The sexual life of woman in its physiological, pathological and hygienic aspects (part 4 of 5)
Whilst Coste’s experiments on a hen gave results contradictory to Thury’s theory, Albini’s experiments, made also on the common fowl, gave results in agreement with that theory. He found that the hens began again to lay fertilized eggs 3 to 6 days after intercourse with the cock (from which they had previously been kept separate); on the average, the distribution of the sexes in the chickens hatched from these eggs was approximately equal, with, however, a slight preponderance of cock birds. On the ninth and tenth days after separation from the cock the eggs laid were half fertilized and half unfertilized; on the twelfth day after separation from the cock the unfertilized eggs were in a great majority; but even as late as the eighteenth day after separation some of the eggs laid were still fertilized. The fertilized eggs laid from the tenth to the fifteenth day after separation when incubated produced a great preponderance of hen birds.
We have to thank breeders for a large number of experiments, such as those made by the breeder Fiquet, at Houston in Texas, who found that a bull upon whose sexual capacities excessive demands were made, procreated bull-calves exclusively; whereas in herds containing numerous bulls there were found among the calves born a preponderance of heifers. In thirty experiments on cattle Fiquet always found that the larger the number of cows a bull had to serve, and the longer they were kept in service, the larger was the proportion of bull-calves among their offspring. On the other hand, if certain cows had their sexual desires first satisfied by a gelded animal and were then served by a vigorous and lusty bull, an excessive proportion of heifers was born to these animals.
Janke obtained similar results in the breeding of sheep. In a report made to Düsing he states that in the early part of the lambing season more ewe-lambs are born than rams; in the latter part of the lambing season, on the contrary, more rams than ewes. The explanation he gives is that at the commencement of the pairing the rams are fresh and lusty, whilst later their potency is comparatively exhausted. In stud-farms, according to the same observer, it is a familiar experience that the most vigorous stallions serving a mare in the morning commonly procreate a filly; but if later in the day they serve a second mare they almost always procreate a colt. This, he thinks, finds its explanation in the fact that the stallion, when he serves the second mare, is in a condition of comparative sexual exhaustion, the more so because he usually covers the first mare twice.
Maritegoute’s breeding experiments at the sheep-farm of Blanc (Haut-Garonne), on the other hand, gave divergent results. In the early part of the pairing season, as long as the ram’s sexual powers were completely unimpaired, he procreated more male than female lambs. But when a few days later a great number of the ewes were simultaneously on heat and the ram, owing to very frequent acts of intercourse, began to be sexually exhausted, the procreation of female lambs was in excess. But when, finally, this period of maximum demands upon the ram’s powers was past, and the number of ewes on heat became once more small, the procreation of male lambs in preference to female was again observed.
The data obtained by Düsing from the Prussian stud-farms, in which, when greater sexual demands were made on the stallions, more males were procreated, have been already mentioned.
Fiquet made interesting experiments on cows and believed that in this way he was able to demonstrate the influence of nutrition upon the determination of sex—to such a degree, indeed, that he believed it was possible to breed calves of either sex at will. The following method gave him positive results in more than thirty instances. He never had the cow served by the bull at the first heat, but only at the second (if a cow is left unserved when on heat, the heat recurs after an interval of three weeks). The interval of three weeks was utilized in the preparation of cow and bull for the copulatory act. If a bull-calf was wanted the cow was supplied with the most invigorating fodder and was kept on the richest pasture available. The bull, on the other hand, that was to serve this cow was turned out to graze on the poorest pasture and was given poor fodder. At the end of the three weeks, when the cow came on heat for the second time, its sexual appetite was as intense as possible, whereas the bull showed but slight inclination to the sexual act. If the bull now served the cow a bull-calf was procreated. The opposite procedure led to the procreation of a heifer. For this purpose Fiquet kept the cow on low diet during the interval between the first and second heats, and had her first served by a castrated animal. When in this way, and by the low diet, the sexual appetite of the cow had been sufficiently diminished, it was served by a lusty bull, which for a long time had not been put to any cow, and the sexual potency of which had been increased to the uttermost by feeding it for several weeks on the most invigorating fodder.
The results of these experiments, according to which the nutrition of the parent-animals before the copulatory act has an influence upon the determination of sex, is explained by Düsing in this way, that nutrition influences also the quality of the reproductive products. “Poor nutrition gives rise to diminished functional capacity of the genital apparatus. Thus, for example, the production of semen is lessened. It can, in fact, hardly be replaced as quickly as it is used up. This occurs when there is a lack of adequate means of subsistence, and also when there is a lack of comparatively young males. In both cases alike we trace the effects in the birth of an excess of males. Converse conditions give rise to an excess of female offspring.”
Passing now to consider investigations made by physiologists, Born, at the anatomical institute at Breslau, has endeavoured to solve the problem of the determination of sex by means of experiment. He employed for this purpose rana fusca, an animal with which positive results can be obtained in a comparatively short period of time. He examined the sex both of the frogs in the free state (165), and also of larvæ which he had bred in specially arranged aquaria. Whereas among the frogs developing in the open, the numbers of the sexes appeared to be approximately equal (there was an excess of females amounting to 2 or 3 per cent.); among those bred in the aquaria there was an enormous preponderance of females (96 per cent.). This remarkable result is referred by Born to the inadequate supply of nutriment in the case of the larvæ bred by him (he fed them on hydræ and on putrefying frog and tadpole meat); from an examination of the alimentary canal of tadpoles caught in the open Born ascertained that their normal food was the mud of the pools in which they were hatched, containing infusoria, radiolariæ, diatoms, algæ, etc. The accuracy of this explanation appeared to Born to be more convincingly shown by the results in the case of one of his twenty-one aquaria. In this one alone the percentage of males was as high as 28 per cent., and the tadpoles in this attained the same size as those developed under natural conditions in the open, whilst in all the other aquaria the tadpoles remained abnormally small. This particular aquarium, owing to an oversight, had pond-mud on its floor, whilst all the other aquaria were floored with clean sand.
A. von Griesheim disputes Born’s results and believes that the latter, determining the sex of the tadpoles by means of a hand lens, must have mistaken a great many female tadpoles for males. He himself, by repeated enumerations of a large number of tadpoles (685), part caught in the open and part taken from a large aquarium, found that the ratio between the sexes in the case of rana fusca was regularly 36.7 males to 63.3 per cent. females.
E. Pflüger refers the divergence between Born’s results and his own and those of von Griesheim not to any error made by Born in the diagnosis of the sex of the tadpoles, but to the fact that in the latter’s aquaria the mortality of the male tadpoles was probably greater than that of the females. Pflüger endeavoured to ascertain whether the concentration of the semen might have an influence in the determination of sex. A quantity of frog-spawn was fertilized with concentrated semen, taken direct from the seminal vesicles, and another quantity of spawn was fertilized with diluted semen, obtained by making an aqueous extract of the incised testicles. The ratio between the sexes in the case of the two lots of tadpoles, which were kept in separate aquaria, proved, however, to be mathematically identical. But another experiment showed that the number of males was very different, according to the kind or race from which the animals were derived. He therefore believes that for the character of the development of the reproductive organs, the race of the parent animals is determinative. There is very little likelihood of being able to modify this inherited sexual ratio by means of outward influences affecting the ova and the ripe semen prior to fertilization, and just as little by means of a number of abnormal influences (change of climate, of water, of nutriment, etc.) acting on the fertilized ova.
Düsing,—who in his work on “The Regulation of the Sexual Ratio” (Jena, 1884) most ingeniously advocates the thesis that all animals have the power, when there is a lack of individuals of one sex, of procreating an excess of individuals of this deficient sex, or, to put it in another way, that an excess of one sex determines the procreation of an excess of the other sex,—instituted experimental investigations regarding the determination of sex in the following manner (in accordance with a suggestion made by Pflüger): About ninety guinea-pigs were distributed in two pens in such a way that in one pen there was a great deficiency of males and a great excess of females, whilst in the other there was a deficiency of females and an excess of males. Thus the sexual ratios in the two stalls were opposed. In accordance with Düsing’s theory, therefore, more males should have been born in the first pen and more females in the second pen. Every week each pen was examined once or twice, the sex of the new-born young was ascertained, and they were distinguished by small incisions in the margin of the ear. A week later, when the young animals had developed a little further, they were re-examined to make sure that no mistake had been made.
At first, in the pen containing the original excess of females, there occurred a quite remarkable excess of male births. This, however, was merely the result of chance, for soon the relationships of the sexes among the new born was reversed, and thenceforward many more females were born than males. But if all the births occurring in this experiment are taken into consideration the number is still far too small to allow trustworthy conclusions to be drawn.
Düsing emphasizes the fact that such an experiment as this, in order to furnish results worth consideration, must be continued until the sexual ratio has become constant, so that it is no longer subject to alteration by chance variations. If we assume that Düsing’s theory is false, the results obtained would be the following: In both the pens, in that in which there was originally an excess of females and in that in which there was originally an excess of males, the births, if observed through a sufficient period, would present a definite sexual ratio which would be the same in both the pens. But if the theory is well founded the sexual ratio of the new born would vary in the two pens: in the stall in which there had originally been a deficiency of males there would be an excess of births of males over females; whereas in the pen in which there had originally been a deficiency of females there would on the contrary be an excess of births of females over males. Düsing recommends that for such experiments even more fruitful animals, such as rats and mice, should be utilized.
Institutes for pisciculture would also be extremely suitable for such experiments in breeding for the determination of the matter under discussion because, owing to the fact that in these animals fertilization is effected outside of the body of the parents, a direct examination of the ova and the semen used in the experiments can be undertaken, and the fertilization can be made to occur under conditions subjected to various alterations; also we can employ the roe and the sperm of fishes whose age, life history, weight and size are accurately known.
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.”
STERILITY IN WOMEN.
When we study the history of human civilization we find that sterility in women is regarded, not merely as a misfortune, but as a reproach. Among savage races, and in the Orient, where the position of women is one of strict subordination, she does not attain an honourable status until she becomes a mother. In Persia, a sterile woman is always divorced by her husband. In India, also, when a sterile married woman has in vain employed the various religious measures advocated for the relief of her barren condition she is sent back to her parents. Both in China and Japan, a barren woman is regarded as a most miserable creature. Among the negro races, a woman who fails to bear children is the object of scorn and contempt. Among the Dualla negroes, a man whose wife fails to bear children demands from her parents the return of the sum which he paid for her at the time of marriage. Many of the indigenous tribes of South America also make a practice of divorcing a sterile wife. Among the better-class Circassians, the women do not attain an assured position until they have borne a child. In Angola a barren woman is the object of universal contempt, and she often feels the ignominy of her position so keenly that she commits suicide. Alike among the Jews and among the Turks, barrenness in a wife is a recognized ground for divorce, and the woman who has been divorced for this reason will hardly ever succeed in obtaining another husband, for she is regarded as one whose body is not properly developed. According to old German law, barrenness in a wife and impotence in a husband were both grounds for divorce. The code of the Emperor Justinian allowed of divorce in cases in which for the space of two years a husband had been unable to fulfil his marital duties, and such a union was termed innuptæ nuptæ. Among the ancient Romans, although they regarded barrenness as a mark of the divine disfavour, according to the laws of Augustus failure to bear children was a punishable offence, and such a punishment was incurred by any married woman who had attained the age of 20 years without having become a mother. In ancient Greece also, divorces due to the barrenness of the wife were by no means uncommon. Among the Slavonic peoples sterility was so greatly despised that there is a Slavonic proverb which runs: “A woman is no woman until she has borne a child”: and in Istria a sterile woman is known by the nickname “Scirke,” which is equivalent to “hermaphrodite.” The Jewish view of the matter is expressed in the Talmudic rabbinical saying: “A wife’s duties are beauty, gentleness, and the bearing of children”; and again, “the poor, the leprous, the blind, and the childless, are like the dead”; and, finally, “he who refrains from marriage with the deliberate intention of having no children, incurs the guilt of murder.” In the Koran we find the fatalistic expression, “God makes a woman barren in accordance with his will.”
We can therefore readily understand that in the most ancient medical writings the question of sterility in women is a matter of earnest consideration. In the works of the early physicians of Hindustan we find several apt remarks on the subject. Susruta says: “Pregnancy most readily results from intercourse during menstruation. At this time the os uteri is open, like the flower of the water lily in the sunshine.” In the Old Testament, in which the newly-created human couples receive the command, “Be fruitful and multiply, and replenish the earth,” we find frequent references to barrenness as a state equally dishonourable and unfortunate, and the use of certain plants is recommended as a means of cure. The Talmud contains several essays dealing with the causes and treatment of sterility.
The Hippocratic collection of writings contains a number of passages dealing with the causes of sterility and with the means to be employed for its relief. We shall have occasion later to refer to these recommendations. Celsus, on the other hand, has little to say on this subject. In the works of Pliny, and also in those of Aristotle, there are references to the topic of sterility.
Among the writers of the first century of our era, Soranus discusses exhaustively the capacity for conception and sterility. In his work we find, among other passages, the unquestionably accurate remark: “Since the majority of marriages are concluded, not from love, but in order to procreate children, it is difficult to understand why, in the choice of a wife, less regard is paid to her probable fertility than to the worldly wealth of her parents.”
In the middle ages, Paulus Agineta more especially treats of the diseases of women, and among these, of sterility in women. That in Arabian medicine much attention was paid to this question, we can learn from the writings of Maimonides.
By sterility in women we understand the pathological state in which a woman who is sexually mature fails to conceive, notwithstanding frequently repeated, normal sexual intercourse throughout a considerable period of time.
Sterility is termed congenital (or absolute) when, notwithstanding repeated intercourse throughout a long period (not less than three years), pregnancy has always failed to ensue; it is termed acquired (or relative), when women who have already been pregnant once or more often, cease to conceive, although they are still quite young enough to do so, and have experienced regular sexual intercourse for a long period (not less than three years). In a wider sense of the term, we say that a woman is sterile, when, notwithstanding prolonged and repeated sexual intercourse, in circumstances favourable to procreation, she has failed to give birth to a living and viable infant.
English authors also make a special distinction regarding that form of acquired sterility (which is no great rarity), in which a woman gives birth to a single infant and subsequently remains sterile (“only-child sterility”).
The civilization of the present day, with its shady side, has made it necessary for us to pay an increasing attention to facultative sterility, dependent upon the use during intercourse of means for the prevention of conception; and very recently the surgical tendency of modern gynecology has brought into being a new variety of sterility in women, viz., operative sterility.
The period which must elapse after marriage, before the absence of pregnancy must lead us to regard a woman as sterile, is fixed at three years. This limitation is based upon the statistical data which (see Table on page 368) I gave regarding 556 fruitful marriages.
The ideal state of fertility, that in which conception is the immediate result of the first act of intercourse between husband and wife, the conception being followed in due course by the birth of a child, is, like most other ideals, one very rarely attained. In the human species, conception as the immediate result of the first act of sexual intercourse, is an extremely unusual occurrence. To invoke medical assistance for women who have failed to conceive during the first three months of married life, which my experience shows to be more frequently done now than formerly, is devoid of all justification; and still worse is it, in this period of “early love” to subject women, as has often been done recently by overenergetic gynecologists, to local treatment, even to the extent of operative procedures.
We are not justified in speaking of the existence of actual sterility until three years of marital intercourse have failed to result in conception; still, when the commencement of the first pregnancy is delayed for more than sixteen months after marriage, there is considerable probability that the woman is sterile; and this probability increases month by month till the expiry of the second year, whilst as the end of the third year approaches, it becomes tantamount to certainty.
Sterility is one of the commonest of the functional disorders of women, and one of those which most often demand gynecological assistance.
By a statistical study of the marriages of the royal and princely families of Europe and of the marriages of the highest families of the aristocracy, I learned that of 626 marriages, 70 were barren; thus the ratio of fruitless to fruitful marriages proved to be as 1 : 8.87. But in other circles of society, in so far as data relating to the matter were obtainable in my practice, the statistics of infertility were by no means so unfavourable, the ratio working out at about 1 barren to 10 fruitful unions. I must point out, however, that these statistics, like all statistics of fertility, are to a degree invalidated by the fact that in a certain number of the instances included among the barren, an unnoticed abortion may have occurred.
Simpson, in his investigation regarding the frequency of sterile unions, found a ratio of 1 : 8.5 (in 1252 instances). In the English aristocracy, where the marriages are for the most part restricted among the members of a comparatively small number of families, the ratio was 1 : 6.11 (495 instances); on the other hand, among the population of Grangemouth and Bathgate, consisting chiefly of persons engaged in seafaring and agricultural occupations, the ratio of barren to fruitful unions was as 1 : 10.5.
Spencer Wells and Marion Sims, as a result of their investigations, give a ratio of 1 : 8.
According to Seeligmann, in Hamburg, among marriages of persons in all classes of society, 11.5% are barren. Prochownick found among 2500 women, all of whom had been married for eighteen months or more, and none of whom were more than 40 years of age, that 9% had failed to conceive.
According to Frank and Burdach, who do not publish the figures upon which their estimate is based, only 1 marriage in 50 proves barren. Lever, who also gives merely his percentage result, states that 5% of married women are completely infertile. Hedin, dealing with a Swedish community of 800 persons, states that the percentage of sterile unions is barely 10.
According to Goehlert’s statistical investigations, in the dynasty of the Capets, among 450 marriages, 19.7% were sterile: in the Wittelsbach dynasty (Bavaria), among 177 marriages, 23.7% were sterile; and among the ruling families of Germany (more than 600 marriages), 20.5% were sterile. In this investigation, however, no attention is paid to the age of husband or wife; marriages and remarriages are classed together without discrimination; and those marriages only in which a living child was born are counted as fruitful, so that the unions counted as sterile must contain many in which abortion or stillbirth occurred. In three Esthonian communities in Livonia, Oehren found that among 2799 marriages, 8.4% were barren, but in this instance also stillbirths were ignored.
Ansell reports that of 1919 marriages of women belonging to the upper classes, their mean age being 25 years, 152 proved barren, a proportion of 1 : 12, or about 8%.
Matthews Duncan communicates the following data. In the year 1855, in the cities of Edinburgh and Glasgow, 4447 marriages were contracted, and of these 725 proved barren, a proportion of 1 : 6.1; 75 of these may however be excluded from consideration, inasmuch as the wives were already at the age of 45 or upwards. Among the remaining 4372 marriages, 662 proved barren, a proportion of 1 : 6.6. In other words, 15% of all marriages of women between the ages of 15 and 44 proved sterile.
From France we obtain figures showing a much higher proportion of sterile unions. According to Rochard, in France in the year 1888, of ten million families, two million had no child at all, and two million had each an only child, so that two fifths of the families of France were taking no practical part in the maintenance of the population. According to Chevin, the proportion in France of barren to fruitful marriages is as 1 : 5. 20% are entirely barren, while 24% exhibit only-child-sterility.
From Massachusetts, Morton reports that according to the last census returns, one fifth of all married women are childless.
In England, numerous trustworthy statistics can be obtained regarding the frequency of sterile marriages. The average proportion of barren to fruitful unions was:
Among the patients in St. Bartholomew’s Hospital 1 : 8 Among the inhabitants of Grangemouth 1 : 10 Among the inhabitants of Bathgate 1 : 10 Among the British peerage 1 : 6 Among the upper classes 1 : 12 Among the inhabitants of Edinburgh and Glasgow 1 : 7
Matthews Duncan compiled the following table relating to 504 absolutely sterile women met with in his practice:
═════════╤═══════════════════════════════════════════════════════════════ AGE AT │ NUMBER OF YEARS MARRIED. MARRIAGE.│ ─────────┼───────┬───────┬───────┬───────┬───────┬───────┬───────┬─────── „ │ Less │4 to 8.│ 9 to │ 14 to │ 19 to │ 24 to │ 29. │Totals. │than 3.│ │ 13. │ 18. │ 23. │ 28. │ │ ─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼─────── 15 to 19 │ 12│ 19│ 15│ 4│ 7│ 2│ 1│ 60 20 to 24 │ 70│ 66│ 37│ 24│ 13│ 9│ │ 219 25 to 29 │ 47│ 51│ 20│ 8│ 8│ │ │ 134 30 to 34 │ 26│ 20│ 8│ │ 1│ │ │ 59 35 to 39 │ 6│ 13│ 4│ │ │ │ │ 23 40 to 45 │ 6│ 3│ │ │ │ │ │ 9 ─────────┼───────┼───────┼───────┼───────┼───────┼───────┼───────┼─────── Totals │ 167│ 172│ 84│ 40│ 29│ 11│ 1│ 504 ═════════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════╧═══════
Ansell bases upon the observations made by him in the case of 152 sterile women the conclusion that there is no longer any chance of the occurrence of pregnancy if a woman is:
More than 48 years old, and has had no child for 2 years More than 47 years old, and has had no child for 3 years More than 46 years old, and has had no child for 4 years More than 45 years old, and has had no child for 6 years More than 44 years old, and has had no child for 8 years Less than 44 years old, and has had no child for 10 years
If we take into account also cases of acquired sterility, the proportion of barren to fruitful marriages becomes even more unfavourable, and the proportion increases enormously if, with Grünewaldt, we number among the barren women those who fail to continue child-bearing up to the normal climacteric period. Grünewaldt, dealing with about 1500 women suffering from affections of the reproductive organs, excluded all those who were either virgins or widows, and also all those who at the time of the observed barrenness were over 35 years of age; this left more than 900 women suffering from affections of the reproductive organs, all of whom were sexually mature, and were living in marital intercourse; of these, nearly 500 were barren, 300 being instances of acquired sterility, and 190 instances of congenital sterility. Thus, according to this observer, disease of the reproductive organs in women led in more than 50% of the cases to disturbance of the reproductive capacity; about one in every three women, previously competent to bear children, became barren when affected with disease of the reproductive organs; and among every five gynecological patients of the condition already specified as regards age and sexual intercourse, one proves congenitally sterile.
It must not, however, be forgotten, that sooner or later after marriage artificial sterility tends to come into being, its early or late appearance depending upon the degree of civilization and upon the national and economical conditions of the people and the individuals concerned. This fact must not be left out of the account.
The manner in which, in the human species, fertilization is effected, is still far from clear in all its details; hence it is easy to understand, that the etiology of sterility remains in many respects obscure. It is impossible in every case to find a definite cause. Whereas, on the one hand, notwithstanding the existence of apparently insuperable obstacles, impregnation may nevertheless be effected; so, on the other hand, sterility may exist in cases in which all the circumstances appear favourable to the occurrence of conception. Hence a classification of the different varieties of sterility from the etiological standpoint, is a very difficult task, and the conclusions thus obtained are often vitiated.
Although it cannot be denied that mechanical causes are competent to lead to sterility in women, Sims, in his advocacy of the mechanical doctrine of sterility, widely overshoots the mark. His authority, however, has led to a general acceptance of this doctrine, which is by no means justified by facts. The theory of mechanical obstruction, according to which sterility in women depends upon mechanical obstacles to the passage of the spermatozoa towards the ovaries, is from time to time strikingly illustrated by cases coming under our notice—cases the nature of which can hardly be overlooked; but it is quite wrong to suppose that this causation accounts for the majority of instances of sterility in women, and strict limitations should be placed upon the employment of surgical measures based upon this mechanical theory of sterility.
The mechanical view has been counterposed by Von Grünewaldt with a doctrine in which especial stress is laid upon obstacles to utero-gestation, sterility being regarded as a functional disorder brought about by affections of the female reproductive organs rendering the uterus unfit for the incubation of the ovum. It cannot be denied that the elucidation of this casual influence was a valuable contribution to the theory of sterility, and it is unquestionable that many morbid conditions of the uterus exist capable of giving rise to sterility in this manner; but we must avoid the error of regarding this doctrine as a full explanation of the cause of sterility.
If, however, both of these theories of sterility are insufficient, we cannot regard a third theory, that of Matthews Duncan, as filling the gaps in our knowledge. It would be most unfortunate if this author were right in maintaining that all our knowledge of the causes of sterility is to be summed up in the phrase “deficient reproductive energy;” we cannot agree with Duncan in his belief that “Sterility is an imperfection devoid of all perceptible, measurable characteristics;” nor can we follow him when he maintains that local causes, whether they are such as hinder conception, or such as hinder utero-gestation, have a very limited sphere of activity. Matthews Duncan adopts an incomprehensible standpoint when he regards sterility as dependent upon a law of nature, as a condition which may affect distinct classes or an entire population.
According to the latest doctrine of sterility, only in quite exceptional instances is the woman regarded as responsible for the occurrence of sterility; contrariwise, the male genital organs are commonly blamed for the affection, which is in the overwhelming majority of cases supposed to be due to azoospermia, usually dependent upon gonorrhœal infection; compare with this, affections of the female reproductive organs are said to play a quite subordinate role in the etiology of sterility. But for my part, though I recognize the important share that gonorrhœa in the male plays in the causation of sterility, I am of opinion that the extreme view just mentioned is by no means justified by the facts.
Sterility, a functional disturbance of an extremely complicated nature, can, in my opinion, be most usefully elucidated from the etiological standpoint by starting with the assumption that three conditions are absolutely essential to procreation:
1. that ovulation proceeds in a perfectly normal manner, the maturation of the discharged ova being complete;
2. that normal spermatozoa have access to these normal ova (conjugation of male and female pronuclei);
3. that the uterus is properly adapted for the gestation of the fertilized ovum.
My classification of the varieties of sterility corresponds to these conditions of procreation:
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.
Incapacity for ovulation, the first and most decisive cause of sterility in women, may be absolute and irremediable, or relative and transient. We have to do with the former in cases in which the ovaries are entirely wanting, or when they are affected with organic disease to such a degree that they have become incapable of fulfilling their function of ovulation; incapacity for ovulation is, on the other hand, relative and transient in certain pathological states of the ovary and neighbouring organs, when there is incomplete development or partial atrophy of the ovaries, when there are new-growths of the ovaries, in cases of oophoritis and perioophoritis, in consequence of disturbances of innervation, diseases of the central and peripheral nervous system, violent emotional disturbance, constitutional disorders, such as syphilis, chlorosis, anæmia, universal lipomatosis, scrofula, alcoholism, and morphinism, also in consequence of changes in the supply of nutriment and in the general mode of living, or of senile changes, and finally in consequence of hereditary influences.
The diagnosis of the etiological influence of suppressed or incomplete ovulation in the production of sterility in women is at times beset with great and even insuperable difficulties. The state of the menstrual function, suppression of the flow, or the regularity or irregularity of its occurrence, serve indeed to inform us as to the general activity or inactivity of the function of ovulation; but the variations in this function give no certain information as to whether a woman is fertile or infertile. Knowing as we do that generally speaking an intimate connexion subsists between menstruation and ovulation, we are indeed able to assert that regular menstruation and fertility in women run a parallel course, and further, that the greater the irregularity of the menstrual function, the greater the tendency to sterility. Recently, great advances have been made in the technique of manual exploration of the ovaries, and by means of vaginal and rectal bimanual examination, we are now able to obtain accurate information regarding abnormalities in the size, shape, and position of these organs, and regarding any other intrapelvic disorders. In this way we have been enabled to recognize a number of pathological states of the ovaries which affect the functions of these organs. In some cases also there are general symptoms which furnish us with the means of drawing conclusions, more or less trustworthy, regarding the state of the ovarian functions; for instance, the general development of a woman’s body, the condition of the external genitals, the vulva, the mons veneris, the pubic hair, the clitoris, and the mammae. Again, we can derive information from various troubles of which women complain; such as sacrache; a sense of weight and pressure in the pelvis; feelings of tension and shooting pains in the breasts; flushings of the face; haemorrhage from the nose, mouth, or rectum, recurring at regular intervals and vicarious in nature. In many instances, however, it will only be by obtaining data regarding the age, mode of life, and family history, of the person affected, that it will be possible to draw conclusions as to the cause of the sterility.
The female reproductive glands, the ovaries, may, owing to developmental disturbances during foetal life, either be entirely wanting, or they may merely be deprived of certain structural constituents, especially their epithelial elements. In the former case, we have congenital complete unilateral or bilateral absence of the ovary, a condition most commonly associated with the absence or with a rudimentary condition of other portions of the reproductive apparatus; in the latter case, we have the condition somewhat inappropriately named congenital atrophy of the ovary.
Complete absence of both ovaries necessarily leads to absolute sterility. Both congenital absence and congenital atrophy of the ovaries, will usually be found in association with other anomalies of the sexual organs. Absence of one ovary, on the other hand, by no means entails sterility; on the contrary, when a single well-formed ovary exists, ovulation usually proceeds in a perfectly normal manner. When such women marry, pregnancy usually follows in the normal proportion of cases; and, in complete opposition to one of the theories of the determination of sex to which allusion has been made, such women bear children of both sexes.
Morgagni described a case of congenital absence of both ovaries in a woman 66 years of age, in whom the external genital organs, the vagina, and the uterus, were imperfectly developed, but the Fallopian tubes were of normal size. Careful examination of the upper borders of the broad ligaments of the uterus disclosed no trace of ovary on either side.
Quain, in a virgin 33 years of age, found the vagina rudimentary, with its mucous membrane but slightly corrugated; at the upper end of this passage was a semilunar fold which probably represented the uterus. The ovaries were absent; a small gland-like body embedded in the left wall of the vagina was regarded by him as a rudimentary ovary. The configuration of the body was feminine, feminine also the disposition; moreover, there was a monthly recurrent epistaxis.
The atrophy of the ovaries which normally takes place at the climacteric period, to be more minutely described in the section on the menopause, has constitutional effects similar to those dependent upon absence or congenital atrophy of the ovaries.
A rudimentary condition of both ovaries, or bilateral atrophy of these organs, with or without associated atrophy of the entire reproductive system, commonly entails sterility. In such cases, in addition to amenorrhœa, we usually find that the breasts are but slightly developed, the pubic hair is scanty, the labia majora and labia minora are small, whilst sexual appetite is deficient, and during coitus the woman is entirely passive. On the other hand, we must not make the mistake of inferring from the fact that the sexual appetite is keen and coitus pleasurable, that therefore the capacity for ovulation is normal. Even after operative removal of both ovaries, some women have assured me, not only that the sexual impulse was as strong as formerly, but even that they continued to experience the sexual orgasm in its full intensity. This is analogous to the well known fact that men who have undergone castration after arriving at sexual maturity may remain capable of performing coitus. It is a matter of history that in the lupanars of ancient Rome, castrated men were kept to enable women to enjoy the pleasures of sexual intercourse without fear of consequences; and it is said that such men are to be found in Italian brothels to this day. In the case of the lower mammals, it appears to be the rule that when the reproductive glands are removed in early youth, every trace of sexual desire disappears.
Incomplete development of the ovaries, with consequent defective ovulation, may result from marriage in girls who are still immature—a fact already known to Aristotle, who wrote, “premature marriage leads to a scanty progeny—that this is the case in man as well as the lower animals is witnessed by the weakly inhabitants of regions in which child-marriage is common.”
It is shown by statistical data that the age at which puberty occurs, the age, that is, at which the menstrual flow begins, has a relation to sterility; and the same is true as regards the age at marriage. In the former connexion, women in whom puberty is comparatively early, are less often sterile than those in whom puberty is comparatively late. Emmet, in an investigation embracing 2330 cases, showed that in our climate the average age at which the first menstruation occurred was 14.23 years, and that in the case of women who subsequently proved fertile, the first flow took place on an average 26 days earlier than in the case of women who subsequently proved barren. We also learn from Emmet’s tables that the mean duration of menstruation and the mean quantity of the flow are larger in fertile than in barren women.
As regards the influence of the age at marriage upon fertility, in women who marry between the ages of 20 and 24 years, sterility is most infrequent; it is commoner in women who marry between the ages of 14 and 20; after the age of 25, the proportion of sterile women increases with each year to which marriage is postponed.
Premature atrophy of the ovaries, with consequent incapacity for ovulation, may occur in a great variety of conditions; it has been observed in scrofula, diabetes, rickets, phthisis, and malarial cachexia; it also occurs in certain chronic intoxications, as from the long-continued use of opium or morphine, and from the abuse of alcoholic beverages. According to the observation of Burkart, Levinstein, and Erlenmeyer, morphinism is a condition which may be relied upon to bring about amenorrhœa and temporary sterility from cessation of ovulation. It has been asserted but by no means proved, that the long-continued administration of quinine hinders ovulation. As a result of various acute and chronic disorders, a simple atrophy of the ovarian follicles can be detected, dependent upon simple fatty degeneration; this has been seen by Grohe in children as a result of general atrophy, and also following caseous and suppurative diseases of the respiratory organs; by Slavjansky in children after chronic pneumonia and chronic dysentery, and in adults as a sequel of typhoid, and in one instance as a sequel of puerperal septicaemia.
Hyperplasia of the ovarian stroma, in slighter degrees of the affection, leads to menstrual disturbances, partly of nervous and partly of inflammatory nature, and in more severe degrees leads to sterility dependent upon the hindrances which the thickened tunica albuginea offers to the bursting of the mature follicles. Klebs believes that this anomaly is always due to a disposition acquired very early in life, and perhaps at the time when the ovaries are first developed.
Follicular cysts of the ovary, which are formed mostly at the time of puberty, and originate under the influence of menstrual congestion, from graafian follicles near to ripeness, are competent to cause sterility, owing to the pressure they exercise upon the superficially placed rudimentary follicles, leading to the atrophy of these latter. Other new-growths of the ovaries have similar effects, such as adenomata, carcinomata, dermoid cysts, cystomata, sarcomata, and fibromata. In many cases of these disorders, however, the ovarian follicles may for long periods remain unaffected; and in these instances, ovulation, menstruation, and even conception, may proceed undisturbed. Even in cases in which a neoplasm attains a great size, if it affects one ovary only, ovulation may occur normally in the other, and conception may ensue; and even in the diseased ovary, if small portions of its tissue remain unaffected, ovules may be discharged from these portions. The minutest portion of healthy ovarian tissue, though all the remainder has been destroyed by disease, may suffice to bring about conception.
Ovarian tumours appear with considerable frequency to be complicated with sterility; but in such cases the question always remains open, whether in the majority of instances the sterility is to be regarded as the cause or as the consequence of the ovarian disease. Boinet’s figures dealing with this problem are the most striking of all. He states that of 500 women with ovarian tumours, 390 were childless. But these results are challenged by other observers. Veit’s estimates, based upon a compilation of the figures of Lee, Scanzoni, and West, is that 34% of women with ovarian tumour are sterile. On the other hand, Negroni’s collection of 400 cases of ovarian tumour, including both married and unmarried, contained 43 only who had never been pregnant. Other lists show: 13 sterile women among 45 suffering from ovarian tumour (von Scanzoni); 1 sterile among 21 (Nussbaum); 8 sterile among 63 (Olshausen). Winckel, among 150 sterile married women, found 32 suffering from ovarian tumour, which in two of these cases only was bilateral. Atlee, in 15 cases of ovarian tumour, observed premature cessation of menstruation at the ages of 30, 39, 40 and 42, respectively.
Although in many cases sterility develops coincidently with the growth of an ovarian cystoma, yet in many other women such tumours have no influence in diminishing fertility. Martin in a case in which sterility existed in connexion with a unilateral ovarian cystoma, the other ovary being healthy, observed pregnancy as a sequel of the removal of the diseased ovary. In one of these cases, after removal of the ovarian cystoma, Martin punctured in the other ovary a dropsical follicle which had attained nearly the size of a walnut. Pregnancy in this case also followed the resumption of marital intercourse. Müller reports that in his clinique within recent years pregnancy complicated with ovarian tumour has been observed in 7 instances; in one of these cases the pregnancy occurred notwithstanding the fact that the new-growth was so large as almost to fill the abdominal cavity. Holst reports the case of a multipara 43 years of age who died in the 18th to the 20th week of pregnancy; at the post mortem examination the left ovary was found to be transformed into three cysts each the size of an apple, whilst in place of the right ovary was a medullary carcinoma the size of a man’s head; on neither side could a trace of normal ovarian tissue be detected. Spiegelberg, in a woman who died shortly after giving birth to her second child, found that both ovaries were transformed into myxo-sarcomatous tumours; in a woman aged 42, who died four weeks after her eleventh confinement, both ovaries were found to be transformed into nodular carcinomatous tumours each larger than a child’s head; in none of these ovaries was any normal stroma to be found. Ruge reports the case of a woman 36 years of age, who miscarried in the sixth month of pregnancy; she had myxo-sarcoma of both ovaries, one weighing 5620 grammes the other 480 grammes.
All these cases indicate that, notwithstanding the existence of extensive degeneration of both ovaries, some minute remaining fragment of healthy ovarian stroma is competent to produce normal mature ova—a fact which has often been proved also by microscopical examination. That under the influence of pregnancy, existing ovarian tumours often take on extremely rapid growth, is also indicated by some of the above cases.
Castration (oöphorectomy, spaying, Battey’s operation), the removal of both ovaries, naturally results in sterility. If in the literature of the subject cases are to be found in which, after this operation, not menstruation merely, but even pregnancy has occurred, this is to be explained either by the fact that in the stump there was left a fragment of the ovary, still containing tissue capable of producing mature ova; or else by the existence of a supernumerary ovary. Schatz reports the case of a woman in whom pregnancy occurred after double oöphorectomy. In the month of February, 1880, this operation was performed on a girl twenty years of age; she married in April, 1884; and in May, 1885, she was delivered of a mature female infant. The history of the case and the details of the operation showed clearly that the left ovary had been completely removed, with the outermost third of the left Fallopian tube; the right ovary was cut away in such a manner that a strip of tissue of at most two millimetres (one twelfth of an inch) in width was left in the body, whilst the right Fallopian tube was left intact. This case teaches us that the smallest remnant of the ovary is competent to render normal pregnancy possible; and further, that a small size of the ovary no more constitutes a hindrance to the proper reception of the ovum in the Fallopian tube, than does an abnormally large size of the ovary, or an unusual shape of this organ.
Miklucho-Mackay relates that among the indigens of Australia the removal of the ovaries is often practised, in order to create a special kind of hetairæ incapable of becoming mothers. McGillivray saw at Cape York a native girl whose ovaries had been removed because she was a congenital deaf-mute, with the object of preventing her giving birth to deaf-mute infants. In the beginning of the last century there existed in Sayn-Wittgenstein a small religious sect whose custom it was always to conclude their religious services by indiscriminate carnal union among the members of the community; when women and girls were first admitted as members of this sect, an attempt was made to render them unfitted for conception “by means of a painful and dangerous compression of the ovaries.” (Ploss.)
A transient, relative hindrance to ovulation may be brought about by various pathological states of the ovaries. Acute oophoritis usually suspends the ovarian functions; chronic oophoritis has sometimes a similar effect, not only because the profound changes that take place in the ovary hinder the formation of the ovules, but also because, as we shall later explain more fully, the expulsion of the ova and their reception by the Fallopian tubes are hindered. In severe oophoritis and perioophoritis, more especially in parenchymatous inflammation, sterility may be brought about by an absorption of the finely granular contents of the follicles, which collapse, with adhesion of their walls; when all or most of the follicles are thus affected, the ovaries become small and hard.
In perioophoritis, the exudation leads to the formation of cord-shaped or ribbon-shaped adhesions between the ovaries and the broad ligaments, the uterus, and the peritoneal folds of the neighbourhood. The ovary in such cases may also be displaced, or may undergo atrophy from pressure.
In the case of 200 sterile women, I found in 46 instances chronic oophoritis and perioophoritis. Olshausen reports that of 12 married women suffering from chronic oophoritis, five were barren, whilst of the remaining 7, three only had given birth to more than one child. Matthews Duncan, on the other hand, saw pregnancy in a case of bilateral ovarian inflammation, in which the organs were considerably enlarged.
Further, local or general peritonitis may lead to parenchymatous inflammation of the ovaries, and this, spreading from the periphery towards the centre of the organ, attacks the follicles irrespective of their ripeness. Again, during the puerperium, the interstitial form of oophoritis is by no means rare, and this may at times lead to permanent sterility in either of two ways: it may be in consequence of the onset of a secondary parenchymatous inflammation, which destroys all the follicles; it may be because a thick and tough layer of sclerosed tissue forms around the periphery of the ovary, which mechanically prevents the maturation and rupture of the follicles. According to Slavjansky, puerperal disease is the principal cause of this form of oophoritis. Olshausen indicates as the most frequent cause of primary perioophoritis, an inflammation propagated from the Fallopian tubes, leading to the formation of masses of exudation, which envelop the ovary, and by the pressure they cause, and by interfering with the blood-supply, lead to atrophy of the gland.
Sometimes the chronic inflammatory induration by means of which the stroma of the ovary is rendered denser and firmer, is due to changes in the vessels, and depends upon valvular defects of the heart—upon venous congestion. In this way, heart disease may hinder ovulation and bring about sterility. Both syphilis and gonorrhoea may give rise to chronic inflammatory changes in the ovary, usually leading to premature contraction of the tissues and to the formation of numerous adhesions. According to Olshausen, amenorrhœa is not a common feature of ovarian disease, except in cases of defective development of these organs, of cirrhosis of the ovaries, and of bilateral new-growths. Disease affecting only a single ovary, even tumour of considerable size, rarely causes amenorrhœa until profound constitutional disturbance has ensued. An exception to this rule is found in the case of carcinomatous tumours of the ovary; these, indeed, are commonly bilateral; but even when confined to a single ovary, amenorrhœa is a comparatively early symptom. According to the same author, sterility is a common consequence of chronic oophoritis and its sequelae, and is usual also in cases of bilateral new-growths; on the other hand, tumours affecting a single ovary often fail to prevent conception even though they have attained a great size.
Syphilis in women must be regarded as a frequent cause of sterility, by interference with ovulation, but is in this regard by no means an absolute bar to the occurrence of pregnancy. According to Parent and Duchatelet, under whose observation during the space of 12 years there came annually an average number of 2625 syphilitic prostitutes, the average annual of births in these cases was 63 only. According to Marc d’Espine, 2000 prostitutes gave birth on an average to two or three children in all during a year. (That there are other causes besides syphilis for the remarkable infertility of women of the town, will be explained later). According to Bednar, Mayr, and others, constitutional syphilis in women invariably leads to sterility; others, as for instance Zeissl, believe that women suffering from inveterate syphilis are commonly, but not invariably, sterile; whilst according to Rosen, conception only takes place in syphilitic women in whom the disease has passed into the tertiary form. Experience shows, however, that neither early nor late forms of syphilis necessarily lead to sterility in women. It must also be pointed out, that syphilis in the male may be the cause of sterility, and must be the cause thereof when the disease is localised in the testicles, and the consequent degeneration of the glandular substance leads to the occurrence of azoospermia, more particularly when syphilitic or gummatous orchitis is bilateral. According to Lewin, we fail to find spermatozoa in 50% of men, otherwise powerful, suffering from syphilitic dyscrasia. Hanc, on the other hand, failed to find azoospermia in any one of ten men suffering from lues. In animals also syphilis is said to cause sterility.
The manner in which certain anomalies of the blood (anæmia and chlorosis), general disturbances of the nervous system, febrile states, and such constitutional disorders as scrofula, have a temporary or permanent influence in checking ovulation, is far from being understood; but the fact that ovulation is checked by such conditions, has been established beyond question by numerous observations. It is well known that severe fevers, more especially typhoid, suspend the ovarian function; that in various chronic disorders of an enfeebling nature, and notably in chlorosis, all signs of menstrual activity disappear; and that in certain nutritive disturbances, as in extreme obesity, amenorrhœa also occurs; finally, numerous cases are on record in which some sudden affection of the nervous system has instantaneously inhibited ovarian activity.
In anæmia and chlorosis, it is probable that the degree of menstrual congestion is insufficient to ensure the bursting of the graafian follicle. The sterility often observed as a sequel of typhoid, malaria, the acute exanthemata, cholera, and septicaemia, is probably due in most cases to the occurrence of parenchymatous oophoritis, with consequent destruction of the ovarian follicles. The researches of Slavjansky have shown that in acute disorders inflammatory changes often occur in the graafian follicles. When infectious disorders ran an acute course, this observer usually found that the parenchymatous inflammation of the ovary had occurred near the periphery, in the cortical layer, the destruction being limited almost exclusively to the primitive follicles; when the course of the primary disorder was more chronic, the mature or nearly mature graafian follicles were the ones destroyed. When inflammation of a follicle has led to its destruction, it is replaced by a linear scar. Lebedinsky found similar changes in the ovary after scarlatina—destruction of a lesser or greater number of follicles, with formation of scars. Thus, parenchymatous oophoritis as a sequel of acute diseases, may, if severe, lead to destruction of all the rudimentary follicles, with consequent sterility. In the post mortem examination of such cases, the condition of the ovaries is similar to that which is elsewhere in this work described as characteristic of these organs after the menopause: the ovary is diminished in size, its surface is furrowed, the tissue is indurated in consequence of overgrowth of fibroid tissue; often not a single follicle is to be detected on section of the organ.
Immoderate obesity is a disorder of nutrition favoring the occurrence of sterility.
In very obese women of an age which normally is the reproductive prime, amenorrhœa or scanty menstruation is a very common accompaniment. In 215 such cases which came under my own observation, amenorrhœa was present in 49, and menstruation was scanty in 116; thus in nearly three fourths of these obese women menstruation was either deficient or entirely wanting. Very remarkable also is the high percentage of sterile women among the obese. In the 215 cases already mentioned (all married women), 48 were sterile—a percentage of 21. Whilst the ordinary ratio of barren to fruitful marriages is 1 : 10 or 1 : 9, in the cases in which the wives, or both wives and husbands, are extremely obese, the ratio is according to my own observations, 1 : 5—or, if we include cases of only-child-sterility, 1 : 4.
We cannot wonder at this great frequency of sterility in obese women when we remember that, apart from the menstrual deficiencies which so commonly accompany this disorder of nutrition, obesity is apt to entail many other disorders of the reproductive organs, as for instance a morbid state of the uterine and vaginal secretions, chronic metritis, and displacements of the uterus; still, it cannot be denied, that in many instances we are unable in such obese women to detect any disorder of the reproductive organs competent to account for the sterility, and we must therefore assume that the excessive development of fat has some direct influence in preventing ovulation, or at least that it in some way exercises an unfavourable influence upon the reproductive process.
That excessive obesity hinders fertility, is shown by experience both as regards the vegetable and the animal kingdom. All animal-breeders are familiar with the fact that undue production of fat limits fertility. Thus, equally in the case of turkeys and in the case of the common fowl, if the hens are overfed and become fat, they cease to lay.
Hippocrates already indicated obesity as a cause of sterility. Writing of the wives of the Scythians, he pointed out as a proof that their excessive obesity was the cause of the sterility from which they commonly suffered, the fact that their female slaves, who were thin, were readily impregnated by intercourse with the Scythian males. The oft repeated dwindling and disappearance of ruling families in India and in Egypt, has doubtless in part depended upon the extreme obesity of the female consorts of such rulers.
In many instances, indeed, a great accumulation of fat on the front of the abdomen and in the vulva, suffices to cause a simply mechanical hindrance to the proper performance of a fertilizing coitus. It is possible also that the phlegmatic temperament of very fat women is a contributory cause to their sterility—if indeed it is in general true that frigidity during sexual intercourse is unfavourable to conception, as is expressed by the old proverb, quo salacior mulier, eo foecundior. It is unquestionable that in very obese women sexual sensibility is commonly greatly deficient, and that their husbands often complain of their coldness and lack of passion. In several cases that have come under my observation, dyspareunia occurred in obese and sterile women.
The dependence of sterility upon obesity is often proved in the most striking manner ex juvantibus. A “cure” for the reduction of fat often results favourably in respect also of rendering the woman who undergoes it readily impregnable—a result by no means ardently desired.
It must also be pointed out that very obese women form a considerable section of those suffering from only-child sterility, and this largely in consequence of their strong predisposition towards abortion. As the impregnated uterus enlarges, the space for its accommodation is insufficient, owing to the great development of the panniculus adiposus, and thus obesity, like intra-abdominal tumour, predisposes to abortion. The excessive accumulation of fat within the abdomen, by exercising pressure upon the inferior vena cava or on its principal tributaries, hinders the venous return, and gives rise to a chronic stasis in the uterine bloodvessels, those alike of the muscle and of the mucous membrane.
Notwithstanding the fact that sterility is so common in very obese women, the fact remains that some such women are remarkably fertile, and have very large families indeed.
Towers-Smith, Duke, and Rodriguez, who have recently all been engaged in examining the relations between obesity and sterility, agree in asserting that sterility due to obesity may be cured by dietetic treatment for the relief of the primary disorder of metabolism.
Though menstruation is usually deficient or absent in obese sterile women, and though it is commonly supposed that amenorrhœa implies sterility, it is necessary to point out that whilst failure of menstruation is a frequent and important sign of suppression of ovulation, it by no means invariably has this significance. It is an established fact, and one borne out by my personal experience, that women who have never menstruated have nevertheless become pregnant; others, again, have become pregnant although they have ceased to menstruate for several years, and this has even occurred in women at a comparatively advanced age. Hence, from the fact that amenorrhœa exists, we cannot with certainty infer that a woman is sterile. Moreover, we must remember that physiologically amenorrhoeic women often enough conceive—during lactation. Although we hold the opinion that there is an intimate connexion between ovulation and menstruation, yet it is always possible in cases in which menstruation fails to occur, that ovulation has taken place, but that the stimulus which that process has exercised upon the reproductive organs has been insufficient to give rise to the customary flow of blood.
The following remarkable case came under my own observation: Mrs. B., 26 years of age, had lived in sterile wedlock for six years, had never menstruated, nor had she ever had any sanguineous discharge from the genitals. The body was delicately formed, the breasts were fairly well developed, the external genital organs showed no abnormality. For some weeks before consulting me, this woman, hitherto childless, and living in regular sexual intercourse with her husband, had noticed a remarkable enlargement of the abdomen. Another medical man whom she had consulted had diagnosed ovarian tumor and had urged operation. A more careful examination of the pelvis showed, however, that the woman was in the sixth month of pregnancy, a diagnosis which was duly confirmed by the delivery of a full-time child. In another of my cases, a woman married at the age of 45 years, having ceased to menstruate two years previously. She became pregnant and gave birth to a child in quite normal fashion. The following instructive case also came under my own observation: The wife of one of my colleagues, living in sterile wedlock for 17 years, extremely obese, had since puberty menstruated but scantily and with great irregularity. The menstrual interval was several months, and when the discharge did appear, it was pale in colour and small in quantity; it lasted moreover but a day or two. Last winter, the flow as usual failed to appear for several months, and since the woman had at the same time become fatter than ever, Turkish baths and energetic muscular movements were prescribed. The result of this treatment was a striking one—abortion. After 17 years of marital intercourse she had for the first time become pregnant.
In the case of sterile women who are amenorrhoeic, even when the amenorrhœa has never been interrupted by a menstrual discharge, or when it appears entirely dependent upon obesity, it is nevertheless necessary to be extremely cautious in making a diagnosis, and above all in employing an intra-uterine sound. In such cases I have known the most eminent gynecologists unwittingly bring about abortion.
Cleveland, Godefroy, Haschek, Ritschie, Sommerus, Stark, Taylor, and Young, have all reported cases in which pregnancy occurred in women suffering from amenorrhœa; but all such cases must be regarded as quite exceptional. Szukits examined 8000 sexually mature women, and found among them fourteen only who had never menstruated. Of these, four were multiparae.
Saint Moulin reports the case of a woman 24 years of age who had never menstruated, but who none the less became pregnant and gave birth to a fine girl. One of the most striking cases of this nature is the one reported by Rodzewitsch, regarding a woman who first began to menstruate at the age of 36 years. This woman had however been married when fifteen years of age, and in the subsequent twenty-one years she gave birth to 15 children, remaining the whole time amenorrhoeic.
Puech reports the case of a woman who ceased to menstruate at the age of 40 years, and remained amenorrhoeic for the subsequent six years. Then menstruation recurred for a year, and finally ceased definitively in consequence of the occurrence of pregnancy, which terminated in the normal birth of a healthy boy. Loewy, in a woman 31 years of age, who had previously been amenorrhoeic all her life, saw menstruation appear for the first time shortly after the birth of her sixth child. Ahlfeld had under observation the case of a woman who was the mother of eight children, and had never menstruated.
Krieger reports the case observed by Mayer, of the wife of an artizan, who between the ages of 17 and 28 years had given birth to five children, and had had one abortion. After the age of 22, she had no trace of menstrual discharge, but notwithstanding this, she subsequently gave birth to three children. Krieger himself saw a woman who had had her last child at the age of 33, and in whom now, at the age of 48, menstruation had just ceased entirely. Two years later, irregular menstrual discharges recommenced; when these ceased, it appeared that the woman was once more pregnant, and she was normally delivered of a full-time girl.
Renaudin relates the case of a lady 60 years of age who gave birth to a child, menstruation having ceased 12 years earlier. Deshhayes saw the delivery of a woman 50 years of age, two years subsequent to the occurrence of a normal menopause. Capwron, quotes the ease of a woman who became pregnant at the age of 65 years. In this case menstruation had recurred, having ceased many years before in a normal menopause. This woman aborted at three months, and the foetus was well-formed.
In such cases of late conception, which occur after the normal cessation of menstrual activity, we cannot be certain whether we have to do with a simple persistence of ovarian activity, associated with temporary or permanent cessation of menstruation; or whether both functions, ovulation and menstruation, had ceased, and were aroused to renewed activity by some determinate cause. It is possible that in coitus we have such a stimulus, capable of reawakening the slumbering ovarian functions. That this may be the case, we are led to suppose by the fact that pregnancy at an unusually advanced age most frequently occurs as a result of marriage late in life. In Scandinavian countries, where the difficulties of providing for a family are so great that a very large number of marriages are inevitably postponed till comparatively late in life, the number of pregnancies occurring in elderly women is correspondingly large. However, pregnancy late in life occurs also in women who have married early, and the most probable assumption to account for such cases is that ovulation has occurred in the absence of menstruation.
Although by these cases the proposition is established that amenorrhœa is by no means equivalent to incapacity for ovulation, still, the former must indubitably be regarded as in general a most important indication of disturbed ovulation. When a woman attains the age of 20 years without having ever menstruated, or even having experienced menstrual molimina, we may in the great majority of such cases infer with justice that there is complete or partial failure of development of the ovaries and the reproductive apparatus generally. In some of these cases, examination discloses the fact that the uterus is in an infantile condition. When we are able to bring about the regular establishment of menstruation, we may hope also to remove the sterility dependent upon the defective ovarian functional capacity. General tonic treatment for the relief of chlorotic amenorrhœa quite as often, in the case of previously barren married women, results in the occurrence of pregnancy, as happens in cases of amenorrhœa and sterility due to obesity, when this latter condition has been relieved and menstruation has been re-established by suitable dietetic treatment. Much less often is it possible to relieve the sterility of scrofulous (tuberculous) persons, for in the majority of such cases, in consequence of the scrofulous (tuberculous) constitutional disorders, pathological changes have occurred in the ovaries already in early youth, and these it is difficult or more often impossible to remove.
Scrofula (tuberculosis) is, according to my own experience, the constitutional disorder which of all most frequently and most seriously affects ovulation; and it appears that the ovaries are subject to changes produced by this disease similar to those which occur in other glandular organs. In cases in which no cause of the existing sterility is ascertainable, the presence of scars due to scrofulous (tuberculous) changes in the lymphatic glands may serve as an indicator to show that the capacity for ovulation has been annihilated or seriously diminished in early life by scrofulous (tuberculosis) disease.
Among the causes of sterility, these three conditions: anæmia, chlorosis, and scrofula (tuberculosis), play a leading part; indeed, their importance in this connexion has hitherto been underestimated, more especially in regard to the comparative frequency with which they cause sterility. A large part of the favourable influence in the relief of sterility in women which is exercised by the “cures” at various watering places, depends upon the amelioration which is thus effected in the aforesaid constitutional disorders.
It has been assumed that diabetes, which renders men impotent, is competent also to cause sterility in women. Hofmeier reports a case which appears decisive on this point. In a woman 20 years of age, who had menstruated regularly since she was 14 until a year previously, when the flow had ceased, he found the uterus extremely small, barely 5 cm. (2 in.) in length, extremely atrophied, the ovaries also atrophied and very small; the urine contained large quantities of sugar. Here was doubtless a case of atrophy of the reproductive organs secondary to diabetes.
In England, where the excessive use of alcohol is observed very frequently in women as well as in men, sterility has frequently been regarded as a result of chronic alcoholism. Matthews Duncan reports cases which lead to the belief that alcohol has a specifically deleterious effect upon fertility. Apart from the general or constitutional disturbances dependent upon the abuse of alcohol, this agent has in many cases a well-recognized pathogenic influence upon the female reproductive organs, the morbid condition which is most frequently and most readily assignable to this cause being chronic oophoritis. The obesity which so frequently results from alcoholic excess is a contributory cause of sterility.
Certain drugs, more especially quinine and morphine, are reputed to cause sterility. Davies, reviving an old opinion, considers that of all drugs tannin is the most effective in leading to sterility, and he considers tea-drinking as responsible for this effect.
The influence of certain cerebral affections and psychical disorders in checking ovulation has been established. Thus, de Montyel has recently shown that in families subject to hereditary mental disorders, there is an unusually large proportion (1 : 7) of barren marriages.
In addition, there are many influences which are known to prevent or to diminish ovulation in the case of the lower animals, and which may therefore be assumed with considerable probability to have a similar effect in women. More especially we are here concerned with external influences affecting unfavourably nutrition and innervation, and therewith also ovulation; also near kinship between the parties to the act of intercourse; and finally hereditary predisposition. In animals, captivity, exposure to cold, over-exertion, insufficient or unsuitable food, and inbreeding, have been proved to result in infertility.
Doubleday asserted that “a too abundant supply of nutriment hinders reproduction, whereas on the other hand insufficient or improper food favours reproductive activity and increases the number of the offspring.” Spencer, however, rightly points out that the infertility noticed in these circumstances is not the direct result of prosperity, but depends upon the pathological obesity which is thus engendered by overfeeding.
No less interesting are the observations that have been made regarding sterility in animals in confinement. In such animals there are wide differences. Some refuse to cohabit, or have lost sexual desire; others, again, show excessive sexual desire and cohabit too often, without any result; or even if fertilization occurs, abortion often ensues. In yet other cases, though conception follows intercourse, and the animals go on to full term before delivery, the young are still-born, or are weakly and misshapen. Caged birds often lay no eggs at all or very few; or if they do lay, they neglect their eggs; or if incubated, the eggs fail to hatch out. In France, experiments regarding this matter were made with domestic fowls. If the hens were given great freedom, 20 per cent only of the eggs remained unhatched; with less freedom, 40 per cent of the eggs were failures; whilst if the fowls were kept in a coop, 60 per cent of the eggs were unhatched.
“Convincing proofs,” writes Darwin, “have been obtained to the effect that wild animals which have recently lost their freedom have their fertility diminished to a most remarkable extent. This infertility is not dependent upon any degeneration of the reproductive organs. There are many animals of the most diverse species, which, whilst they copulate freely in confinement, fail in these circumstances to conceive; others again, even if they conceive and have living young, give birth to these in numbers which are unquestionably much smaller than would be the case were the parents in the free state.”
Interesting observations have been made by pigeon breeders. They state that when pigeons brought up in the same nest pair, the number of their offspring is usually very small.
The influence upon fertility of unfavourable conditions of temperature, either excessive heat or excessive cold, is very great. In the case of pigeons, for instance, if the pigeon cot is adjacent to the heated wall of a dwelling house, the pigeons sometimes begin to lay as early as January, and may have young as often as eight times in a single year. When the dovecot is cold, on the other hand, the number of broods is smaller. In general, the procreative capacity is greater in summer than in winter.
As regards inbreeding, many facts are on record showing the influence of this practice in leading to the birth of malformed offspring and to sterility. Darwin writes, “if in a pure race, characterized by a certain tendency to sterility, we allowed only brothers and sisters to pair, in a few generations the stock would become extinct.” If animals closely related by blood pair, the number of their offspring is always less than the average.
In the case of the human species, however, the influence of the marriage of near kin in diminishing fertility cannot be regarded as definitely proved.
Occasionally the incapacity for ovulation and the sterility dependent thereupon are hereditary—paradoxical as this may appear. It is necessary to assume, that just as the sperm is at times unsuited for effective fertilization, so also the ova may be in a less or greater degree insusceptible of fertilization. In the present state of our knowledge, indeed, we are not in a position to be precise as to the exact nature of such incapacity. It is possible that the enveloping membrane of the ovum varies in its resistance to penetration, as Schenk claims to have proved in respect of certain of the lower mammals. In his experiments on artificial fertilization outside the body of the mother, he ascertained that the cells derived from the discus proligerus, surrounding the ovum in immediate contact with the zona pellucida, are in some instances easily separable one from another, so that the spermatozoa can readily obtain access to the zona pellucida; whereas in other instances, in which the ovum is of the same size and apparently in the same stage of maturation as before, these cells remain closely attached each to the other, and thus prevent the passage of the spermatozoa. This condition of the ovum, so unfavourable to fertilization, may be hereditary in certain families, and its transmission may render certain members of the stock infertile. Such instances as the following from my own practice are by no means rare. Of three sisters, whose family life was intimately known to me, one had one child only, a girl, whilst the two others remained childless. The girl of the second generation married and remained childless. In England it is well established that when, in cases of only-child-sterility, the offspring is of the female sex, this child will probably herself be barren. Galton found that in the case of 14 heiresses (i. e. the only children of wealthy parents), all of whom were married, 8 remained absolutely barren, whilst of the others, 2 had each an only child.
It was formerly believed that when a woman gave birth to twins of opposed sexes, the female infant would prove to be barren, this barrenness being associated with defective development of her reproductive apparatus. John Hunter (Animal Economy) ascertained that in the case of twin calves of opposed sex, the genital organs of the female twin were almost invariably imperfectly developed. But the supposition that this is true also of the human species has not been confirmed by experience. I know several married women who had twin brothers, and these women have borne normal children; however, the number of their offspring is remarkably small. Simpson, in Edinburgh, recorded the results of the marriage of 113 women who had been born with twin brothers; of these, 103 had proved fruitful, and 10 (i. e., about one eleventh of the whole) barren, although of these latter women, one had been married upwards of 5 years, and the remaining 9 for periods ranging from 10 to 40 years. Simpson also gave the history of four women who were all the fruit of triple births, some of which had consisted of two boys and one girl, others of two girls and one boy. All four of these women were parous. Again, a woman who had been one of a quadruple birth (three boys and one girl), herself gave birth to triplets. A collection of all the figures accessible to me relating to this subject, indicates that about ten per cent of the women born in such circumstances prove barren—a ratio which corresponds closely with the ratio of infertility in general.
Interference with Conjugation, Conditions Preventing Access of the Spermatozoa to the Ovum.
A condition essential to fertilization is a material union between the sexual products of the male and the female respectively—the act of conjugation. Thus, all conditions which prevent the spermatozoa from obtaining access to the ova, bring about sterility.
Spermatozoon and ovum being normal, a great variety of pathological conditions may prevent the one from gaining access to the other. It is necessary for fertilization that the mature ovum should leave the ovary, enter the Fallopian tube, and there come into contact with the male sperm. Interference with any one of these essentials may lead to sterility.
Thus, the constitution of the ovum itself may be at fault; or the entrance of the ovum into the Fallopian tube may not be normally effected; defects in these earliest stages of the process of fertilization are precisely the commonest and the most important. The emergence of the ovum from the graafian follicle may be rendered difficult or entirely prevented by pathological states of the ovary; again, by inflammatory processes in the ovary, the tubes, or the ligaments, by developmental defects in the tube, and by obstructions in its interior, the entrance of the ovum into the tube, and its free passage along the tube may be prevented. Numerous abnormalities and diseases of the uterus may on the one hand prevent the entrance of the ovum into the uterine cavity, and on the other may prevent the upward passage of the spermatozoa to their goal. Amongst conditions competent to produce these effects we must enumerate: displacements of the uterus, structural changes in this organ and its annexa, and other congenital defects and acquired states; more particularly must be mentioned, uterus infantilis, acquired atrophy of the uterus, flexions and versions of the uterus, new-growths and inflammatory states of that organ, abnormalities in the shape or size of the cervix uteri, and, finally, all conditions of the vagina or vulva which hinder the proper performance of the act of intercourse.
In diagnosing the cause of sterility, in determining whether in any particular instance it is due to some hindrance to the indispensable conjugation between the male and female reproductive elements, we have in the first place to ascertain the presence or absence of any of the numerous conditions which interfere with the proper passage of the ovum from the ovary through the Fallopian tube to the interior of the uterus. The simpler mechanical hindrances to conception, such as displacements of the uterus, or tumours of that organ or its annexa, are easily recognized; and the same is true of atresia of the cervix uteri, and of congenital or acquired stenosis of the vagina. When obliteration or stricture of the genital tract exists, a very careful examination, visual, digital, and instrumental, must be made, rectal examination not being forgotten. Not infrequently, amenorrhœa is attributed to ovarian disease, and only subsequently on local examination is the cause ascertained to be hymeneal atresia, with haematocolpos; many a woman has believed herself to be pregnant, until examination has disclosed the fact that the hymen is still intact, and that coitus has hitherto been effected through the urethra. The importance of these stenotic conditions as causes of sterility must not, however, be overestimated, for, although they are common among the hindrances to conception, the obstacle is by no means always insuperable.
Morbid changes in the secretions of the genital passages, whereby the vitality of the spermatozoa may be destroyed before they have time to reach the ovum and effect fertilization, are hard to diagnose, for the conditions upon which such changes depend have not as yet been adequately investigated.
Diseases of the Ovaries and the Fallopian Tubes.
Among the conditions which, although the maturation of the ovum proceeds normally to a conclusion, may prevent conjugation between the male and female elements, we must in the first place consider an abnormal condition of the tunica albuginea of the ovary, a thickening of this membrane in consequence of inflammatory processes or of new formation of connective tissue, whereby the dehiscence of the follicle is rendered difficult or entirely prevented. Such thickenings of the ovarian envelope are the residue of perioophoritic processes.
Such a hindrance to conception may be permanent or transient, and thus the sterility dependent thereupon may be relative or absolute. Similar is the effect of inflammatory processes affecting the peritoneal investment of the uterus, the broad ligaments, and the peritoneum clothing the floor of the pelvis; these conditions, perimetritis, perisalpingitis, and pelvic peritonitis, resulting in the formation of thick and extensive pseudomembranous bands, or in less severe cases leaving merely slight adhesions and filaments, which drag the uterus and the ovaries out of place, and thus render conception difficult or impossible.
Perimetritic adhesions are apt to lead to dislocation of the tubes either forwards or backwards, and most commonly into the pouch of Douglas, thus giving rise to sterility. Rokitansky and Virchow already insisted on the great importance of perimetritic processes in causing sterility.
That congenital defects of the Fallopian tubes may lead to sterility, is indeed a possible, but certainly a rare occurrence. The defect may be unilateral or bilateral; or it may be that merely a portion of one tube may be wanting. Bilateral absence of the Fallopian tubes is usually associated with defective development of the uterus, while the ovaries may be apparently normal. Such a case is described by Foerster and Kussmaul. The vagina opened into the urethra, the uterus was not calibrated, and diverged above into two solid horns, to which the round ligaments and the ovaries were attached. A congenital cause of sterility is to be found also in atresia of the tubes, the abdominal extremities of which are closed; this condition is met with also in other mammals. It is also assumed, with less accuracy, that a supernumerary ostium tubae may lead to sterility, in consequence of the ovum, which has found its way into the normal ostium, returning into the abdominal cavity through the supernumerary orifice. An unfavourable influence upon fertility is exercised also by a form of hyperplasia of the tubes which sometimes arises in consequence of erroneous development at the time of puberty; the tubes, increasing unduly in length, become serpentine in form instead of being nearly straight; this tends to lead to accumulation of the secretions, and renders the passage of the ovum difficult. (Freund.) Yet another defect of development which, as Klebs has pointed out, may lead to sterility, is absence of the fimbria which normally retains the abdominal orifice of the Fallopian tube in proximity with the ovary, in which case these structures may be separated by a wide interval.
The entry of the ovum into the tube may thus be rendered difficult by abnormalities of the abdominal orifice of the tube or of the fimbriae; but still more is this the case when the mucous membrane of the tube is diseased. The fringed border of the tubal orifice has a distinct tendency to independent disease. As Klebs’s anatomicopathological studies have shown, inflammatory changes are common in this region, leading to contraction. The free margin of the tube then appears to be strictured by overgrowth of fibrous tissue on the serous surface, the opening being thus narrowed or even entirely closed, whilst the fimbriae themselves may be drawn within the aperture. In other cases, the ring of fimbriae is adherent to some neighbouring part, especially to the ovary itself, when this also is diseased. Further, on the fringed margin of the tube we see papillary growths, telangiectases, or oedema with formation of cystic cavities.
In the interior of the tubes also, pathological processes occur, catarrhal inflammations, haemorrhagic or purulent exudations, sealing up the passage completely. In some cases these exudations lead to great distension and even to rupture of the tube. Thus, among the causes of sterility must be enumerated: simple catarrh of the tube, with swelling of the mucous membrane; purulent catarrh, leading to its distension with pus—pyosalpinx; serous effusion into the tube, hydrosalpinx; and haemorrhagic effusion, haematosalpinx; further, that peculiar form of tubal inflammation, described by Chiari and Schauta under the name of salpingitis isthmica nodosa, in which hyperplasia of the muscular coat of the tube occurs at irregular intervals, so that it appears to be beset with nodes. Special mention must also be made of gonorrhoeal salpingitis, which will subsequently be described in detail.
Inflammatory states of the tube may hinder conception, either mechanically, by swelling of the mucous membrane, or by obstruction of the lumen of the tube by exudations, by injury or destruction of the ciliated epithelium, by lesion of the musculature of the tube, affecting its peristaltic movements—all these hindering or entirely preventing the passage of the ovum downwards or of the spermatozoa upwards; or, again, chemically, by the deleterious influence of many of the morbid secretions that are formed in these conditions upon the vitality of ova or spermatozoa. These inflammatory states of the tubes may also lead to stricture or obliteration of their abdominal extremities, or to displacement of the ostia, and thus lead to sterility; in other cases these same conditions, leading to distortion and displacement of the tube, may prevent the downward passage of the ovum while leaving possible the upward passage of the spermatozoa, and thus give rise to tubal gestation—a condition which we shall not now consider.
It must not be forgotten that tuberculosis of the genital canal attacks the tubes with especial frequency; in these organs we may find miliary tubercles, and more commonly diffuse caseous masses, completely filling the lumen of the canal. Finally we have to mention the diverse forms of saccular dilatation of the tubes (Ger. “Tubensäcke”), all of which possess the common pathological characteristics of enlargement of the tubes and their conversion into saccular cavities; the contents of these distended tubes may, however, be extremely various, and such conditions may depend upon manifold mechanical disturbances and inflammatory processes of the uterus and its annexa.
When we consider how common, during the sexual life of women, are perioophoritic inflammations, more or less intense, but often without severe symptoms (and hence apt to be overlooked); when we remember that the very process of ovulation and also the puerperal state furnish opportunities for slight or severe pelvic peritonitis to arise; and when we further take into account the frequency and importance of gonorrhoeal pelvic peritonitis—we cannot fail to admit that the results of these morbid conditions, such as adhesions between the ovary and the ostium tubae, or closure of the tube with consequent hydro- or pyosalpinx, must be reckoned among the principal causes of sterility. If the frequency and importance of these conditions is still underestimated, two reasons can be adduced for this: first, that the slighter degrees of intrapelvic inflammation often, as previously mentioned, elude diagnosis; and, secondly, that even when the treatment is expectant merely, the exudations are frequently absorbed, the adhesions give way, and the capacity for conception is gradually fully restored.
When considering the etiology of acquired sterility, especial attention must be devoted to gonorrhoeal pyosalpinx, the most important and the most dangerous of the morbid manifestations of gonorrhoeal infection in the female. Gonorrhoeal salpingitis and perisalpingitis are very serious affections, in the first place because they are apt to give rise to oophoritis and perioophoritis, as well as to pelvic peritonitis, and other local inflammatory states. The minuteness of the uterine orifice of the Fallopian tube, and the downward direction of the ciliary movement in the interior of the tube, combine to safeguard against the entrance of gonococci, but none the less they too often find their way up the tube, and small quantities of gonorrhoeal pus enter the pelvic cavity and give rise to inflammations, in which the ovary partakes.
According to Saenger, this gonorrhoeal disease of the uterine annexa is found with especial frequency in women either wholly sterile or affected with only-child-sterility, and is to be regarded as the cause of their infertility; “infertility is indeed the rule, fertility the exception, in all cases in which gonorrhoeal disease has passed upwards beyond the os uteri externum.” The same author maintains that, putting aside tuberculosis and actinomycosis, if, in a case of infective inflammation of the uterine annexa, septic infection can be excluded, and more especially when the disease affects both tubes, when it is reluctant to yield to treatment, and when relapses are frequent, we have no option but to believe that the affection is of gonorrhoeal origin.
In 155 cases of chronic inflammatory disease of the Fallopian tubes, von Rosthorn was able in 37 instances to prove that the affection was the direct result of gonorrhoeal infection.
Recently, however, Noble has published cases which lead us to believe that even pyosalpinx does not necessarily prevent the occurrence of pregnancy. In operating for the relief of a unilateral pyosalpinx, the uterus was opened, and a seven months’ foetus was removed. In another case, the autopsy on a woman who had succumbed to severe peritonitis arising immediately post partum, disclosed a large pyosalpinx.
Closure of the ostium may also be brought about by chronic metritis and endometritis, by chronic catarrhal states of the uterine mucous membrane, and in general by pathological changes in that membrane associated with local hyperaemia or abnormal secretions. In some cases, salpingitis with consequent sterility is the result of puerperal infection; and such a sequence of events is especially common after an abortion followed by retroflexion of the uterus, leading to elongation and kinking of the tubes.
An important hindrance to the entry of the ovum into the uterus is sometimes offered by uterine polypi or myomata; growing from the fundus, these may so fill the uterine cavity that the uterine orifices of the tubes appear to be completely occluded.
At times, also, quite small myomata, growing close to the tubes, may push these latter upwards, closing them, and thus giving rise to sterility; such myomata may also lead to saccular dilatation of the tubes, as occurred in the following case:
Mrs. S., aged 39 years, had one child when 20 years of age, but since then had been barren. For several years she had suffered from profuse menorrhagia. Owing to the enormous thickening of the abdominal wall, bimanual examination of the uterus was impossible; the vagina was relaxed, enlarged, and contained an excess of mucous secretion. The uterus was high up in the pelvis, anteverted, enlarged, movable, sensitive to pressure; the portio vaginalis was enlarged, soft, and excoriated; no tumour could be detected either in the uterus or in the uterine annexa. The menstrual flow recurred at intervals of from two to three weeks, lasting from one to two weeks, and being extremely profuse; menstruation was painful. Whilst the patient was under my observation an excessive menstrual haemorrhage came on quite suddenly, with slight rise of evening temperature (38.2° C.—100.8° F.), but severe general disturbance; there were paroxysms of intense abdominal pain, violent vomiting of greenish bilious masses, which after a time became haemorrhagic, the abdomen was tense and sensitive to pressure, there was cardiac weakness with general failure of strength; treatment proved unavailing, and the patient died in collapse on the third day. The autopsy disclosed: fibroma uteri submucosum, parietale, et subserosum, haematosalpinx dextra, pyosalpinx sinistra, peritonitis. The subserous myoma, of about the size of a pea, was in the middle of the fundus uteri; the submucous myoma, of about the size of a chestnut, filling the uterine cavity, sprang from the posterior wall of the body of the uterus; the intramural myoma, of about the size of a bean, was in the right wall of the corpus uteri. Both tubes were greatly elongated, exhibiting serpentine windings. The right tube was much distended, filled with sanguineous fluid; the left, partially collapsed, contained greyish-green purulent material, having an extremely offensive odour; some of this fluid had flowed through the ostium abdominale into the abdominal cavity. Death in this case ensued with great rapidity in consequence of rupture of the pyosalpinx, and evacuation of its contents into the abdominal cavity.
Cystic formations in the round ligament (hydrocele of the round ligament) sometimes lead to sterility. In the form of elongated tumours of about the size of a hen’s egg they may fill the inguinal canal, and even pass forwards into the labia majora. When as large as this, they demand operative interference. Hennig records a case in which such hydrocele of the round ligament was the cause of sterility lasting 14 years, the woman becoming pregnant after the tumour had been removed by operation. Similarly, infertility may depend upon solid tumours of the round ligaments—myomata, fibromyomata, or sarcomata.
Retro-uterine haematocele often gives rise to sterility. As a rule, prior to the formation of a blood-tumour in the pouch of Douglas, various menstrual disturbances occur, more especially menorrhagia; or it may be preceded by some puerperal disease, especially perimetritis, which by itself, indeed, seriously limits the fertility of the woman thus affected; but when haematocele is superadded, her child-bearing capacity is much more gravely impaired, owing to the permanent displacement of the uterus, to the perimetritic exudations, to the adhesions formed around the ovary, and to stricture or occlusion of the tubes. Still, sterility is by no means an inevitable consequence of haematocele.
By many it is assumed that in cases in which the tubes are perfectly normal, disturbances of innervation are competent to cause sterility (or tubal gestation). It is supposed that nervous influences affect the functions of the Fallopian tubes by leading to spastic contractures of the circular muscular fibres of these structures, or in other cases to paralysis; in this way nervous disorder may lead to the retention within the tube of the unfertilized (or already fertilized) ovum.
Diseases of the Uterus.
Pathological changes in the uterus may in various ways lead to sterility dependent upon prevention of conjugation (physical contact of the male and female reproductive elements). Thus, the incapacity for fertilization may, on the one hand, depend on hindrances to the passage of the ovum from the tube to the interior of the uterus; or on the other, on some abnormal condition of the vaginal portion of the cervix, whereby the passage of the spermatozoa from the vagina into the uterus is prevented; or, finally, upon displacements of the uterus or pathological structural changes in that organ, whereby the implantation of the fertilized ovum in the uterine cavity and its development therein are impeded.
The uterus may be entirely absent, but this is an extremely rare condition; much less infrequent is a rudimentary condition of that organ. In the latter case, it is either represented by a nodular rudiment, or else it is conical or bicorned; whatever its shape, it is a solid mass of muscular and connective tissue. In association with absence or a rudimentary condition of the uterus, the vagina also may be wanting, or may be represented merely by a small, blind pouch; the Fallopian tubes may in such cases either be normally developed or rudimentary. The number of instances of this kind that have been observed is very large (Kussmaul, Klebs, Cusco, Klinkosch-Hill, Cruise, Freund, Fürst, Engel, Gusserow, Nega, Kiwisch, Rokitansky, Braid, Jackson, Lucas, Duplay, Dupuytren, Renaudin, Crédé, Saexinger, and many others).
The uterus and the vagina may be absent in cases in which the vulva is developed in a perfectly normal manner, with a mons veneris projecting as usual, and covered with a proper growth of hair. Ormerod and Quain have reported cases of this kind, in which the external sexual characters were those of a fully mature, perfectly developed woman, but in whom the uterus and ovaries were entirely wanting.
These defects of development necessarily entail complete sterility. Sometimes during life the cause of the sterility is entirely overlooked, and only discovered by chance or in post mortem examination. Although the vagina usually shares to a marked extent in the defects of the uterus, and at puberty undergoes a rudimentary development merely, the marital intercourse of such individuals commonly appears to be perfectly normal. As a result of frequently repeated and vigorous attempts at intercourse, the rudimentary vagina becomes accommodated to the needs of the case; and even when the vagina is absent, the rudimentary depression by which it is represented becomes distended into a large blind sac capable of accommodating the erect penis. In other such cases, the penis finds for itself some abnormal channel, and the husband may continue to indulge in intercourse for a long period without discovering that there is anything unusual. Sometimes it is the urethra which becomes dilated and takes on in part the function of the vagina; in other cases intercourse is effected per anum.
The following most remarkable case came under my own observation. The patient’s husband was a physician, who nevertheless was in complete ignorance of his wife’s abnormalities. The woman was 26 years of age, of medium stature, somewhat obese, breasts moderately well developed, pubic hair well grown. She stated that before marriage she had menstruated regularly, and that it was only after she had married four years previously that menstruation had ceased—statements which were unquestionably false. She consulted me on account of amenorrhœa and sterility, which her husband believed to depend upon her increasing obesity. Examination showed that the vagina admitted two fingers and was 10 cm. (4″) in length; but it was completely blind, and the mucous membrane was strikingly smooth. On bimanual examination, only a rudiment of the uterus could be detected, a mass no larger than a hazel-nut; the ovaries could not be felt.
A similar case is recorded by Heppner. A Finnish peasant woman 31 years of age consulted him on account of amenorrhœa and sterility. She had been married for 12 years, and neither before marriage nor since had menstruated or had had any periodic vicarious bleeding. The pubes and the labia majora were thinly covered with hair; the latter were very flaccid and but slightly prominent; the nymphæ hung down like an apron for as much as an inch below the genital fissure, and were very thin; the clitoris was but slightly developed. The urethral papilla was of normal size, the lacunæ around it were extremely well marked; the urethral orifice had the form of a zigzag slit. Behind this latter was an aperture environed by radiating folds, and this was the entrance to a blind passage about two inches in length; this aperture could not, however, be identified as the introitus vaginae, for the reason that there were no carunculæ myrtiformes, and moreover the callosity of the mucous membrane characteristic of the vaginal orifice was wanting. Behind the strongly projecting commissura labiorum, however, the fossa navicularis appears as a separate depression. The blind passage was clothed with a soft, pale-red mucous membrane, and was entirely devoid of any trace of columnæ rugarum; at the extremity of this passage there was neither scar nor induration. On rectal exploration, no trace of uterus, normal vagina, or ovaries could be felt, notwithstanding the fact that the abdominal walls were very flaccid and examination was therefore easy. The general configuration was feminine, the breasts were flabby and dependent, the waist and hips were those of a woman.
Tauffer reports the case of a woman 25 years of age, married 2½ years, absolutely amenorrhoeic; on examination she was found to have atresia vaginae with rudimentary development of the uterus. The breasts were small, the mons veneris was deficient in fat, but thickly covered with hair, the labiæ and the clitoris were normal.
R. Levi describes a case in which, in a patient 19 years of age, the uterus was wanting, though the general physical development was that of a normal woman. The breasts were well formed, and so also were the external genital organs; a blind passage 4 cm. (1.6 in.) in length, and admitting two fingers, represented the vagina. In the position normally occupied by the ovaries, were two bodies which were doubtless the rudiments of these organs. Menstrual molimina had never been experienced.
Von Hoffmann, in making a post mortem examination on an elderly married woman, found that the vagina ended blindly at a depth of 6 cm. (2.4 in.), whilst the uterus was represented merely by a pyramidally arranged bundle of fibres in the broad ligament. Lissner reports a case in which the physician was the first to draw the husband’s attention to the fact that his wife had no uterus.
Ziehl, in a married woman 57 years of age, found that the uterus was completely wanting; the vagina ended blindly half an inch from the surface; the tubes and ovaries were present. Boyd, in a married woman 72 years of age, found a blind vagina half an inch in length, and the uterus represented by a nodular rudiment on the posterior wall of the bladder.
Rare cases are also recorded in the literature of the subject, in which, notwithstanding the absence of the uterus, normal ovaries were present, and in these latter periodic ripening of the graafian follicles took place. A case of this kind was described by Burggraeve.
Complete sterility is entailed also by a persistence of the foetal condition of the uterus. In these cases, the uterus retains the form it possessed at the beginning of the second half of intra-uterine life. The portio vaginalis projects but slightly into the vagina, and the os uteri externum appears as a small rounded opening. The cervix is comparatively long and wide, and the folds on the mucous membrane of the cervical canal are fully formed. The body of the uterus is imperfectly developed, triangular in shape, with thin walls; it is shorter than the cervix, and its interior is marked by folds of mucous membrane converging towards the os. In these cases menstruation is absent or scanty; the other reproductive organs, including the breasts, are usually in a state of arrested development. Women with foetal uterus are capable of sexual intercourse, and carry on most of the functions of their sexual life in a manner apparently normal; they are, however, invariably sterile.
An analogous cause of sterility is presented by the condition known as uterus infantilis, in which at puberty the uterus fails to undergo the changes proper to this period, and remains in the condition characteristic of infancy. The cervix is disproportionately large, whilst the body of the uterus is cylindrical in form, and the mucous membrane lining its cavity is always smooth. The muscular substance is unduly thin. The vagina may be normal, sometimes, however, it is narrow, and the mucous membrane is less rugose than normal. Associated with an infantile condition of the uterus we find commonly, but by no means invariably, imperfect development of the external genital organs, the labia, the clitoris, and the vagina; the mons veneris is but thinly covered with hair; the breasts are small. As a rule, menstruation is entirely wanting. Occasionally the ovaries are wanting. This infantile condition of the uterus is by no means extremely rare. According to Beigel’s figures, among 155 sterile women, in four the uterus was infantile.
Among 200 cases of sterility in which it was possible for me to make a searching enquiry for the cause, I found 16 instances of infantile uterus. Neither in the general physical configuration of these women, nor in the state of their menstrual functions, was there any striking abnormality; in the condition of the external genital organs, however, in cases of defective development of the uterus and ovaries, certain striking peculiarities were, in my experience, almost invariable, and deserving therefore of close attention. The mons veneris was extremely small, sometimes completely bald, or covered very thinly with hair; and the hair when present, did not exhibit the curliness usually seen in the pubic hair of married women. On examination, the uterus, small in all its diameters from arrest of development, could in every case be detected.
How exceptional it is in adult females with well developed internal reproductive organs for the pubic hair to be scanty or completely wanting, has been shown by the investigation recently made by R. Bergh on this hitherto neglected subject. In 2200 individuals engaged in clandestine prostitution, he found the pubic hair extremely scanty in 148, and the genital region nearly or completely bald in 6. He states that early vigorous growth of the pubic hair is a trustworthy sign of early sexual development; but he remarks that the opinion of Aristotle that women in whom the pubic hair is slight or absent are always sterile, is erroneous.
Note.—The author’s statement regarding the extreme infrequency of absence or deficiency of the pubic hair in women with properly developed internal reproductive organs, while true of European women, does not apply to all races. In Japanese women, for instance, the pubic hair is as a rule much scantier than in European women; and baldness, complete or nearly complete, of the mons veneris is by no means uncommon. It is the exception, in Japanese prostitutes, to find a thick and vigorous growth of genital hair.—Transl.
In the Talmud, there is an interesting reference to this subject, to the effect that it may be assumed that a woman is sterile if by the 20th year of her life the pubic region be not yet covered with hair, if the breasts be not developed, if coitus be difficult, and if the tone of the voice be masculine.
Madame Boivin, Dugès, Lumpe, and Pfau, maintain that the development of the uterus from the infantile condition to that characteristic of the sexually mature virgin, often occurs very late and very slowly; and that women in whom we find the uterus in an infantile condition, may later begin to menstruate and may become pregnant. It has been suggested that in these cases there has been confusion with primary acquired atrophy of the uterus. Still, that it is necessary to be most cautious in cases of infantile uterus in asserting that a woman is permanently sterile, has recently been forcibly impressed on me by a remarkable instance. A married woman consulted me some years ago on account of amenorrhœa and sterility; examination showed clearly that the uterus was in the infantile condition, and for this reason, not I alone, but several leading gynecologists, assured her that there was no hope of her ever becoming a mother; recently, however, after ten years of sterile wedlock, she was safely delivered of a healthy child.
A sub-variety is constituted by the uterus pubescens, a uterus which indeed at puberty has undergone a certain degree of development, but has failed to attain the normal size; in such cases the menses are regular, but sometimes painful. This form of arrest of development of the uterus may occasion sterility, which, however, often proves curable when by frequent sexual intercourse and the congestion dependent thereon, the genital organs have been stimulated to the completion of the process of development; the muscular strength of the uterus then becomes adequate, and the dysmenorrhœic troubles disappear. In general it may be said that if the rudimentary or imperfectly developed uterus is at all competent to carry out the function of gestation, the necessary changes sometimes occur in the organ with remarkable rapidity, and result in normal pregnancy and parturition.
Uterus unicornis, when occurring alone, and not associated with other defects or errors in development, is not a cause of sterility. Women with a uterus unicornis, with or without an accessory horn, menstruate, conceive, and pass through pregnancy and parturition, in a perfectly normal manner; indeed, some women with this developmental defect have given birth to twins. The assumption that uterus unicornis predisposes to abortion does not always hold good. If, however, pregnancy occurs in a rudimentary horn, rupture of the membranes is inevitable, and the ovum or embryo passes into the abdominal cavity, with the usual accompaniment of fatal haemorrhage. The rupture commonly occurs between the third and the fourth month of foetal life (months of four weeks each).
The uterus bicornis, with which may or may not be associated duplication of the vagina, does not as a rule offer any hindrance to conception; and the same statement is true also of the uterus bilocularis or septus. Women with these defects of development may give birth to healthy children; and some such women have had twins, each foetus occupying a separate half of the uterus. Still, births in cases of double uterus and vagina are rare occurrences. Such cases have been published by Lasarewitsch, Litschkus, and Készmarsky. In very rare cases of uterus bicornis associated with double vagina, an obstacle to conception is offered by the fact that one side only of the double vagina, the larger, is utilized in sexual intercourse, and that this is a blind passage.
In cases of uterus bilocularis seu septus, the conditions as regards pregnancy and parturition are similar to those that obtain in cases of uterus bicornis. The twin uterus, uterus didelphys, the condition in which the uterus is represented by two completely separated halves, each of which has developed into an independent organ, has been observed, as P. Müller has shown, in adults as well as in infants; this condition offers no obstacle to conception, unless, indeed, as occurred in a case of Tauffer’s, the vagina is rudimentary, so that normal sexual intercourse is impossible. Satschoma reports a case of uterus didelphys in which pregnancy occurred simultaneously in both uterine cavities.
A careful distinction must be made between the congenital condition known as the infantile uterus (i. e., congenital atrophy) and acquired atrophy of the uterus, affecting the whole organ, or either of its segments, the body or the cervix; the latter condition may offer merely a transient and curable obstacle to conception.
Acquired primary atrophy of the uterus occurs in weakly girls who, just before the age at which the uterus normally undergoes its transformation into the adult state, have suffered from constitutional disorders, from chlorosis or anæmia, or from some other exhausting affection. The uterus is then small, limp, and flaccid, it is usually anteflexed, with a small, often insignificant portio vaginalis; the anterior lip of this structure failing to project from the vaginal fornix; the vagina is usually short and narrow. This form of atrophy of the uterus is distinguished from the foetal and from the infantile uterus more especially by the fact that no disproportion exists between body and cervix, that the muscular wall is better developed, and that the general configuration of the uterus is rather that characteristic of the normal uterus of the sexually mature woman. Persons with primary atrophy of the uterus, are, moreover, backwards in the general development of their sexual characters; the breasts are small, the pubic hair is scanty, the menstrual flow is insufficient or entirely wanting, whilst severe dysmenorrhœal manifestations are usual.
In favourable circumstances, when the constitution becomes more powerful, in these cases of primary atrophy of the uterus, improvement takes place; the uterus undergoes further development, menstruation becomes more abundant, and the woman may become pregnant. Such a favourable prognosis cannot, however, be entertained if a severe flexion of the uterus is associated with the atrophy of the organ; or if the ovaries are also atrophied.
Sterility results also from puerperal atrophy of the uterus. This condition is a sequel of severe puerperal diseases, metritis, parametritis, and perimetritis; sometimes, even in the absence of such inflammatory processes, it is due to puerperal hyperinvolution, occurring especially in women previously weak in constitution, and manifested by the fact that, notwithstanding the weaning of the child, the menstrual flow remains for months in abeyance. The uterus loses its firm consistency; it is sometimes shortened, sometimes of normal length, but the walls are always greatly thinned, so that, as Schroeder points out, the sound can be readily felt, through the abdominal wall. Puerperal atrophy is a curable condition, so that the sterility dependent upon this disease is not necessarily permanent. Thus, in a case of P. Müller’s, a woman in whom a twin delivery had been followed by extreme atrophy of the uterus, with well-marked symptoms both objective and subjective, became once more pregnant eighteen months after the termination of the twin pregnancy.
Other forms of atrophy of the uterus have a similar deleterious effect to that exercised by puerperal atrophy, as, for instance, atrophy from the pressure of tumours of the uterus, or of solid ovarian tumours; or, again, atrophy due to defective innervation of the pelvic organs, occurring in various forms of paralysis, and characterised by amenorrhœa and extreme smallness of the uterus. Von Scanzoni has seen several cases in which young women, previously healthy and menstruating with regularity, have been attacked by paralysis of the lower extremities, and thenceforwards have suffered from amenorrhœa and great contraction of the uterus; in some of these cases a post mortem examination was made, and disclosed the existence of true atrophy of the uterus. Jaquet saw a similar case of atrophy of the uterus in a lady who had been frightened by witnessing the storming of a barricade in front of her dwelling; she was then in her 22nd year, and had given birth to her second child 1½ years previously; thenceforwards she was completely amenorrhoeic, and her uterus measured only 3 cm. (1.2 in.) in length.
Displacements of the uterus (flexions and versions), and abnormalities in the cervix uteri, are among the conditions which lead to sterility by interfering with conjugation—by preventing the necessary physical contact between the male and the female reproductive elements. The frequency with which these diseases give rise to sterility is, however, far from being so great as is commonly asserted by those who maintain a mechanical theory of conception.
Pathological Changes in the Cervix Uteri.
In very early times, the attention of physicians was directed to abnormalities in the shape of the cervix uteri, as offering hindrances to the entry of the semen into the uterus. Amongst the writers of antiquity who have alluded to this matter, the names of Hippocrates and Soranus must especially be mentioned.
The normal cervix uteri (Fig. 72) has the form of a flattened ellipsoid, perforated throughout its longitudinal axis. On making a longitudinal section of the cervical canal, we see that it is dilated in the middle, and tapers towards either extremity, having thus the shape of a spindle; the internal os is, however, somewhat smaller than the external. The latter (os uteri externum, os tincæ, often referred to without qualification as “the os”), has normally the form of a transverse fissure, which, however, tends more towards the circular form, the smaller it is, and the more widely its margins are separated. In childhood, in consequence of the infolding of its margins, the external os has usually a radiated form, later it becomes rounded, and only with the attainment of sexual maturity does it assume the form of a transverse slit. This form is maintained throughout the epoch of active sexual life; but after the climacteric, owing to the separation of the margins of the orifice, it becomes once more rounded.
With regard to the greatly varying size and shape of the portio vaginalis, it may be said that in general its anterior lip appears the shorter of the two, owing to the lesser depth of the anterior vaginal fornix, but that in reality the anterior wall of the cervical canal is longer than the posterior; the actual length of the anterior lip of the portio vaginalis, measured from the summit of the anterior fornix, is from ½ to 1 cm. (0.2 to 0.4 in.), whilst the posterior lip, from the summit of the posterior fornix to the end of the lip measures 1½ cm. (0.6 in.) and upwards. The position of the cervix is such that, owing to the oblique direction of the long axis of the uterus, superadded to the absolutely greater length of the anterior lip of the cervix, the plane across the extremities of the two lips faces almost straight backwards. The axis of the portio vaginalis forms a right angle with the axis of the vagina; the cervical canal, however, is not usually straight, but has a slight S-shaped curvature. The mean length of the cervical canal in the virgin uterus is 3 cm. (1.2 in.). (Lott.)
The “ideal” form of the cervix uteri and of the os uteri externum is described by Sims in the following terms: “The vaginal portion should measure about one fifth, certainly not more than one fourth, of the entire length of the cervix uteri; that is, the anterior lip should have a length of one-fourth to one-third of an inch, and the posterior lip should be a fraction longer. The cervical canal should either be straight, or have a forwardly directed curve; the cervical axis should form a right angle with the vaginal axis; the cervix should not be markedly anteverted or retroverted.” Sims is of opinion that every woman whose uterus is in this condition will conceive within three or four months from the time when she first enters upon conjugal intercourse; he adds, however, the important proviso, “be it understood, that all else is in order.”
In conception, the cervix uteri subserves the important function of providing for the free passage of the spermatozoa to the interior of the uterus; and when we consider the nature of the processes of sexual intercourse and fertilization, and more especially when we bear in mind that normally the two lips of the cervix and the upper segment of the vagina form a chamber for the retention of a portion of the seminal fluid in contact with the os uteri externum, we are readily led to assume that any great abnormality, in size of the cervix (enlargement or diminution), in its shape (malformation), or in its position (displacements—flexion, version, or prolapse), or, finally, stenosis of the cervical canal,—may offer mechanical hindrances to conception. And experience shows that this assumption is justified, at any rate as regards conical elongation of the portio vaginalis (Fig. 73), as regards an apron-shaped or beak-shaped hypertrophy of the anterior lip of the cervix (Figs. 74 and 75), as regards flexion upwards of the elongated cervix, and also as regards stenosis or obliteration of the external or the internal os; although the reservation must be made that no matter how unfavourable the shape of the portio vaginalis, no matter how extensive the changes in the cervix uteri, as long as a permeable upward passage for the spermatozoa exists, conception is still possible, and in exceptional cases may occur.
When the cervix is hypertrophic and greatly enlarged, and the vaginal fornix consequently much elongated, conception is rendered difficult, for the reason that in such cases, either the semen rapidly flows out of the vagina, or else a proper juxtaposition between the penis and the external os no longer occurs, and the semen is ejaculated at some distance from the os. The change in the shape of the portio vaginalis, and also the elongation of the cervical canal, are additional obstacles to the entrance of the spermatozoa into the interior of the uterus; as regards the former condition, in nulliparae the portio vaginalis is commonly conical, or pointed, whilst the external os is very small, thus rendering the passage of the spermatozoa a difficult matter; but in parous women, it is lobulated, owing to the presence of deep fissures, whereby the penis is conducted into the vaginal fornix, and the ejaculation of the semen in this locality is facilitated. Hence, such hypertrophy of the cervix and the portio vaginalis often coincides with the occurrence of sterility. The hypertrophy is less apt to cause sterility when it is limited to one lip of the cervix, unless, indeed, the affected lip (more commonly the anterior) is so greatly enlarged that it bends over and occludes the external os, whilst conducting the penis into the fornix and away from the orifice. Cases have been known in which a single lip of the cervix was hypertrophied to such an extent as to protrude between the labia.
The commonest malformation of the cervix is the conical cervix, when the cervix is not merely elongated, but tapering; associated with this condition is usually found a notable diminution in size of the os uteri externum. According to Sims we find “conical cervix in 85% of all cases of natural sterility.” According to the same author, even in the absence of the conical form of cervix, “sterility is probable in cases in which the portio vaginalis projects fully half an inch into the vagina; if the cervix projects more than one inch, sterility almost inevitably results; whilst if elongation is even greater than this, so that the vaginal portion measures from one and a half to two inches, sterility is absolutely certain.”
On the other hand, congenital smallness of the portio vaginalis, the condition in which this organ appears merely as a slightly projecting nodule on the upper part of the anterior wall of the vagina, the anterior vaginal fornix being almost non-existent, and the posterior fornix very extensive—a wide cul-de-sac—is also unfavourable to conception. The probable reason is that, in consequence of this deformity, the semen, after being ejaculated into the posterior fornix, flows away down the posterior wall of the vagina, without coming into contact with the short portio vaginalis.
According to Beigel, another frequent cause of sterility is to be found in the existence of the so called “apron-shaped” portio vaginalis, the condition in which, either from congenital deformity, or else from hypertrophy or some other disease, one lip of the vaginal portion is so formed as greatly to exceed the other in length.
In consequence of hypertrophy, the portio vaginalis may assume other, very various forms; in some cases it may increase in size to such an extent that it projects into the vagina as a thick, hard ball, and thus offers a serious obstacle to the reception of the semen; or, again, in the form of the elongated, slender cervix, it may become doubled upon itself, and in this way hinder the passage of the spermatozoa (Figs. 76 and 77). Deformities of the cervix due to hypertrophy of the portio vaginalis, rarely cause congenital sterility, but more commonly the acquired form; for such hypertrophy is hardly ever congenital, occurs but rarely in virgins, and is usually met with in married women who have had difficult deliveries, and consequently have suffered from uterine disease.
Another deformity of the vaginal portion of the cervix which is important in its relations to sterility is the “snout-shaped cervix.” Here the cervix is thinnest immediately at its insertion into the vaginal fornix, and thickens gradually below, so that the organ resembles a swine’s snout in form. As a rule, this deformity is due to diffuse hypertrophy of the connective tissue of the cervix, the result of chronic endometritis and cervicitis.
Fritsch, however, in two cases of characteristic col tapiroid, saw pregnancy occur after the relief of the previously existing uterine catarrh; in one of these cases the condition of the organs was virginal, so that it was hardly possible to believe that the patient was a multipara; even after she had had three children, the os uteri externum with difficulty admitted the passage of the uterine sound.
Pajot has devoted especial attention to the hindrances that are offered to the entrance of the spermatozoa by displacements of the cervix. In these cases, during coitus, the extremity of the glans penis is not in contact with the os uteri externum, but passes into a kind of cul-de-sac; in retroversion the posterior fornix; in anteversion, the anterior fornix; in lateral version, the lateral fornix of the side opposed to that towards which the lower extremity of the cervix points.
Complete absence of the vaginal portion of the cervix puts difficulties, though not very serious ones, in the way of conception, since the segment of the uterus which combines with the upper segment of the vagina to form a receptaculum seminis, is wanting. How important in predisposing to fertilization is efficient contact of the external orifice of the vaginal portion with the ejaculated semen during and immediately after intercourse, seems to be established by my own observation, that women of small stature married to men of average height exhibit much higher proportional fertility than women of average stature. In the case of these small women, the favourable circumstance is obvious, inasmuch as intimate contact is facilitated between glans penis and portio vaginalis. I have frequently heard complaints, from the husbands of such women, that a single coitus is sufficient to ensure conception; and again and again I have been informed by such women that they have had 10, 12, or 16 children. In one such instance known to me, the wife had been pregnant 23 times, and had given birth to 19 normal children. Contrariwise, women with a very long vagina, and with a high position of the portio vaginalis, do not so easily become pregnant.
Of special importance in the causation of sterility is stenosis of the cervical canal. This may be congenital, and then usually affects the whole length of the canal; or it may be acquired, being dependent upon inflammation of the mucous membrane. In these latter cases, the swollen follicles of the mucous membrane burst, and their granulating walls adhere. Other causes of acquired stenosis are trauma, severe operative procedures during parturition, puerperal inflammations, syphilitic ulceration, adhesion of the opposed granulating surfaces after operative measures (as, for instance, after severe cauterization, or after amputation of the portio vaginalis), and, in short, from scar-formations however caused.
General swelling of the tissues leading to stenosis occurs at the external os in hyperplastic uteri of virgin configuration; the small round orifice characteristic of the virgin uterus becomes narrowed, or even completely occluded, by the swelling of the tissues of the vaginal portion. True adhesion of the walls does not occur in these cases, but the minute aperture left by the swelling of the walls of the canal is plugged by the epithelium, so that a small blind depression in the centre of the portio vaginalis is all that remains of the cervical canal. Such a condition is seen with especial frequency in cases of prolapse of the vaginal portion, and is often erroneously regarded as an obliteration of the os uteri externum by epithelial adhesion (Klebs). Finally, stenosis of the cervical canal may be caused by tumours, and also by the flexions and versions of the uterus presently to be discussed.
Congenital atresia of the uterus is generally associated with other developmental anomalies of the reproductive organs. In some cases, all that is at fault is that the mucous covering of the vaginal portion passes uninterruptedly from one lip to the other; but in others, the cervix is unperforated throughout, and the vaginal portion is but slightly developed.
Acquired obliteration of the cervical canal may affect either the external or the internal os, with a shorter or longer portion of the rest of the canal. When very extensive necrosis of tissue has occurred, as a sequel of difficult delivery, the adhesion may include the adjoining segment of the vagina (utero-vaginal atresia).
The more marked the stenosis of the cervical canal, the smaller the passage by which the vagina communicates with the uterus, the more difficult will it be for the passage of the spermatozoa to be effected, so that of the millions of spermatozoa deposited in the neighbourhood of the os uteri, thousands will, as in normal cases, find their way to the uterine orifices of the Fallopian tubes. So much the more, then, is the contact between spermatozoon and ovum rendered difficult, and so much the more unlikely is it that conception will occur. Moreover, in consequence of the stenosis, there is retention of the cervical mucus, which becomes thick and glutinous, and offers a further obstacle to the passage of the spermatozoa. The unfavourable influence upon the possibility of conception is, finally, increased if, as is often the case, in association with the stenosis, the cervix becomes elongated and assumes a conical form (these secondary changes probably resulting from the inflammatory states of the cervix common in cases of stenosis); and an additional obstacle is offered to conception by the association with the stenosis of flexion or version of the uterus. It is in such complicated cases that we so often have the associated symptoms of dysmenorrhœa and sterility; the dysmenorrhœa being due to the fact that the menstrual discharge, if abundant, is unable to flow away with sufficient rapidity through the greatly narrowed cervical canal; exuding from the vessels of the uterine mucous membrane more rapidly than it can be discharged, it accumulates in the uterine cavity, and gives rise to painful contractions of the uterus.
Precisely what degree of narrowing of the cervical canal it is which constitutes pathological stenosis, is in practice by no means easy to define; and only in regard to extreme cases of pathological constriction can there be no possibility of dispute. In cases of congenital stenosis of the cervical canal, the diagnosis is very easy, for the os uteri externum is then always extremely small; often the aperture is no larger than a small pin’s head, a very fine probe can be passed through it with considerable difficulty and its passage is opposed all the way up to the internal os. But in cases of acquired stenosis of moderate severity, the diagnosis is often difficult. Owing to the small size of the orifice, and to the distensibility of the soft parts by which it is surrounded, exact measurements are impossible. When the os is with difficulty detected by the skilled finger, when the sound is not readily introduced by the experienced hand, slipping past again and again, and inserted only after repeated efforts—such an os is, as Olshausen insists, always pathological. The normal virgin os uteri permits the easy passage of a thick uterine sound with a diameter of 3 to 4 millimeters (⅛ to ⅙ in.); but there are cases in which, though a sound of this normal size can be passed, the os gives to the examining finger the sensation of being contracted. If, in such a case there is typical mechanical dysmenorrhœa with sterility, Olshausen considers that we are justified in assuming the existence of pathological stenosis of the os uteri, and in treating the case accordingly.
However, as Kehrer insists, it may be one of the greatest difficulties in diagnosis—a difficulty not always to be resolved even when all the attendant circumstances have received the fullest and most painstaking consideration—to determine whether in any individual case an anomaly of the cervix, such as stenosis of the external os or of the whole cervical canal, is or is not to be regarded as a cause of sterility. When stenosis is extreme, there need be no two opinions about the matter; the difficulty is in cases lying somewhere between a moderate degree of contraction and the lower physiological limit of smallness. Every experienced gynecologist will have seen such cases as Kehrer describes, in which before marriage the os appeared extremely small, and yet soon after marriage the woman became pregnant. For this reason we are justified, with O. Johannsen, in reverting rather to the functional than to the anatomical conception of stenosis, and in maintaining that so long as the cervical canal is sufficiently large to permit the uterine secretions to flow freely away, any stenosis that may exist is devoid of pathological significance. Only when the outlet for the uterine secretions is insufficient, so that the uterine cavity becomes distended (as manifested by an elongation of the canal in the supravaginal portion of the uterus, and by various disorders, amongst others chronic endometritis), is the stenosis with its consecutive dilatation of the uterus a serious obstacle to conception. “In such cases, the contractions of the uterus during coitus will not suffice to express the secretions it contains through the narrowed os, and the inevitable consequence of the incomplete evacuation of the uterus is that the aspiratory phase of the orgasm fails to occur.”
According to Winckel, stenosis of the external or of the internal os is a cause of sterility only in cases in which it arises from a follicular inflammation of the cervical mucous membrane; in such cases, the os, (internal or external, as the case may be), being greatly narrowed by the numerous retention cysts, offers an obstruction to the evacuation of the glutinous secretion of the follicles yet remaining open. This secretion may offer an insuperable hindrance to the passage of the spermatozoa; but in the absence of catarrh of this character, a moderate degree of contraction of the cervical canal will not prevent the outflow of the menstrual discharge, or the upward passage of the spermatozoa.
The experience of horse and cattle-breeders also shows the etiological importance of stenosis of the cervix in the production of sterility: and in the case of mares and cows who are unfruitful from this cause, artificial dilatation of the cervix has often been performed, with resulting restoration of fertility.
Swelling of the follicles of the mucous membrane of the cervical canal or of the cavity of the uterus, a condition which often results from cervical catarrh, will, equally with stenosis of the cervical canal, lead to sterility; pushing the mucous membrane before them, and becoming pedunculated, these swollen follicles ultimately enlarge to form polypi of the cervical canal or the uterine cavity, and may at times completely occlude the uterine canal. In Fig. 78 is depicted a polypus of this kind, which I removed from the cervix of a barren woman 30 years of age. On the apex of the polypus was a large ovulum Nabothi.
Long-standing cervical catarrh readily leads to stenosis of the cervical canal, and consequently to sterility. The swelling and hypersecretion of the cervical mucous membrane the more readily hinders the entrance of the semen, inasmuch as the mucous folds on the anterior and posterior walls of the cervical canal which combine to form the plicae palmatae are in the normal state already sufficiently prominent; but in cases of catarrhal swelling they may project to such an extent as completely to occlude the canal. Stagnation of the thickened secretion offers in these cases a further hindrance to the passage of the spermatozoa, a stagnation which becomes aggravated if in course of time the os becomes stenosed by overgrowth of scar tissue. Ultimately, also, in cases of chronic catarrh, a flexion of the enlarged and flabby corpus uteri readily occurs, and this imposes an additional difficulty in the way of conception.
It is for these reasons that those women who in girlhood have suffered from prolonged cervical catarrh, so often remain childless. The sequence of events is that already described: follicular catarrh, stagnation of secretions, stenosis of the cervical canal, enlargement and loss of tone of the uterus; the thin-walled, enlarged, and flaccid uterus ultimately gives way before the intra-abdominal pressure, bending back, usually, into the pouch of Douglas. Thus, retroflexion of the uterus is a common sequel of cervical catarrh (Hildebrand). In some cases of sterility dependent upon cervical catarrh, this sequence of troubles has not occurred, and it is merely the mucus in the canal which prevents the passage of the spermatozoa. B. Schultze reports the case of a woman who had lived for 13 years in sterile wedlock, but became pregnant after a single removal of the cervical mucus.
The significance of chronic cervical catarrh in the causation of sterility explains how it is that in many cases of barren marriage the blame ultimately rests upon the husband, who, when he married, was suffering from “latent gonorrhoea,” the inconspicuous relic of an acute attack, undergone, it may be, months and even years previously, and infected his wife with the disease. Such a gonorrhoeal catarrh is in women especially apt to assume a chronic form, and will then induce all the secondary morbid conditions previously described, and thus lead to sterility.
Gonorrhoea in women frequently results in sterility. In addition to the effect of cervical stenosis and of a morbid condition of the cervical mucus in preventing the upward passage of the spermatozoa, this disease may lead to many other changes inimical to fertility. Thus, gonorrhoeal infection in women often leads to inflammatory manifestations in the peritoneum, the perimetrium, and the parametrium, and to catarrhal changes in the Fallopian tubes (salpingitis, hydrosalpinx, pyosalpinx); these prevent the contact of spermatozoon and ovum, or cause pathological distortions of the walls or calibre of the tubes, which constitute permanent hindrances to the occurrence of conception. Young married women, whose husbands at the time of marriage were the subjects of incompletely cured gonorrhoea, and who shortly after marriage suffer from cervical catarrh, the discharge from the inflamed mucous membrane not infrequently having a suspicious greenish colour analogous to that seen in recent gonorrhoea in the male, often remain sterile for long periods, owing to this gonorrhoeal cervical catarrh, endometritis, and tubal catarrh. For the diagnosis in such cases, in addition to noticing the virulent character of the inflammation of the vulva, urethra, and vagina, we must invoke the aid of the microscope; and it will often be possible to decide at once that the inflammation is gonorrhoeal by finding Neisser’s diplococci enclosed within the pus cells of the cervical secretion.
The influence of “latent gonorrhoea” in diminishing the fertility of women has been especially asserted—and overestimated—by Nöggerath. From the fact that about 90% of sterile women are married to men who have suffered from gonorrhoea either before or during their married life, he infers that the sterility is due to latent gonorrhoea communicated from husband to wife. If this inference were justified, sterility would be far commoner than it actually is. Nöggerath makes use of the term “latent gonorrhoea” because the woman becomes infected without the obvious outbreak of any acute phase of the disorder. The disease remains latent, and a radical cure is not to be expected until the menopause. According to Nöggerath, there are four varieties of this disease: acute, recurrent, and chronic perimetritis, and oophoritis, always accompanied by catarrh of the mucous membrane of the genital organs.
Saenger, also, has asserted that 12% of all cases needing gynecological treatment are of gonorrhoeal origin; and he even considers that the consequences of gonorrhoea are in women more dangerous and destructive than those of syphilis. E. Martin has also maintained that endocervicitis leading to stenosis of the os uteri externum and of the cervical canal is, in the majority of sterile young wives, due to gonorrhoeal infection derived from a chronic, unhealed, but inconspicuous, gonorrhoea in the husband. He further considers it possible that various kinds of mechanical stimulation, for example, intra-vaginal onanism, may, in certain conditions, give rise to inflammation eventuating in cervical stenosis.
Of great interest are the mutual relations between dysmenorrhœa and sterility, a matter to which some allusion has already been made. A high degree of stenosis of the cervical canal is competent to produce both these symptoms; but dysmenorrhœa may arise from many other causes which have no direct influence in preventing conception.
Too much stress has, in fact, been laid upon the association of dysmenorrhœa with sterility, and I must therefore point out that I have seen numerous instances of dysmenorrhœa, including the so-called spasmodic form of the disease, in women who have given birth to many children; that objectively, in such cases, there was an absence of that rigidity of the cervix to which Matthews Duncan attached so much importance; and, finally, that even when the dysmenorrhœal pains had subjectively all the character of labour pains, the introduction of the sound could be effected without using any great force, and without giving rise to any severe pain.
Unquestionably, those authors, with Sims at their head, go too far, who regard dysmenorrhœa as a constant sign of stenosis of the cervical canal, and hence infer that in all cases in which sterility is associated with dysmenorrhœa, the sterility is due to such stenosis—an opinion contested by Schultze on the ground of anatomical investigations. Dysmenorrhœa gives no indisputable sign that the cervix is stenosed to such a degree as to hinder the occurrence of conception; and Sims’s view, that in the great majority of cases dysmenorrhœa is due to mechanical obstruction, is not supported by experience. Women who suffer from severe dysmenorrhœa, frequently become pregnant, though later, it may be, than women in whom menstruation is normal and painless. Dysmenorrhœa is not due solely to contraction of the cervical canal, but also to a variety of other pathological conditions. The anomalies of the genital organs which give rise to dysmenorrhœa do not, for the most part, offer any obstacle to conception; and, on the other hand, stenosis of the cervical canal may exist in women who are entirely free from dysmenorrhœa.
In order to test Sims’s theory of the mutual interdependence of dysmenorrhœa and sterility, Kehrer conducted an investigation into the state of menstruation both before and after marriage in relation to the fertility or infertility of the marriage. He ascertained that in sterile women virginal dysmenorrhœa had only been a very little commoner than in fruitful women. Hence, the changes in the reproductive organs upon which the occurrence of dysmenorrhœa depends, must not be regarded as necessarily constituting hindrances also to conception.
English gynecologists differ from those of Germany in believing that there is an intimate causal relation between dysmenorrhœa, and more especially spasmodic dysmenorrhœa, and sterility. The assumption is, that the contractions of the uterus, which by their violence during menstruation give rise to pains like those of labour, occur also during coitus; by these contractions, the entry of the semen into the uterus is prevented, or, if the semen does enter the uterus, it is speedily expelled. This spasmodic dysmenorrhœa has also been called mechanical or obstructive dysmenorrhœa, in order to call attention to the theory that the aim of the cramp-like contractions of the uterus is the expulsion of the menstrual blood which has accumulated in the uterine cavity; although Duncan himself is compelled to admit that neither the alleged mechanical obstruction, nor the accumulation of menstrual blood, nor yet the dilatation of the uterine cavity, can actually be proved to occur.
NOTE.—The author is not quite correct in his contrast between “English” and “German” opinion in this matter. Most English gynecologists follow Matthews Duncan in calling attention to the fact that, as Herman puts it, “spasmodic dysmenorrhœa is often associated with sterility”; but almost all careful writers insist that while the association is proved, the nature of the causal connexion, if such exists, has not been elucidated. For instance, writing on this very question of the association of dysmenorrhœa with sterility, Hart and Barbour remark, “after a careful survey of the literature, we come to the conclusion that any discussion of sterility in which mechanical considerations have a prominent place, must be inadequate, and will always be bootless.” It is true that Matthews Duncan writes (Diseases of Women, Lecture on Sterility), “The most generally recognized cause of sterility is spasmodic dysmenorrhœa”; but a careful perusal of the whole lecture will show that Duncan is saying more than he really means in using the word “cause,” and that what he wishes to insist upon is the frequent and indisputable association of the two conditions. In the lecture on Spasmodic Dysmenorrhœa he writes, “Latterly it has been generally described as obstructive or mechanical dysmenorrhœa; these words ‘obstructive’ and ‘mechanical’ implying a theory of the disease which ... I am sure is quite erroneous.” Obviously, then, Kisch does injustice to Matthews Duncan when he writes that the latter is “compelled to admit” (obgleich Duncan selbst zugeben muss), what he was as a fact one of the first to maintain, in the face of considerable opposition!—Transl.
Duncan goes so far as to maintain that no actual or suspected local disturbance has such significance in connexion with the doctrine of sterility as spasmodic dysmenorrhœa. It possesses this significance owing to the probable connexion between the dysmenorrhœic neurosis and the outflow of the semen, the deficiency of the sexual impulse and of sexual pleasure, and other disturbances of sexual excitement during coitus. With the relief of the dysmenorrhœa, we have, Duncan holds, made a long stride towards the cure of the sterility. Among 332 married women who were absolutely sterile, Duncan found 159, nearly half of the total number, who were affected with spasmodic dysmenorrhœa.
Burton, in order to ascertain with certain beyond question whether stenosis of the external or internal os gives rise to dysmenorrhœic troubles, examined six women during menstruation and at the time when they were experiencing the greatest pain; he found in no one of them any trace of narrowing of the canal. Owing to the congestion that occurs at this time, the uterus becomes erect, and any moderate flexion that may exist is temporarily straightened. In all the cases, the sound could be passed with extreme ease.
Ectropium of the lips of the cervix (“granular erosion”) constitutes a hindrance to conception which is by no means rare; the condition is due to deep lateral lacerations of the cervix. The gaping of the cervical canal arising from such old-standing, often overlooked, cervical lacerations and from the parametric scars associated therewith, causes various irritative manifestations: blenorrhoea, blennorrhagia, cystic degeneration of the mucous membrane, and these secondary conditions may be contributory causes of sterility; but lacerations of the cervix with ectropium interfere in a manner purely mechanical with the proper constitution of a receptaculum seminis and with the aspiration of the semen into the cervical canal. (Fig. 79.) In an earlier section of this work I laid stress on the fact that in the act of conception the musculature of the cervix had in a sense an active part to play; and the proper performance of this role is prevented by cervical lacerations. The cervical glands also suffer in cases of ectropium, and their function in facilitating the entrance of the spermatozoa into the uterine cavity is no longer properly performed. Finally, it is worthy of note that sexual gratification, the sensation of voluptuous pleasure during the sexual act, seems to be diminished in women with cervical lacerations, a fact noted especially by Mundé and Ill. The last-named found that in 34 women thus affected, sexual gratification was no longer experienced in intercourse; whilst in 27 of these cases, restoration of the integrity of the cervix by operation was followed by return of normal sexual feeling. In women who have given birth to one or two children, and then for a long time have remained barren, we not infrequently find deep cervical lacerations. Breisky, Spiegelberg, Schultze, and Goodell have operated in such cases, and shortly after the operation pregnancy has recurred.
Displacements of the Uterus.
With less justice than in the case of the pathological changes in the cervix above described, it is maintained that displacements of the uterus form a very frequent cause of mechanical hindrances to conception, and thus give rise to sterility.
It certainly cannot be denied that displacements of the uterus are found very commonly in sterile women; and, on the other hand, among women with pathological flexion of the uterus, the percentage of the sterile is far higher than among women with a uterus normal in position and shape—but from these facts it would be erroneous to infer the general conclusion that displacements of the uterus offer a mechanical hindrance to conception. The casual connexion is less simple than this as a rule. In most cases in which displacements of the uterus are associated with sterility, there are additional pathological states of the uterus and its environment, relics of previous inflammation in the uterus, the uterine annexa, or the parametrium, or displacements of the uterine annexa; these changes may be either the cause or the result of the existing displacement of the uterus, and it is upon them, and not primarily upon the displacement, that the sterility depends. The accuracy of this view is proved by the experience, by no means an uncommon one, that in such cases, when the actual cause of the sterility is removed, the woman will become pregnant, although the displacement of the uterus persists.
How difficult it is, in a particular case, to determine whether the pathological anteflexion is the true obstacle to conception, or the antecedent parametritis posterior and the concomitant metritis and endometritis! How can we decide whether a retroflexion is the simple mechanical cause of sterility, or whether the latter condition does not rather depend upon complicating perimetritis and oophoritis?
On the other hand, we must not fly to the other extreme, and absolutely deny that a displacement of the uterus can be the mechanical cause of sterility. We meet with cases in which we are forced to assume that the flexion interferes both with the outflow of the menstrual blood and with the ingress of the seminal fluid. And this is true, not merely of flexion to an acute angle, often associated with infantile dimensions of the cervical canal or of the external or internal os, but also of those advanced degrees of flexion in which, doubtless in part also from the accompanying catarrh, complete stenosis of the os uteri externum has resulted. The combination of displacement of the uterus with stenosis of the cervix, is in these cases the essential hindrance to conception. When the os is reasonably large, a moderate flexion of the uterus forwards, backwards, or to one side or the other, will not often prevent conception, for the action of the muscular bands in the various ligaments of the uterus will retain the os in a sufficiently favourable position. But if a contracted os is associated with flexion, sterility is very likely; and almost inevitable, if fixation of the flexed uterus has occurred from inflammatory exudation and fibrosis in one of the broad ligaments.
That the belief that displacements of the uterus constitute an obstacle to conception is a widely diffused one, is shown by the fact that among certain nations a means employed for the prevention of pregnancy is the artificial production of displacements of the uterus.
Of the displacements of the uterus, the versions, anteversion, retroversion, and lateral version, have a more pronounced influence in hindering conception than the flexions; for, in the case of version of the uterus, the uterus moves as a whole round a horizontal axis, so that when the fundus moves in one direction, the portio vaginalis moves in the opposite. When the neck of the uterus is thus displaced, the tip of the glans penis fails during coitus to come into contact with the os uteri externum, as it normally should do, and passes into a vaginal cul-de-sac, in retroversion, the posterior fornix, in anteversion, the anterior fornix, and in lateral version the lateral fornix of the side opposite to that towards which the cervix uteri is directed. In high degrees of this malposition, the vaginal fornix covers up the os externum as with a valve. (Beigel.)
Von Scanzoni has especially insisted upon the frequency with which sterility results from chronic metritis complicated with anteversion. In 59 sterile women affected with chronic metritis, he found in 34 instances more or less pronounced anteversion, and hence was led to infer that this particular combination of disorders plays a great part in the production of sterility.
Especially frequent is sterility in cases of anteversion of the uterus, if in addition there is some contraction, even though moderate in degree, of the os uteri externum; this combination of disorders is one extremely unfavourable to the entrance of the spermatozoa into the uterus.
Flexion of the uterus offers less hindrance than version to the entrance of the spermatozoa, for the reason that in the former condition the relations between the vaginal portion and the glans penis during coitus are not affected. But when the flexion is extreme in degree, the cervical or uterine canal may at some point become absolutely impassable for the spermatozoa; and further, extreme flexion is apt to lead to the occurrence of parametritis and perimetritis. But, generally speaking, flexions of the uterus are far less often the cause of sterility, than was formerly supposed. It used to be believed that flexion of the uterus was followed by stenosis of the os uteri externum, by which the outflow of the menstrual blood and the ingress of the semen were equally prevented. It is true that infantile acute-angled flexion of the uterus is often associated with infantile stenosis of the cervical canal or of the internal or external os; and it is also true that extreme degrees of flexion associated with uterine catarrh, favour the occurrence of stenosis and obliteration of the external os; but B. Schultze rightly insists that in most of the cases in which a diagnosis is made of stenosis of the uterine canal associated with a flexion of the sexually mature uterus, the supposed “stenosis” merely represents the difficulty which has been experienced in passing the customary rigid uterine sound past the angle in the uterine canal. Still, the fact remains, that among women with uterine flexion there is a larger percentage of sterile individuals than among women whose uterus is normal.
As regards anteflexion of the uterus, either the congenital, uncomplicated anteflexion of the uterus, due to developmental anomaly, or the acquired form, due either to subinvolution of the uterus during the puerperium, or to parametritic or perimetritic processes,—may offer mechanical obstacles to conception, and thus give rise to sterility; sterility with anteflexion occurs especially in cases in which the anteflexion is dependent upon parametritis posterior, associated with metritis and endometritis, or when any other complication is present to make the flexion a severe one. In some sterile women, we find anteflexion associated with supravaginal elongation of the portio, and in such cases both states would appear to result from catarrh of the uterine mucosa. How frequent is the combination of anteflexion of the uterus with sterility, is shown by the figures published by Sims, who in 250 cases of congenital sterility found 103 cases of anteversion, and in 255 cases of acquired sterility found 61 cases of anteversion.
Fritsch writes in the following terms regarding the difficulty with which impregnation is effected in women suffering from anteflexion of the uterus: “In cases of anteflexion of the uterus, the vagina is remarkably long, the portio vaginalis often badly formed; the ejaculated semen flows away rapidly from the contracted vagina, without, perhaps, ever coming into contact with the portio vaginalis.” He states it as a fact that women with anteversion conceive less readily than those with retroversion of the uterus (when this latter is moderate in degree); for in slighter degrees of retroversion, the axis of the uterus is a continuation of the axis of the vagina, so that the orifice of the male urethra and the os uteri externum will be in contact during intercourse—more especially because in such cases, owing to the portio vaginalis being low in the pelvis, the vagina is short; in cases of anteversion, on the other hand, the cervix is high up, and the vagina is long and narrow. Fritsch considers that generally speaking the fact that the internal or the external os is small is of little importance; but the serious factors, those leading to sterility in cases of anteversion—apart from all other considerations—are the unfavourable high position of the portio vaginalis, the occlusion of the os by the close application of the posterior vaginal wall, and the presence of glutinous mucus in the cervical canal. Since in cases of anteflexion we very commonly find hypersecretion of the uterine mucous membrane, whilst, owing to the narrowing of the external os, the mucus is unable to flow freely away, but accumulates and becomes inspissated, we have the uterine mucous membrane covered with a tenacious coating, which may perhaps render the implantation of the ovum a very difficult matter, even though the upward passage of the spermatozoa be still possible. The clinical association of pain produced by drawing forward the portio vaginalis, with marked anteflexion of the uterus, dysmenorrhœa, and sterility, is a strikingly common one.
Schröder points out that, although sterility is common in cases of anteflexion, cases are yet seen in which, notwithstanding the existence of extreme anteflexion, conception occurs very speedily after marriage. The fact that in cases of anteflexion we have difficulty, not impossibility, of conception, explains how it is that of two women suffering from anteflexion of the same severity, one will readily become pregnant, whilst the other remains permanently barren.
Retroversion and retroflexion offer obstacles to conception chiefly in cases in which this displacement is a congenital anomaly, or when it has developed immediately after puberty; or when complications exist, especially when the retroflexed uterus is fixed by exudation. In nulliparae, these deviations backwards will not rarely be found to be the cause of the sterility. Much less often does sterility ensue when retroversion or retroflexion occurs in women who have already given birth to several children, i. e., when the displacement is a puerperal disorder; the reason why such cases are not often sterile, is to be found in the fact that the wide cervical canal favours the passage of the spermatozoa, and the softness of the tissues prevents any serious obstacle to their upward progress being offered at the angle of flexion; on the other hand, severe retroflexion in a woman who has not yet borne a child offers a serious hindrance to conception, on account of the smallness of the cervical canal, and the sharp flexion of the more rigid uterus.
In general, then, retroflexion can be regarded as offering but a slight hindrance to conception. In fact, many women with retroflexion become pregnant again and again, and may abort several times in a single year. When in parous women suffering from retroflexion, sterility ultimately occurs, B. Schultze considers that it is not the retroflexion which is primarily to blame, but rather the secondary consequences so common in this disorder: uterine catarrh; the general constitutional debility due to such catarrh, and to the accompanying menorrhagia; perimetritis, and oophoritis.
Retroflexion and retroversion of the uterus occur chiefly in women who have previously given birth to children; the bend is commonly obtuse or right-angled, and above the upper end of the cervical canal; sterility in such cases, usually acquired, has a favourable prospect of cure. As Kehrer points out, sterility appears to be constant only in cases of retroflexion in which the uterus is fixed; the reason probably is that by the backward inflexion of the uterus the abdominal orifice of the Fallopian tube is dragged away from the ovary, and thus the ovum, when it is discharged from the follicle, fails to find its way into the tube.
Among 57 cases of retroflexion of the gravid uterus, E. Martin found that in 6 the patient was pregnant for the first time, from which it may be inferred that the anomaly existed prior to the occurrence of conception.
That in some cases of sterility it is the retroflexion of the uterus that is to blame, is shown very clearly ex juvantibus, inasmuch as reposition of the uterus and maintenance of the organ in its proper position relieves sterility perhaps of long standing, together with all the other troubles secondary to the displacement of the uterus. As an example, I quote one case from among several of the kind of which I have notes. Mrs. N., 25 years of age, married 6 years, childless, suffers from severe dyspeptic troubles, leading to emaciation and profound depression. She has been treated fruitlessly for gastric catarrh, but has not previously been subjected to gynecological examination. I insisted on making such an examination, and found the uterus somewhat enlarged and completely retroflexed. The successful replacement of the organ was followed by the cessation of the previously constant vomiting after meals, and by the disappearance of the other dyspeptic troubles; shortly afterwards the lady became pregnant, and pregnancy ran a normal course. Since then, she has had three children; there has been no recurrence of the dyspepsia.
According to Sims, retroversion of the uterus is frequently associated with sterility. Among 250 married women who had never been pregnant, we found no less than 68 cases of retroversion; among 255 women who had had one or more children, but had then ceased to be fruitful, he found 111 cases of retroversion; and in some of these cases the retroversion was uncomplicated. Grenser and Vedeler also found retroflexion to be a common cause of sterility; the last-named, examining 7 nulliparous married women, found retroversion in 5; in these cases, however, there was associated disease of the uterus or of its environment.
Inversion of the uterus, even in the minor degrees of the affection, in which coitus is still possible, almost invariably causes sterility, owing to the occlusion of the uterine orifices of the Fallopian tubes. Moreover, in inversion of the uterus, the position assumed by the os uteri externum is such as to render the entrance of the semen almost impossible. Finally, when the uterus is inverted, the mucous membrane undergoes changes which render it unfit for the implantation of the ovum; the researches of P. Ruge show that it is thinned and that the epithelium is cast off and replaced by granulation tissue. In cases in which the inverted uterus has long projected through the genital fissure, its surface becomes covered by a multilaminar pavement epithelium; at the same time, the glandular apparatus undergoes atrophy, only the fundi of the glands being preserved, and the muscular substance is hypertrophied. None the less, in exceptional cases, which have been reported by Emmet, Macdonald, and Tyler-Smith, pregnancy has occurred after long-enduring inversion of the uterus. Lauenstein had a patient in whom an inverted uterus was replaced after a year and a half; the following week she became pregnant. Stevens saw a case in which the woman became pregnant six months after the reduction of an inversion of the uterus of nine months’ standing.
Prolapse of the uterus is seldom the cause of sterility, inasmuch as during coitus replacement of the organ is effected. It may even be said that in cases of prolapse, the low position of the uterus and the enlargement of the os uteri externum, favour the direct ejaculation of the semen into the cervical canal (likewise enlarged), and that thus the conditions are advantageous for impregnation. In fact, conception more commonly occurs in cases of prolapse than might have been anticipated in view of the various consecutive disorders apt to complicate this affection—chronic metritis and endometritis, erosion, hypertrophy of the cervix, displacement and laceration of the annexa, etc. The extent to which the capacity for conception is unfavourably affected in cases of prolapse of the uterus, is proportional to the amount of descent undergone by the uterus, for the nearer the os approximates to the vaginal orifice, the farther removed from the os will be the point at which the semen is ejaculated. In cases of complete prolapsus it has happened that coitus has been effected directly through the everted os uteri, and has resulted in conception; a case of this kind is reported by Hervey.
Unbiassed gynecological experience in no way supports the views of Sims and Hewitt regarding the frequency with which displacements of the uterus constitute mechanical causes of sterility. Sims supports his views with the figures previously quoted, from which the following table is compiled:
_No. of Total cases cases. Anteversion. Retroversion. of displacement._ First class 250 103 68 171 Second class 255 61 111 172 ——— ——— ——— ——— Totals 505 164 179 343 === === === ===
From this it appears that in the 1st class, among 250 married women who had never given birth to a child, there were 103 cases of anteversion, and 68 cases of retroversion; whilst in the 2nd class, among 255 women, who had had children, but for one reason or another had become unfruitful earlier than the natural age for this occurrence, there were 61 cases of anteversion, and 111 cases of retroversion.
The general result of these figures is to show that two-thirds of all sterile women, without regard to the especial cause of the displacement, suffer from one form or the other of uterine displacement, and that the relative frequency of anteversions and retroversions is reversed in the two classes, the nulliparous married women, and the married women previous parous but latterly become sterile, respectively.
Hewitt similarly regards malpositions of the uterus as frequent causes of sterility. He analysed 296 cases of flexion and version of the uterus treated by him at University College Hospital during the years 1865 to 1869, partly in the wards, and partly in the out-patient department. Of these 296 women, 235 were married; 100 were cases of retroflexion, and 135 were cases of anteflexion. Of the 235, 81 had had no full-term children, 57 of the 81 having never been pregnant, and the remaining 24 having had miscarriages only. Of the remaining 154, married and parous women, a large proportion were sterile at the time when they applied for treatment; though in the years immediately after marriage they had given birth to one or more children, they had subsequently ceased to be fruitful.
All that these figures prove to an unbiassed judgment is, however, that displacements of the uterus are apt to render conception difficult; or that, in addition to other pathological states of the pelvic organs, they are frequently met with in sterile women—but in and by themselves, displacements of the uterus do not offer any very serious or very frequently occurring obstacle to conception.
That conception is possible in spite of the very notable mechanical hindrances which certain displacements of the uterus may offer to the occurrence of pregnancy, is shown by many striking examples in gynecological literature. Winckel, Olshausen, and Holst have all seen pregnancy occur in women who at the time of conception were wearing intra-uterine pessaries; and von Scanzoni has published cases in which fertilization took place, notwithstanding extreme anteversion which stenosis of the os uteri, and in another instance, notwithstanding the presence of a polypus filling the external os.
Myoma of the Uterus.
Among the mechanical obstacles to conception which act by preventing or rendering difficult the contact of spermatozoon and ovum, must be enumerated uterine myomata, and these must therefore be included among the causes of sterility.
According to their number, their size and their situation, uterine myomata give rise to different and manifold mechanical disturbances. When there are numerous intramural myomata, even when these are of a moderate size, the uterine cavity becomes bent and narrowed, and retention of the secretions may ensue, often lasting for a lengthy period. Submucous fibromyomata, when situated low down, near the internal os, may occlude this orifice completely; when implanted higher up in the uterine cavity, they are apt to cause flexion of the uterus; large, pedunculated fibromyomata of the uterus may descend into the vagina and narrow this passage.
Myomata interfere with conception in very various ways. Mechanically, they may occlude the uterine orifices of the Fallopian tubes, or may give rise to displacement of either tubes or ovaries, or, again, by blocking the uterine cavity, they may hinder the descent of the ovum and the upward passage of the spermatozoa; their presence may cause catarrhal disease of the uterine mucous membrane, or give rise to profuse hemorrhage, and either of these secondary changes may interfere with the implantation of the ovum; and there is yet another way in which myomata may interfere with conception, and give rise to sterility—this is a subject to which especial attention has been given by Winckel, and to which we may here most conveniently allude. The continued growth of small submucous myomata often gives rise to a hyperæsthetic state of the genital organs analogous to vaginismus, and this interferes with coitus. Large myomata, on the other hand, give rise to catarrhal states of the uterine cavity and to hyperplasia of the mucous membrane, constituting hindrances alike to conception, and to the implantation and further development of the embryo if fertilization should be effected; moreover, the growth of large myomata often causes perimetritis, perisalpingitis, and perioophoritis, and these, partly by abnormal fixation of the uterus, and partly by closing up the tubes and so thickening the tunics of the ovary as to prevent the rupture of the graafian follicles, give rise to sterility.
The existing statistics regarding the relation of the growth of myomata of the uterus to fertility, incomplete as they are and lacking in exactitude, suffice nevertheless to show that the fruitfulness of women suffering from uterine myomata is notably diminished by the growth of these tumours; more particularly, we learn that whilst the number of women with uterine myomata who have one child is sufficiently large, the number of multiparae thus affected falls greatly below the average of fertility. A characteristic feature of the influence of myomata in producing sterility is clearly shown by the statistics, inasmuch as pregnancy is comparatively common in the case of women with subserous myomata, in whom the uterine cavity and mucous membrane are as a rule least affected, whilst fertility is far more seriously impaired in the case of women with submucous myomata.
West, in the case of 43 married women with myomata of the uterus, found 7 childless; the remaining 36 had in all given birth to only 61 children, and 20 of these had only one child each. Of Beigel’s patients, 86 married women with uterine myomata, 21 were sterile; of McClintock’s 21 patients similarly situated, 10 were sterile. Von Scanzoni’s investigation showed 38 sterile women among 60 married women suffering from myoma uteri; Michel, 26 sterile among 127; Winckel, 134 sterile among 415. From a table showing the number of children born to each of 108 women with myoma uteri of whom 46 were observed by Winckel, and 62 were in Süsserott’s collection, it appears that on an average 2.7 children were born to each woman thus affected, whereas in Saxony the average number of children born to each married woman is 4.5.
Many other gynecologists have published statistics regarding this matter, Gusserow, Röhrig, Schröder, E. von Flamerdinghe, and others, some of them dealing with a very large number of cases, and all show that 30% and upwards of married women with uterine myomata remain sterile.
On the other hand, Hofmeier maintains, in opposition to the prevailing view, that in the great majority of cases myomata are not to be regarded as giving rise to sterility. His investigation embraced 313 persons, of whom 25% were unmarried, and 75% married, and of these latter, 25 to 30% were sterile. (It must be pointed out that compared with the average percentage of sterile marriages—about 10%, this figure of 25 to 30% is a very high one.) From a comparison of the age of the sterile married woman with the duration of married life in each case, Hofmeier is led to believe that it is not the myomata which have exercised an influence unfavourable to fertility, and that the occurrence of sterility in these cases is referable to other causes. The origination of myomata he regards as etiologically independent of the exercise or non-exercise of the sexual act. The apparently overwhelming preponderance of the occurrence of myomata in unmarried and in sterile married women is, he thinks, to be explained by the fact that unmarried women and nulliparous married women seldom have occasion to consult a gynecologist, but that the one condition that renders it necessary for them to do so is the growth of a uterine myoma. Generally speaking, pregnancy seldom occurs after the age of 35 years, precisely the age at which the growth of uterine myomata begins to be common. If, however, at this comparatively late age pregnancy does occur, it is so often found to be complicated by the presence of a uterine myoma, that Hofmeier is even led to infer that the presence of such a tumour must have a certain favouring influence upon the occurrence of conception; the facilitation of conception in these cases he explains by the fact that the growth of the tumour renders the blood-supply of the whole reproductive apparatus more active than is normally the case, and protracts the duration of ovarian activity.
Diseases of the Vagina and the Vulva.
Various pathological states of the vagina and vulva may cause incapacity for fertilization by rendering copulation impossible. Such states may be either congenital or acquired.
In rare cases the hindrance consists in abnormal smallness of the vulva, but this condition is usually associated with other defects in development of the reproductive organs, which combine to give rise to sterility. Congenital adhesion of the labia minora and majora is sometimes met with, with or without atresia of the urethral orifice, the connexion between the labia may be superficial and epithelial merely, as in a case recorded by Ziemssen; or the labia may be firmly united throughout their whole thickness. Much less common is acquired adhesion of the labia, causing atresia vulvae, and rendering coitus difficult or entirely impossible. Various other abnormalities of the reproductive organs which may give rise to sterility have already been described in the section on the pathology of cohabitation, these are: abnormalities of the hymen; anomalous formation and hypertrophy of the labia; excessive size of the clitoris; anomalies of the vagina, its absence, stenosis, atresia, duplication, and abnormal termination.
More detailed mention must, however, be made here of vesico-vaginal fistula as leading to sterility. Such a fistula is rightly regarded as one of the conditions preventing conception, but it does not render the occurrence of pregnancy absolutely impossible. It will readily be understood that the unpleasant symptoms commonly met with in these cases, will be apt to deprive both husband and wife of inclination toward sexual intercourse; again, apart from this psychical influence, the functions of the female reproductive apparatus are commonly disturbed to a very serious degree by the existence of a vesico-vaginal fistula; and, finally, the unfavourable influence of the urine on the semen must also be taken into consideration, for, as an acid fluid, the urine will notably check the activity of the movements of the spermatozoa—still, notwithstanding all these unfavourable influences, conception will sometimes nevertheless occur in such cases. But of those who acquire a vesico-vaginal fistula as the result of a difficult labour, a very small proportion only will again become pregnant.
Freund draws attention to Simon’s experiences, reminding us that the latter, in his cases in which women with vesico-vaginal fistula become pregnant, invariably saw the pregnancy terminate in abortion or premature labour; but still, Freund quotes also a case of Schmitt’s, and mentions another of his own, showing that this premature termination of the pregnancy is not absolutely inevitable in such circumstances. Schröder, indeed, goes far in the opposite direction, and writes: “Such women not rarely become pregnant, and their pregnancy usually runs a normal course.” Kroner made a statistical investigation of the question, and found that of 60 women suffering from vesico-vaginal fistula, 6 became pregnant during the persistence of the fistula. Winckel reports a remarkable case in which, after the ordinary means of curing the fistula had been vainly tried, transverse obliteration of the vagina was undertaken; the operation was not completely successful, as a small passage remained patent; the patient returned home for a time, and became pregnant, the spermatozoa having found their way through this passage. Simon reports another noteworthy case, that of a woman 57 years of age, with a vesico-vaginal fistula close to the external os; during the 26 years the fistula had lasted she had complained of cessatio mensium; when the fistula was closed by operation, she again began to menstruate.
Sometimes we meet with abnormalities of the vagina—not strictly speaking morbid states—which, though they may not at first sight appear to be of much significance, yet suffice to render conception difficult, or even impossible. One of these conditions is extreme shortness of the vagina, leading to the formation of a “poche copulatrice” (Courty), in which during coitus the semen is ejaculated at a distance from the os uteri externum; another is excessive length and width of the vagina; another, some displacement of the vagina which diminishes the prospect that the semen will enter the cervical canal. Such vaginal false passages, “fausses routes vaginales,” have been described more especially by Pajot as causes of sterility.
Another cause of sterility is the rapid outflow of the semen after coitus, either in consequence of dyspareunia, or on account of some abnormality in the configuration of the vagina, or, finally, owing to deficient action of the constrictor cunni (or bulbocavernosus muscle) and the muscles of the pelvic diaphragm. In cases of profluvium seminis, the woman herself will often call the physician’s attention to the defect.
Many cases of sterility depend upon a cause the recognition of which in this connexion is comparatively recent, namely, the hermaphroditism of the person concerned. Witness the following case described by Dohrn: The individual had been baptised and brought up as a girl. At the age of twenty years she began to suffer from a distressing sensation of pressure, recurring at intervals of four weeks. A local examination was made by a physician, who assured the mother that “there was no hindrance to menstruation, but that when she married an incision would become necessary.” After a time she became engaged and was married; and shortly afterwards her husband demanded a renewed gynecological examination. This was undertaken by Dohrn, who declared that the supposed girl was of the male sex. The external reproductive organs had the feminine form. The labia majora were large and well-formed; in the anterior extremity of each labium was a rounded, sensitive, soft body, of the size of a large bean, which was capable of being drawn forwards towards the abdomen; the labia were beset with muscular fibres; the clitoris was 4 cm. (1.6 in.) in length, resembling an imperforate infantile penis, it was slightly erectile; in the vestibule there were two openings, the anterior of which was the urethra, the posterior led into a blind passage 2 cm. (0.8 in.) in length, representing the fused lower extremities of the ducts of Müller; per rectum no trace could be found of vagina, uterus, or ovaries, but also no trace of prostate. The marriage, in which this individual declared himself to be happy, was annulled. Leopold observed a similar case, in which the individual had lived as a wife for the space of 25 years. Another striking case is recorded by Steglehner. As Zweifel remarks, to decide the true sex of such individuals is often extremely difficult. “At the present day, indeed,” he continues, “it is no longer the fate of those who from no fault of their own have had imposed on them the name and upbringing of another sex than that which is truly theirs, and who have thus been led to contract marriage with one who in reality is of their own sex, to be treated with the horrible injustice which was meted out to them in the middle ages, when, as we learn from contemporary writers, they were haled before the bar of “ecclesiastical justice,” charged with profaning the sacrament of marriage, and threatened with death at the stake—but even now a mistake in the decision of an infant’s sex entails in later life a thousand distresses and inconveniences.”
Recently, Neugebauer has made as complete a collection as possible of all the recorded cases of hermaphroditism.
Secretions of the Genital Organs.
The constitution of the secretion of the vaginal mucous membrane, or of the secretion formed in the cervical canal, or both of these in combination, may constitute hindrances to the normal contact of spermatozoon and ovum.
The secretions of the female genital organs are manifold. The outer surface of the labia majora is covered with skin, containing sebaceous and sweat glands; but the inner surface of the labia majora and the rest of the external genital organs are covered with mucous membrane, the outer stratum of which consists of stratified pavement epithelium; this epithelium contains sebaceous glands and mucus glands. The intermixture of the secretions of these glands with the epithelial scales which are constantly being cast off in large numbers, constitutes the whitish material with which this region is smeared, known as “smegma.” A mucus secretion of a fluid consistency is discharged from the vulvo-vaginal glands known by the name of Bartholin’s glands.
The mucous lining of the vagina is poor in glands; it contains very numerous papillæ, which do not, however, project from the surface of the membrane, since the depressions between the papillæ are filled in by the stratified epithelium with which the entire extent of the vaginal mucous membrane is covered. The secretion of the vaginal mucous membrane is a fluid of thin consistency with an acid reaction; the admixture of numerous morphological elements, in the form of epithelial cells cast off from the superficial layers of the stratified epithelium, often, however, makes the vaginal secretion thick and opaque. The epithelial lamellae are frequently covered with heaps of lepthothrix granules, and among the granules are seen vibriones and bacteria and also numerous lepthothrix threads of varying length.
The same stratified epithelium extends on to the neck of the uterus to a distance which varies in different individuals; gradually, however, the number of layers diminishes, the flattened cells give place to thicker, prismatic cells, until we have a single-layered prismatic epithelium; finally the cells become columnar and ciliated, and this columnar ciliated epithelium covers the whole of the interior of the uterus. The mucous lining of the cervical canal contains numerous mucous glands, some of which are simple tubular glands, whilst others are racemose; they are lined with columnar ciliated epithelium, and secrete a dense, gelatinous, alkaline mucus, containing a few epithelial cells and occasional leucocytes. The mucous membrane of the uterine cavity is beset with simple tubular glands, lined with a single layer of prismatic epithelium; these glands secrete a grayish alkaline fluid. The secretion formed in the uterine cavity is thinner in consistency than that formed in the cervical canal.
Normally, the secretion of the vaginal mucous membrane is not more than is sufficient to keep the surface of the canal moist and slippery; it is a thin fluid of an acid reaction, and almost as clear as water. Shortly before and after menstruation, the secretion of the vaginal mucous membrane becomes more abundant; it is even thinner than at other times; the reaction remains acid. The secretion of the cervical canal is normally, in the absence of sexual intercourse, small in amount, so that a free flow of secretion from the os uteri externum is by itself sufficient to indicate that the mucous membrane of the canal is in an abnormal condition. The vitreous, gelatinous, alkaline mucus secreted by the glands of the cervical canal is normally retained within the canal, and is seen on examination with the speculum to fill the os uteri externum. In consequence of the congestion of the uterus that occurs during menstruation, and for the same reason during sexual excitement, the secretion of the cervical canal is more abundant, it also becomes less tenacious, and flows out through the os into the vagina. But this evacuation of the cervical secretion through the os is a normal occurrence only during menstruation and as a result of sexual intercourse; in these circumstances it appears in the form of a clear or somewhat yellowish drop of fluid exuding through the os uteri externum.
In catarrhal states, the secretions of the genital passage, like those of other mucous membranes, become abnormal. There is an increase in the number both of epithelial elements and of leucocytes; and in very acute catarrhs, erythrocytes also mingle with the secretion. On microscopical examination we find that the catarrhal secretion differs in its characters according to the part from which it is derived: the mucus from the cervical canal forms gelatinous accumulations; that from the vaginal mucous membrane forms thick opaque masses; and in the mixed secretion which exudes from the vulva, we find also smegma from the external genital organs. In addition to cells from the laminated epithelium, we see often young cells, somewhat oval or polyhedral in form, with granular protoplasm, and a vesicular nucleus. In some inflammatory states, pus corpuscles will also make their appearance. Various micro-organisms are in addition to be found in the catarrhal secretions.
The reaction of the vaginal secretion is normally faintly acid; should it become strongly acid, the movements of the spermatozoa are immediately suspended. The mucus of the cervical canal, the alkaline reaction of which is extremely favourable to the onward movement of the spermatozoa, may, owing to catarrhal processes, be so altered that it becomes acid; it then destroys the spermatozoa, and gives rise to sterility. This fact can sometimes be proved by microscopical examination. In several cases in which endometritis existed in sterile women I made a microscopical examination of the cervical mucus shortly after the completion of sexual intercourse; and in a number of these, no living spermatozoa were to be seen, but only dead, motionless spermatozoa (Fig. 82). I had, of course, in these cases, previously assured myself that the husband’s semen was normally active.
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.
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.
TABLE SHOWING THE CAUSES OF STERILITY IN WOMEN.
I. STERILITY DUE TO INCAPACITY FOR OVULATION.
ABSOLUTE AND IRREMEDIABLE.
Complete absence of the ovaries.
Congenital atrophy of both ovaries.
Premature atrophy of the ovaries, in consequence of infectious disorders, constitutional diseases, and toxic influences.
New-growths of the ovaries, destroying all the follicles.
Senile changes in the ovaries.
Complete oophorectomy, or any equivalent form of operative sterility.
RELATIVE AND TRANSIENT.
Incomplete development of the ovaries.
Imperfect formation of ova, owing to marriage when still too young (amenorrhœa).
Ovarian tumours and oophorectomy, whereby, however, a remnant of healthy ovarian tissue is spared.
Chronic oophoritis and perioophoritis; syphilitic disease of the ovaries.
Excessive obesity, anæmia, chlorosis, scrofula, morphinism, alcoholism, various conditions affecting unfavourably the innervation or nutrition of the ovary; change of climate or mode of life; emotional disturbance; inbreeding, hereditary predisposition.
II. STERILITY DUE TO INTERFERENCE WITH THE CONTACT OF NORMAL SPERMATOZOON AND OVUM.
A. On the Part of the Wife.
ABSOLUTE AND IRREMEDIABLE.
Congenital or acquired universal thickening of the tunica albuginea of the ovaries, preventing the dehiscence of the follicles.
Absence of both tubes, developmental defects of these organs.
Absence or rudimentary condition of the uterus. Foetal uterus.
Congenital atresia of the uterus with arrest of development.
Complete absence of the vagina.
Extreme contraction of the pelvis, whereby the vagina is rendered inaccessible.
Hermaphroditism.
RELATIVE AND TRANSIENT.
Remediable thickening of the tunica albuginea, inflammatory remnants of perioophoritic processes, diseases of the cervical glands, dislocations and adhesions of the tubes, narrowing or obliteration of the ostia, inflammation of the tubes, pyosalpinx, obliteration of the lumen of the tube.
Retro-uterine haematocele.
New growths in the uterine cavity.
Infantile and pubescent uterus.
Primary atrophy of the uterus.
Puerperal atrophy of the uterus.
Displacements of the uterus—versions and flexions.
Hypertrophy or atrophy or changes in the shape of the cervix, cervical stenosis.
Cervical catarrh, especially when gonorrhoeal.
Ectropium of the cervix.
Spasmodic dysmenorrhœa.
Atresia of the vagina, obliteration of the canal by scars or tumours.
Abnormal termination of the vagina—vesico-vaginal and recto-vaginal fistula.
Absence of the external organs of generation and partial absence of the vagina, without defect of the internal organs of generation.
Abnormalities of the hymen.
Pathological states of the genital secretions.
Vaginismus.
Dyspareunia.
Perversion of the sexual impulse.
B. On the Part of the Husband.
ABSOLUTE AND IRREMEDIABLE.
Diseases of the central nervous system, and certain constitutional diseases.
Congenital or acquired absence of both testicles.
Atrophy of the testicles.
Complete azoospermia and aspermatism.
Senile impotence.
RELATIVE AND TRANSIENT.
Developmental defects of the penis, and acquired deformities of that organ.
Stricture of the urethra.
Oligozoöspermia.
Nervous impotence.
Gonorrhoeal and syphilitic infection.
The employment of measures for the prevention of pregnancy (facultative sterility).
III. STERILITY DUE TO INCAPACITY FOR THE IMPLANTATION AND FURTHER DEVELOPMENT OF THE OVUM.
ABSOLUTE AND IRREMEDIABLE.
Arrested development of the uterus.
Complete atrophy of the uterine mucous membrane.
RELATIVE AND TRANSIENT.
Chronic metritis.
Chronic endometritis, especially gonorrhoeal and exfoliative endometritis.
Perimetritis, parametritis, pelvic peritonitis; the consequence of these inflammations.
Tumours of the uterus.
Displacements of the uterus.
III. SEXUAL EPOCH OF THE MENOPAUSE.
THE MENOPAUSE.
That time in a woman’s life at which her sexual activities come to their natural termination, marked by the cessation of menstruation, is known as the menopause, climax, or climacteric period.
This “change of life,” from a condition of sexual maturity to a condition of quiescence of sexual functions, is not a sudden one, the symptoms of sexual retrogression making their appearance gradually, until the cessation of the monthly recurring menstrual flow indicates that the termination of sexual activity has arrived, and that sexual death is taking place.
The influence of this period of life is not manifested by the sexual organs alone—in these latter indeed various changes may be detected already before the cessation of menstruation, whilst after that cessation, the atrophic changes characteristic of old age proceed in these organs with a slow but continuous advance,—but the disturbances evoked by the climacteric involve the entire organism and affect the functions of numerous organs, giving rise to a true storm of irritant phenomena, and to manifestations of decay of manifold nature.
The stormy manifestations, the occurrence of which led the ancients to denote this period as the “critical age” of a woman’s life, are in the first place due to changes in the ovaries; the tissue changes in these organs give rise to a powerful ovarian stimulus, which, by irradiation and reflex action, leads to the occurrence of a number of nervous disturbances, vasomotor manifestations, and circulatory disorders; whilst owing to the cessation of the internal secretions of the ovaries, numerous and intense pathological disorders of metabolism arise. These various symptoms become apparent at the very outset of the menopause, when the oncoming entire cessation of menstruation is already foreshadowed by irregularity in the periods, gradual diminution in the quantity of the flow, and variations in the number of days during which the flow on each occasion persists.
The manifestations of the menopause are in fact so striking, that from ancient times down to the present day a widespread belief has prevailed that especial danger to a woman’s life is threatened by the climacteric age. The statistics available on this subject are, however, of dubious significance. Although it cannot be denied that the changes in the entire organism which attend the extinction of sexual activity, bring numerous dangerous influences into play, yet I feel bound to maintain that these dangers are by no means so great as those which are involved by the sexual life in its ripest period of development—the dangers of pregnancy, parturition, and the puerperium.
It is often asserted that in this “critical period” of the menopause, the mortality of the female sex is notably increased. The data available are somewhat conflicting, but a careful examination leads us to believe that, if due allowance is made for the natural increase in mortality with advancing years, no important increase in the mortality of women can be traced as due to the troubles and disturbances of the climacteric period.
The age at which a woman’s last sexual epoch begins is a very variable one. The duration of the “change of life,” the length of time during which the occurrence of the “change” is manifested by local and general disturbances, also varies greatly. Not less variable are the intensity and the general distribution of the symptoms which mark the climacteric.
The external configuration of woman at the climacteric age is usually characterized by signs of over-ripeness, and these changes appear to exercise upon certain men—more especially very young men—a peculiar kind of erotic stimulus. Many women remain long at this period quite fresh looking, with a vivid, youthful colouring; others, however, early manifest alterations in their finer feminine characteristics, hairs, for instance sprouting on the chin, and the voice becoming deeper in tone.
The outward characters of senescence, with withering of the tissues, are not commonly manifested at this time, but first make their appearance in later years, after the completion of the menopause.
A tendency to the excessive accumulation of fatty tissue is one of the most distinctive characteristics of the menopause, varying, however, greatly in degree according to race, family predisposition, and nutritive conditions. The dominant tone is thus given to the physical configuration by the deposit of fat. The face comes to have a rounded, spherical appearance, the eyes looking smaller in proportion, whilst the furrows and folds which form the natural boundaries between the features become indistinct. The formation of the “double chin,” and the abundant deposit of fatty tissue in the supraclavicular region, gives to these extremely obese women an appearance of such a shortening of the neck, that head and thorax seem to be connected as it were by a great mass of fat, marked by furrows in the thyroid and sub-hyoid regions. The breasts sometimes attain an enormous size, hanging down to the gastric and even to the umbilical region. The abdomen is greatly enlarged, the fat in the anterior abdominal wall projecting more especially in the hypogastric region, hanging down in two or three horizontal rolls over the tops of the thighs, and pushing the mons veneris downwards, so that this latter itself projects over the genital fissure. The posterior projection of the buttocks is also greatly increased, until they form a huge elastic cushion, of which the sensual orientals, who regard obesity in women as a beauty, poetically write: “Her face is like the full moon, and her buttocks are like two pillows.” Occasionally, so huge a mass of fat forms beneath the tuberosity of the ischium, that the configuration of the nates reminds us of the well-known steatopyga or fat-rump of the Hottentot and Bosjesman women. In the genital organs, as already mentioned, the genital fissure is hidden by the projection of the mons veneris. The labia majora are also greatly enlarged by the deposit of fat, so that they look like two great cylinders lying side by side. Another way in which the characteristic sexual beauty is often lost in extremely obese women, is by the falling out of the pubic hair.
Moreau, in his work on The Natural History of Woman, describes the changes occurring in a woman at the climacteric in similar terms, and concludes: “The only elements of a woman’s beauty that may sometimes be saved from the wreck, to persist for a shorter or longer time after the climacteric, are, the abundance of her hair, the vivacity of her glance, and sometimes also the amiable expression of her countenance; gradually, however, even these last remnants of beauty disappear, and old age takes possession with its irresistible force.”
None the less, some women may preserve substantial elements of beauty for a long time after the menopause. A classical example of this fact is furnished by Ninon de l’Enclos. When she died, at the age of 90, she was still beautiful. At the age of 65 she aroused the passionate love of a young man, who, unfortunately, was her own son. When informed of this, he committed suicide. A young abbé fell in love with her when she was 75 years old.
The psychical life of woman is profoundly affected by the stormy physical changes of the climacteric. Not merely does a woman entertain the disturbing thought that the critical age has begun, bringing in its train certain dreaded dangers to her health and even her life, but she is further depressed by the consciousness that she is about to lose her feminine attractions, and to decline in sexual esteem, and that her reproductive capacity is now to be extinguished. She realizes vividly that the beautiful past, the loving and beloved womanhood, is now to be left behind for ever, and by this an intelligent and sensitive woman cannot fail to be profoundly affected. Her feelings at this time were never more characteristically expressed than by the Frenchwoman who said “Autrefois quand j’étais femme.” If, indeed, a woman has been so fortunate as to have made a happy marriage, to have borne healthy children, and to be living a satisfactory family life, she will be enabled to bear with comparative equanimity the disappearance of her sexual life; but it is different with the childless wife and with the unmarried woman, who, at the onset of the climacteric, must bury all their sexual aspirations, and who see the remainder of their lives stretch before them without hopes for the future. The psychical predisposition and the intellectual education of the woman concerned, will now determine whether she will bear the onset of the menopause with composure and resignation, or whether she will become a prey to melancholia. Women of the former kind will seek to find employment for the powers set free by their sexual non-activity, in services of neighbourly affection, in works of benevolence, and in the performance of social duties; women less happily endowed will display their hostility to the world in ill-nature, scandal-mongering, and intrigue, thus giving vent to their inward bitterness; whilst those, finally, with hereditary predisposition to nervous degeneration, will become the prey of veritable psychoses.
A by no means rare result of the excited fantasy and of the eager desire not to grow old, is displayed at the climacteric in the form of self-deception. The women thus affected cannot understand, and cannot be made to believe, that the cessation of menstruation is the natural sign of their sexual decadence, they trick themselves into believing that in their case it is a sign that they have become pregnant. We must not indeed forget that the enlargement of the abdomen, so common at the commencement of the climacteric, in association with the unexpected failure of the menstrual flow to appear, the frequent dyspeptic troubles, and the enlargement of the breasts in consequence of the deposit of fat in these organs, often enough lead to appearance which have a deceptive resemblance to the clinical picture of early pregnancy. The mistake is the more readily made because the breasts sometimes secrete a serous fluid, whilst sacrache is not infrequent, and peristaltic movements of the intestines are mistaken for the movements of the foetus. Cases of this kind, in which all the objective signs of pregnancy appear to be present, and in which it is impossible to convince the woman that she has been deceiving herself, and that all the signs and symptoms are due to the menopause, are mentioned already by very early writers, and have been frequently reported by modern gynecologists. (An example of spurious pregnancy especially familiar to English readers is that of Mary I, Queen of England. Transl.)
Sexual desire in woman by no means reaches its physiological term with the climacteric and the cessation of menstruation. On the contrary, we have observed it to be the rule that shortly before and at the commencement of the climacteric, there is a considerable increase in the libido sexualis, and at the same time an increase in sexual sensibility during coitus. This sexual erethism makes its appearance in a manner often extremely surprising to the husband—and especially surprising in the case of women who have previously been characterized by a certain frigidity in sexual matters, and who have, perhaps, always needed strong persuasion before they would consent to perform their marital duties. It is by no means rare for the increased sexual impulse to manifest itself in some pathological form. Even some time after the menopause, when senile changes in the genital organs are far advanced, the sexual impulse may still be remarkably active. There is an interesting analogy in the fact that Glaevecke observed that the sexual impulse was persistent in women in whom an artificial menopause had been induced by oophorectomy; and that Lawson Tait and L. Smith have reported cases in which dyspareunia, which had existed prior to the operation, passed away after the removal of the ovaries, so that after the artificial menopause, voluptas coeundi for the first time made its appearance. Other authors, Goodell, for instance, report that libido sexualis is retained only for a short time after oophorectomy, but subsequently disappears, as in the course of the physiological menopause, and that at the same time the voluptas coeundi is entirely extinguished.
When the menopause is fully established, and the processes of involution in the reproductive organs have taken place in a normal manner, the woman has had time to acquiesce in the inevitableness of the changes that have occurred, and she often attains a state of emotional repose which was quite unknown to her in the earlier phases of her sexual life. More particularly, those women who hitherto during menstruation, and for some days before and after the flow, have been the prey of numerous nervous symptoms and troubles, rejoice, after the menopause, at their new-won freedom from these pains and disquiets, at their delivery from the excitements of the reproductive system, at their now uninterrupted state of well-being.
I once saw a group of statuary by Pietro Balestra, entitled “Time carries off Beauty.” A beautiful woman was striving in vain to resist the overwhelming might of Chronos, whilst Cupid, about to be abandoned, was standing sorrowfully by. Here we have a symbolic representation of the sexual epoch of the menopause.
In a recently published romance, “Les Demi-Vieilles,” Yvette Guilbert has described in a manner most true to nature the feelings of the “Half-Old,” the mental condition of women at the climacteric, “They endeavour to remain young, to hide their defects, they seek once again the intoxication of love. But that which aforetime in hours of depression they have foreseen, now becomes a dreadful reality. When the lemon has been squeezed dry, the skin is thrown away.”
Sooner or later after the completion of the menopause, the signs of senile marasmus become apparent. The soft, feminine configuration of the face disappears, the features become coarser, approaching the masculine type, hairs appear on the upper lip and on the chin. The voice becomes deeper and harsher. As decrepitude begins, the breasts wither, a change that occurs sooner in proportion to the degree in which their functions have been in previous years exercised by suckling; but also sometimes after a life of complete sexual inactivity. Even in cases in which the loss of substance of the breasts is apparently small, the glandular tissue of the organs has really disappeared, and has been replaced by fat. In advanced age, the breasts become quite small, wrinkled, flaccid, and dependent, and sometimes atrophied to become mere cutaneous folds. The nipples project more prominently, they are darker in colour, and their surface is wrinkled. In the genital organs, the fat disappears from the mons veneris, which becomes flattened, whilst the pubic hair ceases to be curly, and much or all of it is ultimately shed. The labia majora become thin and flaccid, until they are mere empty folds of skin; they are widely separated, so that the vaginal orifice is closed only by the withered nymphæ, until these latter are themselves ultimately indicated by mere traces.
Where the menopause has been artificially induced, the signs of senescence do not appear immediately after the removal of the ovaries; their development is a very gradual one. The sexually mature woman, from whom these tokens of femininity have been removed, experiences at first little change in external configuration, beyond a somewhat exaggerated tendency to the deposit of fat; the other changes described do not usually set in until the physiological climacteric age is attained. A few cases only have been observed in which after oophorectomy a rapid change to the masculine configuration has been observed.
Seldom if ever does it happen that menstruation suddenly ceases without any notable constitutional disturbance, so that in a moment, as it were, the menopause is effected, without any period of transition. Rarely, even, do we meet with cases in which the peculiar manifestations foreshadowing or accompanying the cessation of menstruation last for no more than a few weeks. Most commonly the irregularities of the menstrual function (of which the most noteworthy characteristic has hitherto been its extreme regularity), and the associated symptoms of the climacteric period, endure for months, and occasionally for years. According to my own observations, the mean duration of the climacteric manifestations is from two to three years, the limits of variation in individual cases being, however, exceedingly wide.
The manifestations which accompany the cessation of menstruation are as a rule the following: The woman is for some months in an irritable condition, complains of digestive disturbances, constipation, meteorism, epistaxis, haemorrhoidal flux, congestions of the head, increasing fugitive sensations of heat (Ger. fliegende Hitze), and a tendency to profuse perspiration.
The length of the intermenstrual interval commonly increases, to as much as six or eight weeks; the flow itself becomes scantier. In other cases, however, the flow becomes much more abundant, and the intermenstrual intervals much shorter than normal. In some cases, the regularity of the flow is altogether lost, it appears now soon, now late, and is now scanty, now profuse. Sometimes the intervals are several months, it may be 6, 8, and even 10 months, then again the flow will occur every two or three weeks; in exceptional cases, a scanty flow persists right through what should be the interval, so that menstruation becomes continuous, with periodic increases in the flow. Not infrequently, after a sudden cessation of the flow lasting for many months, menstruation recurs, and continues at regular intervals for a long time, until the final cessation of menstrual activity.
The mode of cessation which is most favourable to a woman’s general health, is for the duration of the intermenstrual interval gradually to increase, whilst pari passu with this increase, the amount of the flow progressively decreases, until it ceases altogether. In such cases, the general constitutional disturbance is reduced to a minimum. On the other hand, the sudden cessation of menstruation gives rise to profound disturbance of the domestic economy of the feminine organism, and causes violent changes therein. But even the gradual cessation of menstruation causes notable disturbance of the woman’s mental and physical equilibrium, if the irregularities in the menstrual process are very great and spread over a very long period—more especially when the loss of blood is extensive.
Even after the menopause, after the final termination of the flow, there persists a more or less regular recurrence of certain symptoms referable to the continuance of ovulation. Sacrache, a sense of abdominal tension, a feeling of heat and fullness in the pelvis, dragging pain in the hypogastrium, and general irritability, occur at intervals, so that the woman thus affected sometimes describes herself as suffering from the continuance of a “bloodless menstruation.”
Tilt made observations in 637 women, in order to ascertain the various modes in which the menopause occurs, and obtained the following results. The menopause occurred:
By gradual diminution of the amount of the flow in 171 women, or 26.84 per cent. By sudden interruption of the flow in 94 women, or 14.76 per cent. By sudden interruption and a terminal attack of metrorrhagia in 43 women, or 6.75 per cent. By a terminal attack of metrorrhagia in 82 women, or 12.87 per cent. By a series of attacks of metrorrhagia in 56 women, or 8.79 per cent. By alternations of very profuse and very scanty menstruation in 36 women, or 5.65 per cent. By irregular recurrence of menstruation, at intervals exceeding 21 days in 99 women, or 15.54 per cent. By irregular recurrence of menstruation, at intervals of less than 21 days in 33 women, or 5.18 per cent. By irregular recurrence of menstruation, the intervals being sometimes longer and sometimes shorter than 21 days in 23 women, or 3.61 per cent. ——— ————— Totals 637 99.99
The two principal dangers of the climacteric period in women are, first, the great tendency to profuse uterine haemorrhages, and, secondly, the liability to the occurrence of malignant tumours, more especially to carcinomatous disease of the ovaries, the uterus, and the mammae.
With regard to the question whether, in any particular individual, the course of the menopause is likely to be favourable or unfavourable, there are, in my experience, four considerations of principal prognostic significance: the condition of the woman during the menarche, the state of the general health at the time of commencement of the menopause, the degree to which the sexual functions have been and are being exercised, and the manner in which the cessation of menstruation takes place.
As a rule, the disturbances and pathological states of the climacteric period will be especially frequent and severe in women whose sexual development at the time of the menarche was accompanied by severe disturbances of the general condition. In every individual, there appears to be a certain connexion between the manifestations attending the menarche and those attending the menopause, of such a nature that according as puberty has been passed through with little or with much disturbance of the general condition, a similar favourable or unfavourable course of the menopause may be prognosticated. If, at the time of the menarche, there were severe nervous manifestations, or heart troubles of a serious kind, the passage of the menopause may be expected to give rise to neuropathic affections and to cardiac disturbances in a similar manner.
The woman’s state of general health is likewise of importance in determining whether the course of the menopause will be favourable or unfavourable. Perfectly healthy women, with a quiescent temperament, and in favourable circumstances of life, will pass most easily through the climacteric period without disturbance of their general condition. Every departure from normal health has an unfavourable influence upon the course of the climacteric. In women of a plethoric habit of body, there is an especial tendency at this time to the occurrence of symptoms of stasis and hyperaemia. Chlorotic and anæmic women are more prone than others to suffer at the time of the menopause from uterine haemorrhages. Women of a sanguino-erethistic constitutional disposition often manifest at this epoch a tendency to neuroses and psychoses. Those women have the best prospect of a smooth and undisturbed passage through the climacteric age, who enter upon it in a state of perfect health. Less favourable is the prognosis in the case of those women who already some time before the climax, at the outset of the fourth decade of their lives, have begun to complain of severe haemorrhages and various other pathological states.
Regarding the influence which the sexual activity of a woman during the menacme exercises upon the course of the climacteric, it may be said, generally speaking, that a previous free exercise of the sexual functions in normal conditions has a favourable influence upon the state of health during the menopause. Women who have been married for many years, who have had many children, and who have suckled these children, pass through the changes of the climacteric much more easily than old maids, than women who have lived for many years in continent widowhood, or than women who have had very few children or none at all. The practice of prohibitive coitus, i. e., the use during intercourse of methods of preventing the occurrence of conception, a form of sexual immorality which has become extraordinarily common during the last few decades, has an unfavourable influence upon the course of the climacteric. Unfavourable, also, is the effect of great sexual activity during the four or five years immediately preceding the menopause. Women who marry shortly before the commencement of the climacteric, and those who have given birth to a child shortly before this time, commonly experience very severe disturbances during the menopause. Prostitutes who continue the active pursuit of their profession until the climacteric age, have at this time much to suffer. Women who have had difficult deliveries, or several miscarriages, or severe puerperal illnesses—and indeed, speaking generally, those women who have been subject to any kind of disease of the reproductive organs—are apt to suffer from serious disturbances of the general health during the climacteric period.
The mode in which the cessation of menstruation takes place, is also causally connected with the easy or difficult course of the menopause. Premature cessation of menstruation, or very sudden interruption of this function, has a deleterious effect, manifesting itself both by local disorders of the reproductive organs, and by general disturbances in the nervous system and in the circulatory organs. On the other hand, a late menopause and a gradual cessation of menstruation, are both usually accompanied by a favourable course of the climacteric phenomena.
The influence of sexual activity upon the course of the climacteric is described by Busch in the following terms: “Women who have led an exhausting mode of life, who have had intercourse too frequently, those who have been given to onanism or to some other sexual irregularity, and who therefore enter upon the menopause with flaccid and deteriorated reproductive organs, are liable to haemorrhagic and mucous fluxes, to prolapse, carcinoma, dropsies, enlargements, and suppurative processes. Women, on the other hand, who have lived a life of strict isolation, and who have forcibly repressed all sexual inclinations, frequently suffer from ossifications, indurations, and atrophic conditions of the reproductive organs, and also from neoplasmata.”
After an artificial menopause, induced by the operative removal of the ovaries, similar manifestations occur to those witnessed during the natural menopause. Similar disturbances and troubles occur in both cases, but in the artificial menopause they are commonly more severe than in the natural; they last also for a longer time, varying usually from three to six years; moreover, in the artificial menopause, as in the natural, the disturbance of health is more severe and lasts longer in proportion to the youth of the individual. Further, in the artificial menopause also, the intensity and the duration of the climacteric manifestations are influenced by the constitutional state and by the condition of the genital organs at the time when the operation is performed. We note, moreover, that, just as in the physiological menopause, the attendant troubles are most violent in the initial period, and then gradually subside, so also after the induction of an artificial menopause by the removal of the ovaries, the resultant disturbances rapidly increase in severity, to attain their maximum in from three to six months, and then, after lasting for a year or so, they gradually become less severe, until they are ultimately extinguished.
The extensive process of transformation which goes on in a woman’s system during this period of the sexual life, from the very first diminution in ovarian activity to the complete extinction of the reproductive functions, manifests itself throughout the organism by means of a series of changes which can for the most part be referred either to states of blood-stasis and their consequences—congestion of various organs, haemorrhages, and disorders of secretion—or else to perversions of nervous function.
The most manifold symptoms of disordered circulation may occur: hyperaemic states of the central nervous system, flushings of the face, the so-called fugitive heats (Ger. fliegende Hitze), a tendency to epistaxis, to haemorrhoidal flux, and to profuse perspiration. The changes which take place in the reproductive organs at the time of the menopause give rise to venous engorgement and to collateral congestions. Such a condition of venous hyperaemia may occur in the gastric and the intestinal mucous membrane, giving rise to various dyspeptic manifestations, and at times, when severe, even to actual gastric and intestinal catarrh. Hyperaemia of the liver may also arise. In this case, the pressure of the distended bloodvessels on the biliary ducts may interfere with the outflow of the bile, and thus give rise to a slight icterus. Further, the intra-abdominal venous congestion leads to overfilling of the haemorrhoidal veins, and hence to bleeding piles.
When the congestion is long-lasting, various further morbid changes may arise, pulmonary hyperaemia may eventuate in bronchitis, hyperaemia of the cerebral meninges may cause very severe headache, there may be syncopal attacks, tinnitus aurium, choroidal congestion, impaired vision, etc.
Congestion of a more active nature arises from an increased and usually accelerated flow of blood through the vessels of a part in which the resistance to the blood stream has been lowered proportionately to its propulsive force. In this way arises that characteristic symptom of the menopause known as ardor fugax—fugitive heat—one link in the long chain of vasomotor manifestations occurring at this period of life. Fugitive heats are commonly most clearly marked in the face, head, and neck, in which region there suddenly occurs a reddening of the skin, with diffuse and increasing subjective sensation of heat. At the same time there is often a sense of tension, as if the part were about to burst. Actual slight swelling may be noticed, the eyes sparkle and are somewhat prominent, the head feels heavy, stupid, and dizzy. Sometimes these symptoms last for a considerable time; at other times they terminate speedily and suddenly with a local perspiration or with an attack of epistaxis. Not infrequently, after lasting a short time in one region, they pass away as rapidly as they came, but are immediately succeeded by a similar attack in some other part of the body, or by vasomotor phenomena of a slightly different kind. Thus, such a flushing and heat of the face may be replaced by a sudden sense of heat in the small of the back or in the sacral region, by pruritus of the extremities, by palpitation of heart, or by an attack of pseud-angina.
A further consequence of active hyperaemia is the onset of those confused states, so common in the climacteric age, of mental and bodily disquiet, which find expression, now in states of excitement, and now in states of depression. So we often observe change of disposition, associated with incapacity for regular work, whilst sleep is restless, and much disturbed by dreams; and again states of dizziness, a sense of mental uneasiness and confusion, and even actual delirium.
In the skin, in addition to the fugitive heats, we often have a peculiar pricking, itching, or stabbing sensation, and various kinds of hyperaesthesia, frequently associated with disturbances of tactile sensation. We observe also muscular twitchings, and general weakness of the organs of locomotion.
In association with the passive and active hyperaemias of the menopause, we frequently see increase or some qualitative change in the various secretions. Above all, these changes affect the various secretions of the different reproductive organs, but we have also increased intestinal secretion, leading to diarrhoea, increased excretion of urinary deposits, and increased secretion by the skin. Symptoms which are common at the menarche, and frequently recurs at the menopause, are: headache, migraine, a state of pseudo-narcotism, slight hysterical attacks, indications of moral insanity, lumbo-abdominal neuralgias, neuralgia of the breasts, leucorrhoea, and various skin eruptions.
According to Tilt, the changes occurring in the organism at the climacteric period may be summarized under the following heads:
1. Increased elimination of carbonic acid by the lungs,
2. Increased elimination of uric acid in the urine,
3. Increased perspiration,
4. Increased mucous flux,
5. Haemorrhages from various organs.
As regards the first point, the extensive researches of Andral and Gavaret have shown that in the female sex the quantity of carbonic acid eliminated by the lungs diminishes when menstruation first appears at puberty, but increases again at the climacteric age, when menstruation ceases—whereas in the male a gradual diminution in the elimination of carbonic acid begins already in the 36th year of life; in old age the quantity eliminated is greatly reduced in both sexes alike.
CHANGES IN THE FEMALE REPRODUCTIVE ORGANS AT THE MENOPAUSE.
In considering the changes that take place in the female reproductive organs at this period of life, we must distinguish between the proper period of the climacteric, with its various manifestations antecedent to and associated with the irregularity and ultimate cessation of menstruation, from the condition of old age in which menstruation has actually and completely ceased, in which the menopause has been fully accomplished, and in which the changes of senescence have set in at once in the organs of the reproductive system and in the organism as a whole.
The most important and most significant changes of this sexual epoch are unquestionably the anatomical alterations in the ovaries. A good many years ago I undertook an investigation whose purpose was to follow the natural involution of the graafian follicles from the time of the climax on into old age, and for this purpose I examined a very large number of ovaries of women at ages varying from 42 to 75 years (Archiv. für Gynecologie, Bd, XII., Heft 3).
Throughout these years a slow but continuously progressive atrophy proceeds in the ovaries; they become smaller and denser, diminishing especially in height and width; their surface becomes extremely uneven; and in extreme old age they wither away until no more is left in the region formerly occupied by the ovaries than a flattened fibro-vascular thickening (Figs. 84–88). The histological characteristic of the changes in the ovary which proceed gradually from the commencement of the menopause to extreme old age, may be summed up as consisting in a continual increase and new formation of the connective tissue stroma at the expense of the cellular layer, accompanied by retrogressive metamorphosis of the graafian follicles.
The connective tissue ground substance of the ovary increases from the periphery towards the centre, and progressively compresses the epithelial structures of the organ. In the outermost layer of the ovarian stroma, the so-called tunica albuginea, the strata of short, dense connective tissue fibres increase notably in number, so that whereas at first three layers at most could be distinguished, the tunic ultimately comes to consist of from six to eight layers; at the same time also the interior ovarian stroma becomes exceedingly dense, so that numerous well-defined interlacing bundles of fibres can be made out in its substance.
The first retrogressive metamorphosis which can be observed in the graafian follicles is fatty degeneration, the formation of granule spheres. Whilst the membrana propria (the theca folliculi) of the follicle remains quite unaltered, we observe in the membrana granulosa, in addition to the ovum, and the ordinary cells of this layer, spherical aggregates of fat droplets, the granule spheres, which continually increase in size, until ultimately of the cellular contents of the follicle nothing whatever remains, and it now appears full of granule spheres and fluid. The theca folliculi has now lost its spherical shape, and assumes an ovid form (Fig. 89).
In a later stage of the degeneration of the graafian follicle, it appears as a vesicular body with a relaxed wall, thrown into numerous folds, this folded wall being formed by the theca folliculi. The cavity of the follicle is reduced to a mere cleft, filled with a transparent substance, and the space between this cleft and the inner surface of the theca folliculi is occupied by round cells and a fibrous intercellular substance, and is traversed by a vascular network. This second stage of the retrogression of the follicle may therefore be designated the stage of vesicular degeneration (Fig. 90).
In the last stage of this retrogressive metamorphosis, we find the follicle completely transformed to a fibrous mass. It appears as an elongated oval body, much lobulated, connected with the surrounding stroma by thick strands of fibres; a trace of the original cavity can still be distinguished in the form of a narrow cleft, without distinguishable contents. The tissue of this body consists of connective tissue fibres, with interspersed nuclei and nuclear fibres (Fig. 91).
The three stages I have observed in the retrogression of the follicle, of which I have given a summary account above, may, I think, be explained in the following manner: When the woman’s reproductive activity ceases, the graafian follicles become subject to a retrogressive metamorphosis, a fatty degeneration setting in in the cells of the membrana granulosa and in the ovum, until ultimately the whole of the granular epithelium has undergone atrophy. The follicle now undergoes a vesicular transformation with shrinkage of its cavity, and with the formation of a new tissue which appears to be young connective tissue. As time goes on, this new connective tissue is formed in increasing quantities, until finally the entire follicle is transformed into a firm fibrous mass.
Thus we are led to infer that the gradual but extensive thickening of the tunica albuginea (i. e., the outer, condensed layer of the ovarian stroma), which, as we have seen, always occurs at the climacteric period, offers a hindrance to the bursting of the follicles as they mature, and in this we find the explanation of the irregularity of menstruation and of the various troubles which attend the performance of that function at the time of the menopause. It is reasonable to assume that the resistance of this thickened tunica albuginea is responsible for the fact that the interval between the bursting of the successive follicles is now greater than normal, as much as six or eight weeks—this retardation of menstruation being one of the commonest ways in which the onset of the menopause is first manifested. Another phenomenon connected with the onset of the menopause also finds a plausible explanation in the anatomical grounds just mentioned. As already pointed out, in parous women the menopause sets in later than in nulliparae. At every pregnancy, the ovaries share in the more abundant nutrition of all the reproductive organs, due to the general dilatation of the intrapelvic vessels which accompanies this process; hence the ovaries become larger, richer in lymph, and therefore softer, the cellular elements increase in size, and perhaps also in number, and it is readily conceivable that in such ovaries the cellular elements are able for a longer time to resist the induration and the new formation of connective tissue which occur at the climacteric.
The numerous nervous disturbances of the climacteric epoch would appear also to depend upon the hyperplasia of the ovarian stroma which we have observed to be the characteristic anatomical change in the ovaries at this period of life.
Associated with the fibrous transformation of the graafian follicles there is, however, a failure of the so-called internal secretion of the ovaries, a matter to which much attention has recently been paid. Brown-Séquard has especially maintained that the ovaries secrete a substance which enters the blood, a substance which, notwithstanding the fact that its presence cannot be proved either by chemical or any other means known to us, yet is of considerable importance for the maintenance of the equilibrium of mental and physical well-being. It is supposed that the various profound disturbances of the general system occurring at the menopause[52] are dependent upon the cessation of this internal secretion of the ovary—disturbances which rise to a maximum as the atrophy of the ovary proceeds, and which only gradually pass away after a considerable lapse of time.
After the menopause is completely over, in the ovaries, as in other parts of the female reproductive organs, the signs of senile degeneration make their appearance.
In old women, we find the ovaries either shrunken to the form of small fibrous cords, or else degenerated to form cysts of smaller or larger size, the stroma surrounding these cysts being extremely hard, dense, and tough.
Whereas at the commencement of the climacteric period, the uterus commonly exhibits a slight increase in size, owing to the condition of passive hyperaemia already described, subsequently a gradual diminution in the size of the organ may be observed. This atrophy begins with the portio vaginalis and proceeds upwards. Whilst the body still appears undiminished in size, the vaginal portion will be found already shorter, more slender, and more flaccid. Gradually, however, the entire organ is involved in the atrophic process. The uterus is then smaller than formerly, its walls are thinner, its cavity reduced in size. Its vascularity and its sensibility are alike diminished. The external os is smaller, and the internal os is sometimes entirely obliterated. There is a tendency at the climacteric period for the tubulo-racemose glands of the cervical mucous membrane (Fig. 92) to undergo a cystic degeneration (Fig. 93), and hence arise the cysts which are so commonly met with on the portio vaginalis of women at this time of life, cysts varying in size from that of a millet seed to that of a pea. In advanced life, the formation of such cysts may be regarded as normal, and sometimes in the form of grape-like clusters they almost completely occupy the lumen of the cervical canal. (Figs. 94, 95, 96, and 97).
Not infrequently, these cysts lead to the formation of polypi, by enlarging until the mucous membrane projects so far that a stalk is formed.
Examining the bodies of 47 women who died at ages varying from 42 to 80 years, I found in 28 ovula Nabothi in the cervical mucous membrane, for the most part at the os uteri externum, but in some cases also extending up to the os internum, sometimes between the plicae palmatae, sometimes isolated, sometimes grouped.
Sometimes in old women no trace of a vaginal portion remains, and the uterus is found to be transformed to a small, thin-walled, shrunken body, no more than one-fourth of its original size; in such cases the saying of Graaf appears to be justified, that after the menopause the uterus returns to the size it has in the young girl. In the majority of such cases, the cavity of the uterus is also contracted (concentric atrophy). It sometimes happens, however, that in old age the os externum and the os internum are the seat of atresia, whilst the intermediate portion of the cervical canal remains unaffected. In this way, especially when the cervical canal and the cavity of the body of the uterus are distended with mucus or with fungous growths, is produced what is known as the uterus bicameratus vetularum.
In many cases, when the cervical canal has been obliterated, we find the uterine cavity distended with mucous secretion (excentric atrophy). The substance of the uterine wall is in old age commonly dense and tough, but occasionally, in extreme old age, less firm than formerly, withered and friable, and traversed by degenerated arteries, and in this state it is predisposed to haemorrhages (apoplexia uteri). Such intramural haemorrhages usually occur in the fundus; the friable uterine substance has then a blackish-red appearance, infarcted with extravasated blood; sometimes the uterine cavity is also filled with blood. In general it may be said that when the menopause is completely over, when uterine activity has entirely ceased, the uterus returns to the state in which it was before the menarche—it is physiologically dead.
The tubes become flaccid, thinner, shorter, and are at times obliterated. In the mucous membrane of the tubes in old women we no longer find any trace of the glands described by Hennig; the epithelial cells have also lost their cilia.
During the climacteric period, the vagina is usually relaxed and roomy, the mucous membrane is smooth, injected and secretes freely; subsequently, in old age, it becomes firm, tough and dry.
Wendeler found that the initial change of the climacteric in the ovary is a chronic and progressive endarteritis obliterans; the result of this process is, in addition to the obliteration of the follicles, a continually increasing hyaline degeneration of the smallest arteries and the arterioles, especially along the line of transition between the cortical and the medullary substance of the organ; this degeneration extends to the surrounding connective tissue, and thus leads to the formation of peculiar, vitreous, translucent foci of sclerotic connective tissue, containing few cells or none; these are the so-called corpora fibrosa or corpora albicantia. Only subsequently to the formation of these bodies does the characteristic wrinkling of the surface of the ovary occur, with general shrinkage of the organ, these changes being due to the contraction that sets in in the numerous scattered foci of connective tissue, which, as already mentioned, are situated in close proximity to the cortex.
The gradual atrophy of the uterus after the extinction of its sexual activity leads to a diminution in all the diameters of the organ, so that in old women it becomes flattened as in childhood, all its curves having disappeared; the muscular substance is replaced by connective tissue; and the portio vaginalis dwindles and even entirely disappears.
As regards the bacterial flora of the genital organs of elderly women, Menge and Koenig find that the vagina for the most part contains bacteria which do not thrive when cultivated aërobically on alkaline agar plates. In exceptional cases, however, such bacteria are found, and may even be sufficiently vigorous to produce pyogenic infection. According to Strogamoff, the vagina in all circumstances contains a great variety of micro-organisms—cocci, diplococci and rod-forms. Rod-forms are the prevailing types found in normal conditions in elderly women, but they are much smaller than in women who are still in the period of reproductive activity. Organisms liquefying gelatine were found in one instance only, a case of vaginal prolapse. In one half of the cases examined, there was no development of culture media inoculated from the cervix uteri, whether on agar or gelatine.
THE TIME OF THE MENOPAUSE.
The age at which the menopause begins is one which varies owing to manifold conditions, congenital and acquired, owing to the local influences which have been brought to bear on the reproductive organs during the menacme, and to the general circumstances of life during this period. In Northern Europe it commonly begins some time between the ages of 40 and 50 years. According to the most trustworthy statistical data, the commonest age for the onset of the menopause is between the ages of 45 and 50 years. Next to these in frequency we find the menopause commencing between the ages of 40 and 45 years. If, however, the menopause does not begin during the fifth decennium, it is more apt to occur during the quinquennium after 50 than during the quinquennium preceding 40 years of age; that is to say, an abnormally late menopause is more often met with than an abnormally early menopause. In a very small proportion of women does the menopause begin either after the age of 55 or before the age of 35.
THE AGE AT WHICH THE MENOPAUSE OCCURS.
My own observations show that the age at which the menopause begins is affected by the following circumstances:
1. The race (nationality) of the woman.
2. The age at which the menarche occurred.
3. The sexual activity of the woman during the period of the menacme, the number of her pregnancies, the exercise or neglect of the function of lactation.
4. The social circumstances of the woman’s life.
5. General constitutional and pathological conditions.
1. Race.
From the statistical data regarding the age at which the menopause occurs among the women of the various nations of Northern Europe, it appears that the latest average age for the cessation of menstruation is met with in Lapland, namely 49.4 years; next comes Norway, where the average age is 48.9; next Germany, where the average age is 47; next England, 46.1; next Russia, 44; and finally Austria, 42.2. In the four principal capital cities, the average age is: in London, 45.5; in Paris, 43.65; in Vienna, 43, and in Berlin, 47. Generally speaking, in southern countries the cessation of menstruation occurs at an earlier age than in northern countries, as the following comparison shows: northern countries: England (Tilt), 48 to 50; France (Courty), 50; North Germany (Mayer), 50; Austria (Szukits), 42; southern counties: Persia (Chardin), 27; Java, 30; various Asiatic races, 30 to 40.
In the case of 500 women of various nationalities in whom I was able to ascertain by personal observation the age at which menstruation ceased, I found that the menopause occurred:
In the quinquennium 35 to 40 in 48 women In the quinquennium 40 to 45 in 141 women In the quinquennium 45 to 50 in 177 women In the quinquennium 50 to 55 in 89 women ——— 455
Thus we see that in about one tenth of my cases, menstruation ceased between the ages of 35 and 40; in more than one-fourth, between the ages of 40 and 45; in more than one-third between the ages of 45 and 50; and in about one-sixth between the ages of 50 and 55. In 267, that is, in more than one-half of the 500, menstruation ceased between the ages of 42 and 51. In 28 women, menstruation ceased before the age of 35; and in 17, after the age of 55. In a very large majority of my 500 cases the women were of German or Austro-Hungarian nationality; next, in order of frequency, came Poles, Russians, women of various southern countries, Swedish women. In women of Slavonic nationality, menstruation ceased remarkably late as compared with women of German nationality.
Brierre de Boismont, Tilt, Courty, and various other observers, have published statistical data regarding the age at which menstruation ceases in women of different nationalities. Krieger, compiling from several authors, statistics relating to 2291 women (European) gives the following average results: menstruation ceased
Between the ages of 35 and 40 in 272 women 11.87 per cent. Between the ages of 40 and 45 in 595 women 25.97 per cent. Between the ages of 45 and 50 in 940 women 41.03 per cent. Between the ages of 50 and 55 in 334 women 14.58 per cent. Before 35 and after 55 in 150 women 6.54 per cent. ———— ————— 2291 99.99
We append a statistical table showing the average age at which menstruation ceases in women of different European nationalities:
══════════════╤════════╤════════════════╤════════╤═════════ │Germany.│Austria-Hungary.│ France │ England │ │ │(Paris).│(London). ──────────────┼────────┼────────────────┼────────┼───────── Number of │ 824│ 256│ 178│ 500 cases │ │ │ │ Average age at│ │ │ │ the │ 47.0│ 42.2│ 44.0│ 46.1 cessation of│ │ │ │ menstruation│ │ │ │ │ │ │Brierre │ Observer │ Magar │ Szukits │ de │ Tilt │ │ │Boismont│ ══════════════╧════════╧════════════════╧════════╧═════════
══════════════╤═══════╤════════╤═══════╤════════ │Russia.│Denmark.│Norway.│Lapland. │ │ │ │ ──────────────┼───────┼────────┼───────┼──────── Number of │ 100│ 312│ 391│ 34 cases │ │ │ │ Average age at│ │ │ │ the │ 45.9│ 44.8│ 48.9│ 49.4 cessation of│ │ │ │ menstruation│ │ │ │ │ │ │ Faye │ Observer │Lieven │Hannover│ and │ Vogt │ │ │ Vogt │ ══════════════╧═══════╧════════╧═══════╧════════
2. The Age at Which the Menarche Occurred.
Until recently, it was generally believed that the earlier the age at which menstruation first made its appearance, the earlier also would the menopause occur; and that, on the other hand, the later the age at which the flow began, the later also would it cease. Virey summarized this opinion in the saying: prius pubescentes prius senescunt. This view of the matter is, however, true only in respect of the influence of climate upon sexual development. In a cold climate, a woman begins to menstruate late and ceases to menstruate late; in a hot climate the opposite conditions prevail. But if we make our comparison between women living in similar conditions as regards latitude and climate, we find that Virey’s saying is far from accurately describing the facts.
In general, and climatic influences apart, it may be said that the earlier in any woman the age at which menstruation first occurs, the later will be the age at which menstruation ceases.
In order to ascertain the influence of the age at the menarche upon the disappearance of menstrual activity, I placed in comparison first the cases of 50 women in whom menstruation had first appeared between the ages of 12 and 16—i. e., cases of early menarche; and secondly the cases of 50 women in whom menstruation had begun between the ages of 16 and 20—i. e., cases of late menarche. The result was the following:
In the 50 women in whom the menarche had been early, the menopause occurred
At ages 35 to 40 in 5 instances At ages 40 to 45 in 12 instances At ages 45 to 50 in 25 instances At ages 50 to 55 in 8 instances
On the other hand, in the 50 women in whom the menarche had been late, the menopause occurred
At ages 35 to 40 in 9 instances At ages 40 to 45 in 28 instances At ages 45 to 50 in 10 instances At ages 50 to 55 in 3 instances
Thus whilst among the women in whom the menarche had been late, there were thirteen only who continued to menstruate until they were at least 45 years of age; among those in whom the menarche had been early, the number in whom menstruation thus continued up to the age of 45 or beyond was 33, nearly three times as great.
On the other hand, in those cases in which the menarche occurred at an abnormally early age, i. e., before the age of 12 years, the menopause was also a remarkably early one. The menopause also came on very early in women in whom the menarche had been extremely retarded, until the age of 20 and upwards. An extremely early and an extremely late menarche alike tend to be followed by a premature menopause.
To this rule there are, however, exceptions, and we occasionally meet with women whose reproductive energies are so powerful, that the menarche occurs at an unusually early age, and the menopause is postponed to an age considerably beyond the average. Thus, among 100 women in the Salpetrière, Raciborski observed 29 in whom menstruation had begun at the exceptionally early age of 12 years, and who, notwithstanding this, all experienced a very late menopause. Three of them were still menstruating at the age of 57, 1 at 56, 2 at 52, 2 at 50, 3 at 48, 3 at 45, and 13 at an age less than 45.
Brierre de Boismont reports the case of a woman who began to menstruate in her 12th year; she married, had several children, and continued to menstruate regularly until she was 60 years of age.
The results obtained by W. Guy, who examined a series of 250 cases, confirm the proposition stated above, that the earlier menstruation begins (the extremely early cases being excluded), the later it ceases.
According to Cohnstein, who bases his conclusions upon the observation of 400 cases, in women who begin to menstruate early, the menopause occurs on an average three years later, than in women who begin to menstruate late. Puech also states that menstruation lasts longer in women who begin to menstruate early, than in those who begin to menstruate late. According to Scanzoni, in women who begin to menstruate in very early youth, the climacteric age is commonly reached earlier, than in those in whom puberty occurs at the normal age—commonly between the ages of 40 and 42 years.
The homology between the pathological states which, in any particular individual, occur at the respective periods of the menarche and the menopause, is sometimes extremely remarkable; the very same symptoms by which the first appearance of menstruation was preceded, recur as antecedents of the menopause. This is seen in the case of certain eczematous conditions of the skin, of dyspeptic manifestations, epistaxis, nervous disturbances, hysterical and epileptic seizures, vasomotor symptoms, congestions, cardiac troubles, albuminuria, etc. Alibert pointed out that certain skin-diseases may appear twice only during life, once shortly before the commencement of menstruation, and the second time shortly before the cessation of menstrual activity. Brierre de Boismont alludes to the occurrence of hysteria and epilepsy before both these important epochs in a woman’s life, whilst in the intervening period the patient had remained entirely free from such troubles. H. Marsh records the observation that women who just before puberty have suffered from repeated attacks of epistaxis, have suffered from the same trouble as a predominant symptom of the climacteric period. Tilt has seen in several cases the outbreak of numerous furuncles with subsequent diarrhoea, and still more frequently peculiar attacks of severe vertigo, occurring in women just before the two critical epochs in her life, whilst in the intervening period there has been no trace of such troubles, either in connexion with menstruation, with the puerperium, or with lactation.
3. The Woman’s Sexual Activity.
An important influence upon the early or late onset of the menopause is exerted by the degree to which a woman’s reproductive functions have been exercised during the menarche. My personal observations have shown me that in women who are in good health and of a powerful build, whose menstrual flow has always been regular and sufficient in quantity, whose reproductive organs have been adequately and properly exercised, who have had a physiological amount of sexual intercourse, have given birth to several children, and have suckled these children, the cessation of the menstrual flow generally occurs much later than in women in whom the conditions of the sexual life have been the opposite of those just mentioned. The more regular menstruation has been, and the more normal the deliveries, the later does the menopause ensue.
Especially striking is the influence of the number of deliveries upon the time of occurrence of the menopause. In women who have given birth to a number of children, menstruation as a rule continues for several years later than in sterile women, or in those who have had one or two children only. If a woman suckles her children, the date of the menopause appears also to be postponed. Deliveries late in life seem likewise to delay the onset of the menopause, whereas abortions accelerate its occurrence. If, however, pregnancy succeeds pregnancy at extremely short intervals, the menopause is likely to occur early; the same result is brought about by sexual intercourse at too early an age. The menopause occurs latest in women who have begun to menstruate early, who have married, have given birth to more than three children, and have been delivered of their last child at full term when 38 to 42 years of age.
As regards the 500 women previously mentioned, in whom I made personal observation as to the age at which the menopause occurred and the circumstances by which its onset was influenced, the effect of marriage and the number of children born is shown by the following details:
Of the 48 women in whom the menopause occurred between the ages of 35 and 40, 16 were unmarried, 6 married and childless, 18 married with one or two children, 8 married with more than two children.
Of the 141 women in whom the menopause occurred between the ages of 40 and 45, 3 were unmarried, 4 married and childless, 46 married with one or two children, 88 married with more than two children.
Of the 177 women in whom the menopause occurred between the ages of 45 and 50, 1 was unmarried, 2 were married and childless, 32 married with one or two children, 142 married with more than two children.
Of the 89 in whom the menopause occurred between the ages of 50 and 55, none were unmarried, none were childless, 19 were married with one or two children, 70 were married with more than two children.
Of the 17 women in whom the menopause occurred at an age above 55 years, there were two only who had not had more than two children, whilst there were 10 who had had six to eight children.
The influence of lactation is shown by the fact that in the case of 40 women who had not suckled their children, the mean duration of menstrual activity was four years less than the established mean duration of 27 years.
4. The Social Circumstances of the Woman’s Life.
The conditions in which a woman passes her life are not without influence upon the time of onset of the menopause. In general it may be said that among the women of the labouring classes, whose livelihood is so often precarious, and who are apt to suffer from habitual physical overwork, menstruation ceases at an earlier age than among the women of the well-to-do classes and those who lead an easier life. But though the climacteric thus occurs earlier among the lower than among the upper classes, the difference is not a considerable one.
According to Mayer’s calculation, the mean age at which menstruation ceases is, in upper class women, 47.13 years, in lower class women, 46.97 years. Small as this difference appears, amounting on the average to no more than two months, it must not be forgotten that among the upper classes, menstruation begins earlier than among the lower classes, by an amount which averages 1.31 years. Thus the total duration of sexual activity is almost one and a half years longer in the upper than in the lower classes.
5. General Constitutional and Pathological Conditions.
An important influence upon the time of occurrence of the menopause is exerted by the individual and hereditary predisposition of the woman, by her constitutional state, and by certain illnesses from which she has suffered. Women who by inheritance are constitutionally weakly and delicate, in whom the menstrual flow has always been pale and scanty, in whom the intermenstrual intervals have been excessive, and who have a slender habit of body, attain the climacteric age earlier than women with vigorous bodily development and powerful muscles, with large breasts, and in whom menstruation has always been regular and abundant. Women with a great tendency to obesity cease to menstruate earlier than women of more normal proportions; blondes earlier than brunettes; women of phlegmatic temperament earlier than women of a sanguine and ardent temperament.
In general it may be said, that all influences which have a weakening effect upon the feminine organism, tend also to accelerate the onset of the menopause: such are, severe labour, great sorrow, wearisome occupations, severe menstrual losses, rapidly succeeding pregnancies, and abortions; also a number of pathological general states shortly to be discussed, as well as local diseases of the reproductive organs.
Fritsch points out that menstruation continues to a later age in proportion as the woman’s state of general nutrition is a good one. He also asserts that women with a very large uterus, who have always had an abundant menstrual flow, those with retroflexion, with hypertrophy of the portio vaginalis, or chronic endocervicitis and endometritis, and those with small myomata which have given rise to no marked symptoms, often continue to menstruate far beyond the usual age.
The mean duration of the climacteric phenomena, from the commencement of these until the final cessation of menstruation, is about two years. This mean is made up of extremely wide individual variations; in a small proportion of the cases the climacteric manifestations may last no more than a month or two, whilst at the other end of the scale we meet with cases in which the duration extends to 4, 6, 8, and even 18 years.
In considerably more than half of all the cases, however, the duration of the climacteric manifestations varies between six months and three years. Thus, in Tilt’s series of cases, the duration of the “change of life” was
6 months in 12.07 of all cases 1 year in 22.64 of all cases 2 years in 18.62 of all cases 3 years in 9.43 of all cases
6. Premature, Delayed and Sudden Onset of the Menopause.
In exceptional cases, the menopause, instead of taking place between the fortieth and the fiftieth year of life, occurs at an abnormally early or an abnormally late age.
Premature cessation of menstrual activity, in the third or the fourth decennium of life—very rarely indeed before the third decade—depends in part upon disturbances of metabolism and of haematopoiesis, and in part upon diseases of the female reproductive organs; in some cases, however, it may be due to some hereditary constitutional peculiarity; or it may occur suddenly, in consequence of some violent shock to the nervous system.
Among the disorders of metabolism which may lead to a premature menopause, excessive adiposity, lipomatosis universalis, occupies the first place. Next in order of importance come a chloro-anæmic condition of the blood, pernicious anæmia, splenic leukaemia, certain of the acute infectious disorders—typhoid, cholera, scarlatina, acute articular rheumatism,—further pulmonary tuberculosis, diabetes mellitus, Graves’ disease, Addison’s disease, and myxoedema. These various conditions may give rise, in part by infective processes, and in part in consequence of the general cachectic condition, to atrophy of the ovaries with destruction of the graafian follicles, and to atrophic processes in the uterus, and these changes lead to the premature cessation of menstrual activity.
Excessive obesity has a restrictive influence upon ovarian activity, manifested in part, as already mentioned, by the occurrence of sterility, but in part also, in very obese women, by the onset of a premature menopause. Among 215 cases of extreme obesity in women, I found 49 in which the menopause occurred at a remarkably early age. In these cases the menopause occurred at the following age:
In 1 woman at the age of 17 years In 14 women at the age of 20 to 25 years In 11 women at the age of 25 to 30 years In 9 women at the age of 30 to 35 years In 14 women at the age of 35 to 40 years
In none of these cases did the local examination of the reproductive organs disclose the existence of any noteworthy disease.
Of the diseases of the genital organs which are competent to give rise to a premature cessation of menstrual activity, the most important are the puerperal infective processes and other inflammatory states of the reproductive organs, with their results—chronic metritis, perimetritic and parametritic exudations, chronic oophoritis, atrophy of the uterus and the ovaries.
After infective puerperal processes, it sometimes happens that there is far-reaching destruction of the uterine musculature, degeneration of the uterine mucosa, permanent and irreparable atrophy of the uterus, and suppuration and atrophy of the ovaries—conditions which result in an extinction of menstrual activity. A similar result may ensue upon the persistent and long-continued pressure upon the uterus and the ovaries of a large intrapelvic exudation; such exudation being commonly post-puerperal, but occasionally arising in the absence of pregnancy. Further, according to Freund, chronic atrophic parametritis may give rise to an incurable atrophy of the uterus, by interference with the circulation of the blood through the broad ligaments, and consequent impairment of the nutrition of the uterus. Gonorrhoeal inflammation may also lead to the termination of menstrual activity, when it gives rise to intramural inflammatory deposits in the uterus, and to chronic inflammatory processes in the ovaries. Tumours of the uterus and the uterine annexa may likewise induce a premature menopause.
We also meet with cases in which after a pregnancy, to all appearance normal in its course and termination, a premature menopause results. To this category belong the cases, according to Kleinwächter of no extreme rarity, in which perfectly healthy women are attacked by profuse uterine haemorrhage during the course of a normal, full-term labour, or during miscarriage; subsequently, though the lying-in period is passed without further misadventure or abnormality, and in the absence of lactation, the patient becomes permanently amenorrhoeic. The normal involution of the uterus passes on into hyperinvolution, and ultimately complete atrophy of uterus and ovaries results. In some cases, moreover, such hyperinvolution with consecutive atrophy follows normal labour or abortion without the occurrence of any excessive haemorrhage.
Much more frequently do we find that rapidly successive pregnancies, with long-continued exercise of the lacteal function, in badly nourished, anæmic women, give rise to a premature menopause, due to permanent atrophy of the uterus and ovaries, which are in such cases so poorly supplied with blood. This “lactationatrophy” is described by Frommel and Thorn as a concentric atrophy first of all affecting the corpus uteri, and to this, if the disease advances, there succeeds a general atrophy of the muscular, connective, and fatty tissues of the parametrium, the vagina, the pelvic floor, and ultimately of the ovaries, leading, when permanent, to a premature menopause.
Trauma of the genital organs may also lead to uterine atrophy and to premature menopause.
By many authors it is believed that too-early marriage, sexual excesses, and prostitution, may be the cause of cessatio praecox. In some cases, there is unquestionably a hereditary predisposition to a premature climacteric, since the mothers of the women in whom it occurs have themselves been similarly affected. In the remarkable case which came under my own observation, of a woman from Smyrna, there was hereditary predisposition. This woman began to menstruate when 12 years of age; menstruation was always scanty; she married when 15 years of age; and she ceased to menstruate for ever at the age of 19. In other cases we find there is a family tendency for menstruation to be delayed in its first appearance to a comparatively advanced age, and to cease at the usual time.
In cases of cessatio mensium praecox (unless the failure of menstruation has been quite a sudden one), and after the premature menopause is fully established, we find in the uterus and the ovaries anatomical changes similar to those met with after the natural climacteric—diminution in the size of the uterus with thinning of its walls, density and firmness of the tissues of the organ, smallness and a soft consistency of the ovaries; sometimes, also, the mammae are atrophic.
In cases of premature menopause, the troubles attending the change are commonly more severe and more enduring than those that occur at the natural menopause. Especially is this the case when the premature menopause is quite a sudden occurrence, but this phenomenon is rare. Most commonly the premature menopause is gradual in onset; the flow becomes more scanty month by month, until at last it fails altogether to appear. Irregularity in the menstrual rhythm is not often seen in such cases. Early senescence is exceptional in these women in whom a premature menopause occurs. Emaciation, greyness of the hair, wrinkling of the skin, the growth of hairs on the face, etc., are not usually associated with the atrophy of the reproductive organs; the physiognomy and figure of women with cessatio praecox being usually similar to those seen in women of corresponding age in whom menstruation still continues.
Tilt enquired regarding the cause of cessatio praecox in 27 instances, with the following results:
In 3 instances, parturition and lactation. In 1 instance, abortion. In 2 instances, a fall on the sacrum during menstruation. In 2 instances, suppression of menstruation from chill. In 1 instance, haemorrhage from the arm during menstruation. In 1 instance, celebration of nuptials during menstruation. In 2 instances, severe medicinal purgation. In 2 instances, cholera. In 2 instances, rheumatic fever. In 2 instances, febrile bronchitis. In 9 instances, intermittent fever.
In 1 case Tilt saw cessation of menstruation occur at the age of 29, in consequence of metritis. Atlee, in 15 cases of ovarian tumour, saw the menopause occur at ages of 30, 39, 40 and 42. Puech saw a premature menopause at the age of 30 in 3 cases, in each a sequel of cholera. Blondel reports a case of cessatio praecox after prolonged galactorrhoea, although the woman had not suckled her infant; Gottschalk and Rokitansky, cases following injury to the cervix uteri; Kiwisch, Simpson, and Kleinwächter, cases following full-time, normal deliveries, in which, however, severe losses of blood had taken place.
Courty and Brierre de Boismont report cases in which the menopause occurred as early as the age of 21; Mayer, 2 cases at the age of 22; Krieger, 1 case at 23; Brierre de Boismont, 1 case at 24; Mayer, 2 cases at 25; Brierre de Boismont, 1 case at 26, and 1 case at 27; Guy and Tilt, each 1 case at the age of 27; Brierre de Boismont, Courty, and Guy, each 1 case at the age of 28; Brierre de Boismont, Courty, and Mayer, each 1 case at the age of 29; Guy and Tilt, each 1 case at the age of 30; and Mayer, 5 cases at the age of 30.
An unusually late climacteric, the continuance of menstruation beyond the age of 50 years, is not an extremely rare occurrence, but is less often seen than cessatio praecox. There is, however, in these cases a difficulty which must not be underestimated, namely, to distinguish between a genuine menstrual bleeding and the other uterine haemorrhages which are common precisely at this age of life, due either to textural changes in the uterus, or to neoplasmata—more especially because in these non-menstrual haemorrhages also a certain periodicity may often be detected. When on careful examination no abnormality can be discovered in the reproductive organs, when the bleeding in question recurs at the intervals and in association with the general symptoms to which the woman thus affected has been accustomed during her previous menstruations, and when the amount of blood discharged is not abnormal, it is permissible to conclude that we have to do with a persistence of true menstruation, even though the woman has some time since completed the fifth decennium of her life. In some women, in fact, the reproductive system is so energetic, that ovulation continues to an age far beyond the average, and such women are to be regarded as sexually long-lived.
Although the instances of protracted menstruation contained in the older literature of the subject are open to suspicion, owing to the fact that at that time it was not possible to distinguish with certainty between menstrual and pathological uterine haemorrhage, quite recently numerous incontestable cases of enduring sexual vitality have been put on record.
I have myself seen no less than 106 cases in which the menopause did not occur until after the age of 50 years; among these there were 4 in which the age at the menopause was 56; 5 in which it was 57; 2 in which it was 58; 1 in which it was 59; and 1 in which it was 60. Tilt records 128 cases of menopause occurring after 50; among these there were 4 in which the woman was 56 when menstruation ceased; 2 who were 57; 4 who were 58; 1 who was 59; 1 who was 60; and 2 who were 61. Courty reports a case in which menstruation persisted after the age of 65; Mayer, 3 cases of menopause at 64; Beigel, 2 cases, 1 in which menstruation continued to the age of 65, the other, to the age of 72. Kleinwächter observed 33 cases in which menstruation continued to an age varying from 50 to 57 years. Emmet, in the year 1886, published the case of a woman who was then 70 years old, and who at this advanced age continued to menstruate regularly.
That not every case in which after the age of 50 years there is recurrent, more or less periodic, haemorrhage from the genital organs, is to be regarded as an instance of delayed menopause, we are taught by the records of post mortem examination in several cases of the kind. Scanzoni reports the case of a woman who at the age of 60 was affected with a fairly regular periodic discharge of blood from the vagina. During one of these haemorrhages, she died of pneumonia, and the autopsy showed that the ovaries were completely atrophied and transformed into dense scar tissue, and contained no trace of corpus luteum or of fresh extravasation of blood, whilst in the upper part of the cervical canal there were two mucous polypi each of about the size of a bean. In another case, that of a woman 64 years of age, periodic losses of blood, at intervals of from three to four weeks, continued to the time of her death. This woman suffered from mitral valvular insufficiency, and it was clear that the haemorrhages had been due to the venous engorgement consequent upon imperfect compensation. The ovaries were completely atrophied, and showed no trace of any recent maturation of ova; the uterus was enlarged, the mucous membrane hyperaemic, and the cavity contained a recent clot.
Not infrequently, the haemorrhages attributed to the persistence of menstruation are really due to senile arteriosclerosis—to rigidity and brittleness of the uterine arteries; in other cases they arise from varicosity of the veins of the cervical canal. A common cause of such bleedings from the genital passage in comparatively advanced life, is to be found in the growth of uterine myomata.
To myoma uteri we must attribute a part, though by no means all, of the cases in which menstruation seems to recur some years after the menopause has, to all appearance, been fully established. In most of these cases, indeed, we have to do with pathological haemorrhages, the cause of which is, however, but too often obscure. Still, cases certainly occur in which, two or three years or even longer after the menopause, some unknown stimulus leads to the regular recurrence of menstruation. The possibility of such an occurrence is, in my opinion, fully proved by post mortem examinations of the bodies of elderly women in whom the menopause has been fully established and yet the ovaries are found to contain follicles of various degrees of ripeness, and also fresh corpora lutea—signs that ovulation may persist for a considerable time after the complete cessation of menstruation. Another proof of the last fact is the well known experience that women who have some time ago ceased to menstruate, may nevertheless become pregnant. Waldeyer, indeed, asserts that when four years have elapsed since the menopause, follicles are never to be found in the ovaries, but this negative experience is not decisive, especially as regards the cases in which regular menstruation is resumed some time after the occurrence of a premature menopause.
I have myself seen several cases in which the menopause occurred at 35, 38, 39, and 42 years, respectively; 3, 4, or 5 years later, as a result of hydropathic treatment, regular menstruation recurred. In one case, a woman who had ceased to menstruate ten years before, gave birth to a child at the age of 45.
Numerous indisputable cases of this kind are reported in the recent literature of the subject. Krieger had under his personal observation a woman of a robust habit of body, in whom menstruation ceased at the age of 48 years, her eighth child having been born fifteen years before. Two years later irregular menstruation recurred, and on the cessation of these haemorrhages, it appeared that the woman was once more gravid; she was delivered at full term of a girl. Mayer observed the following case: A strong working-class woman 33 years of age had begun to menstruate regularly when 13 years old; between the ages of 17 and 28 she gave birth to five children, and in addition had one miscarriage when 19 years old. Widowed at the age of 29, she fell ill, and on examination the uterus was found to be small and relaxed, whilst the vaginal portion of the cervix was reduced to a mere rudiment. Since she had been 22 years of age she had had persistent leucorrhoea, but no trace of menstrual haemorrhage; yet since that age she had had three children. Renaudin delivered a woman 61 years of age, who had ceased to menstruate 12 years earlier. Meissner reports a case in which a woman first began to menstruate at the age of 20, had her first child when 47 years old, and gave birth to the last of her eight children when 60 years of age.
The sudden and permanent cessation of menstruation, whether at the normal climacteric age, or earlier in life, is always a pathological occurrence. As compared with the normal, gradual disappearance of menstruation, associated with the usual climacteric symptoms, such a sudden extinction of menstrual activity is, moreover, quite rare. When it does occur, the cause is to be found in one of various pathological general states, such as one of the acute infectious disorders, or some other exhausting disease, or sometimes in some local disease of the reproductive organs; occasionally, however, it may occur in perfect health, in consequence of some powerful physical or mental stimulus, such as a severe blow or intense fright.
This sudden menopause has been observed after severe labour or abortion with profuse haemorrhage, or after cholera or typhoid; we must assume that in such cases the anæmia of the genital organs has disturbed the function of ovulation; whilst in cases due to mental shock, the interference with ovulation must be through the intermediation of the nervous system. Frequently, of course, in these cases, the sudden menopause is also a premature one.
Tilt reports a case in which a sudden menopause ensued upon phlebotomy during menstruation; several cases also in which women at ages varying from 30 to 34, or 39 years, ceased to menstruate suddenly and permanently in consequence of grief at the unexpected death of the husband; and another case of sudden menopause due to a fall down stairs. Courty reports three cases of sudden menopause at the age of 30, consequent upon an attack of cholera. Dusourd has seen three cases in which, in women aged 40 to 43 years, severe haemorrhoidal bleeding was followed by sudden and permanent cessation of menstruation. Mayer reports the case of a delicate middle-class woman 34 years of age, who had begun to menstruate at the age of 14, had married at the age of 20, and at the age of 21 after a normal delivery, ceased for ever to menstruate; and another case of a working-class woman 34 years of age who first menstruated at the age of 13 years, married at the age of 20, had two children in rapid succession, and finally ceased to menstruate, in consequence of a fright, at the age of 30 years. Krieger reports the case of a very nervous woman who first menstruated at the age of thirteen, and in whom at the age of 23 a sudden menopause ensued upon a nervous attack; in another case reported by the same observer, a sudden menopause occurred in a delicate woman 41 years of age owing to her husband’s death—this woman had previously experienced six months amenorrhœa in consequence of sorrow at the death of one of her children. The following remarkable case is reported by Brierre de Boismont: A sempstress began to menstruate at the age of 13 years; she married very soon after this, and gave birth to four children, the last when 21 years of age. In the course of the following year there was a fire in the house, and owing to this fright a sudden menopause occurred. Similar cases have been reported quite recently by Bossi and Walter.
The harmful influence which the occurrence of a sudden menopause exercises upon the general condition of the woman who experiences it, is manifested chiefly by violent circulatory disturbances, hyperaemia and congestion of the brain, lungs, and abdominal organs, and by states of excitement and depression of the nervous system. Of the vicarious haemorrhages which are apt to ensue upon such a sudden menopause, we have already spoken.
Generally speaking, women in middle life, in whom the whole organism is accustomed to the onset and decline of the menstrual hyperaemia, endure the functional disturbances induced by a sudden and complete cessation of menstruation much more easily than women who have already entered upon the climacteric age, or have nearly attained that age. The climacteric age is one in which women are already predisposed to circulatory disturbances in the pelvic organs, and it will readily be understood that in them the sudden interruption of the menstrual haemorrhages will have more serious consequences than in women in the prime of their sexual life, and therefore endowed with a greater power of resisting disturbances of the normal functions.
PATHOLOGY OF THE MENOPAUSE.
Diseases of the Genital Organs.
Among the commonest of the symptoms of the sexual epoch of the menopause is menorrhagia. It occurs especially in plethoric women, in those who during the prime of their sexual life have been accustomed to menstruate abundantly, and in those who have given birth to many children or had many miscarriages; but it is seen also in weakly and delicate individuals, in whom the tissues of the genital organs have become extremely flaccid and loose in texture. A luxurious mode of life, more especially a free consumption of alcoholic beverages, and also frequent sexual intercourse during the climacteric period, appear to favour the occurrence of menorrhagia at this epoch.
Not infrequently, menorrhagia is the first sign of the commencement of the climacteric, menstruation having been hitherto regular, and not excessive in amount. Generally, when this climacteric menorrhagia begins, the intervals also become shorter, the menstrual period being reduced to three or even two weeks. At times, however, the more profuse menstruation recurs at longer intervals, six weeks, two months, or even longer. In any case, the occurrence at the climacteric age of a severe or atypical haemorrhage, renders it the imperative duty of the physician to undertake a local examination of the genital organs; for it is necessary to ascertain without delay whether such a haemorrhage is a true climacteric phenomenon, or whether it is due to some actual disease of the reproductive organs—a neoplasm, or the like.
If the haemorrhage is due solely to the change of life, the vaginal portion of the cervix will usually be found soft and flaccid, bleeding readily on slight injury, and sometimes eroded; there is generally associated leucorrhoea. This relaxation and loss of firmness in the uterine tissues at the time of the menopause is the cause of the predisposition to excessive haemorrhage. An additional cause exists in the circulatory disturbances in the pelvic organs. We presume that women affected with menorrhagia at this time of life suffer from some persistent disturbance in the region of the inferior vena cava, whereby the outflow of blood from the veins of the pelvis is hindered, and a chronic condition of stasis in the uterus is conditioned. Hence arises distension of the vessels of the uterine mucous membrane, and this rhexis is relieved by the excessive haemorrhages. In these considerations lies the explanation of the fact that women who have had many children or many miscarriages, are especially prone to suffer from climacteric menorrhagia; and also women who for any reason are predisposed to intra-abdominal stasis.
Another cause of climacteric menorrhagia is to be found in the frequent occurrence at this epoch of advanced arteriosclerotic changes in the uterine blood vessels, the disease being in some cases limited to the uterine arteries, and in others part of a general arterial degeneration. The blood may be derived from ruptured sclerotic capillaries of the mucous membrane; but in other cases it exudes in consequence of passive hyperaemia, without actual rupture of the bloodvessels. To such haemorrhages from atheromatous vessels we must refer many of the attacks of uterine haemorrhage that occur in elderly women, such as were formerly, before their true nature was understood, commonly regarded as instances of a very late return of menstruation. By careful examination the exact source of the blood can often be detected in such cases.
According to Theilhaber, one cause of the haemorrhages occurring at the climacteric is to be found in the atrophy of the uterine muscle which takes place at this period of life. Except during pregnancy and the puerperium, the uterus is usually in a state of moderate contraction; during the height of the menstrual flux, however, the uterus is relaxed. Then, as contraction of the muscle sets in, the menstrual hyperaemia and consequent haemorrhage are gradually brought to an end. When this contraction is insufficient, the hyperaemia and swelling of the uterus are more enduring. In association with the atrophy of the uterine muscle at the climacteric, there usually occurs a notable diminution in the size of the uterine vessels, so that, notwithstanding the diminished strength of the muscular contractions, any excessive loss of blood is prevented. But if this diminution in the calibre of the vessels fails to take place, the atony of the uterine muscle leads to hyperaemia, to haemorrhage, and often, in addition, to oedema of the organ, with elongation and thickening of its walls—hyperplasia uteri preclimacterica.
Among diseases of the uterus which during the climacteric may give rise to severe haemorrhage, and may lead to the mistaken opinion that menstruation still continues, we must in the first place mention carcinomatous disease of the cervix and of the body of the uterus; next in importance come myoma and fibrous polypi; less frequent causes of such haemorrhages are fungous endometritis, erosions, mucous polypi, prolapse of the uterus, and ovarian cystoma.
The climacteric age gives rise to a predisposition, not only to bleeding, but also to other pathological changes in the reproductive organs. We can by no means endorse the opinion of Currier—one long ago expressed also by Brierre de Boismont—that women during the sexual epoch of the menopause are less disposed to diseases of all kinds, and among them to diseases of the genital organs, than younger women, for the reason that their tissues are endowed with less vitality, and are, therefore, more resistent to all the causes of disease. On the contrary, the number of pathological disorders liable to affect the reproductive organs precisely at this period of life, is strikingly large. Among my 500 cases of women at the climacteric age, there were 440 who complained of such symptoms, the diseases from which they suffered being, in order of frequency:
Profuse haemorrhages in 286 cases Chronic metritis in 79 cases Leucorrhoea in 327 cases Displacements of the uterus 117 cases viz., prolapsus in 65 cases anteflexion and retroflexion in 52 cases Genital pruritus in 46 cases Vaginismus in 12 cases Carcinoma uteri in 3 cases Myoma uteri in 5 cases Tumor mammae in 8 cases
I need hardly point out that in many individuals more than one of these diseases were present at the same time.
The most obvious feature of these statistics is the extraordinary frequency of uterine haemorrhage and of leucorrhoea in climacteric women. The former condition was present in more than half my cases; the latter actually in three-fourths.
The same two pathological states were also those most frequently recorded in Tilt’s statistics. This author, in 446 women at the climacteric, found the following diseases of the reproductive apparatus:
Haemorrhages in 138 cases Leucorrhoea recurring at irregular intervals in 146 cases Leucorrhoea recurring monthly in 12 cases Remittent menstruation in 33 cases Vaginitis in 4 cases Follicular inflammation of the vulva in 10 cases Inflammation of the labia in 4 cases Ulceration of the cervix uteri in 9 cases Prolapsus uteri in 5 cases Uterine polypi in 4 cases Fibrous tumours of the uterus in 4 cases Cancer of the uterus in 4 cases Chronic ovarian tumours in 3 cases Irritation and swelling of the breasts in 14 cases Lacteal or gelatinous secretion in breasts in 2 cases Hard, non-malignant tumour of the breast in 2 cases Chancre of the breast in 1 case Frequent sedimentation in the urine in 49 cases Difficult and painful micturition in 9 cases Incontinence of urine in 4 cases Haematuria in 2 cases Perineal abscess in 2 cases
Chronic metritis and endometritis come under observation with considerable frequency during the climacteric age, but as a rule these diseases have originated during the period of sexual maturity, and in exceptional instances only does the cessation of the menses appear to be the etiological starting point of these disorders. In fact, this occurs only when the menopause is premature, or when it is quite sudden in onset, whether this be due to noxious influences or to constitutional disorder. For the menstrual process quite normally gives rise to a certain congestion of the genital organs; and should menstruation be suddenly suppressed, the blood-stasis in the uterus becomes so extreme that morbid tissue changes are very likely to ensue. And when chronic metritis has occurred before, the congestion and stasis in the uterus at the climacteric will usually suffice to light up the inflammatory process afresh. This is the explanation of the fact that symptoms of slight metritis make their appearance at the very beginning of the climax, manifested by thickening of the corpus uteri and of the portio vaginalis of the cervix, by swelling and softening of the mucous membrane, and by abundant secretion. In those who, either after full-term delivery or after abortion, have suffered formerly from chronic metritis or endometritis, but who have been quite free from any symptoms of these troubles for many years prior to the climacteric, it often happens that the change of life is ushered in by symptoms of congestion of the uterus with associated leucorrhoea. With the completion of the menopause, however, the resulting involution of the uterus exerts a favourable influence upon all such chronic inflammatory processes in the genital organs; as the atrophy progresses, the periodic attacks of congestion cease to recur. Thus it happens that women who for years have suffered from haemorrhages, from inflammatory disorders of the genital organs, and from various other troubles of a similar nature, will, once the menopause is fully over, feel quite well up to an advanced period of life—they seem as it were to begin life afresh.
According to Bennet, the characteristic signs of climacteric metritis are that the inflammatory symptoms are less pronounced, that the pains are less severe, that elongation of the cervix is less often seen, and that fungous changes are less marked, than is the case in the chronic metritis of younger women. On the contrary, the cervix appears smaller, often somewhat lobulated, it is harder, granulations are numerous, ulceration is rare, the enlargement of the uterine cavity is but slight. Bennet’s views are, however, opposed by Scanzoni, who maintains that there is no notable difference between the chronic metritis of younger women and the disease as it occurs in women at the climacteric.
In fact, the chronic metritis and endometritis of women during the climacteric age, differs in no important respect from these diseases as they are seen in women during their sexual prime. We merely note that the enlargement of the uterus is less marked; but the thickening and extreme hyperaemia of the mucous membrane are the same in both cases, the secretion is increased in quantity, the vaginal portion of the cervix is elongated, and usually displays erosions, excoriations, or ulcers. The subjective troubles appear less pronounced than in the case of the metritis of the menacme. The prognosis is as a rule a more favourable one than in the earlier years of sexual life, for as soon as the series of involuntary processes is completed, when the retrogressive changes in the genital organs are at an end, when senile atrophy of the uterus and the uterine annexa has set in, a cure of the troubles formerly so obstinate and so enduring speedily takes place.
Quite recently, much has been written upon the subject of a peculiar senile endometritis (Patru, Skene, Mundé, Rüder, Sheldon, Herman, and others), and it has been described as “a peculiar form of senile, haemorrhagic, leucocytal hyperplasia of the uterine mucous membrane” (Gottschalk). According to Maurange and Lorain it occurs in as many as 7.2% of elderly women. It is seen especially in women who earlier in life have suffered from diseases of the genital organs, more especially those who have previously suffered from endometritis; at times a senile vulvitis or vaginitis is the cause of the disease. Displacements of the uterus with kinking of its canal, whereby retention of the secretion and its decomposition are induced, has been assigned as an additional cause of the disorder, also prolapse of the uterus, and, in isolated instances, necrotic fibromata. According to the degree to which the atrophy of the tissues has proceeded, and according as the mucous membrane is still partly retained or entirely destroyed, and according to the extent to which the uterine vessels have been affected with the sclerotic processes of old age, does the pathologico-anatomical picture of senile endometritis vary. It may affect the body only of the uterus, it may extend also to the cervix, the vagina, and even the vulva; upwards it may pass to the uterine annexa and to the peritoneum. The first and most important symptom of this senile endometritis is the outflow, usually intermittent, rarely continuous, of a sero-purulent, and sometimes sanguineous discharge, with a powerful foetid smell; there are colicky pains, which pass off when the uterus has emptied itself; often, also, there are atypical bleedings, which are not profuse. The uterus is usually found to be larger than the atrophy general at the patient’s age would have led us to expect, it is often retroflexed, the cervix is thickened, the lips of the os uteri are usually everted and raw. When persistent, this senile endometritis causes profound constitutional disturbance, and is often difficult to differentiate from carcinoma of the uterus.
Under the name of senile irritation of the uterus, Maxwell has described a disease occurring at the climacteric, characterized by an enormously increased irritability of the uterus, with marked reflex manifestations; in these cases also we may perhaps have to do with a senile endometritis. The most pronounced symptom is a severe and constant uterine pain, to which in the course of the disease are superadded pains in the gastric and cardiac regions, the rectum, and the spinal column; these pains lasted a long time, and their severity was such that it became necessary in some cases to remove the uterus.
Hydrometra is a disease which makes its appearance principally late in the climacteric period, when menstruation has already completely ceased, and when the adhesions associated with the climacteric atrophy of the uterus have led to atresia of the cervical canal. Among 74 cases of hydrometra (from the material of the Pathologico-Anatomical Institute of Prague, in the years 1868 to 1871) not one of the women was less than 40 years of age; the age distribution of the cases was in fact the following:
Quinquennium 40 to 45 3 cases Quinquennium 45 to 50 2 cases Quinquennium 50 to 55 2 cases Quinquennium 55 to 60 8 cases Quinquennium 60 to 65 18 cases Quinquennium 65 to 70 12 cases Quinquennium 70 to 75 11 cases Quinquennium 75 to 80 8 cases Quinquennium 80 to 85 4 cases Quinquennium 85 to 90 6 cases
In 40 of these cases, the occlusion was in the region of the os internum, in 23 it was in the region of the os externum, in 9 cases the whole length of the cervical canal was obliterated, and in 2 both the internal and the external os were occluded, the intervening portion of the cervical canal being still patent. In the two latter cases, there was hydrometra bicamerata, with retroflexion of the uterus.
Late in the climacteric period, haematometra also occurs, though less often than hydrometra. When, in cases in which the os uteri externum is occluded, in consequence of adhesion between the vaginal walls and the vaginal portion of the cervix, as a sequel of the vaginitis ulcerosa adhesiva of elderly women, there is haemorrhage from the atheromatous vessels of the uterus or the tubes, the blood necessarily distends the uterine cavity.
During the climacteric period, leucorrhoea is so extraordinarily frequent, as the figures previously given show, that the assumption is justified that with the diminution or cessation of the menstrual flow, this hypersecretion from the genital mucous membranes forms as it were a kind of vicarious flux. Sometimes, as in 12 cases recorded by Tilt, we actually have a periodic “menstrual leucorrhoea”; in one of these cases the discharge recurred at regular monthly intervals for 12 months, in another for 18 months, in several for 2 years, and in one for as long as 7 years. It is only by careful examination that the exact source of the discharge can be determined, for during the climacteric also, as well as earlier in life, leucorrhoea may be due either to endometritis or to colpitis. A muco-serous or sanguino-serous secretion may also be due to slight vulvitis.
A peculiar form of inflammation occurring after the completion of the menopause, and after the atrophic process in the vagina is considerably advanced, is known as colpitis senilis. In this disease, ulceration readily occurs, followed by cicatricial adhesion between the anterior and posterior walls of the vagina (vaginitis adhaesiva vetularum); in other cases herpetiform eruptions arise, with a tendency to pustule formation; occlusion of the vagina may lead to hydrometra and pyometra; sometimes the obliteration of the vagina is complete, so that there is neither outlet for blood from the uterus, nor inlet for the penis during coitus. This vaginitis adhaesiva vetularum is by no means rare in the climacteric period; as a rule it does not give rise to very serious trouble, the most prominent symptom being usually somewhat persistent haemorrhage, unaccompanied by any evil odour. On local examination, the characteristic strings of scar tissue are felt, passing from the portio vaginalis to the narrowed, senile vaginal fornix; from the cervical canal there exudes a usually somewhat vitreous mucus, mixed with blood. The cervix itself is thin and atrophied, the uterus also is greatly diminished in size.
The frequency at the time of the menopause of such catarrhal inflammatory processes in the vagina and vulva is said by Duprès to depend on the weakness or paresis of the bladder which is so common in women at this time of life. Owing to the incomplete evacuation of the urine, cystitis very readily ensues; the urine is evacuated involuntarily during sleep, and some of this fluid passes through the vaginal orifice, giving rise all the more readily to colpitis, because the secretion of the atrophic mucous membrane no longer possesses the normal acid bactericidal properties. According to Scott, vulvitis may also arise as a sequel of calculus-formation in the glands of Bartholin, a frequent occurrence in elderly life, followed by inflammation and abscess-formation in these glands. Among the diseases of the genital organs at the climacteric period, Fritsch also enumerates urethral caruncle and carcinoma of the clitoris.
Displacements of the Uterus.—Among the commonest of the displacements of the uterus occurring during and after the menopause, is prolapse of the organ. Previously existing descent of the uterus is apt to be greatly aggravated at the climacteric, a partial prolapse, for instance, becoming complete; or prolapse of the uterus may first set in at this period of life.
There are several contributory causes of the liability to prolapse at this particular epoch, especially in women who have had a great many children, and in those with either enlargement of the uterus or with lacerated perineum; the most powerful of these causes being the weakening of the uterine supports in consequence of the general relaxation of the pelvic tissues. At the menopause, the connective tissue by means of which the uterus is attached to surrounding structures, withers; simultaneously the vagina atrophies, and this source of support is weakened; the whole pelvic floor loses its firmness and power of support. For these reasons, a uterus which has hitherto been in correct position readily becomes retroverted and to some extent prolapsed; whilst one that was already thus far displaced prior to the menopause, will now be apt to descend still further till it rests upon the perineum. With the disappearance from the vulva and the perineum of the adipose tissue on which their firmness so largely depends, complete prolapse of the uterus is now likely to ensue. Prolapse of the urethra may also result from senile involution of the pelvic contents.
Among my 500 cases of women at the climacteric, there were 65 instances of more or less severe prolapse of the uterus. The frequency of prolapse in women at the climacteric and in those at a more advanced age, is shown by the following figures, which are compiled from the post mortem statistics of the Pathologico-Anatomical Institute of Prague (years 1868 to 1871). Prolapse of the uterus was found:
In the quinquennium 30 to 35 in 2 women In the quinquennium 35 to 40 in 2 women In the quinquennium 40 to 45 in 6 women In the quinquennium 45 to 50 in 3 women In the quinquennium 50 to 55 in 6 women In the quinquennium 55 to 60 in 8 women In the quinquennium 60 to 65 in 6 women In the quinquennium 65 to 70 in 4 women In the quinquennium 70 to 75 in 4 women In the quinquennium 75 to 80 in 4 women In the quinquennium 80 to 85 in 2 women
Flexions and versions of the uterus, common as they are at the time of the menopause, have no longer the same importance that they possessed during the prime of the sexual life. For on the one part the size of the uterus is greatly diminished, in consequence of the lessened blood-supply and of senile involution of the organ; and on the other, after the cessation of menstruation, the profuse haemorrhages and severe colicky pains which for the most part occurred during menstruation in these cases of kinking of the uterine canal, and which gave rise to such severe general disturbance, now no longer occur. Herein lies the explanation of the fact, well known to all experienced practitioners, that women who have for many years suffered from retroflexion or retroversion of the uterus associated with severe and painful symptoms, cease to suffer after the menopause is established, and regain excellent health, although the local condition of the uterus remains unrelieved.
Neoplasmata of the Uterus and of the Uterine Annexa.—The most serious danger to the life of a woman during the climacteric period is to be found in the strong tendency to the occurrence of carcinomatous disease of the uterus—a predisposition so marked that not less than one-half of all illnesses affecting the reproductive organs of women at this age are cases of carcinoma of the uterus. The disease occurs especially at the beginning of the climacteric, between the ages of 45 and 50 years, most often in the form of carcinoma of the portio vaginalis, whereas after the completion of the menopause, carcinoma of the body of the uterus is the preponderant form. The true reason for the frequency of the occurrence of carcinoma at this period of life will only become clear to us when we are more fully acquainted with the nature and origin of this form of malignant disease. Meanwhile, it would seem that the predisposition to cancer during and shortly after the menopause depends upon the anatomical changes in the reproductive organs at the time of involution, which render these organs a more suitable soil for the proliferation of malignant growths; and further it is probable that the loss of the acid, bactericidal quality of the vaginal secretion, opens the door for the entrance of pathogenic micro-organisms. Noteworthy is the observation of Baer and Leopold, that very frequently a preclimacteric or climacteric fungous endometritis forms the stage of transition to the development of carcinoma of the body of the uterus. At the time of the menopause there is also an increased liability to the occurrence of cancer of the ovaries. Numerous statistical data have been published regarding the frequency with which carcinoma of the uterus occurs at various periods in women’s lives, and, notwithstanding all variations, one fact stands out clearly, namely, that this disease occurs most frequently in the fourth and fifth decennia, and above all during the climacteric period.
From Gusserow’s collection of 526 cases, observed by Lebert, Kiwisch, Chiari, Scanzoni, and Saexinger, the following table has been drawn up, and it shows very clearly the great preponderance of the disease in the fifth decennium of a woman’s life:
At ages of from 20 to 30 there were 12 cases At ages of from 30 to 40 there were 161 cases At ages of from 40 to 50 there were 217 castes At ages of from 50 to 60 there were 102 cases At ages of from 60 to 70 there were 38 cases At ages of from 70 and upwards there were 5 cases
From the mortality statistics we obtain a similar result as regards the age incidence of carcinoma of the uterus. Thus, in England there died of this disease in one year:
Women at ages of from 15 to 25 44 Women at ages of from 25 to 35 184 Women at ages of from 35 to 45 717 Women at ages of from 45 to 55 1110 Women at ages of from 55 to 65 1116 Women at ages of from 65 to 75 876
Coming now to the consideration of fibromyomata of the uterus, we cannot share the opinion that at the climacteric age there is a special predisposition to the origination of such tumours, or that the climax favours the growth of already existing fibromyomata. It appears to us that in the preclimacteric epoch and the commencement of the climacteric, the symptoms of existing fibromyomata become more troublesome, the haemorrhages are more severe, the pains more violent; but that as the menopause is established, these troublesome symptoms decline progressively in intensity, and not only is there an arrest in the growth of the tumours, but often an actual diminution in their size.
I have myself repeatedly observed such cases, in which I had the opportunity of watching the growth of the myomata during a period of ten years or more. Other cases, indeed, show that myomata may increase in size after the menopause, at times with remarkable rapidity, and further that at this period of life a malignant degeneration may occur in such tumours. Carcinomatous, sarcomatous, and myxomatous degeneration have been observed, and also the transformation of a myoma into a soft fibrocystic tumour.
Atrophy of fibromyomatous tumours at the menopause, associated with the atrophy of the uterus that then occurs, has been observed by Playfair and by Doran. The tumour shrinks, its muscle-cells become smaller, and undergo fatty degeneration, there is an increase in the interstitial connective tissue, so that ultimately the fibromyoma is transformed into a firm and dense fibroid swelling. Cases in the older literature and also a recent observation of Yamagiron have shown that calcification of uterine fibromyomata sometimes occurs, leading to the formation of the so-called “uterine calculi.” In the case of pure myomata, the diminution in size occurring at the climacteric is generally due to resorption and fatty degeneration, whereas in the case of fibromyoma it depends on induration and atrophy. It remains uncertain whether the growth of purely fibrous tumours is also affected by the climacteric.
Whilst the influence of the climacteric on the growth of fibromyomata is thus usually advantageous to the patient, exceptions occur, as is shown by cases recorded by Lawson Tait, Schorler, and Boerner; the last-named author points out that at the climacteric there is a tendency for the transformation of fibromyomata into sarcomata.
Kleinwächter had under observation 78 cases of fibromyomata of the uterus in women who were older than 45 years; in only 8 of these was a diminution in the size of the tumour observed at the menopause; in 11 cases at this time, the tumour increased in size more or less rapidly; in 3 cases, a carcinomatous change occurred in the tumour; in 3 cases, the tumour was first observed at the time of the menopause; in 13 cases, the haemorrhages appeared to undergo a complete arrest at the menopause, but the size of the tumour was not affected; in the remaining 48 cases, no influence, either favourable or unfavourable, appeared to be exercised by the menopause on the fibromyoma of the uterus.
Cases reported by Rogival, Simpson, and Gusserow indicate the existence of a certain predisposition to the growth of sarcomata of the uterus at the climacteric period. Gusserow more particularly insists on the fact that we must bear in mind the likelihood of the origination of a fibrosarcoma or of the sarcomatous transformation of a fibromyoma, in all cases in which a fibrous tumour of the uterus first attracts attention at the climacteric period; or in which a tumour hitherto small and inconspicuous and giving little or no trouble, begins at this time to increase in size or to give rise to troublesome symptoms.
Neuroses of the Reproductive Organs.—One of the commonest neuroses of the reproductive organs at the climacteric period is pruritus vaginae et vulvae, and it is one of the most distressing symptoms of which women of this age complain. The disorder depends upon a hyperaesthesia of the sensory nerves of the vagina and the external organs of generation. It is characterized by enduring sensations of itching and burning, which may be either periodic (and then usually nocturnal) or continuous; at times it becomes so severe that the women thus affected have an unceasing desire to scratch, avoid all society, and ultimately find life quite unbearable. In the slighter degrees of pruritus, no objective changes are to be observed in the genital organs, or at most some slight hyperaemia of the vaginal orifice. In the more severe forms, however, there are local nutritive changes: the labia are swollen, their surface has an erythematous blush, a number of the hair-follicles are enlarged and prominent; the vaginal orifice is abnormally sensitive, it is scarlet or livid-red in colour and here and there denuded of epithelium, and there are scattered mucous follicles distended with a serous or purulent fluid; these small vessels are to be seen chiefly on the inner surfaces of the labia minora and around the clitoris. At the same time, the vulva secretes an acid, burning fluid, which greatly increases the patent’s sufferings, and at times impels her irresistibly to the practice of masturbation. In cases of long standing, we find hypertrophy, elongation, and deformity of the nymphæ, and pigmentation of these organs, with the formation of varices.
According to Fritsch, in exceptional cases pollutions are the originating cause of the pruritus, and this may be the case in women who are not sexually passionate. It occurs, indeed, especially in matrons who have not had sexual intercourse for years, and who have quite ceased to think about sexual matters; during the night, such a woman will begin to have voluptuous dreams, associated with a degree of sexual stimulation which is described as being actually painful. The woman often suffers greatly from these lascivious sensations. She complains that she cannot understand how it is that she has become affected with such utterly undesired feelings. She becomes profoundly depressed. Coitus often gives no relief whatever; but many women thus affected declare, as Fritsch points out, that by powerful, almost involuntary scratching, the stimulus is speedily subdued, and that for this reason they are absolutely compelled to scratch. It will readily be understood, that in this way persistent pruritus will arise, with local effects of scratching, and vulval eczema. According to the same author, in some instances pruritus is due to great insufficiency of secretion, such as occurs in the endometritis atrophicans which he was the first to describe. This scanty secretion, as it passes over the external genital organs, gives rise to irritation and itching. Haemorrhoids also play a part in the etiology of pruritus.
Diseases of the Mammae.—The sympathy which in the earlier phases of the sexual life—during the menarche, during pregnancy, and during the puerperium—so obviously exists between the breasts and the uterus, is seen also during the climacteric period. It now finds expression chiefly in the marked tendency to new growths in the mammae, a matter to which attention was already drawn by Galen. The commonest of these neoplasmata is carcinoma mammae, a disease which occurs chiefly during the climacteric epoch. In the great majority of cases, cancer of the breast is a primary disorder; in exceptional cases, however, the carcinoma of the breast arises by metastasis from a cancer of the uterus or the ovary. Sometimes the breast tumour is preceded by Paget’s disease of the nipple. For several years the patient suffers from what appears to be a chronic dermatitis of the nipple, the areola mammae, and the surrounding skin; but ultimately, and hardly ever before the commencement of the menopause, carcinoma of the breast ensues.
The older statistical enquiries of Birkett, Lebert, Scanzoni, and Velpeau, showed that carcinoma mammae most commonly occurred between the ages of 40 and 50 years, and next to that in frequency between the ages of 50 and 60 years.
A general hypertrophy of the mammary gland, affecting not only the enveloping and intra-lobular adipose and connective tissue, but also the proper glandular substance, is very rarely observed during the climacteric period; but in the preclimacteric epoch and in the early part of the climacteric, we not uncommonly see a hyperplasia of the adipose tissue of the breast, either as a local manifestation of a developing general obesity, lipomatosis universalis, or as a purely local excessive deposit of fat. In such circumstances, the mammae may at times be transformed into monstrous tumours.
Diseases of the Organs of Circulation.
Among the cardiac disorders of the menopause, the earliest and the commonest is, in my own experience, the following. At the time of the menopause, exceptionally not till after the complete cessation of menstruation, but usually at the commencement of this period of life, some time, that is to say, between the age of 40 and 50, either when menstruation has become irregular, the intermenstrual interval having become longer or shorter than has hitherto been the case, or when the discharge has become abnormal in character, a woman who has not before suffered from any kind of cardiac disorder, will begin to complain of paroxysms of palpitation.
In some cases the attacks of palpitation occur in the absence of any discoverable exciting cause; in others, some trifling stimulus gives rise to them. They may arise when the patient is in any position, walking, standing, sitting, or recumbent; sometimes even during sleep. The subjective sensation aroused by the increased force and frequency of the cardiac action is described as extremely distressing; it is associated with a feeling of anxiety (Angst), with a sense of pressure in the chest, with forcible pulsation of the carotids and of the abdominal aorta; frequently also with a feeling of a rush of blood to the head, with fugitive heats, and severe headache; sometimes towards the end of the attack there is a sense of flickering before the eyes (as of muscae volitantes), tinnitus aurium, dizziness, and in rare cases actual syncope.
Objectively, during the paroxysm, a notable increase in the frequency of the heart’s action can be detected, the pulse-rate rising to 120 or even 150 per minute. In most of my cases, the pulse throughout the attack remained strong, well-filled, and regular. Sphygmographic tracings taken during the seizures showed a remarkably high pulse-wave, the ascending limb of the curve rose rapidly and suddenly, the descending limb fell with corresponding steepness and rapidity, and it reached an unusually low level before the commencement of the dicrotic elevation, which latter was exceptionally large; the predicrotic elevations, on the other hand, were but slightly developed. On auscultation, the tones of the heart were pure, but were louder than normal.
Sometimes during a paroxysm a sudden reddening of the face was noticeable, extending often to the neck and the thorax. In the areas mentioned, vivid red patches would suddenly make their appearance, disappearing more gradually after lasting a few minutes—this appearance was associated with a burning sensation of the affected areas. In some cases during the paroxysm there was an outbreak of perspiration on the head and the back.
Associated with these cardiac troubles of women at the climacteric we usually find a state of physical and mental disquiet; less common associations are, an incapacity for regular work, sleep uneasy and much disturbed by dreams, great general nervous irritability, or signs of passive congestion in various organs; occasionally there is oedema of the lower extremities; the urine remains free from albumen.
In most of the cases of this nature which came under my own observation, a certain plethora was noticeable; among women at the menopause, it was especially the well-nourished, powerful, sanguine individuals, that were liable to palpitation of the heart. Direct examination of the blood sometimes showed a very high haemoglobin richness—110, 115, or even 120, as compared with a haemoglobin-richness of 93 in normal woman. Several of my patients presented the clinical picture of the plethoric form of lipomatosis universalis.
In all, during ten years, I observed 67 cases of paroxysmal tachycardia in climacteric women. The age distribution was the following:
36 years of age 1 woman 38 years of age 1 woman 39 years of age 2 women 40 to 45 years of age 37 women 45 to 50 years of age 28 women Over 50 years of age 8 women
Five of the patients were unmarried, three were married but childless, the remaining 59 were parous women.
As a general rule, women live in great dread of all manifestations of bodily disorder during the menopause; those who become affected with paroxysmal tachycardia are exceptionally anxious, and regard themselves as threatened by a “stroke.” This pessimistic view is however, by no means justified. These cardiac disorders may make their appearance some time before the menopause, they may persist throughout the period during which menstruation is irregular, they may even endure for some time after the total cessation of the flow—but serious consequences of this climacteric tachycardia have never come under my observation. As regards treatment of the disorder, I have seen very favourable results from the following measures: The systematic employment of mild purgatives, combined with suitable dietetic and hygienic regulations (bland diet, regular and strenuous exercise, cold ablutions, and wet compresses surrounding the abdomen).
When we enquire regarding the cause of the tachycardiac paroxysms occurring at the menopause, we must first of all bear in mind that in the cases which have come under my own observation, the cardiac impulse was powerful, the pulse strong and well-filled, that signs of general vasomotor disturbance (ardor fugax, etc.) accompanied the tachycardiac seizures,—hence we are led to infer that we have to do with a stimulation of the excito-motor nerve fibres, which would appear to be due to the climacteric changes previously described as occurring in the female reproductive organs. This view receives support from the fact that after oöphorectomy, when, as in the normal climacteric, atrophic processes occur in the internal reproductive organs, paroxysms of nervous palpitation are frequently observed. The same explanation applies to the fact that in women at the climacteric affected with these tachycardiac troubles, we frequently see in association therewith the symptoms of uterine dyspepsia.
But in addition to these local anatomical changes in the reproductive organs, to which an etiological role must be assigned in the production of climacteric tachycardia, the irritable state of the accelerator nerves must also depend in part upon that general nervous hyperexcitability which is so often a characteristic feature of the climacteric period in women, manifesting itself in manifold hyperaesthesias, hyperkinesias, neuralgias, and, in extreme cases, mental aberration. The sensory nerves are more irritable than in their normal state, so that every stimulus acting upon them evokes a greater central effect than heretofore, and upon this ensues an exaggeration of various reflex manifestations, which appear altogether disproportionate to the strength of the exciting cause; among these disproportionate reflex effects, is to be numbered the tachycardia just described.
But in addition to the causes of climacteric tachycardia already enumerated, we have to take into consideration the results of recent investigations concerning the organo-therapeutic employment of the chemical constituents of the ovarian tissue; it would seem that when at the menopause the ovaries undergo atrophy, so that their internal secretion is no longer poured into the blood, the resulting alteration in the chemical constitution of that fluid gives rise to a disturbance of the vasomotor centre in the medulla oblongata.
In some cases, the tachycardiac paroxysms appear to be connected with the erotic excitement to which women are sometimes subject at the climacteric, voluptuous crises and ejaculation occurring; it is possible that in some of these cases masturbation plays a part.
A second group of cardiac troubles occurring in climacteric women consists of cases which are very common, but not often very severe. The cases in question depend upon the liability to an increased deposit of adipose tissue in the body at the time of the menopause, and in this connexion the plethoric form of lipomatosis universalis almost invariably predominates. It is a well-known fact that between the ages of 40 and 50 years women have an excessive tendency to obesity, and that even those women who have hitherto been extremely lean are apt to become quite plump at the climacteric period. Chiefly in consequence of this increasing obesity, there occurs in climacteric women a series of cardiac troubles of very variable intensity. If the deposit of fat is effected very gradually, and if the obesity does not become extreme, it is only after vigorous bodily exercise, such as fast walking or going upstairs, and after meals, that the patient is troubled with a little shortness of breath and moderate palpitation; appetite, digestion, and sleep remain usually unaffected in cases of this degree of severity. Definite attacks of cardiac asthma, and well-marked signs of cardiac insufficiency affecting the entire circulatory system, will very rarely occur in such persons.
It is an interesting fact, that the troubles which arise from fatty deposits around the heart are in general far less severe in climacteric women than they are in obese men of corresponding age. This may be due to the circumstance discovered by W. Müller, in the course of his investigations on the proportions of the human heart, that in the development of general obesity, the pericardial fat increases proportionately to a greater extent in the male than in female. But in my opinion the true explanation is to be found in the fact that variations in the amount of fat in the body are normally far more extensive in women than in men; at puberty, during pregnancy, and during lactation, extensive though gradually effected changes in the amount of adipose tissue in various parts of the body occur, so that experience has rendered the organism ready to adapt itself to the further changes that take place at the climacteric—above all, the heart has become competent to meet very various demands upon its powers.
Only in women who from youth onwards have exhibited a marked tendency to obesity, and in whom at the climacteric age such obesity has become extreme, do the cardiac troubles attendant on the menopause become very severe. In such persons, palpitation and shortness of breath occur on slight exertion, and attacks of cardiac asthma are frequent. In consequence of the diminished propulsive power of the heart, circulatory difficulties make their appearance in the most widely divergent venous areas; the forms most commonly met with are, varices in the veins of the lower extremities, permanent dilatation of certain of the small superficial veins of the skin, phlebectases of the rectal veins (i. e. “piles”), and ultimately we see the well-known series of symptoms of venous engorgement—oedema of the feet, passive congestion of the lungs, albumen in the urine, etc.
When such cardiac troubles are present, the objective examination of the heart shows in the early stage no gross abnormality; at most the heart-tones seem somewhat weakened, with a moderate enlargement of the area of percussion-dulness, whilst the impulse is displaced a little outwards, and is weaker than normal. In some cases, however, a marked dulness on percussion over the sternum indicates an extensive deposit of fat in the mediastinal tissues. In the second stage of the fatty heart, when the symptoms have become more severe, we find a considerable enlargement of the area of cardiac dulness both in the vertical and the horizontal extent; the cardiac impulse is diffused as well as feeble. The sounds of the heart are usually pure but faint—in some cases they remain loud and clear. Exceptionally, a short blowing murmur is heard with the first sound; and sometimes this sound is reduplicated.
Whilst in the first stage the pulse is hardly abnormal, in the second stage, very various changes occur; often it is subdicrotic or dicrotic in character.
In the great majority of instances, in these cases of cardiac disorder at the menopause, provided a suitable dietetic regimen is early adopted and perseveringly carried out, we may give a hopeful prognosis.
A third, less common but far more serious form of cardiac disorder occurring at the menopause, displays the well-known symptoms of cardiac failure. Those thus affected are usually slightly built, delicate women, who during the years of development suffered from chlorosis, who in adult life were troubled with anæmic symptoms, and in whom the menopause was ushered in by very severe losses of blood; sometimes, again, they are women who throughout their sexual prime have been accustomed to menstruate very abundantly, who have had numerous and severe deliveries, or who have had frequent miscarriages—it is in those who have thus been weakened by frequent and profuse haemorrhages, that the symptoms of cardiac failure ensue at the climacteric period. The women thus affected also frequently suffer from palpitation of the heart; the pulse is abnormally frequent, small, low, and easily compressible, and sometimes intermittent or arrhythmical. The heart’s action is weak and devoid of energy. The heart-sounds are usually obscure, and sometimes a systolic murmur is audible. The patients are short of breath and are subject to attacks of cardiac asthma, not infrequently associated with angina pectoris. In conjunction with these symptoms, we see signs of venous congestion: sudden attacks of coldness in the hands and feet, often also oedema of the feet; the urine at times contains albumen. The haemoglobin-richness of the blood is always notably diminished. I need not discuss in further detail the well-known symptoms of cardiac insufficiency, and I need only insist that when these symptoms are met with in women at the climacteric, it is of the greatest importance, alike from the prognostic and from the therapeutic standpoint, to make a careful examination of the reproductive organs, so as to determine the exact source of the recurrent bleedings which usually constitute the primary cause of the patient’s sufferings.
In several cases of this kind, I found that the haemorrhages were due to a relaxation of the uterine tissues, and that this relaxation was itself referable to intrapelvic circulatory disturbances, dependent upon obstruction in the vena cava inferior, whereby the venous return from the pelvis was rendered difficult, and an engorgement of the uterine vessels was brought about.
In some instances of cardiac failure at the menopause, chronic inflammation within the pelvis is to blame for the menorrhagia upon which the cardiac failure depends. Often, again, the haemorrhages are referable to vasomotor influences, such as are liable during the menopause to affect various vascular areas. In other cases, the recurrent bleeding is due to retroflexion of the uterus, to prolapse of that organ, or to tumour, it may be myoma, polypus, or carcinoma.
Finally, during the menopause, more especially in women in whom menstruation has continued up to or beyond the fiftieth year, or in those who have given birth to a large number of children or have lived lives of severe bodily exertion, cardiac troubles may arise dependent upon arteriosclerosis of the great vessels. The signs of such changes in the walls of the bloodvessels are clearly marked: the cardiac impulse is heaving, the second sound of the heart is accentuated; the pulse is full and large, usually giving a very powerful blow to the examining finger, whilst its sphygmographic tracing exhibits characteristic signs in the exceptional height and great distinctness of the first predicrotic elevation. The subjective troubles are in these cases very severe; dyspnoea and attacks of asthma or of vertigo are common, and sometimes albumen may be found in the urine.
We may thus summarize the cardiac disorders met with at the menopause, and more or less directly dependent upon the changes undergone by the feminine organism at that period of life:
1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric changes in the ovaries.
2. Nervous palpitation in women who were similarly affected at the time of the menarche, and in whom the trouble is merely the expression of a very unstable nervous system, and one influenced with especial readiness by impressions proceeding from the reproductive organs.
3. Cardiac disorder due to the obesity so commonly occurring as a part of the general metabolic changes of the menopause, but more particularly dependent upon a deposit of fat in the neighbourhood of the heart itself.
4. Symptoms of cardiac failure, due to excessive losses of blood at the menopause, either as an exaggeration at this time of menstrual processes, or as a result of some actual disease within the pelvis.
5. Cardiac disorder in women in whom the menopause occurs at an unusually advanced age, and dependent upon arteriosclerosis.
Particular consideration must be given to a symptom not infrequently occurring in association with the cardiac troubles of climacteric women, and referable to the circulatory disturbances characteristic of this period of life, namely, vertigo. The attack in some cases comes on without apparent cause, in others it occurs on the performance of some unusual movement or the adoption of some peculiar posture (stooping, or the like); the patient is suddenly seized with a sense of rotation, either of his own body, or else of his visible and palpable environment; with this is associated a sensation of disturbance of equilibrium, flickering before the eyes (muscae volitantes), tinnitus aurium, palpitation of the heart, increased frequency of the pulse, which may be either full or small, redness or pallor of the face, coldness of the hands and feet, muscular twitchings, a sense of great anxiety, and the outbreak of a cold perspiration. The vertigo occurs in paroxysms, usually of short duration—a few minutes to a quarter of an hour. It is especially plethoric and obese women who are liable at the climacteric to suffer from this disorder.
A somewhat similar condition is described by Tilt under the name of “pseudo-narcotism,” as frequently occurring in climacteric women. Tilt indeed states that in 500 such women, he noted its presence in no less than 277.
Many hypotheses have been promulgated to account for the vertigo that so frequently occurs at the menopause. Both anæmia and hyperaemia of the brain have been assumed as causes, alike dependent upon the irregularity of menstruation, which is supposed to have a reflex influence upon the cerebral circulation. Others regard the vertigo as a climacteric neurosis, since it occasionally occurs before the menstrual irregularities begin, and in such cases a reflex disturbance of the cerebral circulation cannot be supposed to have arisen. According to Matusch, climacteric vertigo is a manifestation of epilepsy—an explanation which has been often extended to include all the menstrual psychoses. Windscheid believes that in many of the cases the vertigo is to be explained by the existence of arteriosclerotic changes in the blood vessels, such as are already by no means rare at the age at which the menopause usually occurs; whilst in other cases, he believes, the vertigo is to be regarded as one of the symptoms of a nervous disorder. That in any case the vertigo is dependent in some way upon the changes that occur in the reproductive organs at the climacteric period, is shown by the fact that after the final cessation of menstrual activity the patient as a rule ceases to suffer from this symptom.
To the circulatory disturbances consequent upon the menopause we must also refer ardor fugax, fugitive heat, the sudden rushes of blood to which women are prone at this period of life.
The cardiac troubles of the menopause are seen especially in women in whom the cessation of menstruation occurs quite suddenly, and in those in whom menstrual activity ceases at an exceptionally early age. It would seem that in such cases, owing to the continuance of periodic maturation of the graafian follicles associated with congestion of the intrapelvic organs, in the absence of the periodic relief to that congestion afforded by the menstrual flux, there results a summation of stimuli, whereby the accelerator nerves of the heart are very powerfully affected.
Thus, I had under my care a lady from Smyrna 36 years of age. She had begun to menstruate when 12 years of age and menstruation was always scanty; she married when 15 years old, and finally ceased to menstruate when 19 years of age; she was sterile, and no abnormality could be detected on physical examination of her reproductive organs. Every month she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of blood to the head, perspiration of the face, etc.
In another case, that of a woman 45 years of age, menstruation, hitherto regular, was suddenly suppressed, during the flow, in consequence of a severe fright. The next month the flow failed to appear at the usual time, but instead the patient was affected with severe cardiac distress, accompanied by sudden sensations of heat in the face, palpitation of the heart, and vertigo; these symptoms lasted for several days, and since then have recurred at intervals of three or four weeks.
The cardiac troubles of the menopause are seen with especial frequency in women who were affected with similar disturbances at the time of the menarche. Experience clearly shows that a certain connexion exists between the manifestations that accompany the commencement of sexual activity, and those that accompany the decline and extinction of that activity; and a physician will rarely be mistaken if he bases on the fact that the general health was or was not seriously affected at the age of puberty, a prognosis that the course of the climacteric will be an unfavourable or a favourable one, respectively. In other words, in women whose nervous system is an unstable one, and in those with hereditary predisposition to the occurrence of cardiac disorder, the changes that take place in the reproductive organs both during the menarche and during the menopause, are likely during these vital phases to arouse reflex disturbances of the cardiac functions. The facts thus noted are analogous to those observed by Potain, who distinguishes a peculiar form of chlorosis, occurring in delicate individuals at the age of puberty, and, though apparently cured during the menacme, recurring in its primitive severity at the time of the menopause.
Again, women with a sanguine and erethistic temperament are more inclined to suffer from cardiac troubles at the menopause than women of a tranquil temperament and those endowed with an unimpressionable nervous system.
Finally, elderly virgins, women who have for many years lived in chaste widowhood, sterile women, women who have married shortly before the menopause, or who at this time have recently been delivered, are all more inclined to the cardiac troubles of the climacteric period than women whose sexual life has been of a less abnormal character.
In the literature of the subject, we find numerous references to the fact that among the disorders of the climacteric, circulatory disturbances play a part. But a full and accurate account of these disorders is lacking alike in the literature of gynecology and in that relating to diseases of the heart—and this is true even of the most recent publications.
Among striking individual cases, one recorded by Moon may be mentioned here, a case of tachycardia consequent upon a sudden menopause: “In a woman 35 years of age the menses were suppressed owing to chill; the pulse-frequency increased from 80 to 200, without any apparent change in the heart or its valves; the symptom lasted for several days, when menstruation became once more established, and the pulse-frequency fell again to the normal.”
Tilt expresses the opinion that the heart is but little involved in the disturbances of the climacteric, his experience coinciding with that of Quain. Boerner and Glaevecke, on the contrary, describe the heart troubles of the climacteric in terms very similar to those employed by myself.
A. Clément describes a peculiar form of disturbance of the functions of the heart at the climacteric period, to which he gives the name of Cardiopathie de la Ménopause, and of which he has seen four cases. The age of his patients varied from 46 to 50 years. They were all vigorous women, free from hysterical symptoms, and they had never suffered from rheumatism or from any functional disturbance of the heart. In all these cases the cardiac disorder occurred at a time of life when menstruation still continued, but had already become somewhat irregular. Usually the trouble in question makes its first appearance during the flow, or, if occurring independently of menstruation, becomes more severe at that time. Prior to the development of the actual heart symptoms, we observe for a time, two or three months it may be, signs of general exhaustion and weakness. Then occurs an attack of palpitation of the heart, rapidly succeeded by faintness, sense of precordial anxiety, and dyspnoea. During repose the patient does not usually suffer from any difficulty in breathing, but sleep is apt to be disturbed by paroxysms of palpitation and severe precordial anxiety. As the disease advances, dyspnoea is observed on the slightest exertion. Ultimately, the symptoms mentioned, palpitation, precordial anxiety and dyspnoea, become permanent, but are less severe when the patient is at rest. Constant now is also the feeling of weakness and faintness, which from time to time increases to actual syncope with complete loss of consciousness, and coldness of the entire surface of the body. Examination of the heart gives negative results. The cardiac impulse is a little stronger than normal; the cardiac rhythm may be either regular or irregular, but actual intermission of the beats does not occur. The heart-sounds are pure, there is no murmur; the first sound, if altered at all, will be stronger, not weaker than normal. Neither swelling of the jugular veins nor venous pulsation is to be observed. The most striking symptom of heart affection, indeed the only positive physical sign, is the great increase in the frequency of the heart’s action, the pulse rate often being as much as 150 or 160 per minute, and in addition weak and somewhat variable in strength. At the outset of the disease, no oedema of the lower extremities is to be observed, and it only appears after three or four attacks. In all the patients the extreme pallor of the face is a striking feature. An increased quantity of urine is eliminated. The course of the disease is characterized by a series of successive paroxysms, separated by periods of almost complete remission. At first, these remissions last for a month or two, but they gradually become shorter and shorter, whereas the duration of the attacks continually increases, until it is as much as seven or eight days. At this stage, disturbance of digestion ensues, the appetite is lost, and the general vigour declines. Recovery ultimately occurs, but very gradually. Clément refers the disease to a profound disturbance of the cardiac innervation through the sympathetic nerves, but believes that anæmia constitutes a contributory cause of the cardiac disorder.
Kostkewitsch has made observations regarding the influence of the climacteric upon previously existing heart-disease, and has thereby been led to conclude that the influence is unfavourable. The functional disturbances of the cardio-vascular apparatus which commonly accompany the menopause, readily lead, should organic heart-disease exist, to the onset of severe cardiac weakness, which may have a rapidly fatal termination. In 55.5% of the women who enter the climacteric period with organic disease of the heart, the menopause gives rise to a failure of compensation. Such failure of compensation is especially likely to occur in women suffering from valvular insufficiency; it is least probable in cases of arteriosclerosis without valvular defect. The symptoms of defective compensation—dilatation of the heart, increased frequency of the pulse, arrhythmia cordis, etc.—are manifested especially during the menstrual flow.
Diseases of the Digestive Organs.
The congestions which, as we have already pointed out, constitute the pathological basis of the majority of the disorders of the climacteric, manifest themselves in the abdominal organs in the well-known form of plethora abdominalis, chronic venous congestion of the gastric and intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the mucous membrane of the bladder, catarrh of the bladder, distension of the haemorrhoidal veins, and the various symptoms dependent upon these several forms of congestion.
Bleeding from the haemorrhoidal veins and chronic diarrhoea are two of the troubles proceeding from the above mentioned congestion of the intra-abdominal vessels, which occur so frequently during the climacteric period that since the days of antiquity they have been regarded as critical manifestations of the menopause, the object of which is to afford a vicarious outlet for the menstrual flux, now become irregular and intermittent. It can, indeed, be readily understood that a discharge of blood and an increased secretion from the mucous membrane of the lower part of the intestine may, if not too violent, exercise a favourable influence upon the congestive states of the climacteric, by relieving the distension of the abdominal vessels—by a local blood-letting which regulates the disordered circulation. In this way, even though we have ceased to regard it as a “critical” manifestation, haemorrhoidal bleeding, accompanied by an increased secretion from the intestinal mucous membrane, may at the climacteric period have a distinctly favourable influence upon a woman’s general condition.
Hippocrates already in his aphorisms pointed out the salutary effect of epistaxis and of diarrhoea in women suffering from suppression of the menses. Other authors have assigned a critical significance to diarrhoeas occurring at the climacteric, and have warned against their suppression. According to Tilt, diarrhoea occurred in 12% of all women of this age coming under his observation; in 4% of the climacteric women, this diarrhoea recurred at regular monthly intervals, whilst in 8%, the recurrence was irregular. In 500 women during the climacteric age, Tilt observed the following abdominal disorders:
Swollen haemorrhoids in 62 cases Diarrhoea in 60 cases Enduring disturbance of the biliary secretion in 56 cases Bleeding haemorrhoids in 24 cases Intestinal haemorrhages in 20 cases Icterus in 6 cases Hæmatemesis in 4 cases Monthly intestinal haemorrhages in 2 cases Monthly bleeding from haemorrhoids in 1 case
In my own observation, constipation is more frequent in climacteric women than diarrhoea, the constipation being also a symptom of abdominal congestion. Sometimes, when diarrhoea occurs, it is really secondary to constipation. The accumulation of the faecal masses stimulates the intestinal mucous membrane, and gives rise to a profuse aqueo-mucous secretion; the firm faecal masses are then liquefied, the intestinal wall is lubricated, and the constipation gives place to diarrhoea lasting perhaps for several days. This is the explanation of many cases in which there is a periodic recurrence of diarrhoea.
Dyspeptic disturbances are rarely absent during the climacteric period. Most often we see disordered appetite, sluggish digestion, pyrosis, eructation, at times nausea and retching, and actual vomiting of a watery or bilious fluid. Occasionally, an abnormal sensation of hunger follows each meal, associated, however, with a feeling of distension of the stomach. A very distressing symptom is an excessive formation of gas within the intestine. At times such meteorism is extreme, and it then gives rise to very severe abdominal pain. The gas is evacuated slowly and with difficulty, the patient is compelled to loosen all her clothing; more especially after a meal she is compelled to take off her stays and undo all the bands of her petticoats and skirt. At the same time we see difficulty in breathing and tachycardia. Such an accumulation of gas within the abdomen may give rise to serious errors in diagnosis, the swelling being attributed to pregnancy or to abdominal tumour.
Noteworthy also at the time of the menopause is the occurrence of vomiting, either as an isolated symptom, or in association with some other well-known climacteric disorder. When this vomiting is associated with some unmistakable form of excessive secretory activity (hyperhydrosis, etc.), we may readily suppose that the vomiting is due to undue secretory activity on the part of the gastric mucous membrane. An excessive production of gastric juice, perhaps altered in quality as well as quantity, combined with some other disorder of gastric innervation (hyperaesthesia, or hyperkinesia) will sufficiently explain the occurrence of the sometimes excessive vomiting, even though in many of the cases there may be no reason to suppose that there exists any primary stimulation of the vomiting centre. In other cases, however, it is probable that the trouble is really due to a primary disorder of that centre; and a careful study of the clinical features of the case will be needed to show how far there may be associated with this other disorders of gastric innervation (Boerner).
Disturbances of the biliary secretion, icterus of greater or less severity, are by no means rare manifestations of the abdominal congestion of climacteric women, and such disorders have also been regarded as vicarious processes originated by the cessation of the menstrual flux (Aran, Bennet, Henoch, and others.) Frerichs also has pointed out that with the cessation of menstruation at the climacteric we not infrequently observe swelling of the liver, which disappears when, after a considerable period, the menstrual flow recurs—a sequence of symptoms which may be repeated again and again for a considerable time.
Diseases of the Skin.
The most characteristic symptom of disorder of the skin met with at the climacteric period—one which, indeed, may be said to be never absent—is ardor fugax, fugitive heat; and scarcely less common is hyperhydrosis, an excessive secretion of sweat. Almost invariably, at the commencement of the menopause, women complain of a feeling of burning heat, rising up from the breast to the face; and if they are kept under observation we see from time to time a sudden redness of the face, and sometimes also of the neck and chest, associated with the outbreak of a thin perspiration. Moreover, in nearly all climacteric women, we notice an increased secretion of sweat over the whole surface of the body, and at times this secretion is extremely profuse.
In association with these symptoms we often see the hyperaemic processes in the skin known by the names of erythema and roseola, taking the form of larger or smaller bright red patches, which are most frequently seen on the sides of the neck, the front of the chest, and the face.
In many women, at the menstrual periods, when the flow has become scanty or has already entirely ceased, we observe the occurrence of eczematous eruptions, which have for this reason received the distinctive name of climacteric eczema. In the majority of these cases, the eczema does not make its appearance until the regular menstrual flux has completely ceased to occur; and in the less common cases in which the flow persists after the climacteric eczema has begun, menstruation is rarely regular, but has begun to exhibit the variability and disorder characteristic of the time of the menopause. If the eczema comes on after the menopause is completely established, it usually appears in from six to twelve months after the cessation of the flow; but in some cases, the eruption appears very soon after the menopause, whilst in others, its onset may be delayed for as long as four or five years. Climacteric eczema is obstinate, and shows no tendency to spontaneous cure. With regard to the localization of the eruption, Bohn found that in three-fourths of the cases it affected the hairy scalp and the ears; Rayer and Hebra also state that the eczema of the menopause is most frequently seen in these two situations, whilst the next commonest site for the eruption is the face. As regards other parts of the skin, it is only that of the extremities that is ever affected by this disease, especially the hands and the fingers, less often the forearms or the backs of the feet; it never appears on the trunk. With regard to the types of eczema occurring in connexion with the menopause, we see almost exclusively the squamous and the weeping forms of the disease.
In general, at the climacteric period, the skin is extremely sensitive, and devoid of powers of resistance to outward noxious influences. Alternations of dampness and dryness or of heat and cold readily give rise to redness, infiltration, and the formation of scales and fissures of the skin; sometimes this occurs merely after cold ablutions. These acute stages of swelling, redness, and vesiculation of the skin, readily pass on into chronic and obstinate dermatitis.
Not infrequently, during the climacteric, as during the menarche, inflammation of the sebaceous glands occurs, acne, at times accompanied by seborrhœic manifestations. In other cases, we see disfigurations of the face in consequence of vascular dilatations, especially on the nose and on the adjoining portions of the cheeks, rosacea, in which disease also there is associated inflammation of the sebaceous glands. Another disorder of the skin of the face which is greatly dreaded by women at this time of life, owing to the unsightly appearance it produces, is the development of sinuous dilatations of some of the superficial vessels, at times associated with connective tissue proliferation in the form of red or violet-coloured painless nodules.
An extremely distressing affection, and one which is especially apt to attack women during the change of life, is the previously mentioned pruritus genitalium. The itching is in some cases confined to the external genital organs, whilst in others it extends into the interior of the vagina; also it may pass backwards over the perineum, and on into the gluteal folds. In some cases, some local pathological condition will be found to account for the disorder: catarrh of the vagina or of the cervix uteri; displacements, inflammations, or new-growths of the uterus; anomalies of the ovary, the bladder, or the urethra. Cohnstein draws attention to a circular hyperplasia of the vaginal portion of the cervix, occurring during the menopause, and, “owing to the vascular dilation by which it is characterized, possessing close analogies with haemorrhoids;” the worst symptom of this affection is pruritus. That in these cases the pruritus is actually dependent upon the “haemorrhoidal hyperplasia” of the portio vaginalis, Cohnstein considers to be proved by the fact that, whilst local applications give no more than momentary relief to the itching, this symptom is completely relieved by the abstraction of blood from the cervix. But in addition to such cases as these, we have from time to time to deal with patients suffering from violent genital pruritus during the climacteric period, in whom we shall vainly seek for any local pathological changes, to the cure of which our therapeutic zeal may be directed. Analogy with some other disorders of the climacteric leads us to conclude that in these cases also we have to do with an idiopathic neurosis (Boerner).
The frequent recurrence of pruritus vulvae leads ultimately to the formation of nodules and papular eruptions.
Many authors state that they have observed the frequent occurrence of erysipelas during the climacteric period; others assert that furunculosis, prurigo, urticaria, and herpes zoster, are seen with especial frequency at this period of life.
Tilt, in his 500 cases of women at the climacteric age, made the following observations:
201, or 40.2%, suffered from heats and tendency to perspiration.
2, or 0.4%, suffered from monthly recurrence of periods of perspiration.
84, or 16.8%, suffered from profuse perspirations. 13, or 2.6%, suffered from cold sweats. 14, or 2.8%, suffered from dry heats (dry flushes). 186, or 37.2%, remained free from such attacks of heat or perspiration.
Krieger gives as an example of the “occurrence of new troubles” at the change of life, furunculosis; so also does Boerner. “The discolouration of the face, occurring usually in connexion with pregnancy or with diseases of the reproductive organs, and known as chloasma uterinum,” has been seen by Cohnstein, during the climacteric period, “chiefly in cases in which, owing to some degree of failure of general nutrition, the skin has been thrown into folds.” Wilson regarded prurigo and eczema as the commonest skin-diseases of the climacteric period; whilst Boerner draws attention to a connexion between climacteric conditions and the outbreak of herpes zoster.
Disorders of Metabolism.
Among the disorders of metabolism to which women are especially prone at the climacteric period, we must in the first place allude to obesity (lipomatosis universalis), and to gout (arthritis urica).
Numerous observations have shown us that the time of the change of life, the period between the ages of 40 and 50 years, is the one especially favourable in women to the extensive deposit of fat in the tissues.
In 200 cases of great obesity (lipomatosis universalis) in women, in which I instituted enquiries regarding the age at which an excessive deposit of fat in the tissues had first been noticed, I obtained the following results:
In early childhood in 19 cases At the age between 15 and 20 years in 30 cases At the age between 20 and 30 years in 45 cases At the age between 30 and 40 years in 52 cases At the age between 40 and 50 years in 54 cases At ages over 50 years 0 cases
We learn from these figures that it is between the ages of 40 and 50 years that there is the greatest tendency in women for the accumulation of fat; but that as early as between the ages of 30 and 40 years this accumulation may in many instances begin. Speaking generally, there is in women an obvious connexion between the development of obesity and the state of the reproductive functions, inasmuch as at puberty, during the puerperium, and above all at the climacteric, there is a special tendency to the accumulation of fat in the subcutaneous tissues. At the commencement of the menopause, it is more especially in the abdominal wall, the breasts, and the buttocks, that we witness the deposit of fat. In the abdomen, owing to the thickening of the subcutaneous tissues and of the great peritoneal folds—especially of the great omentum—a marked protrusion occurs, whilst the umbilicus becomes more deeply hollowed, and ultimately funnel-shaped. In some instances, the deposit of fat around the navel favours the occurrence of umbilical hernia. After an artificial menopause, induced by oöphorectomy, it has also been noticed in from 42 to 52% of the cases that a marked general deposit of fat has occurred, affecting especially the breasts and the buttocks.
This obesity in climacteric women, not only impairs to a serious extent their good looks, but brings in its train a number of troubles, and gives rise to manifold morbid manifestations, and among these, changes in the heart, which may readily threaten the patient’s life. In consequence of extensive fatty deposits in the myocardium, associated with actual fatty degeneration of the muscular fibres, cardiac insufficiency ensues, with all its distressing and disastrous consequences. It is further necessary to insist upon the fact that obesity during the climacteric very definitely favours the occurrence of menorrhagia.
On examining 282 women, 5 years after the complete cessation of the menstrual flow, Tilt found that
121 had become stouter than before, 71 were unchanged in this respect, and that 90 were thinner than formerly.
Alike in the third class and in the first were a very large proportion of women in whom the change of life had entailed much illness and suffering; but in the first class, the women who had been thus affected had at that time lost weight, and only in the latter half of the climacteric period, when their troubles had become less severe, had the condition of embonpoint made its appearance.
Passing now to the consideration of arthritis urica in women at the climacteric, it is worthy of mention that Hippocrates was so much struck by the association that he went so far as to deny that gout occurred at all in women before the menopause. The fact of the matter is that whilst women are in general less disposed than men to the occurrence of gout, the tendency of women to this disease during the climacteric period is so marked, that at this epoch of life the disease is far more common in women than it is in men of corresponding age.
It is in obese women, with a soft, white, and lax integument, with a pallid, somewhat bloated countenance, a poorly developed muscular system, extensive varicosities of the veins of the legs, marked dyspeptic troubles, and habitual constipation, that during the preclimacteric and climacteric periods, gout is especially apt to make its appearance. It is then characterized by the following symptoms. From time to time the woman suffers from tearing or shooting pains in the joints, lasting at first a short time only, and returning after longer or shorter intervals. With the frequent return of the pains, the affected joints become swollen; and finally the patient suffers from the characteristic attacks of acute gouty arthritis, with the well-known consecutive symptoms of this affection.
According to the observations of Geist, during the climacteric period, 28 women suffer from gout as compared with 4 men of corresponding age. Tilt publishes the following figures showing the mortality of women from gout in England:
At ages from 20 to 30 years 56 women At ages from 30 to 40 years 121 women At ages from 40 to 50 years 291 women
At ages from 50 to 60 years 152 women At ages from 60 to 70 years 104 women
Regarding diabetes mellitus during the menopause, Lawson Tait, who maintained there was a distinct form of climacteric diabetes, asserted that this disorder of metabolism was less severe, and runs a longer course during the climacteric period than at other times of life.
Diseases of the Nervous System.
The disturbances of the nervous system that occur during the climacteric period, manifest themselves chiefly in the form of hyperaesthesia and hyperkinesia. The sensory nerves appear to me for the most part to be more irritable than normal, inasmuch as every stimulus by which they are affected arouses a comparatively greater sensation, and gives rise to an excessive reaction in the sphere of consciousness. The cutaneous hyperaesthesia of climacteric women is shown in very various ways, the commonest being the anomaly of sensation which gives rise to the symptom known as pruritus, characterized by paroxysms of itching in more or less extensive areas of skin, with consecutive nutritive changes in the affected portions of the integument. The commonest and the most distressing form of this disorder during the menopause is pruritus vulvae.
In addition to such manifestations of cutaneous hyperaesthesia, vasomotor disturbances of the skin are of frequent occurrence, characterized by redness, rise of temperature, and sometimes the formation of nodules in the affected areas. Almost without exception, at the outset of the climacteric period, and sometimes also in the preclimacteric epoch, women complain of a very distressing feeling of fugitive heat in various portions of the surface of the body, manifested objectively by the rapid appearance and no less rapid subsidence of a red colouration of the skin of the face, the neck, and the chest. Such fugitive heats are due to disturbances of vasomotor innervation giving rise to sudden variations in the amount of blood passing through the vessels of the affected areas of skin.
Hardly less frequent during the climacteric are the sensations of imaginary movement which give rise to the subjective symptom known as vertigo. Often in women at this time of life it occurs quite without apparent cause, but in other cases on the performance of some unusual movement or the adoption of some unusual posture; there is a sudden perception of rotatory movement, either of the patient’s own body or else of her visible and palpable environment. With this feeling of disturbed equilibrium, there is often associated optical and auditory hyperaesthesia, flickering before the eyes (muscae volitantes), tinnitus aurium, painful sensations in the head and more especially in the occipital region, nausea, vomiting, sense of anxiety, cold sweats, muscular twitchings, alternating redness and pallor of the face, and coldness of the feet. The vertigo occurs in paroxysms, usually of short duration, varying from one to fifteen minutes. It is especially in plethoric and obese women that climacteric vertigo occurs.
A peculiar form of this climacteric vertigo is that described by Tilt under the name of “Pseudo-Narcotism” of climacteric women, characterized by a sense of swimming movements, uncertainty in the gait, vacancy of expression, a confused look in the eyes like those of a drunken person, and a kind of mental stupor which the patient cannot shake off without considerable effort. The women thus affected state that they feel as if they had had too much to drink, as if something had gone to their heads; indeed their great fear is that they will be supposed to be intoxicated by those who see them walking in the streets; they feel even that they must refuse to receive the visits of their acquaintances if they wish to preserve their reputation for sobriety. They suffer also from great drowsiness, from a disagreeable sense of weight or pressure in the head, from a feeling “as if the brain was clouded, or needed to have some cobwebs swept away.” They feel a disinclination to both mental and physical exertion, and their memory and all other intellectual powers are impaired.
Boerner maintains that the attacks of vertigo so frequently occurring at the menopause are in a minority of cases only dependent upon hyperaemic states (arising from the cessation of the menstrual flow); on the contrary, he believes that the cause more often lies in hysteria, in chronic disorder of the digestive tract, or, finally, in anæmia. In his opinion, vertiginous attacks dependent upon cerebral anæmia are very common indeed during the climacteric period, and even for a long time afterwards; and he believes that their nature is often completely misinterpreted.
Another very unpleasant indication of disordered nervous function during the climacteric period is the sleeplessness that is so common at this time of life. Women who during the day time feel comparatively well, suffer at night, sometimes periodically at exactly the same hour night after night, from a state of general restlessness, and for this reason are unable to obtain the sleep for which they long. They throw themselves uneasily from side to side of the bed, or wander restlessly about the room, and before long, owing to this want of sufficient repose, become greatly depressed.
Among the neuroses of the sensory apparatus, the various kinds of cutaneous neuralgia are less common than during the menarche and the menacme; but on the other hand, in my personal experience at any rate, the visceral neuralgias are commoner, more especially cardialgia and hypogastric neuralgia. Of the superficial neuralgias, hemicrania and intercostal neuralgia are those which occur most often during the climacteric period.
During the change of life, hemicrania most commonly occurs in typical association with menstruation; or, if the flow has already ceased, the attacks of hemicrania recur at what should be the menstrual periods. This affection is characterized by the paroxysmal occurrence of a severe boring pain in the side of the head, more often the left side than the right, affecting the temporal, the parietal, or the occipital region, or the entire side of the calvaria at once, usually accompanied with redness and local rise of temperature of the painful part; the duration of the paroxysms varies in different cases from one or two to many hours; with the pain are associated chilliness, nausea, exhaustion, and a severe feeling of general malaise.
Of the intercostal neuralgias, one form deserves especial mention in this connexion: I refer to mastodynia, which is both physically and mentally one of the most distressing affections to which women are subject during the climacteric period. For a middle-aged woman suffering from mastodynia—the “irritable breast” of Cooper—almost invariably feels assured that these pains localized in the breast and its immediate vicinity are indications of a commencing cancer of the breast; and it is an exceedingly difficult matter, in most cases, to convince her that her fears are without foundation. In this manner, partly in consequence of the directly depressing effect of the pains, which are commonly intensely severe, and partly owing to the disturbance of mind produced by the belief that an incurably fatal disorder has begun, I have in several instances seen cases of profound melancholia originate.
According to Windscheid, among the enduring painful sensations of the climacteric period, pains in the lower extremities are of somewhat frequent occurrence. Day after day the patient suffers from distressing tearing or lancinating sensations in the legs; the trouble is insusceptible of more exact description, but is none the less a very severe one. In addition to the lower extremities, the back, the spinal column, and more particularly the lumbo-sacral region, are often the seats of incessant pain. In the thoracic region of the back, the pain is usually diffuse; when confined to the spinal column, however, it is commonly limited to individual vertebrae, the spinous processes of those affected being also sensitive to pressure. The sacral pains may in some cases predominate to such an extent, that it is on this ground alone that the patient comes to seek medical advice. The sacrache is equally severe when the patient is standing, sitting, or recumbent; it often radiates into the lower extremities. Boerner draws attention to the fact that in many cases the pains in the sacrum or higher up in the back may be due to excessive tension of the abdominal parietes in consequence of the great accumulation of fat. Among motor manifestations, Windscheid draws especial attention to a certain degree of weakening of the muscles of the lower extremities. Although on examination no abnormality can be detected, fatigue and functional incapacity, more especially in the lower extremities, ensue in a manner altogether disproportionate to the exertion, so that the patient is most unwilling to take even a short walk, to go upstairs, etc. In pronounced cases, the patient will never go out walking without carrying a campstool, so that she can sit down to rest directly she begins to feel fatigued. In association with these disorders of motility we most commonly see the above-mentioned painful sensations in the legs, and by these latter the functional incapacity of the lower limbs is of course increased. Weakness of the arms is far less frequently observed; but occasionally we hear complaints that on the performance of domestic duties, needlework, etc., which previously could be carried out quite easily, the arms and hands are now speedily fatigued, and rendered functionally incapable.
Of the visceral neuralgias, cardialgia is by no means rare during the climacteric period; the pain is concentrated in the epigastric region, but not infrequently radiates to the back and to the chest. Hypogastric neuralgia is also not uncommon, pain in the lower part of the abdomen, associated with a sense of pressure in the bladder, the uterus, and the rectum, and sometimes radiating to the thighs and to the region of the haemorrhoidal nerves.
The opinion expressed by several authorities, that the menopause favours the occurrence of cerebral apoplexy, must, according to Windscheid, be received with caution; we have to remember that with advancing years atheromatous changes are apt to occur in the cerebral arteries, and it is to these changes, altogether independently of the climacteric, that cerebral haemorrhage is due. It appears, however, to be a fact that the menopause favours the onset of progressive paralysis. According to Jung, 60%, and according to von Krafft-Ebing, 27%, of women affected with paralysis were first affected in this way during the climacteric period. Von Krafft-Ebing explains this occurrence by the fact that during the menopause fluxions of vasomotor origin are common, and these serve as the starting point of transudative processes.
Among the neuropathic manifestations of the climacteric period we must reckon the at times excessive increase of the sexual impulse. We have already insisted upon the fact that the sexual impulse is not normally extinguished in women at the time of the cessation of menstruation; on the contrary, sexual desire commonly persists long after the menopause, and on this fact is largely dependent the frequency with which elderly women espouse quite young men. But in some cases, the sexual impulse is enormously enhanced during the climacteric period, and the patient experiences paroxysms of intense voluptuous sensation, associated with manifestations of abnormal reflex and psychical reaction, with increased frequency of the pulse and the respiration, emotional excitement, it may be loss of consciousness, and even general convulsions. Some of these cases of disordered sexuality occur in those previously affected with pruritus vulvae et vaginae.
More particularly Guenceau de Mussy and Boerner have described cases of such excessive libido sexualis during the climacteric period, voluptuous crises with pollutions, occurring independently of any external cause; the women thus affected have a continued succession of erotic ideas, they experience an itching and burning sensation in the genital organs, and from time to time this culminates in a paroxysm of sexual feeling, with orgasm, and increased secretion from the glands of the vulva.
Boerner has observed that characteristic variations in the libido sexualis commonly occur at the climacteric period. Not infrequently at this time the sexual desire becomes greatly diminished in intensity, or even entirely disappears; more often, however, the desire persists throughout this epoch; finally, in many instances, the desire undergoes an increase, at times to a degree amounting to positive torment. The first of these changes, the decline in the intensity of the sexual desire, harmonising as it does with the general extinction of the sexual functions at the change of life, might have been expected to be the normal occurrence. And it is a fact that in many cases characterized by an increase of libido sexualis at the climacteric epoch, Boerner found that there existed anatomical abnormalities in the reproductive organs (fibromata, flexions, etc.). Be this as it may, an increase in the intensity of sexual desire, as long as that increase is not altogether excessive, may be regarded as one manifestation of the visceral hyperaesthesias so general at this time of life. In the excessive degrees of this affection, however, those in which at times the sexual crisis is associated with general convulsions, we must, with Romberg, recognize the existence of a direct neuralgic state of the spermatic plexus. It is especially before the commencement of an actual menstrual period, or before a due period which fails to occur, that during the critical years complaint is made of this state of excessive sexual desire and sensibility; and in many instances the trouble begins at the very first appearance of the menstrual irregularities which foreshadow the menopause.
Windscheid draws attention to the fact that occasionally the nervous manifestations may make their appearance prior to the occurrence of any menstrual irregularity, so that it is by the nervous disturbance that the woman or her physician is warned of the approach of the menopause. “When the menstrual anomalies begin,” continues Windscheid, “that is to say, at the commencement of the climacteric, the nervous troubles may have already attained their maximum and have begun to decline in intensity. As a general rule, however, the appearance of the nervous disturbances coincides with the commencement of the menstrual irregularities. It may happen that these disturbances are intensified with each recurring period, but this is not the rule. Sometimes, however, we may observe that when menstruation occurs with excessive frequency—a by no means rare phenomenon at the outset of the climacteric—the nervous disturbances become more severe; and especially is this the case when the unduly frequent flow is also abnormally profuse, as indeed often happens.” The manifestations of climacteric neurosis occur, as Windscheid rightly insists, most frequently in the sphere of the psyche. “We observe a change in the disposition, which usually becomes more excitable. A woman previously calm and composed becomes irritable, inclined to emotional disturbance and to fits of temper, and unable to bear with equanimity the pinpricks so frequent in daily life, and especially in the daily life of a housewife. In other cases, however, the disturbance of the psyche is rather in the direction of depression: we observe a kind of spiritual inhibition, a deficiency of vital energy, an indifference to things which formerly gave pleasure. Almost always, also, complaints of loss of memory are among the indications of such depression. To these intellectual anomalies are superadded disturbances of sensibility. There is excessive sensitiveness to bright lights, loud noises, and strong odours. Frequently, also, in such cases, we see great intolerance to alcohol, quite small doses giving rise to extremely disagreeable sensations in the head.”
Climacteric Psychoses.
The powerful influence which the changes occurring at the climacteric period has in the origination of psychoses, has long been recognized, the menopause, in fact, being a favourable soil for the cultivation of mental disease. The fact is embodied in medical terminology, since many authors speak of “climacteric insanity,” assuming that the psychoses of this period of life present a definite and characteristic clinical picture.
In an earlier part of this work it was shown that the process of menstruation has generally a marked effect upon the psyche, and that disturbances of menstrual activity are competent to exercise a pathogenic influence upon the mental condition of the woman who suffers from them; still greater and more intense is the influence of the cessation of menstrual activity, with its powerful and widespread disturbance of the entire organism, with its destructive oscillations of equilibrium in the spheres of sensation, perception, ideation, and volition. It is easy to understand how the rarer recurrence of menstruation, the occasional profuse losses of blood, the complete suppression of menstruation, the conditions peculiar to the climacteric period of stasis and congestive hyperaemia of the brain, are competent, more especially in hereditarily predisposed persons, to give rise to the development of psychoses; whilst in those already suffering from mental disorder, the menopause will be likely to bring about an aggravation in their symptoms. At this time of life, also, we have to take into account the effect of certain ideational influences to which allusion has already been made, the thought that womanhood and its joys are passing away for ever, and the fear of the dangers attendant upon this critical period of the change of life. A French proverb alludes to “le diable de quarante ans, si habille à tourmenter les femmes.”
Mental disorder will be more likely to ensue at the climacteric period in those women whose nervous systems have always been unduly irritable, and in those affected with hereditary predisposition to insanity. Further, it is more likely to occur in those in whom the menopause takes place quite suddenly, in a catastrophic manner, than in those in whom the climacteric proceeds gradually, and unaccompanied by any stormy manifestations in the organism at large.
It is not in my opinion possible to recognize any specific form of mental disorder peculiar to the climacteric period, but nevertheless the psychoses occurring at this time of life do exhibit certain striking and characteristic features, more especially in this respect, that states of mental depression with melancholia predominate, whilst erotic influences are manifest in their etiology. In the slighter forms, volition and ideation are unaffected, and the trouble manifests itself in the form of hypochondriacal moods, associated with bodily troubles. In more severe cases we see emotional depression, states of anxiety, limitation of the powers of conception and judgment, indecisiveness, low-spiritedness, and apathy; or on the other hand, restlessness, an inclination to continued moving about, the eager pursuit of continually varying occupations, loquacity, etc.; finally, if the mental disorder becomes still more severe, hallucinations, delirium, paroxysms of intense excitement, and in exceptional instances, fully developed mania.
As with regard to the other disorders attending the climacteric, so also in respect of the climacteric psychoses, women who have been or are married, who have had a reasonable number of children, and have been accustomed to a sufficiency of sexual activity, are more favourably situated, are far more immune, than women whose sexual circumstances have been the opposite of those mentioned, who have had one or two children only, who have indulged in intercourse only when protected from pregnancy by the use of preventive measures, or have remained sexually unsatisfied, and, finally, women who have never married, and those who for many years prior to the commencement of the menopause have lived in chaste widowhood. In “old maids,” to the somatic effects of sexual abstinence (or in some cases of abnormal sexual gratification), are superadded the effects of the intellectual and emotional recognition of a wasted life. Again, it by no means rarely comes under our observation that women who in youth, at the time of the menarche, suffered from psychical disturbances, are apt once again to be affected with transitory mental disorder at the change of life. Once, however, the menopause is completely at an end, a condition of mental quiescence is as a rule established, and then it may happen that previously existent mental disorders undergo amelioration; but on the other hand we have in all cases to reckon with the possibility that they may take an unfavourable turn in the direction of the development of senile psychoses.
Of considerable interest is the fact, first pointed out by Glaevecke, and subsequently confirmed by other observers, that in cases of artificial menopause, melancholic mental disturbances not infrequently follow the operation, in some instances so severe as to lead to weariness of life and actual suicide; and in general, after the artificial induction of the menopause, psychical disturbances are by no means rare, and are sometimes very severe. Such disturbance of the mental balance is seen after oöphorectomy especially in women who are still comparatively young, and whose sexual powers are still in a ripe state; whereas when the operation is performed in women of a more advanced age, whose ovaries were already nearly or completely functionless, no psychopathic changes are likely to ensue. In women belonging to the former category, the same etiological influences come into operation as in the physiological menopause, the patient, that is, is affected by the psychical influences of the removal of the ovaries—not only by the cessation of menstruation and the disappearance of the internal secretion of the reproductive glands, leading to a disturbance of the physical equilibrium, but also by the intellectual recognition of the loss of sexual potency, and a consequent disturbance of the mental balance.
In Schlager’s opinion the climacteric has a potent influence in promoting the development of psychical disturbances in women, even when the involution occurs at the normal age. The course of these disturbances is as follows: soon after the commencement of the process of involution, when for a few months already the menstrual periodicity has been irregular, or the flow has been unduly profuse, a change of disposition makes its appearance, at first hardly noticeable, but after a little time manifesting itself clearly in the form of an increase in irritability. The woman finds fault with everything and everybody, becomes mistrustful, suspicious, full of complaints, imagines that the most insignificant annoyances are due to intentional slights; at the same time she complains of continued sleeplessness, palpitation, various indescribable sensations, and of headache. Occasionally, congestions of the head occur, with alarming dreams, and the moodiness may increase greatly; in this condition three such patients of Schlager’s were impelled to attempts at suicide. Schlager further draws attention to the fact that in 22 cases known to him in which suicide was performed or unsuccessfully attempted by women, in eleven of these the patient was at the climacteric age. He believes that the most important etiological influence in the production of climacteric mental disorder in such cases is the sudden suppression of menstruation. In the majority of these instances, the mental disorder takes the form of mania; exceptionally, however, the form of chorea or of catalepsy.
By Tilt the following forms of “climacteric insanity” are distinguished: delirium, mania, hypochondriasis, melancholia, impulsive insanity, and perversion of the moral instincts. The same author publishes the following table showing the age incidence in 1,320 cases of mental disorder in women, from which it appears that during the age of the menopause, a very considerable number of the cases originate, but that after the change of life comparatively few cases occur.
In these 1,320 cases the women were:
Under 15 years of age in 9 instances Over 15 and under 20 years in 61 instances Over 20 and under 25 years in 216 instances Over 25 and under 30 years in 223 instances Over 30 and under 35 years in 217 instances Over 35 and under 40 years in 218 instances Over 40 and under 45 years in 162 instances Over 45 and under 50 years in 153 instances Over 50 and under 55 years in 122 instances Over 55 and under 60 years in 57 instances Over 60 and under 65 years in 55 instances Over 65 and under 70 years in 27 instances
Fuchs tabulated the ages of 26.300 insane persons. Reducing his results to the ratios per 10,000, he obtained the following results:
Women. Men. At ages under 20 563 649 At ages over 20 and under 30 1,895 2,132 At ages over 30 and under 40 2,557 2,614 At ages over 40 and under 50 2,180 2,080 At ages over 50 and under 60 1,362 1,247 At ages over 60 1,443 1,278
According to Esquirol, among 198 women who committed suicide, there were 77 between the ages of 40 and 50 years—a number considerably larger than those in any other age-decade. Among 235 women suffering from dementia, a moiety had first come under treatment during the climacteric age. The same author published the following data regarding the age-incidence of insanity in the case of 6.713 female patients:
At ages under 20 years 348 cases Between the ages of 20 and 25 563 cases Between the ages of 25 and 30 727 cases Between the ages of 30 and 40 1,607 cases Between the ages of 40 and 50 1,479 cases Between the ages of 50 and 60 954 cases At ages above 60 years 1,035 cases
Matusch found that among 551 women suffering from mental disorder, there were:
At ages 0 to 10 years 9 cases At ages 10 to 20 years 73 cases At ages 20 to 30 years 140 cases At ages 30 to 40 years 114 cases At ages 40 to 50 years 107 cases At ages over 50 years 38 cases
According to von Krafft-Ebing, among 858 insane women, there were about 60 in whom the disorder of the mind appeared to depend upon the influence of the climacteric, and in 25 of these there was hereditary predisposition to mental disease.
From Kowalewski’s interesting work on the psychoses of the climacteric, we quote the following:
“In women, the climacteric has a distinct influence upon the mental life, and that influence is strongly manifested more especially in cases in which during the age of puberty mental disturbance had previously been noticed. The mental condition in which women approach the change of life is a very variable one, and it is one largely dependent upon the circumstances in which the active years of the sexual life have been passed. In some cases, a woman has been so fortunate as to marry early and from affection, and her whole married life has been passed without disturbance; her labours have not been exhausting, and her children have enjoyed good health; all have passed through the years of childhood without untoward incident, and their development has been a happy and successful one; in a word—everything has gone well with her and hers. Such a woman will give thanks to God for the rare felicity she has enjoyed; and quietly, patiently, and with understanding will endure the inevitable end of her sexual life. For such a woman, more especially if she comes of a healthy stock, the changes which occur in her reproductive organs at the epoch of the climacteric, need not entail any serious shock to her nervous system, nor need they form the culture ground for morbid manifestations in her nervous system or in her mind. Even if any anomalies in nervous working should occur, it will be such only as are aroused by the disturbance of the normal menstrual rhythm; in such cases, they will rarely prove of a serious or enduring character.
“But look, on the other hand, upon this picture. A woman has married without affection and from pure necessity. Her husband has been a drunkard, and rough and unfaithful. She has had a great many children, her labours have been tedious and difficult and accompanied with severe losses of blood. Some of the children fell sick and died; those that survived proved idle, good-fornothing, and a burthen. The family life is dominated by quarrelsomeness, disorder, and insufficiency of means. The mother is affected with some chronic disorder of the reproductive organs, and is hardly ever out of the doctor’s hands. After 25 or 30 years of a life of this kind, the woman enters upon the change of life. Physically exhausted, weary of life, never having known happiness, after an existence full of trouble and wretchedness, with nothing joyful either in her memories of the past or in her prospect of the future—the chief hope of such a woman is that her troubles may soon end with her life. Where the soil is thus physically and mentally exhausted, the development of a neurosis or a psychosis is only too probable on the most trifling exciting cause. Her life seems of so little worth, that thoughts of suicide are likely to be very near at hand. Thus, when the climacteric alterations in the reproductive organs are superadded, melancholia is very likely to supervene. When, however, the case is complicated by hereditary predisposition to insanity, and by the occurrence of actual degenerative changes in the central nervous system, instead of the passive depression of melancholia, we shall rather see the ideas of persecution of paranoia. As an actual fact, these two psychoses, melancholia and paranoia, are the commonest forms of mental disorder at this period of a woman’s life.
“These are the two extremes in woman’s mental state at the time when the physical changes of the climacteric period begin in her reproductive organs. It will, of course, be readily understood that between these two extremes lies a series of combinations any one of which may in individual cases occur.
“The conditions of life during earlier years have thus a strong determinative influence in the production of mental disorder; and not infrequently in these conditions alone shall we find the efficient cause of the mental degeneration. At times, the memories of her own life have in a woman at the climacteric age so serious an effect, that these memories alone constitute the causal agent of the development of a psychosis, or at least so influence the soil as to make it a suitable culture-ground for the development of mental disorder, the actual exciting cause of the pathological state being a disturbance of the ordinary menstrual rhythm.
“In considering the mental condition of women at the outset of the climacteric period, we must not forget those who are called ‘old maids.’ In their youth these maidens also have had their ideals, their hopes, their plans, and their sorrows. They also had a natural impulse to love and to be loved in return; they hoped to become wives and mothers. But life has failed to fulfil their hopes and their wishes, and their longings have remained unsatisfied. Some of them have taken up their cross without murmuring, and have devoted their talents, their intelligence, and their love to the service of those nearest to them. But others make an active protest against fate in the form of vindictive feelings towards their environment, of quarrelsomeness, scandal-mongering, etc. Here we see contrasted the two principal types of such women. On the one hand are those who devote their intellectual and spiritual powers to the service of society; these are unselfish sisters-of-mercy, untiring medical women, invaluable school-teachers and governesses, fanatical political agents, etc. Such as these have ceased to live for themselves. In the fullest sense of the words, they mortify the flesh, and guide their conduct by lofty moral principles. They have killed their sexual life, and they remain for ever virgins—both morally and physically. If, owing to a pathological inheritance, faulty conditions of life, exhausting illnesses, etc., a psychosis develops, the hallucinations and delusions from which they suffer very rarely assume a sexual character, nor are they of a degrading type. The sexual side of life seems, in fact, be they sane or insane, to have undergone complete atrophy. They suffer from simple melancholia with stupor, or their insanity takes a religious turn, but very rarely indeed has it an erotic character.
“Very different is it with old maids of the second type. They are dissatisfied with life, irritable, quarrelsome, envious, and malicious. They are spiteful and revengeful, gossips and scandalmongers, boast of their own chaste and innocent lives, and never forgive any real or imaginary attempt upon their spotless virtue. At the same time they never lose hope for the future, and are full of imaginary love-affairs, in which they pass through scenes by no means chaste or innocent; they do not shrink from self-abuse and the abnormal gratification of the sexual needs, in which the lacking partner in the sexual act is supplied by the imagination. Under the influence of such abnormal conditions of life, these women frequently become affected by nervous disorders; migraine, neuralgia, cephalalgia, nervous depression, rachialgia, debility, anæmia, diseases of the reproductive organs, etc. Thus, when they enter the climacteric age, the soil is fully prepared for the development of mental disorder, which in such individuals is often characterized by hallucinations of sexual sensation and perception, erotic visual and auditory hallucinations, delusions of similar character, increased sexual irritability, a search for abnormal means of sexual gratification, a propensity to obscene speech and conduct, etc.
“Mental disorder is so common during the climacteric period, that the term ‘climacteric insanity’ has now become established in the literature of mental alienation. In almost all the textbooks of the subject we find an allusion to this form of mental disease, but there is no real ground for Maudsley’s assumption that there is a climacteric insanity sui generis. At the climacteric, very various forms of mental disorder may occur—paranoia, melancholia, and mania; the only common feature in the attacks, owing to which they are classed as ‘climacteric insanity’ being the fact that the final determining cause in each case is the onset of the change of life. In fact, this period is not without influence upon the manifestation of the disease—its stamp is imprinted upon the clinical picture, it endues the disease with certain characteristic features—but still, the peculiarities common to the cases of mental disorder occurring at this time of life in women are not so great as to justify us in describing them as a separate variety of psychosis.”
According to Kowalewski, this so-called climacteric insanity is met with in two principal forms: in many cases the mental disorder recurs in periodic paroxysms, associated either with the commencement of the menstrual flow, or having the periodicity of menstruation after the flow has already ceased to appear; in the other class of cases the psychosis has no direct connexion with menstruation, and is dependent upon the joint influence of all the manifestations of the climacteric period. Cases belonging to the former class have been distinguished by Bartel as “climacteric pseudomenstrual insanity.”
The psychoses dependent upon the climacteric influences may, according to Kowalewski, appear in almost all the known forms of mental disorder: precordial anxiety, melancholia, mania, amentia, paranoia, etc.; and although they exhibit no features which are absolutely characteristic, or which, as already said, enable us to distinguish a specific “climacteric insanity,” yet they all bear a common imprint by means of which we are enabled to detect in their causation the influence of this critical period of life. Thus, precordial anxiety occurs in paroxysms having a more or less regular periodicity, corresponding with that of the expected menstruation. The same feature is observable in the periodic exacerbations of hysterical and epileptic paroxysms. Often, also, there occur at this time sudden changes in the emotional disposition and in the character, in one direction or the other, without the development of actual melancholia or mania. The melancholia of the climacteric period occurs chiefly in married women, more especially in those whose circumstances are unhappy; and it is often manifested by attempts at suicide.
Mania is comparatively rare at the climacteric period; when it does occur, it commonly assumes a sexual form—sexual impulses, hallucinations, and delusions, and obscene conduct. Such manifestations are seen most often in widows, in “old maids” whose morals are not above reproach, and, speaking generally, in those whose sexual needs have remained partially or completely ungratified, and in those who have greatly erred in the conduct of this side of life. Amentia also occurs at this time of life; rarely in maniacal form, more frequently in association with menstruation as a periodic psychosis, or as a continuous disorder of mind with exacerbations corresponding to the menstrual periods; it is often characterized by pronounced eroticism.
Much more frequent during the climacteric period is the occurrence of paranoia, as Kowalewski rightly insists. It is most often met with in “old maids” with psychopathic predisposition. The imagination of such individuals is always concentrated upon men; they imagine that men in general, but more particularly certain individuals of the opposite sex, are continually regarding them, making eyes at them, making signs to them, in some way or other striving to attract their attention. The most ordinary and invariable forms of polite intercourse are regarded by these women, whose powers of observation are morbidly stimulated, as being indications of a special “attention” paid to themselves. They persecute these men with their own attentions, and imagine that it is the men who are persecuting them. Often this morbid mental state is associated with sexual malpractices, masturbation, etc. Not rarely, such degenerates are affected with lascivious dreams. Often they experience hallucinations of sexual perception in the form of supposed assaults on their virginity. All these states are apt speedily to develop into a condition of general suspiciousness and ideas of persecution. The ideas of persecution assume a peculiar form, one especially characteristic of the climacteric period. The patients believe that a man, often personally unknown to them, and perhaps living in another town, enters into spiritual and bodily intercourse with them. These relations are supposed to be effected in most cases by means of spiritualism, hypnotism, or electricity. The patient importunes the man in question with letters, supposes herself to be legally united with him, and not infrequently wishes to give him the pleasure of paying her bills and providing her with money. It is a very common occurrence for a Catholic priest to be worried by such a woman, her delusion being grounded upon the fact that the priest is supposed to assume an exceptionally intimate spiritual relationship with members of his flock. The patient with ideas of persecution often herself becomes an actual persecutor, not only pestering her victim with innumerable letters, but in her jealousy making “scenes” whenever she can encounter him, and sometimes giving rise to serious scandal. With such a mental state we often see associated sexual hallucinations and delusions; the patient believes herself to be pregnant, imagines herself to have been violated, or to be living in carnal intercourse with a man—some one, it may be, with whom she is not even acquainted. Medical men are especially apt to suffer from the accusations of such women, whom they may have examined in private in entire ignorance of the patient’s mental condition. Frequently, such ideas of sexual persecution are associated with paroxysms of violent nymphomania, and in this way also the unwary physician may find himself placed in an extremely unpleasant position. It occasionally happens in such patients that abnormalities of the sexual instinct arise, and they begin to feel desire towards individuals of their own sex.
Such delusions of persecution by means of hypnotism, spiritualism, the telephone, etc., in association with sexual delusions and nymphomania, are so frequent during the climacteric period, that they may be regarded as pre-eminently constituting climacteric insanity. Frequently some old hysterical state underlies this form of mental disorder.
Thus these peculiar manifestations of eroticism must be regarded as the distinctive characteristics of climacteric insanity and more particularly of climacteric paranoia. A second characteristic of climacteric insanity is, according to Garat, the marked development of jealous emotions and delusions.
In addition to these fully developed psychoses, there occur in degenerates at the climacteric age paroxysms of impulsive insanity in the form of dipsomania, kleptomania, pyromania; exhibitionism; irresistible impulse to suicide, homicide, infanticide, etc. Such paroxysmal impulsive manifestations are, according to Kowalewski, commonly associated with menstrual disturbances; they occur most frequently at the due dates of menstruation when the flow fails to appear.
One hundred and sixty-nine cases of climacteric psychosis were classified by Matusch as follows:
Melancholia 36 cases Mania 2 cases Melancholia passing on into paranoia 28 cases Melancholia passing on into secondary dementia 17 cases Paranoia 43 cases Neurasthenia during the climacteric period followed by mental disorder 19 cases Neurasthenia prior to the climacteric period, followed by mental disorder during the climacteric period 10 cases Apoplexy, cerebral abscess, dementia 6 cases Epilepsy 2 cases Alternating insanity 3 cases Paralytic dementia 5 cases
Von Krafft-Ebing classified 60 cases of climacteric psychosis as follows:
Melancholia 4 cases Alternating insanity 1 case Acute delirium 1 case Primary insanity: a. With primordial delirium 36 cases b. Paralytic dementia 12 cases
The prognosis in cases of climacteric psychosis is regarded by Kowalewski as unfavourable; unfavourable vital conditions are associated with retrogressive metamorphosis of the tissues, hence mental disorder arising at this time of life is hardly less serious than that due to actual degeneration of cerebral tissues. Indeed, according to Schüle there is during the climacteric period an especial danger of the development of atrophic cerebral processes (Encephalitis atheromatosa) with apoplectic and epileptic seizures. Schlager also regards the prognosis of climacteric insanity as unfavourable; but Merson, on the other hand, observed among women suffering from climacteric psychoses a recovery rate of over 50%. On previously existent psychoses in women, the onset of the climacteric exercises in most cases an unfavourable influence, and very exceptionally only at this time do we observe the cure or remission of a chronic mental disorder to occur. Kowalewski has seen cases of chronic mania in which a cure was obtained at the climacteric period; a somewhat excessive excitability and inclination to violence remained, however, as vestiges of the former insanity. Matusch, keeping under observation 60 women affected with chronic mental disorder as they attained the climacteric period, noticed that in 14 instances the mental condition changed for the worse at this period, whilst in 13 the character of the mental disease underwent a change, excitement giving place to apathy and dementia. Griesinger had earlier pointed out that at the time of the cessation of menstruation there would occasionally occur amelioration, and even cure, of a previously existing chronic mental disorder; more often, however, the influence of the menopause was an unfavourable one, a hitherto changeable and irritative form of mental disease becoming transformed into chronic insanity with inalterable delusions, or into dementia. The course of mental disorder, such as melancholia, first making its appearance at the climacteric epoch, was also regarded by Griesinger as likely to be unfavourable.
HYGIENE DURING THE MENOPAUSE.
During the critical years of a woman’s life it is the aim of hygiene to employ all the means available to counteract the changes in the circulation of the blood, the disturbances in the working of the nervous system, and the nutritive disorders, which are in various ways dependent upon the changes occurring in the reproductive organs during the climacteric period; its endeavour should be so to regulate the conduct of life in this epoch that the important episode of the gradual decline and ultimate extinction of sexual productivity shall be effected with as few local troubles as possible, and as slight variations in the general condition.
By means of baths of various temperature, duration, mode of application, and composition, and by other selected hydrotherapeutic procedures, we are enabled during the disturbances of the menopause to exert upon the skin a powerful derivative influence, and in this way to diminish the passive hyperaemia of the uterus and the uterine annexa; by the same means we can exercise a sedative influence on the peripheral nerves and thus further upon the entire nervous system, whenever such measures are called for by the manifold indications of increased irritability; further, by the use of baths we can influence the circulation of the blood, we can increase the sudatory activity of the skin, and in various additional ways we can affect heat production and metabolism, thus modifying the processes occurring in the reproductive organs, making the conditions favourable for the absorption of exudations, and promoting a healthy tissue-change in the mucous membrane of the genital passages.
In climacteric women, the most usual indications are for the employment of water-baths at an indifferent temperature. 35 to 37° C. (95 to 98° F.), of moderate duration, 15 to 20 minutes, the bath being one of simple immersion, not of douche or affusion, and the temperature being kept constant by continuous inflow of a sufficient quantity of hot water. Such baths as these promote in a mild but continuously efficient manner the functions of the skin—so important during the climacteric epoch; and they lessen the almost constant tendency to perspirations and to the development of diseases of the skin (the commonest of which is climacteric eczema). The moderate degree of thermic stimulus exercised by baths at such an indifferent temperature leads them to have an equable sedative effect upon the nervous system, which is probably dependent upon an influence exerted through the intermediation of the sensory nerve-terminals in the skin; and this is most beneficial in lessening the increased general irritability, both spontaneous and reflex, so commonly manifested by the nervous system at the climacteric period. In women at this time of life, such baths are most useful in allaying the common cutaneous hyperaesthesias and neuralgias, and have a reflex influence also upon the visceral neuralgias and psychical hyperaesthesias.
In climacteric women suffering from abnormal sensitiveness to sensory impressions, to strong light and loud noises, or from painful sensations in the most diverse nerve areas; in those subject to palpitation of the heart after some trivial exciting cause; in those affected with cramp-like seizures in the pharynx, the œsophagus, the stomach, and the intestinal tract; in women with distressing sensations of itching and burning in the reproductive organs, or in those in whom there is a great increase in the intensity of the sexual impulse—in all these common disturbances of the menopause, by the daily use of such immersion baths of water at an indifferent temperature, best taken immediately before retiring to rest, we shall often succeed in inducing both local and general repose, in diminishing the spontaneous and reflex irritability of the nervous system, and in inducing quiet and restorative sleep.
In other cases of disturbances of health during the climacteric period, however, more benefit may be derived from hot immersion baths, taken at a temperature well above blood heat, (37° C.—98.4° F.) and lasting longer than the warm baths just described. These are indicated when we wish to increase the activity of the circulation through the skin, to give rise to hyperaemia of the superficial structures of the body, to stimulate powerfully the cutaneous nerves, to promote cutaneous perspiration—in short, to exercise a powerful derivative effect, to promote resorption, and to accelerate the general processes of tissue-change. This method of treatment is suitable for cases in which at the commencement of the menopause there are already pathological conditions of the reproductive organs, the morbid states being now aggravated by the processes of the climacteric—such conditions are metritis and endometritis, chronic inflammations of the intrapelvic connective tissue and of the pelvic peritoneum; and one of the first aims of treatment must be to promote the softening and subsequent absorption of these inflammatory products. Again, in cases in which the climacteric troubles, dependent in part on increased general arterial blood-pressure, manifest themselves chiefly in the form of active congestions, fugitive heats, vertigo, etc., the employment of hot baths is likely to be most useful by leading to a notable enlargement of the cutaneous capillary bloodvessels and consequent lowering of arterial blood-pressure. Further, in cases of compensatory fluxes, periodic diarrhoeas, periodic leucorrhoea, following the suppression of the menstrual flow, in cases of vicarious haemorrhage (especially periodic epistaxis and periodical haemorrhoidal bleedings), the use of hot baths is often competent to restore the functional activity of the ovaries when this has undergone premature cessation. In addition, their use assists us in our endeavours to counteract excessive obesity and gouty disorders, diseases which tend especially to make their appearance in women at the epoch of the menopause, disorders of metabolism intimately associated with the disturbances of the uterine and ovarian functions characteristic of the change of life.
In all the conditions just enumerated, if we desire a still more powerful influence than that exerted by ordinary hot baths, it is in our power to employ hot mineral water baths, by means of which a chemical, and perhaps also an electrical, stimulation of the cutaneous nerves is superadded to the simple thermic stimulus conveyed by the hot water. The different effects of the various mineral baths depends upon both the saline and the gaseous constituents of the different springs, and upon the peculiar physical properties of the mineral waters.
Sudorific baths are of various kinds. Some, Russian baths, consist of hot air saturated with moisture; others, Roman-Irish baths, consist of dry hot air; the most recent of all are the electric light baths, in which the radiant heat of electric lamps is utilized. But owing to the great increase in the body temperature which they cause, with consequent increased frequency of pulse and breathing, and still more on account of the rapid and extensive increase in blood-pressure to which they give rise, these powerful sudorific baths are rarely suitable for climacteric women, and if used at all in such cases the greatest caution must be employed. Their use is indicated only in women in whom at the time of the menopause the rapid onset of obesity has given rise to serious troubles, but in whom the heart is perfectly sound and in whom the blood vessels show no trace of sclerosis.
Far less often than warm or hot baths, or mineral water baths, are cold baths employed during the climacteric period, for baths at a temperature considerably below the indifferent point, and other hydrotherapeutic procedures in which cold water is used, stimulate the nervous system so powerfully and give rise to so great an increase in blood-pressure, that their use is generally to be avoided in climacteric women, since indeed it is apt to entail serious dangers both physical and mental. Immersion baths, plunge baths, or sponge baths, in which the water employed is at a temperature of 18° C. (64° F.) or less, are contra-indicated, for they act too energetically, abstract heat too powerfully, to be safely employed at this epoch of life. If we seek by means of hydrotherapeutic measures to counteract states of congestion at the time of the menopause, and at the same time to bring about a general invigoration of the patient’s nervous system, immersion baths the water of which is not below 20° C. (68° F.), and lasting from five to fifteen minutes, would appear to be indicated. In the majority of such cases, however, a somewhat higher temperature is preferable, from 26 to 28° C. (79 to 82° F.), the patient lying at full length in the bath, immersed to above the shoulders, and the water not being agitated except by a moderate rubbing of the surface of the body whilst the patient is in the bath. When, however, the patient sits in the bath, the water covering only the lower half of the body as high as the navel, a somewhat lower temperature is permissible, 20 to 25° C. (68 to 77° F.); but the duration should not exceed five minutes, moderate mechanical manipulations being carried out meanwhile; such baths appear to reduce nervous irritability and to have a sedative effect in the manifold nervous disturbances of the climacteric period. Sitz-baths, again, of a longer duration, twenty to sixty minutes, the water reaching only to the navel, and being at a temperature varying from 16 to 25° C. (60 to 77° F.), are useful in relieving chronic inflammatory states of the reproductive organs and the associated erotic states and abdominal pain and irritability. Colder sitz-baths, even of brief duration, should, on the other hand, be avoided. Similarly, a shower-bath of water at a temperature of 18 to 24° C. (64 to 75° F.), lasting one to two minutes, and the water falling only from a very slight elevation above the head, have a valuable sedative action; but, on the other hand, a colder shower-bath, of water falling from a greater height, has an exciting action, and is to be avoided at this time of life. When there are severe congestive symptoms, friction of the hands and feet for a short time with water at a temperature from 12 to 17° C. (54 to 63° F.), followed by a quarter of an hour’s rest in bed, may be recommended; also immersion of the feet for a minute in water at a temperature of 10° C. (50° F.), the feet being vigorously rubbed the while, followed by a walk in the open for five or ten minutes. In cases of sleeplessness at the menopause due to congestion, a useful method is to dip the feet for twenty or thirty seconds in water at a temperature of 8 to 10° C. (46 to 50° F.), the feet being briskly rubbed whilst in the water, or moved rapidly up and down with treading movements; after withdrawal, they are quickly dried, and the patient immediately goes to bed. Another useful mild soporific measure is to apply before going to bed bandages wrung out of cold water; these reach from the foot to the knee, and are left on for the whole night. In cases of climacteric menorrhagia, my vaginal refrigerator should be used for the direct application of cold to the reproductive organs; this is a cylindrical apparatus introduced into the vagina, cold water flows through the interior of the apparatus without wetting the vaginal mucous membrane. This cooling apparatus is useful also in troublesome cases of genital pruritus; cold douches to the vulva for one or two minutes at a time are likewise valuable in the relief of this affection.
For climacteric women, cold sea-bathing is as little to be recommended as other cold hydrotherapeutic measures, owing to its powerful refrigerative effect, and the great mechanical influence of the moving water in the waves. But in certain cases, in which sea-air is likely to be beneficial, lukewarm sea-baths may also be recommended; their effect is similar to that of weak brine-baths at a similar temperature.
During the climacteric period, especial attention must be paid to the care of the skin. Owing to the extreme sensitiveness of the skin at this time of life to outward noxious influences, it is necessary to exercise great care to dry the skin very thoroughly after ordinary ablutions of the face and hands; irritating soaps should be avoided, and a bland powder should be applied after drying. During the earlier part of the climacteric period, when menstruation has already ceased, and senile changes in the skin with atrophy of the subcutaneous tissues have commenced, the extreme dryness of the skin may be relieved by lukewarm baths with wet packs to follow; after the bath, the woman is enveloped in moist linen cloths and then covered over all with a blanket. When the skin chaps readily, inunction of lanolin ointment will be found useful.
Cleanliness of the genital organs, at all times of importance, is doubly so during the climacteric period, for the reason that neglect in this respect is apt to lead to the onset of genital pruritus. Not only after defæcation, but after each act of urination as well, the external genital organs and the anus should be carefully washed over with a pad of clean absorbent wool moistened with lukewarm water. After the washing, either powder or ointment should be applied, the former in cases in which the skin of the parts is usually damp from a natural tendency to excessive secretion, the latter in cases in which the skin is dry and tends to crack.
Bodily exercise, carefully selected and regulated to suit the individuality of each patient, is a powerful means of relieving the disturbances of the menopause. Regular and methodical bodily exercise—to which it must be remembered, women at the climacteric period commonly feel considerable aversion—manifests its good effects in the form of improvement in the nutritive conditions and functional activity of all the organs, and increased activity of all metabolic changes, which are commonly sluggish in women at the change of life. Moreover, muscular exercise, by increasing the volume of blood passing through the muscles, has a beneficial derivative influence in diminishing the congestion of the brain and the other troublesome congestive symptoms which are liable to occur in women during the menopause. Again, in cases of excessive obesity such as so commonly occur in women at the change of life, the increased combustion of fat promoted by regular muscular exercise, cannot fail to have a beneficial effect. Finally, suitably selected muscular exercise has a favourable influence also upon the nervous system, the functional activity of which it facilitates, while at the same time it strengthens the powers of the will.
It is therefore of importance that at the time of the menopause women should continue to undertake appropriate active exercise, regular daily walks, which should include walking up a moderate incline. As a preparation for such exercise (in persons hitherto unaccustomed to walk much), or in bad weather, or, again, when there are special reasons against open air exercise, and finally as a supplementary exercise to walking, gymnastics and massage may be employed. Such gymnastic procedures are to be chosen as will serve to deplete the vessels of the head, will have a favourable influence upon the portal circulation, and will withdraw the blood-stream from the pelvic organs; such are, in addition to general gymnastic exercises, methodical deep breathing, methodical exercise of the abdominal muscles, exercises involving the extensors of the back and the abductors and external rotators of the thigh, and exercises of the extremities. Various gymnastic apparatus may be employed with advantage, and more especially those in which the various muscular movements are effected against a resistance. But in all cases extreme care must be taken to avoid over-fatigue and over-exertion. A graduated form of bodily exercise combined with passive gymnastics, suitable for climacteric women, is massage, in which by mechanical stimulation, by pressure and friction of the whole body or of certain parts, the nutrition of the muscles is favourably influenced, and the activity of the general circulation is increased. In the use of massage also, in climacteric women, all undue excitation of the nervous system is to be carefully avoided, a mild form of this powerful agent must alone be employed; gentle stretching and rubbing of the skin of the lower extremities, the back, and the abdomen, followed by gentle kneading of the muscles. Massage of the internal reproductive organs (the method of Thure Brandt), in view of the common tendency to sexual excitability in women at the climacteric, is mentioned only to be prohibited. For the same reason, and also on account of the frequency with which at the time of the menopause women suffer from tachycardia and from other disorders of the heart, bicycling is in most cases an unsuitable exercise at this time of life.
A matter of great importance is the regulation of the diet of women during this phase of life, the aim of such regulation being one which the older physicians sought to fulfil by means of venesection and wet cupping, namely, to overcome the abnormality in the constitution of the blood which arises from the cessation of the internal secretion of the ovaries, and further to relieve the symptom-complex of abdominal plethora and the various passive hyperaemias and collateral congestions; and in addition to subdue the great general nervous irritability, the sensibility to external stimuli, the inclination to excessive reflex manifestations, characteristic in women during the climacteric period.
The diet must be regulated in respect both of quality and quantity, and it is obvious that the regulation must be thoughtfully adapted to the needs of each individual case.
As regards quantity, the main general principle of dietetics for climacteric women is that over-nutrition is to be avoided, that the quantity of nutriment must be reduced to the absolute minimum necessary to supply the needs of the tissues. In view of the fact that we are concerned with women at a comparatively advanced period of life, whose physical labours are not as a rule exhausting, that quantity of food will usually be sufficient which is competent to furnish 35 to 40 calories per body-kilogram per diem. If we assume that the mean body-weight of a woman as the climacteric age is 60 kilograms, the heat-equivalent of the food required daily by such a woman may be estimated at 2,100 to 2,400 calories. This will be approximately supplied by a diet consisting of 100 grams albumen, 60 grams fat, and 350 grams carbohydrate. The customary preference for a large amount of nitrogenous food is, however, not dependent upon physiological requirements, and provided that the needful minimum of albumen is supplied (about 1.5 gram per body-kilogram per diem), the requisite number of calories may be furnished by very various combinations of the different nutritive elements.
The general principles of the qualitative regulation of the diet of climacteric women are: first that after the necessary minimum of albumen has been supplied, there shall be added an amount of carbohydrate and of fat varying in relative proportions and quantities according to the physiological requirements of the individual, but taken together sufficient to supply the necessary heat-equivalent; secondly, that there should be an abundant consumption of water; thirdly, that stimulating dietetic adjuvants should as far as possible be avoided.
The nitrogenous equilibrium of the body may be maintained either by animal or by vegetable proteids; in the case of the former (animal albumens), the climacteric woman should avoid those containing considerable quantities of nucleo-albumen or of deleterious products of tissue-change; in the case of the latter (vegetable albumens), she should avoid those likely to cause undue stimulation of the intestinal tract. Of flesh foods (mammals, birds, and fishes), those kinds are to be preferred which contain small quantities only of extractives (kreatin, xanthin, etc.) since these substances are supposed to have a stimulating influence upon the nerves and the heart. Hence, boiled meat is better than roasted, and the flesh of young animals (veal, for instance) and fish are to be preferred to game, and the last-mentioned is to be avoided especially for this reason, that the flavours for which it is valued by the gourmet are products of partial decomposition arising from prolonged hanging; for similar reasons, meat extracts, animal soups, sausages, smoked flesh and fish, and preserved (potted) meats, should all be avoided. From the intimate connexion between the ingestion of nuclein and the formation of uric acid, albumens rich in nuclein are to be forbidden; such are the various foods consisting chiefly of gland-cells—sweetbread, liver, brain, kidneys, etc. As well as from the appropriate flesh-foods, the requisite albumen may most suitably be obtained from eggs and milk (including buttermilk); on the other hand, caviare is unsuitable owing to its stimulant action on the genital organs, cheese because it contains large quantities of the products of decomposition of casein and milk-fat; the fermented milks, koumiss and kefir, are likewise unsuitable. Suitable vegetable foods for the supply of albumen (in addition to carbohydrates) are porridge, bread, and the leguminosae; nuts, on the other hand, cause too much irritation of the stomach and intestines.
For women during the climacteric period we recommend a mixed diet moderate in quantity; the amount of flesh and fat in the diet should not be large, whilst cereals, green vegetables, and fruit may be taken in greater abundance; irritant vegetable foods must be avoided, and especially those which tend to stimulate unduly intestinal muscular activity and intestinal secretion. It is important that an abundance of water should be taken, not less than two or three pints daily, and a pure, fresh, spring water is preferable to the aerated waters, natural or artificial. Alcoholic beverages are to be avoided, and more especially those which are rich in extractives as well as in alcohol. For this latter reason, beer and champagne are harmful, whilst spirits and liqueurs are to be condemned on account of the high percentage of alcohol they contain. The stimulating alkaloidal drinks, tea and coffee, are also to be avoided, or if taken at all, only in a very dilute form. With regard to the preparation of the food, the cardinal principle is that it should be as little irritant as possible; neither mechanically irritating the alimentary tract by an excess of indigestible or undigested residue, nor irritating it chemically by an excessive admixture of sugar, salt, vinegar, pepper and other spices; nor, finally, giving rise to thermal irritation by being excessively hot or extremely cold.
The individual meals are preferably small ones and they must therefore be taken at comparatively short intervals, five times daily, the principal meal being taken at one or two o’clock in the afternoon, and the supper (which should be small) comparatively early, at seven or eight o’clock.
NOTE.—In his discussion of the details of diet for women during the climacteric period, hours of meals, actual dishes, etc., the author refers exclusively to Austrian and German customs in these matters. The translator has not attempted to adapt the following pages to the needs of English readers, as he feels that the general principles already given will enable the English medical man to construct without serious difficulty suitable diet-tables for the cases with which he has to deal.
Suitable articles of food are the following:
Soups, Broths, and other Liquid Foods: Soups and broths made from the flesh or bones of beef, mutton, veal, chicken, or pigeon, without the addition of meat extract, or of meat juices, peptones, somatose or nutrose, but with _t_he addition of barley, oatmeal, rice, wheatmeal, ryemeal, peas, beans, lentils, vermicelli, or macaroni; also broths or porridge made from any kind of ground cereal, or from potatoes, or from peas, beans, or lentils.
Flesh Foods: Lean beef, veal, mutton, roast or boiled, pigeon, chicken; certain fresh fish—pike, haddock, sole, perch, and trout. Unsuitable are: pork, goose, eels, salmon, herrings, oysters, caviare, lobster, crab, smoked meat, hare, venison, wild-duck, brain, liver, kidneys.
Vegetables, Sweets, and Savouries: Green peas, spinach, cauliflower, carrots, turnips, buttered eggs, omelette, boiled and baked puddings, rice boiled in milk, apples and rice, whipped cream, salads, wheaten bread, French rolls, biscuits, and rusks.
Fruits: Almost all fruits may be taken, raw, cooked, or preserved; also in the form of currant and other fruit cakes, and as fruit-ices.
Beverages: Milk, buttermilk, water, the same acidulated with various fruit-juices and essences (as lemonade, etc.), weak tea with plenty of milk, cocoa, chocolate. To be forbidden are: beer, strong and sweet wines, distilled spirits.
An example is subjoined of a simple diet-table compiled on the above principles:
_Quantity Albumen. Fat. Carbohydrate. in grams._ AFTERNOON: A cup of milk 150 5.4 5.4 7.5 Roll and butter 70 4.9 0.4 39.2 MIDDLE OF MORNING: Soup 100 1.1 1.5 5.7 Roll 70 4.9 0.4 39.2 MID-DAY MEAL: Soup 100 1.1 1.5 5.7 Roast meat 100 38.2 1.7 Green vegetables 100 1.6 0.4 8.4 Pudding 200 17.4 30.0 57.8 Fruit 100 3.0 15.0 Bread 35 2.4 0.2 19.0 BREAKFAST: A cup of milk 150 5.4 5.4 7.5 Roll 70 4.9 0.4 39.2 SUPPER: Soup 100 1.1 1.5 5.7 Two soft eggs 90 11.2 10.8 0.4 Bread 70 4.9 0.4 39.2 Fruit 100 3.0 15.0 ————— ————— ———— ————— Total 1,617 110.5 69.9 304.5 ===== ===== ==== =====
In addition, water, ad libitum, and perhaps a little light wine.
In many cases, however, a mainly vegetarian diet may be more suitable, and more particularly a mainly fruit diet, in order to diminish persistent congestive symptoms. In such cases the following diet-table may be recommended for short periods:
First breakfast: An apple and an orange.
Second breakfast: 25 grams of white bread with butter and three baked apples.
Dinner (mid-day): 100 grams fish or meat, potatoes, green vegetables, 3 boiled or baked apples.
Afternoon: An orange, or an apple, or a pear, or some grapes.
Supper: Milk, apples and rice, oranges, grapes, figs.
Beverages: Water, with or without fruit juices or essences.
Changes in the above diet-table could very readily be effected, whereby the quantity of carbohydrate could be increased and the quantity of albumen lessened.
In women of sanguine temperament and full habit of body, who at the time of the menopause very rapidly become obese, important changes in the diet become necessary. The main principles of a fat-reducing diet are the following: Avoidance of all overfeeding, reduction of the quantity of food taken below the former average amount, with retention, however, of a sufficiency of nutrient material to maintain the metabolic equilibrium of the essential tissues; the maintenance of this metabolic equilibrium demands a sufficiency of nitrogenous foods, but the fats in the diet may be reduced to a minimum, and the carbohydrates may also be very greatly diminished. At the same time, there must be systematic bodily exercise, and the hours of sleep must not exceed a nightly average of seven.
For obese women at the climacteric period, a suitable average diet would contain 160 grams albumen, 12 grams fat, and 120 grams carbohydrate, yielding a daily heat-equivalent of 1,250 to 1,300 calories.
A sample diet-table constructed on these principles is appended:
_Quantity Albumen. Fat. Carbohydrate. in grams._ BREAKFAST: A cup of weak 150 0.45 0.9 tea With milk, but 30 1.29 0.9 1.2 no sugar White bread 50 4.8 0.4 30.0 Lean cold meat 50 19.1 0.9 DINNER (Mid-Day): Small cup of 100 1.1 1.5 5.7 clear soup Lean beef 200 76.4 3.4 Green 100 1.6 0.4 8.4 vegetables, salad, etc. Fruit 100 3.0 15.0 Roll 35 2.4 0.2 19.6 AFTERNOON: A cup of weak 150 0.45 0.9 tea With milk, but 30 1.29 0.9 1.2 no sugar SUPPER: Soup 100 1.1 1.5 5.7 Lean roast meat 100 38.2 1.7 Roll 50 4.8 0.4 30.0 ————— ————— ———— ————— Total 1,245 155.9 13.2 118.6 ===== ===== ==== =====
In the selection of individual articles of diet, it is important to bear in mind the fact that in all climacteric women it must be our aim to stimulate intestinal muscular activity (peristalsis) and intestinal secretion to a moderate extent, for by more active intestinal secretion abdominal congestion is to some extent relieved, and by intestinal transudation and by diminution of the lateral pressure the circulation through the abdominal vessels is facilitated. By thus lowering the intra-abdominal blood-pressure, we shall assist in relieving a number of chronic hyperaemic states of the pelvic and various other organs, from which women are prone to suffer at the menopause. Hence all articles of diet must be forbidden which have a tendency to give rise to constipation. But we must also forbid all substances which leave extensive undigested residues, such as the rinds of fruits, large quantities of porridge, etc., hard meats, nuts, and the like. Most suitable are those articles of diet which contain large percentages of fluid constituents, such as milk, thin soups, weak tea (infused only a short time, so as to contain little tannic acid, which is very constipating), white meat—veal, breast of chicken, etc. Of vegetables, those are best which contain plenty of water and an abundance of the organic acids, young, fresh garden produce, lettuce, cauliflower, young green peas, young carrots, turnips, etc. Juicy fruits are good, apples, pears, cherries, and plums. Butter and honey are also excellent. In many persons suffering from constipation, all that is necessary for their relief is to give a tumblerful of cold water the first thing in the morning; with others, the use in addition of whole-meal bread with plenty of butter and honey and uncooked fruit, is required.
In women suffering from the various disturbances of the climacteric period in an aggravated form, either because the menopause occurs at an unusually early age, or because the suppression of menstruation has taken place suddenly instead of gradually—especially in cases of heart-trouble, severe vertigo, pronounced vasomotor disturbances, or mental excitement (also erotic excitement), I have sometimes found a methodical milk-cure carried on for several weeks most beneficial. By this I do not mean an exclusive diet of milk, but a diet consisting chiefly of milk and milk-foods; owing to the absence of all irritation of the nervous and vascular systems, this diet has a very definite sedative influence in such cases. The milk should be skimmed, and should be given four times daily in gradually increasing quantities, the total amount rising from ten ounces to fifty ounces daily. The only other meal should be a substantial mid-day dinner, consisting of soup, roasted white meat, young green vegetables, and a little fruit. In some instances, to prevent constipation, it is necessary to add ten grams of milk sugar to each glass of milk; in other cases it is necessary to dilute the milk with water. It is obvious that the quantity of milk given is not alone sufficient to maintain the metabolic equilibrium of the body; but the defect in this respect is made up by the substantial meal given at mid-day.
Among the stimulating influences which during the sexual epoch of the menopause are as far as possible to be avoided we must unhesitatingly include the practice of coitus, inasmuch as at this time of life there already exists a strong tendency towards the occurrence of hyperaemia of the reproductive organs; and sexual intercourse, increasing as it inevitably must this tendency to hyperaemia, should be indulged in as little as possible. And yet precisely in women of the climacteric age, in “la femme demi-vieille” there often exists a strong desire to drain the cup of sexual pleasure to its dregs. Not infrequently, therefore, the physician is asked to advise regarding the proposed marriage of a woman in whom the menopause is drawing near, the desired husband being young, or at least still fully virile. If the advice is given in all sincerity with a sole eye to the woman’s health, the medical man will definitely forbid the marriage.
When, however, the changes of the menopause are fully completed, when the woman’s reproductive organs have undergone complete senile atrophy, there is no medical reason why a couple who wish to give a tenderer name to an intimate friendship between man and woman, should refrain from marriage—provided that both have attained a like stage of sexual decline. “But,” writes Tilt, “a union between frosty January and blooming May is likely to be as dangerous to the health as it is to the happiness of both.”
Whilst attending to the regulation of the physical diet of his climacteric patient, the physician should not overlook her psychical regimen. A woman’s mind is very powerfully affected by the processes of the menopause. On the one hand, her fears are stimulated by the thought that she is entering upon the “critical age,” of whose dangers she has often been warned; and, on the other hand, she is mentally depressed by the knowledge that she is about to lose the charms of womanhood, and to decline in sexual esteem. It is well, therefore, for women during the years of change, to have some kind of employment, which fills their hours, occupies their thoughts, and—leaves a certain scope for the exercise of feminine vanity. Works of benevolence or of general utility, and literary occupations, are thus of great advantage to climacteric women. Plato, indeed, pointed out that women at this time of their lives should occupy themselves with literature and intellectual culture.
Just as it is the duty of the physician, more especially of the family physician, to enlighten the maiden on the threshold of her sexual development regarding the processes of the awakening sexual life, and to give her the necessary instruction concerning the hygienic measures which it is proper for her to adopt—so also is it his duty to convey medical information to the woman who stands on the threshold of sexual decadence. A woman’s ignorance is often equally profound at both these epochs of the sexual life. A woman in the early forties often does not suspect, or at least refuses to acknowledge, that she is gradually drawing near to the end of her sexual life; and she is still farther from the knowledge that definite rules of general and sexual hygiene must be observed by her if she wishes to minimize the dangers of the critical period.
The medical friend, in an earnest though far from gloomy manner, will expound to her the nature of the physiological processes of the menopause, and will instruct her regarding the corresponding preventive measures—diet, exercise, clothing, care of the skin, and the regulation of sexual intercourse. Moreover, the physician, by means of skilfully directed enquiries regarding certain symptoms, will be enabled to gain early information about the occurrence of abnormal processes at this period of life, and will in this way detect the first beginnings of many diseases which are amenable to treatment only at the very outset of their course. For example, Brierre do Boismont, an early and accurate observer of this sexual epoch in the life of woman, points out that in cases in which, during the change of life, a woman experiences an increased inclination for sexual intercourse, nineteen times out of twenty, a local examination will disclose the existence of some disease of the reproductive apparatus. Similarly, every gynecologist is now familiar with the fact that unusually free, atypical haemorrhages during the climacteric period, are commonly indications of the existence of a uterine neoplasm.
Much evil may be avoided, and much suffering can be diminished if the physician, in accordance with the advice of Hippocrates, does not limit his activities strictly to the exercise of the healing art, but stands by a woman’s side as her mentor and confidant during the troublesome years of her sexual decline. And he will best fulfil these functions, if he succeeds in convincing the climacteric woman of the profound truth embodied in the saying of the great French philosopher:
Qui n’a pas l’esprit de son âge, De son âge a tout le malheur.
INDEX
[References are to pages.]
Abdominal pains, 46.
Abdominal pressure, 46.
Aberration, moral, 46.
Absence of mind, 154.
Absence of ovaries, 182.
Abnormalities, mental, 155.
Abortion, 223, 414.
Abstinence, 256, 398.
Acromegaly, 102.
Act of intercourse, 84.
Activity, sexual in women, 597.
Acton, 276.
Actual intercourse, 84.
Adamites, 302.
Africa, 43, 45.
Age, average, at marriage, 200.
Agineta, 464.
Ahlfeld, 308, 333, 424, 448.
Air hunger, 419.
Albert, 331.
Albertus Magnus, 1.
Albini, 454.
Albuminuria, 93.
Alcohol, 155, 258, 270.
Algeri, 155.
Alibert, 408, 597.
Almquist, 262.
Ahlfeld, 482.
Amenorrhœa, 84, 128, 160.
Amentia, 103.
America, 43.
Amputation of clitoris, 184.
Amussat, 542.
Amyntor, 219.
Anæsthesia, 184, 187.
Anatomical changes, 8, 50, 141, 209.
Anderson, 331.
Andral, 582.
Aneurysm, 98.
Anger, 183.
Angina pectoris, 240.
Anjel, 191.
Anomalies of vagina, 331.
Antipathic sexuality, 194.
Antitoxic functions, 21.
Ansell, 365, 466, 561.
Ansty, 135.
Anxiety neurosis, 405.
Apes, 22.
Appetite, loss of, 46, 107.
Aqueo-mucous vaginal discharge, 46.
Arabian women, 30.
Aran, 632.
Areola mammae, 208.
Aretæus, 1.
Aristotle, 1, 211, 392, 420, 463, 473, 498, 544.
Arius, 502.
Arndt, 233, 343, 418.
Arthritis, 635.
Artificial fertilization, 317.
Asher, 406, 538, 541, 559, 563.
Ashwell, 109.
Asia, 42.
Aspermatism, 317.
Athenaeus, 302.
Atlee, 474, 603.
Atmocausis, 419.
Atri, 266.
Atrophy, concentric, 590.
Atrophy, excentric, 590.
Atrophy, gradual, 592.
Atrophy of uterine muscle, 609.
Azoospermia, 316.
Babbage, 433.
Bacon, 271.
Bacterial flow, 593.
Baer, 616.
Bain, 203.
Bailly, 183.
Baillarger, 438.
Bainbridge, 331.
Baker-Brown, 546.
Balestra, 575.
Ball, 156.
Balzac, 193.
Bandl, 536, 557.
Barker, 556.
Barnes, 161.
Bartels, 47, 331.
Bartholin’s gland, 529.
Basch, 296.
Baths, 116, 117, 280, 654.
Battey, 475, 564.
Baumes, 260.
Baumgarten, 166.
Baust, 441.
Bazaraignes, 434.
Beard, 106, 405.
Beauty, attribute of, 23.
Beauty, curve of, 24.
Beauty, decline in, 23.
Beauty of woman, 200, 206.
Bebel, 77, 394, 401, 415.
Beck, 296.
Becker, 305.
Bednar, 478.
Beer, 161.
Beigel, 165, 300, 496, 505, 517, 525, 604.
Bélot, 193.
Bennet, 64, 88, 632.
Benzler, 540.
Bergh, 210, 496.
Bernard, 78.
Bernstein, 365.
Bertillon, 218, 264, 382.
Berwitz, 101.
Bidder, 436, 439.
Biermer, 412.
Billroth, 337.
Birch, 305.
Birkett, 619.
Birsmont, 29, 42, 45, 135, 594, 603, 607, 666.
Bischoff, 136, 140.
Bladder, irritable, 107.
Blindness, 108.
Blondes, 45.
Blood, anomalies of, 478.
Blood pressure, 16.
Blumbenbach, 132.
Blundell, 90, 417, 568, 603.
Blushing, spontaneous, 46.
Bock, 353.
Bodily exercise, 658.
Brehm, 62, 331.
Bömer, 182, 618, 629, 632, 640.
Bohn, 635.
Boileux, 419.
Boinet, 474.
Boireau, 2.
Boivin, 498.
Bonton, 88.
Bonvalot, 17.
Books, 121.
Bordier, 556.
Born, 305, 456.
Bottermund, 146.
Bossi, 607.
Bouchardat, 130.
Bowditch, 46.
Bowels, regulation of, 121.
Boyd, 496.
Bradlaugh, 393.
Braid, 494.
Braun, 234, 326, 332, 438, 446.
Breasts, 213.
Brehm, 416.
Breisky, 326, 334, 515.
Breslau, 423, 435, 437.
Breuer, 92.
Brill, 326.
Broudardel, 72.
Brown-Sequard, 20, 587.
Bruce, 364.
Brunettes, 45.
Bruntzel, 182.
Buckle, 378.
Buddha, 168.
Buffon, 167.
Bulimia, 107.
Bulwer, 260.
Burdach, 294, 466.
Burg, 413.
Burggraeve, 496.
Burkart, 473.
Burton, 515.
Busch, 2, 580.
Butlin-Smythe, 235.
Butti, 193.
Cæsarean section, 567.
Calderini, 44.
Campbell, 443.
Cantharides, 186.
Capellmann, 400.
Capwron, 482.
Cardiac disorders, 94, 97, 236, 243, 344, 626.
Cardiopathie de la ménopause, 629.
Cardiopathy, uterine, 235.
Care of genital organs, 279.
Care of skin, 658.
Carey, 394.
Carlile, 393.
Carlier, 195.
Carus, 80, 364.
Casper, 189, 292, 547.
Castan, 86.
Castration, 419, 475.
Catamenial flow, 83.
Catarrh, gastric, 229.
Catarrh in vagina, 614.
Catarrh in vulva, 614.
Cattle-breeders, 358.
Causes of early development of menarche, 49.
Causes for lack of sexual impulse, 188.
Causes for intensity of sexual impulse, 188.
Causes of ungratifying coitus, 357.
Caustics, 119, 568.
Cavum uteri, 56.
Celibacy, 173.
Celsus, 463.
Cervix uteri, absence of, 506.
Cervix uteri, deformities of, 503.
Cervix uteri, hypertrophy of, 334.
Cervix uteri, ideal form of, 502.
Cervix uteri, normal form of, 502.
Cervix uteri, pathological changes of, 501.
Charpignon, 556.
Champonière, 17.
Change of life, 571.
Changes in the skin, 148, 208.
Characteristics, inherited, 25.
Charcot, 100.
Charrin, 21.
Chassaignac, 107.
Chassagne, 260.
Chastity, 123.
Chazan, 138.
Checks to increase of population, 391.
Chevin, 466.
Chiari, 438, 490, 616.
Chlorosis, 21, 86, 91.
Christianity, diffusion of, 6.
Chrobak, 214, 298.
Chronic endometritis, 87.
Chronic metrometritis, 87.
Circulatory organs, 149, 240, 620.
Circumcision of women, 328.
Civilization, progress of, 6.
Clarke, 443.
Cleanliness of genital organs, 658.
Cleft, vulval, 51.
Clément, 629.
Cleveland, 482.
Climacteric insanity, 643.
Climacteric phenomena, 600.
Climacteric psychoses, 643.
Climacteric psychoses, prognosis of, 653.
Climacterium, 571.
Climacterium, dangers of, 578.
Climatic conditions, 27, 37, 117, 132.
Clitoris, 74, 330.
Clitoris crises, 352.
Clothing, 114, 121.
Coccygodynia, 107.
Coffee, 121.
Coffignon, 189.
Cohen, 108.
Cohn, 148.
Cohnstein, 402, 548, 558, 634,
Coitus interruptus, 345.
Coitus, obstacles to completion of, 335.
Coitus, prohibitive, 529.
Coitus, undue frequency of, 294.
Cold nature, 188.
Cold sponging, 281.
Cole, 553.
Collins, 139.
Colpotomy, 418.
Combys, 79.
Comedones, 110.
Compensation, disturbances of, 254.
Competence for marriage, 250.
Conception, 137, 299, 304, 308, 366, 483.
Conditions essential to procreation, 469.
Condoms, 405, 409.
Confucius, 385.
Congestion, premenstrual, 142.
Congfou, 403, 547.
Congressus interruptus, 220, 225.
Congressus reservatus, 225, 227.
Conjugation, interference with, 487.
Conjunction, 108.
Conservants, 109.
Constipation, 107, 228.
Constitution, 38.
Constitutional conditions and menopause, 599.
Constrictor cunni muscle, 348.
Consumption of nitrogen, 22.
Continence, sexual, 400.
Continence, sexual, enforced, 172.
Contraction, pelvic, 334.
Contrectation, 176.
Control of instinctive impulses, 25.
Control of reproductive function, 397.