It has been doubted whether the success resulting from mechanical treatment of the uterine flexion can be taken as an argument that the stenosis resulting from flexion was the obstacle preventing conception. Mistakes are not improbable, since impregnation can take place in the presence of flexion, without any treatment having been instituted. Al though this is true, yet it doe-s not justify a universal scepticism as regards the ebndition. When after a prolonged period of sterility, which has ex tended beyond the general latitude of human sterility, conception fol lows upon a mechanic-al course of treatment, the physician is justified in attributing the result to his therapeutic efforts. Every busy gynecologist has surely met with such cases. The mere introduction of only a sound has often been followed by a happy result. Thus in a case of anteflexion with a period of sterility existing for five years, the sound having been pawed by the stenosis, conception ensued; again in a case where sterility had lasted for twelve years, during the examination the sound was with difficulty introduced, when after an interval of four months, the patient again presented herself, and one of my assistants found a uterus as large as a fist, that is to say, a gravid uterus of about three months. Usually, however, conception only takes place after a long and energetic course of treatment. I will cite but two cases Mrs. S., twenty-nine years of age, married eight years, sterile, ante flexion of the uterus. She was treated for six weeks with dilating instru ments, no cutting operation was performed, and finally she was discharged after the insertion of a pessary. It was removed some weeks afterwards by her physician. Conception ensued.
Mrs. Sch., aged thirty-eight years, married eighteen years, anteflexion of the uterus, sterile. Treated nearly for two months after the same manner. When treatment ceased, menstruation occurred but once, as she immediately became pregnant.
The promptness of the success is noteworthy. Even M. Duncan, who is one of the most determined opponents of the mechanical method of treatment, relates the history of two patients, in one of whom sterility had lasted fifteen years, and in the other twenty-two years, where e,on ception occurred as the result of mechanical treatment. I am not a mathematician, who can by e,alculation determine the causal relation ex isting between conception and mechanical, treatment. But it must be considered as remarkable that, after periods of sterility of eight, thirteen, fifteen and twenty-two years, directly after dilatation of the stenosed portion conception should take place. If cases such as these do not serve to convince, then our therapeutic efforts must be limited within narrow bounds indeed.
Even the arguments of the opponents of mechanical treatment are only apparently of force against flexion as obstacles to conception. Thus cases have been reported in which, although extreme stenosis was present, impregnation had yet occurred. These cases would be convincing, if it had been asserted that flexion,entirely prevented conception, but such is not the case. It is only asserted that flexion renders conception sonie what more difficult, and not that without our interference conception cannot take place. This is apparent in many of the cases reporqd by
Scanzoni in opposition to Sims's teaching, and he thus rather supports than undermines the latter's position. Such cases plainly go to show how long it will take until favorable circumstances are developed for con ception to occur. Moreover it would have been an easy matter for Scan zoni to have drawn from his ample experience, for every favorable case, a dozen others where, after a still longer married state, permanent ste rility was present, for it is not to be gainsaid that where a true and exten sive flexion exists, sterility is the rule, and an early conception the ex ception.
As is apparent from these considerations, I do not think that our present knowledge of flexion justifies us in setting aside its importance as an obstacle to conception. Recent investigation has determined what the normal position and form of the uterus are. Yet it has not solved the problem why in many nullipara3 shortly after puberty, and without any sign of a diseased condition in the pelvic cavity being discoverable, a uterus normal in size is found, the body and cervix of which are in con tact, because of an extremely developed flexion, and where considerable effort is requisite before the sound can be passed into the uterine cavity. Now if sterility of a number of years standing exist, all other concomitant circumstances being favorable, why should not this stenosis be regarded as the preventing cause and be treated as such? And should not this be also allowable when, under otherwise similar circumstances, the cervix is found retroverted with the fundus resting on its anterior surface, so that the flexion is still more marked, and the obstruction to conception still greater? One is strongly tempted to ask, is this still a normal condition of the uterus, and is this appearance not to be considered as rather pa thological, even when the posterior parametritis is not present ? Al though in many cases inflammatory processes in the pelvic cavity un doubtedly indue,e sterility, and although this is even proven to be so in cases of existing flexion, what is to hinder us, when a woman, after nat urally bearing children, remains sterile for a number of years, and a marked auteflexion or retroflexion has been developed, in regarding this as the cause of sterility, mther than the results of an obscure pelvic cellu litis or pelvic pentonitis, which are by no means essential for the pro duction of flexions? It seems to me that as long as true cases of flexion exist, whether they be the so-called congenital or acquired, and where sterility obtains, and yet there are no determinable existing complica tions, flexion must be admitted as the obstacle to conception, and if com plications occur, then stenosis must not be entirely disregarded since experience has shown that after the complication bas disappeared, stenosis and sterility may still persist. This latter fact is of considerable impor tance in connection with treatment. All stenoses resulting from flexions are not, however, of equal importance, and this depends on various cir cumstances.