The normal woman in her prime, no matter how healthy, is more sensitive, more prone to depression, excitable, moody, feels more fatigued, distracted, suffers pain more or less in- tense in different parts of the body, especially in the head, is liable to discontent, quarrelsomeness, unstable in appetite and sleep, disappointed, feels oppressed, and can do less work with mind and body. She is liable to nausea, palpitation, paranoea and hypersesthesia, a feeling of heaviness of body, sick headache, partial and temporary paresis, prosopalgia, fickleness, changes from elation to depression, local chills and flushes, etc. These symptoms gradually diminish and finally the ''rules" cease. Then "the woman is born anew. She is vigorous, energetic, joyful, well. Her soul is clean and ready for ceaseless work." The pains were those of childbirth on a small scale. We might say that in the one case the race is renewed through pain; in the other, the individual. She is now at the very top of her condition, most brilhant, beauti- ful, attractive to men, and most attracted to them. Before, she needed the greatest tenderness, delicacy, and sympathy, but gradually, as the month advances she becomes more inde- pendent and often a little less dominated by her affections.
These processional changes in a strong and healthy nature have something of the magnificence and awfulness of Nature's primitive revelation.
During just the time when savages isolate woman and call her unclean, she is really in her fullest flower and glory, and she must begin by reenforcing her self-respect at this period. She must have freedom to control the entire environ- ment, and thus, perhaps, to some extent, the time of her month. With the birth of the function at adolescence comes one of the most wondrous of all instincts, namely, just how to best care for herself. This has been enfeebled and now PERIODICITY 493 needs more or less help. Man can never understand this, and to him she may always seem somewhat more unique and strange then. The nerves, feelings, and the muscles need a regimen varying in individual women more, perhaps, than the whole range of male variabiUty. In this women differ from each other more than they differ from man. Into this field I can not enter; but happy she who, at twenty-five, has really achieved freedom, intelligence, and true self-knowledge. During the first few days she is introverted to strange sensa- tions which ideally are not painful, but deliciously and some- times almost ecstatically charming. The volume of her emotional life is greatest, as is its depth and range. Then, actually though unconsciously, if entirely healthful, she is more attractive to man; and as the wave of this great cosmic pulse which makes her live on a slope passes, her voice, her eye, complexion, circulation, and her very dreams are more brilliant. She feels her womanhood and glories in it like a goddess. Her toilet is never so detailed, even where it is most hidden, to any other eye than her own. The flow itself has been a pleasure and the end of it is a slight shock. The instinct to conceal is a part of female coyness, which is directed only toward others, and she is most of all reserved toward any chosen one. In the earHest stirrings of the adolescent ferment, she has first dreamed of some ideal of manhood and is altruistic, and only later comes the concep- tion of selfhood. Solitude and the country develop ideals of others, and society and the city tend toward the self-center. So far from ever having wished herself a male, she exults in her womanhood as something superior, and feels it worthy of love, reverence, protection, care, and service. In early adolescence her impulse is to make herself absolutely perfect. When her cycle is complete, her whole life must be regulated to prepare for the next. She develops new sentiments, in- stincts, and insights, is a charm to herself and both a fascina- tion and a study for others; and because these days are not all on a dull, prosaic level, her life is larger and explores all the possibilities of humanity, so that she is less in need of supplementing her own individual limitations by the study of the alien lessons of the schools. So much comes to her by intuition and experience that her way of wisdom is larger and 494 THE PSYCHOLOGY OF ADOLESCENCE must always seem more esoteric and mystic to man. Thus she illustrates the type of wholeness, rather than halfness, which a German scholar has suggestively described.^ Every day of the twenty-eight she is a different being, and the wide range of circumnutation which explores the pleasures and pains of life, its darkness and its light, its de- pressive and exalted states, its hopes and fears, its sense of absolute dependence and of independence, sometimes almost to the declaration of war of sex against sex, reveals her as a more generic creature than man, less consistent than he if we compare days or hours, more so if we compare months as the units of her life. Is all this health or disease, normal or ab- normal, or half-way between, is a question often asked, but which can not be answered till we know whether the human race realizes its ideal. This phenomenon has, perhaps, had very much to do in the development of the persistent concep- tion that man is suffering from the effects of great calamity or error in the remote and forgotten past, that has perverted and left its mark upon his nature.
Very different are the phenomena in girls handicapped by morbid nervous periodicity. All the preliminary symp- toms are exaggerated. On or near the culminating day of first menstruation, a slight shock, joy, or pain, may cause an hysterical outbreak, and if the normal menstrual endeavors are thwarted, abnormal moHmina are intensified. Each stage of the month has its onset of feelings, thoughts, perhaps acts, psychic scenery and color generally, and sometimes the doubts, disturbances, and comparisons of one stage from the standpoint of another, cloud not only the future but may tend to nervous and even mental weakness. There is a man- and school-bred kind of logical consistency to impose which upon her is an outrage to her nature. More often in such cases the impulses of each stage may break away from con- trol by the others, and impulsiveness, epileptic symptoms, senseless terrors, prsecordial anxiety, pyromania, the assump- tion of an alien role, grave illness, one-half of which is real and the other half sometimes consciously feigned, and some- ' Die Ganzen und die Halben: Zwei Menschheitstypen. Deuts. Rundschau, PERIODICITY 495 times honestly fancied, may occur. Hysteria, more often in its mild form of uncontrollable weeping, laughing, or globus hystericus, often makes its first appearance at the time of first menstruation. Slight epilepsy in the form of brief faint- ing fits is liable. The girl falls, perhaps with a cry, has cramps, staring eyes, rapid pulse for a few minutes and recov- ers, and then is as usual till the next period. First menstrua- tions after childbirth and those at the beginning of sexual life are often attended by similar psychic symptoms. Occasion- ally it may cause improvement of specific troubles, e. g., of chorea, and when it first appears as something unknown and unexpected, the dangers to psychic equilibrium are greater, as also when there is a tendency to specific diseases, as of the lungs, heart, etc.
The effects of menstruation upon previously existing morbid mentation and of the cessation of periods upon the onset of disease and its return with convalescence, do not indicate, as is usually thought, a causal relation between the two, but rather both are perhaps concurrent and independent effects of the same cause, like exhaustion and rest. Some- times, indeed, the beginning and end of this period have no effect on the progress of psychic disease. Selager, Schroder, Krafft-Ebing, and Algeri think it intensifies; and Marci and Kovalevski hold that it may often even mitigate the intensity of insane states. Abnormal brain conditions, then, must be regarded as concurrent symptoms of anomalous menstruation, and not as the cause of it. Periodicity with similarity of symptoms on successive months, brief duration and recovery, circular insanity with attending depression or exaltation, and obscenity in word or act, often indicate that the perversity is of menstrual origin. Sometimes, on the other hand, mental disturbance seems the direct and immediate effect of arrest or excess of flux. Some psychoses are vicarious for men- struation.
Very characteristic, although rare, are cases of vicarious puerperal bleeding at the nose, stomach, and elsewhere.' This is far less alarm- ing and far less common than periodic hemorrhages near the meno- ' See a good typical case in a girl of fourteen, in the New Zealand Medical 4-9^ THE PSYCHOLOGY OF ADOLESCENCE pause/ It may be in some respects compared with so-called pregnant menstruation, which is really pathological bleeding and perhaps about as infrequent.'* This strange reciprocity is complicated by the curious clinical fact that mental disturbance should be much more frequent at the natural period of the climacteric than when the menstrual func- tion is suddenly inhibited by accidental cause.^ Meyer urges that the causes of abnormalities and their results are "not to be sought alone, and indeed not predominantly in the sex organs, but in every organ of the body."
Menstrual irregularities which seem to be everywhere increasing are usually grouped under three heads: disorders of defect, or amen- orrhea; of excess, or metrorrhagia; of perversion, or dysmenorrhea.
(a) Amenorrhea may be partial^ involving action of the ovaries only. In such cases the monthly flux may be regular and normal in both quantity and quality, but ovulation does not occur. On the other hand, the ovaries may do their part, but the uterus remains inactive. In such cases the discharge does not occur. These main defects, as well as under-functioning of the Fallopian tubes and vagina, may of course occur in all degrees, from complete absence up to normal activity, and even be well-proportioned in amount and properly connected in time. Non-ovulation is very hard to diagnose, so that suppression of the flow is the chief fact. The latter may be temporary or prolonged; so complete that almost none of the characteristic sensations or symp- toms are felt, or the flow may be only a slightly paler color, at a little longer interval or with reduction in quantity. In such cases supple- mentary hemorrhages often occur. Puech, whose statistics are still the best, found these complementary escapes of blood to occur in the order of frequency as follows: most often it is vomited from the stomach, next most frequently it escapes from the breasts, then come hemorrhages from the lungs, throat, mouth, nosebleed, discharges from the lower limbs, trunk, back, walls of the thorax; intestinal piles, swollen gums or eyelids, lacrymal glands, urine, hands, hair, ears, umbilicus, salivary glands, cheeks, etc., may bleed. Indeed, spontane- ous supplemental hemorrhages may occur almost anywhere or produce congestion in any organ.
The causes of suppression, besides the chief uteropathies and preg- nancy, are many, some well-established and others obscure. Of all these processes the ovaries are, biologically considered, the center and soul, so that any trouble here causes hesitation or crepuscular menstruation, and may slowly and entirely check it, as is seen in cases where the ovaries have been removed. Among the non-genital causes of partial or total suppression, chlorosis and anemia are very common. Consumption has a gradually suppressive effect; so does obesity, and several urinal and sexual abnormalities. Strong or sudden emotioi?
* Levy. Archiv f. Gyn., Bd. 15, pp. 361-383.
* Barus. Scalpel, July, 1896.
PERIODICITY 497 can prevent or almost momentarily arrest the flux, and psychic states have an immediate and profound influence in both increasing and diminishing it. The face itself, which grows pale or flushed with every change of sentiment, and reflects each effect of pleasure or pain, says Auvard in substance, responds no more delicately to every change of moral and intellectual states than do organs involved in menstruation. Fear, whether sudden or chronic, great dread or desire of pregnancy in young married women, certain hysterical manifestations, study or worry about lessons, bad air, constrained positions, improper or fluc- tuating temperatures either local or general, change of diet, of regi- men, environment, the honeymoon, medication, many unknown and idiopathic causes, may lead to the same results. The treatment of so complex a disorder, it need scarcely be said, should be mainly directed to the removal of its cause, and can be completely restorative only when taken before bad menstrual habits have been too long confirmed or too far advanced.
(b) Metrorrhagia, or excessive menstruation, may appear in ab- normal hemorrhages from almost any part of the genital organs. If the female organs in all their varied functions, including parturition, are more prone to hemorrhages than those of the male, the former bear the loss of blood far better and seem to have greater spontaneous styptic or stanching power, and woman's more anabolic activities make all loss good sooner and with greater ease than does the male organism. Excess may appear in quantity, duration, and frequency, and these forms often have an intimate reciprocity. At the pubertal instauration of the periods, as well as at the menopause, various forms of excess are liable. Excluding local mechanical causes and also those due to changes in the composition of the blood, certain cardiac affec- tions, neuralgia and many psychic states and processes, cause uterine congestion, and may aggravate any or all of the factors of menstru- ation. Abdominal compression is prominent among the disturbances that cause aggravation of these disorders. All such forms of excessive activity of course involve loss of vital energy and keep the unfortunate subject on a low plane of vigor and emotional tone, check the later stages of mental and bodily growth, and impair the power of normal procreation, and often before the danger is fully realized condemn girls to a life of semi-invalidism that might have been avoided by a little more care and wisdom at the critical time when these functions were being first established and regulated.
(c) Dysmenorrhea, the third form of abnormality, is often marked by colic, which is to the smooth or involuntary what cramp is to the striated or voluntary muscles. The normal contraction of the uterine muscles is not perceived, but their painful action is analogous to the discomfort of indigestion, colic of the kidneys, or palpitation of the heart. Many varieties and symptom-groups have been proposed, but most features are common to all forms. The pain is intermittent, like the contractions which cause it. It is ill-defined as lumbar, abdominal, hypogastric, crural, etc. It is worst just at the time of the discharge 33 49^ THE PSYCHOLOGY OF ADOLESCENCE or just before, and often hinders sleep. The flux may be serous or clotted, may contain villosities, the detritus of decaying tissue, or it may be scanty and thin. The importance of these pseudo-menstrua- tions, says Auvard, is secondary, and they may be more frequent than is suspected in less observed normal cases. Sometimes the pain at the crisis is so great that the next recurrence is dreaded almost like par- turition, and its discomforts anticipated by those endowed with vivid imagination. Often such accompaniments as bad breath, flushes and pallor, and faintness are watched for with apprehensions, which may themselves become a cause of depression or debility. The source of this, as of all the other genetopathies, may be congenital or even hereditary, but very often its origin is in the nervous system. The tubes, ovaries, or vagina, as well as the uterus, may contribute to dys- menorrhea.
Many of the disturbances, which are hardly less complex or mani- fold than the causes of sterility, have been themes for clinical, surgical, and physiological study, and together make up a rich body of data which constitutes the science of the gynecologists and fills their jour- nals. But some plain and simple statement of the significance and dangers of these periods should be an essential part of the educational equipment of every girl on or before reaching this age.
Dr. C. Clark ^ held that there were no forms of insanity expressive of particular types of menstrual irregularity. Irri- tability, depression, and stupor, the three types of psychic reflex from this can not be ascribed to special forms of it. Icard ^ has constructed a table of great value, although based upon only three hundred and forty-nine cases, indicating the relative frequency of various forms of psychic perversion ob- viously menstrual in character. Most common is a group of disorders of middle life, which he designates somewhat col- lectively as acute mania and impulsive and nameless delirium. Next most common come religious delusions, quite frequent near the menopause. Then follow in order of frequency, suicidal impulses, most of which are in middle life, genesic excitation, melancholia, homicidal impulses, illusion and hal- lucination, pyromania most frequent at puberty, kleptomania, dipsomania, spells of jealousy, lying, and calumny. Icard concludes that the menstrual function in these cases, where predisposition exists, creates a psychological state, varying ^ Jour, of Mental Science, 1888, p. 386.
' La Femme pendant la Pdriode Menstruelle, par D, G. Icard, Paris, 1890, PERIODICITY 499 all the way from simple moral malaise or disquietude to posi- tive alienation, with complete loss of reason, morality, and responsibility. In such cases, those who know most will pardon most. Wherever crime occurs in such states, he would persistently raise the question of legal accountability. The sympathies between the brain and reproductive organs are far more intimate than has hitherto been suspected. Even hys- teria, epilepsy, chorea, chlorosis, and exophthalmic goitre are classified among the neuroses of menstruation. Abnormality of this function is a predisposing cause to any of the obvious disturbances that heredity or the nature of any other troubles of body or mind may determine. It is impossible to ascertain whether psychic disturbances have a more immediate and profound effect on menstrual disorders or vice versa, but the relation of body and mind is nowhere more intimate than here, and a psychology that does not take careful account of this is defective.
In an important article/ a large number of cases of crime in the menstrual state are quoted from Krafft-Ebing, Tuke, Pellmann, West- phal, Mabille, Girand, and others. As typical as any are the fol- lowing: Z., a peasant woman, aged twenty-two, set fire to her own hut. Up to the age of ten she was normal, but afterward led a hard Hfe; menstruation began at sixteen and was attended by pain in the head and collapse. She married at twenty, but was childless. During the summer preceding her crime the courses ceased, but in their place came prsecordial anxiety and irritation, headache, restlessness, loss of sleep, and nameless dread. Her husband's relatives beat her, and she was thought stubborn during her periods. For a supposed neglect due to her confused state she was beaten on the head, and broke out into a fit of anger that made her violent but unconscious. When the family had retired and she had come to herself, she imagined assaults and other terrible things, and finally fired the roof and felt great satisfac- tion. On hearing the alarm she aroused her husband and helped to extinguish the flames. On the same night menstruation appeared and she felt reborn to a new life. All her troubles ceased and she con- fessed everything openly.
Another case was a twenty-year-old daughter of a professor, well- bred and trained but of nervous heredity, and who had convulsions in childhood but no disease. With the first menstruation at fourteen came great access of fear, which she could not account for or define the 1 The Menstrual State and Psychoses, by P. I. Kovalevski. Russian Archiv Psychiatric. Kharkov, 1894, pp. 73-131.
