The term menarche (μήν, a month, ἀρχή, the beginning) was introduced by me into medical literature to denote the period of life in which, as a sign of puberty, menstruation first makes its appearance.

The age at which this occurs is subject to variations depending upon race, occupation, hereditary tendencies, and climate; but in Germany and Austria the average age at puberty is 14 or 15, the extreme limits being 12 to 19.

Until about the age of 13, the physical differentiation of the sexes, except for the anatomical peculiarities of the genital organs, is in our climates a trifling one. But at puberty the important changes occur by which the sexes are so strikingly differentiated. Whereas in the growing boy all physical change takes the form of increasing strength and energy, in the development of the girl, we note the appearances of the rounded outlines so characteristic of womanhood. At the same time the voice alters, becoming less sharp, with a softer quality, and yet a fuller tone; and we may observe that young brunettes have commonly a contralto voice, young blondes, more often a soprano. The intellectual changes undergone by the girl at puberty are no less extensive and characteristic than the physical changes. In brief, the undifferentiated, neuter girl is transformed into a young woman, endowed with all the attributes, mental and bodily, characteristic of femininity.

As regards the age at which the menarche usually occurs, and the manner in which its occurrence is anticipated or retarded by the various influences already mentioned, the following propositions may be put forward, based on the available statistics and observations:

1. Climate is an important factor. In the torrid zone, menstruation appears at a very early age, on the average from 11 to 14; in the temperate zone, it appears later, on the average from the age of 13 to 16; in the frigid zone, later still, on the average from the age of 15 to 18. The mean temperature of the atmosphere appears to have a direct influence on the age at which menstruation begins, the hotter the climate, the earlier being the menarche. The height of the place of residence above the sea level and its distance from the coast also have a certain influence.

2. Race and constitution have a distinct influence upon the age at which menstruation makes its appearance. In women of the Semitic races the menarche occurs earlier than in women of the Aryan races. The average age at which menstruation begins is in Jewish girls, from 14 to 15; in Magyar girls from 15 to 16; in German girls from 16 to 16½; and in Slavonic girls from 16 to 17.

In general the menarche is earlier in girls of a sanguine, lively temperament and a powerful constitution than in girls of a phlegmatic temperament and a weakly constitution; further, other things being equal, menstruation appears earlier in brunettes, girls with black hair, thick skin, dark eyes, and a dark complexion, than it appears in blondes, girls with light hair, thin skin, blue eyes, and a fair complexion.

3. The age at which menstruation begins is also affected by the conditions of life and the social circumstances. In the higher circles of society, in the upper, well-to-do classes, menstruation appears earlier than among women of the laboring classes, who are compelled to strive for their daily bread. Amongst upper-class girls the menarche occurs at the age of 14 in one-fourth of their number, whereas among lower-class girls barely one-sixth begin to menstruate at the age of 14.

In large towns, again, menstruation appears earlier than in small towns, whilst in the open country the menarche is still further delayed. In the women of Paris the average age at the menarche is 14 years and 6 months, in the women of smaller French towns it is 14 years and 9 months, in French countrywomen it is 14 years and 10 months.

How far the mode of nutrition is concerned in the production of these results is not yet determined.

4. The time of the menarche appears to be influenced by inheritance to this extent, that the daughters of women who began to menstruate early begin themselves to menstruate at an early age, whereas in other families we observe that both mothers and daughters began to menstruate late. But this relation is by no means a constant one.

Ploss has collected observations made in various countries and towns regarding the age at which menstruation begins, and the mean results of these observations are given below.

The average age at which menstruation began was:

The collective results of the investigations of French authors regarding the average age at which menstruation first appears are given in the following table:

from these observations we obtain an average of 15 years.

from these observations we obtain an average of 16 years and 3 months.

from these observations we obtain an average of 12 years and 7 months.

