On the other hand, congenital adhesions of the external genitals which completely close the introitus, do not form the object of treatment for sterility, for if the internal genitals are intact, a hematokolpos forms at pnberty, which demands treatment before any question of sterility can arise.
Atrophy of the external genitals, mentioned above, occurs oftenest in undersized individuals, though sometimes seen in those of large frame.
It may form an obstacle to conception from the narrowness of the vulva, although it will probably be gradually dilated by persistent attempts at cohabitation. Medical assistance may become necessary when inflamma tory nervous affection sets in. Operation will be rarely necessary, but the prognosis is doubtful, for the internal genitals are usually also atrophied.
Acquired stenoses of the external genitals usually occur from diseases in childhood, and almost always necessitate operation. From the fact that we are operating upon cicatricial tissue, special care is necessary in the after-treatment to prevent renewed adhesion.
Tumors of the external genitals may be excised. If the labia are very fat, and the penis but small, we must attempt by means of dietetic meas ures to reduce the amount of adipose tissue.
The physician is much more frequently consulted on account of ab normalities of the hymen. This is especially the case with the newly married, in whom the feeling of deception as regards sexual pleasures forms the first sad cloud in conjugal life, but it also occurs with older, inexperienced and bashful married people.
Complete hymeneal closure, of course, leads to hematokolpos, and de mands treatment long before marriage. But there are other abnormali ties of the external genitals, and especially vaginismus, which are of great practical importance.
I would recommend the following procedure in such cases: If the ex ternal genitals ate normal, and no nervous symptoms are present--if the husband is healthy, and the history shows that coitus has been unsuccess ful merely from lack of skill and experience—then full instructions as to the accomplishment of the act will be all that is necessary. The woman's pelvis should be elevated, and her legs widely extended, and she should carefully direct the male organ with her hand. This simple procedure is sometimes sufficient to earn the hearty thanks of a husband who has long exerted himself in vain.
If, however, in addition, the hymeneal ring is narrow, rigid, or thick, it should be dilated by the fingers, or with specula, or best with multi valve dilators. The membrane may be ruptured in our efforts, but in many cases a few bloodless dilatations will accomplish our object. Some time after the last dilatation cohabitation is to be effected as above de scribed.
If inflammation of the external genitals is present, we should avoid. all operative interference. Attempts at cohabitation should be stopped, and sitz-baths, lead-water lotions, and weak solutions of nitrate of silver, carbolic acid and sublimate be employed. Powdered iodoform I found too irritating in one case. If vaginal catarrh is present, the physician himself should make weak astringent injections by means of a csnula. After the inflammation has subsided, bloodless dilatation should be un dertaken.
Treatment is much more difficult when the nervous symptoms of vaginismus are present, and especially' when they rest upon an hysterical basis. Dilatation must be effected after the inflammation is subdued, and in most cases this is a very difficult task. Extreme slowness and caution are necessary not to frighten the patient and render her condition worse. At the first sitting a uterine sound should be passed; at the second a catheter; at the third a fair-sized Ilegar's dilating staff; and probably at tbe fourth the finger can be introduced without meeting too great resistance. Then dilators of increasing sizes, and finally multi valve expanding specula, may be employed. It is sometimes absolutely necessary to employ antesthesia, especially towards the close of treatment.
Not infrequently this procedure, which is that recommended by Scanzoni, will succeed, but there are cases in which all our efforts will be in vain. In these cases, if relief is absolutely demanded, the radical pro cedure of M. Sims will be in place. Circular ablation of the hymen, and incision and permanent dilatation of the vaginal entrance will certainly facilitate the introduction. of the membrum virile. The sensitiveness of the parts may be undiminished, but if the penis be skillfully introduced, the duration of the pain will be but slight.
Those who realize the melancholy consequences of marked vaginismus will feel more favorably inclined to the much-ridiculed method of " ethe real connection," (coitus during narcosis), which appears to have been frequently practised in America. Not only is sterility remedied, but the changes in the genitals at childbirth are such as most frequently to cure the malady itself permanently.
Pathological processes in the vicinity of the external genitals, which may interfere with cohabitation, and so cause sterility, as urethral car uncles, fissures of tbe anus, and coccygodynia, also need treatment.
When sterility or hindrance of cohabitation is caused by pelvic anoma lies, all therapeutic measures are contra-indicated; since the pelvic de formity which must be present is such as to give a very unfavorable prognosis to any intercurrent pregnancy.