The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

Pflüger’s teaching has been opposed by Sigismund, who, whilst admitting the periodicity of ovulation and menstruation, yet regards the two processes, in the uterus the formation of the menstrual decidua, in the ovary the rupture of the graafian follicle, as independent of one another, even though they occur simultaneously. Should fertilization occur, the ovum implants itself in the prepared soil; should fertilization fail to occur, the menstrual hæmorrhage ensues. Thus, the occurrence of menstruation indicates that fertilization of the ovum has failed to occur. On this theory, then, the ovum that is fertilized belongs to the first period missed, whereas Pflüger assumes that when pregnancy occurs, it is always the ovum belonging to the time of the previous menstruation—the last actual menstrual discharge—that is fertilized.

Löwenhardt, in his work on the Diagnosis and Duration of Pregnancy, advances the same views as Sigismund. The fertilized ovum, in his opinion also, is that of the first period missed; and since at the time at which he believes fertilization to occur the ovum is certainly still in the ovary, fertilization, on this theory, must always take place in the ovary itself, and the fertilized ovum cannot begin its intra-uterine life till a month has elapsed after fertilization. Reichert, Kundrat, Engelmann, and Williams, basing their views on anatomical data, are of opinion that ovulation recurs periodically, and that the extrusion of the ovum occurs not before but after the commencement of menstruation.

According to Hensen, the observed facts support the view that the follicles burst as a rule toward the end of menstruation; anticipation or postponement of the opening of the follicle (conception before or after menstruation) would, however, appear not to be impossible.

Leopold, who assumes that menstruation may occur without ovulation and ovulation without menstruation, maintains on anatomical grounds that the rupture of the graafian follicle occurs chiefly during menstruation, under the influence of the swelling due to menstrual congestion. Menstruation with ovulation he believes to be a common occurrence, menstruation without ovulation, an unusual occurrence. Further, it is certain that, at the time when the periodic bleeding is due, ovulation may occur, even though the menstrual discharge fails to make its appearance (ovulation without menstruation).

Chazan and Gläveke also adhere to the generally accepted view that ovulation is a periodic process, usually but not necessarily synchronous with menstruation.

Strassmann bases on clinical facts and on experiments the following view of the connection between ovulation and menstruation. The principal processes in the organism of the sexually mature woman run their course in a periodic rhythm resembling an undulatory movement, the acme of which occurs in the antemenstrual period with the aim of preparing for the development of an infantile organism. Whilst an ovum is maturing in the ovary, in the uterus, in dependence upon this maturation, the antemenstrual mucous membrane, fitted for the reception and nutrition of the fertilized ovum, is also undergoing development. At the acme of the undulatory movement, the graafian follicle ruptures and the ovum is liberated, to undergo fertilization in the infundibulum of the Fallopian tube. If fertilization fails to occur, or if for any reason the graafian follicle fails to rupture, then, in consequence of and at the time of the highest intra-ovarian tension, at the time, when the rupture of the follicle usually occurs, the extrusion of blood from the capillaries of the uterine mucous membrane begins. The intermediation between the ovary and the uterus is probably effected by means of the sympathetic ganglion in the ovary discovered by Elizabeth Winterhalter, and effected in this manner, that the stimulus proceeding from the ripening follicle passes along the nerve-fibrils surrounding the follicle to the processes of the nerve cells of this sympathetic ganglion, accumulating in these cells till a certain degree of intensity has been reached, and then, by means of other processes and of the vasomotor nerves, influencing the vessels of the uterus.

Gebhard likewise believes menstruation to be dependent on the ovarian function, and thinks that it is probably brought about in a reflex manner by the gradual growth of the ovarian follicles. It appears that most commonly at the time of menstruation a graafian follicle ripe to bursting is to be found in the ovary, but to this rule there are many exceptions. We cannot exclude the possibility, that the ovum from a follicle that burst after the commencement of the menstrual flow may be fertilized; but more commonly the ovum that is fertilized is that of the first period missed. The sudden decline in vital energy that occurs just before menstruation is explained by Gebhard as a kind of atavism, dependent on the fact that many of the lower animals, butterflies, for instance, succumb as soon as they have fulfilled their duty of reproducing the species.

A number of modern investigators, however, deny that any relation, temporal or causal, exists between ovulation and menstruation, and affirm that the latter process is quite independent of the former.

Thus, Christopher Martin maintains that a special menstrual centre exists in the lumbar portion of the spinal cord, the impulses from which proceed to the uterus by way of the splanchnic plexus, the ovarian plexus, or perhaps by both. Similar views are held by Lawson Tait, Collins, and Johnstone, who severally maintain that the ovaries are no more concerned in the production of menstruation than any other organ of the body—the liver, for instance. They direct attention to the periodicity that occurs in the functional activity of various other organs, in respiratory and cardiac activity, for instance, both of which undergo rhythmical changes as a result of nervous influences. The cessation of menstruation after oöphorectomy they attribute, not to the cessation of ovulation, but to the division of the nerves which run across the broad ligaments of the uterus and upon which menstruation depends. Heat and rut in animals have a different significance from menstruation. The latter process is induced by civilization and by the adoption of the upright posture.

But, taking all this into consideration, we must hold fast to the fundamental principles, that ovulation occurs at that period of life, and only at that period, during which menstruation proceeds regularly; that ovulation begins when externally and in the whole development of the girl the signs of sexual maturity manifest themselves; and that ovulation ceases at the climacteric, when menstruation also ceases. We must regard as rare exceptions to this rule cases in which ovulation begins before the menarche and persists after the menopause.