In 6,550 cases collected by Krieger menstruation first appeared:

From these figures it appears that in the 6,550 cases under consideration, the age 15 was that at which the first appearance of menstruation was most frequently observed, namely in 1,240 instances, or 18.9 per cent. The age 14 comes next, with 1,193 instances, or 18.2 per cent. The case in this series in which menstruation appeared earliest, namely in the ninth year, was observed by Mayer, the girl being a blonde of average height, good family, and German descent; the case in which menstruation appeared latest, namely in the twenty-ninth year, was that of a woman living in Berlin, who was sickly and chlorotic up to the time of her marriage, and in whom menstruation did not appear until some years after that event.

As regards climatic influences, all the data at our disposal prove that the hotter the climate the earlier the menarche. According to Marc d’Espine the age at puberty varies in an almost geometrical ratio with the mean annual temperature.

The dependence of the menarche upon climatic influences is clearly shown by the statistical data collected from various regions of the world. We append the general compilation of Gebhard dealing with this question.

A. Europe.

For Europe the data furnished by Ploss are grouped by Gebhard in the following manner.

1. Northern Europe.

The average age at which menstruation first appears, according to the older statistics, is in Swedish Lapland 18, in Norway, 16.12. In Copenhagen it is 16.75, in St. Petersburg 14.5.

More recent statistics for Finland are furnished by Engström. Among 3,500 women of pure Finnish descent, he found that menstruation began:

Thus, in nearly half of all Finnish women, menstruation begins with the completion of the fourteenth and fifteenth years. The statistics include women of all classes of society.

At the Pirogoff Congress Grusdeff furnished particulars of the first onset of menstruation in Russia among 10,000 women. Menstruation began:

In women of German race living in Russia puberty was earliest, occurring at the average age of 15.16 years; in Finnish women it was latest, occurring at the average age of 16.17 years.

2. Middle Europe.

In Germany, according to the tables of Krieger and L. Mayer, who have recorded 11,500 cases in all, menstruation begins most commonly (in 18.931 per cent. of the cases) at the age of 15; the next most frequent age is 14 (18.213 per cent. of the cases).

For Berlin, in a number of cases collected from the lower classes of society, we find the average age for the first appearance of menstruation to be 16.18 years.

Notwithstanding the more northerly situation of Berlin, the average age at puberty is somewhat less than in Munich, situated 4½ degrees to the southward, for the reason that the retardation dependent upon altitude makes itself manifest in the latter town, which is situate about 500 metres (1,640 feet) higher above the sea level. Whereas in Berlin 18 per cent. of all cases begin to menstruate at the age of 14, and 19 per cent. at the age of 15, in Munich the two leading years are 15 with a percentage of 17½, and 16 with a percentage of 18¾.

In Great Britain, according to Krieger, the average age at which menstruation begins is 15 years, 1 month, and 5 days. For Manchester the age given is 15 years, 6 months, and 23 days. In France, according to the calculation of Brierre de Boismont, the most frequent age for the first onset of menstruation is 16. In Paris the average age is 14 years, 6 months, and 14 days. Bohemia, Upper and Lower Austria, and Moravia have an average age of 16 years and 2 to 3 months.

3. Southern Europe.

In Southern Europe the influence of the higher mean temperature manifests itself. The average age at which Spanish girls begin to menstruate is 12. In Northern and Middle Italy the most frequent age is 14; in Southern Italy, 13. In Lyons the average age at which menstruation begins is 14 years, 5 months, and 29 days; in Marseilles and Toulon it is 13 years and 10 months. For Hungary, Doktor gives the statistics of 9,600 cases. In 22⅓ per cent. menstruation began at the age of 15; in 20½ per cent. at the age of 16, and in 10 per cent. at the age of 17. The earliest age among these cases was 8 years; the latest, 33 years. (The latter must no doubt be regarded as pathological.)

B. Asia.

In Palestine puberty most commonly occurs at the age of 13; in Turkey even as early as 10. Rouvier calculated the average of 742 cases observed in Syria to be the age of 12. As regards Persian women, the data vary between the age of 14 for the northern part of the country and the age of 9 or 10 for the southern. According to Joubert’s data in 46.4 per cent. of the indigens of India, menstruation begins at the age of 12 or 13. Similar figures are given for Ceylon and for Siam. In Japan menstruation most frequently begins at the age of 14, sometimes as early as 13; mothers of 15 are by no means rarities in this country, but for menstruation to begin before the age of 12 is considered a very exceptional occurrence. According to a table dealing with 584 women of Tokio menstruation began:

The data available regarding China are so exceedingly variable that little importance can be attached to them.

