These views can only be accepted as an expression of the strong reac tion against the theories of Sims regarding the frequency and importance of the causes producing sterility. It is also true, however; that Griine• waldt, in his endeavor to do away entirely with mechanical hindrances to conception, has gone to the opposite extreme. No one has perhaps better judged the importance of chronic metritis on conception as another de• terrnined opponent of Sims, Scanzoni. In his work Oil chronic me tritis he expresses himself very carefully in regard to the influence of dis ease of the parenchyma, and considers the absence of conception as due to purely mechanical conditions existing in the neighboring canals and organs. On the other hand, Beigel, the enthusiastic interpreter of Sims's views, has taken the opposite view, and through his anatomical studies of the numerous obstacles to conception, as they exist outside the uterus, he has deprived both theories of their extreme one-sidedness.
Closely related to endometritis as a cause of sterility. there is a further factor, the so-called membranous dysmenorrlicea. The incapacity of the uterine cavity to receive and further develop the ovum is here very evi dent. Sterility has here been explained on the assumption that the im pregnated ovum, which has attached itself to the mucous membrane of the uterus, is cast off with the shedding of the mucous membrane of the uterus at the next menstrual epoch. (Beigel.) Yet, in this explanation the author is oblivious of the fact that, after impregnation has once taken. place, menstruation ceases. It is possible, however, that the hyperemia resulting from conception being superadded to the tendency of the uterus to exfoliation of the mucous membrane leads to an abortion, and that this inay be mistaken for a timely or a somewhat retarded menstruation. It seems more probable to me (at least in those cases where a shedding of the mucous membrane occurs with every menstruabion) that the mucous membrane is thus constantly rendered unfit for the reception of the ovum. Endometritis exfoliativa is decidedly an obstacle to conception. As preg nancy is but seldom noticed, probably this is only possible when the mem brane is shed only at longer intervals, and impregnation occurs in the early part of the interval.
Even more than an incomplete involution of the puerperal uterus, which is a frequent cause of chronic metritis, can a hyper-involution of this organ affect the generative process. This condition, called puer peral atrophy, occurs more often than is generally supposed. I have re cently seen a large number of cases of this kind, not considering those cases that approach the normal. Among the almost never absent symp toms may be reckoned sterility. Whether the condition of the lining membrane of the uterus is the cause of this is hard to say at the present time, as we do not thoroughly know what the exact condition of the en dometrium is in this affection. According to my experience a cure can
be effected by treatment, and conception can again occur. This was the case with a patient who, after the birth of twins, developed a decided atrophy of the uterus with pronounced objective and subjective symptoms, and who again became pregnant one and a half years after the last con finement. Aside from improvement in the condition of the uterus, con ception depends on the state of the ovaries. If these remain normal, conception may occur, but if the ovaries are likewise atrophied, or per haps affected because of an exudation around them, resulting from the puerperal state, then the sterility will probably be permanent. Thus very recently I had occasion to carefully examine, under chloroform, a woman forty years of age, for an affection of the external genitals, in whom, after two abortions some eight years previously, menstruation had entirely ceased and pregnancy had not aguin occurred. The uterus was considerably atrophied, about two inches long, retroverted and bound down posterivrly. The ovaries, although readily felt, were not larger than ordinary beans. In this case it seems to me that the ovaries were primarily atrophied, and that this prevented the only moderately atrophied uterus from regaining _ its normal size.
Of the tumors of the 'uterine body, (those of the cervix have already been noticed,) the fibromyomata are about the only ones we need consider. It is uniformly granted that they prevent conception. In the majority of women where these tumors exist, conmption does not take place; in others fruitfulness is diminished to such an extent that more than one delivery is exceptional Numerous statistics bear this conclusion out.
I specially mention only those of Beigel, M. Sims, McClintock, Michel, 116krig, Scanzoni, Schr6der and Leopold Meyer. Their statistics differ as regards the frequency of sterility from 15 to 60 per cent. Winckel and Gusserow, who have collated a large number of cases (including the reports from some of the above authors), have reached about the same results. The first finds that almost 24 per cent., the latter about 27 per cent., are abso lutely sterile, making about one-fourth of all women afflicted with fibro myoma unable t,o conceive. From the c,ompilation of Winckel, it becomes evident what a large percentage of acquired cases of sterility are to be at tributed to .fibromyomas. He determined that women with fibromyoma average 2.7 children, whereas, according to his experience, healthy women average 4.5. Since these figures agree with those which we have arrived at concerning the fruitfulness of marriages in general, it is apparent what an unfavorable influence fibromyoma have on the process of reproduction.