By the term menacme I designate the culmination of the sexual development of woman, during which the processes of reproduction, copulation, conception, pregnancy, parturition, and lactation occur.

The processes of puberty in woman are fully completed at the age of from eighteen to twenty years, so that from this time forward she is fully equipped for the performance of her sexual duties. The first act in the fulfilment of these duties is copulation, which in civilized countries is in the great majority of women first undertaken at the commencement of married life. The average age at marriage in the women of this part of the world is 22; but marriages at an earlier age are very common, and in many circles of society the average age is as low as 20. The fullest maturity of sexual activity in women occurs, however, in the thirty-second year of life, this being the year in which on the average the maximum fertility is attained.

At the menacme, the beauty and energy of women attain their fullest evolution, her sexual characteristics their strongest development. It is this period of life, however, that entails the greatest dangers to beauty and health in connection with the functions of the genital organs. Copulation, the first act of sexual intercourse with the male, often produces in the female injuries from which she never completely recovers. Gonorrhœal infection has been a source of unspeakable miseries to women. Motherhood itself entails the risk of a great number and variety of illnesses, which, as puerperal sequelæ, affect this phase of woman’s life. The struggle for existence, in which woman at her prime is also involved, and the fulfilment of duties to husband and children, further lead to the production of a series of changes, both physical and mental, in the feminine organism, which influence all the functions.

The great characteristic of this epoch is maternity. In maternity the fully developed woman lives and has her being, but to maternity also she often succumbs as a sacrifice to the fulfilment of her natural functions. Inasmuch as in this sexual phase the functions of the genital organs are of greater importance, to the same degree is enhanced the importance of the mutual relations between these organs and the other organs of the female body.

Another influence of fundamental importance in the sexually mature woman is that of the sexual impulse, the force of which is at times overwhelming, so that its gratification is sometimes sought without regard for the consequences to married and family life.

The physiology and pathology of the menacme coincides with the normal processes and pathological changes respectively of the female genital organs consequent on their functional activity as organs of sexual sensation and of reproduction. Woman as wife and mother stands at the climax of her existence.

In a quite astonishing manner, however, many of the advocates of the modern movement for the emancipation of women contest the significance of maternity to women.

A modern authoress and supporter of women’s rights, Ellen Key, avows that she was in error when at an earlier date she “regarded maternity as the central point in woman’s existence.” She asserts that it lies within the sphere of a woman’s individual rights, as of a man’s, to reject marriage, or to accept marriage while rejecting maternity. “The grounds for the rejection of maternity may as well be deeply altruistic as deeply egoistic. It lies within the sphere of individual rights to dispense with love or with maternity when either is regarded or both are regarded from this point of view. It is entirely within a woman’s rights to transform herself into a member of the ‘third sex,’ the sex of the worker bee, of the neuter ant, if she finds therein her greatest pleasure. * * * Women exist in whom erotic feeling is totally atrophied; there are yet others who fail to find in intercourse with the modern man that soulful and deep erotic harmony which they rightly desire; and there are others still more numerous who desire love, but not maternity, which indeed they dread.”

A celebrated German authoress of the present day, Gabriele Reuter, refers in similar terms to the justifiable fear with which so many aspiring and hard-working women regard maternity, “the perpetual, watchful, emotional dread of motherhood, a dread which causes them to turn at bay. A dread, a hatred, it is, which has grown so strong, so active, that one might almost regard it as an obscure perverse instinct, awakened and developed and strengthened by bitter necessity. It is as if in the innermost recesses of their nature such women had a belief that should they pay their tribute to sex they would loose all the energy, clearness, and brightness of mind, by means of which they have raised themselves above the level of their sex. And perhaps women of a certain type are justified in this fear.”

Fortunately, however, the woman who does not prize maternity still remains an exception. The great instinct for the preservation of the species, which nature has planted deeply in every human being, still as a rule in women remains much more powerful than the instinct of self-preservation at every one else’s expense—more powerful than such self-sufficient egoism. And now as ever it is the duty of humanity to educate women for maternity from her youth upward, so that she is in every way fitted for the supreme duty of her sexual nature, the renewal of life from generation to generation.

