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.
In a certain number of cases, however, the husband is in no way responsible for the origin of vaginismus, which may depend on pathological states of the female external genitals, leading to hyperaesthesia; or, again, on primary hyperaesthesia of the pudic nerve and its branches; or, finally, on general neurasthenia and hysteria, on excessive sensibility and lack of self-control on the part of a young girl, who has entered upon married life under the dominion of extravagant ideas. Vaginismus dependent upon general neurasthenia especially in cases in which there is no strong affection for the husband to give the spur to desire, and to enable the woman to bear with fortitude the pangs which form the necessary introduction to the joys of wedded life. It must not be forgotten, as throwing light on the origin of vaginismus, that in the digital vaginal examination of a virgin or even of a young wife, unless extreme care is taken, pain and painful muscular spasms are liable to be evoked.
The local pathological conditions of the female genital organs that are most often met with in cases of vaginismus are: a very rigid state of the hymen; inflammation and excoriation of the hymen and its surroundings; fissures at the vaginal orifice; inflammatory affections of the vaginal follicles; inflammation of the carunculæ myrtiformes; a peculiar formation of the vulva, which extends forwards over the pubic symphysis, whereby the urethral orifice and the hymeneal aperture come to lie upon the pubic symphysis or the subpubic ligament; vulvitis; herpes or eczema of the vulva; colpitis; urethritis; fissure of the anus; papillary growths; pruritus papules; urethral caruncle; inflammation of Bartholin’s glands; at times gonorrhoeal infection.