who maintained there was a distinct form 
 of climacteric diabetes, asserted that this disorder of 
 metabolism was less severe, and runs a longer course 
 during the climacteric period than at other times of 
 life. 
 
 Diseases of the Nervous System 
 
 The disturbances of the nervous system that occur 
 during the climacteric period, manifest themselves 
 chiefly in the form of hyperaesthesia and hyperkinesia. 
 The sensory nerves appear to me for the most part 
 to be more irritable than normal, inasmuch as every 
 stimulus by which they are affected arouses a compara- 
 tively greater sensation, and gives rise to an excessive 
 reaction in the sphere of consciousness. The cutaneous 
 
SEXUAL EPOCH OF THE MENOPAUSE 416 
 
 hyperaesthesia of climacteric women is shown in very 
 various ways, the commonest being the anomaly of 
 sensation, which gives rise to the symptom known as 
 pruritus, characterized by paroxysms of itching in 
 more or less extensive areas of skin, with consecutive 
 nutritive changes in the affected portions of the integu- 
 ment. The commonest and the most distressing form 
 of this disorder during the menopause is pruritus 
 vulvae. 
 
 In addition to such manifestations of cutaneous 
 hyperaesthesia, vasomotor disturbances of the skin are 
 of frequent occurrence, characterized by redness, rise 
 of temperature, and sometimes the formation of nodules 
 in the affected areas. Almost without exception, .at 
 the outset of the climacteric period, and sometimes also 
 in the preclimacteric epoch, women complain of a 
 very distressing feeling of fugitive heat in various 
 portions of the surface of the body, manifested objec- 
 tively by the rapid appearance and no less rapid sub- 
 sidence of a red coloration of the skin of the face, the 
 neck, and the chest. Such fugitive heats are due to 
 disturbances of vasomotor innervation giving rise to 
 sudden variations in the amount of blood passing 
 through the vessels of the affected areas of skin. 
 
 Hardly less frequent during the climacteric are the 
 sensations of imaginary movement which give rise to 
 the subjective symptom known as vertigo. Often in 
 women at this time of life it occurs quite without 
 apparent cause, but in other cases on the performance 
 of some unusual movement or the adoption of some 
 unusual posture; there is a sudden perception of rota- 
 tory movement, either of the patient's own body or else 
 of her visible and palpable environment. With this 
 feeling of disturbed equilibrium, there is often as- 
 sociated optical and auditory hyperaesthesia, flickering 
 
416 THE SEXUAL LIFE OF WOMAN 
 
 before the eyes (muscae volitantes), tinnitus aurium, 
 painful sensations in the head and more especially 
 in the occipital region, nausea, vomiting, sense of 
 anxiety, cold sweats, muscular twitchings, alternating 
 redness and pallor of the face, and coldness of the feet. 
 The vertigo occurs in paroxysms, usually of short dura- 
 tion, varying from one to fifteen minutes. It is especi- 
 ally in plethoric and obese women that climacteric 
 vertigo occurs. 
 
 A peculiar form of this climacteric vertigo is that 
 described by Tilt under the name of "Pseudo-Nar- 
 cotism" of climacteric women, characterized by a sense 
 of swimming movements, uncertainty in the gait, va- 
 cancy of expression, a confused look in the eyes like 
 those of a drunken person, and a kind of mental stupor 
 which the patient cannot shake off without consider- 
 able effort. The women thus affected state that they 
 feel as if they had had too much to drink, as if some- 
 thing had gone to their heads; indeed, their great 
 fear is that they will be supposed to be intoxicated by 
 those who see them walking in the streets; they feel 
 even that .they must refuse to receive the visits of their 
 acquaintances if they wish to preserve their reputation 
 for sobriety. They suffer also frrom great drowsiness, 
 from a disagreeable sense of weight or pressure in the 
 head, from a feeling "as if the brain was clouded, or 
 needed to have some cobwebs swept away." They 
 feel a disinclination to both mental and physical exer- 
 tion, and their memory and all other intellectual powers 
 are impaired. 
 
 Boerner maintains that the attacks of vertigo so fre- 
 quently occurring at the menopause are in a minority 
 of cases only dependent upon hyperaemic states (aris- 
 ing from the cessation of the menstrual flow) ; on the 
 contrary, he believes that the cause more often lies in 
 
SEXIUAU EPOCH OF THE MENOPAUSE 417 
 
 hysteria, in chronic disorder of the digestive tract, or, 
 finally, in anaemia. In his opinion, vertiginous attacks 
 dependent upon cerebral anaemia are very common in- 
 deed during the climacteric period, and even for a 
 long time afterward ; and he believes that their nature 
 is often completely misinterpreted. 
 
 'Another very unpleasant indication of disordered 
 nervous function during the climacteric period is the 
 sleeplessness that is so common at this time of life. 
 Women who during the daytime feel compafatively 
 well, suffer at night, sometimes periodically at exactly 
 the same hour night after night, from a state of general 
 restlessness, and for this reason are unable to obtain 
 the sleep for which they long. They throw themselves 
 uneasily from side to side of the bed, or wander rest- 
 lessly about the room, and before long, owing to this 
 want of sufficient repose, become greatly depressed. 
 
 Among the neuroses of the sensory apparatus, the 
 various kinds of cutaneous neuralgia are less common 
 than during the menarche and the menacme; but on 
 the other hand, in my personal experience at any rate, 
 the visceral neuralgias are commoner, more especially 
 cardialgia and hypogastric neuralgia. Of the superfi- 
 cial neuralgias, hemicrania and intercostal neuralgia 
 are those which occur most often during the climacteric 
 period. 
 
 During the change of life, hemicrania most com- 
 monly occurs in typical association with menstruation ; 
 or, if the flow has already ceased, the attacks of hemi- 
 crania recur at what should be the menstrual periods. 
 This affection is characterized by the paroxysmal oc- 
 currence of a severe boring pain in the side of the 
 head, more often the left side than the right, affect- 
 ing the temporal, the parietal, or the occipital region, 
 ot the entire side of the calvaria at once, usually accom- 
 
418 THE SEXUAL LIFE OF WOMAN 
 
 panied with redness and local rise of temperature of 
 the painful part; the duration of the paroxysms varies 
 in different cases from one or two to many hours; with 
 the pain are associated chilliness, nausea, exhaustion, 
 and a severe feelingof general malaise. 
 
 Of the intercostal neuralgias, one form deserves 
 especial mention in this connection: I refer to masto- 
 dynia, which is both physically and mentally one of the 
 most distressing affefctions to which women are sub- 
 ject during the climacteric period. For a middle- 
 aged woman suffering from mastodynia — the "irritable 
 breast" of Cooper — almost invariably feels assured that 
 these pains localized in the breast and its immediate 
 vicinity are indications of a commencing cancer of the 
 breast; and it is an exceedingly difficult matter, in most 
 cases, to convince her that her fears are without founda- 
 tion. In this manner, partly in consequence of the 
 directly depressing effect of the pains, which are com- 
 monly intensely severe, and partly owing to the dis- 
 turbance of mind produced by the belief that an 
 incurably fatal disorder has begun, I have in several 
 instances seen cases of profound melancholia originate. 
 
 According to Windscheid, among the enduring pain- 
 ful sensations of the climacteric period, pains in the 
 lower extremities are of somewhat frequent occurrence. 
 Day after day the patient suffers from distressing tear- 
 ing or lancinating sensations in the legs ; the trouble is 
 insusceptible of more exact description, but is none the 
 less a very severe one. In addition to the lower ex- 
 tremities, the back, the spinal column, and more par- 
 ticularly the lumbo-sacral region, are often the seats of 
 incessant pain. In the thoracic region of the back,' the 
 pain is usually diffuse; when confined to the spinal 
 column, however, it is commonly limited to individual 
 vertebrae, the spinous processes of those affected being 
 
SEXUAL EPOCH OF THE MENOPAUSE 419 
 
 also sensitive to pressure. The sacral pains may in 
 some cases predominate to such an extent, that it is on 
 this ground alone that the patient comes to seek medi- 
 cal advice. The sacrache is equally severe when the 
 patient is standing, sitting, or recumbent; it often radi- 
 ates into the lower extremities. Boerner draws atten- 
 tion to the fact that in many cases the pains in the 
 sacrum or higher up in the back may be due to exces- 
 sive tension of the abdominal parietes in consequence 
 of the great accumulation of fat. Among motor mani- 
 festations, Windscheid draws especial attention to a cer- 
 tain degree of weakening of the muscles of the lower 
 extremities. Although on examination no abnormality 
 can be detected, fatigue and functional incapacity, 
 more especially in the lower extremities, ensue in a 
 manner altogether disproportionate to the exertion, so 
 that the patient is most unwilling to take even a short 
 walk, to go upstairs, etc. In pronounced cases, the 
 patient will never go out walking without carrying a 
 campstool, so that she can sit down to rest directly she 
 begins to feel fatigued. In association with these dis- 
 orders of motility we most commonly see the above- 
 mentioned painful sensations in the legs, and by these 
 latter the functional incapacity of the lower limbs is 
 of course increased. Weakness of the arms is far less 
 frequently observed; but occasionally we hear com- 
 plaints that on the performance of domestic duties, 
 needlework, etc., which previously could be carried 
 out quite easily, the arms and hands are now speedily 
 fatigued, and rendered functionally incapable. 
 
 Of the visceral neuralgias, cardialgia is by no means 
 rare during the climacteric period; the pain is con- 
 centrated in the epigastric region, but not infrequently 
 radiates to the back and to the chest. Hypogastric 
 neuralgia is also not uncommon, pain in the lower part 
 
420 THE SEXUAL LIFE OF WOMAN 
 
 of the abdomen, associated with a sense of pressure in 
 the bladder, the uterus, and the rectum, and sometimes 
 radiating to the thighs and to the region of the haemor- 
 rhoidal nerves. 
 
 The opinion expressed by several authorities, that 
 the menopause favors the occurrence of cerebral apo- 
 plexy, must, according to Windscheid, be received with 
 caution; we have to remember that with advancing 
 years atheromatous changes are apt to occur in the 
 cerebral arteries, and it is to these changes, altogether 
 independently of the climacteric, that cerebral haemor- 
 rhage is due. It appears, however, to be a fact that 
 the menopause favors the onset of progressive paralysis. 
 [A-Ccording to Jung, 60 per cent., and according to von 
 Krafft-Ebing, 27 per cent, of women affected with par- 
 alysis were first affected in this way during the cli- 
 macteric period. Von Krafft-Ebing explains this oc- 
 currence by the fact that during the menopause fluxions 
 of vasomotor origin are common, and these serve as 
 the starting-point of transudative processes. 
 
 Among the neuropathic manifestations of the cli- 
 macteric period we must reckon the at times excessive 
 increase of the sexual impulse. We have already in- 
 sisted upon the fact that the sexual impulse is not 
 normally extinguished in women at the time of the 
 cessation of menstruation; on the contrary, sexual de- 
 sire commonly persists long after the menopause, and 
 on this fact is largely dependent the frequency with 
 which elderly women espouse quite young men. But 
 in some cases, the sexual impulse is enormously en- 
 hanced during the climacteric period, and the patient 
 experiences paroxysms of intense voluptuous sensation, 
 associated with manifestations of abnormal reflex and 
 psychical reaction, with increased frequency of the 
 pulse and the respiration, emotional excitement, it may 
 
SEXUAL EPOCH OF THE MENOPAUSE 421 
 
 be loss of consciousness, and even general convulsions. 
 Some of these cases of disordered sexuality occur in 
 those previously affected with pruritus vulvae et vagina. 
 
 More particularly Guenceau de Mussy and Boerner 
 have described cases of such excessive libido sexualis 
 during the climacteric period, voluptuous crises with 
 pollutions, occurring independently of any external 
 cause; the women thus affected have a continued suc- 
 cession of erotic ideas, they experience an itching and 
 burning sensation in the genital organs, and from time 
 to time this culminates in a paroxysm of sexual feel- 
 ing, with orgasm, and increased secretion from the 
 glands of the vulva. 
 
 Boerner has observed that characteristic variations 
 in the libido sexualis commonly occur at the climacteric 
 period. Not infrequently at this time the sexual de- 
 sire becomes greatly diminished in intensity, or even 
 entirely disappears; more often, however, the desire 
 persists throughout this epoch; finally, in many in- 
 stances, the desire undergoes an increase, at times to a 
 degree amounting to positive torment. The first of 
 these changes, the decline in the intensity of the sexual 
 desire, harmonizing as it does with the general extinc- 
 tion of the sexual functions at the change of life, might 
 have been expected to be the normal occurrence. And 
 it is a fact that* in many cases characterized by an in- 
 crease of libido sexualis at the climacteric epoch, 
 Boerner found that there existed anatomical abnor- 
 malities in the reproductive organs (fibromata, flexions, 
 etc.). Be this as it may, an increase in the intensity 
 of sexual desire, as long as that increase is not alto- 
 gether excessive, may be regarded as one manifesta- 
 tion of the visceral hyperaesthesias so general at this 
 time of life. In the excessive degrees of this affection, 
 however, those in which at times the sexual crisis is 
 
422 THE SEXUAL LIFE OF WOMAN 
 
 associated with general convulsions, we must, with 
 Romberg, recognize the existence of a direct neuralgic 
 state of the spermatic plexus. It is especially before 
 the commencement of an actual menstrual period, or 
 before a due period which fails to occur, that during 
 the critical years complaint is made of this state of 
 excessive sexual desire and sensibility; and in many in- 
 stances the trouble begins at the very first appearance 
 of the menstrual irregularities which foreshadow the 
 menopause. 
 
 Windscheid draws attention to the fact that occa- 
 sionally the nervous manifestations may make their 
 appearance prior to the occurrence of any menstrual 
 irregularity, so that it is by the nervous disturbance 
 that the woman or her physician is warned of the ap- 
 proach of the menopause. "When the menstrual 
 anomalies begin," continues Windscheid, "that is to 
 say, at the commencement of the climacteric, the ner- 
 vous troubles may have already attained their maxi- 
 mum and have begun to decline in intensity. As a 
 general rule, however, the appearance of the nervous 
 disturbances coincides with the commencement of the 
 menstrual irregularities. It may happen that these dis- 
 turbances are intensified with each recurring period, 
 but this is not the rule. Sometimes, however, we may 
 observe that when menstruation occurs with excessive 
 frequency — a by no means rare phenomenon at the out- 
 set of the climacteric — the nervous disturbances become 
 more severe; and especially is this the case when the 
 unduly frequent flow is also abnormally profuse, as 
 indeed often happens." The manifestations of cli- 
 macteric neurosis occur, as Windscheid rightly insists, 
 most frequently in the sphere of the psyche. "We ob- 
 serve a change in the disposition, which usually be- 
 comes more excitable. A woman previously calm and 
 
SEXUAL EPOCH OF THE MENOPAUSE 423 
 
 composed becomes irritable, inclined to emotional dis- 
 turbance and to fits of temper, and unable to bear with 
 equanimity the pinpricks so frequent in daily life, and 
 especially in the daily life of a housewife. In other 
 cases, however, the disturbance of the psyche is rather 
 in the direction of depression: we observe a kind of 
 spiritual inhibition, a deficiency of vital energy, an 
 indifference to things which formerly gave pleasure. 
 Almost always, also, complaints of loss of memory are 
 among the indications of such depression. To these 
 intellectual anomalies are superadded disturbances of 
 sensibility. There is excessive sensitiveness to bright 
 lights, loud noises, and strong odors. Frequently, also, 
 in such cases, we see great intolerance to alcohol, quite 
 small doses giving rise to extremely disagreeable sensa- 
 tions in the head." 
 
