University of Virginia Library

PART I.--MAIDENHOOD.

CHAPTER I.
PUBERTY.

Sexual Development; Age of Puberty; Physical Changes at Puberty; First Onset of Menstruation; Psychic Changes at Puberty.

Sexual Development.--Sexual development goes on during all the years of childhood, but is not complete in the female sex until between the twenty-second and the twenty-fifth year. If the child has no inherited taint, and has been properly educated morally, physically, and intellectually, it must follow that the structural development of the pelvic organs has been normal; and normal organs always perform their functions perfectly.

The commencement of the ovarian function does not cause any more profound change in the system and habits than does dentition. The various epochs of life are generally spoken of as if they were paroxysmal--as though they were separated by some tremendous

chasm, which had to be leapt over or fallen into. Nature makes no such egregious blunders; preparations for every change in life have been going on for a very long time before the evidences of such change become manifest.

In a healthy girl the psychic and physical changes incident to puberty occur so gradually as to escape the girl's own notice. The first and, if the girl has not been properly prepared for it, always startling change is the appearance of the menstrual flow. The mother who has not told her daughter of this coming change in her life before it is due has committed a serious error; it is no uncommon occurrence for girls who know nothing of this function to get into a tub of cold water to stop the flow; and if they stay in long enough, it generally does stop, and the girl's health may be ruined for life.

The opinion of Dr. Ely van de Warker is that "if healthy ovulation is the outcome of healthy childhood, the function will obey the law of periodicity year by year, and all this time the young woman will be able to sustain uninterrupted physical and intellectual work as well as the young man. Not that the laws of health may be violated with impunity at puberty or any other time of a woman's life; but a law of health is no more binding upon a young woman than it is upon a young man; and there really is no such thing as one law for women and another for men."

Age of Puberty.--In the temperate regions the age

of puberty is reached between the ages of twelve and fourteen years. The girl is then said to be nubile; that is, as soon as menstruation appears it is possible for her to bear children; but she is by no means sufficiently developed to do so, as she herself will not be completely developed physically or mentally before the age of twenty-two or twenty-five years.

Physical Changes at Puberty.--The physical changes that gradually take place, beginning at the time of puberty, are: the breasts, pelvis, and neck enlarge; hair develops over the pubis and in the arm-pits; the voice alters. As a rule, women continue to grow in stature until the twenty-fifth year. It is said that brunettes develop sooner than blondes, and that large women develop more slowly than women of small stature; city girls develop younger than girls brought up in the country. Whatever stimulates the emotions causes a premature development of the sexual organs; as children's parties, late hours, sensational novels, loose stories, the drama and the ball-room, talk of beaux, of love and marriage, and children being surrounded with the atmosphere of riper years. It is generally believed that early stimulation of the sexual instincts leads to the premature establishment of puberty, as do also spiced foods and alcoholic beverages.

First Onset of Menstruation.--Sometimes the first menstrual discharge appears suddenly, lasts for a few days, and then stops; it may appear after an interval

of two or three weeks, or not for several months. If for several months the flow appears at the regular time, and the quantity is about the same as the first, the menstrual habit may be said to be established. The mode of onset varies considerably within the limits of health. So long as the general health remains good, no anxiety need be felt in regard to the establishment of the menstrual function.

In other cases there may be a discharge of blood at the first period, and none afterward for several months; in other words, menstruation may be established suddenly, intermittently, or gradually. It must be remembered that certain pathologic conditions cause many disturbances connected with the onset of puberty.

Psychic Changes at Puberty.--The angular, gawky feeling gradually disappears; the girl becomes self-conscious; new impulses arise, and she gives up many of the hoydenish ways of childhood. The girl's imagination is more lively, and just at this time mathematics form an excellent subject for mental occupation. The girl now begins to question the whys and wherefores, and demands reasons for the course that is laid out for her, and is full of ideas of her own; so that while as a child she had accepted almost unquestioningly the commands of her parents, she can be managed now only through the power of reason. And this is just as it should be, for the girl has reached the years of discretion, and now is the time when her reason and judgment are capable of rapid cultivation.

CHAPTER II.
ANATOMY OF THE GENERATIVE ORGANS.

The Vulva; the Hymen; Condition, of the Hymen as a Proof of Virginity; the Bladder; Vagina; Uterus; Respiratory Movements of the Uterus; Fallopian Tubes; Ovaries.

The Vulva.--The female generative organs consist of three groups--the external, the intermediate, and the internal. The vulva, or external generative organs, comprises all those organs which are external to the body.

The vulva is pierced by two openings, the smallest and most anterior of which is the external opening of the urethra, or excretory duct of the bladder. This opening is surrounded by a slight eminence and has a somewhat puckered aspect.

The larger opening is the vaginal orifice. In the virgin this is partially closed by the hymen. About one inch back of this is the anus, or the external orifice of the large bowel. This part of the bowel is known as the rectum.

