MISCELLANY.

ON THE PATHOGENESIS AND TREATMENT OF STERILITY IN THE HUMAN FEMALE.

BY WM. C. ROGERS, M. D., OF NEW YORK.

Concluded from the October Number.

Sometimes, on the same day, one bougie, after remaining in a little while, may be withdrawn, and a larger one passed, but not often. Strictures of the os internum uteri, like strictures of the urethra in the male, are irritable and capricious, and must either be coaxed or taken when in good humor.

If it is going in, the bougie must pass in quickly, almost precipitately. I think I understood Dr. Kammerer to say that he also made use of steel bougies of graduated sizes. All I have to say about this is, that safe as these may be in skillful hands, and successfulthey have not been so in mine-they cause pain, and, I think, excite irritation and spasmodic contraction in the upper os, which makes it difficult to pass them through it; and if pushed in forcibly, might, I should think, do mischief. I can conceive of cases in which it might be necessary to incise the outer os, or to dilate the cavity of the neck with sponge or laminaria, in order to introduce the bougie; but when a hysterotome of any kind, a sponge-tent or slip of laminaria can pass, a slender-pointed, flexible, gum-elastic bougie, I should think, could be passed also, and with time and patience effect the object. Try to learn the course of the stricture, pass in the bougie in it, firmly and quickly, through the os, au fond. If it means to go, it will them, and may be retained for a longer or shorter time. I believe it would be well to leave it in for some hours. If you do not succeed after a short trial suspend the operation till a later day. If the stricture is, or becomes irritable, the more you try, the less likely you are to succeed. Success is either null or immediate. When complete dilatation has been obtained with a bougie of large size, the passage of it becomes easy, but it must be repeated at intervals; after menstruation; perhaps best in the true inter-menstrual period (ten or fourteen days after), for if the women should happen to have conceived, abortion would almost inevitable follow the introduction of the bougie into the uterine cavity. The bougie should be new, firm, and not too flexible, or it will double up and not pass. Bougies that have been used a few times are liable to this objection. If, after withdrawing the bougie, a laminaria tent could be introduced, and left à démeure some days, it

would be well; but it is not easy or always possible, and the bougie alone must be depended upon.

All these operations have for their object the facilitation of the menses and removal of dysmenorrhoea, and the allowing of an easier and freer entrance to the spermatozoa. But beyond this is the aid afforded to methods intended to effect the change in the uterine secretions necessary to insure the vitality of the spermatozoa. If this can not be done, our researches and conclusions upon this point in the pathology of sterility will be of no avail. It is to be effected, as far as I know, by cauterization, chiefly with nitrate of silver, introduced in the solid form, or by injection, into the cavity of the neck and uterus; although other substances are employed. Dr. Sims' pamphlet is unfortunately silent on this point. Courty ranks among curable causes of sterility, simple or complicated imperforation, congenital or accidental narrowness of the uterine orifices, the frequent cause of mechanical dysmenorrhoea; and says, by dilatation and double incision of the neck, he has obtained unquestionable cures of more than fifteen sterile women, whose fecundation followed the treatment in from three to five months. Flexions, when very decided, are causes of sterility, and uncurable when held down by adhesions; and he does not partake of the opinion of Mr. Joulin, on the small importance of deviations of the uterus as causes of sterility. He thinks that the glans penis should, at the moment of ejaculation, be opposite to the meatus uterinus; and that even a temporary restoration to the natural position (p. 1008) suffices sometimes for fecundation; and that after this, and after dilatation even, no time should be lost in attempting fecundation, and that certain positions of the female in coitus are preferable in some cases to others. Hypertrophy even of one lip, and conicity of the neck, congestion, inflammation, granulations and fungosities, are all obstacles to fecundation. This appears to be also the opinion of Kammerer, of C. Mayer of Berlin (1856), whom he cites in his paper.

