Psychotherapy Part 40

English Opinion.--The role of the stomach in disturbing the heart is only less important than that of the nervous system itself. Of course, individual peculiarities, as I have said, are extremely important.

Some people seem to suffer very little cardiac disturbance from a distended stomach, while in others all sorts of heart affections may be simulated as the result of the mechanical interference with the heart action by the pushing up of the diaphragm. Sir William Broadbent in the article on "The Conduct of the Heart in the Face of Difficulties," already quoted from, does not hesitate to say that heart symptoms secondary to gastric disturbance probably cause more suffering than does actual heart disease. Expressions of this kind need to be borne in mind when we rea.s.sure patients who have all sorts of queer, uncomfortable, often even painful, conditions in their cardiac region, "Heart disease" has been, perhaps, mentioned casually to them and as a consequence worry is adding a nervous element to hamper a heart already seriously disturbed by gastric distention. Sir William Broadbent's own words are given because they carry so much weight in this matter:

The difficulties arising out of flatulent distention of the stomach or colon or intestinal ca.n.a.l generally, will require some attention, since they are the cause of most of the functional derangements to which the heart is subject, and give rise to the heart complaints which occasion in the aggregate perhaps more suffering than does actual heart disease. The heart often tolerates a considerable degree of upward pressure of the diaphragm, and it is not uncommon to meet with stomach resonance as high as the fifth s.p.a.ce, and to find the apex beat displaced upwards and outwards to the fourth s.p.a.ce and outside the nipple line, without conspicuous symptoms. But the heart behaves very differently in different subjects in the presence of flatulent distention of the stomach. It partakes of the general const.i.tutional condition of the individual; in the strong, therefore, it is vigorous; in the weak it cannot be anything but weak.

Prognosis.--Nothing sends a young person sooner to a physician than this cardiac unrest and functional disturbance. He comes all a-tremble, as if to hear the worst. Even in middle age and in those whose education might be expected to steady them somewhat in the matter, even in physicians of long experience, there is a tendency so to exaggerate the condition and its possibilities of fatality as a consequence of emotion that inhibitory action on the heart becomes noticeable. It is a rule with very few exceptions that in these cases when the heart is complained of by young persons who have no history of rheumatism, the causative condition will be found in the stomach, or at least in the digestive tract.

I know a number of physicians who have suffered in this way and who have been badly frightened about themselves, yet who have had no serious difficulty once they took reasonable care of their diet, and paid attention above all to regularity of meals and slowness in eating. Indeed, it is rare to find a physician of a nervous temperament who has not had some trouble of this kind, and the demands made on a busy professional man foster this. Some of them are sure that if their cardiac uneasiness does not signify an actual heart lesion, valvular or muscular, at least it portends a premature wearing out of the heart. There are many evidences to show that this is {333} not so. I have had a distinguished physician, now well past his seventy-fifth year, tell me of distinct irregularity in his heart action as a young man which had rather alarmed him, and as this had been preceded by an attack of acute articular rheumatism there seemed to be every reason to think that he was a sufferer not from functional but from organic heart disease; yet he has lived well beyond the span of life usually allotted to man, has accomplished an immense amount of work and is now in excellent general health almost at the age of eighty. The case is all the more striking because, while rest and care of the health and regular life and conservation of energy are usually supposed to be essential for these cases, this colleague is noted for having made serious inroads on the hours which should have been devoted to sleep in order to accomplish certain medical literary work while devoting himself to the care of a most exacting practice.

That the good prognosis of these cases which I suggest is not forced and is not over-favorable nor the result of the wish to soothe patients may be judged from recent studies of the heart as well as from the older ones. In discussing extra-systole, MacKenzie in his "Diseases of the Heart," [Footnote 28] says:

[Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D., 1910, Oxford Medical Publications.]

Dyspeptic and neurotic people are often liable [to suffer from them]. That other conditions give rise to extra-systoles, is also evident from the fact that they may occur in young people in whom there is no rheumatic history and no cardiosclerosis and whose after-history reveals no sign of heart trouble.

It is well to note the frequency of such annoying symptoms in those who have gone through rheumatic fever, and where patients have a history of this it is well to be cautious, but even in these cases he says that the trouble is often entirely neurotic and the one important preliminary to any successful treatment is to get the patient's mind off his condition, improve his general nervous state, and above all relieve as far as possible the gastric symptoms that may be present.

He says further:

Some patients are conscious of a quiet transient fluttering in the chest when an extra-systole occurs; others are aware of the long pause, "as if their hearts had stopped"; while others are conscious of the big beat that frequently follows the long pause. So violent is the effect of this after-beat, that in neurotic persons it may cause a shock, followed by a sense of great exhaustion. Most patients are unconscious of the irregularity due to the extra-systole until their attention is called to it by the medical attendant. Both being ignorant of its origin, and its being characteristic of human nature to a.s.sociate the unknown with evil, patient and doctor are too often unnecessarily alarmed.

Cardiac Stomach Disturbance.--On the other hand, as a word of warning, it seems necessary to say here that later in life acute conditions manifesting themselves through the stomach are often of cardiac origin. Most physicians have been called to see some old man who had partaken of a favorite dish which did not, however, always agree with him and who suffered as a consequence from what at first was thought to be acute gastritis. The severity of the symptoms and the almost immediate collapse without any question of ptomaine poisoning, however, usually make it clear that some other organ is at {334} fault besides the stomach itself. The real etiological train seems to be that a weakened heart sometimes without any valve lesion but with a muscular or vascular degeneration hampering its activity is further seriously disturbed by the overloading of the stomach. The result is a failure for the moment of circulation in the digestive organs with consequent rejection of the contents of the tract, nature's method of relieving herself of substances that cannot be properly prepared for absorption. Unfortunately, the condition sometimes proves so severe a shock to the weakened heart that it stops beating, and the physician is brought face to face with a death from "heart failure."

In these cases it is important to remember that the gastric disturbance may so mask the heart symptoms as completely to deceive the physician. The prognosis of these cases, however, is most serious.

It seems worth while to give a warning with regard to these cases, because anything that we may have to say as to the relations of the stomach and the heart and the possibility of lessening the cardiac depression due to unfavorable mental influence when palpitation occurs as a consequence of gastric distention, has nothing to do with these acute cases in older patients where the condition is serious and the prognosis by no means favorable.

Treatment.--The role of psychotherapy in this form of cardiac disturbance a.s.sociated with gastro-intestinal affections is, after the differentiation of neurotic from serious organic conditions, to give the patient such rea.s.surance as is justified by his condition. It is surprising how many people are worrying about their hearts because their stomachic and intestinal conditions give rise to heart palpitation, that is to such action of the heart as brings it into the sphere of their consciousness, sometimes with the complication of intermittency or even more marked irregularity. The less the experience of the physician the more serious is he likely to consider these conditions and the more likely he is to disturb the patient by his diagnosis and prognosis. Until there is some sign of failing circulation, or of beginning disturbance of compensation, the attachment of a serious significance to these conditions always makes patients worse and removes one of the most helpful forms of therapeusis, that of the favorable influence of the mind on the heart.

On the other hand, unless the patients' own unfavorable auto-suggestions as regards the significance of their heart symptoms are corrected, these people not only suffer subjectively, but bring about such disturbance of their physical condition as makes many symptoms objective.

While there are serious affections in which heart and stomach are closely a.s.sociated, these are quite rare and usually manifest themselves in acute conditions and in old people. In the chapter on Angina Pectoris attention is called to the fact that there are may forms of pseudo-angina due to cardiac neuroses consequent upon gastric disturbance and without heart lesion. Broadbent has not hesitated to say that these forms of angina cause more suffering or at least produce more reaction on the part of the patient and are always the source of more complaint than the paroxysms due to serious cardiac conditions which present the constant possibility of a fatal termination.

Where the stomach is the cause of the cardiac neuroses psychotherapy is an extremely important element in the treatment. The continuance and exaggeration of their symptoms is often due to a disturbance of mind consequent upon the feeling that they have some serious form of heart disease. Without {335} definite rea.s.surance in this matter all the experts in heart disease insist that it is extremely difficult to bring about relief of symptoms in these patients. Whenever the general health of the individual has not suffered from his heart affection, it is quite safe to a.s.sume that no organic disease of the heart is present, no matter what the symptoms, for, as Broadbent and many other authorities emphasize, gastric cardiac neuroses can simulate every form of heart disturbance. The older physicians insisted that what they called sympathy with the hypochondriac organs might produce all sorts of heart symptoms. The patient must be told this confidently.

The slightest exaggeration of the significance of his symptoms can do no possible good and will always do positive harm.

After rea.s.surance, the most important thing is, of course, regulation of the diet and of the digestive functions generally. Unfortunately, regulation of the diet to many patients and even to many physicians seems to mean the limitation of diet. I have seen sufferers from cardiac symptoms have these increased by excessive limitation of diet.

If they are lower than they ought to be in weight they must be made to regain it. Above all, there must be no limitation of meat-eating except in the robust. Very often the heart seems to crave particularly that form of nutrition that comes through meat. It is especially important that the bowels should be regular. Fast eating is very harmful. Occupation with serious business immediately after eating is almost the rule in these cases.

All of these elements of the case need special study in each individual patient. The needed suggestions can then be made. Above all, the patient is made to realize that his case is understood and that it is only the question of a gradual acquirement of certain habits, including proper exercise, that is needed for the restoration of his heart to normal.

CHAPTER V

ANGINA PECTORIS

The two forms of this affection, known commonly as true and false angina, are characterized by pain or anguish in the precordial region with reflected pains in other portions of the body. It used to be said that whenever the precordial pain was accompanied by reflected pains in the neck, or down the arm, or, as they may be occasionally, in the jaw, in the ovary, in the t.e.s.t.i.c.l.e, sometimes apparently in the left loin, this was true angina and the patient was in serious danger of death. We know now that false angina may be accompanied by various reflex pains and that, indeed, a detailed description of the anguish and its many points of manifestation is more likely to be given by a neurotic patient suffering from pseudo-angina than by one suffering from true angina. True angina occurs in most cases as a consequence of hardening of the arteries of the heart or of some valvular lesion that interferes in some way with cardiac nutrition. The definite sign of differentiation is that in practically all cases of true angina, there are signs of arterial degeneration in various parts of the body.

Without these, the "breast pang," as the English {336} call it, is likely to be neurotic and is of little significance as regards future health or its effect upon the individual's length of life.

Besides the physical pain that accompanies this affection there is, as was pointed out by Latham, a profound sense of impending death. It used to be said that this was characteristic of the organic lesions causing true angina pectoris. It is now well known, however, that the same feeling or such a good imitation of it that it is practically impossible to recognize the true from the false, occurs in pseudo-angina. It is this special element in these cases that needs most to be treated by psychotherapy and which, indeed, can only be reached in this way. Where there are no signs of arterial degeneration and no significant murmurs in the heart, it should be made clear to these patients that they are not suffering from a fatal disease, but only from a bothersome nervous manifestation. Especially can this rea.s.surance be given if the angina occurs in connection with distention of the stomach or in a.s.sociation with gastric symptoms of any kind. In young patients who are run down in health and above all in young women, the subjective symptoms of angina--the physical anguish and the sense of impending death--are all without serious significance.

Differential Diagnosis of True and False Angina.--In the diagnosis of angina pectoris the main difficulty, of course, lies in the differentiation between the true and false forms, that is, those dependent on an organic affection of the heart muscle or blood vessels and those resulting from a neurosis. The neurotic form is not uncommon in young people and is often due to a toxic condition. Coffee is probably one of the most frequent causes of spurious angina, though the discomfort it produces is likely to be mild compared with the genuine heart pang. It must not be forgotten, however, that neurotic patients exaggerate their pains and describe their distress in the heart region as extremely severe and as producing a sense of impending death, when all they mean is that, because the pain is near their heart it produces an extreme solicitude and that a dread of death comes over them because of this anxiety. Coffee and tea, especially when taken strong and in the quant.i.ties in which they are sometimes indulged in, may be sources of similar distress. Tobacco will do the same thing in susceptible individuals, or where there is a family idiosyncrasy, and especially in young persons.

For the differentiation of true and spurious angina Huchard's table as given by Osler is valuable:

TRUE ANGINA

Most common between the ages of forty and fifty years.

More common in men. Attacks brought on by exertion.

Attacks rarely periodical or nocturnal.

Not a.s.sociated with other symptoms.

Vaso-motor form rare. Agonizing pain and sensation of compression by a vice.

Pain of short duration. Att.i.tude: silence, immobility.

Lesions. Sclerosis of coronary artery.

Prognosis: grave, often fatal.

Arterial medication.

NEUROTIC FORM

At every age, even six years.

More common in women. Attacks spontaneous.

Often periodical and nocturnal.

a.s.sociated with nervous symptoms.

Vaso-motor form common. Pain less severe; sensation of distention.

Pain lasts one or two hours. Agitation and activity.

Neuralgia of nerves and cardioplexus.

Never fatal.