300 PSYCHOTHERAPY : SCIENTIFIC AND RELIGIOUS chap.
expecting a spectacular and learned dissertation. The first patient was wheeled in and her history read by the clinic clerk. The patient was a middle-aged woman who had suffered since girlhood from a cardiac condition obviously rheumatic in origin. Her cardiac deficiency had apparently been well compensated and the patient had been able to follow a practically unrestricted routine until three months previously, when quite suddenly she had suffered a break in the cardiac compensation. She had since been semi-bedridden. The patient was examined and the physical findings discussed, and Mackenzie arose, ostensibly to lecture on the case. He stepped over to the patient and asked her if she had recently made any changes in her place of residence. His question brought forth the history that the patient had for many years lived in a small basement apartment, but that three months previously, at the same time as the break in her cardiac compensation, she had moved into another apartment, which necessitated her walking up three flights of stairs, several times a day. ' Mackenzie shrugged his shoulders and sat down.' I37
Cardiac pain and tachycardia are common accompaniments of anxiety states, and there may be great cardiac hypochondria. In such cases reassurance should be given, but it is rarely of avail. Deeper psychotherapy is needed, for the alleged symptom is often a displacement of anxiety about some other subject on to the heart, for most people believe this to be a very vulnerable organ.
Vasovagal attacks are rare occurrences, sometimes brought about by pressure on the carotid sinus but often appearing to have a psychological background, though there must obviously be some constitutional factor as well. During an attack patients feel dazed, or may even faint. There are feelings of nausea and pressure over