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 Copyright

Note: The information in this book is true and complete to the best
of our knowledge. This book is intended only as an informative guide
for those wishing to know more about health issues. In no way is
this book intended to replace, countermand, or conflict with the
advice given to you by your own physician. The ultimate decision
concerning care should be made between you and your doctor. We
strongly recommend you follow his or her advice. Information in this
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authors or Hachette Books. The authors and publisher disclaim all
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identifying details of people associated with events described in this
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Copyright © 2020 by Alyson J. McGregor, MD
Jacket design by Amanda Kain
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 CONTENTS

Cover
Title Page
Copyright
Dedication
Introduction

PART ONE
HOW WE GOT HERE
CHAPTER ONE Modern Medicine Is Male-centric Medicine
CHAPTER TWO Sex Is More Than Skin Deep

PART TWO
THE SIX BIGGEST ISSUES FACING WOMEN’S HEALTH TODAY
CHAPTER THREE Women’s Hearts (and Brains) Break Differently
CHAPTER FOUR Drugs for Different Bodies: The Female Side of
Pharmaceuticals
CHAPTER FIVE “Honey, It’s All in Your Head”: Women’s Intuition
Versus Women’s Imagination
CHAPTER SIX A Deeper Sensitivity: The Female Relationship to Pain
CHAPTER SEVEN Beyond Hormonal: Female Biochemistry and
Hormone Therapy
CHAPTER EIGHT A New Perception: Gender, Culture, and Identity
Medicine
 PART THREE
WHERE WE’RE HEADED—AND WHAT YOU CAN DO
CHAPTER NINE A Changing Conversation: The Future of Sex and
Gender Research in Medicine
CHAPTER TEN Your Voice, Your Medicine: How to Have Helpful
Conversations with Your Providers
Afterword

Acknowledgments
Discover More
About the Author
APPENDIX A Your Personal Medical Reconciliation (Med Rec)
APPENDIX B Quick Reference Questions
Resources
Praise for Sex Matters
Notes
 THIS BOOK IS DEDICATED TO

All the women I have had the pleasure

to care for, who taught me about their
illnesses and insight.
All the women whose struggles I have
witnessed through our medical system,
through everything from lack of
understanding, to questioning self-
reflection, to endless testing that leaves
them feeling dismissed, they have
persevered.
AND ALSO TO

My mother and sister, with immense

love and gratitude. As I studied
medicine, I watched the two of you
navigate our medical system from the
outside; you helped me see the full
circle.
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 INTRODUCTION

AS AN UNDERGRADUATE in the University of New Hampshire’s premed

program, I took only one elective that wasn’t directly related to my
major (or, at least, I thought at the time that it wasn’t related). That
course was women’s studies. I loved circling up with other women to
talk about the history of women in society and the gender-related
issues we faced both individually and collectively. It was illuminating
and truly inspiring. When the class ended, and our spirited
discussions were replaced in my schedule by yet another biology lab,
I felt like a bit of the spark had gone out of my collegiate life.
I didn’t know it at the time, but that course—and the questions
about sex, gender, and the female experience it sparked in me—
would have a profound influence on the trajectory of my career.
When I finished medical school at the Boston University School of
Medicine, I applied for a residency at Brown University in my
hometown of Providence, Rhode Island. When my residency ended,
I wanted to stay on and work there. Because Brown is an academic
institution, I needed to choose a research focus in order to apply for
a long-term position. When I sat down and thought about it, the
only path I wanted to take was one that would improve the lives and
health of women. I wanted to know about women’s bodies and how
those bodies affected (and were affected by) modern medicine—in
particular, emergency medicine.
At the time, sex and gender research didn’t even exist. My choice
to pursue a specialty in women’s health felt like a nod to my feminist
beliefs and personal philosophy, a way to keep feeding my passion
for women’s issues.
 I had no idea just how deep an ocean I was diving into or how
many challenges I would face in bringing women’s unique health
concerns into the medical mainstream.
When I mentioned to my advisors that I’d like to explore fields
related to women’s health, the immediate reaction was, “Oh. You
want to do OB/GYN.”
“No,” I’d reply. “I want to study women’s health holistically. As in,
the overall health of women.”
No one seemed to know what I meant. That was my first clue
about what was really happening in our medical establishment.
As I discovered, and as I’ll share in this book, there is far more to
“women’s health” than pelvic exams and mammography. Women are
different from men in every way, from their DNA on up. The medical
practice of differentiating women from men according to their
reproductive organs alone is both reductionist and, as it turns out,
hugely problematic—but the male-centric model of medicine is so
pervasive in our healthcare systems, procedures, and philosophy
that many don’t even realize it exists. Most people simply assume
that women’s differences are already being taken into account—yet
nothing could be further from the truth.
My research on and passion for this issue has placed me at the
forefront of a medical revolution. As a researcher, educator, speaker,
and physician, I—and my colleagues in this cutting-edge field—are
tasked with integrating emerging information about women’s health
into the mainstream medical culture. We are advocates for women
and their unique bodies in a system that has largely ignored them,
marginalized them, and minimized them. We are women (and a few
good men) taking a stand for women in a way that has never been
done before.

Awareness Is the First Step to Change

As a nationally recognized expert on sex and gender medicine, I
have made researching and bringing awareness to health disparities
between men and women across all areas of medicine my life’s
work. In addition to my “day job” seeing patients in the emergency
department of an urban trauma center—and dealing with everything
from colds to car accidents, headaches to heart attacks, and broken
bones to overdoses—I wear a few other hats: I’m the division
director for the first program in sex and gender emergency medicine
at the Alpert Medical School of Brown University and a cofounder of
the Sex and Gender Women’s Health Collaborative. I am also a
sought-after visiting professor and Grand Rounds speaker at medical
institutions across the country, and I’m a keynote speaker for
community advocacy groups, including the Laura Bush Institute for
Women’s Health, the Barbra Streisand Women’s Heart Center, the
National Aeronautics and Space Administration, the Society for
Women’s Health Research, the Organization for the Study of Sex
Differences, and the Office of Women in Medicine and Science at
Brown University, among others. I’ve written or cowritten over
seventy peer-reviewed publications in scientific journals on the topic
of sex and gender, and I’m the lead editor for the medical textbook
Sex and Gender in Acute Care Medicine.
While much of my work is accomplished within the medical
community itself—through educating medical students and
professionals, advocating for changes in research guidelines and
pharmaceutical prescribing standards, and conducting research on
sex and gender issues—changing the system from within is only half
the battle. The other half is educating the women whose lives and
health are being impacted by that system every single day. My TEDx
talk, “Why Medicine Often Has Dangerous Side Effects for Women,”
was intended to open the eyes of women around the world to the
issues discussed in this book.
Every time I talk about sex and gender issues in medicine, I hear
stories from women about how the system has ignored, minimized,
or outright failed them. This failure of care may not be intentional on
the part of women’s doctors and providers—but neither is it
acceptable.
How to Use This Book
While this book contains facts and observations that you may find
revelatory or even shocking, my intention is for it to serve as far
more than an exposé.
Ultimately, information is more useful when it’s actionable. It’s not
enough for us to merely observe the scope of the problems women
face in our modern medical system or even to voice our feelings of
anger and betrayal at what we see; we need to always be asking,
“What can we do about this?”
This book is intended to be both informative and prescriptive. By
the time you turn the last page, I hope that you will understand not
only how male-centric medicine affects women in both broad and
specific terms but also exactly what steps you, personally, can take
right now to begin to reduce your personal risk factors and make
grassroots changes in your local medical community.
In Part I of this book, we will look at the broad picture of male-
centric medicine: how it came to be, how it works in practice, and
how its lack of recognition of women’s physiological differences is
jeopardizing the health of women across America and the world.
In Part II, we will look at specific disease patterns and areas of
health that impact millions of women across the country—including
heart attacks, strokes, pain disorders, pain management, and
pharmaceuticals. We’ll also look at the role of women’s hormones
and biochemistry in various areas of health, as well as at how issues
and biases related to gender, race, ethnicity, and religion affect
medical treatment and outcomes both subtly and explicitly.
In Part III, I’ll write you a prescription for action! We will look at
how the landscape of medicine is changing for the better and how
you can tap into existing resources to take a more active role in your
own health care. In Chapter 10, I’ll share specific questions you can
ask your providers to help you get the answers you need, as well as
resources to assist you in your own research.
By picking up this book, you have become part of a movement for
change. You have chosen to educate yourself about the realities of
how modern medicine treats women and their bodies. Throughout
this book, I will give you tools to translate your new awareness into
advocacy—for yourself and for other women like you.
As a patient and as a woman, you have a voice—and your voice
matters. This book will equip you to use your voice effectively in a
medical setting. You’ll learn what questions to ask, what pitfalls to
look out for, what tests to request or avoid, and what resources to
employ so that you can receive the quality of care you need and
deserve. Effectively, you will become a more equal partner in your
own health care.

ON THE NEXT PAGE, you will begin your journey into the discovery of
women’s health as it stands in our current medical system. You will
learn things that will surprise you and many that may distress you.
But in the end, I hope that you will find in these pages a feeling of
empowerment and the knowledge you need to become a voice for
your own health and the health of women everywhere.
Are you ready to get started?
 PART ONE

HOW WE
GOT HERE
 CHAPTER ONE

MODERN MEDICINE IS MALE-

CENTRIC MEDICINE

I’LL NEVER FORGET THE DAY that a thirty-two-year-old woman almost

walked out of my emergency department while having a heart
attack.
In emergency medicine, there are many algorithms by which we
evaluate risk factors and stratify incoming patients. Not everyone
who walks through the doors of the emergency department is on
death’s door, so we treat the most urgent cases first. For example,
someone who’s asphyxiating or suffering from a stab wound will be
regarded as a higher priority than someone suffering from
nonspecific pain or who “just doesn’t feel quite right.”
This risk assessment makes sense theoretically and works fairly
well in practice too. But once the obvious cases have been dealt
with, we’re navigating a large gray area. Unfortunately, the subtle
(and often subjective) strata by which we prioritize patients who
don’t appear to be at immediate risk are far from perfect—
particularly when those patients are women.
Women are different from men in more ways than merely the
obvious—and nowhere is this more apparent than in the halls of the
hospital where I work and teach every day.
For example, the research upon which our stratification
procedures are based cites things like the “estrogen-protective
effect” (meaning, the way in which blood estrogen levels appear to
reduce or modify traditional risk factors like oxidative stress,
arrhythmia, and fibrosis in premenopausal women) and the
supposedly low statistical likelihood of premenopausal women
presenting with acute heart conditions. In other words, even if a
young woman were to come into the ED and say, “I think I’m having
a heart attack,” unless she displayed blatant and very specific
symptoms, most doctors would immediately look for another
explanation.
Julie, the young woman I met that day, had visited her primary
care doctor several times prior to coming to the emergency
department and had also seen at least two other physicians in the
previous forty-eight hours. She was experiencing discomfort in the
region of her chest and shortness of breath that worsened markedly
the more agitated she became.
I was working in the critical care area when she came in.
Immediately, I thought to myself, This woman doesn’t look good. I
had a gut feeling that something was really wrong.
Her other doctors had attributed Julie’s symptoms to a
combination of anxiety and stress to her heart due to her obesity.
The vagueness of her descriptions when she talked about her
symptoms, combined with her age and the fact that she had been
clinically diagnosed with anxiety several years before, made her
current discomfort seem like a no-brainer for her doctors. She was
having panic attacks, and her weight was compounding the issue.
End of story.
However, as a specialist in sex and gender medicine, I knew that
during myocardial infarction (MI)—aka, a heart attack—and other
cardiovascular events, women often present much differently than
men. In fact, women’s cardiac symptoms are often described as
“atypical” and “unusual” in medical literature. While men might
experience pain radiating down the left arm, chest heaviness, or
other stereotypical signs of a heart attack, women often present
with only mild pain and discomfort, possibly combined with fatigue,
shortness of breath, and a strong feeling that “something isn’t right.”
Julie was very pleasant, but I could tell she was scared. I calmly
explained that, while her current issue might be exactly as other
doctors had described, I would be more comfortable if we ordered
an electrocardiogram (EKG) and blood work to make sure things
looked normal.
When we got the results, I caught my breath. There was
something very wrong here. This could actually be a myocardial
infarction, I thought.
I immediately called our attending cardiologist. “I believe this
woman is having an MI and needs to go to the cath lab,” I told him.
The cath lab is the medical suite where a procedure to fix blocked
arteries is performed.
“A thirty-two-year-old woman?” There was a slight pause, then a
sigh. “Oh, all right. I’ll send someone down to take a look.”
Like Julie’s previous doctors, the cardiologist’s assessment was
that she was displaying symptoms of anxiety. But her EKG was
slightly abnormal, so he finally agreed to take her to the cath lab.
About an hour later, I got a call from the cardiologist. “Dr.
McGregor,” the attending cardiologist began, sounding a bit
astounded, “I wanted to let you know that your patient, Julie, had a
95-percent occlusion of her main coronary artery. We placed a stent
to restore blood flow to her heart.”
An occlusion of the main coronary artery, in a man, is often called
a “widow maker.” We see it all the time in men over fifty and in a
number of postmenopausal women. And yet, here was sweet, thirty-
two-year-old Julie presenting with a condition that was likely to kill
her in weeks, if not days, if left untreated—and no one had thought
to look for it because her symptoms and risk factors weren’t
consistent with the classic male model of a heart attack.
Thankfully, Julie pulled through the procedure and recovered. I
didn’t see her in the ED again, but her story has stayed with me.
Sometimes, I wonder how many other women like her walk out the
doors of other emergency departments every day without receiving
the lifesaving treatment they need and deserve. Even one is too
many—but I have a feeling the number is much, much higher than
that.
Our Modern Medical System Is Failing Women
The human mind built the automobile. It built televisions and
computers and smartphones. When these things break, we
understand how to fix them; we have an inventory of all the relevant
components, diagrams of all the working parts.
But we didn’t create our bodies. In some sense—whether you
believe in evolution, natural selection, or intelligent design—our
bodies are mystical. We are not developing them; we are merely
trying to reveal how they work. And, in many ways, they are still
beyond our ability to fully comprehend.
When we approach our bodies from a scientific perspective, we
are therefore limited in our ability to hypothesize, study, test, and
evolve our understanding. We have made massive strides in the last
several decades, but in a sense, we still enter into every observation
from a place of not having the full picture. We begin with a set of
assumptions built on our prior research, but—as my work and that of
others is beginning to prove—many of those assumptions may be
erroneous.
One of the biggest and most flawed assumptions in medicine is
this: if it makes sense in a male body, it must make sense in a
female one.
In every aspect, our current medical model is based on, tailored
to, and evaluated according to male models and standards. This is
not an abstract statement or even an observation. It’s a fact. All our
methods for evaluating, diagnosing, and treating disease for both
men and women are based on previous research performed on male
cells, male animals, and male bodies. There are reasons our system
has evolved this way, many of them scientifically reasonable.
However, recent research is revealing that female bodies are
physiologically different from men’s on every level—from our
chromosomes to our hormones to our bodily systems and structures.
Therefore, the medicine that works for men doesn’t always work for,
or even apply to, women.
In the ED, I am on the front lines of medicine, and this gives me
a unique perspective. I see a broad view of all aspects of health care
and the conditions that many women live with every day. From
infections to heart conditions, sprained ankles to strokes, head
trauma to back pain, I see them all at play, in real time, across
thousands of patients per year. More, I see how the current male-
centric model of medicine is causing women to receive potentially
inappropriate, ineffective, or even substandard care, every single
day.
Women in cardiac distress don’t receive the diagnostic tests they
need because our protocols don’t account for the way heart disease
presents in women’s bodies. Women are prescribed inappropriate
doses of common medications because the initial drug trials didn’t
take into account the differences in female metabolism and
hormonal cycles. All these issues, and more, contribute to poorer
overall outcomes and higher mortality for women of all ages and
backgrounds.

