Part 71

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.

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

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.

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.