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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:

In the present state of our knowledge the adoption of the following
principles in the management of a case of incipient fatty heart
disease seems justifiable:

We must train the patient gradually but steadily to the giving up of
all luxurious habits. He must adopt early hours, and pursue a system
of graduated muscular exercises; and it will often happen that,
after perseverance in this system, the patient will be enabled to
take an amount of exercise with pleasure and advantage, which at
first was totally impossible, owing to the difficulty of breathing
which followed exertion. This treatment by muscular exercise is
obviously more proper in younger persons than in those advanced in
life. The symptoms of debility of the heart are often removable by a
regulated course of gymnastics or by pedestrian exercise, even in
mountainous countries, such as Switzerland or the Highlands of
Scotland or Ireland. We may often observe in such persons the
occurrence of what is commonly known as "getting the second wind,"
that is to say, during the first period of the day, the patient
suffers from dyspnea and palpitation to an extreme degree, but by
persevering, without over-exertion, or after a short rest, he can
finish his day's work and even ascend high mountains with facility.
In those advanced in life, however, as has been remarked, the
frequent complications with atheromatous disease of the aorta, and
affections of the liver and lungs must make us more cautious in
recommending the course now specified.

Perhaps the most important therapeutic suggestion which Sir William
Broadbent has to make with regard to the cardiac conditions that have
come to occupy much of the patient's attention is of a negative
character. He says that "patients suffering from these functional
derangements of the heart usually make them a pretext for avoiding
exercise and often for taking stimulants or drugs, whereas exercise
and fresh air are what they need. The best way to prevent the
expenditure of superfluous energy on the part of the heart in the form
of palpitation is to give it a fair amount of legitimate physiological
work to do." Personally I have found that most of the cardiac tonics
seem to do harm, in the sense of increasing the subjective symptoms,
except in cases where the patient is run down in general health
because of failure to take sufficient food, when strychnin seems to be
of avail and in the shape of nux vomica acts as an appetizer as well
as a heart tonic. Sir William Broadbent has warned particularly with
regard to the use of alcohol in these cases. Most patients find
that for the moment palpitation is lessened by alcoholic stimulation.
They pay for it afterwards, however, by an increased sense of
discomfort that sometimes lasts for 24 hours or more. As Sir William
Broadbent declared, "To relieve one attack of palpitation or fainting
by alcohol is to invite another, while the terrible danger of dropping
into alcoholism is incurred."

Lest it should be thought that even Broadbent is a little
old-fashioned and not quite to be trusted in the light of our
present-day knowledge, and above all lest it might be feared that
these older men made a better prognosis or emphasized the value of
exercise more than is compatible with our recent discoveries in the
physiology and pathology of the heart, it seems well to give
MacKenzie's opinion of these cases in full. This is all the more
important because, as I have said, the influence of German teaching
has led to the formation of rather different opinions in America,
especially among our younger physicians. Prof. Martius in this country
in his lecture for the Harvey Society gave quite a serious prognosis
for practically all heart irregularity. He almost went so far as to
lay it down as a rule of diagnosis that whenever a heart beats
irregularly there is something the matter with the heart muscle or
good reason to suspect a myocardial lesion of some kind. MacKenzie's
view is very different to this and he warns particularly against
permitting the influence of an unfavorable attitude of mind on the
part of these patients. He says:

The most serious thing about these cases is that the consciousness
of having an irregularity sometimes makes a patient introspective
and depressed. He keeps feeling his pulse, and communicates his
doleful tale whenever he find a sympathetic ear.

As the process which gives rise to it in elderly people is the same
as that which produces the tortuous temporal arteries, no more
significance should be attached to the one symptom than to the
other. I have followed cases for many years, and watched them pass
through seasons of sickness and of stress, and have seen no reason
to attach any serious import to this symptom. In rare instances the
heart, from being occasionally irregular, has after many years
become continuously irregular for short or long periods, and in a
few the permanent establishment of the nodal rhythm has been the
means of hastening the end. But this is infrequent, and in cases of
cardio-sclerosis has only happened in advanced life, and the patient
should on no account be frightened by being warned of the possible
occurrence of this unlikely contingency. In younger and neurotic
people I have never seen it lead to any bad results. It may appear
in serious affections of the heart, as in febrile complaints, but it
does not of itself add to the gravity of the condition, though I am
not sure that when due to an acute infection of the heart, as in
pneumonia and rheumatic fever, it may not be a sign of invasion of
the myocardium by the diseased process.

If the patient is aware of the irregularity, he should be assured
that there is no cause for alarm. It is useless to attempt to treat
the irregularity itself. If in other respects the patient is well,
then there is no need of any special treatment. If the patient be
suffering from conditions which seem to promote irregularity, such
as worry, fatigue, dyspepsia, the treatment should be devoted to the
removal of the predisposing cause. In people with temporary high
blood pressure, who show extra systoles, I find plenty of healthy
exercise in the open air specially beneficial, though until they get
trained, the extra systoles may at times become more frequent by the
exertion.

This last remark of MacKenzie's is particularly important, for at the
beginning of an attempt to relieve the symptoms by insisting on more
exercise, the patient is almost sure to be disturbed by this
symptom of which he will often be conscious, and it takes a good deal
of experience on the part of the physician to reassure him that
because of the increased subjective symptoms at the beginning of the
treatment by increased exertion, he may not be doing harm rather than
good. As a rule, however, it is not long before the good results of
the exercise treatment of these cases begin to make themselves felt
and the patient is reassured. Regulated exercise of body and
occupation of mind are the two important factors even in the treatment
of organic heart disease. They are extremely important even in the
cases with alarming heart symptoms that occur in the very old, once
the acute symptoms have subsided. In all the functional heart
affections exercise is the most important therapeutic resource we
have. It would seem that in the course of muscular exercise some heart
tonic was manufactured, which in all but the cases of absolutely
failing hearts is the best possible therapeutic resource for the
stimulation and steadying of the heart action. Such an internal
secretion would not be surprising in the light of all that we have
learned of the physiological nexus of organs in recent years.

Many so-called cures for heart disease probably depend for their good
effect much more on the graduated exercise that goes with them than on
many of the other remedial measures, though it is these latter that
are usually vaunted most highly. We all now recognize how little value
there is in the Nauheim bath treatment for heart disease away from
Nauheim itself. The reason is because the resisted movements of the
early part of the cure and, above all, the graduated exercise of
walking up the hills around Nauheim, which are such important parts of
the treatment there, cannot be so well given with the baths at a
distance.





Next: Cardiac Palpitation And Gastro-intestinal Disturbance

Previous: Diagnosis And Prognosis In Heart Disease



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