Part 73

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.”