Although in many such cases other affections exist which are the con sequences of the vaginal catarrh, and which might as well be considered causes of sterility, still a strongly acid vaginal mucus can of itself de termine the condition. There are cases, however, where, notwithstanding profuse leucorrhcea, the reproductive functions are undisturbed. There must then exist conditions which can prevent the untoward effects of an acid vaginal secretion. Often these conditions are suspected, but can not be proven to exist, yet we meet in our experience with cases which ex plain these exceptions. Thus in the first place it may be important to consider the quantity of semen. If, as Mantegazza asserts, 45 minims of semen are ejaculated by a healthy man, then it will take a long time for the vaginal mucus to penetrate through this thick and tenacious mass. In all probability tinder favorable circumstances, where the semen is de posit,ed in the neighborhood of the os externum, a sufficient number of spermatozoa may enter the cervical caws! before they are affected by the vaginal mucus.Biker has pointed out the alkaline reaction of the semen, and affirmed that its chemical constitution is such as to neutralize the acidity of the vaginal mucous membrane. Perhaps the alkaline cer vical mucus, which is also poured into the vagina and in genital catarrh is secreted quite abundantly, exerts a like influence, although on account of its tenacity it mixes but little with the vaginal secretion. If the amount of semen is small and deposited low down in the vagina, when a profuse lencorrhom exists, then the chances of impregnation taking place are small, while under the opposite conditions a moderate secretion could not affect the semen Whether gonorrhceal secretion acts more injuriously than so-called laudable secretion, I can not express any opinion from the lack of experience. That the primary cause of the leueorrhcea should not be neglected in the etiology of sterility has already been emphasized. Lastly, it is proper to query if the vaginal secretion may not act in a mechanical way, in that a large production of mucus and pus may wash away the semen.
Malformations and Affections of the External Genitals.—For the com pletion of the act of generation it .is essential that the male organ shall penetrate through the external organs of the female into the vagina. If the latter offers an insurmountable obstacle to the penis, then we speak of an impotentia coeundi muliebris, female incapacity to copulate. This condition is not always accompanied by sterility, as conception is possible, though it rarely takes place. Sterility and impotence are therefore not synonym& The causes of obstruction which produce sterility can depend on a series of malformations of the vulva. The congenital narrowness of the vulva, which !does not allow of an immissio penis, can be produced through various malformations of the external organs. In all forms of true hermaphroditism (in which the male and female are represented by the presence of testicles and ovaries) the external genitals, though small and misshapen, can yet resemble more those of the female. We are con cerned here more, however, with the pseudo-hermaphrodite, in whom portions of the internal genitals may in a less or great,er degree belong to both sexes, but where there is but one kind of sexual glands, and conse quently only ono sex, in which case the external genitals are more apt to resemble the female. Since the sex of the child is determined by the appearance of the external genitals, it may happen that the sex is mis taken, and therefore that two males are married. These cases, of impor tance medico-legally, do not interest us here. We are considering only those cases where the individual who enters into marriage, as wife, Inis abnormalities of the external genitals that prevent an immissio penis.
These abnormalities consist essentially in the fact that the clitoris has de veloped to such a degree as to resemble a penis, while the labia majors have united posteriorly, so that the vagina is narrowed to a mere slit which does not admit the penis. Here the sterility does not depend alone upon an impotentia coeundi, but also on the condition of the internal genitals. If hermaphroditism exists, then conception is only possible when, not only the ovaries are present, but also the necessary canals for the conveyance of the semen and ovum, as vagina, tubes, and, in addition, a normal uterus for its further development. These malformations of the external genitals may exist while the internal are purely womanly, without any rudimentary trace of a male organ, and then we cannot spe,ak properly of hermaphroditism, for the only prevention to conception taking place lies in the imperfect condition of the vulva. In this class belong those cases where the vulva is stenosed, through union of the labia majora, and there exists sterility because of the itnpotentia coeundt. This occlu sion can extend so far forward as to leave but a small orifice for the va gina and urethra. This condition, which is called atresia vulvte, often simply consists in an epithelial union of the labia majom, us Ziemssen has reported; again the union is a firmer one, and includes the labia minora. These congenital atresim resemble in their effects those of the acquired atresia and stenoses. As a result of diseases of childhood, all the parts forming the external genitals may become so united that the vulva is represented only by a membrane, which is perforated by a smaller or larger canal which leads to the vagina and urethra. I have recently seen an interesting case in which the canal was narrow, formed of dense bands of cicatricial tissue, accompanied by small rudimentary labia. Although an immissio penis could not take place conception yet followed. This latter result is the exception, sterility being the rule.
Abnormally small and imperfectly developed external genitals are also considered as causes of sterility. They may render an immissio penis im possible for a considerable time; still conception may ensue, as I have re peatedly noticed in cretins. The perfect development of the internal genital organs must be here granted. According to Roubaud and Tilt, absence or imperfect development of the clitoris may be the cause of sterility, since this is accompanied by frigidity of the female. I myself have seen but two cases of poorly developed clitoris with absence of or gans, and in both cases delivery had occurred. Nevertheless, there are cases where abnormal development of the external genitals is combined with sterility, but here the formation of the vulva is only a sign of the Imperfectly developed sexual organs generally, as is manifested by nar rowness of the vagina, smallness of the uterus, absence of or scanty men struation. These individuals are sometimes small and puny, sometimes strong and well-developed. Of the latter class I once had the opportunity of examining two sisters who consulted me because of their sterility. The vaginx were in both widely dilated, as a result of sexual indulgence for many years, but the uteri were small; in both menstruation was regular but scanty, one had but little sexual appetite. I unfortunately failed to examine the breast. The acquired diseases of the external genitals in later life may induce sterility, in so far as swelling and rigidity of indi vidual parts may render immissio penis an impossibility. Aside from the rare tumors which may develop at any point of the external genitals, cysts and bernite may form in the labia majors, and elephantiasis, and espe cially excessive deposition of adipose tissue, may obstruct the way to the vagina.