We proceed on the principle of rectifying the constitution, where it is injured or weak, and of restoring the menstrual evacuation, to its due and healthy state. The means for effecting these purposes, must depend on the situation of the individual.
Causes.
There are chiefly two states of the constitution productive of those deviations in the action of the womb, which cause barrenness. The first is a state of fulness, and a disposition to obesity.
The person gradually becomes fat and inactive, the menstrual evacuation continues regular for some time; but at last diminishes, and becomes obstructed, or goes to the opposite extreme, and becomes frequent or profuse. The patient is either barren or subject to false conceptions. This state is to be rectified by spare or vegetable diet, total abstinence from malt liquor, regular and constant exercise, especially early in the mornings and on horseback, the prudent use of laxatives, and after some time the cold bath. These means will, if persisted in prudently, effect the desired changes; but if pushed to an undue degree, and especially if repeated purgatives, and much vinegar, or great abstinence be resorted to, the health may be completely ruined.
The second state is that of relaxation; the habit is spare, instead of corpulent; the mind lively, and, perhaps, even irritable; the menstrual evacuation either profuse, or it recurs too frequently, and at times clots and shreds are discharged.
This requires a different treatment: the diet, if not unusually nutritive, is at least not to be sparing, the exercise must not be carried the length of fatigue, the cold bath is useful, and strengthening medicines are required.
Such remedies as have been pointed out for the removal of irregularities of the menstrual evacuations, or of the fluor albus, must be employed when necessary.
There are also certain diseases of the female genital organs, which, when they exist, are found to cause sterility. Polypus in utero is very generally considered to belong to this class; but although the opinion is generally correct, it is not universally true, for it has happened that conception took place notwithstanding the presence of a very large tumor in the uterus. Of this the late Dr. Beatty (Trans. of the Association of Coll. of Phys. in Ireland, vol. 4) has described a very remarkable instance, which occurred in Dublin in the year 1820. The patient was a lady twenty-five years old, who, in consequence of the indisposition of her husband, had left his bed in May, 1819, to which she did not return until August, 1820. In the previous May she first perceived what she termed a “lump in her womb,” attended with external swelling and soreness on pressure at the lower part of the abdomen. This swelling was not permanent, but was observed to disappear during the menstrual period. Finding an increase in her unpleasant symptoms, she applied to Dr. Beatty in September, and on the 28th of that month he made an examination per vaginam. The os uteri was found dilated to the size of a dollar, and in its opening was a large dense substance with a regular smooth surface. On the 10th of November, while out in her carriage, she had a moderate discharge of blood from the vagina, and upon examination the parts were found as they were a month before. At two o’clock the following morning she miscarried, the embryo was entire, the membranes not being ruptured: the contained fœtus was about three months old—a period corresponding with the time at which the connubial intercourse had been resumed, and at which she had last menstruated; and just three months after she first experienced uterine uneasiness. The tumor was expelled in six days afterwards by pains resembling labor, the uterus was inverted by its descent, but on separation of the slight attachment between it and the tumor it was easily reduced. The weight of the tumor was found to be nearly four pounds. This lady was delivered of a healthy boy on the 10th of February, 1822. This was an instance of pregnancy during the existence of a tumor of considerable magnitude in the uterus; but we believe it to be an exception to what usually takes place.
Inflammation, suppuration, calculous depositions, cancer, cauliflower excrescence, corroding ulcer, the irritable uterus of Dr. Gooch, and any disease in which the texture of the uterus is much engaged, or with which the constitution sympathizes strongly, are so many obstacles to impregnation, as are diseases of the ovaria, in which the natural structure of these organs is obliterated, and both of them engaged. Leucorrhœa, when profuse, is very often also attended by barrenness; but this is by no means a constant effect, as we have known instances in which this disease existed to a great extent without preventing impregnation.
A question has arisen whether menstruation is necessary in order that a woman shall be prolific; and it is generally stated that women who do not menstruate cannot conceive. (Paris and Fonblanque, Med. Jur. vol. i., p. 214.) This is true when applied to those who have never menstruated, but is not in cases that have had even a single monthly discharge. Foderé (Méd. Légale, vol. i., p. 397, ed. 2me) states that, in the first edition of his work, he had maintained that females who do not menstruate are sterile: but he afterwards was obliged to change his opinion, from having observed some patients under his own care enjoying good health without this evacuation, and bearing many children. One of them was a woman thirty-five years old, the mother of five children, the last of which she was suckling. She was in good robust health, and had never menstruated but once at the age of seventeen years. It would appear that a single occurrence of this periodical evacuation is a sufficient indication of generative power; and although irregularity in subsequent years is frequently attended by sterility, it is not to be taken as an absolute cause of it. There is a form of dysmenorrhœa described by Dr. Denman (Denman’s Midwifery, 6th edit., p. 90), and Dr. Dewees (Dewees’ Midwifery, p. 154) of Philadelphia, which both these authors state to be productive of barrenness. The striking peculiarity in this disease is the formation of an adventitious membrane in the uterus, which is expelled after severe and protracted suffering at each menstrual period. This membrane is sometimes thrown off in pieces, and at others entire, at which time it bears the strongest resemblance to the decidua, so much so that, when it occurs in unmarried females, it may and sometimes does give rise to most painful suspicions. There is a preparation in the museum of the College of Surgeons, Dublin, of an entire membrane of this kind, which might deceive the most experienced eye. Morgagni relates a very remarkable instance in which pregnancy occurred during the existence of the habit just described, but it is probable that there was a suspension of the disease for a time in that case, when the capability of conceiving might exist.