The full evolution of the sexual life brings in its train many dangers
to a woman’s life. This appears at first sight from a comparison of the
mortality of married women during the period of greatest sexual activity
with that of single women of similar age. Between the ages of 20 and 25
years, the mortality of married women is in all races higher than that
of unmarried women; and the same is true between the ages of 25 and 30
years, except in France, in which country from artificial causes
maternity ceases at a very early age. In Prussia, in the year 1880, of
every 10,000 married women, between the ages named, 21 died, of every
10,000 unmarried women, only 2. In Holland, Belgium, and Bavaria, this
excess in the mortality of married women continues up to the age of 40
years; whilst in Prussia, from the age of 30 upward, the mortality of
married women and unmarried is practically the same. In many countries,
the mortality of married women at many ages exceeds even that of
unmarried men.
This greater comparative mortality of married women is ascribed by
_Hegar_ to the satisfaction of the sexual impulse, and this authority
believes that the dangers attendant on this function would be manifested
yet more clearly if the contrast were made, not between married women
and single, but between those habituated to sexual indulgence and those
who are continent. We, however, are of opinion, that the satisfaction of
the sexual impulse is only harmful to this extent, that it exposes women
to the consequences of venereal infection, and also to the risk of
numerous puerperal and other diseases of the genital organs. This is
proved also by the statistical results of the investigations concerning
mortality during pregnancy, parturition, and the puerperium. According
to _Hegar_, adding deaths resulting from premature delivery to deaths
resulting from delivery at full term, we find the mortality of
childbirth in Germany to be about 0.6 per cent.
Whilst _Bertillon_ and _Simpson_ believe that the lower mortality of
married women above forty years of age as compared with unmarried women
at the same period of life is dependent upon the advantage to the former
of the fulfilment of sexual functions, _Hegar_, on the contrary, gives
another explanation. He writes: “At the age of 40, the less powerful
married women have already been weeded out. At first, owing to the
selection exercised by marriage, the quality of the unmarried women was
inferior to that of the married women; the former, however, have not
been exposed to the dangers attendant on the reproductive process, and
so have passed through the time during which the body possesses the
greatest elasticity; but in the years in which a decline in the vital
powers naturally sets in, the originally inferior quality of the
unmarried women is manifested by a comparatively higher mortality. Also
we have to take into account among the unmarried, the consequences of
extra-marital sexual intercourse and of prostitution, and further the
lack of a family, of the support furnished by husband and children.”
In addition to the far-reaching disturbances of health dependent on
sexual activity at this period of life, there are the minor domestic
troubles by which woman is depressed and by which her powers are
exhausted. The influence of these latter is admirably described by _G.
von Amyntor_: “How many millions of brave house-wives boil and scrub
away their vital energy, their rosy cheeks, their merry dimples, in the
performance of their household duties, until they become wrinkled,
worn-out, dried-up mummies. The ever-renewed question, ‘what must be
cooked for dinner to-day,’ the perpetually recurring necessity for
scouring and sweeping and dusting and washing-up—these are the continual
dropping which slowly but surely wears away soul and body. * * * On the
flaming altar on which the sauce-pan simmers, youth and simplicity,
beauty and good temper, are offered up; and who can recognize in the
old, hollow-eyed cook whose back is bent with toil and trouble, the once
blooming, energetic, chastely coquettish bride adorned with her myrtle
crown?”
A great number of the diseases of the female genital organs occurring at
the epoch of the menacme need only a passing mention. Even coitus, in
cases in which there is great disproportion in size between the penis
and the vaginal orifice, or when the organ is very rapidly introduced or
the act is very roughly performed, may lead to injury to the vulva or
the vagina, a fact to which a very large number of recorded cases bears
witness.
During the acme of the sexual life of woman, disturbances of the
menstrual function are also frequent. Menstruation may cease in
consequence of intercurrent diseases or constitutional anomalies;
amenorrhœa may occur during the convalescence from acute diseases, in
obese women, in those suffering from tuberculosis, diabetes, alcoholism,
or psychoses. On the other hand, severe menorrhagia or atypical
metrorrhagia may occur, the bleeding either being due to diseases of the
uterus, such as endometritis, retroflexion of the uterus, or uterine
myomata, or resulting from infectious diseases, disease of the heart or
kidney, or from general disturbance of the health by chill or
over-exertion. Or, again, dysmenorrhœa may arise, either as a symptom of
some local uterine disease or in consequence of external noxious
influences or weakness of the nervous system.
During the life-epoch of the menacme, moreover, disturbances of the
nutrition of the uterus are of common occurrence, as, for example,
hyperplastic processes in the mucous membrane of the cervical canal and
of the cavity of the body of the uterus. Common also during the menacme
is chronic oöphoritis, which may be due to mal-regulation of marital
intercourse (especially to coitus too soon after childbirth), to
carelessness during menstruation (dancing, skating, or mountaineering),
to incomplete coitus (_congressus interruptus_), and not infrequently,
to gonococcal infection; or, finally, the oöphoritis may occur soon
after the puerperium in association with subinvolution of the uterus.
Next we may mention inflammatory diseases of the Fallopian tubes. In the
etiology of these diseases in latter-day marriage, a dominant rôle must
be assigned to the gonococcus; but they also arise in many cases from
nutritive disturbances, infection (other than gonorrhœal), and
indiscretions during menstruation. Pelvic peritonitis owns similar
causation.
In this phase of women’s life, the commonest new growths of the uterus,
myomata, also develop, most commonly between the ages of thirty-six and
forty-five, and they occur in strikingly larger proportion in unmarried
women; it is between the same ages also that cysto-adenomata of the
ovaries are of commonest occurrence.
