Vaginismus, Its Pathology And Treatment. With Two Cases Cured.
BY THOMAS SKINNER, M.D.
Introductory.—Every Gynecologist knows that there is no class of complaints more difficult to grapple with, more tedious and difficult of cure, than spasm of the sphincter vagina in recently married women, and even in women who have been long married. I have no hesitation in stating that, from an Allopathic standpoint, so far as medical treatment is concerned, it is incurable; at least, such has been my experience, and I have seen cases come from all parts of the world to Sir James Y. Simpson, and, if I mistake not, I have seen them go uncured by both medical and surgical measures.
Vaginismus is a term of surgical and not of medical derivation, which has doubtless arisen from the fact, that the affection hitherto has been considered by obstetric physicians as beyond the pale of medicine. The term Vaginismus misleads one to believe that spasm of the sphincter vagina is the disease, whereas it is only the effect of the disease in its more advanced state. The proper formula of the disease is—it is a true hyperesthesia of the pudic branches of the genito-crural and internal-pudic nerves, and probably also of the pudic branches of the hypogastric plexus of the great sympathetic, founded on the scrofulous or psoric habit, and which may or may not be complicated with a taint of constitutional syphilis. Further, by Vaginismus is not meant those simple cases of painful coitus, which a lavement of hot water, or steaming and warm fomenting, will relieve and cure; but I mean those cases which are in general reserved for the specialist, and which, the general or pure physicians having failed to cure, are handed over to the former, who almost invariably divide the sphincter
vaginae after removing the remains (?)of the caruncula myrtiformes, thought to be the offending part, the funs et origo mali, but certainly not of every case. The hymen in many cases has never been ruptured, and cannot be ruptured in the usual way. The best proof of the existence of the .disease is when the consummation of a marriage is rendered perfectly impossible or so painful from intense suffering referred to the orifice of the front passage in the female, that it amounts to cruelty of the most selfish kind to persist in effecting an entrance. No one, I believe, except the true follower of Hahnemann, can cure or thoroughly eradicate this disease by medicine alone, especially in its more chronic forms—and it .often persists for years and years. The cases which follow have remained perfectly cured until now—two years—although I have not seen either party since February, 1876. From the perfect relief afforded to all their symptoms, if there had been any return, I should have been the first to hear of it.
CASE I.—Was a young woman, of twenty-four years of age, who first consulted me at the Lying-in Hospital Dispensary. She informed me, through her mother, that she had been six months married, but there was no possibility of her husband having intercourse with her; that the marriage had never been, in legal phrase, consummated.
On examination, the mucous surfaces of the external genitals were red, vascular, moist, and exquisitely sensitive to touch. As for a specular or digital examination of the internal surfaces, it was simply out of the question without inducing anesthesia.
The patient was of a pasty, leucophlegmatic temperament, and of scrofulous constitution. On looking into her symptomatology, I found that she was a perfect martyr to the worst forms of chronic headache of a pressing, pulsating, or tearing character, much aggravated by mental exertion, stooping, talking, or cold air; relieved by warmth and warm haps. Of an evening she had frequently profuse perspiration on the head, which always had to her sense a sour smell. She had also a tendency to take cold in the head from slight causes, especially if the head was uncovered. Besides these characteristic head symptoms of Silicea, she had
weight or pressure in the vagina, with painful bearing down, the vagina being tender to touch. The symptoms at once determined me to give her Silicea Cm. (Fincke.) She took it night and morning for a fortnight, when she was perfectly cured of her headaches and the vaginismus as well.
CASE II.—Is rather more complicated and interesting. At first sight it seemed very simple, and unlikely to give me any trouble, but I found it otherwise. Mrs. P., age twenty-seven, has been two years married to a powerful, able-bodied seaman, and she is perfectly certain that the marriage has never been consummated; because, from the intenseness and obstinacy of her sufferings from over-sensitivity of the os vaginae, she is forced to resist to the utmost every advance, even the slightest, on the part of her husband, and it has been always so since her marriage. She further informed me that « if she had only known what marriage really was, she would never have gone in for it. » On examination locally, the mucous surfaces over a large extent are red, angry-looking, vascular, and moist, and cannot be touched ever so lightly without exquisite pain. In the vagina and vulvae she has a constant burning heat and itching, less at night, and a flow of milky whites. The menses are scanty, but regular. She has darting, shooting, very acute pains in the vulvae, as if they came from above downwards. The abdomen is very much swollen, and she often throws up her food as soon as taken, and frequently it is sour.
Head.–She suffers from darting pains in either temple, or from temple to temple, either way. She has giddiness, especially when passing many people in the streets, with cloudiness and dimness of vision.
Characteristic.–She has the following symptoms characteristic of Sulphur. A sinking empty craving at stomach every day, between eleven and twelve o’clock; hot flushes and faintly spells during the day. Sometimes canine hunger. She perspires freely on slight exertion, and has frequent chills and heats. Occasional fits of sneezing, and itching in the ears. Feet and hands either hot or cold. Aggravation of all her symptoms by washing. Bowels constipated.
Sulphur was clearly indicated to commence with, so, on the 30th June last, I gave her Sulphur 2m. (Jenichen), in a single dose of five globules at bed-time. On the 13th July she reported her state as being much the same, only the constipation was greatly improved. On enquiring of her about her temper and disposition, she at once pleaded guilty to having a very violent one; at least, « for the last five or six months she was not herself » —a wrong-directed word from another being sufficient to raise a storm. I prescribed Nux-vomica. Mm. (Boericke) in a single dose of five globules, statim. (I candidly confess that it was my duty to have waited, but I then knew no better. The case must stand as it is, if it was only as a beacon to others, in its good and bad points.) On the 22nd July, she reported herself better in most respects; the vagina, vulvae, and nympha were less sensitive to touch, but still tender. On the 29th July she again called, having had nothing in the interval, as she was better, and the Nux was still working for good. She called chiefly to inform me that her husband had returned from a voyage—the result being that both of them had experienced « a great and a happy change; little or no pain, only very little. » I thought I had effected a cure, but I was bound to be disappointed. Sometime after this she called to tell me that her last menses had been attended by terrific pains, and that they had returned upon her, and were now upon her, but not so violent. I found that she had ill-humour before her last and present menses, accompanied with violent sickly pains in the abdomen, before, during, and after them. I there and then gave her one dose of Chamomilla 10m. (Fincke), and within twenty minutes she was free from all pain and discomfort, for which she expressed herself deeply grateful. To return after her present menses are over.
On the 28th October, 1874, I took fresh stock of her case, as the Vaginismus had returned as violent as ever.
Menses still regular, but scanty; only a day or two ill; stringy, with dark clots. Great dysmenia, both before and after; altogether felt in the bowels fearful griping and cutting-uterine colic. Milky whites. (No ill-humor before, or during now.)
Constant burning heat in the vagina; worse before the menses.
Darting, very acute pains in the vulva, although less than previously; only during the day, and never at night in bed.
During the least attempt at coitus on the part of her husband, all her pain is felt at the entrance of the passage; a supersensitive or intensely sore pain, like to drive her frantic. After her husband has ceased to importune her, the pain continues about half an hour.
She was heavy and sleepy after meals, especially after dinner she must lie down. Pain and sickness at the stomach while standing; relieved by sitting down. Sinking and emptiness at the epigastrium. Total loss of appetite, except at supper-time. Stitches in the breasts. She often has her feet burning hot, or cold; and frequently she feels as if her stockings were cold and damp. Strumous leucophlegniatic diathesis.
Calcarea-c and Calcarea-phos., in high and low potencies, were tried, both internally and locally, as a lotion, but without the slightest good result. Ferri-phos., so much extolled by Schiissler for vaginismus, or pain in the vagina during coition, shared the same fate. I now made up my mind to abandon the case after next visit.
24th Nov., 1874. She reported herself as no better. On looking at her, I observed that one cheek was different from the other, and I remarked it to her. She said that one cheek was generally hot and the other not so. On the head of this valuable symptom I took a fresh photo, which is as follows : —Heat of one cheek, hysteria, constipation with great pain, dreads to go to the closet; total loss of appetite; sinking empty feeling at the epigastrium, with deep sighing inspirations; scanty menses; inflammation of the vagina, vulva, (i.e. Ignatia 1m (Jenichen)in 12 doses, one night and morning, cured her of everything.
6th Dec., 1874. She called, in her own name and in that of her husband, to thank me for all that I had done for her. She felt now that the cure was effected, because, on the previous occasion, when I thought she was cured, she felt better locally, but no better of herself; now she felt « better every way, and all over a new woman. » It is now one month since she took any medicine, and she remains « a perfect cure. » (December, 1874.)
On the 7th February, 1875, I met my patient taking a walk, when she informed me that « she had not felt so well for many a year, even before her marriage », but she regretted to add, that her husband « was drowned during a collision in the channel, five weeks ago. »
Concluding Remarks.—Thefirst case was self-evident, every symptom so perfectly corresponded to Silicea, that, if it had not cured her, one might almost have safely concluded that there was no truth in the law of cure, similia similibus curentur.
In my second case, although Ignatia finally cured, I doubt if it would have acted as the simillimum if it had been given at the first, although it is a fact that Nix-vomica, the brother of Ignatia, all but cured the patient, after Sulphur had removed the constipation. My chief error was in not giving the Sulphur a longer time to act.
I have now been in the profession of medicine thirty years. As a Specialist in the diseases of women, I have practised since 1855, and I have no hesitation in declaring that it is just as possible for a camel to go through the eye of a needle as for an Allopathist, or Old-School physician, to effect two such cures. As for Dr. Marion Sims’ operation, it could not touch either of these cases; and granting that it did relieve one, or both of them, by a mechanical division of the sphincter vagina, and the temporary lessening of the inflammatory action by the loss of blood during the operation,—before one month was past, the last stage of both women would have been worse than the first.
Dr. Marion Sims has given it out that his operation is the only means of permanent relief; the above cases prove this to be a mistake, and from what I have learned of the power and action of homoeopathic medicines in high potencies, carefully selected according to Hahnemann’s directions in his Organon, I should like to see the case of so-called Vaginismus that is not curable by medicine alone, and without local medication or surgical interference of any kind. Of course, I do not include ‘cases of imperforate hymen with rigidity, or of stricture from rigidity or other causes, demanding surgical aid.
Gynecologists have laid it down, and, par excellence, Dr. Marion Sims, that the chief seat of the disease is the curunculae myrtiformes,
or the remains of the ruptured hymen; hence the necessity of delicately dissecting out and removing these remains. This is a grave mistake, and, at the least, it is a very limited view of the pathology of the affection. As I have before stated, the hymen in many cases is unruptured, and cannot be ruptured by the natural means.
According to my experience, there are three varieties of Vaginismus, modifications of each other.
The first is a pure neuralgia, or hyperesthesia of the branches of the lumbo-sacral plexuses to the external genitals. This is the original form; the genitals appear to the eye to be in a normal state.
The second variety is similar, but further advanced to the stage of mucous or follicular irritation.
The third variety is the second, which may have been aggravated by neglect, by malpractice, want of cleanliness, exposure to cold and fatigue, sexual excitement, or constitutional psoric, syphilitic or sycotic influences, into a specific form of inflammation, usually of a chronic type.
The pathology of Vaginismus, according to the schools, is founded on one symptom only of the affection—painful spasm. Hence the brute-force system of treatment adopted—dividing the unoffending sphincter &mince, which is simply contracting in obedience to an influence of which the surgeon, literally knows nothing; or paring away and dissecting out the most apparently offending structures, the curunculae myrtiformes; or by division of the pudic nerve, as first suggested by Burns, of Glasgow, in his Principles of Midwifery, p. 45; or by mechanical and forcible dilatation, combined or not with Burns’ or Sims’ operation. Sir James Simpson, in the later years of his practice, held the most advanced views of the pathology and treatment of this affection. Whilst he believed and practised division of the affected nerve by means of a tenotome subcutaneously, when the pain was limited to a spot, he owned to the existence of a great number of cases of a purely neuralgic type, which could only be reached by long-continued courses of the usual constitutional anti-neuralgic medicines, such as iron, manganese, arsenic, &c. In his own words to his class, he used to say « You have to use general anti-neuralgic tonic medicines and measures; and locally all forms of sedatives and anodyne applications. »
So much for the most enlightened Allopathy. I have no hesitation in saying, that if it was possible always to analyze a case so that a simillimum could be made out, a single dose of that simillimum hi0h will cure such cases without repetition. The difficulty is in arriving at the simillimum—which is only obtainable ‘by practice which makes perfection—a goal which we ought always to strive for, though we may never attain it. Let our watchword be that of the good people of New York « EXCELSIOR ! »