I. THE SEXUAL EPOCH OF THE MENARCHE. (continued 2)

The commonest form of amenorrhœa at this period of life is, however, the constitutional amenorrhœa associated with chlorosis. In chlorotic subjects we have to do, not with a symptomatic absence of the menstrual discharge, but with a failure of the ovarian function, the graafian follicles failing to ripen. We generally find, according to Gebhard, that chlorotic girls begin to menstruate at the usual age, or even earlier. Menstruation recurs once or twice at irregular intervals, and then gives place to complete amenorrhœa, it may be suddenly, it may be gradually, the flow on each occasion being scantier than before. In chlorotic patients, the menstrual discharge, when present, is very thin and watery, and often contains a large admixture of mucus derived from the cervical canal and the cavity of the uterus. The amenorrhœa may be of short duration; or it may last for a long time; so that it is not until after the lapse of months or years, and as a rule in consequence of suitable treatment, that menstruation recurs, being henceforward either normal in frequency and strength, or on the other hand permanently scanty and of the postponing type. The associated disorders from which the patients suffer take the form of headache, dizziness, syncope, feelings of oppression, disinclination for mental and physical exertion, and so on. Since in such cases the ripening of the ovarian follicles also fails to occur, when the amenorrhœa is complete the menstrual molimina are generally wanting (Gebhard).

Stephenson also states that in girls who have been chlorotic for a longer or a shorter time, menstruation frequently begins very early, in any case earlier than in healthy girls.

Usually in these cases various other disorders are associated with the amenorrhœa, such as colicky pains in the abdomen, sensitiveness 86of the abdominal wall to contact or pressure, headaches, attacks of hemicrania, general mental depression, and hysterical manifestations.

In chlorotic girls, at the times when menstruation is due, a watery discharge often occurs, sometimes slightly tinged with blood. Dysmenorrhœa may also occur at such times.

Attacks of menorrhagia in young girls are usually dependent on disturbances of the nervous system. Sometimes such an attack occurs at the very first menstrual period. Occasionally also menorrhagia may occur in association with chlorosis, to be distinguished according to Virchow from a rare condition named by him “menorrhagic chlorosis,” characterized by excessive menstruation of an anticipating type. The bleeding is in such cases seldom very profuse, however, but the periods are very long, and the intervals exceedingly short. Castan regards such profuse menorrhagia and metrorrhagia occurring in young chlorotic girls, especially at the commencement of puberty, as of an endoïnfective nature dependent upon auto-intoxication. The toxins lead to inflammatory and degenerative changes in the muscular substance of the uterus. According to Frænkel in these cases the ovaries are usually enlarged, seldom smaller than normal.

Frœlich has discussed this subject exhaustively in his monograph on Menorrhagia of Young Girls and Hypertrophy of the Cervix Uteri.^[21] He states that the cases of menorrhagia in young girls at the time of the menarche may be arranged in two groups. In one of these the patients are chlorotic, and menstruation is normal neither in amount nor in duration, but it is the long continuance of the flow rather than its profuseness that gives rise to danger; in the cases belonging to the other group the patients are in excellent health at the commencement of puberty, but menstruation soon takes the form of long-continued and profuse menorrhagia. Cases of the latter kind are due to hypertrophy of the cervix uteri and fungous metritis. Such attacks of menorrhagia in young girls are seen also in cases of infectious disorders, as in smallpox, measles, scarlatina, and above all, influenza. The hæmorrhage often begins in the first days of the infection, and even during the period of incubation, one or two days before the appearance of the general symptoms. If the patient is attacked by influenza while menstruating, the menstrual flow may assume the character of a true menorrhagia. More often, however, in such cases, we have to do with an extra-menstrual hæmorrhage, such as may indeed be observed in girls who have not yet begun to menstruate.

87

Inflammatory Processes.

Chronic metro-endometritis, both corporal and cervical, occurs occasionally in young girls during the years of development. It is especially common in chlorotic subjects; and next to these in girls who are careless about the observance of hygienic precautionary measures during the menstruation. Thus it may result from physical exertion among the working classes; and from dancing, skating, riding, or mountaineering, among girls belonging to the well-to-do classes, during menstruation. Again, we meet with it in girls who work very hard at the sewing-machine; and, finally, in those who have long practiced masturbation. Through uncleanliness at the time of menstruation, the blood with which chemise and drawers are stained and the pubic hair soiled, undergoes decomposition, and this may lead to catarrhal inflammation of the vulva and vagina and of the endometrium. The most striking symptom in persons thus affected is the discharge of mucus, which in cervical metro-endometritis leads to a very moist condition of the external genitals, and leaves greenish-yellow spots on the under-linen; in corporal metro-endometritis the discharge is of a thinner consistence, milky in appearance, and not very abundant. As a result of the endometritis, the patient suffers from various pains in the body, a feeling of fulness, sacrache, general sense of fatigue, and diverse nervous manifestations; sometimes also from dysmenorrhœa, strangury, or obstinate constipation. In consequence of the great thickening of the mucous membrane that often occurs, menstruation becomes very profuse and long-continued, lasting from one to two weeks.

A form of chronic vulvitis, sometimes, though indeed quite rarely, met with in girls at this time of life, is inflammation of the external genitals dependent on masturbation. As characteristic signs of this we may observe an elongation of the nymphæ, the clitoris, or the præputium clitoridis, and at the same time on the inner surface of the greatly stretched labiæ we may notice a great increase in the sebaceous glands, so that the yellowish spots formed by these structures may be seen beneath the mucous membrane with the unassisted eye—the mucous surface, indeed, may be slightly uneven in consequence of their enlargement, so that they resemble small retention-cysts. The mucous membrane of the vulva between the margin of the hymen and the nymphæ is moreover, according to Veit’s description of masturbatory vulvitis, often beset with small pointed excrescences, the soft furrow between the clitoris and the external orifice of the urethra being very commonly marked by swelling of the mucous membrane and the presence of these little outgrowths; but sometimes also the parts lying to either side of the urethral orifice may exhibit similar changes. These small structures differ 88entirely from pointed condylomata—they do not branch, they occur only upon the vulval surface proper, not upon the parts exhibiting the characters of true skin, and they are non-infecting. More particularly, it must be remembered, we find these changes principally in virgins in whom on account of obscure symptoms an examination of the genital organs has been undertaken, and who suffer in addition from nervous and hysterical manifestations. The hymen, when intact, as it usually is in these cases, furnishes objective evidence that sexual intercourse is not the cause of the patient’s trouble, and indeed a distinctly ascertainable cause is hard to find. The patient usually exhibits abnormal sensitiveness and excessive prudery. Veit is of opinion that the association of all these symptoms justifies the diagnosis of masturbation as the exciting cause of the chronic vulvitis; in such cases we may at one time find the mucous membrane pale, but at a later examination fiery red, and we often see a clear, transparent secretion exuding from the ducts of Bartholin’s glands.

In consequence of long-continued masturbation, other pathological changes may take place in the female genital organs, such as hypertrophy of the nymphæ, proliferation or glandular hypertrophy of the uterine mucous membrane, ovarian irritation, pains in the ovarian region which, in severe attacks, may radiate to the thighs. These pains become more severe at the menstrual period, especially at the beginning of that period; and are sometimes also especially troublesome in the middle of the intermenstrual interval, in this case usually as a result of great bodily exertion.

These morbid processes in the genital organs of young girls have long attracted the attention of physicians, and it is more than sixty years since Bennet described the “virginal metritis” observed by him in twenty-three virgins. Bonton published in 1887 a monograph on this condition. Gallard assigns masturbation as its principal cause.

Retroflexion of the uterus is also sometimes observed in virgins, induced by the bad habits which are so common in young girls of retaining the urine for excessively long periods and of neglecting constipation. The prolonged distension of the bladder leads to a daily, long-continued stretching of the ligamentous apparatus of the uterus; the full bladder presses the uterus backwards, and after the viscus has been emptied, the flaccid ligaments are no longer able to restore the uterus to its normal position of anteflexion. The organ is left with its fundus directed backwards, and the intra-abdominal pressure keeps it permanently in this position; at the same time, an accumulation of fæces in the rectum, by pressing the cervix forward, favors this displacement of the uterus. Moreover, when the uterine tissues are flaccid through malnutrition in 89chlorotic or anæmic subjects, the organ yields more readily to mechanical influences than it would if its muscular tone was healthy.

Disorders of Hæmatopoiesis.

Chlorosis is in general rightly regarded as a disease of the period of puberty etiologically dependent on the processes that at this time of life occur in the genital organs. Its appearance generally coincides with the menarche, occurring at the age of 14 to 16, or even later, at the age of 19 to 21. As regards the composition of the blood in chlorosis, investigations have shown that its hæmoglobin-richness is always diminished; its specific gravity is proportionately lessened, but the specific gravity of the serum is normal. The erythrocytes are normal in number, or only slightly diminished; their shape is sometimes normal, sometimes, however, poikilocytosis is present. The leucocytes are generally normal both as regards number and form; myelocytes (Markzellen) are also described as present in the blood of chlorotic patients (Neusser, Hammerschlag, Gilbert, Weil); the blood-plates are normal in number, the alkalinity of the blood also normal, the isotonicity of the erythrocytes rather low.

The relation of chlorosis to the menarche is variously explained. Kahane, in his elaborate monograph on chlorosis, regards it as an independent disease belonging to the group of “disorders of vegetation” (Kundrat), one which “according to its essential nature is an expression of the disharmony that obtains between the congenitally inefficient hæmatopoietic apparatus and the demands made upon the feminine organism by the processes of puberty.”

An insufficiency of the hæmatopoietic organs as regards their functional capacity is believed by Kahane to be in the case of women so far physiological inasmuch as their blood is inferior to that of men in hæmoglobin-richness and corpuscular richness to the extent of about 10 per cent. In this way the predisposition of the female sex to chlorosis may perhaps be explained. A further fact which must be taken into consideration is the difference between the development undergone by the respective sexes at puberty. In the female sex, this development is quickly completed, and has the characteristics of a revolution; but in the male, the development is a more gradual one, and has the characteristics of an evolution.

F. A. Hoffmann also regards chlorosis as associated with the development of the uterus and the establishment of menstruation. It is possible that these processes exercise some reflex influence; but we must also remember that the chemical processes involved in the growth and maturation of the ovarian follicles are still insufficiently understood, and that it is quite possible that these too 90may have powerful and unaccustomed effects on the organism such as may well disturb metabolic processes of a somewhat unstable character.

Grawitz, who regards chlorosis as a vasomotor neurosis in which disturbances arise in the interchange of fluids between the tissues and the vessels, refers the appearance of chlorosis at puberty to the general disposition to disorder exhibited at this age by the vasomotor system.

Other authors consider chlorosis to be an ovarian auto-intoxication, believing that under certain conditions the ovaries give off into the organism certain poisons; or, on the other hand, supposing that a certain antitoxic function, normally possessed by the ovary, fails. Von Noorden, for instance, regards chlorosis as a disorder of blood formation referable to a disturbance of the internal secretion of the ovary during the developmental period.

Blondel, who also regards ovarian auto-intoxication as causal, is of opinion that chlorosis is induced by products of decomposition formed in the organism during the process of growth. As in childhood the thymus gland, so later in life the ovary, renders these products innocuous. When this peculiar functional activity of the ovary is retarded in its appearance, the intoxication effected by the products of decomposition formed during the process of growth gives rise to chlorosis.

Meinert, in an interesting manner, brings the harmfulness of wearing a corset during the years of development into etiological relations with chlorosis. In the transitional period between childhood and the age of puberty the wearing of the corset usually begins. Now Meinert discovered that in chlorosis, as a result of wearing a corset, a vertical or subvertical position of the stomach ensues as a partial manifestation of enteroptosis, leading to tension on the abdominal plexus of the sympathetic, which in turn results in changes in the blood, and other nervous symptoms. According to this view, chlorosis is a peculiar general neurosis dependent upon an artificially induced gastroptosis; this form of enteroptosis being due, not to relaxation of the suspensory ligaments of the abdominal viscera, but to pressure exercised by adjacent organs in consequence of a change in the form of the thorax, which has been permanently constricted by tight-lacing (fixierter Schnurthorax).

Of importance is the fact that in girls suffering from chlorosis a condition of hypoplasia of the genital organs is not infrequently met with. It would seem, not only that imperfect development of the female genital organs may be a cause of chlorotic changes in the blood, as appears possible in view of the relations between the ovaries and the hæmatopoietic organs through the intermediation 91of the sympathetic system; but also that genuine chlorosis and the anomalies of the genital organs met with in this disease, may perhaps be common manifestations of some more general disturbance.

According to Virchow, two distinct forms of chlorosis are to be recognized, one form in which no great abnormalities of the reproductive apparatus exist, and another form in which imperfections in the development of the central portion of the vascular system are associated with similar imperfections in the reproductive apparatus. In many cases of chlorosis, he found the ovaries small and imperfectly developed, in an infantile condition; in other cases, however, they were three times the normal size; the development of the uterus in such cases usually corresponds with that of the reproductive glands. With regard to the etiological connection between chlorosis and developmental disturbances, Virchow inclines to the view, that in chlorosis a predisposition, either congenital or else acquired in early youth, must be assumed to exist, but that this does not manifest itself by the production of actual disorder until the arrival of puberty; and he considers it likely that primary deficiencies of the blood and the vascular apparatus hinder the development of the reproductive apparatus.

Stieda found that in chlorotics displacements of the uterus were common, with abnormal narrowness of the vagina, absence of the pubic hair, imperfect development of the pelvis, and the growth of the breasts interfered with to this extent, that the nipples and areolæ were abnormally small. He classifies these manifestations as disturbances of development in the sense that they are among the so-called stigmata of degeneration. If in chlorotics the breasts in certain cases have a normally full and rounded appearance, this appearance is sometimes deceptive, the fulness being due, not to a proper growth of the parenchymatous mammary tissue, but to an excessive deposit of fat. Genuine chlorosis, therefore, not referable to some other primary disorder, is a developmental disorder, in the sense in which various other stigmata of degeneration met with in the human body are developmental disorders, and is indeed frequently associated with other stigmata of degeneration, or with malformations due to arrest of development, as for instance, an infantile type of pelvis or of genital organs, abnormalities of the cranial bones, vaulted palate, the root of the nose broad and depressed, extreme prognathism.

Hegar also maintains the view that chlorosis is in most cases a developmental disturbance, the origin of which is not limited to the so-called years of puberty; it often arises from noxious influences which are either strictly inherited or began to operate when the infant was still in her mother’s womb. Frænkel is inclined to 92regard a primary developmental disorder of the genital organs as the cause of many cases of chlorosis.

Recently, Breuer and Seiler have undertaken experiments on bitches, which they spayed at the outset of puberty, and from the results of these experiments it seems probable that a disordered influence exercised by the ovaries on the blood plays a part, at least, in the pathological mechanism by which chlorosis is induced.

The intimate relationship believed to exist between chlorosis and the sexual life of woman finds expression in the opinion, which dates back to the days of antiquity, and has been widely held even by physicians, that the disease (hence designated morbus virgineus or febris amatoria) is due to sexual abstinence in individuals with powerful sexual impulse, and that for this reason chlorosis is often cured by marriage. This result of marriage, which, though apparent merely, may indeed often be witnessed, is explained by Kahane on the ground, that in very many cases, the symptoms of chlorosis become less severe after the first five years have elapsed since the commencement of puberty, the improvement occurring quite independently of the marriage or continued celibacy of the sufferer. The influence of marriage in curing chlorosis is thus apparent merely to this extent, that a very common age for marriage in women is precisely in the twentieth, twenty-first, or twenty-second year, when five years have passed since menstruation began. By this time the organism will to a large extent have become accommodated to the demands made upon it by the processes of puberty. Experience also shows that chlorotic girls sometimes continue to suffer from the various symptoms of chlorosis even after they have become wives, and that chlorosis is not infrequently rendered more severe by the puerperium—but in a wife it is no longer customary to describe such symptoms by the name of chlorosis, they are called anæmia, hysteria, nervousness, etc. Further, in order to give the doctrine of morbus virgineus its death-stroke, Kahane directs attention to the fact that numerous cases of chlorosis are met with in young girls who are far from practicing sexual abstinence, especially, for instance, amongst the lower classes, amongst whom it is hardly customary to wait for marriage before beginning sexual intercourse. The connection between masturbation and chlorosis, which has also been widely alleged from the etiological standpoint, is moreover one that cannot be admitted. On the other hand it is easy to understand that the erotic reveries which are so often seen in chlorotic girls are very likely to induce the habit of masturbation.