TO ME, Julie’s case was significant because she actually presented

with male-pattern heart disease, but in a distinctly female way.
Women’s symptoms are simply different from men’s. They don’t
always have the classic male symptoms and pain profiles. Their
symptoms often mimic other diseases and events that are
considered more “female”—such as the panic attacks cited by Julie’s
previous doctors. Unfortunately, the difficulty she had in obtaining a
diagnosis is all too common for women with cardiac issues,
particularly younger women.
If a man comes into the ED with chest pain and shortness of
breath, there’s no question that he may be having an MI. If a
woman comes in with the same issue, and she has a history of
anxiety listed in her chart, the consensus will likely be that she’s just
suffering muscular and respiratory spasm related to anxiety. If her
EKG comes back normal or close to normal, she’ll be sent home.
Although the symptoms she’s exhibiting are strong potential
indicators of female cardiac distress, our tests and protocols simply
aren’t designed to diagnose female patterns of disease, which tend
to be more diffuse and uncharacterized than their male counterparts.
Discrepancies like these are what led me to specialize in sex and
gender medicine in the first place. As a fresh-faced attending
physician with a passion for women’s issues and a strong calling to
distinguish myself as a researcher in my chosen field, I found it
fascinating that researchers and specialists alike acknowledged both
vast and subtle differences in symptomology, disease progression,
and outcomes between men and women across the spectrum of
physical and mental health—and yet no one was asking why such
differences were present or how they might be affecting the way
women were being cared for every day in both inpatient and
outpatient settings and across all specialties. Sex and gender
differences in medicine weren’t even being explored beyond the
traditional scope of “women’s health”—meaning, obstetrics and
gynecology (OB/GYN) and breast health—let alone incorporated into
the research and dialogue that ultimately shapes our medical
procedures and policies in the ED and elsewhere.
Although I know that there are researchers like me working
diligently to explore the difference in male and female physiology,
the procedural and practical support necessary to put that
knowledge into action isn’t available to most emergency physicians
when they show up to work. As a system, we simply aren’t set up to
give women the specialized care and treatment they need and
deserve.
There are many reasons for this, which we will explore together
in detail throughout this book. The core issue, however, is that,
despite decades of research and accumulated information, we are
only just beginning to understand the scope of the differences
between men and women and how those differences might impact
everything from how drugs are prescribed, to how routine tests are
performed, to how pain is assessed and treated, to how systemic
disease is diagnosed.
In other words, we need to reinvent modern medicine from the
ground up to include the half of the human population it has, until
now, marginalized and left behind.
The New Women’s Health Revolution?
We are in the midst of a second women’s revolution.
The first was the movement that gained women the right to
operate in the world alongside men as legally equal human beings.
We claimed the right to own and govern our bodies, our minds, and
our property. We demanded the opportunity to pursue our
educations, our passions, and our dreams. My mother’s generation
tore down the walls that, a mere fifty years ago, would have made
my career in medicine and medical leadership challenging, if not
impossible, to pursue.
The first revolution in women’s health began in the 1970s with
the publication of the groundbreaking book Our Bodies, Ourselves.
This was the first time women were invited to understand
themselves as biologically different from men. Women demanded
access to things like birth control and pain relief. They realized that
their bodies were not somehow flawed or “less than” simply because
they were female. They demanded autonomy, and when the
establishment resisted, they claimed it anyway.
Now, though, we need to call in another wave of change—a
change based on the irrefutable facts available to us around
women’s health and women’s bodies in all areas, not just in sexual
and reproductive health.
Although we women have spent the last several decades fighting
for equality, we are also becoming aware, sometimes painfully, that
there are significant differences between men and women—
differences for which our egalitarian vision did not account. These
differences are at the heart of this new women’s revolution, which is
now coming to prominence.
Physiologically, neurologically, cognitively, socially, and
experientially, women are unique. Every system in our bodies
operates according to a biological imperative fine-tuned to our
womanhood and the daily functions that womanhood necessitates.
We are not simply men with breasts and ovaries—or, conversely,
men who lack penises and testicles. We are not a genetic offshoot of
men, as literal interpretations of scripture might imply. We are
unique in every single cell of our bodies.

WHEN I FIRST STARTED my research on sex and gender differences in

emergency medicine, I classified my work as “women’s health.” That
made perfect sense to me, since I was literally researching the ways
in which women’s bodies operate and how their unique physiology
influences diagnosis, disease progression, morbidity, pharmacological
response, and other factors in health care. However, the outdated
thinking around women’s bodies is unbelievably pervasive; I wasn’t
prepared for how often others in my field would miscategorize and
even misrepresent my work.
For most people—including the majority of medical professionals
—“women’s health” is synonymous with “reproductive health.”
OB/GYN and breast health immediately come to mind as areas of
medical practice directly related to the health of women. (In fact, I
spent much of my residency being called all over the ED to perform
pelvic exams—not because no other doctor in the ED could do them,
but because everyone thought that, as a women’s health specialist,
that would be my first priority. It still makes me laugh when I think
about it!)
The truth is, women’s health deals with exactly what the words,
removed from their vernacular context, imply: the overall health and
well-being of women. It is not simply about female reproductive
organs, or pregnancy, or breast health, although those are all vital
components. When I talk about women’s health, I’m referring to the
health of the whole woman, body and mind, with all the complexities
inherent to a physiologically female body.
Every cell in a human body contains sex chromosomes. These
chromosomes in turn influence every biological, chemical, sensory,
and psychological function performed by that body. Most cells both
produce and respond to sex hormones such as estrogen, progestins,
testosterone, and androgens, and the functionality of each cell is
affected in both subtle and overt ways by its relationship to these
hormones.
 Although these genomic differences have not been widely
researched in all organs and systems, in areas where they have
been studied, the implications are clear: women’s bodies deal with
everything from internal communication (neurotransmission) to
external influences such as pharmaceuticals according to a different
set of genetic and hormonal criteria. This means that what is
considered medically “normal” for men may not be normal for—or
even applicable to—women.
Here are a few common examples of how male-centric medicine
impacts women’s health every day:

• Coronary artery disease is the leading cause of death in both

men and women, but women have statistically poorer
outcomes and higher mortality in otherwise equivalent
situations. A 2010 study found that “the under-recognition of
heart disease and differences in clinical presentation in women
lead to less aggressive treatment strategies and a lower
representation of women in clinical trials.”1
• Women are more likely to receive a psychiatric diagnosis for a
multitude of conditions—including stroke, cardiac events,
irritable bowel syndrome, autoimmune disorders, and various
neurological disorders—while men are more likely to be
referred for tests.
• Men and women have markedly different responses and
reactions to pain. Women have both a lower threshold for pain
and a lower pain tolerance—meaning, they are more likely to
perceive and report a lower level of discomfort as “pain” than
men despite an equal degree of stimulation—however, the
more vocal women become about their pain, the more likely
their providers are to “tune them out” and prescribe either
inadequate or inappropriate pain relief medication.
• Women often present with nontraditional symptoms of stroke,
which causes delays in recognition by both them and their
health professionals. When they get to the hospital, women
 experiencing stroke are less likely to receive rapid brain
imaging (which is defined by the American Heart Association
and the American Stroke Association as a CT scan within
twenty-five minutes). They are also less likely to have
echocardiography and carotid ultrasound performed during
their stroke evaluation (important tools in both evaluating the
cause of the stroke and preventing future episodes) or to
receive treatment for acute stroke with the “clot-busting drug”
called tPA (tissue plasminogen activator).2
• Women metabolize prescription drugs differently. For example,
women experience greater adverse effects from using Ambien
(zolpidem), a popular sleep aid, including morning sluggishness
and impairment while driving. As it turns out, women only need
half the originally recommended dose. Nearly twenty years
after the drug’s release, and after thousands of reports from
patients who experienced adverse effects, the Food and Drug
Administration issued its first sex-specific prescribing
guidelines.

And, of course, the current system routinely fails patients like

Julie, whose doctors explained away her symptoms because, as a
thirty-two-year-old woman, she didn’t fit the “expected” pattern of
cardiovascular disease they had learned in school. Across the
country, every day, women like Julie come to their doctors with
symptoms that don’t fit a traditional male-centric pattern of disease.
Sadly, many leave without answers—and, like Julie, might go days or
weeks without the proper treatment for potentially deadly
conditions.
My heart breaks when I consider how many women like Julie visit
emergency departments across America every day and how few of
them are statistically likely to get the treatment they need in a timely
fashion—either because their symptoms don’t fit a male paradigm or
because their providers have an unconscious bias around women.
We need to wake up, individually and collectively, to the reality of
being female in our current medical system. Only when we
understand what’s really going on can we make the fundamental
changes necessary to improve women’s outcomes. This isn’t a
single-layered issue of bias or faulty protocol. Every part of our
current medical system—from research and analysis to medical
education, from diagnostic testing to prescribing guidelines—needs
to evolve at the same time, starting now.
This is a problem that can no longer be ignored. But while it may
seem insurmountable, change is possible. By picking up this book,
you have become part of the new women’s health revolution. From
now on, every time you speak to your doctor, every time you ask the
right questions, every time you advocate for the right tests, you will
be contributing to a landslide effect of awareness, improvement, and
eventual reversal of our current male-centric paradigm. No effort is
too small, no case too insignificant. Every time you advocate for the
sex- and gender-specialized care that you and the women you love
deserve, you will move our whole medical model one small step in
the right direction.
Again, there’s much more information to come, but for now I
want you to understand this: If you are a woman, you are at greater
risk of misdiagnosis, improper treatment, and complications in
common medical situations. To ensure that you receive the
treatment you need and deserve, you need to understand how your
body behaves differently from a man’s and how to ask the simple
questions that can mean the difference between a faulty or delayed
diagnosis and lifesaving treatment.
The medical world is evolving—however, like all revolutions, this
one needs a “grassroots” component. I believe that the best way for
women to effect immediate change in their health and health care is
to advocate for themselves on both an individual and a collective
basis, every day, starting now.
As I noted in the introduction, awareness and advocacy are the
two keys to creating change from the ground up in our medical
system: awareness because simply knowing that these issues exist
for women in our healthcare system can help you get the treatment
you need, and advocacy because, quite frankly, where attention
goes in the medical world, research funding flows.
By picking up this book, you have become a standard-bearer. You
will bring this new knowledge into your doctors’ offices, hospitals,
and urgent care centers and interact with your providers
cooperatively, from a place of knowledge and empowerment. By
advocating for your own health, asking for the tests, treatments, and
prescriptions that will serve you best according to your individual
health concerns, and referencing the details you will learn in this
book and through your own research in conversations with your
providers, you will directly impact your treatments, outcomes, and
overall experiences, in the ED and elsewhere. By the time you turn
the last page of this book, you will have all the information you need
to approach this new conversation with your providers with
confidence and clarity.

You Are Not a Statistic

In medicine, we often speak in broad terms, such as, “A team at the
Technical University of Munich found that women are 1.5 times more
likely to die in the first year after a heart attack than men.”3 This
type of data helps researchers like me to see the big picture. But it
doesn’t speak to the human aspects of this higher mortality rate or
the pain that these women and their families experience as a result.
I want to be clear that, although this book does look at broad-
scope issues, you are not a statistic. You and the women you love
matter. Your health matters. And your feelings matter.
I see the human cost of heart disease, stroke, pain disorders,
neurological conditions, and trauma every day in my emergency
department. I see the pain of families who have lost a mother, a
sister, or a daughter to conditions that disproportionately affect
women. I see women desperate for someone to listen to them, to
believe them, because our male-centric medical model has classified
their very real symptoms as “psychosomatic,” “nonspecific,” or
“idiopathic” (meaning, of unknown origin).
I wrote this book not for our medical community but for you and
the women you love. I want you to know and understand the
differences in physiology that set women apart from men in ways
that are more than just skin deep. And I want you to take this
knowledge with you into your life and into your doctors’ offices so
that you too can be part of this medical revolution. Your contribution
is crucial.
When you know how to ask the right questions, you can work
with your providers to get the right care. Communication is a two-
way street. We are no longer in the era of “doctor knows best.” Yes,
we physicians have dedicated a major chunk of our lives to
understanding the human body and how it works—but in the end,
no one knows your body better than you. With the tools in this book,
you will become a partner in your own health care, and your
provider will become not a dictator but an educated consultant who
can help you decipher what’s happening in your body and create a
plan to address it. You can employ modern medicine in the way it
was meant to be employed—as a tool for discovering, treating, and
ultimately healing the physical and mental conditions that affect us
as human beings.

What Matters—Your Key Takeaways

• Our male-centric medical model impacts women’s health every
day.
• If you are a woman, you are at greater risk of misdiagnosis,
improper treatment, and complications in common medical
situations. To ensure that you receive the treatment you need
and deserve, you need to understand how your body behaves
differently from a man’s and how to ask the simple questions
that can mean the difference between a faulty or delayed
diagnosis and lifesaving treatment. This book will show you
how to do that.
• The most powerful tools for change in this arena are
awareness and advocacy. Knowing how to ask the right
questions can mean the difference between getting the
treatment you need or being misdiagnosed, undertreated, or
otherwise impacted by male-centric medicine.
 CHAPTER TWO

SEX IS MORE THAN SKIN DEEP

NOT LONG AFTER I APPLIED FOR, and was granted, a research position at
Brown University, I submitted a proposal for a didactic presentation
at the annual meeting of the Society for Academic Emergency
Medicine (SAEM). The presentation was titled “Women’s Health and
Gender-Specific Research in Emergency Medicine: Yesterday’s
Neglect, Tomorrow’s Opportunities.”
I was beyond excited about what I was discovering about
women’s bodies and their physiological and biochemical uniqueness,
and I couldn’t wait to share this with my peers. Surely, they would
be as stunned and galvanized as I was.
Honestly, I was shocked that my proposal was accepted. I was a
“newbie,” a mere junior physician, barely out of my residency.
Feeling empowered, I rounded up three experts to discuss sex and
gender in relationship to emergency medicine. We all prepared our
slides and notes and practiced our different roles in the presentation.
We flew out to Chicago for the meeting. I don’t think I’ve ever
been so nervous. This was my chance! I was going to start a
conversation that would change emergency medicine forever!
Finally, it was time for our presentation. The previous didactic
wrapped up, and the room was efficiently changed over. My
colleagues and I came in with our notes and slides and set up
quietly. The room was empty—but that was okay. People were
coming from all over the hotel; it would take them time to arrive.
I fidgeted in my seat, watching the clock. Five minutes to go.
Another random document with
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The nervous system consists of a central ganglion situated in the
proboscis sheath; it is oval and flattened in shape. The ganglion
gives off nerves to the proboscis, and two main trunks which pierce
the proboscis-sheath and run backward surrounded by a cluster of
muscle-fibres, the whole being termed the retinaculum; in the male
they are in connexion with a special genital ganglion which lies near
the ductus ejaculatorius.

With the exception of certain sensory papillae in the neighbourhood

of the male genital orifice, and of three similar papillae mentioned by
Kaiser on the proboscis, the Acanthocephala are devoid of sense
organs.

The Acanthocephala are dioecious; their generative organs are

developed in connexion with the ligament, a cord-like structure which
arises between the inner and outer layer of the hinder end of the
proboscis sheath and traverses the body-cavity, ending posteriorly in
connexion with the genital ducts. The testes lie in this ligament; they
are paired oval bodies which open each into a vas deferens. The
vasa deferentia each bear three lateral diverticula, the vesiculae
seminales; and three pairs of cement glands pour their secretion into
a duct which opens into the vasa deferentia; the latter unite and
open by a penis which is withdrawn into a genital bursa, but is
capable of being extruded.
 Fig. 96.—An optical section through a male Neorhynchus clavaeceps
Zed. (From Hamann.) a, Proboscis; b, proboscis sheath; c,
retractor of the proboscis; d, cerebral ganglion; f, f, retractors of
the proboscis sheath; g, g, lemnisci, each with two giant nuclei; h,
space in sub-cuticular layer of the skin; l, ligament; m, m, testes;
o, glands on vas deferens; p, giant nucleus in skin; q, opening of
vas deferens.

The two ovaries are formed in the ligament of the female in a

corresponding position to that occupied by the testes in the male, but
at an early stage they break down into packets of cells, of which
those of the peripheral layer develop into ova at the cost of the
central cells, which serve them as a food supply. As these masses
grow and increase in number they rupture the walls of the ligament,
and escape into the body-cavity, in which they float. The ova are
fertilised whilst floating in the fluid of the body-cavity. The eggs
segment and the embryo is formed whilst still in the body of the
mother.

The embryos escape by means of a complicated apparatus the

details of which vary in the different species, but which, like many of
the organs in these animals, consists of very few cells with very large
nuclei. This apparatus consists of three parts: the bell, the uterus,
and the oviduct. The bell is a large funnel-shaped structure, which
opens into the body-cavity, and is connected with the end of the
ligament; near its lower end, where it is continuous with the uterus, is
a second smaller opening situated dorsally. By the contraction and
expansion of its lips the oval embryos are swallowed and pass on
through the uterus to the oviduct, which opens at the posterior end of
the body. If the bell takes in any of the less mature eggs which are
spherical in shape, they are passed back into the body-cavity
through the above-mentioned dorsal opening, and the same orifice
permits the passage of the spermatozoa even when the bell is full of
embryos.
 Fig. 97.—An egg of Echinorhynchus acus Rud. surrounded by three
egg-shells. Highly magnified. The egg has segmented, and the
cells are differentiated into a, the entoblast, and b, the ectoblast;
c, spines. (From Hamann.)

Embryology.—After fertilisation the egg surrounds itself with several

egg-shells, three of which are usually distinguished; the embryo is
already far advanced in its development by the time it leaves the
body of the mother and passes out into the alimentary canal of the
Vertebrate host. It leaves the body of this second host with the
faeces, and is eaten by the first or larval host, usually a small
Crustacean or water-insect, but in some cases a fish, within whose
alimentary canal it casts its membranes and becomes actively
mobile. By means of a ring of hooks developed round the anterior
end it bores its way through the wall of the alimentary canal, and
after some time—three weeks in E. proteus—comes to rest in the
body-cavity of its host. By this time most of the organs of the adult,
with the exception of the reproductive glands, are already well
established; the latter only attain maturity when the first host is eaten
by the second, and the larvae find themselves in the intestine of a
Vertebrate.
 Fig. 98.—A, A larval Echinorhynchus proteus Westrumb. further
developed than in Fig. 97. Highly magnified. The entoblast has
developed inside it the proboscis a; b, b, the giant nuclei of the
ectoblast. B, The entoblast at a more advanced stage, the
ectoblast is not shown. The outermost layer of cells will form the
muscles of the body-wall; the body-cavity has appeared; a,
proboscis; b, cerebral ganglion; c, body-cavity; d, d, the testes
beginning to appear in the ligament; e, cells which will form the
generative ducts.

Some of the details of the development are very remarkable, and a

short account of them may be given. The segmentation of the egg is
unequal; it results in the formation of a central biscuit-shaped mass
of small cells and a peripheral mass of larger cells; the former is
called by Hamann[218] the entoblast, the latter the ectoblast. From
the entoblast arise all the organs of the body but the sub-cuticle and
the associated lemnisci, which are formed from the ectoblast. The
latter has a remarkable history; the cells begin to break down and
lose their outlines, whilst their nuclei fuse together and form a small
number of giant nuclei, which lie scattered throughout the syncytium
thus formed. The syncytium surrounds the entoblast on all sides; by
this time the anteriorly-placed hooks have appeared; in E. proteus
there are ten of these, but the number is not the same in all species.
The syncytium is in a fluid state, with a few gigantic nuclei floating in
it; these now lose their spherical shape, and throwing out processes
become amoeboid; in this way they bud off small portions of their
substance, and from these the oval nuclei of the sub-cuticle and the
lemnisci arise. The rest of the syncytium hardens into the fibrillar
matrix of the sub-cuticle, leaving, however, scattered spaces which
form the sub-cuticular sinuses of the adult. An interesting feature of
N. clavaeceps and Arhynchus hemignathi is that the skin of the adult
retains the larval features, and it and the lemnisci consist of a
syncytium with a very few giant nuclei scattered through it. Hamann
counted only eight in the skin and two in each lemniscus in the
example figured on p. 178.

Fig. 99.—A, The larva of Echinorhynchus proteus from the body-cavity

of Phoxinus laevis, with the proboscis retracted and the whole still
enclosed in a capsule. B, A section through the same; a, the
invaginated proboscis; b, proboscis sheath; c, beginning of the
neck; d, lemniscus. Highly magnified. (Both from Hamann.)

The whole of the rest of the body is formed by the entoblast. Within
the latter a circular split arises which separates a single layer of
outermost cells from an axial strand of many cells (Fig. 98, B). The
split is the future body-cavity; the axial strand forms the proboscis, its
sheath, the cerebral ganglion, muscles, etc., and the ligament with
the contained generative organs; the outermost layer of cells forms
the muscular lining to the skin. It is interesting to note that these cells
destined to become muscle-fibres are at first arranged as a single
layer of cubical epithelial cells lining the body-cavity; most of them
become circular muscle-fibres, but a few are pushed inwards so as
to lie next the body-cavity, and these become the longitudinal fibres.

Classification.—Until recently the Acanthocephala were supposed

to include but one genus, Echinorhynchus, with several hundred
species, but Hamann[219] has pointed out that these species present
differences which enabled him to divide the group into three families,
each with a corresponding genus. To these I have ventured to add a
fourth family, to include a remarkable species, Arhynchus
hemignathi, described below. The characters of the first three
families in the account given below are taken from Hamann's paper.
 Fig. 100.—Fully formed larva of Echinorhynchus proteus from the
body-cavity of Phoxinus laevis. (From Hamann.) Highly magnified.
a, Proboscis; b, bulla; c, neck; d, trunk; e, e, lemnisci.

