Heniolytic disease of the newborn To the editor: In reference to the editorial "Hemolytic disease of the newborn" (Can Med Assoc J 111: 382, 1974), Dr. A. D. Kelly has reminded me that to Dr. A. P. Hart of The Hospital for Sick Children, Toronto goes the pride of place in first publishing a report of the use of exchange transfusion in the management of erythroblastosis fetalis (Can Med Assoc J 15: 1008, 1925). Dr. Kelly has drawn this to the attention of readers of the Journal on a previous occasion (Can Med Assoc J 101: 113, 1969). I agree with Dr. Kelly that one should give credit to Dr. Hart's pioneering efforts. His report was made 15 years before the discovery of the Rh blood group system by Landsteiner and Weiner, and therefore represented proper treatment before cause and pathogenesis were known. Needless to say, the donor blood used for the exchange tranfusion might or might not have been Rh-negative. JOHN
W.
BOWMAN,
MD
Department of pediatrics Faculty of medicine University of Manitoba Winnipeg, Man.
Psychologic factors in the genesis of niyocardial infarction To the editor: We would like to report two cases from our recent clinical experience that support Dr. Levene 's findings that psychologic factors appear to play a significant role in the genesis of myocardial infarction (Can Med Assoc J 111: 499, 1974). Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed 1½ pages in length.
The first patient, a 63-year-old woman, experienced central chest pain as her husband was rushed to hospital dying from an acute myocardial infarction. Her pain was relieved by nitroglycerin and an electrocardiogram taken at the time was normal. She experienced no further cardiac symptoms, but 2 weeks later at a routine medical examination her EGG was grossly abnormal and indicative of a recent anterior wall infarction. Her first myocardial infarction had occurred 18 months previously, on the day following the death of her only son from a sudden myocardial infarction. The second patient, a 52-year-old widow, awoke at 3 am with sharp retrosternal pain. She was admitted to hospital, where an EGG showed evidence of an anterolateral myocardial infarction. She had been chronically depressed since the death of her husband from a myocardial infarction 7 years before. He had died suddenly during the early hours of the morning. Her depressive symptoms included early morning wakening and a preoccupation at that time with the circumstances of her husband's death. Two weeks before hospitalization her daughter was married and left home. The patient's father was also terminally ill and died while she was in hospital. His death intensified her depression and she required supportive psychotherapy throughout her convalescence. In both patients the loss or threatened loss of loved ones appeared to be an important factor in the precipitation of myocardial infarctions. This is in keeping with the observations of Engel' and Schmale' that real, threatened or symbolic object loss precedes the onset of a wide variety of physical illnesses. They have described a "giving-up complex" characterized by feelings of helplessness and! or hopelessness and a physiological state of conservation-withdrawal. Investigating a hospitalized medical population Schmale found that up to 70 to 80% of patients had experienced an object loss and feelings of helplessness or
134 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
hopelessness immediately before the onset of physical symptoms. Levene's findings of recent anxiety or depression in 87% of his group with myocardial infarction is therefore not unduly surprising. Questions of whether grief can kill and kill through the heart have also been examined. In a review of the life-settings in which sudden cardiac deaths occurred Engel3 identified psychosocial events that had been impossible for the victims to ignore and to which their response had been overwhelming excitation or giving up, or both. In another study Greene, Goldstein and Moss4 found that the majority of patients had been depressed for a week to several months, and sudden deatfr then occurred in a setting of acute arousal engendered by increased work and activity or circumstances that precipitated reactions of anxiety or anger. These investigators have proposed that the combination of depressive and arousal phychologic states or abrupt transition from one state to another may produce disharmonious responses in the hormonal and autonomic nervous systems and precipitate infarction, arrhythmias or sudden death. Bereavement in particular appears to act as an aggravating or precipitating factor in coronary artery disease. Careful enquiry about recent psychosocial events is therefore an essential aspect of the management of the patient with coronary artery disease. Recognition of grief or feelings of hopelessness and the application of supportive psychotherapy by the physician may favourably influence the course of the patient's illness. GRAEME J. TAYLOR, MD, FRCP[C] JACK M. COLMAN, MD, FRCP[C] ALLAN SHARP, MD, Fac.[c] Departments of medicine and psychiatry New Mount Smar Hospital Toronto, Ont.
W.
BOWMAN,
MD
Department of pediatrics Faculty of medicine University of Manitoba Winnipeg, Man.
Psychologic factors in the genesis of niyocardial infarction To the editor: We would like to report two cases from our recent clinical experience that support Dr. Levene 's findings that psychologic factors appear to play a significant role in the genesis of myocardial infarction (Can Med Assoc J 111: 499, 1974). Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and should not exceed 1½ pages in length.
The first patient, a 63-year-old woman, experienced central chest pain as her husband was rushed to hospital dying from an acute myocardial infarction. Her pain was relieved by nitroglycerin and an electrocardiogram taken at the time was normal. She experienced no further cardiac symptoms, but 2 weeks later at a routine medical examination her EGG was grossly abnormal and indicative of a recent anterior wall infarction. Her first myocardial infarction had occurred 18 months previously, on the day following the death of her only son from a sudden myocardial infarction. The second patient, a 52-year-old widow, awoke at 3 am with sharp retrosternal pain. She was admitted to hospital, where an EGG showed evidence of an anterolateral myocardial infarction. She had been chronically depressed since the death of her husband from a myocardial infarction 7 years before. He had died suddenly during the early hours of the morning. Her depressive symptoms included early morning wakening and a preoccupation at that time with the circumstances of her husband's death. Two weeks before hospitalization her daughter was married and left home. The patient's father was also terminally ill and died while she was in hospital. His death intensified her depression and she required supportive psychotherapy throughout her convalescence. In both patients the loss or threatened loss of loved ones appeared to be an important factor in the precipitation of myocardial infarctions. This is in keeping with the observations of Engel' and Schmale' that real, threatened or symbolic object loss precedes the onset of a wide variety of physical illnesses. They have described a "giving-up complex" characterized by feelings of helplessness and! or hopelessness and a physiological state of conservation-withdrawal. Investigating a hospitalized medical population Schmale found that up to 70 to 80% of patients had experienced an object loss and feelings of helplessness or
134 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
hopelessness immediately before the onset of physical symptoms. Levene's findings of recent anxiety or depression in 87% of his group with myocardial infarction is therefore not unduly surprising. Questions of whether grief can kill and kill through the heart have also been examined. In a review of the life-settings in which sudden cardiac deaths occurred Engel3 identified psychosocial events that had been impossible for the victims to ignore and to which their response had been overwhelming excitation or giving up, or both. In another study Greene, Goldstein and Moss4 found that the majority of patients had been depressed for a week to several months, and sudden deatfr then occurred in a setting of acute arousal engendered by increased work and activity or circumstances that precipitated reactions of anxiety or anger. These investigators have proposed that the combination of depressive and arousal phychologic states or abrupt transition from one state to another may produce disharmonious responses in the hormonal and autonomic nervous systems and precipitate infarction, arrhythmias or sudden death. Bereavement in particular appears to act as an aggravating or precipitating factor in coronary artery disease. Careful enquiry about recent psychosocial events is therefore an essential aspect of the management of the patient with coronary artery disease. Recognition of grief or feelings of hopelessness and the application of supportive psychotherapy by the physician may favourably influence the course of the patient's illness. GRAEME J. TAYLOR, MD, FRCP[C] JACK M. COLMAN, MD, FRCP[C] ALLAN SHARP, MD, Fac.[c] Departments of medicine and psychiatry New Mount Smar Hospital Toronto, Ont.
