Uterine Nerve Supply.-- One set of nerves causes contraction of the muscular fibers of the uterus, while the other set transmits impulses which bring about its vascular engorgement; and they are probably concerned in bringing about the determination of blood to the uterus and its appendages, which is so marked a feature of the menstrual process.

As the result of long-continued investigation, Johnstone has come to the conclusion that the lining membrane of the uterus belongs to that cla.s.s of organs whose function it is to replace organic waste.

"Menstruation is a periodic wasting away of those corpuscles that are too old to make a placenta." He has further found that, as compared with the uteri of very many of the lower animals, the human uterus is very scantily supplied with lymphatics, and the only way to rid the uterus of the overripe, and therefore consequently useless, tissue is to wash it out through the v.a.g.i.n.a by a blood-stream. The tough wall of the human uterus and the increased blood-pressure caused by the erect position cause the difference between menstruation in the human female and rut in the lower animals.

The strong light of recent investigations has necessitated the laying aside of many time-honored theories; and as the close of the nineteenth century has seen the emanc.i.p.ation of the uterus from the thralldom of the ovary, so we may believe that the twentieth century will find women of such fine physique as to prove the error of the popular fallacy that the cause of woman's weakness lies in the performance of her functions.

The Function of the Uterus.-- The function of the uterus is to provide a favorable place for the reception of the product of conception, where it may be protected and nourished during the period of its development. The purpose of menstruation is to keep the uterus in suitable condition for the reception of this product of conception at any time. It is now known that the menstrual flow is not the whole of menstruation, and that the changes going on in the uterus are almost as continuous as the process of digestion. The whole of the reproductive life of woman has been divided into cycles of twenty-eight days each; these cycles have been divided into four stages.

Stages of the Menstrual Cycle.-- The first or constructive stage is one of preparation for the reception of the ovum. During this stage the preparing of a decidua takes place, or building a nest for the expected egg; there is a swelling of the mucous membrane, an enlargement of the uterine glands, and an increase in the connective tissue. It is thought that this stage lasts for one week; when pregnancy does not occur, it is followed by degenerative changes.

The second or destructive stage is marked by destructive changes which give rise to the usual phenomena of the menstrual period; there is a discharge of blood, mucus, and disintegrated mucous membrane. The actively growing cells of the uterine lining membrane undergo rapid destructive changes, the fabric of the half-formed decidua tumbles to pieces, the turgid capillaries burst and pour out the menstrual flow, which sweeps away all the useless debris. The irritation sets up reflex uterine contractions, and so the blood is squeezed out of the distended capillaries and washes away the degenerated cells.

The third or reparative stage, as its name indicates, is one of repair, in which by constructive changes the epithelial lining which was thrown off is replaced by new, which is formed in from three to four days.

The fourth or quiescent stage includes the remaining twelve or fourteen days of the menstrual cycle, and represents the quiescent period prior to the initiative changes which mark the beginning of the next period.

Average Duration of the Menstrual Flow.-- The average duration of the menstrual flow is five days, although the variations are considerable in healthy women. A flow lasting any place from two to six days is perfectly consistent with health; but a flow continuing less than two or more than six days generally indicates local or general disease.

Character of the Menstrual Flow.-- For the first few hours, or perhaps for the first day, the flow is usually slight in quant.i.ty and light in color; on the second and third days the flow reaches its height, and is profuse and dark, but it should never be clotted; after this it gradually ceases. The amount of the flow varies from five to ten ounces. If less than five or six or more than eighteen napkins are pretty well saturated through, the amount may be considered abnormal.

Relation of Ovulation to Menstruation.-- It has not yet been decided just in what relation the processes of ovulation and menstruation stand to each other. It is supposed that the transit of the ovum to the uterus occupies at least one week. It has been thought that the decidua of a particular menstrual period is related, not to the ovum discharged at that period, but to the ovum discharged at the preceding period.

The menstrual wave, or the wave of "supplementary nutrition,"[*] upon which the menstrual process ultimately depends, was first established by Dr. Mary Putnam Jacobi in the Boylston prize essay for 1876; showing that menstrual life is a.s.sociated with a wave of well-marked vital energy, which manifests itself in a monthly fluctuation of the tempera ture of the body, in the daily amount of the excretion of urea and of carbonic acid, and of the rate and tension of the pulse. The wave attains its maximum during the week preceding menstruation, and slowly falls to its minimum, which is reached the week after menstruation.

* Dr. Goodman and Dr. Stephenson have since written on this subject, and the "wave" is often known as the Stephenson wave.

This wave indicates a periodic variation in the bodily metabolism, and is probably directly influenced by the rhythmic activity of the menstrual center. This observation would seem to be nullified by the fact that the phenomena referred to have been found to occur in men as well as in women; and that the lower animals also seem to show the same periodic variations. "It is therefore evident that the phenomena belong not to the function of menstruation, but to a general law of vital energy."

Definition of Menstruation.-- Menstruation may, then, be defined as the periodic discharge of blood from the uterus, accompanied by the shedding of the epithelium of the body, as well as that of the uterine glands near their orifices.

The sanguineous discharge is due partly to the oozing of blood from the surfaces denuded of epithelium, and partly to active congestion.

The discharge from the uterus is largely augmented by mucus secreted in increased quant.i.ty at this period from the enlarged uterine glands.

The tubes take some part in the process of menstruation; their mucous membrane is swollen, the epithelium is shed in places, and they are filled with a thin b.l.o.o.d.y fiuid, containing blood-corpuscles and cast-off epithelium cells.

The menstrual wave continues from p.u.b.erty to the menopause; it is a nervous phenomenon. Ovulation is a progressive, non-periodic process; it begins before birth and continues till the ovarian tissue is atrophied or worn out.

Premonitory Symptoms of the Flow.-- The premonitory symptoms of the monthly flow should not be so marked as to cause the individual any discomfort. The first indication of the return of the period should be the appearance of the flow. There is generally a feeling of abdominal fulness with some la.s.situde, and sometimes slight headache. The temperature is lower and the pulse is slower than at other times. This lowered tone of the system is an additional reason for increased care against exposure in wet or cold weather.

Hygiene of Menstruation.-- During the menstrual periods all cold baths must be strictly prohibited, whether tub-baths or cold sponges. The reason of this is that the application of cold to the surface causes a driving in of the blood from the exterior of the body to the internal organs; and at the menstrual periods there is already a congested condition of the pelvic organs, and it must be remembered that congestion is the first stage of inflammation.

Hot or warm sponge-baths may be taken throughout the period; and the v.u.l.v.a should be bathed with warm water twice a day through the entire period of the flow, as this not only removes the clotted blood before it decomposes and becomes the source of irritation, but also removes other irritating matters, and prevents the nervousness that is caused by a local irritation.

It is strange how women who are scrupulously neat in all other respects will allow the s.m.e.g.m.a to collect in and about the v.u.l.v.a; as a matter of fact, for the purpose of cleanliness it is much more necessary that the external genitals should be washed twice a day with soap and water all through life than that the face should be washed that often.

Another question which is still sub judice is the necessity for and the frequency with which v.a.g.i.n.al douches should be taken; all physicians are agreed that a v.a.g.i.n.al douche taken immediately after the menstrual period is beneficial, as it removes all the debris of the flow, which is sometimes very irritating.

Exercise.-- A moderate amount of exercise should be taken every day; this is needed now quite as much as at any other time, and only good can result from it. And no harm comes of a woman going out in the rain or in cold weather; as has been shown, the menstrual process is going on for a large part of the time, and the flow is only the external appearance, but during the time of the flow the woman must be unusually careful not to get her feet wet or to sit down with damp clothing on. Violent exercise of all kinds is to be prohibited at this time, as dancing, rides on the bicycle, gymnastics, and walks of over three miles. The reason for this is very obvious; the uterus has now reached the height of its turgescence, and is heavier than at any other time, hence the danger that displacements or a very profuse flow would be caused by any kind of violent exercise.

Treatment.-- If the woman has been so unfortunate as to get caught out in a heavy rain so that her clothes have been wet through, or if in the cold weather she should come into the house thoroughly chilled, the best thing to do is to take off her wet things as quickly as possible, be well rubbed down with hot, rough towels, drink a cup of hot tea, go to bed at once and place a hot-water bag over the abdomen.

She should remain in bed until the next morning, to the end that the circulation may regain its equilibrium as quickly as possible by the immediate relief of the pelvic congestion. If this exposure should have caused the sudden cessation of the flow, a hot mustard foot-bath should be taken. One tablespoonful of mustard is used to a gallon of water as hot as can be borne; the pail should be made as full as can be without running over, and a blanket wrapped around the pail and woman, so as to cause a profuse perspiration; this should be kept up for ten minutes; if the water cools off, hot water may be added.

CHAPTER V.

THE ANOMALIES OF MENSTRUATION.

Menorrhagia and Metrorrhagia; Dysmenorrhea; Amenorrhea; Leuchorrhea; Pruritus v.u.l.v.ae.

