When considering the etiology of acquired sterility, especial attention must be devoted to gonorrhoeal pyosalpinx, the most important and the most dangerous of the morbid manifestations of gonorrhoeal infection in the female. Gonorrhoeal salpingitis and perisalpingitis are very serious affections, in the first place because they are apt to give rise to oophoritis and perioophoritis, as well as to pelvic peritonitis, and other local inflammatory states. The minuteness of the uterine orifice of the Fallopian tube, and the downward direction of the ciliary movement in the interior of the tube, combine to safeguard against the entrance of gonococci, but none the less they too often find their way up the tube, and small quantities of gonorrhoeal pus enter the pelvic cavity and give rise to inflammations, in which the ovary partakes.
According to Saenger, this gonorrhoeal disease of the uterine annexa is found with especial frequency in women either wholly sterile or affected with only-child-sterility, and is to be regarded as the cause of their infertility; “infertility is indeed the rule, fertility the exception, in all cases in which gonorrhoeal disease has passed upwards beyond the os uteri externum.” The same author maintains that, putting aside tuberculosis and actinomycosis, if, in a case of infective inflammation of the uterine annexa, septic infection can be excluded, and more especially when the disease affects both tubes, when it is reluctant to yield to treatment, and when relapses are frequent, we have no option but to believe that the affection is of gonorrhoeal origin.
In 155 cases of chronic inflammatory disease of the Fallopian tubes, von Rosthorn was able in 37 instances to prove that the affection was the direct result of gonorrhoeal infection.
Recently, however, Noble has published cases which lead us to believe that even pyosalpinx does not necessarily prevent the occurrence of pregnancy. In operating for the relief of a unilateral pyosalpinx, the uterus was opened, and a seven months’ foetus was removed. In another case, the autopsy on a woman who had succumbed to severe peritonitis arising immediately post partum, disclosed a large pyosalpinx.
Closure of the ostium may also be brought about by chronic metritis and endometritis, by chronic catarrhal states of the uterine mucous membrane, and in general by pathological changes in that membrane associated with local hyperaemia or abnormal secretions. In some cases, salpingitis with consequent sterility is the result of puerperal infection; and such a sequence of events is especially common after an abortion followed by retroflexion of the uterus, leading to elongation and kinking of the tubes.
An important hindrance to the entry of the ovum into the uterus is sometimes offered by uterine polypi or myomata; growing from the fundus, these may so fill the uterine cavity that the uterine orifices of the tubes appear to be completely occluded.
At times, also, quite small myomata, growing close to the tubes, may push these latter upwards, closing them, and thus giving rise to sterility; such myomata may also lead to saccular dilatation of the tubes, as occurred in the following case:
Mrs. S., aged 39 years, had one child when 20 years of age, but since then had been barren. For several years she had suffered from profuse menorrhagia. Owing to the enormous thickening of the abdominal wall, bimanual examination of the uterus was impossible; the vagina was relaxed, enlarged, and contained an excess of mucous secretion. The uterus was high up in the pelvis, anteverted, enlarged, movable, sensitive to pressure; the portio vaginalis was enlarged, soft, and excoriated; no tumour could be detected either in the uterus or in the uterine annexa. The menstrual flow recurred at intervals of from two to three weeks, lasting from one to two weeks, and being extremely profuse; menstruation was painful. Whilst the patient was under my observation an excessive menstrual haemorrhage came on quite suddenly, with slight rise of evening temperature (38.2° C.—100.8° F.), but severe general disturbance; there were paroxysms of intense abdominal pain, violent vomiting of greenish bilious masses, which after a time became haemorrhagic, the abdomen was tense and sensitive to pressure, there was cardiac weakness with general failure of strength; treatment proved unavailing, and the patient died in collapse on the third day. The autopsy disclosed: fibroma uteri submucosum, parietale, et subserosum, haematosalpinx dextra, pyosalpinx sinistra, peritonitis. The subserous myoma, of about the size of a pea, was in the middle of the fundus uteri; the submucous myoma, of about the size of a chestnut, filling the uterine cavity, sprang from the posterior wall of the body of the uterus; the intramural myoma, of about the size of a bean, was in the right wall of the corpus uteri. Both tubes were greatly elongated, exhibiting serpentine windings. The right tube was much distended, filled with sanguineous fluid; the left, partially collapsed, contained greyish-green purulent material, having an extremely offensive odour; some of this fluid had flowed through the ostium abdominale into the abdominal cavity. Death in this case ensued with great rapidity in consequence of rupture of the pyosalpinx, and evacuation of its contents into the abdominal cavity.
Cystic formations in the round ligament (hydrocele of the round ligament) sometimes lead to sterility. In the form of elongated tumours of about the size of a hen’s egg they may fill the inguinal canal, and even pass forwards into the labia majora. When as large as this, they demand operative interference. Hennig records a case in which such hydrocele of the round ligament was the cause of sterility lasting 14 years, the woman becoming pregnant after the tumour had been removed by operation. Similarly, infertility may depend upon solid tumours of the round ligaments—myomata, fibromyomata, or sarcomata.
Retro-uterine haematocele often gives rise to sterility. As a rule, prior to the formation of a blood-tumour in the pouch of Douglas, various menstrual disturbances occur, more especially menorrhagia; or it may be preceded by some puerperal disease, especially perimetritis, which by itself, indeed, seriously limits the fertility of the woman thus affected; but when haematocele is superadded, her child-bearing capacity is much more gravely impaired, owing to the permanent displacement of the uterus, to the perimetritic exudations, to the adhesions formed around the ovary, and to stricture or occlusion of the tubes. Still, sterility is by no means an inevitable consequence of haematocele.