500 THE PSYCHOLOGY OF ADOLESCENCE object of. She was restless, ran from place to place, sobbed, prayed, but when she knelt blasphemous words forced themselves into her mind in connection with the Blessed Virgin, Jesus and his saints, until she beat her head against the wall and tried to spring from the window and choke herself. She understood well that it was all disease, but it drove her to resolve on suicide. This state lasted about three or four days and ceased with the flow, when she became again cheerful, only to renew all these symptoms with great exactness in twenty-eight days, the first being the most painful. Thus in a year and a half there were fifteen such attacks, till at last under treatment the psychical troubles ceased, slight symptoms of which were felt two years later on bereavement. These attacks were severest in September, October, November, and March, and during the summer were mitigated into the form of sleeplessness, uneasiness, and desolate and depressive states of mind. This condition in the many cases of which this is typical usually continues up to the climacteric.
H. Ellis ^ says, " whenever a woman commits a deed of criminal violence it is extremely probable that she is at her monthly periods." Clouston says more specifically, *' the melancholiacs are more depressed, the maniacal more rest- less, the delusional more under the influence of their delu- sions in their conduct, those subject to hallucinations have them more intensely, the impulsive cases are more uncon- trollable, the cases of stupor more stupid, and the demented tend to be excited," at these periods. The matter is by no means so simple, however. Nacke ^ concludes from a careful study of ninety-nine cases of chronic psychoses, that in regu- larity and all other respects these periods do not materially difTer from those of normal people, and that this influence on the course of such disturbances is relatively slight and incon- stant. In sixty-five cases, no influence whatever could be detected. Even abnormalities in these functions had no greater influence than on the sane.
Kiernan^ attempts to elaborate and further illustrate Moll's con- ception of mixoscopic adolescent states. When the factors that make up the ego are disjointed, primitive instincts often arise and new direc- * Man and Woman, p. 254.
' Die Menst. u. ihre Einfluss bei chron. Psychosen. Arch. f. Psychiatric, 1896, vol. xxviii, No. i, p. 169, ' See articles in the Alienist and Neurologist, beginning May, 1903, entitled MixoscoDic Adolescent Survivals in Art, Literature, and Pseudo- Ethics.
PERIODICITY 501 PERIODICITY 501 tions are taken. Religious ecstasy may become associated with salac- ity. Algophily may become love of seeing pain in others or of suffer- ing it one's self. New relations between the cerebral and reproductive system are common. Gross ideas of sex in people of blameless lives; the intensification of lust which may grow with jealousy; hypersensi- tiveness, as, for instance, "the nervous bladder"; philistine conventions beside erotic imaginations; prurience in prudery; the venting of sexual unrest in very eccentric ways, as in the case of Viola Larsen, who leaped into notoriety in the West by stealing, which she described as wildly intoxicating, delicious, beautiful, wonderful, a girl who early burned for fame and took delight in many kinds of strange antics — these symptoms illustrate mixoscopia. The rapture of being plunged into the waves of that great ocean of feeling which underlies our daily life in order to intensify consciousness and feel energy; the indulgence of pungent sexual argot; in "furtively sniggering over indecency"; the depression of the habitual motives of modesty into the realms of the unconscious; the " auto-erotism of the Narcissus type " which sometimes appears as a result of excessive use of the mirror, are further outcrops.
Gall thought there were periodic changes in men at puberty analogous to the twenty-eight-day periods in women. This he held was noticed chiefly in approaching senescence, especially in the feeble. Their complexions grow dull, the perspiration changes, digestion is poorer, and there may be periodic sadness, discomfort, and inability to work.
Sanctonius, Keill, and Laycock long ago held this view/ Clark thinks temperature^ and Hammond says nosebleed, headache, excess of uric acid^ and Clouston that the nisus generativus, show monthly rhythm; Ellis * rather inclines to accept a three-and-a-half day period as the unit, with weekly and fortnightly cycles, seen perhaps also in pulse, rate of respiration and weight, although even his very interesting case of Perry-Coste hardly favors a strictly lunar period. We should expect that such a fundamental rhythm, if it existed, would be overlaid by many social and auto-suggestions. This rhythm may precede and survive sexual life, and menstruation itself may be a special and secondary outcrop of a more basal rhythm that extends from the cradle to the grave in both sexes.
The spells of discomfort, distraction, irascibility, and de- pression in males thought to be of this character are probably much more common than is generally supposed. Young and ' See Gould and Pyle: Anomalies and Curiosities of Medicine, p. 28. ' Psychology of Sex, p. 73 et seq., and Appendix B, p. 251.
502 THE PSYCHOLOGY OF ADOLESCENCE