{/ THE 
OVULATION THEORY OF MENSTRUATION: 
WILL IT STAND? 
BY 
A. REEVES JACKSOil, AM., MI), 
Surgeon-in-Chief of the Woman's Hospital of the State of Illinois; Lecturer on the Diseases of 
Women in Hash Medical College; Corresponding if ember of the Gynecological 
Society of Boston, etc., etc. 
Reprinted from the American tlournM of Obstetrics and Diseases of 
Women and Children, Vol. IX., Xo. IV., October, I87 (i. 
NEW YORK: 
WILLIAM WOOD & CO.. 27 GREAT JONES STREET. 
187G. THE 
OVULATION THEORY OF MENSTRUATION: 
WILL IT STAND? 
\J by 
A. REEVES JACKSON, A.M., M.D., 
Surgeon-in-Chief of the Woman's Hospital of the State of Illinois; Lecturer on the Diseases of 
Women in Hush Medical College; Corresponding Member of the Gynecological 
Society of Boston, etc., etc. 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. IX., No. IV., October, 1876. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1876. THE 
OVULATION THEORY OF MENSTRUATION. 
WILL IT STANDS 
BT 
A. REEVES JACKSON, A.M., M.D., 
Surgeon-in-Chief of the Woman’s Hospital of the State of Illinois; Lecturer on the Diseases of 
Women in Rush Medical College; Corresponding Member of the Gynecological 
Society of Boston, etc., etc. 
[Read, by abstract, before tbe Illinois State Medical Society, at its nnnnql 
meeting, May 17, 1876.] 
It is my purpose, in this paper, to examine the evidence 
upon which is based the ovular or ovulation theory of men- 
struation. 
This subject has received a large share of attention during 
the past few years, and great discrepancy of opinion exists in 
regard to many points connected with it. I do not expect to 
reconcile these discordant views ; indeed, in the present state 
of our knowledge, it would perhaps be impossible to do so. 
Our great need in this, as in many other problems of a physio- 
logical character, is an increased number of well-observed 
facts; those which we have thus far are too few in number, 4 
Jackson : The Ovulation Theory 
and, apparently, too contradictory to warrant a definite and 
entirely satisfactory conclusion. 
The progress of scientific knowledge is greatly retarded by 
the admission of what may be termed, paradoxically, false 
facts; that is to say, facts which by representing only partially 
the truth, lead to false results. Conclusions founded upon 
such premises must almost necessarily be erroneous. Truth 
in science is rarely found wholly unmixed with error, and, in 
order that we may rightly appreciate the former, we must 
properly estimate the latter also. Like the diamond, whose 
facets reflect a differently colored ray according to the angle 
from which they are seen, so may a scientific truth present a 
different aspect to those who behold it from different points of 
observation. While to one person the gem appears green, to 
another it is red, and to a third, yellow. He only who sees it 
from all directions can know the whole truth. Thus it is that 
imperfectly-observed, partial, or perverted facts result in the 
formation of a false theory; and a false theory, once adopted, 
has a most injurious influence. He who is governed by it sees 
everything through a false medium. As observed by Paris, “ He 
who is guided by preconceived opinions, may be compared to a 
spectator who views the surrounding objects through colored 
glasses, each assuming a tinge similar to that of the glass em- 
ployed.” The advocates of the ovulation theory are, it seems to 
me, somewhat in this position. Many facts have been observed 
which give apparent support to their opinions, and on these they 
have been content to rest, overlooking, or, at least under-esti- 
mating other facts, equally well known, which strongly militate 
against those opinions. 
The ovulation theory of menstruation implies the following 
essential propositions: 
1. At regular periods, of about twenty-eight days, in the 
human female, a matured ovule is discharged from the ovary, 
passes into the Fallopian tube, and is transmitted to the 
uterus. 
2. Coincident with, and dependent upon the maturing and 
bursting of the Graafian vesicle and the extrusion of the ovule, 
certain changes occur in the mucous membrane of the body of 
the uterus, which result in a sanguineous discharge from that 
organ. of Menstruation. 
5 
In support of these propositions, evidence consisting of cer- 
tain facts and analogies has been adduced, as follows: (a) 
Observations made on the bodies of women who have died dur- 
ing, or soon after the menstrual period, have revealed the 
presence in one or other ovary of a ruptured Graafian vesicle, 
and its cavity filled with a blood-coagulum, or, its remains, a 
corpus luteum, in various stages of development or decadence; 
(b) Physiologically, the period of menstruation in woman cor- 
responds with the rut or oestrus of other mammalia, when, it is 
well known, ova are discharged from the ovaria ; (c) The ar- 
tificial removal of the ovaries causes an immediate cessation of 
the menstrual function. I purpose considering, seriatim, these 
propositions, together with the facts which have been advanced 
for their support. 
1. At regular monthly periods, in the human female, and 
coincident with the monthly flow, an ovule is discharged from 
the ovary, is received into the Fallopian tube, and by it trans- 
mitted to the uterus. 
The minor proposition, namely, that the matured ovule 
passes from the ovary to the uterus through the Fallopian 
tube is admitted on all hands, and, not being in dispute, need 
not detain us. The essence of the controversy centres in the 
alleged periodicity of this process, and of its time relations 
with the menstrual discharge. 
The Graafian vesicles, from the time of their description in 
1673, by De Graaf, down to the year 1827, were thought to be 
the actual ova of mammalia. It was not until the last named 
period that Baer discovered the true ovule and the relations it 
bore to its containing vesicle. However, as early as 1672, 
Kerkringius1 advanced the idea that ova were discharged at 
the time of menstruation, but it does not seem to have been 
founded upon any observations. The first writer who gives 
positive evidence upon the subject is Sir Everard Home, who 
noticed the ruptured follicle during menstruation, although its 
import was not then understood. In 1821, Dr. Power clearly 
enunciated the doctrine of the periodical ripening of the folli- 
cle at the menstrual period ; and the discovery six years later 
1 Tyler Smith, Lectures on Obstetrics, third edition, p. 80, 6 
Jackson: The Ovulation Theory 
by Baer, already alluded to, that this was only the enveloping 
structure of the ovule and not the ovule itself, made the rup- 
ture an intelligible fact; and so we may regard this as the real 
birth of the ovulation theory. In 1831, Negrier,1 working in- 
dependently, showed by anatomical preparations that the peri- 
odical discharge of menstruation was the consequence of an 
internal hidden function—ovulation. Fresh proofs were 
brought forward by Gendrin, Paterson, Barry, Itaciborski, 
Bischoff, Pouchet, and others, all tending to show that ovula- 
tion and menstruation are simultaneous and necessarily con- 
nected one with the other; and the doctrine was so beautiful 
and reasonable, and seemed so well sustained by the evidence 
adduced, that we cannot wonder at the fact that it was gener- 
ally received and adopted by physiologists. Still, there have 
always been some who were not convinced of its correctness, 
and who regarded the proofs alluded to as insufficient and in- 
conclusive ; who, in the language of Mr. Kesteven,3 looked 
upon the doctrine “ as a plausible and ingenious theory, want- 
ing, however, in the true elements of an inductive theory; in 
short, an example of the post ergo propter line of argument.” 
In examining the cases which have been cited in support of 
the ovulation theory, one cannot fail to be struck with the com- 
placency with which conclusions are frequently drawn from 
irrelevant, or, in some instances, even adverse facts. 
An example of this is to be found in a review of BischoflPs 
work on Human Ovulation, in the American Journal of the 
Medical Sciences, vol. 28, p. 137. 
These cases of Bischoff have always been regarded with 
especial favor and as of great value by the advocates of the 
ovular theory ; and, as they are frequently alluded to, I feel 
constrained to present a very brief synopsis of them. 
The observations3 were thirteen in number. Of these, the 
time of the menstrual period was known in only ten ; the re- 
maining three have therefore no value so far as this inquiry is 
concerned. Of the ten, three died during menstruation, and in 
each of these there was found a ruptured follicle. A fourth 
died two days after menstruation; the right ovary contained a 
1 Recueil de Faits pour servir a I’Histoire des Ovaires. Angers, 1858. 
s Lond. Med. Gazette, 1849. 
