It must be especially mentioned that the same effect is seen whether the affection takes an acute or a chronic course, and that intensity of the process has no effect upon the production of sterility. Thus a septic peritonitis that runs its course with the production of copious exudation may in a short time be followed by conception, while a chronic circum scribed pelvic peritonitis that almost remains latent forever puts an end to fertility. The transferring of the ovule from the Graafian follicle to the tube may be prevented in various ways. There often remain large exudations after a pelvic peritonitis for a long time; this has been more striking to me after gonorrhceal infection than after puerperal inflamma tions. Here the space between tube and ovary is filled up, or the exuda tions encircle the ovaries, especially when the inflammation has started from the latter, forming a thick layer that prevents the exit of any ovum. Often the effect of this perioophoritis is a great thickening of the surface of the ovaries, forming a covering that is stronger than the intra follicular pressure of the Graafian follicles is able to rupture. If the in flammation starts from the tube, the exudation may stop up its fimbriated end; more frequently the exudation forms masses of connective tissue which close the tube; but generally it is not the exudations themselves that cause sterility, but the remains of them, the cicatrices and calluses, the false membranes and bands. The changes which these are able to produce in the region of the true pelvis can be very well studied in operations for the removal of the appendages.
These inflammations also cause dislocations of the ovaries and tubes like those already described. Thus sometimes the ovary is found in the space of Douglas fastened down. Sometimes it is fixed to the corres ponding synchondrosis, so high that it can scarcely be reached through the vagina. In a similar way the fimbriated end of the tube may be dis placed and fixed in its abnormal position. More rarely other organs, bowels or omentum, are interposed between ovaries and tubes and fixed in that position. Not infrequently these adhesions work unfavorably in an indirect manner, for instance by fixing a retroverted uterus in its abnormal position and thus secondarily disturbing the important anatomi cal relations between ovary and tube.
We know much less about the influence of parametritic processes upon reproduction. There is, however, no doubt that the formation of exu dations and cicatrices is able to bring about dislocation of the pelvic organs, especially compression, displacement, and thereby flexion of the tubes. Thus it may probably be accepted that in this indirect way they may unfavorably influence the process of generation. But perhaps in such a case the unfavorable influence may also be explained by the peri metritic changes present at the same time, for these two kinds of inflam mations often occur in combination.
It is necessary to state that frequently affections of the vagina and uterus occur in combination with 'Rua- and perimetritic processes. Thus it may happen that a simple affection of the former is followed by sterility, or that in spite of removal of obstacles that offered themselves to the sperma, for instance in the cervix, yet no conception ensued. Thus these inflammatory processes in the environment of the uterus, form one of the most important and most frequent causes which in many different ways bring about sterility in the same individual.
Almost everybody who has diligently studied the question of sterility, is of the opinion that the inflammations of the pelvic peritoneum and of the parametria, or rather their consequences (exudations, formations of ba.nds and adhesions), are to be regarded among the most frequent causes of female sterility. Thus in 200 cases of sterility reported by Kisch, 110 were due to pelvi-perimetritic, peri-oaphoritic, or parametrial exudations. 8. Kammerer observed 408 cases of sterility clinically, and found in 94 of them that they were due to peri- and paratnetritis. Kehrer was able to find peritonitic adhesions in :33.1 per cent. of his cases of sterility. The anatomical rese,arches of F. Winckel and Beigel also offer much material that shows the importance of the inflammatory processes in the pelvis as obstructions to reproduction.
Diseases of the Tubes.—We have seen in the preceding section to what dangers the ovum is exposed in its course from the ovaries through the peritoneal cavity to the tubes. In the latter it may meet new obstacles, which partly also obstruct the sperma in its movement in the opposite direct ion.
Here also defects in the original condition may offer an insuperable obstruction to conception. Total absence of the tubes, or non-patency of the upper section of Mfiller's ducts, which should change into the tubes, if it exists on both sides, absolutely prevents impregnation. Generally in these eases, the uterus is also in a rudimentary condition, and this assists the production of sterility. If the defect exists only on one side, concep tion is possible, as those cases of pregnancy with a uterus unicornis prove. Similar to these defects is congenital atresia of the tube, where the abdominal end of this organ is closed. This closure is also found among animals as a cause of sterility. It is very uncertain whether supernume rary openings in the tubes, also a failure in development, may be regarded as a cause of sterility. It is said that the ovum after having entered the tube through the fimbriated extremity, again may find its exit through a supernumerary ostium, and that in this way sterility is produced. The possibility of such an occurrence can not be denied, but it is by no means proved. We have already spoken of congenital abnormal length of the tubes. by which their fimbriated extremities are removed too far from the ovaries.