The question of rest for women during menstruation

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O THE UNIVERSITY

Section I. Introductory.— Historical.— General Considerations In Regard To Labor

AN inquiry into the limits of human nature is always legitimate, and often exceedingly useful. When honestly made, it tends to increase real force while dissipating illusions concerning imaginary powers. Thus knowledge of the limits of muscular strength stimulates the invention of machines many times man power. Compressed by the admitted limits of religious thought1 religious speculation is forced into more definite channels, and assumes tasks at once more robust and more profitable than those, only apparently more splendid, which had hitherto absorbed its energies. When arbitrary attempts to modify the social organism are rebutted by the unsuspected limits imposed by its laws, resources as unsuspected are revealed to those who choose to look for them. Such indeed is the audacity of the human intellect^ that the discovery of limits usually proves hopeless in only one case, namely, when they are perceived to apply to a different race, class, or sex, from that to which the investigator himself belongs. An inquiry into the limits to activity and attainments that may be imposed by sex, is very frequently carried on in the same spirit 1 See Mansel. Limits of Religious Thought.

as that which hastens to ascribe to permanent differences in race all the peculiarities of a class, and this because the sex that is supposed to be limiting in its nature, is nearly ahvays different from that of the person conducting the inquiry. It is true that men have inquired with great research into the influence exerted upon the general organization of man by the special character and working of his sexual organization, but it is rare that this influence has been regarded as " limiting " in its nature. Moralists and theologians have pointed out. the narrow limits into which its undue ascendancy might reduce the rest of the physical and mental life, but their exhortations have always assumed that such undue ascendancy would never be attained except by wilful negligence or moral sin. Physiologists and physicians again, while demonstrating the slavery that results from abuse of the sexual functions, have hinted = of no danger consequent upon their normal exercise. On the contrary their stimulating effects upon the rest of the economy have been portrayed .in brilliant colors by even sober pens. To the reproductive apparatus is generally ascribed a permanent influence upon the organism of whose maximum development it constitutes the most elaborate expression. The development and activity of this apparatus, by means of which the life of the individual is linked to that of the race, are said to be correlative with the development and activity of the organs of individual life, and not in inverse proportion to them. It may indeed be considered as quite a modern eccentricity to claim as an element of superiority in man, that, in the intervals of the voluntary exercise of sexual functions, " he is practically unsexed." ! Were the assertion true, which it is far from being, it would prove a marked inferiority on his part to organisms whose sexual characters are permanent, since both in plants and animals, scxual_ orgamsms_rank_higher than asexual ; the development of sex marks a progress from the primitively neutral condition of 1 Ely Vande Walker, Popular Science Monthly, July, 1875.

SEX AS A LIMITATION. 3

young animals, and privation of the organs of sex is liable to seriously deteriorate some of the robust organs of individual life. All this is generally recognized in regard to the masculine sex. But as soon as there is question of the other, the fundamental conception of the subject seems to be changed. Not alone the accidents of sex or the abnormal exercise of its functions, but the sex itself seems to be regarded as a pathological fact, constantly detracting from the sum total of health, and of healthful activities. " Woman, in the interest^ of the race has been endowed with a set of organs peculiar to herself, whose complexity, delicacy, sympathies and force, are among the marvels of creation,1 (Sex in Education, p. 83). C O m_t_y^_ (T.rait4-d£s_ maladies Hes femmes, p. 274). enumer^ ates the natural phenomena of menstruation, copulation, gestation, parturitlonT^mong the ^:auses_of the frequency of uterine disease^ Dr. Guerin (Movement medical quoted by Munde Journal Obstetrics, Aug., 1875), says, " There isnoj pjvysiologiral ronHil-ion gn nearly resembling disease as that whjrhjrrnfhirpq every monfh in an arlnlr woman^ change so profound that it has been looked upon as the expression of a morbid condition." TilL who declares that diseases of menstruation have been the engrossing study of his life, defines this_process_to be a "_sero sanguinolent secretion " propelled b_y_an_j)varian infltreaee-frem- all or different-parts of the generative intestine, and^pjjiicipally from the womb. It is a natural function peculiar to women. . . . who_are. sub.^.. |ect to tfnistiaturalinjirimty for about seven out of the thirty years of jj£mductive_iife.3 Hutchins, in a prize essay ac-

1 It is true the author adds, " If properly nurtured and cared for, they, (these organs) are a source of strength and power to her," and disclaims that any organ or function in plant, animal, or human kind can properly be regarded as a disability or source of weakness.

^ * It is menstruation that is generally considered the peculiarity of the sex, which most seriously cripples the individual energies of woman, since it alone exerts its influence upon all, and at all times during adult life.

*On Diseases of Menstruation, 1851, p. 23.

ceptcd by a State Medical Association, says, ' " Woman has a sumjptal of nervous force equivalent to a man's, but this is distributed over a greater multiplicity of organs and directed to Jhc_development and support of special reproductive energies in addition to those of individual nutrition. The nervous force is therefore weakened in each organ,— and

the period _of resistance of each, organ— is— weakened,^-

it is more scnsiU\^e,_ni^pxeJlaJbj£^_demngejnenti2 In another place the author quotes an experiment of Rabuteau, as a proof that during menstruation the general nutrition of the JDody is diminished.! ~H7rt calls menstruation a condition which, if not precisely morbid, is still often upon the limits of pathology, and under all circumstances determines a greater predisposition to different diseases." 4 The author calculated that " every four weeks the uterus becomes hyperaemiatecl in such manner that almost the entire organism is involved in sympathetic suffering; and this during three to five days every month, or one to two months out of every year." Thus even for the non-pregnant woman, " a great portion of the time during the period of maturity7 is passed under the influence of the genital sphere." * Stprer. in his essay on criminal abortion, appends a note to the paragraph devoted to female physlcians^considcred as a special class of accomplices to this crime (p. 98), in which he remarks that, "granting that women in exceptional cases may have all the courage, tact, ability, pecuniary means, education, and

1 Transactions New York State Medical Association, 1875.

- The inference that women are more liable to contract diseases at the menstrual period' bears so directly upon the subject of this essay that it will be discussed in full further on. It is vigorously contradicted by Herard.

3 We shall have occasion to refer again to this experiment, and to discuss it in view of others made to control it.

4 Die Gewerbeliche Thatigkeit der Frauen, 1873.

5 We shall see, however, that practically, Hirt thinks that no modifications of the industrial work of women, based upon the existence of menstruation, are either desirable or practicable.

MORBID EFFECTS OF MENSTRUATION. 5

patience necessary to fit persons for the cares and responsibilities of professiojiaJMjfe.Jhey still are andjnu&t-ke-subject to the periodical /^/?r/;;/'/£_nf_rheir >;py ; wkich-Cor-fche-tim^ and in every case, however unattended by physical suffering, unfits them for any responsible effort oflmlnd, and in many cases of body also. It is not to women as physicians we would object ; . . . but to their often infirmity, during which neither life nor limb submitted to them would be as safe as at other times. We could hardly allow to a female physician (?) convicted of criminal abortion, the plea that the act was committed &\]u:\ng___ih.&~ temporary insanity of .her. menstruat ion_j and yet at such times a woman is undoubtedly more prone than men to commit any unusual or outrageous act."1 In the same sense Dr. Tilt, in an address to the Obstetrical Society of London for 1874, congratulated the members upon their almost unanimous decision that women were not admissible, — " for the profession felt that the verdict really meant that women 2 were not qualified by nature to make good midwifery practitioners ; that they were unfit to bear the physical fatigues and mental anxieties of obstetrical practice, at menstrual periods, during pregnancy and puerperality ; and that it was unfair to society to encourage women to suppose they could fit themselves to assume responsibilities in those formidable obstetric emergencies which too often completely paralyze even men of experience." * Already, in 1805, Roussel4 had declared menstruation to be

1 Criminal Abortion, p. 101. Boston. 1868.

5 i. e., in the opinion of the Society.

3 British Mecl. Jour., Jan. 16, 1875. It is interesting to find in the same volume of this journal, an editorial commenting upon a local epidemic of puerperal fever that had been caused by the ignorance of a midwife, and concluding with these words : " Every day the fact presents itself with increasing importunity and sometimes hideous vividness, that midwives must be improved or abolished. The latter plan is undesirable and impossible, the former is practicable, urgently demanded, and, to our shame be it written, has been adopted in every European country but Great Britain" 4 Systeme Morale et Physique de la Femme, p. 100.

6 THE QUESTION OE REST FOR WOMEN.

a salutary crisis intended to relieve a pathological condition, induced by the excesses at table common in advanced civilizations ; and Auber1 attributed the phenomena to the unnatural restraint imposed by these same civilizations upon the sexual instinct [see Beimel]. According to Hageivisch, menstruation is an hereditary disease, developed by civilization, and according to Moscati, by the upright position of the human female.3 A modification of the doctrines of the Roussel school has been recently advanced by King, of Washington, who is apparently unacquainted with the arguments of his predecessors. He asserts thar menstruation, far from affording relief to pathological conditions, itself constitutes a morbid state fraught with danger, inasmuch as it is proof of functional inactivity on the part of the uterus, which becomes therefore liable to atrophy by sclerosis.3 It is the function of the uterus to bear the product of conception, but, impregnation not taking place, involution occurs in the membrane by fatty degeneration just as it does in the muscular walls of the womb after delivery, with this difference, that it is at the beginning instead of the end of the normal function, and before the mucous membrane has at all accomplished the office for which it had been so highly developed." Thus, as has been said, a woman menstruates, only because she does not conceive." To Dr. King this remark is not merely the statement of an obvious physiological sequence, as when it is said that a man sleeps because he is not awake, or fasts because not employed in digestion. Hut he infers that since gestation is the proper function of the adult uterus, in the absence of gestation, /. e., in the presence ofjncnstruation, the uterus is_ threat ciiedwith the atrophy incurred by all organs whose functions are unnat-

1 Quoted by Raciborski, Traite de la Menstruation, p. 18. s Quoted and combated by Burdach— Die Physiologie Erste Band p 240 1835.

MORBID EFFECTS OF MENSTRUATION. 7

urally suspended. " Nature will not support the nutrition of a useless organ ; in the physiological offices of the system she will allow no sinecures ; hence we always find that organs performing no useful purpose become prone to disease, degeneration, and decay." As a practical inference, Dr. King reromm.^nfk^fh^t girls bp encouraged to marry immediately upon arriving at the age of puberty, so that menstruation may be at once interrupted by a pregnancy which should be repeated so frequently as to entirely exclude its pathological substitute from th'e existence of the woman. . This view of merfstruatlon as a pathological process grafted upon the female economy by a progressively deteriorating civilization, is in striking contrast with the opinions that prevailed throughout antiquity, the middle ages, and even, until recently, in modern times. According to these elder ideas, women are naturally plethoric, in order to be able at the proper time to utilize their excess of blood for the development of the foetus.1 Aristotle, to whom Raciborski attributes the first enunciation of this theory, calls the menstrual blood the marble, the sperm the sculptor, the foetus the statue.2 The Hindoo Susruta writing thirteen or fourteen hundred years before the Christian era, also explains fecundation by the admixture of the semen with the menstrual blood, in which latter is contained the germ of the

Th^plethoric theory. of menstruation was based ; first upon the general analogy of the menstrual flux with other evacuations; and second upon its relations to pregnancy, of which the most superficial observation showed it to be the substitute. The sense of discomfort or even experience of danger attendant on suppression of the evacuations of faeces or urine, offered a basis of sensation, upon which was easily built the theory,

1 Raciborski, loc. cit., p. 8.

* Quoted by Flourens, Cours d'Embryologie.

