When we study the history of human civilization we find that sterility
in women is regarded, not merely as a misfortune, but as a reproach.
Among savage races, and in the Orient, where the position of women is
one of strict subordination, she does not attain an honourable status
until she becomes a mother. In Persia, a sterile woman is always
divorced by her husband. In India, also, when a sterile married woman
has in vain employed the various religious measures advocated for the
relief of her barren condition she is sent back to her parents. Both in
China and Japan, a barren woman is regarded as a most miserable
creature. Among the negro races, a woman who fails to bear children is
the object of scorn and contempt. Among the Dualla negroes, a man whose
wife fails to bear children demands from her parents the return of the
sum which he paid for her at the time of marriage. Many of the
indigenous tribes of South America also make a practice of divorcing a
sterile wife. Among the better-class Circassians, the women do not
attain an assured position until they have borne a child. In Angola a
barren woman is the object of universal contempt, and she often feels
the ignominy of her position so keenly that she commits suicide. Alike
among the Jews and among the Turks, barrenness in a wife is a recognized
ground for divorce, and the woman who has been divorced for this reason
will hardly ever succeed in obtaining another husband, for she is
regarded as one whose body is not properly developed. According to old
German law, barrenness in a wife and impotence in a husband were both
grounds for divorce. The code of the Emperor Justinian allowed of
divorce in cases in which for the space of two years a husband had been
unable to fulfil his marital duties, and such a union was termed
_innuptæ nuptæ_. Among the ancient Romans, although they regarded
barrenness as a mark of the divine disfavour, according to the laws of
Augustus failure to bear children was a punishable offence, and such a
punishment was incurred by any married woman who had attained the age of
20 years without having become a mother. In ancient Greece also,
divorces due to the barrenness of the wife were by no means uncommon.
Among the Slavonic peoples sterility was so greatly despised that there
is a Slavonic proverb which runs: “A woman is no woman until she has
borne a child”: and in Istria a sterile woman is known by the nickname
“Scirke,” which is equivalent to “hermaphrodite.” The Jewish view of the
matter is expressed in the Talmudic rabbinical saying: “A wife’s duties
are beauty, gentleness, and the bearing of children”; and again, “the
poor, the leprous, the blind, and the childless, are like the dead”;
and, finally, “he who refrains from marriage with the deliberate
intention of having no children, incurs the guilt of murder.” In the
Koran we find the fatalistic expression, “God makes a woman barren in
accordance with his will.”
We can therefore readily understand that in the most ancient medical
writings the question of sterility in women is a matter of earnest
consideration. In the works of the early physicians of Hindustan we find
several apt remarks on the subject. _Susruta_ says: “Pregnancy most
readily results from intercourse during menstruation. At this time the
os uteri is open, like the flower of the water lily in the sunshine.” In
the Old Testament, in which the newly-created human couples receive the
command, “Be fruitful and multiply, and replenish the earth,” we find
frequent references to barrenness as a state equally dishonourable and
unfortunate, and the use of certain plants is recommended as a means of
cure. The Talmud contains several essays dealing with the causes and
treatment of sterility.
The _Hippocratic_ collection of writings contains a number of passages
dealing with the causes of sterility and with the means to be employed
for its relief. We shall have occasion later to refer to these
recommendations. _Celsus_, on the other hand, has little to say on this
subject. In the works of _Pliny_, and also in those of _Aristotle_,
there are references to the topic of sterility.
Among the writers of the first century of our era, _Soranus_ discusses
exhaustively the capacity for conception and sterility. In his work we
find, among other passages, the unquestionably accurate remark: “Since
the majority of marriages are concluded, not from love, but in order to
procreate children, it is difficult to understand why, in the choice of
a wife, less regard is paid to her probable fertility than to the
worldly wealth of her parents.”
In the middle ages, _Paulus Agineta_ more especially treats of the
diseases of women, and among these, of sterility in women. That in
Arabian medicine much attention was paid to this question, we can learn
from the writings of Maimonides.
By sterility in women we understand the pathological state in which a
woman who is sexually mature fails to conceive, notwithstanding
frequently repeated, normal sexual intercourse throughout a considerable
period of time.
Sterility is termed _congenital_ (or _absolute_) when, notwithstanding
repeated intercourse throughout a long period (not less than three
years), pregnancy has always failed to ensue; it is termed _acquired_
(or _relative_), when women who have already been pregnant once or more
often, cease to conceive, although they are still quite young enough to
do so, and have experienced regular sexual intercourse for a long period
(not less than three years). In a wider sense of the term, we say that a
woman is sterile, when, notwithstanding prolonged and repeated sexual
intercourse, in circumstances favourable to procreation, she has failed
to give birth to a living and viable infant.
English authors also make a special distinction regarding that form of
acquired sterility (which is no great rarity), in which a woman gives
birth to a single infant and subsequently remains sterile (“_only-child
sterility_”).
The civilization of the present day, with its shady side, has made it
necessary for us to pay an increasing attention to _facultative
sterility_, dependent upon the use during intercourse of means for the
prevention of conception; and very recently the surgical tendency of
modern gynecology has brought into being a new variety of sterility in
women, viz., operative sterility.
The period which must elapse after marriage, before the absence of
pregnancy must lead us to regard a woman as sterile, is fixed at three
years. This limitation is based upon the statistical data which (see
Table on page 368) I gave regarding 556 fruitful marriages.
The ideal state of fertility, that in which conception is the immediate
result of the first act of intercourse between husband and wife, the
conception being followed in due course by the birth of a child, is,
like most other ideals, one very rarely attained. In the human species,
conception as the immediate result of the first act of sexual
intercourse, is an extremely unusual occurrence. To invoke medical
assistance for women who have failed to conceive during the first three
months of married life, which my experience shows to be more frequently
done now than formerly, is devoid of all justification; and still worse
is it, in this period of “early love” to subject women, as has often
been done recently by overenergetic gynecologists, to local treatment,
even to the extent of operative procedures.
We are not justified in speaking of the existence of actual sterility
until three years of marital intercourse have failed to result in
conception; still, when the commencement of the first pregnancy is
delayed for more than sixteen months after marriage, there is
considerable probability that the woman is sterile; and this probability
increases month by month till the expiry of the second year, whilst as
the end of the third year approaches, it becomes tantamount to
certainty.
Sterility is one of the commonest of the functional disorders of women,
and one of those which most often demand gynecological assistance.
By a statistical study of the marriages of the royal and princely
families of Europe and of the marriages of the highest families of the
aristocracy, I learned that of 626 marriages, 70 were barren; thus the
ratio of fruitless to fruitful marriages proved to be as 1 : 8.87. But
in other circles of society, in so far as data relating to the matter
were obtainable in my practice, the statistics of infertility were by no
means so unfavourable, the ratio working out at about 1 barren to 10
fruitful unions. I must point out, however, that these statistics, like
all statistics of fertility, are to a degree invalidated by the fact
that in a certain number of the instances included among the barren, an
unnoticed abortion may have occurred.
_Simpson_, in his investigation regarding the frequency of sterile
unions, found a ratio of 1 : 8.5 (in 1252 instances). In the English
aristocracy, where the marriages are for the most part restricted among
the members of a comparatively small number of families, the ratio was
1 : 6.11 (495 instances); on the other hand, among the population of
Grangemouth and Bathgate, consisting chiefly of persons engaged in
seafaring and agricultural occupations, the ratio of barren to fruitful
unions was as 1 : 10.5.
_Spencer Wells_ and _Marion Sims_, as a result of their investigations,
give a ratio of 1 : 8.
According to _Seeligmann_, in Hamburg, among marriages of persons in all
classes of society, 11.5% are barren. _Prochownick_ found among 2500
women, all of whom had been married for eighteen months or more, and
none of whom were more than 40 years of age, that 9% had failed to
conceive.
According to _Frank_ and _Burdach_, who do not publish the figures upon
which their estimate is based, only 1 marriage in 50 proves barren.
_Lever_, who also gives merely his percentage result, states that 5% of
married women are completely infertile. _Hedin_, dealing with a Swedish
community of 800 persons, states that the percentage of sterile unions
is barely 10.
According to _Goehlert’s_ statistical investigations, in the dynasty of
the Capets, among 450 marriages, 19.7% were sterile: in the Wittelsbach
dynasty (Bavaria), among 177 marriages, 23.7% were sterile; and among
the ruling families of Germany (more than 600 marriages), 20.5% were
sterile. In this investigation, however, no attention is paid to the age
of husband or wife; marriages and remarriages are classed together
without discrimination; and those marriages only in which a living child
was born are counted as fruitful, so that the unions counted as sterile
must contain many in which abortion or stillbirth occurred. In three
Esthonian communities in Livonia, _Oehren_ found that among 2799
marriages, 8.4% were barren, but in this instance also stillbirths were
ignored.
_Ansell_ reports that of 1919 marriages of women belonging to the upper
classes, their mean age being 25 years, 152 proved barren, a proportion
of 1 : 12, or about 8%.
_Matthews Duncan_ communicates the following data. In the year 1855, in
the cities of Edinburgh and Glasgow, 4447 marriages were contracted, and
of these 725 proved barren, a proportion of 1 : 6.1; 75 of these may
however be excluded from consideration, inasmuch as the wives were
already at the age of 45 or upwards. Among the remaining 4372 marriages,
662 proved barren, a proportion of 1 : 6.6. In other words, 15% of all
marriages of women between the ages of 15 and 44 proved sterile.
From France we obtain figures showing a much higher proportion of
sterile unions. According to _Rochard_, in France in the year 1888, of
ten million families, two million had no child at all, and two million
had each an only child, so that two fifths of the families of France
were taking no practical part in the maintenance of the population.
According to _Chevin_, the proportion in France of barren to fruitful
marriages is as 1 : 5. 20% are entirely barren, while 24% exhibit
only-child-sterility.
From Massachusetts, _Morton_ reports that according to the last census
returns, one fifth of all married women are childless.
In England, numerous trustworthy statistics can be obtained regarding
the frequency of sterile marriages. The average proportion of barren to
fruitful unions was:
Among the patients in St. Bartholomew’s Hospital 1 : 8
Among the inhabitants of Grangemouth 1 : 10
Among the inhabitants of Bathgate 1 : 10
Among the British peerage 1 : 6
Among the upper classes 1 : 12
Among the inhabitants of Edinburgh and Glasgow 1 : 7
_Matthews Duncan_ compiled the following table relating to 504
absolutely sterile women met with in his practice:
═════════╤═══════════════════════════════════════════════════════════════
AGE AT │ NUMBER OF YEARS MARRIED.
MARRIAGE.│
─────────┼───────┬───────┬───────┬───────┬───────┬───────┬───────┬───────
„ │ Less │4 to 8.│ 9 to │ 14 to │ 19 to │ 24 to │ 29. │Totals.
│than 3.│ │ 13. │ 18. │ 23. │ 28. │ │
─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼───────
15 to 19 │ 12│ 19│ 15│ 4│ 7│ 2│ 1│ 60
20 to 24 │ 70│ 66│ 37│ 24│ 13│ 9│ │ 219
25 to 29 │ 47│ 51│ 20│ 8│ 8│ │ │ 134
30 to 34 │ 26│ 20│ 8│ │ 1│ │ │ 59
35 to 39 │ 6│ 13│ 4│ │ │ │ │ 23
40 to 45 │ 6│ 3│ │ │ │ │ │ 9
─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼───────
Totals │ 167│ 172│ 84│ 40│ 29│ 11│ 1│ 504
═════════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════
_Ansell_ bases upon the observations made by him in the case of 152
sterile women the conclusion that there is no longer any chance of the
occurrence of pregnancy if a woman is:
More than 48 years old, and has had no child for 2 years
More than 47 years old, and has had no child for 3 years
More than 46 years old, and has had no child for 4 years
More than 45 years old, and has had no child for 6 years
More than 44 years old, and has had no child for 8 years
Less than 44 years old, and has had no child for 10 years
If we take into account also cases of acquired sterility, the proportion
of barren to fruitful marriages becomes even more unfavourable, and the
proportion increases enormously if, with _Grünewaldt_, we number among
the barren women those who fail to continue child-bearing up to the
normal climacteric period. _Grünewaldt_, dealing with about 1500 women
suffering from affections of the reproductive organs, excluded all those
who were either virgins or widows, and also all those who at the time of
the observed barrenness were over 35 years of age; this left more than
900 women suffering from affections of the reproductive organs, all of
whom were sexually mature, and were living in marital intercourse; of
these, nearly 500 were barren, 300 being instances of acquired
sterility, and 190 instances of congenital sterility. Thus, according to
this observer, disease of the reproductive organs in women led in more
than 50% of the cases to disturbance of the reproductive capacity; about
one in every three women, previously competent to bear children, became
barren when affected with disease of the reproductive organs; and among
every five gynecological patients of the condition already specified as
regards age and sexual intercourse, one proves congenitally sterile.
It must not, however, be forgotten, that sooner or later after marriage
artificial sterility tends to come into being, its early or late
appearance depending upon the degree of civilization and upon the
national and economical conditions of the people and the individuals
concerned. This fact must not be left out of the account.
The manner in which, in the human species, fertilization is effected, is
still far from clear in all its details; hence it is easy to understand,
that the etiology of sterility remains in many respects obscure. It is
impossible in every case to find a definite cause. Whereas, on the one
hand, notwithstanding the existence of apparently insuperable obstacles,
impregnation may nevertheless be effected; so, on the other hand,
sterility may exist in cases in which all the circumstances appear
favourable to the occurrence of conception. Hence a classification of
the different varieties of sterility from the etiological standpoint, is
a very difficult task, and the conclusions thus obtained are often
vitiated.
Although it cannot be denied that mechanical causes are competent to
lead to sterility in women, _Sims_, in his advocacy of the mechanical
doctrine of sterility, widely overshoots the mark. His authority,
however, has led to a general acceptance of this doctrine, which is by
no means justified by facts. The theory of mechanical obstruction,
according to which sterility in women depends upon mechanical obstacles
to the passage of the spermatozoa towards the ovaries, is from time to
time strikingly illustrated by cases coming under our notice—cases the
nature of which can hardly be overlooked; but it is quite wrong to
suppose that this causation accounts for the _majority_ of instances of
sterility in women, and strict limitations should be placed upon the
employment of surgical measures based upon this mechanical theory of
sterility.
The mechanical view has been counterposed by _Von Grünewaldt_ with a
doctrine in which especial stress is laid upon obstacles to
utero-gestation, sterility being regarded as a functional disorder
brought about by affections of the female reproductive organs rendering
the uterus unfit for the incubation of the ovum. It cannot be denied
that the elucidation of this casual influence was a valuable
contribution to the theory of sterility, and it is unquestionable that
many morbid conditions of the uterus exist capable of giving rise to
sterility in this manner; but we must avoid the error of regarding this
doctrine as a full explanation of the cause of sterility.
If, however, both of these theories of sterility are insufficient, we
cannot regard a third theory, that of _Matthews Duncan_, as filling the
gaps in our knowledge. It would be most unfortunate if this author were
right in maintaining that all our knowledge of the causes of sterility
is to be summed up in the phrase “deficient reproductive energy;” we
cannot agree with _Duncan_ in his belief that “Sterility is an
imperfection devoid of all perceptible, measurable characteristics;” nor
can we follow him when he maintains that local causes, whether they are
such as hinder conception, or such as hinder utero-gestation, have a
very limited sphere of activity. _Matthews Duncan_ adopts an
incomprehensible standpoint when he regards sterility as dependent upon
a law of nature, as a condition which may affect distinct classes or an
entire population.
According to the latest doctrine of sterility, only in quite exceptional
instances is the woman regarded as responsible for the occurrence of
sterility; contrariwise, the male genital organs are commonly blamed for
the affection, which is in the overwhelming majority of cases supposed
to be due to azoospermia, usually dependent upon gonorrhœal infection;
compare with this, affections of the female reproductive organs are said
to play a quite subordinate role in the etiology of sterility. But for
my part, though I recognize the important share that gonorrhœa in the
male plays in the causation of sterility, I am of opinion that the
extreme view just mentioned is by no means justified by the facts.
Sterility, a functional disturbance of an extremely complicated nature,
can, in my opinion, be most usefully elucidated from the etiological
standpoint by starting with the assumption that three conditions are
absolutely essential to procreation:
1. that ovulation proceeds in a perfectly normal manner, the maturation
of the discharged ova being complete;
2. that normal spermatozoa have access to these normal ova (conjugation
of male and female pronuclei);
3. that the uterus is properly adapted for the gestation of the
fertilized ovum.
My classification of the varieties of sterility corresponds to these
conditions of procreation: