Part 14

7 A. M.— 250 grammes of milk.

9 A. M.— 250 grammes of bouillon, 1 egg, 20 grammes of brandy.

11 A. M.— 250 grammes of milk.

1 P. M.— 100 grammes of roast meat, 250 grammes of rice-broth with 5 grammes of somatose, and 150 grammes of claret.

3 P. M.— 250 grammes of milk.

5 P. M.— 1 egg, 20 grammes of brandy.

7 P. M.— 250 grammes of bouillon or white soup with 5 grammes of somatose.

As a beverage in the intervals, weak cold tea is allowed. When the hæmorrhage has ceased, the following beverages are suitable: oatmeal, cocoa, Pilsener beer (one pint daily), milk (2 to 3 pints daily), claret (a half bottle daily). For food, the lighter varieties of meat, 200 to 300 grammes daily, sweetbread, pigeon, ham, nutrient and easily digestible vegetables, spinach, carrots, and pea-soup, may be recommended.

In cases of amenorrhœa or scanty menstruation, especially when due to anæmia or to underfeeding, mental excitement, or over-exertion, warm baths at a temperature of 28° to 29° R. (90° to 92° F.), rubbing the body with wet towels, and warm sitz-baths, are of good service.

[NOTE: Although in this translation the English equivalents of the measures used on the Continent have as a rule been appended in parenthesis, this has not been thought necessary in the case of the diet-tables, since even in English works these are commonly stated in terms of the metric system. It may here be mentioned that, as regards fluid measures, 250 grammes (a quarter of a litre) is roughly equivalent to half a pint, an ordinary tumblerful or breakfast-cupful; and that, as regards solid measures, 30 grammes are equivalent to a very little more than an avoirdupois ounce.]

_Menstruation._

Menstruation is the name given to the process which manifests itself in the human female after the age of puberty by the discharge from the genital organs at regular four-weekly intervals of a mucosanguineous secretion. This discharge is not merely the result of a local hyperaemic condition, but is the expression of a periodic excitation of the entire nervous system and blood vascular system, intimately related with the whole sexual life of woman; this excitation is itself dependent upon the process of ovulation, an incident in the series of manifestations that arise from the periodic undulatory movement in the vital processes of woman.

The Mosaic law regarded the process of menstruation as unclean in nature; the menstruating woman was unclean, and must be purified in a prescribed manner. In the fifteenth chapter of Leviticus, vv. 19–29, we read: “And if a woman have an issue, and her issue in her flesh be blood, she shall be put apart seven days: and whosoever toucheth her shall be unclean until the even. * * * Every bed whereon she lieth all the days of her issue shall be unto her as the bed of her separation. * * * But if she be cleansed of her issue, then she shall number to herself seven days, and after that she shall be clean. And on the eighth day she shall take unto her two turtles, or two young pigeons, and bring them unto the priest, to the door of the tabernacle of the congregation.”

In a similar manner the adherents of the faith of Islam regard a menstruating woman as unclean.

This view is found also in the earliest medical writings, alike in the early Indian book of _Susruta_ and in the later writings of _Hippocrates_, and it persists to the present day in the use of the expression “monthly purification.” _Susruta_ teaches that in India menstruation begins at the age of twelve, and recurs monthly, the flow lasting three days. In the Jewish Talmud it is asserted (see “La Médécine du Talmud,” by _Dr. Rabbinowicz_) that menstruation begins as soon as the girl has two hairs on the pubic region, or at the age of twelve, even in the absence of any growth of the pubic hair. The menstrual blood is quite peculiar in its characters. Thus, _Raschi_ relates, the mother of the King of Persia exhibited sixty varieties of blood, and among them _Rabba_ was able to detect which was the menstrual blood. According to a rabbinical authority, a woman can become pregnant as soon as she has completed her twelfth year. As signs of puberty, _Rabbi Jossé_ mentions the appearance of a fold beneath the nipple, _Rabbi Akiba_, the erection of the nipples, _Rabbi d’Azai_, the appearance of a dark areola around the nipples, _Rabbi Jossé_, the recession of the nipple under pressure followed by its gradual protrusion when the pressure is removed, also the softening of the mons Veneris (in consequence of the deposit of fat in its substance). As prodromal signs of the first appearance of menstruation, the Talmud mentions, pain in the region of the umbilicus and in the uterus, flatulence, shivering, white flux, heaviness in the head and the limbs, and nausea.

The blood discharged during menstruation has certain peculiar properties. It is always fluid, and rarely contains fibrinous clots, it is always mixed with a larger or smaller quantity of mucus, which gives it a sticky character; the reaction is alkaline, the smell characteristic. Only when the bleeding is very profuse are coagulated masses evacuated. On microscopical examination of menstrual blood, we detect erythrocytes and leucocytes, the proportional number of the latter being greater than in pure blood; there is an admixture also of epithelium from the genital mucous membranes, cylindrical cells from the uterus, flattened cells from the superficial layers of the stratified scaly epithelium of the vagina, also various micro-organisms and granular detritus. At the beginning of each menstruation, the admixture of mucus is greatest, so that the discharge sometimes has the appearance of blood-stained mucus; but during the height of the discharge the consistency is almost that of pure blood. The quantity of blood lost at each period is said to vary from 90 to 240 grammes (about 3 to 8 fluid ounces); but in tropical climates the average is said to be 600 grammes (20 ounces). According to the accurate analysis of _Denis_, menstrual fluid contains in a thousand parts:

Total solid constituents 175.00 Comprising Fat 3.90 Blood-corpuscles 64.40 Albumin 48.30 Extractives 1.10 Salts 12.00 Mucus 45.30 ————— Water 825.00 ——————

Both the quality and the quantity of the blood are subject to great variations. Thus, for instance, _Bouchardat_ estimates the solid constituents at 99.20 per mille, _Vogel_ at 161 per mille, and _Simon_ at 215 per mille. The amount of blood discharged during menstruation depends upon the temperament, the constitution, and the occupation, of the woman concerned. It is greater in vivacious brunettes than in phlegmatic blondes, greater in southern women than in those dwelling in the north, greater in town dwellers than in women living in the open plains, greater in those whose mode of life is sedentary than in those engaged in some active occupation.

Similar considerations apply with regard to the duration of each period. The mean duration is in the great majority of cases from four to five days, being generally the same in successive periods in the same individual; in exceptional cases the flow may last a week or more. Menstruation lasting more than eight days must be regarded as abnormal.

_Krieger_ has collected data relating to the duration of the individual periods. He found the duration constant in the great majority of cases, _i. e._, 93.285 per cent.; but variable in a small minority, _i. e._, 6.715 per cent.

The periods in which the duration was regular did not always last precisely the same number of days, the duration in many cases being 3 to 4 days, 5 to 6 days, etc.; but the same duration recurred regularly at each successive period, so that all these instances must be reckoned among the periods of regular duration. The duration must be regarded as irregular or variable in those cases in which the variation was from 2 to 4 days, 3 to 8 days, etc. Sometimes a regular three-day or five-day period becomes transformed into an eight-day period; or conversely an eight-day period into a four-day period.

Among the cases in which the duration was regular, it amounted

Most frequently to 8 days, in 26.695 per cent. Next in frequency was a duration of 3 days, in 20.762 per cent. Next, a duration of 4 days, in 16.949 per cent. Next, a duration of 5 days, in 11.864 per cent.

_L. Mayer_ has also drawn a distinction between constant and variable duration of the menstrual periods. Among 4,927 women, he found 4,542 (92.185%) in whom the duration was constant, and 385 (7.815%) in whom it was variable. Of the constant periods, the duration was:

8 days in 1182 women, that is in 26.024 per cent. 4 days in 829 women, that is in 18.252 per cent. 3 days in 731 women, that is in 16.094 per cent. 5 days in 730 women, that is in 16.072 per cent.

An extremely short duration, less than 24 hours, was found in 70 women, an extremely long duration, 7 to 14 days, was found in 175 women, and finally a duration exceeding 14 days was found in 19 women.

The mean duration in these cases was 5.387 days.

The results obtained by _Szukits_, who investigated the duration of the periods in 1,013 women, are somewhat divergent from the above. He found:

A duration of a few hours only in 95 women, that is in 9.38 per cent. A duration of 1 to 2 days in 66 women, that is in 6.51 per cent. A duration of 3 days in 407 women, that is in 40.17 per cent. A duration of 4 days in 171 women, that is in 16.88 per cent. A duration of 5 to 6 days in 115 women, that is in 11.35 per cent. A duration of 7 to 8 days in 118 women, that is in 11.63 per cent. A duration of 9 days and upwards in 41 women, that is in 4.05 per cent.

The mean duration in these cases was 3.87 days.

The mean duration of the menstrual flow is:

In Paris 5 days. In London 4.6 days. In Berlin 4.5 days. In Copenhagen 4.3 days (according to Mayer, 5.3 days). In Austria 3.8 days.

The interval between one menstruation and the next (the period that elapses, that is to say, between the commencement of one period and the commencement of the next) is in the great majority of cases twenty-eight days. The recurrence in many women is extraordinarily exact, not merely as regards the day, but even as regards the hour of the day. The twenty-eight-day type of menstruation is found in about 70 per cent. of the cases; in the remainder, the thirty-day type is most frequent, and next to that the twenty-one-day type. The periodicity of menstruation in any individual may however be very irregular.

The quantity of blood lost during menstruation varies within wide limits; according to approximate estimates the usual loss at a single period is from 90 to 240 grammes (about 3 to 8 fluid ounces). The following summary statement is made by _Krieger_ regarding the quantity lost in different social circumstances and in various nationalities:

The amount of blood lost and the duration of the flow are less in strong, healthy women, leading an occupied, active, and regular life, especially in countrywomen and in women who are poor and chaste, than it is in delicate, weakly women, leading a sedentary life, whose diet is abundant and stimulating, and who are accustomed to an ultra-luxurious and enervating existence. In nuns, for example, the quantity of the menstrual discharge gradually declines; shortly after their entrance into the cloister, various irregularities are apt to occur, but ultimately the flow becomes exceedingly scanty and lasts for a single day only. Climate also has a great influence, for in hot countries women usually menstruate very abundantly, whilst in cold countries the flow is scanty, and often appears only in the warmer months of the year. Of the Lapp and Samoyede women this was already reported by _Linnæus_ and _Virey_. _Tilt_ further relates that Eskimo women menstruate only during the summer months, and even then scantily. In southern France, according to _Courty_, the quantity varies from 120 to 240 grammes (about 4 to 8 ounces); but it may rise to 300, 350, and even to 500 grammes (about 10, 12, and 16½ fluid ounces). In the tropics, severe menorrhagia is said to be common; and the fact was already known to _Blumbenbach_, that women of European descent born in the tropics not infrequently succumb to hæmorrhage during childbirth.

_L. Mayer_ has endeavored to determine the relations between the quantity and the quality of the discharge, and distinguishes the regular composition, when a considerable quantity of dark-tinted, fluid blood is passed, from the irregular composition, when a small quantity of blood, usually pale in color, is passed, or an excessive quantity of dark blood, often coagulated, or a discharge of varying composition.

Of 4,542 women questioned by _Mayer_ in regard to this matter, there were:

2,998, that is 66.006 per cent., in whom the composition was regular. 1,544, that is 33.994 per cent., in whom the composition was irregular.

and among the latter the discharge was

Scanty and for the most part pale in 511; that is 12.250 per cent. Profuse or profuse and coagulated in 838; that is 18.428 per cent. Variable in 196; that is 4.315 per cent.

Investigation regarding the individual variations that occur in this respect among women, showed that blondes usually menstruate more profusely than brunettes, and that in the former also the duration of the individual periods is longer.

The loss of blood must be considered less in respect of its absolute quantity than in respect of the effect which continued observation shows its loss to have upon the organism. If the loss of blood continues to have an effect after the flow has ceased, if a woman recovers but slowly, or even fails to recover fully from one loss before another begins, if symptoms of increasing anæmia become apparent, the bleeding must be regarded as a pathological perversion of normal menstruation. Pathological is it also if the menstrual flow does not exhibit the normal slowly rising and slowly declining curve, but sets in profusely, ceases or almost ceases for a time, and then again suddenly recurs. In some cases the flow is not profuse, but lasts for a long time, and owing to this long duration it has a debilitating effect, especially in anæmic and chlorotic individuals.

As a rule, in normal menstruation, the admixture of the alkaline cervical mucus suffices to keep the menstrual discharge fluid and to prevent the formation of fibrin. On the other hand, the discharge of coagulated masses of blood will alone suffice to indicate an abnormally free and rapid flow of blood.

The commonest type of menstruation is the more or less regular recurrence of the flow at intervals of twenty-eight days. Variations in this respect are, however, very frequent, and are dependent upon constitution, position in life, and race. In general it may be said that in persons of strong constitution, the type of menstruation is much more regular, than in persons of a weakly, delicate constitution; that in vivacious, ardent natures the menses more readily anticipate the expected period of their return, whereas in those of a flaccid, lymphatic temperament a retardation is more likely to occur; and that amongst women of the upper classes of society the type of menstruation is far more frequently irregular than amongst women of the working classes and amongst countrywomen. Whereas in many women the regularity of the menstrual rhythm is so precise that the flow recurs, not merely at regular intervals of twenty-eight days, but even time after time at exactly the same hour of the day—in other cases the interval between two periods may vary from twenty-one to thirty days.

_L. Mayer_, who made observations on the type of menstruation in 5,671 women, and tabulated his results, distinguishes between constant and inconstant intervals. Among the constant intervals he enumerates those forms, both regular and irregular, which do not during the whole life of the individual undergo transformation into another form, but remain always of the same type. If, for instance, in any individual the interval is always either two or eight weeks, in that woman menstruation is indeed irregular, but constant in type. If, however, for some years she menstruates at intervals either of two or of eight weeks, and then proceeds to menstruate at intervals of four weeks, her menstruation is of the inconstant type. _Mayer_ found among his 5,671 cases

The constant type in 4,981 women, that is in 87.83 per cent. The inconstant type in 690 women, that is in 12.16 per cent.

Of the cases in which the type was constant there were 69.68 per cent. in which the regular period of four weeks obtained, and 20.31 per cent. in which it was irregular in the sense above defined. Among these latter, the commonest periods were 15 to 21 days and 22 to 27 days. The same author observed the irregular type of menstruation in nearly one-fourth of the women belonging to the well-to-do classes.

According to the observations of _Krieger_ on 481 cases in which the periods were regular, that is, in which the intervals in each case were equal in duration, the time from the commencement of one period to the commencement of the next was:

28 days in 70.80 per cent. 30 days in 13.74 per cent. 21 days in 1.66 per cent. 27 days in 1.45 per cent.

As regards the season in which menstruation first appears, _Krieger_ states that in one-half of the women examined by him menstruation had begun in the autumn season, in the month of September, October, or November.

_Szukits_, as a result of an investigation into the menstrual functions of Austrian women, determined that among 1,013 women menstruation occurred:

Every 28 to 30 days in 642 women. Every 8 to 21 days in 169 women. Every 35 to 56 days in 128 women. And was quite irregular in 74 women.

In 500 Jewish women, _Hirsch_ found that menstruation occurred:

23 days after the beginning of the last menstruation in 19 24 days after the beginning of the last menstruation in 29 25 days after the beginning of the last menstruation in 36 26 days after the beginning of the last menstruation in 56 27 days after the beginning of the last menstruation in 62 28 days after the beginning of the last menstruation in 73 ——— 275 ===

and in the remaining cases at other intervals than those stated. He is, therefore, of opinion that in the majority of Jewish women the type of menstruation is shorter then twenty-nine days.

According to _Brierre de Boismont_, among 100 women menstruation recurred:

Every 4 weeks in 61 women. Every 3 weeks in 28 women. Every 2 weeks in 1 woman. And at various irregular periods in 10 women.

_Tilt_ found among 100 women that menstruation recurred:

Every 4 weeks in 77 women. Every 3 weeks in 17 women. Every 2 weeks in 1 woman. Every 6 weeks in 5 women.

_Foster_ instituted inquiries regarding this matter in 56 healthy women. In 380 periods, 45 recurred after an interval of 28 days, 225 after a shorter interval than this, 110 after a longer interval. The duration of the flow varied from 1 to 14 days; most commonly it lasted from 3 to 5 days.

A peculiar change in the type of menstruation sometimes manifests itself in this way, that in women in whom the regular four-weekly type of menstruation has prevailed, exactly in the middle of this four-weekly period the menstrual molimina, with or without menstrual discharge, make their appearance; the patient suffers from pain in the lower belly, sacrache, sensation of weight, and bearing-down pains. _Courty_, _Dubois_, and _Pajot Négrier_ have described such cases of _molimen utérin intermenstruel_, which _Tilt_ denotes by the term _remittent menstruation_.

From the earliest times the process of menstruation has attracted the attention of natural philosophers, and has led them to formulate hypotheses and to institute investigations, especially in order to ascertain whether the connection between ovulation and menstruation is one of temporal succession merely, or whether the relation is a causal one.

From _Hippocrates_ and _Galen_ downwards until well beyond the middle ages, the view of the father of medicine was generally accepted, that menstruation is a purificatory process by means of which materials harmful to the organism are eliminated from the body—a view which finds expression also in the religious and legal ordinances of all times.

A new epoch of scientific research into the nature of menstruation began with _de Graaf’s_ discovery of the ovarian follicles (1672). This discovery did not, indeed, bring ovulation and menstruation into immediate relationship, but it certainly paved the way for the opinion expressed by _Sintemma_, a countryman of _de Graaf_, that the ova, even in virgins, leave the ovary spontaneously, and by their contact with the capillary terminations of the bloodvessels give rise to the menstrual bleeding (1728).

As a result of anatomical investigations, _Négrier_, in 1840, was the first to establish the thesis that in women suffering from congenital absence of the ovaries, menstruation never occurs; that after the loss of the ovaries, menstruation always ceases; that during pregnancy and lactation and during the climacteric period, ovulation ceases; and that a relation of temporal succession obtains between ovulation and menstruation. This close relation between the two processes was maintained also by _Gendrin_ at about the same date. Later, _Girdwood_, by post mortem research, proved that the number of scars in the ovary coincides with the number of previous menstruations.

_Brierre de Boismont_, in his exhaustive work on _Menstruation_, lays stress on the view that the periodically recurring ovulation furnishes the impulse for the menstrual flow. First among German investigators, _Bischoff_ upheld the opinion that maturation and discharge of ova are spontaneous processes occurring independently of sexual intercourse, and compared heat or rut in other animals to menstruation in women—a view shared by _Pouchet_ and _Coste_. Ovulation occurs simultaneously with the menstrual flow, and the follicles burst toward the end of menstruation.

_Pflüger_, in his important work on the significance and cause of menstruation, has demonstrated the causal connection between menstruation and ovulation. The bleeding and the discharge of the ova are according to him joint effects of a common cause. It is not the bursting of the follicle, but the ripening of the follicle, that gives rise to the menstrual congestion. The pressure of the growing follicle on the surrounding ovarian tissue gives rise to a continued stimulation of the ovarian nerves; the summation of these stimuli, which after the lapse of a certain time attain always a certain degree of intensity, results in a reflex from the spinal cord taking the form of great congestion of the genital organs; this congestion leads, on the one hand, to hæmorrhage from the uterine mucous membrane, and, on the other hand, and as a rule simultaneously, to the bursting of the ovarian follicle. The swelling and granulation of the uterine mucous membrane at every menstrual period signifies nothing else than the commencement of the formation of the decidua.

_Nägele_ already mentioned the view, that inasmuch as immediately after the first appearance of menstruation a woman has become capable of reproducing the species, each process of menstruation must be regarded as a renewal of the exhausted faculty for conception.