Next to the plugging of the tubes by their 'secretions, comes the fill ing of the canal with tubercular material; for in tuberculosis of the geni tals, inasmuch as the process generally begins in the mucous membrane of the oviducts, and then as a rule is bi-lateral, this affection would indeed be able in such cases to render the tube impervious. Considering, however, the comparative rarity with which this disease attacks the geni tals, and the rapidity with which it also invades the uterus and peritone um, we can not lay so much importance on this etiological factor as some are inclined to do.
Neoplasms like fibromyomata, cysts, in the wall of the oviduct are of rare occurrence; moreover they are so small that they project but little into the lumen of the tube; they, therefore, deserve but little attention in regard to etiology.
While the processes above-mentioned take place in the mucous mem brane of the oviduct itself, and thereby narrow or close the lumen, there may also occur a stenosis of the tube by pathological processes acting from without, the tubes being in a more or less normal condition. Here we must mention the ovarian tumors a,lreakly discussed, also the tumors of the broad ligaments as well as neoplasms in the wall of the uterus. These may remove the abdominal end from the ovaries, may narrow the canal considerably by greatly stretching it, may compress it directly, or may render its peristaltic movement impossible. The perimetritic processes and their remnants, already mentioned, besides forming bands and cica trices, may also flex the canal sharply at one or more places, and thus produce strictures in the lumen.
It is very doubtful whether, with perfectly healthy oviducts, ty may be produced by disturbances of innervation. This has formerly been maintained for the production of tubal pregnancy, and has recently been again advocated by Freund. This serious functional disturbance might consist either in a tetanic contraction of the circular muscle fibres, 80 that the ovum can not get through, or in a paralysis preventing the on ward. movement. In this way psychical factors might be believed to in fluence conception. At the present time, when the phenomena of the normal movement of the tube is not yet thoroughly understood, such opinions can only be regarded as hypotheses, which, considering the long time that ovum and sperma need for their migration and meeting in the tube, have not much probability.
Inasmuch as the defects and diseases of the tubes are rarely ascer tainable clinically with any certainty, there are no figures given by prac titioners as to the frequency of these obstacles to conception. Winckel, on the other hand, in his anatomical researches, very frequently found the ovaries adherent to the tubes, but still in such a condition that con ception might be possible, but in other cases he found such considerable adhesions between oviduct; ovary, uterus and rectum that conception would be an absolute impossibility. Moreover the abdominal end of the tube was closed in nine cases. Tuberculosis was also frequently found. Winckel states the frequency of this condition as an almost surprising one; he puts it at 10 cent. of all cases.
Diseases of th,e Uterus.—Of the malformations of the uterus only a fractional part offer any obstacle to conception.
When the uterus is completely absent or entirely rudimentary, not oven a cavity being formed, conception, of course, is out of the question. These malformations may occur not only in monsters unfit for life, but also in individuals well developed in other respects, with a completely womanly shape, and having normal external genitals, with a vagina ter minating in a blind eitl-de-sae. These cases may, therefore, become sub jects for examination in regard to sterility. I have recently had the opportunity of examining a girl twenty years of age, well developed, and of perfectly womanly appearance, in whom, even under chloroform nar cosis, scarcely a trace of internal genitals could be detected. She con sulted me only because on account of her amenorrhcea she laad hesitations about entering married life. Nothing definite could be detected in regard to sexual tendencies. Even if the ovaries were normal, however, which is not the case, there could of course be no treatment. Of the remaining congenital abnormalities, uterus unicornis, uterus bicornis, uterus bilocu laris, none offer an obstruction to conception, for the paths for sperma and ovule are normal, in spite of the unusual shape of the c,anals. It is only the partition.walls that, if they extend down into the vagina, may prevent cohabitation, and therefore conception; these will be discussed further on. There is still another way in which the double formations render conception difficult. It is known that the genital tract from the fundus down to the hymeneal ring may, by the persistence of the septum, be divided into two more or less symmetrical canals, each of which alone may suffice for the function of generation. It is a difficult matter when only one of these canals remains open, while the other at some one place is closed. If now the discharge of menstrual blood regularly ensues, then after puberty there will .soon be such a collection of blood in the closed cavity, that medical assistance will be sought before the question of ste rility comes into consideration. NVhen, however, the menstrual discharge is very scanty, when it appears only at longer intervals, or when it is altogether omitted, and is replaced only by a more copious production of mucus, the tumor may grow so slowly and without many symptoms, that sterility in marriage only calls attention to this malformation. If then the closure is located at the level of the os uteri externum, then the blood tumor formed by the closed half of the cervix may press the canal so far to one side that the obstruction is similar to that which we shall learn about with tumors situated in the wall of the cervix. But if the atresia is sittutted lower down, the tumor may at the same time also close the oe uteri of the open side from below, and if situated still lower down, it may even obstruct cohabitation.