 Climacteric Psychoses 
 
 The powerful influence which the changes occurring 
 at the climacteric period has in the origination of psy- 
 choses, has long been recognized, the menopause, in 
 fact, being a favorable soil for the cultivation of mental 
 disease. The fact is embodied in medical terminology, 
 since many authors speak of "climacteric insanity," 
 assuming that the psychoses of this period of life pre- 
 sent a definite and characteristic clinical picture. 
 
 In an earlier part of this work it was shown that the 
 process of menstruation has generally a marked efifect 
 upon the psyche, and that disturbances of menstrual 
 activity are competent to exercise a pathogenic influ- 
 ence upon the mental condition of the woman who 
 suffers from them ; still greater and more intense is the 
 influence of the cessation of menstrual activity, with its 
 powerful and widespread disturbance of the entire 
 organism, with its destructive oscillations of equilib- 
 
424 THE SEXUAL LIFE OF WOMAN 
 
 rium in the spheres of sensation, perception, ideation, 
 and volition. It is easy to understand how the rarer 
 recurrence of menstruation, the occasional profuse 
 losses of blood, the complete suppression of menstrua- 
 tion, the conditions peculiar to the climacteric period 
 of stasis and congestive hyperaemia of the brain, are 
 competent, more especially in hereditarily predisposed 
 persons, to give rise to the development of psychoses; 
 whilst in those already sufifering from mental disorder, 
 the menopause will be likely to bring about an aggrava- 
 tion in their symptoms. At this time of life, also, we 
 have to take into account the effect of certain ideational 
 influences to which allusion has already been made, the 
 thought that womanhood and its joys are passing away 
 for ever, and the fear of the dangers attendant upon 
 this critical period of the change of life. A French 
 proverb alludes to "le diable de quarante ans, si habille 
 a tourmenter les femmes." 
 
 Mental disorder will be more likely to ensue at the 
 climacteric period in those women whose nervous 
 systems have always been unduly irritable, and in those 
 affected with hereditary predisposition to insanity. 
 Further, it is more likely to occur in those in whom 
 the menopause takes place quite suddenly, in a catas- 
 trophic manner, than in those in whom the climacteric 
 proceeds gradually, and unaccompanied by any stormy 
 manifestations in the organism at large. 
 
 It is not, in my opinion, possible to recognize any 
 specific form of mental disorder peculiar to the cli- 
 macteric period, but nevertheless the psychoses occur- 
 ring at this time of life do exhibit certain striking and 
 characteristic features, more especially in this respect, 
 that states of mental depression with melancholia pre- 
 doniinate, whilst erotic influences are manifest in their 
 etiology. In the slighter forms, volition and ideation 
 
SEXUAL EPOCH OF THE MENOPAUSE 425 
 
 are unaffected, and the trouble manifests itself in the 
 form of hypochondriacal moods, associated with bodily 
 troubles. In more severe cases we see emotional de- 
 pression, states of anxiety, limitation of the powers of 
 conception and judgment, indecisiveness, low-spirited- 
 ness, and apathy; or on the other hand, restlessness, 
 an inclination to continued moving about, the eager 
 pursuit of continually varying occupations, loquacity, 
 etc.; finally, if the mental disorder becomes still more 
 severe, hallucinations, delirium, paroxysms of intense 
 excitement, and in exceptional instances, fully de- 
 veloped mania. 
 
 As with regard to the other disorders attending the 
 climacteric, so also in respect of the climacteric psy- 
 choses, women who have been or are married, who 
 have had a reasonable number of children, and have 
 been accustomed to a sufficiency of sexual activity, are 
 more favorably situated, are far more immune, than 
 women whose sexual circumstances have been the op- 
 posite of those mentioned, who have had one or two 
 children only, who have indulged in intercourse only 
 when protected from pregnancy by the use of pre- 
 ventive measures, or have remained sexually unsatis- 
 fied, and, finally, women who have never married, and 
 those who for many years prior to the commencement 
 of the menopause have lived in chaste widowhood. In 
 "old maids," to the somatic effects of sexual abstinence 
 (or in some cases of abnormal sexual gratification) , are 
 superadded the effects of the intellectual and emotional 
 recognition of a wasted life. Again, it by no means 
 rarely comes under our observation that women who 
 in youth, at the time of the menarche, suffered from 
 psychical disturbances, are apt once again to be affected 
 with transitory mental disorder at the change of life. 
 Once, however, the menopause is completely at an end, a 
 
426 THE SEXUAL LIFE OF WOMAN 
 
 condition of mental quiescence is, as a rule, established, 
 and then it may happen that previously existent mental 
 disorders undergo amelioration; but on the other hand 
 we have in all cases to reckon with the possibility that 
 they may take an unfavorable turn in the direction of 
 the development of senile psychoses. 
 
 Of considerable interest is the fact, first pointed out 
 by Glaevecke, and subsequently confirmed by other 
 observers, that in cases of artificial menopause, melan- 
 cholic mental disturbances not infrequently follow the 
 operation, in some instances so severe as to lead to 
 weariness of life and actual suicide; and in general, 
 after the artificial induction of the menopause, psy- 
 chical disturbances are by no means rare, and are some- 
 times very severe. Such disturbance of the mental bal- 
 ance is seen after oophorectomy, especially in women 
 who are still comparatively young, and whose sexual 
 powers are still in a ripe state; whereas when the 
 operation is performed in women of a more advanced 
 age, whose ovaries were already nearly or completely 
 functionless, no psychopathic changes are likely to en- 
 sue. In women belonging to the former category, the 
 same etiological influences come into operation as in 
 the physiological menopause, the patient, that is, is 
 affected by the psychical influences of the removal of 
 the ovaries — not only by the cessation of menstruation 
 and the disappearance of the internal secretion of the 
 reproductive glands, leading to a disturbance of the 
 physical equilibrium, but also by the intellectual rec- 
 ognition of the loss of sexual potency, and a consequent 
 disturbance of the mental balance. 
 
 In Schlager's opinion the climacteric has a potent 
 influence in promoting the development of psychical 
 disturbances in women, even when the involution 
 occurs at the normal age. The course of these dis- 
 
SEXUAL EPOCH OF THE MENOPAUSE 427 
 
 turbances is as follows: soon after the commence- 
 ment of the process of involution, when for a few 
 months already the menstrual periodicity has been ' 
 irregular, or the flow has been unduly profuse, a change 
 of disposition makes its appearance, at first hardly 
 noticeable, but after a little time manifesting itself 
 clearly in the form of an increase in irritability. The 
 woman finds fault with everything and everybody, be- 
 comes mistrustful, suspicious, full of complaints, im- 
 agines that the most insignificant annoyances are due 
 to intentional slights ; at the same time she complains 
 of continued sleeplessness, palpitation, various inde- 
 scribable sensations, and of headache. Occasionally, 
 congestions of the head occur, with alarming dreams, 
 and the moodiness may increase greatly; in this condi- 
 tion three such patients of Schlager's were impelled to 
 attempts at suicide. Schlager further draws attention 
 to the fact that in 22 cases known to him in which 
 suicide was performed or unsuccessfully attempted by 
 women, in eleven of these the patient was at the cli- 
 macteric age. He believes that the most important 
 etiological influence in the production of climacteric 
 mental disorder in such cases is the sudden suppression 
 of menstruation. In the majority of these instances, 
 the mental disorder takeS the form of mania; exception- 
 ally, however, the form of chorea or of catalepsy. 
 
 By Tilt the following forms of "climacteric insanity" 
 are distinguished: delirium, mania, hypochondriasis, 
 melancholia, impulsive insanity, and perversion of the 
 moral insuncts. The same author publishes the follow- 
 ing table showing the age incidence in 1,320 cases of 
 mental disorder in women, from which it appears that 
 during the age of the menopause, a very considerable 
 number of the cases originate, but that after the change 
 of life comparatively few cases occur. 
 
428 THE SEXUAL LIFE OF WOMAN 
 
 In these 1,320 cases the women were: 
 
 Under 15 years of age in 9 instances 
 
 Over 15 and under 20 years in 61 instances 
 
 Over 20 and under 25 years in 216 instances 
 
 Over 25 and under 30 years in 223 instances 
 
 Over 30 and under 35 years in 217 instances 
 
 Over 35 and under 40 years in 218 instances 
 
 Over 40 and under 45 years in 162 instances 
 
 Over 45 and under 50 years in 153 instances 
 
 Over 50 and under 55 years in 122 instances 
 
 Over 55 and under 60 years in 57 instances 
 
 Over 60 and under 65 years in 55 instances 
 
 Over 65 and under 70 years in 27 instances 
 
 Fuchs tabulated the ages of 26,300 insane persons. 
 Reducing his results to the ratios per 10,000, he ob- 
 tained the following results: 
 
 Women Men 
 
 At ages under 20 563 649 
 
 At ages over 20 and under 30 1,895 2,132 
 
 At ages over 30 and under 40 2,557 2,614 
 
 At ages over 40 and under 50 2,180 2,080 
 
 At ages over 50 and under 60 1,362 1,247 
 
 At ages over 60 1,443 1,278 
 
 According to Esquirol, among 198 women who com- 
 mitted suicide, there were 77 between the ages of 40 
 and 50 years — a number considerably larger than those 
 in any other age-decade. Among 235 women suffer- 
 ing from dementia, a moiety had first come under treat- 
 ment during the climacteric age. The same author 
 published the following data regarding the age-inci- 
 dence of insanity in the case of 6,713 female patients: 
 
 At ages under 20 years 348 cases 
 
 Between the ages of 20 and 25 563 cases 
 
 Between the ages of 25 and 30 727 cases 
 
 Between the ages of 30 and 40 1,607 cases 
 
 Between the ages of 40 and 50 1,479 cases 
 
 Between the ages of 50 and 60 954 cases 
 
 At ages above 60 years 1,035 cases 
 
SEXUAL EPOCH OF THE MENOPAUSE 429 
 
 Matusch found that among 551 women sufifering 
 from mental disorder, there were: 
 
 At ages to 10 years 9 cases 
 
 At ages 10 to 20 years ".*."' 73 years 
 
 At ages 20 to 30 years 140 cases 
 
 At ages 30 to 40 years 114 cases 
 
 At ages 40 to 50 years ',',',[', 107 cases 
 
 At ages over 50 years 38 cases 
 
 According to von Krafft-Ebing, among 858 insane 
 women, there were about 60 in whom the disorder 
 of the mind appeared to depend upon the influence of 
 the climacteric, and in 25 of these there was hereditary 
 predisposition to mental disease. 
 
 From Kowalewski's interesting work on the psy- 
 choses of the climacteric, we quote the following: 
 
 "In women, the climacteric has a distinct influence 
 upon the mental life, and that influence is strongly 
 manifested, more especially in cases in which during 
 the age of puberty mental disturbance had previously 
 been noticed. The mental condition in which women 
 approach the change of life is a very variable one, and 
 it is one largely dependent upon the circumstances in 
 which the active years of the sexual life have been 
 passed. In some cases, a woman has been so fortunate 
 as to marry early and from affection, and her whole 
 married life has been passed without disturbance; her 
 labors have not been exhausting, and her children have 
 enjoyed good health ; all have passed through the years 
 of childhood without untoward incident, and their 
 development has been a happy and successful one; in 
 a word — everything has gone well with her and hers. 
 Such a woman will give thanks to God for the rare 
 felicity she has enjoyed; and quietly, patiently, and 
 with understanding, will endure the inevitable end of 
 her sexual life. For such a woman, more especially 
 if she comes of a healthy stock, the changes which 
 
430 THE SEXUAL LIFE OF WOMAN 
 
 occur in her reproductive organs at the epoch of the 
 climacteric, need not entail any serious shock to her 
 nervous system, nor need they form the culture ground 
 for morbid manifestations in her nervous system or in 
 her mind. Even if any anomalies in nervous work- 
 ing should occur, it will be such only as are aroused 
 by the disturbance of the normal menstrual rhythm; 
 in such cases, they will rarely prove of a serious or 
 enduring character. 
 
 "But look, on the other hand, upon this picture. 'A 
 woman has married without affection and from pure 
 necessity. Her husband has been a drunkard, and 
 rough and unfaithful. She has had a great many chil- 
 dren, her labors have been tedious and difficult and 
 accompanied with severe losses of blood. Some of the 
 children fell sick and died; those that survived proved 
 idle, good-for-nothing, and a burden. The family life 
 is dominated by quarrelsomeness, disorder, and insuffi- 
 ciency of means. The mother is affected with some 
 chronic disorder of the reproductive organs, and is 
 hardly ever out of the doctor's hands. After 25 or 30 
 years of a life of this kind, the woman enters upon the 
 change of life. Physically exhausted, weary of life, 
 never having known happiness, after an existence full 
 of trouble and wretchedness, with nothing joyful either 
 in her memories of the past or in her prospect of the 
 future — the chief hope of such a woman is that her 
 troubles may soon end with her life. Where the soil 
 is thus physically and mentally exhausted, the develop- 
 ment of a neurosis or a psychosis is only too probable 
 on the most trifling exciting cause. Her life seems of 
 so little worth, that thoughts of suicide are likely to 
 be very near at hand. Thus, when the climacteric 
 alterations in the reproductive organs are superadded, 
 melancholia is very likely to supervene. When, how- 
 
SEXUAL EPOCH OF THE MENOPAUSE 431 
 
 ever, the case is complicated by hereditary predisposi- 
 tion to insanity, and by the occurrence of actual degen- 
 erative charrges in the central nervous system, instead 
 of the passive depression of melancholia, we shall 
 rather see the ideas of persecution of the paranoiac. As 
 an actual fact, these two psychoses, melancholia and 
 paranoia are the commonest forms of mental disorder 
 at this period of a woman's life. 
 
 "These are the two extremes in woman's mental 
 state at the time when the physical changes of the cli- 
 macteric period begin in her reproductive organs. It 
 will, of course, be readily understood that between these 
 two extremes lies- a series of combinations any one of 
 which may in individual cases occur. 
 
 "The conditions of life during earlier years have 
 thus a strong determinative influence in the production 
 of mental disorder; and not infrequently in these con- 
 ditions alone shall we find the efficient cause of the 
 mental degeneration. At times, the memories of her 
 own life have in a woman at the climacteric age so 
 serious an eflfect, that these memories alone constitute 
 the casual agent of the development of a psychosis, or 
 at least so influence the soil as to make it a suitable 
 culture-ground for the development of mental disorder, 
 the actual exciting cause of the pathological state being 
 a disturbance of the ordinary menstrual rhythm. 
 
