UONAl . IBRARv or MEDICINE NLM DD55AH31 5 JV-- v^ V »» w^ V < • • ) / SURGEON GENERAL'S OFFICE LIBRARY. mines Section VJ'iBE No. 113, No. W.D.S.G.O. /iZl^ 3—613 ->^ ' NLM005584312 J r#T \r \ YY. ^ \ * :/■/[ v / '*:_ \ . V> t r- The Hystero-Neuroses. ffiOEGE J. ENGELMANN, M. D., »»» - tFESKOR OF OBSTETRICS AND DISEASES OF WOMEN, I1. LOUIS POST-GRADUATE SCHOOL OF MEDICINE; FELLOW AMERICAN GYNECOLOGICAL SOCIETY ; FELLOW LONDON OBSTETRICAL SOCIETY,. ETC. BEPBINT* FROM VOLUME XII eEfgnecoloflital ^Transactions. 1887. 327 7!^ 70"kr ]*"iz.l.-..\y-l. \*\loo -tr----- THE HYSTERO-NEUKOSES. BY GEOKGE J. ENGELMANN, St. Louis. PART I.—GENERAL. I. Definition. By the term hystero-neuroses, I have designated those phenomena which simulate a morbid condition in 'an organ which is in an anatomically healthy state, the symptoms being due, not to structural changes in the organ in which they appear, but to morbid or physiological changes in uterus and ovaries. The hystero-neurosis is a sympathetic hyperes- thesia, the result of reflex action due to uterine derangement, and demonstrated to be unquestionably so dependent by being intractable to direct local medication, but yielding at once to treatment of the causative pelvic disorder; it is a symptom which may be brought under the head of the gangliopathy of Tilt, being determined by the various ramifications and con- nections of the ganglionic and spinal nerves and centres with the uterine and ovarian nerves, hence hystero-neuroses appear most frequently as nerve-pains, central and peripheral, as changes in the circulation, and as gastric and cardiac symp- toms. The direction of nervous influences like that of the electric current is determined either by the character of the conductor or the terminal attraction: uterine irritation is transmitted either by such nerve-tract, which is already in a state of morbid irritability, to the organs supplied by its terminal fibres, or it is carried by the most direct course to such organ as submits most readily to the morbid impulse, either by reason of its les^ejied^i-os^^i^^an'^lreadylo^- LuHcYGEN-rtALSOrFICL' l_z >.. v. • ' v~' ; -■ ■ ""v , ; ! 2 GEORGE J. ENGELMANN. ered vitality, or an existing hypersensitiveness. Both forces seek the most perfect conductor, and travel directly along such course to the point of greatest attraction, developing their full effect at the terminal radiations. Thus the irritation of the ganglionic nervous system, caused by morbid changes in uterine and ovarian tissue, is most readily conveyed to the spinal and cerebral centres, following sometimes one, some- times another, path, and results in the lumbar or hypogastric pains, in the burning or pain in the top of the head or back of the neck. Most intimate is the connection of the ganglionic with the vaso-motor nerves; hence, changes in the uterine tis- sue influence, through the ganglionic centers, the vaso-motor nerves, and produce either relaxation—which we so often see made apparent by flushes, swelling, heat, and redness of the surface—or hyperactivity, marked by vascular contraction, by a chill, or coldness of the extremities; by their connection with the vagus are brought about the palpitations of the heart, the nausea and vomiting, by which the stomach tells of uterine changes. The anastomosing fibres of the solar plexus account for the gaseous distention of the abdomen, the constipation and diarrheas by which uterine changes find expression. These symptoms are entirely distinct from the transitory and variable ones of hysteria, which I am inclined to place among the cerebro-spinal affections, and which are but indi- rectly influenced by the uterus and its annexa. As hystero-neuroses, I consider only such appearances of disease, without structural changes in the organ in which they occur, which are the direct result of reflex nervous influence, dependent upon changes in uterus or ovaries, coming and going, aggravated or improved, with corresponding changes in the determining, causative disease. We must strictly eliminate coexisting symptoms, and symptoms arising from direct mechanical causes : thus, the stiffness of the leg, with the shooting pain which follows the course of the nerve, often found in ovarian and circumuterine disease at the time of the menstrual period, is not an hystero-neurosis, not a reflex THE HYSTERO-NEUROSES. 3 nerve-symptom, but the direct result of pressure by the con- gested tissues or the enlarged ovary upon the pelvic portion of the nerve; frequent and painful micturition (dysuria), as it is observed during the menstrual period, may be a neu- rosis pure and simple, but it is more frequently the result of increased pressure of the congested uterus upon urethra or bladder. Such symptoms as are produced directly by contact —by pressure upon tissues, nerves, or vessels—must not be confounded with a neurosis, with those symptoms determined only by reflex nerve-action. II. Various Forms of Htstero-Neueoses. As these reflex neuroses are due to changes—pathological and physiological—in uterus and ovaries, we may look for their occurrence in disease, and during periods of heightened functional activity—hence, I have classified the hystero-neu- roses, first, as pathological, second, physiological. The physiological neuroses are those reflex symptoms which appear during the periods of increased functional ac- tivity, at puberty, and the menopause, during menstruation and pregnancy.1 1. Pathological Hystero-Neuroses. These are symptoms referable to and caused by a patho- logical condition of any part of the female sexual organism, aggravated by such causes as intensify uterine disease, though the symptoms may frequently be heightened by, or appear only during, the menstrual period. I shall treat here of the pathological neuroses, or the re- flex symptoms accompanying uterine disease, as I look upon these as the most important to the practitioner, and as the most occult and least readily recognized. 1 This classification is«the most simple, though not strictly correct, as many of those neuroses which are thereby termed physiological, because they accom- pany the physiological congestion, are, in fact, pathological, caused by morbid states of the uterus, but dormant until aroused by the heightened irritation of uterine disease plus physiological congestion. Yet I adhere to the terms, as they facilitate understanding. 4 GEORGE J. ENGELMANN. 2. The Physiological Hystero-Neuroses. a. Hystero-Neuroses of Puberty; I. The Menopause.— These two most important epochs in the sexual life of woman, the coming and going of the menstrual period, are marked by increased susceptibility of the nervous system: the peculiarities of temperament, the freaks and nervous pains with which women are afflicted at these times, are well known in a general way, although they have never been thor- oughly classified or understood. Even Tilt, in his classical work on The Changes of Life in Health and Disease, in which he enumerates and graphically describes the neuroses of the menopause, confounds the neuroses pure and simple, of certain of which he speaks as gangliopathy, with the dis- eases proper of the menopause. If we glance for a moment at his tables, in which he depicts the relative frequency of morbid liabilities at the change of life in 500 women, we find nervous irritability in 459, flushes in 287, pseudo-nar- cotism in 277, dorsal pain in 226, gangliopathy and faint- ness in 220, headache in 208, abdominal pain in 205, perspi- rations in 201; but with these he names leucorrhea in 146 cases, which is a disease and not a neurosis, an hysterical state in 146, flooding of the bowels, biliousness, gangliopathy or strange epigastric sensations in 49, phosphatic or lithic urine in 49, diarrhea in 45, chloro-anemia in 40, dyspepsia in 37, and so on. I have quoted this table—from which we see that those neuroses which are most common at the change of life are also among the most common of the pathological neuroses, or the neuroses accompanying uterine disease—to show the existing confusion, symptoms which are peculiar to the menopause are placed side by side with reflex symptoms which are among the most frequent evidences of uterine dis- ease at all times, the most frequent reflex neuroses which are caused by disturbances in the female sexual organs, deter- mined alike by pathological conditions, by the changes of pu- berty, menstruation, or the menopause. Tilt, in describing the diseases of that period, has given THE HYSTERO-NEUROSES. 5 us a most excellent sketch of the hystero-neuroses as they are found during the entire period of female sexual life. c. The Menstrual Hystero-Neuroses.—I have so termed those neuroses which appear at the time of the menstrual congestion, but in few cases only are they determined by the physiological state pure and simple in a healthy organ. They are mostly dependent changes, such as congestion or displace- ment, aggravated by the physiological condition of men- struation, their peculiarity being that they come at this time only. They are often determined by pathological conditions which in themselves are insufficient to bring about the neu- rosis, and only with the increased congestion or heightened nervous susceptibility accompanying the menstrual state does the neurosis appear: the pathological condition in itself being impotent to excite the symptoms which are at once developed by the additional impetus of the physiological con- gestion. It is upon the congestion and the increased nerv- ous excitability of the menstrual state that these neuroses depend, greater pressure, increase of the causative irritation in the uterus, heightened functional activity, and greater susceptibility of the affected organ and its nerve-fibres; hence they appear not at the time of the sanguineous flow, but during the entire period of congestion, beginning from two or three days to one week before the appearance of the flow, and passing away two or three days after its cessation, often disappearing during its continuance, while the depletion is in progress. d. Hystero-Neuroses of Pregnancy.—Unlike the neuroses of menstruation, those of pregnancy appear most frequently in response to physiological changes pure and simple, and less often to an aggravation of the exciting pathological state, caused by the heightened vitality and increased functional activity of the organ during the pregnant state. These symptoms frequently appear, like the menstrual neuroses, with the congestion and enlargement immediately following conception, and cease with the evacuation of the uterine cavity and the consequent depletion and contraction. 6 GEORGE J. ENGELMANN. The more common hystero-neuroses of pregnancy are known as the doubtful signs of pregnancy, and so well known are certain of these neuroses, and their connection with the preg- nant state, that they are looked upon as probable signs of pregnancy, and as the earliest signs : so frequent is their oc- currence that they have been looked upon as an evidence of pregnancy even by the laity, even by the ignorant among peoples civilized and savage, and by obstetric writers since the time of Hippocrates. They are determined by that con- gestion, enlargement, and changed nervous state which ap- pear soon after conception takes place, long before visible and palpable changes are such as to assure us of the condi- tion which exists. Though the reflex nervous phenomena —the hystero-neuroses—are among the first evidences of pregnancy, they are correctly known as doubtful signs, since, as we well know, they are merely the results of nutritive changes which accompany pathological as well as physiologi- cal conditions. • III. Importance. The importance of the neuroses—this varied conglomer- ation of symptoms—always peculiar, has never been appre- ciated, and in fact they have never been understood, never studied as a group. A trifling derangement in a sensitive organ, not sufficient to attract attention, to cause pain or even discomfort in the part affected, may be the exciting cause, and distant organs respond most violently to this slight abnormity, as the alarm-gong sounds in answer to the tap on the button of the distant station. The distribution of the sympathetic and the ganglionic systems, connecting in innu- merable filaments with the ramifications of the spinal nerves, central and peripheral, leads to the most curious and unex- pected reflex symptoms. These neuroses may be likened to the explosion caused in the magazine by the small spark which has ignited the fuse at a distant point; they are the symptoms by which pathological conditions, generally insig- nificant in character, find expression in vital organs, and, THE HYSTERO-NEUROSES. 7 while these phenomena may result from irritation of termi- nal nerves in any other part, the most numerous and the most striking are those which appear in response to genital lesions. An injury in one part of the body is marked by pain in another. Severe attacks of asthma are often dependent upon a circumscribed hypertrophy of the mucous membrane in the posterior nares, intense headaches upon gastric disturb- ance, and, vice versa, the stomach responds to cerebral changes. Among the best examples of this peculiar reflex nerve-action are the convulsions of childhood and the symptoms of hip- disease caused by the adherent prepuce in the male infant; the convulsions of teething, which in the popular mind ex- ist as an almost unavoidable accompaniment of the stage of development, may be reflex in their nature, the result of ter- minal nerve-pressure. The muco-cutaneous border with its sensitive fibres is a favorite centre, and fissures and urethral caruncles are characterized by reflex symptoms, often more annoying even than the distressing local pain. I merely refer to these well-established reflex phenomena as identical with that great class of neuroses which are re- ferable to the female sexual organs, and which I have de- scribed as the hystero-neuroses, and I need hardly state the self-evident fact that in the highly-sensitive nervous organi- zation of woman we find these reflex symptoms most fre- quent and intense, and that they are most fully developed in response to lesions of the sexual organs, the controlling in- fluence in the functional life of woman. While these symp- toms have been practically ignored by the scientific physician, who has recognized but an insignificant group as the doubtful or early symptoms of pregnancy, they have been observed from time immemorial by the laity, and I may almost say that these neuroses of pregnancy—these doubtful signs of conception—have been accepted by the profession in ac- knowledgment of popular beliefs and of medical tradition from the time of Hippocrates. Thus the ancients mainly recognized the symptoms which have now become obsolete, 8 GEORGE J. ENGELMANN. such as the enlargement of the neck: the Eoman matron cast a fillet around the bride's throat before and after the nuptial night in order to discover whether marriage had been consummated or not—a tribute to the congestion of the thyroid in response to uterine irritation. Horse-breeders at the present day in certain districts measure the necks of their mares before and after they have been covered to determine whether the intercourse has been a fruitful one. (Goodell, Transactions of the American Gynecological Society, vol. i, p. 211.) The most common and best known of these neuroses is the morning-sickness of early pregnancy, which at the same time offers a striking example of the importance of these neuroses. To the ignorance of the reflex nature of this irri- tation of the stomach, resulting from uterine congestion, many a young life has been sacrificed ; many a young wife, happy in the expectations of motherhood, has fallen a victim to the violence of reflex nerve - action, heightened to its greatest intensity in this period of female functional activity. Sad results such as this are unfortunately too frequent; equally sad and still more obscure are those cases of asthma, dyspepsia, headache, and mental derangement which resist all efforts of the physician, and doom the sufferer to hopeless invalidism—all because a simple uterine derangement, of which the supposed disease is but a reflex symptom, is over- looked or ignored. Too long neglected, this group of symp- toms should at length receive the attention which it justly merits on account of its importance: (a) Practical, (b) Sci- entific, and (c) Medico-legal. a. Practical Importance. A thorough understanding of these symptoms, these functional perversions in vital organs in response to trifling uterine lesions, is necessary, not alone to the gynecolo- gist, but above all to the physician in his daily practice; an understanding of these symptoms is necessary, not alone for the diagnosis of uterine and ovarian disease, but for the THE HYSTERO-NEUROSES. 9 correct treatment of the symptom, which is often far more annoymg to the patient than the disease by which it is caused. To the gynecologist these phenomena are but cu- rious accompaniments of uterine disease, and he naturally pursues the only correct and possible method of relief: the treatment of the local disturbance. But the general prac- titioner who fails to recognize the neurosis toys with health, if not with life: deceived by the perfect identity of the symptoms, deceived by this semblance of disease in a per- fectly healthy organ, he treats that organ for the supposed disease, and treats it in vain. The stomach is irritated, the system is ruined by constant medication, and the uterine disease, which is completely ignored, grows gradually worse; the reflex symptoms are correspondingly aggravated, more powerful medication is resorted to, and thus the health of the patient suffers, if her life is not endangered, by the error in diagnosis—the mistaking of the mere semblance, the re- flection, for the disease proper. Such cases are not recog- nized and are not reported—they are regarded as puzzling and obscure by the attending physician, and the patient as an hysterical crank. The disease is not an unusual one, yet all usual remedies fail; the sufferer passes from hand to hand, ■ satisfied to continue existence as an invalid, if death does not put an end to her suffering. Innumerable women have been treated for gastric troubles (mainly dyspepsia or nerve-pains), for cerebral disturbance, and for weak eyes, and have gone through the entire pharmacopeia —" taken whole drug- stores," as they state—until they have given up all hope of improvement, and have become resigned to their fate. Am I not justified in emphasizing the importance of these neuroses ? The healthy organ in which the phenomena occur is treated to the death ; the causative uterine disease is ig- nored because no pelvic or hypogastric pains exist, because no irregularity of menstruation occurs, or because the reflex symptoms so far exceed the trifling pelvic annoyance that the patient demands relief from that symptom which causes the greatest suffering, and both patient and physician over- 10 GEORGE J. ENGELMANN. look the lesser trouble. Several cases now under my care will best exemplify the importance of these symptoms to the practitioner. Case I. Gastric Hystero - Neurosis.—Mrs. M., aged 34, aceration of the cervix ; retroversion and descensus uteri, me- tritis and endometritis.; four children, the oldest nine years of lage. For the past eight years this patient has been under treat ment for what every physician called gastric catarrh (neurosis of the stomach), constantly taking medicines, each of the four physicians who attended her in turn exhausting the pharma- copeia, until her stomach was indeed weakened, her system de- bilitated ; each one had given her particular orders, forbidding such foods as he thought injurious ; and, while this poor woman, who needed nourishment and stimulation, was being medicated and starved, she was urged to exercise ; her house-work done, she walked or drove, and thus constantly aggravated the uter- ine disease. Backache or slight pelvic pains were ignored, and so treatment was continued until she was brought to bed by an exacerbation of the uterine disease, and even then the pelvic trouble would have been overlooked had not the extreme displacement of the congested uterus caused most painful dysuria, and I was consulted on account of the bladder trouble by the physician then in attendance, who had vainly urged a uterine examination nearly a year before. I found an ugly state of affairs. The ovaries were congested, the ligaments very much relaxed, the uterus greatly enlarged, the muscular tissue and the mucous membrane thickened and congested, so that I at once inaugurated treatment of the uterine and ova- rian disease regardless of stomach and bladder. As the uterine congestion was reduced and the position of the organ im- proved, both dysuria and dyspepsia were bettered ; all medi- cation was stopped, and this patient, who had for eight years been treated as a dyspeptic, dieted and medicated, was en- abled to eat with the rest. I restricted her but little, and she digested all foods alike, notwithstanding the weakening of the stomach by continued treatment and dieting. The chronic uterine disease has improved very slowly, hence occasional attacks of dyspepsia still occur ; these are not due, however, to THE HYSTERO-NEUROSES. 11 the character of the food, but to the condition of the uterus, and at those times the stomach resents the lightest diet—milk and lime water—precisely as it does heavier food. For eight years this patient has steadily aggravated the uterine disease, has weakened her constitution, and ruined her stomach by care- ful dieting and gastric medication, until her health is com- pletely broken. Physician after physician attacked the healthy stomach for the semblance of gastric disease resulting from the comparatively painless uterine disturbance. Case II. Central and Peripheral Crebral Reflexes ; Failure of Treatment.—Mrs. B., aged 32, was a sufferer from constant headaches, with exacerbations which resulted in symptoms re- sembling mania. No pelvic pains, no backaches, menstruation regular, patient suffers constantly, and is constantly under treat- ment of a local physician in her Western home ; though now and then temporary improvement was visible, her condition grew steadily worse. The suffering, which had begun with dull headaches,attained such intensity that physicians were consulted in larger cities ; she was plied with nervines and sedatives with- out the slightest benefit; her nerves were shattered, her stomach ruined, and her condition such that she rushed screaming into the street at night, and as a last resort the physician then attend- ing suggested the insane asylum. No physician had ever examined the uterus or inquired as to the state of the repro- ductive organs, as every one was perfectly satisfied with her statement that menstruation was regular, and her back free from pain. Influenced by female friends and by her own be- lief and hope in the possibility of a causative uterine disease, she consulted me. I found an indurated, hyperplastic uterus, with a large, hard cervix, and the remnants of an old laceration, the ligaments indurated, and indications of a perimetritis at an earlier day. Nervines and sedatives were stopped, and local treatment inaugurated. While I have not been able to over- come the symptoms, they have improved very much ; a con- stant headache remains, but the excessive nervous irritability and maniacal symptoms have ceased. Notwithstanding the long duration of the disease, and the injury done the stomach and nervous system by chloral and even stronger remedies, a three months' treatment of the metritis and endometritis served 12 GEORGE J. ENGELMANN. to make life more comfortable, to relieve the more violent symptoms, and to give this patient the hope of recovery, who had been upon the point of being thrust into an insane asylum for the semblance of mental disturbance, these violent reflex- cerebral symptoms resulting from an apparently symptomless uterine disease. Case III. Vomiting of Pregnancy resists Medication, but yields at once to Uterine Applications.—Mrs. X., an only daugh- ter, a bright, happy wife, pregnant with her first child, was attacked by nausea and vomiting. Treated by various physi- cians, homeopaths and allopaths, her condition grew steadily worse. The treatment was of course directed toward the organ affected with the semblance of disease—the stomach. Medi- cine after medicine was tried ; the vomiting grew worse, more frequent, until, when I saw her, without food for weeks, this young bride, four months before the very picture of health and beauty, was upon the point of death—a haggard, emaci- ated wreck. Applications to the eroded and congested cer- vix and the inflamed mucous membrane stopped the vomiting within twelve hours ; but, notwithstanding this satisfactory response, death speedily followed, as the violence and long duration of the neurosis had sapped all vitality. I do not hesi- tate to state that, if the disease proper, the endocervicitis, had been treated in time, a few simple applications would have suf- ficed for the relief of the slight cervical catarrh and erosion, which, by the violence of the reflex symptoms, proved fatal in the end. These are indeed extreme cases, yet not altogether uncom- mon, and does not ignorance of these phenomena appear criminal when we see the persistent and misdirected treat- ment of the symptoms lead to years of suffering, to invalid- ism, and death, while a few trifling applications to the uterus in the early stages would have afforded immediate relief ? b. Scientific Importance. Important as a thorough understanding of these phe- nomena is to the practitioner, it is hardly less so to the stu- dent ; as— THE HYSTERO-NEUROSES. 13 1. It serves an important end in the correct development of medical science, the neuroses being the link which binds specialism and general medicine; and 2. It is of value to the anatomist and physiologist in guid- ing him in the study of the anastomosing fibres of the gan- glionic and spinal systems and their relative functions. 1. This era of medical specialism, to which we owe in so great a measure the marvelous progress of medical science, and the brilliant developments in all its branches, has its faults as well, and the most grievous, which inevitably tends to deterioration, is the close limitation to specialism. The physician is lost in the specialist; the man of science becomes a mechanic, who may be skillful in a laryngological opera- tion or a uterine manipulation, but the system, the nervous organization, the circulation, the great vital forces are for- gotten in the one organ of the particular specialist, and no common bond exists between the specialists who treat these widely different parts. But this is a dangerous course, as Virchow has so justly emphasized in an address delivered some years ago, no man can be a thorough specialist who is not a good physician. The practical importance—the in- tensity of these reflex phenomena—demands attention, and forces the specialist from the narrow confines of a single organ upon broader ground, and necessitates a return to the thorough study of general medicine. Even more, this grand group of symptoms, emanating from an obscure localized irritation, affecting important organs most diverse in their phases, connecting distant parts by a chain of ganglionic and cerebro-spinal nerves, involving the system in all its parts, forms a bond of union between the various specialties. It is a common centre toward which all must converge—a common ground upon which all may unite. A gastric neurosis may be such as to puzzle the practi- tioner, whether the stomach, the uterus, or the nervous sys- tem is at fault, and whether relief may be obtained by gyne- cological treatment, by gastric medication and diet, or by treatment of the nervous system. A neurosis of the eye will 14 GEORGE J. ENGELMANN. necessitate a careful examination of the eye, the brain, the kidneys, and the uterus. It is by concentration on the part of the scientific practitioner of the day that medical progress has been furthered; but this concentration soon tends to limitation, and, while many are benefited, not a few suffer. I have mentioned the sad case of a patient, now under treat- ment for endometritis, metritis, and descensus uteri, who has been for eight years a sufferer from a gastric neurosis, and who has been under constant treatment for this most appar- ent symptom. Medication, of course, proved completely use- less, yet it was tried again and again by physician after phy- sician, as her failing health was attributed to the semblance of gastric disease, while the insidious uterine • lesion escaped detection, as it was not announced by menstrual pain or back- ache, and slowly but surely progressed until it had under- mined her entire system. The ramification of the ganglionic and spinal nerves throughout the body may be compared to a network of electric wires, and, while the irritation of the uterine terminals may find expression in chest or brain, the converse is equally true. The reproductive organs respond readily to a cerebral impulse by the intertwining of the gan- glionic and cerebro-spinal system; morbid changes in the nerve-centres may determine functional changes in distant organs by the response of the terminal fibres to the central impulse, and in woman none respond more readily than those of the sexual organs. The effect of sudden emotion, of joy or fear, upon rectal and vesical nerves is well known: uterine hemorrhage, or the sudden checking of the monthly flow, may be caused by a mental impression. It is not uncommon to see an amenor- rhea in emigrants: the change of life, the leaving of home and friends, produces a powerful mental impression, which results in a disturbance of the uterine function and conse- quent symptoms, such as backache and hypogastric pains; so that in this case we have a morbid condition of the nerv- ous system marked by the symptoms of uterine disease, which the thoughtless specialist would treat as such. More common THE HYSTERO-NEUROSES. 15 and more striking is the picture so graphically drawn by Goodell (" Neurasthenia and Womb Disease," Transactions of the American Gynecological Society, vol. iii, page 31) of the overtaxed school-girl who begins to fail, loses her appetite, grows pale, is distressed by headache, backache, spineache, and a sense of exhaustion; her catamenia, hitherto without suf- fering, become painful; her linen is stained by an exhausting leucorrhea, and bladder trouble sets in; all the symptoms of uterine disease appear, and she is subjected to a painful ex- amination, and unnecessary and humiliating treatment. Now, while I will not say with Goodell that " a moral rape is com- mitted," the physician is guilty of a grievous error, and, as the author truly says, the patient drags herself from one con- sulting-room to another, until, finally, in despair she settles down on a sofa in a darkened room, and lapses into inva- lidism. Such are some of the sad results of confined and false specialism, best exemplified in cases of reflex neuroses, which are hence important to specialist and general practitioner alike; and I believe that the study of these symptoms will serve not only to check the narrow limitation of specialism, but to unite the practitioner of general medicine and the widely-separated specialists. 2. A careful observation of these phenomena must result in establishing much as yet undetermined in regard to the functions and ramifications of the ganglionic system. By means of well-authenticated pathological facts, the obscurities existing in anatomy and physiology may be cleared; hence the scientific importance of these reflex symptoms; and not until the anatomical relations and physiological functions of the various nerve-tracts have been traced from the terminal plates to the central ganglia will these curious reflexes be fully understood. c. Medico-Legal Importance. The dangerous phases assumed by the cerebral neuroses give an aspect of legal import to the study of these phenom- 16 GEORGE J. ENGELMANN. ena (tne hystero-neuroses), and upon the correct diagnosis of certain of these reflexes depend the good name, if not the liberty and even life, of the patient. The unfortunate in- valid who is under the sway of irresistible impulses, whose actions are determined by a mere morbid reflection of uterine or ovarian impulses, is made to suffer alike with the willful criminal unless protected by medical science. As early as 1845 English judges recognized the power of the reproduct- ive organs upon the mind of woman (Tilt, page 192), and they refused to inflict punishment upon the unfortunate mother who had murdered her child in an attack of puer- peral mania. (Regina vs. Burk, Central Criminal Court, June, 1845. Murder of the child proven, but acquittal on the plea of disordered menstruation. Amelia G. Snoswell, tried at Maidstone, March 20, 1855; • acquitted on same ground.) Most common among these central neuroses, which may give rise to legal investigation, are the actions of women under the influence of puerperal insanity, leading to in- fanticide, homicide, kleptomania, dipsomania, and suicidal mania, which appear either as pathological or as menstrual neuroses. The irritability, varying temper, and moral per- version accompanying uterine disease, and tending to exacer- bation during the menopause, is liable to alienate the affec- tions, and to force an innocent, loving wife into the divorce court. Tilt truly says (page 192): "Judges as enlightened and merciful have admitted the doctrine of uncontrollable im- pulses in cases of puerperal insanity ; if they admit that par- turition determines uncontrollable impulses, they must allow the possible occurrence of the same impulse at all the critical periods of woman's life, during puberty, pregnancy, lactation, the menstrual period, and cessation." This curious dependence of moral perversion upon local changes is a subject worthy of the most serious considera- tion on the ground of— (a) its practical importance to the gynecologist, that he may detect uterine disease when the ordinary symptoms are THE HYSTERO-NEUROSES. 17 wanting; to the general practitioner, that he may correctly diagnose and not maltreat but overcome suffering, frequently in patients who may be easily relieved, and yet become lin- gering victims to the treatment of phantom disease; (b) its scientific interest, as it forces the specialist from his narrow confines to the broad fields of scientific medicine, and serves to reunite the widely-separated interests of diverg- ing specialties; as they aid the anatomist and the physiolo- gist in tracing the anastomosing fibres of ganglionic and spinal nerves; (c) the legal import of a correct definition, by which the hand of justice is tempered and the innocent and afflicted are preserved from the punishment of the guilty. IY. History. However well known the fact has been that curious symptoms on the part of various organs are referable to changes in the female genitalia, this knowledge has found general credence among the laity alone. Known to Greek and Roman authors, the neuroses as early symptoms of pregnancy alone have entered more fully into medical writ- ings; alienists, more especially the French, have appreci- ated the influence of these organs upon the mind, yet the neuroses as such have never been fully appreciated; isolated cases, startling phenomena have now and then been reported, but our text-books do not accord the subject the attention it merits. Hippocrates already mentions certain genital reflexes as symptoms of pregnancy; Marce, Tuke, and others, toward the end of the last century and the beginning of the present, have carefully studied the puerperal psychoses, and vaguely indicate their dependence upon changes in the reproductive organs; with the development of our physiological knowl- edge isolated cases of reflex disturbances were recognized, and during the last twenty years sporadic investigations have appeared, quite frequent of late, but no decided progress was made, no permanent interest in the subject was aroused ; 2 18 GEORGE J. ENGELMANN. even the most important of these observations seem to have left no impression upon the professional mind. A distinct series of hystero-psychoses has been described by Mayer, of Berlin; Fordyce Barker, in his work on Uter- ine Disease as an Exciting Cause of Insanity, has cited char- acteristic cases; and Dr. Edgar Holden has described a most striking series of pharnygeal neuroses; but few, with the exception of the above mentioned, seem to have fully appre- ciated the existence of so well defined a group of symptoms, characterized by their positive and striking dependence upon uterine or ovarian disease. Thus Hodge, in the sixth chapter of his work on Diseases of Women, records cases which plainly belong among the hystero-neuroses as homologous with those which are decidedly hysterical, evidently without a proper appreciation of the causative relation in either case. Some such reflexes are mentioned by Tilt in his chapter on gangliopathy, but he places them on a par with those which are purely hysterical, and ascribes all to disease of the gan- glionic nerves—diseases to which he says 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 atten- tion was first attracted to this class of symptoms by the dis- tention of the epigastrium, which so frequently precedes the catamenial flow, and which I have described as the most common inenstrual hystero-neurosis of the stomach. Since the appearance of my paper on the "Hystero-Neuroses" {Transactions of the American Gynecological Society, vol. iii, 1878), the literature on this subject has rapidly increased, and yet I believe that it merits more careful investigation, and deserves a recognition in gynecological text-books which is not yet accorded it. Tilt, in his work on the Diseases of the Change of Life, describes these reflex phenomena most vividly, and, though he refers them to pathological or physiological changes in ovaries or uterus, he does not define the direct causative relation, nor does he clearly estimate this absolute THE HYSTERO-NEUROSES. 