In cases of uterus bilocularis seu septus, the conditions as regards

pregnancy and parturition are similar to those that obtain in cases of

uterus bicornis. The twin uterus, uterus didelphys, the condition in

which the uterus is represented by two completely separated halves, each

of which has developed into an independent organ, has been observed, as

_P. Müller_ has shown, in adults as well as in infants; this condition

offers no obstacle to conception, unless, indeed, as occurred in a case

of _Tauffer’s_, the vagina is rudimentary, so that normal sexual

intercourse is impossible. _Satschoma_ reports a case of uterus

didelphys in which pregnancy occurred simultaneously in both uterine

cavities.

A careful distinction must be made between the congenital condition

known as the infantile uterus (i. e., congenital atrophy) and acquired

atrophy of the uterus, affecting the whole organ, or either of its

segments, the body or the cervix; the latter condition may offer merely

a transient and curable obstacle to conception.

Acquired primary atrophy of the uterus occurs in weakly girls who, just

before the age at which the uterus normally undergoes its transformation

into the adult state, have suffered from constitutional disorders, from

chlorosis or anæmia, or from some other exhausting affection. The uterus

is then small, limp, and flaccid, it is usually anteflexed, with a

small, often insignificant portio vaginalis; the anterior lip of this

structure failing to project from the vaginal fornix; the vagina is

usually short and narrow. This form of atrophy of the uterus is

distinguished from the foetal and from the infantile uterus more

especially by the fact that no disproportion exists between body and

cervix, that the muscular wall is better developed, and that the general

configuration of the uterus is rather that characteristic of the normal

uterus of the sexually mature woman. Persons with primary atrophy of the

uterus, are, moreover, backwards in the general development of their

sexual characters; the breasts are small, the pubic hair is scanty, the

menstrual flow is insufficient or entirely wanting, whilst severe

dysmenorrhœal manifestations are usual.

[Illustration:

FIG. 70.—Congenital Atrophy of the Uterus (after Virchow), oi, Ostium

internum; oe, Ostium Externum.

]

[Illustration:

FIG. 71.

]

In favourable circumstances, when the constitution becomes more

powerful, in these cases of primary atrophy of the uterus, improvement

takes place; the uterus undergoes further development, menstruation

becomes more abundant, and the woman may become pregnant. Such a

favourable prognosis cannot, however, be entertained if a severe flexion

of the uterus is associated with the atrophy of the organ; or if the

ovaries are also atrophied.

Sterility results also from puerperal atrophy of the uterus. This

condition is a sequel of severe puerperal diseases, metritis,

parametritis, and perimetritis; sometimes, even in the absence of such

inflammatory processes, it is due to puerperal hyperinvolution,

occurring especially in women previously weak in constitution, and

manifested by the fact that, notwithstanding the weaning of the child,

the menstrual flow remains for months in abeyance. The uterus loses its

firm consistency; it is sometimes shortened, sometimes of normal length,

but the walls are always greatly thinned, so that, as _Schroeder_ points

out, the sound can be readily felt, through the abdominal wall.

Puerperal atrophy is a curable condition, so that the sterility

dependent upon this disease is not necessarily permanent. Thus, in a

case of _P. Müller’s_, a woman in whom a twin delivery had been followed

by extreme atrophy of the uterus, with well-marked symptoms both

objective and subjective, became once more pregnant eighteen months

after the termination of the twin pregnancy.

Other forms of atrophy of the uterus have a similar deleterious effect

to that exercised by puerperal atrophy, as, for instance, atrophy from

the pressure of tumours of the uterus, or of solid ovarian tumours; or,

again, atrophy due to defective innervation of the pelvic organs,

occurring in various forms of paralysis, and characterised by amenorrhœa

and extreme smallness of the uterus. _Von Scanzoni_ has seen several

cases in which young women, previously healthy and menstruating with

regularity, have been attacked by paralysis of the lower extremities,

and thenceforwards have suffered from amenorrhœa and great contraction

of the uterus; in some of these cases a post mortem examination was

made, and disclosed the existence of true atrophy of the uterus.

_Jaquet_ saw a similar case of atrophy of the uterus in a lady who had

been frightened by witnessing the storming of a barricade in front of

her dwelling; she was then in her 22nd year, and had given birth to her

second child 1½ years previously; thenceforwards she was completely

amenorrhoeic, and her uterus measured only 3 cm. (1.2 in.) in length.

Displacements of the uterus (flexions and versions), and abnormalities

in the cervix uteri, are among the conditions which lead to sterility by

interfering with conjugation—by preventing the necessary physical

contact between the male and the female reproductive elements. The

frequency with which these diseases give rise to sterility is, however,

far from being so great as is commonly asserted by those who maintain a

mechanical theory of conception.

_Pathological Changes in the Cervix Uteri._

In very early times, the attention of physicians was directed to

abnormalities in the shape of the cervix uteri, as offering hindrances

to the entry of the semen into the uterus. Amongst the writers of

antiquity who have alluded to this matter, the names of _Hippocrates_

and _Soranus_ must especially be mentioned.

The normal cervix uteri (Fig. 72) has the form of a flattened ellipsoid,

perforated throughout its longitudinal axis. On making a longitudinal

section of the cervical canal, we see that it is dilated in the middle,

and tapers towards either extremity, having thus the shape of a spindle;

the internal os is, however, somewhat smaller than the external. The

latter (os uteri externum, os tincæ, often referred to without

qualification as “the os”), has normally the form of a transverse

fissure, which, however, tends more towards the circular form, the

smaller it is, and the more widely its margins are separated. In

childhood, in consequence of the infolding of its margins, the external

os has usually a radiated form, later it becomes rounded, and only with

the attainment of sexual maturity does it assume the form of a

transverse slit. This form is maintained throughout the epoch of active

sexual life; but after the climacteric, owing to the separation of the

margins of the orifice, it becomes once more rounded.

With regard to the greatly varying size and shape of the portio

vaginalis, it may be said that in general its anterior lip _appears_ the

shorter of the two, owing to the lesser depth of the anterior vaginal

fornix, but that in reality the anterior wall of the cervical canal is

longer than the posterior; the actual length of the anterior lip of the

portio vaginalis, measured from the summit of the anterior fornix, is

from ½ to 1 cm. (0.2 to 0.4 in.), whilst the posterior lip, from the

summit of the posterior fornix to the end of the lip measures 1½ cm.

(0.6 in.) and upwards. The position of the cervix is such that, owing to

the oblique direction of the long axis of the uterus, superadded to the

absolutely greater length of the anterior lip of the cervix, the plane

across the extremities of the two lips faces almost straight backwards.

The axis of the portio vaginalis forms a right angle with the axis of

the vagina; the cervical canal, however, is not usually straight, but

has a slight S-shaped curvature. The mean length of the cervical canal

in the virgin uterus is 3 cm. (1.2 in.). (_Lott_.)

The “ideal” form of the cervix uteri and of the os uteri externum is

described by _Sims_ in the following terms: “The vaginal portion should

measure about one fifth, certainly not more than one fourth, of the

entire length of the cervix uteri; that is, the anterior lip should have

a length of one-fourth to one-third of an inch, and the posterior lip

should be a fraction longer. The cervical canal should either be

straight, or have a forwardly directed curve; the cervical axis should

form a right angle with the vaginal axis; the cervix should not be

markedly anteverted or retroverted.” _Sims_ is of opinion that every

woman whose uterus is in this condition will conceive within three or

four months from the time when she first enters upon conjugal

intercourse; he adds, however, the important proviso, “be it understood,

that all else is in order.”

[Illustration:

FIG. 72.—Normal Portio Vaginalis.

]

[Illustration:

FIG. 73.—Conoidal Portio Vaginalis.

]

In conception, the cervix uteri subserves the important function of

providing for the free passage of the spermatozoa to the interior of the

uterus; and when we consider the nature of the processes of sexual

intercourse and fertilization, and more especially when we bear in mind

that normally the two lips of the cervix and the upper segment of the

vagina form a chamber for the retention of a portion of the seminal

fluid in contact with the os uteri externum, we are readily led to

assume that any great abnormality, in size of the cervix (enlargement or

diminution), in its shape (malformation), or in its position

(displacements—flexion, version, or prolapse), or, finally, stenosis of

the cervical canal,—may offer mechanical hindrances to conception. And

experience shows that this assumption is justified, at any rate as

regards conical elongation of the portio vaginalis (Fig. 73), as regards

an apron-shaped or beak-shaped hypertrophy of the anterior lip of the

cervix (Figs. 74 and 75), as regards flexion upwards of the elongated

cervix, and also as regards stenosis or obliteration of the external or

the internal os; although the reservation must be made that no matter

how unfavourable the shape of the portio vaginalis, no matter how

extensive the changes in the cervix uteri, as long as a permeable upward

passage for the spermatozoa exists, conception is still possible, and in

exceptional cases may occur.

