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UNIVERSITY OF CALIFORNIA
^-LIFORNIA COLLECT C; - ,, C
IBRARY

JAN 15 1973
WINE, CALIFORNIA 92664



MENSTRUATION

AND

ITS DISORDERS



MENSTRUATION

AND

ITS DISORDERS



BY



EMIL NOVAK, A.B., M.D., F.A.C.S.

ASSOCIATE IK CLINICAL GYNECOLOGY,

JOHNS HOPKINS MEDICAL SCHOOL,

BALTIMORE, MARYLAND



GYNECOLOGICAL AND OBSTETRICAL MONOGRAPHS




WITH FORTY ILLUSTRATIONS



D. APPLETON AND COMPANY

NEW YORK LONDON

1928



COPYRIGHT, 1921, BT

3D. APPLETON AND COMPANY



V. 2_



PRINTED IN THB UNITED STATUS OF AMERICA



TO
HOWARD A. KELLY,

EMERITUS .PROFESSOR OF GYNECOLOGY

JOHNS HOPKINS UNIVERSITY

MASTER GYNECOLOGIST

THIS BOOK IS DEDICATED

AS A TOKEN OF GRATITUDE AND ESTEEM



57S57



PREFACE

It is probably not an exaggeration to say that we have learned more con-
cerning the nature and mechanism of the menstrual phenomenon during the
past fifteen or twenty years than during many centuries preceding. This new
knowledge has been an important factor in the more intelligent treatment of
the disorders of menstruation, which constitute a not inconsiderable pro-
portion of the ailments encountered by every general practitioner. The
gynecologist and the obstetrician likewise have been given a new light on many
hitherto poorly understood problems, by such modern contributions as, for
example, that pertaining to the menstrual histology of the endometrium, or
that dealing with the endocrine relationships of the ovary.

It would seem, therefore, that the time is opportune for the presentation
of a volume devoted to all aspects of the subject of menstruation, both
normal and abnormal. So far as I know, there is no other work in any
language with exactly this scope. This statement, I believe, will apply even
to the rather comprehensive articles in some of the German handbooks.
\Yhile the present volume is monographic in character, every effort has been
made to make it of genuinely practical value, to general practitioners as well
as to specialists in gynecology and obstetrics. The surgical treatment of the
various forms of pelvic disease which may be associated with disturbances of
menstruation has not been considered, for this would mean the inclusion, to
all intents and purposes, of a treatise on operative gynecology. For the sake
of completeness, however, it has seemed best to include a discussion of certain
matters of merely historic interest.

It is hoped that the list of references at the end of each chapter will con-
stitute a good working bibliography for those desirous of going to original
sources. These lists are not by any means exhaustive, but the references have
been selected as the most worthwhile of the many hundreds which have been
consulted in the preparation of this work.

To Drs. Howard A. Kelly and Curtis F. Burnam I am greatly indebted for
the chapter on " X-Ray and Radium Treatment of Menstrual Disorders." To
Dr. Thomas S. Cullen, professor of gynecology, and Dr. J. Whitridge Williams,
professor of obstetrics at Johns Hopkins Medical School, my thanks are due
for their helpful criticisms. Finally, it is a pleasure to acknowledge the
courtesy and cooperation of the publishers, D. Appleton and Company.

EMIL NOVAK



CONTENTS

CHAPTER PAGE

I. THE SUPERSTITION AND FOLK-!X)RE OF MENSTRUATION 1

II. PERIODIC SEXUAL PHENOMENA IN THE LOWER ANIMALS , 10

General considerations, 10; Importance of a study of the comparative physiology

of menstruation, 10; Earliest manifestations of periodic sex activity, 10;
Periodic sexual activity in the lower animals, 11; "Heat" or estrus, 11;
Anestrous cycle, 12; The pro-estrum, 12; The period of estrus, 13; The metes-
trum and di-estrum, 14; The di-estrous cycle, 14; The estrous cycle in various
animals, 14; Are the phenomena of estrus and menstruation analogous? 16.