The Hymen.--The hymen consists of a thin duplicature

of mucous membrane strengthened by fibrous tissue, and is stretched across the posterior part of the vaginal orifice, which it partly occludes. Rupture of the hymen usually, but not always, occurs during the first sexual intercourse. In rare cases it is found intact at the time of the birth of the first child. In women who have borne children the vaginal orifice is surrounded by small irregular elevations; these are the remains of the ruptured hymen, but are usually present only after labor has taken place, since the torn hymen is converted into eminences as the result of the pressure incident to child-bearing, and not to coitus.

The Condition of the Hymen as a Proof of Virginity.--Formerly much stress was laid on the condition of the hymen as a proof of virginity. The hymen tightly closed, barely admitting the tip of a small index-finger, is positive evidence of virginity. But the hymen may lose its tone by a local catarrhal condition or by a general muscular relaxation; it may then become so relaxed that the only positive evidence rendered by the intact hymen is that the woman has not borne a child.

In a paper on the preservation of the hymen, Dr. Hannah M. Thompson writes: "Further, if the hymen was intended as a guarantee of moral character, and for moral protection, either of man or woman, would we not have some reason for reflecting on the wisdom and righteousness of a Creator who has failed to make equal provision, and to give a like guarantee of an uncorrupted manhood? As physicians, we know too well

that where one woman enters the marriage relation tainted in body there are thousands of men reeking with disease; and there is no demonstrable test to distinguish these, no proof for the young woman of the virginity or virtue of the young man."

The Bladder.--The female bladder is relatively broad and capacious, and is also highly distensible. When the bladder is allowed to become overdistended, it is carried backward and tends to cause a backward displacement of the uterus. The urethra, or excretory duct of the bladder, is about an inch and a half long, and lies firmly imbedded in the anterior vaginal wall.

The Vagina.--The intermediate organ is the vagina. This is a musculo-membranous canal which connects the external with the internal organs of generation. The vagina lies in relation with the bladder and the urethra in front, and with the rectum behind. The vagina is sufficiently distensible to allow of the passage of so large a body as the child.

The Uterus.--The internal organs of generation are the uterus, the ovaries, and the Fallopian tubes. Of these, the ovaries and the uterus are the essential female organs of generation. The virgin uterus is a small, hollow, muscular organ, somewhat pear-shaped, whose cavity is about one and a half inches deep. The uterus is divided by a natural constriction into a body and a neck. The neck, or cervix, is somewhat spindle-shaped, and has a canal running through its center which opens by a small aperture--the so-called external

orifice,--into the vagina. In the virgin uterus the apposition of the anterior and posterior walls reduces the cavity to little more than a longitudinal cleft. With the advent of old age the whole organ suffers marked atrophy.

The uterus is situated in the middle of the pelvic cavity, between the bladder and the lower bowel. It is held in place by broad elastic bands which go to different sides of the pelvis; it is also in part supported by the structures below and above it. But so loosely is the uterus held that it is easily pushed about--as, for instance, by a full bladder or a packed bowel. And persistently allowing the bladder to become overfull, and failure to have a daily evacuation of the bowels, are prolific sources of displacements of the womb.

Respiratory Movements of the Uterus.--When no constrictions are placed about the waist, the uterus moves freely up and down with every respiration. So distinctly and with such regularity do these movements take place that an operator by watching the movements of the uterus can tell the effect that the anesthetic is having on the patient's breathing. These so-called respiratory movements play a very important role in the circulation of the uterus, and in the return of the venous blood to the heart.

Anything which interferes with these movements, as the use of corsets, or of tight bands around the waist, prevents the free return of the venous blood. The uterus becomes congested, and through the constant

abnormal weight of the organ itself, as well as the pressing down upon it from above of the superincumbent organs, the uterus is pushed down below its normal position, the ligaments whose duty it is to hold it up become relaxed, and the unhappy woman suffers all the agonies that are attendant on the "falling of the womb." For this reason the disorder is frequently met with in women who have never borne children as well as in those who have.

The Fallopian Tubes.--The Fallopian tubes extend from the upper, rounded angles of the uterus, within and along the free margin of the broad ligaments, for a distance of about two inches, to the vicinity of the ovaries, where each one terminates in a funnel-shaped orifice surrounded by a series of fringed processes. The lumen of the tube is narrowest at its inner end, where it opens into the cavity of the uterus by a minute orifice which scarcely admits a bristle; the diameter of the canal gradually increases until it reaches its ovarian extremity. The mucous lining of the tube is clothed by a single layer of hair-like epithelium, whose current sweeps from the ovarian toward the uterine end of the tube; and it is these movements which propel the ovum from the ovary to the uterus.

The Ovaries.--The ovaries are two small bodies of an almond shape, and lie on either side of the uterus. The bulk of the entire organ consists of connective tissue, in which lie imbedded the Graafian follicles or

ovisacs, in which the ova are contained. These follicles or ovisacs are minute cells which are packed immediately beneath the surface, where they occur in all stages of development. With the increase in size which accompanies their development the follicles pass toward the surface, where they form a distinct projection, and at this point will occur the final rupture of the sac and the escape of the ovum. It is supposed that the ovum is grasped by the fringe-like extremity of the Fallopian tube and is carried through it by the movements of the ciliary epithelium to the uterus.

The formation of new follicles continues only for a short time after birth, when the Graafian follicles are the most numerous; the entire number contained within the ovaries of the child being estimated at over 70,000. In view of the unquestionably large number of follicles in very young ovaries, and the relatively small number of ova which reach maturity, the degeneration of many follicles after reaching a certain degree of development seems certain.

CHAPTER III.
PHYSIOLOGY OF THE FEMALE GENERATIVE ORGANS.

Ovulation; Etiology of Menstruation; Uterine Nerve-supply; the Function of the Uterus; Stages of the Menstrual Cycle; Average Duration of the Menstrual Flow; Character of tahe Flow; Relation of Ovulation to Menstruation; the Menstrual Wave; Definition of Menstruation; Premomitory Symptoms of the Flow; Hygiene of Menstruution.

Ovulation.--At birth the formation of the ova is nearly completed; the production of' new cells probably ceases after the second year. The ovaries of the child of two years contain, therefore, the full quota of ova, although the vast majority of these cells always remain immature and undeveloped. While it is probable that a variable number of the immature ova undergo partial development before puberty, yet the advent of sexual maturity at that time marks the establishment of the regular development of the Graafian follicles and their contained ova, accompanied by the attendant phenomena of menstruation.

During the entire child-bearing period, or from about the age of fifteen to forty-five years, the development of

the Graafian follicles and the discharge of the ova are continually taking place. The liberation of the ova usually takes place at definite times, which in general coincide with the menstrual epochs, one or more ova being set free at each period; but this is by no means invariable.

The ripe human ovum or germ cell is a spheric cell, about 0.2 mm. in diameter, consisting of granular protoplasm, in which lies a nucleus which contains the germinal spot. The proper cell-wall is a structure of great delicacy, outside of which is a secondary envelope.

Menstruation.--The etiology of menstruation has been variously explained at different epochs. The chief theories have been that of plethora, and the ovulation, the tubal, and the nerve theories.

First, the Theory of Plethora.--From the time of Hippocrates to 1835 the theory prevailed that in the female body the formation of blood is sufficiently rich to provide every four weeks for an overflow of the same, the evacuation of which becomes a necessity. It was believed that this excess of blood depended on an excess of formative power in the woman.

Second, the Ovulation Theory.--This was distinctly formulated about 1845. It construed the menstrual hemorrhage as a subsidiary phenomenon, entirely dependent on the periodic dehiscence of ovules. The changes supposed to take place in the Graafian follicles at each menstrual period were believed to involve a peculiar expenditure of nerve force, which was

so much dead loss to the individual life of the woman. The growth of the Graafian vesicle and its contained ovum was supposed to cause an irritation of the nerves of the ovary, which was reflected to the entire nervous system. The gradual accumulation of this irritation finally caused a reflex action which determined an afflux of blood to the uterus and ovaries, which constitutes the catamenial flow.

The ovulation theory was refuted by the following facts: Ovulation may and does occur without menstruation; women who have never menstruated may conceive; conception may occur during lactation, without the menses having returned since the last parturition; children at birth have many ovules contained within the ovaries; ovulation may persist for a time after the menopause, and even pregnancy has occurred, although very rarely after this time; the menses may continue regularly after the removal of the ovaries and Fallopian tubes; this is exceptional, and, as a rule, the periods only continue for two or three years at longest.

Third, the Tubal Theory.--Lawson Tait thought that thorough removal of the tubes was far more essential in determining the menopause, and that cases of periodically recurring hemorrhage after the removal of the ovaries were to be explained by the fact that the tubes had not been sufficiently removed. As an anatomic and surgical fact, the tubes can never be wholly excised unless the upper part of the uterus is also amputated.

Fourth, the Nerve Theory of Menstruation.--This is based upon the following views:

1. That menstruation is a process directly controlled by a nerve-center situated in the lumbar region of the spinal cord.

2. That the menstrual impulses reach the uterus through two sets of nerves.

3. That menstruation is the result of nerve irritation, vascular congestion, and the subsequent relief of these by hemorrhagic discharges.

4. That hemorrhage from the uterus is the result either of a local uterine condition, or of influences outside of the uterus acting directly on the center.

5. That the removal of the appendages arrests menstruation by preventing the propagation of uterine influences to the center.

Uterine Nerve Supply.--One set of nerves causes contraction of the muscular fibers of the uterus, while the other set transmits impulses which bring about its vascular engorgement; and they are probably concerned in bringing about the determination of blood to the uterus and its appendages, which is so marked a feature of the menstrual process.