Against the significance and importance of maternity to woman, the mountainous waves of the movement for the emancipation of women dash themselves as vainly as against the solid rock. Much justification may be found for the efforts of women in modern civilized communities to engage in departments of activity to which hitherto men only have been admitted; and as regards the intellectual capacity of women we may acknowledge their competence for the higher scientific professions; but while admitting this we must hold firmly to the physiological standpoint and must more especially bear in mind the sexual life of woman. Such professions only are suitable for a woman as do not entail a restriction of the sphere of her reproductive activity, a hindrance to her principal duty, that of maternity, an interference with the discharge of her obligations to husband and children, or a diminution of her domestic value and an evasion of her responsibilities in family life. As L. von Stein so justly remarks, the woman who spends the whole day at a desk, in the law courts, or in a house of assembly, may be a most honorable and most useful individual, but she is no longer a woman, she cannot be a wife, she cannot be a mother. In the condition of our society, the emancipation of woman is in its very nature the negation of marriage.

We may not agree with the great misogynist, Schopenhaur, in his depreciation of the female sex, or in his assertion that woman exists simply and solely for the propagation of the species, and that “her life should therefore flow more quietly, more inconspicuously, and more gently than that of man toward its goal;” nor need we regard as justified the severe sentence of the philosopher, E. von Hartmann, that from the moral standpoint, “the greater number of women pass the whole of their lives in a state of minority, and, therefore, to the end stand in need of supervision and guidance;” but the statement made by Friedr. Nietsche in his book Also sprach Zarathustra deserves acceptation, “Everything in woman is a riddle, and everything in woman has its answer: it is called pregnancy,” and again, “For woman, man is only the means; the end is always the child.”

Unsearchable in its judgments, nature has imposed on woman alone the consequences of the act of generation; man has the pleasure, but not the labor and the pain. We might indeed regard as highly unjust the distribution of the rôles in the process of reproduction, were it not that in a mother’s love and a mother’s joys, woman finds a compensatory solace. The man’s part is a much easier one and costs far less than that of woman; with the gratification of his sexual desire, man shakes off any further responsibility, whereas the woman’s body becomes the workshop in the wonderful act of creation of a new human life.

Maternity, says Lombroso, is the characteristic function of the female sex, upon which rests her whole organic and physical variability, and this function is indeed throughout of an altruistic nature. Although there is a certain antagonism between the sexual impulse and maternity—according to Icard, the sexual impulse is extinguished in women during pregnancy,—still, maternity appears to depend upon sexual perceptions. For instance, the act of suckling the infant often arouses voluptuous sensations, and Icard mentions a case in which a woman permitted fertilization to occur solely on account of the pleasure obtained by suckling. The anatomical cause of this fact is to be found in the connections between the nipple and the uterus by way of the sympathetic nervous system. * * * It is likewise probable that in the happy feeling of maternity there intermingle very gentle voluptuous sensations derived from the genital organs. According to Bain also, very delicate sensations of contact form an element in maternal love.

The epoch of the menacme is that in which, independently of maternity, the sexual impulse often becomes so powerful in woman as to be entirely dominant. The problems relating to marriage and to the sexual position of woman, so widely discussed at the present day, are, therefore, of especial importance in regard to women at this period of life. The forcible repression and control of the sexual impulse inculcated by moral and religious ordinances are now, according to the modern leaders, both male and female, of the woman’s movement, to be abandoned; and it is loudly asserted that every woman has the same right as man to physical love and the happiness it produces. Hence, free love is demanded. “Freedom in love, freedom for love—this is what the dignity of the human race demands,” asserts the authoress of a book recently published (Elisabeta von Steinborn, The Sexual Position of Woman). With laws for the regulation of marriage, this section of the women’s rights party will have nothing to do. A truly good and honorable man, they contend, has as little need of laws to regulate his amorous relations as he has of laws against murder and theft. In the first place, love, the sexual relation between man and woman, must be free, and humanity, freed from vexations and needless control, will then seek and find the proper path, even if at the expense of a few errors by the way. Only after this unrestrained sexual intercourse has lasted for a long time, will free marriage become the rule. “Out of this phase will develop the monogamic system willed by God, for which, in its most ideal form, we are not yet sufficiently ripe.” It is hardly necessary to discuss in detail the general deleterious influence of such unlimited, unregulated free love upon the community, upon human society as a whole, to describe the results of free love, to attempt to realize the chaos which it would bring about in the social relations of civilized humanity. We must rather indicate it as desirable from the medical standpoint also, that such a change in general domestic economy shall be aimed at as will enable the great majority of women to share in married life and family happiness, and thus making allowance both for human nature and the demands of social life, to effect a true harmony between sexual morality and sexual practice.

