A similar influence 'is exerted by tumors that start from the uterus, but descend into the cervical cavity. Fibromyomata of the cervical wall occur rarely; they also may obstruct conception by greatly distending the walls of the cervix, and thus closely approximating them, so that the sperms cannot easily move forward through the very narrow slit thus produced. It is probably a rare occurrence that several tumors compress the canal at the same time from different directions, but it happens some what more frequently that the canal is pushed aside by the tumors within the walls or outside of the uterus, and that thereby a similar result is pro duced.
Among the important obstacles to conception, carcinoma of the cervix is also mentioned, and I believe justly so. When the neoplasm has ad vanced to any degree, even if confined only to one wall, the cervical canal is mechanically stopped up, and if ulceration has once begun, the corro sive fluid will exert a deleterious influence upon the sperma. The relative frequency of carcinoma uteri among rather young women on the one hand, and the very rare occurrence of pregnancy with this disease on the other, speak decidedly in favor of this view. Now since the first stage of this disease remains almost latent, or only manifests itself in the first months by profuse menstruation, therefore not by any characteristic sign, and since, furthermore, there has not yet taken place a tedium cohabitationis on the part of the husband, pregnancy ought to occur much more fre quently, if carcinoma could not even in its beginnings prevent concep tion. In the cases where advanced carcinoma is found during labor, we must, considering the relatively short duration of carcinoma uteri, take it for granted that conception took place when the new growth had not yet ulcerated, Ind that the strong congestion determined its earlier decay.
In the few cases that I have seen, the new growth bad advanced so little, that it could certainly only have developed itself after the beginning of pregnancy. Cohnstein's collection of 127 cases of labor complicated by carcinoma, among which he found not less than twenty-one in whom the new growth was said to have existed for a prolonged period of time (even as much as a year), seems to contradict this opinion. But as the duration of the carcinoma is relatively short, it can only be that at the occurrence of conc,eption the new growths had advanced but little, and bad not yet ulcerated. The question of the influence of carcinoma upon conception is a purely theoretical one, and, with the serious course and short duration of the affection, lacks all practic,al significance.
The frequency of new growths that lead to sterility is not great; it seems that the polypoid excrescences form the majority of them, as in deed they arise from one of the most frequent diseases of the uterus, viz., catarrh.
Flerinw of the Uterus.—Conception may be rendered difficult by a flexion of the uterus. This pathological condition iu the majority of cases, implicates the narrowest portion of the uterine body, viz., where normally the inner walls are in simple approximation, they become firmly compressed, thus producing a stenosis of the uterine canal. The production of this stenosis is readily demonstrated in a uterus removed from the body. If a vertical section through the centre of the organ be made, it will be seen that the os internum is the narrowest portion of the uterine cavity. This is specially well seen in the virgin uterus, where it
is covered by a thin mucous membrane, the opposing surfaces of which lie in apposition. If the fundus and cervix be now grasped between the fingers, and the uterus doubled upon itself, the os internum will be caused to disappear. This obliteration of a portion of the uterine canal by flexion, explains the difficulty in making an injection in this condition, which fact I had specially pointed out at the time of X Sims's publica tion on Uterine Surgery. If a horizontal section of the uterus be made, so as to expose the cavity, fluid can, under a slight pressure, be c.aused to pass readily through the os internum, which is not the case on producing an artificial flexion; here strong pressure is requisite to force fluid from the cervix into the uterine cavity, or vice versa. Although the results of these experiments were such as were to be expected, yet they hardly apply to the passage of the semen. Still, they serve to demonstrate what obstacles such an easily penetrating substance meets with under such abnormal conditions.
It is a well-recognized fact that sterility is a common accompaniment of the various forms of flexions. Indeed, various authorities have even given figures, and claimed that a rather high percentage of sterile women have an existing flexion. Yet these figures are not reliable, since their authors have not sufficiently well discriminated between flexions and ver sions of the uterus. They have likewise, on the one hand, paid too little attention to the existing complications, and, on the other hand, they have tabulated the results of their researches before it was positively known. what the normal position of the uterus is. This latter fact especially, in. addition to the conclusions recently arrived at, that many of the so-called causes of sterility are not really such, but that the true cause lies much deeper, have done much to upset the once so strongly accepted belief that flexions were frequently the cause of sterility. As an etiological factor in the production of sterility, no abnormal condition of the uterus has sustained such a reverse in the opinion of the profession as the flexions of this organ. When Marion Sims, in his day, demonstrated in such a clear and. perhaps too simple a manner, the mechanical obstruction to conception, which, according to him, existed more frequently in the cer vix, he met with the approval of not only the majority of gynecologists, but also with that of his numerous followers in this peculiar line of mechanical treatment. It is not to be denied, that flexion as a cause of sterility has been very much over-estimated, and that the application of the recommended mechanical treatment has been followed to an unjus tified degree. Soon a falling off from the extreme position occurred, and the belief gained ground that flexion was not a cause of sterility. This revolution was incited by Scanzoni's criticism of Sims's theory of sterility, and was largely supported by B. Schultze's teaching of the normal posi tion and form of the uterus. It has BO far advanced that many attach no importance to flexion as a cause of sterility, but rather ascribe the source of unproductiveness to conditions existing outside of the uterus, as a para metritis, perimetritis, *Morals, etc.