Psychotherapy

Moreover, the heart has very special relations with the nervous system; it reflects every emotion, beats high with courage, is palsied by fear, throbs rapidly and violently with excitement, and acts feebly under nervous depression; but it is not only through the cerebro-spinal system that the heart is influenced, it is in immediate relation with the vasomotor nervous apparatus, and in a scarcely less degree with the sympathetic system generally. Normally, afferent impulses are constantly flowing from the viscera to the central nervous system and by this reflex process their blood supply is regulated, and their functional activity is governed. These afferent impulses when perverted by functional derangement or disease may become serious disturbing influences.

The nervous system in a large and increasing proportion of people is unduly sensitive and excessively mobile, and the reactions to influences of every kind are exaggerated. In some a little emotional excitement gives rise to palpitation, and a piece of bad news or the bang of a door seems to stop the heart altogether. There is in such subjects no form or degree of cardiac disease which may not he simulated. [Italics ours.] Add a touch of hysteria on the lookout for symptoms and for someone to give ear to the narration of the unparalleled agonies of the sufferer, and the difficulties of the heart, and it may be added of dealing with them, are complete.

Typical Case.—We are prone to think that after the age of seventy the existence of definite heart murmurs with some tendency to blueness of the lips and of the fingers, with coldness of the hands, surely indicates the presence of a serious heart lesion. It is in old people, however, that such symptoms may be most deceptive. The outcome may prove that physical signs ordinarily presumed to be surely indicative of organic disease may be only signs of functional disorder, or at most may represent certain organic affections for which even the old heart is thoroughly capable of compensation. One such instance in my own experience is so striking that I venture to give it in detail.

This was the case of an old physician friend of some eighty years of age. His son had a summer lodge in the Adirondacks. Though for some sixty years the father had been living at the sea level in New York almost constantly, he went up to visit the son and be with his grandchildren at an elevation of nearly 2,500 feet. His heart began to bother him almost at once and he could not go up or down stairs or take any exercise without considerable discomfort, marked shortness of breath and a tendency to palpitation that was almost alarming. He continued his stay for several months in the hope that he would get used to the altitude, though there were always difficulties of circulation manifested by blue lips and finger nails. He returned to New York and placed himself under the care of a heart specialist who found what appeared to be evident signs of heart deterioration of muscular character complicated by valvular lesions. He consoled, the old gentleman by the reflection that a heart that had served his purposes so well for eighty years could not really be complained of if now it should show some signs of deterioration. He also insisted that any mental work would be almost sure to be injurious because of the calls upon the circulation that it would make.

The old gentleman was ordered South for the following winter with an absolute prohibition of any mental work. He had planned to revise an historical work on which he had been engaged for many years and which had served to keep him in good health perhaps more than anything else. This was put away entirely and he proceeded to try to get well doing nothing. Almost needless to say with nothing to do he did not get well. He had been an extremely busy man all his life, had worked at least twelve to fourteen hours a day for most of the preceding fifty years, and for him to do nothing would be quite as impossible as for a child to be kept in utter physical inactivity. His heart palpitation continued and grew worse. He was waked up at night by starts that seriously disturbed him and usually kept him from sleep for hours. As he said himself, after he had read the morning paper and gone to stool, there was nothing else for him to do all day except eat and sleep, and these incidents had never occupied any of his attention in the past. In spite of the doctor's orders he had his manuscript sent to him and proceeded to work. At once he began to grow better. At the end of three months he was feeling better than he had felt for several years. When I saw him, about his eighty-first birthday, he was looking better than he had for some time.

As he said himself in describing his case, his own experience had taught him that the more fuss a heart made the less likelihood was there of its having anything serious the matter with it, at least of such a character as would terminate life suddenly or unexpectedly. The serious heart lesions are those which give no symptoms, or but very slight ones, and the sudden deaths in heart disease usually come from the development of insidious symptoms that do not betray themselves to the patient until the fatal termination is on them. The more the patient himself has been disturbed by his heart, the less likelihood is there of its giving out suddenly. The subjective symptoms are usually due to the fact that the heart is actively overcoming external interference, or resenting over-attention to it in its work. Certain it is, that the neglect of it, so far as that is consonant with reasonably regular life, is the very best thing and the most important part of any prescription given for symptomatic heart disease, whether organic or functional, is to forget it just as far as possible.