The average age at which menstruation begins in the negro women of Africa is from 10 to 13. In Algeria puberty occurs at 9 or 10 years. Among the Australian indigens, menstruation commonly begins as early as 8 years, and at the very latest at the age of 12 years. The data available concerning the indigens of the Oceanic Archipelago are extremely variable and inexact, but we cannot go far astray in stating the age of puberty among these to be from 10 to 13. In tropical South America girls begin to menstruate from the age of 9 to 14 years. The Indian women of North America begin to menstruate at the ages of 12, 13, 14, or even as late as 18 or 20. In the Arctic zone of North America and in Greenland the onset of menstruation is delayed till 17 and even till 23 years.

As regards the position in life and the upbringing years it has been shown by numerous observers that among the well-to-do classes, whose mode of living is luxurious, and whose social circumstances allow free play to the imagination, menstruation begins at an earlier age than among the working classes, whose life is one of want and privation. According to the statistical data of Mayer’s regarding 6,000 women, menstruation began:

From this table we learn that in nearly one-fourth of the girls of the upper classes puberty occurs at the age of 14, whilst in girls of the lower classes barely one-sixth begin to menstruate at this age. The average age at the first menstruation in girls belonging to the upper classes is seen to be 14.69 years, but in girls belonging to the lower classes, 16.00 years. According to other observers the average age at the first menstruation is:

Comparative observations on women living in towns and women living in the country show also that in the former, menstruation begins on the average at an earlier age. According to Brierre de Boismont, the average age at the first menstruation is:

Similarly it was found by Ravn that menstruation first occurred:

Mayer states that the average age at which the first menstruation occurs is:

In Italy, according to Calderini, in a thousand instances, menstruation begins at the age of 14 in 280, at the age of 15 in 219, at the age of 13 in 205, at the age of 12 in 116, at the age of 16 in 89, at the age of 17 in 55, at the age of 18 in 14, at the age of 11 in 7, at the age of 10 in 6, and at the age of 20 in 6 instances. In girls attending town schools, the first menstruation most commonly occurs in the months of June and August; but in girls attending country schools most commonly in the spring months.

A certain hereditary predisposition is so far determinant in the matter of the early or late onset of the first menstruation, that from a knowledge of the age at which menstruation began in the mother, we are able with great probability to predict the age at which it will begin in the daughter. Among fifty cases which I investigated with this point in view, I found forty-one in which the daughters of mothers who had begun to menstruate early began themselves to menstruate early, usually indeed in about the same year of life; or conversely that when the mother had begun to menstruate late, late onset of menstruation was usually to be observed in the daughter also. Tilt relates a case in which a woman began to menstruate at the age of fourteen, and her daughter and granddaughter both began to menstruate at the same age. Courty observed a mother who began to menstruate at the age of eleven, and whose eight daughters all began to menstruate at the same age.

Gynecologists agree in stating that girls of sanguine temperament and powerful constitution begin to menstruate earlier than weakly and phlegmatic individuals. Tilt describes a peculiar ovarian temperament, in which menstruation begins early; such women have as a rule striking nervous sensibilities, with a dark complexion and glistening, longing eyes, always surrounded by dark rings.

The opinion is general that in girls with black hair, dark eyes, thick skin, and dark complexion, menstruation begins earlier than in blondes with blue eyes and delicate white skin. Brierre de Boismont states in this connection that not fair hair only, but also chestnut-tinted locks, indicate a late onset of menstruation. L. Mayer found that:

According to the same author, the average age at which menstruation begins is:

As regards race, it is well known that in Jewesses menstruation begins at an early age. According to Joachim the age of puberty varies very greatly among the different races inhabiting Hungary. The first menstruation appears:

First Appearance of Menstruation.

The first appearance of menstruation is commonly preceded by various symptoms dependent on the increased flow of blood to the genital organs. Such symptoms are: Sacrache; dragging sensation in the loins; an indefinite feeling of pressure in the lower part of the belly, especially in the region of the uterus and the ovaries, which region is sometimes also tender on pressure; a slight feeling of weariness in the lower extremities; sudden flushings or pallors; alternating sensations of heat and chilliness, sometimes accompanied by actual though slight change of temperature. In many cases also there are disturbances in the intestinal evacuations and urinary secretion, in the process of cutaneous transpiration, and in the functional activity of the gastro-intestinal canal. A frequently observed symptom is an increased irritability of the entire nervous system, with an inclination to melancholy and indefinite amorous desires—symptoms which Tilt denotes by the term “ovarianismus,” Emmet by the term “erection,” Lecal by the term “phlogose amoureuse,” and the older writers by the term “molimina menstrualia.”

The nervous irritability manifests itself already before the appearance of the menstrual flow by headache and moodiness, weariness, nervous irritability, and low spirits; further, by slight changes in the facial aspect, dark rings round the eyes, spontaneous blushing, uneasy sensations, epigastric pain, loss of appetite, a sensation of pressure in the abdomen, palpitation, vertigo, dragging sensations passing from the loins to the thighs, feeling of weakness and numbness in the lower extremities—symptoms which often endure for several months and in such cases tend to lower the resisting powers of the organism.

Courty enumerates as prodromal symptoms which are observed in the majority of girls before the first appearance of menstruation: swelling and tenderness of the breasts, sensation of fulness and weight in the hypogastric region, moderate intestinal meteorism, sacrache, aqueo-mucous vaginal discharge, finally, an itching sensation in the genital organs. These manifestations may also assume a morbid character, taking the form of violent abdominal and lumbo-sacral pain, general fatigue and weakness, dyspepsia and diarrhœa, cephalalgia, various kinds of neuralgia, some degree of moral aberration. After the first menstruation, two or three months may elapse before the girl menstruates again, but after the lapse of a year the flow usually recurs at quite regular periods. Sometimes the early periods are very violent and recur very frequently, every twenty days, for instance.

The greatest increase in size and weight occurs in the female sex at the time of the menarche. Amongst the poorer classes the greatest development in size and strength occurs between the ages of 13 and 15 years, whereas in the upper classes of society, those who ultimately attain the same weight exhibit their greatest growth at the ages of 12, 13, and 14 years. According to Pagliani the greatest growth in the female sex always precedes puberty, so that for example a girl who begins to menstruate at the age of 12 will grow most rapidly in the year preceding this, whereas a girl who begins to menstruate at a more advanced age will not undergo her most rapid phase of growth so early as the age of 11. According to the observations of Bowditch, A. Hey, Lombroso, Pagliani, and Ploss, up to the age of 11 or 12 years the growth of girls exceeds that of boys, but whereas in girls growth ceases suddenly at the age of 14, in boys growth proceeds regularly up to the age of 16 years. At birth boys are on the average 1 cm. (⅖″) longer than girls; but during puberty the female sex catches up the male in height, or even surpasses it. According to Ploss, a girl of 16 or 17 years is as tall as a young man of 18 or 19 years.

The earlier development of the female as compared with the male at the time of puberty is a constant phenomenon, to be observed in all races, in every climate, and in all strata of society. According to the statistical data published by the authors just quoted, the age of greatest development in the respective sexes is:

Puberty occurs in the female on the average about two years earlier than in the male, and upon this difference the observed differences in growth also depend.

