Functional disorders of the nervous system in women

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UBRABYOF CONGRESS.

•._ Copyright No,

Chapter I. The Reflex Neuroses

Every woman suffers more or less, and many almost constantly, from functional derangements of some of the organic structures of the body. We are frequently consulted by those who, although suffering from no gross pathological condition, nevertheless require our aid for the great discomforts, both physical and mental, which these various functional disturbances entail, and we should make every effort to afford them consolation and relief.

Many of these simple deviations from the normal are really precursors of conditions of a most serious nature. There is every reason to investigate carefully these minor ailments, because of their great frequency and the important bearing they have upon our success as practitioners.

It is often claimed that many physicians are too scientific and not sufficiently practical in their treatment of patients. This is a matter we should guard against, because the physician's duty is first and foremost that of healing and not altogether that of solving scientific problems. No scientific physician is pleased when he finds he has lost

» FUNCTIONAL NERVOUS DISORDERS.

some of his patients because they have been discontented and annoyed at his lack of interest and sympathy for their minor functional disturbances, and that an arrant impostor has them in charge, because, by his tact and knowledge of human nature, he has readily relieved their imaginary or trifling ailments. Old ladies and lay persons generally are often loud in their praises of these irregular practitioners simply because they have given attention to these minor difficulties.

Among the more important of these lesser derangements are the reflex neuroses, which will be considered from the standpoint of the general practitioner or gynaecologist. There are many who seem to consider them insignificant, and some even appear to doubt their actual existence.

The reflex neuroses are, of course, symptoms, but yet are more than simple symptoms as they are frequently productive of more distress than the organic disease from which they take their origin.

Neurosis is a generic term for conditions of hyperesthesia or disturbance of the nervous system which simulate disease in an organ that is healthy, or without evident lesion of any of its parts. They may be general or local. Every general practitioner should be well acquainted with them, and every specialist also. The latter must first have the knowledge of the general practitioner, otherwise many mistakes will certainly be made in the diagnosis and treatment of chronic ailments. For example, if the confiding and unsuspecting patient with a run-down constitution — the result of anxiety, bad air, and a worse diet — with a headache and some abdominal or uterine symptoms, strays into the office of an enthusiast in ocular tenotomy, he will probably want to relieve her distress by dividing the rec-

THE REFLEX XEUROSES. 3

tus muscle for eye-strain. If, however, as is more likely, she applies to a surgical gynaecologist of a certain class, a symptomatic uterine catarrh, an inoffending laceration, or a harmless, retiring cystic ovary will be pounced upon by this enlightened specialist, and receive most vigorous treatment; and if he does not always sterilize carefully his instruments he usually succeeds in sterilizing the patient. Or perhaps her destiny may lead her into the office of a digestive specialist, who, of course, diagnoses stomach trouble as the cause of all her ills, and proceeds to lower several feet of rubber hose into her surprised stomach, and treat that organ to a wholesome bath. If our specialism be allowed to run into exclusivism, very shortly the only safe man for a patient to consult will be the old-fashioned general practitioner with all his faults and deficiencies. The benefits of specialism are many and most important, but there are also some dangers to be avoided.

The neuroses of women should be studied carefully from both an anatomical and physiological standpoint. There is indeed much yet to be learned and plainly stated; The nervous system must be studied by the general practitioner as well as by the specialist, otherwise he is shut out from a true knowledge of disease. The important bearing of nutrition upon all ailments must be carefully considered before a practical common -sense solution of the many difficult problems which present themselves can be reached.

That many nervous disorders are caused reflexly, there can be no doubt. There is much difference of opinion in regard to the causation of the various neuroses, but many cases are recorded illustrating the fact that peripheral irritation is a very decided factor in their production. Irritation may be set up in any part of the body, and may result in a reflex disorder in a distant organ. Some of the sources of irritation which may be noted, are :

In the Digestive Organs — Indigestion.

a. Stomach — Gastric catarrh, ulcer.

b. Intestines — Para sites, ulcers, intestinal catarrh.

f Haemorrhoids.

c. Rectum-^ ™ cers ;

| Ihread worms.

(_ Pruritus ani.

In the Genitourinary Organs— Inflammations. Internal- —

a. Kidneys — Calculus.

I Catarrhal states.

^ . ( Inflammations.

c. Ovaries — i M ,.-, ,,

( Morbid growths.

d Uterus— i Tnflammation s- ( Morbid growths.

External —

a. Vulva — Pruritus, herpes.

b. Clitoris — Adhesions.

( Inflammation.

In the Respiratory Organs — -j Irritation (catarrhal) .

( New growths.

In the Eyes— -i Eye strain -

( Errors of refraction and accommodation.

IN the JiARS j Impacted cerumen.

The foregoing is by no means a complete summary of the causative factors which operate in the production of reflex disturbances, yet they are fair examples of what we should look for when searching for some peripheral irritation to assist us in the diagnosis and treatment of disease.

Although severe local disease may exist in an organ with but little reflex disturbance, still, usually many reflex nervous disorders depend on slight peripheral irrita-

THE REFLEX NEUROSES.

tions ; and these reflex irritations, if they are not the absolute and complete causes of the nervous phenomena, are certainly exciting causes in those individuals who have a predisposing temperament.

No one has more thoroughly investigated the reflex hystero-neuroses than Dr. George J. Engelmann, of St. Louis, whose contributions on this subject are extremely valuable. Both the sympathetic and the spinal systems are involved, and a condition of anaemia or lowered vitality is the most important causative agent in producing the hypersensitiveness of the nervous system. This weakness is the most prominent factor in the disorder. The study of the subject is of the greatest importance in the diagnosis of disease — for instance, asthma, which one may be led to consider a local pulmonary or cardiac disease, is often of reflex origin, either from the uterus, gastrointestinal tract, or from localized growths in the posterior nares. The spasmodic croup and convulsions in children are good examples of reflex nervous action.

Reflex or nervous diarrhoea is often seen in horses and other animals. It is also very common as an intestinal neurosis in the human subject, and is a result of disturbances of the sympathetic system through mental influences. The condition is analogous to that where the sound of running water causes a reflex stimulation of the renal glands, thus assisting urination.

Strong mental impressions stimulate both the vesical and rectal nerves of the young soldier when going into battle for the first time, while the uterine nerves in the young female emigrant produce amenorrhoea from the excitement incident to leaving home and coming to a foreign country. The diarrhoea of scared soldiers and of nervous horses is of similar origin, and the emission of the malodorous fluid of the Mephiticus americanus when pursued or frightened may be explained in the same way.

The differential diagnosis between a severe reflex headache depending upon uterine or digestive disease, such as pelvic cellulitis or indigestion with constipation, and beginning exophthalmic goitre, where a rapid pulse and swollen thyroid are among the earliest manifestations, is often exceedingly difficult, as the mere fact of entering a physician's office for examination will often produce in nervous young women a great amount of excitability. This may give rise not only to a rapid pulse, but also produce a globus hystericus — itself possibly a temporary congestion of the thyroid. Many of these reflex conditions are certainly common and are yet not always appreciated at their true value. They should be carefully studied in order that the differentiation between functional and organic or structural disease in an organ may be readily determined. They are of interest not only to the gynaecologist, on account of their frequency in women, but to the aurist, the oculist, the dermatologist, the neurologist, and the surgeon. In this class of cases, although the uterus is a great factor in their production, the stomach and intestines play fully as important, if not a greater part. They may be divided according to the following classification.

The neuroses of the nervous system.

The neuroses of the circulatory system.

The neuroses of the digestive system.

The neuroses of the respiratory system.

The neuroses of the genito-urinary system.

The neuroses of the glandular system.

The neuroses of the cutaneous system.

The spinal and cerebral centres are not only implicated in these disorders, but the ganglionic and vasomotor

THE REFLEX XEUROSES. 7

nerves probably even more so. This is readily seen in the flushes, perspirations, or blanching of the surface of the body. The cardiac and solar plexuses are without doubt of great importance in these ganglionic disturbances. The reflex neuroses are not to be confounded with symptoms from local mechanical pressure — mere local inflammatory neuralgia. They may, however, cause severe pain. Every one is familiar with the common reflex neuroses — e.g., those of pregnancy — but it is with the less common, but no less interesting varieties that we are concerned at present. They are important on account of their misleading qualities, and are of great practical import in the daily routine of medical practice.

