Without in the least adopting the rather one-sided opinion of Sims, I cannot agree with those who hold that flexions are in no way connected with sterility. The arguments which have been brought forward against the mechanical theory, as far as flexions are concerned, I consider neither unanswerable nor convincing. Thus it is claimed that the semen traverses a tube the calibre of which is smaller than that of a stenosed os internum, since it passes through the Fallopian tube at every conception, although the calibre of this tube in its passage through the uterine wall is very small. This comparison between a stenosed os internam due to a flexion, with the nterine portion of the Fallopian tube, in my opinion is entirely inadmissible. The tubes have in reality no true lumen, being in this respect like the os internam under normal conditions—the walls lie in contact, yet this contact is a gentle approximation only, there being no pressure brought to bear to produce a strong compression of the opposing wails. It is not so with the stenosis produced by the flexions; here, because of the extreme degree of flexion, together with the greater firmness of the uterine walls, these walls are strongly compressed at the point that is normally of the smallest calibre, and as this compression extends for some distance up and down beyond the isthmus, it becomes, even for microscopic org,anisms difficult, if not impossible, to pass into the uterus, whereas when no such obstacle exists, they very readily enter the uterine cavity. Still less acceptable is the objection that where the menstrual blood can pass out, there the semen can enter. This statement is not correct to begin with, even overlooking the fact that various portions of the body are so constructed as to allow fluid to pass in one direction, but this same fluid. cannot pass in the opposite. The propelling forces which drive the fluid through a constricted canal, must also be taken into con sideration. The blood, which through the action of the heart, is poured into the uterine cavity, distends its walls, and this distension, together with tbe existing flexion, produce uterine contractions, a by no means small force. Thus the resistance offered by the stenosed os to the exit of the menstrual blood can be overcome.. When the blood has once passed. the constricted portion, its own gravity will suffic3 to carry it on through the cervical canal. The semen is not thus favorably endowed with forces; it must, against gravity, pass over this extended barrier by its own inhe rent power, having no vis-a-tergo to favor its propagation. That the semen is thus in every way handicapped in comparison to the menstrual blood, is quite evident.
It is likewise inadmissible, that when a sound can be inserted by the flexed portion, the semen should also be able to pass through. Disre garding the force which we employ in manipulating the sound, in com parison with the forward propelling force, with which the spermatozoa are endowed, it is necessary to keep in mind the fact, that it quite often happens that we fail to istroduce a sound through a constricted os, or only accomplish it after many attempts and by the aid of external man ipulation, factors which do not hold either at the time or after cohabita tion.
The frequency with which sterility occurs, in simple uncomplicated stenosis of the os internum as a result of flexion, is a strong argument in favor of its being the cause of such sterility. It seems to me the assertion
is hardly tenable which considers that many of the cases of sterility said to be due to anteflexion were purely instances of normal flexion. If we study more closely what B. Schultze, to whom we are indebted for this new view, has described and pictured as the normal position, and a cor rect form of the uterus, then we are compelled to admit that this is an anteversion or possibly an antecumture, in no sense, however, an ante flexion to the amount of 90°. I doubt very much if what Schultze calls a normally placed uterus, has been so frequently mistaken by expert ex aminers as a pathological anteflexion. For, although I have latterly removed from the list of anteflexions all those cases that Schultze would not admit, yet the number of anteflexions forming an acute angle among my cases was not diminished. There yet remains a by no means small number of cases, that have to be placed under the category of acute angled flexions.
I further believe that the error is often made of making the accom panying complications of flexions the cause of sterility, rather than the flexions themselves. It is indeed true that pathological conditions in the pelvic cavity are often accompanied by flexion of the uterus. It is also correct to seek in these conditions the c,ause of unproductiveness, even as we do when they are unaccompanied by a flexion. Not rarely upon a closer examination, specially when made under chloroform, which I use quite often in cases of sterility, there are found freely movable, un changed ovaries, replaceable uterine body, and absence of exudation and thickened bands. In fact in those cases in which the anteflexion is most marked, the angle found being less than 90°, but where the anterior por tion of the vaginal portion of the cervix is retroverted, the flexed portion of the body of the uterus resting on the anterior portion of the cervix, a condition frequently met with in virgins, there may be no evidence of a complicating inflammatory process in the vicinity. The instances in which no discoverable change exists in the pelvic cavity, as a cause of tho sterility, and those where there is stenosis the result of flexion, through which a sound can not or only with difficulty be passed, cannot with jus tice be classed together.
Even, however, those cases in which complications are present do not rob the flexions of all importance, a,s where, for instance, there exist catarrhal inflammations of the cervical and uterine mucous membrane.
Even in the cases of anteflexion, which we rightly consider congenital, and in which there is otherwise no abnormality in the pelvic cavity, an aggravated form of catarrh of the mucous membrane is developed. This endometritis is not entirely harmless for production, indeed it alone may act as a very serious check to conception. At present we are compelled to trace back the source of trouble to the flexion. If the unfruitfulness is not directly dependent on the flexion, it is still on the altered condition brought about by this flexion, or, as is most likely, it is due to the combi nation of both anomalies, the primary as well as the secondary. The im portance of flexion, as an originating cause of sterility, as also the impor tance of the consequent therapeutic measures, are not to be denied.