Part 35

During the life-epoch of the menacme, moreover, disturbances of the nutrition of the uterus are of common occurrence, as, for example, hyperplastic processes in the mucous membrane of the cervical canal and of the cavity of the body of the uterus. Common also during the menacme is chronic oöphoritis, which may be due to mal-regulation of marital intercourse (especially to coitus too soon after childbirth), to carelessness during menstruation (dancing, skating, or mountaineering), to incomplete coitus (congressus interruptus), and not infrequently, to gonococcal infection; or, finally, the oöphoritis may occur soon after the puerperium in association with subinvolution of the uterus.

Next we may mention inflammatory diseases of the Fallopian tubes. In the etiology of these diseases in latter-day marriage, a dominant rôle must be assigned to the gonococcus; but they also arise in many cases from nutritive disturbances, infection (other than gonorrhœal), and indiscretions during menstruation. Pelvic peritonitis owns similar causation.

In this phase of women’s life, the commonest new growths of the uterus, myomata, also develop, most commonly between the ages of thirty-six and forty-five, and they occur in strikingly larger proportion in unmarried women; it is between the same ages also that cysto-adenomata of the ovaries are of commonest occurrence.

Sexual intercourse gives frequent opportunities for the introduction of infective germs into the vagina, and for the origination of inflammatory affections of the mucous membrane (colpitis), the intensity of which depends upon the species, the quantity, and the virulence of the germs in question, on the one hand, and upon the local and constitutional predisposition of the infected person, upon the other. Especially grave in its consequences is gonorrhœal infection transmitted by the male, for this virus gives rise to a great variety of pathological processes in the female genital organs. In the act of defloration, considerable injuries are sometimes produced, and these readily supply a breach for the invasion of infective organisms. The condition of passive hyperæmia that occurs in the genital organs during pregnancy also provides a favorable soil for their growth.

Gonorrhœal infection of young married women is so frequent and so serious an occurrence in the sexual life of woman, that it requires special consideration. The cases in which the man entering upon marriage is so unscrupulous and so brutal as to deflower his young wife and to continue copulating with her, while suffering himself from a quite recent and active gonorrhœa, are on the whole rare. More common is it for the bridegroom to believe himself completely cured of his previous claps, and he is declared cured by his physician. The disease is, however, latent merely, the gonorrhœa has become chronic, the discharge is so slight that it is overlooked; but by the stimulation of the frequent acts of coition usual in the early days of marriage, the disease is lighted up afresh, the gonococci multiply quickly and intensely, the young wife is infected, and suffers from an acute gonorrhœa, which may often escape observation for a considerable period.

In a gonorrhœal marriage, one in which both husband and wife have gonococci in their genital organs, very diverse phenomena may be observed and very various conditions may result. On this subject M. Runge writes: “If the husband’s gonorrhœa is not cured, fresh, virulent cocci are repeatedly transmitted to the wife, in whom, therefore, the disease often gets worse by distinct stages. If the wife undergoes treatment, the effect in these circumstances will naturally be nil, since the husband is always supplying fresh infection. On the other hand, the wife on her side returns the gonococci to her husband, and in this way his gonorrhœa may undergo aggravation. If the husband is compelled, by illness, for instance, or by absence, to abstain for a long period from intercourse with his wife, the latter’s gonorrhœa may, in favorable circumstances, undergo alleviation and cure. It may happen, however, that in the husband, in consequence of sexual rest, the gonorrhœa becomes latent, and even entirely disappears, whilst the wife still suffers from infection. If now, after long abstinence, the husband has renewed intercourse with his wife, he may be reinfected, and suffer from an acute attack of gonorrhœa, though this is due to the descendants of the very gonococci that he himself sometime before conveyed to the genital organs of his wife—he reinfects himself, as people say. Such cases have given rise to suspicions of unchastity on the part of the wife, when the husband is in actual fact enjoying his own work in a new edition. A further possibility is that both husband and wife have become habituated to their own gonococcal interchange; that is to say, the organisms produce no notable effect in either. But if the wife in such a condition receives the embraces of a lover, the latter may be infected with an acute gonorrhœa—a fact that has long been known.”

