Dieplazements of the important for reproduction are the versions of the uterus, which I, in contradistinction to B. S. Schultze, sharply differentiate from the flexions; since iu the former, although there is marked change in position, there is yet no change in the lumen of the uterus, in the latter in addition to change of form, there is the above-mentioned atenosis of the genital tract. That both anomalies, so distinctly marked in their pure form, may shade off into one another, and even into the normal uterus, has already been referred to and em phasized. The obstacle caused by version to conception, consists in ren dering the entrance of the semen into the os externem difficult. The vaginal portion is displaced from its normal position either forward, back ward, or laterally, so that the ejaculated semen is not directed toward the external os. Where tbe uterus is firm and there is maxked displacement, the os becomes pressed against the wall of the vagina, so that if this canal is also rigid the os is practically closed. These conditions are certainly of importance in instances where cohabitation is incomplete, e.g., as where the semen is of insufficient quantity and quality. In proportion as the semen is thrown near the os uteri, so ceteris paribus conception may be expected. M. Sims has further pointed out the fact that the semen more readily flows out where there exists a version, although this is less like:y to occur when closure of the vagina is perfect. Sterility seems t,o me to be more dependent on the complications in versions than is the ease with flexions. The versions are more frequently developed after child birth than are the flexions. The pathological changes, which follow in consequence of the puerperal state in the uterus and its surroundings, are capable of prod.ucing displacements, but are also of themselves sufficient to serve as obstructions to conception. It is of uo little importance t,o point out the fact that, perhaps through a displacement of the uterus, dis location of the other internal organs of generation may be brought about, and the tubes and ovaries be so far separated from each other as to render conception unlikely. The greater ease with which untoward conditions to conception are overcome in women who have already borne children, and for reasons which we have studied under flexions, is also apparent in case of versions. With the congenital form of retroversion, which is comparatively ntre, sterility is frequently found, as may be seen from the writings of P. Grenser, while in acquired retroversion, a very common form of displacement in women who have borne children, pregnancies follow one another at about the usual intervals.
In case of latero positions, even more than in versions, pant- and peri metritis and their remnants, which cause them, are of great importance. As regards these changes in the position of the uterus, my experience points to the retro-positions as the most frequent, especially in women who have borne children. As exciting cause we may cite not only Schultze's posterior parametritis, but more frequently the peritonitis involving Douglas's pouch. The uterus appears to be in good position, but is still fixed to the posterior pelvic wall. Even here there are gradations up to a well-marked flexion. Occasionally such women will come to be treated for sterility, but they consult the physician on account of other symptoms. I have found, and I wish to emphasize this, that frequently a number of years have passed since the last confinement, and this strongly points to the fact that the displacement tends to favor sterility.
Prolapsus uteri less frequently produces sterility than we should ex pect, considering the amount of displacement and the accompanying affections. The obstacle to conception is absolute only when there is present a complete and irreducible prolapse, the protruding portions being suspended between the thighs like a bag. In case of an incomplete but irreducible prolapse, if we accept as true certain reported cases, then the direct introduction of the penis into the os uteri has been followed by conception. As a rule, when the prolapse is but slightly marked, the uterus retreats when the woman assumes the dorsal decubitus, or it can then be easily reduced, so that cohabitation takes place under nearly the normal circumstances. On account of the changes which the uterus un dergoes owing to prolapse, and also on account of the at times well-marked metritis and uterine catarrh, conception can be rendered difficult, espe• evilly since with prolapse the vaginal portion is apt to become ulcerated, the cervix hypertrophied and furthermore the internal organs are all dis located. Still these conditions would seem all to be nullified by the in creased size of the os uteri and cervical canal, for it is a fact, that preg nancy takes place more frequently than would be expected. That a sim ple descent of the uterus should ba a greater obstacle to conception than *true prolapse, as Beigel asserted, basing his statements on theoretical considerations, cannot be true, and a great many womon who present themselves with a prolapse for examination, date the beginning of their trouble to a period prior to a number of deliveries. Even if the begin ning is simply a prolapse of the vaginal walls, the uterus must have de scended lower, or in other words descent must have existed. Yet con ception follows. It looks as though the descent towards the introitus of the os externum favors conception.
Hernia of the uterus, where either this organ alone or others with it, are found in a sac, occurs so infrequently that the material at command is insufficient to wart-ant a just conclusion regarding its relation to concep tion, but it should be noted that in nearly one half of ths recorded cases pregnancy ensued, notwithstanding the marked dislocation of the uterus. Pyrhaps this is to be explained on the assumption that the vaginal walls form a funnel-shaped cavity, directed towards the dislocated uterus, and that thus the semen is directed towards the external os. I can thus, at least, account for Scanzoni's case, and for the one which I noted where pregnancy complicated an inguinal hernia of the uterus, Even as with flexion, so it is the case with the older reports concern ing version, that for determining their relative frequency as obstacles to conception they are unreliable. This is specially true of anteversion. Leopold Meyer has found among his 227 cases only 3 primary and 7 secondary anteversions, to which must be added a number of instances where there were other complications. In addition he found 11 eases of acquired retroversion, including complicated cases. I cannot compare these figures with my results, as many cases of anteversion are with diffi culty differentiated from cases of chronic metritis, and it is further diffi cult to separate retroversions from retroflexions.