In Dr. K.'s patients, retroversion (twenty), anteversion (eighteen), anteflexion (eighty-three), retroflexion (seventy-one), hypertrophy (sixty-five), small os (twenty-four), stricture of internal os (thirty-five) were the commonest lesions, and seven-eighths of the whole number were affected with some form or other of uterine catarrh. If the views which I have herein presented, relative to the occasional and frequent destructiveness of the accompanying secretions to the spermatozoa be correct, some of the sterility in them may be fairly, I think, attributed to it, and some of the successes to the means employed for its removal. Courty thinks that very abundant leucorrhoeal secretion may expel the semen from the uterine cavity, when it has once entered, and the very viscid, tenacious mucus which plugs the os oppose its entrance. Vaginal, he thinks less injurious than uterine mucus, the latter of which may have a very injurious inflence upon the relatively very small quantity of sperm which enters the uterine cavity (1012). He adds: In a great number of cases the great abun

Sometimes the semen is all instantly thrown off by the vagina, by too soon rising after coitus. (Sims 12).

dance of the leucorrhoea, and even its purulence, does not prevent fecundation.

Courty differs from Joulin as to the effect of a want of orgasm on the part of the female. He thinks it may occur without being felt or expressed, that it is capable of development and education, and hence fecundation seldom occurs until after some months (twelve, eighteen, twenty-four and thirty-six) of married life; again, in some cases of sterility, coinciding with perfect general health of the genitals, and only attributable to absolute defect of orgasm, even in women very desirous of becoming mothers; or awaking, together with fecundity, after a lapse of years, and thence pursuing the natural course of its evolution; a new lover, or husband perhaps, determining the result. But it is equally certain that many entirely cold and passive women are extremely fecund. Sterility on the other hand, may depend upon a totally opposite condition. Menorrhagia (a precocious abortus), or inter-menstrual menstruation, by its tendency to reproduce itself when the ovum is recently fecundated, becomes an obstacle to gestation. The number of causes, single or allied, upon which sterility may depend, should certainly render us sober of promise to women in whom it is only relative, and affords hope of recovery; while the very frequent realization of that hope, under well-directed treatment, should warrant a patient and continued effort on the part of both patient and physician.

Among the chief means of correcting the morbid conditions of the uterine mucus membrane upon which noxious secretions may depend, may be said to be cauterizations of the mucous membrane of the neck and cavity, and certain intra-uterine injections. The caustic most commonly in use is nitrate of silver, used externally to ulcerations and abrasions of the neck, and internally applied to the mucous membrane of the neck and cavity, to repress granulations and fungosities, to diminish hypersecretion, and by modifying the morbid condition of the glands which produce leucorrhoea, change the character of the secretion itself into one less injurious to the vitality of the spermatozoa. Upon this subject M. Courty says: "The cauterization may be performed, after dilatation, with a camel's hair brush, but as this is an unenergetic method, the idea has arisen to introduce the solid nitrate and apply it directly over the surface."

Various porte-caustics have been devised for this purpose, intended to secure the caustic from being broken off within the cavity. "But," says M. C., "having myself met with the accident and satisfied myself not only of its harmlessness, but of its happy results, I fix a piece of solid nitrate of silver, of suitable length, in an ordinary platinum portenitrate with a long handle; place the patient in supination; introduce a wooden speculum; examine very gently with a sound the direction of the utero-cervical canal, and immediately after carry the crayon of nitrate of silver even into the uterine cavity." This is easily said, but is it quite as easy to do? M. C. continues: "Instead of endeavoring to withdraw it intact, I use, on the contrary, all my endeavors to precipitate it, to break it off, which is not very easy to do, and I abandon

it in this cavity (p. 265). The vagina is then tamponed with a cloth. wetted in a solution of salt in water, sustained by a second one, and the speculum withdrawn." "I can say," he adds, "that I do not know any more heroic means than this little operation, which it is not often necessary to repeat, in the treatment of obstinate leucorrhoea. I have not observed serious accidents to follow it. Once only I saw atrocious pains, not yielding to baths, antispasmodics nor narcotics." The neck having swelled, and the os being occluded, he incised it some hours afterwards, to facilitate the expulsion of the mucus and caustic itself. In all the other cases, the pains, "even very strong in a small number of women," have always yielded, however violent, to general and local antispasmodics, and to cool hip-baths, with continuous vaginal irrigations, prolonged if necessary for some hours.

