Part 51

3. Inhibitory influences proceeding from the cerebral cortex whereby voluptuous sensations and perceptions are checked.

The first-named of these etiological influences is in my experience the commonest. Incomplete or quite inadequate stimulation of the sensory nerves of the genital canal may be due to the maladroit performance of copulation on the part of the male, owing to inexperience, or it may depend on gross disproportion in size between the reproductive organs of the man and the woman; in other cases it may be due to disease of the reproductive organs in either sex, influencing unfavourably the sensibility to stimulation of the nerves of the genital canal. Awkward or incomplete performance of coitus may thus lead to failure of voluptuous sensation, and this may ultimately pass into permanent dyspareunia. Temporary dyspareunia is very common in young wives during the first months of married life, ensuing on the pains of defloration; and very gradually gives place to normal voluptuous sensation. It may be one or two years after marriage before the sensation of ejaculation is first experienced. Not infrequently, dyspareunia depends on incomplete potency in the husband, who is incompetent to arouse voluptuous sensation in his wife. For this reason, dyspareunia is common in young women married to elderly men; but is common also, where (as so frequently among Russo-Polish Jews) the men also marry very young, at an age of from sixteen to seventeen years, and where, moreover, the husband has often before marriage impaired his potency by masturbation: finally dyspareunia is common when girls still undeveloped sexually are married to powerfully built men.

Regarding the pathological conditions of the female reproductive organs which counteract the peripheral sensory excitants of voluptuous sensation, we exclude from further consideration the obvious causes, absence and atrophy of the reproductive organs, and senile marasmus. Of prime importance as a cause of the failure of sexual sensibility in the early period of married life must be mentioned inflammation of the fossa navicularis, due to awkward attempts at intercourse. Other causes of deficient sensibility are: complete or partial persistence of the hymen, lesions of the vaginal inlet, acute or chronic vulvitis in consequence of irritating abundant secretion, especially as a sequel of gonorrhœal vaginitis. The last named infective disorder is especially harmful, because Bartholin’s glands are involved in the associated vulvitis. Even after the cure of the vulvitis, permanent dyspareunia may remain. Perineal fissures may result in the stimulant effect of coitus being insufficient, owing to the slight friction possible at the vaginal inlet in these cases. Not less serious sometimes are small, hardly discernible fissures in the vagina. Additional causes of deficient sexual sensibility are recto-vaginal, and vesico-vaginal fistulæ.

The second cause of dyspareunia, diminution or complete lack of irritability of the reflex centre of the lumbar enlargement of the spinal cord, appears to be less frequently operative. We must, however, assume that certain nervous disorders, such as hysteria and pathological changes in the spinal cord, are responsible in this connection. The activity of the lumbar sexual centre appears in women to be normally subject to variation within certain limits; and seems usually to attain its maximum irritability during menstruation. But normally these variations are never so great as to produce in women complete though merely temporary dyspareunia; in this respect offering a marked contrast to what occurs in other animals at other times than the rutting season, and of which every bitch not on heat furnishes an example when she refuses the sexual advances of the dog.

As regards the third causal influence in the production of dyspareunia, the influence of the brain, this, though important, is less frequently in operation. Diseases of the brain, degenerative processes, may constitute a cerebral cause for the failure of sexual sensation. But more frequently, certain cortical perceptions, such as dislike or hatred of the cohabiting male, an ardent passion for some other lover, grief and trouble, exercise inhibitory influences, which render the occurrence of voluptuous pleasure during the sexual act difficult or quite impossible.

