FIG. 82.

Mucus from the Cervical Canal, taken one hour after sexual

intercourse, from a woman suffering from chronic endometritis.

Among the epithelial cells, pus cells, and finely granular masses, we

see a few motionless, dead spermatozoa.

]

According to _Nöggerath_, in cases of uterine catarrh, we may find one

of three different varieties of secretion. In some cases it is small in

amount, and very thin in consistency; in others, it is moderate in

amount, very thick, non-transparent, bright yellow, and gelatinous in

consistency; in the third class of cases, we have numerous degrees of

variation, starting from the normal, purely mucus, transparent

secretion, mixed with yellow flocculae, up to a secretion which has

almost the aspect of pure pus. The first described variety is, according

to _Nöggerath_, met with chiefly in women whose uteri are small, with

indurated tissues, and its discharge seems to depend upon commencing

atrophy of the mucous membrane. The second form is the most obstinate,

the catarrh being situated chiefly in the cervical and probably also the

uterine glands; whereas the first variety of secretion is rather a

serous transudation, and contains very few formed elements. The third

form is characterized by extensive denudation of the superficial

epithelium, and is mixed with a smaller or larger quantity of pus.

_Levy_, who made microscopical examinations in sterile women (39 cases),

gives it as a “constant fact” that when the cervical secretion contains

epithelial and pus cells in large quantities, the spermatozoa never

retain for long their power of movement. Whereas in examinations made

repeatedly on healthy women 25 hours after sexual intercourse, he found

numerous spermatozoa still in active movement, in women having a

catarrhal discharge with the characters just mentioned, five hours after

intercourse the movements of the spermatozoa had almost entirely ceased.

Not only may the secretions of the genital passage be injurious to the

spermatozoa by their quality, but further a very abundant secretion may

interfere with fertilization. In the first place a very abundant

secretion is apt to be very dilute, and if the spermatozoa are immersed

in a fluid of which the specific gravity is too low, they swell up from

imbibition of water, and their movements are suspended. But excessive

secretion, such as is sometimes met with in cases of cervical catarrh,

may also have a purely mechanical deleterious action, by washing away

the semen out of the vagina. If, again, the quantity of the ejaculated

semen is unusually small, contact with the normally acid vaginal mucus

may suffice to render the spermatozoa speedily motionless. Finally, when

the cervical secretion is of a too tenacious consistency, so that it

fills the os as with a plug, the upward passage of the spermatozoa may

be barred.

Such tenacious cervical mucus will give rise to sterility especially in

women who have not previously born children; whereas in parous women,

owing to the more patulous condition of the os, the entrance of the

spermatozoa is not so effectually prevented. The same distinction

between nulliparous and parous women must be made, as _von Scanzoni_ has

pointed out, also as regards the production of sterility by

hypersecretion of uterine mucus. Women who become affected with uterine

blenorrhoea only after having had one or more children, will readily

become pregnant again; but when such blenorrhoea affects a woman who has

never been pregnant, sterility almost invariably results.

_Von Grünewaldt_ has drawn attention to a somewhat rare form of chronic

endometritis with tenacious secretion, leading to sterility. The shape,

size, and consistency of the uterus appear normal, the organ is often

virginal, but with the speculum we see exuding from the os a greyish

green, extremely tenacious secretion, which is wiped away with

difficulty. He saw 24 women affected with this disease; 10 of these had

lived in marital intercourse for many years without ever having become

pregnant; in 10 others there was acquired sterility, i. e., they had at

first borne children after marriage, but had subsequently ceased to be

fruitful; in the remaining 4 it was not possible to ascertain whether

they were fruitful or sterile, since two of them were living apart from

their husbands, whilst in the case of the other two only two years had

elapsed since the birth of the last child. In any case, not one of the

women thus affected had ever become pregnant subsequent to the time at

which she acquired this form of endometritis, notwithstanding the fact

that in several of the cases the symptoms were alleviated by treatment.

We must here consider also the effect of gonorrhoeal infection in giving

rise to sterility in women. Sterility may arise from gonorrhoea in women

in various ways. Sometimes the abundance of the cervical secretion is

alone sufficient to prevent the entrance of the spermatozoa into the

uterus; in other cases the hindrance to fertility depends upon the

inflammatory conditions in the pelvis that so frequently result from

gonorrhoeal infection—perimetritis and parametritis; it may be catarrhal

changes in the tubes—salpingitis, hydrosalpinx, and pyosalpinx—by which

the contact between spermatozoon and ovum is prevented. Chronic

gonorrhoeal endometritis may give rise to such changes in the uterine

mucous membrane as to unfit it permanently for the implantation of the

ovum, even should there be no obstacle to fertilization. Finally, double

gonorrhoeal oophoritis may result in rendering the formation of mature

ovum an entire impossibility—bringing about a condition analogous to

azoospermia in the male, and causing absolute sterility. Although in

many cases the detection of the gonococcus affords indisputable evidence

of the existence of gonorrhoeal infection, it must be remembered that it

is often difficult, and sometimes entirely impossible, to make the

diagnosis with certainty; and for this reason it is possible that

gonorrhoeal infection plays a much larger part in the causation of

sterility than has until lately been believed.

The observant physician will in cases of sterile marriage frequently

find in husband or wife or both, evidence of previous or still existent

gonorrhoea; but he will cautiously weigh all the circumstances before

deciding that such gonorrhoeal infection is the efficient cause of the

sterility. In many cases, however, the etiological relation is too

obvious to be overlooked, and we can trace all the distresses of the

unfortunate wife to the injury she unwittingly received upon the

momentous wedding night.

Still, we have to remember how extraordinarily common, more especially

in the so-called upper classes of society, is gonorrhoeal infection,

and what an enormous percentage of men entering upon married life have

previously experienced one or more attacks of the disease—so that were

sterility a frequent sequel of such infection, fertility would be the

exception rather than the rule. By inquiry among friends and patients

as to whether when they married they had previously suffered from

gonorrhoea, in conjunction with information regarding the fruitfulness

of their marriages, I have been led to the conclusion, which appears

to me to be one of considerable importance, that the proportion of

sterile to fruitful women among the wives of men who have suffered

from gonorrhoea before marriage, is about the same as the proportional

fertility of all marriages considered independently of gonorrhoeal

infection, viz. 1 : 10. This depends, as it appears to me, not only

upon the fact that very frequently in men gonorrhoea is completely

cured, but also upon the fact that in women gonorrhoeal infection does

not necessarily cause sterility. It may indeed be regarded as

definitely established that women actually suffering from gonorrhoea

may become pregnant, and that the pregnancy may proceed to its natural

termination. The recent investigations regarding the frequency with

which gonococci may be detected in the genital secretions of pregnant

and parturient women—and they are to be found in a surprisingly large

percentage—suffice to prove that gonorrhoeal infection offers no

insuperable obstacle to conception. That the discovery of gonococci in

a man’s urethra does not justify us with apodictic certainty in

forbidding the man thus affected to marry is in fact proved by the

following remarkable case, which came within my own experience. A

young man who had had several attacks of acute gonorrhoea, wishing to

marry, had himself examined by two specialists in genito-urinary

disease. Both detected gonococci in his urethra, and both forbade him

to marry. The patient, however, would not be advised, and married the

lady of his choice; now, six years after marriage, he is the happy

father of four blooming children, and his wife is in perfect health.

_Gosselin_, in an elaborate work published in 1853, was the first to

point out the serious consequences as regards a man’s future potentia

generandi which are entailed by an attack of gonorrhoea followed by

epididymitis. He insisted that the inflammation might lead to the

obliteration at some point of the vas deferens, whereby the secretion of

the testicle was prevented from mixing with the secretions of the

prostate, Cowper’s gland, and the seminal vesicle; and hence the

ejaculated sperm was lacking in its principal constituent. In such

cases, either in the epididymis (usually in the globus minor of that

organ), or else in the course of the vas deferens, somewhere between the

epididymis and the vesicula seminalis, some relic of the former

inflammation is usually to be detected, the globus gonorrhoeicus, and

this usually represents the seat of strangulation of the excretory duct

of the testicle.

In the year 1872 _Nöggerath_ published his book, written with flaming

fiery zeal, entitled “Latent Gonorrhoea in the Female Sex.” In the most

startling colours he depicted all the misery and distress which formed

the wedding gift of the gonorrhoea-infected husband to his wife; when

sowing his wild oats, such a husband is preparing for the crop by which

his young wife’s happiness is destroyed, her health ruined, her life

endangered, and her hopes of offspring annulled. While we may admit that

_Nöggerath’s_ motives were of the noblest, we cannot but wonder that the

wickedness of the male sex has not yet entailed the destruction of the

whole human race, overwhelmed as by a new fall of Sodom and Gomorrah.

_Nöggerath_ maintained that 90% of men infected with gonorrhoea remained

uncured; and that of the women married by men thus permanently infected

with gonorrhoea, barely 10% remained free from the disease. It is

gonorrhoeal infection, of which this author gives so gloomy a picture,

which is, in his opinion, the principle cause of sterility in women.

According to his observations, of 81 women thus infected, 49 remained

absolutely sterile; only 31 became pregnant; 23 were delivered at full

term, 3 had miscarriages, and 5 premature delivery. Thus, not so many as

1 in 3 of these women had a full-time child. Of the 23 who were

delivered at full term, 12 never had more than 1 child each; 7 had 2

children each; 3 had 3 children each; 1 only had 4 children, the normal

average fruit of healthy marriages. In all, the 81 women had only 39

children. If we take 4 to be the average number of the offspring of a

healthy married pair, there was but one normal woman among the whole 81.

Forty-nine were absolutely sterile; 11 of the remainder had 1 child, and

did not again conceive during periods ranging from 3 to 18 years after

the recorded delivery; thus there were 60 sterile women among 81.

_Nöggerath’s_ doctrine regarding the relation between gonorrhoeal

infection and sterility obtained at first little credence—perhaps for

the reason that he drew such far-reaching conclusions from so limited a

material—_Schröder_ mentions _Nöggerath’s_ opinions only to dismiss them

as extravagant; but the idea that the husband was mainly to blame for

the occurrence of sterility in marriage continued to form the topic of

scientific discussion. The indignation which _Nöggerath’s_ assertions,

unquestionably too sweeping, had aroused in gynecological circles,

gradually subsided, as every gynecologist devoted his attention to

supporting or refuting _Nöggerath’s_ conclusions.

It soon became evident, that gonorrhoea in the male had a deleterious

influence upon the fertilizing quality of the semen, and this far more

frequently than had previously been supposed. _Fürbringer_, as a result

of the examination of 124 cases, laid down the important proposition,

that when epididymitis or funiculitis gonorrhoeica duplex had been

observed to occur, the probability that the patient would be an

azoospermist was expressed by the ratio of 9 : 1, and this in direct

opposition to the views of _Zeissl_, who had maintained that in this

respect the consequences of gonorrhoea were trifling.

_Seeligmann_ conducted a pathologico-anatomical investigation which led

him to conclude that in cases of gonorrhoeal epididymitis, in addition

to the inflammation of the epididymis, phlebitis and periphlebitis of

the plexus pampiniformis occurs, and also lymphangitis of the extensive

system of lymphatic vessels which pass through the spermatic cord from

the testicle; the changes left in the blood and lymphatic vessels by the

inflammation, result in the testicle being for the future imperfectly

nourished, and often therefore lead to impairment of the functions of

this organ; thus the oligospermia so frequently seen as a sequel of

gonorrhoeal epididymitis (the ejaculated semen containing but few

spermatozoa, and these with little or no vitality), is not always due to

a complete obliteration of the vasa deferentia by the inflammation, but

in many cases to the functional derangements of the testicle brought

about in the manner above described. It is probable also that lues may

give rise to azoospermia as a result of endarteritic processes. The

remarkable result of _Seeligmann’s_ investigations was that in as many

as 75% of the sterile marriages that came under his observation, the

husband was the one to blame.

Latterly, the view that gonorrhoeal infection plays a very considerable

part in the etiology of sterility in women, has been widely accepted.

Among German gynecologists, _Olshausen_, a man of enormous experience,

considers that _Nöggerath’s_ book, notwithstanding much exaggeration, is

substantially accurate in its main conclusions. A similar view of

_Nöggerath’s_ work is taken by _E. Schwartz_, _Bandl_, _A. Martin_, and

_Hofmeier_.

According to the exhaustive work of _E. Schwartz_, gonorrhoea is in

women one of the commonest causes of sterility. Sterility due to this

disease may be either primary or secondary. In some cases no ovum can

find its way into the uterus, either because the ovaries are completely

enveloped in masses of exudation and pseudo-membranes, or on account of

dislocation of the ovaries and the Fallopian tubes, or because the tubes

have been rendered impermeable by inflammatory stenosis or flexion, or

by loss of their ciliated epithelium; in other cases the ovum, indeed,

enters the uterus, but fails to be implanted upon the diseased mucous

membrane; again, it is conceivable that even when ovum and spermatozoon

are properly formed and encounter one another in the normal manner in

the tube or in the uterine cavity, and when the uterine mucous membrane

is in a condition suitable for the implantation of the fertilized ovum,

contact with gonorrhoeal secretions may have impaired the vitality of

the ovum or of the spermatozoon, or of both, to such a degree, that

either fertilization fails to occur, or the fertilized ovum is incapable

of further development. In some instances, sterility dates from the

first infection of the wife; but more commonly it does not develop until

after the completion of one or more pregnancies.

_Hofmeier_ rightly points out that whilst gonorrhoeal infection in women

may cause sterility, such sterility is by no means an inevitable

consequence of the disease.

Other gynecologists are even more reserved in admitting the importance

of gonorrhoea as a cause of sterility in women. _Fritsch_ is of opinion

that in many cases a casual relation is believed to exist, when in

reality there is nothing more than a coincidence. Sterility and slight

perimetritis, he remarks, are common in women; gonorrhoea is common in

men. But it does not follow that the frequent gonorrhoea of the husbands

is the sole cause of the frequent sterility and perimetritis of the

wives. “For several years,” he continues, “I have examined all the men I

possibly could for evidence of the existence of gonorrhoea, and have

enquired for a history of previous attacks of the disease. To my

astonishment I discovered that the fathers of many children, whose wives

had come to consult me for some quite disconnected condition, had quite

as often suffered formerly from gonorrhoea as the husbands of sterile

wives.”

_M. Saenger_ is one who very vigorously upholds _Nöggerath’s_ views. He

insists that, excluding _puellae publicae_ from consideration, no less

than 12% of all gynecological disorders depend upon pathological

processes referable to gonorrhoeal infection of the female genital

organs. To establish this thesis, it is not necessary to prove that

_Neisser’s_ gonococcus is or has been present; the diagnosis must be

based principally upon clinical considerations. Chronic vaginitis and

urethritis, inflammation of the uterine mucous membrane, tubal

suppuration, oophoritis, and perimetritic adhesions (especially those

which unite all the lateral pelvic organs into a shapeless knot)—these

are conditions thoroughly characteristic of gonorrhoea.

No less unfavourable an influence of gonorrhoeal infection upon

fertility is shown by the observations of _Glünder_. Women numbering 87

were in attendance at the gynecological department of the _Policlinik_

of the University of Berlin, all of them seeking advice on account of

sterility. In the case of 24 of these, the husband was also present; 19

of these men admitted having previously suffered from gonorrhoea; the

remaining 5 denied such infection, although the wives of all of these

had symptoms pointing unmistakably to gonorrhoeal infection; among the

other 63 women, there were 8 only in whom the genital organs were found

perfectly normal, whilst in 38 of them there were signs of previous

gonorrhoeal infection. Thus we see that of these 87 sterile women, 62

(71.3%) had had gonorrhoea; and _Glünder_, assuming that in these cases

the gonorrhoea was the efficient cause of the sterility, and regarding

the average percentage of sterile marriages as 12.34 in every 100

contracted, is led to the conclusion that of every eleven or twelve

marriages, one is rendered sterile in consequence of gonorrhoea.

To the same opinion, that gonorrhoea is the principal cause of

sterility, _Lier_ and _Ascher_ were led by an investigation of numerous

clinical histories. Moreover, they believe that in the large majority of

sterile marriages, the husband is directly or indirectly responsible.

Directly, in so far as a very large percentage of men have their

reproductive capacity annihilated by gonorrhoea; indirectly, because, of

those who retain their fertilizing powers, so large a number infect

their wives with gonorrhoea, and thus render them incapable of

conceiving, that chronic gonorrhoea—in the female harder to eradicate

even than in the male—must be regarded as the arch-enemy of fertility.

Of 80 men affected with azoospermia, all cases observed by _Prochownik_,

in 75 the disease was the sequel of gonorrhoea; of the remaining 5

cases, two were due to syphilitic disease of the testicles, one to

tubercular disease of the same, whilst two were due to long continued

masturbation, with consecutive atrophy of the testis and epididymis.

But that the obstacle offered to conception by gonorrhoeal infection is

by no means so powerful as _Nöggerath_ and his supporters believed, is

shown by the investigations of _Oppenheimer_, who, in _Kehrer’s_

clinique at Heidelberg, examined 108 pregnant women for the presence of

gonococci, and found these organisms, pathognomonic of gonorrhoeal

infection, in no less than 30 of them, that is, in 27.7%. Thus, in this

large number of cases, pregnancy had occurred notwithstanding the

presence of gonorrhoea. _Lower_, again, in _Schröeder’s_ clinique,

examined 32 patients during the lying-in period, and detected the

presence of gonococci in 26; an experience which also proves that

gonorrhoeal infection is no bar to pregnancy. _Dunstone_ has recently

recorded 5 cases in which, notwithstanding the existence of gonorrhoea,

the women became pregnant once or several times.

In the “Medical Brief” the question was mooted, “Can a woman have

children subsequently to being infected with gonorrhoea?” Numerous

affirmative answers were received; and among them one mentioning the

case of a woman who was infected with gonorrhoea at the age of 18, and

subsequently gave birth to 8 children.

The question of sterility in prostitutes has also attracted attention,

since these women may be regarded as invariably infected with

gonorrhoea. _Meissner_ and _Jeannel_ speak of the infertility of

prostitutes as a well-known fact; and the latter states that, whereas,

according to _Montesquieu_, to every 100 women in France, on an average

341 children are born, of which 200 grow up, to 100 prostitutes in

Bordeaux there were born 60 children only, and of these but 21 attained

maturity. _Marc d’Espine_ affirms that among 2,000 prostitutes not more

than two or three will have children in a year. _Parent-Duchatelet_, on

the other hand, regards the sterility of these women as a purely

temporary affair, and writes: “les prostituées conçoivent souvent, mais

elles avortent fréquement;”[49] and this frequency of abortion he

attributes to two causes, in the first place to deliberate induction of

abortion, and in the second place, to their mode of life. He continues:

“cette fécondité a lieu surtout lorsque, quittant leur mettier, elles se

marient ou s’attachent à un seul homme; dans ce cas les grossesses se

succèdent, elles sont toujours heureuses et les infants qui en

proviennent sont aussi vivaces que les autres;”[50] thus, in his opinion

the sterility of prostitutes lasts only as long as they pursue their

occupation.

The question as to what influence, if any, gonorrhoeal secretion has

_per se_ upon the semen, has often been asked, but not yet

satisfactorily answered. We have no certain knowledge whether the

gonococci, the pus cells, or one of the toxins of the secretion,

exercises a deleterious influence upon the vitality of the spermatozoa;

it is certainly possible that this may be the case, for the diplococci,

just as much as streptococci and staphylococci, are found not only

within the cells, but also in the intercellular fluid and in the

detritus, and so must be brought into intimate contact with the

spermatozoa; but inasmuch as quite a number of persons who are at the

time actually suffering from gonorrhoea beget children, we are compelled

to assume that for the harmful influence, if any such exists, to be

exercised, a prolonged contact of the semen with the gonorrhoeal pus is

necessary. In cases of gonorrhoeal epididymitis and prostatitis, and

also in gonorrhoeal urethritis, no such prolonged contact occurs; but

when the vas deferens or the vesicula seminalis is inflamed, the contact

is more prolonged, and may suffice to destroy the vitality of the

spermatozoa, which are extremely sensitive to chemical stimuli. In 8

cases observed by _Kroner_, the fruitful coitus was unquestionably

effected when the husband was suffering from still active gonorrhoea; in

all the cases the children were born at full term, and all suffered from

conjunctival blenorrhoea. That gonorrhoea often fails to induce

sterility, is shown by the familiar fact that a woman frequently has one

child after another, all infected with this conjunctival form of

gonorrhoea, showing that the mother remains fertile notwithstanding the

persistency of the gonorrhoeal infection.

Upon the investigation of 60 carefully written clinical histories,

dealing with the relation between proved gonorrhoeal infection and a

sterile marriage, _Grechen_ has drawn up the following table, showing

the various ways in which chronic gonorrhoea may give rise to sterility:

_A. Absolute Sterility._

a. Owing to impossibility of fertilization, in consequence of defective

formation of spermatozoon or ovum:

I. In the male:

1. Aspermatism.

2. Azoospermia.

II. In the female:

Oophoritis glandularis.

b. Owing to impossibility of pregnancy, although semen and ovum may be

normal, and fertilization can be effected:

Gonorrhoeal endometritis of atrophic character.

_B. Relative Sterility._

a. Owing to mechanical interference with the conjugation of spermatozoon

and ovum:

I. In the male:

1. Epididymitis duplex.

2. Strictura impermeabilis urethrae.

II. In the female:

I. Perioophoritis and perimetritis, and their results, viz.,

adhesions and displacements of the reproductive organs. 2. Tubal

catarrh, pyosalpinx, kinking and other forms of obstruction of the

tubes.

b. Owing to extension of the gonorrhoeal process to the decidua, causing

abortion in the early period of pregnancy:

Endometritis gonorrhoeica chronica, and endometritis decidualis.

_Benzler_ has endeavoured to elucidate the problem of the relations

between gonorrhoea and sterility by a collective investigation in the

army. The investigation was concerned with 474 men who during their

period of service with the colours had been treated for gonorrhoea, and

who subsequently had married. Dealing with all cases alike, without

regard to complications which had been observed in some cases but not in

others, of the 474 wives, there were 64 who never became pregnant =

13.5%; 78 who had one child only = 16.5%; total, 142 = 30%.

Leaving out of consideration the cases in which epididymitis had been

observed, there remained 363 cases of uncomplicated urethritis; of the

363 wives of these men, there were 38 who never became pregnant = 10.5%;

63 who had one child only = 17.3%; total 101 = 27.8%.

Thus, in the cases in which the husbands had had uncomplicated

urethritis, the percentage of absolute sterility was only 10.5; while in

the unselected cases of gonorrhoea, it was no more than 13.5. The

figures show clearly that the influence of uncomplicated gonorrhoea is

but trifling; indeed, it is obvious that this must be the case, for it

is probable that not less than 80% of men experience at least one attack

of gonorrhoea, and did this give rise to sterility, either directly by

its influence on the men themselves, or indirectly by transmission to

their wives, the human race would soon die out. Moreover, the frequent

occurrence of ophthalmia neonatorum is a sufficient proof that

notwithstanding gonorrhoeal infection in all these cases, pregnancy and

delivery have taken place.

To sum up, it is my opinion that in recent years the influence of

gonorrhoeal infection in inducing sterility in women has been painted in

far too gloomy colours, and it is time that these extreme views should

be abandoned.

This is a convenient place to insist upon the fact that in cases which

are by no means rare, in the absence of aspermatism and azoospermia, and

altogether independently of gonorrhoeal infection, it is the husband who

is responsible for the occurrence of sterility; in such cases the

sterility is due to failure of conjugation between spermatozoon and

ovum, dependent upon congenital or acquired defects of the penis. The

great majority of cases of this kind are due to hypospadias.

A case of sterile marriage is reported by _Lier_ and _Ascher_, in which

the husband had suffered from hypospadias and had been operated upon for

the relief of that condition. Although erection of the penis was normal,

and coitus terminated in the usual orgasm, with sense of ejaculation,

the semen did not find its way into the vagina; it accumulated in the

artificial cul-de-sac between the former abnormal urethral orifice and

the artificially constructed meatus, and after coitus the semen had to

be expelled from this region by digital pressure.

_Miclucho-Mackay_ reports that among the Australian aborigines,

hypospadias is artificially induced, in order to prevent fertilization.

In young boys, an incision is made through the lower wall of the urethra

from the meatus as far up as the scrotum, and care is taken that the

several surfaces do not reunite. During coitus, the semen flows away

without entering the vagina. This mutilation is practised, not only in

South and Central Australia, but also by the indigens of Port Darwin.

That hypospadias does not in all cases offer an insuperable obstacle to

impregnation, is, however, shown by a striking case which came under the

notice of _Labalbary_. He saw a hypospadiac who, in micturating, had to

crouch down in the feminine posture, because he was unable to project

the stream of urine forwards; in coitus, he deposited his semen only on

his wife’s vulva. But his wife gave birth to two sons, about whose

paternity there could be no reasonable doubt, since both exhibited the

same malformation as their putative father.

Occasionally, phimosis offers an obstacle to impregnation, and only

after relief of the condition by operation, is the wish for offspring

fulfilled. A case of this nature is recorded by _Amussat_.

In cases of severe stricture of the urethra, sterility may result,

although the constitution of the semen is perfectly normal. During

erection of the penis, the stricture is completely closed, and the semen

accumulates in the urethra above it; when the penis becomes flaccid, the

semen flows away, outside the vagina. In some such cases, the semen

regurgitates into the bladder, and is not discharged until the patient

makes water. Although the supposition is not one in which strict proof

is obtainable, it is probable that the man is at fault in cases in which

the wives of two or more brothers fail to conceive. I have seen several

instances of the kind. Three brothers, all quite healthy, and of virile

aspect, were married to women in whom on gynecological examination no

significant abnormality could be detected; they had been married

respectively for 14, 9, and 8 years; all were childless. Three brothers,

two of whom were practising physicians, had lived a number of years (20,

4, and 14, respectively) in sterile wedlock; one of them (a physician)

informed me that he ejaculated always a very small quantity of semen,

and thought it possible that this was the cause of the sterility. Of

four brothers, two had lived long in barren wedlock; the third had no

child for 14 years after marriage, when at last his wife became pregnant

after a visit to a spa; the fourth brother is a misogynist and a

confirmed bachelor.

_Sexual Sensibility in Women._

In our consideration of the various influences by which the contact of

ovum and spermatozoon may be prevented, the degree of sexual excitement

experienced by the woman during the sexual act must not be overlooked,

for this plays a part not to be underestimated, even though it is a

matter on which it is difficult to obtain accurate information.

It is extremely probable that an active participation on the part of the

woman in coitus has an important influence upon the attainment of

fertilization, i. e., that sexual excitement in the woman is a link in

the chain of conditions leading to conception. This excitement has a

reflex influence, but the influence may be exercised in either (or both)

of two ways: first, it may cause certain reflex changes in the cervical

secretion, whereby the passage of the spermatozoa is facilitated; or,

secondly, it may give rise to reflex changes in the vaginal portion of

the cervix, to a rounding of the os uteri externum and a hardening of

the consistency of the cervix (changes of an erectile nature) coupled

with a slight descent of the uterus—changes which likewise favour the

entrance of the semen into the uterine cavity. _Theopold_ goes so far as

to say that it is only women who experience erotic excitement who are

capable of being impregnated.

My own opinion is that considerable importance is to be attached to

voluptuous excitement of the woman during coitus, for the former of the

two reasons mentioned above, namely, because such excitement leads to

the occurrence of reflex secretion of the cervical glands, the secretion

thus produced maintaining or enhancing the activity of the spermatozoa;

and contrariwise, in the absence of voluptuous excitement on the woman’s

part there is a failure of the reflex secretion, and the passage of the

spermatozoa into the uterine cavity is consequently less easily

effected. That sexual excitement has great influence upon the production

of the first appearance of menstruation, has frequently been shown; and

an analogy between such an influence and the suggested effect of sexual

excitement in favouring the occurrence of conception, must not lightly

be rejected. It is well known that the first menstruation occurs at an

earlier age in girls living in towns than in those living in the

country; not solely (if at all) in consequence of the better nutriment

and easier life of the former, but also, unquestionably, owing to

nervous influences. It is, moreover, a familiar experience that factory

girls, who from early youth are exposed to sexual stimulation, attain

sexual maturity at an extremely early age. Again, from early times it

has been the prevailing opinion of the common people that for the

impregnation of a woman it was necessary for her to experience

voluptuous excitement, or at least, that in the absence of such

excitement, conception was rendered difficult. _Riedel_ relates of the

indigens of the Island of Buru, that they often have sexual intercourse

with foreigners, “but during such intercourse they remain quite passive,

in order to avoid impregnation.” It is not an unusual experience in

gynecological practice for a sterile woman, in the absence of any

prompting, to complain that during coitus she has no “feeling” whatever,

and to attribute to this lack of feeling her failure to conceive.

A cultured lady, the mother of several children, assured me, not only

that she was always aware, whether an act of intercourse would or would

not lead to impregnation, but further, that it was within her power to

determine whether the intercourse should or should not be fruitful. If

she was passive during intercourse, or if, to use her own expression,

her attitude was one of “laisser faire, laisser aller,” conception would

not occur; but if, on the other hand, she took an active part in the

coitus, so that she experienced a powerful voluptuous sensation,

pregnancy would result from the intercourse.

In some cases, the previously described condition of dyspareunia is the

cause of the sterility. In fact, the combination of dyspareunia with

sterility is so strikingly common, that my own observations have led me

to infer that there is a casual connexion between the two states, at

least in a considerable proportion of cases.

I append a short note of a few instances of this kind: Mrs. G., aged 27,

married 6 years, sterile; an anæmic, delicate lady, who has never

experienced the sense of ejaculation. The semen flows away from the

vagina immediately after the completion of coitus. No abnormality to be

detected on gynecological examination. Mrs. S., aged 24, married 5

years, sterile; during intercourse remains completely cold, and has

experienced the sense of ejaculation in dreams only. Gynecological

examination disclosed the existence of slight cervical catarrh, but no

other abnormality. Mrs. E., aged 30, married 10 years, had a child 9

years previously, a difficult delivery followed by puerperal disease,

since then sterile; she states that since her delivery she has not

experienced the sense of ejaculation, with which she was formerly

familiar; further, since that time she has suffered from profluvium

seminis. On gynecological examination the uterus was found to be

enlarged and retroflexed. Mrs. K., aged 28, married 6 years, sterile;

amenorrhoeic, has never experienced the sense of ejaculation, and finds

sexual intercourse so unpleasant that, “in order to be left in peace,”

she has herself begged her husband to keep a mistress. Examination

showed the uterus to be in an infantile condition.

Whilst I have notes of numerous cases similar to those just quoted, I

must also insist upon the fact that I have sometimes had complaints of

dyspareunia from wives whose fertility has been proved by the birth of

numerous children. And, again, anyone whose position permits him

frequent glimpses of what passes behind the scenes of married life, will

from time to time have noticed as signs of relative dyspareunia

instances in which the faithless wife is far more readily impregnated by

her lover than by the husband to whom she is indifferent or whom she

actually dislikes.

To relative dyspareunia dependent upon sexual disharmony we must refer

also those instances in which a man and a woman prove sterile while

living together for a considerable period as man and wife, but after

separation both prove fertile in fresh unions. Several such cases have

come within my own experience, and similar instances attracted the

attention of the observers of antiquity—_Aristotle_, for example.

_Haller_, for this reason, lays stress on the lack of mutual affection

as a cause of sterility; and _Virey_, also, believes that sterility may

often depend upon the absence of the “harmonie d’amour.”

It is possible that the custom, which in certain rural districts has

persisted into quite recent times, of a temporary experimental

cohabitation of candidates for matrimony, was based on an attempt to

discover the existence of such a sexual harmony. _Ploss_, for instance,

reports that in East Prussia, in 1864, he was informed that among the

Mazurs this custom of an experimental year of cohabitation was in force.

If during this year the woman became pregnant, the young couple were

married; but if pregnancy failed to occur, they separated, considering

they were not formed for one another.

A well-known historical example of relative sterility is furnished by

the two marriages of Napoleon I. His first marriage to Josephine

remained sterile, though Josephine had children by Beauharnais; and

Napoleon, remarried to Marie Louise, had a son by the latter.

_Von Gutceit_, a physician of wide experience, points out that

“sensitive women, who have a mental or physical antipathy to

cohabitation, or who have a secret but ardent affection for some other

man, often fail to conceive as a result of intercourse with their

husbands; but when, in illicit intercourse, they experience the

voluptuous sensations to which they have hitherto been strangers,

pregnancy often speedily ensues.” He maintains, further, “that such

women, in consequence of the stimulation of the genital organs in the

absence of sexual gratification, become affected with all kinds of

menstrual irregularities, with fluor albus, prolapse of the uterus, and

chronic metritis; they suffer from digestive disturbances and

constipation, leading to emaciation; and they are prone to hysterical

manifestations.”

Analogous phenomena have been noted, and with much greater distinctness,

in the animal world. _Darwin_, writing on this subject, remarks: “It is

by no means a rare occurrence, that certain males and females will not

be fruitful in intercourse together, whilst the same individuals prove

perfectly fertile in intercourse with other members of their species—and

this in cases in which there is no evidence that the subsequent

fertility is due to any change in the conditions of life. The cause is

probably to be found in an innate sexual disharmony between the

infertile pair. A very large number of instances of this kind have been

reported to me by well-known breeders of horses, cattle, pigs, dogs, and

pigeons. Sometimes a breeder will fail to obtain offspring from a male

and a female of known fertility whom he wishes to couple for some

special reasons. The most celebrated living horse-breeder informed me

that frequently a mare, which in other seasons with other stallions has

proved fertile, may be coupled with a stallion likewise of proved

reproductive potency, and will fail to be impregnated; yet this same

mare will shortly afterwards be impregnated by another stallion.”

_Pflüger_ reports that he has often seen a thoroughbred stallion, which

was fully prepared, at a moment’s notice, to serve a thoroughbred mare,

prove extremely unwilling to serve a common mare on heat, and only

induced to do so with the greatest difficulty, and indeed by a trick.

The stallion is placed in the central one of three stalls, on one side

of him is the thoroughbred mare, whilst in the third stall is the common

mare, covered with a cloth. The stallion’s head is turned to show him

the thoroughbred mare; immediately his appearance undergoes a change.

Every muscle of his body appears to quiver, and never does a fine animal

appear more beautiful than at such a moment, full of pride, fire, and

vitality.[51] As soon as the stallion makes ready to serve the mare, he

is rapidly led to the other stall, and suitably assisted to the actual

commencement of intercourse with the substituted mare. But it sometimes

happens, as _Pflüger_ himself has seen, that the stallion becoming aware

of the deception, refuses to complete the coitus, withdraws his penis,

and immediately turns to the mare of his choice.

_Matthews Duncan_, among 191 sterile women, found that 39 had no sexual

appetite, and 62 had no voluptuous sensations during coitus. He regards

abnormal sexual appetite as one of the principal causes of sterility.

Notwithstanding these facts, it must not be forgotten that many cases

are recorded in medical literature of women conceiving after intercourse

effected against their wishes, as by rape, or when they were in a state

of intoxication, or asleep, or in the entire absence of all voluptuous

sensation. Moreover, the erection of the vaginal portion of the cervix,

and the reflex movements and secretory changes in the uterus, may also

occur independently of sexual desire and voluptuous sensation; but such

cases are certainly exceptional, and their credibility is frequently

open to suspicion. In numerous instances in which conception is stated

to have followed intercourse in a state of unconsciousness, judicial

proceedings have elicited the fact that the intercourse was not entirely

involuntary on the woman’s part, and that the alleged force was no more

than a _vis grata_. _Von Maschka_ reports a case in which a girl

asserted that she had been violated whilst in a condition of epileptic

unconsciousness, but she remembered every detail of the act with

precision. _Casper_, again, in a case in which it was asserted that

defloration had been forcibly effected whilst the girl was in a state of

alcoholic coma, showed that there had been no more than moderate

intoxication combined with great sexual excitement. Assertions that

pregnancy has resulted from intercourse effected during sleep, in a

state of unconsciousness, or in the “magnetic” or “hypnotic” state,

should always be accepted with reserve.

It is interesting to note in this connexion that the Chinese physicians

enumerates among the causes of sterility the practice of “congfou” by

the man, this name being given to a manipulation analogous to hypnotism,

whereby the voluptuous sensation during intercourse is diminished or

abolished by distracting the attention elsewhere.

A proof of the importance of specific sexual sensation for the

attainment of conception is afforded by the fact that in the majority of

women voluptuous excitement is absent at the first act of intercourse,

and only gradually develops thereafter; in correspondence with this, we

find that the first conception does not usually occur until some time

after marriage, and that the period of its occurrence frequently

coincides with the full development of voluptuous sensation during

intercourse. Thus, even in the woman fully fitted for conception, the

actual capacity for impregnation is only developed gradually, and after

a sufficient experience of intercourse.

This transient incapacity for conception may, indeed, also depend upon

the fact that at first coitus is apt to be incompletely effected, and

for this both husband and wife are to blame; but unquestionably in many

cases the reason is the one first mentioned.

In some cases, certain psychical influences which affect the intensity

of the voluptuous sensation, manifest its significance. Thus, in some

instances, the influence of stimulation of the clitoris in leading to

conception has been clearly shown; in others, the performance of coitus

in some unusual position, varying with the woman concerned, is alone

competent to arouse sexual sensibility to its full extent, and to bring

about the orgasm. One occasionally receives confidential information

from a husband that his wife experiences a voluptuous sensation only

when coitus is performed in the lateral posture, or _more bestiarum_, or

in the _situs inversus_, etc., etc.

Excessive frequency of intercourse, prolonged and repeated sexual

excitement, on the other hand, induce sterility, as is well seen in

prostitutes, who rarely become pregnant.

Finally, perverse sexual impulse must be mentioned as a possible cause

of sterility. This may be an acquired perversion, due to the fact that

at the epoch of the menarche, the commencement of puberty, owing to the

strength of sexual desire whilst intercourse is an impossibility, or

simply from evil example, the girl has become a confirmed onanist, and

continues the habit even after marriage. In other cases we have to do

with a psychopathic state, a form of mental degeneration due to very

various causes, or in some cases inverted sexual sensibility exists in a

person whose mind is in other respects normal. In women with sexual

inversion, ordinary copulation with the male is insufficient to arouse

the sexual orgasm, and for this reason, as well as because persons thus

affected avoid coitus as much as possible, sterility commonly ensues.

In sterile homosexual women, and equally so in women addicted to

masturbation, gynecological examination may disclose no abnormality

whatever; but in other cases of the kind we may find a contributory

cause of sterility in the fact that the internal genital organs are

imperfectly developed, or even completely absent. In sterile women, if

on gynecological examination we find certain characteristic changes in

the reproductive organs, a strong suspicion will be aroused that the

sterility is due to abnormal modes of sexual gratification. The changes

in question are: hypertrophy of the clitoris, enlargement and a bluish

colouration of the labia minora, retroversion of the uterus, neuralgia

and displacement of the ovaries, leucorrhoea, and menorrhagia.

The question has been mooted by _Cohnstein_, whether, as is commonly

assumed, a woman is capable of becoming pregnant at any time during the

year, or whether, as in the lower animals, the reproductive capacity can

be exercised only at certain seasons, or again, whether there may not be

individual moments of predilection for the occurrence of conception. He

found that in the great majority of women there were such seasons of

predilection, and only in a minority could conception be effected

indifferently at any time of the year. As a proof of this assertion, he

appends the following case: A married woman, 33 years of age, had

several years before been delivered prematurely of a still-born child,

and since then had not again been pregnant. Her reproductive organs were

normal. The husband’s semen was examined, and also found to be quite

free from abnormality. In the course of the three following years an

attempt was made to cure the sterility by dilatation of the cervical

canal, suggestions for the proper regulation of sexual intercourse,

etc., but all without effect. _Cohnstein_ now calculated the date at

which the full term of the previous pregnancy would have fallen, and

found that this was the middle of February; he therefore inferred that

intercourse effected at the beginning of May would result in

impregnation. As a fact, the woman conceived at this time, and at full

term gave birth to a healthy girl. The assumption that such a time of

predilection for the occurrence of conception exists is, however,

contradicted by the well known fact that in the case of large families

the children’s birthdays are irregularly distributed throughout the

year.

_Baker-Brown_ describes a special form of sterility due to “sympathetic

or reflex action.” It depends upon diseases of the organs adjoining the

uterus, such as vascular tumours of the urethra, bleeding piles,

fistula, fissure, and prolapse of the anus, schirrus of the rectum,

ascarides. “These diseases produce sterility in consequence of the loss

of blood, the menstrual disturbances, the morbid congestion of the

uterine system, and the reflex neuroses, to which they give rise.”

_Courty_ reports a case belonging to this category in which in a young

married lady sterility was due to fissure of the anus, which had long

existed without recognition; after the fissure had healed, conception

occurred. _Palmay_ recently reported a case in which “taenia solium was

the cause of sterility. In a woman 20 years of age, who had lived in

sterile wedlock for three years, the presence in the intestine of a

tapeworm, which she had harboured for many years, gave rise to

dysmenorrhœal troubles. The complete expulsion of the worm relieved the

dysmenorrhœa, the woman became pregnant, and gave birth to a child at

full term; since then menstruation has been painless.” The presence of

the tapeworm may have had an unfavourable influence upon the

blood-supply and the innervation of the uterus. But cases of this nature

do not constitute a special form of sterility; they must be classed,

either with cases due to interference with ovulation, or with those due

to prevention of the contact of ovum and spermatozoon.

_Incapacity for Incubation of the Ovum._

The fertilization of the ovum is, as previously described, probably

effected in man, as in other mammals, in the upper third of the

Fallopian tube. The fertilized ovum is then swept down into the uterus

by the action of the cilia which line the tube, assisted by the

peristaltic movement of the muscular wall of the canal. The uterine

mucous membrane at this time is thickened and thrown into folds, and in

these latter the fertilized ovum is entangled; by its presence the ovum

now exerts a reflex stimulus leading to a still greater proliferation of

the cells of the uterine mucous membrane, which grows up over the ovum

and soon shuts it off completely from the uterine cavity. Thus the ovum

comes to be entirely imbedded in the substance of the mucous membrane.

Thus for the implantation of the ovum, it is first of all necessary that

the uterine mucous membrane should be in a normal condition;

pathological changes in this membrane, and indeed any morbid structural

alteration in the uterine tissues, may prevent the implantation and

incubation of the ovum, and may thus give rise to sterility.

The uterine cavity is normally lined with ciliated epithelium, the cells

of which have an elongated elliptical form. The movement of the cilia is

directed downwards. The epithelium is perforated by the orifices of the

uterine glands; these glands are simple tubular glands, passing through

the mucous membrane with an S-shaped or corkscrew curve; between the

glands lies a rich germinal tissue, made up of rounded cells. The

rounded connective tissue cells have processes which build up the

scaffolding of the mucous membrane. Among the connective tissue cells of

the uterine mucous membrane, wandering leucocytes are almost always to

be seen. Menstruation is characterized by a swelling of the mucous

membrane, and by enlargement of the uterine glands. At the same time,

blood extravasations appear between the more superficial layers of the

membrane, and on its free surface, and various portions of the surface

of the membrane are cast off.

Very numerous are the morbid states of the uterus and its annexa whereby

the implantation and incubation of the ovum are prevented; and

incapacity of the uterus for the fulfilment of these functions is

therefore a common cause of sterility in women.

That developmental defects of the uterus, even when they are not such as

render conception impossible, may yet often give rise to sterility, has

been already explained in writing of the conditions of the uterus which

prevent the contact of ovum and spermatozoon; for defects of development

which are not sufficiently severe to prevent this contact, may yet

suffice to render the uterus unfit for the implantation and incubation

of the fertilized ovum. Inflammatory disorders, such as perimetritis and

the formation of exudations in the parametrium, may render the uterus

unable to undergo the enlargement necessary to pregnancy. Tissue changes

in the uterine musculature may likewise prevent the implantation of the

ovum, or the proper development of the uterus during pregnancy.

New-growths of the uterus or its neighbourhood may bring the development

of the fertilized ovum to an untimely conclusion. Above all, however, it

is diseases of the uterine mucous membrane which unfit the organ for the

implantation of the ovum, and thus give rise to sterility. All those

inflammatory states which lead either to softening or to induration of

the uterine parenchyma, or to swelling and thickening of the endometrium

or parametrium, may offer a hindrance more or less serious to the normal

incubation of the ovum.

The diagnosis whether in an individual case we have to do with sterility

dependent upon _impotentia gestandi_, is often difficult, because the

conditions which cause it are frequently associated with those which

cause sterility by preventing the contact of ovum and spermatozoon. In

any case, a careful examination of the pelvic organs must be made, not

only to determine whether there is any displacement or enlargement of

the uterus, chronic metritis or perimetritis, parametric exudations, or

new growths of the uterus or of neighbouring organs, but also, if

necessary by dilating the cervical canal, to ascertain the condition of

the uterine mucous membrane, and whether there is hyperplasia or atrophy

thereof. In this connexion, examination of the uterine secretion is of

especial importance: a purely mucous, transparent, vitreous, tenacious

secretion in the os and in the cervical canal, indicates the existence

of catarrhal endometritis; a markedly haemorrhagic secretion signifies

hyperplastic endometritis; profuse purulent secretion containing

gonococci, indicates gonorrhoeal endometritis; the discharge of pieces

of membrane shows that there is exfoliative endometritis; the discovery

of fragments of carcinomatous tissue indicates the breaking down of a

malignant tumour of this nature; etc.

Finally, it is necessary to obtain a careful history of the case, asking

whether there have been menstrual irregularities, or miscarriages, and

the characters of previous labours (in cases of acquired sterility); any

pathological conditions in other organs should be investigated; and the

condition of the blood and the state of general nutrition should receive

attention. Chlorosis, anæmia, and scrofula often give rise to catarrhal

endometritis; severe disease of the heart may lead to congestive

troubles of the genital organs; after abortion or difficult labour,

chronic metritis or endometritis are common. Further, the differential

diagnosis between erosion and carcinoma of the portio vaginalis, must

often depend upon consideration of the patient’s age and general health,

and upon the nature and duration of the haemorrhage. Pain on

micturition, appearing soon after marriage, and lasting often a few days

only, will indicate the probability of gonorrhoeal infection, etc.

_Von Grünewaldt_ has vigorously insisted upon the fact that the notion

of sterility, i. e., _impotentia generandi_ in women, is not coincident

with the notion of _impotentia concipiendi_, and there is an important

distinction between cases in which it is impossible that fertilization

should be effected, and cases in which, though fertilization may take

place, the implantation and incubation of the ovum fail to ensue. In

this author’s opinion, the only absolute mechanical hindrance to the

entrance of the semen is to be found in atresia of the genital passage,

and the role of _impotentia concipiendi_ is of quite minor importance as

compared with incapacity on the part of the uterus for the implantation

and incubation of the ovum, an opinion, which, notwithstanding the

record of exceptional cases in which pregnancy has occurred in spite of

the existence of mechanical obstacles to conception, I must regard as

altogether beyond the mark. On the other hand, it is indisputable that

for the occurrence of pregnancy it is necessary, not only that contact

of ovum and spermatozoon should be possible, but further, that the

uterus should be in a condition favourable for the implantation and

further development of the ovum subsequent to fertilization. For this

reason, diseases of the uterine tissues must play an important part in

the causation of sterility, though we cannot go so far as to admit with

_von Grünewaldt_ that these diseases are the _principal_ cause of

reproductive incapacity in women.

Various metritic processes, and also venous hyperaemia consequent upon

heart disease, may lead to atrophy of the uterine mucous membrane, which

then appears thin and smooth, whilst the uterine glands are destroyed,

or transformed into small cysts. The same condition may result from

retention of secretions in the uterine cavity—hydrometra and

haematometra. In all these cases, the epithelium probably loses its

cilia. The process has a serious influence antagonistic to the

reproductive capacity inasmuch as the implantation of the chorionic

villi is rendered difficult (_Klebs_).

Hyperplasia of the uterine parenchyma, affecting either the whole organ

or a large part, and characterized either by enlargement of the entire

organ, or only by thickening and elongation of the cervix, may hinder

the incubation of the ovum. It may be due to endometritic catarrhal

processes; to venous hyperaemia, especially in cases of valvular heart

disease; to subinvolution; and sometimes to excessive sexual

stimulation, as in prostitutes. Both the change in the shape of the

cervix, and the changes undergone by the uterine mucous membrane in

cases of extensive uterine hyperplasia (it commonly becomes atrophic and

discharges a watery secretion), interfere with the reproductive

capacity.

In all cases of chronic metritis, the hyperaemia and hyperplasia of the

uterus may give rise to haemorrhages; these sweep away the ovum, and

thus lead to _impotentia gestandi_. And the nutritive changes in the

mucous membrane that occur in chronic metritis also interfere with the

implantation and incubation of the ovum. Moreover, it is well known that

in these cases, even if conception is effected, abortion is extremely

apt to occur, owing to the pathological state of the endometrium, which

interferes with the normal development of the decidua. Haemorrhages

occur in the decidua, and are followed by abortion. And further, the

replacement of portions of the muscular tissue of the uterine wall by

fibrous tissue, a change which is apt to occur in long continued

metritis, interferes with the proper expansion of the uterus during

pregnancy, and thus leads to abortion.

On the other hand, it cannot be denied that frequently enough patients

with well marked chronic metritis nevertheless conceive in a normal

manner, and give birth to a healthy child; and this not once only, but

again and again.

As sterility due to mesometritis, _von Grünewaldt_ classes the numerous

cases in which sterility ensues upon a confinement in which the patient

reports that inflammation followed delivery—or sometimes in which

nothing abnormal was noticed. The results of local examination are

negative: there is no displacement, no exudation or swelling, and no

relevant affection of the endometrium. But the characteristic feature of

these cases is, according to _von Grünewaldt_, that after her last

full-time delivery, a woman has had a miscarriage or a premature

delivery, and subsequently has been completely sterile. The degenerative

process is at first partial, so that it does not prevent conception, but

renders it impossible for the pregnancy to go on to full term;

subsequently it extends throughout the mesometrium, and conception is no

longer possible.

_Cole_ of San Francisco regards as the most frequent cause of sterility

ensuing upon a single delivery, subinvolution of the uterus, most

commonly due to rising too early after delivery. He therefore considers

it of especial importance after a first delivery that the physician

should satisfy himself that no serious injury has been effected by the

process.

Chronic endometritis is a very frequent cause of sterility: in the first

place, the catarrhal swelling of the mucous membrane, which often

extends from the os uteri externum to the ostium abdominale of the

Fallopian tubes, offers an obstacle alike to the downward passage of the

ovum and the upward passage of the spermatozoa; and secondly, in long

standing cases, the large size of the uterine cavity and the smoothness

of the surface of the atrophied mucous membrane, render the lodgment of

the ovum in the uterus very unlikely. A further powerful obstacle to

impregnation in cases of endometritis is offered by the profuse

muco-purulent secretion which usually, though not invariably,

accompanies that disease. This secretion, in some cases flowing freely

over the surface of the membrane, but in others adhering to it with

tenacity, whitish-yellow in colour, rendered cloudy by admixture of pus,

or tinted red by admixture of blood, sometimes of a gelatinous

consistency with a strongly alkaline reaction, contains globules of

mucus, ciliated and cylindrical epithelial cells, pus corpuscles,

bacteria and cocci,—and, if the endometritis is of gonorrhoeal origin,

the gonococcus of _Neisser_. This secretion, when profuse and thinly

fluid, pours out through the os, and sweeps away the semen; when

tenacious and gelatinous, it fills up the dilated cervical canal above

the constricted os uteri externum, and constitutes a powerful barrier to

the upward passage of the spermatozoa; when purulent, it is destructive

to the vital activity of the spermatozoa. The changes in the mucous

membrane in cases of long standing endometritis whereby the uterus is

rendered unfit for the implantation and incubation of the ovum, are the

following. The epithelial cells, as usual in cases of continued catarrh,

change in form, the ciliated cells disappear, and are replaced, first by

cylindrical cells, later by polymorphic cells, approaching in type those

of pavement epithelium. The mucous membrane is swelled, the vessels are

dilated, there is hyperplasia of the glands, with a moderate amount of

small-celled infiltration of the interglandular tissue (Fig. 83).

Ultimately the mucous membrane undergoes atrophy, its glands disappear,

it comes to resemble a thin stratum of connective tissue.

[Illustration:

FIG. 83.—Uterine Mucous Membrane in Endometritis. (After A. Martin.)

]

Thus, in severe and long-continued endometritis, the changes that occur

in the uterine mucous membrane render the implantation of the ovum and

the formation of normal decidua impossible; even if conception does

occur, the fertilized ovum is speedily discharged. Frequently, in cases

of endometritis, there is consecutive displacement of the uterus which

acts as a contributory cause of sterility. When endometritis lasts a

long time, proliferation of connective tissue in the uterine parenchyma

also occurs, leading often to hypertrophy of the cervix, and to stenosis

of the cervical canal. Since in so many different ways endometritis may

give rise to sterility, the importance that must be attached to this

condition is evident.

The great significance of gonorrhoeal infection in relation to sterility

in women depends, not only on the changes this disease causes in the

Fallopian tubes, leading to interference with the necessary contact of

ovum and spermatozoon, but further, upon the occurrence of gonorrhoeal

cervical and corporal endometritis, of perimetritis, and secondary

parenchymatous metritis. Still, under appropriate treatment, the

inflammatory changes consequent on gonorrhoeal infection are in many

cases curable, and, after absorption of the exudations and restoration

of the normal nutritive conditions of the tissues, conception may take

place. _Fritsch_, who points out that in the woman infected with

gonorrhoea, sterility ensues in a manner analogous to that in which it

occurs in the male (for in the latter it is not the primary urethritis,

the disease of the passage, but the secondary inflammation of the

testicle that leads to sterility), states that he has observed cases in

which beyond question conception has occurred, notwithstanding the

existence of gonorrhoeal endometritis.

In my own experience, whilst gonorrhoeal endometritis is, among

inflammations of the endometrium, the most frequent cause of sterility,

the place of next importance in this connexion is occupied by

exfoliative endometritis, or membranous dysmenorrhœa. This name is given

to a pathological condition in which from time to time, usually during

menstruation, fragments of membrane, or even an entire sac-like cast of

the uterine cavity, are expelled from the uterus; since this condition

is apt to hinder the incubation of the ovum, it is commonly associated

with sterility—a fact mentioned already by _Denman_ in 1790, and since

then confirmed by numerous observers. I have had under observation

several cases of dysmenorrhœa membranacea; in two cases it existed from

the time of marriage—in one case 14 years, in the other 8 years—and in

both sterility was absolute. In the latter of the two cases, vigorous

treatment was undertaken, even curettage of the uterus, but quite

without avail. In other cases, the sterility was acquired, the

membranous dysmenorrhœa having begun after the woman had already had one

or more children; but as I have never seen a case in which a woman

became pregnant after the development of this affection, I am compelled

to regard it as one of the most severe hindrances to conception.

As a general rule, exfoliative endometritis terminates only with the

onset of the climacteric age; in very exceptional cases, however, a cure

may take place earlier. In cases in which this premature termination has

been observed, pregnancy has been known to ensue, cases of this nature

having been observed by _Solowieff_, _Fordyce Barker_, and _Thomas_. And

recently, cases have been reported, in which the disease has returned

after such a pregnancy. _Fritsch_, indeed, is of opinion that

exfoliative endometritis does not cause sterility, and that in this

disease abortion is no commoner than in other diseases of the uterus.

_Charpignon_, _Hennig_, and _Bordier_ have also observed conception

occur in the course of this disease. In 42 cases of membranous

dysmenorrhœa collected by _Kleinwächter_, pregnancy occurred in four

during the existence of the disease. _Löhlein_ also reports that, among

27 patients affected with membranous dysmenorrhœa, six became pregnant,

after the symptoms had been clear and unmistakable for a shorter or

longer period. Two of these patients had been already pregnant before

the first appearance of the exfoliative endometritis; subsequently they

became pregnant and were delivered at full term. The other four had

suffered for varying periods and with varying severity from the

affection, before they first became pregnant. In three of these cases

curettage of the uterus was performed; but in one only, in which

pregnancy ensued very speedily on the operation, could a causal

connexion be inferred. In two of the cases the mothers of the patient

had also suffered from the affection.

It has been asserted by _B. Schultze_ and others that curettage of the

uterus renders it difficult or impossible for pregnancy subsequently to

occur. There is, however, no evidence to justify such an opinion.

Especial attention should be given to inflammatory processes in the

perimetrium and the parametrium as diseases giving rise to sterility in

women. They are extremely common, and at times are so insidious, running

their course without giving rise either to pain or to fever, that even

when very extensive, and even when they have led to the formation of

secondary tumour-growths, they may yet be overlooked. Hence their

pathological significance in the causation of sterility in women is

still underestimated. Chronic pelvic peritonitis and parametritis may

lead to the onset of sterility in various ways: changes may occur in the

cervix, this organ becoming indurated, fixed, and retroposed, and

painful when the uterus is moved; inflammatory changes may affect the

body of the uterus, the ligaments of the ovary, and various portions of

the pelvic peritoneum; displacement of the uterus may occur; one or both

ovaries or tubes may be dislocated and fixed, either to the side of the

uterus, or behind it, in the pouch of Douglas; all kinds of adhesions or

inflammatory nodules may result from these processes. Further, in the

scarred, contracted, sclerosed parametric tissue, the blood and

lymphatic vessels of the parametrium are compressed, and in part

obliterated, and the intimate connexion between the pelvic cellular

tissue and the uterus readily leads to the onset of endometritis,

whereby the implantation of the ovum is interfered with. The occurrence

of sterility in cases of pelvic peritonitis and parametritis, depends in

part on the indirect effects of the inflammatory exudations, and in part

on the direct result of the extension of the inflammation to other

regions. The perimetritis, parametritis, and pelvic peritonitis that

result from gonorrhoeal infection have thus an especially disastrous

influence, for the reason that in these cases cervical metritis and

endometritis with blenorrhoea are commonly superadded. This is the

principal cause of the almost invariable sterility of prostitutes, in

whom, however, we must also take into consideration the influence of the

absence of voluptuous sensation in an act which to them has become a

mere matter of business. The investigations of _Bandl_ in the post

mortem room show that residues of perimetritic and parametritic

inflammation are to be found in the bodies of 58.4% of parous women, and

33.3% of the bodies of women (married or unmarried) who have had

experience of sexual intercourse but have never had a child. This, he

thinks, is the explanation of the great frequency of childless marriages

and of relative sterility in women. In the nulliparae mentioned above,

_Bandl_ commonly found an indurated, functionless, in places cicatrized,

narrowed cervix, paraoophoritic and perisalpingitic residues, and morbid

changes in the tubes and the ovaries. In some cases also the husbands of

such sterile women were found to be affected with azoospermia. The

connexion between azoospermia in men and the discovery of inflammatory

residues in their childless wives, is a very intimate one. The husband

at the time of marriage was suffering from an imperfectly cured

gonorrhoea, and infected his wife. In the other class of cases, in which

the women had had children, and subsequently become sterile, the

limitation of fertility depended chiefly upon inflammatory residues in

and around the ovaries and the tubes. In the majority of such cases,

pregnancy is not rendered impossible, but merely difficult, for,

notwithstanding the presence of very extensive inflammatory residues,

the tubes are often pervious, and the ovaries fully or partially

functional. Therefore, even in cases in which intrapelvic inflammation

has been very severe, we must be cautious in giving a prognosis that

pregnancy has been rendered impossible, for the cases in which both

ovaries are imbedded completely in pseudo-membranes, or in which both

tubes have been rendered impervious, are unquestionably rare.

Carcinoma of the uterus rarely causes sterility. In its initial stages,

in which there is merely papillary proliferation of the portio

vaginalis, or carcinomatous infiltration of the deeper layers of the

mucous membrane, no hindrance is offered to conception; but even in the

later stages of the disease, when ulceration has occurred, and when

there is extensive necrosis of the cancerous masses, there is not

necessarily any absolute impossibility of the occurrence of conception,

so long as cohabitation remains possible, and no insuperable hindrance

has risen to the contact of ovum and spermatozoon. The cases are

numerous in which pregnancy has been observed, notwithstanding extensive

carcinomatous disease of the cervix, with necrosis of the tumour tissue;

and _Cohnstein_ even asserts, though in this he goes too far, that

cancer of the cervix actually favours impregnation. Among 127 cases of

this kind, there were 21 in which the disease had existed for a year or

more before the occurrence of conception.

_Winckel_ summarizes in the three following propositions his experience

regarding the relation between uterine carcinoma and sterility: 1.

Married women form the very large majority of those affected with

carcinoma of the uterus; 2. The marriage of such women has very rarely

proved sterile; 3. On the contrary, the women affected with this disease

have generally been exceptionally fertile.

Other tumours of the uterus cause sterility, not merely by giving rise

to mechanical interference with the necessary contact of ovum and

spermatozoon, but also by leading to catarrhal states and hyperplasia of

the mucous membrane, which interfere with the implantation of the ovum,

even when fertilization has been effected. Uterine polypi give rise to

mechanical obstruction of the os uteri externum or of the cervical

canal; but they predispose to sterility in an additional way, inasmuch

as in a woman affected with such a new growth any vigorous bodily

movement is apt to cause profuse uterine haemorrhage.

In cases of myoma of the uterus, apart from the mechanical hindrances to

conception imposed by these tumours, there is also interference with the

implantation of the ovum. When numerous myomata have formed in the

uterine wall, the mucous membrane is usually smooth and atrophied, and

discharges a watery secretion, and for these reasons the imbedding of

the ovum in the uterine cavity is rendered extremely difficult. But that

there is often an additional cause of sterility in cases of myomata

uteri, has been shown by the researches of _Schorler_, who examined 822

patients affected with fibromyoma of the uterus. He found that in most

of those in whom sterility was observed, the tumours were not submucous

but subserous, and that the sterility was to be explained in these cases

by the frequent occurrence of partial peritonitis, with its evil results

to the uterine annexa.

_Schorler_ appends the following table:

_Sterile._ _Percentage._

Of 85 women with interstitial myoma 21 24.7

Of 92 women with subserous myoma 44 47.8

Of 18 women with submucous myoma 7 38.8

Of 44 women with polypous myoma 4 9.0

Of 14 women with cervical myoma 3 18.7

——— —— ————

253 79 31.2

When there are polypous new formations in the uterine cavity, even if

conception occurs, abortion follows, for the reason that the rupture of

the hypertrophied capillaries in the growths themselves and in the

neighbouring tissues, prevents the normal development of the embryo.

_Horwitz_ has, however, described a case in which pregnancy went on to

full term, notwithstanding the existence of growths of this nature.

Owing to the frequency with which chronic metritis and endometritis

ensue upon parturition, it can readily be understood that delivery

itself is often the primary cause of subsequent sterility. A temporary

sterility often follows the first delivery. It is well known that the

birth of boys is in general more difficult than the birth of girls;

_Pfannkuch_ collecting information regarding the first and second

deliveries of 300 married women, ascertained that after 166 of the first

deliveries, in which boys were born, the average lapse of time to the

second delivery was 30.2 months, whereas after 134 of the first

deliveries in which girls were born, the average lapse of time to the

second delivery was only 27.4 months.

The importance of previous delivery in leading to sterility, in

consequence of mesometritis and diffuse connective tissue hyperplasia of

the uterus, is shown by _von Grünewaldt_, who published the following

figures as a result of his investigations. Of 56 women affected with

chronic metritis, 46.4% were sterile; in 19.2% of these the sterility

was congenital, in 80.7% it was acquired. Of 134 women suffering from

myometritis and its consequences, 71.6% were sterile; in 17.7 of these

the sterility was congenital, and in 82.2% it was acquired. On the other

hand, of 321 women suffering from endometritis, 29.5% were sterile; in

28.4% of these the sterility was congenital, and in 71.5% it was

acquired.

_Lier_ and _Ascher_ also insist upon the importance of puerperal

diseases in the causation of acquired sterility, basing their opinion

upon _Prochownick’s_ clinical material. They draw, however, the

following distinction. If the puerperal infection takes place by way of

the external organs of reproduction, through the vagina to the cervix

and thence to the connective tissue of the pelvis—the most common form,

that which occurs soonest after delivery, and the most severe in its

course—the women thus affected are likely soon to become pregnant again;

if, on the other hand, the disease is pelvic peritonitis, the exciting

cause of the inflammation proceeding from the interior of the uterus

through the Fallopian tubes to reach the peritoneum, in the majority of

cases the women thus affected will prove sterile for a long time or in

perpetuity. In almost all the cases in which sterility resulted, the

pelvic peritoneum had been severely affected by the puerperal

inflammation. Regarding sterility in women, the two following general

propositions are laid down by _Lier_ and _Ascher_: 1. Hardly any single

cause of sterility in women is so severe as to be competent by itself to

render sterility inevitable throughout the period of sexual maturity,

with the exception of defects of development and premature cessation of

sexual activity. 2. Most of the hindrances to conception in women depend

upon affections of the internal superficies of the reproductive organs,

from the vulval mucous membrane upwards to the pelvic peritoneum; of

these, the most important are affections of the endometrium.

On the other hand, it must not be forgotten, that the general tendency

of a previous delivery is to increase the capacity for impregnation.

_Olshausen_ especially insists upon the well-known gynecological fact,

that as a result of the first delivery, there occurs an enlargement of

the os uteri, which facilitates conception throughout the remainder of

the period of sexual maturity. This is well shown by the not infrequent

cases in which sterility persists for several years after marriage, and

then, with or without artificial aid, the first pregnancy occurs;

thereafter one child after another appears in rapid succession.

_Spiegelberg_ has pointed out that cervical lacerations may give rise to

sterility by interference with the incubation of the ovum. _Olshausen_

maintains that this affection is liable to cause abortion, for the

reason that by the gaping of the cervical canal the inferior pole of the

ovum is from time to time exposed, and this gives rise to reflex

contractions of the uterus.

_Von Grünewaldt_ publishes figures in support of his opinion that

disturbances of the integrity of the uterus, whereby the implantation

and further development of the ovum are interfered with, play on a whole

a greater part in the causation of sterility than the various conditions

previously described which interfere with contact of ovum and

spermatozoon. But in this, we think, he goes too far.

Finally, in this connexion, must be mentioned among the hindrances to

fertilization, sexual excesses, such as are so common during the first

weeks of married life. Too frequent coitus gives rise to enduring

congestion of the uterus, and hence to an irritable state of the uterine

mucous membrane, whereby the implantation of the ovum is rendered

difficult. In prostitutes chronic metritis, due to the excessive

frequency of intercourse, may be a contributory cause of the sterility

which is almost invariable in these women; doubtless, however, the

principal cause of their sterility is gonorrhoeal perimetritis.

As a variety of the third kind of sterility, sterility due to incapacity

for implantation or further development of the ovum, must be classed the

cases in which, though conception and implantation of the ovum are known

to occur, and the first stages of development of the embryo certainly

take place, the woman proves incapable of giving birth to a viable

infant. Some of these cases depend upon abnormal modes of development,

myxoma of the chorion and the like. In rare cases, women abort every

month, discharging every four weeks a fully developed decidua vera, in

which sometimes no trace of ovum can be detected. But this monthly

abortion ceases as soon as marital relations are interrupted.

It would be passing beyond the scope of this work to discuss the

pathological processes which lead to premature interruption of the

pregnancy, after conception, implantation of the ovum, and the first

stages of development, have occurred in a normal manner; to discuss, in

short, the causes of abortion. Moreover, these pathological processes

are outside the concept of sterility. It is sufficient here to enumerate

the principal conditions in which abortion occurs. They are: various

tissue disorders of the uterus, chronic hyperaemia of the mucosa,

displacement of the uterus with fixation, parametric and perimetric

exudations, laceration of the cervix with ectropium; further, various

constitutional disorders, such as the specific fevers, acute infective

processes, chronic circulatory disturbances consequent upon cardiac,

pulmonary, renal and hepatic disease, syphilis, anæmia, chlorosis,

diabetes, etc.

_Only-Child-Sterility._

Until recently, only-child-sterility had received attention in England

only, for the reason that it is comparatively common in that country;

but this form of relative sterility is by no means rare with us (in

Germany and Austria) also. I had a collection made in Austria of the

number of children resulting from 2000 fruitful unions, and found that

among these there were 105 marriages in which one child only had been

born; thus the ratio of these marriages to those which proved fully

fruitful was about 1 : 19. But the figures are untrustworthy, since

abortions and deaths in infancy were not taken into account. _Ansell_

found that in England, among 1767 fruitful marriages in which the mean

age of the wives at marriage had been 25, there were 131 cases of

only-child-sterility, giving a ratio of the latter to the fully fruitful

unions of 1 : 13.

This form of relative sterility, in which the wife gives birth to one

child, and thereafter remains barren, was referred by _Matthews Duncan_,

either to a premature exhaustion of the reproductive capacity, the

general bodily powers remaining unaffected, or else to a simultaneous

weakening of the sexual powers and of the constitutional force in

general. This explanation is a very inadequate one. The significant fact

upon which an understanding of the nature of only-child-sterility must

be based, is that the first delivery is the one which entails the

greatest dangers to the mother, and that the subsequent sterility is

attributable to the difficult delivery, and to the illnesses that follow

in its train. In fact, only-child-sterility is observed chiefly after

difficult deliveries, followed by long enduring inflammatory processes

of the uterus and the uterine annexa, which seriously affect the woman’s

reproductive capacity. It occurs especially in delicately organized,

anæmic, scrofulous women, whose powers of resistance have been

undermined by a single pregnancy and parturition. Finally, it is met

with in women suffering from myoma uteri, a form of tumour which beyond

others renders the recurrence of pregnancy difficult and unlikely. This

form of sterility has been seen also in cases in which comparatively

soon after the birth of her first child, the mother has suffered from

typhoid, scarlatina, or some other severe infective fever, which appears

in some way to interfere for the future with the development of normal

ova. We must also take into consideration the fact that at the time of

the wife’s first confinement, when the love which brought about the

union has often already begun to diminish in intensity, the husband,

finding too irksome the continence enforced upon him by his wife’s

condition, is not unlikely to go elsewhere for temporary sexual

gratification, and to acquire a venereal disease, which he subsequently

transmits to his wife, and which is responsible for the latter’s future

sterility. And we must not forget to take into account the adoption of

means for the prevention of pregnancy after the first child has been

born. Again, I saw three cases of only-child-sterility in which the

husbands were respectively 24, 26, and 29 years older than their wives,

and in these instances no profound search was needful for the discovery

of the cause of the wife’s unfruitfulness; it was obvious that in each

case the elderly husband’s reproductive powers had sufficed for the

procreation of a single child, but had then been completely exhausted.

My experience in the mysteries of sterility in women has informed me of

yet another cause of only-child-sterility, met with in cases in which

the only child was born after several years of unsuccessful marital

intercourse. In most of these cases, the wife has finally been impelled

to seek a substitute for her husband, whose reproductive powers have

proved insufficient; having succeeded in obtaining the child she

desires, the wife does not again wander in strange pastures, and

consequently remains sterile.

According to _Kleinwächter_—who gives a somewhat wider significance to

the term “only-child-sterility,” including as he does cases of premature

interruption of the first and only pregnancy, since these even more

frequently entail permanent sterilization—only-child-sterility is by no

means rare. Among 1081 gynecological cases, he observed it in 90, that

is, in 8.32% of the cases. In these 90 cases, there were 69 instances in

which the sterility ensued upon full term delivery, and 21 instances in

which it followed abortion or premature delivery. _Kleinwächter_,

moreover, on the basis of his personal experience, supports my view of

the importance of the sterilizing influence of the first delivery; but

he has been unable to determine whether early marriage has any influence

in the production of only-child-sterility.

_Lier_ and _Ascher_ also class as instances of only-child-sterility

those cases in which a woman has had a single miscarriage, and

subsequently remained sterile, since by this miscarriage the capacity of

the woman for impregnation has been proved, and the question of capacity

for full-term delivery has nothing to do with that of capacity for

conception. As causes of this form of sterility, they lay especial

stress upon puerperal infection, gonorrhoeal infection, perimetritis,

tubo-ovarian tumours, etc.

_Operative Sterility._

Finally, in order to complete the etiologically classified series of

forms of sterility, we must allude to yet another variety of sterility

which is due to the surgical direction of modern gynecology, viz.,

operative sterility. However much we may prize the gains we owe to

modern operative gynecology, it cannot be denied that the new

developments have brought many evils in their train. Not the least of

these is operative sterility, due to operative procedures involving the

female reproductive organs, by which, whether intentionally or

unintentionally the reproductive capacity is destroyed. Doubtless, in

certain severe organic diseases of the female reproductive apparatus, in

which the use of the knife is indicated, the fact that by operating we

are sterilizing the patient cannot even be taken into consideration; but

many sins have been committed in this kind, and with a ready hand, and,

be it openly admitted, with an easy conscience, many an eager operator

has undertaken the destruction of a woman’s potentialities for

motherhood, without having given the careful consideration that is

demanded by the irreparable character of his undertaking. Happily,

however, the time has nearly passed away, in which it could be said of

many a gynecologist, that no ovaries and no Fallopian tubes were safe

from his operative zeal, and from his desire to heap up a mountain of

statistics.

Three operative measures very commonly undertaken at the present day are

responsible for the production of operative sterility: ovariotomy,

oophorectomy, and salpingotomy.

The removal of the ovaries, with the object of permitting to the women

concerned unbridled sexual indulgence without risk of consequences, was

performed, according to _Strabo_, by the ancient Egyptians and Lydians.

The same practice is described by modern writers as occurring in

Hindustan (_Roberts_), and in Australia (_Miklucho-Mackay_).

With a curative aim, the removal of the ovaries was first undertaken in

the early years of the nineteenth century, although the operation had

already been discussed as a possibility by leading physicians of the

eighteenth century. The first ovariotomy for the removal of an ovarian

tumour was performed by _MacDowell_ in the year 1809. During the last

three or four decades, the operation has become an extremely common one,

and is performed by the surgeons of all nations. Removal of a single

ovary, as long as the other ovary is healthy, does not necessarily lead

to any impairment of fertility; but when both ovaries are removed,

operative sterility is the necessary result. In order to avoid this,

_Schröder_ has recommended that a fragment, at least, of healthy ovarian

tissue should be left behind, in order to preserve the reproductive

capacity. In discussing the subject of impaired ovulation, we have

already mentioned cases in which pregnancy has occurred after bilateral

removal of the ovaries, a circumstance explicable only on one of two

assumptions, either that a fragment of ovarian tissue was left behind,

or else that a supernumerary ovary existed.

The extirpation of healthy ovaries, or at any rate, of ovaries which are

not notably enlarged, is known as oophorectomy (spaying, _Battey’s_

operation, in Germany, castration). It dates from the year 1869

(_Koeberlé_); but in the strictly modern sense the operation was first

performed by _Hegar_ in the year 1872. [_Lawson Tait_ removed both

ovaries for pain in October, 1871. _Battey’s_ first operation of this

kind was _successfully_ performed on August 17th, 1872; this was three

weeks subsequent to the first performance of the operation by _Hegar_ of

Freiburg. But _Hegar’s_ patient died from the operation, and _Hegar_ did

not publish the case at the time—Transl.] The aim of ovariotomy is to

remove an ovarian cystoma; if the other, apparently healthy, ovary is

removed, it is with the object of removing an ovarian tumour in the

initial stage. Oophorectomy has an altogether different purpose, namely,

to relieve or cure pathological manifestations in other organs which are

believed to depend on the periodical recurrence of ovulation, to cure

them by instituting a premature menopause. At one period, when

overzealous operators performed oophorectomy for the supposed relief of

comparatively unimportant nervous affections, and the statistics of the

operation began to assume gigantic proportions, operative sterility

actually came to play no inconspicuous part on the stage of sterility in

general. But a reaction inevitably followed; severe diseases were alone

considered as furnishing sufficient indications for the operation; of

late it has been performed chiefly in cases in which the primary

disorder has already rendered the occurrence of pregnancy impossible, or

at any rate very unlikely, or, finally, if probable, yet to be avoided,

on account of the dangers it would entail. In short, the fertility of

women is no longer seriously threatened by this operation.

Some years ago, I was consulted by a beautiful married woman, 26 years

of age, of a blooming and healthy aspect. When a young girl, she had

suffered every month at the time of the menstrual flow from violent

vomiting, accompanied by various spasmodic troubles. Just at this time,

oophorectomy was the fashionable operation for the relief of nervous

troubles; this girl was subjected to the operation, and the vomiting at

the periods ceased, but the other nervous symptoms persisted without

alleviation—indeed were at times worse than before. Since then, she had

married a man belonging to the upper circles of society; and now, after

living for four years in sterile wedlock, she came to me to ask my

advice as to whether anything could be done to enable her to have a

child! Two other cases have come within my own knowledge, in which women

whose ovaries had been removed on account of nervous troubles, had

subsequently married, and felt most unhappy owing to their hopeless

state of sterility.

It is impossible to make even an approximate estimate of the number of

women who in recent years have had their ovaries removed during the

period of sexual maturity, and who have thus been made the subjects of

operative sterility; nor is it possible to ascertain in what proportion

of cases the healthy ovaries, the normal female reproductive glands,

have been removed for the problematical relief of nervous troubles or of

uterine haemorrhage, and in what proportion of cases there has existed a

genuine indication, owing to the presence of fibromyoma of the uterus,

for the induction of an artificial and premature menopause.

Unquestionably, the number of women thus operated on during the menacme

is by no means a small one. In a work by _Hermes_, “On the Results of

Oophorectomy in Cases of Myoma of the Uterus,” _Archiv für Gynecologie_,

1894, we find that, among 55 women whose ovaries were removed on account

of myoma of the uterus, there were 52 who were between the ages of 21

and 45, i. e., in the period of sexual maturity. The assumption that all

these patients were already sterile before the operation, on account of

a degenerate condition of the uterine annexa, cannot be justified.

_Keppler_, indeed, puts forward a very remarkable defence of the removal

of the ovaries of women who are competent to become mothers, asserting

that such oophorectomy offers no obstacle to marriage, and that many

women who have been operated on in this manner are extremely happy in

conjugal life. Marriage with a wife whose ovaries have been removed is

the ideal Malthusian marriage, the one way in which Malthusianism can be

practised without endangering the health and life-happiness of the

participators!

Another danger soon appeared, one which threatened the fertility of

women to an even greater extent, in the form of operations on the

uterine annexa—the first salpingotomy was performed by _Hegar_ in 1877.

As knowledge advanced of the various diseases of the Fallopian tubes,

salpingitis, hydrosalpinx, and pyosalpinx, whilst at the same time the

development of the antiseptic method rendered operative gynecology

continually bolder and bolder in its undertakings, there was disclosed

an extensive field for radical measures in removal of the tubes,

generally combined with removal of the ovaries, since these latter

organs commonly were found to have suffered from association in the

destructive inflammatory process. The operation of salpingo-oophorectomy

soon became a very common one; and since patients with diseased tubes

are for the most part still comparatively young, in the period of sexual

maturity, there arose a new and frequent variety of operative sterility,

and one which the zeal of American gynecologists made especially common

on the other side of the Atlantic. An American gynecologist, indeed, has

sarcastically observed that “It is the dish-full of excised tubes that

shows the master gynecologist”; and _Landau_ has been impelled to lament

that “salpingotomy has been performed on a very large number of women

who have complained of nothing more serious than uterine haemorrhages,

or of insignificant pains, and even on some women who have come to the

gynecologist with no other complaint than that—they are sterile”!

_Fritsch_, also, writing of the too rapidly formed diagnosis “tumor of

the annexa,” and the consequent resort to operation, remarks: “I know

many a happy mother who at one time had worn every variety of pessary,

had been through every kind of ‘cure,’ and had visited every accessible

spa; until, at last, she came to consult me, with the express wish to

have her ovaries removed. Latterly, she had been advised to this course

by every physician she had consulted. I agreed, in such cases, to

perform the operation, with the stipulation that first of all, for the

space of an entire year, the patient should not see a single doctor,

should visit no spa, should take no medicine, and, in short, should pay

no attention whatever to her health. The success of this course of

‘treatment’ was often extraordinary. As soon as the reproductive organs

were left in peace, recovery ensued.” The conservative tendencies of the

surgery of the last decade, have manifested themselves also in the

department of gynecology, for the happy protection of woman and her

reproductive capacity. Operative measures are now commonly restricted to

the relief of certain severe forms of disease of the uterine annexa; in

cases of chronic inflammation of the annexa, the surgeon often contents

himself with dividing or breaking down the adhesions, and leaves the

organs in situ; even in cases of bilateral disease, one tube only may be

removed; whilst in the most recent method of all, after opening the

abdomen, and separating the pelvic organs from their adhesions, an

aperture is made in the closed tube, and this artificial ostium is

brought into apposition with the ovary by the insertion of sutures. In a

word, surgeons have come to realize that they have in the past been too

ready to sterilize their patients by the performance of double

salpingo-oophorectomy, and are much more reluctant than formerly to

sacrifice the ovaries and the Fallopian tubes.

_Porro’s_ operation is another cause of operative sterility, excision of

the ovaries being combined with the partial excision of the uterus,

whereas sterility was seldom the consequence of the older method of

Caesarian section. Indeed, _Porro’s_ operation has been extolled

precisely on this account, that, indicated as it is for the relief of

extremely difficult labour, it renders it impossible for the same

difficulty and danger ever to recur.

The classical operation of Caesarian section, if the patient makes a

favourable recovery, does not involve sterility, unless in very

exceptional cases (as in one described by _Lecluyse_, in which, after

the Caesarian section, a communication persisted between the uterine

cavity and the cavity of the abdomen, through which the semen passed

during coitus). Occasionally, also, in performing the older operation,

the operator has thought it right to prevent the future recurrence of

pregnancy by adding an oophorectomy to the primary operation.

Pregnancy and parturition are still possible after the healing of

spontaneous or traumatic ruptures of the uterus; but it must be

remembered that after such serious injuries, as after extensive

operative procedures on the pelvic organs, widespread peritoneal

inflammation is apt to occur, with perimetritic and parametritic

exudations, leading commonly to sterility.

Amputation of the vaginal portion of the cervix, an operation sometimes

undertaken for the relief of sterility in cases of hypertrophy of the

cervix, may on the other hand lead to sterility in cases in which a

cicatricial stenosis of the cervical canal results from the operation.

By the too frequent application of caustics to the cervical canal, or by

the employment of these agents in too powerful a form, occlusion of the

os externum may be caused, or even adhesion of the opposing walls of the

vagina just below the cervix, thus giving rise to sterility. Rough use,

also, of the uterine sound, and maladroit and violent gynecological

massage, have often enough been responsible for the occurrence of

sterility, by giving rise to perimetritic inflammation. _Landau_

enumerates among the causes of intrapelvic abscesses, “whereby the

specific functions of womanhood are nullified in consequence of

degeneration of the tubes or the ovaries,” “certain therapeutic

procedures,” and more especially, intra-uterine therapy, (the use of the

sound, curettage, injections, cauterization), and operations on the

cervix or the vagina, on which intrapelvic inflammation and even

suppuration has ensued. How easily pelvic peritonitis and its

consequences lead to sterility in women, has been shown many times in

the course of our exposition of this subject.

Finally, we must class with operative sterility the result of surgical

procedure undertaken by gynecologists to save women, whose lives have

already been seriously threatened by pregnancy or parturition, from a

repetition of this experience. In such cases, _Blundell_ recommends

division of the Fallopian tubes, having found from experiments upon

rabbits that this is a safe and certain means for the prevention of

conception. _Frorieps_ and _Kocks_ have both frequently brought about an

artificial sterility in women by closure of the tubes, the first-named

by cauterization with nitrate of silver—the caustic being attached to

the end of a piece of whalebone and introduced through a canula into the

uterine orifice of the Fallopian tube—whilst _Kocks_ has constructed for

the same purpose a galvano-caustic uterine sound, which is only rendered

red-hot by passage of the current after it has been introduced into the

uterine ostium of the tube. Both these methods are in the first place

too uncertain to be relied upon for the attainment of the desired end,

and in the second place their employment appears to be neither easy, nor

free from danger.

As the importance of conservative methods of procedure becomes once more

fully recognized in modern gynecology, cases of operative sterility will

become ever more and more rare.