Part 4

The greater number of the spinal nerves distributed to the genital organs arise from the lumbar portion of the spinal cord, pass as rami communicantes to the first four lumbar ganglia of the great sympathetic cord, whence they proceed to the series of symmetrical (paired) and asymmetrical (azygos) sympathetic plexuses in front of, and adjacent to the abdominal aorta, which already contain afferent and efferent spinal fibres derived from the pneumogastric, phrenic, and splanchnic nerves. A small number only of coarse nerve-filaments, a larger number of fine nerve-filaments, derived from the sacral nerves, proceed direct to the internal genital organs; many of these fibres enter the lower extremity of the pelvic or inferior hypogastric pleans, some pass to the cervical ganglia of the uterus. Below the bifurcation of the aorta and in front of the sacral promontory, a large number of the uterine nerves, both of spinal and of sympathetic origin, unite to form an azygos plexus which has been shown by experiment to possess great functional importance. Anatomically this constitutes the upper undivided portion of the hypogastric plexus, which is the downward continuation of the abdominal aortic sympathetic plexus; but inasmuch as it is the principal channel of nervous impulses to the uterus it is often known at the present day as the great uterine plexus (plexus uterinus magnus). The nerves to the ovary and Fallopian tube (ovarian nerves) are derived from the spermatic (ovarian) plexus, an offshoot of the renal plexus; as the spermatic plexus descends, it is reinforced by branches from the abdominal aortic plexus, these branches often arising from a small ganglion (spermatic ganglion). The hypogastric or great uterine plexus, single and median above, divides below into the paired pelvic or inferior hypogastric plexuses, which pass downward and forward on either side of the rectum; these plexuses are reinforced by spinal elements derived from the sacral nerves. Before the terminal expansions of the pelvic or inferior hypogastric plexus enter the tissues of the internal genital organs, the bladder, and the rectum, small masses of ganglionic matter are interspersed among the nerve fibres.

To the above general sketch, which has been based on the synoptical description of Chrobak von Rosthorn, must be added a more detailed account of the innervation of the ovaries, this branch of the subject being of especial importance. The nerves of the ovary are derived from the sympathetic system, in part from the spermatic ganglion, in part from the second renal ganglion, and in part from the superior mesenteric plexus. The nerves of the ovary are for the most part vascular nerves, which unite before entering the ovary to form the ovarian plexus, and then pass into the hilum with the vessels, envelop the vessels of the medullary layer, and thence pass to the follicular region; exceedingly numerous, they form a close-meshed network, surrounding all the vessels up to the finest capillary ramifications; those fibres which terminate in the capillary walls and those also which reach the follicles are regarded by Riese as sensory. The great trunks of the uterine nerves are transversely disposed in relation to the great lateral vessels of the uterus, and passing inward toward the mucous membrane they break up into pencils of filaments; the uterine nerves proper are distributed for the most part to the muscular substance. In the Fallopian tubes, the nerves form arches around the lumen of the tube; some fibres also pass to the longitudinal folds of the mucous membrane.

This expansion of the nerves of the cerebrospinal and sympathetic systems in the female reproductive organs manifests the multiple interconnection of the two systems in this region, and proves beyond doubt that the sensory nerves of the genital organs have manifold connections with the motor tracts of the whole organism on the one hand and with the sensory ganglia of the central nervous system on the other, and in addition with the vasomotor centres and with efferent motor and secretory fibres.

As regards the vascular system of the female genital organs, the latter are supplied by the internal iliac artery. One of the two terminal branches of the common iliac, the internal iliac artery, descends into the pelvis over the sacro-iliac synchondrosis. Its branches may be arranged in four groups: anterior group, the hypogastric, iliolumbar, and obturator arteries; posterior group, the lateral sacral, gluteal, and sciatic arteries; internal group, the inferior vesical, uterine, and middle haemorrhoidal arteries; inferior group, comprising a single artery only, the internal pudic; the uterine artery supplies the uterus and the vaginal fornices; the ovarian artery supplies the ovary, the Fallopian tube, and the broad ligament of the uterus; the vaginal, cervicovaginal, or vesico-vaginal artery supplies the vagina; the internal pudic artery supplies the vestibule and the clitoris; the superior and inferior external pudic arteries (branches of the femoral artery) supply the labia majora. The veins of the female genital organs correspond in general to the arteries in their course and nomenclature, and empty their blood into the internal iliac vein.

