The dilatation may be effected in rhe same way as that of the stenosed cervical cavity. Rapid and forcible dilatation may be done, as Fritsch has recommended, by means of inflexible steel dilators, or Hegar's well-known dilating apparatus may be employed. With either of them dilatation should be accomplished, if possible, in one sitting. The method is the nine as that employed by Simon for the female urethra. In more sensi tive patients, and when the tissues are very resistant, gradual dilatation may be more advisable. I prefer, since we have mostly nullipayous women to treat, to use tents of sponge, gentian root, tupelo or laminaria; their even thickness and small calibre rapidly accomplishing our object. Hausmann's objection, that the antiseptics used may prove injurious to the spermatozoa, is not well founded, since the fluid has long disappeared before the tent is removed.
Where there has been no previous mechanical treatment, I resort to the following simple method: Lifting the body of the uterus manually or drawing down the vaginal portion with hooked forceps, if that be necessary, I introduce uterine sounds of varying size. Then I pass in Peaslee's instrument, which is constructed upon the principle of a urethral dilator, and dilate by means of the screw. This instrument is to be recommended because its upper end is so thin that it can be readily passed through the stenosed spot. A more forcible dilatation can be effected by Ellinger's instrument, or by the one which J. Schramm has recently de scribed, and the new American trivalve instrument may be employed to complete the dilatation. If possible theae instruments should be intro duced daily for several weeks, and they should be used in the order named. In this simple way I have seen conception induced in a short time in repeated eases. If in spite of this the stenosis rapidly returns, I do not he,sitate to employ the rather discredited intra-uterine stem, of course with the necessary precautions. I prefer those made of hard rub ber, and which rest upon and are supported by a pessary. At their first introduction the patient remains in bed, and of course they are re . moved during menstruation. If they are well borne, they may be left in situ for weeks and months, even during menstruation, Their use gives us also a much more favorable version, instead of the flexion. I have not observed the ill consequences which have been described, but of course they were only left in situ for lengthy periods of time when careful observation and repeated examination had shown that they caused neither objective nor subjective disturbances.
Sometimes the simple introduction of the sound is sufficient to cause conception to occur, and in very sensitive individuals, or where circum stances forbid other treatment, it may be tried. It is to be introduced
frequently, and finally is to be left in place daily for a short time. When anteflexion exists, and the uterus is not fixed, a cautious attempt might be made to reposit the organ with the sound.
In hopeless cases we might adopt Ilausmann's plan, and push the sperma which has attained the cervical canal up into the uterine cavity with a sound-shaped instrument I do not know if any su.ccessful cases have been thus treated, but certain disadvantages attendant upon artificial impregnation are present here also.
The above treatment, of course, is only indicated in true pathologic:al flexions, and then only in simple, non-complicated cases, which, I take it, are not so rare as is generally supposed.
From what we have said above concerning the complications of flex ions, it will be seen that mechanical treatment alone is not sufficient in all cases to relieve the sterility. The almost constantly present genital catarrh, and the pars, and perimetric processes must also be treated. If these appear to be the primary condition, our efforts must be principally directed against them. In fact they sometimes directly contra-indicate a, mechanical treatment of the flexion, until after the other troubles are relieved, and when the sterility persists.
In cases of flexion in which all the various methods of treatment have been unsuccessful, the following process has sometimes been employed: When, for one reason or another, the semen ejaculated into the vagina cannot reach the uterus, the surgeon may help its transfer by means of what is called artificial impregnation. Spallanzani did the operation successfully in dogs, but M. Sims was the first to try it upon the human being.
Almost all the cases of sterility due to congenital or acquired faults of vagina or cervix may be treated in this way. We need not mention them individually—they include any condition which mechanically or chemically can prevent the passage of the zoosperms. Yet it is only jus tifiable when all other means for the cure of the sterility have been ex hausted, and both man and wife have been fully informed of the dangers of the operation, and the small prospects of its success. Properly done, it is not dangerous to life, and it may be successful. It is our last resort in otherwise hopeless cases. There are no moral reasons against it either for physician or patient, but it is a disagreeable process for all parties. • So far as our experience yet goes, its value is but small. M. Sims 'himself saw conception ensue but once in twenty-seven cases. Doubtless many gynecologists have followed Sims's example, but the absence of all recorded cases shows that there have been no favorable results to note.