19 dependence, since he seeks relief by medication and lays but little stress upon local treatment, which, in a true neurosis, is the most rational and direct means of cure, and, with the exception of sedatives, the only. He records the symptoms without fully appreciating their dependence, and considers them among the diseases peculiar to that period of life. Esquirol frequently refers to the dependence of various forms and phases of insanity upon changes in the reproduc- tive organs, the exacerbation of mental disease at the men- strual period, its inception at puberty or the menopause; yet rarely is a proof of the causative relation established by the restoration of a healthy mental state by gynecological treat- ment, and so only can the existence of a hystero-neurosis proper be proved. The studies of Hegar are most interesting: he has been attracted to these marvellous phenomena by his observation of ovarian disease, and has pointed out to the profession the importance which attaches to these symptoms, which, by their diversity, unite upon themselves the varying interests of all branches of the profession. Undoubtedly these phenomena are determined mainly by the influence of the ganglionic nervous system; to the uterine ganglia an irritation of the terminal fibres is commu- nicated, and thus the link is established by which the im- pulse can be directed toward any of the functional organs of the body, all organs of nutritive life being supplied with ganglia or a ganglionic plexus. The largest is in the pit of the stomach—the solar plexus—hence gastric neuroses are the most common, distention of the stomach, faintness, perverted appetite. The vagus, itself an important tract, is in direct connection with the ganglionic centres, and carries the uter- ine impulse to heart, lungs, and stomach; and no reflex, next to the gastric, is more common than the cardiac: palpitation, pain, and all the symptoms of heart disease. Few are more annoying than the bronchial, especially the asthmatic, attacks. This same nerve, so intimately connected with the gangli- onic centres, is the bridge which connects this system to the 20 GEORGE J. ENGELMANN. spinal and cerebral centres, and admits of the direct trans- mission of the uterine impulse to the brain, hence the nerve- pains and mental phenomena. The ganglionic system di- rectly follows the blood-vessels to the capillary circulation, so that we may readily appreciate the influence of uterine and ovarian impulse upon the circulation; the flushes, sweats, clammy coldness of hands and feet, are the expression given to uterine irritation by the vaso-motor nerves. No one neurosis is always referable to one and the same uterine or ovarian lesion, as far as I have observed. The irritation of the genital terminals I believe due to compression by the surrounding congested, hyperplastic edem- atous, or contracted tissues, and this is transmitted by the most available and homogeneous conductor to the point of greatest attraction. It may be likened to the electric current which seeks through the network of wires the largest metallic surface over the most perfect metallic connection. The irritation of the uterine terminals is transmitted over nerve- fibres which are already in a state of morbid activity, and is thus guided to the nearest ganglionic centre, or it seeks by the most direct path a responsive central plexus, which is itself in an unstable equilibrium, with heightened suscepti- bility to impression; why, we can not say. The effect of compression upon nerve terminals is more clearly demon- strated in the infantile convulsions, which disappear when the cause is relieved by lancing a gum or by stretching the prepuce. In osseous structures the immediate site can be determined, and the surgeon gives relief by opening the un- yielding canal. Yet I would not assume this as the one and only cause of genital neuroses, as is done by Ohr (" Genital Reflex Neuroses in the Female," American Journal of Ob- stetrics, vol. xvi, Nos. 1 and 2, 1883). The cause may be an exposure of the nerve as in an erosion, or a compression by congestion or hyperplasia from within, by a narrowing of the uterine canal by small growths, induration of the mu- cous membrane, or a flexion, from without by superimposed structures. Compression of the ovarian nerve-fibres is caused THE HYSTERO-NEUROSES. 21 in the same way, especially by induration, chronic interstitial inflammation, yet I have rarely traced a reflex symptom dis- tinctly to ovarian cause. This irritation of the terminal fibre may extend along the course of the nerve, and, if continued for a length of time, may result in a true morbid condition along the irritated tract. The continuance of such reflex neuroses after removal of the cause is well exemplified by the following case, which, at the same time, conveys to us most clearly the therapeutic principles which should govern the treatment of the hystero- neuroses : Case IV. Continuance of Characteristic Hystero-Neuroses of ter Removal of Uterus and Ovaries ; Cure by Galvanic Treat- ment of the Causative Uterine Terminals.—Patient was referred to the department for nervous diseases as an incurable—after failure of all treatment, local and general—by the surgeon who had, with signal success, removed uterus and ovaries to save his patient, who had been rapidly failing with the develop- ment of a sarcoma uteri. After the operation her general condition improved steadily, her strength returned, and she was enabled to resume her usual duties in the enjoyment of good health. Such uterine pains as had existed before disap- peared, or, at least, diminished, among others a not infrequent uterine reflex, a pain in heel and ankles. This well-being was of short duration. Although her physical condition seemed per- fect, the pelvic viscera in a most satisfactory state, certain of the reflexes—the hystero-neuroses which had existed before the operation, and had temporarily disappeared after the removal of the uterus—returned, and increased rapidly to an intensity hitherto unknown. The pains in heel and ankle spread to the foot, and became so severe as to interfere with her duties, and at times even to prevent walking or standing altogether ; and, what appears still more strange, other typical uterine reflexes, which patient had not known hitherto, made their appearance and attained unusual intensity, especially the burning heat in the top of the head. As before stated, her previous attendant had exhausted all efforts, and, failing to afford relief, referred his patient, as a hopeless case, to the nerve department of the 22 GEORGE J. ENGELMANN. polyclinic. Prof. Hermann treated the affected parts, apply- ing the sedative qualities of the electric current to the top of the head and to the feet. Now—mark the result—temporary improvement followed, all pains disappeared for some hours after each application, but invariably they returned, though less severe, and she was obliged to seek relief again and again. She was at least able to walk since under Prof. Hermann's care. I accidentally entered Dr. H.'s clinic while this patient was under treatment, and, as the doctor briefly recounted the symptoms, I assured him that he must refer the case to my de- partment—that this suffering was clearly a uterine reflex. I cannot deny that I was somewhat astonished by the informa- tion that uterus and ovaries had been removed ; nevertheless, I desired to see the patient, and Dr. H. kindly transferred her to my care. Vaginal canal and pelvic tissues appeared to be in good condition, but, as I looked upon the distressing symptoms as uterine reflexes, a corresponding treatment was accordingly inaugurated. Positive vagino-abdominal galvanism was applied 20 milliamperes, for four minutes, medium plate as negative pole on the abdomen. This treatment, directed to the irritated uter- ine nerves precisely as if the organ had been still in place, gave greater relief than all applications heretofore, and after the third seance the pains and burning in the head and the agonizing pain in the heels had almost completely disap- peared. The case is one of the most striking I have seen, and affords the most incontrovertible evidence of the continuance of reflex symptoms after removal of the exciting cause, and the dependence, in this case at least, of the reflex upon a morbid irritability of the uterine nerve-fibres, as proved by the treat- ment ; in others, such continuance may be due to a hyper- activity or hyperesthesia of the ganglia or nerve-terminals in the responding organ, as is especially the case in the eye. The result of the various treatments employed is characteristic of the therapic called for in genito-reflex neurosis : 1. Treatment of the symptom is useless. 2. Sedative applications to the nerve-fibres at the distal terminus, at the site of the symptom, may afford temporary relief. 3. To effect a cure the cause THE HYSTERO-NEUROSES. 23 must be removed, and if this be not possible we must resort to sedative action upon the causative uterine terminals. V. Cause. The exciting cause of genito-reflex neuroses is to be sought in an irritation of the terminal nerves, which is com- municated to connecting fibres of ganglionic or spinal nerves, and thus conveyed to the responding organ, and the reflex is excited by pressure upon or irritation of the nerve termi- nations within the uterine or ovarian tissue, caused by con- gestion, or by the distention of the peritoneal covering through enlargement of the organ. Either of these theories would seem plausible when we consider the coexistence of the reflex symptom and the uterine engorgement preceding the flow, which is especially marked in flexions and in chronic inflammations; the neurosis generally appears two or three days before the menstrual flow, during the period of engorge- ment, and continues for several days after its cessation, though it may cease during the continuance of the flow. 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 changes, disturbed men- struation, amenorrhea, this means of escape is not afforded, and the neurosis continues. A violent asthmatic attack is caused by a flexion of the uterus, and ceases within fifteen minutes after this flexion is overcome; the circulation is re- stored, but the congestion can be but little reduced in that time. The symptoms may result from the pressure upon nerve-terminals in the fundus by reason of the congestion following the obstruction of the venous circulation, or, what appears more likely in this particular case, it may be due me- chanically to pressure in the angle itself. In physiological as well as in pathological conditions, we may expect pressure upon nerve-terminals from congestion or hypertrophy of tissue at puberty, during menstruation and pregnancy, at the time of the menopause, and in disease; this may occur 24 GEORGE J. ENGELMANN. during the fluctuations in circulation previous to the final depletion, and when this takes place the reflex symptoms disappear. Tilt refers reflex symptoms mainly to the ovary; likewise Hegar; especially Schroeder, who urges the performance of oophorectomy for the relief of violent reflex symptoms, even, as he state?, if disease of the ovarian tissue cannot be detected. The uterus he ignores, and yet the great mass of cases which I have described as hystero-neuroses, and proved to be such by their disappearance upon treatment of the uterine disease, were mostly referable to the uterus—few to the ovaries. However great the influence which the ovary is generally supposed to exert upon the entire system, es- pecially the nervous organization of woman, my study of the hystero-neuroses has proved most conclusively that the im- portance of the ovary in this respect has been overestimated, and that it is the uterus in which the controlling influence centres. VI. Diagnosis. The differential diagnosis between the pathological state and a reflex neurosis—however simple it may appear to dis- tinguish between disease and the mere semblance of disease— is not always easy. The afflicted organ, in which the reflex neurosis appears, will be found in a perfectly healthy condi- tion, with no structural changes, yet the symptoms of disease are so well portrayed that the most expert will be deceived, as the structural changes, often slight even in disease, can not always be readily observed ; only the transparent struct- ure of the eye admits of ready differentiation. In other tissues it is often impossible to distinguish between slight inflammation and a distention of the capillaries due to vaso- motor paralysis; and many of the vaso-motor reflexes present all the features of the disease proper. The difficulty of diag- nosis culminates in the dermatoses in which phantom and disease blend ; the reflex symptom presents even the struct- ural changes of the disease, which itself is possibly only a vaso-motor effect. THE HYSTERO-NEUROSES. 25 It is the existence of neurosis or disease which must be determined; the peculiar nerve connections which lead to the reflex, however interesting from a scientific point, are of no importance to the practitioner. It is for him to deter- mine the absence of structural changes in the functionally deranged organ, in order that he may not annoy his patient by injudicious medication, and to detect the immediate cause of the disturbance in order that he may discover the morbid condition, perhaps otherwise not indicated, and by properly directed treatment relieve the reflex symptoms as well as the local disease in the causative organ. The existence of neu- roses can of course be determined by the absence of struct- ural changes in the afflicted part, but this is not always pos- sible. We must resort to other means. 1. A neurosis is probable and may be suspected— a. By the existence of violent symptoms without corre- sponding pathological changes or febrile reaction. b. By the existence of lesions, uterine or ovarian. c. By the failure of proper remedies to afford relief. d. By the aggravation of symptoms in the afflicted organ corresponding to exacerbation of uterine disease. 2. A neurosis is proven— a. If the symptoms are not aggravated by causes which are known to aggravate existing pathological changes in the organ affected. Thus, the use of indigestible food will not aggravate a gastric neurosis, while the most violent symp- toms may appear in response to a diet which would seem indicated in disease proper. b. If the symptoms are aggravated by causes from which exacerbation of uterine disease may be expected. c. Improvement of symptoms upon treatment of uterine or ovarian disease regardless of any interference with the or- gan in which the neurosis appears. d. By a cessation of symptoms upon improvement or cure of uterine disease. 26 GEORGE J. ENGELMANN. VII. Treatment. The treatment of the hystero-neuroses may be— a. Curative, by the treatment of the causative disease; and, b. Palliative, by the use of nervines and sedatives, or the direct action of electricity upon the irritated nerve-tract. a. The diagnosis established, the most satisfactory and correct treatment of a reflex neurosis, however violent, is the treatment of the causative uterine disease, regardless of the neurotic symptoms. Mild remedies to mitigate the severity of the symptoms may be employed, but permanent relief or cure can not be expected until efficient treatment of the causative disease is inaugurated. The neurosis may disappear after a few treatments with but slight amelioration of the genital trouble, or it may continue until an approximately normal condition is established. b. A reflex neurosis may be relieved, and even overcome, by the administration of nervines and sedatives and by the use of electricity, by the sedative influence of the current upon the irritated uterine terminals ; and, although this is by no means a method upon which reliance can invariably be placed, it is worthy of trial. Violent symptoms, such as bronchial or gastric reflexes, may yield to the bromides, but, unless a successful treatment of the uterine lesion ac- company this medication, a relapse is liable to occur. Since I have observed the instantaneous disappearance of persistent neuroses under the galvanic treatment of uterine or ovarian affections, I have repeatedly and successfully attempted their treatment by electric application to the uterine terminals, and I can say that, if it be of importance to relieve the neu- rosis as speedily as possible, this should be attempted, and as uterine treatment is inaugurated the sedative action of the current should be applied to the nerve-fibres in the causative organ. The morning-sickness of pregnancy still resists the per- sistent efforts of medical science, for the simple reason that THE HYSTERO-NEUROSES. 27 medication is persistently directed to the affected organ, and the phantom of disease is persistently plied with all the weap- ons from the great arsenal of our materia medica. Even in this simple case the strict causative relation of the reflex symp- toms to the uterine condition is unheeded. Like all reflex neuroses, the morning-sickness and often the violent vomiting of pregnancy yield readily and positively to local treatment. If it be a pathological neurosis, originating in a congested condition of the cervix, an erosion, or an endocervicitis, it can easily be overcome. If it be a pathological neurosis due to distention of the uterus, a scarification may prove efficient; but to a certainty this symptom will yield to an evacuation of the uterine cavity. We have no better example than the gastric neurosis of pregnancy for guidance in treatment of the hystero-neuroses. Relief of the most violent vomiting may be obtained by a single application of carbolic acid to the cervical canal or of a tannated tampon to the eroded cervix. It may not yield at once: a prolonged treatment of the local lesion may be necessary, but the symptoms are mitigated as local improvement is obtained. Heroic medication of the stomach is not only useless but injurious. Nervines and sedatives may afford relief, not by medication of the gas- tric mucosa, but by allaying the irritability of the nervous. system. A complete deadening of the gastric nerves by cocaine will, as a rule, afford only temporary relief, while this astringent sedative applied to the cervix is more likely to attain the desired result. It is by action on the uterine terminals that the rebellious stomach must be quieted, and not through the gastric nerves. If gastric medication were abandoned and uterine treatment inaugurated, little difficulty would be experienced with this frequent and annoying symp- tom, which the obstetrician is glad to escape; so much so that, in one of the latest and most able works, the author ad- vises the phvsician to send the patient to her mother-in other words, get her out of the way, and don't attempt treat- ment—and Lusk gives the same view of the subject. Cure is certain, but through the uterus only; and, if other means 28 GEORGE J. ENGELMANN. fail, premature labor must be inaugurated. Gastric medica- tion as an adjuvant is not contra-indicated, but violent treat- ment of the stomach must be condemned as useless and ruinous. Schroeder advises the removal of the ovary, notwithstand- ing the absence of structural changes, for the relief of these perplexing reflex symptoms. It is now generally accepted that removal of the ovaries is only admissible after all efforts at treatment have failed, and, let me add, after the sedative action of galvanism has been tried. But, as the cause is by no means in the ovaries alone, the patient can not be certain of relief even after she has made this sacrifice, and has risked her life upon the assurance of her physician that oophorec- tomy is her only hope. The uterus is more liable to influ- ence the system and to determine nerve-reflexes than the ovary. This position has been proved by those cases in which suffering continued after removal of these organs, and, be- cause the neurosis in other cases has abated in time, the advocates of this course claim justification. I believe that relief may be so obtained, though the causative lesion is uterine and not ovarian, as the indirect effect of oophorec- tomy. Involution follows this operation, a lessening of the uterine impulse results, and hence we may expect relief, though the ovary itself is not directly causative. VIII. Prognosis. The prognosis in a hystero-neurosis, however violent, is favorable, as a rule, though it is impossible to predict with certainty. Until the immediate cause — the local nerve- lesion—is revealed, the prognosis is shrouded in mystery, and can be told by the result of treatment only. At times, relief of the most violent symptoms is sudden, the result of a trifling interference without any very apparent im- provement in the local condition: a single astringent ap- plication, a rectification of position, may cause the most annoying symptoms to vanish. Again, it is slow, coming only with visible improvement in the uterine condition. I THE HYSTERO-NEUROSES. 29 have seen the most distressing epileptiform attacks cease instantaneously upon a dilatation of the uterine canal; a persistent melancholia, with excessive nervous irritability, yield within a few hours after the closing of .a lacerated cer- vix ; even a sallow, sickly hue of the face, which had persisted for years, change within a few days to a fresh, bright com- plexion after a conical excision of the cervix for the relief of laceration and hyperplasia. The vomiting of pregnancy, which had emaciated the sufferer to the last degree, ceased upon the application of the tannated tampon; likewise a pes- sary or a tampon properly applied will produce an immediate response in lung, heart, or brain. I have seen an agonizing asthma cease shortly after the placing of a pessary, intense cardiac pains and insomnia vanish upon the insertion of a tampon, and a single application of electricity cause a violent dyspnea with great nervous depression to disappear, even during the application, while the patient was still upon the table, though haunted by suffering and reduced to invalidism for over two years. Again, the improvement comes but slowly with restoration of a healthy condition of uterus and ovaries; or, if it has existed for any length of time, the neu- rosis may abate but slowly, to cease long after the local lesion has been overcome. This is especially noticeable in those neuroses and psychoses resulting from laceration of the cer- vix and its sequences; as, after oophorectomy, the neurosis may not disappear until many months after the performance of Emmet's operation ; but, as a rule, unless it has been most violent in character, and has. continued for a long term of years, complete restoration of healthy functional action and permanent relief may be expected upon proper treatment of the causative uterine lesion ; but, if the neurosis has been severe and long continued, a weakness of the nerves impli- cated may remain, and the morbid action of the governing ganglia so long continued may be perpetuated. In a case of gastric neurosis, which had continued for eight years, I was astonished to find the stomach in a fairly healthy condition, notwithstanding eight years of medication and diet, and the 30 GEORGE J. ENGELMANN. constitutional debility of the patient. A certain weakness may be expected to remain in those cases, and in some a perverted nerve-action is likewise perpetuated. Even violent psychoses, such as mania, melancholia, and epilepsy, will dis- appear completely upon relief of the uterine lesion, but the reflex neuroses of the eye offer a less favorable prognosis; if continued for a length of time, a weakness of that important organ is likely to remain, and, in certain forms of ophthalmic neurosis, though of short duration, functional changes are perpetuated. With this exception, the prognosis of the reflex disturbances, referable to the female reproductive or- gans, is an excellent one, provided the part be not abused by misdirected treatment, and the efforts of the practitioner centre upon the causative genital condition. PART II.—SPECIAL. HYSTERO-NEUROSES OF INDIVIDUAL OEGANS—THE VARIOUS KEFLEX FUNCTIONAL DISTURBANCES REFERABLE TO THE FEMALE SEXUAL APPARATUS. I. Nervous System. The impressionable nervous system of woman is the most susceptible of all organs, and responds most readily to periph- eral irritation ; every vibration of the nerve-fluid in the genital terminals meets with a sympathetic reverberation, and is often re-echoed a hundred-fold in the spinal arid cere- bral centres, which reflect even the physiological action of the reproductive organs. During the entire period of female sexual life, variations of any kind in these great centres, in which the functional life of woman is concentrated, evokes ready response in the nervous system. So intimately are these two most potent factors of the female organism linked that, while the nervous system signalizes uterine and ovarian changes, the sexual organs respond readily to central vibra- tions ; nervous debility is marked by leucorrhea and uterine pains; powerful nerve-impressions by hemorrhage or cessa- tion of the physiological flow. THE HYSTERO-NEUROSES. 31 Perverted action of the nervous system, which appears as a reflex symptom in response to a morbid uterine or ovarian stimulus, may be either central, on the part of the brain, or peripheral, on the part of the spinal nerves. The peripheral neuroses or nerve-pains are more common as constant or pathological neuroses, referable to uterine or ovarian disease; while the central neuroses, psychoses, more frequently sig- nalize physiological waves, and result from the powerful impressions made by the great epochs in the functional life of woman, puberty, menstruation, parturition, and the meno- pause. a. The Brain ; Cerebral Hystero-Neuroses or Hystero- Psychoses. Uterine and ovarian disease is frequently characterized by nerve-depression or irritability, loss of memory, insomnia, or uncontrollable desire for sleep in the daytime, vague fear of misfortune, and dread of insanity. These are the mildest and most common of the central reflexes. Perversion of the moral sense, epileptiform attacks, melancholia, and mania are the more severe forms which are referable to the physi- ological changes, menstruation, parturition, and the meno- pause. It is difficult to draw the line between ganglionic reflexes and true cerebral symptoms. The neuroses present so true a fac-simile of the diseases which they simulate that the differential diagnosis is difficult. Continued observation or treatment, the recurrence of an attack with each menstrual period, or the improvement of the condition upon the inau- guration of uterine treatment, indicate that it is a reflex symptom, a neurosis, and that all therapeutic efforts must be directed toward the relief of the uterine disease. I must emphasize that I confine myself exclusively to those symp- toms which are proved to be strictly dependent upon uterine or ovarian irritation, and respond to changes in these parts as readily as the electric bell does to pressure upon a distant button. These psychoses, though presenting a complete per- version of moral and mental faculties, are distinguished from 32 GEORGE J. ENGELMANN. the true central lesion by the favorable prognosis of the one and the dark future of the other ; while the reflex symptoms readily yield to proper uterine treatment, the true psychosis is of a much more serious nature. While the fact has always been appreciated that a certain relation exists between the impressionable mind of woman and the reproductive organs, while it has been well known that the diseases of the mind in their development and in their various phases are closely connected with the vibrations of sexual life, but little posi- tive evidence has been introduced as to the direct dependence of the mental state upon the uterine condition, much less have those forms of insanity been defined which are mere reflections of functional derangement or of disease and mal- position of the womb. I must say, as I did in my first paper on the hystero-neuroses, that the causative connection, though vaguely evident, has as yet been distinctly defined by only a few. Alienists have always acknowledged an influence of the sexual organs upon the mental functions: all works on in- 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 dis- orders of the sexual organs. . Such cases may be entirely excluded, as venereal excite- ment is not only not an indication, but even a rare concomitant, of the hystero-psychoses. Other alienists, however, relate well-marked cases, which distinctly show the causative con- nection, and insist on the importance of uterine examinations in the treatment of the insane. Esquirol especially refers to the frequent exacerbations of mental disease, its occurrence and recurrence at the period of functional activity in the reproductive organs ; yet he does not appear to appreciate the immediate causative relation, and certainly does not limit his treatment to the treatment of the uterine state, nor does he even lay stress upon this. Gyne- THE HYSTERO-NEUROSES. 33 cological text-books give us but little information upon this point. Our earliest knowledge we owe to Louis Mayer,1 of Berlin, Fordyce Barker, of New York, and Horatio Storer,2 of Boston. But within the last decade both gynecologists and alienists have been attracted to the intricacy and im- portance of these peculiar phenomena; from the great num- ber of striking but still unexplained observations, we shall soon be able to determine with greater certainty the extent of the influence exerted by the genital changes upon the mental state, and the accumulated evidence indicates an un- doubted causative dependence in certain cases. Among the numerous publications which have resulted, I must note one of the peculiar positions taken: Gynecology, Neuroses, and Psychoses: a Protest against Reckless Gynecological Treat- ment for Nervous Disorders, L. Bremer, M. D. Does it not appear strange that an alienist should complain of the encroachment of the gynecologist, as injury can be done only by an ignoring of the reproductive organs % If uterine dis- ease should exist as a concomitant of mental aberration, local treatment of the existing disease is unquestionably indicated, whether the psychosis be in any way dependent upon it or not; if a morbid condition of the reproductive organs exists, this must be relieved, whatever its relation be to the mental disturbance, and, should the latter be a resultant reflex symp- tom, the only possible correct course has been taken. No harm can be done by treatment of a uterine lesion when co- existing with mental disease, and, though there be no direct causative relation, the mental disturbance will often improve, as it does with the improvement of any functional derange- ment—as an exacerbation takes place during the period of uterine congestion, during menstruation or pregnancy, though there be no direct causative connection. But the alienist who overlooks a causative local lesion, and treats a reflex symptom as a true psychosis, does his patient a criminal wrong. It is, 1 " Die Beziehungen der krankhaften Zustande und Vorgange in den Sexual- Organen des Weibes zu Geistesstorungen," Berlin, 1869. 2 Storer, Tlie Course and Treatment of Reflex Insanity in Women. 3 34 GEORGE J. ENGELMANN. perhaps, a difficult task to eliminate the hystero-psychosis prop- er—those cases of mental alienation which have been proved to be dependent upon and caused by uterine disease ; if they are not rare, they are at least little known as yet, and will remain so until uterine examination and therapeutics become an acknowledged factor in the treatment of the insane ; the relation can be established with certainty by the crucial test of treatment only. The nervous system and the reproductive or- gans—these two governing centres of female life—co-respond even when not in direct causative relation. A sympathy ex- ists, as it is marked by the exacerbation of mental disease with pregnancy, menstruation, and the menopause, hence it is difficult, if not impossible, to determine fully the precise relationship and to differentiate between direct causative con- nection and mere correspondence or sympathetic exacerba- tion. 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 irregu- larities in the functional activity of the sexual 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 ab- erration but trifling. Incipient mental derangement was gen- erally accompanied by the appearance of some abnormity 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 de- pendent upon, the psychoses. 1 "Das Verhalten der Menstruation bei Psychosen," Beitr&ge zur Geburts- hulfe und Gynakologie, III, 3, p. 293, Berlin, 1875. THE HYSTERO-NEUROSES. 35 Classification.—While we may classify the hystero-psy- choses, like all of the neuroses, as constant or pathological— those due to morbid conditions, on the one hand, and on the other those accompanying the physiological states of puberty, menstruation, parturition, and the menopause—it is true of this group, as it is of all hystero-neuroses, that the impression is often referable to a pathological condition, more or less marked, to which the nervous system has accommodated itself, and hence it responds only to the exacerbation of this pathological state by the additional impulse of the physio- logical congestion. The indications for the treatment are correspondingly well defined: a search for the existing uter- ine deviation and relief, or, at least, relief of the temporary congestion, and, if this prove ineffectual, a systematic quiet- ing of the uterine nerve-terminals by the galvanic current. I cannot refer certain of the mental conditions to certain uterine or ovarian lesions, though one period seems to tend more to the development of one psychosis than another. But, if a weakness exists, a tendency to a certain form of cere- bral disturbance, this will be developed by a morbid inten- sification of the uterine stimulus, and, though it be allayed and a healthy action restored, the chain is established, and the return of genital irritation, at however late a period, will be marked by the same cerebral response. The woman who in childhood has been affected with chorea may expect a return of the disease with the advent of puberty or of pregnancy, if her nervous system be in a sensitive state, or a pathological variation accompany the physiological conges- tion of the sexual organs. A psychosis which has appeared at puberty may be looked for as an accompaniment of the menstrual congestion or the menopause at any time that cir- cumstances occur which favor a morbid hyperactivity; the intense nervous excitement of menstruation may develop into maniacal symptoms with the increased congestion of pregnancy. I have seen symptoms of melancholia develop with the advent of puberty in a girl who had inherited an excessively sensitive nervous system, which had caused her 36 GEORGE J. ENGELMANN. much annoyance in childhood; I have seen both melancholia and mania developing in one parturition repeated at the next; but, what is more sad, a maniacal attack which had persisted for three months at puberty, and had left the mind of the sufferer free throughout all her functional life, returns at the menopause, and, under peculiarly unfavorable external conditions, threatens to become permanent. Had the sur- roundings been favorable, as they were at the time of pu- berty, I am sure that this second attack would have passed off as readily as the first. I can but quote the words of For- dyce Barker, in speaking of those cases of insanity which are developed immediately after marriage, as the most pitiable of all the conditions under which insanity is developed as a reflex irritation of the brain from disease of the sexual or- gans ; and here, again, I recall such recurrence, with the first nuptial embrace, in a bright, healthy, happy bride, of an attack of melancholia, to which she had been a victim dur- ing two months at the time of puberty. Symptoms.—Phases of mental or nervous derangement, well known to every physician, which reflect a morbid state of uterus or ovaries, are the nervous prostration or great nervous irritability which form so common an accompaniment of pelvic disease, and are so indicative of functional changes. Tilt finds these conditions in four hundred and fifty-nine out of five hundred of the,patients examined by him for irregularities during the menopause. This lack of energy, listlessness, and nervous depression, as well as excessive irritability, are perhaps the most frequent of the mental re- flexes ; then comes the loss of memory, insomnia, or an irre- sistible desire for sleep during the daytime; a depressing fear of something terrible about to happen. A dread of in- sanity, though a frequent resultant from uterine disease, is one of the most common psychoses of pregnancy, and a sad burden to the young wife who is oppressed with the vague fear of death, and, instead of looking forward with joy to a happy future, she is in tears, depressed, certain of a fatal termination of the expected labor. Complete change of the THE HYSTERO-NEUROSES. 37 mental and even the moral state is a reflex common alike to disease and physiological changes. A girl with a bright, happy disposition, becomes depressed, downcast with the ad- vent of puberty, to resume her natural cheerfulness when the menses have been fully established ; an amiable, cheerful woman becomes discouraged, dissatisfied, believes herself deceived by her friends, offends and insults those nearest and dearest to her during the exacerbation of uterine disease by the menstrual congestion ; a bright disposition yields to peev- ishness or melancholia through disease or the physiological changes of pregnancy or the menopause. The more intense psychoses, deep-seated melancholia, and mania, are more lia- ble to reflect the intense physiological changes of parturition, puberty, or the menopause, and these intense morbid delu- sions find expression in suicidal attempts or murderous at- tacks upon a new-born infant. Delusions are often referable to pathological changes, but become more marked by the increased stimulus of menstruation or other physiological con- gestions ; hence they are more frequently referred to these conditions than to their true cause, the pathological change in the reproductive organs. We are guided in our diagnosis of a hemiplegia or a paraplegia, reflex in its nature, by the fact that the disease proper is most liable to occur in old age, while the symp- toms as a reflex psychosis appear most commonly in the young. In the male child, it is almost a characteristic mark of the adherent prepuce, while in infants of both sexes it may appear as the result of intestinal irritation; again we see these symptoms as an accompaniment of puberty con- tinuing until a healthy functional activity of the reproduc- tive organs is established. Like chorea, aphonia, lameness of the limbs on one side, more or less marked hemiplegia, paraplegia, but most commonly the former, are found most frequently during the period of development. Numbness, tingling of the extremities, especially the fingers, are more likely to appear as an evidence of disease. Among these psychoses are the maniacal attacks which reflect the intense 38 GEORGE J. ENGELMANN. genital stimulus of marriage and parturition, the melancholia of puberty, the thoughts of death which haunt the expec- tant mother, and the mental and moral perversions so fre- quently accompanying uterine disease; the latter are char- acteristic as well of the inauguration of woman's sexual life as of the terminal period, during which love is changed to hate, a kind, gentle disposition to one that is treacherous and malevolent. As Tilt has already told us, much domestic unhappiness is due to morbid uterine stimulus : as an ugly disposition takes the -place of one heretofore passive and gentle, the kindly mother grows indifferent to her child, the thrifty housekeeper appears as a spendthrift; in short, the good qualities are perverted, and such evil impulses as may have lain dormant take full possession of the unfortunate victim. I have cited only such of the psychoses as I have my- self observed, and, as is but natural, these are the less vio- lent—the more intense are referred to our alienists ; and, unfortunately, notwithstanding all that has been written, the full importance of these reflexes is by no means suffi- ciently appreciated by them, and patients, who are brought to the asylum or to the specialist with maniacal attacks, or the more marked forms of mental disturbance, are treated for the disease which is so closely copied by the reflex phantom. The full bearing of the reflex irritation is not acknowledged, and they are dosed with nervines, while the speculum, by which the causative disease may perhaps be easily relieved, is not thought of. Hence, with the exception of puerperal mania, and those comparatively rare attacks which occur while the patient is under the care of gynecologists, those who suffer from this phantom disease are merged with the great mass of the insane or the mentally afflicted, and, not- withstanding the observations and the writings of such keen observers as Esquirol, Mayer, and others, who constantly call attention to the undulations of mental symptoms with the functional waves of reproductive life, the positive depend- ence is not established; hence the key to the relief of the THE HYSTERO-NEUROSES. 39 fettered mind is not yet found, and it is impossible to say how frequent are the more violent of the reflex psychoses. Violent epileptiform attacks, among the most intense of the reflex symptoms, and as a rule referable to pathological conditions, occur also as the accompaniment of pregnancy and menstruation, but even when appearing at these times they are mostly due to morbid changes in the uterus. Case V. Aphonia, Chorea, and Hemiplegia due to Amenorrhea during the Advent of Puberty. — Miss X., from Buffalo, who had suffered from a light attack of chorea minor during early childhood, was brought to me with many of the symptoms of hemiplegia, an aphonia which was complete for hours at a time, and a slight return of chorea. Being an only daughter, an unusually sweet and amiable child, and treated for several months without benefit, her mother was in great distress. The diagnosis, however, was simple : the girl in her fourteenth year had grown rapidly, and was fast approaching womanhood ; her figure was de- veloping, a faint flow had appeared several times at irregular intervals. The symptoms varied greatly in intensity, with the most complete semblance of disease when under the in- fluence of the emotions, or after bodily exertion ; the move- ments of the tongue were at all times imperfect,.but, when tired or excited by an unexpected noise or the sudden entry of a visitor, the aphonia was complete: at times the limbs re- laxed as if paralyzed, at times they twitched under the uncon- trollable tremor of chorea. She had been treated for several months with such remedies as are usual in cases of chorea, and, as is so commonly done with young girls suffering with the symptoms, direct or indirect, of uterine disease, she was urged to take exercise ; in the earlier stages of the disease to ride, to see as much company as possible ; mind and body, both in need of rest, were forced to exertion, and the irritation of the sexual organs was increased. I looked upon the symptoms as purely of a reflex nature, and they were proved to be so by the good result of the treat- ment, directed only to the establishing of the menstrual function. Abdominal and spino-abdominal faradism was applied, as I be- 40 GEORGE J. ENGELMANN. lieved it right to attempt this, and not to inaugurate a direct uterine treatment unless absolutely necessary ; at the same time, the current was applied to the spinal column, the cervical nerves, and the throat. But, although this may have afforded relief, the cure is unquestionably due to the development of a healthy menstrual function by abdomino-spinal faradism. Within six weeks, the young lady left for her home with full control of all her muscles, the menstrual flow free, without a trace of the symptoms but a short time ago so threatening. Case VI. Psychosis and Neurosis of Puberty. Left Hemiplegia, Partial Aphonia, Choking Sensations, Tingling of the Extremities, Mental Depression, due to Amenorrhea during Puberty.—Miss L., from Alabama, a young lady of sixteen, of good figure, but imperfectly developed, presented a case similar to the last, the chorea of the one being replaced by a hemiplegia, at times well marked, in the other. Although the amenorrhea might have been referable to chlorosis, the existence of an endocervicitis and slight endometritis, with aggravated virginal anteflexion, rendered the dependence of the distressing reflex symptoms upon morbid uterine conditions more plausible, and the retarded development seemed referable rather to the dis- turbance in the genitalia. The correctness of the diagnosis was soon verified by the result of local treatment: utero- abdominal faradism, vaginoabdominal faradism for the pur- pose of stimulating functional activity of uterus and ovaries, and negative utero-abdominal galvanism, with cunents of 15 to 25 milliamperes (5 minutes, cotton-wrapped applicator as negative pole in utero, medium plate as positive pole on abdo- men over fundus, 9 volts), as a direct uterine stimulus, and a mild alterative application to the lining membrane. Tonics were also given. After the second treatment the menstrual flow appeared, the first in the past six months, and with it came an amelioration of all the symptoms: heaviness of the tongue and hemiplegia disappeared; choking sensations, tingling in the extremities, though lessened, still persisted, and yielded but slowly during the six weeks' treatment, disappearing with the endocervicitis. The cure of the slight uterine abnormity, the improvement in the circulation of the pelvic viscera, first marked by the coming of the menstrual flow, seemed as by a THE HYSTERO-NEUROSES. 41 sudden impulse to stimulate retarded development; this girl, in whom the period of puberty had so long continued, bloomed forth all at once, and the child that came returned to her home a woman, as her mother wrote to me. In this case the symptoms were in part due to imperfect ' functional activity, in part to morbid conditions ; the more marked psychoses, melancholia, and hemiplegia yielded at once with the appearance of the monthly flow, while the tingling of the extremities and choking sensations, being dependent upon the endocervicitis, resisted until this had been relieved. Case VII. Menstrual Psychosis; Melancholia with Mani- acal Attacks accompanying the Menstrual Congestion, Con- tinuing for Ten Days, returning regularly with each Period after the First Appearance of the Psychosis immediately after Marriage; Uterus Duplex; Retroversion; Endometritis; Partition of the Vaginal Canal. Treatment of the Local Lesion regardless of the Mental Symptoms. Cure.—Mrs. K., from Illinois, farmer's wife, twenty-four years of age, strong, of good constitution, and well developed ; can recall no symp- toms in her earlier life indicative of uterine or mental disturb- ance with the exception of slight menstrual pains. Consum- mation of the marital rights was followed by an attack of melancholia, a strangely changed mental condition, and this attack returned with each menstruation, continuing for a period of from eight to ten and sometimes fourteen days ; she was depressed, sad, the symptoms, as described by her husband, giving evidence of a well-marked melancholia. She seemed to attend mechanically to the more necessary house- hold duties, being perfectly rational in the brief inter-men- strual period, in full control of her mental faculties, willing and able to attend to her work—to all appearances, in perfect health and sound in mind. During the last months her melan- cholia—this reflex menstrual psychosis—began to assume a more threatening aspect, taking the form of low maniacal attacks. The usual treatment had been inaugurated, the attending physi- cian evidently regarding the case as one of mental aberration. Dr. Binney, of Mount Olive, Illinois, being consulted, was at once led to suspect the reflex nature of the disease by reason of the monthly recurrence and its development at the time of 42 GEORGE J. ENGELMANN. marriage, the local lesion being indicated by the existence of spinal and hypogastric pains, and hence he referred the patient to me. January 13, 1887, I saw this lady for the first time. Ex- amination revealed a uterus duplex ; both fundi enlarged, on the floor of the pelvis, retroflexed, and retroverted ; the external os and cervical canal in each very narrow, and the endometrium diseased. Treatment, however, was impossible until the vagi- nal septum had been removed, as it rendered the organ on the left inaccessible. January 14th, the vaginal septum was excised under anti- septic precautions, and the electro-cauterization of the cavities of both uteri undertaken. The negative pole, a delicate copper probe, with a current of 50 milliamperes, was applied to the endometrium ; and after this the largest possible instrument, an ordinary sound, was introduced into the cervical canal with a current of 100 milliamperes, for three minutes, and forced toward the internal os, for the purpose of dilatation. The bowels had been thoroughly evacuated, the parts were dusted with iodoform, the fundus elevated with the elastic tampon, and the patient instructed to lie in the semi-prone position. Before the wound had healed and before further treatment was possible, the menstrual flow came on without any of the usual accompaniments, without any untoward symptoms, direct or reflex ; the patient was comfortable and quite rational, per- fectly quiet, not even nervous, and her eyes clear and bright. During the following inter-menstrual period, she remained in the hospital department of the polyclinic, and treatment was continued : galvanism, negative electro-cauterization of the en- dometrium, with mild astringent applications, and the elastic tampon to overcome the displacement. Mrs. K. proved one of the most satisfactory patients we have had under treatment. Careful in obeying instructions, quiet and clear-headed, entirely free from the annoying ner- vousness so common to uterine disease, the local condition rapidly improved ; a second menstrual period passed off with- out the slightest evidence of any irregularity either direct or reflex, uterine or cerebral. The patient was not dismissed, however, as I desired to keep her under observation until a THE HYSTERO-NEUROSES. 43 perfectly normal condition of the pelvic viscera was attained. Devotedly attached to her husband, she gave way to an intense home-sickness against which she had long struggled. Daily she grew more anxious to return to her home, and this intense anxiety culminated in a relapse into that state of melancholia which had previously been the accompaniment of the men- strual congestion. Her husband was telegraphed for, but before he arrived reason had fled. In this patient the severe nervous strain, which in others would have led to irritability, exacerbation of local or general symptoms, resulted in a return of the melancholia which here- tofore had appeared only in response to the morbid uterine stimulus when intensified by the menstrual congestion. The force of the uterine irritation had been allayed by improvement in the existing morbid condition, so that it proved powerless to evolve a response even under the heightened pressure of the menstrual excitement; but the tension of the nervous system, strained to the utmost, was such that it proved unable to resist the influence of even the greatly diminished local irritation: before, it had been the stronger pressure upon the trigger which caused the explosion, now it was the weakening of the spring which forced it to yield to but trifling pressure. Believing that under favorable conditions no relapse would occur, I urged her immediate return home, as the cause of her trouble was evident, homesickness ; her condition was one of melan- cholia, tending to mania. Unconscious of her surroundings, her eyes unsteady, without the light of reason, she recognized no one but her husband, for whom she constantly called, and whose momentary absence caused a wild despair. My diag- nosis was verified : upon his coming and the promise of a speedy journey homeward, she at once became quiet, and with- in a few days reason returned. Her health has been greatly improved, she no longer complains of pelvic pains, and several periods have passed without either local or reflex symptoms, with a mind clear and unruffled. Case VIII. Violent Epileptiform Attacks during Pregnancy relievedby Cauterization of the Eroded Cervix}—Mrs. O., aged twenty-eight, menstruated at the age of fifteen, married at 1 " A Hystero-Pyschosis," St. Louis Clinical Record, 1878. 44 GEORGE J. ENGELMANN. twenty-four, has always been healthy ; gave evidence of no hereditary taint; menstruation, perfectly normal before and after marriage, is never painful ; has had one miscarriage in the sixth week, soon after marriage ; has since borne two children, the youngest of which is eighteen months old. A few wreeks after the last confinement she first complained of that heaviness of the head, with dizziness and languor, from which she has suf- fered ever since, together with epileptiform attacks which appeared at about the same time—at first in a very mild form, once or twice a month, as an oppression of the chest and a shortness of breath, which would pass away in the course of five or ten minutes. These attacks rapidly increased in fre- quency and in severity, always beginning in the same way with a shortness of breath, with an oppression of the chest—a feeling of constriction—then twitching of the fingers with spasmodic closing of the hands, and she becomes unconscious ; convulsive motions of the arms and opisthotonus follow. This is sometimes so intense that the heels almost touch the head, and the contraction of the dorsal muscles has been so sudden and so violent that the patient has hurled herself from the middle of the bed upon the floor by a single effort. Dur- ing the attack, which lasts from ten to fifteen minutes, she is totally unconscious, the eyes closed, hands not firmly clinched, thumbs not turned in ; then a state of relaxation follows. During the last month she was confined to her bed, the attacks were severe and quite frequent, and her condi- tion grew constantly more unbearable notwithstanding the lib- eral use of chloral and bromide of potash, which were properly prescribed by the physician in attendance. As the patient did not improve, Dr. H. Greiner was called in. He pursued a simi- lar course of treatment, adding opium injections. By an over- sight on the part of an attendant a teaspoonful of the strong tincture of opium was administered internally, but even this did not check the attacks, which appeared three or four times a day, continuing with great intensity from ten to fifteen min- utes at a time. March 18, 1878, I first saw Mrs. O. in consultation with Dr. Greiner. We had hardly entered the room when her hands began to twitch nervously, her eyes closed, her head was THE HYSTERO-NEUROSES. 45 plunged backward and buried in the bedding in violent opis- thotonus. The spasm yielded for a moment, to return with increased severity, with violent contractions of the dorsal mus- cles, hurling the patient from one side to the other, so that she was with difficulty held down by the combined efforts of those about. After the attack, which had lasted twelve minutes, a stupor supervened. Her husband was constantly by her side, as in these convulsive contractions, by which she was bent almost into a circle, she was in danger at any moment of hurl- ing hei'self from the bed, as if thrown from a spring-board, and it was only possible for her husband to prevent injury by hold- ing her in his arms until the muscles relaxed, catching her as she bounded upward, head and feet almost in contact. Upon recovering, she complained of dorsal and hypogastric pains and heaviness of the head, which had persisted for weeks, with occasional nausea and vomiting, more particularly in the morn- ing ; the conjunctiva was slightly injected, the pupils normal, their reaction perfect but slow ; she had a dull, stupid look, and was slow in her answers. The uterus was enlarged, the cervix lacerated, eroded, and congested, the erosion sensitive ; one period had been missed. The eroded cervix was thoroughly cauterized with nitric acid, and a glycerine cotton tampon with tannic acid was introduced into the vagina. With the exception of a slight spasm on the evening of the 18th, the epileptiform attacks did not recur from the time of the application of the nitric acid until the 22d, notwithstanding the discontinuance of all sedatives. On the 24th the patient had a severe attack, for which Dr. Greiner was obliged to resort to chloroform. This was the last, but nausea and vomiting steadily increased until, on the 26th, they had become most dis- tressing, but this I looked upon as a reflex of pregnancy. A sponge-tent was introduced in order to favor the expulsion of the ovum which occurred on the 31st. I did not see the patient until two days later, and found her remarkably changed : her complexion was better ; she had lost that pale, bleached appear- ance and distressed look ; the vomiting had ceased with the dilatation of the canal and the expulsion of the ovum, and the epileptiform attacks had yielded instantaneously to the cauteri- zation of the cervix, returning but once in a severe attack on 46 GEORGE J. ENGELMANN. the 24th. Two weeks after the miscarriage Mrs. O. was attend- ing to the lighter duties of the household, feeling more vigor- ous and more cheerful than she had at any time since the birth of her last child, to which the laceration and erosion are referable. In this case we have an hystero-epilepsy proper in a most aggravated form, of sixteen months' duration, checked by a single application of nitric acid to the eroded cervix, and cured by the second. Co-existing are the nausea and vomiting, the reflex gastro-neurosis of pregnancy, which yielded only to the dilatation of the canal, and was in no way affected by the cauterization which overcame the psychosis; the lat- ter evidently referable to the erosion of the cervix, the former to the congestion of the muscular tissue or lining membrane. Two years later I saw this patient under precisely similar circumstances, with the same terrible epileptiform attacks, but, though the symptoms abated after the same cervical applica- tion, they were in this second case not overcome until the canal had been dilated by the sponge-tent, and complete re- covery did not take place until after the expulsion of the ovum; proving that in this attack the psychosis—which had before been referable to a morbid condition, the erosion of the cervix—was in this instance clearly dependent upon the pregnant state. Case IX. Recurring Puerperal Melancholia.—Mrs. X., wife of a confrere, a healthy matron of twenty-nine, happy in all her surroundings, free from all evidence of pelvic disease, began to show symptoms of mental aberration in the second week of her first confinement. A local cause was sought for, and remnants of placental tissue removed, yet no change took place. Constitutional treatment proved ineffective ; local appli- cations were not possible on account of the condition of the patient, and not permitted by her; a deep melancholia, varied at times with maniacal attacks, followed, and not until involu- tion had been completed did any improvement take place. With a restoration of a normal condition of the reproductive THE HYSTERO-NEUROSES. 47 organs the mental faculties returned, and the patient continued in the best of health, robust in body, cheerful in mind. Three years after this period conception again occurred, pregnancy was marred by no unfavorable symptoms, and labor progressed favorably ; a healthy child was born, but within a few days a return of the same symptoms was threatened, and for two months the patient was guarded with the utmost care. No explosion occurred, yet she was constantly upon the verge of mental alienation, and not until involution had taken place did a healthy state return. The case is an exceptionally well-defined example of a re- current physiological reflex, the psychosis appearing during the puerperium, independent of pathological conditions, and con- tinuing throughout this entire period, notwithstanding all that the love of a devoted husband and the care of watchful nurses and expert physicians could do, and recurred with the return of similar physiological conditions in a healthy body, with a healthy mind and healthy reproductive organs, notwithstanding the precautions taken to avert the expected and dreaded con- dition. Case X. Recurring Physiological Hystero - Psychosis. Melancholia with Maniacal Attacks accompanying Puberty and the Menopause.—Mrs. K., a bright, sunny girl in child- hood, gave way to melancholia in her sixteenth year with the advent of puberty. For some three or four months she was in a state of religious mania, shrinking from contact with the world, fearful of hurt or accident, singing psalms, and begging her family to join in her religious exercises ; with full develop- ment of the menstrual function, a normal mental condition returned. During an active life, a healthy condition of mind and body was retained, even during menstruation and preg- nancy ; but, as the menopause approached, occasional attacks of a similar nature recurred, as patient was in a state of con- stant mental anxiety, and haunted by fear in her domestic infelicity. Her marital relations were not happy : she was in great dread of her husband, who threatened and maltreated her, and with the cessation of the menses this condition became one of mania. At times in great fear of others ; always ex- pecting an accident; fearing, if her children were out at play, 48 GEORGE J. ENGELMANN. "that the trees would fall upon them, or that lightning would strike them" ; above all, she was in dread of being buried alive. Religious conceptions gave color to her delusions, but in the maiu they were governed by fear of her husband ; and the cruelty of the man, aggravated by his wife's misfortune, led to bodily injury, which, in her present mental state, will, I fear, result in confirmed and permanent mania; while, un- der more favorable circumstances, with a happy home life, I am sure that this hystero-psychosis of cessation would have ceased as readily as did the first reflex, at the time of puberty, when the functional wave had died out—like the ship at sea, upon which the tidal wave crushes down, she passes through the ordeal unscathed if her timbers are strong, but is wrecked if worm-eaten ribs support her frame. This is a recurrent physiological reflex under adverse con- ditions, contrasting, in this respect, with the one previously cited. Case XL A Pathological Hystero-Psychosis, referable to a Retroflexion of the Uterus, first appearing after Marriage, Checked by the Placing of a Pessary and by Reposition of the Uterus.—I cite this striking case from the practice of Dr. J. Cheston Morris, of Philadelphia, who has kindly placed the history at my disposal. Mrs. G. W. L., aged forty, had continued in good health, free from nervous or mental disturbance, until the appearance of the first epileptic attack, three weeks after marriage. These attacks, at first mild, gradually increased in severity, and were followed by nausea, headache, and intense depression, so com- pletely overcoming the sufferer that, in the agony of each at- tack, she despaired of living through another. Patient had been treated in various ways, and most heroically, under all the various theories of epilepsy, even to losing a number of sound teeth in hopes of curing a neuralgic condition of the superior maxillary branch of the fifth pair, which at one time was supposed to be accountable for this sad condition. Her general health was fair; no uterine symptoms had been de- tected ; the only child was eight years of age.1 1 I quote the words of Dr. Morris, who himself records the opinion of the previous attendant when he says that no uterine symptom existed, though no dis- THE HYSTERO-NEUROSES. 49 When seen by Dr. Morris, fifteen years after the occur- rence of the first attack, he found some retroversion and a small warty growth on the posterior lip. This was excised, the base touched with nitric acid, the uterus replaced, and a Hodge pessary inserted ; a careful diet was prescribed, and bromide of potash and Plummer's pills were given. With the removal of the growth and the reposition of the uterus, these attacks suddenly ceased. As the husband had kept strict account of his wife's terri- ble condition, we know that in those fifteen years she has had six hundred and fifty-one of these attacks. Six months after this one treatment and cure, a single slight attack appeared, but since then, and four years have passed, the patient has con- tinued in the enjoyment of perfect health. This striking case, which so thoroughly demonstrates the direct causative relation between the psychoses and the uter- ine disease, is but one of many I have observed and might record, and I will but refer briefly to another. Case XII. Pathological Hystero-Psychosis in a Virgin (Case II, "The Hystero-Neuroses," Transactions American Gynecological Society, 1878).—A robust, well-developed girl of seventeen, suffering from daily epileptiform attacks, was relieved by the cure of the causative erosion and endocervicitis. A single application of nitric acid to the cervix checked the attacks for five days, and complete relief was afforded by cure of the endocervicitis by means of slippery-elm tents and occa- sional applications to the inflamed cervical mucosa. While cauterization of the erosion lessened the violence of the reflex psychosis, it did not cease until the endocervicitis had been checked, and thereupon the pain disappeared, the head became clear, and the complexion improved. Prof. Barker, in his memorable paper, " Uterine Disease as an Exciting Cause of Insanity " {Journal of the Gyneco- comfort was complained of, and the patient may have been in the best of health, continued sterility after the birth of one child would lead us to suspect some serious lesion of the reproductive organs, most probably an injury of the uterus referable to this one confinement. 4 50 GEORGE J. ENGELMANN. logical Society of Boston, May, IS72, page 347), cites an equally characteristic case, in which insanity was caused by a displacement of the uterus, and reposition of the extremely retroverted and enlarged organ was followed by immediate disappearance of the mental disturbance. To use his own words, u 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 perfectly quiet, and before I left the room felt happy. On visiting her next morning, I was surprised to see her sitting at the breakfast-table smiling and happy." The above described are true cases of hystero-epilepsy— as I define it: epilepsy directly dependent upon uterine dis- ease, a strictly genito-reflex psychosis, which is widely differ- ent from the hystero-epilepsy of Charcot and others, marked by sexual hallucination, the insanity which is principally manifested by morbid cravings and sexual hallucinations, and said by alienists to be pure exaltations. The insanity of old maids, though in connection with uterine or ovarian dis- ease, has never been proved to be strictly a reflex, an hystero- psychosis, or an hystero-epilepsy. Case XIII. Pathological Reflex. Melancholia and Ner- vous Irritability, due to Laceration of the Cervix, cured by Emmet's Operation.—Mrs. S., from Illinois, suffering from mental and physical prostration, great nervous depression, was referred to me on account of spinal and hypogastric pains. Her symptoms were sufficiently explained by a retroversion of the enlarged uterus, laceration of the cervix and perineum, metritis, and endometritis. Local treatment was inaugurated, and the subsequent improvement of the uterine lesion was ac- companied by a corresponding improvement in the general health of the patient, while the mental condition remained unchanged. The melancholia and nervous depression, being in no way affected by the decided change in the uterine inflammation, I referred the psychosis to the laceration, and decided upon an THE HYSTERO-NEUROSES. 51 operation ; at the same sitting, the patient once under the an- esthetic, the endometrium was curetted, and both lacerations of the cervix and perineum closed. The uterus was reduced in size, the vagina very much narrowed, and a strong perineum established ; also a small, healthy cervix ; but the smaller left angle of the cervical laceration did not perfectly unite, although all parts were covered by healthy mucous membrane, and no raw surface remained, so that I looked upon the object as ac- complished. Still, the mental condition remained unchanged, and I ascribed the imperfect result, the continuance of the mental depression to the slight retroversion which remained. The patient, a farmer's wife, upon whom a household and three little children depended, looked forward anxiously to per- fect restoration, and remained for treatment, which was con- ducted with all possible care, and a perfectly healthy condition of all pelvic organs was finally attained. No change, however, was effected in the mental status, and I advised the patient to go home, and continue the use of douches and tampons, giving tonics, urging a milk-diet, all to no purpose. Six months there- after she returned, entered the polyclinic, and treatment was resumed ; again to no purpose. Melancholia continued ; pa- tient was languid, with a dull, heavy appearance, indifferent to everything about her ; irritable when in contact with others, so that she was disagreeable to resident physician and patients, and her treatment became an annoyance to me. Seeing no result whatsoever, I determined to resort to a second opera- tion. Though the cervix was small, and the os appeared merely like an enlarged oval, not at all unusual for a multipara, lined with perfectly healthy mucous membrane, I again pared the left side, which had not perfectly united, and closed it with three catgut sutures. From the moment of her recovery from the chloroform her disposition was changed ; her eyes were bright, the persistent melancholia had disappeared, and a pleas- ant smile now greeted her fellow-patients in place of irritable avoidance which they had met with before. She was soon on her feet, a comfort and help to the other patients while she remained in the ward. Although complete involution had been accomplished by the first operation, the mental disposition, depression, and irri- 52 GEORGE J. ENGELMANN. tability were in nowise changed, and not until a complete clos- ure had been effected, and an os established hardly large enough to admit the sound, was this altered ; but, from the very mo- ment that this angle was united by the suture, the morbid mental symptoms disappeared, characterizing the marked de- pendence of the psychosis upon a trifling localized lesion. b. The Nervovs System. Hystero-Neuroses Proper, Gmito- Rcficx Nervous Disturbances. The terminal fibres of spinal and cerebral nerves give ready evidence of uterine and ovarian disturbance; whether the impulse is conveyed through the ganglionic system or the pneumogastric, spinal and cerebral nerves respond to uterine irritation either throughout the entire body or in circum- scribed areas upon any one part. Uterine changes are reflected in the course of the spinal column, in the hypogastric and lumbar regions, on the top of the head, the occiput, the wrist and ankles, toes, knees, in fact, upon any part of the body. Most common of all these are the spinal and hypogastric pains, together with the pain on the top of the head and in the back of the neck, so that these symptoms have become pathognomonic of uterine dis- ease. Tilt, out of his 500 patients examined during the me- nopause, finds dorsal pains in 226, and abdominal pains in 205; in fact, so thoroughly have these pains become assimi- lated in the popular mind with uterine disease, that the physi: cian will find it difficult to convince a patient that she could possibly have any disturbance of the reproductive organs if the backache and hypogastric pains are wanting, and, if in addition no menstrual irregularity exists, this becomes simply impossible. While these symptoms may remain permanent in one patient, varying with the vacillations of the condition upon which they depend, they change most rapidly in others, so much so, that they are likened to rheumatic pains, some- times in one place, sometimes in another, moving about con- stantly. As a rule, certain pains exist in one and the same patient, THE HYSTERO-NEUROSES. 