Sexual intercourse gives frequent opportunities for the introduction of
infective germs into the vagina, and for the origination of inflammatory
affections of the mucous membrane (_colpitis_), the intensity of which
depends upon the species, the quantity, and the virulence of the germs
in question, on the one hand, and upon the local and constitutional
predisposition of the infected person, upon the other. Especially grave
in its consequences is gonorrhœal infection transmitted by the male, for
this virus gives rise to a great variety of pathological processes in
the female genital organs. In the act of defloration, considerable
injuries are sometimes produced, and these readily supply a breach for
the invasion of infective organisms. The condition of passive hyperæmia
that occurs in the genital organs during pregnancy also provides a
favorable soil for their growth.
Gonorrhœal infection of young married women is so frequent and so
serious an occurrence in the sexual life of woman, that it requires
special consideration. The cases in which the man entering upon marriage
is so unscrupulous and so brutal as to deflower his young wife and to
continue copulating with her, while suffering himself from a quite
recent and active gonorrhœa, are on the whole rare. More common is it
for the bridegroom to believe himself completely cured of his previous
claps, and he is declared cured by his physician. The disease is,
however, latent merely, the gonorrhœa has become chronic, the discharge
is so slight that it is overlooked; but by the stimulation of the
frequent acts of coition usual in the early days of marriage, the
disease is lighted up afresh, the gonococci multiply quickly and
intensely, the young wife is infected, and suffers from an acute
gonorrhœa, which may often escape observation for a considerable period.
In a gonorrhœal marriage, one in which both husband and wife have
gonococci in their genital organs, very diverse phenomena may be
observed and very various conditions may result. On this subject _M.
Runge_ writes: “If the husband’s gonorrhœa is not cured, fresh, virulent
cocci are repeatedly transmitted to the wife, in whom, therefore, the
disease often gets worse by distinct stages. If the wife undergoes
treatment, the effect in these circumstances will naturally be nil,
since the husband is always supplying fresh infection. On the other
hand, the wife on her side returns the gonococci to her husband, and in
this way his gonorrhœa may undergo aggravation. If the husband is
compelled, by illness, for instance, or by absence, to abstain for a
long period from intercourse with his wife, the latter’s gonorrhœa may,
in favorable circumstances, undergo alleviation and cure. It may happen,
however, that in the husband, in consequence of sexual rest, the
gonorrhœa becomes latent, and even entirely disappears, whilst the wife
still suffers from infection. If now, after long abstinence, the husband
has renewed intercourse with his wife, he may be reinfected, and suffer
from an acute attack of gonorrhœa, though this is due to the descendants
of the very gonococci that he himself sometime before conveyed to the
genital organs of his wife—he reinfects himself, as people say. Such
cases have given rise to suspicions of unchastity on the part of the
wife, when the husband is in actual fact enjoying his own work in a new
edition. A further possibility is that both husband and wife have become
habituated to their own gonococcal interchange; that is to say, the
organisms produce no notable effect in either. But if the wife in such a
condition receives the embraces of a lover, the latter may be infected
with an acute gonorrhœa—a fact that has long been known.”
The principal rôle in the etiology of the diseases of the female genital
organs must be assigned to pregnancy and childbirth. Anæmic women
readily suffer during pregnancy from a further decrease in the
corpuscular richness of the blood; those affected with valvular
incompetence find their troubles much aggravated by pregnancy; where the
kidneys are in an irritable condition, pregnancy not infrequently
results in the onset of nephritis, those with disordered digestion often
suffer from increased disturbance of the functions of the stomach and
the intestinal tract; those with gall-stones are apt to suffer from
exceptionally severe attacks of biliary colic, and acute yellow atrophy
of the liver is especially apt to occur during pregnancy. In women in
whom dilatations of the veins already exist, very great increase of the
enlargement is apt to occur during pregnancy; and in the same
circumstances, trifling telangiectases increase to extensive angiomata.
Enlargements of the thyroid body undergo rapid increase during
pregnancy, so that they may attain threatening proportions. In women in
whom the abdominal walls are flaccid, the viscera may protrude during
pregnancy through the enlarged lacunæ, giving rise to herniæ. The great
relaxation of the peritoneal and other ligamentous attachments of the
great abdominal glands, occurring during pregnancy and the puerperium
results in displacements of these organs; hepatoptosis (migrating or
movable liver), lienoptosis (splenoptosis or wandering spleen),
nephroptosis (ren mobile, floating or movable kidney), and other
varieties of enteroptosis (splanchnoptosis, visceroptosis, or Glénard’s
disease). During pregnancy, previously sound teeth are apt to become
carious, and already existing caries rapidly advances. New growths of
various kinds originate at this period, those previously present exhibit
rapid increase; and relapse after operations for the extirpation of
malignant tumors is especially apt to occur. Even the bones are
unfavorably influenced. A weakened nervous system is subject to a storm
of changing nervous troubles, in some cases so severe as to lead to the
outbreak of actual psychoses; while mental disorder already present
tends, as a rule, to be seriously aggravated during pregnancy. In the
eyes, serious disorders may occur, such as retinitis, and atrophy of the
choroid with complete amaurosis. As regards the hearing, tinnitus aurium
is not uncommon, and sometimes complete deafness occurs. Numerous
diseases of the skin are apt to occur during pregnancy; in addition to
the well-known pigmentation of the face, the areola mammæ, and other
parts, we may have herpes, eczema, or pruritus.
The serious aggravation which pregnancy is liable to induce in many
disorders previously existent, is well known, and this exacerbation
provides in some cases an indication for the induction of artificial
abortion. This necessity may arise in severe cases of renal, cardiac,
pulmonary, or hepatic disease, in progressive anæmia, severe
osteomalacia, hæmophilia, and many other acute and chronic pathological
states, since, in exceptional cases, as pregnancy advances, the symptoms
of any one of these diseases may become so threatening, that the
patient’s life is either in immediate danger or is almost certain to be
in danger within a very short space of time—this may occur, for
instance, in diabetes, struma (goitre), or certain nervous diseases,
such as chorea, polyneuritis (multiple neuritis), or mental disorders.
Undoubtedly, in this connection, as _W. A. Freund_ insists, it is not
the actual nature of the disease that is of decisive importance, but
rather its intensity, and its influence on the health of the pregnant
women; these circumstances, considered in relation to the resisting
powers of the patient, must be determinative in the adoption of measures
for terminating the pregnancy. An indication for the induction of
artificial abortion is generally furnished also by uncontrollable
vomiting dependent on pregnancy and endangering the life of the patient;
irreducible incarceration of a retroflexed gravid uterus in the pouch of
Douglas, or of a gravid uterus in a hernia, or irreducible prolapse of a
gravid uterus will also necessitate abortion.
_W. A. Freund_ gives an example of a common pathological state, usually
quite free from danger, but now and again, when associated with
pregnancy, seriously endangering life and rendering the induction of
artificial abortion absolutely necessary—this is acute _struma
vasculosa_—(vascular enlargement of the thyroid body), which may during
the first three months of pregnancy exhibit such rapid growth as to lead
to severe orthopnœa and cyanosis and so to imperil the patient’s life.
In cases in which laryngeal tuberculosis exists as a complication of
pulmonary tuberculosis, the former disease sometimes progresses so
rapidly in the course of pregnancy that sudden death from œdema of the
glottis is by no means rare. _Freund_, therefore, sees in this
complication an absolute indication for the artificial termination of
the pregnancy.
In cases of previously well-compensated valvular lesions of the heart,
disturbances of compensation not infrequently occur as a result of
pregnancy; whilst in cases in which cyanosis, dyspnœa, albuminuria, and
dropsy existed even before pregnancy, the latter condition is likely to
result in an aggravation of these symptoms to a degree that imperils
life.
Parturition, to an even greater extent than pregnancy, may induce
serious injuries to the female organism. Thus, during parturition,
lacerations of the vagina are frequent, with consequent scar-formation
and stenosis; lacerations of the perineum are also common, causing great
inconvenience, and when complete, leading to incontinence of fæces with
all its unpleasant consequences. Great is the danger arising from septic
puerperal inflammations, such as pelvic peritonitis (perimetritis);
serious are the results of puerperal vesico-vaginal and recto-vaginal
fistulæ.
A large part in the local pathology of the female genital organs is
played by the various displacements of the uterus, either arising in
consequence of inflammatory processes in their ligaments, or dependent
upon relaxation of these ligaments from subinvolution of the internal
generative organs, either following delivery at full term or following
abortion.
The injury which women alike of the well-to-do and of the laboring
classes suffer in consequence of numerous and frequently repeated
pregnancies, is minutely described by _Hegar_. “We can,” he writes,
“calculate the danger to life to which such an unfortunate woman is
exposed by the act of reproduction. If we assume the ordinary mortality
of women in childbed to be 6 per mille, then, in a woman who within 15
years has been delivered 16 times (whether prematurely or at full term),
the danger will be 16 times as great as that of a single delivery, and
the mortality will be 6 × 16 = 96 per mille; that is to say, of 1,000
women who have all been pregnant that number of times, 96 will
die—nearly 1 in 10. Moreover, in this calculation the increased danger
consequent upon the unusually rapid sequence of the deliveries has not
been taken into consideration. And, again, only the immediate results of
the deliveries have been taken into the account. Not infrequently women
succumb at a later date to illnesses acquired in childbed; whilst
others, in consequence of repeated pregnancies, have their powers of
resistance so greatly diminished, that they are unequal to the contest
with incidental diseases. In any case, a woman who has experienced
numerous and rapidly successive pregnancies, has sustained damages which
will endure for the rest of her life. Her tissues have lost their
elasticity, the abdominal walls are flaccid, the abdomen is prominent,
the abdominal viscera are displaced, the vessels dilated, the
reproductive organs in a state of subinvolution, and are the seat of
structural alterations. The greatest dangers arise in cases in which the
pregnancies are consequences that have to be paid for illicit love,
since in such cases syphilitic and gonorrhœal infection are
exceptionally common. These complications, indeed, are not excluded in
the case of married women, since marital infidelities occur, and, again,
a premarital but not completely cured venereal illness may bear fruit in
marriage, the latter occurrence being almost always attributable to the
husband. Syphilitic or gonorrhœal infection may also arise in some other
way than by copulation, and to this women are more exposed than men,
owing to the greater size of the genital passage in the former.”
Very numerous are the disorders of the nervous system referable to the
sexual functional activity of woman during this epoch of her sexual
life.
_Freund_, in his description of a neurasthenic symptom-complex to which
he gives the name of _angst-neurosis_,[36] maintains that the cause of
these attacks of anxiety[36] is very frequently to be found in a number
of injurious influences in the sphere of the sexual life. In women,
these anxiety-neuroses occur:
_a_) As virginal anxiety, or anxiety of adolescents. _Freund_ has
observed a number of unequivocal instances showing that a first
encounter with the sexual problem, a rather sudden unveiling of what has
hitherto been concealed, as, for instance, the sight of some sexual act,
or something read or heard in conversation, may, in a girl at the time
of puberty, give rise to an anxiety-neurosis, which is in a very typical
manner combined with hysteria.
