Women's Diseases

Women's Diseases. Definition, scope and content of the concept. Until recently, the essence of W. d. was seen exclusively in local anatomical changes of the sexual apparatus, and therefore W. d. were classified only on a morphological principle, overlooking the fact that diseases, heterogeneous in etiology, can give the same picture. Subsequently, with the successes of bacteriology, new classifications appeared, built on an etiological principle, since a particular infection could be the basis for individual diseases. The fascination with the brilliant results of surgical treatment of W. d. again pushed everything else into the background. The doctrine of internal secretion, clarification of the chemical (rather neurochemical) correlations between the ovary and all other endocrine glands, subsequently made it obvious that the normal course of all sexual phases and the correctness of all sexual functions are possible only under the condition of complete hormonal equilibrium. Thus, as the cause of W. d., one or another biochemical substrate (toxins, hormones, changes in blood composition, fluctuations in metabolism) came to be considered. It became impossible to interpret any system of organs in isolation, apart from connections with others, and even more so the female sexual sphere, which is always connected with the whole organism by many threads under all conditions. Gynecology gradually went beyond the limits of the small pelvis and ceased to be, as before, synonymous with 'the doctrine of female sexual organs.' It has now turned into the biology and pathology of woman. Of course, the psychological sphere also entered these broad frames as a significant factor in health. Viewed from these points of view, many W. d. proved to be pathological manifestations of the entire organism, as it were, a local reflection of general disorders. Therefore, along with one-sided local therapy, general therapy developed with all its possibilities. The doctrine of constitution became that clinical concept which, by focusing attention on frequently observed combinations of individual signs into certain typical groupings - constitutional types, resp. anomalies - facilitated both the general diagnosis of women's diseases and their therapy. Even broader horizons have opened before gynecology now, in connection with the entire new socio-domestic structure of our life. Woman is throwing off the shackles of family slavery; in the struggle for her independence, for economic independence, she is gradually penetrating almost all areas of professional activity. Naturally, modern doctrine of W. d. must (and does) take on a completely new social direction. Gynecology places in the foreground the etiological significance of all professional-domestic factors as important sources of female morbidity. Setting as its immediate task to study not only the already diseased, but mainly the healthy woman, and not in isolation from the external environment, as was the case before, but in close connection with the entire working and domestic environment, gynecology sees its further goal in the rational improvement of working and living conditions for women, necessary for the improvement of her body. Early sources of W. d. Genotypical diseases of the female sexual sphere have been studied very little. There are few data in this regard regarding menstruatio praecox, climacterium praecox, aplasia mammae, hypoplasia of the sexual apparatus (and associated infertility), chondrodystrophic pelvis, etc. The causes of many W. d. come down to harmful influences of the external environment, which makes itself known sometimes very early. The sex cells can suffer certain damage even when they are still enclosed in the gonads of the parents; here they can be exposed to toxic effects of such poisons circulating in the blood as alcohol, lead, etc. As a result of this, defective offspring can be obtained. Professional poisons can also manifest themselves later, being transmitted through the mother's blood to the fetus, and through her milk to the newborn child. Artificial feeding, so common in our domestic life, and the rickets developing in connection with it can seriously affect the fate of the girl-future mother, since this disease is the most common cause of the development of a flat pelvis, which leads to a whole range of very serious complications during childbirth. On the other hand, excessive early physical labor, especially carrying heavy loads, contributes to the development of a flat pelvis. The early years of a girl, not provided with rational care and upbringing, also contain a number of other dangers and sources of future W. d. These include, for example: 1) extragenital infection with gonorrhea (gonorrheal vulvovaginitis, leaving behind persistent anatomical changes); 2) catarrhal vulvovaginitis as a result of unhygienic care of the external genital parts; 3) constipation, already encountered in the very early age (especially among children fed artificially); 4) the bad habit of delaying emptying of the intestines and bladder for a long time, which can lead to incorrect positions of the uterus; 5) masturbation with its local and often distant general consequences as a result of an abnormal environment conducive to premature development of sexual feeling; 6) childhood infections, insofar as they (especially scarlet fever and diphtheria) leave serious consequences (kidney damage, heart damage, and above all - damage to the parenchyma of the ovaries, which can subsequently manifest as disruption of their functions). All these diseases are to a greater or lesser degree the result of unfavorable economic and domestic conditions that contribute to the development in a girl of diseases that very early imprint an unhealthy mark on her growing organism, creating obviously unfavorable conditions for impending motherhood, and which can be prevented with the appropriate development of preventive institutions for the protection of motherhood and infancy (women's and children's consultations). The period of sexual maturation from the point of view of etiology