ON THE CAUSES OF FEMALE STERILITY DEPENDENT UPON LOCAL DISEASES.
As a counterpart t,o these, though not entirely separate from them, there are those ca,uses of sterility which are founded upon defects, diseases, and functional disturbances of the genitals themselves. Those are the con stitutional factors, these the purely local ones.
Among the latter we generally distinguish three kinds: We speak of " impotentia coeundi," when impregnation is made impossible or difficult by the very inability of executing cohabitation in the regular manner; of " impotentia concipiendi," in the more narrow sense, when coition takes place properly, but still conception does not occur; thirdly of " impoten tia gestandi," when conception takes place, but the impregnated ovum can not develop itself further. A considerable number of pathological conditions of the genitals can be classified with certainty under the one or the other kind, but with a number of others the classific,ation is doubt ful. I therefore prefer not to make any such distinction, but to treat of the obstacles to reproduction, under which term we may embrace the three groups, purely anatomically, Le., according to the separate organs of generation in order.
Diseases of tlu3 function of the ovary as an organ for preparing or secreting germs may be interfered with in various ways and sterility be thereby produced. But it must not be forgotten that the ovaries are paired organs, and therefore sterility necessarily requires an affection of both ovaries. The cause may rest in certain material distur bances of the ovaries themselves, or their functions may be disturbed 'by causes at work close by or at a distance, their own structure being intact.
An absolute obstacle to conception is brought about bv total absence of both ovaries, This defect probably occurs very rarely by itself in an individual otherwise normally built; there is in fact but ono authentic case recorded (Morgagni). Generally this defect is coupled with total ab sence of the remaining internal organs, or at lea4 with a nidinientary development of thorn. In the one case as well as in the other acre is of course no possibility of conception taking place. But there also occurs a deficiency of one ovary, generally with mal-development of the corre sponding side of the internal genital apparatus (uterus and tubes). If the other ovary is normally developed and.the corresponding half of the internal genitals likewise, as for instance with the " uterus unicornis," conception is not excluded. Of almost equal importance with the total absence is an imperfect development of the ovaries (so.called congenital atrophy). The anomaly consists in a smallness of the ovaries, and at the same time an absence or very imperfect development of the Graafian fol licles. An ovary which in size, form, and structure represents the infan tile ovary, may occur with other internal organs that are normal. This condition also as a rule brings about an insuperable sterility.
Besides these congenital anomalies which from the start exclude any production of germs, there are a number of affections which attack a fully developed ovary that has had its normal function, and deprive it of the ability of producing the female element. The function of the ovaries does not persist throughout life, but is extinguished after an activity at a time which we call the climacteric period. This extinction keeps pace with a change in the ovaries, that consists essentially in a degeneration of the glandular, follicular elements, and in a hyperplasia of the connective tissue stroma. This change, which as a rule does not take place suddenly, hut gradually within A number of years, brings about the greater rarity of conception in the third decennium of the sexual life of a woman, but this period may occur much earlier without any assignable cause, accom panied by all the other phenomena of the climacteric age: stoppage of menstruation, strong development of the adipose tissue, various troubles, etc. The cause of premature menopause can often with certainty be traced to an atrophy of the ovaries. Not infrequently women who have married late, and to whom, with the small number of their children, ste rility is by no means welcome, are surprised by this premature involution of their ovaries, and present themselves for a closer examination of these organs. This premature senile atrophy of the ovaries, however, rarely occurs as an idiopathic affection; it is generally combined with other changes in the genitals or general diseases of the body. I must, however, remark at once that the interruption of menstruation alone by no means indicates a premature extinction of ovarian activity, but is often caused by other conditions already stated, or yet to be mentioned. But then the ovaries as a rule are found intact. Another cause of acquired sterility is found in the inflammatory processes in the ovaries. It is well under steod that in nulliparm, and much more frequently in multiparm, changes take place in the ovaries which, together with a certain train of symp toms, are designated. as chronic ooplioritis, cystic degeneration, etc. I have in another place expressed my opinion to this effect, that here there is a disease which sometimes may attack more of the follicular apparatus, sometimes more of the connective-tissue stroma, and thereby may present different anatomical pictures. According to my experience this disturb ance in the nutrition, when strongly pronounced, gives rise to sterility. At least I find among the cases treated by me a considerable number in which the acquired sterility had to be considered as a consequence of this trouble. Sterility here is brought about either by the degeneration of the follicles iu consequence of hyperplasia of the fibrous framework, or by a thickening of the surface which prevents a rupture of the Graafian fol licles. Among our domestic mammals, also, it is said that ofiphoritis is a cause of sterility.