Much attention has recently been paid to the theory of Schenk, based, as he states, upon numerous experiments regarding the influences by which sex is determined. This observer also starts from the principle that ovulation is not independent of the influences of nutrition and metabolism. He believes that in the cases in which combustion in the body is effected in such a manner that remnants of unconsumed substances, still capable of heat-production, make their appearance in the urine, the ovum of the human female in process of formation is not so far advanced in its development as it is in cases in which the urine is entirely free from sugar, or at any rate is free from any demonstrable traces of the presence of this body. In the former case we shall find that the ovum is not only less mature, but also that it is presumably less well nourished. In his view such an ovum is less completely endowed in respect of the indwelling qualities and forces of its protoplasm, and it appears for this reason to be adapted only for the development of a female individual. But when, on the contrary, in the maternal individual, all the substances formed in and assimilated by the organism have undergone combustion so completely that there is no sugar in the urine, not even in the minutest discernible traces, the maternal body is in a condition suitable for the development of an ovum adapted to become a male individual. From these inferences, weak though the chain of argument is, Schenk draws the conclusion, that by the regulation of the nutritive material supplied to the organism, and by the suitable choice of that material, we are to a considerable extent enabled to support an ovum in its process of maturation in such a manner as to cause it to develop into a male individual.
The nutritive material selected for this purpose must be of such a nature that the elimination in the urine of even the minutest quantities of sugar may be prevented; the urine must appear free from sugar even when the phenyl-hydrazine test is employed. Thus in every case in which we wish to influence a woman’s nutrition in such a way as to lead to the procreation of a male individual we must above all ascertain whether, in the woman in question, the normal quantity of sugar is present in the urine. If after the most careful examination no trace of sugar can be found in the urine, and if reducing substances are present in this excretion in abundance, no change need be made in the diet, and all we have to do is to recommend that the requisite fertilization should be effected as soon as possible, since there is every probability that in this condition the embryo will prove to be of the male sex. But when, on the other hand the “normal” quantity of sugar is present in the urine, or when even traces only of that substance can be detected, it is necessary by changes in the diet to cause the disappearance from the urine of every trace of sugar, and at the same time to bring about the appearance in that fluid of an abundance of reducing substances. Schenk claims by the experiments he has made along these lines to have obtained results which show that it is possible in this way to influence the determination of sex.
His method is to nourish the mother mainly on nitrogenous materials and fat, and to give in addition only so much carbohydrate as is necessary to prevent the absence of this from being seriously felt. This diet should be continued for a considerable period, at best for two or three months before the fertilization is effected. After conception also, the same diet should be continued. In such a manner we are able in certain cases to bring about the procreation of male offspring. On the other hand, the desire for the procreation of female offspring remains one which as yet we have no direct means of fulfilling.
These vague experiments and ill-grounded theories of Schenk’s do not, as a matter of fact, constitute an important advance in the theory of the voluntary determination of the sex of the human offspring. What in reality are the decisive influences in the determination of sex, and how the final impulsion in one direction or the other is actually effected, remain altogether obscure. Prediction of the sex of the offspring, and the voluntary procreation of male or female infants, remain problems for the solution of which the most essential data are still lacking.
Ernest Hæckel writes regarding Schenk’s theory: “This important ‘discovery,’ which at the time of its first announcement attracted throughout the world an attention rarely given to true scientific advances, has now dwindled to the incomplete demonstration that the nutritive condition of the mother exercises a certain influence upon the determination of the sex of the child. But we knew this much a long time ago. Düsing and others, partly by physiological experiments and partly by statistical demonstrations, had shown that changes in the quantity and the quality of the nutriment supplied to either parent is capable of influencing the procreation of boys or girls. But if what Professor Schenk maintains were really true peoples living chiefly upon meat (as, for instance, in the pampas of South America) should have an exceptionally large proportion of male offspring; whereas those living mainly on a proteid-free diet (on meal, sugar, and other carbohydrates), should have an exceptionally large proportion of female offspring (as, for example, the rice-eating Indian and Mongolian nations). But this is by no means the case. And many other well-known facts are likewise opposed to the ‘epoch-making’ theory of Schenk. Whether the fertilized ovum develops into a boy or a girl, depends, I am convinced, upon far more complex, and to a large extent still entirely unknown, physiological causes. The final judgment upon the ‘Schenk theory’ must be, ‘Much Ado About Nothing.’”
Our exposition of the present standpoint of the doctrine of the origination of sex in the human species, has, in fact, shown that hitherto by statistical work, nor by anatomical investigations, nor, finally, by the experimental method, have results been obtained which render it possible to predict the sex of the unborn infant. And even in respect of the study of those influences which exercise a determining influence upon the origination of sex, no positive, indisputable conclusions have been reached. We can only say it appears probable that there exist several causes of the determination of sex the co-operative action of which proves effectual. Not in the ovum alone, nor in the spermatozoon alone, but in the reciprocal influence they exert one upon the other in the act of conception is sex determined. In the latter connection the relative and absolute ages of the progenitors appear to have a certain influence in the determination of the sex of the embryo; of importance also is the greater or less demand made upon the sexual capacity of the begetter; of influence too is the time at which the ovum is fertilized after its discharge from the ovary. It appears to be fairly well established that when the husband is at least ten years older than the wife, while the latter is at the age at which a woman’s reproductive powers are at a maximum, more boys are conceived than girls (Kisch); also that one of the progenitors upon whose sexual capacities the greater demands are made, tends to procreate an excess of individuals of his or her own sex (Piquet, Düsing); and, finally, that intercourse a considerable time after the cessation of the menstrual flow (in the second week of the intermenstrual interval or later) is favourable to the procreation of a male infant (Thury, Hensen). The influence of nutritive conditions in the determination of sex is less clearly established.
Statistical evidence has proved beyond dispute that given a sufficiently large number of instances in varying conditions the sexual ratio is 106, and this fact suggests that the determination of sex is dependent upon the interaction of two influences operating in opposite directions within narrow limits, in such a manner that the chances of the birth of a male infant preponderate over the chances of the birth of a female infant in the proportion of 106 to 100. In elucidation of this fact Hensen makes the following comparison: “Let us imagine a balance the beam of which has two arms of equal length; from the two extremities of this beam two balls of nearly equal weight begin to roll toward one another; if one ball rolls more quickly than the other, if one is lighter than the other, or if one starts to roll before the other, the opposite end of the beam will sink. The three influences are variously distributed; one influence may reinforce another, or may counteract another; but a decisive sinking of one end of the beam will always ultimately ensue. A minimal shortening or lightening of one arm of the balance will make the chance that the other arm will descend correspondingly greater.”
When we study the history of human civilization we find that sterility in women is regarded, not merely as a misfortune, but as a reproach. Among savage races, and in the Orient, where the position of women is one of strict subordination, she does not attain an honourable status until she becomes a mother. In Persia, a sterile woman is always divorced by her husband. In India, also, when a sterile married woman has in vain employed the various religious measures advocated for the relief of her barren condition she is sent back to her parents. Both in China and Japan, a barren woman is regarded as a most miserable creature. Among the negro races, a woman who fails to bear children is the object of scorn and contempt. Among the Dualla negroes, a man whose wife fails to bear children demands from her parents the return of the sum which he paid for her at the time of marriage. Many of the indigenous tribes of South America also make a practice of divorcing a sterile wife. Among the better-class Circassians, the women do not attain an assured position until they have borne a child. In Angola a barren woman is the object of universal contempt, and she often feels the ignominy of her position so keenly that she commits suicide. Alike among the Jews and among the Turks, barrenness in a wife is a recognized ground for divorce, and the woman who has been divorced for this reason will hardly ever succeed in obtaining another husband, for she is regarded as one whose body is not properly developed. According to old German law, barrenness in a wife and impotence in a husband were both grounds for divorce. The code of the Emperor Justinian allowed of divorce in cases in which for the space of two years a husband had been unable to fulfil his marital duties, and such a union was termed innuptæ nuptæ. Among the ancient Romans, although they regarded barrenness as a mark of the divine disfavour, according to the laws of Augustus failure to bear children was a punishable offence, and such a punishment was incurred by any married woman who had attained the age of 20 years without having become a mother. In ancient Greece also, divorces due to the barrenness of the wife were by no means uncommon. Among the Slavonic peoples sterility was so greatly despised that there is a Slavonic proverb which runs: “A woman is no woman until she has borne a child”: and in Istria a sterile woman is known by the nickname “Scirke,” which is equivalent to “hermaphrodite.” The Jewish view of the matter is expressed in the Talmudic rabbinical saying: “A wife’s duties are beauty, gentleness, and the bearing of children”; and again, “the poor, the leprous, the blind, and the childless, are like the dead”; and, finally, “he who refrains from marriage with the deliberate intention of having no children, incurs the guilt of murder.” In the Koran we find the fatalistic expression, “God makes a woman barren in accordance with his will.”
We can therefore readily understand that in the most ancient medical writings the question of sterility in women is a matter of earnest consideration. In the works of the early physicians of Hindustan we find several apt remarks on the subject. Susruta says: “Pregnancy most readily results from intercourse during menstruation. At this time the os uteri is open, like the flower of the water lily in the sunshine.” In the Old Testament, in which the newly-created human couples receive the command, “Be fruitful and multiply, and replenish the earth,” we find frequent references to barrenness as a state equally dishonourable and unfortunate, and the use of certain plants is recommended as a means of cure. The Talmud contains several essays dealing with the causes and treatment of sterility.
The Hippocratic collection of writings contains a number of passages dealing with the causes of sterility and with the means to be employed for its relief. We shall have occasion later to refer to these recommendations. Celsus, on the other hand, has little to say on this subject. In the works of Pliny, and also in those of Aristotle, there are references to the topic of sterility.
Among the writers of the first century of our era, Soranus discusses exhaustively the capacity for conception and sterility. In his work we find, among other passages, the unquestionably accurate remark: “Since the majority of marriages are concluded, not from love, but in order to procreate children, it is difficult to understand why, in the choice of a wife, less regard is paid to her probable fertility than to the worldly wealth of her parents.”
In the middle ages, Paulus Agineta more especially treats of the diseases of women, and among these, of sterility in women. That in Arabian medicine much attention was paid to this question, we can learn from the writings of Maimonides.
By sterility in women we understand the pathological state in which a woman who is sexually mature fails to conceive, notwithstanding frequently repeated, normal sexual intercourse throughout a considerable period of time.
Sterility is termed congenital (or absolute) when, notwithstanding repeated intercourse throughout a long period (not less than three years), pregnancy has always failed to ensue; it is termed acquired (or relative), when women who have already been pregnant once or more often, cease to conceive, although they are still quite young enough to do so, and have experienced regular sexual intercourse for a long period (not less than three years). In a wider sense of the term, we say that a woman is sterile, when, notwithstanding prolonged and repeated sexual intercourse, in circumstances favourable to procreation, she has failed to give birth to a living and viable infant.
English authors also make a special distinction regarding that form of acquired sterility (which is no great rarity), in which a woman gives birth to a single infant and subsequently remains sterile (“only-child sterility”).
The civilization of the present day, with its shady side, has made it necessary for us to pay an increasing attention to facultative sterility, dependent upon the use during intercourse of means for the prevention of conception; and very recently the surgical tendency of modern gynecology has brought into being a new variety of sterility in women, viz., operative sterility.
The period which must elapse after marriage, before the absence of pregnancy must lead us to regard a woman as sterile, is fixed at three years. This limitation is based upon the statistical data which (see Table on page 368) I gave regarding 556 fruitful marriages.
The ideal state of fertility, that in which conception is the immediate result of the first act of intercourse between husband and wife, the conception being followed in due course by the birth of a child, is, like most other ideals, one very rarely attained. In the human species, conception as the immediate result of the first act of sexual intercourse, is an extremely unusual occurrence. To invoke medical assistance for women who have failed to conceive during the first three months of married life, which my experience shows to be more frequently done now than formerly, is devoid of all justification; and still worse is it, in this period of “early love” to subject women, as has often been done recently by overenergetic gynecologists, to local treatment, even to the extent of operative procedures.
We are not justified in speaking of the existence of actual sterility until three years of marital intercourse have failed to result in conception; still, when the commencement of the first pregnancy is delayed for more than sixteen months after marriage, there is considerable probability that the woman is sterile; and this probability increases month by month till the expiry of the second year, whilst as the end of the third year approaches, it becomes tantamount to certainty.
Sterility is one of the commonest of the functional disorders of women, and one of those which most often demand gynecological assistance.
By a statistical study of the marriages of the royal and princely families of Europe and of the marriages of the highest families of the aristocracy, I learned that of 626 marriages, 70 were barren; thus the ratio of fruitless to fruitful marriages proved to be as 1 : 8.87. But in other circles of society, in so far as data relating to the matter were obtainable in my practice, the statistics of infertility were by no means so unfavourable, the ratio working out at about 1 barren to 10 fruitful unions. I must point out, however, that these statistics, like all statistics of fertility, are to a degree invalidated by the fact that in a certain number of the instances included among the barren, an unnoticed abortion may have occurred.
Simpson, in his investigation regarding the frequency of sterile unions, found a ratio of 1 : 8.5 (in 1252 instances). In the English aristocracy, where the marriages are for the most part restricted among the members of a comparatively small number of families, the ratio was 1 : 6.11 (495 instances); on the other hand, among the population of Grangemouth and Bathgate, consisting chiefly of persons engaged in seafaring and agricultural occupations, the ratio of barren to fruitful unions was as 1 : 10.5.
Spencer Wells and Marion Sims, as a result of their investigations, give a ratio of 1 : 8.
According to Seeligmann, in Hamburg, among marriages of persons in all classes of society, 11.5% are barren. Prochownick found among 2500 women, all of whom had been married for eighteen months or more, and none of whom were more than 40 years of age, that 9% had failed to conceive.
According to Frank and Burdach, who do not publish the figures upon which their estimate is based, only 1 marriage in 50 proves barren. Lever, who also gives merely his percentage result, states that 5% of married women are completely infertile. Hedin, dealing with a Swedish community of 800 persons, states that the percentage of sterile unions is barely 10.
According to Goehlert’s statistical investigations, in the dynasty of the Capets, among 450 marriages, 19.7% were sterile: in the Wittelsbach dynasty (Bavaria), among 177 marriages, 23.7% were sterile; and among the ruling families of Germany (more than 600 marriages), 20.5% were sterile. In this investigation, however, no attention is paid to the age of husband or wife; marriages and remarriages are classed together without discrimination; and those marriages only in which a living child was born are counted as fruitful, so that the unions counted as sterile must contain many in which abortion or stillbirth occurred. In three Esthonian communities in Livonia, Oehren found that among 2799 marriages, 8.4% were barren, but in this instance also stillbirths were ignored.
Ansell reports that of 1919 marriages of women belonging to the upper classes, their mean age being 25 years, 152 proved barren, a proportion of 1 : 12, or about 8%.
Matthews Duncan communicates the following data. In the year 1855, in the cities of Edinburgh and Glasgow, 4447 marriages were contracted, and of these 725 proved barren, a proportion of 1 : 6.1; 75 of these may however be excluded from consideration, inasmuch as the wives were already at the age of 45 or upwards. Among the remaining 4372 marriages, 662 proved barren, a proportion of 1 : 6.6. In other words, 15% of all marriages of women between the ages of 15 and 44 proved sterile.
From France we obtain figures showing a much higher proportion of sterile unions. According to Rochard, in France in the year 1888, of ten million families, two million had no child at all, and two million had each an only child, so that two fifths of the families of France were taking no practical part in the maintenance of the population. According to Chevin, the proportion in France of barren to fruitful marriages is as 1 : 5. 20% are entirely barren, while 24% exhibit only-child-sterility.
From Massachusetts, Morton reports that according to the last census returns, one fifth of all married women are childless.
In England, numerous trustworthy statistics can be obtained regarding the frequency of sterile marriages. The average proportion of barren to fruitful unions was:
| Among the patients in St. Bartholomew’s Hospital | 1 : 8 |
| Among the inhabitants of Grangemouth | 1 : 10 |
| Among the inhabitants of Bathgate | 1 : 10 |
| Among the British peerage | 1 : 6 |
| Among the upper classes | 1 : 12 |
| Among the inhabitants of Edinburgh and Glasgow | 1 : 7 |
Matthews Duncan compiled the following table relating to 504 absolutely sterile women met with in his practice:
| Age at Marriage. | Number of Years Married. | |||||||
|---|---|---|---|---|---|---|---|---|
| Less than 3. | 4 to 8. | 9 to 13. | 14 to 18. | 19 to 23. | 24 to 28. | 29. | Totals. | |
| 15 to 19 | 12 | 19 | 15 | 4 | 7 | 2 | 1 | 60 |
| 20 to 24 | 70 | 66 | 37 | 24 | 13 | 9 | 219 | |
| 25 to 29 | 47 | 51 | 20 | 8 | 8 | 134 | ||
| 30 to 34 | 26 | 20 | 8 | 1 | 59 | |||
| 35 to 39 | 6 | 13 | 4 | 23 | ||||
| 40 to 45 | 6 | 3 | 9 | |||||
| Totals | 167 | 172 | 84 | 40 | 29 | 11 | 1 | 504 |
Ansell bases upon the observations made by him in the case of 152 sterile women the conclusion that there is no longer any chance of the occurrence of pregnancy if a woman is:
| More than 48 years old, and has had no child for | 2 years |
| More than 47 years old, and has had no child for | 3 years |
| More than 46 years old, and has had no child for | 4 years |
| More than 45 years old, and has had no child for | 6 years |
| More than 44 years old, and has had no child for | 8 years |
| Less than 44 years old, and has had no child for | 10 years |
If we take into account also cases of acquired sterility, the proportion of barren to fruitful marriages becomes even more unfavourable, and the proportion increases enormously if, with Grünewaldt, we number among the barren women those who fail to continue child-bearing up to the normal climacteric period. Grünewaldt, dealing with about 1500 women suffering from affections of the reproductive organs, excluded all those who were either virgins or widows, and also all those who at the time of the observed barrenness were over 35 years of age; this left more than 900 women suffering from affections of the reproductive organs, all of whom were sexually mature, and were living in marital intercourse; of these, nearly 500 were barren, 300 being instances of acquired sterility, and 190 instances of congenital sterility. Thus, according to this observer, disease of the reproductive organs in women led in more than 50% of the cases to disturbance of the reproductive capacity; about one in every three women, previously competent to bear children, became barren when affected with disease of the reproductive organs; and among every five gynecological patients of the condition already specified as regards age and sexual intercourse, one proves congenitally sterile.
It must not, however, be forgotten, that sooner or later after marriage artificial sterility tends to come into being, its early or late appearance depending upon the degree of civilization and upon the national and economical conditions of the people and the individuals concerned. This fact must not be left out of the account.
The manner in which, in the human species, fertilization is effected, is still far from clear in all its details; hence it is easy to understand, that the etiology of sterility remains in many respects obscure. It is impossible in every case to find a definite cause. Whereas, on the one hand, notwithstanding the existence of apparently insuperable obstacles, impregnation may nevertheless be effected; so, on the other hand, sterility may exist in cases in which all the circumstances appear favourable to the occurrence of conception. Hence a classification of the different varieties of sterility from the etiological standpoint, is a very difficult task, and the conclusions thus obtained are often vitiated.
Although it cannot be denied that mechanical causes are competent to lead to sterility in women, Sims, in his advocacy of the mechanical doctrine of sterility, widely overshoots the mark. His authority, however, has led to a general acceptance of this doctrine, which is by no means justified by facts. The theory of mechanical obstruction, according to which sterility in women depends upon mechanical obstacles to the passage of the spermatozoa towards the ovaries, is from time to time strikingly illustrated by cases coming under our notice—cases the nature of which can hardly be overlooked; but it is quite wrong to suppose that this causation accounts for the majority of instances of sterility in women, and strict limitations should be placed upon the employment of surgical measures based upon this mechanical theory of sterility.
The mechanical view has been counterposed by Von Grünewaldt with a doctrine in which especial stress is laid upon obstacles to utero-gestation, sterility being regarded as a functional disorder brought about by affections of the female reproductive organs rendering the uterus unfit for the incubation of the ovum. It cannot be denied that the elucidation of this casual influence was a valuable contribution to the theory of sterility, and it is unquestionable that many morbid conditions of the uterus exist capable of giving rise to sterility in this manner; but we must avoid the error of regarding this doctrine as a full explanation of the cause of sterility.
If, however, both of these theories of sterility are insufficient, we cannot regard a third theory, that of Matthews Duncan, as filling the gaps in our knowledge. It would be most unfortunate if this author were right in maintaining that all our knowledge of the causes of sterility is to be summed up in the phrase “deficient reproductive energy;” we cannot agree with Duncan in his belief that “Sterility is an imperfection devoid of all perceptible, measurable characteristics;” nor can we follow him when he maintains that local causes, whether they are such as hinder conception, or such as hinder utero-gestation, have a very limited sphere of activity. Matthews Duncan adopts an incomprehensible standpoint when he regards sterility as dependent upon a law of nature, as a condition which may affect distinct classes or an entire population.
According to the latest doctrine of sterility, only in quite exceptional instances is the woman regarded as responsible for the occurrence of sterility; contrariwise, the male genital organs are commonly blamed for the affection, which is in the overwhelming majority of cases supposed to be due to azoospermia, usually dependent upon gonorrhœal infection; compare with this, affections of the female reproductive organs are said to play a quite subordinate role in the etiology of sterility. But for my part, though I recognize the important share that gonorrhœa in the male plays in the causation of sterility, I am of opinion that the extreme view just mentioned is by no means justified by the facts.
Sterility, a functional disturbance of an extremely complicated nature, can, in my opinion, be most usefully elucidated from the etiological standpoint by starting with the assumption that three conditions are absolutely essential to procreation:
1. that ovulation proceeds in a perfectly normal manner, the maturation of the discharged ova being complete;
2. that normal spermatozoa have access to these normal ova (conjugation of male and female pronuclei);
3. that the uterus is properly adapted for the gestation of the fertilized ovum.
My classification of the varieties of sterility corresponds to these conditions of procreation:
1. sterility due to incapacity for ovulation;
2. sterility due to some hindrance to the conjugation of ovum and spermatozoon (under this head come also those cases in which the male is at fault—azoospermia, and the like);
3. sterility due to incapacity for gestation.
It must also be admitted that there are additional causes of sterility, causes which lie beyond our control. Moreover, as I have already mentioned, in most cases of sterility, we have to do, not with a single cause, but with the resultant of two or more cooperating causes.
Incapacity for ovulation, the first and most decisive cause of sterility in women, may be absolute and irremediable, or relative and transient. We have to do with the former in cases in which the ovaries are entirely wanting, or when they are affected with organic disease to such a degree that they have become incapable of fulfilling their function of ovulation; incapacity for ovulation is, on the other hand, relative and transient in certain pathological states of the ovary and neighbouring organs, when there is incomplete development or partial atrophy of the ovaries, when there are new-growths of the ovaries, in cases of oophoritis and perioophoritis, in consequence of disturbances of innervation, diseases of the central and peripheral nervous system, violent emotional disturbance, constitutional disorders, such as syphilis, chlorosis, anæmia, universal lipomatosis, scrofula, alcoholism, and morphinism, also in consequence of changes in the supply of nutriment and in the general mode of living, or of senile changes, and finally in consequence of hereditary influences.
The diagnosis of the etiological influence of suppressed or incomplete ovulation in the production of sterility in women is at times beset with great and even insuperable difficulties. The state of the menstrual function, suppression of the flow, or the regularity or irregularity of its occurrence, serve indeed to inform us as to the general activity or inactivity of the function of ovulation; but the variations in this function give no certain information as to whether a woman is fertile or infertile. Knowing as we do that generally speaking an intimate connexion subsists between menstruation and ovulation, we are indeed able to assert that regular menstruation and fertility in women run a parallel course, and further, that the greater the irregularity of the menstrual function, the greater the tendency to sterility. Recently, great advances have been made in the technique of manual exploration of the ovaries, and by means of vaginal and rectal bimanual examination, we are now able to obtain accurate information regarding abnormalities in the size, shape, and position of these organs, and regarding any other intrapelvic disorders. In this way we have been enabled to recognize a number of pathological states of the ovaries which affect the functions of these organs. In some cases also there are general symptoms which furnish us with the means of drawing conclusions, more or less trustworthy, regarding the state of the ovarian functions; for instance, the general development of a woman’s body, the condition of the external genitals, the vulva, the mons veneris, the pubic hair, the clitoris, and the mammae. Again, we can derive information from various troubles of which women complain; such as sacrache; a sense of weight and pressure in the pelvis; feelings of tension and shooting pains in the breasts; flushings of the face; haemorrhage from the nose, mouth, or rectum, recurring at regular intervals and vicarious in nature. In many instances, however, it will only be by obtaining data regarding the age, mode of life, and family history, of the person affected, that it will be possible to draw conclusions as to the cause of the sterility.
The female reproductive glands, the ovaries, may, owing to developmental disturbances during foetal life, either be entirely wanting, or they may merely be deprived of certain structural constituents, especially their epithelial elements. In the former case, we have congenital complete unilateral or bilateral absence of the ovary, a condition most commonly associated with the absence or with a rudimentary condition of other portions of the reproductive apparatus; in the latter case, we have the condition somewhat inappropriately named congenital atrophy of the ovary.
Complete absence of both ovaries necessarily leads to absolute sterility. Both congenital absence and congenital atrophy of the ovaries, will usually be found in association with other anomalies of the sexual organs. Absence of one ovary, on the other hand, by no means entails sterility; on the contrary, when a single well-formed ovary exists, ovulation usually proceeds in a perfectly normal manner. When such women marry, pregnancy usually follows in the normal proportion of cases; and, in complete opposition to one of the theories of the determination of sex to which allusion has been made, such women bear children of both sexes.
Morgagni described a case of congenital absence of both ovaries in a woman 66 years of age, in whom the external genital organs, the vagina, and the uterus, were imperfectly developed, but the Fallopian tubes were of normal size. Careful examination of the upper borders of the broad ligaments of the uterus disclosed no trace of ovary on either side.
Quain, in a virgin 33 years of age, found the vagina rudimentary, with its mucous membrane but slightly corrugated; at the upper end of this passage was a semilunar fold which probably represented the uterus. The ovaries were absent; a small gland-like body embedded in the left wall of the vagina was regarded by him as a rudimentary ovary. The configuration of the body was feminine, feminine also the disposition; moreover, there was a monthly recurrent epistaxis.
The atrophy of the ovaries which normally takes place at the climacteric period, to be more minutely described in the section on the menopause, has constitutional effects similar to those dependent upon absence or congenital atrophy of the ovaries.
A rudimentary condition of both ovaries, or bilateral atrophy of these organs, with or without associated atrophy of the entire reproductive system, commonly entails sterility. In such cases, in addition to amenorrhœa, we usually find that the breasts are but slightly developed, the pubic hair is scanty, the labia majora and labia minora are small, whilst sexual appetite is deficient, and during coitus the woman is entirely passive. On the other hand, we must not make the mistake of inferring from the fact that the sexual appetite is keen and coitus pleasurable, that therefore the capacity for ovulation is normal. Even after operative removal of both ovaries, some women have assured me, not only that the sexual impulse was as strong as formerly, but even that they continued to experience the sexual orgasm in its full intensity. This is analogous to the well known fact that men who have undergone castration after arriving at sexual maturity may remain capable of performing coitus. It is a matter of history that in the lupanars of ancient Rome, castrated men were kept to enable women to enjoy the pleasures of sexual intercourse without fear of consequences; and it is said that such men are to be found in Italian brothels to this day. In the case of the lower mammals, it appears to be the rule that when the reproductive glands are removed in early youth, every trace of sexual desire disappears.
Incomplete development of the ovaries, with consequent defective ovulation, may result from marriage in girls who are still immature—a fact already known to Aristotle, who wrote, “premature marriage leads to a scanty progeny—that this is the case in man as well as the lower animals is witnessed by the weakly inhabitants of regions in which child-marriage is common.”
It is shown by statistical data that the age at which puberty occurs, the age, that is, at which the menstrual flow begins, has a relation to sterility; and the same is true as regards the age at marriage. In the former connexion, women in whom puberty is comparatively early, are less often sterile than those in whom puberty is comparatively late. Emmet, in an investigation embracing 2330 cases, showed that in our climate the average age at which the first menstruation occurred was 14.23 years, and that in the case of women who subsequently proved fertile, the first flow took place on an average 26 days earlier than in the case of women who subsequently proved barren. We also learn from Emmet’s tables that the mean duration of menstruation and the mean quantity of the flow are larger in fertile than in barren women.
As regards the influence of the age at marriage upon fertility, in women who marry between the ages of 20 and 24 years, sterility is most infrequent; it is commoner in women who marry between the ages of 14 and 20; after the age of 25, the proportion of sterile women increases with each year to which marriage is postponed.
Premature atrophy of the ovaries, with consequent incapacity for ovulation, may occur in a great variety of conditions; it has been observed in scrofula, diabetes, rickets, phthisis, and malarial cachexia; it also occurs in certain chronic intoxications, as from the long-continued use of opium or morphine, and from the abuse of alcoholic beverages. According to the observation of Burkart, Levinstein, and Erlenmeyer, morphinism is a condition which may be relied upon to bring about amenorrhœa and temporary sterility from cessation of ovulation. It has been asserted but by no means proved, that the long-continued administration of quinine hinders ovulation. As a result of various acute and chronic disorders, a simple atrophy of the ovarian follicles can be detected, dependent upon simple fatty degeneration; this has been seen by Grohe in children as a result of general atrophy, and also following caseous and suppurative diseases of the respiratory organs; by Slavjansky in children after chronic pneumonia and chronic dysentery, and in adults as a sequel of typhoid, and in one instance as a sequel of puerperal septicaemia.
Hyperplasia of the ovarian stroma, in slighter degrees of the affection, leads to menstrual disturbances, partly of nervous and partly of inflammatory nature, and in more severe degrees leads to sterility dependent upon the hindrances which the thickened tunica albuginea offers to the bursting of the mature follicles. Klebs believes that this anomaly is always due to a disposition acquired very early in life, and perhaps at the time when the ovaries are first developed.
Follicular cysts of the ovary, which are formed mostly at the time of puberty, and originate under the influence of menstrual congestion, from graafian follicles near to ripeness, are competent to cause sterility, owing to the pressure they exercise upon the superficially placed rudimentary follicles, leading to the atrophy of these latter. Other new-growths of the ovaries have similar effects, such as adenomata, carcinomata, dermoid cysts, cystomata, sarcomata, and fibromata. In many cases of these disorders, however, the ovarian follicles may for long periods remain unaffected; and in these instances, ovulation, menstruation, and even conception, may proceed undisturbed. Even in cases in which a neoplasm attains a great size, if it affects one ovary only, ovulation may occur normally in the other, and conception may ensue; and even in the diseased ovary, if small portions of its tissue remain unaffected, ovules may be discharged from these portions. The minutest portion of healthy ovarian tissue, though all the remainder has been destroyed by disease, may suffice to bring about conception.
Ovarian tumours appear with considerable frequency to be complicated with sterility; but in such cases the question always remains open, whether in the majority of instances the sterility is to be regarded as the cause or as the consequence of the ovarian disease. Boinet’s figures dealing with this problem are the most striking of all. He states that of 500 women with ovarian tumours, 390 were childless. But these results are challenged by other observers. Veit’s estimates, based upon a compilation of the figures of Lee, Scanzoni, and West, is that 34% of women with ovarian tumour are sterile. On the other hand, Negroni’s collection of 400 cases of ovarian tumour, including both married and unmarried, contained 43 only who had never been pregnant. Other lists show: 13 sterile women among 45 suffering from ovarian tumour (von Scanzoni); 1 sterile among 21 (Nussbaum); 8 sterile among 63 (Olshausen). Winckel, among 150 sterile married women, found 32 suffering from ovarian tumour, which in two of these cases only was bilateral. Atlee, in 15 cases of ovarian tumour, observed premature cessation of menstruation at the ages of 30, 39, 40 and 42, respectively.
Although in many cases sterility develops coincidently with the growth of an ovarian cystoma, yet in many other women such tumours have no influence in diminishing fertility. Martin in a case in which sterility existed in connexion with a unilateral ovarian cystoma, the other ovary being healthy, observed pregnancy as a sequel of the removal of the diseased ovary. In one of these cases, after removal of the ovarian cystoma, Martin punctured in the other ovary a dropsical follicle which had attained nearly the size of a walnut. Pregnancy in this case also followed the resumption of marital intercourse. Müller reports that in his clinique within recent years pregnancy complicated with ovarian tumour has been observed in 7 instances; in one of these cases the pregnancy occurred notwithstanding the fact that the new-growth was so large as almost to fill the abdominal cavity. Holst reports the case of a multipara 43 years of age who died in the 18th to the 20th week of pregnancy; at the post mortem examination the left ovary was found to be transformed into three cysts each the size of an apple, whilst in place of the right ovary was a medullary carcinoma the size of a man’s head; on neither side could a trace of normal ovarian tissue be detected. Spiegelberg, in a woman who died shortly after giving birth to her second child, found that both ovaries were transformed into myxo-sarcomatous tumours; in a woman aged 42, who died four weeks after her eleventh confinement, both ovaries were found to be transformed into nodular carcinomatous tumours each larger than a child’s head; in none of these ovaries was any normal stroma to be found. Ruge reports the case of a woman 36 years of age, who miscarried in the sixth month of pregnancy; she had myxo-sarcoma of both ovaries, one weighing 5620 grammes the other 480 grammes.
All these cases indicate that, notwithstanding the existence of extensive degeneration of both ovaries, some minute remaining fragment of healthy ovarian stroma is competent to produce normal mature ova—a fact which has often been proved also by microscopical examination. That under the influence of pregnancy, existing ovarian tumours often take on extremely rapid growth, is also indicated by some of the above cases.
Castration (oöphorectomy, spaying, Battey’s operation), the removal of both ovaries, naturally results in sterility. If in the literature of the subject cases are to be found in which, after this operation, not menstruation merely, but even pregnancy has occurred, this is to be explained either by the fact that in the stump there was left a fragment of the ovary, still containing tissue capable of producing mature ova; or else by the existence of a supernumerary ovary. Schatz reports the case of a woman in whom pregnancy occurred after double oöphorectomy. In the month of February, 1880, this operation was performed on a girl twenty years of age; she married in April, 1884; and in May, 1885, she was delivered of a mature female infant. The history of the case and the details of the operation showed clearly that the left ovary had been completely removed, with the outermost third of the left Fallopian tube; the right ovary was cut away in such a manner that a strip of tissue of at most two millimetres (one twelfth of an inch) in width was left in the body, whilst the right Fallopian tube was left intact. This case teaches us that the smallest remnant of the ovary is competent to render normal pregnancy possible; and further, that a small size of the ovary no more constitutes a hindrance to the proper reception of the ovum in the Fallopian tube, than does an abnormally large size of the ovary, or an unusual shape of this organ.
Miklucho-Mackay relates that among the indigens of Australia the removal of the ovaries is often practised, in order to create a special kind of hetairæ incapable of becoming mothers. McGillivray saw at Cape York a native girl whose ovaries had been removed because she was a congenital deaf-mute, with the object of preventing her giving birth to deaf-mute infants. In the beginning of the last century there existed in Sayn-Wittgenstein a small religious sect whose custom it was always to conclude their religious services by indiscriminate carnal union among the members of the community; when women and girls were first admitted as members of this sect, an attempt was made to render them unfitted for conception “by means of a painful and dangerous compression of the ovaries.” (Ploss.)
A transient, relative hindrance to ovulation may be brought about by various pathological states of the ovaries. Acute oophoritis usually suspends the ovarian functions; chronic oophoritis has sometimes a similar effect, not only because the profound changes that take place in the ovary hinder the formation of the ovules, but also because, as we shall later explain more fully, the expulsion of the ova and their reception by the Fallopian tubes are hindered. In severe oophoritis and perioophoritis, more especially in parenchymatous inflammation, sterility may be brought about by an absorption of the finely granular contents of the follicles, which collapse, with adhesion of their walls; when all or most of the follicles are thus affected, the ovaries become small and hard.
In perioophoritis, the exudation leads to the formation of cord-shaped or ribbon-shaped adhesions between the ovaries and the broad ligaments, the uterus, and the peritoneal folds of the neighbourhood. The ovary in such cases may also be displaced, or may undergo atrophy from pressure.
In the case of 200 sterile women, I found in 46 instances chronic oophoritis and perioophoritis. Olshausen reports that of 12 married women suffering from chronic oophoritis, five were barren, whilst of the remaining 7, three only had given birth to more than one child. Matthews Duncan, on the other hand, saw pregnancy in a case of bilateral ovarian inflammation, in which the organs were considerably enlarged.
Further, local or general peritonitis may lead to parenchymatous inflammation of the ovaries, and this, spreading from the periphery towards the centre of the organ, attacks the follicles irrespective of their ripeness. Again, during the puerperium, the interstitial form of oophoritis is by no means rare, and this may at times lead to permanent sterility in either of two ways: it may be in consequence of the onset of a secondary parenchymatous inflammation, which destroys all the follicles; it may be because a thick and tough layer of sclerosed tissue forms around the periphery of the ovary, which mechanically prevents the maturation and rupture of the follicles. According to Slavjansky, puerperal disease is the principal cause of this form of oophoritis. Olshausen indicates as the most frequent cause of primary perioophoritis, an inflammation propagated from the Fallopian tubes, leading to the formation of masses of exudation, which envelop the ovary, and by the pressure they cause, and by interfering with the blood-supply, lead to atrophy of the gland.
Sometimes the chronic inflammatory induration by means of which the stroma of the ovary is rendered denser and firmer, is due to changes in the vessels, and depends upon valvular defects of the heart—upon venous congestion. In this way, heart disease may hinder ovulation and bring about sterility. Both syphilis and gonorrhoea may give rise to chronic inflammatory changes in the ovary, usually leading to premature contraction of the tissues and to the formation of numerous adhesions. According to Olshausen, amenorrhœa is not a common feature of ovarian disease, except in cases of defective development of these organs, of cirrhosis of the ovaries, and of bilateral new-growths. Disease affecting only a single ovary, even tumour of considerable size, rarely causes amenorrhœa until profound constitutional disturbance has ensued. An exception to this rule is found in the case of carcinomatous tumours of the ovary; these, indeed, are commonly bilateral; but even when confined to a single ovary, amenorrhœa is a comparatively early symptom. According to the same author, sterility is a common consequence of chronic oophoritis and its sequelae, and is usual also in cases of bilateral new-growths; on the other hand, tumours affecting a single ovary often fail to prevent conception even though they have attained a great size.
Syphilis in women must be regarded as a frequent cause of sterility, by interference with ovulation, but is in this regard by no means an absolute bar to the occurrence of pregnancy. According to Parent and Duchatelet, under whose observation during the space of 12 years there came annually an average number of 2625 syphilitic prostitutes, the average annual of births in these cases was 63 only. According to Marc d’Espine, 2000 prostitutes gave birth on an average to two or three children in all during a year. (That there are other causes besides syphilis for the remarkable infertility of women of the town, will be explained later). According to Bednar, Mayr, and others, constitutional syphilis in women invariably leads to sterility; others, as for instance Zeissl, believe that women suffering from inveterate syphilis are commonly, but not invariably, sterile; whilst according to Rosen, conception only takes place in syphilitic women in whom the disease has passed into the tertiary form. Experience shows, however, that neither early nor late forms of syphilis necessarily lead to sterility in women. It must also be pointed out, that syphilis in the male may be the cause of sterility, and must be the cause thereof when the disease is localised in the testicles, and the consequent degeneration of the glandular substance leads to the occurrence of azoospermia, more particularly when syphilitic or gummatous orchitis is bilateral. According to Lewin, we fail to find spermatozoa in 50% of men, otherwise powerful, suffering from syphilitic dyscrasia. Hanc, on the other hand, failed to find azoospermia in any one of ten men suffering from lues. In animals also syphilis is said to cause sterility.
The manner in which certain anomalies of the blood (anæmia and chlorosis), general disturbances of the nervous system, febrile states, and such constitutional disorders as scrofula, have a temporary or permanent influence in checking ovulation, is far from being understood; but the fact that ovulation is checked by such conditions, has been established beyond question by numerous observations. It is well known that severe fevers, more especially typhoid, suspend the ovarian function; that in various chronic disorders of an enfeebling nature, and notably in chlorosis, all signs of menstrual activity disappear; and that in certain nutritive disturbances, as in extreme obesity, amenorrhœa also occurs; finally, numerous cases are on record in which some sudden affection of the nervous system has instantaneously inhibited ovarian activity.
In anæmia and chlorosis, it is probable that the degree of menstrual congestion is insufficient to ensure the bursting of the graafian follicle. The sterility often observed as a sequel of typhoid, malaria, the acute exanthemata, cholera, and septicaemia, is probably due in most cases to the occurrence of parenchymatous oophoritis, with consequent destruction of the ovarian follicles. The researches of Slavjansky have shown that in acute disorders inflammatory changes often occur in the graafian follicles. When infectious disorders ran an acute course, this observer usually found that the parenchymatous inflammation of the ovary had occurred near the periphery, in the cortical layer, the destruction being limited almost exclusively to the primitive follicles; when the course of the primary disorder was more chronic, the mature or nearly mature graafian follicles were the ones destroyed. When inflammation of a follicle has led to its destruction, it is replaced by a linear scar. Lebedinsky found similar changes in the ovary after scarlatina—destruction of a lesser or greater number of follicles, with formation of scars. Thus, parenchymatous oophoritis as a sequel of acute diseases, may, if severe, lead to destruction of all the rudimentary follicles, with consequent sterility. In the post mortem examination of such cases, the condition of the ovaries is similar to that which is elsewhere in this work described as characteristic of these organs after the menopause: the ovary is diminished in size, its surface is furrowed, the tissue is indurated in consequence of overgrowth of fibroid tissue; often not a single follicle is to be detected on section of the organ.
Immoderate obesity is a disorder of nutrition favoring the occurrence of sterility.
In very obese women of an age which normally is the reproductive prime, amenorrhœa or scanty menstruation is a very common accompaniment. In 215 such cases which came under my own observation, amenorrhœa was present in 49, and menstruation was scanty in 116; thus in nearly three fourths of these obese women menstruation was either deficient or entirely wanting. Very remarkable also is the high percentage of sterile women among the obese. In the 215 cases already mentioned (all married women), 48 were sterile—a percentage of 21. Whilst the ordinary ratio of barren to fruitful marriages is 1 : 10 or 1 : 9, in the cases in which the wives, or both wives and husbands, are extremely obese, the ratio is according to my own observations, 1 : 5—or, if we include cases of only-child-sterility, 1 : 4.
We cannot wonder at this great frequency of sterility in obese women when we remember that, apart from the menstrual deficiencies which so commonly accompany this disorder of nutrition, obesity is apt to entail many other disorders of the reproductive organs, as for instance a morbid state of the uterine and vaginal secretions, chronic metritis, and displacements of the uterus; still, it cannot be denied, that in many instances we are unable in such obese women to detect any disorder of the reproductive organs competent to account for the sterility, and we must therefore assume that the excessive development of fat has some direct influence in preventing ovulation, or at least that it in some way exercises an unfavourable influence upon the reproductive process.
That excessive obesity hinders fertility, is shown by experience both as regards the vegetable and the animal kingdom. All animal-breeders are familiar with the fact that undue production of fat limits fertility. Thus, equally in the case of turkeys and in the case of the common fowl, if the hens are overfed and become fat, they cease to lay.
Hippocrates already indicated obesity as a cause of sterility. Writing of the wives of the Scythians, he pointed out as a proof that their excessive obesity was the cause of the sterility from which they commonly suffered, the fact that their female slaves, who were thin, were readily impregnated by intercourse with the Scythian males. The oft repeated dwindling and disappearance of ruling families in India and in Egypt, has doubtless in part depended upon the extreme obesity of the female consorts of such rulers.
In many instances, indeed, a great accumulation of fat on the front of the abdomen and in the vulva, suffices to cause a simply mechanical hindrance to the proper performance of a fertilizing coitus. It is possible also that the phlegmatic temperament of very fat women is a contributory cause to their sterility—if indeed it is in general true that frigidity during sexual intercourse is unfavourable to conception, as is expressed by the old proverb, quo salacior mulier, eo foecundior. It is unquestionable that in very obese women sexual sensibility is commonly greatly deficient, and that their husbands often complain of their coldness and lack of passion. In several cases that have come under my observation, dyspareunia occurred in obese and sterile women.
The dependence of sterility upon obesity is often proved in the most striking manner ex juvantibus. A “cure” for the reduction of fat often results favourably in respect also of rendering the woman who undergoes it readily impregnable—a result by no means ardently desired.
It must also be pointed out that very obese women form a considerable section of those suffering from only-child sterility, and this largely in consequence of their strong predisposition towards abortion. As the impregnated uterus enlarges, the space for its accommodation is insufficient, owing to the great development of the panniculus adiposus, and thus obesity, like intra-abdominal tumour, predisposes to abortion. The excessive accumulation of fat within the abdomen, by exercising pressure upon the inferior vena cava or on its principal tributaries, hinders the venous return, and gives rise to a chronic stasis in the uterine bloodvessels, those alike of the muscle and of the mucous membrane.
Notwithstanding the fact that sterility is so common in very obese women, the fact remains that some such women are remarkably fertile, and have very large families indeed.
Towers-Smith, Duke, and Rodriguez, who have recently all been engaged in examining the relations between obesity and sterility, agree in asserting that sterility due to obesity may be cured by dietetic treatment for the relief of the primary disorder of metabolism.
Though menstruation is usually deficient or absent in obese sterile women, and though it is commonly supposed that amenorrhœa implies sterility, it is necessary to point out that whilst failure of menstruation is a frequent and important sign of suppression of ovulation, it by no means invariably has this significance. It is an established fact, and one borne out by my personal experience, that women who have never menstruated have nevertheless become pregnant; others, again, have become pregnant although they have ceased to menstruate for several years, and this has even occurred in women at a comparatively advanced age. Hence, from the fact that amenorrhœa exists, we cannot with certainty infer that a woman is sterile. Moreover, we must remember that physiologically amenorrhoeic women often enough conceive—during lactation. Although we hold the opinion that there is an intimate connexion between ovulation and menstruation, yet it is always possible in cases in which menstruation fails to occur, that ovulation has taken place, but that the stimulus which that process has exercised upon the reproductive organs has been insufficient to give rise to the customary flow of blood.
The following remarkable case came under my own observation: Mrs. B., 26 years of age, had lived in sterile wedlock for six years, had never menstruated, nor had she ever had any sanguineous discharge from the genitals. The body was delicately formed, the breasts were fairly well developed, the external genital organs showed no abnormality. For some weeks before consulting me, this woman, hitherto childless, and living in regular sexual intercourse with her husband, had noticed a remarkable enlargement of the abdomen. Another medical man whom she had consulted had diagnosed ovarian tumor and had urged operation. A more careful examination of the pelvis showed, however, that the woman was in the sixth month of pregnancy, a diagnosis which was duly confirmed by the delivery of a full-time child. In another of my cases, a woman married at the age of 45 years, having ceased to menstruate two years previously. She became pregnant and gave birth to a child in quite normal fashion. The following instructive case also came under my own observation: The wife of one of my colleagues, living in sterile wedlock for 17 years, extremely obese, had since puberty menstruated but scantily and with great irregularity. The menstrual interval was several months, and when the discharge did appear, it was pale in colour and small in quantity; it lasted moreover but a day or two. Last winter, the flow as usual failed to appear for several months, and since the woman had at the same time become fatter than ever, Turkish baths and energetic muscular movements were prescribed. The result of this treatment was a striking one—abortion. After 17 years of marital intercourse she had for the first time become pregnant.
In the case of sterile women who are amenorrhoeic, even when the amenorrhœa has never been interrupted by a menstrual discharge, or when it appears entirely dependent upon obesity, it is nevertheless necessary to be extremely cautious in making a diagnosis, and above all in employing an intra-uterine sound. In such cases I have known the most eminent gynecologists unwittingly bring about abortion.
Cleveland, Godefroy, Haschek, Ritschie, Sommerus, Stark, Taylor, and Young, have all reported cases in which pregnancy occurred in women suffering from amenorrhœa; but all such cases must be regarded as quite exceptional. Szukits examined 8000 sexually mature women, and found among them fourteen only who had never menstruated. Of these, four were multiparae.
Saint Moulin reports the case of a woman 24 years of age who had never menstruated, but who none the less became pregnant and gave birth to a fine girl. One of the most striking cases of this nature is the one reported by Rodzewitsch, regarding a woman who first began to menstruate at the age of 36 years. This woman had however been married when fifteen years of age, and in the subsequent twenty-one years she gave birth to 15 children, remaining the whole time amenorrhoeic.
Puech reports the case of a woman who ceased to menstruate at the age of 40 years, and remained amenorrhoeic for the subsequent six years. Then menstruation recurred for a year, and finally ceased definitively in consequence of the occurrence of pregnancy, which terminated in the normal birth of a healthy boy. Loewy, in a woman 31 years of age, who had previously been amenorrhoeic all her life, saw menstruation appear for the first time shortly after the birth of her sixth child. Ahlfeld had under observation the case of a woman who was the mother of eight children, and had never menstruated.
Krieger reports the case observed by Mayer, of the wife of an artizan, who between the ages of 17 and 28 years had given birth to five children, and had had one abortion. After the age of 22, she had no trace of menstrual discharge, but notwithstanding this, she subsequently gave birth to three children. Krieger himself saw a woman who had had her last child at the age of 33, and in whom now, at the age of 48, menstruation had just ceased entirely. Two years later, irregular menstrual discharges recommenced; when these ceased, it appeared that the woman was once more pregnant, and she was normally delivered of a full-time girl.
Renaudin relates the case of a lady 60 years of age who gave birth to a child, menstruation having ceased 12 years earlier. Deshhayes saw the delivery of a woman 50 years of age, two years subsequent to the occurrence of a normal menopause. Capwron, quotes the ease of a woman who became pregnant at the age of 65 years. In this case menstruation had recurred, having ceased many years before in a normal menopause. This woman aborted at three months, and the foetus was well-formed.
In such cases of late conception, which occur after the normal cessation of menstrual activity, we cannot be certain whether we have to do with a simple persistence of ovarian activity, associated with temporary or permanent cessation of menstruation; or whether both functions, ovulation and menstruation, had ceased, and were aroused to renewed activity by some determinate cause. It is possible that in coitus we have such a stimulus, capable of reawakening the slumbering ovarian functions. That this may be the case, we are led to suppose by the fact that pregnancy at an unusually advanced age most frequently occurs as a result of marriage late in life. In Scandinavian countries, where the difficulties of providing for a family are so great that a very large number of marriages are inevitably postponed till comparatively late in life, the number of pregnancies occurring in elderly women is correspondingly large. However, pregnancy late in life occurs also in women who have married early, and the most probable assumption to account for such cases is that ovulation has occurred in the absence of menstruation.
Although by these cases the proposition is established that amenorrhœa is by no means equivalent to incapacity for ovulation, still, the former must indubitably be regarded as in general a most important indication of disturbed ovulation. When a woman attains the age of 20 years without having ever menstruated, or even having experienced menstrual molimina, we may in the great majority of such cases infer with justice that there is complete or partial failure of development of the ovaries and the reproductive apparatus generally. In some of these cases, examination discloses the fact that the uterus is in an infantile condition. When we are able to bring about the regular establishment of menstruation, we may hope also to remove the sterility dependent upon the defective ovarian functional capacity. General tonic treatment for the relief of chlorotic amenorrhœa quite as often, in the case of previously barren married women, results in the occurrence of pregnancy, as happens in cases of amenorrhœa and sterility due to obesity, when this latter condition has been relieved and menstruation has been re-established by suitable dietetic treatment. Much less often is it possible to relieve the sterility of scrofulous (tuberculous) persons, for in the majority of such cases, in consequence of the scrofulous (tuberculous) constitutional disorders, pathological changes have occurred in the ovaries already in early youth, and these it is difficult or more often impossible to remove.
Scrofula (tuberculosis) is, according to my own experience, the constitutional disorder which of all most frequently and most seriously affects ovulation; and it appears that the ovaries are subject to changes produced by this disease similar to those which occur in other glandular organs. In cases in which no cause of the existing sterility is ascertainable, the presence of scars due to scrofulous (tuberculous) changes in the lymphatic glands may serve as an indicator to show that the capacity for ovulation has been annihilated or seriously diminished in early life by scrofulous (tuberculosis) disease.
Among the causes of sterility, these three conditions: anæmia, chlorosis, and scrofula (tuberculosis), play a leading part; indeed, their importance in this connexion has hitherto been underestimated, more especially in regard to the comparative frequency with which they cause sterility. A large part of the favourable influence in the relief of sterility in women which is exercised by the “cures” at various watering places, depends upon the amelioration which is thus effected in the aforesaid constitutional disorders.
It has been assumed that diabetes, which renders men impotent, is competent also to cause sterility in women. Hofmeier reports a case which appears decisive on this point. In a woman 20 years of age, who had menstruated regularly since she was 14 until a year previously, when the flow had ceased, he found the uterus extremely small, barely 5 cm. (2 in.) in length, extremely atrophied, the ovaries also atrophied and very small; the urine contained large quantities of sugar. Here was doubtless a case of atrophy of the reproductive organs secondary to diabetes.
In England, where the excessive use of alcohol is observed very frequently in women as well as in men, sterility has frequently been regarded as a result of chronic alcoholism. Matthews Duncan reports cases which lead to the belief that alcohol has a specifically deleterious effect upon fertility. Apart from the general or constitutional disturbances dependent upon the abuse of alcohol, this agent has in many cases a well-recognized pathogenic influence upon the female reproductive organs, the morbid condition which is most frequently and most readily assignable to this cause being chronic oophoritis. The obesity which so frequently results from alcoholic excess is a contributory cause of sterility.