Family I. Echinorhynchidae.—The body is elongated and smooth.

The proboscis-sheath has a double wall, and the proboscis is
invaginated into it. The central nerve-ganglion lies in the middle line,
as a rule on the posterior blind end of the proboscis-sheath. The
papillae which bear the hooks are only covered with a chitinous cap
at their apex, and the hooks have a process below. This family is by
far the largest; a few species only can be mentioned.
Echinorhynchus proteus lives in its mature form in fishes; the young
forms, up to a centimetre in length, are found living freely in the
intestine of numerous fresh-water fishes. Those found in Gobio
fluviatilis, the gudgeon; Leuciscus virgo; Lota vulgaris, the burbot or
eel-pout; young trout; Thymallus vulgaris, the grayling, seldom
surpass this size, but those found in Acerina cernua, the pope fish; in
Abramis bipunctatus; in Esox lucius,the pike, and in older trout,
attain or surpass double the length. As the parasites grow older they
bury their proboscis and neck in the wall of the intestine, the inner
surface of which is studded with the orange-coloured bodies of the
parasites. The proboscis is so deeply sunk in the wall of the
alimentary canal as to form a papilla on its outer surface (Fig. 92).
The larvae of E. proteus are found in the body-cavity of Gammarus
pulex, one of the Amphipod Crustacea, and also in the same position
in numerous fresh-water fishes; they must have passed into this first
host by the mouth and alimentary canal. If the liver of an infested
minnow, Leuciscus phoxinus, be examined, it will be found to contain
on its surface numerous spherical or egg-shaped capsules of an
orange colour, 2 to 2.5 mm. in length; these contain the larval forms
of the parasite. They develop into the adult form when the first host
is eaten by a carnivorous fish, but a complication may take place
when the larval form is found in Gammarus, as the latter, the first
host, may be eaten by a fish (intermediate host) in which the larva
does not become mature, and only develops sexual organs when
eaten by a carnivorous fish (second host). The larval form is also
found in Nemachilus barbatulus, Gobio fluviatilis, and the
sticklebacks Gasterosteus aculeatus and G. pungitius.

E. clavula Duj. is found in Salmo fario, Abramis brama, Cyprinus

carpio, Gobius niger, Lepadogaster gouanii, etc.; E. linstowi Ham. in
Leuciscus idus, Abramis ballerus, Abramis bipunctatus, and
Acipenser huso; E. lutzii Ham. was found by Dr. Lutz in Brazil in the
intestine of Bufo agua; E. angustatus Rud. occurs in such numbers
in the perch, Perca fluviatilis, as to almost occlude the lumen of the
intestine, and one out of every three or four fish in certain districts is
infested by it. It is also found in the pike, Esox lucius, and the barbel,
Barbus vulgaris. The first or larval host of this species is the Isopod
Asellus aquaticus. E. moniliformis Brews. is stated to attain maturity
in the human intestine. Except for the fact that G. gigas has once
been observed in the same place, this is the only human parasite
amongst the Acanthocephala. Its normal second hosts are Mus
decumanus and Myoxus quercinus, and its first or larval host, the
larvae of the beetle Blaps mucronata. E. porrigens Rud. is found in
considerable numbers in the small intestine of a fin-whale
(Balaenoptera sibbaldii), and E. strumosus Rud., in the small
intestine of a seal (Phoca vitulina), and in the body-cavity of the
angler fish (Lophius piscatorius). E. acus is common in the whiting,
Gadus merlangus.

Family II. Gigantorhynchidae.—Large forms with ringed, flattened,

and Taenia-like bodies. The hook-papillae are covered all over with
transparent chitinous sheaths with two root-like processes. The
proboscis-sheath is muscular and without a lumen. The central
nervous system is excentrically placed below the middle of the so-
called sheath. The lemnisci are long twisted tubes with a central
canal.

Hamann places three species in this family: Gigantorhynchus

echinodiscus, G. spira, and G. taenioides; but as he points out that
E. gigas resembles these in its more important structural features, it
seems advisable to include it here under the name G. gigas. The
members of the first family often present a transversely ringed
appearance after death, but the Gigantorhynchidae are ringed when
alive, and the circular canals in the skin show a certain regularity,
being arranged one between each two rings. There is no lumen in
the proboscis-sheath, which is not attached to the boundary between
the proboscis and the trunk, but to the inner surface of the proboscis,
and the whole can be retracted within the anterior portion of the
body, which is invaginable. There are always eight cement-glands,
and other differences exist in the musculature, hooks, and position of
the nervous system.

G. gigas occurs in the adult state in the small intestine of swine; in

Europe its first or larval host is believed to be the grubs of
Melolontha vulgaris and Cetonia aurata, but these beetles are
absent from America, though the parasite infests American hogs.
Stiles[220] has recently made some experiments which tend to show
that in the United States the source of infection is some species of
the beetle Lachnosterna, and he has succeeded in infecting the grub
of L. arcuata by feeding it on the eggs of the parasite; from one larva
he took 300 parasites six weeks after feeding it. L. arcuata is, like M.
vulgaris, phytophagous, but the grubs of both the beetles are fond of
frequenting manure heaps and patches of dung, and thus are much
exposed to the dangers of infection.

G. echinodiscus inhabits the intestine of ant-eaters, having been

found in Myrmecophaga jubata and Cycloturus didactylus. G. spira
lives in the king vulture Sarcorhampus papa, and G. taenioides in
Dicholophus cristatus, a species of Cariama.
Family III. Neorhynchidae.—Sexual maturity is reached in the larval
stage. The proboscis-sheath has a single wall. A few giant nuclei
only are found in the sub-cuticle and in the lemnisci. The circular
muscle layer is very simply developed. The longitudinal muscle-cells
are only present in certain places.

This family includes two species, Neorhynchus clavaeceps and N.

agilis, which afford interesting examples of paedogenesis. The sub-
cuticle and the lemnisci are dominated by a few giant nuclei, which
remain in the embryonic state and do not break up into numerous
nuclei as in other forms. The musculature is but little developed and
the longitudinal sheath hardly exists. The proboscis-sheath consists
of a simple muscular layer, and the short proboscis has few hooks
and presents an embryonic appearance.

The sexually-mature form lives in the carp, Cyprinus carpio; the

larval form is found, according to Villot,[221] encysted in the fat
bodies of the larva of Sialis lutaria, one of the Neuroptera, and in the
alimentary canal of the leech Nephelis octocula, and successful
experiments have been made in infecting some species of the water
snail Limnaea. N. agilis occurs in Mugil auratus and M. cephalus.

Family IV. Arhynchidae.—Short forms with the body divided into

three well-marked regions—head, collar, and trunk. The head is
pitted, the collar smooth, and the trunk wrinkled, not annulated, in
spirit specimens. There is no eversible introvert, and no introvert
sheath and no hooks. The sub-cuticle and the lemnisci have a few
giant nuclei, and the lemnisci are long and coiled.[222]

This family resembles the Gigantorhynchidae in the length and

curvature of its lemnisci, and the Neorhynchidae in the persistence
of the embryonic condition of the nuclei in the sub-cuticle and the
lemnisci; but in the shape of the body, its division into three well-
marked regions, the absence of eversible proboscis, proboscis
sheath, and hooks it stands alone, though it is nearer to the
Neorhynchidae than to either of the other families.

