Chapter Five
PUBERTY
Physical Changes in Puberty—Physical Changes in the Genital Organs and in the Rest of the Body—Psychic Changes—Puberty and Adolescence—Nubility.
Puberty is the most wonderful, the most significant period in a girl's life. Important as it is in a boy's life and development, it is still more so in a girl's. At this period there are often laid the foundations which either make or mar the girl's future life.
The meaning of the word puberty is maturity. It is the period at which the girl and the boy reach sexual maturity; in other words, the period at which the sex glands of the boy begin to generate spermatozoa, and the sex glands of the girl begin to mature and expel eggs or ova; with the girl puberty is marked by an additional phenomenon, which has no analogue in the boy, namely, menstruation.
Physical Changes. The word puberty is derived from the word puber, which in Latin means mature, ripe. But the word puber is itself derived from the word pubes, which in Latin means fine hair or down. For at this period of maturity all mammals (that is animals which have breasts and nurse their young) begin to develop a growth of hair. You know that our entire body, with the exception of the palms of the hands and the soles of the feet, is covered with innumerable hair follicles, and from our birth our entire body, with the exception named, is covered with fine hair. The hair may be too delicate to be seen, but it is there, and with a magnifying glass you can see it without any trouble. But at puberty the hair increases in thickness and in quantity, and becomes abundant in places where it was hardly noticeable before—the upper lip and face in boys, and the armpits and lower part of the abdomen in both boys and girls.
And so the first apparent physical sign of puberty in a girl is the gradual appearance of hair in the armpits, on the mons Veneris and the labia majora. But all the genital organs are undergoing rapid development; the vulva, the vagina, the uterus and the ovaries become larger, and the ovaries which up to that time were elaborating an internal secretion only, now also begin to manufacture ova; in other words, the monthly process of ovulation is begun. Synchronously with the process of ovulation, there commences the monthly function of menstruation. The breasts also increase in size, assume the characteristic contour, develop their glandular substance, and become capable of secreting milk for the use of any possible offspring. During this period of development they are often very sensitive to the touch or feel painful without being touched.
But not only the genital organs undergo growth and development—the entire body participates in the process. The growth in height is the most rapid at this period; the greatest growth takes place in the limbs—legs and arms. The pelvis becomes broader, and the chest or thorax also becomes broader and larger. The muscles become larger and rounder and finally give the girl the beautiful womanly form.
Psychic Changes. But the changes are not only physical; the changes that take place in the girl's psychic sphere during the pubertal years are also highly important. That is the period of the development of the emotions; she is overflowing with emotion; she becomes sensitive; in her relations with boys and men she becomes self-conscious. Distinct sexual desire fortunately does not make its appearance in the girl at this period, as it does in the boy, but she becomes filled with vague undefined and undefinable longings. It is the period of "crushes" when the girl is apt to bestow her overflowing emotion on a girl friend. There is nothing reprehensible in these crushes—they act as a safety valve—and only in rare cases are they apt to lead to abnormal development. This is also the period of day-dreaming and of romancing; the girl likes to read love-stories and novels in which she identifies herself with the heroine. And it makes quite some difference as to what the girl reads during this period, for literature has a strong influence on the young in the most plastic period of their lives; and it is important that older persons see to it that those in their care spend their time on books of noble ideals and high artistic value.
Girls of a highly sensitive or so-called "nervous" temperament, especially if there is "nervousness" in the family, must be particularly looked after. For it is during the years of puberty and adolescence that any neurotic traits are apt to develop and become emphasized. It is also the period when bad sexual habits (masturbation) are apt to develop, and the careful mother will devote special attention to her girls in their years of puberty, and guard them as much as possible against physical and emotional shocks.
The age of puberty in girls is by many writers considered as synonymous or synchronous with the onset of menstruation, which in this country in the majority of cases occurs between the ages of thirteen and fourteen. The year of gradual development before the onset of menstruation is by some referred to as the pre-pubertal year; and the first year after the onset of menstruation is the post-pubertal year. The period from puberty to full sexual maturity is called adolescence, and this term is applied generally to the period between thirteen and eighteen. For at eighteen the boy and the girl have reached full maturity. Mentally we acquire things as long as we live, and even physically the body gets larger for some years after eighteen. But sexually both boys and girls are fully mature at eighteen, though in order to become parents it is best, for various reasons, to wait to the ages of twenty or twenty-five.