We must point out that in so far as the modern woman’s movement aims at dispensing with man and at basing the entire life of woman upon the independent ego, that movement is in opposition to nature and its eternal laws. A woman who thus seeks the solution of the woman’s question in the direction of freedom and independence is one who endeavors to avoid the burthen of womanhood. She desires to escape, always from guardianship, often from maternity, and usually from the restrictions, the unselfishness of womanhood. But none the less does she remain unable to escape from her femininity.

“The true significance of woman,” insists Laura Marholm in opposition to the modern tendency, “has at all times consisted rather in what she is than in what she performs, and it is precisely in the former point that the women of the present day seem so unusually wanting. Their performances are indeed many and various, they study and they write innumerable books, they are the directors or principals of all possible concerns and collect funds for every possible object, they wear doctors’ gowns, conduct agitations, and found clubs, and they come continually more and more into publicity. And yet their public significance is after all diminished. The greater the influence of woman in the mass and as a numerical majority, the less is her influence as an individual, the smaller is the triumph of her sex. She herself has induced man to sound the trumpet note of the abhorrence of women. Tolstoi in The Kreuzer Sonata, Strindberg in numerous dramas, Huysmans in En Ménage, write in this strain; and in the works of many lesser luminaries we encounter this mistrust of love. * * * The modern system of education for girls, with its polyglossia and polymathy, favors a superficial development of the understanding, and produces women who are pretentious without being profound.”

Feminine beauty suffers during the menacme from the stress of the demands made on the sexual activity as well as on the functional capacity of the individual. Repeated, rapidly succeeding pregnancies and confinements impair the beauty of the breasts and the abdomen, the figure and the carriage. In consequence of suckling, the breasts, hitherto firm and elastic, usually become more or less pendent and wrinkled, sometimes also flabby and inelastic, sometimes nodular. Diseases of the genital organs and the disorders of the general health dependent thereon, leave disfiguring wrinkles in the face and other traces in the whole structure of the body. Toil, anxiety, and grief also write their horrible marks deeply on the appearance. The mature working-class woman, through sharing in masculine labors, through long-continued muscular exertion, and through neglect of bodily care, frequently assumes in her features, her carriage, her figure, and her whole appearance, a rather masculine type.

The beauty and the youthful freshness of girls belonging to the labouring classes seldom endure for long after the menarche, and in cases in which the environment is one of poverty, they last through a very short part only of the epoch of the menacme. The early appearance of wrinkles in the face, the stiff, angular character of the movements, the ungraceful carriage of the body, all these combine to make a woman of five-and-twenty who groans under the burthen of toil appear at the first glance an elderly woman, and a closer investigation shows what damage has been wrought to the attributes of beauty, how the breasts are flabby and flattened, the belly prominent, the buttocks pendulous, the arms muscular.

In the well-to-do classes, again, at this period of life, when generous diet combines with insufficient exercise, an abundant deposit of adipose tissue may already have occurred, resulting in a great impairment of beauty, the body and limbs being enlarged, the gait and the carriage correspondingly altered for the worse—changes which seem desirable only to those orientals to whom such obesity, such exaggeration of femininity, is sexually stimulating. If, however, this deposit of fat is not excessive, this it is which endows women during these years of fullest development with an imposing appearance and buxom form. In favourable circumstances, beauty of this type may persist to the fortieth year of life and even beyond, and it is of such a character as to justify the proverb that woman’s first sexual epoch is dedicated to love, her second to voluptuousness.