These are the symptoms which connect general with special medicine, and without a knowledge of them the practitioner no longer remains a scientific physician, but gradually drifting into exclusivism, becomes little more than a skilled mechanic, and under his care the wrong organ will often receive the benefit of the medication.

Comparatively little has been written upon this subject. Fordyce Barker was well aware of its importance, and wrote a work dealing with some of the hystero-psychoses, entitled " Uterine Disease, an Exciting Cause of Insanity." Hodge and Tilt have recorded many cases. Hegar has studied them, and has shown also their importance in gynaecology. The alienist Esquirol has pointed out their connection with insanity. Dr. Engelmann has given them special study in an elaborate article in the Gynaecological Transactions for 1887, and Dr. H. J. Boldt has described the " Cardiac Neuroses in Connection with Ovarian and Uterine Disease" in an interesting article in the American Journal of Obstetrics for August, 1886. A number of other writers have also enlarged upon this interesting subject.

The frequency of hystero-neuroses may be judged when Dr. Engelmann states that he has observed in private practice, in the ten years since writing his first paper in 1877, over a thousand cases of menstrual hystero neuroses of the stomach alone.

The intimate connection, reflexly, between the uterine and digestive organs is often manifested by gastralgia in cases of retroversion, the cure of the retroversion causing the immediate and permanent disappearance of the pain in most cases. Cases of violent vomiting occurring during the act of coition have been noted. Here, in this true reflex neurosis there is generally an excessive secretion of hydrochloric acid. A case of this kind has been recently reported in the Medical Record by Dr. M. Gross. The digestive disorders are frequent causes reflexly of genital weakness, although anaemia may also be present.

No part of the body should be regarded as an independent tissue, as each one holds the closest relations with the rest of the system and is always influenced by morbid conditions in the other parts.

Digestive and uterine disorders at the menopause frequently manifest themselves by reflex disturbances of sensation in the lower extremities. One of the curious symptoms of such disturbance is diminished sensibility and a feeling as if the patient were walking over feather beds, or large puff balls, and sinking at every step. Cramps of the muscles of the calf of the leg are also of common occurrence in these disorders. These cramps are, in my opinion, of vasomotor origin, and when attacking the toes or calves, are similar in many respects to migraine. It is not alone a muscular cramp, the circulation being prin-

THE REFLEX NEUROSIS. 9

cipally disturbed. There is much between the two that is analogous.

Almost every gynaecological surgeon, who has given the matter any attention, has seen reflex neuroses dependent upon lacerated cervix. The scar tissue probably includes nerve filaments, and so keeps up a persistent irritation. It is not the specialist but the general practitioner who is most liable to discover the various reflex neuroses and give them their proper weight and treatment.

No attempt whatever has been made to go into the subject exhaustively. It is simply desired to speak of symptoms and conditions which are commonly met with, especially in women patients, and to consider some of the disorders which lie in that comparatively unknown region between gynaecological surgery and general medicine.

It is to be regretted that many gynaecologists, in the treatment of diseases of women, never permit their range of vision to extend beyond the pelvis. This is more particularly so in the case of the younger physicians who become specialists immediate!}" upon graduating, and who have never bad the advantages to be derived from a general practice.

Neuroses of ophthalmic nature require careful investigation of the digestive function, the kidneys, and the uterus. A regulation of the diet, or some gynaecological treatment, is often all that is required. Many cases of apparent gastric disease have been treated for years by medication directed to the stomach, when an endometritis was the principal causative factor in the production of the symptoms. And vice versa many a leucorrhcea has been treated locally by douches and astringents when chronic dyspepsia and hepatic congestion were responsible for its continuance. Through the ramifications of the spinal and ganglionic nerves irritation in one part of the body shows itself in distant organs. Thus, cerebral irritations may expend their force in gastric distress, and again, most of the headaches from which patients suffer are the result of disturbances within the abdominal and pelvic cavities. By a series of plates illustrating this subject it is hoped to exhibit in a graphic manner certain pathological facts, and still further to establish certain connections and functions of the ganglionic system in order that some obscurities in the physiology of the nervous system may possibly be removed.

