Scrofula and tuberculosis, as we have said, do not play a very promi nent part in the etiology of sterility; nevertheless, if we find in sterile women no anomaly save the first symptoms of these affections, it would be proper to employ mud-baths, change of climate, etc., to combat them.
If alcoholism is the cause of the sterility, as A. Duncan has clainied is in some cases, it must be appropriately treated.
As regards venereal diseases, sve have said enough above in regard to female gonorrhoea as a cause of sterility. The catarrhs so caused need persistent local treatment, as do the consecutive inflammations (para- and perimetritides). Unfortunately purulent tubal catarrh and peritoneal inflammations are not accessible to direct treatment, and thus the prog nosis of chvonic cases is always very doubtful.
Constitutional syphilis demands appropriate treatment, and since it is so frequently complicated with gonorrlicea, the local condition of the geni tals should be carefully kept in view. The results of antisyphilitic treat ment, if we reckon ?n,potentia in grarescendi as sterility, is often very remarkable; the abortions cease, and normal pregnancy and delivery occur.
In the second group of causes of female sterility, local maladies, dis turbances, and diseases of the genitals, local treatment is necessarily the most important. We will begin with those dependent upon the ovaries.
Rudimentary ovaries—or absence of the ovaries—are usually combined with other anomalies of the external genitals, which would render con ception impossible; no treatment is to be thought of.
Premature atrophy of the ovaries also cannot be treated. It must not be forgotten, however, that scanty menstruation, or its disappearance, does not always point to this condition. And on the other hand we should not forget that with the beginning of the third decennium fecun dity diminishes, and in the sixth lustrum conception is a rarity. Chronic inflammation of the ovaries, in which I include cystic degeneration, can hardly be relieved as far as the sterility thereon ensuing is concerned, since, as a rule, both ovaries are affected. The appropriate measures are those proper for the tre,atment of the perioophoritis and perimetritis, which are always present. I have above drawn attention to the fact that
acute puerperal peritonitides may cause destruction of the ovarian folli cular apparatus, and consequent sterility. In that case, of course, we have no means to restore the organs to their former condition. Never theless, amenorrlicea persisting after lactation is ended is not always due to ovarian changes. After excessive hemorrhages, difficult labors, and mild puerperal inflammations, there often remains a chronic anaemic condition without any material disturbance of the genitals, and giving neurotic symptoms. In this case the condition can be cured.
For the larger ovarian tumors the physician will be consulted apart from the sterility. Most of these patients have passed the period of fruit fulness, and the frequent involvement of the second ovary renders the prognosis exceedingly unfavorable.
When the tumor is small, growing slowly, and unilateral, ovariotomy may cure the sterility. But the prospects are doubtful, the openitiou is dangerous, and the decision should be left to the patient herself.
We have seen above the frequency with which pathological conditions of the peritoneum cause sterility. Of the congenital anomalies, a number cannot be recognized during life, AS, for instance, a want of connection between the ovaries and the fimbriated ends of the tubes.' In other cases, as where the ovaries lie in a hernial sac, mechanical treatment will be ap plicable.
But of much greater importance in causing sterility are the inflamma tions of the pelvic peritoneum and the parametrium, as well as hemato eele. The more recent the remains of such processes are, even if large in amount, the better the prognosis. If firm bands and cicatricial masses hare already formed, causing adhesions and displacements of the pelvic organs, the prognosis is not a very favorable one. There have been cases, however. where absorption of the inflammatory products has occurred even after lengthy periods of time; and we are entitled to attempt to ren der conception possible even in these apparently hopeless cases. The treatment is the ordinary ono for the affection in question; of more recent remedies, hot-water injections, iodoform sprays, and massage, are to be recommended.