The Hystero-Neuroses With Especial Reference to the Menstrual Hystero-Neurosis of the Stomach BY GEORGE J. ENGELMANN, M.D. ST. LOUIS, MO. REPRINT FROM VOLUME It (SimrcoloQfcal Cransactfons 1878 THE HYSTERO-NEUROSES, WITH ESPECIAL REFERENCE TO THE MENSTRUAL HYSTERO-NEUROSIS OF THE STOMACH. BY GEORGE J. ENGELMANN, M. D., Si. Louis, Mo. Introduction. The Hystero-Neuroses 1. of the Brain. • 2. of the Eye. 3. of the Pharynx. 4. of the Larynx. 5. of the Bronchi. 6. of the Breasts. 7. of the Intestines. 8. of the Joints. 9. of the Stomach. THE HYSTERO-NEUROSES OF THE STOMACH. A. Constant or pathological Hystero-Neuroses of the Stomach. B. Menstrual Hystero-Neuroses of the Stomach. Frequency. Symptoms. Time of appearance and duration. Time of development. Conditions under which the Neurosis is found. Exacerbation when menses are checked by disease. Cause. C. Gastric Hystero-Neurosis of Pregnancy. Conclusion. THE HYSTERO-NEUROSES, WITH ESPECIAL REFERENCE TO THE MENSTRUAL HYSTERO-NEUROSIS OF THE STOMACH. Among the numerous ailments to which woman is subject by virtue of her sexual organization is a series of nervous phenomena of the various organs which form a group of symptoms not as yet acknowledged or studied as such, as they appear under apparently different conditions, and in the most varied phases. However heterogeneous they may seem, these nervous symptoms are closely related, being dependent upon one and the same cause,— a pathological condition of the womb, and I have, therefore, grouped them under the common name of hystero-neuroses. By this term, hystero-neuroses, I would designate those phenomena which simulate’a morbid condition of an organ, unaccompanied by any structural changes in that organ, and which are the result of a reflex action, a sympathetic hyperesthesia, due to uterine derangements, and demon- strated to be unquestionably so dependent by being in- tractable to direct local medication, but yielding at once upon treatment of the causal pelvic disorder. They are entirely distinct from the transitory and variable symptoms of hysteria which I am inclined to place among the cerebro-spinal affections, and which are but very in- directly influenced by the condition of the uterus or its annexa. Moreover, the hystero-neuroses are generally found in women who can by no means be called hysterical in the sense in which this word is ordinarily used. 4 In their earlier stages purely nervous, they are at once and permanently removed by relieving the disease of the uterus ; should this, however, continue, structural changes will grad- ually develop in the organs, which are the seat of the hys- tero-neurosis, so that in the end we shall actually find the disease which at first was only simulated by irritation of a certain set of nerves. These hystero-neuroses may be more or less continuous, due to chronic uterine disease, or only appearing at certain times during exacerbation of such disease; they may also be brought about by the physiological changes of menstru- ation, or of pregnancy, in an irritable or diseased womb, and we may hence classify them in accordance with their causative connection, as constant or pathological hystero- neuroses, menstrual hystero-neuroses, and hystero-neuroses of pregnancy. The literature of the subject is very meagre ; but few such cases have been described ; and the only distinct series are the hystero-psychoses of Mayer, the characteristic cases cited by Fordyce Barker in his article on Uterine disease as an exciting cause of Insanity, and the pharyngeal-neu- roses of Dr. Edgar Holden. Hodge, in the sixth chapter of his work on “ Diseases of Women,” records cases which plainly belong among the hystero-neuroses as homologous with others which are de- cidedly hysterical, evidently without proper appreciation of the causative relation in either case. Some such cases are mentioned by Tilt, in his chapter on Gangliopathy, also on a par with those which are purely hysterical, and he ascribes them all to a disease of the gan- glionic nervous system to which he says that women at the change of life are especially subject. Both authors relate those cases indiscriminately, and in such connection that it would but confuse the reader to refer to them. My attention was first attracted to this class of symptoms by the distention of the epigastrium, which so frequently THE HYSTERO-NEUROSES. GEORGE J. ENGELMANN. 5 precedes the catamenial flow, the menstrual hystero-neurosis of the stomach ; this we shall study more in detail, after we have discussed some of the more remarkable of the many nervous symptoms in other organs, which are caused by a morbid condition of the womb. The cerebral hystero-neuroses or hystero-psychoses are among the most puzzling and interesting of all the morbid conditions due to uterine affections. We readily perceive that a reflex relation exists between the sexual organs and the sensitive, impressionable mind of woman ; we know that diseases of the mind, in their devel- opment, and in their various phases, are often closely con- nected with the periods of sexual disturbance, with puberty and the change of life, with the menstrual flow, or the period of pregnancy and childbed, but it is not thoroughly understood that insanity may be dependent upon functional derangement, upon disease or malposition of the womb. This, causative connection, though vaguely evident to all, has yet been distinctly defined by only a few ; thus Storer 1 tells us that there is an intimate relation existing between the mind and the sexual organs of woman; but his state- ments are wholly inadequate to establish a causative rela- tion, and he does not strengthen his position by the numer- ous authorities which he quotes or their frequently irrelevant cases. Hammond, on the contrary, seems to ignore this reflex connection entirely ; he does not refer at all to those cases of nervous derangement which are distinctly caused by uterine disease, and although he speaks of catalepsy, ecstasy, and hystero-epilepsy as hysteroid affections, he means by that, cerebro-spinal, not uterine affections, as he justly classes hysteria itself among the cerebro-spinal diseases. Alienists have always acknowledged an influence of the sexual organs upon the mental functions; all works on in- I. HYSTERO-NEUROSES OF THE BRAIN. 1 The Course and Treatment of Reflex Insanity in Woman. 6 THE HYSTERO-NEUROSES. sanity bear evidence of this, but the statements made are generally very vague; thus Bucknill, Tuke, Esquirol and others cite those frequent cases of sexual excitement and the disgusting exhibitions of many insane patients as in- stances of the dependence of mental derangements upon disorders of the sexual organs. Such cases may be entirely excluded, as venereal excite- ment is not only not an indication, but even a rare concom- itant of the hystero-psychoses. Other alienists, however, relate well-marked cases, which distinctly show the causa- tive connection, and insist on the importance of uterine examinations in the treatment of the insane. Gynecologists have paid but little attention to this sub- ject, and the text-books give us either very unsatisfactory information, or do not even refer to the fact that a relation may exist between diseases of the womb and mental aber- ration. We owe our entire knowledge of these conditions to the close and careful observation of Louis Mayer, of Berlin, and of Fordyce Barker, of New York. I will not dwell upon those reflex phenomena which are frequently developed in the cerebral centres during the periods of greatest excitement in the sexual life of woman: such as the epileptiform attacks at the age of puberty, perhaps returning with each menstrual period ; the exac- erbation of mental diseases at the time of menstruation ; puerperal mania ; or the derangements accompanying the change of life ; which all point to an intimate relation between these organs, and, perhaps, to the irritation of common nerve centres, but in which a distinct causative connection cannot be established. Case I. will serve to illustrate such a correlation which is apparently independent of causation. Mrs. V., aged 40, suf- fering from melancholia, has a marked exacerbation at each period, so that her condition at that time is a very dis- tressing one, yet no abnormity of the sexual organs could be detected ; the flow was regular and unaccompanied by pain ; the uterus was normal in size and position ; there were no erosions, no catarrh, and the ovaries were neither enlarged nor sensitive. In other cases uterine disease may accompany the mental affection, and yet in no way influence its course, and again morbid brain action may be the causative element which produces irregularities in the functional activity of the sex- ual organs. The labors of Schroeter in this direction deserve to be better known.1 He has carefully observed two hundred and twelve female patients during a six years’ service in a well-regulated insane asylum, and finds the large majority of these women afflicted with menstrual irregularities. When menstruation was normal, he found the mental aberration but trifling; incipient mental derangement was generally accompanied by the appearance of some abnor- mity of the previously regular catamenia, which became more patent as the insanity developed ; but in no instance was the patient restored by regulating the menstrual flow. The author makes the existence of a certain sympathetic relation between these organs very evident, but in his cases the menstrual derangements seem to be secondary to and dependent upon the psychoses. I desire to call attention to the hystero-psychosis proper, to those comparatively.rare cases of mental alienation which have been proven to be dependent upon uterine disease ; I say, comparatively rare, for if they are not rare they are at least little known as yet, and will remain so, until uterine examinations and therapeutics become an acknowledged feature in the treatment of the insane. I have seen two marked cases in which epilepsy was caused by amenorrhea and endo-cervicitis. Case II.—J. R., a robust, well-developed girl of seven- teen, suffered from daily epileptiform attacks ; menstruation was irregular and scanty; the uterus somewhat anteflexed with erosions and endo-cervicitis. GEORGE J. ENGELMANN. 7 1 “ Das Verhalten der Menstruation bei Psychosen.” Beitrage zur Geburtshiilpe u. Gynakologie, iii. 3, p. 293. Berlin, 1875. 8 THE HYSTERO-NEUROSES. A single application of nitric acid to the cervix checked the attacks almost entirely; for five days they did not ap- pear, and then at much longer intervals than before the application ; gradually increasing in frequency they again became very annoying. I then made a slight bilateral in- cision (Peaslee), merely cutting through the mucosa, dilated the uterine canal and rectified the position of the womb ; menstruation now became normal; slippery elm tents were used, and occasional applications made to the inflamed cer- vical mucosa, the epileptic attacks ceased, the pain disap- peared, the head became clear, and her complexion greatly improved. Case III. — N. H., aged 18, amenorrhea, erosions, endo- cervicitis. Patient is an undeveloped, pale, almost idiotic child, with complete hemiplegia; in childhood she suffered from epileptic attacks ; was paralyzed in her tenth year; in her fifteenth she was placed in the Webster Orphan Asy- lum, could scarcely walk, thought and spoke in a rambling way, was confined to her bed totally unconscious for weeks, and then was fed, but sometimes would not even swallow the food forced upon her, would often scream and toss about in an almost delirious condition. In these prolonged epileptic attacks she seemed fre- quently to suffer with intense headache of which she also complained in her sane moments. A monthly exacerba- tion of her condition was marked ; at these times she was always in bed, deranged and suffering with headache, back- ache and often vomiting. I first saw patient in October, 1877 ; the profuse vaginal discharge as well as the amenorrhea and monthly exacerba- tion of her suffering led me to seek the cause of her mental disturbance in some uterine derangement. Vaginitis, vaginismus, and the exquisitely sensitive con- dition of the eroded os made it impossible to subject the frightened, half-witted girl to local treatment for the pres- ent ; the vaginal douche was ordered, tonics were given, and the condition of the bowels regulated. The uterine GEORGE J. ENGELMANN. 9 symptoms improved, and the first monthly period following was one of comparative comfort, no headache, but as yet no appearance of the menstrual flow, which was, however, es- tablished during the next month after some local applica- tions had been made. Upon the third return, toward the end of December, it was more copious, and since then it has been perfectly normal, regular, sufficiently free, lasting four days, without the slightest pain, the patient even attending to her duties about the Home during the entire period. This patient has undergone a remarkable change since erosions and endo-cervicitis have been cured, and the men- strual flow has been established ; the idiotic child has devel- oped into a fine-looking girl (barring the hemiplegia) with well rounded limbs, who looks and feels well, and has no more headache, backache, or vaginal discharge. I have lately advised the use of electricity, and hear that she is beginning to gain much more control over the use of her limbs. . The monograph of Louis Mayer upon the subject1 is concise, complete, and admirably illustrated by instructive cases of characteristic hystero-psychoses ; a few of these I will outline in brief, as clearly showing the causative con- nection of uterine disease with the cerebral disturbance. Case IV. [i.]2—Melancholia, with alternating stages of delusions and exaltation,3 hereditary predisposition, begin- ning with all the symptoms of marked hysteria, caused by galactorrhea and pelvic trouble developed in child- bed, — anteversion, uterine congestion, erosions, mucous polypi and cure after removal of the uterine disease by a four months’ persistent local and tonic treatment. Case V. [6.] — Hypochondria, with delusions, due to masturbation in a well-developed young girl, scanty and re- 1 Die Beziehungen der Krankhaften Zustdnde U7id Vorgdnge in den Sexual-Organen des Weibes zn Geistesstorungen. Berlin, 1869. 2 The numbers in brackets are those of the author’s cases as num- bered in his paper. 8 Folie Circulaire. 10 tarded menstruation, anteversion, chronic metritis, catarrh of the vulva and vagina, cured by local treatment. Case VI. [26.] — Melancholic depression with delusions,, suicidal and homicidal mania ; hereditary predisposition. The disease developed in a healthy young woman of twenty- one, in good circumstances, during her second child-bed. Treatment of the vaginismus, vaginal catarrh, chronic metritis, uterine tumefaction and erosions, entirely freed the patient from the terrible mental condition under which she had been laboring for a year and a half. Overexertion caused a return of the uterine and vaginal catarrh, and at the same time the symptoms of melancholia reappeared ; local treatment soon cured the metritis, and with it all men- tal disturbance again vanished. Several other cases are cited in which melancholia kept pace with uterine disease, returning with a relapse of the latter, and again passing away after local treatment; the author also mentions a parallel and equally striking case of mania (34) which is less frequently found dependent upon pelvic irregularities. The classic contribution of Fordyce Barker1 adds greatly to the list of these interesting cases ; he tells of two instan- ces in which insanity was induced by amenorrhea ; in the one accompanied by an infantile uterus, in the other by congestion of the cervix and erosions of the os ; in both cure of the amenorrhea was followed by an entire disap- pearance of the insanity ; a third, similar case in which no vaginal examination was allowed, terminated in suicide. Professor Barker’s explanation of these cases seems to be that when the uterus does not permit relief of the physio- logical congestion which accompanies ovulation, hyperemia of the brain, with a disturbance of its functions, may follow. He speaks of two cases in which insanity seemed to result from menorrhagia, probably inducing anemia of the brain; the mental derangement disappeared when the men- THE HYSTERO-NEUROSES. 1 “Uterine Disease as an Exciting Cause of Insanity,” Journal of the Gynecological Society of Boston, May, 1872, p. 347. GEORGE J. ENGELMANN. 11 orrhagia was cured, and the anemic condition was over- come. Displacement of the uterus he has but once observed as a cause of insanity, and reposition of the extremely retroverted and enlarged organ was followed by immediate disappearance of the mental disturbance. To use his own words, “ I found the uterus retroverted, packed down, so that it required some force to replace it; as soon as this was done, she loudly ejaculated, with a kind of satisfied grunt, ‘ There now! ’ and at once ceased spitting, became per- fectly quiet, and before I left the room she fell asleep. On visiting her next morning I was surprised to see her sitting at the breakfast table, smiling and happy.” The insanity which is principally manifested by sexual hallucinations, in connection with uterine and ovarian disease, is said by alienists to be par excellence the insanity of old maids. At the change of life, the milder forms of monomania, manifested by religious depression, remorse, exaggerated apprehensions of disease or of poverty, are not uncommon, and have remained permanent in only one case known to Professor Barker. The last of his cases are those in which insanity is devel- oped immediately after marriage, and he justly speaks of this as perhaps the most pitiable of all the conditions under which insanity is developed as a reflex irritation of the brain from disease in the functions of the sexual organs. Although melancholia, and perhaps epilepsy, appear oft- ener as reflex psychoses, respondent to uterine causation, all other nervous and cerebral diseases may be developed as hystero-neuroses, and in the examination of female pa- tients so afflicted the condition of the sexual organs should never be overlooked. Even more rare, but verified by reliable observers, are the ophthalmic hystero-neuroses which may either accompany uterine disease, pregnancy, or the congestion preceding the menstrual flow. 2. HYSTERO-NEUROSES OF THE EYE. 12 I refer, of course, only to those cases in which impaired vision is unquestionably due to uterine abnormities, and no structural lesion is revealed by the ophthalmoscope. Such cases as those related by MacKenzie in his work, or the one seen by Von Graefe in consultation with Louis Mayer,1 do not belong here. Although they show a certain connection between the diseases of the eye and of the womb, they are not neuroses but cases of actual amblyopia in connection with amenorrhea and dysmenorrhea caused by extravasation of blood into the retina during intense cerebral and pulmonary congestion dependent upon the ob- struction of the menstrual flow. So also must we exclude cases of amaurosis during preg- nancy and lactation, indirectly due to changes in the sex- ual organs as they are found in connection with albumi- nuria and accompanied by lesions of the optic nerve. Every gynecologist has observed that patients with chronic uterine disease, especially endometritis and metri- tis, generally complain of impaired or defective vision ; and, on the other hand, a prominent oculist of this city assures me that the great majority of his cases of asthenopia are in females, many of them suffering from menstrual irregulari- ties, yet he is unable to state whether a direct or causative relation exists between these conditions. The prevalence of the ophthalmic affection in women may be due, in the lower classes, to needle-work, and in the higher, to novel- reading, not necessarily to the existence of uterine disease. I have no test case in which treatment of the uterine dis- ease removed the coexisting defect of vision. Mayer, in his article on hysterical amaurosis says, that he has repeatedly seen transitory amblyopia in hysterical and non-hysterical women suffering from uterine disease, espe- cially at the time of the menses and just preceding the flow ; sudden and total amaurosis which passed away rapidly he had observed but once. He cites but two cases which can with certainty be considered as hystero-neuroses of the eye ; THE HYSTERO-NEUROSES. 1 Mayer, Beitr. z. Geburtsh. u. Gyn., iii. 3, Sitzungs-Berichte, p. 116. GEORGE J. ENGELMANN. 13 one from the “ Journ. de M6d. et de Chirurg. Prat.,” 1861, p. 257,1 in which a lady who had been a sufferer from intense uterine pain began to lose her eyesight while in church and in the course of three or four hours was entirely blind. No changes could be detected by the ophthalmoscope ; an- tiphlogistic and revulsive remedies were resorted to in vain ; after the lapse of a week, intra-uterine injections of brandy were made which caused great pain, but were followed at once by a sensitiveness to light, gradual improvement, and in three days by perfect recovery. Another case he himself observed in a healthy lady of thirty-five, lately married ; menstruation had always been regular but painful, and in the preceding four or five years symptoms of uterine disease had begun to manifest them- selves, sacral pain, constipation, abdominal fullness, etc. ; at the time of the menstrual flow there was general debility with the senses of hearing and smell greatly intensified ; in addition to these symptoms, ptosis appeared, “ mouches vo- lantes ” and a marked decrease in the power of vision. The oculist who was consulted could detect no changes, the eye was sound, and the patient in the inter-menstrual period could read the finest print, yet during the time of the cata- menial flow her vision was so much impaired that she could not distinguish the largest letters. Clemens Mayer relates the case of a maiden lady of forty, in whom the menstrual flow is ushered in by an amaurosis of several hours’ duration, which disappears as suddenly as it comes, but is never accompanied by any of the symptoms of cerebral congestion. So marked a case I have never seen, but have in several instances observed a heaviness of the eyes with some dimness of vision in young girls on the first day of the catamenial flow, which would disappear as the flow became more free. In none of these cases was vaginal examination permitted, but in quite a number I suspected anteflexion from the ex- cessively painful dysmenorrhea and the pressure felt on the bladder. 1 Schmidt’s Jahrbiicher, Bd. 114, p. 233. THE HYSTERO-NEUROSES. 14 Although we have as yet but few cases recorded, I am confident that ophthalmic hystero-neuroses will be detected now and then, if oculists and gynecologists will carefully observe questionable cases of this kind. Since writing the above Professor Barker has informed me that he recalls some six or eight cases of hystero-neuro- sis of the eye which he has either seen in his own practice or which have been sent to him by oculists ; two of these cases, which are very marked, I record as related to me by Dr. Barker. Case VII. — Mrs. Y., aged 30, had been comparatively well until after the birth of her second child, in her twenty- fourth year, when menstruation became gradually less and less, until it ceased entirely at twenty-eight ; she then suf- fered more or less from pelvic pain and violent headache for a week each month. Soon after the cessation of the catamenia she began to suffer with pain in her eyes, which became very severe, and moreover she lost her sight so far as to be unable to read or write. The excessive superinvolution was treated by laminaria and sponge tents, and then by electro-galvanism, with the effect of developing the womb to twice the size it had when first seen, and of reestablishing the menstrual flow. The removal of the morbid condition of the uterus was accompanied by the entire disappearance of all trouble with her eyes, which had previously been seen by Drs. Agnew and Noyes, who, however, failed to discover any pathological changes. Sight was entirely restored. Case VIII. — Lady, unmarried, aged 38, came to Dr. Barker on account of constant severe headache, which she had had for four years ; vision was impaired so that she could neither read nor write, and could distinguish persons but very imperfectly ; there was a constant mobility of the pupil. Her headaches were continuous, so that she never lost consciousness of them, even in sleep; ovulation seemed to be continued, from the fact that for a period of a few days in each month the headaches were still more severe, and the patient suffered from diarrhea and nausea (men- strual hystero-neurosis of the stomach and of the intes- tines). In six years she gained fifty-four pounds, her weight increasing from one hundred and sixteen to one hundred and seventy pounds. Examination revealed circumuterine inflammation ; lam- inaria and sponge tents and hot-water injections were used, until finally, three months after the commencement of the treatment, the patient had a hemorrhage from the uterus which was estimated at nearly sixteen ounces ; the follow- ing month four leeches were applied to the cervix, and she menstruated for five days ; leeches were again applied, and in a few months menstruation was perfectly reestablished, and has continued regularly ever since, during the last nine years. After the return of the flow the headaches disappeared, and sight was entirely restored without resorting to any treatment of the eye whatsoever, which had been vainly tried again and again in former years. GEORGE J. ENGELMANN. 15 It has not been my good fortune to observe a typical case of pharyngeal hystero-neurosis in the short space of time which has elapsed since my attention was first attracted to these remarkable phenomena ; and in order not to refer to questionable cases, such as I saw several years ago and am now inclined to class under this head, I will refer to that most valuable paper on “ Pharyngeal Neuroses due to Uterine Disease,” by Dr. Edgar Holden of Newark, N. J., published in the August number of the “ New York Medical Journal ” for 1877. Dr. Holden gathers four instructive cases from a number which have come under his observation ; in all but one the patients were well-to-do, one only unmarried, the youngest twenty-four; the eldest, who had borne seven children, forty- 3. HYSTERO-NEUROSES OF THE PHARYNX. 16 THE HYSTERO-NEUROSES. three, approaching the change of life ; two of them remarka- bly healthy and robust. The sufferings of the patients were continual and severe: their complaints were about the same, of intense aching pain just behind the whole length of the posterior pillars of the palate; sore throat extending up and down the sides, pain ; varying in intensity, often worse after fatigue, rarely lancinating, more of a slow torturing ache. In no case did the most careful examination, rhinoscopic and laryngeal, reveal any signs of disease in the parts com- plained of. The patients had been treated by Dr. Holden and by others for subacute pharyngitis with local applica- tions of nitrate of silver, or chloride of zinc, — sometimes without benefit, sometimes with temporary relief, but in no instance with perfect success. In the second case mentioned by Dr. Holden, after the treatment of the throat difficulty had been abandoned, the success being but partial, the patient came to him for treat- ment of her dysmenorrhea, due to anteflexion and endo- cervicitis. The erosion and inflammation were successfully treated and the pharyngeal trouble disappeared, recurring at times, but permanent relief finally followed the removal of the extreme anteversion. The pharyngeal symptoms above described, unaccom- panied by any evidence of disease, such as congestion, in- filtration, or follicular swelling, have been found to depend sometimes upon erosions and leucorrhea, but, as it seems, mainly upon anteflexion, and have always disappeared without any application whatsoever to the pharynx, upon treatment of the womb disease. No better description of the hystero-neuroses of the pharynx could be given than that of Dr. Holden, who has so strikingly verified the dependence of the pharyngeal trouble on uterine derangements. GEORGE J. ENGELMANN. 17 4. HYSTERO-NEUROSES OF THE LARYNX. Much more frequent than any of the neuroses as yet described is the disagreeable and intractable cough which we sometimes find associated with malposition or disease of the uterus. This hystero-neurosis of the larynx, a short, hacking laryngeal cough, will often be noticed in young girls in a mild form, but at times it becomes a source of great an- noyance. Examination will, in such cases, reveal a healthy larynx, but generally flexion or stenosis and painful dys- menorrhea, sometimes uterine catarrh. The only treatment is per vaginam, and as soon as the uterine disorder is improved the cough ceases. We must not confound with this hystero-neurosis, hys- terical aphonia or the laryngismus of nervous and hyster- ical women, those distressing paroxysmal attacks of cough or of suffocation and strangulation which are as harmless as they are alarming, and disappear as rapidly as they come. When the bronchial filaments of the pneumogastric and those of the plexus pulmonalis respond to uterine irrita- tion, the hystero-neurosis of the bronchi is developed which may appear as a severe, irrepressible cough, in the form of dyspnea, or as a most troublesome asthma. The following case I shall give more in detail, as it is the most marked that I have ever seen, and the relation of cause and effect could be demonstrated at will with the certainty of a laboratory experiment; moreover, the post- mortem added a proof, if such were needed, of the fact that the distressing bronchial symptoms were merely nervous and not accompanied by any structural changes. Case IX. — Mrs. S. I first saw in consultation with Dr. Otto Greiner, of St. Louis, by whose courtesy I am enabled to give the full history. The patient was an exceedingly irritable, nervous woman of forty two, who had had four 5. HYSTERO-NEUROSES OF THE BRONCHI. 18 children ; formerly healthy and strong, she had become emaciated to the last degree, with a careworn, haggard look; menstruation in former years was comparatively regular, and unaccompanied by pain. In October, 1875, she began to suffer from nightly at- tacks of asthma. When these attacks first appeared, they presented all the symptoms of a nervous or hysterical asthma with bronchial cough and expectoration toward the end of the attack as the asthma subsided. Coming every night, soon after eleven o’clock, they would continue for an hour or more, according to their severity, and then disap- pear, leaving the patient entirely free from the annoying symptoms ; but as the disease progressed her suffering be- came continuous, the trouble persisting, though in a milder form, throughout the entire day. The case had gone from hand to hand, and the pharma- copoeia had been exhausted by the numerous physicians consulted ; she herself, supposing a prolapse, had inserted various kinds of pessaries. From these facts, Dr. Greiner, when called in, suspected that the bronchial trouble might be in some way connected with a morbid condition of the uterus, and he was confirmed in this by the marked exac- erbations a few days previous to the menstrual period, the bronchial asthma continuing unabated throughout the en- tire duration of the uterine congestion and gradually yield- ing in intensity as the catamenial flow disappeared. The symptoms always abated more or less after the cessation of the flow, but continued throughout the intermenstrual period, again to become more violent at the approach of the next period. Notwithstanding the grave symptoms, auscultation and percussion revealed but little ; while, upon vaginal examina- tion, Dr. Greiner found an elongated, acutely retroflexed uterus, movable and straightened by the probe without much difficulty. He introduced a sponge tent: the patient soon began to feel more comfortable, and in less than twelve hours the annoying cough and asthma which had so long THE HYSTERO-NEUROSES. GEORGE y. ENGELMANN. 19 troubled her entirely disappeared. An intra-uterine stem, ingeniously constructed to suit the case by Dr. Greiner, was next introduced, and as long as it could be borne with- out irritating the mucosa, the cough and asthma ceased. The symptoms, as I have myself several times observed, would abate soon after the introduction of the stem, to cease entirely within a few hours, but upon removal of the in- strument the former suffering was sure to return in from five to twenty-four hours. The bronchial symptoms responded with the greatest certainty and regularity to a change in the position of the womb. Retroversion pessaries did but little good, some even proving injurious ; pressure, even the slightest, on the pos- terior wall of the corpus uteri caused intense pain and a fearful exacerbation of the symptoms, as was demonstrated by a glycerine cotton tampon which had been introduced with a view of elevating the fundus. At last the stem could no longer be borne, and the pa- tient’s suffering became so unbearable at the time of the catamenia, while she was free from the asthma for two weeks of the intermenstrual period, that J determined to bring about the menopause by Battey’s operation. I removed both ovaries, and the patient, enfeebled by long suffering1, died on the sixth day after the operation. The post-mortem examination showed the lungs to be almost normal, somewhat emphysematous, but the bronchi free, nowhere enlarged, their mucous membrane perhaps a trifle thickened; thus it was evident that the dyspnea and the severe and continuous cough with muco-purulent sputum was a purely nervous phenomenon, and clinical ex- periment had shown the causation to be uterine. Case X. — An analogous case is related by Prof. Hegar of Freiburg.1 The patient, a maiden lady, 31 years of age, had been troubled during the period of puberty with an annoying cough, which returned in her twenty-sixth year 1 Wiener Med. Presse, 1877, Nos. 14, 15, 16, 17. THE HYSTERO-NEUROSES. 20 and grew constantly more troublesome ; she complained of intense cervical and hypogastric pains, bearing down and other uterine pains, loss of appetite, but, above all, of the hoarse, irritating, and constant cough, which was only tem- porarily relieved by the use of strong opiates; menstrua- tion was profuse and painful. Examination revealed an anteflexion, with chronic metritis and oophoritis. The introduction of an intra-uterine stem pessary afforded almost instant relief from the terrible coughing spells, pre- cisely as in my case, where it was used to overcome the retroflexion, and Professor Hegar’s farther experience with the stem was perfectly analogous to my own. It seemed to act unfavorably in other ways, so that as the period ap- proached he was obliged to remove it; in from three to four hours after the removal the attacks returned with all their former severity. The stems were used for several months, but although the cough was checked the pain, irri- tation, and menorrhagia grew unbearable, and the use of the instrument was given up. Electricity, as well as all medication, failed, and the extirpation of the uterus and the ovaries was determined upon, as the condition of the patient was such that she must apparently soon succumb, and it was highly probable that the cough would subside upon removal of the uterus and ovaries. The operation was suc- cessfully performed, and up to the date of the writing of the article, — three months after the extirpation, the cough had not reappeared. Similar cases are cited by Chroback,1 Griinewald,2 and Tripier.3 Hodge gives a number of cases in point, after referring to that tired feeling of the chest and the nervous cough,— the dry, the hard, and the paroxysmal cough coexistent with the irritable uterus, he cites several which are decided bron- 1 Wiener Med. Presse, 1869, Nos. 1 and 2. 3 Petersburger Med. Zeitschr., 1875, P- 575* 8 Lemons de Forme et de Situation de V Uterus, etc. Paris, 1874, p. 87. Observ. XXII., XXIII. GEORGE J. ENGELMANN. 21 chial hystero-neuroses, as their dependence upon uterine disease is made plainly manifest.1 Case XI. — In one case, that of a large, healthy lady who suffered from neuralgic and spasmodic complaints due to displacement of the uterus, a troublesome and continuous cough was produced by the use of a certain pessary, which at once disappeared when the support was changed. Cases XII., XIII. — In two other cases the cough would continue for many hours without intermission, defying the ordinary appliances of anodynes, demulcents, etc., causing great fatigue and exhaustion to the patients, who were pre- vented from taking nourishment or sleep by its severity. In both patients relief was instantaneously obtained by attention to the pelvic irritation. In every instance the at- tacks were immediately relieved by such mechanical means, without the assistance of medicine. Case XIV. — Lastly, the author mentions the no less characteristic case of an unmarried lady, who had been for many years an invalid with a bad cough, short and op- pressed respiration, often amounting to spasmodic asthma, who was relieved by attention to the uterine disease, and this after her physician had treated her as a hopeless con- sumptive for an entire winter and lavished the wealth of our materia medica upon her. 6. HYSTERO-NEUROSES OF THE BREASTS. The mammary hystero-neuroses, menstrual as well as continuous, generally appearing as a mastodynia, are of fre- quent occurence, as might well be expected from the inti- mate relation which must exist between the various organs of the same group. Even structural changes in the breasts are concomitant with or follow and are dependent upon changes in the uterus ; the development, the various stages of physiologi- cal activity, and the retrograde metamorphosis of the womb, all have an exponent in coexisting changes in the 1 Page 186. THE HYSTERO-NEUROSES. 22 mammae, and even its pathological changes are at times there depicted. The tenderness of the breasts, the mastodynia, which accompanies certain cases of dysmenorrhea and of uterine disease, may be illustrated by a case or two, although this neurosis occurs so frequently that it need only be referred to. Case XV. — Constant hystero-neurosis of the breast. — Mrs. $., aged 30, hysterical, nervous, married nine years ; sterile ; has acute anteflexion, endocervicitis, oophoritis and hydro-salpinx. While the fluid in the cyst is accumula- ting, the patient is confined to her bed with neuralgic head- aches and intense hypogastric pains ; at such times the breasts become tense and exceedingly sensitive, with a dull, heavy, rarely a lancinating pain which penetrates to the shoulder-blade. This period of accumulation and suffering, direct and reflex, is followed by a copious watery discharge per vaginam, and relief from the pain. The breasts then become less tense and painful ; the menses are compara- tively regular and have no causal connection with the mam- mary enlargement and suffering, which in this case is de- pendent upon and indicative of the intensity of the pelvic suffering. Case XVI. — Menstrual hystero-neurosis of the breast. — Mrs. M., aged 33, married at nineteen, sterile ; anteflexion, painful dysmenorrhea ; the appearance of the menses is preceded by shooting pain in the breasts, most severe when the general suffering is increased and always easier when the flow comes, or ceasing altogether with the disappearance of the discharge. After operation for the flexion these severe premenstrual mammary pains disappeared, but instead a soreness of the nipple and swelling of the breasts showed itself in the week preceding the flow. Case XVII. — Mrs. S., aged 22, married at nineteen ; sterile; lateroflexion with slight anteflexion ; dysmenorrhea. Two or three days before the time of the monthly change, GEORGE J. ENGELMANN. 23 lancinating pains begin to appear in the breasts, which become tender to the touch but do not increase in size ; this condition continues throughout the period and disap- pears with the cessation of the flow. The turgescence and tenderness of the mammary gland, often found in young girls just before and during the men- strual flow, is not to be classed among the mammary hys- tero-neuroses. 7. HYSTERO-NEUROSES OF THE INTESTINES. I can but indicate the occurrence of such neuroses, as I have not as yet been able to study cases clearly belonging under this head. As an intestinal hystero-neurosis of pregnancy, I should regard a case in which diarrhea preceded labor, and did not yield to medication, but ceased at once with the appearance of the pains. Dr. Noeggerath has related a menstrual neurosis in which the patient suffered from diarrhea previous to each cata- menial flow, notwithstanding all precautions which were taken. Medication seemed to have as little effect as in a case of looseness of the bowels, recently seen by me, which had been treated for atony of the rectum, and which a pessary relieved. 8. HYSTERO-NEUROSES OF THE JOINTS. When the attention of surgeons, as well as gynecologists, is once directed to the varying and puzzling reflex symp- toms due to uterine disease, I am confident that some of the cases of so called hysterical joints will be found to be hystero-neuroses. Hip disease is in some instances so closely simulated by a hystero-neurosis of the hip that the diagnosis is an exceedingly difficult one, as in a case seen by one of our most careful and prominent surgeons, and supposed by him to be hip disease, until the apparent cox- algia disappeared upon successful treatment of the accom- panying uterine disease. I have such a case now under 24 THE HYSTERO-NEUROSES. treatment, which has caused me considerable annoyance ; it appeared to be hip disease, and I suspected a hystero- neurosis, but was not allowed to make an examination. Case XVIII. — Miss S., a young lady of twenty, has the appearance of great suffering ; she complains of leucorrhea, backache, headache, and weakness of the eyes, of great tenderness and pain in the hip, and the feeling that one leg is shorter than the other, “as if all the tendons were stretched.” The pelvis is inclined to one side, she favors the afflicted limb, and her position whether erect or reclin- ing is that of a person suffering with hip disease ; none of the characteristic symptoms of this disease are wanting, with the exception that there is little or no pain upon direct pressure on the joint, but that the sensitive spot is above the joint, on and below the crista ilei, behind the anterior spine ; pain in the knee, rotation and position of the foot, etc., are all well marked. I was somewhat astonished to find that Miss S. wa£ fond of walking, and, although fatigued, would not complain of increased pain in the hip after exercise. Dr. Sims kindly consented to see the patient with me; permission was granted, and a careful examination of the pelvic organs was made ; the uterus was found normal in size and position, somewhat congested, showing erosions and marked endo-cervicitis. The uterine symptoms, and, as we thought, all others, were now explained ; local treatment was not allowed, but by the use of tonics, astringent in- jections, etc., the uterine symptoms have improved, and at the same time the hip-trouble has become less annoying, and I expect to overcome it entirely as soon as I shall be enabled to resort to uterine applications. Of late the reflex nature of the disease has become more apparent by exacer- bation at the time of the menstrual period. These cases should be studied, and ought no longer to be confounded with those due to hysteria.1 1 Professor Erb, in his 12th volume of Ziemssen, has an excel- lent article on the neuroses of the joints, but he barely refers to such as are distinctly due to uterine disease. GEORGE J. ENGELMANN. 25 HYSTERO-NEUROSES OF THE STOMACH. These are the most frequent of the hystero-neuroses, and should therefore be fully understood, although they are not as striking or as interesting as many of the other pheno- mena resulting from uterine disease. I have grouped them, like all these neuroses, in accord- ance with the causative influence, as the symptoms them- selves remain very much the same. I shall treat of them in the following order : — A. Constant or strictly Pathological Hystero-neuroses of the Stomach. B. Menstrual; and C. Neuroses due to Pregnancy. A. Constant, strictly Pathological Hystero-neuroses of the Stomach. Fullness in the epigastric region, loss of appetite, nausea and vomiting, all the symptoms of indigestion, even of gastritis, are not unfrequently found in women suffering from uterine disease. Without especial medication these annoying troubles gradually disappear as the uterine disor- der yields to local treatment ; whilst before the inauguration of such treatment, any remedies that may be given to ease the suffering caused by the apparent gastritis, will be either fruitless or will at best afford but partial and tem- porary relief. Case XIX. — Mrs. W., aged 27, began to menstruate in her fifteenth year, has always been regular, with pain on the first day, and a profuse flow. Married at seven- teen, she bore two healthy children ; she first began to complain, six years ago, of lassitude, headache, backache, and unusually profuse menstruation; at the same time gastric symptoms developed ; her stomach was continually deranged, weak, with a feeling of fullness after taking any, even the lightest, food. She was under treatment for al- most two years for the uterine derangement, but expe- 26 THE HYSTERO-NEUROSES. rienced so little relief that she ceased all medication for the next two years, when her suffering increased, and she con- sulted me in the spring of 1875. Combined with pelvic complaints were all the symptoms of a chronic catarrh of the stomach. I found a slight prolapse of the tumefied, retroverted uterus, the lower lip elongated, hard and nodular, and an eroded granulating surface surrounding the os ; the bowels irregular, often bloated ; during the menstrual period there was profuse and continued hemorrhagic flow, which I found it difficult to check. Suspecting a granular condition of the uterine cavity, I made a digital examination after dilating with sponge-tents, and removed the excrescences with the scoop. The operation was followed by speedy recovery, and with the improvement of her pelvic suffering the dis- tressing gastric symptoms disappeared, although I had be- fore in vain sought to remedy the evil with bismuth, pepsin, nux vomica, and similar agents. At a later date I was obliged to insert a Hodge pessary, as the retroversion became more marked and caused an- noyance, backache, bearing down pains, and a slight return of the stomach trouble ; the instrument at once relieved both pelvic and gastric trouble ; but at times, when she has not worn it for several days, her digestion again suffers. Case XX. — Several equally marked cases have been recently reported. The first was by Dr. Wm. M. Chamber- lain, at a meeting of the New York Obstetrical Society, September 19, 1876.1 In this case, the point of irritation, at which reflex action was excited, is supposed to have been at the os internum, as this was the seat of a small fibroid which acted as a ball valve, and when it closed the canal the stomach trouble ap- peared ;*not medication but removal of the fibroid brought relief to the sufferer from so-called chronic gastric disease. Patient 30 years of age, married. Has one child, now five years old, after the birth of which symptoms of( uterine 1 Am. Jour. Obstet., January, 1877, p. 98. GEORGE J. ENGELMANN. 27 disease began to appear ; during gestation the nausea and vomiting had been excessive ; three years later she had gastric trouble, nausea, vomiting, and a boring burning pain in the epigastric region ; no food could be retained, so that for twenty-seven days she was kept alive by enemata. She slowly improved, and finally recovered. This patient again became pregnant, and all the old symptoms recurred. At this time Dr. Chamberlain first saw the patient, in the second month of her pregnancy, and finding the pregnancy to be complicated with large uterine fibroids, one smaller one being within the cervix, determined to produce abortion. He began dilating at 11 a. m., and at 7 p. m. vomiting, pain, and all other distressing gastric symptoms had ceased. They began to diminish in two hours, and five hours afterwards she ate a hearty meal. When the cervical canal was open, and unobstructed, the patient was comfortable, but with every labor pain, as the fibroid was forced down, and the valve closed, the nausea, gastralgia, etc., returned. Dr. C. justly remarks that the old trouble two years ago was undoubtedly uterine in its origin, as the last was dis- tinctly proven to be. Case XXI.—The other case, a “sympathetic hystero- neurosis of the stomach,” by Dr. Formento, of New York, appeared in the July number of the “ American Journal of Obstetrics ” of 1877. Intractable vomiting, and hysterical convulsions lasting for several years, caused by the indurated conical cervix with stenosis of the canal, were cured by incision and dilatation. The patient was a healthy lady of twenty-one, who had known no uterine suffering, save a somewhat painful though regu- lar menstruation, previous to marriage. The vomiting, un- accompanied by any pain in the epigastric region or other symptom indicating organic disease of the alimentary ap- paratus, at first appeared soon after marriage, then coming only in the morning when the stomach was empty. It grad- ually became more frequent, coming at all times, before and 28 THE HYSTERO-NEUROSES. after meals, often provoked by some unpleasant sensation or a slight moral impression. The patient soon lost flesh, there was extreme prostration with perversion of moral and intellectual faculties. Finally, these disorders of in- nervation went so far as to produce convulsions with com- plete loss of consciousness, general, and at times partial anesthesia, or, during certain attacks, extreme hyperes- thesia ; at times phenomena of catalepsy, or trismus, opis- thotonus, contractions of pharynx, esophagus, etc. These occurrences often took place several times during the month, menstruation continuing regular, neither more diffi- cult nor less copious than normal. Several physicians had been consulted: antispasmodics, tonics, hydropathy, electricity, sea-baths, mineral waters, blisters, morphia hypodermically, etc., had all been tried in vain. Dr. Formento found an abnormal sensibility of the external organs, a narrow vagina, a conical, hard, resistant cervix, of a deep red color and smooth surface ; the external os scarcely visible and impermeable even to the smallest sound ; the uterus normal in size and position. The cervical canal was enlarged by bilateral incision in its entire length, especially at its two orifices, and before the incision healed the vomiting had ceased ; the external genitals and cervix became more natural, the congestion disappeared and a large sound could be readily introduced to the normal depth ; all suffering was relieved, and the patient became cheerful, strong, and healthy. This satisfactory condition continued for nine or ten months following the operation, when the derangements of the stomach and nervous system again began to appear. Upon examination the os and cervical canal were found to have become considerably narrower than they were two months after the operation ; this was now repeated, the same immediate and remarkable amelioration following 'and continuing for over a year ; then again, for the third and fourth times the knife was resorted to. After a period varying from ten to sixteen months, the return of the same GEORGE J. ENGELMANN. 29 disorders compelled Dr. Formento to have recourse to the same method of treatment, always with the same good result. The symptoms in different patients necessarily vary somewhat, but more in intensity than in kind, and I have cited these cases at length in order to elicit the gastric symptoms as they appeared in each, and more particularly to demonstrate the causative relation existing between the affections of the stomach and the uterus, and the depend- ence of those reflex phenomena upon chronic uterine dis- ease. B. Menstrual Hystero-neuroses of the Stomach. Among the reflex phenomena due to uterine irritation previously mentioned, we find quite a number which accom- pany the menstrual period ; many are of comparatively rare occurrence, as the menstrual hystero-neurosis of the eye, the pharynx, the bronchi; more frequent is the mammary pain preceding the monthly flow, but none of all these symptoms are as common as the swelling of the stomach accompanied by either nausea, pain, or vomiting, — the menstrual hystero-neurosis of the stomach. Frequency. It will be safe to say that one third, or at least one fourth of all the patients in the wards of a general female hospital complain of this gastric trouble in connec- tion with the monthly period, so that this enlargement of the stomach at the time of the menstrual engorgement would almost appear as one of the symptoms of the cata- menia,— certainly as one pertaining to difficult menstrua- tion ; and yet it is not referred to in our text books, and is unknown to the general practitioner in its relation to the female sexual organs, so that a case of this kind when observed is treated as an indigestion or as a gas- tritis. In the Female Hospital1 of this city, sixty-four of the one 1 I am under great obligations to Dr. P. V. Schenck, the physician in charge of the Female Hospital, as well as his assistants, for the 30 hundred and seventy-four patients questioned, or (36 per cent.) suffered from the menstrual hystero-neurosis of the stomach. Patients were examined indiscriminately from the surgical, medical, venereal, and lying-in wards. The average seemed a fair one, as similar results were obtained in 1876 and 1877. Thirty-four out of the ninety-four patients ex- amined in July, 1876, complained of the menstrual swelling, and when after a complete change of inmates the rounds were again made in August, 1877, twenty-nine sufferers were found among eighty questioned. THE HYSTERO-NEUROSES. SYMPTOMS OF THE MENSTRUAL HYSTERO-NEUROSIS OF THE STOMACH. Swelling only, or with pain and indigestion . . 46 per cent. Swelling with nausea 19 “ Swelling with nausea and vomiting . . .16 “ Nausea, often with pain, very slight swelling . 19 “ TIME OF APPEARANCE OF THE SYMPTOMS IN RELATION TO THE MENSTRUAL FLOW. Immediately preceding, or together with, the ap- pearance of the flow 10.6 per cent. 1- days before appearance of the flow . 37.9 “ 2- days before appearance of the flow . *27.3 “ 3- days before appearance of the flow . 9.0 “ 5-6 days before appearance of the flow . .3.0 “ 7 days, more or less before the appearance of the flow 10.6 “ In middle of intermenstrual period . . 1.5 “ DISAPPEARANCE OF THE NEUROSIS. With appearance of the menstrual flow . . 61.8 per cent. On the first and second day of the flow . . 25.4 “ With cessation of the flow . . . .12.7 “ facilities for study so kindly afforded me, and for their personal efforts in furtherance of my investigation. GEORGE J. ENGELMANN. 31 DURATION OF THE NEUROSIS. Several hours 3.7 per cent. 1- days 11.2 “ 2- days 42.6 “ 3- days 14.8 “ 4- days 7-4 6-8 days 20.3 “ Symptoms. — The symptoms of this neurosis are some- what varied ; its appearance is however always ushered in by a distention of the epigastric region, more rarely of the entire upper part of the abdomen, — the patient will always speak of the “ swelling of the stomach,” which often be- comes so marked that the clothing must be very much loosened if it be worn at all. The enlargement is, in al- most all cases, confined to the epigastric region, which is tense, sensitive to the touch, and extremely tympanitic. This flatulent distention is frequently accompanied by more or less pain in the stomach, cramps, and bearing-down pains, or cramps and pains passing from the stomach down into the back. The backache and headache, or fullness of the head, which so often precede and accompany difficult menstrua- tion, generally complicate the neurosis of the stomach. In at least one third of the cases (35 per cent.) nausea succeeds the swelling and when once established continues until the cessation of the neurosis. In more aggravated cases the gastric discomfort is such as to produce vomiting, but this only when the neurosis is at its height, shortly be- fore the flow, and it ceases, as all other symptoms do, with the appearance of the catamenia. In only 16 per cent, of the cases was the distention accompanied by vomiting, and then not regularly with every period, but only when all the symptoms were intensified. Sometimes we find indigestion, frequently anorexia, but in some instances a very good appetite, notwithstanding the nausea ; the flatu- lent distention of the stomach as a reflex phenomenon is 32 THE HYSTERO-NEUROSES. not necessarily accompanied by that disgust for food which is a symptom of gastric disease. Time of appearance and duration of the neurosis. This neurosis of the stomach generally (65 per cent, of the cases) makes its appearance from one to three days before the catamenia ; beginning with the distention of the epigastrium, the symptoms increase and reach their climax just before the coming of the flow, and they disappear (62 per cent, of the cases) when the engorged uterus finds relief in the escape of the sanguineous fluid. In some cases the symptoms do not appear until the coming of the flow (10.6 per cent.), and rarely are they found as early as the fourth (9 per cent.) or the fifth and sixth day (3 per cent.) before its appearance. In 10.6 per cent, of my cases they came on a week previous to the flow, lasting until its appearance, and in two cases, in the middle of the intermenstrual period. These gastric symptoms generally disappear at once when the menstrual discharge comes on ; occasionally they con- tinue, until the flow is freely established on the first or second day (25.4 per cent.) ; less frequently (12.7 per cent.) do they last throughout the entire duration of the period. The average duration of the menstrual hystero-neurosis of the stomach is consequently from one to three days, (54.0 per cent.), seldom but a few hours, (3.7 per cent.) ; in 14.8 per cent, it was from three to four days, in 7.4 per cent, from four to five days, but again more often (20.3 per cent.) from six to eight days. Time of development of the neurosis. Only thirty-four of the seventy cases observed were carefully questioned as to the time at which the distention of the epigastrium, in connection with the catamenia, had been developed. Of these thirty-four patients, twenty-five (73.5 per cent.) had observed this more or less annoying symptom from the time they first menstruated, and it had returned regularly with each period, always preceding the flow so that they had learned to look upon it as a part of the suffering to GEORGE 7. ENGELMANN. 33 which they were doomed during the continuance of their sexual life. It is probable that for reasons such as this, the advice of the physician is not often sought by women suf- fering with this trouble, and when he is consulted, as in several instances related to me, it is in aggravated cases which are naturally looked upon as very serious forms of gastric derangement, because his attention has never been called to the milder forms of this affection or to its causes and relations. It might be of interest to add that the age at which menstruation appeared varied greatly, ranging from the eleventh to the nineteenth year. In the nine other patients (25.5 per cent.), the neurosis appeared later in life in connection with uterine disturb- ances ; six of these first observed the gastric suffering upon the reappearance of the menstrual flow after childbed, mostly when this had been aggravated by uterine inflammation. In one instance the swelling appeared at the same time with the development of uterine disease ; in another after mar- riage, by which the congestion of the anteflexed womb and all menstrual suffering was increased. And in only one of these nine cases is no sufficient cause mentioned for the late appearance of the neurosis. Conditions under which the neurosis is found. My sta- tistics are gathered entirely from women in the lower walks of life, as I was dependent for data and comparisons upon the one hundred and seventy-four patients of the Female Hospital; these were mostly servants, quite a number were prostitutes, some housewives, seamstresses, and laun- dresses. During the short space of time which has elapsed since my attention was first called to this point I have not been able to gather a sufficient number of cases in private prac- tice to allow the expression of a settled opinion, but my im- pression is that the menstrual neurosis of the stomach is somewhat less frequent among the more comfortably sit- uated classes. The ages of those examined cover almost the entire 34 THE HYSTERO-NEUROSES. range of menstrual life, from the fourteenth to the fifty- first year, and the diseases from which they were suffering at the time were such as will be found in a general female hospital. Connection with Uterine Disease. Cases in which the neurosis appeared .... 63 Under treatment for uterine disease ... 16 No uterine disease acknowledged . . . .47 Cases in which the neurosis did not exist . . . in Under treatment for uterine disease . . . 15 No uterine disease acknowledged .... 96 Total number of cases examined . . . .174 Of the thirty-one cases in the hospital under treatment for pelvic trouble, sixteen suffered from the neurosis, but as vaginal examination was not made in all cases, it is im- possible to say how many of the other patients labored under some slight uterine difficulty unknown to themselves, or not acknowledged to the physician. Of the seven private cases which I have recorded as showing the menstrual hystero-neurosis of the stomach, only one was free from severe uterine disease. In many of those cases of neurosis in which the patient did not complain of the symptoms of uterine disease an irregularity of menstruation was found ; thus in twenty- seven of thirty-six patients whose histories were more care- fully recorded, menstruation was decidedly abnormal, mostly irregular, or, if regular, profuse and of long duration, or very scanty. In the other nine the flow was perfectly nor- mal ; in eight of these nine' cases the swelling had been noticed since the first appearance of the courses, and had since then regularly preceded every period. The cases in which menstruation is regular and normal are mostly the milder types of the neurosis, and in the mildest forms the flow is always regular. The most severe cases, in which the epigastric swelling is GEORGE J. ENGELMANN. 35 vdry marked and painful, occur when the menstrual flow has been checked by some pathological influence in pa- tients suffering from the neurosis ; thus, a woman, now thirty-one years old, first menstruated at fourteen, and, af- fected with the neurosis since that time, did not see a return of the period until her eighteenth year, the flow having been checked by a severe cold. In these four years, during which the menses did not appear, the neurosis returned regularly each month, being more severe and causing her greater suf- fering than she had experienced while the flow was reg- ular, both before it was checked and since its reappearance ; her case is still one of the most troublesome. I find several other equally marked cases among the number recorded, and I deem them most instructive as showing the depend- ence of the neurosis upon uterine engorgement. In those cases in which a physiological cessation of the flow takes place, as in consequence of conception, I could detect no regularity in its effect upon the neurosis ; thus the patient last referred to, whom I saw in childbed, tells me that her stomach was in a very fair condition through- out the entire period of pregnancy and that she did not suf- fer from vomiting until the last month ; another, who has suffered greatly from the neurosis since puberty, says that she had never felt so well as during the nine months fol- lowing conception, and that her stomach had never before been in so good a condition ; on the other hand, in some pa- tients so affected, swelling and tenderness of the stomach with vomiting always appear at the end of the first month of conception and continue throughout pregnancy, which may be brought to a premature termination by the suffer- ing and debility of the patient, if the medical attendant does not himself resort to the only means of relief,—an early abortion. I recall two marked cases of this kind, in both of which I was summoned in consultation on account of the exces- sive vomiting and gastric suffering. The history told of menstrual hystero-neurosis ; the 36 THE HYSTERO-NEUROSES. courses had been missed in one case but once, in the other twice, and the suffering and vomiting dated from the period at which the flow was for the first time vainly expected. This at once led me to infer a conception, and I was ena- bled to verify the diagnosis ; in one case I was obliged to relieve the uterus of its contents, after which the vomiting at once ceased. Causes of the neurosis. I can adduce no better proof of my theory, that this gastric disorder is a reflex neurosis dependent upon a pathological condition of the uterus and a disturbance of its functions, than by citing the following characteristic cases : — Case XXII. — L. S., aged 31, Bohemian ; healthy during childhood ; first menstruated in her fourteenth year; has been regular, without pain or bloating; married at twenty- three; had five children. Since her last childbed in 1873 she has been troubled with a swelling of the stomach at the time of her courses ; this precedes the flow by one or two days and ceases with its appearance. As the patient herself expresses it, she feels at that time “just as if she were in the family way ; ” the stomach is distended and tender ; she is nauseated, has no desire for food, but rarely vomits ; is greatly debilitated by each attack of this kind and has been incapacitated for work for several months, being often con- fined to her bed for days at a time. I saw the patient in May, 1876 ; the examination showed a prolapse of the ute- rus with elongation of the cervix ; operation was refused ; I reduced the prolapse and retained it in place by a Hodge pessary, advising in addition to this the use of astringent cotton tampons. In October, 1876, Mrs. S. returned, now a healthy, strong woman, earning a livelihood for herself and an idle husband, by washing ; the next flow after the introduction of the pessary passed off without the usual suf- fering, and the hystero-neurosis has not returned since the uterus has been in place. Th$ prolapse also is so far im- proved that she no longer wears a pessary or tampon unless she is looking forward to an unusually severe day’s labor. Case XXIII. — Mrs. C., aged 36, German ; menstruated first in her nineteenth year ; has been regular ; had one child twelve years ago, since which time the neurosis has always preceded the scanty menstrual flow; most intense gastral- gia, lasting six to twelve hours, accompanies the usual symp- toms of the neurosis in this case. The examination revealed an anteflexion with endocervi- citis and erosions. One single application of iodine to the cervical mucosa and the eroded os was followed by a more copious menstrual flow, and a great improvement in the gas- tric symptoms ; the patient was unable or unwilling to come regularly for treatment, but again returned several times two or three days before the menstrual period, and a local application was always followed by the same beneficial result. Cases such as these prove conclusively the causative con- nection existing between uterine disorders and the derange- ment of the stomach, and I need scarcely recall the men- strual irregularities which generally coexist, or the fact that the neurosis is often developed at the same time with uter- ine disease, whether following puerperal affections or other exciting causes. This hystero-neurosis does not accompany any especial condition, but is found associated with the various displace- ments as well as with catarrhal affections and obstructions of the ora ; perhaps most frequently with anteflexions and with chronic metritis. The symptoms are those of a neurosis, and not, per- chance, of a hyperemia of the gastric mucosa accompany- ing the pelvic congestion. The termination of the nerves supplying the female sex- ual organs and their radiation is too little known to enable us to explain the causative connection between these organs so distinct in function and location ; possibly the reflex ir- ritation of the stomach’ may be due to pressure upon the nerve terminations within the uterine tissue, caused by congestion of that organ, or to the distention of its peri- GEORGE J. ENGELMANN. 38 THE HYSTERO-NEUROSES. toneal covering, owing to its enlargement; either of these theories would seem plausible, when we consider the coex- istence of the neurosis with the uterine engorgement pre- ceding the flow, which is especially marked in uterine flexions and chronic inflammation. Under ordinary circumstances the uterine engorgement is relieved by the flow from the congested capillaries and the reflex symptoms disappear, but when the catamenial discharge has been checked by local or general disturbance, as in the cases related, this means of escape is not afforded. The congestion will disappear more slowly as the circulation becomes equalized, and the resultant suffering must of ne- cessity become more intense. Why the menstrual conges- tion should be accompanied by such phenomena in some cases of a uterine disease and not in others apparently similar, and why in seemingly healthy uteri, I am at loss to explain. ‘ C. Hystero-neurosis of Pregnancy. I will merely recall the various gastric symptoms which occasionally accompany pregnancy, as they admit of a simi- lar explanation; the uterus, after conception, as previous to the menstrual flow, is in a more active, sensitive condition ; it is congested and enlarged, and the nausea, the vomiting, and epigastric distention occasionally found during preg- nancy may also be classed among the hystero-neuroses, as we know that in some cases these symptoms may be re- lieved by dilatation of the cervical canal, and always by dis- charge of the ovum, whether at term or sooner, thus proving their dependence upon the uterine condition.