womb (what we call the mucous membrane or endometrium) becomes congested and its bloodvessels become distended with blood. If the woman has sexual intercourse and pregnancy happens to take place, then this extra blood is used to nourish and develop the new child; but if no pregnancy takes place, that extra blood exudes from the bloodvessels (some of the bloodvessels rupture) and is discharged from the uterus into the vagina, and from there to the outside, where it is caught on cotton, sanitary napkins or some other pad. At what age does menstruation begin? The usual age at which menstruation begins in this country is thirteen or fourteen; in some it may occur as early as twelve, in others as late as fifteen, sixteen or even seventeen. For menstruation to begin earlier than twelve or later than seventeen is in this country a rare exception. But in cold northern climates the age of eighteen is not rare, and in the hot southern climates menstruation often starts at the ages [73]of ten or eleven. Change of climate or of country will often have an influence on the menses. In the early years of his medical practice, the author had many Finnish girls as patients. It was a very common occurrence for them to stop menstruating for the first few months or even for the first year of their residence in this country. At what age does menstruation cease? The age at which menstruation ceases is called the menopause or climacteric. It usually takes place at the age of forty-eight or fifty. In some cases it does not take place until the age of fifty-two, in others it takes place as early as forty-five or forty-four. In general, it may be said that the woman's menstruating period, during which she is able to have children, lasts about thirty-five years. And if no restraint be taken, and if no precautions be taken against conception, a woman could have twenty or thirty children during her childbearing period. 19 How many days does a woman menstruate? The usual number of days is from three to five; in some cases menstruation lasts only two days, in others as long as seven. As a rule, the greatest amount of blood passed is during the first two days. The amount of blood. It is hard to estimate the exact amount of blood passed by a woman during her menses, but it reaches about an ounce and a [74]half to three ounces. In some women the amount may reach as much as four or five ounces and in exceptional cases as much as eight ounces. Where it exceeds this amount, it is an abnormal condition, requiring treatment. The usual statement that a normally menstruating woman should not have to use more than three napkins during the twenty-four hours is correct. The periodical regularity with which menstruation recurs in many women is remarkable. I know a woman who has not missed her menses in twenty years; during those twenty years the menses have started every fourth Friday, almost always at the same hour. I know another one who has her menses every fourth Wednesday, about seven in the morning. She skipped her periods during her two pregnancies, then they were irregular for a while, then they came back to Wednesday. Other women have their menses on a certain day of the month, say the first or the fifth, regardless of the number of days in the month (such cases are, however, exceptional). And in some women the menses are irregular: every three weeks, every five or six weeks, every six or seven weeks,
etc. Some women never know when they may expect their menses, so irregular they are. [75] Chapter SevenToC ABNORMALITIES OF MENSTRUATION Disorders of Menstruation--Menorrhagia--Metrorrhagia--Amenorrhea--Vicarious Menstruation--Dysmenorrhea of Organic and of Nervous Origin. In many girls and women menstruation is a perfectly normal, physiological process. They suffer no discomfort whatever from it. They suffer no pains, no headache, no irritability, they have no admonition of its onset, until they feel the blood oozing or trickling out. But, unfortunately, this is true only of a small percentage. The majority of women have some unpleasant symptoms. Some have a headache for a day or two, some complain of a dragging down sensation, some are irritable, feel depressed or quarrelsome; some have no appetite, no ambition, no desire for work or company, while some girls have such severe pains and cramps that they are obliged to go to bed for a day or two and call in medical aid. When the menstruation is very profuse, resembling more a hemorrhage than normal menstruation, it is called menorrhagia; if the hemorrhage from [76]the uterus occurs out of the regular menstrual periods, it is called metrorrhagia. When the menses are skipped, or when they are so scanty that you can hardly notice any blood, we use the term amenorrhea. In a few rare cases the menstruation instead of coming normally from the uterus, comes from some other part of the body, for instance, the nose. Some women have a hemorrhage from the nose every month. In some a bloody discharge may come from the breasts. To such a substitute menstruation we apply the term vicarious menstruation. Such cases, however, are rare, and are mere curiosities. Dysmenorrhea. I mentioned before that in some girls and women the menses are accompanied by pains and cramps. This affliction, which is the lot of millions of women, and from which men are entirely free, is called dysmenorrhea. Dysmenorrhea means painful and difficult menstruation. A slight pain or at least a feeling of discomfort is present in most cases of menstruation. But in many cases the pain is so severe, so excruciating, that the sufferer, girl or woman, is incapacitated for any work, and must go to bed for a day or two. In some cases the pain is so severe as to necessitate the use of morphine, and as it is a very bad thing to have to give morphine every three or four weeks, [77]every endeavor should be made to find out the cause of the trouble and to remove it. It is a mistake, however, to think that all or even most cases of dysmenorrhea are due to some local trouble, that is, to an inflammation of the ovaries, or a displacement of the womb. Many cases of dysmenorrhea are of nervous origin; the cause resides in the central nervous system, and not in the genital organs themselves. It is, therefore, not advisable to undertake any local treatment, unless a competent physician has made a thorough examination and has decided that local treatment is advisable. As to the percentage of dysmenorrhea, a recent statistical examination of 4,000 women showed that dysmenorrhea of some degree was present in over one-half, namely, 52 per cent. 20 [78] Chapter EightToC THE HYGIENE OF MENSTRUATION Lack of Cleanliness During Menstrual Period--Superstitious Beliefs--Hygiene of Menstruation. The hygiene of menstruation can be expressed in two words: cleanliness and rest. Common sense would suggest these two measures, and as far as rest is concerned, many women do rest or take it easy while they are unwell. Some are forced to do it, because, if they don't, their dysmenorrhea is worse and the amount of blood they lose is considerably increased. The same cannot be said of cleanliness. Due undoubtedly to the superstitious opinions about menstruation, which came over to us from the ages-of-long-ago, menstruation is still considered a noli-me-tangere, and women are afraid to bathe, to douche or even to wash during the periods. And if there is any period when a woman needs a douche it is during menstruation. Any leucorrhea that a woman may be suffering from becomes aggravated around the periods; the menstrual blood of some women has a decided odor, and if no cleansing douche is taken during four [79]or five days, some of the blood decomposes and acquires a decidedly offensive odor, which can be noticed at some distance and to which some men and women are very susceptible. There are some women who never take a vaginal douche. Some consider it a useless and unnecessary luxury; while some orthodox puritanical women consider it an ungodly procedure (forgetting that cleanliness is next to godliness) fit only for women of gay and questionable character. If these orthodox women knew what was good for them--and for their health--they would take a douche at least during menstruation, if at no other time. Cleanliness. When the girl reaches the age of twelve or thirteen the mother should explain to her the phenomenon of menstruation and the likelihood of its making its appearance in a short time. Of course she should be told that there is nothing shameful in it, that when it makes its appearance she should at once tell her mother, who will instruct her what to do. She should be shown the use of sanitary napkins. Rags, unless recently washed and kept wrapped up and protected from dust, should not be used. Unclean rags may lead to infection. I have no doubt that many cases of leucorrhea date back their origin to unwashed rags. Every morning and every evening the girl should wash the [80]external genitals with warm water, or plain soap and water. Married women should also take a douche once a day--the douche may consist of two quarts of water in which has been dissolved a teaspoonful of common table salt, or a tablespoonful of borax or boric acid. Such things like alum, potassium permanganate, carbolic acid, lactic acid, or tincture of iodine should only be used when there is leucorrhea present and generally only under a physician's directions. Bathing is permissible, but it is safe to use only a lukewarm bath. Cold tub baths, cold shower baths, as well as ocean and river bathing are best avoided during the period; at least during the first two days. I do not give this as an absolute rule; I know women who bathe and swim in the ocean during their menstrual periods without any injury to themselves, but they are exceptionally robust women; advice in books is for the average person, and it is always best to be on the safe side. Rest. Rest is just as important
