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.





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