The abnormal communications of the vagina with the neighborin,g or gans (vesico-vaginal fistulce, vaginal fistulEe communicating with the ure thra and rectum) can become very considerable obstacles to conception. The fact that with vesical fistula3 conception is exceedingly rare, is borne out by the statistics of Kroner. He found from his material that only in 10 per cent did pregnancy ensue; consequently, sterility is not an in frequent result. The situation and size of the fistula seem to be entirely without influence in the production or prevention of impregnation. As regards the cause of sterility, it is essential to point out the fact that menstruation is frequently absent, often reappearing first some time after confinement, and then seldom recurring at regular intervals, and being accompanied by dysmenorrlicea. The connection is often evident. As the result of the delivery which caused the fistula, such changes occurred in the internal organs, that through these menstruation and conception are prevented, 118, for instance, exudations around the ovaries, atrophy of the uterus, stenosis or complete occlusion of the cervix, etc. In other cases, however, and this I would emphasize, examination does not reveal any of these pathological processes, and yet menstruation ceases and pregnancy does not occur. So that it is necessary to claim the fistula as the cause, especially since after repair of the fistula menstruation returns. It seems, therefore, as though the fistula itself were capable of preventing men struation and consequently ovulation. In those cases in which it must be admitted that ovulation continues, the urine must be considered as capable of preventing conception. Since it is an acid fluid, it robst he spermatozoa of their independent power of motion, or else directly kills them. Still there are cases where the semen had to pass through the receptacle of the urine in order to reach the uterus, and conception has taken place. I simply recall the cases of Simon, Fehling, Winckel, where conception took place, although on account of intractable fistula, trans verse obliteration of the vagina had been attempted and had only partially succeeded. Perhaps these cases are explainable on the assumption that the urine in the pouch had become slightly alkaline and had thus lost its dele terious effects on the semen. Possibly the urine in cases of fistula acts more as a mechanical than a chemical obstruction, in that it washes the semen away. The bladder is compressed during coition by the male organ, so that the urine in it is forced out into the vagina, and when the penis is removed the escaping urine washes away the semen, and it is aided in this, since the vagina is often rigid and the introitus wide open.
In what way recto-vaginal fistulEe affect the reproductive process is not determinable. The cases are seen too infrequently by the single ob server to enable him to draw any conclusion. Perhaps the fEeees exert an influence. But since in case of fistulEe there exists a tiedium coeundi, this fact will preferably explain the sterility.
In not a small number of women, who have already given birth to children, the absence of pregnancy is accounted for by the reflux of semen after coitus. It is proper in this connection to consider if there is in reality any truth in this almost universal opinion. As is well known, the older vrriters (Hippocrates and Soranus) sought the cause of sterility in this loss of semen. Even M. Sims, although he gives a different mechani
cal explanation, lays great stress on it.
There e,an be no doubt that the supposed reflux of semen is frequently based on a delusion, inasmuch as we have seen above that the secretion of the little follicles and especially the Bartholin glands during the act of copulation is excited, and that this moistens the external genitals, and is mistaken for regurgitated semen. Connection, indeed, can hardly occur vrithout the male organ, on its withdrawal, smearing the external genitahi with semen, while the bulk of it remains in the vagina. Still, on the other hand, it is not impossible that on rapid withdrawal of the penis the greater part of the rather tenacious semen may adhere to and follow it. Ordinarily, owing to the position of the woman, and the di rection of the vagina upwards and downwards, the semen is retained. It is otherwise when the external genitals have been dilated by many de liveries, for then the introitus vaginEe is directed forward. If the peri neum has been lacerated, however, then 011 this account, but more es pecially through the consecutive cicatrization of the vagina, the direction of the e,anal is more vertical, and the ostium vaginEe opens downwards. Then because of the insufficient closure and abnormal direction of the track, the reflux of semen is possible. The contraction of the pelvic muscles (levator ani) in this state of affairs will greatly favor reflux, for whereas in normal conditions it would send semen forward, it now assists in ejecting it towards the external genitals. In a woman of extremely lax external genitals, who had repeatedly given birth to children, and who always insisted on refluie of the semen, I cautioned her to catch the semen after coitus, and I found it to be in reality semen and in consider able quantity. In a woman under the same conditions, and with by no means a deep laceration of the perineum, I determined to pare the edges and to increase the length of the perineal body anteriorly. In her case conception soon followed. Although these two cases do not possess much weight, they still tend to support this supposed cause of sterility.
The influence of the vaginal mucus in causing sterility is but little understood. We know, as the result of a long series of experiments, that the spermatozoa of man and animals lose their power of motion, and in deed their vitality, when placed in contact with a variety of chemical sub stances. The acids act first as exciters and promoters of movements, and then as paralyzers. In cases of vesical fistulEe we have already noticed the detrimental action of the acid urine. On the other hand, it is known that the vaginal secretion is slightly acid, yet not sufficient to affect the semen. Still, under certain pathological conditions, the secretion may become so acid in reaction, that it acts aa any other acid and induces sterility. It is an undenied fact that women who suffer from a severe vaginal catarrh not infrequently remain sterile. It is furthermore proven that under such circumstances, after cohabitation, spermatozoa are found rigid and dead.
A case of this kind which illustrates this cause of sterility luu3 been reported by Lang. In a patient for fourteen years sterile, the semen was found to contain dead spermatozoa four hours after copulation, but directly after the act they were found still alive. After treating the vaginal catarrh, conception occurred within three months.