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.”
Recently, Neugebauer has made as complete a collection as possible of all the recorded cases of hermaphroditism.