a peculiar and somewhat heavy odour which

* Whitehead, loc. cit. p. 24.

t Brierre de Boismont, op. cit. p. 68.

J De Mul. Organ. Lag. Bat 1672, p. 134.



663

is as characteristic of it, as is the gravis odor
puerperii of the lochial and other discharges
in childbed.* But these circumstances afford
no evidence that the excretion is, when first
formed, necessarily unhealthy.

The menstrual fluid, when first formed, ap-
pears to consist almost entirely of pure blood ;
but, in its course through the vagina, it re-
ceives in addition the secretions of that
canal, whereby both its physical condition and
chemical constitution are materially altered.
Hence the differences of opinion which have
so long prevailed regarding the real nature of
this fluid, and the extent to which it differs
from pure blood. These differences have been
maintained chiefly by the well-known fact that
menstrual blood seldom coagulates, and also
by the difficulty of discovering fibrine in it.
But a solution of this difficulty is found in the
fact that the mucus of the vagina has always
an acid reaction, and that in this acid the
fibrine of the blood is so readily dissolved,
that not only is its coagulation prevented, but
chemical analysis fails usually to reproduce
more than a trace of it.

The menstrual fluid, therefore, as escaping
from the vaginal orifice, and that collected
from the os uteri, are essentially two different
products, and this distinction should be ob-
served in all examinations having reference to
its chemical or physical composition. But it
would be perhaps arbitrary to designate either
of these alone the menstrual fluid. Probably
this term is most suitable to the first. Both
the vagina and uterus are concerned in the
production of this fluid in the form in which
it is most familiarly known, and in this form
it may first be examined, the pure and un-
mixed* product of the uterus being reserved
for subsequent consideration.

Composition of menstrual fluid according to Hf. Denis.

Water - ... 82'50

Fibrine - - - Q'05

Hematosine - - - 6-34

Mucus - - - 4-53

Albumen - 4-83

Oxide of iron - 0-05

Osmazome and cruorine, of each - (Ml

Salts and fatty matter - - 1*59

Microscopic examination. The menstrual
flux exhibits three periods or stages ; viz. the
periods of invasion, stasis, and decline. In
the first the discharge is of a paler colour,
and sometimes consists mainly or entirely
of mucus menstrua alba. But this stage
is not always observed, the discharge often
commencing at once of the deep red colour
characteristic of the middle stage. This con-
tinues during the greater part of the period,
and is succeeded by the third stage or that of

* Doubtless this led Pliny to draw up that dire
catalogue of evils, in which he informs us, that the
presence of a menstruating woman turns wine sour ;
causes trees to shed their fruit, parches up their
young shoots, and makes them for ever barren ;
dims the splendour of mirrors and the polish of
ivory ; turns the edge of sharpest iron ; converts
brass to rust ; and is a cause of canine rabies. C.
Plinii, Nat. Hist, liber vii. xiii. ed. Cuvier, 8vo.
vol. i. Paris, 1*27.

V U 4



664



UTERUS AND ITS APPENDAGES.



decline, when the discharge loses its deep red
colour and assumes the hue of water in which
raw flesh has been washed. This is very com-
monly the condition of the discharge during
the last day or two of each period, especially
in those women in whom the flow is of long
continuance.

M. Pouchet* has examined with great care
the menstrual discharge at each of these
periods. The following are the results of his
observations : 1st invasion. A very few blood
globules mixed with mucus may be observed,
together with mucous-corpuscles and scales of
epithelium, mostly entire, floating in an abun-
dance of limpid fluid. Almost all the mucous-
corpuscles contain smaller globules or granules
which form in them a central nucleus. 2.
Stasis. Menstruation havingreached its apogee,
the blood-globules are much more numerous
than at the onset. The plates of epithelium
usually remain entire. 3. Decline. The fluid
contains the same substances, and presents
nearly the same appearances as at the time of
commencement of the flow.

These observations agree generally with my
own, and also with those of Donne, who found
the menstrual fluid to consist of, 1. Ordinary
blood-globules of the proper character, and in
great abundance. 2. Mucus from the vagina
mixed with epithelial scales. 3. Mucous-
corpuscles from the cervix uteri.

