It must also be admitted that there are additional causes of sterility,
causes which lie beyond our control. Moreover, as I have already
mentioned, in most cases of sterility, we have to do, not with a single
cause, but with the resultant of two or more cooperating causes.
_Incapacity for Ovulation._
Incapacity for ovulation, the first and most decisive cause of sterility
in women, may be absolute and irremediable, or relative and transient.
We have to do with the former in cases in which the ovaries are entirely
wanting, or when they are affected with organic disease to such a degree
that they have become incapable of fulfilling their function of
ovulation; incapacity for ovulation is, on the other hand, relative and
transient in certain pathological states of the ovary and neighbouring
organs, when there is incomplete development or partial atrophy of the
ovaries, when there are new-growths of the ovaries, in cases of
oophoritis and perioophoritis, in consequence of disturbances of
innervation, diseases of the central and peripheral nervous system,
violent emotional disturbance, constitutional disorders, such as
syphilis, chlorosis, anæmia, universal lipomatosis, scrofula,
alcoholism, and morphinism, also in consequence of changes in the supply
of nutriment and in the general mode of living, or of senile changes,
and finally in consequence of hereditary influences.
The diagnosis of the etiological influence of suppressed or incomplete
ovulation in the production of sterility in women is at times beset with
great and even insuperable difficulties. The state of the menstrual
function, suppression of the flow, or the regularity or irregularity of
its occurrence, serve indeed to inform us as to the general activity or
inactivity of the function of ovulation; but the variations in this
function give no certain information as to whether a woman is fertile or
infertile. Knowing as we do that generally speaking an intimate
connexion subsists between menstruation and ovulation, we are indeed
able to assert that regular menstruation and fertility in women run a
parallel course, and further, that the greater the irregularity of the
menstrual function, the greater the tendency to sterility. Recently,
great advances have been made in the technique of manual exploration of
the ovaries, and by means of vaginal and rectal bimanual examination, we
are now able to obtain accurate information regarding abnormalities in
the size, shape, and position of these organs, and regarding any other
intrapelvic disorders. In this way we have been enabled to recognize a
number of pathological states of the ovaries which affect the functions
of these organs. In some cases also there are general symptoms which
furnish us with the means of drawing conclusions, more or less
trustworthy, regarding the state of the ovarian functions; for instance,
the general development of a woman’s body, the condition of the external
genitals, the vulva, the mons veneris, the pubic hair, the clitoris, and
the mammae. Again, we can derive information from various troubles of
which women complain; such as sacrache; a sense of weight and pressure
in the pelvis; feelings of tension and shooting pains in the breasts;
flushings of the face; haemorrhage from the nose, mouth, or rectum,
recurring at regular intervals and vicarious in nature. In many
instances, however, it will only be by obtaining data regarding the age,
mode of life, and family history, of the person affected, that it will
be possible to draw conclusions as to the cause of the sterility.
The female reproductive glands, the ovaries, may, owing to developmental
disturbances during foetal life, either be entirely wanting, or they may
merely be deprived of certain structural constituents, especially their
epithelial elements. In the former case, we have congenital complete
unilateral or bilateral absence of the ovary, a condition most commonly
associated with the absence or with a rudimentary condition of other
portions of the reproductive apparatus; in the latter case, we have the
condition somewhat inappropriately named congenital atrophy of the
ovary.
Complete absence of both ovaries necessarily leads to absolute
sterility. Both congenital absence and congenital atrophy of the
ovaries, will usually be found in association with other anomalies of
the sexual organs. Absence of one ovary, on the other hand, by no means
entails sterility; on the contrary, when a single well-formed ovary
exists, ovulation usually proceeds in a perfectly normal manner. When
such women marry, pregnancy usually follows in the normal proportion of
cases; and, in complete opposition to one of the theories of the
determination of sex to which allusion has been made, such women bear
children of both sexes.
_Morgagni_ described a case of congenital absence of both ovaries in a
woman 66 years of age, in whom the external genital organs, the vagina,
and the uterus, were imperfectly developed, but the Fallopian tubes were
of normal size. Careful examination of the upper borders of the broad
ligaments of the uterus disclosed no trace of ovary on either side.
_Quain_, in a virgin 33 years of age, found the vagina rudimentary, with
its mucous membrane but slightly corrugated; at the upper end of this
passage was a semilunar fold which probably represented the uterus. The
ovaries were absent; a small gland-like body embedded in the left wall
of the vagina was regarded by him as a rudimentary ovary. The
configuration of the body was feminine, feminine also the disposition;
moreover, there was a monthly recurrent epistaxis.
The atrophy of the ovaries which normally takes place at the climacteric
period, to be more minutely described in the section on the menopause,
has constitutional effects similar to those dependent upon absence or
congenital atrophy of the ovaries.
A rudimentary condition of both ovaries, or bilateral atrophy of these
organs, with or without associated atrophy of the entire reproductive
system, commonly entails sterility. In such cases, in addition to
amenorrhœa, we usually find that the breasts are but slightly developed,
the pubic hair is scanty, the labia majora and labia minora are small,
whilst sexual appetite is deficient, and during coitus the woman is
entirely passive. On the other hand, we must not make the mistake of
inferring from the fact that the sexual appetite is keen and coitus
pleasurable, that therefore the capacity for ovulation is normal. Even
after operative removal of both ovaries, some women have assured me, not
only that the sexual impulse was as strong as formerly, but even that
they continued to experience the sexual orgasm in its full intensity.
This is analogous to the well known fact that men who have undergone
castration after arriving at sexual maturity may remain capable of
performing coitus. It is a matter of history that in the lupanars of
ancient Rome, castrated men were kept to enable women to enjoy the
pleasures of sexual intercourse without fear of consequences; and it is
said that such men are to be found in Italian brothels to this day. In
the case of the lower mammals, it appears to be the rule that when the
reproductive glands are removed in early youth, every trace of sexual
desire disappears.
Incomplete development of the ovaries, with consequent defective
ovulation, may result from marriage in girls who are still immature—a
fact already known to _Aristotle_, who wrote, “premature marriage leads
to a scanty progeny—that this is the case in man as well as the lower
animals is witnessed by the weakly inhabitants of regions in which
child-marriage is common.”
It is shown by statistical data that the age at which puberty occurs,
the age, that is, at which the menstrual flow begins, has a relation to
sterility; and the same is true as regards the age at marriage. In the
former connexion, women in whom puberty is comparatively early, are less
often sterile than those in whom puberty is comparatively late. _Emmet_,
in an investigation embracing 2330 cases, showed that in our climate the
average age at which the first menstruation occurred was 14.23 years,
and that in the case of women who subsequently proved fertile, the first
flow took place on an average 26 days earlier than in the case of women
who subsequently proved barren. We also learn from _Emmet’s_ tables that
the mean duration of menstruation and the mean quantity of the flow are
larger in fertile than in barren women.
As regards the influence of the age at marriage upon fertility, in women
who marry between the ages of 20 and 24 years, sterility is most
infrequent; it is commoner in women who marry between the ages of 14 and
20; after the age of 25, the proportion of sterile women increases with
each year to which marriage is postponed.
Premature atrophy of the ovaries, with consequent incapacity for
ovulation, may occur in a great variety of conditions; it has been
observed in scrofula, diabetes, rickets, phthisis, and malarial
cachexia; it also occurs in certain chronic intoxications, as from the
long-continued use of opium or morphine, and from the abuse of alcoholic
beverages. According to the observation of _Burkart_, _Levinstein_, and
_Erlenmeyer_, morphinism is a condition which may be relied upon to
bring about amenorrhœa and temporary sterility from cessation of
ovulation. It has been asserted but by no means proved, that the
long-continued administration of quinine hinders ovulation. As a result
of various acute and chronic disorders, a simple atrophy of the ovarian
follicles can be detected, dependent upon simple fatty degeneration;
this has been seen by _Grohe_ in children as a result of general
atrophy, and also following caseous and suppurative diseases of the
respiratory organs; by _Slavjansky_ in children after chronic pneumonia
and chronic dysentery, and in adults as a sequel of typhoid, and in one
instance as a sequel of puerperal septicaemia.
Hyperplasia of the ovarian stroma, in slighter degrees of the affection,
leads to menstrual disturbances, partly of nervous and partly of
inflammatory nature, and in more severe degrees leads to sterility
dependent upon the hindrances which the thickened tunica albuginea
offers to the bursting of the mature follicles. _Klebs_ believes that
this anomaly is always due to a disposition acquired very early in life,
and perhaps at the time when the ovaries are first developed.
