138 THE TREATMENT OF STERILITY IX WOMEN.

any sustained dry period the risk of pollution isenhanced, and must be kept under close observation.Wherever the purity of the water is threatened,special means of purification should be undertaken.The readiest of these is chlorination, which shouldbe employed only under expert supervision. Properlychlorinated, water which ordinarily could not beused without some danger to health may be safelyput into service, and some water authorities mayhave to resort to such supplies in order to meetthe present emergency. Where general measuresof purification are not practicable, if any seriousdanger of pollution is ascertained, the individualhouseholders should be impressed with the needfor boiling the water used by them.Where expense has to be incurred by a local

authority in relieving water shortage in their districtCounty Councils and Rural District Councils are

empowered, under sections of the Local GovernmentAct, 1929, to contribute to the expenditure.

THE B.M A. MEETING.

THE ninety-seventh annual meeting of the BritishMedical Association opens at Manchester to-day(Friday) with the first session of the RepresentativeBody, which again meets under the chairmanshipof Dr. C. 0. Hawthorne. A strenuous four days’ workis anticipated by the representatives, and the agendacontains subjects lending themselves to almostunlimited discussion, including a national maternityservice, a specialist refraction service, the relation ofthe general practitioner to hospitals and the publichealth service, and such topical matters as thelicensing of motor drivers before their accidentsand the care of their injuries afterwards. At theannual general meeting, on Tuesday next, the newPresident, Prof. A. H. Burgess of Manchester, willbe invested with the badge of office and the President-elect for 1930, Prof. Harvey Smith of Winnipeg, will beintroduced to the meeting. The scientific sessionsbegin their deliberations, as usual, on the Wednesdaymorning. A popular lecture on Frogs and Men willbe given by Prof. A. V. Hill, F.R.S., on Friday,the 26th, and the following day will be taken up by anexcursion to Colwyn Bay. The annual exhibition willbe on view from Monday afternoon until Friday.

INDEX TO " THE LANCET," VOL. I., 1929.THE Index and Title-page to Vol. I., 1929, which

was completed with the issue of June 29th, is nowin preparation. A copy will be sent gratis to sub-scribers on receipt of a post-card addressed to theManager of THE LANCET, 1, Bedford-street, Strand,W.C. 2. Subscribers who have not already indicatedtheir desire to receive Indexes regularly as publishedshould do so now.

DONATIONS AND BEQUESTS.-Dr. H. T. George, ofHampstead and Cardiff, left 21000 to St. Bartholomew’sHospital and 2100 to St. Dunstan’s Hostel for the Blind.-Mr. Edwin Brough, of Hastings, left 21000 to the EastSussex Hospital.

THE OSLER CLUB.-A meeting of the Osler Clubwas held in the evening of July 12th to celebrate the ieightieth anniversary of Sir William Osler’s birthday. Sir iArchibald Garrod delivered the Oslerian Oration which Imarks these annual occasions ; his subject was the Powerof Personality, as exemplified in the teaching and practiceof medicine by Osler. A discussion followed, which wasopened by Dr. A. G. Gibson, and joined in by Dr. G. Feine,Prof. F. R. Fraser, and others. A selection of Osler’swritings on Medical Education was displayed, and manymessages were read which had been received from friendsand corresponding members of the Club abroad. Amongthose present were Sir D’Arcy Power, Sir William Hale-White, Sir F. G. Kenyon, Dr. Andrew Balfour, Mr. HughCairns, Mr. Philip Franklin, Dr. Marshall Fulton, Mr.R. H. Hill, Dr. Gerald Horner, Mr. Muirhead Little, Dr.J. D. Rolleston, and Mr. Paterson Ross.

Modern Technique in TreatmentA Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CCXCV.-THE TREATMENT OF STERILITYIN WOMEN.

PART I.-GENERAL CONSIDERATIONS.1

THE questions of sterility on the one hand and that.of over-fecundity on the other seriously affect thelives of women of all classes. The doctor is consultedwith almost equal insistency on the problems ofhow to acquire the wished-for child, at almost anycost, and of how to avoid acquiring another childfor a time at least.

Diagnosis of the Cause of Sterility.In dealing with sterility, every effort must be made-

to diagnose with exactitude the underlying causeor causes before any treatment is initiated. Casesof " functional " sterility become fewer as methodsof diagnosis improve. Treatment of a woman shouldnot be started, even when an obvious lesion exists,without proof that her partner is normal. Untilcomparatively recently the question of male sterilitywas not seriously considered. It is still usually thewoman who seeks advice, though I notice a growingtendency among my patients to come with a historythat their husband has been examined and foundnormal. It is, generally speaking, easier to dealwith the male side of sterility in private practicethan among hospital patients. Clinical facilitiesfor the necessary examinations and tests are not.great in hospital, and under the conditions that doexist the patient has diffidence in voicing hisrequirements.

Examination of the husband may be direct or

indirect. Direct examination involves, as well ashistory-taking and examination for any physicaldisability which might interfere with fruitful inter-course, the microscopic examination of the semenfor active spermatozoa. Indirect knowledge of thehusband’s condition with complete knowledge ofthe wife’s reception can be obtained in positivecases by microscopic examination of specimensfrom the cervix uteri taken within two to threehours of normal coitus. If active spermatozoa arefound, the search for the cause or causes of sterilityare much narrowed down. If impotence exists in thepresence of living spermatozoa, artificial inseminationcan be tried (see below), but should not be undertakenuntil the woman has been examined and treatedfor any lesion which might prevent a successful issue.

Investigation of the History.At a woman patient’s first visit, attention should

be paid to her general appearance, and guidanceas to treatment may be gained from a careful history,the main points being-age ; general health, past andpresent ; duration of married life ; whether thesterility is primary or secondary (if secondary,details of previous confinements should be given) ;menstrual history, as regards age of onset, periodicity,and flow ; presence of any abdominal pain-or vaginaldischarge, or of dyspareunia. The incidence ofcoitus, its frequency and the position taken shouldbe ’ascertained ; also details of any contraceptivemeasures used in the past. The family history mayalso be of interest. The reason for obtaining informa-tion on most of these points is obvious. Regarding themenses, although we know that pregnancy can

and does occur without them, a poor menstrualhistory is often associated with poor developmentof the pelvic organs and, especially if the patientis comparatively young, good results can be obtainedwith treatment directed towards stimulating

1 Part II., on Local Measures, will appear next week.

139THE TREATMENT OF STERILITY IN WOMEN.

development. With regard to dyspareunia, oftenassociated with incomplete coitus, as a cause ofsterility, it is surprising how long patients continueto suffer without seeking advice. Material help.can be given in some cases regarding the best timefor fruitful intercourse, which, in my experience,is the first week after the period. R. Kurzrok recordedtwo cases recently where Jewish women, misinter-preting the old Talmudic Law, waited consistentlyfor a full fortnight after each period before inter-course took place. When, according to advice,intercourse took place within a week of the onset ofHow, both women conceived readily.

It is also important that the wife should be ina positive phase of sexual excitability. Althoughit is very doubtful whether the cervix actually:gapes during orgasm, there can be no doubt thatreceptivity is increased when the emotion of bothparties reaches its height simultaneously.

The use of contraceptives has frequently been- cited as a cause of sterility. In view of the verypowerful drugs we use in the treatment of cervicitisand infections of the lower part of the genital tract,and failing statistics, my view is that such- contraceptives as quinine pessaries can hardly beso seriously culpable. Any device introduced and leftin the uterine cavity, such as the gold wish-bonepessary, or caps which fit tightly on to the cervixand hold up the normal secretions are almost certainto produce inflammatory changes and are muchto be deprecated.

Position during and after Coitu8.Conception takes place more readily when the

cervix is directly inseminated. In its normal positionin the posterior fornix this is best obtained by the’ normal " position for coitus-the wife lies on herback with the knees flexed and separated. Free.access is obtained, energy is in no way restricted,and there is the further advantage that the semencan be retained in the vagina. In patients withlax vagina and mobile uterus there is a tendencyfor the uterus to fall into the retroflexed positionwhen the thighs and knees are flexed. Such patientsafter intromission should straighten and adductthe legs. More important than the position duringcoitus, when the cervix is not well placed, is positionafter coitus. Semen can be retained in the vaginaby contraction of the sphincters and a change intothe semi-prone position. Muscular movement canthen further aid insemination of the cervix. It isin these cases that a saline or mildly alkaline douchebefore coitus may further help by retaining thevitality of the spermatozoa, which is soon destroyedin the natural acid medium of the vagina.

Methods of Examination.This involves a survey of the patient’s general

development, the condition of her thyroid, herpulse, and so forth, and a detailed local and bimanualexamination. Added to these are the methodsintroduced in the last few years of per uterineinsufflation and injection of the Fallopian tubes-methods which have revolutionised our views oncases of sterility. Before these methods of diagnosiswere available, the presence of tubal lesions could bedetermined only by bimanual palpation or suspectedfrom the history associated with minor degrees ofpelvic peritonitis. Now conditions of blockage arefound when little suspected and their site definedwith a view to treatment. In certain cases the methodof diagnosis alone has worked a cure.

Uterine ZMSMjaHMon.—It was in 1920 that Rubin readhis first paper on insufflation and not long afterwards S.Forsdike and others were successful in obtaining goodresults from the injection into the uterus and tubes ofa solution opaque to X rays. Now both methodsare greatly improved and widely practised. Neithercan be used in inflammatory conditions of the tract,when uterine haemorrhage exists, on account of therisk of air-embolism, or in patients with cardiacor other serious lesions. The insufflation method

can be practised without anaesthesia and is indeedonly complete under these conditions, becausethe patient’s sensations are of value in diagnosis,localised pain being felt at the site of blockage.The apparatus consists in a cannula that entersthe uterus, fitted with an " acorn," which pushesfirmly into the external os. Air or gas is driventhrough the uterus and tubes at a known pressure.Leakage can only be prevented by firm pressureof the acorn into the os, firm traction of the cervixdownwards on to the acorn or clamping the cervixon to the cannula. Many patients do not bearthis procedure well. If we use anaesthesia for insuffla-tion, it is possible to say only whether the tubes arepatent or impermeable. For the anaesthetised patientdilatation is performed and a cannula that fits tightlyinto the cervix is used.

ZecMoM.—Lipiodol is the fluid of choice for theinjection method. Since its presence in the pouchof Douglas has been found by experience to beinnocuous, the only disadvantage of this methodis the obvious one that X ray apparatus must beavailable for its practice. In other respects it is

essentially more satisfactory than insufflation, theapparatus being simple (a 10 c.cm. serum syringeattached to a cannula with acorn, as describedabove), leakage obvious, and the results to be seen,rather than to be interpreted. Injection can be doneequally successfully with or without anaesthesiaaccording to the requirements of the patient, anda permanent record can be kept of the results obtained.

FRANCES M. HUXLEY, M.D., Ch.B. Manch.,Surgeon to the South London Hospital

for Women.

The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Capt. B. P. Pick to Egmont, for Malta Hospital.Surg. Comdrs. L. W. Gemmell to Ganges, for R.N. Sick

Quarters, Shotley ; G. H. Hayes to Pembroke, for R.N. Hospl.Gt. Yarmouth ; J. F. Hayes to President, for RecruitingHeadquarters ; R. F. Quinton to -Dectcg ; H. H. Ormsbyto Vernon and J. H. McDowaIl to Pegasus.

Surg. Lt.-Comdr. A. W. McRorie to il-,Iedway and (oncombing.).

Surg. Lt. J. K. G. Way to Ark Royal.

ROYAL NAVAL VOLUNTEER RESERVE.

Surg. Lt. (D.) C. T. Pomeroy to Vivid, for R.N. Barracks,Devonport.

ROYAL ARMY MEDICAL CORPS.

Capts. P. A. Stewart (prov.) and W. C. Mackinnon tobe Majs.

ARMY MEDICAL RESERVE OF OFFICERS.

2nd Lt. R. H. Bland, from Gen. List, Jnf., to be Lt.

TERRITORIAL ARMY.

Col. J. S. Riddell (late R.A.M.C., T.F., retd.) to be Hon.Col. R.A.11LC. units, 51st (Highland) Div., T.A.

Capt. R. J. W. A. Cushing to be Maj.C. R. Greene to be Lt.Supernumerary for service with O.T.C. : Lt. H. S. Allen

to be Capt.TERRITORIAL ARMY RESERVE OF OFFICERS.

Maj. H. G. L. Haynes from Active List, to be Lt.-Col.Maj. C. Webb-Johnson having attained the age limit

relinquishes his cominn. and retains his rank.Lt. A. S. Gough, from Active List (Supern. for serv. with

Med. Unit, Univ. of Lond. Contgt., Sen. Div., O.T.C.),to be Lt.

ROYAL AIR FORCE.AUXILIARY AIR FORCE.

Flying Officer J. S. Jerome, N. 605 (Co. of Warwick)(Bomber) Squadron, to be Flight Lt.

INDIAN MEDICAL SERVICE.

Temp. Capt. Mangharam Rochiram Lalvani relinquisheshis temp. commn. and retains his rank.The undermentioned relinquish their prob. appts.:

Lts. W. Walsh and G. J. O’Connor.