Part 90

But in addition to the causes of climacteric tachycardia already enumerated, we have to take into consideration the results of recent investigations concerning the organo-therapeutic employment of the chemical constituents of the ovarian tissue; it would seem that when at the menopause the ovaries undergo atrophy, so that their internal secretion is no longer poured into the blood, the resulting alteration in the chemical constitution of that fluid gives rise to a disturbance of the vasomotor centre in the medulla oblongata.

In some cases, the tachycardiac paroxysms appear to be connected with the erotic excitement to which women are sometimes subject at the climacteric, voluptuous crises and ejaculation occurring; it is possible that in some of these cases masturbation plays a part.

A second group of cardiac troubles occurring in climacteric women consists of cases which are very common, but not often very severe. The cases in question depend upon the liability to an increased deposit of adipose tissue in the body at the time of the menopause, and in this connexion the plethoric form of lipomatosis universalis almost invariably predominates. It is a well-known fact that between the ages of 40 and 50 years women have an excessive tendency to obesity, and that even those women who have hitherto been extremely lean are apt to become quite plump at the climacteric period. Chiefly in consequence of this increasing obesity, there occurs in climacteric women a series of cardiac troubles of very variable intensity. If the deposit of fat is effected very gradually, and if the obesity does not become extreme, it is only after vigorous bodily exercise, such as fast walking or going upstairs, and after meals, that the patient is troubled with a little shortness of breath and moderate palpitation; appetite, digestion, and sleep remain usually unaffected in cases of this degree of severity. Definite attacks of cardiac asthma, and well-marked signs of cardiac insufficiency affecting the entire circulatory system, will very rarely occur in such persons.

It is an interesting fact, that the troubles which arise from fatty deposits around the heart are in general far less severe in climacteric women than they are in obese men of corresponding age. This may be due to the circumstance discovered by W. Müller, in the course of his investigations on the proportions of the human heart, that in the development of general obesity, the pericardial fat increases proportionately to a greater extent in the male than in female. But in my opinion the true explanation is to be found in the fact that variations in the amount of fat in the body are normally far more extensive in women than in men; at puberty, during pregnancy, and during lactation, extensive though gradually effected changes in the amount of adipose tissue in various parts of the body occur, so that experience has rendered the organism ready to adapt itself to the further changes that take place at the climacteric—above all, the heart has become competent to meet very various demands upon its powers.

Only in women who from youth onwards have exhibited a marked tendency to obesity, and in whom at the climacteric age such obesity has become extreme, do the cardiac troubles attendant on the menopause become very severe. In such persons, palpitation and shortness of breath occur on slight exertion, and attacks of cardiac asthma are frequent. In consequence of the diminished propulsive power of the heart, circulatory difficulties make their appearance in the most widely divergent venous areas; the forms most commonly met with are, varices in the veins of the lower extremities, permanent dilatation of certain of the small superficial veins of the skin, phlebectases of the rectal veins (i. e. “piles”), and ultimately we see the well-known series of symptoms of venous engorgement—oedema of the feet, passive congestion of the lungs, albumen in the urine, etc.

When such cardiac troubles are present, the objective examination of the heart shows in the early stage no gross abnormality; at most the heart-tones seem somewhat weakened, with a moderate enlargement of the area of percussion-dulness, whilst the impulse is displaced a little outwards, and is weaker than normal. In some cases, however, a marked dulness on percussion over the sternum indicates an extensive deposit of fat in the mediastinal tissues. In the second stage of the fatty heart, when the symptoms have become more severe, we find a considerable enlargement of the area of cardiac dulness both in the vertical and the horizontal extent; the cardiac impulse is diffused as well as feeble. The sounds of the heart are usually pure but faint—in some cases they remain loud and clear. Exceptionally, a short blowing murmur is heard with the first sound; and sometimes this sound is reduplicated.

Whilst in the first stage the pulse is hardly abnormal, in the second stage, very various changes occur; often it is subdicrotic or dicrotic in character.

In the great majority of instances, in these cases of cardiac disorder at the menopause, provided a suitable dietetic regimen is early adopted and perseveringly carried out, we may give a hopeful prognosis.

A third, less common but far more serious form of cardiac disorder occurring at the menopause, displays the well-known symptoms of cardiac failure. Those thus affected are usually slightly built, delicate women, who during the years of development suffered from chlorosis, who in adult life were troubled with anæmic symptoms, and in whom the menopause was ushered in by very severe losses of blood; sometimes, again, they are women who throughout their sexual prime have been accustomed to menstruate very abundantly, who have had numerous and severe deliveries, or who have had frequent miscarriages—it is in those who have thus been weakened by frequent and profuse haemorrhages, that the symptoms of cardiac failure ensue at the climacteric period. The women thus affected also frequently suffer from palpitation of the heart; the pulse is abnormally frequent, small, low, and easily compressible, and sometimes intermittent or arrhythmical. The heart’s action is weak and devoid of energy. The heart-sounds are usually obscure, and sometimes a systolic murmur is audible. The patients are short of breath and are subject to attacks of cardiac asthma, not infrequently associated with angina pectoris. In conjunction with these symptoms, we see signs of venous congestion: sudden attacks of coldness in the hands and feet, often also oedema of the feet; the urine at times contains albumen. The haemoglobin-richness of the blood is always notably diminished. I need not discuss in further detail the well-known symptoms of cardiac insufficiency, and I need only insist that when these symptoms are met with in women at the climacteric, it is of the greatest importance, alike from the prognostic and from the therapeutic standpoint, to make a careful examination of the reproductive organs, so as to determine the exact source of the recurrent bleedings which usually constitute the primary cause of the patient’s sufferings.

In several cases of this kind, I found that the haemorrhages were due to a relaxation of the uterine tissues, and that this relaxation was itself referable to intrapelvic circulatory disturbances, dependent upon obstruction in the vena cava inferior, whereby the venous return from the pelvis was rendered difficult, and an engorgement of the uterine vessels was brought about.

In some instances of cardiac failure at the menopause, chronic inflammation within the pelvis is to blame for the menorrhagia upon which the cardiac failure depends. Often, again, the haemorrhages are referable to vasomotor influences, such as are liable during the menopause to affect various vascular areas. In other cases, the recurrent bleeding is due to retroflexion of the uterus, to prolapse of that organ, or to tumour, it may be myoma, polypus, or carcinoma.

Finally, during the menopause, more especially in women in whom menstruation has continued up to or beyond the fiftieth year, or in those who have given birth to a large number of children or have lived lives of severe bodily exertion, cardiac troubles may arise dependent upon arteriosclerosis of the great vessels. The signs of such changes in the walls of the bloodvessels are clearly marked: the cardiac impulse is heaving, the second sound of the heart is accentuated; the pulse is full and large, usually giving a very powerful blow to the examining finger, whilst its sphygmographic tracing exhibits characteristic signs in the exceptional height and great distinctness of the first predicrotic elevation. The subjective troubles are in these cases very severe; dyspnoea and attacks of asthma or of vertigo are common, and sometimes albumen may be found in the urine.

We may thus summarize the cardiac disorders met with at the menopause, and more or less directly dependent upon the changes undergone by the feminine organism at that period of life:

1. Paroxysmal tachycardia, a reflex neurosis due to the climacteric changes in the ovaries.

2. Nervous palpitation in women who were similarly affected at the time of the menarche, and in whom the trouble is merely the expression of a very unstable nervous system, and one influenced with especial readiness by impressions proceeding from the reproductive organs.

3. Cardiac disorder due to the obesity so commonly occurring as a part of the general metabolic changes of the menopause, but more particularly dependent upon a deposit of fat in the neighbourhood of the heart itself.

4. Symptoms of cardiac failure, due to excessive losses of blood at the menopause, either as an exaggeration at this time of menstrual processes, or as a result of some actual disease within the pelvis.

5. Cardiac disorder in women in whom the menopause occurs at an unusually advanced age, and dependent upon arteriosclerosis.

Particular consideration must be given to a symptom not infrequently occurring in association with the cardiac troubles of climacteric women, and referable to the circulatory disturbances characteristic of this period of life, namely, vertigo. The attack in some cases comes on without apparent cause, in others it occurs on the performance of some unusual movement or the adoption of some peculiar posture (stooping, or the like); the patient is suddenly seized with a sense of rotation, either of his own body, or else of his visible and palpable environment; with this is associated a sensation of disturbance of equilibrium, flickering before the eyes (muscae volitantes), tinnitus aurium, palpitation of the heart, increased frequency of the pulse, which may be either full or small, redness or pallor of the face, coldness of the hands and feet, muscular twitchings, a sense of great anxiety, and the outbreak of a cold perspiration. The vertigo occurs in paroxysms, usually of short duration—a few minutes to a quarter of an hour. It is especially plethoric and obese women who are liable at the climacteric to suffer from this disorder.

A somewhat similar condition is described by Tilt under the name of “pseudo-narcotism,” as frequently occurring in climacteric women. Tilt indeed states that in 500 such women, he noted its presence in no less than 277.

Many hypotheses have been promulgated to account for the vertigo that so frequently occurs at the menopause. Both anæmia and hyperaemia of the brain have been assumed as causes, alike dependent upon the irregularity of menstruation, which is supposed to have a reflex influence upon the cerebral circulation. Others regard the vertigo as a climacteric neurosis, since it occasionally occurs before the menstrual irregularities begin, and in such cases a reflex disturbance of the cerebral circulation cannot be supposed to have arisen. According to Matusch, climacteric vertigo is a manifestation of epilepsy—an explanation which has been often extended to include all the menstrual psychoses. Windscheid believes that in many of the cases the vertigo is to be explained by the existence of arteriosclerotic changes in the blood vessels, such as are already by no means rare at the age at which the menopause usually occurs; whilst in other cases, he believes, the vertigo is to be regarded as one of the symptoms of a nervous disorder. That in any case the vertigo is dependent in some way upon the changes that occur in the reproductive organs at the climacteric period, is shown by the fact that after the final cessation of menstrual activity the patient as a rule ceases to suffer from this symptom.

To the circulatory disturbances consequent upon the menopause we must also refer ardor fugax, fugitive heat, the sudden rushes of blood to which women are prone at this period of life.

The cardiac troubles of the menopause are seen especially in women in whom the cessation of menstruation occurs quite suddenly, and in those in whom menstrual activity ceases at an exceptionally early age. It would seem that in such cases, owing to the continuance of periodic maturation of the graafian follicles associated with congestion of the intrapelvic organs, in the absence of the periodic relief to that congestion afforded by the menstrual flux, there results a summation of stimuli, whereby the accelerator nerves of the heart are very powerfully affected.

Thus, I had under my care a lady from Smyrna 36 years of age. She had begun to menstruate when 12 years of age and menstruation was always scanty; she married when 15 years old, and finally ceased to menstruate when 19 years of age; she was sterile, and no abnormality could be detected on physical examination of her reproductive organs. Every month she suffered from severe paroxysmal tachycardia, with dyspnoea, rush of blood to the head, perspiration of the face, etc.

In another case, that of a woman 45 years of age, menstruation, hitherto regular, was suddenly suppressed, during the flow, in consequence of a severe fright. The next month the flow failed to appear at the usual time, but instead the patient was affected with severe cardiac distress, accompanied by sudden sensations of heat in the face, palpitation of the heart, and vertigo; these symptoms lasted for several days, and since then have recurred at intervals of three or four weeks.

The cardiac troubles of the menopause are seen with especial frequency in women who were affected with similar disturbances at the time of the menarche. Experience clearly shows that a certain connexion exists between the manifestations that accompany the commencement of sexual activity, and those that accompany the decline and extinction of that activity; and a physician will rarely be mistaken if he bases on the fact that the general health was or was not seriously affected at the age of puberty, a prognosis that the course of the climacteric will be an unfavourable or a favourable one, respectively. In other words, in women whose nervous system is an unstable one, and in those with hereditary predisposition to the occurrence of cardiac disorder, the changes that take place in the reproductive organs both during the menarche and during the menopause, are likely during these vital phases to arouse reflex disturbances of the cardiac functions. The facts thus noted are analogous to those observed by Potain, who distinguishes a peculiar form of chlorosis, occurring in delicate individuals at the age of puberty, and, though apparently cured during the menacme, recurring in its primitive severity at the time of the menopause.

Again, women with a sanguine and erethistic temperament are more inclined to suffer from cardiac troubles at the menopause than women of a tranquil temperament and those endowed with an unimpressionable nervous system.

Finally, elderly virgins, women who have for many years lived in chaste widowhood, sterile women, women who have married shortly before the menopause, or who at this time have recently been delivered, are all more inclined to the cardiac troubles of the climacteric period than women whose sexual life has been of a less abnormal character.