In exceptional cases we find as additional morphological
elements, especially in elderly people, scattered erythrocytes,
cylinder-epithelium cells, and masses or granules of yellow pigment.
The spermatozoa are about fifty micromillimetres in length. Two parts
may be distinguished in each, a head and a tail. The head, four or five
micromillimetres in length, is flattened, and differs in apparent
shape—though generally more or less pear-shaped—according as to whether
it is seen sideways or on the flat.
The tail, which is about forty-five micromillimetres in length, narrows
from before backwards. The fine posterior extremity is said to contain
the contractile element, so that it is upon this portion that the
familiar movements of the spermatozoa depend (Fig. 61).
The spermatozoa are made up of a substance very rich in sodium chloride,
and strongly resistent to reagents and to putrefaction. In consequence
of their richness in mineral constituents, the ash, when they are
calcined, retains their original form.
The movements of the spermatozoa can be properly observed only in fresh,
pure semen (Fig. 62).
If freshly ejaculated semen is treated with water, the movements of the
spermatozoa very shortly cease, and their tails become rolled up in a
spiral form.
[Illustration:
FIG. 61.—a. b. c. Prostatic calculi from normal semen. d. Spermatozoa.
e. Large and small cells, some containing granules, as morphological
elements of semen. f. Spermatozoon distorted by imbibition of water.
g. Crystals. (After Bizzozero.)
]
[Illustration:
FIG. 62.—Normal semen.
]
If semen is left undisturbed for twenty-four hours or longer, the
vitreous substance dissolves in the surrounding fluid, and this latter
separates into two layers, an upper which is thinner, and a lower, which
is thicker and non-transparent. In the former, the morphological
elements are found but sparingly, whilst in the latter, they are
plentiful. In addition to the elements already described, we find often
two varieties of crystals. One of these varieties, which appears only
when decomposition is far advanced, consists of ammonium magnesium
phosphate. The other variety has a chemical composition not yet
determined. These crystals belong to the monoclinic system, forming
prisms or pyramids, often with curved surfaces; they are colourless or
light yellow; they lie superimposed, often forming beautiful star-shaped
figures. They are soluble in mineral and vegetable acids, and in
ammonia, but are insoluble in alcohol, ether, and chloroform; they are
remarkably resistent to the solvent powers of cold water, but not so to
those of boiling water. _Shreiner_ has proved that these crystals
consist of a phosphate of a base which is represented by the formula C2.
H5. N. According to _Fürbringer_, these crystals are produced as a
result of the action of the semen upon the prostatic secretion.
The quantity of semen ejaculated during coitus is very variable,
depending upon the age and size of the individual and the formation of
his testicles, upon his individual sexual capacity, and upon the
question whether antecedently there has been sexual excess on the one
hand or long continued continence on the other. In general, the quantity
of semen ejaculated at one time varies between 0.75 and 6 c.c. (10 to
100 minims).
If healthy, normal semen, with adequate fertilizing potency, is properly
preserved from cold and light, we may, even after the lapse of
twenty-four hours, find under the microscope spermatozoa still engaged
in active movement. _Ultzmann_ employs for the description of a drop of
fresh semen, the comparison that it is full of movement, “like a stirred
up ant-heap.” Influenced by the whiplike lashings of the tail, the
spermatozoön moves steadily forwards, finding its way through the
narrowest passages on the microscopic field without striking any of the
cellular structures that may lie in its path. The longer the semen
remains under observation, the less active are these movements of the
spermatozoa, for after ejaculation they gradually die, exhibiting after
death an extended, or at most a slightly curved tail; those spermatozoa,
on the other hand, that were dead before ejaculation, have the tail
spirally twisted, rolled up, or acutely bent. In the case of spermatozoa
which have been destroyed by the action of some other deleterious
secretion, as by urine or by acid vaginal secretion, such a condition of
the tail is very commonly seen. When the semen is treated with water,
the movements of the spermatozoa soon cease, and the ends of their tails
frequently roll up to form loops. By the addition, however, of
concentrated solutions of neutral salts, of albumen, of urea, etc., it
is possible to reanimate these motionless spermatozoa, so that they once
more are seen to perform active movements. Moderately concentrated
animal secretions of an alkaline reaction are favourable to the motor
activity of the spermatozoa, whilst on the other hand dilute and acid
secretions, such as urine, acid mucus (including the acid vaginal
mucus), and catarrhal secretions, even when alkaline in reaction, have a
depressant influence on this activity. Caustic potash and caustic soda
stimulate the movements of the spermatozoa. When they are cooled down to
a temperature below 15° C. (59° F.), the movements cease entirely. Salts
of the heavy metals, and mineral acids in solution, also bring their
movements to a pause. Frequent repetition of coitus causes a diminution
in the number and in the motor activity of the spermatozoa.
Semen which contains no spermatozoa, or in which the spermatozoa are
motionless, is absolutely devoid of fertilizing power; in the case of
such semen, it makes no difference whatever that the external genitals
of the man generating it are strongly formed, that his testicles are of
normal size, and that erection and ejaculation take place promptly. Of
very little value, though not absolutely sterile, is semen containing
very few living spermatozoa, or, among very numerous motionless
spermatozoa, containing a few only that are engaged in active movement.