As the result of long-continued investigation, Johnstone has come to the conclusion that the lining membrane of the uterus belongs to that class of organs whose function it is to replace organic waste. "Menstruation is a periodic wasting away of those corpuscles that are too old to make a placenta." He has further

found that, as compared with the uteri of very many of the lower animals, the human uterus is very scantily supplied with lymphatics, and the only way to rid the uterus of the overripe, and therefore consequently useless, tissue is to wash it out through the vagina by a blood-stream. The tough wall of the human uterus and the increased blood-pressure caused by the erect position cause the difference between menstruation in the human female and rut in the lower animals.

The strong light of recent investigations has necessitated the laying aside of many time-honored theories; and as the close of the nineteenth century has seen the emancipation of the uterus from the thralldom of the ovary, so we may believe that the twentieth century will find women of such fine physique as to prove the error of the popular fallacy that the cause of woman's weakness lies in the performance of her functions.

The Function of the Uterus.--The function of the uterus is to provide a favorable place for the reception of the product of conception, where it may be protected and nourished during the period of its development. The purpose of menstruation is to keep the uterus in suitable condition for the reception of this product of conception at any time. It is now known that the menstrual flow is not the whole of menstruation, and that the changes going on in the uterus are almost as continuous as the process of digestion. The whole of the reproductive life of woman has been divided into cycles of twenty-eight days each; these cycles have been divided into four stages.

Stages of the Menstrual Cycle.--The first or constructive stage is one of preparation for the reception of the ovum. During this stage the preparing of a decidua takes place, or building a nest for the expected egg; there is a swelling of the mucous membrane, an enlargement of the uterine glands, and an increase in the connective tissue. It is thought that this stage lasts for one week; when pregnancy does not occur, it is followed by degenerative changes.

The second or destructive stage is marked by destructive changes which give rise to the usual phenomena of the menstrual period; there is a discharge of blood, mucus, and disintegrated mucous membrane. The actively growing cells of the uterine lining membrane undergo rapid destructive changes, the fabric of the half-formed decidua tumbles to pieces, the turgid capillaries burst and pour out the menstrual flow, which sweeps away all the useless debris. The irritation sets up reflex uterine contractions, and so the blood is squeezed out of the distended capillaries and washes away the degenerated cells.

The third or reparative stage, as its name indicates, is one of repair, in which by constructive changes the epithelial lining which was thrown off is replaced by new, which is formed in from three to four days.

The fourth or quiescent stage includes the remaining twelve or fourteen days of the menstrual cycle, and represents the quiescent period prior to the initiative changes which mark the beginning of the next period.

Average Duration of the Menstrual Flow.--The average duration of the menstrual flow is five days, although the variations are considerable in healthy women. A flow lasting any place from two to six days is perfectly consistent with health; but a flow continuing less than two or more than six days generally indicates local or general disease.

Character of the Menstrual Flow.--For the first few hours, or perhaps for the first day, the flow is usually slight in quantity and light in color; on the second and third days the flow reaches its height, and is profuse and dark, but it should never be clotted; after this it gradually ceases. The amount of the flow varies from five to ten ounces. If less than five or six or more than eighteen napkins are pretty well saturated through, the amount may be considered abnormal.

Relation of Ovulation to Menstruation.--It has not yet been decided just in what relation the processes of ovulation and menstruation stand to each other. It is supposed that the transit of the ovum to the uterus occupies at least one week. It has been thought that the decidua of a particular menstrual period is related, not to the ovum discharged at that period, but to the ovum discharged at the preceding period.

The menstrual wave, or the wave of "supplementary nutrition,"[1] upon which the menstrual process ultimately depends, was first established by Dr. Mary

Putnam Jacobi in the Boylston prize essay for 1876; showing that menstrual life is associated with a wave of well-marked vital energy, which manifests itself in a monthly fluctuation of the tempera ture of the body, in the daily amount of the excretion of urea and of carbonic acid, and of the rate and tension of the pulse. The wave attains its maximum during the week preceding menstruation, and slowly falls to its minimum, which is reached the week after menstruation.

This wave indicates a periodic variation in the bodily metabolism, and is probably directly influenced by the rhythmic activity of the menstrual center. This observation would seem to be nullified by the fact that the phenomena referred to have been found to occur in men as well as in women; and that the lower animals also seem to show the same periodic variations. "It is therefore evident that the phenomena belong not to the function of menstruation, but to a general law of vital energy."

Definition of Menstruation.--Menstruation may, then, be defined as the periodic discharge of blood from the uterus, accompanied by the shedding of the epithelium of the body, as well as that of the uterine glands near their orifices.

The sanguineous discharge is due partly to the oozing of blood from the surfaces denuded of epithelium, and partly to active congestion. The discharge from the uterus is largely augmented by mucus secreted in increased

quantity at this period from the enlarged uterine glands.

