II. THE SEXUAL EPOCH OF THE MENACME. (continued 2)

Not all diseases, however, of the female reproductive apparatus, tend in a similar manner and with equal frequency to give rise to consecutive cardiac disorders. According to my own observations, the diseases of the vulva and the vagina, catarrhal inflammation, colpitis (vaginitis), leucorrhœa, and prolapse of the vagina (cystocele and rectocele), are those which most rarely induce cardiopathy; 239unless, indeed, the diseases just enumerated have led to the occurrence of vaginismus, for in this latter condition cardiac trouble not uncommonly ensues. More commonly than by vulval and vaginal diseases, cardiac troubles are induced by inflammation of the uterine mucous membrane, as by chronic endometritis, by erosion and “ulceration” of the cervix (chronic cervical catarrh); they also sometimes occur in connection with perimetritic and parametritic exudations. Most frequently of all, and most severely, cardiac disorders are aroused by displacements of the uterus, flexions or versions; by structural changes of the uterus accompanied by enlargement of that organ, such as chronic metritis and the growth of myomata (especially intramural); by prolapse, enlargement, and tumor of the ovary; by intrapelvic exudations which when extensive give rise to displacement or compression of the uterus or its annexa. In cases of carcinomatous or other malignant new growths affecting the reproductive organs, I have in comparison very rarely observed the occurrence of reflex cardiac disorders.

Disturbances of menstrual activity, amenorrhœa, menorrhagia, and dysmenorrhœa, owning the most varied causes, very frequently give rise to cardiac trouble, a point on which we have already insisted. (See page 142, et seq.)

Very violent forms of cardiac neurosis have been observed by me in women suffering from chronic disorder of the reproductive organs, who have consulted one gynecologist after another and have been subjected to many different methods of local treatment; also in women who have for a long time suffered from some gynecological ailment hitherto believed to be trifling, but who have at length suddenly been informed that some severe operative procedure has become necessary. In such cases the cardiac trouble took a paroxysmal form, the intervals being usually considerable, several weeks or months in duration, and the general system was as a rule seriously involved in the attacks. These latter began with severe cardialgia, radiating from the cardiac region outward along the intercostal spaces, upward to the shoulder and along the left arm, sometimes indeed extending into both arms. At the same time the heart’s action was greatly increased in frequency, there being sometimes more than 200 beats per minute, the pulse was soft, small, difficult to count, the respiration greatly increased in frequency, sometimes very shallow, with respiratory anxiety, and exceptionally severe general excitement and sense of impending death. In some cases also I observed spasm of various groups of muscles, dizziness (with a sense that the objects of vision were flickering), aphasia, and mental stupor. The paroxysms lasted for some time, two or three hours, as a rule, and gradually passed away. Their character was 240that of the cardiac disorder variously described under the names of pseudo-angina and angina pectoris hysteria.

Such attacks as these are followed by a sense of severe general depression and want of energy, and by a decline in body-weight. They are distinguished from true angina pectoris by the absence of any signs of arteriosclerosis or of degeneration of the myocardium. They may be regarded as cardiac disorder of duplex causation, being partly dependent on the disease of the genital organs, which gives rise to a number of local afferent stimuli, and partly dependent on mental influences which have a depressant, paralyzing influence on the cardiac nerves; it is possible also that spasmodic contraction of the walls of the coronary arteries or of the myocardium itself is induced as a reflex effect of the local disorder of the reproductive organs.

With regard to uterine myoma as the exciting cause of cardiac degeneration, very numerous observations and experiments have recently been made, and the reality of the occurrence is no longer open to dispute, even if its significance is subject to various interpretations, whilst no satisfactory explanation has yet been forthcoming.

L. Landau writes concerning the disturbances induced in the circulatory apparatus by the growth of myomata in the uterus: “The formation of varices, the occurrence of thrombosis, and, finally, the onset of degeneration of the myocardium, are very common. Should the last-named process result—and it is truly alarming to observe the frequency with which cardiac affections are associated with uterine myomata,—then, by a vicious circle, the uterine hæmorrhages become continually more profuse, in consequence of increasing passive hyperæmia dependent upon diminishing power of the cardiac pump. Venous congestion in the province of the inferior vena cava results in ascites, and sometimes in general œdema; and even in cases in which no increase of the uterine hæmorrhages is observed, the patient may succumb in consequence of secondary disease of the heart. * * * In the great majority of cases, the myoma and the uterine hæmorrhages that result from its growth are the primary cause of the morbus cordis. Naturally in cases which come under observation only when both uterine and cardiac disease are already present, it is difficult to determine with certainty the true causal connection. When, however, a number of patients suffering from uterine myomata are observed, in whom at first the heart was found to be healthy, and subsequently to have become affected; and when, on the other hand, we see patients affected with myoma uteri in whom operation is undertaken notwithstanding the existence of cardiac disease, and in whom, after the 241operation has been successfully performed, the cardiac murmurs disappear as well also as the other signs of heart disease, when dilatation can no longer be detected, when the pulse-frequency declines to normal, whilst a previously feeble and compressible pulse gains in tension and power—then it is impossible to doubt that the heart disease was secondary, and was etiologically dependent upon the primary myoma and the uterine hæmorrhages.”

Lehmann and P. Strassmann examined the material of the Charité-Policlinik at Berlin in order to throw light on the relation between uterine myomata and diseases of the heart, a connection already proved to exist alike by recent pathologico-anatomical researches, by clinical experience of the results of operations (death from shock), and, finally, by the subjective troubles of the patients (palpitation, venous congestion, giddiness, and syncope). Examining 71 women suffering from myoma uteri, Lehmann and Strassmann found in 29 (41%) that some abnormality existed in the cardio-vascular system, such abnormalities being extremely variable in character, as for instance: hypertrophy or dilatation of the heart, irregularity of the cardiac action, passive hyperaemias, œdema, albuminuria, angina pectoris, and cardiac asthma. The next point was to determine the mutual relations between the heart disease and the development of the uterine myoma. Hitherto it has been assumed that the latter is the primary disease, and such a sequence is certainly the commoner, more especially in cases in which hæmorrhage has been profuse, with consecutive anæmia and fatty degeneration of the heart. In these cases, a certain time after the commencement of the severe hæmorrhages, cardiac troubles make their appearance; such troubles are beyond question secondary, and they disappear as soon as the hæmorrhage has been controlled. In other patients, however, we obtain a history of the appearance of cardiac disorder at a date prior to that when any symptoms occurred indicating the growth of a myoma; in these cases, therefore, the heart disease has developed independently of the uterine disease, and has run a parallel course to the latter; perhaps, indeed, by leading to venous congestion or to rapid changes in blood-pressure, the heart disease may have favored the growth of the commencing or fully developed tumor. In some of the patients, operative measures were followed by rapid recovery from the cardiac disorder (cases of simple anæmia); in a second group of cases, however, the heart disease was uninfluenced by operation (cases of irreparable anæmia, and cases of heart disease independent of the myomata); and, finally, a considerable number of patients remained, constituting a third group, in whom, notwithstanding the removal of the tumor by operation, the heart disease continued to grow worse (cases of progressive heart disease independent of the myomata, especially cases of arteriosclerosis).

242Among 120 women of ages between 17 and 48, in whom I found very various functional disorders of or pathological changes in the genital organs, and in whom I made a particular investigation concerning the presence or absence of heart disease and examined the heart carefully, I was able to detect the presence of cardiac troubles in 38 instances. Thus, heart trouble was found to exist in 32.7 per cent. of women suffering from disease of the reproductive organs.

In these 38 persons suffering from cardiac disorder, I found:

Nervous Tachycardia in 21 instances, that is, in about 55.2 per cent. of the cases.

Hypertrophy of the Heart in 4 instances, that is, in about 10.4 per cent. of the cases.

Pseudo-Angina Pectoris in 3 instances, that is, in about 7.8 per cent. of the cases.

Asthenia Cordis in 7 instances, that is, in about 18.4 per cent. of the cases.

Mitral Incompetence in 1 instance, that is, in about 2.6 per cent. of the cases.

Fatty Heart in 2 instances, that is, in about 5.2 per cent. of the cases.

As regards the varieties of functional and organic disease of the genitals met with in the 120 cases, and the number of instances complicated with heart trouble in each variety, I found:

Chronic Metritis in 32 patients, complicated with cardiac disorder in 13 instances.

Chronic Oöphoritis in 10 patients, complicated with cardiac disorder in 4 instances.

Parametric Exudations in 14 patients, complicated with cardiac disorder in 6 instances.

Chronic Endometritis in 16 patients, complicated with cardiac disorder in 2 instances.

Flexions and Versions of the Uterus in 26 patients, complicated with cardiac disorder in 9 instances.

Stenosis of the Cervix in 6 patients, complicated with cardiac disorder in 0 instances.

Tumors of the Uterus and its Annexa in 8 patients, complicated with cardiac disorder in 4 instances.

Infantile Uterus in 3 patients, complicated with cardiac disorder in 0 instances.

Colpitis (Vaginitis) in 5 patients, complicated with cardiac disorder in 0 instances.

From these figures we obtain the following percentages, showing the frequency with which heart trouble occurred as a complication of the respective diseases of the genital organs:

In Chronic Metritis, cardiac disorder was found in 40.6 per cent. of the cases.

In Chronic Oöphoritis, cardiac disorder was found in 40 per cent. of the cases.

In Parametric Exudations, cardiac disorder was found in 42.8 per cent. of the cases.

In Chronic Endometritis, cardiac disorder was found in 12.5 per cent. of the cases.

In Versions and Flexions of the Uterus, cardiac disorder was found in 34.6 per cent. of the cases.

In Tumors of the Uterus and its Annexa, cardiac disorder was found in 50 per cent. of the cases.