"Defer not till to-morrow to be wise, To-morrow's sun on thee may never rise."

-- CONGREVE

Menorrhagia and Metrorrhagia.-- By menorrhagia is meant an excessive or too profuse menstrual flow; by metrorrhagia, a flow of blood between the menstrual periods. Neither one const.i.tutes a disease by itself, but is a symptom of some pathologic condition.

It has already been stated that the excretory organs, by constantly eliminating from the system the worn-out material, keep the machine healthy and in good working order. Kept within natural limits, this elimination is the source of strength and health; beyond these limits, the menstrual flow becomes an actual hemorrhage that, by draining away the life, becomes the source of weakness and disease.

No physician would dare to bleed a man or woman once a month, year in and year out for thirty years; but, through ignorance or folly, this is what many girls do for themselves.

This excessive flow, aside from actual local disease, is brought about by excessive muscular exercise during menstruation; by the use of all stimulants, whether alcoholic beverages or quinin; as well as by the thinness of the blood.

When the flow is excessive, it must be considered a pathologic condition, which needs the physician's attention. Rest in the rec.u.mbent position is the first essential; the diet must be plain and unstimulating, and attention must be paid to the condition of the blood.

The general diseases which generally cause this condition are anemia, Bright's disease, malaria, the early stages of tuberculosis, and heart disease.

The local causes may be reflex, as powerful emotions; or due to local disease of the uterus and its appendages, as the various inflammations and displacements of the uterus, fibroid tumors, polypi, and cancer.

Dysmenorrhea is painful menstruation. The most frequent forms are due to uterine congestion; to mechanical causes, as a narrowing of the cervical ca.n.a.l, particularly at its internal opening, or to a constriction caused by the bending over of the uterus at the junction of the body and the neck; or to ovarian irritation.

The pain varies in intensity from slight discomfort to the most intense uterine colic, which is experienced in the lower part of the abdomen. In severe cases the general health becomes undermined, the nervous system gives way, and hysteria and other disorders of the nervous system result.

The congestive variety usually occurs in patients who have previously menstruated painlessly. The pain comes on suddenly with the flow and ceases when the flow stops; it is very severe and is generally accompanied by a diminution or a cessation of the flow. There is severe headache, marked diminution in the secretion of the kidneys, and general restlessness. The patient frequently experiences pain in walking, is easily fatigued, has leucorrhea and an irritable bladder.

In ovarian dysmenorrhea the pain precedes the flow for several days and ceases when a free flow is established. The pain is of a dull aching character, and may be felt on one or both sides of the abdomen, according as one or both ovaries are involved.

Amenorrhea.-- In amenorrhea the menstrual flow may not appear for some years after it is normally due; or the flow may cease after some months or years of continuance; or the flow may be abnormally scanty or even absent.

The menstrual flow is much later in appearing in some families than in others, so that this may be considered as a family idiosyncrasy; and if the girl's health is good, it need cause no anxiety. If, on the contrary, the girl has severe headaches, or suffers in any way, the physician should be summoned at once, as the absence of menstruation may be indicative of some serious pathologic condition,

A scanty flow is often indicative of thinness of the blood; on the other hand, serious anemias often lead to profuse menorrhagias or metrorrhagias, as has already been stated. The cause of the profound anemia itself may be insufficient nutrition, overwork, or lack of exercise.

Scanty menstruation is often seen to occur in fevers, in the later stages of consumption, in advanced Bright's disease, in malaria, or in any other very serious disease. In these cases it seems to be a conservative process on the part of nature in the run-down state of the system. As consumption progresses menstruation generally ceases absolutely, never to return again; and in this case nothing should be done to try to induce a return of the flow.

Great shock sometimes causes a sudden cessation of the flow; and sometimes a sea-voyage, followed by the change of habitat, will cause an obstinate form of amenorrhea.

But it cannot be too well understood that, after the menstrual flow has been regularly established, it continues with the greatest regularity throughout the child-bearing period, unless the exposure to wet or cold has been sufficiently severe to cause great indisposition on the part of the woman. In this case it is possible that, if the exposure took place just previous to the time of the expected flow, one period may remain out. But except in case of serious illness,-- as for example, typhoid fever,-- two or more periods do not fail to appear except in the case of pregnancy.

Leucorrhea.-- Leuchorrhea, or "whites," is a mucous or mucopurulent discharge from the v.a.g.i.n.a; it may be a symptom of uterine or v.a.g.i.n.al disease.