Psychopathology in Heart Disease Aside From Cardiac Surgery: A Historical Perspective of Cardiac Psychosis Rudolf Meyendorf
M
ODERN CARDIAC SURGERY began in 1944 with the correction of the tetralogy of Fallot by Blalock and Taussig. In 1948, Brock operated successfully on the pulmonary valve and also in 1948 Bailey performed mitral commissurotomy. In 1952, Bigelow introduced hypothermia in cardiac surgery. which led to open cardiac surgery by way of extracorporal circulation.’ Since cardiac surgery established itself as a routine operation, it has brought into focus for psychiatrists and surgeons alike psychopathologic and neurologic phenomena. of which cardiac delirium is only the most conspicuous. While investigating neuropsychiatric complications after cardiac surgery in 1972. and at the same time surveying the fast growing literature since the beginning of the 1960s on the subject. I came to believe that cardiac delirium. and other psychotic reactions after cardiac surgery, were indeed a kind of new exogenous psychosis due to the peculiar operative procedure of heart surgery, mainly caused by extracorporal circulation. Postoperative psychoses aside from cardiac surgery were known long ago-yet the difference in incidence is striking. General surgery, and any other operative procedure in man. offers figures between 0.02% and 0.04%; cardiac surgery has an incidence between 10% and 60%. By sheer accident I came across a Dutch article by the late professor Riimke “Over psychoses bij hartziekten” (psychoses associated with heart disease).” dating from 1939. Reading the very detailed descriptions of the “cardiogenic psychoses,” as he called them-a term which Riimke defends as an entity sui generis over against other symptomatic or organic psychoses-l discovered that these psychoses associated with cardiac disease generally did not differ at all from postoperative cardiac psychoses. Riimke describes very vividly the delirium with confusion and clouding of consciousness, i.e., the obvious organic components of the deranged state of mind. as well as the lucid visual and auditory hallucinations, the paranoid symptomatology, and the characteristic fear and anxiety of these patients. culminating often in the conviction of impending death. Moreover. he draws attention to the frequent occurrence of both insomnia and frightful dreams. symptoms that are now-a-days attributed to circumstances belonging to the intensive care unit with either sensory deprivation or overstimulation. Finally, depressions, including suicidal impulses, were pointed out in patients with advanced organic heart disease, a syndrome that we recognize to be very common after cardiac surgery. Fro177 The Psychiatrische Addre.\s siltif.
reprint
requests
NuJbaumstraJe,
@ 1979 by Crane
326
Kin&
der Ut7ilBersitiiir.
to Radulf
7. D-8000 & Stratton,
Meyendorf,
Miinchrn Inc.
Bunde.wepublik M.D.,
C. M..
2. Bundesrepublik
Deutschland. P.tychiatrische
Deutschland
Klinik (Matzich,
drr
Unil?r-
Grrmat7~J.
00/O-440X/79/2004-0003$01.0010
Comprehensive
Psychiatry,
Vol. 20, No. 4 (July/August),
1979
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
327
The study of Riimke’s article led naturally to further references on the subject of cardiac psychoses, which goes as far back as to the beginning of the last century. In 1818, Nasse wrote a remarkable modern monograph “Von der psychischen Beziehung des Herzens” (On the relationship between heart disease and psychological state).3 He correlated severity of heart disease, psychopathological changes and post mortem finding of the heart valves. Bergmann in 1844 described a case of “Mania metastatica, vom Herzen ausgehend” (Metastatic mania arising from the heart).4 At the same time he presented the post mortem findings of mitral stenosis with thrombosis. Again in 1844, the French author Saucerotte published seven cases of organic heart disease that resemble in every way today’s postoperative deliriums or other psychotic states after cardiac surgery. He called the title of his paper “L’influence des maladies du coeur sur les facultes intellectuelles et morales de l’homme” (The influence of heart disease on the intellectual and moral faculties of rnatQs5 The intellectual derangements are “demence cardiaque,” i.e., cardiac dementia, a term that appeared from there on very frequently in the literature. The “moral impairments” are suspiciousness, impulsions, changes of moods, and peculiar passions and hallucinations. At the end of the last century, all over central Europe there was a distinguished support for the view that there exists a close relationship between insanity and disturbances of the cerebral circulation caused by cardiac defects. Textbooks of psychiatry and internal medicine mention these connections. One reads in a “Textbook of Mental Diseases” (1897) by Theodore Kellog: “Cardiac diseases have a direct relationship to mental disorders which they aggravate, modify and sometimes cause in the first instance through defects of circulation and nutrition of the cerebral tissues.“6 There are a few classical papers on the subject in the latter part of the last, and the beginning of this, century. Krishaber published, in 1872, a paper “Nevropathie cerebra-cardiaque,” a very telling title.7 He presented 24 cases of cardiac psychoses, describing most carefully the psychopathology: ideas of reference and of persecution, heavy dreams, different delusions, and a case of double ego. At the same time he took account of the concomitant neurologic deficits of organic heart disease: disturbances of vision, of the sensory system, and of the locomotor system, thus pointing out that the cerebral pathology of heart disease is reflected in most cases by a neuropsychiatric symptomatology; an observation that modern heart surgery now supports. In 1881 there appeared a thesis in Paris by D’Astros “Etude sur l’etat mental et les troubles psychiques des cardiaques,” which became for some time a kind of reference article.* The author gives 38 case histories, attempting to systematize for the first time the various psychopathologic symptoms, mainly into (1) hysterical phenomena (hysterisme et hysteric cardiaque); (2) lessening of intellectual functions (affaiblissement et demence dans les maladies de coeur); and (3) cardiac insanity (folie cardiaque), which can manifest itself as (A) hallucinations; (B) delire a forme melancholique; (C) delire systematise a forme de manie; and (D) delire incoherent a forme de demence.
328
RUDOLF MEYENDORF
In Great Britain, in 1888, Mickle delivered the Goulstonian lectures on “Insanity in relation to cardiac and aortic disease and phthisis.“g He enumerated 80 cases of valvular diseases, 20 of which he described in detail. He first made sure that he excluded “. . . the delirium or other mental symptoms occasionally observed in the acute and febrile affections of the heart” from another category of symptoms that interested him. These were cases showing delusions of conspiracy, monomania of the persecutory, expansive, OI hypochondriacal type, cases that suffer from melancholia agitata. or those that have hallucinations of sight and hearing. Others had been just grotesquely irrational in demeanor and language. Mickle made the attempt to correlate the psychological disturbances with the general physical state and the stage of heart disease in particular, trying even to show the difference of mental symptoms in the different types of valvular lesions. In 1901, the Goulstonian lectures took up again the subject of heart disease associated with psychosis. Henry Head,‘O who became famous for his concept of referred visceral pain, spoke on “certain mental changes that accompany visceral disease.” Besides diseases of the lung he described 27 cases of heart disease. The cardiac delirium, with clouding of consciousness, confusion, and disorientation, he separated from the mental changes proper of heart disease in the same manner as Mickle did 13 years earlier. The mental changes he spoke of were (1) hallucinations of vision, hearing, and smell: (2) changes of moods with depression or exaltation: (3) suspicion: and (4) changes in memory and attention. Today’s psychoses associated with cardiac surgery have to be divided in a similar manner, since “cardiac delirium” is only one type of mental derangement after operation. The last major work of importance on the subject appeared in 1909, a prize-winning paper by Jakob, “Zur Symptomatologie. Pathogenese and pathologischen Anatomie der Kreislaufpsychosen” (On the symptomatology, pathogenesis and morbid anatomy of circulatory psychoses). Jakob described with great detail the general physical and cardiac status of 9 patients, the development of psychoses during the course of disease. and the post mortem findings on the brain. He concerned himself mainly with the severe states of cardiac delirium-witnessed by the fact that all his cases came ad exitum. The major symptoms consisted of delirious psychomotor excitement accompanied by hallucinations and delusions. On the other hand, Jakob also drew attention to premonotory syndromes before the full picture of delirium has developed. e.g., depressions, fear and anxiety (Angstaffekt), and suicidal impulses. He also mentioned loss of memory. especially of recent events. The literature on psychological changes and cardiac delirium in the course of heart surgery is a fast growing one and has surpassed by now the literature on cardiogenic psychoses aside from cardiac surgery. This being so, one can be only amazed however, that not in a single paper, as far as I know, has there been mention of the fact that cardiac psychoses were known long before heart surgery started. In more than a few of these recent papers one can even incorrectly learn that the term “cardiac delirium” and other psychological
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
329
changes associated with heart surgery were only discovered with the beginning of heart surgery. We would like to know how this former knowledge got lost so that when cardiac surgery began no one could really refer to the problem of cardiac psychosis in its larger context. Aside from a regrettable loss for the sense of historical perspective there seem to be three main reasons for this gap of continuation in the concept of cardiac psychosis before and since the era of heart surgery. (1) Reasons in psychiatric classification; (2) Reasons in specialization in medical fields; and (3) Reasons in the advancement of treatment. REASONS
IN PSYCHIATRIC
CLASSIFICATION
In 1911, Bonhoeffer introduced his concept of “exogenous psychoses” (exogene Reaktionstypen) into psychiatry, implying the uniformity of psychopathologic reactions independent of the various and different causes of known etiologies, e.g., infectious, traumatic, metabolic. Terms like “cardiogenic” or “circulatory” psychoses were no longer favored as an etiologic entity. REASONS
IN SPECIALIZATION
IN MEDICAL
FIELDS
Specialization in the medical fields led toward separation of psychological and psychiatric interest and knowledge in internal medicine. Textbooks of medicine and cardiology no longer mentioned and taught the mental complications of somatic disease as before. Psychiatry separated itself too from the medical disciplines and only shared psychoanalytical or neurologic interests, or occupied itself mainly with “endogenous“ psychoses. REASONS
IN THE ADVANCEMENT
OF TREATMENT
The advance of science, mainly in treating acute endocarditis and chronic heart failure more effectively, especially through the discovery of antibiotics, brought a change about in the incidence of severe disabling heart disease in its early course. The incidence of cardiac psychosis went down accordingly, yet only to reappear at a much later stage under special circumstances: in cardiac surgery, which proves to be a kind of experimental device for producing cardiac psychosis. The interest cardiac surgeons and psychiatrists take today in mental changes during the course of heart surgery reminds one of the similar interest taken a century ago by physicians of general and internal medicine, and by psychiatrists in the relationship between heart disease and mental disease. If one takes a close look at the literature one can find, however, that the awareness of mental complications during the course of heart disease-aside from cardiac surgery-has been there all the time.1-26 CONCLUSIONS
During the last 5 years I had not only the opportunity to study psychiatric and neurologic changes in the course of heart surgery, but also to set up an investigation into mental changes in organic heart disease outside of cardiac
RUDOLF MEYENDORF
330
Table
1. Mental Changes in Organic Heart Disease (61 patients)
45 Mental Changes (73.8%) 19 Depressive syndromes (31 .l%) 9 Dysphoric syndromes (14.8%) 8 Manic syndromes (13.1%) 7 Organic brain syndromes (11.5%) 2 Phobic obsessive syndromes (3.3%)
Table 2. Nine Cases of Acute Cardiogenic Psychoses 4 Paranoid-hallucinatory syndromes 3 Paranoid-depressive syndromes 2 Delirant syndromes (cardiac delirium with clouding of consciousness and loss of orientation)
surgery. Within 6 months, 61 patients, whose caridac and mental state cannot be discussed in detail here, were evaluated for psychiatric disturbances. Forty-five showed mental changes in form of the following syndromes (Table I). Within this group, which was examined consecutively. there was not a single case of acute psychosis of the type of cardiac delirium or other acute cardiogenic psychosis. strictly speaking, though some patients with depressive or manic syndromes did show loss of reality testing. which is characteristic of psychotic symptoms. However, in the last 5 years I was called in cases of emergency to 9 patients with organic heart disease who developed a classical cardiogenic psychosis (Table 2). There cannot be any doubt from my own investigations and from the study of the literature that there are virtually no differences in the kind of minor and major mental derangements of cardiac patients who undergo heart surgery and of those who show these symptoms without having had cardiac surgery. In patients who have had cardiac surgery the incidence is however very much higher. This leads to the question as to the common causes of these two groups of cardiac patients who develop psychiatric (and neurologic) symptoms. The two common causes for the surgery and nonsurgery group of cardiac patients that are mainly responsible for the development of psychiatric and neurologic changes, particularly for cardiogenic psychoses. are embolization and hypoxaemia. However, not every patient does show the same psychopathologic syndrome, though the exogenous etiologic agent may be very much the same. A different hereditary predisposition may probably account for the difference in psychopathologic reactions. REFERENCES I.
Meade
Springfield.
RH: A history of thoracic III, Charles
C Thomas,
surgery.
1961
2. Riimke
HC:
Over
ten. Ned T Geneesk
psychoses
1:728-735.
hi hartziek1939
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
3. Nasse F: Von der psychischen Beziehung des Herzens. Ztschr f psychische Arzte 1:49116, 1818 4. Bergmann G: Mania metastatica. vom Herzen ausgehend. Allg Ztschr Psych 1:574582, 1844 5. Saucerotte G: L’influence des maladies du coeur sur les facultes intellectuelles et morales de I’homme. Annal MCd Psych 4: l73182. 1844 6. Kellogg TH H: A textbook on mental diseases. New York, William Wood, 1897 7. Krishaber M: Nevropathie cerebrocardiaque. Gaz Hebd MCd Paris 9:323, 342, 371, 422, 434, 485. 550. 581, 1872 8. D’Astro L: Etude sur I’etat mental et les troubles psychiques. Paris, Adrien Delahaye et E Lecrosnier. 1881 9. Mickle J: Insanity in relation to cardiac and aortic disease and phthisis. Br Med J 1:503-510, 1888 IO. Head H: Certain mental changes that accompany visceral disease. Brain 24:345-429, 1901 A: Zur Symptomatologie, II. Jakob Pathogenese und pathologischen Anatomie der “Kreislaufpsychosen.” J Psycho1 Neurol 14:209-248. 1909 12. Bonhoeffer K: Die Psychosen im Gefolge von akuten Infektionen. Allgemeinkrankheiten und inneren Erkrankungen. in Handbuch der Psychiatric, F. Deuticke. Leipzig und Wien. 1912 13. De Busscher J. Matthijs R: Les troubles psychiques. symptomatiques d’alterations circulatoires d‘origine cardiaque. Folia Psychiatrica Neerlandia 61: 101-108. 1958 14. Gordon AH, Cohen W: The mental complications of heart disease. Can. Med Ass J 39517-522. 1938
331
15. Heidrich R, Ott J: Exogene Psychosen bei Herzkrankheiten. Psychiat Neruol med Psycho1 (Lpz) 17 (1965) 401-404. 16. Hoffmann SO: Riickbildung eines sog. nach SchrittmacherDermatozoenwahns implantation-Zum Problem der symptomatischen NervenarP;y4c4h;r5 I ,b9zi3 Herzkrankheiten. 17. Lueg W, Weber R: Uber psychotische Storungen bei dekompensierten Herzkranken. Med Welt 20:505-507, 1940 18. Leibbrandt CW: Psychose bij stenose van de isthmus aortae. Ned T Geneesk 93:1875-1877. 1949 19. Lennartz H: Psychische Verlnderungen bei Herz-und Kreislauferkrankungen. Med Welt 35:1279-1283, 1958 20. Leyser E: Herzkrankheiten und Psychosen. Abhandlungen aus der Neurologie , Psychiatric, Psychologie und ihren Grenzebieten, Heft 25. Berlin, S. Karger, 1924 21. Meyendorf R: Hirnembolie und Psychose. J Neurol 213:163-177. 1976 22. Meyendorf R: Zur Frage psychischer und neurologischer Stiirungen bei Herzoperationen. Thoraxchirurgie 25:339-344. 1977 23. Riesman D: Acute psychoses arising during the course of heart disease. Am J Med Sci 161:157-162. 1921 24. Targowla MR: “Folie cardiaque” et insuffisance ventriculaire gauche. Bull Sot Med 14:615-617. 1923 25. Urechia Cl: A propos de la psychose cardiaque. Arch Neurol 51:473-485, 1932 26. Von Nostitz-Wallwitz M: Zur Frage psychischer Auffiilligkeiten und des Intelligenzabbaus bei Herzerkrankungen. lnauguralDissertation, Munchen. 1976
M
ODERN CARDIAC SURGERY began in 1944 with the correction of the tetralogy of Fallot by Blalock and Taussig. In 1948, Brock operated successfully on the pulmonary valve and also in 1948 Bailey performed mitral commissurotomy. In 1952, Bigelow introduced hypothermia in cardiac surgery. which led to open cardiac surgery by way of extracorporal circulation.’ Since cardiac surgery established itself as a routine operation, it has brought into focus for psychiatrists and surgeons alike psychopathologic and neurologic phenomena. of which cardiac delirium is only the most conspicuous. While investigating neuropsychiatric complications after cardiac surgery in 1972. and at the same time surveying the fast growing literature since the beginning of the 1960s on the subject. I came to believe that cardiac delirium. and other psychotic reactions after cardiac surgery, were indeed a kind of new exogenous psychosis due to the peculiar operative procedure of heart surgery, mainly caused by extracorporal circulation. Postoperative psychoses aside from cardiac surgery were known long ago-yet the difference in incidence is striking. General surgery, and any other operative procedure in man. offers figures between 0.02% and 0.04%; cardiac surgery has an incidence between 10% and 60%. By sheer accident I came across a Dutch article by the late professor Riimke “Over psychoses bij hartziekten” (psychoses associated with heart disease).” dating from 1939. Reading the very detailed descriptions of the “cardiogenic psychoses,” as he called them-a term which Riimke defends as an entity sui generis over against other symptomatic or organic psychoses-l discovered that these psychoses associated with cardiac disease generally did not differ at all from postoperative cardiac psychoses. Riimke describes very vividly the delirium with confusion and clouding of consciousness, i.e., the obvious organic components of the deranged state of mind. as well as the lucid visual and auditory hallucinations, the paranoid symptomatology, and the characteristic fear and anxiety of these patients. culminating often in the conviction of impending death. Moreover. he draws attention to the frequent occurrence of both insomnia and frightful dreams. symptoms that are now-a-days attributed to circumstances belonging to the intensive care unit with either sensory deprivation or overstimulation. Finally, depressions, including suicidal impulses, were pointed out in patients with advanced organic heart disease, a syndrome that we recognize to be very common after cardiac surgery. Fro177 The Psychiatrische Addre.\s siltif.
reprint
requests
NuJbaumstraJe,
@ 1979 by Crane
326
Kin&
der Ut7ilBersitiiir.
to Radulf
7. D-8000 & Stratton,
Meyendorf,
Miinchrn Inc.
Bunde.wepublik M.D.,
C. M..
2. Bundesrepublik
Deutschland. P.tychiatrische
Deutschland
Klinik (Matzich,
drr
Unil?r-
Grrmat7~J.
00/O-440X/79/2004-0003$01.0010
Comprehensive
Psychiatry,
Vol. 20, No. 4 (July/August),
1979
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
327
The study of Riimke’s article led naturally to further references on the subject of cardiac psychoses, which goes as far back as to the beginning of the last century. In 1818, Nasse wrote a remarkable modern monograph “Von der psychischen Beziehung des Herzens” (On the relationship between heart disease and psychological state).3 He correlated severity of heart disease, psychopathological changes and post mortem finding of the heart valves. Bergmann in 1844 described a case of “Mania metastatica, vom Herzen ausgehend” (Metastatic mania arising from the heart).4 At the same time he presented the post mortem findings of mitral stenosis with thrombosis. Again in 1844, the French author Saucerotte published seven cases of organic heart disease that resemble in every way today’s postoperative deliriums or other psychotic states after cardiac surgery. He called the title of his paper “L’influence des maladies du coeur sur les facultes intellectuelles et morales de l’homme” (The influence of heart disease on the intellectual and moral faculties of rnatQs5 The intellectual derangements are “demence cardiaque,” i.e., cardiac dementia, a term that appeared from there on very frequently in the literature. The “moral impairments” are suspiciousness, impulsions, changes of moods, and peculiar passions and hallucinations. At the end of the last century, all over central Europe there was a distinguished support for the view that there exists a close relationship between insanity and disturbances of the cerebral circulation caused by cardiac defects. Textbooks of psychiatry and internal medicine mention these connections. One reads in a “Textbook of Mental Diseases” (1897) by Theodore Kellog: “Cardiac diseases have a direct relationship to mental disorders which they aggravate, modify and sometimes cause in the first instance through defects of circulation and nutrition of the cerebral tissues.“6 There are a few classical papers on the subject in the latter part of the last, and the beginning of this, century. Krishaber published, in 1872, a paper “Nevropathie cerebra-cardiaque,” a very telling title.7 He presented 24 cases of cardiac psychoses, describing most carefully the psychopathology: ideas of reference and of persecution, heavy dreams, different delusions, and a case of double ego. At the same time he took account of the concomitant neurologic deficits of organic heart disease: disturbances of vision, of the sensory system, and of the locomotor system, thus pointing out that the cerebral pathology of heart disease is reflected in most cases by a neuropsychiatric symptomatology; an observation that modern heart surgery now supports. In 1881 there appeared a thesis in Paris by D’Astros “Etude sur l’etat mental et les troubles psychiques des cardiaques,” which became for some time a kind of reference article.* The author gives 38 case histories, attempting to systematize for the first time the various psychopathologic symptoms, mainly into (1) hysterical phenomena (hysterisme et hysteric cardiaque); (2) lessening of intellectual functions (affaiblissement et demence dans les maladies de coeur); and (3) cardiac insanity (folie cardiaque), which can manifest itself as (A) hallucinations; (B) delire a forme melancholique; (C) delire systematise a forme de manie; and (D) delire incoherent a forme de demence.
328
RUDOLF MEYENDORF
In Great Britain, in 1888, Mickle delivered the Goulstonian lectures on “Insanity in relation to cardiac and aortic disease and phthisis.“g He enumerated 80 cases of valvular diseases, 20 of which he described in detail. He first made sure that he excluded “. . . the delirium or other mental symptoms occasionally observed in the acute and febrile affections of the heart” from another category of symptoms that interested him. These were cases showing delusions of conspiracy, monomania of the persecutory, expansive, OI hypochondriacal type, cases that suffer from melancholia agitata. or those that have hallucinations of sight and hearing. Others had been just grotesquely irrational in demeanor and language. Mickle made the attempt to correlate the psychological disturbances with the general physical state and the stage of heart disease in particular, trying even to show the difference of mental symptoms in the different types of valvular lesions. In 1901, the Goulstonian lectures took up again the subject of heart disease associated with psychosis. Henry Head,‘O who became famous for his concept of referred visceral pain, spoke on “certain mental changes that accompany visceral disease.” Besides diseases of the lung he described 27 cases of heart disease. The cardiac delirium, with clouding of consciousness, confusion, and disorientation, he separated from the mental changes proper of heart disease in the same manner as Mickle did 13 years earlier. The mental changes he spoke of were (1) hallucinations of vision, hearing, and smell: (2) changes of moods with depression or exaltation: (3) suspicion: and (4) changes in memory and attention. Today’s psychoses associated with cardiac surgery have to be divided in a similar manner, since “cardiac delirium” is only one type of mental derangement after operation. The last major work of importance on the subject appeared in 1909, a prize-winning paper by Jakob, “Zur Symptomatologie. Pathogenese and pathologischen Anatomie der Kreislaufpsychosen” (On the symptomatology, pathogenesis and morbid anatomy of circulatory psychoses). Jakob described with great detail the general physical and cardiac status of 9 patients, the development of psychoses during the course of disease. and the post mortem findings on the brain. He concerned himself mainly with the severe states of cardiac delirium-witnessed by the fact that all his cases came ad exitum. The major symptoms consisted of delirious psychomotor excitement accompanied by hallucinations and delusions. On the other hand, Jakob also drew attention to premonotory syndromes before the full picture of delirium has developed. e.g., depressions, fear and anxiety (Angstaffekt), and suicidal impulses. He also mentioned loss of memory. especially of recent events. The literature on psychological changes and cardiac delirium in the course of heart surgery is a fast growing one and has surpassed by now the literature on cardiogenic psychoses aside from cardiac surgery. This being so, one can be only amazed however, that not in a single paper, as far as I know, has there been mention of the fact that cardiac psychoses were known long before heart surgery started. In more than a few of these recent papers one can even incorrectly learn that the term “cardiac delirium” and other psychological
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
329
changes associated with heart surgery were only discovered with the beginning of heart surgery. We would like to know how this former knowledge got lost so that when cardiac surgery began no one could really refer to the problem of cardiac psychosis in its larger context. Aside from a regrettable loss for the sense of historical perspective there seem to be three main reasons for this gap of continuation in the concept of cardiac psychosis before and since the era of heart surgery. (1) Reasons in psychiatric classification; (2) Reasons in specialization in medical fields; and (3) Reasons in the advancement of treatment. REASONS
IN PSYCHIATRIC
CLASSIFICATION
In 1911, Bonhoeffer introduced his concept of “exogenous psychoses” (exogene Reaktionstypen) into psychiatry, implying the uniformity of psychopathologic reactions independent of the various and different causes of known etiologies, e.g., infectious, traumatic, metabolic. Terms like “cardiogenic” or “circulatory” psychoses were no longer favored as an etiologic entity. REASONS
IN SPECIALIZATION
IN MEDICAL
FIELDS
Specialization in the medical fields led toward separation of psychological and psychiatric interest and knowledge in internal medicine. Textbooks of medicine and cardiology no longer mentioned and taught the mental complications of somatic disease as before. Psychiatry separated itself too from the medical disciplines and only shared psychoanalytical or neurologic interests, or occupied itself mainly with “endogenous“ psychoses. REASONS
IN THE ADVANCEMENT
OF TREATMENT
The advance of science, mainly in treating acute endocarditis and chronic heart failure more effectively, especially through the discovery of antibiotics, brought a change about in the incidence of severe disabling heart disease in its early course. The incidence of cardiac psychosis went down accordingly, yet only to reappear at a much later stage under special circumstances: in cardiac surgery, which proves to be a kind of experimental device for producing cardiac psychosis. The interest cardiac surgeons and psychiatrists take today in mental changes during the course of heart surgery reminds one of the similar interest taken a century ago by physicians of general and internal medicine, and by psychiatrists in the relationship between heart disease and mental disease. If one takes a close look at the literature one can find, however, that the awareness of mental complications during the course of heart disease-aside from cardiac surgery-has been there all the time.1-26 CONCLUSIONS
During the last 5 years I had not only the opportunity to study psychiatric and neurologic changes in the course of heart surgery, but also to set up an investigation into mental changes in organic heart disease outside of cardiac
RUDOLF MEYENDORF
330
Table
1. Mental Changes in Organic Heart Disease (61 patients)
45 Mental Changes (73.8%) 19 Depressive syndromes (31 .l%) 9 Dysphoric syndromes (14.8%) 8 Manic syndromes (13.1%) 7 Organic brain syndromes (11.5%) 2 Phobic obsessive syndromes (3.3%)
Table 2. Nine Cases of Acute Cardiogenic Psychoses 4 Paranoid-hallucinatory syndromes 3 Paranoid-depressive syndromes 2 Delirant syndromes (cardiac delirium with clouding of consciousness and loss of orientation)
surgery. Within 6 months, 61 patients, whose caridac and mental state cannot be discussed in detail here, were evaluated for psychiatric disturbances. Forty-five showed mental changes in form of the following syndromes (Table I). Within this group, which was examined consecutively. there was not a single case of acute psychosis of the type of cardiac delirium or other acute cardiogenic psychosis. strictly speaking, though some patients with depressive or manic syndromes did show loss of reality testing. which is characteristic of psychotic symptoms. However, in the last 5 years I was called in cases of emergency to 9 patients with organic heart disease who developed a classical cardiogenic psychosis (Table 2). There cannot be any doubt from my own investigations and from the study of the literature that there are virtually no differences in the kind of minor and major mental derangements of cardiac patients who undergo heart surgery and of those who show these symptoms without having had cardiac surgery. In patients who have had cardiac surgery the incidence is however very much higher. This leads to the question as to the common causes of these two groups of cardiac patients who develop psychiatric (and neurologic) symptoms. The two common causes for the surgery and nonsurgery group of cardiac patients that are mainly responsible for the development of psychiatric and neurologic changes, particularly for cardiogenic psychoses. are embolization and hypoxaemia. However, not every patient does show the same psychopathologic syndrome, though the exogenous etiologic agent may be very much the same. A different hereditary predisposition may probably account for the difference in psychopathologic reactions. REFERENCES I.
Meade
Springfield.
RH: A history of thoracic III, Charles
C Thomas,
surgery.
1961
2. Riimke
HC:
Over
ten. Ned T Geneesk
psychoses
1:728-735.
hi hartziek1939
CARDIAC
PSYCHOSIS
ASIDE FROM SURGERY
3. Nasse F: Von der psychischen Beziehung des Herzens. Ztschr f psychische Arzte 1:49116, 1818 4. Bergmann G: Mania metastatica. vom Herzen ausgehend. Allg Ztschr Psych 1:574582, 1844 5. Saucerotte G: L’influence des maladies du coeur sur les facultes intellectuelles et morales de I’homme. Annal MCd Psych 4: l73182. 1844 6. Kellogg TH H: A textbook on mental diseases. New York, William Wood, 1897 7. Krishaber M: Nevropathie cerebrocardiaque. Gaz Hebd MCd Paris 9:323, 342, 371, 422, 434, 485. 550. 581, 1872 8. D’Astro L: Etude sur I’etat mental et les troubles psychiques. Paris, Adrien Delahaye et E Lecrosnier. 1881 9. Mickle J: Insanity in relation to cardiac and aortic disease and phthisis. Br Med J 1:503-510, 1888 IO. Head H: Certain mental changes that accompany visceral disease. Brain 24:345-429, 1901 A: Zur Symptomatologie, II. Jakob Pathogenese und pathologischen Anatomie der “Kreislaufpsychosen.” J Psycho1 Neurol 14:209-248. 1909 12. Bonhoeffer K: Die Psychosen im Gefolge von akuten Infektionen. Allgemeinkrankheiten und inneren Erkrankungen. in Handbuch der Psychiatric, F. Deuticke. Leipzig und Wien. 1912 13. De Busscher J. Matthijs R: Les troubles psychiques. symptomatiques d’alterations circulatoires d‘origine cardiaque. Folia Psychiatrica Neerlandia 61: 101-108. 1958 14. Gordon AH, Cohen W: The mental complications of heart disease. Can. Med Ass J 39517-522. 1938
331
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