Whether the acute inflammations of the ovaries, also, can by their se quelte diminish germ production, is uncertain; with our imperfect know ledge of these pathological processes, it is difficult to say anything de• finite about this. But when at aubopsies we see the severe lesions of the ovaries in puerperal septictemia, and when, on the other hand, we find, though not so very frequently, that women who have recovered from severe puerperal fever have their menstruation interfered with and re main sterile, and this where no remains of exudations can be found, we are then not unjustified in believing that this sterility is dependent upon extensive changes in the ovaries. It is similar with those fairly frequent cases of gonorrhreal infection with acute and sub-acute peritonitic symp toms; here also sterility is not a rare sequel. If in these cases remains of a peritonitis can not be detected, the belief would be justified that here as well as in males the germ-producing gland bad been infected, and that its function was similarly interfered with. Could it not be possible that here the ovules, like the sperms, experience a similar degeneration which makes them useless for reproduction? Another class of sterile women is furnished by the tumors of the ovaries. Absolute sterility, however, is out of the question, unless both ovaries are attacked by the neoplasm, and unless in both the follicular apparatus has degenerated. Those kinds of tumors, therefore, which preferably possess these qualities, will prevent conception. But of the various tumors, it is the carcinomata that show this tendency, the very tumors which by their malignancy, rapid development, and unfavorable influence upon the constitution would exclude the possibility of concep tion. With the most frequent form of tumor, the adenoma of the ovary (cystoid), conception is not a rare occurrence. Thus in the last years, in the obstetrico-gynecological clinic of this place, ovarian tumors were observed not less than seven times complicated with pregnancy; in these cases the tumors later on have generally seriously complicated labor. Even with a plossal development of such cystoids, conception is not ex cluded; thus I know a case where the neoplasm ffiled almost the entire abdominal cavity, and still pregnancy occurred. Abortion with consider able hemorrhage led to her death. (The preparation is in the collection of the gynecological clinic of Wfirzburg.) lit spite of all this these cases must be considered very exceptional; their number is very small as compared with the cases of ovarian tumors that, growing slowly, are found on both sides in different stages of de velopment. Sterility is certainly the rule, which has but few exceptions. The cause of this is fairly plain. When there is bi-lateral disease, even when the tumor is small, the neoplasm embraces the whole ovary; the follicles either degenerate or become enlarged, but they no longer rupture, and therefore are no longer fitted for secreting ova. But even when only a part of the ovary is taken up by the new growth, and the remainder is pmerved, regularly discharging ova from the unchanged follicles, yet the change of the relations of space brought about by the enlargement of the ovary renders difficult the conduction of the ovum into the tube. The part whose tissue is normal is removed from the fimbriated extremity of the tube, and it requires very favorable conditions to enable the ovum to find its way. To this is added the considerable elongation, narrowing, and distortion which the tube suffers by following the expansion of the tumor with the wall of which it is connected. The changes mentioned are also unfavorable for the onward movement of the ovum. But even in ease the second ovary is normal, yet the growth of the degenerated ovary pro duces such changes in the position of the pelvic organs, that the tube of the healthy side is also removed from its ovary, so that the ovum is not received in it. In case of small, slowly developing tumors the partial inflammations of the peritoneum are not to be disregarded. By these, as we shall see, new difficulties are presented to the onward movement of the ovum. If a physician is consulted because of sterility, it is much less frequently a case of large ovarian tumor than one of small tumor, slowly growing cystoid, hard tumor, dermoid. According to my experience, the sterility here chiefly depends upon the circumstance that both ovaries were affected, though one tumor may exceed the other considerably in size. I have oft,en found tumors of the size of a walnut up to that of an egg. By no means do all tumors, not even cystoids, grow so rapidly as is often believed. It is just these small tumors which not rarely are found to be the cause of sterility. Of equal importance to the ovarian tumor proper are the parovarian tumors, inasmuch as they also produce sterility mechanically by the above-described dislocations and changes in the pelvic organs.
Formerly the question was often raised whether sterility was not rather the cause than the result of ovarian tumors. According to my opinion, there is very little that speaks for sterility as the primary thing. The cases where ovarian tumors developed in women who had for a long time been sterile, the only cases which could support the above hypothesis, are much more easily explained by an adenomatons disease of the ovaries, which appeared early, preventing conception, but which remained latent until it raanifested itself much later by an increased growth. A number
of cases of sterile women, in which I have watched the exceedingly slow growth of the tumors, prove to me that the belief is untenable that the interference with the sexual function should have such serious conse quences for the ovaries.
As for the frequency of ovarian disease as a cause of sterility. it is somewhat less than affections of the surrounding parts. Boinet states that+ of the women who have ovarian tumors are sterile; this number is probably somewhat too high. Veit comes nearer the truth when he ac cepts the percentage of sterile women at 34 per cent., and Scanzoni agrees with him. He found among 45 WOMCI1 13 childless ones. The anatomical researches of Winckel also showed a considerable number of ovarian tumors among sterile women; in 150 cases he found them not less than 32 times; among these, 30 were unilateral, a fact worthy of our observa tion. Among malignant tumors conception is still rarer, probably bee,ause they almost invariably attack both ovaries. In the two cases that I have met in literature, there was in the one ( Mosler) but one diseased ovary, in the other case (Forster) only the beginnings of a carcinoma in both ovaries were present. ' Diseases of the Peritoneum and of the Parametria.—We have already seen how imperfect is the contact between ovary and tube, and how the ovum in the distance which it has to travel within the peritoneal sac, even under normal conditions, is in danger of missing its aim and thus perish ing But this very place is also frequently the seat of pathological pro cesses which prevent the wanderings of the ovum. In fact a great many cases of sterility are traceable to such affections.
The cause of sterility may sometimes reside in congenital defects. Klebs has called attention to the fact that sometimes the only connection existing between ovary and tube, which consists in a fimbria of the tube reaching over to the ovary, may be absent, thus considerably separating the two. Still more unfavorable a condition is found when abnormal formations, as for instance small cysts, interpose themselves between these two organs. An abnormally long tube also seems to have a similar effect. A simple change in place of the ovaries may bring about a similar separa tion. If one or both ovaries are situated in a hernial sac, be it congenital or acquired, conception is hereby rendered much more difficult. though it is not entirely prevented, as some examples show. Sterility which ac companies a position of the ovaries in Douglas's sac, though freely mov able, may sometimes be in part ascribed to this same condition. Of course here there are frequently further changes of the ovaries themselves also at work.
Still more important than these abnormalities, the unfavorable effect of which is not rarely paralyzed by the fact that they are unilateral, so that the healthy side may perform its normal function, are the inflam matory processes, which often occur in this region, and not infrequently are bi-lateral. Their etiology is not a part of my task; be it only briefly mentioned that they occur as consequences of puerperal inflammatory processes, gonorrhceal infection, hemorrhages in the environs of the uterus, especially in the pouch of Douglas (hematocele), local diseases and dislocations of the pelvic organs, especially the ovaries and tubes, more rarely the uterus.
As for the frequency of the etiological factors leading to these ob stacles, an important rdle among women who have borne children, and, therefore, have acquired their sterility, is played by puerpeml affections that remainea after difficult instrumental deliveries, or in consequence of aeptic infection. Among women who have never conceived, it is often the dise-ases of the ovaries already mentioned, as chronic inflammation and cystic degeneration, that give rise to adhesions, etc. Somewhat more frequently in such women a gonorrhceal .infection is responsible for these changes. There has been much dispute in regard to the frequency of this extremely important factor. The cause of this difference of views consists, in my opinion, in the fact that in many cases much too long a time has elapsed since the real or imagined infection, so that the original train of symptoms, which is somewhat characteristic for gonorrhceal in fection, can no longer be ascertained, the less so inasmuch as in newly married women the traumatic irritation of the genitals may call forth similar symptoms. Furthermore, inasmuch as gonorrhceal secretion and benign discharge, the existence of which can not be denied, are not as yet distinguishable, and as the disease of the husband can not at all or not evidently enough be determined, it is often difficult to recognize goner Aces by the aid of these imperfect items. (Whether the gonococci in these cases also are of diagnostic value the future must teach.) Accord ing to the greater or less degree of scepticism that we adopt, the frequency with which we accept infection as a cause of sterility will also vary. I am not inclined to lay too much of the burden at the husband's door, for simple catarrhs of the genitals occur often enough in virgins and even in children, which extend over the entire genital tract, and are certainly able to produce adhesions at the abdominal end of the tube, so that chaste women may well have had this obstacle to conception on entering married life. Much more rarely the history points to the various changes in the position and form of the uterus, and still less frequently to a pre ceding hematocele.