Suspect, is semen which does not possess the normal light greyish white
tint, but is brownish-red, brownish-yellow, yellow, or violet; these
variations in colour indicating an admixture with the semen of varying
quantities of blood or pus, in consequence of disease of the urethra,
the prostate, the seminal vesicles, or some other part of the uropoietic
system; such admixtures seriously impair the quality of the semen. An
unfavourable judgment must also be passed on semen which, at each
successive ejaculation, is voided in very small quantities only—from
half a drachm to a drachm. When thus scanty, semen is often found to
contain an exceptionally large proportion of dead spermatozoa. We may
regard very favourably semen which is voided in quantities considerably
in excess of the average; sometimes, when there is a veritable
polyspermia, there may be an ounce or upwards, more than three times as
much as normal—provided, of course, that this semen so richly voided is
of a satisfactory quality, and contains an ample proportion of active
spermatozoa. The most valuable characteristic in semen is exhibited when
the spermatozoa it contains are not only very numerous and vigorously
active, but when they are also very long-lived, when, that is to say,
they retain the power of active movement sometimes for as long as three
days. A decisive opinion as to the quality of a man’s semen can be given
only as the result of precise and repeated microscopic examinations, and
the medical man must be most careful, when in his first examination he
has not been able to detect the presence of any living spermatozoa, to
abstain from giving, on that account alone, an adverse decision—from
pronouncing sentence of death on the man’s reproductive potency.
It has not hitherto been accurately determined how long spermatozoa can
continue to live in the interior of the uterus, although the point is of
great importance, not only in relation to conception, but also in regard
to the theory of menstruation. _Percy_ has published a case in which,
eight and a half days after the last coitus, he saw living spermatozoa
emerge from the os uteri externum. _Sims_ bases upon his own researches
the decisive opinion that in the vaginal mucus, spermatozoa can never
survive longer than twelve hours, but states that in the mucus of the
cervical canal they can live much longer. If thirty-six to forty hours
after coitus, we examine the cervical mucus under the microscope, we
commonly find living and dead spermatozoa in about equal numbers. Many
of the living ones will survive their removal from the cervix for as
much as six hours longer.
Of especial interest are the conditions which are liable to deprive a
man of the power to produce fertilizing semen. In the first place must
be mentioned congenital absence of both testicles—a condition which, in
otherwise normally formed male individuals, is one of extreme rarity.
Congenital absence of _one_ testicle is less rare, and is usually
accompanied by absence also of the epidydimis, vas deferens, and seminal
vesicle of the same side. The potentia gestandi of a monorchid depends
upon the proper development of his single testicle, and the functional
capacity of this organ must be ascertained by a careful microscopic
examination of his semen. Much more frequent than absence of the
testicle, though still sufficiently rare, is the condition of
cryptorchism, non-descent of one or both testicles, a state not
necessarily associated with functional incapacity of the organ. Most
commonly, however, an undescended testis is an imperfectly developed
testis, and in the very great majority of cases the ejaculated fluid
contains no spermatozoa.
A further cause of the lack of potent semen is atrophy of the testicles
with notable diminution in the size of the glands, and more or less
complete disappearance of the seminiferous tubules and their cellular
contents. This state is rarely congenital, being nearly always acquired:
in consequence of inflammatory conditions affecting the testicle proper
or the epididymis (syphilitic inflammation, especially, is apt to lead
to overgrowth of the interstitial connective tissue and to gradual
destruction by pressure of the seminal tubules)[46]; or in consequence
of the pressure of a hernia, a varicocele, a hydrocele, or a tubercular,
carcinomatous, or other new growth; or in consequence of constitutional
disorders, especially long-lasting, severe, and exhausting diseases,
such as diphtheria, diabetes, or chronic alcoholism; in consequence of
diseases affecting that portion of the central nervous system from which
the nerves supplying the genital organs arise; in consequence of
degenerative changes resulting from sexual excesses; or, finally, in
consequence of senile changes, such as fatty changes in the cells of the
seminiferous tubules. Certain drugs also, digitalis, salicylic acid,
mercury, iodide of potassium, arsenic, and morphine, have an
unfavourable influence alike on the quality of the testicular secretion
and on the potency of the individual. _Von Gyurkovechky_ reports that in
Bosnia a plant locally known as “neven” is employed among the peasantry
for the temporary suppression of sexual potency, wives giving it to
their husbands when the latter are about to leave them and go upon a
journey, and sprinkling the leaves of the plant among the underclothing.
[Illustration:
FIG. 63—Semen consisting chiefly of sperm-crystals, cylindrical
epithelium and small granules exhibiting molecular movement—but
containing _no_ spermatozoa.
]
By the name of azoospermia is denoted a condition whose existence can be
determined only by microscopic examination.
The subject of this affection has normal potentia coeundi, the semen is
ejaculated in quite normal fashion, and it is its constitution only that
is faulty. In appearance it is extremely fluid, and is somewhat cloudy;
its sediment contains molecular detritus and spermatic crystals, but no
spermatozoa (Fig. 63). If the medical man makes it his rule, in all
cases in which he is consulted on account of sterility, in deciding how
far this sterility is dependent on the condition of the husband, not to
confine himself solely to the customary questions, whether intercourse
is regularly practised, whether before or after menstruation, etc.—but
if in every case he makes a careful examination of the semen under the
microscope, he will be astonished to learn the comparative frequency
with which he will note the complete or nearly complete absence of
spermatozoa. This condition of azoospermia may be permanent or
transitory.
