Part 37

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, 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.