The single species Arhynchus hemignathi was found attached to the

skin around the anus of a Sandwich Island bird, Hemignathus
proceros. The bird is a member of a family Drepanididae, which is
entirely confined to the Sandwich Island group. Professor Newton
tells me that it is probable that the "food of Hemignathus consists
entirely of insects which it finds in or under the bark of trees," hence
it is probable that the second host of this parasite, if such exists,
must be looked for amongst the Insecta.

CHAPTER VII

CHAETOGNATHA

STRUCTURE—REPRODUCTION—HABITS—FOOD—CLASSIFICATION TABLE
OF IDENTIFICATION

At certain seasons and at certain times of the day the naturalist who
is investigating the fauna of the surface of the sea is apt to find his
tow-net crammed with innumerable transparent spindle-shaped
animals, which by their number and the way in which they become
entangled with rarer objects, often render useless the result of his
labours. These animals belong to the class Chaetognatha, which
includes three genera, Sagitta, Spadella, and Krohnia. Amongst
them are divided about twenty species, some of which, however, are
of doubtful value.

Anatomy.—The body of these animals is as transparent as crystal; it

is elongated, and bears a resemblance to certain torpedos, except
that the head forms a somewhat blunt termination to the spindle-
shaped body. The tail bears a caudal fin, and Spadella and Krohnia
have a single pair, and Sagitta two pairs, of lateral fins; all of which
are flattened horizontally.

The body is externally divisible into three regions—head, trunk, and

tail—and these correspond with the arrangement of the internal
organs.

Fig. 101.—Sagitta bipunctata. a, Vesicula seminalis. × 4. (After

Hertwig.)

The head is surrounded by a fold of skin, forming a hood, which is

most prominent at the sides (Fig. 102, g); within the hood the head
bears from two to four rows of short spines, and outside these a right
and left row of sickle-shaped hooks, the free ends of which in a state
of rest converge round the mouth, but when disturbed these hooks
can be widely divaricated.

The cavity of the body, or coelom, is divided into three distinct

chambers by the presence of two thin transverse walls or septa, one
situated between the head and the trunk, the other between the
trunk and the tail (Figs. 104, 105). In the head, this cavity is much
reduced by the presence of special muscles which move the spines,
hooks, etc.; and in the small species, such as Spadella
cephaloptera, the other two cavities are almost entirely occupied by
the digestive and reproductive organs[223]; but in the large species,
e.g. Sagitta hexaptera, a considerable space is left between the
internal organs and the skin, and this is occupied by a coelomic fluid.
If the skin of one of these larger species be punctured the fluid
escapes and the animal shrivels up. A longitudinal partition or
mesentery, with numerous pores in it, runs through these spaces,
dividing the body-cavity into a right and left half; in the region of the
trunk this mesentery supports the alimentary canal.

In addition to certain muscles in the head, which move the hooks,

etc., there is a muscular lining to the body-wall. This is divided into
two dorsal and two ventral bands, much in the same way as in
Nematodes. The muscle fibres are striated.

The mouth, situated either terminally—Spadella marioni[224]—or

below the head, leads into a pharynx; this passes into an intestine
lined by a single layer of ciliated cells with a few glandular ones
intermingled. The intestine runs straight through the body without
loop or coil, and opens by an anus situated at the junction of the
trunk and the tail. In most cases the anus is ventral or on the lower
surface, but Gourret asserts that in Spadella marioni it is on the
upper surface.

There are no special respiratory, excretory, or circulatory organs,

unless a glandular structure described by Gourret in the head of
Spadella marioni be a real kidney.

The nervous system consists of a supra-oesophageal ganglion or

brain situated in the head, and of a ventral ganglion lying in the
trunk; both these nerve centres are embedded in the epidermis, and
are connected with one another by means of two stout peri-
oesophageal nerves (Figs. 102, 104). The brain also gives off a pair
of nerves to the eyes, another pair to the olfactory organ, and a pair
which ultimately meet one another and so form a ring; on this are
certain ganglia giving off nerves which supply the muscles of the
head. Both the chief ganglia give off numerous nerves, which divide
and split up into a network of fibres which permeate the whole skin.
The sense organs are comparatively simple. A pair of very small
eyes lie in the skin of the head; they are of complex structure, and to
some extent remind one of the simple eyes of certain Crustacea.
Behind the eyes and also on the upper surface of the animal is an
unpaired organ which is usually described as olfactory in function
(Figs. 103, 105). This is a ring-shaped modification of the epidermis
drawn out into different shapes in the various species. The modified
epidermal cells bear long cilia. The remaining sensory organs found
in the group consist of clumps of modified cells scattered in round
groups over the surface of the body and of the fins. The central cells
of each group bear long tactile hairs, and are surrounded by
supporting cells.

Fig. 102.—Head of Sagitta bipunctata. A, Dorsal view; B, ventral view.

× about 33. (From Hertwig.) A, a, spines; b, nerves to lateral
cephalic ganglia; c, hooks; d, cephalic ganglion; e, olfactory
nerve; f, optic nerve; g, hood; h, commissure to ventral ganglion; j,
olfactory organ: B, a, c, and g as in A; k, mouth.

The Chaetognatha are hermaphrodite, and carry the female organs

in the trunk, the male in the tail. In a mature specimen the two
ovaries occupy almost all the space in the trunk between the
alimentary canal and the skin, and each is supported by a narrow
lateral mesentery. The ovary is traversed by a oviduct which often
contains spermatozoa; it is not clear how the eggs make their way
into the oviduct, which seems to have no internal opening and to act
largely as a receptaculum seminis. The oviducts open externally on
the upper side at the base of the lateral fin, close to the junction of
the tail and the trunk.
The cavity of the tail is divided into two lateral chambers by the
extension backward of the median vertical mesentery. In each of
these a testis and a vas deferens are found. The testes are solid
ridges formed by the growth of the lining cells of this part of the
body-cavity; the cells mature into spermatozoa, which break off and
float freely in the coelomic fluid. At the breeding season the whole
tail may be crowded with masses of spermatozoa, which are kept in
a more or less regular circulation by the ciliated cells lining the body-
wall. The vas deferens opens internally into the space where the
spermatozoa lie, and at the other end into a vesicula seminis, which
opens to the exterior. The position of the latter structure varies, and
is of some systematic value.

The eggs are laid in the water and as a rule float at the surface of the
sea. Spadella cephaloptera is, however, an exception to this rule, as
it attaches its eggs by means of a gelatinous stalk to sea-weeds. The
segmentation of the ovum is regular, and gives rise to a two-layered
stage or gastrula, which opens by a pore, the blastopore. This does
not, however, become the mouth, but closes up and the mouth
arises at the opposite pole. Perhaps the most interesting feature of
the development of Sagitta is that the cells destined to form the
reproductive organs separate from the other cells of the embryo at a
very early date, whilst it is still in the gastrula stage. There is no
larval form, but the young hatch out from the egg in a state
resembling the adult in all respects but that of size.
 Fig. 103.—Spadella cephaloptera. Dorsal view. x 30. (From Hertwig.) a,
Cephalic ganglion; b, commissure to ventral ganglion; c, olfactory
organ; d, alimentary canal; e, ovary; f, oviduct; g, testis; h,
vesicula seminalis.

Habits.—The Chaetognatha are essentially pelagic, and resemble

many other creatures that dwell at the surface of the ocean in being
almost completely transparent. Most species have been taken far out
at sea, but some are perhaps rather more numerous near the coast,
and one species, Spadella cephaloptera, is littoral. They swim by
means of muscular movements of the whole body; the fins have no
movement of their own, and seem to serve as balancers, and not as
locomotory organs. Although usually found at the surface of the
water, many species have been taken at considerable depths.
Chun[225] states that they are found in countless numbers at depths
of from 100 metres to 1300 metres. The commonest species at
these depths are Sagitta hexaptera and Sagitta serratodentata.
Sagitta bipunctata, according to the same authority, confines itself to
the surface. Whether the change of depth is diurnal, or whether it
has any relation to sexual maturity, or to any other cause, has not
been satisfactorily determined.

