Part 49

In a certain number of cases, however, the husband is in no way responsible for the origin of vaginismus, which may depend on pathological states of the female external genitals, leading to hyperaesthesia; or, again, on primary hyperaesthesia of the pudic nerve and its branches; or, finally, on general neurasthenia and hysteria, on excessive sensibility and lack of self-control on the part of a young girl, who has entered upon married life under the dominion of extravagant ideas. Vaginismus dependent upon general neurasthenia especially in cases in which there is no strong affection for the husband to give the spur to desire, and to enable the woman to bear with fortitude the pangs which form the necessary introduction to the joys of wedded life. It must not be forgotten, as throwing light on the origin of vaginismus, that in the digital vaginal examination of a virgin or even of a young wife, unless extreme care is taken, pain and painful muscular spasms are liable to be evoked.

The local pathological conditions of the female genital organs that are most often met with in cases of vaginismus are: a very rigid state of the hymen; inflammation and excoriation of the hymen and its surroundings; fissures at the vaginal orifice; inflammatory affections of the vaginal follicles; inflammation of the carunculæ myrtiformes; a peculiar formation of the vulva, which extends forwards over the pubic symphysis, whereby the urethral orifice and the hymeneal aperture come to lie upon the pubic symphysis or the subpubic ligament; vulvitis; herpes or eczema of the vulva; colpitis; urethritis; fissure of the anus; papillary growths; pruritus papules; urethral caruncle; inflammation of Bartholin’s glands; at times gonorrhoeal infection.

A case came under my own observation in which a newly married woman suffered from vaginismus. The husband believed the cause of the trouble was his own partial impotence, consequent upon youthful venereal excesses, and yielded to the desire of his wife and her relatives that a divorce should be obtained. A year later, the woman remarried, when, to her horror, the symptoms returned in full force. Now for the first time she consulted me, and on local examination I could detect no abnormality whatever. The vaginismus was in this instance a pure neurosis, the only possible cause of which was to be found in bygone overstimulation of the vaginal orifice, the wife admitting previous onanistic excesses. In another case known to me, vaginismus in the wife made the husband an involuntary sodomite. The movements of the wife when the spasm came on led to the introduction of the penis per anum, and coitus had repeatedly been effected by this abnormal route, when the fact first became apparent as the result of a local examination.

Le Fort reports the case of a young Russian wedded pair who were spending their honeymoon in Paris. The husband took so much to heart his inability to fulfil his marital obligations in consequence of the vaginismus from which his wife suffered, that he shot himself through the heart. The distressing situation of a husband whose wife suffers from vaginismus, rendering coitus impossible, is depicted in the well-known French romance, “Mademoiselle Giraud, Ma Femme.” From a false shame, women often continue to suffer from vaginismus for months and even years, without a single effective coitus having ever taken place; it is only the consequent sterility which at last leads to medical advice being sought. The physician then usually ascertains that the hymen is still intact, or at least incompletely destroyed, that on this membrane and on various parts of the vulva there are erosions, and that the whole of the external genitals outside the hymen are in a state of inflammation more or less acute. In other cases, however, neither excoriations, erosions, nor inflammation can be detected, and the existence of vaginismus can be proved only by the pain and the muscular spasm set up by contact with the vagina. Often, indeed, the cause of this most distressing affection cannot be discovered.

Introduction of the penis may be rendered impossible by spasm of the constrictor cunni (bulbocavernosus) muscle, but equally so by spasm of the transversus perinei or the levator ani muscle. Sometimes the spasm affects all three muscular groups; in which case the narrowing of the vagina is extreme, and extends for some way up into the canal. When the levator ani alone is affected by the spasm, the penis can, indeed, be introduced into the vagina, to encounter a powerful obstacle in the interior of that canal; and it may happen, when the spasm comes on and affects the levator ani only after complete intromission of the penis, that the glans is retained in the vaginal fornix by the active contraction of the pelvic floor.

More or less credible instances of penis captivus thus brought about are on record. The following history is by Davis: A gentleman entering his stable found therein his coachman and a servant-maid in a most compromising position. All endeavours of the pair thus surprised to separate proved ineffectual, and their attempts to draw apart caused them intense pain. Davis was sent for, and ordered an iced douche, which, however, failed to liberate the imprisoned penis. Release was impossible until the woman had been placed under chloroform. The swollen and livid penis exhibited two strangulation-furrows, a proof that two distinct areas of the levator ani muscle had been spasmodically contracted.

Hildebrand records three cases observed by himself in which there was spasm of the upper part only of the vagina, unaccompanied by vaginismus (i. e., by pain). In two of these cases, the spasm was originated by the contact of the examining finger with very painful ulcers of the portio vaginalis; the third patient had a very sensitive prolapsed ovary. Fritsch reports having had on one occasion to give a woman chloroform for the release of a swollen and imprisoned penis.

Hildebrand suggests that vaginismus may be caused by an abnormal size of the penis, or by a condition occurring in weaklings and alcoholic subjects, in whom the greatest swellings of the glans penis occurs before intromission, whilst this greatest swelling is normally deferred until towards the end of the act, when the glans is in the vaginal fornix.

Schröder writes as follows regarding the etiology of vaginismus: “The affection is dependent upon trauma, sustained in maladroit, frequently repeated attempts at sexual intercourse; for this reason it is met with, in the great majority of cases in young, newly married women. Impotence in the male is by no means necessary for its production, and such impotence is not even a frequent antecedent. Abnormal narrowness of the vagina, or extreme firmness of the hymen, is occasionally found, but neither is in any way necessary; all that can be said in this connection of a small vaginal orifice is, that it predisposes to vaginismus. If the husband is devoid of previous experience in sexual matters, maladroit attempts at intercourse are exceedingly likely to occur. The penis is thrust in the wrong direction, pressing against either the anterior or the posterior commissure of the vulva. Very often, moreover, the position of the vulva, which is subject to very striking individual variations, is concerned in the production of vaginismus. There are many women in whom the vulva lies in part in front of the symphysis pubis, so that the lower border of the symphysis lies below the urethral orifice. In such cases the penis is directed too far backwards, and instead of passing into the vaginal orifice, slips into the fossa navicularis. The frequent repetition of such maladroit attempts at intercourse gives rise to a gradually increasing sensitiveness of the parts concerned, with the formation of excoriations. It now results that, on the one hand, the woman dreads attempts at intercourse on account of the pain to which they give rise; she shrinks away from the man, so that penetration of the vagina by the penis is rendered even more difficult than it was before; and, on the other hand, ungratified sexual desire leads to the frequent repetition of attempts at complete intercourse (from which, moreover, if conception should ensue, a cure of the trouble is expected). In this way, the trauma is rendered more severe, the congestion and excoriation of the fossa navicularis or of the urethral region are aggravated, and the sensitiveness of the parts increases to such a degree that the woman thus affected screams out when the vulva is merely touched. Ultimately reflex cramps set in whenever intercourse is attempted, and we then have the fully developed clinical picture of vaginismus.”

Winckel maintains that in most cases there are two principal elements in the causation of vaginismus. In the first place, in consequence of more or less pronounced anatomical changes, there is undue sensitiveness and tenderness of the vaginal inlet and its neighbourhood, and in exceptional cases also of the upper part of the vagina, the uterus, and the ovaries. In the second place, the patient manifests an increased general sensitiveness and nervous irritability; this is in some cases primary, but in others it is entirely the result of the repeated stimulation; and in either case it is heightened by the effects of ungratified sexual desire.

A. Martin points out that the spasm of the muscles of the pelvic floor, and especially of the levator ani muscle, upon which vaginismus depends, may be due in some cases to the influence of chill, since the same cause will lead to pathological contractions in other muscular areas. But in such cases it is always open to question if masturbation or some other sexual perversion is not the true cause of the disorder. In some instances vaginismus is merely a symptom, in extremely sensitive women, of various diseases of the reproductive organs, and is brought on by the increased pain which in such cases is caused by attempts at intercourse; when produced in this way, vaginismus is usually a transient manifestation.

Veit considers that among the pathological conditions giving rise to vaginismus, we must also enumerate diseases of the internal pelvic organs, such as chronic metritis, displacements of the uterus, oöphoritis, etc.; but he also attaches great importance to nervous predisposition, consequent upon previous sexual stimulation, and upon pre-existing inflammatory changes due to gonorrhœal infection. A peculiar form of vaginismus is, according to Veit, sometimes observed after the birth of the first child; happily the duration of this is usually brief. After parturition the vulval mucous membrane remains for a time very tender, and when cohabitation is resumed, often too soon, and perhaps, after the enforced abstinence, too frequently repeated at brief intervals, fissures are readily produced. Moreover, vaginismus which has existed prior to parturition may, in some cases, recur after that event. An unusual position of the vulva, undue smallness of the vaginal inlet, and relative impotence of the man, may combine to cause such a recurrence. Finally, vaginismus often persists throughout pregnancy, and manifests itself during parturition. The magical effect which chloroform has in some primiparæ, when the head is delayed at the vulva, is explicable only by the supposition of vaginismus.

According to Arndt, vaginismus is not purely a local disorder, but is in many cases the local manifestation of a neuropathic diathesis, which may in some instances lead to general mental disorder.

Olshausen regards hyperæsthesia and vaginismus as different stages of a single disease; he believes that the excessive sensitiveness is seated chiefly in the hymen; he explains the spasm as the reflex result of fissures and inflammatory changes. Pozzi considers that excessive nervous irritability and an irritable state of the vulva are the indispensable preliminaries to the occurrence of vaginismus. Herman distinguishes between excessive smallness of the vaginal inlet and vaginismus; he regards the latter as a nervous disorder, characterized by hyperæsthesia of the vulva, and by spasmodic contraction of the levator ani and adjoining muscles. Frost distinguishes vaginodynia from vaginismus; in vaginodynia the pain is so intense as to cause syncope, and the muscular spasm involves the entire length of the vagina.

It is a notable fact, to which Veit has especially drawn attention, that among the poorer classes of the population, vaginismus is practically unknown. Among women of these classes, their sexual needs, not having been so much lessened by “culture,” suffice to withdraw their attention even from the pains of defloration, which would otherwise often be very severe; whereas the sexually neurasthenic woman of the upper classes, filled with dread at the idea of the pain she expects to suffer, and not infrequently in a condition of hyperexcitability or hypersensibility dependent upon previously employed abnormal means of sexual gratification, is unable to endure the pains of defloration even when these might be expected to prove far from severe.

In some cases, painful contractions of the vagina, to which we cannot properly give the name of vaginismus, arise from organic diseases of the uterus and the uterine annexa; these painful contractions render copulation impossible. Von Hofmann reports the case of a young prostitute, who found herself unable to continue the practice of her profession owing to the severe pain she suffered during intercourse; she died, and the post mortem examination disclosed bilateral salpingitis, with reproductive organs in other respects normal.

Maladroit and incomplete attempts at intercourse, and the consequent repeated failure to obtain complete sexual gratification, affect a woman’s nervous system to a varying degree; but apart from this, in women who have long cohabited with men of deficient sexual potency, we often find a remarkable condition of complete relaxation of the genital organs, associated with great hypersecretion of the mucous membrane, flaccidity of the muscles of the pelvic floor, and displacements of the uterus. Moreover, the nervous shock to which the repeated but unsatisfying attempts at intercourse give rise, affects the spinal cord in such a manner that symptoms of spinal irritation ensue. The patient complains of pains in the back, the loins, and the nape of the neck; these pains also radiate round the front of the abdomen and along the intercostal spaces; hyperæsthetic points may be detected when the finger is passed along the spine; there is weakness of the limbs with a sensation of numbness; and neuralgic manifestations of varying nature occur.

The dangers which sexual intercourse may entail upon women—over and above the irritable conditions and inflammatory disorders of the female reproductive organs, dependent upon impetuous or unduly frequent coitus, or upon coitus practised during menstruation—are principally due to gonorrhœal and syphilitic infection transmitted by the cohabitating male.

Cardiac Troubles Due to Sexual Intercourse.

Among the troubles from which women at times suffer as a result of sexual intercourse, certain cardiac disorders are especially worthy of attention.

Every act of sexual intercourse in a young and sensitive woman exercises an exciting influence on the nervous mechanism controlling the cardiac movements, and this influence is more clearly manifested in a degree directly proportional to the intensity of the sexual orgasm. The heart’s action is markedly increased in frequency, the cardiac impulse is more powerful, the large arteries of the neck are seen to pulsate far more vigorously, the conjunctiva is markedly injected, the respiration is increased in frequency, the respiratory movements are more superficial and have a panting character.

But when, in a woman who is sexually irritable in an excessive degree, the peripheral stimulation occurring in the act of sexual intercourse is unusually powerful, there may result a notable increase or modification of the reflex manifestations which normally occur during sexual intercourse in the province of cardiac activity; similar results ensue when there is a summation of stimuli owing to excessive sexual intercourse, or contrariwise when the act of intercourse is broken off just before its physiological climax and the natural termination of the orgasm fails to occur.

The former cause is not infrequent in young wives during the period of the honeymoon. The latter cause is in operation when there are diseases of the female reproductive organs preventing the physiological completion of intercourse; but especially in consequence of the modern practice of coitus interruptus, in which the man breaks off the act of intercourse the moment he feels that ejaculation is imminent, without troubling himself regarding the natural course of sexual excitement in the woman. Yet another cause of excessive cardiac reflex manifestations in women is incomplete potency of the male, which may either cause a premature ejaculation of semen, or may lead to incomplete penetration of the penis.

In all such cases, as a result of sexual intercourse, there may arise cardiac disorders of various kinds; among these, tachycardial paroxysms are the most frequent, occurring either inter actum, or at a longer or shorter interval after intercourse.

In several cases of vaginismus occurring in young married women which have come under my notice, it was observed that the attempts at intercourse gave rise to violent involuntary spasmodic contractions of the constrictor cunni and the other muscles of the urogenital and anal regions, and in addition it was found that these attempts were followed by tachycardial paroxysms with dyspnœic manifestations, lasting for a considerable period, it might be as long as one or two hours.

In women who had practised coitus reservatus for a prolonged period, in fact for several years, in such a manner that, notwithstanding the occurrence of intense voluptuous excitement, complete sexual gratification rarely, if ever, occurred—in such women, in whom these marital malpractices seemed to have profoundly influenced their psychical life, I have frequently witnessed a form of reflex cardiac disorder which I must regard as a variety of the multiform neurasthenia cordis vasomotoria. In such women, still at the climax of their physical powers and of their sexual needs, attacks of palpitation suddenly occur at irregular intervals, several times daily or less frequently. Associated with this increased frequency of the cardiac activity are an extremely distressing feeling of anxiety, a sensation of faintness, headache, vertigo, a weakness of the muscular system, and at times actual attacks of syncope. Physically, the women are extremely depressed, irritable, inclined to weep, unhappy, and weary of life. At the same time, digestion is impaired, the appetite is small, and there is constipation. The pulse is in most cases feeble, small, of low tension, easily compressible, increased in frequency, often intermittent, sometimes more distinctly arhythmical. The heart is found to be sound on physical examination, nor can any abnormality be detected in the great vessels. The lower extremities are free from œdema; the urine does not contain albumen.

Women thus affected are sometimes believed to be suffering from cardiac disorder, in other cases they are subjected to various modes of gynecological treatment; until at length the physician, by appropriate questions, becomes enlightened regarding the true cause of the cardiac disorder, namely, coitus interruptus. If it is possible to prohibit effectually this unwholesome practice, the cardiac symptoms soon cease to recur.

Finally, in women at the climacteric age, cardiac troubles sometimes ensue, which are dependent on interference with sexual intercourse in consequence of anatomical changes in the vagina; changes of this character frequently occur at the time of the menopause; owing to hyperaemic or inflammatory processes, a partial or general stricture of the vaginal passage results; in many cases this passage becomes narrower, shorter, and almost conical in shape, whilst the vaginal inlet is greatly diminished in size. Such a vaginal stricture, which Hegar has also seen in younger women after an artificial climacteric (oöphorectomy), interferes with sexual intercourse; and the incomplete sexual gratification gives rise to a series of nervous manifestations, and, among others, to the above described reflex cardiac neurosis.