Of vaginal atresias, only those in which the internal genital system is normal need be considered; and in these cases operation is undertaken not to remove sterility, but to give vent to the retained menstrual blood. It may be necessary to dilate the canal subsequently; a difficult task when it is long.
The higher grades of congenital vaginal stenoses must be treated in the manner laid down for cervical stenoses. Since the walls of the attic tured vagina, consist of normal tissue, they may be best dilated by means of small multi-valvular specula, thus permitting coitus to be practised.
It is much more difficult to dilate and maintain open acquired steno ses, since the tendency to recontraction is so great. Ring-slutped partial stenoses are most readily incised, and give the best prognosis.
In duplexity of the vagina the septum often interferes with cohabita tion, and thus hinders conception, or the larger vagina, which receives the penis, may end above in a blind sac. In either case the septum must be incised.
If vaginal tumors, or uterine tumors which project into that canal, form obstacles to cohabitation and conception, an operation is our only resource.
The various kinds of vaginal prolapse demand reduction and reten tion by means of suitable pessaries.
Hindrance of conception by vaginal, fistulte can only be remedied by the closure of the abnormal opening.
Women frequently believe that the flowing out of the semen from the vagina after coitus is the cause of their sterility. In that case the woman may see to it that her hips are in an elevated position, infra coituni, so that the vaginal vault lies lower than the introitus. The penis should be left in the vagina for a long time post efaculationem, thus helping to retain the semen until both the general muscular relaxation and the spas modic motions of the pelvic muscles which so often ex-pel the semen, have ceased. Crossing the leg-s immediately after intercourse, and remaining quietly in this position, may also help retention. The advice of the older physicians, which Eustache has recently reiterated, to push the semen further up the vagina as soon as the penis has been removed, seems very disagreeable.
Ilegar and Kaltenbach advise that immediately after intercourse the abdominal wall be elevated, so as to exercise an aspirating force upon the semen.
I have already recorded a successful case in which I prevented a too free outflow by perineorraphy; and when the rupture is extensive the operation, simple and not dangerous, will be called for by other symp toms as well as by the ensuing sterility.
The unfavorable influence upon the semen of the abnormal genital secretions which collect in the vagina have already been considered. In any case of sterility a marked leucorrhcea, whether it occur alone or in connection with other diseases, must be-treated. The text-books on gy necology give full particulars as to the treatment of vaginal catarrhs. Often it will be enough for us simply to minimize the vaginal secretion. The above-mentioned alkaline injections will be in place here; and while cohabitation may give no results during treatment, it possibly may im mediately after its cessation. Phosphate of soda has been especially recommended by Chariere. (Water thirty-two ounces, the white of one egg, and about two ounces of the drug.) Weak saccharine or glycerine solutions are said also to exercise a preservative effect upon the sperma tozoa. If these injections are made immediately ante coition, the injec tions should not be taken in the recumbent position, or the patient should stand up afterwards and exert the abdominal muscles to express any ex cess, for it is sufficient if the vaginal surface be simply moistened, and any great amount of fluid tends to wash away the zoosperms.
Anomalies and Diseases of the External Genitals.—Troubles of the ex ternal genitals usually hinder conception by preventing coitus or render ing it very- difficult. In liermaphroditism the internal genitals are usu ally so abnormal that there can be no question of reproduction at all. If, however, the internal genitals are normally female, and the condition depends solely upon malformation of the external organs, simulating the male parts, operative procedure to relieve the vulvar constriction may be successful. This is also the case when there is congenital adhesion of the labia. Though the labia may be so grown together as to be almost unrecognizable, they may be separated, and by carefully suturing the edges the rime pudendi can be re-established, and cohabitation and con ception rendered possible.