III. THE SOURCE OF THE MENSTRUAL FLOW 19

The endometrium Ihe source of the menstrual flow, 19; The role of the cervix

uteri, 19; Do the fallopian tubes participate in menstruation? 20; clinical
evidence, 20; histological evidence, 21.

IV. MENSTRUAL CYCLIC CHANGES IN THE UTERUS 24

Historical, 24; Macroscopic changes in the uterus at the time of menstruation, 25.

THE ENDOMETRIUM 25

Macroscopic changes associated with menstruation, 25 ; Histological changes asso-
ciated with menstruation, 26 ; Structure of normal endometrium, 26 ; Views
as to menstrual histology of the endometrium, 26; Changes in epithelium dur-
ing menstrual cycle, 31 ; Changes in uterine glands during menstrual cycle, 33 ;
Stromal changes during menstrual cycle, 34 ; Vascular changes of menstruation,
35; Is there any loss of uterine mucosa at the time of menstruation? 36.

V. ANATOMIC CHANGES IN OVARY DURING MENSTRUAL CYCLE, INCLUDING

LIFE CYCLE OF CORPUS LUTEUM 40

Gross anatomy of ovary, 40; Macroscopic changes in ovary as result of menstrua-
tion, 40; Histology of ovary, 41.

THE FOLLICIES OF THE OVARY 42

THE CORPUS LUTEUM 43

General, 43; Older views as to corpus luteum, 43; Modern conception of corpus
luteum, 44 ; Life cycle of corpus luteum, 45 ; The stage of proliferation, 45 ; The
stage of vascularization, 48; The stage of maturity, 50; The stage of retro-
gression, 50; Chronological relation of corpus luteum cycle to menstrual and
endometrial cycles, 52; Comparison of corpus luteum of menstruation and
corpus luteum of pregnancy, 55.

ORIGIN OF LUTEIN CELLS 58

Two principal theories, 58; Origin of lutein cells in lower animals, 58; Theory
of origin from connective tissue, 58; Theory of epithelial origin of lutein cells,
58; Present status of question, 60.

THE INTERSTITIAL CELLS OF THE OVARY 60

General, 60; Interstitial cells in ovaries of lower animals, 61; Interstitial cells in
human ovary, 61 ; Origin of interstitial cells from walls of atretic follicles, 63.

VI. HISTORICAL SKETCH OF OLDER THEORIES OF MENSTRUATION 67

Introduction, 67; The earliest theories of menstruation, 67; The theory of lunar

influence, 67: The ferment theory the "Fervor uterinus " of Democritus.
67; The plethora theory of Galen, 67; The theory of Pfluger, 68; The "tubal
nerve" of Tait, 68; The influence of the vertical position in causing menstrua-

ix



x CONTENTS.

CHAPTER

tion, 68; Menstruation as a result of the sexual appetite, 69; "Women men-
struate because they do not conceive," 69 ; Menstruation as an " unnatural
process," 69; Menstruation as a true secretory process, 70; The theory of a
menstrual centre, 70; Steps leading to the modern conception of menstrua-
tion, 70.

VII. THE MODERN THEORY OF MENSTRUATION 73

The ovary the underlying cause of menstruation, 73; The ovarian influence
exerted through blood stream, and not through nerves, 73 ; Which constituent
of the ovary is concerned with menstruation? 74; The corpus luteum theory
of Fraenkel, 74; Other modern views as to cause of menstruation, 74; Theory
of Marshall, 74; Theory of Theilhaber, 74; Studies of Aschner, 75; Investiga-
tions of Loeb, 75 ; Theory of Halban, 75 ; Recent histological confirmation of
corpus luteum theory, 76; Injection experiments, 77; Conclusion as to cause
of menstruation, 77; Influence of endocrine glands other than ovary, 78;
Vascular and vasomotor factors in menstruation, 78; A local factor in the
endometrium, 78.

VIII. CLINICAL CHARACTERISTICS OF NORMAL MENSTRUATION 81

Introduction, 81; Is pain a symptom of normal menstruation? 81; Site of pain

or discomfort, 82; Other subjective symptoms of menstruation, 83; Statistics
as to character and severity of subjective symptoms, 83; The "libido
sexualis " and menstruation, 84; The "menstrual wave" theory, 85; Effect
of menstriiation on body temperature, 86; Effect of menstruation on blood
pressure, 87; Effect of menstruation on pulse rate, 87; Effect of menstruation
on muscle power, 88; Effect of menstruation on knee-jerk, 88; Periodicity
of the menstrual flow, 88; The interval between menstrual periods, 89;
Duration of the menstrual period, 90; Amount of blood lost at menstruation,
91; Individual differences, 91; Methods of estimating amount, 91; Amount
of menstrual discharge, 91; Influence of menstruation on blood picture, 92;
Erythrocytes. 92; Hemoglobin, 92; Leukocytes, 93; The sugar content of the
blood, 94; Objective phenomena of menstruation, 94; The menstrual discharge,
94; Chemical composition of menstrual blood, 94; Non-coagulability of
menstrual blood, 95 ; Reasons for differences of opinion, 95 ; Importance of
the problem, 95; The role of the alkaline cervical mucus, 95; Possibility of a
local factor in the endometrium, 96; The possible influence of changes in coagu-
lating time of body blood at time of menstruation, 96; The absence of fibrin
ferment in menstrual blood, 96', The formation of antithrombin by the endo-
metrium, 96 ; The biological role of the endometrium an important factor, 97.

IX. PUBERTY AND THE ONSET CF MENSTRUATION 100

General considerations, 100; General body changes at puberty, 100; Changes in

reproductive organs, 100; Psychic changes, 101; Physiological changes, 101;
Menstruation only one of the manifestations of puberty, 101 ; Age at which
menstruation appears, 102; Factors influencing age of onset of menstruation,
104; Cause of puberty, 105.

X. THE HYGIENE OF PUBERTY 108

The role of the mother, 108; Instruction in sex hygiene, 108; School life, 109;
Working conditions, 109; Recreation and rest, 110; Clothing, 110; Bathing,
111; Diet, 111; Care of the bowels, 112; Other hygienic measures of im-
portance, 112.

XI. PRECOCIOUS MENSTRUATION 113

What constitutes precocious menstruation? 113; Early manifestations of premature

development, 113; Frequency, 113; Age at which precocious menstruation may
be observed. 114; Types of precocious menstruation, 115; Clinical manifesta-
tions, 115; Subsequent history of patients with precocious menstruation, 116;
Psychic development, 117; Pregnancy in cases of precocious menstruation,
117; Cause of precocious menstruation, 117; Diagnosis of precocious menstrua-
tion, 118; Treatment of precocious menstruation, 119.

XII. _ NON-MENSTRUAL GENITAL HEMORRHAGE IN THE NEW BORN 121

Differentiation from precocious menstruation, 121 ; Frequency, 121 ; Time of occur-
rence of bleeding, 121; Duration of bleeding, 122; Amount and character of
bleeding, 122; Accompanying symptoms, 122; Prognosis, 122; Etiology, 122;
Treatment, 123.



CONTENTS. xi

CHAPTER PAGE

XIII. THE MENOPAUSE 125

Definition, 125 ; Historical, 125 ; The age at which the menopause occurs, 126 ;

Factors influencing the age of the menopause, 127; Age at which menstruation
begins, 127; Maternity, 127; Climate, 127; Race, 128; Heredity, 128; Social
condition, 128; Obesity, 128; Wasting diseases, 128; Pelvic disease, 128; Early
menopause, 128; Delayed menopause, 129; The Surgical menopause, 129; Dura-
tion of menopause, 130; Symptoms of the menopause, 130; General course,
130; Cessation of menstruation, 131; Vasomotor symptoms, 132; Psychic
symptoms, 133; Nervous symptoms, 133; Other symptoms, 134; Factors in-
fluencing the severity of the menopause, 134; Anatomic changes of the meno-
pause, 135; External genitalia, 135; Internal genitalia, 136; Other changes,
137; Diagnosis, 137.

TREATMENT OF MENOPAUSAL DISTURBANCES 139

General measures, 139; Treatment by drugs, 139; Hemorrhage, 139; Nervous
symptoms, 140; Vasomotor symptoms, 140; Local symptoms, 141; Organo-
therapy, 142.

XIV. THE HYGIENE OF THE MENOPAUSE 143

General measures, 143 ; Significance of climacteric hemorrhage, 143 ; The education

of women as to the dangers of cancer, 143; The responsibility of the phy-
sician, 144.

XV. PSYCHOPATHIES OF THE MENOPAUSE 146

Incidence, 146; Influence of the marital state, 146; Age of patients, 146; Influence

of heredity, 147; Correlated causes, 147; Previous attacks, 147; Types of
mental disorder, 147; Illustrative cases, 148; Prognosis, 148.

XVI. RELATION OF MENSTRUATION AND OVULATION 150

Historical, 150; Relation of estrus and ovulation in lower animals, 150; Clinical

observations on relation of menstruation and ovulaton, 152; General con-
siderations, 152; Ovulation before puberty, 152; Ovulation during "dodging
period" of puberty and menopause, 152; Ovulation after menooause. 153;
Ovulation during pregnancy, 153 ; Ovulation during lactation, 153 ; Ovulation
during pathological amenorrhea, 153 ; Evidence from operative and postmortem
findings, 154; Summary of clinical evidence, 155; Histological studies on
relation of ovulation and menstruation, 155 ; General, 155 ; Evidence from
embryological studies, 155; Histological studies of ovary, 158; Summary of
histological evidence, 159.

XVII. RELATION OF MENSTRUATION TO LACTATION 162

Is amenorrhea the rule during lactation? 162; Statistics bearing on the dis-
cussion, 162 ; Reasons for the discrepancy in statistics, 163 ; Cause of amenor-
rhea during lactation, 163; Ovulation during lactation, 164; Influence of
menstruation on breast milk, 164.

XVIII. AMENORRHEA . . 167

Definition and varieties, 167; Primary amenorrhea, 167; Secondary amenorrhea,

167; Distinction between amenorrhea, retention of menses, and suppression
of menses, 167.

CAUSES OF AMENORRHEA 168

Classification of causes, 168; Local causes, 168; Congenital absence or malformation
of reproductive organs, 168; Acquired pathological conditions of pelvic organs,
169; General causes, 170; Physiological amenorrhea, 170; Function?.! amenor-
rhea, 171; Amenorrhea due to acute infectious diseases, 172; Amenorrhea
dxie to constitutional diseases, 172; Amenorrhea due to mental and nervous
disorders, 173; Amenorrhea due to ductless gland disorders, 173; Significance
of amenorrhea as a symptom, 174; Is amenorrhea detrimental to the health?
174; Symptoms which may be associated with amenorrhea, 175; Diagnosis of
cause, 176.

TREATMENT OF AMENORRHEA 177

Treatment of underlying cause, 177; General measures, 177; Medical treatment,
178; Iron in the treatment of amenorrhea. 178; Arsenic, 17i'; Questionable
value of emmenagogues, 179; Organotheraphy of amenorrhea, 181.



xii CONTENTS.

CHAPTER

XIX. GYNATRESIA AND RETENTION OF THE MENSTRUAL DISCHARGE 183

General conditions, 183; Types of gynatresia, 183; Causes of primary or con-
genital gynatresia, 183; The Nagel-Veit theory, 183; Imperforate hymen, 184;
Other forms of obstruction, 184; Secondary or acquired gynatresia, 184;
Puerperal infection or lacerations, 184; Infectious diseases, 185; Trauma, 185;
Senile atresia, 185; Mechanical occlusions from within or without the genital
canal, 186; Symptoms of gynatresia, 187; Chemical composition of retained
menstrual discharge, 187; Cause of hematosalpinx in cases of gynatresia, 187;
Diagnosis of gynatresia, 187; Prognosis, 188; Treatment, 188.

XX. DYSMENORRHEA 190

General considerations, 190; Types of dysmenorrhea, 191; Frequency of dysmenor-

rhea, 191.

CAUSES OF PRIMARY DYSMENORRHEA 191

General considerations, 191 ; Mechanical obstruction of uterine canal, 192 ; relation
of anteflexion to dysmenorrhea, 193; Hypoplasia of reproductive organs, 193;
Role of neuroses in causation of dysmenorrhea, 196; Hysterical dysmenorrhea,
197; Dysmenorrhea of neurasthenic origin, 198; Neuralgic dysmenorrhea, 199.

CAUSES OF SECONDARY DYSMENORRHEA 199

General considerations, 199; Constitutional disease as a factor, 199; Chlorosis and
other forms of anemia, 199; Tuberculosis, 200; Other constitutional disorders,
200; Dysmenorrhea due to local pelvic disease, 200; Retrodisplacement of
uterus, 201 ; Inflammatory disease of pelvic organs, 201 ; Myomata of uterus,
202; Other forms of pelvic disease, 202.

CLINICAL CHARACTERISTICS OF DYSMENORRHEA 202

Ginical types, 202; Spasmodic dysmenorrhea, 202; Congestive dysmenorrhea, 203.

TREATMENT OF DYSMENORRHEA 203

General considerations, 203 ; Treatment during attack, 203 ; General measures, 203 ;
Drugs, 203; The atropin treatment of spasmodic dystnenorrhea, 205; Treat-
ment by benzyl benzoate, 208; The mammary treatment of dysmenorrhea,
208; Measures for permanent relief of dysmenorrhea, 208; Measures for per-
manent cure of primary dysmenorrhea, 209; The physiological cure, 209;
Importance of accurate diagnosis, 209; Dilation of cervix by rapid method,
209; Continuous dilation by stem pessaries, 210; Plastic operations on cervix,
211 ; The permanent cure of secondary dysmenorrhea, 211.

MEMBRANOUS DYSMENORRHEA 211

General considerations, 211; Clinical characteristics, 212; Etiology, 212; Mechanism
of detachment of membrane, 213; Structure of menstrual membranes, 214;
Macroscopic appearance, 214; Microscopic structure, 215; Diagnosis, 215;
Prognosis, 217; Treatment, 217

NASAL DYSMENORRHEA 218

General considerations, 218; The "genital spots" in the nose, 218; Theories as to
nature of relation between generative organs and nose, 218; The cocain test
of nasal dysmenorrhea, 219; Permanent cure of nasal dysmenorrhea, 219;
Need of caution in estimating results of treatment, 220; Method of treat-
ment, 220.

XXI. INTERMENSTRUAL PAIN 224

Definition, 224; Frequency, 224; Time of occurrence of attacks, 224; Character of

pain, 225 ; Location of pain, 225 ; Duration of pain. 225 ; Associated vaginal
discharge, 225 ; Age of patients, 225 ; Marital and obstetrical histories of
patients, 226; Character of menstruation, 226; Associated pelvic lesions, 226;
Etiology, 226; Treatment, 227.

XXII. UTERINE HEMORRHAGE 229

General considerations, 229; Relative importance of anatomic and physiologic fac-
tors, 229; Classification of causes of uterine bleeding, 230; Constitutional
causes of uterine hemorrhage, 230; Acute infections diseases, 230: Constitutional
diseases, 230; Organic diseases, 231; Chronic intoxications, 231; Anatomic



CONTENTS. xiii

CHAPTER PAGE

causes of uterine hemorrhage, 231 ; Polypi, 231 ; Cervical polypi, 231 ; Corporeal
polypi, 232; Cervical ectrppion and erosion, 232; Retention of gestation
products, 232; Clinical considerations, 232; Histological findings, 233; Endotne-
tritis, 234; Hyperplasia of the endometrium, 234; Muscular insufficiency of
the uterus, 236; Arteriosclerosis of the uterine vessels, 238; Carcinoma of the
uterus, 239; Sarcoma of the uterus, 239; Hydatidiform mole, 239; Chorio-
epithelioma, 239; Uterine myoma and adenomyoma, 240; Ectopic pregnancy,
242; Tuberculosis of the generative organs, 242; Inflammatory disease of the
adnexa, 243 ; Tumors of the ovary, 243 ; Tumors of the tube, 244 ; Internal
secretory causes of uterine hemorrhage, 244; Hyperoophorism, hypergonadism,
244; Disorders of other endocrin glands than ovary, 245; Local factor in
endometrium, 246; Functional uterine bleeding, 246; The role of the endocrine
glands, 247; The nervous causes of uterine hemorrhage, 251; General con-
siderations, 251 ; Vasomotor disturbance due to nervous or psychic influence,
251; Treatment of uterine bleeding, 252; Treatment of cause, 252; Constitu-
tional treatment, 253 ; Physical measures, 253 ; Rest in bed, 253 ; Cold applica-
tions to abdomen, 253; Hot vaginal douches, 253; Vaginal tampons, 254;
Treatment by drugs, 254; Ergot, 254; Hydrastis, 255; Cotarnine phthalate, 255;
Other drugs for internal administration, 255; Intra-uterine applications of
drugs, 255; Injections of blood and serum, 256; Treatment of functional uterine
hemorrhage, 256.

XXIII. VICARIOUS MENSTRUATION 261

Definition and varieties, 261 ; Incidence, 261 ; Sources of hemorrhage, 261 ; The
nasal mucous membrane, 261; The stomach, 262; The intestinal canal, 262;
The lungs, 262 ; The mammary glands, 263 ; The skin, 263 ; The lips, 264 ;
The eye and eyelids, 264; Nevi, 264; The kidneys, 264; Old cicatrices, 264;
Abdominal fistulae, 265 ; The umbilicus, 265 ; Other seats of vicarious men-
struation, 265 ; Menstrual history in cases of vicarious menstruation, 265 ;
Vicarious menstruation during pregnancy, 265 ; Cause of vicarious menstru-
ation, 265 ; Diagnosis, 266 Treatment 267.

XXIV. MENSTRUATION AND THE ENDOCRINE GLANDS 269

Introductory, 269 ; Characteristics of endocrine bodies, 269 ; The principal endocrine

structures, and their importance to the body economy, 269.

THE OVARY 270

The ovary as an endocrine gland, 270 ; The part played by the ovary at puberty and
at the menopause, 270; Castration in early life, 270; The surgical menopause
and its manifestations, 271; Cause of symptoms of artificial menopause, 272;
Transplantation of the ovaries, 272; General results, 272; Operative technic of
autotransplantation of ovarian tissue, 273; Present status of ovarian trans-
plantation, 273 ; Menstruation after removal of the ovaries, 274 ; " Pseudo
menstruation," 274; Menstruation after apparently complete removal of
ovaries, 274; Theories of persistence of menstruation after oophorectomy, 274.

THE THYROID GLAND 276

Evidences of relation between thyroid gland and gonads, 276; Thyroid disease as a
result of pelvic lesions, 276; Menstrual disorders accompanying thyroid dis-
ease, 276.

THE PITUITARY BODY 277

General, 277: Adiposogenital dystrophy (Frohlich's syndrome), 277; Influence
of pituitary on body growth, 278; Pituitary hypertrophy in pregnancy, 278;
Pituitary hypertrophy after castration, 278.

t

THE SUPRARENAL BODIES 279

Difference in function between cortex and medulla, 279; Indications of relation
between function of suprarenals and gonads, 279 ; Effects of suprarenal tumors
on reproductive system, 279; Changes in sexual apparatus associated with
suprarenal hypertrophv, without tumor, 280; Retarded sexual development
associated with suprarenal hypoplasia, 280.



xiv CONTENTS.

CHAPTER PAGE

THE PINEAL BODY 280

General, 280; The so-called pineal syndrome, 280; Feeding experiments, 281;
Results of extirpation, 281.

THE THYMUS GLAND 281

THE MAMMARY GLAND 282

THE PANCREAS 283

XXV. RECIPROCAL RELATIONS OF MENSTRUATION AND VARIOUS DISEASES 288

Introduction, 288.

TUBERCULOSIS AND MENSTRUATION 288

General considerations, 288; The influence of tuberculosis upon menstruation,
288; Ainenorrhea more common than menorrhagia, 288; Influence of the age
of the patient, 289 ; Influence of the stage of the disease, 289 ; Menstrual dis-
turbance not usually dependent on local lesions in pelvis, 289; Explanation of
amenorrhea in tuberculosis, 290; Practical importance of amenorrhea in tuber-
culosis, 290; Menorrhagia in tuberculosis, 290; Dysmenorrhea in the tuberculous,
291; Influence of menstruation upon tuberculosis, 292; General considerations,
292; Historical, 292; Premenstrual fever in consumptives, 292; Postmenstrual
fever, 293; Other types of fever in consumption, 293; Influence of menstrua-
tion upon subjective symptoms of the disease, 293.

TYPHOID FEVER AND MENSTRUATION 294

Effect of typhoid on menstruation, 294 ; General considerations, 294 : Menstruation
usually diminished or absent, 294; Significance of uterine bleeding in the
hemorrhagic type of typhoid, 294; Variations in effect of typhoid on men-
struation, 294; Menstruation during convalescence, 295; Effect of menstruation
upon typhoid fever, 295 ; General considerations, 295 ; Importance of relation
of menstrual date to time of onset of disease, 295 ; Effect of menstruation on
fever, 2%; Influence of menstruation on treatment of typhoid, 296.

PNEUMONIA AND MENSTRUATION 297

Effect of pneumonia on menstruation, 297; Occurrence of menstruation, 297.

OTHER INFECTIOUS DISEASES AND MENSTRUATION 297

Syphilis, 297; Influenza, 298; Acute exanthematous diseases, 298; Other infectious
diseases, 298.

DISEASES OF THE BLOOD IN RELATION TO MENSTRUATION 298

Chlorosis, 298; Characteristics of the disease, 298; Effect of chlorosis on men-
struation, 299; Amenorrhea the common menstrual symptom in chlorosis,
299; Menorrhagia occasionally observed, 300; Dysmenorrhea a frequent
symptom, 300; Treatment of menstrual disorders of chlorosis, 300; Effect
of menstruation on chlorosis, 300; Harmfulness of emmenagogues, 300; Per-
nicious anemia, 300; Leukemia, 300; Hemophilia, 301.

DISEASES OF THE THYROID GLAND IN RELATION TO MENSTRUATION 301

Graves' disease and menstruation, 301 ; Myxedema and menstruation, 302.

DIABETES AND MENSTRUATION 302

GASTRO-INTESTINAL DISEASES AND MENSTRUATION 303

Effect of menstruation on secretory and motor functions of stomach, 303 ;
Stomach disorders and menstruation, 303 ; Liver diseases, 303 ; Menstrual
hyperemia of the liver and menstrual jaundice (icterus menstrualis), 303;
Cholelithiasis, 304.

JOINT DISEASES AND MENSTRUATION 304

Acute articular rheumatism and "menstrual arthitis," 304.



CONTENTS. xv

CHAPTER PAGE

NERVOUS AND MENTAL DISEASES AS RELATED TO MENSTRUATION 305

Epilepsy, 305; Hysteria, 306; Insanity, 307; Chronic intoxication, 307.

THE MENSTRUAL DERMATOSES 307



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