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.

_Pflüger’s_ teaching has been opposed by _Sigismund_, who, whilst

admitting the periodicity of ovulation and menstruation, yet regards the

two processes, in the uterus the formation of the menstrual decidua, in

the ovary the rupture of the graafian follicle, as independent of one

another, even though they occur simultaneously. Should fertilization

occur, the ovum implants itself in the prepared soil; should

fertilization fail to occur, the menstrual hæmorrhage ensues. Thus, the

occurrence of menstruation indicates that fertilization of the ovum has

failed to occur. On this theory, then, the ovum that is fertilized

belongs to the first period missed, whereas _Pflüger_ assumes that when

pregnancy occurs, it is always the ovum belonging to the time of the

previous menstruation—the last actual menstrual discharge—that is

fertilized.

_Löwenhardt_, in his work on the _Diagnosis and Duration of Pregnancy_,

advances the same views as _Sigismund_. The fertilized ovum, in his

opinion also, is that of the first period missed; and since at the time

at which he believes fertilization to occur the ovum is certainly still

in the ovary, fertilization, on this theory, must always take place in

the ovary itself, and the fertilized ovum cannot begin its intra-uterine

life till a month has elapsed after fertilization. _Reichert_,

_Kundrat_, _Engelmann_, and _Williams_, basing their views on anatomical

data, are of opinion that ovulation recurs periodically, and that the

extrusion of the ovum occurs not before but after the commencement of

menstruation.

According to _Hensen_, the observed facts support the view that the

follicles burst as a rule toward the end of menstruation; anticipation

or postponement of the opening of the follicle (conception before or

after menstruation) would, however, appear not to be impossible.

_Leopold_, who assumes that menstruation may occur without ovulation and

ovulation without menstruation, maintains on anatomical grounds that the

rupture of the graafian follicle occurs chiefly during menstruation,

under the influence of the swelling due to menstrual congestion.

Menstruation with ovulation he believes to be a common occurrence,

menstruation without ovulation, an unusual occurrence. Further, it is

certain that, at the time when the periodic bleeding is due, ovulation

may occur, even though the menstrual discharge fails to make its

appearance (ovulation without menstruation).

_Chazan_ and _Gläveke_ also adhere to the generally accepted view that

ovulation is a periodic process, usually but not necessarily synchronous

with menstruation.

_Strassmann_ bases on clinical facts and on experiments the following

view of the connection between ovulation and menstruation. The principal

processes in the organism of the sexually mature woman run their course

in a periodic rhythm resembling an undulatory movement, the acme of

which occurs in the antemenstrual period with the aim of preparing for

the development of an infantile organism. Whilst an ovum is maturing in

the ovary, in the uterus, in dependence upon this maturation, the

antemenstrual mucous membrane, fitted for the reception and nutrition of

the fertilized ovum, is also undergoing development. At the acme of the

undulatory movement, the graafian follicle ruptures and the ovum is

liberated, to undergo fertilization in the infundibulum of the Fallopian

tube. If fertilization fails to occur, or if for any reason the graafian

follicle fails to rupture, then, in consequence of and at the time of

the highest intra-ovarian tension, at the time, when the rupture of the

follicle usually occurs, the extrusion of blood from the capillaries of

the uterine mucous membrane begins. The intermediation between the ovary

and the uterus is probably effected by means of the sympathetic ganglion

in the ovary discovered by _Elizabeth Winterhalter_, and effected in

this manner, that the stimulus proceeding from the ripening follicle

passes along the nerve-fibrils surrounding the follicle to the processes

of the nerve cells of this sympathetic ganglion, accumulating in these

cells till a certain degree of intensity has been reached, and then, by

means of other processes and of the vasomotor nerves, influencing the

vessels of the uterus.

_Gebhard_ likewise believes menstruation to be dependent on the ovarian

function, and thinks that it is probably brought about in a reflex

manner by the gradual growth of the ovarian follicles. It appears that

most commonly at the time of menstruation a graafian follicle ripe to

bursting is to be found in the ovary, but to this rule there are many

exceptions. We cannot exclude the possibility, that the ovum from a

follicle that burst after the commencement of the menstrual flow may be

fertilized; but more commonly the ovum that is fertilized is that of the

first period missed. The sudden decline in vital energy that occurs just

before menstruation is explained by _Gebhard_ as a kind of atavism,

dependent on the fact that many of the lower animals, butterflies, for

instance, succumb as soon as they have fulfilled their duty of

reproducing the species.

A number of modern investigators, however, deny that any relation,

temporal or causal, exists between ovulation and menstruation, and

affirm that the latter process is quite independent of the former.

Thus, _Christopher Martin_ maintains that a special menstrual centre

exists in the lumbar portion of the spinal cord, the impulses from which

proceed to the uterus by way of the splanchnic plexus, the ovarian

plexus, or perhaps by both. Similar views are held by _Lawson Tait_,

_Collins_, and _Johnstone_, who severally maintain that the ovaries are

no more concerned in the production of menstruation than any other organ

of the body—the liver, for instance. They direct attention to the

periodicity that occurs in the functional activity of various other

organs, in respiratory and cardiac activity, for instance, both of which

undergo rhythmical changes as a result of nervous influences. The

cessation of menstruation after oöphorectomy they attribute, not to the

cessation of ovulation, but to the division of the nerves which run

across the broad ligaments of the uterus and upon which menstruation

depends. Heat and rut in animals have a different significance from

menstruation. The latter process is induced by civilization and by the

adoption of the upright posture.

But, taking all this into consideration, we must hold fast to the

fundamental principles, that ovulation occurs at that period of life,

and only at that period, during which menstruation proceeds regularly;

that ovulation begins when externally and in the whole development of

the girl the signs of sexual maturity manifest themselves; and that

ovulation ceases at the climacteric, when menstruation also ceases. We

must regard as rare exceptions to this rule cases in which ovulation

begins before the menarche and persists after the menopause.

A physiological interruption of menstruation occurs during pregnancy and

lactation; it seems improbable, however, that during this interval

ovulation also is in abeyance. It is established by anatomical

investigations that ovulation and menstruation commonly occur in

association; but that menstruation sometimes, though rarely, occurs in

the absence of ovulation; and, finally, that intermenstrual ovulation is

also a rare occurrence. In the majority of cases, either just before or

just after the commencement of the menstrual flow, rupture of a graafian

follicle occurs. After complete oöphorectomy, menstruation ceases; it is

only when functionally active portions of ovarian tissue have been left

behind, that menstruation continues to occur. In the absence of the

ovaries, the menstrual function is in abeyance; hence, for the

performance of that function, the presence of ripening ovarian follicles

and of other follicles capable of ripening later, is an indispensable

requisite.

A certain analogy between heat and rut in animals and menstruation in

women may, according to the investigations of _Bischoff_, _Hegar_,

_Strassmann_, and others, certainly be maintained. Heat or rut is a

process occurring in mammals, dependent on the reproductive glands,

characterized by an increase in sexual and general excitability, with

congestion of the pudendum and the vagina, swelling of the sebaceous

glands of the external genitals, and increased secretion; from the

vulval cleft there flows a peculiar, strong-smelling mucus, often tinted

red from admixture with blood; there is frequent micturition, the

uterine glands are swollen, the Fallopian tubes are also swollen, and

are soft and erected. A well-developed menstrual bleeding, analogous to

that which occurs in the human species, occurs, among the lower animals,

only in apes. Maturation of ova precedes the period of heat, and rupture

of the graafian follicle occurs during that period.

Heat or rut occurs in animals at certain seasons of the year, which may,

according to the species and the mode of life of the animal concerned,

be in spring, summer, autumn, or winter. The season of heat or rut has

further several periods of heat, each lasting several days, and among

domesticated animals, mares, cows, and bitches, succeeding one another

at intervals of three or four weeks; in wild animals, rut occurs once

only in the year. In animals, sexual intercourse takes place during the

time of the menstrual discharge, and during this time also the capacity

for conception is increased; in the absence of heat, the genital organs

are in a more quiescent condition. In this connection, the experiments

on animals made by _Strassmann_, with a view to determining the

influence upon the uterus of rise of pressure in the ovary, are of great

interest; these experiments showed that a rise of intra-ovarian

pressure, produced by the injection of fluid into the parenchyma of the

ovary, led to changes in the endometrium and the external genital organs

corresponding to those occurring in an animal on heat.

In the human species, however, in contradistinction to what occurs in

the lower animals, there is a certain disinclination, on the part of the

male at any rate, to sexual intercourse during menstruation. The human

female moreover, notwithstanding the periodicity of her sexual life, is

at all times capable of conception; this capability is not confined to

any particular part of the intermenstrual period, for conception may

occur at any time during that period, and has even been known to result

from intercourse during menstruation. This peculiar characteristic of

the human reproductive capacity has been regarded as compensatory,

furnished by nature in her continual endeavour for the perpetuation of

the species, to counteract the restricting influences imposed by

civilization on the normal process of reproduction.

Credible observations even exist, indicating that among many primitive

peoples, in whom at the time of puberty no social laws hinder the

limitless exercise of the reproductive functions, this capacity on the

part of woman to conceive at any time has no existence, and that the

reproductive capacity of such human beings is, like that of the lower

animals, confined to a certain season of the year. Thus, _G.

Schlesinger_ reports of the Ainus of the island of Yezo, “A friend of

mine in Sapporo believes himself to have observed that the Ainus have a

certain definite rutting period, and that in them, as in many of the

lower animals, the process of reproducing the species occurs only at a

certain season of the year.” An identical statement is current

concerning the Indians of Western America.

The mucous membrane of the uterus undergoes during menstruation

important changes, and a question much disputed is, whether in the

course of menstruation the whole of the uterine mucous membrane is

removed, or a part only, whether it is shed in its entire thickness, or

is at least deprived of its epithelium. According to the observations

made by _Leopold_ on dead bodies, the mucous membrane of the uterus

becomes swollen shortly before the commencement of the menstrual

discharge, until, partly in consequence of cellular proliferation,

partly in consequence of œdematous infiltration, and partly in

consequence of enlargement of the lymph-spaces, it attains a thickness

of 6 to 7 millimetres (¼ of an inch). The superficial capillaries are

notably enlarged, and an effusion of blood-elements continues for

several days, without the occurrence of any fatty degeneration in the

tissues. The epithelium and the most superficial cell-layers of the

mucous membrane are, however, undermined and shed. No complete

destruction of the mucous membrane occurs, however, and fatty

degeneration forms no part of the menstrual process as such.

_Möricke_, who examined portions of the uterine mucous membrane removed

with the curette during menstruation from living women, found the

superficial layers of the mucous membrane to be intact, and he regards

the shedding of the epithelium described by other authorities as

cadaveric phenomenon. _Sinéty_, who also found the uterine mucous

membrane intact during menstruation, adheres to the same view.

_Von Kahlden_ concludes, as a result of investigations made post mortem,

that during menstruation the greater part of the mucous membrane, not

the superficial epithelium only, but the stroma itself down to its

deepest layers, is shed. According to _von Tassenbroek_ and _Mendes le

Leon_, however, the most superficial layers only are shed during

menstruation.

According to _Westphalen_, whose investigations were made, partly on

masses removed by the curette, and partly on freshly extirpated uteri, a

sanguineo-serous infiltration of the mucous membrane begins about ten

days before menstruation. Great vascular dilatation occurs only just

before menstruation. The uterine glands undergo enlargement, and during

and immediately after the flow, numerous shed epithelium cells occupy

the lumen of the glands. For the rest, however, in the interior of the

uterus shortly after menstruation, we find an almost continuous

epithelial covering. Some days after menstruation, the proper

regeneration of the mucous membrane occurs.

_Mandl_, who examined totally extirpated uteri, asserts that during

menstruation the epithelial covering of the mucous membrane is never

completely lost, but that just as little does it remain completely

intact. The regeneration of the lost areas of epithelium proceeds even

during menstruation.

The researches of _Kundrat_ and _Engelmann_ on uteri obtained post

mortem led these authors to describe as follows the anatomical changes

that occur in the uterine mucous membrane at the time of the catamenial

hæmorrhage. In the premenstrual epoch a round-cell infiltration occurs

in the interglandular tissue, the lumina of the uterine glands become

enlarged, and the bloodvessels dilated; subsequently, fatty degeneration

of the superficial epithelium and the epithelium of the glands occurs,

leading to laceration of the vessels and destruction of the affected

area of tissue; after the cessation of the bleeding, regeneration of the

mucous membrane occurs.

According to _Gebhard_, three stages may be distinguished. The first

stage is that of premenstrual congestion, or stage of engorgement: the

capillary vessels of the mucous membrane become distended with blood,

the membrane itself becomes softened, the meshes of the stroma become

enlarged and are filled with the morphological constituents of the

blood, subepithelial hæmatomata are formed. The second stage is that in

which the blood finds its way to the exterior: owing to the turgescence

of the mucous membrane the blood is able to exude between the cells of

the intact epithelium; further, the epithelium becomes lacerated in

various places where hæmatomata have formed beneath it, allowing the

blood to exude through the apertures thus formed; shreds of epithelium

may be washed away by the blood-stream. The third stage is that of

post-menstrual regeneration: the swelling of the mucous membrane

disappears, the detached areas of epithelium readhere, the blood effused

into the interstices of the tissue is reabsorbed, or is in part

transformed into yellowish-brown flakes of pigment. According to

_Gebhard’s_ view, during menstruation destruction of the uterine mucous

membrane does not occur. At no time is the membrane denuded of large

areas of epithelium; a very active process of regeneration occurs,

however, in the superficial epithelium and the epithelium of the glands,

which fits the uterine mucosa for the reception of the fertilized ovum

by keeping it in an ever-young and renovated condition. The mucous

membrane of the cervix takes part in menstruation at most by an

increased secretion of mucus.

According to _Landau_ and _Rheinstein_, the mucous membrane of the

Fallopian tubes contributes to the menstrual hæmorrhage; _Fritsch_ and

_Strassmann_, however, are opposed to the view that there is a regular

tubal menstruation.

_Pathology of Menstruation._

Only a small proportion of girls and women are entirely free, at the

time of menstruation, from all change both in their bodily and in their

mental state. A very great majority complain of feeling more or less

unwell, of sensations of weight and pressure in the hypogastric region,

of a general feeling of languor, loss of appetite, headache,

irritability, sometimes of an inclination to weep; in women, a change in

the intensity of the sexual impulse manifests itself, an increase in

some, a decrease in others.

Not infrequently during menstruation, the cardiac activity is notably

affected, so that, regularly at the commencement of each period,

disagreeable sensations occur in the cardiac region, with increased

frequency of the heart’s action; or complaint is made of coldness and

dampness of the hands, of icy coldness of the feet, which feel as if

“dead” to half way up the calves, and cannot be warmed—phenomena which,

in the cases under consideration, occur only at the time of

menstruation, and are to be regarded as manifestations of the menstrual

reflex.

I examined 140 women in whom the heart and the vascular system were

normal, during a number of successive menstrual periods, and in 12 of

these women, either at the commencement or during the course of the

flow, I observed an increase in the frequency of the heart to the extent

of from 12 to 28 beats per minute; in young girls, a systolic murmur was

sometimes audible during menstruation, but was inaudible in the

intermenstrual intervals. In all these persons, menstruation was

regular; there was no abnormality in respect either of the duration or

of the quantity of the flow. The heart in these cases was, therefore,

affected by the normal menstrual process.

A remarkable illustration of the alleged influence of menstrual

disturbances on the pulse is reported by _de Villeneuve_, who states

that Chinese physicians, being accustomed to feel the pulse in many

different arteries, are able, by a comparison of the characters of the

pulse in the two arms, to determine whether a woman menstruates

regularly or irregularly.

Many women and girls show well-marked menstrual molimina, uneasy or

actually painful local sensations in the genital organs, sacrache,

painful uterine contractions, and disturbances of the general

constitutional state, which are dependent upon menstrual congestion of

the pelvic organs, upon local engorgement; sometimes such symptoms are

the result of uterine contractions caused by hyperæmia of the uterus,

and these cases often take a paroxysmal form.

Important disturbances of the general constitutional state result from

sudden suppression of the normal menstrual flow, such as may be the

effect of a severe chill, of sudden mental impressions, even of errors

in diet or the use of certain drugs, and may sometimes follow artificial

withdrawal of blood.

In many women, a few days or it may be a few hours only before every

menstruation, changing manifestations of manifold disorders may recur.

Among these may be mentioned, general excitement of the nervous system,

notable alteration in the voice, strong inclination to sadness,

tearfulness, erotic longings, great irritability and sensitiveness of

the sensory system, drowsiness, flushings of the face, giddiness,

swooning. The appetite is impaired, the breath has a disagreeable smell,

the digestion is disturbed, there is a tendency to diarrhœa; the facial

aspect may be altered, there are blue rings round the eyes, eruptions on

the skin, tendency to sweating, palpitation and feeling of anxiety, and

a sensation in the extremities as if they had been beaten. Local

symptoms also occur: disturbances of the function of micturition,

swelling of the breasts, pains and colics in the renal region, feeling

of warmth in the genital organs, pruritus vulvæ, sensation of weight in

the uterus, and a strong impulse toward coition. The secretions may be

pathological, sometimes there are profuse sweats, sometimes profuse

mucous or bilious diarrhœa, whilst the urine may either be very

abundant, almost colorless, and nearly free from saline matter, or thick

and overladen with phosphates and urates.

_Schauta_ writes regarding the complex of menstrual phenomena which

occur in normal menstruation: “In the process of menstruation, blood and

sanguineous mucus find their way through a mucous canal, the normal

calibre of which is merely a capillary fissure. If the flow is slow,

without the formation of coagula, and if the passage through the cervix

is free, very gentle contractions of the uterine muscle suffice on the

whole, as the blood exudes into the cavity of the uterus, to expel it

into the vagina. Without such contractions, menstruation is hardly

conceivable. Physiologically, they are characterized by a bearing-down

sensation, passing down toward the thighs, and by pains in the back. It

is rarely, that no pain at all is experienced; there are some women,

however, who affirm that in their case menstruation begins quite

unexpectedly, and without the slightest warning; but it does not follow

that contractions of the uterus do not occur in these women also during

menstruation. * * * The local disturbances which occur as an

accompaniment even of physiological menstruation are, a sensation of

fulness and weight in the pelvis, and pains in the lower part of the

back, and these probably all result from the uterine contractions. The

general disturbances of a reflex nature consist of tenderness on

pressure in the epigastrium, headaches, general sense of languor,

irritability, and an inclination to shed tears. Among changes in the

functions of remote organs may be mentioned, swelling of the breasts, of

the vocal cords, and of the thyroid body, increased respiratory capacity

shortly before menstruation followed by rapid decrease during the flow,

tendency to diarrhœa, nausea, vomiting, flatulence, salivation, profuse

secretion of the sebaceous glands of the vulva, increased secretion of

sweat, tendency to the formation of acne pustules. The mental condition

also exhibits as a rule a considerable change during menstruation, even

in cases which cannot in any sense be regarded as pathological. In many

instances, an apparently normal woman may during menstruation exhibit a

mental state so abnormal that we are led to speak of it as a menstrual

psychosis. Apart from this, however, it appears that during menstruation

the mental life of woman never remains entirely unaffected. Finally, we

must mention certain changes in the sense-organs which not infrequently

accompany menstruation, such as herpes conjunctivæ, exophthalmos,

limitation of the visual field, and swelling of the nasal turbinate

bodies.”

In the digestive organs, during the menstrual process, changes in the

secretions of the glands, nausea, vomiting, and flatulence are not

infrequently observed. In one-half of the women concerning whose state

during menstruation _Krieger_ made inquiries, he found, especially just

before and during the discharge, a tendency to diarrhœa, or at least to

more copious and more frequent evacuations of the bowels than occurred

at other times. On the surface of the tongue, at the premenstrual epoch,

a pronounced exfoliation of the epithelium may occur, so that in some

instances the papillæ are entirely exposed.

Not infrequently hyperæmia of the liver appears to be connected with the

menstrual process; and by many observers, among whom _Senator_ and

_Fleischmann_ may be mentioned, jaundice, slight or intense, has been

seen to occur during menstruation. In a case of long-standing

amenorrhœa, _Duncan_ noted the appearance of a transient vicarious

jaundice, apparently reflex in its origin. In some cases, jaundice

precedes menstruation, and disappears as the flow becomes established.

In the respiratory organs also, menstrual changes frequently occur.

According to _von Ott_, respiratory capacity attains a maximum shortly

before menstruation, and diminishes rather rapidly during the flow; the

expiratory power is similarly affected. In the larynx, according to

_Bottermund_, great swelling of the posterior wall occurs during

menstruation, whereby the closure of the glottis is hindered, and a

rapid onset of fatigue ensues in the muscles that perform this action

when the woman sings or speaks; the fulness of the voice is also

diminished. More or less extensive swelling of the thyroid body[32]

occurs during the menstrual period. According to _Fliess_, in most

women, the inferior, sometimes the middle and the inferior nasal

turbinate bodies are greatly swollen; sometimes also the tubercula septi

are swollen. It is said that the right half of the nose is more

frequently and more intensely swollen than the left half. Epistaxis is

sometimes observed at the menstrual periods.

In the urinary organs, the influence of the menstrual period is

manifested by a change in the urine. According to _Schrader_, the

elimination of urea is diminished shortly before menstruation; according

to _Laval_, the elimination of uric acid undergoes a sudden diminution

on the second day of the flow, followed by an increase on the third day,

subsequently rising above the normal level. This change is to be

attributed, not to any excitation of the genital organs, but to the loss

of blood.

_Hebra_ already drew attention to the connection between diseases of the

skin and the physiological and pathological processes occurring in the

female genital organs; and emphasized the fact that for the cure of

certain eruptions, local treatment of the disorder of the reproductive

organs was requisite. He gave four examples of such eruptions: 1, an

acute attack of eczema, which disappeared only after the removal of a

badly fitting pessary; 2, in a chlorotic girl, two large red spots on

the cheeks disappeared when menstruation was established; 3, improvement

of a skin-affection when a coexisting disorder of the genital organs

received appropriate treatment, followed by recrudescence of the skin

trouble when the genital disorder became more severe; 4, a case of

obstinate seborrhœa, lasting for many years, which disappeared only when

the patient became pregnant, for the first time, seven years after her

marriage.

Similar cases have been recorded by subsequent observers, and numerous

monographs have been published on menstrual skin-eruptions. _Schramm_,

for instance, reports the case of a woman in whom at each menstrual

period tubercles and papules appeared on the backs of the hands and on

the neck; and the same author mentions another case in which during

menstruation red papules arranged in rows appeared on the back.

_Wilhelm_ observed dark blue macules, the size of hazelnuts, which

appeared on the thighs shortly before menstruation and disappeared when

the flow was over. Of two cases of menstrual disorder of the skin

reported by _Stiller_, in one, an itching eruption appeared on the upper

and the lower extremities; in the other, small red papules appeared on

the dorsum of the hands and feet. Other cases of menstrual

skin-eruptions were published by _Joseph_, _Pauli_, _Janovsky_, and

_Schwing_. Sometimes at the menstrual periods severe pruritus vulvæ

occurs, due, no doubt, to the temporary increase in the secretion of the

menstrual passages, and to the more active influence exercised by this

secretion on the vulva.

In two cases in which the menstrual flow was in abeyance, _Heitzmann_

observed affections of the skin. In one of these, a young woman aged

twenty who had not yet begun to menstruate, there appeared every four

weeks isolated papules surrounded by a bright red areola, itching so

violently that scratching resulted. In the other, macules the size of a

lentil, of a light red or dark red color, appeared, and lasted two or

three days; when menstruation became regular, fresh crops no longer

formed.

_Schauta_, in a case of chronic oöphoritis, observed the regular

recurrence of urticaria at each successive menstrual period. The

suffering being very great, the rest at night being greatly disturbed

during the periods of eruption, and the patient’s general health

declining more and more in consequence, extirpation of the ovaries was

undertaken, and the operation resulted in a complete cure. _Schauta_

further observed that in cases of obstinate skin-affections of unknown

causation occurring in persons of the female sex, some disorder of the

genital organs was nearly always present; moreover, in many of these

cases, as soon as the genital disorder was cured by appropriate

measures, the skin-affection disappeared spontaneously and without any

further treatment. He had been able to collect twenty-six cases of this

nature, in which an indubitable connection obtained between disease of

the skin and disease of the reproductive system. The forms of affection

of the genital organs chiefly noticed in this association were,

retroflexion and retroversion of the uterus, erosion and ectropium or

eversion of the cervix (chronic cervical catarrh), chronic endometritis,

oöphoritis, and salpingitis, and finally with especial frequency uterine

myomata; the skin-diseases observed were, acne, eczema, disorders of

pigmentation, psoriasis, lichen, and urticaria.

During menstruation we observe not infrequently a number of changes in

the skin, such as hyperidrosis, acne, seborrhœa, erythema, and the form

of dermatitis known as erysipelas of menstruation; sometimes also

effusion of blood into the skin as a form of vicarious menstruation, and

peculiar forms of cutaneous œdema. In many women during menstruation the

secretion of sweat is markedly increased every month; in exceptional

cases, menstruation is vicariously replaced by profuse sweating. In

association with menstruation we frequently observe excessive secretion

of the sebaceous glands, especially of those of the hairy scalp. Often

urticaria manifests itself as a recurrent menstrual eruption. In cases

of scanty menstruation and of amenorrhœa, discoloration and excessive

pigmentation of the skin may occur, sometimes taking the form (as also

in pregnancy) of chloasma uterinum. Sometimes also in these cases the

formation of dark rings round the eyes, already seen in slighter degree

as an accompaniment of normal menstruation, is excessive.

