to the passage of a probe. The left ovary was prolapsed and sensitive. By treatment the patient was entirely cured in six months. She had one relapse of cardiac trouble about a year after treatment was stopped, when I found the uterus again displaced; that being remedied by a short course of treatment, she has been well and had a child since. CASE II.-Et. 43 years; married twenty-two years; two children, the last born thirteen years ago; present illness seven years. Oppression about chest, principally in the heart region, almost constant. Heart stroke intermits once in from twenty to thirty beats, which worries the patient very much; she is afraid that her heart might stop beating altogether. Pain in the lumbar region radiating to hypogastrium. Menstruates every three to four weeks, the flow continuing eight days. Organic cardiac lesion eliminated. Lacerated perineum and cervix; the cervix feels sclerematous to touch. Endometritis; both ovaries prolapsed, enlarged, and very tender (oöphoritis). The general condition was very much improved by surgical and medicinal treatment. The intermittency has entirely disappeared. CASE III.Et. 23; Hebrew; menstruation began at 14; married four years; never was pregnant. The period is regular every twenty-eight to thirty days, from six to eight days' duration; loses much blood; no dysmenorrhea. The abdomen is occasionally bloated. Constipation. The patient consults me about frequent attacks of oppression in the precordial region; she has attacks of faintness frequently, occasionally merging into syncope. When she has a severe attack, accompanied by unconsciousness, she is ill four to five days. The attacks have no marked relation to the monthly epoch. She has been examined by two other physicians previously, on account of sterility, and pronounced well with regard to the reproductive organs; the heart trouble was thought to be due to some disease in the organ itself. Physical examination shows a very tender point on pressure over the apex; firm pressure applied here causes immediate faintness, and the pain radiates down the left arm. The first heart sound is somewhat accentuated. Pulse feeble and frequent. Taking into consideration the age of the patient and absence of any other signs on physical examination which would indicate an organic heart lesjon, I considered the condition to be a neurosis, and looked for cause. Vaginal examination is painful; there is marked tenderness behind the vaginal portion, which feels firm and hard to the examining finger; there is also slight retroversion; the body of the uterus is tender. The introduction of a sound shows no stenosis, but excessive tenderness at the internal os; the moment the probe touches this point the patient shrieks with pain. Diagnosis.-Reflex angina pectoris. Retroversion, first de Six gree. Endometritis; hyperesthesis of the os internum. months' steady treatment cured the patient entirely of her cardiac distress. The heart sounds and pulse, however, have not changed, except in frequency. The treatment adopted was galvanism over the painful spot and over the median nerve at its exit from the brachial plexus. Internally, various remedies were used. The cervical canal was fully dilated, and the cavity of the uterus gently curetted with a dull instrument; then an application of carbolic acid and glycerin made to the interior; finally, an intrauterine stem was inserted. Later intrauterine injections of iodine and glycerin. Behind the cervix glycerinated tampons. Two years have passed without a relapse, and the patient is now in about the third month of pregnancy. I may add that, after the dilatation and curetting, the monthly flow was decreased to from four to five days' duration, and much diminished in quantity. CASE IV.-Patient 25 years old; menstruation began at 16; married six years; two children; no miscarriage; last child four years ago. The illness dates back to the date of the birth of last child. Pains in the left hypogastric and inguinal region; frequent and painful micturition. Much nausea, but no vomiting; headaches. Frequent attacks of palpitation and pain over the heart; when an attack of pain comes on, it continues from half an hour to two hours. Dysmenorrhea; constant leucorrhea. I Diagnosis.-Lacerated perineum and cervix. Hyperplasia uteri; slight procidentia; anteflexion with endometritis. Prolapse of the left ovary with periovaritis. Perineorrhaphy and trachelorrhaphy performed; a few months' treatment resulted in cure. saw this patient to-day, after the lapse of nearly two years, while operating on one of her relatives, and she tells me that she has been perfectly relieved of her heart and other symptoms, until, for the past two months, she is beginning to feel the same condition coming on again, but in a much milder degree. CASE V.-Patient æt. 32. Married ten years; three children, the last child born five years ago; menstruation began at 13 years. She has been ill since the birth of her last child; the symptoms, however, increasing much in severity for the past three months. Languid feeling throughout is complained of. Cardiac palpitation, pulse 120; pain in the region of the heart and between the shoulders; constipation; loss of appetite. The symptoms are not increased about the menstrual period. Lacerated perineum and cervix. Retroflexion with version. Treatment improved her very much, but on account of her husband's business she removed South soon afterwards, and I have been unable to hear from the lady since. ČASE VI.-Et. 29. Married eleven years; never pregnant; menstruation began at 12 years. The present illness dates from the time of matrimony. Was said to have had inflammation of the womb four years ago. Complains principally of pain in the heart, which is described as paroxysms of "piercing and sticking," and in the intervals as a dull, continuous pain, which tra verses down the left arm. Two tender points are present on pressure over the precordia. Dysmenorrhea and other symptoms are present which point to uterine trouble. Diagnosis.-Retroversion of the portio vaginalis with the body of the uterus pushed slightly to the left. An old exudation is felt on the right side. Chronic endometritis. Patient cured. CASE VII.-Aged 27; married nine years; four children; five miscarriages; last child two years ago. Present illness since that time. Complains of much dyspnea; bloated abdomen; when the abdomen begins to "swell," intense cardiac pain and palpitation begin, so severe that she is unable to move; full inspirations increase the pain over the heart. Symptoms which point to disease of the sexual organs are present also, such as constipation, frequent micturition, and constant leucorrhea, but not the slightest pain either during or before menstruation. Neither are the heart symptoms of greater severity at these periods. Anteflexion and procidentia, first degree, diagnosticated. Patient cured of all morbid symptoms; she consults me now about once per month, and sometimes only once in two months, to have a Gehrung pessary removed and readjusted. One time I left the supporter out, but she returned in two weeks again complaining of her old symptoms. CASE VIII.-Pt. 28 years, married eight years; three children. Hysteria; cardiac palpitation and severe precordial pain; pulse irregular, sometimes intermittent; menorrhagia. Diagnosis.-Laceration of perineum and cervix; anteflexion with version and second degree of procidentia. Prolapse of right tube and ovary. In the region of the left ovary much tenderness; it cannot be mapped out on account of the severe pain which is caused by examination in this site. Much improvement by treatment, so that the patient is quite comfortable. She says CASE IX. The patient came under my observation in the clinic on the 1st of April. 31 years old; married ten years; four children; no miscarriage; the last child two years ago. that she had been feeling perfectly well up to five weeks ago, when she lifted a heavy wash-tub, when suddenly she felt abdominal pains, and, a few hours later, lumbar pains; she rapidly grew weaker; loss of appetite. For the past three weeks severe palpitation, pain over the heart, and oppressed feeling throughout the chest, with slight dyspnea. The cardialgia at times is very severe, the pain radiating down the left shoulder and arm, formication being felt in the extremity; pulse 130. Three painful spots over the precordial region, viz.: second sternocostal articulation; fourth intercostal space, one inch from the sternum; and in the sixth intercostal space, on a line with the nipple. The uterus was found retroverted and flexed; the left ovary and tube prolapsed. The uterus was readily replaced, and tampons introduced to retain the organ. I saw her the following day, when she said that she already felt some relief, especially from the thoracic symptoms. 1 Dr. Theilbaber's case, on account of its great interest, I will briefly review. A laboring woman, 46 years old, shortly after the cessation of her monthly period, supposed herself to have taken cold" while picking hops. A few days later, while doing some work, she was afflicted with a severe attack of cardiac palpitation, on account of which she consulted the author. Other morbid symptoms, such as dyspnea, vertigo, etc., accompanied the palpitation; the pulse rate by the least exertion was increased to 240 beats per minute; medication had very little or no effect; rest in the recumbent position alone afforded relief. She remained an invalid for several years, until after the menopause had taken place, and yet no relief of her palpitation. Shortly after the establishment of the menopause, the author insisted on a vaginal examination. He found the uterus retroflexed, enlarged, and the portio vaginalis tumid. Reduction of the displacement quickly cured the patient. Comment on this case is unnecessary. Resumé.-There are a large number of patients afflicted with uterine or ovarian disorders who also suffer from nervous heart affections, and some cases who give only a history of the latter, in whom this will be found dependent on the former disorder, as is well illustrated by example No. III. The symptoms of the affection do not differ from the cardiac neurosis dependent on other causes. It is necessary to make a careful examination, in justice to the patient, of the reproductive organs, if no other positive cause can be found to account for the neurosis. That grave organic lesions may be suspected by only a superficial examination, when the condition is but a nervous imitation of disease, is well illustrated by numerous citations of cases. Flint's case is a good example. When the neurosis is due to ovarian lesion, it is usually the left ovary which produces the mischief, as has already been pointed out by Dr. J. Milner Fothergill, and coincides with my own observations. In conclusion, I would say that the cases cited were such in which the reflex cardiac neurosis caused the greatest inconvenience to the patients, when they presented themselves for treatment, and that an argument that treatment for the neurosis directed to other organs than the pelvic, would in these cases not hold good, as they were thoroughly tested previously; also, that the observations are not confined to a few patients, "Tachycardie durch Lageveränderung des Uterus." Münchner Medicinische Wochenschrift, vol. xxxi., p. 465. 2 Pepper's "System of Med.," vol. iii., p. 750. but extend over a series of nearly two thousand patients taken as they came, after beginning my own investigation, and it is from this list that I take my per centum. A CASE OF ANENCEPHALUS. BY WM. C. WANAMAKER, M.D., I Do not report this case on account of its being anything new -for it is not-nor yet to attempt to throw any light upon the subject, but merely because it is a very rare freak of nature, and one of the most puzzling cases that the obstetrician is ever called upon to diagnose. Indeed I doubt whether, in a great majority of such cases of fetal deformities, a correct diagnosis is made until the fetus is expelled. Not that the ignorance of the practitioner as to the condition of affairs will make any difference in the termination of the case for the labor generally proceeds to a rapid and favorable end-but it is natural for us to feel an unnecessary degree of solicitude and alarm if we are unable to distinguish this condition from the more dangerous one which it so closely simulates. Mrs. A., æt. 25, primipara, delicate, was taken in labor on the night of the 17th of November, 1885. The first indication of labor was the passage of an unusual amount of liquor amnii. 1 saw her two hours after the rupture of the membranes, made an examination immediately, found the cervix dilated to the size of a silver half-dollar, and a soft flabby mass presenting itself. The mass felt exactly like placental tissue, but following it up as far as I could reach by the introduction of my index and middle fingers, I could not feel any connection between it and the uterus; nor was there any hemorrhage or history of hemorrhage. As labor was progressing satisfactorily-as far as the mother was concerned-I waited an hour, made the second examination, and found the entire vagina filled by this peculiar mass. Violent contractions now came on, and every pain caused a marked bulging of the tumor. I now passed my index and middle fingers beyond the tumor, |