and prevention of W. d. also has important significance. At this time, the nature itself makes great demands on the entire organism of the adolescent girl. Therefore, any excessive work (school, domestic, professional, social) without proper regard for the importance of the phase of sexual maturation can adversely affect health. Non-compliance with the requirements of physical and mental hygiene, especially when the phenomena of the ovarian-menstrual cycle appear, often from the very beginning gives an incorrect character to this important general manifestation of the organism (scanty or profuse, irregular or very painful menstruations). All this should serve as the basis for a careful approach to the adolescent girl. In the interests of the correct development of her organism, there must be a certain understanding between educators, pediatricians, and gynecologists. The gynecologist should participate in sex education, which requires special skill and tact. For the timely prevention of W. d., elementary literacy in all important questions of a woman's sexual life is absolutely necessary. From this same preventive point of view, professional selection and professional consultation in general and in particular for adolescent girls have special significance. Since professional pathology of woman is not yet always able to give a definite answer as to how this or that profession affects the sexual sphere and the general condition of the female organism, repeated examinations are of course essential, which make it possible: 1) to correct the advice given at the initial examination, 2) to gradually monitor the dynamics of professional morbidity itself, 3) to timely influence it with preventive measures. Abnormal sexual life as a source of women's diseases. The beginning of a woman's sexual life is always fraught with the dangers of infection with venereal diseases. Social causes play an important role in their spread. The entire living environment in industrial centers contributes to the premature awakening of sexual desire and often leads to early onset of sexual life, to disorderly and random short-term extramarital relations. This applies mainly to the transient population, to women leaving the village for itinerant occupations and in general those who break away from their families, not provided with either permanent earnings or housing, not having any definite material base and therefore unstable in all respects. Sometimes such an element, due to heavy economic conditions, directly turns to prostitution. Venereal diseases are also common among permanent urban residents, especially among representatives of free professions, employees (in pubs, in cafes, restaurants, etc.), individual artisans, domestic workers and other persons without permanent earnings, engaged in some temporary work, or unemployed. Alcoholism, observed not only among men but also among women (though to a lesser degree), also plays a significant role in the pathology of sexual life with all its consequences.

It must also be borne in mind that the modern woman, who is being liberated economically and therefore sexually, has become much more active in manifestations of her sexual desire, is freer in choosing her sexual object, shows more initiative than before in sexual intercourse, and does not always realize the dangers threatening her. Marriage represents an important counterweight to the spread of venereal diseases; however, its significance is diminished by the relative instability of modern marital relationships. Unculturedness and anti-hygienic living conditions are an important cause of the non-sexual spread of syphilis, and women, especially in primitive rural conditions, who are in closer contact with infected children and all objects of domestic use, contract syphilis much more often than men. Socio-economic causes (or purely domestic ones) often immediately cloud the beginning of married life for a woman. The normal course of the sexual act is easily disrupted by inhibitory psychological influences: some often obsessive idea can play the role of a psychological brake, as it were, 'a foreign body in the consciousness' of a woman; inserting itself between libido and orgasm each time during coitus, it acts destructively on its entire emotional side. Most often, this role is played by the fear of pregnancy, which is always possible but undesirable. A sense of grievance toward a husband who (especially in a state of intoxication) often manifests a crude, too hasty approach to coitus (sometimes not considering the wife's physical fatigue or her mood, ignoring such states as the menstrual period and pregnancy, even in the days immediately before childbirth) also has an inhibitory effect on sexual emotions; the crude aggressiveness of a man is often, especially at the beginning of sexual life, a psychosexual trauma for a woman and leads to complete sexual indifference, sometimes even to aversion or to a special disease of psychogenic origin, vaginismus (see). Whatever the cause of a woman's sexual dissatisfaction, it always leads to harmful consequences. In coitus that lacks positive emotional coloring, there are no usual and essential psychophysiological prerequisites, psycho-erotic readiness, and therefore, of course, the necessary 'psychogenic' lubrication of the vulva with mucus and 'sexual pleasure' and its climax - orgasm are also absent. If coitus only arouses but does not satisfy a woman, if the range of sexual emotions is cut off at the very beginning and in any case never ends with a final chord, then due to the long-lasting and unresolved rush of blood to the pelvic organs, persistent congestive phenomena gradually develop. The usual consequences of this are pathologically enhanced secretion (incorrectly called 'leukorrhea'), prolonged, abundant, often painful menstruations due to increased nervous excitability, various pains in the lower abdomen, constipation, neuroses, psychoneuroses. All this affects mood, general well-being, and work capacity. Many contraceptives, insofar as they introduce an element of rationality and cold calculation into the spontaneous sexual life and do not always inspire a woman with complete confidence in terms of guaranteeing against pregnancy, also have a harmful effect on her sexual psyche (not to mention the immediate dangers to health associated with them). In general, abnormal sexual life is the etiological soil on which a whole series of functional women's diseases can subsequently develop, which do not respond to any local treatment but are relatively quickly eliminated when normal sexual intercourse is resumed. The above-mentioned consequences of improper sexual life especially apply to such a harmful surrogate as 'coitus interruptus,' which, due to heavy economic and domestic conditions, occupies a prominent place in the pathology of sexual life and plays an important (usually hidden from the medical eye) role in the etiology of many women's diseases. Women's diseases of the 'time of hunger,' as mass experiments set by life itself, are instructive from the point of view of social gynecology. In years of war, epidemics, famine, and general devastation, which fell with considerable severity on women, causing exceptional strain on all their forces, all gynecologists noticed as a mass phenomenon a sharp increase in cases of prolapse and displacement of the uterus and vagina, occasionally observed even in young nulliparous women engaged in heavy, physically unbearable labor. These phenomena were undoubtedly the result of general nutritional decline and decreased tone of all tissues, including the entire smooth muscle system of the genital organs, their ligamentous apparatus, and the striated muscles of the pelvic floor, which under these conditions provided poor support for the genitals. For the same general reasons, cases of enteroptosis were observed relatively more often in still young women, especially in the presence of an asthenic constitution, and the combination of enteroptosis and prolapse, which is generally common and understandable, was observed particularly often at that time. In the same years, cases of prolonged amenorrhea were also not uncommon, sometimes driving a woman to an illegal abortion in the absence of pregnancy. The cause of amenorrhea was obviously the same nutritional disorders, and in addition, impulses originating from the central nervous system, which was constantly subjected to acute and chronic psychological trauma and in any case was extremely overworked, probably acted depressively on ovarian functions, inhibiting its work. After the devastation ended, all these women's diseases of the 'time of hunger' quickly returned to their usual level. Pathological motherhood as a cause of women's diseases. The great significance of socio-economic and domestic conditions in the origin of women's diseases is especially evident in such an important source of them as motherhood. In major centers and in cities in general, the state of obstetrics is generally at a proper level. Institutions for the protection of motherhood and infancy (maternity homes, consultations for pregnant women and parturients, consultations for children, houses of mother and child, nurseries, etc.) to a large extent ensure the interests of both mother and child, especially if we consider the long (4-month) pregnancy leave that exists nowhere except in the USSR. All this has already yielded great beneficial results. But the network of Okhmatmald institutions, which is quite dense in cities where it covers almost all the working female population, is still far from sufficient on the outskirts and in the village. In the village, a woman is still often a victim of midwifery in all its forms. In many cases, even physiological births are often complicated here by a pathologically occurring postpartum period - postpartum infection with all its immediate dangers and distant severe consequences. The connection between living conditions and postpartum morbidity is especially evident in the busy season in the village, when a woman often has to work in the last days of pregnancy and resume work the very next day after childbirth, which of course contributes to the development of prolapse phenomena. Conflicts between the biological peculiarities of a woman (motherhood), her professional work, and her way of life as a source of women's diseases. The biological peculiarities of a woman - all her sexual functions - as general manifestations of the organism do not always manifest uniformly, already depending on belonging to one or another constitutional type; and in the presence of any clearly expressed constitutional anomaly, they give such pathological deviations that have serious clinical significance. In the life of a working woman, these biological peculiarities acquire special significance. From this side, in all phases of sexual life (the period of sexual maturation, phenomena of the ovarian-menstrual cycle, pregnancy, childbirth, postpartum period, lactation, climacterium), the female organism is distinguished by increased vulnerability, special sensitivity to any infection and intoxication, including of course industrial poisons, to any somatic and psychological trauma, and to all generally harmful influences, of which there are always many in the environment of professional work. All this exposes a woman to a relatively greater risk, threatens her health, and at the same time reduces her work capacity. True, the 4-month pregnancy leave in the USSR is a huge counterweight to the harmful influences of the profession, but 1) domestic conditions often force a woman to use this leave for intensified housework, 2) after deducting the time of leave, there still remain many more or less long intervals when, all other conditions being equal, the harmful influences of the profession act on a woman's body more strongly than on a man's (for example, during menstrual days). In addition, it must be added that due to the peculiarities of her organism, a woman cannot engage in many professions, and due to the lack of sufficient preparation, women are employed mainly in less skilled professions, and therefore their wages are usually lower than men's.

In asserting her rights and maintaining the positions she has already taken in the arena of professional activity, woman very often tries to 'step over her biology'. As a result, she undertakes work beyond her capabilities, clearly exceeding the limits of physical endurance. Furthermore, the involuntary, and often forced by the conditions of professional work, neglect of elementary hygienic requirements (for example during menstruation), the use of contraceptives that are far from always safe, and above all, artificial abortion—all this makes the position of woman in production comparatively heavier and requires special measures—protection of motherhood. The operation of artificial abortion, even when apparently successful in all respects and technically flawless, is accompanied in a certain percentage of cases by both immediate and remote consequences; they are easily detected during dispensary re-examination, which reveals the very dynamics of morbidity among women undergoing this operation. The harmful consequences affect the general state of health of the woman rather than the local condition (of the sexual organs themselves). But artificial abortion—a phenomenon caused by deep socio-economic reasons and still inevitable—is by no means the only evil in the life of the working woman. The revolution in our way of life, which should lead to the lightening of the domestic burden on woman, has only just begun. And meanwhile a whole range of long-existing and not yet overcome social factors leads to the fact that the entire burden of housework and care for children falls entirely on the shoulders of woman. Thus the 'biological load' of woman is added to her professional and domestic burdens; all this together often puts woman in a difficult position from which she seeks one way or another and of course not without detriment to herself, since artificial abortion and contraceptives, which, due to the not yet overcome sexual inequality, fall mainly on her with their weight—equally threaten her health. The resolution of conflicts between motherhood, profession and domestic life is achieved at a high price; it is an abundant source of both general morbidity and specifically women's diseases. All these general considerations are confirmed by a number of factual materials. A. Data concerning the position of woman in industry. Woman's participation in the total labor force as of January 1, 1928 amounted to 28.7%. The main mass of women employed in production is given by the following professional groups: food industry workers, medical-sanitary-labor workers, seamstresses, textile workers, and workers' education workers. B. Information on the question of general morbidity. The study conducted by S.M. Bogoslavsky of 115,000 sanitary journals in Moscow, compiled in the order of dispensary examination, covering 37,423 production workers of different professions, 2,763 auxiliary workers, and 2,378 office workers, for a total of 42,564 women, showed that pathological involvement, expressed as 'pathological marks', is greater in women (both workers and office workers) than in men. It is important to note that tuberculosis (excluding AI) occurs among all three of the indicated categories of women more often than in men (namely—7.2; 7.9; 8.1% in women and—6.7; 6.6 and 6.5% in men). Furthermore, women more often suffer from general exhaustion, anemia, obesity, Basedow's disease, heart neuroses, varicose veins, diseases of teeth and stomach, atony of the intestines (constipation) and appendicitis. Women suffer from neurasthenia equally often as men. Hysteria occurs predominantly among office workers, and professional seniority, tuberculosis and Women's diseases increase its incidence. C. The results of gynecological and partly general examination of certain professional women's groups showed that professional harmful factors do not selectively affect the sexual sphere, but rather reflect on the entire organism of the woman. The experimental study of the effect of industrial poisons, begun by the gynecological department of the Obukh Institute, showed that benzene, used in both small and toxic doses on a pregnant female, had a fatal effect on her offspring: the fetuses soon died; examination of their organs revealed necrotic areas in liver tissue, disappearance of fat in its cells, and lipemia. The influence of ovarian-menstrual cycle phenomena on labor productivity was also studied (methods—accounting for output by days and studying fatigue). It turned out that during menstrual days the woman's working capacity undoubtedly falls, and then quickly recovers (see figure). D. Data on the productive function of the working woman. The large statistical work produced by the obstetric clinic of the 2nd Moscow State University from materials of all Moscow maternity homes, covering data from maternity records of 507 sewing-machine operators, 500 weavers, 485 spinners, 289 galosh makers, 283 tram conductors, 183 tobacco workers, and 131 typesetters, made it possible to draw the following general conclusions. For a number of professions it has not yet been possible to prove any sharp and typical deviations from the norm, except for those in which workers come into contact with industrial poisons. In these cases (especially among typesetters) very significant violations of the productive function were established in all respects. To a lesser extent this applies to tobacco workers, and to an even lesser extent, and then only

