and miscarriages. An inflamed endometrium, for instance, offers a poor soil for the growth of an ovum, so that fetal development is likely to be arrested, the pregnancy ending in a miscarriage; but the ovum may also be washed out by hemorrhagic and leucorrheal discharges, before it ever becomes imbedded, and perhaps before it is fertilized.

Diagnosis.-Fecundity depending upon the union of elements derived from two individuals, it is proper in a case of sterility to look for the cause or causes in both persons concerned; but, unfortunately, it happens that the husband, while he is quite willing to submit his wife not only to the most searching physical examination, but even to operative procedures, absolutely refuses to be examined himself. There is, sometimes, a lingering doubt in his mind that the fault might be on his side, and he dreads above all to acquire this certainty, or at least to let his wife know it. If he is willing to give the necessary information, he should, first of all, be questioned in regard to copulation, ejaculation, syphilis, and gonorrhea. The proper position of his meatus urinarius should be ascertained. His urethra should be carefully examined with a bougie-à-boule or an endoscope as to caliber and small pus-secreting surfaces lurking behind strictures. Finally, his semen must be examined microscopically. The proper way of obtaining it unmixed with foreign substances is to let him have intercourse with his wife, using a condom. Immediately after copulation this bag with its contents is thrown into a wide-mouthed bottle and brought to the physician, who examines it without delay. If the man's semen is full of living spermatozoids, the examination may be extended to the woman, in order to find out if there is any discharge in the vagina that kills the spermatozoids. For this purpose the husband should be allowed to have normal intercourse with his wife, and shortly after the act a little semen should be removed from the posterior vault of the vagina with a Simon's spoon and examined microscopically. Often it suffices, however, to examine the woman without having recourse to this somewhat repugnant procedure.

In examining the woman the physician will bear in mind all the malformations and diseases just enumerated that may entail sterility. The vaginal secretion should be tested with litmus-paper. It is normally acid, but it may be so to such a degree that it kills the spermatozoids. It should also be examined microscopically for pus-corpuscles, the presence of which always shows inflammation. The uterotubal mucus is obtained by introducing a speculum and taking the mucus directly out of the cervical canal. This is normally alkaline, and any acid fluid is deleterious to the spermatozoids.

Treatment. In regard to the treatment of the man the reader is referred to works on venereal diseases.

Often a certain mutual adaptation seems to be necessary. Nothing is more common than that impregnation does not take place immediately upon entering upon marital relations. Many months may even elapse before it occurs between perfectly healthy individuals. A little patience is, therefore, always to be recommended. But, on the other hand, accurate statistics have shown that three-fourths of married women get a child in the course of the first year of their marriage, and that if three years elapse without offspring the chances of having children become very small. As a practical rule, we may say that if a woman does not conceive during the first year of her marriage, and wishes to become a mother, she had better seek medical advice.

The entrance of the semen into the uterus may be favored by raising the pelvis during copulation or by coition modo brutorum. Traveling has a marked influence, which may be due to climatic influences, change of diet, or, more likely, the diversity of couches.

The causes of sterility in the female being so manifold and comprising most of the malformations and diseases treated of in this work, the treatment will, of course, also vary much, the general rule being to remove, if possible, whatever cause or causes we may find by the means indicated in the preceding chapters.

Anemia is treated with iron, manganese, strychnine, cod-liver oil, terraline, and a diet in which albuminoids preponderate, and into which enters the use of milk, beer, or wine. Adipose tissue is reduced by iodine, fucus marina, exercise, massage, Turkish baths, and a diet from which sweets and cereals are nearly excluded, and in which liquids are limited as much as possible.'

A too small uterus may sometimes be enlarged by the galvanic

current.

Many different operations may be called for in order to remedy sterility. The labia may have to be separated; a resistant hymen removed; a painful caruncle destroyed; a vagina made; or an elongated cervix amputated. The cervical canal may require dilatation, which may be kept up by the use of Outerbridge's permanent dilator (p. 184); a polypus may have to be cut off; a spongy endometrium may need curetting, etc. Sometimes the operation required is not one of division, but of union, as when a torn perineum and vagina are repaired or trachelorrhaphy is performed. A torn cervix would seem to favor impregnation by offering freer entrance to

1 Such a diet should be composed of beef, mutton, veal, pork, game, poultry, eggs, fish, lobsters, crabs, shrimps, oysters, clams, scollops, muscles, cheese, green vegetables, lettuce salad, and a small amount of juicy fruit, with a pint of claret or Moselle wine, a cup of black coffee, a cup of tea without milk, and four ounces of bread per day. Butter and other fats are harmless. Forbidden, on the other hand, are soups, water, milk, beer, potatoes, beets, puddings, pies, and other sweet dishes, as well as bananas.

the interior of the womb; but, on the other hand, the endometritis following the tear is a barrier to conception; and, as a matter of fact, I may state that I have repeatedly removed sterility by this operation.

Laparotomy or colpotomy will hardly be undertaken for sterility alone, since it would risk an existing life in the uncertain hope of rendering another possible; but when it is undertaken for legitimate causes, it may perhaps even cure sterility, if the operator finds it possible to leave one or both ovaries and render the tubes permeable (p. 533).

When all other means fail, or no cause for the sterility can be found, or the woman refuses any kind of cutting operation, we may yet try artificial impregnation. Since the fundamental condition of fecundity is the union of a spermatozoid and an ovum (p. 121), since in most cases it is an easy matter to introduce semen all the way up to the fundus of the uterus, and since artificial fertilization is used on a large scale in pisciculture, one would think that artificial impregnation of a woman could likewise be performed without difficulty. But it is not so. It has been tried many times, but has nearly always proved a failure.

The operation is very simple. The semen of the husband having been found normal, and especially after ascertaining that it does not contain pus-corpuscles, he has intercourse with his wife, using a condom. This he brings to the physician waiting in another room. The latter has in readiness an intra-uterine syringe (p. 172), properly disinfected and kept warm. He sucks a small amount of semen up with the syringe, exposes the os uteri with a speculum, wipes it off with cotton dipped in some antiseptic fluid, introduces the nozzle up to the fundus, and expresses a few drops slowly into the interior of the womb. The woman should stay in bed on her back, and if she feels any pain an ice-bag should be applied to the hypogastric region. The most favorable time for performing the operation is shortly before menstruation is expected, and the next best period is immediately after the catamenia (p. 119). It may, of course, be repeated during several months, if the first attempt does not succeed.

II. LACK OF ORGASM.

A CONDITION for which we are not infrequently consulted is lack of the normal feeling of the highest sexual excitement called orgasm (p. 121). Both the husband and the wife deplore a defect which deprives the marital relation of its highest physical satisfaction, and some knowing women, in order to retain their husbands' affection,

simulate a state which does not exist in reality. Some women have never felt this sensation. With them the fault is congenital, and is probably due to some imperfection in the central nervous system. Others know the sensation from previous experience, but have lost the faculty of feeling it. Some feel it dreaming, but never during intercourse. The lack of orgasm, both the primary and the secondary, may be found in otherwise perfectly healthy women, and is not a barrier to conception.

Primary lack of orgasm is incurable, and it is very doubtful if the acquired form allows us to give a better prognosis. In my own practice I have constantly failed with the use of tonics, the galvanic current, and aphrodisiac drugs, such as damiana, phosphorus, and cantharides.

III. INTESTINAL SURGERY.

IN operations on the internal genitals, especially ovariotomy and salpingo-oophorectomy, the gynecologist is sometimes incidentally forced to operate on the intestine. A short description of the chief operations of this kind, such as resection, lateral anastomosis, end-toend approximation by artificial invagination, the use of the intestinal button, and the removal of the appendix vermiformis, may, therefore, not be out of place here.

A. Resection of Intestine.-The bowels are squeezed empty for five or six inches in either direction from the part to be removed and compressed with special forceps (Murphy), a safety-pin and sponge (Maunsell), a strip of gauze, or an elastic ligature carried through a hole in the mesentery and tied round the intestine. The intestine is cut across, and the mesentery is treated in one of two ways, either by excision or by folding. Either a wedge is cut out, the base of which corresponds to the piece of intestine to be removed, and the apex to the root of the mesentery; next, the two edges are stitched together, according to the thickness of the mesentery, by a single running suture or by a double, stitching each layer of the mesentery separately. Or the mesentery is cut along the piece of intestine to be removed, using blunt scissors, and separating the peritoneum as much as possible from the intestine before cutting it. When the ends of the intestine have been brought together, the edge of the mesentery is doubled up and stitched together, and the flap formed in this way is itself fastened to the remainder of the mesentery with a few stitches.

B. Lateral Anastomosis.'-A part of the intestine having been resected, each end of the inverted gut is closed with a double row of continuous sutures with fine black silk. Next, the mesentery is 1 Robert Abbe, Med. Record, April 2, 1892, vol. xli. p. 365.

divided sufficiently to draw the ends of the severed gut past each other, so as to make them overlap for six inches (Fig. 332). In this position they are sutured together by two rows of Lembert sutures, a quarter of an inch apart, carrying a running suture of finest black embroidery silk with a cambric needle. Half a dozen such needles should be threaded with silk threads twenty-four inches long, and the silk tied to the eye of the needle with a simple knot, leaving a short end two inches long. The lines of sutures are made about five inches long, and the two needles are left on their silk threads. Next, an incision four inches long is made with scissors in both ends of intestine, a quarter of an inch from the nearest of the two sutures, applying hemostatic forceps to bleeding points. Next, another overhand suture is started at one end of the incision, uniting the two edges nearest the previous sutures, and penetrating both serous and mucous coats, which arrests hemorrhage. This suture is then continued round each of the two free edges separately. Finally, the needles

of the first two sutures are taken up one after the other, and used to complete the double row of Lembert sutures around the opening made in the intestine.

There is no doubt of the excellence of this operation, but in order to be performed within a reasonable time it demands a hand used to that kind of work.

C. End-to-end Approximation by Artificial Invagination.'-Two temporary sutures are placed, one at the mesentery and one just opposite, carrying them through all three coats of the two ends of the severed intestine. Next, a longitudinal hole, one and a half inches long, is cut in the larger part of the intestine one inch from the end, and the two temporary sutures are hauled out through this opening, carrying the end of the intestine after them. Ten horsehair or silkworm-gut sutures are now carried through both walls of intestine (Fig. 333), picked up in the middle, and cut, thus forming twenty 1 H. Widenham Maunsell, Amer. Jour. Med. Sci., March, 1892, p. 245.