 "In considering the mental condition of women at 
 the outset of the climacteric period, we must not forget 
 those who are called 'old maids.' In their youth these 
 maidens also have had their ideals, their hopes, their 
 plans, and their sorrows. They also had a natural 
 impulse to love and to be loved in return; they hoped 
 to become wives and mothers. But life has failed to 
 fulfil their hopes and their wishes, and their longings 
 have remained unsatisfied. Some of them have taken 
 
132 THE SEXUAL LIFE OF WOMAN 
 
 up their cross without murmuring, and have devoted 
 their talents, their intelligence, and their love to the 
 service of those nearest to them. But others make an 
 active protest against fate in the form of vindictive 
 feelings toward their environment, of quarrelsome- 
 ness, scandalmongering, etc. Here we see contrasted 
 the two principal types of such women. On the one 
 hand are those who devote their intellectual and 
 spiritual powers to the service of society; these are 
 unselfish sisters-of-mercy, untiring medical women, in- 
 valuable school-teachers and governesses, fanatical 
 political agents, etc. Such as these have ceased to live 
 for themselves. In the fullest sense of the words, they 
 mortify the flesh, and guide their conduct by lofty moral 
 principles. They have killed their sexual life, and 
 they remain for ever virgins — both morally and phy- 
 sically. If, owing to a pathological inheritance, faulty 
 conditions of life, exhausting illnesses, etc., a psychosis 
 develops, the hallucinations and delusions from which 
 they suffer very rarely assume a sexual character, nor 
 are they of a degrading type. The sexual side of life 
 seems, in fact, be they sane or insane, to have under- 
 gone complete atrophy. They suffer from simple mel- 
 ancholia with stupor, or their insanity takes a religious 
 turn, but very rarely indeed has it an erotic character. 
 "Very different is it with old maids of the second 
 type. They are dissatisfied with life, irritable, quarrel- 
 some, envious, and malicious. They are spiteful and 
 revengeful, gossips and scandalmongers, boast of their 
 own chaste and innocent lives, and never forgive any 
 real or imaginary attempt upon their spotless virtue. 
 At the same time they never lose hope for the future, 
 and are full of imaginary love-affairs, in which they 
 pass through scenes by no means chaste or innocent; 
 they do not shrink from self-abuse and the abnormal 
 
SEXUAL EPOCH OF THE MENOPAUSE 433 
 
 gratification of the sexual needs, in which the lacking 
 partner in the sexual act is supplied by the imagina- 
 tion. Under the influence of such abnormal conditions 
 of life, these women frequently become affected by 
 nervous disorders; migraine, neuralgia, cephalalgia, 
 nervous depression, rachialgia, debility, anaemia, dis- 
 eases of the reproductive organs, etc. Thus, when they 
 enter the climacteric age, the soil is fully prepared for 
 the development of mental disorder, which in such 
 individuals is often characterized by hallucinations of 
 sexual sensation and perception, erotic visual and audi- 
 tory hallucinations, delusions of similar character,, in- 
 creased sexual irritability, a search for abnormal means 
 of sexual gratification, a propensity to obscene speech 
 and conduct, etc. 
 
 "Mental disorder is so common during the climac- 
 teric period, that the term 'climacteric insanity' has 
 now become established in the literature of mental 
 alienation. In almost all the text-books of the subject 
 we find an allusion to this form of mental disease, but 
 there is no real ground for Maudsley's assumption 
 that there is a climacteric insanity sui generis. At the 
 climacteric, very various forms of mental disorder may 
 occur — paranoia, melancholia, and mania; the only 
 common feature in the attacks, owing to which they are 
 classed as 'climacteric insanity,' being the fact that the 
 final determining cause in each case is the onset of 
 the change of life. In fact, this period is not with- 
 out influence upon the manifestation of the disease — 
 its stamp is imprinted upon the clinical picture, it en- 
 dues the disease with certain characteristic features — 
 but still, the peculiarities common to the cases of mental 
 disorder occurring at this time of life in women are 
 not so great as to justify us in describing them as a 
 separate variety of psychosis." 
 
434 THE SEXUAL LIFE OF WOMAN 
 
 According to Kowalewski, this so-called climacteric 
 insanity is met with in two principal forms : in many 
 cases the mental disorder recurs in periodic paroxysms, 
 associated either with the commencement of the men- 
 strual flow, or having the periodicity of menstruation 
 after the flow has already ceased to appear; in the other 
 class of cases the psychosis has no direct connection 
 with menstruation, and is dependent upon the joint 
 influence of all the manifestations of the climacteric 
 period. Cases belonging to the former class have been 
 distinguished by Bartel as "climacteric pseudo-men- 
 strual insanity." 
 
 The psychoses dependent upon the climacteric influ- 
 ences may, according to Kowalewski, appear in almost 
 all the known forms of mental disorder: precordial 
 anxiety, melancholia, mania, amentia, paranoia, etc.; 
 and although they exhibit no features which are ab- 
 solutely characteristic, or which, as already said, enable 
 us to distinguish a specific "climacteric insanity," yet 
 they all bear a common imprint by means of which we 
 are enabled to detect in their causation the influence 
 of this critical period of life. Thus, precordial anxiety 
 occurs in paroxysms having a more or less regular perio- 
 dicity, corresponding with that of the expected men- 
 struation. The same feature is observable in the perio- 
 dic exacerbations of hysterical and epileptic paroxysms. 
 Often, also, there occur at this time sudden changes in 
 the emotional disposition and in the character, in one 
 direction or the other, without the development of 
 actual melancholia or mania. The melancholia of the 
 climacteric period occurs chiefly in married women, 
 more especially in those whose circumstances are 
 unhappy; and it is often manifested by attempts at 
 suicide. 
 
 Mania is comparatively rare at the climacteric 
 
SEXUAL EPOCH OF THE MENOPAUSE 435 
 
 period; when it does occur, it commonly assumes a 
 sexual form — sexual impulses, hallucinations, and de- 
 lusions, and obscene conduct. Such manifestations are 
 seen most often in widows, in "old maids" whose morals 
 are not above reproach, and, speaking generally, in 
 those whose sexual needs have remained partially or 
 completely ungratified, and in those who have greatly 
 erred in the conduct of this side of life. Amentia also 
 occurs at this time of life; rarely in maniacal form, 
 more frequently in association with menstruation as a 
 periodic psychosis, or as a continuous disorder of mind 
 with exacerbations corresponding to the menstrual 
 periods ; it is often characterized by pronounced eroti- 
 cism. 
 
 Much more frequent during the climacteric period 
 is the occurrence of paranoia, as Kowalewski rightly 
 insists. It is most often met with in "old maids" with 
 psychopathic predisposition. The imagination of such 
 individuals is always concentrated upon men; they 
 imagine that men in general, but more particularly 
 certain individuals of the opposite sex, are continually 
 regarding them, making eyes at them, making signs 
 to them, in some way or other striving to attract their 
 attention. The most ordinary and invariable forms 
 of polite intercourse are regarded by these women, 
 whose powers of observation are morbidly stimulated, 
 as being indications of a special "attention" paid to 
 themselves. They persecute these men with their own 
 attentions, and imagine that it is the men who are per- 
 secuting them. Often this morbid mental state is as- 
 sociated with sexual malpractices, masturbation, etc. 
 
 Not rarely, such degenerates are affected with las,- 
 civious dreams. Often they experience hallucinations 
 of sexual perception in the form of supposed assaults on 
 their virginity. All these states are apt speedily to 
 
436 THE SEXUAL LIFE OF WOMAN 
 
 develop into a condition of general suspiciousness and 
 ideas of persecution. The ideas of persecution assume 
 a peculiar form, one especially characteristic of the 
 climacteric period. The patients believe that a man, 
 often personally unknown to them, and perhaps living 
 in another town, enters into spiritual and bodily inter- 
 course with them. These relations are supposed to be 
 effected in most cases by means of spiritualism, hyp- 
 notism, or electricity. The patient importunes the 
 man in question with letters, supposes herself to be 
 legally united with him, and not infrequently wishes to 
 give him the pleasure of paying her bills and provid- 
 ing her with money. It is a very common occurrence 
 for a Catholic priest to be worried by such a woman, 
 her delusion being grounded upon the fact that the 
 priest is supposed to assume an exceptionally intimate 
 spiritual relationship with members of his flock. The 
 patient with ideas of persecution often herself becomes 
 an actual persecutor, not only pestering her victim 
 with innumerable letters, but in her jealousy making 
 "scenes" whenever she can encounter him, and some- 
 times giving rise to serious scandal. With such a men- 
 tal state we often see associated sexual hallucinations 
 and delusions; the patient believes herself to be preg- 
 nant, imagines herself to have been violated, or to be 
 living in carnal intercourse with a man — someone, it 
 may be, with whom she is not even acquainted. Medi- 
 cal men are especially apt to suffer from the accusa- 
 tions of such women, whom they may have examined 
 in private in entire ignorance of the patient's mental 
 condition. Frequently, such ideas of sexual persecu- 
 tion are associated with paroxysms of violent nympho- 
 mania, and in this way also the unwary physician may 
 find himself placed in an extremely unpleasant posi- 
 tion. It occasionally happens in such patients that 
 abnormalities of the sexual instinct arise, and they 
 
SEXUAL EPOCH OF THE MENOPAUSE 437 
 
 begin to feel desire toward individuals of their own 
 sex. 
 
 Such delusions of persecution by means of hypno- 
 tism, spiritualism, the telephone, etc., in association with 
 sexual delusions and nymphomania, are so frequent 
 during the climacteric period, that they may be re- 
 garded as preeminently constituting climacteric in- 
 sanity. Frequently some old hysterical state underlies 
 this form of mental disorder. 
 
 Thus these peculiar manifestations of eroticism must 
 be regarded as the distinctive characteristics of cli- 
 macteric insanity and more particularly of climacteric 
 paranoia. A second characteristic of climacteric in- 
 sanity is, according to Garat, the marked development 
 of jealous emotions and delusions. 
 
 In addition to these fully developed psychoses, there 
 occur in degenerates at the climacteric age paroxysms 
 of impulsive insanity in the form of dipsomania, klep- 
 tomania, pyromania; exhibitionism; irresistible im- 
 pulse to suicide, homicide, infanticide, etc. Such par- 
 oxysmal impulsive manifestations are, according to 
 Kowalewski, commonly associated with menstrual dis- 
 turbances ; they occur most frequently at the due dates 
 of menstruation when the flow fails to appear. 
 
 One hundred and sixty-nine cases of climacteric 
 psychosis were classified by Matusch as follows: 
 
 Melancholia 36 cases 
 
 Mania 2 cases 
 
 Melancholia passing on into paranoia 28 cases 
 
 Melancholia passing on into secondary dementia 17 cases 
 
 Paranoia 43 cases 
 
 Neurasthenia during the climacteric period followed by 
 
 mental disorder 19 cases 
 
 Neurasthenia prior to the climacteric period, followed by 
 
 mental disorder during the climacteric period 10 cases 
 
 Apoplexy, cerebral abscess, dementia 6 cases 
 
 Epilepsy 2 cases 
 
 Alternating insanity 3 cases 
 
 Paralytic dementia 5 cases 
 
438 THE SEXUAL LIFE OF WOMAN 
 
 Von Krafft-Ebing classified 60 cases of climacteric 
 psychosis as follows : 
 
 Melancholia ' 4 cases 
 
 Alternating insanity 1 case 
 
 Acute delirium 1 case 
 
 Primary insanity: 
 
 a. With primordial delirium 36 cases 
 
 b. Paralytic dementia 12 cases 
 
 The prognosis in cases of climacteric psychosis is 
 regarded by Kowalewski as unfavorable; unfavorable 
 vital conditions are associated with retrogressive meta- 
 morphosis of the tissues, hence mental disorder arising 
 at this time of life is hardly less serious than that due 
 to actual degeneration of cerebral tissues. Indeed, ac- 
 cording to Schiller, there is during the climacteric 
 period an especial dangei: of the development of atro- 
 phic cerebral processes (Encephalitis atheromatosa) 
 with apoplectic and epileptic seizures. Schlager also 
 regards the prognosis of climacteric insanity as un- 
 favorable; but Merson, on the other hand, observed 
 among women suffering from climacteric psychoses a 
 recovery rate of over 50 per cent. On previously exist- 
 ent psychoses in women, the onset of the climacteric 
 exercises in most cases an unfavorable influence, and 
 very exceptionally only at this time do we observe the 
 cure or remission of a chronic mental disorder to occur. 
 Kowalewski has seen cases of chronic mania in which 
 a cure was obtained at the climacteric period ; a some- 
 what excessive excitability and inclination to violence 
 remained, however, as vestiges of the former insanity. 
 Matusch, keeping under observatidh 60 women af- 
 fected with chronic mental disorder as they attained 
 the climacteric period, noticed that in 14 instances the 
 mental condition changed for the worse at this period, 
 whilst in 13 the character of the mental disease under- 
 
SEXUAL EPOCH OF THE MENOPAUSE 439 
 
 went a change, excitement giving place to apathy and 
 dementia. Griesinger had earlier pointed out that at 
 the time of the cessation of menstruation there would 
 occasionally occur, amelioration, and even cure, of a 
 previously existing chronic mental disorder; more 
 often, however, the influence of the menopause was 
 an unfavorable one, a hitherto changeable and irrita- 
 tive form of mental disease becoming transformed into 
 chronic insanity with inalterable delusions, or into de- 
 mentia. The course of mental disorder, such as melan- 
 cholia, first making its appearance at the climacteric 
 epoch, was also regarded by Griesinger as likely to be 
 unfavorable. 
 
 Hygiene During the Menopause 
 
 During the critical years of a woman's life it is the 
 aim of hygiene to employ all the means available to 
 counteract the changes in the circulation of the blood, 
 the disturbances in the working of the nervous system, 
 and the nutritive disorders, which are in various ways 
 dependent upon the changes occurring in the repro- 
 ductive organs during the climacteric period; its en- 
 deavor should be so to regulate the conduct of life in 
 this epoch that the important episode of the gradual 
 decline and ultimate extinction of sexual productivity 
 shall be effected with as few local troubles as possible, 
 and as slight variations in the general condition. 
 
 By means of baths of various temperature, duration, 
 mode of application, and composition, and by other 
 selected hydrotherapeutic procedures, we are enabled 
 during the disturbances of the menopause to exert upon 
 the skin a powerful derivative influence, and in this 
 way to diminish the passive hyperaemia of the uterus 
 and the uterine annexa; by the same means we can 
 exercise a sedative influence on the peripheral nerves 
 
Mo THE SEXUAL LIFE OF WOMAN 
 
 and thus further upon the entire nervous system, when- 
 ever such measures are called for by the manifold in- 
 dications of increased irritability; further, by the use 
 of baths we can influence thei circulation of the blood, 
 we can increase the sudatory activity of the skin, and 
 in various additional ways we can afifect heat produc- 
 tion and metabolism, thus modifying the processes oc- 
 curring in the' reproductive, organs, making the condi- 
 tions favorable for the absorption of exudations, and 
 promoting a healthy tissue-change in the mucous mem- 
 brane of the genital passages. 
 