_b_) As anxiety of the newly married. Young wives who have been without
sexual feeling in their first experience of intercourse are not
infrequently attacked by an anxiety-neurosis, which, however, disappears
as soon as the sexual feeling becomes normal. Since, indeed, the
majority of young women who lack sexual feeling in their first
experience of sexual intercourse remain nevertheless quite healthy, it
is evident that some other cause must coöperate in arousing the
anxiety-neurosis.
_c_) As anxiety in married women whose husbands suffer from _ejaculatio
praecox_ or from great diminution of sexual potency, or
_d_) Whose husbands practice _coitus interruptus_ or _coitus
reservatus_. Cases in these two classes are closely associated, since it
is easy to ascertain, from the analysis of a sufficiently large number
of cases, that the really important question is, whether during coitus
the wife obtains or fails to obtain sexual satisfaction. In the latter
event, the condition requisite to arouse the anxiety-neurosis is
supplied.
_e_) As anxiety in widows and in voluntary abstinents, not infrequently
in typical combination with impulsive ideas.
_f_) As anxiety in the climacteric period, during the final flare-up of
sexual passion.
Numerous anomalies of the genital organs which gave rise in the virgin
to no trouble whatever display their influence during the menacme by
unfavorably affecting the nervous system. Thus, in cases of
malformations of the external organs of generation, slight atresia of
the vagina, a rudimentary condition of the vagina, a rigid hymen, or
local changes in the vagina, it is only when sexual intercourse begins
that neuroses or hysteroneurasthenic troubles ensue. So also at times
nervous diseases which, though the disposition to them was present, were
latent in the girl, such as epilepsy and various mental disorders, first
become apparent in consequence of sexual intercourse.
The mechanical irritation of the nerves of the pelvis that occurs in
sexual intercourse may, even in women whose reproductive organs are
healthy, arouse sensations of weight, pressure, and bearing-down,
various painful sensations in the sacral region, over the coccyx, in the
buttocks, or in the upper part of the thighs, and also “lumbar
enlargement symptoms,”[37] viz., weakness of the lower extremities,
abnormal sensations of fatigue in the lower extremities and the back,
sometimes also disorders of micturition and defæcation.
Throughout the manifold diseases of women in or connected with the
reproductive system during the age of sexual maturity, associated mental
processes take place, which powerfully affect the nervous system. Such
processes are, melancholy and anxious thoughts concerning the possible
influence of the illness on the happiness of married life, concerning
childlessness, or concerning loss of a husband’s sexual esteem, or
again, fear that the affection will become cancerous, fear of some
necessary operative procedure, or vexation in consequence of the
limitation of her usefulness as housewife, wife, and mother. Thus in
women suffering from sexual affections, a state of general neurasthenia,
or some neurasthenic functional disturbance of other organs, very
commonly arises.
The knowledge that she is suffering from an affection of the genital
organs, makes a deep and lasting impression on the mind of a woman who
takes a serious view of her duties as a wife, and whose thoughts and
feelings are concentrated in the sexual sphere. The result is, that
minor troubles are regarded through the magnifying lens of anxiety, and
the general sensibility is increased. This hyperæsthesia is not confined
to the affected region, but manifests itself in various other parts of
the body by numerous phenomena of a reflex character. In the first place
must be mentioned severe headaches, sacrache, sensations of pressure in
the abdomen, cardiac troubles, palpitation, stomach-ache, nausea and
retching and disorders of appetite and digestion. Capacity for work and
the enjoyment of life are destroyed by these disorders.
We have further to take into account the numerous conditions liable to
disturb the mind at this period of life. In childless women, we have the
subject of their sterility, the continued yearning to be blessed with
children, the eager search for a remedy, and not rarely in these cases
the conflict between the reproductive impulse and the ethical principle
of conjugal fidelity. In fruitful mothers, on the other hand, we have
the anxiety lest, by too frequent child-bearing their beauty should be
impaired and the livelihood of the family endangered; these
considerations leading in many cases to the practice of _coitus
reservatus_, with its deleterious physical and moral consequences. In
the middle and working classes, we have the strain of the endeavor to be
a helpful companion to the husband and at the same time to assist in the
support and the education of the children. Last but not least, we have
the potent influence of local therapeutic measures, and the fear of
operative procedures, both of which have a most agitating effect on a
woman’s mind. In truth, the menacme is a period full of stormy
excitations and powerful revolutions.
In addition to its influence on the genital organs themselves, the
sexual life of woman during the period of the menacme manifests its
powers for evil especially in relation to the digestive functions, and
to the functions of the heart and the nervous system.
When we compare the various consequences which may be induced in the
principal organic systems as a result of functional disturbances and
organic diseases of the female genital organs, we find that in respect
of the frequency of their occurrence the diseases of the nervous system
occupy the first rank; next in frequency come the disorders of the
digestive organs that arise in sympathetic association with diseases of
the female reproductive organs; whilst the third rank in respect of
frequency and importance is occupied by the cardiac disorders that arise
in connection with changes in the female organs of generation, and take
the form either of disturbances of the heart’s functions or structural
changes in the heart’s muscle.
_Dyspepsia Uterina._
Although it has long been a familiar observation that pregnant women and
women suffering from diseases of the reproductive organs suffered from
various dyspeptic troubles, I was myself the first (in the _Berliner
Klinische Wochenschrift_, 1883) to bring together, and to describe under
the name of _dyspepsia uterina_, a peculiar group of dyspeptic
conditions which are dependent upon diseases of the female reproductive
organs. I dismissed from consideration organic diseases of the stomach
and intestine dependent upon anatomical changes in these organs, even
though these also might owe a similar etiology, and described only the
more frequent dyspepsias occurring without organic change in the
digestive apparatus, the origin of which is to be explained by the fact
that certain structural changes and displacements of the uterus (to be
discussed later) arouse centripetal impulses, and that these exercise a
reflex influence on digestive activity.
This influence, according to my observations, affects the secretory and
muscular apparatus and also the nervous elements of the digestive tract,
and I regard the following conditions as characteristic of uterine
dyspepsia, though they do not necessarily all occur simultaneously:
changes in the gastric secretion, excitement of the vomiting centre, an
inhibitory influence on intestinal peristalsis, and hyperæsthesia of the
stomach.
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.
Such attacks as these are followed by a sense of severe general
depression and want of energy, and by a decline in body-weight. They are
distinguished from true angina pectoris by the absence of any signs of
arteriosclerosis or of degeneration of the myocardium. They may be
regarded as cardiac disorder of duplex causation, being partly dependent
on the disease of the genital organs, which gives rise to a number of
local afferent stimuli, and partly dependent on mental influences which
have a depressant, paralyzing influence on the cardiac nerves; it is
possible also that spasmodic contraction of the walls of the coronary
arteries or of the myocardium itself is induced as a reflex effect of
the local disorder of the reproductive organs.
With regard to uterine myoma as the exciting cause of cardiac
degeneration, very numerous observations and experiments have recently
been made, and the reality of the occurrence is no longer open to
dispute, even if its significance is subject to various interpretations,
whilst no satisfactory explanation has yet been forthcoming.
_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).
Among 120 women of ages between 17 and 48, in whom I found very various
functional disorders of or pathological changes in the genital organs,
and in whom I made a particular investigation concerning the presence or
absence of heart disease and examined the heart carefully, I was able to
detect the presence of cardiac troubles in 38 instances. Thus, heart
trouble was found to exist in 32.7 per cent. of women suffering from
disease of the reproductive organs.
In these 38 persons suffering from cardiac disorder, I found:
Nervous Tachycardia in 21 instances, that
is, in about 55.2 per cent. of the cases.
Hypertrophy of the Heart in 4 instances,
that is, in about 10.4 per cent. of the cases.
Pseudo-Angina Pectoris in 3 instances,
that is, in about 7.8 per cent. of the cases.
Asthenia Cordis in 7 instances, that is,
in about 18.4 per cent. of the cases.
Mitral Incompetence in 1 instance, that
is, in about 2.6 per cent. of the cases.
Fatty Heart in 2 instances, that is, in
about 5.2 per cent. of the cases.
As regards the varieties of functional and organic disease of the
genitals met with in the 120 cases, and the number of instances
complicated with heart trouble in each variety, I found:
Chronic Metritis in 32 patients, complicated with cardiac
disorder in 13 instances.
Chronic Oöphoritis in 10 patients, complicated with
cardiac disorder in 4 instances.
Parametric Exudations in 14 patients, complicated with
cardiac disorder in 6 instances.
Chronic Endometritis in 16 patients, complicated with
cardiac disorder in 2 instances.
Flexions and Versions of the Uterus in 26 patients,
complicated with cardiac disorder in 9 instances.
Stenosis of the Cervix in 6 patients, complicated with
cardiac disorder in 0 instances.
Tumors of the Uterus and its Annexa in 8 patients,
complicated with cardiac disorder in 4 instances.
Infantile Uterus in 3 patients, complicated with cardiac
disorder in 0 instances.
Colpitis (Vaginitis) in 5 patients, complicated with
cardiac disorder in 0 instances.
From these figures we obtain the following percentages, showing the
frequency with which heart trouble occurred as a complication of the
respective diseases of the genital organs:
In Chronic Metritis, cardiac disorder was
found in 40.6 per cent. of the cases.
In Chronic Oöphoritis, cardiac disorder
was found in 40 per cent. of the cases.
In Parametric Exudations, cardiac disorder
was found in 42.8 per cent. of the cases.
In Chronic Endometritis, cardiac disorder
was found in 12.5 per cent. of the cases.
In Versions and Flexions of the Uterus,
cardiac disorder was found in 34.6 per cent. of the cases.
In Tumors of the Uterus and its Annexa,
cardiac disorder was found in 50 per cent. of the cases.
To summarize the result of my observations regarding the cardiac
disorders secondary to diseases of the female genital organs:
1. Tachycardial paroxysms in cases of amenorrhœa were premenstrual in
rhythm, the paroxysms occurred, that is to say, some days before the due
date of the suppressed flow.
2. In cases of dysmenorrhœa, I observed heart trouble with severe
dyspnœa and feelings of anxiety, also in some cases symptoms of cardiac
asthenia; these symptoms were perhaps dependent upon acute dilatation of
the heart. The heart trouble associated with profuse menorrhagia
exhibited similar characters.
3. Attacks of pseudo-angina pectoris occurred in women in whom local
treatment for disease of the genital organs had been carried out for a
long time, and in cases in which operative measures were in
contemplation.
4. Paroxysms of tachycardia and cardiac distress were observed in
connexion with displacements of the uterus, and especially in cases of
retroflexion; also in association with oöphoritis and with parametric
exudations.
5. Cases of degeneration of the myocardium, sometimes running a rapidly
fatal course, were found to be consecutive to tumors of the uterus and
its annexa, especially to myomata of the uterus.
_Nervous Diseases Secondary to Diseases of the Genital Organs._
In earlier chapters of this work we have frequently referred to the
reflex influence exercised upon the nervous system in general, alike by
the normal functions and the pathological states of the female genital
organs. We must now briefly explain the more intimate connection between
nervous diseases and diseases of the genital organs, the causal
dependence of local nervous disturbances and of general neuroses upon
diseases of the reproductive organs.
The origination of a local nervous disease by a primary disease of the
genital organs is dependent upon a simple mechanical process, which is
explained by _Windscheid_ in the following terms: “In this connection,
the two principal mechanical factors are pressure and traction. Pressure
may affect individual nerves or an entire nerve plexus, and may be
exercised by a tumour, an exudation or a misplaced organ (_Hegar_);
further causes of pressure are furnished by inflammatory nodules, by
connective tissue hyperplasias, and, according to _Freund_, by
contractile processes in the organs themselves and in the ligaments.
Traction on the nerves results from displacements, as from prolapse of
the uterus or the ovaries, and, according to _Hegar_, from traction on
the pedicle of small tumours. A combination of pressure and traction
occurs especially in affections of the abdominal attachments of the
uterus, also where there is scarring of the neck of the uterus and of
the vaginal fornices. Great importance, also, in relation to the
production of local nervous disorders, must be attributed to the laying
bare of nerve-terminals by catarrhal and other inflammatory processes.
Abnormal mobility of the genital organs as a partial manifestation of
enteroptosis must also be mentioned as a cause of mechanical stimulation
of the nerves. Finally, in this connection, must be considered the
paresis of the abdominal walls that follows frequent and severe
confinements.”
The symptoms of the local nervous disorders to which these mechanical
stimuli may give rise, are very various, but may, according to _Hegar_,
be comprised under the general designation of _lumbar enlargement
symptoms_ (_Lendenmarksymptome_), inasmuch as the local stimulation of
the intrapelvic nerves, affects the nerve-centres of the lumbar
enlargement of the spinal cord. Among the symptoms, severe pains are
prominent, either continuous or intermittent, within the pelvis and in
the sacral region, accompanied by a sense of weight and pressure in the
abdomen, or by dragging pain in the region of the hips, in the gluteal
region, in the outer and back parts of the thighs, in the inner surface
of the leg, in the calf, in the dorsum of the foot, the sole of the
foot, and the heel; or by coccydynia (pain over the coccyx and the lower
extremity of the sacrum), or hyperæsthesia and anæsthesia of the
external genitals in the region of the vaginal orifice, or, finally, by
disorder of the processes of micturition and defæcation. In some of
these cases, the weakness of the lower extremities is so severe that a
paralytic condition is simulated. Actual paralysis may however occur, in
consequence of the extension of peritoneal inflammation to the
nerve-plexuses of the pelvis, leading to the occurrence of neuritis.
The development of a general neurosis in consequence of disease of the
genital organs, either as a complication dependent upon the nervous
stimulation excited by the primary disease, or as a reflex consequence
of this disease, implies, as _Windscheid_ strongly maintains, the
existence prior to the occurrence of the disease of the genital organs
of diminished power of resistance on the part of the nervous system.
This neuropathic constitution may be the result of inheritance, and,
according to _Engelhardt_, was so in 40 per cent. of his cases of women
suffering from nervous disease secondary to the disease of the genital
organs; or it may be acquired. Given this weakness of the nervous
system, a local disturbance of the genital organs may act as the
ultimate exciting cause of the onset of the neurosis in one of two
different ways (_Windscheid_). “1. The stimulus which the nerves of the
affected genital organ (or those of some adjacent area, affected by
direct extension) have received, proceeds upward from segment to segment
of the spinal cord, and ultimately passes to the highest centres. 2. Or,
on the other hand, the local nerves are not directly involved in the
morbid process in the genital organs, but this latter acts as a source
of reflex disturbance, a disturbance which must also pass through
nervous channels. To this latter class of cases belong the instances,
comparatively so frequent, in which, for example, a trifling
retroflexion of the uterus must be regarded as the exciting cause of the
neurosis.” The commonest neurosis of those that may be excited by local
disease of the genital organs is undoubtedly hysteria, next in frequency
come chorea and epileptic seizures.
_Schauta_ draws attention to the important fact that hereditarily
predisposed, neurasthenic individuals bear very badly repeated
gynecological examinations and long-continued local treatment, inasmuch
as, in such persons, a notable increase in the severity of the nervous
affection may result, and even the outbreak of actual mental disorder;
and he further points out that in hereditarily predisposed individuals,
psychoses not infrequently occur in consequence of the performance of
gynecological operations.
The processes of pregnancy make a deep impression on woman’s entire
nervous system, and more especially on her mental functions. This is
especially noticeable in the case of primiparæ. The fact is easily
understood, for a woman is filled with expectation and anxiety
concerning the unknown event, the complete revolution in her
organization, the powerful impressions on her physical ego, the
formation of a new being within her womb. How many joyful hopes, how
many distressing fears, are connected with that which is about to take
place, with the act of creation within her bosom; what changeful
glimpses into the future, on the one hand the gladness, on the other the
terror, of motherhood; often, also, the anxious doubts as to the
probable sex of the newcomer. Consider, too, the stormy sensations
experienced by a woman who, unmarried, has become pregnant contrary to
her desires and expectations, especially one in a poverty-stricken
condition—consider the agonizing thoughts in such a case regarding the
consequences of giving birth to a child. It is only to be expected that
in pregnant women in general there will almost always be increased
irritability of the nervous system combined with a tendency to the rapid
variation of emotional states. _Neumann_ found, in almost all the
pregnant women he examined in respect to the point, that there was an
increase of the knee-jerks, as a manifestation of the general increase
of nervous irritability. Nor does this change depend upon mental
influences exclusively; there are other factors, such as the reflex
processes aroused by the enlargement of the uterus, and also the changes
in the composition of the blood which occur during pregnancy, and cannot
fail to have an influence on the nutrition of the brain. Finally, also,
the deposit of carbonate of lime on the inner surfaces of the cranial
bones (the parietal and frontal bones) which occurs during pregnancy,
may be regarded as having some casual connection with the changes in the
nervous system; and, again many authors assume that the cerebral
circulation is influenced by the formation of the placental circulation.
The pathological consequences of pregnancy, as far as they affect the
nervous system, take the form of neuralgia and of peripheral neuritis of
various nerves, of chorea, of disturbances of the sense organs, and of
actual psychoses.
Peripheral neuritis in pregnant women affects chiefly the lower
extremities, but has been observed in the arms also; it is characterized
by muscular wasting with reaction of degeneration, by trophic
disturbances, and by disorders of sensation. A cure may ensue even
during the pregnancy, but in other cases the illness persists until
after parturition and on into the puerperium. To the same cause
_Windscheid_ assigns the paræsthesias of pregnancy, burning, prickling,
and numb sensations of the finger-tips, less commonly of the toe-tips;
these sensations are continuous, not paroxysmal, and cause very great
suffering.
Pregnancy favors the occurrence of chorea, a circumstance explicable by
the increased irritability of certain nerve centres characteristic of
the pregnant woman. The chorea of pregnancy occurs for the most part in
primiparæ, it is commoner in young than in older pregnant women, and
appears especially in the early months of pregnancy. In the majority of
cases the disease undergoes spontaneous cure before the end of the
pregnancy, but cases with a fatal termination have been observed.
On the other hand, a curative influence in previously subsisting
hysteria has been assigned to pregnancy. This in fact only occurs in
cases in which the hysterical manifestations have been evoked by
influences which are counteracted or removed by the occurrence of
pregnancy, such, for instance, as intense longing to bear a child,
dissatisfaction with the existing circumstances of married life, etc.
Conversely, it is by no means unusual to observe that, in patients who
have previously suffered from hysteria, the attacks become more frequent
during pregnancy, and that other nervous disturbances associated with
the hysteria become more prominent; hysterical paralysis, even, may
appear. Very variable also is the influence of pregnancy in epileptics.
Most commonly, indeed, a certain quiescence sets in, the attacks
becoming less frequent and less severe; but the reverse of this is at
times observed. In the domain of the sense organs we observe amblyopia
and hemianopia, deafness, and tinnitus aurium, and disorders of taste;
all these appear as pure nervous disturbances without known anatomical
basis (_Windscheid_).
Finally, among neuroses, tetany may be mentioned. In women, this disease
occurs almost exclusively during pregnancy and the puerperal state, in
the form of paroxysmal spasm, affecting chiefly the extremities, and
especially the hands; the spasm is bilateral, tonic in character, and
painful. The tetany of pregnancy usually runs a favourable course.
The slighter forms of mental disorder consist of perversions of taste
and smell. Of actual psychoses occurring during pregnancy, the commonest
forms are melancholia and mania. The former condition, which, according
to _Ripping_, occurs in 84.4 per cent. of the cases, is usually very
severe, and is characterized by a peculiar dreamy condition; it often
leads to suicide, or to infanticide immediately after parturition. The
psychoses of pregnancy are seen with greater frequency in the second
half of pregnancy, they occur especially in primiparæ, and are also
commoner in unmarried women. The prognosis is on the whole an
unfavorable one; sometimes, indeed, the mental disorder terminates with
the pregnancy, but in other cases it continues during the puerperium.
Mental alienation occurring in the early months of pregnancy is apt to
be less severe and to permit of a more favorable prognosis, than that
which makes its appearance during the later months or at the end of the
pregnancy.
In 32 cases of insanity of pregnancy recorded by _Ripping_, 8 cases
occurred in the first pregnancy, 5 in the second, 6 in the third, 3 in
the fourth, 4 in the fifth, 1 in the sixth, 1 in the seventh, 3 in the
eighth, 1 in the tenth. Of these women
3 became affected in the 1st month[41] of pregnancy.
4 became affected in the 2d month of pregnancy.
1 became affected in the 3d month of pregnancy.
2 became affected in the 4th month of pregnancy.
1 became affected in the 5th month of pregnancy.
0 became affected in the 6th month of pregnancy.
5 became affected in the 7th month of pregnancy.
5 became affected in the 8th month of pregnancy.
5 became affected in the 9th month of pregnancy.
6 became affected in the 10th month of pregnancy.
The neuralgias of pregnancy affect the most diverse nerve tracts, and
may occur either spontaneously, without any discernible local exciting
cause, or in consequence of the pressure exercised by the enlarging
uterus. To the former class of cases belong severe trigeminal neuralgia,
the familiar toothache affecting quite sound teeth at the very beginning
of pregnancy, intercostal neuralgia, and paroxysms of mastodynia. The
pressure neuralgias affect chiefly the domain of the great sciatic
nerve, manifesting themselves by the occurrence of pain down the back of
the thigh, in the calf, and on the dorsum of the foot, sometimes
associated with formication and other kinds of paræsthesia.
Parturition, by its powerful effect on the emotional nature in
combination with intense physical suffering, may give rise to numerous
nervous disturbances. The chief of these are, neuralgia, occasioned by
the pressure of the fœtal head as it passes through the pelvis of the
mother, paræsthesias, convulsions, maniacal paroxysms, transitory mental
alienation, cerebral hæmorrhages, and eclampsia.
The nervous disturbances dependent upon the processes of the puerperium
are numerous and severe. According to _Windscheid_, four types of
affection of the motor nerves may arise at this period. 1.
Pressure-paralysis may occur in cases of generally contracted pelvis, or
even in the absence of such contraction in cases of prolonged labor,
from the pressure exercised by the child’s head upon the intrapelvic
nerves, and above all on the great sciatic nerve; pressure-paralysis may
also result from obstetric operations, and especially from forceps
delivery. The symptoms of pressure-paralysis consist chiefly of
paralysis of the extensors of the feet and the toes; sensory symptoms
are usually wanting. 2. Inflammatory infective paralyses, due to the
extension to adjacent nerves of puerperal inflammation of the pelvic
connective tissue. 3. Acute multiple neuritis, occurring either during
the latter half of pregnancy or a few days after delivery, and affecting
not only the nerves of the lower extremities, but those of remote
regions, even the cranial nerves. 4. The rare puerperal hemiplegia due
to cerebral hæmorrhage, occurring usually at the time the patient leaves
her bed after delivery; puerperal hemiplegia may also arise from
embolism consecutive to endocarditis, which may itself have originated
before the termination of the pregnancy.
Other puerperal diseases of the nervous system requiring mention are, on
the one hand, tetany, occurring during lactation, and permitting of a
favorable prognosis, and on the other, the infective puerperal tetanus,
the prognosis of which is exceedingly unfavorable. Finally, the
puerperal state has to be considered as a factor in determining the
onset of psychoses.
The puerperal psychoses are for the most part dependent upon the great
loss of blood occurring during delivery, leading to anæmia and increased
irritability of the brain, in association also with the circulatory
disturbances that arise in the central nervous organs in consequence of
the sudden emptying of the abdomen by the act of childbirth; but
additional causes of mental disorders are to be found in the changes in
the composition of the blood that occur during pregnancy, and the
influence of these changes upon the nutrition of the brain. Inherited
predisposition plays its usual part in these cases; and accessory
factors in producing mental disturbance during the puerperal state are
to be found in puerperal infection, eclampsia, osteomalacia, and
emotional shock.
Thus, for example, among 49 cases of puerperal psychoses, _Hansen_ found
that in 42 instances there was puerperal infection; and among 200 cases
of puerperal eclampsia, _Olshausen_ found 11 patients suffering from
mental disorder. The principal forms of insanity occurring at the
puerperium are mania and melancholia, next in frequency come monomania
(Ger. _Verrücktheit_), dementia (Ger. _Blödsinn_), alternating or
circular insanity (_folie circulaire_), hallucinatory paranoia (chronic
delusional insanity with hallucinations), and hysterical mental
disorder.
According to _Windscheid_, the commonest cases are those which are
purely puerperal, the rarest those in which the insanity of pregnancy
continues during the puerperal state; the age at which puerperal
psychoses most commonly occur varies between 31 and 35 years, the
average age being 29.1; multiparæ are more often affected than
primiparæ; the outbreak of mental disorder most commonly occurs within a
week after the birth of the child; there is nothing specific about the
various forms of puerperal insanity, which are identical with the
respective varieties owning another etiology. According to this author,
before an attack of puerperal mania, prodromal symptoms usually occur,
such as headache, dizziness (Ger. _Augenflimmern_), feelings of anxiety,
insomnia, followed by various congestive symptoms, and either by great
restlessness or by great apathy, and very often by indifference to the
infant; to these symptoms succeeds the period of motor excitability,
characterized by great bodily restlessness and by continued
talkativeness; the culmination takes the form of a maniacal outburst, in
which infanticide even may occur; the delirium runs mostly in erotic and
religious channels. Puerperal melancholia also exhibits the usual
clinical picture of this form of mental disorder; after prodromal
headache, stupor sets in, often associated with attacks of anxiety and
with hallucinations of sense, and always characterized by great loss of
appetite and by a suicidal tendency.
In relation to the puerperal psychoses, it appears that the first
menstruation after the birth of the child has, like the very first
appearance of the menstrual flow during the menarche, a tendency to
favor the onset of mental disorder. According to _Marcé_, this first
post-puerperal menstruation has a very definite significance in the
causation of psychoses. Among forty-four cases of puerperal psychoses,
there were eleven instances in which the mental disorder made its
appearance six weeks after childbirth, exactly at the moment, that is to
say, in which, had the mothers not given suck to their children,
menstruation ought to have reappeared. In those who did not nurse their
infants, and in whom menstruation recommenced at the due date, the
psychosis usually began on the first day of menstruation, less often on
the fourth or fifth day. In some instances the psychosis appeared at the
time at which menstruation might have been expected to occur, but when
the flow was still in abeyance. And in some women who suckled their
children for a time and then weaned them, the psychosis made its
appearance at the time of the first recurrence of menstruation.
Among diseases of the sense-organs occurring during the menacme, ocular
lesions are by no means rare as sequels of pathological changes in the
genital organs. Thus, in cases of displacements of the uterus,
especially prolapse, retroflexion, and retroversion, we sometimes see
retinal hyperæsthesia and reflex amblyopia, photophobia and
lachrymation, and accommodative or muscular asthenopia. Inflammation of
the pelvic connective tissue, perimetritic and parametritic exudations,
and especially parametritis atrophicans, may give rise to functional
disorders of the eye, reflex hyperæmia of the trigeminal and optic
nerves, various painful sensations, and photophobia. Severe metrorrhagia
may also cause disturbances of vision, either by inducing local anæmia
and consequent functional failure of the nervous apparatus, or by
leading to serious infiltration of the optic nerve which manifests
itself also in the retina in the form of a transudation. In cases alike
of congenital and of acquired atrophy of the uterus, and frequently,
therefore, in sterile women, optic nerve atrophy may occur.