University of Virginia Library

CHAPTER III.
PHYSIOLOGY OF THE FEMALE GENERATIVE ORGANS.

Ovulation; Etiology of Menstruation; Uterine Nerve-supply; the Function of the Uterus; Stages of the Menstrual Cycle; Average Duration of the Menstrual Flow; Character of tahe Flow; Relation of Ovulation to Menstruation; the Menstrual Wave; Definition of Menstruation; Premomitory Symptoms of the Flow; Hygiene of Menstruution.

Ovulation.--At birth the formation of the ova is nearly completed; the production of' new cells probably ceases after the second year. The ovaries of the child of two years contain, therefore, the full quota of ova, although the vast majority of these cells always remain immature and undeveloped. While it is probable that a variable number of the immature ova undergo partial development before puberty, yet the advent of sexual maturity at that time marks the establishment of the regular development of the Graafian follicles and their contained ova, accompanied by the attendant phenomena of menstruation.

During the entire child-bearing period, or from about the age of fifteen to forty-five years, the development of

the Graafian follicles and the discharge of the ova are continually taking place. The liberation of the ova usually takes place at definite times, which in general coincide with the menstrual epochs, one or more ova being set free at each period; but this is by no means invariable.

The ripe human ovum or germ cell is a spheric cell, about 0.2 mm. in diameter, consisting of granular protoplasm, in which lies a nucleus which contains the germinal spot. The proper cell-wall is a structure of great delicacy, outside of which is a secondary envelope.

Menstruation.--The etiology of menstruation has been variously explained at different epochs. The chief theories have been that of plethora, and the ovulation, the tubal, and the nerve theories.

First, the Theory of Plethora.--From the time of Hippocrates to 1835 the theory prevailed that in the female body the formation of blood is sufficiently rich to provide every four weeks for an overflow of the same, the evacuation of which becomes a necessity. It was believed that this excess of blood depended on an excess of formative power in the woman.

Second, the Ovulation Theory.--This was distinctly formulated about 1845. It construed the menstrual hemorrhage as a subsidiary phenomenon, entirely dependent on the periodic dehiscence of ovules. The changes supposed to take place in the Graafian follicles at each menstrual period were believed to involve a peculiar expenditure of nerve force, which was

so much dead loss to the individual life of the woman. The growth of the Graafian vesicle and its contained ovum was supposed to cause an irritation of the nerves of the ovary, which was reflected to the entire nervous system. The gradual accumulation of this irritation finally caused a reflex action which determined an afflux of blood to the uterus and ovaries, which constitutes the catamenial flow.

The ovulation theory was refuted by the following facts: Ovulation may and does occur without menstruation; women who have never menstruated may conceive; conception may occur during lactation, without the menses having returned since the last parturition; children at birth have many ovules contained within the ovaries; ovulation may persist for a time after the menopause, and even pregnancy has occurred, although very rarely after this time; the menses may continue regularly after the removal of the ovaries and Fallopian tubes; this is exceptional, and, as a rule, the periods only continue for two or three years at longest.

Third, the Tubal Theory.--Lawson Tait thought that thorough removal of the tubes was far more essential in determining the menopause, and that cases of periodically recurring hemorrhage after the removal of the ovaries were to be explained by the fact that the tubes had not been sufficiently removed. As an anatomic and surgical fact, the tubes can never be wholly excised unless the upper part of the uterus is also amputated.

Fourth, the Nerve Theory of Menstruation.--This is based upon the following views:

1. That menstruation is a process directly controlled by a nerve-center situated in the lumbar region of the spinal cord.

2. That the menstrual impulses reach the uterus through two sets of nerves.

3. That menstruation is the result of nerve irritation, vascular congestion, and the subsequent relief of these by hemorrhagic discharges.

4. That hemorrhage from the uterus is the result either of a local uterine condition, or of influences outside of the uterus acting directly on the center.

5. That the removal of the appendages arrests menstruation by preventing the propagation of uterine influences to the center.

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

As the result of long-continued investigation, Johnstone has come to the conclusion that the lining membrane of the uterus belongs to that class of organs whose function it is to replace organic waste. "Menstruation is a periodic wasting away of those corpuscles that are too old to make a placenta." He has further

found that, as compared with the uteri of very many of the lower animals, the human uterus is very scantily supplied with lymphatics, and the only way to rid the uterus of the overripe, and therefore consequently useless, tissue is to wash it out through the vagina by a blood-stream. The tough wall of the human uterus and the increased blood-pressure caused by the erect position cause the difference between menstruation in the human female and rut in the lower animals.

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

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

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

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

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

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

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

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

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

The menstrual wave, or the wave of "supplementary nutrition,"[1] upon which the menstrual process ultimately depends, was first established by Dr. Mary

Putnam Jacobi in the Boylston prize essay for 1876; showing that menstrual life is associated with a wave of well-marked vital energy, which manifests itself in a monthly fluctuation of the tempera ture of the body, in the daily amount of the excretion of urea and of carbonic acid, and of the rate and tension of the pulse. The wave attains its maximum during the week preceding menstruation, and slowly falls to its minimum, which is reached the week after menstruation.

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

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

The sanguineous discharge is due partly to the oozing of blood from the surfaces denuded of epithelium, and partly to active congestion. The discharge from the uterus is largely augmented by mucus secreted in increased

quantity at this period from the enlarged uterine glands.

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

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

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

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

organs, and it must be remembered that congestion is the first stage of inflammation.

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

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

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

Exercise.--A moderate amount of exercise should be taken every day; this is needed now quite as much as at any other time, and only good can result from it. And no harm comes of a woman going out in the rain or in cold weather; as has been shown, the menstrual process is going on for a large part of the time, and the flow is only the external appearance, but during the

time of the flow the woman must be unusually careful not to get her feet wet or to sit down with damp clothing on. Violent exercise of all kinds is to be prohibited at this time, as dancing, rides on the bicycle, gymnastics, and walks of over three miles. The reason for this is very obvious; the uterus has now reached the height of its turgescence, and is heavier than at any other time, hence the danger that displacements or a very profuse flow would be caused by any kind of violent exercise.

Treatment.--If the woman has been so unfortunate as to get caught out in a heavy rain so that her clothes have been wet through, or if in the cold weather she should come into the house thoroughly chilled, the best thing to do is to take off her wet things as quickly as possible, be well rubbed down with hot, rough towels, drink a cup of hot tea, go to bed at once and place a hot-water bag over the abdomen. She should remain in bed until the next morning, to the end that the circulation may regain its equilibrium as quickly as possible by the immediate relief of the pelvic congestion. If this exposure should have caused the sudden cessation of the flow, a hot mustard foot-bath should be taken. One tablespoonful of mustard is used to a gallon of water as hot as can be borne; the pail should be made as full as can be without running over, and a blanket wrapped around the pail and woman, so as to cause a profuse perspiration; this should be kept up for ten minutes; if the water cools off, hot water may be added.