A thorough knowledge of these reflex symptoms is extremely important, as it helps to broaden the domain of medical treatment, and careful study of the subject will increase the usefulness of both specialist and general practitioner, and tend to promote more harmonious relations between the different branches of medical science. The methods of treatment of the old-fashioned general practitioner are much more to be commended in the treatment of uterine disease than are those of some of the up-to-date gynaecologists, who think it their bounden duty to make a digital and visual examination of every patient, married or single, who enters their offices, regardless of the fact that the uterine symptoms are simply the results of overwork, bad hygiene, and poor diet, the rectification of which would cause them speedily to disappear, or of local conditions alone. It is really criminal to make a physical uterine examination of a young unmarried woman unless such a course is unmistakably indicated. The great majority of these cases do not call for any such procedure. In the married it is entirely different, and examinations may be made much more freely.

I have seen violent attacks of apnoea produced by uterine disease, and many of the cerebral neuroses are the re-

THE KEFLEX LEUKOSES. 11

suits of irritations springing up in the gastro-intestinal tract. Much of the irritability, bad temper, and moral perversion takes its origin in the abdominal cavity. The differential diagnosis between a reflex neurosis and a local inflammatory condition is often difficult, and many times the two are combined. When the neurosis is present the symptoms are out of proportion to the local pathological changes. We find lesions and pathological conditions existing in various parts of the body which, increasing in severity, increase correspondingly the severity of the neurosis, and treatment directed to these pathological states decreases the neurosis or causes its disappearance, while local remedies applied directly to the seat of the neurosis are productive of no benefit.

Some of the neuroses are very persistent. Cases of hemiansesthesia, hemiplegia, and paraplegia lasting for years have frequently been seen.

I am led to believe that in the reflex neuroses there is undoubtedly local congestion dependent on the irritation. In the globus hystericus in many instances this congestion can be determined by placing the finger, during its existence, on the front of the throat just below the larynx, where it will be found very tender to the slightest pressure.

The digestive and genital organs of women are so intimately connected by their nervous and vascular relations that to treat them separately, and yet successfully, is impossible, therefore it is readily seen how important it is for every gynaecologist to be thoroughly familiar with the digestive disorders. As I have already said in an article, the uterus, tubes, and ovaries are often treated as if they were in no way connected with each other ; so it is with the digestive tract. Its connection with the genital organs is so extremely intimate that neither of them should be treated without a careful investigation of the other, lying as they do in the same cavity, with the same vascular and nerve supply.

The skin, digestive and nervous systems are very intimately connected. Dermatoses, where the eruption covers the nose and upper part of the cheeks in butterfly form, are very common in the country districts where large quantities of indigestible fried foods are eaten. The dermatoses of reflex origin are very numerous. The laryngologist and rhinologist also should give special attention to these disorders.

Dr. S. C, a personal friend, tells me that every month or two, when suffering from an attack of aggravated indigestion, he also has regularly a severe pharyngeal and tonsillar inflammation accompanying it. This, however, might be due to an extension of the disease by continuity along the oesophagus. Yet it is probably of reflex origin. Dr. L., after a continued indulgence in strong coffee, is always attacked with severe congestion of the nasal mucous membrane, and coryza, which in this case is nothing more than a reflex neurosis. These reflex symptoms have been to a great extent ignored by the profession as a whole. The ancient Eomans recognized the congestion and enlargement of the thyroid as a result of uterine irritation.

Probably the most common of all the neuroses is the well-known morning sickness of pregnancy; migraine, and other types of headache dependent on gastric and liver disturbances are also good examples of the reflex neuroses.

It is not supposed that grave diseases, such as epilepsy, chronic mania, and other organic diseases of the nervous system, are dependent upon slight peripheral irritations, but it is certain that many important and decided functional disorders are. On the other hand, it may be said that there is not the slightest doubt that there have been many errors in ascribing conditions depending upon a general blood state, the result of mal-assimilation or autoinfection, to some slight peripheral disturbance. Some physicians are inclined to repudiate entirely the reflex theory of functional disorders, and this seems to have been quite fashionable of late. The study of the reflex neuroses is nothing more than a study of the sj'mptoms of disease which manifest themselves in distant portions of the body.

A perfect classification of the reflex neuroses of individual organs is at present impossible, but for clinical purposes we may include the following among the more common forms :

1. Cerebral. 10. Kenal.

2. Spinal. 11. Vesical.

3. Cardiac. 12. Genital.

4. Vascular. 13. Glandular.

5. Pharyngeal. 14. Ophthalmic.

6. Laryngeal. 15. Aural.

7. Bronchial. 16. Lingual.

8. Gastric. 17. Articular.

9. Intestinal. 18. Dermal.

Many of these are combined, as in the cerebro-spinal and gastro-intestinal. And two or more may exist at the same time, as gastric and dermal, cardiac and respiratory, vascular and glandular.

In his article "A Clinical Study of Neuralgias," in the New York Medical Journal, July 30th, 1887, Dr. Dana says in speaking of The Origin of " Reflex" or Transferred Neuralgias and Pain:

" No point connected with the clinical history of neuralgias is of more interest than that of their so-called ' reflex ' origin. The production of migraine has been attributed, as we have seen, to the stomach and liver, to the eye, the tonsils, and the nose. Digital, plantar, cardiac, intercostal, and, in fact, all the neuralgias have been attributed to extrinsic causes. So much has appeared in literature regarding the effects of such remote irritation that the importance of this influence has perhaps become exaggerated. At the same time the subject is one deserving of further and persistent study until its present many obscurities are removed.

" In this study it is to be remembered that the term reflex used here is not technically a correct one. An irritation in the stomach may cause a pain which is felt in the forehead. The impulse, starting in the stomach nerves, is conveyed to the cortex of the brain, and this is felt as a sensation excited by the trigeminal nerve. It is a transferred sensation, not a reflex one. since the impulse is afferent only, and the outward reference of the pain is purely psj^chical.

"Reflex pains are, therefore, really 'transferred pains,' as a rule. In some cases it may be, however, that irritations provoke reflex vasomotor changes in remote parts, and the ansemia or congestion thus produced causes pain. There may be, therefore, 'indirectly produced reflex pains.' The term reflex pain is so widely used that I cannot attempt to discard it. I use it, however, with the explanation here given. . . .

"Irritations from the stomach cause reflexly a larger variety of pains. It is not possible to decide always whether these pains are reflex, or are due to vaso-motor disturbances or the circulation of morbid products in the blood as in cases of fermentative dyspepsia, and of constipation associated with dyspepsia.

" We all know that the simple ingestion of a glass of icewater will cause a sharp frontal or temporal pain. Lauder Brunton finds that constipation and presumable intestinal irritation cause a diffuse frontal headache over the whole brow. When there is no constipation and the condition is one of gastric irritation the pain is either just above the eyes, or more rarely in the occiput (when it will be relieved by acids) , or just at the roots of the hair (when it will be relieved by alkalies). . . .

" The scapular or shoulder pains in dyspepsia, and the pains felt between the scapulae, due to the involvement of the posterior branches of the second to the sixth intercostal nerves, are common phenomena familiar to all.

" Gastric irritations must have a certain severity to be felt as pain in the stomach or epigastrium, and in these cases there is doubtless, as a rule, some muscular spasm of the stomach walls.

"The milder irritations produced by gas, undigested food, excess of acid, etc., seem to be reflected most often upon the upper intercostal nerves or the cardiac nerves, vagal or sympathetic. The headaches in gastric irritation so often involve some toxic element that we cannot speak of their origin with much positiveness.

" The stomach and intestines are probably the most frequent cause of transferred pains; after this I would place the uterus and its appendages, and next the eye or heart. Lange considers that the heart ranks second.

" In kidney disease neuralgic pains may be felt in the lumbar region, radiating forward to the lower abdomen and genitals— in other words, a lumbo-abdominal neuralgia is produced. In a case of renal colic I have observed the pain to be repeatedly centred about the anterior superior crest of the ilium.

"Pains started up by the gall-bladder are felt in the right side of the thorax and right arm, while it is one of the aphorisms of medicine that disorders of the liver may cause pain in the right shoulder. Bilious headaches cured by a dose of calomel I have observed to be located sometimes in the vertex and occiput.

" In abscess of the spleen there is a pain felt in the left shoulder (Grotonelli, Wardell).

" Lange says (loc. cit.) that in uterine troubles the reflex pains occur oftenest in the form of arthralgias. I have had a patient suffering with painful spasms of the bladder who had intense pain in the palms of the hands every time she had a bladder spasm {Medical Record, July 25th, 1885) ; another patient, while pregnant, suffered from digital neuralgia, and in a third case reported by myself, a patient of Dr. Nilsen's, suffering from ovarian prolapse, had severe and continuous neuralgic pains in the wrist. Studies of the cause of reflex pains in the feet show that they may be referred in almost all cases to irritation of the genito-urinary tract, and occur more often in the male {Medical Record, July 25th, 1885). The pains of uterine disorder, when reflected down, appear rarely to go below the knee; in other words, they affect the lower branches of the lumbar plexus, and not the sacral nerves.

" It has been stated that pain in the heels may be caused by ovarian abscess. In my experience, such pains are due to lithsemic and neurasthenic conditions, and will be relieved by remedies addressed to such states. It may be said in general, then, that pelvic irritations are felt most frequently in the upper and short branches of the lumbar plexus, next perhaps in the intercostal nerves and upper cervical nerves, then in the trigeminus, and last in the hands and feet.

" Lesions in the lung itself cause reflex pains in the form of intercostal neuralgia. Slight pulmonary congestions, such as occur at the very onset of phthisis, may cause intercostal neuralgia, and Anstie speaks of the value of these pains as warnings of the approach of phthisical disease. Apart from these neuralgias, the lung is very rarely an excitant of reflex pains, perhaps because its nerve supply is small, aside from the sensory fibres of the vagus. Further study, however, may show that lung irritation may cause some of the painful affections of the larynx, tongue, or throat.

" The question now arises whether, with these various facts before us, any general statements can be made with regard to the production of transferred pains. If we study them in connection with the anatomical arrangements of the cerebro-spinal and so-called sympathetic system, it is possible that the diffusion and transference of pain, though in 'a mighty maze,' will not appear entirely without a plan.

" The cerebro-spinal nerves are sent out from their centres in divisions or companies of seven, and each company acts together and serves a common definite physiological purpose. These divisions are :

"1. The oculo-motor nerves, the trifacial, and the seventh — which supply motion and feeling to the face and anterior scalp. The remaining cranial nerves supply internal parts.

" 2. The four upper cervical nerves forming the cervical plexus. This leash of nerves supplies motion and sensation to the neck and occiput, and controls the movements of the cephalic extremity. It is in close connection with the trifacial, both at its origin and periphery, both directly and via the sympathetic. It is subjected to much the same disturbances, and may be looked upon as physiologically almost a part of the first set — i.e., of the common sensori-motor cranial nerves.

" 3. The third leash of nerves is composed of the last four cervical and first dorsal. They form the brachial plexus, and furnish motion and sensation to the upper extremities.

"4. The fourth set includes the dorsal nerves from the second to the sixth. This supplies the chest wall, including the pleura, and with the sympathetic the lungs beneath .

" 5. The fifth set consists of the lower seventh to eleventh intercostals, which supply motion and sensation to the abdominal walls, to the lower dorsal muscles, and the skin over them.

" 6. The sixth set consists of the first four lumbar nerves with part of the twelfth dorsal, which is really a lumbar nerve. This supplies motion and sensation to, in general words, the hip girdle — i.e., the muscles (erector spinae, etc.) of the loins, those of the anterior, inner, and outer portion of the thigh, and the skin over these regions, extending down to the upper half of the buttock and to the groin, scrotum, and labia. It is the lumbar plexus which furnishes most of this supply.

"7. The seventh and last set consists of the sacral nerves, whose anterior branches (those of the first four, with the lumbo-sacral cord) form the sacral plexus. This supplies the external genitals of the male, the clitoris and

THE EEFLEX NEUROSES.

Area I.

Area II.

Area III.

Area IV.

Area V.

Strands of

cerebrospinal

nerves.

Trigeminus, facial, etc.

Upper 4 cervical.

Lower 4 cervical and 1st dorsal.

Upper 6 dorsal.

Lower 6 dorsal except last.

Area VI.; 12th dorsal, 4 i lumbar.

Area VII. 5th lumbar and 5 sacral.

Distribution.