The menarche in the wider signification of the term includes the development which occurs at the time of puberty, and continues through a period of several months, and even years, before complete sexual maturity is attained; and includes also the time, which may be considerable, following the first appearance of the menses and before the regular rhythm of the menstrual function is established and the full development of the female genital organs is attained. This time, which forms a notable phase of the sexual life of woman, is characterized by great changes in the genital organs and in the vital processes connected therewith, by a strong tendency to suffer from a series of very various pathological changes and disorders of function in the principal organs, and a lessened general resisting power to disease—a change which finds its most definite expression in the well-established fact that in this period of life the mortality among females is much greater than among males of corresponding age. According to the statistical data of Quetelet and Smits, from the age of 14 to the age of 18 (the period of the menarche) there are 128 deaths of females for every 100 deaths of males; and even in the four succeeding years, from the age of 18 to the age of 22, the unfavorable conditions peculiar to sex are witnessed by 105 deaths of females to every 100 deaths of males.

Many authors draw a distinction between the age of puberty (from the Latin pubes, puberis), when the growth of the pubic hair occurs as an external sign of sexual development, and the age of nubility (from the Latin nubere), when the individual becomes fitted for marriage. The distinction is a partial one only, inasmuch as capacity for copulation is attained already at puberty. The law, however, maintains such a distinction, the Austrian Penal Code, for example, regarding intercourse with a female less than fourteen years old as rape, and the German Code likewise punishing carnal knowledge of a girl under fourteen.

The signs of puberty in girls were noticed and explained in very early times. From the anthropological studies of Ploss and Bartels we take the following data regarding this matter. In the Bible we read (Ezekiel, xvi, 7): “Thy breasts are fashioned and thine hair is grown, whereas thou wast naked and bare.” The early Indian physician, Susruta, refers only to the regular recurrence of menstruation as a sign of puberty. That a woman is menstruating may be known by the fact that her face is swollen and bright. In the Roman Empire Justinian ordained that all young women should be examined as to the growth or absence of the pubic hair in order to ascertain if they were ripe for marriage. The early Chinese physicians recorded that in every woman at the age of fourteen or fifteen years a monthly flow of blood from the genital organs began, the period of recurrence being thirty days. The physicians of the Talmud express themselves variously regarding puberty in women. In one place they advance as a sign of puberty the growth of the hair on the genital organs; in another they speak of the notable enlargement of the breasts, and mention as a sign of more complete sexual development that the nipples become elastic. Other Talmudists refer to the appearance of a dark brown coloration in the areola and to the enlargement of the mons Veneris as signs of puberty. Savage races regard the first appearance of the menstrual flow as the only certain sign of puberty, and among many such races this is the occasion of peculiar ceremonial rites. The attainment of puberty in savage tribes is often solemnized by the seclusion of the girls from the time of the first menstruation; they fast during the period of seclusion, which sometimes terminates in an elaborate ritual of purification.

For two reasons in particular, the period of the menarche is a time of storm and stress to women, first on account of the developmental processes in the genital organs, and secondly on account of the intellectual changes that occur at this period.

The local cause is to be found in the extensive transformation of the ovaries and the uterus, by means of which a peculiar and powerful stimulus, the menstrual stimulus, is elaborated, which has a reflex influence upon heart and brain, vascular and nervous systems, and secretory and nutritive processes. Since we know that in every premenstrual period by the growth of the follicles hyperæmia is excited in the ovary, by means of which the liquor folliculi is increased in amount, we can well understand that at the time of the menarche the ripening of the graafian follicles is accompanied by a considerable degree of hyperæmia of the ovaries and of the whole of the genital organs, now undergoing their fullest development, and we can easily see how this hyperæmia may result in manifold reflex disturbances. But in addition to these reflex disturbances, we have once more to take into consideration the as yet imperfectly known chemical processes which are associated with the ripening and development of the graafian follicles, and an abnormal course of which may give rise to a disordered constitution of the blood, manifesting itself as chlorosis or in other ways. In connection with the growth and ripening of the ova, extensive and novel demands are made on the organism, and these may well endanger metabolic processes which are not established on a very secure foundation.

The other cause is to be found in the intellectual processes which occur at this time in the youthfully receptive, highly sensitive organ of mind, the brain. The girl growing into womanhood, who with astonishment and stress has witnessed the visible changes in her body, the outward signs of puberty, as they gradually make their appearance, receives powerful psychical stimulation which cannot fail to exercise an influence upon the entire nervous system and its complex interlacements, alike in the sensory and in the motor sphere.

The degree to which these influences radiating from the genital organs make themselves manifest is chiefly dependent upon the resisting power of the nervous system as a whole, upon the temperament, the inherited constitution, and the mode of education of the young girl. In children belonging to families noted for sensibility and irritability, in dwellers in large cities who have attended high schools for girls and have at an early age lifted the veil that covers the sexual processes, the reflex disturbances of the menarche will be more manifold and will manifest themselves with greater intensity than in children brought up in country districts, whose sensibilities are chiefly physical and whose mind is less susceptible to the influence of external stimuli.

A further important consideration is the time at which the menarche occurs, and whether on the one hand it is at or near the average age, or whether on the other, as precocious menstruation, it is unusually early, anticipating the general bodily development, or again as retarded menstruation it is unduly delayed. In some cases of retarded menstruation, the external genital organs are thoroughly well developed, and it is menstruation only that remains in abeyance; but in other cases the external genitals are also backward in development, the pubes and mons Veneris being but sparsely supplied with hair, and the breasts remaining very small.

In addition to these abnormal temporal relations of the menarche, certain other irregularities at the commencement of menstruation are worthy of note. Thus, the first menstruation may be normal, but thereafter amenorrhœa may persist for several months, or if the flow occurs it may be exceedingly scanty, or very pale in color; on the other hand, menstruation may be very profuse, lasting many days.

The environment in which the young girl is placed during the period of her sexual development has a great influence on the processes of the sexual life and on the pathological disturbances that affect these processes.

In working-class families the immoderate physical strain often thrown upon girls, in many cases continuous movements of the upper extremities whilst the lower extremities and the pelvis are absolutely quiescent, or conversely, an excessive employment of the muscles of the lower extremities—these circumstances in conjunction with insufficient nutriment, night-work, association when at work with persons of the opposite sex, and the frequent premature sexual stimulation, will combine to have a most deleterious effect.

Amongst country-folk, indeed, the girl has the enjoyment of fresh air, and as a rule nutritive food, moreover, there are not so many occasions of nervous stimulation; puberty therefore arrives more slowly and gives rise to less disturbance; but the ignorance of the girls very frequently leads to an early experience of coition, the natural and unnatural consequences of which have then to be taken into account.

Amongst the better classes of townspeople such hygienic regulations and educational measures are in common employment that young girls during the years of development usually receive reasonable care and attention—but very frequently, intercourse with older girls, association with young men, visits to theatres, evening-parties, and balls, and the perusal of stimulating literature, form unfavorable features of urban life which exercise their inevitable effects in the sexual sphere. In some cases, fortunately sufficiently rare, the stimulation of the sexual impulse and the longing for its satisfaction are so intense, that a kind of demi-vierge is brought into being, a young woman who is concerned only to preserve the physical token of virginity, but whose thoughts and fancies are anything but maidenly. It is to be feared that in consequence of the excessive freedom in education and the emancipated independence of feminine youth, these “half-virgins” are increasing both in number and in intensity, a fact which cannot fail to increase also the number of sexual maladies and perversions.

Anatomical Changes in the Female Genital Organs in the Period of the Menarche.

The female reproductive organs, which in childhood were in a comparatively quiescent state, now become powerfully active, as is witnessed by the changes that occur in the external genitals.

The soft, hairless vulva of the child becomes enlarged at the time of the menarche by the deposit of fat, and its substance becomes tough and elastic. Some time before puberty, fine, pale hairs make their appearance here and there, but not until puberty does the hairy covering of the pubic region become more or less thick. The growth of the denser pubic hair begins with the appearance of hairs along the middle of the mons Veneris and at the margins of the labia majora. Early sexual development is commonly indicated by an early and thick growth of the pubic hair. In the virgin this hair is smoother and less curly than in the later course of the sexual life. In certain tribes of negroes it is the custom for the young unmarried girls to shave off the pubic hair, which is not allowed to grow freely until after marriage. In some of the tribes of South Sea Islanders it is customary at puberty to tattoo the external genitals and the surrounding skin.