Certain Causes of (Sterility in tje Female 
AND 
TfiEJtJ 
BY 
EGBERT H. GRANDIN, M- D , 
OF NEW YORK. 
REPRINT FROM THE 
NASHVILLE MEDICAL NEWS, 
APRIL 15, 1887. 
BRANDON PRINTING COMPANY. Certain Causes of Sterility in the Female 
THEIR TREATMENT 
-:and:- 
BY EGBERT H. GRANDIN, M. D., 
Obstetric Surgeon, New York Maternity Hospital, Instructor 
in Gynecology at the New York Polyclinic, etc. 
(STERILITY in the female is one of the most unsatisfactory sub- 
jects, as regards therapeutic results, for which we may be 
consulted. Rational treatment demands correct diagnosis, and 
correct diagnosis necessitates the proper estimation of the causal 
factor, or factors, of a disease. In the face of sterility the physi- 
cian is called upon for the exercise of all his judicial powers, and 
not infrequently even then he will fail in detecting a tangible cause 
against which he may bring to bear his therapeutic battery. 
By sterility in the female I mean absence of evidence of con- 
ception after at least three years of married life in a woman who 
is not prevented from conceiving by any appreciable vice in con- 
formation, congenital or acquired. Statistical data have amply 
proved that no woman is entitled to be called sterile until after 
the lapse of at least three years from marriage, The presence of 
imperfections in the genital organs, constituting per se a bar to 
conception, are not amongst the causes of sterility which I pro- 
pose to consider here. These may be remediable by art, but I 
purpose solely to sketch the causes and the treatment of sterility 
in women who present no strikingly apparent reason why they do 
not conceive, and in whom, as far as we can detect, the ovaries 
and the tubes functionate normally. At once then, in addition to 
imperforate vagina, cervical canal, or uterus deficient in size, I 
exclude from consideration those causes which have their outcome 
from inflammatory affections around the uterus. The sterile 
woman I am writing about has not an adherent uterus, and, so far 
as careful bimanual palpation .justifies the assertion, has normal 
oviducts and ovaries. 2 
In the estimation of the possible causes of sterility in any given 
case we should always remember that the husband may be at fault, 
and not necessarily the woman. Gross tells us that in one out of 
six cases, at least, lack of fertility must be credited to the husband, 
and, therefore, in any abscure case, the semen must be submitted 
the microscope before we will be in a position to treat the wife 
intelligently, or to tell her that the fault is hers, and very likely 
not remediable. A point about the semen worth remembering is 
that it may contain active spermatozoa, and yet not be efficient 
for fecundation. Pajot, of Paris, has pointed out that anomalies 
in shape of the spermatozoon may incapacitate it irom subserving 
its purpose. 
Supposing now the semen to contain active and comely sperm- 
atozoa, and therefore probably healthy, we are justified in believing 
the man capable to fecundate, and must seek for the cause of ste- 
rility in the woman. What now are the most obvious causes, and 
how, if at all, may they be relieved? 
Two broad divisions may be made: lha pschychic and the physical. 
Pschychic causes may be dismissed in a few words. Neither desire 
nor pleasure are essential to fertility. Impregnation whilst the 
woman is under the influence of an anaesthetic, conception from 
forced intercourse or rape, in other words, fertility under condi- 
tions when both desire and pleasure are absent being possible, we 
are not warranted in saying that absence of these qualities will ex- 
plain sterility. Whilst we may say, generally, that the sexual 
appetite favors fertility, the reverse is not strictly true, and it is 
really to the physical causes we must look for explanation of the 
absence of fertility, whether the sexual appetite is normally de- 
veloped or not. 
The physical causes of sterility, the treatment of which I pro- 
pose to consider, are: 
Repeated congestion of the pelvic organs. 
Displacements or distortions of the uterus. 
Abnormal shape and size of the cervix and its external orifice. 
Abnormal discharges from the uterus, cervix and vagina. 
Faulty development of the vagina. 
Repeated Congestion.-Paradoxical as it may seem, miscarriage 
is a frequent cause of sterility! The fecundated ovule, in order 
that it may grow and may thrive, needs a healthy soil even as does 
the seed from which the tree or the cereal is to develop. All 
causes which lead to repeated congestion of the uterus in partic- 3 
ular, so modify the mucous membrane which is to assist in the 
formation of the decidua, so alter, in other words, the soil in which 
the egg is going to engraft itself, that this mucous membrane 
proves unfit for the egg's growth, and therefore it dies, even though 
fecundated, and passes away, usually at the next menstrual period. 
Thus then the woman is sterile, and remains so. although she pos- 
sesses the capacity of reproduction, and requires purely, perhaps, 
organic quietude, so to speak, in order to make visible this capacity 
in its full maturity, in order, that is to say, to be ranked as fertile 
instead of as sterile. Our paradox is therefore explained, and the 
sterility of many a woman exists only from the fact that she does 
not herself give her uterus an opportunity to display its ability to 
bear the ovule, which is-duly fructified, but dies from lack of proper 
and nutritious soil. 