Nubility. Nubility is the age or state when a boy or a girl is "fit" for marriage. This is a vague and unsatisfactory term. At the age of thirteen to fifteen boys and girls are physically "fit" for marriage, that is at that age a boy is capable of begetting and a girl of having children. But it does not mean that it would be advisable for them to marry at such an early age. Neither their bodies nor their minds are fully developed, and children begotten of such young parents are apt to be weaklings, both mentally and physically. The youngest age for girls to marry should be eighteen, and for boys twenty; but the youngest age for becoming parents should be twenty to twenty-two for the mother and twenty-three to twenty-five for the father.
Chapter Six
MENSTRUATION
Definition of Menstruation—Where Menstrual Blood Comes From—Age of Menstruation—Age of Cessation of Menstruation—Duration—Amount—Regularity and Irregularity.
The first function with which the girl will be confronted, which will impress upon her that she is a creature of sex, that she is decidedly different from the boy, is menstruation. And this function we will now proceed to study.
What is menstruation? Menstruation is a monthly discharge of blood. The word is derived from the Latin word mensis, which means a month; and menstruation is also frequently spoken of as the menses. It is also called the catamenia or catamenia-flow (Greek, kata—by, men—a month). Other terms are: the periods, courses, monthlies, turns, monthly changes, monthly sickness, sickness, flowers, to be unwell, to be regular. "Not to see anything" is a common term for having missed the menses. This flow of blood recurs in most cases with remarkable regularity once a month; not a calendar month, but once a lunar month, i.e., once every twenty-eight days. And as there are thirteen lunar months a year, a woman menstruates not twelve but thirteen times a year.
Where does the menstrual blood come from? The menstrual blood comes from the inside of the womb. Every month, for a few days prior to menstruation, the inside lining of the womb (what we call the mucous membrane or endometrium) becomes congested and its bloodvessels become distended with blood. If the woman has sexual intercourse and pregnancy happens to take place, then this extra blood is used to nourish and develop the new child; but if no pregnancy takes place, that extra blood exudes from the bloodvessels (some of the bloodvessels rupture) and is discharged from the uterus into the vagina, and from there to the outside, where it is caught on cotton, sanitary napkins or some other pad.
At what age does menstruation begin? The usual age at which menstruation begins in this country is thirteen or fourteen; in some it may occur as early as twelve, in others as late as fifteen, sixteen or even seventeen. For menstruation to begin earlier than twelve or later than seventeen is in this country a rare exception. But in cold northern climates the age of eighteen is not rare, and in the hot southern climates menstruation often starts at the ages of ten or eleven. Change of climate or of country will often have an influence on the menses. In the early years of his medical practice, the author had many Finnish girls as patients. It was a very common occurrence for them to stop menstruating for the first few months or even for the first year of their residence in this country.
At what age does menstruation cease? The age at which menstruation ceases is called the menopause or climacteric. It usually takes place at the age of forty-eight or fifty. In some cases it does not take place until the age of fifty-two, in others it takes place as early as forty-five or forty-four. In general, it may be said that the woman's menstruating period, during which she is able to have children, lasts about thirty-five years. And if no restraint be taken, and if no precautions be taken against conception, a woman could have twenty or thirty children during her childbearing period.
How many days does a woman menstruate? The usual number of days is from three to five; in some cases menstruation lasts only two days, in others as long as seven. As a rule, the greatest amount of blood passed is during the first two days.
The amount of blood. It is hard to estimate the exact amount of blood passed by a woman during her menses, but it reaches about an ounce and a half to three ounces. In some women the amount may reach as much as four or five ounces and in exceptional cases as much as eight ounces. Where it exceeds this amount, it is an abnormal condition, requiring treatment. The usual statement that a normally menstruating woman should not have to use more than three napkins during the twenty-four hours is correct.
The periodical regularity with which menstruation recurs in many women is remarkable. I know a woman who has not missed her menses in twenty years; during those twenty years the menses have started every fourth Friday, almost always at the same hour. I know another one who has her menses every fourth Wednesday, about seven in the morning. She skipped her periods during her two pregnancies, then they were irregular for a while, then they came back to Wednesday. Other women have their menses on a certain day of the month, say the first or the fifth, regardless of the number of days in the month (such cases are, however, exceptional). And in some women the menses are irregular: every three weeks, every five or six weeks, every six or seven weeks, etc. Some women never know when they may expect their menses, so irregular they are.
Chapter Seven
ABNORMALITIES OF MENSTRUATION
Disorders of Menstruation—Menorrhagia—Metrorrhagia—Amenorrhea—Vicarious Menstruation—Dysmenorrhea of Organic and of Nervous Origin.
In many girls and women menstruation is a perfectly normal, physiological process. They suffer no discomfort whatever from it. They suffer no pains, no headache, no irritability, they have no admonition of its onset, until they feel the blood oozing or trickling out. But, unfortunately, this is true only of a small percentage. The majority of women have some unpleasant symptoms. Some have a headache for a day or two, some complain of a dragging down sensation, some are irritable, feel depressed or quarrelsome; some have no appetite, no ambition, no desire for work or company, while some girls have such severe pains and cramps that they are obliged to go to bed for a day or two and call in medical aid.
When the menstruation is very profuse, resembling more a hemorrhage than normal menstruation, it is called menorrhagia; if the hemorrhage from the uterus occurs out of the regular menstrual periods, it is called metrorrhagia. When the menses are skipped, or when they are so scanty that you can hardly notice any blood, we use the term amenorrhea. In a few rare cases the menstruation instead of coming normally from the uterus, comes from some other part of the body, for instance, the nose. Some women have a hemorrhage from the nose every month. In some a bloody discharge may come from the breasts. To such a substitute menstruation we apply the term vicarious menstruation. Such cases, however, are rare, and are mere curiosities.
Dysmenorrhea. I mentioned before that in some girls and women the menses are accompanied by pains and cramps. This affliction, which is the lot of millions of women, and from which men are entirely free, is called dysmenorrhea. Dysmenorrhea means painful and difficult menstruation. A slight pain or at least a feeling of discomfort is present in most cases of menstruation. But in many cases the pain is so severe, so excruciating, that the sufferer, girl or woman, is incapacitated for any work, and must go to bed for a day or two. In some cases the pain is so severe as to necessitate the use of morphine, and as it is a very bad thing to have to give morphine every three or four weeks, every endeavor should be made to find out the cause of the trouble and to remove it. It is a mistake, however, to think that all or even most cases of dysmenorrhea are due to some local trouble, that is, to an inflammation of the ovaries, or a displacement of the womb. Many cases of dysmenorrhea are of nervous origin; the cause resides in the central nervous system, and not in the genital organs themselves. It is, therefore, not advisable to undertake any local treatment, unless a competent physician has made a thorough examination and has decided that local treatment is advisable.
As to the percentage of dysmenorrhea, a recent statistical examination of 4,000 women showed that dysmenorrhea of some degree was present in over one-half, namely, 52 per cent.
Chapter Eight
THE HYGIENE OF MENSTRUATION
Lack of Cleanliness During Menstrual Period—Superstitious Beliefs—Hygiene of Menstruation.
The hygiene of menstruation can be expressed in two words: cleanliness and rest. Common sense would suggest these two measures, and as far as rest is concerned, many women do rest or take it easy while they are unwell. Some are forced to do it, because, if they don't, their dysmenorrhea is worse and the amount of blood they lose is considerably increased. The same cannot be said of cleanliness. Due undoubtedly to the superstitious opinions about menstruation, which came over to us from the ages-of-long-ago, menstruation is still considered a noli-me-tangere, and women are afraid to bathe, to douche or even to wash during the periods. And if there is any period when a woman needs a douche it is during menstruation. Any leucorrhea that a woman may be suffering from becomes aggravated around the periods; the menstrual blood of some women has a decided odor, and if no cleansing douche is taken during four or five days, some of the blood decomposes and acquires a decidedly offensive odor, which can be noticed at some distance and to which some men and women are very susceptible. There are some women who never take a vaginal douche. Some consider it a useless and unnecessary luxury; while some orthodox puritanical women consider it an ungodly procedure (forgetting that cleanliness is next to godliness) fit only for women of gay and questionable character. If these orthodox women knew what was good for them—and for their health—they would take a douche at least during menstruation, if at no other time.
