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.