CHAPTER IX.

"In a portion of the cervix uteri, comprising only three rugæ and their interspaces, upwards of 500 mucous follicles were easily counted; so that it is within the limits of moderation to say that a well-developed virgin cervix uteri must contain at least 10,000 mucous follicles." DR. TYLER SMITH.

ON THE MUCOUS DISCHARGES OF MENSTRUATION.

I HAVE said that the critical discharge from the organs of generation is mucous as well as sanguine, that it generally constitutes the first and last part of each periodic crisis, and the first and last effort of the whole menstrual function; that it is often periodically repeated for years previous to the appearance of first menstruation, and is in some rare cases completely substituted for the sanguineous discharge. Thus, the first result of the ovarian uisus is to determine pain; the second is to increase the habitual mucous secretion; the third is to determine the flow of blood. Having considered the first and third results, the second now demands attention. The following statistics of leucorrhoea in relation to the menstrual function only deserve the limited credence which can be awarded to information founded on the assertions of patients. In some of the cases the discharge may have been caused by inflammatory affections of the womb or the vagina; but upon the whole, I think the statements represent the action of the ovarian nisus on the generative mucous surface. First menstruation was preceded by an increased amount of vaginal secretion in 85 cases out of 250. Similar results have been obtained by other observers. Thus,

Dr. Blatin found it in 15 women out of 139, or in 1-9th of cases. Marc Despine in 26

B. de Boismont in .

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This increased mucous discharge generally lasted from one

to six months, and often longer, in women with flaxen hair, blue eyes, pale skin, and other attributes of a lymphatic temperament. Thus, B. de Boismont found that in thirtyone lymphatic women, subject to leucorrhoea previous to menstruation, the mean average of first menstruation was nineteen years four months instead of fourteen years. These results are confirmed by my own statistics. This has been spoken of as arising from the influence of leucorrhoea in retarding menstruation by those who, taking a partial view of the phenomena, did not observe that it was of itself a critical discharge of an ovarian nisus, insufficient to cause a discharge of blood. The critical mucous discharge, however, is less effectual than the sanguineous, and only relieves, without entirely removing, the cerebral and spinal symptoms. Such was the case with eight women in whom a mucous discharge occurred regularly every month for many months before first menstruation, and in the case of F. D., who first menstruated at ten. From ten to seventeen years she had a copious mucous discharge from the vagina almost every month; at seventeen she became regular. Such cases have been described by old authors under the name of menstrua alba, or palida, or menorrhagia alba, vicarious or substitutive diarrhoea, and they may be considered as indicating not uterine disease, but a morbidly diminished ovarian nisus; for in such women the mucous discharge is often replaced by a sanguineous discharge when the powers of vegetative life have been increased by stimulating emotions and tonic medicines. I have already said that the lymphatic temperament, a delicate constitution, and inhabiting large towns, produces an increased amount of vaginal secretion; and the peculiar constitution most liable to this vicarious leucorrhoea, as well as the nature of the treatment required, will be shown by the following case:

CASE 29.-M. A. N. applied for relief at the Paddington Dispensary, Feb. 13, 1850. She was sixteen, tall, largeboned, with red hair, blue eyes, thick lips, puffy chin, and every appearance of a strongly-marked lymphatic temperament, an inference confirmed by the fact that when a child she was very subject to glandular swellings. She had lived almost always in London, and first menstruated at fifteen under peculiar circumstances. While nursing a boy for small

pox, she caught the disease, took to her bed, and before the eruption came out the menstrual flow made its appearance in very great abundance, lasting four days. The patient recovered well from the small-pox, and menstruation returned two months after its first appearance. Previous to the first menstrual flow there was no leucorrhoeal discharge, but it appeared after the second, and has lasted ever since, sometimes in a slight degree, at others being very abundant, but always painless and of an inoffensive quality. During the last year, in the place of the sanguineous flow a very abundant discharge came on regularly every month, lasting from three to eight days, and was accompanied by pains exactly similar to those felt during menstruation. About the time of the second appearance of menstruation-whether before or after she cannot remember-there appeared on the elbow a large patch of eczema, which disappeared to reappear abundantly on her legs and thighs, without ascending higher. This skin affection was in general indolent, except during the spring and summer, when it became endowed with great activity lately the scalp having become affected, she has had her head shaven to relieve the intense feelings of heat and itching. The digestive functions were in a state of perfectly good order. After purging the patient, I put her on a course of steel and tonics, ordering a tepid bath every week. When the next menstrual period came on, the discharge was sanguineous instead of mucous. It afterwards became regular, returning every three weeks with pain, and being always preceded for two or three days by a white discharge. On March 3rd, 1851, she consulted me for some large patches of eczema on the head, and I then learned that since the last application for relief, menstruation had continued regular, but that lately the leucorrhoea had been abundant, and was always more so when the secretion from the diseased portions of the skin was diminished. In such a case it would have been just as absurd to employ astringents or caustics to the vaginal surface, as to smear the mucous membranes of the nostrils with nitrate of silver to cure a constitutional tendency to cold in the head.

In another case, where there was no leucorrhoea at intermenstrual periods, but in which the menstrual pains had no

other relief than an abundant leucorrhoeal discharge, the patient, of her own accord, stopped this flow by injections of cold aluminous water. The attendant pains were more severe, particularly that habitually experienced at menstrual times in the left ovarian region.

Catamenial leucorrhea, or an increased amount of mucous discharge from the vagina, before and after each menstrual epoch is the rule:

For in 200 cases an increased amount of mucous secretion

160 cases.

2

4

preceded and followed it in. Catamenial leucorrhoea preceded only in Catamenial leucorrhoea followed only in Those women in whom a leucorrhoeal discharge precedes first menstruation are most liable to menstrual leucorrhoea. Leucorrhoea may appear between two menstrual epochs: this is a very frequent occurrence in women subject to the weakening influence of civilisation, for I find it occur in 20 out of 94 cases, and as it is attended by no pain, it is merely suggestive of greater cleanliness, and not of treatment. Some of the cases in which I have seen this persist with the greatest obstinacy through life, without in any way interfering with the patient's health, were in strong plethoric women -a remark coinciding with Friend's experience, although somewhat contrary to the dictum of theory or to received opinions. Leucorrhoea is frequent during pregnancy and in women who cannot suckle.

Of 260 women in whom the menstrual function had ceased, 143 had never been subject to leucorrhoea; of the remaining 117,

The vaginal secretion was increased at cessation in 77 cases. It was diminished in

It remained stationary in

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As previous to first menstruation, so after its cessation, the diminution of the ovarian nisus may be thus indicated by the substitution of a periodical mucous discharge for one of blood. In one case this occurred regularly every month for a year, for eighteen months in another, in a third for two years.

Thus the natural history of woman shows the frequency

of the increased mucous discharge from the generative intestine. Pouchet has proved that this discharge is an inseparable portion of the phenomena of menstruation; and the motto of this chapter indicates that the phenomena rest on an anatomical basis. It must be borne in mind that, under the term leucorrhoea is meant an increase of all the habitual secretions from the whole mucous surface. There is the alkaline, thick, transparent, glutinous fluid from the cervix, the chronic catarrh of the oviducts, according to Rokitanski, and the acid creamy secretion from the vagina, so well studied by Mr. Whitehead. In his work on Abortion and Sterility, he observes that the mucus of the vagina always possesses acid qualities, and that the discharges from the interior of the uterus are as constantly alkaline. "This point I have verified," says he, "by numerous trials. In the ordinary state I find, moreover, that the secretion not only of the vagina but of the os and external surface of the cervix is acid, while it becomes alkaline within the labia uteri. If a piece of litmus paper be applied to the surface of the os uteri, it is instantly reddened, but the blue colour is restored by passing it within the cervix. The margin of the cervical canal, and the limits of the villi covered by squamous epithelium, and the commencement of the villi covered by dentated epithelium, seem to mark the division between the acid and alkaline secretion. It is to the alkali that the secretion within the cervix owes its viscidity and transparency, while the curdled appearance of the vaginal mucus is owing to the presence of the vaginal acid. The acid of the vagina is quite sufficient to more than neutralize a moderate quantity of the alkaline secretion of the cervix, and when any secretion from the cervical canal enters the vagina, it becomes curdled from the coagulation of its albumen. The same thing may be imitated out of the body. On the addition of a little weak acetic acid, the thick viscid mucus of the cervix becomes after a time changed into the curdy mucus of the vagina." This fact is important; for, in common with many other writers, Mr. Whitehead thinks a profuse secretion of the uterine mucus "extremely rare," whereas it is remarkably common in leucorrhoea; but the fact has been masked by the circumstance of its becoming altered when it descends into the vagina, so