The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

Incapacity for Ovulation.

Incapacity for ovulation, the first and most decisive cause of sterility in women, may be absolute and irremediable, or relative and transient. We have to do with the former in cases in which the ovaries are entirely wanting, or when they are affected with organic disease to such a degree that they have become incapable of fulfilling their function of ovulation; incapacity for ovulation is, on the other hand, relative and transient in certain pathological states of the ovary and neighbouring organs, when there is incomplete development or partial atrophy of the ovaries, when there are new-growths of the ovaries, in cases of oophoritis and perioophoritis, in consequence of disturbances of innervation, diseases of the central and peripheral nervous system, violent emotional disturbance, constitutional disorders, such as syphilis, chlorosis, anæmia, universal lipomatosis, scrofula, alcoholism, and morphinism, also in consequence of changes in the supply of nutriment and in the general mode of living, or of senile changes, and finally in consequence of hereditary influences.

The diagnosis of the etiological influence of suppressed or incomplete ovulation in the production of sterility in women is at times beset with great and even insuperable difficulties. The state of the menstrual function, suppression of the flow, or the regularity or irregularity of its occurrence, serve indeed to inform us as to the general activity or inactivity of the function of ovulation; but the variations in this function give no certain information as to whether a woman is fertile or infertile. Knowing as we do that generally speaking an intimate connexion subsists between menstruation and ovulation, we are indeed able to assert that regular menstruation and fertility in women run a parallel course, and further, that the greater the irregularity of the menstrual function, the greater the tendency to sterility. Recently, great advances have been made in the technique of manual exploration of the ovaries, and by means of vaginal and rectal bimanual examination, we are now able to obtain accurate information regarding abnormalities in the size, shape, and position of these organs, and regarding any other intrapelvic disorders. In this way we have been enabled to recognize a number of pathological states of the ovaries which affect the functions of these organs. In some cases also there are general symptoms which furnish us with the means of drawing conclusions, more or less trustworthy, regarding the state of the ovarian functions; for instance, the general development of a woman’s body, the condition of the external genitals, the vulva, the mons veneris, the pubic hair, the clitoris, and the mammae. Again, we can derive information from various troubles of which women complain; such as sacrache; a sense of weight and pressure in the pelvis; feelings of tension and shooting pains in the breasts; flushings of the face; haemorrhage from the nose, mouth, or rectum, recurring at regular intervals and vicarious in nature. In many instances, however, it will only be by obtaining data regarding the age, mode of life, and family history, of the person affected, that it will be possible to draw conclusions as to the cause of the sterility.

The female reproductive glands, the ovaries, may, owing to developmental disturbances during foetal life, either be entirely wanting, or they may merely be deprived of certain structural constituents, especially their epithelial elements. In the former case, we have congenital complete unilateral or bilateral absence of the ovary, a condition most commonly associated with the absence or with a rudimentary condition of other portions of the reproductive apparatus; in the latter case, we have the condition somewhat inappropriately named congenital atrophy of the ovary.

Complete absence of both ovaries necessarily leads to absolute sterility. Both congenital absence and congenital atrophy of the ovaries, will usually be found in association with other anomalies of the sexual organs. Absence of one ovary, on the other hand, by no means entails sterility; on the contrary, when a single well-formed ovary exists, ovulation usually proceeds in a perfectly normal manner. When such women marry, pregnancy usually follows in the normal proportion of cases; and, in complete opposition to one of the theories of the determination of sex to which allusion has been made, such women bear children of both sexes.

Morgagni described a case of congenital absence of both ovaries in a woman 66 years of age, in whom the external genital organs, the vagina, and the uterus, were imperfectly developed, but the Fallopian tubes were of normal size. Careful examination of the upper borders of the broad ligaments of the uterus disclosed no trace of ovary on either side.

Quain, in a virgin 33 years of age, found the vagina rudimentary, with its mucous membrane but slightly corrugated; at the upper end of this passage was a semilunar fold which probably represented the uterus. The ovaries were absent; a small gland-like body embedded in the left wall of the vagina was regarded by him as a rudimentary ovary. The configuration of the body was feminine, feminine also the disposition; moreover, there was a monthly recurrent epistaxis.

The atrophy of the ovaries which normally takes place at the climacteric period, to be more minutely described in the section on the menopause, has constitutional effects similar to those dependent upon absence or congenital atrophy of the ovaries.

A rudimentary condition of both ovaries, or bilateral atrophy of these organs, with or without associated atrophy of the entire reproductive system, commonly entails sterility. In such cases, in addition to amenorrhœa, we usually find that the breasts are but slightly developed, the pubic hair is scanty, the labia majora and labia minora are small, whilst sexual appetite is deficient, and during coitus the woman is entirely passive. On the other hand, we must not make the mistake of inferring from the fact that the sexual appetite is keen and coitus pleasurable, that therefore the capacity for ovulation is normal. Even after operative removal of both ovaries, some women have assured me, not only that the sexual impulse was as strong as formerly, but even that they continued to experience the sexual orgasm in its full intensity. This is analogous to the well known fact that men who have undergone castration after arriving at sexual maturity may remain capable of performing coitus. It is a matter of history that in the lupanars of ancient Rome, castrated men were kept to enable women to enjoy the pleasures of sexual intercourse without fear of consequences; and it is said that such men are to be found in Italian brothels to this day. In the case of the lower mammals, it appears to be the rule that when the reproductive glands are removed in early youth, every trace of sexual desire disappears.

Incomplete development of the ovaries, with consequent defective ovulation, may result from marriage in girls who are still immature—a fact already known to Aristotle, who wrote, “premature marriage leads to a scanty progeny—that this is the case in man as well as the lower animals is witnessed by the weakly inhabitants of regions in which child-marriage is common.”