In young girls at the time of the menarche, especially in those who suffer from amenorrhœa or from irregular menstruation, the anæmic form of obesity not infrequently develops. Such patients 93at the time of puberty exhibit signs of marked anæmia in association with a notable increase in fat. The skin in such cases is always strikingly pale and of a whitish-yellow color; in bodies which are in other respects beautiful the bust may have the appearance of a marble statue. Such girls are strikingly stout, but the fatty tissue is flaccid, soft, and spongy, and dependent parts readily become œdematous; the muscular system is generally feeble.

What especially characterises this anæmic form of lipomatosis in young girls is, that, even in mild forms of the affection, cardiac symptoms are apt to become prominent. Frequent and violent palpitation will occur even in the absence of any severe exertion or especial excitement, often also we see shortness of breath, precordial pain, anxiety, respiratory distress, and sensations of chilliness and fatigue.

The principal cause of the obesity in these cases is to be found in the anæmia, inasmuch as the diminution in the number of the erythrocytes is a diminution in the number of the oxygen-carriers, and this entails defective and insufficient oxidation. The deficiency in the albuminous constituents of the body also gives rise to a rapid and extensive deposit of fat, the power for the combustion of the fats absorbed from the food being insufficient. An auxiliary factor in producing obesity in such anæmic girls is their disinclination to physical exercise, dependent on the speedy onset of sensations of fatigue. The long-continued repose of the muscles, and the remaining almost continuously in close rooms insufficiently supplied with oxygen, also result in the withdrawal from the blood of the circulating fat and its deposit as adipose tissue.

Albuminuria at the time of the menarche is a disease of development which is not infrequently met with in chlorotic girls, as in adolescent boys. On examination of the urine in such young girls we detect the presence of a variable quantity of albumin, which is present especially after severe physical exertion, mental application, or emotional excitement, whilst the urine secreted at night is usually free from albumin. The skin is pale, the accessible mucous surfaces are comparatively colorless, the face is puffy, the eyelids are œdematous; the patients suffer from various nervous troubles, especially headache and dizziness, and they are also liable to dyspeptic disorders.

The cause of this albuminuria of puberty is according to von Leube in part disordered hæmatopoiesis, in part a slight degree of cardiac insufficiency with a tendency to stasis. At the time when the processes of development and the growth of the body in height are most active, there is not a corresponding increase in the energy of hæmatopoiesis, and the heart also fails to keep pace with the growth 94of the body and to meet the demands thus made upon it by vigorous growth and increased energy. In general the capacity of the heart in such individuals is indeed sufficient to maintain the circulation through the kidneys; but as soon as the functional activity of the heart is more strongly taxed and the energy of the circulation consequently declines, albuminuria occurs—and occurs all the more readily in consequence of the fact that, the hæmoglobin-richness of the blood having been lowered by the customary anæmia, the epithelium of the renal glomeruli is badly nourished and functionally inadequate.

When the period of the menarche is safely passed, when the menses recur with regularity, and the chlorotic manifestations disappear, when the process of hæmatopoiesis has improved in quality, and the growth of the body is completed—when, in short, the functional equilibrium of all the vital processes becomes re-established, the albuminuria of puberty ceases. It seems, however, that those who have suffered in this way are predisposed to a return of the albuminuria at the climacteric period, when the metabolic balance is once more disturbed.

Cardiac Disorders.

The commonest cardiac disorder at this period of life is nervous palpitation, occurring in young girls who are in other respects in good health, being free from anæmia and from any discoverable disease of the heart or vessels. That this disorder is dependent on the sexual processes is indicated by the fact that it first manifests itself in a stormy manner some time, weeks it may be or months, before the first appearance of menstruation; recurring at irregular intervals, the attacks continue till after the first menstruation, and cease soon after the regular return of the period. Objectively, the palpitation of the heart manifests itself by an increase in the frequency and strength of the cardiac impulse, and increased frequency and tension of the pulse; in a few cases, however, it is perceived subjectively only by the patient, as a distressing sensation of excessively frequent and powerful cardiac action. In the former group of cases, the enhanced activity of the heart is perceptible, not only by auscultation, by which we usually find the heart-sounds quite pure, but also by inspection, which shows us the violent agitation of the thoracic wall and increased pulsation of the carotids. On percussion, no change is found in the area of cardiac dulness. The frequency of the pulse is increased, usually reaching 120 to 140 beats per minute; it is full, and may be intermittent or irregular. In those cases in which the palpitation of the heart is a purely subjective sensation, we find no increase either in the frequency or 95in the strength of the pulse, which may indeed be less frequent than normal. With the palpitation is associated a sensation of strong pulsation in the great vessels of the neck, and often there is pain on the left side of the lower part of the chest, with a sensation of shortness of breath, respiratory distress, precordial pain, and a feeling of pressure upon the chest. Respiration is shallow, and abnormally frequent. The attacks of palpitation recur daily in some patients, in others at intervals of several days; they may occur entirely without exciting cause, or with a cause so trifling that it would not in a normal subject have produced any nervous excitement; the duration of the attacks varies from a few minutes to several hours, and they may occur either by day or by night; in the intervals between the attacks the functions of the heart and the arteries are conducted in a normal manner. The pulse-curves I have obtained during the attacks of palpitation, in those cases in which the manifestations were objective as well as subjective, exhibit a high pulse-wave, the upstroke being rapid and steep, the downstroke also sudden and steep, the predicrotic elevation but little marked, the dicrotic elevation often very distinct.

Less frequent than such attacks of palpitation recurring at irregular intervals are paroxysmal attacks of tachycardia, in which the frequency of the heart and pulse is increased to an enormous extent. This disorder manifests itself a little time before the first appearance of menstruation, thenceforward recurring regularly every three or four weeks, accompanying menstruation, or occurring at the proper menstrual period if menstruation is in abeyance; the attacks last several days. This trouble also disappears a few months after the establishment of menstruation.

Associated with these cardiac troubles are, not constantly indeed, but in the majority of cases, disturbances of the digestive organs.

From the heart-troubles already described, another group of cases must be distinguished, which are also observed at the time of the menarche. They occur in girls in whom the first appearance of menstruation is strikingly delayed, not having yet begun at the ages of 18, 19, or 20 years, or in whom considerable irregularities have occurred in connection with the commencement of menstruation. In such girls, in whom menstruation has appeared late and been irregular, or who are perhaps entirely amenorrhoeic, cardiac troubles may be so pronounced that the physician may be led to suspect the presence of organic disease of the heart. The most prominent symptom is frequent and violent palpitation, with strong pulsation in the carotids, respiratory distress, and feeling of anxiety, on continued exertion or even on very slight occasion. On percussion, the heart is not found to be enlarged; on auscultation, the heart-sounds 96are found to be very loud, often with a systolic murmur in the mitral region, whilst over the lower end of the internal jugular vein, the humming-top murmur (bruit de diable) is audible. The pulse is increased in frequency, at times arhythmical, and easily compressible. The sphygmographic tracing usually shows a subdicrotic or dicrotic character. The upstroke is not high; the downstroke descends low, almost to the lowest level of the curve, before the enlarged dicrotic elevation begins. The skin is always strikingly pale, pale also are the visible mucous surfaces, the hæmoglobin-richness and the corpuscular richness of the blood are considerably diminished, a feeling of fatigue and various other nervous manifestations are constantly present—in short, in all cases we have to do with the well-known chlorotic disposition, sometimes in association with the manifestations of the anæmic form of lipomatosis universalis. In several such cases, skin affections were also present. Some suffered from acne vulgaris of the face with the usual comedones; others perspired profusely from the palms of the hands and the soles of the feet; others exhibited a bluish coloration of the nose and the ears.

There is yet a third form of heart trouble, much rarer indeed than the forms already described, from which young girls sometimes suffer at the time of the menarche. It occurs in girls who just before the first appearance of menstruation have grown very rapidly, “shooting up to a great height.” They are not anæmic, nor do they appear “nervous;” but they are extremely thin, and they have grown enormously in height during the previous year. These individuals also, who in the previous course of their life have been free from heart trouble, now complain of cardiac distress. As in the cases previously described, they complain of severe palpitation, a feeling of fulness in the chest, shortness of breath on exertion, etc.; but the results of the objective examination are very different. The cardiac dulness is increased in area, especially in vertical extent, the apex-beat may be normal in position or displaced outwards, the impulse is always heaving, abnormally powerful and resistant, the heart-sounds, especially those of the left ventricle, are louder than usual, the aortic second sound accentuated, sometimes ringing, the carotids pulsate visibly. The radial pulse, the tension of which is abnormally high, can be compressed by the finger only with difficulty; sometimes it is jerky in character. The sphygmographic tracing shows a rapid and steep upstroke; in the downstroke, the predicrotic elevation is much larger than normal and also nearer the summit of the curve. Thus we see that all the signs of cardiac hypertrophy are present, hypertrophy, that is to say, of the left ventricle.

