Part 70

An analogous cause of sterility is presented by the condition known as uterus infantilis, in which at puberty the uterus fails to undergo the changes proper to this period, and remains in the condition characteristic of infancy. The cervix is disproportionately large, whilst the body of the uterus is cylindrical in form, and the mucous membrane lining its cavity is always smooth. The muscular substance is unduly thin. The vagina may be normal, sometimes, however, it is narrow, and the mucous membrane is less rugose than normal. Associated with an infantile condition of the uterus we find commonly, but by no means invariably, imperfect development of the external genital organs, the labia, the clitoris, and the vagina; the mons veneris is but thinly covered with hair; the breasts are small. As a rule, menstruation is entirely wanting. Occasionally the ovaries are wanting. This infantile condition of the uterus is by no means extremely rare. According to Beigel’s figures, among 155 sterile women, in four the uterus was infantile.

Among 200 cases of sterility in which it was possible for me to make a searching enquiry for the cause, I found 16 instances of infantile uterus. Neither in the general physical configuration of these women, nor in the state of their menstrual functions, was there any striking abnormality; in the condition of the external genital organs, however, in cases of defective development of the uterus and ovaries, certain striking peculiarities were, in my experience, almost invariable, and deserving therefore of close attention. The mons veneris was extremely small, sometimes completely bald, or covered very thinly with hair; and the hair when present, did not exhibit the curliness usually seen in the pubic hair of married women. On examination, the uterus, small in all its diameters from arrest of development, could in every case be detected.

How exceptional it is in adult females with well developed internal reproductive organs for the pubic hair to be scanty or completely wanting, has been shown by the investigation recently made by R. Bergh on this hitherto neglected subject. In 2200 individuals engaged in clandestine prostitution, he found the pubic hair extremely scanty in 148, and the genital region nearly or completely bald in 6. He states that early vigorous growth of the pubic hair is a trustworthy sign of early sexual development; but he remarks that the opinion of Aristotle that women in whom the pubic hair is slight or absent are always sterile, is erroneous.

Note.—The author’s statement regarding the extreme infrequency of absence or deficiency of the pubic hair in women with properly developed internal reproductive organs, while true of European women, does not apply to all races. In Japanese women, for instance, the pubic hair is as a rule much scantier than in European women; and baldness, complete or nearly complete, of the mons veneris is by no means uncommon. It is the exception, in Japanese prostitutes, to find a thick and vigorous growth of genital hair.—Transl.

In the Talmud, there is an interesting reference to this subject, to the effect that it may be assumed that a woman is sterile if by the 20th year of her life the pubic region be not yet covered with hair, if the breasts be not developed, if coitus be difficult, and if the tone of the voice be masculine.

Madame Boivin, Dugès, Lumpe, and Pfau, maintain that the development of the uterus from the infantile condition to that characteristic of the sexually mature virgin, often occurs very late and very slowly; and that women in whom we find the uterus in an infantile condition, may later begin to menstruate and may become pregnant. It has been suggested that in these cases there has been confusion with primary acquired atrophy of the uterus. Still, that it is necessary to be most cautious in cases of infantile uterus in asserting that a woman is permanently sterile, has recently been forcibly impressed on me by a remarkable instance. A married woman consulted me some years ago on account of amenorrhœa and sterility; examination showed clearly that the uterus was in the infantile condition, and for this reason, not I alone, but several leading gynecologists, assured her that there was no hope of her ever becoming a mother; recently, however, after ten years of sterile wedlock, she was safely delivered of a healthy child.

A sub-variety is constituted by the uterus pubescens, a uterus which indeed at puberty has undergone a certain degree of development, but has failed to attain the normal size; in such cases the menses are regular, but sometimes painful. This form of arrest of development of the uterus may occasion sterility, which, however, often proves curable when by frequent sexual intercourse and the congestion dependent thereon, the genital organs have been stimulated to the completion of the process of development; the muscular strength of the uterus then becomes adequate, and the dysmenorrhœic troubles disappear. In general it may be said that if the rudimentary or imperfectly developed uterus is at all competent to carry out the function of gestation, the necessary changes sometimes occur in the organ with remarkable rapidity, and result in normal pregnancy and parturition.

Uterus unicornis, when occurring alone, and not associated with other defects or errors in development, is not a cause of sterility. Women with a uterus unicornis, with or without an accessory horn, menstruate, conceive, and pass through pregnancy and parturition, in a perfectly normal manner; indeed, some women with this developmental defect have given birth to twins. The assumption that uterus unicornis predisposes to abortion does not always hold good. If, however, pregnancy occurs in a rudimentary horn, rupture of the membranes is inevitable, and the ovum or embryo passes into the abdominal cavity, with the usual accompaniment of fatal haemorrhage. The rupture commonly occurs between the third and the fourth month of foetal life (months of four weeks each).

The uterus bicornis, with which may or may not be associated duplication of the vagina, does not as a rule offer any hindrance to conception; and the same statement is true also of the uterus bilocularis or septus. Women with these defects of development may give birth to healthy children; and some such women have had twins, each foetus occupying a separate half of the uterus. Still, births in cases of double uterus and vagina are rare occurrences. Such cases have been published by Lasarewitsch, Litschkus, and Készmarsky. In very rare cases of uterus bicornis associated with double vagina, an obstacle to conception is offered by the fact that one side only of the double vagina, the larger, is utilized in sexual intercourse, and that this is a blind passage.

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.

FIG. 70.—Congenital Atrophy of the Uterus (after Virchow), oi, Ostium internum; oe, Ostium Externum. ]

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.”

FIG. 72.—Normal Portio Vaginalis. ]

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.

FIG. 74.—“Apron-shaped” Vaginal Portion. a. Greatly elongated anterior lip; b. Shorter posterior lip of the cervix. ]

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