A Study of Sterility; Its 
Causes aid Treatment. 
BY 
THOS. W. KAY, M.D., 
OF SCRANTON, PA. 
Being an Essay which received the First Prize of the Alumni Associ- 
ation of the College of Physicians and Surgeons, Baltimore. 
Reprinted from the "Journal of the American Medical 
Association," Feb. 7, 14 and 21, 1891. 
CHICAGO : 
Printed at the Office of the Association 
1891. A Study of Sterility; Its 
Causes and Treatment. 
BY 
THOS. W. KAY, 
OF SCRANTON, PA. 
Being an Essay which received the First Prize of the Alumni Associ- 
ation of the College of Physicians and Surgeons, Baltimore. 
Reprinted from the "Journal of the American Medical 
Association," Feb. 7, 14 and 21, 1891. 
CHICAGO : 
Printed at the Office of the Association 
1891. A STUDY OF STERILITY, ITS CAUSES 
AND TREATMENT. 
INTRODUCTORY. 
General Remarks.-" Be fruitful, and multiply, 
and replenish the earth," was the first command 
given to man, and it is as binding to day as it 
was at the close of the creation, for a neglect of 
its fulfilment necessarily implies an extinction of 
the species. It is the desire, unconscious it may 
be, to fulfil this command that prompts man to 
seek the society of woman. The late Dr. Carpen- 
ter, of England, says "love" is based on the 
innate desire for offspring. This fact was recog- 
nized as early as the time of Soranus, who says, 
"As most marriages are not contracted for love, 
but to beget offspring, it is unwise, in the choice 
of a wife, to consider her social standing and 
riches rather than her fitness for bearing children. ' ' 
Sterility is one of the most potent factors in 
producing domestic unhappiness, and was so as 
long ago as the time of Abraham, when, having 
begotten a child by Hagar, Sarai "was despised 
in her eyes " because of her unfruitfulness. 
Historical.-Though Jacob loved Rachel better 
than Reah, he turned his affection to his less 
comely wife after she had borne him a son. After 
having brought forth several children, Leah ex- 
claims : " Happy am I, for the daughters of men 4 
will call me blessed. God hath endowed me with 
a good dowry, for I have borne him six sons." 
The barren Rachel, feeling keenly her disgrace, 
cries in her anguish, " Give me children or I 
die, ' ' after which we are told that ' ' the Lord saw 
that she was hated and opened her womb." 
Among the ancient Greeks, as among the Jews, 
sterility was considered a disgrace, and was a fre- 
quent cause for divorce, the unfortunate woman 
being looked upon as a lower, or imperfectly de- 
veloped, being. Travelers, among the inhabi- 
tants of nearly all uncivilized countries, remark 
that the pregnant women take pains to show, and 
frequently point with pride to, their enlarged ab- 
domens. In Angola, says Livingstone, sterility 
is such a disgrace and such a cause for ridicule, 
that the unfortunate women are frequently driven 
to suicide. Pallas states that the well-to-do Cir- 
cassians give a dowry to their daughters only 
after they have proved themselves fruitful. 
Among the Moslem inhabitants of Turkey, di- 
vorces are very common, and in most cases steril- 
ity is found to be the cause. It is from the ranks 
of these unfortunates that the native prostitutes 
are obtained. 
Sterility and fecundity were frequent themes 
for the ancient historians and poets. In the Sus- 
ruta, a book of ancient India, conception is said to 
' ' take place easiest at the menstrual period, for at 
this time the mouth of the womb is opened like 
the blossom of the water-lily in the sunshine." 
In the Bible we find sterility frequently mention- 
ed, and examples of it are recorded, with remedies 
for its relief. The Talmud also makes many al- 
lusions to it and its remedies. Sterility is fre- 
quently mentioned, and discussed at some length, 
in the works of Hippocrates. Celsus, Pliny and 
Aristotle also devote some space to it, but enter 5 
into the subject less fully than Hippocrates. Pau- 
lus Agineta has much to say on the subject, and 
devotes some space to the subject of diseases of 
the female organs of generation. From the works 
of Maimonides, we know that the subject was fre- 
quently mentioned in the writings of the Arabs. 
We see, then, the importance that has been at- 
tached to it from the earliest times to the Middle 
Ages, and from that time to the present the ques- 
tion has been gaining in weight. 
But what is it ? 
Definition.-The term ''sterility" is applied to 
both the male and the female, and must not be 
confounded with impotence, which indicates a 
physical inability on the part of the male to ful- 
fil the marital rights. 
Sterility may be congenital, where the woman, 
after reaching the age of puberty, has maintained 
the marital relations for three years without be- 
coming pregnant; or acquired, where, after hav- 
ing borne one or more children, she remains three 
years, while subject to intercourse, without re- 
conceiving, By some the term has, in a wider 
sense, been applied to all who, though becoming 
pregnant, are unable to bring forth a healthy liv- 
ing child. 
Some English writers use the term " only child 
sterility " to designate sterility acquired after the 
first birth. 
In very few fruitful marriages is the first birth 
postponed later than the third year. Kisch col- 
lected the histories of 556 fruitful marriages and 
found that, in 156 of these, the first birth occurred 
in ten months after marriage; in 199, it occurred 
between the eleventh and fifteenth months; in 
115, between the sixteenth and twenty-fourth 
months; in 60, between the twenty-fourth and 
thirty-sixth months; and in onl> 26, or 2.6 per 6 
cent., did it occur after the third year. Duncan 
gives seventeen months as the average time be- 
tween marriage and the first birth for the women 
of Edinburgh and Glasgow. Ansell places it at 
sixteen months, and finds that less than 5 per 
cent, bear their first child after the third year. 
The justice, then, of classing those women as 
sterile who have not become pregnant during the 
first three years of married life, is apparent. 
It may also be remarked, from the above sta- 
tistics, that impregnation at the first approach of 
the male, the rule in brutes, is the exception in 
man. 
Frequency.-The frequency of sterility is much 
greater than it is generally supposed to be. Of 
495 marriages among the English aristocracy, 
Simpson found 81, or about 16 per cent., sterile. 
Kisch inquired into the histories of 626 marriages 
among the royalty and highest classes of Europe, 
and found sterility in 70, or nearly 12 per cent. 
The figures for England are large because of the 
necessity, among the nobility, of marrying near 
relatives. Ansell, Sims, Simpson and Wells place 
the general average of sterility, for marriages in 
all classes, at about 12.5 per cent. Hedin thinks 
this too high for Sweden, where he claims only 
one-tenth of the marriages are sterile. 
Griinewaldt has collected some very interesting 
statistics on this subject. After excluding, from 
1,500 women suffering from uterine diseases, all 
virgins, widows, and those over 35 years of age, 
there remained 900 married women, of whom 500 
were sterile. In about 200 of these the sterility 
was congenital, while it was acquired in the re- 
maining 300. This gives uterine disease as the 
cause of 60 per cent, of the cases of sterility, and 
one of every three m arried women, wTho suffer 
from uterine disease, will become sterile. 7 
One must not always look for the causes of 
sterility in the female, for, as has frequently been 
the experience with all gynecologists, after hav- 
ing subjected the female to a long course of treat- 
ment, the male has been found to be the one at 
fault. Of 40 unfruitful marriages, Kehrer found 
the man at fault in 16, or about 35 per cent., and 
he claims that in a still larger per cent, the male 
is the indirect cause by transmitting the gonor- 
rhoeal or syphilitic poison to the female, thus set- 
ting up changes which militate against conception. 
Courty gives the relative frequency of the seat 
of the causes of sterility in the male and female 
as 1:10, Duncan gives it as 1 :8, and Noegge- 
rath places it as high as 8 : 14. 
Foetal Development of Genital Organs.-To un- 
derstand fully the causes and treatment of steril- 
ity, it is necessary to have, at least, a rudimentary 
knowledge of the development of the organs of 
generation. About the end of the third week, 
after the ovum becomes impregnated, the allantois 
begins to develop, and communicates, by the ura- 
chus, with the primitive intestine. As the sixth 
week approaches, the urachus dilates in its lower 
portion, so as to form the bladder, which commu- 
nicates with the rectum by a canal-the future 
urethra. The Wolffian bodies are found, a§ early 
as the third week, on either side of the primitive 
vertebrae. At first they act as primitive kidneys, 
their ducts emptying into the bladder, but later 
on they disappear, with the exception of a small 
portion of each, which can be seen, between the 
ovaries and Fallopian tubes, as the organs of Ro- 
senmuller. Between the fifth and sixth weeks, 
two small glandular bodies, formed from the ger- 
minal epithelium, begin to make their appearance 
to the inner side of the Wolffian bodies. These 
are the genital glands, and they are covered by 8 
the peritoneum which attaches them, as a mesen- 
tery, to the Wolffian bodies. With time, the gen- 
ital glands develop, and at the end of the sixth 
week they can be recognized as ovaries. They 
remain, however, in the abdominal cavity till the 
ninth month, when they descend into the pelvis. 
Developing contemporaneously with the ovaries, 
we find the conduits of Muller, situated in front 
of and to the inner side of the Wolffian ducts. 
It is from the upper portions of these conduits, 
extending from their superior closed extremities 
to that point where the lumbar ligament is at- 
tached to the Wolffian bodies, that the Fallopian 
tubes are formed. In their lower portions the 
conduits of Muller unite, in a common body, with 
the Wolffian ducts, to form the genital cord, in 
which the conduits of Muller are situated, to the 
rear and separated from each other by a partition. 
The absorption of this partition forms the ute- 
ro-vaginal canal, in which, until about the fifth 
month, no distinction can be made between the 
uterus and vagina. It is from those parts of the 
conduits of Muller, situated between the genital 
cord and the lumbar ligament, that the cornua of 
the uterus are formed. At first there is no lower, 
external, opening to the intestine, but gradually 
an involution of the epithelium dips down, and, 
about the fourth week, the septum disappears. 
At this time the intestine, behind, and the ura- 
chus, in front, open into the common cloaca. 
About the sixth week, a transverse septum is 
formed across the cloaca, dividing it into the rec- 
tum, posteriorly, and the uro-genital opening, 
anteriorly. The upper portion of the bladder 
receives the two ureters, while the conduits of 
Muller and the ducts of Wolff empty into its 
lower portion. That portion situated between 
the openings of the four ducts and the point 9 
where the bladder empties into the cloaca is the 
uro-genital sinus, which forms the vestibule of 
the vagina. At the junction of the vestibule and 
the vagina, a fold of mucous membrane-the hy- 
men-is finally formed, which, partially or whol- 
ly, closes the opening to the vagina. From these 
foetal parts all the organs of reproduction of the 
female are developed, and, bearing them in mind, 
it will be easy to account for all malformations of 
the female genitals, a common cause of sterility. 
Ovulation.-No organs of the body exert as 
great an influence over physical development as 
the ovaries. At birth they are small, smooth 
and flat, but as age advances they enlarge, and 
become oval and tense. This is in large part 
due to the increase in size and approach to the 
surface of the Graafian follicles, to allow their 
easy rupture for the discharge of the ova-ovu- 
lation. 
Menstruation. - Menstruation usually begins 
about the same time and accompanies ovulation 
throughout the child-bearing period. It consists 
of a discharge of blood and detritus, which comes 
from the uterus, and is probably due to a disinte- 
gration of the uterine mucous membrane, prepar- 
atory for the implantation of the ovum. 
After ovulation has been established, the ova- 
ries assume a nodular appearance due to cicatri- 
ces left after the discharge of the ova, and this 
condition remains till late in life, when they atro- 
phy and present the appearance of short and 
thickened bands. 
Puberty.-As the time for the first menstrual 
period approaches we find the breasts enlarging, 
the nipples becoming more prominent, the vagina 
growing more roomy, and the uterus increasing 
in size. The pelvis broadens out, the hips and 
thighs increase in size and become rounder, and 10 
hair begins to make its appearance on the pubes. 
This is puberty, which indicates the time about 
which impregnation first becomes possible. 
Relation of Ovulation to Menstruation.-The 
relation of menstruation to ovulation has often 
been discussed, and is still an unsettled question, 
but it can be asserted with certainty that men- 
struation is due to ovulation, while the latter is 
independent of the former. Conception may take 
place in girls, before the menses have made their 
appearance; in nursing women, while they are 
absent, or in females after the establishment of 
the menopause. In all women, however, with 
few exceptions, a suppression of menstruation is 
established very soon after the removal of both 
ovaries. 
The age at which conception becomes possible 
varies greatly in races and individuals. In Per- 
sia menstruation is established by the ninth to 
tenth year; in Syria by the tenth to eleventh year; 
and on the Guinea Coast by the eighth or ninth 
year. 
Taylor reported a case of conception in a girl 
of 12 years ; Molitor, one in a girl of 9 years 5 
months; Riittel, one in a girl of 9 years; and 
Kussmaul one in a girl of 8 years. I have met 
with a case of twins in a girl of 13 years, and I 
have had reported to me, on pretty good author- 
ity, the case of a Damascus Jewess who became 
a grandmother at 21 years. 
Maturation of the female is early in hot, and 
late in cold countries. Rich food also stimulates, 
while insufficient or poor nourishment retards it. 
Girls nurtured in cities, where it is hot and the 
mental excitement is great, mature at an earlier 
age than their country cousins. Heredity is a 
most important factor in this connection, and it 11 
is not uncommon to know of many successive 
generations developing at an early age. 
Menopause.-The menopause is established be- 
tween the 46th and 50th years, at which time we 
see something of a return to the masculine type 
-the voice becoming harsher, the breasts under- 
going atrophy, and more or less hair appearing 
on the chin and lip. Those influences which 
have been mentioned as affecting the establish- 
ment of menstruation affect also the establish- 
ment of the menopause. The length of the 
child-bearing period is pretty definite, for where 
puberty is early the menopause will be early, and 
vice versa. 
A few remarkable cases of child-bearing at an 
advanced age have been recorded. Rush report- 
ed one in a woman of 60 years; Dewees, one in 
a woman of 61 years; Haller, one in a woman of 
70 years; and Thibaut de Chauvalon reported one 
in a woman of Martinique of 90 years. 
Copulation.-During copulation, in most of the 
lower vertebrata, the relative position of the two 
participants is back-to-belly, the part played by 
the female being passive throughout; but in man 
she is more of an active agent, this being ren- 
dered possible by the belly-to-belly position. This 
position also brings the most sensitive parts of 
the genital organs of each sex in contact. The 
engorged and sensitive clitoris is drawn down by 
muscular action so as to come in contact with the 
penis, while the corona glandis of that organ 
causes friction agains the roughened folds of the 
anterior vaginal wall. 
In many married women, and some virgins, I 
have found that that part of the anterior wall of 
the vagina situated just behind the symphysis 
pubis, is as sensitive as, and in some cases more 
sensitive than, the clitoris. As friction is con- 12 
tinued all of the female organs of generation be- 
come engorged with blood, and muscular action 
is excited. The uterus enlarges, becomes more 
cylindrical, and straightens out the axis of its 
canal. Its external os becomes dilated and round, 
while the plug of mucus normally closing that 
opening is expelled. With these changes we 
have a slight descent of the uterus towards the 
ostium vaginae, while it is tilted back nearer.the 
sacrum, so as to bring the utero-vaginal axis closer 
to a right line. When orgasm approaches the 
contents of the vulvo-vaginal glands is discharged 
in jets, and the vagina and uterus take on a rhyth- 
mical contractile action, which probably assists 
the entrance of the seminal fluid, as it is ejacu- 
lated over the cervix, into the uterine cavity. It 
is not improbable that the uterine terminations of 
the Fallopian tubes may also be opened by these 
rhythmical contractions of the uterus. On more 
than one occasion I have satisfied myself as to 
the existence of this uterine action, when making 
a not over-careful digital examination of very am- 
orous females. In examining a woman with pro- 
lapsus uteri, J. Beck noticed that the os uteri, 
during sexual excitement, opened, and closed 
convulsively, five or six times, after which it be- 
came firmly contracted. This rhythmic action 
has been observed by Brundell in the vaginae of 
rabbits, while in heat. 
Seminal Fluid.-The seminal fluid, as it leaves 
the penis, is composed of secretions of the testes, 
the prostate, and Cowper's glands, with a small 
quantity of mucus derived from the urethra. If 
examined under the microscope many different 
objects are seen, but the moving spermatozoa, 
only, are necessary for impregnation. These pro- 
gress, according to Lott, at the rate of 36 milli- 
metres a minute. Mavrhofer claims that for 13 
impregnation it is necessary that the spermatozoa 
be deposited, during coitus, in the cervical canal 
where the reaction is alkaline. Sims found that 
they died in the vaginal secretions within twelve 
hours, but in the cervical canal he found them 
alive forty hours after intercourse, and Percy re- 
ports a case where he found them alive as long as 
eight and a half days after coitus. The cilia in the 
upper part of the cervical canal may assist them in 
entering the uterus, but their passage through the 
Fallopian tubes is due to their inherent mobility, 
as the cilia of the tubes move in an opposite di- 
rection. 
Impregnation.-The seat of impregnation is dif- 
ficult to settle. In the lower animals it is known 
to frequently take place in the Fallopian tubes, 
and the frequency of extra-uterine pregnancy in 
woman leads us to infer that it may take place in 
both the tubes and the ovaries. Lowenthal ad- 
vances the hypothesis that about every four weeks 
an unimpregnated ovum passes to the uterus and 
becomes imbedded in the mucous membrane, 
where it is impregnated or degenerates. If this 
hypothesis were true, extra-uterine pregnancy 
would be almost unknown. 
Impregnation consists in the entrance of one or 
more spermatozoa into the substance of the ovum. 
In the ova of the lower animals, where obser- 
vations can be made with facility, the presence of 
only one spermatozoon has been recorded, but 
several spermatozoa have been observed in the 
ovum of the rabbit. Keber was the first to re- 
cord, in the ova of the fresh-water muscle, an 
opening, or microphyte, for the entrance of the 
male element. This has been observed in the 
ova of other animals, and the ova of some of 
the lower orders has the power of throwing out 
processes, or pseudopodia, with which they seize 14 
and draw in the spermatozoa, but none of these 
phenomena have been observed in the mammalia. 
Passage of Ova to Uterus.-The old theory of 
the fimbriated extremities of the tubes applying 
themselves to the ovaries so as to receive the ova, 
is now known to be only partially true. In many 
animals the distance between the extremities of 
the tubes and the ovaries is too great to permit 
of this. It is now a well established fact that the 
motion of the cilia in the tubes creates a slow 
current of fluid in both tubes and peritoneal cav- 
ity. Oldham, Rokitansky, Scanzoni and others 
have recorded cases where the serum passed from 
the ovary of the one side into the tube of the op- 
posite side. This was proved by the absence or 
closure of the tube on the side where the corpus 
luteum existed. 
Of four rabbits from which Leopold removed 
the ovaries of the one and the tubes of the other 
side, two subsequently became pregnant. 
When the impregnated ovum reaches the cav- 
ity of the uterus, it is arrested by the folds of the 
mucous membrane, becomes attached and begins 
to grow, but if it should fail to become impreg- 
nated it degenerates and is cast off. 
Necessary Conditions for Impregnation. - For 
reproduction, then, three conditions are necessary, 
viz.: i. A production of healthy ova and sperm- 
atozoa ; 2. The union of the ova and spermato- 
zoa ; 3. The implantation of the impregnated 
ovum in a uterus fitted for its development. All 
influences acting, directly or indirectly, so as to 
prevent the fulfilment of one or more of these 
conditions, will produce sterility. 
CAUSES. 
i. Non-production.-Non-production of healthy 
ova and spermatozoa may be caused by (a) ab- 15 
sence, non-development or malposition of the 
genital glands; (b') inflammatory troubles pro- 
ducing atrophy or destruction of those organs; 
(r) tumors or new growths affecting the nutrition 
of, or directly invading, the gland substance; and 
(d) all influences which affect the glands indi- 
rectly by altering the general condition of the 
body. 
In all barren marriages where symptoms of 
uterine disease are not well pronounced, we 
should first make a microscopical examination of 
the spermatic fluid. This can be easily obtained 
by withdrawal of the organ as orgasm approach- 
es, or by collecting the fluid, by means of a small 
syringe, from the vagina after the act has been 
completed. The best method, however, is the 
use of a condum during coitus. 
Male.--The quantity of the seminal fluid de- 
pends on the size of the testes and the habits and 
physical condition of the male. Sims places the 
average quantity at about 2 drachms. It is not 
the quantity, however, but the quality, that con- 
cerns the physician, for though there may be a 
normal quantity of fluid discharged, the sperma- 
tozoa may be entirely absent-azoospermia. 
Should there be no discharge-aspermia-it is 
useless to look for spermatozoa, but they may 
exist in large quantities and in a perfectly healthy 
condition when only a small quantity of fluid is 
discharged. Either of the above conditions may 
be congenital or acquired. The congenital vari- 
ety, as a rule, is permanent, but the acquired form 
is either permanent or temporary. 
(a.'} In the congenital variety there is an ab- 
sence or imperfect development of the testes, 
which prevents the production of the spermatic 
fluid. The absence of one testis-monorchism 
-is of little moment, but the absence of both 16 
testes from the scrotum-cryptorchidism-gener- 
ally indicates sterility. This, though, is not al- 
ways the case, for one or both testes may exist 
in the abdominal cavity and be in a healthy con- 
dition. 
(A) The most common cause of the acquired 
form is orchitis, due to external injury, mumps, 
gonorrhoea, syphilis, or other troubles in which 
an atrophy of the glandular elements is caused 
by the inflammatory process. 
(^.) Hernia, hydrocele, varicocele, and all be- 
nign tumors disturb the nutrition of the testes by 
pressure or by dragging on the blood-vessels, and 
thus produce atrophy. Cystic diseases, tubercle 
and malignant tumors destroy the testis by a di- 
rect invasion of its glandular structure. 
(d.) All fevers and inflammatory or wasting 
diseases affect the testis temporarily by impairing 
the general health. The sterility due to exces- 
sive venery, masturbation, and affections of the 
nervous system, is usually temporary, but may 
become permanent through organic changes tak- 
ing place in the testes. Heredity, consanguinity, 
and many other agencies affect the reproductive 
organs of the male, but in exactly the same way 
in which they affect those of the female. At 
what time senile sterility is established in the 
male is not definitely known, but as his develop- 
ment is less rapid than that of the female, so is his 
loss of power postponed till later in life. In tem- 
perate climates the reprocreative power may be 
established as early as the 14th year and be main- 
tained, in persons of robust constitutions, as late 
as the 70th, 80th and 90th year. 
Female.-(a.) The ovaries may be, one or both, 
congenitally absent or imperfectly developed. The 
absence of one is of little importance, for the other, 17 
if healthy, is sufficient to furnish ova for impreg- 
nation. 
Congenital absence or defect of both ovaries is 
generally accompanied by other abnormal condi- 
tions of both the internal and external organs of 
generation. Many interesting cases of this kind 
are found in all works on gynecology. Pro- 
lapse of the ovaries may affect their nutrition 
and set up inflammatory changes which result in 
atrophy and destruction of the Graafian follicles. 
(^.) Aristotle seems to have been the first author 
to point out the fact that early marriages are a 
frequent cause of sterility, and the statistics col- 
lected by Duncan and Kisch show conclusively 
that not only is sterility more frequent, but the 
birth of the first child is postponed longer in those 
marriages where the woman is 15 to 19 years of 
age than where she is 20 to 24 years of age. This 
is due to inflammatory changes caused by injury 
during coitus or at childbirth, to imperfectly de- 
veloped genital organs. The researches of Slav- 
jansky have shown that inflammation, with sub- 
sequent atrophy of the Graafian follicles, may 
occur in rickets, scrofula, tuberculosis, pneumo- 
nia, typhoid fever, and all inflammatory and wast- 
ing diseases. In both acute and chronic ovaritis 
there may be an absorption of the follicular con- 
tents, followed by a collapse and adhesion of the 
follicular walls, which results in atrophy of the 
ovaries. It is in a different way that pelvic peri- 
tonitis acts. Here, the inflammatory products 
thrown out contract, and both dislocate and com- 
press the ovaries so as to disturb their blood sup- 
ply. Syphilis causes atrophy, directly, by affect- 
ing the ovaries, and indirectly, by setting up 
peritoneal inflammation. 
(c.) All new growths of the ovaries-cystic 
(follicular, multilocular, dermoid, papillary and 18 
myxo-polypoid), and solid (papilloma, fibroma, 
fibromyxoma, sarcoma, carcinoma and enchon- 
droma) induce sterility by destroying the struc- 
ture of or producing atrophy of the ovaries. As 
long, however, as a healthy portion of the ovary 
remains, conception is possible. Schroder took 
advantage of this in operating, and would always 
leave a piece of healthy ovary when it was possi- 
ble. The possibility of spayed sows getting with 
pig has long been known to stock-raisers, and I 
have seen several examples of it in my own neigh- 
borhood. Schatz reported a case where a young 
woman of 20, on whom double ovariotomy had 
been performed, conceived. In all of these cases 
a part of the ovary must have been left, or it may 
be that a supernumerary or accessory ovary ex- 
isted, as in cases reported by Biegel, Klebs, Ols- 
hausen, Winckel and others. In the female, as in 
the male, varicocele may exist, about the organs 
of Rosenmiiller, and produce atrophic changes by 
disturbing the circulation of the ovaries, but this 
affection is exceedingly rare. 
(if.) In females suffering from diabetes, anaemia, 
chlorosis, and chronic affections of the nervous 
system, conception is rare, because of lack of suf- 
ficient energy to produce healthy ova. It is prob- 
ably in the same way that the excessive or long 
continued use of alcoholic stimulants, opiates and 
other drugs prevent conception. The causative 
influence of obesity in producing sterility is very 
doubtful. It does not prevent the production of 
healthy ova, but indicates a lack of vigor and a 
sluggish condition of the general system unfavor- 
able to ovulation. The ova are discharged peri- 
odically about once a month, and it is about that 
time that impregnation is most apt to occur. Of 
248 cases, in which the time of copulation was 
definitely known, Hasler found that conception 19 
took place in 86 per cent, during the first ten 
days after the cessation of the menstrual flow. 
Capeliman advises sexual abstinence for fourteen 
days after the cessation of, and three or four days 
before the appearance of the menstrual flow, if 
one desires to avoid conception. The Jews, the 
most prolific of all people, allow five days for the 
menstrual flow and to this add seven days, mak- 
ing in all twelve days, from the first appearance 
of the menses, during which coitus is forbidden. 
The season of the year also affects conception, 
and we find it occurring much more readily in 
spring and summer than in autumn and winter. 
Haycroft, who has carefully studied the subject, 
finds that in Scotland the number of women who 
conceive increases with the rise of temperature. 
The quantity and quality of the food materially 
affects conception, it being a well known fact that 
more children are born during years of plenty than 
during famines. Women in moderate circum- 
stances, however, • are more prolific than those 
who live in luxury and idleness. Hensen points 
out the fact that melons and cucumbers are more 
productive when raised in the shade and furnish- 
ed with moisture than when exposed to the sun 
and a dry heat, and argues that women are af- 
fected, to a certain extent, by the same causes. 
We saw that this was so when speaking of food 
and temperatures, and it is even more noticeable 
in the lower animals than it is in man. Pigeons 
are much more prolific when well housed and lib- 
erally fed than when they are allowed to look out 
for themselves. Indoor confinement or change of 
long established habits will tend to cause sterility 
in both the lower animals and in man. All show- 
men know that wild animals are remarkably un- 
productive when deprived of their accustomed 
freedom. 20 
In France it has been shown that of eggs laid 
by unCooped hens only 20 per cent, are sterile, 
but this figure rises to 60 per cent, when they are 
closely confined. Darwin calls attention to the 
fact that mares rarely get in foal just after being 
taken from the stable and turned to pasture. 
In what way consanguinity acts in causing ster- 
ility is not known, but it is a common cause in 
both the lower animals and man. Interbreeding 
of stock will cause the most improved breeds to 
degenerate in a very short time, and in families 
we see the same result, the progeny becoming 
sterile, deformed or mentally deficient. Mitchell 
points out the fact that this can be partly averted 
by good food and hygienic surroundings. 
Galton, who has studied the question of hered- 
ity in all of its bearings, more thoroughly than 
any one else, finds that it is a potent factor in 
producing sterility. In England, where only- 
child sterility is as frequent as one in every thir- 
teen marriages, Susell finds heredity one of its 
chief causes. The absence of menstruation has 
been given by some authors as a cause of sterility, 
but this cannot be, for it only indicates a condi- 
tion of the ovaries unfavorable for ovulation, and 
should be considered as a symptom. When it 
exists up to the 20th year, it is usually a sign of 
non-development or atrophy of some of the inter- 
nal organs of generation. From the forty-sixth 
to the fiftieth year it usually becomes permanently 
established and indicates the presence of senile 
sterility. The menses may also be arrested by 
catching cold, by fright, or by any great physical 
or mental excitement, and generally indicates a 
condition unfavorable for conception. 
2. Non union.-Non-union of healthy ova and 
spermatozoa may be caused by (a) absence, ste- 
nosis, atresia or dilatation of any part of the 21 
course traversed by the human germs; (b) by dis- 
eased conditions of the passages which tend to 
impair the vitality of either ova or spermatozoa; 
(r) by artificial means employed to prevent con- 
ception ; (d} by all influences tending to hasten, 
prevent or retard orgasm. 
Male.-(a.) The possible existence of the ova- 
ries, with the absence or imperfect development 
of one or all of the remaining internal organs of 
generation-those developed from the Wolffian 
bodies and the conduits of Muller-is well known, 
and it is but reasonable to suppose that the cor- 
responding portions of the male genital tract- 
the ducts from the testes to the urethra-can also 
be absent or undeveloped while the testes are 
present. Such a condition must prevent the en- 
trance of semen into the urethra. 
Dunley found that in old age an obliteration of 
the ducts took place, probably before the testes 
ceased to generate spermatozoa. Pressure from 
tumors of the cord may also cause occlusion of 
the ducts. Epispadias, hypospadias and urethral 
fistula, unless situated near the glans penis, will 
allow the escape of the semen before it enters 
the vagina, and in those cases where it is depos- 
ited in the vagina it fails to be ejaculated against 
the cervix. 
Stricture of the urethra is a very common cause 
of sterility. When narrow and situated in the 
anterior portion of the urethra, it obstructs the 
canal during erectio^ so as to dam up the semen 
till the organ becomes flaccid, when it gradually 
oozes out. Should the stricture be situated far 
back, a regurgitation of the fluid may take place 
into the bladder, and be passed only as the urine 
is voided. When a slight stricture is present, 
impregnation may be affected by a change in the 
normal spiral direction of the urethra. This, as 22 
a rule, twists from right to left, as can be seen 
when passing urine from a healthy urethra, and 
it can also be demonstrated by passing a large 
olivary bougie well back into the canal and with- 
drawing it by a small thread attached to its end. 
In connection with this it is interesting to note 
what Courty says, in speaking of the ' ' arbor 
vitae" of the cervical canal. ''The posterior 
tree," says he, " deviates to the left in proportion 
as it approaches the superior orifice. The ante- 
rior tree is, on the contrary, directed towards the 
right." It will be observed, then, that when the 
meatus urinarius is applied to the external os 
uteri, the spiral is continuous to the cavity of the 
uterus. Phimosis and stenosis of the meatus uri- 
narius have the same effect as stricture, and a too 
large meatus acts in the same way as hypospa- 
dias. 
(^.) L,evy has shown that catarrhal secretions, 
when containing many pus corpuscles and much 
epithelial detritus, destroy the vitality of the 
spermatozoa in a very short time, but it is not 
probable that urethritis, simple or specific, will 
directly cause sterility in many cases, as it is such 
a short time in contact with the spermatic fluid. 
I recall a case in my own practice in which im- 
pregnation and gonorrhoeal infection, in all prob- 
ability, took place from the same individual at 
the same time. 
(c) Little need be said about the artificial means 
used by the male to preveht conception. The 
practice of "withdrawing" as orgasm approach- 
es and the use of the condum are only too well 
known to all classes, both married and single. 
In some parts of France and Syria, the prosti- 
tutes adopt a practice not generally known in 
America. It consists in tightly compressing the 
male urethra in front of the prostate, as orgasm 23 
approaches, so as to cause a regurgitation of se- 
men into the bladder. 
(dl) Many men of excitable dispositions, when 
first beginning to gratify the sexual appetite, are 
unable to control themselves and have a prema- 
ture emission, sometimes even before entrance 
into the vagina has been gained. One individual 
under my care, who has since married and begat 
children, would have a seminal discharge as soon 
as his limbs came in contact with those of a fe- 
male, even when sitting at meals. 
Different neuroses of the genital tract may re- 
tard or prevent orgasm, and in one case which 
came to my notice I had reason to believe that 
spasmodic stricture of the urethra caused seminal 
regurgitation into the bladder. These neuroses 
are found in persons who have been addicted to 
excessive venery or to masturbation, and in those 
who have suffered from frequent or long-continued 
nocturnal emissions. In all debilitated individu- 
als, from any cause whatever, or in those suffering 
from affections of the nervous system, the reflex 
centres governing the ejaculatory act may lose 
their excitability, so that, though erection takes 
place, there will be no discharge of semen. It is 
a not uncommon complaint of sterile women that 
they feel no discharge from the man during coi- 
tus. Non-erection prevents orgasm, and this may 
be caused by physical or mental affections. In 
some cases a too rapid flow of blood through the 
dorsal veins of the penis may bring this about. 
Female.-(a.) Congenital defects, preventing 
the union of the ova and spermatozoa, may be 
found in any part of the female genital tract. 
Kisch calls attention to an abnormal thickness of 
the tunica albuginea as an obstacle to the escape 
of the ova, and Schenk has seen the cellular cov- 
ering of the zona pellucida, as it escapes from the 24 
Graaffian follicle, act as an obstacle to the en- 
trance of the spermatozoa, in rabbits. 
Should the outer portions of the conduits of 
Muller, one or both, fail to develop, or their blind 
extremities neglect to open, there may be an en- 
tire absence or a rudimentary development of 
either or both of the tubes, or it may result in a 
closed termination where the fimbriated extremi- 
ties should be. If an imperfect fusion of the lowet 
portion of the conduits of Miiller take place, ir 
will result in some abnormal shape in the body 
of the uterus, but this does not prevent concep- 
tion, nor does the imperfect condition arising from 
lack of development of one of the conduits of 
Miiller. 
The septum dividing the conduits may persist 
in all or any part of its course, and cause the for- 
mation of a double uterus or double vaginae, but 
this is an impediment to impregnation only when 
it prevents copulation-conception being possible 
in either or both sides of the uterus. Should the 
conduits fail to develop or should they be ar- 
rested in their growth, the result will be an ab- 
sence or malformation of both, either, or any part 
of the uterus or vagina, and any of these condi- 
tions may exist in females who are apparently 
well developed. 
Examples of entire absence of the uterus are 
quite numerous, its diagnosis being easily made, 
on the living individual, by introducing the fin- 
ger of one hand into, the rectum and a probe, cath- 
eter, or finger of the other hand into the bladder. 
Total or partial absence of the vagina may 
exist when the uterus is present or when it is 
absent, and this abnormal condition can be diag- 
nosed in the same way as the abnormal conditions 
of the uterus. Should only the lower portion of 
the vagina be absent, it does not necessarily cause 25 
sterility, for the genital canal may open into the 
urinary or intestinal tracts, and there are cases 
of this kind on record where impregnation took 
place through the anus or the urethra. If, dur- 
ing foetal development, the free edges of the hy- 
men unite so as to entirely close the opening to 
the vagina, sterility must result. In all other 
anomalies of the hymen impregnation is possible, 
though the penis may not gain access to the va- 
gina, and many cases of impregnation without 
penetration have been recorded, the spermatozoa 
having found their way through the opening into 
the cervix uteri. Congenital malformations of 
the vulva are also found occasionally, in which 
coitus is impossible. It may be abnormally small, 
or there may be adhesion of either the labise ma- 
jorae or the nymphae. This union may be simply 
between the epithelial surfaces and easily over- 
come by traction, or it may be firm and require 
operative interference. 
A small vagina, as a rule, is not a serious draw- 
back to conception, and Kisch calls attention to 
the fact that small women with large husbands 
-presumably where the fit is tight-are more 
prolific than where the two are of the same size, 
or the woman is larger than the man. The above 
statement is borne out by my own observations. 
Congenital atresia of the cervical canal may exist 
in any part or all of its course. If situated only 
at the external os, as is most frequently the case, 
it usually consists of a continuation of the mu- 
cous membrane across that opening, and is easily 
remedied, but when more extensive it is difficult 
to treat. It usually attracts attention about pu- 
berty by the formation of a haematometra. Ac- 
quired atresia of the cervical canal is quite a com- 
mon occurrence in women after they have passed 
the menopause, but here it is usually at the in- 26 
ternal os, and is due to adhesion following degen- 
erative changes. 
Stenosis of the cervical canal may occur at 
either the external or internal os, and can be de- 
termined by the failure, in any uterus of normal 
position, to pass a good-sized uterine sound with 
ease. Olshausen calls attention to the fact that 
in women who bear their first child long after 
marriage a second birth follows close on the first, 
and he accounts for this by the stenosed os be- 
coming larger after the child has been born. A 
lady of my acquaintance was barren for six years 
after her marriage, since which time she has given 
birth six times in nine years. Stenosis of the 
cervix is a common cause of sterility, not only in 
man but also in the lower animals. The Arabs 
use the hand and various hard instruments for 
dilating the cervical canal in mares that are un- 
fruitful, and the Tyrolese incise the cervix of bar- 
ren cows, in both cases, it is said, with successful 
results. The intra-vaginal portion of the cervix 
may be abnormally short or entirely absent, and 
in either case may cause sterility by prevent- 
ing the application of the glans penis to the cer- 
vix uteri. Hypertrophy of the vaginal portion, 
if general, results in an elongation of the cervix, 
which is so great in some cases as to prevent coi- 
tus. This great length is exceedingly rare, but 
moderate elongation is quite common, and causes 
the cervix to be displaced as the seminal discharge 
takes place. If the hypertrophy is confined to 
one side it results in flexion, so that the os is 
tilted towards the vaginal wall during coitus. 
The conical and the nozzle-shaped cervices indi- 
cate an abnormal condition of the muscular struc- 
tures, and probably prevent an active participa- 
tion of that part of the uterus in the act of co- 
ition. 27 
Where the cervix is torn or everted, sterility 
may be caused by the granulations closing the 
canal so as to prevent the passage of the sperma- 
tozoa, by the cervix allowing the escape of the 
semen after it has entered the canal, or by a 
catarrhal condition of the lining membrane caus- 
ing a change in the normal secretion which is 
unfavorable to the life of the spermatozoa. A 
lacerated perineum also favors the escape of the 
semen and promotes secondary changes in the 
internal genital organs unfavorable for reproduc- 
tion. 
All uterine displacements, whether from a re- 
laxed condition of the ligaments, from increased 
weight or external pressure, or from the contrac- 
tion of inflammatory deposits, tend to prevent the 
entrance of semen to the ova. 
In inversion of the uterus conception is neces- 
sarily impossible, and next to this versions are 
most certain to produce sterility, for not only is 
the cervix tilted out of the way but the os is 
covered by the vaginal wall as with a lid. In 
flexions the obstruction is in the canal at the 
point of greatest convexity, but this is somewhat 
overcome by the congestion and erection taking 
place during coitus. 
In prolapse, unless complete, there is nothing 
to prevent conception except the debilitated con- 
dition of the uterus and vagina, for the penis 
naturally pushes the organ back towards its normal 
position as it comes in contact with the cervix. 
Hervey relates an interesting case of prociden- 
tia uteri where coitus took place through the 
dilated cervical canal and was followed by con- 
ception. 
As the uterus becomes displaced it draws upon 
and displaces the tubes to a certain extent, and 
in this way the entrance of semen into their 28 
uterine extremities or of the ova into their fim- 
briated extremities may be retarded. 
Displacements may also prevent conception by 
producing congestion and thickening of the lin- 
ing membrane of both the uterus and the tubes so 
as to occlude these channels. 
Contracted pelvis may also prevent the union 
of ova and spermatozoa by hindering coitus, and 
Hofmann has recorded an example of this kind 
where connection was impossible. 
Atresia or stenosis of any part of the genital 
tract may be brought about by inflammatory 
trouble. All pelvic inflammations-salpingitis, 
ovaritis, peri-metritis, para-metritis, etc., properly 
included by Dr. Georges Apostoli under the 
term "salpingo-ovaritis" - originate almost al- 
ways in the uterine mucous membrane and spread 
from there, through the tubes, to the surrounding 
organs where inflammatory products are thrown 
out, the contraction of which results in a disloca- 
tion of the uterus, of the ovaries, or of the tubes, 
or in a closure of the lumen of the tubes. The 
lining membrane of the tubes also becomes thick- 
ened and when closure takes place in two or more 
places so as to prevent the escape of the secre- 
tions into the uterine or peritoneal cavities there 
results a haemato-, hydro-, or pyosalpinx. 
Inflammation of the fimbriated extremities is 
quite common, and a dropsical condition may be 
found which causes an obstruction to the entrance 
of the ova into the tubes. In a case of laparotomy 
where I removed the right ovary the end of the 
tube was found inflamed, adherent to the ovary 
and closed, but it was healthy in all the rest of its 
course. 
Tubercular disease may attack the tube? but 
the most common cause of salpingitis is an en- 
dometritis of gonorrhoeal origin. 29 
Acquired stenosis or atresia of the cervix may 
follow injuries during labor, or it may be due to 
syphilitic ulceration. In follicular endo-cervititis 
the canal may be entirely closed by the enlarged 
follicles, or ulceration and contraction may take 
place, thus causing atresia or stenosis and pre- 
venting the entrance of the semen. 
The application of the sharp curette or of too 
strong medicinal applications may bring about 
the same results through cicatrization. Vaginal 
stenosis or atresia may be due to injuries during 
delivery or to syphilitic ulceration. Diphtheria 
may also cause sloughing and subsequent con- 
traction. Simpson has seen simple vaginitis in 
children result in stenosis, due to an epithelial 
denudation with subsequent adhesion of the vag- 
inal walls. 
Vaginismus is a hyperaesthetic condition of the 
genitals, usually in virgins, causing a spasmodic 
contraction of the muscles of the perineum and 
vagina. It may be due to the small size of the 
vagina, to ulcers and fissures, to irritability of 
the hymen, and to organic disease of the uterus. 
Winckel reports cases in which subperitoneal 
fibroids seem to have been the cause of it, and Mar- 
tin gives cold as one of the causes. In many cases 
self-abuse in childhood seems to have produced a 
congested and hyperaesthetic condition of the parts. 
This was the only cause that I could find in a 
married lady of nineteen, who had been married 
for nine months without ever having had connec- 
tion. The hymen was elastic and normal in ap- 
pearance, but when any attempt was made to in- 
troduce the finger into the vagina, intense pain was 
experienced and a splastic closure of the sphinc- 
ter vaginae would occur. 
E. Davis reported an interesting case where he 
was sent for by a gentleman to separate his 30 
coachman and maid, and this could only be ac- 
complished after chloroform had been adminis- 
tered to the woman. The liberated organ showed 
that there had been a constriction at the sphincter 
and one higher up in the vagina. 
Hypertrophy or new growths of any of the ex- 
ternal genitals may be an obstacle to coitus and 
thereby a cause of sterility. 
The clitoris may be so developed as to prevent 
the access of the male to the female. Hyrtl states 
that in certain of the African tribes the size of 
the clitoris is so great that it is fastened to the 
perineum by rings so as to act as a protection to 
virginity. It was most likely on account of its 
size that circumcision was formerly practiced in 
certain parts of Egypt, and is now in parts of the 
Turkish dominions. Elephantiasis of the vulva 
is sometimes a cause of sterility, and hypertrophy 
of the nymphae is said to be a frequent cause 
among the Hottentots, Bushmen and Abyssin- 
ians. A large accumulation of fat on the pubes 
and around the vulva is a not infrequent cause of 
sterility in persons of somewhat advanced age. 
Benign and malignant growths of the perineum 
will prevent the introduction of the penis into the 
vagina. In a girl of 16 years, from whom I re- 
moved a large angioma of the right labia majora, 
coitus would have been almost impossible. 
The vagina may also be so obstructed as to 
prevent the union of the ova and spermatozoa. 
This may be caused by cysts, fibrous tumors, 
polypi, and malignant tumors of the vagina; by 
pressure from ovarian or rectal tumors; or by 
cystocele, rectocele, or enterocele. Kisch reports 
a case in which a mass of hardened faeces in the 
rectum prevented coitus, and Schulze had a case 
in which the perineum of a 14 year old girl was 31 
developed to such an extent that the urine was 
passed with difficulty. 
Tumors of the uterus may prevent conception 
by occluding either the os uteri or the openings 
of the tubes; they may also cause displacement 
of the ovaries and tubes, and when very large 
they may draw the uterus up so as to be out of 
reach of the glans penis. Indirectly uterine 
tumors may cause congestion or inflammation of 
the genital tract producing a condition unfavor- 
able to the passage of the spermatozoa. 
Hennig has recorded an interesting case in 
which hydrocele seems to have been the cause of 
sterility. Ovarian tumors may prevent the en- 
trance of the spermatozoa either by causing com- 
pression or by drawing up the uterus, as in the 
case of large uterine tumors, and the same is true 
of tumors of the broad ligaments. 
(£.) The normal vaginal secretion is slightly 
acid, and as stated before, unfavorable to the life 
of the spermatozoa, while that of the cervical 
canal is alkaline and will preserve their vitality 
for several days. Should, however, an inflamma- 
tion of any part of the genital tract be set up, the 
spermatozoa, as has been shown by Lott, lose 
their vitality and die in a short time. This may 
be caused by vaginitis, endocervicitis, endometri- 
tis, or salpingitis. It is probable that the ova 
are also injured by coming in contact with diseased 
secretions, but on this point our knowledge is 
not definite. 
There are many causes which may produce in- 
flammation of the genital tract, but the most fre- 
quent of all is gonorrhoea. Nbggerath thinks 
that "latent gonorrhoea" is the cause in 90 per 
cent, Of all cases of sterility. This figure seems 
too high, but it may be correct for the inhabit- 
ants of large cities. 32 
Diseased conditions of the genital tract produce 
sterility more frequently by offering a mechanical 
obstruction to the entrance of the sperm, or by 
rendering the endometrium unfit for the implant- 
ation of the ova than by destroying the vitality 
of the germs. 
Urinary and faecal fistula of the genital tract 
prevent conception not only because of the sense 
of disgust connected with them, but also by pro- 
ducing a diseased condition of the mucous mem- 
brane. 
(e.) Among the artificial means used by wo- 
men to prevent conception may be mentioned 
sponges and tampons of cotton introduced into 
the vagina against the cervix. Small rubber caps 
are also used by placing in the vagina so as to fit 
as a cap over the cervix uteri and thus prevent 
the entrance of semen into the cervical canal. 
Other means are used to destroy the vitality of 
the spermatozoa. Among these may be men- 
tioned injections of hot and cold water, and solu- 
tions of vinegar, alum, boracic acid and other 
medicinal substances. These methods are not as 
sure and much more injurious than the former. 
Abstinence from coitus for fourteen days after 
the last menstrual period and for three or four 
days before the appearance of the next flow is 
also a pretty safe practice, there being no ovum 
in the tract at that time. 
The sexual desire in the male is much stronger 
than it is in the female, and in some females it is 
entirely absent. I have questioned many women 
on the subject and have frequently been told that 
it was months, and in some cases years after mar- 
riage before they could look on sexual intercourse 
with any feeling but disgust. This has been told 
me so often that I am inclined to think that the 
desire among the more highly educated women 33 
is educated and not natural. This also accounts 
for the fact that the first birth among the better 
classes is postponed longer than among the labor- 
ing classes. Most likely this is due to the devel- 
opment of the cerebrum at the expense of the 
cerebellum, and in time it is possible that the 
better class of Americans may become extinct, as 
have the cliff-dwellers, in whom, judging from 
their crania, the "organ of philoprogenitiveness'' 
was poorly developed. Many women claim to be 
able to tell the exact time at which impregnation 
occurs, and there seems to be good grounds for 
accepting these statements as true. This is prob- 
ably due to the perfect orgasm taking place in 
both parties at the same time. I have ascertained 
from many prostitutes that though they go 
through all the motions, when having intercourse, 
they allow orgasm to take place only when they 
are with their lovers. To this cause they ascribe 
the fact of not becoming pregnant and also of re- 
taining their health for a long time. A married 
woman, whose husband is now suffering from 
syphilloderma, informs me that she has escaped 
contracting the disease by not allowing her pas- 
sions to be aroused, and by bearing down and 
forcing out the seminal fluid after the act has 
been accomplished. 
We see then that orgasm is more or less under 
the will-powTer, so that it can be hastened, re- 
tarded or kept in abeyance. It is also affected 
by all influences which debilitate the body or the 
nervous system. All agents then which tend to 
prevent complete and simultaneous orgasm in the 
two individuals are causes of sterility. 
5. Nonimplantation.-Nonimplantation of the 
impregnated ovum in a healthy uterus may be 
due to disease of the tubes or of the uterus. After 
the ovum has become impregnated, most likely 34 
in the outer part of the tubes, it is carried by the 
current in the tubes, which is caused by the mo- 
tion of the ciliated epithelium and which is prob- 
ably assisted by a peristaltic action of the tubes, 
to the uterus. The uterus is also lined with cili- 
ated epithelium whose motion is towards the 
tubes. This motion probably assists the entrance 
of the spermatozoa into the tubes and also acts as 
an impediment to the downward passage of the 
ovum. We have seen before that ovulation and 
menstruation are closely connected, so that by 
the time the ovum has reached the uterine cavity 
the endometrium has become swollen and its 
outer layer, at least, has been thrown off as de- 
tritus so as to offer a suitable nidus for the ovum. 
Here, if all is favorable, the impregnated ovum 
becomes attached and remains, undergoing de- 
velopment, till normal delivery takes place. 
The frequent arrest of the ova in the tubes is 
shown by the number of cases of ectopic gesta- 
tion. Mr. Tait claims that all cases of exra-uter- 
ine pregnancy are primarily of tubal origin. He 
admits the possibility of ovarian pregnancy, but 
denies that it is possible to have a case of primary 
abdominal pregnancy, and his assertions are 
borne out by recent investigations. 
The arrest of the ovum in the tube may be 
caused by peritoneal or cellular inflammation, in 
which a constriction is brought about by the con- 
traction of the inflammatory products; by pres- 
sure from tumors and new growths; by catarrh 
and swelling of the lining membrane, which may 
also affect the ciliary motion of the epithelial lin- 
ing or the peristaltic motion of the tubes, and by 
pouches or dilatations in the tubes where the 
action of the current is lost. 
The uterus may be sufficiently developed to re- 
ceive the ovum and yet be unsuitable as a seat 35 
for future development. An arrest of growth 
may take place in foetal life, before the uterus 
and vagina have become differentiated, giving 
the "uterus fcetalis," or its growth may be 
arrested in infancy while the cervix is very long 
and the body undeveloped, which results in 
"uterus infantilis,'' which, according to Biegel, 
is as frequent in cases of sterility as 4:155. 
Winckel has shown that foetal inflammation is a 
frequent cause for non-development of the uterus. 
Atrophy of the uterus may also be acquired, as in 
the condition known as "primary atrophy,'' 
which occurs in girls before the period of puberty, 
when they suffer from wasting constitutional dis- 
eases, from anaemia or from chlorosis. In weak 
mothers, who have suffered from puerperal com- 
plications, it is not uncommon to find the menses 
suppressed and the uterine walls in a thin and 
flaccid condition. This is known as "puerperal 
atrophy'' of the uterus. A condition of the uterus 
which is unfavorable for implantation or devel- 
opment of the ovum may be brought about by 
inflammation of the peritoneum and cellular tis- 
sue surrounding the uterus; by inflammation of 
the uterine parenchyma, or by inflammation of 
the endometrium. 
Peri- and para-uterine inflammations may 
spread to the uterine tissue itself, but most fre- 
quently they contract and produce displacements 
of the uterus or bind it down so that when the 
ovum enlarges abortion follows. They may also 
prevent the return of the venous blood from the 
parenchyma of the uterus, which results in hyper- 
plasia, with a subsequent catarrh of the endom- 
etrium. Hyperplasia may also be produced by 
disturbances of the circulation due to valvular 
disease of the heart, but it most frequently follows 
the first birth and is caused by subinvolution. 36 
The constant excitement due to excessive 
venery results in hyperplasia, and we find flex- 
ions producing the same results, but by arresting 
the return of the venous blood. 
In all cases of hyperplasia the endometrium is 
found congested and the secretion from its glands, 
and the glands of the cervix, much more profuse and 
watery than when in a normal condition. It is prob- 
ably in this way that hyperplasia acts, for in many 
cases where the endometrium is not too much 
diseased pregnancy occurs in spite of the thick- 
ened uterine walls. Hyperplasia may run into 
chronic metritis where true inflammatory pro- 
ducts are thrown out, and this will prevent the 
development of the ovum even though it become 
attached. 
As stated above, the inflammations around or 
within the uterus may extend to the muscular 
tissue proper, in which condition we find haem- 
orrhages from the endometrium quite common, 
and in this way the ovum, after having reached 
the uterine cavity, may be washed out. The 
cavity of the uterus also becomes larger than 
normal so that there is less chance for the arrest 
of the ovum, the nutrition of the endometrium is 
more or less disturbed so that implantation of the 
ovum is not likely to take place, and the irrita- 
bility of the nerve supply is favorable to uterine- 
contraction, which frequently results in the ex- 
pulsion of the ovum. 
Inflammation of the endometrium is the most 
frequent, directly or indirectly, of all causes in 
producing sterility. We have seen how it may 
produce changes which prevent the entrance of 
or are injurious to the vitality of the spermatozoa. 
We have also seen how most para- or peri-uter- 
ine inflammations start from the endometrium, 
and either affect the production of the ova or pre- 37 
vent their union with the spermatozoa. It now re- 
mains to consider how inflammations of the en- 
dometrium may prevent the implantation of or 
development of the impregnated ovum. In en- 
dometritis there is a production of many small 
round cells which are deposited between the 
glands, so that compression of the glands takes 
place and results in atrophy, not only of the 
.glands, but also of the mucous membranes. With 
this the secretion becomes thin and watery and 
its reaction is altered, while the ciliated epithe- 
lium is thrown off and replaced by cylindrical 
and polyhedral epithelium. This gives a smooth 
and slick condition to the endometrium so that 
the arrest of the ovum in the uterine cavity is 
very difficult, or, should it be arrested and be- 
come implanted, the atrophied condition of the 
mucous membrane with the alterations in the 
subjacent tissues will favor its early expulsion. 
All intra-uterine growths, whether submucous 
fibroids, polypi, malignant or other tumors, pre- 
vent implantation or favor early abortion by alter- 
ing the condition of the mucous membrane, or 
by offering a mechanical resistance to the devel- 
opment of the ovum. 
Growths in the muscular tissue also alter the 
condition of the mucous membrane, but they act 
chiefly by preventing the uniform enlargement of 
the uterus as the ovum develops. The subserous 
growths may produce a condition closely resem- 
bling vaginismus and, if impregnation occur, the 
excitable condition of the nerves may cause early 
abortion. Intra-abdominal tumors may, if large, 
be an obstacle to the development of the ovum by 
directly compressing the uterus, as is sometimes 
seen in cases of multilocular ovarian cysts. 
Cancerous tumors act by infiltrating the tissue 
of the uterus as well as by preventing copulation 38 
through the sense of disgust connected therewith. 
Should laceration of the cervix extend nearly up 
to the internal os it causes infiltration of the 
uterine tissue, which results in a loss of the rela- 
tion between the ovum and uterus as develop- 
ment progresses, of which abortion is the conse- 
quence. Membranous dysmenorrhcea is in some 
cases a cause for the discharge of the ovum, but 
not in all cases, for many examples of child-bear- 
ing have been reported in women who were suf- 
fering from that trouble. Another cause for non- 
implantation of the ovum, which is probably more 
frequent than is generally supposed, is the appli- 
cation of the sharp curette or strong medicinal 
substances to the endometrium by unskilful 
hands. Their value, in suitable cases, when 
carefully applied, can not be over-estimated, but 
if the mucous membrane be destroyed in its entire 
thickness it must be replaced by cicatricial tissue 
unsuitable for the implantation of or nourishment 
of the ovum. 
To enter into the subject of abortion would be 
rather foreign to the present subject, and it would 
require too much space for the present paper. 
Suffice to say that where habitual abortions occur,, 
if neither the father nor the mother show any 
signs of syphilis, attention should at once be 
directed to the uterus. I have under my care now a 
lady who has aborted five times, and it was only 
in her last accident, the first in which I attended 
her, that a large uterine polypus -was discovered. 
The trouble was supposed to be due to "habit."' 39 
TREATMENT. 
i. Nonproduction.-Male.-(a.) Should the 
testes of the male be congenitally absent from the 
scrotum there is a possibility of their being pres- 
ent in the abdominal cavity, but in either case if 
aspermia or azoospermia exists, treatment is use- 
less. Should spermatozoa exist in small quan- 
tities the same remedies can be used that are em- 
ployed in early decay. These can also be used in 
cases of retarded development. 
(bP) Where inflammatory or other troubles have 
produced destruction of the glandular structure, 
restoration of the destroyed tissue is impossible; 
but under iodides and mercurials with counter- 
irritants and electricity, the inflammatory de- 
posits may be absorbed and the arrested secretion 
from the remaining healthy portions reestablished. 
(cP) When sterility in the male is accompanied 
by atrophy or softening coincident with varicocele, 
hernia, or other benign tumors, the prognosis is 
good, if the individual will submit to surgical 
treatment in time. The tumors should be extir- 
pated and the testes injured as little as possible. 
In all cases of hernia where a truss is not suit- 
able the radical cure should be undertaken. Of 
all the methods used for varicocele the best is 
ligating the veins above and below, by the open 
method, and dividing them between. Hydrocele 
should -be first treated by withdrawing the fluid 
and injecting irritating substances, after which, if 
a cure is not effected, more radical measures can 
be adopted. For malignant tumors, thorough 
extirpation has to be resorted to and the prog- 
nosis is very unfavorable for future posterity. 
(dP) If sterility is subsequent to some consti- 
tutional disease, attention must be directed to 
building up the general health. A sea voyage, 40 
a trip to the mountains, sea bathing, or a stay at 
some chalybeate springs will be found beneficial 
in anaemic or debilitated persons. 
In obese and plethoric subjects the saline 
springs will be preferable, while a course of lax- 
atives, careful dieting and regular exercise will 
exert a beneficial influence. Should the cause 
be traced to masturbation or excessive venery, 
bromides must be used, while the will power is 
appealed to and the patient removed as far as pos- 
sible from all exciting causes. 
Debility of the sexual organs can be best over- 
come by cold douches and electricity, while the 
phosphides, nux vomica, and cantharides are 
employed internally. 
Female.-(a.) Congenital absence of the ova- 
ries can not, of course, be remedied, and non-de- 
velopment is almost as hopeless, though there is 
reason to believe that the use of electricity and 
massage, long continued, may stimulate the de- 
velopment of the glands. Where dislocation of 
the ovaries depends on uterine displacements it 
should be treated by attending to the false uterine 
position. If the ovary alone is dislocated it can 
frequently be treated by a pessary, unless in the 
inguinal canal, when it should be replaced and 
supported by a proper fitting truss. 
(b.} Little can be done when atrophy of the 
ovaries follows wasting diseases, except to use 
tonics and such remedies as are used in atrophied 
testes, hoping thereby to cause development of 
such follicles as have escaped the inflammatory 
process. Much, however, can be done to pre- 
vent inflammatory troubles by preventing early 
marriages. Women, as a rule, unless well de- 
veloped, should not marry under twenty years of 
age, and in many cases it is best to wait until 
the twenty-second year. In pelvic inflammations, 41 
where exudation has taken place, it is well to 
withdraw, by aspiration, what fluid can be ob- 
tained and thus abort the trouble. Dr. Hardon, 
of Atlanta, Ga., speaks highly of this treatment, 
and I have seen the happiest results follow its 
use. Where due to syphilitic infection the in- 
flammatory deposits must be treated by iodides 
and mercurials while tonics are given to build up 
the general health. Where atrophy of the ovaries 
is due to contraction of inflammatory deposits, 
which dislocate or compress the ovaries, much 
benefit can be obtained from the long-continued 
use of hot water vaginal injections, massage and 
galvanism. Vaginal and rectal suppositories, 
containing iodine, iodoform, or one of the iodides, 
can also be used with advantage. With the 
local treatment we should also use tonics and 
such remedies as are best calculated to build up 
the constitution. 
(c) Where malignant growths affect the 
ovaries, early and complete removal must be re- 
sorted to, but if the growth is benign, the opera- 
tor should, if possible, leave as much of the ovary 
as appears to be healthy, in the interest of future 
generations. 
(d.) The sterility attending anaemia, chlorosis 
and other constitutional affections must be treated 
on general principles. Tonics, baths, chalybeate 
wate s, voyages, change of scenery and surround- 
ings, can all be used, while good and nutritious 
food must be furnished and regular out-door ex- 
ercise enjoined. Where the persons are addicted 
to the use of drugs they will have to be gradually 
weaned off and some substitute used till the phy- 
sical and moral nature is sufficiently strong to 
enable them to abstain. 
In cases of obesity, rich, saccharine, fatty and 
starchy foods must be forbidden, regular and 42 
daily out-door exercise required, and sea bathing 
and saline waters advised. In the way of med- 
ication aloes, iron, nux vomica, and phosphorus 
can be employed advantageously. Despres re- 
lates cases where the application of electricity 
produced sexual excitement with a discharge of 
vaginal and uterine secretions, and it is more 
than likely that the same agent will be found of 
use where non-production of ova is due to a slug- 
gish condition of the female genitalia. Little 
can be done by the physician in inherited sterility 
except to pay attention to the general functions 
of the body, but he should, wherever he can act 
as the family adviser, impress on his patients the 
evils of inter-marriage, and do all that he can to 
prevent such unions. 
2. Nonunion. Male.- {a.'} Any absence or 
occlusion of the ducts situated between the testes 
and the urethra is naturally out of reach of the 
surgeon, unless the occlusion is due to pressure 
from a tumor of the cord or elsewhere, in which 
case it can be readily removed. The causes of 
non-union in the male are fortunately situated, 
as a rule, in the urethra, and these can gen- 
erally be remedied. In urethral fistula, epispa- 
dias, and hypospadias, the defect can be reme- 
died by a plastic operation. Phymosis, stenosed 
meatus and dilated meatus can also be easily 
remedied by simple operations. It is in strict- 
ures of the urethra, however, that the surgeon has 
to employ his ingenuity, and wide differences of 
opinion exist as to the best methods to employ. 
Soft stricture usually yields readily to dilatation, 
but the fibrous stricture should be treated by 
urethrotomy and electrolysis. Otis, of New York, 
prefers internal urethrotomy; Stein, of New York, 
thinks gradual dilatation best; Keyes, of New 
York, practices external urethrotomy for strictures- 43 
from injuries; Lavaux, of Paris, claims a new 
method which he calls "divulsion progressive," 
where a cure can be effected in eight days; and 
every town of any size now has its ardent advo- 
cate of electrolysis. Should the breadth of a 
fibrous stricture be narrow it may be advantage- 
ously excised by external urethrotomy and the 
two portions of the urethra carefully drawn to- 
gether and united by sutures. 
(A) Though the gonorrhoeal poison is one of 
the most potent factors in producing sterility, 
yet it probably affects the vitality of the sperma- 
tozoa very little as they pass through the urethra. 
It is well, though, in every case to check the dis- 
charge as soon as possible, and for this I have 
found injections of creolin or of sublimate solu- 
tions among the best remedies. 
(r.) The use of artificial means by the male to 
prevent conception can not be too severely con- 
demned, for they are injurious both morally and 
physically. Abstinence from coitus, and coitus 
only about midway between the two monthly 
periods are the only legitimate means to be em- 
ployed, where there is a desire to avoid concep- 
tion. 
(^7.) In individuals of excitable dispositions, 
where orgasm comes on before that of the female, 
bromides can be given, but in time each individ- 
ual will learn the other's disposition and be able 
to hasten or delay orgasm till the proper moment. 
If this is not accomplished in a reasonable length 
of time, it may be well to separate the parties for 
a longer or shorter period, at the end of which 
time the difference in disposition will probably 
not be as great. Where neuroses of the genital 
tract exist there will generally be found some 
tenderness, or it may be a stricture of the urethra. 
In either case attention must be directed to the 44 
seat of the trouble. If orgasm seems to be re- 
tarded by exhaustion of the nerve centres nothing 
will be found better than phosphide of zinc and 
nux vomica. Where the trouble seems to be due 
to a dilatation of the dorsal vein of the penis, sub- 
cutaneous injections of ergotin by the side of the 
vein will be found useful. Jamin, of Paris, re- 
ported a case where imperfect erection was cured 
by the surgical treatment of an accompanying 
varicocele. Vidal de Cassis reported a similar 
case and I have succeeded in curing another case 
by the same treatment. 
Female.-(a.) All abnormal conditions of the 
ovaries and of the ova which prevent the escape 
of the ova or the subsequent entrance of the sper- 
matozoa are irremediable. So also is absence or 
imperfect development of the tubes and absence 
of the uterus. In cases of double uterus opera- 
tive interference is not called for, nor is it in 
double vagina unless the septum prevents coitus. 
Where there is partial or complete absence of the 
vagina, with a normal uterus present, an artificial 
vagina can be made by carefully dissecting be- 
tween the bladder and rectum so as to avoid 
injury to these organs. In unmarried females 
tents will have to be used occasionally to keep it 
from contracting, but after marriage the male 
organ will usually render the use of the tent un- 
necessary. 
The discovery of an imperforate hymen is usu- 
ally made at puberty, and is easily remedied by 
incising, but all antiseptic precautions must be 
used to prevent septic absorption. Should coitus 
be prevented by a rigid hymen or an abnormal 
condition of the vulva, a slight and harmless sur- 
gical operation will set all to rights. 
Atresia of the cervical canal is best operated on 
by a trocar, and dilators used afterwards. If 45 
haematometra is present the same care must be 
used as recommended in operating on haemato- 
colpas, for septic poisoning is exceedingly easy 
after the operation. Stenosis of the cervical canal 
can be treated by incision, or by dilating with 
instruments for that purpose, but the best and 
most permanent results are obtained from the 
occasional use of tents. 
For absence or abnormal shortness of the intra- 
vaginal portion of the cervix there is no remedy. 
Where uniform elongation or hypertrophy of the 
cervix exists amputation must be resorted to, but 
in the operation care should be used to unite the 
mucous membrane of the cervical canal to that 
surrounding the cervix so as to prevent subse- 
quent stenosis. In sterility due to stenosis or 
flexions the "Outerbridge dilator" will be found 
of service, if introduced several days before the 
menses make their appearance. Where hyper- 
trophy of the cervix is confined to only one side, 
amputation can be practiced or the convex por- 
tion of the cervix can be incised so as to remove 
the obstruction. Conical and nozzle-shaped cer- 
vices must also be amputated. In cases of lacer- 
ated cervix or lacerated perineum the duty of the 
surgeon is to repair the injured part as soon as 
possible. 
In all displacements of the uterus an effort 
should be made to restore the normal position. 
Prolapse can be treated by massage, hot 
douches, astringent tampons, pessaries, sup- 
porters, or some of the surgical procedures to be 
mentioned hereafter. Where flexions exist tents 
should be used to soften the uterine tissue and 
straighten out its axis, after which intra-uterine 
stems, tampons or pessaries should be used to 
keep it in its normal position. Versions can 
often be treated by tampons and pessaries, and 46 
Bouilly, of Paris, recently reported eighty cases 
of retro-deviations treated successfully by pes- 
saries; of this number three had subsequently be- 
come pregnant. Should, however, the displace- 
ments be of long standing it will be well to re- 
sort to surgical interference. Alexander has de- 
vised a means of shortening the round ligaments 
of the uterus, which has been modified somewhat 
by Polk and Wylie. This operation gives the 
best results for simple retro-deviations, but it has 
also been used in prolapse. In the latter case it 
is best to accompany it by some operation for 
narrowing the vagina or increasing the perineal 
support. In a case of prolapse Freund, of Strass- 
bourg, opened Douglas' cul-de-sac and attached 
the fundus uteri to the peritoneum of the sacrum. 
This he calls retro fixation. Ventro-fixation con- 
sists in opening the abdominal cavity and attach- 
ing the uterus to the abdominal parietes. It is 
steadily growing in favor and has the hearty sup- 
port of such men as Ducas-Championniere, 
Polaillon, and Terrier, of Paris; Sanger, of Ger- 
many; Kelly,'of America, and many others. It 
gives the best results in cases of simple retrover- 
sion, but has been used in nearly all displace- 
ments. Picque, following the operation Olshau- 
sen, has, where the uterus was bound down, 
opened the abdomen, divided the bands and at- 
tached the uterine ligaments to the abdominal 
parietes. The result was good, but it might be 
well to adopt the method of Brich and forcibly 
separate the adhesions by a large steel sound in- 
troduced into the uterine cavity. It seems also 
that the safety of these operations might be in- 
creased by incising only as far as the peritoneum 
and suturing without opening the abdominal 
cavity. Contracted pelvis is a rare cause of im- 47 
pediment to the entrance of the semen, and when 
it is can not be remedied. 
Acquired stenosis or atresia of the genital tract 
must be treated in the same way as the congeni- 
tal form, and usually gives better results. 
The evil results of inflammatory deposits about 
the uterus and its appendages have been dwelt 
on in speaking of the causes of sterility. When 
the acute stage has passed such remedies should 
be used as will favor the absorption of the de- 
posits. Copious injections of hot water, in both 
vagina and rectum, are found very serviceable in 
producing these results, but they must be long 
continued to produce the best results. Tampons 
of glycerine with or without iodine, or iodide of 
potash also exert a favorable influence. Rectal 
and vaginal suppositories of iodine, iodide of 
potash, or iodoform have yielded excellent re- 
sults in my hands, when combined with tonics 
-and hot-water injections. 
In some cases local blood-letting will be found 
serviceable. With all these remedies absolute 
abstinence from sexual excitement must be en- 
joined. 
Electricity has been introduced by Dr. Georges 
Apostoli in the treatment of these affections, and 
its long continued use in chronic and subacute 
cases has been followed by the most excellent re- 
sults. Engelmann and many others, both here 
and abroad, testify to its efficacy. 
Major Thure Brandt, of Stockholm, was the 
first to use massage in uterine affections, after 
which it was practiced by Dr. Sahlin of the 
Stockholm medical school. In 1870 Dr. Nos- 
trbm, of Paris, became interested in the subject, 
and after carefully studying it introduced it into 
Paris in 1872, since which time it has been dif- 
fused over the whole civilized world. 48 
It has been used for uterine displacements, 
metritis and ovaritis, but its most satisfactory re- 
sults have been made in peri-uterine exudates of 
long standing. Semianikoff, of St. Petersburgh, 
reports favorably of it, as do also Profs. Jackson 
and Martin, of Chicago, Drs. Smith and Athill, of 
England, and many others. Boldt, of New York, 
calls attention to the fact that great care must be 
used where accumulations of fluid exist in the 
tubes. To get satisfactory results massage must 
be carried out by the gynecologist himself, and 
persevered in for a long time. Only chronic and 
subacute cases should be subjected to treatment, 
and where the finger of the operator is not long 
enough to reach the deposits he may resort to 
the obturator of Wissenberg, the end of which 
may be covered with rubber if much tenderness 
is experienced. 
When hydro-, haemato-, or pyo-salpinx exist, 
they may be overcome by putting the patient 
under an anaesthetic, dilating the uterus, break- 
ing up what adhesions exist, and thoroughly 
curetting the endometrium, especially around the 
openings of the tubes. Intra-uterine galvanism 
is also useful, and cases have been reported where 
the obstruction in the tube has been overcome in 
this way. In the early stages of salpingitis it is 
well to follow the treatment of Dr. Mangan, of 
Marseilles- use rest, sedatives, and cold to the 
abdomen, while hot vaginal injections are em- 
ployed, and when the case becomes more chronic 
apply medicated glycerine tampons to the cervix 
and iodoform pencils to the interior of the uterus. 
With these remedies it is well to combine tonics 
and baths. 
Should vaginismus be the cause of sterility the 
remedies employed must be adapted to the cause 
of the vaginismus. Solutions of lead, silver and 49 
zinc may be employed for the inflammatory pro- 
cess, while cocaine, belladonna and morphia will 
relieve the irritation and pain. Coitus under 
chloroform has been advised but does not relieve 
the trouble. Gradual dilatation with specula has 
been used, but probably the best remedy is to ex- 
cise the hymen close to its insertion. When vag- 
inismus is due to uterine fibroids galvanism will 
usually effect a cure if sufficiently long continued. 
In all cases where non-union of the ova and 
spermatozoa is due to hypertrophy or tumors of 
either the external or internal organs of genera- 
tion, the surgeon should remove the cause if pos- 
sible. The fact of sterile women becoming preg- 
nant after the removal of uterine or ovarian tu- 
mors is well known to all. 
Should the acid secretions of the vagina be in- 
jurious to the spermatozoa, boracic acid will be 
found to be an excellent remedy. Potter, of Buf- 
falo, employs vaginal tamponnement with this rem- 
edy in cases of sterility, and claims good results 
from its use. Kisch recommends a warm aque- 
ous saccharine solution rendered alkaline by 
caustic potash, and Chassier uses a solution of 
white of egg and phosphate of soda, in which the 
spermatozoa are said to live for a long time. 
Where the impediment seems to be due to a 
thickened cervical secretion, it will be well to in- 
troduce a tampon, saturated with glycerine, sev- 
eral hours before coitus, and remove it before the 
act is accomplished. 
Vaginal catarrh can be best remedied by injec- 
tions of solutions of corrosive sublimate, creolin 
and boracic acid, though the astringent metallic 
salts can be used with advantage, and where much 
pain exists sedatives and demulcents should be 
employed. Parvin, of Philadelphia, and Jules 
Cheron, of Paris, speak in the highest terms of 50 
the use of creolin, employed either in solution or 
as an ointment. 
The diagnosis of acute endometritis is usually 
easy, but where chronic endometritis is suspected 
it is best to follow the advice of Schultze, of Jena. 
This consists in inserting a glycerine tampon 
against the external os at night, which, on re- 
moval in the morning, will have a small quantity 
of pus on it, if endometritis is present. The cure 
of simple catarrhal endometritis may be effected 
by glycerine tampons, and hot douches as rec- 
ommended by Hermann, of London; or a solu- 
tion of morphine may be employed with success, 
according to Siviecceki. Where the cases are 
more obstinate solutions of nitrate of silver, sul- 
phate of copper, tr. of iodine, carbolic acid or 
creasote can be used with advantage, but better 
results are obtained from introducing crayons 
made from tragacanth dissolved in glycerine and 
water, which contain iodoform, corrosive subli- 
mate, creolin, resorcin or salol. Where the en- 
dometritis has become chronic, Dumontpallier 
uses Canquoin's paste, and Rheinstaedter, of Co- 
logne, Dorff, of Belgium, and Brose, of Berlin, 
speak in the highest terms of a 50 per cent, solu- 
tion of chloride of zinc applied to the endome- 
trium, w'hich can be followed in a few weeks 
by a 20 per cent, solution. With the above 
remedies tonics must be used, and all agents that 
are calculated to build up the general system. 
The treatment of salpingitis has been spoken of 
before, and the line of treatment mapped out. 
Where fistulae exist, surgical procedures must 
be resorted to, and it is well, where it is possible, 
to follow Tait's operation, as it probably gives 
better results than any other. 
(r.) Nothing need be said about the artificial 
means used by women to prevent conception, ex- 51 
cept to condemn them as injurious and unnatural. 
It is rare that the physician is called in to 
treat cases of retarded orgasm or the contrary con- 
dition, and when he is, little can be done except 
to appeal to the moral power while the functions 
of the body are put in order. In some cases a 
separation of the man and wife for a lengthy pe- 
riod of time will be found to be very beneficial to 
both parties, and will overcome the trouble. 
5. Non-implantation.-Non-implantation after 
impregnation is due to some trouble in the tubes 
or the uterus. The treatment of diseased tubes 
has been spoken of while discussing the union of 
the ova and the spermatozoa, and it now remains 
to consider briefly the affections of the uterus. 
The prognosis in the undeveloped or atrophied 
uterus is poor, and yet, with the long continued 
use of tents, stimulating crayons, hot douches, 
electricty, massage, emmenagogues, and strict at- 
tention to the general health, much good can be 
obtained. The treatment of peri- and parauterine 
deposits has been spoken of in connection with 
uterine displacements, and endometritis was treat- 
ed of when considering agencies injurious to the 
life of the spermatozoa. It remains to say, how- 
ever, that in exceedingly obstinate cases of chronic 
endometritis, with or without fungous or other 
growths of the endometrium, the application of 
the blunt curette will be found most useful. After 
its application a solution of the subsulphate or 
the perchloride of iron should be applied to the 
endometrium, as recommended by Kay, of Scran- 
ton, or the iodized phenol can be substituted with 
advantage, according to Roony, of Quincy. 
In curetting the uterus it is well to remember 
that paralysis of the muscular walls sometimes 
takes place, and the instrument seems to pass into 
blank space. Cases of this kind have been re- 52 
ported by Doleris and Geijl. For implantation 
of the ovum it is necessary to remove all intra- 
uterine growths, but where they are subserous or 
situated in the muscular tissue, the application of 
electricity should be persevered in, as its results 
are excellent and little danger attends its appli- 
cation. Ergot has been used subcutaneously, but 
little good has been obtained from its use. If 
sterility is due to compression of the uterus from 
intra-abdominal growths, laparotomy must be re- 
sorted to to remove the trouble. If cancer of 
the cervix is taken in time, its removal will 
justify a favorable prognosis, but where the dis- 
ease has attacked the body of the organ nothing 
can be done in the interest of child-bearing. 
In cases of membranous dysmenorrhoea the cav- 
ity of the uterus can be dilated and various me- 
dicinal substances applied to its interior. The cu- 
rette has also been used with success, and Winckei 
has had good results from the application of leech- 
es to the cervix uteri. But in many cases all 
treatment fails to relieve the trouble, and all that 
can be done is to see to the general health while 
sedatives and opiates are employed as required. 
In menorrhagia and metrorrhagia the cause must 
be looked for and the case treated accordingly. 53 
LITERATURE. 
Apostoli, G., "The Treatment of Salpingo-ovaritis by 
Electricity," The Journal, June 27, 1889. 
Athill, "Massage in Gynecological Practice," The 
Journal, June 15, 1889. 
Barnesfather, " On the Menstrual Discharge," Cincin- 
nati Med. Jour., August, 1889. 
Beauni et Bouchard, " Nouveau Elementes d'Anatomie 
descriptive et d'Embriologie," Paris, 1885. 
Biegel, " Pathologische Anatomic der wieblichen Un- 
fruchtbarkeit, " Braunschweig, 1878. 
Bouilly, "Traitement des retro-deviations uterine," 
La Semaine Medicate, April 17,1889. 
Boldt, "Advances in Diseases of Women," The Jour- 
nal, October 12, 1889. 
Brose, P., "Traitement du catarrhe uterine par les 
badigeonnages au chlorure de zinc," La Semaine Medi- 
cate, March 20, 1889. 
Capellmann, "Facultative Sterilitat ohne Verlitzung 
der sittengesetze," Aachen, 1883. 
Carpenter, "Handbook of Physiology, " Fond., lasted. 
Charrier, " Du traitement par les alcalins d'une cause 
peu connue de sterilite," Paris, 1880. 
Ch€ron, Jules, " Creolin in Gynecology," Maryland 
Med. Jour., June 15, 1889. 
Davis, E., Deutsche Med. Zeitung, 1885. 
Despres, " Traitement electrique des fibroms," La Se- 
maine Med., August 3, 1889. 
Doleris, "The Curette and Paralysis of the Uterus," 
Maryland Med. Jour., September 21, 1889. 
Dorff, "Traitement du catarrhe uterine par les badige- 
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