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 | NEUROTIC FORM |
| Most common between the ages of forty and fifty years. | At every age, even six years. |
| More common in men. Attacks brought on by exertion. | More common in women. Attacks spontaneous. |
| Attacks rarely periodical or nocturnal. | Often periodical and nocturnal. |
| Not associated with other symptoms. | Associated with nervous symptoms. |
| Vaso-motor form rare. Agonizing pain and sensation of compression by a vice. | Vaso-motor form common. Pain less severe; sensation of distention. |
| Pain of short duration. Attitude: silence, immobility. | Pain lasts one or two hours. Agitation and activity. |
| Lesions. Sclerosis of coronary artery. | Neuralgia of nerves and cardioplexus. |
| Prognosis: grave, often fatal. | Never fatal. |
| Arterial medication. | 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 [{338}] 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.