Those of my readers who may feel disposed to adopt this heroic and comparatively innocious and "incomparable" little remedy, 619, will do well to consult M. Courty's Traité Prat., &c., Paris, 1866, p. 264 and 7, 618. It is to be employed only, be it remembered, when the passages are freely pervious, and there exists neither metritis, perimetritis, ovaritis, flexion, deviation, stricture, nor constriction of orifices.

M. Courty is not in favor of intra-uterine injections. He says that they are the most dangerous that can be employed, and has seen them instantly followed by very formidable accidents, to say nothing of the possibility of their passing through the tubes into the peritoneal cavity and giving rise to fatal peritonitis. M. C. uses no other fluid than pure water, and even then only where there exists a perfect facility for the escape of the injected fluids.

Dr. James Kammerer, of this city, whose paper on Uterine Catarrh, reprinted from the American Journal of Obstetrics, vol. ii., No. 2, August, 1869, I have just been favored with, is a warm advocate, on the other hand, in their behalf, and uses them constantly with safety and success. When catarrh is accompanied with true angular anteflexion, the posterior lip of the uterus must be incised by Emmet's operation, to straighten the canal and provide for a free exit for the catarrhal secretion; and extreme smallness of the external os requires a bilateral incision. The patient being placed in a recumbent position, a sound is introduced into the uterus, and the depth, capacity of the cavity and the mobility of the organ accurately measured and ascertained. A cylindrical speculum is then introduced into the vagina. In order that an entire permeability of the cervico-uterine canal shall exist before the injection is attempted, Dr. K. is careful to dilate it by means of a series of sounds, four in number, of varying sizes, made of copper or German silver, of which exact figures are given on pp. 14 and 15 of the pamphlet alluded to. These are successively introduced through the speculum, until full dilatation of the canal is ob tained; after which injection and escape of the injected liquids are easy and safe. After washing out the cavity of the uterus with a longnozzled india-rubber bag syringe, the appropriate remedy, in liquid form, is injected. These are chromic acid, Lugol's solution of iodine,

dilute or concentrated, and carbolic acid diluted, and also sulph. zinci, ten grains to the ounce. Of carbolic acid as an intra-uterine injection, I find no notice in the three French works I have consulted, Joulin, Courty and Becqurel, and do not know with whom it originated.

Dr. Squibb, in a recent pamphlet, speaks of it as a mild local anaesthetic, useful in cystitis and leucorrhoea, and says that its use has often been favorably noticed in the foreign journals. Weak solutions of these dilute substances may be freely injected, raised to a certain temperature, not cold; but of the concentrated, ten to twenty drops is the most that can be safely injected, the dilute being in ordinary cases the most prudent. Caution and skill are necessary; for Dr. K. himself allows (p 23) that accidents may occur occasionally, notwithstanding the most careful observance of the rules he has laid down (p. 12). Dr. K. observes that he has often cured patients of their catarrh, as well as their sterile condition; but the peculiar morbid action of the secretions upon the spermatozoa, to which in this paper, I have endeavored to direct attention, is not, so far as I have observed, alluded to. Dr. K. remarks that a new cause of sterility, hitherto little attended to, may be a destruction of ciliary uterine epithelium from the too powerful application of escharotics. The direction of the cilia, however, is from, and not toward the uterine cavity. There can be no doubt of the safety and efficacy of intra-uterine injections in Dr. K.'s experienced hands, and many cases are cured by it no doubt, which would resist any other mode of treatment. Dr. K. looks upon uterine catarrh as the most frequent cause of sterility in the female, having met with it in three hundred and forty-two cases out of four hundred and eight, but without assigning any reason.

The womb, in the present state of therapeutics, must be looked upon as a meek and long-suffering organ, which endures with wonderful patience the rough handling, the burnings, slashings, pokings and scrapings it receives at the hands of the gynæ-atrics. Still gentleness and caution are necessary; for it does not always submit to them without resistance, remonstrance, or recalcitration.

If these remarks shall conduce to a better study and understanding of the causes of sterility, and a more successful treatment for its removal, my object in writing them will be happily attained. The action of the vagino-uterine secretions upon the spermatozoa, will soon, I have no doubt, become an interesting and important specialty, and I trust, will receive speedy and due attention.-Medical Record, Sept. 15, 1869.