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Puberty is that period during which childhood develops into sexual maturity, and the individual becomes capable of reproduction.

The age at which puberty occurs varies with climate, race, occupation and with individuals of the same status. But the average age for girls, in temperate climates, is from the twelfth to the sixteenth year; for boys from the fourteenth to the seventeenth year. Girls in southern climates sometimes mature as early as the eighth or ninth year, while in colder regions puberty may be delayed until the eighteenth or twentieth year.

At this time there are many physical and psychical manifestations of the maturing changes in the internal female generative organs. The undeveloped girl grows rapidly at this stage. Her entire body rounds out and assumes a more graceful contour; her breasts increase in size; her hips broaden; the external genitalia enlarge and hair appears over the pubis and on other parts of the body.

As this physical maturity progresses, there is a dawning sex consciousness and the developing girl becomes shy, modest, retiring and introspective. She is very likely to be emotional and hysterical and to display a lack of stability and nervous control, which are not in accord with her usual temperament. A formerly dependable child may become capricious, erratic, and perplexingly inconsistent. One day she may be quite her normal, little-girl self and the next show inexplicably mature qualities. Or she may display a bewildering number of moods and fancies in the span of one short day.

Too much cannot be said of the importance of wise supervision and guidance of the girl’s physical, mental and emotional life at this critical, emotional period. Many gynecological, obstetrical and neurological difficulties in her later life may be averted by her observance of sane rules of personal hygiene.

Vigorous and regular out-of-door exercise; a simple, nourishing and well-balanced diet; adequate sleep in a well-ventilated room; regular bathing, and correction of any discoverable physical defects are the essentials.

But of equal, if not greater, importance is an understanding and sympathetic oversight of the girl’s mental and emotional life, a steadying sort of comradeship.

Her extreme sensitiveness and impressionability should be recognized and borne in mind, and every effort made to save her from strain and shock. Her nervous forces should be sedulously conserved by protecting her against experiences and diversions which would be unduly stimulating or irritating. Nor should demands be made upon her uncertain nervous endurance which she is able to meet only by great strain, if at all.

It is important to her future poise and health that her confidence be courted, and when it is won, that all of her outpourings be received with a respect and seriousness commensurate with their great importance to her. Ridicule, and even unresponsiveness or indifference to her interests, may, and often do, result in a hurtful repression of one form or another. The logical consequence of such repression is an increasingly damaging neurosis later on in her life, capable of greatly impairing her health, happiness and usefulness.

In short, all phases of the life of the adolescent girl should be made as wholesome, tranquil and free from stress and strain as is humanly possible.

These comments upon the importance of mental hygiene at puberty may seem irrelevant to a discussion of obstetrical nursing. But the preparation of the entire female organism for its supreme function—that of child-bearing—is of concern to the obstetrical nurse, and should be understood by her. Moreover, every nurse is inevitably a health teacher, either by precept or example, or both. An awareness on her part of the maturing girl’s needs will fit her to help many perplexed mothers whom she meets along the way to a happy solution of this grave and vexing problem.

The occurrence of puberty marks the establishment of ovulation and menstruation. These two functions are usually performed once a month, ovulation probably occurring about midway during the intermenstrual period.

Ovulation, which is the prime function of the ovary, may be defined as the formation and development of the ovum, and its expulsion, when mature, from the ovary.

The formation of each woman’s full quota of ova is probably complete at birth, though the process may continue until about the second year. At this time it is variously estimated that each of the two ovaries contains from 50,000 to 70,000 ova, but they remain unmatured until puberty, the period at which ovulation is most active.

Fig. 16.—Diagram of human ovum.

As the entire complex human body has its origin in this tiny ovum, its course of development is of momentous importance to us, and at the same time it provides a tale of intense interest.

In its unmatured state, the ovum, termed a primordial follicle, or oöcyte, is a single cell, 1 125 inch in diameter, consisting of clear protoplasm, the vitellus, and a surrounding vitelline membrane composed of small, spindle-shaped epithelial cells. The protoplasm contains a fairly large nucleus, or germinal vesicle, within which lies a nucleolus known as the germinal spot. (Fig. 16.)

The primordial follicle probably lies dormant in this state until puberty, when developmental changes take place, though it is the belief of some authorities that follicles are in the process of development from birth until the end of sexual life, though none fully mature until puberty.

With the advent of puberty the cells composing the vitelline membrane change in character and proliferate rapidly, with the result that the ovum is surrounded by several layers of epithelial cells. Some of the inner cells degenerate and liquify, thus surrounding the ovum with fluid which is contained in a membrane of vascular connective tissue, the theca folliculi; this in turn is lined with epithelial cells, the membrana granulosa. This structure constitutes a Graafian follicle, named for Dr. de Graaf who first described it, and in the course of its maturation is pushed toward the surface of the ovary, where it presents more or less the appearance of a clear blister.

At one point in the enveloping membrana granulosa, the cells proliferate into a mass in which the floating ovum becomes embedded. This mass is termed the discus proligerus and the fluid which surrounds it is the liquor folliculi.

Usually for some strange reason, one, and only one, ovum ripens regularly each month during the years from puberty to the menopause, excepting during pregnancy, when this function is suspended. Occasionally, however, several ova mature at once, a condition which may be one factor in the development of twins. After puberty the ovary contains ova in all stages of development, from the primordial follicle to the Graafian follicle just described.

When a Graafian follicle containing a matured ovum reaches the ovarian surface, its membrane becomes thinner and finally ruptures because of increased tension in the ovary, due to certain circulatory changes. The ovum surrounded by the discus proligerus is thus discharged into the peritoneal cavity near the fimbriated end of the tube. Some ova enter the tube and others float about in the peritoneal cavity, finally disintegrate and are lost.

The torn envelope of the follicle which remains in the cortex of the ovary becomes filled with blood, which forms into a clot. This clot is first surrounded, and then invaded, by cells containing bright yellow pigment called lutein. The membrane formed from these cells compresses the clot and brings about other changes which speedily transform it into the corpus luteum.

If the discharged ovum becomes fertilized, the corpus luteum remains practically unchanged for months and is termed the corpus verum or corpus luteum of pregnancy. Its secretion is believed to influence the implantation of the ovum and to promote the woman’s general well-being during the period of gestation. It continues to exist throughout pregnancy, and until after delivery, when it is soon absorbed and replaced by normal ovarian tissue, without the formation of scar tissue.

If fertilization does not occur, the body in the ovarian cortex, which is then termed the corpus luteum of menstruation, or false corpus, undergoes rapid degenerative changes and is almost wholly absorbed within a few weeks.

By means of this rather complicated procedure the ovary is saved from becoming a steadily enlarging mass of scar tissue, and consequently devoid of reproductive powers, which would be the case if the wound made by the rupturing of each Graafian follicle were to heal by the usual formation of cicatricial tissue.

Ordinarily the ovum remains unfertilized and is propelled down the Fallopian tube, by the cilia in its lining, to the uterine cavity, where it is lost in the uterine secretions and ultimately carried out in the menstrual flow.

Each time that an ovum matures, however, and is discharged from the ovary the lining of the uterine cavity increases in vascularity and becomes thicker and more velvety; a condition which facilitates an attachment of the ovum in case of fertilization. This preparation of the endometrium is termed “pre-menstrual swelling,” or in popular language, nest-building.

Of the enormous number of ova existing in each woman, relatively few mature and it is apparent that still fewer are fertilized, since each impregnation results in an abortion, a premature labor or a full term child.

Nature’s lavish provision of something more than 100,000 ova for each woman, who uses only about 500 in the course of her life, excites no little wonder. But whatever the purpose of this enormous supply, its existence makes possible the removal of all but a small fragment of ovarian tissue in cases of disease, without interference with the process of ovulation, which in turn permits reproduction.

Menstruation, which is the evidence of sexual maturity, is a monthly hemorrhage from the uterus which escapes through the vagina, normally recurring throughout the entire child-bearing period, except during pregnancy and lactation. The duration of this child-bearing period, or sexual activity, is about thirty years and continues from puberty to the menopause.

The frequency of the menstrual periods varies in different women from twenty-one to thirty days, but the normal interval between periods is twenty-eight days, which corresponds in point of time to the menstrual cycle. Thus it is usually four weeks, or a lunar month, from the beginning of one period to the beginning of the period following, making thirteen menstrual periods during each calendar year.

Just why menstruation occurs about every twenty-eight days is not known, but the belief is that, although menstruation is in some way dependent upon ovulation, its periodicity is regulated by the corpus luteum. It is also believed that the corpus luteum of pregnancy holds menstruation in check during the nine months of gestation.

The menstrual cycle is divided into four stages, and though there is not entire unanimity of opinion concerning the changes which take place during these four stages, the preponderance of evidence is in favor of the following processes.

The first or constructive stage lasts about seven days. It is during this stage that the preparative changes, which have been described, are made for the reception of the matured ovum. The uterus becomes engorged with blood and is somewhat enlarged and softened as a result. The endometrium grows deep red, thick and velvety, partly because of the greatly augmented blood supply, and partly because of an actual increase of connective tissue in its structure. There is also an increase in the size and activity of the uterine glands and in the amount of their secretions. If the ovum remains unfertilized, which is usually the case, it does not attach itself to this elaborately prepared lining, but passes out with the uterine discharges, and all of this preparation and increased vascularity not only go for naught, but must be undone.

The second stage, therefore, which lasts about five days, is the destructive stage, during which the newly developed tissues are broken down and the menstrual discharge occurs. During this period the greatly increased secretions of the uterine glands mix with the blood that oozes from the engorged endometrium and with the disintegrated uterine tissues, and pour from the vagina as the menstrual flow.

The third, or reparative stage, which follows, occupies about three days. During this stage the destroyed uterine tissues are regenerated by new growth from the deeper, uninjured tissues, and the entire organ returns to its normal state.

The fourth, or quiescent stage, now follows, the damage having been repaired, and lasts twelve or fourteen days. This is the time remaining before Nature with unwearying patience begins all over again to prepare for the reception and attachment of the next matured ovum, in case of its possible fertilization.

It will be seen that the duration of the menstrual period, which is coincident with the destructive stage of the menstrual cycle, is about five days, but it is entirely within normal bounds if it varies in length from two to seven days.

The discharge is usually scant at the beginning of the period, increasing in amount until about the third day, after which it diminishes steadily until its cessation. The normal odor of this discharge, consisting as it does of blood and uterine secretions, has been likened to that of marigolds.

The average amount of blood lost is from six to ten ounces, but it varies greatly among women who are otherwise normal and in good health. Some women regularly lose what seems to be an alarming quantity of blood at each period without suffering any apparent ill effect. Others lose so little that they are scarcely aware of their menses.

As a rule the menstrual flow is more profuse among women in warm climates than in cold regions. English women, for example, frequently menstruate profusely while in India, and upon their return to England note a marked decrease in the amount of the discharge. The same is often true of American women who move from Southern to Northern states, while removal from a low to a high altitude usually results in a more profuse flow.

The quantity of the menstrual discharge is affected also by diet, living conditions and by any form of mental or physical excitement or stimulation.

Accordingly, the highly strung, richly nourished women living in luxurious circumstances are likely to menstruate more freely than those less favored who are overworked and poorly nourished.

A shock or great grief, or any great emotional experience; a sea voyage or a long railroad journey may bring on a period before it is due, while the regularity of the periods may be much disturbed, temporarily, by a marked change of climate or altitude, a serious illness or a decided change in one’s daily régime.

The function may be entirely suspended for several months or a year in women who suddenly take up hard work or violent exercise, and persist with it regularly. In such cases the periods gradually recur and finally become normal and regular.

The menstrual period is frequently attended by evidences of marked mental and physical disturbances. While many women are fortunate enough to suffer little or no inconvenience during menstruation, the vast majority are more or less wretched and miserable at this time, although in good health in all other respects. Many are tired, have less endurance than usual and are likely to take cold easily. Headaches with a sense of fullness, dizziness, and heaviness are common accompaniments. Backache is a frequent source of discomfort, while abdominal pain, varying from an uncomfortable sense of dragging heaviness to almost unendurable agony, is the rule rather than the exception. And there may be pain in the hips and thighs as well.

This state of wretchedness is sometimes increased by a loss of appetite, nausea and even vomiting. At the same time there are changes in the breasts which are much the same as, though slighter than, those occurring during pregnancy. They are firmer, may be somewhat increased in size, and many women experience a burning, tingling sensation, soreness and even pain. The nipples are turgid and prominent and the pigmented areas grow darker for the time being.

The skin over the rest of the body sometimes changes in appearance and pimples are common; some women are pale and others are flushed during their periods.

These physical disturbances accompanying menstruation vary so widely in different women, and in the same women at different times and under different conditions, that it is not possible to draw a classical picture of the condition. But all of the symptoms above described will persist with more or less severity throughout the entire menstrual life of one woman, while perhaps only one or two of them will occasionally disturb another. Whatever discomfort there may be usually begins from one day to a week before the discharge appears; is at its height during the following day and from that time subsides steadily, until the normally comfortable state is regained. In fact, many women feel better at the end of their periods and during the days immediately following than at any other time during the cycle.

Heat applied to the abdomen and lumbar region during the uncomfortable days; hot baths, rest and quiet, will usually give great relief, as might be expected when there is local congestion and general nervous irritability. In this connection, it is worth mentioning that the discomfort of many women is needlessly increased by their heeding the widespread but fallacious belief that general bathing during menstruation is injurious. While cold plunges and cold showers are not recommended, certainly warm baths are innocuous and immensely satisfying.

In addition to the physical discomfort which is coincident with menstruation, and quite as common, are the evidences of mental and nervous instability. These often show themselves in the form of unwarranted irritability, and in a lack of poise and self-control. Drowsiness and mental sluggishness are not uncommon, and many otherwise cheerful women are almost overwhelmed by depression during menstruation.

All of these departures from what we are accustomed to regard as the normal, or average, mental and physical state of women are very baffling, as they may persist after every discoverable defect has been corrected.

But aside from all other considerations it is of obstetrical importance for the sufferer to ascertain the cause of her discomfort if possible. For example, a misplacement of the uterus is a frequent cause of dysmenorrhea and, if it remains uncorrected, may make conception impossible; or if conception perchance does take place, the malposition of the uterus may later be the cause of an interrupted pregnancy.

Endometritis is another cause of menstrual difficulty and if allowed to persist may be one factor in the causation of abnormalities in the attachment of the placenta.

There is evidently an intimate relation between the process of menstruation and the functions of the ductless glands throughout the body; a relation which is far from being understood.

For example, the administration of various preparations of ductless glands for maladies which are apparently unrelated to menstruation, results not alone in an improvement of the condition treated, but frequently in much more comfortable menstrual periods, as well.

It should be borne in mind, also, that the influence exerted by a woman’s mental, or psychic, state upon her menstrual periods is so apparent that it is being given increasingly serious recognition. It is frequently observed that patients who are under treatment for nervous and mental disorders, who are also sufferers from painful menstruation, grow more comfortable during their periods as their neurosis improves.

We have constantly before us examples of painful menstruation being relieved coincidently with an improved mental state among women situated at the two extremes of the social and financial scale. Indolent, self-centred and unoccupied women at one end often become excessively nervous and irritable, and suffer great pain with each period, while the overworked, harassed, poverty-stricken women at the other extreme have similarly trying menstrual experiences. When the self-indulgent sister can be persuaded to engage in some form of physical activity and to interest herself in some work which requires mental effort, and which perhaps makes an emotional appeal as well, she frequently finds that her menstrual difficulties become less troublesome.

In the case of the woman in poorer circumstances, an improvement in her mode of living which approaches the normal, and a relief from undue stress and anxiety, will very often be followed by more comfortable menstruation.

A recognition of these rather intangible facts is of consequence to the nurse, as it deepens her appreciation of the necessity for nursing her patient as a complete entity, mentally, physically, spiritually and emotionally. We are insistently reminded at every turn that no one part of the patient, no one aspect of her condition can be separately considered and the remainder overlooked.

