Among these cases, moreover, there is not one in which the period of suffering is as long as would be indicated by Dr. Clarke. Six, twelve, forty-eight hours is the outside limit. If extended beyond this, or even if very severe during this time, there is always reason to suspect actual disease of the uterus or ovaries, and the cases must be excluded from considerations only applicable to persons in average health. From this point of view, the week of rest demanded by Dr. Clarke, is as excessive as the three weeks' disturbance so imaginatively described by Michelet.
But it is true that the stand-point in Dr. Clarke's book is somewhat different from this. He scarcely alludes to the presence of pain in menstruation, because this is presumed, when existing, to itself constitute a sufficient warning against over mental exertion, indeed, to render such exertion impossible. But the warning in question is directed against a more insidious accident, that may occur without pain, and which is more easily and imprudently defied. This imminent danger is hæmorrhage, or an increase of the physiological flow to such an extent that the vitality of the patient is drained as from an open vein. The constant repetition of such hæmorrhage may lead to uterine congestions, or even to amenorrhea, i.e., entire absence of menstruation. But it originates in functional disturbance, in exhaustion of the nervous system by intellectual exertion. On account of the imminence of this danger, the period of real incapacity for mental effort lasts much longer than conscious discomfort is likely to do—lasts, indeed, as long as the physiological afflux of blood to the uterus—which, by the means described, may at any moment become excessive.
Dr. Clarke alleges but one kind of proof of this assertion. He relates a certain number of cases, interesting in themselves, but whose histories are lacking in many important details, where healthy girls, whose menstruation was at first perfectly normal, became, after two or three years' study at school, liable to monthly hæmorrhages, so excessive that their health was completely undermined. No organic cause for such disorder could be discovered. By interruption of study, rest, amusement, travel, the hæmorrhages were diminished, the health restored. In several of these cases, however, resumption of study on the old plan was followed by the immediate return of all the previous accidents, and often the constitution was entirely ruined.
We think that this argument might be exactly paralleled by the following, which should prove whisky drinking to be an efficient[37] cause of yellow fever. A physician might select twenty cases of men, personally known to him, who had lived twenty and thirty years in New York or Boston, and never had yellow fever. During this time they had taken little or no whisky, but afterwards, removing to New Orleans, they fell into the habit of drinking, and, at varying intervals from that date, caught the fever, and in many instances, died. Therefore, fever was due, at least in these cases, to the newly contracted habit of drinking whisky.
-A and -B = -C -A +B = C. Therefore, C = A.
Hamerton, in his little book on the intellectual life, accuses women, even the bright and intelligent among them, of a “plentiful lack” of intellectual curiosity. If their attention is attracted to a phenomenon, they rarely inquire as to its cause. If an assertion is made, they accept it with enthusiasm or repel it with indignation, but rarely analyze the conditions upon which the assertion is based. This remark seems justified, though perhaps not exclusively among women, by the total absence of curiosity that has been shown in regard to the physiological facts in question. The assertion that nervous excitement, produced by intellectual work, is capable of affecting an apparatus apparently so remote from the organ of the intelligence as is the vascular system of the uterus, certainly implies some most interesting physiological facts and a mechanism the reverse of simple. Into these facts and this mechanism it behooves all to inquire, who assume the responsibility of either accepting or rejecting Dr. Clarke's theory and the deductions that have been made from it.
This theory concerns exclusively one class of uterine hæmorrhages, those, namely, which may be traced to the influence of the nervous system. Before analyzing such influence it is important to notice two other causes of menorrhagia, that are very frequently present in just such cases as Dr. Clarke describes. These are prolonged sedentary position, and deficiency of physical exercise. Either may determine anemia, or impoverishment of the blood, a condition which alone is sufficient to induce excessive menstrual flow.[38] But, in addition, each has a special action more direct. By long continuance of a sedentary position the equilibrium of the circulation is disturbed, the blood is driven from the limbs to the internal organs and the dependent portions of the trunk, hence to the pelvis; but almost equally to the head, that is hanging down over the school-desk. Hence, the uterine hæmorrhages, that are necessarily confined to girls, are paralleled by the nose-bleeding, common to girls and boys, and very frequent in such circumstances. The cramped position of the chest interferes with respiration; the bowels are generally constipated, and both conditions again favor congestions of the visceral organs, including the uterus, but not confined to it. To deficiency of physical exercise is due, besides the disturbance in the equilibrium of the circulation, first, a loss of heat that should be evolved during the chemical processes of muscular action; second, a loss of stimulus to the spinal cord, which has, therefore, less power to control ganglionic action. This latter, therefore, becomes irregular, and the consequences of this irregularity will be presently described. The influence of these two conditions—cramped sedentary position, and deficiency of muscular exercise—either sufficient to induce uterine hæmorrhage, must, therefore, be eliminated, before such accident can be attributed to any other cause less simple and direct. The first criticism to be addressed to the “statistics” contained in Dr. Clarke's clinical chapter, is, that this necessary elimination has not been made, and one possible cause arbitrarily selected out of an entire group of known causes.
As far as may be gathered from his book, Dr. Clarke's theory may be thus formulated. Two intense nervous actions cannot, without detriment, be sustained at the same time by the same organization. The mental labor demanded by school studies on the one hand, and the physiological process of menstruation on the other, are each connected with intense action of different parts of the nervous system. They are, therefore, incompatible with each other; and from the attempt to sustain them simultaneously, results, first, the imperfect accomplishment of each; second, the general exhaustion of the over-burdened nervous system. To this exhaustion is to be attributed the uterine hæmorrhages upon which Dr. Clarke insists as the accident particularly liable to be induced by any continuous, i.e., non-intermitting, system of education.
For non-medical readers it is important to develop the ellipsis and explain the facts upon which, if anywhere, this theory is based.
The nervous system, though in many respects a unit, consists of two great sections, called respectively, the ganglionic system, and the cerebro-spinal; the latter formed by the brain, the spinal cord, and the medulla-oblongata, that connects them; the former, constituted by smaller masses of nervous matter distributed in three ways: First, in a double chain lying on each side of the spinal cord, from the upper part of the neck to the pelvic cavity that terminates the trunk. These masses are called especially the sympathetic ganglia. Second, in so-called plexuses, occupying different positions in the cavity of the trunk, and standing in especial relation to various organs; the solar or cœliac plexus to the stomach, liver, and spleen; the two renal plexuses to the kidneys; the mesenteric plexuses to the intestine; finally, on each side of the pelvis, the hypogastric plexus to the bladder, uterus, and ovaries—the so-called genito-urinary organs. Third, besides these principal ganglia exist others, much more minute, imbedded in the muscular walls of certain organs—as the heart (intro-cardiac ganglia), the intestine (intestinal ganglia).