Women suffering from heart disease should not have sexual intercourse frequently, because, if the peripheral nervous stimulation of the genital organs is excessive in consequence of too frequent acts of coitus, cardiac activity is likely to be influenced powerfully in a reflex manner, leading to the occurrence of attacks of cardiac asthenia. Again, sexual intercourse must always be effected in such a manner that the act attains its physiological conclusion, and that in the woman as well as in the man the orgasm has its normal outcome, that is to say that at the conclusion of the act the woman’s cervical glands are evacuated with the accompaniment of the sense of ejaculation. The congressus interruptus, which precisely in these cases in which the wife suffers from heart disease is so frequently practiced by the husband with a view to preventing conception, must be strictly forbidden, since this mode of intercourse tends to give rise to various forms of reflex cardiac disturbance, most commonly to paroxysms in which the cardiac action becomes unduly frequent, in association with diminution of vascular tone, vasomotor disturbances, and states of mental depression; and where organic heart disease already exists, these reflex functional disturbances involve various dangers.
The physician is further justified in advising that a woman with organic heart disease should not give birth to more than one or two children. This advice is the more needful for the reason that with each successive pregnancy the functional capacity of the woman’s diseased heart diminishes according to a geometrical ratio, and to a corresponding degree the danger to life increases. These are cases in which in my opinion it is the physician’s duty to concern himself with the subject—in general so equivocal—of the use of preventive measures, and, having regard for the preservation of a woman’s life, and uninfluenced by any false delicacy, but with moral earnestness, to inform his patient with respect to the needful prophylactic measures. The artificial termination of pregnancy, which unquestionably is often justified in women suffering from heart disease, but which unfortunately is apt to have very unfavorable results, will rarely need to be discussed if by the proper employment of preventive measures care is taken that pregnancy does not recur too frequently.
To enable us to answer the question whether, in the case of neurasthenic and hysterical young women, and in those hereditarily predisposed to the occurrence of mental disorders, the physician shall advise for or against marriage, attention must in the first instance be directed to the established facts relating to the favorable or unfavorable influence, as the case may be, of sexual intercourse and its consequences (pregnancy and childbirth) upon existing nervous disorders and upon the predisposition to their occurrence.
Without regarding as fully justified the opinion that in the female sex sexual abstinence has in all circumstances an unfavorable influence upon the nervous system or even that such abstinence is to be regarded as the principal cause of nervous and hysterical troubles, we must consider it fully proved that in a number of the commonest varieties of nervous disease occurring in neurasthenically predisposed subjects, such as neurasthenia, hysteria and neurosis of anxiety[[43]], the lack of sexual satisfaction aggravates these troubles, whilst suitably regulated sexual intercourse has an actively beneficial effect. Not, indeed, that it is an infallible means, but none the less the effects are often striking, as I have frequently had occasion to observe, both in young women so affected entering upon marriage for the first time, and also in young widows who have remarried. Especially is this true of women in whom the sexual impulse is exceedingly powerful, and even pathologically increased to the extent of marked sexual hyperæsthesia; likewise also in women whose social circumstances and manner of life induce increased sexual appetite. Be it understood, I refer here to regular and moderate sexual intercourse, and not to sexual excesses, which latter, by inducing nervous exhaustion, may have a distinctly deleterious effect. In many cases, however, we observe in women suffering from sexual neurasthenia, that sexual intercourse, even when practiced at long intervals, gives rise to nervous prostration with deep emotional depression and long-lasting aggravation of the existing nervous disorder. This statement applies with especial force to very hysterical epileptic girls with hereditary predisposition to mental disorder.
From the fact that among persons hereditarily predisposed to mental disorder, the unmarried are on the average more often affected with insanity than the married, the inference has been drawn that marriage may be recommended to such persons as a measure likely to counteract their hereditary tendency to insanity. The argument, however, lacks validity, more especially as regards women; among whom, moreover, from the age of sixteen to the age of thirty, insanity is proportionately more prevalent among the married, though above the age of thirty it is more prevalent among the unmarried.
In the great majority of neurasthenic women, normal sexual intercourse, practiced in moderation, has, according to Löwenfeld, no deleterious effect; often, indeed, as a consequence of unaccustomed abstinence, an aggravation of existing nervous troubles may be observed. But, as this author maintains, nervous exhaustion may result in the complete disappearance of the orgasm during sexual intercourse, or in great difficulty in its production; this circumstance suffices for the most part to explain the fact that in women suffering from great depression of the nervous functions, the fulfilment of their sexual duties has sometimes an unfavorable influence on their general condition. As regards hysteria, it cannot be denied, that in many hysterical women marriage results in a favorable change in the general condition; we must, however, be careful not to overrate the significance of such observations. As a rule all that actually takes place is a diminution in the intensity or even a disappearance of certain morbid manifestations previously present, without, however, an eradication of the hysterical temperament.
In epileptic young women, the first experience of sexual intercourse may precipitate a fit. Cases are indeed on record in which, in hereditarily predisposed girls, the first coitus was the exciting cause of the first epileptic fit, the fits recurring every time sexual intercourse was repeated.
It is a comparatively frequent occurrence in psychopathically predisposed girls for severe mental disturbances to make their appearance during the honeymoon, after the first experience of sexual intercourse; when this occurs, it is doubtless to be accounted for by the combined influence upon the mind of all the changes in the circumstances of life which have resulted from the marriage. In the case of two newly married women, one of whom had well-marked hereditary predisposition, whilst in the other there was no known family history of mental disorder, Löwenfeld observed shortly after marriage the onset of severe melancholia, with refusal of food. The delicate, nervous temperament of these two women, on the one hand, and, on the other, possibly, a somewhat too eager and passionate attitude on the part of their respective husbands, led their first experience of sexual intercourse to result in a nervous impression of the nature of shock, which their nervous system was too weak to resist.
Frequently recurring pregnancy and childbirth may, according to Krönig, act as the predisposing cause in the production of neurasthenia. In regard to hysteria also we must admit that the onset of some disease of the organs of generation frequently leads previously latent hysteria to manifest itself openly, and further we have to recognize that diseases of the reproductive system often give the clinical picture of hysteria a quite distinctive coloration; the physiological course of the functions of the generative organs is also competent to produce both of these effects. Krönig, however, rejects the view that the lack of sexual intercourse has an unfavorable influence upon the nervous system in women, and gives rise to hysterical and neurasthenic disorders. The favorable influence which marriage is often observed to exercise upon the course of nervous disorders is explicable with reference to psychical considerations of a very different nature. Sexual abuses, masturbation, and the use of preventive measures, give rise in women far less often than in men to neurasthenic and hysterical conditions.
Féré asserts that in certain neurasthenic patients sexual intercourse induces a general blunting of the senses, and especially of hearing and sight. Actual amaurosis of short duration may even be observed; also cutaneous anæsthesias, paralytic conditions of the extremities taking the form either of hemiplegia or paraplegia, convulsive attacks, and somnolent paroxysms.