The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

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.

In the literature of the subject, we find numerous references to the fact that among the disorders of the climacteric, circulatory disturbances play a part. But a full and accurate account of these disorders is lacking alike in the literature of gynecology and in that relating to diseases of the heart—and this is true even of the most recent publications.

Among striking individual cases, one recorded by Moon may be mentioned here, a case of tachycardia consequent upon a sudden menopause: “In a woman 35 years of age the menses were suppressed owing to chill; the pulse-frequency increased from 80 to 200, without any apparent change in the heart or its valves; the symptom lasted for several days, when menstruation became once more established, and the pulse-frequency fell again to the normal.”

Tilt expresses the opinion that the heart is but little involved in the disturbances of the climacteric, his experience coinciding with that of Quain. Boerner and Glaevecke, on the contrary, describe the heart troubles of the climacteric in terms very similar to those employed by myself.

A. Clément describes a peculiar form of disturbance of the functions of the heart at the climacteric period, to which he gives the name of Cardiopathie de la Ménopause, and of which he has seen four cases. The age of his patients varied from 46 to 50 years. They were all vigorous women, free from hysterical symptoms, and they had never suffered from rheumatism or from any functional disturbance of the heart. In all these cases the cardiac disorder occurred at a time of life when menstruation still continued, but had already become somewhat irregular. Usually the trouble in question makes its first appearance during the flow, or, if occurring independently of menstruation, becomes more severe at that time. Prior to the development of the actual heart symptoms, we observe for a time, two or three months it may be, signs of general exhaustion and weakness. Then occurs an attack of palpitation of the heart, rapidly succeeded by faintness, sense of precordial anxiety, and dyspnoea. During repose the patient does not usually suffer from any difficulty in breathing, but sleep is apt to be disturbed by paroxysms of palpitation and severe precordial anxiety. As the disease advances, dyspnoea is observed on the slightest exertion. Ultimately, the symptoms mentioned, palpitation, precordial anxiety and dyspnoea, become permanent, but are less severe when the patient is at rest. Constant now is also the feeling of weakness and faintness, which from time to time increases to actual syncope with complete loss of consciousness, and coldness of the entire surface of the body. Examination of the heart gives negative results. The cardiac impulse is a little stronger than normal; the cardiac rhythm may be either regular or irregular, but actual intermission of the beats does not occur. The heart-sounds are pure, there is no murmur; the first sound, if altered at all, will be stronger, not weaker than normal. Neither swelling of the jugular veins nor venous pulsation is to be observed. The most striking symptom of heart affection, indeed the only positive physical sign, is the great increase in the frequency of the heart’s action, the pulse rate often being as much as 150 or 160 per minute, and in addition weak and somewhat variable in strength. At the outset of the disease, no oedema of the lower extremities is to be observed, and it only appears after three or four attacks. In all the patients the extreme pallor of the face is a striking feature. An increased quantity of urine is eliminated. The course of the disease is characterized by a series of successive paroxysms, separated by periods of almost complete remission. At first, these remissions last for a month or two, but they gradually become shorter and shorter, whereas the duration of the attacks continually increases, until it is as much as seven or eight days. At this stage, disturbance of digestion ensues, the appetite is lost, and the general vigour declines. Recovery ultimately occurs, but very gradually. Clément refers the disease to a profound disturbance of the cardiac innervation through the sympathetic nerves, but believes that anæmia constitutes a contributory cause of the cardiac disorder.

Kostkewitsch has made observations regarding the influence of the climacteric upon previously existing heart-disease, and has thereby been led to conclude that the influence is unfavourable. The functional disturbances of the cardio-vascular apparatus which commonly accompany the menopause, readily lead, should organic heart-disease exist, to the onset of severe cardiac weakness, which may have a rapidly fatal termination. In 55.5% of the women who enter the climacteric period with organic disease of the heart, the menopause gives rise to a failure of compensation. Such failure of compensation is especially likely to occur in women suffering from valvular insufficiency; it is least probable in cases of arteriosclerosis without valvular defect. The symptoms of defective compensation—dilatation of the heart, increased frequency of the pulse, arrhythmia cordis, etc.—are manifested especially during the menstrual flow.

Diseases of the Digestive Organs.

The congestions which, as we have already pointed out, constitute the pathological basis of the majority of the disorders of the climacteric, manifest themselves in the abdominal organs in the well-known form of plethora abdominalis, chronic venous congestion of the gastric and intestinal mucous membrane, hyperaemia of the liver, hyperaemia of the mucous membrane of the bladder, catarrh of the bladder, distension of the haemorrhoidal veins, and the various symptoms dependent upon these several forms of congestion.