Such are the common causes of vaginismus. Cases like that of Terbes, where a lady could not sleep at night on account of a sensation of spasm in the vagina, are very rare. The same remark is applicable to the view advocated by Arndt, that vaginismus is not an uncommon accompani ment of the neuropathic diathesis (?) and may lead to insanity, as also to the two cases of Neftels, where lead poisoning was the cause of vaginis mus, in the one accompanied by purulent discharge and by paralysis, and in the other by colic.
As pointing to a common cause of vaginismus Hildebrandt's observa tion is of value, that women whom he could examine without finding vaginismus acquired the spasm after frequent after-examinations by the students. These cases clearly prove how vaginismus may not only be evoked from irritation of a painful spot in the neighborhood of the con tracting muscles, but also in irritable individuals from the mere fear of pain, although the parts are not at all inflamed.
In Sims's first paper he laid stress on hypermsthesia of the hymen as a cause of vaginismus, the affection only developing on irritation of this spot. Beige] agreed with him and claimed its existence in two personal cases. In the one case an unmarried woman of thirty-two woke up in the night suffering from great pain in the left side of the face, and a few days thereafter developed the same spasmodic pain in the left side of the vulva. Whenever the clothing touched this side of the vulva, she suf fered from the cramp-like pain. On digital examination vaginismus was found to exist. In the second case the woman had in childhood long suffered from chorea major, and frequently was for months confined to her room. On her nuptial night she suffered such agony that further attempts at copulation were desisted from. She conceived, however, miscarried at the fourth month, but was still unable to endure the sexual act on account of vaginismus. Simpson considered the cause of such ex cessive vulvar pain to lie in a hypersesthesia of the pudic nerve, and he, even as had Burns before him, counselled section of this nerve. The majority of writers, however, seek the cause of vaginismus in local changes in the hymen (Sims, Winckel and others).
We will briefly rehearse the various opinions. Demarqnay, Ewart, Stoltz and Fritsch, believed in the existence of a fissure of the vulva. Demarquay also contended that fissure of the anus might cause vaginis mus. Ewart found the sensitive spot, irritation of which would excite the spasm, to be at the caruncula myrtiformes. Oldham laid stress on an
inflammatory affection of the vaginal follicles; Braxton-Hicks on inflam mation of the papillae of the vagina; Tyler Smith and Spencer Wells believed it dependent on a vaginitis. Debout and Michon mention as the most frequent causes inflammation of the vaginal Mucous membrane, herpes and eczema of the vulva, inflammation of the mucous glands, fissure of the introitus vaginae. Fritsch also found a small excoriation, covered over with a yellow deposit, situated at the introitus, to be the seat of the excruciating pain. Vedeler has latterly reported two cases where the cause of the vaginismus was fissure of the anus. Schroeder and Seanzoni lay great stress on ineffectual attempts at cohabitation as a Mae.
When now we consider the question of vaginismus from an etiological standpoint, the fact results that there are two varieties: the one and the most frequent depends on tonic reflex contractions, the result of local irritation and more or less dependent on lack of self-control and willful contractions; the other must be considered a purely hypersesthetic fOrtn, and there are found sensitive spots, sometimes red, and again smarting. In illustration of this form we will relate the following personal case: At her first confinement a woman suffered rupture of the perineum, which was sewed up and healed only partially, a recto-vaginal fistula remaining. At the operation for the closure of this fistula the left labium minus was lacerated by the speculum. Both nymplun became swollen and reddened, and when they were touched, or a vaginal examination was attempted, the patient became frantic, and had spasm of the constrictor cunni, although there was no evidence of abrasion or excoriation or recent wound.
The diagnosis of vaginismus is not at all difficult, if we only take notice of the spasmodic contraction at the introitus. It may be difficult, however, to determine the source of the spasm and of the pain. We must first look for fissures, excoriations, at the introitus, for inflammatory swelling of the hymen, the carunculie myrtiformes, the glands of Bartho lin, the mucous membrane of the vagina, etc. Note is to be taken of the inclination of the pelvis, of the position of the vulva. Finally, we should not omit to seek for fissure of the anus as a case of vaginismus. Hilde brandt suggests too that the pain may also depend on disproportion in size between the male and the female organs.