The symptoms of uterine dyspepsia may vary greatly in intensity, but not infrequently become so severe as to disturb very seriously the general health of the woman so affected. They may be enumerated as follows: The appetite in uterine dyspepsia is variable, but is generally good; the tongue is not usually coated to any great extent, nor does the mucous membrane of the mouth commonly exhibit any notable change; pain in the epigastrium is common after meals, with acid eructations and heartburn (pyrosis);^[38] sometimes there is violent vomiting, occurring after every meal, or in the morning on an empty stomach; in addition, constipation is an almost constant symptom, associated with excessive development of gases in the intestinal canal. The pain is usually dull in character, and somewhat relieved by pressure, but it may be severe and lancinating, and may shoot along the intercostal spaces. The accumulation of flatus within the abdomen gives rise to various painful sensations, distension, a sense of fulness; and its expulsion is attended with notable relief.

As regards the composition of the gastric secretion, an increase of acidity is sometimes noticed. Gastric digestion is retarded; experimental evacuation of the stomach, after a simple test meal (beefsteak and roll) showed that small quantities of undigested remnants were to be found in the stomach as long as seven or eight hours afterwards. The frequent eructations evacuate flatus, or else a watery fluid with an acid reaction (pyrosis or water-brash—see note 38). By the act of vomiting, larger or smaller masses of the food that has been taken are evacuated; in the vomit, sarcinæ in large numbers may frequently be detected by the microscope. Constipation is present in nearly all cases of uterine dyspepsia; and even in cases in which attacks of diarrhœa occur from time to time, careful examination will show that these are generally transient, being sequelæ of constipation due to the irritation caused by the accumulated masses. In one case of long-standing uterine dyspepsia, I observed, in the absence of any gastric dilatation, the well-known phenomenon of “peristaltic restlessness of the stomach” (tormina ventriculi nervosa), in which the peristaltic activity of the stomach is greatly exalted, and becomes visible to the naked eye in the form of large and powerful undulations in the gastric region, moving from left to right.

With these symptoms affecting the digestive organs are associated variable nervous manifestations in different organs, such as neuralgia of various nerves, palpitation of the heart, vertigo, headache, and nervous asthma. The general nutrition of the body often suffers considerably in cases of long-enduring uterine dyspepsia; excessive emaciation and general marasmus may ensue; we see also mental depression, melancholia, an irritable disposition, and disinclination for every kind of work.

Very important, but very difficult, is the differential diagnosis between uterine dyspepsia, on the one hand, and, on the other, chronic gastric catarrh, chronic ulcer of the stomach, nervous dyspepsia, and sometimes even carcinoma of the stomach.

As regards the distinction from chronic gastric catarrh, in this latter disease loss of appetite and changes in the oral mucous membrane are prominent symptoms; the vomit also usually contains much mucus. More difficult is the differential diagnosis of chronic ulcer of the stomach, in cases in which anæmic subjects complain of anomalies of menstruation, associated with dyspeptic troubles and cardialgia. In severe cases of uterine dyspepsia, the distinction from carcinoma of the stomach may be very difficult—at any rate in cases in which no examination of the genital organs has been made. Obstinate dyspeptic troubles, resisting all curative measures (unless indeed these are directed to the relief of the local disorder of the reproductive organs), progressive anæmia, great emaciation, and pains localized in the stomach, are all conditions common to both of these maladies. The absence of a tumor of the stomach, careful examination of the vomit, and examination of the genital organs, will lead to a correct diagnosis if the case is one of uterine dyspepsia. A superficial investigation is exceedingly likely to result in a case of uterine dyspepsia being regarded as one of nervous dyspepsia (von Leube); none the less, even though a very close resemblance exists between the symptoms of the two diseases, to differentiate them is a matter of importance. In nervous dyspepsia, the act of digestion influences the nervous system in such a manner that, even when the chemical processes are normal, the organism as a whole is sympathetically affected by a reflex from the stimulation of the nerves of the stomach, and in return reacts on the mechanical process of digestion in a more or less violent manner. In uterine dyspepsia, however, the relationship that obtains is exactly the reverse of this, inasmuch as the gastric activity is influenced by the nervous system, by reflex impulses originating in the morbid processes in the reproductive organs; moreover, in this form of dyspepsia, in direct contrast with nervous dyspepsia, the chemistry of digestion is often disordered, and, in addition, the process is not completed within the normal period.

Oftentimes, the diagnosis of uterine dyspepsia can be made with certainty only ex juvantibus.^[39] For this disorder cannot be cured unless the disease of the reproductive organs on which it depends is first relieved; and, conversely, local measures for the relief of uterine disease, will often at once remove all the dyspeptic troubles from which the patient suffers.

My own experience has led me to conclude that it is certain distinct local mechanical stimuli affecting the female genital organs which, acting for a long period on the sensory nerves of the uterus or its annexa, induce by reflex action the before-mentioned digestive disturbances. Diseases of the vulva and the vagina, catarrhal inflammation, colpitis and leucorrhœa, and prolapse of the vagina, do not by themselves lead to the occurrence of uterine dyspepsia; nor do inflammations of the uterine mucous membrane, such as endometritis (unless associated with parenchymatous changes of the whole uterus), chronic catarrh of the mucous membrane, erosion and ulceration of the cervix to an inconsiderable extent, or moderate perimetritic and parametritic exudations. On the other hand, uterine dyspepsia frequently ensues in cases of uterine displacements, flexions, or versions, or in cases of structural changes of the uterus accompanied by enlargement of the organ, chronic metritis, myomata, especially when intramural (interstitial), displacement of the Fallopian tubes and the ovaries, chronic oöphoritis, extensive inflammatory exudations, resulting from pelvic peritonitis, and leading to dislocation, “compression” or distortion of the uterus and its annexa, deep follicular or carcinomatous ulceration of the cervix, or, finally, ovarian tumors. As the commonest condition giving rise to dyspeptic disturbances of the kind under consideration, retroflexion of an enlarged uterus must be mentioned.

Under the head of uterine dyspepsia, we may also classify dyspeptic disturbances occurring at the time of puberty or of the menopause, and in association with certain amenorrhoeic and dysmenorrhœic conditions, and, in addition, the vomiting of pregnant women.

The vomiting of pregnant women, which must be regarded as a reflex disturbance of the stomach, occurs, with especial severity in first pregnancies, in the early months of pregnancy, with such regularity that it is regarded as one of the most typical signs of pregnancy. Thus, in 177 pregnant women, Horwitz observed vomiting in 147 (83 of whom were primiparæ, and 64 multiparæ), and in 29 only was this symptom wanting. In this series of cases, it most commonly made its appearance between the tenth and eleventh week of the pregnancy. The vomiting of pregnant women occurs most commonly early in the morning, immediately after rising (morning sickness), but also at other times of the day; it usually takes place easily, without any great distress, and after it is over the patient feels quite comfortable. It rarely continues later than the fourth month of pregnancy.

Very serious in its effect on the general state of nutrition is the uncontrollable vomiting that sometimes occurs in pregnant women (hyperemesis gravidarum), lasting throughout the whole term of pregnancy. It must be regarded as an exaggeration of the physiological vomiting of pregnant women, in patients whose nervous equilibrium is profoundly disturbed; but equally with the ordinary “morning sickness” is it dependent on the reflex stimulation of the nerves of the stomach exercised by the growing uterus. One source of such stimulation may be found in the stretching of the peritoneal investment of the uterus which results from the enlargement of that organ; another, in certain displacements of the uterus; but in addition to these local anomalies, we must assume the existence of a peculiar predisposition on the part of the nervous system, in virtue of which reflex irritability is increased, while the power of reflex inhibition is diminished.

The prognosis and treatment of uterine dyspepsia depend chiefly upon the nature of the diseases of the female genital organs that have given rise to the disturbances of digestion, and this pathological relationship demands above all a careful investigation. The following instance from my own case-book may be regarded as typical of cases of this class. Mrs. N., aged 25, married 6 years, barren, complains of severe dyspeptic trouble. Appetite fairly good, but after every meal severe gastralgia occurred, with heartburn and acid eructations, and very often the food was rejected; there was also obstinate constipation, and great distress from the accumulation of flatus in the intestinal canal. No blood was ever seen in the vomit. The patient was much emaciated, and was greatly depressed in spirits. Neither in the lungs nor in the digestive organs had any of the physicians under whose care the lady had been for the last four years found any abnormal change to account for the stormy manifestations. Now, at length, the gynecological examination, which had hitherto been neglected, was undertaken. The uterus was found to be strongly retroflexed and enlarged. Rectification of the position of this organ was immediately followed by the disappearance of all the stomach troubles; the vomiting ceased, some months later the woman became pregnant, and pregnancy and parturition were quite normal; since then there has been no return of the dyspepsia.

Since the appearance of my work on dyspepsia uterina, numerous observations have in recent years been published, proving even more clearly the causal dependence of disturbances of the gastric function upon diseases of the female genital apparatus.

Lamy, for example, has made an elaborate study of one of the above-mentioned symptoms of uterine dyspepsia, namely, excitement of the vomiting centre. His conclusions are as follows: Among the general symptoms of diseases of the uterus, dyspepsia, in all its forms and in all degrees of intensity, occupies the first rank in respect of frequency of occurrence. Among the accompaniments of these reflex processes, uterine vomiting must be mentioned. It seldom occurs as the sole symptom of disorder of the digestive organs; but when it does occur alone, it is of great importance that the cause of the affection should not be misunderstood. Diseases of the uterus and periuterine affections are the conditions that most commonly give rise to this trouble, but in a certain number of cases it is due to physiological changes in the female genital organs. Such changes are those associated with the functional activity of the reproductive apparatus at the time of puberty, during menstruation, in connection with coitus, during pregnancy, and at the change of life, the menopause. The vomiting of pregnant women is of the same nature, and confirms our belief in the uterine origin and pathogenesis of vomiting at other times than during pregnancy. The diagnosis of the true cause of uterine vomiting cannot be made from the nature of the latter, but only from a knowledge of the conditions in which it occurs, just as with other uterine reflexes, such as neuralgia or cough. The vomit may consist merely of the food last taken, or it may contain bile, without the presence of this latter constituent indicating the existence of any disease of the liver. The treatment of this disorder, which indeed does not threaten life, but does seriously impair the general state of nutrition, must be local, directed against the disease of the genital organs: Thus, in one case of this nature, a cure was effected by oöphorectomy.

The majority of the women in whom Lamy observed this symptom of uterine dyspepsia were chloro-anæmic individuals with an irritable nervous system, town-dwellers, young girls in whom frequent evening parties and dances, ill-chosen diet, and a generally unsuitable mode of life, had led to the development of a “virginal metritis.” The signs of the disturbance of the gastric functions were in the first place a retardation of gastric digestion while the appetite remained good. Moreover, the stomach was often distended with flatus, and this caused frequent gaseous eructations; there was also epigastric pain, which made it difficult for the patient to bear the pressure of the clothing, and sometimes great pain was aroused by the slightest contact. The attacks of vomiting, which occurred in a characteristic manner with periodical intervals of freedom, were usually preceded for a longer or shorter period by dyspeptic symptoms. The vomiting itself, if it occurred immediately after a meal, was not accompanied by nausea, a feeling of faintness, or cold sweats, but rather resembled a kind of painless regurgitation; but when the vomiting did not occur till some hours after food had been taken, it was painful, and the vomit was then green-tinted owing to the admixture of bile.

The gastric troubles that occur during menstruation are regarded by P. Müller as a further indication of the intimate connection between the genital organs and the digestive tract. In women who suffer from hysterical manifestations, gastric disturbances, cardialgia, and nervous dyspepsia, are very frequently associated with menstruation. These gastric symptoms generally make their appearance a few days before menstruation is due, and disappear as soon as the flow is established. In other forms, again, the digestive troubles set in with the appearance of the flow, to disappear during the later course of menstruation; and in yet other cases the gastric disturbance begins even later, and ceases only when the flow comes to an end. These symptoms may occur in women in whom the genital organs are perfectly healthy and in whom menstruation runs a regular course. More severe symptoms may, however, appear if menstruation is disturbed for any reason, or if it is suppressed. Not rarely such women, when they become pregnant, suffer, especially during the early months, from dyspeptic symptoms; but similar dyspepsia may occur in pregnant women who have previously been quite healthy.

To the same category belong the cases formerly described by von Leyden under the designation of neuralgia and hyperæsthesia of the stomach, which he observed in young girls as a sequel of menstrual disturbances, and more particularly of suppressio mensium. In these circumstances, the sensibility of the stomach may become so extreme that every time food is taken the patient suffers from such severe pains, or from so distressing a sense of anxiety and oppression, that she comes to eat less and less, and an extreme degree of emaciation and marasmus results. In one such case, congenital atrophy of the uterus was discovered on gynecological examination.

According to R. Arndt, it is especially in chloro-neurotic individuals that the stimuli proceeding from morbid conditions of the reproductive organs frequently induce, by reflex action, all kinds of disturbances of the alimentary tract, such as constipation and flatulence, gastric uneasiness and loss of appetite, weakness of digestion, cardialgia, and stricture of the œsophagus. Even simple menstruation suffices to give numerous proofs of this fact, but still more do such consequences arise from serious diseases of the reproductive organs, such as changes in form, displacements, and inflammatory states, and also, on the other hand, more or less pronounced hypoplasia.

G. Braun has published three cases illustrating the connection between neurosis of the stomach and uterine disorders. In the first of these cases, severe digestive disturbances occurred after every meal, with occasionally violent vomiting, in a woman, aged twenty-five years. No changes were found in the stomach or other digestive organs, and the symptoms obstinately resisted all direct treatment. Gynecological examination showed extreme mobility of the uterus, and for the relief of this a suitable pessary was introduced. The vomiting thereupon immediately ceased, all the other digestive troubles passed completely away, and the general state of nutrition, which had before been so much impaired as to necessitate the use of nutrient enemata of meat-solution, now became normal. The second case was that of a woman aged thirty, who, since her last confinement two years before, had continually suffered from disagreeable gastric sensations and from vomiting, which latter had proved quite uncontrollable. Gynecological examination disclosed extensive laceration of the cervix with ectropium of the mucous membrane. An operation was performed for the relief of this condition, and the vomiting of two years standing was also thereby cured. In the third case, that of a woman twenty-eight years old, vomiting began three months after her confinement, and recurred whenever the patient left the recumbent posture, in which latter she felt quite well. On local examination, the uterus was found to be prolapsed, the vaginal portion of the cervix moderately enlarged and just within the vaginal orifice. Amputation of the vaginal portion of the cervix cured the vomiting and completely restored the patient’s health.

The frequency of gastric affections in cases of retroflexion of the uterus is insisted on by Panecki. In eight instances he found neuroses of the stomach consequent upon such retroflexion, and in all cases a cure immediately followed rectification of the position of the uterus. He urges that if after the reposition of the retroflexed uterus the gastric troubles should still persist, a careful local examination of the stomach is indispensable.

Eisenhart, in a woman forty-two years of age, corrected a mobile retroflexion of the uterus, and thereupon very severe gastric symptoms of several months’ duration soon disappeared. Graily-Hewitt, in an unmarried woman twenty-seven years of age, cured by reposition of a retroflexed uterus a gastric disorder which had subsisted for nine years; Elder and Henrik report identical results in gastric troubles consequent on retroflexion or retroversion of the uterus. Jaffé, in a virgin, aged twenty-three, who had been brought near to death by gastric disorder with vomiting, found on local examination that there was a profuse, thick, purulent discharge from the interior of the uterus; curetting, and irrigation of the uterine cavity with antiseptic solutions, gave immediate relief to the stomach trouble. Similar experiences are recorded by C. van Tussenbeck and Mendes de Leon in cases of gastric disorder consequent on endometritis fungosa and endometritis interstitialis parenchymatosa; and by Gottschalk, in cases consequent on sarcoma of the chorionic villi. Lewy and Butler-Smythe have observed the relief of pernicious vomiting by Emmet’s operation (trachelorraphy).

As regards the relations of gastro-intestinal affections to the diseases of the reproductive organs, Theilhaber, in the cases observed by himself, distinguishes three groups. In the first group of cases, the gynecological abnormality was a chance accessory, and was not the cause of the gastric trouble. In the second group, he regards the gynecological trouble as dependent upon the affection of the gastro-intestinal tract, believing that, in consequence of atony of the intestine and an accumulation therein of fæces and flatus, a retardation of the circulation occurs in the region of the inferior vena cava, resulting in venous stasis in the uterus, and so giving rise to metrorrhagia, dysmenorrhœa, and fluor albus. In the third group of cases, Theilhaber believes that the uterine trouble is the cause of the disturbances in the stomach and intestine. He, like myself, has found in all these patients an inhibition of the intestinal movements; but he found, on the other hand, that the gastric secretions were more commonly normal, and that only in a small proportion of the cases was the vomiting centre excited. Further, in the majority of these women, the course of the digestive processes was quite normal; and, finally, in his series of cases, endometritis was one of the commonest causes of consecutive gastric disorders. His observations led him to conclude that “in consequence of affections of the uterus a large number of different symptom-complexes of gastric trouble occur:” the pure nervous dyspepsia of Leube, dependent on atony of the large intestine and atony of the stomach, hyperchlorhydria and anacidity, periodic gastralgia without anatomical cause, etc.

Cardiopathia Uterina.

I use the term cardiopathia uterina to denote the manifold cardiac disorders which occur in women as reflex processes excited by the physiological functions and the pathological disorders of the genital organs, and take the form of very various disturbances of the cardiac function. Every phase of the sexual life of women—that in which the reproductive organs attain complete development and menstruation first appears (the menarche); the commencement of sexual intercourse; pregnancy, parturition, and the puerperium; finally the retrogressive process at the climacteric age, of which the menopause is the outward manifestation—may give rise to the occurrence of such cardiac troubles. In order to explain these troubles as reflex in their nature, we must on the one hand recur to the anatomical changes in the uterus and its annexa that take place in every one of the above-mentioned phases of the sexual life; and on the other hand we must take into consideration the mental processes that accompany these anatomical changes, in order to estimate their influence upon the motor and sensory nerves of the heart (see the sections on the Menarche and the Menopause).

A certain predisposition to uterine cardiopathy exists in many individuals and in many families. This predisposition may be manifested in this way, that in women who at the time of the menarche have suffered from cardiac disorder, similar cardiac disorder is likely to recur at the time of the menopause, the symptoms of the recurrent attack being in most cases identical with those that occurred during the menarche. In the well-to-do and cultured circles of society, uterine cardiopathy is far more frequently encountered than among the working classes. Both unusually early and unusually late commencement of menstruation tend to favor the occurrence of uterine cardiopathy. The most valuable therapeutic measures that we can employ to combat these disorders are suitable dietetic and hygienic regulations, in association with favorable mental influences.

Diseases of the female reproductive organs, including simple functional disturbances, are very frequently accompanied—far more frequently than has hitherto been supposed—by cardiac disorders. But whereas in some cases these cardiac disorders are directly dependent upon the disease of the genital organs; in other cases no such etiological relationship can be shown to exist, and the association must, therefore, be regarded as fortuitous.

In cases of the former kind, the dependence of the cardiac disorder upon the disease of the genital organs is very variable in its nature.

Reflex manifestations on the part of the nervous system may be aroused by pathological changes in the genital organs, in a manner similar to that discussed in other parts of this work in regard to the cardiac troubles that are liable to occur during the menarche and the menopause; such cardiac disorders are indeed excited especially by changes in the ovaries, by disturbances of menstrual activity, by suppression of the menses—as manifestations, that is to say, of the menstrual reflex. The cardiac disorder most commonly takes the form of tachycardiac paroxysms, recurring periodically, either in association with the menstrual flow, or, if this is in abeyance, at the times at which it ought to appear. We must assume in these cases that the local stimuli aroused by the pathological changes in the uterus and the ovaries have a reflex influence upon the cardiac nerves, by means of which the heart’s action is increased in frequency, without inquiring more particularly whether the reflex influence is effective by inhibiting the normal action of the vagus, or by stimulating the sympathetic, or, perhaps, by a combination of these factors. Much more rarely do we notice, in association with disorders of the reproductive system, a reflex decrease in the frequency of the heart’s action, this effect being explicable in the same manner as the well-known experiment of Golz, in which, if the abdomen of a frog be laid bare, and the intestine be struck sharply with the handle of a scalpel, the heart will stand still in diastole with all the phenomena of vagus inhibition.

In another group of diseases of the genital organs, the disturbances of cardiac activity may be brought about by pressure which, in consequence of the morbid processes in the reproductive organs, is exercised upon individual nerves or upon an entire nerve plexus. Tumefied and prolapsed ovaries, an enlarged and misplaced uterus, inflammatory nodules and hyperplasias of the intrapelvic connective tissue, contractile processes in the parametric connective tissue,^[40] tumors of the uterus whether intramural or in the interior of that organ, ovarian tumors, prolapse of the uterus, and intrapelvic peritoneal adhesions resulting from inflammatory processes—these are the principal conditions liable to occasion reflex cardiac disorder; but certain tissue changes, such as endometritis, erosions (chronic cervical catarrh), and ulcerations of the genital passages, with or without exposure of nerve-endings, are also competent to produce the same effect. Here the sympathetic nervous system constitutes the channel by means of which the stimuli affecting the nerves of the genital organs are conveyed to the central nervous system, and by means of which also the reflex manifestations of this stimulation are produced, taking the form, partly of disorder of the cardiac action, of palpitation of the heart and paroxysmal tachycardia, and partly of pains in the cardiac region and disturbances along the course of the great vessels.

Further, in cases of long-continued disease of the female genital organs associated with severe hæmorrhage and in some cases fluor albus, nutrition in general and hæmotopoiesis may be seriously affected, and disturbances of cardiac activity may result, as, for instance, is frequently witnessed in chloro-anæmic states. In such cases we have palpitation of the heart, both subjective and objective, a weak and compressible pulse, often irregularity of the heart’s action, singularly clear heart sounds, often, however, systolic murmurs at various orifices, increased frequency of heart and respiration to a disproportionate degree on slight exertion, strong pulsation of the carotids, and slight œdema of the ankles.

Often, however, the disturbance of cardiac activity is dependent also upon degenerative processes in the myocardium, upon fatty degeneration and the consequent dilatation of the cavities, this degeneration being a consequence of the growth of a uterine tumor and especially of uterine myomata, or resulting from some constitutional disorder which is itself dependent upon the affection of the genital organs. In such cases the signs of degeneration of the heart are very striking: weakening of the cardiac impulse, notable faintness of the sounds of the heart, occasionally reduplication of the second sound, a galloping rhythm, while percussion shows the existence of considerable dilatation of the left, and still more frequently of the right ventricle; in many cases also we have angina pectoris, passive hyperæmia of the lungs, the mucous membranes, and the extremities; and sudden death sometimes ensues.

No less important are the mental influences exercised by diseases of the genital organs in which operation is proposed or actually performed, also by long-lasting diseases of the reproductive organs and by the disturbances these diseases produce in the reproductive functions, more especially in relation to copulation and the actual process of reproduction. In this way cardiac neuroses of various kinds may be induced.

Finally, cases have come under my notice in which the cardiac trouble was not the direct result of the disease of the genital organs, but was a consequence of the therapeutic measures employed for the relief of the latter; and in this connection I must regard as especially blameworthy, in addition to intra-uterine manipulations, such as sounding and cauterization, the modern practice of gynecological massage.

Not all diseases, however, of the female reproductive apparatus, tend in a similar manner and with equal frequency to give rise to consecutive cardiac disorders. According to my own observations, the diseases of the vulva and the vagina, catarrhal inflammation, colpitis (vaginitis), leucorrhœa, and prolapse of the vagina (cystocele and rectocele), are those which most rarely induce cardiopathy; unless, indeed, the diseases just enumerated have led to the occurrence of vaginismus, for in this latter condition cardiac trouble not uncommonly ensues. More commonly than by vulval and vaginal diseases, cardiac troubles are induced by inflammation of the uterine mucous membrane, as by chronic endometritis, by erosion and “ulceration” of the cervix (chronic cervical catarrh); they also sometimes occur in connection with perimetritic and parametritic exudations. Most frequently of all, and most severely, cardiac disorders are aroused by displacements of the uterus, flexions or versions; by structural changes of the uterus accompanied by enlargement of that organ, such as chronic metritis and the growth of myomata (especially intramural); by prolapse, enlargement, and tumor of the ovary; by intrapelvic exudations which when extensive give rise to displacement or compression of the uterus or its annexa. In cases of carcinomatous or other malignant new growths affecting the reproductive organs, I have in comparison very rarely observed the occurrence of reflex cardiac disorders.

Disturbances of menstrual activity, amenorrhœa, menorrhagia, and dysmenorrhœa, owning the most varied causes, very frequently give rise to cardiac trouble, a point on which we have already insisted. (See page 142, et seq.)

Very violent forms of cardiac neurosis have been observed by me in women suffering from chronic disorder of the reproductive organs, who have consulted one gynecologist after another and have been subjected to many different methods of local treatment; also in women who have for a long time suffered from some gynecological ailment hitherto believed to be trifling, but who have at length suddenly been informed that some severe operative procedure has become necessary. In such cases the cardiac trouble took a paroxysmal form, the intervals being usually considerable, several weeks or months in duration, and the general system was as a rule seriously involved in the attacks. These latter began with severe cardialgia, radiating from the cardiac region outward along the intercostal spaces, upward to the shoulder and along the left arm, sometimes indeed extending into both arms. At the same time the heart’s action was greatly increased in frequency, there being sometimes more than 200 beats per minute, the pulse was soft, small, difficult to count, the respiration greatly increased in frequency, sometimes very shallow, with respiratory anxiety, and exceptionally severe general excitement and sense of impending death. In some cases also I observed spasm of various groups of muscles, dizziness (with a sense that the objects of vision were flickering), aphasia, and mental stupor. The paroxysms lasted for some time, two or three hours, as a rule, and gradually passed away. Their character was that of the cardiac disorder variously described under the names of pseudo-angina and angina pectoris hysteria.

L. Landau writes concerning the disturbances induced in the circulatory apparatus by the growth of myomata in the uterus: “The formation of varices, the occurrence of thrombosis, and, finally, the onset of degeneration of the myocardium, are very common. Should the last-named process result—and it is truly alarming to observe the frequency with which cardiac affections are associated with uterine myomata,—then, by a vicious circle, the uterine hæmorrhages become continually more profuse, in consequence of increasing passive hyperæmia dependent upon diminishing power of the cardiac pump. Venous congestion in the province of the inferior vena cava results in ascites, and sometimes in general œdema; and even in cases in which no increase of the uterine hæmorrhages is observed, the patient may succumb in consequence of secondary disease of the heart. * * * In the great majority of cases, the myoma and the uterine hæmorrhages that result from its growth are the primary cause of the morbus cordis. Naturally in cases which come under observation only when both uterine and cardiac disease are already present, it is difficult to determine with certainty the true causal connection. When, however, a number of patients suffering from uterine myomata are observed, in whom at first the heart was found to be healthy, and subsequently to have become affected; and when, on the other hand, we see patients affected with myoma uteri in whom operation is undertaken notwithstanding the existence of cardiac disease, and in whom, after the operation has been successfully performed, the cardiac murmurs disappear as well also as the other signs of heart disease, when dilatation can no longer be detected, when the pulse-frequency declines to normal, whilst a previously feeble and compressible pulse gains in tension and power—then it is impossible to doubt that the heart disease was secondary, and was etiologically dependent upon the primary myoma and the uterine hæmorrhages.”

Lehmann and P. Strassmann examined the material of the Charité-Policlinik at Berlin in order to throw light on the relation between uterine myomata and diseases of the heart, a connection already proved to exist alike by recent pathologico-anatomical researches, by clinical experience of the results of operations (death from shock), and, finally, by the subjective troubles of the patients (palpitation, venous congestion, giddiness, and syncope). Examining 71 women suffering from myoma uteri, Lehmann and Strassmann found in 29 (41%) that some abnormality existed in the cardio-vascular system, such abnormalities being extremely variable in character, as for instance: hypertrophy or dilatation of the heart, irregularity of the cardiac action, passive hyperaemias, œdema, albuminuria, angina pectoris, and cardiac asthma. The next point was to determine the mutual relations between the heart disease and the development of the uterine myoma. Hitherto it has been assumed that the latter is the primary disease, and such a sequence is certainly the commoner, more especially in cases in which hæmorrhage has been profuse, with consecutive anæmia and fatty degeneration of the heart. In these cases, a certain time after the commencement of the severe hæmorrhages, cardiac troubles make their appearance; such troubles are beyond question secondary, and they disappear as soon as the hæmorrhage has been controlled. In other patients, however, we obtain a history of the appearance of cardiac disorder at a date prior to that when any symptoms occurred indicating the growth of a myoma; in these cases, therefore, the heart disease has developed independently of the uterine disease, and has run a parallel course to the latter; perhaps, indeed, by leading to venous congestion or to rapid changes in blood-pressure, the heart disease may have favored the growth of the commencing or fully developed tumor. In some of the patients, operative measures were followed by rapid recovery from the cardiac disorder (cases of simple anæmia); in a second group of cases, however, the heart disease was uninfluenced by operation (cases of irreparable anæmia, and cases of heart disease independent of the myomata); and, finally, a considerable number of patients remained, constituting a third group, in whom, notwithstanding the removal of the tumor by operation, the heart disease continued to grow worse (cases of progressive heart disease independent of the myomata, especially cases of arteriosclerosis).