3 Beitrage zur Lelire von der Menstruation und Befruchtung, 1853. of Menstruation. 
7 
pretty large projecting follicle, which was still dosed. Both 
ovaries contained small corpora lutea. In a fifth case, the 
menstrual period had just passed; the left ovary contained a 
very distinct corpus luteum, and the right ovary a ruptured 
Graafian follicle filled with fresh blood. Number six died 
seven days after menstruation ; in the right ovary was a recent 
corpus luteum. In the seventh, death occurred ten days after 
menstruation; the right ovary contained a very large Graafian 
follicle unopened. Number eight died ten days after men- 
struation ; the right ovary contained a recently ruptured Graa- 
dan follicle and a fresh corpus luteum. In number nine, 
menstruation had occurred eighteen days before death; the 
right ovary contained a very large corpus luteum. Lastly, 
number ten died four weeks after menstruation; the right ovary 
contained a ruptured Graafian follicle. 
After detailing these cases, the reviewer says: “ The results 
here obtained show that in the human female, at each men- 
strual period, a Graafian follicle is ripened, swells, and usually 
bursts, discharging an egg,1 and forming a corpus luteum.” 
Now, I submit to any candid inquirer that the cases cited do 
not show these things. Indeed, so far as they prove anything, 
it is that there is not even an approximate correspondence be- 
tween the rupture of the follicle and the menstrual period. In 
two of the cases menstruation had occurred without any such 
rupture at all. In Cases 5 and 8 the ovaries are described as 
containing a fresh corpus luteum and a recently ruptured fol 
licle; yet, in the one case, menstruation had “just passed,” and 
in the other, had ceased ten days before death. Inasmuch as 
a corpus luteum is an older formation than a recently-ruptured 
follicle, we should naturally refer the latter to the last men- 
strual period. But to what period or periods do the fresh 
corpora lutea belong ? Dalton2 says that the corpus luteum 
of menstruation “ reaches its greatest development about three 
weeks after ovulation, and from this time rapidly disappears, 
a small cicatrix only remaining.” This being the case, can we 
refer these “ fresh ” corpora lutea to a menstrual period, in one 
case thirty and the other thirty-eight days past ? If we can do 
1 Notwithstanding the most diligent search, Bischoff was unable, in a single 
instance, to discover the ovule. 
2 Prize Essay “ On the Corpus Luteum of Menstruation and Pregnancy.” Jackson : The Ovulation Theory 
8 
so—if a recent corpus luteum signifies one which may be asso- 
ciated with a menstruation which occurred four to six weeks 
before—then what shall we say of Case 6, where the presence 
of such a one is connected with a period seven days past ? 
Barnes,1 too, with a similar disregard of consistency, after 
stating that the preparations of Coste, preserved in the College 
of France, prove that the ripening of a Graafian follicle always 
coincides with the turgescence of the genital organs, and, ac- 
cording as the circumstances are more or less favorable, bursts 
at the commencement, towards the end, or at any time during 
the menstrual discharge—proceeds to state what these prepara- 
tions are in detail, thus: “In a woman who died on the first 
day of the appearance of the menses, the ovarian vesicle was 
manifestly ruptured. In another, who died four or five days 
after the cessation of the menses, the right ovary presented a 
vesicle still intact, but so distended that the slightest pressure 
made it burst. Lastly, in a young virgin, who died fifteen 
days after menstruation, there was no recent trace of a yellow 
body, and it could not be doubted that the Graafian vesicle 
had been arrested in its development.” Surely, these cases, 
taken together, so far from proving that a Graafian follicle 
bursts at the menstrual period, show that menstruation occurs, 
in two-thirds of the cases, without such rupture, and in one- 
third without even a maturation of a follicle. For in one only 
of the three was there actually found a ruptured follicle; in 
one, menstruation had occurred and ceased several days before 
without any rupture, the follicle being burst by external force 
>-post-mortem,, and in the third there had not been even the 
ripening of one! 
Such a course as is indicated in the foregoing instances is 
more reprehensible than reasoning without facts; it is reason- 
ing against them. Yet these are only samples of the sort of 
argumentation which is frequently found in connection with 
this subject 
(a) menstruation may occur without accompanying ovulation. 
At first glance it would seem that we ought to accept the 
discovery of a rent follicle filled with blood, in persons who 
3 Diseases of Women, p. 147. of Menstruation 
9 
have died during menstruation, as a proof that the flow is, if 
not the result of, at least coincident with, ovulation. But such 
evidence is not at all conclusive, and may be erroneous, for 
Ritchie 1 has “ repeatedly seen the opening of a discharged 
vesicle to be still patent, and sometimes the vesicle to be filled 
with a florid blood-clot in the third and fourth month of preg- 
nancy ; and, in one case, he found the corpus luteum of a 
woman in the ninth month to communicate with the surface 
by a distinct foramen.” 
We must bear in mind, in the consideration of this subject, 
that Graafian vesicles are maturing and rupturing, and corpora 
lutea are forming and disappearing continually; hence it 
should be expected that, in a woman dying at almost any time, 
some of these conditions would be found in the ovary. And 
when we further consider that the menstrual periods occupy 
from one-sixth to one-fourth of a woman’s lifetime for thirty 
years, we may equally expect to find such ovarian changes at 
these periods also. So that it seems strange, indeed, that per- 
sons who are satisfied of the correctness of the ovular theory 
because occasionally a ruptured follicle or a corpus luteum is 
found coincident with a menstrual period, should ever have a 
lack of evidence. And yet, abundant as such evidence unques- 
tionably is, it does sometimes fail; for menstruation frequently 
occurs without any such contemporaneous change in the ovary. 
Many instances of this character have been recorded, but it is 
only necessary to call attention to a few of them. 
Dr. W. W. Gerhard3 presented to the College of Physicians 
of Philadelphia the uterus and appendages of a multipara, 
twenty-five years old, who died of apoplexy during a menstrual 
period. “ At several points on the surface of the ovary there 
were minute dot-like orifices, each one corresponding to a 
Graafian follicle. Two of these being examined under the mi- 
croscope, were found to present a few granular nucleated cells 
floating in a homogeneous liquid.” Although this woman had 
been the subject of menorrhagia, the discharge latterly return- 
ing profusely every two weeks, there was no evidence of any 
recent ripening or rupture of a follicle. Again, Dr. Stedman* 
1 Tilt, Uterine and Ovarian Inflammation, p. 66. 
s Amer. Jour. Med. Science, vol. 36, p. 410. 
3 Amer. Jour. Med. Science, vol. 24, p. 83. 10 
Jackson : The Ovulation Theory 
has reported the case of a married woman, forty-five years of age, 
who died of some pulmonary affection. Menstruation was regu- 
lar nearly to the time of her death, and yet on examination 
there was found no trace of the left ovary, but in its place a 
thin and simple serous cyst nearly two and a half inches in 
diameter ; while on the other side there was a collection of cysts, 
forming' a mass twice the size of an English walnut, upon the 
surface of which were spread out the thin flattened atrophied 
remains of the ovary. 
Furthermore, it is the experience of ovariotomists, that in 
many cases in which both ovaries have been removed, these 
organs have been found so thoroughly diseased as to preclude 
the idea that they could possibly have performed their function 
of ovulation normally, if at all, and yet the regularity of men- 
struation has suffered no interruption. 
Some of the reported cases of hernia of the ovaries throw 
valuable light upon this question. For example, Dr. Oldham1 
presented one to the Royal Society, the subject of which was a 
tall, well-formed woman, nineteen years of age, in whom both 
ovaries had descended through the inguinal canals, and occupied 
positions in the upper part of the labia majora. The mammae 
and external genital organs were well developed, but neither 
uterus nor vagina could be detected. The left ovary was in a 
quiescent state, and had never been the seat of pain or swell- 
ing. She was under Dr. Oldham’s observation six years, during 
which time he had frequent opportunities of seeing her. For 
the first three years the right ovary was exclusively enlarged, 
the intervals varying from three weeks to three months. For 
the last two years the left ovary was most frequently affected, 
the right remaining quiescent. • Occasionally both were tumid, 
but one always more so than the other. The swelling some- 
times occurred suddenly, although usually it was gradual, the 
volume of the organ increasing slowly for four days, remaining 
stationary for three days, and then slowly declining, the whole 
process lasting ten or twelve days. During this period the or- 
gan was tender when pressed, but was otherwise not painful, 
and did not interrupt the patient’s ordinary duties. There 
were no manifest sympathies excited in the mammary glands 
1 Amer. Jour. Med. Science, vol. 35, p. 284. of Menstruation. 
11 
or other organs ; and there was no vicarious flux, either of blood 
or other secretion. The ovary alone seemed engaged in the 
act. It was supposed, reasonably, that these periods of enlarge- 
ment were those of ovulation, and I beg to call attention to the 
fact that they were quite irregular in their occurrence, the in- 
tervals varying from three weeks to as many months. 
Dr. Alfred Meadows,1 also, mentions a case of similar charac- 
ter. The patient was a single woman, twenty-three years of age, 
who began to menstruate at fifteen, and continued doing so at 
regular intervals, with some pain, down to the age of twenty, 
when, after stooping, a swelling suddenly appeared in the right 
inguinal region, caused, as was subsequently learned, by the 
prolapsed ovary. At the menstrual period following this she 
suffered violent pain of a character different from any she had 
experienced before ; it preceded the hemorrhage; at the same 
time the tumor was much increased in size. From that time 
on she suffered in a similar way, sometimes more acutely, so 
that at every monthly period she was obliged to lie in bed for 
a week or more. Sometimes the tumor would swell up to the 
size of “ two fists,” and be exquisitely tender to the touch. She 
had no suffering during the inter-menstrual periods. To what 
does this history point? Are we not prepared to accept it as 
an evidence of the truth of the ovular theory ? Prior to the 
occurrence of each monthly flow, for a period of three years, 
the ovary enlarges, becomes the seat of pain, and the swelling 
does not subside until after the cessation of the discharge. 
What more ought we to require ? 
Mark the sequel. At the suggestion of Dr. Meadows the 
tumor was removed. It was not contained in any cyst or sac, 
and was readily separated from its fatty and cellular attach- 
ments. The upper portion or pedicle, which went through the 
abdominal ring, was found distended with fluid. This was 
punctured and about an ounce of the contents let out. The 
pedicle was then tied and the tumor removed. “ The tumor, 
which measured about two inches in diameter, proved, on sec- 
tion, to be the right ovary. It had, however, undergone remark- 
able structural change. Instead of presenting the usual dense 
compact appearance, it contained throughout numerous irregu- 
1 Amer. Jour. Obstetrics, etc., vol. 6, p. 231. 12 
Jackson : The Ovulation Theory 
larly-shaped spaces varying in size from a pin’s head to a quarter 
or even half an inch, and all were filled with the same kind of 
fluid as flowed from the pedicle. These cells appeared to com- 
municate with one another, and the whole organ to be infil- 
trated, as it were, with the fluid in question. There were no 
proper Graafian vesicles to be seen.” No Graafian vesicles,—no 
ovules—no ovulation, to account for the great increase in the 
size of the ovary preceding and during the catamenial period. 
What' is the plain inference ? Is it not that the swelling of the 
ovary was caused by the pelvic congestion attendant upon the 
menstrual period ? And yet, Dr. Meadows has introduced the 
account of this case in an argument affirming, among other 
things, the dominating influence of the ovaria, and the fact of 
ovulation producing the menstrual flow. 
This last mentioned case of ovarian hernia, as also one re- 
ported by Dr. McCluer,1 and another which I am informed3 has 
been published by Dr. Joseph English, of Vienna, shows that 
the cystic degeneration of the prolapsed ovary, even when its 
essential vesicular structure is wholly destroyed, does not pre- 
vent the organ from enlarging and becoming painful during 
the menstrual epoch. In all of these cases the ovary, which 
had swollen month after month at regular periods correspond- 
ing with the menstrual flow, was found to be so diseased as to 
leave no vestige of Graafian vesicles, thus proving ovulation to 
be impossible. 
Dr. Tilt says: “ In three cases in which Dr. Ashwell had 
opportunities of examining the ovaria of women who died 
during the flow of the catamenia, there were no signs of the 
rupture of the Graafian vesicle and the escape of ovules. In 
one of these cases, the woman had menstruated regularly for 
several years, and yet the ovaria were perfectly smooth; there 
was neither rent nor cicatrix marking the site of either a pres- 
ent or former maturation and escape of a Graafian vesicle.” 
Ritchie3 also reports five examples of menstruation which were 
not accompanied, and could not have been caused, by ovulation. 
In one of these, the woman died ten days after menstruation. 
The ovaries were filled with vesicles, but neither of them pre- 
1 Amer. Jour. Obs., vol. vi., p. 613. 
2 Dr. Paul F. Munde, private letter. 
3 Ovarian Phys. and Path., London, 1865. of Menstruation. 
13 
sented either a puncture or cicatrix. In another, death occurred 
thirteen days after menstruation. Here, too, the ovaries con- 
tained numerous vesicles, one as large as a garden pea, but in 
neither of them was puncture or cicatrix. In a third, men- 
struation had occurred a week before death; but there was 
neither scar nor opening on the surface of either ovary. Again, 
in another case where death occurred a fortnight after men- 
struation, neither ovary presented any sign of recent rupture. 
Dr. John Williams1 has published a series of cases hearing 
upon the temporal relations of the discharge of ova with the 
menstrual flow. He believes that the ova are discharged, 
usually, before the appearance of the catamenial dux, and de- 
tails observations made by him upon sixteen cases. In several 
of these, where death occurred during the inter-menstrual period, 
his conclusions are drawn from the condition of the corpus 
luteum ; but inasmuch as the changes in these bodies do not 
always take place uniformly, and, as it is always difficult to 
determine the age of effused blood, the results founded upon 
these cannot be accepted as certainly accurate. Passing by 
these, therefore, I wish to invite attention to those of his cases 
in which death occurred during the menstrual period. 
(1.) Was a young woman who died on the fifth day of the flow. 
“ On the surface of the left ovary was a rough, brownish-col- 
ored, star-like cicatrix. On section there was seen under the 
cicatrix a corpus luteum dilated in the middle and narrow at 
botli ends, nearly three-quarters of an inch in length and half 
an inch in width ; its walls were in some parts of a pinkish, 
and in others of a yellowish color. In the centre was a par- 
tially decolorized clot.” (2.) Was a patient who died on the 
ninth day of typhoid fever and the fourth day of menstruation. 
One ovary contained a corpus luteum, similar to that in case 
Ho. 1. In both of these rupture of the follicle had taken place 
evidently several days before. (3.) Woman had undergone 
operation for fistula-in-ano, and died five days after the ap- 
pearance of menstruation ; one ovary contained a follicle five- 
eighths of an inch by one-third of an inch, in which was found 
a bright-red, fresh, loose clot, and its walls were thin and smooth. 
JYo rupture had taken place. (4.) Patient with fibroid tumor 
1 Obstet. Jour. Great Britain and Ireland, vol. 3, p. 620. 14 
Jackson : The Ovulation Theory 
of the uterus; died on the third or fourth day of menstruation. 
Left ovary contained a follicle nearly an inch in length, in 
which was found a soft, dark-colored clot, which appeared to 
be several days old ; follicle had not ruptured. (5.) Patient 
died when the menstrual flow had almost ceased. There was 
no rupture in either ovary, but the right ovary contained a 
Graafian follicle about the size of a small pea. (6.) Young 
suicide ; died three days after cessation of the flow. There was 
no recent Hipture in either ovary ; the left contained a follicle 
similar to the preceding. 
Of the foregoing six cases, in only two did a ruptured Graaf- 
ian vesicle even seem to correspond with a menstrual period ; 
and in two of the cases, the follicles most advanced were 
so immature that Dr. Williams expresses the opinion that 
they would probably have ripened by the next return of the 
flow. 
Mr. Paget1 has reported a case of a woman who was executed 
for some crime, and the post-mortem appearances tell very 
forcibly against the ovular theory. The woman had begun to 
menstruate twelve hours before her execution. “ The ovaries 
were of moderate size and presented numerous marks of cic- 
atrices upon their surfaces. In the right ovary, three Graafian 
follicles projected slightly on the surface and looked healthy, 
containing clear serous fluid. A fourth was of very large size 
and prominent. In the left ovary, one Graafian follicle was 
fully developed and prominent. We looked for ova in the con- 
tents of all these, but in vain. The surface of the ovaries was 
generally rather more than usually vascular, but there was no 
peculiarly vascular spot, nor any appearance of the recent rup- 
ture of a vesicle, or the discharge of an ovum. In the right 
ovary, near the surface, was a small cyst or cavity, containing 
what looked like a decolorized clot, and bounded by a thin 
layer of a bright yellow-ochre substance, an excellent example 
of a fibro-corpus luteum, of one or more months’ date, certainly 
not more recent.” 
