In my own experience, whilst gonorrhoeal endometritis is, among inflammations of the endometrium, the most frequent cause of sterility, the place of next importance in this connexion is occupied by exfoliative endometritis, or membranous dysmenorrhœa. This name is given to a pathological condition in which from time to time, usually during menstruation, fragments of membrane, or even an entire sac-like cast of the uterine cavity, are expelled from the uterus; since this condition is apt to hinder the incubation of the ovum, it is commonly associated with sterility—a fact mentioned already by Denman in 1790, and since then confirmed by numerous observers. I have had under observation several cases of dysmenorrhœa membranacea; in two cases it existed from the time of marriage—in one case 14 years, in the other 8 years—and in both sterility was absolute. In the latter of the two cases, vigorous treatment was undertaken, even curettage of the uterus, but quite without avail. In other cases, the sterility was acquired, the membranous dysmenorrhœa having begun after the woman had already had one or more children; but as I have never seen a case in which a woman became pregnant after the development of this affection, I am compelled to regard it as one of the most severe hindrances to conception.

As a general rule, exfoliative endometritis terminates only with the onset of the climacteric age; in very exceptional cases, however, a cure may take place earlier. In cases in which this premature termination has been observed, pregnancy has been known to ensue, cases of this nature having been observed by Solowieff, Fordyce Barker, and Thomas. And recently, cases have been reported, in which the disease has returned after such a pregnancy. Fritsch, indeed, is of opinion that exfoliative endometritis does not cause sterility, and that in this disease abortion is no commoner than in other diseases of the uterus. Charpignon, Hennig, and Bordier have also observed conception occur in the course of this disease. In 42 cases of membranous dysmenorrhœa collected by Kleinwächter, pregnancy occurred in four during the existence of the disease. Löhlein also reports that, among 27 patients affected with membranous dysmenorrhœa, six became pregnant, after the symptoms had been clear and unmistakable for a shorter or longer period. Two of these patients had been already pregnant before the first appearance of the exfoliative endometritis; subsequently they became pregnant and were delivered at full term. The other four had suffered for varying periods and with varying severity from the affection, before they first became pregnant. In three of these cases curettage of the uterus was performed; but in one only, in which pregnancy ensued very speedily on the operation, could a causal connexion be inferred. In two of the cases the mothers of the patient had also suffered from the affection.

It has been asserted by B. Schultze and others that curettage of the uterus renders it difficult or impossible for pregnancy subsequently to occur. There is, however, no evidence to justify such an opinion.

Especial attention should be given to inflammatory processes in the perimetrium and the parametrium as diseases giving rise to sterility in women. They are extremely common, and at times are so insidious, running their course without giving rise either to pain or to fever, that even when very extensive, and even when they have led to the formation of secondary tumour-growths, they may yet be overlooked. Hence their pathological significance in the causation of sterility in women is still underestimated. Chronic pelvic peritonitis and parametritis may lead to the onset of sterility in various ways: changes may occur in the cervix, this organ becoming indurated, fixed, and retroposed, and painful when the uterus is moved; inflammatory changes may affect the body of the uterus, the ligaments of the ovary, and various portions of the pelvic peritoneum; displacement of the uterus may occur; one or both ovaries or tubes may be dislocated and fixed, either to the side of the uterus, or behind it, in the pouch of Douglas; all kinds of adhesions or inflammatory nodules may result from these processes. Further, in the scarred, contracted, sclerosed parametric tissue, the blood and lymphatic vessels of the parametrium are compressed, and in part obliterated, and the intimate connexion between the pelvic cellular tissue and the uterus readily leads to the onset of endometritis, whereby the implantation of the ovum is interfered with. The occurrence of sterility in cases of pelvic peritonitis and parametritis, depends in part on the indirect effects of the inflammatory exudations, and in part on the direct result of the extension of the inflammation to other regions. The perimetritis, parametritis, and pelvic peritonitis that result from gonorrhoeal infection have thus an especially disastrous influence, for the reason that in these cases cervical metritis and endometritis with blenorrhoea are commonly superadded. This is the principal cause of the almost invariable sterility of prostitutes, in whom, however, we must also take into consideration the influence of the absence of voluptuous sensation in an act which to them has become a mere matter of business. The investigations of Bandl in the post mortem room show that residues of perimetritic and parametritic inflammation are to be found in the bodies of 58.4% of parous women, and 33.3% of the bodies of women (married or unmarried) who have had experience of sexual intercourse but have never had a child. This, he thinks, is the explanation of the great frequency of childless marriages and of relative sterility in women. In the nulliparae mentioned above, Bandl commonly found an indurated, functionless, in places cicatrized, narrowed cervix, paraoophoritic and perisalpingitic residues, and morbid changes in the tubes and the ovaries. In some cases also the husbands of such sterile women were found to be affected with azoospermia. The connexion between azoospermia in men and the discovery of inflammatory residues in their childless wives, is a very intimate one. The husband at the time of marriage was suffering from an imperfectly cured gonorrhoea, and infected his wife. In the other class of cases, in which the women had had children, and subsequently become sterile, the limitation of fertility depended chiefly upon inflammatory residues in and around the ovaries and the tubes. In the majority of such cases, pregnancy is not rendered impossible, but merely difficult, for, notwithstanding the presence of very extensive inflammatory residues, the tubes are often pervious, and the ovaries fully or partially functional. Therefore, even in cases in which intrapelvic inflammation has been very severe, we must be cautious in giving a prognosis that pregnancy has been rendered impossible, for the cases in which both ovaries are imbedded completely in pseudo-membranes, or in which both tubes have been rendered impervious, are unquestionably rare.

Carcinoma of the uterus rarely causes sterility. In its initial stages, in which there is merely papillary proliferation of the portio vaginalis, or carcinomatous infiltration of the deeper layers of the mucous membrane, no hindrance is offered to conception; but even in the later stages of the disease, when ulceration has occurred, and when there is extensive necrosis of the cancerous masses, there is not necessarily any absolute impossibility of the occurrence of conception, so long as cohabitation remains possible, and no insuperable hindrance has risen to the contact of ovum and spermatozoon. The cases are numerous in which pregnancy has been observed, notwithstanding extensive carcinomatous disease of the cervix, with necrosis of the tumour tissue; and Cohnstein even asserts, though in this he goes too far, that cancer of the cervix actually favours impregnation. Among 127 cases of this kind, there were 21 in which the disease had existed for a year or more before the occurrence of conception.

Winckel summarizes in the three following propositions his experience regarding the relation between uterine carcinoma and sterility: 1. Married women form the very large majority of those affected with carcinoma of the uterus; 2. The marriage of such women has very rarely proved sterile; 3. On the contrary, the women affected with this disease have generally been exceptionally fertile.

Other tumours of the uterus cause sterility, not merely by giving rise to mechanical interference with the necessary contact of ovum and spermatozoon, but also by leading to catarrhal states and hyperplasia of the mucous membrane, which interfere with the implantation of the ovum, even when fertilization has been effected. Uterine polypi give rise to mechanical obstruction of the os uteri externum or of the cervical canal; but they predispose to sterility in an additional way, inasmuch as in a woman affected with such a new growth any vigorous bodily movement is apt to cause profuse uterine haemorrhage.

In cases of myoma of the uterus, apart from the mechanical hindrances to conception imposed by these tumours, there is also interference with the implantation of the ovum. When numerous myomata have formed in the uterine wall, the mucous membrane is usually smooth and atrophied, and discharges a watery secretion, and for these reasons the imbedding of the ovum in the uterine cavity is rendered extremely difficult. But that there is often an additional cause of sterility in cases of myomata uteri, has been shown by the researches of Schorler, who examined 822 patients affected with fibromyoma of the uterus. He found that in most of those in whom sterility was observed, the tumours were not submucous but subserous, and that the sterility was to be explained in these cases by the frequent occurrence of partial peritonitis, with its evil results to the uterine annexa.

Schorler appends the following table:

Sterile.Percentage.
Of85women with interstitial myoma2124.7
Of92women with subserous myoma4447.8
Of18women with submucous myoma738.8
Of44women with polypous myoma49.0
Of14women with cervical myoma318.7
253 7931.2