Nor should we neglect the important procedure of practising cohabi tation a la vache in marked retroversions; thus, instead of ejaculating the semen in the posterior vaginal vault remote from the os, as occurs in the dorsal position, the male urethral orifice is brought into close contact with the external os.
A. Edis recommends reposition in the knee-elbow position in these cases, the introduction of a pessary, and the practice of cohabitation in this position.
A. Sims has proposed to split the anteiior lip in anteversion, and the posterior in retroversion up to the os internum, and then to carefully keep the new channel open. This method of securing free access for the semen to the womb has found but few adherents.
Descensus and prolapsus uteri rarely cause sterility; and if they do, the treatment is the ordinary palliative and curative one for' these male dies.
Hernia of the uterus also need no special treatment to procure con ception. Reposition, though often difficult, and sometimes impossible t,o effect, is the main thing.
The various uterine displacements and especially retro-position, are, as we have before said, almost invariably the result of old pars- and peri metric inflammations, and these must constitute the objective points of our treatment. Here also catarrhal and exudative processes play the chief part.
We have already mentioned the important position occupied by endo metritis, as a causal agent of sterility; and we include in this catarrh of the entire genital tube, from the infundibuli of the tubes to the external genitals. They must form special objects of treatment, not only when we regard them as the direct cause of the infecundity, but even when they only occur as complications of other processes, for they are fre quently masked by other and more apparent disorders; while if they are cured, the obstacle to conception may either be entirely removed or at all events greatly lessened.
The more energetic treatment of endometritis which has recently be come common, promises a more favorable prognosis for sterility. I have repeatedly seen women, who had been sterile for years, conceive immedi ately after the uterine cavity had been curetted for the relief of the hem orrhage and fluor; and so have others, and especially A. Martin. But we must be prepared for many failures, for the catarrh seldom affects the uterus alone, but involves the tubes,which are not accessible to treatment.
If endometritis is recognized as the cause of the sterility, the diseased mimosa may be destroyed, and an opportunity for its regeneration given by an energetic curetting and subsequent local treatment. I need not here go into details; but will simply state that I remove the mucous membrane with the sharp spoon, and then cauterize the surface with a 50 per cent. carbolic acid solution applied with a Braun's syringe. This injection is repeated twice more, and then for eight days more a daily in jection of diluted tincture of iodine is made. Other methods may be used, but the curetting is the chief point. Simple cauterization is not sufficient.
Poesibly a like treatment may be applicable to cases of membranous dysmenorrhcea, a malady so unfavorable to pregnancy, and so refractory to treatment. I know of no recorded cases, however.
As regards chronic metritis, the cause of the sterility will be found in the never-failing endometritis, and it is rational to begin with the above mentioned treatment, though other general or local means are not ex cluded. Among these latter we may mention hot vaginal irrigation, massage, and the application of iodine.
The so-called acquired atrophy of the uterus will rarely be the ob ject of treatment quoad sterilitatem. General roborant measures must be our chief reliance, while local remedies will only be of subsidiary benefit The prognosis is not good, but there are cases in which conception has occurred, of which I have recorded one above. The prognosis will de pend ultimately upon the condition of the ovaries; if these are also atro phic there is but little to hope from treatment.
'Uterine fibromyomata, though frequently the cause of sterility, are not often treated on that account. They cause too much suffering; and in most cases they would form a serious complication in pregnancy and childbirth. Only where isolated sub-mucous fibromyomata and fibroid polypi can be easily removed per rims naturales, could a special treatment to permit conception to occur be entered upon. In all other cases the bad prognosis of pregnancy with these neoplasmata forbids all attempts to remedy the sterility.