Cleanliness. When the girl reaches the age of twelve or thirteen the mother should explain to her the phenomenon of menstruation and the likelihood of its making its appearance in a short time. Of course she should be told that there is nothing shameful in it, that when it makes its appearance she should at once tell her mother, who will instruct her what to do. She should be shown the use of sanitary napkins. Rags, unless recently washed and kept wrapped up and protected from dust, should not be used. Unclean rags may lead to infection. I have no doubt that many cases of leucorrhea date back their origin to unwashed rags. Every morning and every evening the girl should wash the external genitals with warm water, or plain soap and water. Married women should also take a douche once a day—the douche may consist of two quarts of water in which has been dissolved a teaspoonful of common table salt, or a tablespoonful of borax or boric acid. Such things like alum, potassium permanganate, carbolic acid, lactic acid, or tincture of iodine should only be used when there is leucorrhea present and generally only under a physician's directions. Bathing is permissible, but it is safe to use only a lukewarm bath. Cold tub baths, cold shower baths, as well as ocean and river bathing are best avoided during the period; at least during the first two days. I do not give this as an absolute rule; I know women who bathe and swim in the ocean during their menstrual periods without any injury to themselves, but they are exceptionally robust women; advice in books is for the average person, and it is always best to be on the safe side.
Rest. Rest is just as important during menstruation as cleanliness, if not more so. Some women as mentioned before feel during their menses just as well as they do at other times, and do not need any special hygiene. But these are in the minority. Most girls and women do feel somewhat below par during that period, and it is very important that they take it easy, particularly during the first two days. It is an outrage that many delicate, weak girls and women must stay on their feet all day or work on a machine when they should be at home in bed or lying down on a couch.
The womb is congested during the period, is larger and heavier than normal, and it is then that there is often laid the foundation for some future uterine disease, the well-known "womb trouble," or "female disease." It is not necessary that work be given up altogether, but there certainly should be less of it and there should be as much rest as possible. For delicate and sensitive girls it is always best to stay away from school during the first and second days. Speaking again of the average and not the exception, it is best that dancing, bicycle riding, horseback riding, rowing, and other athletic exercises be given up altogether during the menses. Automobile riding and railroad and carriage travelling prove injurious in some instances, greatly increasing the flow of blood. But these are the exceptions at the other extreme.
Chapter Nine
FECUNDATION OR FERTILIZATION
Fecundation or Fertilization—Process of Fecundation—When the Ovum Matures—Fate of Ovum When no Intercourse Has Taken Place—Entrance of Spermatozoa as Result of Intercourse—The Spermatozoa in Search of the Ovum—Rapidity of Movements of Spermatozoa—Absorption of Spermatozoön by Ovum—Activity of Impregnated Ovum in Finding Place to Develop—Pregnancy in the Fallopian Tube and Its Dangers—Twin Pregnancy—Passivity of Ovum and Activity of Spermatozoön Foretell the Contrasting Rôles of the Man and the Woman Throughout Life.
Fecundation and fertilization are important terms to remember. They stand for the most important phenomenon in the living world. Without it there would be no plants and no animals, excepting a few very low forms of no importance, and of course no human beings.
Fecundation or fertilization is the process of union of the female germ cell with the male germ cell; speaking of animals, it is the process of union of the egg or ovum of the female with the spermatozoön of the male. When a successful union of these two cells takes place a new being is started. The process of fertilization or fecundation is also known as impregnation and conception. We say, to fertilize (chiefly, however, when speaking of plants) or to fecundate an ovum, or to impregnate a female or woman, and to conceive a child. We say the woman has become impregnated or has conceived.
The Process. The process of fecundation is briefly as follows. An ovum becomes mature, breaks through its Graafian follicle in the ovary and is set free. It is caught by the fimbriated or trumpet-shaped extremity of the Fallopian tube and, moved by the wave-like motion of the cilia4 of the lining of the tube, it begins its travel towards the uterus. If no sexual intercourse has taken place nothing happens. The ovum dries up, or "dies," and either remains somewhere in the tube or womb or is removed from the latter with the menstruation, or mucous discharge. But if intercourse has taken place, thousands and thousands of the male germ cells or spermatozoa enter the uterus through its opening or external os, and begin to travel upward in search of the ovum. The spermatozoa are capable of independent motion, and they travel pretty fast. It is claimed that they can travel an inch in seven minutes, which is pretty fast when you take into consideration that a spermatozoön is only 1/300 of an inch long. Many of the spermatozoa, weaker than the others, perish on the way, and only a few continue the journey up through the uterus to the tube. When near the little ovum, which remains passive, their movements become more and more rapid, they seem to be attracted to it as if by a magnet, and finally one spermatozoön—just one—the one that happens to be the strongest or the nearest, makes a mad rush at it with its head, perforates it, and is completely swallowed up by it. As soon as the spermatozoön has been absorbed by the ovum, the opening through which it got in becomes tightly sealed up—a coagulation takes place near it—so that no other spermatozoa can enter the ovum. For if two or more spermatozoa got into the same ovum a monstrosity would be apt to be the result.
Spermatozoön Penetrating the Ovum.
What becomes of all the other spermatozoa? They perish. Only one is needed. But in the ovum that has been impregnated, and which is now called an embryo, a feverish activity commences. First of all it looks for a fixed place of abode. If the ovum happened to be in the uterus when the spermatozoön met and entered it, it remains there. It becomes attached to some spot in the lining of the womb and there it grows and develops, until at the end of nine months it has reached its full growth, and the womb opens and it comes out into the outside world. If the ovum is in the Fallopian tube when the spermatozoön meets it, as is usually the case, it travels down to the uterus, and fixes itself there.
Extra-Uterine Pregnancy. The tube is a bad place for the ovum to grow and develop, because the tube cannot stretch to such an extent as the uterus can, nor can it furnish the embryo such good nourishment as the uterus can. Occasionally, however, it happens that the impregnated ovum remains in the tube and develops there; we then have a case of what we call extra-uterine (outside-of-the-uterus) or tubal pregnancy. Extra-uterine pregnancy is also called ectopic pregnancy, or ectopic gestation. Unless diagnosed early and operated upon, the woman may be in great danger, for after a few weeks or months the tube generally ruptures.
From the moment the spermatozoön has entered the ovum, a process of division or segmentation commences. The ovum, which consists of one cell, divides into two, the two into four, the four into eight, the eight into sixteen, these into thirty-two, these into sixty-four, 128, 256, 512, 1,024, until they can no longer be counted. This mulberry mass of cells arranges itself into two layers, with a cavity in between. And from these layers of cells there develop gradually all organs and tissues, until a fully formed and perfect child is the result. If two ova are impregnated at the same time by two spermatozoa, the result is twins.5
I might mention here that the moment the ovum is impregnated, i.e., joined by a spermatozoön, it is called technically a zygote; it is also called embryo, and this name is applied to it until the age of five or six weeks. Some use the term embryo up to two or three months. After that, until it is born, it is called fetus.
A study of the development of the embryo and the formation of the various organs from one single cell, the ovum, vitalized or fecundated by another single cell, the spermatozoön, is the most wonderful and most fascinating of all studies. But that belongs to the domain of Embryology, which is a separate science.
What we see in the process of fecundation is a foreshadowing of the future man and woman. The ovum has no motion of its own, it is moved along by the wave-like motions of the lining cells of the Fallopian tube, and throughout the entire act it remains passive. The spermatozoön, on the other hand, is in a state of continuous activity from the moment it has been ejaculated by the male until it has reached its goal—the ovum. And as the spermatozoa carry in them the entire impress of the man, and the ova of the woman, they foretell us the fates of the future boy and girl. The woman's rôle throughout life is a passive and the man's an active one. And in choosing a mate the man will always be the active factor or pursuer. So biology seems to tell us. Whether education—using the word in its broadest sense—will effect a radical change in the relation of man and woman remains to be seen. A change putting the man and the woman on a footing of equality would be desirable; but whether biological differences having their roots in the remotest antiquity can be obliterated, is a question the answer of which lies in the distant future. As Geddes and Thomson so well said: The differences [between the sexes] may be exaggerated or lessened, but to obliterate them it would be necessary to have all the evolution over again on a new basis. What was decided among the prehistoric Protozoa cannot be annulled by act of Parliament.