But we are not here concerned with the history of the topic. Both physiologists and gynecologists differ widely both as to the causes and nature of menstruation. Some ascribe the chief or primal role to the ovaries, some to uterine proc- esses, some to the nerves; and it is certain that the first two can and often do act independently of each other. Current views, which seem to the writer as no longer incapable of har- monization in our higher synthesis, may be summarized from their leading representatives as follows: Most widely held now is probably the theory of Pfliiger's, that the significance of menstruation is not to escape plethora, but to denude a fresh uterine surface to which the egg, if im- pregnated, can graft itself. The constant ovarian growth causes a reflex stimulation which tumefies the uterus and prob- ably also matures a Graafian follicle. Both ovulation and the monthly flow, while very distinct phenomena, either of which PERIODICITY 483 may occur without the other, are yet both due to this congestion. By one process the nest is prepared, by the other the egg is laid in it. If the ovum is fertiHzed and attaches itself to the thick- ened uterine wall, then the menstrual decidua become the de- cidua of pregnancy, and are not detached till parturition, of which menstruation is the homologue and forerunner.^ Pflii- ger thus holds that menstruation and ovulation have thus only a reflex connection, and that the former is a periodic wounding of the surface in order that the ovum may be more readily at- tached to it.^ This view is not inconsistent with that which Virchow was the first to suggest, that every monthly illness is a pregnancy on a small scale. Aveling long ago pointed out the difference and similarities between a womb and a nest, and considered menstruation as infecund oviposition. Changes in the uterine mucus, he thought preparatory nidification. The decidua were nidal and nidation could come on independently of the ovaries. Occasionally the nest was ready too soon or in vain, and at other times was unfinished and too early. Hyper- nidation sometimes may be due to decline of nutrition, and may cause sterility. The nest may be expelled whole.^ Jacobi thinks it the homologue of parturition and perhaps an ontoge- netic relict of the frequent births of lower forms.
Lowenthal * thinks that the unfertilized ovum causes the menstrual decay of tissue which its impregnation prevents, and opposes the idea that the relation between these two events is merely temporal. On this view the periodicity of the hemorrhages depends on the duration of the extra follicular life power of the imbedded but unimpregnated egg. Menstrual hemorrhage, he thinks, is not physiological, but the natural effect of the non-impregnation and consequent death of the ovum, and must be regarded like other pathological bleedings and the flux be reduced to a minimum, so that amenorrhea is not always a dis- ease and diapedism is the least morbid way. King * also thinks menstru- ation a pathological process, and that women live abnormally in sex. Nature requires them to bear children throughout their sexual life, ^ See Am. Text-Book of Physiology, p. 399. Also, Lee: Reproduction, p, 898. ' Untersuchungen, 1865.
• Nidation in the Human Female. Obstet. Journal of Great Britain and Ire- * Eine neue Deutung des Menst. Processes. Arch. f. Gynacol., 1889, pp.
» Am. Jour, of Obstet., 1875.
THE PSYCHOLOGY OF ADOLESCENCE and thus to mostly escape menstruation. Stemham ^ says, on the con- trary, that it is a physiological adaptation of a special kind to keep the uterus in functional health, and while it is pathological in bleeding and degeneration, it is otherwise essentially normal, and no more ab- normal than the excessive production of ova. It seems to be an ad- justment, so that there shall be times favorable and others unfavorable for conception.
Oliver ^ approached the subject in a somewhat unique and philo- sophical way by assuming that the molecular world is in a condition of highly sensitized vital trepidation, and that equilibrium is the out- come of inherent powers of adaptation. Both structural and functional integrity are maintained in the animal body by the dependence of organs upon each other, and every tissue and part is thus in a relation of vicarious compensation, and this is a fundamental law. All double organs compensate, growing and doing extra work if the other is incapacitated. Uterine changes are anticipated by spontaneous ones in the nerve-centers, perhaps in the oblongata, so that neural symptoms may grow and be quite developed without the common physical changes. The periodic death of the endometrium does not start in the mucous membrane, is not the analogue of the loss and reproduc- tion of limbs, the shedding of its skin by the serpent, moulting, etc. There are frequently monthly disturbances of the psyche with menstru- ation, and epilepsy is the disease which most effects it. This nervous rhythm, as it were out toward the next generation, is due to some gradual but unknown vital energy which is primary. Ovulation he too saw to be a process quite distinct and apart.
Westphalen ^ believed that he had decided finally the question whether menstruation is a shedding of the outer mucous layer and the consecutive regeneration of its mucous. He concludes, first, that diffuse fine granular infiltration of fat is at all times a frequent finding in normal uterine mucous and is in no causal relation to bleeding; second, that the shed tissue undergoes fatty degeneration; third, at the end of the period there is an increased tendency to fatty metamorphosis of the protoplasm in the upper mucous membrane. This fatification is not death of the part, for it can be resorbed. As to whether in different phases of menstruation the conditions for the insertion of an egg are differently favorable, and what time is most so, is not yet solvable. From his studies upon extirpations and scrapings of fifty cases, he concludes that the cells, especially those of the epithelium, are renewed by indirect cell division periodically from six to eighteen days after the beginning of menstruation, and from the eighteenth day onward no proliferation occurs. The decidua are simply decadent * Menst. und Ovulation in ihre gegenstandliche Beziehungen. Gekronte Preis- schrift, Leipzig, 1890.
' Menstruation: Its Nerve Origin not a shedding of Mucous Membrane. Jour, of Anatomy and Physiology, 1886-67, p. 378.
' Zur Physiol, der Menstr. Arch. f. Gynacol., 1896, p. 35.
PERIODICITY 4^5 growths, broken down and removed after they are dead by gravity, a process made easy and economical by man's upright position.
It seems that man's self-domestication has had upon his own species the same result of increased fecundity and more frequent reproductive periods that it has had upon domesticated plants and animals. Menstrual phenomena seem more pro- nounced in the higher forms of animal life, and it has even been suggested that we may infer that in woman they will increase as civilization advances.
Reinl ^ held menstruation a result of a periodical dis- turbance of the entire circulatory system, and describes a growing contraction of vessels alternating with hyperaemia, which is greatly accentuated by puberty. He believed in the existence of this rhythmic period in men, children, and old people as well as during pregnancy and lactation. Degen- eration and removal of the ovaries does not afifect the form of this wave, and menstruation is only one manifestation of it. The wave may take many forms and even be reversed in pathological cases.
Dr. O. W. Johnston ^ may be cited as the best represen- tative of the neuro-ovulation theory. The ovaries are active before birth and continue to form follicles as long as the woman lives. She ripens probably four or five a year, but this has nothing to do with rut. The latter in animals occurs when they are at the very top of their condition and never when they have all they can do to live. As civilization has overcome climate, man may be said to be always at his best. Thus deer rut in the fall, birds in the spring, etc. All animals have desquamation times after the procreative periods, when hair, antlers, etc., are shed. Sex ornaments are akin to the manufacture and decay of the endometrium, as are feathers, papillae, and other sex decorations, arising as they do from the same embryonic layer. Thus we have here only a special case of karyokinetic growth and of the regeneration of tissue by which all wear and tear is supplied. Remak's view, that 1 Die Wellenbewegung der Lebensprocesses des Weibes. Samml. klin. Vor- trage Gynacol., No. 67 (whole No. 243).
2 Relation of Menstruation to Other Reproductive Functions. Am. Jour, of Obstetrics, 1895, p. 33.
4^6 THE PSYCHOLOGY OF ADOLESCENCE the sensory motor system comes from the epiblast; the muscles, bones, excretory, secretory, and generative organs from the mesoblast; while the hypoblast is largely nutritive, is said to favor this standpoint.
The first really careful curves of temperature were plotted by Dr. Stephenson,^ while Dr. Jacobi established the first proof of a nutritive wave. The pulse tension curve culminat- ing a few days before menstruation is generally accepted as another part of the well-marked curve of vital energy. Stephenson held that equal parts of the curve were below and above the line; that they varied with individuals; that the temperature wave was most uniform in its rise and fall, and that the waves were more or less independent of each other.
This wave may be further described as follows: From about seventeen days after the cessation of the flow, the pel- vis is anemic and the curve is a low level plateau with few and slight modifications and but a very gradual ascent. On or near the eighteenth day the rise is distinct and increas- ingly rapid, reaching its greatest angle of ascent about the twenty-third day, and continuing to augment till hydrostatic pressure causes local hemorrhage, when the pressure falls rapidly and the process is repeated twenty-eight days later.^ This view may perhaps harmonize with the older conception of the dominance of the uterine nerve plexi as a sort of pelvic brain, analogous to the solar plexus, often called the abdomi- nal brain. This uterine center would thus be a sort of tele- phonic switchboard, and hysteria would be due to derange- ment of its connections. In addition to the above blood pres- sure curve, there is a closely coinciding urea wave and a carbonic acid wave, the ash and smoke respectively of the combustion of the products of a hyperanabolic activity. These are indexes of the increased oxidation just preceding the flux necessary to get rid of the albuminoid surplus in the blood, produced because every normal female constantly produces food for two. Menstruation is a vast improvement upon the way in which this surplus in the endometrium, de- » On the Menstrual Wave. Am. Jour, of Obstetrics, 1882, vol. xv, p. 287. ' Pathol. Aspects of the Stephenson Wave. O. W. Johnston, M.D., Amer. Jour. Obstet., vol. xxxi, 1895, p. 662.
PERIODICITY 487 posited there for the manufacture of the placenta, was got rid of by slow absorption before the erect position was attained.
The Stephenson wave ^ thus best explains vicarious men- struation. It is a process in upright animals akin to.moulting or yearly loss of horns, hair, etc., and is a great biologic advance over the process so common among the lower ani- mals of slowly removing the endometrium through the lym- phatics. If there is obstruction, the wave is thrown to whatever point of the system is weakest. Every trouble in woman, which is aggravated or relieved at the same point of the menstrual wave, be it trough or crest, demands that special attention be given to the pelvis. Dr. Johnston found these periodicities in many cases of indigestion, constipation, liver symptoms, glycosuria, certain inflammation and congestion and Bright's disease, Basedow's disease, loss or weakness of voice, tinnitus aurium, amblyopia, choked disk, many brain troubles, etc., which are really inexplicable without knowl- edge of this wave, the detection of which. Dr. Johnston thinks, " is equaled in its benefits to our calling only by Har- vey's immortal discovery." About five days after the onset of the flow is the best time to perform surgical operations in the anemic trough of the wave. Just what of all the great number of periodic phenomena are causative, concomitant, or resultant, can not yet be told. If this author is right, that only five ova ripen each year, it would seem that the ovarian factor is less central than has been thought. He too holds that there are traces of such a wave observant in males.
The curve on p. 488, from Engelmann,^ illustrates almost equally well the rise and fall of pulse, temperature, blood pres- sure, muscular force, pulmonary capacity, morbid nervous symptoms, like the hystero-neuroses and the anatomical changes which he found in the uterine mucosa. This wave does not represent the amount or degree, but only the time of these undulations, the numbers being the days of the mensal period and the shaded days those of the flux.
The cyclic theory in its various forms assumes nervous centers in the walls of the blood vessels, which slowly elab- * The Clinical Importance of the Menstrual Wave, by C. A. Johnston, M. D.
• The American Girl of To-day. Am. Physical Ed. Rev., November, igai.