53 and vary with the causative condition; like all other hystero- neuroses, they are usually dependent upon a pathological con- dition, aggravated by functional congestions, menstruation, or pregnancy; but may also occur at the time of the physio- logical congestion only. These symptoms usually appear two or three days before the menstrual flow, with the coming of the uterine and ova- rian congestion, and cease upon the second or third day after the flow has stopped ; during its continuance they may dis- appear. If the neuroses persist, continuing throughout the intermenstrual period, they are intensified during the time of physiological congestions. It is a characteristic mark of a reflex neurosis that, like uterine disease, it is aggravated by exertion, exposure to cold, and menstruation—I may add, by every physiological wave; but, as certain of these symptoms disappear during the continuance of the menstrual flow, they may disappear likewise during the period of pregnancy. They are more frequent and more intense during puberty and the menopause, as they are during the menstrual period. The most common and best known of these symptoms are the dorsal pains, the pain in the small of the back, either limited to that point or extending, like the pain of labor, from the spine toward the hypogastric region; this pain may also occur between the shoulder-blades. The hypogastric pain is usually upon the affected side, that is, the side of the cervical laceration, the side of greatest ovarian irritation or of periuterine disease; like the higher dorsal pain, it may be at the height of the shoulder-blades but lateral. This hy- pogastric pain, which is a reflex neurosis, must not be con- founded with the actual pain of cellulitis or the pain from localized pressure, and careful differentiation is necessary, as certain of these reflex nerve-pains closely resemble inflamma- tory pains, and those which arise from direct pressure, either upon sensitive organs, or upon a nerve, as upon the sciatic, and then extend along its course down the leg. While the one is superficial and diffuse, the other is deep-seated, often more clearly circumscribed, and, if from nerve-pressure, fol- 54 GEORGE J. ENGELMANN. lows the central nerve-tract so perfectly that this can be traced by the pain as in a dissection. A very frequent sensation is that of quivering in the al> domen, likened by some to the quivering of a mass of jelly; mostly an evidence of ovarian congestion or cervical lacera- tion, and mistaken for movements of the child by those long- ing for pregnancy. Pain, burning, and pressure on the top of the head, are extremely common, and the spot feels warm to the touch, or is so sensitive that the comb is painful. Pain in the nape of the neck, and drawing back of the occiput, as in opisthotonus, likened by the experienced to the evidences of cerebro-spinal meningitis, are likewise frequent; more rare is that feeling of drawing upward of the neck and back of the head. Less common, but still frequent, is the feeling of an encircling band, the symptom being referred by some to the waist, by others to chest or head—a painful sensation of com- pression as by an iron band. Pains in the ankle and in the wrists are frequent, refer- able, as a rule, to the side of the pelvis in which the diseased part lies from which the reflex originates. These pains may appear in the soles of the feet, in the heels, or in the toes; they may be so intense as to make walking impossible. In a patient afflicted with ovarian disease and bedridden, I have seen the pain in the heels so intense that it was with the greatest difficulty that a comfortable position could be found for her; she was obliged to lie on her back, so that her heels must almost inevitably touch the bed in some way, and even the light contact with the bedding caused agony. These superficial pains—genito-reflex nerve-symptoms— arising from reflex irritation, in localized groups of terminal nerves, may appear in any part of the body ; over the heart they cause the dread of cardiac disease, with cardiac and pre- cordial pains; in the shoulders, in the chest, they resemble rheumatism. While they may exist in any part, those named are the most common and characteristic. Many a patient afflicted with uterine disease, without local symptoms, is sent by the unsuccessful family physician to an eminent neurolo- THE HYSTERO-NEUROSES. 55 gist for her nervousness, or to a watering-place for gastric or cardiac rheumatism. Even while writing this, in a European watering-place, I meet an American lady from the far West, who has been sent abroad to prominent physicians for treat- ment of an unyielding gastric and muscular rheumatism. These authorities have sent her to this Spa, to overcome what they have diagnosed nervousness and nervous debility; the iron waters and salt baths, which have truly regenerated her merely debilitated sister, have failed completely in her case. Naturally so, a uterine disease is evidently the cause of this reflex neurosis, which simulates the above maladies, and no Spa can overcome this causative affliction. Unfortunately she is but one of many who gradually sink into invalidism under continued treatment of this phantom disease, the genito-re- flex neurosis. Most frequent (and in the order named) are the spinal and hypogastric pains, the pains in the top of the head, back of the neck, quivering in the abdomen, pains in the wrist, ankle, and heels. The pain of cocydenia, while at times referable directly to pressure or disease of the bone or surrounding membranes, is liable to be a reflex neurosis, a concentration of spinal pains in the terminal bone. So common and so well known is this dependence and the fluctuation of these pains with the improvement or exacerba- tion of local conditions, that I need but briefly mention a few striking cases: Case XIV. A Pathological Genito-Reflex Neurosis; In- tense Spinal Pains due to Laceration of the Cervix ; Complete Disappearance immediately after Operation.—Mrs. X., from Mississippi, a beautiful octoroon, was completely debilitated by the intense backache from which she had suffered since the birth of a child some three years previously. She had been con- stantly under treatment, local and general, without relief. Ap- plications of all kinds had been tried, blisters, cautery to the spine, the usual remedies to the uterus and cervix, with but temporary improvement at times. Relief was but rarely af- forded, and then for a short time only. 56 GEORGE J. ENGELMANN. Emmet's operation was performed, but no anesthetic given, as the patient preferred to do without. Before she was re- moved from the table, from the moment the sutures had been united, the pain ceased; with slight assistance she walked to her bed, happy in the complete relief afforded. During con- valescence, she was free from all pain, and felt perfectly com- fortable. Upon the eighth day the sutures were removed ; only partial union had taken place, and from the time of the removal of the sutures, as the surfaces fell apart, her backache returned. After the cessation of the next menstrual period, a second operation was performed with precisely the same re- sult ; the backache ceased as soon as the parts were firmly united. I was unfortunately obliged to perform the operation under the most unfavorable surroundings in a filthy hospital, and I am unable to speak of the final result, as the patient was carried away by septic poison. I cite the case, however, to show the dependence of this spinal pain upon a local cause—in this instance, the laceration—and not, as is usually supposed to be the case, upon uterine displacement, traction upon ligaments, or pressure of the enlarged fundus upon the spinal column. Case XV. Pathological Genito-Reflex Neurosis ; Relief by a Single Well-placed Tampon.—Mrs. X., from East St. Louis, suffering with a variety of reflex neuroses, insomnia, pain in the region of the heart and below the liver, especially violent, so that cardiac and hepatic disease were supposed by the pa- tient to exist, notwithstanding all I could say, and the assur- ances to the contrary of the various specialists consulted. Re- peated examinations of heart and liver revealed a healthy con- dition of those organs. The patient was afflicted with the usual concomitants of lacerations of the cervix and perineum, endo- metritis, uterine enlargement, retroversion, and, later, perime- tritis. Many of the symptoms were relieved, and her general health was greatly improved by operation on the cervix and peri- neum, but the neurotic pains, insomnia, and pains in the region of the heart and liver remained, hence treatment was again re- sorted to. Great relief was afforded by utero-abdominal fara- dization ; reposition of the uterus was attempted by an elastic tampon ; still, though improved at times, the above-mentioned pains persisted. THE HYSTERO-NEUROSES. 57 The patient was under constant care in the gynecological department of the polyclinic, and the routine treatment was continued. Coming by accident on an off-day, she was attended by a member of the staff, hitherto unfamiliar with her case. Dr. T. E. Holland, who forced a reposition of the retroverted uterus much more violently than had been before attempted, causing the patient great pain. Two days later she returned, completely relieved. She had suffered very much from the treatment, and experienced a feeling, as she expressed it, of something giving way, but from that moment the annoying pain ceased, and she slept soundly throughout the night—the persistent and annoying insomnia had vanished. Notwith- standing the pain caused locally by the tampon, the effect was a most happy one ; the distressing mental and nervous condition of the patient yielded at once, and gave way to perfect well- being. Case XVI. Reflex Neurosis, dependent upon Uterine Dis- ease, relieved by Uterine Galvanism, by Sedative Applications to the Irritated Uterine Terminals.—Mrs. H., suffering from a laceration of the cervix, with the consequent train of symp- toms, endometritis, retroversion of the enlarged uterus, a con- gested and everted cervix, was afflicted with a series of violent reflex phenomena, dyspeptic symptoms, palpitations of the heart, dyspnea, spinal pains, hypogastric pains, with a most annoying quivering in the abdomen, headaches, and insomnia. Emmett's operation was proposed, but preparatory to this I ad- vised treatment for the purpose of overcoming the more vio- lent inflammatory symptoms, especially the endometritis. As treatment progressed, her general condition improved, but the reflex symptoms were not alleviated. I had once resorted to electro-cauterization of the uterus with no more than slight improvement. Two days later I determined upon an electro- puncture, inserting a platinum needle, in connection with the negative pole, to the depth of one inch into the engorged cervical tissue, the positive dispersing plate being placed upon the abdomen, a current of 100 milliamperes was passed for three minutes, and before the expiration of the sitting the patient gave a sigh of relief and expressed her complete well-being. As she stepped off the table her motions were free, and when 58 GEORGE J. ENGELMANN. she returned three days later she informed me that she was perfectly well, her appetite was excellent, sleep perfect, the dyspnea had disappeared, she had taken long walks, and was no longer troubled by the reflex neuroses, pain in back and sides, and abdominal quivering. This is one of those cases of a reflex neurosis relieved by the sedative action of the remedy upon the irritated uterine nerve-terminals, and not by improvement in the uterine dis- ease, as the symptoms had persisted, notwithstanding the change for the better in the local lesion, but disappeared at once apparently by the action of the electric current accident- ally directed immediately to the suffering nerve. Case XVII. Continuance of Genito-Reflex Neuroses, after Complete Extirpation of Uterus and Ovaries, cured by the Seda- tive Action of Galvanism to the Irritated Nerve-tracts.—Mrs. K. had been subjected to the extirpation of uterus and ovaries on account of a uterine sarcoma, which was causing a rapid fail- ing in health. After the operation, from which she rapidly recovered, her general condition improved greatly, she gained in flesh and general appearance, and lost the cachectic look which had previously existed. The burning pain in the top of the head, which had annoyed her so much, disappeared for a time after the operation, but soon returned greatly increased in intensity, and with it appeared that pain in the ankles, shoulders, and soles of the feet, which is characteristic of uter- ine and ovarian disease. These symptoms were so annoying that, after persistent treatment by the physician who had operated so successfully, she was referred as an incurable neurotic to Prof. Hermann of the department of nervous dis- eases (St. Louis polyclinic). When this patient came under Prof. Hermann's care, she was hardly able to walk, so intense was the pain in feet and ankles on both sides. He treated this as a nervous disease, as he did the pain in the top of the head, affording relief by each application of electricity to the afflicted part; she was rendered more comfortable, better able to walk, but it became necessary to repeat the treatment, as the relief afforded was but tempo- rary. Entering the clinic-room by accident, while this patient was under treatment, Prof. Hermann related her symptoms to THE HYSTERO-NEUROSES. 59 me, and I at once urged that the case be turned over to the gynecological clinic, as it was evidently one of uterine disease. I was not a little astonished to hear that uterus and ovaries had been removed, yet urged the treatment of the patient upon the supposition of an irritation of the uterine terminals. She was accordingly referred to the gynecological department and treatment inaugurated as for a reflex neurosis, arising from pelvic disease, vagino-abdominal galvanism was applied, the negative vaginal electrode to the cul-de-sac, the positive ab- dominal plate directly over this upon the abdominal walls. After the first application greater relief was experienced than had ever been obtained by direct treatment of the affected parts ; pains in head and feet both were greatly improved, and after the third treatment they practically disappeared, to return, however, after an interval of time. The patient came but a few times after this, and I have seen nothing more of her, whether relieved or not by the treatment I can not say— certain it is that the pains in head and heels were relieved more rapidly and more completely by the application to the uterine tracts than to the site of pain. I have cited this case in evidence of the fact that reflex neuroses may be induced by a continuance of the irritation in a nerve-fibre even after the causative terminal is removed ; the impulse emanated from the stump of the uterine fibres at its point of amputation, precisely as it had from the terminal before its removal. As a pain of former years is often felt in a foot long after amputation of the leg, which must be referred to morbid action in the nerve at the point of amputation, so did this uterine fibre determine a reflex action as if the causa- tive terminal was still under the influence of morbid action. The result is at the same time an evidence of the possibility of affording relief in case of reflex neuroses by sedative action upon the affected nerve-terminals, though the morbid condi- tion which causes the impulse may continue. n. The Circulation. The circulatory system throughout the entire body is under the direct control of the vaso-motor nerves, which fol- low its innumerable ramifications from the cardiac centre to 60 GEORGE J. ENGELMANN. its capillary meshes. By reason of the direct connection of the ganglionic fibres with the vaso-motor nerves, these readily respond to changes, morbid or physiological, which may take place in the vital centres. No system gives evi- dence of these reflex impressions more rapidly or more viv- idly than the circulatory. In response to peripheral stimu- lus, we see the hot flush of the dilated capillaries, or the cold pallor of the contracted vessels which mark the undulations in the vaso-motor fibres, on the one hand; paralysis, increased tension, on the other. All nerve-action finds a ready reflex in the vaso-motor system, so much so that we involuntarily regard this as an index of the emotions and the secret work- ings of the mind. Hardly less than the changes in the great cerebral centre are the waves emanating from the re- productive organs delineated by these sensitive fibres. Hip- pocrates has already called attention to shivering and an unusual development of heat as a sign of pregnancy, symp- toms of a purely reflex nature, and not in any way referable to the increased vascular development accompanying the physiological hypertrophy. So intimate and so intricate is the relation existing be- tween the vaso-motor nerves, uterus, and ovaries, and the central nervous system, that it is not always easy to trace the existing relation and to determine cause and effect; a periph- eral congestion or hemorrhage may be a simple concomi- tant or a natural result of pelvic congestion, or it may be a reflex symptom. The circulatory system may respond to uterine or ovarian irritation in its entirety, or in any one of its parts, as it is governed throughout by the accompanying fibres and ganglia, which control its every action as truly and as promptly as a steam-valve does the workings of the engine ; hence, genital irritation may be characterized by symptoms on the part of the heart or portions of the peripheral system, especially superficial capillaries upon the skin, or this reflex may be general throughout the entire peripheral system, made evident by chill or fever; or, as is more usually the case, it is localized and recognized by the coldness of hands THE HYSTERO-NEUROSES. 61 or feet, or by the flushes of the face. Coldness of extremi- ties is a frequent symptom of uterine disease; palpitations of the heart, irregularity of the heart's action, usually inter- mittent, accompany morbid conditions. Ovarian disease is often marked by flushes; by the hot flushes of the face which we frequently find at the change of life, where it may, however, be dependent upon irregularity of the circulation. These symptoms, so varying in their nature—all, however, the result of contraction or relaxation of portions of the vascular system in response to morbid stimulus carried from uterus and ovaries to the vaso-motor nerves through the ganglionic system—may be classified as: 1. Cardiac or central; and, 2. Yascular or peripheral. 1. Cardiac or Central Circulatory Reflexes. As the heart's action varies with the emotions and the state of the mind, so it responds to a variety of uterine or ovarian states, both physiological and pathological. I will not enter upon the difficult differential diagnosis between physiological hyperactivity and the reflexes of pregnancy, as observation alone can determine the origin of symptoms referable in part to one, in part to the other cause, and I shall speak only of the true or pathological reflexes as the same phenomena may exist as menstrual neuroses, and neurosis of puberty and the menopause. a. Palpitations of the heart.—This is among the most common of the hystero-neuroses, as it is the most frequent response to emotional impulse; but not until this violent beat- ino- of the heart has been proved to be a uterine reflex, by cessation upon uterine treatment, can its origin be definitely determined, as the same symptom is referable to so many other causes. b. Rapidity of the heart's action, frequently accompanied by intermission, I have repeatedly observed as a symptom of uterine disease, annoying the operator, who may be in doubt 62 GEORGE J. ENGELMANN. as to the propriety of using anesthesia until he has fully solved the question of cardiac disease. The direct dependence of cardiac action upon ovarian changes is strikingly evident in the sudden slowing of the heart-beat upon constriction of the ovarian nerve. So strik- ing is this symptom that repeatedly has the careful assistant, while giving the anesthetic for me, called a halt, and inaugu- rated resuscitation as the pulse fell from 80 to 34 at the moment of ligating the ovarian pedicle. My attention being thus called to the matter, I have observed the same reac- tion in almost every instance, and have assured myself of the direct dependence of the heart's action upon the ovarian impulse by the loosening of the ligature, in response to which the beat at once returned to the previous frequency. Dr. Hodgen, our lamented surgeon, informed me that he had ob- served the same phenomenon in ligating the spermatic ves- sels before removal of the testicles. While a very rapid beat of the heart, 120 to 130 in a minute, may accompany uterine and ovarian disease, this is often varied by an intermission more or less regular, sometimes one in six or eight, even in three or four, and again it may be observed repeatedly in rapid succession, and not again for minutes. c. Pains in the heart, such as may simulate an endocar- ditis, are frequently complained of by women suffering from uterine disease, or when in a state of functional change dur- ing menstruation and at the change of life. Occasionally it is precordial, more like a rheumatic pain, or it may appear as a feeling of compression, as if by an iron band, which is spoken of. These symptoms, violent palpitations, or irregularity of the heart's action, and pains in the cardiac region, so nearly simulate heart disease, that a careful examination may be necessary before the giving of an anesthetic; and so decep- tive are they that I have repeatedly sent the sufferer to a specialist for examination, notwithstanding that, as in other neuroses, we have a reasonable assurance of the reflex nature of the symptom by its exacerbation at the menstrual period THE HYSTERO-NEUROSES. 63 or upon a slight cold or exertion, such as would aggravate the existing uterine symptoms; and upon this I would lay, perhaps, greater stress than upon the negative evidence of auscultation and percussion, which assure us only of the ab- sence of disease. The cardiac reflexes of pregnancy are more obscure, as actual circulatory changes exist at the time, and it is impossi- ble to demonstrate their true nature by removal of the cause; hence I have not touched upon these, and have cited only such as have been clearly proved to be reflex in their nature by their prompt cessation upon cessation of the cause of the trouble. The cardiac neuroses, more than those of other organs, have of late received attention on the part of careful observers. They are symptoms of extreme importance from a practical and diagnostic point of view. I need only refer to the re- sults of an erroneous diagnosis in the case of a patient seek- ing insurance: she is debarred from all its advantages on account of a slight, possibly unnoticed, uterine disease, which produces the deceptive vaso-motor reflex. The neurosis is mistaken for the disease proper, and her family are deprived of the benefits of life insurance. Although the phantom is distinct from the disease, its re- flex nature is by no means practically appreciated, as it should be even by those who have given attention to the subject. One of the most instructive articles is the chapter on neuro- ses of the heart (" Functional Diseases of the Heart's Ac- tion, Angina-Pectoris, and Exophthalmic Goitre," by Austin Flint) in Pepper's System- of Medicine, Yolume III, page 750, in which the symptoms are clearly outlined, but their treat- ment as a reflex disease hardly demonstrated with sufficient emphasis. The cardiac neuroses are here considered as a whole, from whatever source they may originate. The cardiac hystero-neuroses have also been well de- scribed by H. J. Boldt, M. D., in a paper on " Cardiac Neu- roses in Connection with Ovarian and Uterine Disease " (read before the New York Academy of Medicine, American • 64 GEORGE J. ENGELMANN. Journal of Obstetrics)—he prefers the term reflex cardiac disturbance for those fluctuations which present symptoms similar to those attended with organic lesions, deeming the term " neurosis " faulty, as these troubles are either of reflex origin or arise in the cardiac ganglire. Boldt believes these functional affections of the heart, unaccompanied by inflam- matory changes, to appear as reflex symptoms in eight per cent, of all uterine diseases, and divides them into four classes: 1, palpitation ; 2, disturbance of rhythm (irregu- larity) ; 3, suspension of one distinct beat (intermittency); 4, angina-pectoris. Class 1 is the most frequent neurosis, being caused by the emotions; class 2 is caused by a modifi- cation of the rhythmic discharge in the cardiac ganglise—it may be congenital or the result of emotion, as passion, grief, joy. Angina-pectoris, the most painful of all the neuroses, so closely resembles the symptoms of organic lesion that only an examination of the heart during the attack would exclude this. The pain is often felt radiating down the left shoulder, arm, and hand, in which formication is at times observed. These attacks are intermittent, the patient being entirely free in the interval; the heart's action is at times feeble, at times irregular, and painful spots are found over the region of the heart. The functional disturbance, he correctly says, may be cured by attention to the pelvic disease; but in chronic cases attention to the pelvic disorder alone will not suffice, systemic treatment being necessary. This is more or less true of all hystero-neuroses, yet some become more firmly established than others ; those of the eye are the most persistent, as we have seen. While in their early stages the cardiac neuroses respond readily to changes in the uterine condition, at a later stage, when the molecular disturbance in the contracting nerve-fibrils is long continued, it will persist after removal of the causative stimulus. Though constitutional medication may assist in treatment, and is always desirable in chronic cases, this alone should not be relied on if a cure is to be achieved. THE HYSTERO-NEUROSES. 65 #. Vascular or Peripheral Circulatory Neuroses. These may be general or local, referable to the entire sys- tem, like the fever, or limited to a circumscribed region, internal or external: upon the extremities cold feet, on the face a flush ; upon the mucous membrane of throat or lungs a laryngitis or an asthma. a. General Peripheral Neuroses.—The most marked of these are chills and fevers, which can be unquestionably re- ferred to changes in the reproductive organs. The chlorosis, which is often observed at the change of life, and in connec- tion with uterine disease, has been considered by some as a circulatory disturbance attending the ovarian nisus; and it has been explained as a resultant of the ovarian impulse in an already ill-balanced circulation. As I have myself not satisfactorily demonstrated the direct causative relations, I am unable to assert the positive reflex nature of chlorosis. The chills, known to the sufferer herself as nervous chills, are more readily referable to local changes; but most charac- teristic and most deceptive are the fevers, with or without elevation of pulse, apparently a partial paralysis of the entire vaso-motor system. This peculiar peripheral hystero-neurosis of the circula- tory system appears either as a resultant of some exacerbation of the morbid uterine stimulus, now and then, after undue exertion or other cause of aggravation, or as an accompani- ment of the physiological wave, with the intensity and with the regularity of a malarial attack. It was the occurrence of these reflex fevers that called my attention to the peculiar periodicity in certain of the symptoms of uterine disease; and I have described them more fully in a paper read before the Gynecological Section of the Eighth International Con- gress.1 The fever comes with a certain intensity of the uter- ine irritation, and subsides whenever the morbid stimulus sinks below the given point. Thus in some patients the fever > " The Periodicity of Symptoms of Uterine Disease," by George J. Engelmann. —Transactions of Section of Obstetrics of the Eighth International Congress. 5 66 GEORGE J. ENGELMANN. occurs only after unusual irritation and aggravation of the causative uterine disease; in others, it is constant, and sub- sides only when every precaution is taken, and every, even the ordinary, irritation is removed. I have occasionally seen patients with a constant slight heat, called fever, which ceased and yielded to a normal temperature only upon rest in bed; whenever the friction of the eroded cervix against the vagi- nal walls was prevented by a recumbent position, the fever ceased, walking or standing would aggravate it. Those symp- toms which come with a daily periodicity and monthly recur- rence—coming like a malarial attack, daily at a certain hour, at a certain time of the menstrual period—seemed to be con- fined to the malarial regions, such as the Mississippi Valley. That this periodicity is not due to the febrile condition or in any way referable to malarial origin has been proved by the absolute inertness of antiperiodic remedies, and the positive correspondence of the vacillation with the uterine symptoms. The fact that these symptoms have been but rarely if ever observed elsewhere necessitates the conclusion that this peri- odicity is referable to some intercurrent malarial influence, but it can be only the periodicity of nerve-action, indirectly so influenced, as the typical recurrence is the only point of re- semblance. The symptoms in which I have observed this periodicity are fever, pelvic pain, nerve pain, and discharge; fever and pelvic pain are the most frequent. Most striking in our malarial region is the appearance of high intermittent fever of strictly miasmatic type, which is not influenced by chinin, and unquestionably dependent upon uterine disease, as proved by the disappearance of the fever with the improvement in the condition of the womb. Cause and effect are made evi- dent by the failure of antiperiodic medication and the suc- cess of local treatment without accompanying medication, the disappearance of periodic symptoms with the restoration of the diseased uterus to its normal and healthy state. Case XVIII. Intermittent Fever toward the Close of the In- termenstrual Period.—Mrs. S., from Illinois, aged thirty-two, in THE HYSTERO-NEUROSES. 67 good circumstances, the mother of four children, had been suffer- ing more or less since the birth of her youngest child, five years ago, from debility, nervous prostration, backache, and pelvic pains. Her condition was such that she was under constant treatment, yet no signs of improvement appeared ; on the con- trary, her condition grew slowly worse, so that she was unable to attend to her household duties, and came to St. Louis to con- sult me. I found the uterus anteflexed, indurated, and enlarged, in consequence of the existing subinvolution, with a catarrhal condition of the mucosa of cervix and fundus, and the latter hypertrophied. In addition to the symptoms already men- tioned, the patient suffered, at the close of each intermen- strual period from an intense and debilitating intermittent fever. This fever, with acceleration of pulse and rise of tem- perature, appeared upon the fifth day before the coming of the menstrual flow, at eleven o'clock in the morning, reaching its acme at one, continuing during the afternoon and passing away in the evening. It thus returned day after day until the coming of the menstrual flow. For several years this inter- mittent, apparently malarial fever had recurred before each menstrual period, and from the time of its first appearance her attendant (her uncle), one of the ablest and most respected physicians in that section of the State, thoroughly conver- sant with malaria and all its varied forms, had in vain at- tempted to subdue it until he had exhausted antiperiodic medication. Quinine had been given until the stomach was affected and the patient rebelled against its continuance. This was the first case of the kind I had observed, and when the fever came on, so thoroughly identical with a malarial fever in all its symptoms, the inaugural chilly sensation, the pains in back and loins radiating down toward into the thighs, espe- cially the bilious tinge of the face, I did not doubt its miasmatic origin, and concluded to treat it as such, much to the horror and disgust of the patient, a very sensible and observing lady, who assured me over and over again that these fevers had in- variably taken the same course, and disappeared with the com- ing of the flow, whether she had taken chinin or not, and that 68 GEORGE J. ENGELMANN she even felt worse when medication was attempted, as the fre- quent use of chinin had made it obnoxious to her. Nevertheless, believing the previous treatment to have been inefficient, I gave eight grains of calomel, which I followed with thirty of chinin, repeating the chinin before each attack of fever. I failed completely to change its course. I then suspended all medication and allowed the next period to pass without medication of any kind. The fever returned as usual, but was no more severe than wdth the use of chinin. As treatment progressed the severity of the fever diminished, and ceased altogether after I dilated and curetted the uterine cavity. Some months later I dismissed the patient, who re- turned to her home and her household duties in the full enjoy- ment of health. This occurred ten years ago, and, although Mrs. S. has now and then suffered from slight intercurrent dis- eases, the premenstrual intermittent fever has never returned. Case XIX. Intermittent Fever in the Middle of the Inter- menstrual Period.—Miss A., aged nineteen, a well-developed brunette, in the most comfortable circumstances (the patients to whom I here refer come from the higher walks of life), who had but recently left school, where she had overexcited herself like so many American girls, suffered from neurasthenia, indiffer- ence, prostration, backache, pain in the head. Her home is in a beautiful and healthy portion of Missouri, yet for almost a year she suffered, in the middle of each intermenstrual period, from a severe intermittent fever, which recurred upon three successive days. Every possible attention was bestowed upon this only daughter by anxious parents : she had been under the treatment of the best physicians, especially one able practitioner, a near relative, yet neither medical skill nor change of climate accomplished any perceptible change in her condition. When she was placed under my care I discovered an en- larged, slightly moveable retroflexed uterus, with marked endo- cervicitis, accompanied by the symptoms usually characteristic of such disease, the only peculiar and unusual feature being the attack of intermittent fever which invariably came on the 11th, 12th, and 13th day after the cessation of the monthly flow, in the middle of the intermenstrual period. The attending physi- cian, supposing it to be malarial, had never failed to give chinin, THE HYSTERO-NEUROSES. 69 and repeated his medication, which had been varied in every possible manner each month, because it was supposed, notwith- standing the regularity of its return, that the progress and the continuance of the fever were at least checked by the antiperi- odic treatment. Quinine was taken again and again though the system began to revolt as the recurrence of these burning fevers told severely on the delicate sufferer. I had but inaugurated local treatment when the period of these dreaded fevers approached, and I well knew that it would return as the disease was not yet sufficiently under control ; but experience had also taught me the utter inefficiency of chinin or medication of any kind (nervines relieve the condi- tion somewhat and make it more bearable). I explained this to patient and friends, prepared them for the coming of the fever, but at the same time assured them that it would cease as usual without medication, and proba- bly never again return. The attack came at the usual time, at ten o'clock on the evening of the 11th day after the cessation of the menstrual flow, and continued during the night. Upon my visit next morning she was entirely free from fever, but in the evening it returned as usual; dreading its continuance the patient's mother anxiously demanded the giving of chinin, but finally desisted upon my assuring her of the futility of the remedy. During the night of the third attack, on the 13th day of the intermenstrual period, I was sent for, that I might assure my- self of the intensity of the fever, and in hopes that I would then be induced to give chinin. The patient was certainly in a desperate condition, almost delirious, face flushed, hot, eyes congested, skin dry and hot, throat and lips parched, and her mother naturally dreaded a repetition, and again urged the giv- ing of chinin, threatening to give it herself, in the firm belief that it was the use of this remedy only which had cut short all former attacks on the third day. It was with difficulty that I succeeded in urging her to refrain from its use. The fever disappeared without the use of chinin after the third attack, just as it did when large doses had been given; and one month later, when local treatment had sufficiently progressed, the condition of the uterus had improved, and the flexion and endocervicitis had been relieved, no fever appeared, to the 70 GEORGE J. ENGELMANN great relief of every one, and the much-dreaded period was passed with perfect comfort. All other symptoms steadily im- proved, and the fever has not since returned, time sufficient (four years) having now elapsed. b. Localized Genito-Rnschrift, No. 25, 18S2) enumerates some of the more striking of these rellex neu- roses. He has observed epilepsy, uncontrollable cough, asth- ma, and violent attacks of sneezing in response to such nasal irritation. Like the uterine-reflexes, these nasal neuroses are confined as a rule to the side of the nasal disease, if that be unilateral; thus, a left hemicrania appears in response to a chronic catarrh of the left nasal mucosa. Fraenkel has devoted much attention to the subject, and the remarkable cures achieved in asthmatic attacks, however violent, when of a reflex nature, by the galvano-cauterization of the indurated mucosa, aroused the delusive hope in cer- tain recent writers, by false generalization from individual cases, that that form of asthma known as hay-fever might be overcome by such cauterization. Hack dwells at length upon the practical import of these reflex neuroses, and he gives expression to the same thought which I have so often enunciated—" that however marked the causative relation in these cases, however well known the dependence of such reflex symptoms, practically this is ignored by the profession. The treatment in all cases is di- rected to the site of the symptom, and the patient is plied in vain with remedies, while a simple treatment, often a single application, might give relief if directed to the site from which the reflex emanates." Unquestionably these reflex neuroses, whatever be their nature, though theoretically ac- cepted, are practically disregarded. It seem3 but natural that an organ so intimately associated in function and in nerve connection with the genitalia, so susceptible to reflex irrita- tion, should respond readily to uterine stimulus. The most common of these bronchial hystero-neuroses THE HYSTERO-NEUROSES. 