The tubes take some part in the process of menstruation; their mucous membrane is swollen, the epithelium is shed in places, and they are filled with a thin bloody fiuid, containing blood-corpuscles and cast-off epithelium cells.

The menstrual wave continues from puberty to the menopause; it is a nervous phenomenon. Ovulation is a progressive, non-periodic process; it begins before birth and continues till the ovarian tissue is atrophied or worn out.

Premonitory Symptoms of the Flow.--The premonitory symptoms of the monthly flow should not be so marked as to cause the individual any discomfort. The first indication of the return of the period should be the appearance of the flow. There is generally a feeling of abdominal fulness with some lassitude, and sometimes slight headache. The temperature is lower and the pulse is slower than at other times. This lowered tone of the system is an additional reason for increased care against exposure in wet or cold weather.

Hygiene of Menstruation.--During the menstrual periods all cold baths must be strictly prohibited, whether tub-baths or cold sponges. The reason of this is that the application of cold to the surface causes a driving in of the blood from the exterior of the body to the internal organs; and at the menstrual periods there is already a congested condition of the pelvic

organs, and it must be remembered that congestion is the first stage of inflammation.

Hot or warm sponge-baths may be taken throughout the period; and the vulva should be bathed with warm water twice a day through the entire period of the flow, as this not only removes the clotted blood before it decomposes and becomes the source of irritation, but also removes other irritating matters, and prevents the nervousness that is caused by a local irritation.

It is strange how women who are scrupulously neat in all other respects will allow the smegma to collect in and about the vulva; as a matter of fact, for the purpose of cleanliness it is much more necessary that the external genitals should be washed twice a day with soap and water all through life than that the face should be washed that often.

Another question which is still sub judice is the necessity for and the frequency with which vaginal douches should be taken; all physicians are agreed that a vaginal douche taken immediately after the menstrual period is beneficial, as it removes all the debris of the flow, which is sometimes very irritating.

Exercise.--A moderate amount of exercise should be taken every day; this is needed now quite as much as at any other time, and only good can result from it. And no harm comes of a woman going out in the rain or in cold weather; as has been shown, the menstrual process is going on for a large part of the time, and the flow is only the external appearance, but during the

time of the flow the woman must be unusually careful not to get her feet wet or to sit down with damp clothing on. Violent exercise of all kinds is to be prohibited at this time, as dancing, rides on the bicycle, gymnastics, and walks of over three miles. The reason for this is very obvious; the uterus has now reached the height of its turgescence, and is heavier than at any other time, hence the danger that displacements or a very profuse flow would be caused by any kind of violent exercise.

Treatment.--If the woman has been so unfortunate as to get caught out in a heavy rain so that her clothes have been wet through, or if in the cold weather she should come into the house thoroughly chilled, the best thing to do is to take off her wet things as quickly as possible, be well rubbed down with hot, rough towels, drink a cup of hot tea, go to bed at once and place a hot-water bag over the abdomen. She should remain in bed until the next morning, to the end that the circulation may regain its equilibrium as quickly as possible by the immediate relief of the pelvic congestion. If this exposure should have caused the sudden cessation of the flow, a hot mustard foot-bath should be taken. One tablespoonful of mustard is used to a gallon of water as hot as can be borne; the pail should be made as full as can be without running over, and a blanket wrapped around the pail and woman, so as to cause a profuse perspiration; this should be kept up for ten minutes; if the water cools off, hot water may be added.

CHAPTER IV.
THE ANOMALIES OF MENSTRUATION.

Menorrhagia and Metrorrhagia; Dysmenorrhea; Amenorrhea; Leuchorrhea; Pruritus Vulvae.

Menorrhagia and Metrorrhagia.--By menorrhagia is meant an excessive or too profuse menstrual flow; by metrorrhagia, a flow of blood between the menstrual periods. Neither one constitutes a disease by itself, but is a symptom of some pathologic condition.

It has already been stated that the excretory organs, by constantly eliminating from the system the worn-out material, keep the machine healthy and in good working order. Kept within natural limits, this elimination is the source of strength and health; beyond these limits, the menstrual flow becomes an actual hemorrhage that, by draining away the life, becomes the source of weakness and disease.

No physician would dare to bleed a man or woman once a month, year in and year out for thirty years; but, through ignorance or folly, this is what many girls do for themselves.

This excessive flow, aside from actual local disease, is brought about by excessive muscular exercise during

menstruation; by the use of all stimulants, whether alcoholic beverages or quinin; as well as by the thinness of the blood.

When the flow is excessive, it must be considered a pathologic condition, which needs the physician's attention. Rest in the recumbent position is the first essential; the diet must be plain and unstimulating, and attention must be paid to the condition of the blood.

The general diseases which generally cause this condition are anemia, Bright's disease, malaria, the early stages of tuberculosis, and heart disease.

The local causes may be reflex, as powerful emotions; or due to local disease of the uterus and its appendages, as the various inflammations and displacements of the uterus, fibroid tumors, polypi, and cancer.