To _Kehrer_ belongs the credit of having pointed out that sterility is
less often due to impotence or to aspermatism than to azoospermia—a
condition often unsuspected by husband and wife, and one to be diagnosed
by the physician only after repeated microscopic examinations of the
semen. For this reason, indeed, its existence is often overlooked.
_Kehrer_ believes himself to be justified in asserting that one-fourth
of all cases of sterility (if not indeed more) must be referred to
conditions affecting the husband, and most often to azoospermia; hence
he concludes, that the husband must still more often be regarded as the
one to blame for the occurrence of sterility, when the cases are borne
in mind in which a man marries with an imperfectly healed gonorrhœa, and
infects his wife, giving rise to a chronic tubo-uterine blennorrhœa, and
ultimately to sealing up of the tubes and to sterility.
Complete absence or marked scarcity of spermatozoa in the semen may
occur also without any change in the testicle that can be detected by an
external examination, as a consequence of contusions of the testicle, or
of gonorrhœal inflammation of the epididymis or vas deferens; further as
a sequel of severe general diseases, long-continued physical exertion,
or great sexual excess.
In some cases, a microscopical examination reveals, not azoospermia, but
oligozoöspermia, that is to say, the number of living spermatozoa in the
semen is remarkably small. Or, again, the anomaly may be of this
character that the spermatozoa are smaller than normal, that they are
motionless, and that their tails are broken off—such are the
peculiarities, as a rule, of the semen of old men.
A less common condition than azoospermia, but one the pathological
importance of which is equally great, is aspermatism, in which the man,
neither during coitus, nor in any other form of sexual excitement, is
able to ejaculate any semen. This condition may be congenital or
acquired; it may be permanent, or transitory (lasting a few weeks or
months). In these cases we have to do with organic changes in the
testicles, diseases of the prostate, gonorrhœal processes, or nervous
disturbances resulting in a loss of irritability in the reflex centre
for ejaculation. Aspermatism in the narrower sense of the term, a
condition, that is to say, in which there is total suspension of the
activity of all the three glands which combine to secrete the composite
fluid known as semen, namely, of the testicle, the prostate, and the
seminal vesicles—is, according to _Fürbringer_, probably non-existent.
The pathological state underlying aspermatism would rather appear to be,
not a failure to secrete semen, but a failure to ejaculate it.
[Illustration:
FIG. 64.—Oligozoöspermia. a. Living spermatozoa, b. Dead spermatozoa,
c. Pus corpuscles, d. Erythrocyte, e. Seminal granules.
]
Last of all, we have to speak of conception without copulation, of
artificial fertilization. In consequence of the mechanical hindrances
which in many cases prevent the entrance of the semen into the interior
of the uterus, the idea has arisen to introduce the semen by means of
instruments directly into the cervical canal, dispensing with the
natural act of copulation. Experience long ago gained in artificial
pisciculture, no doubt gave rise to this idea. _Spallanzani_ and _Rossi_
by means of a syringe injected the semen of a dog into the vagina of a
bitch, the procedure resulting in impregnation. _Girault_ appears to
have been the first,[47] in the year 1838, to introduce semen
artificially into the human uterus, if we leave out of consideration the
experiment of _Léseurs_, who introduced a tampon moistened with semen
into the interior of the vagina. The procedure employed by _Girault_ is
thus described: The patient having been placed in the position usually
employed for gynecological examination, a canula resembling a male
catheter with the eye in its point, and with a funnel-shaped enlargement
at the opposite extremity, is introduced into the uterus, this
instrument having first been prepared by moistening its interior with
mucilage and filling it with semen; by insufflation, the semen is now
expelled into the uterine cavity. It is stated that neither uterine
colic nor any other dangerous symptom has ever been brought on by this
procedure. The experiments were made at various periods between the year
1838 and the year 1861; they were ten in number, and of these eight
proved successful, two unsuccessful. In the ten cases, the total number
of insufflations made was twenty-one—the minimum number in any single
case being one, the maximum five. In one case, the insufflation was
effected immediately after the cessation of menstruation; in the
majority, from one to four days after the cessation of menstruation; in
one case twelve days, in one case twenty-three days, after the cessation
of the flow. _Gautier_, instead of insufflations, has employed
injections of semen, using two injections in each case, one just before
menstruation was expected, the other a day or two after the cessation of
the flow. _Marion Sims_ endeavoured in twenty-seven cases to bring about
conception by the injection of semen into the uterus; in one of these
cases only was the desired result obtained. In this latter instance the
patient was twenty-eight years of age, had been married for nine years,
but had remained barren. Throughout her menstrual life, she had suffered
more or less from dysmenorrhœa, often accompanied by severe
constitutional disturbance, such as syncope, vomiting, and headache.
Local examination disclosed the existence of retroversion of the uterus
with hypertrophy of the posterior wall, an indurated, conical cervix,
with stricture of the cervical canal, especially in the region of the os
uteri internum. In addition to all these mechanical obstacles to
conception, it was found that the semen was never retained in the vagina
after coitus. _Sims_ examined the patient immediately after coitus had
taken place, but never found a single drop of semen in the vagina,
notwithstanding the fact that this fluid had been ejaculated in
abundance. _Sim’s_ first care was to bring about reposition of the
uterus, and to keep the organ in its proper place by the insertion of a
suitable pessary. Injections of semen were then undertaken, and were
continued throughout a period of nearly twelve months. In two instances,
the injection was effected immediately before the onset of the menstrual
flow; in eight instances it was effected at varying times (two to seven
days) after the cessation of the flow. At first, three drops of semen
were injected, but later only half a drop. The semen (first ejaculated
into the vagina during normal intercourse) was injected by means of a
glass syringe, which was kept in a vessel of warm water at a temperature
of 98° F. Since during the removal of the instrument from the water and
its insertion into the vagina, some fall in temperature necessarily
occurred in the vagina, _Sims_ allowed the syringe to remain for some
minutes in the vagina before he drew the semen into it, in order that he
might feel assured that syringe and vagina had regained the temperature
most adapted to the vital activity of the spermatozoa. The nozzle of the
syringe was then carefully introduced into the cervical canal, and half
a drop of semen was slowly injected into the uterine cavity. For two or
three hours after the operation, the patient remained lying quiet in
bed. After the tenth experiment, conception ensued—the first recorded
case of artificial fertilization in the human species.
With right, however, this case of _Sim’s_ was not regarded as
conclusive, since both before and after the injection, ordinary coitus
had been effected, and it is therefore impossible to determine whether
the fertilizing spermatozoön was one of those introduced by means of the
syringe, or in the antecedent or subsequent coitus—more especially in
view of the fact that by the insertion of a pessary _Sims_ had,
previously to undertaking the injections, restored the uterus to a
position more suited to the occurrence of conception in the natural
manner.
In a case which a priori seemed exceedingly well adapted for the
performance of artificial fertilization, one of marked hypospadias in a
man whose semen was abundant and contained a large number of vigorously
moving spermatozoa, I saw this experiment fail, in spite of all possible
care in its performance. In fact, not a single conclusive instance of
successful artificial fertilization in the human species is known to me,
though I have seen reports of numerous disagreeable and even dangerous
results of attempts to effect it. Both parametritis and perimetritis
have occurred in such cases; and semen, being a material in a state of
most intense molecular movement, may be regarded as extremely liable to
noxious transformations.
_Sim’s_ procedure has been modified by other gynecologists. Thus,
_Courty’s_ plan was that during coitus the semen should be collected in
a condom, fitting not too closely, from which receptacle it was drawn up
into a syringe and carefully injected into the cervical canal. _Pajot’s_
plan was that the semen should be ejaculated into the vagina in natural
coitus, and should thence be pressed into the uterine cavity by means of
a piston-like instrument introduced into the vagina.
In London, _Harley_ frequently made the experiment of injecting semen
into the uterine cavity, but in all cases without any result.
_P. Muller_, in two cases, on account of extreme anteflexion of the
uterus, performed this experiment. Though the general conditions were in
both cases extremely favourable, in neither instance was there any
result. It must, however, be mentioned that in one of his cases only had
there been any preliminary examination of the semen under the
microscope.
_Fritsch_ reports a case in which gonorrhœal secretion was injected in
place of semen. Peritonitis, which for a month endangered life, was the
result.
In Paris, _Lutaud_ has earnestly advocated artificial impregnation in
cases of sterility in which all other means have failed. It is obvious
that it would be useless to employ this measure after the menopause, or
in women in whom menstrual activity has ceased prematurely, with
simultaneous disappearance of all menstrual molimina. Equally useless
would it be in uterine atrophy and in cases of irremediable malformation
of the female genitals. Further contra-indications, according to
_Lutaud_, are offered by chronic pelvic peritonitis, since here, on
account of the obliteration of the lumen of the Fallopian tubes, the
operation is foredoomed to failure. Chronic inflammatory states of the
uterus and its mucous membrane, will also render the attempt useless.
Moreover, it is a condition indispensable to success that the semen to
be employed shall have been examined microscopically, and shall have
been found to be thoroughly healthy. The operation has the greatest
prospect of success when undertaken from three to two days before the
due date of menstruation. The method employed is that of _Sims_. If
after the first attempt, the due menstruation should begin, the
injection should be repeated a week after the flow has ceased; the
attempt should not, however, be repeated more than about six times in
all, since the probability of success rapidly diminishes with each
successive endeavour. Before the operation is undertaken, the
permeability of the cervical canal must be ascertained. Further, in
order that the spermatozoa shall be placed in conditions in which they
have the best possible chance of survival, a weak alkaline solution,
such as 1 per cent. of potassium bicarbonate, should as a preliminary
measure be injected into the vagina.
_Lutaud_ thus describes the procedure he employs. Immediately after the
woman has had intercourse with her husband, a Fergusson’s speculum is
introduced into the vagina, the patient remaining in the dorsal
decubitus. As the speculum passes in, its margin scrapes the surface of
the vagina, and by this means the semen is collected in the vicinity of
the cervix. The semen is then drawn up into a Pravaz syringe or an
analogous instrument, such as a uterine catheter armed at one end with a
rubber ball. The fluid is then carefully injected into the cervical
canal, or preferably into the uterine cavity, great care being taken not
to injure the mucous membrane in any way, since the slightest bleeding
may nullify the whole procedure. Finally, a small tampon of absorbent
cotton-wool is inserted into the os uteri externum. For some hours the
woman must remain quiet in bed; the tampon is not removed for ten hours.
As regards results, _Lutaud_ informs us that he has in this way treated
twenty-six cases. In twenty-two of these, failure was complete; in one
case, success was partial—the patient was impregnated, but abortion
occurred two weeks later; in another case, abortion occurred after three
months pregnancy; finally, in two cases, success was complete.
Indications for the employment of artificial impregnation are: first,
the existence of stenosis in the upper part of the cervical canal,
especially stenosis from flexion, provided, of course, that other
measures are contra-indicated or have been fruitlessly employed;
secondly, a deleterious character of the secretion of the cervical
canal; thirdly, extreme cases of hypospadias in the male. _Haussmann_
recommends the employment of artificial impregnation in cases in which
the spermatozoa are found to enter the cervical canal, but fail to pass
through the os uteri internum. Whilst artificial impregnation is
theoretically a sound measure, yet in the practice the indications for
its performance are by no means easy to establish. For, in cases in
which there is some mechanical hindrance to the contact of the
spermatozoön with the ovum (and it is for such cases only that this
method of artificial fertilization can properly be employed), it is
often extremely difficult, and may even be quite impossible, to exclude
the possibility of there being some failure in ovulation itself, or in
the maturation of the ova; or, again, sterility may depend, not on the
fact that no ova are fertilized, but on the fact that when fertilized
they always fail, for some reason, to find a resting place in the
uterus; in a word, in any case in which sterility appears to be due to
mechanical obstacles to conception, it may in reality be due to some
other disease which has escaped recognition, some organic disease of the
uterus, the tubes, the ovaries, of the periuterine tissues.
Finally, it must be remembered that the manipulation is far from easy in
its performance. Above all, the semen must be subjected to a most
rigorous microscopical examination in respect of its fertilizing
capacity. But this examination cannot be made in the case of the semen
that is actually used for the attempt at artificial fertilization; it
can only be done with an earlier specimen from the same man. If the
semen contains no living spermatozoa, or very few only and these
sluggish in their movements, still more if it contains pus corpuscles or
gonococci, all idea of its employment for artificial fertilization must
be rejected.
The method employed by _Sims_, in which the semen is drawn into a
syringe inserted into the vagina post coitum, is one which I am not able
to recommend, since in this way together with the semen some vaginal
mucus is drawn up, thus, instead of pure semen, we inject into the
vagina semen mixed with various impurities, and more especially with an
acid secretion known to be unfavourable to the life of the spermatozoa—a
circumstance that will doubtless explain many of the failures that have
hitherto taken place. It is certainly better that the semen of the
husband should be collected in a rubber condom. The preservation of the
material to be injected at a suitable temperature (the normal
body-temperature), is by no means easy. The syringe, an ordinary Braun’s
uterine syringe, is first disinfected, and then lies ready in water of
the proper temperature. The semen is rapidly drawn up into the syringe,
the nozzle of which is then passed down to the fundus uteri. Quite a
small quantity of semen will suffice. After the manipulation, which
should of course be undertaken at the time most favourable to
conception, just after menstruation, the woman should lie quiet in bed
for some hours.
In considering the probability of a successful issue to any such attempt
to secure artificial fertilization, we cannot leave out of consideration
the likelihood that that result may be prejudiced by the lack of all
normal sexual feeling on the part of the wife; concerning the
significance of such feeling in relation to the sexual act, we have
however as yet no certain knowledge.
That this procedure of artificial fertilization is extremely
disagreeable to all concerned therein, the physician not excepted, and
that various moral and social considerations can be alleged against it,
is incontestable. It is indeed recorded that in Bordeaux a legal penalty
was inflicted on a medical man who undertook to bring about artificial
fertilization. The Society of Medical Jurists debated this matter, and
came to the conclusion that, whilst a medical man was not justified in
recommending the practice, neither was he justified in refusing to
undertake it when requested by his patients. In Paris, a candidate for
the degree of Doctor of Medicine made artificial fecundation the subject
of his thesis, and maintained that its practice, when effected with all
proper social precautions and according to scientific principles, was
possible, reasonable, useful, and moral, and that in many instances it
should be recommended by the physician. After a long and stormy debate,
the Faculty of Medicine determined to reject the thesis and to destroy
all specimens of it already printed, on the ground that “they feared, if
they gave their sanction to the practice, that a number of more or less
unscrupulous physicians would make that sanction the basis of improper
practices, dangerous alike to the family and to the state, since the
operative method under consideration was one likely to be eagerly
exploited by the whole tribe of medical charlatans.” This weighty
pronouncement would appear to be sufficient ground for rejecting
artificial fecundation as a matter of routine practice; still, very
exceptional cases may be encountered in which it may be seized as an
ultimum refugium.
_Pathology of Copulation._
The act of copulation may be interfered with or entirely prevented by
pathological conditions affecting the genital canal of the woman, and
also by disturbances of the nervous system—naturally also by any
abnormality affecting the performance of the male partner in the act.
Abnormality of the hymen, such as excessive strength and rigidity,
rendering the organ unduly persistent, is a not infrequent hindrance to
intercourse, one that sometimes is not overcome even after years of
married life; to such a state of affairs ignorance on the part of the
married pair in respect to the proper method of intercourse, lack of
sufficient sexual power on the part of the male, or inflammation of the
fossa navicularis brought on by maladroit attempts at penetration, may
contribute, likewise undue passivity on the part of the female partner.
[Illustration:
FIG. 65.—Septate Hymen, the septum having a tendinous consistency.
]
A notable and sometimes an insuperable obstacle (of which it has been
written, _nec Hannibal quidem has portas perfringere valuisset_) is
constituted by that abnormality of the hymen in which the aperture in
that membrane is guarded by a sagittally placed or sometimes oblique
septum, dense and almost tendinous in structure. In a woman of
twenty-four years, who for two years had lived in sterile wedlock, I
found such a tendinous hymen septum. She had menstruated regularly since
the age of seventeen years, but always painfully. She complained that
her husband was “very weak,” inasmuch as on her bridal night he was
unable to succeed in completing intercourse, and since then whenever he
attempted intercourse, premature ejaculation resulted, before
penetration of the penis had been effected. In consequence of this
repeated ineffectual sexual excitement, she had herself become very
nervous. On local examination, I found an elongated oval hymen, not
completely covering the vaginal orifice, rather strong and thick, and
divided in two halves by a median sagittal septum, of a densely
tendinous consistency. On either side of the septum, the vaginal orifice
would admit no more than the head of an ordinary uterine sound. I
divided this septum, and was informed later that the woman had become
pregnant as a result of the first subsequent act of intercourse (Fig.
65).
A remarkable case of abnormality of the hymen is recorded by
_Heitzmann_, having been observed by him in a woman aged twenty-seven
years. In this instance, the hymen was represented by a swelling, smooth
on the surface and separated from the nymphæ by a deep furrow. Behind
this swelling, between it and the posterior commissure, there was a deep
depression, into which the finger could be passed to a depth of an inch
and a half or more. Anteriorly, the very firm and fleshy prominence was
bounded by a ridge, from the middle of which to the urethral orifice ran
a short but strong and tense septum. Right and left of this septum were
small apertures, with difficulty admitting the point of a probe. Between
the anterior extremity of the septum and the urethral orifice was a
nodular representative of the swelling normally present in this
situation. Surrounding the urethral orifice were two or three additional
small nodules. The two lateral margins of the hymen were prolonged
around the urethral orifice, and united in front thereof to form a
raphe, which could be traced as far as the base of the clitoris. The
young woman had been married for some months, and asserted that she had
repeatedly had intercourse. With such a condition of the female
genitals, penetration of the penis into the vagina was however quite
impossible. During coitus, the penis must have been inserted into the
aforesaid depression behind the swelling, which was sufficiently
extensible for the purpose.
A less serious hindrance to intercourse, but one more frequently
encountered, is a partial persistence of the septum of the hymeneal
orifice, in such a manner that there is a projecting tongue of membrane
from the anterior and posterior margins of the orifice, partially
blocking this latter; or there may be a single median projection only,
either in front or behind. Such processes may be remarkable alike for
their size and their shape. _Liman_ describes a cordiform hymeneal
orifice, constituted by an anterior or posterior protection of the kind
here described.
In cases of imperforate hymen in which the occlusion of the vagina is
not complete, impregnation may in rare instances occur, even though
proper intromission of the penis is quite impossible. Cases of this kind
have been observed by _Scanzoni_, _Horton_, _K. Braun_, _Leopold_,
_Brill_, _Breisky_, and others.
[Illustration:
FIG. 66.
]
In most of these cases there was a thick, dense, “imperforate,” or
rather _persistent_ hymen, with an orifice no larger than the head of an
ordinary probe, notwithstanding which pregnancy had occurred. The cases
reported by _Brill_ were of a different character, being those of two
young unmarried Russian girls, with normal undestroyed hymens, who were
found to be pregnant. According to _Brill_, such cases are by no means
uncommon among the peasantry of Little Russia, where the barbarous
practice prevails of adolescent girls and boys sleeping together. In
these circumstances, sexual intercourse takes place, but, from fear of
consequences, it is often incomplete. Hence, in occasional cases,
results pregnancy in a young girl with intact hymen.
In the first complete act of intercourse, the defloration of the virgin,
the hymen is as a rule torn in several directions, and in consequence
there is usually moderate bleeding. The lacerations of the hymen soon
skin over. When the initial coitus is effected maladroitly or roughly,
more extensive lacerations are apt to occur, and the injury may not be
limited to the hymen, but may extend longitudinally along the vaginal
wall, and even involve the posterior vaginal fornix. Or, again, without
any such extensive laceration, there may result very profuse bleeding,
in consequence of abnormally profuse vascularization of the hymen. Cases
are also recorded in which (presumably not from normal coitus alone, but
from other, unacknowledged manipulations), whilst the hymen has been
left intact, false passages have been made, leading to the formation of
fistulæ, with subsequent death from haemorrhage or sepsis.
Apart from impotence in the male, the hymen may remain intact when it is
not touched at all during coitus. Inexperience, as _Veit_ remarks, will
in this matter lead to results almost incredible. This author has been
informed by such inexperienced married couples, that in attempts at
intercourse “the penis of the man is introduced between the thighs of
the woman, which are closely pressed together, the man having his legs
on either side. Naturally, in this method of intercourse, the hymen
escapes destruction. In such attempts at coitus, things are done which
can hardly be compared with the normal act of copulation.”
In isolated instances, the introduction of the penis is prevented by
congenital or acquired defects in the formation of the external
genitals. Adhesion between the labia majora and the labia minora is
sometimes met with a congenital deformity, which may or may not be
associated with atresia of the urethral orifice; in some cases the
adhesion is dependent merely upon a superficial epithelial continuity,
but in others the labia are firmly adherent throughout. Less rare are
acquired adhesions, the result of accident, between the labia majora and
the labia minora, leading to atresia of the vulva, and thus making
copulation impossible.
Intromission of the penis may be rendered quite impossible by excessive
size of the labia majora, consequent upon elephantiasis, in which
disease there is enormous hypertrophy of the subcutaneous connective
tissue. New growths may have the same result, fibroids, for instance,
lipomata, and cysts, which may attain a remarkable size in the cellular
tissue of the labia, the mons veneris, and the perineum, and also in the
nymphæ and in the cellular tissue between the clitoris and the urethral
orifice. In a very obese woman twenty-eight years of age I saw a lipoma
attached to the right labium majus. In the course of six years it had
grown to such an enormous size, that it extended downwards over the
thigh, blocked the entrance to the vagina, and made coitus absolutely
impossible (Fig. 67). Various forms of labial hernia are also competent
to occlude the vaginal orifice.
[Illustration:
FIG. 67.—Lipoma of the right labium majus, occluding the vaginal
inlet.
]
Hypertrophy of the nymphæ, which, as the so-called _Hottentot Apron_ has
to be regarded as a racial peculiarity, is known also in Europe as a
pathological condition which may at times constitute a hindrance to
sexual intercourse (Fig. 68). According to _Otto_ there are three
fundamental forms of the Hottentot apron, viz., excessive enlargement of
the nymphæ, overgrowth of the labia majora, and, lastly, the formation
of a peculiar lobe of flesh and skin, attached to the mons veneris by a
pedicle, containing the clitoris, and covering the genital fissure as
with a valve. Hypertrophy of the nymphæ is said to be common also in
Turkish and in Persian women. Owing to the obstacle to intercourse
presented by hypertrophied nymphæ, it is among certain races an
established custom to amputate clitoris and nymphæ together. _Virey_
writes: “The Portuguese Jesuit missionaries to Abyssinia in the
sixteenth century, endeavoured to abolish this practice of the
circumcision of women, which they regarded as a relic of Mohammedanism;
the uncircumcised maidens, however, could find no husbands, owing to the
inconvenient length of their nymphæ. The pope sent surgeons to the
country, to enquire into the matter, and their reports were in such
sense that circumcision was permitted as necessary.” Davis reports
observations made by Sonini on the female indigens of lower Egypt, in
whom the vulva hangs down in the form of a loose, flabby mass of flesh,
of striking length and thickness, completely covering the genital
fissure. He believes that the circumcision that was practised on the
women of ancient Egypt consisted in the removal of this hypertrophied
vulva.
[Illustration:
FIG. 68.—“Hottentot apron” in an adult woman, hanging down between the
thighs. (After Zweifel.)
]
_Courty_ saw a case in which the remarkable length of the labia minora,
which when an attempt was made to introduce the penis, covered the
vaginal orifice, had rendered coitus ineffective, and had caused
sterility for five years. Resection of the labia minora was followed by
successful intercourse and conception.
The lipomatous form, especially, of elephantiasis vulvae often attains a
gigantic size. Growths of this nature, of the size of a child’s head,
weighing six or seven kilo (thirteen to fifteen pounds), and reaching
down to below the knee, are by no means rare. I have known several cases
in which an excessive accumulation of fat in the vulva associated with
pendulous belly has constituted a mechanical obstacle to the completion
of sexual intercourse.
[Illustration:
FIG. 69.—Elephantiasis of the labia majora
]
Hypertrophy of the clitoris may constitute an obstacle to coitus. In
exceptional cases, this organ is as large as the male penis, and hangs
down over the genital fissure like a valve. _Hyrtl_ relates that in
certain African races, this congenital enlargement of the clitoris is so
enormous, that the organ, made fast to the perineum with rings, serves
for the protection of virginity. _Schönfeld_ describes the case of a
woman aged twenty-eight years, in whom the vaginal orifice was almost
completely occluded by a dry and firm growth, with a granulated surface.
Close observation proved this growth to be produced by a hypertrophied
and degenerated clitoris, which had attained the size of a child’s head.
Elephantiasis of the clitoris is especially inconvenient in consequence
of the hindrance which the enlarged organ offers to sexual intercourse.
_Bainbridge_ describes a case of tumour of the clitoris measuring 8 cm.
(3.2 in.) in length and 5 cm. (2 in.) in width. The following remarkable
case is recorded by _Oesterlen_: A young man wished to break off his
engagement on the ground that his intended wife was a hermaphrodite.
Examination, however, disclosed the existence of a strong intact hymen,
a very large clitoris, and pregnancy of the twentieth week.
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_.
Various tumours may narrow or even completely close the vaginal passage,
myoma, sarcoma, carcinoma, and especially the polypoid form of
fibromyoma, which may even project without the vaginal orifice. And even
when tumours of or in the vagina do not actually hinder coitus by the
space they occupy, they may affect that operation by bleeding whenever
it is undertaken, a manifestation extremely alarming to young married
persons.
The vagina may also be partially occupied, and coitus may be impeded, by
elongation of the hypertrophied cervix uteri, by inversion or prolapse
of the uterus, by cystocele or rectocele, and by uterine polypi.
_Horwitz_ records the case of a woman aged twenty-two years in whom
_impotentia coeundi_ was dependent upon the occlusion of the vaginal
orifice by a rounded, strongly projecting body, which proved on closer
examination to be a hypertrophied vaginal bulb.
Tumours of the rectum and other intrapelvic growths may encroach upon
the vaginal passage and impede coitus. Closure of the vagina has been
brought about even by abnormal size and abnormal toughness of the
perineum.
Finally, in extreme degrees of pelvic contraction, the vagina may be so
much narrowed as to interfere with coitus. _Von Hofmann_ records a case
of this nature: In a woman thirty years of age, affected with
kypho-scoliosis, who suffered extreme pain whenever her husband
attempted sexual intercourse, the pelvis was twisted and narrowed to
such an extent that the conjugate measured barely one inch, and the
vagina was so small as barely to admit the finger.
Duplication of the vagina will constitute an obstacle to coitus when
both halves of the passage are too narrow to allow of intromission of
the penis. Difficulty in intercourse will also be caused by abnormal
termination of the vagina, as by its termination in the rectum, likewise
by severe perineal laceration which has converted the lower parts of the
vagina and rectum into a cloaca, likewise by recto-vaginal and
vesico-vaginal fistulæ; in the case of all these latter states a feeling
of disgust is apt to be aroused in the male which may effectually check
sexual desire. Still, coitus, and even conception, are quite possible in
these conditions. _Kroner_, among sixty cases of vaginal fistula,
observed six in which conception took place while the fistula was
actually open.
Apart from all local pathological conditions, coitus may be interfered
with by general nervous disturbances, manifesting themselves locally,
and depriving the woman so affected of potentia coeundi. First among
such states must be mentioned vaginismus, a condition so important as to
demand discussion in a separate chapter.
An important and by no means rare obstacle to the completion of
intercourse, affecting the male partner in the act, is partial or
complete incapacity for erection of the penis. Even excessive smallness
of the penis may render coitus inadequate; still more so, however,
organic diseases of the membrum, such as obliteration of the corpora
cavernosa, or of some of the trabecular channels of these bodies,
nodular formations resulting from injury, or cavernitis from gonorrhoea.
In such cases, erection is extremely irregular, and the erect penis is
sharply bent (chordee) instead of being straight, a condition which
renders intromission mechanically difficult if not impossible. A similar
effect is produced by ossification of some part of the tunica albuginea
of the corpora cavernosa—the so-called penis bone. Mechanical obstacles
to coitus are also offered by inguinal and scrotal hernias; and by
excessive obesity, where the increase in thickness of the panniculus
adiposus of the abdominal wall and the mons pubis, whilst the penis
itself remains as slender as before, causes the organ almost to
disappear from view.
Psychical impotence in the male is much more frequently observed than
organic impotence. We meet with this condition especially in
neurasthenically predisposed individuals, or in men who have been given
to excessive venery or have masturbated excessively in youth, and who,
when entering upon married life, fear they will be unable to satisfy the
legitimate desires of their wives; or in newly married men who have
suffered often from gonorrhoeal inflammations, such as prostatitis,
vesical catarrh, and epididymitis. The fear and anxiety from which such
persons suffer has an inhibitory influence upon the erection of the
penis. In some instances, this inhibitory influence is partial only, and
the man thus affected, while perfectly competent in intercourse with a
prostitute, who employs means of sexual stimulation to which he has
become accustomed, is unable to complete intercourse with his wife, who
is ignorant and innocent, and assumes a purely passive role; or it may
be that erection is not sufficiently powerful to bring about rupture of
the hymen, and thus to overcome the difficulties _primae noctis_.
As regards gonorrhoeal infection, it appears that in men who in other
respects are perfectly competent, this disease has an inhibitory
influence upon the nervous mechanism concerned in producing erection of
the penis.
_Psychical impotence_ is usually transitory, but it may endure for a
very long time; and it may be many months before the husband, whose
nervousness has led to failure in the decisive moment at the outset of
married life, is able to command an erection sufficiently powerful to
bring about the defloration of his wife. Occasionally such psychical
impotence is not absolute but relative, it relates, that is to say, to
one particular woman—unfortunately, as a rule, a man’s own lawful
wife,—whilst coitus with another woman, even in default of any measures
for artificial sexual stimulation, is easily effected. This fatal
misfortune is especially liable to occur in cases in which a man fully
experienced in sexual matters marries a woman whom he dislikes or for
whom he has no regard; the marriage being determined by material
considerations. From such women I have heard the painful confession that
the husband, a man renowned for his gallantries, played a very poor part
in the bridal bed.
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.