Dalton, in the essay on the Corpus Luteum, already referred 
to, reports two cases, in one of which death occurred during the 
menstrual period and in the other at its termination. In neither 
1 Tilt’s Uterine and Ovarian Inflammation, p. 64. of Menstruation. 
15 
of them had a follicle recently ruptured, although in the second 
there was one on the point of doing so. 
I have had two opportunities of examining the ovaries of 
women who died at or near the menstrual period. One was the 
case of a healthy unmarried woman, twenty-eight years of age, 
who died from an overdose of morphia, taken accidentally. 
She had menstruated regularly, and a period had ceased four 
days before death. Both ovaries were normal in structure and 
size, the right being somewhat larger than the left. It con- 
tained several Graafian vesicles scattered throughout the stroma. 
Two of these were larger than the rest, one being about an 
eighth of an inch in diameter, and the other as large as a small 
currant. This latter was near the surface and caused a slight 
projection. It contained a clear serous fluid. The left ovary 
contained fewer vesicles, but had the indistinct remains of a 
corpus luteum not less, certainly, than four or five weeks old. 
The mucous membrane of the uterine body was pale and cov- 
ered with a grayish-pink mucus. The other case was that of a 
young girl, fifteen years old, who died from the effects of a 
burn. She had commenced menstruating eighteen months be- 
fore, but the function had been regularly performed only for 
about ten months. A period had ceased twelve days prior to 
death. Neither ovary contained corpora lutea, nor bore the 
marks of recent rupture. The largest vesicle, which was about 
a quarter of an inch in diameter, was found in the left ovary 
about a sixteenth of an inch from the surface. 
(b) ovulation may occur without accompanying menstruation. 
I will next proceed to adduce evidence to show that ovula- 
tion certainly and frequently takes place without menstruation. 
Malpighi and Yallisneri long ago observed that fully-devel- 
oped Graafian vesicles are occasionally found in the fully grown 
foetus. Ritchie,1 also, has demonstrated by at least ten dissec- 
tions, that in the ovaries of new-born infants, and children as 
early as the sixth year, may be found highly vascular Graafian 
vesicles; and that at the age of fourteen, and prior to menstru- 
ation, they are found as large as small raisins, filled with their 
usual transparent granular fluid ; that menstruation is not essen- 
1 Loc. cit., p. 62. 16 
Jackson : The Ovulation Theory 
tial, either as cause or effect, of these conditions ; that prior to 
menstruation, the vesicles are found, as at every other period of 
life, in continual progression towards the circumference of 
the ovaries, which they penetrate, discharging themselves 
through the peritoneal coat, thus proving that the catamenial 
flow is not an indispensable prerequisite to their rupture. 
So, likewise, the more recent researches of Grohe, Slav- 
jansky, and Haussmann have shown that the growth of the 
Graafian vesicle is quite independent of the menstrual period ; 
and the last named authority,' whose observations were made 
upon eighty-four subjects, asserts that such early development of 
the follicles as was noticed by Ritchie takes place in about ten 
per cent, of all cases. Dr. Sinety* confirms these observations, 
and maintains that “ in the ovaries of the newly-born, Graafian 
follicles are almost always visible to the naked eye ; and they 
may at this time often be discovered as well developed as in the 
adult female, and constituting true cystic ovaries, in which are 
to be seen ovules whose origin is indubitable. In the ovaries 
of infants, there are often cicatrices and follicles in different 
stages of atrophy.” What, 1 would ask, causes these cicatrices ? 
Is it aught but the rupture of the Graafian follicles which, as 
would seem from the foregoing, may take place at any period 
of infantile and adult life ? 
Slavjansky,3 who has devoted a great deal of time to researches 
on the physiology and pathology of the ovaries, thus summa- 
rizes the results obtained by him: 
1. The Graafian follicles develop themselves from the prim- 
ordial follicles, and are growing towards maturity from the 
first month of birth to the fortieth year. 2. The larger num- 
ber of follicles do not mature, do not rupture, do not discharge 
their contents, but pass over into a condition of atrophy which 
is analogous to the formation of the corpora lutea. 3. The 
development and ripening of the Graafian follicles do not take 
place periodically in a regular manner, and there is no connec- 
tion between ovulation and menstruation. 4. Menstruation is 
a physiological phenomenon unconnected with the development 
and ripening of the Graafian follicle. 5. The rupture of the 
1 Centralblatt, No 2. 
2 Le Progres Medical. 
3 Allg. Med. Centr. Z. 54, 1874. of Menstruation. 
17 
more or less ripe follicle is associated with congestion of the 
genital organs, and is, as yet, an unexplained matter. 
On the other hand, ovulation may continue after the meno- 
pause. Lawson Tait1 says: “ The cessation of the menses at the 
climacteric, though it diminishes the activity of the cell-growth 
at once to a marked extent, never extinguishes it; for the devel- 
opment and extrusion of immature Graafian follicles ceases only 
with life itself. They are to be found of some size even fifteen 
or twenty years after the cessation of menstruation.” 
Of course, ovulation is the necessary condition of impregna- 
tion, and it is admitted by all writers that conception may 
occur in the absence of menstruation. Our literature contains 
many instances of girls who have conceived prior to the first 
appearance of the flow; of women who have become pregnant 
subsequent to the menopause, and during lactation before men- 
struation has reappeared. Dr. James Young,3 Tanner,3 Du- 
bois,4 Tilt,6 and, indeed, almost every obstetric author, mention 
cases of this character. Leishman speaks of a woman who 
married at twenty-seven, and who menstruated the first time 
two months after her eighth labor. Raciborski states that he 
has seen on the ovaries one or two cicatrices, although the sub- 
jects had never menstruated. 
An argument which has been frequently urged in support of 
the ovular theory, is the fact that conception is more likely to 
take place shortly after a menstrual period than at any other 
time. 
Dr. W. II. Studiev,6 alluding to this, considers it as admit- 
ting of a very different explanation, and not at all as proving 
the coincidence of ovulation and the menstrual flow. lie says: 
“ My opinion in regard to the rationale of the fact is this : im- 
pregnation is more likely to be secured at this time because of 
the recent deluging with menstrual blood, by which the secre- 
tions, especially of the cervical canal, have been washed away, 
which secretions often prevent impregnation either by their 
1 Hastings Prize Essay of 1873, London, p. 4. 
2 Am. Jour. Med. Science, vol. 60, p. 568. 
3 Hand-book of Pract. Obstetrics, p. 24. 
4 Journal de Mud., 1850. 
6 Uterine and Ovarian Inflammation, p. 49. 
6Amer. Jour. Obstetrics, 1875, p. 487. 18 
Jackson : The Ovulation Theory 
chemical incompatibility with the vitalizing fluid, or by the 
mechanical obstruction in the form of the firm mucous plug so 
often found in the canal.” 
If the ovular theory were true, conception could take place 
only at or near a menstrual period ; but there is abundant evi- 
dence to show that it may and does frequently occur at times 
quite remote from it. My own experience has furnished me 
with a number of instances where married women, anxious to 
prevent an increase of family, have observed the “ physiological 
rule ” of abstinence for a fortnight after a period, and who 
have found, to their chagrin, after a time, that their precaution 
had been unsuccessful. 
Dr. Oldham observes: “ I know of cases which I have care- 
fully inquired into, where impregnation occurred at the re- 
spective times of ten, twelve, and twenty-one days after the 
menstrual period; and while, on the one hand, I am quite 
ready to admit a greater disposition to impregnation shortly 
after a menstrual period, yet I know of no facts to disprove 
the opinion that the human female is susceptible of impregna- 
tion at any time between her monthly periods.” Ilirsch,1 like- 
wise, has seen a case where impregnation took place twenty- 
two days after a normal menstrual period ; and he observes 
that, “ as the Jewish women are obliged to abstain from inter- 
course five days before and seven days a i ter menstruating, 
that race could not be so prolific as it is known to be if the 
ovular theory of menstruation is true.” Tilt,* also, mentions 
the case of a lady, aged forty-seven years, in whom menstru- 
ation had been irregular for two years, and who after a 
single coitus, seventeen days subsequent to a period, became 
pregnant. 
An attempt has been made to explain these and similar 
cases, by supposing that the spermatozoa, on the one hand, and 
the ovule, on the other, may retain their vitality in the genera- 
tive passages for a sufficiently long time to permit the occur- 
rence of impregnation under the circumstances named. But 
the facts bearing upon the subject, so far as known, do not 
justify such an explanation. The ovule occupies from eight to 
ten days in its passage from the ovary to the uterus, and it 
1 Schmidt’s Jahrbuch, 1853, No. 2. 
2 Change of Life, p. G9. of Menstruation. 
19 
may be impregnated at any time within that period, provided 
it meet with fertilizing material. If, as maintained by Wil- 
liams and others, the ovule is discharged at the commencement 
of a menstrual period, rather than at or near its termination, 
we can still understand how a coitus taking place within a few 
days prior to the flow might be fruitful as well as one had within 
eight or ten days subsequent to a period. But when a single 
intercourse takes place from twelve to twenty-two days after a 
menstrual period, or ten days before the next, and becomes 
fruitful, we cannot accept the explanation given by the ovula- 
tionists without additional and different facts. 
To meet the obvious difficulty here presented, it is urged 
that the spermatozoa may live a long time—indefinitely, in- 
deed—in the generative passages of the woman. While we 
are not able to say positively that such is not the truth, we do 
say, that so far as we have actual knowledge on the subject, the 
tenure of life in the spermatozoa is quite limited. Dr. Sims,1 
who made many examinations of the semen in order to deter- 
mine how long the spermatozoa may retain their vitality in the 
matrix, found none alive at a longer period than forty hours, 
although he admits that they may live longer under favorable 
circumstances. And he quotes Dr. S. G. Percy as reporting 
a case in which he found “ living spermatozoa, and many dead 
ones ” issuing from the os uteri eight and a half days after the 
last sexual connection. If we admit the correctness of all these 
statements we have no right to assume the persistence of vital- 
ity in the human spermatozoon for a longer period than that 
given. Granting this term of vitality—which I feel assured 
must be quite exceptional—let us see whether it is sufficient 
to meet the requirements of some of these cases of impregna- 
tion following a single coitus. For example, Montgomery2 re- 
ports a case in which the last menstruation occurred on the 8th 
of October. Insemination took place on the 10th of Novem- 
ber ; pregnancy resulted. Now, if the ovule impregnated were 
shed at the last menstrual period, twenty-three days must have 
elapsed between that time and insemination. We cannot sup- 
pose the ovule to have retained its vitality and capability of 
impregnation during this long period, for such a supposition is 
1 Uterine Surgery, p. 374. 
* Signs, etc., of Pregnancy, p. 258. 20 
Jackson : The Ovulation Theory 
quite at variance with all observed facts both as regards it1 and 
the history of the decidua (Aveling, Williams, Engelmann). 
On the other hand, if we suppose that the semen remained in 
the generative tract until an ovule belonging to the next period 
was extruded, we must suppose the spermatozoa to resist the 
mechanical washing away by means of the menstrual flow—a 
highly improbable notion, and one not made more reasonable 
by the fanciful idea that the uterus, by a sort of instinct antici- 
pates what is going to take place and governs itself according- 
ly.2 Likewise, it implies the vitality of the spermatozoa for a 
period of eight days, plus the time necessary to meet the de- 
scending ovule—probably four or five days more. 
It is well known that many women continue to menstruate, 
with entire regularity, for a considerable time prior to the final 
cessation without conceiving ; and I believe that this fact is 
explainable by the gradual failure of the ovaries to furnish per- 
fectly developed ovules. Indeed, it is quite probable that all 
ova which are thrown off are not capable of impregnation at 
any period of life ; for, where other conditions are apparently 
equal, some females are impregnated every twelve or thirteen 
months, others every eighteen months or two years, while 
others have still longer intervals of rest. Dewees mentions an 
instance of a lady who conceived ever}7 seven years, and who 
bore four children at that interval; and I knew one who had a 
lapse of three years between each of six successive pYegnancies. 
It would seem, therefore, that it requires a certain period to 
perfect an ovule, and that the time required is much greater 
in some instances than in others. And, if menstruation is pro- 
duced by ovulation, it appears scarcely probable that a succes- 
sion of imperfectly developed ovules—so imperfect, indeed, as 
not to be susceptible of impregnation, or even of extrusion, as 
we have seen is frequently the fact—should yet be sufficient to 
maintain a completely normal monthly flow. 
Finally, it is not at all uncommon to And the menses suppressed 
1 “ How long after its maturation the ovum can retain its vitality and sus- 
ceptibility to the seminal influence is not known, but probably the time is 
short.”—Duncan, Fecundity, Fertility, and Sterility, p. 428. 
5 1 ‘ Under such circumstances, menstruation often does not take place at all, 
or only very scantily; the uterine system, as it were,anticipating the conception 
and preventing the failure which might result from a free discharge of blood.” 
—Duncan, Fecundity, etc., p. 431. of Menstruation. 
21 
for some months immediately after marriage, without the oc- 
currence of pregnancy. Are these cases to be explained by 
supposing that marriage suppresses or retards the development 
of Graafian follicles ? 
From all the foregoing considerations, it seems to me con- 
clusive that ovulation and menstruation may, and frequently 
do, occur independently of each other; that while they may be 
coincident, there certainly is no such constant connection be- 
tween the two as to warrant the assertion that “ at every 
menstrual period a matured ovule escapes from the ovary ”— 
an assertion which embodies the very essence of the ovular 
theory. 
2. Physiologically, the period of the menstruation in 
woman corresponds with the oestrus or rut of other mammalia. 
It is well known that during certain periods, the intervals 
between which vary in different species of mammalia below 
man, ova are matured and extruded from the ovary, and that 
this process is attended by great excitement of the entire gen- 
erative apparatus. Upon the supposed similarity of this 
function—termed rut, oestrus, or cestruation—to menstruation in 
the human female is based one of the strongest arguments in 
favor of the ovular theory. Indeed, Cazeaux1 and Pouchet2 
lay especial stress upon it. 
Down to the time of Martin Barry it wTas believed that sexual 
congress was the essential determining cause of the rupture of 
the Graafian follicle, but the experiments of Bischoff, Coste, 
Pouchet, and others proved that such rupture was spontaneous 
and entirely independent of male influence of any kind, both 
in man and the lower animals, although it was hastened in 
some instances by coitus. Reasoning, then, from the known 
analogy existing between this and many other of the vital 
processes in the lower mammalia and the corresponding ones 
in man, it was assumed that the conditions of rut and menstru- 
ation were analogous, and had the same significance. 
While it is true that many physiological conditions in man 
and the other animals of the order to which he belongs are 
1 Second Amer. ed., p. 9. 
s Theorie Positive de l’Ovulation Spontanee, p. 227. 22 
Jackson : The Ovulation Theory 
subject to the same general laws, these conditions differ in 
specific points just as much as do the different genera and 
species of that order in their anatomical features. 
It may be well in this connection, and before enumerating 
the important points in which cestruation and menstruation 
differ, to call attention to the fact, that even in those cases in 
which the oestrus and ovulation are synchronous, it has never 
been proven that the former is caused by the latter. Indeed, 
it is far more probable that they are both the result of a com- 
mon cause—some erethism of the system resulting in conges- 
tion and excitement of the entire sexual apparatus. 
The appeal to comparative physiology by the ovulationists 
has always seemed to me an unfortunate one, for the note- 
worthy differences between oestruation and menstruation are 
quite sufficient, I think, to stamp the two processes as wholly 
dissimilar. These points of difference are as follows: 
1. When, during the eestrus, there is a discharge from the 
genitals (which is not always the case), it is mucous in charac- 
ter, and its source is chiefly the glands of the external organs; 
its object is to lubricate the parts, and, in some instances, by 
its odor to attract the male. In woman the discharge is 
blood, from vascular rupture ; its seat, the mucous lining of 
the body of the uterus, and its presence an indication of the 
disintegration of that structure. 
2. The excitement characterizing the oestrus is the only 
period during which the male is received, and the only time when 
impregnation is possible. In woman, while pregnancy is possible 
at any time, it usually occurs during the period of rest, that is, 
in the intermenstrual period. 
3. On the subsidence of the oestrus, there is a period of 
inappetence, during which the female not only no longer in- 
vites, but successfully resists the male approach. At the 
corresponding time in woman, sexual desire is commonly in- 
creased, and in some, present at no other time. 
4. The oestrus, or period of sexual desire, is necessary in the 
lower mammalia, for the reproduction of the species. In 
woman, desire is not essential either for intercourse or impreg- 
nation. 
5. (Estruation and ovulation in many animals are determined 
by changes in the seasons and other surrounding circum- of Menstruation. 
23 
stances,1 and in some animals (deer) the semen is only elabo- 
rated at such times. In man, changes of season, etc., produce 
no such effect, and semen is secreted constantly. 
6. The oestrus may be excited in some animals (the mare) 
by the importunities or teasing of the male. Menstruation is 
neither excited nor hastened by the presence of the male; on 
the contrary, undue excitement of the generative organs, or of 
the sexual passion, seems frequently to have a tendency to 
arrest it, as witnessed in newly-married women. 
7. During the oestrus, both the male and female evince a 
desire for copulation. During menstruation, the female has a 
delicate shrinking from the act, and the male likewise feels 
more indifference than at any other time, amounting in many 
cases to positive repugnance. 
8. The ovaries in the lower animals contain ripe ova only 
at the period of heat (Bischoff). In the human female, ripe 
ova are found at all times without reference to the period of 
menstruation. 
The foregoing points of disimilarity are so distinctive, and' 
refer to such important features, that I feel warranted in 
denying that cestruation and menstruation are corresponding 
processes. 
3. The removal of the ovaries is at once followed by-cessa- 
tion of menstruation. 
Percival Pott, Cazeaux, Wells, Battey, and others, have re- 
ported cases in which the artificial removal of the ovaries was 
followed by the immediate and permanent cessation of the 
menstrual function; and these facts have been cited to prove 
the necessity of these organs for the maintenance of the peri- 
odical flow. 
It must be admitted that, if such an effect were the constant 
and certain result of double ovariotomy, it would go far towards 
showing the necessity for ovarian influence. But such result is 
not constant; indeed, the instances in which both ovaries have 
1 Barnes, Diseases of Women, p. 148, states that in the wild state the rabbit 
has only one or two litters a year, but when its young are taken away at a 
suitable time, it has perhaps seven. So likewise the period of ovular mat- 
uration is changed in the case of the pigeon, domestic hen, etc. 24 
Jackson : The Ovulation Theory 
been removed without interruption or discontinuance of the 
menstrual flow are so numerous and authentic, that recent 
writers, who, like Leishman, aflirm as an admitted fact, “ the 
invariable and immediate cessation of menstruation when the 
ovaries have been removed,” subject themselves fairly to 
charges either of ignorance or want of candor. 
Dr. John Goodman1 has compiled the following table show- 
ing the effect of double ovariotomy upon the menstrual func- 
tion in all the cases of which he could obtain information 
down to the year 1872: 
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 
Lancet, 1848 
1847 
32 
Menstruation uninterrupted; ten- 
dency to menorrhagia. 
4 
Peaslee 
Lyman’s Table 
Lyman’s Table 
1850 
24 
5 
Burnham 
1853 
42 
6 
W. L. Atlee.... 
Atlee on Ov. Tumors.. 
1854 
35 
Menstruation regular. Ceased in 
1864, forty-fifth year. 
7 
W. L. Atlee.... 
Atlee on Ov. Tumors.... 
1855 
19 
Regular molimen with white dis- 
charge. 
8 
W. L. Atlee.... 
Atlee on Ov. Tumors.... 
1861 
40 
Menstruation regular to 1863, when 
last reported. 
9 
Peaslee 
A. J. Med. Sci., 1863.... 
1862 
35 
10 
Peaslee 
A. J. Med. Sci., 1864.... 
1863 
39 
11 
W. L. Atlee.... 
Atlee on Ov. Tumors... 
1864 
34 
Last report 1870. Menstruation reg- 
ular to that time. 
12 
Beattey 
Wells, His. of Ovaries 
1865 
37 
13 
Storer 
A. J. Med. Sci., 1868 ... 
1866 
Menstruating regularly a year after 
operation. 
14 
Storer 
Peaslee on Ov. Tumors.. 
1867 
43 
15 
Wells 
Wells, Dis. of Ovaries... 
1868 
39 
10 
Wells 
Wells, Dis. of Ovaries... 
186'.) 
22 
17 
Hicks 
Wells, Dis. of Ovaries... 
1869 
39 
18 
Monro 
Wells, Dis. of Ovaries... 
1870 
34 
19 
Mayer 
Wells, Dis. of Ovaries... 
1871 
29 
Last report one year after operation. 
Menstruation regular. 
20 
Meadows 
Lancet, 1872 
1871 
Last report six months after opera- 
tion. Menstruation regular. 
21 
Priestly 
Wells, Dis. of Ovaries.. 
1872 
22 
22 
A. R. Jackson. 
Peaslee, Ov. Tumors 
1865 
44 
Continued to menstruate to the 
forty-seventh year of her age. 
23 
Le Fort 
Peaslee, Ov. Tumors 
Menstruation regular. 
24 
Baker Brown.. 
Peaslee, Ov. Tumors 
Menstruates, but not regularly. 
25 
Baker Brown.. 
Peaslee, Ov. Tumors 
* Menstruates regularly from cicatrix 
and vagina. 
26 
Koeberle. ... 
Peaslee, Ov. Tumors 
Menstruation regular. 
27 
| Battey 
Personal information.... 
1872 
23 
Irregular sanguineous discharges; 
sometimes profuse. 
Clay, of Manchester, had four cases in which there was subsequent sanguineous discharge.— 
(Peaslee.) 
* The whole uterus, except cervix, removed with ovaries. 
Dr. Goodman says: “ In order to determine as accurately as 
1 Bichmond and Louisville Med. Jour., Dec., 1875. of Menstruation. 
25 
possible the effects of the removal of both ovaries upon the 
menstrual function, I have carefully examined and arranged 
all the cases of which I could obtain reports ; irregular 
sanguineous discharges, I have, of course, not counted as men- 
strual. 
“Of the twenty-seven cases here recorded, it will be observed 
that in nearly one-half menstruation was not affected by the 
removal of the ovaries; in one, the hemorrhagic discharge was 
increased; in one, it was diminished; and, in several, sangui- 
neous flows occured at irregular intervals.” 
Dr. Ely McClellan, of Louisville, Ivy., in a private letter, 
dated March 18, 1876, gives the following facts bearing upon 
this point, and kindly places them at my disposal. The cases 
referred to were operated upon for pernicious ovulation, by 
“ Battey’s Operation,” or that known as “ Normal Ovariotomy.” 
“ Case I.—But one ovary was removed. 
“ Case II.—Both ovaries were removed, one in May, 1875, 
and the other in September, 1875. This lady has regularly and 
persistently menstruated since the operation. 
“ Case III.—Both ovaries removed in August, 1875. This 
case had menstruated vicariously prior to the operation, and is 
still the subject of such disorder. 
“ Case IV.—The ovaries of this lady were removed in Sep- 
tember, 1875. She menstruates regularly. 
“ So far as these Louisville cases go, the removal of both 
ovaries, after the menstrual function has been established, pro- 
duces no influence upon the regularity of its occurrence. What 
may result after the lapse of a few more months, it is of course 
impossible to determine.” 
Indeed, it is so well known that the removal of the ovaries 
does not necessarily induce the menopause, that many of those 
who formerly denied the fact now admit it; but they endeavor 
to explain the circumstance consistently with the ovular theory. 
Some of these allege that the ovaries are not the only source 
of Graafian vesicles. Spencer Wells, for example, states,1 that, 
occasionally, the essential elements of the ovaries are sometimes 
scattered between the layers of the peritoneum, as in the lower 
animals ; and that in some cases “ Graafian follicles have been 
1 Diseases of the Ovaries, p. 11. 26 
Jackson : The Ovulation Theory 
seen developing in some of the mammalia at a distance from 
the entire ovary, and that such vesicles have developed into 
unilocular tumors.” Sappey,1 likewise, states that it is not rare 
to tind a score or more cystic ovules, some of them the size of 
a pea, on the alar mesentery, in the neighborhood of the ovary, 
and he accounts for their presence in this unnatural situation 
by supposing that they “ failed to reach their destination owing 
to some abnormal relations on the part of the Fallopian tube.” 
Now, while it would be presumptuous to deny that such a 
condition of things as that mentioned by the last named author 
is possible, surely it must be exceedingly rare ; and, so far as I 
am aware, there is no instance in which such an anomaly has 
been found in the human female. I apprehend, therefore, that 
not the most ardent advocate of the ovular theory would be will- 
ing to advance such a hypothetical circumstance to account 
for the appearance of a periodic monthly hemorrhage in thir- 
teen of twenty-seven cases of removal of the ovaries. For, such 
an argument would involve the absurd assumption that an ovum 
which had failed to reach the uterus, after maturation and 
extrusion, could return to the immature condition and ripen 
over again, and that, too, without its enveloping fluid and 
capsule! 
The condition mentioned by Mr. Wells must be equally rare, 
and seems equally weak as a foundation for an argument. In 
regard to both of these conditions, Dr. Goodman, in the paper 
already referred to, says: “ I think it a very fair conclusion that 
if such vesicles really existed, they were totally extirpated in 
some, if not the greater part of the thirteen cases, in which 
menstruation continued after the removal of both ovaries. 
Even if some of them remained, it is clearly impossible that 
they could have been sufficiently numerous 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 the ovarian development.” 
Others, again, have explained the persistence of menstrua- 
tion after extirpation of the ovaries by force of habit. Schroe- 
der2 expresses the argument thus : “We prefer in such excep- 
tional cases, instead of drawing the conclusion which is directly 
1 Quoted by Savage, on the “ Female Pelvic Organs.” 
2 Diseases of the Female Sexual Organs, p. 318. of Menstruation. 
27 
opposed to all our views, viz., that menstruation has absolutely 
nothing to do with the presence of ovaries, to assume that in 
these women, too, menstruation was caused by the growth of 
Graafian follicles in their ovaries, but that the organism had, 
in the course of years, become so accustomed to the regular 
discharge of blood that this still continued, although the ovaries 
were removed.” 
But, surely, this is no explanation ; it is nothing more than 
a reiteration of the fact in other terms. The “ habits ” of our 
bodies are not causeless; they are all explainable on a rational 
basis. Iso act is performed in the animal economy without 
some antecedent cause, and the same may be said of every re- 
currence of such act. In the case of the menstrual flow, if its 
periodicity were maintained in the past by the successive evo- 
lution of ovules, such ovular action would be necessary still; 
and if the cause ceased at any time to act, so likewise would 
the effect cease. But even this alleged force of habit fails to 
meet the facts in a case reported by the writer in the Chicago 
Medical Journal for October, 1870, and which appears in Dr. 
Goodman’s table as No. 22. In this case, the patient, forty- 
four years of age, had both ovaries, together with a portion of 
the Fallopian tubes, removed. A menstrual period had ceased 
on the 30th August, 1865 ; the operation was performed the fol- 
lowing day. On October 1st, thirty-one days afterwards, a san- 
guineous discharge appeared and lasted four days, attended by 
the usual symptoms of menstruation—lassitude, nervousness, 
backache, etc. There now occurred an interval of eighty-three 
days, the discharge reappearing December 22d. Its next ap- 
pearance was on January 20, 1866—four weeks after—and 
from this last date it continued to return with entire regularity 
every twenty-eight or twenty-nine days, attended by all the 
ordinary menstrual accompaniments, and lasting each time 
from three to five days, down to October, 1867—a period of 
twenty-two months. It then ceased until February, 1867, 
when it appeared for the last time, the lady being then forty- 
seven years of age. 
In this instance, the interval of nearly three months, during 
which the discharge was absent, was certainly sufficiently long 
to break up any mere habit, and shows that we must look to 
some other impelling force in order to account for the subse- 28 
Jackson : The Ovulation Theory 
quent return to regularity. Here were no ovaries, no monthly- 
developing ovules, an interruption for nearly three periods of 
the menstrual “ habit,” and yet menstruation returned and con- 
tinued regularly to reappear down to the normal time of final 
cessation. 
The facts of periodicity in the human body are more numer- 
ous than generally supposed, and most interesting in their 
character. Without any intention of amplifying upon the 
subject, I will merely remark that it is now universally ad- 
mitted that all the forms of periodicity, whether of a physiolo- 
gical or pathological character, depend upon the nervous sys- 
tem ; and there are numerous facts which warrant us in nar- 
rowing this dependence still farther, and limiting it to a parti- 
cular division of the nervous system—the sympathetic. It is 
well known that a frog’s heart will continue its regular systole 
and diastole a considerable time after its removal from the 
thorax. The only motive agency left to it then, so far as we 
know, is that furnished by the sympathetic ganglia which are 
embedded in its substance. The influence of these centres of 
nervous action is neither continuous nor occasional, but rhyth- 
mical—that is, periodic. The uterus resembles the heart in also 
possessing numerous sympathetic ganglia embedded in its 
walls*, and in being wholly independent of the cerebro-spinal 
system in its movements. Furthermore, the recent researches 
of Goltz and Freusberg 1 seem to show that there exists in the 
lumbar portion of the spine a nervous centre for the sexual 
functions. These facts and investigations may afford a clue to 
the explanation of the persistence of sexual appetite and 
functional activity of the generative organs after the destruc- 
tion by disease, or removal of the ovaries—although in these 
organs undoubtedly originates the primary impelling force 
which sets this complex sexual machinery in motion. But 
whatever may be the nature or exact seat of this force, I believe 
that its action must be persistent and, in a sense, continuous, 
although some of its results be rhythmical. A pendulum may 
be set in motion by a single forcible impulse, and for a time it 
will continue to swing; but unless the application of the force 
be continuous or repeated, the arc described by the moving 
1 See Dr. Duncan’s Address, Obstet. Jour., Great Brit, and Ireland, 1875, 
p. 361. of Menstruation. 
29 
body will become shorter and shorter, until finally the motion 
will cease wholly. 
According to the light thrown upon the subject of menstrua- 
tion by the latest researches, we are perhaps justified in pro- 
pounding the following as embodying the main facts: 
The reproductive organs of the female, including the ova- 
ries, Fallopian tubes, uterus, and vagina, receive their vascular 
and nervous supplies from the same sources. Prior to the age 
of puberty, all these organs are in a state of comparative 
quiescence, and the uterus of a girl of eleven or twelve years 
is scarcely larger than the organ in infancy. Notwithstanding 
the fact that ova undergo some degree of development and are 
discharged from the ovaries from early childhood onward, 
their growth proceeds slowly, and, so to speak, unperceived by 
the nervous system. At or about the fifteenth year, the uterine 
mucous membrane attains a high degree of development, and, 
at the same time, the erectile tissues of the other genital or- 
gans, external and internal, arrive at their structural comple- 
tion. Like a wound-up clock, with its needed touch to the 
pendulum, these organs now only wait for some sufficient im- 
pulse to arouse them to functional activity. This is afforded 
by the next recurring period of ovulation. By the advancing 
growth of one or more vesicles, an irritation of the ovarian 
nerves is produced ; the effect of this upon the sympathetic, 
and, by reflex action, upon the vaso-motor nerves, is an in- 
creased hyperemia in the uterus and other genital organs. 
The uterine congestion thus produced especially affects the 
lining membrane of the organ, for the reason that, structurally, 
it is more liable to vascular turgescence than the parenchyma. 
This vascular activity is followed by a corresponding increase 
of nutrition and hyper-growth—this latter consisting both in 
multiplication of the cellular elements of the part and develop- 
ment of those already existing. The superficial vessels of the 
membrane are greatly enlarged around the glandular orifices, 
as are also the glands themselves. The entire membrane is so 
thickened and convoluted that the uterine cavity seems scarcely 
large enough to contain.it. This process—called “nidation” 
by Aveling—takes place in order to supply the possible needs 
of an impregnated ovum, and should such a one reach the 
uterine cavity the developed membrane becomes its future nidus. 30 
Jackson : The Ovulation Theory 
But if not, a retrograde metamorphosis now takes place. The 
super-grown parts of the uterus, consisting, as already stated, 
chiefly of the mucous membrane, lose their excess of blood supply 
and die of starvation. The first elements which suffer death 
are the epithelial cells which line the mucous membrane; next, 
the new cells of the connective-tissue stratum below; and, 
finally, the vessels which are developing, or may have de- 
veloped from this surface. All these parts become infiltrated 
with fat, the new formations are carried off, the vessels open, 
and there results the active hemorrhage which constitutes the 
menstrual flow. This process is repeated at regular intervals 
corresponding to the periodic life of the individual, and vary- 
ing somewhat in different cases. 
In the sense and to the extent just indicated, I regard ovu- 
lation as necessary to menstruation ; it furnishes to the struc- 
turally-completed uterus, through the medium of the gangli- 
onic nervous system, a needed hypercemia to originate the 
menstrual discharge. In order to do this, it is not necessary 
that a follicle should burst (Ritchie), although it may do so. 
Indeed, I have no doubt that a follicle may pass through several 
periods without discharging its contained ovule. Doubtless, 
the pelvic congestion of the menstrual period greatly stimu- 
lates the maturation of the follicle, just as does the excitement 
of sexual intercourse, and to a much greater extent, probably, 
because of its longer continuance; and a follicle which has 
been subject to these successive periods of excitement event- 
ually matures and bursts, with, perhaps, an occasional excep- 
tion. The increase in its fluid contents, the thinning of its 
walls, and its near approach to the surface of the ovary, all 
conduce to its easy rupture; and such rupture may occur at 
any time, although it is clearly more likely to do so during the 
menstrual congestion, the excitement of intercourse, or, when 
on the point of bursting, from a blow on the abdomen 
(Schroeder). Such is probably the usual course, although, as 
already intimated, not an invariable one; for all authorities 
admit that some follicles never attain full development, but 
after arriving at a certain stage of growth, cease to enlarge 
and finally shrink and disappear. 
Menstruation, with its phenomena of regularly recurring 
development and disintegration of the uterine mucous mem- of Menstruation. 
31 
brane, once established, proceeds side by side with the process 
of ovulation. The two, while accompanying and aiding each 
the other, are yet mutually independent; and menstruation, 
instead of being an effect of ovular maturation and dehiscence, 
is rather, in a certain sense, their cause. In menstruation, the 
organ chiefly, and the only one essentially employed, is the 
mucous membrane of the body of the uterus; the other pelvic 
organs, that is to say, the uterus proper, the ovaries, Fallopian 
tubes and vagina, have no part in the process beyond their 
share in the attendant general pelvic congestion (Beigel). 
There are many facts connected with menstruation which 
are not satisfactorily accounted for by the ovular theory, and I 
desire, in conclusion, to call attention briefly to a few of them. 
(a) The first is that variety of the function known as remit- 
tent, where the habitual type is changed to another in which the 
flow occurs usually at shorter intervals—every fortnight, for 
example. These cases are strongly antagonistic to the received 
theory. Tilt1 considers them as dependent “ upon some per- 
version of the nervous force presiding over the generative 
function, because those in whom the anomaly is observed are 
generally of a delicate and nervous temperament,” and also 
because he has always succeeded in restoring menstruation to 
the monthly type by the exhibition of quinine, a remedy whose 
efficacy in controlling nervous derangement of a periodical 
character is well known. Negrier,* quoted by Tilt, after 
observing that several patients did not suffer from fortnightly 
menstruation, says: “ 1 do not believe that the ripening of the 
ovarian vesicles can take place in less than a month; so, in 
these cases, I think it more natural to suppose that the two 
ovaries might so progress monthly that, for instance, the right 
would contain a ripe vesicle on the first of the month, while in 
the left ovary a vesicle would ripen on the fifteenth.” Does 
anyone regard ovulation as a process whose type of periodicity 
would be changed by the administration of quinine ? 
(b) Again, the ovular theory does not account for the regular 
recurrence of menstruation after the removal of one ovary. 
1 Uterine and Ovarian Inflammation, third Lond. ed., p. 205. 
2 This author believed that the ovaries alternated their action, one furnish- 
ing an ovule one month, and the other the next. This is likewise the opinion 
of Gixdwood. 32 
J aokson : The Ovulation Theory 
Ovariotomists' are unanimous in the statement that in cases 
where a single ovary is removed, a healthy one being left, 
menstruation is not interrupted, or, at least, the function is no 
more deranged than it would be by any other equally severe 
surgical operation. 
It is not known how the wTork of maturing ovules is 
divided between the two ovaries. Mr. Girdwood, from obser- 
vations made in several cases, states that the number of cica- 
trices found in the ovaries corresponded with the known 
number of menstrual periods, and that they wrere equally dis- 
tributed between the two organs. Others think that for many 
months in succession one ovary may furnish all the ovules, and 
then remaining quiescent, that the other assumes the work for 
an equal, or possibly an unequal length of time. But it rs 
plain that if either of these hypotheses be accepted—if ovula- 
tion be regular in any manner, and its periodicity depend upon 
the presence of both ovaries, it would be interrupted neces- 
sarily by the removal of either of these organs. In the first 
case it would occur only at intervals of two months ; and, in 
the second, according as the active or quiescent organ, for the 
time being, were removed, we should have an entire temporary 
cessation at once, or at the end of its term of activity; and if 
menstruation were dependent upon ovulation, a corresponding 
aberration of regularity wrould be observed in it also. But 
this never takes place, for, as already stated, single ovariotomy 
is, as a rule, followed by no change whatever in the menstrual 
periodicity. 
It cannot be said, in answer to this, that, as in the case of 
the kidneys or testicles, the removal of one gland is followed 
by increased and compensating work by its fellow. The ovary 
is not a gland, and the Graafian vesicle is not a secretion. The 
office of the ovary is simply and only to furnish a suitable place 
for the development of the primordial follicles existent in its 
stroma from the beginning. 
(c) The remarkable regularity in the ripening and discharge 
of ovules, one after another, month after month, which is 
assumed by the ovular theory, is combatted also by the fre- 
quent occurrence of a simultaneous discharge of two or more 
ova.1 Multiparous pregnancies can, I think, only be rationally 
1 Ritchie, in a case reported by Cazeaux, found six ova in the uterus at one 
time. of Menstruation. 
33 
accounted for by the fact that the shedding of ovules is an ir- 
regular function, proceeding in both ovaries simultaneously and 
independently. 
(d) The ovular theory wholly fails, too, to account for the men- 
strual irregularities caused by mental influence. Tilt2 says : 
“ I have patients in whom any unusual nervous emotion or 
over-exertion will bring on the menstrual flow, with the usual 
menstrual symptoms, although they may have only just re- 
covered from this discharge. How can it be supposed that an 
ovule can be ripened, and the dense ovarian envelope suddenly 
perforated, by the fatigue of a dinner party, by hearing disa- 
greeable news, or by an altercation with a servant \ ” It is 
well known that influences such as those just mentioned may 
cause the discharge to appear, and may equally check it when 
present; and it is likewise known that these, or other similar 
disturbing causes, may at once change the menstrual regularity ; 
the flow appearing after the usual interval, whether the last 
one occurred at the right or wrong time. “ This sudden shift- 
ing of periodic action is the special attribute of the nervous 
system; it shows the menstrual flow to be impelled by nervous 
influence, and explains how a strong emotion may repel it or 
alter the time of its appearance ” (Tilt). 
The argument which I have endeavored to make may be 
thus summarized: 
1. Ovulation and menstruation may each occur independently 
of the other. 
2. Ovulation is the irregular but constant function of the 
ovaries, while menstruation is the regular rhythmical function 
of the uterus (Kesteven). 
3. Ova are matured and discharged from the ovaries at all 
periods of female life, from early childhood to old age, both 
before puberty and after the menopause; hence, the one cannot 
be the sign of the other. 
4. Menstruation is the consequence of conditions established 
by the structurally-completed uterus, and depends upon ovula- 
tion only for its origination. 
5. The mucous membrane of the uterine body is the only 
organ essentially concerned in the menstrual act; the uterus 
s Change of Life, p. 72. 34 
Jackson : Ovulation Theory of Menstruation. 
proper, tlie ovaries, Fallopian tubes and vagina have their 
functional activity increased, however, by receiving a share of 
the general pelvic congestion which accompanies the process. 
6. The menstrual congestion of the pelvic organs—of the 
ovaries in particular—is, of all causes, the one most likely to 
determine the ovipont when a Graafian vesicle is sufficiently 
mature, and hence ovulation and menstruation are frequently 
concurrent. 
7. The theory that would make menstruation dependent upon 
ovulation fails to account for the possible occurrence of preg- 
nancy at any and all times between the menstrual periods; for 
multiparous conceptions ; for the frequent persistence of men- 
struation after the removal of both ovaries ; for the non-inter- 
ference with menstrual regularity by removal of one ovary, and 
for the menstrual derangements and the shifting of menstrual 
periodicity from mental emotion. 
8. All the known facts in regard to both ovulation and men- 
struation are consistent with the theory that, after the latter is 
once established, the two functions proceed side by side, but 
independently of each other, the former occurring at irregular 
and the latter at regular intervals; while,on the contrary, many 
of these facts are wdiolly inconsistent with the theory, that as- 
sumes a necessary ovular maturity and rupture at each men- 
strual period.