 In climacteric women, the most usual indications are 
 for the employment of water-baths at an indifferent 
 temperature, 35° to 37° C. (95° to 98° R), of moderate 
 duration, 15 to 20 minutes, the bath being one of simple 
 immersion, not of douche or affusion, and the tempera- 
 ture being kept constant by continuous inflow of a 
 sufficient quantity of hot water. Such baths as these 
 promote in a mild but continuously efficient manner 
 the functions of the skin — so important during the cli- 
 macteric epoch; and they lessen |he almost constant 
 tendency to perspirations and to the development of 
 diseases of the skin (the commonest of which is cli- 
 macteric eczema). The moderate degree of thermic 
 stimulus exercised by baths at such an indifferent 
 temperature leads them to have an equable sedative 
 effect upon the nervous system, which is probably de- 
 pendent upon an influence exerted through the inter- 
 mediation of the sensory nerve-terminals in the skin; 
 and this is most beneficial in lessening the increased 
 general irritability, both spontaneous and reflex, so 
 commonly manifested by the nervous system at the cli- 
 macteric period. In women at this time of life, such 
 baths are most useful in allaying the common cutaneous 
 hyperaesthesias and neuralgias, and have a reflex in- 
 
SEXUAL EPOCH OP THE MENOPAUSE 441 
 
 fluence also upon the visceral neuralgias and psychical 
 hyperaesthesias. 
 
 In climacteric women suffering from abnormal sensi- 
 tiveness to sensory impressions, to strong light and loud 
 noises, or from painful sensations in the most diverse 
 nerve areas ; in those subject to palpitation of the heart 
 after some trivial exciting cause ; in those affected with 
 cramp-like seizures in the pharynx, the oesophagus, the 
 stomach, and the intestinal tract; in women with dis- 
 tressing sensations of itching and burning in the re- 
 productive organs, or in those in whom there is a great 
 increase in the intensity of the sexual impulse — in all 
 these common disturbances of the menopause, by the 
 daily use of such immersion baths of water at an indif- 
 ferent temperature, best taken immediately before re- 
 tiring to rest, we shall often succeed in inducing both 
 local and general repose, in diminishing the spontane- 
 ous and reflex irritability of the nervous system, and 
 in inducing quiet and restorative sleep. 
 
 In other cases of disturbances of health during the 
 climacteric period, however, more benefit may be de- 
 rived from hot immersion baths, taken at a temperature 
 well above blood heat (37° €.—98.4° F.), and lasting 
 longer than the warm baths just described. These are 
 indicated when we wish to increase the activity of the 
 circulation through the skin, to give rise to hyperaemia 
 of the superficial structures of the body, to stimulate 
 powerfully the cutaneous nerves, to promote cutaneous 
 perspiration— in short, to exercise a powerful derivative 
 effect, to promote resorption, and to accelerate the gen- 
 eral processes of tissue-change. This method of treat- 
 ment is suitable for cases in which at the commencement 
 of the menopause there are already pathological condi- 
 tions of the reproductive organs, the morbid states being 
 now aggravated by the processes of the climacteric— 
 
442 THE SEXUAL LIFE OF WOMAN 
 
 such conditions are metritis and endometritis, chronic 
 inflammations of the intra-pelvic connective tissue and 
 of the pelvic peritoneum; and one of the first aims of 
 treatment must be to promote the softening and subse- 
 quent absorption of these inflammatory products. 
 
 In cases in which the climacteric troubles, dependent 
 in part on increased general arterial blood-pressure, 
 manifest themselves chiefly in the form of active con- 
 gestions, fugitive heats, vertigo, etc., the employment 
 of hot baths is likely to be most useful by leading to a 
 notable enlargement of the cutaneous capillary blood- 
 vessels and consequent lovi^ering of arterial blood-pres- 
 sure. Further, in cases of compensatory fluxes, periodic 
 diarrhoeas, periodic leucorrhcea, following the suppres- 
 sion of the menstrual flow, in cases of vicarious haemor- 
 rhage (especially periodic epistaxis and periodical 
 haemorrhoidal bleedings) , the use of hot baths is often 
 competent to restore the functional activity of the ova- 
 ries when this has undergone premature cessation. In 
 addition, their use assists us in our endeavors to coun- 
 teract excessive obesity and gouty disorders, diseases 
 which tend especially to make their appearance in 
 women at the epoch of the menopause, disorders of 
 metabolism intimately associated with the disturbances 
 of the uterine and ovarian functions characteristic of 
 the change of life. 
 
 In all the conditions just enumerated, if we desire 
 a still more powerful influence than that exerted by 
 ordinary hot baths, it is in our power to employ hot 
 mineral water baths, by means of which a chemical, 
 and perhaps also an electrical, stimulation of the cu- 
 taneous nerves is superadded to the simple thermic 
 stimulus conveyed by the hot water. The different 
 effects of the various mineral baths depends upon both 
 the saline and the gaseous constituents of the different 
 
SEXUAL EPOCH OF THE MENOPAUSE 443 
 
 springs, and upon the peculiar physical properties of 
 the mineral waters. 
 
 Sudorific baths are of various kinds. Some, Russian 
 baths, consist of hot air saturated with moisture; 
 others, Roman-Irish baths, consist of dry hot air; the 
 most recent of all are the electric light baths, in which 
 the radiant heat of electric lamps is utilized. But ow- 
 ing to the great increase in the body temperature which 
 they cause, with consequent increased frequency of 
 pulse and breathing, and still more on account of the 
 rapid and extensive increase in blood-pressure to which 
 they give rise, these powerful sudorific baths are rarely 
 suitable for climacteric women, and if used at all ,in 
 such cases the greatest caution must be employed. 
 Their use is indicated only in women in whom at the 
 time of the menopause the rapid onset of obesity has 
 given rise to serious troubles, but in whom the heart 
 is perfectly sound and in whom the blood vessels show 
 no trace of sclerosis. 
 
 Far less often than warm or hot baths, or mineral 
 water baths, are cold baths employed during the cli- 
 macteric period, for baths at a temperature consider- 
 ably below the indifferent point, and other hydrothera- 
 peutic procedures in which cold water is used, stimu- 
 late the nervous jystem so powerfully and give rise to 
 so great an increase in blood-pressure, that their use 
 is generally to be avoided in climacteric women, since, 
 indeed, it is apt to entail serious dangers, both physical 
 and mental. Immersion baths, plunge baths, or sponge 
 baths, in which the water employed is at a temperature 
 of 1 8° C. (64° F.) or less, are contraindicated, for they 
 act too energetically, abstract heat too powerfully, to 
 be safely employed at this epoch of life. If we seek 
 by means of hydrotherapeutic measures to counteract 
 states of congestion at the time of the menopause, and 
 
444 THE SEXUAL LIFE OF WOMAN 
 
 at the same time to bring about a general invigoration 
 of the patient's nervous system, immersion baths, the 
 water of which is not below 20° C. (68° F.), and last- 
 ing from five to fifteen minutes, would appear to be 
 indicated. In the majority of such cases, however, a 
 somewhat higher temperature is preferable, from 26° 
 to 28° C. (79° to 82° F.), the patient lying at full 
 length in the bath, immersed to above the shoulders, 
 and the water not being agitated except by a moderate 
 rubbing of the surface of the body whilst the patient 
 is in the bath. When, however, the patient sits in the 
 bath, the water covering only the lower half of the 
 body as high as the navel, a somewhat lower tempera- 
 ture is permissible, 20° to 25° C. (68° to ']']° F.) ; but 
 the duration should not exceed five minutes, moderate 
 mechanical manipulations being carried out mean- 
 while ; such baths appear to reduce nervous irritability 
 and to have a sedative effect in the manifold nervous 
 disturbances of the climacteric period. Sitz-baths, 
 again, of a longer duration, twenty to sixty minutes, 
 the water reaching only to the navel, and being at a 
 temperature varying from r6° to 25° C. (60° to 77° 
 F.), are useful in relieving chronic inflammatory states 
 of the reproductive organs and the associated erotic 
 states and abdominal pain and irritability. Colder 
 sitz-baths, even of brief duration, should, on the other 
 hand, be avoided. Similarly, a shower-bath of water 
 at a temperature of 18° to 24° C. (64° to 75° F.), 
 lasting one to two minutes, and the water falling only 
 from a very slight elevation above the head. Rave a 
 valuable sedative action; but, on the other hand, a 
 colder shower-bath, of water falling from a greater 
 height, has an exciting action,' and is to be avoided 
 at this time of life. When there are severe congestive 
 symptoms, friction of the hands and feet for a short 
 
SEXUAL EPOCH OP THE MENOPAUSE 445 
 
 time with water at a temperature from 12° to 17° C. 
 (54° to 63° F.), followed by a quarter of an hour's 
 rest in bed, may be recommended; also immersion of 
 the feet for a minute in water at a temperature of 
 10° C. (50° F.), the feet being vigorously rubbed the 
 while, followed by a walk in the open air for five or ten 
 minutes. In cases of sleeplessness at the menopause 
 due to congestion, a useful method is to dip the feet 
 for twenty or thirty seconds in water at a temperature 
 of 8° to 10° C. (46° to 50° F.), the feet being briskly 
 rubbed whilst in the water, or moved rapidly up and 
 down with treading movements ; after withdrawal, they 
 are quickly dried, and the patient immediately goes 
 to bed. Another useful mild soporific measure is to 
 apply before going to bed bandages wrung out of cold 
 water; these reach from the foot to the knee, and are 
 left on for the whole night. In cases of climacteric 
 menorrhagia, a vaginal refrigerator should be used 
 for the direct application of cold to the reproductive 
 organs; this is a cylindrical apparatus introduced into 
 the vagina, cold water flows through the interior of 
 the apparatus without wetting the vaginal mucous 
 membrane. This cooling apparatus is useful also in 
 troublesome cases of genital pruritus; cold douches to 
 the vulva for one or two minutes at a time are likewise 
 valuable in the relief of this affection. 
 
 For climacteric women, cold sea-bathing is as little 
 to be recommended as other cold hydrotherapeutic 
 measures, owing to its powerful refrigerative effect, 
 and the great mechanical influence of the moving water 
 in the waves. But in certain cases, in which sea-air 
 is likely to be beneficial, lukewarm sea-baths may also 
 be recommended ; their effect is similar to that of weak 
 brine-baths at a similar temperature. -.i 
 
 During the climacteric period, especial attention 
 
446 THE SEXUAL LIFE OF WOMAN 
 
 must be paid to the care of the skin. Owing to the 
 extreme sensitiveness of the skin at this time of life 
 to outward noxious influences, it is necessary to exer- 
 cise great care to dry the skin very thoroughly after 
 ordinary ablutions of the face and hands; irritating 
 soaps should be avoided, and a bland powder should 
 be applied after drying. During the earlier part of the 
 climacteric period, when menstruation has already 
 ceased, and senile changes in the skin with atrophy of 
 the subcutaneous tissues have commenced, the extreme 
 dryness of the skin may be relieved by lukewarm baths 
 with wet packs to follow; after the bath, the woman is 
 enveloped in moist linen cloths and then covered over 
 aill with a blanket. When the skin chaps readily, in- 
 unction of lanolin ointment will be found useful. 
 
 Cleanliness of the genital organs, at all times of 
 importance, is doubly so during the climacteric period, 
 for the reason that neglect in this respect is apt to 
 lead to the onset of genital pruritus. Not only after 
 defecation, but after each act of urination as well, the 
 external genital organs and the anus should be care- 
 fully washed over with a pad of clean absorbent wool 
 moistened with lukewarm water. After the washing, 
 either powder or ointment should be applied, the for- 
 mer in cases in which the skin of the parts is usually 
 damp from a natural tendency to excessive secretion, 
 the latter in cases in which the skin is dry and tends 
 to crack. 
 
 Bodily exercise, carefully selected and regulated, to 
 suit the individuality of each patient, is a powerful 
 means of relieving the disturbances of the menopause. , 
 Regular and methodical bodily exercise — to which, it 
 must be remembered, women at the climacteric period 
 commonly feel considerable aversion — manifests its 
 good ^effects in the form of improvement in the nutri- 
 
SEXUAL EPOCH OF THE MENOPAUSE 447 
 
 tive conditions and functional activity of all the organs, 
 and increased activity of all metabolic changes, which 
 are commonly sluggish in women at the change of life. 
 Moreover, muscular exercise, by increasing the volume 
 of blood passing through the muscles, has a beneficial 
 derivative influence in diminishing the congestion of 
 the brain and the other troublesome congestive symp- 
 toms which are liable to occur in women during the 
 menopause. Again, in cases of excessive obesity such 
 as so commonly occur in women at the change of life, 
 the increased combustion of fat promoted by regular 
 muscular exercise, cannot fail to have a beneficial effect. 
 Finally, suitably selected muscular exercise has a fav- 
 orable influence also upon the nervous system, the func- 
 tional activity of which it facilitates, while at the same 
 time it strengthens the powers of the will. 
 
 It is therefore of importance that at the time of the 
 menopause women should continue to undertake ap- 
 propriate active exercise, regular daily walks, which 
 should include walking up a moderate incline. As a 
 preparation for such exercise (in persons hitherto un- 
 accustomed to walk much), or in bad weather, or, 
 again, when there are special reasons against open-air 
 exercise, and finally as a supplementary exercise to 
 walking, gymnastics and massage may be employed. 
 Such gymnastic procedures are to be chosen as will 
 serve to deplete the vessels of the head, will have a 
 favorable influence upon the portal circulation, and 
 will withdraw the blood-stream from the pelvic organs ; 
 such are, in addition to general gymnastic exercises, 
 methodical deep breathing, methodical exercise of the 
 abdominal muscles, exercises involving the extensors 
 of the back and the abductors and external rotators of 
 the thigh, and exercises of the extremities. Various 
 gymnastic apparatus may be employed with advantage, 
 
448 THE SEXUAL LIFE OF WOMAN 
 
 and more especially those in which the various mjjs- 
 cular movements are effected against a resistance. 6ut 
 in all cases extreme care must be taken to avoid over- 
 fatigue and overexertion. A graduated form of bodily 
 exercise combined with passive gymnastics, suitable for 
 climacteric women, is massage, in which by mechani- 
 cal stimulation, by pressure and friction of the whole 
 body or of certain parts, the nutrition of the muscles is 
 favorably influenced, and the activity of the general 
 circulation is increased. In the use of massage also, in 
 climacteric women, all undue excitation of the nervous 
 system is to be carefully avoided, a mild form of this 
 powerful agent must alone be employed ; gentle stretch- 
 ing and rubbing of the skin of the lower extremities, 
 the back, and the abdomen, followed by gentle knead- 
 ing of the muscles. Massage of the internal reproduc- 
 tive organ (the method of Thure Brandt), in view of 
 the common tendency to sexual excitability in women 
 at the climacteric, is mentioned only to be prohibited. 
 For the same reason, and also on account bf the fre- 
 quency with which at the time of the menopause women 
 suffer from tachycardia and from other disorders of 
 the heart, bicycling is in most cases an unsuitable exer- 
 cise at this time of life. 
 