Among the injuries to beauty effected by pregnancy, one above all evident to the eye is the almost invariably ensuing change in the skin, principally taking the form of a change in pigmentation, with the appearance of spots varying in size and tint, on the face and especially on the lips and the forehead; there is greatly increased pigmentation also of the areola mammæ and the linea alba, and in addition of the labia majora and minora and of the anal region. It is not certain whether this chloasma uterinum is dependent, as Jeamin assumes, on the discontinuance of menstruation, or, as Virchow believes, on changes in the blood and the blood-pressure. Sometimes also, in pregnant women, we observe on the face, chiefly on the nose and the cheeks, dilatations of the small cutaneous vessels, often associated with acne nodules.

A permanent disfigurement is caused by the lineæ (vel striæ) albicantes, white lines or streaks of varying length and resembling scar tissue in appearance on the skin of the abdomen, the adjoining parts of the buttocks and thighs, the lower part of the front of the thorax, and the mammæ. They are not true scars, not being new formations of connective tissue, being on the contrary dependent on solutions of continuity, on relative diminution, that is to say, of the connective tissue layer of the skin. They are formed in consequence of the fact that the connective tissue bundles are not able to keep pace in their superficial enlargement with the necessarily rapid extension of the cutis, hence great meshes appear in the former, situate in the direction of the greatest tension of the skin. (Spietschka and Grünfeld).

In the case of 1,000 adult women examined by Eggel with regard to the colour of the pubic hair, the colour of the eyes, and the colour of the hair of the head, there were 239 with dark eyes, 333 with dark hair on the head, and 329 with dark pubic hair; contrariwise, 761 had light eyes, 667 light hair on the head, and 679 light pubic hair. Obviously, then, a considerable number of women with light-coloured eyes must have had dark pubic hair. Roth, in 1,000 North German women examined by him, found the pubic hair blonde, but a rather dark blonde, in a large majority of the cases; in red-haired women, the pubic hair was in all cases bright red, in black-haired women the pubic hair was black in two-thirds only of the cases, in nearly a third it was brown, in two cases dark blonde; in Jewesses, in a large majority of instances, the pubic hair is brown. The arrangement of the pubic hair is described by Roth as very variable. “Sometimes it is short and frizzly, sometimes a luxuriant bushy growth; sometimes the hairs are scanty and thinly set; sometimes they are irregularly distributed; sometimes we see only a narrow strip of long hairs down the middle of the mons Veneris, which is bare at the sides. In some the lateral boundaries of the pubic hair are sharply defined, in others the hairy covering spreads beyond the usual limits.”

The vaginal orifice gapes a little, so that the irregular carunculæ myrtiformes are visible. In parous women, the vaginal orifice is enlarged in such a manner that the wall of the vagina passes directly and without limitation into the wall of the vestibule, and the external orifice (meatus) of the urethra is situate immediately in front of the anterior vaginal column, and thus lies within the vaginal orifice.

During the menacme, in consequence of the act of reproduction, the uterus undergoes important changes in form. In a nulliparous married woman, the uterus differs little from that of a virgin; the cavity is somewhat more extensive, the convexity of the outer surface a little greater, there is some increase in width in the neighborhood of the fundus, the plicæ palmatæ (arbor vitæ uterinum) are confined to the cervical canal; further, under the influence of copulation the appearance of the vagina changes, it becomes larger, and its walls become smoother, sometimes quite smooth, from the disappearance of the rugæ of the mucous membrane and especially of those attached to the posterior vaginal column. Much more extensive are the alterations in the uterus of a multipara. According to Toldt, “the parts of the cavity representing the cornua, which are pointed on either side as they pass toward the Fallopian tubes, become completely included in the lower undivided portion of the cavity, this change being effected chiefly by means of the increasing outward curvature of the walls, so that the cavity comes to assume an amygdaloid form; the cervical canal is also enlarged, especially the lower part, where also the plicæ palmatæ (arbor vitæ uterinum) becomes less distinct; the vaginal portion of the cervix is shortened, the os uteri externum gapes, the lips of the cervix are tumid, nearly equal in length, and usually beset with scarred depressions.” In nulliparae, the vaginal portion of the cervix is, as in a virgin, of a rather tough consistency, smooth on the surface, while the external os is small, like a dimple, or transversely oval; the color of the vaginal portion of the cervix is identical with that of the vaginal mucous membrane in general. Through frequent copulation, however, the form of the vaginal portion of the cervix is so far altered inasmuch as it is more freely supplied with blood, and, therefore, changes slightly, in consistency. In multiparæ, in consequence of lacerations of the cervix, the os uteri externum changes to a wide transverse fissure with tumid margins, justifying the old designation of this orifice as os tincæ;, carp’s mouth. A large size of the external and internal os, moderate enlargement of the cavity, rounding of the upper angles adjacent to the uterine orifices of the Fallopian tubes, increased convexity of the walls, and partial or complete effacement of the plicæ palmatæ (arbor vitæ uterinum), are the characteristics of the uterus of a multipara (Chrobak and von Rosthorn). According to Hennig, the vaginal portion of the cervix is longest in women who have undergone defloration, and in nulliparae; widest in prostitutes; narrowest in childless wives; thickest in young widows. This author gives the following measurements of the external os, showing its variations in accordance with age and sexual activity:

Diseases of the uterine mucous membrane during the period of sexual maturity often induce various pathological changes in these cervical glands. In consequence of obstruction of their excretory ducts, they may undergo cystic degeneration, forming follicles filled with mucus and epithelium, or cavities containing blood, which pass through the substance of the cervix in every direction; or they may give rise to the formation of slowly-growing glandular polypi and other glandular new formations—changes the general result of all of which is to interfere with the secretory function of the glands.

Pathology of the Menacme.

The full evolution of the sexual life brings in its train many dangers to a woman’s life. This appears at first sight from a comparison of the mortality of married women during the period of greatest sexual activity with that of single women of similar age. Between the ages of 20 and 25 years, the mortality of married women is in all races higher than that of unmarried women; and the same is true between the ages of 25 and 30 years, except in France, in which country from artificial causes maternity ceases at a very early age. In Prussia, in the year 1880, of every 10,000 married women, between the ages named, 21 died, of every 10,000 unmarried women, only 2. In Holland, Belgium, and Bavaria, this excess in the mortality of married women continues up to the age of 40 years; whilst in Prussia, from the age of 30 upward, the mortality of married women and unmarried is practically the same. In many countries, the mortality of married women at many ages exceeds even that of unmarried men.

This greater comparative mortality of married women is ascribed by Hegar to the satisfaction of the sexual impulse, and this authority believes that the dangers attendant on this function would be manifested yet more clearly if the contrast were made, not between married women and single, but between those habituated to sexual indulgence and those who are continent. We, however, are of opinion, that the satisfaction of the sexual impulse is only harmful to this extent, that it exposes women to the consequences of venereal infection, and also to the risk of numerous puerperal and other diseases of the genital organs. This is proved also by the statistical results of the investigations concerning mortality during pregnancy, parturition, and the puerperium. According to Hegar, adding deaths resulting from premature delivery to deaths resulting from delivery at full term, we find the mortality of childbirth in Germany to be about 0.6 per cent.

Whilst Bertillon and Simpson believe that the lower mortality of married women above forty years of age as compared with unmarried women at the same period of life is dependent upon the advantage to the former of the fulfilment of sexual functions, Hegar, on the contrary, gives another explanation. He writes: “At the age of 40, the less powerful married women have already been weeded out. At first, owing to the selection exercised by marriage, the quality of the unmarried women was inferior to that of the married women; the former, however, have not been exposed to the dangers attendant on the reproductive process, and so have passed through the time during which the body possesses the greatest elasticity; but in the years in which a decline in the vital powers naturally sets in, the originally inferior quality of the unmarried women is manifested by a comparatively higher mortality. Also we have to take into account among the unmarried, the consequences of extra-marital sexual intercourse and of prostitution, and further the lack of a family, of the support furnished by husband and children.”

In addition to the far-reaching disturbances of health dependent on sexual activity at this period of life, there are the minor domestic troubles by which woman is depressed and by which her powers are exhausted. The influence of these latter is admirably described by G. von Amyntor: “How many millions of brave house-wives boil and scrub away their vital energy, their rosy cheeks, their merry dimples, in the performance of their household duties, until they become wrinkled, worn-out, dried-up mummies. The ever-renewed question, ‘what must be cooked for dinner to-day,’ the perpetually recurring necessity for scouring and sweeping and dusting and washing-up—these are the continual dropping which slowly but surely wears away soul and body. * * * On the flaming altar on which the sauce-pan simmers, youth and simplicity, beauty and good temper, are offered up; and who can recognize in the old, hollow-eyed cook whose back is bent with toil and trouble, the once blooming, energetic, chastely coquettish bride adorned with her myrtle crown?”

A great number of the diseases of the female genital organs occurring at the epoch of the menacme need only a passing mention. Even coitus, in cases in which there is great disproportion in size between the penis and the vaginal orifice, or when the organ is very rapidly introduced or the act is very roughly performed, may lead to injury to the vulva or the vagina, a fact to which a very large number of recorded cases bears witness.

During the acme of the sexual life of woman, disturbances of the menstrual function are also frequent. Menstruation may cease in consequence of intercurrent diseases or constitutional anomalies; amenorrhœa may occur during the convalescence from acute diseases, in obese women, in those suffering from tuberculosis, diabetes, alcoholism, or psychoses. On the other hand, severe menorrhagia or atypical metrorrhagia may occur, the bleeding either being due to diseases of the uterus, such as endometritis, retroflexion of the uterus, or uterine myomata, or resulting from infectious diseases, disease of the heart or kidney, or from general disturbance of the health by chill or over-exertion. Or, again, dysmenorrhœa may arise, either as a symptom of some local uterine disease or in consequence of external noxious influences or weakness of the nervous system.

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.

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.

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.

Freund, in his description of a neurasthenic symptom-complex to which he gives the name of angst-neurosis,^[36] maintains that the cause of these attacks of anxiety^[36] 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,”^[37] 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.

When we compare the various consequences which may be induced in the principal organic systems as a result of functional disturbances and organic diseases of the female genital organs, we find that in respect of the frequency of their occurrence the diseases of the nervous system occupy the first rank; next in frequency come the disorders of the digestive organs that arise in sympathetic association with diseases of the female reproductive organs; whilst the third rank in respect of frequency and importance is occupied by the cardiac disorders that arise in connection with changes in the female organs of generation, and take the form either of disturbances of the heart’s functions or structural changes in the heart’s muscle.

Dyspepsia Uterina.

Although it has long been a familiar observation that pregnant women and women suffering from diseases of the reproductive organs suffered from various dyspeptic troubles, I was myself the first (in the Berliner Klinische Wochenschrift, 1883) to bring together, and to describe under the name of dyspepsia uterina, a peculiar group of dyspeptic conditions which are dependent upon diseases of the female reproductive organs. I dismissed from consideration organic diseases of the stomach and intestine dependent upon anatomical changes in these organs, even though these also might owe a similar etiology, and described only the more frequent dyspepsias occurring without organic change in the digestive apparatus, the origin of which is to be explained by the fact that certain structural changes and displacements of the uterus (to be discussed later) arouse centripetal impulses, and that these exercise a reflex influence on digestive activity.

This influence, according to my observations, affects the secretory and muscular apparatus and also the nervous elements of the digestive tract, and I regard the following conditions as characteristic of uterine dyspepsia, though they do not necessarily all occur simultaneously: changes in the gastric secretion, excitement of the vomiting centre, an inhibitory influence on intestinal peristalsis, and hyperæsthesia of the stomach.