Kitabı oku: «Psychotherapy», sayfa 41

CHAPTER II
DIAGNOSIS AND PROGNOSIS IN HEART DISEASE

The more carefully heart disease, and particularly individual patients affected by various heart lesions, have been studied in recent years the more it has come to be appreciated that the most important element in the treatment of organic heart disease is the definite recognition of the difficulty of exact diagnosis of most cardiac conditions and the unfortunate tendency to make the prognosis worse than it really is. Many heart affections are quite compatible with long life. In the past both of these problems of diagnosis and prognosis have been only too often solved unfavorably to the patient, to the serious detriment of his power of physical reaction against the ailment. Many a patient has been seriously disturbed and even his power of compensation lessened by having a diagnosis of an organic affection of the heart made with the usual prognosis, or at least strong suggestion of early death that goes with it, when there was no justification for such an unfavorable opinion.

Mental Attitude of Patient.—We do not pretend to cure tuberculosis, but we do relieve its symptoms and bring about a remission in the progress with a shutting in of the lesions. In heart disease something of the same kind can very often be accomplished. This does not mean that in advanced cases of heart disease much good can be accomplished any more than in advanced cases of tuberculosis, though in both a change of the mental attitude may lift the patient from what seems almost a death-bed into renewed activity for a prolonged period. Probably heart disease is more serious in its prognosis than tuberculosis, yet undoubtedly the lives of many patients could be prolonged nearly as much as in the pulmonary affection and a large amount of suffering saved through mental influence. We do not hesitate to change the occupation and the place of abode of the patient suffering from tuberculosis. There is even greater reason for doing this same thing when it seems advisable with patients suffering from heart disease.

With regard to heart disease, the best authorities are now agreed that it is better, as a rule, not to tell the patient himself unless it is absolutely necessary to do so in order to get him to take the precautions that will prevent further deterioration of his cardiac condition. The depression incident to the knowledge that one has a serious heart lesion is not reacted against, and especially not during a threatening break in compensation, and a more favorable time must be waited for to reveal his condition to him. The danger of sudden death in valvular heart disease is much less than is popularly supposed. Only sufferers from aortic heart disease are likely to die without warning, and this form of the disease is comparatively rare. The death of the patient suffering from mitral disease is likely to be lingering. Mitral disease is the commonest form of heart disease, and the prognosis of it in ordinary cases is by no means so grave as is usually supposed. I have seen a patient still alive with a mitral murmur who told the story of having had his affection originally diagnosed as mitral regurgitation by Skoda, the distinguished Vienna diagnostician, over forty years before. This patient at the time I saw him was nearly seventy years of age, still had the mitral murmur, but his apex beat was scarcely if at all displaced and there was neither enlargement of the ventricle nor apparently any degeneration of the auricle.

The Apex Beat and Heart Murmurs.—In this regard an expression of Prof. Carl Gerhardt of Berlin deserves to be recalled. That distinguished clinician used to say that if the apex beat was not displaced there was no good reason for thinking that any heart affection which might be present was serious enough to require active treatment. Heart murmurs have been made entirely of too much significance and any man of considerable experience is likely to have seen a number of patients who, because they had a heart murmur, had been seriously and needlessly disturbed by having a physician tell them that they had heart disease, with an air of finality that seemed to the patients to say that they might prepare for the worst very soon. Patients suffering from diseased hearts have to care specially for themselves, but not to the extent of living such maimed lives as is likely to be the case if they are depressed by an unfortunate exaggeration of the seriousness of their condition.

Our best authorities in heart disease have at all times proclaimed their uncertainty as to the diagnosis of heart conditions from murmurs, while mediocre men of comparatively slight experience have not hesitated to declare their certainty in this difficult matter. It is not an unusual thing to hear of a supposed expert having declared upon the witness stand and under oath that he could tell whether a man had heart disease by listening to his heart, and some have even gone the length of making their decisions in this matter while listening for a few moments sometimes even above the clothing of the patient! Needless to say, this is quite unjustifiable in our present knowledge of the status of heart affections and only men of small experience and over-confidence in themselves make any such declarations. The more experience a physician has had in heart disease, the more careful he is not to make positive declarations. One or two examinations may very easily be deceptive unless there are signs quite apart from those in the heart itself. Indeed, it is much more the state of the individual than the state of the heart itself, or anything that can be found out about it, except after a prolonged and repeated study, that enables us to make definite decisions. Probably no one during the nineteenth century had studied hearts more carefully than Prof. William Stokes, whose books on the subject were so widely read. He wrote:

We read that a murmur with a first sound, under certain circumstances, indicates lesion of the mitral valves. And again, that a murmur with the second sound has this or that value. All this may be very true, but is it always easy to determine which of the sounds is the first, and which is the second? Every candid observer must answer this question in the negative. In certain cases of weakened hearts acting rapidly and irregularly, it is often scarcely possible to determine the point. Again, even where the pulsations of the heart are not much increased in rapidity, it sometimes, when a loud murmur exists, becomes difficult to say with which sound the murmur is associated. The murmur may mask not only the sound with which it is properly synchronous, but also that with which it has no connection, so that in some cases even of regularly acting hearts, with a distinct systolic pulse, and the back stroke with the second sound, nothing is to be heard but one loud murmur.

So great is the difficulty in some cases, that we cannot resist altering our opinions from day to day as to which is the first and which the second sound.

To the inexperienced the detailed descriptions of such phenomena as the intensification of the sounds of the pulmonary valves; of constrictive murmurs as distinguished from non-constrictive; of associations of different murmurs at the opposite sides of the heart; of pre-systolic and post-systolic, pre-diastolic and post-diastolic murmurs, act injuriously—first, by conveying the idea that the separate existence of these phenomena is certain, and that their diagnostic value is established; and secondly, by diverting attention from the great object, which—it cannot be too often repeated—is to ascertain if the murmur proceeds from an organic cause; and again, to determine the vital and physical state of the cavities of the heart. . . .

There are too many cases in which murmurs have no such serious significance as was often attributed to them when first studied, and yet it used to be almost a universal custom among physicians, and the custom still obtains with many, to tell a patient rather emphatically whenever a heart murmur was present, that he had heart disease. Above all, too much significance has been ascribed to murmurs in initial cases of heart disease and these are just the cases that should not be disturbed by unfavorable suggestion. The louder the murmur the less likelihood there is of there being heart disease in the ordinarily accepted sense of the term, that is, that the heart is so affected as to be incapable of doing its work properly, for where loud murmurs are present this is almost never the case. A murmur that may be heard a foot distant is usually associated with perfect compensation.

If this were remembered by those who examine hearts generally, there would be much less disturbance of heart action by unfavorable mental influence. A great many more who are suffering from certain symptomatic conditions of the heart not surely or necessarily dependent on organic lesions, are plunged into depression by unfortunate, premature or exaggerated expressions on the part of their physicians. It is almost a rule to have men and even women patients say that it makes no difference to them, that they should be told the exact truth as to what their condition is. The future has been mercifully hidden from us in most things and there is no doubt that this plan is the better for human comfort and accomplishment generally.

The truth is not easy to find and oftener in these cases lies on the side of favorable prognosis and refusal to think the worst than the opposite. In this there has been a great difference between the German and the Irish schools of medicine. The three great Irish physicians, Graves, Stokes and Corrigan, insisted on the place of the individual and upon how much depends upon the general conditions in pulmonary and cardiac disease. Our teaching in America in this matter has come not from the conservative British schools of medicine, but from the German school, and that has had a notable tendency to exaggerate the significance of heart signs over the general condition.

What a great distinction there is between this mode of looking at these diseases and the German method was pointed out by Prof. Lindwurm of Munich, when he translated Prof. Stokes' work on the heart into German. Prof. Lindwurm said:

Thus our modern German works are to a greater or lesser extent only treatises on the physical diagnosis of organic affections of the heart. Stokes, on the contrary, resists this one-sided tendency which bases the diagnosis solely on physical signs and disregards the all-important vital phenomena; he lays less weight on the differential diagnosis of lesions on the several valves and on the situation of a sound than on the condition of the heart in general, and especially on the question as to whether a murmur is organic or inorganic, and whether the disease itself is organic or functional.

Broadbent on Cardiac Diagnosis.—What Stokes taught the English-speaking world so emphatically in the first half of the nineteenth century Sir William Broadbent was just as insistent about in the latter half. It is evident, then, that clinical experience has not changed its viewpoint in these matters in spite of all our study of the heart in the interval. In his paper on "The Conduct of the Heart in the Face of Difficulties" he has many suggestions that will prevent the physician of less experience from taking too pessimistic a view of heart symptoms. He said:

Moreover, the heart has very special relations with the nervous system; it reflects every emotion, beats high with courage, is palsied by fear, throbs rapidly and violently with excitement, and acts feebly under nervous depression; but it is not only through the cerebro-spinal system that the heart is influenced, it is in immediate relation with the vasomotor nervous apparatus, and in a scarcely less degree with the sympathetic system generally. Normally, afferent impulses are constantly flowing from the viscera to the central nervous system and by this reflex process their blood supply is regulated, and their functional activity is governed. These afferent impulses when perverted by functional derangement or disease may become serious disturbing influences.

The nervous system in a large and increasing proportion of people is unduly sensitive and excessively mobile, and the reactions to influences of every kind are exaggerated. In some a little emotional excitement gives rise to palpitation, and a piece of bad news or the bang of a door seems to stop the heart altogether. There is in such subjects no form or degree of cardiac disease which may not he simulated. [Italics ours.] Add a touch of hysteria on the lookout for symptoms and for someone to give ear to the narration of the unparalleled agonies of the sufferer, and the difficulties of the heart, and it may be added of dealing with them, are complete.

Typical Case.—We are prone to think that after the age of seventy the existence of definite heart murmurs with some tendency to blueness of the lips and of the fingers, with coldness of the hands, surely indicates the presence of a serious heart lesion. It is in old people, however, that such symptoms may be most deceptive. The outcome may prove that physical signs ordinarily presumed to be surely indicative of organic disease may be only signs of functional disorder, or at most may represent certain organic affections for which even the old heart is thoroughly capable of compensation. One such instance in my own experience is so striking that I venture to give it in detail.

This was the case of an old physician friend of some eighty years of age. His son had a summer lodge in the Adirondacks. Though for some sixty years the father had been living at the sea level in New York almost constantly, he went up to visit the son and be with his grandchildren at an elevation of nearly 2,500 feet. His heart began to bother him almost at once and he could not go up or down stairs or take any exercise without considerable discomfort, marked shortness of breath and a tendency to palpitation that was almost alarming. He continued his stay for several months in the hope that he would get used to the altitude, though there were always difficulties of circulation manifested by blue lips and finger nails. He returned to New York and placed himself under the care of a heart specialist who found what appeared to be evident signs of heart deterioration of muscular character complicated by valvular lesions. He consoled, the old gentleman by the reflection that a heart that had served his purposes so well for eighty years could not really be complained of if now it should show some signs of deterioration. He also insisted that any mental work would be almost sure to be injurious because of the calls upon the circulation that it would make.

The old gentleman was ordered South for the following winter with an absolute prohibition of any mental work. He had planned to revise an historical work on which he had been engaged for many years and which had served to keep him in good health perhaps more than anything else. This was put away entirely and he proceeded to try to get well doing nothing. Almost needless to say with nothing to do he did not get well. He had been an extremely busy man all his life, had worked at least twelve to fourteen hours a day for most of the preceding fifty years, and for him to do nothing would be quite as impossible as for a child to be kept in utter physical inactivity. His heart palpitation continued and grew worse. He was waked up at night by starts that seriously disturbed him and usually kept him from sleep for hours. As he said himself, after he had read the morning paper and gone to stool, there was nothing else for him to do all day except eat and sleep, and these incidents had never occupied any of his attention in the past. In spite of the doctor's orders he had his manuscript sent to him and proceeded to work. At once he began to grow better. At the end of three months he was feeling better than he had felt for several years. When I saw him, about his eighty-first birthday, he was looking better than he had for some time.

As he said himself in describing his case, his own experience had taught him that the more fuss a heart made the less likelihood was there of its having anything serious the matter with it, at least of such a character as would terminate life suddenly or unexpectedly. The serious heart lesions are those which give no symptoms, or but very slight ones, and the sudden deaths in heart disease usually come from the development of insidious symptoms that do not betray themselves to the patient until the fatal termination is on them. The more the patient himself has been disturbed by his heart, the less likelihood is there of its giving out suddenly. The subjective symptoms are usually due to the fact that the heart is actively overcoming external interference, or resenting over-attention to it in its work. Certain it is, that the neglect of it, so far as that is consonant with reasonably regular life, is the very best thing and the most important part of any prescription given for symptomatic heart disease, whether organic or functional, is to forget it just as far as possible.

Heart Symptoms in the Young.—In young people particularly it is important not to suggest the possibility of heart disease until there are definite signs in the circulation apart from the heart which place the diagnosis beyond all doubt. The psychotherapeutics of organic heart disease that is most important is that of prophylaxis. Patients' minds must be guarded as far as possible against disturbance from the thought that they have heart disease, for this of itself adds a new factor which tends to disturb compensation and adds to the heart's labor because worry interferes with the vasomotor mechanism. In this matter it seems advisable to repeat once more that there must be a complete reversal of the customs that have existed until now with regard to tuberculosis and heart disease. Consumptives have from the very nature of their disease a tendency to hopefulness which soon brings about a favorable reaction against the bad news, but heart patients derive no advantage from the announcement and, indeed, if they are of the nervous, worrying kind, the effect of it is likely to be cumulative. A week after being told the worst a consumptive has reacted vigorously and hopefully, and if he has a fair share of immunity, the scare will do good by making him take the precautions necessary to increase his resistive vitality. At the end of the same time a heart patient will be just realizing all the significance of the unfavorable diagnosis and prognosis of his case.

It may be urged that heart patients by knowing their condition will be preserved better from injuring themselves by over-exertion, but what we have said elsewhere about the value of exercise in the treatment of heart cases shows how much patients may be injured by having their exercise too much reduced and their activity inhibited by the dread consequent upon the announcement made to them. It is perfectly easy to insist with them that they shall not do sudden things, or take violent exercise, or overdo activity, without disturbing them by the dread words "heart disease."

CHAPTER III
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.