Part 69

In the interior of the tubes also, pathological processes occur, catarrhal inflammations, haemorrhagic or purulent exudations, sealing up the passage completely. In some cases these exudations lead to great distension and even to rupture of the tube. Thus, among the causes of sterility must be enumerated: simple catarrh of the tube, with swelling of the mucous membrane; purulent catarrh, leading to its distension with pus—pyosalpinx; serous effusion into the tube, hydrosalpinx; and haemorrhagic effusion, haematosalpinx; further, that peculiar form of tubal inflammation, described by Chiari and Schauta under the name of salpingitis isthmica nodosa, in which hyperplasia of the muscular coat of the tube occurs at irregular intervals, so that it appears to be beset with nodes. Special mention must also be made of gonorrhoeal salpingitis, which will subsequently be described in detail.

Inflammatory states of the tube may hinder conception, either mechanically, by swelling of the mucous membrane, or by obstruction of the lumen of the tube by exudations, by injury or destruction of the ciliated epithelium, by lesion of the musculature of the tube, affecting its peristaltic movements—all these hindering or entirely preventing the passage of the ovum downwards or of the spermatozoa upwards; or, again, chemically, by the deleterious influence of many of the morbid secretions that are formed in these conditions upon the vitality of ova or spermatozoa. These inflammatory states of the tubes may also lead to stricture or obliteration of their abdominal extremities, or to displacement of the ostia, and thus lead to sterility; in other cases these same conditions, leading to distortion and displacement of the tube, may prevent the downward passage of the ovum while leaving possible the upward passage of the spermatozoa, and thus give rise to tubal gestation—a condition which we shall not now consider.

It must not be forgotten that tuberculosis of the genital canal attacks the tubes with especial frequency; in these organs we may find miliary tubercles, and more commonly diffuse caseous masses, completely filling the lumen of the canal. Finally we have to mention the diverse forms of saccular dilatation of the tubes (Ger. “Tubensäcke”), all of which possess the common pathological characteristics of enlargement of the tubes and their conversion into saccular cavities; the contents of these distended tubes may, however, be extremely various, and such conditions may depend upon manifold mechanical disturbances and inflammatory processes of the uterus and its annexa.

When we consider how common, during the sexual life of women, are perioophoritic inflammations, more or less intense, but often without severe symptoms (and hence apt to be overlooked); when we remember that the very process of ovulation and also the puerperal state furnish opportunities for slight or severe pelvic peritonitis to arise; and when we further take into account the frequency and importance of gonorrhoeal pelvic peritonitis—we cannot fail to admit that the results of these morbid conditions, such as adhesions between the ovary and the ostium tubae, or closure of the tube with consequent hydro- or pyosalpinx, must be reckoned among the principal causes of sterility. If the frequency and importance of these conditions is still underestimated, two reasons can be adduced for this: first, that the slighter degrees of intrapelvic inflammation often, as previously mentioned, elude diagnosis; and, secondly, that even when the treatment is expectant merely, the exudations are frequently absorbed, the adhesions give way, and the capacity for conception is gradually fully restored.

When considering the etiology of acquired sterility, especial attention must be devoted to gonorrhoeal pyosalpinx, the most important and the most dangerous of the morbid manifestations of gonorrhoeal infection in the female. Gonorrhoeal salpingitis and perisalpingitis are very serious affections, in the first place because they are apt to give rise to oophoritis and perioophoritis, as well as to pelvic peritonitis, and other local inflammatory states. The minuteness of the uterine orifice of the Fallopian tube, and the downward direction of the ciliary movement in the interior of the tube, combine to safeguard against the entrance of gonococci, but none the less they too often find their way up the tube, and small quantities of gonorrhoeal pus enter the pelvic cavity and give rise to inflammations, in which the ovary partakes.