Earnings in rubles per day. Intermenstrual and menstrual days; triod "^L"

Earnings by days of the month. Non-menstrual

Labor productivity in connection with the ovarian-menstrual cycle. (Group of workers from the wrapping department of the 'Bolshevik' factory, Moscow.) partially, to the galosh makers. Other professions, from the point of view of obstetric pathology, did not stand out noticeably, with the exception, however, of weavers. In all the professional groups studied, spontaneous abortion, as can be judged from the anamnesis (and also to some extent premature births), is still observed noticeably more often, sometimes even incomparably more often, than among housewives. Profession, regardless of greater or lesser length of service, does not have a noticeable effect on the duration of the labor act or on the weight of the fetus. The general conclusion drawn from the aforementioned works in the field of professional pathology of women is as follows: professional factors undoubtedly exert a certain harmful effect both on the non-pregnant woman, aggravating her existing diseases, and on the pregnant woman with her offspring. However, the female sexual apparatus, which generally possesses considerable biological stability, can apparently adapt to a certain extent to those relatively new conditions into which professional labor places it. In any case, the sexual sphere of woman is not the sole object of the action of professional harmful agents, which undoubtedly affect all other organ systems and already through their intermediary are reflected secondarily on the sexual sphere. Therefore, one must always keep in mind not so much the local gynecological, but the general professional pathology of woman. D. Artificial abortion (see) as a new source of Women's Diseases requires special study of the immediate and remote consequences of this operation. Method - long-term dispensary observation of women after artificial abortion. These observations can be one of the topics of scientific work for each women's consultation. Prevention of Women's Diseases requires improvement of conditions of upbringing and development and then of the labor and domestic environment of woman. 1. The entire network of health-prevention institutions dealing with the protection of women's health (women's consultations, maternity homes, children's consultations) must form a continuous preventive chain, covering all periods of a woman's life, from the first days of existence to the climacteric and old age. 2. Preventive educational measures with respect to early childhood and adolescent girls should be developed jointly by pediatricians and obstetrician-gynecologists. 3. Rational organization of physical education in the broad sense of this word as the most important health factor, in particular 'sublimating', redirecting the accumulating sexual energy into other types of energy, first of all into creative social work. In dosing physical exercises, the biological properties of woman in general and the peculiarities of individual sexual phases and constitutional inclinations must be taken into account. 4. Expansion of the network of Okhmatmald institutions. 5. Deepened and expanded sanitary-educational work in the field of obstetrics and gynecology. 6. Preventive work in the fight against cancer of the uterus. Since its success depends primarily on timely, i.e., early microscopic diagnosis, it is necessary, in addition to purely organizational efforts and expenditures, to raise the general cultural level of woman and to have at least elementary sanitary literacy. 7. Further deepened study of all professional harmful agents with the aim of practically developing measures of professional prevention aimed at improving the entire labor environment of woman. 8. Domestic unloading of woman (organization of nurseries, public canteens, laundries, etc.) with simultaneous organization of all cultural public entertainments that improve the somatic and psychic sphere of woman. 9. Implementation of all measures contributing to the greatest possible improvement in the qualification of women's labor in order to equalize women's earnings with men's and thereby place woman in approximately equal domestic conditions. 10. Introduction into practice of contraceptives as safe as possible for woman's health, which should be applied equally by both woman and man. 11. Systematic struggle with prostitution in all its overt and masked forms and in general with disorderly sexual life. 12. Development of medical contraindications to abortion. 13. Reform of the teaching of obstetrics and gynecology with the calculation that all the educational material, both theoretical and practically worked through, should be presented to the future physician (gynecologist-preventor) from a socio-hygienic point of view. (See also statistics of women's diseases in the article Sexual Organs and Childbirth.)