THE PROGNOSIS OF STERILITY IN GENERAL.
The Hippocratic axiom as to the importance of the prognosis is certainly applicable here. And first arid foremost, estimating the patient's chances of recovery, we must de cide whether the sterility is an absolute or only a relative one, whether in fact conception may not occur without any interference upon our part. If the hindrance to conception is an absolute one, the prognosis is always unfavorable—if it is only a relative one, the prognosis will vary in the different cases. But not only will the nature of the obstacle influence our conclusions, the complications, if any are present, will also do so. The length of time during which infecundity has been present must also be considered, for we have seen above how rapidly fecundity diminishes after a certain period of married life. Pregnancy after five years of sterility is a relatively very uncommon occurrence. Nor must it be forgott,en that, in the married relation, the prognosis depends upon the behavior of both individuals, and not alone upon the one in whom we discover the obsta cle. Not only in the newly married, but later also, normal or heightened bodily potency, moral self control, and also a certain amount of adroitness and pliability in the act, may do much to obviate the difficulty.
The consideration of all these points will enable us to reach a progno sis. In those cases in which no diagnosis or only an uncertain one is made, we can simply regard conception as a future possibility.
The prognosis is entirely different as regards the curability of indivi dual cases of sterility. There are curable and incurable cases among both the relatively and absolutely sterile. Thus, absence of the uterus is an absolute hindrance, but so also may be ext,ensive deformity of the exter nal genitals, though it may be remedied by operative procedure when the internal genitals are normal. And the same is the case with the male. A preputial lipoma as large as a goose's egg is an absolute obstacle (such a man brought his wife to a prominent gynecologist to be examined for sterility ! !); yet a simple operation will enable cohabitation to take place, and remove the sterility. Marked atrophy of the testicles, however,
will prove an obstacle which persists in spite of all treatment We see the same difference in cases of relative sterility. Sterility due to marked flexion of the uterus may be remedied by appropriate treatment, while a simple genital catarrh may in spite of all our efforts continue to prevent the zoosperms from reaching the ovum. And in the male again an ap _parently simple and. long past gonorrhoea may absolutely destroy the procreative power, while extensive scrotal hernia may be remedied surgi cally, so that intercourse can be effected and conception procured.
It would be interesting to know how many of the special causes of sterility can be remedied by medical aid But the statistics which we possess are unreliable. Treatment, in females especially, may be begun very early, and to nature is due a large part of the credit which the phy sician assumes. Only cases where sterility has lasted four years, and where conception occurs within six months after the conclusion of the course of treatment, should be considered. The statistics of my own cases, made in this careful way, show a percentage of not more than twenty to twenty-five cases cured. This is not very satisfactory, and is by no means what was expected when the mechanical treatment of sterility was inaugurated. But on the other hand these figures do not sustain the extensive pessimism which has lately sprung up in regard to the treat ment of sterility. The low percentage of cures will render us cautious in stating the probabilities of the case to our patients. I never omit to tell my patients at once that out of four or five cases one only can be cured, and that it is impossible to tell beforehand whether or not she will be the lucky one.
As to the prognosis of the special causes of sterility, we will have more to say under the head of treatment.