97The cases of this nature that have come under my observation have not been in girls of the working classes, but among the well-to-do. We cannot therefore regard them as due to overstrain of the heart in consequence of excessive bodily exertions, comparable to the cases met with in young recruits after long marches and violent exercise. We must rather assume that the development of the female genital organs has evoked a storm in the cardio-vascular system, more especially that in some way an increased resistance has been offered to the work of the heart, and that thus the hypertrophy has been brought about; though we may suppose that other unfavorable influences have also been in operation. Such an influence, in these cases, is the rapid growth of the body, which makes enhanced demands on the work of the heart; another is furnished by the almost universally worn unhygienic article of clothing, the cuirass-like corset, which offers a rigid hindrance to the rapid growth of the female body, to the development of the breasts, the thorax, and the upper abdominal organs, and which fails to accommodate itself to the changing conditions of growth, so that much extra work is thrown upon the heart. In such young girls we have very frequently found tight stays, which were worn unchanged without regard to the growth of the body in length, and which, by pressure on the epigastric region, elevation of the diaphragm, and limitation of the respiratory movements of the thorax, actually offered such considerable resistances to the driving power of the heart, as ultimately to lead to hypertrophy of the cardiac muscle.

Summing up our observations, we find that at the time of the menarche cardiac disorders occur in young girls which may be arranged in three groups of cases:

1. Nervous palpitation and paroxysmal tachycardia in persons in other respects in good health, the affection appearing shortly before the commencement of menstruation, and disappearing soon after the flow is regularly established.

2. Cardiac disorders occurring in young girls suffering from chlorosis, which itself results from the processes of the menarche.

3. Cardiac hypertrophy developing at the time of the menarche, and dependent on the circulatory disturbances associated with that process, its appearance being favored also by rapid growth of the girl and by unsuitable clothing (tight lacing).

With respect to the activity of the heart and the circulation of the blood at the time of the menarche, the little-known observations made by Beneke, on the growth of the heart and arteries in the various stages of development, deserve especial attention. According to this writer, the growth of the heart is slow until the age of fifteen years is attained, but becomes accelerated at the commencement 98of puberty. During this time of puberty, the blood-pressure attains its highest level, being comparatively low in childhood and later in life. The development at puberty of the female heart is less extensive than that of the male heart, and for this reason throughout adult life the capacity of a woman’s heart is on the average 25 to 30 cubic centimeters (1.5 to 1.8 cubic inches) less than that of a man. In women, also, the great arteries are on the average somewhat smaller than in men. The various arteries do not develop with equal rapidity throughout the period of growth; after puberty the common carotid grows very much more slowly than the common iliac artery, the former vessel being the only large trunk which has already nearly reached its maximum size at puberty.

The comparatively great development which the heart undergoes at the time of puberty is a phenomenon so important alike in its physiological and its pathological relations that it deserves the special designation of the puberal development of the heart; the commencement and the completion of puberty appear beyond question to be to a large extent dependent upon this development of the heart and upon the simultaneous rise in the blood-pressure of the systemic circulation due to the comparative diminution in the calibre of the arteries.

In the literature of this subject of cardiac disorders during the menarche, we find only short annotations on palpitation of the heart in young adolescent girls, and on cardiac manifestations in chlorotic subjects. Further, the statistical fact that valvular lesions of the heart are commoner in women than in men is by many authors explained on the ground that the disturbances of the time of puberty, which certainly occur more frequently and are more severe in the female sex than in the male, play an important part in their causation. Changes also in the vessel, such as cirsoid aneurysm (angioma arteriale racemosum), are supposed to be connected with the sexual processes of this period of life. C. Heine maintains that in consequence of puberty and of the sexual functions that become established at this period, a telangiectases will not infrequently undergo transformation into a cirsoid aneurysm; especially in cases in which menstruation is scanty and irregular, angiectatic tumors may exhibit a vicarious periodic increase.

Krieger describes nervous palpitation and also “cramps of the heart”^[22] as occurring in girls who have not yet begun to menstruate, in the form of prodromal manifestations; similar attacks may occur also at every menstrual period in girls in whom menstruation is 99fully established. In most of these cases the pulse is increased in the patients who complain of a sensation of anxiety, and speak of feeling the heart roll, tremble, or flutter, to which is sometimes superadded a sensation of sudden cessation in its activity. Not infrequently there is a blowing adventitious sound, masking or accompanying the heart-sounds; there are also venous murmurs, especially when the heart-trouble is associated with anæmia or chlorosis. Of the cases of pseudo-angina pectoris^[22] observed by Krieger, the attacks occurred as prodromal manifestations before the first appearance of menstruation in 22 per cent. of the cases, after menstruation was fully established in 78 per cent. of the cases; as regards the relation of the attacks, in cases of the latter group, to the menstrual period, they occurred before the flow in 33 per cent., during the flow in 67 per cent.; menstruation was irregular in 10 per cent. of the cases under observation, in most of the other cases menstruation had been irregular, but was now regular.

Hennig records a case in which he observed as a prodromal symptom before the establishment of menstruation the regular recurrence of congestion of the pelvic organs associated with cardiac disorder.

Diseases of the Nervous System.

The extensive transformatory processes occurring in the genital organs of young girls at the time of the menarche, and the powerful impression which the new thoughts, hopes, and fears excited at this period of life cannot fail to exercise on the nervous and emotional life, will enable us to understand how it is that the appearance of the first menstruation may give rise, especially in neurasthenic or psychopathic subjects, to manifold nervous disturbances and also to disorders of the mind.

Amongst the severe neuroses and psychoses liable to occur at the menarche in those suffering from congenital nervous weakness, in those the conditions of whose life are very unfavorable, and in those affected by some sudden disagreeable and powerful influences, we may enumerate: Hemicrania, precordial pain, hysteria, and epilepsy; impulsive manifestations, such as bulimia, longings for various unsuitable things, kleptomania, and pyromania; severe feelings of anxiety; various forms of psychoses.

On the other hand, the first appearance of menstruation has sometimes a favorable influence in girls suffering from nervous or mental disorder. This is seen, for example, in cases of chorea in 100fully developed, rapidly growing girls who have not yet begun to menstruate; in such subjects the chorea sometimes disappears as soon as menstruation is regularly established.

Quite frequently, the first appearance of hemicrania in young girls coincides with the menarche. According to Warner, hemicrania made its first appearance:

In 1 girl of 3 to 4 years.

In 2 girls of 5 to 6 years.

In 1 girl of 6 to 7 years.

In 5 girls of 8 to 9 years.

In 5 girls of 9 to 10 years.

In 4 girls of 10 to 11 years.

In 2 girls of 11 to 12 years.

In 4 girls of 12 to 13 years.

In 15 girls of 13 to 15 years.

Toothache, according to Holländer, in the early days of puberty sometimes exhibits the twenty-eight-day type of menstruation. The same periodicity has been recorded in cases of vicarious bleeding from the gums in girls suffering from disturbance of the menstrual function.

In the period of the menarche and before this period, chorea minor occurs, as a functional disturbance of the motor region of the nervous system, and especially in girls is it associated with the processes of the period of physical development. The statistical data supplied by a number of authors, Hughes, Pye-Smith, Russ, Sée, and Steiner, show that the proportion of boys to girls affected with chorea minor is 1 to 2.8, and that of all ages 49 per cent. of the cases occurred at the ages of 6 to 11 years, 29.8 per cent. at the ages of 11 to 13 years. In several cases, in quite young girls suffering from chorea, pathological changes were found in the genital organs. Thus, in 24 out of 27 girls from the age of 9 to 15 years affected with chorea, Marie found the symptom-complex designated by Charcot as ovarie. Ovarian tenderness was manifested on palpation, and always on that side on which the chorea had first manifested itself. Leonard found in a girl aged eleven suffering from chorea, adhesion of the præputium clitoridis; after the separation of the prepuce, the chorea disappeared.

As in respect of various nervous affections, so also in respect of various mental abnormalities, we witness at the time of the menarche numerous manifestations confirming the statement that, “no spinal reflex has such widely-opened and easily accessible paths of conduction toward the organ of mind, as the sexual reflex.” “The menstrual process,” continues Friedmann, “is the only bodily process in relation to which the organ of mind somewhat readily loses the remarkable stability of its equilibrium.”

In the experience of all alienists, it is, speaking generally, the inherited psychopathic tendency that especially manifests itself at the time of puberty; and it appears that this predisposition, the manifestations of which the resisting powers of childhood have 101hitherto been competent to suppress, undergoes a sudden and stormy development in consequence of the action of the menstrual stimulus, leading to the unexpected appearance of mental disorders. The commonest of these are mania and melancholia of the ordinary type, the prognosis in first attacks being favorable; next in frequency to these are the psychoses characterized by fixed ideas, which usually terminate favorably after a short time; finally, we meet with the moral psychoses of puberty, and the form of melancholia distinguished by Kahlbaum as Hebephrenie,^[23] the prognosis of which is very unfavorable, for it speedily terminates in dementia, similarly to the dementia of puberty described by Svetlin, dependent upon or associated with premature synostosis of the cranial bones. Very often we witness at puberty the beginning of the periodic varieties of mental disorder, which develop into periodic menstrual psychoses, manifesting themselves regularly at the recurrence of every menstrual period.

The fact that hysteria often first manifests itself at the time of the first appearance of menstruation was noticed already by Hippocrates, who indeed believed that the association was sufficiently explained by the well-known manifold relations between this nervous disease and disturbances in the female genital organs. The first hysterical attack often coincides with the first menstruation; or the first menstruation may lead to the recrudescence of hysteria which had manifested itself previously, but had passed into abeyance. We have to deal chiefly with the minor forms, such as uncontrollable and unconditioned attacks of laughing and crying, globus hystericus, clavus hystericus, etc.; hysteria major, on the other hand, is very seldom observed at the time of the menarche. As regards the frequency of hysteria at the time of puberty, we append certain statistical data.

Landouzy found:

4 cases of hysteria occurring at the ages of 1 to 10 years.

45 cases of hysteria occurring at the ages of 10 to 15 years.

105 cases of hysteria occurring at the ages of 15 to 20 years.

80 cases of hysteria occurring at the ages of 20 to 25 years.

After the age of twenty-five is attained, the frequency of hysteria declines very rapidly.

According to Bernutz, all the statistical data prove that hysteria in more than half the cases first manifests itself either just before or simultaneously with the commencement of menstruation. It seems also that at the time of puberty amenorrhoeic and dysmenorrhœic 102manifestations may give rise to the development of hysteria. In girls at this time of life, hysteria seldom takes the form of the great hystero-epileptic crisis, manifesting itself rather as nervous and moody states of mind, moral changes, weakness of will, in association with various forms of anæsthesia, spasm, and paralysis.

On the threshold of puberty the girl with a hereditarily neuropathic disposition may exhibit a tendency to epilepsy. In such cases, as Kowalewski writes, the patient has sudden attacks of loss of consciousness, commonly ushered in by a wild scream; during the attacks, tonic and clonic muscular spasms occur, the patient is completely insensible, the pupils are dilated and do not react to light, the pulse-frequency is increased—in short, the typical phenomena of an epileptic fit are exhibited. The loss of consciousness lasts from two to three minutes; and when the girl recovers, she remembers nothing of what has occurred during the fit. Though consciousness has returned, the mind is still at first somewhat disordered; but this disorder soon passes off, the girl becomes calm, and forgets what has happened. The physician is summoned, but in ninety-nine cases out of a hundred, he assures the relatives that “the attack is nothing of any consequence—a simple fainting-fit, the result of menstruation—a transient trouble merely.” A second “fainting-fit” disturbs the calm of the parents, but the reiterated authoritative assurance of the physician that “the trouble will soon pass away” restores their confidence; and they gradually become accustomed to the “fainting-fits” from which their daughter suffers at each successive menstrual period. The daughter marries, and gives birth to neuropathic and psychopathic children, and every one wonders what can be the cause of this misfortune. Hence it is necessary to pay careful attention to these “fainting-fits during menstruation.” In the great majority of cases they are in fact epileptic seizures, and as such they must be treated. Binswanger points out that in such cases, in which epilepsy first appears at the commencement of menstruation, the attacks may continue to accompany menstruation for several years thenceforward. Already established epilepsy is said by some authors, Lawson Tait, Tissot, and Marotte, for instance, to undergo at puberty in young girls an increase both in the severity and in the frequency of the attack; Esquirol, on the contrary, attributes to puberty a favorable influence on the course of epilepsy, a view held already by Hippocrates.

Not infrequently, attacks of precordial pain associated with tachycardia occur during the first menstruation. These attacks are usually of short duration.

Acromegaly, a disease regarded as a trophoneurosis, also requires mention here, this disturbance of growth being considered by several 103authors, and especially by W. Freund, to be in some way connected with the development of puberty; the tendency to acromegaly, it is suggested, is produced by the remarkable transmigration that occurs at puberty of the energy of growth from its accustomed paths into new channels. The relations which Neusser has shown to exist between the ovaries on the one hand and the vegetative nervous system and the process of hæmatopoiesis on the other, give a certain amount of support to this hypothesis, even though we have no intimate knowledge of disturbances occurring in the reproductive system during the period of development, which might have an influence in the causation of acromegaly.

Of old and of recent observations on the psychoses connected with the menarche, there is no lack. From the time of Hippocrates down to the present day, the authorities have continued to report cases in which the commencement of menstruation proved the exciting cause of the appearance of psychoses. Rousseau writes of a girl at the time of the menarche, who before the first appearance of menstruation suffered from attacks of melancholia and a tendency to pyromania, and under the influence of the latter tendency she twice committed acts of incendiarism.

According to Kirn, the psychoses that manifest themselves in the first period of the commencement of menstruation, sometimes melancholia, sometimes amentia in the form of slight and transitory maniacal derangement, more rarely a katatonic^[24] condition, may precede the menarche, or may accompany or follow it.

A special form of psychosis is associated with the menarche (von Krafft-Ebing, Griesinger, Friedmann, Schönthal). The influence exercised by puberty in this direction manifests itself in various ways, and is the more powerful for the reason that several factors are in operation, each of which exercises an individual influence upon the type of the psychical affection; these factors are, childhood, the development of puberty, and the periodicity of the disturbance exercised by the menstrual reflex. The last named of these influences is the most potent. It manifests itself in the following manner: Certain psychoses which develop before the commencement of menstruation or during the suppression of the flow, undergo modification when menstruation appears; further, in the typical menstrual psychoses of psychopathically predisposed girls, the attacks recur either at the beginning of each period, or, when the flow is in abeyance, at the dates when it should appear—the menstrual stimulus thus being the exciting cause of the successive attacks in an organ of mind whose resisting powers are deficient; and, finally 104a disturbance in the development of menstruation may be, not merely the exciting cause, but the efficient cause of the psychosis.

In cases of the last kind, which have been observed by Schönthal and also by Friedmann, who has described them very fully under the name of primordial menstrual psychosis, we have to do with young girls in whom the appearance of menstruation is retarded, or in whom the flow has been suppressed very soon after its commencement. The girls were as a rule hereditarily well endowed, and the psychosis thus appeared without warning, like a storm from a clear sky. Exactly periodical in form and character, the period of recurrence being three or four weeks, this psychosis clearly showed its dependence upon menstruation; the individual attacks usually lasted a few days only, and were characterized by distinct mental disorder, in the form either of maniacal restlessness, or of dominant depression; vasomotor disturbances were very prominent, with disordered pulse, as for instance, a rapid rise in the pulse-wave just before the onset of the attack, succeeded during the attack by a correspondingly rapid decline.

Friedmann enumerates a number of the peculiarities that characterize these attacks. The general course of the malady is an exceptionally stormy one. The ultimate cure may coincide with the definite regularization of menstruation; or, in cases in which menstruation is restored but remains inadequate, the course of the disorder may become a gentle undulatory one, the violent stimulus of total suppression being replaced by a more moderate stimulus—here also, however, a cure ultimately follows when menstruation at length becomes free as well as regular. But during the height of the malady a proper development of menstruation is always wanting. The total duration of the malady may vary from as little as two to as long as nine months, or even longer. The cure is, however, ultimately a complete one. The combination of a disturbed and delayed development of menstruation with a stormy periodic cycle of attacks of mental disorder, and the ultimately favorable termination, constitute according to Friedmann the peculiar characteristics of this form of puberal psychosis.

Masturbation.

Masturbation is sometimes practised in very early childhood, being then commonly due to local irritation of some kind, as for instance when threadworms find their way into the vagina. Itching results, leading the child to rub the genital organs. This rubbing produces a pleasurable sensation, and gives rise to repeated masturbation. But in adolescent girls at the time of the menarche, a vague impulse arises to handle the genital organs, depending upon cerebral 105processes which are themselves the result of sexual sentiments, of reading, or of conversations with sexually instructed female friends. This vague impulse may lead to masturbation, and will do so earlier and more surely if the girl is a neuropsychopath by inheritance. The local influence of menstrual congestion, however, also plays a part in provoking the impulse toward masturbation, since at every period a hyperæsthetic state recurs in the genital organs.

Girls thus addicted have sometimes a very striking general appearance. They are pale, with a weary expression of countenance, their eyes are dull-looking and darkly ringed, their movements are sluggish, they like to spend a long time in bed—signs, however, which I by no means wish to adduce as characteristic of onanists.

Temperament and mode of life are decisive in determining the greater or less frequency of the habit of masturbation in young girls. Girls of a passionate temperament, those also who from early childhood have been accustomed to mix much with young persons of the opposite sex, and those, finally, in whom from conversation on the subject with female friends or from the perusal of erotic literature, sexual enlightenment has occurred at an early age, experience the awakening of the sexual impulse earlier and with greater force, than phlegmatic girls, than those who have grown up apart from boys, and than those who have been strictly and carefully brought up. Masturbation may arise either instinctively or from instruction.

In young girls masturbation is usually effected by friction of the clitoris; less often by intra-vaginal manipulation, since this is liable to lead to injury to the hymen. For the former purpose the finger may be used; or some other article, such as a knot tied in the nightgown, or a rounded projection on some article of furniture; in one case the friction was effected by the naked heel. If two female onanists come together, they practice tribadism, presently to be described. Opportunity for this practice occurs especially in institutions in which young girls occupy a common dormitory, and sleep together without adult supervision.

An experienced physician, Gutceit, is of opinion that in young girls of 10 to 16 years of age masturbation is on the whole less common than in boys of the same age, but that on the other hand from the ages of 18, 19, and 20 onward, “sexual self-gratification is almost universally practiced by women, even if it be not always practiced to excess,” an opinion which cannot, however, be regarded as conclusive. As consequences of masturbation in the female sex, this author has observed: Fluor albus, menorrhagia, enlargement and prolapse of the uterus, pains in one or other ovary, hysterical paroxysms, great pallor.

106L. Löwenfeld remarks that the manifestations of the sexual impulse are not normally present in the days of childhood. In consequence of pathological conditions, especially of such as effect the genital organs, in consequence of chance impressions, or in consequence of a bad example, sexual passion may indeed be awakened in children in its fullest intensity. Normally, however, the distinct manifestation of the sexual impulse is associated with a certain degree of development, of ripeness, of the reproductive organs. Physiologically, sexual passion is entirely wanting in young girls before the age of puberty.

As regards the act of sexual self-gratification, this author distinguishes two forms of masturbation: (a) Peripheral-mechanical; (b) mental (psychical onanism). In the former class of cases, the sexual orgasm is produced solely or chiefly by mechanical stimulation of the skin or mucous membrane of the genital organs. In the female sex, in addition to manual stimulation, an extraordinary variety of hard and soft articles are introduced into the vagina for this purpose. Many females effect sexual self-gratification by rubbing and pressing movements of the thighs one against the other, in which the clitoris is implicated. In psychical onanism, on the contrary, as Löwenfeld points out, the orgasm is produced solely by central stimulatory representations, without the assistance of any manipulation of the genital organs. The ideas that have this effect are for the most part lascivious trains of thought or the recollection of previous sexual experiences, on which the attention is concentrated. If we wish to estimate the harmfulness of the different forms of masturbation as regards the mind and the nervous system, psychical onanism must incontestably be regarded as the most deleterious.

In the female sex onanism is, in Löwenfeld’s opinion, less widely practiced than in the male; none the less, it is in the former sex far commoner than is generally believed, a fact on which Eulenburg likewise insists. Frequently, also, in females, a congenital neuropathic tendency plays a part in the causation of masturbation, in so far as this tendency takes the form of premature sexual excitement or of excessive intensity of the sexual impulse. In the absence of this tendency, masturbation rarely leads to the production of well-marked nervous disturbances, and does so only when practiced to very great excess. Beard reports that in the powerful and full-blooded working-class girls of the Irish race, masturbation, even when practiced for many years, did not result in any notable disorder to health.

As regards the nature of the nervous manifestations met with in women as a result of masturbation, there develops, according to 107Löwenfeld, in one group of the cases, the sexual form of myelasthenia, characterized principally by sacrache and lumbago, hyperæsthesia and paræsthesia in the domain of the genital organs (ovarie,^[25] pruritus vulvæ et vaginæ, etc.), irritable bladder, coccygodynia, weakness and paræsthesia of the legs (feelings of fatigue and chilliness), finally, the onset of erotic dreams. In many cases, in the course of time, to these symptoms are superadded the manifestations of cerebral and visceral neurasthenia (headache, insomnia, nervous dyspepsia, palpitation), so that the clinical picture comes to be one of general neurasthenia. In addition to the neurasthenic troubles, manifold hysterical manifestations may occur.

Disorders of Digestion.

Disorders of the digestive apparatus are quite common in girls during the period of puberty, and usually take the form of nervous dyspepsia. Disturbances of sensibility predominate, with a sensation of pressure after meals, sometimes increasing to nausea, retching, and vomiting, as manifestations of general hyperæsthesia of the gastric mucous membrane, loss of appetite, a pasty or acid disagreeable taste, sometimes bulimia, perverse sensations of taste, and pyrosis. Especially in chlorotic girls, periodic attacks of pain occur, localized in the epigastrium and its neighbourhood, and exhibiting no relation to the ingestion of food. The free hydrochloric acid varies in amount, being now normal, now diminished, sometimes also increased. In chlorotic cases, the symptoms of round ulcer of the stomach are sometimes observed. Intestinal activity is usually depressed, peristalsis is diminished, so that more or less obstinate constipation is one of the most frequent symptoms.

Hypertrophy of the tonsils at the time of puberty is in some way related to the menstrual processes, whether by the intermediation of the nervous system or by that of the blood. Eisenhart quotes observations made by Chassaignac, of girls eighteen or nineteen years of age with hypertrophy of the tonsils, associated with retarded puberty, menstruation having begun late and being scanty, and the breasts being underdeveloped; in one young girl with tonsillar hypertrophy, one of the breasts had failed to develop properly, but after the removal of the tonsils it speedily grew to the normal size.

Diseases of the Respiratory Organs.^[26]

Not uncommonly at this period of life the growth of a goitre is observed. The influence of puberty on the growth of the thyroid 108body has indeed been asserted by several authors; and Neudörfer maintains that precisely during the period of puberty to this body must be assigned an important regulatory trophic significance for the nourishment and growth of the reproductive organs. Steinberger and Sloan record the observation of cases occurring in young girls in whom, menstruation having first been regular, but having been suddenly suppressed in consequence of external noxious influences, a rapidly growing goitre suddenly appeared.

P. Müller states that in many regions, as for instance in Canton Berne in Switzerland, where the school children exhibit with extraordinary frequency a hereditary tendency to the formation of goitre, during the years of childhood these growths are much less frequent in girls than in boys. At the time of puberty, however, this relation is entirely changed. Whereas in boys from this time onward no further growth of the thyroid body is observed, in girls at puberty the hypertrophy greatly increases, so that very large goitres are formed. The same author recurs to the earlier observations of Heidenreich and Schönlein, as well as to those of Friedreich, by which this influence of puberty is strikingly manifested, and he believes it to be established by experience that sexual excitement can produce a transient swelling of the thyroid body. He alludes also to the remarkable fact that a swelling of the thyroid body, to which a number of animals show a tendency, occurs chiefly at the time of heat or rut; this is especially well known to occur in the case of stags. Similarly, during menstruation, a transient swelling of the thyroid body can sometimes be detected; the swelling is greater if the menstrual discharge fails to occur.

Diseases of the Organs of the Senses.

At the time of the menarche in cases in which there is retardation or some other disturbance in the regular appearance of menstruation, affections of the eye are observed, which are in part functional, dependent on reflex influences proceeding directly from the genital organs without organic changes, and in part are due to circulatory disturbances. Mooren, S. Cohn, and Power have discussed the relations between the uterus and the eyes in general, and also in this especial connection. Of ocular troubles during the menarche, iridochoroiditis, hæmorrhages into the vitreous body, long-continued blindness, and pannous keratitis, are mentioned, which may either disappear with the reestablishment of menstruation (spontaneous or artificially effected), or may exhibit in such circumstances a notable alleviation. Chronic inflammatory states of the conjunctiva, usually of an eczematous nature, which frequently occur at the time of puberty, often exhibit a relation to the menstrual process, a monthly exacerbation of the ocular trouble 109coinciding with disordered menstruation, and cure taking place only when menstruation has become perfectly regular. Vicarious hæmorrhages into the vitreous body also occur, associated with disturbances of menstruation, the relapses ceasing as soon as menstruation becomes regular; such a case was observed by Courserants in a girl of fourteen years.

Disturbances of hearing have been observed at the time of puberty in young girls addicted to masturbation; the patients complain of subjective noises, rising in intensity till actual hallucinations may be experienced. Lichtenberg reports the case of a strong girl eighteen years of age, in whom the congestion associated with puberty was followed by atrophy of the auditory nerve. The same author, also Ashwell, Law, Puech, Rossi, Stepanow, and Gilles de la Tourette, have published cases of vicarious menstrual hæmorrhage from the external auditory meatus, occurring in girls of ages varying from 14 to 16, 17, 20, and 22 years. Amongst these cases, in some the auditory organ was in a healthy condition, but in others there was associated purulent discharge; the bleeding took place from the ears at the menstrual periods, the proper menstrual discharge being absent or scanty; after the ear trouble was cured, menstruation was normal. Of 200 cases of vicarious menstruation, there were, according to Puech, six in which the vicarious bleeding was from the ears.

Disturbances of the olfactory sense, taking the form, sometimes of diminished acuteness of this sense, sometimes of increased acuteness, and sometimes of perversion, also anomalies in the secretion of the nasal mucous membrane, either abnormal dryness, or greatly increased secretion of mucus, come under observation at this period of life, either as reflex manifestations through the intermediation of vasomotor nerves at the time of the first appearance of menstruation, or in consequence of chronic nasal catarrh, which may be connected with masturbation. In cases in which the menarche is retarded, vicarious epistaxis may also occur, the bleeding sometimes being very profuse, in one case, indeed, reported by Fricke, in a girl seventeen years of age, having a fatal termination. According to Mackenzie, sexual excitement leads to swelling of the nasal mucous membrane, and habitual masturbation to chronic nasal catarrh; the same author asserts that during menstruation, swelling of the turbinate bodies may always be observed, and that in this lies the explanation of the fact that many women complain of a monthly cold in the head as an accompaniment of menstruation.

Diseases of the skin are not uncommon in young girls at the time of the menarche, and later as an accompaniment of each successive menstruation. It is a well-known fact that at puberty girls sometimes lose a hitherto beautiful complexion, and suffer from various 110disfigurements of the skin of the face. These are produced especially by the profuse secretion of sweat, and by the excessive secretion of the sebaceous glands, which so often results in acne, an inflammation of these glands. Ecchymoses also, effusions of blood into the skin, are observed, especially, as a form of vicarious menstruation, in cases in which menstruation is irregular. When actual bleeding occurs from the intact skin, the blood finds its way out through the sudoriferous ducts—hæmatidrosis occurs; in some cases, however, the hæmorrhage takes place from areas of skin altered and injured by disease, from wounds or other injuries, from ulcers, or from excrescences. Hæmorrhage into the skin occurs also in the so-called stigmatization, in which condition also an etiological role has been assigned to menstruation.

In the skin, remark Spietschka and Grünfeld, a new life begins at the time of the development of puberty, and it is this which first gives to human beings the external characteristics of sexual maturity. In certain regions which have hitherto been covered only by fine downy hairs,^[27] thick, strong hairs develop, and at the same time the general growth of hair becomes more active. These regions are, the genital region, and the axillæ. This increased growth of hair is accompanied by a stronger secretion of the sebaceous glands, which very often is in excess of actual requirements, and may thus lead to cosmetic disturbances and to various diseases of the skin. Thus arise the various forms of seborrhœa.^[28] The commonest of these is the formation of comedones, which, at the time of puberty, may make their appearance especially on the nose, the forehead, and below the corners of the mouth, but also on other parts of the face or on the back and the breast; in those regions, that is to say, in which the sebaceous glands attain a considerable size. The retention of the sebum may give rise to inflammation, which the access of micro-organisms converts into suppuration. Thus arises acne vulgaris. In another form of seborrhœa,^[28] the secretion is more fluid in consistence, and collects on the surface of the skin, furnishing this with an oily covering—seborrhœa oleosa.^[28] This most 111commonly occurs on the face; if the fatty layer is removed, the skin remains dry for a brief period only, and soon becomes greasy and shiny once more. Dust readily adheres to the greasy surface, and this gives the face a dirty appearance. Seborrhœa faciei is readily converted into eczema.

With the puberal development of the external genital organs is associated an increase in the sebaceous secretion of these regions. On the clitoris and its prepuce, and on the folds and in the furrows of the vulva, in consequence of insufficient cleanliness, an accumulation of sebum and cast-off epidermic scales readily occurs; such an accumulation may become rancid, may irritate the skin, and may thus give rise to erosions and to purulent secretion.

In chlorotic girls at the time of puberty, on account of the anæmic condition of the blood, eczema is not uncommon, especially on the hands and the face. On the face, or on the forehead, red papules appear on circumscribed areas, and become vesicular; raw, weeping spots are thus formed, and have a very disfiguring appearance. Such eczema may occur also in connection with disturbances of menstruation, when the menses are scanty and pale, or when dysmenorrhœa is present.

At the time when menstruation ought to appear, but fails to do so, sometimes also, when menstruation is regular, with each successive period, an eruption of urticaria takes place; it usually disappears quickly, but in some cases is more persistent; owing to the intense itching it is always an extremely distressing complaint. Sometimes it takes the form of urticaria factitia, in which the skin reacts to every kind of mechanical stimulation, such as rubbing, scratching, or pressure, all of which alike lead to the formation of weals, which may be diffused all over the body. Less often in association with disturbances of menstruation, acute œdema or erythema are observed.

Finally, we must mention herpes progenitalis, a rather uncommon acute condition in which, with violent itching and burning sensation, intense redness and œdematous swelling of the skin, vesicles form on the præputium clitoridis, the nymphæ, and the inner surface of the labia majora.

Hygiene During the Menarche.

It is the object of rational hygiene to increase the resisting power of the organism, which has been depressed by the processes of the menarche, in order that the increased demands made by the awakened sexual life may be adequately met.

The principal means for this purpose are, suitable diet, a suitable mode of life, and the employment of physical therapeutic measures, 112among which strengthening and hardening measures are to be preferred.

The diet should be at once as richly albuminous as possible and readily digestible, there should be several, four or five, meals every day; in chlorotic patients food should be taken at regular intervals of two to three hours. Meat should be a predominant article in the diet, but fresh vegetables should also be eaten in abundance for the sake of the nutritive salts they contain; the vegetables rich in compounds of iron, such as spinach, oats, beans, and lentils, are to be recommended; fruit, raw or cooked, should also be taken in considerable quantities. The evening meal^[29] should not be too succulent or too plentiful; it may best consist of soft-boiled eggs, an omelette, or milk. Alcoholic beverages should be avoided or taken in minimal quantities; only as a stomachic may a glass of beer or of light wine be recommended.

Chlorotic patients should even at their first breakfast^[29] have a meal rich in albumin, such as a considerable helping of meat, or a beefsteak, with rolls, butter, and tea or coffee. Milk should be taken in small quantities only, not more than a pint to a pint and a half daily; only when solid food cannot be tolerated should milk be given freely. Beer and wine are often of value in chlorotic girls from their stimulant action on digestion and circulation. Half an hour’s rest before and after meals is useful.

For the bill of fare of these patients I recommend especially: Roast beef and veal, underdone beefsteak à l’Anglaise, ham; roasted venison, hare, partridge, grouse, fieldfare, hazel-hen, ptarmigan, pheasant, chicken, pigeon, turkey, oysters; asparagus, cauliflower, and spinach. For variety, fish or shellfish may occasionally be taken. Sweetbread in soup or with sauce forms a very delicious and easily digestible dish.

Kahane recommends for chlorotic patients the systematic use of Bavarian beer, to the amount of about two pints daily; it should, he says, be a beer rather dark in tint, full-brewed, rich in malt, but containing a comparatively small proportion of hops, alcohol, and carbonic acid. Jaworski has recommended a dietetic iron-beer, containing 4.7 per cent. of alcohol and from 0.0317 to 0.0644 per cent. of iron.

When girls are at the same time anæmic and very thin, fat-containing foods must be taken in abundance, such as milk, butter, and 113cream; also large quantities of carbohydrates. Farinaceous foods, rice, potatoes, arrowroot, sago, tapioca, oatmeal, barley meal, carrots, turnips, sweet fruits, grapes, dates, pippins, plums, pears, and preserved fruits—all these must appear at table more frequently than usual; beverages, in addition to milk, that are suitable are chocolate and cocoa, Bavarian beer, and sweet, heavy wines.

The diet-table of such thin chlorotic patients should be as follows:

First breakfast, 7.30 to 8 A. M.: Coffee or cocoa with milk, or a pint of milk, white bread and butter, honey. Second breakfast, 10 A. M.: Half a pint to a pint of milk, egg and bread and butter, or sandwiches of sausage, ham, or roast meat. Mid-day dinner, 1 P. M.: Soup, roast meat with vegetables and potatoes, or fish may take the place of the soup, sweets to follow. Afternoon, 4 P. M.: Coffee with milk, or a pint of milk, with bread and butter. Supper, 7.30 P. M.: A plate of meat with accessories. Evening, 9 P. M.: A glass of milk.

In the treatment of the anæmic form of obesity, to which chlorotic patients of the better classes are subject, in consequence of sedentary habits and overfeeding, the diet must be so arranged that albumins predominate, whilst carbohydrates should be given sparingly, and as little fat as possible. As the average quantities of the food elements required in such cases, I suggest, 200 grammes of albumin, 12 grammes of fat, and 100 grammes of carbohydrate.

The quantity of fluid taken must be as small as possible, since the deprivation of water may result in a proportionate increase in the solid constituents of the blood, and thus increase its hæmoglobin-richness.

The amount of physical exercise taken by young girls at this period of life must vary according to the circumstances of each individual case. In general, we may recommend for them much active movement, especially in the open air, in order to counteract the effects of sedentary habits and confinement in close rooms. Chlorotic patients must, however, be careful to avoid overdoing their exercise, and in some cases it will be necessary to limit the amount of this very strictly. In severe cases of chlorosis, Nothnagel, Hayem, and other authorities recommend complete rest in bed for from four to six weeks. This rest-cure can be carried out as far as possible in the open air, and can be combined with systematic massage and the use of passive movements.

114I have drawn up the following diet-table for obese chlorotic patients:

Quantity in Grammes. Contains of

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

White bread 30 2.9 0.2 18.0

Total 1380 206.97 11.92 97.6

Contains about 1300 calories.

For young girls at this period of life systematic gymnastic 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 clothing of young girls at the time of the menarche must receive attention to this extent, that all articles of clothing should be rejected which increase the tendency already existing to hyperæmia 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 restricts the freedom of movement of the thorax and the abdomen, tight collars, and tight garters—all these must be forbidden; moreover excessively warm underclothing, of the lower extremities especially, which may stimulate the genital organs, must also be prohibited.

115As 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 exercise 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 chill; in summer, swimming and rowing. The reading 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, appropriate 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 temperature of the water ranging from 10° 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 anæmic, 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 anæmia 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 anæmic 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 116is delayed, and in whom menstruation, when begun, has been scanty and irregular, cold sitz-baths of short duration, the abdomen being 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 especially recommended for girls suffering from chlorosis, at first, by Scholz and Schubert, in association with phlebotomy, but also without this. Kühne, for example, has seen the most satisfactory results follow the simple use of sudatory baths in cases of chlorosis; improvement was manifested by an increase in the corpuscular richness of the blood, an increase in the hæmoglobin-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 consequent diaphoresis.

Still more recently Dehio and especially Rosin have recommended hot baths for girls suffering from chlorosis. 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 treatment 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-intoxication theory of chlorosis may regard the diaphoresis as a means for the elimination of noxious substances from the body.

Bathing in water aerated with carbonic acid may be recommended for patients suffering from anæmia 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 effective principally in virtue of the carbonic acid they contain, which stimulates the skin; this stimulus being conducted by the nervous system from the periphery to the nerve-centres, is reflected thence, and by irradiation exercises a quickening effect on all the processes of nutrition. These baths are usually taken at a temperature progressively reduced from 32° C. 117to 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 menarche is delayed, also for chlorotic patients with amenorrhœa 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 hæmoglobin-richness, 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, scrofulous girls, suffering from scanty or irregular menstruation, may also practice sea-bathing with advantage, especially at watering places on the sea coast, where the waves are powerful. In such cases, however, it is advisable in the first instance to take artificially 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, aromatic herb baths are sometimes useful. For this purpose such herbs should be employed as contain a notable quantity of ethereal oils, such as sage (salvia officinalis), wild thyme (thymus serpyllum), hyssop (hyssopus officinalis), wild marjoram (origanum vulgare), rue (ruta graveolens), archangel (archangelica officinalis), levisticum (levisticum officinale). Equally 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 recommended. 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 hæmatopoiesis 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 118corpuscular richness and hæmoglobin-richness of the blood in consequence of residence in a mountain climate, is lasting or merely transitory, yet it is certain that the hæmatopoietic organs are favorably influenced by such residence, and that the good results are augmented by the stimulating 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 dysmenorrhœa 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 resisting 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 coast of the North Sea is especially suitable. For the slighter forms of anæmia, 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 anæmia or chlorosis.

Such very weakly, intensely anæmic and chlorotic patients should spend the 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 disfigured by comedones and acne, must be carefully guarded against the accumulation of sebum in the sebaceous glands by sedulous washing with warm water and a good soap. If the seborrhœic^[30] process in these glands becomes at all severe, ordinary soaps are unsuitable, 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 seborrhœa is according to Spietschka and Grünfeld the following: The washing 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 Pharmacopœia) 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 material, such as boric vaseline, in order to prevent the plugging of the pores with 119dust, and to protect the sebum subsequently exuded from dessication. 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 accumulation 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 with toilet powder should be placed in the labial furrows.

It is of great importance 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 observed in which a vaginal examination, the introduction 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 treatment 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 result. If in such cases, especially in girls of a neuropathic temperament, gynecological treatment is quite indispensable, a single, though energetic, operative procedure 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. Saenger, 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 curetting as compared with milder intra-uterine impressions 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 to 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 resisting power, temperament, and constitution of the 120girl 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 Gœthe’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 desires 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 insufficient 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 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, neurasthenic and hysterical states, disorders of menstruation, 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 removed. For the adolescent girl a systematic alternation 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 121avoided, 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 imagination may remain pure and in order that girlish illusions may not be prematurely destroyed. Domestic recreations in the way of games, music, singing, painting, and other forms of artistic culture, are of importance for the development of a strenuous faculty for learning. Travel in regions where the scenery is beautiful, forms a most valuable means for the ennoblement of the intellect and the emotions.

Additional matters demanding attention are, as already 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 forbidden, 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. Gymnastics, with or without apparatus, swimming, skating, and lawn tennis, involve a number of bodily movements 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 onanistic manipulations.

Especial attention must be paid to the clothing, regarding which the requirements of fashion so often conflict with those of hygiene, the victory, unfortunately, in most cases falling to the former. The period of the menarche is indeed usually regarded as the proper time for the young girl to begin wearing a corset, if it has not been worn before. In this connection 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 122former feature, the compression of the abdominal viscera, the corset liver (lacing liver, constricted liver, Ger. Schnürleber), the movable kidney, etc.—all are so well known that they need not be particularly described. But the strong pressure from above has a deleterious effect upon the internal genital organs also, leading to passive hyperæmia and to displacements. The ‘bones’ of the corset take part in the compression, 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 become 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. 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 supporting 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 petticoats is too great to be borne by the shoulders, the burden can be divided, some being fastened to the corset, 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’ under garment, 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.