243To summarize the result of my observations regarding the cardiac disorders secondary to diseases of the female genital organs:

1. Tachycardial paroxysms in cases of amenorrhœa were premenstrual in rhythm, the paroxysms occurred, that is to say, some days before the due date of the suppressed flow.

2. In cases of dysmenorrhœa, I observed heart trouble with severe dyspnœa and feelings of anxiety, also in some cases symptoms of cardiac asthenia; these symptoms were perhaps dependent upon acute dilatation of the heart. The heart trouble associated with profuse menorrhagia exhibited similar characters.

3. Attacks of pseudo-angina pectoris occurred in women in whom local treatment for disease of the genital organs had been carried out for a long time, and in cases in which operative measures were in contemplation.

4. Paroxysms of tachycardia and cardiac distress were observed in connexion with displacements of the uterus, and especially in cases of retroflexion; also in association with oöphoritis and with parametric exudations.

5. Cases of degeneration of the myocardium, sometimes running a rapidly fatal course, were found to be consecutive to tumors of the uterus and its annexa, especially to myomata of the uterus.

Nervous Diseases Secondary to Diseases of the Genital Organs.

In earlier chapters of this work we have frequently referred to the reflex influence exercised upon the nervous system in general, alike by the normal functions and the pathological states of the female genital organs. We must now briefly explain the more intimate connection between nervous diseases and diseases of the genital organs, the causal dependence of local nervous disturbances and of general neuroses upon diseases of the reproductive organs.

The origination of a local nervous disease by a primary disease of the genital organs is dependent upon a simple mechanical process, which is explained by Windscheid in the following terms: “In this connection, the two principal mechanical factors are pressure and traction. Pressure may affect individual nerves or an entire nerve plexus, and may be exercised by a tumour, an exudation or a misplaced organ (Hegar); further causes of pressure are furnished by inflammatory nodules, by connective tissue hyperplasias, and, according to Freund, by contractile processes in the organs themselves and in the ligaments. Traction on the nerves results from displacements, as from prolapse of the uterus or the ovaries, and, according to Hegar, from traction on the pedicle of small tumours. A combination of pressure and traction occurs especially in affections 244of the abdominal attachments of the uterus, also where there is scarring of the neck of the uterus and of the vaginal fornices. Great importance, also, in relation to the production of local nervous disorders, must be attributed to the laying bare of nerve-terminals by catarrhal and other inflammatory processes. Abnormal mobility of the genital organs as a partial manifestation of enteroptosis must also be mentioned as a cause of mechanical stimulation of the nerves. Finally, in this connection, must be considered the paresis of the abdominal walls that follows frequent and severe confinements.”

The symptoms of the local nervous disorders to which these mechanical stimuli may give rise, are very various, but may, according to Hegar, be comprised under the general designation of lumbar enlargement symptoms (Lendenmarksymptome), inasmuch as the local stimulation of the intrapelvic nerves, affects the nerve-centres of the lumbar enlargement of the spinal cord. Among the symptoms, severe pains are prominent, either continuous or intermittent, within the pelvis and in the sacral region, accompanied by a sense of weight and pressure in the abdomen, or by dragging pain in the region of the hips, in the gluteal region, in the outer and back parts of the thighs, in the inner surface of the leg, in the calf, in the dorsum of the foot, the sole of the foot, and the heel; or by coccydynia (pain over the coccyx and the lower extremity of the sacrum), or hyperæsthesia and anæsthesia of the external genitals in the region of the vaginal orifice, or, finally, by disorder of the processes of micturition and defæcation. In some of these cases, the weakness of the lower extremities is so severe that a paralytic condition is simulated. Actual paralysis may however occur, in consequence of the extension of peritoneal inflammation to the nerve-plexuses of the pelvis, leading to the occurrence of neuritis.

The development of a general neurosis in consequence of disease of the genital organs, either as a complication dependent upon the nervous stimulation excited by the primary disease, or as a reflex consequence of this disease, implies, as Windscheid strongly maintains, the existence prior to the occurrence of the disease of the genital organs of diminished power of resistance on the part of the nervous system. This neuropathic constitution may be the result of inheritance, and, according to Engelhardt, was so in 40 per cent. of his cases of women suffering from nervous disease secondary to the disease of the genital organs; or it may be acquired. Given this weakness of the nervous system, a local disturbance of the genital organs may act as the ultimate exciting cause of the onset of the neurosis in one of two different ways (Windscheid). “1. The stimulus which the nerves of the affected genital organ (or those 245of some adjacent area, affected by direct extension) have received, proceeds upward from segment to segment of the spinal cord, and ultimately passes to the highest centres. 2. Or, on the other hand, the local nerves are not directly involved in the morbid process in the genital organs, but this latter acts as a source of reflex disturbance, a disturbance which must also pass through nervous channels. To this latter class of cases belong the instances, comparatively so frequent, in which, for example, a trifling retroflexion of the uterus must be regarded as the exciting cause of the neurosis.” The commonest neurosis of those that may be excited by local disease of the genital organs is undoubtedly hysteria, next in frequency come chorea and epileptic seizures.

Schauta draws attention to the important fact that hereditarily predisposed, neurasthenic individuals bear very badly repeated gynecological examinations and long-continued local treatment, inasmuch as, in such persons, a notable increase in the severity of the nervous affection may result, and even the outbreak of actual mental disorder; and he further points out that in hereditarily predisposed individuals, psychoses not infrequently occur in consequence of the performance of gynecological operations.

The processes of pregnancy make a deep impression on woman’s entire nervous system, and more especially on her mental functions. This is especially noticeable in the case of primiparæ. The fact is easily understood, for a woman is filled with expectation and anxiety concerning the unknown event, the complete revolution in her organization, the powerful impressions on her physical ego, the formation of a new being within her womb. How many joyful hopes, how many distressing fears, are connected with that which is about to take place, with the act of creation within her bosom; what changeful glimpses into the future, on the one hand the gladness, on the other the terror, of motherhood; often, also, the anxious doubts as to the probable sex of the newcomer. Consider, too, the stormy sensations experienced by a woman who, unmarried, has become pregnant contrary to her desires and expectations, especially one in a poverty-stricken condition—consider the agonizing thoughts in such a case regarding the consequences of giving birth to a child. It is only to be expected that in pregnant women in general there will almost always be increased irritability of the nervous system combined with a tendency to the rapid variation of emotional states. Neumann found, in almost all the pregnant women he examined in respect to the point, that there was an increase of the knee-jerks, as a manifestation of the general increase of nervous irritability. Nor does this change depend upon mental influences exclusively; there are other factors, such as the reflex 246processes aroused by the enlargement of the uterus, and also the changes in the composition of the blood which occur during pregnancy, and cannot fail to have an influence on the nutrition of the brain. Finally, also, the deposit of carbonate of lime on the inner surfaces of the cranial bones (the parietal and frontal bones) which occurs during pregnancy, may be regarded as having some casual connection with the changes in the nervous system; and, again many authors assume that the cerebral circulation is influenced by the formation of the placental circulation.

The pathological consequences of pregnancy, as far as they affect the nervous system, take the form of neuralgia and of peripheral neuritis of various nerves, of chorea, of disturbances of the sense organs, and of actual psychoses.

Peripheral neuritis in pregnant women affects chiefly the lower extremities, but has been observed in the arms also; it is characterized by muscular wasting with reaction of degeneration, by trophic disturbances, and by disorders of sensation. A cure may ensue even during the pregnancy, but in other cases the illness persists until after parturition and on into the puerperium. To the same cause Windscheid assigns the paræsthesias of pregnancy, burning, prickling, and numb sensations of the finger-tips, less commonly of the toe-tips; these sensations are continuous, not paroxysmal, and cause very great suffering.

Pregnancy favors the occurrence of chorea, a circumstance explicable by the increased irritability of certain nerve centres characteristic of the pregnant woman. The chorea of pregnancy occurs for the most part in primiparæ, it is commoner in young than in older pregnant women, and appears especially in the early months of pregnancy. In the majority of cases the disease undergoes spontaneous cure before the end of the pregnancy, but cases with a fatal termination have been observed.

On the other hand, a curative influence in previously subsisting hysteria has been assigned to pregnancy. This in fact only occurs in cases in which the hysterical manifestations have been evoked by influences which are counteracted or removed by the occurrence of pregnancy, such, for instance, as intense longing to bear a child, dissatisfaction with the existing circumstances of married life, etc. Conversely, it is by no means unusual to observe that, in patients who have previously suffered from hysteria, the attacks become more frequent during pregnancy, and that other nervous disturbances associated with the hysteria become more prominent; hysterical paralysis, even, may appear. Very variable also is the influence of pregnancy in epileptics. Most commonly, indeed, a certain quiescence sets in, the attacks becoming less frequent and less severe; 247but the reverse of this is at times observed. In the domain of the sense organs we observe amblyopia and hemianopia, deafness, and tinnitus aurium, and disorders of taste; all these appear as pure nervous disturbances without known anatomical basis (Windscheid).

Finally, among neuroses, tetany may be mentioned. In women, this disease occurs almost exclusively during pregnancy and the puerperal state, in the form of paroxysmal spasm, affecting chiefly the extremities, and especially the hands; the spasm is bilateral, tonic in character, and painful. The tetany of pregnancy usually runs a favourable course.

The slighter forms of mental disorder consist of perversions of taste and smell. Of actual psychoses occurring during pregnancy, the commonest forms are melancholia and mania. The former condition, which, according to Ripping, occurs in 84.4 per cent. of the cases, is usually very severe, and is characterized by a peculiar dreamy condition; it often leads to suicide, or to infanticide immediately after parturition. The psychoses of pregnancy are seen with greater frequency in the second half of pregnancy, they occur especially in primiparæ, and are also commoner in unmarried women. The prognosis is on the whole an unfavorable one; sometimes, indeed, the mental disorder terminates with the pregnancy, but in other cases it continues during the puerperium. Mental alienation occurring in the early months of pregnancy is apt to be less severe and to permit of a more favorable prognosis, than that which makes its appearance during the later months or at the end of the pregnancy.

In 32 cases of insanity of pregnancy recorded by Ripping, 8 cases occurred in the first pregnancy, 5 in the second, 6 in the third, 3 in the fourth, 4 in the fifth, 1 in the sixth, 1 in the seventh, 3 in the eighth, 1 in the tenth. Of these women

3 became affected in the 1st month^[41] of pregnancy.

4 became affected in the 2d month of pregnancy.

1 became affected in the 3d month of pregnancy.

2 became affected in the 4th month of pregnancy.

1 became affected in the 5th month of pregnancy.

0 became affected in the 6th month of pregnancy.

5 became affected in the 7th month of pregnancy.

5 became affected in the 8th month of pregnancy.

5 became affected in the 9th month of pregnancy.

6 became affected in the 10th month of pregnancy.

The neuralgias of pregnancy affect the most diverse nerve tracts, and may occur either spontaneously, without any discernible local exciting cause, or in consequence of the pressure exercised by the 248enlarging uterus. To the former class of cases belong severe trigeminal neuralgia, the familiar toothache affecting quite sound teeth at the very beginning of pregnancy, intercostal neuralgia, and paroxysms of mastodynia. The pressure neuralgias affect chiefly the domain of the great sciatic nerve, manifesting themselves by the occurrence of pain down the back of the thigh, in the calf, and on the dorsum of the foot, sometimes associated with formication and other kinds of paræsthesia.

Parturition, by its powerful effect on the emotional nature in combination with intense physical suffering, may give rise to numerous nervous disturbances. The chief of these are, neuralgia, occasioned by the pressure of the fœtal head as it passes through the pelvis of the mother, paræsthesias, convulsions, maniacal paroxysms, transitory mental alienation, cerebral hæmorrhages, and eclampsia.

The nervous disturbances dependent upon the processes of the puerperium are numerous and severe. According to Windscheid, four types of affection of the motor nerves may arise at this period. 1. Pressure-paralysis may occur in cases of generally contracted pelvis, or even in the absence of such contraction in cases of prolonged labor, from the pressure exercised by the child’s head upon the intrapelvic nerves, and above all on the great sciatic nerve; pressure-paralysis may also result from obstetric operations, and especially from forceps delivery. The symptoms of pressure-paralysis consist chiefly of paralysis of the extensors of the feet and the toes; sensory symptoms are usually wanting. 2. Inflammatory infective paralyses, due to the extension to adjacent nerves of puerperal inflammation of the pelvic connective tissue. 3. Acute multiple neuritis, occurring either during the latter half of pregnancy or a few days after delivery, and affecting not only the nerves of the lower extremities, but those of remote regions, even the cranial nerves. 4. The rare puerperal hemiplegia due to cerebral hæmorrhage, occurring usually at the time the patient leaves her bed after delivery; puerperal hemiplegia may also arise from embolism consecutive to endocarditis, which may itself have originated before the termination of the pregnancy.

Other puerperal diseases of the nervous system requiring mention are, on the one hand, tetany, occurring during lactation, and permitting of a favorable prognosis, and on the other, the infective puerperal tetanus, the prognosis of which is exceedingly unfavorable. Finally, the puerperal state has to be considered as a factor in determining the onset of psychoses.

The puerperal psychoses are for the most part dependent upon the great loss of blood occurring during delivery, leading to anæmia and increased irritability of the brain, in association also with the 249circulatory disturbances that arise in the central nervous organs in consequence of the sudden emptying of the abdomen by the act of childbirth; but additional causes of mental disorders are to be found in the changes in the composition of the blood that occur during pregnancy, and the influence of these changes upon the nutrition of the brain. Inherited predisposition plays its usual part in these cases; and accessory factors in producing mental disturbance during the puerperal state are to be found in puerperal infection, eclampsia, osteomalacia, and emotional shock.

Thus, for example, among 49 cases of puerperal psychoses, Hansen found that in 42 instances there was puerperal infection; and among 200 cases of puerperal eclampsia, Olshausen found 11 patients suffering from mental disorder. The principal forms of insanity occurring at the puerperium are mania and melancholia, next in frequency come monomania (Ger. Verrücktheit), dementia (Ger. Blödsinn), alternating or circular insanity (folie circulaire), hallucinatory paranoia (chronic delusional insanity with hallucinations), and hysterical mental disorder.

According to Windscheid, the commonest cases are those which are purely puerperal, the rarest those in which the insanity of pregnancy continues during the puerperal state; the age at which puerperal psychoses most commonly occur varies between 31 and 35 years, the average age being 29.1; multiparæ are more often affected than primiparæ; the outbreak of mental disorder most commonly occurs within a week after the birth of the child; there is nothing specific about the various forms of puerperal insanity, which are identical with the respective varieties owning another etiology. According to this author, before an attack of puerperal mania, prodromal symptoms usually occur, such as headache, dizziness (Ger. Augenflimmern), feelings of anxiety, insomnia, followed by various congestive symptoms, and either by great restlessness or by great apathy, and very often by indifference to the infant; to these symptoms succeeds the period of motor excitability, characterized by great bodily restlessness and by continued talkativeness; the culmination takes the form of a maniacal outburst, in which infanticide even may occur; the delirium runs mostly in erotic and religious channels. Puerperal melancholia also exhibits the usual clinical picture of this form of mental disorder; after prodromal headache, stupor sets in, often associated with attacks of anxiety and with hallucinations of sense, and always characterized by great loss of appetite and by a suicidal tendency.

In relation to the puerperal psychoses, it appears that the first menstruation after the birth of the child has, like the very first appearance of the menstrual flow during the menarche, a tendency 250to favor the onset of mental disorder. According to Marcé, this first post-puerperal menstruation has a very definite significance in the causation of psychoses. Among forty-four cases of puerperal psychoses, there were eleven instances in which the mental disorder made its appearance six weeks after childbirth, exactly at the moment, that is to say, in which, had the mothers not given suck to their children, menstruation ought to have reappeared. In those who did not nurse their infants, and in whom menstruation recommenced at the due date, the psychosis usually began on the first day of menstruation, less often on the fourth or fifth day. In some instances the psychosis appeared at the time at which menstruation might have been expected to occur, but when the flow was still in abeyance. And in some women who suckled their children for a time and then weaned them, the psychosis made its appearance at the time of the first recurrence of menstruation.

Among diseases of the sense-organs occurring during the menacme, ocular lesions are by no means rare as sequels of pathological changes in the genital organs. Thus, in cases of displacements of the uterus, especially prolapse, retroflexion, and retroversion, we sometimes see retinal hyperæsthesia and reflex amblyopia, photophobia and lachrymation, and accommodative or muscular asthenopia. Inflammation of the pelvic connective tissue, perimetritic and parametritic exudations, and especially parametritis atrophicans, may give rise to functional disorders of the eye, reflex hyperæmia of the trigeminal and optic nerves, various painful sensations, and photophobia. Severe metrorrhagia may also cause disturbances of vision, either by inducing local anæmia and consequent functional failure of the nervous apparatus, or by leading to serious infiltration of the optic nerve which manifests itself also in the retina in the form of a transudation. In cases alike of congenital and of acquired atrophy of the uterus, and frequently, therefore, in sterile women, optic nerve atrophy may occur.

Competence for Marriage of Women Suffering from Disease.

In this section we must consider the competence for marriage of women suffering from heart disease, of those suffering from hereditary tendency to mental disorders and neurasthenic states, and, finally, of those affected with tuberculosis.

Every doctor is confronted during the practice of his profession by the problem whether a young woman known to suffer from heart disease is justified in entering upon marriage and in exposing herself to the dangers entailed on her diseased heart by copulation, pregnancy, parturition, and the puerperium. The solution of this problem is as important as it is difficult. On the one hand, it determines 251the whole future course of a human life which is still ascending the upward path of its vital career, and a negative decision often annuls in a moment the young woman’s ideals and hopes; on the other hand, an affirmative decision involves the responsibility for the consequences of marriage, often grave in these cases.

The consequences are in fact apt to be very serious indeed. The normal act of intercourse, in a young and sensitive woman, has already an exciting influence on the nerve apparatus by which the movements of the heart are controlled. The frequency of the heart’s action is greatly increased, the cardiac impulse becomes much stronger, there is marked pulsation of the peripheral arteries, the conjunctiva is injected, the respiration more frequent. These manifestations, which normally are quite transient, attain a greater intensity and exhibit a longer duration in persons affected with heart disease. In some instances, violent tachycardial paroxysms occur, with considerable dyspnœa, pains in the cardiac region, headache, and even syncopal attacks.

Pregnancy, in consequence of the extensive changes undergone not only by the reproductive apparatus but also by the general system, and further in consequence of the vital needs of the developing embryo, involves extensive claims upon the cardiac activity. It is easy to understand that the diseased heart must be taxed more severely than the healthy heart by the extension of existing vascular areas, the addition of new vascular areas, and the increase in the quantity of the blood, during pregnancy; and it is not surprising if the overtaxed organ threatens sometimes to give way under the strain. Thus, during pregnancy in women affected with morbus cordis, we observe numerous troubles in the way of disturbances of cardiac activity and passive congestion of various organs, culminating at times in abortion.

Parturition and the puerperium, moreover, bring several factors into play which tend to affect unfavorably even a heart that is quite normal; and in cases in which there is disease either of the heart or of the great vessels, these factors may lead to the occurrence of most alarming symptoms. In this connection we may refer to endocarditis, to fatty degeneration of the myocardium, and to the rupture of atheromatous arteries.

