It is very questionable whether it is proper to use a mechanical plan of treatment in conjunction with the dietetic pharmaceutic course. The danger of exciting renewed inflammation and hemorrhage would prevent our attempting to remedy adhesions by manual exertion or instruments, like the uterine sound; nor could we do better with laparotomy. But there are cases in which recurrent local inflammations appear at one side of the pelvis. They may be combined with sterility, and then the abla tion of one ovary, perhaps together with the corresponding tube, may cure the inflammation and permit the other ovary to functionate properly. But in all these operations the benefit to be obtained is so problematical, and the dangers yet so great, that their consideration as remedies for sterility may well be left to the future.
The tubes, which are certainly of importance in the causation of sterility, are less accessible to special treatment than is the peritoneum; nor do the congenital and most of the acquired tubal anomalies permit of an exact diagnosis. Nor have we either local or general means for combat ing their diseases. Catheterization of the tubes, or cauterization of the mucous membrane, however advisable theoretically, cannot yet be done. Inflammatory conditions of the tubes, with their consequences, strictures and obstructions, cannot be directly attacked. Dislocations of the tubes can hardly be diagnosed, and constrictions and atresias caused by perito nitic processes can only be treated by removing the inflammation.
As to uterine malformations, entire absence or rudimentary formation of the organ cannot be treated, and are of bad prognosis. Duplexity of the uterus permits conception; cohabitation only may be interfered with. by a vaginal septum. Retention tumors of the uterus, projecting into the vaginal canal, must be treated operatively. The stenoses of the genital canal, so frequently left after these opemtions, must be treated like the' constrictions of the cervix.
The higher grades of congenital smallness of the uterus are of unfavor able prognosis. We may attempt, as in cases of acquired atrophy, by impmving the geneml health, by local irritants, (hot vaginal douches, cauterization of the uterine mucosa, the introduction of sounds, electri city, etc.), to cause increased uterine nutrition, but the results of treat ment have been so discouraging that, if the period of genital growth has passed, we may as well give up all such attempts. In cases where the deficient size is not so marked, and where anwmic-nervous symptoms and slight non-pathological flexions are present, the case is different; the prognosis is better, and conception may possibly occur. Here again the care of the general health is of more importance than the use of local irritants. These latter are liable to set up catarrhal processes, and they
do not tend to relieve the general symptoms of chlorosis and nervousness, but the reverse In sterile women who have married very young, and in whom imper fect uterine development and the changes of the genitals caused by co habitation prevent conception, a prolonged continence is indicated.
When the vaginal portion is absent, and there is conical elongation, operative procedure only can be relied upon. Its exact nature will de pend upon the length of the vaginal portion. If it is but small, it will suffice to enlarge the os uteri; if it is longer, a portion of it must be ab lated, thus giving the os externum a higher position in the oervical canal, and increasing the possibility of keeping it open.
As we have seen, hypertrophy of the vaginal portion, or of one lip of the os, can only cause sterility when it is large or occurs conjointly with other changes, such as stricture of the os and cervical canal, or intense cervical catarrh, etc. In this case there is no remedy but amputation, with subsequent care to maintain the patency of the canal.
Hypertrophy of the supra-vaginal portion of the cervix demands the usual treatment for that condition.
Cervical stenoses play an important part both in the etiology and the therapy of sterility, though they are not considered of as much conse quence to-day as they were some time ago. If we find the os externum of a nullipara to be too narrow. and especially if a large collection of mucus forms a still further hindrance to conception—and no other mani fest cause for sterility, such as exudation, is present—dilatation of the cervix is indicated. We may first try to effect this bloodlessly, using the dilators of Peasley, Ellinger or J. Schramm, etc., though we will often partially rupture the cervix in our attempts. If this does not succeed after repeated trials, we should incise the orifice at either side, and then try by suitable treatment to enlarge the canal. This may be done with out anesthetization or special preparation. If these simple measures do not suffice, we must adopt more radical means. We must remove enough tissue to give the necessary width to the orifice, and then unite the cer vical and vaginal mucous membrane; thus placing the os higher up in the wider part of the cervical canal, and preventing too great contraction. The exact methods of operation are detailed in the treatises on gyne cology. I formerly removed the apex of the vaginal portion, and then united the mucous membranes of the four sides, giving the os a rosette shape. Later, however, I followed Schrader's proceduro exactly.