81 appear in the form of an irrepressible cough, a dyspnea more or less violent, and the asthmatic attack, although either of the morbid conditions to which the bronchii are subject may be simulated. A true reflex neurosis, however violent, is always unaccompanied by structural changes, and may be demonstrated with the certainty of a laboratory experiment in cases where the determining uterine status can be removed and reproduced at will—for instance, if this be a non-adher- ent, movable flexion, as in the following case, already cited as Case IX in my first paper on the hystero-neuroses : Case XXIV ( Case IN). Genito-Reflex Dyspnea, Uterine Asthma ; Instantaneous Relief by Reposition of the Retro- flexed Uterus.—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 irri- table, nervous woman, of forty-two, who had had four chil- dren ; formerly healthy and strong, she had become emaciated to the last degree, with a careworn, haggard look ; menstrua- tion in former years was comparatively regular, and unaccom- panied by pain. In October, 1875, she began to suffer from nightly attacks of asthma. When these attacks first appeared, they presented all the symptoms of a nervous or hysterical asthma, with bron- chial 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 disappear, leaving the patient entire- ly free from the annoying symptoms ; but as the disease progressed her suffering became continuous, the trouble per- sisting, though in a milder form, throughout the entire day. The case had gone from hand to hand, and the pharma- copeia had been exhausted by the numerous physicians con- sulted ; 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 exacerbations a few days pre- ti 82 GEORGE J. ENGELMANN. vious to the menstrual period, the bronchial asthma continuing unabated throughout the entire duration of the uterine conges- tion, and gradually yielding in intensity as the catamenial flow disappeared. The symptoms always abated more or less after the cessation of the flow, but continued throughout the inter- menstrual 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 troubled her entirely dis- appeared. An intra-uterine stem, ingeniously constructed to suit the case by Dr. Greiner, was next introduced, and, as long as it could be borne without 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 instru- ment the former suffering was sure to return in from five to twenty-four hours. The bronchial symptoms responded with the greatest cer- tainty and regularity to a change in the position of the womb. Retroversion pessaries did but little good, some even prov- ing injurious ; pressure, even the slightest, on the posterior wall of the corpus uteri caused intense pain and a fearful ex- acerbation of the symptoms, as was demonstrated by a glycer- ine cotton tampon which had been introduced with a view of elevating the fundus. At last the stem could no longer be borne, and the patient's suffering became so unbearable at the time of the catamenia, while she was free from the asthma for two weeks of the inter- menstrual period, that I determined to bring about the meno- pause by Battey's operation. I removed both ovaries, and the patient, enfeebled by long suffering, died on the sixth day after the operation. THE HYSTERO-NEUROSES. 83 The post-mortem examination showed the lungs to be al- most 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 se- vere and continuous cough with muco-purulent sputum was a purely nervous phenomenon, and clinical experiment had shown the causation to be uterine. (Case N.)—An analogous case, characterized, moreover, by the recurrence consequent upon uterine disease of a phys- iological reflex of puberty, is related by Prof. Hegar of Freiburg.1 The patient, a maiden lady, thirty-one years of age, had been troubled during the period of puberty with an annoying cough, which returned in her twenty-sixth year 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 temporarily relieved by the use of strong opiates ; menstruation was profuse and pain- ful. 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 retro- flexion, and Prof. Hegar's further experience with the stem was perfectly analogous to my own. It seemed to act unfa- vorably in other ways, so that as the period approached 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, irritation, and menorrhagia grew unbearable, and the use of the instrument was given up. Elec- tricity as well as all medication failed, and the extirpation of the uterus and the ovaries was determined upon, as the condi- tion 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 opera- tion was successfully performed, and up to the date of the writing of the article, three months after the extirpation, the 1 Wiener med. Fresse, 1811, Nos. 14, 15, 16, 17. 84 GEORGE J. ENGELMANN. cough had not reappeared. Similar cases are cited by Chrobaek,1 Grtlnewald,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 irri- table uterus—he cites several which are decided bronchial hystero-neuroses, as their dependence upon uterine disease is made plainly manifest. Case XXV. Genito-Reflex Dyspnea, Uterine Asthma, dis- appearing upon Relief of the Cetusative Uterine Disturbance by Conception.—Mrs. X., forty-eight years of age, had for many years been a sufferer from terrific attacks of asthma, was in no way affected by internal medication, but somewhat relieved by cauterization of the sensitive area of the nasal mucosa by my friend Dr. Glasgow, who kindly gave me the details of the case. Though somewhat ameliorated and diminished in intensity, the disease persisted until conception took place, when a perfectly healthy functional activity of the respiratory organs was re-es- tablished, and up to date, the eighth month of pregnancy, breathing has been perfectly normal, and no evidence, even the slightest, of the before so violent asthma has been observed. Case XXVI. Bronchial LTystero-Neurosis of Pregnancy. —Mrs. X. consulted my friend Dr. Glasgow on account of a persistent asthma which had developed with conception, per- sisted throughout pregnancy, and was still continuing, then in the seventh month. The patient is a lady in whose family a disposition to asthma has existed, and in other members of the family the attacks have been brought about by very tri- fling exciting causes; in one sister a slight cold appeared as the impelling cause, in another a laryngeal trouble, both respond- ing ' to proper treatment. The reflex nature of the attack in this instance was made evident, not alone by the peculiar co- incidence of its appearance with conception, but by the utter failure of constitutional and local treatment from which relief could be expected. 1 Wiener med. Presse, 1869, Xos. 1 and 2. 1 Petersburger med. Zeitschr., 1875, p. 575. 3 Lecons de Ibrme et de Situation de V Uterus, etc. Paris, 1874, p. 87. Observ. XXII, XXIIL THE HYSTERO-NEUROSES. 85 While in the first case a displacement of the uterus, possibly a retroflexion, or a narrowing of the canal, which had excited the reflex symptom, was overcome by the functional changes consequent upon pregnancy, and thus, the cause being removed, the bronchial reflex abated, in the second, the physiological hypertrophy of the uterus due to pregnancy seemed to produce the irritation which resulted in the bronchial response. Most likely with parturition, the emptying of the cavity and the contraction of the organ, the reflex symptoms will abate.1 Case XXVII. Bronchial Hystero-Neurosis, Cheyne-Stokes Respiration and Pleuritic Pains determined by the Men- strual Exacerbation of Chronic Uterine Disease. — Mrs. C, from Warrensburg, Mo., aged twenty-six, consulted me in November, 1886. Examination revealed laceration of cervix and perineum, erosion of the congested and everted lips, retroflexion of the enlarged uterus, and metritis, endometritis, and oophoritis. Intense backache was the only symptom char- acteristic of these morbid conditions, which resulted from a first and only labor three years ago, and which had caused com- plete nervous and physical prostration and a variety of reflex neuroses, prominent among which seemed those of the pneumo- gastric, pain in the heart, palpitations, exciting a fear of heart disease, nausea, belching, distention of the stomach, and Cheyne-Stokes respiration ; while cardiac and gastric symp- toms persisted in a milder form, a violent exacerbation, to- gether with a development of pulmonary symptoms, accom- panied the menstrual congestion, the thoracic pain, and the peculiar respiration so characteristic of pulmonary disease, that I requested the opinion of my friend Dr. Glasgow in the case. Although the breathing was characteristic; and the patient gave a history of repeated attacks of pleurisy and " lung fever," he could detect no pathological changes, and as- sured Mrs. C, as I had done, that her lungs were in a perfectly healthy state notwithstanding the distressing symptoms. We observed this neurosis, which had appeared with the development of pelvic disease for the past year, during two 1 Dr. Glasgow has kindly informed me since that his expectations have been realized, that the asthmatic attack, which persisted throughout pregnancy re- gardless of treatment, ceased immediately after confinement. 80 GEORGE J. ENGELMANN. menstrual periods. It was most intense, the peculiar respira- tion most marked during the violent menstrual attack follow- ing her journey to the city, by which the uterine symptoms had been aggravated. The period following this, after the inauguration of treatment, and after the patient had had an opportunity to rest properly, passed off with all symptoms less severe. As treatment progressed and the displacement was relieved, the inflammation reduced, the erosion healed, the bronchial neurosis ceased, likewise the cardiac. The gastric symptoms alone remained, but in a milder form. With constant improve- ment the menstrual pains constantly diminished, and the bronchial neurosis has never reappeared. Case XXVIII. Genito-Reflex Dyspnea and Cardiac Neu- rosis.—Difficulty of breathing, palpitation of the heart, dis- tention of the stomach, resulting from laceration of the cervix and consequent hyperplasia with descensus uteri. Persistent or pathological neurosis permanently checked by galvanism to the uterine terminals. The patient, Mrs. H., had been a constant sufferer from violent reflex neuroses excited by uterine disease, and her insomnia added to the bodily and nervous prostration. In this case the palpitation of the heart and dyspnea were so marked that, after walking fifty steps, the patient had to keep her mouth open and gasp for air. She could not walk up a single flight of stairs without resting a few times, rarely at- tempting to walk two squares to market. The neuroses were constant or pathological, with a slight exacerbation at the menstrual period, and after cold or exertion, by which the uterine disease was aggravated. Before resorting to operation upon the lacerated cervix, I decided to relieve the inflammatory symptoms with mild astringent applications to the endometrium, medication to cervix and cul-de-sac by powders and medicated cotton, and reposition of the uterus by the elastic tampon. As the uterine congestion diminished, discharge and erosion bettered, her suffering was lessened ; she slept more, and complained less of palpitation and dyspnea ; still she was unable to walk up-stairs, or any distance on level ground, with comfort. Believing that THE HYSTERO-NEUROSES. 87 the hyperplasia of the uterus would be more readily reduced by galvanism I resorted to electrolysis by galvano-puncture in addition to the before-mentioned treatment. A platinum needle attached to the negative pole of the galvanic battery was inserted to the depth of one inch into the indurated uterine tissue, the positive dispersing plate upon the abdomen : a cur- rent of 40 milliamperes was employed for five minutes. Two days later the same treatment was repeated ; while still upon the table the patient gave a sigh of relief, and before leaving the room told me that she now felt well. I did not see her for three days, and when she returned she appeared in the best of spirits, completely relieved of all the annoying reflex symp- toms. She slept soundly throughout the entire night, could walk any distance, even go rapidly up-stairs without any dis- comfort. The dyspnea had entirely disappeared, and by the operation, undertaken soon after, her health was completely restored. The sudden disappearance of the violent neurosis in this case is evidently due to the sedative action of galvanism, as it is not possible that a single treatment could so suddenly cause so great an amelioration of the uterine disease as to remove the exciting cause of the reflex neurosis, but as so pointedly shown in Case IV, in which the reflex neuroses, which persisted after the removal of uterus and ovaries, were relieved by galvanic treatment of the irritated nerve-termi- nals in which the molecular disturbance excited by uterine disease had continued after the removal of the exciting cause, so I believe in this case, the morbid nerve-irritation was over- come by the galvanic current, and thus the reflex neuroses checked while the causative disease continued. IV. The Gastko - Intestinal Canal—Reflex Gastko-In- testenal Neuroses. Though not so strange or so striking as many of the other phenomena resulting from uterine disease, the reflex neuroses of the gastro-intestinal tract are important to the practitioner, especially on account of the frequency and occasional vio- *3 GEORGE J. ENGELMANN. Ience of the most common of these reflexes, the gastric neu- rosis of pregnancy. We will consider : 1. The hystero-neuroses of the stomach. 2. Those of the intestines. 1. The Gv.nito-Iuflex Gastro-Neurosis.—FxAlnesa in the epigastric region, gaseous distention of the stomach, loss of appetite, belching, nausea and vomiting—all the symptoms of indigestion, even of gastritis, may be determined by mor- bid or physiological changes in the reproductive organs. Like other neuroses, without medication, these annoying troubles gradually disappear as the uterine disorder yields to local treatment; while, before the inauguration of such treatment, any remedies that may be given to ease the suffer- ing caused by the apparent gastritis will be either fruitless or will at best afford but partial and temporary relief; seda- tives and anodynes alone allay the intensity of the symptoms. The semblance of disease is so perfect that, unless the monthly recurrence or the existence of known pathological or physio- logical uterine changes be verified, a tentative treatment only will determine whether it be a mere phantom of disease or the result of actual pathological changes. Gastric neuroses occur in response to physiological or pathological changes, and we need scarcely consider all the varieties, often trifling in character ; the most important are the nausea and vomiting of pregnancy, often with fatal ter- mination, and the gaseous distention of menstruation; belch- ing, nausea, and vomiting as a menstrual neurosis, dependent upon the exacerbation of uterine disease with the monthly congestion, may be most violent in character. The diseased sexual organs may excite the gastric nerve through the sympa- thetic, and it is claimed by Jaffe (" Dyspepsia uterina," Memo- rabilia, 1886, No. 4, Frankfurt-on-the-Main) that the reflex vomiting is brought about by irritation of the vomer centre by a morbid stimulus imparted by reflex action to branches of the vagus or gastric nerves. The insidious control exercised upon the stomach by the reproductive organs is well marked by the frequency of the THE HYSTERO-NEUROSES. 89 epigastric faintness, which is a direct resultant of uterine changes, physiological and pathological. As Tilt expresses it, the vagus is a bridge which unites the central portion of both nervous systems, resembling both, not well isolated, often anastomosing with the sympathetic, which helps to form the celiac plexus, so that affections of the vagus and the epigastric ganglia generally coincide, and the viscera by their ganglia react upon the brain, and a paralysis of the epigastric centres causes this uneasy sensation in the pit of the stomach, the feeling of sinking and faintness, nausea, weakness, and perverted appetite. Hyperesthesia or paralysis of the solar ganglia and celiac plexus may result from uterine disease. Tilt, however, overestimates the frequency or importance of this gangliopathy, as he calls it. Though it may be more frequent in response to the changes of the menopause, it does not play so important a role as a reflex to uterine dis- ease or the earlier physiological congestions. Those spells of faintness, this sinking and feeling of emptiness, which we also find in patients suffering from uterine disease, are a direct reflex occasioned by uterine or ovarian congestion, as is evident by their direct cessation upon an improvement in the uterine condition. Were they a mere resultant of con- stitutional debility caused by uterine disease, relief would not immediately follow local improvement, but would result only from an improvement in the tone of the system, which is, however, but slowly effected after a cure of the pelvic dis- turbance. This epigastric faintness, though annoying, is not of as much importance even during the menopause as it is sup- posed to be by Tilt, who finds it in two hundred and twenty out of five hundred of his cases, and claims that " women voluntarily unfasten their stays and clothing on account of their liability to gangliopathy ; and for this reason many of my patients have left off their stays," he says. A striking example of an explanation suited to the wishes of the writer. This leaving off of corsets and unfastening of stays is not in the main to avoid the epigastric pressure, but to prevent that 90 GEORGE J. ENGELMANN. downward pressure of the intestines upon the reproductive organs, and of these downward into the pelvis, by which an exacerbation of uterine and ovarian symptoms is caused. Pressure from above is injurious, as descensus takes place when the patient is in the erect posture, and the hint is thus given by Nature to the physician that he instruct his patients to avoid those dangerous garments altogether, and to support their clothing from the shoulders, that they may prevent this injurious pressure. a. Constant, Strictly Pathological Hystero-Neuroses of the Stomach.—Belching, nausea, and vomiting, caused by re- flex irritation of the gastric nerve, are less frequently a perma- nent accompaniment of uterine disease; more commonly they are excited by the menstrual congestion. So closely resembling the various forms of dyspepsia and the well- known gastric symptoms, they are usually treated as such, and, I regret to say, notwithstanding the strong arguments and the striking cases cited in my first paper, I seemed to remain alone in my ideas as to the causative relation of these phenomena; but lately the reflex nature of these symptoms has been more fully appreciated, as we see from the case cited by Jaffe. Case XXIX. Pathological Genito-Reflex Gastro-Neurosis. —Symptoms of Gastric Catarrh; Cure by Treatment of Ex- isting Endometritis.—Patient, twenty-three years of age, suffer- ing greatly from nervous prostration, complained of heartburn, eructations, and vomiting after meals. Constitutional treat- ment was at first resorted to ; iron and other tonics were given, without effect. The stomach-pump even was tried, and showed a perfectly healthy condition of the gastric mucosa ; the stom- ach was clear of secretions, not over-acid. The uterine symp- toms, which had been neglected on account of their apparently trifling importance as compared to the gastric and constitu- tional condition, were now examined into, and a douche was ordered. The stomach grew worse, evidently in consequence of the irritation caused by the examination. As the vaginal injection proved useless, local treatment was insisted upon ; THE HYSTERO-NEUROSES. 91 the uterus was anteflexed, the body enlarged, the mucosa dis- eased ; the curette was resorted to for the relief of the endo- metritis, and the cavity thoroughly cleansed ; the belching and vomiting ceased at once, and the stomach was restored to a healthy condition, but after a time the dyspeptic symptoms slowly reappeared, though not with that severity, and without vomiting. This is evidently a reflex neurosis, well demonstrated by the imperfect treatment of the case. Metritis and endometritis of long standing are not suddenly cured by a single curetting, although the diseased mucous membrane is much improved, and an opportunity given for cure by prolonged treatment. With the improvement following the curetting, the reflex symptoms ceased, but, as the advantage was not followed up, the uterine condition again grew slowly worse, and with it the gastric neurosis reappeared. Had curative treatment been in- augurated immediately after the operation, a permanent cure would have been effected. Case XXX. Pathological Gastro - Neurosis.—Mrs. W., aged twenty-seven, began to menstruate in her fifteenth year, has always been regular, with pain on the first day, and a pro- fuse flow. Married at seventeen, she bore two healthy chil- dren. 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 con- tinually 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 experienced so little relief that she ceased all medication for the next two years, when her suffering increased, and she consulted 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, gran- ulating surface surrounding the os ; the bowels irregular, often bloated. During the menstrual period there was profuse and 92 GEORGE J. ENGELMANN. 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 re- moved the excrescences with a scoop. The operation was fol- lowed by speedy recovery, and with the improvement of her pelvic suffering the distressing gastric symptoms disappeared, although I had before 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 annoyance, backache, bearing-down pains, and a slight return of the stom- ach 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 XXXI.—Several equally marked cases have been re- cently reported. The first was by Dr. Wm. M. Chamberlain, 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 appeared. Not medication, but removal of the fibroid brought relief to the suf- ferer from so-called chronic gastric disease. Patient thirty years of age ; married. Has one child, now five years old, after the birth of which symptoms of uterine 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 epi- gastric region ; no food could be retained, so that for twenty- seven days she was kept alive by enemata. She slowly im- proved, and finally recovered. This patient again became pregnant, and all the old symp- toms 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. vomit- 1 Am. Jour. Obstet., January, 1877, p. 98. THE HYSTERO-NEUROSES. 93 ing, pain, and all other distressing gastric symptoms had ceased. They began to diminish in two hours, and five hours afterward she ate a hearty meal. When the cervical canal was open and unobstructed, the patient was comfortable, but with every la- bor pain, as the fibroid was forced down and the valve closed, the nausea, gastralgia, etc., returned. Dr. Chamberlain justly remarks that the old trouble two years ago was undoubtedly uterine in its origin, as the last was distinctly proved to be. Case XXXII.—This case, a " sympathetic hystero-neurosis of the stomach," by Dr. Formento, of New York, appeared in the July number of the Americdn 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 irregular menstruation previous to marriage. The vomiting, unaccom- panied by any pain in the epigastric region or other symptom indicating organic disease of the alimentary apparatus, at first appeared soon after marriage, then coming only in the morning when the stomach was empty. It gradually became more fre- quent, coming at all times, before and after meals, often provoked by some unpleasant sensation or a slight moral im- pression. The patient soon lost flesh ; there was extreme pros- tration with perversion of moral and intellectual faculties. Finally these disorders of innervation went so far as to produce convulsions with complete loss of consciousness, general, and at times partial anesthesia, or, during certain attacks, extreme hyperesthesia ; at times phenomena of catalepsy, or trismus, ophisthotonus, contractions of pharynx, esophagus, etc. These occurrences often took place several times during the month, menstruation continuing regular, neither more difficult nor less copious than normal. Several physicians had been consulted ; antispasmodics, tonics, hydropathy, electricity, sea-baths, mineral waters, blis- ters, morphia hypodermically, etc., had all been tried in vain. Dr. Formento found an abnormal sensibility of the external or- gans, a narrow vagina, a conical, hard, resistant cervix, of a 94 GEORGE J. ENGELMANN. 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 in- cision 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 cheer- ful, 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 examina- tion the os and cervical canal were found to have become con- siderably narrower than they were two months after the opera- tion ; this was now repeated, the same immediate and remark- able amelioration following and continuing for over a year ; then again, for the third and fourth times, the knife was re- sorted to. After a period varying from ten to sixteen months, the return of the same 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, but more in intensity than in kind. I have cited these cases at length in order to elicit the gastric symptoms as they ap- peared in each, and more particularly to demonstrate the causative relation existing between the affections of the stomach and the uterus, and the dependence of these reflex phenomena upon chronic uterine disease. However frequent these cases have come under my observation, I have seen none more characteristic than those cited in my first, paper. b. Menstrual Hystero-Neuroses of the Stomach.—While nausea, hiccough, or vomiting may appear at a menstrual hystero-neuroses, the most frequent of the menstrual hystero- neuroses is the gaseous distention of the stomach, accompa- nied by either pain, nausea, or vomiting, the menstrual hys- tero-neuroses of the stomach par excellence. It was the THE HYSTERO-NEUROSES. 95 frequency of this peculiar symptom and its strict dependence upon the uterine condition which first called my attention to the reflex neuroses, and I believe that I am safe in saying that at least one-third or one-fourth of all female patients suffering from pelvic disease have this enlargement of the stomach at the time of the menstrual engorgement, so that this swelling which appears, not with the flow, but a few days earlier, with the uterine congestion, may be looked upon almost as an indication of the approaching catamenia. This neurosis accompanies almost every menstrual disorder, and yet it is not referred to in our text-books, and is but little known to the practitioner in its relation to the female sexual organs, so that a case of this kind when observed is usually treated as an indigestion or a gastritis; 64 of'the 174 patients in the female hospital in this city in 1876 and 1877 suffered from the menstrual hystero-neurosis of the stomach—36 per cent. I made these examinations repeatedly at intervals of several months, examining indiscriminately patients from surgical, medical, venereal, and lying-in wards, and I always attained about the same per cent.; 34 out of 94 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, 29 sufferers were found among 80 patients. 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 TIMB OF APPEARANCE OF THE SYMPTOMS IN RELATION TO THE MENSTRUAL FLOW. Immediately preceding, or together with, the appear- ance of the flow............................. 1°'6 percent. 1-2 days before appearance of the flow.............. 37*9 2-3 days before appearance of the flow.............2'7"3 3-4 days before appearance of the flow............. 9#0 5-6 days before appearance of the flow.............. 3*0 1 days, more or less, before the appearance of the flow 10'6 " In middle of inter-menstrual period................. 1'6 96 GEORGE J. ENGELMANN. DISAPPEARANCE OF THE NEUR0SI3. With appearance of the menstrual flow........... On the first and second day of the flow........... With cessation of the flow...................... DURATION OF THE NEUROSIS. Several hours.................................... 3-7 per cent. l-2days........................................ H"2 " 2-3days........................................426 3-4 days........................................ 148 " 4-5 days........................................ 1^ " 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 becomes so marked that the clothing must be very much loosened if it be worn at all. The enlargement is, in almost all cases, con- fined 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 menstruation, 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, contin- ues until the cessation of the neurosis. In more aggra- vated cases the gastric discomfort is such as to produce vomit- ing, but this only when the neurosis is at its height, shortly before 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 indiges- tion, frequent anorexia, but in some instances a very good 61 "8 per cent 25-4 127 THE HYSTERO-NEUROSES. 97 appetite, notwithstanding the nausea; the flatulent distention of the stomach as a reflex phenomenon is not necessarily accompanied by that disgust for food which is a symptom of gastric disease. Time of Appearance and Duration of tlie 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 com- ing 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 106 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 inter- menstrual period. These gastric symptoms generally disappear at once when the menstrual discharge comes on ; occasionally they continue 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 34 of the 70 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 34 patients, 25 (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 7 98 GEORGE J. EN G ELM AN X. flow, so that they had learned to look upon it as a part of the suffering to which they were doomed during the continu- ance of their sexual life. It is probable that, for reasons such as this, the advice of the physician is not often sought by women suffering with this trouble, and when he is con- sulted, 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 174 patients of the Female Hospital. These were mostly servants, quite a number were prostitutes, some housewives, seamstresses, and laundresses. Since writing my first paper I have observed over one thousand cases in private practice, and, while the frequency of this neurosis among those more comfortably situated is about the same, the symptoms, as a rule, appear to be less violent. The ages of patients examined for the above statistics cover almost the entire range of menstrual life, from the fourteenth to the fifty-first year, and the diseases from which THE HYSTERO-NEUROSES. 99 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................ Ill Under treatment for uterine disease............... 15 No uterine disease acknowledged................. 96 Total number of cases examined.................... 174 Of the 31 cases in the hospital under treatment for pelvic trouble, 16 suffered from the neurosis; but, as vaginal examination was not made in all cases, it is impossi- ble 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 had recorded in my first paper as showing the menstrual hystero-neurosis of the stomach, only one was free from severe uterine disease. Since that time I have had very little opportunity of observ- ing morbid symptoms in patients not suffering from uterine disease, as none but those so afflicted are seen in a practice strictly gynecological. 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 27 of 36 patients whose histories were more carefully 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 normal; 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 mild- est forms the flow is always regular. 100 GEORGE J. ENGELMANN. The most severe cases, in which the epigastric swelling is very marked and painful, occur when the menstrual flow has been checked by some pathological influence in patients suffering from the neurosis. Thus, a woman, now thirty-one vears old, first menstruated at fourteen, and, affected 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 suffering than she had experienced while the flow was regular, 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 dependence 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, whieh 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 excessive vomiting and gastric suffering. THE HYSTERO-NRUROSES. 101 The history told of menstrual hystero-neurosis; the 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 enabled 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 de- pendent upon a pathological condition of the uterus and a disturbance of its functions, than by citing the following characteristic cases: Case XXXIII. Menstrual Hystero-Neurosis of the Stom- ach.—L. S., aged thirty-one, Bohemian ; healthy during child- hood ; 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 confined to her bed for days at a time. I saw the patient in May, 1876 ; the examina- tion showed a prolapse of the uterus with elongation of the cervix ; operation was refused ; I reduced the prolapse and re- tained 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 with- out the usual suffering, and the hystero-neurosis has not re- turned since the uterus has been in place. The prolapse, also, is so far improved that she no longer wears a pessary or tampon unless she is looking forward to an unusually severe day's labor. 102 GEORGE J. ENGELMANN. Other of the genito-reflex gastro-neuroses, which are strictly due to pathological causes and cease with their re- moval, appear during the physiological congestion of the catamenia, and hence resemble the menstrual reflexes proper. As an example of such neuroses, I may cite some peculiar cases of perverted appetite, a gastro-neurosis which has by no means received the merited attention. The school- girl who refuses her wonted food, and, regardless of admo- nition and medication, endeavors to subsist on pickles, on bread and sugar, or such other unusual articles as her fancy may crave, is ridiculed, scolded, or punished as' a wilful, disobedient child, while she is suffering from the effects of a morbid gastric stimulus, due to puberty, some malposition, or cervical catarrh, and physician and parents merely aggravate her condition by gross mismanagement. Occasionally this peculiar symptom persists as the result of uterine disease, when it is, of course, attacked by gastric medication, but it is most frequent during the physiological periods, during puberty, menstruation, and pregnancy. Known to the an- cients, known to the laity, as a resultant of conception, even considered as a certain symptom of pregnancy, the physician still seeks to overcome this reflex by gastric medication, in- stead of attacking the causative uterine lesion. It is well known as a symptom of pregnancy, and cited as one of the early signs, and it is unnecessary to substan- tiate this by the rehearsal of well-known cases. More or less common is the pathological reflex, of which a typical case is appended: Case XXXIV. A Ravenous Appetite accompanying the Menstrual Congestion immediately before and after the Tri- fling Show; Amenorrhea, Endometritis, Perimetritis; Relief by Local Treatment {Gynecological Department, St. Louis Polyclinic).—Lizzie----, a colored girl, nineteen years of age, fairly developed, has never been regular, her menses appearing in her fifteenth year, have always caused her great pain, with a slight, scarcely perceptible flow, which has even diminished of late, coming for an hour or two only. The patient complains THE HYSTERO-NEUROSES. 103 of backache, hypogastric pains, distention of the abdomen and general languor ; the uterus is small, retroverted, with an ante- flexion of the fundus, and the still-existing right perimetritis is probably the cause of all her trouble. Two days before the appearance of the flow, with the menstrual congestion, patient develops a ravenous appetite, eats constantly anything and everything within reach ; roams about the house at night to seize upon whatever is available. If the flow continues for any length of time, the symptoms abate, to return a day or two after. The girl has now been under treatment for two months ; the endometritis is greatly bettered ; the menstrual pains have diminished ; the flow is increased in quantity, and this ravenous appetite has yielded to a normal condition. Case XXXV. A Genito-Reflex Intestinal and Gastric Menstrual Neuroses ; Looseness of Bowels and Lack of Appe- tite during the Menstrual Period.—The patient, a married lady, twenty-eight years of age, mother of two children, suffering from laceration of the cervix, metritis, endometritis, and chronic perimetritis, complains of looseness of the bowels, with bad taste in the mouth, and lack of appetite during the entire menstrual period, from the second or third day before the ap- pearance of the flow to twenty-four or thirty-six hours after its cessation. In this case also the symptoms yielded to uterine treatment solely, as was clearly demonstrated, since, for experi- mental purposes, no gastric or constitutional medication was resorted to, and the symptoms disappeared with improvement of the uterine disease upon local treatment alone. It is only in the menstrual and pathological neuroses that we can so positively prove their reflex nature. The perver- sion of appetite, and other gastric symptoms accompanying pregnancy, we know only as concomitants of that condition, and not positively as reflexes, since we can not always dem- onstrate their real nature; it is by abortion, the inauguration of premature labor only, that this is done, and, when accom- plished, it affords indeed a striking proof. With mathematical exactness, the most violent gastric symptoms cease in fifteen minutes, either with the dilatation of the cervical canal and the internal os by the dilator or sponge-tent, or after expul- 104 GEORGE J. ENGELMANN. sion of the uterine contents. The remedy is too severe to be recommended for general adoption, but, when premature labor was inaugurated for other causes, I have repeatedly ob- served the sudden cessation of such gastric neuroses. The most available method of treatment, when the phy- sician has assured himself that the reflex is purely physiologi- cal, and not due to a tangible pathological cause—an erosion, a laceration, or similar lesion—is by sedatives administered internally, or by the sedative action of galvanism upon uter- ine and gastric fibres. c. Gastric Neurosis of Pregnancy.—Unfortunately the dependence of nausea and vomiting, the morning-sickness of pregnancy, upon pathological or physiological conditions of the uterus, though theoretically acknowledged, is not practi- cally accepted, and, notwithstanding the vast literature of the subject, notwithstanding the clear demonstration of the reflex character of those symptoms, the perverse treatment of earlier days is still persisted in, and the stomach is treated until the emaciated sufferer, after months of agony, is at death's door, when premature labor is inaugurated, often too late, however, to save life. If the determining cause is to be sought in the physiological congestion, it is possible that relief is to be obtained only by evacuation of the uterus ; but, if the gastric reflex is in response to a pathological change or its exacerbation by the physiological congestion, relief is readily obtained by local treatment, usually simple in its na- ture. That the nausea and vomiting of pregnancy is a reflex symptom is too well known to be in need of discussion or proof, and it seems indeed strange that it has as yet been im- possible to establish a correct therapy, and to do away with the totally irrational treatment by internal medication—the direct treatment of the gastric symptom—which appears to emanate from an ignorance of the true state of affairs. While there is no objection to the giving of light sedatives, such as bitter-almond water or bromide of potash, from which relief may be experienced, a cure can be expected with cer- tainty only by treatment of the causative uterine condition. THE HYSTERO-NEUROSES. 105 It seems almost a parody upon the advanced state of mod- ern medicine to see eminent authors still advising the let- alone treatment, conscious of the utter inefficiency of medi- cation. They urge an expectant course, unless the symptoms should threaten to become dangerous in their severity. Is this rational ? Is it the course to be recommended in other maladies ? I would strongly urge that the morning-sickness of pregnancy, however light in its character, should be re- lieved in its early stages. Mild, sedative, gastric medication may be attempted; but relief—speedy and certain—can be attained only by uterine treatment, which may be aided by gastric sedatives. The existing conditions must be noted, and any morbid deviations at once corrected, as it is impossi- ble to say precisely from which particular condition the mor- bid stimulus emanates. A congestion of the cervix may be relieved by scarification; an erosion by a sedative or astrin- gent application ; an endocervicitis likewise; friction of the congested cervix against the vaginal walls, the floor of the pelvis or the sacrum, by the elastic tampon; an astringent tampon may serve to contract the tissues. The dilatation of the cervical canal, at one time so highly recommended, should be one of the last resorts, but, when all fail, the inauguration of premature labor is indicated, and the physician should never hesitate, as a life is at stake. A rational course should be pursued, and our treatment should be consistent with our diagnosis, as is so clearly dem- onstrated by any and every one of the many cases of reflex neuroses here recorded. The morbid symptoms yield only to proper treatment of the causative morbid conditions from which the reflex impulse emanates. 2. Hystero-Neuroses of the Intestine.—Flatulence, con- stipation, and diarrhea may appear in response to uterine changes: on the one hand, the splanchnic nerves, coming from the sympathetic, may check or retard intestinal action, and on the other, an influence more or less active is exerted by the glandular secretions under control of the vaso-motor nerves, which answer so readily to general changes. Whether 106 GEORGE J. ENGELMANN. * diarrhea is due to a hypersecretion of the intestinal glands or to an increased peristaltic action, as constipation is to mus- cular relaxation, I can not say. Flatulence, and often dis- tressing distention of the bowels, without diarrhea or consti- pation, which appears in response to uterine lesions, may be likened to the most common of the menstrual neuroses of the stomach, the gastric distention. Flatulence or distention of the bowels may accompany uterine disease, or appear as a physiological neurosis during menstruation, pregnancy, or the menopause. While I have observed violent diarrheas during puberty, the most common intestinal neurosis, next to abdominal distention, is the diarrhea ; less frequently, con- stipation accompanying menstruation. Case XXXVI. Reflex Intestinal Neurosis of Puberty.— Miss H., aged fifteen, under treatment for vesical weakness, is suffering from nervous prostration, probably due to rapid growth during this time of physiological functional develop- ment. The patient had been afflicted with habitual constipa- tion, which yielded but slowly to treatment, for a few days be- fore the appearance of the first flow. I believed that a natural action of the bowels had been accomplished and a healthy tone restored ; the constipation seemed overcome. After the cessa- tion of the flow, previously existing conditions were re-estab- lished. With the advent of the second menstrual period the patient was seized with a diarrhea, uncontrollable at times, so that I found her in tears from mortification at her distressing state : one passage followed another. This annoying reflex persisted during the two days previous to the flow, yielding to constipation during its continuance, and returning again for thirty-six hours after cessation of the menses. The third period was accompanied by the same symptoms, together with other reflexes, of which we shall speak hereafter. Precisely the same condition was observed in the case of Miss B. Diarrhea a few days before the catamenia, yielding to the pre-existing constipation during the flow, with a return of the diarrhea for two days after its cessation ; costive dur- ing the intermenstrual period. This neurosis seemed to THE HYSTERO-NEUROSES. 107 alternate with the pharyngeal neurosis; as the latter im- proved, the former was intensified, both finally disappearing with treatment. This peculiar alternation of reflex symp- toms I have repeatedly observed in patients suffering at the same time from gastric and bronchial neuroses—one growing worse as the other improved, always in inverse ratio. During the complete cessation of one, the other was most intense. Our lamented friend, fellow, and president, Dr. Albert Smith, of Philadelphia, related to me several cases of diar- rhea and profuse mucous discharge from the bowels accom- panying menstrual congestion in patients suffering from uterine disease. Diarrhea is by far more frequent as a reflex symptom than constipation. I have observed a violent diarrhea dur- ing labor coming on with dilatation of the os, and ceasing suddenly with delivery. Constipation may occur like diar- rhea, as a menstrual neurosis, with the uterine congestion. In all cases but the first mentioned, where the symptoms were not such as to warrant uterine treatment, the intestinal neurosis has responded promptly to uterine treatment, and with an improvement of the local condition, reflex symptoms have ceased. The same is true of flatulence and distention of the bowels when existing as genito-reflex neuroses. Case XXXVII. Hystero-Neurosis of the Intestines {Bron- chial Hystero-Neurosis, Case JCNVII).—Painful menstrual intestinal neurosis ; localized flatulence; disappearance upon treatment of the uterine disease. Perhaps even more distressing than the bronchial neurosis was a localized flatulence which preceded the appearing of the catamenia, passing away like the bronchial neurosis with the improvement of the uterine condition, after treatment. With the appearance of the menstrual congestion came a flatulent distention of the left side, causing great pain, apparently by pressure ; to the left of the stomach, the abdomen appeared distended, tympanitic, as if by a collection of gas either in the duodenum or at the juncture of transverse and descending 108 GEORGE J. ENGELMANN. colon. So painful was this distention, which emitted a crack- ling sound, that the patient pressed her hand upon the part in agony, endeavoring with pressure and friction " to force the wind out," as she stated, pressing it to the right, and, as it es- caped, relief was afforded. Medication had, of course, been repeatedly attempted by others for this agonizing pain, which had returned with each menstrual period for almost a year, but, without success, narcotics only affording temporary relief ; but, after the inauguration of proper uterine treatment, it soon ceased like other reflex symptoms. V. Hystero-Neuroses of the Eye. Notwithstanding the frequency of ophthalmic symptoms in connection with uterine disease, their nature and the char- acter of the existing relation is by no means well established. Though it may appear simple to distinguish between condi- tions merely reflex and those due to structural changes by means of the ophthalmoscope, and by a tentative treatment if the ophthalmoscope reveals no morbid lesion, we are still greatly in the dark, strange as it may seem, since no organ is so clearly revealed to us as the eye, and in none are minute changes so readily detected. While we know that patients afflicted with chronic pelvic disease usually complain of weak eyes or impaired vision, the relation of these conditions to each other is by no means well established. Cases of ophthalmic disease are related as dependent upon uterine lesions even by MacKenzie and Mayer, also by Von Graefe, which show a certain connection between the diseases of the eye and of the womb, but no re- flex relationship; they are not neuroses, but cases of actual ambliopia in connection with amenorrhea and dysmenorrhea, caused by extravasation of blood into the retina during in- tense cerebral and pulmonary congestion, and depending upon the retention of the menstrual flow. So also may we exclude those cases of amaurosis during pregnancy and lactation which are indirectly due to changes in the sexual organs, as they are found in connection with albuminuria and accom- panied by actual lesions of the optic nerve. THE HYSTERO-NEUROSES. 109 The observing gynecologist will almost expect to hear patients suffering from chronic uterine disease, especially endometritis, metritis, and perimetritis, complain of weak- < ness of the eyes, dimness of vision, or mouches volantes ; and oculists assure me that the great majority of cases of asthe- nopia are found in females, many of them suffering from menstrual irregularities: yet, while tonics are given and an ef- fort is made to invigorate the system, the ophthalmic lesions- are treated as such without reference to the causative uterine lesions. Occasionally a patient is sent me by an oculist, usually one whom he has treated in vain for a long period of time, and, by reason of the failure of proper treatment in pro- ducing the expected result, he supposes the lesion to be re- flex in its nature, so indistinct is the relation as yet. Ophthalmic symptoms, especially ambliopia, may occur in hysterical patients, which need not be referred directly to a uterine condition; but, when transitory amaurosis or ambliopia appears at the menstrual period, the same symptoms recur- ring each month, we may look upon this as a hystero-neuro- sis, though the direct dependence can be proved only by the disappearance of the amaurosis upon the treatment of the ex- isting uterine lesion. Decrease in the power of vision, dim- ness of sight, as if from a cloud flitting before the eye, and mouches volantes, occur both as menstrual and pathological neuroses, and are then relieved by treatment of the uterine disease without interference of any kind with the ophthalmic lesion. Clement Meyer relates the case of a maiden lady, aged forty, in whom the menstrual flow is ushered in by an amaurosis of several hours' duration, which disappears as sud- denly as it comes, but is never accompanied by any of the symptoms of cerebral congestion, evidently a menstrual reflex, which would have yielded to proper uterine treat- ment. In all cases of true reflex neuroses, no structural changes exist, in the early stages at least, and the ophthalmoscope will reveal an absolutely healthy condition of the eye; but after a duration of years the disease, heretofore simulated, 110 GEORGE J. ENGELMANN. may develop in place of the phantom. In no organ is the persistent continuance of a reflex so liable to result in actual changes as in the eye. Characteristic cases are those related to me by Dr. Barker, and reported in an earlier paper. Hyperinvolution, after a second confinement, in a lady of thirty years of-age, with ces- sation of menstruation, was accompanied by a severe pain in the eyes and dimness of vision. Careful examination by Drs. Agnew and Noyes failed to discover any pathological changes, and after successful treatment of the hyperinvolu- tion by laminaria and sponge-tents, later by galvanism, the menstrual flow was re-established, the uterus restored to its normal size, and, with the removal of the morbid condition of the uterus, the trouble of the eyes disappeared. In another case, that of an unmarried lady, thirty-eight years of age, who consulted Dr. Barker on account of the severe headaches which had existed for four years, vision was impaired so that she could neither read nor write, and could distinguish persons but very imperfectly. For a period of a few days in each month the headaches were even more in- tense, and the patient suffered from diarrhea and nausea— menstrual hystero-neuroses of the intestines and stomach. Examination revealed certain uterine inflammations; hot douches were ordered, sponge-tents inserted, and leeches applied to the cervix at the time of the monthly exacerba- tion. With the return of the flow the headaches disappeared, sight was entirely restored without resorting to any treatment whatsoever for the eye, and this has remained in a perfectly healthy condition ever since, now nine years, menstruation remaining normal; while in former years treatment of the eye had been vainly tried again and again by the ablest spe- cialists. I have seen dimness of vision, never excessive, but frequently so as to prevent the patients reading, mouches volantes, and the appearance of clouds both as pathological and menstrual neuroses, frequently one eye only being af- fected, always upon the side of the most intense pelvic dis- ease. THE HYSTERO-NEUROSES. \\\ The lighter forms of ophthalmic disease which appear in response to uterine lesions yield but slowly with improve- ment of the causative disease if treatment is not inaugurated until after they have existed for some time, and it is only the more violent and rapidly-developing symptoms which respond as readily to uterine treatment as do the other reflex neuroses. It has appeared to me that the ophthalmic reflexes are much more persistent and yield more slowly than those on the part of any other organ, and, if they have persisted for years, they are very liable to result in structural changes and disease proper of the eye, which is not the case with other reflexes. This view is confirmed by the statement of one of our most able oculists, my esteemed friend Dr. Michel, who informs me that asthenopia though first developed as a reflex symp- tom in response to uterine disease, was very liable to result in structural changes even though the causative lesion be over- come after short duration. This one reflex yields only to uterine treatment when quite recent in its origin. I have been unable to refer certain ophthalmic symptoms to individual uterine or ovarian affections, but I will quote the statements of Kampoldi, of Pavia {Annales Universe! les de Medecine, September, 1881), who groups these various symptoms very positively, and refers each to a distinct pelvic disease, to show what some believe to have found. Accord- ing to Kampoldi these five groups of sexual diseases which affect the eye are as follows: 1. Hysteria and chronic perimetritis, he states, is causa- tive of asthenopia, retineal hyperesthesia, rarely of ptosis or anesthesia of the retina. 2. Menstraal disorders. Amenorrhea, he believes, is caus- ative of conjunctivitis, keratitis, iritis, and phlictania. To suppression of the menses he refers disease of the choroid, together with neuritis, retinitis, and says that they can only be improved after reappearance of the menses. The ten- dency to glaucoma is known to accompany a sudden sup- pression. 3. Inflammatory diseases result in hyperesthesia and neu- 112 GEORGE J. ENGELMANN. ralgias of the trigeminus, protracted forms of iritis serosa and sclerosis. 4. Pregnancy causes the difficulties accompanying the albuminuria of pregnancy; amblyopia and amaurosis have been common from three to fourteen days after hemorrhage. 5. Lactation and the puerperium cause panophthalmitis and many diseases resulting from weakness and debility, ulcers of the cornea, retinitis, retineal hyperesthesia, photo- phobia, and disturbance of accommodation. I cite these diseases, which are here considered as cause and effect, but, though they may be so, certainly but few are reflex neuroses ; and, though Kampoldi has observed in individual cases these ophthalmic lesions in connection with the pelvic affections mentioned, I can positively assert that, as far as reflexes are concerned, that no such positive relationship of individual phases of uterine disease to ophthalmic lesions can ever be established. Caie XXXVIII. Pathological Genito-Reflex Ophthalmic Neurosis ; Glaucoma, apparently resulting from Uterine Dis- ease, appearing with Structural Changes after long duration. —Mrs. H., forty years of age, has suffered for the last fifteen years from the results of laceration of cervix and perineum, with consequent descensus, subinvolution, metritis, and left perimetritis; had been under treatment, had even been sub- jected to operation without benefit; after coming under my care, improved slowly under treatment preparatory to operation. While she was hesitating with regard to the time of operation, after the inflammatory symptoms had been reduced, violent exertion caused an exacerbation of the cellulitis in the left side, and household cares have since then, for the past year, prevented persistent treatment. Since that time she began to suffer from pain and weakness in the left eye, which always yielded to improvement in the uterine condition, and though intense was usually relieved by the application of electricity to the uterus ; a change, however, moving into a large new house, necessitated physical exertion, and was accompanied by a good deal of excitement, and at that time the ophthalmic pain grew intense, recurring periodically at nine or ten o'clock each THE HYSTERO-NEUROSES. 113 night. I now referred Mrs. H. to my friend Dr. Michel, who was unable to detect all the characteristic marks of glaucoma, and yet took the case to be such, and not a pure reflex, from certain structural changes, though in the first place the symp- toms may have been aroused in response to uterine irritation. This case is one of those in which structural changes seem to have followed the simple reflex symptom, the phantom to have yielded to the disease.1 Case XXXIX. Ophthalmic Reflex; Photophobia, alter- nating with Dimness of Vision, mainly hi the Left Eye; Retroversion, Endometritis, and Left Cellulitis.—Miss B. M., aged twenty-one, subject to neuralgic headaches, was pros- trated by undue physical exertion, and afflicted with a dis- placement of the uterus and periuterine inflammation. Patient improved under treatment, but fright and exertion—running to avoid a herd of cattle dashing through the street—caused an exacerbation of the cellulitis, while under intense mental strain resulting from annoying family trouble. Jhe dimness of vision which had heretofore existed, and had greatly im- proved with the improvement of the uterine disease by treat- ment, now returned, and, added to this, was a violent photo- phobia, at times accompanied by intense pain in the eye. Rest, poultices, and the hot douche brought about an im- provement in the uterine condition, and a disappearance of the photophobia. The haziness and dimness of vision will, I trust, again yield as soon as treatment can be resumed. Case XL. Weakness of the Eyes, Dimness of Vision, Laceration of the Cervix, Operation, Cure.—Patient, Mrs. R., was referred to me by an oculist after an unsuccessful treat- ment for several months at a time during the past year. The reflex nature of the ophthalmic disease had been suggested to the physician by the complete failure of treatment in the com- paratively simple case. The uterus was enlarged, retroverted, the cervix lacerated, the lips everted and eroded. After a brief treatment the operation was performed ; during the convales- 1 I now hear from Dr. Michel (four months after writing the above) that the symptoms are yielding, and that this affliction, so narrowly resembling true glaucoma, is evidently a reflex. 8 114 GEORGE J. ENGELMANN. cence reading was prohibited, which was the only precaution taken and the only advice given in regard to the ophthalmic troubles ; her sight at once improved, her eyes gained strength, and progress was such that all symptoms disappeared in a month after operation. Case XLI. Menstrual WeaJc?iess of the Eyes.—Miss II., who had never before suffered from her eyes, complained, upon the appearance* of the first menstrual period with the ad- vent of puberty, of a weakness of the eye, and an irritation of the lids in the outer angle, a small crust appearing in the cor- ner which felt sore, so that she could not well open her eyes. This symptom appeared for the first time with the advent of the catamenia, and has returned now for the fourth time with each menstrual period, coming shortly before the flow and dis- appearing with its cessation. As but little suffering was expe- rienced no examination was made, and I have attempted to approximate a healthy functional activity by the precautionary measures adopted, avoidance of exposure, regulation of diet, warmth and rest in bed during the period. Case XLII. Mouches Volantes, Pain and Weakness of the Eyes, especially the Left, corresponding to the Left Cellulitis. —Mrs. S., twenty-eight years of age, married three years, sterile ; had been under treatment for a supposed uterine tumor, which proved to be a periuterine deposit. With the aggravation of symptoms by misdirected treatment, her eyes began to fail, un- til she was no longer able to read on account of the dimness of vision and the intense pain, at times black specks floating in the line of vision. The disease had existed nearly two years when she first came under my care, and an endometritis had developed in the displaced uterus, which was fixed in a posi- tion of retroversion with the fundus in the left side. At home she was not under the most favorable circumstances, and im- provement was exceedingly slow. Unable to work, unable to read, her condition was a trying one ; but her eyes were not alone weak—they troubled her so that I referred her to an ocu- list in hopes that something might be done, contrary to my expectations. No structural changes were detected, still an independent treatment was inaugurated. The use of weak glasses for a short time each day, tonics, and local applications k THE HYSTERO-NEUROSES. 115 gave no appreciable relief, and improvement did not take place until a decided amelioration of the pelvic trouble had been obtained. Finally, with the improvement in the uterine and circumuterine inflammation, her eyesight improved. The direct relation of the ophthalmic symptoms to the pelvic disease in this case was marked not only by its coming and going with the development and cure of the uterine in- flammation, the negative results of local examination and treat- ment, but also by the effect of certain pelvic applications upon the eye : an application of iodine to the uterine cavity, or tbe application of a tampon of iodized cotton to the cervix caused a burning—a reflex neurotic symptom—on the left side of the head and in the back of the eye, with a feeling, as she ex- pressed it, as if the eye was being pushed out. Within fifteen minutes after the application of the iodine to the uterine cav- ity, this post-ophthalmic pain and this feeling of distention— pushing out of the eye—comes on and continues until the iodine effect passes off. This reflex appeared so strange that I repeatedly made the application to test the correctness of the observation, and often unknown to her ; the same symptoms however appeared each time, while no other uterine or intra- uterine application produced any unusual results. Amblyopia with complete amaurosis may occur in the healthy eye as a well-marked reflex, and these symptoms re- spond as readily as the less threatening neuroses to every vacillation of the causative uterine ailment; thus I recall the case of a young lady twenty-four years of age, suffering from endometritis, cellulitis, and amenorrhea, in whom an amblyopia followed by amaurosis appeared with an exacer- bation of the uterine disease, which was always improved by uterine treatment. No structural changes having been de- tected by ophthalmoscopic examination, no local treatment whatsoever was resorted to. As the patient is not a resident of the city I have not been able to treat her continuously, but, whenever it was possible for her to come to the city and place herself under my care for three or four weeks, her eye- sight was always improved, as were the direct pelvic symp- 116 GEORGE J. ENGELMANN. toms, a cure being out of the question on account of existing pulmonary trouble. The eye is perhaps the most important organ for the study of the reflex neuroses. Since the ophthalmoscope so readily detects even the most delicate structural changes, we can draw the line between structural changes and reflex symptoms, not only by the practical test of treatment ap- plied to the causative disease of the uterus, but also by ob- servation of the condition of the eye itself; by a harmoni- ous co-operation of gynecologist and ophthalmologist the true nature of these puzzling and deceptive symptoms may be - determined, and in this transparent organ the disease distinguished from its phantom. It is possible that by the aid of the ophthalmoscope we may learn to trace to their true source those confusing symptoms in which structural changes—disease proper—secondary pathological changes or sympathetic lesions, and purely reflex symptoms converge. Symptoms precisely alike to the superficial observer may ex- ist as disease accompanying uterine changes, and independ- ent of these they may result from the congestion, or the increased quantity of blood, due to the stimulation of the circulatory system by pregnancy, as resultants, we might say, of the uterine congestion ; or they may appear as simple re- flexes without any structural changes whatsoever. This the opthalmoscope must determine, and gynecological treatment must prove. The true cause of ophthalmic symptoms once recognized, the study of those emanating from other organs will be, to say the least, greatly facilitated. Barnes, in the paper already referred to {Transactions American Gynecological Society, vol. i, p. 150), says: "Certainly the eye, in pregnancy, supplies many most interesting facts of the utmost value in extending and con- trolling the conclusions derived from other sources of inves- tigation ; for example, amaurosis is generally connected with structural change or degeneration of the retina, but there is a form of amaurosis not seldom associated with albuminuric eclampsia which may end in complete recovery. I have THE HYSTERO-NEUROSES. 117 seen such cases, and one has been recorded in the Archives de tocologie, 1876. On the other hand, the lesion thus aris- ing is, in some cases, permanent, and in these cases we may see the disease manufactured quickly under conditions more simple, more precisely defined, therefore more instructive than under any other circumstances." The amaurosis of pregnancy may occur as a simple reflex in response to uterine distention and engorgement, or it may appear as a resultant of renal disease caused by pressure of the enlarged uterus or by renal congestion. VI. Hystero-Neuroses of the Joints. While the hystero-neuroses of the joints are not frequent, they are extremely annoying, and many most puzzling reflex symptoms, due to uterine disease, some of the so-called hysteri- cal joints, are undoubtedly true hystero-neuroses. While all possible treatment is vainly tried, a careful examination of the reproductive organs would undoubtedly reveal morbid changes of some kind, and their proper treatment would readily re- lieve the heretofore unmanageable symptoms. Prof. Erb, in his twelfth volume of Ziemssen, has an excellent article on neuroses of the joints, but he barely refers to those which are distinctly reflexes due to uterine disease, and does not seem to recognize their importance. Unfortunately these reflex symptoms are still classed with those due to so-called hysteria. The articular reflexes which may be. confounded with disease proper, I have seen mainly in the hip and knee, less frequent in ankles and wrists. So deceptive is this neuro- sis that I recollect one case of a young girl at puberty who was brought to my father for examination in the early years of my practice. She had been seen by our prominent physi- cians and surgeons, had been under the trying treatment for disease of the hip, but no improvement had taken place. The most careful examination, at which I assisted, failed to reveal disease, and yet the symptoms were all present. It was long before my attention had been called to these re- flexes, and the later history of the case is unknown to me. 118 GEORGE J. ENGELMANN Undoubtedly it was an hystero-neurosis of puberty, as I have since observed it, yet never again so deceptive, simulating disease so perfectly, without any indication of existing pelvic trouble, as the reproductive organs were not considered in this base, since the menstrual function had not yet made its appearance, but this retarded development was a most serious source of neurotic phenomena of various kinds. Examination under chloroform will, of course, at once solve the mystery, and in a young girl this is the course indi- cated, examination of uterus and ovaries being admissible only after the reflex nature of the symptoms has been- assured, and constitutional treatment has proved ineffectual. Case XLIII. Genito-Reflex Neurosis of the Knee, Lacera- tion of the Cervix and Perineum, Endometritis; Relief after the Second Application.—Mrs. T., aged forty-one, came to me in June, 1887, on account of annoying uterine symptoms. She had been in good health and free from pelvic symptoms until after the birth of her third child, eight years ago, when she was confined for months by a severe attack of puerperal fever which terminated in a pelvic abscess. The symptoms of uterine disease began to develop ; these were increased by the next labor one year later. Her condition grew worse, and three years ago an operation was performed upon cervix and peri- neum, after which her general health improved ; the local symptoms were very much lessened ; but it appears that, as the patient felt well, she neglected all precautionary measures and continued in her usual course of life. Not alone did the uterine inflammation return with increased severity, but, in ad- dition to the other previously existing symptoms, backache, hypogastric pains, and pain in the top of the head, came an an- noying nausea and flow of saliva from the mouth. She again sought medical advice, and an endometritis f ungosa was dis- covered complicating the relapse, and to this the recently de- veloped reflexes, nausea, and salivation must be referred, and this supposition proved to be correct. A great amount of hypertrophied mucous membrane was removed with the curette, and immediately thereafter the nausea, vomiting, and salivary flow ceased. No after-treatment followed, and ere THE HYSTERO-NEUROSES. 119 long a lameness of the left knee became apparent. The patient walked like one suffering from an anchylosis of the knee-joint, the pain she described as being in the joint itself, and her walk was characteristic of an articular lesion. This last operation was performed in January, 1887. The gastric reflex ceased at once, but the neurosis of the knee appeared soon after, and has been growing gradually worse ever since, in proportion as the uterine symptoms increased. The curetting was well timed, and by it the cause of the one reflex was removed. Had a proper treatment of the uterine and periuterine inflammation followed at this opportune time, a perfect result might have been achieved, but, as no further assistance was offered, only one of the various morbid conditions was removed. The patient came to me May 31, 1887. I found a deep laceration of cervix and perineum, the uterus very low, en- larged, the cavity wide, an active endometritis, a deep cervical laceration, mainly to the left, with a left, chronic periuterine inflammation, and an induration of the tissues, probably lefer- able to the cellulitis in the puerperium eight years ago. I re- sorted to negative electro-cauterization of the uterus for relief of the endometritis, 40 milliamperes four minutes, platinum sound in uterus, medium plate with positive pole on the abdo- men ; this was followed by an application of 25 per cent, car- bolic acid to the endometrium, iodoform and iodine tampons to the cervix, the uterus being supported by elastic astringent tampons. The pain in the knee thereupon diminished and her walk improved. The treatment was repeated June 2d, and again June 4th. The menstrual period came on with less pain, and, upon return for treatment, June 15th, the pain in the knee had ceased, and her walk was but little impaired. The case is instructive, as it shows well-marked reflexes of different organs, each dependent upon one distinct uterine lesion, and the correct instinct of the patient is revealed. Medical advice had never been sought, as the patient had cor- rectly diagnosed her own condition, having suffered from a gastric neurosis, and, observing the direct dependence of this symptom upon the uterine condition, she supposed the stiffness and pain in the knee-joint to originate in the same way, espe- cially as it was worse when the pelvic pains increased. To ob- 120 GEORGE J. ENGELMANN tain some relief, at least, she had tried all possible inunctions and liniments, applications which had been recommended, but without any benefit; even blisters were used. 1 was surprised to see the ready yielding of the neurosis with the slight im- provement in the extensive and severe pelvic condition, and hence attribute the change rather to the direct influence of galvanism upon the uterine nerves from which the reflex ema- nates. Case XLIV. Genito-Reflex Neurosis of the Hip.—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 reclining is that of a sufferer from 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, and 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. was fond of walking, and, although fatigued, would not complain of in- creased pain in the hip after exercise. Dr. Sims kindly consented to see the patient with me. Per- mission 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 endocervicitis. The uterine symptoms, and, as we thought, all others, were now explained; local treatment was not allowed, but, by the use of tonics, astringent injections, 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 exacerbation at the time of the menstrual period. Case XLV. Pathological Reflex with Menstrual Exacerba- tion, Violent Contraction of the Points, Laceration of the THE HYSTERO-NEUROSES. 121 Cervix ; Operation ; Cure.