The same plan may be followed in those rare ca,ses in which women have borne children, and are Buffeting from consequent cicatricial ste nosis.
Some authorities claim most brilliant results from this operation. E. Martin has done it 384 times for sterility; 97 women, 25 per cent., after wards conceived. G. Braun saw pregnancy occur in 23 out of 66 cases opemted on, 34 per cent. Chrobak has collected statistics from various sources, showing the successes to be about 30 per cent. The frequency with which some physicians have done this operation lays them open to the criticism that the stricture of the os cannot always have been such as to demand discission; and that perhaps the result,s have been regarded too much in the light of " post hoc ergo propter hoc." Hegar and Sal tenbach rightly call attention to the fact that other changes of the vagi nal portion, which might prevent conception, are removed at the same time; vaginal catarrh is cured, and the plug of mucus removed. Never theless there are a large number of cases in which pregnancy does occur after the discission; and, from the absence of danger in the procedure, it is to be recommended that an os as large as is natural in the fully de veloped uterus be made in this way.
As regards stenoses of the cervical canal itself, we have seen above that a general narrowness in nulliparte frequently occurs in connection with general under-development of the organ. Yet the abnormality may occur alone. Acquired stenosis, however, is a much severer malady. and appears especially as cicatricial bands and flap-shaped projections. The tendency to recontraction after dilatation renders this form especially hard to treat; and the malady causing the cicatricial stenosis (gonorrhcea or severe childbed diseases) has frequently caused other disturbances in the genitals and their neighborhood, which require special attention. We must here act as in flexions of the uterus, since a temporary dilata tion will sometimes suffice to relieve the sterility. We should dilate the canal, either rapidly with sound-like instruments, or more slowly with dilators. Intra-uterine pessaries may sometimes advantageously be left in situ. Thus in a woman who bad marked stenosis of the entire cervi cal canal, in consequence of a severe labor six years bef ore, a uterine stem was left in place a whole year by mistake. She bore it well, however, anti half a year after removing it I could still easily introduce a sound. But the tendency to recontmction is such, that in women who desire their sterility to be removed at all hazards, I always proceed to operation. The operation is attended with but little danger when the stenosis is not very deep-seated and full antiseptic precautions aro observed. A careful after-treatment, however, is necessary to keep the canal open. The reader is referred to the text-books upon gynecology for the details of the operation.
Cervical catarrh, occurring alone or with other physiological conditions of the genitals, deserves careful consideration in regard to its influence upon sterility. Radical treatment of the endometritis colli is of course
more reliable than an att,empt by the application of fluids, containing glycerine or tampons soaked in that liquid, to liquefy the tough cervical mucus ante (-alum, or to remove it by means of a speculum and a camel's hair brush. These latter may be done when treatment of the catarrh gives no results.
Ulcerations of the vaginal portion, ectropion of the mucous membrane of cervix and os, and lacerations, require appropriate treatment Of cervical tumors only fibroids and mucous polypi need detain us. Their treatment consists, of course, in ablation, followed by radical treat ment of the diseased mucous membrane. The sessile fibro-myomatous tumors of the cervix, when large, and malignant neoplasmata of the vagi nal portion, are of unfavorable prognosis as regards pregnancy, hence there need be no special treatment of sterility arising from these causes.
In cases of flexion of the uterus, the difficulty, as we have seen, lies in the marked stenosis of the internal os caused by the flexure. Treat ment must be directed to raising the organ, or at all events lessening the amount of constriction. This would be best done by re-establishing the normal relative positions of the uterine body and the cervix. We may endeavor to effect it either by intra-uterine pessaries or by giving external support to the organ. The first is by far the more efficacious means, and will be considered later; the latter, in spite of all the various forms of pessaries in use, will not enable us to entirely re-establish the form of the womb. A more or less marked angle will always remain behind. Nevertheless, these means of support are of some use in the treatment of sterility, since they diminish the angle, and bring the organ at least ap pro x i ma tely into the pelvic axis& But direct dilatation of the stenosed parts is more trustworthy. Al though the shape of the uterus is not re-established, conception is cer tainly rendered easier, and we see women who have long remained sterile from this cause have rapidly succeeding pregnancies after their first de livery, though the bend in the organ post partum is almost as great as it was at first. A similar dilatation may be attempted with instruments for the relief of sterility. That such dilatation is only temponu7, is. proven by the fact that women who have had flexions, and have suffered from mechanical dysmenorrhcea, often remain free from trouble for months afterwards. Such a temporary removal of the hindrance may enable the semen to reach the uterine cavity. It has been proposed to enlarge the internal os by discission, and the operation has been done; but the gers attendant upon it are too great for it to be allowable as a remedy for sterility, and there is but little chance of maintaining the opening patent.