The food of the Chaetognatha consists of floating diatoms, Infusoria,

small larvae, and such Copepods as Calanus finmarchicus, and
small Amphipods as Phoxus plumosus.[226] At times they also
devour small larval or post-larval fishes, and owing to their incredible
numbers, they doubtless do considerable damage to sea fisheries. It
is also recorded that they eat one another, and specimens have
been taken which have ingested the whole body of another Sagitta
except the head, which hangs out of the mouth of the eater, and
gives it the appearance of a double-headed monster.[227] It has been
said that they attack hydroid polypes, but here at any rate they do
not have it all their own way. Masterman[228] has figured the apical
group of five polypes of Obelia, three of which are engaged in
ingesting as many young Sagitta.
They exist in incredible numbers; Grassi describes the surface of the
sea at Messina on certain days as being literally covered with them,
and they must form the food supply of numerous animals which prey
upon the pelagic fauna. The immense number of individuals is
probably accounted for to some extent by the fact that they lay eggs
all the year round, and pass through a very short and rapid
development. They are not known to be phosphorescent.

Classification.—The features of the Chaetognatha which have most

systematic value are the size of the adult, the relations of the length
to the breadth, and of the three divisions to one another; the size,
number, and position of the lateral fins, and of the hooks and spines
on the head; the thickness of the epidermis, and the structure of the
olfactory organ; and, finally, the form of the reproductive organs.

Strodtmann,[229] who gives the latest and most complete account of

the species of Chaetognatha, arranges them under three genera,
which he characterises as follows:—

(i.) Sagitta Slabber.—Two pairs of lateral fins, two rows of spines on

the head. The lateral thickening of the epidermis absent or
insignificant.

Under this genus are included nine definite species and five others—
S. gracilis Verrill, S. elegans Verrill, S. darwini Grassi, S. diptera
d'Orbigny, and S. triptera d'Orbigny—whose position, owing to the
inadequacy of their description, is of doubtful validity.
 Fig. 104.—Sagitta hexaptera. Ventral view. × 4. (From Hertwig.) a,
Mouth; b, hooks; c, anterior septum; d, alimentary canal; e,
commissure from the brain to the ventral ganglion; f, ventral
ganglion; g, ovary; h, oviduct; i, posterior septum; j, testis; k,
vesicula seminalis.

The distribution of the other species may be mentioned. S.

hexaptera is the largest Chaetognath known, and reaches in the
adult stage a length of 7 cm. It is very widely distributed, being found
in practically all the temperate and warm seas, usually at the surface
of the water, though at times it is found at a depth of one metre, or
even deeper. S. lyra, Mediterranean, very rare. S. tricuspidata,
widely distributed. S. magna, Mediterranean and Madeiran, living at
the surface. S. bipunctata, the most frequently described form,
smaller than the preceding species, 1-2 cm. in length, widely
distributed, and as a rule living near the coast line. S. serratodentata,
Mediterranean. S. enflata, on the surface of the sea, Mediterranean
and Madeiran. S. minima, a very small species, 1 cm. in length,
Mediterranean. S. falcidens, Atlantic, off the coast of New Jersey.

(ii.) Krohnia Langerhans.—A single lateral fin extending on to both

trunk and tail segment, no lateral epidermal extensions behind the
head, only one row of spines on the head. Trunk longer than the tail.

Krohnia has but two species: K. hamata Möbius, with a length of 3-4
cm., found in the North Atlantic and at considerable depths, 200 to
300 fathoms; and K. subtilis Grassi, 1.5 cm. long, with an
extraordinary slender body and a relatively large head, found at
Messina, but very rare; as a rule only one specimen has been found
at a time.

(iii.) Spadella Langerhans.—A single pair of lateral fins; these are

situated on the tail segment. Behind the head a thickening of the
epidermis extends down each side of the body to the fin, or even
farther. Two rows of spines on the head. Small animals, not longer
than 1 cm.

Fig. 105.—Spadella draco. Dorsal view. × 12. (From Hertwig.) a,

Cephalic ganglion; b, commissure between the cephalic ganglion
and the ventral; c, eye; d, olfactory organ; e, alimentary canal; f,
ovary; g, oviduct (the line goes a little beyond the duct); h, testis; j,
vesicula seminalis.

S. cephaloptera Busch is the smallest species of Chaetognatha,

attaining at most a length of .5 cm. The body is not so transparent as
in other species, and is of a yellowish colour. It has been found from
the Orkney Islands to the Mediterranean. Strodtmann is of the
opinion that the three species S. mariana Lewes, S. batziana Giard,
and S. gallica Pagenstecher differ from the above-named only in
size, or that their description is too indefinite to permit of accurate
characterisation. He recognises three other distinct species: S.
pontica Uljanin, from the Black Sea; S. marioni Gourret, from the
Gulf of Lyons; and S. draco Krohn, Mediterranean and Madeiran,
and from the Canaries.

Much confusion has been introduced into the classification of the

Chaetognatha by Grassi,[230] who calls some—but not all—of what
other writers term Sagitta, Spadella, and vice versâ. The following
table was compiled by Strodtmann,[231] but I have incorporated in it
two species recently described from Amboyna by Béraneck,[232] and
called by him Sagitta bedoti and Spadella vougai respectively:—

CHAETOGNATHA

I. Two pairs of lateral fins; two rows of spines on the head;

slender forms.

(i.) Number of spines in posterior row greater than in anterior.

a. Border of hooks smooth, their point not curved.

α. No interval between the two fins on each side. 3.5 cm.

long; 4-7 anterior spines, 8-11 posterior spines; olfactory
organ lying entirely on the trunk. The anterior nerves of the
ventral ganglion lie close to one another as far as the
head.—Sagitta lyra.

β. A distinct interval between the two fins on each side.

aa. Adult animals large; hooks 6-7; anterior spines 3-4;

posterior spines 5-7; tail ¼ or ⅕ of the total length; lateral
areas relatively larger.—Sagitta hexaptera.

bb. Greatest length 1-2 cm.

 αα. Thickening of the epidermis behind the head;
prominently projecting vesiculae seminales; olfactory
organ very long; hooks 8-10; anterior spines 4-6;
posterior spines 10-15.—Sagitta bipunctata.

ββ. No epidermal thickening; two caeca on the anterior

end of intestine; length 1 cm.; hooks 6-9; anterior
spines 3-4; posterior spines 7-8; point of the hooks
somewhat bent round.—Sagitta minima.

γγ. Epidermis thin; no caeca; hooks 8-9, their ends not

bent; anterior spines 3-4; posterior spines 7-8; length 2
cm.; small head; trunk proportionately thick.—Sagitta
enflata.

δδ. Hooks 11-14, usually 12; length 1.8 cm.; anterior

spines 6-7; posterior spines 18.—Sagitta falcidens.

εε. Hooks 7 on each side; length 1.3 cm.; anterior

spines 8-10, posterior spines 18-22; no olfactory organ.
—Sagitta bedoti.

b. Edge of hooks toothed and their point bent round; hooks

6-8; anterior spines 6-8; posterior spines 10-12; length 1.5
cm.; slender; conspicuously projecting vesiculae seminales.
—Sagitta serratodentata.

(ii.) Number of the spines in posterior row smaller than in

anterior.

a. Anterior spines 3; posterior spine 1; hooks 8; length 3.5

cm.—Sagitta tricuspidata.