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 testicle, sometimes apparently in the left
loin, t
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 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
reassurance be given if the angina occurs in connection with
distention of the stomach or in association 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 quantities 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 associated with other symptoms.
Vaso-motor form rare. Agonizing pain and sensation of compression
by a vice.
Pain of short duration. Attitude: 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.
Associated 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.
Antineuralgic medication.
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
classical 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 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 passed 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 reassurances 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 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 practitioners 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
appetite 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. Reassurance 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 constitutes 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.
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