Menstruation

MENSTRUATION. Contents: Time of onset and conclusion.........85 5 Duration, nature and character of M. ... 857 Causes and biological significance of M......861 Influence of the menstrual cycle on the body, on individual systems and organs.........8R6 Hygiene of M.....................87 6 Menstruation (from Latin mensis-month), monthly cleansing, regulation, blood, menses, menorrhoea, menstruata, periodic, occurring at more or less definite intervals, bloody discharge from the female genital organs. M. represents one of the basic sexual functions of woman, and this is not only a local isolated process limited only to the discharge of blood, but also a general manifestation of life, consisting of cyclic changes both in the sexual sphere and in the entire organism as a whole. The first appearance of M. indicates the impending sexual maturity, but is not yet an indicator of sexual maturity. The appearance of the first M. is usually preceded by a number of significant changes both in the mental and physical state of the girl. The entire complex of these changes characterizes the period of sexual maturation. In anatomical terms, its main signs are the enhanced development of subcutaneous fatty tissue on the large labia, thighs, buttocks, the appearance of vegetation on the pubis and in the armpits, the formation of mammary glands and nipples, the rounding of the entire body's form and a significant increase in the size of the uterus. Time of onset and conclusion of M. The time of the first M. (menarche) varies depending on nationality, climate, living conditions, external environment, nutrition, the beginning of physical labor, and other constitutional peculiarities of a given organism. Thus, large statistical data have proven that the first M. occurs in rural women later than in city women, that M. appears earlier in the south, that in girls fed predominantly on meat food, the time of onset is earlier than with a vegetarian regime, etc. The first appearance of M. by no means always marks the beginning of its regular alternation; cases are not uncommon when M. is established correctly only after several months (and even more), as well as cases where in the first months it comes with large intervals and is not uniform in its duration. In Russia, according to data from 34 authors who examined 64,759 women, Gruzdev established that the beginning of sexual maturity on average refers to 15.83 years, varying depending on social position.

According to the statistical compilation of Gruzdev (1894), the average age of onset of M. for women of various nationalities also varies, as shown in Table 1. Table 1. Nationality Number examined Average age of onset of M. Georgian women .... Armenian women .... Polish women ..... Karelian women (Tver) Russian women...... Finland . . . Zyryan women .... 6 466 2 1!)5 1 000 33 688 3S83 2 430 14,27 14,1Э 14,78 15,36 16,46 16,87 15,93 16,13 16,25 Among Russian women (based on 33,688 examined), M. begins earlier in the south than in the north; specifically, for Russian women the average age of onset of M. is 16.64 in the north, 15.8 in the central region, and 15.3 in the south; for peasant women in the north-16.57, in the central region-16.15, in the south-15.83. In this regard, the observations of Sokolov (1880) on peasant women in the northeastern part of the Moscow province are also interesting: before the abolition of serfdom, they began to 'carry blood' relatively late. In recent times, many authors have pointed to the importance of constitutional factors, particularly emphasizing the role of pathological constitution and in particular predisposition to neoplasms. Thus, the early onset of M. in future patients with uterine fibroids, noted already by Trell (Troell), has been confirmed in subsequent observations by other authors. Lelchuk (clinic of the North-Caucasus University) also noted a difference in the onset of M. in fibroids and cancer. He statistically proved that with fibroids, an earlier onset of menstruation is usually observed, while with cancer, on the contrary, the timing of its appearance appears relatively later. Constitutional anomalies (e.g., infantilism) also influence to a significant extent, as well as organic diseases of the central nervous system (e.g., dementia praecox, epilepsy), which can serve as a cause of late onset of M. (Ashner). Late M. (menstruation tarda) can also be a consequence of severe infections in childhood, various chronic diseases (for example tbc), exhaustion of the body, etc. All this can lead to disruption of ovarian function, to its 'insufficiency' with subsequent delay in the onset of menarche. Along with menstruation tarda, on the contrary, cases of early appearance (menstruation praecox) are encountered. This is observed in precocious puberty, where along with menstrual bleeding there is already an almost fully formed female organism both in relation to the sexual sphere (developed uterus, abundant vegetation characteristic of an adult woman) and of the entire body, with characteristic and typical features of female structure, roundness of forms, etc. M. praecox is rare; it has been observed in girls even at the age of 2-4 years and should be considered as a pathological phenomenon (see Pubertas praecox). M. lasts on average for 30 years, after which a woman enters the period of menopause, which occurs at approximately 45-48 years (rarely before 40 and after 50 years). Just as the time of onset of the first M. varies (depending on a number of combined conditions), so does the time of onset of menopause. Improper sexual life, artificial abortions (especially repeated), postpartum diseases, inflammatory processes in the sexual sphere, neoplasms, and finally general acute and chronic diseases can have a significant influence on its premature onset (see Climax). Some authors (e.g., Schauta) consider it possible to establish as a rule that M. ceases later the earlier it begins; others, on the contrary, believe that early onset of M. leads to its early cessation. Duration, intensity, and character of M. The duration of menstrual bleeding is not the same in individual women. The most common average duration is 3-5 days, rarely are cases encountered where M. lasts only 1-2 days, or, conversely, 6-8 days. The duration of M. is not an absolutely constant quantity in the same woman, but rather a variable quantity; this variability may depend not only on various inflammatory processes, but also on such factors as sexual life, consequences of pregnancy, childbirth, abortions, etc. Changes in the duration of M. of physiological character may also occur with the onset of menopause. Kopstein (Gohnstein) believes that a longer M. is observed with its early onset, with early sexual life (provided there are children and breastfeeding).-Intervals between M. are also very different; on average, M. most often occurs after 28 days, but cases are not uncommon where intervals lengthen (even to 35-40 days) or, conversely, decrease (to 25 days and even to 3 weeks). Vigne (Vignes), based on questioning women who carefully monitor their M., found that in 424 cases the intervals were more or less regular and only 21 instances of lengthening or shortening were noted. Based on these same data, Vigne considered it possible to establish 5 groups of intervals, of which the 28-day interval is most common (Table 2). Table 2. Number of days Number of cases Percentage 20-21-22 (3 Weeks).......... 50 178 108 8 12 44 27 25-26 (a little less than a lunar month.) 30-31-32 (solar month)..... On the proposal of Seitz (L. Seitz), the earlier onset of M. is now called proimenorrhea, while the later onset is called opsomenorrhea. The duration, intensity, character of menstrual bleeding, as well as the intervals between individual cycles depend on one or another constitution, on the different ability to develop the egg cell and transformations of the corpus luteum. Lengthening or shortening of intervals between M. may be observed in the same woman depending on a number of external life conditions (see further-M. and profession), the influence of which is most strongly manifested in moments of formation of the female organism and in moments of the beginning of fading of the function of the sex glands (in the preclimacteric and climacteric periods). As for the question of the relationship between the duration of the interval and the duration of menstrual bleeding, apparently no connection exists between them; it can only be noted that the average normal duration of M. corresponds to the average duration of the interval. Vigne also points out that the longer the intervals between M., the longer the duration of M.-However, this cyclicity of the menstrual cycle is not observed in all countries. Thus, as early as 1887, Hennig pointed out that among Lapp and Greenland women living in polar countries, intervals between M. significantly lengthen (3 months or more), among Eskimo women M. does not occur in winter time, and on Tierra del Fuego women do not have M. at all, and if they do, then extremely rarely. (On pathological absence of M. see Amenorrhea.) The appearance of menarche is accompanied by a number of peculiar sensations; only in a small number of cases does it not cause any noticeable experiences and deviations of the psyche. Molimina menstrualia. Menstruation, just like some other phases of the entire ovarian-uterine cycle, is accompanied by a number of peculiar painful sensations both in the sexual sphere and throughout the body. These specific sensations are classified as cyclic physiological phenomena and are inherent in the majority of women. Maria Tobler (M. Tobler) based on 1,000 observations of women in the menstrual period came to the conclusion that one or another painful sensations are observed in 75-80%. Not so rarely (10-15%) these 'physiological' menstrual pains can manifest in a more severe degree (even with a properly proceeding M.) and are already considered as a pathological phenomenon. The entire complex of various kinds of painful sensations before and during M. is called molimina menstrualia; they can be very different and depend both on external conditions and on individual peculiarities of a given person. Molimina menstrualia according to numerous observations occur at any age-before and after the onset of sexual life, before and after childbirth. Pains originating from the sexual apparatus are observed in the lower abdomen, in the lumbar region, sacrum and are dull, often cramping in nature; they can also be pulling, extending to the legs; a feeling of heaviness, a feeling of pressure in the lower abdomen is often observed. These sensations are often accompanied by symptoms from the urinary bladder and intestines (frequent urges, constipation, diarrhea). Pains can be caused (even in the absence of any diseases of the sexual sphere) by uterine contractions or by endocrine influences (ovary). Many other symptoms are explained by increased blood filling in the uterine cavity, hyperemia. Pankow gives these pains the name 'uterine prolapse phenomena.'- General phenomena are extremely diverse; they occur independently of local pains and sensations, but can also be directly related to them. These include general weakness, malaise, rapid and easy fatigue, fluctuations in mood, deviations in the psyche, headaches, sensation of heat, loss of appetite, nausea, etc. (see below). The duration of these pains and general phenomena varies in different women; usually they occur on the eve of M. (one day before, rarely earlier) and last one to two days.