By far the most frequent causes of this apparent sterility are 
some of the ordinary means resorted to for the prevention of con- 
ception, and which it is unnecessary to here specify. Another 
cause, acting in particular during the early years of married life, 
before experience has taught the wisdom of self-restraint, is in- 
ordinate sexual commerce. Such and the like causes eventuate 
necessarily in chronic hyperemia of the endometrium, and later 
still in hyperplasia, both of which morbid states are directly inim- 
ical to fertility if not to conception. 
The treatment, of course, is self-suggestive. The point I wish in 
particular to impress is the necessity of questioning our sterile 
patients closely in regard even to these sacred matters, before we 
are in a position to treat the condition rationally. 
Displacements and Distortions of the Uterus.-It is a disputed 
matter as to how the spermatozoa effect entrance into the uterus 
in order to fecundate the ovum. Some believe that the semen is 
thrown directly into the cervix, the orifice of which opens in order 
to receive it; others claim that the spermatozoa, possessing the 
power of motion, find their own way into the interior of the uterus, 
and point to the fact that impregnation may result when the semen 
is simply deposited at the entrance to the vagina, as proof of their 
belief. Whichever t>f these statements be true, if either is alone, 
it may be broadly stated that, other factors equal, impregnation is 
most likely to result in instances where the uterine axis bears 
such a relation to the vaginal as to bring the external os in close 
apposition to the male urethra, that is to say, when the cervix 
points towards the posterior vaginal cul-de-sac, which has been not 4 
inappropriately called the receptaculum seminis. The cervix in 
such a position is bathed in the pool of semen, and the sperm- 
atozoa find it a simpler matter to enter the uterus than if the 
cervical axis bore a different relation to the vaginal. When now, 
in particular, the uterus is retroverted, or in the position described 
by Munde and Fritsch as one of retroposition with anteflexion, or 
when there exists flexion of the cervix anteriorly, then the cervix 
is more or less above the proper axis, and, as experience daily 
proves, the chances of fertility are lessened, and of sterility, re- 
lative or absolute, are increased. A similar remark applies to ex- 
treme degrees of anteversion, a condition far less commonly met 
with than the preceding. When we examine such patients, after 
many years of sterile married life, we are often struck by the great 
depth of one or another cal-de-sac, in particular the posterior. 
Pajot says that this increased depth is due to the fact that the 
male organ has made a "fausse route," false passage, that is to 
say, instead of impinging on the cervix, as probably is the case 
where the relations of uterus and vagina are normal, it has deep- 
ened the vaginal vault posteriorly, anteriorly, or laterally. The 
treatment which he recommends is somewhat peculiar, but he 
assures us that it has frequently succeeded in his hands. In brief, 
according to him, if the uterus be retroverted let the woman de- 
liberately constipate herself for a number of days, when the dis- 
tended rectum will in a measure correct the displacement, and 
then let intercourse take place, and the semen will have an oppor- 
tunity to gain entrance into the uterus, If, on the contrary, the 
uterus is anteverted, he recommends retention of urine until the 
bladder is completely distended, the result of which is elevation 
and backward tipping of the fundus, during which intercourse 
should be had. Such methods might be successful, but I believe 
that there are simpler and less disagreeable ones, and these I 
proceed to discuss in turn. 
In case of pure retroversion of the non-adherent uterus nothing 
is simpler than to relieve the displacement. First antevert the 
uterus, and then apply a properly curved and well-fitting pessary. 
If, however, the uterus cannot be replaced awing to congenital 
shortness of the anterior or posterior folds of peritoneum which 
constitute the so-called uterine ligaments (I am not considered in 
this paper morbid adhesions), then the problem is a very difficult 
one, and I must confess has not been at all satisfactorily solved. 
Sometimes the uteruscan be raised forward sufficiently to bring 5 
the uterine axis nearer the vaginal. This is not enough to warrant 
us in inserting a purely vaginal pessary, for as surely as we do the 
result will be the conversion of the retroversion into a retroflexion, 
but it is enough to justify the adaptation of the Thomas-Cutter 
pessary, and this instrument will keep the uterus in the position 
we are able to place it without being at all open to the same ob- 
jection as the pure internal pessary. If, owing to the congenital 
vice, we are unable to replace the uterus at all, then it is my belief 
that the chances of curing the woman's sterility are slight, except 
through an attempt at artificial impregnation. Posterior discission, 
after Sims' well-known method, might be tried, although experi- 
ence has not proved it of much value. Tamponing, however pro- 
tracted, I do not believe will do more than lift the uterus and the 
rectum bodily upward, and also deepen the vaginal pouch. 
The next form of displacement, retroposition with anteflexion, 
is probably more often associated with sterility as a likely cause 
than any other, and it is decidedly the form of all others the most 
difficult to remedy satisfactorily. We must do two things: Cor- 
rect the retroposition, and overcome the flexion. The former we 
may occasionally do, but the latter-,lthere's the rub." There 
are numerous methods extant for overcoming flexion, but that any 
will permanently cure the distortion I have serious doubts. Of 
course the intra-uterine stem may be inserted, but I am simply 
afraid to let any patient of mine wear a stem unless to it is attached 
a string, the other end of which I can hold in my hand to withdraw 
the stem at the first danger signal. There are far too many cases 
of death recorded directly traceable to the wearing of the stem 
pessary, and knowing how quickly pelvic inflammatory trouble 
may result, I have discarded the stem altogether, and thus save 
my patients risk and myself anxiety. Possibly the best method 
of overcoming the flexion temporarily, if not permanently, is by 
thorough divulsion under an anaesthetic. The divulsion should be 
to the extent of at least one and a quarter inches. The aim is not 
to rupture the cervix, but to cause the muscular fibres to yield to 
the applied pressure. A good instrument for the purpose is the 
Palmer, or the Ellinger-Goodell. These are strong enough not to 
feather at the level of the internal os, and they assure thorough 
and equable dilatation. Goodell assures us that in the large pro- 
portion of cases the flexion is permanently remedied. My experi- 
ence would lead me to the reverse opinion, but then it has been 
by no means as vast as his. For true cervical flexion, where it 6 
seems to be at the bottom of sterility, our only resource is poste- 
rior discission. It will be noted that I do not believe flexion itself 
to be a cause of sterility, but rather the resultant abnormal posi- 
tion of the cervix relative to the vagina. If flexion does not in- 
terfere with the exit of menstrual blood, it will hardly interfere 
with entrance of the semen. 
If the conditions which I have so far spoken of are uncompli- 
cated by others, and are remediable, our sterile patient will some- 
times become fertile. Unfortunately, however, displacements and 
distortions of the uterus, when of long standing, are accompanied 
by hyperemia, or worse, of the endometrium, and this we have 
already seen is a common cause of sterility, so that our therapeutic 
aim will frequently be obliged to be a higher one than simple cor- 
rection of version or overcoming of flexion. 
Abnormal shape and size of the cervix and its external orifice.- 
The association of sterility with conical shape of the cervix, and 
with the so-called pin-hole os, has over and again been noted. It 
is said that the conicity of the cervix does not give the male organ 
a surface on which to impinge, and the size of the external os has 
been considered as insufficient for the spermatozoa to enter by. 
These explanations are utterly insufficient, however, for the reason 
that the uterus may occupy such a position as to allow its conical 
cervix to dip into the pool of semen, and yet the woman be sterile; 
and again, an external os large enough to admit a very flue probe, 
and ample enough to allow of the escape of the menses, can hardly 
be so small as to act as a barrier to the entrance of the sperma- 
tozoa. The true explanation of the very frequent association of 
sterility with these anomalies of the cervix must be sought in the 
fact that with the conical cervix there is ordinarily present a pin- 
hole os, and, in connection with both, the real cause of the ster- 
ility-an endocervical catarrh with its thick mucous plug which 
cannot escape by the narrow orifice and effectually blocks the road 
which the spermatozoa must follow in order to reach the endom- 
etrium. The treatment of these conditions, therefore, belongs 
properly under the one which I next consider. 
Abnormal discharges from the Uterus, Cervix and Vagina.-A 
certain amount of discharge from the vagina is physiological, and 
only when it becomes excessive are women in the habit of com- 
plaining of lucorrhcea. Even a slight apparently physiological dis- 
charge, however, may be the sole cause of sterility, not so much 
from its presence as from its reaction. An excessively acid dis- 
charge is deadly to the spermatozoa, and in any case of sterility 
the cause cannot be held as estimated until by means of litmus pa- 
per the reaction of the discharge has been tested. If acid and appar- 
ently from the vagina the indication for treatment is to order a 
weak alkalina douche to be taken a trifle prior to sexual inter- 
course. The sterility dependent on the presence of leucorrhcea 
is very rarely, however, such a simple matter as this. Usually we 
are dealing with an endometritis, accompanying general hyper- 7 
emia or hyperplasia, which condition may be met with in the nul- 
lipara, or with an endocervicitis and its accompanying erosion, or 
with a vaginitis, simple or specific. The treatment of these affec- 
tions I aim at sketching purely in a broad maimer, since my space 
will not admit of minute detail. 
General hyperemia of the uterus is of course accompanied by 
catarrh of the endometrium, and if the discharge does not kill the 
spermatozoa, the endometrium, as we have stated, is not a fit home 
for the ovum. The first aim of treatment is to remove the cause 
and this means, ordinarily, abstinence for a certain period from 
sexual intercourse. Next, since the hyperemic uterus is a heavy 
uterus it sinks downward, and this enhances the pelvic congestion. 
The aim of treatment then, in addition to rest of the organ, is to 
relieve the pelvic and general congestion, and this aim is fulfilled 
admirably by the hot-douche, taken in the recumbent position, and 
the glycerine tampon. The hot water, if taken in sufficient quan- 
tity, lessens the pelvic congestion, the glycerine does the same by 
depletion, the tampon the same by holding the uterus at its proper 
level in the pelvis, whereby the peri-uterine circulation is equal- 
ized and the uterine hyperemia lessened. A most valuable adju- 
vant in treatment is galvanization of the uterus, one electrode 
against the cervix, the other over the fundus. If the current be 
mild, and it should be, it is indifferent which pole is internal. I 
am in the habit of using by preference the interrupted galvanic 
current. When, however, the hyperemia has been of long dura- 
tion, the uterus has passed into the hyperplastic condition, and 
here, in addition to the measures already spoken of, some- 
thing more is requisite, and this is repose to intra-uterine ap- 
plications, and possibly the curette. The endometrium is no 
longer simply hyperemic. There has occurred hyperplasia of its 
constituent parts, and to cure, or rather to alleviate this hyperplasia, 
the fungosities, the vegetations, must be removed, and the inner 
surface of the uterus treated like other accessible mucous mem- 
branes of the body affected with a so-called chronic catarrh. 
The characteristic feature of the discharge from the cervix, is its 
consistency. The tenacious mucous plug fills the entire canal, and 
it is readily apparent how it blocks the way of the spermatozoa. 
The cure of an aggravated case of endocervical catarrh is a most 
difficult matter. Thorough and persistent treatment are called for. 
If the external os is pin-hole, the first thing to do is to enlarge it 
so as to make the canal of the same calibre throughout, and not 
only must it be enlarged, but maintained so. The crucial incision 
with trimming off the edge of each little flap, as described by 
Munde, will do this. The next step is to thoroughly scrape away 
the diseased follicles, and then to cauterize deeply, either by the 
fuming nitric acid, or by the actual cautery. The after-treatment 
should be prolonged. In these instances of endocervical catarrh 
I have latterly been trying galvanism, but the results so far ob- 
tained have scarcely been satisfactory. 8 
For the discharges resulting from an inflammation of the vagina, 
the treatment called for will vary from simple astringent injections 
to direct application of strong silver solution. Where there is a 
suspicion that the discharge is specific in its nature, I cannot lay 
sufficient stress oii the necessity of meeting it with most radical 
measures before it has spread beyond the vagina. It is here, in 
particular, that I believe solutions of nitrate of silver, one-half 
drachm to one ounce, are most efficacious. They have been 
proved directly destructive to the coccus, which, it is claimed, is 
the cause of virulency. Of gonorrhea as a cause of sterility I 
cannot speak further. I would only add that observers through- 
out the world are coming to believe with Noeggerath that it is a 
very common one. 
Faulty Development of the Vagina.-By this I mean those vagi me 
which are lacking in depth, and the result is the non-retention of 
semen. Close questioning of our patient is absolutely necessary 
to determine this cause of sterility, and yet it is a relatively fre- 
quent one. The woman will tell us on direct questioning, but 
hardly otherwise, that on withdrawal of the male organ the semen 
follows. Unless in these instances, therefore, the semen be di- 
rectly ejected into the cervix, the woman's chances of sterility are 
great. The remedy is in taking the necessary measures to cause 
retention, and in addition to those suggested by Marion Sims, it is 
a good plan to direct the patient to push a cotton tampon into the 
vagina as the penis is withdrawn. 
Such, then, are the most common causes of sterility, and yet this 
subject, of such prime importance, has been by no means exhaus- 
ted. Now, if in a given case we have corrected version and flexion, 
have cured the pathological factors which cause discharges, and 
yet the woman remains sterile, what is to be done ? If the woman 
is excessively anxious for offspring, artificial impregnation may be 
attempted, although but few women will accede to the attempt, 
and the physician is naturally loth to insist upon it. The method 
has succeeded about a dozen times when the syringe has been used, 
and Rheinstaedter, of Cologne, has been successful in as many 
more by dipping a cotton-wrapped probe in the semen and then 
passing it into the uterus. This method is open to the charge 
that the probe may have simply removed a plug of mucous and 
thus rendered impregnation possible at the succeeding copulation. 
The most that can be said, however, relative to artificial impreg- 
nation, is that, as yet it has not been established on a firm scien- 
tific basis, that nothing can be predicted from it, and that com- 
parative experiments on animals, if carefully made, may, in the 
future warrant frequent resort to the method in the human female.