In the organ of vision, changes associated with menstruation have been

recorded by various observers. Hordeolum menstruale (menstrual stye) may

recur month after month at the menstrual periods as an exacerbation of a

chronic conjunctivitis. Herpes of the ocular or palpebral conjunctive

and eczematous affections may be connected with menstruation; also

exophthalmos may occur during menstruation in association with swelling

of the thyroid body and palpitation of the heart (_H. Cohn_); again, as

an accompaniment of normal menstruation, severe papillitis with retinal

hæmorrhages may occur (_Heber_). According to the investigations of

_Finkelstein_, a limitation of the field of vision may be noticed during

menstruation, beginning on the first, second, or third day of the flow,

attaining its greatest intensity on the third or fourth day of the flow,

and gradually disappearing during the three or four days next ensuing.

The organ of hearing is stated by _Haug_ to be affected during

menstruation, inasmuch as congestive redness and swelling of the

external ear, of the external auditory meatus, and of the skin over the

mastoid process, sometimes occurs; occasionally also, periodic neuralgia

manifests itself at the menstrual periods.

In the circulatory organs, as already mentioned, normal menstruation

quite frequently manifests its influence by the production of disorders

of greater or less severity, referable to the stimulus of ovulation. In

8.5 per cent. of the women of whom I have made inquiries with regard to

this matter, palpitation of the heart of variable severity occurred

during menstruation, and was most frequent and most severe on the first

and second days of the flow. Associated with the palpitation in some

cases were, vasomotor disturbances, transient feelings of heat, a sense

of congestion in the head, and profuse perspiration without apparent

cause. The day before the commencement of the flow, the blood-pressure

rises considerably, but falls rapidly during the flow. This menstrual

rise in blood-pressure is accompanied by a rise in temperature and an

increase in metabolic activity. The influence of menstruation on the

heart is most powerfully displayed in cases in which for some reason a

disturbance occurs of the normal appearance or normal course of

menstruation.

Disorders of menstruation likely to give rise to cardiac disorders are,

amenorrhœa, menorrhagia, and dysmenorrhœa.

Amenorrhœa is especially apt to induce cardiac disorder in cases in

which, in consequence of some sudden impression, such as a fright or a

severe chill, menstruation, which began at puberty in normal fashion and

subsequently recurred with perfect regularity, has undergone sudden and

complete suppression; also in cases in which severe anæmia or obesity

has rapidly led to the onset of amenorrhœa. In such cases, attacks of

tachycardia sometimes occur, it may be at irregular intervals, or it may

be exhibiting a menstrual rhythm, the cardiac affection manifesting

itself always a few days before the date at which menstruation ought to

begin. In these cases, also, systolic murmurs are not infrequently

audible.

In cases in which menstruation is very painful, the dysmenorrhœa may

give rise to attacks of colic or to convulsive seizures, whether the

dysmenorrhœa is itself due to inadequacy or to complete suppression of

the flow, to metritis, to anteflexion, to new growths in the uterus, or,

finally, to diseases of the ovaries or to pathological disorders of

ovulation. Among the various disorders associated with dysmenorrhœa,

heart troubles are not infrequent, most often taking the form of reflex

neuroses, evoked by the stimulus of the pain in the genital organs; but

it has also been asserted that an acute dilatation of the heart occurs

in these attacks.

Very threatening cardiac symptoms as an accompaniment of severe

dysmenorrhœa have been seen by me especially in the case of two women,

one of whom was in the thirties and the other in the forties. The

attacks took the form of increased frequency of the heart’s action, with

severe cardiac dyspnœa on trifling exertion, sense of suffocation, and

intense anxiety. This severe cardiac and respiratory distress was a

sequel to the appearance of severe dysmenorrhœa, and was relieved as

soon as the course of menstruation became regular and painless; but the

cardiac trouble recurred in association with each successive attack of

dysmenorrhœa. In one of these two women, the dysmenorrhœa was the result

of extreme anteflexion of the uterus; in the other woman, the cause of

the dysmenorrhœa was not apparent. I was unable to decide with certainty

whether in these cases an acute dilatation of the heart occurred. French

authorities, who describe similar cardiac trouble resulting from

diseases of the liver and the stomach by the name of _asystolic

gastrohépatique_ (_Potain_), give the following explanation of its mode

of occurrence. The intra-abdominal plexus of the sympathetic is

stimulated, this stimulus is reflected to the lungs, in which organs it

gives rise to vaso-constriction, resulting in increased tension in the

lesser circulation; in consequence of this the right heart has

difficulty in emptying itself, when weak it undergoes dilatation, and a

moderate or extreme tricuspid insufficiency ensues. We have to do, then,

in these cases, with reflex symptoms, with a reflex arc, the starting

point of which is the sensory nerve-terminals in the abdomen, the

afferent tract of which is formed by the sympathetic and pneumogastric

nerves, and the efferent tract of which passes along the pulmonary

sympathetic nerves.

In other cases of dysmenorrhœa we observed signs of cardiac weakness;

the pulse was small, very frequent, and barely perceptible, the face

became suddenly pale, the hands and feet were cold; complete syncope

sometimes occurred.

Menorrhagia sometimes leads to cardiac symptoms, owing to the severity

of the anæmia which follows extensive and long-continued loss of blood;

sometimes, however, the heart troubles associated with menorrhagia are

reflex manifestations, dependent on the disease which has also caused

the menorrhagia, endometritis, it may be, new growths, lukæmia, or

scurvy. Sometimes here also we observe transient attacks of acute

dilatation of the heart.

Nervous disturbances during menstruation, which are so frequent that

_Emmet_ regards it as abnormal for a menstruating woman to be entirely

free from pain and from uneasy sensations, are divided by _Windscheid_

into two classes, general nervous disorders, and local nervous

manifestations. Among general disorders, the commonest is a general

bodily incapacity; in women, who in other respects are quite healthy,

during menstruation everything will be too great an exertion, and

fatigue speedily ensues on the performance of occupations which at other

times are undertaken without the slightest difficulty. Another common

nervous disorder is an uneasy sensation in the head, it may be a feeling

of weight or pressure, sometimes described as a feeling as if an iron

band were compressing the forehead. Slight mental irritation is commonly

present also, the woman is capricious, her mental equilibrium is

disturbed. Very common also are vasomotor disturbances, transient

feelings of heat, a sense of congestion in the head, or an outbreak of

perspiration. Among local nervous disturbances, _Windscheid_ enumerates,

pains in the back (occasionally and erroneously described as spinal

irritation), sacrache, pains in the lower extremities, which by

preference generally take the course of the great sciatic nerves. Pains

in the abdomen also frequently accompany menstruation; these may be

diffused over the whole abdomen, or may predominate in the two

hypochondriac regions. Disorders of the sense-organs sometimes occurring

during menstruation are, the flickering of objects before the eyes,

photophobia, and tinnitus aurium. The heart may also be affected with

palpitation in association with these nervous disturbances; the stomach

may exhibit associated disorder in the form of cardialgia, or more

frequently in the form of vomiting, this latter being very frequent at

the outset of the flow. Less common is profuse diarrhœa, pain in the

anus, or spasm of the sphincter ani.

The intensity of such nervous manifestations during menstruation is

dependent upon the woman’s general state of nutrition, upon the degree

of instability of her nervous system, and upon her occupation. Robust

and powerful women, regularly employed in the open air, such as the

wives and daughters of farmers and agricultural laborers, are much less

affected by the nerve-weakening influences of menstruation than the

sedentary and anæmic town-dwelling women, whether these latter belong to

the higher classes of society and are addicted to nerve-straining

enjoyments, or to the class of shop-girls, seamstresses, and

factory-women, whose employment is apt to lead to nervous exhaustion.

As regards the forms of neuralgia most apt to accompany menstruation,

_Windscheid_ mentions trigeminal neuralgia as the commonest, especially

affecting the first division of the nerve, and producing localized pains

which are to be distinguished from the headaches already mentioned. They

are characterized by their intensity and their persistence in spite of

anti-neuralgic treatment, and by their spontaneous disappearance as soon

as menstruation is over. According to the same author, the relations

between hemicrania and the process of menstruation are indisputable; at

the very least it must be admitted that menstruation predisposes to an

attack of hemicrania.

Cases also occur in which convulsions almost invariably accompany

menstruation, convulsions which are to be regarded as symptoms of

hysteria.

The extraordinarily powerful influence which the menstrual stimulus

exercises on the mind is shown by the frequency with which the slighter

psychopathic states occur as an accompaniment even of normal

menstruation, these manifestations being sometimes melancholic in type,

sometimes maniacal or erotic, and, when of long duration, leading

ultimately to pronounced mental disorder. This influence of the

menstrual stimulus is yet more potent in cases in which important

changes in the course of menstruation have occurred, in cases, for

instance, of suppressed, painful, or irregular menstruation. In this

connection, however, in order to avoid a confusion of cause and effect,

we must carefully bear in mind, that it is a much commoner causal

sequence for psychical disorders to disturb the normal course of

menstruation, than for disorders of menstruation to evoke psychical

disorders. This view has only quite recently become established, and for

this reason it is necessary to regard such data when obtained from the

writings of the older gynecologists in a somewhat critical spirit.

By the modern alienist, the influence of the menstrual reflex on mental

affections is recognized only in cases in which a proper valuation of

the predisposing causes has been made, in such cases as the following:

First, we have to recognize the modifying influence exercised by the

menstrual stimulus on established psychoses, inasmuch as these latter

not infrequently undergo cure when previously irregular menstruation has

become regular, and, moreover, the recurrence or the first appearance of

menstruation has often a powerful influence on the course of some

established mental disorder. In some cases this influence is a

strikingly favorable one on psychoses that have developed before the

commencement of menstruation, or during the suppression of that

function; it may be, however, and, indeed, more frequently is, an

unfavorable influence, inasmuch as such a psychosis, on the first

appearance or on the reappearance of menstruation, may assume a

menstrual type, the attacks becoming more frequent or more violent with

the successive recurrence of each menstrual or premenstrual period. This

is the history of the typical menstrual psychosis.

Again, certain processes of the sexual life, disorders of menstruation,

diseases of the genital organs, operations on these organs, and the

processes of the climacteric, influence the origin and the character of

mental disorder, generally giving rise to chronic affective insanity

(insanity of the emotions and feelings) or to paranoia (chronic

delusional insanity, insanity of the intellect). The menstrual stimulus

must in these cases be regarded as a psychopathically exciting physical

cause.

Further, physical disturbances may equally affect the menstrual function

and the functions of the mind, rendering the exact causal sequence in

such cases a difficult one to determine; and, conversely, the

circumstances that restore the normal working of the mind may also

regulate the menstrual function.

Finally, we may have to do with isolated sporadic occurrences in which

the exciting influence of menstrual processes may be traced. Thus, for

the outbreak of a periodical menstrual psychosis, an especial temporal

predisposition must exist, connected with the great developmental epoch

of the sexual life.

There is, for instance, a group of transitory states occurring during

menstruation, and taking the form of disorders of the intelligence or of

explosive emotional states; such may be witnessed, not in those

suffering from psychopathic predisposition, but in quite healthy

individuals.

The successive menstruations as they recur regularly throughout the

course of the sexual life may, just like the first menstruation, though

with diminished intensity, give rise to manifestations of nervous and

mental disorders. In many women who are in other respects healthy, we

see during menstruation, hemicrania, nervous irritability, ill-temper,

low-spiritedness, and even hysterical and epileptic attacks; these occur

chiefly on the first and second days of the flow, and disappear

altogether toward the end of the period. These manifestations are more

severe in individuals weakened by profuse losses of blood or by chronic

disorder in various organs, more severe also in those predisposed to

such disturbances in consequence of neuropathic inheritance, more severe

in women suffering from menorrhagia and dysmenorrhœa, and from any kind

of mental stress.

In his work on the influence of the so-called menstrual wave on the

course of mental disorders, _Schüle_ remarks that the mental equilibrium

even of a perfectly healthy woman is not a stable one, but is subject to

a series of oscillations. “The menstrual period,” he continues, “has a

distinct influence on woman’s mental equilibrium. Even in those whose

nervous system is a healthy one, menstruation evokes a state, now of

depression, now of excitement; in neurotic women, on the other hand,

menstruation may give rise to nervous diseases which may equally exhibit

the characteristics of depression or the characteristics of excitement.

In nervously predisposed women, the influence of regularly established

menstruation, even when the circumstances are favorable, is pretty much

the same as the influence of menstruation when it first makes its

appearance; the influence is merely somewhat weaker in so far as the

woman has learned to endure and to be patient. The menstrual state, in

nervously predisposed women, evokes the particular neurosis to which the

individual happens to be liable. The disorders most commonly met with in

this association are, hysteria, hemicrania, swimming in the head,

epileptic paroxysms, toothache, and neurasthenia.”

Especially frequent during menstruation is hemicrania. Sometimes

hemicrania may begin a day or two before menstruation, as a prodromal

sign, and may accompany its whole course, becoming, however, less severe

toward the end of the flow. Hysteria most commonly manifests itself in

association with menstruation by a depressed emotional state, by

tearfulness, by complaints made without sufficient grounds, by globus

hystericus or clavus hystericus; sometimes also by paroxysms of muscular

spasm; very rarely by hystero-epileptic seizures. Epilepsy may occur

either by day or by night. Nocturnal seizures usually occur without any

apparent external cause, as a result of the central stimulus; diurnal

attacks, on the other hand, have usually some external exciting cause.

Often, however, years may elapse without any attack of major epilepsy

occurring, the disease manifesting itself in one or more of the many

varieties of the minor form (_petit mal_), as transient absences of

mind, attacks of vertigo, etc.

The nervous disturbance in a menstruating woman may be so great as to

lead to the production of psychoses. The question of the existence of a

menstrual insanity _sui generis_ has been answered by many alienists in

the affirmative; by others, however, who see in the alleged cases

nothing specific, it has been answered in the negative. The relation of

menstruation to the mental disorder may be a double one: 1, menstruation

may occur repeatedly in the course of an already established mental

disorder; 2, menstruation and its morbid variations may favor the

occurrence of psychoses that exist already in a latent form, and may

lead to the origination of psychoses to which the organism is

predisposed.

In the former connection, _Brierre de Boismont_ undertook an

investigation which showed that in women suffering from mental disorder,

an exacerbation of that disorder was to be observed during menstruation.

_Schlager_, who regards the menstrual process as possessing when

anomalous a high significance for the development and course of mental

disturbances, observed that in 33 per cent. of women suffering from

mental disorder, the menstrual state had an unfavorable influence upon

the course of that disorder, inasmuch as it led to an increased

irritability; in the rest of the cases, however, menstruation was

without influence upon the course of the ordinary chronic psychoses. In

the cases that were unfavorably influenced, epileptic attacks usually

became more frequent, and chronic melancholia became much more profound.

_Schröder_ observed in chronic forms of melancholia that during

menstruation the sadness became intolerable and was associated with a

suicidal tendency; in chronic maniacal forms of mental disorder, the

excitement underwent an increase during menstruation. _Von

Krafft-Ebing_, as a result of his investigations into insanity during

menstruation, came to similar conclusions with regard to the unfavorable

influence of the menstrual process. _Algeri_ likewise states that

menstruation notably aggravates the cerebral symptoms in the course of

mental disorders.

Other authors, _Marcé_ and _Kowalewski_ for instance, whilst emphasizing

the powerful influence exerted by menstruation on any existing

psychosis, point out that in some instances, as in states of mental and

physical depression, this influence is for the worse; but in other

instances, especially in states of maniacal excitement, the condition of

the patient undergoes notable amelioration during menstruation.

_Schäfer_ also, in his researches into the relations between the

processes of menstruation and psychoses, discovered that anomalies in

the course of menstruation ran almost parallel with anomalies in the

course of mental activity.

In psychopathically predisposed women, disorders of menstruation, such

as amenorrhœa, delayed menstruation, and dysmenorrhœa, are more

effective than the normal process of menstruation in evoking

manifestations of psychical abnormalities previously latent, and in

leading to attacks of precordial anxiety, pathological emotional states,

melancholic seizures, epilepsy in all its varieties, and impulsive

manifestations, such as pyromania, kleptomania, infanticide, homicide,

etc. As results of a special predisposition may appear in this

connection, congenital imbecility, idiocy, melancholia, and chronic

weak-mindedness.

A rich literature exists of cases in which mental abnormalities occurred

in psychopathically predisposed individuals as a result of menstruation.

Thus, _von Krafft-Ebing_ reports a case in which, during menstruation, a

mentally undeveloped woman murdered her husband; and another case in

which to chronic weak-mindedness and chronic delusional insanity were

superadded during menstruation peculiar attacks having the character of

psychical storms. _Tuke_ reports a case in which a mother, in a state of

alcoholic excess during menstruation, murdered her daughter. _Pelmann_

records acts of pyromania committed during menstruation by a girl

seventeen years of age. _Mabille_ records a case in which a woman

suffering from severe mental disorder was affected during menstruation

by impulsive kleptomania, whilst after the periods the memory of what

had happened passed away. _Philo-Indicus_ records the case of a woman

suffering from severe neuropathy who at the menstrual periods exhibited

great irritability, experienced marked sexual excitement, and had

suicidal impulses, and who on one occasion attempted to murder a female

friend who had refused to assist her in the practice of sexual

aberrations. _Giraud_ describes a woman suffering from passive

melancholia, in whom during menstruation horrible fantastic ideas

occurred. _Ball_ records the case of a woman who suffered always from

acute mental disorder during menstruation, and who, in one of these

attacks, murdered her son. _Kowalewski_ reports a case of chronic

imbecility, in which during menstruation attacks of precordial anxiety

developed, and in the course of one of these attacks the patient set

fire to her own house. “In such cases,” remarks _Kowalewski_,

“menstruation represents the last drop that makes the full goblet

overflow.”

In addition, we meet with cases in which the influence of menstruation

is so powerful that it must be regarded as the principal cause of the

psychosis. We must then speak of a true menstrual psychosis, the impulse

to which is supplied by the normal or abnormal changes occurring in the

process of menstruation, and characterized by the menstrual periodicity

and the brief duration of the attacks. These are the characteristics of

the menstrual psychoses of the menarche and of the climacteric period;

and such cases occur also during the period of full menstrual activity.

The menstrual psychosis most commonly makes its appearance shortly

before the flow, becomes less severe with the establishment of the flow,

and disappears when the flow ceases; in other cases, the psychosis

appears toward the end of menstruation, and speedily passes away; or,

again, in amenorrhoeic cases, the attacks of mental disorder replace the

proper menstrual flow, and become less severe or disappear entirely as

soon as the flow is regularly re-established. The commonest forms of

these menstrual psychoses are, melancholia, mania, irresistible

impulses, acute amentia, in rare cases alternating insanity (_folie

circulaire_) in which the periods of alternation assume the menstrual

rhythm. The duration of these psychoses is usually short, from a few

days up to a fortnight; there may be only a single attack, or there may

be a number of attacks presenting precisely similar characters.

The consciousness may be more or less disturbed. _Von Krafft-Ebing_

points out, as a very dangerous peculiarity of the menstrual psychoses,

that the fact that the morbid process has once occurred in connection

with menstruation furnishes in itself a sufficient reason for the

recurrence of such attacks, which are dependent on constantly repeated

functional changes in the brain closely analogous to those that occur in

epilepsy. When the menstrual insanity recurs frequently, it gradually

becomes less acute in its characters and more protracted in its course;

the lucid intervals are less clearly indicated and shorter in duration;

and thus in course of time the mental disorder may be transformed into

chronic imbecility—a transformation liable to occur in all forms of

periodic psychosis. In such cases we must always assume the existence of

a certain lack of resisting power on the part of the organism,

especially of the nervous system, which amounts to a congenital

predisposition. During the period of full menstrual activity, the

favorable soil for the cultivation of such disorders is usually

furnished by anomalies of menstruation, by difficult labor and its

consequences, severe losses of blood, prolonged lactation, physical

over-exertion, and mental shock and stress.

In the development under the influence of menstruation of such periodic

acute mental disorders, we may observe various gradations, as for

instance short, syncope-like cataleptic seizures, states of

hallucinatory confusion lasting several hours or several days,

disordered consciousness, and even severe mania.

Such a case was observed by _Wille_. Under the influence of menstruation

and of a trifling source of mental disturbance (having soldiers billeted

on them in a quiet country village), a young woman aged twenty-one,

whose mental health had previously been good, had a sudden attack of

anxiety, succeeded by a violent but transitory mania, lasting five or

six hours; after a short free interval came another attack, this time

lasting several days. Similar cases were recorded by _Friedmann_. A

blooming and healthy maid-servant eighteen years of age (some mental

unsoundness was recorded in both grandfather and aunt on the maternal

side) fell asleep in a chair a few days before menstruation, awakened

with a start, was subsequently disordered in mind, though tranquil, with

many hallucinations, listening to voices which repeated monotonously

“they come,” was drowsy, and slow to answer when spoken to. On the third

day she was recovered, her mind being clear and normal; she was not

fully aware of what had happened. Since this attack, her mind has been

free from disorder, during menstruation as well as at other times. She

is said to have had a similar attack about four years ago, that is, at

the commencement of puberty.—A girl aged thirteen, quite healthy, not

nervous, physically rather powerful, with quite healthy family history.

Complaints of having suffered for two days from general sense of

depression with pains in the abdomen; during the afternoon was lying on

a sofa, but suddenly sprang up, looked extremely anxious and confused,

ran about the room, begged to be protected from the black man, etc., her

speech was disconnected, gabbling, and difficult to understand. After

two hours she became quiet, and fell into a sound sleep, from which she

awoke calm and quite forgetful of what had passed. On the following day

menstruation appeared for the first time, with abdominal pains, but

without any mental abnormality. During the subsequent six years she has

remained quite well.

Since the days of antiquity an extremely important part has been

assigned to suppression of the menses in the production of mental

disorders; but in the opinion of modern alienists, who are opposed to

the old humoral pathology, no more is to be recognized in this

connection than the ordinary menstrual stimulus, which, indeed, when the

soil is already prepared, may furnish a causal determinant for an

increase in the intensity of an already existing anomalous mental

condition. Quite recently numerous cases have been published in which

such an influence has been recognized as powerful. _Von Krafft-Ebing_

writes: “In isolated cases, as a sequel of sudden cessation of the

menstrual flow, generally, due to a fright or to a chill, the

development of insanity (usually acute mania) has been observed, and the

suppression of menstruation has been regarded as the causal determinant.

It is indeed conceivable that the connection between the two events is

supplied by a collateral vicarious congestion of the brain. As a rule,

however, the psychosis and the suppression of menstruation are the

coeffects of the same cause, and are both of vasomotor origin.”

_Mairet_ reports a case of violent mental disorder of a maniacal type,

associated with chorea, occurring at puberty, the exciting cause of

which, in a constitution hereditarily predisposed to insanity, he

believed to be suppression of the menses. _Diamant_ had under

observation a girl in whom, at the age of six years, menstruation

ceased, having previously been regular since the age of two years; after

the suppression of menstruation, violent epileptiform seizures set in,

occurring at what should have been the menstrual periods. _Westphal_

described a case of infanticide committed in a state of melancholia at

the proper menstrual period, the menses being suppressed.

Menstrual psychoses are observed for the most part in comparatively

young women; after the age of thirty-five they are uncommon. Among _von

Krafft-Ebing’s_ cases there were:

4 patients between the ages of 15 and 20 years.

6 patients between the ages of 20 and 25 years.

2 patients between the ages of 25 and 30 years.

6 patients between the ages of 30 and 35 years.

2 patients above the age of 35 years.

The same author insists that for the development of a menstrual

psychosis a predisposition on the part of the brain must exist, either

in the form of an inherited predisposition, or in the form of a primary

mental disorder, or, finally, as the result of some special exciting

cause, such as emotional disturbance, the abuse of alcohol, or bodily

illness. Among 19 cases observed by _von Krafft-Ebing_

12 were hereditarily predisposed.

4 had previously exhibited great nervousness during menstruation.

7 suffered from primary mental weakness.

Very remarkable is the influence, demonstrated especially by _Lombroso_,

exercised by menstruation on the commission of certain crimes. Of eighty

women taken into custody for resisting the police, there were nine only

who were not menstruating at the time. Four notorious murderesses and

one woman convicted of arson were all menstruating at the times when

their crimes were committed. _Krugenstein_ found evidence of

menstruation in the bodies of 107 women who committed suicide. Thefts

committed by ladies in the great shops of Paris are most commonly

effected during menstruation, as was found by _Legrand du Saulle_ to be

the case in thirty five instances out of fifty-six investigated by him

in respect to this matter. According to the same author, hysterical

girls who steal articles of clothing, bottles of scent, and the like,

from the counters of shops, are almost always menstruating at the time.

_Von Krafft-Ebing_ puts forward the following propositions with regard

to the forensic significance of offences committed by women during

menstruation: 1. The mental integrity of a menstruating woman is

questionable from the forensic standpoint. 2. In the case of women on

trial for any offence, the point should be determined whether that

offence was committed at a menstrual period. 3. An inquiry into the

mental condition is expedient in cases in which such a coincidence is

established; light is thrown on the matter when investigation shows the

existence of hereditary predisposition, when we learn that psychopathic

manifestations have occurred at previous menstrual periods, or when the

very nature of the offence is one suggesting the presence of mental

disorder. 4. A recognition of the powerful influence which the menstrual

process exercises upon the mental life should lead, even in cases in

which no menstrual psychosis has been proved to exist, to the admission

of extenuating circumstances in apportioning the punishment for the

offence. 5. In the case of the commission of a punishable act during

menstruation by a weak-minded individual, we must as a rule admit the

plea of irresponsibility—at any rate in the case of an offence committed

under the influence of strong emotion. 6. Persons who have been

discharged without punishment on the plea of mental disorder

accompanying menstruation must be regarded as dangerous to the

community, and should always be under careful supervision during the

menstrual periods.

_Amenorrhœa, Menorrhagia, and Dysmenorrhœa._

Amenorrhœa, permanent or transient abnormal lack of the menstrual flow,

may depend upon anatomical changes in the genital organs, upon

incomplete development or absence of the uterus and the ovaries, upon

enduring or transient defective nutrition or upon atrophy of these

organs, or upon parenchymatous disease of the ovaries; or it may be due

to functional disturbances of ovarian activity, itself dependent upon

changes in the nervous system, upon constitutional diseases, or upon

general nutritive disturbances in the body. Among the latter conditions

must be especially mentioned chlorosis, obesity, diabetes, chronic

alcoholism, and morphinism, myxoedema, exophthalmic goitre, etc.

The amenorrhœa that occurs at the time of the menarche has already been

described in connection with the symptomatology of that period.

If in cases of amenorrhœa the ovaries continue to perform their

functions, we frequently witness severe and painful menstrual molimina,

occurring periodically at the times when the flow might be expected, but

fails to appear. In cases of atrophy of the uterus and the ovaries, we

see complete and permanent amenorrhœa without any discomfort. As a kind

of vicarious menstruation, in certain cases of amenorrhœa, we see

hæmorrhages into the vitreous body or conjunctival hæmorrhages; also, as

more extensive disturbances of the visual organs, interstitial

keratitis, disseminated choroiditis, intermittent amaurosis, acute

retrobulbar neuritis, amblyopia, and limitation of the field of vision.

_Mooren_ publishes the following cases, showing the influence of

amaurosis on the eye. A girl aged fourteen, with severe bilateral

pannous keratitis, was amenorrhoeic notwithstanding the existence of

well-marked menstrual molimina. Every four weeks, at the times when the

menstrual flow should have appeared, the corneal inflammation became

more severe; it became amenable to treatment for the first time a year

later, when the menstrual flow had become established. A peasant woman,

twenty-eight years of age, had never menstruated; the uterus was badly

developed; every month an intolerable heat and swelling of the face

recurred. Since the age of fifteen she had suffered from bilateral

interstitial keratitis, which had resisted all treatment, and had been

subject every four weeks to a recurrent exacerbation of this trouble,

lasting several days. The exhibition of powerful emmenagogues and the

use of Friedrichshall water brought about on a few occasions a scanty

discharge of blood. The comfort to the patient, relieved as if by

miracle from her pain and photophobia, was most remarkable.

Unfortunately, however, this state of comparative happiness lasted from

twelve to fourteen weeks only, after which, in spite of everything that

was tried, there was no further recurrence of menstruation, and the

condition of the eyes relapsed to what had existed for thirteen years.

In other cases described by _Mooren_ the amenorrhœa was complicated with

disseminated choroiditis and with posterior sclero-choroiditis.

_Beer_ reports a case of retrobulbar neuritis occurring with amenorrhœa,

consequent on infantile aplasia of the uterus. An interesting case was

recorded by _Dunn_ of a girl fifteen years of age, who had not yet begun

to menstruate, and who suffered from interstitial keratitis, with severe

photophobia. The ocular symptoms vanished with extreme rapidity as soon

as menstruation first appeared. _Napier_ observed complete blindness,

without discernible anatomical cause, associated with amenorrhœa of

sudden onset; the amaurosis disappeared as soon as menstruation was

re-established.

Striking and manifold are the disturbances of the nervous system which

may be caused by amenorrhœa, ranging from increased irritability,

hyperæsthesia of various nerve tracts, neuralgia, and the like, to

severe psychoses.

_Barnes_ reports a case of mental disturbance consequent upon amenorrhœa

in a woman twenty-seven years of age, who had begun to menstruate when

sixteen years old, and in whom the menses had been suppressed a year

earlier when she was informed of the sudden death of her father. From

that time a progressively increasing weakness of the mind was observed.

In a case recorded by _Macnaughton Jones_ the mental depression

consequent on amenorrhœa was so great that it led to an attempt at

suicide.

_Lawrence_ observed in young girls who from any cause suffered from

amenorrhœa, that an increased pigmentation of the skin sometimes

occurred, analogous to that met with in _Addison’s_ disease. This

amenorrhoeic pigmentation he compares to the chloasma that is seen in

pregnant women.

By menorrhagia we understand the occurrence of typical discharges of

blood from the uterus, occurring at more or less regular intervals and

differing from normal menstruation in respect either of the greater

intensity or of the longer duration of the hæmorrhage; whereas by

metrorrhagia we understand the occurrence of atypical discharge of blood

from the uterus, which is related to menstruation neither in respect to

its causation nor in respect to the time of its appearance.

Menorrhagia may be due to local changes in the genital organs, to

organic diseases of other organs, and to general diseases.

Local changes which may give rise to menorrhagia are, active hyperæmia

and passive hyperæmia (hyperæmia from engorgement) of the genital

organs, such hyperæmia being itself due to sexual excitement, especially

when ungratified, to violent physical exercise, or to chill during

menstruation; menorrhagia is also liable to occur when the abdominal

circulation is disturbed by extreme obesity or by the presence of

tumors, also in connection with endometritis, uterine myomata, erosions

of the cervix, etc. Diseases of organs other than those belonging to the

reproductive system which are especially likely to give rise to severe

bleeding are, disease of the heart, such as valvular incompetence, lung

disease, and nephritis. General diseases in which menorrhagia may occur

are, anæmia, chlorosis, hæmophilia, scurvy, scarlatina, cholera,

smallpox, influenza, and obesity.

Through severe loss of blood in menorrhagia, whether the bleeding be

sudden and profuse or more moderate but long continued, a condition of

chronic anæmia results, with all its threatening consequences to the

health and the life of the woman affected. She becomes pale and weak,

unfitted for any great physical or mental exertion, and is liable to

attacks of cardiac enfeeblement and to fainting fits; in some cases

degenerative changes ensue in the cardiac muscle.

Dysmenorrhœa is characterized by severe pain occurring before, during,

and after menstruation. The pain is caused either by abnormally powerful

contractions of the uterus or else by abnormal sensitiveness of that

organ. Abnormally powerful contractions are caused by various mechanical

hindrances to the normal processes of menstruation; abnormal

sensitiveness is due to inflammatory and congestive states of the uterus

and its annexa or to a general increase of nervous sensibility.

_Schauta_, therefore, distinguishes a mechanical, an inflammatory, and a

nervous form of dysmenorrhœa. Mechanical dysmenorrhœa is most frequently

due to stenosis or flexion of the canal of the cervix in some part of

its course from the internal to the external os, dependent upon

malformation or flexion of the uterus, hyperplasia of the mucous

membrane, chronic metritis, scarring resulting from operative

procedures, uterine polypi, etc. In inflammatory dysmenorrhœa we have to

do “either with an inflammatory process or with excessive tension of the

intrapelvic organs, dependent upon abnormal distension of their blood

vessels.” To the same category belong ovarian dysmenorrhœa, and

dysmenorrhœa due to inflammatory changes in the Fallopian tubes and to

pelvic peritonitis. In nervous dysmenorrhœa, no anatomical cause is

apparent, but the uterine contractions normally occurring during

menstruation, and the normal congestive distension of the intrapelvic

organs at that period, become extremely painful, in consequence of a

morbid increase in the sensibility of the nervous system.

The influence of dysmenorrhœa on the general condition of the woman

suffering from it is often a very potent one.

The normal undulatory course of the bodily temperature—which as _Reinl_

has shown, undergoes a gradual rise until shortly before the appearance

of the menstrual flow, gradually falls during menstruation, and

continues to fall for a time after menstruation is over—undergoes a

change in cases of dysmenorrhœa due to anteflexion of the uterus,

parametritis, or salpingitis, inasmuch as in these cases the acme of the

temperature curve is reached actually during menstruation and the

decline of temperature comes, not at the commencement of the menstrual

flow, but often only after the flow has ceased. The curve of blood

pressure and the curve indicating the excretion of urea are similarly

affected in these cases.

