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.