—Mrs. P., aged twenty-nine, mul- tipara. Though annoyed for years before her marriage by a persistent leucorrhea and dysmenorrheal pains, had never com- plained of pelvic weakness. In her first confinement, cervix and perineum were lacerated, and the cervical tear aggravated in the second. Of nervous temperament, she became the victim of distressing reflex symptoms, suffering almost continuously from a headache, which finally culminated and centred in in- tense pain in the left temple. In place of the usual symptoms in the back of neck and head, pain and pressure, she had a feel- ing of drawing up, which caused such suffering that she was obliged to let down her hair and seek every possible means of relief. Her memory was impaired ; gastric neurosis was marked ; distention of the abdomen, with belching of wind and vomiting. These symptoms were greatly intensified during the menstrual period, so also was the pain in the side and across the small of the back, which became excessive at this time. With the menstrual congestion came a blinding head- ache and attacks, during which she lost consciousness, marked by violent motion in all joints, a jerking of arms, kicking, so that constant watchfulness on the part of her friends was ne- cessary to prevent injury to herself. The attacks were so se- vere that hypodermics of morphine were tried after milder sedatives and nervines had failed, but this morbid reflex did not abate until the giving of morphine was supplemented by chloroform, and the patient had been kept under its influence for an hour or more. Local treatment, followed by improve- ment in the uterine condition, lessening of the discharge and of the menorrhagia, did not affect the reflex symptoms, which in no way abated. I saw Mrs. C. in consultation with my clinical assistant Dr. F. C. Ameiss, the attending physician, who had repeatedly urged operation. Treatment proving unavailing, the patient finally consented, as her suffering grew unbearable, the head- aches more intense and almost permanent, the menstrual exa- cerbations more severe. The operation was performed March 20th, and upon recovery from the anesthetic a remarkable change was noticeable ; the patient was quiet, free from pain, her headache gone, no more nausea, not even from the chloro- 122 GEORGE J. ENGELMANN. form, and during the night natural sleep in place of the trying insomnia, from which she had heretofore suffered. The reflex nature of the symptoms in this ease and their dependence upon the laceration was most strikingly demon- strated. In no way affected by the successful treatment of the inflammatory condition, cerebral, neurotic, gastric, and joint symptoms all disappeared with the closing of the cervical tear. Two months after the operation a family birthday gave rise to unnecessary excitement and exertion, and in consequence a slight return of some of the previous symptoms—belching, with a slight nausea, and some pain in the head. These disappeared after a day's rest, and the patient is now in full enjoyment of health. Her memory is as good as ever, she sleeps well, and is free from pain ; a cheerful disposition has taken the place of the irritable temper which had before rendered home-life un- bearable. Whether the violent motions are properly referable to the joints or to the spinal nerves I will not decide. Case XLVI. Pain in the Ankles from Persistent Irrita- tion of the Uterine Fibrils after Removal of Uterus and Ova- ries.—Case XVII, referred to as an example of nerve-pains in ankles and soles of the feet, incapacitated at times from walk- ing, partially by the pain in the soles of the feet, partially by the pain in the ankle-joint, relieved by the sedative action of electricity upon the pelvic nerves. A most peculiar neurosis, which I have only twice observed, is a cracking of the joints, which has appeared as a well- marked reflex in one instance only, in a patient suffering from retroversion with metritis and endometritis, laceration of cer- vix and perineum, who noticed a peculiar cracking in elbow- and knee-joints on the right side, upon which the most severe pelvic symptoms existed. These symptoms yielded to im- provement in the uterine condition upon local treatment, after having continued for a twelvemonth. In the following case I was not able to positively demon- strate the reflex nature, but relate the history as one of the most striking on record. Case XLVII. Cracking of the Joints, with Hystero-Neu- rosis of Stomach, Heart, Eyes, and Breasts ; Metritis, Endo- THE HYSTERO-NEUROSES. 123 metritis, and Perimetritis. With some Improvement in the Pel- vic Disease after Energetic Treatment, the Symptoms dimin- ished in Intensity.—Mrs. Dr. L. is afflicted with severe pelvic disease, brought about by exposure to cold, by being driven from her home by fire on a winter's night while the ground was covered with snow. All the pelvic viscera are affected ; the uterine canal is tortuous, adhesions forcing the organ to right and left ; anteflexion, with lateral flexion ; metritis, endo- metritis, chronic cellulitis ; moreover, her condition is compli- cated by the existence of a floating kidney on the right side. Nausea and vomiting are constant, mainly at night, but most distressing during the menstrual congestion, which is relieved by only a very slight show. The neurosis of the eyes is marked ; the pain in the breasts intense during the catamenia. While the gastric neurosis is intense even during the flow, certain of the symptoms, like the painful drawing in the back of the neck, almost resembling opisthotonus, or the pain of cerebro-spinal meningitis, cease with the appearance of the bloody discharge. Since the intensification of the pelvic disease, the patient has observed a cracking of the joints, so marked that in walk- ing up-stairs the cracking of the knee-joint is audible some yards, and the same sound can be heard in elbows and wrists ; even motion of the eyelids during exacerbation of the symp- toms produces a crackling sound. The uterine and ovarian disease being so intense and of so long standing, I was un- able to attain much improvement, and suggested oophrectomy as the only possible means of relief. This was not acceded to, and, as the improvement was but slight, I can not positively re- fer the cracking of the joints to the pelvic disease, but believe it to be a reflex symptom, as it was proved to be in the case before mentioned, in which it existed, however, in a very slight degree. The stiffness of the leg, which occasionally appears as a concomitant of cellulitis or ovarian inflammation, and which may present the characteristics of a reflex hystero-neurosis, must not be mistaken for the same, as it is usually directly due to pressure upon the main tract of nerve or vessel, by 124 GEORGE J. ENGELMANN. the displaced or engorged viscera, and often by a patho- logical mass in the side of the pelvis; hence, we find this stiffness always upon the same side with an existing cellu- litis, ovaritis, or neoplasm. A case in point is that of a lady now under treatment, suffering from trying cerebral reflexes, but at present very much weakened by a cellulitis brought about by misdirected treatment at her home. The uterus is enlarged, inflamed, slightly drawn to the left side, which is the seat of a cellulitic effusion. The menstrual period is one of great suffering, and the flow is always predicted by the beginning stiffness of the left leg, which precedes its appear- ance by two days. The stiffness begins forty-eight hours be- fore the catamenia, increases until it reaches its height shortly before the appearance of the flow, to pass off slowly with its cessation. The leg is constantly weak, but this weakness is greatly increased with the stiffness during the period. VII. Dermatoses. Reflex Dermatic Neuroses. The pigmentation of the skin during pregnancy has been one of the few symptoms generally noted which link the diseases of this large surface to the reproductive organs. So little has the direct causative relation between the morbid conditions of the skin and uterus and ovaries been suspected, so little plausible did it seem, that the remarkable and note- worthy investigations which have lately been published have received but little attention. Unquestionably the persistency of many dermatological conditions is referable to their na- ture, but in some cases it is due to the fact of their being genito-reflex neuroses, and, like other reflex conditions, these are intractable, yielding only to a removal of the cause. It is perhaps more difficult to arrive at the true nature of reflex dermatoses, as they receive but passing attention from the gynecologist, being noted only as accidental accompaniments of uterine disease, and the dermatologist, though he may suspect this dependence, is not in a condition to demonstrate this, and suspects it only from the fact of the failure of his THE HYSTERO-NEUROSES. 125 treatment. Ten years ago I received but an unsatisfactory response to my inquiry among dermatologists. Dermatoses had indeed been observed with exacerbation during the menstrual period, occasionally appearing only during the catamenia, but their direct dependence upon uterine disease was questioned. While the pigmentation of the linea alba and of the areola was recognized as an evidence of preg- nancy, the sallow complexion of uterine disease and the peculiar facies of cystic degeneration of the ovary were referred to degenerated nerve-action, to imperfect circula- tion, to inability of the morbidly influenced centres to pro- mote the healthy performance of nutrition, or to a reduction in the number of red blood corpuscles. The folly of such a theory is readily recognized by the close observer, who has seen the sudden change of complexion after an operation upon the cervix or after the removal of a diseased ovary. Even while the patient is still in bed, before recovery has taken place, the sallow complexion of disease has yielded to a fresh, healthy appearance. It is a true neurosis. The genito-reflex neuroses of the skin differ from all others in the fact that they represent actual change—the disease and not the phantom; thus we have pigmentation, pustules, acne, erythema, in no way differing from the dis- ease proper, which yield to treatment of a causative uterine disease, or appear only with its exacerbation during the menstrual period, but prove intractable to local medication. I speak of them as dermatoses—as neuroses of the skin— because we may so most readily classify them. They are equally referable to the circulatory and glandular systems, as they are in fact the result of vascular changes, and must be traced to the vaso-motor nerves ; hence they resemble the symptoms which I have considered as vascular, the flushes, sweats, etc. The vaso-motor nerves, by their direct connec- tion with the uterine fibres and ganglia, must serve to explain these peculiar symptoms, which are in fact dermatoses de- pendent upon pathological and physiological changes in the reproductive organs rather than simply reflex nerve-symp- 126 GEORGE J. ENGELMANN toms simulating disease without the structural changes of disease proper. Tilt finds prurigo and eczema in intractible and recur- rent forms during the menopause. Others have observed the frequency of erysipelas at this period recurring often during two years until perfect cessation, even after long in- tervals, to cease entirely with an attack five years later. Erasmus Wilson does not consider women very liable to cu- taneous disease at the menopause, though he believes these obstinate if they do occur. Unquestionably we have equal if not more reason for these reflex symptoms during the en- tire menstrual life of woman than at this particular "period. Acne rosacea, lichen, pruritus pudendi, nettle-rash, have been observed during the menopause in patients never be- fore afflicted with cutaneous disease. How little the true nature of the reflex neuroses has been appreciated is evident from the constant placing side by side of coexisting or result- ing diseases with the reflexes. Alibert has observed a cuta- neous eruption in a patient during the menopause, who had been afflicted with the same eruption during puberty, and who had been free from any similar affection during the en- tire period of her life—a recurring reflex precisely as I have described it in other organs. Behrend, in his work on dis- eases of the skin, has more fully recognized the reflex nature of certain dermatoses than any other author hitherto, and yet he appears to regard them, as he distinctly states, rather as symptoms of the same morbid condition, and is extremely incredulous as regards their trae reflex nature, looking upon them in part as a vicarious menstruation; but he honestly states that he has not as yet been able to determine the pre- cise relationship between the cutaneous and uterine condi- tions. He has most correctly observed the frequency of eruptions during periods of pathological change in the uterus, aud says that it is a well-known fact that many of the sexual changes in woman are accompanied by morbid con- ditions of the skin—that they appear together with disease of the uterus and its annexa, or with physiological changes. THE HYSTERO-NEUROSES. 127 It is not uncommon to see women afflicted with metritis, oophoritis, and uterine displacement, suffering from persist- ent eczemata or urticaria, which do not disappear until the uterine disease subsides or the displacement of the organ is relieved; so, also, irritation of the uterus by pessaries or applications causes such eruptions. Most common, however, is the pigmentation, especially in the face, as a concomitant of chronic uterine disease or neoplasm. The same dermatoses are also observed, together with physiological changes in the reproductive organs, but, as he truly says, gynecologists have not yet paid sufficient at- tention to these cases, and he himself is not in a position to give a plausible explanation of the relationship between dis- eases of the skin and genitalia; hence he has confined himself to a description of those diseases of the skin which accompany menstruation, and he has classed them with the eruptions resulting from medication and vaccination, though he con- cedes that there is no kinship. According to his statement, puberty and the advent of menstruation are marked by sebor- rhea, the appearance of acne and comedones in the face. This is so common that the inauguration of sexual life is predicated from the appearance of these symptoms, yet he is in doubt as to a direct relationship on account of the appearance of similar diseases in men, and the fact that an acne appearing in a girl at this period may continue unchanged for years. The causal relation is better marke d, Behrend continues, in eruptions which appear a few days before the menstrual period, disappearing spontaneously with its cessation. This is more especially the case during the first menstrual periods; at times they return later in life with the catamenia. That the dermatoses which he has observed and believes to be de- pendent upon uterine changes are strictly reflex symptoms is proved by the following typical description : " They begin several days before the appearance of the flow and vanish spontaneously as it ceases, or a few days thereafter, but re- turn regularly with each period; so that the coming of the flow can always be predicted by the appearance of the erup- 128 GEORGE J. ENGELMANN. tion." This is the best evidence of a reflex neurosis, and characteristic of a causal relation, as the menstrual neurosis almost invariably bears this same temporal relation to the hemorrhagic flow. Behrend has well described another peculiarity of these menstrual dermatoses: their localized or isolated appearance. A single pustule suddenly devlopes with the coming of the menstrual congestion; a single red spot upon chin or cheek, upon the thigh, or any part of the body; thus, in one patient a single acne pustule was observed, which appeared at different times in different places, sometimes upon the knees, sometimes upon the elbow or chin ; not the slightest evidence of a second pustule being anywhere observable. Ery- thema he has observed in the same way, and cites an erythe- ma multiforma and a herpes iris continuing for a period of eight or ten days during the catamenia. Lailler, Steller, and Schramm describe such cases. Herpes and ecchymoses are related by Bartholemius and Steller; hemorrhagic nodules by Wilhelm; diffuse inflammatory dermatoses of an erysipela- tous character by Behier, Grreletti, Wagner, and Pauli. These inflammations are occasionally accompanied by edema, and followed by desquamation. In France this is known as the erysipel catamenal, and was formerly confound- ed with true erysipelas. Behrend tells us that these derma- toses are occasionally concomitants of menstrual disorders, displacements, or catarrhal conditions, but frequently without marked disease (undoubtedly an erroneous statement, the re- sult of imperfect examination). At times the causative con- nection is distinguished, as in the case cited by Schramm: A lady thirty-six years of age, formerly regular, became the subject of a uterine catarrh in consequence of a cold ; this was followed by a cutaneous eruption, which, notwithstanding its repeated recurrence, steadily diminished with the improve- ment of the uterine disease in consequence of local treatment. In all cases observed by Behrend, the recurrence of the men- strual dermatoses was temporarily checked during pregnancy. Collard relates the case of a young Norwegian in whom the THE HYSTERO-NEUROSES. 129 first appearance of menstruation was accompanied by red spots, probably petechia, over the entire body; the admin- istration of sudorifics was followed by hemorrhagic perspira- tion ; and these symptoms recurred regularly for several months with each period. Conception taking place imme- diately after marriage, menstruation ceased, and with it the cutaneous symptoms, which never returned. In other cases which have been observed, the eruption returned after con- finement. He seeks the cause in certain unknown constitu- tional changes, which take place in the system during the menstrual period or during pregnancy. While this may be true of the dermatoses of pregnancy, even of menstruation, of puberty, and the menopause, it is certainly not true of those accompanying a slight uterine or ovarian disease, and I must consider them as true reflex nervous symptoms, directly de- pendent upon the morbid or physiological changes in the reproductive organs, but determined by nerve-influence and not by constitutional changes. Striking cases have of late been recorded in medical liter- ature, among them the erythema uterinum cited by Kidd {Proceedings Dublin Obstetrical Society, April, 1880); men- strual erythema (Pauley, Berliner klin. Wochenschrift, 1880, No. 45); Joseph Beziehung, " Der Dermatosen zu den Geni- tal-Erkrankungen des Weibes" {Berliner klin. Wochen- schrift, 1881, No. 37). Among the most common of the dermatoses, I may cite the acne of puberty, flushes, sweats, and seborrhea, which give truth to the statement of Tilt that the skin is the safety- valve of the system. The eczematous eruption of the auricle and directly behind the ear I have observed twice at this period as menstrual neuroses. I have repeatedly seen the appearance of a single red spot or a single pustule (a herpes), the latter especially on the lip and on the vulva, coming like all menstrual neuroses two or three days before the appearance of the flow, to pass away with its cessation. The more common pathological neuroses are the erysipelatous inflammation of the face, petechia, pigmentation, and nod- 9 130 GEORGE J. ENGELMANN. ules over the skin, discolorations, and a sallow complexion. The pigmentation of pregnancy is so common, and so thor- oughly accepted as dependent upon this state, that it need hardly be mentioned. Generally known and recognized as dependent in some way upon genital changes in women are the acne of puberty, the pigmentation of pregnancy and disease, the sallow complexion of uterine and ovarian dis- ease ; less generally known is the herpes upon lip or vulva, which is a marked indication of genital disorders. Pig- mentation, so uniformly looked for in pregnancy that it is one of the most certain signs, is likewise a frequent accom- paniment of uterine and ovarian disease; and yet I will by no means insist that it is always a direct reflex neurosis, as no one symptom is more liable to appear in response to the changed condition of the nervous and circulatory systems, and pigmentation is dependent upon both, and may result as well directly from morbid states of these important systems ; but dominating all blood distribution and all secretions is nerve-power (Barnes), and the irritation of the important nerve-centres arising from morbid stimulus of uterine fibres may determine such results as well. As authorities have been rather inclined to associate secondary conditions with the more directly related and easily explained causative states, so pigmentation, which is so readily determined by conditions of the blood, is referred by most investigators to this cause. That the pigmentation which accompanies physiological and pathological changes in the uterus is caused by perverted nerve-action is evident by the peculiarity of this pigmentation, almost invariably symmetrical, as it is so well characterized by the butterfly of pregnancy or disease. So it is argued by Barnes, who cites the case, related by Dr. Godson in the Lon- don Obstetrical Transactions, of a girl eighteen years of age sent to St. Bartholomew's Hospital for chorea in the seventh month of pregnancy. The girl exhibited a characteristic dark pigmentation of the areolae of both breasts, leaving about one third perfectly free from discoloration. This area was almost exactly symmetrical on the two sides; it was sharply THE HYSTERO-NEUROSES. 131 limited, and, as Barnes justly says, it is inconceivable that any difference in the quality of the blood going, to the part could exist. Such cases are not uncommon, but they have escaped observation, as parts of the body are often concerned which are concealed by the clothing or bedding, and, as neither pain nor pruritus is caused, the patient herself does not call the attention of the physician to her condition. The pigmentation of the face is better known, as this must be no- ticed by the most superficial observer, and vanity forces the patient to seek relief. It is upon the large surfaces of the body that the striking characteristics of this genito-reflex neurosis are most fully de- veloped ; the most peculiar configurations are traced with per- fect symmetry, precisely alike on both sides. It is needless to describe cases, as no two are alike, yet all coincide in their origin and symmetrical appearance, as a rule. Thus, the case of a lady recently seen, in whom pigmentation of the forearm began during pregnancy, and was developed and intensified by a cellulitis during the puerperium. When I saw the patient during convalescence, the discoloration had already greatly diminished, but the peculiar configuration was still perfect, alike in every detail, every dot, and every ramifica- tion on both sides. In this case the course of the ulnar nerve and its radiations had evidently been followed; darkest toward the elbow, the density diminished and terminated in numerous branches upon the ulnar side of the back of the hand, extending around toward the palm, and the flexor front of the arm near the wrist, here and there a perfectly white spot in the darker mass, on one side precisely as it was on the other, then toward the border isolated blotches of pigment. The only possible conclusion is that this partial pigmenta- tion and peculiar distribution were determined by nerve-in- fluence ; hence the determining cause of pigmentary deposits must, in some cases at least, be a peculiar condition of the nerves at their ultimate peripheral distribution. Morbid nerve-impulse from uterine terminals may determine such 132 GEORGE J. ENGELMANN. pigmentation. It is unnecessary and far-fetched to refer this phenomenon to changes in the suprarenal capsules produced by the changes of pregnancy. Blepharal melasma is seen in women with chlorosis or mel- ancholia, but the pigmentation of the eyelids must be distin- guished from the simple venous lividity so marked during menstruation. Among the peculiar cases cited by Barnes is one of blue discoloration in a pregnant woman, and, in evi- dence of the striking nerve-influence, the complete blacken- ing of the skin of a woman condemned to death by a Parisian mob, and threatened with execution during menstruation. Fright caused a sudden cessation of the menstrual flow. Her execution being deferred for a few days, her skin became as black as that of a moderately dark negro, the joints of the fingers blacker than other parts. She became anemic, and died at the age of seventy-five, more than thirty-five years after the shock, the skin remaining dark until death. This was an unusually potent mental reflex, but no less intense may be the pigmentation which appears as a genital reflex. As a rule, the neurosis, like the cause, is insidious in its development, and not so violent in character. I shall cite only such cases as have occurred in my practice, and which have been proved to be neuroses by their direct de- pendence upon uterine and ovarian conditions. Case XLVIII. Sallow, Livid Complexion; Endometritis Fungosa ; Profuse Menorrhagia ; Operation ; Cure.—Mrs. H., forty years of age, suffered from profuse menstruation, menor- rhagia almost to exsanguination, the result of a small submu- cous fibroid and an hypertrophy of the endometrium, laceration of the cervix, enlargement and descensus of the uterus. Her complexion was so striking—leather-like, sallow—that I had often observed her on the street when passing in her carriage before she came under my care. Energetic treatment with local applications of perchloride of iron bettered the condition, but failed to check the profuse flow, merely lessening it; though she lost much less blood, her complexion remained the same. Operation was then determined upon ; the uterus cu- THE HYSTERO-NEUROSES. 133 retted, the laceration repaired. Within two days after the operation her complexion began to clear, and before she left her bed, less than ten days later, before she had gained strength, still weakened by the operation, Mrs. H. presented a completely changed appearance, a youthful, healthy complex- ion, as I said to her at the time, of " milk and roses"; a complexion to be envied by a young girl in the best of health. The above case is a striking evidence of the dependence of this livid complexion upon nerve-influence and not upon nutri- tion or the blood state, and in fact I have now so often ob- served this that I assure a patient, afflicted with such uterine disease as is susceptible of decided improvement, of a youth- ful appearance. Especially after operation for laceration of the cervix have I seen this change, rarely as sudden as in the case above described, but always sufficiently rapid to determine the question of its origin, a healthy complexion appearing long be- fore an improvement in nutrition and a gain in weight. Case XLIX. Genito-Reflex Abdominal Melasma ; Retrover- sion, Metrititis, Endometritis with Erosion; Local Treatment; Cure.—Mrs. X., from the interior of Missouri, had been under treatment for the uterine disease which had impaired her general health, but, no improvement being visible, and the attending physician having placed a Hodge pessary which had cut into the cervical tissue and caused additional pain, confin- ing patient completely to her bed, she was referred to me. When this lady came under my care she was in a wretched condition, emaciated, debilitated, with beginning bed-sores ; and I found, in addition to the ugly cervical erosion, a deep semi-lunar cut, which marked the position of the pessary ; this, like the granulating cervical erosion, suppurated freely. The abdomen was absolutely black, a lighter ring about the navel, with a fading margin toward the spine of the ilium. I was told that this condition—which had frightened them very much, as they supposed the patient was mortifying—had appeared since the aggravation of her condition by the placing of the pessary. The local condition yielded rapidly to antiseptic washes, iodoform, and carbolated tampons, together with mild applications to the endometrium, and after the third or fourth application the abdomen began to pale ; and, when the patient 134 GEORGE J. ENGELMANN. returned to her home after the second week of treatment, the surface was mottled, quite pale in places, with darker grayish, brown spots. Although her general condition had improved very much during her short stay, this perfectly black pigmen- tation could never have disappeared with the comparatively slight constitutional change had it not been under direct nerve-control, dependent upon the post-cervical ulceration, with which it made its appearance, and with the cure of which it vanished before any very decided constitutional change had taken place. This is one of the most striking cases of pig- mentation which I have seen ; the milder forms are common. Case L. Genito - Reflex Facial Dermatosis; Acne Ro- sacea ; Laceration of the Cervix ; Metritis, Perimetritis, Ante- version, and Descensus Uteri.—Mrs. E., aged thirty-six years, mother of five children, whom I attended in her sixth confine- ment, had suffered from this annoying eruption of the face, which covered the nose, and, in part, the cheeks, in butterfly form. She had not been benefited by treatment either by der- matologists or general practitioners. Gynecological applications were made, I am told, but most probably in a very superficial manner, as no local or general improvement followed the uter- ine treatment. The slight treatment which was permitted after the confinement, while I attended the patient, was fol- lowed by a very marked improvement in the cutaneous disease, but, her general condition being fair, she ceased treatment as soon as she was free from suffering, before the long-existing chronic uterine disease had been relieved—hence the derma- tosis was only relieved, not cured. Case LI. Erythematous Eruption of the Face with Men- strual Exacerbation; Retroversion with Metritis and En- dometritis.—This long-existing and annoying dermatosis dis- appeared almost completely without direct interference of any kind, upon treatment directed solely toward the uterine disease ; a relapse following injudicious exertion during my absence in the summer, the erythema partially returned, but yielded again so as to be scarcely noticeable upon the plac- ing of a proper pessary. Case LII. Reflex Erysipelatous Inflammation of the Feice; improved by Gynecological Treatment; finally cured by Re- THE HYSTERO-NEUROSES. 135 position of the Uterus.—Mrs. X., suffering from pelvic pain, nervous and physical prostration due to hyperplasia, endo- metritis, and anteflexion of the enlarged uterus, was afflicted with an erysipelatous inflammation of the face, which had per- sisted during the past two and a half years, the cutis being always in an irritated condition, showing a decidedly erysipel- atous condition during the menstrual congestion. A specialist had never been consulted, no well-defined treatment had been attempted, but various popular remedies and mild applications, occasionally recommended by the family attendant, had been tried, always in vain. With improvement in the uterine state, by treatment of the endometritis, the severity of the menstrual attacks diminished, and by continuous treatment with tonic medication, but without any cutaneous applications, the derma- tosis gradually faded, but a trifling evidence of the previous state appearing with the coming of the menstrual congestion. With the placing of a pessary, by which the uterine displace- ment was overcome, after cure of the inflammation, all traces of the reflex at once disappeared, and during the last five or six years, though the patient has not consulted me, I have heard of no return, and have seen no evidence of the trouble in oc- casionally passing her on the street. Bleeding from navel, from eyelids, nose, and ears, at the menstrual period, I have recorded among the neuroses of the circulatory system. Case LIII. Acne Pustule on the Side of the Nose recurring with each Menstrual Period; Anteflexion, Endometritis, and Perimetritis.—-Miss C, from Texas, twenty-six years of age, long afflicted with vesical pains, the result of pressure of the anteflexed uterus, menstrual suffering, and great nervous de- pression, was much annoyed by an acne pustule, which ap- peared for three successive menstrual periods upon one and the same place, on the right side of the nose, but ceased to come with decided improvement in both the position of the organ and the catarrhal inflammation. Case LIV. Vesicular {Herpetic?) Eruption on the Labia; Retroversion, Descensus Uteri, Endometritis, Metritis; Cure, with Reposition of the Uterus and Relief of the Inflammatory 136 GEORGE J. ENGELMANN Symptoms.—Mrs. E., mother of several children, suffered from a number of reflex nervous symptoms : loss of vision, amblyo- pia, cloud before the eyes, abdominal distention, and the ap- pearance of several herpetic vesicles upon the labia during the menstrual period. This eruption had accompanied the cata- menia since the exacerbation of her symptoms, but ceased to make its appearance after two months of successful treatment. It is hardly necessary to enter into the details of these cases, as it is impossible to rehearse all the numerous forms of dermatoses, as every one of them may, I believe, appear as a genito-reflex neurosis, and not in response to any one definite uterine lesion, attacking such part as is predisposed and determined in character by the condition of the system or of the tissues at the time. The red spot which has always appeared on the chin, the vesicle which has appeared upon the lip during the menstrual period, I have observed, but not for a sufficient length of time, to determine the effect of uterine treatment upon the cutaneous affection. The pru- ritus, which I have observed in two cases coming shortly after the menopause, and most inaccessible to treatment, I believe to have been a neurosis, on account of its extremely persistent character. Having resisted dermatological treatment for many years, it was mitigated and greatly improved by local applications combined with careful treatment of the uterine disease, which existed in both cases. A complete cure was finally effected in the one case only by galvanism, and the neurotic character of the disease was well marked by the success of the single application by which the disease which had so long resisted treatment was suddenly cured ; though it again returned some weeks later in a mild form, its vio- lence was broken. In the male, the preputial herpes has been observed in distinct dependence upon ulceration of the penis. Among the hysterical cases is that of Le Cat (Barnes), who observed a patient whose left leg became black during each pregnancy. The menstrual erythema of the thighs, around the vulva, I have seen as a concomitant of uterine disease, but can not positively assert its direct reflex relation. THE HYSTERO-NEUROSES. 137 The formation of small tumefactions I have observed but twice: In one instance, as an occasional occurrence in an ex- tremely neurotic patient, a great sufferer from dysmenorrheal pains; but, as uterine treatment was out of the question, I was obliged to resort to the bromides, without effect, but found the action of a mild faradic current most successful in relieving the blinding headaches and overcoming the intense pains which followed the course of certain nerves. When the suffering occurred in the arm the appearance of the nerve in this extremely emaciated patient, in whom every fibre could be observed, was that of a whip-cord stretched from the lower portion of the humerus to the upper por- tion of the forearm, over which the skin hung, the arm being slightly bent: upon various parts of the body small tume- factions, of the size of half a walnut, appeared, to pass away with the cessation of the menstrual flow as rapidly as they had come. I can only regard their appearance with the coincidences of menstruation and exacerbation of the uterine disease, at times of great bodily suffering and ner- vous excitement, as indicative of their reflex nature. In the other case, which I would cite more fully, the reflex nature of the phenomena is clearly depicted. The influence of morbid nerve-impulse upon the develop- ment of cutaneous eruptions is apparent in some of the most common of these diseases, as the herpes zoster, which is con- fined to the area of a certain intercostal nerve, and the pruri- tus vulvas, which has been known to return and persist even after the affected part of the skin had been completely excised (Schroeder); and, on the other hand, I have seen a most un- yielding case subside upon a single application of galvanism. Herpes preputialis in the male may appear as a reflex in response to urethral irritation, as in the case of emotional icterus, cited under the hepatic reflexes, in which the lichen, like the jaundice, appeared either as a cerebral reflex, in re- sponse to a sudden moral emotion—great fear—or to the balanoposthitis, and ulceration of the penis, with the cure of which it disappeared. 138 GEORGE J. ENGELMANN Case LV.— Genito-Reflex Tumefactions of the Cutis and Subcutaneous Tissue; Menstrual Hystero-Neurosis of Vari- ous Organs.—Miss E. H., under treatment for chronic uterine and ovarian inflammation, metritis, endometritis, anteflexion, complained less of direct pains than of the numerous reflex symptoms depending upon the pelvic disease. When the pa- tient first came under treatment, the most striking of the re- flexes appeared at the time of the menstrual congestion. Pain in the top of the head, in the back of the neck, with distention of the stomach were constant ; the menstrual neuroses were in- tense in character ; the breasts became tense and painful; small tumors appeared, especially upon forehead, breast, and back ; the pain in the top of the head was intense. Invariably with the nausea comes a tingling in the fingers, but she can never vomit. Nausea and tingling in the fingers always coexist. All these symptoms now appear simultaneously with the com- ing of the menstrual congestion ; the majority have existed since the development of a catarrhal condition in the utero- vaginal tract, the result of a severe cold, taken in a winter's frolic some five years ago. Both local pains and reflex phe- nomena were mild in character, but with the aggravation of the uterine disease, brought about two years ago by the pa- tient's slipping and falling heavily upon the ground, evidently determining or aggravating the anteflexion, the tingling in the fingers and body grew worse, and the pain in the head, which , did not exist before, came on. The case is a typical one. We see a group of symptoms, mild in character, appearing as functional reflexes in re- sponse to uterine and ovarian irritation, suddenly very much aggravated by. the development of a new uterine status, an increase and exacerbation of the old condition. The gastric neurosis, which before this accident existed as a mere gaseous distention, developed into intense nausea, the tingling in the fingers and other parts of the body grew worse, and the pain in the head came on as an entirely new feature in the case. All yielded to uterine treatment. Not in certain of these dermatoses only, but in almost all, is it difficult to determine their proper status, unless by its THE HYSTERO-NEUROSES. 139 vacillation with the improvements and exacerbation of uter- ine disease, independent of the condition of the system, and by the effect of gynecic therapy; even menstrual exacerbation may take place in a dermatosis not reflex in character, but secondary to, or a mere concomitant of, the uterine disease. The failure of proper dermatological treatment may lead us to suspect a reflex, and this will be proved by the disappear- ance of the eruption upon gynecological treatment alone. Like other genito-reflex neuroses, the dermatoses are im- proved by, and may yield temporarily to, the sedative action of galvanism. It is difficult to differentiate as to the correct causative dependence of these phenomena. Whether reflex or symp- tomatic, whether secondary or vicarious, whether incidental co- incidences or resultants of the same condition to which must be ascribed the pelvic symptoms, we are not yet in a position to determine without the aid of the unfailing test-treatment. VIII. Mammary Hystero-Neuroses. Keflex Symptoms on the Part of the Breast. The precise position which mammary changes assume in relation to the reproductive organs is difficult to determine, on account of the close connection existing between these parts, which we might term internal and external sexual or- gans ; and it is for this reason only that I here treat of the mammary hystero-neurosis in a separate chapter, distinct from the glandular reflexes, the breast being a gland so different from all others by reason of its intimate connection with the sexual organs—in fact, it is usually considered as a member of that group, and must justly be classed so, as we see all physiological phases of sexual life represented in the mam- mary glands precisely as they are in uterus and ovaries—the development at the time of puberty, even the menstrual con- gestion, and, the period of sexual life being closed, the shriv- eling of the breasts. A separate functional activity, how- ever, is established during the puerperium, while the devel- opment of the mammary gland accompanies that of the 140 GEORGE J. ENGELMANN. uterus—its highest functional activity is in process when in- volution takes place in the pelvic viscera. Hence we see a distinct purpose served, and the functions of the mammary gland independent in time and purpose of those in the pel- vic viscera. All physiological changes in the pelvic organs have an exponent in well-characterized changes in the mam- mae, and even physiological changes are there depicted. The enlargement of the breast which accompanies puberty and pregnancy, the retrograde metamorphosis during the meno- pause, is not a resultant of uterine and ovarian changes, but a concomitant dependent upon the same general fluctuation of sexual life. The same mammary symptoms may appear in very different relation to the pelvic status, as a resultant of the same cause, as a concomitant or an indirect response. The congestion of the gland which accompanies conception or menstruation is by no means an evidence of dependence upon the uterine condition—a reflex response to pelvic stimu- lus; and yet such swelling occurs frequently as a reflex. Pathological changes in the pelvic organs are more likely to determine reflex symptoms in the mammary gland, the con- comitant changes more commonly accompanying physiological conditions. The most frequent of the mammary reflexes are a swelling of breast, or nipple, or both, and a pain, more or less deep seated—a mastodynia. These may appear as constant or pathological neuroses, with menstrual exacerba- tion, or merely in response to the monthly intensification of uterine disease. Case LVI. Menstrual Hystero-Neurosis of the Breast; Peripheral Cardiac Neurosis; Laceration of the Cervix, Endo- metritis, Retroversion, Descensus Uteri; Operation; Cure.—Mrs. McC, thirty-two years of age, of good constitution, had been in excellent health before her marriage, but began to fail slowly after the birth of her first and only child. Nervous symptoms slowly developed ; great prostration, nervous and physical, re- sulted from the profuse menorrhagia and the painful central symptoms. Hemorrhage was checked by curetting of the uterus, and the patient appeared to gain strength, but the re- THE HYSTERO-NEUROSES. 141 flex symptoms in no wise abated. Great nervous prostration existed, and she suffered intensely from mental anxiety, a sud- den feeling of something terrible about to happen ; she could not lie still in one room, jumping up to seek a safe place in an- other ; her fears drove her from place to place. At times she had spells, as she called them, as if she must die ; insomnia, palpitations of the heart, with a thumping that appeared audi- ble, caused great anxiety ; she had a feeling as if her breath was being drawn from out of her ; all symptoms being aggra- vated with the coming of the menstrual congestion, and with this exacerbation came a swelling, with pain, in the left breast, the left side of the pelvis being the most affected ; left laceration with slight perimetritis. April 26th, treatment was inaugurated, local application of mild astringents to the cavity ; galvanism, reposition, and sup- port of the uterus with elastic tampons, repeated on alternate days. After the third treatment the severity of the symptoms abated. The menstrual period, coming on after the fourth or fifth treatment, was accompanied by much less suffering. She was enabled to rest with comfort at night and to lie quietly in the day-time, her fears no longer haunting her; the masto- dynia was slightly diminished. The patient improved in appear- ance, in spirits, and her complexion cleared, and, after nine more treatments in the next intermenstrual period, the flow came on without that swelling and pain in the breast which for the past year had invariably preceded it, and which had come with such regularity and severity that the patient looked upon it as an indication that the period was at hand. In this case the reflex nature of the symptom was clearly proved; its appearance with anteflexion, and development with uterine symptoms, and its cessation with improvement in the pelvic condition even before a cure was effected, characterized it as a genito-reflex neurosis. Case LVII. (Case XV.) Constant Hystero-Neurosis of the Breast—Mrs. S., aged thirty, hysterical, nervous, married nine years ; sterile ; has acute anteflexion, endocervicitis, oopho- ritis, and hydro-salpinx. While the fluid in the cyst is accu- mulating, the patient is confined to her bed with neuralgic 142 GEORGE J. ENGELMANN. headaches 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 shoul- der-blade. This period of accumulation and suffering, direct and reflex, is followed by a copious watery discharge per vag- inam, and relief from the pain. The breasts then become less tense and painful; the menses are comparatively regular, and have no causal connection with the mammary enlargement and Buffering, which, in this case, is dependent upon and indicative of the intensity of the pelvic suffering. Case LVIII. ( Case XVI.) Menstrual Hystero-Neurosis of the Breast.—Mrs. M., aged thirty-three, married at nineteen, sterile ; anteflexion, painful dysmenorrhea. The appearance of the menses is preceded by shooting-pains in the breast, most severe when the general suffering is increased, always easier when the flow comes, and ceasing altogether with the disap- pearance 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, which passed away completely with relief of the hyperplasia by treatment after cure of the stenosis. Case LIX. (Case XVII.) Mrs. S., aged twenty-two, mar- ried at nineteen ; sterile ; lateroflexion with slight anteflexion ; dysmenorrhea. Two or three days before the time of the monthly change, 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 disappears with the cessation of the flow. The development of the mammary gland accompanying that of the pelvic organs at puberty is often associated with an unnecessary turgescence and pain, which is most probably a reflex neurosis, and not a necessary concomitant of the physiological condition. The gland may be the seat of in- tense pain without swelling, the nipple alone may be swollen and sensitive, or the entire gland tense and painful to the touch. The latter is the more frequent of the mam- mary hystero-neuroses, usually appearing two or three days THE HYSTERO-NEUROSES. 143 before the flow, and passing away with its cessation, rarely a few days later—sometimes with the coming of the free discharge, when the catamenia are well established. IX. The Glandular Neuroses. The dependence of glandular changes upon the varying conditions of the female sexual organs has never been brought to the attention of the profession in its full extent, notwith- standing the close relationship which is known to exist be- tween certain glands and the reproductive organs. Popular belief in olden times pointed to the thickened neck as an evidence of consummated marriage, or of pregnancy. This was the reflex congestion of the thyroid. Ovariotomists know that inflammation of the parotid is liable to accompany ova- rian sepsis, or inflammation of the pelvic peritoneum ; and in the male the response of parotid disease to affections of the testicle is known to every practitioner, as well as a relation of somewhat different character—the metastasis, as it is called, of the mumps to the testicle. Perspiration, hypersecretion of the sudoriparous glands, and increased salivation, which I believe to be glandular re- flexes, were looked upon as signs of pregnancy by the fathers of medicine. The glandular changes which accompany physiological and pathological fluctuations in the reproductive organs are by far more numerous than is generally supposed. I have enumerated above the best known of these peculiar phe- nomena, but even the important glandular organs seem to respond occasionally to a perverted or morbid impulse from the genital fibres. The liver especially seems at times to answer the ganglionic impulse, as do these less important cutaneous and subcutaneous glands, and the small glands of the stomach and intestines. I do not wish to be misunder- stood, and to appear as saying that the glandular changes which accompany the development of menstruation or preg- nancy are of necessity reflex neuroses. Changes in the en- tire system which are the natural resultants of the potent 144 GEORGE J. ENGELMANN stimulus which accompanies the physiological changes in the reproductive organs, hypertrophy of the heart, increase in the quantity and quality of the blood, increased pressure to force the nutrient fluid through the developing tissue and the new-formed channels, must naturally determine a hyper- activity in the parts, and thus bring about changes of various kinds; and between the precise nature of these, whether re- sultant, concomitant, or reflex, we are not yet in a position to differentiate thoroughly. The functions of the cutaneous glands are supplementary to those of lungs and kidneys; in fact, not only is increased labor demanded from all, but in individual cases, under peculiar circumstances, infirmity of one may necessitate increased action in another—the refuse material must be cast off whatever the path may be. Thus even the kidneys are influenced, and, on the other hand, we well know the peculiar dependence of renal action upon the emotions, and that the anastamosing ganglionic fibres connect with the uterus as well as with the brain and spinal cord, so that they may be influenced by uterine irritation as well. While the profuse, pale urine indicates a hypersecretion in response to cerebral stimulus, the frequent and painful mic- turition may be the result of morbid molecular action im- parted from the uterine centre. Painful or frequent mictu- rition, which accompanies the menstrual period or uterine disease, is not of necessity caused by pressure of the tempo- rarily enlarged uterus, but may be an evidence of nerve- irritation—a reflex symptom. Thyroid Enlargement.—This symptom, taken as an evi- dence of physiological activity of the reproductive organs by the poets and physicians, as well as the common people of Home, was even regarded by so acute an observer as Meckel (Barnes) as a repetition of the uterus in the neck. This I have repeatedly observed as an accompaniment, I can not say posi- tively a reflex, of uterine disease. Thus, this enlargement existed, together with a pharyngeal neurosis, in a young girl suffering from painful menstruation ; and, after resisting local treatment, yielded slowly, long after the disappearance of the THE HYSTERO-NEUROSES. 145 accompanying reflex, with general improvement and a cessa- tion of the menstrual pain. As a proof of the peculiar influence of the nervous system upon this gland, I may cite the coexistence of goitre, idiocy, and deformity in the cretins of the Alpine valley. Case LX. Genito-Reflex Thyroid Enlargement.—Mrs. H. was annoyed by this very observable thickening of the neck, which appeared to decrease a Uttle upon the application of galvanism, after having resisted the iodine treatment, and les- sened decidedly with improvement of the uterine disease. Whether it first appeared in response to this or as an accom- paniment of pregnancy I can not say, as its development was coincident with both ; it yielded to uterine and not to local treatment. Salivary Glands, Salivation, Induration, and Impeded Activity.—A hypersecretion in both glands may accompany menstruation or pregnancy, and when it occurs is frequently one of the first evidences of conception, so that its appearance in the second pregnancy is recognized at once by the patient as a mark of her condition, of which she has no other proof at the early day at which this reflex appears. It is the fact of this rapid development so soon after conception has taken place, long before secondary circulatory changes occur, that leads me to look upon this as a physiological reflex. A highly educated lady, the wife of a physician, was afflicted in her first pregnancy with this same symptom, which again appeared soon after the second conception, and in less than twenty-four hours. The salivation had been so an- noying that she well remembered it, and at once looked upon its return as an evidence of pregnancy. In time this sup- position was verified, the reflex persisting throughout the en- tire period ; severe in the earlier months, it became less an- noying in time, to pass away entirely with delivery. The hardening of the salivary gland upon one side I have observed as an accompaniment of excessive hypertrophy of the uterus, with cellulitic effusion; and in a young girl at 10 146 GEORGE J. ENGELMANN. puberty it existed as an accompaniment of a painful men- struation, and so certain an indication was this that a harden- ing, more or less intense, invariably served to indicate the character of the coming period. Goodell, in his paper on " Inflammation of the Parotid Glands following Operations on the Female Genital Organs," * mentions two patients: one with excessive salivation dur- ing menstruation, the other suffering from a congested and diseased left ovary, with a left parotid gland which did not secrete during menstruation, causing the mouth and fauces on that side to be dry and painful, as in my own cases mentioned above. Barnes looks upon salivation as simply an evidence of the general glandular activity induced by preg- nancy, which, it may be conjectured, is a provision for the elimination of excess of circulating fluid and products of nu- trition which are to be cast off. This physiological provis- ion will at times easily pass into morbid excess, as in the patient who comes into his consulting-room holding a pint mug, which is a constant companion, being filled several times a day. I can hardly agree with this statement of the able author, because we may see likewise a diminution of the secretion, as in my own cases, and the one mentioned by Goodell, which serves to strengthen my belief in the reflex nature of these symptoms. The hystero-neuroses of the salivary glands, precisely like the reflex symptoms on the part of the nerves, the skin, and other organs, may exist either as a parlysis or a hyperactivity, so well observed in the circulatory system, which gives evi- dence of the reflex either by the flushes, the paralysis of the vaso-motor system, or by the cold skin, the chill, the hyper- activity. The sudoriferous glands respond in the same way, either by perspiration or by a dry skin. The metastasis of mumps to the sexual organs in both sexes is a remarkable evidence of the existing nerve-connec- tion. In the female, the breasts, the ovary, the womb, and the labia are the organs in which the sympathetic transfer- 1 Transactions of the American Gynecological Society, vol. x, p. 211. THE HYSTERO-NEUROSES. 147 ence takes place ; in the male, it is the testes. During the later stages of acute specific fever, it is not uncommon to meet with parotid bubo, a septic inflammation of the parotid glands, ending very generally in suppuration. This form of parotitis, Goodell tells us—from whom I have quoted the pre- ceding—is not deemed sympathetic, but symptomatic of a poi- son in the blood, which is exploded in the parotid glands ; yet, he continues: I am not sure that an element of sympathy does not exist even in this form of suppurative parotitis, and that the parotid glands are not perverted, because we have septic fever which starts from lesions of the sexual organs. Parotid bubo seems liable to follow ovariotomy whenever sepsis takes place. In two hundred cases of ovariotomy per- formed by Schroeder, and reported by Morike {Zeitschrift fur Geburtshuelfe und Gynaehologie, vol. viii, 1880), five cases of parotid bubo took place, with two deaths. Goodell reports a swelling of a parotid gland on the third day after an ovariotomy with barely a rise in the tempera- ture, which passed off without any untoward symptoms, not- withstanding the alarm caused by the belief that the swelling was mumps, and that it might do mischief by metastasis. This inflammation of the parotid glands after ovariotomy is confirmed by observations of Dr. Matweff, of St. Peters- burg. Dr. Emmet, Dr. Mann, Dr. Baker, and Dr. Kearny, all record similar cases. Goodell also relates a case of puffing of first one and then the other parotid gland, the second week after an operation for laceration of the cervix, which persisted for ninety-two weeks, so that the patient was unable to masticate solid food, and had to be fed on fluids. I heartily endorse his belief that these are more than mere coincidences, but I would even go further than the statement made by this able teacher, that " a kinship of sympathy exists between the parotid glands and the adult sexual apparatus," and would say that a direct nerve connection is established through the ganglionic fibres by which reflex activity is excited. The Liver.—The direct control of hepatic changes by 148 GEORGE J. ENGELMANN morbid uterine stimulus I cannot positively assert, and yet hepatic pains undoubtedly occur as neurotic responses to morbid conditions of the uterus, and hepatic congestion I have repeatedly observed in patients suffering from uterine disease, the circumstances being such that we might elimi- nate external influences, and I have been sorely tempted to refer the condition directly to the genitalia. We can not as- sume a dependence upon similar causes, as we may in the systemic congestion of pregnancy; certain it is, whatever the cause, that in this Mississippi Valley, abounding in malarial influences, hepatic conditions will readily occur in the weak- ened systems of patients suffering from uterine disease. The first case of the kind which attracted my attention was that of a patient afflicted with other neuroses (Case XV), who suffered from a pain in the region of the liver, and was imbued with the idea that she had hepatic trouble. Never satisfied with the explanation given, she was perfectly content after the statement of a physician, who examined her but superficially, that she had an enlargement of the liver, which was not the case, however, when examined by myself and others soon after—it may possibly have been a menstrual congestion. The occurrence of hepatic symptoms in patients suffering from uterine and ovarian disease is surprisingly frequent, even though we consider the influence under which we live, and that a certain percentage of febrile hypertro- phies must be expected in this malarial region. Certainly, at such periods, when fevers are common, patients under treatment for uterine disease are the most ready victims, and at such times I invariably see many cases, as a large per- centage of my patients show more or less marked symptoms of malaria, usually with hepatic complications. Barnes, in the article so frequently referred to, believes that the glycosuria of pregnant women illustrates the po- tency of nerve-influence upon hepatic functions, and may one day be the means of solving the mystery of diabetes, and, I would add, of reflex hepatic symptoms. Claud Bernard's experiments—the production of sugar in THE HYSTERO-NEUROSES. 149 the liver by pricking the floor of the fourth ventricle—fur- nished a striking proof of the influence of nerve-force over the action of the secreting organs. Possibly (?), as Barnes states, the " altered quality of the blood passing through the liver is an essential condition." Whether the action is in response to uterine stimulation through direct ganglionic con- nection, or by means of the medulla oblongata, is a question ; certainly, organic lesion of the nerve-structure, as Barnes cor- rectly observes, is not necessary as a factor, as is proved by the complete disappearance of sugar after glaucorrhea during pregnancy, and by the integrity of the nerves after its termi- nation. Every observation in regard to the hepatic reflexes is of value at this period; hence, I will add a case of emotional icterus, recently reported by Dr. McGrew {The American Lancet, 1886, p. 364), to substantiate the occurrence of hepatic neuroses, be they direct nerve-reflexes or brought about through the vaso-motor system, though proved, I be- lieve, by physiological experiment and by the genito-reflex symptoms in women. A patient, who had for two years suf- fered from a slight urethral discharge, was attacked by a severe balanoposthitis in consequence of a powerful cauterization. He became greatly alarmed, fearing the sloughing off of the penis, and the emotion was followed by an intense jaundice and an eruption of lichen upon the dorsal and lateral por- tions of the thorax, part of the abdomen, face, and scrotum ; little or no itching. Notwithstanding treatment, the jaundice and lichen at first grew worse, but began to subside in ten days, with great improvement in the ulceration. At the end of three weeks, the balanoposthitis and preputial ulceration became entirely well, jaundice hardly distinguishable on the sclerotics, urine normal; lichen on face disappeared, but re- mained on the body for a week longer. The icterus and lichen can only be attributed, as the author states, to sudden moral emotions caused by fear, since the liver and other or- gans were normal; no excess had been committed, and no chill had occurred. 150 GEORGE J. ENGELMANN. Among the glands affected by pregnancy, Barnes mentions enlargement of the spleen. Peculiar are the cases observed by me of women who for several years had been wholly cured of ague, and who suf- fered a relapse when pregnancy overtook them, and that not once only, but in successive pregnancies; when they were not pregnant, not a single attack occurred. Barnes records similar cases, and he asks: Is this recurrence due to a suddenly induced enlargement of the spleen, by the blood degradation attending pregnancy, to the exaltation of neurotic irritability, or to a combination of all three conditions, or to some other cause which has escaped attention ? An exalted centric nerve- irritability certainly exists, but the blood degradation I should hardly consider as the concomitant of healthy pregnancy; heightened activity, of course, determines a greater amount of refuse to be carried away. The Kidneys.—Unfortunately I have not observed with sufficient care those cases of renal and cystic irritability, of frequent and painful micturition, or variations in the secre- tion of urine, to determine their true nature, whether secondary, sympathetic, symptomatic, or reflex. I have been satisfied to see such cases improve and disappear with im- provement in the uterine disease. But, as to the true causa- tive relation, I can make no assertion. I had not ventured to suspect their reflex nature, and, occupied of late with ques- tions of greater interest to me, I have allowed such cases, as might perhaps have led to a solution, to pass from observa- tion, satisfied with the result without sufficiently careful in- quiry into the possible cause. Hypersecretion, hyperactivity of bowel and kindey are known to result from increased nerve-stimulations. Even in animals these functions respond to the emotions. Diarrhea I have repeatedly seen as an unquestioned reflex symptom, a menstrual hystero-neurosis yielding to treatment of the uterine disease, even when violent in character, and unaf- fected by local medication. For instance, as in the case of a patient who was obliged to get up six or eight times during THE HYSTERO-NEUROSES. 151 the night for some days previous to each period; a men- strual diarrhea which had continued for several years unabated, unaffected by remedies which had been tried, yielded to an im- provement in the uterine condition after six weeks' treatment. Frequent micturition, as the result of mental excitement, especially if emotional in character, is a "most common occur- rence ; the copious, clear urine is an almost invariable response to nervous excitement occurring so frequently that it may be taken as an evidence of such state; the same conditions may appear as a response to uterine irritation. More doubtful is the albuminuria of pregnancy without structural changes, which I believe at times to be the result of nerve-stimulus arising in the uterine terminals, a reflex neurosis. This is one of the various forms of albuminuria gravidarum, and I believe equally dangerous to the patient as a cause of puerperal con- vulsions, and I doubt that albuminuria determined by any other cause could result in symptoms so violent; the loading of the urine with albumen, and dangerous convulsions, all of which suddenly cease with removal of the cause, with the expulsion of the fetus, the emptying of the uterus. Un- fortunately I cannot adduce evidence as satisfactory as I should like to bring forward, as proof of the reflex nature of cystic and renal phenomena. The theory has been sufficiently discussed, and upon this I will not enter, and facts sufficiently positive I cannot add. The hysterical bladder by which vesical catarrh and even stone is simulated is one of the symptoms of hysteria, a response to spinal irritation ; but, as we know that the in- numerable fibrils, which carry the uterine stimulus not only to all the great centres but to the venous terminals, extend to the bladder as well, as they do to more distant organs, we may expect to find these neuroses in response to irritation from uterine gangliae as readily as from the spinal centres. RESUME. I trust that I may have succeeded in directing attention to the frequency and importance of the hystero-neuroses, 152 GEORGE J. ENGELMANN. those reflex symptoms on the part of the different organs which so closely resemble disease, in the cutis and in the glands even approximating it in all particulars, with accom- panying structural changes. The reflex nature of these phan- toms of disease has been appreciated by the popular mind in olden times, as it is at the present day. Certain of these phenomena are so common that they have been popularly accepted as signs of pregnancy, and, notwithstanding the apparent intuitive understanding of their nature by the masses, the medical profession apparently persists in ignoring their true nature. There is no more striking evidence of this unfortunate fact than the unswerving course of the practitioner in the treatment of the nausea and vomiting of pregnancy. This well-known reflex symptom, which yields promptly in most instances to uterine treatment, like other reflexes is indifferent to direct medication. Of late years these most interesting, most peculiar, and by their frequency and violence important, symptoms have been studied by various specialists, and yet the intricate coil has not been fully unravelled, because the study at all times has been from one side only. The gynecologist alone cannot solve the secret of the reflex dermatoses ; while, by his treatment of the uterine disease he cures the cutaneous eruption, his igno- rance of all special study of dermatology does not enable him to fully utilize the advantages offered him for observation. The dermatologist, on the other hand, recognizing a kinship between certain eruptions and the functional changes and diseases of the reproductive organs of women, is not able to assure himself positively of its nature; he recognizes only a cutaneous disease which is peculiarly unyielding to treatment. While the existence of reflex symptoms on the part of vari- ous organs and the known dependence especially of mental and nervous phenomena upon uterine changes, so evident more particularly during puberty, menstruation, and the meno- pause, has excited the interest of individual observers, the reflex has rarely been clearly distinguished from the secondary or concomitant phenomenon, and the practical bearing of THE HYSTERO-NEUROSES. 153 the question has not been revealed, hence, it has been avoided by teacher and text-book, and this eminently practical and important field is hardly beginning to receive the merited attention. The specialist alone seems to have observed these phenomena, and has looked upon them more as oddities, and not sufficiently as subjects for scientific investigation and medical teaching. Text-books and medical teachers tell the student practically nothing of this grand group of symptoms, and yet it is an element in his education as important almost as auscultation and percussion. To demonstrate the necessity of such knowledge, and the injury caused by this omission, let me recall a few of the cases I have mentioned in this paper. A gastero-neurosis, treated for years as a disease of the stomach, irritated by constant medication, the sys- tem deprived of proper nutrition, and the unrecognized uterine disease insidiously progressing until it has become unmanageable when finally discovered—the health of this lady has been destroyed, after years of most unnecessary suffering, because the reflex nature of the gastric symp- toms was unknown to any of the physicians who had been in attendance; a bronchial reflex, culminating in the most violent asthmatic symptoms, so that the patient spent night after night in the greatest agony, never able to lie down, was treated as a true bronchial affection for years until the constitution had been broken, and the pelvic disease had pro- gressed so that treatment alone was no longer sufficient; al- though the reflex even then, after persisting for years, yielded to the reposition of the retroflexed uterus within a few min- utes, all her organs, above all, her nervous system, had suf- fered, so that she did not survive the necessary operation; if taken in time, proper uterine applications, mild in character, would have stayed at once the development of all the morbid processes, but this patient likewise fell a victim to the treat- ment of the most apparent symptom, the reflex, instead of the causative uterine disease, which was completely ignored; I may also instance the case of the lady treated for her gas- tric and muscular rheumatism, which, of course, did not 154 GEORGE J. ENGELMANN. yield, who was then sent abroad, and there directed to min- eral springs for what was termed a nervous debility, and urged to exercise, sent upon long walks, which, of course, aggravated the uterine disease, which has so far been com- pletely ignored; as a consequence, all efforts have been in vain, and how easily would a proper local treatment have restored her to health! Such of these reflex phenomena as are dependent upon disease and changes in the female reproductive organs I have endeavored to picture in my study of the hystero-neu- roses ten years ago. Since then the subject has been elabo- rated, and especially the reflex phenomena which appear with the semblance of disease in the lungs, bronchii, and eye, and the reflex dermatoses have been developed by observers in this country and abroad, and all who have studied the re- flexes in whatever organ they may occur, coincide fully with me in the stress laid upon treatment of the causative disease, and the utter inefficiency of all attempts to allay the symp- toms by direct medication, by such treatment as is indicated by the disease proper, of which the phantom only is be- fore us. I have here sought to describe the hystero-neu- roses, the reflex symptoms depending upon changes in the sexual organs of women, and I have accepted as such none of the various symptoms of hysteria, but only such as have been proved to be directly dependent upon the geni- tal lesion. An examination of the cases cited will prove the fact, which may appear somewhat strange, that the great mass of these symptoms seem dependent upon uterine changes, and not upon those of the ovary. While in the cases I have cited the treatment has always been directed toward relief of all exist- ing pelvic disease, the uterus has been in the main the part affected, and in the majority of cases it was an improvement in the condition of this organ which was followed by a dis- appearance of the reflex symptoms. In many cases, and in the most violent, such as the terrible asthma or the tetanic convulsions, uterine treatment was followed by a prompt re- THE HYSTERO-NEUROSES. 155 sponse—the insertion of a stem pessary, by correcting the retroflexion, suddenly checking the terrible asthma which had persisted for years: upon the cauterization of an eroded cervix the most violent epileptiform attacks vanished as if by magic. Treatment of the ovary alone has never been at- tempted, and a direct reference of the reflex symptom to ovarian lesions I have not been able to detect. A careful examination of the numerous cases here recorded leads me to believe that the cure of violent neurotic symptoms by oophorectomy—by Battey's operation—is obtained indirectly by the uterine involution following, and not directly by the removal of the ovary as the offending organ. This will be readily accepted, if we recall how suddenly a reflex symptom vanishes if the causative condition be reached, the displaced uterus supported, a narrowed canal dilated. After operation for laceration of the cervix, the most painful neuroses, even the discoloration of the skin, frequently pass off, if not at once with the placing of the suture when union has taken place, long before constitutional improvement can be ex- pected. Such striking relief has rarely been afforded by the removal of the ovaries by oophorectomy, though undertaken for the relief of supposedly incurable nervous diseases. This fact, together with the known dependence of these reflexes upon uterine changes, leads unquestionably to the belief that a cure of nervous symptoms by this operation is impossible unless it is attained by uterine involution following the op- eration, and not by the operation itself. The reflex neuroses, we have observed, may persist after the molecular nerve-changes have continued for an undue length of time, and it is especially the eye, that most delicate organ, which is liable to a persistency of the reflex after the cure of the causative disease, and to the development of the disease proper from the phantom. Likewise we have seen that the reflexes may be relieved by the sedative action of galvanism upon the irritated uterine terminals. The action of this agent upon the affected nerve in the organ in which the symptom appears leads only to temporary improvement; 156 GEORGE J. ENGELMANN. while this is permanent when directed to the uterine fibres or ganglia, from which the morbid impulse emanates. The variety and the importance of these reflex neuroses, whether dependent upon lesions in the sexual organs of women, upon changes in the mucous membrane of the nose, of the throat, or other parts, should secure for them a per- manent chapter in the theory and practice of medicine, and the student should be taught the diagnosis and treatment of phantom disease as he is of the disease itself. C a K ^x ;V> -s- - .;© * \ \ *V' V i ^ V ^K^r-- -j*y 1 ^ NLM005584312