As the Heart Slows Down
The late ABRAHAM MYERSON was one of Boston’s most distinguished psychiatrists. He received his training at Tufts Medical School; he had been affiliated with several private and state hospitals, and at the peak of a versatile, rigorous career he was brought down by heart disease. He took the diagnosis courageously and so sensibly that he lived out twelve full years. This account of how he kept a stop watch on himself was written shortly before his death and is drawn from the book When Doctors Are Patients, edited by Max Pinner. M.D., and Benjamin F. Miller, M.D., which Norton will publish this month.
IN 1937, at least six months before I knew I had any heart disease, I experienced for the first time a peculiar noise in my head. It started off as a hissing sound, but shortly there was added to this a rhythmic hiss synchronous with the heartheat. In general, when the sound was very low in pitch and intensity, it was difficult to make out the heartheat; but for at least seven years I could tell at what rate my heart was going and many things about its activity merely from listening to this noise in my head. Later there was a dull, equally rhythmic sound in the right ear, associated with a marked sense of pulsation throughout the head and at times throughout the body. If the head was placed lower than the heart, the sound increased. If I stood erect, there was some diminution of sound, but at present this is linked with a disagreeable lightheadedness.
However, I did not know that cardiac disease was associated with this sound until nearly a year after its inception, when I happened to listen to my own heart after examining my brother’s. He came in to see me, complaining of cardiac difficulty, I listened to his heart and found nothing that was pathological by the stethoscope or the sphygmomanometer. It later turned out that he was developing a coronary disease, Causually enough, I put the stethoscope to my own heart and heard a loud murmur at the base, systolic and diastolic in time. There was no rub or thrill that I could find at that time although one later developed. I had felt entirely well, but I had noticed three months previously, on an occasion when I hurried upstairs on my way to give a lecture, that I lost my breath for at least a minute. I paid no attention to this: in fact, I had been examined a year before for a large life insurance policy and had come through with flying colors.
I am not hypochondriacal. I rarely have taken my own blood pressure or examined myself. Except for minor illnesses, my health had been universally of the best, and I had been a very hard worker, energetic, in general tending to be exuberant and giving the impression of a man of excessive energy and buoyant mood. But now, shortly after my casual checkup, I had a physical examination which resulted in the diagnosis of arteriosclerotic heart disease.
There was an initial emotional shock in realizing that I had heart disease, a certain feeling of unreality as I listened to my heart and later took my blood pressure, but within a very short lime there was acceptance of the fact and I made up my mind to lessen my physical activities, though I did not diminish my medical work. At that time my program of work was somewhat as follows: I started at 7.30 A.M., and after private hospital visits I spent most of each morning either visiting the wards at the Boston City Hospital or directing the laboratory at the Boston State Hospital. As Professor of Neurology at Tufts, I gave most of the lectures in my course, which took place in the afternoon during half the year. I did a certain amount of bedside leaching of student groups, and each afternoon I carried on an active practice, which often ran into the evening and usually involved Sunday mornings. I employed a chauffeur to take off the burden of driving, and I believe f accepted ihe situation philosophically and without any great anxiety, although perfectly well aware of the possibilities and eventualities.
It is important to state that there was very little pain with the cardiac condition. On one occasion I had acute pain in the left side of the heart after an accident while driving my car. If I exerted myself physically beyond a reasonable limit, there would be some feeling of tension and pain along the left border of the heart, which I assumed to be due to ventricular strain. There was never any pain that ran down the left arm, although from time to time there was numbness of this arm. There was no precordial pain except possibly during the height of the heart block in the latter part of 1947.
In fact, until 1946 I got along reasonably well except for the ordeal of noise in my head. When I was in a crowd or exposed to excitement, as in a theater or at a symphony concert, the heart would become rapid and the noise in the head would mount until it was almost as loud as the symphony orchestra itself. At any rate, I could hear it, no matter how loud Dr. Koussevitzky and his orchestra played a Wagnerian overture. And at night I had to take sedatives to fall asleep.
This noise in my head remained the Devil in my life from the time it was first established, and I have often stated that heart disease itself, the consequent limitation of activity, and all the egodisturbing physical regression were minor matters compared with this ever persistent noise. Once in a great while it would disappear for a few hours, all of a sudden and for no apparent reason. And then my life seemed unbelievably calm and I realized that I lived in a continuous storm.
All my life my appetite and digestion were of the very best. I woke up hungry, ate a reasonable amount of all kinds of foods, never had indigestion save for some slight tendency to flatus. I was a hedonist so far as food was concerned, but a controlled one. I drank very little. Sometime in 1945 the picture changed. Spastic colitis appeared with some pain. This symptom remained with me; that is, there were irregular bowel movements associated often with spastic colon, although there was no mucous colitis.
