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, 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 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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