Part 22

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

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

Menstruation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The mean duration in these cases was 5.387 days.

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

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

The mean duration in these cases was 3.87 days.

The mean duration of the menstrual flow is:

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

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

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

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

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