since in the Med. -Chir. Transactions; Mr. Girdwood and M. Gendrin have each added five cases, and M. Negrier five more, of the same kind. All the observations agree that, in females dying during or soon after menstruation, a small irregular rupture or cicatrix was found in the coats of the ovarium (fig. 41), and that this communicated with the remains of one of the Graafian vesicles; from which Dr. Lee concludes that it is "extremely probable that all the phenomena of menstruation depend upon, or are connected with, some peculiar changes in the Graafian vesicles, in consequence of which an opening is formed in the peritoneal and proper coats. Whether an entire vesicle, or only the fluid it contains, escapes through this opening at the period of menstruation, further observations may hereafter determine."

The changes which take place in the vesicle are thus stated by M. Negrier: an afflux of transparent fluid occurs in the vesicles, distending and ultimately causing its rupture at the least resisting part, which corresponds to the surface of the ovary. This opening is cicatrised, at least externally, in about eight or ten days, so as to prevent the escape of the blood which proceeds from the lacerated vessels of the vesicle, and, in consequence, a clot is frequently formed in the capsule of the vesicle (fig. 42). Sometimes it contains a serous fluid, colorless, or tinged with blood.

cases

A very valuable prize essay on the subject has lately been published by Dr. J. C. Dalton,' in which he records eleven cases in which he observed these menstrual corpora lutea, and gives very minutely the changes which take place in them. He thinks the exact period of the menstrual flow, at which the vesicles rupture, variable: sometimes during the flow, in other as stated by Bischoff, Pouchet, and Raciborski- at the termination. The appearance of the corpus luteum will depend upon the extent of the rupture, and the amount of hæmorrhage into the cavity. "As to the seat of the peculiar growth which characterizes these bodies," he considers it to be the proper membrane of the vesicle hypertrophied, and that the proligerous disc, and a considerable portion of the membrana granulosa are expelled with the ovum. "The new growth or deposit of yellow matter, when examined under the microscope, is seen to consist of an abundance of peculiar, irregular-shaped granular cells, varying in size, and sometimes enclosing minute, opaline, yellowish globules, like oil. The contour of the cell wall can in most instances be completely traced throughout; but in some instances it is indistinct in certain parts of the circumference. There are also to be seen in the field of the microscope a few oil globules similar to those in the interior of the cells, but for the most part of larger size." Recent researches seem to show that the development of fatty matter is an early step in the death and removal of tissues; and it is possible that a similar step may thus be observed in these menstrual corpora lutea, for we find them attain their maximum in the course of three weeks, then rapidly retrograde until the yellow matter diminishes in size, becomes softer and more friable, and at length merely exhibits a cicatrix, with a small, faint yellow spot. Dr. Dalton agrees with those already mentioned, who regard the discharge of ova as an essential part of menstruation.

I may add here the examination of the ovary in the case related by Dr. Janser, to which I have already referred. The surface of the left ovary presented a deep red spot, surrounded by finely injected vessels. This spot was formed by a small globular mass, embedded in the ovary, and of an intense red through its whole thickness. The mass in question was separated from the tissue of the ovary by a thin yellow envelope, and was composed of fibres like those of areolar tissue, arranged in superimposed layers. The

1 On the Corpus Luteum of Menstruation and Pregnancy, p. 45. [See also Treatise on Human Physiology, by the same author, pp. 478, et seq.]

yellow envelope was formed by the same kind of fibres, among which there was a pretty considerable quantity of fat, not contained in cells. Near this body, there was seen a small yellow, spherical, nodulated mass, composed of areolar tissue and fat. The right ovary contained two yellow bodies."" No ovule was found; but the examination was four or five days after menstruation.

M. Bischoff has published the minute examination of thirteen cases, in which the clot was found in the place of the discharged ovum, the rent in the coats, cicatrices, and marks of former ova, congestion of the uterine mucous membrane, but neither decidua nor ovule. There are but two or three cases (by Hyrtl and Letheby) in which the ovum has been found.

If the reader will carefully compare the cases here quoted, and those recorded by the authors mentioned, but which it would be out of place to detail more fully here, he will agree with me, I think, that they justify the following conclusions:

1. That ovarian influence is necessary to menstruation: a. because when the ovaries are congenitally absent, or have been removed, or have become disorganized, menstruation is absent or ceases. b. Because when the uterus is absent or has been removed, the ovaries being present, the menstrual molimen may still recur periodically. c. Because coincident with the commencement and cessation of menstruation we find corresponding organic changes in the ovaries.

2. We find that the ovaries do not contain a definite and limited number of Graafian vesicles, as Haller and others have thought, but a vast assemblage, according to the researches of Dr. Martin Barry, and the number of which vesicles may be increased, according to Dr. Ritchie.

3. In the ovaries of women who menstruate regularly, there may be observed a number of the Graafian vesicles, in different degrees of development, from the size of a millet seed to that of a cherry stone.

4. There are cases on record of women who died just before menstruating, in one of whose ovaries a vesicle was observed in a state of great maturity, enlarged and prominent, with its outer coverings much thinned, semi-transparent, and in one point apparently about to burst.

5. In a considerable number of cases of death during menstruation, one ovary presented a cavity recently emptied, or partially filled by a clot, from which a duct-like canal passed through the coats of the ovary. cavity contained a Graafian vesicle cannot reasonably be doubted.

That this

6. On examining the ovaries, a number of cicatrices may be observed, some more, some less recent; and in several cases these have been ascertained to correspond exactly with the number of the menstrual periods. According to Mr. Girdwood's researches, this is always the case.

7. These cicatrices, when cut open, exhibit the yellow spots, which result from an hypertrophied condition of the proper membrane of the Graafian vesicle. These menstrual corpora lutea have given rise to much controversy as to their difference from, or relation to, the corpora lutea of pregnancy, of which I shall have more to say presently.

8. Cases are on record in which (according to Dr. Ritchie) menstruation has taken place without the escape of a vesicle, and others, also, in which there was evidence of the escape of a vesicle previous to menstruation. This latter case has occurred more frequently than the former (and answers to those cases in which conception has preceded menstruation, or occurred during lactation), but both are so rare as scarcely, if at all, to affect the question.

9. This view is further supported by the analogy of other mammalia, as

1 London Journal of Med., April, 1850.

both Bischoff and Raciborski have shown in the case of the bitch; so much so that the former accurate observer lays down the law as equally applicable, that "the ova formed in the ovaries of females of the human species and of mammiferous animals, undergo a periodical maturation quite independent of the influence of the male seminal fluid."1

The conclusions which have been so ably put forth by M. Pouchet are as follows: "1. That in all classes of mammalia ova are produced spontaneously in the ovaries. 2. That they are expelled spontaneously at regular intervals, independently of coition. 3. That in the human female they are so expelled at each menstrual period, this period corresponding to the rutting season of animals. 4. That the ova are, and can be, fecundated only after their expulsion from the ovary; the various solid membranes by which they are protected previous to this expulsion opposing a complete obstacle to the access of the spermatic corpuscles, the actual contact of which is indispensable to the impregnation of the ovum. 5. That in all probability the part where fecundation usually takes place, is the cavity of the uterus, or the lower part of the fallopian tube."2 With these views Bischoff, Raciborski, and others agree; but although there is a great body of evidence in support of this view, it may be doubted whether it is as yet sufficient to warrant such positive deductions.

Professor Müller's opinion, which is more cautiously expressed, is perhaps more strictly in accordance with the present state of our knowledge. He observes that "the number of facts at present collected are insufficient to establish it as a law, that an ovum is discharged from the ovary of the human female at every normally developed period of menstruation. Yet it must be observed, that although the diseases causing death must, in the majority of instances, disturb the function of the ovaries, and prevent the extrusion of the ovum, yet to each of those inquirers who have been on the watch for such cases, several instances of ruptured follicles in menstruating women have occurred within a short space of time. And the fact that the ovaries of the human female become turgid and vascular at the menstrual periods, as those of animals do at the time of heat, strongly favors the opinion that the generative system of the human female is subject to the almost universal law of the periodical discharge of ova.

110. The final cause of menstruation is said to be, 1, To get rid of the surplus blood employed during gestation in the nutrition of the fœtus, but which in the unimpregnated state might be injurious; and, 2, To prepare the uterus for impregnation and conception. The first is a mere hypothesis grounded on an assumption, for it is not proved that there is any surplus blood when the female is not pregnant; I need, therefore, say no more about it.

As to the second theory, it is based upon the observation, that conception. seldom or never takes place before the period of the first menstruation, or puberty; that it does not occur in those who do not menstruate, or after the cessation of menstruation; and that calculations show that it takes place more readily soon after a menstrual period. This latter is a very old observation, and is held by most modern obstetricians. Naegelè, for instance, calculates the duration of pregnancy at nine months and eight days from the last menstrual period, and in normal cases he says he has never been wrong. The popular mode of calculation is pretty much the same.

[As regards the coincidence of menstruation and conception we have conflicting testimony. The late Dr. Dewees, whose experience was very extensive, wrote as follows: "The final cause of the menses is perhaps en

1 Müller's Physiology: Supplement, p. 45. Physiology: Supplement, p. 50.

2 Théorie Positive de la Fécondation.

veloped in some obscurity; but of this we know at least one incontrovertible fact, namely, that the healthy performance of this function is in some way or other connected with the capacity for impregnation; as no well-attested instance is upon record, where this has taken place in a female who never had had this discharge, or even when it was not of a healthy character, and with a greater or less degree of regularity." In these remarks we must understand Dr. Dewees as merely asserting his own experience, for the experience of numerous equally competent observers is in direct opposition. The regular and healthy performance of the menstrual function is certainly indicative of a natural condition of the female genital organs, and of the consequent aptitude of the individual for impregnation; yet it is not always so; every healthy menstruating female is not fruitful; and I have known many instances where women bore children regularly, although the menstrual office was neither regularly nor healthfully performed. Professor Dunglison well observes: "As a general rule, the appearance of the menses denotes the capability of being impregnated, and their cessation the loss of such capability. Yet, females have become mothers without ever having menstruated. Foderé attended a woman who had menstruated but once. in her seventeenth year, although thirty-five years of age, healthy, and the mother of five children. Morgagni instances a mother and daughter, both of whom were mothers before they menstruated. Sir E. Home mentions the case of a young woman, who was married before she was seventeen, and having never menstruated, became pregnant; four months after her delivery, she became pregnant again; and four months after the second delivery, she was a third time pregnant, but miscarried. After this she menstruated for the first time, and continued to do so for several periods, when she again became pregnant; and Mr. Harrison, at a meeting of the Westminster Medical Society, remarked, that he knew an instance in which the mother of a large family had never menstruated.1 Such instances prove that ova are maturated without the ordinary recurrence of a sanguineous exhalation from the lining membrane of the womb."