Dysmenorrhea is painful menstruation. The most frequent forms are due to uterine congestion; to mechanical causes, as a narrowing of the cervical canal, particularly at its internal opening, or to a constriction caused by the bending over of the uterus at the junction of the body and the neck; or to ovarian irritation.

The pain varies in intensity from slight discomfort to the most intense uterine colic, which is experienced in the lower part of the abdomen. In severe cases the general health becomes undermined, the nervous system gives way, and hysteria and other disorders of the nervous system result.

The congestive variety usually occurs in patients who

have previously menstruated painlessly. The pain comes on suddenly with the flow and ceases when the flow stops; it is very severe and is generally accompanied by a diminution or a cessation of the flow. There is severe headache, marked diminution in the secretion of the kidneys, and general restlessness. The patient frequently experiences pain in walking, is easily fatigued, has leucorrhea and an irritable bladder.

In ovarian dysmenorrhea the pain precedes the flow for several days and ceases when a free flow is established. The pain is of a dull aching character, and may be felt on one or both sides of the abdomen, according as one or both ovaries are involved.

Amenorrhea.--In amenorrhea the menstrual flow may not appear for some years after it is normally due; or the flow may cease after some months or years of continuance; or the flow may be abnormally scanty or even absent.

The menstrual flow is much later in appearing in some families than in others, so that this may be considered as a family idiosyncrasy; and if the girl's health is good, it need cause no anxiety. If, on the contrary, the girl has severe headaches, or suffers in any way, the physician should be summoned at once, as the absence of menstruation may be indicative of some serious pathologic condition,

A scanty flow is often indicative of thinness of the blood; on the other hand, serious anemias often lead to profuse menorrhagias or metrorrhagias, as has already

been stated. The cause of the profound anemia itself may be insufficient nutrition, overwork, or lack of exercise.

Scanty menstruation is often seen to occur in fevers, in the later stages of consumption, in advanced Bright's disease, in malaria, or in any other very serious disease. In these cases it seems to be a conservative process on the part of nature in the run-down state of the system. As consumption progresses menstruation generally ceases absolutely, never to return again; and in this case nothing should be done to try to induce a return of the flow.

Great shock sometimes causes a sudden cessation of the flow; and sometimes a sea-voyage, followed by the change of habitat, will cause an obstinate form of amenorrhea.

But it cannot be too well understood that, after the menstrual flow has been regularly established, it continues with the greatest regularity throughout the child-bearing period, unless the exposure to wet or cold has been sufficiently severe to cause great indisposition on the part of the woman. In this case it is possible that, if the exposure took place just previous to the time of the expected flow, one period may remain out. But except in case of serious illness,--as for example, typhoid fever,--two or more periods do not fail to appear except in the case of pregnancy.

Leucorrhea.--Leuchorrhea, or "whites," is a mucous

or mucopurulent discharge from the vagina; it may be a symptom of uterine or vaginal disease.

Immediately after the menstrual flow there is a well-marked vaginal secretion which is whitish in appearance; it may be transparent or of a milky color, and is sometimes very acrid. This secretion may also precede the flow, and there is nothing abnormal in this. But any discharge occurring between the periods sufficient to stain the clothing--the so-called whites or leucorrhea--is abnormal, and is caused by an inflammation of the vagina or the neighboring parts. In addition to the discharge there is heat and swelling of the parts, more or less local distress, and generally intense nervousness.

If the disease is not cured, it may become chronic. The pain, heat, and scalding disappear, but a copious discharge continues, and in this stage the disease may be very obstinate and greatly reduces the strength. The constant drain breaks down the system, producing pallor, debility, pain in the back, palpitation, indigestion, and so forth.

The character of the discharge in leucorrhea varies considerably, from a whitish or mucous secretion, to a yellowish or mucopurulent secretion, and is debilitating in proportion as it is profuse. It is to be remembered that this is not in itself a disease, but indicates a disease of some of the pelvic organs; and that all such inflammations left to themselves incline to grow worse.

A severe leucorrhea is generally attended with frequent

and finally painful micturition; pain in walking in the lower part of the abdomen, which may become so severe as to compel the patient to go to bed.

Pruritus Vulva.--This is an intense and persistent itching of the vulva, and is a symptom rather than a disease. It is not an infrequent result of leucorrhea, the acrid discharge of the latter leading to an irritation of the parts; this causes rubbing of the parts until a veritable inflammation is produced.

Other causes of pruritus vulvae are: The local congestion, such as occurs at the menstrual period, or in certain cases of pelvic inflammations, or in early pregnancy; constipation; sedentary habits; congestion of the liver; incontinence of urine, and diabetes. When dependent on the latter, the malady is most obstinate in yielding to treatment. Indigestible foods or drinks, the rubbing of the clothes, the friction of walking, and the heat of the bed act as exciting causes in those predisposed to it.

The essential treatment here is to at once ascertain and remove the cause; aids in the treatment are vaginal douches and cooling lotions.

CHAPTER V.
THE MARRIAGE QUESTION.

Herbert Spencer's Definition of Love; What Constitutes a Suitable Husband; Best Age for Marriage; Shall Cousins Marry? Contraindications to Marriage; Do Reformed Profligates Make Good Husbands? the Proper Length of Time for the Engagement; the Right Time of the Year to Marry; the Selection of the Wedding Day.

Herbert Spencer's Definition of Love.--"Love is habitually spoken of as though it were a simple feeling, whereas it is the most compound, and therefore the most powerful, of all the feelings. Added to the purely physical elements of it, are first to be noticed those highly complex impressions produced by physical beauty; around which are aggregated a variety of pleasurable ideas, not themselves amatory, but which have an organized relation to the amatory feelings. With this there is united the complex sentiment we term affection--a sentiment which, as it can exist between those of the same sex, must be regarded as an independent sentiment, but one which is here greatly

exalted. Then there is the sentiment of admiration, respect, reverence, in itself one of considerable power, and which in this relation becomes in a high degree active. There comes next the feeling called the love of approbation. To be preferred above all the world, and that by the one admired above all others, is to have the love of approbation gratified in a degree passing every other experience, especially as there is added that indirect gratification of it which results from the preference being witnessed by others. Further, the allied emotion of self-esteem comes into play. To have succeeded in gaining such attachment from and sway over another is a proof of power which cannot fail to agreeably excite amour propre. Yet again, the proprietary feeling has its share in the general activity. There is the pleasure of possession, the two belonging to each other. Once more, the relation allows of an extended liberty of action. Toward each other a strained behavior is requisite. Around each there is a suitable boundary that may not be crossed; an individuality on which none may trespass. But in this case the barriers are thrown down, and the love of unrestrained activity is gratified. Finally, there is an exaltation of sympathies, egotistic pleasures of all kinds are doubled by another's sympathetic participation, and the pleasures of another are added to the egotistic pleasures. Thus around the physical feeling forming the nucleus of the whole, are gathered the feelings produced by personal beauty that constitutes simple attachments, of self-esteem, of property, of love of freedom, of sympathy. These, all greatly exalted and severally tending to reflect their excitements on one another, unite to form the mental state we call love. And as each of them is comprehensive of multidinous states of consciousness, we may say that this passion fans into immense aggregate most of the elementary excitations of which we are capable; and that hence results its irresistible power."

What Constitutes a Suitable Husband.--It is desirable that the husband shall be a few years older than the wife. Man is later in coming to maturity, and also retains his sexual powers considerably longer than woman; so that for these functions to cease about the same time, the wife must be younger than the husband. A difference of from two to five years is best; if the parties are young, it is not essential that the husband should be much the wife's senior, as it is later in life. The husband may be ten years older, but a greater disparity of age than this is rarely compatible with congeniality of tastes and dispositions, so essential to a happy married life. The woman who risks her happiness with a man many years younger than herself violates a precept of nature.

The average stature of the man is about three inches greater than that of the woman, and in the physiologic marriage any great deviation from this should be avoided.

The essentials for a happy marriage may be summed

up as follows: that the parties shall be of suitable age; that they shall be physically well mated and in full sympathy with each other's views of life, of the same social position, and of equal education.

The Best Age for Marriage.--The reproductive life begins with puberty, but maturity is not reached before the age of twenty-one. It is only then that the standard of development is reached that is most compatible with the successful bearing of the grave responsibilities of wifehood and motherhood. The too early exercise of the reproductive functions leads to increased suffering on the part of the mother, depresses her vitality, and increases her liability to disease. Statistics show that the mortality is very much greater where girls marry under twenty years of age.

The offspring are apt to be small and ill developed, and die in large numbers in early life; only a small percentage live long and robust lives. In France it has been observed that where the fear of conscription has caused many young people to marry the offspring were lacking in vigor. Among the offspring of immature parents there is a larger proportion of idiots, cripples, criminals, scrofulous, insane, and tubercular than among the children of nubile parents.

In our climate women are best fitted to become wives and mothers between the ages of twenty-four and twenty-eight years. Before this age neither their self-knowledge, their knowledge of the world, nor their experience is sufficiently mature to fit them to wisely

make the choice of a companion for life, or to become mothers. After forty, most women cannot hope for children. Men had better wait until between the ages of twenty-seven and thirty years, before they undertake the responsibilities of parenthood.

Shall Cousins Marry?--They might if both families were perfectly healthy; but as few families are without some lurking predisposition to disease, it is not well, as a rule, to run the risk of developing this by too repeated unions.

Contraindications to Marriage.--Young women in whose family there is a distinct history of such hereditary diseases as cancer, tuberculosis, or insanity for two generations back, should not marry at all. Not only is this a fearful legacy to hand down to their children, but pregnancy and child-bearing very decidedly favor the development of these diseases.

Syphilis in either sex is a distinct bar to marriage; first, the party married is sure to contract the disease, even though it may have been supposed to have been cured. Fortunately, the children of such marriages are generally still-born; still, they do sometimes live, and are most pitiable and sickly objects. For any one to marry under these conditions is a crime against society, against the State, and against posterity.

Women who have serious forms of heart disease, tuberculosis, or Bright's disease would, by becoming pregnant, run a serious risk of losing their lives toward the close of the pregnancy or at the time of their confinement.

In case of heart disease, the pulmonary congestion that accompanies pregnancy, together with the encroachment of the pregnant uterus on the cavity of the chest, would greatly add to the embarrassment of the heart's action.

In normal pregnancy there is some congestion of the kidneys; where there is actual disease of the kidneys prior to the pregnancy, this congestion is apt to become so severe as to threaten the woman's life. These organic diseases are not to be confounded with functional diseases which are dependent on some other cause; as palpitation of the heart due to indigestion, or heart murmurs dependent on the thin state of the blood, or congestion of the kidneys due to exposure to cold;--all of which may be cured by proper treatment.

Should a woman with a fibroid tumor marry, she would run a great risk to her life; she should have the tumor removed, or, if this is not possible, she should give up all thoughts of marriage, since the increased irritation and congestion consequent upon the marital relations would tend to favor its growth. Should pregnancy ensue, delivery might be attended with serious complications, as very difficult labor, postpartum hemorrhage, or, as these tumors have but little vitality, and the pressure to which they are subjected during labor is liable to cause their death, disorganization, sloughing, and, as a result, puerperal septicemia.

Sometimes there is such a lack of development of the

genital organs as to prevent the woman from having children.

Two persons with even a slight tendency to the same disease, either inherited or acquired, should not intermarry, even if they are in comparatively good health at the time. Their offspring would be quite sure to inherit their diseased tendencies.

Persons whose constitutions have been somewhat injured, but who are not tainted with actual disease, may rear children much healthier than themselves, provided their own lives are wisely regulated. If they are growing better all the time, and are not too much broken in constitution, it may be safe for them to marry.

Among the Jews the physician is frequently consulted before matrimonial alliances are contracted. This custom could not but be of universal benefit; many local or general diseases would be eradicated before marriage, and in this way much suffering and unhappiness would be spared; or, in other cases, the patient would be advised of the inadvisability of marriage.

Do Reformed Profligates Make Good Husbands?--The manner of life that has been led by this class of men is such as to undermine their health, if not to have rendered them physical wrecks. There is the overindulgence in alcoholic beverages, and perhaps, added to this, some drug habit. In addition to this, these men early in their career are apt to become infected with some of the venereal diseases, or perhaps with all of them--

gonorrhea, syphilis, and so forth; and these diseases have the horrible characteristics of becoming latent. A man who contracts this kind of a disease can never be really sure that he is cured. All venereal diseases are highly contagious.

It is now a well-established fact that gonnorrheal infection is not only one of the most common causes of pelvic inflammations in women, but that these same inflammations are of the most virulent types, unless they are recognized and treated in the early stages. It is also a well-known fact that a large percentage of married women suffer from this disease. Sterility almost always results.

In the case of a syphilitic parent, one or two children may be born, but the offspring is generally sickly and diseased. Inebriety as well as sexual excesses are both well recognized as distinct forms of disease accompanied by degeneracy of brain tissue. It is nothing less than criminal for such men to have children, since these children would at least inherit the tendency to the same diseases, if they did not actually have them; there is also a strong probability of such children being born idiots or imbeciles.

It is therefore self-evident that, instead of a reformed profligate making a good husband, he must make a very diseased one. It has therefore been suggested that the parents of the prospective bride should demand from the intended groom a certificate of freedom from all venereal diseases by a physician of their own selection.

Also that there should be legislation upon the subject, and that before a man is granted a license of marriage, he should have a certificate from the health officer of freedom from syphilis, gonorrhea, and tuberculosis.

The Proper Length of Time for the Engagement.--A period not shorter than three months, nor longer than one year, should elapse between the engagement and the marriage.

There are strong physiologic reasons against long engagements: they keep the affections and the passions in an excited and unnatural condition, which after a time tends to weaken the nervous system and undermine the health. These evil consequences are common to both sexes. It is far better that the subject of marriage should not be entertained at all unless the circumstances are such that the union might with propriety be effected at once.

The Right Time of the Year to Marry.--When woman marries she enters upon a new life, and a very trying one. Extreme heat and extreme cold are both very taxing to the human economy. Midsummer and midwinter are therefore both objectionable, but especially the former.

The Selection of the Wedding-day.--This is by common consent left to the bride. She should select a time about ten or fifteen days after the end of one of her menstrual periods, as this is the time of comparative sterility, and it is most desirable that the first sexual relations should be fruitless.