Part 48

Injuries of the vagina resulting from coitus are, generally speaking, rare. The usual cause of such injuries is disproportion in size between the erect penis and the calibre of the vagina, or else brutal violence in the performance of coitus; sometimes, however, it is dependent on the pathological state of the female genital organs, which have undergone senile atrophy.

To the first group belongs the case reported by Albert, in which a girl of eleven years was found to have a laceration of the vagina communicating with the peritoneal cavity, the injury resulting from coitus. To the second group belongs the case reported by Böhm, of lacerations of the vaginal mucous membrane resulting from forcible coitus in elderly women. E. Frank reports a case of injury due to violent coitus in a woman in whom the vagina was already greatly stretched by retroflexion; and another case in which injury occurred during intercourse in a woman with vagina duplex—in this case, not only was the hymen of the right vagina torn, but also the septum between the two vaginae.

By no means extremely rare are injuries to the vagina in the act of defloration, causing severe hemorrhage. Martin records a fatal case of this nature. Maschka and Hofmann, the authorities on Forensic Medicine, deny that vaginal laceration is the result of simple coitus, and Hofmann maintains that such serious injury can occur only from digital manipulations; in fact, these writers believe that the penis alone cannot be employed with sufficient force to cause laceration. Barthel and Anderson, however, saw vaginal lacerations in nulliparous women; and Zeis records a case of vaginal laceration in a woman twenty-five years of age, with whom, six weeks after parturition, her husband, then in a state of intoxication, had had intercourse in the position à la vache.

Anomalies of the vagina, absence, stricture, duplication, and abnormal apertures, also diseases of the vaginal tissues, may induce incapacity for sexual intercourse. In frequency as in significance, among these disorders, absence of the vagina and stenosis and atresia of the canal, stand in the first rank. Congenital atresia may be complete or only partial, according as the two ducts of Müller from the fusion of which the tube is formed, remain totally or only partially solid—or, having duly canalized, subsequently, by a foetal inflammatory process, become transformed into a thick, more or less solid cord. If the obliteration of the vagina is at the lower extremity of the canal, coitus is impossible, unless, as sometimes happens, by frequent attempts at intercourse, the short blind sac representing the lower end of the vagina has been stretched upwards in the form of a pouch. When the obliteration of the ducts of Müller is complete, we have total atresia of the vagina, in which case the uterus is also as a rule wanting, or is but imperfectly represented. In some cases, from the ducts of Müller, instead of the normal vagina, there is formed a tract of membrane of varying density and width, through which passes a small canal for the passage of the menstrual discharge; this condition is known as atresia vaginalis membranacea.

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.

The vagina may also be partially occupied, and coitus may be impeded, by elongation of the hypertrophied cervix uteri, by inversion or prolapse of the uterus, by cystocele or rectocele, and by uterine polypi. Horwitz records the case of a woman aged twenty-two years in whom impotentia coeundi was dependent upon the occlusion of the vaginal orifice by a rounded, strongly projecting body, which proved on closer examination to be a hypertrophied vaginal bulb.

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.