The atrophy of the mucous membrane is, however, but the result of a chronic inflammatory condition, and has been preceded by a period of chronic hyperplasia of the mucosa extending back for years. Even in this stage many women remain sterile, although not so frequently as in the second stage. The excessive menstruation which occurs during this stage, the frequent abortions that take place in the early months of pregnancy, are only explainable as due to the excessive hypermmia, and this leads one to suspect that, even in the sterile, abortions at the begin ning of pregnancy are c,aused by the severing of the loosely attached ovum. In addition to this is the condition that, as is the case in all catarrhs, in endometritis a constant shedding of the superficial cells and layers of cells takes place—that is to say, a throwing off of the very elements which in the beginning should surround and embed the impregnated ovum. That the possibility of a longer sojourn of the impregnated ovum in the uterine cavity largely decreases, and the probability of the continuance of the sterility increases with the greater development of the affection, is self evident. For this re,ason, in women who have been for a longer time sterile, and suffering from a chronic catarrh, do we so frequently find after dilatation of the cervix a marked endometrits, which either mani fests itself as a diffuse decidua-like hyperplasia of the mucous membrane, or else by the presence of many polypoid growths or excrescences, an affection to which in its worst form has been applied the name of adenoma of the uterus.
That these affections of the interior of the uterus oan indeed prevent conception, is proven by the results obtainable from treatment of chronic roetritis, and it frequently has happened that women conceive even though they have no desire for children. This has also been witnessed by other observers, and I need only refer to the discussions of the Berlin Obstetri cal Society in this connection.
With this endometritis there is not seldom associated a pathological condition of the walls of the uterus, known as chronic metritis. I am not of the opinion that this affection is as common as is generally repre sented. I do not belong to those who ascribe every disturbance of the genital track, for which they can not find a pathologico-anatomical cause, to chronic metntis, but I do believe that the most important part of a chronic metritis is the seldom absent endometritis. Nevertheless, the obstacle to conception due to the catarrh is considerably increased by the accompanying inflammation of the muscular wall of the uterus. The catarrh and the afflux of blood, because of•the hypenemia which charac terizes the first stage of the disease, are sustained and favored, while on account of the rigidity of the walls which accompany the second stage, the induration through the diffuse development of connective tissue, the dilatability of the uterus is lessened, and the further development of the ovum in the uterine cavity is rendered impossible.
Although now there is no doubt that the chronic catarrh of the uterine cavity, with or without the chronic metritis, in one way or another pro. duces sterility, and even if it is likely that this happens quite often, still, according to my opinion, it is not justifiable to say that sterility, in case of chronic catarrh of the cavity of the uterus, entirely depends on the unfitness of the mucous membrane for the fixation and nourishment of the ovum. Seldom is this catarrh the only thing present. Cervical catarrh is in my opinion very frequently combined with it, and because of the disposition of genital catarrh, not only gonorrlicea, to spread over the whole extent of the canal, salpingitis is not a rare accompaniment. These complications alone are sufficient to prevent the .contact of the semen and ovum, aside from the sequelx of the catarrh in the surround ings of the uterus, which, as we have shown, are of themselves sufficient to cause sterility.
I cannot further grant that chronic metritis, whether it be primary or a result of other genital affections, can cause, to such a marked degree, sterility. Even when we reckon the abortions occurring during the early months as cases of sterility, we can not deny that in a by no. means small percentage of cases, in which, both by an examination and from the train of symptoms, we are justified in making a diagnosis of chronic metritis, occasionally one and sometimes successive births take place at the end of full term. This fact, which is assented to by all unprejudiced observers, should warn against over-estimating this affection as a cause of sterility. We are again thus reminded that in chronic metritis, even as in other affections accompanied by sterility, the cause is not to be sought for in one, but rather in a number of condition& In addition, at least in my opinion, the fact must be borne in mind that sterility is frequent in women who have never conceived, and yet tltat chronic metritis is only exceptionally met with in them. True enough this condition is often diagnosticated nulliparx--I need simply refer to Griinewaldt's work; but whoever has had occasion: to treat such cases of chronic metritis will agree with me that the diagnosis is frequently based on the subjective symptoms of the patient rather than on any proven change in the uterus. These facts, to which many others might be added, are calculated to sus tain the recently advocated view, that unproductiveness in the female depends more on an impotentia gestandi than on an impossibility to con ceive.