The unmixed menstrual fluid. But in order
to determine the nature of the menstrual fluid
as it issues from the uterine orifice, unmixed
with the secretions of the vagina, it must be
collected by a speculum accurately fitting the
uterine neck. The fluid so obtained possesses
properties very different from those of the
flux already described. Its sensible characters,
as observed in more than a dozen specimens,
are well described by Mr. Whitehead. Thus
procured, the fluid is never so dark in colour
as ordinary menstrual blood, so called, nor so
fluid always as that of the arteries. Its colour
varies slightly, but whatever is its tint, this
is not subsequently affected by intermixture
with the vaginal mucus. It appears usually
rather more viscid than systemic blood, pro-
bably on account of its slow exudation. When
thus collected it invariably coagulates, the
separation into clot and serum being complete
in three or four minutes. It sometimes passes
off" in a continued stream as pure blood, but
more often as a thin coloured serum mixed
with small flattened clots, the size of orange
seeds, which, becoming broken down and, as
it were, dissolved in the vaginal mucus,
appear at the external orifice in the usual
uncoagulable fluid form. It is invariably
alkaline.

In menorrhagia the discharge is as fluid as
arterial blood, and not being delayed on ac-
count of the greater rapidity of escape, it
trickles in drops along the tube.

On account of the great difficulty which is
experienced in obtaining the pure fluid from
the uterus in quantities sufficient for chemical

* Theorie Positive, Atlas, plate xii.



analysis, the following results by Bouchardat
are the more valuable. The woman, a multi-
para, was thirty-five years of age. To explain
the large proportion of water Bouchardat
states that she had subsisted chiefly on a
vegetable and milk diet.

BouchardaPs analysis of pure menstrual blood.

Water - - 90-08

Solid matter - - 6'92

The solids were composed of

Fibrine, albumen, colouring matter - 75-27

Extractive matter - - 0-42

Fatty matter - 2-21

Salts - - 5-31

Mucus - -.. 16-79

100-00

It will be observed that the proportion of
fibrine is here much larger than in the former
example. But chemical analysis is not needed
to show that this element of the blood con-
stitutes a part of the fluid exuded from the
uterus. For in women who have died men-
struating fibrinous clots have been found in
the uterine cavity ; coagula have also just
been described as forming at the os uteri and
mixing with the fluid collected by the specu-
lum, and it cannot have escaped observation
that clots sometimes form about the vulva, at
times of menstruation, especially when the
discharge is freer than usual.

But the notion that the menstrual discharge
differs from ordinary blood " in containing
only a very small quantity of fibrine, or none
at all,"* which view has gained general cur-
rency of late, and in support of which the in-
vestigations of Brande or Lavagna are usually
quoted, appears to be altogether a modern
one. For the older writers considered the
menstrual discharge as identical with blood.
Hippocrates says in reference to it, " procedit
autem sanguis velut a victima, et cito coagu-
latur, si sana fuerit mulier." Mauriceau-j- says
that menstrual blood does not ordinarily differ
in any way from that which remains in the
woman's body. So also Haller and Hunter,
both of whom regarded menstruation as a
natural evacuation of blood.

The results of these careful investigations
therefore warrant the conclusion that the men-
strual fluid, at the moment of its effusion, con-
sists of pure blood, mixed only with the small
quantity of mucus and epithelium which it
receives in passing through the body and neck
of the uterus, and that at this point it always
has an alkaline reaction. But that in the
course of its passage through the vagina the
original fluid becomes mixed with the mucus
of that canal, which there exists in increased
quantities, and that in the acid of that mucus
the fibrinous portion is so far dissolved as to
render the detection, by chemical means, of
fibrine, as a constituent of the secretion, diffi-
cult or impossible. So much, however, of
fibrine as belongs to the blood-corpuscles must
always be present, for these bodies exist in

* Mailer's Physiology by Baly, p. 1481.
f Traite des Mai. des Fern. Gross, p. 45. 3rd ed.
1681.



UTERUS (FUNCTIONS).



large quantities in every instance of a healthy
menstrual flux.

Source of the menstrual fluid. The vagina,
the os and cervix, and the body of the uterus,
have been severally regarded as the parts
which furnish the menstrual flux. And so
far as the mucous element is concerned it is
probable that all these surfaces contribute a
certain proportion ; but that the blood in nor-
mal menstruation is derived mainly from the
lining membrane of the body of the uterus, is
placed almost beyond doubt by the following
considerations :

1. In the uterus of one who has died whilst
menstruating, a remarkable difference is usu-
ally perceptible in the condition of the mu-
cous membrane lining the cavity of the body
and cervix respectively. That of the body is
highly injected, of a deep red colour, the ves-
sels distinct, and the capillaries numerous.
That of the cervix exhibits a condition the
opposite of this. It is pale, uninjected, and
free from all appearance of distended vessels.

2. If such a uterus be injected, the same
conditions are observed in a more marked
degree. All the capillaries on the mucous
membrane of the body are filled, but compa-
ratively few of the cervix ; an abrupt line
of demarcation occurring sometimes at the
internal os uteri.

3. If gentle pressure be employed, as by
taking the uterus in the palm of the hand,
and slightly approximating the two sides,
blood is perceived to flow up from the little
pores or orifices of the utricular glands, which
are everywhere perceptible, upon the surface
of the mucous membrane, until this collects in
the cavity in a quantity sufficient to cover the
surface.

4. If the same experiment be made under
water, in a dish or shallow basin, with the
aid of very gentle pressure on the sides of the
uterus, such as could not apparently cause
any rupture of uterine vessels, the little
streamlets of blood are seen welling up from
each pore, and mingling with the water. In
neither of these cases is the blood seen to
proceed from any part of the cervix, but only
from the lining membrane of the uterine
cavity.

5. The blood, in ordinary menstruation, is
seen to flow from the os uteri into the specu-
lum, but is never observed to proceed from
the lips of the cervix, except the latter be in
an abnormal state.*

6. The cavity of the uterus, after death
during menstruation, has been frequently
found to contain blood or a coagulum.

From these observations it may be con-
cluded, that in normal menstruation the blood
is furnished by the walls of the uterine cavity.
Whether the lining membrane of the oviducts
also contributes any portion of the fluid is not
certainly known. But I have had reason to
think this very probable, from observing that, in
cases of death during menstruation, the tubes
as well as the uterus contained blood, which

* Whitehead, loc. cit. p. 24.



665

may in some cases, however, have entered them
by regurgitation from the latter. (See also p.
618.)

By what means does the blood escape from
the uterine vessels in healthy menstruation ?
The investigation of this question is attended
by great difficulties, and data sufficient even
for its approximate determination are, yet
wanting.

The explanations which have been offered
are chiefly the following :

(a.) The blood is supposed to escape in
the form of a secretion.

So long as it was maintained that the men-
strual fluid differed essentially from pure
blood, the view that it was eliminated from
the general circulating current by a process
analogous to that which obtains in true secret-
ing glands received ready acceptance, and the
menstrual fluid was, in accordance with such
views, denominated a secretion. But since it
is now known with tolerable accuracy to what
portion alone of the menstrual fluid the term
secretion can, with any degree of truth, be
applied, it seems useless further to argue the
question of secretion or non-secretion, in
reference to the main ingredient of this fluid,
which has already been shown to be pure
blood, unaltered in its physical and chemical
constituents, until after it has become mixed
with other and adventitious matters.

(6.) The blood is supposed to escape by
transudation through the capillaries of the
uterine mucous membrane.

This view, which is proposed by Coste *
and others, need not be considered specially
with reference to the uterus. Those who
think that the blood-corpuscles, which mi-
croscopic examination proves to be abun-
dantly present in the menstrual fluid, can pass
by transudation, unaltered and entire, through
the w r alls of capillary or other vessels without
rupture of their coats, will find no difficulty
in applying this explanation to the production
of a like phenomenon, as it may be supposed
to occur in the uterus.

(c.) The blood is supposed to escape
through lacerated capillary vessels.

Many observed facts give to this view a cer-
tain amount of probability. Thus, in an in-
jected uterus the capillary vessels, which form
so fine a network upon its inner surface
(fig. 439.), may be occasionally observed de-
nuded, and hanging forth in detached loops.
In such a condition I have found the vessels
when death has occurred during menstrua-
tion.f Unless this is a post-mortem change,
which is improbable, it may be assumed that
this laying bare of the capillaries is the conse-
quence of a vital action, whereby a portion of
the epithelial and mucous surfaces are broken

* Histoire da Developpement, torn, prem., 1 fasc.
p. 209. 1847.

f I am not prepared to assert that this condition
is always present during menstruation, or that it is
limited to such periods. A larger number of ex-
amples than those in which I have observed this
feature would be necessary to establish such a fact ;
and the whole subject requires a closer examination
than has yet been given to it.



666



UTERUS AND ITS APPENDAGES.



down, and subsequently discharged, along with
the menstrual fluid. According to the observa-
tions of Pouchet*, such an exfoliation of ute-
rine epithelium takes place monthly in women
and the mammalia generally. Pouchet, indeed,
maintains that not only is there a monthly
desquamation from the uterus, but that this
extends to the separation and expulsion of a
deciduous membrane on each occasion, and
that this expulsion, which takes place in the
form of the broken down elements of the
deciduous lining of the uterus, constitutes the
process described by him under the title of
intermenstruation. Such an exfoliation, if
it extended only to the epithelial cells sur-
rounding the uterine capillaries, would simply
leave them bare, but if proceeding to the ex-
tent of removing the whole deciduous uterine
lining, would of necessity carry off with it the
whole capillary network of vessels, (see fig.
539.) lying upon the face of this membrane,
and consequently would leave a surface of
torn capillaries, from which the haemorrhage
might occur f , and this in fact takes place in
cases when dysmenorrhceal membranes are
discharged (fig. 443.).

(rf.) The blood is supposed to escape by
permanent vascular orifices.

In the present state of our knowledge, the
evidence in support of this view is not more
conclusive than that upon which the preceding
hypothesis is built : yet many circumstances
lend colour to it. The question of a termina-
tion of the uterine vessels by open orifices has
been occasionally, though obscurely, touched
upon by different authors. Thus, Madame
BoivinJ, a most careful observer, after speak-
ing of the " perspiratory orifices of extreme
minuteness," visible upon the inner uterine
surface, evidently meaning the orifices of the
now well-known uterine glands, describes the
manner in which the blood may be made, by
pressure, to appear in droplets upon the inner
surface of the uterus when death has occurred
during menstruation ; and,without giving a per-
sonal opinion, she elsewhere quotes the then
prevailing views, that the blood is furnished
by the exhalent extremities of arteries termi-
nating upon the inner surface of the uterus.
Dr. Sharpey endeavoured, by various ex-
pedients, to determine what is the precise re-
lation of the blood-vessels to these orifices

* The'orie Positive, Huitieme Loi.

f Pouchet, who does not enter upon the question
of the effect which such a monthly denudation of
the inner surface of the uterus would have upon its
capillary vessels, nor, indeed, at all upon the con-
sideration of the precise mode in which the menstrual
fluid escapes, makes this supposed exfoliation and
expulsion of the menstrual decidua occur at the
periods intermediate between those of the menstrual
flux. Thus the idea of a separative process, which
might have been made comparable with that occur-
ring in labour, when the entire ovum is thrown off
and a bleeding surface is left, from which the lochi-
al discharge takes place, loses its significance from
the circumstance that this phenomenon is said to
happen at periods when there is no bleeding.

J Me'm. de 1'Art des Accouch., quarto ed. p. 61.



Miiller's Physiology by Baly, p. 1579.



in the decidua a little more advanced*, as, for
example, in early pregnancy ; but after express-
ing his conviction upon the subject, the pre-
cise anatomical connection between the two is
left undetermined. Ordinarily, in injecting the
uterus with fine coloured fluids, I have ob-
served the cavity to become filled, the injec-
tion apparently escaping by the glandular ori-
fices, which also themselves may be seen filled
with injection. In some specimens a capillary
branch may be observed passing to and stop-
ping short at one of these canals or orifices,
and having much the appearance of an open
vessel. Without personally expressing an
opinion upon this point until I have carried
further some experiments now in progress,
I may observe, that the idea of a permanently
open termination of vessels here need not be
set aside upon the objection that such an ar-
rangement would produce a constant bleeding,
because the vessels supplying the blood must
first pass through a dense muscular tissue,
amply sufficient to control or arrest bleeding,
as indeed it does effectually after labour, when
much larger mouths are laid open, and also
occasionally when menstruation is suddenly
arrested by powerful mental impressions, acting
apparently upon the muscular fibre of the
uterus ; while many positive facts might be
adduced in support of such a view, such as the
frequent bleedings of uterine polypi, which are
always invested by mucous membrane, the
ready passage of fluids through the surface of
the latter when their main vessels are injected,
and the like.

What is the purpose of menstruation ? To
this question no reply will be satisfactory
which does not include the consideration of
many other circumstances besides the mere
escape of blood. Menstruation has evidently
a much deeper signification than is declared
simply by the flux, which is probably not the
most important part of the function, although
it constitutes the external sign or evidence
of it.

Amid all the crude hypotheses of former
times, such as that menstruation is due to fer-
mentation, lunar influence, and the like, some
of the older writers appear nevertheless to have
had a dim perception of the truth when, under
the form of an elegant type, they shadowed
forth that which appears to be the real pur-
pose of the menstrual act. The French term,
" fleurs," and the English, " flowers," are now
fallen into disuse ; but they were employed in
earlier times as designations of menstruation,
for the purpose of suggesting that, after the
example of trees, which do not bear unless
the fruit is preceded by the blossom, so a
woman does not become pregnant until she
also has had her flowers.f

Menstruation is not established until the
ovaries have reached a certain stage of de-
velopment, and the maturation and discharge

* It must be observed that throughout this
article the terms " decidua " and " mucous or lining
membrane of the uterus" are employed as strictly
synonymous.

f Mauriceau, Malad. des Femmes grosses. 1681.



UTERUS (FUNCTIONS).



of ova has commenced.* It continues to be
performed as long as the process of ovulation
is continued ; but when the latter ceases, and
the ovaries have become shrunken, their tissues
attenuated and wasted, and Graafian follicles
can be no longer distinguished, menstruation
ceases to be performed.

These facts show that menstruation and
ovulation proceed pari passu ; but they do not
alone prove that the one function is dependent
upon the other.

If, however, both ovaries are congenitally
deficient, no attempt at menstruation is ever
observed ; while, on the other hand, in cases
where the ovaries are present but the uterus
is deficient, puberty becomes established in
due course, and then a regularly recurring
menstrual molimen may be observed, although
for the want of the uterus this function can-
not be carried out. See note .

Or if, under ordinary circumstances, after
the regular establishment of menstruation,
both ovaries become extensively diseased, or
both are removed by operationf, menstruation
is from that moment permanently suspended.

Hence it appears that the presence of the
ovary in a healthy state is essential to men-
struation.

But something more also is needed ; for the
ovaries may be present and healthy, yet if
they cease for a time to mature or emit ova,
as for example during pregnancy and lactation,
when they are passive j, then, so long as those
processes endure, menstruation is also com-
monly suspended, but returns after the com-
pletion of one or both of them.

A series of facts so consistent appears to
admit of but one interpretation : namely, that
a menstruating condition of the uterus bears
a direct relation to the active operations of
the ovaries, and that this function is only per-
formed under circumstances which render
pregnancy possible so far as the ovaries are
concerned ; but if the conditions are such that
impregnation cannot take place, then the ute-
rus, although it may be healthy, does not
menstruate.

But, in addition to this general relationship
between menstruation and ovulation, it is ne-
cessary to determine further if any direct cor-
respondence exists between each separate act
of menstruation and the maturation or dis-
charge of one or more ova from the ovary, so
that these two acts shall be coincidentally
performed.

The following evidence supports this view.

The ovaries at the menstrual periods are
not unfrequently the seat of pain and tender-
ness, indicating some unusual activity of this
part. This is most remarkable in the rare
case of hernia of the ovary.$

* The views of Dr. Ritchie in dissent from this
statement have been already noticed, p 572.

f See Mr. Pott's case, p. 573.

J Negrier's, loc. cit.

In a case of this kind recorded by Dr. Oldham
(Proceedings of the Roy. Soc. vol. viii. p. 377.), both
ovaries had descended through the inguinal canals,
and were permanently lodged in the upper part of
the external labia. "At intervals of about three



667

In women who have died during a men-
strual period the ovaries have been frequently
observed to present unmistakable signs of the
recent rupture of one or more Graafian fol-
licles. Some examples of this fact have been
already given. In one case the ovum itself
was found in the Fallopian tube (p. 567.).*

Conception is supposed to take place most
frequently within a few days after a menstrual
period, and therefore during the time which