"The menstrual flow," remarks Dr. Dalton," "is, in fact, only the external sign and accompaniment of a more important process taking place within. It is habitually scanty in some individuals, and abundant in others. Such variations depend upon the condition of vascular activity of the system at large, or of the uterine organs in particular; and though the bloody discharge is usually an index of the general aptitude of these organs for successful impregnation, it is not an absolute or necessary requisite. Provided

a mature egg be discharged from the ovary at the appointed period, menstruation, properly speaking, exists, and pregnancy is possible."

The modern ovular doctrine of menstruation is unquestionably encompassed with some difficulties: these have caused it by a few to be considered rather as "a plausible and ingenious hypothesis, than as a well-established theory." Mr. Kester thinks that "the actual state of our knowledge of the nature of menstruation may be expressed in the following propositions:"1 Menstruation is a periodical function of the uterus.

"2. Ovulation is the constant function of the ovaries.

"3. Ova are matured in the ovaries at all ages, but more rapidly during menstrual life.

"4. Ova are discharged at all periods of female life, in the intervals of, as well as at the time of, menstruation.

5. Ovulation and menstruation being often concurrent, indicate that they

[Human Physiology, 4th edition, vol. ii. p. 357. 3 [London Medical Gazette, Nov. 1849.]

2 Human Physiology, p. 476.]

are both the result of the attainment of a certain point in the development of the female economy.

"6. The law of periodicity in the one not obtaining in the other, leaves still wanting the inseparable link in the chain of causation whereby menstruation can be shown to be the effect of ovulation.

"7. At the menstrual period, the ovaries experience an extension of the uterine congestion, and become, equally with the uterus, the seat of increased functional activity.

"8. The menstrual flow is a true hæmorrhage, as shown by chemical analysis, and by the phenomena of disease."]

M. Bischoff thus expresses himself: "At certain periods, known as those of 'heat' or 'the rut' in animals, and 'menstruation' in the human female, the ova which have become mature disengage themselves from the ovary, and are extruded. Sexual desire manifests itself in the human female with greater intensity at these periods, and in the females of mammiferous animals at no other time. If the union of the sexes takes place, the ovum is fecundated by the direct action of the semen upon it. If no union of the sexes occur, the ovum is nevertheless extruded from the ovary, and enters the fallopian tubes, but there perishes."

I may here remark, 1, That if this view be strictly correct, conception could scarcely occur previous to the appearance of the menses, or without their reappearance; and yet both cases do occur, and the latter not very rarely. 2, That the discharge of the ovum must necessarily be about the termination of menstruation, or it would escape with that excretion. 3, That conception must take place within a few days of that period, or the ovum would escape, and only during that short space, because afterwards there would be no vesicle to be fecundated. How long this period may be it is difficult to say; but it would be difficult to reconcile this view with the cases which occur, of impregnation taking place ten, twelve, or twenty days. after the cessation of the menstrual period,' which are not uncommon. Jewish females are required to abstain from intercourse for five days before and seven days after menstruation, and yet they are very fruitful; and Hirscher mentions a case of conception, where he ascertained that impregnation occurred twenty-two days after healthy menstruation. If we calculate the period of pregnancy according to Naegelè, or allow a few days more (reckoning from the mid-period, in the popular mode), my own experience, and that of others, would show that more women overrun than anticipate the nine months. I cannot think that the period for conception is so limited as these opinions, if correct, would require; neither am I sure that there is an increase of sexual desire at the menstrual period.

111. Dr. F. H. Ramsbotham has lately put forth his views of the final cause of menstruation, which I think it right to lay before the reader. He conceives that the function of menstrution is "identical with the nutrition of the young ovum, and that the menstrual discharge indeed is nothing less than the rudiments of the deciduous membrane itself; or rather that it would have become the deciduous membrane, provided conception had occurred :" and he explains the process more fully thus,-"An ovule ripe for impregnation parts from the nest in which it had been elaborated, being conveyed by the grasp of the fallopian fimbriæ. At the same time Nature establishes an action for the purpose of preserving it, provided an opportunity of becoming impregnated by contact with the male semen is afforded it. Should that contact take place, and conception follow, the fluid formed is retained within the uterus, and is gradually converted into the deciduous membrane, which becomes the first medium of communication between the newly animated

1 Oldham: Med. Gaz., July 13th, 1849.