Part 2

Menarche Praecox et Tardiva 78 Precocious and Retarded Menstrual Activity 78

Pathology of the Menarche 82 Anomalies of Menstruation 83 Inflammatory Processes 87 Disorders of Haematopoiesis 89 Cardiac Disorders 94 Diseases of the Nervous System 99 Masturbation 104 Disorders of Digestion 107 Diseases of the Respiratory Organs 107 Diseases of the Organs of the Senses 108 Hygiene during the Menarche 111 Menstruation 128 Pathology of Menstruation 143 Amenorrhœa, Menorrhagia, and Dysmenorrhœa 160 Vicarious Menstruation 164

The Sexual Impulse 166

Nymphomania, Anæsthesia and Psychopathia Sexualis 184

II. THE SEXUAL EPOCH OF THE MENACME 200

Anatomical Changes in the Female Genital Organs in the Period of the Menacme 209

Pathology of the Menacme 218 Dyspepsia Uterina 227 Cardiopathia Uterina 235 Nervous Diseases Secondary to Diseases of the Genital Organs 243

Competence for Marriage of Women suffering from Disease 250

Hygiene during the Menacme 261

Copulation and Conception 284 Copulation 284 Conception 304 Pathology of Copulation 323 Vaginismus 337 Cardiac Troubles Due to Sexual Intercourse 344 Dyspareunia 347

Fertility in Women 363 The Restriction of Fertility and the Use of Means for the Prevention of Pregnancy 388

The Determination of Sex 420 I. Statistical Investigations 422 II. Anatomical Investigations 446 III. Experimental Investigations 452

Sterility in Women 462 Incapacity for Ovulation 470 Interference with Conjugation, Conditions Preventing Access of the Spermatozoa to the Ovum 487 Diseases of the Ovaries and the Fallopian Tubes 489 Diseases of the Uterus 494 Pathological Changes in the Cervix Uteri 501 Displacements of the Uterus 515 Myoma of the Uterus 523 Diseases of the Vagina and the Vulva 526 Secretions of the Genital Organs 528 A. Absolute 540 B. Relative Sterility 540 Sexual Sensibility in Women 542 Incapacity for Incubation of the Ovum 549 Only-Child-Sterility 561 Operative Sterility 563 Table Showing the Causes of Sterility in Women 569

III. THE SEXUAL EPOCH OF THE MENOPAUSE 571

The Menopause 571

Changes in the Female Reproductive Organs at the Menopause 583

The Time of the Menopause 593

The Age at which the Menopause occurs 593 1. Race 594 2. The Age at which the Menarche Occurred 595 3. The Woman’s Sexual Activity 597 4. The Social Circumstances of the Woman’s Life 599 5. General Constitutional and Pathological Conditions 599 6. Premature, Delayed, and Sudden Onset of the Menopause 600

Pathology of the Menopause 608 Diseases of the Genital Organs 608 Diseases of the Organs of Circulation 620 Diseases of the Digestive Organs 630 Diseases of the Skin 632 Disorders of Metabolism 635 Diseases of the Nervous System 637 Climacteric Psychoses 643

Hygiene during the Menopause 653

LIST OF ILLUSTRATIONS (Kisch).