The principal rôle in the etiology of the diseases of the female genital organs must be assigned to pregnancy and childbirth. Anæmic women readily suffer during pregnancy from a further decrease in the corpuscular richness of the blood; those affected with valvular incompetence find their troubles much aggravated by pregnancy; where the kidneys are in an irritable condition, pregnancy not infrequently results in the onset of nephritis, those with disordered digestion often suffer from increased disturbance of the functions of the stomach and the intestinal tract; those with gall-stones are apt to suffer from exceptionally severe attacks of biliary colic, and acute yellow atrophy of the liver is especially apt to occur during pregnancy. In women in whom dilatations of the veins already exist, very great increase of the enlargement is apt to occur during pregnancy; and in the same circumstances, trifling telangiectases increase to extensive angiomata. Enlargements of the thyroid body undergo rapid increase during pregnancy, so that they may attain threatening proportions. In women in whom the abdominal walls are flaccid, the viscera may protrude during pregnancy through the enlarged lacunæ, giving rise to herniæ. The great relaxation of the peritoneal and other ligamentous attachments of the great abdominal glands, occurring during pregnancy and the puerperium results in displacements of these organs; hepatoptosis (migrating or movable liver), lienoptosis (splenoptosis or wandering spleen), nephroptosis (ren mobile, floating or movable kidney), and other varieties of enteroptosis (splanchnoptosis, visceroptosis, or Glénard’s disease). During pregnancy, previously sound teeth are apt to become carious, and already existing caries rapidly advances. New growths of various kinds originate at this period, those previously present exhibit rapid increase; and relapse after operations for the extirpation of malignant tumors is especially apt to occur. Even the bones are unfavorably influenced. A weakened nervous system is subject to a storm of changing nervous troubles, in some cases so severe as to lead to the outbreak of actual psychoses; while mental disorder already present tends, as a rule, to be seriously aggravated during pregnancy. In the eyes, serious disorders may occur, such as retinitis, and atrophy of the choroid with complete amaurosis. As regards the hearing, tinnitus aurium is not uncommon, and sometimes complete deafness occurs. Numerous diseases of the skin are apt to occur during pregnancy; in addition to the well-known pigmentation of the face, the areola mammæ, and other parts, we may have herpes, eczema, or pruritus.

The serious aggravation which pregnancy is liable to induce in many disorders previously existent, is well known, and this exacerbation provides in some cases an indication for the induction of artificial abortion. This necessity may arise in severe cases of renal, cardiac, pulmonary, or hepatic disease, in progressive anæmia, severe osteomalacia, hæmophilia, and many other acute and chronic pathological states, since, in exceptional cases, as pregnancy advances, the symptoms of any one of these diseases may become so threatening, that the patient’s life is either in immediate danger or is almost certain to be in danger within a very short space of time—this may occur, for instance, in diabetes, struma (goitre), or certain nervous diseases, such as chorea, polyneuritis (multiple neuritis), or mental disorders. Undoubtedly, in this connection, as W. A. Freund insists, it is not the actual nature of the disease that is of decisive importance, but rather its intensity, and its influence on the health of the pregnant women; these circumstances, considered in relation to the resisting powers of the patient, must be determinative in the adoption of measures for terminating the pregnancy. An indication for the induction of artificial abortion is generally furnished also by uncontrollable vomiting dependent on pregnancy and endangering the life of the patient; irreducible incarceration of a retroflexed gravid uterus in the pouch of Douglas, or of a gravid uterus in a hernia, or irreducible prolapse of a gravid uterus will also necessitate abortion.

W. A. Freund gives an example of a common pathological state, usually quite free from danger, but now and again, when associated with pregnancy, seriously endangering life and rendering the induction of artificial abortion absolutely necessary—this is acute struma vasculosa—(vascular enlargement of the thyroid body), which may during the first three months of pregnancy exhibit such rapid growth as to lead to severe orthopnœa and cyanosis and so to imperil the patient’s life.

In cases in which laryngeal tuberculosis exists as a complication of pulmonary tuberculosis, the former disease sometimes progresses so rapidly in the course of pregnancy that sudden death from œdema of the glottis is by no means rare. Freund, therefore, sees in this complication an absolute indication for the artificial termination of the pregnancy.

In cases of previously well-compensated valvular lesions of the heart, disturbances of compensation not infrequently occur as a result of pregnancy; whilst in cases in which cyanosis, dyspnœa, albuminuria, and dropsy existed even before pregnancy, the latter condition is likely to result in an aggravation of these symptoms to a degree that imperils life.

Parturition, to an even greater extent than pregnancy, may induce serious injuries to the female organism. Thus, during parturition, lacerations of the vagina are frequent, with consequent scar-formation and stenosis; lacerations of the perineum are also common, causing great inconvenience, and when complete, leading to incontinence of fæces with all its unpleasant consequences. Great is the danger arising from septic puerperal inflammations, such as pelvic peritonitis (perimetritis); serious are the results of puerperal vesico-vaginal and recto-vaginal fistulæ.

A large part in the local pathology of the female genital organs is played by the various displacements of the uterus, either arising in consequence of inflammatory processes in their ligaments, or dependent upon relaxation of these ligaments from subinvolution of the internal generative organs, either following delivery at full term or following abortion.

The injury which women alike of the well-to-do and of the laboring classes suffer in consequence of numerous and frequently repeated pregnancies, is minutely described by Hegar. “We can,” he writes, “calculate the danger to life to which such an unfortunate woman is exposed by the act of reproduction. If we assume the ordinary mortality of women in childbed to be 6 per mille, then, in a woman who within 15 years has been delivered 16 times (whether prematurely or at full term), the danger will be 16 times as great as that of a single delivery, and the mortality will be 6 × 16 = 96 per mille; that is to say, of 1,000 women who have all been pregnant that number of times, 96 will die—nearly 1 in 10. Moreover, in this calculation the increased danger consequent upon the unusually rapid sequence of the deliveries has not been taken into consideration. And, again, only the immediate results of the deliveries have been taken into the account. Not infrequently women succumb at a later date to illnesses acquired in childbed; whilst others, in consequence of repeated pregnancies, have their powers of resistance so greatly diminished, that they are unequal to the contest with incidental diseases. In any case, a woman who has experienced numerous and rapidly successive pregnancies, has sustained damages which will endure for the rest of her life. Her tissues have lost their elasticity, the abdominal walls are flaccid, the abdomen is prominent, the abdominal viscera are displaced, the vessels dilated, the reproductive organs in a state of subinvolution, and are the seat of structural alterations. The greatest dangers arise in cases in which the pregnancies are consequences that have to be paid for illicit love, since in such cases syphilitic and gonorrhœal infection are exceptionally common. These complications, indeed, are not excluded in the case of married women, since marital infidelities occur, and, again, a premarital but not completely cured venereal illness may bear fruit in marriage, the latter occurrence being almost always attributable to the husband. Syphilitic or gonorrhœal infection may also arise in some other way than by copulation, and to this women are more exposed than men, owing to the greater size of the genital passage in the former.”

Very numerous are the disorders of the nervous system referable to the sexual functional activity of woman during this epoch of her sexual life.

Freund, in his description of a neurasthenic symptom-complex to which he gives the name of angst-neurosis, maintains that the cause of these attacks of anxiety is very frequently to be found in a number of injurious influences in the sphere of the sexual life. In women, these anxiety-neuroses occur:

a) As virginal anxiety, or anxiety of adolescents. Freund has observed a number of unequivocal instances showing that a first encounter with the sexual problem, a rather sudden unveiling of what has hitherto been concealed, as, for instance, the sight of some sexual act, or something read or heard in conversation, may, in a girl at the time of puberty, give rise to an anxiety-neurosis, which is in a very typical manner combined with hysteria.

b) As anxiety of the newly married. Young wives who have been without sexual feeling in their first experience of intercourse are not infrequently attacked by an anxiety-neurosis, which, however, disappears as soon as the sexual feeling becomes normal. Since, indeed, the majority of young women who lack sexual feeling in their first experience of sexual intercourse remain nevertheless quite healthy, it is evident that some other cause must coöperate in arousing the anxiety-neurosis.

c) As anxiety in married women whose husbands suffer from ejaculatio praecox or from great diminution of sexual potency, or

d) Whose husbands practice coitus interruptus or coitus reservatus. Cases in these two classes are closely associated, since it is easy to ascertain, from the analysis of a sufficiently large number of cases, that the really important question is, whether during coitus the wife obtains or fails to obtain sexual satisfaction. In the latter event, the condition requisite to arouse the anxiety-neurosis is supplied.

e) As anxiety in widows and in voluntary abstinents, not infrequently in typical combination with impulsive ideas.

f) As anxiety in the climacteric period, during the final flare-up of sexual passion.

Numerous anomalies of the genital organs which gave rise in the virgin to no trouble whatever display their influence during the menacme by unfavorably affecting the nervous system. Thus, in cases of malformations of the external organs of generation, slight atresia of the vagina, a rudimentary condition of the vagina, a rigid hymen, or local changes in the vagina, it is only when sexual intercourse begins that neuroses or hysteroneurasthenic troubles ensue. So also at times nervous diseases which, though the disposition to them was present, were latent in the girl, such as epilepsy and various mental disorders, first become apparent in consequence of sexual intercourse.

The mechanical irritation of the nerves of the pelvis that occurs in sexual intercourse may, even in women whose reproductive organs are healthy, arouse sensations of weight, pressure, and bearing-down, various painful sensations in the sacral region, over the coccyx, in the buttocks, or in the upper part of the thighs, and also “lumbar enlargement symptoms,” viz., weakness of the lower extremities, abnormal sensations of fatigue in the lower extremities and the back, sometimes also disorders of micturition and defæcation.

Throughout the manifold diseases of women in or connected with the reproductive system during the age of sexual maturity, associated mental processes take place, which powerfully affect the nervous system. Such processes are, melancholy and anxious thoughts concerning the possible influence of the illness on the happiness of married life, concerning childlessness, or concerning loss of a husband’s sexual esteem, or again, fear that the affection will become cancerous, fear of some necessary operative procedure, or vexation in consequence of the limitation of her usefulness as housewife, wife, and mother. Thus in women suffering from sexual affections, a state of general neurasthenia, or some neurasthenic functional disturbance of other organs, very commonly arises.

The knowledge that she is suffering from an affection of the genital organs, makes a deep and lasting impression on the mind of a woman who takes a serious view of her duties as a wife, and whose thoughts and feelings are concentrated in the sexual sphere. The result is, that minor troubles are regarded through the magnifying lens of anxiety, and the general sensibility is increased. This hyperæsthesia is not confined to the affected region, but manifests itself in various other parts of the body by numerous phenomena of a reflex character. In the first place must be mentioned severe headaches, sacrache, sensations of pressure in the abdomen, cardiac troubles, palpitation, stomach-ache, nausea and retching and disorders of appetite and digestion. Capacity for work and the enjoyment of life are destroyed by these disorders.

We have further to take into account the numerous conditions liable to disturb the mind at this period of life. In childless women, we have the subject of their sterility, the continued yearning to be blessed with children, the eager search for a remedy, and not rarely in these cases the conflict between the reproductive impulse and the ethical principle of conjugal fidelity. In fruitful mothers, on the other hand, we have the anxiety lest, by too frequent child-bearing their beauty should be impaired and the livelihood of the family endangered; these considerations leading in many cases to the practice of coitus reservatus, with its deleterious physical and moral consequences. In the middle and working classes, we have the strain of the endeavor to be a helpful companion to the husband and at the same time to assist in the support and the education of the children. Last but not least, we have the potent influence of local therapeutic measures, and the fear of operative procedures, both of which have a most agitating effect on a woman’s mind. In truth, the menacme is a period full of stormy excitations and powerful revolutions.

In addition to its influence on the genital organs themselves, the sexual life of woman during the period of the menacme manifests its powers for evil especially in relation to the digestive functions, and to the functions of the heart and the nervous system.