In the case of sterile women who are amenorrhoeic, even when the amenorrhœa has never been interrupted by a menstrual discharge, or when it appears entirely dependent upon obesity, it is nevertheless necessary to be extremely cautious in making a diagnosis, and above all in employing an intra-uterine sound. In such cases I have known the most eminent gynecologists unwittingly bring about abortion.
Cleveland, Godefroy, Haschek, Ritschie, Sommerus, Stark, Taylor, and Young, have all reported cases in which pregnancy occurred in women suffering from amenorrhœa; but all such cases must be regarded as quite exceptional. Szukits examined 8000 sexually mature women, and found among them fourteen only who had never menstruated. Of these, four were multiparae.
Saint Moulin reports the case of a woman 24 years of age who had never menstruated, but who none the less became pregnant and gave birth to a fine girl. One of the most striking cases of this nature is the one reported by Rodzewitsch, regarding a woman who first began to menstruate at the age of 36 years. This woman had however been married when fifteen years of age, and in the subsequent twenty-one years she gave birth to 15 children, remaining the whole time amenorrhoeic.
Puech reports the case of a woman who ceased to menstruate at the age of 40 years, and remained amenorrhoeic for the subsequent six years. Then menstruation recurred for a year, and finally ceased definitively in consequence of the occurrence of pregnancy, which terminated in the normal birth of a healthy boy. Loewy, in a woman 31 years of age, who had previously been amenorrhoeic all her life, saw menstruation appear for the first time shortly after the birth of her sixth child. Ahlfeld had under observation the case of a woman who was the mother of eight children, and had never menstruated.
Krieger reports the case observed by Mayer, of the wife of an artizan, who between the ages of 17 and 28 years had given birth to five children, and had had one abortion. After the age of 22, she had no trace of menstrual discharge, but notwithstanding this, she subsequently gave birth to three children. Krieger himself saw a woman who had had her last child at the age of 33, and in whom now, at the age of 48, menstruation had just ceased entirely. Two years later, irregular menstrual discharges recommenced; when these ceased, it appeared that the woman was once more pregnant, and she was normally delivered of a full-time girl.
Renaudin relates the case of a lady 60 years of age who gave birth to a child, menstruation having ceased 12 years earlier. Deshhayes saw the delivery of a woman 50 years of age, two years subsequent to the occurrence of a normal menopause. Capwron, quotes the ease of a woman who became pregnant at the age of 65 years. In this case menstruation had recurred, having ceased many years before in a normal menopause. This woman aborted at three months, and the foetus was well-formed.
In such cases of late conception, which occur after the normal cessation of menstrual activity, we cannot be certain whether we have to do with a simple persistence of ovarian activity, associated with temporary or permanent cessation of menstruation; or whether both functions, ovulation and menstruation, had ceased, and were aroused to renewed activity by some determinate cause. It is possible that in coitus we have such a stimulus, capable of reawakening the slumbering ovarian functions. That this may be the case, we are led to suppose by the fact that pregnancy at an unusually advanced age most frequently occurs as a result of marriage late in life. In Scandinavian countries, where the difficulties of providing for a family are so great that a very large number of marriages are inevitably postponed till comparatively late in life, the number of pregnancies occurring in elderly women is correspondingly large. However, pregnancy late in life occurs also in women who have married early, and the most probable assumption to account for such cases is that ovulation has occurred in the absence of menstruation.
Although by these cases the proposition is established that amenorrhœa is by no means equivalent to incapacity for ovulation, still, the former must indubitably be regarded as in general a most important indication of disturbed ovulation. When a woman attains the age of 20 years without having ever menstruated, or even having experienced menstrual molimina, we may in the great majority of such cases infer with justice that there is complete or partial failure of development of the ovaries and the reproductive apparatus generally. In some of these cases, examination discloses the fact that the uterus is in an infantile condition. When we are able to bring about the regular establishment of menstruation, we may hope also to remove the sterility dependent upon the defective ovarian functional capacity. General tonic treatment for the relief of chlorotic amenorrhœa quite as often, in the case of previously barren married women, results in the occurrence of pregnancy, as happens in cases of amenorrhœa and sterility due to obesity, when this latter condition has been relieved and menstruation has been re-established by suitable dietetic treatment. Much less often is it possible to relieve the sterility of scrofulous (tuberculous) persons, for in the majority of such cases, in consequence of the scrofulous (tuberculous) constitutional disorders, pathological changes have occurred in the ovaries already in early youth, and these it is difficult or more often impossible to remove.
Scrofula (tuberculosis) is, according to my own experience, the constitutional disorder which of all most frequently and most seriously affects ovulation; and it appears that the ovaries are subject to changes produced by this disease similar to those which occur in other glandular organs. In cases in which no cause of the existing sterility is ascertainable, the presence of scars due to scrofulous (tuberculous) changes in the lymphatic glands may serve as an indicator to show that the capacity for ovulation has been annihilated or seriously diminished in early life by scrofulous (tuberculosis) disease.
Among the causes of sterility, these three conditions: anæmia, chlorosis, and scrofula (tuberculosis), play a leading part; indeed, their importance in this connexion has hitherto been underestimated, more especially in regard to the comparative frequency with which they cause sterility. A large part of the favourable influence in the relief of sterility in women which is exercised by the “cures” at various watering places, depends upon the amelioration which is thus effected in the aforesaid constitutional disorders.