THE PSYCHOLOGY OF ADOLESCENCE orate power and contract the arterial muscular coats, acting partly by their own law and partly dependent upon higher nerve-centers, and thus cause a slight elevation of pressure throughout the entire body, till in certain parts best adapted thereto anatomically the hemorrhage occurs when the vascu- lar tension becomes sufficiently high. Even in pregnancy traces of these periods often continue, and miscarriages are more liable at such times. No surgical operation during or just preceding the monthly epoch should be performed. Vi- carious menstruation is not uncommon and flow of blood is then harder to stanch. Sleep, hibernation, peristaltic action, the uterine contractions once every two to thirty minutes, are at root, like menstrual periodic muscular phenomena, of nervous origin. Prepubertal growth is hypertrophy of cer- tain tissues dominated by trophic nerves, which must thus first undergo structural development, and then indirectly, by affecting circulation, cause the larynx, pelvis, and probably the vascular muscles, walls, etc., to grow. Motility does not ultimately reside in the non-striated muscles any more than it was thought to reside in the voluntary muscles in the days when the doctrine of independent muscular irritability pre- vailed. Congestion thus not only precedes, but actually causes the flow. Growth and nutrition are thus not purely vegetative, but are indirectly influenced by nerves. This view, it is claimed, affords a principle large enough to explain erection, vicarious menstruation, the flushing in hemorrhage of capillary birthmarks, excessive swelling, varicose veins, nosebleed, spitting blood, enlargement of the thyroid gland PERIODICITY 489 PERIODICITY 489 and spleen, puffiness, and dark coloration under the eye, and in rare cases where this interesting phenomenon is seen, stig- matization and cutaneous extravasation.
Dr. Schmey ^ pleads for a higher standpoint concerning menstruation, and assumes monthly plethora in both sexes. In men wounds often bleed periodically. Hemorrhages from the lungs are often monthly, as are hemorrhoidal and other sores. Senator demonstrated menstrual hyperemia of the liver. Both menstruation and ovulation are signs of a peri- odic fulness of blood in both sexes, at the height of which in woman the Graafian follicle is likely to be emptied and men- struation to occur. There is a cyclic change in the total amount of blood, and menstruation is a chance symptom due to the sensitiveness of the mucous membrane of the uterus. The lunar tide theory he thought suggestive.
On the basis of careful clinical studies upon the metabolism of menstruation, F. Schroder'' found that in both urine and feces less nitrogen was excreted from the system during these periods than dur- ing the rest of the month, while nutrition remained the same. This means, of course, less decomposition of albumin and the formation of less urea. The monthly hemorrhage is thus attended by the accu- mulation of nitrogen in the system, and not, as previous very tentative experiments on animals had indicated, by the increased decomposition of albumin. In these periodic and complementary groups of processes the blood loses albumin, but the cells of the body demand less of it, all processes thus adapting themselves to the needs of the sexual life. It is surprising to see how many of the studies of the menstrual curve of urea, nitrogen, and temperature failed to take account of either food or feces, and are therefore of almost no value. Whether all the monthly variables in the life of woman can be connected with the catamenia is also rarely considered.
Marro ' thinks that during the menstrual epoch the girl exhales less carbonic acid; eliminates less urea and sulphuric acid. Calcic phos- phate is eliminated in less quantities.
Silva* made very careful observations, although only on a few cases, from which he concludes that the alkaline reaction of the blood in normal girls is less during menstruation; that the influence of elec- ' Zur Theorie der Menst. u. z. Behandlung einiger Mens. Storungen. Thera- peut. Monatshefte, February, 1897, p. 93.
' Stoffwechsel wahrend der Menst. Zeitsch. klin. Med., 1894, pp. 72-90; see also Annali di Freniatria. Turin, 1895.
' Annali di Freniatria. Turin, 1898.
* Contribution k I'Etude de la Physio-pathologie de la Menst. Arch. Ttal de 490 THE PSYCHOLOGY OF ADOLESCENCE trie stimulation of the vaso-motor system is slight during the flux, but exquisite during the rest of the month. The same he finds true for the influence of heat and cold. Reaction time was slower and feebler. Respiration was more irregular and less affected by external stimulation. During the flow a strong stimulus less readily changed the costal to the abdominal type of respiration. Silva holds that the vaso- motor state which is the chief defense against bacteria has a real effect upon the organism's power of resistance; that the chemotactic action of the leucocytes probably does not affect the state of the vessels, and that in low nutrition the organism is easily impregnated by poison. Menstruation he regards as somewhat like pyrexia, and calls it an embryonal puerperal process. The bactericide power of serum dimin- ishes with alkalinity, which increases the consumption of albumin; and vice versa, immunized animals have more alkalinity. This com- ports with Schroder's view that during menstruation the urine and feces excrete about one half less azote, its budget measuring the loss of albumin.
Normally the pulse rate increases and the vascular tension rises as the period approaches, the minimal point being a few days after the cessation of the flow and the maximum just before. Temperature may increase before the flow as much as half a degree F. The amount of urine is increased, while the urea increases just before and after, but perhaps falls ofif a trifle during the flux. The thyroid and parotic glands and breasts are swollen, and the Fallopian tubes congested. Fin- klestein showed a concentric narrowing of the field of vision beginning one to three days before, and culminating on the third or fourth day of menstruation, and vanishing three or four days later. His perimetric tests showed this narrowing of the field for red, blue, green, and yellow, as well as for white, while distinctness of vision in the central field was also slightly impaired. Traces of pigmentation, so marked at this period in the anal regi.ons in some monkeys, where it is very brilliant, are seen under the eyes and around the nip- ples and sometimes on the renal parts. An odor quite dis- tinct from that peculiar to the organs, and aromatic, is often noticed, and the voice may grow dull and flat. Women are more easily hypnotized, more prone to jealousy, ill-temper, and confessionism, can make less accurate and energetic movements, and mental activities are less brilliant, while these powers are at their best at the time of strongest genitive impulses and greatest conceptive power.
PERIODICITY 491 The total period of twenty-eight days may, according to Minot, be approximately divided as follows: tumefaction of the mucosa and its attendant phenomena, five days; men- strual flux, four days; restoration of the mucosa, seven days; resting period, twelve days. In a sense, as Ellis ^ says, a woman during her reproductive life is always engaged in menstruating. Everything she does or says must be judged by its exact position in this cycle which permeates her whole physical and psychical organism; and especially in unbalanced and neurotic persons, even guilt for crime is lessened, so that in criminal trials this should always be considered. This is in distinct opposition to views like those of Miss F. P. Cobbe and Mrs. Fawcett, the latter of whom declares, in contradic- tion to Mr. Harrison's statement, that nearly "all women are subject to functional interruptions absolutely incompatible with the highest forms of continuous pressure," that ''the ordinary healthy woman is as fit for work every day of her life as the ordinary healthy man." Miss E. B. Gamble asserts that these eternal wounds of love and their cicatrization, which may even account for woman's smaller size as com- pared with man, which fill the month with a drama which has a new motive each day, and often makes her an invalid one- fifth of the time, are normally pathological, and due in some way, she does not attempt to explain, to long ages of man's brutality.
Although every recurrent period has the closest rapport with the neuro-psychic functions, the few first and last men- struations have a far greater influence upon the brain and soul than do those when the sexual rhythm is best estab- lished. The psychoses caused by the former are often acute and stormy. The first periods are often very irregular in time, sometimes occurring once in three to five months, one in two years, or even more.^ This has a very disturbing effect upon the organism. Esquirol thought one-sixth of all psychic diseases in women were influenced if not caused by menstruation. A similar view also led Morel to ascribe great ' On these points see Ellis: Man and Woman, p. 251 et seq.y also p. 247. 'P. I. Kovalevski: Des Menstruations-Zustand und der Mens. Psychosen. Med. Wochensch., St. Petersburg, 1894, p. 216 et seq.
49 2 THE PSYCHOLOGY OF ADOLESCENCE etiological importance in insanity to the way in which first menstruation was established. Headache, tearfulness, irrita- bility, relaxation, and indisposition often appear two or three days before the illness is due; and often these symptoms are repeated every twenty-eight to thirty-two days, three or four days before the flux appears; or again after the latter has once appeared, six months may elapse before another occurs, while the above nervous symptoms occur monthly.