Chapter XIII. , page 199), does not ordinarily have amenorrhea as (Part 2)

it may show a gleety urethra] discharge. Microscopical examination of the semen on a warm slide will show whether it contains living spermatozoa or not. Care must be exercised not to heat the bottle containing the semen too much or to let it get cold, or the spermatozoa may be killed. Sterility in the Male The frequency with which the fault lies with the husband in cases of sterility is obviously a matter difficult to determine. San- ger, and Lier and Ascher (quoted by Kelly, "Medical Gynecology") have studied this matter in a number of cases. Of 242 husbands of sterile marriages examined by these authors, 104, or 43 per cent, showed absence of living spermatozoa, or deficiency of semen and impotency, the proportions being, respectively, 79 cases, and 25 cases. Further, 55 of the men had infected their wives with gonorrhea, producing, as the authors assume, indirect sterility. A fair inference from these statistics, by three competent observ- ers, is that in something over half of the sterile marriages the fault lies with the husband, hence the importance of investigating the man as well as the woman. Sterility in Women Age as a Factor. — As pointed out by Matthews Duncan and shown in the following table, the age at marriage is the chief factor in the expectation of sterility. Age at Marriage. 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Percentage of wives bearing a child within two years .... 43.7 90.5 75.8 62.9 40.9 15.4 4.3 From this it will be seen that fecundity is greatest in women who have been married between the ages of twenty and twenty-four, and decreases progressively until the menopause. STERILITY 149 Duncan has shown also by his statistics that of the wives married between the ages of twenty and twenty-four who were all fertile, only six and two-tenths per cent began to bear after three years of marriage. In other words, when the expectation of fertility is greatest the question of probable sterility is soonest decided. The age of the wife has a bearing on sterility, for, according to this same author's statistics, the following percentages were observed : — Age of Wives at Marriage. 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50 and over. 700 1,835 1,120 402 205 110 46 29 51 0 311 151 109 100 44 29 7.3 0 27.7 37.5 53.2 90.9 95.6 100 Total. Number of wives observed Sterile wives Percentage sterile 4,447 725 16.3 Other Factors. — The factors essential for procreation, as far as the woman is concerned, are, the presence of a living ovum, a healthy endometrium upon which the ovum may develop, permeability of the genital tract so that the spermatozoon may reach the ovum, and secretions of the genital tract that are not inimical to the life of the spermatozoon, or that do not bar its upward progress to the ovum. Entrance of the penis into the vagina is not necessary to produce conception, for cases are on record where pregnancy has occurred, and women have come to labor even, with an unruptured hymen which presented only a minute opening; therefore deposition of semen on the vulva is all that is necessary in some cases. Also, sexual feeling is not a necessity, for women have conceived after intercourse while unconscious from intoxication and other causes, and artificial insemination has produced conception. Still, conception is more likely to occur if the penis enters the vagina and if sexual feelings with an orgasm are present, the spermatozoa, in all probability, finding a more ready entrance to the uterine cavity during the orgasm. Leaving out of account the question of age, already considered, the following may be enumerated as causes of sterility in women: — ■ (1) Bars to conception in the form of anomalies and diseases of the uterine organs. (2) Conditions of the uterine organs causing interruption of pregnancy and death of the fertilized ovum or fetus 150 THE CHIEF SYMPTOMS OF PELVIC DISEASE (abortion and extra-uterine pregnancy) , and (3) Constitutional diseases and general causes acting either in preventing conception, or in terminating it after it has begun. 1. Anomalies and Diseases of the Uterine Organs. — The following is a list of the pelvic diseases commonly found associated with sterility, beginning with the vulva and ending with the ovaries : — Imperforate or rigid hymen (preventing penetration). Tumors of the vulva (preventing penetration). Urethral caruncle (dyspareunia). Absence or atresia of the vagina (preventing penetration). Vaginismus (preventing penetration). Vaginitis (destruction of spermatozoa by discharges, especially gonorrhea). Rupture of the pelvic floor (allowing semen to run out). Inversion of the vagina with uterine prolapse (preventing in- semination). Infantile uterus (lack of normal endometrium). Anteflexion of the uterus (mechanical obstruction, together with endometrial discharges). Endometritis and polypi (abnormal endometrium and discharge). Erosions of the cervix (spermatozoa barred, or killed by dis- charge). Lacerations of the cervix (spermatozoa barred, or killed by discharge). Cancer of the cervix and body (spermatozoa barred, or killed by discharge). Fibroids of the uterus (unknown direct cause). Hyperin volution of the uterus (abnormal endometrium). Nodular and obliterating salpingitis (very frequent cause, especially of one-child sterility. » Canal of tube obstructed by nodules or closed by adhesive inflammation). Under-development or atrophy of the ovaries (oophoron of ovary affected, so that healthy ova are not produced, or are not thrown off). Ovarian tumors (all of functionating oophoron destroyed, or ova can not reach tubal ostium). Adhesions about the ovaries (same as ovarian tumors). 2. Conditions of the Uterine Organs that Cause Interruption of Pregnancy. — The chief local causes of abortion are: — VESICAL SYMPTOMS 151 Pelvic congestion from excessive coitus. Endometritis (abnormal endometrium). Retroclisplacements of the uterus (preventing the progressive enlargement of the uterus). Lacerations of the cervix (through endometritis and lack of protection of the ovum or fetus). Syphilis of the placenta or decidua. Introduction of foreign bodies, such as catheters, into the uterus. Follicular salpingitis (furnishing diverticula for the development of extra-uterine gestation). 3. Constitutional Diseases and General Causes. — The chief con- stitutional affections that either cause failure to conceive, or in- terrupt pregnancy are : — The acute diseases, especially the infectious diseases, such as acute rheumatism, scarlatina, and typhoid fever. Alcoholism and morphinism. Syphilis (frequent cause. From syphilis of placenta and decidua, or transmitted from father through semen). Excessive obesity, occurring rapidfy. Anemia, associated with chronic heart disease, kidney disease, diabetes, or tuberculosis. The psychoses (mental diseases or sudden nervous shocks). Inbreeding (marriage of cousins). Masturbation (chronic pelvic congestion from conjugal onan- ism, simple masturbation, or douches). VESICAL SYMPTOMS The chief symptoms of disease or derangement of function of the urinary organs are : — (1) Difficult, retarded, or painful urination, dysuria. (2) Too frequent urination, frequent micturition. (3) Incontinence of urine, enuresis. (4) Retention of urine, ischuria. (5) Suppression of urine, anuria. i. Dysuria, from the Greek words, dus, ill, and oupov, urine, signifies an inability to start the stream and to empty the bladder, and also pain attending the act of micturition. When the urine is passed drop by drop with spasmodic pain the condition is known 152 THE CHIEF SYMPTOMS OF PELVIC DISEASE as strangury (from arpdy^i a drop and ohpov} urine). It is found in cystitis, especially in those forms of cystitis that are due to poisoning by cantharides or turpentine. Painful or difficult urination is a very common symptom com- plained of by women who suffer with gynecological affections. Some authors estimate the number of such women who have vesical symptoms as high as one-half of all the cases applying to the physician for relief. A greater or less degree of dysuria almost invariably accompanies pelvic inflammation and also gonococcus infection, but more of this later. The physician will do well to rule out first the general constitu- tional causes of dysuria. Pain and burning during urination may be due to a too acid or too concentrated urine. This is the case in patients who habitually ingest a small quantity of fluids and also in lithemic women. Sometimes this symptom is indicative of acute nephritis, because then the urine is concentrated. The ingestion or absorption, through the lungs or skin, of turpentine may cause dysuria, and in the same manner cantharides, mustard, and pepper, when taken internally or applied to the skin, may be attended by this bladder symptom. The local causes of dysuria, beginning at the meatus urinarius, are, urethral caruncle (see Chapter XXIII. , page 453). Here the pain may be so severe that the nervous system is upset and the patient becomes melancholic. The pain is described as " scalding," "stabbing," " shooting," or " cutting," and is felt while the urine is passing over the caruncle and for some little time afterward. The pain is apt to be aggravated during the menstrual period, and the dread of the pain is often so great that urination is deferred as long as possible, so that retention may result. In many of these cases there is a constant pain in the vulva as well as the pain which attends micturition, the constant pain being aggravated by walking. Dyspareunia generally accompanies dysuria in these cases, and there may be bleeding on coitus. Urethritis is due in a great majority of cases to gonorrhea and is a common cause of dysuria. Anything that increases the con- gestion of the pelvic organs, such as menstruation or pregnancy, exaggerates the inflammation of the urethra, and therefore increases the severity of the symptom of difficult or painful micturition. (See Chapter XXIII., page 450.) VESICAL SYMPTOMS 153 Doionivard dislocation of the urethra is a not infrequent cause of difficulty in passing urine, and so is stricture of the urethra, one of the results of urethritis. Suburethral abscess generally causes difficulty in urination. It is a subacute disease and is attended by pain, fever, dyspareunia, and the intermittent discharges of pus. The causes of dysuria that are situated in the bladder are: — (a) Calculi and foreign bodies, which are usually attended by cystitis; (6) cystitis in its various forms (see Chapter XXIV., page 462) ; and the (c) new growths of the bladder, the most frequent of which are papilloma and cancer. 2. Too Frequent Urination. — The time-worn term " irritable bladder" has given way to a more rational and more exact descrip- tion of both the symptoms and the pathological conditions present. To establish the fact of too frequent urination, the physician must inquire as to the patient's habit as regards emptying the bladder. Many women are accustomed to void urine only at long intervals of time, perhaps once or twice a day. Perhaps they ingest very small quantities of fluids. Under the influence of excitement, of taking more fluids, or of cold, the amount of urine may be larger, and the desire to pass it consequently more pressing and more frequent. On the other hand, a small amount of fluid taken by the mouth and abundant perspiration will diminish the amount of urine secreted, and therefore the necessity for passing it. Inquiry into too frequent urination should deal with the custom of the individual under ordinary conditions of health. How many times by day, and how many times by night. Too frequent urina- tion must be differentiated from incontinence, and this will be taken up in the section on incontinence. Most conditions which make micturition painful also cause it to be too frequent. This is the case with the inflammations of the pelvic organs. Here we are considering only the affections which are chiefly distinguished by abnormal frequency. During pregnancy the urethra and the neck of the bladder partake of the congestion of all the pelvic organs at this time. Why this congestion of the neck of the bladder is attended by too frequent micturition in some pregnant women and not in others we do not know. The statement may be made that, as a general rule, micturition is more frequent during pregnancy, especially during early preg- 154 THE CHIEF SYMPTOMS OF PELVIC DISEASE nancy, than at other times. Women who suffer with uterine disease may have too frequent micturition onfy at the time of menstruation because of the additional congestion of the neck of the bladder at that .period. The ingestion of large quantities of fluids, especially of those which have a diuretic effect, like tea, coffee, and beer, is followed by frequent micturition, so also are diabetes mellitus, diabetes insipidus, and hysteria, because of the secretion of an abundant supply of urine in these diseases. Urethritis and stricture of the urethra are causes of frequency, — even congenital smallness of the meatus may cause frequency. Contracted bladder, by not permitting any considerable quantity of urine to accumulate, causes frequency, and so do tumors of the bladder situated in the neighborhood of the vesical trigone. Cystitis is attended by increased frequency of micturition, in fact it is a cardinal symptom, but there are no data in hand to show that increased frequency is due to ureteral or kidney disease where the bladder is not at the same time affected, although put from a suppurating kidney, in the same manner as concentrated urine, — perhaps containing crystals, — may stimulate the bladder neck and cause frequency of urination, also the passage of a renal calculus along the ureter may cause a reflex desire to urinate. The bladder is so frequently involved in cases of pyelitis and ureteral calculus, however, that frequency of urination may be considered a symptom of these diseases. 3. Incontinence of Urine {Enuresis). — 1. Local Causes. — Inability to control the escape of urine from the bladder, or the passing of it unconsciously, may be due first of all to an overdistended bladder. In this event the urine escapes a little at a time and the patient may not realize that the bladder is overfilled; her complaint being- only that her clothes are wet or that she can not control the urine, permanent incontinence exists in vesico-vaginal fistula, also in vesico-uterine and uretero- vaginal, or uretero-uterine fistula. (See