PHYSIOLOGY OF THE FEMALE GENERATIVE ORGANS.
Ovulation; Etiology of Menstruation; Uterine Nerve-supply; the Function
of the Uterus; Stages of the Menstrual Cycle; Average Duration of the
Menstrual Flow; Character of tahe Flow; Relation of Ovulation to
Menstruation; the Menstrual Wave; Definition of Menstruation; Premomitory
Symptoms of the Flow; Hygiene of Menstruution.
"Toil and grow strong; by toil the flaccid nerves
Grow firm, and gain a more compacted tone."
-- ARMSTRONG.
Ovulation.-- At birth the formation of the ova is nearly completed;
the production of' new cells probably ceases after the second year.
The ovaries of the child of two years contain, therefore, the full
quota of ova, although the vast majority of these cells always remain
immature and undeveloped. While it is probable that a variable number
of the immature ova undergo partial development before puberty, yet
the advent of sexual maturity at that time marks the establishment of
the regular development of the Graafian follicles and their contained
ova, accompanied by the attendant phenomena of menstruation.
During the entire child-bearing period, or from about the age of
fifteen to forty-five years, the development of the Graafian follicles
and the discharge of the ova are continually taking place. The
liberation of the ova usually takes place at definite times, which in
general coincide with the menstrual epochs, one or more ova being set
free at each period; but this is by no means invariable.
The ripe human ovum or germ cell is a spheric cell, about 0.2 mm. in
diameter, consisting of granular protoplasm, in which lies a nucleus
which contains the germinal spot. The proper cell-wall is a structure
of great delicacy, outside of which is a secondary envelope.
Menstruation.-- The etiology of menstruation has been variously
explained at different epochs. The chief theories have been that of
plethora, and the ovulation, the tubal, and the nerve theories.
First, the Theory of Plethora.-- From the time of Hippocrates to 1835
the theory prevailed that in the female body the formation of blood is
sufficiently rich to provide every four weeks for an overflow of the
same, the evacuation of which becomes a necessity. It was believed
that this excess of blood depended on an excess of formative power in
the woman.
Second, the Ovulation Theory.-- This was distinctly formulated about
1845. It construed the menstrual hemorrhage as a subsidiary
phenomenon, entirely dependent on the periodic dehiscence of ovules.
The changes supposed to take place in the Graafian follicles at each
menstrual period were believed to involve a peculiar expenditure of
nerve force, which was so much dead loss to the individual life of the
woman. The growth of the Graafian vesicle and its contained ovum was
supposed to cause an irritation of the nerves of the ovary, which was
reflected to the entire nervous system. The gradual accumulation of
this irritation finally caused a reflex action which determined an
afflux of blood to the uterus and ovaries, which constitutes the
catamenial flow.
The ovulation theory was refuted by the following facts: Ovulation may
and does occur without menstruation; women who have never menstruated
may conceive; conception may occur during lactation, without the
menses having returned since the last parturition; children at birth
have many ovules contained within the ovaries; ovulation may persist
for a time after the menopause, and even pregnancy has occurred,
although very rarely after this time; the menses may continue
regularly after the removal of the ovaries and Fallopian tubes; this
is exceptional, and, as a rule, the periods only continue for two or
three years at longest.
Third, the Tubal Theory.-- Lawson Tait thought that thorough removal
of the tubes was far more essential in determining the menopause, and
that cases of periodically recurring hemorrhage after the removal of
the ovaries were to be explained by the fact that the tubes had not
been sufficiently removed. As an anatomic and surgical fact, the tubes
can never be wholly excised unless the upper part of the uterus is
also amputated.
Fourth, the Nerve Theory of Menstruation.-- This is based upon the
following views:
1. That menstruation is a process directly controlled by a
nerve-center situated in the lumbar region of the spinal cord.
2. That the menstrual impulses reach the uterus through two sets of
nerves.
3. That menstruation is the result of nerve irritation, vascular
congestion, and the subsequent relief of these by hemorrhagic
discharges.
4. That hemorrhage from the uterus is the result either of a local
uterine condition, or of influences outside of the uterus acting
directly on the center.
5. That the removal of the appendages arrests menstruation by
preventing the propagation of uterine influences to the center.
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
class 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 vagina 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 emancipation 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 quantity 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 associated 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 quantity 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 bloody fiuid, containing blood-corpuscles and
cast-off epithelium cells.
The menstrual wave continues from puberty 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 lassitude, 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
vulva 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 smegma to collect in and about the vulva; 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 vaginal douches should be taken; all
physicians are agreed that a vaginal 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.