[Illustration:

FIG. 74.—“Apron-shaped” Vaginal Portion. a. Greatly elongated anterior

lip; b. Shorter posterior lip of the cervix.

]

[Illustration:

FIG. 75.—“Beak-shaped” Vaginal Portion. Posterior aspect.

]

When the cervix is hypertrophic and greatly enlarged, and the vaginal

fornix consequently much elongated, conception is rendered difficult,

for the reason that in such cases, either the semen rapidly flows out of

the vagina, or else a proper juxtaposition between the penis and the

external os no longer occurs, and the semen is ejaculated at some

distance from the os. The change in the shape of the portio vaginalis,

and also the elongation of the cervical canal, are additional obstacles

to the entrance of the spermatozoa into the interior of the uterus; as

regards the former condition, in nulliparae the portio vaginalis is

commonly conical, or pointed, whilst the external os is very small, thus

rendering the passage of the spermatozoa a difficult matter; but in

parous women, it is lobulated, owing to the presence of deep fissures,

whereby the penis is conducted into the vaginal fornix, and the

ejaculation of the semen in this locality is facilitated. Hence, such

hypertrophy of the cervix and the portio vaginalis often coincides with

the occurrence of sterility. The hypertrophy is less apt to cause

sterility when it is limited to one lip of the cervix, unless, indeed,

the affected lip (more commonly the anterior) is so greatly enlarged

that it bends over and occludes the external os, whilst conducting the

penis into the fornix and away from the orifice. Cases have been known

in which a single lip of the cervix was hypertrophied to such an extent

as to protrude between the labia.

The commonest malformation of the cervix is the conical cervix, when the

cervix is not merely elongated, but tapering; associated with this

condition is usually found a notable diminution in size of the os uteri

externum. According to _Sims_ we find “conical cervix in 85% of all

cases of natural sterility.” According to the same author, even in the

absence of the conical form of cervix, “sterility is probable in cases

in which the portio vaginalis projects fully half an inch into the

vagina; if the cervix projects more than one inch, sterility almost

inevitably results; whilst if elongation is even greater than this, so

that the vaginal portion measures from one and a half to two inches,

sterility is absolutely certain.”

On the other hand, congenital smallness of the portio vaginalis, the

condition in which this organ appears merely as a slightly projecting

nodule on the upper part of the anterior wall of the vagina, the

anterior vaginal fornix being almost non-existent, and the posterior

fornix very extensive—a wide cul-de-sac—is also unfavourable to

conception. The probable reason is that, in consequence of this

deformity, the semen, after being ejaculated into the posterior fornix,

flows away down the posterior wall of the vagina, without coming into

contact with the short portio vaginalis.

According to _Beigel_, another frequent cause of sterility is to be

found in the existence of the so called “apron-shaped” portio vaginalis,

the condition in which, either from congenital deformity, or else from

hypertrophy or some other disease, one lip of the vaginal portion is so

formed as greatly to exceed the other in length.

In consequence of hypertrophy, the portio vaginalis may assume other,

very various forms; in some cases it may increase in size to such an

extent that it projects into the vagina as a thick, hard ball, and thus

offers a serious obstacle to the reception of the semen; or, again, in

the form of the elongated, slender cervix, it may become doubled upon

itself, and in this way hinder the passage of the spermatozoa (Figs. 76

and 77). Deformities of the cervix due to hypertrophy of the portio

vaginalis, rarely cause congenital sterility, but more commonly the

acquired form; for such hypertrophy is hardly ever congenital, occurs

but rarely in virgins, and is usually met with in married women who have

had difficult deliveries, and consequently have suffered from uterine

disease.

Another deformity of the vaginal portion of the cervix which is

important in its relations to sterility is the “snout-shaped cervix.”

Here the cervix is thinnest immediately at its insertion into the

vaginal fornix, and thickens gradually below, so that the organ

resembles a swine’s snout in form. As a rule, this deformity is due to

diffuse hypertrophy of the connective tissue of the cervix, the result

of chronic endometritis and cervicitis.

[Illustration:

FIG. 76.—Simple Hypertrophy of the Portio Vaginalis, which projected

from the Vulva.

]

[Illustration:

FIG. 77.—Elongated Cervix, bent upwards.

]

_Fritsch_, however, in two cases of characteristic _col tapiroid_, saw

pregnancy occur after the relief of the previously existing uterine

catarrh; in one of these cases the condition of the organs was virginal,

so that it was hardly possible to believe that the patient was a

multipara; even after she had had three children, the os uteri externum

with difficulty admitted the passage of the uterine sound.

_Pajot_ has devoted especial attention to the hindrances that are

offered to the entrance of the spermatozoa by displacements of the

cervix. In these cases, during coitus, the extremity of the glans penis

is not in contact with the os uteri externum, but passes into a kind of

cul-de-sac; in retroversion the posterior fornix; in anteversion, the

anterior fornix; in lateral version, the lateral fornix of the side

opposed to that towards which the lower extremity of the cervix points.

Complete absence of the vaginal portion of the cervix puts difficulties,

though not very serious ones, in the way of conception, since the

segment of the uterus which combines with the upper segment of the

vagina to form a receptaculum seminis, is wanting. How important in

predisposing to fertilization is efficient contact of the external

orifice of the vaginal portion with the ejaculated semen during and

immediately after intercourse, seems to be established by my own

observation, that women of small stature married to men of average

height exhibit much higher proportional fertility than women of average

stature. In the case of these small women, the favourable circumstance

is obvious, inasmuch as intimate contact is facilitated between glans

penis and portio vaginalis. I have frequently heard complaints, from the

husbands of such women, that a single coitus is sufficient to ensure

conception; and again and again I have been informed by such women that

they have had 10, 12, or 16 children. In one such instance known to me,

the wife had been pregnant 23 times, and had given birth to 19 normal

children. Contrariwise, women with a very long vagina, and with a high

position of the portio vaginalis, do not so easily become pregnant.

Of special importance in the causation of sterility is stenosis of the

cervical canal. This may be congenital, and then usually affects the

whole length of the canal; or it may be acquired, being dependent upon

inflammation of the mucous membrane. In these latter cases, the swollen

follicles of the mucous membrane burst, and their granulating walls

adhere. Other causes of acquired stenosis are trauma, severe operative

procedures during parturition, puerperal inflammations, syphilitic

ulceration, adhesion of the opposed granulating surfaces after operative

measures (as, for instance, after severe cauterization, or after

amputation of the portio vaginalis), and, in short, from scar-formations

however caused.

General swelling of the tissues leading to stenosis occurs at the

external os in hyperplastic uteri of virgin configuration; the small

round orifice characteristic of the virgin uterus becomes narrowed, or

even completely occluded, by the swelling of the tissues of the vaginal

portion. True adhesion of the walls does not occur in these cases, but

the minute aperture left by the swelling of the walls of the canal is

plugged by the epithelium, so that a small blind depression in the

centre of the portio vaginalis is all that remains of the cervical

canal. Such a condition is seen with especial frequency in cases of

prolapse of the vaginal portion, and is often erroneously regarded as an

obliteration of the os uteri externum by epithelial adhesion (_Klebs_).

Finally, stenosis of the cervical canal may be caused by tumours, and

also by the flexions and versions of the uterus presently to be

discussed.

Congenital atresia of the uterus is generally associated with other

developmental anomalies of the reproductive organs. In some cases, all

that is at fault is that the mucous covering of the vaginal portion

passes uninterruptedly from one lip to the other; but in others, the

cervix is unperforated throughout, and the vaginal portion is but

slightly developed.

Acquired obliteration of the cervical canal may affect either the

external or the internal os, with a shorter or longer portion of the

rest of the canal. When very extensive necrosis of tissue has occurred,

as a sequel of difficult delivery, the adhesion may include the

adjoining segment of the vagina (utero-vaginal atresia).

The more marked the stenosis of the cervical canal, the smaller the

passage by which the vagina communicates with the uterus, the more

difficult will it be for the passage of the spermatozoa to be effected,

so that of the millions of spermatozoa deposited in the neighbourhood of

the os uteri, thousands will, as in normal cases, find their way to the

uterine orifices of the Fallopian tubes. So much the more, then, is the

contact between spermatozoon and ovum rendered difficult, and so much

the more unlikely is it that conception will occur. Moreover, in

consequence of the stenosis, there is retention of the cervical mucus,

which becomes thick and glutinous, and offers a further obstacle to the

passage of the spermatozoa. The unfavourable influence upon the

possibility of conception is, finally, increased if, as is often the

case, in association with the stenosis, the cervix becomes elongated and

assumes a conical form (these secondary changes probably resulting from

the inflammatory states of the cervix common in cases of stenosis); and

an additional obstacle is offered to conception by the association with

the stenosis of flexion or version of the uterus. It is in such

complicated cases that we so often have the associated symptoms of

dysmenorrhœa and sterility; the dysmenorrhœa being due to the fact that

the menstrual discharge, if abundant, is unable to flow away with

sufficient rapidity through the greatly narrowed cervical canal; exuding

from the vessels of the uterine mucous membrane more rapidly than it can

be discharged, it accumulates in the uterine cavity, and gives rise to

painful contractions of the uterus.

Precisely what degree of narrowing of the cervical canal it is which

constitutes pathological stenosis, is in practice by no means easy to

define; and only in regard to extreme cases of pathological constriction

can there be no possibility of dispute. In cases of congenital stenosis

of the cervical canal, the diagnosis is very easy, for the os uteri

externum is then always extremely small; often the aperture is no larger

than a small pin’s head, a very fine probe can be passed through it with

considerable difficulty and its passage is opposed all the way up to the

internal os. But in cases of acquired stenosis of moderate severity, the

diagnosis is often difficult. Owing to the small size of the orifice,

and to the distensibility of the soft parts by which it is surrounded,

exact measurements are impossible. When the os is with difficulty

detected by the skilled finger, when the sound is not readily introduced

by the experienced hand, slipping past again and again, and inserted

only after repeated efforts—such an os is, as _Olshausen_ insists,

always pathological. The normal virgin os uteri permits the easy passage

of a thick uterine sound with a diameter of 3 to 4 millimeters (⅛ to ⅙

in.); but there are cases in which, though a sound of this normal size

can be passed, the os gives to the examining finger the sensation of

being contracted. If, in such a case there is typical mechanical

dysmenorrhœa with sterility, _Olshausen_ considers that we are justified

in assuming the existence of pathological stenosis of the os uteri, and

in treating the case accordingly.

However, as _Kehrer_ insists, it may be one of the greatest difficulties

in diagnosis—a difficulty not always to be resolved even when all the

attendant circumstances have received the fullest and most painstaking

consideration—to determine whether in any individual case an anomaly of

the cervix, such as stenosis of the external os or of the whole cervical

canal, is or is not to be regarded as a cause of sterility. When

stenosis is extreme, there need be no two opinions about the matter; the

difficulty is in cases lying somewhere between a moderate degree of

contraction and the lower physiological limit of smallness. Every

experienced gynecologist will have seen such cases as _Kehrer_

describes, in which before marriage the os appeared extremely small, and

yet soon after marriage the woman became pregnant. For this reason we

are justified, with _O. Johannsen_, in reverting rather to the

functional than to the anatomical conception of stenosis, and in

maintaining that so long as the cervical canal is sufficiently large to

permit the uterine secretions to flow freely away, any stenosis that may

exist is devoid of pathological significance. Only when the outlet for

the uterine secretions is insufficient, so that the uterine cavity

becomes distended (as manifested by an elongation of the canal in the

supravaginal portion of the uterus, and by various disorders, amongst

others chronic endometritis), is the stenosis with its consecutive

dilatation of the uterus a serious obstacle to conception. “In such

cases, the contractions of the uterus during coitus will not suffice to

express the secretions it contains through the narrowed os, and the

inevitable consequence of the incomplete evacuation of the uterus is

that the aspiratory phase of the orgasm fails to occur.”

According to _Winckel_, stenosis of the external or of the internal os

is a cause of sterility only in cases in which it arises from a

follicular inflammation of the cervical mucous membrane; in such cases,

the os, (internal or external, as the case may be), being greatly

narrowed by the numerous retention cysts, offers an obstruction to the

evacuation of the glutinous secretion of the follicles yet remaining

open. This secretion may offer an insuperable hindrance to the passage

of the spermatozoa; but in the absence of catarrh of this character, a

moderate degree of contraction of the cervical canal will not prevent

the outflow of the menstrual discharge, or the upward passage of the

spermatozoa.

The experience of horse and cattle-breeders also shows the etiological

importance of stenosis of the cervix in the production of sterility: and

in the case of mares and cows who are unfruitful from this cause,

artificial dilatation of the cervix has often been performed, with

resulting restoration of fertility.

Swelling of the follicles of the mucous membrane of the cervical canal

or of the cavity of the uterus, a condition which often results from

cervical catarrh, will, equally with stenosis of the cervical canal,

lead to sterility; pushing the mucous membrane before them, and becoming

pedunculated, these swollen follicles ultimately enlarge to form polypi

of the cervical canal or the uterine cavity, and may at times completely

occlude the uterine canal. In Fig. 78 is depicted a polypus of this

kind, which I removed from the cervix of a barren woman 30 years of age.

On the apex of the polypus was a large ovulum Nabothi.

[Illustration:

FIG. 78.—Cervical Polypus, originating from an Ovulum Nabothi.

]

Long-standing cervical catarrh readily leads to stenosis of the cervical

canal, and consequently to sterility. The swelling and hypersecretion of

the cervical mucous membrane the more readily hinders the entrance of

the semen, inasmuch as the mucous folds on the anterior and posterior

walls of the cervical canal which combine to form the _plicae palmatae_

are in the normal state already sufficiently prominent; but in cases of

catarrhal swelling they may project to such an extent as completely to

occlude the canal. Stagnation of the thickened secretion offers in these

cases a further hindrance to the passage of the spermatozoa, a

stagnation which becomes aggravated if in course of time the os becomes

stenosed by overgrowth of scar tissue. Ultimately, also, in cases of

chronic catarrh, a flexion of the enlarged and flabby corpus uteri

readily occurs, and this imposes an additional difficulty in the way of

conception.

It is for these reasons that those women who in girlhood have suffered

from prolonged cervical catarrh, so often remain childless. The sequence

of events is that already described: follicular catarrh, stagnation of

secretions, stenosis of the cervical canal, enlargement and loss of tone

of the uterus; the thin-walled, enlarged, and flaccid uterus ultimately

gives way before the intra-abdominal pressure, bending back, usually,

into the pouch of Douglas. Thus, retroflexion of the uterus is a common

sequel of cervical catarrh (_Hildebrand_). In some cases of sterility

dependent upon cervical catarrh, this sequence of troubles has not

occurred, and it is merely the mucus in the canal which prevents the

passage of the spermatozoa. _B. Schultze_ reports the case of a woman

who had lived for 13 years in sterile wedlock, but became pregnant after

a single removal of the cervical mucus.

The significance of chronic cervical catarrh in the causation of

sterility explains how it is that in many cases of barren marriage the

blame ultimately rests upon the husband, who, when he married, was

suffering from “latent gonorrhoea,” the inconspicuous relic of an acute

attack, undergone, it may be, months and even years previously, and

infected his wife with the disease. Such a gonorrhoeal catarrh is in

women especially apt to assume a chronic form, and will then induce all

the secondary morbid conditions previously described, and thus lead to

sterility.

Gonorrhoea in women frequently results in sterility. In addition to the

effect of cervical stenosis and of a morbid condition of the cervical

mucus in preventing the upward passage of the spermatozoa, this disease

may lead to many other changes inimical to fertility. Thus, gonorrhoeal

infection in women often leads to inflammatory manifestations in the

peritoneum, the perimetrium, and the parametrium, and to catarrhal

changes in the Fallopian tubes (salpingitis, hydrosalpinx, pyosalpinx);

these prevent the contact of spermatozoon and ovum, or cause

pathological distortions of the walls or calibre of the tubes, which

constitute permanent hindrances to the occurrence of conception. Young

married women, whose husbands at the time of marriage were the subjects

of incompletely cured gonorrhoea, and who shortly after marriage suffer

from cervical catarrh, the discharge from the inflamed mucous membrane

not infrequently having a suspicious greenish colour analogous to that

seen in recent gonorrhoea in the male, often remain sterile for long

periods, owing to this gonorrhoeal cervical catarrh, endometritis, and

tubal catarrh. For the diagnosis in such cases, in addition to noticing

the virulent character of the inflammation of the vulva, urethra, and

vagina, we must invoke the aid of the microscope; and it will often be

possible to decide at once that the inflammation is gonorrhoeal by

finding Neisser’s diplococci enclosed within the pus cells of the

cervical secretion.

The influence of “latent gonorrhoea” in diminishing the fertility of

women has been especially asserted—and overestimated—by _Nöggerath_.

From the fact that about 90% of sterile women are married to men who

have suffered from gonorrhoea either before or during their married

life, he infers that the sterility is due to latent gonorrhoea

communicated from husband to wife. If this inference were justified,

sterility would be far commoner than it actually is. _Nöggerath_ makes

use of the term “latent gonorrhoea” because the woman becomes infected

without the obvious outbreak of any acute phase of the disorder. The

disease remains latent, and a radical cure is not to be expected until

the menopause. According to _Nöggerath_, there are four varieties of

this disease: acute, recurrent, and chronic perimetritis, and

oophoritis, always accompanied by catarrh of the mucous membrane of the

genital organs.

_Saenger_, also, has asserted that 12% of all cases needing

gynecological treatment are of gonorrhoeal origin; and he even considers

that the consequences of gonorrhoea are in women more dangerous and

destructive than those of syphilis. _E. Martin_ has also maintained that

endocervicitis leading to stenosis of the os uteri externum and of the

cervical canal is, in the majority of sterile young wives, due to

gonorrhoeal infection derived from a chronic, unhealed, but

inconspicuous, gonorrhoea in the husband. He further considers it

possible that various kinds of mechanical stimulation, for example,

intra-vaginal onanism, may, in certain conditions, give rise to

inflammation eventuating in cervical stenosis.

Of great interest are the mutual relations between dysmenorrhœa and

sterility, a matter to which some allusion has already been made. A high

degree of stenosis of the cervical canal is competent to produce both

these symptoms; but dysmenorrhœa may arise from many other causes which

have no direct influence in preventing conception.

Too much stress has, in fact, been laid upon the association of

dysmenorrhœa with sterility, and I must therefore point out that I have

seen numerous instances of dysmenorrhœa, including the so-called

spasmodic form of the disease, in women who have given birth to many

children; that objectively, in such cases, there was an absence of that

rigidity of the cervix to which _Matthews Duncan_ attached so much

importance; and, finally, that even when the dysmenorrhœal pains had

subjectively all the character of labour pains, the introduction of the

sound could be effected without using any great force, and without

giving rise to any severe pain.

Unquestionably, those authors, with _Sims_ at their head, go too far,

who regard dysmenorrhœa as a constant sign of stenosis of the cervical

canal, and hence infer that in all cases in which sterility is

associated with dysmenorrhœa, the sterility is due to such stenosis—an

opinion contested by _Schultze_ on the ground of anatomical

investigations. Dysmenorrhœa gives no indisputable sign that the cervix

is stenosed to such a degree as to hinder the occurrence of conception;

and _Sims’s_ view, that in the great majority of cases dysmenorrhœa is

due to mechanical obstruction, is not supported by experience. Women who

suffer from severe dysmenorrhœa, frequently become pregnant, though

later, it may be, than women in whom menstruation is normal and

painless. Dysmenorrhœa is not due solely to contraction of the cervical

canal, but also to a variety of other pathological conditions. The

anomalies of the genital organs which give rise to dysmenorrhœa do not,

for the most part, offer any obstacle to conception; and, on the other

hand, stenosis of the cervical canal may exist in women who are entirely

free from dysmenorrhœa.

In order to test _Sims’s_ theory of the mutual interdependence of

dysmenorrhœa and sterility, _Kehrer_ conducted an investigation into the

state of menstruation both before and after marriage in relation to the

fertility or infertility of the marriage. He ascertained that in sterile

women virginal dysmenorrhœa had only been a very little commoner than in

fruitful women. Hence, the changes in the reproductive organs upon which

the occurrence of dysmenorrhœa depends, must not be regarded as

necessarily constituting hindrances also to conception.

English gynecologists differ from those of Germany in believing that

there is an intimate causal relation between dysmenorrhœa, and more

especially spasmodic dysmenorrhœa, and sterility. The assumption is,

that the contractions of the uterus, which by their violence during

menstruation give rise to pains like those of labour, occur also during

coitus; by these contractions, the entry of the semen into the uterus is

prevented, or, if the semen does enter the uterus, it is speedily

expelled. This spasmodic dysmenorrhœa has also been called mechanical or

obstructive dysmenorrhœa, in order to call attention to the theory that

the aim of the cramp-like contractions of the uterus is the expulsion of

the menstrual blood which has accumulated in the uterine cavity;

although _Duncan_ himself is compelled to admit that neither the alleged

mechanical obstruction, nor the accumulation of menstrual blood, nor yet

the dilatation of the uterine cavity, can actually be proved to occur.

NOTE.—The author is not quite correct in his contrast between

“English” and “German” opinion in this matter. Most English

gynecologists follow Matthews Duncan in calling attention to the

fact that, as Herman puts it, “spasmodic dysmenorrhœa is often

associated with sterility”; but almost all careful writers insist

that while the association is proved, the nature of the causal

connexion, if such exists, has not been elucidated. For instance,

writing on this very question of the association of dysmenorrhœa

with sterility, Hart and Barbour remark, “after a careful survey of

the literature, we come to the conclusion that any discussion of

sterility in which mechanical considerations have a prominent place,

must be inadequate, and will always be bootless.” It is true that

Matthews Duncan writes (_Diseases of Women_, Lecture on

_Sterility_), “The most generally recognized cause of sterility is

spasmodic dysmenorrhœa”; but a careful perusal of the whole lecture

will show that Duncan is saying more than he really means in using

the word “cause,” and that what he wishes to insist upon is the

frequent and indisputable association of the two conditions. In the

lecture on _Spasmodic Dysmenorrhœa_ he writes, “Latterly it has been

generally described as obstructive or mechanical dysmenorrhœa; these

words ‘obstructive’ and ‘mechanical’ implying a theory of the

disease which ... I am sure is quite erroneous.” Obviously, then,

Kisch does injustice to Matthews Duncan when he writes that the

latter is “compelled to admit” (_obgleich Duncan selbst zugeben

muss_), what he was as a fact one of the first to maintain, in the

face of considerable opposition!—_Transl._

[Illustration:

FIG. 79.—Ectropium in a Case of Bilateral Laceration of the Cervix.

After A. Martin.

]

_Duncan_ goes so far as to maintain that no actual or suspected local

disturbance has such significance in connexion with the doctrine of

sterility as spasmodic dysmenorrhœa. It possesses this significance

owing to the probable connexion between the dysmenorrhœic neurosis and

the outflow of the semen, the deficiency of the sexual impulse and of

sexual pleasure, and other disturbances of sexual excitement during

coitus. With the relief of the dysmenorrhœa, we have, _Duncan_ holds,

made a long stride towards the cure of the sterility. Among 332 married

women who were absolutely sterile, _Duncan_ found 159, nearly half of

the total number, who were affected with spasmodic dysmenorrhœa.

_Burton_, in order to ascertain with certain beyond question whether

stenosis of the external or internal os gives rise to dysmenorrhœic

troubles, examined six women during menstruation and at the time when

they were experiencing the greatest pain; he found in no one of them any

trace of narrowing of the canal. Owing to the congestion that occurs at

this time, the uterus becomes erect, and any moderate flexion that may

exist is temporarily straightened. In all the cases, the sound could be

passed with extreme ease.

Ectropium of the lips of the cervix (“granular erosion”) constitutes a

hindrance to conception which is by no means rare; the condition is due

to deep lateral lacerations of the cervix. The gaping of the cervical

canal arising from such old-standing, often overlooked, cervical

lacerations and from the parametric scars associated therewith, causes

various irritative manifestations: blenorrhoea, blennorrhagia, cystic

degeneration of the mucous membrane, and these secondary conditions may

be contributory causes of sterility; but lacerations of the cervix with

ectropium interfere in a manner purely mechanical with the proper

constitution of a receptaculum seminis and with the aspiration of the

semen into the cervical canal. (Fig. 79.) In an earlier section of this

work I laid stress on the fact that in the act of conception the

musculature of the cervix had in a sense an active part to play; and the

proper performance of this role is prevented by cervical lacerations.

The cervical glands also suffer in cases of ectropium, and their

function in facilitating the entrance of the spermatozoa into the

uterine cavity is no longer properly performed. Finally, it is worthy of

note that sexual gratification, the sensation of voluptuous pleasure

during the sexual act, seems to be diminished in women with cervical

lacerations, a fact noted especially by _Mundé_ and _Ill_. The

last-named found that in 34 women thus affected, sexual gratification

was no longer experienced in intercourse; whilst in 27 of these cases,

restoration of the integrity of the cervix by operation was followed by

return of normal sexual feeling. In women who have given birth to one or

two children, and then for a long time have remained barren, we not

infrequently find deep cervical lacerations. _Breisky_, _Spiegelberg_,

_Schultze_, and _Goodell_ have operated in such cases, and shortly after

the operation pregnancy has recurred.

_Displacements of the Uterus._

With less justice than in the case of the pathological changes in the

cervix above described, it is maintained that displacements of the

uterus form a very frequent cause of mechanical hindrances to

conception, and thus give rise to sterility.

It certainly cannot be denied that displacements of the uterus are found

very commonly in sterile women; and, on the other hand, among women with

pathological flexion of the uterus, the percentage of the sterile is far

higher than among women with a uterus normal in position and shape—but

from these facts it would be erroneous to infer the general conclusion

that displacements of the uterus offer a mechanical hindrance to

conception. The casual connexion is less simple than this as a rule. In

most cases in which displacements of the uterus are associated with

sterility, there are additional pathological states of the uterus and

its environment, relics of previous inflammation in the uterus, the

uterine annexa, or the parametrium, or displacements of the uterine

annexa; these changes may be either the cause or the result of the

existing displacement of the uterus, and it is upon them, and not

primarily upon the displacement, that the sterility depends. The

accuracy of this view is proved by the experience, by no means an

uncommon one, that in such cases, when the actual cause of the sterility

is removed, the woman will become pregnant, although the displacement of

the uterus persists.

How difficult it is, in a particular case, to determine whether the

pathological anteflexion is the true obstacle to conception, or the

antecedent parametritis posterior and the concomitant metritis and

endometritis! How can we decide whether a retroflexion is the simple

mechanical cause of sterility, or whether the latter condition does not

rather depend upon complicating perimetritis and oophoritis?

On the other hand, we must not fly to the other extreme, and absolutely

deny that a displacement of the uterus can be the mechanical cause of

sterility. We meet with cases in which we are forced to assume that the

flexion interferes both with the outflow of the menstrual blood and with

the ingress of the seminal fluid. And this is true, not merely of

flexion to an acute angle, often associated with infantile dimensions of

the cervical canal or of the external or internal os, but also of those

advanced degrees of flexion in which, doubtless in part also from the

accompanying catarrh, complete stenosis of the os uteri externum has

resulted. The combination of displacement of the uterus with stenosis of

the cervix, is in these cases the essential hindrance to conception.

When the os is reasonably large, a moderate flexion of the uterus

forwards, backwards, or to one side or the other, will not often prevent

conception, for the action of the muscular bands in the various

ligaments of the uterus will retain the os in a sufficiently favourable

position. But if a contracted os is associated with flexion, sterility

is very likely; and almost inevitable, if fixation of the flexed uterus

has occurred from inflammatory exudation and fibrosis in one of the

broad ligaments.

That the belief that displacements of the uterus constitute an obstacle

to conception is a widely diffused one, is shown by the fact that among

certain nations a means employed for the prevention of pregnancy is the

artificial production of displacements of the uterus.

Of the displacements of the uterus, the versions, anteversion,

retroversion, and lateral version, have a more pronounced influence in

hindering conception than the flexions; for, in the case of version of

the uterus, the uterus moves as a whole round a horizontal axis, so that

when the fundus moves in one direction, the portio vaginalis moves in

the opposite. When the neck of the uterus is thus displaced, the tip of

the glans penis fails during coitus to come into contact with the os

uteri externum, as it normally should do, and passes into a vaginal

cul-de-sac, in retroversion, the posterior fornix, in anteversion, the

anterior fornix, and in lateral version the lateral fornix of the side

opposite to that towards which the cervix uteri is directed. In high

degrees of this malposition, the vaginal fornix covers up the os

externum as with a valve. (_Beigel._)

_Von Scanzoni_ has especially insisted upon the frequency with which

sterility results from chronic metritis complicated with anteversion. In

59 sterile women affected with chronic metritis, he found in 34

instances more or less pronounced anteversion, and hence was led to

infer that this particular combination of disorders plays a great part

in the production of sterility.

Especially frequent is sterility in cases of anteversion of the uterus,

if in addition there is some contraction, even though moderate in

degree, of the os uteri externum; this combination of disorders is one

extremely unfavourable to the entrance of the spermatozoa into the

uterus.

Flexion of the uterus offers less hindrance than version to the entrance

of the spermatozoa, for the reason that in the former condition the

relations between the vaginal portion and the glans penis during coitus

are not affected. But when the flexion is extreme in degree, the

cervical or uterine canal may at some point become absolutely impassable

for the spermatozoa; and further, extreme flexion is apt to lead to the

occurrence of parametritis and perimetritis. But, generally speaking,

flexions of the uterus are far less often the cause of sterility, than

was formerly supposed. It used to be believed that flexion of the uterus

was followed by stenosis of the os uteri externum, by which the outflow

of the menstrual blood and the ingress of the semen were equally

prevented. It is true that infantile acute-angled flexion of the uterus

is often associated with infantile stenosis of the cervical canal or of

the internal or external os; and it is also true that extreme degrees of

flexion associated with uterine catarrh, favour the occurrence of

stenosis and obliteration of the external os; but _B. Schultze_ rightly

insists that in most of the cases in which a diagnosis is made of

stenosis of the uterine canal associated with a flexion of the sexually

mature uterus, the supposed “stenosis” merely represents the difficulty

which has been experienced in passing the customary rigid uterine sound

past the angle in the uterine canal. Still, the fact remains, that among

women with uterine flexion there is a larger percentage of sterile

individuals than among women whose uterus is normal.

[Illustration:

FIG. 80.—Anteflexio Uteri. After A. Martin.

]

As regards anteflexion of the uterus, either the congenital,

uncomplicated anteflexion of the uterus, due to developmental anomaly,

or the acquired form, due either to subinvolution of the uterus during

the puerperium, or to parametritic or perimetritic processes,—may offer

mechanical obstacles to conception, and thus give rise to sterility;

sterility with anteflexion occurs especially in cases in which the

anteflexion is dependent upon parametritis posterior, associated with

metritis and endometritis, or when any other complication is present to

make the flexion a severe one. In some sterile women, we find

anteflexion associated with supravaginal elongation of the portio, and

in such cases both states would appear to result from catarrh of the

uterine mucosa. How frequent is the combination of anteflexion of the

uterus with sterility, is shown by the figures published by _Sims_, who

in 250 cases of congenital sterility found 103 cases of anteversion, and

in 255 cases of acquired sterility found 61 cases of anteversion.

_Fritsch_ writes in the following terms regarding the difficulty with

which impregnation is effected in women suffering from anteflexion of

the uterus: “In cases of anteflexion of the uterus, the vagina is

remarkably long, the portio vaginalis often badly formed; the ejaculated

semen flows away rapidly from the contracted vagina, without, perhaps,

ever coming into contact with the portio vaginalis.” He states it as a

fact that women with anteversion conceive less readily than those with

retroversion of the uterus (when this latter is moderate in degree); for

in slighter degrees of retroversion, the axis of the uterus is a

continuation of the axis of the vagina, so that the orifice of the male

urethra and the os uteri externum will be in contact during

intercourse—more especially because in such cases, owing to the portio

vaginalis being low in the pelvis, the vagina is short; in cases of

anteversion, on the other hand, the cervix is high up, and the vagina is

long and narrow. _Fritsch_ considers that generally speaking the fact

that the internal or the external os is small is of little importance;

but the serious factors, those leading to sterility in cases of

anteversion—apart from all other considerations—are the unfavourable

high position of the portio vaginalis, the occlusion of the os by the

close application of the posterior vaginal wall, and the presence of

glutinous mucus in the cervical canal. Since in cases of anteflexion we

very commonly find hypersecretion of the uterine mucous membrane,

whilst, owing to the narrowing of the external os, the mucus is unable

to flow freely away, but accumulates and becomes inspissated, we have

the uterine mucous membrane covered with a tenacious coating, which may

perhaps render the implantation of the ovum a very difficult matter,

even though the upward passage of the spermatozoa be still possible. The

clinical association of pain produced by drawing forward the portio

vaginalis, with marked anteflexion of the uterus, dysmenorrhœa, and

sterility, is a strikingly common one.

_Schröder_ points out that, although sterility is common in cases of

anteflexion, cases are yet seen in which, notwithstanding the existence

of extreme anteflexion, conception occurs very speedily after marriage.

The fact that in cases of anteflexion we have difficulty, not

impossibility, of conception, explains how it is that of two women

suffering from anteflexion of the same severity, one will readily become

pregnant, whilst the other remains permanently barren.

Retroversion and retroflexion offer obstacles to conception chiefly in

cases in which this displacement is a congenital anomaly, or when it has

developed immediately after puberty; or when complications exist,

especially when the retroflexed uterus is fixed by exudation. In

nulliparae, these deviations backwards will not rarely be found to be

the cause of the sterility. Much less often does sterility ensue when

retroversion or retroflexion occurs in women who have already given

birth to several children, i. e., when the displacement is a puerperal

disorder; the reason why such cases are not often sterile, is to be

found in the fact that the wide cervical canal favours the passage of

the spermatozoa, and the softness of the tissues prevents any serious

obstacle to their upward progress being offered at the angle of flexion;

on the other hand, severe retroflexion in a woman who has not yet borne

a child offers a serious hindrance to conception, on account of the

smallness of the cervical canal, and the sharp flexion of the more rigid

uterus.

In general, then, retroflexion can be regarded as offering but a slight

hindrance to conception. In fact, many women with retroflexion become

pregnant again and again, and may abort several times in a single year.

When in parous women suffering from retroflexion, sterility ultimately

occurs, _B. Schultze_ considers that it is not the retroflexion which is

primarily to blame, but rather the secondary consequences so common in

this disorder: uterine catarrh; the general constitutional debility due

to such catarrh, and to the accompanying menorrhagia; perimetritis, and

oophoritis.

[Illustration:

FIG. 81.—Retroflexio Uteri. After A. Martin.

]

Retroflexion and retroversion of the uterus occur chiefly in women who

have previously given birth to children; the bend is commonly obtuse or

right-angled, and above the upper end of the cervical canal; sterility

in such cases, usually acquired, has a favourable prospect of cure. As

_Kehrer_ points out, sterility appears to be constant only in cases of

retroflexion in which the uterus is fixed; the reason probably is that

by the backward inflexion of the uterus the abdominal orifice of the

Fallopian tube is dragged away from the ovary, and thus the ovum, when

it is discharged from the follicle, fails to find its way into the tube.

Among 57 cases of retroflexion of the gravid uterus, _E. Martin_ found

that in 6 the patient was pregnant for the first time, from which it may

be inferred that the anomaly existed prior to the occurrence of

conception.

That in some cases of sterility it is the retroflexion of the uterus

that is to blame, is shown very clearly _ex juvantibus_, inasmuch as

reposition of the uterus and maintenance of the organ in its proper

position relieves sterility perhaps of long standing, together with all

the other troubles secondary to the displacement of the uterus. As an

example, I quote one case from among several of the kind of which I have

notes. Mrs. N., 25 years of age, married 6 years, childless, suffers

from severe dyspeptic troubles, leading to emaciation and profound

depression. She has been treated fruitlessly for gastric catarrh, but

has not previously been subjected to gynecological examination. I

insisted on making such an examination, and found the uterus somewhat

enlarged and completely retroflexed. The successful replacement of the

organ was followed by the cessation of the previously constant vomiting

after meals, and by the disappearance of the other dyspeptic troubles;

shortly afterwards the lady became pregnant, and pregnancy ran a normal

course. Since then, she has had three children; there has been no

recurrence of the dyspepsia.

According to _Sims_, retroversion of the uterus is frequently associated

with sterility. Among 250 married women who had never been pregnant, we

found no less than 68 cases of retroversion; among 255 women who had had

one or more children, but had then ceased to be fruitful, he found 111

cases of retroversion; and in some of these cases the retroversion was

uncomplicated. _Grenser_ and _Vedeler_ also found retroflexion to be a

common cause of sterility; the last-named, examining 7 nulliparous

married women, found retroversion in 5; in these cases, however, there

was associated disease of the uterus or of its environment.

Inversion of the uterus, even in the minor degrees of the affection, in

which coitus is still possible, almost invariably causes sterility,

owing to the occlusion of the uterine orifices of the Fallopian tubes.

Moreover, in inversion of the uterus, the position assumed by the os

uteri externum is such as to render the entrance of the semen almost

impossible. Finally, when the uterus is inverted, the mucous membrane

undergoes changes which render it unfit for the implantation of the

ovum; the researches of _P. Ruge_ show that it is thinned and that the

epithelium is cast off and replaced by granulation tissue. In cases in

which the inverted uterus has long projected through the genital

fissure, its surface becomes covered by a multilaminar pavement

epithelium; at the same time, the glandular apparatus undergoes atrophy,

only the fundi of the glands being preserved, and the muscular substance

is hypertrophied. None the less, in exceptional cases, which have been

reported by _Emmet_, _Macdonald_, and _Tyler-Smith_, pregnancy has

occurred after long-enduring inversion of the uterus. _Lauenstein_ had a

patient in whom an inverted uterus was replaced after a year and a half;

the following week she became pregnant. _Stevens_ saw a case in which

the woman became pregnant six months after the reduction of an inversion

of the uterus of nine months’ standing.

Prolapse of the uterus is seldom the cause of sterility, inasmuch as

during coitus replacement of the organ is effected. It may even be said

that in cases of prolapse, the low position of the uterus and the

enlargement of the os uteri externum, favour the direct ejaculation of

the semen into the cervical canal (likewise enlarged), and that thus the

conditions are advantageous for impregnation. In fact, conception more

commonly occurs in cases of prolapse than might have been anticipated in

view of the various consecutive disorders apt to complicate this

affection—chronic metritis and endometritis, erosion, hypertrophy of the

cervix, displacement and laceration of the annexa, etc. The extent to

which the capacity for conception is unfavourably affected in cases of

prolapse of the uterus, is proportional to the amount of descent

undergone by the uterus, for the nearer the os approximates to the

vaginal orifice, the farther removed from the os will be the point at

which the semen is ejaculated. In cases of complete prolapsus it has

happened that coitus has been effected directly through the everted os

uteri, and has resulted in conception; a case of this kind is reported

by Hervey.

Unbiassed gynecological experience in no way supports the views of

_Sims_ and _Hewitt_ regarding the frequency with which displacements of

the uterus constitute mechanical causes of sterility. _Sims_ supports

his views with the figures previously quoted, from which the following

table is compiled:

_No. of _Total cases

cases._ _Anteversion._ _Retroversion._ of

displacement._

First class 250 103 68 171

Second class 255 61 111 172

——— ——— ——— ———

Totals 505 164 179 343

=== === === ===

From this it appears that in the 1st class, among 250 married women who

had never given birth to a child, there were 103 cases of anteversion,

and 68 cases of retroversion; whilst in the 2nd class, among 255 women,

who had had children, but for one reason or another had become

unfruitful earlier than the natural age for this occurrence, there were

61 cases of anteversion, and 111 cases of retroversion.

The general result of these figures is to show that two-thirds of all

sterile women, without regard to the especial cause of the displacement,

suffer from one form or the other of uterine displacement, and that the

relative frequency of anteversions and retroversions is reversed in the

two classes, the nulliparous married women, and the married women

previous parous but latterly become sterile, respectively.

_Hewitt_ similarly regards malpositions of the uterus as frequent causes

of sterility. He analysed 296 cases of flexion and version of the uterus

treated by him at University College Hospital during the years 1865 to

1869, partly in the wards, and partly in the out-patient department. Of

these 296 women, 235 were married; 100 were cases of retroflexion, and

135 were cases of anteflexion. Of the 235, 81 had had no full-term

children, 57 of the 81 having never been pregnant, and the remaining 24

having had miscarriages only. Of the remaining 154, married and parous

women, a large proportion were sterile at the time when they applied for

treatment; though in the years immediately after marriage they had given

birth to one or more children, they had subsequently ceased to be

fruitful.

All that these figures prove to an unbiassed judgment is, however, that

displacements of the uterus are apt to render conception difficult; or

that, in addition to other pathological states of the pelvic organs,

they are frequently met with in sterile women—but in and by themselves,

displacements of the uterus do not offer any very serious or very

frequently occurring obstacle to conception.

