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.

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.

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.

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.

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.

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.

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.

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.

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:

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 mucous lining of the vagina is poor in glands; it contains very numerous papillæ, which do not, however, project from the surface of the membrane, since the depressions between the papillæ are filled in by the stratified epithelium with which the entire extent of the vaginal mucous membrane is covered. The secretion of the vaginal mucous membrane is a fluid of thin consistency with an acid reaction; the admixture of numerous morphological elements, in the form of epithelial cells cast off from the superficial layers of the stratified epithelium, often, however, makes the vaginal secretion thick and opaque. The epithelial lamellae are frequently covered with heaps of lepthothrix granules, and among the granules are seen vibriones and bacteria and also numerous lepthothrix threads of varying length.