« PreviousContinue »
mean a child born an epileptic; it mean the hy. persensitized brain that later grows into an epileptic because of the inherent developmental frailty which through neglect, social precept or ignorance, or all three, strays from a functional defect into a true pathology.
Dr. Bledsoe has broadly hinted at the future
possibilities of psychiatric eugenic, the growing of minds through the proper and persistant step by step training and cultivation within the physiological limits of the individual rather than the unmaking of minds by stressing and straining beyond the physiological limits before the tender plant is sufficiently developed to withstand the wrecking whirl winds of our civilization.
The Unembelished One.
Victor Robins in Life.
The Truly Proper Doctor.
-Louise Seymour Hasbrouck.
Kansas City Academy of Medicine
Meeting every Saturday evening at the Coates House
Censor, C. B. Francisco, M. D.
Treasurer, C. B. Hardin, M. D.
STERILITY OF WOMEN.*
tion has this condition seemed, that only a H. C. CROWELL, M. D., Kansas City, Mo.
rather general treatment has been em
ployed, and that treatment may be summed In gynecological practice one of the most up by a dilatation and curettement, with common conditions or complaints which the little regard being paid to its real indicaphysician meets is sterility. By this state- tions, sometimes, however, resulting in apment we would not presume to say that a parent benefit as we have seen in some even larger number desire children than do not, who have simply waited. for we are disposed to think it the reverse, We would not assume that in some cases a larger number being desirous of escaping the proper treatment may not be to curette, the burdens of child-bearing, at least for but we would take occasion to emphasize a certain number of years, or until a more the fact that curettement not infrequently convenient time shall arrive, when, in may be the beginning of trouble that makes other words, they are ready to give up so- apparent sterility positive. The curette is ciety and its exactions. During this period not the innocent instrument it is held to of delay often develops the condition which be. The work done by it, intrauterine, is renders them sterile at the time when they so imperfect and uncertain, that resulting become reconciled to bearing children. In infection, quite enough, we are sure, may general terms, however, it has been claimed result to travel out through the tubes interthat a woman must remain childless three fering with the delicate fimbriae and causyears, exercising no hindrance to preg- ing a closure of the distal end, precluding nancy, before she can be said to be sterile. the entrance of the ovum into the tube, or This period of time, however, is not essen- in adhesions that distort and defeat. Moretial to establish well founded reasons for over it has been demonstrated that a failure to fecundate. While this condition thorough curettement with a sharp curette is so very common, and treatment results in may so thoroughly remove the endometrium futility and not fertility in such a large that it is regenerated in but an embryonic per cent of cases, it nevertheless deserves form not well calculated to fix the fecundnot to be ignored but to be given even ating ovum. We must, then, in the incepgreater thought and attention than is cus- tion, expect for physiological results to obtomary. It is easy and, I judge the practice, tain, that the communication from vulva to of most men, to turn such cases off with ovary must be untrammelled by disease or some unmeaning excuse, such practice is mechanical interference. Gonorrhea, as is encouraged by the fact that it has always we have said, is the most common cause of existed and always will, that, occasionally, conditions deleterious, if not absolutely a woman will come into her own and get abrogating all possibility of pregnancy. pregnant though no treatment has been in- Among the resulting conditions that stituted. In my own experience I have might be mentioned in passing are periknown a case to go sixteen years barren and oophoritis, oftentimes symptomless and yet then be gratified with offspring, when all effective, resulting from a mild form of hope had departed.
peritonitis following a so-called latent gonWhile the profession is well agreed upon orrhea. Such cases may fully recover by the almost universal cause resting in some expectant treatment, if very mild. True, form of gonorrheal infection (70 per cent at the minuteness of the Fallopian tube and least), of these cases, yet it is well known the downward movement of the cilliary that so many other conditions figure epithelium serve, in a measure, to safe. as etiological factors that it may well be guard the entrance of gonococci; neverthe. considered a result of protean origin, re- less, they do find their way to the pelvic quiring the greatest diagnostic discrimina- cavity and set up inflammations of the fimtion in order that intelligent conception briated end of the tube and the ovary. It is may be entertained or effective treatment quite common to find this class of cases to instituted. As we have previously indi- have had but one child, if any. In such cated, so intractable to ordinary considera cases it is often possible to elicit the history that they had at some time a pelvic peri- to consider the reasons why we are forced tonitis. If, upon examination of smears to charge such tremendous responsibility from such cases the gonococci are not de- to gonorrhea and its results. To properly monstrable and that they do not yield to appeciate the merits of the situation, we treatment and remain well, but are attended must needs be very plain. In the first by relapses, it is fair to assume that we place, parents are often to blame for alloware dealing with a gonorrheal inflamma- ing children to grow up ignorant of the tion. In order that pregnancy may not take nature of the disease, its frequency and re. place, it is essential that the disease be sults. And here perhaps we should not bilateral. We may not be obliged to look exact of the parent that of which they may as far back as the tubes and ovaries to ac- know little or nothing, but shift the recount for the sterility. Chronic inflamma- sponsibility to the family physician and extion of the otsium uteri, or endometrium pect him to give the necessary information, producing a chronic catarrh may, and, in acting, as he should, not only as adviser in my experience often does, effect a complete time of need, but as a protector of those in impediment to the entrance of the sperma- whom he should have an interest. Too tozoa. Polypi in the cervix, or growths little is known of the nature and harm ariswithin the uterus afford obvious and more ing from gonorrheal infection. This is a easily demonstrated causes of sterility. condition that may be trifled with so long The uterus itself may, upon examination, as it is limited to the male, for they can be be found to be a probable cause, especially cured, but it is not so with the female to when found to be undersize, as in infantile the same degree. uteri. While this condition if appreciated In the second place, physicians who treat might readily be ascribed as a cause, we or are consulted in relation to the results of must advert to the fact that the true condi- treatment are not painstaking enough to tion is easily overlooked, for the reason be sure that all danger from inoculation that the cervix presents to the examining has been eliminated before marriage is finger often a practically normal size, which permissible. It is known that men capable if alone taken into account would not reveal of inoculation have married and had chilthe true condition. Bimanual examination dren with no serious results to the mother, might aid and suggest the sounding of its but this is the exception. Some women are depth, which would be found shallow, with more susceptible than others, so frequently thin walls. The endometrium is thin and is this the case and so disastrous may it beunsuitable for impregnation. With this come to them that no small number are uncondition is usually found an imperfect de- sexed by operations thereby made necesvelopment of all of the genital organs, sary. which may be early suggestive of an in
not prepared to accept the fantile uterus. Atrophy of the uterus, Negorath theory-gonorrhea once, gonor. simulating the infantile, may result follow- rhea always--in the male; in the female it ing a pregnancy in which some infective may be true, but we do subscribe to the be. trouble has been experienced, and from lief that all cases can and should be cured which the patient may recover. Displace- before marital vows are taken. It has been ments and flexions of the uterus have been claimed that a large percent of married considered by some as prolific causes of women applying for local treatment, are sterility. My observation has led me to re- suffering from a mild form of gonorrhea. gard them as merely factors not acting per Such being found to be the case, should se in any very pronounced degree. The suggest and exact an examination of the conical os has seemed to be often a causa- husband, and if he is found to be possessed tive factor, especially when we had a so- of the exciting gonococci, as one in six called pinhole os. According to Sims 85 are, he should also be subjected to treatper cent of all cases of natural sterility" ment and quarantine. have a conical cervix.
The credulity and innate goodness of It is well recognized that long standing women has made it possible for men to catarrhal conditions of the cervix will lead impose upon and endanger their lives withto a stenosis of the canal and must be dif- out turning upon them the inexorable eye ferentiated from the above lesions. Young of investigation. When once they shall bewomen are frequently neglected who suffer come aroused to the full meaning of this for years with a chronic catarrh of the situation, they will, as in other matters, cervix and remain childless after marriage, rise up in righteous indignation and demand often charging it to the husband, sometimes a better and more wholesome state of things properly so.
before they surrender their bodies to the At this juncture we may profit in pausing slaughter. Were the condition reversed,
legislative halls would be crying for legal "That it was an imperfection devoid of all protection and a higher morality with pop- perceptible, measurable characteristics.' ular acclaim.
Placing sterility, as he did, as a law of Perhaps no symptom has been so fre- nature, it failed to gain any lasting hold quently charged with being the cause of upon the profession. sterility as dysmenorrhea, being encouraged After a careful review of the subject, and largely by no less an authority than Sims, bringing it down to date, we are forced and yet it has been proven that a large per more and more to recognize the most potent cent of dysmenorrheas are unexplainable cause to lie in the results of a gonorrheal and are often associated with conditions infection, either in the male or female. which when relieved and fertility estab- Rougy, in the Medical Record of February lished, still suffer from a dysmenorrhea. 18, 1911, reports 120 cases of sterility seen Not all dysmenorrheas, as was thought by in which the husbands were also examined Sims, are due to a stenosis of the cervix; and found 70 per cent due to gonorrheal inindeed, a large per cent are never under- flammation. Dysmenorrhea was present in stood. The reaction of the vaginal secre- 84 per cent. Displacements not a great tion is of considerable importance in reach- factor, nor does obstruction seem to be a ing a diagnosis or the cause of sterility. frequent cause. Leucorrhea in 95 per cent. The normal vaginal secretion is faintly Acid reaction in 20 per cent, all of which acid, if it should from any cause become is in full accord with our observations as strongly acid, the life and movement of the herein set forth. spermatozoa are jeopardized and sterility It is not necessary to advert to the treatresults. The cervical mucus is alkaline ment, as that must conform to the findings. naturally, and favors the inward movement The sole object of this paper was to atof the spermatozoa, but if from catarrhal tract the attention of the physician to a processes it becomes acid, it, too, checks all closer observation of these unfortunate palikelihood of impregnation.
tients. Atrophied conditions of the ovaries, re
819 Gloyd Building. sultant upon such diseases as rickets, phthisis, diabetes, syphilis, tuberculosis, or
DISCUSSION. other toxic affections, should not be forgot- DR. LESTER HALL: Dr. Crowell's paper ten. The long continued use of morphine treats the subject thoroughly and leaves little to lessens the probability of fecundation, as
be added to what has been said. Personally I also does quinine, in the opinion of some.
find most of my cases due to obstruction. By re
peated dilation until the os becomes patulent, Repeated ovarian congestions at the time many of these cases become pregnant. The part of puberty from various causes, now well that gonorrhea plays is recognized yet the gonoappreciated results in follicular cysts of the
coccus travels so slowly that the disease is often
cured before the infecting organism reaches the ovary and sterility.
endometrium. While we have essayed to indicate some I have dealt with a class of women not exposed of the etiological factors in the production to gonorrhea and have had good results as menof sterility suggestive of the necessity for a
tioned. Gonorrhea may be a remote cause. In
clinical practice it may be the most potential painstaking consideration in order that we
cause, but I doubt if it is in the general practice may the more intelligently deal with such of most physicians. cases, we are not unmindful of the fact that I would rather think the habit of not having we are not fully clear in regard to all the
babies is a more potential cause, fighting against intricacies of fertility.
conception for years for a more suitable time to We must admit
have their children. This brings on nervous disthat not every case of sterility will reveal turbances and a sympathetic endometritis results a cause, however carefully we may work to from cheating nature. There are many ways elicit it. On the other hand, we have,
this is done and the fact that men often with
draw from the copulation act before the woman with apparent reason, given an unfavorable
has experienced her orgasm may be a potent prognosis, to be in due time greatly sur- cause. True, many times, the man is at fault prised, if not chargined. We feel con
rather than the woman. There are many of the strained to caution gynecologists against a
modern ways of cheating nature out of her just
reward and, it seems to me, are more potential in preformed notion as to the usual cause of causing sterility even than gonorrhea. sterility, as was Sims when he claimed that the majority were due to mechanical causes,
DR. GEO. M. GRAY: Sterile women often are or of others who claim that it was due to a
desirous of having children, but are unable to do
so. I cannot agree with Dr. Hall that the majorfunctional defect of the uterus, although it ity of these cases are due to stenosis of the cerwill be admitted that it may be either or a
vix. In most of them the uterine sound passes combination of both. Matthews Duncan
easily. Many of them have an inflammation of
the cervical endometrium, causing a mucous plug brought out the theory that sterility was to obstruct the canal very often. I think we are due to a “deficient reproductive energy." justified in assuming that there is some obstruct
read several articles stating that very few people understood the art of perfect copulation, and while that may be true, yet it has nothing to do with pregnancy. Healthy normal women do become pregnant when spermatozoa find their way to the proper place. I knew one woman who raised a family who has never had a satisfactory copulation. Her husband is one of those rare specimens, excitable, and usually ejaculates before entering, and if he did enter properly, she never experiences an orgasm, yet she has been pregnant several times. I think there is frequently a condition existing in the ovum, or, where the corpus luteum is not developed properly and, when the ovum encounters the spermatozoa, the endometrium is not stimulated properly by the corpus luteum to perform the product of conception. I have had several women tell me of passing a small clot a number of days after copulation, which it seems to me may be in this type of cases. This is a complex subject and, in a large number of cases, after we have gone over the entire category of troubles, eliminating gonorrhea, we find they are still sterile. I would not be surprised if they might have an atrophic condition. We dislike to admit that gonorrhea plays so important a part here, but I think it is true.
During the past few years shortness of the vagina has been emphasized. If a
woman is healthy, and the canal is open and if the endometrium is in proper condition, there should be conception.
ion in the passage of the ovum to the uterus, or an obstruction at the cervix, either from plugs or due to the inflammation. I think beyond any question, the majority can be attributed to the obstruction in the tube, due to some infection, and there is no question but what gonorrhea is the most frequent of all. In this country we are handicapped for full statistics, giving some idea as to the prevalence of this condition in the different nationalities. In Jewish women sterility furnishes grounds for divorce yet they are as free from gonorrhea as any people we see, though unable to conceive. If the obstruction is not at the cervix or at the tube, we must look to the male for causes of sterility, such as gonorrheal epididymitis, mumps, and other infective conditions. I have observed several young men afflicted with a double gonorrheal epididymitis who married and have never had children. It is not always the fault of the woman, but probably is most often in the woman due to the closure of the tubes.
DR. HOWARD HILL: I do not care to discuss the whole question of sterility in women. Is it not a possibility that this is a complicated process? Ovulation out of time without proper conditions of the uterus, alone, with the irregularities in menstration is a factor. We notice some of these cases flowing once in two weeks, then sometimes in a month, then twenty-one days and so on. This sort of a thing might bear an important relation to sterility it seems to me. There may also be conditions of the ovary interfering with the release of the ovum at the right time, as for instance a thickened tunica albuginia. It seems to me we must think of some of these other things besides simply a mechanical obstruction.
DR. FROEHLING: There are two in the contract to blame for sterility. Professor Case, of Heidelberg, made extensive investigation in several thousand cases of sterility. He examined the men and women too, and found the cause in two-thirds of the cases in the women and onethird in the male, Inflammatory processes inside, outside, or in the neighborhood of the sexual organs of the woman no doubt produces much of the sterility. I agree with Dr. Hall in seeing more cases where gonorrhea did not figure, or, any abnormal condition of the sexal organs, and where I could demonstrate spermatozoa in the male yet the woman was sterile.
DR. BELOVE: I have but one thing to say relative to causes of sterility and that is that some cases of sterility may be due entirely to the fact that the posterior part of the vagina, the culdesac of Douglas, is shallow and due to the fact that it takes some time for the spermatozoa to travel to the cervix and the spermatozoa are not retained for a sufficient time for conception to take place. This is entirely a mechanical trouble.
DR. H. C. CROWELL (closing): There are so many causes we cannot decide as to the cause of sterility. The shallow culdesac referred to by Dr. BeLove has been talked of a great deal during the last year. As to this I do not know, I have never had a case of that kind.
The arrest of the ovum in passing is an important consideration.
Relative to flexions I do not think there are many that produce sterility. Spermatozoa will find their way through a small opening and as for the particular peculiarities of certain individuals in regard to copulation I question whether this has anything much to do with the subject. I have
CASE REPORTS OF SYPHILIS.
Male, white, American; 52 years; musi. cian.
Family History.-Two brothers dead of tuberculosis and one has attacks of vertigo and diplopia. One child dead of tuberculosis.
Personal History.-Thirty years ago had venereal sore diagnosed as chancre. Had secondary sore throat and eruption over body. Twenty years ago patient had cough with some bloody expectoration. heavy drinker most of his life.
Drunk occasionally now.
Present Illness. -Patient complains of growing more nervous” for fifteen years and of having difficult and frequent micturition. Vague shooting pains with numbness of extremities the past three years. Ten months ago patient lost control of urinary sphincter; six months ago of sphincter ani. At the same time he began having trouble with his legs, tired easily, and could not walk steadily. Difficulty in speaking, and in playing the violin and coronet developed. Walking, lifting his left leg and descending stairs became difficult. Two weeks ago he had a severe attack of vertigo, with diplopia, lasting five minutes with similar attacks daily; later he became quite deaf. He is now