Psychotherapy Part 41

Antineuralgic medication.

{337}

True Angina and Psychotherapy.--One of the most frequent occasions for the development of true angina is vehement emotion. The place of psychotherapy then in the affection will at once be recognized. A cla.s.sical example of the influence of the mind and the emotions in the production of attacks of angina pectoris in those who are predisposed to them by a pre-existing pathological condition, is the case of the famous John Hunter. He was attacked by a fatal paroxysm of the affection in the board room of St. Thomas' Hospital, London, when he was about to begin an angry reply with regard to some matter concerning the medical regulation of the hospital. He had previously recognized how amenable he was to attacks of the disease as a consequence of emotion or excitement, and had even stated to friends that he was at the mercy of any scoundrel who threw him into an attack of anger. Some of the deaths from fright or sorrow at a sudden announcement of the death of a relative, or even the deaths from joy are due to angina pectoris precipitated by the serious strain put upon the heart by the flood of terror or emotion.

Men who are sufferers from what seems to be true angina pectoris must be made to understand without disturbing them any more than is absolutely necessary that strong emotions of any kind--worry, anger, exhibitions of temper, and, above all, family quarrels, must be avoided. Not a few of the serious attacks of angina pectoris which physicians see come as a consequence of family jars, owing to the persistence of a son or daughter in a course offensive to the parent.

A part of the prophylaxis, then, consists in impressing this fact on members of the family and making them understand the danger. The disposition that causes the family friction is, however, often hereditary and will, therefore, prove difficult of control. It is one of the typical cases of inheritance of defeats.

_Solicitude and Prognosis_.--The distinguished French neurologist, Charcot, had several attacks of what seemed to be true angina pectoris. His friends were much disturbed by it. Physicians who saw him during the attack feared that he was suffering from an incurable heart lesion. He himself, as his son, Dr. Charcot, told me, refused to accept this diagnosis, and preferred to believe that what he was suffering from was a cardiac neurosis--and, of course, he had seen many of them. He was unwilling to have a heart specialist examine him very carefully for he did not wish to be persuaded of the worst aspects of his condition.

What he said in effect was, "This is either a neurotic condition, as I think it is, or it is an organic condition. If it is organic, my physicians would be apt to tell me that I must stop working so hard, and I am sure that if I should do that I would do myself more harm than good by having unoccupied {338} time on my hands. I want to go on doing my work. If I am wrong some time I shall be carried off in one of these attacks. That will not be such a serious thing, for after all I must die some time and my expectancy of life cannot normally be very long. I prefer, then, to go on with my work and think the best, for it does not seem that I could do anything that would put off the inevitably fatal issue if I am to die a cardiac death." He was found dead one morning, but he had pa.s.sed into the valley of death without being seriously disturbed and without any of the neurotic symptoms that so often develop in discouraged patients. Curiously enough, one of our most distinguished heart specialists in this country went through almost the same experience and preferred to live "the brief active life of the salmon rather than the long slow life of the tortoise."

The best possible factor in therapy is secured if patients can be brought to the state of mind of these distinguished physicians who calmly faced the future, refusing to disturb themselves or their work, because they feared that the worry that would come down upon them in inactivity would aggravate their disease. Where men are occupied with some not too exacting occupation, that takes most of their attention and at which they have been for years, it is best to leave them at it, though the harder demands of it must be modified. If they can be brought to persuade themselves, as did the two physicians--though probably only half-heartedly--that their affections may possibly be merely neurotic and not true angina, it will always be better for them. Death may come, and commonly will, suddenly, but, after one has lived a reasonably full life, that is rather a blessing (and not in disguise) than the terror which it is sometimes supposed to be.

Pseudo-Angina.--The neurotic form of angina is quite compatible, not only with continued good health but with long life, and even after a long series of attacks, some of them very disturbing in their apparent severity, there may be complete relief for years, or for the rest of life. Exaggeration of feeling due to concentration of attention plays a large role in these cases, and it is evident that the dread of something the matter with the heart connected with even a slight sense of discomfort may readily become so emphasized as to seem severe pain, though many people have similar feelings without making any complaint.