The patient can be nursed quite satisfactorily only when she is nursed completely.

Relation Between Ovulation and Menstruation.—Menstruation and ovulation are apparently associated and interdependent, but the exact relation between the two is still obscure and puzzling. It is generally accepted that complete removal of the ovaries stops ovulation and is followed by a cessation of menstruation, and yet cases have been recorded which suggest that these two functions are not invariably correlative.

Evidence of this possible independence is that, although pregnancy must be preceded by ovulation, it has occurred before puberty or after the menopause. And not infrequently pregnancy occurs during lactation, a period when the menstrual function is usually suspended.

It has been claimed by some observers that menstruation has occurred after the complete removal of both ovaries, which would, of course, preclude the possibility of further ovulation. It is possible, however, that in such cases either the ovaries were not entirely removed, though believed to be, or that an accessory ovary existed, since a very small fragment of ovarian tissue will permit the occurrence of ovulation.

As to their chronological relation, information available at present suggests that ovulation occurs about ten or twelve days after the close of the preceding period, and that the corpus luteum formed at the site of the rupture reaches its highest development some ten or twelve days later, and that the degenerative changes in the corpus luteum, in case of non-fertilization of the ovum, give rise to menstruation.

Modifications of Menstruation. Dysmenorrhea is painful menstruation.

Menorrhagia is an abnormally copious menstrual flow.

Amenorrhea is irregularity or, to be exact, suppression of the menses. The suppression may be due to an obliteration of the neck of the uterus, or to an occlusion of the vaginal opening.

Vicarious menstruation is an escape of blood from other parts of the body coincident with menstruation. Blood may ooze through the skin covering the breasts; also from hemorrhoids or from the surface of ulcers. Or there may be nose-bleeding, vomiting of blood or pulmonary hemorrhage, particularly among tuberculous patients. Vicarious menstruation usually occurs among nervous, high-strung women and may be regarded as an evidence of ill health. The amount of blood lost in this way is much less than the amount of the menstrual flow.

The menopause, also termed the climacteric and the change of life, marks the permanent cessation of menstruation and of sexual activity. It occurs ordinarily between the ages of forty and fifty; the majority of women stop menstruating at their forty-sixth year. The menopause has occurred as early as the twenty-fifth year, and as late as the eightieth or ninetieth year. But such cases are, of course, extremely rare and their infrequent occurrence is of interest rather than of importance in an effort to ascertain the general average.

As the child-bearing period is normally about thirty years in duration, the prevailing belief is that the menopause comes earlier to women who began menstruating early, than to those who did not reach puberty until later. Some authorities contend, however, that early menstruation indicates extreme vitality, and that this vitality tends to prolong the child-bearing period. According to this theory, then, the menopause would come late to those who matured early and vice-versa.

As the menopause approaches, menstruation occurs irregularly; the discharge sometimes increases slightly but usually diminishes in amount and finally disappears altogether, while the generative organs all undergo atrophic changes.

Bearing in mind the disquieting effect of adolescence, and of ovulation, upon the general nervous, mental and physical state, we may reasonably expect that a complete cessation of the ovarian function would be attended by more or less disturbance of the general well-being.

It is true that very many women suffer a certain amount of nervous instability at the menopause; they tire easily; have “hot flashes” and possibly headaches. But under ordinary conditions the discomfort is not great, and after the function has entirely ceased and they become physiologically adjusted to the new order of things, these women often enjoy better health than ever before.

Unfortunately wide currency has been given to exaggerations concerning the symptoms of the menopause. The result is that serious organic diseases which are in no way related to the climacteric are not infrequently attributed to it. For this reason excessive bleeding, heart symptoms and what not are all too often accepted as a matter of course, and accordingly neglected until the patient is beyond medical aid. This is particularly and tragically true of cancer of the uterus.

It is a wise precaution, therefore, to regard with apprehension an increase in the amount of the menstrual flow of any woman past thirty, and not to accept it as a normal forerunner of the menopause.

In the dark womb where I began

My mother’s life made me a man.

Through all the months of human birth

Her beauty fed my common earth.

—John Masefield.