From the time of Galen onwards all medical writers have agreed that the heart is unfavorably influenced by pregnancy and its consequences—but from this incontestable proposition to deduce the general conclusion that young women affected with heart disease must be forbidden to marry is in my opinion too great a jump, and altogether too sweeping a statement. The apophthegm of Peters, an 252author to whom we are certainly indebted for some of our knowledge of the accidents gravido-cardiaques, that in the case of women suffering from morbus cordis the rule must be enforced, fille pas de mariage, femme pas de grossesse, mère pas d’allaitement, has a fine air of apodictic brevity, but is entirely devoid of justification. No such rigid prohibition is advanced by recent writers on heart disease, such as Huchard, von Leyden, and Rosenbach; not, at least, without qualifications.

The question as to the permissibility of marriage to girls and women affected with heart disease cannot, in fact, be answered by any general proposition; and each case demands separate inquiry and a careful balancing of individual considerations. I have known cases in which the marriage of young girls suffering from morbus cordis was equivalent to a sentence of death, the execution of which was delayed for a few months only. On the other hand, I have known many women belonging to the upper classes and suffering from cardiac defects to pass through numerous pregnancies and to give birth to a number of children with no more than trifling disturbances of compensation. I am acquainted with a lady who when a young girl was urgently advised against marriage, on account of extensive aortic valvular incompetency, by two celebrated physicians. The advice was disregarded, and this lady is now the mother of four children, the eldest of whom is twenty-two years of age, and her general condition is in no way worse than it was before her marriage. The dangers of marriage in women suffering from morbus cordis are in my opinion generally overrated.

The degree to which a woman affected with heart disease will be injured by married life, will depend on the nature of the cardiac affection, on the time it has already existed, on the adequacy of compensation or the intensity of existing disturbances of compensation, on the general state of nutrition of the patient, on the more or less favorable social position, and on the manner in which sexual intercourse is regulated.

My own opinions in respect of this question may be summed up as follows: A woman who has comparatively recently (within a few years) acquired a valvular defect, and in whom the disease has run such a course that, in consequence of dilatation of certain chambers of the heart and of hypertrophy of those segments of the myocardium on which increased work has been thrown, and thus in consequence of adaptation of the cardio-vascular apparatus to the new conditions, the circulation and distribution of the blood take place in a manner closely resembling that in which these functions are effected in a normal, healthy individual—in a word, a woman in whom the valvular disease appears to be adequately compensated,—if, 253in addition, the patient is well nourished, if the hæmatopoietic function has not undergone any notable disturbance, if the muscular system is powerful and the nervous system possesses sufficient power of resistance—then marriage may be permitted without hesitation. In the case of such a girl or woman, we can confidently assume that the adequate compensation of the valvular disease will enable the heart to meet with success the claims made upon its reserve energies by sexual intercourse, by pregnancy, and by parturition, and that these processes will not involve any excessive danger to life.

A woman with valvular heart disease, even when that disease is well compensated, will indeed during pregnancy and still more during parturition and the early days of the puerperium, be liable to suffer from various manifestations of cardiac disorder. The action of her heart will be subject to paroxysmal increase in frequency and force, sometimes also there may be transient attacks of cardiac asthenia; at the same time the breathing will become more frequent and deeper, and occasionally, even, there may be severe dyspnœa. Perhaps also symptoms of venous congestion may manifest themselves, digestive disturbances, sense of pressure in the head, swelling of the feet, œdema of the abdominal wall, even slight albuminuria. Just after childbirth, moreover, an abnormally intense depression of the circulation with infrequency of the heart’s action will be liable to ensue. In the great majority of cases, however, in which the conditions detailed above are fulfilled, the disturbances of compensation occasioned by pregnancy and the puerperal state will not seriously threaten life; and as soon as the puerperal period has been safely passed through, the heart will again be competent for its duties and will do its work as well as before.

These statements apply, not only to cases of well-compensated valvular disease, especially mitral insufficiency, mitral stenosis, and aortic insufficiency, but also to cases in which the heart has made a good recovery after an attack of pericarditis, and to cases of moderately extensive disease of the myocardium consequent on acute articular rheumatism or the acute infections.

As indispensable conditions for such a favorable prognosis, we naturally assume that the pregnant woman is in a position to command the extreme bodily care that in her condition is doubly needful, that she is able to avoid all severe physical exertion, and that she will be subjected to continuous medical supervision in respect of the adoption of suitable dietetic and hygienic measures.

Such a favorable prospect as regards marriage in cases of well-compensated heart disease will, however, be clouded in the case of women who are either very anæmic or predisposed to nervous disorders; nor is the prognosis favorable as regards women in whom the heart disease is either congenital, or acquired in early youth, or 254as regards women contemplating marriage when already well up in years.

For in very anæmic women, even when the heart is quite sound, frequently recurring attacks of tachycardia often occur during pregnancy, in the absence of any obvious exciting cause; œdema of the lower extremities, and the formation of extensive varices, are also common. Increased nervous reflex irritability has also an unfavorable influence upon cardiac innervation. In cases, again, in which the heart disease is of long standing, the functional capacity of the heart is so notably depressed that the organ is likely to prove incompetent to meet the increased demands made upon it by the processes of pregnancy. Finally, in elderly women, superadded to the valvular defects, we have the dangers dependent upon the already beginning arteriosclerotic changes in the bloodvessels. In all such cases, therefore, it will be the duty of the physician to advise his patient not to marry; and in any case to impress upon her mind the extreme probability, amounting almost to certainty, of serious aggravation of the heart disease by marriage, with permanent impairment of the general health.

In cases of valvular disease accompanied by serious disturbances of compensation, and in cases of notable degeneration of the myocardium in which pronounced symptoms of cardiac muscular insufficiency have made their appearance, marriage must be absolutely forbidden, as directly imperilling life. When even moderate bodily exertion suffices to cause palpitation, increased frequency of the pulse, and shortness of breath, when extensive œdema of the lower extremities is present and fails to disappear even after the patient has been strictly confined to bed, when the pulse very readily becomes irregular both in rhythm and force, whilst the urine is often scanty and contains variable quantities of albumin, when conditions of cardiac asthenia readily arise, characterized by a small, irregular pulse, coldness of the extremities, cyanotic tint, nausea, respiratory need,^[42] and syncopal attacks—in all such cases, whether the symptoms just described are dependent upon valvular defects, upon pathological changes in the arteries, or upon diseases of the myocardium, in all alike the occurrence of pregnancy is a true disaster, which in the vast majority of cases causes a great and enduring aggravation of the disease, and frequently enough costs the patient her life.

Even in such cases as were previously described, in which, the heart disease not being severe, the patient was told that marriage was permissible, it is the duty of the physician to lay down certain rigid rules regarding sexual activity.

Women suffering from heart disease should not have sexual intercourse 255frequently, because, if the peripheral nervous stimulation of the genital organs is excessive in consequence of too frequent acts of coitus, cardiac activity is likely to be influenced powerfully in a reflex manner, leading to the occurrence of attacks of cardiac asthenia. Again, sexual intercourse must always be effected in such a manner that the act attains its physiological conclusion, and that in the woman as well as in the man the orgasm has its normal outcome, that is to say that at the conclusion of the act the woman’s cervical glands are evacuated with the accompaniment of the sense of ejaculation. The congressus interruptus, which precisely in these cases in which the wife suffers from heart disease is so frequently practiced by the husband with a view to preventing conception, must be strictly forbidden, since this mode of intercourse tends to give rise to various forms of reflex cardiac disturbance, most commonly to paroxysms in which the cardiac action becomes unduly frequent, in association with diminution of vascular tone, vasomotor disturbances, and states of mental depression; and where organic heart disease already exists, these reflex functional disturbances involve various dangers.

The physician is further justified in advising that a woman with organic heart disease should not give birth to more than one or two children. This advice is the more needful for the reason that with each successive pregnancy the functional capacity of the woman’s diseased heart diminishes according to a geometrical ratio, and to a corresponding degree the danger to life increases. These are cases in which in my opinion it is the physician’s duty to concern himself with the subject—in general so equivocal—of the use of preventive measures, and, having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with moral earnestness, to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently.

To enable us to answer the question whether, in the case of neurasthenic and hysterical young women, and in those hereditarily predisposed to the occurrence of mental disorders, the physician shall advise for or against marriage, attention must in the first instance be directed to the established facts relating to the favorable or unfavorable influence, as the case may be, of sexual intercourse and its consequences (pregnancy and childbirth) upon existing nervous disorders and upon the predisposition to their occurrence.

256Without regarding as fully justified the opinion that in the female sex sexual abstinence has in all circumstances an unfavorable influence upon the nervous system or even that such abstinence is to be regarded as the principal cause of nervous and hysterical troubles, we must consider it fully proved that in a number of the commonest varieties of nervous disease occurring in neurasthenically predisposed subjects, such as neurasthenia, hysteria and neurosis of anxiety^[43], the lack of sexual satisfaction aggravates these troubles, whilst suitably regulated sexual intercourse has an actively beneficial effect. Not, indeed, that it is an infallible means, but none the less the effects are often striking, as I have frequently had occasion to observe, both in young women so affected entering upon marriage for the first time, and also in young widows who have remarried. Especially is this true of women in whom the sexual impulse is exceedingly powerful, and even pathologically increased to the extent of marked sexual hyperæsthesia; likewise also in women whose social circumstances and manner of life induce increased sexual appetite. Be it understood, I refer here to regular and moderate sexual intercourse, and not to sexual excesses, which latter, by inducing nervous exhaustion, may have a distinctly deleterious effect. In many cases, however, we observe in women suffering from sexual neurasthenia, that sexual intercourse, even when practiced at long intervals, gives rise to nervous prostration with deep emotional depression and long-lasting aggravation of the existing nervous disorder. This statement applies with especial force to very hysterical epileptic girls with hereditary predisposition to mental disorder.

From the fact that among persons hereditarily predisposed to mental disorder, the unmarried are on the average more often affected with insanity than the married, the inference has been drawn that marriage may be recommended to such persons as a measure likely to counteract their hereditary tendency to insanity. The argument, however, lacks validity, more especially as regards women; among whom, moreover, from the age of sixteen to the age of thirty, insanity is proportionately more prevalent among the married, though above the age of thirty it is more prevalent among the unmarried.

In the great majority of neurasthenic women, normal sexual intercourse, practiced in moderation, has, according to Löwenfeld, no deleterious effect; often, indeed, as a consequence of unaccustomed abstinence, an aggravation of existing nervous troubles may be observed. But, as this author maintains, nervous exhaustion may result in the complete disappearance of the orgasm during sexual intercourse, or in great difficulty in its production; this circumstance suffices for the 257most part to explain the fact that in women suffering from great depression of the nervous functions, the fulfilment of their sexual duties has sometimes an unfavorable influence on their general condition. As regards hysteria, it cannot be denied, that in many hysterical women marriage results in a favorable change in the general condition; we must, however, be careful not to overrate the significance of such observations. As a rule all that actually takes place is a diminution in the intensity or even a disappearance of certain morbid manifestations previously present, without, however, an eradication of the hysterical temperament.

In epileptic young women, the first experience of sexual intercourse may precipitate a fit. Cases are indeed on record in which, in hereditarily predisposed girls, the first coitus was the exciting cause of the first epileptic fit, the fits recurring every time sexual intercourse was repeated.

It is a comparatively frequent occurrence in psychopathically predisposed girls for severe mental disturbances to make their appearance during the honeymoon, after the first experience of sexual intercourse; when this occurs, it is doubtless to be accounted for by the combined influence upon the mind of all the changes in the circumstances of life which have resulted from the marriage. In the case of two newly married women, one of whom had well-marked hereditary predisposition, whilst in the other there was no known family history of mental disorder, Löwenfeld observed shortly after marriage the onset of severe melancholia, with refusal of food. The delicate, nervous temperament of these two women, on the one hand, and, on the other, possibly, a somewhat too eager and passionate attitude on the part of their respective husbands, led their first experience of sexual intercourse to result in a nervous impression of the nature of shock, which their nervous system was too weak to resist.

Frequently recurring pregnancy and childbirth may, according to Krönig, act as the predisposing cause in the production of neurasthenia. In regard to hysteria also we must admit that the onset of some disease of the organs of generation frequently leads previously latent hysteria to manifest itself openly, and further we have to recognize that diseases of the reproductive system often give the clinical picture of hysteria a quite distinctive coloration; the physiological course of the functions of the generative organs is also competent to produce both of these effects. Krönig, however, rejects the view that the lack of sexual intercourse has an unfavorable influence upon the nervous system in women, and gives rise to hysterical and neurasthenic disorders. The favorable influence which marriage is often observed to exercise upon the course of nervous disorders is explicable with reference to psychical considerations 258of a very different nature. Sexual abuses, masturbation, and the use of preventive measures, give rise in women far less often than in men to neurasthenic and hysterical conditions.

Féré asserts that in certain neurasthenic patients sexual intercourse induces a general blunting of the senses, and especially of hearing and sight. Actual amaurosis of short duration may even be observed; also cutaneous anæsthesias, paralytic conditions of the extremities taking the form either of hemiplegia or paraplegia, convulsive attacks, and somnolent paroxysms.

Delasiauve observed that epileptic patients, who during residence in an asylum had remained almost entirely free from fits, after returning home and resuming sexual intercourse, even in strict moderation, suffered from a recrudescence of the convulsive seizures; when intercourse was excessive, the relapse was naturally even more severe.

In two instances, in women who in a single night had practiced intercourse to very great excess, Hammond observed paralysis of both legs to ensue; he saw also in numerous cases spinal irritation and other nervous disturbances as a consequence of sexual excesses.

Von Krafft-Ebing points out, with reference to the prophylactic influence of marriage in respect of mental disorder, that in men early marriage diminishes the danger of the occurrence of such disorder, whereas in women marriage is undesirable before the attainment of complete physical maturity.

With regard to marriage in the case of persons suffering from nervous diseases, Ribbing lays down the rule that when such diseases have been severe and have occurred in numerous members of a family, whilst a few only in the family have remained healthy, when, moreover, the illness has been accustomed to make its first appearance only after the attainment of maturity, no indications of its onset being noticeable in childhood or youth—one belonging to a family thus afflicted should be advised not to marry. Where, however, the hereditary tendency is to a disease likely to manifest itself in childhood or youth, a member of such a family who has been fortunate enough to pass through the years of development without exhibiting any pronounced disturbance of the nervous system, may be permitted to marry if certain precautions are observed. A woman with a tendency to alcoholism should in no circumstances be allowed to marry. In the cases, fortunately rare, in which the drink-craving exists in women, marriage is even more undesirable than it is in the case of men similarly afflicted, for the female drunkard is in a position in which she can mishandle and neglect her children throughout the entire day; and, moreover, this affection appears to be even more obstinately incurable in women than it is in men.

259Löwenfeld very rightly insists that in deciding on the advisability of marriage in the case of neurasthenic and hysterical girls the anticipated influence of sexual intercourse must not be the sole determinant. “Regulated sexual intercourse, such as is rendered possible by marriage, has often a favorable influence on previously existing states of nervous weakness. But we should go too far if we were to attribute the beneficial effect of married life on such conditions solely to sexual intercourse. This latter is but one factor among several, the others being no less important. These others are: The pleasures of an orderly domestic activity; the withdrawal of the patient’s attention from her own condition, partly by domestic duties and difficulties, and partly by the novelty of marital companionship; the gratification, especially strong in women, at having obtained a support in life; and, finally, the joyful expectation of motherhood. These factors, however, are not present in every marriage. When their presence cannot reasonably be anticipated, when, in consequence of insufficient means, the marriage is likely to entail increasing troubles, or when, owing to the want of suitability of temperament, annoyances and quarrels are likely to occur, we must throw the weight of our advice into the scale against the proposed marriage, since the advantages of regulated sexual intercourse are not likely to outweigh the disadvantages just detailed. Even when means are ample and the characters of the couple contemplating marriage are unquestionably harmonious, we must nevertheless (temporarily, at any rate) advise against marriage, we must, that is to say, advise the postponement of marriage, if the bride is suffering from severe hysterical or neurasthenic states. Where, further, such neurasthenic or hysterical troubles occur in a woman with pronounced hereditary predisposition to nervous disease, we must, both for the sake of the possible progeny and on account of the uncertain influence of married life on the health of the patient, absolutely and unconditionally prohibit marriage. In cases also in which severe hereditary predisposition to mental disorder exists (especially when derived from both parents), and in addition stigmata of psychopathic degeneration are actually apparent in the patient, or she has already suffered from the development of a psychosis, we must decisively object to the patient’s marriage.”

As regards the marriage of young women suffering from tuberculosis, we must take into consideration a fact that medical experience has conclusively established, namely, that the processes of generation have an unfavorable influence upon pulmonary phthisis. Girls with an inherited predisposition to tubercular disease, sometimes first manifest the symptoms of pulmonary tuberculosis at the time of the menarche. In cases of developed tuberculosis, copulation 260and the excitement of the vascular system associated therewith have a more or less unfavorable influence—and all the more inasmuch as, in accordance with the saying omnis phthisicus salax, women affected with tuberculosis often exhibit a very lively sexual impulse, an almost insatiable sexual appetite. Sexual excesses are, moreover, very likely to lead to the occurrence of hæmoptysis.

In former days it was believed that conception and pregnancy, when occurring in women suffering from tuberculosis, had a restraining influence on the progress of the pulmonary disease, a view which found expression in the assertion of Baumes and Rosières de la Chassagne that of two women affected with tuberculosis to the same degree of severity, one who became pregnant would always outlive the other who failed to become so. Careful and sufficient observations on the part of physicians and gynecologists have, however, shown that this view was fallacious, and, on the contrary, that during pregnancy tuberculosis advances with more rapid strides, that pregnancy, and lying-in accelerate the fatal event (Grisolle, Lebert), that tuberculosis acquired shortly before pregnancy or in the course of that condition, progresses with exceptional rapidity (Larcher), and that the lying-in period is especially perilous to these patients (A. Hanau). In some cases of consumption it is the first pregnancy that is the most perilous, but in other cases a later pregnancy proves more destructive.

Ribbing goes even further, insisting that neither man nor woman affected with pulmonary consumption should marry. “If, indeed,” he writes, “consumptives desire to enter upon marriage, merely with the aim of being faithful to one another and assisting one another for the short time that remains to them, I should offer no opposition. But there must be a complete mutual understanding of the facts of the case, and an unalterable determination on the part of both to carry out the resolutions made prior to marriage, for failing this the consequences will be most disastrous. In most cases, however, the course adopted by Bulwer’s Pilgrims of the Rhine is to be preferred, the lovers contenting themselves with the condition of a betrothed pair, and in that state awaiting the approach of death—or, if exceptionally fortunate, proceeding to marriage only after restoration to health.”

It would certainly appear that in the case of girls suffering from pronounced phthisis, we are justified in advising against marriage, on account of the great danger which this state entails of a rapid advance in the pulmonary disease.

Based upon the observations of Schauta and Fellner, the latter author advances the rule that in the case of a woman suffering from disease, marriage should be forbidden only when the mortality from 261the disease in question is not less than 10 per cent. In this category we must include severe cases only of pulmonary tuberculosis; whilst cases of laryngeal tuberculosis will, according to this rule, be absolutely unfitted for marriage. Among heart-affections contra-indicating marriage, he includes mitral stenosis, other valvular affections in which there is serious disturbance of compensation, and myocarditis; he considers marriage inadmissible also in cases of chronic nephritis, and, among surgical affections, in cases of malignant tumour. In cases in which during a previous pregnancy the patient has been affected by one of the following diseases, viz., severe chorea, mental disorders, severe epilepsy, pulmonary tuberculosis which progressed much during the pregnancy, morbus cordis with considerable disturbance of compensation, severe heart trouble due to Graves’ disease—in all such cases, a repetition of pregnancy should be avoided.

Hygiene During the Menacme.

During the sexual epoch of the menacme a woman’s principal hygienic need is marriage completely satisfactory alike to body and to mind. It cannot be denied that sufficient sexual gratification, regular, of course, and free from all excess, such as is usually experienced in married life, is very advantageous to the health of a woman who has attained sexual maturity—even though we admit that the drawbacks of sexual abstinence, regarded as a cause of disease of the female genital organs and the nervous system have been as a rule greatly exaggerated.

The inability to marry always makes a deep impression on the mental life of woman, and in many cases also gives rise to burning desire and tormenting yearning of an erotic nature. The unmarried miss life’s true goal and fail to enjoy the natural exercise of their functional capacities; alike in the cultured lady and in the poor working woman who has failed to marry, the thoughts and feelings return again and again to her own condition in a self-tormenting manner.

The physical and mental disadvantages entailed by sexual gratification when obtained by an unmarried woman, one who, according to modern phraseology, “wishes to secure her natural share of the joys of love,” and who regards voluntary chastity as “a sacrifice to meaningless prejudices”—need not be more particularly described.

Free love, moreover, is the most important disseminator of gonorrhœal infection. “In any future commonwealth,” says Runge, “in which marriage is abandoned in favour of the general practice of free love, the human race will be overwhelmed by gonococci in a manner now hardly conceivable, and the reproductive capacity in 262both sexes will be diminished by the results of gonorrhœa to a very serious extent.”

Frequently enough, also, free love leads to prostitution, which at the present day is so widely prevalent. Various reasons have been suggested to account for the increase of prostitution. Among these are: The growth of modern industry, with the consequent aggregation of the population in large towns; the decline in the marriage rate; the postponement of marriage; universal military service; the freer mutual companionship of the sexes; and many others. At any rate, the fact would appear to be established, that in the case of woman the determining cause of prostitution is hunger rather than the sexual impulse. The worst paid classes of workwomen are shown by official statistics to furnish the largest number of recruits to the ranks of prostitutes; and it is during times of deficient employment that the number of women practicing occasional prostitution increases. Thus, material need is the most important of the causes of prostitution.

This remains true even though the doctrine of Lombroso and Tarnowsky should find fuller justification, the doctrine that the practice of prostitution by women is the natural expression of a congenital morbid predisposition, “which impels them, in defiance of their direct advantage, of reason, and of all counter-advice, to adopt this accursed mode of life.” Prostitution, in this view, is to be regarded as the inevitable outcome of congenital moral insanity. This is certainly true of a small proportion of prostitutes, but is as certainly false of the great majority, in whom unfavorable, difficult conditions of life form the determining cause. A certain inherited or acquired mental disposition may, indeed, be assumed to exist in these cases also—an unstable moral equilibrium, an insufficient development of the force of the will and of the power of resistance.

The hygienic requirement of married life for woman during the menacme is undoubtedly sometimes hard to fulfil in our day, when the more elaborate and expensive standard of life has increased the difficulty of supporting a family; but from the medical point of view it is necessary to insist forcibly on this categorical imperative, in opposition to the view advanced by the modern women’s rights’ party, that “love is moral also in the absence of legal marriage” (Ellen Key); in opposition to the yet more extreme opinion of George Sand and of Almquist, who, regardless of consequences, declare marriage to be immoral; and, finally, in opposition to the advocates of “free love,” who wish woman to be as free as man in sexual relations.

Much as we may wish that man and wife should be in complete harmony in marriage, and that they should feel themselves to be 263firmly united alike by mutual love and by a reciprocal sense of duty, none the less we must consider the modern maiden ripe for marriage as unjustified in demanding, before undertaking marriage, “perfect love as typifying the inner yearning of two beings to become one;” and we must regard the latter-day woman as extravagant in insisting that the man shall enter upon marriage in a condition as virgin as that of his contemplated wife. “Perfect love” is as rare and as little to be expected as perfect beauty; and the sexual life of man differs entirely in nature and in the course of its development from the sexual activity of women.

Doubtless they spring deep from the soul of woman, the demands expressed by the writer of the book “Vera” and by her numerous imitators, the apostles of “Veraism,”—the demands of the maiden entering upon marriage that her husband shall be as chaste and sexually as unspotted as herself. Difficult of fulfilment as they are, if fulfilment is even possible, these demands must none the less be regarded as characteristic of the sexual life of modern womanhood. “Is man’s sexual honor,” exclaims Vera, “then altogether different from that of woman? Is not the alleged necessity for sexual gratification in youth either a well-organized fraud or an enormous error on the part of physicians? Is it possible that chastity can entail diseases as terrible, as destructive to life and happiness as those that result from unchastity? And is it not a crying sin, even if some of these fears are justified, to ruin both mentally and physically the whole race of women? * * * Man demands from the girl of his choice, not chastity alone, but an absolutely unblemished character. And rightly so. But the wife must share her husband with street-walkers? She must bear the pangs of maternity, while fortified by the terrible knowledge that the father of her children has wasted his youthful virility in purchased embraces, that he has not recoiled from impurity, that he has exposed himself to the risk of infection with the most horrible diseases, that he has squandered his virginity in the most bestial sensuality? * * * We girls must also be granted the right to demand from the man of our choice the same purity, the same unspottedness by sensuality, that he so rigorously demands from ourselves! We must no longer content ourselves with the remnants that are left for us by others! We must no longer be satisfied with man’s moral inferiority! Then there will be more happiness, more love, more health and joy of life!”

These accusations and demands so boldly made are not to be disposed of by mere mockery. With deep sorrow we must admit the absolute truth of the charge that too many men clamber out of the abyss of debauchery to a blighted marriage. But the demand 264for equal moral rights, for the abandonment of the hitherto prevalent bisexual ethical standards, is in vain conflict with actuality, with the defensive instincts of young men, with the difficulties entailed by the struggle for existence, with the increasing pretensions (to sexual freedom) of women themselves; but above all is it in conflict with the thousand-year-old notions of sexual honor in the male and the female respectively, and with the undeniable fact that the mature man is capable of elevating himself out of the base intoxication of the senses characteristic of youth, to attain the noblest and most intimate married love, whereas the girl who has once descended into such an abyss sinks therein and is beyond the possibility of rescue. Thus early marriage with equal purity of husband and wife remains a postulate which the present can hardly be expected to satisfy, and one whose fulfilment must be left to the future.

In consequence of modern writings and discussions concerning the erotic problem, there has arisen a hypersensibility on the part of women in respect of the conditions in which they pass their married life, leading them to demand greater independence, a greater expansion of their own individuality; this tendency must, however, be resisted, if the marriage is to be a happy one, with mutual comfort and reciprocal consideration, one suitable, not for exceptional beings in an ideal state, but for men and women as they really are. In such a marriage, affection and a sense of duty will strengthen love and preserve fidelity. A prudent, clever woman will always understand how, notwithstanding all necessary self-surrender, to preserve the freedom of her own individuality and the esteem of her husband.

Marriages based upon true inclination usually result in the birth of stronger and more beautiful children than marriages in which the money-bags were the sole or the principal determining cause. In England, where people commonly marry when still quite young, beautiful and healthy children are more often seen than in France, where marriages of expediency form the great majority. According to Bertillon, of 1,000 young men from 20 to 25 years of age, in England 120 marry, but in France less than half that number, viz., 57 only. And 100 wives between the ages of 15 and 40 give birth annually, in England to 39 children, in France to 26 only, a number less by one-third.

In deciding upon marriage, hereditary influences deserve careful consideration in respect alike of the family of the prospective husband and that of the prospective wife. For it is well established that the law of inheritance relates not only to the peculiarities of external configuration, to the features, the stature, the tint of the skin, but also that children inherit from their parents their mode of bodily development, the functional activity of their organs, the duration 265of their life, their predisposition to disease, and even their intellectual and moral qualities. As regards hereditary predisposition to disease, the most important are, as is well known, the predisposition to tuberculosis, that to malignant tumors, and that to mental disorders.

Great disparity in the respective ages of prospective husband and wife entail various kinds of unsuitability for marriage. An elderly man who marries a young girl, even if he still possesses a certain amount of virility, is unlikely to procreate healthy and powerful children; and these latter for the most part will be weakly, scrofulous cachectic, endowed with deficient powers of resistance, and often badly equipped from the intellectual standpoint. Similar considerations prevail in respect of marriages in which the husband has been exhausted by earlier sexual excesses, so that he retains no more than remnants of virility, whilst his semen is of doubtful fertilizing power. D. Richard relates that Louis XIV asked his physician why it was that the children he (the king) had by his wife were delicate and deformed, whilst those he had by his mistresses were beautiful and powerful. “Sire,” was the answer, “c’est parce que vous ne donnez à la reine que les rincures.”

Plato maintains that before every marriage the man and the woman should both undergo official examination to determine their fitness or unfitness for the married state, the man being absolutely nude, and the woman stripped to the waist, for the examination. This author goes so far as to regard it as “a form of homicide for a man to embrace a woman when he is incapable of fertilizing her.” How rarely it happens in our day, however, that the physician, the official with the requisite knowledge to fulfil Plato’s requirements, is asked for his opinion regarding the desirability of a contemplated marriage! The only occasion on which this is likely to occur is when a man intending to marry wishes to be assured that he is completely cured from an earlier infection with syphilis, and, therefore, runs no risk of transmitting the disease to his wife or to possible offspring. But it never occurs to the parents of a girl about to marry to ask the physician whether she is physically suitable for marriage.

In deciding on marriage, however, care should before all be taken to determine that the girl has attained complete physical and especially complete sexual development. The age at which woman attains complete sexual maturity is in our climate and race coincident on the average with the twentieth year of life.

