Part 18

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 hitherto 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, 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 manifestations 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 authors, 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 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 a 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 processes which are themselves the result of sexual sentiments, of reading, or of conversations with sexually instructed female friends. This vague impulse may lead to 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.

L. 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 Löwenfeld, 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, 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.