The treatment of vaginismus varies, of course, according to the cause, and also is it different according to the theoretical view held in regard. to the disease. Those reflex spasms which result from great pain at the first sexual intercourse, require different treatment from that which depends on local hyperEesthesia. A glance at the literature of the subject will prove the truth of my statement, that the treatment varies according to the theory held as to the origin. What useless disputes in regard to the value of hyper-extension or antiphlogistics in the cure of the affection! The truth is that vaginismus has been cured in both ways.
When careful inspection of the vulva reveals nothing abnormal in the mucous membrane, only a highly reddened succulent condition of the surface between the labia and the introitus, a papillary condition, so to speak—when, further, we notice that the mere touch of any portion of this surface evokes a reflex spasm, which interferes with the insertion of the finger—when, still further, we hear that the woman, only recently married, cannot submit to intercourse on account of the pain, then we are justified in accepting Scanzoni's view: The vulva is irritable from frequent ineffectual endeavors at copulation, and its reddened, swollen, sensitive condition warrants the use of the term inflamed. Here rest of the parts and antiphlogistic measures will effect cure, and after the dis appearance of the redness and local sensitiveness, sexual intercourse will be facilitated by hyper-extension under anesthesia.
If, on the contrary, a local hypertesthesia is found, this must be allayed before we can hope to see the vaginismus disappear. We must, however, most carefully seek for the hypertesthetic spot, for if we draw a false in ference as to the cause and resort to hyper•extension, and thus make a hyperesthetic spot, the affection is intensified instead of being cured.
Among the antiphlogistic measures, we mention lukewarm water compresses, lead wash, phenic acid solutions (2 to 5 per cent.), black wash. We especially recommend regular application of nitrate of silver solu tions (2 to 5 per cent). Dilute tincture of iodine is also advocated. In case eczema or erythema is present, then white precipitate ( 3 as to 3 j to 5 ss of vaseline) or sublimate (gr. xv. to 5 ss) ointments are useful. Sitz baths, warm or hot douches, medicated, are of value. In ease of general neurasthenia, the bromides, etc., are indicated. Gutneau de Mussy orders suppositories of the bromide of potassium. Naturally the woman must abstain for awhile from sexual intercourse.
The next step aims at rendering possible the sexual act by overcoming the intensity of the spasm, and this is accomplished by hyper-distension of the introitus vagine, under, of course, narcosis. For the purpose of
distension Sims preferred glass dilators. The ordinary cylindrical specu lum has been used, as also Simon's blade specula, traction on which by the hand distended the introitus. Personally we prefer stretching with the fingers of the hand. This method was first recommended by Charriere, Horwitz, Courty and Sutugin, and has been used by Hegar. We can thus feel the muscles yield and tear, which subcutaneous separation ren ders unnecessary the cutting of the constrictor ennui, which Sims deemed advisable.
When we find hyperwsthesia in spots, this must be allayed by means of local treatment. In case the hymen or a remnant of it is at fault, this must be excised. If there are excoriations and fissures and whitish patches on the mucous membrane, these must be thoroughly cauterized. The most commonly used caustic is the stick of nitrate of silver, followed by ice compresses. The slough separates in a few days, and the cicatrix resulting from the granulation process is not sensitive. Of course other caustics may be used, such as chromic acid, the thermo-cautery, etc. In this variety of vaginismus, hyper-distension is not useful, since the re flex spasms disappear after the healing of the hyperesthetic places.
Simpson performed section of the pudic nerve; but to-day this is not deemed necessary. The procedure is subcutaneous and free from danger, but there is no certainty that the nerve has been cut.
Sims's suggestion to cause the husband to cohabit while the woman is under the influence of an anesthetic, in the hope that cure may follow on labor, is for many reasons not to be recommended.
In case of fissure of the anus and resulting vaginismus, Yedeler has hyper-distended the sphincter ani, and cured both the painful defecation and cohabitation.
In addition to spasm of the constrictor cunni, the usual cause of vagi nismus, Hildebrandt directed the attention of observers to spasm of the levator ani. He saw cases where the constrictor cunni gave rise to no trouble on cohabitation or examination, but where the obstacle was met with deeper in the vaginal canal, and this obstacle was found to be duo to a tonic contraction of the levator ani. In the three women where this was noted, there existed hyperesthesia of one or another of the internal genital organs. In one there was a prolapsed very sensitive ovary. The woman had been subject to nervous affections in infancy. The two other women presented very painful tumors of the portio vaginalis, associated with great vaginismus interfering absolutely with sexual intercourse. Removal of the tumors cured the vaginismus.