For the hygiene of marriage it is necessary that the bride should not be extremely youthful. Notwithstanding the fact that the legal codes of civilized countries nowhere demand for girls a greater age 266than fifteen years before permitting marriage, this limit is, generally speaking, fixed far too low. Before becoming a wife, the girl should not merely have attained complete physical development, with her reproductive organs in a state of maturity, but she must also be developed intellectually to such an extent that she is fully capable of understanding the nature and significance of marriage. At the age at which marriage is legally permissible, a girl is still far from having attained physical and mental ripeness for marriage, reproduction, and maternity.

Especially with reference to the last consideration is it inadvisable that in our climates a girl should marry earlier than from 18 to 20 years of age, and preferably even she should first attain the age of from 20 to 22. In that case her happiness as a mother will be more secure, and there will be a greater probability of her producing a healthy progeny. In the East, indeed, quite different views prevail. According to the laws of Manus, a girl might marry on attaining the age of eight years; if within three years thereafter her father failed to provide her with a husband, she might choose one for herself. Among the Hindus it is regarded as a disgrace to the parents if a girl does not marry quite young, indeed before the first appearance of menstruation. Atri and Kasypa state that if a girl begins to menstruate before she leaves her father’s house, the latter must be punished as if he had destroyed a fœtus, while the daughter herself loses caste. Marriage delayed till after the appearance of menstruation being regarded as sinful, girls are married while still children, in order to prevent the loss of mature ova, which is regarded as equivalent to infanticide. Very early marriage has thus in India been legally ordained for thousands of years. The Hindus, who even now regard every menstruation which has not been preceded by coitus in the light of infanticide, marry their daughters before the age of puberty.

According to oriental tradition, Mahomet married Khadijah when five years of age, and cohabited with her three years later. In the Bible, numerous similar examples are recorded. Among many savage tribes, as, for instance, among some of the aborigines of India, and among the indigens of Australia, copulation is usually effected before girls reach the age of puberty; in India, indeed, according to Ploss and Bartels (Das Weib in der Natur und Völkerkunde), marriage with immature girls is a widely diffused custom, and in Australia a child of ten or eleven is often found to be the wife of a man of fifty or the concubine of a sailor. In general, according to these authors, we find that the age of nubility in girls is lower in proportion to the lowness of the stage of civilization attained by the race or people to which they belong. Among the 267ancient Romans, girls were commonly married between the ages of thirteen and sixteen years.

In the Talmud, Rabbi Joshua gives the following advice regarding early marriage in Jewish girls: “If your daughter has attained puberty and is twelve years and six months old, she must be married at any cost. If no other means are available, manumit one of your slaves, and give her to the freedman to wife.”

Experience proves, however, that in our climate, at any rate, girls who marry at a very early age are inferior in fertility to those who refrain from marriage until the genital organs have attained complete maturity; and statistics show that those women who marry before attaining the age of twenty must wait longer for their first pregnancy than those who marry between the ages of twenty and twenty-four. At the higher age also, women bear parturition and its consequences more easily than those who marry very young. A similar influence in marriage to that resulting from undue juvenility is exercised by its opposite, marriage when a woman is already elderly; in this case fertility is limited, and health also is especially apt to suffer. When the indications of the climacteric are clearly apparent, marriage is contra-indicated, not only on account of the impossibility of fertilization, but also in respect of its general unsuitability in the closing stage of the sexual life.

Not only is the absolute age of the woman of importance in deciding on the advisability of marriage, but the relative ages of the proposed husband and wife must also be taken into account, first of all in respect of the wife’s possible fertility, and secondly in respect of her general health. The most suitable arrangement is that in which there is no marked difference in age. The husband may be, and indeed in existing social circumstances almost necessarily is, somewhat older than his wife, as much perhaps as eight or ten years. But a very great disparity of age (in either direction) is a serious error. If a very young girl marries an elderly man, or a developed matron marries a young man, the true purpose of marriage is unfulfilled, the eternal laws of nature and all ethical principles are infringed. In the breeding of animals, the fundamental principle has long prevailed that the animals chosen for coupling should be well suited each to the other and should be in perfect physical condition; and breeders are also familiar both with the favorable influence of good nourishment and with the advantage of the opportune crossing of distinct varieties. The same principles are equally applicable to the human race, neglected as they commonly are in practice.

With regard to the marriage of near kin, we can only remark that the marriage of those closely related by blood should as far 268as possible be avoided, and that such a marriage must be absolutely prohibited when in both families there is a history of tuberculosis, mental disorders, diabetes, and the like. When first cousins contemplate marriage, it is indispensable, not only that both individuals should be in perfect health, but also that on neither side there should be any serious family history of transmissible disease or transmissible morbid tendency; and, further, it is absolutely necessary that no such marriage of near kin should have taken place in the proximate ancestry of the cousins, i. e., their cousinship must not be a double one, derived both from the paternal side and the maternal. It is indeed to be recommended, with a view to the production of a healthy and powerful posterity, that marriage should bring about a crossing of healthy individuals proceeding from different families, different places, and different constitutional types. An instance of the advantage to be found in this practice is pointed out by Ribbing, who shows that the most powerful aristocracy in Europe, that of England, by the gradual creation of new peers, on the one hand, and by the gradual decline of younger sons and their descendants into the middle class, on the other, has undergone a continual crossing with less exalted but originally sounder stocks; in this way its vigor and fertility have been maintained, in contrast to the nobility of many continental states, which has so largely perished, in consequence of its exclusiveness in the matter of marriage.

“In this connection,” continues Ribbing, “we must bear in mind, that blood-relationship is not the only matter that has to be considered; in the interest alike of the family, and of society, it is necessary to demand that certain degrees of relationship by marriage alone, should fall within the ‘prohibited degrees’ of love and marriage. There are certain groups related by marriage and held together by the bond of affection, from which foster-parents and guardians may most suitably be selected to fulfil the duties as regards education and training of children who have been orphaned in early years. For such a purpose none seem better adapted than the brothers and sisters of the deceased parents; but the upbringing of the children can be confidently entrusted to the former only if the relationship between the older and the younger branches of the family is one regarded by law, and still more by morality and custom, as one precluding the possibility of the occurrence of sexual love and marriage.”

Möbius, writing on “The Ennobling of the Human Race by Selection in Marriage,” observes: “The most important aim of natural development is the perfection of humanity. The qualities of the coming generation depend for the most part upon the qualities of the parents. Marriage from affection ensures the fulfilment of 269nature’s aims with more security than marriage from reason; since what we have to think of is not the happiness of the married pair but the quality of their children. Of great importance, also, to the development of the human race are the conditions during the commencement of life, and the mode of education. The improvement of the race has not hitherto been the conscious aim of the generality of people. The law does not as yet, as it should, take into account the advantage of posterity. Capital punishment is fully justified and purposive. Criminals should not be allowed to marry. The perpetuation of disease by inheritance should be checked by the utmost powers of the state. Any one marrying while suffering from any venereal disease still in an infective condition should be punished. The marriage of persons suffering from tuberculosis should be prohibited. For the prevention of disease is more important than its cure. The most important factor in preventive medicine is an improvement in the conditions of life. The human ideal should be, goodness of heart in association with physical and mental health. Goodness, beauty, and strength should be simultaneously pursued. Since, however, man is made by birth far more than by education, selection in marriage is of fundamental importance. In the choice of a partner, attention is rightly paid to beauty, since beauty and health are fundamentally identical; moreover, a human being endowed with beauty is usually also more moral than one devoid of that attribute. Equality of birth is as a rule desirable in marriage; but not the family only is to be considered in determining the existence of such equality, individual characteristics must likewise be taken into account. Whether the crossing of races is desirable is not yet certainly determined.”

From the hygienic standpoint it is necessary that in marriage also the frequency and the manner of sexual intercourse should be regulated.

Wise men and lawgivers of all the nations of antiquity have insisted upon the necessity of certain intervals between the acts of intercourse. Thus, Mahomet prescribed 8 days, Zoroaster 9 days, Solon 10 days, Socrates also 10 days. Moses forbade intercourse during menstruation and for a week after the cessation of the flow. Luther prescribed intercourse “twice a week.”

Birds and many mammals are competent to perform intercourse at exceedingly short intervals. A well-bred cock will repeat this act 50 times daily; a sparrow, 20 times in an hour; a bull, 3 to 4 times in an hour. In the human species, however, too rapid repetition of intercourse is deleterious not only to the male, but to the female also, though the latter certainly suffers in less degree. For in this act the female plays a more passive part, and for this reason 270can repeat it with impunity more frequently than the male, who loses semen at each repetition. It is not possible, however, to lay down precise rules as to the permissible frequency of intercourse in either sex; the matter must depend upon physical needs. Moderate and regular indulgence in sexual intercourse is unquestionably advantageous to women both physically and mentally, regulating all the functions of the body, and tending to produce a contented and cheerful frame of mind.

During menstruation, a woman should refrain from intercourse. By the Mosaic law the death punishment was allotted both to the man and to the woman who indulged in coitus while the latter was menstruating. As a matter of fact, considerations alike of hygienic cleanliness and of sanitary precaution prohibit the performance of coitus during this period. Severe menorrhagia, perimetritic irritation, and parametritic inflammations, have been observed to follow such indiscretions. On the other hand, it is more than doubtful whether, in the event of pregnancy resulting from intercourse performed during menstruation (and conception is especially apt to occur at this time), the child is likely, as earlier authors maintained, to be unfavorably affected, and to suffer from cachexia, scrofula, or rickets.

After the act of intercourse, a woman should rest; and indeed sleep for some hours is especially to be recommended. A vaginal douche should not be administered until several hours have elapsed, otherwise there will be a risk of preventing fertilization of the ovum. The water employed for vaginal irrigation should never be quite cold; a temperature of 79°–82° F. (26°–28° C.) is best.

All measures for the purpose of artificially increasing sexual desire, such as alcoholic beverages (especially champagne), and certain drugs (especially cantharides), are even more harmful to women than they are to men. The woman who conceives while in a state of intoxication commits a great sin against the coming generation.^[44] Just as harmful, however, are the anaphrodisiacs sometimes employed to diminish the intensity of sexual desire when this cannot be gratified. When affected with intense sexual excitement, a woman is much more unfavorably situated than a man, since man claims the right to indulge in sexual intercourse whenever he feels disposed, 271and has, moreover, ample opportunity for sexual gratification. A woman, however, properly endowed with self-respect, will understand how to bridle her senses. Bodily exercise, moderate, unstimulating diet, intellectual occupation with serious matters, the avoidance of equivocal literature and of sensual dramatic representations, cold bathing, and the use of a hard mattress and light bed-clothing—these means will coöperate powerfully toward the prevention of excessive sexual desire. Horace already remarked: “Otia si tolles, periere Cupidinis arcus.”

The wife should know how to bridle, not her own desires only, but also those of her husband. She must not demand too much during the intoxication of youthful vigor; she must prevent the complete combustion of the flames of masculine passion, and must keep sparks glowing in the ashes. Economy during the sexual prime preserves sexual power, enables a man to continue intercourse to a ripe age, and avoids premature exhaustion and satiety. When the husband is drawing near the end of his sixth decade, the wife must accustom herself to see in him rather the father of her children than her own husband, and must reduce her sexual demands to that measure which will not be injurious to his health. Demosthenes, writing of the sexual life of the Athenians of his time, said: “In order to obtain legitimate offspring and to provide a faithful guardian of our household, we marry a wife; for our service and for the performance of daily household duties, we keep concubines; for the joys of love, we seek the hetairai.” The task is extremely difficult, but a clever and virtuous modern wife must endeavor to combine in her single personality the sensual attractiveness of an Aspasia, the chastity of a Lucrece, and the intellectual greatness of a Cornelia; she must bear in mind the epigram of Bacon, “A wife must be a young man’s mistress, a middle-aged man’s companion, an old man’s nurse.”

In the act of intercourse the woman must always play the more passive part; she must be desired, rather than desire. Woman’s modesty increases man’s desire. By this coquetry, permissible because natural, the woman can bind the man to herself, and can give the lie to the assertion that marriage is the grave of love. Partial concealment of her desire on the part of the woman is more stimulating to the man than an open manifestation of the sexual impulse; and a certain amount of modest reluctance is more alluring to him than a plain invitation. Plenty of room must be left for the play of fancy and imagination. Schiller makes Fiesco say to the Countess Julia, as he covers up her bosom, “The senses must be blind letter-carriers only, and must not be aware of that which nature and the imagination communicate each to the other. The best of news is stale as soon as it has become the talk of the town.”

272For this reason, also, it is more suitable that intercourse should take place, not by day, consequent on the brutal prompting of vision, but by night only, beneath the protecting veil of darkness. A night’s rest, moreover, will serve to restore the exhausted nerves, and to replace the expended secretions. Less advisable is coitus in the morning, on awaking from sleep, since the labors of the day must immediately thereafter be undertaken. Partially impotent men only, who wake up with an erected penis, endeavour to avail themselves without delay of this favorable opportunity, bearing in mind the French proverb, “On aime quand on peut, et non pas quand on veut.”

The French custom, in accordance with which the married pair sleep together in a double-bed is undesirable on several hygienic grounds, and, in the first place, for the reason that this continuous nocturnal proximity is likely to give rise to the habit of indulging in excessively frequent acts of intercourse. The best and most affectionate of men has neither disposition nor capacity to play the part of Romeo every night, and thus the value and enjoyment of marital duties becomes lessened. The fulfilment of his desires should not be rendered quite so easy to the husband; he should always appear the lover, one who seeks a woman’s favours because he longs for her; he should not be the master, exacting an unquestioned right. For this reason, separate beds are advisable for the married pair, and, when possible, even separate bedrooms.

Among the ancients, Lycurgus, the Spartan law-giver, regarded maternity as woman’s principal attribute, and considered the sexual impulse to be the means merely by which healthy citizens were provided for the state. In accordance with this view, the sanctity of marriage was violated, and every powerful, handsome, and valiant Spartan had the right to request the privilege of intercourse with the wife of another, in order to enrich that other’s family with his seed. Elderly, impotent men conducted well-formed young men into the arms of their own wives. The girls, like the young men, went through a course of gymnastic exercises, in order to harden their bodies, and to fit them for the bearing of strong and healthy children. No man might marry before attaining the age of thirty, no woman before attaining the age of twenty. Girls ripe for marriage were assembled in a dark place, and there the young men chose their brides, as chance might direct. The young men were allowed to visit their wives by night only, and secretly, in order that the vigor of the sexual impulse might be increased and maintained.

Among the Spartans, it happened quite frequently, that a man whose wife had remained childless, and who believed himself to be 273at fault in the matter, would beg one of his fellow-countrymen, or even a foreigner, to come to his assistance. It was enacted by one of Solon’s laws, to prevent a man from neglecting his marital duties, that he should have intercourse with his wife not less than three times monthly. According to another of Solon’s laws, an Athenian heiress might call upon her nearest relative for the gratification of her sexual desires.

The bluntest contrast to this Spartan simplicity is furnished by the unbridled lasciviousness that prevailed in Rome under the Cæsars, when women’s sole desire was sexual enjoyment, while maternity was a state to be avoided. To such an extreme was this carried, that the Roman ladies of that day preferred to marry eunuchs, and further, as Pliny reports, hermaphrodites were in great request. Juvenal writes: “There are women who prize the infertile embraces of base eunuchs; thus they are able to dispense with the use of abortifacients.”

The hygiene of the nuptial night deserves from the physician more attention than it has hitherto generally received. He should warn and enlighten the young husband, in order that the brutality with which the act of defloration is apt to be performed may be lessened, and further in order that mistakes in this connection, resulting from ignorance and likely to have serious consequences, may be avoided. It is well known that lacerations of the hymen and its environment, and even serious injuries of the genital organs, may result from maladroit attempts at penetration. The physician will admonish the husband in the words of Michelet: “Bear in mind in this hour that thou art an enemy, a tender, considerate, and gentle enemy!”

The young woman entering upon marriage should receive instruction from her mother regarding all the sexual processes of copulation, instruction at once earnest and complete. By such enlightenment, the young bride will be spared much suffering, and a sudden disillusionment which might seriously affect the whole of her future life will be avoided; complete ignorance, on the other hand may lead, not merely to needless mental and physical suffering, but to the most tragic consequences on the bridal night. In one case known to me, the young wife, who before marriage was utterly ignorant of the nature of physical love, was so completely overwhelmed in her ideals by the somewhat energetic procedure of the bridegroom as soon as he found himself alone with his wife, that she fled from her new home then and there in the night, and by no persuasions could be induced to return.

In that decisive moment in which the maiden loses her virginity, she must find in her husband, not the brutal man who forcibly takes 274possession of her body, but the chosen man of all, to whom her love can refuse nothing.

“Delicate foresight and restraint,” writes Ribbing, “are needful above all at the commencement of married life. The young wife, coming to the bridal bed a pure virgin, is not, like her husband, fully prepared for what is to take place. In all cases she is somewhat fearful of the new experience. The first act of intercourse involves for her a certain amount of pain, and this pain is not solely physical. * * * Moreover, we must remember that the entire change in her mode of life makes a deep impression upon a woman’s mind; time and quiet are needed before she can find herself at home in the novel surroundings, before she can adapt to the changed circumstances her moral and religious convictions, and before she can ‘think true love acted simple modesty’ (Romeo and Juliet, III, 2.16). Impatient husbands, through want of knowledge and lack of consideration during the honeymoon, have often ruined the happiness of subsequent married life.”

It happens often, unfortunately, that the wife has reason to complain of the reckless manner in which her husband has used, or misused, his sexual powers. Frequently enough, on the bridal night, the man proceeds with such violence in his assault on the virgin reproductive organs of his newly-wedded wife, that we must actually speak of him as ravishing an ignorant and timid girl. Later, when the stimulus of novelty has passed away, the husband often performs intercourse in a manner more calculated to awaken his wife’s sexual desires, but in seeking his own lordly gratification and obtaining it he is still apt to leave out of the reckoning the need for effecting coitus in such a way as will give complete satisfaction also to his wife.

The wedding journey likewise deserves consideration from the hygienic standpoint. Much is to be said in favor of such a journey, inasmuch as it endows the necessarily somewhat brutal first act of intercourse with an aspect of romance. The removal to a foreign country, to a strange environment, will spare the chaste maiden much shame and vexation. On the journey, moreover, the young couple are much in each other’s company, and the process of mutual adaptation is agreeably favored. And yet this modern custom of making a wedding journey entails certain serious disadvantages. The young woman leaves her home and her nearest relatives, and is in a moment involved in the excitement of travel, an excitement liable to increase to the degree of morbid anxiety. The fatigues of railway-travel, of wandering about strange towns, of visits to museums and picture-galleries, are apt to cause general loss of nervous tone, and also local hyperæmia of the genital organs. In 275addition, false modesty and the prescribed arrangements for the journey may lead the onset of menstruation to be ignored and the customary rest at this period to be dispensed with. Still more, the possibility of the occurrence of conception and of the commencement of pregnancy is usually left altogether out of the account. Many an attack of menorrhagia, of perimetritis, and of endometritis, many a miscarriage, and many instances of protracted sterility, are dependent upon the hygienic mistakes of the wedding journey, and less, indeed, upon the abuses arising out of the intoxication of passion, than upon the fatigues of excessive travel both by day and by night. The bride who on her wedding-day was young, healthy, and full of vitality, not infrequently returns from the wedding journey a sickly and debilitated woman.