Acquired stenosis also may either affect the canal in its course to a greater degree, or at its beginning, the oa externum. In the former case it is often with difficulty that even a fine probe can be introduced through the stiff canal, and sometimes it cannot be introduced at all; often the stenosis only begins in the middle of the canal, sometimes it is ring shaped, sometimes valvular, recurring at several places. Very rarely one receives the impression as if the stenosis extended even beyond the os in ternum; sometimes it extends into the vagina, where tbe fornix is then included in the formation of a utero-vaginal stenosis. The origin of these narrowings of the cervical canal is various. Often it is a very diffi cult course of a labor, with or without instrumental assistance, where the long-continued pressure of the head or injuries have affected that part of the parturient canal, or it is severe inflammatory processes in childbed, that bring it on. But not infrequently considerable stenosis remains after deliveries, where nothing took place, either in the course of the labor or of the childbed period, that could have explained the severity of the stenosis. I have seen such cases repeatedly. Gonorrheal infection also may produce stenosis of the cervix in addition to the changes in other parts of the genitals, that have already been.shown to lead. to sterility. Ring-shaped and valve-shaped stenoses are not infrequently traceable to it. In a case which I had the opportunity of treating, the husband had strictures of the urethra and the wife a considerable stricture difficult of removal in the vicinity of the internal os. While this disease plays an important role in the etiology of sterility, E. Martin again has gone too far when he ascribes sterility of the majority of young women to gonor rheal infection. Still less near the truth is that well-known assertion of E. Noeggerath, according to which 90 per c,ent. of all cases of sterility are thiceable to that disease which, according to his opinion, may for a, very long time remain in a latent condition, and yet be active. Even if the unfavorable influence upon the generative power of the male be also considered, it is still at once apparent that a preformed opinion has here taken precedence of cool, impartial observation. Many also accuse an intense cervic,a1 catarrh as being a cause of sterility, inasmuch as it may be followed by stenosia. This is said to arise through a, growing together of the folds that are opposite to each other, the plice palmatir, or by cicatrization of ulcers that arise from the follicles. I am not acquainted with this form of origin of stenoses, but I have seen in two exquisite cases that a high degree of stenosis occurred from too long-continued and too intense caustic applications to the swollen cervical mucous membrane.
The changes that we have just mentioned may, however, if confined to the external oe, easily produce an acquired stenosis of this opening alone. Even in nulliparre with severe catarrhs we get the impression as though stenosis might be acquired not merely by a swelling of the tissues, but also by the formation of small cie-atrices. The so-called agglutination of the os in pregnancy, the existence of which, however, has been lately questioned by Schroder, also would speak in favor of this manner of its origin. This is still more the case in women who have recovered from difficult labors and childbeds, or have for an extended period of time suffered from ulcerations of the vaginal portion. Healing by cicatrization may change the formerly wide os externum into an exceedingly fine open ing. This form of origin of stenoses at the external os uteri can be watched most exactly in prolapse of the uterus. Opemtive interference also, resorted to for various purposes on the vaginal portion and the cer vix, especially amputation of these parts, may produce a severe stenosis.
Considering the frequency with which these operations are now under taken, this possibility must also be mentioned. This danger is partly diminished by the care that is now taken in such cases to cover the open wound with normal mucous membrane, but this is not always possible, 8.nd if it is done, it does not always prevent stenosis.
It needs scarcely to be remarked that these various forms of acquired stenosis do not prevent conception, but render it difficult, the degree of the difficulty, other things being the same, depending upon the size and extent of the stenosis; however, the valvular stenoses seem to me to offer a much gre-ater obstruction than those which are more even. A compli cating catarrh and its consequences, which we shall soon discuss, may essentially increase the evil effect of the stenosis.
The experience of breeders of animals and of veterinary surgeons, that sterility in horses and cows not infrequently is traceable to a stenosis of the cervix, is of considerable interest. Thus General Daumas tells us in his work upon the horses of the Sahara, of an entire series of remedies which the Ambs use for the apparently not rare sterility of the " buttoned up" mares, and which consisted mainly in dilating the narrowed cervix with the hand or with some hard instrument. " Would it not be a pecu liar fact if the Arabs had made a discovery so important for science ?" Daumas adds in his report Veterinary surgeons, especially the French ones, like Andr6, Eleonet, and M. A. Collin, also found stenosis of the cervix and os to be a frequent cause of sterility. It speaks considerably in favor of the correctness of the diagnosis of this cause of sterility, that their manual attempts at dilatation were not infrequently successful. In cows also this kind of obstacle to conception does not seem to be mre. Thus Ph. von Walther called attention to the process which the Tyrolese peasants pursue, consisting in an artificial dilatation of the os uteri by in cision, a proceeding which is said to have been followed by success. Fur thermore M. Bosley, and especially Bohm and J. Fuchs, have found it necessary to undertake a manual and instrumental proceeding for dilating the cervix in these animals for overcoming sterility. It must, however, be remarked that these stenoses are chiefly acquired, generally by difficult labors with improper artificial assistance.
As for the frequency of stenoses of the cervix and of the external os in man, we must confess that some statements make us believe that too many intermediate conditions between normal and abnormal have been included as stenoses, and have been treated as such too early, the supposed favorable results having been looked at as proofs of the previous existence of an obstacle. It is a matter of course that the figures in regard to fre quency thus attained were too high. This is an unfortunate fact which we meet again and again in all the works on sterility. Even physicians who are by no means fond of the mechanical theory of sterility state the percentage of stenoses as not very small. Thus Kehrer states the fre quency of stenosis as an obstacle to conception as somewhat higher than 8 per cent. Ikely own estimate is lower; only in 4 per cent. of all cases— in these of course there was considerable narrowing—have I deemed it necessary to adopt a therapy directed especially to the stenosis. Chro bak's figure of frequency is somewhat higher; he found the anomaly in somewhat less than 6 per cent. of his cases. Kisch puts it at 7 per cent., while Kammerer found the anomaly in about 9 per cent. of cases. In 35 cases of the latter observer 21 had a stenosis confined to the external os, and only in 11 did he find the entire cervical canal stenosed.