In favourable circumstances, when the constitution becomes more powerful, in these cases of primary atrophy of the uterus, improvement takes place; the uterus undergoes further development, menstruation becomes more abundant, and the woman may become pregnant. Such a favourable prognosis cannot, however, be entertained if a severe flexion of the uterus is associated with the atrophy of the organ; or if the ovaries are also atrophied.
Sterility results also from puerperal atrophy of the uterus. This condition is a sequel of severe puerperal diseases, metritis, parametritis, and perimetritis; sometimes, even in the absence of such inflammatory processes, it is due to puerperal hyperinvolution, occurring especially in women previously weak in constitution, and manifested by the fact that, notwithstanding the weaning of the child, the menstrual flow remains for months in abeyance. The uterus loses its firm consistency; it is sometimes shortened, sometimes of normal length, but the walls are always greatly thinned, so that, as Schroeder points out, the sound can be readily felt, through the abdominal wall. Puerperal atrophy is a curable condition, so that the sterility dependent upon this disease is not necessarily permanent. Thus, in a case of P. Müller’s, a woman in whom a twin delivery had been followed by extreme atrophy of the uterus, with well-marked symptoms both objective and subjective, became once more pregnant eighteen months after the termination of the twin pregnancy.
Other forms of atrophy of the uterus have a similar deleterious effect to that exercised by puerperal atrophy, as, for instance, atrophy from the pressure of tumours of the uterus, or of solid ovarian tumours; or, again, atrophy due to defective innervation of the pelvic organs, occurring in various forms of paralysis, and characterised by amenorrhœa and extreme smallness of the uterus. Von Scanzoni has seen several cases in which young women, previously healthy and menstruating with regularity, have been attacked by paralysis of the lower extremities, and thenceforwards have suffered from amenorrhœa and great contraction of the uterus; in some of these cases a post mortem examination was made, and disclosed the existence of true atrophy of the uterus. Jaquet saw a similar case of atrophy of the uterus in a lady who had been frightened by witnessing the storming of a barricade in front of her dwelling; she was then in her 22nd year, and had given birth to her second child 1½ years previously; thenceforwards she was completely amenorrhoeic, and her uterus measured only 3 cm. (1.2 in.) in length.
Displacements of the uterus (flexions and versions), and abnormalities in the cervix uteri, are among the conditions which lead to sterility by interfering with conjugation—by preventing the necessary physical contact between the male and the female reproductive elements. The frequency with which these diseases give rise to sterility is, however, far from being so great as is commonly asserted by those who maintain a mechanical theory of conception.
Pathological Changes in the Cervix Uteri.
In very early times, the attention of physicians was directed to abnormalities in the shape of the cervix uteri, as offering hindrances to the entry of the semen into the uterus. Amongst the writers of antiquity who have alluded to this matter, the names of Hippocrates and Soranus must especially be mentioned.
The normal cervix uteri (Fig. [72]) has the form of a flattened ellipsoid, perforated throughout its longitudinal axis. On making a longitudinal section of the cervical canal, we see that it is dilated in the middle, and tapers towards either extremity, having thus the shape of a spindle; the internal os is, however, somewhat smaller than the external. The latter (os uteri externum, os tincæ, often referred to without qualification as “the os”), has normally the form of a transverse fissure, which, however, tends more towards the circular form, the smaller it is, and the more widely its margins are separated. In childhood, in consequence of the infolding of its margins, the external os has usually a radiated form, later it becomes rounded, and only with the attainment of sexual maturity does it assume the form of a transverse slit. This form is maintained throughout the epoch of active sexual life; but after the climacteric, owing to the separation of the margins of the orifice, it becomes once more rounded.
With regard to the greatly varying size and shape of the portio vaginalis, it may be said that in general its anterior lip appears the shorter of the two, owing to the lesser depth of the anterior vaginal fornix, but that in reality the anterior wall of the cervical canal is longer than the posterior; the actual length of the anterior lip of the portio vaginalis, measured from the summit of the anterior fornix, is from ½ to 1 cm. (0.2 to 0.4 in.), whilst the posterior lip, from the summit of the posterior fornix to the end of the lip measures 1½ cm. (0.6 in.) and upwards. The position of the cervix is such that, owing to the oblique direction of the long axis of the uterus, superadded to the absolutely greater length of the anterior lip of the cervix, the plane across the extremities of the two lips faces almost straight backwards. The axis of the portio vaginalis forms a right angle with the axis of the vagina; the cervical canal, however, is not usually straight, but has a slight S-shaped curvature. The mean length of the cervical canal in the virgin uterus is 3 cm. (1.2 in.). (Lott.)
The “ideal” form of the cervix uteri and of the os uteri externum is described by Sims in the following terms: “The vaginal portion should measure about one fifth, certainly not more than one fourth, of the entire length of the cervix uteri; that is, the anterior lip should have a length of one-fourth to one-third of an inch, and the posterior lip should be a fraction longer. The cervical canal should either be straight, or have a forwardly directed curve; the cervical axis should form a right angle with the vaginal axis; the cervix should not be markedly anteverted or retroverted.” Sims is of opinion that every woman whose uterus is in this condition will conceive within three or four months from the time when she first enters upon conjugal intercourse; he adds, however, the important proviso, “be it understood, that all else is in order.”