As symptoms in other organs occurring in cases of dysmenorrhœa _Schauta_

mentions “sensations of heat, coldness of the feet, retching and

vomiting, cramps of the stomach and of the voluntary muscles, general

disorders of nutrition, loss of appetite, strangury, constipation,

dyspepsia, headache, and finally hysteria. As symptoms of the latter

affection we may notice, anæsthesia, hyperæthesia of certain parts of

the abdomen, attacks of cramp, paralysis, uterine cough, hiccough, spasm

of the glottis, epileptiform seizures. The repeated severe attacks of

pain may seriously disturb the nervous system, leading to the appearance

of general neuroses and psychoses. Frequently we observe, as a peculiar

accompaniment of dysmenorrhœa, changes in the fulness of the blood

vessels of the face and also in other regions of the skin, in

consequence of vascular paralysis. In other cases, actual effusion of

blood occurs, and, as a sequel of this, deposits of pigment; and the

semicircles beneath the eyes may become so dark as to look as if they

had been artificially tinted (_Macnaughton Jones_). In one case, during

menstruation periodic swelling of the gums was observed (_Regnier_).

Finally, in association with dysmenorrhœa, various forms of neuralgia,

changes in refraction, and slight attacks of neuritis and retinitis may

occur.”

One of the commonest symptoms and sequelæ is headache, sometimes in the

form of hemicrania, which may be associated with dyspeptic

manifestations, sometimes diffused over the whole surface of the skull.

Dyspepsia is a very frequent associate of dysmenorrhœa. Thus we meet

with pain and tenderness in the gastric region, nausea, vomiting, and

also cardialgia. Sometimes the liver becomes enlarged and tender on

pressure; in many cases also jaundice is witnessed.

_Gebhard_ refers to another phenomenon which may be classed under the

head of dysmenorrhœa, from the character of the pain that is

experienced, even though this pain is not felt at the menstrual periods,

but in the intermenstrual epoch. This is the so-called intermediate

dysmenorrhœa (intermenstrual pain, Ger. _Mittelschmerz_). In the

character of the localized pain, intermediate dysmenorrhœa closely

resembles ordinary dysmenorrhœa; it recurs often with precise regularity

on certain days during the intermenstrual interval. _Croom_

distinguishes three forms of intermediate dysmenorrhœa; that in which

there is no discharge at all from the uterus, that in which there is a

sanguineous discharge, and that in which there is a clear watery

discharge. The first form he attributes to asynchronism in the processes

of ovulation and menstruation; the second form, to endometritis with

disintegration of the mucous membrane; the third, to a kind of hydrops

tubæ profluens (profluent dropsy of the Fallopian tubes—hydrosalpinx in

which the fluid accumulates in the tube, and at a certain stage of its

accumulation flows into the uterus). Cases of intermediate dysmenorrhœa

are somewhat rare, if we eliminate the cases in which pains occur in the

intermenstrual epoch in consequence of disease of the uterine annexa.

Inflammatory manifestations may be discovered in nearly all typical

cases of intermediate dysmenorrhœa.

Long-continued dysmenorrhœa may give rise to numerous hysterical

troubles, general convulsive seizures, local muscular spasm and

paralysis, hiccough, spasm of the glottis, uterine cough, twitching and

spasm of various groups of voluntary muscles. In some cases we see fully

developed epileptic convulsions, with complete loss of consciousness and

immobility of the pupils. Finally, psychoses may arise in association

with dysmenorrhœa.

In cases of pathological changes in menstruation, a carefully arranged

hygiene at the menstrual periods is of importance both for prophylactic

and for therapeutic purposes, and in this connection I may refer to what

I have written in the section on _Hygiene during the Menarche_. In cases

of dysmenorrhœa a certain amount of repose and precaution are needed

during the flow, with avoidance of chill, scrupulous cleanliness, and

regulation of the bowels. In cases of amenorrhœa we must prescribe

attention to the general nutrition by means of an easily digested

roborant diet, as much fresh air as possible, and systematic bodily

exercise. In these cases, bicycling, lawn tennis, and suitable

gymnastics are often of value; also baths, in the form of warm general

baths, hot sitz baths, and hot foot baths.

_Vicarious Menstruation._

In cases in which, in consequence of morbid conditions of the uterus,

the ovaries, or the organism as a whole, the menstrual flow has at the

time of the menarche either failed entirely to appear or been

exceedingly scanty, hæmorrhages from other organs have since ancient

times been witnessed, and these hæmorrhages have been regarded as

vicarious menstruation. The congestion that occurs during menstruation

is not limited to the genital organs, and when the flow of blood from

the uterus fails to occur, the organism seeks another outlet, in order

to restore the disturbed equilibrium of blood distribution, and

vicarious hæmorrhages take place from the mouth, the nose, the

intestines, the anus, the gums, the mammæ, the ears, and the lungs; or

hæmorrhages occur in the brain, the nerves, or the eyes.

Although it must be admitted that confusion has often occurred between

vicarious menstruation and hæmorrhages dependent on pre-existing genuine

organic disease, such as hæmoptysis due to pulmonary tuberculosis, or

hæmatemesis due to gastric ulcer, still the existence of a true

vicarious menstruation must be regarded as fully established.

Thus, _Fricker_, _Fleischmann_, _Obermeier_, _Beigel_, _Withrow_,

_Plyette_, and _Parsons_ observed vicarious epistaxis; _Watson_,

_Decaisne_, _Edebohls_, _Fischel_, and _Seeligmann_, vicarious

hæmatemesis; _Franchi_, _Hotte_, _Ratgen_, _Voigt_, and _Windmüller_,

vicarious hæmoptysis; _Dunlap_, vicarious gingival hæmorrhage; _Law_ and

_Petiteau_, vicarious otorrhagia; _Heusinger_ and _le Fort_, vicarious

hæmorrhages, occurring variously from the anus, bladder, hand, ear,

nipple, stomach, and nose; _Baumgarten_, vicarious hæmorrhage from the

vocal cords and trachea; _Hahn_, from the bladder; _Kerley_, in the

thyroid body; _Gallemairts_, in the eyes. _Puech_ found, in the cases he

collected, that vicarious menstrual hæmorrhage occurred from the stomach

thirty-eight times, from the mammary glands twenty-five times, from the

lungs twenty-four times, and from the nasal mucous membrane eighteen

times. In all the cases menstruation had long been in abeyance.

Regarding vicarious epistaxis, especially exact observations have been

published, showing the mutual relationship between the genital and the

nasal mucous membrane. A series of cases has been recorded by _Fliess_.

In one of these a remarkably well-developed girl of fourteen, who

complained at three-weekly intervals of molimina, in the form of

languor, headache, and sacrache, after an interval of four weeks

epistaxis occurred instead of the expected menstruation; three weeks

later came another attack of epistaxis; and finally, after an interval

of seven weeks, came the first menstruation, which henceforward recurred

every three weeks. In another case, that of a girl aged fifteen,

menstruation appeared once; four weeks later came an attack of epistaxis

instead of menstruation, and these attacks of epistaxis were continually

repeated, at intervals of twenty-nine days, in place of menstruation,

until finally pregnancy occurred. During pregnancy the epistaxis ceased,

to recur however six weeks after parturition; the attacks continued for

eight monthly periods, when they ceased finally at the commencement of

the second pregnancy.

Other similar cases are known in which epistaxis recurred with all the

regularity of the menstruation it replaced _during_ pregnancy and ceased

at parturition. Analogous cases occur in which epistaxis has persisted

during pregnancy, during the puerperium, and at the climacteric period,

replacing the physiologically suppressed menstrual flow. Similarly

_Liégois_ has observed vicarious hæmoptysis during pregnancy. According

to _Baumgarten_, in vicarious epistaxis the bleeding almost always

proceeds from the region of the cartilaginous septum, and may become

very violent; vicarious hæmorrhage from the larynx proceeds from the

true and false vocal cords. Tracheal hæmorrhage is a much rarer

occurrence.

Analogous to these cases are those in which the vicarious hæmorrhages

occur after removal of the ovaries. Thus _Tauffer_ in one case saw

epistaxis replace menstruation after this operation. _Schmalfuss_

reports a case in which a woman suffering from valvular disease of the

heart, was said after oöphorectomy to have had almost daily attacks of

hæmoptysis and epistaxis. _Glaevecke_ found in the post-operative

history of forty-four cases of oöphorectomy that two patients suffered

from vicarious hæmorrhages. The last-quoted author is of opinion that

the suppression of menstruation resulting from oöphorectomy rarely leads

to vicarious hæmorrhages, and that even when these do occur they are so

inconsiderable in amount as to have no practical significance.

_Quain_ records the case of a woman aged thirty-three, in whom uterus

and ovaries were absent, and in whom for two years epistaxis recurred

every month with considerable regularity.

In cases in which menstruation is in abeyance, we sometimes witness,

instead of vicarious hæmorrhages, the occurrence of non-sanguineous

vicarious discharges from various mucous membranes. Thus, vicarious

leucorrhœa is seen, especially in chlorotic patients, in whom, from the

time of the menarche onward, such a discharge may occur every month,

instead of the delayed menstruation. Similarly, vicarious diarrhœa and

vicarious salivation have been observed.