A condition like dyspareunia, our knowledge of which depends entirely upon the subjective sensations of the woman concerned, is naturally one regarding whose existence accurate information is difficult to obtain. Very rarely does it happen that women spontaneously approach the physician with complaints of this condition; indeed, in my experience, they do so only when they are sterile, and when they assume, in accordance with the widespread popular belief, that their sterility is connected with the absence of voluptuous sensation during sexual intercourse. More commonly, however, it is the husband who feels it his duty to confide to the medical man the remarkable apathy of his wife in sexual intercourse. But when once the medical man’s attention has been directed to this question, and when he institutes enquiries among his patients in a scientific, passionless manner, one making due allowance for a woman’s modesty, as the moral importance of the subject demands, he will be astonished at the frequency of dyspareunia, and he will find herein the explanation of many obscure phenomena in the life of women. On the other hand, it must never be forgotten that a certain number of women complain of dyspareunia without any justification whatever, in order to arouse interest and sympathy, by representing themselves as unwilling sacrifices on the marital altar: the experienced gynecologist will readily detect the cases in which he is being misinformed; he can, moreover, always check the wife’s statements by conversation with the husband.

The constant sign of dyspareunia is the failure of ejaculation during coitus. We have previously described the muscular contractions which lead to ejaculation of the secretion of Bartholin’s glands and to the expulsion of the uterine and cervical mucus, as reflex actions evoked by the sensory stimulus dependent on friction of the female genital organs. The voluptuous sensation of ejaculation, associated with these muscular contractions, which the woman whose sensibility is normal experiences as the culminating point of her sexual “gratification,” is either quite unknown to a woman affected by dyspareunia, or is experienced by her only in a voluptuous dream, as a pollution, in which the sexual dream-perceptions act as the psychical stimuli by which the reflex discharge is originated. It has repeatedly happened to me, that on enquiring of women suffering from dyspareunia regarding their experience of the sensation of ejaculation, I have been informed that such sensations are known to them only from the descriptions of their female friends, or occasionally from dreams from which they have awakened with a feeling of moisture in the external genitals. Von Krafft-Ebing refers this process to a peristaltic contraction of the muscular fibres of the Fallopian tubes and the uterus, “whereby the tubal and uterine mucus is expressed;” whereas, for my part, I am of opinion, that ejaculation affects in the first place and principally the glands of Bartholin, the secretion of which is expressed by the contraction of the constrictor cunni muscles, and secondarily only affects the cervical glands of the uterus.

As a second sign of dyspareunia, I recognize a remarkably rapid outflow of the male semen from the female genital canal, immediately after coitus (profluvium seminis). The woman thus affected complains, when suitably questioned, that she is unable to retain the semen, and that it flows out of the vagina immediately after ejaculation. The cause of this remarkable phenomenon no doubt lies in the fact, that, owing to the absence of the voluptuous sensation, the reflex contractions of the muscles of the female genital organs, normally accompanying this sensation during intercourse, fail to occur. At the vaginal inlet, in normal conditions, the constrictor cunni muscle contracts, and farther up in the vagina a peristaltic contraction of the circularly disposed muscular fibres of the tunica media occurs: in this way the semen ejaculated into the vagina is for a time retained under a certain pressure. But in the absence of these muscular contractions, as well as of the muscular contraction of the pelvic floor, retention of the semen fails to occur. Cattle-breeders and horse-breeders have made similar observations regarding cows and mares, namely, that these animals are sometimes unable to retain the semen after coitus, and it is suggested that in these cases the animals are not properly on heat. Experienced cattle-breeders recommend in such cases that the retention of the semen should be promoted by douching the root of the tail and the external genitals with cold water. It is well known that by stimulating the peripheral sensory nerves in the neighbourhood of the genital organs, a reflex excitement of the lumbar sexual nerve centre is produced, as is seen, for example, in the practice of flagellation of the buttocks, for the increase of sexual desire.

Passing to the consideration of the pathological changes to be found in the reproductive organs of women suffering from dyspareunia, the nature of these will for the most part be obvious in relation to the etiology of the disorder. Most frequent, in my experience, were chronic inflammatory states of the vulva and of the vaginal and uterine mucous membrane, chronic metritis and parametritis. A very frequent appearance, and one practically characteristic of dyspareunia when of long standing, is a marked total relaxation of the reproductive apparatus. The uterus is extremely mobile, usually retroverted and partially prolapsed, thin, with lax walls, and usually an enlarged cavity; the portio vaginalis is flaccid, and runs to a point; the vagina is roomy; there is marked hypersecretion of the mucous membrane of the entire genital canal; there is great flaccidity of the constrictor cunni and levator ani muscles, and of the perineum. In several women with dyspareunia, I found old unhealed lacerations of the perineum. In some cases, the very small size of the clitoris is noteworthy. In one case amenorrhœa was present with an infantile uterus. In a large proportion of the cases I was able to detect a diminution both of the tactile and algic sensibility of the vaginal mucous membrane. The women were for the most part anæmic; many were extremely obese, and of lymphatic constitution. In some cases, however, no pathological changes whatever could be detected in the reproductive apparatus.

Dyspareunia is a condition which affects a woman’s whole nature, powerfully influences her mental life, and thus gives rise to greater psychical than physical damage. The consciousness of being deprived of the greatest joy of physical love produces great emotional depression, even in a woman by no means sensually inclined, and gives rise to a hypochondriacal state, at times even to melancholia. In other cases, the idea, not infrequently suggested by more happily situated women friends, that the woman herself is not to blame for this condition, has a demoralizing effect upon her, and destroys the happiness of married life. (It has been confessed to me, in isolated cases, that the dyspareunia was relative only.) Apart from this, the absence of sexual gratification gives rise to a series of nervous troubles, presenting either the variable characters of hysteria, or else the symptoms of neurasthenia. Finally, the frequently repeated incomplete coitus, incomplete inasmuch as the woman does not experience the sensation of ejaculation, induces chronic hyperæmia in the female reproductive organs, passing on into blood stasis, and ultimately into chronic inflammatory tissue changes; in this way arise metritis, perimetritis, and parametritis, salpingitis, oöphoritis, disorders of menstruation, menorrhagia, and atypical uterine hæmorrhages. The possibility cannot be disproved, that in this way new-growths of the reproductive organs may also originate. The act of sexual intercourse, which at first may be to the woman a matter of comparative indifference, and in which she plays her part merely from a sense of duty, becomes, in cases of long-standing dyspareunia, something to which she feels a positive dislike, and is recognized by her as the actual cause of the troubles that ensue upon intercourse, such as sacrache, sensations of weight and pressure in the pelvis, strangury, fluor albus, a feeling of exhaustion, etc.

At times, perverse sexual sensation is associated with dyspareunia. Women who find no enjoyment in normal sexual intercourse with a male, sometimes masturbate, sometimes indulge in amor lesbicus, etc.

Of great importance appears to me the relation between dyspareunia and sterility in women. As already pointed out, dyspareunia comes chiefly under medical observation in cases in which it is associated with sterility. The husband, seeking advice concerning his wife’s failure to conceive, complains of her frigidity in sexual intercourse as the probable cause; or the wife comes to seek advice, saying that she never experiences sexual gratification, and that for this reason she has failed to become pregnant. As a matter of actual fact, dyspareunia and sterility are associated with such remarkable frequency, that my own experience leads me to believe in the existence of an etiological connection between the two conditions, at least in a certain proportion of the cases. Among 69 sterile women whom I questioned regarding dyspareunia, the latter condition was present in 26, that is to say, in 38% of the cases. Matthews Duncan reported that of 191 sterile women, 62 did not experience sexual enjoyment. Sexual excitement of the woman during copulation would certainly appear to have a definite bearing upon the occurrence of conception, for we know that by the voluptuous sensation reflex actions are aroused in the genital canal, favouring the retention of semen and its passage through the os to the interior of the uterus, and perhaps also giving rise to reflex changes in the cervical secretion which favour the passage of the spermatozoa into the uterine cavity.