 A matter of great importance is the regulation of 
 the diet of women during this phase of life, the aim 
 of such regulation being one which the older physicians 
 sought to fulfil by means of venesection and wet cup- 
 ping, namely, to overcome the abnormality in the con- 
 stitution of the blood which arises from the cessation 
 of the internal secretion of the ovaries, and further to 
 relieve the symptom-complex of abdominal plethora 
 and the various passive hyperaemias and collateral con- 
 gestions; and in addition to subdue the great general 
 nervous irritability, the sensibility to external stimuli, 
 
SEXUAL EPOCH OF THE MENOPAUSE 449 
 
 the inclination to excessive reflex manifestations, char- 
 acteristic in women during the climacteric period. 
 
 The diet must be regulated in respect both of quality 
 and quantity, and it is obvious that the regulation must 
 be thoughtfully adapted to the needs of each individual 
 case. 
 
 'As regards quantity, the main general principle of 
 dietetics for climacteric women is that overnutrition 
 is to be avoided, that the quantity of nutriment must 
 be reduced to the absolute minimum necessary to supply 
 the needs of the tissues. In view of the fact that we 
 are concerned with women at a comparatively ad- 
 vanced period of life, whose physical labors are not, as 
 a rule, exhausting, that quantity of food will usually 
 be sufficient which is competent to furnish 35 to 40 
 calories per body-kilogram per diem. If we assume 
 that the mean body-weight of a woman at the climac- 
 teric age is 60 kilograms, the heat-equivalent of the 
 food required daily by such a woman may be esti- 
 mated at 2,100 to 2,400 calories. This will be approxi- 
 mately supplied by a diet consisting of 100 grams 
 albumin, 60 grams fat, and 350 grams carbohydrate. 
 The customary preference for a large amount of ni- 
 trogenous food is, however, not dependent upon physio- 
 logical requirements, and provided that the needful 
 minimum of albumin is supplied (about 1.5 grams per 
 body-kilogram per diem) , the requisite number of cal- 
 ories may be furnished by very various combinations 
 of the different nutritive elements. 
 
 The general principles of the qualitative regulation 
 of the diet of climacteric women are: first, that after 
 the necessary minimum of albumin has been supplied, 
 there shall be added an amount of carbohydrate and 
 of fat varying in relative proportions and quantities 
 according to the physiological requirements of the in- 
 
460 THE SEXUAL LIFE OF WOMAN 
 
 dividual, but taken together sufficient to supply the 
 necessary heat-equivalent; secondly, that there should 
 be an abundant consumption of water; thirdly, that 
 stimulating, dietetic adjuvants should, as far as pos- 
 sible, be avoided. 
 
 The nitrogenous equilibrium of the body may be 
 maintained either by animal or by vegetable proteids; 
 in the case of the former (animal albumins), the cli- 
 macteric woman should avoid those containing con- 
 siderable quantities of nucleo-albumin or of deleterious 
 products of tissue-change; in the case of the latter 
 (vegetable albumins), she should avoid those likely 
 to cause undue stimulation of the intestinal tract. Of 
 flesh foods (mammals, birds, and fishes), those kinds 
 are to be preferred which contain small quantities only 
 of extractives (kreatin, xanthin, etc.), since these sub- 
 stances are supposed to have a stimulating influence 
 upon the nerves and the heart. Hence, boiled meat is 
 better than roasted, and the flesh of young animals 
 (veal, for instance) and fish are to be preferred to 
 game, and the last-mentioned is to be avoided especially 
 for this reason, that the flavors for which it is valued 
 by the gourmet are products of partial decomposition 
 arising from prolonged hanging; for similar reasons, 
 meat extracts, animal soups, sausages, smoked flesh 
 and fish, and preserved (potted) meats, should all be 
 avoided. From the intimate connection between the 
 ingestion of nuclein and the formation of uric acid, 
 albumins rich in nuclein are to be forbidden; such are 
 the various foods consisting chiefly of gland-cells — 
 «weatbread, liver, brain, kidneys, etc. As well as from 
 the appropriate flesh-foods, the requisite albumin may 
 most suitably be obtained from eggs and milk (includ- 
 ing buttermilk) ; on the other hand, caviare is unsuit- 
 able owing to its stimulant action on the genital organs, 
 
SEXUAL EPOCH OF THE MENOPAUSE 451 
 
 cheese because it contains large quantities of the 
 products of decomposition of casein and milk-fat; the 
 fermented milks, koumiss and kefir, are likewise un- 
 suitable. Suitable vegetable foods for the supply of 
 albumin (in addition to carbohydrates) are porridge, 
 bread, and the leguminosae; nuts, on the other hand, 
 cause too much irritation of the stomach and intestines. 
 
 For women during the climacteric period we recom- 
 mend a mixed diet moderate in quantity; the amount 
 of flesh and fat in the diet should not be large, whilst 
 cereals, green vegetables, and fruit may be taken in 
 greater abundance; irritant vegetable foods must be 
 avoided, and especially those which tend to stimulate 
 unduly intestinal muscular activity and intestinal secre- 
 tion. It is important that an abundance of water should 
 be taken, not less than two or three pints daily, and 
 a pure, fresh, spring water is preferable to the aerated 
 waters, natural or artificial. Alcoholic beverages are 
 to be avoided, and more especially those which are rich 
 in extractives as well as in alcohol. For this latter 
 reason, beer and champagne are harmful, whilst spirits 
 and liquors are to be condemned on account of the high 
 percentage of alcohol they contain. The stimulating 
 alkaloidal drinks, tea and coffee, are also to be avoided, 
 or if taken at all, only in a very dilute form. With 
 regard to the preparation of the food, the cardinal 
 principle is that it should be as little irritant as pos- 
 sible; neither mechanically irritating the alimentary 
 tract by an excess of indigestible or undigested residue, 
 nor irritating it chemically by an excessive admixture 
 of sugar, salt, vinegar, pepper and other spices; nor, 
 finally, giving rise to thermal irritation by being ex- 
 cessively hot or extremely cold. 
 
 The individual meals are preferably small ones and 
 they must therefore be taken at comparatively short in- 
 
452 THE SEXUAL LIFE OF WOMAN 
 
 tervals, five times daily, the principal meal being taken 
 at one or two o'clock in the afternoon, and the supper 
 (which should be small) comparatively early, at seven 
 or eight o'clock.^ 
 
 Suitable articles of food are the following: 
 
 Soups, Broths, and other Liquid Foods: Soups and 
 broths made from the flesh or bones of beef, mutton, 
 veal, chicken, or pigeon, without the addition of meat 
 extract, or of meat juices, peptones, somatose or nu- 
 trose, but with the addition of barley, oatmeal, rice, 
 wheatmeal, ryemeal, peas, beans, lentils, vermicelli, or 
 macaroni; also broths or porridge made from any kind 
 of ground cereal, or from potatoes, or from peas, beans 
 or lentils. 
 
 Flesh Foods: Lean beef, veal, mutton, roast or 
 boiled, pigeon, chicken; certain fresh fish — pike, had- 
 dock, sole, perch, and trout. Unsuitable are: pork, 
 goose, eels, salmon, herrings, oysters, caviare, lobster, 
 crab, smoked meat, hare, venison, wild-duck, brain, 
 liver, kidneys. 
 
 Vegetables, Sweets and Savories: Green peas, spin- 
 ach, cauliflower, carrots, turnips, buttered eggs, ome- 
 lette, boiled and baked puddings, rice boiled in milk, 
 apples and rice, whipped cream, salads, wheaten bread, 
 French rolls, biscuits, and rusks. 
 
 Fruits : Almost all fruits may be taken, raw, cooked, 
 or preserved; also in the form of currant and other 
 fruit cakes, and as fruit-ices.- 
 
 Beverages : Milk, buttermilk, water, the same acidu- 
 lated with various fruit-juices and essences (as lemon- 
 
 1 In his discussion of the details of diet for women during the 
 climacteric period, hours of meals, actual dishes, etc., the author refers ex- 
 clusively to Austrian and German customs in these matters. The trans- 
 lator has not attempted to adapt the following pages to the needs of 
 English readers, as he feels that the general principles already given will 
 enable the English medical man to construct without serious difficulty 
 suitable diet-tables for the cases with which he has to deal. 
 
SEXUAL EPOCH OF THE MENOPAUSE 463 
 
 ade, etc.), weak tea with plenty of milk, cocoa, choco- 
 late. To be forbidden are: beer, strong and sweet 
 wines, distilled spirits. 
 
 An example is subjoined of a simple diet-table com- 
 piled on the above principles: 
 
 Quantity Carba- 
 rn grains. Albumin. Fat, hydrate. 
 Afternoon : 
 
 A cup of mUk ISO 5.4 5.4 7.5 
 
 Roll and butter 70 4.9 0.4 39.2 
 
 Middle of Morning : 
 
 Soup 100 1.1 1.5 5.7 
 
 Roll 70 4.9 0.4 39.2 
 
 Mid-Day Meal: 
 
 Soup 100 1.1 1.5 5.7 
 
 Roast meat 100 38.2 1.7 
 
 Green vegetables 100 1.6 0.4 8.4 
 
 Pudding 200 17.4 30.0 57.8 
 
 Fruit 100 3.0 .... 15.0 
 
 Bread 35 2.4 0.2 19.0 
 
 Breakfast : 
 
 A cup of milk .-. 150 5.4 5.4 7.5 
 
 Roll 70 4.9 0.4 39.2 
 
 Supper: 
 
 Soup 100 1.1 1.5 5.7 
 
 Two soft eggs 90 11.2 10.8 0.4 
 
 Bread 70 4.9 0.4 39.2 
 
 Fruit 100 3.0 .... 15.0 
 
 Total 1.617 110.5 69.9 304.5 
 
 In addition, water, ad libitum, and perhaps a little light wine. 
 
 In many cases, however, a mainly vegetarian diet 
 may be more suitable, and more particularly a mainly 
 fruit diet, in order to diminish persistent congestive 
 
454 THE SEXUAL LIFE OF WOMAN 
 
 symptoms. In such cases the following diet-table may 
 be recommended for short periods: 
 
 First breakfast: An apple and an orange. 
 
 Second breakfast: 25 grams of white bread with 
 butter and three baked apples. 
 
 Dinner (mid-day) : 100 grams fish or meat, potatoes, 
 green vegetables, three boiled or baked apples. 
 
 Afternoon: An orange, or an apple, or a pear, or 
 some grapes. 
 
 Supper: Milk, apples and rice, oranges, grapes, figs. 
 
 Beverages: Water, with or without fruit juices or 
 essences. 
 
 Changes in the above diet-table could very readily 
 be effected, whereby the quantity of carbohydrate could 
 be increased and the quantity of albumin lessened. 
 
 In women of sanguine temperament and full habit 
 of body, who at the time of the menopause very rapidly 
 become obese, important changes in the diet become 
 necessary. The main principles of a fat-reducing diet 
 are the foUowing: Avoidance of all overfeeding, re- 
 duction of the quantity of food taken below the former 
 average amount, with retention, however, of a suffi- 
 ciency of nutrient material to maintain the metabolic 
 equilibrium of the essential tissues; the maintenance of 
 this metabolic equilibrium demands a sufficiency of 
 nitrogenous foods, but the fats in the diet may be re- 
 duced to a minimum, and the carbohydrates may also 
 be very greatly diminished. At the same time, there 
 must be systematic bodily exercise, and the hours of 
 sleep must not exceed a nightly average of seven. 
 
 For obese women at the climacteric period, a suit- 
 able average diet would contain 160 grams albumin, 
 12 grams fat, and 120 grams carbohydrate, yielding a 
 daily heat-equivalent of 1,250 to 1,300 calories. 
 
SEXUAL EPOCH OF THE MENOPAUSE 455 
 
 A' sample diet-table constructed on these principles 
 is appended: 
 
 ~> Quantity Carbo- 
 
 Breakfast: '" ^'■''""- ^'^'""*"- ^'"- *^''''''"- 
 
 A cup of weak tea. . . ; 150 0.45 ^ 
 
 with milk, but no 
 
 „ sugar 30 1.29 0.9 1.2 
 
 White bread 50 4.8 0.4 30.0 
 
 Lean cold meat SO 19.1 0.9 
 
 Dinner (Mid-Day) : 
 
 Sniall cup of clear soup lOO 1.1 1.5 57 
 
 Lean beef 200 76.4 3.4 
 
 Green vegetables, salad, 
 
 etc 100 1.6 0.4 8.4 
 
 Fruit 100 3.0 .... 15.0 
 
 Roll 35 2.4 0.2 19.6 
 
 f 
 
 Afternoon : 
 
 A cup of weak tea 150 0.45 .... 0.9 
 
 with milk, but no 
 sugar 30 1.29 0.9 1.2 
 
 Supper: 
 
 Soup 100 1.1 1.5 5.7 
 
 Lean roast meat 100 38.2 1.7 
 
 Roll 50 4.8 0.4 30.0 
 
 Total 1,245 155.9 13.2 118.6 
 
 In the selection of individual articles of diet, it is 
 important to bear in mind the fact that in all cli- 
 macteric women it must be our aim to stimulate in- 
 testinal muscular activity (peristalsis) and intestinal 
 secretion to a moderate extent, for by more active 
 intestinal secretion abdominal congestion is to some 
 extent relieved, and by intestinal transudation and by 
 diminution of the lateral pressure the circulation 
 through the abdominal vessels is facilitated. By thus 
 lowering the intra-abdominal blood-pressure, we shall 
 
456 THE SEXUAL LIFE OF WOMAN 
 
 assist in relieving a number of chronic hyperaemic, 
 states of the pelvic and various other organs, from 
 which women are prone to suffer at the menopause. 
 Hence all articles of diet must be forbidden ^which- 
 have a tendency to give rise to constipation. But we 
 must also forbid all substances which leave extensive 
 undigested residues, such as the rinds of fruits, large 
 quantities of porridge, etc., hard meats, nuts, and the 
 like. 
 
 Most suitable are those articles of diet which con- 
 tain large percentages of fluid constituents, such as milk, 
 thin soups, weak tea (infused only a short time, so as 
 to contain little tannic acid, which is very consti- 
 pating) , white meat — ^veal, breast of chicken, etc. Of 
 vegetables, those are best which contain plenty of water 
 and an abundance of the organic acids, young, fresh 
 garden produce, lettuce, cauliflower, young green peas, 
 young carrots, turnips, etc. Juicy fruits are good, 
 apples, pears, cherries, and plums. Butter and honey 
 are also excellent. In many persons suffering from 
 constipation, all that is necessary for their relief is to 
 give a tumblerful of cold water the first thing in the 
 morning; -with others, the use in addition of whole- 
 meal bread with plenty of butter and honey and un- 
 cooked fruit, is required. 
 
 In women suffering from the various disturbances 
 of the climacteric period in an aggravated form, either 
 because the menopause occurs at an unusually early 
 age, or because the suppression of menstruation has 
 taken place suddenly instead of gradually — especially 
 in cases of heart-trouble, severe vertigo, pronounced 
 vasomotor disturbances, or mental excitement (also 
 erotic excitement) , I have sometimes found a methodi- 
 cal milk-cure carried on for several weeks most bene- 
 ficial. By this I do not mean an exclusive diet of 
 
SEXUAL EPOCH OF THE MENOPAUSE 46T 
 
 milk, but a diet consisting chiefly of milk and milk- 
 foods. Owing to the absence of all irritation of the 
 nervous and vascular systems, this diet has a very defi- 
 nite sedative influence in such cases. The milk should 
 be skimmed, and should be given four times daily in 
 gradually increasing quantities, the total amount rising 
 from ten ounces to fifty ounces daily. The only other 
 meal should be a substantial midday dinner, consisting 
 of soup, roasted white meat, young green vegetables, 
 and a little fruit. In some instances, to prevent con- 
 stipation, it is necessary to add ten grams of milk sugar 
 to each glass of milk; in other cases it is necessary to 
 dilute the milk with water. It is obvious that the 
 quantity of milk given is not alone sufficient to main- 
 tain the metabolic equilibrium of the body; but the 
 defect in this respect is made up by the substantial meal 
 given at mid-day. 
 
 'Among the stimulating influences which during the 
 sexual epoch of the menopause are as far as possible 
 to be avoided we must unhesitatingly include the prac- 
 tice of coitus, inasmuch as at this time of life there 
 already exists a strong tendency toward occurrence 
 of hyperaemia of the reproductive organs; and sexual 
 intercourse, increasing as it inevitably must this ten- 
 dency to hyperaemia, should be indulged in as little 
 as possible. And yet precisely in women of the cli- 
 macteric age, in "la femme demi-vieille" there often 
 exists a strong desire to drain the cup of sexual pleasure 
 to its dregs. Not infrequently, therefore, the physician 
 is asked to advise regarding the proposed marriage of 
 a woman in whom the menopause is drawing near, the 
 desired husband being young, or at least still fully 
 virile. If the advice is given in all sincerity with a 
 sole eye to the woman's health, the medical man will 
 definitely forbid the marriage. 
 
458 THE SEXUAL LIFE OF WOMAN 
 
 When, however, the changes of the menopause are 
 fully completed, when the woman's reproductive 
 organs have undergone complete senile atrophy, there 
 is no medical reason why a couple who wish to give 
 a tenderer name to an intimate friendship between 
 man and woman, should refrain from marriage — pro- 
 vided that both have attained a like stage of sexual 
 decline. "But," writes Tilt, "a union between frosty 
 January and bloomiag May is likely to be as danger- 
 bus to the health as it is to the happiness of both." 
 
 Whilst attending to the regulation of the physical 
 diet of his climacteric patient, the physician should 
 not overlook her psychical regimen. A woman's mind 
 is very powerfully affected by the processes of the 
 menopause. On the one hand, her fears are stimulated 
 by the thought that she is entering upon the "critical 
 age," of whose dangers she has often been warned; 
 and, on the other hand, she is mentally depressed by 
 the knowledge that she is about to lose the charms of 
 womanhood, and to decline in sexual esteem. It is 
 well, therefore, for women during the years of change 
 to have some kind of employment, which fills their 
 hours, occupies their thoughts, and — leaves a certain 
 scope for the exercise of feminine vanity. Works of 
 benevolence or of general utility, and literary occu- 
 pation, are thus of great advantage to climacteric 
 women. Plato, indeed, pointed out that women at this 
 time of their lives should occupy themselves with liter- 
 ature and intellectual culture. 
 
 Just as it is the duty of the physician, more especi- 
 ally of the family physician, to enlighten the maiden 
 on the threshold of her sexual development regarding 
 the processes of the awakening sexual life, and to give 
 her the necessary instruction concerning the hygienic 
 measures which it is proper for her to adopt — so also 
 
SEXUAL EPOCH OF THE MENOPAUSE 459 
 
 is it his duty to convey medical information to the 
 woman who stands on the threshold of sexual deca- 
 dence. A woman's ignorance is often equally profound 
 at both these epochs of the sexual life. A woman in 
 the early forties often does not suspect, or at least 
 refuses to acknowledge, that she is gradually drawing 
 near to the end of her sexual life; and she is still 
 farther from the knowledge that definite rules of 
 general and sexual hygiene must be observed by her 
 if she wishes to minimize the dangers of the critical 
 period. 
 
 The medical friend, in an earnest though far from 
 gloomy manner, will expound to her the nature of 
 the physiological processes of the menopause, and will 
 instruct her regarding the corresponding preventive 
 measures — diet, exercise, clothing, care of the skin, and 
 the regulation of sexual intercourse. Moreover, the 
 physician, by means of skilfully directed inquiries re- 
 garding certain symptoms, will be enabled to gain early 
 information about the occurrence of abnormal pro- 
 cesses at this period of life, and will in this way detect 
 the first beginnings of many diseases which are amena- 
 ble to treatment only at the very outset of their course. 
 For example, Brierre de Boismont, an early and ac- 
 curate observer of this sexual epoch in the life of 
 woman, points out that in cases in which, during the 
 change of life, a woman experiences an increased in- 
 clination for sexual intercourse, nineteen times out of 
 twenty a local examination will disclose the existence 
 of some disease of the reproductive apparatus. Simi- 
 larly, every gynecologist is now familiar with the fact 
 that unusually free, atypical haemorrhages during the 
 climacteric period, are commonly indications of the 
 existence of a uterine neoplasm. 
 
 Much evil may be avoided, and much suffering can 
 
460 THE SEXUAL LIFE OF WOMAN 
 
 be diminished if the physician, in accordance with the 
 advice of Hippocrates, does not limit his activities 
 strictly to the exercise of the healing art, but stands by 
 a woman's side as her mentor and confidant during the 
 troublesome years of her sexual decline. 
 
INDEX 
 
 Abdominal plethora, 143 
 Abortifacients, 177 
 Abortion, 288 
 
 artificial, 254 
 
 induction of, 258 
 Abuse of alcohol, 240 
 Accumulation of fatty tissue, 342 
 Acne, 104 
 
 nodules, 159 
 Acromegaly, 82 
 Active congestion, 442 
 Acute delirium, 438 
 Adenomata, 299 
 Aerated waters, 451 
 Esthetic feelings, 55 
 Africa, 41 
 Age of parents influences vitality of 
 
 children, 235 
 Agricultural chemistry, 260 
 
 labor, 245 
 Albumin, animal, 450 
 
 in the urine, 394 
 Albuminuria, 69, 371 
 Alcohol, 95, 109, 190, 238, 298, 302, 
 
 423, 451 
 Alcoholism, 294 
 Alkaloidal drinks, 451 
 Alternating insanity, 437 
 Amenorrhoea, 275, 297, 299, 386 
 
 functional, 60 
 Amentia, 434, 435 
 America, 41 
 Amor lesbicus, 223 
 Anaemia, 294, 302, 395, 433 
 Anaemic women, 378 
 Anaphrodisia, 207 
 Anaphrodisiacs, 174 
 Anatomico-physiological changes, 54 
 Angina pectoris, 395 
 Angst, 388 
 Animal soups, 450 
 Antipathy to husband, 212 
 Anthropoid apes, 146 
 Anus, fissure of, 317 
 
 fistula of, 317 
 
 prolapse of, 317 
 Anxiety, 388 
 
 neurosis, 278 
 Apathy of the sexual sense, 59 
 Apoplexia uteri, 364 
 Apoplexy, 437 
 
 Apples, 452 
 
 Archangel, 103 
 
 Ardor fugax, 391, 399, 407 
 
 Arrhythmia cordis, 404 
 
 Arteriosclerosis, 396 
 
 senile, 383 
 Arthritis, acute gouty, 414 
 
 urica, 411, 413 
 Artificial feeding of infants, 195 
 
 menopause, 346 
 Ascarides, 317 
 Asia, 40 
 Asparagus, 96 
 Atresia, 322, 363 
 Atrophic changes, 340 
 
 conditions, 354 
 Atrophy of ovaries, 298 
 
 uterus, 279 
 Ausfallserscheinungen, 362 
 Auto-onanist, 113 
 Azoospermia, 293, 330 
 
 Balls, 108 
 Barley, 452 
 Barrenness, 283 
 Baths, 100, 439 
 Bavarian beer, 96 
 Beans, 95, 452 
 Bearing-down in pelvis, 212 
 Beaute du diable, 19 
 Beauty, 17 
 
 of the devil, 19 
 Bedding, soft, 190 
 
 warm, 190 
 Bedroom, 187 
 Beef, lean, 452 
 Beefsteak, 96 
 Beer, 95, 451, 453 
 
 Beneficial influence of marriage, 139 
 Bicycling, 99, 109, 448 
 Biliary secretion, 405 
 Birds, 450 
 Biscuits, 452 
 Bleeding piles, 317 
 Blennorrhoea, 329 
 Blindness, 251 
 Blondes, 44, 375 
 Boer women, 237 
 Books, 108 
 Bowels, 109 
 
 461 
 
462 
 
 INDEX 
 
 Brain, 450 
 
 diseases of, 218 
 Bread, 451 
 
 Breast of chicken, 456 
 Breeding in-and-in, 242 
 Bridal night, 179 
 Brides, age of, 147 
 Broths, 452 
 Brunettes, 44, 375 
 Bubonic plague, 8 
 Bulbocavernosus muscle, 209 
 Butter, 96, 456 
 Buttered eggs, 452 
 Buttermilk, 450 
 
 Cachexia, malarial, 298 
 Caged birds, 304 
 Cannibalism, 257 
 Cantharides, 144, 173 
 Capet dynasty, 243 
 Carcinoma, 299, 354 
 
 uterine, 192, 280 
 Carcinomatous diseases of matnmse, 
 351 
 
 ovaries, 351 
 
 uterus, 35t 
 Cardiac disorders, 70, 75, 397 
 
 hypertrophy, 75 
 
 asthma, 393, 395 
 
 insufficiency, 393, 395 
 
 failure, 397 
 
 troubles, 371 
 
 troubles due to sexual intercourse, 
 203 
 Cardialgias, 279, 417, 419 
 Cardiopathie de la Menopause, 401 
 Carrots, 452, 456 
 Caseous diseases, 299 
 Castration, 257 
 Catalepsy, 427 
 Cauliflower, 96, 452, 456 
 Caviare, 450 
 
 Celibate, religious orders, 138 
 Central perceptions, 142 
 Centripetal impulses, 143 
 Cephalalgias, 279, 433 
 Cereals, 451 
 Cerebral anxmia, 417 
 
 apoplexy, 420 
 
 excitement, 142 
 Cervical lacerations, 335 
 Cessatio praecox, 379 
 Chaliza, 249 
 
 Chalybeate peat baths, 102 
 Chamomile, 103 
 Champagne, 173, 451 
 Change of life, 340 
 Changes in refraction, 127 
 Chastity, 6, 112, 273 
 Cheese, 451 
 
 Chemical processes, 50 
 
 Cherries, 456 
 
 Chicken, 96, 452 
 
 Childless wife, 344 
 
 Chloasma uterinum, 411 
 
 Chlorosis, 65, 68, 103, 140, 192, 294, 
 
 302, 395, 400 
 Chocolate, 96, 453 
 Cholera, 381, 386 
 Chorea, 78, 427 
 Clap-threads, 186 
 Cleanliness, 116, 187 
 Climacteric age, 341 
 
 insanity, 423 
 
 insanity pseudo menstrual, 434 
 
 manifestations, duration of, 376 
 
 neurosis, 398 
 
 period, 340 
 
 psychoses, 423 
 
 vertigo, 398 
 Climate, 34 
 
 Climatic conditions, 103, 240 
 Climax, 340 
 Clitoris, 208 
 
 crises, 213 
 
 hypertrophy of, 316 
 Clothing, 99, 109 
 Coccus, 365 
 Cocoa, 96, 453 
 Coffee, 96, 109, 451 
 Coitus, awkward performance of, 216 
 
 condomatus, 212 
 
 incomplete performance of, 216 
 
 interruptus, 203, 212, 265 
 
 prohibitive, 352 
 
 reservatus, 204, 212 
 
 too frequent, 335 
 
 ungratifying, 212 
 
 unsympathetic, 212 
 Cold bathing in rivers, 100 
 
 full baths, 190 
 Combination undergarment. 111 
 Comedones, 93, 104 
 Complete frigidity, 138 
 Concentric atrophy, 363 
 Conception, 195, 196 
 
 curve, 201 
 
 time of, 227 
 Concubines, 175 
 Conditions of life, 34 
 Condoms, 277 
 Congenital atrophy, 296 
 Congestions, 371 
 
 of the head, 349 
 
 of the lungs, 394 
 Congfu, 314 
 
 Congressus interruptus, 275 
 Constancy, 181 
 Constipation, 109, 349 
 Constitution, 34 
 Constricted liver, 110 
 
INDEX 
 
 463 
 
 Constrictor cunni, 204, 209 
 
 muscle, 209 
 Continence, 270 
 
 Continuous nocturnal proximity, 176 
 Contrectation-impulse, 140 
 Convulsive seizures, 128 
 Convulsions, 279 
 Copulation, 195 
 Corpora albicantia, 365 
 
 fibrosa, 365 
 
 lutea, 384 
 Corset, 110 
 Counterfeit of voluptuous enjoyment, 
 
 211 
 Country-folk, 52 
 Crabs, 452 
 
 Cramps of the heart, 76 
 Cream, 452 
 
 Criminality in the married, 140 
 Critical age, 340, 458 
 
 period, 341 
 Croquet, 99 
 Crossing of races, 172 
 Cry of the su£Eering organ, 22 
 Curettage, 3^ 
 Currant cakes, 452 
 Curve of beauty of woman, 20 
 Curve of the sexual life of woman, 5 
 Cystoma, 299 
 
 ovarian, 300, 301 
 Cysts, 363 
 
 dermoid, 299 
 
 follicular, 299 
 
 Dangers of the sexual life of woman, 
 
 183 
 Deafmutism, 251 
 Debility, 433 
 
 Deficient reproductive energy, 292 
 Delirium, 425, 427 
 Delusions, 432 
 Dementia, 79 
 Demi-Vieilks, 347 
 
 -vierge, 9, 52 
 Desire for children, 132 
 
 of carnal union, 132 
 Dermatitis, 409 
 Desque's diet-table, 118 
 Detumeszenztrieb, 140 
 Detumescence-impulse, 140 
 Developmental disturbances, 66 
 Diabetes, 250, 298 
 
 climacteric, 414 
 
 mellitus, 414 
 Diarrhoea, 371, 404, 442 
 Dicrotic elevation, 389 
 Diet, 190 
 
 tables, 117, 118, 119, 453, 455 
 Dietetics of parturition, 195 
 
 pregnancy, 195 
 
 Difference between ages of husband 
 
 and wife, 233 
 Differences in temperature during the 
 
 menstrual cycle, 13 
 
 Digestion, disorders of, 88 
 
 Digestive disturbances, 349 
 
 organs, diseases of, 404 
 
 Dilatation of the heart, 403 
 
 small cutaneous vessels, 159 
 Diplococcus, 365 
 Dipsomania, 437 
 Discus proligerus, 306 
 Disorders of the climacteric, 362 
 Disparity in ageSj 165 
 Dissimilarity in physical constitution, 
 
 244 
 Distilled spirits, 453 
 Domestic recreations, 108 
 
 upbringing, 107 
 Domesticated breeds of animals, 236 
 Double chin, 342 
 Douches, 100 
 Down quilts, 190 
 Dropsy, 354 
 Dwellings, 187 
 Dysentery, chronic, 299 
 Dysmenorrhoea, 63, 125 
 Dyspareunia, 206, 216, 309, 346 
 Dyspepsia, 128, 371 
 uterine, 391 
 
 Early love, 286 
 
 senescence, 380 
 Ecchymoses, 92 
 Eczema, 94, 144, 159, 371, 408, 411, 
 
 440 
 Educational views of the present, 107 
 Eels, 452 
 Eggs, 95, 450 
 Ejaculation, 209, 213 
 
 prsecox, 212 
 Electric light baths, 443 
 Electricity, 436 
 
 Elongation of the cervix uteri, 279 
 Emancipated woman, 184 
 Embonpoint, 413 
 Embrace, 196 
 Embryo, 282 
 Emigration, 265 
 Encephalitis atheromatosa, 438 
 Endocervicitis, 375 
 Endogamy, 250 
 Endometritis, 212, 3^,375 
 Enduring sexual activity, 382 
 Enervating mode of life, 240 
 Enforced abstinence, 214 
 Enlargements, 354 
 Enlightening the daughter, 114 
 Entertainments, 108 
 Environment, 51 
 Epididymitis, 186 
 
464 
 
 INDEX 
 
 Epilepsy, 251, 371, 437 
 Epistaxis, 349, 35S, 371, 442 
 Equivocal literature, 190 
 Erethismus genitalis, 143 
 Erethistic temperament, 400 
 Erotic excitement, 456 
 
 feeling, 151 
 
 harmony, 151 
 
 problem, 164 
 
 stimulus, 342 
 Eroticism, 435, 437 
 Eructation, 405 
 Erysipelas, 410 
 Erythema, 159, 407 
 Ethnography, 250 
 Eunuchs, 177 
 Europe, 38 
 Evening parties, 108 
 Evolution, 281 
 
 Exhausting occupations diminish fer- 
 tility, 237 
 Excentric atrophy, 364 
 Excito-motor fibres, 391 
 Exhibitionism, 437 
 Exogamy, 250 
 
 Experimental cohabitation, 311 
 Extractives, 450 
 Eye, affections of, 90 
 
 Figs, 454 ■ 
 
 Figure, woman's, 110 
 First cousins, 169 
 .: marriage, 243 
 Fish, 96, 450 
 
 diet, 239 
 Fistulae, recto-vaginal, 217 
 
 vesico-vaginal, 217 
 Fixed ideas, 79 
 Flesh foods, 450, 452 
 Flexions, 421 
 Fliegende Hitze, 349, 355 
 Fluor albus, 212. 223 
 Fluxes, haemorrnagic, 354 
 
 mucous, 354 
 Free love, 160 
 
 marriage, 155 
 Freedom for love, 154 
 
 in love, 154 
 French rolls, 452 
 
 Frequency of sexual intercourse, 181 
 Fruits, 95, 451 
 Fruit cakes, 452 
 Fruit-ices, 452 
 Fugitive heat, 349, 355, 388, 399, 407, 
 
 442 
 Furuncles, 371 
 Furunculosis, 410 
 
 Fainting fit, 81 
 Famine, 265 
 
 restrains progeny, 237 
 Farinaceous foods, 96 
 Fat-coMtainin|r foods, 96 
 Fat, increase in, 68 
 
 reducing diet, 454 
 
 rump, 343 
 Feather beds, 99, 190 
 Female reproductive organs, changes 
 
 in, 358 
 Feminine sense of delicacy, 259 
 fertility, conjugal, 245 
 
 extraconjugal, 245 
 
 ideal, 226 
 
 in woman, 224 
 
 of married women, 229 
 
 premature, 225 
 
 restriction of, 253 
 Fertility of women, biogenous, 232 
 
 influence of climate, 240 
 
 influence of constitution, 244 
 
 Influence of season, 240 
 
 influence of temperament, 244 
 
 maximum, 231 
 
 monogenous, 232 
 
 physiological, 230 
 Fertilization, 197, 291, 307 
 Fertilized ovum, 252 
 Fibromata, 299, 421 
 Field fare, 96 
 
 Galactorrhcea, 3S1 
 Game, 450 
 
 Gastric innervation, 407 
 General mode of life, 240 
 
 hygiene during acme of sexual ac- 
 tivity, 187 
 
 constitutional conditions, 374 
 
 pathological conditions, 374 
 Genital corpuscles, 208 
 Genitals, diseases of, 377 
 
 pruritus, 446 
 
 trauma of, 379 
 Germans, 7 
 
 Germinal rudiments, 251 
 Glottis, spasm of, 129 
 Goitre, 89 
 
 Gonocoecus, 186, 325 
 Gonorrhoea, 186 
 Gonorrhoeal infection, 149, 160 
 Good harvests increase childbirth, 237 
 Goose, 452 
 Gout, 411 
 Grapes, 454 
 
 Gratification, sexual, 219 
 Greeks, 7 
 Green peas, 456 
 Green vegetaMes, 451 
 Grief, 218 
 Grouse, 96 ' 
 Gymnastics, 109, 447 
 Gynecological examination, 106 
 
INDEX 
 
 465 
 
 Habitual excess, 278 
 Haddock, 452 
 Hamatemesis, 130, 405 
 Haematometra, 322 
 Hxtnatopoiesis, disorders of, 65 
 Haemoptysis, 130 
 Haemorrhage, 129 
 
 atypical uterine, 222 
 
 into the skin, 92 
 Haemorrhoidal bleeding, 386, 442 
 
 flux, 349, 355 
 
 hyperplasia, 410 
 Haemorrhoids, 405 
 Hair mattress, 99, 190 
 Half-old, 347 
 
 virgin, 9, S3 
 Hallucinations, 425, 432 
 Ham, 96 
 
 Hapsburg-Lothringen djTiasty, 243 
 Hardships diminish fertility, 237 
 Hare, 96, 452 
 Harmonic d'amour, 311 
 Hazel-hen, 96 
 Headache, 357 
 
 Hearing, disturbances of, 91 
 Heart-trouble, 456 
 Hebephrenie, 79 
 Hemicrania,127,-417 - 
 Hereditary influences, 294 
 Hermaphrodites, 177, 284 
 Herpes progenitalis, 94 
 
 zoster, 410 
 Herring, 452 
 Hetairai, 175 
 Hiccough, 128 
 High altitudes, 104 
 Higher civilization, 261 
 Homicide, 437 
 Homosexual women, 316 
 Honey, 456 
 Honeymoon, 179 
 Hot-air baths, 101 
 Hottentot women, 238 
 Housewife, 7 
 Hyaline degeneration, 364 
 Hydrometra, 322 
 Hydrotherapeutics, 100, 439 
 Hygiene during the menarche, 95 
 
 of marriage, 166 
 Hyperaemia, 125, 276, 355 
 
 chronic, 279 
 Hyperaesthesia, 391, 406, 414, 440 
 Hyperhydrosis, 406 
 Hyperkinesia, 391, 406, 414 
 Hyperplasia, 299, 323 
 Hypnotic state, 314 
 Hypnotism, 436 
 Hypochondriacal moods, 425 
 Hypochondriasis, 427 
 Hypogastric neuralgia, 417 
 Hyssop, 103 
 
 Hysteria, 80, 192 
 
 pure, 213 
 Hysterical attacks, 357 
 
 paroxysms, 27,9 
 
 troubles, 128 
 Hystero-epileptic crisis, 81 
 
 neurasthenic, 212 
 
 Icterus, 405 
 
 Idea of persecution, 431 
 
 Ideal passion, 32 
 
 Ideas of sexual persecution, 436 
 
 Ideational influences, 424 
 
 Idiocy, 251 
 
 Idiopathic neurosis, 410 
 
 Ill-nature, 345 . 
 
 Impetigo herpetiformis, 159 
 
 Impotence in husband, 283 
 
 Impotentia concipiendi, 322 
 
 generandi, 321 
 
 gestandi, 320, 323 
 Impulse to sexual satisfaction, 142 
 
 toward copulation, 132 
 
 toward intimate contact, 140 
 
 toward motherhood, 131 
 
 toward reproduction,- 132 
 ■ aiigratified .sexual; 191 : . .' 
 
 Impulsive insanity, 427, 437 '' 
 Inbreeding, 242 
 
 Incapacity for jticubation ' of the 
 ovum, 318 
 
 ovulation, 305 
 Incest, 243 
 
 Incontinence during menstruation, 185 
 Individual nutritive elements, 238 
 Indurations, 354 
 Infanticide, 167, 258, 437 
 Infective fever, 338 
 
 puerperal processes, 377 
 Infibulation, 257 
 Inflammatory processes, 63 
 Influence of lactation, 228 
 Inheritance, 35 
 Inhibitory influence, 210 
 
 perceptions, 210 
 
 process, 210 
 Innate sexual disharmony, 312 
 Innuptae nuptae, 283 
 Insanity, 251 
 
 in unmarried women, 191 
 
 in the male sex, 191 
 Instinctive criminality, 251 
 Intellectual culture, 458 
 
 processes, S0_ 
 Intercourse during lactation, 185 
 Intermenstrual pain, 128 
 Intrapelvic disorders, 295 
 Intrigue, 345 
 Introduction, 1 
 Irish baths, 443 
 Iron-beer, 96 
 
466 
 
 INDEX 
 
 Irritable breast, 418 
 Irritant phenomena, 340 
 Ischiocavernosus muscle, 209 
 
 Jealous delusions, 437 
 
 emotions, 437 
 Juicy fruits, 456 
 June weddings, 241 
 
 Kaffir women, 237 
 Katatonia, 83 
 Kefir, 451 
 Kidneys, 450 
 Kiss, 196 
 Kleptomania, 437 
 Kongfou, 275 
 Kontrektationstrieb, 140 
 Koumiss, 451 
 Kreatin, 450 
 
 Labium majus, 208 
 
 minus, 208 
 Lacerations of hymen, 178 
 Lacing^ liver, 110 
 Lactation atrophy, 378 
 La femme demi-vieille, 457 
 Lascivious dramatic representations, 
 190 
 
 dreams, 435 
 Lassitude, 277 
 Lawn tennis, 99, 109 
 Legumes, 451 
 Lemonade, 452 
 Lentils, 95, 452 
 Leprosy, 8 
 Lettuce, 456 
 
 Leucorrhcea, 130, 316, 357, 385, 442 
 Levisticum, 103 
 Light baths, 101 
 Limitation of the number of children, 
 
 192 
 Lipomatosis, 68, 294 
 
 universalis, 390, 411 
 Liquid foods, 452 
 Literary occupation, 458 
 Literature, 458 
 Liver, 450 
 Lobster, 452 
 Lqcaj baths, 188 
 
 irritation of the sensory nerves, 
 142 
 Loss of memory, 423 
 Love, 195 
 
 in women, 133 
 Lumbo-abdominal neuralgia, 357 
 Lupinar, 297 
 Luxurious society life, 190, 240 
 
 Macaroni, 452 
 Magiietic state, 314 
 Malaise, 418 
 
 Malignant tumors, 351 
 
 Malt, 103 
 
 Malthusian doctrine, 259 
 
 society, 260 
 
 league, 260 
 Malthusianism, 278 
 Malthusians, 259 
 Mammals, 450 
 Mania, 79, 425, 427, 437 
 Manifestations of decay, 340 
 Marasmus, senile, 217 
 Marjoram, 103 
 Marriage, barren, 303 
 
 consanguineous, 253 
 
 contempt for, 257 
 
 first cousins, 243 
 
 fruitful, 289 
 
 hated, 258 
 
 late, 257 
 
 near, 242 
 
 of the poor, 254 
 
 premature, 297 
 
 sterile, 289 
 Massage, 447 
 Mastodynia, 418 
 
 Masturbation, 64, 68, 85, 99, 216, 277, 
 280, 316, 392, 435 
 
 peripheral-mechanical, 87 
 Maternal body, 252 
 
 duty, 114 
 
 organism, 252 
 Maternity, 150 
 Maximum family, 266 
 May weddings, 241 
 Means for prevention, 246 
 Measures for prevention, 186, 247 
 Meat, 95, 239 
 
 extracts, 450 
 Mechanical obstruction, 291 
 Medical point of view, 254 
 Melancholia, 79, 345, 418, 427, 437 
 Melancholic mental disturbances, 426 
 Menacme, 149 
 
 hygiene during, 159 
 
 physiology of, 150 
 
 pathology of, 150 
 Menarche, age at which it occurred, 
 368 
 
 prscox, 56 
 
 tardiva, 56 
 Menopause, 340 
 
 age at which it occurs, 366 
 
 delayed, 376 
 
 hygiene during, 439 
 
 premature, 376 
 
 sudden, 376 
 
 race, 367 
 
 time of, 366 
 Menorrhagia, 124, 222, 316, 413, 445 
 Menorrhagic chlorosis, 63 
 Mensinga, 279 
 
INDEX 
 
 467 
 
 Menstrual psychoses, 398 
 
 wave, 117 
 Menstruation, 120 
 
 bloodless, 350 
 
 first appearance of, 45 
 
 sudden cessation of, 350 
 
 vicarious, 129 
 Mental aberration, 391 
 
 shock, 386 
 
 excitement, 456 
 Mesometritis, 324 
 Metabolism, disorders of, 376, 411 
 Meteorism, 349, 406 
 Metritis, 212 
 
 chronic, 180, 221, 222, 279, 320 
 
 vaginal, 65 
 Middle Europe, 39 
 Mid-winter, 241 
 Migraine, 357, 433 
 Milk, 95, 450 
 Milk-cure, 456 
 Mineral baths, 189 
 
 waters, 102 
 Miscarriage, 185 
 
 Mitral valvular insuflSciency, 383 
 Mittelschmerz, 128 
 Moderation, 270 
 
 enjoyment of physical love, 181 
 Modern culture, 8 
 Moral demand, 32 
 
 insanity, 357 
 
 virginity, 112 
 Morphine, 298, 303 
 Morphinism, 294 
 Mortality, general increased, 265 
 
 of childhood, 185 
 
 of married men, 139 
 Mother's joys, 153 
 
 love, 153 
 Movable kidney, 110 
 Muscae volantes, 388, 398, 416 
 Muscular exercise, 447 
 
 spasm, 128 
 Mutton, 452 
 Mutual freedom, 32 
 Myoma, 375 
 Myopia, 250 
 
 Nature frigidae, 135 
 Natural instincts, 108 
 
 method of feeding of infants, 195 
 Near kin marriage, 242 
 Neo-Malthusians, 264 
 Neoplasmata, 354 
 Nervous degeneration, 345 
 
 depression, 433 
 
 disturbances, 361 
 
 end-organ, 208 
 
 palpitation, 74 
 
 system, diseases of, 77, 414 
 
 Neuralgia, 127, 391, 433, 440 
 
 intercostal, 4l7 
 
 of the breasts, 357 
 
 superficial, 417 
 Neurasthenia sexualis, 144, 210. 211, 
 
 212, 215, 277, 437 
 Neuritis, 127 
 Nitrogenous balance, 117 
 
 equilibrium, 450 
 Northern Europe, 38 
 Nubility in girls, 168 
 Nucleo-albumin, 450 
 
 vegetable, 451 
 Nuns, 138 
 Nutriment affects number of births, 
 
 236 
 Nuts, 451 
 Nymphomania, 192, 436 
 
 Oats, 95 
 
 Oatmeal, 452 
 
 Obesity, 68, 97, 98, 411 
 
 excessive, 376 
 Obscene conduct, 435 
 Occlusive pessary, 264, 279 
 Occupation, 234 
 Oceania, 41 
 CEdema, 279 
 
 of the feet, 394 
 Official examination, 165 
 Old-fashioned methods of education, 
 107 
 
 maids, 425, 431,. 435 
 Olfactory sense, disturbances of, 91 
 Omelettes, 95, 452 
 Onanism, 275 
 
 mental, 87 
 Only child, 267 
 
 sterility, 306, 336 
 Oophorectomy, 205, 346, 412, 426 
 Oophoritis, 212, 222, 279, 294 
 Opium, 298 
 Oranges, 454 
 Organic heart disease, 265 
 Organs of the senses, diseases of, 90 
 
 circulation, diseases of, 388 
 Ossifications, 354 
 Ovaries, 294 
 
 anatomical changes in, 358 
 
 displacement of, 316 
 
 neuralgia of, 316 
 
 removal of, 354 
 Overnutrition, 449 
 Ovulation, 293 
 
 cessation of, 299 
 
 incapacity of, 294 
 Ovum, 196 
 
 female, 281 
 
 gestation of the fertilized, 293 
 
 male, 281 
 Oysters, 96, 452 
 
468 
 
 INDEX 
 
 Palpitation, 68 
 
 of the heart, 389 
 
 paroxysms of, 388 
 Paralytic dementia, 437 
 Paralysis, 128 
 Parametric exudations, 320 
 Parametritis, chronic, 221, 222 
 Paranoia, 431, 433, 437 
 Parent organism, 251 
 Parental body, 252 
 Paroxysmal tachycardia, 74 
 Paroxysms, 425 
 
 epileptic, 434 
 
 hysterical, 434 
 Partial frigidity, 138 
 Partridge, 96 
 
 Patriarchal relationship of woman, 7 
 Pears, 454 
 Peas, 452 
 
 Pelvic deformity, 265 
 Pepper, 451 
 Perch, 452 
 
 Percussion dulness, 394 
 Perfect love, 162 
 Perimetritis, 222, 279, 320 
 Perineal fissures, 217 
 Perioophoritis, 294 
 Peripherally aroused perceptions, 142 
 Peristalsis, 455 - 
 Peritonitis, 329 
 Perverse sexual impulse, 315 
 Perversion of the moral instincts, 
 
 427 
 Pheasant, 96 
 Phlebectasis, 394 
 Phlebotomy, 386 
 Phthisis, 298 
 Physical changes, 33 
 
 development inferior, 265 
 
 exercise, 97, 99, 109 
 
 loathing of overwork, 374 
 
 sexual intercourse, 210 
 Physiological custom, 145 
 Physiology of love, 54 
 Pigeon, 96, 304, 452 
 Pike, 452 
 Piles, 394 
 
 Pine needle baths, 103 
 Platonic love, 56 
 Pleasurable sensations, 142 
 Plethora abdominalis, 404 
 Plums, 456 
 
 Pneumonia, chronic, 299 
 Polar globules, 198 
 Pollutions in the female, 213 
 Polyglossia, 156 
 Polymathy, 156 
 Polypus, 363, 383 
 Population, excessive increase of, 267 
 
 distribution, unfavorable of, 265 
 
 increase of human, 256 
 
 Population, increase of human, checks 
 to, 257 
 
 law of, 255 
 
 principle of, 255 
 Pork, 452 
 Porridge, 451 
 Potatoes, 239, 452 
 Potted meats, 450 
 Precocious menstrual activity, 56 
 Precordial anxiety, 434 
 
 pain, 71 
 Predicrotic elevation, 389 
 Predilection, 273 
 Predisi)osition hereditary, 374 
 
 individual, 374 
 Pregnancy, 153 
 
 prevention of, 253 
 Preserved meats, 450 
 Prevention, measures of, artificial, 
 270 
 
 mechanical, 270 
 
 operative, 270 
 
 physiological, 270 
 Previous delivery, 333 
 Primary insanity, 438 
 Primitive man, 146 
 
 state, 6 
 Process of growing up, 114 
 
 involution, 185 
 Procreation, 293 
 Profluvium seminis, 220 
 Profuse perspiration, 349, 355 
 Progressive endarteritis obliterans, 
 
 364 
 Prolapse, 354 
 Prolonged courtship, 133 
 Pronuclei, conjugation of, 293 
 Pro-nucleus, female, 198 
 
 male, 198 
 Prostitution, 268 
 Proteids, animal, 450 
 
 vegetable, 450 
 Protracted mens,truation, 382 
 Prurigo, 410 
 Pruritus, 143, 144 
 
 genitalium, 409 
 
 vaginae, 421 
 
 vulvae, 410, 415, 421 
 Pseud-angina, 356 
 Pseudo-membranes, 330 
 
 narcotism, 357, 398, 416 
 Psychical disturbances, 426 
 
 influences, 10 
 
 stimuli proceeding from the brain, 
 213 
 Psychoses of puberty, 79 
 Ptarmigan, 96 
 
 Puberal development of the heart, 76 
 Puberty, 33 
 Puddings, 452 
 Pudic nerve, 208 
 
INDEX 
 
 469 
 
 Puerperal diseases, 333 
 
 inflammation, 334 
 
 mania, 192 
 Pulmonary tuberculosis, 265 
 Pulse, frequency of, 70 
 Pure marriage, 31 
 Pyogenic infection, 365 
 Pyromania, 437 
 Pyrosis, 405 
 
 Quality of semen, 186 
 Quarrelsomeness, 432 
 Quinine, 303 
 
 Rachialgia, 433 
 
 Race, 34, 240 
 
 Rachitic habit of body, 102 
 
 Rape, 314 
 
 Reflex action, 317 
 
 cramps of sphincter vaginae, 207 
 Regulation of the reproductive 
 
 process, 194 
 Reigning families, 229 
 Relig^ion, 234 
 Religious fanaticism, 55 
 
 reverie, .108 
 Reproduction, regulation of, 265 
 Reproductive cells, 252 
 
 glands, female, 295 
 Respiratory distress, 71 
 
 organs, diseases of, 89 ^ 
 Retarded menstrual activity, 56 
 Retention of the urine, 117 
 Retinitis, 127 
 
 Retrogressive metamorphosis, 359 
 Rh3rthmical variation in the vital 
 
 processes, 14 
 Rice, 239, 452 
 Rickets, 298 
 Right to love, 194 
 Roast beef, 96 
 Rod forms, 365 
 Roman baths, 443 
 Romans, 7 
 Roseola, 407 
 Rowing, 100 
 Rue, 103 
 Rusks, 452 
 Russian baths, 443 
 Rye meal, 452 
 
 Sacrache, 212, 223 
 
 Sage, 103 
 
 Salads, 452 
 
 Salmon, 452 
 
 Salpingitis, 222 
 
 Salt, 451 
 
 Sanitary towels, 116 
 
 Sanguine temperament, 400 
 
 Sarcomata, 299 
 
 Satisfaction of the sexual impulse, 
 
 140 
 Sausa^^es, 450 
 Savones, 452 
 
 Scandal-mongering, 345, 432 
 Scanty progeny, 297 
 Scarlatina, 338 
 Schirrus of rectum, 317 
 Schniirleber, 116 
 Schrader's diet-table, 118 
 Scirke, 284 
 Sclerosis, 443 
 Scrofula, 294, 298, 302 
 Scrofulous habit of body, 102 
 Sea side, 104 
 
 voyage, 104 
 Season of predilection, 317 
 Seborrhoea, 93 
 
 treatment of, 105 
 Second wife, 249 
 Segmentation-sphere, 199 
 Selection in marriage, 171 
 Self-deception, 345 
 Self-sufiicient egoism, 152 
 Semen, 202 
 Senescence, 342 
 Senile changes, 294 
 
 degeneration, 362 
 
 marasmus, 348 
 Sensations of weight, 212 
 Sense organs, 25l 
 Separate beds, 176 
 Septicaemia, puerperal, 299 
 Severe intelfecfual exertion, 240 
 Sex, determination of, 280 
 Sexual abstinence, 136, 263 
 
 activity in woman, 372 
 
 desire, artificial increase of, 173 
 
 disharmony, 224 
 
 dream-perceptions, 219 
 
 epoch of the menacme, 149 
 
 epoch of the menarche, 33 
 
 erethism, 346 
 
 excesses, 240, 335 
 
 freedom, 163 
 
 heat, 144 
 
 honor, 163 
 
 hyperaesthesia, 145 
 
 impulse, 130, 435 
 
 inactivity, 348 
 
 intercourse, frequency of, 172 
 
 intercourse, in state of intoxication, 
 173 
 
 intercourse, manner of, 172 
 
 malpractice, 435 
 
 maturity (at what age), 166 
 
 position of woman, 154 
 
 retrogression, 340 
 
 sensibility in woman, 307 
 Sexually asthenic women, 214 
 Shellfish, 96 
 
470 
 
 INDEX 
 
 Shortness of breath, 393 
 Shower-baths, 100, 444 
 Singing, 116 ' 
 
 Sitting, 99 
 
 Sitz-baths, 100, 188, 444 
 Skating, 99, 109 
 Skin diseases, 92, 407 
 
 eruption, 357 
 Slavonic people, 7 
 Smoked fish, 450 
 
 flesh, 450 
 Social consanguinity, 250 
 
 circumstances, 34, 374 
 
 organisation, 8 
 
 position, 234 
 Sociologist, 254 
 Sole, 4f2 
 Solon's law, 177 
 Song of Solomon, 19 
 Soups, 452 
 Southern Europe, 40 
 Spartan law, 176 
 Spasms, 129 
 Spermatozoon, 196, 293 
 Sphincter vaginae, 209 
 Spices, 451 
 Spinach, 95, 452 
 Spirit of soap, 105 
 Spiritualism, 436 
 Sponge-baths, 100 
 Sponging of body, 190 
 Springtime, 240 
 Spring water, 451 
 Spurious pregnancy, 346 
 State of minority, 153 
 Steam bath-cabinets, 101 
 Steatopyga, 343 
 Sterility, absolute, 285 
 
 acquired, 285, 321 
 
 artificial, 270 
 
 congenital, 285 
 
 facultative, 286 
 
 in women, 282 
 
 only-child, 286, 306, 336 
 
 relative, 285, 337 
 Stigmata of degeneration, 251 
 Stillbirth, 288 
 Stomach, ulcer of, 88 
 Strangury, 223 
 Stroke, 390 
 
 Suckling the infant, 154 
 Sudatory baths, 101 
 Sugar, 451 
 
 Suicide, 139, 426, 428, 437 
 Sun baths, 101 
 Suppurative diseases, 299 
 
 processes, 354 
 Surgical measures, 291 
 Sweetbreads, 96, 450 
 Sweets, 452 
 Swimming, 100, 109 
 
 Sympathetic action, 317 
 
 Syncope, 388 
 
 Synostosis of the cranial bones, 79 
 
 Syphilis, 8, 294 
 
 Systolic murmur, 395 
 
 Tachycardia, 401, 448 
 
 Tachycardial paroxysms, 204, 390 
 
 Taenia solium, 318 
 
 Tannin, 303 
 
 Tapeworm, 318 
 
 Tea, 96, 109, 303, 451, 453 
 
 Theatres, 108 
 
 Thyme, 103 
 
 Tight collars, 99 
 
 Tight garters, 99 
 
 Tinnitus aurium, 398, 416 
 
 Tonsils, hypertrophy of, 88 
 
 Toothache, 78 
 
 Trout, 452 
 
 Touchstone of marital hygiene, 182 
 
 Townspeople, 52 
 
 Travels, 108 
 
 Tribadists, 215 
 
 Trophoneurosis, 82 
 
 Tropics, 241 
 
 Trouble, 218 
 
 Tuberculosis, 302 
 
 Tumors, in pelvic cavity, 265 
 
 malignant, 265 
 
 mammary, 192 
 
 ovarian, 192, 265 
 
 uterine, 192 
 Turkey, 96 
 Turnips, 452, 456 
 Twitchings, 129 
 
 Two-children-system, 247, 254, 267 
 Typhoid, 299, 338, 386 
 
 Umbilical hernia, 412 
 Union of Neo-Malthusianism, 260 
 Universal military service, 245 
 Unphysiological modes of sexual in- 
 tercourse, 277 
 Urethra, vascular tumors of, 317 
 Urticaria, 94, 159, 410 
 Uterine cough, 129 
 
 neoplasm, 459 
 
 polypi, 331 
 Uterus, bicameratus vetularum, 364 
 
 carcinoma of, 330 ' 
 
 fibromyoma, 332 
 
 hyperplasia of, 333 
 
 myoma of, 332 
 
 new growths of, 320 
 
 retroversion of, 316 
 
 tumors of, 331 
 
 Vagina, disinfection of, 188 
 fissures in, 217 
 
INDEX 
 
 471 
 
 Vaginal douche, 173, 188 
 
 injection, 187 
 
 refrigerator, 445 
 Vaginismus, 204 
 Vaginitis, gonorrhoeal, 217 
 Vapor baths, 101 
 Varices, 159, 394 
 Vasomotor disturbances, 84, 456 
 
 symptoms, 371 
 Veal, 96, 450 
 Vegetables, 95, 452 
 Vena cava, 396 
 Venesection, 448 
 Venison, 96, 452 
 Venous engorgement, 394 
 
 hy^ersemia, 322 
 Veraism, 162 
 Vermicelli, 452 
 Vertigo, 371, 415, 442, 456 
 Vestibule, bulb of, 208 
 
 margin of, 208 
 Vicarious bleeding from the gums, 78 
 Vinegar, 451 , 
 
 Virginity, sanctification of, 257 
 Vis grata, 314 
 Vitality of children, 234 
 
 Voluptas cceundi, 346 
 
 Voluptuous excitement, 308 
 sensations, 208 
 
 Vulva, inflammations of, 188 
 Vulvitis, acute, 217 
 chronic, 217 
 
 Weak erection, 212 
 Wedding journey, 179 
 Wet-capping, 448 
 
 nurse, 193 
 
 packing, 101 
 Wettin dynasty, 243 
 Wheat bran, 103 
 
 bread, 452 
 
 meal, 452 
 White meat, 456 
 Widows, 435 
 Wife's occupations, 187 
 Wild breeds of animals, 236 
 
 duck, 452 
 Winckel's diet table, 119 
 Wines, 95, 453 
 Wittelsbach dynasty, 243 
 Woman a chattel, 6 
 Working class, 52 
 Works of benevolence, 458 
 Wrinkles in the face, 157 
 
 Xantbin, 450 
 
 Zona pellucida, 306 
 Zoosperm, 281