Of the abnormalities of the hymen atresia scarcely calls for consideration, since the retention of the menstrual blood early leads to hematocolpos and hematometra, and an operation is required, which keeps the road open for the future reception of semen. It is still possible, however, that the opening, when sexual intercourse is to take place, may be found to be too small, especially if a simple puncture has been made. The obsta cle then resembles those anomalies soon to be described. The deviations of the hymen from the normal are numerous, but the conditions which render cohabitation difficult are in reality only two, either the orifice is too small or the membrane too dense. These conditions prevent the dila tation or laceration of the hymeneal ring by the penis, particularly when both are combined, but that conception is even here possible is well known, for cases are recorded where the hymen was an obstacle to delivery. These cases, indeed, are so often referred to in text-books on Gynecology and Medical Jurisprudence, and have so frequently received attention in connection with sterility, that I need not specially refer to them.
We must state, however, that not every intact hymen forms an ob struction to copulation, since it often is pressed in and assumes a funnel shape, or the apparently narrow opening is very dilatable, so that an immissio penis can take place without rupturing the membrane. Never theless this unruptured and unchanged membrane must be considered as rendering conception somewhat difficult. The obstruction may remain permanent, but not rarely the penis will form for itself a passage, or there may result a condition which will render copulation very difficult. This brings us to the most important of all obstacles to copulation which are connected with the external genitals, and this is vaginismus, which is the result of a nervous influence.
We may differentiate several forms of this affection, although they are always separable. Occasionally the external genitals of virgins are so hypercesthetic that the first attempt at copulation produces such excessive pains that any further effort at coitus is rendered impossible. The hyper testhesia is at times confined to individual parts. Thus Friedreich in his posthumous essay on " Hysteria of the Clitoris," considers this organ the seat, and claimed that special treatment sbuld be directed to the clitoris in order to cure the sterility. Simpson described localized points of hypermsthesia, situated not only at the urethra, but at other points, and probably dependent on the presence of little neuromata. In this connection should be mentioned the condition of the nerve ends in the labia minora, as described by my assistant Dr. H. Carrard, which are at the bottom of pruritus vulvte, but in all probability they can give rise to hypenesthesia as well. Occasionally the hypenesthesia is a general one, and not confined to any one part, and then it may be considered an accompaniment of hysteria, and thus it is particularly seen in chlorotic individuals. The external organs are intact, but the very first sexual approach produces such pain that the women rebel against further attempts, even as they occasionally do from a digital examination. Unquestionably this is often the ca.se at the first coition, but the wife being determined to comply, and the exalted sexual desire on the part of the ambitious husband combined, overcome the reluctance and pain. Yet at times this condition, especially when there is a state of apathy present, becomes permanent, and then comes under the observation of the physician. I have seen two pro nounced cases of this kind. In both instances the external genitals were uninjured. One woman was represented i143 nervous, and possessed of peculiar ideas; the second was afflicted during her childhood with scrofula and was decidedly chlorotic.
In another class of cases this hypercesthesia is wanting. In the begin ning copulation takes place without pain or resistance, yet it does not accomplish its object, but simply results in producing irritation. Thence it follows secondarily that, on account of the pain, the act is only passively taken part in, and if the efforts are persisted in the local affection is sim ply increased, and painful spasm is finally induced. On inspection the
external genitals are strongly congested, the nymphie swollen, the hyme neal orifice inflamed, generally slightly torn. Secretion is only present after long suffering, and then only copious when there is gonorrhceal in fection present. I have not as yet seen a case where there was un doubted specific infection.
The causes of this affection are manifold, and they may depend on either sex. Often it is a resistant hymen which, as we have seen above, prevents the introduction of the penis and thus the vulva is irritated. Very often awkward coitus seems to induce the affection. It is not always the case that it is a young, inexpert husband, but often such as have been accustomed to copulate easily, but are now obliged to dispense with the guiding hand of the chaste woman. It may also result from men who from impotence have not the power to overcome the resistance of the in tact genitals. The woman may be at fault as well in that she does not aEsume a favorable position for the a,ccomplishment of the act, and does not direct the male in the proper direction. In addition to smallness of the rulva aud the resistance of the hymen, an unfavorable position of the external genitals may act as a cause, inasmuch as they are not under the pubic arch, but rather over the symphysis, so that the glans is directed against the latter instead of against the introitus vaginEe. On account of these conditions the external genitals are so irritated and inflamed that any further attempts at copulation are prevented. Occasionally the bru tality of the husband will accomplish the act, but in other cases contrac tions of the neighboring muscles are induced, thus giving rise to the third form, which has received the special name of vaginismus. At every attempt to copulate, indeed even before the glans has ipproached the irritated genitals, further even at the very thought of coitus, contrac tion of the constrictor ennui, which in reality acts as a supporting organ t,o the penis, takes place, and this prevents further entrance of the male organ into the vagina. Probably the levator ani takes part in this spasm. Here also by attempts at further indulgences increased suffering is in flicted. There is no doubt that where simple hypenesthesia of the exter nal genitals occurs without any inflammatory irritation, contraction can be induced, and then as the result of the attempts to overcome the ob struction, inflammatory manifestations take place. As is evident these separate forms can merge into each other.
Other affections situated in the neighboring parts can, by inducing the above contractions, prevent cohabitation—as, for instance, urethral car uncle, especially since it comes in direct contact with the penis. As for fissure, it is a problematical e.ause. In case of coccygodynia, I have not notimd that coition is disturbed.
The last-named affections do not always cause disturbances in the early years of married life, but, on the contrary, usually first appear after deliv ery. Inflammatory processes--as, for example,those of the introitus vaginEe with pronounced congestion, and sensitiveness of the carunoulte myrti formes—may, after a number of confinements, prevent cohabitation, but medical aid is seldom sought because of non-conception.
It happens very rarely that the introitus vagime is displaced because of narrowness of the pelvis, the columns of the pubic arch being so close together as to make an immissio penis an impossibility. It is seldom that the physician is consulted because of sterility in instances of this kind, since marriage is not entered into with such a deformity. $uch cases do occur, however, frequently in patients suffering from osteomalacia. It has happened only once to me that, after recovery from this disease, com plaint was made of the inability to cohabit. In forensic medicine, the question whether a woman thus deformed should be allowed to copulate might be of practical importance.