It is worth stating that physicians do not pay enough attention to the care of the bowels in the case of patients suffering from heart or arterial disease. Straining at stool, for example, raises the intracranial and intrathoracic pressures enormously, and also raises the carotid arterial blood pressure. It does more damage and carries with it more potential sudden death than walking up a flight of stairs or many of the skeletal muscular exertions forbidden so sternly. Many a stroke of paralysis dates back to the early morning pilgrimage to the stool and to straining for a bowel movement, which thus makes an ignominious ending to life or activity.
I THINK I can safely say that the physicians who studied me knew that there was one thing I would not accept from them, and that was a mandate that I retire from activity. When I was fifty-nine years of age (after four years of illness), this possibility was brought up by my doctor and my insurance agent. My insurance policies were such that I could have retired at that time with a very comfortable income, had I cared to claim total disability, No one could have disputed any such claim. As the situation turned out, I continued to work at a good speed in the medical field for about six years, and then came a collapse.
Slow pulse had never been present until sometime in July of 1947. It did not become constantly present until August, when I noticed that there were periods when the pulse rate, now never above sixty, would slow down to forty and less. At times there would be a long pause between beats. I could hear the sound of the beat, then it would frail off into complete silence. I felt somewhat giddy or, as I later learned, slightly impaired in consciousness, but the heart would start up again and nothing of serious consequence took place.
Sometime in July of 1947 I noted a series of changes in my condition. In the first place, a very troublesome sweating which had pestered me ever since my illness was greatly modified. But much more important — and it. was a symptom which I did not at that time understand — the heart, instead of increasing in rate from exertion, excitement, or noise, became slower and markedly irregular. I could hear the long pauses of the heart in my head, the sound fading away until it seemed as if it would never come back, and then the rhythm becoming irregular, perhaps slightly rapid, but never anywhere near as rapid as it had been up to this time. I had noted previously that in crowds, under tension of any kind, my heart rate would reach ninety to one hundred. There was only one occasion of paroxysmal tachycardia, and that took place in 1945, while I was hurrying to catch a train and had stupidly carried a heavy bag. This tachycardia, which reached a level of about one hundred and fifty, lasted only one minute, then disappeared and never recurred.
For at least a year I had been taking digitalis, one tablet a day. I neglected to say that for about four months I had been on the salt-free acid-ash diet. This was because, in April of 1947, I experienced a marked shortness of breath, not on first lying down, but as 1 started to fall asleep. I would awaken suddenly with a feeling of air hunger, would have to breathe heavily a few times, and then I could lie down again. At this time there also appeared some evidence of rattling in the chest. I was therefore given in rapid succession several doses of mercuhydrin and was placed on the rigid diet. As a result of the mercuhydrin, I lost nearly twenty pounds of edema fluid in about a month, but the shortness of breath disappeared completely and in a very short time. Then I felt I was getting along well on a daily quota of digitalis, a weekly injection of mercuhydrin, and this diet. The diet had reached the point where it was acceptable to me because of my wife’s ingenuity in preparing the food.
Other symptoms soon developed which belong in several groups: first, when the heart became slow, there would be a pulsation in the face, in the legs —in fact it was both latent and patent everywhere. If I raised my arm above my head, there would gradually develop a rhythmic pulsation synchronous with the heartheat and an accompanying tingling of my fingers. When my arm was placed at the level of my heart or below it, this sensation would disappear. It my heart was laboring excessively — that is, it the pulse rate went into the thirties— then I could feel this tingling in my face and sometimes in my legs, even though I did not raise my arm. The pulsation in the face was a constant accompaniment of a heart that was pumping away doggedly and with great, great difficulty. I could tell this by the sound in my head. If the sound became very sharp and loud and if it also became very slow, if it showed irregularity, this facial and peripheral pulsation would appear most markedly with the beat succeeding the skipped systole. This has remained the case since that time, and with it there has developed a threatening situation when I stand on my feet for more than a minute or two. At such times the pulsations in the face and head gradually appear and there is a very definite feeling of uncertainly and insecurity. There is no actual dizziness. If I put my head down, the sensation tends to disappear. Thus it seems to be related to gravity and the difficulty of the heart in pumping the blood upward against gravitation.
As I partially shut my eyes, I can see as I direct my gaze against a dark wall a pulsation of streaks which come and go synchronously with the heart activity and which may be due to the filling and emptying of the blood vessels of the retinae. The diastolic blood pressure has never gone below seventy, probably because the valve became adhesively sclerosed and thus limited in range of opening and closing.
A MORE disturbing symptom came on me very suddenly, without my heeding the plainly manifest warnings. I went to an inn for a month from July 15 to August 15. One morning I started to read the paper after finishing breakfast. My family was still upstairs. The next I knew I was in bed in my own room, with a vague recollection that I had been escorted up there by a waitress and a waiter. I had no memory of anything else. I was confused and in a certain sense I was asking for security because I pleaded with my wife not to leave me and I had to have her assurance that she would not do so and that she loved me. This maudlin state gradually disappeared. In half an hour I was clear and was consumed with curiosity as to what had happened. In the light of what later took place, there is no doubt that a heart block with the disappearance of the ventricular systole had taken place.
But because of some unreasonable optimism I did not really believe that the loss of consciousness would occur again. 1 did not relate it to a beginning Stokes-Adams syndrome and heart block. This, however, started to manifest itself unmistakably in the latter part of September after I returned from my vacation. The vacation itself was not very pleasant. Although I did my best to enjoy it, I was unable to carry on any physical activity at all. I1 found that discussion tired me more than almost anything else—that it seemed to bring about the slowed-up pulse and especially the irregular heart action with its lapses of activity.
When I got back to my office, I lessened my activity somewhat, but nothing happened at my work. In the week of September 13 (prior to my entrance to the hospital on the 20th) certain phenomena started to take place, especially at night, and very actively on September 20. I could hoar the heart slow up. There would be a long pause and on two or three occasions I lost consciousness for a moment, almost as if I had had a petit mal attack. There were no convulsive movements and, in fact, this lapse occurred on two public occasions when nobody seemed to notice what had happened. On one occasion, I was talking to my wife. She noticed that I paused, my head dropped, and then 1 looked around as if I were confused and disoriented, and that I came back to myself with a very puzzled look, as if I were trying to fathom an inexplicable occurrence. I was not aware of doing this, but I definitely knew I had lost consciousness.
The next morning 1 went back to my office again, and it was on Saturday, September 20, that the attacks took a very critical turn. On that day I had at least ten spells of loss of consciousness with marked pulsating in my head and face and a constant feeling that my hold on consciousness was very precarious. Each attack would be preceded by a slowing of the pulse, a marked increase in the pulsations of the hands, head, and face, a gradual disappearance of the noise in the head. Then the quick lapse into unconsciousness was followed by a quick return to consciousness. The pulse became markedly irregular in force and in rhythm.
At times the heart would bound against my chest wall so that there was actual pain experienced, and the chest wall would forcibly move in irregular fashion. There was a vibratory thrill to be fell and seen near the base of the heart. I was horribly and continually conscious of my circulation in one way or another, and this independently of the noise in the head. There was a very definite feeling that I had no strength and that a snap of the fingers, so to speak, would put out the flame of life, and at this time I was almost eagerly hopeful that the turmoil of my tormented body would soon end. It was at this juncture that a cardiac consultant was called. While he was listening to my chest, I had one of the attacks of loss of consciousness and he very clearly informed me that I had the Stokes-Adams syndrome; that the heart was undergoing a block; that if the case turned out fortunately, the ventricular heart would establish itself at a slow and continuous rhythm and would stay indefinitely at that, rhythm, while the auricles would carry on at the rhythm established by the nervous system.
Adrenalin was immediately started, and since its use no complete loss of consciousness has taken place as of this date, November 20, 1947. Adrenalin was given in large amounts by subcutaneous injection for at least a week while I was in the hospital. Then gradually it was diminished over a period of one and one-half months. At the same time, a very interesting transition of heart activity took place as the block became either complete or adequate. At first I had many attacks of irregular and tumultuous heart activity at some times, and at others a threat that the attacks of unconsciousness would return. Gradually the slow pulse became dominant and the irregularity of action and activity became less marked. The pulse finally reached a phase where, with the rate at forty and reasonably regular, I could walk and stand up for one or two minutes at a time and could, as I finally did, go back to seeing patients several hours a day without any great difficulty. If the pulse fell lower than forty, let us say around thirty-five, I became conscious of the pulsation in my face and in my head; the ability to stand or walk became greatly lessened; a definite inability to talk for any length of lime became manifest and my voice became weak. A sense of precarious vital balance is the phrase I have used to express this state, as if it would take very little to make the laboring heart stand still permanently.
At forty beats of the heart to the minute I was reconciled to my condition, philosophic about it, cheerful, could get very much interested in anything pertaining to my work or to the world around me. I was not introverted or paying any marked attention to myself. When the pulse rate dropped to thirty-five, my personality changed in the most extraordinary way. I could with great difficulty concentrate on work. I found myself absorbed in myself, in the noise in my head, in the pulsation throughout my body. 1 became flitter and wondered, as people have done from the days of Job, why this had to come to me. The thought of death became welcome as a way out ol this intolerable dragged-out illness.
When the pulse rate was forty, I was interested in writing articles, in research, in the ills of other people. This vast emotional difference is directly related to a drop of five beats per minute of a sick and tired heart.
MY present program of life is to go to the office at about ten o’clock each morning, see patienls until noon, resi until one-thirty, again see patients, go back home and to bed at live o’clock, and stay in bed until nine o’clock the next morning. This is the order of events on Mondays, Tuesdays, Thursdays, and Fridays. On Wednesdays I stay home and I am in bed practically all day, although I may see one or two patients. On Saturdays and Sundays I stay in bed almost all day although I may be up for perhaps three or four hours. Breakfast is taken in bed, generally dinner also. Lunch is at the office on the days when I go in. It will thus be seen that I am spending over sixteen hours in bed each day and nearly twenty-four hours on three days of the week.
I have given up sex, all physical activity, the theater, movies, public lectures, conferences, and all social life except what comes to my house. I no longer play any exciting games of cards although I loved poker. Thus the transition from being a lover of athletics, a very active person, mixing easily and well, hedonistic in every direction, to being a person whose activities are limited to a little work and a great deal of reading has been achieved without, I believe, any fundamental change in mood except when the circulatory flow and the laboring heart bring about a reaction of disgust and of weariness of life. It is interesting to me as a psychiatrist that one can give up so much and not feel particularly bitter about it, and have no envy of those who still enjoy all of these goods of life.
I must, however, toll of one phase of this illness which bears on the question of anxiety states, their genesis and their treatment. Sometime in April of 1945, I developed a fear of dying while alone in my house, as a consequence of which I felt an overpowering uneasiness if I had to stay in the house when my family were away at night. This reached such a point that when my wife and daughter did go away on one occasion, I found it necessary to stay in a hotel or at a friend’s house for two days. On the third day I made up my mind I was going to break the back of this fear by going to the house and spending the night there “though the heavens fall,”thus following a formula which I had blithely given to my patienls for over thirty years. I had dinner with one of my sons, staying at his house until ten o’clock that night, and then I went home, appalled by my inner turmoil. As I approached the door to unlock it, my hand shook so severely that I could hardly insert the key into the keyhole. Beating down an impulse to jump into my car and spend the night at a hotel, I persisted until I opened the door of the dark house. The intensity of my reaction increased and I realized to the full what my patients meant when they said, “My heart pounded; I felt as if I were going to faint, or die, or scream, or go crazy.” I went upstairs to the bathroom adjoining my bedroom, and there promptly vomited. When the vomiting and retching ceased, I felt entirely tranquil, went to bed, and slept perfectly well throughout the night. The fear entirely disappeared and has never reappeared even though the possibility of death when my family is away has enormously increased.
This is the only episode of pathological anxiety that 1 had during a period of nearly eleven years. My condition, subjectively, has deteriorated. In general, the pulse has been slower. Psychologically, I must say there have been periods of despair or, at least, such a profound weariness of the whole situation that I would, at such times, be glad if the end came. There is sometimes a restless, irritable impatience with the situation, but I think, on the whole, that it has been easy for me to maintain cheerfulness and to continue to work. I have a notion that what I am doing Interests and to some extent thrills and amuses my family and friends. They find it consoling, I believe, that I am interested and willing to work and have not yielded to the circumstances of the situation. I find this latent admiration very pleasant and perhaps I go out of my way a little bit to pose as the stoical philosopher. On the other hand, if there exists such a tendency, it is merely an exaggeration of an existing state of mind.
The healthy mind does not really dwell with death. One throws it off as an inevitable event, though he may die tomorrow by edict. I remember interviewing a man once whose death sentence was revoked on the day set for his execution. He told me, and this was corroborated by prison officials, that he became restless, but, he said, “I never quite figured that I was really going to die. At least I couldn’t think consecutively about it.”
In the bright sunshine of today, writing at my desk, I feel reasonably well; and though I would not bet that I shall live six months, it seems as if iho real I were indestructible. I think psychiatrists preach nonsense when they say adjust to reality. We can only really endure life if we cherish healthy illusions, if we have faith no matter how fantastic, or the kind of healthy-mindedness that shakes off, as a dog shakes off water, the disagreeables of now and the future.