CHAPTER VII.

The quantity of a critical discharge is of far less importance than its quality and the punctuality of its performance.

ON THE CRITICAL DISCHARGES OF MENSTRUATION.

MANY morbid or healthy functions of vegetative life are repetitions of the same process, because they are presided over by the same ganglionic nervous system. Thus, in all fevers, in active hemorrhage, as in menstruation : 1st. There are the nervous prodromata, which testify to the existence of a hidden force, by which the vegetative nervous system is being moved to action. 2nd. There is a period of elaboration whenever the circulating system shows that it responds to the appeal of the nervous system, by the rapidity or fulness of the vital current. 3rd. There are the critical discharges by which the blood-vessels are relieved, and the nervous. system restored to healthy action. I have considered the varied phenomena which manifest the ovarian nisus, and its action on the sanguineous system, and shall now pass in review its various critical discharges. It has been well established by Hippocrates and his numerous commentators, that in fever the benefit of a critical discharge is not to be measured so much by its quantity, as by its appearing at the appointed time. This is the case with active hemorrhages and with the menstrual flow. Again, with regard to the nature of the critical discharges by which the ovarian nisus is relieved, it would be taking a very narrow view of the phenomena, to suppose that this monthly fever of the female organism had no other effect that to let flow a portion of blood from the womb. The ovarian nisus has a more extended influence, and is relieved by a mucous, as well as by a sanguineous discharge from the generative intestine, by an increased mucous discharge from the intestinal canal, by abundant perspirations from the skin, as in fever, by saline substances

deposited in the urine. Such are the usual effects of the ovarian nisus, and without becoming pathological, it may also find relief by causing the sanguineous fluid to transude from some other mucous membrane than the uterine; from the ulcerated surface of the skin, or even from its unimpaired structure. I shall proceed to sketch the phenomena of these critical discharges of menstruation in the order in which they have been enumerated.

CHAPTER VIII.

"The menstrual blood should be like

the blood of a victim."-HIPPOCRATES.

ON THE SANGUINEOUS DISCHARGE OF MENSTRUATION.

A MUCO-SANGUINEOUS discharge from the organs of generation is the normal crisis of the ovarian nisus. I mean by organs of generation the whole extent through which the ovum passes from the ovary to the vulva.

In many of the lower animals the surface destined to elaborate food is merely the inverted skin, so that there is but one orifice for the ingestion of food and the elimination of its residue, and it is on this plan that the organs of generation are formed in all animals, a point set at rest by the researches of Kölliker, who has demonstrated the existence of the non-striated class of muscular fibres in the integument. The generative apparatus forms a continuous canal; and although in woman this is not the case when these organs are in a state of quiescence, it becomes one canal when impelled to action by the ovarian nisus, or by sexual stimuli. At the extremity of the reproductive system is the simplest of glands-the germiparous ovary, and the ovarian nisus may so distend it with blood, and ulcerate its coats, as to let the germ burst from it as from a "matrix superior." To receive the ovum, the Fallopian tube embraces in its leaflike folds that part of the ovary ready to expel a germ. So that if ovulation happens to occur at a menstrual period, the first origin of a menstrual discharge is to be found in the

ovary.

Ovulation has been studied and described by Pouchet, Ritchie, Martin, Barry, Négrier, and many others. It is, like dentition, a species of physiological inflammation, and I shall describe it in discussing the causes of subacute ovaritis. Suffice it now to state that from two to four scruples of blood have been supposed to escape from the rent ovary at each ovula

tion, and that, should adherences prevent the fimbria from encircling the perforated ovary, the ovum and blood will pass into the peritoneum, causing peritonitis, and that from an ovarian rent of unusual dimensions has sometimes passed sufficient to fill the pelvis; cases now described as hæmatocele.

All those who have had the opportunity of viewing the Fallopian tubes recently subjected to the ovarian nisus, or after menstruation, have described them as being in a swollen and highly congested state. Gendrin, Paget, Hanover, and Letheby, in two cases, have described the blood and mucuswhich they found in the Fallopian tubes. In Mr. Paget's report of Mrs. Manning's autopsy, it will be seen that the fimbriated extremities of both tubes were closed, therefore the blood they contained could not come from the ovaries. It was different in appearance from the blood contained in the womb, so I believe, with Mr. Paget, that it must have been secreted from the internal surface of the tubes, and am permitted by Prof. Owen to state, that he also admits that the menstrual secretion may take place from the whole surface of the reproductive organs; and my friend, Dr. Farre, observes, in his excellent contribution to Todd's Cyclopedia of Anatomy, that "these collections of menstrual fluid within the tube, which I have found to be considerable in some instances, where I have ascertained beyond doubt that death had taken place during a menstrual period, are instructive, as showing that the menstrual fluid is supplied in part by the walls of the Fallopian tubes, as well as by those of the womb itself. For I have seen it in cases where both orifices of the tube were obstructed; and therefore in cases where it was not probable that the fluid could have regurgitated from the uterus to the tube."

I have therefore here a second origin of the menstrual critical discharge, and when this quantity is considerably increased beyond its usual limits, the blood may flow from the Fallopian tubes into the peritoneum-the only possible explanation of the following cases:

CASE 25. The late Mr. John Shaw examined a young lady, who, while in full health, was suddenly seized with menorrhagia, accompanied by a succession of fainting fits, under which she succumbed. A large mass of coagulum was

found in the abdomen, but the source of the hemorrhage was a mystery until the Fallopian tubes were laid open, when it was discovered that, for the space of about an inch and a half of one of them, its lining membrane was pointed with bloody spots, from which the fluid found in the peritoneum had been rapidly poured out.

CASE 26.-Mr. Barlow-Lond. Med. Gaz., Vol. XXV.— mentions the sudden death of a patient during an attack of purpura hemorrhagica, which occurred five days after a miscarriage of six months. On opening the body, blood was found in the Fallopian tubes, for small coagula still projected from their orifice. Rokitansky has twice seen this hemorrhage from the tubes in women affected with typhus fever, one of whom was pregnant. The same circumstance was noticed at the Hôtel Dieu of Paris, in several instances, during the epidemic puerperal fever of 1746.

CASE 27.-Mr. Field, of Stanhope-terrace, has mentioned the case of a lady, who, while pregnant, took fright; she died soon after, and it was found that both the womb and one of the oviducts had been ruptured, but in such a way that the peritoneal membrane remained intact, therefore the blood which was found in the abdomen must have come from the tubal openings.

CASE 28. Mr. Russell-P. M. and Surg. Journ., Vol. XII., p. 104-relates the case of a lady, twenty-five years of age, who had been four months married, and who menstruated a fortnight before he was called in, for sudden symptoms of collapse, of which she soon died. Large clots were found in the abdomen; the left Fallopian tube was ruptured towards its inner third; the ruptured portion was distended by a mass of fibrine, about the size of a large hazel-nut, in which no ovum was found; the walls of the tubes were thin; the uterus was enlarged and lined with decidua.

Dr. Desmond-Med. Times, 1852-on examining a woman who died on the second day of menstruation, found a perforation of the ovary; the fimbriated extremities of the oviduct were much congested, and contained bloody mucus like that found in the womb.

In all these cases, the observers do not seem to have ascertained whether there existed any obliteration of the uterine