Neuralgia and the Diseases That Resemble It. Francis Edmund Anstie
virgin condition. So far from these females being disposed to sterility, as is too often the case with those dysmenorrhœal subjects whose troubles depend upon occlusion, distortion, or narrowing of the outlets, they are often extremely apt to the generative function; and, what is more, the full and natural exercise of the sexual function appears necessary to the health of their organs, as is shown by the fact that these menstrual pains lose their abnormal character, completely or in great part, after marriage, and especially after child-bearing. The contrast between the two types of dysmenorrhœal patients is sharply brought out by the two following cases:
Case I.—S. M., a housemaid, aged twenty-three when first under my notice, was the picture of physical health and strength, very intelligent, and a girl of excellent character and most industrious habits. At every menstrual period, however, she suffered, for some hours previously to the occurrence of the flow, from severe pain in the uterine region, which was tumefied and tender. Hot hip-baths gave some relief, apparently by hastening the discharge; as soon as the latter was established, the pain rapidly subsided. This young woman married a healthy and vigorous young man, but has never had any children, and at the date of my last inquiries still suffered periodically from her old troubles.
Case II.—Mrs. B. was married at the age of twenty-six. Up to the date of her marriage she used to suffer the most severe pain at every menstrual period; the pain, however, bore no relation to the freedom of the discharge, but always lasted about the same length of time, under any circumstances, or was only less or more according as the general bodily vigor was greater or less at the moment. From the date of marriage these troubles steadily declined; a child was born at the end of twelve months, and the menstrual troubles have never resumed a serious shape up to the present time, a period of nearly nine years. This lady is herself a neuralgic subject, liable to migraine in circumstances of fatigue, and suffering horribly from it during her pregnancies; and she comes of a family in whom the nervous temperament is strongly developed.
It must not always be concluded, because the menstrual pain is very severe before the discharge and is relieved at or soon after its appearance, that the case is one of occlusion, and not of neuralgia. There is a class of cases in which the affection appears to be a very severe ovarian neuralgia, attended with a vaso-motor paralysis which causes great engorgement of the ovary and consequent difficulty of "ovulation." I have seen several instances which I could not explain in any other way.
Case III.—One patient I particularly remember, from the fact that she was always attacked with dreadful pain, which was sometimes seated in one groin and sometimes in the other, but was regularly attended with large and palpable tumefaction of the ovary, which began to subside when the discharge commenced. This woman married rather late, but her menstrual troubles immediately became less, and she became pregnant and was happily delivered, nearly as soon as was possible. She, too, was a decidedly neuralgic subject, independently of her tendency to dysmenorrhœal ovarian pain.
In some women who remain single long after the marriageable age, ovarian or uterine neuralgia becomes a constantly-recurring torment, not only at the menstrual period, but at various other times when they are depressed or fatigued in body or mind. As might be expected, this tendency is greatly aggravated in the rarer cases where the patient's mind dwells in a conscious manner on sexual matters, especially if by an evil chance she becomes addicted to self-abuse. Among the many reproaches that have been thrown upon the indiscriminate use of the speculum in examining unmarried women, it has often been urged that it tends to excite sexual feelings. I do not for a moment doubt that this is the case, or that the indiscriminate use of the instrument is altogether indefensible. But I expect that neuralgic pain of the uterus or ovaries, in unmarried women, connected with an already irritable condition of the sexual organs, has often been the reason why such women have applied for advice and have consequently been examined with the speculum; and that the same thing has frequently happened in the case of women who have been left widows at a time of life when the sexual powers were still in full vigor. These patients deserve great pity.
The peripheral irritation which gives rise to peri-uterine neuralgia is not always originally seated in the organs of generation. The following are various sources of external irritation which I have known to produce the affection:
1. Ascarides in the rectum sometimes produce pelvic neuralgia. A woman, aged thirty-four, single, was under my care in King's College Hospital many years ago, under suspicions of ulcerated cervix. On examination, no lesion could be detected. It was discovered that the rectum was infested with ascarides, and, after the use of appropriate vermifuges and tonics, the patient entirely lost the uterine pains and also a tormenting pruritus vaginæ, from which she suffered. This woman had at various times suffered from neuralgic headache a good deal.
2. Profuse and intractable leucorrhœa, whether associated or not with ulceration of the cervix, may produce peri-uterine neuralgia, even of great severity, when there are strongly-marked neurotic tendencies. It must be noted, however, that many cases of pain in leucorrhœal subjects, which superficially bear the aspect of neuralgia, turn out on closer investigation to be merely examples of myalgia of the abdominal muscles or aponeuroses.
3. Calculus in the kidney, or in the ureter, sometimes causes intolerable ovarian neuralgia. In the case of a woman who was under my care at the Chelsea Dispensary, some years ago, this was the unsuspected origin of severe neuralgic pains in the left ovary, which recurred several times a day, and which certainly contributed to the patient's death by the exhaustion which they produced. A calculus was found tightly impacted in the ureter, near the kidney.
4. Prolapsus uteri sometimes gives rise to severe peri-uterine neuralgia, or what appears to be such; though it is difficult here to draw the line between neuralgia and myalgia. The commonest kind of pains from prolapsus uteri are not neuralgic in their nature at all, but are of a "bearing down" character, and probably depend upon actual contractile movement of the walls of the uterus.
5. The presence of tumors, either cancerous or fibroid, in the uterus or its appendages, gives rise, frequently, to severe and indeed almost intolerable pains of a distinctly intermittent character. In the early stages of cancerous diseases these pains are usually felt at the lower part of the back; in the later stages they are felt also in the hypogastric region, and are then much more severe.
6. Ulcer of the cervix, of a non-malignant kind, probably sometimes gives rise to neuralgic pain of the uterus, though this is not so severe as in cancer.
7. Large masses of scybalous fæces, impacted in the rectum, will occasionally, by the pressure which they exert on nerves, set up violent neuralgia of uterus or ovaries, the true nature of which is accidentally discovered by the use of aperients which unload the intestine and put an end to the suffering. No doubt it is chiefly in persons with neuralgic predisposition that this effect is produced; for, common as is the occurrence of extreme constipation in women, it is comparatively very rare for us to hear of distinctly neuralgic pain being caused by it.
8. The condition known as "irritable uterus," ever since Gooch's classical description of it, is always attended with uterine pain, which is continuous, but is liable to periodical exacerbations of great severity. In this disorder there is no recognizable physical disease of the pelvic organs, and the patient will generally be found to have suffered neuralgia in other parts of the body on previous occasions. [There is some difference of opinion about this affection: some authors (e.g., Hanfield Jones) considering it as distinct from the true neuralgias.]
9. Reflex irritation, the source of which is in some quite distant part of the body, has in many recorded instances occasioned uterine neuralgia, in highly-predisposed persons. I have seen one case in which severe pain of this kind was clearly proved to have been excited by the presence of a carious tooth which was itself little, if at all, painful, but the removal of which at once cured the pelvic pain.
Neuralgia of the urethra is an affection which is occasionally seen, both in males and females. I have observed it three times; all these cases were apparently traceable to the effects of excessive self-abuse. The male subject was an unmarried man, aged forty-two, of cadaverous appearance, much emaciated, with clammy, perspiring skin, and habitual coldness of the extremities; he suffered much from dyspepsia and palpitation of the heart. The pain ran along the under side of the penis, which was very large, with an elongated prepuce.