Part 78

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.