In spite of rea.s.surances attacks of pseudo-angina are likely to worry both patient and physician. The only working rule is that in younger people discomfort in the heart region, even though it may be accompanied by some sympathetic pain in the arm or in the left side of the neck, is usually spurious angina. Broadbent goes so far as to say that this is true also in many older persons. His method of making the differentiation is interesting because so easy and practical that it deserves to be condensed here. The earlier attacks of true angina are practically always provoked by exertion, while spurious angina is especially liable to come on during repose. Any cardiac symptom or pain that can be walked off may be set down as functional and due to some outside disturbing influence, or to nervous irritability. When palpitation or irregular action of the heart, or intermission of the pulse, or pain in the cardiac region, or a sense of oppression follows certain meals at a given interval, or comes on at a certain hour during the night, there need be little hesitation in attributing the disturbance, whatever it may be, to indigestion in {339} some of its forms. Nightmare from indigestion, Broadbent thought, is not a bad imitation of true angina.

In Broadbent's mind acute consciousness of any heart disturbance lays it in general under the suspicion of being neurotic in origin. He was talking to some of the best clinical pract.i.tioners in the world and some of the most careful observers of our generation, when, before the London Medical Society, he said: "The intermission of the pulse of which the patient is conscious and the irregularity of the heart's action--though this can be said with less confidence--which the patient feels very much, is usually temporary and not the effect of organic heart disease." This is particularly true, of course, in people of a neurotic character, and Broadbent went on to say that "speaking generally, angina pectoris in a woman is always spurious, and the more minute and protracted and eloquent the description of the pain, the more certain may one be of the conclusion."

I had the opportunity to follow the case of a young woman who had a series of attacks of angina pectoris some twenty years ago, so severe that a bad prognosis seemed surely justified, and though at times the attacks were rather alarming to herself and friends, nothing serious developed and for the past ten years, since she has gained considerably in weight, they have not bothered her at all. She used to be rather thin and delicate, trying to do a large amount of work and living largely on her nervous energy. At times of stress she was likely to suffer from pain in the precordia running down the left arm and accompanied by an intense sense of the possibility of fatal termination. With reasonably large doses of nux vomica, an increase in appet.i.te came and a steadying of her heart that soon did away with these recurrent attacks. These came back later several times when she neglected her general condition, but there never were any objective symptoms that pointed to an organic lesion. After twenty years she is in excellent health, except for occasional attacks of a curious neurotic indigestion that sometimes produces cardiac disturbances. Of course, such cases are not uncommon in the experience of those who see many cardiac and nervous patients.

For the treatment of pseudo-angina, mental influence is all important.

Of course, the conditions which predispose to the mechanical interference with heart action that occasions the discomfort, must be relieved as far as possible. The severity of the symptoms, however, are much more dependent on the patient's solicitude with regard to them, they are much more emphasized by worry about them, than by the physical factors which occasion them. Rea.s.surance is the first step towards cure. After relief has been afforded from the severer attacks, the patient's solicitude as to the future must be allayed and the fact emphasized that there are many cases in which a number of attacks of cardiac discomfort simulating angina pectoris have been followed by complete relief and then by many years of undisturbed life. It is important to make patients understand that, in spite of the fact that their attacks occur during the course of digestion, as is not infrequently the case, this const.i.tutes no reason for lessening the amount of food taken. Nearly always these attacks occur with special frequency among those who are under weight, and disappear rather promptly when there is a gain in weight. Solicitude with regard to the heart must be relieved wherever possible and then with the regaining of general health the heart attacks will disappear.

{340}

CHAPTER VI

TACHYCARDIA

Etymologically tachycardia means rapid heart. There are two forms of rapid heart, that which is constant and that which occurs in periodical attacks. It is for this latter that the term tachycardia has been more particularly used, though occasionally the adjective paroxysmal is attached to it to indicate the intermittent character of the affection. With regard to the persistent type of rapid heart something deserves to be said, however, because patients' minds are often seriously disturbed by them. Often it has existed for years, sometimes is known to be a family trait and probably has existed from childhood, yet the discovery of it may be delayed until some pathological condition develops, calling for the attendance of a physician who may be needlessly alarmed and in turn alarm his patient by his recognition of it. The cause for this persistent rapid pulse is not well known and is difficult to determine. Heredity, as has been suggested, sometimes plays an important role in it. Certain families have one or more members in each generation with rapid hearts.

Whenever persistent rapid heart is a family trait the patient can be a.s.sured, as a rule, without hesitation, that the general prognosis of the case is that of the lives of the rest of the family. Usually the symptom seems to mean nothing as regards early mortality or any special tendency to morbidity.

Favorable Prognosis.--While a rapid pulse often and indeed usually has some serious significance, it must not be forgotten that it may be an individual peculiarity and be quite compatible with long life and hard work. One of the first patients that I saw as a physician had a pulse between ninety-six and one hundred. As there was a slight tendency to irregular heart action also, I was inclined to think that there must be some cardiac muscle trouble. There was apparently no valve lesion.

He told me that a physician ten years before had noted his rapid pulse and had made many inquiries about it which rather seriously disturbed him. He had been an extremely healthy man during his fifty-five years of life and there seemed no reason to conclude, since his rapid pulse had been in existence for ten years, that it meant anything serious.

He has now lived well beyond the age of seventy and still has a pulse always above ninety. Contrary to what might be thought, he is an extremely placid, unexcitable individual, who, under ordinary circ.u.mstances, will probably live for many years to come. He has no family history of tachycardia, though there is a history of rather nervous irritable hearts in other members for two generations.

An interesting case of this kind came under my observation about fifteen years ago in a clergyman whose pulse was never below ninety, and who on slight excitement, or after a rapid walk, or after a heavy meal, would have a pulse of 120. He knew that it was a family trait, his father having had it yet living to be past seventy. He gave a history of its having been recognized in his own person more than twenty years before. His general health, however, was excellent. He took long walks and, indeed, pedestrian excursions {341} were his favorite exercise. He was able to go up flights of stairs rather rapidly without discomfort. He was the pastor in a tenement house district so he had plenty of opportunity for such exertion. Infections of any kind, colds and the like, disturbed his pulse very much, if the ordinary standard was taken, but it was not irregular and the increase in rapidity was probably only proportionate to the original height of the pulse in his case. After all, as the normal pulse of sixty to seventy rises to between ninety and one hundred even in a slight fever, it is not surprising if a pulse normally above ninety should rise fifty per cent. to one hundred and thirty-five under similar conditions. He is now well past sixty, after over thirty-five known years--and probably longer--of a pulse above ninety, yet he is in excellent general health and promises, barring accident, to live beyond seventy.

Some ten years ago I first saw another of these cases of fast heart, with a family history of the affection in a preceding generation. He was a man who had not taken good care of himself and had been especially over-indulgent in alcohol. This indulgence consisted not in rare sprees but in the persistent daily taking of large quant.i.ties of straight whiskey. In spite of warnings, he has not given up this habit; yet at the age of sixty-five he is apparently in good health and is able to fulfill the duties of a rather exacting occupation.

Persistent rapid pulse often occurs in connection with some disturbance of the thyroid gland. The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves'

disease, but they are often only functional and the symptoms may pa.s.s away entirely. The rapid heart action may come and go, though usually the attacks last for some days and oftener for a week or more at a time.

Paroxysmal Tachycardia.--A rapid heart may not only exist continuously in an individual for many years without any impairment of general health or shortening of life, but there may be spasmodic attacks of this condition with the pulse running up so high as to deserve the name of paroxysmal tachycardia; yet the patient may live for many years and die from some affection not connected with his heart.

Perhaps the most remarkable case of this kind on record is that reported by Prof. H. C. Wood of Philadelphia. The patient was a physician in his later eighties when he came under Dr. Wood's observation. His first attack of paroxysmal tachycardia came in his thirty-seventh year. These attacks had apparently always been similar to those he then suffered and were abrupt in onset and the pulse would rise rapidly to 200 a minute. The original prognosis had been, of course, very unfavorable. The physician had outlived all the prophets of evil in his case, however. When large numbers of these cases were studied, it was found that they always last more than ten years, and, while heart failure in such cases is reported, it is doubtful if this occurs with more frequency in these patients as the result of strong reflexes than in the general run of patients, for it must not be forgotten that there is a certain average number of deaths from so-called heart failure in people supposed to be in good health.

{342}

In connection with these attacks of paroxysmal tachycardia, there often come intense feelings of depression and even local disturbances of circulation. It is probable that in many cases there is a serious factor at work. MacKenzie has suggested that they are due to nodal rhythm of the heart in which the heart beat does not start at the root of the sinus as is usual, but in some other portion of the musculature and as a consequence there is serious interference with the regular rhythmic action. In a number of cases of heart failure, tachycardia becomes a prominent feature and it is probably due to some such disturbance as this. Such cases often look very serious for a time, yet frequently recover completely after a brief interval. This must not disguise the fact, however, that many of these cases, especially where acute dilatation of the heart can be demonstrated, are extremely dangerous and may end in a sudden fatal termination. The patient seems so much prostrated that occasionally the physician may doubt whether it is worth while to put him to the bother necessary in order to diagnose the acute dilatation of the heart. It always is, however. If it were nothing else but the occupation of the patient's attention with the doctor's manipulations, as far as that is possible, the effect would be good, besides whatever irritation may be caused to the heart muscle itself by percussion of the heart area will probably do mechanical good.

The most important element evidently is that the patient shall not be allowed to lose courage or to think that nothing can be done for him.

Something must be done, and a combination of swallowing movements and deep breathing, as far as that is possible, with counter-irritation through the chest wall should be carried out. Drugs also should be employed and the aroma of strong coffee with the irritating effect of ammonia upon the nostrils should be employed. These act upon the vagus so as to stimulate the heart, but above all they act upon the mind, and nothing so stimulates the heart as reawakened hope.

CHAPTER VII

BRADYCARDIA

Bradycardia, or persistent slow pulse, is much rarer than the persistent rapid pulse discussed at the beginning of the chapter on tachycardia. Cases are, indeed, sufficiently rare to be medical curiosities. Prof. Clifford Allb.u.t.t has called attention to the fact that the status of bradycardia or brachycardia, as Osler (following Riegel because of the a.n.a.logue tachycardia) prefers to call it, is very different from that of tachycardia. In the latter, especially, in the specific sense of the term, the symptoms occur paroxysmically, endure for a definite length of time and then there is a return to the normal pulse rate. For this, or at least for the condition known as essential tachycardia, there is no well-defined cause and no definite pathological lesion. Bradycardia or brachycardia, however, is usually present as the result of some known physiologic or pathologic condition; it endures as long as the cause continues to act and then ceases, usually not to return unless the same cause gives rise to it again.

{343}

There are some cases, however, of slow pulse that cannot be traced to any definite lesion and in which the pulse is much slower at certain times than at others, though without its being possible to trace any definite immediate cause. These cases seem to be physiological a.n.a.logues of tachycardia. In tachycardia there is an irritation of the accelerator nerves to the heart, in brachycardia of the inhibitory nerves.

Depressed Mental States.--Occasionally the reason for this can be found, though it is rather vague. In depressed mental states, for instance, a pulse between fifty and sixty is common. In people who suffer from periodic fits of depression it is not unusual to find that in the early morning the pulse is not more than fifty-five. I have seen patients who were worrying about their hearts present records of early morning pulse before they got up that were always below sixty.

This is probably in a certain number of people quite normal. I remember a series of observations made on the attendants in the Charite Hospital in Berlin in which it was clear that the normal German morning temperature at seven a.m. was below 97 F., while the pulses were always below sixty. A rea.s.surance of this kind is helpful to patients who have acquired the bad habit of taking their own pulse and have been disturbed by finding it so much below what they consider normal.

Ill.u.s.trative Case.--A number of cases of persistent slow pulse seem to be congenital or produced by some definite pathological lesion, yet do not prove serious for the patient. Some years ago I described one of these cases in a paper read before the Section on Medicine of the New York Academy of Medicine [Footnote 29] and I have had the opportunity to follow it for about fifteen years. Though the patient's pulse is usually below forty and even after a rapid walk does not rise above fifty, she is in reasonably good health and during those years has buried two husbands. When I saw her she was compelled to go up and down stairs frequently and yet did not experience much difficulty.

While patients suffering from palpitation would find it impossible, because of the discomfort produced, to make the journeys up and down stairs that she did, she felt only about as much respiratory discomfort as would come to a woman of her size. Her respirations were somewhat hurried--22 to 24 to the minute--but her general health was very good. Her urine was normal, her liver not enlarged, her ordinary organic functions were not disturbed and there was no sign of arterial degeneration.

[Footnote 29: _The Medical News_, November 10, 1900.]

With the pulse rate as low as this one might expect to find the patient phlegmatic, slow of movement and not readily moved to emotion.

On the contrary, she has always been rather nervous and high-strung and inclined to be excitable. Her cardiac condition was first noted just after the first grip epidemic in this country, though her attention was not called to it during the course of the grip. It seems probable that the heart condition was acquired as a consequence of some irritative lesion affecting the inhibitory nerves to the heart that developed at that time. After her heart condition had been discovered she was for a time a skirt dancer and frequently danced for the amus.e.m.e.nt of her friends. She was always lively and active and after her first husband's death, when it became necessary for her to earn her own living, she was on the stage for a time and danced without any embarra.s.sment of either {344} heart or respiration. As a consequence of running down in weight and general health, owing to conditions since her husband's death, she noticed that dancing proved exhausting to her and she gave it up.

In general, she considered herself quite as capable as any of her friends for the ordinary duties and amus.e.m.e.nts of life. When I first saw her her digestion had been somewhat disturbed by worries and unsuitable nutrition taken at irregular intervals and this, I think, accounted much more than her heart for her complaint of tiredness on exertion. Later, after her second marriage, when she was in better circ.u.mstances, all her symptoms disappeared and even her heart rate rose so that it was seldom below forty, and after exertion always went to fifty. What was needed in her case more than anything was a change of environment, the satisfaction of mind that comes with freedom from worries and the cares of making her own living, and the improvement in digestion due to regular meals of good, simple, nutritious food.

Compatibility with Health and Activity.--The above case is interesting as ill.u.s.trating mental influence upon such a serious condition as bradycardia. Most people who suffer from it are likely to be over-depressed and this reacts to disturb digestion and also further to disturb the heart itself. What these patients need above all, then, is rea.s.surance with regard to their condition. There are some striking examples in history and in medical literature of bradycardia or persistent slow pulse in persons who are able to accomplish a large amount of work and whose general health and capacity for accomplishment were not at all disturbed by this physical condition.

Above all, they were not depressed and did not lack initiative.

Napoleon I, whose pulse is said normally to have been about forty, rising during the excitement of battle to fifty, is a typical example.

Medical literature records a number of patients with congenital slow pulse without any discernible heart lesion who lived long and successful lives. One of these was a very successful English athlete.

The prognosis of these cases is not as bad as it might seem to be and the mental state of the patient is more important than anything else in the treatment.