FIG. PAGE 1. Curve of the sexual life of woman from the tenth to the sixtieth year of life 4 2. Portion of the pelvic viscera in the female, etc. 9 3. The distribution of the pudic nerve in the female perineal and pubic regions 11 4. The distribution of the lateral sacral arteries, etc. 14 5. Curve of menstrual cycle 19 6. Curve of rhythmical variations 20 7. Curve of beauty of woman. 24 8. Internal genital organs of new-born female infant 51 9. Reproductive organs of a new-born female infant 52 10. Internal genital organs of a girl aged eight years 52 11. Reproductive organs of a girl aged ten years 53 12. Female external genital organs of a virgin 54 13. The external genital organs of a virgin 55 14. Sagittal section of the female pelvis 56 15. Primitive follicles 58 16. Ripening follicles 61 17. Graafian follicles 62 18. Annular Hymen 64 19. Annular Hymen 64 20. Semilunar Hymen 65 21. Annular Hymen with Congenital Symmetrical Indentations 65 22. Fimbriate Hymen 65 23. Deflorated Fimbriate Hymen 65 24. Septate Annular Hymen 67 25. Septate Semilunar Hymen 67 26. Extremely tough Annular Hymen with an obliquely disposed Septum 67 27. Septate Hymen with Apertures of unequal Size 67 28. Septate Hymen with Apertures of unequal Size 68 29. Hymen with rudimentary Septum 68 30. Hymen with posterior rudimentary Septum 68 31. Labiate Hymen with posterior rudimentary Septum 68 32. Hymen with anterior rudimentary Septum 69 33. Hymen with anterior rudimentary Septum projecting in a opiniform Manner 69 34. Hymen with anterior and posterior rudimentary Septa 69 35. Hymen with filiform Process projecting from the anterior Margin 69 36. Hymen in which there are two symmetrically disposed thinned Areas. The left of these is perforated 69 37. Very unusual form of Hymen 70 38. Semilunar Hymen with cicatrized Lacerations in its Border 70 39. Deflorated Semilunar Hymen with laterally disposed symmetrical Lacerations 70 40. Deflorated Annular Hymen with several cicatrized Lacerations 70 41. A. Septate Hymen in which defloration has been effected through one of the Apertures. U. Urethra. Cl. Clitoris. H. Cicatrized Margin. C. Septum. B. Lateral view of Septum 70 42. Deflorated Septate Hymen 71 43. Hymen with larger anterior and smaller posterior Apertures 71 44. Carunculæ Myrtiformes in a Primipara 71 45. Vaginal Inlet of a Multipara, without Carunculæ Myrtiformes. Slight Prolapse of Anterior and Posterior Vaginal Walls 71 46. The breast of a virgin aged eighteen years 73 47. Horizontal section through the female breast 75 48. The female pudendum, or vulva, with the labia majora 204 49. Vestibule of the vagina, with the labia minora or nymphæ, etc 205 50. The uterus, the left Fallopian tube and the left ovary, etc 207 51. Female internal genital organs in the fully developed state 208 52. Sagittal Section through the Cervix Uteri of a Woman twenty-six years of age. Dendriform branched glands 217 53. Cervix of a Woman seventy-two years of age, with glands that have undergone cystic degeneration 217 54. Sagittal Section through the Cervix Uteri of a Woman sixty-five years of age. The glands have undergone cystic degeneration 217 55. First Stage. A. Entrance of a Spermatozoon into the Ovum of Ascaris Megalocephala. B. After preparations by M. Nussbaum. (Half of the ova only are depicted) 306 56. Ovum of Asterakanthion ten minutes after Fertilization 306 57. Fusion of Male Pro-nucleus and Female Pro-nucleus to form the Segmentation Nucleus of the Fertilized Ovum 306 58. Passage of Spermatozoon through the Zona Pellucida of the Ovum of Asterakanthion 307 59. Ovum of Scorpæna Scrofa Thirty-five Minutes after Fertilization 307 60. Male Pro-nucleus and Female Pro-nucleus in Fertilized Ovum of Frog, prior to the Formation of the Segmentation Nucleus 307 61. a. b. c. Prostatic calculi from normal semen, d. Spermatozoa. e. Large and small cells, some containing granules, as morphological elements of semen. f. Spermatozoon distorted by imbibition of water. g. Crystals (after Bizzozero) 311 62. Normal Semen 311 63. Semen consisting chiefly of sperm-crystals, cylindrical epithelium, and small granules exhibiting molecular movement—but containing no spermatozoa 315 64. Oligozoöspermia. a. Living Spermatozoa, b. Dead Spermatozoa, c. Pus Corpuscles, d. Erythrocyte, e. Seminal granules 317 65. Septate Hymen, the septum having a tendinous consistency 324 66. 326 67. Lipoma of the Right labium majus, including the Vaginal Inlet 328 68. “Hottentot Apron” in an adult Woman, hanging down between the thighs (after Zweifel) 329 69. Elephantiasis of the Labia Majora 330 70. Congenital Atrophy of the Uterus (after Virchow), oi, Ostium internum; oe, Ostium externum 500 71. 500 72. Normal Shape of the Portio Vaginalis 503 73. Conoidal Shape of the Portio Vaginalis 503 74. “Apron-Shaped” Vaginal Portion, a. Greatly elongated anterior lip; b. Shorter posterior lip of the cervix 504 75. “Beak-Shaped” Vaginal Portion. Posterior aspect 504 76. Simple Hypertrophy of the Portio Vaginalis, which projected from the Vulva 506 77. Elongated Cervix, bent upwards 506 78. Cervical Polypus, originating from an Ovulum Nabothi 510 79. Ectropium in a Case of Bilateral Laceration of the Cervix (after A. Martin) 514 80. Anteflexio Uteri (after A. Martin) 518 81. Retroflexio Uteri (after A. Martin) 520 82. Mucus from the Cervical Canal, taken one hour after sexual intercourse, from a woman suffering from chronic endometritis. Among the epithelial cells, pus cells, and finely granular masses, we see a few motionless, dead spermatozoa 531 83. Uterine Mucous Membrane in Endometritis (after A. Martin) 554 84. Sagittal section through the ovary of a girl aged sixteen 583 85. Sagittal section through the ovary of a woman aged seventy-two years 584 86. Diagrammatic Representation of the Graafian Follicle 585 87. Ovary of a Girl aged nineteen years (Normal Size) 585 88. Ovary of a Woman seventy-two years of age (Normal Size) 585 89. 586 90. 587 91. 588 92. Sagittal Section through the Cervix of a Woman twenty-six years of age. Dendriform branched glands 588 93. Sagittal Section through the Cervix of a Woman sixty-five years of age. Glands which have undergone Cystic Degeneration 589 94. Cervix of a Woman seventy years of age. The Cervical Glands have undergone Cystic Degeneration 589 95. Ovula Nabothi in the Portio Vaginalis 590 96. Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane 591 97. Mucous Glands undergoing Cystic Degeneration 592

THE SEXUAL LIFE OF WOMAN.

By the sexual life of woman we understand the reciprocal action between the physiological functions and pathological states of the female genital organs on the one hand and the entire female organism in its physical and mental relations on the other; and the object of this book is to give a complete account of the influence exercised by the reproductive organs, during the time of their development, their maturity, and their involution, on the life history of woman.

From the earliest days of the medical art this sexual life of woman has aroused in the leaders of medical thought the highest interest, and for this reason great attention has been directed, not only to the anatomy of the genital organs and to the diseases of the reproductive system, but also to the individual manifestations of sexual activity and to the influence exercised by these on the female organism as a whole.

Several works by Hippocrates are extant on this subject, among which may be mentioned: περι Γυναικειης Φυσεος, a treatise on the physiology and pathology of woman; περι Αφορων, which discusses sterility in women; περι παρθενιων, a treatise on the pathological states of virgins. These writings of Hippocrates contain some very remarkable observations on the influence exercised by disorders of the reproductive organs on the general health of women.

Aristotle wrote at some length on the functions of the female genital organs. In the writings of Aretæus and Galen on the diseases of women we find striking observations, as for instance, in Galen’s De Locis Affectis, which contains a “Statement of the Similarity and Dissimilarity of Man and Woman.” Another notable work is that of Albertus Magnus, entitled De Secretis Mulierum.

The numerous works on the diseases of women published in the sixteenth century consisted for the most part of a repetition of the observations of ancient writers. The gynecological treatises of the eighteenth century, however, bore witness to an increased knowledge of the anatomy of the female reproductive organs, and were illumined by Haller’s researches on the functions of these organs.