According to Saenger, this gonorrhoeal disease of the uterine annexa is found with especial frequency in women either wholly sterile or affected with only-child-sterility, and is to be regarded as the cause of their infertility; “infertility is indeed the rule, fertility the exception, in all cases in which gonorrhoeal disease has passed upwards beyond the os uteri externum.” The same author maintains that, putting aside tuberculosis and actinomycosis, if, in a case of infective inflammation of the uterine annexa, septic infection can be excluded, and more especially when the disease affects both tubes, when it is reluctant to yield to treatment, and when relapses are frequent, we have no option but to believe that the affection is of gonorrhoeal origin.

In 155 cases of chronic inflammatory disease of the Fallopian tubes, von Rosthorn was able in 37 instances to prove that the affection was the direct result of gonorrhoeal infection.

Recently, however, Noble has published cases which lead us to believe that even pyosalpinx does not necessarily prevent the occurrence of pregnancy. In operating for the relief of a unilateral pyosalpinx, the uterus was opened, and a seven months’ foetus was removed. In another case, the autopsy on a woman who had succumbed to severe peritonitis arising immediately post partum, disclosed a large pyosalpinx.

Closure of the ostium may also be brought about by chronic metritis and endometritis, by chronic catarrhal states of the uterine mucous membrane, and in general by pathological changes in that membrane associated with local hyperaemia or abnormal secretions. In some cases, salpingitis with consequent sterility is the result of puerperal infection; and such a sequence of events is especially common after an abortion followed by retroflexion of the uterus, leading to elongation and kinking of the tubes.

An important hindrance to the entry of the ovum into the uterus is sometimes offered by uterine polypi or myomata; growing from the fundus, these may so fill the uterine cavity that the uterine orifices of the tubes appear to be completely occluded.

At times, also, quite small myomata, growing close to the tubes, may push these latter upwards, closing them, and thus giving rise to sterility; such myomata may also lead to saccular dilatation of the tubes, as occurred in the following case:

Mrs. S., aged 39 years, had one child when 20 years of age, but since then had been barren. For several years she had suffered from profuse menorrhagia. Owing to the enormous thickening of the abdominal wall, bimanual examination of the uterus was impossible; the vagina was relaxed, enlarged, and contained an excess of mucous secretion. The uterus was high up in the pelvis, anteverted, enlarged, movable, sensitive to pressure; the portio vaginalis was enlarged, soft, and excoriated; no tumour could be detected either in the uterus or in the uterine annexa. The menstrual flow recurred at intervals of from two to three weeks, lasting from one to two weeks, and being extremely profuse; menstruation was painful. Whilst the patient was under my observation an excessive menstrual haemorrhage came on quite suddenly, with slight rise of evening temperature (38.2° C.—100.8° F.), but severe general disturbance; there were paroxysms of intense abdominal pain, violent vomiting of greenish bilious masses, which after a time became haemorrhagic, the abdomen was tense and sensitive to pressure, there was cardiac weakness with general failure of strength; treatment proved unavailing, and the patient died in collapse on the third day. The autopsy disclosed: fibroma uteri submucosum, parietale, et subserosum, haematosalpinx dextra, pyosalpinx sinistra, peritonitis. The subserous myoma, of about the size of a pea, was in the middle of the fundus uteri; the submucous myoma, of about the size of a chestnut, filling the uterine cavity, sprang from the posterior wall of the body of the uterus; the intramural myoma, of about the size of a bean, was in the right wall of the corpus uteri. Both tubes were greatly elongated, exhibiting serpentine windings. The right tube was much distended, filled with sanguineous fluid; the left, partially collapsed, contained greyish-green purulent material, having an extremely offensive odour; some of this fluid had flowed through the ostium abdominale into the abdominal cavity. Death in this case ensued with great rapidity in consequence of rupture of the pyosalpinx, and evacuation of its contents into the abdominal cavity.

Cystic formations in the round ligament (hydrocele of the round ligament) sometimes lead to sterility. In the form of elongated tumours of about the size of a hen’s egg they may fill the inguinal canal, and even pass forwards into the labia majora. When as large as this, they demand operative interference. Hennig records a case in which such hydrocele of the round ligament was the cause of sterility lasting 14 years, the woman becoming pregnant after the tumour had been removed by operation. Similarly, infertility may depend upon solid tumours of the round ligaments—myomata, fibromyomata, or sarcomata.

