MENSTRUATION ANDT LAW OF MONTHLY PERIODICA. From December No. Richmond and Louisville Medical Journal, 1875. The occurrence of a sanguineous flow from the gen- ital organs of women at the period of puberty, and its recurrence there after at intervals of a lunar month for thirty years, unless interrupted by pregnancy, lactation or disease constitutes a phenomenon sufficiently strange to excite wonder and to stimulate inquiring minds to its investigation. Accordingly, from the days of Hip- pocrates to the present time, attempt after attempt has been made to solve the problems of its causation and periodicity. To the modern physician such questions are not simply matters of laudable scientific curiosity, but have a direct bearing upon the pathology, diag- nosis, and treatment of female diseases. Thus far, physiologists have not been able to answer them in a definite manner, and, baffled in their search for facts, have contented themselves with the fabrication of- theories. These have varied in character from the grossest superstitions to the most subtile refinements of scientific ingenuity; but in this connection it is un- necessary to enumerate even the most plausible, for 14 Menstruation. there is only one that is now regarded with any thing like general favor. This is the ovular theory, which assumes that menstruation is due to the periodic dis- charge of ovules from the Graafian follicles. Inti- mately associated in its origin with the discovery of an important physiological law,* and ably advocated by high authorities, it has come to be received by the Profession at large as demonstrated and established; and for the last twenty years has exercised a decided influence in modifying our views on practice. But to my mind it is unsatisfactory, and I will proceed in as brief a manner as possible to assign the reasons. It is necessary, however, in the outset, to obtain a distinct enunciation of the theory in question, that we may understand the extent and nature of its claims; and instead of expressing this in my own words, it is certainly fairer to accept it as set forth by some of its most intelligent advocates. In looking over the vari- ous authorities for explicit statements of this kind, I find the language of many so ambiguous that it is im- possible to determine exactly what opinions they hold. But there are some who entertain definite ideas and are capable of expressing them accurately. By these, the ovular theory is presented to us under two phases, the one simply maintains that the regularity of men- struation is dependent on the regularity of ovulation; the other goes a step further, and prescribes a cause for the periodicity of ovulation. The first is the form in which it is adopted by Cazeaux, as these extracts from his "Treatise on Midwifery" will serve to show. "After having read all that has been written on the subject, the mind rests entirely satisfied in its ability to refer this singular phenomenon to one unchangeable and easily verified fact; namely, the successive evolu tion of Graafian vesicles." (Second Am. edition, p. 91) "Menstruation is, therefore, intimately connected with the evolution * The law of spontaneous ovulation. Menstruation. 15 of the ovarian vesicles, and can not occur without it; and every time that it appears, we may feel satisfied as to the existence of a vesicular development." (Page 92.) "Why is it that ovulation in the human species recurs about every month? To this question science is unable to reply, for it is probably one of the impenetrable mysteries of nature." (Page 93.) Of the second phase, our own countryman, Dr. Meigs, is probably the most lucid expounder. His views are fully elaborated in his System of Midwife- ry; but the following passages, the one from his work entitled Woman and Her Diseases, and the other from a note to his translation of Columbat on Diseases of Females, are more concise. "A healthy woman matures and deposits an ovum every twenty-eight days from the age of fifteen to that of forty-five years, failing only in pregnancy and lactation, and sometimes not even then. She sometimes suffers an arrest of the force during lactation, yet in the majority even that arrest is of short duration; and in many it does not take place at all. The closing stage of maturing and depositing or discharging the ovum is attended with a discharge of bloody fluid from the genitalia, which is called menstruation, because it takes place once a month. That bloody fluid exudes from vessels on the inner aspect of the womb, which has become engorged in common and along with the ovary, and which, by this discharge, is relieved of its hyperaemia." "The question as to why it (ovulation) should have so exact a peri- odical character, is no more difficult of solution than that of the stated periods of eruption of the first and second dentition, the growth or fall of the hair on the head," ect. All this seems very plain and easy to be understood, and I admit would be so if there was only one ovary. There are two of these bodies, however, equally con- cerned in the elaboration of ovules; but numerous ob- servations have shown that, as a rule, only one Graafian vesicle it ruptured at a menstrual period. The ques- tion then very naturally arises, How do the ovaries di- vide the work between them? What is their rhythm of action? One of the two things must be the case, they must alternate month by month, first one and 16 Menstruation. then the other maturing an ovule, or each must remain in functional activity for two or more consecutive months while the energies of the other are in abeyance. Mr. Girdwood seems to have entertained the former idea, as he claimed to have met with cases in which women have menstruated a certain number of times, and after death a corresponding number of cicatrices were found upon the ovaries, equally distributed between the two. In either event the removal of one ovary should affect the periodicity of menstruation. If the first supposi- tion were correct, it would take place thereafter bi- monthly; if the second, it would be rendered irregu- lar. But nothing of this kind ever happens. Innum- erable instances are on record, in which, after the ex- tirpation of one ovary, menstruation has continued in the ordinary manner. Here, then, we encounter a serious obstacle to our acceptance of this theory at the very first step. I am fully aware that its friends might attempt to bridge over the difficulty by a simple and ingenious hypothe- sis. They might say that when one ovary is removed the other takes on compensatory action and does double duty, just as when one kidney is removed the other assumes its functions and excretes as much urine as was previously excreted by both. To the disciples of Dr. Meigs, I would reply that this is an impossibility, for the time of ripening and rupture of each Graafian vesicle is preordained from the birth of the individual, as much so as the "periods of eruption of the first and second dentition," ect. To the other faction I would answer somewhat more at length. In the first place I would deny the just- ness of the analogy, for the ovary is not a gland in the ordinary acceptation of the term* it neither secretes nor excretes, v The rudimentary ovules exist in the embryo, and the ovaries merely afford a favorable Menstriiation. 17 nidus within which they are matured. Suppose the analogy were insisted upon, is it not reasonable to believe that some degree of additional development would be necessary in the remaining ovary to enable it to accomplish its task. This development would require time for its completion, and in the meanwhile we would expect menstruation to be somewhat irreg- ular, whereas experience tells us that single ovari- otomy does not interfere with the menstrual function any more than other grave surgical operations. In many cases there is not a single interruption. It has been justly urged against this theory, that it is not fully sustained by the results of post-mortem examinations. If menstruation is secondary to and de- pendent upon ovulation, then in every instance in which a woman dies during or soon after a menstrual period, we should be able to find evidences of the recent rupture of a Graafian follicle. But several observers* have encountered cases in which no such evidences could be detected. In evasion of this objection, it is claimed that the vesicle may proceed in its develop- ment up to the final stage, when without rupturing, it excites the menstrual congestion, and then aborts or undergoes a process of atrophy.f As Tilt has said, this is a virtual abandonment of the whole theory. At best it is a mere assumption, for what other proof could we possibly have of the maturation of a vesicle except its rupture? On the other hand, ovulation may be accomplished without causing menstruation, as it is shown by the frequency of conception in nursing women, when men- struation is suspended, and in youug women who have never menstruated. Furthermore, it is quite certain * Coste, Ritchie, Ashwell, Paget, Bischoff, Williams and others, f Caseaux, p. 91. 18 Menstruation that ovulation takes place in some persons more frequently then menstruation; that is, it happens not only at menstrual periods, but during the interregnum. This would be inferred from the possibility of impreg- nation at this time, and has been ascertained to be a fact by actual observation.* The most conclusive of all testimony against the ovular theory of menstruation has been furnished by the results of recent operations of double ovarioto- my. We now know that a woman, after this oper- ation, may menstruate for years; in fact up to the or- dinary climacteric age in a perfectly natural manner, "as to time, quality and quantity." In order to determine as accurately as possible the effects of the removal of both ovaries upon the men- strual function, I have carefully examined and arrang- ed in the accompaning table all the cases of which I could obtain reports. In every instance in which no mention is made of subsequent menstruation, I have taken it for granted that it did not occur, and irregu- lar sanguineous discharges I have, of course, not count- ed as menstrual. Of the twenty seven cases here recorded, it will be observed that in nearly half, menstruation was not af- fected by the removal of the ovaries; in one the haem- orrhagic discharge was increased (3); in one it was di- minished (7); and in several sanguineous flows occur- ed at irregular intervals (24 and 27). [Since the original publication of this article, I have obtained reports of nine additional cases; three by Thomas, three by Batty, one by Trenholme, one by Kimball and one by Bryant. In three of them the subsequent history was not given, the reports having been made im- mediately after the operation; in two menstruation was arrested; in one it recurred three times at the usual intervals and then ceased, and in three, among which was a case of vicarious menstruation, it was not affected.] ♦Ritchie, Lon. Med.Gaz., 1844. p. 138 'case 4. Menstruation 19 Table of Cases in which both Ovaries have been Successfully Removed from Women under Forty-five years of age. No. Operator. Quoted from D'te Age 1 Pott 178- 23 2 J. L. Atlee A. J. Med. Sci., 1844 1843 29 3 Bird 1848 1847 32 Menstruation uninterrupted; tendency to mennorrhagia. 4 Peaslee "Lyman's Table 1850 24 5 Burnham Lyman's Table 1853 42 6 W. L. Atlee Atlee on Ov. Tumors 1854 35 Menstruation regular. Ceased in 1864, 45th year. Regular molimen with white discharge. Menstruation regular to 1863, when last reported. 7 W. L. Atlee □AtJee nn Ov Tumors 1855 19 8 AV. Tj Atlee 1861 40 9 Peaslee A J Mpfl Sci 1863 1862 35 10 Peaslec A J Med Sci., 1864 1863 39 11 W. L. Atlee 1864 34 Last report 1870. Menstruation regular to that time. 12 Beattey Wells, Dis. of Ovaries... 1865 37 13 Storer A. J. Med. Sci., 1868 Peaslee on Ov. Tumors.. Wells, Dis. of Ovaries... Wells, Dis. of Ovaries... 1866 Menstruating regularly a year after operation. 14 Storer 1867 43 15 Wells 1868 39 16 Wells 1869 22 17 Hicks Wells, Dis, of Ovaries... 1869 39 18 Munro Wells, Dis. of Ovaries... Wells, Dis. of Ovaries... 1870 34 19 Mayer 1871 29 Last report one year after oper ation. Menstruation regular. Last report six months after op- eration. Menstruation regular. 20 Meadows 1871 21 Priestly Wells, Dis. of Ovaries... 1872 22 22 23 R. A. Jackson Le Fort Peaslee, Ov. Tumors 1865 44 ♦Continued to menstruate to the 47th year of her age. Menstruation regular. Menstruates, but not regularly. fMenstruates regularly from cica- trix and vagina. Menstruation regular. Irregular sanguineous discharges sometimes prufuse. 24 Baker Brown Peaslee, Ov. Tumors 25 26 Baker Brown Koeberle Peaslee, Ov. Tumors.... Peaslee, Ov. Tumors.. 27 Battey Personal Information 1872 23 Clay, of Manchester, had four cases in which there was subsequent sanguineous discharge.- (Peaslee.) * "Her regular monthly period had ceased the day before the operation. A flow per va ginam recurred thirty days afterward, and continued four days, with the usual symptoms of • lassitude, nervousness, and backache. It again appeared after an interval of eighty-three days; and after this time it recurred with perfect regularity every twenty-eight or twenty-nine days for twenty-two months accompanied by all the ordinary symptoms of menstruation, and lasting each time from three to five days; it then ceased for four months to reappear for the last time; the patient being now forty-seven years of age. During all the time, the patient's health was excellent, and Dr- Jackson satisfied himself that there was no disease ol the uterus or vagina. f The whole uterus, except cervix, removed with ovaries. 20 Menstruation The only explanation that can be offered by those who still adhere to the ovular theory of this persist- ence of menstruation, is that it is due to the force of habit. Yet in case No. 22 the function was suspended for three months at one time, which we would suppose should have been sufficient to have broken up the habit. But such an explanation is unscientific, as well as unsatisfactory; in fact it is no explanation at all. Habit may be defined to be a faculty or a proneness for the performance of any act in consequence of its frequent repetition, and may for our present purpose be divided into two classes, entitled respectively habits of aptitude and habits of recurrence. A habit of apt- itude is simply a faculty acquired by practice, as when we say, "this man sleeps soundly in spite of the noise, because he has acquired the habit of doing so." Our so called habit of menstruation belongs to the second class. The most familiar example of this is the habit of "regularity of the bowels." It is well known that if a person will persistingly solicit a movement of the bowels daily at a fixed hour, in the course of time he will experience an inclination to go to stool regularly at that hour. This is said to be the result of force of habit. Let us investigate the subject, and see if we can not arrive at a more accurate understanding of it. The enforced regularity engenders a healthy state of the bowels, promotes its secretions and peristaltic action, and restores its nervous sensibilities to a normal con- dition; the rectum being each day subjected to about the same distension before it is evacuated, acquires a tolerance for the presence of a certain amount of fecal matter, and after awhile whenever this quantity has accumulated, an impression is made upon the nerves of the part and transmitted to the sensorium. It might still be said that it is the nerves which have Menstruation 21 acquired a habit of responding to a given degree of irritation. True, but this is a habit ol aptitude, not a habit of recurrence; no one would pretend to say that a sensation would be experienced if there were no faecal matter in the rectum. Here then, is a habit analyzed and rationally explained; and all habits of recurrence may be treated in a similar way and attributed to some antecedent cause or causes. This fact has long been recognized in mental philosophy, some writers consid- ering all habits in which a mental process is concern- ed as the result of an association of ideas.* Thus, we perceive, the word habit is used either as a short way of expressing a complex series of acts, or as a cloak to cover our ignorance in obscure cases. There must be a cause for menstruation after the removal of the ovaries. Is it not probable (yes, I may say certain,) that it is the same cause which existed previously? The ovaries being wanting, there are no vesicles to rup- ture. The logical conclusion is, that the periodicity of menstruation never did depend upon the discharge of ovules. This conclusion can not be disputed if our premises are admitted. We have proceeded upon the hypoth- esis that the Graafian vesicles exist only in the struc- ure of the ovaries, and that the ablation of the latter would necessarily involve their removal from the econo- my but this point deserves some consideration. Spencer Wells "The ovaries are usually two in num- ber; not necessarily so, for their essential elements may be dispersed between the layers of the peritoneum, as in the lower animals. Ovisacs or Graafian vesicles have been seen developing in some of the mammalia at a distance from the entire ovary." In another place he speaks of the development of vesicles thus situated * Dugald Stewart. t Diseases of the Ovaries, p. 11. 22 Menstruation. into unilocular tumors. Savage says nothing on the subject himself, but gives the following obscure quota- tion from Sappey;* "It is not a rare circumstance to find on the alar mesentery, especially 'round about the ovary, ten, fifteen, twenty, or more even, cystic ovules, some of them the size of a pea. Such ovules having failed to reach their destination, owing to some abnor- mal relations on the part of the Fallopian tube. I have looked through all the writings at my dispos- al, and conferred with several anatomists and physiol- ogists, to obtain definite information on this subject, but without success; and my own limited investigations on the cadaver have resulted negatively. No obser- vations would be of value unless acompanied by a mi- croscopic examination, in order to determine by the detection of the ovules whether small cysts found in this locality were truly Graafian follicles. In the or- dinary operation of ovariotomy, a considerable portion of the broad ligament contiguous to the ovary consti- tuting the pedicle, is excised. In Baker Brown's case (No. 25), the whole uterus, except the cervix, was re- moved with the ovaries. Storer reported a case in the "American Journal of the Medical Sciences," 1868, in a woman forty-seven years of age (consequently not included in the table), from whom he removed the uterus and both ovaries. Yet on the eighteenth day after the operation and the twenty-sixth day after the last appearance of the catamenia, "there occurred a sanguineous effusion, attended by feelings of backache lassitude, ect., lasting thirty hours, and being an evi- dent attempt at the reestablishment of menstruation". I think it a very fair conclusion, that if such vesicles really existed, they were totally extirpated in some, if not in the greater part, of the thirteen cases in which * Savage on the. Female Pelvic Organs. Menstruation. 23 menstruation continued after the removal of both ova- ries. Even if some of them remained, it is clearly impossible that they could have been sufficiently nu- merous to have afforded a ripened vesicle every month for ten or more years. Their only effect would have been to stimulate the nervous system and maintain in a more perfect degree of its ovarian development. The foregoing objections are only a tythe of those that may be offered to the ovular theory of menstru- ation, but they are enough to compel me to reject it. It must not be inferred, however, that I deny all influ- ence to the ovaries in determining the menstrual func- tion. Observation has conclusively demonstrated that the presence of mature Graafian follicles within the organism of the individual is absolutly necessary for its primary establishment; for, in every instance in which the ovaries have been congenitally absent, or ar- tificially removed before the period of puberty, men- struation has failed to take place. The ripening of the germ cells exerts an influence upon the female econo- my generically similar to but specifically different from that which the ripening of the sperm cells has upon the economy of the male. The evolution of sperma- tozoa by the testes reacts in some mysterious manner upon the nervous system and determines characteris- tic changes in distant portions of the body, especially the development of the larynx and the growth of hair upon the face. So in the female the maturation of ova creates an erethism of the nervous system that results in structural changes throughout the entire organism, the minute ramifications of which we can not trace, but its grosser manifestations are seen in the expansion of the pelvis, the enlargement of the breasts, and the increase of the adipose tissue. The power to develop hair upon the face may be considered an inherent Menstruation. 24 power of the economy, since rudimentary hair bulbs preexist in that locality; and the same may be said with reference to the power to develop the larynx, the pelvis, the breasts, and the adipose tissue; the state of the generative centres simply calling these powers into play. Sometimes in consequence of disordered states of the generative organs, this synergy of the nervous system is perverted from its usual channels, and other in- nate powers are aroused. A marked case of this kind is reported in the "London Medical Gazette" for 1843-4, in which suppression of menstruation, due to an acute affection of the ovaries arising from exposure to cold, was followed by a growth of hair over the whole sur- face of the body. Is it not a legitimate inference that the Lazu of Monthly Periodicity which dominates the menstrual function is also inherent in the animal econo- my, and is simply stimulated into activity by the ovular erethism? When once the physical modifications referred to have been induced at the period of puberty, the sub- sequent removal of the testes or ovaria does not nec- essarily cause them to recede. Sometimes there is a tendency to a return to a neutral type, as was evinced in Pott's celebrated case, where after the removal of both ovaries, the voice became coarser, the form more angular, ect. On the other hand, after many of the operations of double ovariotomy, no loss of woman- ly attributes has been noticed; and almost every sur- geon is familiar with cases of castration of men where the voice and personal appearance have remained un- changed. If, then, the manifestation of the Law of Periodicity has an origin in common with the physical alterations-that is, depends on the same condition or development of the nervous system-we would expect Menstruation 25 that it would exhibit an equal tendency to permanency after the withdrawal of the primary exciting cause. In this way alone can we account for the persistance of menstruation after the removal of the ovaries. To what extent does this law prevail? Is it an essen- tial, all pervading principal of life, under ordinary cir- cumstances accomplishing its work without external signs? Or is it a dormant energy of the system, which is only exerted in order to accomplish a specific purpose? If it were the first, we would expect to see it occasionally displayed in the male subject. It is true, instances of this kind have been reported, but all of them will be found, upon investigation, to be open to charges of error. In the "American Journal of the Medical Sciences" for 1853, there is an account of a being who, in all external appearances, seemed to be a man, in whom menstruation occurred regularly from the urethra. After death, an examination revealed the fact that the creature was an hermaphrodite. In the same journal for 1867, there- is another case, in which a young man is said to have experienced a monthly sanguineous flow from the glans penis. Such cases, even admitting their authenticity, are incomplete without a post-mortem examination to demonstrate the absence of the ovaries. There is still another class of cases in which the symptoms are too vague and shadowy to deserve notice. In short, there is a total absence of positive proof that periodic phenomena of a monthly type are ever present in the human male. The statement of naturalists with reference to perio- dicity among the lower animals is very unsatisfactory. This is due, in part, to the fact that most of them being converts to the ovular theory, have regarded menstru- ation and oestruation as analogous. 26 Menstruation According to Saint-Hilaire, menstruation occurs in several species of monkey every month and is exactly similar to the process in the human female. Dr. John Percy, of Birmingham (quoted by Girwood), says he has had constant opportunities of observing the female mandrill and drill during four years. "At intervals of abcntt six or eight weeks, the labia become uncommonly distended, red, and shining. The swelling proceeds gradually and attains its maximum in about five days or a week. It then gradually declines and a quantity of sanguineous discharge makes its appearance, gen- erally, though, so far as I have observed, not uniform- ly." Dr. Girwood maintained that each genus of the mammalia has its own catamenial cycle, and endeavor- ed to determine them chiefly by a microscopic examin- ation of the vaginal discharges. To a rabbit, he as- signed ten days; to the mare, a fortnight; to the cow, three weeks; to the dog,- twelve to sixteen days, and so on. All that can be deduced from such testimony is, that if there are periodic phenomena among the lower animals, they are confined to the female sex, and are, as a general rule, o? a different type from those observed in the human species. I would, there- fore, conclude that the Law of Monthly Periodicity is not an essential element of organic life, and is inoper- ative, except in the human female, and possibly in the females of some of the higher mammalia, where it subserves a special purpose in connection with the process of reproduction. Let us next inquire somewhat more closely into the nature of this law. "Laws of animal nature," says Webster, are "the inherent principles by which the functions of animal bodies are performed." These principles are not always primary in their character, Menstruation. 27 but are, as a rule, resultants of antecedent acts which take place with sufficient precision to establish the principle or law for the goverment of the consequent function. The Law of Monthly Periodicity is that which governs and determines the periodic return of menstruation and its attendant phenomena, and must necessarily be the result and exponent of certain changes or series of changes that transpire within the organism in recurring cycles; these cycles being uniform in their duration, definite in their manifesta- tions, and common to woman-kind. The essence or factor of the Law, then, is a dynamic cycle of physio- logical acts. But in what part of the system does this cycle revolve? Where is the seat of these changes? Not in the ovaries, as Tilt supposed, for'their anni- hilation does not always arrest the action of the law. Nor in the uterus, for women in whom this organ has been congenitally absent, have experienced unmis- takable signs of monthly periodicity. Paracelsus, DeGraff and others located the process in the blood, Nature has negatived this class of theories by presenting us with the Hungarian Sisters, in whom the bloodvessels were united at the loins, thus giving them a common circulation, but their men- strual periods were different. Tyler Smith has advanced an ingenious hypothesis according to which the monthly cycle is attributed to reciprocal action between the uterus, ovaries, and mammae. But, as we have seen, two of these supposed agents may be withdrawn with impunity. An affirmative answer to this question is just as easy and may be just as absolute as those in the negative. There is not the slightest doubt that the functional process by which the monthly cycle is accomplished 28 Menstruation. is seated in the ganglionic nervous system. The ex- pansion of the pelvis, the growth of the breasts, and the increase of adipose tissue which take place when the young girl arrives at the age of puberty, depend upon a modification in the nutrition of the parts, and that nutrition throughout the body, is presided over by the ganglionic nerves, no one of the present day will deny. In order to achieve such important varia- tions from the previous course of nutrition, the nervous tissue itself must undergo structural development, which, as we have already said, like all other struct- ural alterations, has a tendency to be permanent. In the course of this development, the elements of the Law of Periodicity are elaborated and the series of changes constituting the monthly cycle are instituted. The operation of the Law, being usually declared through the circulation (by means of haemorrhages) which, like nutrition, is controlled by the ganglionic system. [While this reprint has been going to press T have met with the re- port of a case of double ovariotomy by Verneuil and Terrier, in the American Medical BiWeekly for Jan. 19, 1878, which is of interest in connection with the attempt to explain the continuence of menstru- ation after the removal of both ovaries, by force of habit. The follow- ing is an extract therefrom. "The operation took place on July 6, 1875. No uterine haemor- rhage took place till the following December. On December 25th menstruation appeared, was very profuse for four days, and lasted in all six days. Menses did not recur till February 20, but were then so abundant as to compel the patient to keep in bed, lasting for ten days- * * * Until the summer of 1876, menstruation only occurred each alternate month; from that time it became regular with an inter- val of from four to five days over a month, lasting regularly from six to eight days, and accompanied by neuralgic pain in the left breast and arm." annales de gynaecology.]