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Med., vol. III, p. 7). These cases, which embraced the numerons descents, deviations, and diseases to which the uterus and its appeadages are liable, were treated with more or less success, according to the usual methods; the proportion of success, so far as the removal of the sterility was concerned, being about ove-third of the cases treated. One case in particular, however, deserves to be mentioned (No. twelve); that of a woman whose inner uterine orifice was dilated at one session just after menstruation, and who conceived, after a barrenness of four years, immediately after; whether propter hoc, can not perhaps be exactly determined. The physiological causes of sterility are not alluded to in Dr. K.'s paper, unless indeed the dilatations of the uterine orifices were intended to allow of an easier admission of the spermatozoa to the cavity of the uterus; and the intra-uterine injections employed to remove the noxiousness of the secretions.
In the papet which I read before the Academy, I showed:
1. That the generative apparatus of both sexes must be in a healthy condition. In the male, the penis must be capable of erection and ejaculation, and of emitting healthy semen.
In the female, the uterus and its appendages must exist, and be perfect; the ovaries contain fecundible ova; the tubes be pervious, the lining membrane of the cavity and neck healthy, and the os uteri externum and internum, hymen and vagina pervious.
2. That it was by no means necessary that there should exist, at the moment of coitus, any orgasm on the part of the female, or a complete introition of the male organ intra vaginum; a very slight peri-vulvular congressus depositing the semen upon the vulva, sufficing for impregnation.
3. The ripe graafian vesicle, secreted either just before, during, or after menstruation, and even, though not often, during the intermenstrual period, must, in some part of its course into the uterus, come into direct and immediate contact with one or more living spermatozoa, in order to be fecundated.
4. Semen contains, as its most important constituent, animalcules, spermatic cells, zoospermes, spermazotoa, or zoids, as they are variously called according to the idea which is formed of their nature. In the field of the microscope, they are seen to move about with vary. ing activity, and whether or not they be endowed with true vitality, life, or be or be not organized animals, which last seems generally now to be believed, their volition is seemingly directed by instinct, towwards, and in spite of all obstacles, the ovum which they are to impregnate. In a natural temperature, they live for forty-eight or seventy-two hours; are found living even in the cadaver, after twentyfour hours, and in bitches have been seen to move seven or eight days after copulation. Acids, urine, electricity, strychnia, narcotics, and certain vagino-uterine secretions destroy them; but of this last hereafter. Probably they are reproduced; they are certainly nourished: strange creatures, which, by union with an ovule, are capable of communicating to it, not only the physical resemblance, but the temperament and constitution of the parent. They appear in the semen at puberty; are found afterwards at all periods of life; and in men of
advanced age (eighty-two) have been found. as numerous as in the adult.
4. The material contact of the semen and the ovule, both animated by their vitality, and perfect in themselves, is the essential condition of fecundation, and the intimate fusion of these two elements is alone capable of giving birth to the new being. If any obstacle impedes the immediate contact of the two germs, conception on the part of the female is impossible. Upon an accurate knowledge in regard to these causes depends the successful treatment or cure of sterility.
5. The aura seminalis alone is insufficient. Filtered semen is equally so. No part of the semen but the animalcules suffices.
6. The fecundating power of the animalcules seems connected with their vitality, for it diminishes, and is completely extinguished with their movements. Semen is infecundible without living spermatozoa; and it is certain, however they enter it, that they get within the ritelline membrane of the ovule, and have been seen in immediate contact with the yolk, when they part company and disappear by liquefaction.
7. The merest drop of a high dilution of the semen of a frog, directly applied to the egg of the female, suffices to fecundate; but more than one spermatozoid is required. Two hundred and fifty-five, in the experiments of Prevost and Dumas, impregnated sixty eggs out of three hundred.
8. Neither the movements of the vibratory cilia, nor an aspiratory spasm, nor capillarity, can account for the progression of the spermatozoa. It is to their own motility, and to their power of overcoming obstacles, that this is wholly due. The passage of the spermatozoa from the uterus into the tubes occupies eight to ten hours; arrived at the free extremity of the tube, they reach to, or upon the ovary, by means of the fimbriæ which unite the pavillon to that or. gan. If there they meet with a mature ovule, fecundation may result. Twenty or thirty minutes are required to enable them to enter the uterus. The tubes take from two to six days to transmit the detached ovule to the uterus, where, if previously fecundated, or when fecundated, it stops and is developed, embedded in decidua. If not, it es. capes with the decidua in ten or twelve days, or at the end of menstruation. The period most favorable for impregnation, then, is immediately before, or during, or soon after menstruation ceases. The flow of menstrual blood does not impede, but rather accelerates the
spermatozoa. But how are we to account for fecundation during inter-menstrual periods, unless we suppose that coition hastens the development and detachment of a mature ovum? Fecundation and coition are separated at least for the time which is required for the spermatozoa to pass through the uterus and tubes, and reveals itself by no special signs. A single act of coitus may suffice for impregnation, of which many instances are known. If, now, we attempt to assign the causes of infecundity from a physiological point of view, we shall find that men are infecunds because they are impotent or aspermatic, i. e., incapable of erection or ejaculation; and even when capable of emission, are aspermatozoic, that is, secrete a semen
progress of the
or fluid which contains either no or no living spermatozoa. Eunuchs possess for awhile an incomplete power of erection and an ejaculation which must be aspermatozoic, which for the lack of the stimulus of venereal appetite, they gradually lose. Impotence is not necessarily associated with either aspermatism or aspermatozoa. It is sometimes purely nervous, and when cured, the power of fecundation may exist or return. It occurs among the newly married and in the old. But very old men are not necessarily infecund, as we have seen, and the case of old Parr is in point. The only way in which aspermatozoa can be positively ascertained, is by submitting the semen to the microscope soon after its emission.
But it is chiefly with infecundity in the female that we are concerned, and allowing that there is no fault in the generative faculty of the male, it behooves us to inquire into its causes. Admitting that no physical defect of organism occurs in her, and that, as we so often see, she is robust, healthy, menstruates more or less perfectly, and is free from organic uterine malformation or disease, why is it that the sper. matozoa do not reach and fecundate her ova? Ill-health may, I think, possibly prevent this from occurring, by impairing the fecundity of the ova, or faults in the ovary or ova may have a similar effect. Dysmenorrhæa, though often associated with infecundity, does not neces. sarily cause it, and the reason of the association is probably purely a mechanical one.
The cause which prevents the easy escape of the menses, and renders it painful, may equally prevent the access of spermatozoa to the uterus, tubes, and ovaria. To these we shall presently advert.
But these are not the only causes for infecundity on the part of the woman. There is another and a principal one, to which passing allusion may be found in authors, but it has by no one been so markedly assigned and scientifically considered as by Donné, and our countryman, Dr. Sims, to whom Surgery and Science are alike both deeply indebted.
I allude to the destruction of the spermatozoa by the vitiation or peculiar constitution of the vagino-uterine secretions, by which fecundation is rendered impossible.
In Donné's “ Cours de Microscopie," &c., the work of a zealous, cautious, and candid observer, we find much that is interesting and important on this subject. Acetic acid instantly kills the spermatozoa, but leaves them perfectly intact for years. Blood and milk exert upon them no deleterious influence, saliva kills them rapidly, urine instantly. Pus and the muco-purulent matter of uterine leucorrhæa does not affect them by its contact. They live perfectly well in the mucus secreted by the vagina in a normal state, which is slightly acid; but, and this observation is most important, the acidity of the mucus secreted by the vagina becomes such in some circumstances, as when there is congestion, acute irritation, or inflammation of this organ, that the zoospermes seem unable to live in it more than a few moments. He has even seen them, particularly, give no sign of life, in less than two minutes, in the vaginal mucus of a woman of twenty-two, affected with
an extremely acid discharge. "Can this, then," Donné says, " be considered as the cause of sterility in some women?"
Vaginal mucus is white, opaque, creamy, not viscid, and always acid. Uterine mucus, on the contrary, is transparent, stringy, tenacious, like albumen, sometimes clouded with purulent matter, but always alkaline, turning litmus paper blue, whilst the mucus of the vagina always reddens it.
The action of this (uterine mucus on the animalcules, varies according to circumstances. Generally the spermatozoa brought into contact with uterine mucus do not suffer. But certain kinds of uterine mucus kill the animalcules with the greatest rapidity. Nor is this mueus distinguished from others by any appreciable characteristic, microscopic or otherwise, being either pure and transparent or opaque. An excess of alkali seems to be the only probable cause of its deleteriousness, litmus paper becoming instantaneously intensely blue.
No possible means of ascertaining the fact seems to exist, except that of submitting the spermatozoa to the action of uterine mucus of various kinds or qualities. “Do not,” says Donné, “the facts related lead to the belief that alterations of the vaginal and uterine secretions play an important part in causing sterility, by killing the fecupdating liquid ; and is not some light thrown on its hitherto obscure causes, and a suggestion made of a rational and efficacious remedy?"
It is but doing simple justice to our countryman, Dr. J. M. Sims, to say that he is the first among us to revive those ideas, and give to them a practical application (On Mic. in Diag. and Treat of Sterility, N. Y. Ned. Jour., Jan., 1869). In this paper he lays it down: 1st, we must have spermatozoa in the semen; 2d, they must enter the utero-cervical cabal; 3d, the state of the secretions must be favorable to their vitality. In the absence of the second of these conditions only is any operation to be thought of. How are these facts to be ascertained? By examining the condition of the vaginal and uterine secretions after coition. A little of each is to be withdrawn with a syringe, and placed under the microscope; and to do this accurately, the fluid must be retained for some time after in the vagina. He thinks the best period for making the investigation is the fifth or sixth day after the menstrual flow. Dr. Sims, in one respect, differs from Donné. He says, "the vaginal (normal) mucus, by its natural acidity, kills very quickly every spermatezoon, and seems to be a perfect poison for the superabundant ones.” If this were true, fecundation would very seldom, almost never occur. Donné, more correctly, I think, says its slight natural acidity is not noxious to the spermatic animalcules, but is only so when excessive. The cervical mucus is to be carefully separated and distinguished from the vaginal, and withdrawn with a syringe for examination. Dr. S. thinks it possible to obtain a second specimen from higher up the canal, or even from within the os internum, which I should think would be difficult, and finds in the one sometimes living, in the other, dead spermatozoa. Donné does not carry his researches so far. He is content to take the mucus which hangs out of the os externum, or can be withdrawn from within the neck. Dr. Sims thinks that if the cervical secretion contain little
opaque spots of milky whiteness, and when it is very thick and albumino-purulent (as also when perfectly clear), it is poisonous. Donné's observations generally (p. 293) oppose this assertion :- A certain quality of mucus necessary to produce this effect, which can not be told from its natural or microscopic appearances : too alkaline (?) if uterine: too acid if vaginal. Be all that as it may, there is a peculiar condition of either of these secretions, whatever it be, which does kill the spermatozoa, and occasion sterility; and the great point is to remedy it. Dr. Sims justly says, it is not every woman who has dysmenorrhea (and I add, or leucorrhea), who is sterile, nor every man who may be vigorous and enjoy good health, who is capable of procreation. He has kuown half-a-dozen husbands—in one place he says many—whose semen had no spermatozoa. Dr. Sims' paper proves, and he frankly acknowledges, that the operation of incising the cervix is seldom necessary or proper, often quite uselessly performed; and he no longer thinks that the most common obstacle to conception is a more or less contracted utero-cervical canal (p. 24, lib. cit.) I quite agree with Dr. S. that the necessary investigations into this interesting and practical subject, by which alone a true and scientfic knowledge and basis of action can be obtained, involve neither indecency nor sacrifice of self-respect on the part of either surgeon or patient.
If, then, it should be asked, What necessity, then, exists for dilating the two orifices and neck of the uterus, we answer, 1st, because of its allowing of a more easy escape for the menstrual blood; and, 2d, because it allows an easier access to the spermatozoa. Although neither an aggravated dysmenorrhea, nor a very contracted os uteri
, internum or externum, are necessarily fatal to, they are unfavorable to impregnation, and should, as a part of the treatment, be remedied. I can not, for my own part, imagine that flexions, however great, of a part so short and so flexible as the neck of the uterus, which are so readily restored by the introduction of a long and suitably-sized spec. ulum, and which, morever, I so seldom encounter, can offer any serious impediments to fecundation. But the contractions of the orifices are real and unmistakable, often obstinate, and contribute, I doubt not, to this result; but even then very partially, for, as Dr. Sims justly observes, cases are recorded where conception occurred when the os barely admitted a small-sized probe, and that spermatozoa now and then pass along the Fallopian tubes, which ordinarily admit a bristle. It is, then, to the state of the vaginal and uterine secretions, the se. men being healthy, that we must look for the great cause of infecundity in the female. The remarks of Joulin on this subject are worthy of repetition :—“The contraction which has its seat at the internal orifice of the uterine neck is one of the most common causes of infecundity; and particularly among multiparæ. But women who have borne children sometimes exhibit this disposition, which oftenest coincides with an extreme narrowness of the neck of the womb and imbri. cation of the folds of the arbor vite. This cause of sterility, which is usually accompanied with the phenomena of dysmenorrhæa, was until lately unknown.
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