Retro-uterine haematocele often gives rise to sterility. As a rule, prior to the formation of a blood-tumour in the pouch of Douglas, various menstrual disturbances occur, more especially menorrhagia; or it may be preceded by some puerperal disease, especially perimetritis, which by itself, indeed, seriously limits the fertility of the woman thus affected; but when haematocele is superadded, her child-bearing capacity is much more gravely impaired, owing to the permanent displacement of the uterus, to the perimetritic exudations, to the adhesions formed around the ovary, and to stricture or occlusion of the tubes. Still, sterility is by no means an inevitable consequence of haematocele.

By many it is assumed that in cases in which the tubes are perfectly normal, disturbances of innervation are competent to cause sterility (or tubal gestation). It is supposed that nervous influences affect the functions of the Fallopian tubes by leading to spastic contractures of the circular muscular fibres of these structures, or in other cases to paralysis; in this way nervous disorder may lead to the retention within the tube of the unfertilized (or already fertilized) ovum.

Diseases of the Uterus.

Pathological changes in the uterus may in various ways lead to sterility dependent upon prevention of conjugation (physical contact of the male and female reproductive elements). Thus, the incapacity for fertilization may, on the one hand, depend on hindrances to the passage of the ovum from the tube to the interior of the uterus; or on the other, on some abnormal condition of the vaginal portion of the cervix, whereby the passage of the spermatozoa from the vagina into the uterus is prevented; or, finally, upon displacements of the uterus or pathological structural changes in that organ, whereby the implantation of the fertilized ovum in the uterine cavity and its development therein are impeded.

The uterus may be entirely absent, but this is an extremely rare condition; much less infrequent is a rudimentary condition of that organ. In the latter case, it is either represented by a nodular rudiment, or else it is conical or bicorned; whatever its shape, it is a solid mass of muscular and connective tissue. In association with absence or a rudimentary condition of the uterus, the vagina also may be wanting, or may be represented merely by a small, blind pouch; the Fallopian tubes may in such cases either be normally developed or rudimentary. The number of instances of this kind that have been observed is very large (Kussmaul, Klebs, Cusco, Klinkosch-Hill, Cruise, Freund, Fürst, Engel, Gusserow, Nega, Kiwisch, Rokitansky, Braid, Jackson, Lucas, Duplay, Dupuytren, Renaudin, Crédé, Saexinger, and many others).

The uterus and the vagina may be absent in cases in which the vulva is developed in a perfectly normal manner, with a mons veneris projecting as usual, and covered with a proper growth of hair. Ormerod and Quain have reported cases of this kind, in which the external sexual characters were those of a fully mature, perfectly developed woman, but in whom the uterus and ovaries were entirely wanting.

These defects of development necessarily entail complete sterility. Sometimes during life the cause of the sterility is entirely overlooked, and only discovered by chance or in post mortem examination. Although the vagina usually shares to a marked extent in the defects of the uterus, and at puberty undergoes a rudimentary development merely, the marital intercourse of such individuals commonly appears to be perfectly normal. As a result of frequently repeated and vigorous attempts at intercourse, the rudimentary vagina becomes accommodated to the needs of the case; and even when the vagina is absent, the rudimentary depression by which it is represented becomes distended into a large blind sac capable of accommodating the erect penis. In other such cases, the penis finds for itself some abnormal channel, and the husband may continue to indulge in intercourse for a long period without discovering that there is anything unusual. Sometimes it is the urethra which becomes dilated and takes on in part the function of the vagina; in other cases intercourse is effected per anum.

The following most remarkable case came under my own observation. The patient’s husband was a physician, who nevertheless was in complete ignorance of his wife’s abnormalities. The woman was 26 years of age, of medium stature, somewhat obese, breasts moderately well developed, pubic hair well grown. She stated that before marriage she had menstruated regularly, and that it was only after she had married four years previously that menstruation had ceased—statements which were unquestionably false. She consulted me on account of amenorrhœa and sterility, which her husband believed to depend upon her increasing obesity. Examination showed that the vagina admitted two fingers and was 10 cm. (4″) in length; but it was completely blind, and the mucous membrane was strikingly smooth. On bimanual examination, only a rudiment of the uterus could be detected, a mass no larger than a hazel-nut; the ovaries could not be felt.

A similar case is recorded by Heppner. A Finnish peasant woman 31 years of age consulted him on account of amenorrhœa and sterility. She had been married for 12 years, and neither before marriage nor since had menstruated or had had any periodic vicarious bleeding. The pubes and the labia majora were thinly covered with hair; the latter were very flaccid and but slightly prominent; the nymphæ hung down like an apron for as much as an inch below the genital fissure, and were very thin; the clitoris was but slightly developed. The urethral papilla was of normal size, the lacunæ around it were extremely well marked; the urethral orifice had the form of a zigzag slit. Behind this latter was an aperture environed by radiating folds, and this was the entrance to a blind passage about two inches in length; this aperture could not, however, be identified as the introitus vaginae, for the reason that there were no carunculæ myrtiformes, and moreover the callosity of the mucous membrane characteristic of the vaginal orifice was wanting. Behind the strongly projecting commissura labiorum, however, the fossa navicularis appears as a separate depression. The blind passage was clothed with a soft, pale-red mucous membrane, and was entirely devoid of any trace of columnæ rugarum; at the extremity of this passage there was neither scar nor induration. On rectal exploration, no trace of uterus, normal vagina, or ovaries could be felt, notwithstanding the fact that the abdominal walls were very flaccid and examination was therefore easy. The general configuration was feminine, the breasts were flabby and dependent, the waist and hips were those of a woman.

Tauffer reports the case of a woman 25 years of age, married 2½ years, absolutely amenorrhoeic; on examination she was found to have atresia vaginae with rudimentary development of the uterus. The breasts were small, the mons veneris was deficient in fat, but thickly covered with hair, the labiæ and the clitoris were normal.

R. Levi describes a case in which, in a patient 19 years of age, the uterus was wanting, though the general physical development was that of a normal woman. The breasts were well formed, and so also were the external genital organs; a blind passage 4 cm. (1.6 in.) in length, and admitting two fingers, represented the vagina. In the position normally occupied by the ovaries, were two bodies which were doubtless the rudiments of these organs. Menstrual molimina had never been experienced.

Von Hoffmann, in making a post mortem examination on an elderly married woman, found that the vagina ended blindly at a depth of 6 cm. (2.4 in.), whilst the uterus was represented merely by a pyramidally arranged bundle of fibres in the broad ligament. Lissner reports a case in which the physician was the first to draw the husband’s attention to the fact that his wife had no uterus.

Ziehl, in a married woman 57 years of age, found that the uterus was completely wanting; the vagina ended blindly half an inch from the surface; the tubes and ovaries were present. Boyd, in a married woman 72 years of age, found a blind vagina half an inch in length, and the uterus represented by a nodular rudiment on the posterior wall of the bladder.

Rare cases are also recorded in the literature of the subject, in which, notwithstanding the absence of the uterus, normal ovaries were present, and in these latter periodic ripening of the graafian follicles took place. A case of this kind was described by Burggraeve.

Complete sterility is entailed also by a persistence of the foetal condition of the uterus. In these cases, the uterus retains the form it possessed at the beginning of the second half of intra-uterine life. The portio vaginalis projects but slightly into the vagina, and the os uteri externum appears as a small rounded opening. The cervix is comparatively long and wide, and the folds on the mucous membrane of the cervical canal are fully formed. The body of the uterus is imperfectly developed, triangular in shape, with thin walls; it is shorter than the cervix, and its interior is marked by folds of mucous membrane converging towards the os. In these cases menstruation is absent or scanty; the other reproductive organs, including the breasts, are usually in a state of arrested development. Women with foetal uterus are capable of sexual intercourse, and carry on most of the functions of their sexual life in a manner apparently normal; they are, however, invariably sterile.