Follicular cysts of the ovary, which are formed mostly at the time of
puberty, and originate under the influence of menstrual congestion, from
graafian follicles near to ripeness, are competent to cause sterility,
owing to the pressure they exercise upon the superficially placed
rudimentary follicles, leading to the atrophy of these latter. Other
new-growths of the ovaries have similar effects, such as adenomata,
carcinomata, dermoid cysts, cystomata, sarcomata, and fibromata. In many
cases of these disorders, however, the ovarian follicles may for long
periods remain unaffected; and in these instances, ovulation,
menstruation, and even conception, may proceed undisturbed. Even in
cases in which a neoplasm attains a great size, if it affects one ovary
only, ovulation may occur normally in the other, and conception may
ensue; and even in the diseased ovary, if small portions of its tissue
remain unaffected, ovules may be discharged from these portions. The
minutest portion of healthy ovarian tissue, though all the remainder has
been destroyed by disease, may suffice to bring about conception.
Ovarian tumours appear with considerable frequency to be complicated
with sterility; but in such cases the question always remains open,
whether in the majority of instances the sterility is to be regarded as
the cause or as the consequence of the ovarian disease. _Boinet’s_
figures dealing with this problem are the most striking of all. He
states that of 500 women with ovarian tumours, 390 were childless. But
these results are challenged by other observers. _Veit’s_ estimates,
based upon a compilation of the figures of _Lee_, _Scanzoni_, and
_West_, is that 34% of women with ovarian tumour are sterile. On the
other hand, _Negroni’s_ collection of 400 cases of ovarian tumour,
including both married and unmarried, contained 43 only who had never
been pregnant. Other lists show: 13 sterile women among 45 suffering
from ovarian tumour (_von Scanzoni_); 1 sterile among 21 (_Nussbaum_); 8
sterile among 63 (_Olshausen_). _Winckel_, among 150 sterile married
women, found 32 suffering from ovarian tumour, which in two of these
cases only was bilateral. _Atlee_, in 15 cases of ovarian tumour,
observed premature cessation of menstruation at the ages of 30, 39, 40
and 42, respectively.
Although in many cases sterility develops coincidently with the growth
of an ovarian cystoma, yet in many other women such tumours have no
influence in diminishing fertility. _Martin_ in a case in which
sterility existed in connexion with a unilateral ovarian cystoma, the
other ovary being healthy, observed pregnancy as a sequel of the removal
of the diseased ovary. In one of these cases, after removal of the
ovarian cystoma, _Martin_ punctured in the other ovary a dropsical
follicle which had attained nearly the size of a walnut. Pregnancy in
this case also followed the resumption of marital intercourse. _Müller_
reports that in his clinique within recent years pregnancy complicated
with ovarian tumour has been observed in 7 instances; in one of these
cases the pregnancy occurred notwithstanding the fact that the
new-growth was so large as almost to fill the abdominal cavity. _Holst_
reports the case of a multipara 43 years of age who died in the 18th to
the 20th week of pregnancy; at the post mortem examination the left
ovary was found to be transformed into three cysts each the size of an
apple, whilst in place of the right ovary was a medullary carcinoma the
size of a man’s head; on neither side could a trace of normal ovarian
tissue be detected. _Spiegelberg_, in a woman who died shortly after
giving birth to her second child, found that both ovaries were
transformed into myxo-sarcomatous tumours; in a woman aged 42, who died
four weeks after her eleventh confinement, both ovaries were found to be
transformed into nodular carcinomatous tumours each larger than a
child’s head; in none of these ovaries was any normal stroma to be
found. _Ruge_ reports the case of a woman 36 years of age, who
miscarried in the sixth month of pregnancy; she had myxo-sarcoma of both
ovaries, one weighing 5620 grammes the other 480 grammes.
All these cases indicate that, notwithstanding the existence of
extensive degeneration of both ovaries, some minute remaining fragment
of healthy ovarian stroma is competent to produce normal mature ova—a
fact which has often been proved also by microscopical examination. That
under the influence of pregnancy, existing ovarian tumours often take on
extremely rapid growth, is also indicated by some of the above cases.
Castration (oöphorectomy, spaying, _Battey’s_ operation), the removal of
both ovaries, naturally results in sterility. If in the literature of
the subject cases are to be found in which, after this operation, not
menstruation merely, but even pregnancy has occurred, this is to be
explained either by the fact that in the stump there was left a fragment
of the ovary, still containing tissue capable of producing mature ova;
or else by the existence of a supernumerary ovary. _Schatz_ reports the
case of a woman in whom pregnancy occurred after double oöphorectomy. In
the month of February, 1880, this operation was performed on a girl
twenty years of age; she married in April, 1884; and in May, 1885, she
was delivered of a mature female infant. The history of the case and the
details of the operation showed clearly that the left ovary had been
completely removed, with the outermost third of the left Fallopian tube;
the right ovary was cut away in such a manner that a strip of tissue of
at most two millimetres (one twelfth of an inch) in width was left in
the body, whilst the right Fallopian tube was left intact. This case
teaches us that the smallest remnant of the ovary is competent to render
normal pregnancy possible; and further, that a small size of the ovary
no more constitutes a hindrance to the proper reception of the ovum in
the Fallopian tube, than does an abnormally large size of the ovary, or
an unusual shape of this organ.
_Miklucho-Mackay_ relates that among the indigens of Australia the
removal of the ovaries is often practised, in order to create a special
kind of hetairæ incapable of becoming mothers. _McGillivray_ saw at Cape
York a native girl whose ovaries had been removed because she was a
congenital deaf-mute, with the object of preventing her giving birth to
deaf-mute infants. In the beginning of the last century there existed in
Sayn-Wittgenstein a small religious sect whose custom it was always to
conclude their religious services by indiscriminate carnal union among
the members of the community; when women and girls were first admitted
as members of this sect, an attempt was made to render them unfitted for
conception “by means of a painful and dangerous compression of the
ovaries.” (_Ploss_.)
A transient, relative hindrance to ovulation may be brought about by
various pathological states of the ovaries. Acute oophoritis usually
suspends the ovarian functions; chronic oophoritis has sometimes a
similar effect, not only because the profound changes that take place in
the ovary hinder the formation of the ovules, but also because, as we
shall later explain more fully, the expulsion of the ova and their
reception by the Fallopian tubes are hindered. In severe oophoritis and
perioophoritis, more especially in parenchymatous inflammation,
sterility may be brought about by an absorption of the finely granular
contents of the follicles, which collapse, with adhesion of their walls;
when all or most of the follicles are thus affected, the ovaries become
small and hard.
In perioophoritis, the exudation leads to the formation of cord-shaped
or ribbon-shaped adhesions between the ovaries and the broad ligaments,
the uterus, and the peritoneal folds of the neighbourhood. The ovary in
such cases may also be displaced, or may undergo atrophy from pressure.
In the case of 200 sterile women, I found in 46 instances chronic
oophoritis and perioophoritis. _Olshausen_ reports that of 12 married
women suffering from chronic oophoritis, five were barren, whilst of the
remaining 7, three only had given birth to more than one child.
_Matthews Duncan_, on the other hand, saw pregnancy in a case of
bilateral ovarian inflammation, in which the organs were considerably
enlarged.
Further, local or general peritonitis may lead to parenchymatous
inflammation of the ovaries, and this, spreading from the periphery
towards the centre of the organ, attacks the follicles irrespective of
their ripeness. Again, during the puerperium, the interstitial form of
oophoritis is by no means rare, and this may at times lead to permanent
sterility in either of two ways: it may be in consequence of the onset
of a secondary parenchymatous inflammation, which destroys all the
follicles; it may be because a thick and tough layer of sclerosed tissue
forms around the periphery of the ovary, which mechanically prevents the
maturation and rupture of the follicles. According to _Slavjansky_,
puerperal disease is the principal cause of this form of oophoritis.
_Olshausen_ indicates as the most frequent cause of primary
perioophoritis, an inflammation propagated from the Fallopian tubes,
leading to the formation of masses of exudation, which envelop the
ovary, and by the pressure they cause, and by interfering with the
blood-supply, lead to atrophy of the gland.
Sometimes the chronic inflammatory induration by means of which the
stroma of the ovary is rendered denser and firmer, is due to changes in
the vessels, and depends upon valvular defects of the heart—upon venous
congestion. In this way, heart disease may hinder ovulation and bring
about sterility. Both syphilis and gonorrhoea may give rise to chronic
inflammatory changes in the ovary, usually leading to premature
contraction of the tissues and to the formation of numerous adhesions.
According to _Olshausen_, amenorrhœa is not a common feature of ovarian
disease, except in cases of defective development of these organs, of
cirrhosis of the ovaries, and of bilateral new-growths. Disease
affecting only a single ovary, even tumour of considerable size, rarely
causes amenorrhœa until profound constitutional disturbance has ensued.
An exception to this rule is found in the case of carcinomatous tumours
of the ovary; these, indeed, are commonly bilateral; but even when
confined to a single ovary, amenorrhœa is a comparatively early symptom.
According to the same author, sterility is a common consequence of
chronic oophoritis and its sequelae, and is usual also in cases of
bilateral new-growths; on the other hand, tumours affecting a single
ovary often fail to prevent conception even though they have attained a
great size.
Syphilis in women must be regarded as a frequent cause of sterility, by
interference with ovulation, but is in this regard by no means an
absolute bar to the occurrence of pregnancy. According to _Parent_ and
_Duchatelet_, under whose observation during the space of 12 years there
came annually an average number of 2625 syphilitic prostitutes, the
average annual of births in these cases was 63 only. According to _Marc
d’Espine_, 2000 prostitutes gave birth on an average to two or three
children in all during a year. (That there are other causes besides
syphilis for the remarkable infertility of women of the town, will be
explained later). According to _Bednar, Mayr_, and others,
constitutional syphilis in women invariably leads to sterility; others,
as for instance _Zeissl_, believe that women suffering from inveterate
syphilis are commonly, but not invariably, sterile; whilst according to
_Rosen_, conception only takes place in syphilitic women in whom the
disease has passed into the tertiary form. Experience shows, however,
that neither early nor late forms of syphilis necessarily lead to
sterility in women. It must also be pointed out, that syphilis in the
male _may_ be the cause of sterility, and _must_ be the cause thereof
when the disease is localised in the testicles, and the consequent
degeneration of the glandular substance leads to the occurrence of
azoospermia, more particularly when syphilitic or gummatous orchitis is
bilateral. According to _Lewin_, we fail to find spermatozoa in 50% of
men, otherwise powerful, suffering from syphilitic dyscrasia. _Hanc_, on
the other hand, failed to find azoospermia in any one of ten men
suffering from lues. In animals also syphilis is said to cause
sterility.
The manner in which certain anomalies of the blood (anæmia and
chlorosis), general disturbances of the nervous system, febrile states,
and such constitutional disorders as scrofula, have a temporary or
permanent influence in checking ovulation, is far from being understood;
but the fact that ovulation is checked by such conditions, has been
established beyond question by numerous observations. It is well known
that severe fevers, more especially typhoid, suspend the ovarian
function; that in various chronic disorders of an enfeebling nature, and
notably in chlorosis, all signs of menstrual activity disappear; and
that in certain nutritive disturbances, as in extreme obesity,
amenorrhœa also occurs; finally, numerous cases are on record in which
some sudden affection of the nervous system has instantaneously
inhibited ovarian activity.
In anæmia and chlorosis, it is probable that the degree of menstrual
congestion is insufficient to ensure the bursting of the graafian
follicle. The sterility often observed as a sequel of typhoid, malaria,
the acute exanthemata, cholera, and septicaemia, is probably due in most
cases to the occurrence of parenchymatous oophoritis, with consequent
destruction of the ovarian follicles. The researches of _Slavjansky_
have shown that in acute disorders inflammatory changes often occur in
the graafian follicles. When infectious disorders ran an acute course,
this observer usually found that the parenchymatous inflammation of the
ovary had occurred near the periphery, in the cortical layer, the
destruction being limited almost exclusively to the primitive follicles;
when the course of the primary disorder was more chronic, the mature or
nearly mature graafian follicles were the ones destroyed. When
inflammation of a follicle has led to its destruction, it is replaced by
a linear scar. _Lebedinsky_ found similar changes in the ovary after
scarlatina—destruction of a lesser or greater number of follicles, with
formation of scars. Thus, parenchymatous oophoritis as a sequel of acute
diseases, may, if severe, lead to destruction of all the rudimentary
follicles, with consequent sterility. In the post mortem examination of
such cases, the condition of the ovaries is similar to that which is
elsewhere in this work described as characteristic of these organs after
the menopause: the ovary is diminished in size, its surface is furrowed,
the tissue is indurated in consequence of overgrowth of fibroid tissue;
often not a single follicle is to be detected on section of the organ.
Immoderate obesity is a disorder of nutrition favoring the occurrence of
sterility.
In very obese women of an age which normally is the reproductive prime,
amenorrhœa or scanty menstruation is a very common accompaniment. In 215
such cases which came under my own observation, amenorrhœa was present
in 49, and menstruation was scanty in 116; thus in nearly three fourths
of these obese women menstruation was either deficient or entirely
wanting. Very remarkable also is the high percentage of sterile women
among the obese. In the 215 cases already mentioned (all married women),
48 were sterile—a percentage of 21. Whilst the ordinary ratio of barren
to fruitful marriages is 1 : 10 or 1 : 9, in the cases in which the
wives, or both wives and husbands, are extremely obese, the ratio is
according to my own observations, 1 : 5—or, if we include cases of
only-child-sterility, 1 : 4.
We cannot wonder at this great frequency of sterility in obese women
when we remember that, apart from the menstrual deficiencies which so
commonly accompany this disorder of nutrition, obesity is apt to entail
many other disorders of the reproductive organs, as for instance a
morbid state of the uterine and vaginal secretions, chronic metritis,
and displacements of the uterus; still, it cannot be denied, that in
many instances we are unable in such obese women to detect any disorder
of the reproductive organs competent to account for the sterility, and
we must therefore assume that the excessive development of fat has some
direct influence in preventing ovulation, or at least that it in some
way exercises an unfavourable influence upon the reproductive process.
That excessive obesity hinders fertility, is shown by experience both as
regards the vegetable and the animal kingdom. All animal-breeders are
familiar with the fact that undue production of fat limits fertility.
Thus, equally in the case of turkeys and in the case of the common fowl,
if the hens are overfed and become fat, they cease to lay.
_Hippocrates_ already indicated obesity as a cause of sterility. Writing
of the wives of the Scythians, he pointed out as a proof that their
excessive obesity was the cause of the sterility from which they
commonly suffered, the fact that their female slaves, who were thin,
were readily impregnated by intercourse with the Scythian males. The oft
repeated dwindling and disappearance of ruling families in India and in
Egypt, has doubtless in part depended upon the extreme obesity of the
female consorts of such rulers.
In many instances, indeed, a great accumulation of fat on the front of
the abdomen and in the vulva, suffices to cause a simply mechanical
hindrance to the proper performance of a fertilizing coitus. It is
possible also that the phlegmatic temperament of very fat women is a
contributory cause to their sterility—if indeed it is in general true
that frigidity during sexual intercourse is unfavourable to conception,
as is expressed by the old proverb, _quo salacior mulier, eo
foecundior_. It is unquestionable that in very obese women sexual
sensibility is commonly greatly deficient, and that their husbands often
complain of their coldness and lack of passion. In several cases that
have come under my observation, dyspareunia occurred in obese and
sterile women.
The dependence of sterility upon obesity is often proved in the most
striking manner _ex juvantibus_. A “cure” for the reduction of fat often
results favourably in respect also of rendering the woman who undergoes
it readily impregnable—a result by no means ardently desired.
It must also be pointed out that very obese women form a considerable
section of those suffering from only-child sterility, and this largely
in consequence of their strong predisposition towards abortion. As the
impregnated uterus enlarges, the space for its accommodation is
insufficient, owing to the great development of the panniculus adiposus,
and thus obesity, like intra-abdominal tumour, predisposes to abortion.
The excessive accumulation of fat within the abdomen, by exercising
pressure upon the inferior vena cava or on its principal tributaries,
hinders the venous return, and gives rise to a chronic stasis in the
uterine bloodvessels, those alike of the muscle and of the mucous
membrane.
Notwithstanding the fact that sterility is so common in very obese
women, the fact remains that some such women are remarkably fertile, and
have very large families indeed.
_Towers-Smith_, _Duke_, and _Rodriguez_, who have recently all been
engaged in examining the relations between obesity and sterility, agree
in asserting that sterility due to obesity may be cured by dietetic
treatment for the relief of the primary disorder of metabolism.
Though menstruation is usually deficient or absent in obese sterile
women, and though it is commonly supposed that amenorrhœa implies
sterility, it is necessary to point out that whilst failure of
menstruation is a frequent and important sign of suppression of
ovulation, it by no means invariably has this significance. It is an
established fact, and one borne out by my personal experience, that
women who have never menstruated have nevertheless become pregnant;
others, again, have become pregnant although they have ceased to
menstruate for several years, and this has even occurred in women at a
comparatively advanced age. Hence, from the fact that amenorrhœa exists,
we cannot with certainty infer that a woman is sterile. Moreover, we
must remember that physiologically amenorrhoeic women often enough
conceive—during lactation. Although we hold the opinion that there is an
intimate connexion between ovulation and menstruation, yet it is always
possible in cases in which menstruation fails to occur, that ovulation
has taken place, but that the stimulus which that process has exercised
upon the reproductive organs has been insufficient to give rise to the
customary flow of blood.
The following remarkable case came under my own observation: Mrs. B., 26
years of age, had lived in sterile wedlock for six years, had never
menstruated, nor had she ever had any sanguineous discharge from the
genitals. The body was delicately formed, the breasts were fairly well
developed, the external genital organs showed no abnormality. For some
weeks before consulting me, this woman, hitherto childless, and living
in regular sexual intercourse with her husband, had noticed a remarkable
enlargement of the abdomen. Another medical man whom she had consulted
had diagnosed ovarian tumor and had urged operation. A more careful
examination of the pelvis showed, however, that the woman was in the
sixth month of pregnancy, a diagnosis which was duly confirmed by the
delivery of a full-time child. In another of my cases, a woman married
at the age of 45 years, having ceased to menstruate two years
previously. She became pregnant and gave birth to a child in quite
normal fashion. The following instructive case also came under my own
observation: The wife of one of my colleagues, living in sterile wedlock
for 17 years, extremely obese, had since puberty menstruated but
scantily and with great irregularity. The menstrual interval was several
months, and when the discharge did appear, it was pale in colour and
small in quantity; it lasted moreover but a day or two. Last winter, the
flow as usual failed to appear for several months, and since the woman
had at the same time become fatter than ever, Turkish baths and
energetic muscular movements were prescribed. The result of this
treatment was a striking one—abortion. After 17 years of marital
intercourse she had for the first time become pregnant.
In the case of sterile women who are amenorrhoeic, even when the
amenorrhœa has never been interrupted by a menstrual discharge, or when
it appears entirely dependent upon obesity, it is nevertheless necessary
to be extremely cautious in making a diagnosis, and above all in
employing an intra-uterine sound. In such cases I have known the most
eminent gynecologists unwittingly bring about abortion.
_Cleveland_, _Godefroy_, _Haschek_, _Ritschie_, _Sommerus_, _Stark_,
_Taylor_, and _Young_, have all reported cases in which pregnancy
occurred in women suffering from amenorrhœa; but all such cases must be
regarded as quite exceptional. _Szukits_ examined 8000 sexually mature
women, and found among them fourteen only who had never menstruated. Of
these, four were multiparae.
_Saint Moulin_ reports the case of a woman 24 years of age who had never
menstruated, but who none the less became pregnant and gave birth to a
fine girl. One of the most striking cases of this nature is the one
reported by _Rodzewitsch_, regarding a woman who first began to
menstruate at the age of 36 years. This woman had however been married
when fifteen years of age, and in the subsequent twenty-one years she
gave birth to 15 children, remaining the whole time amenorrhoeic.
_Puech_ reports the case of a woman who ceased to menstruate at the age
of 40 years, and remained amenorrhoeic for the subsequent six years.
Then menstruation recurred for a year, and finally ceased definitively
in consequence of the occurrence of pregnancy, which terminated in the
normal birth of a healthy boy. _Loewy_, in a woman 31 years of age, who
had previously been amenorrhoeic all her life, saw menstruation appear
for the first time shortly after the birth of her sixth child. _Ahlfeld_
had under observation the case of a woman who was the mother of eight
children, and had never menstruated.
_Krieger_ reports the case observed by _Mayer_, of the wife of an
artizan, who between the ages of 17 and 28 years had given birth to five
children, and had had one abortion. After the age of 22, she had no
trace of menstrual discharge, but notwithstanding this, she subsequently
gave birth to three children. _Krieger_ himself saw a woman who had had
her last child at the age of 33, and in whom now, at the age of 48,
menstruation had just ceased entirely. Two years later, irregular
menstrual discharges recommenced; when these ceased, it appeared that
the woman was once more pregnant, and she was normally delivered of a
full-time girl.
_Renaudin_ relates the case of a lady 60 years of age who gave birth to
a child, menstruation having ceased 12 years earlier. _Deshhayes_ saw
the delivery of a woman 50 years of age, two years subsequent to the
occurrence of a normal menopause. _Capwron_, quotes the ease of a woman
who became pregnant at the age of 65 years. In this case menstruation
had recurred, having ceased many years before in a normal menopause.
This woman aborted at three months, and the foetus was well-formed.
In such cases of late conception, which occur after the normal cessation
of menstrual activity, we cannot be certain whether we have to do with a
simple persistence of ovarian activity, associated with temporary or
permanent cessation of menstruation; or whether both functions,
ovulation and menstruation, had ceased, and were aroused to renewed
activity by some determinate cause. It is possible that in coitus we
have such a stimulus, capable of reawakening the slumbering ovarian
functions. That this may be the case, we are led to suppose by the fact
that pregnancy at an unusually advanced age most frequently occurs as a
result of marriage late in life. In Scandinavian countries, where the
difficulties of providing for a family are so great that a very large
number of marriages are inevitably postponed till comparatively late in
life, the number of pregnancies occurring in elderly women is
correspondingly large. However, pregnancy late in life occurs also in
women who have married early, and the most probable assumption to
account for such cases is that ovulation has occurred in the absence of
menstruation.
Although by these cases the proposition is established that amenorrhœa
is by no means equivalent to incapacity for ovulation, still, the former
must indubitably be regarded as in general a most important indication
of disturbed ovulation. When a woman attains the age of 20 years without
having ever menstruated, or even having experienced menstrual molimina,
we may in the great majority of such cases infer with justice that there
is complete or partial failure of development of the ovaries and the
reproductive apparatus generally. In some of these cases, examination
discloses the fact that the uterus is in an infantile condition. When we
are able to bring about the regular establishment of menstruation, we
may hope also to remove the sterility dependent upon the defective
ovarian functional capacity. General tonic treatment for the relief of
chlorotic amenorrhœa quite as often, in the case of previously barren
married women, results in the occurrence of pregnancy, as happens in
cases of amenorrhœa and sterility due to obesity, when this latter
condition has been relieved and menstruation has been re-established by
suitable dietetic treatment. Much less often is it possible to relieve
the sterility of scrofulous (tuberculous) persons, for in the majority
of such cases, in consequence of the scrofulous (tuberculous)
constitutional disorders, pathological changes have occurred in the
ovaries already in early youth, and these it is difficult or more often
impossible to remove.
Scrofula (tuberculosis) is, according to my own experience, the
constitutional disorder which of all most frequently and most seriously
affects ovulation; and it appears that the ovaries are subject to
changes produced by this disease similar to those which occur in other
glandular organs. In cases in which no cause of the existing sterility
is ascertainable, the presence of scars due to scrofulous (tuberculous)
changes in the lymphatic glands may serve as an indicator to show that
the capacity for ovulation has been annihilated or seriously diminished
in early life by scrofulous (tuberculosis) disease.
Among the causes of sterility, these three conditions: anæmia,
chlorosis, and scrofula (tuberculosis), play a leading part; indeed,
their importance in this connexion has hitherto been underestimated,
more especially in regard to the comparative frequency with which they
cause sterility. A large part of the favourable influence in the relief
of sterility in women which is exercised by the “cures” at various
watering places, depends upon the amelioration which is thus effected in
the aforesaid constitutional disorders.
It has been assumed that diabetes, which renders men impotent, is
competent also to cause sterility in women. _Hofmeier_ reports a case
which appears decisive on this point. In a woman 20 years of age, who
had menstruated regularly since she was 14 until a year previously, when
the flow had ceased, he found the uterus extremely small, barely 5 cm.
(2 in.) in length, extremely atrophied, the ovaries also atrophied and
very small; the urine contained large quantities of sugar. Here was
doubtless a case of atrophy of the reproductive organs secondary to
diabetes.
In England, where the excessive use of alcohol is observed very
frequently in women as well as in men, sterility has frequently been
regarded as a result of chronic alcoholism. _Matthews Duncan_ reports
cases which lead to the belief that alcohol has a specifically
deleterious effect upon fertility. Apart from the general or
constitutional disturbances dependent upon the abuse of alcohol, this
agent has in many cases a well-recognized pathogenic influence upon the
female reproductive organs, the morbid condition which is most
frequently and most readily assignable to this cause being chronic
oophoritis. The obesity which so frequently results from alcoholic
excess is a contributory cause of sterility.
Certain drugs, more especially quinine and morphine, are reputed to
cause sterility. _Davies_, reviving an old opinion, considers that of
all drugs tannin is the most effective in leading to sterility, and he
considers tea-drinking as responsible for this effect.
The influence of certain cerebral affections and psychical disorders in
checking ovulation has been established. Thus, _de Montyel_ has recently
shown that in families subject to hereditary mental disorders, there is
an unusually large proportion (1 : 7) of barren marriages.
In addition, there are many influences which are known to prevent or to
diminish ovulation in the case of the lower animals, and which may
therefore be assumed with considerable probability to have a similar
effect in women. More especially we are here concerned with external
influences affecting unfavourably nutrition and innervation, and
therewith also ovulation; also near kinship between the parties to the
act of intercourse; and finally hereditary predisposition. In animals,
captivity, exposure to cold, over-exertion, insufficient or unsuitable
food, and inbreeding, have been proved to result in infertility.
_Doubleday_ asserted that “a too abundant supply of nutriment hinders
reproduction, whereas on the other hand insufficient or improper food
favours reproductive activity and increases the number of the
offspring.” _Spencer_, however, rightly points out that the infertility
noticed in these circumstances is not the direct result of prosperity,
but depends upon the pathological obesity which is thus engendered by
overfeeding.
No less interesting are the observations that have been made regarding
sterility in animals in confinement. In such animals there are wide
differences. Some refuse to cohabit, or have lost sexual desire; others,
again, show excessive sexual desire and cohabit too often, without any
result; or even if fertilization occurs, abortion often ensues. In yet
other cases, though conception follows intercourse, and the animals go
on to full term before delivery, the young are still-born, or are weakly
and misshapen. Caged birds often lay no eggs at all or very few; or if
they do lay, they neglect their eggs; or if incubated, the eggs fail to
hatch out. In France, experiments regarding this matter were made with
domestic fowls. If the hens were given great freedom, 20 per cent only
of the eggs remained unhatched; with less freedom, 40 per cent of the
eggs were failures; whilst if the fowls were kept in a coop, 60 per cent
of the eggs were unhatched.
“Convincing proofs,” writes _Darwin_, “have been obtained to the effect
that wild animals which have recently lost their freedom have their
fertility diminished to a most remarkable extent. This infertility is
not dependent upon any degeneration of the reproductive organs. There
are many animals of the most diverse species, which, whilst they
copulate freely in confinement, fail in these circumstances to conceive;
others again, even if they conceive and have living young, give birth to
these in numbers which are unquestionably much smaller than would be the
case were the parents in the free state.”
Interesting observations have been made by pigeon breeders. They state
that when pigeons brought up in the same nest pair, the number of their
offspring is usually very small.
The influence upon fertility of unfavourable conditions of temperature,
either excessive heat or excessive cold, is very great. In the case of
pigeons, for instance, if the pigeon cot is adjacent to the heated wall
of a dwelling house, the pigeons sometimes begin to lay as early as
January, and may have young as often as eight times in a single year.
When the dovecot is cold, on the other hand, the number of broods is
smaller. In general, the procreative capacity is greater in summer than
in winter.
As regards inbreeding, many facts are on record showing the influence of
this practice in leading to the birth of malformed offspring and to
sterility. _Darwin_ writes, “if in a pure race, characterized by a
certain tendency to sterility, we allowed only brothers and sisters to
pair, in a few generations the stock would become extinct.” If animals
closely related by blood pair, the number of their offspring is always
less than the average.
In the case of the human species, however, the influence of the marriage
of near kin in diminishing fertility cannot be regarded as definitely
proved.
Occasionally the incapacity for ovulation and the sterility dependent
thereupon are hereditary—paradoxical as this may appear. It is necessary
to assume, that just as the sperm is at times unsuited for effective
fertilization, so also the ova may be in a less or greater degree
insusceptible of fertilization. In the present state of our knowledge,
indeed, we are not in a position to be precise as to the exact nature of
such incapacity. It is possible that the enveloping membrane of the ovum
varies in its resistance to penetration, as _Schenk_ claims to have
proved in respect of certain of the lower mammals. In his experiments on
artificial fertilization outside the body of the mother, he ascertained
that the cells derived from the discus proligerus, surrounding the ovum
in immediate contact with the zona pellucida, are in some instances
easily separable one from another, so that the spermatozoa can readily
obtain access to the zona pellucida; whereas in other instances, in
which the ovum is of the same size and apparently in the same stage of
maturation as before, these cells remain closely attached each to the
other, and thus prevent the passage of the spermatozoa. This condition
of the ovum, so unfavourable to fertilization, may be hereditary in
certain families, and its transmission may render certain members of the
stock infertile. Such instances as the following from my own practice
are by no means rare. Of three sisters, whose family life was intimately
known to me, one had one child only, a girl, whilst the two others
remained childless. The girl of the second generation married and
remained childless. In England it is well established that when, in
cases of only-child-sterility, the offspring is of the female sex, this
child will probably herself be barren. _Galton_ found that in the case
of 14 heiresses (i. e. the only children of wealthy parents), all of
whom were married, 8 remained absolutely barren, whilst of the others, 2
had each an only child.
It was formerly believed that when a woman gave birth to twins of
opposed sexes, the female infant would prove to be barren, this
barrenness being associated with defective development of her
reproductive apparatus. _John Hunter_ (Animal Economy) ascertained that
in the case of twin calves of opposed sex, the genital organs of the
female twin were almost invariably imperfectly developed. But the
supposition that this is true also of the human species has not been
confirmed by experience. I know several married women who had twin
brothers, and these women have borne normal children; however, the
number of their offspring is remarkably small. _Simpson_, in Edinburgh,
recorded the results of the marriage of 113 women who had been born with
twin brothers; of these, 103 had proved fruitful, and 10 (i. e., about
one eleventh of the whole) barren, although of these latter women, one
had been married upwards of 5 years, and the remaining 9 for periods
ranging from 10 to 40 years. _Simpson_ also gave the history of four
women who were all the fruit of triple births, some of which had
consisted of two boys and one girl, others of two girls and one boy. All
four of these women were parous. Again, a woman who had been one of a
quadruple birth (three boys and one girl), herself gave birth to
triplets. A collection of all the figures accessible to me relating to
this subject, indicates that about ten per cent of the women born in
such circumstances prove barren—a ratio which corresponds closely with
the ratio of infertility in general.
_Interference with Conjugation, Conditions Preventing Access of the
Spermatozoa to the Ovum._
A condition essential to fertilization is a material union between the
sexual products of the male and the female respectively—the act of
conjugation. Thus, all conditions which prevent the spermatozoa from
obtaining access to the ova, bring about sterility.
Spermatozoon and ovum being normal, a great variety of pathological
conditions may prevent the one from gaining access to the other. It is
necessary for fertilization that the mature ovum should leave the ovary,
enter the Fallopian tube, and there come into contact with the male
sperm. Interference with any one of these essentials may lead to
sterility.
Thus, the constitution of the ovum itself may be at fault; or the
entrance of the ovum into the Fallopian tube may not be normally
effected; defects in these earliest stages of the process of
fertilization are precisely the commonest and the most important. The
emergence of the ovum from the graafian follicle may be rendered
difficult or entirely prevented by pathological states of the ovary;
again, by inflammatory processes in the ovary, the tubes, or the
ligaments, by developmental defects in the tube, and by obstructions in
its interior, the entrance of the ovum into the tube, and its free
passage along the tube may be prevented. Numerous abnormalities and
diseases of the uterus may on the one hand prevent the entrance of the
ovum into the uterine cavity, and on the other may prevent the upward
passage of the spermatozoa to their goal. Amongst conditions competent
to produce these effects we must enumerate: displacements of the uterus,
structural changes in this organ and its annexa, and other congenital
defects and acquired states; more particularly must be mentioned, uterus
infantilis, acquired atrophy of the uterus, flexions and versions of the
uterus, new-growths and inflammatory states of that organ, abnormalities
in the shape or size of the cervix uteri, and, finally, all conditions
of the vagina or vulva which hinder the proper performance of the act of
intercourse.
In diagnosing the cause of sterility, in determining whether in any
particular instance it is due to some hindrance to the indispensable
conjugation between the male and female reproductive elements, we have
in the first place to ascertain the presence or absence of any of the
numerous conditions which interfere with the proper passage of the ovum
from the ovary through the Fallopian tube to the interior of the uterus.
The simpler mechanical hindrances to conception, such as displacements
of the uterus, or tumours of that organ or its annexa, are easily
recognized; and the same is true of atresia of the cervix uteri, and of
congenital or acquired stenosis of the vagina. When obliteration or
stricture of the genital tract exists, a very careful examination,
visual, digital, and instrumental, must be made, rectal examination not
being forgotten. Not infrequently, amenorrhœa is attributed to ovarian
disease, and only subsequently on local examination is the cause
ascertained to be hymeneal atresia, with haematocolpos; many a woman has
believed herself to be pregnant, until examination has disclosed the
fact that the hymen is still intact, and that coitus has hitherto been
effected through the urethra. The importance of these stenotic
conditions as causes of sterility must not, however, be overestimated,
for, although they are common among the hindrances to conception, the
obstacle is by no means always insuperable.
Morbid changes in the secretions of the genital passages, whereby the
vitality of the spermatozoa may be destroyed before they have time to
reach the ovum and effect fertilization, are hard to diagnose, for the
conditions upon which such changes depend have not as yet been
adequately investigated.
_Diseases of the Ovaries and the Fallopian Tubes._
Among the conditions which, although the maturation of the ovum proceeds
normally to a conclusion, may prevent conjugation between the male and
female elements, we must in the first place consider an abnormal
condition of the tunica albuginea of the ovary, a thickening of this
membrane in consequence of inflammatory processes or of new formation of
connective tissue, whereby the dehiscence of the follicle is rendered
difficult or entirely prevented. Such thickenings of the ovarian
envelope are the residue of perioophoritic processes.
Such a hindrance to conception may be permanent or transient, and thus
the sterility dependent thereupon may be relative or absolute. Similar
is the effect of inflammatory processes affecting the peritoneal
investment of the uterus, the broad ligaments, and the peritoneum
clothing the floor of the pelvis; these conditions, perimetritis,
perisalpingitis, and pelvic peritonitis, resulting in the formation of
thick and extensive pseudomembranous bands, or in less severe cases
leaving merely slight adhesions and filaments, which drag the uterus and
the ovaries out of place, and thus render conception difficult or
impossible.
Perimetritic adhesions are apt to lead to dislocation of the tubes
either forwards or backwards, and most commonly into the pouch of
Douglas, thus giving rise to sterility. _Rokitansky_ and _Virchow_
already insisted on the great importance of perimetritic processes in
causing sterility.
That congenital defects of the Fallopian tubes may lead to sterility, is
indeed a possible, but certainly a rare occurrence. The defect may be
unilateral or bilateral; or it may be that merely a portion of one tube
may be wanting. Bilateral absence of the Fallopian tubes is usually
associated with defective development of the uterus, while the ovaries
may be apparently normal. Such a case is described by _Foerster_ and
_Kussmaul_. The vagina opened into the urethra, the uterus was not
calibrated, and diverged above into two solid horns, to which the round
ligaments and the ovaries were attached. A congenital cause of sterility
is to be found also in atresia of the tubes, the abdominal extremities
of which are closed; this condition is met with also in other mammals.
It is also assumed, with less accuracy, that a supernumerary ostium
tubae may lead to sterility, in consequence of the ovum, which has found
its way into the normal ostium, returning into the abdominal cavity
through the supernumerary orifice. An unfavourable influence upon
fertility is exercised also by a form of hyperplasia of the tubes which
sometimes arises in consequence of erroneous development at the time of
puberty; the tubes, increasing unduly in length, become serpentine in
form instead of being nearly straight; this tends to lead to
accumulation of the secretions, and renders the passage of the ovum
difficult. (_Freund_.) Yet another defect of development which, as
_Klebs_ has pointed out, may lead to sterility, is absence of the
fimbria which normally retains the abdominal orifice of the Fallopian
tube in proximity with the ovary, in which case these structures may be
separated by a wide interval.
The entry of the ovum into the tube may thus be rendered difficult by
abnormalities of the abdominal orifice of the tube or of the fimbriae;
but still more is this the case when the mucous membrane of the tube is
diseased. The fringed border of the tubal orifice has a distinct
tendency to independent disease. As _Klebs’s_ anatomicopathological
studies have shown, inflammatory changes are common in this region,
leading to contraction. The free margin of the tube then appears to be
strictured by overgrowth of fibrous tissue on the serous surface, the
opening being thus narrowed or even entirely closed, whilst the fimbriae
themselves may be drawn within the aperture. In other cases, the ring of
fimbriae is adherent to some neighbouring part, especially to the ovary
itself, when this also is diseased. Further, on the fringed margin of
the tube we see papillary growths, telangiectases, or oedema with
formation of cystic cavities.
In the interior of the tubes also, pathological processes occur,
catarrhal inflammations, haemorrhagic or purulent exudations, sealing up
the passage completely. In some cases these exudations lead to great
distension and even to rupture of the tube. Thus, among the causes of
sterility must be enumerated: simple catarrh of the tube, with swelling
of the mucous membrane; purulent catarrh, leading to its distension with
pus—pyosalpinx; serous effusion into the tube, hydrosalpinx; and
haemorrhagic effusion, haematosalpinx; further, that peculiar form of
tubal inflammation, described by _Chiari_ and _Schauta_ under the name
of salpingitis isthmica nodosa, in which hyperplasia of the muscular
coat of the tube occurs at irregular intervals, so that it appears to be
beset with nodes. Special mention must also be made of gonorrhoeal
salpingitis, which will subsequently be described in detail.
Inflammatory states of the tube may hinder conception, either
mechanically, by swelling of the mucous membrane, or by obstruction of
the lumen of the tube by exudations, by injury or destruction of the
ciliated epithelium, by lesion of the musculature of the tube, affecting
its peristaltic movements—all these hindering or entirely preventing the
passage of the ovum downwards or of the spermatozoa upwards; or, again,
chemically, by the deleterious influence of many of the morbid
secretions that are formed in these conditions upon the vitality of ova
or spermatozoa. These inflammatory states of the tubes may also lead to
stricture or obliteration of their abdominal extremities, or to
displacement of the ostia, and thus lead to sterility; in other cases
these same conditions, leading to distortion and displacement of the
tube, may prevent the downward passage of the ovum while leaving
possible the upward passage of the spermatozoa, and thus give rise to
tubal gestation—a condition which we shall not now consider.
It must not be forgotten that tuberculosis of the genital canal attacks
the tubes with especial frequency; in these organs we may find miliary
tubercles, and more commonly diffuse caseous masses, completely filling
the lumen of the canal. Finally we have to mention the diverse forms of
saccular dilatation of the tubes (Ger. “_Tubensäcke_”), all of which
possess the common pathological characteristics of enlargement of the
tubes and their conversion into saccular cavities; the contents of these
distended tubes may, however, be extremely various, and such conditions
may depend upon manifold mechanical disturbances and inflammatory
processes of the uterus and its annexa.
When we consider how common, during the sexual life of women, are
perioophoritic inflammations, more or less intense, but often without
severe symptoms (and hence apt to be overlooked); when we remember that
the very process of ovulation and also the puerperal state furnish
opportunities for slight or severe pelvic peritonitis to arise; and when
we further take into account the frequency and importance of gonorrhoeal
pelvic peritonitis—we cannot fail to admit that the results of these
morbid conditions, such as adhesions between the ovary and the ostium
tubae, or closure of the tube with consequent hydro- or pyosalpinx, must
be reckoned among the principal causes of sterility. If the frequency
and importance of these conditions is still underestimated, two reasons
can be adduced for this: first, that the slighter degrees of intrapelvic
inflammation often, as previously mentioned, elude diagnosis; and,
secondly, that even when the treatment is expectant merely, the
exudations are frequently absorbed, the adhesions give way, and the
capacity for conception is gradually fully restored.
When considering the etiology of acquired sterility, especial attention
must be devoted to gonorrhoeal pyosalpinx, the most important and the
most dangerous of the morbid manifestations of gonorrhoeal infection in
the female. Gonorrhoeal salpingitis and perisalpingitis are very serious
affections, in the first place because they are apt to give rise to
oophoritis and perioophoritis, as well as to pelvic peritonitis, and
other local inflammatory states. The minuteness of the uterine orifice
of the Fallopian tube, and the downward direction of the ciliary
movement in the interior of the tube, combine to safeguard against the
entrance of gonococci, but none the less they too often find their way
up the tube, and small quantities of gonorrhoeal pus enter the pelvic
cavity and give rise to inflammations, in which the ovary partakes.
According to _Saenger_, this gonorrhoeal disease of the uterine annexa
is found with especial frequency in women either wholly sterile or
affected with only-child-sterility, and is to be regarded as the cause
of their infertility; “infertility is indeed the rule, fertility the
exception, in all cases in which gonorrhoeal disease has passed upwards
beyond the os uteri externum.” The same author maintains that, putting
aside tuberculosis and actinomycosis, if, in a case of infective
inflammation of the uterine annexa, septic infection can be excluded,
and more especially when the disease affects both tubes, when it is
reluctant to yield to treatment, and when relapses are frequent, we have
no option but to believe that the affection is of gonorrhoeal origin.
In 155 cases of chronic inflammatory disease of the Fallopian tubes,
_von Rosthorn_ was able in 37 instances to prove that the affection was
the direct result of gonorrhoeal infection.
Recently, however, _Noble_ has published cases which lead us to believe
that even pyosalpinx does not necessarily prevent the occurrence of
pregnancy. In operating for the relief of a unilateral pyosalpinx, the
uterus was opened, and a seven months’ foetus was removed. In another
case, the autopsy on a woman who had succumbed to severe peritonitis
arising immediately post partum, disclosed a large pyosalpinx.
Closure of the ostium may also be brought about by chronic metritis and
endometritis, by chronic catarrhal states of the uterine mucous
membrane, and in general by pathological changes in that membrane
associated with local hyperaemia or abnormal secretions. In some cases,
salpingitis with consequent sterility is the result of puerperal
infection; and such a sequence of events is especially common after an
abortion followed by retroflexion of the uterus, leading to elongation
and kinking of the tubes.
An important hindrance to the entry of the ovum into the uterus is
sometimes offered by uterine polypi or myomata; growing from the fundus,
these may so fill the uterine cavity that the uterine orifices of the
tubes appear to be completely occluded.
At times, also, quite small myomata, growing close to the tubes, may
push these latter upwards, closing them, and thus giving rise to
sterility; such myomata may also lead to saccular dilatation of the
tubes, as occurred in the following case:
Mrs. S., aged 39 years, had one child when 20 years of age, but since
then had been barren. For several years she had suffered from profuse
menorrhagia. Owing to the enormous thickening of the abdominal wall,
bimanual examination of the uterus was impossible; the vagina was
relaxed, enlarged, and contained an excess of mucous secretion. The
uterus was high up in the pelvis, anteverted, enlarged, movable,
sensitive to pressure; the portio vaginalis was enlarged, soft, and
excoriated; no tumour could be detected either in the uterus or in the
uterine annexa. The menstrual flow recurred at intervals of from two to
three weeks, lasting from one to two weeks, and being extremely profuse;
menstruation was painful. Whilst the patient was under my observation an
excessive menstrual haemorrhage came on quite suddenly, with slight rise
of evening temperature (38.2° C.—100.8° F.), but severe general
disturbance; there were paroxysms of intense abdominal pain, violent
vomiting of greenish bilious masses, which after a time became
haemorrhagic, the abdomen was tense and sensitive to pressure, there was
cardiac weakness with general failure of strength; treatment proved
unavailing, and the patient died in collapse on the third day. The
autopsy disclosed: fibroma uteri submucosum, parietale, et subserosum,
haematosalpinx dextra, pyosalpinx sinistra, peritonitis. The subserous
myoma, of about the size of a pea, was in the middle of the fundus
uteri; the submucous myoma, of about the size of a chestnut, filling the
uterine cavity, sprang from the posterior wall of the body of the
uterus; the intramural myoma, of about the size of a bean, was in the
right wall of the corpus uteri. Both tubes were greatly elongated,
exhibiting serpentine windings. The right tube was much distended,
filled with sanguineous fluid; the left, partially collapsed, contained
greyish-green purulent material, having an extremely offensive odour;
some of this fluid had flowed through the ostium abdominale into the
abdominal cavity. Death in this case ensued with great rapidity in
consequence of rupture of the pyosalpinx, and evacuation of its contents
into the abdominal cavity.
Cystic formations in the round ligament (hydrocele of the round
ligament) sometimes lead to sterility. In the form of elongated tumours
of about the size of a hen’s egg they may fill the inguinal canal, and
even pass forwards into the labia majora. When as large as this, they
demand operative interference. _Hennig_ records a case in which such
hydrocele of the round ligament was the cause of sterility lasting 14
years, the woman becoming pregnant after the tumour had been removed by
operation. Similarly, infertility may depend upon solid tumours of the
round ligaments—myomata, fibromyomata, or sarcomata.
Retro-uterine haematocele often gives rise to sterility. As a rule,
prior to the formation of a blood-tumour in the pouch of Douglas,
various menstrual disturbances occur, more especially menorrhagia; or it
may be preceded by some puerperal disease, especially perimetritis,
which by itself, indeed, seriously limits the fertility of the woman
thus affected; but when haematocele is superadded, her child-bearing
capacity is much more gravely impaired, owing to the permanent
displacement of the uterus, to the perimetritic exudations, to the
adhesions formed around the ovary, and to stricture or occlusion of the
tubes. Still, sterility is by no means an inevitable consequence of
haematocele.
By many it is assumed that in cases in which the tubes are perfectly
normal, disturbances of innervation are competent to cause sterility (or
tubal gestation). It is supposed that nervous influences affect the
functions of the Fallopian tubes by leading to spastic contractures of
the circular muscular fibres of these structures, or in other cases to
paralysis; in this way nervous disorder may lead to the retention within
the tube of the unfertilized (or already fertilized) ovum.
_Diseases of the Uterus._
Pathological changes in the uterus may in various ways lead to sterility
dependent upon prevention of conjugation (physical contact of the male
and female reproductive elements). Thus, the incapacity for
fertilization may, on the one hand, depend on hindrances to the passage
of the ovum from the tube to the interior of the uterus; or on the
other, on some abnormal condition of the vaginal portion of the cervix,
whereby the passage of the spermatozoa from the vagina into the uterus
is prevented; or, finally, upon displacements of the uterus or
pathological structural changes in that organ, whereby the implantation
of the fertilized ovum in the uterine cavity and its development therein
are impeded.
The uterus may be entirely absent, but this is an extremely rare
condition; much less infrequent is a rudimentary condition of that
organ. In the latter case, it is either represented by a nodular
rudiment, or else it is conical or bicorned; whatever its shape, it is a
solid mass of muscular and connective tissue. In association with
absence or a rudimentary condition of the uterus, the vagina also may be
wanting, or may be represented merely by a small, blind pouch; the
Fallopian tubes may in such cases either be normally developed or
rudimentary. The number of instances of this kind that have been
observed is very large (_Kussmaul_, _Klebs_, _Cusco_, _Klinkosch-Hill_,
_Cruise_, _Freund_, _Fürst_, _Engel_, _Gusserow_, _Nega_, _Kiwisch_,
_Rokitansky_, _Braid_, _Jackson_, _Lucas_, _Duplay_, _Dupuytren_,
_Renaudin_, _Crédé_, _Saexinger_, and many others).
The uterus and the vagina may be absent in cases in which the vulva is
developed in a perfectly normal manner, with a mons veneris projecting
as usual, and covered with a proper growth of hair. _Ormerod_ and
_Quain_ have reported cases of this kind, in which the external sexual
characters were those of a fully mature, perfectly developed woman, but
in whom the uterus and ovaries were entirely wanting.
These defects of development necessarily entail complete sterility.
Sometimes during life the cause of the sterility is entirely overlooked,
and only discovered by chance or in post mortem examination. Although
the vagina usually shares to a marked extent in the defects of the
uterus, and at puberty undergoes a rudimentary development merely, the
marital intercourse of such individuals commonly appears to be perfectly
normal. As a result of frequently repeated and vigorous attempts at
intercourse, the rudimentary vagina becomes accommodated to the needs of
the case; and even when the vagina is absent, the rudimentary depression
by which it is represented becomes distended into a large blind sac
capable of accommodating the erect penis. In other such cases, the penis
finds for itself some abnormal channel, and the husband may continue to
indulge in intercourse for a long period without discovering that there
is anything unusual. Sometimes it is the urethra which becomes dilated
and takes on in part the function of the vagina; in other cases
intercourse is effected per anum.
The following most remarkable case came under my own observation. The
patient’s husband was a physician, who nevertheless was in complete
ignorance of his wife’s abnormalities. The woman was 26 years of age, of
medium stature, somewhat obese, breasts moderately well developed, pubic
hair well grown. She stated that before marriage she had menstruated
regularly, and that it was only after she had married four years
previously that menstruation had ceased—statements which were
unquestionably false. She consulted me on account of amenorrhœa and
sterility, which her husband believed to depend upon her increasing
obesity. Examination showed that the vagina admitted two fingers and was
10 cm. (4″) in length; but it was completely blind, and the mucous
membrane was strikingly smooth. On bimanual examination, only a rudiment
of the uterus could be detected, a mass no larger than a hazel-nut; the
ovaries could not be felt.
A similar case is recorded by _Heppner_. A Finnish peasant woman 31
years of age consulted him on account of amenorrhœa and sterility. She
had been married for 12 years, and neither before marriage nor since had
menstruated or had had any periodic vicarious bleeding. The pubes and
the labia majora were thinly covered with hair; the latter were very
flaccid and but slightly prominent; the nymphæ hung down like an apron
for as much as an inch below the genital fissure, and were very thin;
the clitoris was but slightly developed. The urethral papilla was of
normal size, the lacunæ around it were extremely well marked; the
urethral orifice had the form of a zigzag slit. Behind this latter was
an aperture environed by radiating folds, and this was the entrance to a
blind passage about two inches in length; this aperture could not,
however, be identified as the introitus vaginae, for the reason that
there were no carunculæ myrtiformes, and moreover the callosity of the
mucous membrane characteristic of the vaginal orifice was wanting.
Behind the strongly projecting commissura labiorum, however, the fossa
navicularis appears as a separate depression. The blind passage was
clothed with a soft, pale-red mucous membrane, and was entirely devoid
of any trace of columnæ rugarum; at the extremity of this passage there
was neither scar nor induration. On rectal exploration, no trace of
uterus, normal vagina, or ovaries could be felt, notwithstanding the
fact that the abdominal walls were very flaccid and examination was
therefore easy. The general configuration was feminine, the breasts were
flabby and dependent, the waist and hips were those of a woman.
_Tauffer_ reports the case of a woman 25 years of age, married 2½ years,
absolutely amenorrhoeic; on examination she was found to have atresia
vaginae with rudimentary development of the uterus. The breasts were
small, the mons veneris was deficient in fat, but thickly covered with
hair, the labiæ and the clitoris were normal.
_R. Levi_ describes a case in which, in a patient 19 years of age, the
uterus was wanting, though the general physical development was that of
a normal woman. The breasts were well formed, and so also were the
external genital organs; a blind passage 4 cm. (1.6 in.) in length, and
admitting two fingers, represented the vagina. In the position normally
occupied by the ovaries, were two bodies which were doubtless the
rudiments of these organs. Menstrual molimina had never been
experienced.
_Von Hoffmann_, in making a post mortem examination on an elderly
married woman, found that the vagina ended blindly at a depth of 6 cm.
(2.4 in.), whilst the uterus was represented merely by a pyramidally
arranged bundle of fibres in the broad ligament. _Lissner_ reports a
case in which the physician was the first to draw the husband’s
attention to the fact that his wife had no uterus.
_Ziehl_, in a married woman 57 years of age, found that the uterus was
completely wanting; the vagina ended blindly half an inch from the
surface; the tubes and ovaries were present. _Boyd_, in a married woman
72 years of age, found a blind vagina half an inch in length, and the
uterus represented by a nodular rudiment on the posterior wall of the
bladder.
Rare cases are also recorded in the literature of the subject, in which,
notwithstanding the absence of the uterus, normal ovaries were present,
and in these latter periodic ripening of the graafian follicles took
place. A case of this kind was described by _Burggraeve_.
Complete sterility is entailed also by a persistence of the foetal
condition of the uterus. In these cases, the uterus retains the form it
possessed at the beginning of the second half of intra-uterine life. The
portio vaginalis projects but slightly into the vagina, and the os uteri
externum appears as a small rounded opening. The cervix is comparatively
long and wide, and the folds on the mucous membrane of the cervical
canal are fully formed. The body of the uterus is imperfectly developed,
triangular in shape, with thin walls; it is shorter than the cervix, and
its interior is marked by folds of mucous membrane converging towards
the os. In these cases menstruation is absent or scanty; the other
reproductive organs, including the breasts, are usually in a state of
arrested development. Women with foetal uterus are capable of sexual
intercourse, and carry on most of the functions of their sexual life in
a manner apparently normal; they are, however, invariably sterile.
An analogous cause of sterility is presented by the condition known as
uterus infantilis, in which at puberty the uterus fails to undergo the
changes proper to this period, and remains in the condition
characteristic of infancy. The cervix is disproportionately large,
whilst the body of the uterus is cylindrical in form, and the mucous
membrane lining its cavity is always smooth. The muscular substance is
unduly thin. The vagina may be normal, sometimes, however, it is narrow,
and the mucous membrane is less rugose than normal. Associated with an
infantile condition of the uterus we find commonly, but by no means
invariably, imperfect development of the external genital organs, the
labia, the clitoris, and the vagina; the mons veneris is but thinly
covered with hair; the breasts are small. As a rule, menstruation is
entirely wanting. Occasionally the ovaries are wanting. This infantile
condition of the uterus is by no means extremely rare. According to
_Beigel’s_ figures, among 155 sterile women, in four the uterus was
infantile.
Among 200 cases of sterility in which it was possible for me to make a
searching enquiry for the cause, I found 16 instances of infantile
uterus. Neither in the general physical configuration of these women,
nor in the state of their menstrual functions, was there any striking
abnormality; in the condition of the external genital organs, however,
in cases of defective development of the uterus and ovaries, certain
striking peculiarities were, in my experience, almost invariable, and
deserving therefore of close attention. The mons veneris was extremely
small, sometimes completely bald, or covered very thinly with hair; and
the hair when present, did not exhibit the curliness usually seen in the
pubic hair of married women. On examination, the uterus, small in all
its diameters from arrest of development, could in every case be
detected.
How exceptional it is in adult females with well developed internal
reproductive organs for the pubic hair to be scanty or completely
wanting, has been shown by the investigation recently made by _R. Bergh_
on this hitherto neglected subject. In 2200 individuals engaged in
clandestine prostitution, he found the pubic hair extremely scanty in
148, and the genital region nearly or completely bald in 6. He states
that early vigorous growth of the pubic hair is a trustworthy sign of
early sexual development; but he remarks that the opinion of _Aristotle_
that women in whom the pubic hair is slight or absent are always
sterile, is erroneous.
Note.—The author’s statement regarding the extreme infrequency of
absence or deficiency of the pubic hair in women with properly
developed internal reproductive organs, while true of European
women, does not apply to all races. In Japanese women, for instance,
the pubic hair is as a rule much scantier than in European women;
and baldness, complete or nearly complete, of the mons veneris is by
no means uncommon. It is the exception, in Japanese prostitutes, to
find a thick and vigorous growth of genital hair.—_Transl._
In the Talmud, there is an interesting reference to this subject, to the
effect that it may be assumed that a woman is sterile if by the 20th
year of her life the pubic region be not yet covered with hair, if the
breasts be not developed, if coitus be difficult, and if the tone of the
voice be masculine.
Madame _Boivin_, _Dugès_, _Lumpe_, and _Pfau_, maintain that the
development of the uterus from the infantile condition to that
characteristic of the sexually mature virgin, often occurs very late and
very slowly; and that women in whom we find the uterus in an infantile
condition, may later begin to menstruate and may become pregnant. It has
been suggested that in these cases there has been confusion with primary
acquired atrophy of the uterus. Still, that it is necessary to be most
cautious in cases of infantile uterus in asserting that a woman is
permanently sterile, has recently been forcibly impressed on me by a
remarkable instance. A married woman consulted me some years ago on
account of amenorrhœa and sterility; examination showed clearly that the
uterus was in the infantile condition, and for this reason, not I alone,
but several leading gynecologists, assured her that there was no hope of
her ever becoming a mother; recently, however, after ten years of
sterile wedlock, she was safely delivered of a healthy child.
A sub-variety is constituted by the uterus pubescens, a uterus which
indeed at puberty has undergone a certain degree of development, but has
failed to attain the normal size; in such cases the menses are regular,
but sometimes painful. This form of arrest of development of the uterus
may occasion sterility, which, however, often proves curable when by
frequent sexual intercourse and the congestion dependent thereon, the
genital organs have been stimulated to the completion of the process of
development; the muscular strength of the uterus then becomes adequate,
and the dysmenorrhœic troubles disappear. In general it may be said that
if the rudimentary or imperfectly developed uterus is at all competent
to carry out the function of gestation, the necessary changes sometimes
occur in the organ with remarkable rapidity, and result in normal
pregnancy and parturition.
Uterus unicornis, when occurring alone, and not associated with other
defects or errors in development, is not a cause of sterility. Women
with a uterus unicornis, with or without an accessory horn, menstruate,
conceive, and pass through pregnancy and parturition, in a perfectly
normal manner; indeed, some women with this developmental defect have
given birth to twins. The assumption that uterus unicornis predisposes
to abortion does not always hold good. If, however, pregnancy occurs in
a rudimentary horn, rupture of the membranes is inevitable, and the ovum
or embryo passes into the abdominal cavity, with the usual accompaniment
of fatal haemorrhage. The rupture commonly occurs between the third and
the fourth month of foetal life (months of four weeks each).
The uterus bicornis, with which may or may not be associated duplication
of the vagina, does not as a rule offer any hindrance to conception; and
the same statement is true also of the uterus bilocularis or septus.
Women with these defects of development may give birth to healthy
children; and some such women have had twins, each foetus occupying a
separate half of the uterus. Still, births in cases of double uterus and
vagina are rare occurrences. Such cases have been published by
_Lasarewitsch_, _Litschkus_, and _Készmarsky_. In very rare cases of
uterus bicornis associated with double vagina, an obstacle to conception
is offered by the fact that one side only of the double vagina, the
larger, is utilized in sexual intercourse, and that this is a blind
passage.