Part 11

A further important consideration is the time at which the menarche occurs, and whether on the one hand it is at or near the average age, or whether on the other, as precocious menstruation, it is unusually early, anticipating the general bodily development, or again as retarded menstruation it is unduly delayed. In some cases of retarded menstruation, the external genital organs are thoroughly well developed, and it is menstruation only that remains in abeyance; but in other cases the external genitals are also backward in development, the pubes and mons Veneris being but sparsely supplied with hair, and the breasts remaining very small.

In addition to these abnormal temporal relations of the menarche, certain other irregularities at the commencement of menstruation are worthy of note. Thus, the first menstruation may be normal, but thereafter amenorrhœa may persist for several months, or if the flow occurs it may be exceedingly scanty, or very pale in color; on the other hand, menstruation may be very profuse, lasting many days.

The environment in which the young girl is placed during the period of her sexual development has a great influence on the processes of the sexual life and on the pathological disturbances that affect these processes.

In working-class families the immoderate physical strain often thrown upon girls, in many cases continuous movements of the upper extremities whilst the lower extremities and the pelvis are absolutely quiescent, or conversely, an excessive employment of the muscles of the lower extremities—these circumstances in conjunction with insufficient nutriment, night-work, association when at work with persons of the opposite sex, and the frequent premature sexual stimulation, will combine to have a most deleterious effect.

Amongst country-folk, indeed, the girl has the enjoyment of fresh air, and as a rule nutritive food, moreover, there are not so many occasions of nervous stimulation; puberty therefore arrives more slowly and gives rise to less disturbance; but the ignorance of the girls very frequently leads to an early experience of coition, the natural and unnatural consequences of which have then to be taken into account.

Amongst the better classes of townspeople such hygienic regulations and educational measures are in common employment that young girls during the years of development usually receive reasonable care and attention—but very frequently, intercourse with older girls, association with young men, visits to theatres, evening-parties, and balls, and the perusal of stimulating literature, form unfavorable features of urban life which exercise their inevitable effects in the sexual sphere. In some cases, fortunately sufficiently rare, the stimulation of the sexual impulse and the longing for its satisfaction are so intense, that a kind of demi-vierge is brought into being, a young woman who is concerned only to preserve the physical token of virginity, but whose thoughts and fancies are anything but maidenly. It is to be feared that in consequence of the excessive freedom in education and the emancipated independence of feminine youth, these “half-virgins” are increasing both in number and in intensity, a fact which cannot fail to increase also the number of sexual maladies and perversions.

Anatomical Changes in the Female Genital Organs in the Period of the Menarche.

The female reproductive organs, which in childhood were in a comparatively quiescent state, now become powerfully active, as is witnessed by the changes that occur in the external genitals.

The soft, hairless vulva of the child becomes enlarged at the time of the menarche by the deposit of fat, and its substance becomes tough and elastic. Some time before puberty, fine, pale hairs make their appearance here and there, but not until puberty does the hairy covering of the pubic region become more or less thick. The growth of the denser pubic hair begins with the appearance of hairs along the middle of the mons Veneris and at the margins of the labia majora. Early sexual development is commonly indicated by an early and thick growth of the pubic hair. In the virgin this hair is smoother and less curly than in the later course of the sexual life. In certain tribes of negroes it is the custom for the young unmarried girls to shave off the pubic hair, which is not allowed to grow freely until after marriage. In some of the tribes of South Sea Islanders it is customary at puberty to tattoo the external genitals and the surrounding skin.

FIG. 8.—Internal genital organs of a new-born, powerfully developed female infant. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

In young virgins the rima urogenitalis or vulval cleft is closed by the accurate opposition of the labia majora; the labia minora or nymphæ are delicate in texture, rose-red in color, hairless, free from fat, and completely covered by the labia majora; whilst the clitoris is likewise concealed. The sebaceous glands of the labia minora secrete a smegma which collects especially around the glans clitoridis, and as it undergoes decomposition diffuses a peculiar odor, resembling that of old cheese. A wing-like elongation of the labia minora in young girls, with free secretion and a generally moist appearance, leads to a suspicion of the practice of masturbation. In the virgin the orifice of the vagina is covered by the hymen.

FIG. 9.—Reproductive organs of a new-born, powerfully developed female infant in median sagittal section. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

FIG. 10.—Internal genital organs of a girl aged eight years. Seen from behind. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

The entrance to the vagina in the virgin is rounded, the posterior border of the aperture being deeply concave, whilst the anterior border is often slightly convex backwards. Where this feature is strongly marked, the orifice has a semilunar shape. The posterior concave border projects forward in the form of a fold, continuous above with the posterior vaginal wall; this fold is the hymen.

FIG. 11.—Reproductive organs of a girl aged ten years in median sagittal section. Left half. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

FIG. 12.—Female external genital organs of a virgin, attached to the vagina which has been isolated and opened, and a portion of the cervix uteri, Hymen, etc. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

FIG. 13.—The external genital organs of a virgin, drawn apart transversely (after von Preuschen). c. Clitoris. f. c. Frænum of the clitoris. n. Nymphæ. l. Labia majora. o. u. Urethral orifice. h. Hymen. f. n. Fossa navicularis. ]

The infantile uterus is so proportioned that its neck (collum vel cervix uteri) constitutes the larger part of the organ, as much indeed as two-thirds. Owing to the small size of the body (corpus uteri), the whole uterus is very flat, and its borders ascend in a direction almost parallel to each other, diverging somewhat abruptly into the Fallopian tubes, recalling in some degree the two-horned embryonic form of the organ (uterus bicornis). The plicæ palmatæ on the surface of the cervical canal, which make up the arbor vitæ uterina, are strongly developed; the median longitudinal ridge bifurcates, and its divisions can be traced on either side into the uterine orifice of the Fallopian tube (ostium uterinum tubæ). The lips of the vaginal portion of the cervix are comparatively speaking very large and terminate in sharp angles. The vaginal mucous membrane is everywhere beset with long papillæ. The development of the uterus shortly before puberty consists chiefly in the enlargement of the body of the uterus, and the growth of its walls in thickness.

FIG. 14.—Sagittal section of the female pelvis (after Breiolei). ]

At the time of puberty, according to Toldt, the body of the uterus in the virgin has already increased till its length is half that of the entire organ; and at the first appearance of menstruation the body and neck of the virgin uterus are nearly equal, with perhaps a slight preponderance in size of the cervix, and the walls of the uterus have become convex. In consequence of this change the organ becomes pear-shaped, and the uterine cavity (cavum uteri) assumes the form of a triangle with moderately incurved sides. The cervical canal becomes wider in the middle; the margin of the os uteri becomes smooth and rounded. The walls of the virgin vagina are marked with numerous dentate transverse ridges (rugæ), especially near the lower end and on the anterior walls, the columns of the vagina (columnæ rugarum), from which the transverse ridges run to either side at right angles, extend half way up the vagina, and are of a hard consistence.

The characteristic changes in the ovary at the time of the menarche originate in the changes undergone by the ovarian follicles. A large number of small separate follicles is to be found already in the ovary of the new-born infant. These structures, known as primitive follicles, are formed by detachment from the egg-tubes that grow down into the stroma from the superficial germinal epithelium; they are spheroidal vesicles, enveloped by a single layer of cubical cells, and their interior is entirely filled by the primitive ovum or egg-cell. This latter consists of very finely granulated protoplasm with spherical nucleus and distinct nucleolus, but no trace of an investing membrane can as yet be discerned. The further development of the ovarian follicles takes according to Toldt the following course: A rapid multiplication of the cubical cells that form the wall of the follicle occurs, so that the ovum is surrounded by two, three, or several layers of cubical or rounded cells, and the whole follicle gradually increases in size. At the same time the ovum assumes an eccentric position in the interior of the follicle. At or near the middle of the follicle a slit-shaped space now appears, filled with a clear colorless fluid. As this space gradually enlarges, the follicle becomes converted into a vesicle filled with fluid, the wall of which is composed of small cubical cells. Simultaneously with the growth of the follicle a lamination of the elements of the surrounding stroma takes place, so that a somewhat sharply defined capsule is formed. In this condition these glandular structures of the ovary are known as graafian follicles.

Before puberty, these graafian follicles are small vesicles of a diameter of one to two millimetres, containing the large unicellular ova. Each of these consists of an envelope, the zona pellucida (also known as the zona radiata, or striated membrane of the ovum); an external granular mass of protoplasm, the vitellus or yolk; a vesicular, spherical nucleus, the germinal vesicle; and a nucleolus, which if single is large and prominent, the macula germinativa or germinal spot. As early as the second year of infancy every imaginable intermediate stage between the primitive follicle and the fully-developed vesicular graafian follicle can be observed.

At the time of puberty certain larger follicles are always to be distinguished, which have moved inward toward the interior layers of the ovary, whereas the smaller follicles have a more peripheral situation; thus, according to Waldeyer, we observe at this time in a section of the ovary, proceeding from without inward, first the epithelium, next the fibrous tunic, next the zone of younger follicles, and finally the zone of older follicles. According to Henle and Waldeyer, at the commencement of puberty, there are in each ovary about 36,000 ova, giving a total for the two of 72,000.

FIG. 15.—Primitive follicles. ]

In the further course of development of the graafian follicles at this period, the most advanced now reapproach the surface of the ovary, so that a fully-matured follicle comes to occupy almost the entire thickness of the cortical substance, and may even give rise to a localized bulging of the surface of the organ. In such a mature follicle, which has attained nearly the size of a pea, we recognize an outermost connective-tissue investment (theca folliculi), consisting of condensed ovarian stroma, in which two layers are distinguished, sometimes called simply outer tunic and inner tunic, sometimes known by the names of tunica fibrosa (outer) and tunica propria (inner), respectively; within this is the cellular layer known as the membrana granulosa (or stratum granulosum), the portion of which, now greatly enlarged, immediately surrounding the ovum is known as the discus proligerus (or cumulus oöphorus); the interspace between the discus proligerus and the membrana granulosa is filled with a clear fluid, the liquor folliculi. In consequence of the continued increase in its fluid contents, the graafian follicle ultimately bursts along the most prominent portion of the superficial wall, and the ovum passes out through the rupture, finding its way under normal conditions into the Fallopian tube and through this into the uterus. The follicle itself then undergoes a regressive metamorphosis, forming the corpus luteum, the rent in the envelope of which, after the absorption of the yellowish semi-fluid contents, undergoes cicatrization. Contemporaneously with this development at puberty of the process of ovulation, menstruation also for the first time makes its appearance, recurring thenceforward at four-weekly intervals as the regular catamenial discharge.

We append the account given by Pfannenstiel regarding the ovarian follicles. He writes: “In correspondence with the especial function of the female reproductive gland, which is to bring to maturity and to evacuate only after the lapse of a considerable period and at successive intervals, the ova which it has contained from the very outset, we find that primitive follicles continue to exist in the ovary up to the very end of the period of sexual activity, though naturally in diminishing numbers; and the size and shape of these primitive follicles remain nearly identical throughout the various periods of life. As the follicle ripens, the epithelium grows, the cells becoming cubical with a rounded nucleus, and increasing in number by cell-division, so that several layers are formed. As soon as these layers are three or four in number, a space, at first slit-shaped, forms in the epithelium on the peripheral surface of the ovum; this space is filled with fluid, known as the liquor folliculi; the peripheral layer of cells, the membrana granulosa, is thus separated from the mass of epithelial cells immediately enveloping the ovum, the discus proligerus, which is situate in the side of the follicle adjacent to the hilum of the ovary. By the increase of the liquor folliculi the graafian follicle is formed, a vesicle the envelope of which is formed by the multilaminar membrana granulosa, whilst in the pole of the vesicle directed toward the hilum ovarii is the ovum imbedded in the mass of cells forming the discus proligerus, a mass which has the form of a truncated cone. The liquor folliculi is formed by the epithelium, the nuclei of which disappear by chromatolysis or by simple atrophy whilst the cell-bodies liquefy in consequence of albuminous, not fatty, degeneration (Schottländer). Within the epithelium of the follicle we find the faintly glistening epithelial vacuoles of Fleming, likewise cells which liquefy and assist in increasing the bulk of the liquor folliculi. This liquor is a thin, serous fluid, and contains albumin. * * * Every graafian follicle has a bilaminar investing membrane, which is formed by the ovarian stroma. * * * The ovum of the growing follicle increases in size very slowly indeed, attaining on the average, according to Nagel, a diameter of 165 to 170 µ, it retains its zona pellucida, the greater part of the protoplasm of the cell is transformed into deutoplasm (food-yolk, or yolk-granules), the nucleus assumes an eccentric position. Between the zona pellucida and the cell-body a narrow perivitelline space appears. The ovum is then full-grown, but not yet fully prepared for fertilization; for this, maturation is required, certain changes in the germinal vesicle, which occur after the bursting of the follicle. * * * As a rule each follicle contains a single ovum. But two and even three ova have beyond doubt been observed in one follicle.”

According to Waldeyer, the bursting of the follicle is not to be regarded as dependent upon a sudden rise of pressure in its interior, but as the result of a gradual ripening process. At the deepest pole of the follicle, which in the course of its development has now approached the surface of the ovary, an exuberant growth takes place in the internal layer (tunica propria) of the theca folliculi, with a profuse formation of new vessels. Here numerous “epithelioid” cells, the “lutein-cells,” make their appearance. In consequence of this proliferation of the lutein-cells, the contents of the follicle are gradually pressed toward the “stigma,” the superficial pole of the follicle, and the follicle itself is pushed toward the surface until it finally comes into contact with the germinal epithelium. Meanwhile the follicular epithelium undergoes fatty degeneration, alike in the membrana granulosa and in the discus proligerus. In consequence of the proliferation of the lutein-cells, on the one hand, and the fatty degeneration of the epithelium, on the other, the follicle opens at its weakest point, the stigma, and the ovum is extruded, with the liquor folliculi, and a number of cells belonging to the follicular epithelium. (To illustrate these changes we have borrowed FIGS. 15, 16, and 17 from the monograph, by Pfannenstiel on Diseases of the Ovary, in J. Veits’ Handbook of Gynecology.)

The ovaries, which in the new-born female infant are flattened, ribbon-like bodies one-half to one centimeter (0.2 to 0.4″) in length, and in childhood are cylindrical, with a perfectly smooth surface, assume at the time of puberty a more or less flattened form. During the menarche they have an elongated oval shape, flattened from side to side, their average length being 2.5 to 5.0 centimetres (1 to 2″), width 1.5 to 3.0 centimetres (0.59 to 1.18″), thickness 0.6 to 1.4 centimetres (0.24 to 0.55″), weight 5 to 8 grammes (77 to 123 grains). After the repeated occurrence of ovulation, the surface of the ovary becomes more and more uneven, being thickly covered with fossæ or scar-like fissures.