Part 50

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.

The pleasure which normally occurs in woman during sexual intercourse is brought about in this way, that contact with and friction by the penis stimulates the sensory nerves of the clitoris, the vulva, the vestibule, and the vagina; this stimulus is propagated to the cerebral cortex, where it gives rise to voluptuous sensations, and then, by reflex stimulation of the genito-spinal centre, gives rise to a series of reflex discharges. The pudic nerve, a branch of the sacral plexus, supplies the female external genital organs. Some of its branches pass in the clitoris to a peculiar form of nervous end-organ discovered by W. Krause, Krause’s genital corpuscles: the structure of these corpuscles appears to fit them exceptionally well for the transmission of stimulatory waves to the nerve centres. “When this stimulus,” says Hensen, in his work on the physiology of reproduction, “in addition to other effects, also gives rise to a voluptuous sensation, the cause must be sought in central nervous connections and apparatus. Similar relations are to be found in connection with the mechanism of nutrition, for example, in the association of hunger, appetite, agreeable sensations of taste, the act of mastication, and the secretion of saliva.” By means of this stimulus, several reflex processes are originated in the reproductive canal, the most notable of which are the erection of the clitoris, and the ejaculation of the secretions of various glands. The cavernous tissue of the clitoris is connected with that of the bulbus vestibuli, and the dorsal nerve of the clitoris is one of the principal nerves of voluptuous sensation. The venous plexus constituting the bulb of the vestibule lies at either side along the margin of the vestibule at the boundary between the labium majus and the labium minus, and laterally it is covered by the constrictor cunni muscle. During coitus the blood is driven out of this bulb into the glans clitoridis, and thus the sensibility and the erection of the glans are increased. The constrictor cunni and ischiocavernosus muscles draw the clitoris, which is bent at a right angle downwards, into contact with the penis. By means of the pressure of the constrictor cunni, the mucous secretion of Bartholin’s glands, which open into the vulva at the back of the labia majora, is expressed.

As additional reflex actions, dependent upon the activity of the reflex centre in the lumbar enlargement of the spinal cord, there ensue contractions of the vagina, peristaltic movement of the tubes, some descent of the uterus, relaxation of the os uteri and rounding of this orifice, and induration of the portio vaginalis, whereby the tubal and uterine mucus and the secretion of the cervical glands are expressed. This process of ejaculation constitutes the culminating point of the voluptuous sensation occurring in the sexual act; this act thus exhibits two phases, the sensation of friction, and the sensation of ejaculation.

With regard to voluptuous sensations, and processes analogous to pollutions, occurring in women, we append an extract from von Krafft-Ebing.

“The occurrence of voluptuous excitement during coitus is dependent in the women, just as in the man, upon:

“1. The peripheral influence of the intensity and duration of the sensory stimulation (anæsthesia of the genital passage may be the cause of the absence of voluptuous sensation). 2. The condition of excitability of the reflex (ejaculation) centre in the lumbar spinal cord. The activity of this centre varies within wide limits, not merely in different individuals, but in the same individual at different times. There are, indeed, women in whom it seems as if this centre were always in vigorous activity. In normal women, the irritability of the centre appears to be most marked at the menstrual epoch, and to decline rapidly soon after menstruation. In pathological conditions, the activity of the centre may be temporarily in abeyance (organic inhibitory processes, such as are seen in certain cases of hysteria with temporary frigidity); or again the centre may be abnormally active owing to irritable weakness (neurasthenia sexualis), in consequence of which ejaculation may, just as in the male in similar circumstances, occur too easily. 3. The occurrence of the voluptuous sensation in woman is unfavourably influenced by psychical inhibitory perceptions (analogous to the inhibitory influence of psychical processes in the male, such as, for example, fear of incapacity to perform sexual intercourse). As examples of such inhibitory perceptions in women may be mentioned, dislike of the man, physical loathing to sexual intercourse, etc.”

Gutceit records interesting experiences, which are readily intelligible in view of what we have already quoted. He finds that of ten women after defloration, two only immediately experience full sexual pleasure. Of the eight others, four only have an agreeable sensation produced by the friction during coitus: but the sensation of ejaculation does not make its appearance until the lapse of at least six months, or it may be even several years, after marriage. In the remaining four women, pleasure during sexual intercourse may never become properly established. The women of the first class are described by the author as being of a very ardent temperament, and passionately attached to their husbands. In such women, the sensation of ejaculation occurs during intercourse with any man toward whom they are sympathetic. Women of the second class are of a less ardent temperament, and are often comparatively indifferent toward the man with whom they cohabit. Women of the third class have little or no amatory feeling, and they either hate the man with whom they are cohabiting, or at least feel physical repulsion to the idea of intercourse with him. Gutceit considers that meretrices usually belong to the third category. In the practice of their trade, they make a counterfeit of voluptuous enjoyment, and only experience real sexual gratification in intercourse with the man of their choice.

It is of great practical interest, alike from the gynecological and from the neuropathological standpoint, to determine the consequences in women of ungratifying sexual intercourse. In the present state of our experience it must be assumed that the effect of abnormal sexual intercourse, that is of intercourse which does not culminate in gratification produced by the sensation of ejaculation, is deleterious. This is explained by the fact that, owing to the absence of the muscular contraction of the genital passage, the latter remains engorged with blood; the resultant hyperæmia passes away very slowly, and, when frequently repeated, gives rise to chronic tissue changes, manifesting themselves as diseases of the reproductive organs. Injury to the nervous system ensues, partly in consequence of these organic changes, partly also in consequence of psychical non-gratification in the widest sense of the term. The nervous disorders thus produced are typical forms of (sexual) neurasthenia; and in cases in which the pathogenesis is predominantly psychical (antipathy to the husband, etc.) hysterical types of disorder are especially frequent. Von Krafft-Ebing believes that incomplete coitus, that is, coitus not culminating in the sensation of ejaculation, is a frequent cause of hysterical disorders in women.

When once the clinical picture of neurasthenia sexualis is fully developed, each act of intercourse (like pollutions or coitus in the sexually neurasthenic male) gives rise to renewed troubles, which are easily recognized as symptoms of venous stasis in the reproductive organs (sacrache, sensations of weight and bearing-down in the pelvis, fluor albus): in addition we observe exacerbations of the lumbar spinal disorder, in the form of spinal irritation, irradiating pains in the sacral plexus, etc. In this way general neurasthenia develops. The conditions found in such cases on gynecological examination (chronic endometritis, metritis, oöphoritis, etc.) are produced by the same cause as the nervous symptoms, namely, by an unhygienic mode of sexual intercourse. They are not the cause of the neurosis, but important concomitant disorders; and their effect in rendering the nervous disturbances more severe must be freely admitted.

Among important causes of ungratifying coitus must be enumerated: weak erection and ejaculatio praecox in the male, rendering the stimulation inefficient; in addition, coitus reservatus, coitus interruptus, and coitus condomatus. If the noxious influence is frequently repeated, the occurrence of neurasthenia sexualis and its consequences is greatly to be feared, and in women of neuropathic constitution it is practically inevitable.

Unsympathetic coitus appears to act, not merely in a somatic manner, but mainly upon the psyche, and to originate states of hystero-neurasthenia or pure hysteria. If the influence of such unhygienic conditions of the vita sexualis co-operates with that of inherited or acquired sensuality, further dangers ensue: in cases of ungratifying sexual intercourse, the danger of manustupration; in cases of unsympathetic intercourse, the danger of psychical onanism, or that of marital infidelity.

Although until recently the matter received but little attention, it must now be regarded as a well-established fact, that in the female (as in the male) the climax of voluptuous sensation in sexual intercourse is normally characterized by a process of ejaculation, accompanied by a voluptuous sensation of ejaculation, dependent upon the acme of excitement of a reflex centre in the lumbar enlargement of the spinal cord.

Just as in the male, this centre may be excited to action, not only by local stimulation of the genital organs, but also by (psychical) stimuli proceeding from the brain (pollutions), so also in the female a similar process may occur, and for this reason it is correct to speak of “pollutions in the female.” Rosenthal appears to have been the first writer to speak of pollutions in women. In his clinical study of nervous diseases, Rosenthal described processes of the nature of pollutions, originated in erotically over-stimulated women by lascivious dreams. In one case he detected the outflow of a “mucus-like” fluid from the apparently intact genital organs; he believed this to proceed from the ducts of Bartholin’s glands, and from the mucous glands surrounding the urethral orifice. Féré reports the case of a patient who had an erogenic zone in the region of the upper part of the sternum; pressure on this zone gave rise to a profuse secretion of vulvo-vaginal fluid. In this connection we may also recall the “clitoris-crises” to which tabetic women are subject. Gutceit described the process of pollution in women in the following words: “It is remarkable that in dreams such women experience the sensation of ejaculation.”

The psychical preliminary is invariably constituted by lascivious dream perceptions. It merely remains open to question whether this process, which in the male is indisputably physiological, in the female may be said to occur within physiological limits. The researches published by von Krafft-Ebing more than twenty years ago, under the title “Concerning Processes Analogous to Pollutions Occurring in the Female,” gave negative results as far as healthy individuals were concerned; on the other hand, the phenomenon in question was by no means rare in nervously disordered, and above all in sexually asthenic women. The neurosis was in part found as a result of psychical or manual onanism in virgins with morbidly intensified libido: in part in married women, as a result of ungratifying coitus, as previously described: in part, also, in married women with powerful libido and enforced abstinence from intercourse, owing to acquired impotence or death of the husband.

Just as in the case of the neurasthenic male, these pollutions made the primary neurosis more severe, and relief from the nervous trouble was not obtained until the factor of the “pollutions” had been recognized, and made the object of special treatment. In exceptional cases the “pollutions” appeared to be the starting point of the entire neurosis.

It was further remarkable, again here displaying analogy with what occurs in the male, how much stronger and more deleterious was the shock-effect of an inadequate process of ejaculation occurring in a sexual dream, as compared with the far less deleterious influence of similar incomplete ejaculation when occurring viâ coitus. In very severe degrees of neurasthenia sexualis, just as in the male, the waking imagination may give rise to a “pollution.” In such cases the shock-effect on the nerve centres tends to be excessively severe. A still higher degree of irritability of the genital system appears to exist in cases in which excitement and orgasm of the reproductive organs may culminate in a “pollution” by purely spinal paths, without the intervention of the imagination. The significance of this fact would appear to be considerable for the proper comprehension and for the treatment of certain conditions of neurasthenia (sexualis) in the female. The “pollution” may here be the actual cause of the neurosis. But in any case, in the female, the occurrence of pollutions is an extremely important symptom as regards both diagnosis and therapeutics. It is extremely probable that hallucinations of coitus, and the complaints made by insane women of attempted violation during the night, are really dependent upon such “pollutions.”

Von Krafft-Ebing reports the following characteristic case. Miss X., thirty years of age, belonging to a family predisposed to insanity, and herself neuropathic since early childhood, declared that since she was six years old she had been subject to lascivious imaginations, to which she became continually more liable as she grew older. Ultimately, typical psychical onanism developed, and in recent years her trouble assumed the form of sexual neurasthenia. The patient herself suspected there was a connection between her nervous disorder and her evil habit. The popular work by Bock finally brought her full enlightenment, associated with severe emotional disturbance. This latter was now increased by misfortunes from which the family suffered. The patient then relinquished her bad habit, but her state of health nevertheless became worse. She was nervously extremely irritable; her sleep was insufficient, unrefreshing, and disturbed by lascivious dreams; she suffered from spinal irritation, anæmia, scanty and painful menstruation. Inclination toward the opposite sex and toward marriage, hitherto but slight, now sank to a minimum: on the other hand, the patient, in spite of all efforts to the contrary became more and more subject to a condition analogous to priapism in the male, a genital orgasm by no means voluptuous in character, and often indeed actually painful. Associated therewith, nocturnal pollutions occurred, the patient awaking from lascivious dreams with a voluptuous sensation and moistness of the external genital organs. After such pollutions, throughout the ensuing day, she felt extremely weary and depressed and suffered from severe spinal irritation. After a time, the nocturnal pollutions occurred without being preceded by lascivious dreams, and ultimately analogous states were experienced in the daytime. With much difficulty the patient now made up her mind to seek medical advice. She was anæmic, emaciated, emotional, and moody. The lumbar and cervical regions of the spine were extremely sensitive to pressure. Sleep was scanty and unrefreshing, the patient felt weary and miserable, she complained of dragging sensation and other paralgic sensations, in the regions supplied by the lumbar and sacral plexuses. The deep reflexes were increased. She dreaded the onset of disease of the spinal cord, and believed that the cause of her illness was to be found in the prolonged indulgence in psychical onanism. The perusal of Bock’s book had first made her understand the true nature of her misconduct. She had never practised manual masturbation. Her principal complaint was of an almost unceasing uneasiness and excitement in the genital organs. She compared it to the uneasiness in the stomach produced by hunger. In the genital organs (which on examination appeared quite normal), she had a distressing sense of burning heat, of pulsation, of disquiet as if there were a clockwork mechanism working there. Very rarely now were these sensations associated with voluptuous ideas. This sexual neurosis had an intensely depressing constitutional effect. She had transient relief only when the local sensations culminated in pollution; but this, on the other hand, increased her general neuropathic troubles. She suffered most severely during the menstrual period. She was ordered sitz-baths at a temperature of 23° to 19° R. (84° to 75° F.), suppositories of monobromide of camphor, 0.6 (9 grains), with extr. belladon. 0.04 (⅗ gr.), sodium bromide 3.0 to 4.0 (45 to 60 grains), every evening; also powders containing camphor 0.1 (1½ grains), lupulin 0.05 (¾ grain), extr. secal 0.08 (1¼ grains), twice daily. This treatment gave the patient great relief, and secured complete ease during the daytime. Therewith returned her greatly impaired trust in the future, and her emotional calm was restored.

The frequent occurrence of pollutions in women, the so-called vulvo-vaginal crises and clitoris-crises, is regarded by Eulenburg as a striking manifestation of sexual neurasthenia in woman; in such cases a lascivious dream is spontaneously followed by a more or less abundant discharge of the clear gelatino-mucous secretion of Bartholin’s glands. In women who masturbate, and in tribadists, a profuse and even violent secretion of these glands is produced by touching the clitoris or the erogenic zones at the entrance to the vagina, close to the orifices of Bartholin’s ducts.

Dyspareunia, the absence of voluptuous sensation in women during coitus, may be referred to three fundamental causes:

1. Insufficient or completely wanting peripheral stimulation of the sensory nerve terminals in the female reproductive canal: in these cases the conducting tracts to the nerve centres never become active.

2. Diminution or cessation of the excitability of the reflex centre in the lumbar enlargement of the spinal cord: this leads to failure of the sensation of ejaculation.