8 Quoted by Kreiger, Die Menstruation, 1869.

8 PLETHORIC THEORY OF MENSTRUATION.

that all spontaneous evacuations implied the existence of some morbific material whose retention was extremely perilous to the economy. The menstrual " purgation " was included in the generalization. "The opinion, observes Kreiger, that the bodv was purified by the flux from the uterus, became permanent, and was asserted still more emphatically in the Commentaries on Hippocrates in the sixteenth and seventeenth centuries. So for instance, Bapt. Moretarns, de uterin affectionibus, p. 221." "The uterus is the sewer of all the excrements existing in the body ; for all decrements flow to the uterus." ' On the other hand, the enormous amount of nutritive material required for the development of the fcetus was supposed to be derived from some reserve habitually not utilized for individual nutrition ; this reserve could be none other than the blood thrown away as superfluous during non-pregnant states, but retained as soon as the embryo began to develop. If women escaped annihilation during pregnancy, it could only be in virtue of a plethora existing in all other conditions. Hippocrates gives an ingenious explanation of the cause of this plethora, not accepting as sufficient the teleological statement of its utility. " The woman," he says, " has a flesh more loose and soft (in texture) than the man, and which therefore absorbs from the abdomen (nourishing) fluids more rapidly and in greater abundance than the masculine body. With this laxity, when the body is (stuffed) full of blood, the tissues become hot and plethoric, and if no evacuation is effected, a state of suffering supervenes. The blood of the Avoman is warmer, and this is why she herself is warmer than the man.2 If, however, the plenitude is evacuated (in due time) neither heat nor suffering is produced. The body of the man, on the other hand, not being soft (and relaxed) is not susceptible of such vascular plenitude, and he is not therefore liable to an excess of heat as a consequence of plethora. Besides, as he exercises 1 Kreiger. Loc. cit. p. 5. 2 This is also asserted by Longet.

PLETHORIC THEORY OF MENSTRUATION. 9

more than the woman, a part of the (nutritive) fluid is dissipated by fatigue." 1

Sanctorius believed that a monthly plethora occurred in both men and women, each of whom increased periodically in weight to the amount of one or two pounds." 2

Boerhaave explains the plethora of women in a different manner. " About the time," he says, " that the body of a female is arrived at its full growth, it uses to make a greater quantity of blood, than what the vessels will contain, which is the reason why part of it is let out at the end of the arteries of the womb, which evacuation is called the monthly courses. If the blood is retained then follows a plethora." 3 The correlation between the cessation of growth, and the establishment of the menstrual flow that is presumed to represent the nutritive material become excessive for the needs of the body, is insisted upon at greater length by Haller. " At the age of thirteen, at the same time that the semen begins to form in the male, the whole mass of blood circulates with increased force. At this time when the growth of the body begins considerably to diminish, and the blood, rinding easy admittance to completed viscera, is prepared in greater quantity, a plethora frequently (?) follows. In the male this is frequently vented by the nose. In -the female a more easy vent is found downwards. The uterine vessels are enlarged, of a soft fleecy fabric, seated in a loose hollow part, with a great deal of cellular fabric interspersed, very yielding and succulent. For these causes the vessels being more easily distensible, the blood finds a more easy passage into the cavity of the uterus than into any other part. — Again, the return of blood is more slow, both because of the flexures of the arteries which become serpentine, and retard

1 Oeuvres d'Hippocrate Traduction Littre Traite des maladies des femmes, P. IS-

* Aphorism LXV., 17^).

3 Aphorisms, 1290 and 1291. Translation from Latin. 1728.

the blood motion, and also because it passes with more difficulty through the veins. The blood, therefore, first collects in the vessels of the uterus, then accumulates in the arteries of the loins, and the aorta itself, which, urging on a new torrent of blood augments in force so far as to discharge the red blood into the serous vessels.' The quantity of the menstrual flux is promoted by everything that either increases the quantity or the momentum of the blood more particularly to the uterus, such as joy, lust, rich diet, warm air, lively temperament." "

Burdach3 (1835) remarks that "as menstruation offers local and general phenomena, so it depends upon local and general causes. The general cause is evidently, that in the female body the formation of blood is sufficiently rich to provide every four weeks for an overflow of the same — whose evacuation becomes a necessity. For after this evacuation is there complete health and regularity of all forces, and the body has the same weight as before. The menstruation is richer when the formation of blood is abundant, and weaker when blood is deficient, from insufficient foods, tedious disease, etc. We believe this excess of blood depends upon an excess of formative power in the woman, and that the menstruation, in its increase and decrease, stands in exact proportion to the formative activity, and also to its expenditure. For where matter and force are employed for the movement and nutrition of the muscles, the plastic force can develop itself less in other directions ; when on the contrary the muscular power is less exercised, then developes easily a (' UPP'SC ') formation of fluid material. The menstruation is more profuse in weakness than in vigorous health, in towns-

1 This partly foreshadows Rouget's theory of the erectile accumulation of blood in the pelvic blood vessels, on account of the serpentine flexures of the arteries, and of hindrance to the reflux through the veins.

- Haller Elements of Physiology, 1786. (English Translation, vol. 2, p. 183.)

SOURCES OF THE MENSTRUAL BLOOD. II

women than in peasants. The local cause of menstruation is the specific direction of the plastic force to the organs of generation. On account of their high vitality, menstruation may exist even in the absence of any general abundance of blood." Wagner (Handworterbuch, Bd. 4. p. 879. 1853), after accepting the ovular theory of menstruation, unknown to Burdach, says : " The blood that is evacuated at the time of menstruation contains all the constituents of normal blood, and is a part of the blood which circulated in the body. It is an excess which is acquired in the (' Getriebe'} of the individual life, whose formation is rendered possible through the entire mechanical disposition (anlage) of the body. It is completely analogous to the formative material elsewhere employed for the development of the embryo. The menstrual flow ceases during pregnancy. The excess, which at other times may be eliminated without danger to the individual life, which indeed must be eliminated, under pain of multiple disturbances, now serves to cover the increased expenditure." ' " The evacuation of the menstrual blood is nothing else than the elimination, under a special form, of superfluous productive material." The author, who considers the slight hemorrhages accompanying the rut in some of the higher mammalia to be completely analogous to menstruation, observes that this evacuation is confined to mammalian animals because in them the ovum is so small as to make only the most insignificant demand upon the plastic force, and this therefore remains in excess. Astruc declared that the blood and lymph destined for the nutrition of the foetus is derived from that which, previous to puberty, had been used for growth, and during the maturity of the woman continually accumulates in certain veins on the inner surface

1 Wagner endeavors to show that the weight of menstrual blood saved during ten months gestation exactly equals the weight of the foetus at term. But by the utmost stretching this can only be found by admitting that ten ounces of blood are lost at each menstruation, which is evidently too much.

of the uterus. When these are swollen by the accumulation, they protrude into the uterine cavity, are called " ccecal appendages," and from them flows the blood at menstruation. Allan Thompson, writing about the same time as Burdach,1 says menstruation is to be regarded as the means for relieving the female system from an overplus of blood, which exists during the whole time that it is capable of propagation. It is to be regarded as indicating a surplus, but not constituting the whole amount required for the foetus. For as only five or six ounces are lost at each menstrual period, only fifty ounces or eight pounds (three pounds and two ounces avoirdupois) could be accumulated in the ten months of pregnancy, whereas the foetus weighs from six to ten pounds. Capuron attributes the theory of plethora to Galen, and disputes it. He himself explains menstruation as the result of a general shock given to all the organism and especially to the womb, to dispose it to conceive, to retain the germ, and to develop it during pregnancy.

It may therefore be confidently asserted that, previous to the discoveries which associated menstruation with the clehiscence of ova, this peculiar phenomena was almost universally regarded as a proof of an excess of nutritive force in the sex upon whom devolved the greatest cost of reproduction. From Hippocrates to Burdach (see ut suprai, this presumed excess of nutritive force in women is constantly contrasted with their deficiency of muscular force as compared with that of man, and with the arrest of the growth which is continuous in children. Menstruation__hi women, muscular force in man, growth in children, were held tQ be more^oFTcsT cxirct trqrriT7dCTits'T6~mTc~an other.2 But in 1845, with the establishment o? the fact of spontaneous ovulation, the conditions of general nutrition upon which

5 Though Hermann considers the menstrual fluid to be the exact equivalentis! plastic force — of the sperm.

PERIODICITY OF MENSTRUATION. 13

menstruation could be supposed to depend began to be lost sight of in comparison with the remarkable local phenomena with which they were, asserted to be exclusively associated. The congestion of the ovary, ripening of the ovule, effusion of the serum and blood into the Graafian follicle ; its rupture ; the escape of the reproductive cell ; its seizure by the fimbriae of the Fallopian tube ; its journey along the oviduct and descent into the uterus ; the hyperannia of the latter, the turgesence of its mucous membrane, the rupture of its blood vessels, and local hemorrhage ; this entire succession of processes seemed the more surprising because more recently demonstrated, and to cause a greater perturbation of the economy, because occurring at intervals. For the first time the periodicity of menstruation began to be considered as a morbid circumstance. Although physiologists pointed out that the periodicity of menstruation belonged to the general law of vital phenomena,1 as earlier rude observations had associated it with the periodicity of cosmic phenomena,2 clincians came gradually to look upon it as a fact which isolated menstruation from all other physiological processes, which rendered its ordinary course dangerous, its derangements fatal, and itself was sufficient to make any utero-ovarian disease baffle the skill of the physician. Aran, who disputes the ovular theory of menstruation, saw in the periodical return of uterine "congestions" the main reason for the desperate tenacity of uterine disease — the patient