Heart Symptoms in the Young.—In young people particularly it is important not to suggest the possibility of heart disease until there are definite signs in the circulation apart from the heart which place the diagnosis beyond all doubt. The psychotherapeutics of organic heart disease that is most important is that of prophylaxis. Patients' minds must be guarded as far as possible against disturbance from the thought that they have heart disease, for this of itself adds a new factor which tends to disturb compensation and adds to the heart's labor because worry interferes with the vasomotor mechanism. In this matter it seems advisable to repeat once more that there must be a complete reversal of the customs that have existed until now with regard to tuberculosis and heart disease. Consumptives have from the very nature of their disease a tendency to hopefulness which soon brings about a favorable reaction against the bad news, but heart patients derive no advantage from the announcement and, indeed, if they are of the nervous, worrying kind, the effect of it is likely to be cumulative. A week after being told the worst a consumptive has reacted vigorously and hopefully, and if he has a fair share of immunity, the scare will do good by making him take the precautions necessary to increase his resistive vitality. At the end of the same time a heart patient will be just realizing all the significance of the unfavorable diagnosis and prognosis of his case.

It may be urged that heart patients by knowing their condition will be preserved better from injuring themselves by over-exertion, but what we have said elsewhere about the value of exercise in the treatment of heart cases shows how much patients may be injured by having their exercise too much reduced and their activity inhibited by the dread consequent upon the announcement made to them. It is perfectly easy to insist with them that they shall not do sudden things, or take violent exercise, or overdo activity, without disturbing them by the dread words "heart disease."

CHAPTER III

CARDIAC NEUROSES

If, as all the authorities recognize, the attitude of mind toward organic heart disease is extremely important and when favorable is a most helpful therapeutic factor, it is easy to understand that in neurotic conditions of the heart this is of even more significance. The term "heart disease" is bound up with so many unfortunate and persistently unfavorable suggestions that it seems advisable not to use it with regard to non-organic conditions, even though it may be associated with the epithets functional or neurotic. For these the term cardiac neuroses, which avoids the implication of heart disease in the ordinary sense, seems preferable. Many of the cardiac neuroses are quite trifling. Many of them endure for years without producing any serious effect or disturbance of the general health. Many functional disturbances of the heart action which are extremely annoying may disappear entirely with judicious regulation of life. The one important condition in all of these cases is to be sure that the patient does not worry over the condition, for that hampers heart activity and leads to functional disturbances of other organs which make the heart's work harder.

Varieties.—There are many forms of cardiac neuroses. Indeed, functional heart affections are so individual that it is hard to classify them. In every case it is extremely important to study the individual and recognize just what are the special factors bringing about the disturbance of heart action.

Palpitation .—In a certain number of the cases it will be found, indeed, that there is no real disturbance, but that in some way the heart action has been brought above the threshold of consciousness and has become noticeable to the patient. It must not be forgotten that the heart is an intensely active organ. Several gallons of blood are pumped through it every minute and yet it accomplishes its work, as a rule, with such noiseless, frictionless regularity that most people know nothing about it. When the action of the heart becomes conscious, it is usually spoken of as palpitation. Patients are sure to think that this must mean serious over-action, though, as a rule, no sign of over-action or at most a slight exaggeration of the muscular sounds of the heart will be found.

Missed Beats .—A further stage of this cardiac neurosis is the missing of beats. This occurs particularly in those whose attention has been directed for some time to their heart action by the presence of palpitation. It may be due to nothing more than this over-concentration of attention. It may be due, however, to mechanical disturbances, an over-distended stomach, constipation, or certain nervous factors.

Arrhythmia .—A third stage of cardiac neuroses consists of irregularity of the heart action, in which not only are the beats missed occasionally, but there may be certain heart sounds much less vigorous than others and the spaces between the sounds may be very unequal. This condition is usually said to be due to some serious condition of the heart muscles, and undoubtedly it often is. There is no doubt, however, that great irregularity of the heart may occur entirely as a neurotic condition without any organic affection and from factors quite extraneous to the heart itself.

Etiology.—There are three causative conditions for cardiac neuroses that deserve careful study and that can be very much modified by changing the attitude of the patient's mind toward his condition. The first of these is an over-attention to self such as is particularly induced by a life without much exercise and devoted to things intellectual. The direct causation is probably intimately connected with the second etiological factor in the production of cardiac neuroses. This consists of an absence of sufficient exercise for the heart itself, when it actually seems to disturb its own activity because adequate calls for exertion are not made on it to use up accumulated energy. Cardiac neuroses are seen particularly in those who having had considerable exercise in earlier years, have settled down to a sedentary life in which there are few calls made upon their muscular system. The third etiological factor is the most important. It is due to cardiac disturbance from the stomach and intestinal tract; this will be discussed in a separate chapter.

Prognosis.—The prognosis in cardiac neuroses is always worse in the patient's mind than it ought to be. If then the physician shows that he is uncertain as to the real significance of the affection, some hint of this uncertainty will be communicated to the patient with resultant unfavorable suggestion. The more carefully neurotic heart affections have been studied, the better the prognosis becomes. Morgagni in the olden time, Stokes and Corrigan in the early nineteenth century, Broadbent and MacKenzie in our time, have all emphasized the necessity for favorable prognosis. Even extreme irregularity is quite compatible with long life without any symptoms of serious circulatory disturbance. MacKenzie has, in his very careful studies of heart action, shown that extra systoles may cause marked irregularity in many forms without warranting unfavorable prognosis.

Arrhythmia may begin in comparatively early life, persist in spite of treatment, and yet continue up to old age. Sir William Osler tells of the case of the late Chancellor Ferrier of McGill University who died at the age of eighty-seven after having exhibited an extremely irregular heart action for the last fifty years of his life. He has seen several other patients who have had heart irregularity for many years without the slightest disturbance of their general health. His experience is not uncommon, and probably every physician who sees many cases of heart disease can recall a few of them. Ten years ago I saw a man past seventy suffering from distinctly irregular heart action, though he gave the history of having had cardiac irregularity for some years at least, and he is still alive, past eighty, and with his heart irregularity still present. I have a patient over seventy whom I know to have had irregular heart action for fifteen years, and he himself is sure that it has been present since he was about forty, at least. It is cases of this kind, together with MacKenzie's recent studies of the subject, that must be before the physician's mind when he makes his prognosis for these patients. There must be no hesitancy about his declaration. Patients think that physicians are prone to deny the significance of heart trouble so as to avoid disturbing their patients. The slightest hesitation, then, will be surely looked upon as of ominous import.

The Intellectual Life and Cardiac Palpitation.—It is curious how many people who give themselves to intellectual work and live an almost exclusively indoor life have subjective symptoms relating to their hearts. Many of the English literary men and women of the last century had complaints of this kind. Sir Walter Scott described very vividly his sensations as if his heart did not have room to accomplish its functions, and said that he used to feel within his chest a fluttering as if there were a bird there beating its wings against a cage too small for it. Other literary people have told of this sense of overfullness in the chest, as if somehow there were not room for all the organs. This discomfort is mainly referred to the precordial region. In oversensitive, nervous people it may be described as painful, though analysis of what they mean by the word pain will show that they have only a persistent feeling of pressure which is uncomfortable and gives a sense of crowdedness in that region rather than any genuine ache. Where the feeling is much dwelt on, however, it may be exaggerated into pain, as, indeed, will any sensation, however trivial, if attention is concentrated on it. On the other hand, in practically all of these cases, just as soon as the mind is strongly diverted by any pleasant occupation, the sense of discomfort disappears not to reappear again until the patient has time to think about himself.

Heart Surveillance.—Prof. Oppenheim of Berlin has in his usual direct way expressed the power of the mind to influence the heart beat, and he does not hesitate to say that certain nervous people who have been watching their hearts overmuch, and continually thinking about them, are capable of playing all sorts of tricks on themselves and sometimes even on their physicians, by this concentration of mind upon their heart and its action. Prof. Oppenheim in his "Letters to Nervous Patients," writing to a patient complaining of irregular heart action, says:

Whenever you succeed in controlling the action of your heart by means of introspection, there flows from your brain to your heart a current of innervation which disturbs the automatic movement of the organ. You now know what you have to thank for the irregularity in the action of your heart. I have frequently proved this to myself in your case: if I succeeded in feeling your pulse without your becoming aware of it, holding your attention by a conversation which interested you, the action of your heart was always absolutely regular. If, however, I tried it under your control, while your attention was anxiously directed to your heart, its action at once became irregular, and you experienced the very unpleasant sensation of palpitation.

Irritable Heart of Athletes.—A curiously interesting form of heart neuroses has appealed to me very much because I have suffered somewhat from it myself and owing to circumstances I think I have seen a larger number of patients suffering from it than usually come to a single individual. I refer to the tendency to irritability of the heart which is so marked in men who have been athletes when they were younger, and have taken a large amount of exercise during the years between fifteen and twenty-five. If these men later settle down to a sedentary life they almost inevitably suffer from a marked sense of discomfort in the precordial region because of palpitation, and are apparently much more liable than other people to have an intermittent pulse. Just what these symptoms are due to is not always easy to discover, and in different individuals there seem to be different accessory causes at work. I have seen it particularly in professional men who while at college have been on the teams and have played such hard games as handball, hockey on the ice, and the like. I do not refer only to those who have played an occasional game, but who every day of the college year have had some severe muscular exercise.

Whether this irregularity of heart action has not at least been predisposed to by over-exertion remains to be determined. Strenuous athletics produce curious heart symptoms. Missed heart beats and irregular heart action and even leakages at the valves are not unusual even in the best of hearts after severe exertion. A careful examination of the hearts of those who took part in a Marathon run at Harvard some years ago showed that immediately after the race many of them were irregular and some of them had leakages at the mitral valve which lasted from one to twenty-four hours. These were probably due to irregularity in the action of the papillary muscles as a consequence of the fatigue. I had occasion to examine the hearts of some theatrical dancers a few years ago, immediately after they came off the stage. One of them is one of the most successful of modern dancers and is able to occupy the better part of an hour in the severest kind of exertion before an audience. Her heart was not only very rapid immediately after she left the stage, but there were missed beats and a distinct disturbance at the mitral valve. It was hard to determine absolutely, but the sounds at all the valves were impure and there seemed to be imperfect closure or irregularity of action. In another case there was a regular missed beat at every sixth or seventh pulsation. This seemed to be due to an abortive systole. Usually within an hour regularity of heart action is restored and the valve sounds become normal. At times when the patient is run down for any reason, the cardiac disturbance may persist for many hours, or even until after long hours of sleep.

The patients I have mentioned seem to have developed their muscles to a noteworthy degree and have enlarged and strengthened their hearts by this exercise. Later on their occupation in life prevents them from taking any severe exercise, or at least furnishes no opportunity for it, and they often settle down to existence that, beyond a short, quiet walk perhaps once a day, affords no exercise at all. Under these circumstances the muscular development that they secured as young men and which kept them in such magnificent health during their adolescent years seems to prove a positive detriment to good health, or at least to good feeling. The muscular system seems to crave to be kept up. Occasionally I have been sure that the intermittent heart action so often seen in these cases was due to the fact that the appetite, or as I should rather put it, the habit of eating, which they formed while they were accustomed to taking vigorous exercise, remains with them during their sedentary life and as a consequence they overeat, particularly of proteid food materials. The large consumption of these materials gives rise to the presence of substances in the blood which make all the muscles more irritable than usual, and this seems to add particularly to the irritability of the heart.

Dietetic Regulation .—For many of these people a regulation of diet seems to be the best possible remedy. They must be made to eat less substantially, since they do not need the same amount of proteid material to make up for muscle waste, now that there is no longer the old use of muscles. Some of them become very heavy. These, however, are mainly individuals who, besides eating abundantly of proteids, also consume carbohydrates in large quantities. In these there is a distinct disturbance of digestion and a tendency to dilatation of the stomach with gas which interferes with the heart action and brings on the intermittent pulse so often seen in them. In a certain number, however, there are no accessory symptoms of indigestion, but the heart symptoms are most prominent.

Exercise .—For these people the only real relief is afforded by a certain amount of exercise every day. They become ever so much more comfortable just as soon as their physician insists that they shall have an hour's walk at least every morning and every afternoon and that this walk shall be brisk and always have some definite purpose in it, so that there is no mere sauntering or delaying on the way. Most business men to whom this prescription of an hour's walk is given will reply that it is impossible. Most clergymen will say that their duties are such that they cannot arrange their hours for this purpose. As a rule, it is not difficult to show the business man, however, that if instead of riding to his business, he should walk every day, and this will probably only take twenty minutes to a half-hour longer than if he goes by trolley or even by automobile, this walk will provide him with a full hour of brisk exercise in the open air. The walk back from business will provide the other hour, whenever golf or some other diversion cannot be provided instead. In most cities men live from three to five miles away from their business, and it is not too much to ask them to take this walk. The muscular clergyman must be made to understand that there shall be no trolley cars for his ordinary clerical calls, or at least that none are to be taken unless he has had his full two hours of brisk walk.

There is always the fear in the patient's mind that exercise, by calling for heart exertion, is almost sure to make the condition worse. This fear of itself further hampers heart action. When exercise is first increased in those who have been living sedentary lives the heart action for a time is brought more and more into the sphere of consciousness and any irregularity that is present is likely to be emphasized. A little persistence, however, soon shows that what the heart actually was craving was the opportunity to expend some of its energy and it was this pent-up force that was disturbing its action. There is often the fear in physicians' minds lest the advising of exercise should really do harm to the patient. They fear the presence of perhaps a fatty condition, or of some obscure muscular condition, or of some other heart lesion not easy to detect, yet likely to produce serious symptoms. Stokes, who probably knew fatty heart disease better than anyone else in the nineteenth century, outlined his views of the therapy of it as follows: