F. Kehrer has corrected the exaggerated estimation of dysmenorrhass as a cause of sterility which has been held especially by English-speaking gynecologists, represented by M. Sims on the one side. who claims it to be the expression of mechanical disturbance, and M. Duncan upon the other, who believes it to be simply a phenomenon of a constitutional malady. Kehrer examined a large number of cases, and found that it vus fairly a matter of indifference whether a woman had suffered from dysmenorrhcea or not before marriage. Dysmenorrhcea was absent about SS often in sterile women as it was present in women who conceived re gularly a short time after marriage.
Influence of the State of Nutrition.--We have,already called attention to the importance of this factor as regards the fecundity of plants and animals. Nor can we fail to recognize its influence in human beings. Otumity especially is regarded as a potent factor, and the frequently sudden and rapid increase of bodily fat at the climacterinm gives decided evidence of a connection between the malady and the disturbance of the sexual function. The same thing occurs when the menopause is premature. Veterinarians have observed the same thing in their patients, it having been especially noticed in English sheep.
The patients who consult us for this malady are usually young women who before marriage have been thin and delicate, and who have rapidly become fat after, or perhaps in consequence of marriage. In some cases chlorosis was present before corpulency began to set in. Most frequently, however, it appears after a pregnancy, usually the first, and is followed by a lengthy period of infecundity. There may be no genital lesion; men struation may be regular or scanty, or amenorrlicea may be present.
Though attempts have been made to explain the connection between obesity and sterility as due to the direct pressure of fat upon the ovaries, it is more probable that the extensive deposition of nutritive material in the form of fat hinders the developmental processes in those organs. The interference with menstruatiJn points in this direction. Though, from the fat, the examination of the ovaries is difficult in this condition, it is probable that they are not organically affected, since menstruation sets in again when the obesity disappears. In two cases which I examined under chloroform for some other cause, I found the ovaries intact, and I hold that obesity only causes sterility indirectly by hindering the expulsion of MI, and not their development.
Obesity is frequently accompanied by sterility, though in many cases fecundity is undiminished. Kisch found that among 200 sterile women at 3farienbad, no less than 48 were obese.
The prospect of offspring seems to depend more upon the menses than upon the amount of fat, amenorrhoic patients furnishing a much larger proportion of cases of sterility than those in whom menstruation is normal or only scanty. Nor must we forget that the hypertrophy of the external genitals in this condition may afford a mechanical hindrance to impregnation. It will be considered further on under affections of the external genitals.
Scanty nutrition does not seem to have much influence upon human fecundity. It is true that statisticians show diminished increase in po pu 1 ation in times of famine, etc., but it .has only an ephemeral influence. Thinness only affects fertility when it is dependent upon some chronic disease.
Influence of Chlorosis. —Antemia is a not inconsiderable cause of sterility. It is, however, usually not chlorosis alone, but the genital affections occurring with it, which exercise an unfavonible influence upon fertility. Chlorosis alone is but a relative cause of sterility. Chlorotic women often conceive, but sterile women just as often show no cause for their infecundity other than chlorosis. It appears that when the malady is so marked, the women menstruating scantily or not at all, conception is very rare. This would go to show that in consequence of the alteration in the blood, the genital congestion does not become marked enough either to cause sufficient serous effusion into the Graafian follicles to rupture them, or to cause the exudation of blood from the uterine vessels. (Scanzoni.) In other cases of chlorosis moderate atrophy of the genitals causes the sterility. In two cases which I remember very vividly, I could by no means succeed in feeling the ovaries, and the uterus was extremely small; in one the organ was anteflexed. It may be that the early setting in of chlorosis interfered with the development of the genitals, or that the non-developed state of the genitals led to the blood condition. The effect in either case was to hinder the development and expulsion of ova.