Apart from impotence in the male, the hymen may remain intact when it is not touched at all during coitus. Inexperience, as Veit remarks, will in this matter lead to results almost incredible. This author has been informed by such inexperienced married couples, that in attempts at intercourse “the penis of the man is introduced between the thighs of the woman, which are closely pressed together, the man having his legs on either side. Naturally, in this method of intercourse, the hymen escapes destruction. In such attempts at coitus, things are done which can hardly be compared with the normal act of copulation.”

In isolated instances, the introduction of the penis is prevented by congenital or acquired defects in the formation of the external genitals. Adhesion between the labia majora and the labia minora is sometimes met with a congenital deformity, which may or may not be associated with atresia of the urethral orifice; in some cases the adhesion is dependent merely upon a superficial epithelial continuity, but in others the labia are firmly adherent throughout. Less rare are acquired adhesions, the result of accident, between the labia majora and the labia minora, leading to atresia of the vulva, and thus making copulation impossible.

When, notwithstanding malformation of the external genital organs and partial absence of the vagina, there is no defect in the internal genital organs, conceptions may sometimes be effected through some abnormal channel, as for instance through a communication established per anum; or, again, some operative procedure may bring relief. Rossi reports a case of congenital absence of the external genital organs, in which an incision was made in the region of the absent vagina, and an artificial vagina was thus constructed; copulation was in this way rendered possible, and conception ensued. In this connection, we may turn with interest to the essay by Louis, entitled Deficiente Vagina, Possuntne per Rectum Concipere Mulieres? Here we are told of a case in which vulva and vagina were absent, and there was a monthly discharge of blood per anum; the woman’s lover employed this passage also ad immissionem penis, and the woman became pregnant. Pope Benedict XIV expressly allowed to women suffering from imperforatio vaginae the practice of coitus parte posteriori.

Further, in cases of atresia vaginae in which the genital canal terminates in the urethra, conception can result from urethral coitus, as is proved by cases recorded by K. von Braun, Weinbaum, and Wyder. In Weinbaum’s case, the obliteration of the vagina was complete, neither eye nor finger could detect the slightest aperture; the woman having become pregnant after coitus per urethram, delivery was effected by Caesarian section. In Wyder’s case, the vaginal orifice was closed, with the exception of a minute aperture, by means of dense fibrous tissue; the woman was in labour and the head of the child was in the pelvis. Under anæsthesia, the septum, which was nearly an inch thick, was divided, the opening was enlarged, and the child was extracted by forceps. An investigation disclosed that the husband had always had intercourse by introducing his penis into the dilated urethra; it was evident that the semen had passed through the urethra into the bladder, and thence had found its way through a vesico-vaginal fistula into the vagina and uterus.

Acquired obliteration and stricture of the vagina from the contraction of scar tissue, in consequence of deep ulceration, especially when croupous or diphtheritic in nature, following typhus or typhoid, pyaemia, puerperal sepsis, and the acute exanthemata (especially variola)—may likewise serve as obstacles to coitus. Syphilitic affections also, through contraction of exudations, the adhesion of ulcerated opposing surfaces, condylomata, etc., may give rise to stricture or obliteration of the vagina. The same conditions may be induced by trauma, as by wounds, by attempts at rape, or by the use of caustic acids and alkalis.

Thus, Ahlfeld saw severe stricture of the vagina as a sequel of the excision of four large condylomata. Hennig the same, after variola, and again in lunatics who had introduced caustic fluids into the vagina. By L. Mayer, atresia vaginae was seen as a sequel of typhoid; by Weiss as a sequel of diphtheria; by Martin from the action of irritant secretions in cases of uterine tumour; by Billroth as a result of continued irrigation of the vagina with alkaline urine after lithotomy or urethrotomy, and in cases of vesico-vaginal fistula. Ulcerative processes set up by the long continued action of a vaginal tampon, a pessary, or some other foreign body, have been noted as leading to consecutive obliteration of the vagina.

Such stenosis, when partial only, may prevent complete coitus, and yet allow conception to occur. Cases illustrating this fact have been numerously recorded. Thus, van Swieten already reported the case of a girl aged sixteen years, whose vagina was strictured to such an extent that the passage would barely admit a crow-quill; nevertheless she became pregnant, and was successfully delivered. Similar cases are mentioned by von Scanzoni, Kennedy, Devilliers, Varge, Moreau, and Plenk.

Serious obstacles to coitus, of a nature analogous to acquired stenosis of the vagina, are constituted by the irregular ligamentous bridges which sometimes arise in the vagina from the adhesion of a strip torn from the mucous membrane on one side of the vagina to the other side of that tube—or, again, a portion of a lacerated cervix may adhere to the wall of the vagina. An interesting case of this nature came under my own observation. It was a woman aged thirty-two years, who had twice had difficult deliveries, the last time nine years before. Since then she had been barren. On local examination I found in the vagina a fleshy bridge, about 4 cm. (1.6 in.) wide and 6 cm. (2.4 in.) long, extending from the left side of the portio vaginalis to the right wall of the vagina; this mass of tissue was so placed that the intromitted penis must necessarily have slipped past it into a blind sac, such as the French name une poche copulatrice. Similar membranes in the vagina have been described by Breisky, Murphy, and Thomson.

Various tumours may narrow or even completely close the vaginal passage, myoma, sarcoma, carcinoma, and especially the polypoid form of fibromyoma, which may even project without the vaginal orifice. And even when tumours of or in the vagina do not actually hinder coitus by the space they occupy, they may affect that operation by bleeding whenever it is undertaken, a manifestation extremely alarming to young married persons.

Tumours of the rectum and other intrapelvic growths may encroach upon the vaginal passage and impede coitus. Closure of the vagina has been brought about even by abnormal size and abnormal toughness of the perineum.

Finally, in extreme degrees of pelvic contraction, the vagina may be so much narrowed as to interfere with coitus. Von Hofmann records a case of this nature: In a woman thirty years of age, affected with kypho-scoliosis, who suffered extreme pain whenever her husband attempted sexual intercourse, the pelvis was twisted and narrowed to such an extent that the conjugate measured barely one inch, and the vagina was so small as barely to admit the finger.

Duplication of the vagina will constitute an obstacle to coitus when both halves of the passage are too narrow to allow of intromission of the penis. Difficulty in intercourse will also be caused by abnormal termination of the vagina, as by its termination in the rectum, likewise by severe perineal laceration which has converted the lower parts of the vagina and rectum into a cloaca, likewise by recto-vaginal and vesico-vaginal fistulæ; in the case of all these latter states a feeling of disgust is apt to be aroused in the male which may effectually check sexual desire. Still, coitus, and even conception, are quite possible in these conditions. Kroner, among sixty cases of vaginal fistula, observed six in which conception took place while the fistula was actually open.

Apart from all local pathological conditions, coitus may be interfered with by general nervous disturbances, manifesting themselves locally, and depriving the woman so affected of potentia coeundi. First among such states must be mentioned vaginismus, a condition so important as to demand discussion in a separate chapter.

An important and by no means rare obstacle to the completion of intercourse, affecting the male partner in the act, is partial or complete incapacity for erection of the penis. Even excessive smallness of the penis may render coitus inadequate; still more so, however, organic diseases of the membrum, such as obliteration of the corpora cavernosa, or of some of the trabecular channels of these bodies, nodular formations resulting from injury, or cavernitis from gonorrhoea. In such cases, erection is extremely irregular, and the erect penis is sharply bent (chordee) instead of being straight, a condition which renders intromission mechanically difficult if not impossible. A similar effect is produced by ossification of some part of the tunica albuginea of the corpora cavernosa—the so-called penis bone. Mechanical obstacles to coitus are also offered by inguinal and scrotal hernias; and by excessive obesity, where the increase in thickness of the panniculus adiposus of the abdominal wall and the mons pubis, whilst the penis itself remains as slender as before, causes the organ almost to disappear from view.

Psychical impotence in the male is much more frequently observed than organic impotence. We meet with this condition especially in neurasthenically predisposed individuals, or in men who have been given to excessive venery or have masturbated excessively in youth, and who, when entering upon married life, fear they will be unable to satisfy the legitimate desires of their wives; or in newly married men who have suffered often from gonorrhoeal inflammations, such as prostatitis, vesical catarrh, and epididymitis. The fear and anxiety from which such persons suffer has an inhibitory influence upon the erection of the penis. In some instances, this inhibitory influence is partial only, and the man thus affected, while perfectly competent in intercourse with a prostitute, who employs means of sexual stimulation to which he has become accustomed, is unable to complete intercourse with his wife, who is ignorant and innocent, and assumes a purely passive role; or it may be that erection is not sufficiently powerful to bring about rupture of the hymen, and thus to overcome the difficulties primae noctis.

As regards gonorrhoeal infection, it appears that in men who in other respects are perfectly competent, this disease has an inhibitory influence upon the nervous mechanism concerned in producing erection of the penis.

Psychical impotence is usually transitory, but it may endure for a very long time; and it may be many months before the husband, whose nervousness has led to failure in the decisive moment at the outset of married life, is able to command an erection sufficiently powerful to bring about the defloration of his wife. Occasionally such psychical impotence is not absolute but relative, it relates, that is to say, to one particular woman—unfortunately, as a rule, a man’s own lawful wife,—whilst coitus with another woman, even in default of any measures for artificial sexual stimulation, is easily effected. This fatal misfortune is especially liable to occur in cases in which a man fully experienced in sexual matters marries a woman whom he dislikes or for whom he has no regard; the marriage being determined by material considerations. From such women I have heard the painful confession that the husband, a man renowned for his gallantries, played a very poor part in the bridal bed.

The impotence of irritable weakness is characterized by premature, and therefore fruitless ejaculation. A man thus affected has a powerful erection of the penis, preparatory to coitus, but at the moment of contact with the female genital organs, before there has been time for penetration to occur, ejaculation takes place, and is immediately followed by relaxation of the penis. Such irritative impotence is often met with in young men at the outset of their sexual career, in beginners, whose sexual passion is very readily excited, whose imagination shoots forward to the goal, and who are unable to restrain themselves. This form of impotence can also be cured by wisely chosen measures.

The paralytic form of impotence, on the other hand, is characterized by the entire absence of erections of the penis, both overnight in bed, and during the early morning hours; the penis always remains flaccid, or at most becomes semi-erect only, insufficiently rigid for penetration. Ejaculation is much retarded or altogether wanting.

Impotentia coeundi in the male may be complete, in cases in which the erection-apparatus is entirely inactive, and in which even an attempt at intercourse is out of the question; or, and this is more frequently met with, it may be partial only, and manifests itself in various degrees of imperfection in the performance of coitus.

This latter form may often escape the woman’s notice. Whilst complete impotentia coeundi, in which intromission of the penis is impossible, is a state about which neither husband and wife can fail to be fully informed, cases of partial impotence, with semi-erection of the penis or premature ejaculation, are often glozed over by the husband, ignored by the wife, and underestimated by the physician—and yet such incomplete intercourse entails a series of ill-consequences alike upon the genital organs and upon the nervous system of the wife. Erection is incomplete, and thus the penis passes into the vestibule only, and not deep into the vagina; even if penetration is more thorough, the venous return of the blood from the corpora cavernosa is not checked sufficiently to distend the penis to its full size, and to bring it into close contact with the vaginal walls; or ejaculation occurs prematurely, before the sexual organism of the wife has attained that supreme degree which is needful alike for the attainment of sexual gratification and for the occurrence of conception.

Vaginismus.

Vaginismus is a disordered state, characterized by hyperaesthesia of the hymen and of the entrance to the vagina, so extreme that, even though the organs may be entirely free from any anatomical abnormality, coitus is prevented, whenever attempted, by violent, involuntary spasmodic contractions of the constrictor cunni and the other muscles of the urogenital and anal region.

The centripetal paths of the reflex spasm characteristic of vaginismus, run through the branches of the inferior hypogastric plexus, and especially through the utero-vaginal plexus. The spinal nerves connected with this part of the sympathetic are the 2d, 3d, and 4th sacral. The plexuses are constituted by fibres in part from sympathic and in part from the 2d, 3d, and 4th sacral nerves. Through the same nerves passes the centripetal motor tract for the transversus perinei muscle, and for the sphincter and levator ani muscles. According to Eulenburg, the centre for this reflex is to be found at the level of the first sacral nerve; when the disturbance irradiates more widely, the lumbar and sacral plexuses as a whole are involved. The constrictor cunni (sphincter vaginæ or bulbocavernosus muscle) is supplied by the perineal branch of the pudic nerve. The symptom-complex of vaginismus consists of violent spastic contraction, for a term varying greatly in duration, of the constrictor cunni (bulbocavernosus), sphincter ani, levator ani, and transversus perinei muscles, the spasm spreading, in severe cases, to other muscles in the neighbourhood, and especially to the adductor muscles of the thigh; the spasm comes on when any attempt at intercourse is made, and even when the genitals are merely touched.

In young married couples especially, vaginismus is an extremely distressing condition, and one that entails very serious consequences, inasmuch as the pains and reflex spasms which result from any attempt at coitus, and even from the mere approximation of the penis to the female genital organs, render sexual intercourse absolutely impossible. The cause of this pathological manifestation is in part to be found in unskilful attempts at intercourse, which have stimulated the female genital organs at some improper region. It may be that the young husband is not fully instructed in sexual matters, and does not really know how coitus ought to be effected; in other cases there is some abnormality of the hymen, which has rendered the rupture of that membrane extremely difficult; in some cases there is partial impotence in the male, whose penis becomes semi-erect only, so that ever-renewed attempts at intercourse are followed by ever-renewed failure. Any of these causes may suffice, in susceptible women, to originate vaginismus. The sufferer in these cases will usually be found on enquiry to be hereditarily predisposed to nervous disorder, and to be extremely sensitive to pain. By the fruitless efforts of her ignorant or partially impotent husband, she is sensually excited without ever being satisfied; the injured nervous system responds by these local spasms, whilst ultimately, in some of these cases, an actual psychosis ensues.

In a certain number of cases, however, the husband is in no way responsible for the origin of vaginismus, which may depend on pathological states of the female external genitals, leading to hyperaesthesia; or, again, on primary hyperaesthesia of the pudic nerve and its branches; or, finally, on general neurasthenia and hysteria, on excessive sensibility and lack of self-control on the part of a young girl, who has entered upon married life under the dominion of extravagant ideas. Vaginismus dependent upon general neurasthenia especially in cases in which there is no strong affection for the husband to give the spur to desire, and to enable the woman to bear with fortitude the pangs which form the necessary introduction to the joys of wedded life. It must not be forgotten, as throwing light on the origin of vaginismus, that in the digital vaginal examination of a virgin or even of a young wife, unless extreme care is taken, pain and painful muscular spasms are liable to be evoked.

A case came under my own observation in which a newly married woman suffered from vaginismus. The husband believed the cause of the trouble was his own partial impotence, consequent upon youthful venereal excesses, and yielded to the desire of his wife and her relatives that a divorce should be obtained. A year later, the woman remarried, when, to her horror, the symptoms returned in full force. Now for the first time she consulted me, and on local examination I could detect no abnormality whatever. The vaginismus was in this instance a pure neurosis, the only possible cause of which was to be found in bygone overstimulation of the vaginal orifice, the wife admitting previous onanistic excesses. In another case known to me, vaginismus in the wife made the husband an involuntary sodomite. The movements of the wife when the spasm came on led to the introduction of the penis per anum, and coitus had repeatedly been effected by this abnormal route, when the fact first became apparent as the result of a local examination.

Le Fort reports the case of a young Russian wedded pair who were spending their honeymoon in Paris. The husband took so much to heart his inability to fulfil his marital obligations in consequence of the vaginismus from which his wife suffered, that he shot himself through the heart. The distressing situation of a husband whose wife suffers from vaginismus, rendering coitus impossible, is depicted in the well-known French romance, “Mademoiselle Giraud, Ma Femme.” From a false shame, women often continue to suffer from vaginismus for months and even years, without a single effective coitus having ever taken place; it is only the consequent sterility which at last leads to medical advice being sought. The physician then usually ascertains that the hymen is still intact, or at least incompletely destroyed, that on this membrane and on various parts of the vulva there are erosions, and that the whole of the external genitals outside the hymen are in a state of inflammation more or less acute. In other cases, however, neither excoriations, erosions, nor inflammation can be detected, and the existence of vaginismus can be proved only by the pain and the muscular spasm set up by contact with the vagina. Often, indeed, the cause of this most distressing affection cannot be discovered.

Introduction of the penis may be rendered impossible by spasm of the constrictor cunni (bulbocavernosus) muscle, but equally so by spasm of the transversus perinei or the levator ani muscle. Sometimes the spasm affects all three muscular groups; in which case the narrowing of the vagina is extreme, and extends for some way up into the canal. When the levator ani alone is affected by the spasm, the penis can, indeed, be introduced into the vagina, to encounter a powerful obstacle in the interior of that canal; and it may happen, when the spasm comes on and affects the levator ani only after complete intromission of the penis, that the glans is retained in the vaginal fornix by the active contraction of the pelvic floor.

More or less credible instances of penis captivus thus brought about are on record. The following history is by Davis: A gentleman entering his stable found therein his coachman and a servant-maid in a most compromising position. All endeavours of the pair thus surprised to separate proved ineffectual, and their attempts to draw apart caused them intense pain. Davis was sent for, and ordered an iced douche, which, however, failed to liberate the imprisoned penis. Release was impossible until the woman had been placed under chloroform. The swollen and livid penis exhibited two strangulation-furrows, a proof that two distinct areas of the levator ani muscle had been spasmodically contracted.

Hildebrand records three cases observed by himself in which there was spasm of the upper part only of the vagina, unaccompanied by vaginismus (i. e., by pain). In two of these cases, the spasm was originated by the contact of the examining finger with very painful ulcers of the portio vaginalis; the third patient had a very sensitive prolapsed ovary. Fritsch reports having had on one occasion to give a woman chloroform for the release of a swollen and imprisoned penis.

Hildebrand suggests that vaginismus may be caused by an abnormal size of the penis, or by a condition occurring in weaklings and alcoholic subjects, in whom the greatest swellings of the glans penis occurs before intromission, whilst this greatest swelling is normally deferred until towards the end of the act, when the glans is in the vaginal fornix.

Schröder writes as follows regarding the etiology of vaginismus: “The affection is dependent upon trauma, sustained in maladroit, frequently repeated attempts at sexual intercourse; for this reason it is met with, in the great majority of cases in young, newly married women. Impotence in the male is by no means necessary for its production, and such impotence is not even a frequent antecedent. Abnormal narrowness of the vagina, or extreme firmness of the hymen, is occasionally found, but neither is in any way necessary; all that can be said in this connection of a small vaginal orifice is, that it predisposes to vaginismus. If the husband is devoid of previous experience in sexual matters, maladroit attempts at intercourse are exceedingly likely to occur. The penis is thrust in the wrong direction, pressing against either the anterior or the posterior commissure of the vulva. Very often, moreover, the position of the vulva, which is subject to very striking individual variations, is concerned in the production of vaginismus. There are many women in whom the vulva lies in part in front of the symphysis pubis, so that the lower border of the symphysis lies below the urethral orifice. In such cases the penis is directed too far backwards, and instead of passing into the vaginal orifice, slips into the fossa navicularis. The frequent repetition of such maladroit attempts at intercourse gives rise to a gradually increasing sensitiveness of the parts concerned, with the formation of excoriations. It now results that, on the one hand, the woman dreads attempts at intercourse on account of the pain to which they give rise; she shrinks away from the man, so that penetration of the vagina by the penis is rendered even more difficult than it was before; and, on the other hand, ungratified sexual desire leads to the frequent repetition of attempts at complete intercourse (from which, moreover, if conception should ensue, a cure of the trouble is expected). In this way, the trauma is rendered more severe, the congestion and excoriation of the fossa navicularis or of the urethral region are aggravated, and the sensitiveness of the parts increases to such a degree that the woman thus affected screams out when the vulva is merely touched. Ultimately reflex cramps set in whenever intercourse is attempted, and we then have the fully developed clinical picture of vaginismus.”

Winckel maintains that in most cases there are two principal elements in the causation of vaginismus. In the first place, in consequence of more or less pronounced anatomical changes, there is undue sensitiveness and tenderness of the vaginal inlet and its neighbourhood, and in exceptional cases also of the upper part of the vagina, the uterus, and the ovaries. In the second place, the patient manifests an increased general sensitiveness and nervous irritability; this is in some cases primary, but in others it is entirely the result of the repeated stimulation; and in either case it is heightened by the effects of ungratified sexual desire.

A. Martin points out that the spasm of the muscles of the pelvic floor, and especially of the levator ani muscle, upon which vaginismus depends, may be due in some cases to the influence of chill, since the same cause will lead to pathological contractions in other muscular areas. But in such cases it is always open to question if masturbation or some other sexual perversion is not the true cause of the disorder. In some instances vaginismus is merely a symptom, in extremely sensitive women, of various diseases of the reproductive organs, and is brought on by the increased pain which in such cases is caused by attempts at intercourse; when produced in this way, vaginismus is usually a transient manifestation.

Veit considers that among the pathological conditions giving rise to vaginismus, we must also enumerate diseases of the internal pelvic organs, such as chronic metritis, displacements of the uterus, oöphoritis, etc.; but he also attaches great importance to nervous predisposition, consequent upon previous sexual stimulation, and upon pre-existing inflammatory changes due to gonorrhœal infection. A peculiar form of vaginismus is, according to Veit, sometimes observed after the birth of the first child; happily the duration of this is usually brief. After parturition the vulval mucous membrane remains for a time very tender, and when cohabitation is resumed, often too soon, and perhaps, after the enforced abstinence, too frequently repeated at brief intervals, fissures are readily produced. Moreover, vaginismus which has existed prior to parturition may, in some cases, recur after that event. An unusual position of the vulva, undue smallness of the vaginal inlet, and relative impotence of the man, may combine to cause such a recurrence. Finally, vaginismus often persists throughout pregnancy, and manifests itself during parturition. The magical effect which chloroform has in some primiparæ, when the head is delayed at the vulva, is explicable only by the supposition of vaginismus.

According to Arndt, vaginismus is not purely a local disorder, but is in many cases the local manifestation of a neuropathic diathesis, which may in some instances lead to general mental disorder.

Olshausen regards hyperæsthesia and vaginismus as different stages of a single disease; he believes that the excessive sensitiveness is seated chiefly in the hymen; he explains the spasm as the reflex result of fissures and inflammatory changes. Pozzi considers that excessive nervous irritability and an irritable state of the vulva are the indispensable preliminaries to the occurrence of vaginismus. Herman distinguishes between excessive smallness of the vaginal inlet and vaginismus; he regards the latter as a nervous disorder, characterized by hyperæsthesia of the vulva, and by spasmodic contraction of the levator ani and adjoining muscles. Frost distinguishes vaginodynia from vaginismus; in vaginodynia the pain is so intense as to cause syncope, and the muscular spasm involves the entire length of the vagina.

It is a notable fact, to which Veit has especially drawn attention, that among the poorer classes of the population, vaginismus is practically unknown. Among women of these classes, their sexual needs, not having been so much lessened by “culture,” suffice to withdraw their attention even from the pains of defloration, which would otherwise often be very severe; whereas the sexually neurasthenic woman of the upper classes, filled with dread at the idea of the pain she expects to suffer, and not infrequently in a condition of hyperexcitability or hypersensibility dependent upon previously employed abnormal means of sexual gratification, is unable to endure the pains of defloration even when these might be expected to prove far from severe.

In some cases, painful contractions of the vagina, to which we cannot properly give the name of vaginismus, arise from organic diseases of the uterus and the uterine annexa; these painful contractions render copulation impossible. Von Hofmann reports the case of a young prostitute, who found herself unable to continue the practice of her profession owing to the severe pain she suffered during intercourse; she died, and the post mortem examination disclosed bilateral salpingitis, with reproductive organs in other respects normal.

Maladroit and incomplete attempts at intercourse, and the consequent repeated failure to obtain complete sexual gratification, affect a woman’s nervous system to a varying degree; but apart from this, in women who have long cohabited with men of deficient sexual potency, we often find a remarkable condition of complete relaxation of the genital organs, associated with great hypersecretion of the mucous membrane, flaccidity of the muscles of the pelvic floor, and displacements of the uterus. Moreover, the nervous shock to which the repeated but unsatisfying attempts at intercourse give rise, affects the spinal cord in such a manner that symptoms of spinal irritation ensue. The patient complains of pains in the back, the loins, and the nape of the neck; these pains also radiate round the front of the abdomen and along the intercostal spaces; hyperæsthetic points may be detected when the finger is passed along the spine; there is weakness of the limbs with a sensation of numbness; and neuralgic manifestations of varying nature occur.

The dangers which sexual intercourse may entail upon women—over and above the irritable conditions and inflammatory disorders of the female reproductive organs, dependent upon impetuous or unduly frequent coitus, or upon coitus practised during menstruation—are principally due to gonorrhœal and syphilitic infection transmitted by the cohabitating male.

Cardiac Troubles Due to Sexual Intercourse.

Among the troubles from which women at times suffer as a result of sexual intercourse, certain cardiac disorders are especially worthy of attention.

Every act of sexual intercourse in a young and sensitive woman exercises an exciting influence on the nervous mechanism controlling the cardiac movements, and this influence is more clearly manifested in a degree directly proportional to the intensity of the sexual orgasm. The heart’s action is markedly increased in frequency, the cardiac impulse is more powerful, the large arteries of the neck are seen to pulsate far more vigorously, the conjunctiva is markedly injected, the respiration is increased in frequency, the respiratory movements are more superficial and have a panting character.

But when, in a woman who is sexually irritable in an excessive degree, the peripheral stimulation occurring in the act of sexual intercourse is unusually powerful, there may result a notable increase or modification of the reflex manifestations which normally occur during sexual intercourse in the province of cardiac activity; similar results ensue when there is a summation of stimuli owing to excessive sexual intercourse, or contrariwise when the act of intercourse is broken off just before its physiological climax and the natural termination of the orgasm fails to occur.

The former cause is not infrequent in young wives during the period of the honeymoon. The latter cause is in operation when there are diseases of the female reproductive organs preventing the physiological completion of intercourse; but especially in consequence of the modern practice of coitus interruptus, in which the man breaks off the act of intercourse the moment he feels that ejaculation is imminent, without troubling himself regarding the natural course of sexual excitement in the woman. Yet another cause of excessive cardiac reflex manifestations in women is incomplete potency of the male, which may either cause a premature ejaculation of semen, or may lead to incomplete penetration of the penis.

In all such cases, as a result of sexual intercourse, there may arise cardiac disorders of various kinds; among these, tachycardial paroxysms are the most frequent, occurring either inter actum, or at a longer or shorter interval after intercourse.

In several cases of vaginismus occurring in young married women which have come under my notice, it was observed that the attempts at intercourse gave rise to violent involuntary spasmodic contractions of the constrictor cunni and the other muscles of the urogenital and anal regions, and in addition it was found that these attempts were followed by tachycardial paroxysms with dyspnœic manifestations, lasting for a considerable period, it might be as long as one or two hours.

In women who had practised coitus reservatus for a prolonged period, in fact for several years, in such a manner that, notwithstanding the occurrence of intense voluptuous excitement, complete sexual gratification rarely, if ever, occurred—in such women, in whom these marital malpractices seemed to have profoundly influenced their psychical life, I have frequently witnessed a form of reflex cardiac disorder which I must regard as a variety of the multiform neurasthenia cordis vasomotoria. In such women, still at the climax of their physical powers and of their sexual needs, attacks of palpitation suddenly occur at irregular intervals, several times daily or less frequently. Associated with this increased frequency of the cardiac activity are an extremely distressing feeling of anxiety, a sensation of faintness, headache, vertigo, a weakness of the muscular system, and at times actual attacks of syncope. Physically, the women are extremely depressed, irritable, inclined to weep, unhappy, and weary of life. At the same time, digestion is impaired, the appetite is small, and there is constipation. The pulse is in most cases feeble, small, of low tension, easily compressible, increased in frequency, often intermittent, sometimes more distinctly arhythmical. The heart is found to be sound on physical examination, nor can any abnormality be detected in the great vessels. The lower extremities are free from œdema; the urine does not contain albumen.

Women thus affected are sometimes believed to be suffering from cardiac disorder, in other cases they are subjected to various modes of gynecological treatment; until at length the physician, by appropriate questions, becomes enlightened regarding the true cause of the cardiac disorder, namely, coitus interruptus. If it is possible to prohibit effectually this unwholesome practice, the cardiac symptoms soon cease to recur.

Finally, in women at the climacteric age, cardiac troubles sometimes ensue, which are dependent on interference with sexual intercourse in consequence of anatomical changes in the vagina; changes of this character frequently occur at the time of the menopause; owing to hyperaemic or inflammatory processes, a partial or general stricture of the vaginal passage results; in many cases this passage becomes narrower, shorter, and almost conical in shape, whilst the vaginal inlet is greatly diminished in size. Such a vaginal stricture, which Hegar has also seen in younger women after an artificial climacteric (oöphorectomy), interferes with sexual intercourse; and the incomplete sexual gratification gives rise to a series of nervous manifestations, and, among others, to the above described reflex cardiac neurosis.

Whether, and in which cases, the cardiac disorders evoked as a result of the local stimulatory influences of sexual intercourse, are dependent on a reflex stimulation of the sympathetic nerve on the one hand, or upon a transient paresis of the inhibitory centre of the heart and of the vasomotor centre on the other, cannot here be fully discussed; just as little can we consider in what manner the psyche is sympathetically affected by the irritative processes in the genital organs, and its functional activity thus impaired.

Here I can do no more than briefly state that experience has taught me that sexual intercourse is competent to originate cardiac troubles in women.

1. In extremely sensitive, sexually very irritable women, tachycardial paroxysms may result from sexual excesses.

2. Tachycardial paroxysms with dyspnœa occur in young women affected with vaginismus; also in women at the climacteric with constrictive changes in the vagina.

3. Cardiac troubles, characterized mainly by symptoms indicating diminished vascular tone, occur in women who have long practised coitus interruptus with incomplete gratification of their voluptuous desires.

Dyspareunia.

In normal conditions the act of sexual intercourse is accompanied in women, as in men, by a voluptuous sensation, and this sensation must be regarded as a necessary link in the chain of those processes by which gratification of the sexual impulse—the most powerful of all our natural impulses—is obtained. The absence of this voluptuous sensation in a woman, the state in which she experiences during coitus no voluptuous sensations, but feels either apathy, or positive distaste, is termed dyspareunia: in former times it was also known as anaphrodisia. This abnormal state of sexual sensibility, which up to the present is hardly alluded to in gynecological textbooks, has received remarkably little attention from the medical standpoint, and its importance has been underestimated. Most unfortunately so, for dyspareunia is an important symptom, exercising a powerful influence on the general health of the woman who suffers from it, upon her social status in marriage, and, as is easy to understand, upon her procreative capacity.

Dyspareunia must be clearly distinguished from two somewhat similar conditions, with which at first sight it is liable to be confused, namely, from anæsthesia sexualis, and from vaginismus. By sexual anæsthesia we understand, as previously explained, the absence of the sexual impulse, a symptom which, when the reproductive organs are normal in structure and function, is either of central nervous origin, a result of disease of the brain or spinal cord, or else is due to general nutritive disorders such as diabetes, morphinism, or alcoholism. A woman affected with dyspareunia does, however, experience the sexual impulse, it may be very actively, but sexual intercourse brings about no gratification of her desires. In vaginismus, on the other hand, the introduction of a foreign body, that is to say of the membrum virile, into the vagina, gives rise to painful reflex cramps of the sphincter vaginæ, or of the muscles of the pelvic floor, whereby the completion of coitus is rendered impossible: whereas in dyspareunia coitus can be effected, but gives rise to no voluptuous sensations.