FIG. 4.—The distribution of the lateral sacral arteries, the superior haemorrhoidal or superior rectal artery, the uterine artery, the ovarian artery and the distal portion of the internal pudic artery. (From Toldt: Atlas of Human Anatomy.—Rebman Company, New York.) ]

Attention must also be paid to the extremely rich lymphatic vascular system of the female genital apparatus. The body of the uterus and the annexa of that organ, the neck of the uterus and the vaginal fornices, the middle segment of the vagina, the lower segment of the vagina, the vestibule and the external genital organs—each of these possesses an independent set of lymphatic vessels, leading moreover to independent groups of lymphatic glands. It may be said that the lymph from the vulva passes to the inguinal glands, that from the vagina and the neck of the uterus to the internal and the external iliac lympathic glands, that from the upper part of the uterus and also that from the ovaries and Fallopian tubes to the median group of lumbar lymphatic glands (also known, from their position in front of the aorta and the vena cava, as the aortic lymphatic glands) (Chrobak von Rosthorn).

The important influence which the genital processes exercise on the female organism as a whole is established not only by the anatomical relations just described but also by a number of physiological investigations and experiments and by the result of operations on the female genital organs.

Thermic and mechanical stimulation of the female genitals has, as my own experiments have shown, a notable influence on the heart and the general circulation. In these experiments, when uterine douches were given at temperatures of 4° C. (39° F.) and 45° C. (113° F.), the reflex nervous impulse which resulted from these manipulations had a two-fold influence on the circulation, manifesting itself first by an immediate and considerable augmentation in the functional activity of the heart, the frequency of which was increased in a degree proportional to the nervous sensibility of the individual, and secondly by a notable rise in blood pressure.

With a view to determining the influence of stimulation of the ovary on blood-pressure, Röhrig carried out some experiments on bitches, from which it appeared that electrical stimulation of the ovary invariably produced a remarkable increase in the general blood-pressure, an increase ranging from twelve to twenty-four millimeters of mercury. It further appeared in the course of these experiments that toward the end of the period of stimulation the rise in blood-pressure was always followed by a decline; to which, however, a renewed rise of blood-pressure succeeded after the stimulation was discontinued, provided the duration of this had not been excessive. Only after this second rise was the normal mean blood-pressure regained. Finally it was established that the pronounced phenomena of vagus-irritation exhibited by the curve during and immediately after the stimulation of the ovary were invariable concomitants of the rise of blood-pressure produced by such stimulation.

According to the observations of Federns, the blood-pressure undergoes a rhythmical change between one menstrual period and the next, the pressure curve being normally at its lowest at the time of the commencement of the flow, and at its highest at some time during the two days immediately preceding the flow. This rhythmical change of blood-pressure manifests itself also some time before the first onset of menstruation, when the approach of puberty is indicated only by the menstrual molimina.

Observations made by Kretschy in a patient with a gastric fistula have proved the influence exercised on gastric digestion by the physiological processes occurring in the female reproductive organs. In this patient, his attention was especially directed to determining at what period of digestion the secretion of acid by the stomach attains its maximum, and how that secretion increases and diminishes. He observed that the digestion of breakfast was completed in four and one-half hours, the acid-maximum occurring in the fourth hour, and the reaction of the gastric contents becoming neutral one and one-half hours later. This apparently constant acid-curve began, however, to become irregular as soon as the first symptoms of the approach of menstruation became apparent. When the flow had actually begun, he found that the reaction of the gastric contents remained acid throughout the entire day. As soon as the flow was over, the normal acid-curve was immediately reëstablished.

These observations have been confirmed by Fleischer. This investigator carried out his researches in menstruating women with normal stomachs, and found that with the appearance of the catamenia the process of digestion was almost always notably retarded, but that with the diminution and cessation of the flow digestion returned to the normal.

By stimulation of the central segment of the divided hypogastric or great uterine plexus, Cyon was able to provoke vomiting, a confirmation of the well-known physiological fact that irritative disturbances of the female reproductive organs have a reflex influence on the vomiting centre.

It is also clearly established that diverse stimulation of peripheral nerves, those for instance of the mammary gland, of the internal genitals, or of the epigastrium, is capable of affecting the motor centre of the uterus.

Worthy of note also are Strassmann’s experiments, showing that rise of pressure in the ovary causes swelling and structural changes in the uterine mucous membrane.

Striking also are Neusser’s discoveries that during menstruation there is an increase in the eosinophil cells of the blood, and that by the intermediation of the sympathetic nervous system the ovaries exercise an influence on the hæmatopoietic function of the red marrow of the bones. Most noteworthy is the connection between the functional activity of the ovaries and osteomalacia. In this disease of metabolism we have to do, according to Fehling’s now generally accepted assumption, with a trophoneurosis of the bones, a stimulation of the vasodilator nerves of the osteal vessels, dependent on a reflex impulse from the ovaries. The connecting path between the ovaries and the bones Neusser finds in this case also in the sympathetic nervous system.

The reflex influence exercised on the heart and the general circulation has been shown also by the results of operations on the female genital organs. In cases in which the ovaries have been removed, or in which these organs have been roughly handled, Hegar has noticed a great diminution in the frequency of the pulse, sometimes even cessation of the heart’s action. In similar circumstances Champonière also observed as a rule diminished frequency of the pulse, but in some cases increased frequency. Mariagalli and Negri have described tachycardia following laparotomy and the extirpation of double pyosalpinx. Bonvalot has published cases in which, in consequence of vaginal or intra-uterine injections, in consequence of simple examination, and in consequence of the performance of version, sudden death has resulted from cardiac syncope.

The psychical influences which proceed from the female genital organs in the different periods of sexual life have also great significance for the organism as a whole. Manifold impulses both stimulating and depressing arising in the reproductive organs affect the workings of the mind. The maiden at puberty is affected by the knowledge of sexuality; the sexually mature woman, by the desire for sexual satisfaction, and by the yearning for motherhood; the wife, by the processes of pregnancy, parturition, and suckling, or, on the other hand by the distressing consciousness of sterility; the woman at the climacteric period, by the knowledge of the disappearance of her sexual potency. The mind is further sympathetically influenced by the stimulation of the terminals of the sensory nerves in the genital organs. Through the increase of such stimulation, through its spread to adjacent nerves and nerve tracts and to the entire nervous system, the mind is affected, directly by irradiation, or indirectly by vasomotor processes and spinal hyperæsthesia.

Psychical manifestations and the nervous states associated with these are somewhat frequently, and even actual psychoses occasionally, encountered in the various phases of the sexual life of woman, sometimes taking the form of violent sexual storms, which may indeed, as ordinary menstrual reflexes, accompany every catamenial period.

Of great interest are the facts which have, in recent times especially, been scientifically established, pointing to a certain periodicity, to an undulatory movement of the general bodily functions of the female organism, dependent upon the sexual life. The observations of Goodman, Jacobi, von Ott, Rabuteau, Reinl and Schichareff, have shown that in woman the principal vital processes pursue a cycle made up of stages of increased and diminished intensity, and that this periodicity of the chief general processes of vital activity finds expression also in the functions of the reproductive organs. Goodman has compared this play of general vital functions to an undulatory movement. According to this writer, a woman’s life is passed in stages, each of which corresponds in duration with a single menstrual cycle. Each of these stages exhibits two distinct halves, in which the vital processes are respectively ebbing and flowing: in the latter we see an increase of all vital processes, a larger heat production, a rise in blood-pressure, and an increased excretion of urea; in the former we see, on the contrary, that all these vital processes display a diminished intensity. The moment when the period of increased vital activity is at an end, the moment when the ebb begins, corresponds, according to Goodman, to the commencement of the catamenial discharge.

Goodman sought for verification of this undulatory theory of the sexual life of woman in certain data regarding the bodily temperature and the blood-pressure. A more extensive research was undertaken by Jacobi, who, as the result of her observations, came to the following conclusions. In eight cases she noticed in the premenstrual epoch a rise of temperature ranging from 0.05° C. to 0.44° C. (0.09° F.–0.79° F.); and during the catamenial discharge a gradual fall of 0.039° C.–0.25° C. (0.072° F.–0.45° F.), never less, that is to say, than a quarter of a degree Centigrade; but in the majority of cases the temperature did not, while the catamenia lasted, regain the normal mean. She further observed in the generality of cases an increased excretion of urea during the premenstrual epoch; and a notable fall in blood-pressure during menstruation.

Reinl’s observations on healthy women, in whom menstruation ran a normal course, showed that in the great majority of cases in the premenstrual epoch the temperature was elevated as compared with that of the interval, that in eleven out of twelve cases the temperature gradually declined during menstruation, to fall in three-fourths of the cases below the mean temperature of the entire interval, and exhibiting in the post-menstrual epoch a still further depression, giving place, however, to a somewhat higher mean temperature during the first half of the interval. In the second half of the interval a higher mean temperature was observed than in the first half.

If we make a graphic representation of the mean differences in temperature commonly observed throughout the various stages of an entire menstrual cycle, we see that the curve does in fact take the form of a wave. That drawn by Reinl is shown in the following figure: (FIG. 5.)

FIG. 5. ]

The rising portion of the wave, the beginning of the tidal flow, corresponds to the second half of the interval; the height of the tidal flow, the crest of the wave, corresponds to the premenstrual epoch. As the flow gives place to the ebb, as the wave begins to decline, we come to the actual period of the catamenial discharge; later in the ebb is the post-menstrual epoch, and the lowest portion of the declining wave corresponds to the first half of the interval. Rhythmic changes corresponding to those observed in the temperature have been recorded—at least in isolated stages of the menstrual cycle—affecting the blood-pressure by Jacobi and by von Ott, affecting the excretion of urea by Jacobi and by Rabuteau, and affecting the pulse by Hennig. It is evident that the vital activity of the organism attains its maximum shortly before menstruation; and that with or immediately before the appearance of the catamenial discharge, a decline of that activity commences.

Schrader, through his researches on metabolism during menstruation in relation to the condition of the bodily functions during this process, has established that immediately before menstruation the elimination of nitrogen in the fæces and the urine is at its lowest, a fact which indicates that at this period of the menstrual cycle the disintegration of albumen in the body is notably diminished.

Von Ott found in thirteen cases out of fourteen that at the beginning of the catamenial discharge or just before a considerable fall in blood-pressure occurred, and that throughout the flow the pressure almost always remained below the mean, no rise taking place till menstruation was finished; this fall in blood-pressure during menstruation was more considerable than could be accounted for by the moderate hæmorrhage. The same author, in conjunction with Schichareff, examined fifty-seven healthy women in respect of heat-radiation, muscular power, respiratory capacity, expiratory and inspiratory power, and tendon-reflexes. He found that the energy of the functions of the female body increased before the beginning of menstruation, but declined with or immediately before the appearance of the catamenial discharge. He exhibited this rhythmical variation in the vital processes by means of the following curve, in which the line A B represents these physiological variations, whilst on the abscissa line c e, the days of observation are recorded, and the interval m n represents the menstrual period. The degree of intensity of the united functions is indicated by the numbers 0–100 on the ordinate.

FIG. 6. ]