1 Dalton, Treatise on Physiology, p. 548. Beclard, Elements de la Physiologic, 1867. Longet, Traite de la Physiologic.

2 See Mead, De imperio solis et Lunae. Darwin, Descent of Man, p. 204, vol. II, associates it with periodical alterations of nutrition, to which were subjected the primitive ascidian ancestors of the human race, from the lunar revolutions of the tides. " All vital functions tend to run their course in fixed and recurrent periods, and with tidal animals the periods would probably be lunar, for such animals must have been left dry or covered deep with water — supplied with copious food or stinted — during endless generations, at regular lunar intervals."

14 TIIK QUESTION" OF REST FOR WOMEX.

being exposed to incessant relapses at the very brink of recovery. In the same spirit, Courty remarks that "menstruation" constantly intervenes to produce and aggravate uterine disorders by fluxion, congestions, and critical evacuation.1 Scan/.oni says that during a chronic mctritis, every menstruation offers an occasion for the development of a new acute inflammation.2 Khvisch, speaking of the dcsquamation of the mucous membrane of the uterus during menstruation, observes: "This periodic physiological process determines at the same time a disposition to various anomalies of menstruation ;" 3 and again, "Chronic inflammatory affections of the uterus are almost constantly aggravated at each menstrual period, or even return after thc\' have been removed, so that the greatest hindrance in the treatment of many cases of metritis is the repeated menstrual congestion."4 Finally, all writers, of whom some have been already quoted, who call menstruation an " infirmity," base the epithet mainly upon the periodicity of the hemorrhage. " It is a constantly recurring infirmity that occupies about seven years out of thirty of a woman's adult life." It would seem as if for these writers, were the flux continual, or of as frequent occurrence as defecation or micturition, the idea of infirmity would be abolished. On the other hand. Beigel/' writing in most recent times, and after investigations have shown the " periodical congestion of the uterus to be much more extended in duration than was formerly supposed," observes that " menstruation is of so much the more

1 Loc. cit., p. 2S6.

- Die Chronische Mctritis. 1867. (For a more favorable view by the same author, see at infra.)

s Mutterkrankheiten, Ld. I. p. 4.

Loc. cit., p. 14. This is equivalent to saying that the greatest obstacle to the cure of any visceral disease is the continuance of the functions of the organs involved, which keep up hyperiemia and innervation. The fact is true, but not peculiar to uterine pathology.

DANGERS OF PHYSIOLOGICAL PROCESSES. 1 5

significance in relation to chronic metritis because its influence is almost uninterrupted. In the most favorable cases we can only suppose ten to fourteen days rest, and that is not quite certain. This continual ebb and flow of circulation of the pelvic organs, constitutes a predisposition to the development of most diseases of the female sexual sphere." "At the time of menstruation the uterus is in a state which offers all the conditions from which metritis developes itself." 1

Thus one of the most essential apparent peculiarities of the menstrual process, its periodicity, that formerly was supposed to indicate a periodical increase in the vital forces of the female organism, has come to be considered as a mark of constantly recurring debility, a means of constantly recurring exhaustion demanding rest as decidedly as a fracture or a paralysis. The comparative novelty of this view is assuredly no proof that it is erroneous. Investigations into the laws of animal organisms, have repeatedly shown them to be far more complex and more delicate than had been imagined by the rough common sense of mankind. The nature and urgency of the perils menacing the life of young children, of puerperal women, of wounded men, have only recently been demonstrated with sufficient clearness to attempt their prophylaxis. The dangers have been proven to be inherent in crowds of habitual circumstances that for centuries have been regarded with indifference or accepted with complacency ; air, supposed to be healthful has been proved foul ; water, believed innocuous, has been convicted of poison ; food, the staple support of entire populations, has been accused as the cause of their most desolating epidemics ; or certain articles of food considered insignificant, have been shown to be so essential that 'certain diseases are specifically correlated to their absence.2 Lucrative trades have been condemned as

1 The same might be said of the stomach during digestion, or the brain during activity, i.e., that then gastritis or meningitis seemed to be the most imminent.