A transient, relative hindrance to ovulation may be brought about by various pathological states of the ovaries. Acute oophoritis usually suspends the ovarian functions; chronic oophoritis has sometimes a similar effect, not only because the profound changes that take place in the ovary hinder the formation of the ovules, but also because, as we shall later explain more fully, the expulsion of the ova and their reception by the Fallopian tubes are hindered. In severe oophoritis and perioophoritis, more especially in parenchymatous inflammation, sterility may be brought about by an absorption of the finely granular contents of the follicles, which collapse, with adhesion of their walls; when all or most of the follicles are thus affected, the ovaries become small and hard.
In perioophoritis, the exudation leads to the formation of cord-shaped or ribbon-shaped adhesions between the ovaries and the broad ligaments, the uterus, and the peritoneal folds of the neighbourhood. The ovary in such cases may also be displaced, or may undergo atrophy from pressure.
In the case of 200 sterile women, I found in 46 instances chronic oophoritis and perioophoritis. Olshausen reports that of 12 married women suffering from chronic oophoritis, five were barren, whilst of the remaining 7, three only had given birth to more than one child. Matthews Duncan, on the other hand, saw pregnancy in a case of bilateral ovarian inflammation, in which the organs were considerably enlarged.
Further, local or general peritonitis may lead to parenchymatous inflammation of the ovaries, and this, spreading from the periphery towards the centre of the organ, attacks the follicles irrespective of their ripeness. Again, during the puerperium, the interstitial form of oophoritis is by no means rare, and this may at times lead to permanent sterility in either of two ways: it may be in consequence of the onset of a secondary parenchymatous inflammation, which destroys all the follicles; it may be because a thick and tough layer of sclerosed tissue forms around the periphery of the ovary, which mechanically prevents the maturation and rupture of the follicles. According to Slavjansky, puerperal disease is the principal cause of this form of oophoritis. Olshausen indicates as the most frequent cause of primary perioophoritis, an inflammation propagated from the Fallopian tubes, leading to the formation of masses of exudation, which envelop the ovary, and by the pressure they cause, and by interfering with the blood-supply, lead to atrophy of the gland.
Sometimes the chronic inflammatory induration by means of which the stroma of the ovary is rendered denser and firmer, is due to changes in the vessels, and depends upon valvular defects of the heart—upon venous congestion. In this way, heart disease may hinder ovulation and bring about sterility. Both syphilis and gonorrhoea may give rise to chronic inflammatory changes in the ovary, usually leading to premature contraction of the tissues and to the formation of numerous adhesions. According to Olshausen, amenorrhœa is not a common feature of ovarian disease, except in cases of defective development of these organs, of cirrhosis of the ovaries, and of bilateral new-growths. Disease affecting only a single ovary, even tumour of considerable size, rarely causes amenorrhœa until profound constitutional disturbance has ensued. An exception to this rule is found in the case of carcinomatous tumours of the ovary; these, indeed, are commonly bilateral; but even when confined to a single ovary, amenorrhœa is a comparatively early symptom. According to the same author, sterility is a common consequence of chronic oophoritis and its sequelae, and is usual also in cases of bilateral new-growths; on the other hand, tumours affecting a single ovary often fail to prevent conception even though they have attained a great size.
Syphilis in women must be regarded as a frequent cause of sterility, by interference with ovulation, but is in this regard by no means an absolute bar to the occurrence of pregnancy. According to Parent and Duchatelet, under whose observation during the space of 12 years there came annually an average number of 2625 syphilitic prostitutes, the average annual of births in these cases was 63 only. According to Marc d’Espine, 2000 prostitutes gave birth on an average to two or three children in all during a year. (That there are other causes besides syphilis for the remarkable infertility of women of the town, will be explained later). According to Bednar, Mayr, and others, constitutional syphilis in women invariably leads to sterility; others, as for instance Zeissl, believe that women suffering from inveterate syphilis are commonly, but not invariably, sterile; whilst according to Rosen, conception only takes place in syphilitic women in whom the disease has passed into the tertiary form. Experience shows, however, that neither early nor late forms of syphilis necessarily lead to sterility in women. It must also be pointed out, that syphilis in the male may be the cause of sterility, and must be the cause thereof when the disease is localised in the testicles, and the consequent degeneration of the glandular substance leads to the occurrence of azoospermia, more particularly when syphilitic or gummatous orchitis is bilateral. According to Lewin, we fail to find spermatozoa in 50% of men, otherwise powerful, suffering from syphilitic dyscrasia. Hanc, on the other hand, failed to find azoospermia in any one of ten men suffering from lues. In animals also syphilis is said to cause sterility.
The manner in which certain anomalies of the blood (anæmia and chlorosis), general disturbances of the nervous system, febrile states, and such constitutional disorders as scrofula, have a temporary or permanent influence in checking ovulation, is far from being understood; but the fact that ovulation is checked by such conditions, has been established beyond question by numerous observations. It is well known that severe fevers, more especially typhoid, suspend the ovarian function; that in various chronic disorders of an enfeebling nature, and notably in chlorosis, all signs of menstrual activity disappear; and that in certain nutritive disturbances, as in extreme obesity, amenorrhœa also occurs; finally, numerous cases are on record in which some sudden affection of the nervous system has instantaneously inhibited ovarian activity.
In anæmia and chlorosis, it is probable that the degree of menstrual congestion is insufficient to ensure the bursting of the graafian follicle. The sterility often observed as a sequel of typhoid, malaria, the acute exanthemata, cholera, and septicaemia, is probably due in most cases to the occurrence of parenchymatous oophoritis, with consequent destruction of the ovarian follicles. The researches of Slavjansky have shown that in acute disorders inflammatory changes often occur in the graafian follicles. When infectious disorders ran an acute course, this observer usually found that the parenchymatous inflammation of the ovary had occurred near the periphery, in the cortical layer, the destruction being limited almost exclusively to the primitive follicles; when the course of the primary disorder was more chronic, the mature or nearly mature graafian follicles were the ones destroyed. When inflammation of a follicle has led to its destruction, it is replaced by a linear scar. Lebedinsky found similar changes in the ovary after scarlatina—destruction of a lesser or greater number of follicles, with formation of scars. Thus, parenchymatous oophoritis as a sequel of acute diseases, may, if severe, lead to destruction of all the rudimentary follicles, with consequent sterility. In the post mortem examination of such cases, the condition of the ovaries is similar to that which is elsewhere in this work described as characteristic of these organs after the menopause: the ovary is diminished in size, its surface is furrowed, the tissue is indurated in consequence of overgrowth of fibroid tissue; often not a single follicle is to be detected on section of the organ.
Immoderate obesity is a disorder of nutrition favoring the occurrence of sterility.
In very obese women of an age which normally is the reproductive prime, amenorrhœa or scanty menstruation is a very common accompaniment. In 215 such cases which came under my own observation, amenorrhœa was present in 49, and menstruation was scanty in 116; thus in nearly three fourths of these obese women menstruation was either deficient or entirely wanting. Very remarkable also is the high percentage of sterile women among the obese. In the 215 cases already mentioned (all married women), 48 were sterile—a percentage of 21. Whilst the ordinary ratio of barren to fruitful marriages is 1 : 10 or 1 : 9, in the cases in which the wives, or both wives and husbands, are extremely obese, the ratio is according to my own observations, 1 : 5—or, if we include cases of only-child-sterility, 1 : 4.