The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

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.