That conception is possible in spite of the very notable mechanical

hindrances which certain displacements of the uterus may offer to the

occurrence of pregnancy, is shown by many striking examples in

gynecological literature. _Winckel_, _Olshausen_, and _Holst_ have all

seen pregnancy occur in women who at the time of conception were wearing

intra-uterine pessaries; and _von Scanzoni_ has published cases in which

fertilization took place, notwithstanding extreme anteversion which

stenosis of the os uteri, and in another instance, notwithstanding the

presence of a polypus filling the external os.

_Myoma of the Uterus._

Among the mechanical obstacles to conception which act by preventing or

rendering difficult the contact of spermatozoon and ovum, must be

enumerated uterine myomata, and these must therefore be included among

the causes of sterility.

According to their number, their size and their situation, uterine

myomata give rise to different and manifold mechanical disturbances.

When there are numerous intramural myomata, even when these are of a

moderate size, the uterine cavity becomes bent and narrowed, and

retention of the secretions may ensue, often lasting for a lengthy

period. Submucous fibromyomata, when situated low down, near the

internal os, may occlude this orifice completely; when implanted higher

up in the uterine cavity, they are apt to cause flexion of the uterus;

large, pedunculated fibromyomata of the uterus may descend into the

vagina and narrow this passage.

Myomata interfere with conception in very various ways. Mechanically,

they may occlude the uterine orifices of the Fallopian tubes, or may

give rise to displacement of either tubes or ovaries, or, again, by

blocking the uterine cavity, they may hinder the descent of the ovum and

the upward passage of the spermatozoa; their presence may cause

catarrhal disease of the uterine mucous membrane, or give rise to

profuse hemorrhage, and either of these secondary changes may interfere

with the implantation of the ovum; and there is yet another way in which

myomata may interfere with conception, and give rise to sterility—this

is a subject to which especial attention has been given by _Winckel_,

and to which we may here most conveniently allude. The continued growth

of small submucous myomata often gives rise to a hyperæsthetic state of

the genital organs analogous to vaginismus, and this interferes with

coitus. Large myomata, on the other hand, give rise to catarrhal states

of the uterine cavity and to hyperplasia of the mucous membrane,

constituting hindrances alike to conception, and to the implantation and

further development of the embryo if fertilization should be effected;

moreover, the growth of large myomata often causes perimetritis,

perisalpingitis, and perioophoritis, and these, partly by abnormal

fixation of the uterus, and partly by closing up the tubes and so

thickening the tunics of the ovary as to prevent the rupture of the

graafian follicles, give rise to sterility.

The existing statistics regarding the relation of the growth of myomata

of the uterus to fertility, incomplete as they are and lacking in

exactitude, suffice nevertheless to show that the fruitfulness of women

suffering from uterine myomata is notably diminished by the growth of

these tumours; more particularly, we learn that whilst the number of

women with uterine myomata who have one child is sufficiently large, the

number of multiparae thus affected falls greatly below the average of

fertility. A characteristic feature of the influence of myomata in

producing sterility is clearly shown by the statistics, inasmuch as

pregnancy is comparatively common in the case of women with subserous

myomata, in whom the uterine cavity and mucous membrane are as a rule

least affected, whilst fertility is far more seriously impaired in the

case of women with submucous myomata.

_West_, in the case of 43 married women with myomata of the uterus,

found 7 childless; the remaining 36 had in all given birth to only 61

children, and 20 of these had only one child each. Of _Beigel’s_

patients, 86 married women with uterine myomata, 21 were sterile; of

_McClintock’s_ 21 patients similarly situated, 10 were sterile. _Von

Scanzoni’s_ investigation showed 38 sterile women among 60 married women

suffering from myoma uteri; _Michel_, 26 sterile among 127; _Winckel_,

134 sterile among 415. From a table showing the number of children born

to each of 108 women with myoma uteri of whom 46 were observed by

_Winckel_, and 62 were in _Süsserott’s_ collection, it appears that on

an average 2.7 children were born to each woman thus affected, whereas

in Saxony the average number of children born to each married woman is

4.5.

Many other gynecologists have published statistics regarding this

matter, _Gusserow_, _Röhrig_, _Schröder_, _E. von Flamerdinghe_, and

others, some of them dealing with a very large number of cases, and all

show that 30% and upwards of married women with uterine myomata remain

sterile.

On the other hand, _Hofmeier_ maintains, in opposition to the prevailing

view, that in the great majority of cases myomata are not to be regarded

as giving rise to sterility. His investigation embraced 313 persons, of

whom 25% were unmarried, and 75% married, and of these latter, 25 to 30%

were sterile. (It must be pointed out that compared with the average

percentage of sterile marriages—about 10%, this figure of 25 to 30% is a

very high one.) From a comparison of the age of the sterile married

woman with the duration of married life in each case, _Hofmeier_ is led

to believe that it is not the myomata which have exercised an influence

unfavourable to fertility, and that the occurrence of sterility in these

cases is referable to other causes. The origination of myomata he

regards as etiologically independent of the exercise or non-exercise of

the sexual act. The apparently overwhelming preponderance of the

occurrence of myomata in unmarried and in sterile married women is, he

thinks, to be explained by the fact that unmarried women and nulliparous

married women seldom have occasion to consult a gynecologist, but that

the one condition that renders it necessary for them to do so is the

growth of a uterine myoma. Generally speaking, pregnancy seldom occurs

after the age of 35 years, precisely the age at which the growth of

uterine myomata begins to be common. If, however, at this comparatively

late age pregnancy does occur, it is so often found to be complicated by

the presence of a uterine myoma, that _Hofmeier_ is even led to infer

that the presence of such a tumour must have a certain favouring

influence upon the occurrence of conception; the facilitation of

conception in these cases he explains by the fact that the growth of the

tumour renders the blood-supply of the whole reproductive apparatus more

active than is normally the case, and protracts the duration of ovarian

activity.

_Diseases of the Vagina and the Vulva._

Various pathological states of the vagina and vulva may cause incapacity

for fertilization by rendering copulation impossible. Such states may be

either congenital or acquired.

In rare cases the hindrance consists in abnormal smallness of the vulva,

but this condition is usually associated with other defects in

development of the reproductive organs, which combine to give rise to

sterility. Congenital adhesion of the labia minora and majora is

sometimes met with, with or without atresia of the urethral orifice, the

connexion between the labia may be superficial and epithelial merely, as

in a case recorded by _Ziemssen_; or the labia may be firmly united

throughout their whole thickness. Much less common is acquired adhesion

of the labia, causing atresia vulvae, and rendering coitus difficult or

entirely impossible. Various other abnormalities of the reproductive

organs which may give rise to sterility have already been described in

the section on the pathology of cohabitation, these are: abnormalities

of the hymen; anomalous formation and hypertrophy of the labia;

excessive size of the clitoris; anomalies of the vagina, its absence,

stenosis, atresia, duplication, and abnormal termination.

More detailed mention must, however, be made here of vesico-vaginal

fistula as leading to sterility. Such a fistula is rightly regarded as

one of the conditions preventing conception, but it does not render the

occurrence of pregnancy absolutely impossible. It will readily be

understood that the unpleasant symptoms commonly met with in these

cases, will be apt to deprive both husband and wife of inclination

toward sexual intercourse; again, apart from this psychical influence,

the functions of the female reproductive apparatus are commonly

disturbed to a very serious degree by the existence of a vesico-vaginal

fistula; and, finally, the unfavourable influence of the urine on the

semen must also be taken into consideration, for, as an acid fluid, the

urine will notably check the activity of the movements of the

spermatozoa—still, notwithstanding all these unfavourable influences,

conception will sometimes nevertheless occur in such cases. But of those

who acquire a vesico-vaginal fistula as the result of a difficult

labour, a very small proportion only will again become pregnant.

_Freund_ draws attention to _Simon’s_ experiences, reminding us that the

latter, in his cases in which women with vesico-vaginal fistula become

pregnant, invariably saw the pregnancy terminate in abortion or

premature labour; but still, _Freund_ quotes also a case of _Schmitt’s_,

and mentions another of his own, showing that this premature termination

of the pregnancy is not absolutely inevitable in such circumstances.

_Schröder_, indeed, goes far in the opposite direction, and writes:

“Such women not rarely become pregnant, and their pregnancy usually runs

a normal course.” _Kroner_ made a statistical investigation of the

question, and found that of 60 women suffering from vesico-vaginal

fistula, 6 became pregnant during the persistence of the fistula.

_Winckel_ reports a remarkable case in which, after the ordinary means

of curing the fistula had been vainly tried, transverse obliteration of

the vagina was undertaken; the operation was not completely successful,

as a small passage remained patent; the patient returned home for a

time, and became pregnant, the spermatozoa having found their way

through this passage. _Simon_ reports another noteworthy case, that of a

woman 57 years of age, with a vesico-vaginal fistula close to the

external os; during the 26 years the fistula had lasted she had

complained of cessatio mensium; when the fistula was closed by

operation, she again began to menstruate.