Some authors (Schroder) have noted that pains during M. itself are most often local, while premenstrual phenomena more often have a psychological character. In addition to these painful sensations directly related to menstrual bleeding, pains also occur midway between two M.s. They are called 'intermediate' pains (Mittelschmerz, dysmenorrhoea intermenstrualis, crise intermenstruelle) and can sometimes be accompanied by slight bleeding ('intermediate' bleeding; dysovulation, according to Stratz; règles surnuméraires). 'Intermediate' pains occur less frequently than molimina menstrualia, but are similar to them; dysovulation is observed even less frequently. Vin (1925) points out that the most frequent symptoms of these crises are a feeling of heat in the genital area and pressure in the lower abdomen, pains in the sacrum and lower back, leukorrhea, slight bleeding, nervous excitement, etc. Cases where the entire symptom complex is fully expressed are rarely observed. Based on his observations, Vin came to the following conclusions: among 424 women who lived a sexual life and had children, intermenstrual sensations occurred in 3%; their duration ranged from several hours to two days; in many women they were noted as a constant phenomenon, while in some they occurred only when fatigued; among 370 women who had not lived a sexual life (later they married and had children), these sensations also occurred in 3%; their duration in one case was noted as 4 days. Among 60 women who sought advice regarding infertility, intermenstrual crises were noted in 13%, and they were of longer duration (up to 6-8 days). Given that these sensations in infertility are often noted in connection with accompanying inflammatory diseases, it can be assumed that their cause lies in insufficient or improper ovarian function (most likely on the same inflammatory basis). The amount of blood lost both during the day and during the entire M. is subject to significant individual variations. Thus, it has been noted that in the south this amount is greater than in the north, that it is greater at night than during the day. The lifestyle also has an influence: in women of physical labor it is less significant than in those leading a sedentary lifestyle, especially with excessive nutrition. Furthermore, these variations may also depend on thermal irritations; thus, cold decreases, while heat increases the intensity of bleeding. On average, during M. 50 to 100 g of blood is lost, but even in normal cases up to 150 and even up to 250 g can be lost. It must be kept in mind that along with blood, there is also a significant secretion of mucus from the uterus. The amount of blood lost may depend on constitutional features, e.g., properties of the vascular system, certain tone of uterine musculature, etc. Some authors draw a parallel between the amount of blood lost and the general condition of the body. Thus, for example, Vin cites examples of lengthening of M. in some women suffering from liver diseases. When deciding the question of what amount of blood lost should be considered physiological and what pathological, one cannot proceed from any specific figures; one must mainly consider the general condition and well-being of the woman. Along with greater blood loss and developing general malaise, a pathological sign can also be the discharge of blood clots (especially with pain), even if small. The composition of menstrual blood in chemical and morphological aspects, as well as some of its specific features, is also of interest. Menstrual blood is dark in color, contains a large amount of mucus and has a characteristic (sometimes unpleasant even for the women themselves) odor, which often appears before the blood itself flows, even during premenstrual mucus discharge. Compared to ordinary blood, menstrual blood contains less Hb, red and white blood cells. It has a lower specific gravity, high water content, reduced molecular concentration, increased alkalinity, and in addition lacks the ability to clot. The reason for this latter feature has not yet been fully clarified. Most authors connect the non-coagulability of blood with the absence of fibrin and fibrinogen, which in the very first moments of menstrual flow are destroyed by the formed trypsin enzyme. Other explanations for the causes of this non-coagulability (such as: the presence of a large amount of mucus, the possibility of the action of lactic acid, the content of an anticoagulating substance in the endometrium itself, the presence of antithrombin in the uterus, ovary and corpus luteum, etc.) have not received general recognition. In menstrual blood, in addition to mucus and glycogen, calcium, lecithin, cholesterol, arsenic, phosphorus, etc. have been found. The content of some of these substances exceeds that in ordinary blood (for example lecithin) or, conversely, appears lower (cholesterol). Regarding the total protein content, opinions differ: some believe it is less, while others consider it equal to the protein content in ordinary blood. The presence of all these substances in the shedding mucous membrane and in menstrual blood is interpreted by many authors as the removal from the body of unnecessary and not indifferent to it nutrients, which cannot be utilized due to the non-occurrence of pregnancy. The question of whether so-called 'menotoxins' (a name given to supposed toxins circulating in the blood and produced in connection with the ovarian-uterine cycle) are excreted with menstrual blood should be (at least at the present moment) answered negatively. The presence of 'menotoxin' in the milk of menstruating women (Frank) has also not yet been confirmed. Schickele definitely speaks against the presence of 'menotoxins' in menstrual blood. In his numerous experiments with menstrual blood on animals, he never noted any harmful effect of it. He noted only a brief decrease in blood pressure after its injection, for which reason he suggests that it contains the same substances (vasodilating and causing a decrease in blood pressure) that are found in the uterus and ovary. Causes and biological significance of M. Attempts to explain the causes of M. are found even in the most ancient sources. It is quite understandable that these interpretations had an empirical, primitive character even in the words of the founders of ancient medicine. The main view that held for centuries was that during M. a woman is freed from various poisonous substances, which is why the very name 'monthly cleansing' arose. This view was cultivated by religion, which prohibited communication with a woman during M. and considered everyone who came into contact with her during this period defiled. In Hindu medicine, M. was equated with abortion, and the noted cyclical nature of it gave rise to the so-called 'lunar theory,' according to which it was believed that M. occurs after the full moon (mentions of the lunar theory are also found in later sources, and even recently there have been individual attempts to substantiate it). In centuries close to us, we encounter a number of other views, but all of them were based on empiricism and differed in the same fantastic nature. Thus, for example, there were indications of local congestion on the basis of sexual desire (Le Cat, 1765), of the uterus being filled with blood (Astruc, 1768), of the oblique position of the uterus and the corresponding arrangement of blood vessels (Baude locque, 1789), etc. M. was explained by the degree of culture and civilization; thus, Roussel (1803) believed that it is an act inherent only to a civilized woman and arising on the basis of excessive nutrition. The idea that arose and was soon abandoned (1837) by Burdach that M. constitutes as it were an additional equivalent to the act of respiration and that supposedly with menstrual blood excess CO2 is removed from the body can serve as an example of how various views on M. usually reflected the prevailing directions in medicine and were caused by the desire to explain the mysterious essence of it with new ideas (as is known, Burdach's view was based on the then newly discovered fact of the non-coagulability of menstrual blood, which he explained by the body being overloaded with CO2). Scientific substantiation of the origin of M. begins only in the 19th century after K. Baer's (Baer, 1827) discovery of the human egg. And indeed, in the very years following this, the question of M. begins to acquire a completely new character; instead of the speculative views that had prevailed for centuries, factual material, i.e., purely anatomical data, is placed at the foundation of M. The credit for these new investigations undoubtedly belongs to the French scientist Negrier, whose classic works begin a new era in the doctrine of M.; they brought definite scientific revival and served as an impulse for a series of new investigations not only in France (Raciborsky) but also in Germany (Bischoff) and in England.

Negrie, on the basis of a series of anatomical studies, came to the conclusion about the cyclic transformation of follicles, about their monthly rupture. In addition, he indicated the dependence of M. on ovulation, noted that in women without ovaries there is never M., and that it ceases with their artificial removal. The initial assumptions about the relationship between M. and ovulation consisted in the fact that menstrual bleeding was viewed simply as a consequence of the release of blood when the follicle ruptures and its subsequent passage along with the egg cell through the tube into the uterus. Only later, thanks to the research of a number of authors (Virchow and especially Leopold), it was established that menstrual bleeding originates only from the mucous membrane of the uterus, which required a new interpretation of the phenomena occurring. First, the famous Pflüger's theory of reflex irritation appeared; subsequently, in connection with the appearance and development of the doctrine of internal secretion, the internal secretion theory began to win more and more rights, which is now shared by all scientists. Pflüger's theory (whose supporters were such prominent gynecologists as Leopold and others) was recognized by many until the very last time, when the important role of the ovary in the individual phases of the menstrual cycle and its direct hormonal influence on the cyclic transformations in the uterine mucosa had been completely clarified. Pflüger set out to clarify the mechanism and essence of the relationship between M. and ovulation. He believed that the cause of menstrual bleeding is irritation emanating from the maturing and growing follicle, i.e., the growth of the follicle is accompanied by irritation of the ovarian nerves, which is summed up, transmitted further along nerve pathways and finally reflected on the uterine mucosa; in it, due to such a reflex action, premenstrual transformations occur. Pflüger believed that these changes in the uterine mucosa could be caused not only by the growing follicle, but also by other reflex influences, to which he also included the sexual act. Pflüger's theory during the second half of the 19th century was the most widespread because after its appearance by Bischoff, the simultaneity of the ovulatory and menstrual phases was proven (menstrual bleeding occurs almost at the same time as the rupture of the follicle), and by Strassmann, the possibility of such a reflex effect was even experimentally verified on dogs with positive results. Strassmann introduced saline solution and other fluids into the ovaries of dogs in order to cause irritation in them and indeed observed in them increased secretion from the vagina and uterus, which he equated to estrus. The long-prevailing theory of Pflüger was shaken by subsequent experimental research and observations on a living woman in the era of the development of the surgical era in the therapy of female diseases. It was proven that indeed certain relationships exist between the ovary and the uterus, that under the influence of the ovary periodic changes occur in the uterine mucosa, but this connection is not nervous, i.e., not reflex, but of a hormonal nature (experiments with the transplantation of the ovary to various parts of the body). Further research fully confirmed the importance of the internal secretory activity of the ovary in the ovarian-uterine cycle. The modern view of M. is that its main cause is the internal secretion of the ovary, that the cyclic changes occurring in the uterine mucosa with the subsequent separation of blood depend on the ovary, mainly on its follicular apparatus. The modern understanding of the biological significance of M. is based on the essence of the cyclic changes occurring both in the sexual sphere and in the entire female organism. It is an established fact that without ovulation there is no M. All periodically occurring complex physicochemical processes in the organism have as their ultimate goal to prepare it for the possibility of pregnancy; the bleeding itself has the basis that it maintains the mucous membrane functioning for a certain time and serves as a moment for its renewal, without which the implantation of a fertilized egg would be impossible. Data from the analysis of menstrual blood can additionally indicate that menstrual bleeding, marking the death of the unfertilized egg cell, also has the purpose of carrying away with it the nutrients prepared for pregnancy but unused due to fertilization not having occurred. Menstrual cycle. As has already been said above, M. is now considered not as an isolated local phenomenon, but as a collection of systemic changes, which, bearing the general collective name 'ovarian-uterine cycle,' can be divided into three main groups: 1) changes in the ovary - the ovarian cycle (see Ovulation), 2) changes in the uterus (the uterine, or menstrual cycle) and in other parts of the sexual apparatus and 3) changes in the entire organism and in individual organs (see below). All modern knowledge about the ovarian-menstrual cycle is based on a whole series of numerous studies, of which the classical, basic ones are the works of Hitschmann and Adler, Schröder, R. Meyer, Seitz and Fraenkel (Hitschmann u. Adler, R. Meyer, L. Fraenkel) and others. The great merit of Hitschmann and Adler is that they undermined the old view of the immutability of the uterine mucosa in the individual phases of the menstrual cycle and histologically proved the constant, cyclic changes occurring in it. R. Schröder, in turn, later came to the conclusion about the presence in the uterine mucosa of a 'functional layer' and its cyclic transformations into the corresponding stages of the uterine cycle (proliferation, desquamation, regeneration). The uterine menstrual cycle is directly connected with the cyclic changes that occur in the ovary (see Ovulation); the various phases of this latter cycle depend on the maturation of the egg cell, in which many authors see the first and main cause (Robert Meyer- 'Primat des Eies') of all biological periodic phenomena in the female organism. In the menstrual cycle, the main, most significant changes occur in the uterine mucosa. In view of the fact that due to these changes corresponding favorable conditions are created for the reception, strengthening and further development of the fertilized female egg cell, some (e.g. Zuntz and others) propose to call the phase before menstrual bleeding not 'premenstrual,' but 'pregnvidar.' This proposal is based on the fact that the cyclic transformations of the uterine mucosa in this phase are similar to the morphological changes that occur in it in the initial stages of pregnancy; on the basis of these same morphological data, the name decidua is also proposed to be replaced by praedecidua. The division of the uterine cycle into corresponding phases is based on the histological changes that cyclically occur in the uterine mucosa and which in turn are connected with the activity of the ovary and the changes in the maturing and growing follicle, the exit of the egg cell and the formation of the corpus luteum. The changes in the uterine mucosa are divided into 4 phases or stages (R. Schröder): 1) the stage of regeneration (or the stage of rest after the previous menstrual bleeding); 2) the stage of proliferation (proliferative); 3) the secretory stage (or secretion) and 4) the stage of desquamation, or rejection (menstrual). The first stage (regeneration) consists in the restoration of the mucous membrane (the functional layer), which begins already in the last moments of the previous menstrual bleeding. The rejection of the mucous membrane down to its basal layer begins already at the beginning of M., and immediately after its removal in the first days, its regeneration begins, which consists in the proliferation of epithelial cells of the glands, in the formation of straight glandular passages (tubuli), in the lining of the entire surface of the uterus with newly formed mucous membrane and in the restoration of the reticular fibers of the stroma. In this stage, the epithelium of the glands does not function, the glands are considerably narrowed and do not contain secretion. The second stage (proliferation) begins eight days after menstrual bleeding and continues for 7-8 days. The initial change of this stage is the rapid and significant thickening of the mucous membrane (due to the growth and multiplication of stromal cells), followed by the multiplication of the epithelium covering the uterine glands. There is a significant increase in the number of glands, an increase in their cavities, the glands expand and take on a tortuous (corkscrew-like) character. On average, these progressive phenomena in the mucous membrane and uterine glands continue until the 14-15th day after the end of bleeding; after the completion of development in the mucous membrane, further transformations begin, characterized as the third stage, the secretory stage (secretion, premenstrual, pregravvidar). The stage of proliferation corresponds to the completion of the maturation of the egg cell and the beginning of the rupture of the follicle.

The secretory phase occurs about 15 days after menstrual bleeding and consists of the fact that the proliferated epithelium of the uterine glands increases in volume and begins to secrete a secretion consisting mainly of glycogen and mucin. Due to the increase in the glandular epithelium, the cavity of the glands enlarges, and the glands themselves become highly convoluted, acquiring a saw-toothed shape on cross-sections. The entire mucosa gradually acquires a very characteristic appearance, in which it is possible to distinguish three layers: the most superficial - compact, consisting of closely grouped decidual cells (a product of a special metamorphosis of stromal cells) and the narrow necks of the uterine glands lying among them; behind this layer comes a spongy layer, very rich in the aforementioned glands, and in the depth - the third, basal layer, not undergoing special changes during M. The most typical moment for this entire phase is the changes in the epithelium of the uterine glands and the stroma of the mucosa; this phase continues until the next bleeding, and in time corresponds to the stage of organization and flourishing of the corpus luteum. The fourth stage (desquamation) consists in the disintegration of the mucosa and the onset of bleeding. Preliminary changes in the mucosa can be observed some time before the appearance of M itself; for example, the capillaries are more dilated, there are already individual hemorrhages, an increase in the number of leukocytes in the area of the functional layer is observed; chromatolysis and pyknosis are also clearly expressed in it. Subsequently, all these phenomena intensify, the mucosa ruptures and with the appearance of bleeding it is rejected either in separate small fragments or in large pieces (depending on the nature, intensity of the menstrual cycle, the presence of one or another pathological process in the genital sphere). Menstrual blood therefore comes only from the mucosa, which, during the occurring disintegration, is excreted along with the blood (the shedding, or decidual membrane). This shedding membrane really resembles the decidual membrane in the early stages of pregnancy both in terms of the mentioned changes and in the content of glycogen, mucin and other substances characteristic of the decidual membrane during pregnancy. The uterus in the premenstrual period (uterus praemenstrualis) and during M itself increases due to hyperemia by one third or one quarter (its muscles are thicker and juicier; the mucosa is thickened by 5-6 mm, temperature in the uterus is elevated). These changes were noted even by Raciborski, who equated them to changes during pregnancy, but only expressed to a lesser degree. Nothing definite can be said about the participation of other parts of the genital sphere, but the existing observations indicate that cyclic changes similar to those occurring in the mucosa of the uterine body probably do not occur in them (mucosa of the cervix, mucosa of the tubes); some authors admit the possibility of corresponding changes in the tubes as well, but so far this is only a hypothesis, and the existing individual case reports of 'tubal M' should be regarded as pathological changes. For example, Grudev described a case where in a woman who died during M, blood was found in completely healthy tubes. Assuming that this blood was secreted by the tubal mucosa, Grudev, however, did not consider it possible to consider tubal M as a rule and attributed it to such exceptions as tubal pregnancy. However, recent research again speaks of changes in the tubal mucosa (ampullary part) in the secretory phase and in the premenstrual period; these changes are observed until the very end of menstrual bleeding, and then the mucosa returns to its normal appearance (Schickele, attributing these transformations of the mucosa to hyperemia, considers them as cyclic changes). Changes in the vagina have been little studied. Some (Graefenberg) noted an increase in the acidity of vaginal contents, especially strongly expressed at the end of the secretory phase on the eve of menstrual bleeding. In addition, more or less pronounced hyperemia and increased secretion are observed in the premenstrual period. The temperature of the vagina and external genital organs is slightly elevated. The latter are also hyperemic. Characteristic changes associated with the various phases of the menstrual cycle also occur in the mammary glands (see). The influence of the menstrual cycle on the body, on individual systems and organs. The cyclic changes occurring in the genital apparatus are directly reflected in the vital activity of the entire organism and in the functions of individual organs. This totality of physiological periodic manifestations in the body was noted by Ott; it received full confirmation in a number of subsequent experimental studies and clinical observations. Thus, many authors during M note a drop in body temperature, changes in the pulse (a decrease in its frequency, on the eve of M, however, a certain acceleration is observed), a decrease in heat output, blood pressure (it increases before M, and at the beginning of bleeding it drops slightly below normal limits), a decrease in vital lung capacity, some slowing of breathing; finally, periodic fluctuations have been traced in metabolism, blood properties, the function of individual organs and entire systems. Along with a decrease in temperature, many authors note its premenstrual elevation, which some qualify as 'premenstrual fever', and it can occur not only in any general diseases or diseases of the genital sphere, but also in completely healthy women. Caussimon in his dissertation, specifically devoted to the question of menstrual fever in pulmonary tuberculosis (1925), believes that during the menstrual period conditions may exist that can both raise and lower body temperature. This thermal reaction, in Caussimon's opinion, can be explained by toxic, vasomotor, nervous and endocrine influences. Leuret and Caussimon believe that M in general, and especially M with fever, in some tuberculous women can worsen the process; in some cases, women themselves are reinfected every month due to M, which thus contributes to the further gradual exhaustion of the body. Premenstrual fever can often be observed in a number of other inflammatory processes, in diseases of the kidney, ear, etc., as well as in diseases of the genital sphere. M and metabolism. It is quite natural to expect that cyclic changes in the genital sphere are reflected accordingly in the main types of metabolism. Although this question, despite a number of very valuable recent studies, cannot be considered finally studied, nevertheless the existing observations already allow one to speak of a certain regularity and cyclicity of physiological changes also from the side of metabolism. Thus, in relation to mineral metabolism, changes in the excretion of NaCl (namely, in the premenstrual stage, hyperchloremia is observed) have been noted. Heilig's (1924) experiments with the administration of large doses of NaCl during M also speak of its significantly reduced excretion from the body compared to normal. Imparato (1929) in his research on the calcium content in the blood at different periods of the menstrual cycle did not note any fluctuations and came to the conclusion that the difference obtained by individual authors should be explained simply by the peculiarities of the organism, due to which the calcium content in different individuals may vary. Imparato nevertheless established fluctuations in calcium content in oligomenorrhea (the more pronounced it is, the higher the calcium content). He also noted a larger amount of calcium with profuse M and with amenorrhea. Fluctuations in fat and carbohydrate metabolism have also been noted. Thus, it has been established (Chauffard, 1917) an increase in the cholesterol curve, reaching its highest point at the initial moment of menstrual bleeding. Vigne showed that with delayed M, hypocholesterolemia may occur and that on the first day of M there is a tendency to hypercholesterolemia. All researchers also confirm the increased sugar content in the blood, which begins at the very end of the premenstrual stage and lasts almost throughout the menstrual bleeding. Changes in carbohydrate metabolism were also tested in experiments with artificial introduction of sugar into the body. Kustner-son notes as almost a constant phenomenon the onset of glycosuria on the eve of M after the introduction of grape sugar and subsequent injection of adrenaline; Heilig, however, when giving sucrose before meals, points to a greater delay of sugar (2-3 times) compared to normal in the periods preceding menstrual bleeding. There are also indications of changes in protein metabolism both in normal M and in its deviations (these data require additional research). The existing research here also shows greater activity of chemical processes - an increase in ammonia excretion in the premenstrual period, increased urea content (and the higher the increase, the more intense the menstrual bleeding).

Apparently, gas exchange also fluctuates, but precise and definite data are not yet available. Menstruation and blood. Various changes in the blood have also been noted in one phase or another of the menstrual cycle; the non-identical data of different authors can be explained by the fact that in the blood, apparently, no strictly defined regularity is encountered; these changes are rather of an individual nature and depend on the woman's constitution, as well as on the nature of Menstruation itself (duration, amount of blood discharged, etc.). The difference in some data is fully explained by the fact that the material was not always homogeneous: results from healthy women and women with general diseases, as well as local diseases of the sexual sphere, were compared. For example, in relation to hemoglobin (Hb), there are indications of fluctuations in its content before Menstruation (increase), during it (decrease), and after its completion (new increase). Smirensky believes that on average Hb during Menstruation decreases by 2-6%, whereas Averbakh, Bobrov, and Shvartsman speak generally of fluctuations in one direction or another in the content of Hb and in the height of the color index during the menstrual cycle. On the other hand, observations by M. Tyler and F. Underhill on 10 healthy women over 14 normal menstrual periods showed that no significant fluctuations occur; only minor deviations were noted (sometimes an increase, sometimes a decrease), but they were not associated with any specific phase of the menstrual cycle. The number of red blood cells tends to increase before Menstruation, and during the bleeding their number decreases, and according to Smirensky, the maximum decrease occurs on the second day, while from the third day their number begins to increase, and in the first days after the completion of Menstruation there is even a tendency to some slight increase. As for fluctuations in the resistance of red blood cells, nothing definite is yet known. There is also no agreement regarding the parallelism in fluctuations in the content of Hb and the percentage of decrease or increase in the number of red blood cells. Thus, Vigne admits the possibility of parallel changes, while others (Hofstatter and others) could not note such parallelism. Changes in the white blood have also been described. Most researchers indicate that there is leukocytosis in the premenstrual period, which persists throughout the menstrual bleeding, with some noting that the increase in the number of white blood cells is more pronounced in cases of greater blood loss. Others (Nesmelova, Smirensky) believe that leukopenia is observed during Menstruation, and it is most sharply expressed on the second day, while in the days immediately following the menstrual bleeding, a gradual return to the normal number begins (Nesmelova). Similarly, the data from research on the leukocyte formula are different; the most constant phenomenon must apparently be recognized as an increase in the number of lymphocytes during Menstruation itself. Quite a few studies have also been conducted on platelets. All authors note certain fluctuations in their content, with disagreement only on the question of at what moments of menstrual bleeding their greater decrease occurs. Thus, Henning and Smirensky believe that the maximum decrease in the number of platelets occurs on the second day (Smirensky noted the beginning of their decrease a day before the appearance of blood), while Pfeiffer and Hoff, pointing to a sharp decrease (from 1/2 to 3/4 of the normal content) on the first or second day, believe that their recovery can also begin from the second day. The increase in the number of platelets rapidly increases in the following days; in some cases, a day after the completion of Menstruation, they reach normal numbers (Smirensky). Averbakh, Bobrov, and Shvartsman also consider the decrease (on average by 34%) in the number of platelets (greatest in the first days of Menstruation) as indisputable and, together with other authors (e.g., Gudim-Levkovich), believe that this decrease is not related to blood loss but to the influence of hormones from both the ovary and other endocrine glands. Interesting are the observations of Vinogradov and Artifeksova, who did not limit themselves to determining the number of blood platelets but studied the entire hemorrhagic syndrome—the Rumpel-Leede symptom, the number of platelets, blood coagulability, and bleeding time (Duke's phenomenon), retraction of the blood clot, and vessel vulnerability. Having obtained positive results both in healthy women and in women with various diseases, Vinogradov and Artifeksova came to the conclusion that the presence of this syndrome is a consequence not of bleeding but of hormonal influence. Vinogradov and Artifeksova (as well as other authors—for example, Henning) in almost all cases observed the appearance of the endothelial Rumpel-Leede symptom during menstrual days. Vigne also believes that in some women the endothelial symptom can be induced 2 days or 8 days before Menstruation. The studies of the same authors on blood coagulability during Menstruation generally confirm the data of other authors (Nesmelova, Gudim-Levkovich, Schrader) that it either remains unchanged or, if it changes, it is only slightly; in a more recent work, Averbakh, Bobrov, and Shvartsman indicate that Menstruation affects blood coagulability and that this effect manifests as an increased duration of coagulation, beginning already before Menstruation and sometimes persisting for some time after its completion. As for viscosity and alkalinity, no firmly established data are available; the reduced alkalinity noted by some authors was not subsequently confirmed; also, the values of blood viscosity are not equivalent among different authors; thus, Averbakh, Bobrov, and Shvartsman give significantly higher figures compared to Nesmelova and others. Menstruation and endocrine glands. In view of the close connection and chemical correlational relationships that exist between the sex glands (and the sexual apparatus in general) and other endocrine glands, it is natural to expect corresponding cyclic changes in them, parallel to the transformations in the uterine mucosa and ovary due to the diverse hormonal activity of the corpus luteum in its various stages of development. However, this question has not yet been sufficiently studied, and the available data are contradictory. Regarding the pituitary gland, some believe that it is in a state of hyperfunction and that this explains the premenstrural polyuria and contractions of the uterine musculature. Increased activity is noted in the adrenal glands—increase in lipoids, greater development of the granular layer. The parathyroid glands apparently do not participate in the cycle, although Vigne, citing Oliver, indicates that the mental depression and increased knee and elbow reflexes observed in some women during Menstruation can be attributed to some insufficiency of them. More data is available on the thyroid gland, which often increases in size before and during Menstruation, which can be traced by simple palpation of the neck. Freund and many others already pointed this out, emphasizing the particularly noticeable swelling of the thyroid gland in cases of thyrotoxicosis. The wave-like changes in the thyroid gland during the menstrual cycle were most thoroughly studied by Weidemann. He concluded that in most cases there is a periodic increase and decrease in the thyroid gland; an increase is observed at the time of menstrual bleeding (an average increase of 2 cm and even more), beginning already in the premenstrual period and reaching its maximum on the first day of Menstruation; with its completion, the gland returns to its normal size. Ikonen and Kunin recently (1930) checked the changes in thyroid gland function under the influence of Menstruation using serum-atropine titration, simultaneously determining the erythrocyte sedimentation reaction. Monthly studies conducted by them on women over a year showed that there is a clear difference in the state of the thyroid gland in different phases of the menstrual cycle (increase 7-8 days before Menstruation and a sharp drop on the 2nd-3rd day). Parallel to the changes in the thyroid gland, according to Ikonen and Kunin, went the erythrocyte sedimentation reaction (slowing in the premenstrual period and acceleration on the second day of Menstruation). Ikonen and Kunin observed, as did some other authors, atypical cases of thyroid gland function, namely a decrease in it in the premenstrual period and an increase on the second day of Menstruation (the possibility of this atypicality being connected with ovarian dysfunction is not ruled out). Menstruation and changes in individual organs. Along with the indicated changes in the whole organism and in the general metabolism occurring in individual phases of the ovarian-uterine cycle, reactive phenomena are also observed from the side of individual organs. A special group of these phenomena consists of the so-called vicarious bleedings in individual organs, and they either replace the absent Menstruation or are observed simultaneously with it.

These hemorrhages can be caused by or occur in connection with Menstruation changes in one organ or another, or by the influence of a previously observed pathological process, and they sometimes can occur not only in amenorrhea or menstrua parva, but also during a normally proceeding Menstruation. Menstruation and nose. Menstrual changes in the nose have been described by many authors. Thus, marked redness of the mucous membrane, its swelling, and increased sensitivity are noted. This periodically occurring hyperemia is the moment that causes nasal bleeding; in anomalies of Menstruation (e.g., in amenorrhea), epistaxis is considered as vicarious bleeding, which can be combined with slight uterine bleeding and in such cases is called 'compensatory' bleeding (Novak). Novak believes that there is no special difference between these two forms and that simultaneous bleeding from the uterus and from the nose can vary in intensity and character depending on various conditions and causes. There are no exact data on the frequency of menstrual changes in the nose; some (e.g. Fliess) believe that these phenomena represent almost a constant phenomenon (being especially sharply expressed in dysmenorrhea), and they can be unilateral or bilateral, while others not only do not consider these phenomena characteristic but generally deny the possibility of their occurrence. The usual site of bleeding is considered to be locus Kiesselbachii. Menstrual bleeding from the nose can be the cause of worsening various pathological processes in it, serve as a reason for exacerbation and increased frequency of previously observed nasal bleeding. M. and ears. No specific menstrual changes in the ear are noted; the occurring disorders (of hearing) during the period of puberty and sexual maturity by many authors (Dalcb.6, Labernadie) are attributed to disruption of the activity of the endocrine glands and sympathetic nerves. Vin' indicates that hearing disorders occur especially in profuse M.; proof that this is not a simple coincidence is that these disorders pass with the end of menorrhagia. Some (e.g. Freund, Muller) described vicarious bleeding from the ear (from the middle ear or from the external auditory canal); there are also isolated reports of severe hemorrhages into the labyrinth on the basis of amenorrhea. Individual authors (Novak) are skeptical about the possibility of such bleeding from a healthy ear and believe that these bleeding, coinciding with the menstrual wave, can only occur from a diseased ear; it is necessary to consider the possibility of self-injury on a hysterical basis (Novak). M., pharynx and larynx. Phenomena from the pharynx side are noted significantly less frequently. The majority accepts that the occurring vicarious bleeding from the pharyngeal mucosa can only occur in the presence of some pathological processes in it. Changes in the larynx can be of two kinds. Previously existing diseases almost invariably worsen (especially tuberculosis) and not only with any deviations of M., but also with a normally proceeding M. There can be vicarious bleeding with completely undamaged mucosa (Baumgarten and others). Among the physiological changes on the basis of M. are phenomena from the vocal cords (changes in voice in singers, greater fatigue of it, etc.). It is necessary to note also that in nervous women, in the presence of hysteria or with any severe emotional experiences, during M. spasm of the larynx, attacks of coughing and other hysterical manifestations can be observed. M. and eyes. As in other organs, changes in the eye are most often observed in the absence of M. or with its improper course (especially in dysmenorrhea); thus, cases of visual disturbances have been described: narrowing of the visual field, decreased vision, hemorrhages into the eyelids, into the conjunctiva, into the retina (Dolganov and others). Often characteristic dark circles under the eyes, eyelid edema, transient paretic state of the eye muscles are noted. Cases of premenstrual eruptions (herpes) in the conjunctiva and in the cornea have been observed. In amenorrhea and dysmenorrhea, a number of pathological processes have been observed (amaurosis, pareses, paralyses of the eye muscles, neuritis, neuroretinites and even atrophy of the optic nerves, noted already in 1874 by Galezowsky). Finkel'shtein (1887) on the basis of his observations came to the conclusion that the visual field begins to narrow concentrically even before M. (1-2-3 days beforehand) and continues to narrow during M., and the degree of narrowing depends on the amount of blood loss. M. can exert a direct influence on previously existing eye diseases and cause their periodic exacerbation (e.g. neuritis of the optic nerve, chronic blepharitis, etc.). M. and gastrointestinal canal. Various kinds of symptoms from the gastrointestinal tract in connection with M. occur quite often (pain in the stomach, nausea, vomiting, increase or decrease in appetite, diarrhea, constipation, etc.), and these phenomena can be observed both in the premenstrual period and during M. Despite the fact that the first indications of these deviations date back to 1876 (Kretschy), their closest cause is still unknown. The opinion of Eisner (1899) about the possible influence of M. on the increase or decrease in the acidity of gastric juice cannot be considered generally accepted. There are also no precisely established data on the influence of M. on fluctuations in gastric secretion in its healthy state. In recent times (1930) Schlango indicates that during M. fluctuations in the acidity of gastric juice do not exceed normal limits; similarly, no changes in the mobility of the stomach itself are noted. All the above-mentioned symptoms can be especially sharply manifested in dysmenorrhea. M. has a harmful effect on chronic diseases; thus, the tendency to bleeding in gastric ulcer undoubtedly increases, and pathological symptoms worsen and exacerbate in diseases of the intestine. Regarding the possibility of 'vicarious' bleeding, the prevailing opinion is that with undamaged mucosa they are hardly possible. It is also necessary to note symptoms from the oral cavity and teeth (toothache on the eve of M., swelling of the gums, their bleeding, which some authors consider as 'vicarious' M.). In view of this, serious interventions are not recommended during M. (Novak). Anufriev described a case of severe uterine bleeding on the basis of tooth extraction during M. M. and skin-see Dermatoses, menstrual dermatoses.-M. and heart. Phenomena from the heart can often be observed in women completely healthy in this respect. Subjective phenomena of a vasomotor nature come down to the sensation of cold, palpitations, feeling of heaviness in the chest area. These phenomena occur by no means in all women, but if they are observed, they have a tendency to recur with each M. In such cases, signs of heart lability, tendency to tachycardia, respiratory arrhythmia with corresponding changes from the pulse side are found. Jagic attributes these symptoms to physiological phenomena (if they manifest in a mild degree) and believes that among the causes causing them, the thyroid gland plays a major role, and considers these disorders as thyrotoxicosis.-M. and kidneys, liver. There are not isolated indications that there is a certain dependence between M. and kidney activity. Thus, menstrual polyuria is quite often noted, which some explain by increased activity of the pituitary gland. Cases of menstrual albuminuria have also been described, which, in Vin's opinion, is usually insignificant and is often observed between the period of sexual maturity and the beginning of sexual life. Indeed, there are isolated cases of more severe phenomena from the kidneys during M. Kapsammer observed a woman in whom for seven months before the onset of M., hematuria appeared, which eventually turned into chronic nephritis. The presence of one or another kidney disease does not remain without influence on the course of M. itself; in such cases, various kinds of anomalies of the menstrual cycle, increased blood loss, menorrhagia, and amenorrhea are often observed. Changes from the liver side are also not rare, which is quite understandable if one considers the physiological shifts that occur in metabolism. Thus, enlargement of the liver, its painfulness are observed (Clrvostek in a number of women found before and during M. enlargement of the liver). Menstrual jaundice is also often noted, which can vary in intensity, time of onset, and course. Frerichs, the first (1861) to draw attention to premenstrual jaundice and also noting pain and enlargement of the liver, even proposed a special name - 'menstrual neuralgia of the liver,' since he observed these phenomena for a certain time with each M. It is necessary to note the rather frequent influence of M. on already existing liver diseases (increase in pain, increased frequency of hepatic colic attacks), as well as the irregularities of M. itself in liver diseases (shortening of intervals between individual menstruations, their greater duration, greater blood loss). M. and the nervous system.

Changes in the nervous system under the influence of M. have been described by many authors. They are most sharply expressed in the premenstrual period and during M. A general increased tone is noted, and symptoms are observed indicating increased irritation in both the autonomic and sympathetic nervous systems (Novak). Recent research allows one to speak of the existence of 'menstrual vagotonia.' Marian Frankl, noting the complex and varied symptom complex before and during M. [changes in the skin (dermatographism, increased sweating, altered coloration), cardiac phenomena, tremor, increased tendon reflexes, a state close to fainting, dizziness, etc.], states that all this can be regarded precisely as 'menstrual vagotonia.' New observations have fully confirmed the possibility of its existence ('vagotonia menstrualis intermittens'). One often has to deal with headaches that intensify during M. in persons who generally suffer from them, or that arise directly during this period. They often take the form of migraine (Vigne); more frequently they are observed in various general diseases (for example, syphilis) and in irregular M. Cases of premenstrural neuralgia (in the area of the sciatic, trigeminal nerve) have also been described. Numerous works have been devoted to the question of menstrual epilepsy. The connection between epilepsy and M. is no longer in doubt for the majority. Cases have been frequently observed where epilepsy arose for the first time only with the appearance of the first menstrual bleeding, and also cases where epileptic seizures significantly increased during the menstrual period or occurred only during M. Confirmation that epilepsy can indeed be connected only with the ovarian-uterine cycle can be found in observations of women in whom epileptic seizures completely disappeared after castration. The influence of M. on organic diseases of the nervous system has been little studied, but there are indications that the first manifestations of such diseases may occur precisely with the beginning of M. In recent times, the attention of researchers has been turned to the question of the permeability of the meninges during M. and the composition of the cerebrospinal fluid (increased sugar content and decreased chlorides). Benda, noting increased permeability of the meninges on the first day of M., believes that this phenomenon can explain the so frequently encountered menstrual disorders of a neuropsychic nature, and sometimes organic changes as well. M. and p s y c h i c s. Menstrual psychoses. According to the definition of most gynecologists and psychiatrists, even a completely normal M. represents such a manifestation of life in which even a completely healthy woman with a perfectly healthy psyche is often on the verge of physiological psychic deviations and pathological mental experiences. One can definitely say that the most frequent, almost constant companion of M. is one or another fluctuation in the woman's psyche. Representing a very diverse and complex symptom complex, they can manifest throughout the entire ovarian-uterine cycle, but most often and most sharply they are expressed in the premenstrual phase or during the menstrual bleeding itself. The phenomena mentioned above can sometimes take one or another form of obvious psychic disorder, which, when periodically repeated during M., is already called a menstrual psychosis. The frequency of psychic deviations, the degree of their manifestation, the entire set of individual symptoms depend on a number of factors, of which the main significance is the special predisposition of a given organism, its structure, constitution, and the harmful influences of the external environment. A more pronounced character of these physiological deviations is observed in periods of greatest instability of the female organism—periods of transition (final sexual maturation and sexual extinction). The most frequent manifestations: increased excitability, irritability, groundless anger, capriciousness, changes in mood (laughter, sadness, tears), sometimes a depressive state. There are indications that some symptoms are more often encountered in the premenstrual phase (for example, increased excitability), while others—in the first days of menstrual bleeding (for example, a depressive state). Serbsky wrote that even in completely healthy women during M. the excitability of the nervous system increases and the ability to resist external irritations decreases, and this is more sharply manifested in unbalanced individuals and especially in degenerates. Korsakov also pointed to the sharp change that occurs in a woman during M. (for example, from calm she becomes irritable, which naturally requires more considerate treatment from those around her and greater indulgence for individual actions). The most recent research by Hauptmann (1924) also shows that an increased sensitivity of all sense organs is observed, and that the character and degree of this increased sensitivity are often connected with one or another constitutional peculiarities of the organism. Ikari admitted in pathological cases the influence of M. on the activity of the brain and vice versa. (This idea was expressed much later by Hanse, who noted amenorrhea in catatonia in 62.5%, in melancholia in 60%, and in epilepsy in 40%.) Stransky says that cases can occur in which mild deviations sometimes pass into a paranoid state, which happens especially on the first day of M. Menstrual psychoses do not represent anything specific; their forms are extremely diverse. Even Serbsky said that along with obsessive ideas, manic excitement and clouding of consciousness can be observed. Korsakov also believed that a menstrual psychosis can give an extremely varied clinical picture. The time of appearance of a developed menstrual psychosis can also be different; it often manifests itself already before M., but cases are not rare where its onset coincides directly with the menstrual bleeding. The cause of psychic disorders during M. is considered to be those changes that occur in the entire woman's organism during M. Even Korsakov pointed out that along with changes in circulation, reflex influences, and general nutritional disorders, auto-intoxication can also play a role. In recent times, there is a tendency to attribute the occurrence of individual psychic symptoms to one or another peculiarities of a given woman; for example, it is believed that with hyperfunction of the thyroid gland, increased excitability is most often encountered, while with hyperfunction of the ovary, on the contrary, a depressive state, both mental and physical (Vigne). The influence of M. on previously existing mental diseases is also undeniable: almost all indicate worsening and exacerbation of mental disorders at this time; however, their absence can serve as an indicator of stable recovery (Serbsky). However, the most recent clinical observations (Repond, 1925) show that by no means in every case and not with every disease does M. cause a worsening of a previously existing psychosis. M. and m u s c u l a r system. Indications of fluctuations in muscular strength under the influence of M. are found even in Ott; he, and later other authors, noted an increase in muscular strength in the premenstrual period; however, there are also indications that before M. not an increase, but on the contrary, a decrease in muscle tone is observed. In general, it must be admitted that in the various phases of the menstrual cycle, fluctuations undoubtedly occur in the neuromuscular system. Apparently, all the mentioned changes in all organs and systems in each individual case are very individual; they depend on a number of accompanying moments, among which constitutional factors can play a certain role, but even greater—socio-domestic conditions. Hygiene of menstruation. M. and sexual life. All the phenomena that accompany M. in most women require a certain setting and observance of a number of hygienic measures. A correct way of life for a woman during M. is the basic factor for its normal course and at the same time a prevention ensuring the correctness of the cycle of subsequent M.s and eliminating the possibility of female diseases of both endocrine and inflammatory nature. In view of the importance that the onset of the first M. has for the psyche of a teenage girl, her hygiene must be thought of in advance. The basic preventive factor is gradual preparation for this physiological act, corresponding explanation of its meaning and significance. With skillful sex education, the girl will be spared at the right time from unnecessary, often distressing experiences, from the strained striving to solve a task beyond her strength. In everyday hygienic advice to a woman during M., one should proceed from the basic position that if a woman cannot be considered sick at this time, she certainly cannot be recognized as absolutely healthy either. This advice should pursue a therapeutic and preventive purpose, i.e., to alleviate, eliminate, and even better to prevent one or another frequently observed painful sensations and symptoms.

The most important hygienic requirement during M. is the maintenance of the greatest possible cleanliness and rest. This is achieved by washing the external genital organs 2-3 times a day with warm boiled water (26-27°) (with cotton wool or gauze). Vaginal douches should not be performed: they are not only not advisable, but even harmful. General baths should also not be taken, as they can contribute to increased menstrual bleeding, and besides, they do not at all prevent the introduction of dirt from the body surface into the vaginal canal, wiping with a sponge and washing the entire body are not contraindicated. River and sea bathing must be prohibited. It is necessary to avoid any cooling of the lower part of the body and legs. During M., it is necessary to wear special 'menstrual' pads (sanitary napkins) to protect the genital organs and to minimize the soiling of the body with blood. These pads should be made of soft material (linen) or of cotton wool wrapped in gauze. The most advisable is the T-shaped menstrual pad; the pad is changed several times a day depending on the amount of blood lost. Due to the special tendency to constipation at this time, it is necessary to monitor proper bowel function; timely emptying of the bladder is also necessary. During M., heavy physical labor, lifting heavy objects (see above), excessive mental work, and in general any overexertion should be avoided. Violent emotional experiences and affects are especially harmful at this time. Physical exercises and even light sports should not be allowed (especially horseback riding, cycling). Rest and bed rest are indicated only in cases of excessive blood loss, pain, and general weakness (lying down under normal conditions is even harmful; Baisch). In terms of nutrition, moderation should be observed, irritating food should be avoided; alcohol and stimulating beverages must be prohibited. Special attention should be paid to sexual life. It is unacceptable, as it increases the blood flow to the pelvic organs, and besides, it can also be a cause of infection. The harm of sexual life during M. has been pointed out for a long time. Thus, for example, Selignac (1861) wrote about the harm of coitus during M. and said that its performance during or shortly after the end of M. can lead to its return, which is especially often observed in newlyweds. References to the harm of sexual intercourse are also found in a number of other authors (Popova-Terebinskaya, Selitsky). Furbringer believes that sexual intercourse during M. is unacceptable and that at this time complete abstinence is required even in cases where menstrual bleeding continues for a very long time, since at these moments a woman needs especially careful treatment due to the increased sensitivity of the sexual sphere and the instability of the nervous system. The question of sexual desire in the premenstrual period and during M. is treated differently. Some point to the almost constantly observed sexual excitement; others believe that it is observed far from always and that, on the contrary, at this time cases of aversion to sexual intercourse are not uncommon. The point of view on the time of appearance of sexual excitement is also different. Some believe that it occurs already in the premenstrual period, while others consider that it manifests itself at the moments of menstrual bleeding itself. It should also be noted that in so-called frigid women, libido often increases or only appears precisely at the moments coinciding with M. In general, it must be concluded that sexual desire can undoubtedly increase, although not in all women, and that the time of appearance of this increased desire is also subject to significant individual variations; the sometimes occurring cases of its sharp increase, cases of sexual promiscuity associated precisely with M., even cases of sexual perversions and crimes must once again speak of the need to provide a woman with complete sexual rest at this time. In any case, it is hardly possible to agree with those authors who consider the fear of coitus during M. to be a false prejudice, and even recommend trying coitus intramenstrualis in cases of infertility or decreased or absent sexual desire, due to the greater blood filling in the pelvic cavity at this time and the increased excitability of both peripheral sensory nerves and the main (hypothetically assumed) psychosexual center.

S. Selitsky. MENTHOL (paramethyl-isopropyl-cyclohexane, or methyl-isopropyl-hexahydrophenol, or menthol camphor), a secondary alcohol, obtained from the essential oil of peppermint (Mentha piperita L.); it consists of volatile colorless crystals, levorotating; N_D²⁰ = -50°; C₁₀H₂₀O

the crystals have the smell and taste of peppermint, melt at 42-43°

C₁₀H₂₀O

44°, boil at 212-213°, are almost insoluble in water, easily dissolve in alcohol, ether, chloroform, acetic acid, fatty and essential oils. M. must be completely dry and when pressed on paper should not leave a stain. When M. is rubbed in equal parts with certain substances, e.g. camphor, chloral hydrate, boric acid, thymol, a liquid is formed. Due to the presence of an alcohol group, M. easily forms complex esters (see below).-M. has many common pharmacological properties with ordinary camphor. M. has clearly expressed disinfectant properties. The local action of M. is characterized by the appearance of a sensation of cold when rubbed into the skin, which most authors explain by the excitation of sensory endings that perceive cold. Along with this, it causes local vasoconstriction and some anesthesia. After 10-15 minutes, the sensation of cold is replaced by a sensation of burning and tingling, associated with the irritation of nerve endings that perceive heat. (In those areas of the skin surface where these endings are more numerous, the sensation of heat and burning occurs earlier.) With the local action of M. on mucous membranes, a sensation of cold, vasoconstriction, and anesthesia also occur, and with high concentrations of M., an irritating effect as well. In small children, when M. is applied to the nasopharynx, a life-threatening reflex respiratory arrest, as well as cardiac arrest, may occur (Ch.-chaud).-The resorptive action of M. is manifested in sufficient doses on the central nervous and cardiovascular systems. Exciting, like ordinary camphor, the central nervous system, M. however acts mainly on the centers of the medulla oblongata, not giving, unlike camphor, convulsive symptoms; in large doses it directly leads to paralysis. On the isolated heart M. acts in a similar way to camphor, but weaker, causing excitation in the 'stage of withdrawal' (Kravkov). On the lumen of blood vessels, especially coronary vessels, M., as found in conditions of isolated organs, acts in an expanding manner. M. is excreted mainly by the kidneys in the form of paired glucuronic acids and partly with bile. The use of M. in therapy is quite diverse. Externally it is used as an analgesic for neuralgias and especially for migraine in the form of migraine pencils (M. fused with a small amount of paraffin in the form of sticks), as well as in the form of alcoholic (5-10%) solutions and ointments (0.5-1-1.5%). In the latter two forms it is also used for skin diseases as an antipruritic. For diseases of the nasal mucosa (acute and chronic catarrhs) it is used in the form of ointments, drops (1% solutions on Provence, almond oils and on liquid paraffin), in the form of snuff powder (2-3% in boric acid powder); for catarrhs of the upper respiratory tract (also for asthma and tbc) in the form of inhalations (e.g. 10% M. in chloroform). In the treatment of these catarrhal conditions, the disinfectant, anesthetic, and vasoconstrictive action of M. is important. M. is also used for mouthwashes (a few drops of 1% alcoholic solution per glass of water), as well as for toothache (a liquid mixture of M. and chloral hydrate is applied on cotton wool into the cavity of a carious tooth). Internally in doses of 0.05-0.2 (in powders, alcoholic or oily solutions and in emulsions) several times a day it is prescribed for gastralgias, vomiting (e.g. vomiting of pregnancy), for increased fermentative processes in the intestine, for the purpose of disinfection of the bile ducts, as well as as a carminative. M. is included in a number of complex prescriptions, such as e.g. Simanovsky's ointment against cold (Cocaini hydrochlor. 0.2, Mentholi 0.4, Zinci oxydat. 2.4, Lanolini 40.0, Vaselini 60.0), various mouthwashes and others. Besides M. itself, a number of its complex esters are used in therapy: forman, Forman, chloromethyl ether of M.-a colorless oily liquid, prescribed in the form of so-called forman cotton wool or ointment for colds. Coryfin, Coryfin, ethylene glycol ether, M.-a colorless liquid, almost odorless, prescribed for nasopharyngeal catarrhs in 6-20% solution in liquid petrolatum or oil; for children in the form of 2% ointment. Estoral, Estoral, boric acid M.-a white crystalline powder, prescribed for the same indications. Salimenthol, Salimenthol, salicylic acid menthol; for the same indications in the form of 25% ointment, and internally 0.25 several times a day. Menthospirin, Menthospirin, menthol ester of acetylsalicylic acid (aspirin)-a pale yellow thick oily liquid, prescribed internally 0.25 two to three times a day. Validol, Validol, menthol ester of valerianic acid, prescribed internally 3-5 drops three times a day for cardiovascular neuroses of various origins. The last three preparations partly already have the pharmacological properties of the acids that form the esters.