Part 25

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 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.