In cases of relative dyspareunia, the influence of this condition in producing sterility is also manifested, the unfaithful wife being impregnated by her lover though she has remained sterile in intercourse with the husband to whom she is indifferent. To dyspareunia of this nature (dependent upon sexual disharmony), we may also refer the sterility of a married pair who have for some time lived together in unfruitful intercourse, whereas, after divorce and the contraction of fresh unions, both the man and the woman prove normally fertile. Such cases have been personally known to me; and similar instances aroused the attention of the natural philosophers of antiquity, for instance, that of Aristotle. The importance of voluptuous sensation in promoting conception is also manifest from the fact that in the majority of women, after the pains of defloration, dyspareunia usually persists for a season during the early period of married life; and, corresponding with this, the first conception is usually deferred for some little time after marriage, to a period corresponding with the awakening of the sensation of ejaculation. In this connection, Courty reports the case of a lady who, although in blooming health, remained sterile during the first fifteen years of her married life; she then gave birth to a child whose father was unquestionably her lover; and after this in succession to two other children whose progenitor was the legal husband. This lady had never experienced voluptuous sensation in intercourse prior to the time of her first conception. Similar circumstances with an even clearer significance have been frequently observed among the lower animals; and Darwin records several striking observations of this character. Taking all the evidence into consideration, we are compelled to regard dyspareunia as a condition capable of causing sterility in women, although the sequence is not an absolutely necessary or invariable one.

In order to excite voluptuous sensation during intercourse, savage races make use of various means, some of which we here transcribe from the work of Ploss-Bartels. In Abyssinia, and on the Zanzibar coast, young girls receive instruction in certain rotary muscular movements known by the name of duk-duk, which they employ during coitus for the increase of sexual pleasure. Many Daiaks perforate the glans penis with a silver needle from above downwards; this needle is kept in place like a seton, until a permanent canal is formed through the glans: in order during coitus to stimulate the woman more powerfully, into this canal, just before coitus, various small articles are inserted, such as little rods of brass, ivory, silver, or bamboo, or silver instruments ending in small bundles of bristles; these project from the surface of the glans, and exercise a more powerful friction of the vagina, thus increasing the sexual pleasure of the woman. Men without such an apparatus are rejected by the women, whilst those who have made several such canals in the glans, and can therefore insert several instruments, are especially sought after and prized by the women. Such an apparatus is known as an ampallang, and in a symbolic manner the woman indicates to a man of her choice her desire that he should make use of one; he finds in his bowl of rice a rolled-up leaf, enclosing a cigarette which represents the size of the desired ampallang. Among the Alfurs of North Celebes, in order to increase the voluptuous pleasure of the woman during intercourse, the men bind round the corona glandis the eyelids of a goat, beset with the eyelashes, thus forming a bristly collar; in Java and in Sunda, before coitus, the men surround the penis with strips of goat-skin, leaving the glans free. In China they wind round the corona glandis torn fragments of a bird’s wing; these also project like bristles and increase the friction. Among the Batta of Sumatra, travelling medicine-men perform an operation by means of which they insert, beneath the skin of the penis, small stones, sometimes to the number of ten, at times also angular fragments of gold or silver; these heal in beneath the skin, and increase the stimulus of coitus for the women. Among the Malays of Borneo the penis is perforated, and some fine brass wire with the ends turned inwards is inserted: before coitus, the sharp ends of the wire are drawn out so as to project from the skin.

In our own part of the world, voluptuaries make use of an india-rubber ring beset with spines, which before coitus is passed over the corona glandis, in order to promote sexual gratification in the woman during intercourse. In cases of diminished potency in the male, in order to produce sufficient sexual excitement in the female by more powerful erection of the penis, various mechanical means are now employed. For instance, in such a partially impotent man, a constricting band of india-rubber may be passed over the root of the penis, whereby the reflux of blood from the corpora cavernosa is hindered, and a more complete and more enduring erection is induced. Elderly men have frequently declared to me that they were well satisfied by the employment of this simple measure, whilst behind their backs, their wives have assured me that the results were far from satisfactory. The apparatus described by Roubaud for the enlargement of the penis is no longer employed. Partially impotent men make use, however, of an instrument known by the name of “schlitten,” made of gold, silver, or white-metal; it consists of two delicate laminæ, united at the base by a metal ring, and at the upper end by an india rubber ring. This small apparatus, which must be made exactly to measure, renders possible the introduction of the imperfectly erect penis into the vagina; it supports the penis, and readily accommodates itself to the change in size of the organ as it slowly becomes erect.

FERTILITY IN WOMEN.

Fertility in women is the basis of the fecundity of a nation, of its growth, its power, and its importance. It is especially the fertility of married women which enters here into consideration, and forms the source of the statistical data of fertility; these are usually obtained by drawing a ratio between the number of marriages contracted in a given period, and the number of children born in the same period.

The fertility of women is a function beginning at an age varying in dependence on many conditions, and undergoing extinction at a definite period of life. It is, in fact, associated with the duration of the sexual life of woman, and, generally speaking, extends from the sixteenth to the fiftieth year of life. Climate, race, constitution, and morbid conditions, influence alike the first appearance of menstruation and the first pregnancy; and as they influence the duration of menstrual activity, so also do they influence the duration of fertility.

In the Bible are recorded numerous instances of the early commencement of fertility. At the present time also, in warm climates we meet with many examples of early motherhood. From the great work of Ploss-Bartels, from which we have already frequently quoted, we extract and summarize the following ethnographical details. Among the wives of the Bosjesman, mothers aged ten are frequently seen; travellers in New Zealand often saw mothers of eleven years, and mothers of the same age among the Samoyedes and in Palestine; mothers of twelve in British Guiana, in Jamaica, among the Schangallas, at Shiraz in Persia, among the Copts in Egypt; mothers aged thirteen in Cuba, among the Sioux and the Dakotas, and in New Caledonia; mothers aged fourteen among the Negroes of Gaboon.

According to the observations of Robertson, of sixty-five Indian women there gave birth for the first time:

At the age of 10 years 1 At the age of 11 years 4 At the age of 12 years 11 At the age of 13 years 11 At the age of 14 years 18 At the age of 15 years 12 At the age of 16 years 7 At the age of 17 years 1

Moreover, in the records of European countries, we find numerous instances of very early motherhood. Molitor’s case, a girl nine years old giving birth to a vesicular mole with an embryo; von Haller’s case, pregnancy in the ninth year of life; Carus’ case, pregnancy at the age of eight. Caspar saw a girl in Berlin who became pregnant at the age of twelve, and was delivered of a living child. Rüttel saw a girl nine years of age pregnant. King attended the confinement of a girl who at the time of her delivery was not yet eleven years old. Taylor reports the case of a girl twelve years and six months of age who was then in the last month of pregnancy. Koblanck attended a girl of fourteen who was delivered of a child weighing four and a half pounds.

In most of these cases the premature fertility is followed by a premature cessation of fertility. And there is more or less truth in Bruce’s statement regarding the Arab women in Africa, that those who began to bear children at the age of eleven were seldom still fertile at the age of twenty.

At times we may observe a remarkable extension of fertility beyond the average age, that is, beyond the age of fifty years.

In northern Europe pregnancy at a comparatively advanced age is by no means rare. From the official statistics of Denmark we learn that among 10,000 women, 465 were delivered at ages between 50 and 55 years. In Sweden, of 10,000 mothers, 300 gave birth to children when more than 50 years of age. In Ireland, the proportion of mothers over 50 was 345 per 10,000. In England the official figures dealing with the delivery of 483,613 women, showed that 7,022 were between 45 and 50 years of age, and 167 over 50 years of age.

The Surgical Academy of Paris, in an authoritative statement regarding the late age at which conception could take place, alluded to the fact that Cornelia, of the family of the Scipios, gave birth to Volusius Saturninus when sixty years of age, that the physician Marsa in Venice recorded the existence of pregnancy in a woman of sixty, that de la Motte recorded pregnancy in a woman of fifty-one, and that he believed it to be true that another Parisian woman had given birth to a girl at the age of sixty-three, and had herself suckled the infant.

In an important case, however, which came before the Court of Chancery in England, the court held that there was no definite evidence of the possibility of pregnancy in a woman sixty years of age; but that the greatest age at which, in England, pregnancy had indisputably occurred, was 54.

Among 4,925 deliveries occurring in the Prague Maternity Hospital, Schwing reports that there were 9 women delivered for the first time when over 40 years of age. Of these: