Part 72

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.

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.

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.

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.