Sometimes we meet with abnormalities of the vagina—not strictly speaking

morbid states—which, though they may not at first sight appear to be of

much significance, yet suffice to render conception difficult, or even

impossible. One of these conditions is extreme shortness of the vagina,

leading to the formation of a “poche copulatrice” (Courty), in which

during coitus the semen is ejaculated at a distance from the os uteri

externum; another is excessive length and width of the vagina; another,

some displacement of the vagina which diminishes the prospect that the

semen will enter the cervical canal. Such vaginal false passages,

“fausses routes vaginales,” have been described more especially by

_Pajot_ as causes of sterility.

Another cause of sterility is the rapid outflow of the semen after

coitus, either in consequence of dyspareunia, or on account of some

abnormality in the configuration of the vagina, or, finally, owing to

deficient action of the constrictor cunni (or bulbocavernosus muscle)

and the muscles of the pelvic diaphragm. In cases of profluvium seminis,

the woman herself will often call the physician’s attention to the

defect.

Many cases of sterility depend upon a cause the recognition of which in

this connexion is comparatively recent, namely, the hermaphroditism of

the person concerned. Witness the following case described by _Dohrn_:

The individual had been baptised and brought up as a girl. At the age of

twenty years she began to suffer from a distressing sensation of

pressure, recurring at intervals of four weeks. A local examination was

made by a physician, who assured the mother that “there was no hindrance

to menstruation, but that when she married an incision would become

necessary.” After a time she became engaged and was married; and shortly

afterwards her husband demanded a renewed gynecological examination.

This was undertaken by _Dohrn_, who declared that the supposed girl was

of the male sex. The external reproductive organs had the feminine form.

The labia majora were large and well-formed; in the anterior extremity

of each labium was a rounded, sensitive, soft body, of the size of a

large bean, which was capable of being drawn forwards towards the

abdomen; the labia were beset with muscular fibres; the clitoris was 4

cm. (1.6 in.) in length, resembling an imperforate infantile penis, it

was slightly erectile; in the vestibule there were two openings, the

anterior of which was the urethra, the posterior led into a blind

passage 2 cm. (0.8 in.) in length, representing the fused lower

extremities of the ducts of _Müller_; per rectum no trace could be found

of vagina, uterus, or ovaries, but also no trace of prostate. The

marriage, in which this individual declared himself to be happy, was

annulled. _Leopold_ observed a similar case, in which the individual had

lived as a wife for the space of 25 years. Another striking case is

recorded by _Steglehner_. As _Zweifel_ remarks, to decide the true sex

of such individuals is often extremely difficult. “At the present day,

indeed,” he continues, “it is no longer the fate of those who from no

fault of their own have had imposed on them the name and upbringing of

another sex than that which is truly theirs, and who have thus been led

to contract marriage with one who in reality is of their own sex, to be

treated with the horrible injustice which was meted out to them in the

middle ages, when, as we learn from contemporary writers, they were

haled before the bar of “ecclesiastical justice,” charged with profaning

the sacrament of marriage, and threatened with death at the stake—but

even now a mistake in the decision of an infant’s sex entails in later

life a thousand distresses and inconveniences.”

Recently, _Neugebauer_ has made as complete a collection as possible of

all the recorded cases of hermaphroditism.

_Secretions of the Genital Organs._

The constitution of the secretion of the vaginal mucous membrane, or of

the secretion formed in the cervical canal, or both of these in

combination, may constitute hindrances to the normal contact of

spermatozoon and ovum.

The secretions of the female genital organs are manifold. The outer

surface of the labia majora is covered with skin, containing sebaceous

and sweat glands; but the inner surface of the labia majora and the rest

of the external genital organs are covered with mucous membrane, the

outer stratum of which consists of stratified pavement epithelium; this

epithelium contains sebaceous glands and mucus glands. The intermixture

of the secretions of these glands with the epithelial scales which are

constantly being cast off in large numbers, constitutes the whitish

material with which this region is smeared, known as “smegma.” A mucus

secretion of a fluid consistency is discharged from the vulvo-vaginal

glands known by the name of Bartholin’s glands.

The mucous lining of the vagina is poor in glands; it contains very

numerous papillæ, which do not, however, project from the surface of the

membrane, since the depressions between the papillæ are filled in by the

stratified epithelium with which the entire extent of the vaginal mucous

membrane is covered. The secretion of the vaginal mucous membrane is a

fluid of thin consistency with an acid reaction; the admixture of

numerous morphological elements, in the form of epithelial cells cast

off from the superficial layers of the stratified epithelium, often,

however, makes the vaginal secretion thick and opaque. The epithelial

lamellae are frequently covered with heaps of lepthothrix granules, and

among the granules are seen vibriones and bacteria and also numerous

lepthothrix threads of varying length.

The same stratified epithelium extends on to the neck of the uterus to a

distance which varies in different individuals; gradually, however, the

number of layers diminishes, the flattened cells give place to thicker,

prismatic cells, until we have a single-layered prismatic epithelium;

finally the cells become columnar and ciliated, and this columnar

ciliated epithelium covers the whole of the interior of the uterus. The

mucous lining of the cervical canal contains numerous mucous glands,

some of which are simple tubular glands, whilst others are racemose;

they are lined with columnar ciliated epithelium, and secrete a dense,

gelatinous, alkaline mucus, containing a few epithelial cells and

occasional leucocytes. The mucous membrane of the uterine cavity is

beset with simple tubular glands, lined with a single layer of prismatic

epithelium; these glands secrete a grayish alkaline fluid. The secretion

formed in the uterine cavity is thinner in consistency than that formed

in the cervical canal.

Normally, the secretion of the vaginal mucous membrane is not more than

is sufficient to keep the surface of the canal moist and slippery; it is

a thin fluid of an acid reaction, and almost as clear as water. Shortly

before and after menstruation, the secretion of the vaginal mucous

membrane becomes more abundant; it is even thinner than at other times;

the reaction remains acid. The secretion of the cervical canal is

normally, in the absence of sexual intercourse, small in amount, so that

a free flow of secretion from the os uteri externum is by itself

sufficient to indicate that the mucous membrane of the canal is in an

abnormal condition. The vitreous, gelatinous, alkaline mucus secreted by

the glands of the cervical canal is normally retained within the canal,

and is seen on examination with the speculum to fill the os uteri

externum. In consequence of the congestion of the uterus that occurs

during menstruation, and for the same reason during sexual excitement,

the secretion of the cervical canal is more abundant, it also becomes

less tenacious, and flows out through the os into the vagina. But this

evacuation of the cervical secretion through the os is a normal

occurrence only during menstruation and as a result of sexual

intercourse; in these circumstances it appears in the form of a clear or

somewhat yellowish drop of fluid exuding through the os uteri externum.

In catarrhal states, the secretions of the genital passage, like those

of other mucous membranes, become abnormal. There is an increase in the

number both of epithelial elements and of leucocytes; and in very acute

catarrhs, erythrocytes also mingle with the secretion. On microscopical

examination we find that the catarrhal secretion differs in its

characters according to the part from which it is derived: the mucus

from the cervical canal forms gelatinous accumulations; that from the

vaginal mucous membrane forms thick opaque masses; and in the mixed

secretion which exudes from the vulva, we find also smegma from the

external genital organs. In addition to cells from the laminated

epithelium, we see often young cells, somewhat oval or polyhedral in

form, with granular protoplasm, and a vesicular nucleus. In some

inflammatory states, pus corpuscles will also make their appearance.

Various micro-organisms are in addition to be found in the catarrhal

secretions.

The reaction of the vaginal secretion is normally faintly acid; should

it become strongly acid, the movements of the spermatozoa are

immediately suspended. The mucus of the cervical canal, the alkaline

reaction of which is extremely favourable to the onward movement of the

spermatozoa, may, owing to catarrhal processes, be so altered that it

becomes acid; it then destroys the spermatozoa, and gives rise to

sterility. This fact can sometimes be proved by microscopical

examination. In several cases in which endometritis existed in sterile

women I made a microscopical examination of the cervical mucus shortly

after the completion of sexual intercourse; and in a number of these, no

living spermatozoa were to be seen, but only dead, motionless

spermatozoa (Fig. 82). I had, of course, in these cases, previously

assured myself that the husband’s semen was normally active.

[Illustration: