vegetative life are seriously disturbed in their functions or structure, pain is experienced, sometimes in the viscera themselves, but most frequently in some portion of the walls of the cavities in which they are contained. The spinal nerves which are distributed through the viscera, receive the morbid influence, transmit it to that portion of the spinal column whence they originate, and the pain is then reflected through the spinal nerves which proceed to the cavities containing the viscera.

The ovary may transmit pain to the spinal nerves by means of the splanchnic nerves. The upper part of the womb is supplied with spinal nerves from the intercostal branches, through the medium of the splanchnic nerves and ovarian plexus, and any disease seated in that part of the womb may cause the reflected pains to be felt in various parts of the spinal column. The middle and lower portion of the uterus is furnished with branches of spinal nerves from the lumbar plexus through the medium of the hypogastric, and when this part of the womb is diseased, the pains are transmitted along these nerves and reflected on those which arise from the lumbar plexus, and therefore along the nerves supplying the muscles of the lumbar portion of the back, the walls of the abdomen, inside of the thighs, the front of the leg, and even sometimes to the instep. The spinal nerves distributed to the vaginal portion of the generative intestine arise from the sacral plexus; hence disease of the vagina causes pains to be reflected along the nerves which come from this plexus, and as this plexus furnishes nerves to the sacral region, to the peritoneum, the posterior part of the thighs, and the calves of the legs, pains may be experienced in all this course, and, in some rare cases, even in the soles of the feet. It will therefore be seen that it is not possible to ascribe the dorsal and the hypogastric pains, each to a distinct set of nerves.

DORSAL PAINS.-These are almost always fugitive in the upper portions of the spinal cord, and principally settle in its lower extremity, radiating to the small of the back, the loins, thighs, and legs. The pain is generally described as an aching or numbing pain, a gnawing, dragging, burning, or grinding pain; a sensation as if the back were broken, or as if it were opening and shutting-varieties of pain, like those of neuralgia

in other parts of the body; their intensity varies from that of slight pain, which does not prevent moving about, to that which, for a time, usurps the place of all other sensations, confining women to their beds for a few days. The frequency of these pains is as follows:

Lumbo-dorsal pains already existed in.
They were augmented at cessation in

70 per cent.

46

66

A great intensity of pain in the brain and spinal column is seldom met with at the same time, for the two are in general so counterbalanced, that when a great amount of cerebral disturbance exists, the spinal symptoms have not a similar intensity. During the prodroma of menstruation, and during the "dodging time," the cerebral symptoms are most intense; the spinal symptoms are, in general, more common and annoying during the period of the full activity of the generative function; and at cessation great is the intensity of both modes of suffering.

HYPOGASTRIC PAIN. This pain is generally referred to the ovarian, and to the uterine regions. It differs from the symptom just described, in being a pressing, forcing, or bearingdown pain. It seems to indicate a tenesmus of the cervix uteri, to have an expulsive character, and to mark the direction of those neural currents which direct the course of blood towards the womb, and procure its expulsion from that organ. Even when the menstrual flow has ceased, these pains sometimes recur monthly, and determine the leucorrhoeal discharge, or the diarrhoea, by which they are often accompanied. Such pains had previously recurred during menstruation in

I have known women suffer habitually from colics for eight and ten years after cessation, the intestines being the seat of pain, which, however, did not interfere with their proper functions. The following was a tedious case in which dorsal and a fixed ovarian pain were the prominent symptoms:

CASE 38.-Lumbo-abdominal neuralgia.-Patience K. was tall, stout, with a broad face, thick masculine eyebrows, dull, squinting gray eyes, brown hair, a sanguine temperament, and she was in her forty-eighth year. The menstrual flow appeared at fifteen, and continued regular without disturbance. She was once laid up for a year by some acute affection of the brain before she married at twenty-four, but was fruitless. At fortyfour she again suffered much from pains in the head, and pain in the right arm, which was benumbed and contracted for some time. This was cured, but P. K. has been ailing ever since, off and on, subject to a throbbing, heavy pain at the top of the head, to nervousness, to trembling, to loss of memory, to palpitation, to epigastric pain, sometimes only after taking food, at others without a cause. This has been more troublesome during the past year, and for the last four months she regurgitated sour or bitter stuff once a week. She looks vacant, bewildered, and of late has had fainty feelings, and a clammy skin. For the last two years there have been frequent pains in the ovarian regions, "as if from the plunging in of a knife," and for the last year intense pains have arisen at the lower part of the back and sacrum; her other sufferings have increased and have become more frequent. During this time the menstrual flow has also been irregular, much more abundant, and with scarcely more than ten or twelve days between the menstrual periods.

To allay the derangement of the biliary functions was the first indication; the next was to prevent the too frequent recurrence of the menstrual flow, by adding 6 drachms of tincture of cinchona to the comp. camph. mixture. Two tablespoonfuls to be taken three times a day. I also prescribed 20 drops of liquor potassæ in a little water, after meals, and at night 4 grs. of blue pill, with 2 of ext. of rhubarb, to be followed by an ounce of castor oil in the morning. An opium plaster to be applied to the pit of the stomach. Feb. 12th.-Ten oz. of

220

LUMBO-ABDOMINAL NEURALGIA.

blood were taken from the arm. The previous remedies were continued, with the exception of the pills, which were now to be taken only on alternate nights. March 11th.-The menstrual flow has not appeared for six weeks. The food is better digested, but the tongue is still furred, and there is much pain under the left breast and in the left ovarian region. Leucorrhoea is abundant, the os uteri has the usual size, it is painful on pressure, which also increases the habitually felt hypogastric pains. There is no ovarian swelling. April 21st.-A blister to the left ovarian region only relieved the intense pain for two days. Mercurial and ext. of belladonna ointments rubbed in twice a day did no good, so I ordered 20 drops of Battley's solution and I drachm of tinct. of hyoscyamus mixed in a little warm milk to be injected once a day into the rectum. May 20th. The sedative injections have given great relief. The menstrual flow came without much pain after an interval of three weeks. There is still intense pain in the back. On again examining the patient I can find no organic uterine disease. The pains are caused by the cessation of the uterine function in a woman whose nervous system has been shattered for the last five years. July 22d. The menstrual flow came after an interval of ten weeks. The patient is again very bilious, and is ordered the blue pill and previously named remedies; 4 oz. of blood are to be taken from the arm. November 1st.-The biliousness has gone, the sedative injections control the intense pains; the head symptoms are better. The menstrual flow has again appeared after an interval of thirteen weeks. When I lost sight of the patient she had been many months without menstrual flow, the pains much less severe, and her health good.

TREATMENT.-There is a distinct indication to use sedatives until the habitual pains are assuaged, and they may be continued for weeks without ill effects. Soothing liniments may be rubbed in night and morning; I mean camphorated liniment, with the addition of tinc. of opium, belladonna, hyoscyamus, separately or combined, as the case may suggest. Soft opium or belladonna plasters may be applied and renewed every four or five days; and, better still, my ready-made plasters, made by spreading atropia glycerine ointment on Mackintosh calico,

as described in my "Handbook of Uterine Therapeutics." Linseed-meal poultices sprinkled with camphor, mustard poultices, and even blisters, may be useful. For abdominal pains the best application is a piece of piline large enough to cover twothirds of the abdomen, to the upper corners of which tapes are to be sewn, so that the piline may be worn like an apron next the skin during the day. This alone often gives relief, but a teaspoonful of laudanum sprinkled over the cloth side of the piline makes the remedy more efficacious.

Paraplegia. In infants, paraplegia generally depends on intestinal irritation; in adults, on vesical or uterine affections; and in old age, it appears as an idiopathic disease. It might have been supposed from the manner and frequency with which the lower part of the spinal cord is influenced by menstruation, miscarriages, parturition, and diseases of the sexual organs, that women would suffer more than men from diseases of the spinal cord, but out of 177 cases of paraplegia tabulated by Brown-Séquard, only forty-nine occurred in women. Out of 114 cases of locomotor ataxy collected by Dr. Topinard, there were only thirty-three women; and in seventy cases of the same disease collected by Eisenmann, there were only twenty women. With regard to paraplegia at the change of life, it must be considered a very rare disease.

Gardanne mentions having seen paraplegia occur after the sudden cessation of the menstrual flow, but he gives no details. My six cases and a few others subsequently observed were of a mild nature, and all recovered. There were pricking sensations in the feet, numbness of the lower limbs, great pain in the dorsal region, and an inability to walk. Three complained of a difficulty in passing water, and the sensibility of the skin of the lower limbs being impaired. Similar cases have been met with by Dr. G. Bedford and B. de Boismont. Paraplegia occurred in two out of Dr. R. Leroy d'Etiolles' twelve cases, and on careful inquiry at the Salpêtrière, where there is a great number of paralytics, many of the paraplegics dated their complaints from the change of life. Most of them might have been. cured in the early stage of the disease, when it depended upon congestion of the spinal cord; but, subsequently, atrophy of its lower portion prevented the possibility of cure. In many