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.