Part 65

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: